Step 2 Missing Knowledge Flashcards
Ureteral injury during pelvic surgery
Postop: ureteral obstruction and hydronephrosis (nonradiating focal back pain, unilateral CV angle tenderness)
Dissociative amnesia
Isolated impairment in autobio memory
Sudden onset preceded by traumatic event
AOM rfs
Age (6-18 mo)
Lack of breastfeeding
Daycare attendance
Smoke exposure
Polycythemia Vera Tx
Serial phlebotomy +/- hydroxyurea if high risk of thrombosis
Recurrent tinea cruris
Common (not suggestive of immunosuppression)
Suggests reexposure to external source or autoinfection from concurrent dermatophyte infection (e.g. tinea pedis/corporis)
Thorough skin inspection, any other infection sites tx
Lactation failure jaundice vs breast milk jaundice
LFJ: age < 1wk; insufficient intake of breast milk: decreased bili elimination, increased enterohep circ; suboptimal breastfeeding, signs of dehydration, excessive weight loss
BMJ: age >1wk; increased glucuronidase in breast milk: increased deconj of intestinal bili, increased enterohep circ; adequate breastfeeding, well hydrated
Erythema toxicum neonatorum
Benign neonatal rash
First 3 days of life
Erythematous papules, macules or pustules on trunk and prox extremities (sparing palms/soles)
Self resolves within a week
PPROM complications
Preterm labor
Intraamniotic infection
Placental abruption (from oligo leading to uterine decomp and placenta separation)
UC prolapse
High risk conditions for infective endocarditis (needing abx for dental work etc)
Prosthetic heart valve
Prev IE
Structural valve abnormality in transplanted heart
Unrepaired cong cyanotic heart disease
Repaired cong heart disease with residual defect
Zollinger Ellison syndrome can cause diarrhoea and steatorrhoea. Why?
Increased gastrin increased gastric acid inactivation of pancreatic enzymes and injury to mucosal brush border
Granulosa cell tumour
High estrogen and inhibin
Juvenile GCT: precocious puberty& adrenal mass
Hyposthenuria
Inability of kidneys to concentrate urine
can occur in sickle cell disease & SCT
polyuria, low serum Specific gravity& normal serum Na
Bladder injury
Extraperitoneal (anterior bladder wall): localised sx and neg FAST; pelvic fracture injury
Intraperitoneal (bladder dome - weakest part): pos FAST, abdo distention, chem peritonitis
Renal and urinary changes in normal preg
Increased RBF
Increased GFR
Increased renal basement membrane perm
Effects:
Decreased serum BUN
Decreased serum creatinine
Increased renal protein excretion
Glucagonoma
Necrolytic migratory erythema: painful, pruritic papules that coalesce to form large plaques on face, groin and extremities
DM, weight loss, diarrhoea, anaemia
Glucagon > 500
N.B: phaeochromocytoma can cause unexplained hyperglycaemia (catecholamines inhibit insulin secretion)
Diffuse axonal injury MRI findings
Punctate haemorrhages in white matter (axons)
Blurring of gray-white matter (oedema)
Cerebral palsy: major rf
Prematurity
Leading to ischaemia and necrosis in area near lateral ventricles: periventricular leukomalacia
Also friable GM vessels, leading to intraventricular haemorrhage
Bartholin duct cyst
Large sx can present w vaginal discomfort and pressure with sex, sitting, walking
Soft, nontender mobile mass behind post labium majus extension into vagina
Sx: incision and drainage tx
Community acquired bacterial meningitis: m/c cause
Strep pneumoniae
Raised ICP tx
Decrease brain parenchymal vol: osmotic therapy (hypertonic saline, mannitol) to extract water
Decrease CBV:
head elevation
Sedation
Hyperventilation
Decrease CSF vol:
External ventricular drain
Increase cranial vol:
Decompressive craniectomy
Meningovascular syphilis
Days/weeks of meningeal sx then acute ischaemic infarction
Vasa previa
Fetal vessels overlying cervix
Rfs: placenta previa, multiple gestations, IVF, succenturiate placental lobe
Presentation:
1. PAINLESS vaginal bleeding with ROM/contractions
2. FHR abnormalities (e.g. brady, sinusoidal pattern)
3. fetal exsanguination and demise
Mx: emergency C section
Hammer toe vs claw toe
Hammer: dorsal flexion MTP, plantar flexion PIP, DORSAL FLEXION DIP
Claw: dorsal flexion MTP, plantar flexion PIP & DIP
Both seen in diabetic peripheral neuropathy (other complications of DPN: callusing, ulceration, joint subluxation and Charcot arthropathy)
Chronic osteomyelitis fracture complication
Fracture nonunion
Intermittent pain and swelling and sinus tract formation
Open bone biopsy, surgical debridement of infected and necrotic bone
Preterm infants vaccination schedule
Given according to chronological age rather than age corrected for gestation
Postpartum uterine atony rfs
Uterine fatigue from prolonged, induced, or precipitous labor
Intraamniotic infection
Uterine overdistension (multiple gestation, fetal macrosomia, polyhydramnios)
Retained placenta
Grand multiparity
Operative vaginal delivery
Anti-D Ig post preg
Standard dose at 28 weeks gest
After delivery or procedures, Kleihauer-Betke test performed to determine whether higher dose needed due to increased risk of fetal blood cells entering maternal circ
Psychosis and Parkinson’s
Common, seen more in pts taking dopamine agonists (e.g. ropirinole, pramipexole) than those treated with carbidopa-levodopa.
Psychotic sx treated with antiparkinson med dose reduction and/or addition of LOW potency antipsychotic (quetiapine, pimavanserine)
Ludwig angina
Rapidly progressive cellulitis of submandibular and sublingual spaces
Airway obstruction can occur due to displacement of tongue posteriorly
Post-traumatic neuroma (following amputation)
Due to transection of nerve fibers
Form over several weeks - months following injury/amputation
FOCAL tenderness, altered local sensation
Pain with local pressure that can complicate fittings for amputational prosthetics
Injection of local anesthetic can provide transient pain relief and confirm dx
Mx: excision of neuroma
Preterm birth prevention
Rfs for preterm delivery:
Prior spont preterm delivery (main rf)
Tobacco use, multiple gest, prior cervical surgery (e.g. cold knife conization for CIN)
No prior preterm delivery: TV US cervical length measurement at 16-24 weeks gest to assess risk for preterm delivery (if short cervix identified, <= 2.5cm on USS, high risk for preterm, so offered vag progesterone (prevent uterine contractions))
Prior preterm delivery:
… w/ Painful contractions = prior preterm labor: Tx = progesterone
… w/o painful contractions = cervical insufficiency: Tx = prophylactic cerclage
Sensorimotor polyneuropathy in DM
Small fiber: pos sx: pain, paresthesia, allodynia
Large fiber: neg sx: numbness, loss of proprioception and pos sense, diminished ankle reflexes
Children w pneumonia not improving after 48-72 hr of abx
CXR to assess for complications (e.g. parapneumonic effusion, abscess, necrotising pneumonia)
Cervical spine injury imaging indications
CT preferred test for screening
Indications: high-energy mechanism of injury or any one of following:
neuro deficit
spinal tenderness
altered mental status
intox
distracting injury
N.B: presence of single vertebral # in pt w blunt trauma indication to image ENTIRE SPINE (CT scan)
Long-term (>= 5 years) metformin therapy side effect
B12 def due to alterations in ca homeostasis, leading to impaired absorp of b12 in terminal ileum
May have isolated neuro findings (paraesthesias, sensory ataxia, neuropsych changes) w/o megaloblastic anaemia
Cushing syndrome screening test
Late-night salivary cortisol assay, 24-hour urine free cortisol and/or low dose overnight dex suppression test
NOT early morning cortisol!
TOF: tx of tet spells
Placement of pts in knee-chest pos during hypercyanotic spell causes kinking of femoral arteries, increasing SVR so reduces R to L shunting through VSD so increases PBF and improves hypoxaemia
Tourette syndrome tx
(Multiple motor tics and at least one vocal tic)
Habit reversal training
Pharmocotherapy: ANTIPSYCHOTICS, dopamine depleters, or alpha adrenergic receptor agonists
Spontaneous pneumomediastinum
Severe coughing paroxysms can increase intraalveolar pressure and cause air to leak into subcut tissues (subcut emphysema) resulting in SPM
CXR to confirm dx and rule out pneumothorax
Appropriate compensation for acid base disorders
Met ac (acute/chronic): Winter’s formula: expected PaCO2 = (1.5 x HCO3-) + 8 +/- 2
Met alk (acute/chronic): ~7 increase in PaCO2 per 10 increase in HCO3-
Resp ac (chronic only): ~ 4 increase in HCO3- per 10 increase in PaCO2
Resp alk (chronic only): ~ 4 decrease in HCO3- per 10 decrease in PaCO2
Acute bacterial rhinosinusitis
Distinguished by viral URTI by presence of severe, persistent or worsening sx (cough, nasal discharge)
Tx = oral abx
Suspected appendicitis (modified Alvadaro score >= 4)
Imaging: CT abdo/pelvis if nonpregnant/adult; USS +/- MRI if pregnant/child
If nonperforated appendicitis visualised: Abx & appendectomy <= 12 hrs
If perforated appendicitis: Abx & bowel rest; contained abscess: PCD; diffuse contamination: I&D with appendectomy
Pes anserinus pain syndrome
Localised pain and tenderness over medial tibial condyle
Assoc w overuse
Rfs: obesity, DM, knee OA and angular deformity of knee
Dx clinical but Xray can exclude concurrent OA
Mx: quads strengthening exercises and NSAIDs (N.B: same mx as for PF syndrome)
CF PF syndrome: more common in Females; anterior (rather than medial) pain worsened by squatting, climbing stairs, prolonged sitting
Ehrlichiosis
Suspect if pt from endemic region (southeastern and south central US) w/ hx of tick bite, febrile illness w/ systemic sx, leukopenia and/or thrombocytopenia, and elevated aminotransferases.
Rash uncommon
Tx = doxycycline
Dumping syndrome
Common postgastrectomy complication
GI sx (nausea, diarrhoea, abdo cramps)
Vasomotor sx (palpitations, diaphoresis)
Tx: dietary mod (avoid simple sugars etc), improves over time
ALS: resp insufficiency
Early resp insufficiency may manifest as orthopnea and appear similar to OSA (daytime fatigue, early morning headaches)
NIPPV prolongs survival and improves QofL
Drug-induced lichen planus (lichenoid drug reaction)
Assoc w/ ACEi, thiazide diuretics, beta blockers, hydroxychloroquine
Idiopathic LP: wrists and ankles
Drug-induced LP: more diffuse
Tx = topical high-potency glucocorticoids (e.g. betamethasone) and discontinue suspected med
Cryptococcal meningitis tx
3 phases to ensure eradication and prevent disease relapse
1. induction with amphotericin B and flucytosine for 2 weeks
2. consolidation with high-dose oral FLUCONAZOLE for 8 weeks
3. maintenance with low-dose oral FLUCONAZOLE until CD4 count recovers to >100 for >3mo on ART
N.B: ART initiation delayed for approx 2 weeks after tx for Cryptococcus due to risk of life-threatening CNS complications from immune reconstitution syndrome
M/c cause of gastroenteritis in US?
NOROVIRUS
Assoc w outbreaks on cruise ships and schools etc
Vomiting, watery diarrhoea, abdo pain 1-2d after exposure
Supportive tx
CF Basillus cereus and Staph aureus: vom 6 hours after eating contaminated food
BNP and heart failure
Very good at ruling out heart failure (ie very sensitive) if under 100
Caveat: can be falsely low in pts w heart failure and OBESITY (BNP undergoes increased clearance by fat cells)
Performance anxiety (performance-only social anxiety disorder)
Tx = as needed beta blockers or benzos
Avoid benzos in pts with personal OR family history of SUBSTANCE USE DISORDER or when cog and sedative side effects could impair performance
CF social anxiety disorder (generalised): SSRI/SNRI
Hyperkalaemia ECG changes order
Peaked T waves -> loss of P waves -> widened QRS -> SINE WAVE PATTERN -> asystole
Ecthyma gangrenosum
Rapidly progressive cutaneous disorder seen in immunocompromised pts w P aeruginosa bacteraemia/sepsis
Lesions begin as painless red macules, quickly progress to pustules/bullae and then form punched out gangrenous ulcers
Pts usually febrile and ill
Tx: Blood cultures and empiric IV Abx
Renal cysts
Simple renal cysts mostly benign and do not require any investigations
Malignant renal mass: multilocular mass, irregular walls, thickened septa and contrast enhancement
Adenomyosis
Women over 40 w CHRONIC PELVIC PAIN (CF fibroids), dysmenorrhoea and heavy menstrual bleeding
SYMMETRICALLY enlarged uterus (CF fibroids), boggy, globular and tender
Cervical radiculopathy
Caused by compression of nerve root due to disk herniation or spondylosis
Neck pain, shoulder/arm pain, paraesthesia and diminished reflexes
Improvement of radicular sx when hand placed over head dx and tx
Vit C def
Ecchymosis, petechiae, poor wound healing, perifollicular hemorrhage, coiled hairs and gingivitis
Platelet count, PT, PTT normal
Paraesophageal hiatal hernia
Gastric fundus migrates into thoracic cavity
Large defects can result in herniation of surrounding stomach and intraabdo organs
Sx: N&V, POSTPRANDIAL FULLNESS, dysphagia, epigastric pain, chest pain
Chest imaging: retrocardiac air-fluid level within thoracic cavity (can also be seen in sliding hernias)
Dx confirmed with barium swallow/upper endoscopy
Mx: surgery (medical antireflux for sliding hernia)
LUTS investigations
Urinalysis to evaluate for HM and infection
PSA in sx pts to assess risk for prostate ca unless life expectancy under 10 years
PCOS med to induce ovulation
Letrozole
N.B: cyclic progesterone for endometrial protection but does not induce ovulation
All sexually active women under 25 annual screening for what?
Gonorrhoea and Chlamydia due to high rate of asx infection and risk of long term sequelae (infertility)
NAAT used
N.B: cervical ca screening begins at age 21 w cervical cytology (Pap smear)
But routine HPV testing not performed for those under 30 cos most HPV infections transient and spont clear in this age group
Acute unilateral cervical lymphadenitis in children
Erythematous, tender, warm lymph node
Fever, fluctuance
Periodontal disease or dental caries: ANAEROBES m/c organisms (e.g. Prevotella)
Unilateral = bacterial
Bilateral = viral (acute adeno, subacute chronic EBV CMV)
Signs of traumatic arterial injury
Hard signs (require immediate surgery):
Distal limb ischaemia
Absent distal pulse
Active bleeding or rapidly expanding haematoma
Bruit or thrill at site of injury
Soft signs (require further imaging e.g. CT angio):
Diminished distal pulses
Unexplained hypotension
Stable haematoma
Documented haemorrhage at time of injury
Assoc neuro deficit
NAFLD AST/ALT ratio
Less than 1
USS: Hyperechoic liver (fatty infiltration)
Fetal growth restriction complications
Polycythaemia: chronic Hypoxia EPO
Hypoglycaemia: low nutrients, low plasma glucose, low insulin
Hypothermia: shunting blood to vital organs, decrease subcut fat, increase heat loss
Hypocalcaemia: Placental dysfunction less ca transfer to fetus
Perinatal asphyxia and meconium aspiration
HIV-assoc neurocog disorders
Impaired memory and attention/concentration
PERSONALITY, MOOD and BEHAVIOUR CHANGES
Motor sx (ataxia, slowed mvts)
Varies in severity from asx to dementia
Rfs: long-standing HIV disease, age >= 50, CD4 < 200
MRI: DIFFUSE brain atrophy, ventricular enlargement and increased white matter intensity
CF PML: sx: focal cortical involvement (e.g. motor deficits, ataxia, vision abnormalities); MRI well delineated ASYMMETRIC white matter lesions
N.B: primary CNS lymphoma: CD4 <100, focal neurological deficits, neuropsychiatric symptoms (e.g., personality changes), and headaches
Tx: Combination chemotherapy with high-dose METHOTREXATE (after a brain biopsy has been obtained). Radiotherapy if the patient has a poor functional status and for patients with intraorbital or spinal cord lesions.
NOT SURGERY
In patients with HIV-related PCNSL, administering antiretroviral therapy concurrently with definitive cancer treatment is essential for facilitating immune reconstitution.
Autoimmune hepatitis labs
Hepatocellular pattern of liver injury (raised AST/ALT, normal ALP and bili)
High levels of auto antibodies, leading to elevated serum globulins and GAMMA GAP (total protein - albumin >= 4)
Pos serology (anti smooth etc) and hypergammaglobulinaemia confirms dx
SSRI Anxiety
Activating effects (e.g. anxiety, insomnia) possible EARLY side effects of SSRI but improve with time
Pts w anxiety more sensitive to these effects so benefit from temp dose reduction or starting off at a lower dose
All children with social or language deficits should have what test
Hearing (repeated ear infections can cause conductive hearing loss, which can be confused with some behavioural disorders of childhood)
Uncontrolled infection of facial skin (/sinuses/orbits) can lead to?
Cavernous sinus thrombosis (facial/ophthalmic venous system is valveless)
CN 3, 4, 5 and 6 deficits
Severe headache, binocular palsies, bilateral periorbital oedema (impaired venous flow in orbital veins), hypo/hyperesthesia in V1/V2 distribution, vomiting (ICH), papilloedema
CF brain abscess: raised ICP from brain abscess -> brain herniation not bilateral periorbital oedema
Aortic regurg: valve disease vs root disease location of murmur
Both early diastolic
Valve disease: left sternal border
Aortic root disease: right sternal border
Neuro manifestation of sarcoid?
Facial nerve palsy
Other extrapulm manifestations:
cutaneous (papules, nodules, plaques, erythema nodosum),
opthal (ant/post uveitis, keratoconjunctivitis sicca),
neuro (FNP, central DI, hypogonadotropic hypogonadism),
cardio (AV block, dilated/restrictive cardiomyopathy),
GI (HSM, asx LFT abnormalities)
Plus: hyperca, peri lymphadenopathy, parotid gland swelling, polyarthritis, constitutional sx (fever, malaise)
* Lofgren syndrome
Sternal dehiscence
Complication of cardiac surgery
Separation of bony edges of sternum
Mild pain or sensation of chest wall instability and ‘clicking’ w chest mvt
Palpable rocking or clicking of sternum confirms dx
Mx: URGENT surgical exploration & repair
Trousseau syndrome
Hypercoag disorder
Recurrent and migratory superficial thrombophlebitis at UNUSUAL SITES (arm, chest area)
Assoc w pancreatic ca (also stomach/lung/prostate ca)
Ascites mx
Spiro with furosemide
Etoh abstinence, SODIUM RESTRICTION
Avoid ACEi, ARB, NSAID
Acute stress disorder: initial mx
Educate pts on range of reactions to trauma (physical, emotional): NORMALISING
Trauma-focused CBT beneficial for pts w severe and persistent sx
N.B: do not initially refer for individual psychotherapy as pt unlikely to be compliant
Borderline personality disorder pt w splitting: how to manage in hosp
See pt JOINTLY AS A TEAM to provide clear and consistent info and minimise tendency for splitting to impact tx
Polycythaemia in neonates
Hct > 65% in term neonates
Rfs: excessive transfusion (delayed UC clamping, T2T transfusion syndrome), intrauterine hypoxia (uteroplacental insufficiency e.g. smoking, mat DM) and genetic conditions (e.g. trisomy 21)
High blood viscosity limits organ perfusion and can cause resp distress, hypoglycemia and poor feeding
What to screen for in ALL women postpartum
INTIMATE PARTNER VIOLENCE (higher risk due to increased emotional, physical and financial stressors)
Essential tremour: tx
Beta blockers: propranolol
Anticonvulsants: primidone (given if beta blockers contraindicated e.g. asthma etc)
Diarrhoea not explained after extensive evaluation?
FACTITIOUS DIARRHOEA
Investigations:
stool osmolality (hypoosmolar = addition of dilute fluid; hyperosmolar = addition of conc fluid e.g. urine),
stool electrolytes (elevated Mg or phosph = use of saline osmotic laxatives),
stool osmotic gap (osmotic laxatives = high osmotic gap diarrhoea)
Unilateral cyrptoorchidism mx
<6mo: monitor for spont descent
>= 6 mo: refer for orchiopexy (perform at age 1 to reduce risk of test torsion, infertility and ca). Imaging not indicated prior to referral
Neonatal clavicular #
Rfs = birth weight > 4kg, shoulder dystocia, vacuum delivery
Mx = reassurance and gentle handling (self-limiting); place affected arm in long sleeve garment & pin sleeve to chest w elbow flexed to 90 degrees to decrease pain
Milk-alkali syndrome
Excessive intake of CALCIUM & ABSORBABLE ALKALI (usually in form of CALCIUM CARBONATE ANTACIDS)
Renal vasoconstriction and decreased GFR
Renal loss of sodium and water, reabsorp of bicarb
Triad: HYPERCALCAEMIA, AKI, MET ALKALOSIS
Rfs: CKD, thiazide use, NSAID, ACEi
Suppressed serum PTH, hypophosphataemia (intestinal binding of phosph by caco3), hypomagnasaemia (decreased renal absorp of mag)
Photosensitive skin w vesicles or bullae in areas of trauma or sun exposed skin
Porphyria cutanea tarda
Assoc w HEP C and warrants screening
Toxoplasmosis maternal acquisition
Ingestion of cat feces or UNDERCOOKED MEAT from animals infected with TG
N.B: diffuse intracranial calcifications of newborn seen (periventricular c in cong CMV infection which is spread by saliva
Also TG: macrocephaly/microcephaly; seizures. Serology/PCR
CMV: microcephaly; SNHL. Urine/saliva PCR
Routine prenatal lab tests (24-28 weeks; 36-38 weeks)
24-28 wks: Hb/Hct; Ab screen if RhD neg; 1hr 50g GCT (initial prenatal visit screening if high risk for T2DM)
36-38wks: GBS rectovag culture (not earlier even if GBS in prior preg)
Newborn cyanosis worsened by feeding and improved by crying
CHOANAL
Failure to pass catheter through nares into oropharynx dx
CF TEF w EA: coughing and choking w feeds and resp distress
Topical glucocorticoid eyedrops and systemic glucocorticoids can cause what in the eye?
RAISED IOP -> OAG
OAG: insidious loss of PERIPHERAL VISION
steroid-induced OAG: central blurriness due to corneal oedema
Second stage arrest of labour
Lack of fetal descent after >= 4hrs in a primi with epidural (>=3hrs w/o) and >=3hrs in multigravida with epidural (>=2hrs w/o)
Mx: operative vaginal delivery (e.g. VACUUM-ASSISTED)
Other indications for op vag delivery: mat exhaustion, fetal distress and mat conditions in which Valsava not recommended (e.g. HOCM)
All preterm neonates born <32 wks gest require what test?
Screening HEAD USS
Preterm babies increased risk of developing ICH due to presence of germinal matrix (friable, highly vasc area in brain). N.B: ICH can be asx therefore must screen ALL preterm babies
Synthetic cathiones (bath salts)
Amphetamine like properties
Severe agitation, combativeness, psychosis, delirium, myoclonus, seizures
Tachy, increased BP
Effects of intox may take up to a week to subside (CF other stimulants/hallucinogens which have much shorter duration of effect)
Labial adhesions (fused labia minora)
Seen in PREPUBERTAL GIRLS w LOW ESTROGEN production
Inflam from poor hygiene, infection, irritation, trauma also contributes
Partial adhesions asx no tx needed
Top estrogen first line for sx lesions
Microscopic colitis
Occurs in women >60
Water diarrhoea during periods of FASTING and/or at NIGHT
Colonoscopy: normal appearing mucosa
Biopsy: mononuclear infiltrate within lamina propria, subepithelial collagen band
Rfs: concurrent autoimmune diseases, cigarette smoking, NSAID use
Suppurative parotitis
Exquisitely painful swelling (firm, erythematous) of parotid glands
Exacerbated by chewing/palpation
Trismus, systemic findings (fever, chills)
Elevated serum amylase w/o pancreatitis
Rfs:
ELDERLY, DEHYDRATION, POSTSURGICAL
Decreased oral intake (NPO periop)
Meds (anticholinergics)
Obsrtuction (calculi, neoplasm)
Mx:
USS or CT scan (ductal obstruction, abscess)
Hydration, oral hygiene
Abx
Massage
Sialogogues
Aspirin exacerbated resp disease
Samter triad:
Asthma
Chronic rhinosinusitis with nasal polyps
NSAID-induced resp reactions (worsening sx after NSAIDs)
COX inhibitors result in imbalanced production of leukotrienes over prostaglandins
Crohn’s disease: fibrotic stricture
Severe uncontrolled inflam in CD can lead to fibrotic stricture of small bowel w SBO
Smoking and young age (under 30) at dx increases risk
Bilious emesis, severe abdo pain and inability to pass flatus and/or stool
Tx= surgery to remove strictured portion of small bowel
Rapidly progressive hirsutism w virilisation
Suggests very high androgen levels due to androgen-producing neoplasm
Elevated DHEAS seen in androgen-producing adrenal tumours:
Raised DHEAS, T; low LH
CF: PCOS (not as rapidly progressing): normal/raised DHEAS, T; high LH
Best study to study rare diseases and diseases with a long latency period?
CASE-CONTROL
SIBO
Proliferation of colonic or oral bacterial in SB
Rfs:
anatomic abnormalities (strictures, ILEOCECAL RESECTION or other surgeries, SB diverticulosis)
motility disorders (DM, scleroderma, opioid use)
immunodef (IgA def)
chronic pancreatitis
gastric hypochrlorhydria, PPI use
Bloating, flatulence
Chronic watery diarrhoea
Poss malabosption
Low B12 (bacteria consump), raised folate (bacterial synthesis)
Dx: CARBOHYDRATE BREATH TESTING (lactulose or glucose -> hydrogen production by bacteria fermenting carb earlier than normal)
Gold standard (but invasive): endoscopy w jejunal aspirate/culture
Tx: oral Abx (rifaximin, cipro, doxy)
Hypoparathyroidism mx
Calcium and vit D supplementation
CALCITRIOL (1,25D) preferred because it does not need PTH-mediated renal conversion to active form (ie renal 1 alpha hydroxylase dependent on PTH to convert 25 to 1,25D)
HypoPTH = iatrogen in adults, autoimmune in children
Suspected corneal injury (abrasion/laceration)
Look out for OGI w high velocity injury mechanism
OGI signs: visible entry wound, globe deformity, irregularly shaped pupil
In absence of OGI (CI to use of fluorescein/topical agents), further corneal assessment should be performed via FLUORESCEIN STAINING
N.B: penlight test (pupils, foreign body) and visual acuity before fluorescein staining
Fluorescein concentrates on BASEMENT MEMBRANE exposed by coreneal epithelial defect
Localised uptake: corneal abrasion
Uptake followed by CLEARING IN WATERFALL PATTERN = FULL THICKNESS CORNEAL LACERATION with OGI (caused by washout from leaking aqueous humour) -> IMMEDIATE OPHTHALM CONSULT
Rectus abdominis diastasis
Weakening of linea alba between rectus abdominis muscles
Nontender abdo bulge in PREGNANT/POSTPARTUM pts
Conservative mx reassurance
Recent acid ingestion -> gastric outlet obstruction sx?
PYLORIC STRICTURE
Confirm dx with UGI endoscopy; tx = surgery
Acute acalculous cholecystitis
Rfs:
Severe trauma/recent surgery
Prolonged fasting/TPN
Critical illness (sepsis, ICU, mech vent)
Fever, leucocytosis, RUQ pain +/- raised LFTs
Abdo USS
HIDA/CT if needed
Tx:
Enteric Abx coverage
Cholecystostomy for initial drainage
Consider cholecystectomy once stable
Neonatal withdrawal bleeding
Usually benign, caused by WITHDRAWAL OF MATERNAL HORMONES
Pathophys: fetal endometrial proliferation from mat estrogen followed by endometrial sloughing after delivery from mat progesterone withdrawal
Light, self-limited vag bleeding
+/- additional signs of maternal estrogen exposure: phys leukorrhoea, labial swelling, breast hypertrophy +/- galactorrhoea
Reassure pt
Resolves on its own within few days
Burns pts: initial mx
Initial stabilisation
If covering large TBSA, aggressive fluid resusc
URETHRAL CATHETERISATION ASAP to monitor UO (delay can lead to oedema that obstructs visualisation and catheterisation of urethra)
N.B: sharp surgical debridement for full thickness burns only performed 72 HOURS AFTER when burns fully demarcated (e.g. partial thickness may progress to full thickness during that time)
Idiopathic intracranial hypertension in children
VISIONAL ABNORMALITIES most prominent in prepubertal children (CF headaches in obese women)
Papilloedema leading to blurry vision and ENLARGED PHYSIOLOGIC BLIND SPOT (no rods/cones over area of optic nerve)
CN VI esp affected in children (diplopia and impaired eye abduction)
JVP waveform: Cannon A waves
JVP waveform: right atrial haemodynamics throughout cardiac cycle
Cannon A waves: intermittent, prominent A waves caused by surge in JVP that occurs due to RA contraction against closed tricuspid valve
Indicative of cardiac arrhythmia involving ATRIOVENTRICULAR DISSOCIATION (VT, complete AV block)
N.B:
ACxVy (A = RA contraction; C = RV contraction; V = peak of RA filling)
Absent A wave = AF
Prominent V wave & absent x descent = tricuspid regurg
Flattened y descent = cardiac tamponade
Achilles tendinopathy mx
Acute: activity mod, NSAIDs, ice
Chronic: eccentric calf-strengthening resistance exercises
Acute salicylate tox presentation
N/V, hyperventilation, HYPERTHERMIA (from HAGMA. leading to impaired aerobic resp so LACTIC ACIDOSIS (because gluconeogenesis impaired) and hyperthermia (byproducts of energy production))
ALTERED MENTAL STATUS
Septic abortion
Rfs: Retained POC from:
elective abortion w nonsterile technique
missed or incomplete abortion (rare)
Fever, chills, abdo pain
Sanguinopurulent malodorous vag discharge
Boggy, tender uterus; dilated cervix
Pelvic USS: retained POC; thick endometrial stripe
Mx:
IV fluids
Broad spectrum Abx
SUCTION CURRETAGE for uterine evacuation to remove nidus of infection
(Hysterectomy if pelvic abscess or condition does not improve after suction curretage and 48hrs of abx)
Drowning resp complication
ARDS
Aspirated liquid causes hypoxemia and can wash out pulm surfactant leading to ARDS
ARDS can develop INSIDIOUSLY so CARDIOPULM MONITORING required for at least 8 hours in all pts with a draining event, even if asx
Human factors engineering (HFE) design systems
Based on expected human behaviours to reduce errors
The most effective type involves PHYSICAL CHANGES that facilitate safe action w/o human effort and eliminate poss of error
e.g. epidural solution bags incompatible with peripheral IV catheters
Less effective HFE designs incorporate physical design changes but have a greater reliance on human effort (e.g. visual cues on bags)
Uterine inversion
Uterine fundus inverts and prolapses through cervix or vag after delivery
Firm, rounded mass protruding through cervix or vag
Likely occurs due to excessive fundal pressure and TRACTION ON UC prior to placental sep -> cord avulsion
Fundus no longer palpable transabd
Severe abdo pain and heavy vag bleeding w poss hemorrhagic shock
Mx: discontinuation of uterotonics (e.g. oxy) and IMMEDIATE MANUAL REPLACEMENT OF UTERUS to prevent exsanguination
If unsuccessful, uterine relaxants and laparotomy
Mag tox
Mild: nausea, flushing, headache, hyporeflexia
Mod: areflexia, hypocalcaemia, somnolence
Severe: resp paralysis, cardiac arrest
Common rf: renal insuff (as mag excreted by kidneys)
Tx: stop mag
Give IV calcium gluconate bolus
N.B: MgSO4 given to prevent eclamptic seizures and also for fetal neuroprotection at under 32 weeks gest (decrease risk for cerebral palsy)
M/c cause of MR in developed countries?
MVP
Occurs due to myxomatous degen of mitral valve leaflets and chordae causing mid-systolic click followed by mid-late systolic murmur
Interstitial cystitis
Aka painful bladder syndrome
Pain exacerbated by bladder filling and relieved by voiding
May also have dyspareunia and urinary frequency/urgency
More common in women; assoc w psych and pain disorders (e.g. fibromyalgia)
Rett syndrome
Period of normal dvp followed by regression of speech, loss of purposeful hand use (e.g. twisting fingers), stereotypical mvts, gait disturbance
DECELERATION IN HEAD GROWTH (microcephaly), BREATHING ABNORMALITIES (alt hyper/hypoventilation esp during periods of heightened emotion), autistic behaviours and seizures
SAAG
> = 1.1 indicates PORTAL HTN (cirrhosis, HF)
↑ Protein levels (> 2.5 g/dL)
Right heart failure
Early Budd-Chiari syndrome
↓ Protein levels (< 2.5 g/dL)
Cirrhosis
Severe liver metastases
Late Budd-Chiari syndrome
<1.1 indicates no portal HTN (malignancy, TB, nephrotic syndome, pancreatitis)
↑ Protein levels (> 2.5 g/dL)
Peritoneal carcinomatosis
Pancreatitis
Tuberculosis
Chylous ascites (not secondary to cirrhosis)
↓ Protein levels (< 2.5 g/dL)
Nephrotic syndrome
Severe malnutrition
Mediastinal masses
Characterised according to location
Anterior: thymoma, lymphoma, germ cell tumours, thyroid tissue (ectopic, substernal goiter)
Middle: lymphadenopathy (sarcoid, lung ca), lymphoma, benign cyst masses (pericardial cysts, BRONCHOGENIC CYST*), vasc masses, oes tumours
Posterior: neurogenic tumours (schwannoma, neurofibroma), meningocele, spinal masses (metastases), lymphoma
*arise from anomalous budding of foregut
infancy/adulthood: may become sx with chest discomfort and recurrent coughing/frequent resp infections
CT chest w IV to confirm
Premature adrenarche
More common in OBESE children
Early activation of adrenal androgens
Precocious dvp of pubic and axillary hair, acne and body odour in child with normal bone age
CF CAH: advanced bone age due to much higher levels of androgens
Shiga toxin E coli
Food borne pathogen (eg contaminated beef) causes inflammatory diarrhoea
Stools initially watery then become bloody
Most pts AFEBRILE (if fever, consider other pathogens)
Signs of uteroplacental insufficiency
Late decelerations on non-stress test
OLIGOHYDRAMNIOS on USS (single deepest pocket <2cm) because blood shunted from kidney (which produces amniotic fluid) to brain
Late (>= 41wks) or post-term (>= 42wks) preg plus one of above: IMMEDIATE DELIVERY due to risk of intrauterine fetal demise
If reactive non-stress test and/or vertex pos -> induction of labour
If abnormal fetal heart rate tracings (e.g. late decelerations) or fetal malpresentation (e.g. breech) -> C section
N.B: amnioinfusion done if variable decelerations (which occur 2 to oligohydramnios from ROM and subsequent cord compression)
Nonstress test
Performed for preg at risk for fetal hypoxemia, acidemia and/or demise or for decreased fetal mvts
Reactive vs non reactive
Reactive:
Baseline of 110 to 160/min
Mod variability (6-25/min)
>= 2 accelerations in 20 mins, each peaking >=15/min above baseline and lasting >= 15sec
Nonreactive:
Does not meet criteria for reactive
Concerning for fetal hypoxemia and acidemia
M/c cause of nonreactive is benign: QUIET FETAL SLEEP CYCLE (lasts <= 40min)
Therefore nonreactive nonstress test extended (40-120min) to ensure that fetal activity outside of sleep noted
PICC line DVT
Increases risk of upper extremity DVT
Risk highest in hosp pts, esp those w malignancy or hypercoag state
Arm swelling, erythema and pain
Dx: DUPLEX USS
Tx: 3 mo anticoag
Complicated vs uncomplicated parapneumonic effusions
Complicated: bacterial invasion of pleural space, requires drainage w chest tube in addition to abx
Pos pleural fluid gram stain/culture dx of complicated effusion and require CHEST TUBE placement
Pleural fluid characteristics: pH <7.2, glucose <60, wbcs >50,000, LDH >1000
CF uncomplicated is sterile invasion of pleural space and opp figures to above. Only require abx
Single brain abscess
Usually results from direct extension of an adjacent infection (OM, sinusitis, dental infection)
VIRIDANS STREP & STAPH AUREUS 2 m/c isolated organisms
Headache, fever, focal neuro deficit, seizure
Brain imaging (CT/MRI): single ring-enhancing lesion with central necrosis
CF Rhizopus causes nectroic and highly destructive lesions and occur in pts w DM or severe immunocompromise
Infected pancreatic necrosis
Worsening abdo pain, unstable vital signs or signs of infection 7-10d after onset of acute necrotising pancreatitis
CT ABDO: gas within pancreatic necrotic collection
Cerebral vein and venous sinus thrombosis presentation
Variable
Comb of headache, increased ICP, seizures and/or focal deficits
N.B: venous sinuses’ dual anatomic function: CSF drainage and cerebral venous blood return
So raised ICP signs/sx, impeded blood return leading to venous stroke/hemorrhage
Dx clinical and prothrombotic rfs (e.g. OCP use) often present
Brain MRI w MR venography dx
Tx anticoag w heparin (continue even if hemorrhage as risk of worsening hemorrhage low)
CF ICH: focal neuro signs not present
Retropharyngeal abscess in children
Fever, dysphagia, muffled voice and pain w neck extension
Lateral neck soft tissue X ray: WIDENED PREVERTEBRAL SPACE
Mx: airway protection, IV abx, +/- surgical drainage
Transverse myelitis
Immune med destruction of spinal cord
Often post infectious (molecular mimicry)
Bilateral motor weakness, early flaccid (LMN) then late spastic (UMN)
Bilateral sensory dysf (ALL modalities CF infarction of ant spinal artery: vib and proprioception spared, loss of pain and temp sensation below present)
DISTINCT SENSORY LEVEL
Aut dysf (bladder/bowel)
MRI spine: no compressive lesion, T2 hyperintensity
LP: raised WBCs, raised IgG index
Tx: high dose IV glucocorticoids
Plasmapheresis
N.B: GBS aka acute inflam demyelinating polyneuropathy: no UMN signs and no distinct sensory level
N.B. 2: presentations of MS include: transverse myelitis, INO, optic neuritis and cerebellar dysfunction. These initial presentations may not be disseminated in time.
Metartasus adductus vs clubfoot
MA (m/c congenital foot deformity): medial deviation of forefoot, neutral position of hindfoot, flexible pos typical. Tx: REASSURANCE
Clubfoot: medial/upward deviation of forefoot & hindfoot, hyperplantar flexion of foot, rigid pos typical (congenital clubfoot). Tx: SERIAL MANIPULATION & CASTING; surgery for refractory cases
Telogen effluvium
Acute, diffuse, noninflam hair loss
Triggered by stressful event, e.g. weight loss, preg, major illness/surgery, or psych trauma
Widespread thinning of hair but scalp and hair shafts normal
Self-lim disorder, takes up to 1 year to resolve
Penetrating chest trauma with signs of shock
HEMORRHAGIC until proven otherwise
Tx: TUBE THORACOSTOMY
EMERGENT THORACOTOMY for extreme bleeding incl:
Initial bloody output >1500ml
Persistent hemorrhage or continuous blood transfusion to maintain HD stability
PLT dysf in CKD
M/c cause of abnormal haemostasis (easy bruising, nonpalpable purpura)
PT and PTT normal; PLT count normal or slightly low
Pathophys: uraemia -> elevated urea -> arginine (substrate for urea production) and its precursors shunted to diff pathway -> increased NO -> inhibit primary hemostasis via decreased PLT adhesion, activation and aggregation
Psychogenic pseudosyncope
Type of CONVERSION DISORDER
Assoc w:
Prolonged LOC e.g. 20 mins vs 1-2 min in syncope
Absence of objective findings (e.g. pallow, sweating, abnormal vital signs)
Pt’s awareness of sx during syncopal episode e.g. felt head throbbing while on floor
Postop pneumonia: postop measures
INCENTIVE SPIROMETRY
Deep breathing exercises
N.B: prophylactic abx prior to surgery only given to pts w preexisting lung condition
IRB approval and informed consent
All research involving human participants require IRB approval
If using secondary data (e.g. medical charts) and limited risk to participants, informed consent NOT needed
Fragile X syndrome life expectancy
Normal (CF Down’s)
Long face, prominent chin and forehead, protruding ears, joint hypermobility and macrocephaly
Assoc dvp delays and ADHD common
Heat exhaustion vs exertional heat stroke
HE: hyperthermia (<= 40C) assoc w weakness, dizziness, profuse sweating, headache and/or nausea
NORMAL MENTATION (CF EHS)
Mx: cooling (e.g. cold water shower) and oral hydration w salt-containing fluids
Pseudothrombocytopenia
Lab error characterised by PLT aggregation in vitro
Peripheral smear: large clumps of PLTs
No further investigations needed
Adolescent girl w high suspicion for fibroadenoma
OBSERVATION & REEXAMINATION after completion of full menstrual cycle (e.g. 6 weeks) as oes sensitive and size/tenderness change w menses
If enlarging after 6 weeks then eval w breast USS
If static at 6 weeks, continue to follow up every 6-12 months for 1-2 years to evaluate for tumour growth and exclude malignancy/phyllodes tumour
LTOT criteria in COPD
PaO2 <= 55 or SaO2 <=88% RA
PaO2 <=59 or SaO2 <=89% in pts w cor pulmonale, evidence of RH strain or Hct > 55%
Dialysis related amyloidosis
Inadequate clearance of beta 2 microglobulin despite dialysis
Prevalence increases w age and dialysis duration
Predilection for OSTEOARTICULAR structures presenting as:
SCAPULOHUMERAL PERIARTHRITIS (shoulder pain/hypertrophy)
carpal tunnel syndrome
bone cysts
PCP: when to give corticosteroids (in addition to TMP-SMX)?
PaO2 <= 70
Alveolar-arterial grad >= 35
or Pulse ox < 92% on RA
to reduce risk of resp decompensation
M/c cause of acute pancreatitis in otherwise healthy child?
BILIARY CYST (dilation of biliary tree, most commonly involves CBD)
Asx: incidental finding on imaging
Sx: RUQ pain, jaundice and/or RUQ mass
Acute complications: pancreatitis, cholangitis and stone formation
Why increase risk of pancreatitis? Due to abnormally long pancreatobiliary junction so predisposes to obstruction, leading to reflux of pancreatic fluid as well as cholestasis (conj hyperbili)
M/c lung ca in young nonsmokers?
BRONCHIAL CARCINOID tumours
Arise in prox airway, causing airway obstruction (dyspnea, wheezing, postobstructive pneumonia) or hemoptysis
CT scan w contrast: avidly enhancing (hypervasc) mass w an endobronchial component
CF small cell: bulky hilar and mediastinal mass
squamous cell: central cavitation (heterogeneous density) due to tumour necrosis
Rare cause of delayed passage of meconium (>48hr)?
CONGENITAL HYPOTHYROIDISM
Constipation, large fontanelle (delayed bony maturation), hypotonia and poor feeding or growth
IE pathogens
Following dental/resp tract procedures: VIRIDANS STREP (e.g. Strep sanguinis, mitis, mutans, milleri). Causes late-onset IE of prosthetic valve (>1 year after valve placement). CF staph epidermidis causes early-onset IE of prosthetic valve (<1 year after valve placement)
Manipulation of infected areas of GI/GU tract: ENTEROCOCCUS
Following skin/soft tissue infection or in IVDU: STAPH AUREUS (acute) or coag neg Staph (STAPH EPIDERMIDIS)
OSA in children
Nighttime snoring and GASPING FOR AIR
Caused by ADENOTONSILLAR HYPERTROPHY (CF obesity in adults)
Open mouth breathing during day (nasal obstruction secondary to adenoid hypertrophy)
Tx: tonsillectomy and adenoidectomy
Selective mutism in children
Verbal at home but refuse to speak in specific social settings e.g. school
Considered an anxiety disorder and should be tx early to prevent long-term educational and social impairment
CBT w graded exposure to social situations, family therapy or SSRI
CVC placement complications
Placed in internal jugular vein (using USS) or subclavian vein (anatomic landmark)
CVC tip ideal placement is in lower SVC
Tip placement in smaller veins -> VENOUS PERFORATION
Inappropriate tip placement -> PNEUMOTHORAX or myocardial perf leading to PERICARDIAL TAMPONADE
ARTERIAL PUNCTURE (e.g. subclavian) also risk esp if done without USS
PORTABLE CXR should be performed immediately post insertion (except if completely uncomplicated insertion)
Chronic radiation proctitis
Obliterative endarteritis and submucosal fibrosis
Leading to ANORECTAL STICTURE formation, reduced rectal compliance, constipation and fecal intolerance
Chronic tissue hypoxia -> neovasc and telangiectasia -> hemorrhage
Vertebrobasilar insufficiency
M/c due to ATHEROSCLEROTIC DISEASE
Results in transient ischaemia of regions supplied by VB system (brainstem, cerebellum, occipital lobes) when cerebral perfusion is further reduced (e.g. standing up)
Dizziness/vertigo, brainstem sx (diplopia, dysarthria) and bilateral motor and/or sensory sx
CT angio head/neck dx
Hemoptysis initial mx
Establish adequate patent airway
Maintain adequate ventilation and gas exchange
Ensure HD stability
Place pt w bleeding lung in dependent pos (lateral pos)
BRONCHOSCOPY to identify site and attempt early therapeutic intervention
Surgery if ongoing unilateral bleeding despite initial bronchoscopy and/or pulm artery embolisation
N.B: massive hemoptysis = >600ml of blood over 24 hr period or bleeding rate > 100ml/hr
Achilles tendinopathy location of tenderness
2-6cm prox to insertion of tendon on calcaneus
CF sc calcaneus bursitis: at calcaneal prominence (Achilles tendon insertion site)
Myasthenic crisis
Precipitating factors:
infection or surgery
preg or childbirth
tapering of immunosuppressive meds
meds (aminoglycosides, beta blocker)
Increased generalised and oropharyngeal weakness
resp insufficiency/dyspnea
INTUBATION for deteriorating resp status
PLASMAPHARESIS or IVIG as well as CORTICOSTEROIDS
N.B: do NOT increase pyridostigmine dose as it is an cholinomimetic so causes increased secretions, worsening resp status
Multifocal atrial tachycardia
SVT
Distinct P waves with >= 3 different P wave morphologies, atrial rate > 100/min and irregular rhythm
Precipitated by acute resp illness in pts w underlying lung disease
Tx: correct underlying inciting disturbance
Bariatric surgery indications
BMI >= 40
or BMI >= 35 and additional weight-related comorbidity
Weight loss med indicated for pts w BMI >= 30 or those w BMI 25-29.9 and weight related complications
Both interventions may be pursued concurrently
Malignant pericardial effusion
Large and prone to recurrence
Acute mx w pericardiocentesis
Prevention of reaccumulation, either by PERICARDIAL WINDOW or PROLONGED CATHETER DRAINAGE
First step in tick mx
Removal with small forceps as close to skin surface as possible
Pull firmly upwards without twisting
N.B: body of tick should not be squeezed or crushed as this can expel secretions into the wound and increase transmission risk
If deer tick attached for >= 36 hours, prophylactic single dose of DOXY within 3d of tick removal
CF abx prophylaxis not effective for anaplasmosis and babesiosis
Pyromania
Intentional and repeated fire setting with no obvious motive
Pts have fascination with fire and deliberately start fires to reduce tension and feel pleasure or relief
Rfs for C diff infection
Abx use, CYTOTOXIC CHEMO, recent hospitalisations, advanced age (>65)
Stool PCR dx
C diff: watery diarrhoea, abdo cramps, nausea, fever, LEUKOCYTOSIS
Hepatorenal syndrome
Rfs: advanced cirrhosis w portal HTN
Acute liver failure, severe alcoholic hepatitis
Patho: splanchnic vasodilation (from release of vasodilators e.g. NO) -> renal hypoperfusion -> RAAS activation -> overwhelming renal vasoconstriction -> AKI
Precipitants: GI bleed, infection (e.g. SBP)
N.B: SBP tx = cefotaxime;
prophylaxis = fluoroquinolones
Dx: bland urinalysis (no red cells, casts or protein)
very low urine Na (<10)
exclusion of other causes of AKI
NO IMPROVEMENT W TRIAL OF VOL EXPANSION
Tx: albumin + splanchnic vasoconstrictors (terlipressin, norepi, or midodrine + octreotide)
liver transplantation curative
N.B: cirrhosis (not advanced): release of prostaglandins -> vasodilation -> ascites and ADH release -> H20 retention -> hyponatraemia; hypokalaemia as well due to vomiting/diarrhoea/diuretic use
M/c cause of congenital bone marrow failure
FANCONI ANEMIA
Defective DNA repair impairs normal HSCT production and predisposes to malignancy (e.g. leukaemia)
Pancytopenia, short stature, HYPOPLASTIC THUMBS, ABNORMAL SKIN PIGMENTATION
Gabapentin toxicity
Encephalopathy and myoclonus, relieve on discontinuation
Other causes of myoclonus:
Physiologic (sleep transitions, hiccups)
Infectious/metabolic (meningitis, liver failure)
Neurodegenerative disease (Parkinson’s, CJD)
Seizure disorder
Med side effects (serotonergics, anticonvulsants)
Female and male pattern hair loss
Follicular miniaturisation
Men: effect of DHT on genetically suspectible follicles
Women: isolated/idiopathic (most cases) or due to hyperandrogenism (e.g. PCOS)
Men: vertex, frontal hairline, temporal areas
Women: vertex, frontal scalp (spares hairline)
Tx men: oral finasteride, top minoxidil
Women: top minoxidil
Chemo causes what type of amenorrhoea?
Hypergonadotropic hypogonadism (primary ovarian insufficiency)
Recommendations for intubated pts to reduce risk for VAP
HEAD OF BED ELEVATION AT 30-45 degrees
Suction of subglottic secretions
Min of pt transport
Limited use of gastric acid inhibitors (to reduce burden of microorganisms in gastric secretions)
Causes of acute cholangitis?
Acute cholangitis: infection of extrahepatic biliary system, occurs due to biliary obstruction (bile stone, ca, STRICTURE e.g. PSC)
Vit K deficiency
Due to inadequate dietary intake (e.g. NPO), intestinal malabsorption and hepatocellular disease
An acutely ill pt with underlying liver disease can become vit K def in 7-10d
Labs: prolonged PT followed by prolonged PTT
CF DIC: prolonged PT, PTT but low platelets, low fibrinogen, raised D dimer etc
QI methodologies
Lean: identification and removal of inefficiency and waste in a CURRENT workflow (CF failure modes and effects analysis: prospective so identifies POTENTIAL errors)
Six Sigma: near elimination of defects through STATISTICALLY DRIVEN process improvement
Model for improvement: incremental cycles of planning, piloting, assessing and refining intervention to achieve goal (PDSA cycle)
Change management: engaging personnel to adopt innovation & implement organisational changes
Acute painless vision loss
Central retinal artery occlusion
Central retinal vein occlusion
Retinal detachment: floaters, photopsia, progressive visual field defect; funds w vitreous hemorrhage and marked elevation of retina; surgical correction
Vitreous hemorrhage: hazy vision +- red hue or vision loss, floaters/shadows; PROLIFERATIVE DIABETIC RETINOPATHY rf; decreased/absent red reflex, RBCs/floating debris in vitreous, obscured view of fundus; bed rest, HOB elevation (30-45 deg), photocoag/vitrectomy in some cases
Normal internal genitalia, external virilisation and undetectable serum estrogen levels in F pt?
Aromatase deficiency
CF CAH: classic type (21 alpha hydroxylase def): ambiguous ext genitalia at birth, normal female internal repro organs, hyponatremia; non-classic type: later in life: primary amenorrhoea and virilisation at puberty but normal genitalia at birth
Anti-NMDA R encephalitis assoc w what in young women?
M/c in young women (median age 21)
Assoc w OVARIAN TERATOMA
Exercise-assoc hyponatraemia
Due to combination of EXCESSIVE FLUID INTAKE and NONOSMOTICALLY MEDIATED RELEASE OF INAPPROPRIATELY HIGH LEVELS OF ADH
In severe cases, pts may experience seizures, profound confusion and even death
Other nonosmotic causes of ADH release:
nausea, pain, physical or emotional stress, hypotension, hypovol, hypoxia, hypoglycaemia
N.B: high altitude cerebral edema is rare and accompanied with severe headache and concomitant pulm oed
Chikungunya virus infection
Carribean, central/South America, Africa, Asia
Aedes mosquito
Incubation: 3-7d
HIGH FEVER, SEVERE POLYARTHRALGIA
Headache, conjunctivitis, myalgia, MP diffuse rash (CF SLE sun-exposed eg malar)
Lymphopenia, thrombocytopenia, transaminitis (like Ehrilichiosis)
Supportive care
Chronic arthralgia frequently occurs (MTX may be needed)
Buproprion useful for MDD with what features?
Low energy, impaired concentration, hypersomnia and weight gain
As it has MILD STIMULANT PROPERTIES
Can also be used for SMOKING CESSATION
Pregnancy and exercise
Absolute CIs:
amniotic fluid leak
cervical insufficiency
multiple gestation
placental abruption or previa
premature labor
preeclampsia/GHTN
severe heart or lung disease
Antepartum fetal surveillance
BPP= Nonstress test plus USS measuring:
amniotic fluid vol
fetal breathing mvt
fetal mvt
fetal tone 2 points per cat if normal, 0 if abnormal. normal = 8 or 10
N.B: if NST is abnormal (< 2 accelerations / recurrent variable/late decelerations) indicative of either fetal sleep cycle (benign cause) or fetal hypoxia/acidemia. Further eval w BPP
Contraction stress test (FHR monitoring during contractions) used to assess fetal wellbeing if BPP equivocal (6/10) . Abnormal if late decelerations w >50% contractions
Umbilical artery doppler USS used to monitor FGR (est FW < 10th centile)
Hyperventilation syndrome tx
Reassurance w BREATHING RETRAINING (abdo diaphragmatic breathing)
If not improving, small dose of benzo e.g. lorazepam
breathing into paper bag NOT recommended as can cause hypoxia
Uric acid kidney stones tx
ALKALINISATION of urine (POTASSIUM CITRATE)
Reduction of uric acid production (low-purine diet, allopurinol)
N.B: thiazide diuretics decrease uric acid secretion but can lower urine pH so making uric acid stones more likely to form
Displaced supracondylar fracture of humerus
FOOSH w post displacement of distal humerus fragment
Ant displaced prox humerus fragment can entrap BRACHIAL ARTERY & MEDIAN NERVE which pass anterior to the humerus
N.B: ulnar nerve injury from supracondylar fracture from FLEXED elbow (not hyperextended)
Asthma exacerbation: reduced breath sounds, dullness to percussion, trach deviation to affected side?
Mucous hypersecretion (dark-coloured sputum) leading to formation of MUCOUS PLUG in airways
Leading to ATELECTASIS
N.B: trach dev away from affected side if large pleural effusion/TP
Which asx murmurs require echo?
DIASTOLIC & CONTINUOUS usually due to pathological cause so require TTE
CF midsystolic murmurs in young asx pts usually benign no need for echo
Abrupt cessation of short acting benzos e.g. alprazolam causes?
Sig withdrawal sx
Incl risk for GENERALISED SEIZURES & CONFUSION
Also tremours, anxiety, perceptual disturbances, psychosis
Food-protein induced allergic proctocolitis
Non-IgE mediated reaction to a protein (typically COW’S MILK/SOY)
BLOODY STOOLS in well-appearing infants (m/c age 1-4 weeks)
Rf for ABRUPTIO PLACENTAE?
UTERINE OVERDISTENSION (twin gest, severe polyhydramnios) because sudden loss of amniotic fluid leads to uterine decompression causing placental hemorrhage and separation
Rigid, tender uterus and uterine irritability (high-frequency contractions) because bleeding increases intrauterine pressure
Other rfs: HTN, pre-eclampsia, cocaine, tobacco, abdo trauma, prior placental abruption
Mechanism for kidneys compensating for primary met ac?
Increase bicarb reabsorption (in prox tubule: carbonic anhydrase enzyme) and H+ excretion
Increased bicarb reabsorp causes increased Cl- excretion (in collecting duct) (to maintain total body electronegative balance)
Most of excreted H+ in form of NH4+ or H2PO4-
(Resp compensation w hyperventilation is main compensation for primary met ac)
Acute interstitial nephritis triad
FEVER, MP RASH, AKI (+/- arthralgias)
Pyruia, HM, white cell casts
Eosinophilia, urinary eosinophils
Drugs: penicillins, TMP-SMX, NSAIDS, cephalosporins
Neonate w cholestasis (jaundice, acholic stools, dark urine) and mass in RUQ (subhepatic)
BILIARY CYST
(Biliary atresia = absent or abnormal GB)
Late-look (Neyman) bias seen in which study?
Cross-sectional
Biased in favour of longer-lasting and milder conditions as cross-sectional is a snapshot so misses out acute and more severe conditions
CF ecological fallacy is when you are analysing country-level data and then making inferences on individuals
Hyperextension injuries in elderly pts can cause what?
CENTRAL CORD SYNDROME
(esp if elderly pts have cervical spondylosis)
Loss of pain and temp sensation (decussating fibers of spinothalamic tract) in upper extremities and disproportionate upper extremity weakness (with larger lesions affecting lateral corticospinal tracts)
Another classic (altho slowly progressive) cause of CCS is syringomyelia
Mixed cyroglobulinemia syndrome
Small-vessel vasculitis that causes PALPABLE PURPURA (CF TTP nonpalpable petechial rash), GLOMERULONEPHRITIS, ARTHRALGIAS & PERI NEUROPATHY
Labs: cryoglobins, RHEUMATOID FACTOR (due to IgM binding to Fc region of IgG). Immune complexes activate complement so HYPOCOMPLEMENTEMIA and deposit in small vessels of organs causing the vasculitis
CHRONIC HEP C m/c cause, check serologies in all cases
False labour
Mild, irregular contractions that cause no cervical change and ultimately resolve without intervention
Discharge home w labour precautions
Acute calculous cholecystitis tx
PIPERACILLIN-TAZOBACTAM (due to high risk for secondary bacterial infection w aerobic/anaerobic pathogens) while awaiting cholecystectomy
Language disorder vs specific learning disorder
Language disorder: persistent difficulties in acquisition and use of language due to deficits in comprehension and/or production
Specific learning disorder: requires use of standardised achievement testing to dx but language disorder is a rf for SLD
AVN features
Groin pain on weight bearing
Pain on hip ABDUCTION & INT ROTATION
No erythema, swelling or point tenderness
NORMAL WBC
NORMAL ESR & CRP
CRESCENT SIGN seen in advanced stage (X ray may be normal initially)
MRI most sensitive modality
Pathologic murmur characteristics vs benign
Pathologic:
Holosystolic (could be VSD)/diastolic
Harsh
Grade >= 3 intensity
Intensity persists w Valsalva & standing
Loud, fixed or single S2
Hepatomegaly
ECG & ECHO
Benign:
Early or midsystolic
Musical or vib
Grade 1-2 intensity
Decreases or disappears w Valsalva & standing (N.B: venous hum is benign but increases w standing)
Normal S1 & S2
REASSURANCE
Dupuytren contracture
Rfs:
Male, age >50, FHx
DM
Tobacco and alcohol
MANUAL WORK (e.g. gardening)
Thickening of palmar fascia at 3rd, 4th & 5th digits
Discrete FIBROTIC NODULES & CORDS along flexor tendons near distal palmar crease
Gradual decrease in extension of digits
Mod of hand tools
Needle aponeurotomy
Intralesional glucocorticoid injection
Surgery for contractures or advanced disease
Bacterial aspiration pneumonia mx
No empyema/lung abscess: treat for CAP (ie pen tolerant: amox/co-amox (if higher risk) & macrolide/doxy; if pen allergic: cephalosporin & macrolide/doxy; if cephalosporin intolerant: fluoroquinolone)
Empyema/lung abscess present: extend coverage to include ANAEROBES (AMPICILLIN-SULBACTAM)
Sedative-hypnotic overdose
E.g. combined effects of etoh & benzos
Benzo OD on its own: altered mental status, ataxia, slurred speech
When VITAL SIGN DERANGEMENT OR RESP DEPRESSION seen, CO-INGESTION with other sedative-hypnotics or CNS depressants should be considered
Torus palatinus
Benign bony growth (exostosis) on midline suture of hard palate
Congenital or dvp later in life
Chronic and asx
Surgery if mass becomes sx, interefers w speech/eating/denture fitting etc
Infective endocarditis abx tx
Depends on condition of valve (prosthetic or native) and prior hx of IVDU
Native: VANCO
Once organisms identified on blood cultures than abx can be changed accordingly
Infantile hemangioma mx
Observation for most lesions
PROPRANOLO for high risk e.g.
Large, facial, segmental, rapidly growing
Periorbital
Hepatic
Subglottic
Distal symmetric polyneuropathy triggers
DM (diabetic neuropathy)
Long standing HIV infection
Uraemia
Meds (FLUOROQUINOLONES, METRONIDAZOLE)
Chemo (cisplatin, paclitaxel)
Toxicity (alcohol abuse, heavy metal exposure)
Proportionality ethical principle
Ensure that methods used to achieve a worthwhile goal are necessary, appropriate and not excessive
Congenital melanocytic nevus
First few months of life as hyperpigmented patches w an INCREASED DENSITY OF HAIR FOLLICLES
CF nevus simplex (eyelids, neck, fade w time) and flammeus (port wine stains, does not fade with time, unilateral on face) are flat, blanchable and erythematous vasc birthmarks
Constrictive pericarditis
Etiology:
Recurrent idiopathic or viral pericarditis
Cardiac surgery or radiation therapy
Tuberculous pericarditis
Fatigue, dyspnoea on exertion
Peripheral oedema, ascites, hepatic congestion
Pericardial knock in early diastole
JVD w positive Kussmaul sign and prominent y descent
ECG: low voltage QRS complexes
CXR/CT: PERICARDIAL CALCIFICATION
Echo: BIATRIAL ENLARGEMENT, NORMAL ventricular wall thickness and cavity size
CF cardiac amyloidosis: ventricular Wall thickness present and no calcified pericardium
Physiologic anaemia of infancy
Asx condition
Normal decrease in Hb with a nadir at age 2-3 mo
Normocytic anaemia with low to normal retic count
Transient downregulation of EPO due to increased tissue oxygenation after birth
Anaemia resolves with increased erythropoietin drive after age 3 mo
Molluscum tx in adults
Cryotherapy w liquid nitrogen
Curettage
Topical therapy (cantharidin, podophyllotoxin)
Pts w GDM required regular what?
Non-stress tests beginning from 3rd trimester due to increased risk for stillbirth
Emphysematous cholecystitis
Life-threatening form of acute cholecystitis
Fever, RUQ pain, N/V
Crepitus in abdo wall adjacent to GB
Rfs: DM, vasc compromise, immunosuppression
Air-fluid levels in GB, GASS IN GB WALL
Cultures w gas-forming Clostridioides, E coli
Unconj hyperbili, mildly elevated aminotransferases (CF acute cholecystitis: raised ALP, conj bili)
Emergency cholecystectomy
Broad spectrum abx w Clostriodes coverage (tazosin)
Effects of positioning in a pt w pneumonia
Alveolar consolidation causes V/Q mismatch from localised intrapulm shunting
Pneumonia down -> increased perfusion of poorly ventilated region -> increased V/Q mismatch and worsened hypoxaemia
Pneumonia up -> decreased perfusion of poorly ventilated region -> decreased V/Q mismatch and improved hypoxaemia
Blood products in haemorrhagic shock
Administer early in ratio of 1:1:1 (FFP/packed red cells/platelets) to reduce coagulopathy (major mortality in trauma pts)
Mixed connective tissue disease
Clinical features of SLE, SS, RA and polymyositis that appear sequentially
Important manifestations: Raynauds, swelling of fingers and hands, inflam arthritis and myositis
AUTOANTIBODIES for U1 RIBONUCLEOPROTEIN
Hodgkin lymphoma prognosis, recurrence, second malignancy
Usually curable w chemo and radiation
Risk of death sig elevated in those getting treatment compared to age-matched pop
For first 8-10 years, most deaths due to HL relapse; thereafter most due to second malignancy and cardiovascular disease
Can parents refuse life-saving treatment for their child in emergency situations?
No
Mag tox
Causes: renal impairment, increased mag intake
Neuromuscular: low reflexes, paralysis, weakness, resp failure
CVS: hypotension, brady, conduction defects
Electrolyte: hypoca
Discontinue mag meds
IV fluids +- loop diuretics
IV ca for NM and CVS sx
HD in severe renal impairment
Left ventricular vs right ventricular MI
Left:
pulm oed, S3 & S4
ischaemic changes in ant, lateral or inf leads
increased LV and RV preload
increased SVR
Mx: fluid restriction (due to pulm oed), preload and afterload reduction, reperfusion therapy
Right:
clear lungs & JVD, marked hypotension
atypical epigastric pain, nausea, no SOB
inf ischaemic changes, ST elevation in V4R*, bradyarrhythmias (due to RCA occlusion so infarct to SAN/AVN)
increased RV preload, decreased LV preload
increased SVR
Mx: *RV involvement eval w right-sided precordial ECG, fluid resuscitation, avoid preload reduction, reperfusion therapy
N.B: cardiogenic shock: dobutamine/norepinephrine/ dopamine
Endometrioma USS findings
e.g. endometrioma may be on ovary
UNILOCULAR, HYPOECHOIC adnexal mass on USS
CF tuboovarian abscess: complex multicystic adnexal mass w enhancing rims
DVT and absolute CI to anticoag. Mx?
IVC FILTER
Lupus anticoagulant (anti-phospholipid abs) features
Prolonged PTT that fails to correct w MIXING TEST (combination w normal plasma)
Most pts w these autoantibodies are asx but can go on to develop APS
CF VWD: mixing test would correct PTT
IE: organism assoc w nosocomial UTI
ENTEROCOCCI esp Enterococcus faecalis
Multidisciplinary rapid response teams
Provide clinical assessment and early intervention for hosp pts at high risk for clinical deterioration
Can support primary care teams and reduce in-hosp mortality rates
Necrotising (malignant) otitis externa
Rfs:
Eldery (age >60)
DM
Aural irrigation (cerumen removal)
Micro: PSEUDOMONAS AEURIGINOSA
Severe, unremitting ear pain (WORSE AT NIGHT & WITH CHEWING)
Deficits of lower CNs (VII, IX, X)
GRANULATION TISSUE in ext aud canal
Elevated ESR
IV cipro +- surgical debridement
High-grade squamous intraepithelial lesion Pap test requires?
IMMEDIATE COLPOSCOPY (even in preg pts) and biopsy of cervical abnormalities due to high risk of progression to cervical ca
Colposcopy identifies cervix under magnification and uses acetic acid to contrast and identify abnormal (ACETO-WHITE CHANGES) from normal cells, abnormal vessels (feature of high-grade) also become visible
Inadequate colposcopy -> endocervical curettage (invasive and deferred during preg due to high risk of miscarriage and preterm delivery)
Cervical biopsy performed during preg if high-risk lesion
HPV co-testing used if atypical squamous cell of undetermined sig and low-grade intraepi lesion
N.B: women >= 35 with ATYPICAL GLANDULAR CELLS on Pap test -> endometrial biopsy (in addition to colposcopy) as AGC can be caused by either cervical or endometrial ca
Endometrial biopsy if AGC and under 35 years of age but rfs for endometrial ca (obesity, anovulation)
N.B2: if atypical squamous cells or pos cytology/HPV then perform reflex triage testing (ie HPV testing if cytology pos or cytology testing if HPV pos)
Drug-induced rhabdo
Direct myotox: statins, fibrates, colchicine, ethanol, cocaine
Vasoconstrictive ischaemia: cocaine, amphetamines
Prolonged immobilisation (compressive ischaemia): ethanol, benzos, opiates
Management of chest pain due to cocaine use
BENZOS for BP and anxiety
ASPIRIN for inhibition of cocaine-induced PLT aggregation
Nitroglycerin & Ca channel blockers for vasoconstrictive pain
Immediate cardiac cath if indicated (STEMI)
Caution with: fibrinolysis (increase risk for ICH), beta blockers (increase risk for coronary vasoconstriction)
Acute bronchitis
Aetiology: preceding resp illness (90% viral)
Cough for >5d to 3 weeks (+- purulent sputum)
Absent systemic findings (fever/chills)
Wheezing or rhonchi, chest wall tenderness
Clinical dx, CXR only when pneumonia suspected
Symptomatic tx (NSAIDs/bronchodilators)
Abx NOT recommended
Intrapartum abx prophylaxis for GBS given to whom?
Unknown GBS status and any of the following rfs for vertical transmission:
Rupture of membranes for >= 18 hours
Intrapartum fever
Fetal prematurity (<37 weeks gest)
Brown Séquard syndrome
Hemisection of spinal cord
Ipsilateral hemiparesis and diminished proprioception, vib sensation and light touch at the level of the spinal cord injury and below
Contralateral diminished pain and temp sensation 1-2 LEVELS DISTAL TO THE CORD INJURY & BELOW
Paradoxical vocal cord movement (aka vocal cord dysfunction)
Episodic, inappropriate closing (adduction) of vocal cords during inspiration
Resulting in laryngeal obstruction and inspiratory stridor (CF exp wheezing in asthma, exp stridor in tracheomalacia)
Throat tightness and impaired inspiration
Triggers: strong smells, stress or exercise
Laryngoscopy dx (vocal cord adduction during inspiration)
Acute episodes tx: ask pt to SNIFF/PANT or NIV
Long-term mx: education and therapy w speech-language pathologist
Can present in ELITE ATHLETES & often mimics exercise-induced asthma
Arsenic poisoning
Binds to sulfhydryl groups
Disrupts cellular respiration and gluconeogenesis
Sources: pesticides/insecticides, contaminated water (esp from wells), pressure-treated wood (e.g. used in outdoor fences)
Acute: garlic breath, vomiting, watery diarrhoea, QTc prolongation, severe: PANCYTOPENIA, HEPATITIS
Chronic: hypo-hyperpigmentation, hyperkeratosis, stocking-glove neuropathy, Mees lines (horizontal striation of fingernails)
Dx: urine arsenic levels
Tx: DIMERCAPROL (British anti-Lewisite)
DMSA (succimer)
Is syphilis screened for in preg?
YES
UNIVERSAL at FIRST prenatal visit
3rd trimester and delivery (if high risk)
Frostbite
Superficial pallor and anaesthesia
Blistering, eschar formation
Deep tissue necrosis and mummification
Mx: RAPID REWARMING IN WATER BATH 37-39C
Analgesia & wound care
ANGIOGRAPHY/T99M SCAN to assess for thrombosis if rewarming unsuccessful, if thrombosis present then…
…Thrombolysis in severe, limb-threatening cases
Theophylline tox
Nonselective phosphodiesterase inhibitor, causes bronchodilation, used in COPD
Tox from decreased clearance of drug eg CYP450 inhibitors
CNS (tremour, seizure), CVS (tachyarrhythmia, hypotension) & GI (vom) sx
Primary ovarian insufficiency
Amenorrhoea at age <40
Hypoestrogenic sx (hot flashes)
Raised FSH
Low estrogen (hence no withdrawal bleed after progesterone withdrawal test)
Major causes:
Idiopathic
Turner syndrome
FRAGILE X SYNDROME (FMRI PREMUTATION leading to accelerated follicle depletion)
Autoimmune oophoritis
Anticancer drugs
Pelvic radiation
Galactosemia
N.B: levonorgestrel IUD can cause amenorrhoea by thinning endometrium; copper IUD causes heavy bleeding; both FSH normal
Is having imaginary friends normal in pre-school and school-aged children?
YES!
Represents form of creative play, aiding in dvp of social and emotional competence, as well as providing comfort in times of distress
Salmonella gastroenteritis: abx needed?
No as this is caused by nontyphoid subtype
Self-limited infection
Supportive mx
N.B: abx tx paradoxically assoc w EXTENDED TIME OF ASX CARRIAGE (due to disruption of gut microbiota which normally prevents it from colonising)
If higher risk of invasive disease, then abx warranted (extremes of age, immunocompromised, SCD, CV or sig joint disease, severe disease requiring hosp)
CF typhoidal requires abx due to serious complications (intestinal perforation, encephalopathy)
Mx of mammalian bites
Wound care: copious irrigation w saline
Debridement of dead tissue
Secondary intention healing
Imaging: radiographer if # or foreign body suspected
Infection mx: CO-AMOX if wound infected or high risk for infection:
PUNCTURE WOUND (e.g. cat bite)
Involvement of face, hand/foot, joint, genitalia
Immunocompromised
Primary closure (cosmetic reasons or involvement of deep MSK or vasc structures)
TETANUS prophylaxis if incompletely vaccinated or last dose >= 5 years ago
Rabies prophylaxis if high-risk animal cannot be quarantined/observed
N.B: oral flora of cats includes PASTEURELLA MULTOCIDA and anaerobes
Large VSD in children
Growth failure, easy fatigability and heart failure
Holosystolic murmur loudest at left lower sternal border and an APICAL DIASTOLIC RUMBLE due to increased blood flow across mitral valve
First febrile UTI in children
Age < 2: RBUS followed by VCUG if abnormal
Age >= 2: observation alone
Recurrent febrile UTIs: RBUS and VCUG
Type of gait in NPH
MAGNETIC GAIT: slow, wide-based steps as if feet stuck to ground
N.B: UMN signs may also occur in addition to triad
Dx confirmed w improved sx w large-vol LP (Miller Fisher test), MRI scan
VP shunting tx
N.B: secondary causes of NPH include SAH, meningitis, trauma causing scarring and destruction of arachnoid granulations
Diabetic foot ulcers: investigation
FOOT IMAGING (X ray, MRI) for all DFU that are:
deep (exposed bone)
long-standing (> 7-14d)
large (>=2 cm)
raised ESR/CRP
adjacent soft tissue infection
Initial mx of priapism
ASPIRATION OF BLOOD from corpus cavernosa
Intracavernous injection of PHENYLEPHRINE
ARDS: mx
Mechanical ventilation:
1. Lung protection: limit alveolar distending vol (VT 6) & pressure (Pplat <=30)
2. Ventilation: tolerate permissive hypercapnia (raised PaCO2 & decreased pH acceptable) to avoid excessive VT
3. Oxygenation: set lowest feasible FiO2 (SpO2 92-96%) to avoid O2 tox
4. Increasing the PEEP: to distend the alveoli (thereby increasing alveolar ventilation as well as decreasing the work of breathing) and increase oxygen diffusion into the pulmonary capillaries. Patients with severe ARDS often require higher levels of PEEP to help recruit alveoli and improve gas exchange.
Supportive care:
1. Treat underlying cause
2. Prevent iatrogenic harm: NEGATIVE FLUID BALANCE (due to increased vasc permeability), timely extubation (minimise sedation)
3. +/- corticosteroids in mod-severe early cases
N.B: Prone positioning is technically difficult and is usually only pursued after alternative interventions to stabilize the patient’s oxygenation have been attempted.
Cyclic vomiting syndrome
Hx:
Personal/FHx of MIGRAINES
Episodes have an identifiable trigger (infection, stress)
Sx:
Stereotypical vomiting episodes, self-limited lasting 1-2d
Between episodes: usually asx, regular intervals (2-4wks)
Adolescent idiopathic scoliosis
Lateral curvature of spine without known aetiology in child >= 10
Forward bend test: asymmetric thoracic or lumbar prominence
X RAY SPINE to determine degree of scoliosis and assess skeletal maturity
Most curves mild: monitor every 6mo
Thoracolumbar spinal brace if child has growth potential remaining and Cobb angle >= 30 degrees
Surgical fixation for severe curvature (>= 40-50 degrees)
Systemic JIA
QUOTIDIAN FEVER for >= 2 weeks
FIXED ARTHRITIS for >= 6 weeks
PINK MACULAR RASH that WORSENS DURING FEVER (CF acute RF: transient and migratory rash)
Leukocytosis, thrombocytosis, elevated ESR and anaemia
CF poly/oligoarticular JIA not assoc w fever/rash
Chronic cough in nonsmokers
Postnasal drip, GORD, asthma m/c causes
Cough following URTI: ORAL 1ST GEN ANTIHISTAMINE (chlorphenamine) or comb antihistamine-decongestant (brompheniramine and pseudoephedrine)
Cough following rhinitis: intranasal glucocorticoids
If pts do not respond after 2-3 weeks, further investigation needed (e.g. sinus imaging, high res CT chest, PFTs) or empiric therapy for suspected cause e.g. GORD, asthma etc
Heart complications in pts w Kawasaki disease
Coronary artery aneurysms
Also increased risk of ventricular dysfunction due to LYMPHOCYTIC MYOCARDITIS, esp in infants
HF sx (diaphoresis with feeds) and signs (hepatomegaly, pulm oed, S3 gallop)
Secondary lactase deficiency
Caused by intestinal epithelial damage (e.g. gastroenteritis, coeliac)
Leads to carb (ie lactose) malabsorption and TRANSIENT sx of diarrhoea, crampy abdo pain and bloating
CF milk protein induced proctocolitis: non-IgE mediated reaction causing bloody, mucoid stools in early infancy
Cervical insufficiency
Rfs:
collagen defects
uterine abnormalities
cervical conisation
obstetric injury
Clinical features:
>= 2 prior painless, 2nd trimester losses OR
painless cervical dilation in current preg OR
2nd trimester cervical length <= 2.5cm plus a prior preterm delivery
Mx:
CERCLAGE placement
performed in 1st trimester if hx of cervical insufficiency
Suture removed at term to allow vag delivery
Descending aortic dissections can cause what neuro condition?
Interruption of blood flow to anterior spinal artery
Leading to anterior spinal artery ischaemia particularly in lower thoracic levels
Acute bladder paralysis, lower extremity paresis, crude touch/pain sensation loss and diminished reflexes initially
Vibration and deep touch sensation preserved because post columns receive blood supply from intact posterior spinal arteries
Cryptococcal meningoencephalitis
Common in pts w advanced AIDS
Signs of elevated ICP
Elevated ICP can compress 6th cranial nerve resulting in diplopia and lateral gaze palsy
Abrupt onset of psoriasis with rapid progression
Secondary cause:
HIV infection
Strep pharyngitis (guttate psoriasis)
Meds (systemic glucocorticoid withdrawal, antimalarials, lithium, beta blocker)
Endometrial cells on pap testing
Women <45: normal finding, not reported
Postmenopausal: abnormal finding, may indicate ENDOMETRIAL HYPERPLASIA/CA due to shedding so needs to be investigated with endometrial biopsy!
Mechanical ventilation: extubation readiness
Criteria:
pH > 7.25
Adequate ox (Pa)2 >= 60) on minimal support (FiO2<= 40 and PEEP <= 5)
Intact resp effort and sufficient mental awareness to support airway
If meet criteria, pt undergoes SPONTANEOUS BREATHING TRIAL (remain intubated but vent support turned off for around 1-2 hrs)
Also during SBT, RSBI can be calculated and if >105 indicates breathing rapidly and shallow so not ready for extubation
N.B: tidal vol 6-8 is a good level to prevent barotrauma from ventilator
Oesophageal pain vs angina
Oes: PROLONGED (>1hr)
Occurrence at REST in younger pts w/o multiple cardiac rfs
Tricuspid atresia findings
Tall P waves (RA enlargement) and left axis deviation (left sided vol overload) on ECG
Decreased pulm markings on CXR (hypoplasia of RV and pulm outflow tract)
Reason:
Tricuspid atresia -> pulm stenosis due to lack of development of pulm valve/artery)
ASD and VSD present to allow mixing of blood
HSV clinical course
Resolves spont within a week of dvp
Assoc w recurrent illness which can become less frequent over time
Antivirals used to decrease sx duration and number of recurrences
Traumatic carotid injuries
Aeitiology:
Penetrating trauma
Fall w object in mouth (toothbrush, pencil)
Neck manipulation (yoga, sports)
Gradual onset hemiplegia
Aphasia
Neck pain
Thunderclap headache
CT or MR angio
Congenital CMV vs TG
CMV: periventricular haemorrhages and hydrocephalus ex vacuo (due to parenchymal blood loss); SNHL
TG: parenchymal haemorrhages and obstructive hydrocephalus; chorioretinitis
Rubella: cataracts, SNHL
Syphilis: osteoarticular destruction (Hutchinson teeth, saddle nose)
Alopecia areata
Patchy, nonscarring hair loss
Exclamation point hairs may be seen
Autoimmune
TOPICAL/INTRALESIONAL CORTICOSTEROIDS (e.g. triamcinolone)
Extensive hair loss: oral Janus kinase inhibitor (baricitinib) or topical immunotherapy
Recurring course common, most pts have regrowth over time
CF trichotillomania: irregular patches w broken hairs of varying lengths
MS rfs
Female, HLA DRB1
Environmental factors (e.g. Western hemisphere)
LOW VIT D LEVELS
EBV
Eval of precocious puberty, first investigation
BONE AGE
N.B. abdo/pelvic USS if Peripheral precocious puberty but first need to do bone age Eval followed by basal LH levels and GnRH stim test to confirm peripheral
Drugs that can increase digoxin levels
AMIODARONE, verapamil, quinidine, propafenone can lead to dig tox in pt on a stable dig regimen
DECREASE DIG DOSE by 25-50% when initiating amiodarone, close monitoring of dig levels
Seizures in setting of acute bacterial gastroenteritis in children?
SHIGELLA
High fever, abdo cramping, mucoid and/or bloody diarrhoea (may be watery initially)
Spontaneous coronary artery dissection
Intimal layer tear or vaso vasorum bleed -> intramural haematoma -> coronary artery occlusion
Women <55
Rfs: POSTPARTUM, multiparty, CTD (esp fibromuscular dysplasia)
Similar chest pain sx to MI, elevated trop
Dx: coronary angio (dissection plane w/o atherosclerosis)
Tx: conservative (beta blockers, aspirin)
PCI
CABG
Gastric bypass post-op complications
Early:
Anastomotic leak (sepsis)
Bowel ischaemia (diffuse abdo pain)
Late:
Anastomotic stricture (dysphagia, bowel obstruction)
Marginal ulcer (abdo pain, bleeding, perianastomotic perforation)
Cholelithiasis, cholecystitis (RUQ pain, N.B: rapid weight loss after surgery -> altered bile composition (cholesterol supersaturation), GB stasis (lower CCK release as duodenum bypassed) -> gallstones)
Dumping syndrome (diarrhoea, crampy abdo pain, vasomotor)
Stomach (anastomotic) stenosis caused by progressive narrowing of GJ anastomosis leading to obstruction of gastric pouch outflow
Occurs within 1st YEAR of surgery
Progressive sx of nausea, postprandial vomiting, GO reflux and dysphagia
Dx and tx OGD to visualise anastomosis and open narrowing
CF Dumping syndrome: sx above but also hypotension, tachycardia, diaphoresis, light-headedness, syncope
CF anastomotic leak from either GJ/JJ: WEEK after sx; fever, abdo pain, tachypnoea, tachycardia; ORAL CONTRAST-ENHANCED ABDO CT followed by URGENT SURGICAL REPAIR if leak indicated (OGD CI as can worsen leak and cause frank perforation)
CF marginal ulcer at GJ anastomosis: several months after surgery; nausea, abdo pain, signs of bleeding; OGD
WPW pts who develop fast AF: tx
Cardioversion if HISS
Antiarrhythmics e.g. IV PROCAINAMIDE or ibutilide
N.B: AVN blockers e.g. beta blockers, ca channel blockers, dig and adenosine should be avoided as they cause increased conduction through the accessory pathway
First trimester bleeding
Spontaneous abortion
Benign causes (cervical polyp) to life threatening (ectopic, septic abortion)
Speculum and pelvic USS indicated
N.b: acute cervicitis is a cause (mucopurulent endocervical discharge)
Empiric abx therapy indicated: usually Cef and doxy but doxy CI in pregnancy so cef and azithro
Untx can ascend the uterus and cause obstetric/fetal complications so test of cure needed after
Monoamniotic twins at risk of what?
UC ENTANGLEMENT because foetuses move around each other in uterus
Can lead to hypoxia and foetal demise
Cord entanglement is spontaneous and unpredictable and labour increases the risk due to constant agitation from uterine contractions
Therefore, mo-mo twins require close antenatal foetal surveillance and elective C section prior to onset of labour (if in labour, emergent C section)
Narcolepsy
Excessive daytime sleepiness, cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis
Tx: sleep hygiene, naps, avoidance of alcohol and drugs that cause drowsiness
MODAFINIL to decrease daytime somnolence
Ovarian cyst rupture
Common cause of acute, unilateral lower abdo pain in repro-age woman
USS: THIN-WALLED ovarian cyst with PELVIC FREE FLUID
Haem stable patients managed with observation and reassurance
CF h unstable pts who may have continuous bleeding require surgery
Retropharyngeal abscess
Neck pain, odynophagia and fever following penetrating trauma to posterior pharynx
Infection within retropharyngeal space can drain into superior mediastinum (with spread to carotid sheath, resulting in thrombosis of IJV* and deficits in CN 9, 10, 11 & 12)
Extension through alar fascia into ‘danger space’ can transmit infection into posterior mediastinum (potential space between pericardium and vertebral column) and result in ACUTE NECROTISING MEDIASTINITIS: dx with CXR: WIDENED MEDIASTINUM (all pts w retropharyngeal abscess require CXR therefore)
Tx for ANM: urgent surgery
*Lemierre syndrome caused by oropharyngeal infection (tonsillitis/pharyngitis) that leads to local invasion of lateral pharyngeal wall and infection of neurovascular bundle, especially IJV.
Thrombosis of IJV allows septic embolisation to different sites. FUSOBACTERIUM NECROPHORUM most frequent bacterial cause of LS
Plantar puncture wounds causing osteomyelitis: bacteria?
STAPH AUREUS & PSEUDOMONAS (warm, moist environment) osteomyelitis
N.B: bone changes consistent w osteomyelitis take >= 2 weeks to form
Tx: IV abx (cipro and tazosin) and surgical debridement
Myoclonic status epilepticus
Aetiology: severe neuro injury (e.g. cardiac arrest) causing prolonged cerebral hypoxia
Comatose pt
Appears within 72hr of injury
Myoclonus
Generalised, symmetric
EEG
Antiepileptic meds
Complete SBO
Obstipation
No air in the rectum on AXR
NG tube insertion for gastric decompression followed by EMERGENCY LAPAROTOMY due to high risk of bowel ischaemia, perforation
CF partial SBO: conservative mx only
Renal stone: 5-10mm
Tamsulosin (alpha blocker) given to cause ureteral smooth muscle relaxation and facilitate stone removal
<5mm: small - mx expectantly
5-10mm: medium - tamsulosin
>10mm: surgery
Conditions that alter TBG concentration
Increased TBG:
Estrogens & estrogenic meds
Acute hepatitis
Decreased TBG:
Androgenic hormones
High-dose glucocorticoids/hypercortisolism
HypoproteinaN.B2:emia (nephrotic syndrome. starvation)
Chronic liver disease
N.B: if TBG conc increased, more TBG binds to thyroid hormone so thyroid hormone production increases to maintain euthyroid state (so total T4 high, free T4 normal)
N.B2: salicylates, furosemide and heparin displace T4 from its binding hormones so leads to decreased thyroid hormone production…
Pts who undergo lap appendectomy (vs laparotomy) at risk of what?
INTRA-ABDO ABSCESS:
fever and abdo sx return several days after abdo op
e.g. subphrenic abscess: RUQ pain, leucocytosis, fever, pulm manifestations
Neonates with jitteriness should be eval for what?
HYPOCALCAEMIA in infants of diabetic mothers due to mat hypomag (caused by osmotic diuresis)
Bile acid diarrhoea
Unresorbed bile acids spill into colon, resulting in mucosal irritation
- Bile acid enters terminal ileum too rapidly & overwhelms resorptive capacity (e.g. post cholesytectomy)
- Ileal disease impairs absorptive capacity (e.g. CD, abdo radiation damage)
Secretory diarrhoea (fasting diarrhoea, nocturnal episodes)
Bloating. abdo cramps
Unremarkable serum and stool studies
Tx: BILE-ACID BINDING RESINS (cholesyramine, colestipol)
CF budesonide for microscopic colitis (women, triggered by meds e.g. PPI, NSAIDs)
Takotsubo cardiomyopathy echo findings
LV apical hypokinesis, basilar hyperkinesis -> balloon shape on echo (octopus trap)
Kleptomania
Impulse control disorder characterised by inability to resist impulse to steal objects of low monetary value or not needed for personal use
Rare, seen in adolescene
CBT tx
PNH triad
Haemolytic anaemia, cytopaenias, and HYPERCOAG STATE (intraabdo or cerebral venous thrombosis)
Tremour in PD: mx
TRIHEXPHENIDYL (anticholinergic)
Used in YOUNGER pts where tremour is primary concern
CF propranolol and primidone for ET
Maternal alpha fetoprotein screening
Raised (perfrom USS of foetal anatomy):
Open neural tube defects (anencephaly, open spina bifida)
Ventral wall defects (omphalocele, gastroschisis)
Multiple gestation
Lowered:
Aneuploidies (trisomy 18 & 21)
Disorders of active phase of labour (6-10cm)
Normally cervix should dilate >= 1cm every 2 hours
Protraction: cervical change slower than expected, +/- inadequate contractions; tx = OXYTOCIN
Arrest: no cervical change >=4 hours with adequate contractions / no cervical change >=6 hours with inadequate contractions; tx = C SECTION
Cervical insufficiency
> = 2 prior painless, 2nd trimester losses
Painless cervical dilation
Mild sx, no pain or contractions and a dilated cervix (bulging and prolapsing membranes)
Rfs:
Collagen defects
Uterine abnormalities
Cervical conisation
Obstetric injury
Mx:
Cerclage placement
Foreign body aspiration
Focal, unilateral and/or monomorphic wheeze
Focal area of diminished breath sounds
Xray: HYPERINFLATION of AFFECTED side +- mediastinal shift towards unaffected side
Atelectasis if complete obstruction
+- foreign body (however most radiolucent so difficult to see)
CF pneumothorax: no wheezing, xray: air without lung markings and ipsilateral lung collapse not hyperinflation
HHS K+ levels
Initially normal or mildly elevated due to lack of insulin and hyperosmolality causing increased EC shift of K+
But TOTAL BODY K+ DEFICIT present as osmotic diuresis develops (causing loss of water, sodium, pot, phos)
Bedbug bites
Small, pruritic, erythematous papules
LINEAR PATTERN on exposed areas (breakfast, lunch, dinner), each w a haemorrhagic central punctum
Mx: supportive, bug eradication
Eval & mx of pharyngitis
Centor criteria:
0 - 1 present: no testing/tx for strep infection
2 - 3 present: rapid strep antigen test -> pen/amox if pos
4 present: rapid strep antigen test or empiric pen/amox
Discoid lupus vs PCT
Discoid lupus: scaly, erythematous plaques leading to atrophy, hypopigmentation and scarring
PCT: lesions form fragile blisters and erosions rather than scaly plaques; individual lesions triggered by minor trauma
Both affect sun-exposed areas
N.B: PCT tx: phlebotomy, hydroxychloroquine, deferoxamine; sun protection and avoidance of ppt factors (e.g. exogenous oestrogen)
TB meningitis
Subacute fever, vomiting, headache, lethargy
Cranial nerve palsy
Stroke
Imaging: BASILAR MENINGEAL ENHANCEMENT & hydrocephalus
CSF: WBC 100-500, mildly increased protein, low glucose, increased ADA
NAAT or AFB CSF smear
TB meningitis
Subacute fever, vomiting, headache, lethargy
Cranial nerve palsy
Stroke
Imaging: BASILAR MENINGEAL ENHANCEMENT & hydrocephalus
CSF: WBC 100-500, mildly increased protein, low glucose, increased ADA
NAAT or AFB CSF smear
Septic arthritis continued sx despite vanco
Indicates infection w gram neg bacterium e.g. Kingella kingae
3rd gen ceph needed e.g. ceftriazone
Miller Fisher Syndrome
Variant of GBS
Characterised by OPTHALMOPLEGIA, ataxia and areflexia
Strength preserved
Assoc w anti-GQ1b antibody
Spinal epidural haematoma
Potential complication of neuraxial anaesthesia (e.g epidural block) LP, or spinal surgery
More common in older adults taking ANTITHROMBOTIC MEDS
Slowly progressive motor and sensory dysfunction and localised back pain
Bowel and bladder dysfunction potentially
URGENT MRI & NEUROSURG DECOMP
Meds to avoid in MG
MAGENSIUM SULPHATE (so in pts with preeclampsia w MG give valproate instead)
fluoroquinolones, aminoglycosides
NM blocking agents
CNS depressants
muscle relaxants
ca channel blockers
beta blockers
opioids
statins
Bilirubin-induced neurologic dysfunction
Due to extreme unconjugated bilirubinemia
Unbound bilirubin crosses BBB
Chronic disease (kernicterus) results in hyperkinetic mvts (chorea, dystonia), sensorineural hearing loss and gaze abnormalities
Polyhydramnios mx
Most cases (AFI >= 24) are idiopathic and asx
Pts at term gest with mild, asx poly expectantly mx
CF pts w severe or sx poly at preterm gest increased risk for obstetric complications (e.g. preterm labour, PPROM); amniocentesis for these pts
Breath-holding spell (BHS)
Common and benign childhood condition
Cyanotic vs pallid subtypes
Cyanotic: triggered by vigorous crying; apnoea & cyanosis -> LOC; rapid return to baseline
Pallid: triggered by minor trauma, pain or fear; brady, pale, diaphoretic, limp -> LOC; brief (<5min) confusion/sleepiness
CF seizure which is prolonged (>5min) post-ictal confusion
BHS: dx clinical, no further ix; assoc w IDA so screening important
Testicular ca dx workup
Bilateral scrotal USS: solid hypoechoic lesion = seminoma; cystic area and calcifications = NSGCT
Serum tumour markers: beta hCG, AFP & LDH elevated in NSGCT
RADICAL INGUINAL ORCHIECTOMY to confirm dx histologically and definitive tx
Minimal variability CTG
Typically indicates foetal met ac
However, OPIOIDS and other meds can cause minimal variability due to foetal CNS depression
Nonhered SNHL in children: m/c cause?
Congenital CMV infection
Most infected infants are asx (don’t have classic SGA, microcephaly, jaundice, HSM)
Hearing loss can be at onset or DELAYED until later in childhood; one or both ears can be affected
Sx infants tx to prevent progressive hearing loss; asx individuals w isolated SNHL not tx
Tardive dyskinesia
Prolonged exposure to dopamine blocking agents
UPREGULATION & SUPERSENSITIVITY of dopamine receptors
Abnormal invol mvts of mouth, tongue, trunk and extremities
Can first appear during tx or following antipsych dose ruduction/discont
Gonococcal proctitis
Receptive anal intercourse
Direct spread from vag
Mucopuruluent anal discharge +/- rectal bleeding
Tenesmus, constipation
Pruritus, rectal pain, rectal fullness
NAAT of rectal swab
Cef + doxy (Chalmydia coverage)
Acute mediastinitis
Can occur following cardiac surgery
Fever, chest pain, leukocyotsis and mediastinal widening on CXR
Tx: drainage, surgical debridement, prolonged abx
N.B: AF commonly occurs within a few days of CABG and is self-lim usually; rate control (beta blockers/amiodarone); anticoag +/- cardioversion if AF lasts >24hr after CABG
Pulmonary contusion
Present <24hr after blunt thoracic trauma
Tachypnoea, tachycardia, hypoxia
Rales/decreased breath sounds
CT scan (most sensitive) or CXR with patchy alveolar infiltrate NOT CONFINED BY ANATOMIC BORDERS (ie nonlobular)
CF ARDS alveolar infiltrates bilateral and do not manifest until 24-48hr after traumatic injury
Tx: pain control
Pulm hygiene (incentive spiro, chest PT)
Supplemental oxygen and vent support
Glucocorticoid-induced myopathy (Cushing’s related)
Progressive, PAINLESS muscle weakness involving prox muscles
Results from direct catabolic effects of cortisol on skeletal muscle that lead to MUSCLE ATROPHY
CK and ESR NORMAL (as no direct damage to myocytes and no inflam)
Atraumatic splenic rupture
Rfs:
Haem malignancy
Infection (CMV, EBV, malaria)
Inflam disease (SLE, pancreatitis)
Splenic congestion (cirrhosis, preg)
Meds (anticoagulation, G-CSF)
Diffuse or LUQ pain, peritonitis
Referred left shoulder pain (Kehr sign)
HD instability
Dx: acute anaemia due to intraperitoneal haemorrhage; intraperitoneal free fluid on imaging
Tx: catheter-based angioembolisation (stable pts)
Emergency splenectomy (unstable pts)
Post-op urinary retention rfs
Common
Pt factors: increasing age and male (prostate enlargement)
Type of surgery: HERNIA REPAIR, joint arthroplasty or anorectal ops
Anaesthetic factors: prolonged an duration, excessive fluid admin, use of meds (opioids, anticholinergics)
N.B: in addition to suprapubic pain etc, pts may be hypertensive, tachy due to symp stimualtion (distended bladder noxious stimulus)
Dx: PORTABLE BLADDER USS (BLADDER SCAN)
if POUR present (>600ml on USS), URINARY CATHETERISATION
Causes of sellar masses
Benign:
Pituitary adenoma (m/c)
Craniopharyngioma (N.B: in children AND adults)
Meningioma
Pituicytoma (low-grade glioma)
Malignant:
Primary (GCT, chordoma, lymphoma)
Metastatic (breast, lung)
Septic shock phases & clinical signs
Early: hyperdynamic CVS occurring in response to peripheral vasodilation with capillary leak and intravasc hypovol
Leading to an increase in SV, HR and PP resulting in BOUNDING PERIPHERAL PULSES
N.B: severe hypodynamic phase: cool and clammy extremities due to shunting of blood to vital organs; decreased CO and increased SVR
Neonatal cephalic pustulosis
Erythematous papules and pustules lim to face and scalp around 3 WEEKS of age
Used to be called neonatal acne
Mx: daily cleansing w GENTLE SOAP & WATER; self-res w/o scarring
Ulnar nerve injury: wrist vs elbow
Wrist: hamate #, compression from bike handlebar: numbness in medial 1.5 fingers plus intrinsic hand weakness “clumsiness”
Elbow: similar sx plus numbness in HYPOTHENAR EMINENCE and MEDIAL DORSUM OF HAND, DECREASED GRIP STRENGTH and WEAKER WRIST FLEXION
Compression can occur at epicondylar groove (repeated leaning on elbow e.g. on car windowsill) or cubital tunnel (repeated or prolonged flexion of elbow e.g. cell phone use)
N.B: pts w ESRD receiving HD at risk for ulnar injury due to pos during HD sessions plus chronic uraemia causing gen muscle wasting and loss of sc soft tissue
Methods to control confounding
Design stage:
Matching
Restriction
Randomisation
Analysis stage:
Stratified analysis
Statistical modelling
Amniotic fluid embolism syndrome key features
Hypoxaemic resp failure (leading to coma/seizures)
Obstructive shock (leading to pulm oedema and CVS collapse)
DIC
Supportive care: intubation w mechanical ventilation, vasopressors, massive transfusion
HS infant w bilious emesis and nondx xray…
UPPER GI SERIES to eval for midgut volvulus
Dx: abnormally located LIGAMENT OF TREITZ on RIGHT SIDE of abdomen (malrotation) and a DUODENAL CORKSCREW or bird’s beak appearance (volvulus)
Septic bursitis
Rfs:
Local cellulitis, abrasions or pentrating trauma
Bursal instrumentation/injection, prior bursal inflammation
Immunocompromised
Painful, localised bursal swelling w erythema and warmth
+/- fever, chills, myalgia
Dx aspiration of bursal fluid
Consider xray (for suspected fracture, foreign body, osteomyelitis)
Systemic abx
Drainage in select cases
Prosthetic joint infection timeline organisms
Early onset (<3mo post surgery): Staph aureus, gram neg rods, anaerobes; acute pain, wound infection or breakdown, fever
Delayed onset (3-12 mo):
Coag-neg staph (e.g. epidermidis), Pribionibacterium species, Enterococci; chronic joint pain, implant loosening, sinus tract formation
Late onset (>12mo):
Staph aureus, gram neg rods, beta haemolytic strep; acute sx in previously asx joint, recent infection at distal site (e.g. UTI)
Perilymphatic fistula
Rare complication of head trauma or barotrauma
Leakage of endolymph from semicircular canals and cochlea into surrounding tissues
Progressive SNHL
Episodic vertigo w nystagmus triggered by changes in pressure in inner ear (e.g. VALSALVA/elevation changes causing extra endolymph loss)
Limit activities causing increased inner ear pressure
ENT referral
Rhabdo: good way to dx
DISCORDANCE between urinalysis and urine microscopy
Myoglobinuria due to rhabdo leads to pos blood on urinalysis (myoglobin degradation -> haeme) in absence of rbcs on urine microscopy
Paroxysmal sympathetic hyperactivity
TBI can damage cortical areas responsible for inhibiting lower sympathetic centres
Disrupted inhibition -> PSH: rapid onsets of tachy, hypertension and tachypnoea often accompanied by fever and diaphoresis
These episodes triggered by external stimuli (bathing, repositioning)
SCD pregnancy
Pts more likely to have acute vasoocclusive pain episodes (e.g. abdo pain) due to increased met demands and hypercoag state
Also at increased risk for preeclampsia and its sequelae incl. placental abruption, FGR and preterm delivery
Therefore more frequent prenatal visits, baseline 24-hr urine collection and protein level testing, and low-dose aspirin for pre-eclampsia prophylaxis
Infectious ileocecitis (pseudoappendicitis)
Can present similarly with RLQ pain, fever and leukocytosis
PROFUSE WATERY/MUCOID DIARRHOEA highly suggestive of infectious ileocecitis
M/C causes are YERSINIA & CAMP JEJUNI
N.B: Yersinia: consumption of contaminated food, most commonly RAW PORK. Additional sources of disease transmission include unpasteurized dairy, unfiltered water, and food contaminated with pet feces.
The incubation period is typically 4–6 days, after which patients develop inflammatory diarrhea, nausea, low-grade fever, and, in some cases, right lower quadrant tenderness that may mimic appendicitis (pseudoappendicitis).
N.B: unwashed veg -> Shigella dysenteriae (2d incubation period)
Leprosy
Primarily developing world
Resp droplets/nine banded armadillo
Low infectivity
Macular, anaesthetic skin lesions w raised borders
Nodular, painful nearby nerves w loss of sensory/motor function
FULL-THICKNESS BIOPSY of skin lesion (active edege)
Non culturable
Paucibacillary: DAPSONE + RIFAMPIN
Multibacillary: … plus CLOFAZIMINE
Primary TB radiography vs reactivation TB
Primary: LOBAR INFILTRATE (due to unchecked prolif) and sig IPSILATERAL HILAR LYMPHADENOPATHY, compression of RML and pleural effusions also may occur
Reactivation: CAVITARY INFILTRATE
Postpartum urinary retention
Inability to void >= 6 hours post vag delivery (or >=6 hours after catheter removal post C section)
Dribbling of urine from overflow incontinence
URETHRAL CATHETERISATION dx and tx (as decompresses bladder)
Postvoid residual vol >= 150 ml dx
Life-threatening complication of spinal cord injury?
Autonomic dysreflexia
Noxious stimulus (urinary retenion, constipation, pressure ulcer etc) below lesion stimulates symp activity but no counterbalance parasymp activity
Above lesion: parasymp intact causing brady and vasodilation (facial flushing)
Below lesion: unreg symp response -> hypertension
Cyanide poisoning causes
Structure fires (e.g. combustion of plastics)
Occupational exposure (e.g. mining)
Cyanide-containing meds (e.g. SODIUM NITROPRUSSIDE - used for HTN emergency)
Can cause HAGMA with raised lactic acid (inhibits ox phosph and forces anaerobic respiration)
Presbyopia
Age-related eye disorder resulting from DECREASED ELASTICITY OF LENS
So cannot accomodate easily so harder to read objects close up
Epidural spinal cord compression
Suspect in any pt w hx of malignancy who develops back pain w motor and sensory abnormalities
Bowel and bladder dysf late signs
IV GLUCOCORTICOIDS first then MRI spine
Internal carotid artery dissection
Common cause of stroke in young patients
Can occur spont (rfs) or after mild trauma or illness
Partial Horner syndrome (ptosis and miosis w/o anhidrosis), unilateral headache and neck pain and cerebral ischaemia (TIA, stroke)
Which abx is CI in aortic aneurysm hx
FLUOROQUINOLONES - increase collagen degradation, assoc w Achilles tendon rupture, retinal detachment and aortic aneurysm rupture or rfs for aortic aneurysm (ED, Marfan’s, CVD)
Methanol toxicity signs
Encephalopathy, abdo pain/vom, HAGMA
OPTIC NEURITIS common complication that distinguishes methanol ingestion from other toxic alcohol ingestions (e.g. ethylene glycol which would present with AKI, flank pain due to calcium oxalate stones)
Vit D and iron supplementation in neonates
Iron: given to pre-term neonates exclusively breastfeeding from birth and continued until 1 year
(Also mat iron def and early initiation of cow’s milk before age 12 mo increases risk of IDA in neonates)
Vit D: given to all neonates exclusively breastfeeding from birth
ARDS mx to reduce mortality
Mech vent with low tidal volume ventilation
Reduces alveolar overdistension of remaining open alveoli (functional “baby lung”)
Prone pos also decreases mortality by homogenising ventilation throughout lungs (by distributing ventilation from ventral to dorsal (dependent) lung regions where majority of alveoli located)
Blinding increases what of a study?
INTERNAL VALIDITY (ability of research design to provide evidence of causal relationship between treatment and outcome) so increases as study becomes more tightly controlled CF external v
CF external v: describes generalisability so increases as study becomes more like real world CF internal v
Acute liver failure definition
Acute onset of severe liver injury (raised aminotransferases) w encephalopathy and impaired synthetic function (INR >= 1.5) in a pt w/o cirrhosis or underlying liver disease
Lung abscess tx
AMPICILLIN-SULBACTAM, imipinem, meropenem
Alt: clindamycin
N.B: metro not indicated as useful against only obligate anaerobes (whereas lung abscess contains obligate and facultative anaerobes)
HIV neuropathy
Distal, symmetric polyneuropathy beginning with numbness/tingling/pain in feet and progresses proximally
Older pts with long-standing, poorly controlled HIV at greatest risk
Antiretrovirals decrease risk of progression
GABAPENTIN first line for sx mx
Bronchopulmonary dysplasia
Premature arrest of pulm dvp
Alveolar hypoplasia with decreased septation
Impaired vasculogenesis
Premature infant w continued supplemental oxygen requirement >= 28d from birth
Mild: diffuse hazy infiltrates, low/normal lung volumes
Severe: fibrocystic changes, hyperinflation
Supportive tx (oxygen, nutrition, fluid restriction/diuretics)
Complications:
pulmonary artery HTN
CVD (HTN)
Recurrent respiration infections
PTSD nightmares tx
PRAZOSIN (in addition to SSRI/SNRI)
Type of stridor heard in laryngomalacia, subglottic stenosis, tracheomalacia
Inspiratory stridor (due to dynamic collapse of supraglottic tissues (epiglottis, arytenoids ie extrathoracic airway) on inspiration)
Stridor increases in periods of increased airflow (crying, feeding)
CF biphasic stridor heard in subglottic stenosis (subglottic airway less flexible than supraglottic so min change in inspiration vs exp therefore biphasic)
CF expiratory stridor heard in tracheomalacia (collapsable intrathoracic airway) as increase intra thoracic pressure during expiration narrows intrathoracic trachea
Meliodosis
Rare infection caused by gram neg bacilli Burkholderia pseudomallei
Endemic to Thailand, Malaysia, Singapore and Northern Australia
Transmitted when contaminated soil or water gets inoculated in sc tissue
Those w DM at risk of severe disease
Bipolar staining w safety pin appearance
Fulminant pneumonia, cutaneous ulcers/abscesses (purple coloured lesions) and organ abscesses (spleen, liver, kidney, prostate)
Tx: ceftazidime or a carbapenem followed by TMP-SMX
Retroperitoneal haematoma postpartum
May occur due to uterine artery injury, leading to massive blood loss and HD instability despite minimal abdo pain (due to retroperitoneal space being large) and no obv source of bleeding
HD unstable and retroperitoneal haematoma -> EMERGENCY LAPAROTOMY
N.B: suspect if post C-section delivery w haemorrhagic shock and no signs of uterine atony (uterine atony: enlarged boggy uterus and heavy vag bleeding)
M/c cause of lobar intracranial haemorrhage?
CEREBRAL AMYLOID ANGIOPATHY
Assoc w Alzheimer’s dementia, occurs due to beta amyloid deposition in walls of small and medium cerebral arteries leading to increased fragility of vessels
Often involves occipital and parietal lobes, usually sparing ventricles and deep brain structures (CF hypertensive haemorrhage)
N.B: AVM rupture most common cause of ICH in children
Syphilis: severe pen allergy tx?
Oral DOXY or IV/IM CEFTRIAXONE for all stages of syphilis EXCEPT NEUROSYPHILIS (who require pen desensitisation followed by pen)
All pts w syphilis require nontreponemal titres at time of tx (e.g. RPR) and again 6-12 mo to ensure adequate response (4-fold drop)
Tarsal tunnel syndrome
Compression of post tibial nerve under flexor retinaculum in medial ankle
Trauma
Overuse injury
Inflamm disorder
Burning pain, numbness, paraesthesia
Medial ankle, heel, sole, toes
Dx: clinical presentation, nerve conduction studies
Tx: activity mod, orthotics, NSAIDs/corticosteroid injection, surgical release (refractory cases)
Normal lower extremity alignment at different ages
6 months: genu varum
2 years: straight legs
4 years: genu valgum
>7 years: straight legs
Physiologic genu varum features:
symmetric bowing
normal stature
no leg length discrepancy
no lateral thrust when walking
D-xylose test of proximal small intestine absorption
Monosaccharide absorbed in prox small intestine w/o degradation by pancreatic or brush border enzymes
Pts w small intestinal mucosal disease will have impaired absorption of D-xylose
Pts w malabsorption due to enzyme deficiencies will have normal absorption of D-xylose
N.B: false-pos D-xylose test (low urinary D-xylose despite normal mucosal absorption) seen in:
Delayed gastric emptying
Impaired glomerular filtration
SIBO (bacterial fermentation of D-xylose before it can be absorbed); SIBO tx w rifaximin
Causes of paralytic ileus
M/c from abdo surgery
But also seen in
Retroperitoneal/abdo haemorrhage, intraabdo inflam (e.g. pancreatitis), intestinal ischaemia, electrolyte abnormalities
Dilated, gas filled loops of bowel w NO TRANSITION POINT
Staphylococcal toxic shock syndrome
Risks:
Tampon use, nasal packing, SURGICAL/POSTPARTUM WOUND INFECTION
Exotoxin release acting as superantigens
Fever > 38.9
Hypotension
Diffuse macular rash involving palms & soles
Desquamation 1-3 wks after disease onset
Vom, diarrhoea
Altered mentation w/o focal neuro signs
Tx: supportive therapy, removal of foreign body, abx (VANCO, CEFEPIME, CLINDAMYCIN)
Exchange transfusion in neonates w unconj hyperbili indications
Rapid rise in bili despite phototherapy or levels > 25 or sx BIND (e.g. lethargy, change in tone)
N.B: low albumin increases risk of BIND as less to bind w bili
N.B. 2: IVIG for severe haemolytic disease of newborn due to Rh incompatibility
Dissociative identity disorder
Marked discontinuity in identity & loss of personal agency w fragmentation into >= 2 DISTINCT PERSONALITY STATES
Assoc w severe childhood trauma/abuse
Tx: long-term psychotherapy
Hypocomplementaemic IC-mediated forms of GN
PSGN: Antistreptolysin O antibodies
MPGN: Serum cryoglobulins
Lupus nephritis: ANA, anti-dsDNA
Endocarditis-assoc GN: pos blood cultures
N.B: PSGN causes renal-lim disease so hypocomplementaemic glomerulonephritis assoc w systemic vasculitis usually due to MPGN or lupus nephritis
Lymph node features
Reassuring: soft, mobile, <2cm; localised; absent systemic sx
Worrisome: firm or hard, immobile, >2cm; generalised or supraclavicular; systemic sx present
Optimal form of nutrition for critically ill pts?
ENTERAL NUTRITION
Multiple benefits (reduction in infection, maintenance of gut integrity) when initiated early (<= 48hr)
TPN only used for those w CI to EN (e.g. intestinal discontinuity, prolonged ileus)
Cardiac catheterisation local vasc complications
Bleeding, haematoma (within 12hrs - localised or w retroperitoneal extension), arterial dissection, acute thrombosis, pseudoaneurysm, AV fistula formation
Retroperitoneal haematoma: sudden HD instability, ipsilateral flank or back pain
CT scan of abdo and pelvis/abdo USS
Supportive, bed rest, intensive monitoring., IVF and/or blood transfusion
Central cord syndrome
Common after whiplash-type injuries in older adults w underlying cervical spondylosis
Damage to central cervical spinal cord causes upper extremity motor, sensory and reflex abnormalities Sacral (bowel/bladder) and lower extremity function generally preserved (due to central location of lesion and lateral spinal tracts therefore spared)
MRI of cervical spine w/o contrast initial dx test (to determine extent of injury, may also perform non contrast CT cervical spine)
Cervical myelogram dx and shows persistent cord compression but ordered second line as invasive
Tx: glucocorticoids and/or surgery
BWS increased risk of what and so require what screening?
Wilms tumour and hepatoblastoma so abdo USS and AFP every 3 mo and renal USS every 3 mo
N.B: BWS: fetal macrosomia, rapid growth until late childhood, omphalocele or umbilical hernia, macroglossia, hemihyperplasia; caused by dysregulation of imprinted gene on Chr 11p15
Meds that increase risk of CAP in elderly pts
ATYPICAL ANTIPSYCHOTICS (e.g. quetiapine) due to anticholinergic and antihistaminergic effects which reduce ability to form food bolus and increase aspiration risk
Also acid suppressants, sedatives, immunomodulatory agents
Clinical manifestations of trace mineral deficiencies
Chromium: impaired glucose control in diabetics
Copper: brittle hair, skin depigmentation, neuro dysf (ataxia, peripheral neuropathy) similar to SCD, anaemia, osteoporosis, oedema
Iron: microcytic anaemia
Selenium: thyroid dysf, cardiomyopathy, immune dysf
Zinc: alopecia, pustular skin rash (perioral region & extremities), hypogonadism, poor wound healing, impaired taste, immune dysf
Trimethoprim electrolyte disturbance?
Hyperkalaemia due to blockage of ENaC so K+ does not move into lumen of collecting tubule
Also increase in serum creatinine as inhibits renal tubular creatinine secretion, but GFR unchanged
HIV mx during preg
Antepartum:
Testing of HIV viral load monthly until undetectable, then every 3 mo
CD4 count every 3 mo
Resistance testing if not previously performed
Initiation or continuation of HAART IMMEDIATELY!
Avoidance of amniocentesis if viral load detectable
Intrapartum:
Avoidance of artificial ROM, foetal scalp electrode, operative vag delivery
Viral load <= 50: ART + vag delivery
Viral load > 50 to <= 1000: ART +/- zidovudine + vag delivery
Viral load > 1000: ART + zidovudine + C section
Rib # location and assoc injuries
1-3: subclavian vessels, brachial plexus, mediastinal vessels (e.g. aorta)
3-6: CVS
9-12: intraabdo: liver (right), spleen (left), kidney (post ribs 11 & 12)
any level: pulm
Secondary (late) PPH
Retained POC: heavy bleeding, +/- uterine atony, boggy or firm uterus, secondary to intraamniotic infection (causing inflam and adherence of tissues); pelvic USS, D&C
Placental site subinvolution: heavy bleeding, uterine atony; uterotonics (oxytocin, methylergonovine*, carboprost**)
Postpartum endometritis: fever, uterine tenderness, purulent lochia; broad spectrum IV abx (clind & gent)
N.B: retained placenta causes immediate PPH w uterine atony (boggy, enlarged uterus); rfs = extreme PRETERM DELIVERY, retained placenta in prior delivery, uterine abnormality, placenta accreta spectrum, intraamniotic infection, intrauterine foetal demise; mx= downward traction of cord and oxytocin; manual placental extraction, D&C
*CI in pts w hypertension as it is a potent vasoconstrictor
** CI in pts w asthma as causes bronchospasm
Bacterial gastroenteritis: why to be cautious w abx prescribing?
Suspect bacterial gastroenteritis in pt w bloody or mucoid diarrhoea
Tx supportive, with close follow-up in well-appearing children
Empiric abx NOT recommended primarily due to increased risk of HUS assoc w STEC
Community-acquired MRSA affects which pt groups
Young pts with recent influenza
Causes rapidly progressive, necrotising pneumonia w high fever, productive cough (often w haemoptysis), leukopaenia and multilobar cavitary infiltrates
Admission to ICU w broad spectrum abx, either vanco or linezolid
CF Strep pneumo m/c cause of influenza-related bacterial pneumonia but rare in young individuals and less likely to cause cavitary infiltrates
Secretory vs osmotic diarrhoea
Nomal stool osmotic gap = 50-125
Secretory diarrhoea: watery diarrhoea ocurring even during fasting or sleep. Can be caused by toxins (e.g. Vibrio cholerae), hormones (e.g. VIPoma), congenital disorders of ion transport (e.g. CF), or unabsorbed bile acids (e.g. due to postsurgical changes). Low stool osmotic gap (<50)
Osmotic diarrhoea: polyethylene glycol, sorbitol, lactose which inhibits water resorption and results in high SOG (>125). Occurs after ingestion of causative substance (e.g. milk in pt w lactose intolerance) and does not occur during fasting
Pancreatic injury following BAT
BAT can compress upper abdomen against vertebral column and injure pancreas
Persistent abdo discomfort or nausea, increasing amylase, of peripancreatic fluid collection
CF liver/spleen injury can cause free fluid on abdo USS but would be picked up on CT abdo/pelvis if sig bleeding
Indomethacin tocolysis side effect
OLIGOHYDRAMNIOS (due to decreased prostaglandins so foetal vasoconstriction so decreased RBF) and premature closure of ductal arteriosus
What worsens Graves ophthalmopathy?
RAI can raise titers of TRAB and worsen opth
Glucocorticoids and antithyroid drugs can be used to minimise effects of RAI
Complications of myopia?
Myopia caused by increased axial length of the eye or corneal protrusion
Retinal detachment
Macular degeneration
Due to stretching and thinning of sclera, choroid and retina
Burn wound sepsis
Clinical signs may overlap with post-burn hypermetabolic response
Burn wound sepsis signs:
Temp <36.5 or >39
Vital sign changes incl tachy
Evolving lab abnormalities (leukocytosis/penia, thrombocytopenia)
Organ hypoperfusion and/or dysfunction e.g. oliguria or NEW-ONSET ENTERAL FEEDING INTOLERANCE (e.g. high gastric residual vol) after a period of tolerance, reflecting splanchnic hypoperfusion leading to GI hypomotility and ileus
Tx for Lyme disease in preg pts
Amoxicillin
N.B: Lyme disease during preg does not cause harm to foetus but still tx w amox
(Azithro reserved if intolerant to doxy and amox)
Nicotine poisoning clinical features and mx
Biphasic reaction due to nicotine action at ACh receptors:
Stimulatory phase: hypertension, tachy, seizures, myoclonus
Inhibitory phase: hypotension, brady, coma
Muscarinic sx: DUMBELLS
Tx: primarily supportive
Decontamination if transdermal exposure (e.g. green tobacco sickness from tobacco leaves)
Benzos for seizures
Atropine for sx brady and muscarinic sx
What drug can be given to pts w congenital long QT syndrome?
At risk for PVT that leads to syncope or SCD, esp during periods of rapid heart rate and high symp activity
Beta blockers (esp nonselective e.g. propranolol, nadalol) dampen symp activity and shorten QT interval AT HIGH HEART RATES (prolong QT at slow heart rates) to reduce risk of these complications
N.B: do not give sotalol as it is also a potassium channel blocker (AIDS) and do not give 1A as it has some K+ channel blocking properties too
Murmur following implantable pacemaker or cardioverter-defib placement?
Transvenous lead placement through tricuspid valve -> severe tricuspid regurgitation due to direct leaflet damage or inadequate leaflet coaptation
Suspect if R HF following those procedures
Herpangina vs herpetic gingivostomatitis
Coxsackievirus A (causes HFM disease) vs HSV1
3-10 years vs
6mo - 5 years
Late summer/early fall vs
No seasonality
Fever & pharyngitis; grey vesicles/ulcers on POSTERIOR oropharynx vs
fever & pharyngitis; clusters of vesicles/ulcers on ANTERIOR oral mucosa & lips; erythematous & oedematous gingiva
Supportive vs
oral acyclovir
Uncertain foetal presentation on digital cervical exam…
TRANSABDO USS to confirm foetal presentation and determine safest route of delivery
N.B: where no palpable presenting foetal part, transabdo USS must be performed before amniotomy to avoid UC prolapse in pts w funic presentation (also amniotomy good for induction of labour but not helpful once labour begun)
Most specific arrhythmia for dig tox?
Increased automacity of myocardial conduction and/or increased vagal tone
Atrial tachy w AV block involves both of these mechanisms and is the answer
Whistling noise during inspiration after rhinoplasty?
Nasal septal perforation secondary to septal haematoma
Patellar tendon rupture vs quadriceps tendon rupture
PT rupture: high-riding patella w a palpable defect at inferior pole
QT rupture: low-riding patella, palpable defect superior to patella
Purulent pericardial effusion
Haematogenous or direct intrathoracic spread
Rfs: immunosuppression, HD, recent thoracic surgery/trauma
Organisms: Staph aureus (m/c), Strep pneumo, Salmonella, Candida
Severely ill on acute presentation
Fevers, chills, chest pain (pleuritic/non-pleuritic)
Can be rapidly fatal
ECG: tachy, diffuse ST elevation. +/- low-voltage QRS complexes
CXR: enlarged cardiac silhouette and clear lung fields
Echo: pericardial effusion
Cytology: turbid fluid w increased WBCs (neutrophilia), increased protein. low glucose
IV abx + pericardial drainage (pericardiocentesis dx and tx)
Predictive values depend on what?
Disease PREVALENCE
As disease prevalence increases, PPV increases and NPV decreases
N.B: sensitivity/specificity are intrinsic test parameters that are not changed by disease prevalence.
Uterine sarcoma
Rfs:
Pelvic radiation
TAMOXIFEN use
Postmenopausal patients
Abnormal/PMB bleeding
Pelvic pain or pressure
Uterine mass
USS +- additional imaging
Endometrial biopsy
Histopath of surgical specimen
Tx: hysterectomy, +- adjuvant chemo/radiation
Abdominal compartment syndrome
Aetiology:
Increased intraabdo pressure causing organ dysfunction
Rfs: massive fluid resusc, major intraabdo surgery/pathology
Tense, distended abdo
Increased vent requirements (diaphragmatic elevation, increased intrathoracic pressure)
Increased CVP (venous compression but decreased venous return and cardiac preload)
Hypotension, tachycardia
Decreased urine output (decreased intraabdo organ perfusion)
Mx: Temporising measures:
Avoid over resusc w fluids
Decrease intraabdo vol (NG tube)
Increase abdo wall compliance (sedation)
Def mx: surgical decompression
Pulmonary contusion
Present <24hr after blunt thoracic trauma
Tachypnoea, tachycardia, hypoxia
Rales or decreased breath sounds
CT scan (most sensitive) or CXR (may be normal) w PATCHY ALVEOLAR INFILTRATE not restricted by anatomic borders (IRREGULAR)
N.B: alveolar oedema can be exacerbated by subsequent fluid resusc efforts -> CT: ground-glass opacities in lung adjacent to affected chest wall
Pain control
Pulm hygiene (incentive spirometry, chest PT)
Supplemental oxygen and ventilatory support
Patellar dislocation
Rfs:
Joint laxity
Misaligned lower extremity
Tight iliotibial band
Patellar subluxation
Competitive sports, dance, military training
Quick, twisting motion around a flexed knee
Feeling of knee giving way, severe pain, popping noise
Examination: LATERAL dislocation of patella, decreased extension
Pts w peri-infarction pericarditis should receive what?
ECHO to characterise any assoc pericardial effusion and rule out any other post-MI complications (e.g. free wall rupture). Monitor if pericardial effusion becomes large enough to cause tamponade although rare in PIP
Supportive mx
Paracetamol for pain control but NSAIDs avoided for at least 7d due to poss increased risk of free wall rupture
Galactomann antigen (plus haemoptysis, dyspnoea, fever) seen in what condition?
Invasive asperigillosis
Triad: fever, pleuritic chest pain and haemoptysis.
CT: pulmonary NODULES with SURROUNDING GROUND-GLASS OPACITIES (“HALO SIGN”)
Tx: voriconazole + echinocandin (caspofungin)
All pts w suspected chronic venous disease should receive?
DUPLEX USS before any tx (e.g. compression stockings)
To determine if pt has correctable cause of venous reflux (e.g. in superficial system) and plan for any interventional procedure
N.B: mild CVD (varicose veins or oedema only) or preg pts -> compression stockings
Advanced CVD (skin changes: pruritic dermatitis, venous ulcer) /correctable cause -> endovenous thermal ablation provided no CIs (DVT, PAD)
All pts w CVD to be counselled on lifestyle changes
M/c parasitic disease assoc w pulm HTN?
SCHISTOSOMIASIS
Genitourinary sch -> SCC bladder
Hepatosplenic sch -> presinusoidal portal HTN -> portosystemic shunts -> embolisation of sch eggs into pulm circulation -> granulomatous pulmonary endarteritis (pulm sch) -> irreversible pulm HTN
Cysticercosis vs intestinal taeniasis
Both caused by Taenia solium
Cysticercosis: Ingestion of T solium eggs excreted in human faeces
Intestinal taeniasis: Ingestion of larva from raw/undercooked pork
Diverticulitis dx imaging?
CT scan abdo w oral + IV contrast
CT: bowel wall thickening (>4mm) and inflam of pericolic fat w fat stranding (visible traces of fluid in fat)
CT also helpful in ruling out complications e.g. abscess (fluid collections surrounded by inflam changes), obstruction (dilated air loops, air-fluid levels), perforation (free air in abdo cavity) and fistula (air in other organs other than bowel)
Blind loop syndrome
Type of SIBO that develops in pts who have a blind intestinal loop following abdo surgery
Blind pouch no longer connected to stomach -> decreased intestinal motility and a lack of acidity -> SIBO (loose, fatty stools, malabsorption, vit B12 def)
Dx SIBO w endoscopic cultures from jejunum (gold standard) or pos lactulose breath test
HAP vs CAP tx
HAP or sepsis: IV vanc & IV cefepime (covering Pseudomonas and Staph aureus)
CAP: IV ceftriaxone & IV azithromycin
Impaired reaction time is assoc w which intox?
Cannabis intox
Fever, facial oedema, diffuse morbiliform rash, lymphadenopathy and hepatomegaly within weeks after initiating anticonvulsant tx?
DRESS syndrome
Type IV hypersensitivity reaction
Caused by anticonvulsants, allopurinol or antibiotics (e.g. sulfonamide)
R sided IE manifestations
Septic pulmonary emboli
N.B: peripheral disease manifestations (e.g. Janeway lesions, Osler nodes) occur in left sided IE
Appropriate birth weight and height increase by 12 months?
Tripled birth weight
1/5 times size at birth
All pts w HELLP require what if they develop severe abdo pain?
IMMEDIATE Abdo USS as serious complication is hepatic subcapsular haematoma which can rupture
Pts develop abdo pain w HELLP due to stretching of Glisson capsule from hepatic swelling
Posterior reversible encephalopathy syndrome
Seizures, headaches, visual disturbances, AMS
BILATERAL VASOGENIC OEDEMA in subcortical white matter in PARIETO-OCCIPITAL regions
Dx NEUROIMAGING
Rfs: hypertensive emergency, preeclampsia, renal failure, sepsis, immunosuppressive meds
Tx: supportive, tx underlying condition
CF herpes simplex encephalitis affects temporal lobes and gives lymphocytosis in CSF
Dysphagia and circumferential oes narrowing w normal histo findings in a pt w GORD?
Oes ring (Schatzki ring)
Tx: MECHANICAL DILATION w a bougie or balloon dilator
N.B: assoc w hiatal hernia but first tx oes ring w mechanical dilation then perform Nissen fundoplication to tx hernia (as otherwise if done first, it would further narrow the lower oes and worsen dysphagia)
Foster Kennedy syndrome
Ipsilateral atrophy of optic nerve (due to nerve compression), CONTRALATERAL papilloedema (raised ICP) and anosmia.
Usually caused by FRONTAL LOBE tumours (e.g. meningioma)
Anosmia from meningiomas arising from olfactory groove
Preg pt beta hCG <1000 investigation?
TVUSS 2-3 days after initial test
(TVUSS may give false-neg result if beta hCG < 1500-2000 or if < 5wks gest)
Repeated measurement of beta hCG to check appropriate rise (double approx every 2.5d); slow rise = ectopic/abortion; rapid rise = hydatidiform mole/chorioca or twin preg
Caudal regression syndrome
Strongly assoc w UNCONTROLLED DIABETES during PREG
CRS = caudal half of spine develop abnormally; m/c pres = absent sacrum and coccyx
Can also manifest as part of VACTERL syndrome
Chronic inducible urticaria
Recurrent andioedema and/or pruritic wheals >6 weeks, can be physical/non-physical by cause
If suspected, PROVOCATION & THRESHOLD TESTING performed to identify triggers and confirm dx
Tx = trigger avoidance, pt education, second gen H1 receptor antagonist
Secondary prophylaxis for variceal bleeding
Propranolol (causes splanchnic vasconstriction -> less blood in portal veins -> less portal venous pressure) and EVL every 1-2 weeks until all varices obliterated
N.B: TIPS only used as secondary prophylaxis in pts w recurrent variceal bleeding despite first line mx as TIPS can cause HE
Absolute CIs for organ donation?
Incurable or metastatic malignancy, sepsis, transmissible spongiform encephalopathies (CJD) and a cardiac arrest that occured before brain death
N.B: HIV pts can donate organs to HIV recipients; similarly for HCV who can donate to HCV recipients
Narcolepsy tx
Optimise sleep hygiene
MODAFINIL (+- sodium oxybate/pitolisant)
Second line = dextroamphetamine, methylphenidate
N.B: narcolepsy = EDS (excessive daytime sleepiness) with cataplexy, hypnagogic/hypnopompic hallucinations and sleep paralysis
N&V of preg not improved by vit B6 (pyridoxine) tx?
DOXYLAMINE
Also dietary changes (cut out spicy/high fat/acidic foods) and avoidance of triggers (loud noises, strong odours) may help improve N
If P+D unsuccessful, antiemetics can be trialled (e.g. promethazine, diphenhydramine)
Central cord syndrome
Common in whiplash-type injuries (hyperextension) in older adults with underlying cervical spondylosis
Upper extremity motor, sensory and reflex abnormalities; sacral (bowel/bladder) and lower extremity function preserved
N.B: syringomyelia can also cause central cord syndrome
TTE or TOE for aortic dissection?
TTE: only for prox ascending aorta; fast, non-invasive but low sensitivity/specificity
TOE: fast, high S/S; preferred in HD unstable pts/renal insufficiency (CT angio w contrast not best in these cases); N.B: if interscapular pain suggests prox descending aorta involvement so TOE not TTE
Brain death assessment
Before dx, evaluate for confounding factors:
Core body temp >36C for min 24hrs as hypothermia may impede neuro assessment and affect apnoea test
Also poisoning, drug intox, electrolyte imbalances, hypotension, BD mimics (e.g. locked-in syndrome), SBP >100 (may need vasopressors)
If these conditions met, plus pts still present w coma and brainstem areflexia, apnoea testing performed to make dx
OCPs assoc w which liver benign tumour?
Hepatic adenoma (if taking OCPs, increased risk of haemorrhage so stop)
Not FNH (central hypoattenuated scar on CT) so can continue OCP and just observe
Simple breast cyst ix
Well-circumscribed anechoic mass w posterior acoustic enhancement on USS in premenopausal woman
If sx/concerned about breast ca, FNA dx and tx
N.B: core needle biopsy only if solid mass on USS/mammo and if malignant features on FNA (i.e. does not resolve upon aspiration)
Severe Lyme disease tx
Severe: sx, 1st degree AV block PR >= 300ms, second or third degree; encephalopathy, polyneuropathy and persistent arthritis
IV CEFTRIAXONE (not oral doxy)
M/c cause of GB metastasis
Malignant melanoma
Exercise-induced bronchoconstriction mx
Improve control of underlying asthma
Premedicate before exercise: ICS-formoterol (10min before) preferred over SABA, LTRA (2hr before)
Daily ICS-beta agonist or LTRA may be needed for frequent, prolonged exercise
Acute tonsillitis: neg Strep test then what?
Throat culture if still suspect bacterial infection (no viral tonsillitis signs: conjunctivitis, hoarseness, cough, stomatitis)
Rapid strep test low sensitivity high specificity
Neonatal bacterial meningitis tx
GENTAMICIN, ampicillin, cefotaxime
N.B: vanc and cefotaxime/ceftriaxone used instead in adults
if >50: V, A, C
if immunocompromised: V, A, C/M (cefepime/meropenem)
Acute patellar dislocation plus osteochondral # (suggestive of avulsion #) tx
Osteochondral # repaired and removed BEFORE reducing patellar dislocation to prevent osteochondral damage, which can occur during reduction due to shearing forces
Repair osteochondral # with ARTHROSCOPY
Pts w FGR require what?
High risk for intrauterine foetal demise so require immediate UMBILICAL ARTERY DOPPLER USS to assess placental perfusion
Lyme disease in children: 1st line therapy?
Oral AMOXICILLIN (also tx of choice if preg/lactating)
Doxy is an alternative
N.B: tetracycline CI in children < 8 due to bone growth inhibition and teeth discolouration
Pregnant woman and high-grade precancerous lesion (CIN2/3) mx?
Colposcopic surveillance w HPV-based testing every 12-24 weeks (or deferring colposcopy until >= 4 weeks after delivery)
Excisional procedure only if invasive ca suspected
Drug induced ICH
Vitamin A and its analogues e.g. ATRA, isotretinoin. Also tetracyclines, growth hormones and lithium
Calcaneal apophysitis
Common cause of heel pain in children (growth spurts) who play running or jumping sports
Tenderness at base of heel with calcaneal compression
Supportive tx
CF plantar fasciitis: unilateral not bilateral; pain on first stepping out of bed and improving throughout the day; pain also worsens after long periods of standing or walking; tenderness at insertion of plantar fascia on calcaneus, worse during PASSIVE DORSIFLEXION of TOES
Thyroglobulin
Precursor to thyroid hormones
Produced only by thyroid tissue (normal or malignant)
Serum thyroglobulin measurements used as a tumour marker once normally functioning thyroid tissue removed
N.B: levo given after thyroidectomy for 2 reasons: replace thyroid hormone and to suppress TSH release from pituitary (less thyroid tissue growth so prevent thyroid cancer recurrence)
Oesophageal rupture dx
Contrast oesophagography with gastrographin if HD stable (better than barium swallow which can cause mediastanitis/fibrosis)
CT scan chest if HD unstable/not suited to contrast oes
Adenosine/dipyrimadole use during cardiac stress testing
Both cause coronary vasodilation and can cause coronary steal syndrome (diversion of blood flow from stenotic coronary arteries) leading to tissue ischaemia (see Amboss diagram) and subsequent ECG changes
CF exercise stress test/dobutamine stress test increases myocardial oxygen demand so won’t cause ischaemia/ECG changes
IE Abx tx?
IV ceftriaxone (4 weeks)
Staphylococci
MSSA: nafcillin, oxacillin
MRSA: vancomycin
Prosthetic valve endocarditis (≤ 1 year after placement): Add GENTAMICIN PLUS RIFAMPIN to the regimen
Viridans group streptococci: beta-lactam (e.g., penicillin G, ampicillin)
Enterococci: combination therapy (e.g., ampicillin PLUS gentamicin)
N.B: empiric therapy:
Native valve endocarditis: vancomycin PLUS ceftriaxone
Prosthetic valve endocarditis: Add GENTAMICIN PLUS RIFAMPIN to vancomycin PLUS a beta-lactam (if ≤ 1 year after placement).
Appendiceal abscess tx
Nonoperative measures (IV abx, fluids, bowel rest) and percutaneous drainage of abscess if large (>4cm)
Do not perform emergency OR interval appendectomy
Only perform interval appendectomy if age >40 and worried about appendiceal tumour/recurrent sx
Paediatric empyema
Bacterial invasion of pleural space resulting in fibrinopurulent consolidation
Strep pneumo, Staph aureus (e.g. MRSA)
Pneumonia sx
No improvement with routine pneumonia tx
Signs of pleural effusion (e.g. dullness to percussion)
Lab evidence of inflam (leukocytosis, thrombocytosis)
Supportive care
Empiric abx (ceftriaxone/cefotaxime + VANCO/clinda to cover MRSA)
and Drainage (chest tube w intrapleural fibrinolytics/step up to surgical VATS if advanced or highly loculated)
Methamphetamine intox
Euphoric/dysphoric mood (anxiety, irritability)
Agitated behaviours (restlessness, tremours)
Bruxism, POOR DENTITION, gingivitis “METH MOUTH”
CARDIOMYOPATHY/HEART FAILURE
TRANSIENT Psychotic sx (d/h/formication) (CF primary psychotic disorder)
Anorexia
Decreased need for sleep
Sympathomimetic effects (as it is a stimulant!)
SKIN EXCORIATIONS due to recurrent skin picking
Acute pericarditis vs chronic constrictive pericarditis auscultation findings
Acute pericarditis: friction rub
Chronic constrictive pericarditis: pericardial knock (high pitched early diastolic sound, like a premature S3)
Strongest predisposing factor for bipolar disorder?
GENETIC PREDISPOSITION
SCLC vs NSCLC tx
SCLC: polychemo (cisplatin & etoposide) & radiation therapy
N.B: SCLC is non-resectable (surgery only considered is very small lesions and no nodal involvement)
NSCLC: lobectomy
Risk of bleeding from angiodysplasias increased with which conditions?
ESRD & aortic stenosis (destruction of circulating vWF multimers when pass through valve)
Cervical myelopathy
Age > 55
Degenerative cervical spine/disks -> canal stenosis -> cord compression
GAIT DYSFUNCTION - usually first
Extremity weakness & numbness
LMN signs (arms): muscle atrophy, hyporeflexia
UMN signs (legs): Babinski, hyperreflexia
Decreased proprioception/vibration/pain sensation
MRI of cervical spine
CT myelogram
Nonsurgical - immobilisation
Surgical decompression
Severe aortic stenosis signs
Pulsus parvus et tardus
LATE-PEAKING crescendo-decrescendo systolic murmur
Soft and single S2 during inspiration (split narrowed during inspiration and paradoxical split during expiration)
Placenta previa rfs
Prior C SECTION (uterine scar and change in vascularity alter early preg implantation)
Prior PP, multiple gestation (increased placental SA) and advanced maternal age
Spondylolysis
Defect (e.g. fatigue fracture) of pars interarticularis commonly seen in young athletes
Pain on LUMBAR EXTENSION which stresses fracture site (low central back pain) and occasionally compresses nerve roots (radicular pain); flexion offloads fracture site and relieves pain
Dx on AP & lateral X RAY of lumbar spine, which are obtained if low back pain persists for 2-4 weeks
Tx: activity reduction for 90 DAYS
Varicocele
Primary or secondary
Primary:
Compression of left renal vein between SMA and aorta
Incompetent venous valves
Bag of worms mass
Pubertal onset
Left-sided
Decompresses when supine (increases with standing/Valsalva)
Reassurance and observation
Secondary:
Extrinsic compression (renal or retroperitoneal mass) of IVC
Venous thrombus
Bag of worms mass
Prepubertal onset
Right-sided
Persists when supine
Abdo USS (to ix for secondary cause)
Massive haemothorax
Tube thoracostomy often sufficient to manage haemothorax but some pts need EMERGENT THORACTOMY for extreme bleeding:
Initial bloody output > 1500ml
Persistent haemorrhage: >200ml/hr for > 2hr or continuous need for blood tx to maintain HD stability
N.B.: clamping chest tube not recommended as does not stop internal bleeding and can negatively impact chest expansion
Tick-borne paralysis
RAPIDLY progressing ascending paralysis (may be asymmetrical CF GBS which is symmetrical and not as rapid), absence of fever and sensory abnormalities, NO AUTONOMIC DYSFUNCTION (e.g. tachy, urinary retention, arrhythmias seen in GBS), NORMAL CFS findings (as due to neurotoxin release by tick)
METICULOUS SEARCH for ticks and removal -> resolution
Penetrating trauma located anteriorly below nipple line (4th ICS on right/5th ICS on left), eval for what?
Trauma to BOTH THORAX & ABDOMEN
Therefore may need emergent exploratory laparotomy even if equivocal FAST exam (and obv evisceration, signs of peritonitis, free air under diaphragm)
N.B: haemothorax can present with lower lobe opacification on CXR but would expect to have blunting of CP angle, meniscus line due to pleural effusion etc, dyspnoea, diminished breath sounds
Myxoedema coma
A condition of severe hypothyroidism characterized by altered mental status, hypothermia, myxedema (PERIORBITAL OEDEMA & NON-PITTING OEDEMA of LOWER EXTREMITIES - seen in Graves disease and hypothyroidism), hypoventilation, hypotension, and bradycardia.
Etiologies include nonadherence to thyroid replacement therapy, infections, surgery, and/or trauma that result in decompensation of an existing thyroid hormone deficiency.
Treatment with liothyronine and levothyroxine should be started immediately if myxedema coma is suspected; patients should also be treated with glucocorticoids until coexisting adrenal insufficiency can be ruled out.
Ischaemic colitis phases
Hyperactive phase: crampy abdo pain w bloody, loose stools
Paralytic phase: diffuse pain, bloating, absent bowel sounds, cessation of stools
Shock phase: signs of peritonitis and septic shock
Absolute CI to ECT?
NONE!
Hydatid cyst (Echinococcus) tx
Oral albendazole 1-6 mo
Check CBC before initiating as can cause leukopaenia
Surgery/PAIR (aspiration) if cyst >5cm or assoc w complications (rupture, pulm cyst, biliary fistulae)
Which drugs cause impaired thermoregulation?
PHENOTHIAZINES (FLUPHENAZINE, PROCHLORPERAZINE), which are used for maintenance therapy in patients with chronic psychotic disorders (e.g., schizoaffective disorder), cause impaired thermoregulation (i.e., hypothermia or hyperthermia), resulting in intolerance of extremes in environmental temperature. This side effect is believed to be due to the drug’s effect on the hypothalamus, which leads to inappropriate responses to heat (e.g., lack of sweating/peripheral vasodilation) or cold (e.g., lack of shivering). Therefore, patients on fluphenazine therapy who are likely to be exposed to extreme temperatures (e.g., those who are homeless) should be closely monitored.
Prolonged immobilisation can do what to serum ca?
HYPERCA
Due to increased osteoclastic activity, esp in individuals with high baseline bone turnover rate (e.g. young individuals, Paget)
BISPHOSPHONATES tx to prevent bone loss and reduce hyperca
N.B: corrected ca = measured ca + 0.8 x (4-albumin)
Hyperalbuminaemia assoc w increase in total serum ca but does not affect ionised levels so will not have ca related sx
Alcohol use disorder meds
Naltrexone (mu opioid receptor antagonist)/acamprosate (glutamate modulator)
Naltrexone: can be initiated while pt still drinking, CI in pts taking opioids as can precipitate withdrawal, and in pts w ACUTE HEPATITIS/LIVER FAILURE
Acamprosate: used to maintain abstinence, CI in pts w SEVERE RENAL IMPAIRMENT
N.B: disulfiram (alcohol dehydrogenase inhibitor) can only be used in abstinent pts (causes unpleasant reaction when drinking), pts must be highly motivated/taken in supervised setting and used 2nd line after naltrexone/acamprosate
Increased talkativeness, excessive movement, and agitation following an administration of lorazepam?
PARADOXICAL REACTION TO BENZOS
Most commonly occurs in older individuals and children; risk factors include substance use (e.g., alcohol use disorder) and preexisting psychiatric conditions (e.g., anxiety disorder, personality disorders).
Tx = Taper and discontinue drug
Asx bacteriuria during preg tx
CO-AMOXICLAV
Or oral cephalosporins (cefpodoxime, cephalexin), fosfomycin, and nitrofurantoin (during 2nd and 3rd trimesters)
N.B: TMP-SMX for uncomplicated cystitis in nonpreg women (can be given second line in 2nd/3rd trimesters)
Cipro for complicated UTIs in nonpreg women (CI in preg)
Preg and acute pyelonephritis: IV 3rd gen ceph (USS kidneys only if anatomic anomaly/structural renal disease/immunocompromise/hx of recurrent UTIs/do not respond to appropriate antibiotic therapy within 48–72 hours)
Pregnancy loss tx
First trimester: D&C
IUFD (absent foetal cardiac activity after 20 weeks gestation): spont expulsion usually occurs within 2 weeks but offer vaginal misoprostol/oxytocin infusion if spont expulsion not occurred by 2 weeks or pt wants immediate intervention
N.B: retention of dead foetus for more than 2 weeks leads to systemic absorption of THROMBOPLASTIN (tissue factor) produced by placenta and dead foetus -> coag cascade activation -> DIC
First dx step in all pts w LUTS?
URINALYSIS: can give info about DM (glucosuria) /UTI (pyuria and bacteriuria) and haematuria (?malignancy)
N.B: PSA not routinely done in pts w LUTS and suspected BPH; only perform if suspect prostate ca and life expectancy > 10 years and candidates for tx
Side effects of protease inhibitors
UROLITHIASIS (poorly soluble and renally excreted)
As well as metabolic abnormalities and lipodystrophy
Secondary prophylaxis of recurrent ARF in pts with carditis but no permanent valve damage
IM BENZATHINE PENICILLIN every 4 weeks for 10 YEARS
(- carditis: … for 5 years)
(+ permanent valve disease: … until age 40)
Erythema nodosum diagnostic workup
Could be underlying/preceding systemic illness, esp STREP PHARYNGITIS/SARCIDOSIS
CBC & ASO TITRES
CXR (hilar lymphadenopathy)
LATENT TB TESTING (TST/IGRA)
N.B: ANA is NOT part of dx workup
Suspected septic CVT tx
Septic CVT assoc with cavernous sinus syndrome: A condition caused by compression of the cranial nerves that pass through the cavernous sinus (i.e., III, IV, V1, and V2).
Empiric therapy with VANCOMYCIN (for coverage of MRSA) should be combined with a third- or fourth-generation CEPHALOSPORIN (ceftriaxone or cefepime) and, if the infection originated from the sinus or the teeth, METRONIDAZOLE (for anaerobic coverage). Affected patients should be treated with high-dose, prolonged antibiotic therapy to reach bacteria sequestered within thrombi. Antifungal therapy (amphotericin B) is indicated in confirmed cases of fungal origin.
N.B:
Anticoagulation: indicated for all patients with CVT (intracerebral hemorrhage and underlying infection are not absolute contraindications)
Acute phase
First line: low molecular weight heparin (LMWH)
Second-line: unfractionated heparin
Long-term anticoagulation: Transition to vitamin K antagonists
Mood reactivity is a key feature of what?
ATYPICAL DEPRESSION
Hypersomnia, weight gain, leaden paralysis, hypersensitivity to rejection
Intrauterine foetal demise mx vs spontaneous abortion
Spontaneous abortion (ie miscarriage) before 20 weeks gest
IUFD (ie stillbirth) absent cardiac activity after 20 weeks gest
Spont abortion: based on pt preference (expectant, medical, surgical - surgical indicated for other reasons eg septic abortion, heavy bleeding etc)
IUFD:
20-23 wks: dilation and evacuation or vaginal delivery (C section if requested and prior hx of C section)
>= 24 wks: vaginal delivery (or C section…)
N.B: INDUCTION OF LABOUR IMMEDIATELY OR WITHIN A WEEK due to maternal coagulopathy complication after several weeks of retention
Chronic DIC
Seen in pts w mucin-producing tumours (e.g. pancreatic ca) due to periodic release of tissue factor into bloodstream
Normal plt counts and coagulation times (CF acute DIC) but at increased risk for venous and arterial thrombosis and also mucocutaneous bleeding (e.g. gums/nose)
N.B: acute DIC more likely to present w bleeding; chronic with thromboembolism
Late-onset GBS in neonates/young infants vs early-onset
Early onset (age <7d): usually within 24hrs; sepsis, pneumonia, meningitis
Late onset (age >= 7d): typically at age 4-5 weeks; bacteraemia, meningitis, focal infection (e.g. CELLULTIS-ADENITIS)
Spinal muscular atrophy: common presentation in children?
RECURRENT HIP DISLOCATION (diff in leg length w ext rotation of affected leg)
Autosomal recessive condition caused by apoptosis of lower motor neurons.
Hypotonia, BULBAR PALSY symptoms (e.g., tongue fasciculations, difficulty feeding), and hyporeflexia
Cranial nerves III, IV, and VI are not affected in SMA, resulting in normal ocular movement (CF infant botulism which is descending paralysis affecting eyes). In addition, cognition and behavior in these patients are normal.
Diagnosis is confirmed with genetic testing.
Treatment with nusinersen, risdiplam, or onasemnogene abeparvovec is considered definitive therapy. Patients with SMA also often need supportive therapy with respiratory and nutritional support, physical therapy, and/or orthotics.
Rf for pyloric stenosis?
BOTTLE FEEDING
Infants who are breastfed have a lower incidence of pyloric stenosis compared to infants who are bottle-fed. Infants who are bottle-fed (whether breastmilk or formula) tend to consume a larger volume in less time compared to infants who are breastfed, which may lead to pylorus muscle hypertrophy via overstimulation. In addition, higher levels of vasoactive intestinal peptide (VIP) in breast milk may help mediate pyloric relaxation, facilitating gastric emptying compared to infants who are formula-fed.
HAPE (high-altitude pulm oed) vs multifocal pneumonia
HAPE:
Recent arrival at high altitude (<1wk)
Absent/mild leukocytosis (<15,000, no bands)
Procalcitonin normal
Marked early improvement with supplemental oxygen
Vice versa for multifocal pneumonia
Lymphangitis
Cutaneous injury -> pathogen invasion of lymphatics in deep dermis
STREP PYOGENES & MSSA
Tende, erythematous streaks prox to wound
Regional tender lymphadenopathy (lymphangitis)
Systemic sx (fever, tachycardia)
CEPHALEXIN tx
CF sporotrichosis causing nodular lymphangitis characterised by nodules and develops over weeks not days
Extraintestinal manifestations of coeliac disease
Autoimmune related
e.g. PERIPHERAL NEUROPATHY, ATROPHIC GLOSSITIS, depression/anxiety
plus all other malabsorption nutrition related sx
Diastasis recti tx
EXERCISE PROGRAM 6-8 WEEKS AFTER DELIVERY to help strengthen abdominal rectus muscles and reduce abnormal extension of linea alba
Weight loss if caused by obesity
Surgical repair only if conservative measures fail or if recurring and sx etc
N.B: compression garment for seroma
UC prolapse rfs
Iatrogenic interventions (e.g., induction of labor, assisted vaginal delivery),
fetal prematurity and low birth weight,
polyhydramnios,
multiple gestations,
long umbilical cord,
FOETAL MALPRESENTATION (e.g., BREECH presentation) is another important risk factor for umbilical cord prolapse. In breech presentation, an unengaged fetal head creates enough space for the umbilical cord to prolapse through the cervical opening past the fetal presenting part.
Target blood glucose goals in GDM
Fasting <= 95
1hr PP <= 140
2hr PP <= 120
Mx:
1st line = diet
2nd line = insulin, glyburide, metformin
N.B: weight loss NOT indicated due to FGR, preterm delivery etc
Anaemia seen in SCD
Normochromic, normocytic with increased retic
But with chronic haemolysis and inadequate folate intake, can get folate deficiency anaemia (raised MCV as BM using folate to produce more RBCs) and inappropriately normal retic (due to inadequate erythropoiesis)
Prevention of perinatal GBS: intrapartum antibiotic prophylaxis choice
IV penicillin
Minor pen reaction (e.g. nonpruritic MP rash): cefazolin
Severe pen reaction w high risk for anaphylaxis (e.g. resp distress/urticaria): dual testing for erythro/clina (as erythro resistance can induce clinda resistance); if both sensitive then clinda; if both resistant/inconclusive then vanc (but need to monitor neonate if given vanc as does not reach as high conc in amniotic fluid CF pen)
Vascular dementia features
EXECUTIVE DYSFUNCTION (CF frontotemporal = change in personality, hyperorality; AD = memory loss)
PROGRESSIVELY WORSENING COURSE: can be step-wise if large/multiple infarcts (e.g. overt strokes) but can be smooth decline if small vessel disease; abrupt decline in cognitive functioning if single, strategic infarction (medial frontal lobes, medial temporal lobes, thalamus)
LOCALISING NEURO SIGNS
SUBCORTICAL DEFICITS: urinary incontinence, gait disturbance
CF poststroke depression: sadness not apathy; evidence of strategic infarct causing abrupt decline in cog functioning more consistent with vasc dementia
Endometrial polyp presentation
Woman in 20s/40s with regular monthly menses (do not affect ovulation) and additional painless INTERMENSTRUAL BLEEDING
If sx: tx = hysteroscopic polypectomy
Opioid meds in pts w impaired kidney function
Recommended:
Fentanyl (has inactive metabolites)
Hydromorphone
Methadone (not renally excreted)
Buprenorphine
Avoid:
Morphine, mepiridine, codeine, tramadol (all have active metabolites and are renally excreted)
Dx test to confirm primary hyperaldosteronism
PAC:PRA > 20 suggestive of primary hyperaldosteronism but SALINE INFUSION TEST to confirm it
Failure to inhibit aldosterone release (PAC > 10) upon saline infusion indicates autonomous (renin-independent) aldosterone release and confirms dx
Other confirmatory tests: oral sodium loading test, fludrocortisone suppression test, captopril suppression test
After dx confirmed, ADRENAL CT to identify cause
Hepatic encephalopathy precipitating factors
Hypovolaemia, GI bleeding, electrolyte disturbances (e.g. HYPOKOLAEMIA)
Hypokalemia, which can be precipitated by the use of diuretics, is accompanied by the intracellular movement of hydrogen ions into cells to maintain electrical neutrality. The resulting intracellular acidosis in renal tubular cells can lead to increased production of ammonia and bicarbonate from glutamine to maintain acid-base balance. Metabolic alkalosis, which can also be precipitated by the use of diuretics, leads to increased conversion of ammonium to ammonia. Ammonia is then able to cross the blood-brain barrier, resulting in increased neurotoxin accumulation in the brain.
Tx = CORRECT PRECIPITATING FACTORS, lactulose to allow ammonia (rifaxmin given with lactulose to prevent recurrent episodes after 2nd episode)
Malaria prophylaxis in pregnant pts
Chloroquine resistant P falciparum (widespread) endemic region (e.g. sub Saharan Africa/SE Asia): MEFLOQUINE (doxy can be given for nonpreg pts)
N.B: Primaquine CI during preg and only for vivax and ovale
Atovaquone-proguanil covers chloroquine resistant falciparum but not used in preg
Corpus luteum removal during preg (e.g oophorectomy after ovarian torsion)
During early preg corpus luteum produces progesterone which prepares endometrium for implantation, promotes implantation and maintains preg through 10 weeks gest (luteal-placental shift after)
If corpus luteum removed prior to 10 weeks gest, pts require PROGESTERONE SUPPLEMENTATION to prevent preg loss (discontinue after 10 weeks gest)
Diaphragmatic rupture confirmatory test
CT SCAN CHEST & ABDO
Can present months - years after blunt thoracoabdo trauma in children
More commonly on left side due to lack of liver protection and diaphragm pos
CXR findings: bowel loops in thorax, mediastinal shift
Congenital dacrocystenosis
M/c cause of eye discharge in infants
NLD obstruction due to incomplete canalisation of distal duct in utero
Intermittent or chronic tearing, mucoid discharge
Eyelash crusting/matting
Absence of conjunctival injection
Mx: lacrimal sac massages, reassurance (resolution typical at age 6-12mo)
Complications:
dacrocystocoele; dacrocystitis
DKA resolution markers
NORMALISATION OF SERUM ANION GAP (reflecting disappearance of ketoacid anions) and SERUM BETA HYDROXYBUTYRATE levels (predominant ketoacid in severe DKA)
Acute endophthalmitis tx
VITRECTOMY (if severe vision loss) followed by INTRAVITREAL ABX
Acute-onset visual loss, ocular pain, conjunctival injection, hypopyon, and a hazy retina after undergoing cataract surgery
Ophthalmological emergency as patients can rapidly develop permanent vision loss.
Abx to cover coagulase-negative Staphylococci and Staphylococcus aureus (e.g., vancomycin plus ceftazidime) - most common causative pathogens.
Intraocular lens placed during cataract surgery left in place
Indications for HD over sodium bicarb in salicylate tox
Pts unlikely to tolerate large vol of bicarb needed, e.g. ESRD, renal failure and salicylate-induced resp failure (noncardiogenic). Also in severe ingestions, refractory acidosis or clinical worsening despite bicarb use
Activated charcoal within 2 hours of acute ingestion
Preferred method for collecting urine sample for urinalysis/culture in children not toilet trained
TRANSURETHRAL CATHETERISATION (or suprapubic aspiration but invasive)
Clean catch not recommended as very easily contaminated
N.B: A renal ultrasound to evaluate the urinary tract for conditions that may predispose to UTIs is indicated in children < 2 years with a FEBRILE UTI as well as in children with structural abnormalities of the urinary tract, recurrent UTIs, or UTIs not responsive to antibiotic therapy
Bladder cancer tx
Non-muscle invasive:
low grade - TURBT w intravesical chemo
high grade - TURBT w intravesical BCG vaccination
Muscle invasive: radical cystectomy w construction of urinary diversion (e.g. neobladder, ileal conduit); neoadjuvant cisplatin chemo
Preeclampsia without severe features prior to 34 wks gest mx
Home BP monitoring and follow-up exam 1-2 times per week (PLT count, liver enzymes, Cr)
Fetal monitoring should also be performed, including a nonstress test at every follow-up visit and an ultrasound every 3 weeks.
Patient education about findings of preeclampsia with severe features (e.g., SBP ≥ 160 mm Hg, DBP ≥ 110 mm Hg, severe headache, epigastric pain, blurry vision, reduced fetal movement) and the need to seek medical attention if any of these findings are present.
If the patient develops preeclampsia with severe features, she should be admitted to the hospital for antihypertensive therapy with intravenous hydralazine, intravenous labetalol, or oral nifedipine; eclampsia prophylaxis with magnesium sulfate; and antenatal corticosteroid therapy. Delivery should be considered after stabilization.
Tethered cord syndrome (spinal dysraphism)
Stretch-induced dysfunction of spinal cord
Closely related with CLOSED SPINAL DYSRAPHISM (e.g. dimple, hair tuft, haemangioma or subcut mass e.g. lipoma)
Back/leg pain worse with activity
Neuro findings (weakness, hyporeflexia)
Leg weakness due to muscle denervation can lead to gait abnormalities, muscle atrophy and foot drop
New-onset scoliosis due to improper pos to relieve back discomfort
Lumbosacral cutaneous abnormality
Colle’s fracture can injure what nerve?
MEDIAN
N.B: FOOSH can cause displaced supracondylar fractures of the humerus with posterior displacement of distal humerus fragment. Anteriorly displaced prox humerus fragment can entrap BRACHIAL ARTERY & MEDIAN NERVE, which pass anterior to humerus
N.B.2: ulnar nerve injury is a rare type of supracondylar fracture that occurs with flexed (rather than hyperextended) elbow. Anterior displacement of distal humerus fragment, impinge on ulnar nerve located posterior to medial epicondyle of humerus
Bacillary angiomatosis vs kaposi sarcoma
BA: bright red, firm, friable, exophytic nodules, fever
KS: lesions also occur on trunk and extremities; papules then plaques/nodules; light brown to pink to dark violet
All suspected cases of child abuse mx
SKELETAL SURVEY & FUNDOSCOPY
Findings that support physical child abuse include multiple fractures at different stages of healing, metaphyseal and epiphyseal corner fractures, posterior rib fractures, spiral diaphyseal fractures of long bones (e.g., humerus), retinal hemorrhage, and vitreous hemorrhage. Suspected child abuse warrants an immediate notification of Child Protective Services.
PCP allergy to sulfa drugs tx
IV CLINDA & ORAL PRIMAQUINE
(N.B: Glucocorticoids are added to treat PCP in the case of respiratory insufficiency (PaO2 < 70 mm, arterial‑alveolar oxygen gradient > 35, or room air oxygen saturation < 92%).
Mercury poisoning
Neuropsychiatric symptoms including anxiety, erethism mercuralis (abnormal irritability), ataxia, and tremor.
Polyneuropathy may also be observed.
Another common sign is GINGIVAL and/or BUCCAL INFLAMMATION with a characteristic bluish‑violet discoloration.
Lead poisoning would manifest with symptoms very similar to the ones in this case, including neuropsychiatric disturbances and anorexia. DIMERCAPROL is also the first-line treatment (also used in arsenic poisoning). However, this patient’s prominent excess salivation, odynophagia, and gingival inflammation would not be expected in cases of lead poisoning
N.B: lead poisoning:
Blood lead < 45: address risk factors for lead poisoning (e.g., by treating pica) and limiting lead exposure by removing the source (e.g., paint, furniture, water, toys, soil, dust, secondhand exposure).
Blood level > 45: Chelation therapy (e.g., with oral succimer)
Blood level > 70/acute lead encephalopathy: chelation with IM dimercaprol
N.B. 2: pica is a rf for lead poisoning (pica can be caused by IDA, preg, stress, psych illnesses)
HBV PEP (post)
Hepatitis B immunoglobulin (HBIG) is included as part of the PEP for hepatitis B in individuals with occupational exposure who have not undergone a 3-dose vaccination schedule or did not properly respond to it (as with this patient).
The HBV vaccine is a recombinant vaccine that uses hepatitis B surface antigen (HBsAg) and is always given as part of HBV PEP.
Since this individual did not respond to his initial 3-dose vaccination regimen, he should undergo another regimen, starting with an initial dose of the HBV vaccine along with the HBIG. The next 2 vaccine doses should be administered according to the vaccination schedule.
It is recommended that all healthcare personnel, including this patient, are vaccinated with a complete 3-dose series of the HBV vaccine. If after ≥ 6 doses of HBV vaccine this individual still has an anti-HBs < 10 mIU/mL, he would be considered a nonresponder.
African-American pt with isolated HTN tx
THIAZIDE DIURETICS/DCCB
Pasteurella vs bartonella clinical presentation
Pasteurella: cellulitis within days of dog/cat bite
Bartonella: initial papule (may go unnoticed) followed by painful regional lymphadenopathy in subsequent 1-2 wks
Common warts w assoc pain/functional impairment or discomfort tx
TOPICAL SALICYLIC ACID
Can also be combined with other first-line treatment options, such as cryotherapy with liquid nitrogen, for a faster and more effective therapeutic response.
N.B: pulsed dye laser therapy is a second line tx option, side effects: skin discoloration, scarring, pain
AOM abx in children
Oral abx if
1st line: amox if age < 6mo or >= 6mo plus high fever, bilateral, severe pain
2nd line: co-amox if refractory to 1st line or recurrent AOM (within 30d) after abx
Splenectomy in adults: when to give immunisations post-op?
Urgent/emergency splenectomy:
Most immunisations given 2 WEEKS after op (e.g. PCV15, meningococcal & Hib; CF PPSV23 given 10 weeks after op)
If elective splenectomy, immunisations given 14d pre-op
Since the risk of developing sepsis is low in asplenic adults compared to asplenic children, daily antibiotic prophylaxis is not recommended for adults. However, adult asplenic patients should be advised to immediately start broad-spectrum antibiotics (e.g., oral amoxicillin/clavulanate, cefuroxime, or fluoroquinolones) at the first sign of possible infection (e.g., fever, chills).
Suspect achalasia in a pt but has hx of weight loss/smoking, mx?
Suspect OESOPHAGEAL CA
So perform GO ENDOSCOPY to r/o malignancy as secondary cause of achalasia (ie pseudoachalasia)
Coefficient of variation (CV)
CV = SD/mean
CV, which is a statistical relative measure of dispersion, allows SD to be interpreted relative to the mean, allowing for the comparison of multiple data sets that may have means of different magnitudes or units of measurement.
A high CV indicates that values are widely spread around the mean.
In a system with multiple processes, such as the various aspects of a patient’s visit, the process with the highest CV should be optimized first to improve the system’s overall reliability and efficiency. Optimization of vital parameter measurements, which has the highest CV (5 ÷ 8 = 0.62), will therefore most likely have the greatest impact on reducing the average time that patients spend in the practice.
In contrast, SD, which is an absolute measure of dispersion, describes the variability of data in relation to the mean within a single data set.
Achondroplasia with muscle weakness/increased DTR mx
CT HEAD (or MRI head) as worried about BRAIN STEM COMPRESSION and SPINAL STENOSIS.
Narrowing of the foramen magnum commonly occurs in achondroplasia because of increased growth of the head compared to the torso, which can cause compression of the cervical medulla and lead to subsequent muscular hypotonia/quadriparesis, apnea/hypopnea, and sudden infant death.
Nephrogenic DI tx
INDOMETHACIN (inhibits renal prostaglandin synthesis, which promotes the action of ADH on the collecting ducts, resulting in decreased diuresis).
Other therapeutic measures to treat nephrogenic DI are adequate hydration, dietary salt and protein restriction (to prevent solute diuresis), and hydrochlorothiazide (HCTZ) therapy. Although HCTZ is a diuretic, in patients with nephrogenic DI it paradoxically decreases urine volume by an incompletely understood mechanism.
Upper airway cough syndrome (UACS) tx
Chronic cough (> 8 weeks), a history of rhinitis, evidence of a postnasal drip (e.g., cobblestone mucosa in the posterior pharynx), and no features of lower respiratory involvement (e.g., dyspnea, crackles, stridor) are compatible with upper airway cough syndrome (UACS), the most common cause of chronic cough.
FIRST-GEN ANTIHISTAMINE (e.g., dimetindene, diphenhydramine) for 2 WEEKS to achieve decongestion and subsequent reduction of postnasal drip. If symptoms improve within these 2 weeks, the diagnosis of UACS is confirmed. The underlying cause of UACS (e.g., allergic rhinitis, nonallergic rhinitis, chronic rhinosinusitis) should be subsequently treated.
Intranasal corticosteroids (e.g., fluticasone, budesonide) can be considered in patients with treatment-refractory UACS.
Tibiofemoral dislocation types and tx
Anterior TF dislocation: Immediate CLOSED reduction (then reevaluate pulses, ABPI to consider vascular ix ie doppler, CT angio)
Posterolateral TF dislocation (tibia posterior to femoral condyles plus medial collateral ligament and medial capsule invaginate into the joint): ORIF
Threshold for phototherapy in neonate with hyperbilirubinaemia?
> =18
In a 3-day-old term newborn who is medically well and lacks certain risk factors (e.g., lethargy, G6PD deficiency, isoimmune hemolytic disease), this threshold is at ≥ 18 mg/dL. If treatment is not initiated swiftly, the risk of neurotoxic damage (e.g., kernicterus) due to hyperbilirubinemia increases.
Exclusively breastfed newborns are at increased risk of developing neonatal jaundice. This patient’s jaundice is most likely caused by cephalohematoma acquired during vacuum-assisted delivery. Hemolysis of erythrocytes within the hematoma results in hyperbilirubinemia.
N.B: Exchange transfusion is indicated in newborns with total bilirubin serum levels above the age-adjusted threshold (≥ 24 mg/dL in a 3-day-old term newborn), an inadequate response to phototherapy, a rapid rise in total serum bilirubin levels, or signs of neurotoxicity (e.g., hypotonia, lethargy, shrill cry).
Normal serum osmolality
275-295
Child under 5 years with recent exposure to person with TB but normal TST mx?
Initiate RIFAMPIN therapy
A 4-month course of rifampin monotherapy is one regimen for the treatment of latent TB infection (LTBI). Children < 5 years of age have an underdeveloped immune system, which increases the likelihood of FALSE-NEGATIVE TST results, a rapid progression from LTBI to active TB, and a severe disease course.
WINDOW PROPHYLAXIS should therefore be offered to all children of this age with significant exposure to TB in the past 8 weeks, regardless of the initial examination findings and/or test results. A follow-up TST should be performed 8–10 weeks after the child was last exposed to TB. If the follow-up TST is negative and there is no suspicion of a false-negative result, the treatment may be discontinued. HIV-positive individuals should be managed similarly but receive full-length prophylaxis, even if the follow-up TST is negative. Isolation measures apply only to those with suspected or confirmed active TB.
PTH dependent hypercalcaemia causes
Primary hyperPTH
Familial hypocaliuric hypercalaemia
Lithium
Urine calcium creatinine clearance ratio (UCCR) = (Ca urine/Ca serum) / (Creatinine urine/Creatinine serum)
UCCR < 0.01 = FHH
UCCR > 0.02 = PH
Caustic ingestion
Acidic substances -> coagulative necrosis
Alkaline substances -> liquefactive necrosis
Chemical burn or liquefactive necrosis resulting in:
Laryngeal damage (hoarseness, stridor)
Esophageal damage: dysphagia, odynophagia
Gastric damage: epigastric pain, bleeding
ABC
Decontamination: remove contaminated clothing & visible chemicals; irrigate exposed skin
CXR if resp sx and to identify perforation
Endoscopy within 24 hours
N.B: activated charcoal decreases absorption of poisons (CF ingestions cause immediate local damage on contact with oesophagus)
Outpatient tx of CAP
Can tolerate penicillins:
Amoxicillin or co-amox (if severe disease ie >65, smoking, recent abx, major comorbidities, alcoholic)
PLUS
Macrolide/doxy
Cannot tolerate penicillins, can tolerate cephalosporins:
3rd gen ceph
PLUS
Macrolide/doxy
Cannot tolerate penicllins/ceph:
Resp fluoroquinolone
N.B: aspiration pneumonia caused by anaeobes and aerobes so tx in same way as CAP if no abscess/empyema (ie metro insufficient as only covers anaerobes)
Chronic tension headache prophylactic tx
AMITRYPTILLINE
Episodes occurring at least 15 days per month for more than 3 months.
Plus lifestyle and behavioral modification
Acetaminophen can be used to treat episodic tension headache, which is defined as 1–14 episodes of headache per month.
Meconium ileus mx
GASTROGRAFIN ENEMA
Bilious vomiting, a distended abdomen, and sparse bowel sounds, all of which are consistent with bowel obstruction. The findings of dilated small bowel loops on abdominal x-ray and a microcolon indicate meconium ileus as the cause for obstruction and explains why he has not yet passed stool.
Gastrografin enema is both diagnostic and therapeutic for meconium ileus. A gastrografin enema will allow visualization of the rectum and bowel to rule out other anatomical causes for bowel obstruction (e.g., intestinal atresia or volvulus) and, in the case of meconium ileus, can reveal the Neuhauser sign, microcolon, or meconium pellets. The contrast agent can also induce a laxative effect as the increase of osmolarity within the lumen of the bowel results in the breakdown and passage of the meconium obstruction.
More than 90% of patients with meconium ileus will have cystic fibrosis (CF). For unknown reasons, newborn screens for CF in patients with meconium ileus are often initially negative and require additional testing. Infants with meconium ileus should undergo diagnostic testing for CF through a sweat test or, if sufficient amounts of sweat cannot be obtained, through genotyping.
Acute vs chronic hyponatraemia tx
Acute (<48hr): at risk for brain herniation. So Na <130 with any sx of raised ICP: hypertonic 3% saline boluses to correct it rapidly (low risk of ODS)
Chronic (>= 48hr): hypertonic saline only if Na < 120, severe sx (seizure), or concurrent intracranial pathology
Hypertonic saline tx goal: raise Na by 4-6 over a period of hours (to reduce risk of herniation). Max rate of correction is 8 in 24 hrs to reduce risk of ODS
Breech presentation
Frank: hips flexed & knees extended (buttocks presenting)
Complete: hips & knees flexed
Incomplete: 1 or both hips not flexed (feet first)
Rfs:
Advanced maternal age
Uterine didelphys, septate uterus
Uterine leiomyomas (esp submucosal)
Foetal anomalies (e.g. anencephaly)
Preterm
Oligo/polyhydramnios
Placenta previa
Mx:
ECV (if no CI to vaginal delivery e.g. placenta previa, prior classical C section)
C section
Screening
Breast:
Mammography biennially age 50-74
Screening from 40-49 and over 75 not recommended but can be considered on individual basis
Colon:
Recommended at age 45 but definitely from 50
Annual FIT or 10 yearly colonoscopy
Flexi sig every 5 years (or every 10 years with annual FIT)
FDR w CRC/high-risk adenomatous polyp:
Colonoscopy at 40 (or 10 years prior to age of diagnosis in FDR, whichever first)
Rpt every 5 years (every 10 years if FDR dx > 60 y/o)
Pts w UC:
Start screening 8-10 years after dx
Colonoscopy every 1-3 yrs
Surveillance after colon ca resection:
Stage 1: Colonoscopy in 1 year and then every 3-5 years
Stage 2/3: As above, periodic CEA screening, annual CTAP
Stage 4: individualise, as above but more frequent CT scans
Cervical:
21-29: cytology alone (ie Pap smear)
30-65: Primary HPV every 5 years or HPV/Pap co-testing every 5 years or cytology alone every 3 years
Discontinue screening of average-risk individuals with a cervix at age ≥ 65 years if all the following criteria are fulfilled:
Documented adequate screening with negative results over the last 10 years, defined as any of the following:
2 consecutive negative primary HPV tests
2 consecutive negative cotests
3 consecutive negative cytology-alone screening
The most recent screening test should have been performed within the last 3–5 years.
No history of CIN 2+ within the past 25 years
Discontinue screening in individuals (of any age) with a limited life expectancy.
Lung:
Smokers: low-dose CT scan
Cholesterol screening: every 3-5 years
Resting ECG: once at 65 with Medicare
DM:
>= 35 regardless of rfs
<35 and overweight/obese and >= 1 other rf (FDFH, race/ethnicity e.g. Native American, hypertension)
Meningitis: LP, CTH or abx?
Because bacterial meningitis is associated with severe neurological sequelae and can be fatal (especially when treatment is delayed), a bacterial etiology must be presumed until the results of CSF analysis prove otherwise.
If any ALARM SX (mnemonic: FAILS: Focal neurological deficits, AMS, Immunocompromised, ICP elevated, Lesions in brain or skin near LP site, Seizures) are present, CT HEAD BEOFRE LP to mitigate the risk of brain herniation.
If LP is delayed for any reason (e.g., the need for a CT scan ie if ALARM sx present), obtain BLOOD CULTURES and administer empiric ANTIBIOTIC THERAPY until it can be performed. In the absence of alarm symptoms, the patient should first undergo an LP and then immediately receive empirical therapy.
The empiric therapy of choice for immunocompromised patients with suspected bacterial meningitis is vancomycin and ampicillin with either cefepime or meropenem. Additionally administering dexamethasone to reduce the risk of hearing loss may be considered for children with bacterial meningitis, especially if infection with Haemophilus influenzae type b is suspected.
Auricular haematoma: needle aspiration or I&D?
Needle aspiration: within 2d of injury and small (< 2cm)
I&D: larger (>= 2cm) and <7d old
Plus: 7–10 day course of LEVOFLOXACIN administered as prophylaxis against infection with skin flora or Pseudomonas aeruginosa.
Patients should be followed up daily to assess for reaccumulation of the hematoma or signs of infection and can return to sports after 7 days if the hematoma does not reaccumulate.
Accuracy
Probability that an individual is CORRECTLY CLASSIFIED by a test
Accuracy = (TP+TN)/(TP+FP+FN+TN)
NOT the same as PPV!
Homogenously enhancing mass compressing spinal cord (ie extramedullary)?
Spinal meningioma
Rfs:
Older age
Female
Genetic predispositions (e.g. NF2, schwannomatosis)
Exposure to IONISING RADIATION ( long latency period)
Graft rejection (e.g. renal)
Hyperacute/chronic: removal of graft as irreversible
Acute (1wk - 3mo after): PULSE STEROID THERAPY as reversible
Simple blood tx or exchange tx in SCD crises?
Simple transfusion:
acute mx of severe anaemia in SSC, aplastic crisis & nonsevere acute chest syndrome.
Avoid raising Hb to >8.
Splenectomy if hypersplenism/life-threatening/recurrent episodes
Exchange transfusion:
severe acute chest syndrome, treatment and secondary prevention of STROKE (N.B: DAPT not helpful), and treatment of hepatic sequestration crisis.
ADHD mx based on age
4-5 years (ie preschool): BEHAVIOURAL INTERVENTIONS (incl behavioural parent training)
> =6: pharmacotherapy (methylphenidate; atomoxetine 2nd line if p/fhx of substance abuse/parents object to stimulants)
Unilateral conjunctivitis w ipsilateral preauricular lymphadenopathy (Parinaud oculoglandular syndrome) causes?
FRANCISELLA TULARENSIS - normally causes ulceroglandular disease: single papuloulcerative lesion, tender, suppurative lymphadenopathy; if gets in contact w eye -> oculoglandular disease
Other causes: Bartonella henselae & HSV
PAD: no improvement despite conservative measures (smoking cessation, supervised exercise therapy), mx?
CILOSTAZOL
Therapeutic trial for 3-6 mo
Cilostazol improves symptoms of claudication and walking distance but has not been shown to decrease major cardiovascular events. Adverse effects are common and include headache, palpitations, diarrhea, and dizziness.
In addition to cilostazol, all patients with PAD should receive medical therapy with an antiplatelet agent (aspirin or clopidogrel), a statin to reduce the risk of myocardial infarction, stroke, and mortality, and antidiabetic agents if appropriate.
N.B: PTA/bypass surgery for patients with PAD and critical limb ischemia (ie rest pain, ulcers, gangrene) or lifestyle-limiting claudication persisting despite conservative and pharmacologic treatment.
Postop atelectasis: prevention strategies
Intraoperative ventilation with PEEP provides positive pressure to the lungs, which reduces alveolar collapse by stenting open the airways, thereby reducing the risk of postoperative atelectasis.
Postoperatively, lung expansion maneuvers that increase PEEP can also be used, such as CPAP or INCENTIVE SPIROMETRY. Other strategies to prevent postoperative atelectasis include deep breathing exercises, adequate pain control, and early mobilization.
N.B: postop atelectasis: early after op (e.g. 1d CF DVT/PE d5) and can also cause wedge-shaped opacity in lung region
Pyruvate kinase deficiency
Pyruvate kinase deficiency (PKD) is an autosomal recessive enzyme defect of the glycolytic pathway that results in extravascular hemolytic anemia.
It is the second most prevalent erythrocyte enzyme disorder (after glucose-6-phosphate dehydrogenase deficiency).
The severity of the disease is highly variable; PKD can manifest with fetal demise due to hydrops fetalis, symptomatic anemia from birth that requires lifelong transfusions, or chronic compensated hemolysis. A peripheral blood smear typically shows normal erythrocyte morphology, but echinocytes are sometimes seen. Diagnosis is confirmed by measuring pyruvate kinase enzyme activity.
Acute LMN weakness beginning asymmetrically in lower extremities in unvacc child?
POLIO VIRUS
Weakness ascends over hours/days
Parotid surgery induced facial nerve palsy presentation?
Paralysis of ipsilateral lower lip
Marginal mandibular branch of the facial nerve, which provides motor control of the lower lip, is one of the most commonly injured branches of the facial nerve. Most cases of post-parotidectomy facial nerve palsy resolve within one month.
Infection control isolation precautions
Airborne (require N95 repirator, neg pressure room):
TB
SARS, measles, varicella
Contact (single occupancy room):
MRSA, VRE, ESBL (multi-drug resistant bug)
C diff, E coli O157:H7
Scabies
RSV
Droplet (surgical masks within 6 feet):
N meningitidis, Hib, Mycoplasma pneumoniae
Influenza, adenovirus
Mallet finger vs jersey finger tx
Mallet finger: extensor tendon injury of distal phalanx (DIP held in flexion)
Tx: if uncomplicated - stack splint in hyperextension
(tendon repair if complicated, failure of conservative mx etc)
Jersey finger: flexor tendon injury of distal phalanx
Tx: tendon repair
Medical equipment types of error (e.g. cardiac telemetry)
When humans interact with medical equipment, three types of errors occur: human errors, device errors, and errors at the level of the device-human interface.
Failure at the level of the device-human interface (e.g., disconnection of the patient from or improper connection of the patient to the telemetry device) is the most common cause of inpatient cardiac telemetry-related errors (approx. 50% of cases) and typically occurs after patients are shifted (e.g., for a test).
CF desensitisation to alarms from telemetry device can lead to cardiac events going undetected but not as common as failure at device-human interface
HUS causing AKI: mechanism
Small vessel endothelial damage -> THROMBOTIC MICROANGIOPATHY -> renal vasc occlusion -> intrinsic AKI
Also thrombotic microangiopathy causes:
Thrombocytopaenia due to PLT consumption
Haemolytic anaemia by shearing of rbcs
N.B: other causes of paediatric renal vasc disease inducing AKI: vasculitis, renal artery thrombosisstone
Renal stones mx
<= 10mm: observe (can give tamsulosin/nifedipine)
> 10mm: intervention
URS: mid or distal ureter stones
OR ESWL (avoid if obese/mid/distal ureter stones)
> 20mm or lower renal pole stones >10mm: PCNL
N.B: ureteral stenting if (infected) hydronephrosis/sepsis. Also only done after above interventions
Diffuse erythroderma with intense pruritus, generalized lymphadenopathy, and a peripheral blood smear that shows numerous atypical cells with highly grooved (cerebriform) nuclei
Sezary syndrome
SS is a subtype of cutaneous T-cell lymphoma (CTCL) characterized by leukemic dissemination of malignant T cells in the skin. This condition can evolve from mycosis fungoides (another CTCL subtype) or arise de novo. The evaluation of SS should include a skin biopsy to assess cell morphology, immunophenotype, and clonality as well as a peripheral blood smear with flow cytometry and clonality studies. The diagnosis is confirmed by the presence of Sézary cells (atypical T cells with cerebriform nuclei) in the peripheral blood. Treatments include skin-directed therapies (e.g., topical corticosteroids, topical nitrogen mustards) and systemic therapies (e.g., phototherapy, chemotherapy, monoclonal antibodies).
M/c cause of sepsis in SCD pts
S PNEUMONIAE
From non-vaccine serotypes
Therefore prophylactic penicillin until age 5
Pts at high risk for sepsis from encapsulated organisms (S pneumo, H influenzae, N meningitidis but S pnuemo m/c)
Developmental milestones in infants (2, 4, 6, 9, 12mo)
2mo:
1. raises head
2. recognises familiar voices
3. social smile
4mo:
1. holds head
2. holds toy
3. coos
6mo:
1. rolls over
2. laugh
3. reaches for toy
9mo:
1. sits unsupported
2. babble
3. transfers objects between hands
4. separation anxiety/stranger anxiety
12mo:
1. cruises
2. pincer grip
3. says “mama, dada”
Chronic dyspnoea in SCD
Causes:
asthma
pulm HTN (from chronic intravasc haemolysis -> depletion of NO -> pulm vasoconstriction -> vasc remodelling -> PVR (N.B: normal spiro but decreased DLCO as loss of vasc bed)
pulm fibrosis (following recurrent episodes of acute chest syndrome)
PPV beneficial effects on acute cardiogenic pulm oed?
Decreases
LV preload (decreases RV preload and increases RV afterload);
LV afterload (decreases MAP and decreases LV transluminal pressure)
Leading to enhanced stroke vol in systole (due to decrease in LV afterload) and improved filling in diastole (improved LV relaxation)
LV aneurysm
Late complication of transmural (STEMI) MI
ECG: PERSISTENT ST ELEVATION & DEEP Q WAVES
Progressive LV enlargement -> heart failure, refractory angina, ventricular arrythmias, secondary MR; mural thrombus -> systemic arterial embolisation (e.g. stroke)
SVC syndrome tx
ENDOVENOUS STENTING followed by RADIATION tx
(high-dose corticosteroids may be helpful if malignancy causing SVC syndrome is a lymphoma, but of no help if caused by e.g. small cell lung ca)
Glomerular HM initial mx
24HR URINARY PROTEIN EXCRETION (NOT one time urine dip as may miss nonalbumin proteinuria and less s/s)
Kidney biopsy to establish dx
Juvenile myoclonic epilepsy
Adolescents
Absence seizures
MORNING MYOCLONUS
Generalised tonic-clonic seizures
EMG: bilateral polyspike and slow wave activity
Tx: valproic acid, avoid triggers (etoh, sleep deprivation)
CF Lennox Gastaut syndrome: childern <5, various, severe seizure types, intellectual disability
Central vs peripheral cyanosis wrt arterial o2 sat
Central: low arterial o2 sat (e.g. CHD: tachypnoea, diaphoresis with breast feeding)
Peripheral: increased o2 extraction secondary to SLUGGISH BLOOD FLOW (e.g. increased venous pressure/neonatal polycythaemia)
Sunburn
Mild - mod: erythema, tenderness
Severe: as above + BLISTERING, systemic sx (fever, vom, headaches)
Tx:
Mild-mod: topical (cool compresses, aloe vera, calamine lotion); oral (NSAIDs)
Severe: hospitalisation, IVF, wound care
Chronic hypoPTH complication
Deposition of ca in basal ganglia leading to extrapyramidal manifestations
Also nephrocalcinosis and cataracts
Ca-PO4 product (serum ca x serum PO4) > 55 increases risk of soft tissue calcification
Acute colonic pseudoobstruction (Ogilvie syndrome)
Aeitiologies:
Major surgery, traumatic injury, severe infection
Electrolyte derangement
Meds (opiates, antichol)
Neuro disorders (dementia, stroke)
Abdo distension, pain, obstipation, vomiting
Tympanic to percussion, decreased bowel sounds
Can lead to colonic ischaemia and perforation
X ray: colonic dilation, normal haustra, nondilated small bowel
CT: colonic dilation W/O ANATOMIC OBSTRUCTION
Mx:
NPO, NG tube/rectal tube decompression
Neostigmine if no impv within 48hrs
CF postop ileus: does not cause severe colonic dilation and develops before a return of bowel function ie no bowel mvt
Prox muscle weakness episodes + hyporeflexia + hypokalaemia
Hypokalaemic periodic paralysis (hypoKPP)
HypoKPP, the most common cause of periodic paralysis, is typically caused by incompletely penetrant, autosomal dominant mutations of sarcolemmal calcium or sodium channels.
These mutations exaggerate the potassium influx that occurs in response to physiological triggers such as sympathetic activation (e.g., during stress or physical exertion) and insulin release (e.g., following a high-carbohydrate meal).
Therefore, affected individuals develop episodic hypokalemia and reduced muscle excitability in the context of low serum potassium. The episodes of weakness usually resolve within a couple of hours after onset but can last for several days. The respiratory muscles, bulbar muscles, and extraocular muscles are typically spared during these episodes, and in between episodes, patients typically have normal serum potassium levels.
Hirsutism 2nd line tx (after COCP)
Spironolactone
In patients with renal dysfunction, spironolactone should be avoided because it can lead to metabolic and electrolyte imbalances, such as hyperkalemia, hyponatremia, and metabolic acidosis. If used as monotherapy (e.g., in women with contraindications to COCs), spironolactone should be combined with other contraceptive methods since it carries a risk of undervirilization in male fetuses.
Noncyclical mastalgia mx
Screen for ca with USS/mammo
If neg for ca then conservative mx
Pregnant pt with chorioamnionitis in 3rd trimester and PPROM. Newborn with neonatal sepsis and meningoencephalitis cause?
LISTERIA
Consumption of unpasteurized milk products is a risk factor for listeriosis, which typically manifests with self-limiting gastroenteritis in healthy adults. In pregnant women, however, listeriosis can cause complications (e.g., fever, chorioamnionitis, PPROM) and result in preterm birth or spontaneous abortion. Transmission from an infected mother to the fetus can either occur transplacentally or via direct contact with infected vaginal secretions and/or blood during delivery. This patient likely has early-onset neonatal listeriosis (granulomatosis infantiseptica), manifesting with severe systemic infection and disseminated organ involvement (i.e., of the liver and lungs). Signs of meningitis (e.g., fever, seizures, hypotonia, abnormal cerebral ultrasound) may develop as early as seen here, especially in preterm neonates, or have a delayed onset in the 3 weeks after birth, typically in full-term neonates with perinatal infection. Both mother and newborn should be treated with IV ampicillin and gentamicin.
CF toxoplasma gondii: infected mothers usually asx and severity of neonate’s infection decreases with gest age: while first-trimester infection usually results in a classic triad (chorioretinitis, diffuse intracranial calcifications, hydrocephalus) and other nonspecific features (e.g., blueberry muffin rash, jaundice, macrocephaly), second- or third-trimester infections are mostly subclinical or mild.
Granuloma inguinale
Caused by KLEBSIELLA
Large, painless vascular lesions in the absence of inguinal lymphadenopathy that appear up to one year after exposure.
Diagnosis is based primarily on clinical findings, although Donovan bodies in ulcer smears or biopsies can confirm the diagnosis.
Management focuses on antibiotic treatment with azithromycin, which is continued until the ulcers have completely healed.
Cauda equina vs conus medullaris syndrome
CES: asymmetric muscle weakness, decreased reflexes, and saddle anesthesia due to damage of LMNs; bowel/bladder late findings; pain radiates along dermatomes as nerve roots compressed
CMS: compression of most distal region of SC; both UMN and LMN signs. Bladder and bowel dysfunction within hours of the injury, hyperreflexia of the ankles, symmetric lower extremity weakness, and back pain
Perianal strep dermatitis
GAS cause
WELL-DEMARCATED, erythematous, perianal rash that can also develop a pseudoexudate, crusting, and superficial anal fissures or cracks.
Pruritus, rectal pain during defecation, and blood-streaked stools.
Signs of systemic infection (e.g., fever, abnormal vitals) are usually absent because of the superficial nature of the infection.
A history of intrafamilial spread of perianal dermatitis or of close contact with people with streptococcal infection (e.g., pharyngitis) is common.
The diagnosis is primarily clinical but can be confirmed with bacterial culture. While penicillin is an effective agent against GAS, amoxicillin is often preferred for pediatric patients because it can be administered as an oral emulsion. Topical monotherapies are ineffective in the treatment of perianal streptococcal dermatitis, likely because deeper layers of the epidermis are infected.
Umbilical artery catheterisation -> HTN weeks later cause?
Renal artery thrombosis
Can present up to several weeks after catheter removed
Congenital Zika syndrome
Microcephaly, spasticity, sensorineural hearing loss, and pigmentary retinal mottling
CF Toxoplasma: hydrocephalus, chorioretinitis, diffuse intracranial calcifications
Giardiasis tx
Most common parasitic cause of diarrhoea in US
Drinking contaminated untreated water
TINIDAZOLE (type of abx)
or metronidazole (higher rates of resistance)
Plus supportive care
Common causes of diarrhoea in pts w AIDS
Cryptosporidium (<180): SEVERE WATERY DIARRHOEA, low grade fever, weight loss
Microsporidium/isosporidium (<100): watery diarrhoea, crampy abdo pain, weight loss, FEVER RARE
MAC (<50): watery diarrhoea, HIGH FEVER, weight loss
Cytomegalovirus (<50): FREQUENT SMALL VOL DIARRHOEA, HAEMATOCHEZIA, ABDO PAIN, low-grade fever, weight loss
Asx microhaematuria/gross haematuria at increased risk for malignancy ix?
Cystoscopy PLUS
Renal USS (intermediate risk)
CT UROGRAPHY (high risk - smoking hx, recurrent UTIs etc)
to evaluate for urothelial ca of lower AND upper urinary tract
Wrong way eyes seen in which stroke
Thalamus
The combination of hemiparesis, hemisensory deficits, miotic and nonreactive pupils, and gaze deviation downward and toward the affected side of the body (i.e., away from the side of the brain lesion) is a phenomenon known as “wrong way eyes” and characteristically occurs in thalamic hemorrhage.
IM complication
Cholestatic hepatitis:
check AST/ALT in pts with underlying liver disease/coagulopathy
N.B: causes of IM = EBV, CMV, HIV
If severely elevated transaminases, consider CMV/viral hepatitis as cause
Transient synovitis: raised ESR/CRP?
YES
Ectopic pregnancy locations
Ampulla (most common), isthmus, cornuate (interstitial)
Repeated interim analyses increase risk for what error?
Type 1 error
As alpha level describes chance of type 1 error each time data analysis performed
Gallstone pancreatitis, first step in dx?
CT abdo w contrast (ie before ERCP etc)
Gastritis ix
OGD to visualise mucosa
Suspect gastritis if nonspecific GI sx but no alarm features
M/c after acute MI?
Decline in left ventricular function leading to congestive heart failure and cardiogenic shock
After an acute myocardial infarction, consider complications based on the post-MI time frame. Immediate complications (within 24 hours) include arrhythmias and heart failure, while structural complications like ventricular septal defect and papillary muscle rupture tend to occur days after the event.
Congenital hypothyroidism mx
Immediate treatment takes precedence over serial monitoring to prevent developmental issues (e.g. intellectual disability)
Keloid scar mx
Suspect if growth beyond wound (CF hypertrophic scar) and assoc trauma (e.g. ear piercing)
Intralesional corticosteroid: reduces the size and itchiness of keloids by decreasing collagen synthesis and increasing collagenase activity.
Alcohol or smoking -> HTN
ALCOHOL
