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know the diferent types o shock- hypovolemic, septic, cardiogenic cardiogenic (CO, MA, !"#$ meta%olic acidosis leads to hyperkalemia dia%etes mellit&s and rhi'op&sm&cormycosis rhi'op&sm&cormycosis inections) optic ne&ritis is associated with m<iple sclerosis hemolytic &remic syndrome ater gastrointestinal illness w *$ ac&te renal ail&re +$ microangiopathic hemolytic anemia $ throm%ocytopenia throm%ocytopenia hypertension is most important risk actor or strokes ACi and dia%etes mellit&s) ACis decrease ./# and // (dilates eferent arteriole$ theophylline toxicity maniests as CNS (headache, (headache, insomnia$, gastrointestinal (na&sea, vomiting$, cardiac (arrhythmias$ renal transplant transplant dys&nction can %e ca&sed %y a variety o actors) acute rejection is %est treated w steroids) thiazide di&retics ca&se hyperglycemia, increased LDL cholesterol , increased triglycerides) hyperuricemia (go&t$, hypercalcemia (protects against calci&m stones$ beckwith-wiedemann syndrome has macrosomia, macroglossia, visceromegaly, omphalocele, hypogylcemia, and hyperins&linemia) 0a%ies with thyroid disorder will have umbilical herniation) liestyle modi1cations to decrease 02 lose weight 3 r&its and vegs 3 decrease sodi&m 3 e4ercise 3 alcohol intake hyperosmolar nonketosis (5O67$ occ&rs in type + dia%etes mellit&s) have severe hyperglycemia res<ing in dehydration) !8#! criteria + o the ollowing2 *$ temp 3 *9*) or : ;< +$ p&lse 3 ;9 $ resp resp 3 +9 =$ >0C 3 *+k or :=k %&rn patients have have !8#! with hypermeta%olic hypermeta%olic syndrome B. pertussis has pertussis has %&rsts o whooping co&gh (lo&d inspiratory so&nd$) 1rst stage is catarrhal (rhinorrhea and congestion$ treatment is macrolide ?mycin osteosarcoma osteosarcoma has @s&n%&rst@ pattern and periosteal elevation (codmans triangle$) increased increased ABB5) occ&rs at metaphyses o long %ones gran&losa cell t&mors (type o se4-cord stromal stromal along with sertoli-leydig cell$ give precocio&s p&%erty i early) %i-modal distri%&tion) e4cess estrogen) not necessary to treat asymptomatic pagets disease) only when have %one pain, hypercalcemia, ne&rological de1cits, high o&tp&t cardiac ail&re diamond blackfan anemia has p&re red cell aplasia with short stat&re, we%%ed neck, cleft lip, shielded chest, triphalangeal thumbs, hypogonadism craniopharyngioma is a s&prasellar t&mor leading to bitemporal hemianopsia, headaches, and hypopit&itarism) hypopit&itarism) steroids ca&se neutrophilia, lymphopenia, and eosinopenia) familial hypocalciuric hypercalcemia !"" $ will have decreased &rinary calci&m e4cretion despite hypercalcemia) Dhe patiet will have normal or high D5) Dhe D5 should be low (high calci&m$ %&t parathyroid gland is %roken) %rocas aphasia is e4pressive aphasia where patient cant speak or artic&late) lesion in dominant rontal lo%e) will have motor symptoms)
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hypovolemic hyponatremia hyponatremia d&e to vol&me depletion leading to increased increased #AA! and A5) A5 will contri%&te to hyponatremia) hyponatremia) hypovolemic hyponatremia E di&retics, .8, skin congestive heart ail&re has %i-%asilar crackles at l&ng %ases) decreased %reath so&nds at l&ng %ases co&ld %e d&e to ple&ral ef&sions) ef&sions) whee'ing can %e present present rom cardiac asthma) respiratory alkalosis, hypo4ia, hypocapnia) S. pneumoniae, pneumoniae , N. meningitidis, meningitidis , H. infuenzae or infuenzae or asplenics) marans syndrome is an a&tosomal dominant disorder res<ing rom m&tations in 1%rillin-* gene) it presents with tall stat&re, long and emaciated e4tremities, arachnodactyly, arachnodactyly, hypermo%ility hypermo%ility o Foints, Foints, upward lens dislocation ) give *99G o4ygen or an ac&te attack o cl&ster headache patients with sheehanHs syndrome present post-part&m with ail&re to lactate and other eat&res o pit&itary hormonal de1ciency) cystic 1%rosis has a wide range o maniestations2 anemia, heat intolerance, intolerance, steatorrhea, whee'ing, rec&rrent inections, hemoptysis, cl&%%ing, rectal prolapse) Isweat test to con1rm) syringomyelia has are#exic weakness in upper extremities and dissociated anesthesia in a “cape” distri%&tion) the presence o a cord cavity is the most characteristic eat&re) cyclosporine$tacrolimus toxicities 2 nephrotoxic, gum hypertrophy, hyperkalemia, hypertension, hirsutism, tremor) (tacrolimus has no hirsutism or gum hypertrophy$ azathioprine2 diarrhea, leukopenia, hepatotoxic mycophenolate2 bone marrow suppression ) ulnar ner%e entrapment occ&rs at site where &lnar nerve lies at medial epicondylar groove, in the el%ow) decreased sensation in &th and 'th (ngers and weak grip d&e to interosseus muscles) patient ret&rning rom a developing co&ntry with symptoms s&ggesting mala%sorption sho&ld %e treated w metronida'ole or giardiasis) pathogenesis incl&des adhesive disks and mala%sorption) choanal atresia appears in an inant who has cyanosis d&ring eeding and relieved %y crying) canHt %reathe while mo&th is closed patients with panic disorder have increased incidence o depression, agorapho%ia, generali'ed an4iety disorder and s&%stance a%&se) &nderstand pathophysiology, peristalsis peristalsis and B! tone in dif&se esophageal spasm (!$ 'enkerHs achalasia scleroderma inectio&s esophagitis to treat hyperkalemia &se %eta-+ agonist, it will shit potassi&m into cells) otosclerosis in middle aged people d&e to conducti%e hearing loss of stapes) pres%yc&sis in older patients d&e associated with bony o%ergrowth of stapes to sensorine&ral hearing loss right coronary artery occlusion can ca&se inferior wall myocardial infarction and posterior wall M8) inerior wall M8 shows !D segment elevations in inerior leads (88 888 a"/$ w reciprocal depressions in "* and "+) !D segment depression in leads "* and "+ s&ggest a posterior wall M8) inferior wall )* is associated with hypotension, bradycardia, and +, blocks ) to %reak %ad news ollow steps2 *$ make s&re patient is comorta%le comorta %le environment +$ ask how m&ch they know or what they think $ ask what they want want to know =$ give them a warning shot <$ %reak the %ad news J$ give prognosis in hyperthyroidism give propanolol or symptomatic relie &ntil the &nderlying ca&se is identi1ed and treated de1nitively) /!.! is more common in arican americans, o%esity, heroin &se, and 58") or aortic dissection do D or CD w contrast
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in d&%in-Fohnson yo& see a dark granular pigment present in hepatocytes %&t not in patients with rotor syndrome) shock liver arises rom sepsis or ischemic hepatic inF&ry) Dhere is rapid rise in transaminases incentive spirometry has %een shown to %e the most efective meas&re in decreasing decreasing the risk o post-op pne&monia in consolidation the l&ngs have dullness to percussion and the breath sounds are bronchial which are lo&der and have a more prominent e4piratory component) pleural eusion prod&ces d&llness to perc&ssion also, %&t decreased breath sounds (the liK&id is o&tside o the l&ngs$ the most important complication o #OM is p&lmonary hypoplasia) give steroids when premat&re r&pt&re o mem%ranes (#OM$ occ&rs at less than = weeks o gestation) malignant otitis externa is ca&sed %y Pseudomonas ) will have otorrhea, gran&lation tiss&e in the ear canal) or actinomyces &se penicillin) anaero%ic gramI %ranching %acteria ca&sing cer%icofacial, thoracic or abdominal infections) drains s&l&r gran&les which appear yellow ye llow)) loop diuretics (furosemide$ ca&se hearing loss and tinnit&s) aspirin &s&ally ca&ses tinnit&s %&t not hearing loss &nless the doses are very very high) can get hall&cinations early ater given levodopacar%idopa) (e4cess dopamine$ ater several years invol&ntary movements more likely to occ&r) lynch syndrome"N.CC) at least relatives w colorectal cancer, one who is * st degree relative) involvement o + or more generations, at least * case %eore <9, /A has %een e4cl&ded) e4tracolonic t&mors incl&de endometrial carcinoma occ&ring in =G o emales hypo4ia with respiratory ail&re, cardiogenic shock, and 8C can occ&r ater amniocentesis ? amniotic L&id em%olism) immediately int&%ate and mechanically ventilate and then give iv L&ids single non-healing &lcer in vermilion 'one o lower lip is sK&amo&s cell carcinoma showing sK&amo&s cells with keratin pearls) especially i s&n e4pos&re) herpetic &lcer wo&ld heal in two weeks, wo&ld %e m<iple &lcers, wo&ld show giant cells on t'anck smear) mastitis associated with %reast eeding is treated with analgesics, anti%iotics, and contin&ation o %reast eeding) rhe&matic ever leads to mitral stenosis leading to enlargement o let atria and pushes up left main stem bronchus ) will have dyspnea, p&lmonary edema, and irritation of phrenic ner%e and let main stem %ronch&s --3 persistent co&gh) Atrial 1%rilation can also occ&r andor let atrial enlargement to avoid contrast ind&ced nephropathy adeK&ate hydration, acetylcysteine, acetylcysteine, and non-ionic contrast) whenever iv access canHt %e esta%lished in pediatric emergency cases , go or intraosseus access ) then once hydrated go or iv access again) donHt go or emoral %eca&se o perineal contamination) orbital cellulitis has opthalmoplegia and pain w e4traoc&lar movements, %&t preseptal cell&litis does not) preseptal cell&litis is a mild inection o the eyelid anterior to or%ital sept&m) or%ital cell&litis is a serio&s inection posterior to the orbital septum) or%ital cell&litis can lead to blindness and intracranial infection) maranHs eat&res with mitral reg&rgitation, M", aortic root dilation, and throm%oem%olic events Idownward dislocation of the lens is homocystinuria) a&tosomal recessive ca&sed %y cystathionine synthase de1ciency) treat with high doses o %itamin b/
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when ple&ral ef&sion s&spected or diagnosed, determine i trans&date or e4&date) do diagnostic thoracentesis) headache, elevated %p, renal %r&it is s&ggestive o renovasc&lar hypertension secondary to renal artery stenosis) in yo&ng ad<s ca&se is most likely (bromuscular dysplasia , in older patients itHs an atheromato&s plaK&e) treatment is angioplasty with stent placement or a yo&ng person when patient presents with all, sta%ili'e and treat pain, then try to &ncover etiology o all with appropriate investigation and assess pre-op risk) insulin resistance plays a central role in the pathophysiology o non-alcoholic atty liver disease %y increasing rate of lipolysis and elevating circ&lating ins&lin levels) intrahepatic fatty acid oxidation leads to increase in o4idative stress ca&sing a release of local pro-in#ammatory cytokines like tnf-alpha and conseK&ent li%er in#ammation leading to increased transaminase le%els) reversi%le acetylcholinesterase inhi%itors s&ch as donepezil, ri%astigmine, and galantamine are o %ene1t in slowing cognitive decline associated with alzheimer0s dementia) paralysis o hand and ipsilateral horner syndrome res< rom inF&ry to th and Nth cervical nerve and * st thoracic nerve, which is a rare orm o %rachial palsy called klumpke paralysis) d&chenne-er% is C< - CJ “waiters tip” whippleHs disease is a m<i-systemic illness characteri'ed %y arthralgias, weight loss, ever, diarrhea, and a%dominal pain) .+S1 material in lamina propria o small intestine is o&nd on %iopsy) in a patient with (5O67$ non-ketotic hyperglycemic coma start normal saline 23456 (rst then replace with 9)=
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S*+D" has hyponatremia (too m&ch water in %lood$, low serum osmolality, and inappropriately high urine osmolality (&rine is very conc$ platelet dysfunction is the most common ca&se o a%normal hemostasis in patients with chronic renal ail&re) D, DD and platelet co&nt are normal) 87 is prolonged) "A is &s&ally the treatment o choice i needed) "A increases release o actor N2 vw) acc&m&lation o le&kotrienes and changed prostaglandinle&kotriene %alance triggers characteristic reactions o %ronchoconstriction, nasal polyp ormation in s&scepti%le individ&als) aspirin sensitivity syndrome is a pse&do allergic reaction) treatment involves avoidance o 6!A8s and &se o le&kotriene receptor antagonists) give oral isoretinoin to patients with moderate-to-se%ere acne that is predominantly nodulocystic form and to those who have de%eloped scars ) it greatly decreases se%&m e4cretion %&t is teratogenic) anore4ia nervosa are at risk or n&mero&s complications incl&ding2 miscarriage, 8.#, hyperemesis gravidar&m, premat&re %irth, cesarean delivery, and postpart&m depression) parkinsonism gives yo& a sh&Ping hypokinetic gait) patient appears as i he was chasing his center o gravity) friedreich ataxia has ne&rological symptoms (gait ataxia, alls, dysarthria$ res<ing rom degeneration o the spinal tracts (spinocere%ellar, posterior col&m%, pyramidal$) non-ne&rological maniestations incl&de concentric hypertrophic cardiomyopathy, dia%etes and skeletal deormities (scoliosis and hammer toes$) most common ca&se o death is cardiomyopathy) folic acid de(ciency can %e ca&sed %y some dr&gs that itHs a%sorption (phenytoin6 or antagoni'e itHs physiological efects ( methotrexate, trimethoprim$ depressed C9 (normal is Q
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ne&raminidase inhi%itors zanami%ir and oseltami%ir are active against %oth a and %) treatment for 7C+ o%erdose incl&des sodium bicarbonate) this dr&g not only helps correct the acidosis %&t to narrow the =>S complex ) %en'odia'epines are given when patient presents with sei'&res) seborrheic dermatitis (dandr&f$ is a common chronic inLammatory pap&losK&amo&s diease that can afect all age gro&ps) transparent to yellow papules and occasional scaling pla;ues are characteristic) treat with moist&ri'ers, anti&ngals, and topical steroids) tinea %ersicolor is a s&per1cial &ngal inection o the skin) characteri'ed %y pale, %el%ety pink or whitish hypopigmented macules that do not tan and do not appear scaly %&t scale on scraping ) ca&sed my Malassezia furfur ) 7O5 preparation reveals large %l&nt hyphae and thick walled %&dding spores (spaghetti and meat%alls$) treat with selenium sul(de and ketoconazole) surgical resection ollowed %y whole brain radiation is the standard practice in the management o solitary brain mets with sta%le e4tracranial disease 3 multiple brain mets are %est treated with palliati%e whole brain radiation ) cl&ster headache &s&ally presents with ac&te, severe retroor%ital pain that wakes the patient rom sleep) it may %e accompanied %y redness o the ipsilateral eye, tearing, st&fed or r&nny nose, and ipsilateral hornerHs syndrome) treatment is *99G o4ygen) patients with renal disease can have low levels o erythropoietin ca&sing them to have anemia that is normocytic and normochromic) treatment is recom%inant O which is given i hemoglo%in : *9) the most common side efects are worsening of hypertension ?256 headaches (*
0C cast ? interstitial nephritis and pyelonephritis ) atty cast ? nephrotic syndrome) %road and wa4y cast ? chronic renal ail&re) weight gain is most common side efect o olanzapine) consider C. dicile in a patient with diarrhea i they have recieved anti%iotics recently and develop na&seavomitinga%dominal pain and elevated >0C) cytotoxin assay in the stool is a highly sensitive test to diagnose this condition) most colon cancers develop rom polyps) risk actors or polyp progressing ino malignancy are %illous adenoma, sessile adenoma, and size @ A3'cm) only adenomato&s polyps are clearly premalignant, %&t :*G o lesions progress to malignancy) hyperplastic polyps are non-neoplastic and do not reK&ire &rther work&p) prader-willi syndrome (o%esity hypogonadism syndrome$ hypotonia, hypogonadism and obesity) severe hypotonia at %irth or inancy, hyperphagia, short stat&re and mental retardation) lesch-nyhan syndrome is ca&sed %y a de1ciency in 5.#D, and has self-mutilation, mental retardation, hyperuricemia, and ne&rologic signs) patau0s syndrome- scalp defects, cleft lip or palate , microcephaly, congenital heart defects , Le4ed 1ngers with polydactyly edward0s syndrome is characteri'ed %y closed (sts , microcephaly, prominent occip&t, rocker bottom feet and renal$cardiac problems ) increased risk o sepsis or &p to 9 years ater splenectomy with encaps&lated organisms) get anti-pne&mococcal, haemophil&s and meningococcal vaccines %eore splenectomy, and daily oral penicillin prophyla4is or -< years ater splenectomy)
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homocysteine can %e meta%oli'ed to cysteine or methylated to orm methionine) homocysteine to cysteine pathway is catalya'ed %y cystathionine %eta synthase &sing co-actor %J (pyrido4ine$) homocysteine to methionine pathway &ses methylene-tetrahydroolate-red&ctase and methionine synthase with co%alamin (%*+$ as coactor) give bBA, folate, and b/ to a patient with ele%ated homocysteine) calci&m channel %lockers are contraindicated in myocardial inarction %eca&se vasodilate -3 reLe4 tachycardia association %etween angiodysplasia and aortic stenosis *n "eyde0s Syndrome with colonic angiodysplasia associated with ,:! issue so coagulopathic with bloody stools6 endocarditis can have septic emboli to lungs ca&sing nodular in(ltrate with ca%itation prolonged S#! is %radyarrhythmia, prolonged SD is tachyarrhythmia (leads to torsades$ myocardial inarction -3 ventric&lar ane&rysm days to months ater) presents like congestive heart ail&re, arrhythmias, mitral reg&rgitation andor throm%&s ormation treat aortic regurgitation with afterload reduction ? calcium channel blocker or +Ci prinzmetal angina occ&rs in young females, smoking is a risk ator) transient S7 ele%ation, treatment with calcium channel blockers or nitrates) betablocker and aspirin are contraindicated aortic dissection leads to aortic regurgitation, will have normal 7.) d4 with transesophageal echocardiogram *st degree heart %lock is when # interval 3 9)+ constricti%e pericarditis is when pericardi&m is thickened) poor diastolic 1lling) --3 T", ascites, hepatic congestion (looks like right sided heart ail&re$) Bow voltage 7. arrhythmia most speci1c or digoxin toxicity is atrial tachycardia with +, block ) increased ectopy (tachy$ and increased vagal tone (av %lock$ lericheEs syndrome is *$ hip thigh and buttocks claudication +$ impotence $ symmetric atrophy of bilateral lower extremity cholesterol embolization ater cardiac angiogram) can have increased eosinophils in blood$urine) decreased complement ) livedo retic&laris and ac&te renal ail&re stasis dermatitis is ca&sed %y %enous %al%ular incompetence res<ing in veno&s hypertension) hemosiderin deposition colors the legs) %est *st line di&retic is hydrochlorothia'ide s&praventric&lar tachycardia incl&des m<iocal atrial tachycardia, atrial 1%rillation, A" nodal reentrant tachycardia (A"6#D$, atrioventric&lar reentrant tachycardia (A"#D$, F&nctional tachycardia) or .S,7s (narrow S#! comple4 tachycardia$ &se %agal maneu%ers or adenosine) "ypertrophic obstructi%e cardiomyopathy (5OCM$ (a&tosomal dominant$ m&rm&r will increase as preload decreases (valsalvastanding$ %eca&se the
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ventric&lar cavity is a smaller si'e, and will have increased out#ow obstruction) ? - F days post )* is inter%entricular$papillary$%entricular wall rupture) infectious endocarditis leads to triscuspid regurgitation) holosystolic m&rm&r which increases with inspiration (decreased intrathoracic press&re, easier to p&mp into l&ngs$) disting&ishing eat&re hypertrophic obstructi%e cardiomyopathy has crescendo-decrescendo m&rm&r w no radiation to carotids and is o&nd in lower let sternal %order) A! radiates to carotids) hemodynamically sta%le s&praventric&lar tachycardia sho&ld try vagal mane&ver and adenosine) i &nsta%le then do dc cardioversion) adenosine will increase cond&ction delay thro&gh the av node) in systolic heart failure2 cardiac index is decreased (meas&re o cardiac o&tp&t$, total peripheral resistance is increased (ne&roh&moral activation o #AA!$, and let ventric&lar end diastolic vol&me is increased %eca&se the heart is not p&mping o&t hypo%olemic shock will have decreased C9, decreased .:C., increased S,> (raas$, increased 5# and decreased 0 in heart failure there is a decrease o %lood going to kidney, acti%ates >++S ) angiotensin + constricts eferent arteriole, aldosterone a%sor%s more sodi&m --3 water retention and elevation o total %ody vol&me pericardial eusions appear as enlarged @ water bottle @ shaped cardiac silho&ette) pericardial ef&sion will have a non-palpable point of maximal impulse, diminished heart sounds pericardial eusion and cardiac tamponade have2 hypotension, distended neck veins (high int) F&g&lar veno&s press&re$, and m&Ped heart so&nds) will also have positi%e hepatojugular re#ex and pulsus paradoxus) L&id acc&m&lation in the pericardial cavity that increases the intrapericardial press&re a%ove the diastolic ventric&lar press&re) restricts veno&s ret&rn to the heart) decreases diastolic 1lling and lowers preload) infecti%e endocarditis can present with systemic arterial emboli (cns, renal, splenic$, glomer&lonephritis, roth spots, oslerHs nodes, Faneway lesions, mycotic ane&rysms dihydropyridine -dipine6 calcium channel blockers like amlodipine can ca&se peripheral edema) strongest inL&ence on long-term prognosis or an !D-elevation M8 is the d&ration o time that passes %eore coronary %lood Low is restored via DCA or 1%rinolysis) or 8. control weight loss is most important intervention) weight loss 3 physical activity 3 salt restriction 3 alcohol mitral regurgitation is a holosystolic m&rm&r radiating to axilla ) will have sot s* %eca&se improper clos&re o the mitral valve) aortic regurgitation has a wide pulse pressure (systolic ? diastolic$ which patients e4perience as a “ poundingG heartbeat) lying Lat %rings heart closer to chest wall and patients are more aware o the orce&l heart%eat) constricti%e pericarditis ca&sed %y pericardial (brosis and o%literation o pericardial space) presents like ch (atig&e, dyspnea on e4ertion, m&scle wasting, elevated Fvp, ascites, positi%e kussmaul0s sign - increase j%p on inspiration6, pedal edema) in de%eloping countries can %e ca&sed %y tuberculosis) give nitroglycerine or cardiogenic pulmonary edema) will decrease preload and relieve dyspnea and tachycardia) cardiogenic p&lmonary edema will have %i%asilar rales and whee'ing as well)
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digoxin and furosemide$loop diuretics red&ce congestive heart ail&re symptoms %&t do not impro%e sur%i%al ) patients with a history of rheumatic fe%er have an increased risk o rec&rrent episodes and progression o rhe&matic heart disease with repeated inection %y gro&p A streptococc&s pharyngitis) need penicillin prophylaxis) class *C anti-arrhythmics #ecainide$propafenone6 %lock sodi&m channels) they elongate period o depolari'ation, and prolong the action potential) slower cond&ction thro&gh the A" node and his-p&rkinFe system) class 8C meds have the slowest binding and dissociation from the sodium channel ) Lecainide is a 8C that demonstrates Huse-dependenceG where the 5# increases LecainideHs efect on the sodi&m channels) /lecainide is stronger at aster heart rates) there is less time %etween As or the medication to dissociate rom itHs receptor) so the =>S complex will prolong as the "> increases ) aortic stenosis needs echocardiogram to con1rm diagnosis) i symptomatic then treat with %al%e replacement ) long =7 syndrome congenital is Ier%ell syndrome with deafness6 can present as syncopal episodes, hearing loss, and a amily history o s&dden cardiac death) treat with beta blockers mitral regurgitation can ca&se a holosystolic m&rm&r that radiates to the axilla) Mitral valve prolapse is the most common ca&se o mitral reg&rgitation) mitral reg&rgitation can lead to let atrial dilation and atrial 1%rillation) digoxin toxicity side efects are gastrointestinal (anore4ia, na&sea, vomiting$) %erapamil increases digoxin concentrations and predisposes to to4icity) mitral stenosis has a lo&d s* and a mid-diastolic r&m%le) can ca&se atrial (brillation %eca&se o let atrial dilation ca&ses o pulsus paradoxus incl&de cardiac tamponade , tension pneumothorax, and se%ere asthma3 3 B2 mm"g drop in systolic blood pressure on inspiration3 cor pulmonale has hypotension, j%d, distant heart so&nds, and pulsus paradoxus) elevated Fvp, hepatomegaly, ascites, lower e4tremity edema witho&t evidence o p&lmonary congestion is s&ggestive o isolated right sided heart failure, cor p&lmonale) most common cause is C9.D) in a patient with an M8 who develops a clot, do echocardiogram to r&le o&t throm%&s in let ventricle) in ventric&lar 1%rillation and p&lseless ventric&lar tachycardia, de(brillation is the treatment) ,entricular (brillation is recogni'ed on 7. %y 1%rillatory waves and absence of regular ;rs complexes ) time to de1% is correlated with s&rvival) a CJ> sho&ld %e o%tained in all patients who &ndergo central %enous catheterization to con1rm proper placement o the catheter tip %eore administering dr&gs or other agents thro&gh the catheter) ac&te M8 presents with s&%sternal chest pain with radiation to neck, diaphoresis, shortness o %reath) a new &th heart sound is a classic (nding of myocardial infarction) ischemic damage may lead to diastolic dys&nction and a stifened let ventricle, res<ing in an atrial gallop (= th heart so&nd$ abdominal ultrasound is the st&dy o choice or diagnosis and ollow-&p o abdominal aortic aneurysms ) nearly *99G sensitive and speci1c or this condition (smoking is the most common risk actor$ mitral stenosis classically presents during pregnancy) most oten d&e to rheumatic fe%er and occ&rs m&ch more oten in co&ntries with limited access to anti%iotics) Dhere is an increase in plasma vol&me with pregnancy) an e4ercise stress test witho&t imaging is the most reasona%le 1rst step i %aseline resting 7. is normal in a patient complaining o e4ertional cardiac pain)
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i patients are hemodynamically unstable and have sustained monomorphic %entricular tachycardia (!M"D$ then electrically cardio%ert, %&t i they are sta%le and asymptomatic yo& can give anti-arrhythmics ( amiodarone$) !M"D is a wide complex tachycardia ) in patients who present with abdominal pain and ha%e risk factors for myocardial infarction, rule out myocardial infarction before &rther gastrointestinal workup coarctation of the aorta presents with se%ere symptomatic hypertension (headaches, epistaxis, and evidence o let ventric&lar hypertrophy$) 7. will show increased %oltage of =>S complexes and S7 and 7 wa%e changes in let precordial leads) all patients (especially yo&ng$ with systemic hypertension sho&ld %e eval&ated or coarctation with sim<aneo&s palpation o %rachial and emoral p&lses to assess or brachial-femoral delay ) also have s&pine %ilateral arm (%rachial$ and prone right andor let leg (popliteal$ %lood press&res meas&red to assess or diferential press&res) coarctation may %e congenital (D&rners$ or ac;uired (7akayasu0s Hpulseless diseaseG $ cardiac tamponade prod&ces a decrease in CO %eca&se the press&re e4erted on the heart %y the pericardial L&id is greater than the veno&s press&re that 1lls the right atri&m d&ring diastole) pulsus paradoxus is a eat&re o tamponade and is de1ned as a large decrease in the systolic blood pressure on inspiration ) demonstrated by loss of a palpable radial pulse during inspiration ) !&perior vena cava syndrome is a potential complication o l&ng malignancy, and is maniested %y headache, facial swelling, and jugular %enous engorgement without peripheral edema) headaches worse when leaning forward d&e to decreased gravitational efects on the %lood col&mn) Fvd is present, %&t there is no peripheral edema to s&ggest cardiac ail&re) the primary treatment is radiation therapy as a palliati%e measure ) 7. with wide-complex tachycardia with monomorphic %entricular tachycardia in a sta%le patient is treated with amiodarone) peripheral %ascular disease sho&ld %e s&spected in a patient with risk actors or atherosclerosis who has an e4tremity with shiny, thin, hairless skin, partic&larly i a non-healing &lcer is present) &se ankle-%rachial inde4 to assess pvd) septic shock has impaired circ&lation res<ing in ins&Ucient o4ygen delivery to the peripheral tiss&es and s&%seK&ent anaero%ic meta%olism) leads to an increase in the prod&ction o lactic acid prod&cing metabolic acidosis myocarditis can lead to the development o dilated cardiomyopathy ) bibasilar crackles, pitting edema, and displacement o the point of maximal impulse) patients with mitral %al%e prolapse have a slightly higher risk o developing inective endocarditis ater certain invasive proced&res) +99 A5A g&idelines or the prevention o inective endocarditis do not recommend anti-microbial prophylaxis for patients with mitral %al%e prolapse incl&ding those with reg&rgitation) i yo& have prosthetic heart %al%es , pre%ious history of infecti%e endocarditis, or unrepaired congenital heart disease yo& get prophylaxis) atrial 1%rillation has irregularly irregular =>S complex , absent . wa%es) treatment is rate control or rythm control and anti-coag&lation) to treat rate &se beta-blocker or %erapamil$diliazem) +trial septal defect has wide, (xed splitting o sA) patients with moderate to severe let to right sh&nts may have a systolic m&rm&r %est heard at the &pper let sternal %order rom increased %lood Low across p&lmonic valve)
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septic shock sho&ld %e s&spected in patients with hemodynamic insta%ility and evidence o an inection) initial treatment is *, #uids ollowed %y %asopressors (dopamine or norepinephrine$ i they do not respond to L&ids) as mitral stenosis becomes more se%ere , the transvalv&lar gradient increases and causes the murmur to be heard earlier in diastole at the apex ) early diastolic m&rm&r at let lower sternal %order is heard in patients with aortic reg&rgitation) systolic murmur that increases with decreased preload (standing$ is mitral %al%e prolapse or hypertrophic obstructi%e cardiomyopathy ) in mvp there is a mid-systolic click and a late systolic m&rm&r %est heard at ape4) in hocm the m&rm&r increases when standing %eca&se o less veno&s ret&rn and the left %entricular out#ow tract obstruction worsens) more common in yo&ng arican americans) "ypotension is ca&sed %y a decreased left %entricular preload in a hemothorax) (similar mechanism as tension pne&mo$) hemothora4 will have lack o %reath so&nds, and dullness to percussion on the ipsilateral side as the hemothora4 d&e to acc&m&lation o L&id in the ple&ral space) hemothora4 is a potential complication of thoracentesis and sho&ld %e s&spected in patients who rapidly reacc&m&late a ple&ral ef&sion, diUc<y %reathing, and hemodynamic instability shortly after a thoracentesis %enodilation decreases the pain associated with ac&te myocardial inarction %y red&cing preload, leading to a reduction in myocardial oxygen demand ) aortic regurgitation is a diastolic decrescendo murmur over let sternal %order) aortic reg&rgitation commonly d&e to aortic root dilation or a bicuspid %al%e) #attening of . wa%e , prolonged .> and =>S .eaked 7 wa%es huge6 are consistent with hyperkalemia) give calcium gluconate to sta%ili'e cardiac cell mem%rane) hypokalemia has u wa%es, #at and broad 7 wa%es) r&pt&red a%dominal aortic ane&rysm is an important ca&se o a%dominal and reerred lower a%dominal pain) patients also have atherosclerosis o other vessels s&ch as coronary or carotid arteries) cyanosis in highly %ascularized tissues like lips and m&co&s mem%ranes is consistent witth central cyanosis) peripheral cyanosis &s&ally only involves the distal e4tremities) central cyanosis is ca&sed %y low arterial oxygen saturation, peripheral cyanosis is d&e to increased o4ygen e4traction (slow %lood Low, allows the tiss&e to ma4imally e4tract the o4ygen$ secondary to sluggish blood #ow ) in peripheral cyanosis the e4tremities are cool and clammy) lipemic serum (milky and opalescent$ along with palmar xanthomas is consistent with se%ere hypertriglyceridemia) treat with (bric acid derivatives like feno(brate) arrhythmia has sudden-onset syncope without a prodrome) sotalol &sed to maintain sin&s rythm (in patients with atrial 1%rillation$ has a side eect of prolongation of the =7 inter%al which predisposes to torsades de pointes ) hypokalemia and hypomagnesemia (rom diarrhea$ are predisposing factors) SD interval prolongation and # interval prolongation) treat with magnesium sulfate (not anti-arrhythmics$ initially) wolf-parkinson-white (wpw$ synrome is characteri'ed %y an accessory pathway %etween the atri&m and ventricle res<ing in pree4citation and increased risk or tachyarrhythmias) the accessory pathway cond&cts antegrade (orward$ rom atria to the ventricles aster than the cond&ction thro&gh the av node, which allows part o the ventricle to depolari'e early) shortened .> inter%al, slurred initial portion of =>S delta wa%e $ and widened =>S complex )
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before exercise K withhold medications that are anti-ischemic andor slow the heart) beta-blockers sho&ld %e withheld *+-+= ho&rs %eore the test) most common cause of death in patients with ac&te myocardial inarction is complex %entricular arrhythmia) ac&te ischemia creates a heterogeneity of conduction in the myocardium ) areas o partial %lock o cond&ction are reK&ently ormed that predispose the patient to reentrant arrhythmia) ,entricular (brillation is a t ypical example of reentrant arrhythmia3 paroxysmal supra%entricular tachycardia most commonly res<s rom accessory cond&ction pathways thro&gh the av node) %agal maneu%ers and medications that decrease conduction through the a% node adenosine6 oten resolve the !"D) pericarditis presents with pain that worsens with deep inspiration , improved on leaning orward) 7. 1ndings show diuse S7 ele%ation and .> depression in ** a,!6 with the exception of reciprocal depression in a,> where S7 depression is seen) dresslerHs syndrome is pericarditis occ&ring weeks ater a myocardial inarction) NS+*Ds are the mainstay o therapy or dresslerHs syndrome) progressive decrease in baroreceptor sensiti%ity and defects in the myocardial response to this reLe4 are the main reasons or increased orthostatic hypotension in the elderly) (%lood press&re drops, heart rate sho&ld increase to compensate$ screen patients who are J< - < and who have ,> smoked cigarettes %eore with a%dominal <raso&nd or a%dominal aortic ane&rysm) athero-em%olism res<s rom dislodgement o cholesterol plaK&es rom the aortic root) “%l&e toe syndrome” in which em%oli to the pedal circ&lation ca&se cyanotic and pain&l toes with intact p&lses is one common presentation o catheterind&ced atheroem%olism) may %e accompanied %y li%edo reticularis purple mottled skin6, and ele%ation of creatinine res<ing in atheroembolism of renal circulation) all patients who have had a myocardial inarction sho&ld recieve secondary prevention) the ollowing medications have %een shown to have a mortality bene(t when given as + nd prevention2 aspirin, beta-blocker, +Ci, lipid lowering statin, clopidogrel$ticlopidine (i they are post percutaneous coronary inter%ention$) digoxin is a cardiac glycoside with ad%erse eects that incl&de gastrointestinal dist&r%ances, vision changes, and arrhythmias) patients taking digo4in sho&ld have ro&tine monitoring o their digo4in level) peripheral %ascular disease commonly ca&sed %y atherosclerosis) presents with cla&dication, erectile dysfunction, and atypical leg pain or can %e asymptomatic) take the ankle-%rachial inde4 (a%i$ &sing doppler as the 1rst step to diagnose in high-risk o symptomatic patients) do e4ercise testing with pree4ercise and post-e4ercise a%i meas&rement to con1rm diagnosis) ever, chills, BS pain, and splenic #uid collection s&ggests 1ndings consistent with infecti%e endocarditis with septic emboli to the spleen) let sided endocarditis can send septic em%oli to regions rich in %lood s&pply2 %rain, kidneys, liver, spleen) right sided endocarditis tends to send septic p&lmonary em%oli) will have elevated ne&trophils) ever and a new m&rm&r in a patient who may a%&se iv dr&gs sho&ld raise concern or endocarditis) staphylococci (incl) M#!A$ is a more common ca&se o endocarditis in *,D+, thereore %ancomycin is the initial empiric antibiotic of choice) a%dominal aortic ane&rysm r&pt&re presents with proo&nd hypotension, a%dominal or %ack pain ollowed %y syncope, and possi%le p&lsatile mass on e4amination) aaa can rupure into the peritoneum and create an aortoca%al
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(stula with the inerior vena cava leading to %enous congestion in retroperitoneal structures (e)g) %ladder$) the ragile and distended veins in the %ladder can r&pt&re and ca&se gross hemat&ria) ascending aortic aneurysms are most oten d&e to cystic medial necrosis or connecti%e tissue disorders eg )arfan0s6 ) Descending$thoracic aortic aneurysms are &s&ally d&e to atherosclerosis) diastolic dysfunction is also called heart failure with preser%ed left %entricular ejection fraction) systemic hypertension is the classical ca&se o diastolic dys&nction) treatment is with diuretics and bp control) dilated cardiomyopathy can occ&r secondary to acute %iral myocarditis (co4sackie %, parvo %*;, hhvJ, adeno, entero, Chaga0s$) viral myocarditis ca&ses dilated cardiomyopathy via direct viral damage and as a res< o h&moral or cell&lar imm&ne responses to viral inections) diagnose via echocardogram which shows dilated ventricles with diuse hypokinesia res<ing in a low eFection raction) hepato-F&g&lar reLe4 can %e &sed to diferentiate %etween heart and liver disease-related ca&ses o lower e4tremity edema) 1hepato-jugular re#ex indicates that the %enous pressure is ele%ated and s&ggests that heartdisease related edema is present ) hepato-F&g&lar reLe4 is negative in patients with liver disease related edema) cool dusky (ngertips ater %asopressors can %e the res< o norepinephrine-induced %asospasm) norepinehrine has alpha-B agonist properties which ca&se %asoconstriction, which is good when trying to increase the %p o hypotensive patients, however in patients with decreased %lood Low it can ca&se ischemia and necrosis of distal (ngers$toes ) can also occ&r in intestines mesenteric ischemia$ or kidney renal failure6 native valve bacterial endocarditis d&e to S. viridans highly s&scepti%le to penicillin is well-treated with i% penicillin g or i% ceftriaxone) do not &se oral anti%iotics or subacute bacterial endocarditis3 symptomatic sinus bradycardia sho&ld %e treated with i% atropine, ollowed %y trancutaneous pacing) i they are hemodynamically unstable the &se o epinephrine is appropriate) (do no con&se with adenosine or !"D VVVVV$ three most common ca&ses o aortic stenosis are *$ senile calci(c aortic stenosis, +$ bicuspid aortic %al%e and $ rheumatic heart disease) %ic&spid aortic valve is the ca&se o aortic stenosis in the maFority o patients : 9 yo) systolic m&rm&r in right &pper sternal %order with radiation to the carotids ) aortic regurgitation ca&ses an early diastolic m&rm&r and can %e associated with a hyperdynamic pulse, incl&ding bounding or “water hammer” peripheral p&ses) acute pericarditis is characteri'ed %y sharp pleuritic chest pain that is worse in the s&pine position and improved %y sitting &p and learning orward) occ&rs in the 1rst several days ater myocardial inarction) diuse S7 ele%ations, especially with .> depressions are typical 7. 1ndings) o&tLow o%str&ction in hypertrophic obstructi%e cardiomyopathy res<s rom %oth septal hypertrophy and systolic anterior motion S+)6 o the mitral %al%e) hocm presents as crescendo-decrescendo m&rm&r in the lower let sternal %order) increases d&ring valsalva d&e to decreased preload and decreased 1lling o let ventricle) 7. 1ndings in acute pericarditis are diuse S7 ele%ation and depression of .> segment except in a,>6 ) most common ca&se is %iral infection) can also %e ca&sed %y uremia (patient with renal pro%lems$) treatment o &remic pericarditis is dialysis) indications or hemodialysis are *$ reractory hyperkalemia +$ vol&me overload or p&lmonary edema not responding to
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di&retics $ reractory meta%olic acidosis (ph : )+$ =$ &remic pericarditis <$ &remic encephalopathy or ne&ropathy J$ coag&lopathy d&e to renal ail&re kussmaul0s sign increased j%p on inspiration6 is seen in2 constricti%e pericarditis, cardiac tamponade , right heart failure) hypotension, Fvd and clear l&ng 1elds point to right %entricular infarction) treat with i% #uids and a%oidance of preload reducing medications (nitrates and di&retics$, they are preload dependent) right heart failure preload dependent eg *nferior )*6 E liK&ids cardiac cath is typically done %y cann&lating the emoral artery to access the cardiac vessels) a common complication is hematoma formation in soft tissues of the upper thigh) i the arterial p&nct&re was done abo%e the inguinal ligament, this hematoma can extend directly into the retroperitoneal space and ca&se signi1cant %leeding, with hypotension and tachycardia) patients can also develop ipsilateral #ank pain$back pain and neurologic defects on the ipsilateral side ) ne4t step wo&ld %e to o%tain a C7 of the abdomen and pel%is without contrast to con1rm) acute heart failure can ca&se p&lmonary edema or “ #ash pulmonary edema ” secondary to anterior wall myocardial inarction) a di&retic s&ch as furosemide is the dr&g o choice in this setting) decreases the cardiac preload there%y decreasing the p&lmonary capillary press&re) also ca&ses venodilation which &rther decreases preload) clear l&ng 1elds, hypotension, and F&g&lar veno&s distension in the setting o an inerior wall mi are s&ggestive o a right %entricular infarct) #uid resuscitation is the appropriate management, and nitrates should be a%oided %eca&se they decrease preload and will limit cardiac o&tp&t) anterolateral myocardial infarction can ca&se papillary muscle ischemia or rupture, which can ca&se mitral regurgitation) will have %i%asilar crackles, orthopnea) meas&rement o p&lmonary capillary wedge press&re (>Clet atrial press&re$ with a swan-gan' catheter will reveal increased press&re in the let atri&m premat&re ventric&lar comple4es ("Cs$ are common in post-myocardial infarction patients and can %e recogni'ed %y their widened =>S @ BA2 msec, %i''are morphology, and compensatory pause ) no treatment unless symptomatic) amyloidosis can res< in a restricti%e cardiomyopathy with thickened %entricular walls and preserved ventric&lar dimensions as well as li%er (clotting, %r&ising$ and kidneys (protein&ria$ calcium gluconate is given or hyperkalemia to protect the heart) on 7. hyperkalemia will have peaked 7 wa%es , and prolongation of .> and =>S inter%als event&ally leading to a sine wave) sodi&m %icar% is &sed in DCA and aspirin overdose) magnesium sulfate is &sed or torsades de pointes ) a polymorphic %entricular tachycardia associated with a prolonged =7 inter%al) it commonly occ&rs in patients with long SD syndrome as well as patients with a history o alcoholism and recent intiation of #uconazole and moxi#oxacin) myocarditis presents as a L&-like illness with ever, anore4ia, lethargy, irrita%ility in children) ollowed %y respiratory distress rom acute heart failure) CW# will show cardiomegaly and pulmonary edema) 7. shows low %oltage =>S and sinus tachycardia) echocardiogram shows global hypokinesis, left %entricular hypertrophy, left %entricular dysfunction, and pericardial eusion) gold standard is myocardial biopsy but no one really does that too in%asi%e6)
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aortic stenosis can cause anginal chest pain %eca&se the left %entricle will hypertrophy re;uiring additional oxygen ) increased myocardial o4ygen demand myocarditis presents like congesti%e heart failure with cardiomegaly, paroxysmal nocturnal dyspnea , dyspnea on exertion, peripheral edema, hepatomegaly, bilateral pleural eusions, and a third heart sound) %iral myocarditis is oten d&e to coxsackie b vir&s)
dermatology •
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senile purpura is characteri'ed %y ecchymoses that occ&r on elderly patients extensor surfaces d&e to peri%ascular connecti%e tissue atrophy ) renal ail&re can also ca&se platelet dys&nction (&remia ca&ses platelet dys&nction, creatinine wo&ld %e elevated) basal cell carcinoma in s&n e4pos&re) nod&le with pearly rolled borders and telangiectasia actinic keratosis descri%ed as erythematous papules with a central scale ) @sandpaper like@ te4t&re) s&n e4posed areas stevens Fohnson E erythema m<iorme maFor) target shaped muco-c&taneo&s lesions and systemic signs o to4icity) type hypersensitivity eschar ormation can compromise %lood Low and lymphatic circ&lation) decreased p&lses and edema) do escharotomy) sK) cell carcinoma with chronic wo&nds) rosacea in middle-aged patietns with telangiectasias over cheeks, nose, and chin) L&shing made worse %y hotcold drinks, s&n, emotion) has pap&les and p&st&les) t4 is metronidazole porphyria cutanea tarda has painless blisters, photosensiti%ity, increased skin ragility on dors&m o the hands, hypertrichosis) associated with hep c infection (think liver st&f$ tinea corporis has ring-shaped scaly patches with a central clearing and scaly borders) treatment is terbina(ne) normal skin X %irth with progression to dry scaly skin with horny plates o%er extensor surfaces is icythosis %ulgaris) worsens in winter) looks like li'ardy skin allergic contact dermatitis has vesicles at the site o e4pos&re) can %ecome secondarily infected and have pus (lled %esicles ) or SCC do a punch biopsy to con1rm d4 vitiligo is d&e to a&toimm&ne destr&ction o melanocytes seborrheic keratosis is a %enign growth that occ&rs in many places on the %ody, %&t avors acetr&nk) the lesions have a waxy stuck on warty and well circ&mscri%ed appearance) actinic keratosis is a pre-malignant lesion that is dry scaly #at papule with erythematous base) bullous pemphigoid is a&toimm&ne %listering disorder marked %y tense %&llae, &rticarial plaK&es) igg and c along basement membrane zone ) ermal layer vs epidermal or pemphig&s v&lgaris)
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the most common dr&gs in the treatment o acne to prod&ce phototoxic drug reactions are the tetracyclines, namely doxycycline) s&n%&rn reactions with erythema, edema, and vesicles over s&n-e4posed areas) sK&amo&s cell carcinoma is the + nd most common orm o non-melanoma skin cancer ater %asal cell carcinoma) e4pos&re to s&nlight is the most important actor in the development o scc) %est way to prevent malignant melanoma is wearing protective clothing) s&n screen protects against non-melanoma skin cancer like sK) cell carcinoma or basal cell carcinoma do mohs surgery, wherein microscopic shaving is done s&ch that B-Amm of clear margins are excised3 this techniK&e has the highest c&re rate or %asal cell cancer) %&t is indicated only in patients with highrisk eat&res or in those with lesions in &nctionally critical areas (perioral, nose, lips, ears$ pemphigus %ulgaris is a m&coc&taneo&s %listering disease that is characteri'ed %y Laccid %&llae and intercell&lar igg deposits in the epidermis) autoantibodies are ormed against desmoglein, an adhesion molec&le) bullous pemphigoid rarely has oral lesions ) (not in m&co&s mem%ranes$ dermatitis herpetiformis is associated with gl&ten-sensitive enteropathy (celiac disease$) dapsone is an efective treatment) mild acne (non-in#ammatory comedones $ are treated with topical retinoids 1rst) topical antibiotics are added with mild-to-moderate in#ammatory acne) &se oral isoretinoin or patients with nodulocystic and scarring acne ) seborrheic dermatitis is a common inLammatory disease that afects areas with sebaceous glands , s&ch as the scalp dandru $ face eyebrows nasolabial folds and external ear canal posterior ear6 chest and intertrigino&s areas) se%orrheic dermatitis occurs in all ages %&t is o&nd in increased reK&ency in patients with parkinsons and "*,3 pr&ritic erythemato&s plaK&es with (ne loose yellow , and greasy looking scales ) acne rosacea is a rosy hue with telangiectasia over the cheeks nose and chin ) #ushing o these areas is typically precipitated %y hot drinks, heat, emotion, and other ca&ses o rapid %ody temp changes) atopic dermatitis eczema6 in inancy afects ace, scalp, and extensor surfaces of the extremities ) lesions &s&ally %egin with pruritis alone, and evolve to erythematous excoriated papules and plaK&es that may weep and %ecome secondarily impetiginized) atopic dermatitis is the res< o decreased skin barrier function d&e to improper synthesis o components o the epidermal corni1ed cell envelope) allergens can readily access deeper levels o the epidermis where they may generate the imm&ne resopnse) the diaper region is typically spared ) excisional biopsy with narrow margins is the preerred st&dy or the diagnosis o melanoma) i the depth o the lesion is :* mm the melanoma can %e e4cised with a * cm t&mor ree margin and they have a ;;G < year s&rvival) t&mors 3 * mm in depth sho&ld have a sentinel lymph node st&dy) do not do excision with wide margins like B cm6 until the diagnosis of melanoma is made) toxic epidermal necrolysis is a severe mucocutaneous exfoliati%e disease ) erythematous morbiliform eruption that rapidly evolves into exfoliation of the skin) in steven Fohnson syndrome &p to *9G o the %ody s&race area is involved, in 7N @ ?25 of the body surface is involved) molluscum contagiosum ca&sed %y pox%irus) dome shaped lesions with central umbilication) acne rom steroids has no comedones and monomorphous pink papules ) adolescent acne has %oth open and closed comedones )
electrolytes •
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chronic alcoholism -3 pancreatitis -3 mala%sorption) low %itamin D means will ha%e low phosphorous and low calcium malignancy is the most common ca&se o hypercalcemia in admitted patients) osteolytic mets, secretion o pth-rp, increased vit d, and 8B-J hypocalcemia ca&ses increased deep tendon re#exes ) can occ&r ater m<iple trans&sions (d&e to calci&m chelation %y citrate in %lood prod&cts$) hypermagnesemia has decreased deep tendon re#exes ) or hyperkalemia *$ sta%ili'e mem%rane with calcium gluconate +$ ins&lingl&cose and $ remove rom %ody (kaye4alate$ or a patient with se%ere hypo%olemic hypernatremia gi%e 2345 saline isotonic saline63 patients with less severe hypovolemic hypernatremia are treated with
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an acute rise in serum calcium is most commonly seen in hypercalcemia of malignancy) primary hyperparathyroidism does not res< in calci&m levels as high as those seen with malignancy) S*+D" ca&ses hyponatremia (water retention$, plasma hypoosmolality (water retention$, and a high &rine osmolality (3+99$ and a high urine sodium concentration urine na @?2me;$l6 to determine ca&se o hyponatremia calc&late ser&m osmolality E (+ Y na$ I (%&n +)N$ I (gl&cose*N$ i they are hypotonic and hyponatremic then look at vol&me stat&s2 hypovolemic, e&volemic, or hypervolemic) hypovolemic hypotonic hyponatremia can %e d&e to renal or e4rarenal losses o sodi&m and water) e4trarenal losses have a &rine na : *9, (renal losses will have &rine 6a 3 +9$ and can %e secondary to diarrhea and vomiting vol&me res&scitation with normal saline will correct contraction alkalosis) hypokalemia sho&ld %e treated as well) in patients with malignancy, hypercalcemia is d&e to the increased resorption of bone and release of calcium from bone ) the pathology involves osteolytic mets with local release of cytokines and tumor secretion of pth-rp ) bisphoshonates are the dr&g o choice or mild to moderate hypercalcemia d&e to malignancy) *, #uids and furosemide are &sed in the treatment of hypercalcemic crisis3 isotonic sol&tions s&ch as normal saline 23456 are the L&id o choice or initial res&scitation in severe hypo%olemic hypernatremia) chronic renal ail&re can increase pth leading to + nd hyperparathyroidism) seen with moderate to severe renal ins&Uciency) ser&m calci&m levels are normal to low in patients with + nd hyperpth %eca&se the ca&se o elevated pth is hypocalcemia)( also elevated phosphate will prevent Ca rom rising too m&ch$ primary hyperpth will have an elevation o pth and calci&m levels along with a history of renal stones and osteoporosis) vigoro&s hydration with i% normal saline is 1rst step in managing se%ere symptomatic hypercalcemia renal failure ca&ses hypocalcemia) immobilization o an individ&al with a high bone turno%er results in increased osteoclastic acti%ation that can lead to hypercalcemia) bisphosphonate therapy in patients who are immo%ili'ed is help&l in reducing hypercalcemia and pre%enting osteopenia) vomiting ca&ses meta%olic alkalosis (losing vol&me and losing 5I$ with hypochloremia and hypokalemia) vol&me contraction ca&ses secondary hyperaldosteronism ca&sing hypokalemia) it will have low &rine chloride :+9 (the kidney is rea%sor%ing 6aCl$ and chloride sensitive) increased e4tracell&lar p5 ( alkalosis$ can cause an increase in the anity of serum albumin to calcium causing hypocalcemia) siadh is a common complication of lung cancer , partic&larly small cell lung cancer) low sodi&m and high potassi&m) initial treatment is #uid restriction) addisons disease has aldosterone de(ciency leading to non-anion gap, hyperkalemic hyponatremic metabolic acidosis ) (aldosterone removes hI and kI, saves naI$ saline-responsi%e metabolic alkalosis has urine cl M A2 8ody is dehydrated wants to retain Na 1 Cl6 and is typically d&e to conditions ca&sed %y hypovolemia or gastrointestinal proton loss) treat with isotonic saline infusion) recogni'e diabetic ketoacidosis as metabolic acidosis , polyuria, dehydration, decreased level o conscio&sness, and diuse abdominal pain ater an inection ) dka is characteri'ed %y an osmotic diuresis that reduces
total body potassium stores even tho&gh serum potassium may be ele%ated) loop diuretics give hypokalemia, and also res< in increased distal sol&te delivery as well as increased aldosterone le%el ) increased hydrogen ion e4cretion --3 metabolic alkalosis
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or ethylene glycol poisoning &se fomepizole) will have calci&m o4alate stones in the kidneys) Lank pain, hemat&ria, olig&ria, acute renal failure, anion gap metabolic acidosis ) iron poisoning has a corrosi%e eect on the gi mucosa ) a%) pain, na&sea, vomiting, diarrhea and hematemesis) hypotension and %enodilation lead to hypoper&sion and leads to metabolic acidosis ) iron is radio-opaK&e so it can %e seen in stomach on a%dominal 4r) Do diagnose meas&re ser&m iron levels, to treat &se iv deferoxamine when patient ingests acetaminophen, before gi%ing n-acetylcysteine make s&re ser&m level is toxic check at & hours63 can give n-aceylcysteine within N ho&rs o ingestion) give activated charcoal is good within = ho&rs) when a patient ingests lye (sodi&m hydro4ide$ which is a strongly alkaline solution, m&st do upper gi endoscopy to assess e4tent o esophageal inF&ry and determine i any &rther management is needed) i perforation is suspected do a gastrogra(n study ) sodi&m %icar%onate is &sed to treat DCA poisoning) tca o%erdose ca&ses hyperthermia, sei'&res, hypotension, and anti-cholinergic eects2 dilated pupils, #ushed and dry skin , intestinal ileus and =>S prolongation ) %lind as %at, dry as %one, hot as hare, mad as hatter, red as %eet) diphenhydramine o%erdose presents with anti-cholinergic symptoms, drowsiness, and con&sion) diphenhydramine is an anti-histamine %&t can give anti-cholinergic efects as well) treatment involves giving administration o physostigmine, a cholinesterase inhi%itor which reverses itHs efecs) or frostbite injuries, %est treatment is rapid re-warming with warm water ) ater warming, re-eval&ate the e4tremity) amo&nt o de%ridement is always less ater re-warming) methanol intoxication can ca&se %ision loss and coma) physical e4am will show optic disc hyperemia , la% st&dies will show anion gap meta%olic acidosis) increased osmolar gap is oten seen as well) in heat stroke the temperat&re is &s&ally 3 *9
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%ronchospasm (dif&se whee'ing$ ne&rological efects (deliri&m and sei'&res$ and hypoglycemia) 1rst give i% #uids and atropine, then give glucagon to increase cAM and higher levels o intracell&lar calci&m to a&gment cardiac contractility) cocaine related cardiac ischemia is treated with benzodiazepines, nitrates, and aspirin) beta-blockers are contraindicated ) iron tablet intoxication appears as a%dominal pain and hematemesis, hypo%olemic shock and metabolic acidosis ) will appear radioopaK&e (can see$ on 4r) give deferoxamine) sodium bicarbonate narrows =>S complex preventing development o arrhythmia in patients with DCA to4icity %y alle%iating the cardio-depressant action on sodium channels ) caustic poisoning does not ca&se alterations in conscio&sness) presents with dysphagia, severe pain, hea%y sali%ation and mo&th %&rns) the damage is the res< of necrosis of the tissue that lines the gastrointestinal tract) in severe cases peroration o the stomach or esophag&s can occ&r, ca&sing peritonitis or mediastinitis) give atropine to re%erse organophosphate poisoning (acetylcholineeserase inhi%itor$) will have cholinergic e4cess so atropine can reverse) %&t 1rst remove all clothes which may %e soaked in the poison to prevent transc&taneo&s a%sorption) treat cat bites prophylactically with amoxicillin$cla%ulanate) pasteurella multicoda is resistant to erythromycin <9G o the time heat stroke is temp 3 =9)DS, dic, and hepaticrenal ail&re can occ&r)
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isoniazid ca&ses hepatitis with similar pathological pict&re to viral hepatitis (panlo%&lar monon&clear cell in1ltration and hepatic cell necrosis$ treat symptomatic syndrome o inappropriate antidi&retic hormone ( S*+D"$ with hypertonic saline 23?5 (patient will %e hyponatremic$ hereditary hemochromatosis patients are v&lnera%le to inections o Listeria monocytogenes, Yersinia enterocolitica, and Vibrio ulni!cus corticosteroids have mineralocorticoid like efects (hypokalemia, alkalosis, hypernatremia$ in psychogenic polydipsia, water depri%ation will increase urine concentration, %&t in dia%etes insipid&s (8$ the water will not concentrate (A5 is not &nctioning$) Dhe ne4t step is to administer A5 and i it concentrates &rine then the patient has central dia%etes insipid&s, i the &rine is still not concentrated then the patient has nephrogenic dia%etes insipid&s) hyperthyroidism can have rapid bone loss i let &nreated) Dhe patient will have increased +L. aromatase de(ciency leads to high testosterone, no estrogen and %irilization of females) A patient with congenital adrenal hyperplasia (CA5$ will still have estrogen) Aromatase converts testosterone into estrogen) chronic s&praphysiological doses of glucocorticoids suppress C>" from hypothalamus) Ater removal o iatrogenic corticosteroids the 5A a4is takes a ew months to recover)
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)NB parathyroid, pit&itary, pancreatic (ins&linoma, gl&cagonoma$) )NAa med&llary thyroid, pheochromocytoma, parathyroid) )NAb med&llary thyroid, pheochromocytoma, m&cosal ne&romas ( )arfanoid "abitus6) All are associated with the >7 oncogene %est test or +ddison0s is cosyntropin stimulation test ) Addisons presents with weakness, atig&e, depression, increased pigmentation due to increased +C7"$) Ca&ses o adrenal ins&Uciency *$ diseased adrenal gland +$ pit&itary not releasing ACD5 $ decreased C#5 %y hypothalam&s dia%etes mellit&s ca&ses ischemic ner%e damage) somatic nerve oc&lomotorC6 - leads to “down and o&t”) factitious thyrotoxicosis is ca&sed %y ingestion o exogenous thyroid, ca&sing the thyroid gland to atrophy and less release of thyroglobulins ) i &rine osmolality : 99 (low conc, lots o water$ then yo& have complete dia%etes insipid&s) partial dia%etes insipid&s is &rine osm %etween 99-J99) patients with psychogenic polydipsia have hyponatremia, and dia%etes insipid&s presents with hypernatremia) Dhe main categories o dia%etic retinopathy are *$ simple ? microane&rysms, hemorrhages, e4&dates, retinal edema +$ pre-proliferati%e ? cotton wool spots $ proliferati%e ? neovasc&lari'ation (most common res< o poor hyperglycemic control is retinopathy$ A pit&itary adenoma : *9 mm is a microadenoma) i itHs a prolactinoma, will have %ilateral galactorrhea and amenorrhea) &se cabergoline$bromocriptine which are dopamine agonists) dia%etic nephropathy starts with increased !> and microalbuminuria) once yo& have 3 99mg proteinday yo& have macroproteinuria and the only intervention to red&ce the decline in ./# at this point is intensi%e blood pressure control) intensive glycemic control only lowers the progression to microal%&min&ria) hypothyroidism is associated with myopathies incl&ding ele%ated serum CK , myalgias, m&scle hypertrophy (with my4omato&s %&ild&p$, proximal myopathy, rhabdomyolysis) tricyclic antidepressants are dr&gs o choice or diabetic neuropathy) 0&t %eca&se they can worsen &rinary symptoms and give orthostatic hypotension yo& can &se gabapentin as a backup) sick e&thyroid syndrome is when a patient has a%normally low D in ac&te, severe illness ( 7S" normal6 diabetic neuropathy can lead to a dener%ated bladder leading to o%er#ow incontinence) Dhe patient will present with &rinary reK&ency, noct&ria, reK&ent leakage o small vol&mes o &rine and the post residual %olume will be high ) renal failure gives hypocalcemia, hyperphosphatemia, and increased parathyroid hormone levels) Dhe ./# alls and kidneys retain phosphate ca&sing hypocalcemia, leading to hyperparathyroidism) D!5-secreting pit&itary adenomas can ca&se a goiter d&e to the efect o D!5 on the growth o the thyroid ollicles) Dhe patient wonHt have e4trathyroidal maniestations o .raveHs s&ch as in1ltrative opthalmopathy and preti%ial my4edema) Conn0s syndrome (hyperaldosteronism$ ca&ses hypertension, mild hypernatremia, hypokalemia, and metabolic alkalosis (e4creting more 7I and 5I$) “pop&llary” (papillary$ carcinoma is the most common thyroid malignancy) propylthiouracil and methimazole can ca&se agranulocytosis) 8 the patient presents with fe%er, sore throat, stop anti-thyroid dr&g and do a C0C) if :8C M B222 permanently stop drug)
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ins&lin resistance or patients with central type o%esity is a key pathogenic actor in the development o type + dia%etes mellit&s and associated a%normalities) .raveHs opthalmopathy is d&e to a&toimm&ne lymphocytic in1ltration o the e4traoc&lar m&scles res<ing in 1%ro%last prolieration, hyal&ronic acid deposition, edema and 1%rosis D"+-S is prod&ced %y the adrenal glands only ) 5A, androstenedione, and testosterone are made %y the ovaries and the adrenals) se to diferentiate %etween secondary central6 hypogonadism has low testosterone and inappropriately normal gonadotropin levels (/!5B5$) meas&re serum prolactin le%els prolactin inhibits the release of n>" ) the most speci(c test or making a diagnosis o acromegaly is to meas&re growth hormone le%els following an oral glucose load " le%els should drop after oral glucose load6 ) *!-B is a good screening test or acromegaly (8./-* will %e increased in acromegaly$, %&t it is an indirect meas&re o .5, and other diseases can lead to decreased 8./-* levels) normal saline is the initial L&id o choice in a hypotensi%e, dehydrated patient with dia%etes insipid&s) hypotonic L&ids can %e started once the intravasc&lar vol&me improves) glucagonoma has a triad o *$ hyperglycemia +$ necrotizing dermatitis $ weight loss) the skin lesion is called necrolytic migratory erythema) dia%etic patients develop ne&ropathy) when the small colon is involved it &s&ally ca&ses diarrhea d&e to bacterial o%ergrowth, involvement o the large colon causes constipation , involvement o the stomach causes gastroparesis, which commonly presents as anore4ia, na&sea, vomiting, and a%dominal %loating and early satiety) treat with metoclopramide, bethanecol or erythromycin) M6+a consists o med&llary carcinoma o the thyroid, hyperparathyroidism, and pheochromocytoma) the ser&m calcitonin le%el is ele%ated in patients with medullary thyroid cancer ) paraneoplastic Cushing0s syndrome is ca&sed %y ectopic +C7" prod&ction %y small cell lung carcinoma ) 8t is not s&ppressed %y de4amethasone and yo& get clinical eat&res o hyperpigmentation in s&n e4posed areas (skin, scars, palmar creases, inner s&race o lips, andor %&ccal m&cosa$, easy %r&ising, tr&ncal o%esiy, moon acies, %&falo h&mp, striae, hypertension, atig&e, gl&cose intolerance, osteopenia, weakness, edema, electrolyte dist&r%ances) dizziness, palpitations, trembling and sweating with exercise are consistent with hypoglycemia in patients who take ins&lin and e4ercise intensely) C&shingHs syndrome is ca&sed %y high levels o gl&cocorticoidscortisol) proximal muscle weakness, obesity, easy bruising, oily skin, acne, hirs&tism) treat dia%etic ketoacidosis with *$ aggresive rehydration, +$ ins&lin therapy and $ potassi&m repletion) Dhe most efective treatment in slowing progression o dia%etic nephropahy is maintaining a blood pressure of M B?2$<2 with +Cis or +>8s) Cushing0s syndrome ca&ses secondary hypertension, hyperglycemia (cortisol activates gl&cagon$, hypokalemia, psychiatric problems (sleep, depression, psychosis$) neurogenic arthropathy or charcot0s joint is a complication o ne&ropathy and repeated Foint tra&ma) pseudohypoparathyroidism has low serum calcium high serum phosphate, and high serum .7") (calci&m and phosphate levels are as i D5 levels are low, %&t D5 levels are elevated$
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J-linked hypophosphatemic rickets have low serum phosphate d&e to renal phosphate wasting) patients with generalized resistance to thyroid hormones have high serum 7& and 7? le%els with normal to mildly ele%ated 7S" ) patients have features of hypothyroidism despite having elevated ree thyroid hormones) subclinical hypothyroidism is characteri'ed %y mildly ele%ated 7S" and normal circulating thyroid hormones) Dhese patients do not ha%e features of o%ert hypothyroidism ) hyperlipidemia, unexplained hyponatremia, and ele%ated serum muscle enzymes are indications or thyroid function tests) somogyi eect occ&rs when co&nterreg&latory hormones react to nocturnal hypoglycemia too much insulin6 there%y res<ing in early morning hyperglycemia) the patient will have low serum glucose at ?O22 +) ) in the dawn phenomenon the patient will have an increased ?O22 am glucose concentration %eca&se o the secretion of nocturnal growth hormone ) hemosiderosis is the deposition o e4cessive iron to tiss&es) ca&sed %y a variety o inherited meta%olic disorders) not considered to be a distinct disease entity) hemochromatosis is an a&tosomal recessive disorder characteri'ed %y increased skin pigmentation, diabetes, cirrhosis, and arthralgia (pse&dogo&t$ in the later stages) treatment is phlebotomy for A-? years to deplete iron stores, and deferoxamine as a + nd line treatment) plasma aldosterone to plasma renin activity ratio .+O.>+6 is &sed as an initial screening test or primary hyperaldosteronism) a ratio 3 9 is s&ggestive o the diagnosis) hyperpigmentation o the skin and mucous membranes is characteristic o primary adrenocortical de(ciency , and is d&e to increased le%els of +C7" ) this eat&re is not seen in secondary adrenal insuciency due to hypothalamo-pituitary failure) gl&cocorticoid de1ciency presents as weakness, atig&e, depression, irrita%ility, hypotension, lymphocytosis, neutropenia, and eosinophilia) hypothyroidism presents as cold intolerance, constipation, dry and ro&gh skin, %radycardia) mineralocorticoid de1ciency presents as hypokalemia, alkalosis, and mild hypernatremia) when yo& 1nd a thyroid nodule, 1rst do serum 7S") i serum 7S" is low , do radionuclide thyroid scan ) i hyperfunctioning then e%aluate for hyperthyroidism) i non-functioning nodule then do diagnostic ultrasound of thyroid) i nodule is suspicious for malignancy do !N+ of nodule ) i the /6A is %enign, ro&tine ollow &p and s&rveillance) i 7S" is normal or high then do ultrasound of nodule ) !teps2 *$ D!5, +$ radion&clide scan, $ <raso&nd, =$ /6A hypothyroidism leads to accumulation of matrix substances thro&gho&t the %ody) i this occ&rs in the median nerve and the tendons o the carpal t&nnel then it may cause carpal tunnel syndrome ) treat diabetic ketoacidosis %y giving *, normal saline ollowed %y regular insulin, and potassium) hypertension in patients with thyrotoxicosis is predominantly systolic and ca&sed %y hyperdynamic circulation) increased target organ sensiti%ity to endogenous catecholamines %y increasing the e4pression o adrenergic receptors as well) subacute lymphocytic painless6 thyroiditis can ca&se thyroto4icosis with reduced radioacti%e iodine uptake ) other ca&ses o thyroto4icosis with red&ced radioactive iodine &ptake incl&de2 subacute granulomatous de ;uer%ain6 thyroiditis, iodine-induced thyroid toxicosis , le%othyroxine o%erdose, struma o%arii)
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hyperthyroidism and hypothyroidism can ca&se proximal muscle weakness) look or additional symptoms o thyroid dys&nction (atig&a%ility, tremor, an4iety, weight changes, menstr&al$
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matching is reK&ently &sed in case-control studies %eca&se it is an eUcient method to control cono&nding) Case control ? determine o&tcomes, then 1nd e4pos&re risk, can calc&late 9> a two sample t-test is a statistical method commonly &sed to compare the means o two gro&ps o s&%Fects) A6O"A is &sed to compare three or more means) Cohort study is a st&dy done %ased on presencea%sence o risk actors, can calc&late >> 6&m%er needed to treat E *a%sol&te risk red&ction the correlation coecient shows the strength and direction positi%e or negati%e$ o linear association %etween two varia%les, %&t it doesnt imply causality) a actorial design &ses + or more e4perimental interventions each with + or more varia%les that are st&died independently) (wtZZ$ in a cross-sectional study , e4pos&re and o&tcome are meas&red sim<aneo&sly at a partic&lar point o time (snapshot st&dy, shows pre%alence$) i the o&tcome o a case-control st&dy is not common in the pop&lation, the odds ratio is close to the relative risk) the p val&e is the pro%a%ility that the res< o a st&dy was o%tained %y chance alone) a st&dy is statistically signi1cant when the p val&e is : 9)9< (lower p val&e is less d&e to “chance”$ case control studies are also known as retrospecti%e studies) researcher %egins with a pop&lation with a certain o&tcome and s&%Fects are classi1ed as cases or controls %ased on o&tcome stat&s) a retrospective cohort st&dy starts at some point %etween the e4pos&re and o&tcome) the researcher reviews past records, classi1es s&%Fects as “e4posed” and “not e4posedH and ollows them &ntil the o&tcome) &se tests with high sensitivity to screen or diseases) (B8!A or 58"$) speci1city to con1rm (western %lot$) sn-o&t) sp-in chi-sK&are test is &sed to compare proportions) precision is the meas&re o random error) the tighter the con1dence interval, the more precise the res<) increasing the sample size increases precision ) .., 7.$+ll .s6depends on prevalence o disease) N., also depends on the prevalence o disease, %&t has an in%erse association with the prevalence) as prevalence o disease increases, 6" will decrease)
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chronic pancreatitis can lead to pancreatic cancer) Do look or pancreatic cancer do a CD scan o a%domen zinc def has alopecia, abnormal taste, bullous pustulous lesions, and can occ&r in total paraenteral n&trition or mala%sorption ac&te iron into4ication has < phases) *$ gastrointestinal phase- na&sea, vomiting, hematemesis, melena, a%dominal pain +$ asymptomatic $ shock and meta%olic acidosis =$ hepatoto4icity <$ m&cosal scarring leading to %owel o%str&ction calci&m channel %lockers and nitrates rela4 myocytes in esophag&s) relieves dif&se esophageal spasm) diagnose with manometry hepatic hydrothorax is a trans&dative ple&ral ef&sion in a patient with cirrhosis) salt restriction and diuretics, and then 7*.S crohnEs disease has non-caseating granulomas (pathognomonic or C$) &lcerative colitis does not) .8, l&ng, %reast generally mets to liver) prostate mets to pelvic lymph nodes and l&m%ar spine) non-bleeding %arices treated with beta-blockers) decreases risk o %leeding %y [ bowel ischemia and infarction is an early complication of +++ repair ) pse&domem%rano&s colitis takes =-< days ater anti%iotic &se to develop) ischemic colitis will show thickening of the bowel wall on C7 ) in a patient with ac&te pancreatitis, check or &nderlying ca&se (gallstones$ do #S <raso&nd in#ammatory bowel disease also occ&rs w in#ammatory arthritis) ankylosing spondylitis is an association) I-anca and also erythema nodos&m %iliary colic ca&sed %y ingestion o atty meals) gall %ladder contracts and presses gallstone against cystic d&ct opening, increasing gall %ladder press&re, ca&sing distension and colicky pain) gall %ladder rela4es and stone alls %ack in d&ct) 0iliary colic is temporary, cholecystitis is more constant pain) pyloric stricture (and gastric outlet obstruction $ lead to early satiety, succussion splash, non %ilio&s vomiting) ac&te appendicitis sho&ld have immediate s&rgery i clinical diagnosis is clear hematochezia is %right red %lood per stool) &s&ally d&e to lower gastrointestinal %leed) do colonoscopy, i negative then do labeled erythrocyte scintigraphy) laxati%e abuse on %iopsy will show dark brown discoloration of colon with lymph follicles shining thro&gh as pale patches (melanosis coli$ H. pylori is associated with gastric lymphoma$)+L7oma %&t not adenocarcinoma) once diagnosis o cancer is made, ne4t step is to 1nd e4tent o disease)
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inLamm %owel disease has a %i-modal distri%&tion) erythemato&s m&cosa possi%ly w &lcers) &lcerative colitis has shallow &lcers compared to crohns transm&ral) persistence o "bs+g in ser&m or months con1rms diagnosis o chronic hep b infection) or ac&te hepatitis &se B/Ds and serology %&t or chronic hepatitis do li%er biopsy) acalculous cholecystitis is seen in se%ere trauma, ischemia, post-op patients) similar to cholecystitis with thickening o gall %ladder wall, and pericholecystic pericholecystic L&id) drug induced esophagitis ca&sed %y potassium chloride, NS+*Ds, alendronate, doxycycline) mechanical small bowel obstruction presents with abdominal discomfort , %omiting, abdominal distention, constipation, increased 8S dilated loops of bowel on x-ray ) most commonly %c o adhesions rom previo&s previo&s operations) painless Fa&ndice I conF&gated hyper%ilir&%inemia I elevated AB sho&ld raise concern or intraa%dominal malignancy malignancy that is o%str&cting the %iliary system ? pancreatic adenocarcinoma chronic pancreatitis is diagnosed with stool elastase ) ser&m amylase and lipase concentrations can %e normal or only modestly elevated) acute di%erticulitis is &ncomplicated ( sided circulation6 ) prec&rsor o serotonin is tryptophan so patients can get niacin de(ciency) Niacin de(ciency presents as “the = s” diarrhea, dermatitis, dementia, and death in patients with liver cirrhosis and who have esophageal varices give %eta%lockers to decrease the risk o variceal hemorrhage) hemorrhage is the most common complication o peptic ulcer) will present as hematemesis with or witho&t melena) i itHs massive &pper gi %leeding it will appear as hematoche'ia (%right red %lood in stool$) 8oerhaa%e0s syndrome is spontaneo&s r&pt&re o the esophag&s when intraa%dominal press&re goes high) retrosternal pain and crepitus in the suprasternal notch are the res< o pneumomediastinum which can occ&r ater r&pt&re o esophag&s within the mediastin&m)
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d&odenal &lcer presents with epigastric pain %etter &pon eating) ;9G inected with h. pylori so pylori so give 8 I anti%iotics (a'ithro, clarithro$ echinococcus granulosus ca&ses hydatid cyst disease which appears as eggshell calci(cations on CD scan o liver) emphysematous cholecystitis is a orm o ac&te cholecystitis that arises arises d&e to infection of gall bladder wall with gas forming bacteria) #S pain, na&sea, vomiting, low ever) diagnosis with a%dominal W# demonstrating air #uid le%els in gall bladder or an <raso&nd showing cur%ilinear gas shadowing in the gall %ladder) i have patient with migratory thrombophlebitis$7rousseau syndrome try to 1nd occ< t&mor) .# is present in &p to
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a choledochal cyst is a congenital abnormality of the biliary ducts characteri'ed characteri'ed %y the dilatation of intra or extra-hepatic biliary ducts or both) in children in can ca&se a%dominal pain, Fa&ndice, and attacks o recurrent pancreatitis, which may %e evident %y increases in the amylase and lipase levels) all patients with chronic liver disease sho&ld %e imm&ni'ed against 5A" and 50" gallstones are mainly cholesterol stones and mi4ed stones (N9G$) cholesterol stones are radiol¢ not seen on xray $) patients 3 << with new-onset symptoms o dyspepsia and those o any age with alarming symptoms (weight loss, dysphagia, persistent vomiting$ sho&ld &ndergo endoscopy (concerning or esophageal carcinoma$) other patients sho&ld have either H. pylori serology pylori serology or empiric treatment with 8) peritoneal L&id can acc&m&late d&e to a n&m%er o dif) ca&ses incl&ding portal hypertension, tra&ma, inection, pancreatitis, and malignancy) to diferentiate trans&dative rom e4&dative e4&dative yo& can &se the !AA.) ser&m al%&min ? ascites al%&min) if @ B3B then itHs a transudati%e process ? cirrhosisportal hypertension, hypertensi on, C5/, !AA. : *)* is e4&dative ? t&%erc&losis, pancreatitis, neoplasm small bowel obstruction has colicky or paro4ysmal a%dominal pain with episodic hyperacti%e bowel sounds attri%&ta%le to peristaltic r&shes, a%dominal distension, and dif&se a%dominal tenderness) failure to stool or #atus obstipation6 indicates a complete bowel obstruction has occurred ) small %owel o%str&ction also has na&sea and vomiting more oten than large %owel o%str&ction) complete s%o reK&ires s&rgical correction) patients get metabolic acidosis lactic acidosis d&e to ischemia of a strangulated loop of small bowel ) strang&lation leading to ischemic necrosis and peroration o small %owel is a maFor lie- threatening complication o !0O) when this happens the patient will have peritoneal signs) in patients getting total parenteral nutrition, the stimulus for CCK release is impaired %eca&se the gastrointestinal tract is %ypassed) cck normally stim&lates gall %ladder contraction, and when this doesnt occ&r there is stasis and bile sludge tending to form gall stones predisposing to cholecystitis) know these dr&gs ca&sing .ancreatitis2 *$ di&retics (&rosemide, thia'ides$, +$ inLamm %owel disease dr&gs (s&lasala'ine, (s&lasala'in e, <-A!A$ $ imm&nos&ppresants imm&nos&p presants (azathioprine, l-asparaginase$ l-asparaginase $ =$ sei'&re%ipolar sei'&re%ipol ar disorder ( %alproic acid $ <$ A8! (didanosine, pentamidine$ J$ anti%iotics ( metronidazole, tetracycline$ pernicio&s anemia can occ&r in the setting o other a&toimm&ne diseases) and while dietary de(ciency is a common ca&se o folate de(ciency only a few months of reser%es6 , it &s&ally does not ca&se 0*+ (years o reserves$ de1ciency) increased intragastric press&re d&ring vomiting can ca&se tears in the m&cosa o the distal esophag&s and pro4imal stomach) these are called )allory-:eiss tears and acco&nt or *9G o &pper .8 %leeds) tears cause bleeding from submucosal arteries) %leeding stops in ;9G o patients, however %asopressin, endoscopic injection or electrocautery may %e reK&ired in a ew cases) spontaneo&s %acterial peritonitis peritonitis is a common complication o ascites in which the peritoneal L&id %ecomes inected %y an enteric organism) 1nding o @ A'2 .)N in the ascitic L&id is diagnostic) patients will have abdominal pain , ascites, tachycardia, low-grade fe%er3 painless jaundice sho&ld %e considered considered secondary to pancreatic cancer &ntil proven otherwise) otherwise) elevated AB and total %ilir&%in %ilir&%in s&ggest a cholestatic cholestatic pattern o Fa&ndice which co&ld %e ca&sed %y a pancreatic mass o%str&cting the common %ile d&ct)
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treat alcohol withdrawal with benzodiazepines) treat hepatic encephalopathy with lact&lose) hepatic encephalopathy patient will have a cirrhotic li%er (hypoal%&mminemia and increased 86#$ hepatorenal syndrome is a deadly complication of cirrhosis characteri'ed %y kidney failure that doesnt respond to %olume resuscitation ) it is %est treated with li%er transplantation) cirrhosis sho&ld %e s&spected in any patient with new ascites and pedal edema and with stigmata o chronic liver disease like spider angiomatagynecomastia) most common ca&ses o cirrhosis are chronic alcohol abuse and chronic %iral hepatitis) alcohol hepatitis is characteri'ed %y mallory bodies, in(ltration by neutrophils, li%er cell necrosis, and peri%enular distribution of in#ammation) atty liver, alcohol hepatitis, and even early 1%rosis are all potentially reversi%le i patient stops alcohol ingestion) tr&e cirrhosis with regenerative nod&les is irreversi%le) hypertriglyceridemia is a ca&se o ac&te pancreatitis) patients can have yellow-red papules on the arms and shoulders , a description s&ggestive o erupti%e xanthomas) do a fasting lipid panel to see i the levels are @B222 and causing the pancreatitits3 steatorrhea with severe intermittent epigastric pain s&ggests chronic pancreatitis) \* ca&se is d&e to alcoholism) portal hypertension is the most common ca&se o ascites) portal hypertension is &s&ally d&e to cirrhosis rom chronic liver disease (alcoholic or viral$) *,D+ predisposes to cirrhosis %y p&tting individ&als at increased risk or chronic inection with 5ep 0 or 5ep C vir&s) development o a palpable mass in the epigastri&m = weeks ater onset of acute pancreatitis is s&ggestive o pancreatic pseudocyst) the pse&docyst is comprised o inLammatory L&id, tiss&e, and de%ris that acc&m&late within the pancreas) when the amylase-rich #uid leaks into circulation , serum amylase becomes markedly ele%ated ) ultrasound is the preerred means o imaging pse&docysts) oten resolves spontaneo&sly so only drain i it persists or 3 J weeks is 3 < cm in diameter or %ecomes secondarily inected) pancreatic abscess presents with fe%er and leukocytosis) tender epigastric mass ) Niacin de(ciency leads to pellagra (diarrhea, dermatitis, dementia, and death$) patients will have glossitis and dermatitis in sun exposed areas resem%ling a s&n%&rn) as the rash progresses the skin %ecomes hyperpigmented and thickened) ribo#a%in de(ciency can lead to cheilosis, glossitis, seborrheic dermatitis, pharyngitis, and edema or erythema of the mouth ) or cholelithiasis do right upper ;uadrant ultrasound) signs are #S pain ater eating and at night) 0oaHs sign is right s&%scap&lar pain o %iliary colic) s&spect celiac disease in any patient with malabsorption and iron de(ciency anemia) celiac disease is associated with anti-endomysial antibodies ) will have de(ciency of %it + (hyperkeratosis$ %it d (osteomalacia, %one pain$, %it k (easy %r&ising$, loss o s&%c&taneo&s at, %&lky o&l smelling Loating stools) echinoccoccus infections are known as hydatid cysts and can %e o&nd in almost any part o the %ody %&t the liver is most common) common in areas where sheep and dogs are raised) hydatid cyst is a L&id 1lled cyst with an inner germinal layer and an outer acellular laminated membrane ) the germinal layer gives rise to n&mero&s secondary daughter cysts ) eggshell calci(cations on liver) %acterial overgrowth, pancreatic ins&f, celiac disease, and crohns disease all res< in chronic diarrhea with increased ecal at content) d-xylose test helps to distinguish between bacterial o%ergrowth and celiac disease intestinal %illous atrophy6) d-xylose is a simple s&gar, reK&ires only an intact m&cosa to
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%e a%sor%ed) in normal individ&als ater +Q= abdominal pain ) &6 confusion and '6 hypotension may also %e o%served with suppurati%e cholangitis prod&cing >eynolds pentad) i symptoms persist then there is an indication or &rgent %iliary decompression preera%ly %y endoscopic retrograde cholangiopancreatography ercp63 the absence of peristaltic wa%es in the lower A$? of the esophagus and signi(cant decrease in lower esophageal sphincter LS6 tone %ersus Chaga0s which is increased LS tone and achalasia6 are characteristic or esophageal dysmotility associated with Scleroderma) diuse esophageal spasm is characteri'ed %y chest pain and dysphagia, not heart%&rn) manometry may reveal periodic high-amplitude non-peristaltic wa%es )
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somatic pain is well-localized and in the a%domen is &s&ally secondary to peritoneal inLammation) visceral pain is vag&e in locali'ation and d&e to mechanical stretching o the a%dominal viscera) H%isceral is %ague peritoneal is preciseG in a patient with direct hyper%ilir&%inemia the ca&ses can %e d&e to intrahepatic or e4trahepatic o%str&ction) hepatocell&lar diseases like virala&toimm&ne hepatitis, alcoholic hepatitis, will have elevated aminotranserases whereas when there is a dominant elevation o +L. have predominant intra or extra hepatic biliary obstruction3 the two dr&gs approved or Chronic "epatitis 8 are interferon and lami%udine) Chronic 5ep 0 presents with persistently ele%ated +L7 le%els , detecta%le ser&m "bs+g, "be+g, and "8, DN+) massive doses o asiprin and 6!A8s can ca&se acute erosi%e gastritis and &pper .8 %leeding) alcohol can aggravate this efect) N+S" appears histologically similar to alcoholic hepatitis ) impaired responsiveness o at cells to ins&lin, there%oy ca&sing accumulation of fat in the li%er) steatosis can then progress to steatohepatitis and (brosis, secondary to lipid peroxidation and oxidati%e stress bacterial o%ergrowth is a mala%sorption syndrome which can %e associated with a history o a%dominal s&rgery) physical e4am 1ndings may reveal abdominal distention with identi1a%le succussion splash rom palpa%le, sot, #uid-(lled loops of bowel ) >eye syndrome occ&rs in children who take aspirin) characteri'ed %y diuse mitochondrial injury leading to na&sea, vomiting, headache, hypoglycemia, li%er failure and cns damage) extensi%e fatty %acuolization of the li%er without in#ammation micro%esicular changes6 ) liver is enlarged %&t there is no icter&s) in patients with dysphagia where the diferentials are %road, a barium esophagram is &s&ally perormed %eore upper endoscopy) progestins can help or cancer-induced cachexia rupture of the esophagus (8ooerhaa%e0s Syndrome$ occ&rs ater severe retching and presents as chest or epigastric pain, na&sea, vomiting, ever, and unilateral pleural eusion) Penker0s di%erticulum oten have o&l smelling %eath secondary to pooling o material in the divertic&l&m) increased risk or aspiration pneumonia) contrast esophagram is the diagnostic test o choice) treatment or ascites2 salt and water restriction -3 spironolactone -3 loop diuretic -3 paracentesis (check renal &nction$ ilbert0s syndrome is a amilial disorder o bilirubin glucuronidation where .D en'yme prod&ction is red&ced) maniests as icter&s secondary to a mild unconjugated hyperbilirubinemia (sho&ld %e M ?-&$) certain events like asting, hemolysis, physical e4ertion, e%rile illness etc are tho&ght to trigger an e4acer%ation) treatment is generally unnecessary) Crigler-Najjar type B has se%ere jaundice and neurological impairment d&e to kernicterus and &nconF&gated hyper%ilir&%inemia ( A2-A' mg$dl$) liver en'ymes and histology are normal) i 8" phenobarbital is given the ser&m %ilir&%in remains &nchanged) liver transplant is only c&re) Crigler-Najjar type A is milder disorder characteri'ed %y lower ser&m %ili M A2 mg$dl ) no kernicter&s)
hematologyoncolog y •
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ac&te drop in hemoglo%in ca&sed %y hyperhemolytic crisis, splenic seK&estration, or aplastic crisis .roxysmal Nocturnal "emoglobinuria tx with !e$!olate and clusimab6 can have hepatic %ein thrombosis %s +cute *ntermittent .orphyria warfarin activity is increased %y ,it supplements6 and oods rich in %itamin K will decrease its ecacy acute graft-%s-host disease ,"D6 presents with skin ( maculopapular rash$ intestines ( diarrhea with blood$ and liver ( abnormal L!7s and jaundice$ bronchogenic cysts are located in the middle mediastinum) thymoma is &s&ally o&nd in the anterior mediastinum) all ne&rogenic t&mors (like ne&ro%lastoma$ are located in the posterior mediastin&m) sickle cell patients can get stroke d&e to occl&sion and sl&dging in the cere%ral vessels) treat with exchange transfusion sickle cell anemia will have retic&locytosis d&e to chronic e4travasc&lar hemolysis) most head and neck cancers are s;3 cell carcinomas ) will have a normal cell co&nt in t&mor lysis syndrome yo& release all the 7I and phosphate in cells) phosphate binds calcium leading to hypocalcemia) :aldenstrom0s )acroglobulinemia 7ype of Non "odgkin0s Lymphoma excess abnormal 8 cells6 can have demyelinating sensorimotor neuropathy, easy bruising$bleeding fatigue, hepatosplenomegaly) hypersegmented ne&trophils seen in olate de) and 0*+ (co%alamin$ de which will increase homocysteine) only 8BA de(ciency raises methylmalonic acid) hereditary spherocytosis leads to cholecystitis d&e to pigment stones) with chemotherapy and radiation or 5odgkinHs disease develop a secondary malignancy usually many years down the line since treatment is often during childhood6) risk is highest when chemotherapy is com%ined with radiation) "odgkin0s Disease is a c&ra%le lymphoma tending to afect yo&nger patients) a%o&t G o patients treated in a yo&ng child a microcytic anemia is likely to %e iron de1ciency or thalassemia) >D: >8C distribution width6 can tell yo& the diference i itHs @ A25 then most likely to %e iron de(ciency anemia) Dhalassemia have increased )C"C3 &nconF&gated %ilir&%in is highly insol&%le in water (to4ic, goes to %rain$, does not go to &rine) conF&gated %ilir&%in goes to the &rine) hereditary telangiectasia osler-weber-rendu syndrome6 is an a&tosomal dominant disorder characteri'ed %y * $ diuse telangiectasias +$ widespread +,)s $ recurrent epistaxis) in this syndrome avmHs tend to occ&r in m&co&s mem%ranes, skin, .8 tract) the avmHs in l&ng can sh&nt %lood rom right heart to let heart, ca&sing chronic hypoxemia and reacti%e polycythemia)
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acute hemolytic transfusion reaction develops an ho&r ater trans&sion starts) lie-threatening reaction res<ing rom transfusion of mismatched blood, typically +89 mismatch) rapidly develop ever, hemolysis, shock , and D*C) delayed hemolytic transfusion res<s rom anamnestic response to a minor rbc antigen which has %een previo&sly enco&ntered) low grade hemolysis A-B2 days after trans&sion) reaction to cytokines presents with transient fe%ers, chills, malaise) wash >8C blood products especially for *g+ de(cient patients otherwise just do Leukoreduction ) patients with sickle cell disease have &nctional asplenia %y +- years) need imm&ni'ations against h3 in#uenza and s3 pnuemoniae) high grade ever, hypotension, altered mental stat&s, elevated w%c with %andemia is s&ggestive o sepsis, which is most commonly ca&sed %y pne&mococc&s in sickle cell) m<iple episodes o throm%osis witho&t a clear precipitating actor sho&ld raise concern or hypercoag&la%ility d&e to a genetic deect in a yo&nger patient, or a primary malignancy in an older patient) anemia o chronic disease has decreased iron, decreased D80C (wants to %ind iron less to “hide it rom the %&gs”$, and decreased iron sat&ration with increased or elevated erritin (storage iron, inLammatory marker$ levels) sinopulmonary and * infections with transfusion reaction point to *g+ de(ciency) patients orm a&toanti%odies to 8gA) patients with sickle cell anemia may e4perience pain&l vaso-occl&sive episodes which may %e triggered %y inection, dehydration or hypo4ia) hydro4y&rea is indicated in patients with reK&ent ac&te pain&l episodes (3J year$) folic acid supplementation is help&l in pre%enting aplastic crisis) febrile reaction is a common trans&sion reaction that is ca&sed %y anti%odies in the patientHs plasma reacting with the donorHs le&kocytes) cell washing decreases the pro%a%ility o e%rile non hemolytic trans&sion reaction) no hemodynamic a%normalities and renal dys&nction are &s&ally present) ac&te hemolytic E a%o mismatch, delayed hemolytic E minor r%c antigen in a patient who gets 58D ( heparin induced thrombocytopenia $ and needs to %e anti-coag&lated stop heparin immediately and start argatroban) s&spect heparin ind&ced throm%ocytopenia when2 platelet co&nt : <9G rom %aseline, arterial or veno&s throm%osis, necrotic skin lesions at heparin injection sites, ac&te systemic reactions ater heparin) diagnosis2 serotonin release assay is the gold standard glucose-/-phosphate dehydrogenase de1ciency is an 4-linked recessive disorder commonly seen in arican-american men) hemolytic episodes in response to o4idant dr&gs, inections, or ava eans) heinz bodies are seen in the peripheral %lood smear) "owell-Iolly bodies are nuclear remnants within r%cs typically removed %y the spleen) their presence strongly s&ggests physical or &nctional hyposplenism) patients who develop serio&s %leeding (e)g) intracere%ral hemorrhage$ d&e to e4cess anticoag&lation with wararin sho&ld %e gi%en !!. for the rapid re%ersal of anticoagulation ) vitamin k reverses wararin action %&t takes N-*+ ho&rs to %e efective) (in real lie give %oth$ warfarin inhi%its protein C prod&ction in the 1rst ew days itHs given) --3 skin necrosis) protein C is anti-coag&lation) with no protein c --3 clot "QS is *$ throm%ocytopenia +$ renal involvement (%&mp in creatinine$ $ hemolytic anemia (i yo& add ne&ro and ever yo& have 77.6) Dreatment or 5! is lasmapheresis (plasma e4change$ and steroids, add resh ro'en plasma
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8C can present in a patient with %reast cancer) la% val&es show thrombocytopenia, decreased (brinogen , increased *N>, ele%ated LD", ele%ated reticulocyte count and bilirubin macrocytic anemia with throm%ocytopenia and le&kopenia as well as neutrophils with reduced segmentation can occ&r in myelodysplastic syndromes) con1rm with bone marrow biopsy patients with a splenectomy will have thrombocytosis %c spleen remo%es old platelets from the circulation ) patients with "D in whom anticoag&lation is contraindicated reK&ires placement of inferior %ena ca%a (lter to prevent p&lmonary em%olism) anaphylactic reactions to trans&sed %lood prod&cts occ&r rarely, %&t are more common in patients with *g+ de(ciency) rapid onset of symptoms with associated bronchospasm and hypotension pl&s the absence of fe%er help to disting&ish anaphyla4is rom other possi%le trans&sion reactions) +89 mismatching patients have rapid hemolysis with maniestations o fe%er, Lank pain, dark urine and dic) amamnestic antibody response to a minor rbc antigen can lead to delayed hemolysis several days after transfusion) reaction to cytokines E fe%er chills malaise) patients with alpha-thalassemia minor or beta-thalassemia minor will have impressi%e microcytosis mc% can be in F2s6 %&t only modest anemia) reassurance is only intervention that is needed) patients with thalassemia major are generally se%erely symptomatic and transfusion dependent) spontaneous hemarthrosis sho&ld give s&spicion or hemophilia or which factor < assay is diagnostic ) prolonged ptt, normal pt, normal %t, and normal 1%rinogen level and low ser&m actor N are the la% 1ndings) treatment is to replace actor N) i mild can treat with demospressin) do coag&lation st&dies to diagnose ollowed %y actor N and ; levels) arterialveno&s throm%osis and throm%ocytopenia in patients recieving heparin therapy is s&ggestive o heparin induced thrombocytopenia ) antibodies against heparin-platelet factor-& complex are responsi%le) Schilling test helps diferentiate %etween dietary de(ciency rom pernicious anemia and malabsorption as ca&ses o vit %*+ de1ciency and megalo%lastic anemia) give oral radio-%*+ and intram&sc&lar %*+) check &rinary e4cretion) i urine has radioacti%e-bBA then a%sorption is normal and dietary de(ciency) i low radioactive %-*+ in &rine then itHs d&e to poor a%sorption) so do part + to diferentiate %etween pernicio&s anemia or mala%sorption) give radio-%*+ with intrinsic actor and check &rine) low excretion of bBA ater giving i r&les o&t pernicio&s anemia and suggests malabsorption (pancreatic ins&Uc, %acterial overgrowth, short g&t syndrome$) normal excretion ater adding i s&ggests pernicious anemia) in a patient with a "D, treat with heparin and wararin or the 1rst < days) ater < days i the 86# is therape&tic (+-$ then the heparin may %e discontin&ed and wararin contin&ed or J months) a progressing clot in a patient with a s&%therape&tic 86# reK&ires %ridging heparin &ntil the inr is therape&tic) // has all the clotting actors and is * st line treatment or %leeding patients with a coag&lopahy) factor ' leiden is the most common inherited disorder ca&sing hypercoag&la%ility and predisposition to throm%oses) hemolytic anemia in a patient with a malignant lymphoproliferati%e disorder is likely to %e o the warm autoimmune type, ca&sed by anti->8C *g antibodies) give prednisone, i not efective then do splenectomy)
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%itamin k de(ciency can %e seen in a patient who has %een kept npo for a prolonged time and recei%ing broad-spectrum antibiotics ) la%s show prolonged D ollowed %y prolonged ptt) cystic 1%rosis can lead to impaired a%sorption o at sol&%le vitamins) vitamin k is necessary or post-translational modi1cation o several anticoag&lant actors2 + ; and *9 as well as protein c and s) NS+*Ds ca&se iron de(ciency anemia thro&gh chronic low grade$occult blood loss per the .8 tract) anemia o chronic disease can %e seen in rhe&matoid arthritis, %&t not generally seen in osteoarthritis) ( osteoarthritis is N97 an in#ammatory condition$ radiation therapy is the most appropriate management for bone pain in a patient with prostate cancer ater androgen ablation orchiectomy $) presence o thrombocytopenia has a poor prognosis in CLL3 stage 9 E lymphocytosis only) stage * E lymphocytosis I adenopathy) stage + E splenomegaly stage E anemia stage = E throm%ocytopenia elderly patient with %one pain, renal ail&re and hypercalcemia has m<iple myeloma &ntil proven otherwise) obstruction of distal and collecting tubules %y large laminated casts containing paraproteins (0ence Tones protein$ ca&ses renal ail&re) serotonin antagonists that block '"7? receptors are dr&gs o choice or treating and preventing chemotherapy-induced nausea and %omiting ) (9ndansetron$Pofran$ ele%ated serum protein with normal albumin (gamma gap$ s&ggests disorders like m<iple myeloma, waldenstromHs macroglo%&linemia, and monoclonal gammopathy o &ndetermined signi1cance) M.! is an asymptomatic elevation o a monoclonal (m$ protein on !) diagnosis is made %y e4cl&ding m<iple myeloma (anemia, pancytopenia, hypercalcemia, %ony lytics lesions, and renal disease$) mg&s patients &s&ally have : gdl with :*9G o plasma cells o&nd in %one marrow) mm patients have 3 gdl m protein on spep with 3*9G plasma cells in the %one marrow) myeloproliferati%e disorders have the IakA mutation) i they have polycythemia vera then the .9 will be low ) will have symptoms like headache, di''iness, %isual disturbances d&e to hyper%iscosity) pruritis d&e to release of histamine and prosaglandins) facial plethora, hepatosplenomegaly) 8C>-+8L mutation is seen in C)L patients) +LL is the most common leukemia in children) may have a h4 o viral respiratory inection or e4anthem) on physical e4am there may %e pallor, hepatosplenomegaly, petechiae, andor lymphadenopathy) diagnosis is s&ggested %y anemia, thrombocytopenia, and blast cells @A'56 on a peripheral smear) )) has %ack pain, anemia, renal dys&nction, and ele%ated S>) hypercalcemia rom MM may maniest as severe constipation, anore4ia, weakness, increased &rination, or ne&rologic a%normalities) rituximab is a monoclonal anti%ody directed against the CDA2 antigen on %lymphocytes that is oten &sed to treat patients with symptomatic CLL) patients will have “ smudge cells” and can have autoimmune hemolytic anemia and immune thrombocytopenia) malignant melanoma mets to varia%le places in the %ody and lie dormant or *<+< years and then rec&r even when the primary t&mor was resected) malignant melanomas are known or ca&sing bleeding inside the metastatic mass in the brain)
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s;3 cell carcinoma of the mucosa of the head$neck is common in people with a signi1cant history o alcohol and to%acco &se) the 1rst maniestation may %e a palpa%le cervical lymph node) %est initial test is panendoscopy (triple endoscopy E esophagoscopy, bronchoscopy, laryngoscopy$ to detect the primary t&mor) patients with m<iple myeloma canHt make &nctional anti%odies and le&kopenia that develops as %one marrow is 1lled with malignant plasma cells so they are at an increased risk or inection) a reciprocal translocation of 4OAA res<s in philadelphia chromosome containing the bcr$abl fusion gene ) 1nd this in C)L) tyrosine kinase inhibitors &nction %y inhi%iting the a%normal %cra%l gene like imatinib are a key component o treatment or C)L) retinoic acid receptor is &sed to treat acute promyelocytic leukemia3 .7"-rp is produced locally when the tumor mets into the bone to induce bone resorption ) acute monocytic fab m'6 leukemia has a dramatic onset with headaches, evers, weight loss, and %leeding rom the g&msnose) 1alpha-naphtyl esterase test is characteristic) +cute promyelocytic leukemia is characteri'ed %y +uer rods in cells ) high incidence o D*C in this le&kemia) 7>+.1 in "airy Cell Leukemia
inectio&s disease •
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serous otitis media is most common middle ear pathology in +*DS) hiv lymphadenopathy or lymphomas ) d&ll tympanic membrane that is hypomobile) or disseminated histoplamosis (t4 with itracona'ole$ check antigen in urine or serum3 isseminated histoplasmosis can ca&se oral &lcers, and %one marrow (pancytopenia$ give all patients 3 J< or with co-mor%idities pne&mococcal vaccine primary hiv-associated throm%ocytopenia- asymptomatic throm%ocytopenia is presentation in *9G o 58" cases) Dreat with 'idov&dine malignant otitis externa treated with anti-pseudomonal (cipro#oxacin$) symptoms are gran&lation tiss&e and discharge in rhinitis i yo& dont 1nd ca&se %y history and physical e4am do nasal cytology) ne&trophils E inectio&s, eosinophils E allergic, vasomotor E no eosinophils nasopharyngeal carcinoma can present w recurrent otitis media, recurrent epistaxis) strongly associated with Iserology or 8,) mediterranean and ar eastern descent) necrotizing fasciits has purplish discoloration o the skin with gangrenous changes and systemic toxicity ) CDM#8 can show pockets o gas deep within tiss&e) Can oten eel skin crepit&s)
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the most eared complication o a retropharyngeal abscess is spread o inection into the mediastinum, which can lead to acute necrotizing mediastinitis need +bx and surgical debridement6 ) recent history o #8, pharyngitis, otitis, sin&sitis, etc) happens in children) symptoms are sore throat, dysphagia, neck stifness, muRed hot potato %oice ) patients with retropharyngeal abscess complain o sore throat, ever, diUc<y swallowing (dysphagia$ and pain with swallowing (odynophagia$ and pain with certain neck movements) treat rapidly to pre%ent the spread of infection into the mediastinum) 8, DN+ in the CS! is speci1c or primary CNS lymphoma) will have a solitary, weakly ring-enhancing mass in the periventric&lar area) cutaneous lar%a migrans ca&sed %y helminth A. braziliense) o&nd in tropical regions) itchy, elevated serpiginous lesions) contact %y sand progressi%e multifocal leukoencephalopahy .)L6 is ca&sed by IC ,irus) M#8 will show multiple non-enhancing lesions with no mass efects) toxoplasmosis will be ring-enhancing ) C6! lymphoma is single, weakly enhancing) bacillary angiomatosis has a c&taneo&s lesion o a large ped&nc&lated e4ophytic caps&le with a collarette) like a cherry angioma) %isceral angioma-like %lood vessel growths) Ca&sed %y Bartonella henselae inections, o&nd in A8! patients) herpes 'oster opthalmic&s has dendriorm corneal uclers and conF&nctivitis, and vesicles aro&nd the or%it) nocardia is treated with 7).-S)J) %ranching, %eaded, aero%ic gramI partially acid-ast pne&monia ca&sing a cavitary p&lmonary inection) C), retinits in 58" patient M '2 CD&) yellowish-white patches o retinal opaci(cation and retinal hemorrhages) rubella has posterior cer%ical and post3 auricular lymphadenopathy and polyarthralgia) #ash %egins at the head and moves down) condyloma accuminata (anogenital warts$ ca&sed %y ".,) skin colored %errucous papilliform lesions aro&nd an&s) treatment is podophyllin or trichloroacetic acid) erythema multiforme is an extrapulmonary manifestation of #. pneumonia) d&sky red, target shaped skin lesions) malaria ca&ses anemia and splenomegaly with cyclical evers 58" sho&ld get MM# and varicella live vaccines i their C= is 3 +99 and not imm&ne to MM# (titers$ amoxicillin-cla%ulanate is anti%iotic o choice or polymicro%ial human and dog bites) leukoplakia is a whitish plaK&e that has a gran&lar appearance and is not scraped o ) can transorm into !CC epiglottitis is ca&sed %y H. infuenza and S. pyogenes) high grade ever, sore throat, odynophagia, drooling, muRed %oice, shrill on e4piration) has thumb sign on lateral xray) S. pneumoniae is a caps&lar polysaccharide vaccine that ind&ces a D cell independent 0 cell response do a C7 scan to diagnose intraa%dominal a%scess) psoas abscess can present w ever, w%c co&nt increased, lower a%dominal or %ack pain) can occ&r d&e to perorated appendicitis) or local impetigo super(cial6 &se topical mupirocin or oral erythromycin) not penicillin %eca&se S. aureus is resistant long term seK&elae associated with %acterial meningitis incl&de2 *$ loss o cognitive &nction +$ hearing loss $ sei'&res =$ M# <$ spasticity or paresis
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most common ca&se o %iral meningitis are the non-polio entero%iruses like echo%irus and coxsackie%iruses3 Ludwig0s angina is inection o the submandiblar and sublingual glands) the so&rce o inection is most commonly an infected tooth) asphy4iation is the most common ca&se o death) presents with odynophagia, ever, dysphagia, and drooling) mycobacterium a%ium complex prophylaxis %y giving azithromycin to aids patients) C= : <9 will have co&gh and ever) or CM" inection give prophyla4is when C= : <9 and ser&m CM" 8g. is positive or I%iopsy or CM") histoplasma capsulatum is common and &s&ally asymptomatic infection in endemic areas like mississippiohiomisso&ri river valleys and central america) isseminated goes to %ones) D4 with itracano'ole treatment or toxoplasmosis is sulfadiazine and pyrimethamine) Nocardia is gramI partially acid-ast 1lamento&s %ranching rod ca&sing lung ca%ities, or nodules in 58" patients) treatment is 7).-S)J3 isseminates to skin and %rain a patient rom Caliari'ona with pulmonary infection and cutaneous (ndings like erythema multiforme and erythema nodosum has coccidiodomycosis) septic arthritis can res< in rapid and permanent joint destruction) synovial L&id aspiration that shows 3*99k le&kocytes 3 ;9G pmns, and p&r&lent L&id sho&ld prompt orthopedic consultation for emergency surgical drainage ) in 58" patients %oth "S, and ,P, can ca&se se%ere acute retinal necrosis associated with pain, keratitis, &veitis, and &ndoscopic 1ndings o peripheral pale lesions) C), retinitis is painless $ not associated with keratitis or conF&nctivitis, and has hemorrhages or #uy$granular lesions around retinal %essels) 7).-S)J can ca&se hyperkalemia) so does succinylcholine, 6!A8s, heparin, non-selective beta-blockers, and digoxin) N. gonorr"ea septic arthritis can present as an oligoarthritis that is asymmetric with tenosyno%itis and skin rash) legionella ca&ses gastrointestinal symptoms with pne&monia) a%dominal pain and loose stools and also can have hyponatremia and ele%ated L!7s) fulminant hepatitis has a mortality rate o 3 N9G so p&t on li%er transplant list) not steroids, intereron or lamiv&dine) rhe&matic ever2 sore throat, ever, pericarditis, erythema marginat&m, arthritis, chorea, s&%c&taneo&s nod&les) TO6! (Foints, heart, nod&les, erythema, syndeham chorea$ 7richinella roundworm6 ca&ses trichinellosis acK&ired %y eating undercooked pork ) three phase disease *$ larvae in%ade intestinal wall) a%dominal pain, na&sea, vomiting, diarrhea) +$ local and systemic hypersensiti%ity reaction ca&sed %y larval migration, has HsplinterG hemorrhages, conF&nctival and retinal hemorrhages, periorbital edema and chemosis) $ lar%ae enter muscle ca&sing muscle pain , tenderness, swelling, and weakness) osinophilia3 7x with mebendazole >ubella0s rash is erythemato&s and mac&lopap&lar) starts on ace and progresses to tr&nk and e4tremities) ad< women &s&ally present with arthritis) occipital and posterior cer%ical lymphadenopathy also s&ggest this diagnosis) N. gonorrhea &rethritis is less common than chlamydial urethritis) the discharge is p&r&lent and not mucopurulent like it is in chlamydia) peritonsilar abscess presents with sore throat, m&Ped “hot potato voice” and de%iation of the u%ula) itHs a complication o tonsilitis) generally have &nilateral lymphadenopathy) treat with needle peritonsillar aspiration)
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8 patient has &ncomplicated pyelonephritis can switch to oral anti%iotic ater +- days o parenteral therapy) patient with I sho&ld %e given isonia'id I pyrido4ine or ; months) blastomycosis occ&rs near the great lakes, mississippi and ohio river %asins (wisconsin$) symptoms o l&ng inection may resem%le t&%erc&losis and histoplasmosis, however also ca&ses ulcerated skin lesions and lytic bone lesions) “blasts the bone and skinG all newly diagnosed 58" patients sho&ld have2 C= co&nt, ,D>L, ..D, antitoxoplasmosis titer , pne&mococcal polysaccharide vaccine &nless C= :+99, 5A"50" vaccines i seronegative patient with headaches and ocal ne&ro symptoms ater ac&te otitis media or sin&sitis most likely has %rain a%scess) will appear as ring-enhancing lesion on C7 or )>* enterohemorrhagic %. coli "C$ ca&ses a%dominal pain, %loody diarrhea, with no fe%er) it prod&ces a shiga to4in that ca&ses %loody diarrhea) in%asi%e$disseminated +spergillosis occ&rs in immunocompromised patients with ever, co&gh, dyspnea, or hemoptysis) CW# will show a ca%itary lesion, and CD will show pulmonary nodules with a halo sign , or with an air crescent) histoplasmosis will show hilar lymphadenopathy and coccidiodomycosis will have p&lmonary inection and cutaneous 1ndings, like erythema multiforme and erythema nodosum and arthralgias) i a wound is se%ere or dirty, and not imm&ni'ed always give tetanusdipheria toxoid td6 and give tetanus immune globulin tig6) however i imm&ni'ed :*9 years ago to4oid alone is 1ne) or minorclean wo&nds i not imm&ni'ed to4oid alone is 1ne, i imm&ni'ed : *9 years ago then no treatment) blastomycosis afects l&ngs, skin, bones, Foints and prostate) cutaneous disease is either %errucous or ulcerati%e) verr&co&s lesions are papulopustular then become crusted heaped up and warty with a %iolaceous hue3 wet prep will show the yeast orm o the organism) oral tmp-smx is efective in pre%enting .C. infection in transplant patients) doxycycline is good or treating lyme disease and coe4isting anaplasma phagocytophil&m however in children (:N years old$ do4y is contraindicated so &se oral amoxicillin to treat lyme) primary 58" inection can present with a monon&cleosis-like syndrome consisting o ever, night sweats, lymphadenopathy, arthralgias, and diarrhea) common ac&te lie-threatening reactions associated with 58" therapy incl&de2 didanosine nrti6 pancreatitis abaca%ir nrti6 hypersensiti%ity$rash any nrti lactic acidosis any nnrti -%ir-6 ste%ens-johnson syndrome efa%irenz nnrti6 CNS ne%irapine nnrti6 hepatotoxicity indina%ir protease inhibitor6 crystal induced nephrotoxicity in patients with chronic hepatitis c , i their li%er enzymes are persistently normal on m<iple occasions have minimal histological a%normalities and do not need treatment, just follow up) ehrlichiosis is a type o tick-%orne illness that is ca&sed %y one o three dif) species o gram? %acteria, each with a diferent vector) endemic in the se, so&thcentral, mid-atlantic, and &pper midwest regions o &s as well as caliornia) clinical eat&res incl&de2 ever, malaise, myalgias, headache, na&sea, vomiting) &s&ally no rash hence the name “ spotless rocky mountain spotted fe%e r)” la%s show leukopenia andor thrombocytopenia along with ele%ated aminotransferases) treatment is doxycycline)
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in 58" patient with CD& @ A22 and no evidence o A8! de1ning illness gi%e ))> %accine) disseminated N. gonorr"ea inection oten presents with a triad o *$ polyarthralgias +$ tenosyno%itis and $ %esiculopustular skin lesions) in the adult orm o botulism, the patient eats the toxin and gets symptoms) in infantile botulism the infant eats the bacteria (in ood$ and it then produces the toxin in the intestinal tract) %locks ACh release) presents with constipation and poor eeding, ollowed %y hypotonia, weakness, loss o deep tendon reLe4es, cranial nerve a%normalities and respiratory diUc<ies) signs o a&tonomic dys&nction can occ&r early in disease co&rse) S. pneumoniae is the most common pathogen ca&sing pneumonia in nursing home patients) measles is characteri'ed %y a prodrome o cough, coryza, conjuncti%itis, ollowed %y koplik0s spots and maculopapular rash initially appearing on the face ca&sed %y paramyxo%irus) in an immunocompromised patient a lesion on the oot that is erythematous and edematous %&t later develops into a bulla surrounded by erythema and then r&pt&res leaving a painless ulcer with a black center is P. aeruginosa) lesion is called ecthyma gangrenosum looks like anthra4) treat with antipse&domonal penicillins (piperacillinticarcillin$ aspiration pne&monia CW# typically shows consolidation of the dependent lung segments, which incl&des the posterior basal segment of the right lung i the patient aspirates while in a s&pine position) CW# in tuberculosis will show a upper lobe in(ltrate with ca%itation and hilar lymphadenopathy patients who are incarcerated have an increased risk or t&%erc&losis) tuberculosis involving the %ertebrae (.ott0s disease$ typically presents with chronic back pain o insidio&s onset) epidural abscess in l&m%ar region o spine has acute onset back pain and fe%er ) diabetics, *,D+, and patients with recent spinal trauma are at increased risk 3 S. aureus is the most common etiological agent) treat with %ancomycin and surgical drainage rheumatic fe%er is linked to streptococcal pharyngitis S. pyogenes 6 %&t not &s&ally seen ollowing impetigo) strep impetigo can lead to glomerulonephritis) fa%irenz is an 66#D8 that ca&ses CNS side eects in &p to <9G o patients, weird %i%d dreams) .roteus is the most likely ca&se o Q7* in patients with alkaline urine) legionella pneumonia is intracell&lar gram? organism spread %y cooling towers and water s&pplies) travel-associated inection is well doc&mented) co&gh, ever 3;C gastrointestinal symptoms and con&sion) diagnose %y urine antigen testing or c<&re on charcoal agar) treat with azithromycin or le%o#oxacin) also has hyponatremia and elevated B/Ds recurrent pneumonias in the same anatomic region o the l&ng s&ggests bronchial obstruction, itHs a red #ag for lung cancer ) when l&ng cancer is s&spected do a C7 scan of the chest ) %ronchoscopic or CD g&ided %iopsy may then %e perormed depending on whether the lesion has a peri%ronchial or peripheral location) herpes mainly afects temporal region of the brain and may present ac&tely (:* week d&ration$ with ocal ne&rological 1ndings) CS! has lymphocytic pleocytosis, increased erythrocytes and elevated protein) "S, polymerase chain reaction is the gold standard)
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chloroK&ine-resistant lasmodium falciparum is partic&larly common in s&%saharan arica and indian s&%continent) me#o;uine is dr&g o choice or chemoprophylaxis) “me-Ly”ing to travel &se amoxicillin in the treatment o a pregnant patient or lactating patients with lyme disease) do4ycycline is contraindicated) s&spect C), pneumonitis in any patient with a bone marrow transplant (%mt$ with l&ng and intestinal in%ol%ement) CW# will show m<iocal dif&se patchy in1ltrates) CD will show parenchymal opaci1cation or m<iple small nod&les) bronchoal%eolar la%age bal6 is diagnostic ) other than pne&monitis it maniests as upper$lower gastrointestinal ulcers , bone marrow suppression, arthralgias, myalgias and esophagitis and colitis ) most common ca&se o dysphagia$odynophagia in "*, patient is candidal esophagitis) i persists despite therapy (L&cona'ole$ then investigate other possi%ilities) 58" patients with se%ere odynophagia %&t without oral thrush are likely to have ulcerati%e esophagitis ca&sed most commonly by C), ) triad o B6 focal substernal burning pain with odynophagia A6 e%idence of large shallow super(cial ulcerations and ?6 presence of intranuclear and intracytoplasmic inclusions is diagnostic o CM" esophagitis) treatment is ganciclo%ir synovial L&id will show an inLammatory pro1le with average leukocyte count of A'222 in lyme arthritis) treat mucormycosis with amphotericin b) i necrotic tiss&e is present need s&rgical de%ridement erysipelas is a speci1c type o cell&litis) characteri'ed %y inLammation o the s&per1cial dermis, there%y prod&cing prominent swelling) classic 1nding is a sharply demarcated, erythematous, edematous, tender skin lesion with raised borders) systemic signs &s&ally present incl&ding ever and chills) legs are most reK&ently involved site) most likely ca&sative organism is group + beta-hemolytic streptococcus S. pyogenes 63 N. meningitides vaccine sho&ld %e given to a person regardless o 58" stat&s) college age or living in %arracks or dormitories, patients who are asplenic and those with travel e4pos&res) all "*, patients sho&ld get 7d booster e%ery B2 years) in an 58"-inected patient, %loody diarrhea and a normal stool e4am are s&spicio&s or C), colitis) CM" may ca&se esophagitis, gastritis, colitis, proctitis or small %owel disease) colonoscopy will show multiple mucosal erosions and colonic ulceration) %iopsy will show the presence o large cells with eosinophilic intranuclear and basophilic intracytoplasmic inclusions Howls eyeG eect63 treatment o choice is ganciclo%ir or foscarnet treat tinea corporis ringworm $ with topical anti&ngals like terbina(ne) s&per1cial &ngal inection seen in hot, h&mid climates) lesions are pr&ritic, erythemato&s, scaly and have a red ring with central clearing) most common in preadolescents) diagnosed with skin scrapings and 7O5 e4amination) "*, patients who develop esophagitis are 1rst started on #uconazole directed against candidiasis) ail&re to respond to -< day co&rse o oral L&cona'ole warrants further in%estigation with endoscopy) in#uenza pneumonia has symptoms o a%r&pt onset o ever, chills, malaise, myalgias, co&gh, and cory'a) typically occ&rs in an epidemic pattern in the winter) patients will oten %e e%rile and amy have a variety o p&lmonary 1ndings s&ch as whee'es, crackles, and coarse %reath so&nds) leukopenia is common and proteinuria may %e present) CW# may show an interstitial or alveolar pattern, or %e normal) con1rm with nasal swab for in#uenza antigen and treat with anti%irals within =N ho&rs) ne&raminidase inhi%itors oseltami%ir and
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zanami%ir) rimantadine and amantadine are other options %&t only work or in#uenza a) ac&te rhe&matic ever ater gro&p a streptococcal pharyngitis ( S. pyogenes$) maFor Fones criteria incl&de2 carditis, migratory polyarthritis, sydenham chorea, s&%c&taneo&s nod&les, and erythema marginat&m) minor criteria are arthalgias, ever, elevated ac&te phase reactants (C# or !#$, prolonged # interval on 7.) m&st have + maFor criteria, or * maFor I + minor along with preceding gro&p a strep inection) a common ca&se o empyema is after a hemothorax ) %lood in the chest, i not evac&ated, can get inected) the maFority o patients will present with a low-grade ever, dyspnea, and chest pain) surgery is re;uired to remo%e the clotted blood and (brinous peel) bright red, friable, exophytic nodules in an 58" inected patient are most likely bacillary angiomatosis ) ca&sed %y %artonella, a gram? %acill&s) oral erythromycin is the treatment o choice) 8abesiosis Hmalaria of the westG6 is transmitted %y the i4odes tick (same tick as lyme disease$) endemic in the northeastern &s) the parasite enters the patients r%cs and ca&ses hemolysis --3 jaundice, hemoglobinuria, renal failure, death) ehrlichiosis has leukopenia and thrombocytopenia treat with doxycycline) = fe%er is ca&sed %y coxiella burnetii) main so&rces o inection are inected cattle, goat, and sheep) meat processing workers and veterinarians) maniestations o S ever may incl&de #u-like syndrome, hepatitis, or pneumonia) B. pertussis ca&ses whooping cough) it is a highly contagio&s inection %&t itHs incidence has dramatically decreased %eca&se o imm&ni'ation) &s&ally presents with severe %o&ts o coughing spells after an Q>* ) co&ghing spells can %e so severe that they ca&se rectal prolapse, epista4is, and pneumothoraces) treat with a macrolide) infectious mononucleoisis ca&ses ever, sore throat, Fa&ndice, and mild hepatosplenomegaly) symmetrical lymphadenopathy involving the posterior cer%ical chain o lymph nodes more reK&ently than the anterior chain) inguinal and axillary lymphadenopathy can also %e present) tonsillar exudates, tonsilitis, pharyngitis and mild palatal petechiae may %e o&nd, %&t also in strep pharyngitis) a complication o im is autoimmune hemolytic anemia and thrombocytopenia) *g) cold-agglutinin antibodies which lead to complement-mediated destruction of >8Cs ) disseminated N. gonorr"ea inection presents with high ever, chills, tenosyno%itis, and migratory polyarthritis early in illness) skin lesions ranging rom < - =9 and are most commonly seen on the e4tremities) lesions are discrete purpuric or pustular with hemorrhagic components and occasionally central necrosis) %lood c<&res and cultures rom the c&taneo&s p&st&les are often negati%e d&e to speci1c growth reK&irements o the strain o N. gonorrhea ca&sing this disseminated orm o inection) no p&st&les in ac&te 58" syndrome) imm&nocompromised patients get shingles ( herpes zoster$ in an area with constant %&rning pain witho&t any other physical a%normalities) the pain often precedes the rash by se%eral days, or they can appear together) the rash is %esicular in a dermatomal pattern) %lood trans&sion %eore *;NJ sho&ld %e screened or 50") *;;+ or hep c) % or “%eore” hep c (*;NJ %eore *;;+$ can0t screen for hepatitis 8 using "bs+g and anti-"bs %eca&se o the window period) instead do *g) anti-"bc) 1rm #esh colored , dome shaped, umbilicated papules are typical o molluscum contagiosum pox%irus6 ) cell&lar imm&node1ciency, corticosteroid
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&se, and chemotherapy predispose patients to moll&sc&m contagios&m) common in patients with 58") nail puncture wo&nd res<ing in osteomyelitis is most likely d&e to P. aeruginosa ever, headache, ocal ne&ro signs, sei'&re, spasticity or signs o increased 8C are presentation o %rain a%scess) brain abscess more likely to occ&r in patients with congenital heart disease , head trauma, infections of jaw$mouth , infections of scalp$face , meningitis, cranial instrumentation) scabies ca&sed %y Sarcoptes scabiei) highly contagious disease presents with generalized itching and pruritic papules over the penis and scrotum in males, areolas and breasts in emales, and in runs over the (nger webs , heels of palms , and wrist creases) treat with '5 permethrin cream post-splenectomy patients are at an increased risk or sepsis rom encapsulated organisms d&e to impaired antibody-mediated opsonization in phagocytosis) intracellular killing is defecti%e in patients with chronic granulomatous disease, a deect in N+D." oxidase ) aspergillosis may orm a ca%itary lesion %eca&se o destruction o the underlying pulmonary parenchyma, and debris and hyphae may coalesce and form a fungus ball aspergilloma6 which lies ree in the cavity and mo%es around with position change ) patients with 58" have a *9G risk per year o reactivating t&%erc&losis) maniests as ever, night sweats, weight loss, atig&e, ple&ritic pain, chronic co&gh and hemoptysis) c4r 1ndings classically incl&de an apical cavitary lesion) coccidiodomycosis res<s in a #u-like illness with dyspnea and a slightly producti%e cough) miliary pattern is most common l&ng lesion (like little tiny dots$ mild maniestations o a drug allergy (&rticaria and pr&ritis witho&t systemic symptoms$ are &s&ally treated with anti-histamines and discontin&ation o the afending dr&g) rash rom 8, infectious mononoculeosis who take amoxicillin is polymorphous maculopapular and de%elops after A& hours ) secondary syphilis presents as a diuse maculopapular rash involving the ace tr&nk e4tremities palms and soles in addition to generali'ed lymphadenopathy with systemic$constitutional symptoms (ever, malaise, sore throat Z “great imitator”$ 58" patients with CD& counts M '2 reK&ire )+C prophylaxis with azithromycin or clarithromycin) “mac or mac” lymphadenitis is diagnosed when the lymph node %ecomes tender and erythematous in addition to %eing enlarged) &s&ally ca&sed %y %acterial inection with S. aureus %eing the most common pathogen isolated) or community-ac;uired acute bacterial meningitis &se %ancomycin 1 ceftriaxone in ad<s and children since it will cover the most reK&ent etiological agents2 S. pneumoniae %ancomycin6 H. infuenza ceftriaxone6 and N. meningitidis ceftriaxone6) add ampicillin to cover L. monocytogenes which can ca&se meningitis in patients 3 <<) immunocompromised patients are at risk or listeria) allergic bronchopulmonary aspergillosis (+8.+$ is a hypersensiti%ity reaction to aspergillus coloni'ation o the %ronchi) it occ&rs most commonly in patients with asthma$cystic (brosis, and presents with ever, prod&ctive co&gh, eosinophilia and hemoptysis) t&%erc&losis will have chronic co&gh, hemoptysis, and intermittent evers) CD can show &pper lo%e cavitary lesions (more than * possi%leVV$ with s&rro&nding alveolar in1ltration) facial$opthalmic %enous system is %al%eless, uncontrolled infection of the skin can re&slt in ca%ernous sinus thrombosis) red-Lag symptoms incl&de severe headache, bilateral periorbital edema, and cranial nerve =<J
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de1cits) orbital cellulitis can present similarly with ever, proptosis, opthalmoplegia, and vis&al deects, however there will not likely be bilateral periorbital edema, and bilateral cranial ner%e (ndings) nocardia is a gramI partially acid-ast 1lamento&s aero%e that is found in soil) nocardiosis may %e con&sed with t&%erc&losis or actinomyces inection) weight loss, ever, night sweats) co&gh o p&r&lent sp&t&m CW# 1ndings incl&de al%eolar in(lrates and nodules often with ca%itation ) disseminated disease is most likely to maniest as subcutaneous or brain abscessess ) &s&ally occ&rs in immunocompromised patients ) treatment is tmp-smx) whipple disease has .+S1 macrophage) symptoms are chronic mala%sorptive diarrhea, weight loss, migratory non deforming arthritis, lymphadenopathy, and low-grade ever) treatment or cat scratch disease is azithromycin) symptoms are tender regional lymphadenopathy and cutaneous lesions) &se doxycycline or azithromycin in penicillin allergic patients who have syphilis) give tmp-smx and steroids in "*, patients with pneumocystis pneumonia i .a9A M F2 mm"g or +-a gradient @ ?' mm"g ) pcp occ&rs when C= : +99) presents with dry co&gh, ever, e4ertional dyspnea) and c4r &s&ally shows %ilateral interstitial in1ltrates) instr&mentation o &pper airway or esophag&s can lead to anaerobic pneumonia) ever I foul smelling sputum) clindamycin is most commonly &sed or this inection) in#amed #uctuant cer%ical lymph nodes are typically ca&sed %y strep or staph infection) the anti%iotic o choice is dicloxacillin) other efective anti%iotics are cephalexin or clindamycin)
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(bromyalgia E pain in m&scles, no weakness, no swelling) psychological, la%s normal) treat with 7C+samitriptyline) Aero%ic e4ercises also help) systemic lupus erythematosus anti Ds DN+ abs6 has ;9G Foint involvement however joint deformity in%ol%ing the hands is uncommon) or myasthenia crisis, int&%ate and withdraw acetylcholinesterase inhi%itors or a ew days seronegative spondyloarthropathy (A8#$ like ankylosing spondylitis ca&ses lower %ack pain and stifness in yo&ng men) symptoms are worse in the morning and improve as the day progresses) atients also get arthritis o peripheral Foints and anterior u%eitis) will have elevated !# and negative #h actor) &se 7N!alpha antagonists) %iral arthritis secondary to parvo 0*; inection has polyarticular and symmetric arthritis) afects MC, 8, wrist, ankle and resol%es within A months) will have ele%ated anti-bB4 *g) antibodies3 Common in teachers or people who work in day care centers3 patients who have ankylosing spondylitis or two decades or longer are at an increased risk of %ertebral fracture d&e to decreased %one mineral density) these ract&res may occ&r with minimal tra&ma)
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spondylolisthesis is a developmental disorder characteri'ed %y a forward slip of %ertebrae on the ca&dal verte%rae) verte%rae) most commonly at B=-B< and B<-!*) ca&ses %ack pain and neurological dysfunction (&rinary incontinence$) incontinence$) %iral arthritis presents with symmetric arthritis o D*., )C. and wrist like rhe&matoid arthritis, however it is acute in onset , and has no ele%ated in#ammatory markers) 8ehTet0s syndrome is a m<i-systemic inLammatory disease) presents with painful oral ulcers and genital ulcers and erythema nodosum like lesions o the skin) also can have ocular lesions (anterior &veitis, optic ne&ritis$, arthritis and C6! lesions mimicking m<iple sclerosis (meningoencephalitis$) (meningoencephalitis$) seen in t&rkish, asian, and middle eastern pop&lations) systemic sclerosis anti topoisomerase etc6 is a condition afecting every organ system in the %ody) c&taneo&s 1ndings incl&de thickening o skin %eginning in acral sites (hand and eet$ with edema, that transitions into dermal sclerosis with o%literation o skin appendages (hair ollicles and sweat glands$ and Le4ion contract&res) contract&res) rayna&d phenomenon and calcinosis c&tis are also common) involvement o the kidneys prod&ces hypertension, pulmonary artery hypertension res<s in right heart failure in these patients) patients have Ianti-nuclear autoantibodies and Ianti-topoisomerase-abs 8aker0s cysts develop as a res< of excessi%e #uid production by in#amed syno%ium, as occ&rs in cases o rheumatoid arthritis, osteoarthritis and cartilage tears) ankylosing spondylitis is con1rmed %y plain 1lm 4-ray demonstrating fused sacroiliac joints andor bamboo spine ) SjUgren syndrome is a&toimm&ne condition most commonly afects women in their <9-J9Hs) clinical 1ndings incl&de keratoconjuncti%itis (4erophthalmia$ and xerostomia) increased incidence o dental caries (saliva is antimicro%ial and l&%ricating$ and will complain o diUc<y swallowing) lymphocytic in(ltration of sali%ary glands prod&ces enlargement and 1rmness to palpation o these glands) ser&m a&toanti%odies directed against anti-SS+$anti->o andor antiSS8$anti-La 9steoarthritis o the spine can ca&se LQ)8+> S.*N+L S7N9S*S) narrowing of the lumbar spinal canal leads to mechanical compression and ischemia of the ner%e roots) shows “pseudoclaudication” which is lower e4tremity pain when walking and prolonged standing, especially walking downhill (e4tension$) to make %etter lean orward (resting on shopping cart, Le4ion$) polymyalgia rheumatica has pro4imal m&scle tenderness and no ele%ations of +S7$+L7$C.K +S7$+L7$C.K ele%ated S>6 tx with low dose steroids3 Strong association with giant cell arteritis) weakness in pro4imal m&scles with ele%ated ferritin$LD"$C.K are are consistent with breakdown of muscle tissue 2 polymyositis) anti-smith and anti-dsDN+ are speci1c or systemic lupus erythematosus) treat raynaud phenomenon (cold ind&ced vasospasm$ with calcium channel blockers like nifedipine) %iral arthritis can present with symmetric small joint in#ammatory arthritis) 1 markers s&ch as ana and rheumatoid factor may occ&r) olyartic&lar with Foint swelling and low-grade ever) will resolve in less than + months so treat with NS+*Ds alone is s&Ucient) systemic lupus erythematosusH systemic maniestations incl&de nondeforming arthritis, oral &lcers, serositis, hematologic a%normalities, protein&ria, protein&ria, rash) !ystemic l&p&s erythematos&s arthritis afects mcp and pip commonlyZZ
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psoriatic artritis occ&rs in <-9G o psoriasis patients) the classic presentation involves the 8 Foints) morning stifness, deormity, dactylitis (“sa&sage digit”$ and nail involvement are common) rhe&matoid arthritis predisposes predisposes to the development o septic arthritis) (new Foint that is very tender, swollen$ systemic l&p&s erythematos&sH efects on the kidneys can range rom minimal mesangial l&p&s nephritis to advanced sclerosing l&p&s nephritis and are graded class * - =) the treatments and o&tcomes are diferent depending on the class o l&p&s nephritis) renal biopsy is re;uired in all patients with new onset lupus nephritis) steroid induced myopathy is a well-descri%ed res< o chronic corticosteroid &se characteri'ed %y painless proximal muscle weakness ) it will slowly improve once the ofending medication is discontin&ed) .aget0s disease of bone (osteitis deormans$ is associated with normal ser&m calci&m and phosphate levels and increased +L. and urinary hydroxyproline le%els) lumbar spinal stenosis is most commonly ca&sed %y osteoarthritisdegenerati%e joint disease3 the term “neuropathic claudication” is oten &sed to descri%e l&m%ar stenosis) e4acer%ation o leg symptoms with walking, however unlike p%d, the symptoms are positional and remain while standing still) pain is relie%ed by #exion of the spine ) diagnose %y clinical history and )>* of spine) m&sc&lar weakness in paraneoplastic syndromes can %e d&e to a variety o processes at diferent levels) skin rash I weakness s&ggests dermatomyositis associated with an increase incidence in cancer6 ) will have ele%ated CK$aldolase le%els and in#ammation in the muscle wegener0s is granulomatosis with polyangiitis) triad o *$ systemic %asculitis +6 upper and lower airway granulomatous in#ammation in #ammation and $ glomerulonephritis) there can %e cutaneous lesions (tender nodules palpable purpura ulcerations$ as well as joint and eye lesions) treat with cyclophosphamide) patients with rheumatoid arthritis are at increased risk o developing osteopenia and osteoporosis) treat polymyalgia rheumatica with low-dose prednisone ) ain (not really weakness$ and stiness in neck, sho&lders, and pelvic girdle in a patient over <9 years old with ele%ated S> and morning stifness 3 * ho&r) ind&ction chemotherapy res<s in rapid tumor cell lysis and releases uric acid into the circulation) or pre%ention of gout , allopurinol and probenecid are &sed, while NS+*Ds and colchicine and steroids are &sed d&ring acute attacks) tenderness to gentle percussion over the lumbar %ertebrae is an important cl&e to %ertebral osteomyelitis) %ertebral compression fractures can also ca&se local tenderness to palpation %&t this &s&ally occ&rs in elderly patients with a history of osteomalacia$osteoporosis ) )>* is the most sensitive st&dy or %ertebral osteomyelitis) corticosteroid induced a%ascular necrosis o the emoral head presents as progressi%e hip or groin pain witho&t restriction o motion range, and normal W# in early stages) )>* is gold standard or the diagnosis o a%ascular necrosis of the hip %ertebral osteomyelitis is %est diagnosed with )>* of spine ) atient will have low-grade ever and elevated !#) physical e4am will re%eal local tenderness on percussion of the aected %ertebrae and para%ertebral muscular spasm)
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the pancytopenia in systemic lupus erythematosus is d&e to ormation o auto-antibodies against cells) a type o type A hypersensiti%ity reaction) common side efects o methotrexate incl&de mucositisstomatitis, na&sea, a%dominal pain, and ever) can also ca&se hepatotoxicity and myelosuppression) Also teratogenic reacti%e arthritis is a type o seronegati%e spondyloarthropathy ) classic reactive arthritis is a triad o B6 nongonococcal urethritis A6 asymmetric oligoarthritis and ?6 conjuncti%itis) it oten involves the knee and sacroiliac spine) there are also mucocutaneous lesions and enthesitis (achilles tendon pain$) Book or gastrointestinal inection in the history as well) NS+*Ds are 1rst line o therapy) “canHt seecanHt peecanHt clim% a tree” polymyositis is an inLammatory m&scle disease) presents w muscle weakness o pro4imal m&scles (sho&lderhip$) >ill have elevated !#C7aldolase) !#C7aldolase) treat with high dose corticosteroids) corticosteroids) osteoarthritis has subchondral sclerosis, joint space narrowing, and osteophytes) it afects weight %earing Foints and maniests with deformity and degenerati%e joint disease and loose bodies on imaging) imaging) W# will will show loss of cartilage , osteophyte de%elopment as well) .agetEs disease can present with asymptomatic increased +L. ) d&e to %one remodeling) can have hearing loss) treatment is bisphosphonates due to o%eracti%e osteoclasts6 l&m%osacral strain is most common ca&se o %ack pain) ater heavy liting in the l&m%ar area with no radiation) no sensory de1cits) (bromyalgia is m&sc&loskeletal pain) patients (more oten women$ will complained o disturbed sleep, m&scle stifness, la%s are normal) DCAs like amitriptyline will help restore sleep and can %e efective treatment) Also treat with aero%ic e4ercises) trendelenburg sign is a dropping o contralateral pelvis when asked to stand on * leg) indicates gluteal muscle weakness ) or hydroxychloro;uine yo& have to do eye e4ams every J mos) to check or retinopathy cer%ical spondylosis is osteoarthritis o spinal verte%rae) >ill have chronic neck pain) radiology will show bony spurs (osteophytes$ and sclerotic facet joints) in a rotator cu tear , the patient has a positi%e drop arm test where the arm is &na%le to %e lowered slowly) hairline ract&res are common in athletes, especially o the second metatarsal) treat with rest, analgesia, and a hard-soled shoe) ac&te %ack pain and I straight leg raise test disk herniation (sciatica$) pain radiates down posterior s&race o thigh) manage with 6!A8s and early mobilization3 osteonecrosisaseptic necrosis a%ascular necrosisischemic necrosisosteochondritis necrosisosteochondritis dessicans is d&e to disrupted %asculature and bone is not able to remodel , leading to trabecular thinning and collapse) early on 4rays will not show a%normalities) a%normalities) )>* is the most sensiti%e test or this condition) stress ract&re most common in anterior ti%ia) 4-rays reK&ently normal d&ring initial eval) most common ca&se o asymptomatic ele%ation of +L. in an elderly patient is .aget0s disease o %one (osteitis deormans$, look o&t or increasing hat si'e or hearing pro%lems) de ;uer%ain tenosyno%itis is a condition afecting new mothers who hold their inants with th&m% o&tstretched) the a%d&ctor pollicis long&s and e4tensor
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pollicis %revis tendons are afected) passive stretching o those tendons elicits pain) lumbar spinal stenosis has %ack pain made worse by extension (narrowing the canal$ and made better %y #exing widening the canal $) “neurogenic claudication” is the leg pain o spinal stenosis that can %e con&sed with " %&t ankle-%rachial inde4 is normal and so are p&lses) posterior dislocations of the shoulder commonly occ&r after a tonic-clonic seizure with the patient holding the arm add&cted and internally rotated) todd0s paralysis is a transient &nilateral weakness ollowing a tonic-clonic sei'&re) ac&te sho&lder pain ater orce&l a%d&ction and e4ternal rotation at glenoh&meral Foint s&ggests anterior shoulder dislocation which can ca&se axillary ner%e or axillary artery damage scaphoid ract&res are the most common o the wrist ? alling on o&tstretched hand) immo%ili'e wrist or J-*9 weeks) tear o medial meniscus occ&rs d&ring a twisting inF&ry) patients complain o a “popping sound ” ollowed %y se%ere pain at the time of injury ) menisc&s is not directly per&sed so eusion takes some time to present ) McM&rrayHs sign is a palpa%le or a&di%le snap occ&rring while slowly e4tending the leg at the knee rom &ll Le4ion while applying ti%ial torsion) carpal tunnel syndrome presents with paresthesias o the 1rst )< digits and thenar eminence atrophy) radial ner%e is most commonly inF&red nerve with fracture of midshaft humerus) paget0s disease is d&e to increased %one t&rnover, d&e to osteoclast dysfunction ca&sing increased %one %reakdown and a compensatory increase in production) pelvis, sk&ll, spine and long %ones are most commonly involved) symptoms may incl&de skeletal deformities like femoral bowing) %one and Foint pain and hearing loss are less common symptoms) l&m%ar spinal stenosis “ne&rogenic cla&dication” is a degenerative condition where the spinal canal is narrowed) Le4ion o the spine gives pain) d&e to enlarging osteophytes at the acet Foints and hypertrophy of the ligamentum #a%um) %ack pain radiating to the %&ttocks and thighs) con1rm diagnosis with )>*) “doublesoap bubbleG appearance in the epiphyseal end o long %one is a giant cell tumor$osteoclastoma ) presents in +9-=9 yo females with knee pain) pain to palpation of the %ertebra on e4am is s&ggestive o spinal infection or lytic lesions in the spine) initial test of choice is a J> o the %ack to look or lytic lesions and compression ract&res) i test is non diagnostic then )>*$C7 can %e done to eval&ate or disc disease, cancer, and spinal inections) trochanteric bursitis is in#ammation of the bursa s&rro&nding insertion of the gluteus medius onto the em&rHs greater trochanter) patients with this condition complain o hip pain when press&re is applied (ie2 sleeping on that side$ and with e4ternal rotation or resisted a%d&ction) osgood-schlatter traction apophysitis6 is a common ca&se o knee pain, partic&larly in adolescent male athletes) during periods of rapid growth where the K&adriceps tendon p&ts traction on the apophysis o the tibial tubercle where the patellar tendon inserts) worsened %y sports that involve repetitive r&nning, F&mping, kneeling, and it improves with rest) pain can %e reprod&ced %y e4tending the knee against resistance) radiograph 1ndings are nonspeci1c and incl&de anterior sot tiss&e swelling, liting o t&%ercle rom the shat, and irreg&larity or ragmentation o the t&%ercle)
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femoral ner%e gives sensation to anterior thigh and medial leg ) responsi%le or knee extension and hip #exion) tibial ner%e s&pplies m&scles o the posterior compartment o thigh, posterior comparment of leg , and plantar muscles of the foot ) obturator ner%e innervates the medial compartment o the thigh) supracondylar humeral fractures are associated with brachial artery inF&ries res<ing in the loss of the radial pulse R assess radial p&lse when ract&re is red&ced) meniscal tears are &s&ally ca&sed %y a twisting inF&ry when the oot is in a 14ed position) knee pain is elt initially %&t the swelling is worse the day ater the inF&ry and is d&e to an ef&sion) con1rm %est with )>* midshat ract&re o humerus will damage radial ner%e3 )>* is the investigation o choice or de1ning soft tissue injuries of the knee) high-stepping or HsteppageG gait is d&e to oot drop) res<s rom an inability to dorsi#ex the foot ) to compensate patients m&st overly Le4 the hipknee to %ring the oot orward with each step) the toes may also drag on the gro&nd with this type o gait) most commonly ca&sed %y peripheral neuropathy) may also classically res< rom tra&ma to the common peroneal$(bular ner%e or radic&lopathy to any o the spinal roots that contri%&te to the common peroneal nerve (L&-SA$) may also %e congenital s&ch as in charcot-marie-tooth disease ) osteomalacia has symmetrical Hlooser zones ” or pseudofractures and blurring of the spine) will have low or low-normal calcium and low phosphate, high .7" and low %itamin d ) vitamin d de1ciency leads to decreased intestinal calci&m and phosphate rea%sorption, res<ing in hypocalcemia and hypophosphatemia) hypocalcemia then stim&lates parathyroid gland) %ertebral compression fractures almost always occ&r when bone demineralization is present) will present as intense, ocal verte%ral pain witho&t ne&rological symptoms) occ&rs in osteomalacia and osteoporosis) spinal cord compression can %e ca&sed %y cauda e;uina syndrome and res<s in absent rectal tone , urinary incontinence, motor$sensory loss in extremities)it is a surgical emergency) )>* to identiy the site o compressionract&re followed by surgery )
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+Ci are the most common ca&se o ac;uired angioedema) other efects are co&gh, hyperkalemia, and precipitation of acute renal failure in patietns with bilateral renal artery stenosis) angioedema can occ&r anytime taking the med, not F&st within a ew weeks o starting) type & renal tubular acidosis (looks like hypoaldosteronism, %&ild &p o ammonia and canHt e4crete 5I$ occ&rs w diabetic nephropathy or interstitial renal disease) chronic renal ail&re&remia is a ca&se o hypochloremic anion gap meta%olic acidosis) in type = cant e4crete 5I and acc&m&lation o organic anions, so yo& get non-anion gap meta%olic acidosis)
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chronic pyelonephritis is characteri'ed %y ocal parenchymal scarring and blunting of calices systolic-diastolic a%dominal %r&it in a patient with hypertension and atherosclerosis is renal artery stenosis normally calci&m %inds o4alate in g&t and prevents re-a%sorption) when have at mala%sorption, the calci&m is %o&nd %y at, and o4alate is &n%o&nd and rea%sor%ed, and orms stones (parado4ically, yo& treat %y increasing calci&m in diet$ renal artery stenosis is most common ca&se secondary hypertension) interstitial cystitis is triad of B3 urinary urgency A3 urinary fre;uency ?3 chronic pel%ic pain , relie%ed %y %oiding) gives wbc casts ) ele%ations in bun$creatinine d&e to pre-renal ail&re, post-renal ail&re, systemic steroids, or gastrointestinal bleeding (re-a%sorption o &rea rom gastrointestinal tract ater %acteria %reakdown hemoglo%in$ in dia%etes mellit&s 1rst there is glomer&lar hyper1ltration (shows &p as increased ./# and microal%&min&ria$) thickening o glomer&lar %asement mem%rane and then comes mesangial expansion goodpastureEs disease afects lungs and kidney d&e to *g antibodies attacking collagen type 8") treat with plasmapheresis) ultrasound or other imaging techniK&es are indicated when patients with pyelonephritis do not respond after &<-FA hrs o appropriate antibiotic therapy renal stones present as Lank pain (BBS, #BS$ radiating to the groin along with na&sea and vomiting) to diagnose &se non contrast C7 of abdomen and pel%is) in pre-renal ail&re &rine na : *9 meKl (the kidney is rea%sor%ing salt to %ring in water, so there will %e very little salt in the &rine$ amyloid will give renal enlargement and hepatomegaly) s&spect in patient with chronic disease like rhe&matoid arthritis aminoglycoside are anti%iotics &sed or se%ere gram negati%e infection and potentially nephrotoxic) amikacin is an aminoglycoside renal papillary necrosis d&e to 6!A8s is d&e to papillary ischemia %y analgesia mediated vasoconstriction o med&llary %lood vessels (vasa recta$) *g+ nephropathy 8erger0s6 is most common cause of glomerulonephritis in adults) rec&rrent episodes o gross hematuria %eginning several days after an upper respiratory infection %ersus post strep N which can take weeks6) 8n children 8gA nephropathy is 5! with skin lesions and a%dominal %leeding) oodpasture0s is a triad o *$ pulm hemorrhage +$ prolif3 glomerulonephritis and $ *g to anti-gbm large %lood on &rinalysis with low #0Cs on sediment microscopy is myoglo%in) d&ring rha%domyolysis myoglo%in can res< in t&%&lar inF&ry and ac&te renal ail&re) sei'&res can ca&se rha%domyolysis d&e to tonic-clonic movement) oodpasture0s syndrome is ca&sed %y circ&lating anti-gbm antibodies ) early removal o these anti%odies %y emergency plasmapheresis is imperative in order to minimi'e e4tent o kidney damage) :egener0s granulomatosis with polyangiitis6 is treated with a com%ination o cyclophosphamide and steroids3
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s&spect mixed cryoglobulinemia in a patient with palpable purpura$skin lesions, proteinuriahematuria) other maniestations incl&de nonspeci1c systemic symptoms, arthralgias, hepatosplenomegaly, and hypocomplementemia) maFority o patients have underlying "C, infection the strongest predictor o a%dominal aortic ane&rysm e4pansion and r&pt&re are *$ large ane&rysm diameter +$ rapid rate o e4pansion and $ c&rrent cigarette smoking) Smoking cessation has the greatest likelihood of slowing down +++ expansion) membranoproliferati%e glomerulonephritis (dense deposit disease$ is ca&sed %y persistent activation o the alternative complement pathway) dense intramem%rano&s deposits that stain or c? is a characteristic 1nding) *g antibodies c? nephritic factor6 directed against c convertase) "8,, "C,, lupus, cryoglobulinemia in chronic renal failure a red&ction in ./# leads to phosphate retention and poor vitamin d processing res<ing in hypocalcemia) stim&lates the parathyroid glands leading to hypertrophy and + nd hyperparathyroidism) dia%etes can ca&se ne&rogenic %ladder ca&sing o%er#ow incontinence (detrusor underacti%ity$) overLow incontinence is marked %y &rinary reK&ency, noct&ria, reK&ent leakage o small vol&mes o &rine, and high post%oid residual urine %olumes) &se cholinergic agents like bethanechol) most common ca&se o renal ail&re in multiple myeloma is a toxic eect of light chain casts on the renal tubules3 initial hemat&ria s&ggests &rethral damage) terminal hemat&ria indicates %ladder or prostatic damage, and total hemat&ria reLects damage in the kidneys or &reters) clots are not &s&ally seen with renal ca&ses o hemat&ria) when patient has 8." do urinalysis to assess or &rinary inection, o%str&ction, or hemat&ria) transrectal <raso&nd o the prostate is &sed to help g&ide prostate %iopsy, %&t not a sensitive screening test or prostate cancer or eval&ating %ph) to treat hemolytic uremic syndrome can ha%e neurologic disturbances6 do plasmapheresis$!!. (plasma e4change$) ethylene glycol ca&ses calci&m o4alate crystals (rectang&lar envelope-shaped crystals$ methanol ca&ses %isual (eld changes (“snow1eld vision”$ and acute pancreatitits) cardiovasc&lar disease is the most common ca&se o death in dialysis patients) appro4 <9G o all deaths in this pop&lation mem%rano&s nephropathy is most common nephropathy associated with carcinoma, however nephrotic syndrome is a well known complication o "odgkin0s lymphoma and is &s&ally ca&sed %y minimal change disease) patients with recurrent hypercalciuric renal stones sho&ld %e advised to increase #uid intake, sodium restriction, and a thiazide diuretic) do not restrict calci&m) uric acid stones are needle shaped on &rinalysis) ureterolithasis can ca&se ileus no propulsion in the * tract6 due to a %agal reaction ) eval&ate &ric acid stones %y C7 of the abdomen or *, pyelography) unilateral %aricocele dilated pampiniform plexus6 that fails to empty when a patient is recumbent lying down6 raise s&spicion or an &nderlying mass pathology s&ch as renal cell carcinoma that obstructs %enous #ow )
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C7 scan of the abdomen is the most sensitive and speci1c test or diagnosing >CC) renal %ein thrombosis is an important complication o nephrotic syndrome) antithrombin ?$protein C$protein S are lost in the urine and p&ts patients at risk or veno&s and arterial throm%osis) presents with s&dden onset o abdominal pain, ever, and hematuria) it can occ&r in any orm o nephrotic syndrome %&t it is most common with membranous glomerulonephritis) hypertension ca&ses intimal thickening and arteriosclerotic lesions o aerent and eerent renal arterioles and glomerular capillary tufts) dia%etes nephropathy is characteri'ed %y increased extracellular matrix basement membrane thickening mesangial expansion and (brosis3 < to ;9G o kidney stones are composed o calcium oxalate) calci&m o4alate crystals are envelope-shaped and radioopaK&e ( can be seen on J> $ when KQ8 shows no stone in a patient with typical renal colic think o three scenarios2 B6 radiolucent stone disease (uric acid stones $, A6 calcium stones M B-? mm and ?6 non-stone causes (o%str&ction %y a %lood clot or t&mor$) uric acid stones are most commonly seen in patients with an unusually low urine ph) treatment incl&des hydration, alkalinization of urine (potassium bicarb or potassium citrate$, and low p&rine diet) &ric acid stones are highly sol&%le in alkaline &rine) %ring &rine &p to ph 3 J)< hyposthenuria is an impairment in the kidneyHs a%ility to concentrate &rine) this is o&nd in patients with sickle cell disease , and also in sickle cell trait altho&gh in a less severe manner) tho&ght to res< rom >8Cs sickling in the %asa rectae of the inner medulla) this can res< in noct&ria) acyclovir gives yo& nephroto4icity) will precipitate ca&sing o%str&ction and ac&te kidney inF&ry) "8, "C,, lupus is associated with membranous glomerulonephritis) !SS is ass) w "*,, heroin, blacks) membranoproliferati%e glomerulonephritis is ass w "8,, "C,, lupus, and also cryoglobulinemia (proteins insol&%le at low temps$ and c? nephritic factor (too m&ch complement pathway$ post-strep glomerulonephritis presents B2-A2 days ater streptococcal throat or skin infection) hemat&ria, hypertension, red cell casts, protein&ria) will have low serum c? complement (imm&ne comple4 deposition$ analgesic nephropathy ca&ses papillary necrosis (constriction o vasa recta$ and chronic t&%&lointerstitial nephritis) edema rom glomerulonephritis res<s rom glomerular damage and decreased !> (also the case in end-stage renal disease$) as the vol&me increases rom third spacing, the ./# will drop, leading to renal sodi&m retention (>++S$) the increasing vol&me rom #AA! can ca&se a signi1cant rise in %p) the protein&ria also contri%&tes to edema) edema rom nephrotic syndrome res<s rom hypoal%&minemia) hypoal%&minemia does not &s&ally ca&se p&lmonary edema %c alveolar capillaries have a higher permea%ility to al%&min at %aseline (so there is less o an oncotic press&re diference$ and greater lymph Low than skeletal m&scle, protecting the l&ngs rom edema) (rst-generation hB-antihistamines s&ch as diphenhydramine have signi1cant anticholinergic efects in addition to antihistamine efects) common anticholinergic side-efects incl&de dryness o eyes, oral m&cosa and
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respiratory passages , urinary retention and dys&ria) &rinary retention ca&sed %y anticholinergic agents res<s rom failure of detrusor contraction) ethylene glycol poisoning ca&ses renal t&%&lar damage and ormation o calci&m o4alate crystals) methanol into4ication ca&ses vis&al dist&r%ances) will have a meta%olic acidosis (low ph low %icar%$ renal tubular acidosis is a normal anion gap metabolic acidosis ) type * is distal ? canHt secrete hI so patient is acidotic, hypokalemia (kidney will e4crete 7I instead o 5I$ and have elevated &rinary p5) patients get nephrolithiasis) type A is pro4imal ? patients canHt a%sor% %icar% in pro4imal t&%&le) >ill have low &rine p5) fanconi syndrome is a ca&se in children) type & ? deect in naIkI e4change in distal t&%&le res<ing in hyperkalemic, hyperchloremic acidosis ) (like having addisonHs disease, no aldosterone working$ can present as growth ail&re ail&re to thrive) la%s show low bicarb with an increase in Cl-
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Al'heimerHs dementia has cortical and s&%cortical atrophy on CD scan) ca&da eK&ina syndrome is ca&sed %y damage to nerve roots) Dhe patient will have %ladder%owel dys&nction, saddle anesthesia, decreased Achilles tendon reLe4) or migraine headaches yo& can &se prochlorperazine as adF&vant or antiemesis) propanolol is &sed or or prophylaxis) %ertigo is spinning sensation accompanied %y na&sea) %ertigo can %e central or peripheral) ear fullness and preerence or hearing with one ear o%er the other is s&ggestive o a peripheral cause) ear fullness is partic&larly s&ggestive o )eniere0s disease which res<s rom a%normal accumulation of endolymph within the inner ear) disorders o the middle ear can ca&se hearing loss, %&t not typically vertigo bone conduction @ air conduction on the rinne test is s&ggestive o conducti%e hearing loss and can %e com%ined with the we%er test to con1rm the 1ndings) otosclerosis is a common ca&se of conducti%e hearing loss in ad<s, d&e to %ony overgrowth o stapes) ototoxic antibiotics &s&ally res< in sensorineural hearing loss) left frontal lobe infarction will give yo& 8rocaEs aphasia and right motor problems) i patient has a rapid heart rate that is irreg&lar, check or cardiac so&rce o em%ol&s) @cerebral salt wastingV syndrome can happen in people with sub-arachnoid hemorrhage) *$ release o %asopressin +$ release o 8N.) res<s in hyponatremia diuse axonal injury shows numerous minute punctate hemorrhages with blurring of grey-white interface3 %eore starting - triptans check or pregnancy contraindicated6
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ac&te la%rynthitis and vesti%&lar ne&ritis %oth ca&se vertigo) +cute labyrinthitis has hearing loss$tinnitus and vesti%&lar ne&ritis does not) meniereEs disease (sensorine&ral hearing loss, tinnit&s, vertigo$ *st line therapy is reduced salt diet no orehead movement means 8ell0s palsy (both upper$lower$) afects &pper and lower parts o ace) i central acial paresis (M6 lesion$ was the ca&se o acial paralysis then the patient wo&ld %e a%le to move orehead %eca&se o contralateral innervation) ring enhancing lesion on brain C7 scan and #uid collection in maxillary sinus is an abscess d&e to maxillary sinusitis) aero%ic and anaero%ic streptococci (J9-9G$ are responsi%le and also Bacteroides (anaero%e +9-=9G$ hemi-neglect syndrome is characteri'ed %y ignoring the let side o a space, and involves the right non-dominant6 parietal lobe ) i patient has a normal ne&rologic e4am %&t paresthesias, non-detectable pulses, pallor in a limb , immediately anticoagulate and get s&rgical intervention or embolectomy) (arterial throm%osis$ anterior cord syndrome is commonly associated with burst fracture of the %ertebra, characteri'ed %y total loss of motor function below the le%el of the lesion with loss of pain$temp bilateral below the lesion ) intact proprioception (posteriordorsal col&mn$ stat&s epileptic&s is seizure acti%ity @ '-B2 minutes not responding to antisei'&re medication) 1rst step is making s&re airway and %lood press&re are sta%le with endotracheal int&%ation) dia'epam --3 phenytoin --3 pheno%ar%ital dr&g o choice or trigeminal neuralgia is carbamazepine) Shy-Drager syndromemultiple system atrophy has .arkinsonism I autonomic dysfunction (orthostatics, erectile dys&nction, etc$ and widespread ne&rological signs (cere%ellar, pyramidal, BM6$ can have s&%clavian arterial atherosclerosis wih a preerence or the let artery and may present with verte%ro%asilar ins&Uciency secondary to subcla%ian steal syndrome3 pse&dot&mor cere%ri (idiopathic intracranial hypertension$ in o %ese emales) vitamin A and OCs) headache, %l&rry vision, papilledema and cranial ner%e palsies) Dreat weight weight loss and aceta'olamide) cerebellar dysfunction is common in chronic alcoholics) gait insta%ility, diUc<y with to and ro movements, intention tremor) A I%a%inski s&ggests an &pper motor ne&ron lesion) cerebellar tumors &s&ally prod&ce ipsilateral ata4ia, nystagm&s, intention tremors, and loss o coordination) thiamine de(ciency ca&ses :ernicke0s which is *$ encephalopathycon&sion, +$ oc&lomotor dys&nctionophthalmoplegia and $ ata4ia) normal pressure hydrocephalus has a%normal gait, incontinence, and dementia (“wet, wacky, wo%%ly”$) treat with large vol&me l&m%ar p&nct&res and %enriculoperitoneal shunt) cere%ellar dys&nction gives intention tremor, which gets worse near the end of mo%ement , %&t is improved %y rest, will likely have other cere%ellar signs (ata4ia, etc$) essential tremor is similar (ZZ$ s&ppressed at rest and e4acer%ated near the end o a movement) medial medullary syndrome is associated with contralateral spastic hemiplegia, contralateral %ibratory and proprioception loss , and tongue de%iation to the injured side) &e to lesion o the anterior spinal artery) (corticospinal 1%ers, dorsal col&mn medial lemnisc&s, C6 *+$ lateral medullawallenberg syndrome and has ipsilateral horner0s, loss of pain and temp3 in the face , and cerebellar ataxia) loss of pain and temp
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on contralateral side of body ) &e to lesion o the posterior inferior cerebellar artery .*C+6 ) (C6 <-ace st&f,N-ata4ia,;-dysphagiagag,*9-$ central cord syndrome$syringomyelia occ&rs with hyperextension injuries in elderly patients with degenerative changes in the cervical spine) ca&ses damage to corticospinal tracts motor $ and the dec&ssating 1%ers o lateral spinothalamic tract nociception temperature $) central cord syndrome is characteri'ed %y weakness that is more prono&nced in the upper extremities than in the lower e4tremities) artial sei'&res are simple or comple4) complex partial seizure 2 %rie episodes o impaired conscio&sness, ail&re to respond to vario&s stim&li d&ring the episode, staring spells, automatisms, and post-ictal con&sion) . pattern is &s&ally normal or may show %rie discharges) sei'&res are partial or generalized (generali'ed is tonic-clonicgrand mal and a%sence$) partial sei'&res can %e %roken down into B6 simple partial consciousness intact6 A6 complex partial impaired consciousness6 or ?6 partial with secondary generalization ) patients with comple4 partial have a&tomatisms (lip smacking, hands moving$ and patients who have partial seizures w$ secondary generalization &s&ally have tonic-clonic mo%ements) a patient with tongue biting or bladder$bowel incontinence most likely has comple4 partial with secondary generali'ation) ater having a subarachnoid hemorrhage patients are at risk or subse;uent %asospasm o the arteries at the %ase o the %rain) maFor ca&se o mor%idity and mortality so &se calci&m channel %lockers like nimodipine to prevent vasospasm) essential tremor has a tremor that is s&ppressed at rest and made worse at the end of a goal-directed mo%ement ) parkinsonHs disease has a resting tremor made %etter with movement) treat essential with propanololprimidone cere%ral %lood Low increases with hypercapnia (increased CO+$ and increased meta%olic demand and hypo4ia thro&gh cerebral %asodilation) interventions or lowering intracranial pressure are *$ head elevation to increase veno&s o&tLow, +$ sedation to decrease meta%olic demand and control o hypertension $ intraveno&s mannitol to e4tract water o&t o %rain and =$ hyper%entilation to remo%e C9A leading to %asoconstriction) most common site or a lacunar infarct is posterior internal capsule, prod&cing pure motor stroke ) lac&nar inarcts are oten not appreciated on noncontrast CD o%tained d&ring or shortly ater the event) cerebellar hemorrhage presents with acute onset occipital headache , repeated %omiting and gait ataxia) patients will %e hypertensive, and might have C6Ja%d&cens nerve paralysis, conF&gate deviation, coma) hypertensi%e intracranial hemorrhages occ&r most commonly in the %asal ganglia, thalam&s, pons, and cere%ell&m) patients tend to present initially with focal symptoms %&t can rapidly progress to signs o elevated intracranial press&re) intracere%ral hemorrhage presents with ocal ne&rological symptoms early %&t is followed by features of increased intracranial pressure (vomiting, headache, %radycardia, decreased alertness$) lacunar strokes also occ&r in hypertensive patients %&t present with severe ocal ne&rological symptoms depending on the afected area) Bac&nar strokes do not cause rapidly worsening global neurologic symptoms ) Cere%ellar symptoms are vomiting, occipital headache, ata4ia)
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neuro(bromatosis type A in a patient with bilateral acoustic neuroma, cataracts and multiple cafe-au-lait spots hypopigmented6 ) )>* with gadolinium enhancement is %est method to diagnose aco&stic ne&romas complex partial seizures oten stare %lankly or several min&tes and engage in automatisms (lip smacking or chewing$) will have con&sion ater s&ggesting a post-ictal state) can have toddHs paralysis ater, a transient post-sei'&re ne&rologic symptom (leg dragging, arm weakness, etc$ the prognosis o astrocytomas is most aected by tumor grade , with increased atypia, mitoses, neovasc&larity or necrosis con%eying a worse prognosis (glioblastoma multiforme is just a se%ere type of astrocytoma6 #attening of nasiolabial fold is ca&sed %y a%normal &nction o the facial ner%e$CNF) Dhere will %e an ina%ility to close the eye as well) facial ner%e nucleus is located in the pons) co-administration o triptans and ergotamine may res< in prolonged %asospasm d&e to o%eracti%ation of '-"7 receptors ) th&s ?triptans should not be gi%en for at least A& hours after ergotamine is gi%en ) creutzfeldt-jakob disease sho&ld %e s&spected in an old patient with rapidly progressi%e dementia, myoclon&s, and a periodic high %oltage complex on ) wernicke0s encephalopathy presents with the triad o *$ con&sion +$ ata4ia, and $ opthalmoplegia) ca&sed %y a de1ciency o thiamine) itHs a ca&se o ac&te deliri&m andor ac&te ata4ia especially malno&rishedalcoholic patients) internuclear opthalmoplegia is a characteristic 1nding o multiple sclerosis (M!$ and d&e to demyelination of the medial longitudinal fasciculus )L!63 acute attacks of multiple sclerosis )S6 are treated with intra%enous steroids) to red&ce reK&ency o ac&te e4acer%ations, &se intereron, plasmapheresis, cyclophosphamide, intraveno&s imm&noglo%&lins and glatiramer acetate normal pressure hydrocephalus res<s rom increased %entricular size witho&t elevations in intracranial press&re) distortion o periventric&lar %rain matter) benign$idiopathic intracranial hypertension pseudotumor cerebri6 presents with a headache that is pulsatile in nature, awakens patient from sleep, and is associated with pulsatile tinnitus (“whooshing” so&nd in ears$) patients can complain o headaches %ecoming worse with lying Lat, and %etter standing &p) %isual loss, sl&ggish p&pillary reLe4es to light, papilledema on &ndoscopy and abducens ner%e$CN/ palsy) obese young women , and certain medications ( %itamin + 9C.s $) %rain M#8 will show an empty sella and slit-like %entricles) get l&m%ar p&nct&re with opening press&re (will %e elevated$) treatment involves weight reduction and acetazolamide) %lindness is the most signi1cant complication o this otherwise %enign condition) tick-borne paralysis is characteri'ed %y a rapidly progressi%e ascending paralysis, absence of fe%er, absence of sensory abnormalities and normal C!/ &nction) botulism presents with a descending paralysis and aects cranial ner%es early) (a tick %ites at eet, so ascends$ essential to disting&ish %etween a sei'&re and a syncopal event) a sei'&re res<ing in loss o conscio&sness will oten %e ollowed %y a post-ictal state o clo&ded sensori&m, whereas people rapidly return to their baseline mental status after a syncopal e%ent ) lewy body dementia parkinsons 1 dementia6 has alterations in conscio&sness, disorgani'ed speech, %isual hallucinations, e4tra pyramidal symptoms) “lewy bodies” o eosinophilic intracytoplasmic inclusions representing accumulations of alpha-synuclein protein may %e seen in
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ne&rons o the s&%stantia nigra) treatment incl&des acetylcholinesterase inhibitors like ri%astigmine) or hall&cinations reractory to AChe inhi%itors, atypical antipsychotics may %e o %ene1t) ne&ro1%rillary tangles and senile plaK&es are pathological hallmarks o al'heimerHs dementia) cerebellar hemorrhage ca&ses ataxia, %omiting, occipital headache , ga'e palsy, and acial weakness) there is no hemiparesis) pontine hemorrhage presents with a deep coma and paraplegia that develops in a ew min&tes) decere%rate rigidity and no hori'onal eye movements) neurocardiogenic syncope (%aso%agal syncope $ is characteri'ed %y nausea, diaphoresis, tachycardia and pallor immediately prior to syncopal episode) arrhythmias generally have no preceding signs or symptoms other than palpitations in some) sei'&res have a post-ictal period ater a syncopal event) guillain-barre syndrome is treated with intra%enous immunoglobulins and plasmapheresis) ascending paralysis, areLe4ia, and sensory changes -= weeks ater an &pper respiratory inection or gastroenteritis is the common presentation) riluzole is a glutamate inhibitor that is c&rrently approved or &se in patients with amyotropic lateral sclerosis +LS63 &se trihexyphenidyl$benztropine (anticholinergic$ or the treatment o patients where tremor is the primary symptom o .arkinsons) anterior cerebral artery occlusion --3 contralateral weakness afecting lower extremity, urinary incontinence) middle cerebral artery --3 contralateral hemiplegia afects upper extremity more, aphasia, hemineglect) (>ernickeHs0rocaHs$ post limb of internal capsule --3 motor hemiparesis and %isual (eld) (most common lac&nar$ %ertebrobasilar --3 contralateral hemiplegia and ipsilateral cranial ner%e spinal cord compression is characteri'ed %y signs and symptoms o upper motor neuron dysfunction distal to the site o compression, s&ch as weakness, hyperre#exia, decreased sensation , and bowel$bladder dysfunction ) cord compression is a medical emergency reK&iring prompt diagnosis via spinal )>*) stroke does not have %ilateral leg weakness) creutzfeldt-jakob disease incl&des rapidly progressi%e dementia , myoclonus, and sharp triphasic synchronous discharges on eeg ) the most common site of hypertensi%e hemorrhage is the putamen ?'5$) the internal capsule ne4t to the p&tamen is almost always in%ol%ed leading to hemiparesis) the eyes are deviated away rom the paralytic side) s&%arachnoid hemorrhage has a s&dden dramatic onset o severe headache, and &s&ally no ocal ne&rological signs) with cere%ral lesions, motor de1cits are &s&ally opposite the site o the lesion whereas ga'e deviation is &s&ally towards the side o the lesion) hypertensive %leeds occ&r most commonly in the %asal ganglia) primidone is an anti-conv&lsant agent &sed to treat benign essential tremors) it can precipitate acute intermittent porphyria, which can %e diagnosed %y checking for urine porphobilinogen) symptoms will incl&de a%dominal pain, ne&rologic, and psychiatric a%normalities) pronator drift is a sensitive and speci1c physical e4am 1nding or upper motor neuron ner%e damage afecting &pper e4tremities) close eyes and e4tend arms with palms &p, and will tend to pronate) i a patient presents within &-' hrs ater the onset o an ischemic stroke, thrombolytic therapy with tpa sho&ld %e started if the C7 scan does not show hemorrhage)
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anterior cerebral artery stroke has contralateral motor and$or sensory more prono&nced in the lower limb) other eat&res that may %e seen are urinary incontinence, gait apraxia) middle cerebral artery characteri'ed %y contralateral motor and$or sensory more prono&nced in upper limb and homonymous hemianopia) i dominant lobe involved may have aphasia, i non-dominant lobe involved may have neglect andor anosognosia) posterior cerebral artery stroke characteri'ed %y homonymous hemianopia, hallucinations, sensory symptoms, third ner%e palsy with paresis o eye movements) hemi-sensory loss with severe dysesthesia o the afected area is typical or a thalamic stroke) anticholinergic excess is characteri'ed %y “red as a %eet, dry as a %one, hot as a hare, %lind as a %at, mad as a hatter, and &ll as a Lask” #ushing, anhidrosis, hyperthermia, mydriasis$%ision, delirium$confusion, and urinary retention$constipation) can also ca&se retro-or%ital headache d&e to precipitation of acute-glaucoma3 glatiramer acetate is a long term disease modiying treatment or multiple sclerosis that works %y mod&lating t-cell mediated a&toimm&nity to myelin basic protein3 recogni'e m<iple sclerosis %y peri%entricular white matter) tonic-clonic sei'&res can res< in lactic acidosis d&e to lactic acid prod&ction %y the m&scle and red&ced hepatic &ptake o lactate) post-ictal lactic acidosis is transient and resolves in J9-;9 mins)
o%stetricsgynecology •
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chorionic %illus sampling is done %etween B2-BA weeks of gestation ) indicated in women @ ?' years ollowing an abnormal ultrasound) serum screening does not pro%ide a con(rmatory diagnosis ) risks or C"! incl&de etal death and lim% red&ction deects) an increase incidence of distal limb reduction defects occ&rs when the proced&re is carried o&t before 4-B2 weeks gestational age ) (most important risk actor$ lichen sclerosis chronic inLammation o anogenital region mostly afecting women) white mac&les and patches with an atrophic Vcigarette paper @ K&ality) do a %ul%ar punch biopsy %eca&se the lesion is pre-cancero&s or sK&amo&s cell carcinoma) &se topical steroids to treat) patients with polycystic ovarian syndrome .C9S6 ha%e increased risk of dyslipidemia, type + dia%etes mellit&s) do fasting lipid panel and oral glucose tolerance test endometritis has ever, uterine tenderness in post part&m period, and foul smelling lochia) risk actors are prolonged r&pt&re o mem%ranes, prolonged la%or, c-section) treatment or endometritis is clindamycin 1 gentamycin) gentamycin aminoglycoside6 for gram- clindamycin gi%es anaerobic co%erage trans%aginal ultrasound is @gold standard@ or eval&ating cer%ical incompetence hypogonadotropic hypogonadism is a decrease in se4 hormones d&e to decreased !S"$L") increased risk of osteoporosis ) can %e d&e to stren&o&s e4ercise, anore4ia, mariF&ana &se, stress, starvation, depression, and chronic illness
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intra-uterine fetal demise when the woman doesnt eel any movements ater +9 weeks and cant hear etal heart tones on doppler) ne4t step is to do ultrasound to con(rm i patient has high ever, cant take oral meds (na&seavomiting$ then hospitali'e and treat with intraveno&s cefotetan and doxycycline or .*D) intraductal papilloma is a %enign %reast mass presenting aro&nd perimenopa&sal area) intermittent bloody discharge rom one nipple) tend to %e small : +mm uterine rupture has intense abdominal pain and %aginal bleeding) the fetal station retracts) deli%er %ia emergency c-section ) or .C9S i patient wants to concei%e give clomiphene citrate) emergency contraception is efective &p to *+9 ho&rs ater interco&rse, &se le%onorgestrel (plan 0$) intram&sc&lar medro4yprogesterone (depo-provera$ is a method o %irth control, not an a%ortiacient) or stopping lactation &se ice packs and tight (tting bra) do not &se %romocriptine (dopamine agonist) stops prolactin$ &. aginalis ca&ses malodorous, gray-green, thin, frothy %aginal discharge ) wet mo&nt will show Lagellated motile organisms) will also have %aginal pruritis and in#ammation) bacterial %aginosis (gardenerella increased %aginal p"$ will not have pruritis and in#ammation) depressed deep tendon re#ex is 1rst sign o magnesium sulfate toxicity ) discontin&e and administer calcium gluconate) endometriosis has pel%ic pain before cycle begins) laparoscopy is gold standard or diagnosing) endometriosis leads to increased risk o infertility) p to 9G o people worked &p or inertility o&nd to have endometriosis) abruptio placentae can present w uterine tenderness, hyperacti%ity, and increased uterine tone w rd trimester %aginal bleeding) for ectopic pregnancy do trans%aginal ultrasound to locate site o ectopic implantation) laparoscopy as a last resort to vis&ali'e ectopic pregnancy, itHs more invasive to treat and prevent sei'&res in eclampsia &se magnesium sulfate) renal plasma #ow and !> increase in pregnancy ca&sing a decrease in 8QNcreatinine) missed a%ortion involves a dead et&s still retained in the &ter&s) disappearance o na&sea and vomiting in early pregnancy and arrest o &terine growth) do D!5D= or amenorrhea, as well as /!5 to r&le o&t ovarian ail&re, prolactin or hyperprolactinemia) symmetric intrauterine growth restriction (8.#$ incl&de2 -chromosomal abnormalities -congenital anomalies tetralogy of fallot6 -congenital infections) asymmetric growth restriction ca&ses incl&de2 -maternal hypertension, -preeclampsia, uterine anomalies, -maternal anti-phospholipid syndrome , -collagen %ascular disease , -maternal cigarette smoking i fetal mo%ement is decreased or %ecomes impercepti%le %y the mother do a non-stress test) s;uamous cell carcinoma is is most common %aginal cancer ) vaginal %leeding and malodoro&s vaginal discharge are the most common symptoms) stage 8 and stage 88 : + cm are s&rgically e4cised i 3 + cm then radiation therapy is given)
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DO#C5 inections ca&se microcephaly (symmetric 8.#$) smoking ca&ses 8.# %&t not microcephaly asymmetric *Q>6 ) obese post-menopa&sal women have higher estrogen le%els %eca&se o conversion o adrenal androgens to estrogens by adipose tissue ) i patients has sudden onset hirsutism$%irilization during pregnancy do pel%ic ultrasound) *$ no ovarian mass then do abdominal C7 to rule out adrenal mass) +$ i on <raso&nd yo& 1nd bilateral cystic masses then theca-lutein cysts) r&le o&t high %eta-hcg states) $ i on <raso&nd yo& 1nd bilateral solid masses then mostly pregnancy luteoma) =$ i on <raso&nd yo& 1nd unilateral solid mass then do laparotomy to r&le o&t malignancy) normally patients have low-grade ever and le&kocytosis and %loody vaginal discharge ollowing the delivery) i the lochia was foul smelling and the uterus was tender, endometritis) when patient has placental abruption manage aggressively to ens&re rapid %aginal deli%ery) can ca&se D*C) only do c-section when deterioration o the et&s or o%stetrical complications) &terine r&pt&re -3 immediate c-section &ric"omonas %aginitis presents as erythematous %aginal mucosa with thin grayish %aginal discharge ) treat with metronidazole and avoid alcohol) menstrual diary or at least cycles or premenstrual syndrome) %loating, atig&e, %reast tenderness, headaches, an4iety, mood swings, decreased li%ido and irrita%ility) patients with ine%itable or incomplete abortions sho&ld %e hospitali'ed, given 8" L&ids, s&ction c&rettage, and rhogam i #h-) they may get septic, 8C, and hemorrhage) with a etal anomaly incompati%le with lie, allow spontaneo&s delivery i preterm la%or with r&pt&re o mem%ranes) give pulsatile n>" leuprolide6 to someone with acK&ired hypogonadotropic hypogonadism d&e to hypothalamic dys&nction) copious %aginal discharge %y itsel witho&t pr&ritis, %&rning, malodoro&s discharge, erythema, edema and ria%ility o the vaginal m&cosa, tenderness o the cervi4, and green or c&rd-like vaginal discharge is not concerning) most likely physiological leukorrhea) bacterial %aginosis has thin gray-white %aginal discharge, %aginal ph @ &3', 1:hi test with 7O5 prep, and Hclue cellsG which are vaginal epithelial cells with adherent %acteria) no pr&ritis or inLammation) Dreat with metronida'ole) pse&dohyphae on wet mo&nt are consistent with candida %ul%o%aginitis) will have pr&ritis, thick white discharge that has a “cottage cheese” appearance) treat with oral #uconazole ) ater + weeks with preterm, premat&re r&pt&re o mem%ranes (#OM$ itHs &nclear i corticosteroids are %ene1cial, %&t give penicillin i their .0! stat&s is &nknown) dysmenorrhea, enlarged uterus, and hea%y menses is uterine (broids) primary dysmenorrhea is ca&sed %y increased le%els of prostaglandins and presents with lower a%dominal pain occ&rring with menstr&ation) 6!A8s and OCs can improve these symptoms) early ollic&lar phase ollows menstr&ation) cervical m&c&s is thick, scant, and acid in this phase) no penetration %y spermato'oa) d&ring o%ulatory phase the cervical m&c&s is profuse clear and thin , and is @/3' in p" and will stretch @/ cm when lited vertically) in mid and late l&teal phases ov&lation has occ&rred and the m&c&s %ecomes thicker and inhospita%le to sperm) increase in blood pressure before A2 weeks of gestation is d&e to chronic hypertension or h-mole) i <raso&nd shows a normal sac then itHs not h-mole)
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hypertension is the most commonly identi1ed risk actor or placental abruption) lithi&m in pregnancy can give %steinHs anomaly2 atriali'ed right ventricle, malormed tric&spid valve, and atrial septal deect) at necrosis o the %reast associated with %reast tra&ma or s&rgery) can mimic %reast cancer and presents as a 14ed mass with skin or nipple retraction) has calci1cations on mammography) %iopsy shows fat globules and foamy histiocytes) emale phenotype lacking a normal vagina and &ter&s is either mullerian agenesis (WW, %&t &lly &nctioning ovaries$, androgen insensitivity (cryptorchidism, remove ater p&%erty to maintain ad< height growth, low risk o malignancy (dysgerminoma$ compared to D&rners (remove the streak ovaries$, or <-alpha-red&ctase de1ciency) in the latter + yo& have an W] genotype) precocious puberty is de1ned as development o + nd se4 characteristics %eore age N in girls, ; in %oys) accelerated bone growth and ad%anced bone age are common ) central ca&se is res< o early activation o hypothalamicpit&itary-ovarian a4is %y .n#5) !S" and L" are ele%ated ) in peripheral precocious puberty they ha%e low !S"$L" le%els , %eca&se o gonadaladrenal release o se4 hormones (negative eed%ack$) i central then diagnose with %rain imaging CDM#8 and treat with n>" analog leuprolide6 therapy) uterine rupture has intense abdominal pain and vaginal %leeding along with hyperventilation, and tachycardia) placenta pre%ia ca&ses painless %aginal bleeding the risk actors are prior c-section, advanced maternal age, m<iparity, smoking, m<iple gestation, and previo&s placenta previa) asymptomatic %acter&ria progresses to pyelonephritis in 9-=9G o cases, need to treat asymptomatic pylenphritis) hyperemesis can occ&r with gestational trophoblastic disease , so meas&re beta-hcg cause nausea63 i %eta-hcg is high, do an <raso&nd) hyperemesis gravidar&m presents with ketonuria) "C rom the syncytiotropho%lasts is mainly responsi%le or the maintenance o the corpus luteum d&ring pregnancy) inLammatory %reast carcinoma presents as an edemato&s c&taneo&s plaK&e with a pea& dHorange appearance overlying a %reast mass) presents with a4illary lymphadenopathy, and +
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midcycle pain ( mitelschmerz$ presents as a%dominal pain in a yo&ng emale in the middle o her cycle with a %enign history and physical e4am) in a pregnant patient who has syphilis and is allergic to penicillin, do desensiti'ation) galactorrhea can %e yellow, brown, or green) 1rst step to do in patient with galactorrhea is to check 7S" and prolactin le%els) red Lags are unilateral, guaiac positi%e #uid and a %reast l&mp) tamoxifen carries an increased risk for endometrial carcinoma raloxifene doesnEt but does increase risk of thromboembolism6 ) %&t is an antagonist at %reast tiss&e and prevention o %reast cancer) also decreases risk o osteoporosis) in premenopausal women with simple or complex hyperplasia without atypia &se cyclic progestins to treat dys&nctional &terine %leeding (0$) the chance or progression to &terine cancer is very low *G and G or simple and comple4 respectively) pre-eclampsia can ca&se centrilobular necrosis of the li%er, with hematoma formation and the formation of thrombi in the portal capillary system) these processes can ca&se swelling of the li%er with distention of the hepatic lisson0s6 capsule res<ing in >Q= pain ) preterm la%or is la%or occ&ring 3 +9 weeks %&t : weeks gestation) reK&ires the occ&rrence o doc&mented uterine contractions at a rate of & per A2 min or more, and doc&mented cer%ical changes consistent with labor ) #espiratory distress syndrome (#!$ is a common complication in preterm inants as etal l&ng mat&rity has not yet %een reached) other complications incl&de intra%entricular hemorrhage, sepsis, nectroti'ing enterocolitis and kernicter&s) the management dependens on the gestational age o et&s and presence or a%sence o comor%idities that pose a risk to et&s and mother) in normal pregnancies systemic corticosteroids are delivered when the gestational age is A&-?& weeks) tocolysis sho&ld then %e attempted with the goal o maintaining the pregnancy or at least =N ho&rs to allow the steroids to work) 1rst treatment or %ariable decels (cord compression$ is give oxygen to mother and change maternal position ) &terotonic dr&gs need to %e discontin&ed and maternal hypotension eval&ated and treated) %ariable decels may re;uire amnioinfusion) choriocarcinoma is a metastatic orm o gestational tropho%lastic disease) it may occ&r ater molar pregnancy or normal gestation and the lungs are the most fre;uent site of metastatic spread ) s&spect choriocarcinoma in any postpart&m woman with pulmonary symptoms and m<iple nod&les on CW#) ele%ated beta-hcg helps to con1rm the diagnosis) androgen insensiti%ity syndrome is characteri'ed %y a deecta%sence o androgen receptors res<ing in androgen resistance o peripheral tiss&es) these patients are W] and have testes) )*! is produced %y the testes and prohi%its ormation o &ter&s, allopian t&%es, and &pper portion o the vagina) %reasts develop %eca&se conversion o testosterone to estrogen) stress incontinence is characteri'ed %y loss o small amo&nts o &rine with increased intra-a%dominal press&re) ineecti%e closure of urethral sphincter) weakening of pel%ic #oor musculature leading to urethral hypermobility) will show an angle 3 9 with a cotton swa% in the &rethral ori1ce &pon increase o inra-a%dominal press&re) treat with kegel exercises and urethropexy) &se oxybutynin to treat urge incontinence) res<s rom detrusor hyperacti%ity and is characteri'ed %y a sudden urge to urinate) hypotension is a common side efect o epidural anesthesia) the ca&se o hypotension is %lood redistribution to lower extremities and %enous pooling)
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thyroid function in pregnancy is afected %y + separate mechanisms) *$ increase in thyroid binding globulin 786 concentration and +$ stimulation of the 7S" receptor by chorionic gonadotropin "C $) an increase in estrogen leads to an increase in D0. prod&ction, which res<s in an increase in D0.-%o&nd D and D=) as a res< elevated D0. leads to increased total D= and D, %&t the free 7& and 7? remain normal) the elevated levels o hcg in pregnancy can also ca&se a mild stimulation of 7S" receptor , res<ing in a small increase in free 7? and 7& and a mild decrease in 7S" ) infants born to patients with gra%es disease treated with surgery are at risk or thyrotoxicosis %eca&se o the passage of thyroid stimulating *g across the placenta) C"lamydia trac"omatis is the most common ca&se o mucopurulent cer%icitis) in a patient recieving estrogen therapy the re;uirement or l-thyroxine increases) estrogen may ca&se induction of li%er enzymes, increased le%el of 78, and increased vol&me o distri%&tion o thyroid hormones) weight gain is not associated with the &se o com%ination oral contraceptives) abdominal circumference is the most efective parameter for estimation of fetal weight in cases o s&spected etal growth restriction) protraction o la%or reers to a slow progression o cervical dilatation, whereas arrest disorders are diagnosed when the cer%ix ceases to dilate after reaching at least & cm ) i the mem%ranes are still intact, an amniotomy is the 1rst step to promote progression) o%arian malignancy can present as right adne4al &llness, and nod&larity along the recto%aginal septum possible peritoneal mets $) pleural eusion can %e d&e to metastatic spread to the ple&ra) most common ca&se o malignant pleural eusions are breast cancer and lung cancer) will %e an exudati%e eusion (BightHs criteria$) or LS*Lmild dysplasiaC*N B do a colposcopy with a targeted biopsy ) cone %iopsy is or more aggressive C86) chlamydia does not involve the vagina, it ca&ses cer%icitis and urethritis) candidiasis presents with perineal itching and a thick white curd-like %aginal discharge and a %aginal ph of &32 ) trichomonas presents with an ele%ated %aginal ph and a green frothy malodorous discharge ) bacterial %aginosis can ca&se similar symptoms to candidiasis %&t the discharge is thinner and the %aginal ph is higher than normal no in#ammation or itching) treat prolactinoma with dopamine agonist like cabergolinebromocriptine to restore ertility) will have %ilateral galactorrhea) olycystic ovarian syndrome will not have galactorrhea) treat infertility of .C9S with n>" analog (leuprolide$ or clomiphene) third trimester %leeding is oten commonly placenta pre%ia painless6 and placental a%r&ption (pain&l$) i hemodynamically sta%le, the ne4t step wo&ld %e a transabdominal ultrasound) do not do bimanual examination or speculum %aginal examination until placenta pre%ia has been ruled out %y a%dominal <raso&nd) several tocolytic agents can ca&se pulmonary edema in rare cases) most common with %eta-agonists ( terbutaline and ritodrine$) reassurance and outpatient follow &p is standard o care or threatened abortion) (%leeding, closed cervi4 %eore +9 weeks gestation$ one o the side efects o epidural anesthesia is o%er#ow incontinence ca&sed %y bladder dener%ation) patient cant sense a &ll %ladder and then the hypotonic bladder distends gradually ) when the press&re rises a%ove &rethral
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press&re the &rine is lost and press&re eK&ali'es) transient incontinence treated by Hin-and-outG catheterization3 (same with dia%etic ne&ropathy$ placental abruption presents with sudden onset abdominal pain in the third trimester with the a%sence o tra&ma) %leeding is seen in N9G o cases and in some cases it may %e retroplacental and not appear on vaginal e4am) most common risk actor is maternal hypertension) +nti-phospholipid antibody syndrome (A!$ is associated with false 1,D>L, prolonged .77 and thrombocytopenia) can promote arterial and veno&s throm%oses and res<ant tendency toward sponaneo&s a%ortions) prophylaxis with L):" is recommended) polycystic o%arian syndrome .C9S6 patients are hyperandrogenic women with adeK&ate amo&nt o active estrogens) androgens converted into estrogens in peripheral tiss&es) they are oligo- or anov&latory and are de(cient in progesterone secretion, th&s they have unopposed estrogen stimulation leaving them at a risk for endometrial cancer ) d&ring pregnancy the higher serum concentration of progesterone has a stimulatory eect on the dorsal respiratory group (#.$ o the med&llary respiratory center) %y stim&lating this central respiratory center, high progesterone concentrations lead to tachypnea and conseK&ent chronic mild respiratory alkalosis) will have high p5, decrease in aCO+ and a decrease in 5CO- to compensate Ipregnancy test %&t with no <raso&nd 1ndings o intra- or e4ra&terine pregnancy has a diferential o2 early via%le intra&terine pregnancy, ectopic pregnancy, or nonvia%le intra&terine pregnancy) an intrauterine pregnancy sho&ld %e seen with trans%aginal ultrasound at B'22-A222 beta-hcg) if the le%el is M B222, repeat %oth beta-hcg and trans%aginal ultrasound in +- days) adenomyosis is the presence o endometrial glands in the uterine muscle ) occ&rs most reK&enly in women @ &2 with se%ere dysmenorrhea and menorrhagia) physical e4am will show an enlarged and generally symmetric uterus) leiomyomas also present similarly with dysmenorrhea, menorrhagia, and a large-si'ed &ter&s %&t it is asymmetrical$irregularly shaped) dysfunctional uterine bleeding DQ86 reers to heavy vaginal %leeding that occ&rs in the a%sence o str&ct&ral or organic disease) 0 is most often the result of ano%ulation) treatment depends on the severity o %leeding, i mild then give iron s&pplementation) if moderate and no active %leeding then add progestin) i moderate with acti%e bleeding or i severe give estrogen) in women @ ?' with DQ8 endometrial biopsy is indicated a missed abortion is a orm o spontaneo&s a%ortion that is characteri'ed %y intra&terine etal death %eore +9 weeks gestational age with complete retained products of conception and a closed cer%ix ) patients present with loss o pregnancy symptoms and some %rown vaginal discharge) a trans%aginal ultrasound is necessary to con(rm the diagnosis ) the most appropriate treatment is removal o OC rom the &ter&s with a dilation and curettage , or medically with %aginal misoprostol or e4pectantly with serial imaging to ens&re complete nat&ral e4p&lsion o OC) +89 incompatibility generally occ&rs in a group 9 mother with a group + or 8 baby, %&t A0O incompati%ility ca&ses less se%ere hemolytic disease o the new%orn than does >hD6 incompatibility) afected inants are &s&ally asymptomatic at %irth with a%sent or mild anemia and develop neonatal Fa&ndice, which is &s&ally s&ccess&lly treated with phototherapy) pseudocyesis is an &ncommon condition in which a woman presents with many signs and symptoms of pregnancy (amenorrhea, enlargement o %reasts and a%domen, morning sickness, sensation o etal movement,
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Ipregnancy test reported$ however <raso&nd will reveal a normal endometrial stripe and the pregnancy test in the oUce will %e negative) &s&ally seen in women who have a strong desire to %ecome pregnant) form of con%ersion disorder and management reK&ires psychiatric e%aluation and treatment ) ele%ated prolactin levels suppress n>" release there%y suppressing L" and !S" production and ov&lation) this is the reason or anov&lation and amenorrhea in lactating mothers) palpa%le %reast mass in woman M ?2 years do an ultrasound ) i simple cyst then do needle aspiration) i complex cyst$mass solid6 then do image guided core biopsy) in a woman 3 9 years do mammo ^ <raso&nd) i s&spicio&s or malignancy then do core %iopsy) the three hallmark eat&res o endometriosis (the three dHs$ are dyspareunia, dysmenorrhea, and dyschezia) de1nitively diagnosed via laparoscopy) the most pop&lar treatment is combined estrogen and progestin pills ) other possi%ilities incl&de n>" analogs leuprolide $ or danazol) in androgen insensiti%ity syndrome, do a gonadectomy after completion of puberty) this allows or completion o %reast development and attainment o ad< height) immediate removal o gonads is indicated in cases o W] gonadal dysgenesis Swyer syndrome $ or D&rnerHs !yndrome as malignant change can occ&r at any age) endometrial biopsy is indicated in cases o dysfunctional uterine bleeding (0$ afecting women @ ?' y$o) also indicated in cases o 0 i hypertension, dia%etes, or o%esity are present) i %iopsy is negative then can %e treated with cyclic progestins) (i moderate and active %leeding, estrogens$ rapidly de%eloping hyperandrogenism with %irilzation is highly s&ggestive o an androgen-secreting neoplasm o the ovary or adrenal gland) ser&m testosterone and 5A-! are very help&l in delineating the site o androgen prod&ction) ele%ated testosterone levels with normal D"+-S indicate an o%arian source, whereas ele%ated D"+-S with relatively normal testosterone indicate an adrenal source ) rapidly developing virili'ation is rare in CO!) LS*L on pap smear gets colposcopy) in post menopausal woman also do "., testing and repeat pap smear at /$BA months ) i 5" is ? then ro&tine screening, i 5" is I then colposcopy) ruptured fetal umbilical %essel presents with antepartum hemorrhage with very characteristic fetal heart changes progressing rom tachycardia to bradycardia to a sinusoidal pattern) %asa pre%ia is a rare condition where the etal %lood vessels traverse the etal mem%ranes across the lower segment o the &ter&s (%etween the %a%y and the internal cervical os$) these vessels are %ulnerable to tearing during natural or arti(cial rupture of the membranes) treatment is immediate c-section) tmp-smx is contraindicated in pregnancy ) to treat asymptomatic bacteriuria in a pregnant woman &se amoxicillin) treatment or %aginismus is rela4ation, kegel exercises to relax the %aginal muscles, and insertion of objects gradually increasing their size to encourage desensitization) primary o%arian failure res<s in decreased estrogen le%els , increased !S" and L" le%els ) !S"OL" ratio will be @ B32 ) /!5 elevation in the setting o 3 months o amenorrhea in a woman under age &2 con1rms the diagnosis o premat&re ovarian ail&re) premature o%arian failure is characteri'ed %y amenorrhea, hypoestrogenism, and ele%ated serum gonadotropin le%els in women age M &2 years ) may %e associated with autoimmune disorders s&ch as hashimotoHs thyroiditis, addisonHs, type * dia%etes mellit&s, and pernicio&s
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anemia) women present with signssymptoms similar to those seen in menopa&se) con(rm diagnosis with increased serum !S"$L" le%els and decreased estrogen le%els ) i yo& want to get pregnant, then do in-%itro fertilization %eca&se they lack %iable oocytes ) the ideal range o maternal fasting glucose is %etween F' 42 mg$dL ) treatment is %est accomplished with subcutaneous insulin) does not cross the placenta) gestational dia%etes p&ts %a%y at risk or2 macrosomia, hypocalcemia, hypoglycemia, hyperviscosity d&e to polycythemia, respiratory diUc<ies, cardiomyopathy and congesti%e heart failure) mammogram or women e%ery A years starting at '2 until they are F' y$o Q.S7! guideline for low risk women6 i patient has atypical sK&amo&s cells o &ndetermined signi1cance ( +SC-QS on pap smear $ ollowed %y colposcopy showing C*N B then do repeat pap smear at /$BA months or "., testing in BA months ) i two ? smears, then ro&tine ollow &p in * year) i +SC-QS or +SC-" on repeat pap6 or if "., 1 then do colposcopy again) i colposcopy shows persistent C*N then diagnostic procedure ) "S*L C*N A and C*N ? re;uire e4cisional diagnostic$treatment modality like cold knife conization or L.) intraamniotic infection sho&ld %e s&spected in the setting o prolonged or premature rupture of the membranes (%eore weeks$ when maternal fe%er, leukocytosis, and uterine tenderness or tachycardia are detected) fetal tachycardia is another feature of chorioamnionitis) the most appropriate treatment o chorioamnionitis associated with premat&re r&pt&re o the mem%ranes is systemic broad spectrum antibiotic therapy and expedited deli%ery of the fetus ) ! e4pos&re in &tero increases risk o clear cell %aginal adenocarcinoma in ofspring) Kallmann0s syndrome consists o a congenital absence of n>" secretion associated with anosmia) patients have a normal JJ genotype and normal female internal reproducti%e organs) present with amenorrhea and absent secondary sexual characteristics s&ch as %reast and p&%ic hair development) abnormal de%elopment o the olfactory bulbs tracts res<s in hyposmia or anosmia) la%or sho&ld %e ind&ced witho&t delay in patients with intra&terine etal demise who develop coag&lation a%normalities) (brinogen and platelet levels in the low-normal range can indicate de%eloping D*C) screen all pregnant women for syphilis , regardless o risk actors or !Ds (DO#C5$) only screen or chlamydia in women : += or at increased risk (m<iple se4&al partners or history o !Ds$ d&ring pregnancy the primary goal o colposcopy is the e4cl&sion o invasive cervical cancer) the management o women with any cytological specimen suggesting "S*L consists o colposcopy and directed biopsy3 i the initial %iopsy is negative, repeat colposcopy and biopsy should be done at /-< weeks after deli%ery) management or septic abortion is *$ cer%ical and blood cultures, +$ antibiotics, and $ gentle suction curettage) Dhe patient will %e e%rile, tachycardic, hypotensive, and have %loody p&r&lent vaginal discharge rom the cervi4) contraindications to %reasteeding are acti%e drug abuse, tuberculosis, "*, infection) 5epatitis C is not a contraindication to %reast eeding) 8 taking metronida'ole stop or *+-+= ho&rs) arrest of dilation is de1ned as lack of cer%ical change for A hours in n&llipario&sm<iparo&s patients) arrest o descent is de1ned as lack o change o station or + ho&rs in primigravid patients and * ho&r in m<igravid patients, with
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e4tra ho&r allowed i epid&ral in place) prominent ischial spines can lead cephalopel%ic disproportion which is one o the three pHs ca&sing protraction and arrest disorders (passenger, passage, power$) do a c-section i there is an abnormality in the maternal pel%is ) progestin-only contracepti%es are the preferred hormonal contracepti%es in lactating women as they do not afect the vol&me or composition o milk prod&ced %y the mother) they have no known efects on the inant and they do not carry the risk of %enous thrombosis associated with com%ination pills) lactation alone is not considered a relia%le orm o %irth control as ov&lation can res&me while a mother is still %reasteeding) corticosteroid treatment is not proven to have a %ene1t ater = weeks gestation) itHs &se is limited to the period %etween A& ?& weeks ) etal distress (repetiti%e late decelerations $ is an indication for emergent cesarean section) a yo&ng woman presenting with a %reast l&mp can %e asked to ret&rn ater her menstr&al period or re-e4amination which may reveal regression o the mass i no o%vio&s signs o malignancy are present) in a patient with primary amenorrhea do pel%ic exam or ultrasound2 i a uterus is present --@ serum !S") i !S" increased --@ karyotyping , i !S" decreased --@ cranial )>* ) i the uterus is absent on <raso&nd --3 karyotyping) i normal karyotype and normal female testosterone levels then most likely abnormal mullerian de%elopment ) i =J W] and normal male testosterone levels then androgen insensiti%ity syndrome) c-section sho&ld %e perormed on women with acti%e genital herpetic lesions (primary or secondary$ in order to red&ce risk o neonatal 5!") low %ack pain is very common in third trimester o pregnancy) %elieved to %e ca&sed %y increase in lumbar lordosis and the rela4ation o the ligaments s&pporting the Foints o the pelvic girdle) in intra&terine etal demise, there is a concern or 8C) low (brinogen le%els and low platelets are indicators for D*C ) i they are not low, yo& dont need need to deliver the et&s promptly) weigh the delivery options) C section shown to red&ce maternal transmission o 58" to new%orn %y <9G) Driple therapy with antivirals d&ring pregnancy is over ;9G efective) Also give new%orns A_D or J weeks
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ac&te gla&coma has an inFected eye and a mid-dilated p&pil) orbital cellulitis has opthalmoplegia, proptosis, diplopia, pain with eye mo%ement) Can %e ca&sed %y %acterial sin&sitis) age-related macular degeneration presents with bilateral loss of central %ision wa%y line distortion on %isual test )
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%itreous hemorrhage presents with a sudden loss of %ision and onset o #oaters) the &nd&s is diUc< to vis&ali'e and there will %e Loating de%ris) #ed color .ost-operati%e endopthalmitis &s&ally occ&rs within J weeks o s&rgery) patients have pain and decreased vis&al ac&ity) will have swollen eyelids, conF&nctiva, hypopyon, corneal edema and inection) ama&rosis &ga4 is characteri'ed %y vis&al loss that is monoc&lar and transient) descri%ed as a “c&rtain alling down” similar to central retinal artery occlusion, however opthalmoscopy in C#AO shows pallor of optic disc , cherry red fo%ea and boxcar segmentation o %lood in %oth arteries and veins) in ama&rosis &ga4 yo& see a white edemato&s retina ollowing the distri%&tion o the retinal arterioles) chalazion presents as a pain&l swelling that progresses to a nodular rubbery lesion) itHs a chronic gran&lomato&s condition that develops when a mei%omian gland %ecomes o%str&cted) persistent or recurrent chalazion may %e d&e to meibomian gland carcinoma ) do a histopath i rec&rrent) cataracts has %l&rred vision and glare) ca&sed %y thickening of the lens) retinal detachment patients complain o a “ curtain coming down o%er my eyes” and photopsia (#ashes of light $ and #oaters (spots in their vis&al 1eld$) can %e d&e to oc&lar tra&ma (previo&s s&rgery o the eye s&ch as or cataracts$) opthalmoscopy will reveal a grey, elevated retina) spontaneo&s s&%conF&nctival hemorrhage is a %enign 1nding) looks like eye is colored %right red) dacrocystitis is an infection of the lacrimal sac ) it &s&ally occ&rs in inants and ad<s 3 =9) characteri'ed %y the sudden onset of pain and redness in the medial canthal region) sometimes a p&r&lent discharge is noted rom the p&nct&m) s3 aureus, beta-hemolytic strep are &s&al organisms) treat with systemic antibiotic therapy cataracts occ&r d&e to opaci(cation of the lens ) and presents with painless blurring of %ision) description o a “ glareG while dri%ing at night is classic manifestation) angle clos&re gla&coma in ppl age <<-9 years) acute onset of se%ere eye pain, blurred %ision associated with na&sea and vomiting) e4amination reveals a red eye with steamy cornea and moderately dilated pupil that is non reacti%e to light ) treat central retinal a3 occlusion with ocular massage and high-#ow oxygen administration) will present with painless monoc&lar loss o vision) &ndoscopy will show dif&se ischemic retinal whitening and cherry red spots) sympathetic opthalmia is characteri'ed %y damage of one eye (the sympathetic eye$ after a penetrating injury to the other eye) it is d&e to an imm&nologic mechanism involving the recognition o hidden antigens) external hordeolum stye6 is a common staphylococcal a%scess o the eyelid) it is treated with warm compresses ) incision and drainage is perormed i resol&tion does not %egin in the ne4t =N ho&rs) macular degeneration is the most common ca&se o %lindness in ind&striali'ed nations) activities that reK&ire 1ne vis&al ac&ity are &s&ally the 1rst afected and patients with this condition may report that straight grid lines appear cur%ed ) ocular tonometry is the best test or acute glaucoma (s&dden onset o eye pain, photopho%ia, and mid-dilated p&pil$ atropine is a muscarinic antagonist) do not gi%e in a patient with acute glaucoma) will dilate the eye) instead &se mannitol, acetazolamide, pilocarpine, or timolol)
pediatrics henoch-schonlein purpura E 8gA mediated vasc&litis o small vessels ollowing #8) rash, arthralgia, abdominal pain, renal disease3 #ash on %&ttocks and legs) #elated to 8gA nephropathy) esophageal atresia occ&rs with trachoesophageal 1st&la) air enters stomach -3 distended stomach) acids pass 1st&la -3 pneumonia compartment syndrome (pallor, pain, paresthesias, poikilothermia, p&lselessness, paralysis$ can lead to %olkmann0s ischemic contracture where the dead muscle has %een replaced with (brous tissue ) kawasakiEs disease - ever with *$ conF&nctivitis +$ oropharyngeal changes $ cervical adenopathy =$ tr&ncal rash <$ changes in distal e4tremities fetal hydantoin syndrome - ca&sed %y anti-conv&lsant medications (phenytoincarbamazepine$) clet palate, microcephaly, digital hypoplasia, hirs&tism laryngomalacia is congenital Laccid laryn4 - ca&ses inspiratory stridor) hold child &pright ater eeding and not eed when lying down conF&nctivits ater %irth2 * day E chemical + - < days E gonorrhea <-*< days E chlamydia .ive oral erythromycin (not topical$ to reduce risk of pneumonia staphylococcal scalded skin syndrome - prodrome o ever) erythema and %listers with a Inikolskys sign gauchers disease is a de(ciency of beta-glucosidase ) ashkenazi jew with atig&e (anemia$ easy %r&ising ( thrombocytopenia$ and pathological fractures) radiology shows erlenmeyer #ask deformity of distal femur and gaucher cells with wrinkled paper appearance ) fanconi anemia is a&tosomal recessive disorder presenting with pancytopenia (macrocytic anemia$ and morphological a%normalities) horseshoe kidney, thumb abnormalities, short stat&re, abnormal skin pigmentation ) L+D-B has no CDB< so le&kocytes cant e4it vessels) no pus formation, delayed umbilical cord separation ) rec&rrent inections) increased >0C with high ne&trophils epistaxis, mass, and bony erosion on the back of the nose is angio(broma e%rile sei'&re when temp is 3 *99)= and age : J associated with inection henoch-schonlein-purpura seen ater #8) give steroids and monitor renal function) abdominal pain -3 r&le o&t gastrointestinal %leeding and int&ss&sception) d&odenal atresia has a @do&%le %&%%le@ sign, FeF&nal atresia has a @triple %&%%le@ on a%dominal radiographs) will have air L&id levels and a gas-less lower a%domen)
congenital hypothyroidism has hypotonia, large tong&e, sl&ggish movement, a%dominal %loating, umbilical hernia) todds paralysis is a post-ictal condition with motor restoration occ&ring rapidly ater the sei'&re vitamin rickets has craniotabes (ping pong %alls all over occip&t$, rachitic rosary (enlargement o costo-chondral F&nctions$, thickening of wrist and ankles, cupping and fraying at the distal ends of long bones cri d& chat is deletion o
torus palatinus benign bony growth on the midline suture o the hard palate) most common ca&se o secondary hypertension in children is (bromuscular dysplasia) “h&m” or %r&it in the C"A) angiography shows @ string of beads@ pattern in renal artery waterhouse friderichsen syndrome is characteri'ed %y s&dden vasomotor collapse and skin rash d&e to adrenal hemorrhage) (N. meningitidis$ inants who are small for gestational age at risk or2 hypothermia, hypoglycemia, hypocalcemia, polycythemia, meconium aspiration) hyaline membrane disease lungs are de(cient in surfactant6 presents with s&%costal retraction, nasal Laring, hypo4emia, tachypnea, d&skiness within a ew min&tes ater %irth) CW# will show 1ne reticular granularity of lung parenchyma) prolonged labor is a risk actor or cerebral anoxia which can lead to cerebral palsy short height, high arched palate, widely spaced nipples and WO is turner syndrome) patients with t&rner have a higher risk o osteoporosis %eca&se lower estrogen le%els ) rec&rrent sel-limiting episodes o vomiting and na&sea in children in the a%sence o any apparent ca&se, s&ggests cyclical %omiting oral thr&sh, lymphadenopathy, hepatosplenomegaly may %e the presenting symptoms o A8! in inants) in an inant with congenital diaphragmatic hernia place an orogastric tube to suction and decompress the bowels and pre%ent further lung compression) to prevent !8! place inant in s&pine position while sleeping) (on their %acks$ %reath holding spells are episodes o apnea (no e4ternal %reathing$ associated with loss o conscio&sness) common and sel-limited) #eass&rance is all that is needed) 7urcot0s syndrome is an association %etween brain tumors (med&llo%lastoma and glioma$ and !+. or "N.CC) or patients with cystic 1%rosis need double co%erage of pseudomonas when they have pne&monia) &se aminoglycoside gentamycin6 I antipseudomonal penicillin) even with vaccination over F'5 of household contacts will develop symptoms of Bordetella pertussis so give erythromycin for prophylaxis to all ho&sehold contacts) nursemad0s elbow is also called subluxed radial head , and is one o the more common inF&ries in children) occ&rs when parents p&ll or lit children rom the arm or hand) child keeps arm in a pronated position) rotating the hand and orearm to a supinated position with press&re over the radial head red&ces the ann&lar ligament with an audible HclickG and restores normal &se o the e4tremity) in gastroschisis the bowel protrudes through a defect on the right of the umbilical cord) itHs not covered %y any mem%rane, it looks matted and is not associated with any other abnormalities) in omphalocele the bowel is co%ered by an amnioperitoneal membrane , and can %e associated with other congenital anomalies (chromosome **N+*$ transient syno%itis is most common cause of hip pain in children ) occ&rs after %iral infection) synovial inLammation leads to pain, decreased range o motion, and limping) the afected hip is Le4ed, slightly a%d&cted and e4ternally rotated) this position ma4imi'es the Foint space
in children appro4 J9G o C6! t&mors are inratentorial and + to rule out ) fragile x is a C.. trin&cleotide repeat disorder) large testicles, long prominent jaw, a&tism, large low set ears3 Neisseria gives meningitis with petechial or p&rp&ral rash on a4illa, wrists, Lanks, ankles) :ilm0s tumor &s&ally %etween ages o + - <) most common primary renal tumor o childhood) N9G have asymptomatic a%dominal mass that does not cross the midline ) symptoms may %e2 hypertension, hemat&ria, a%dominal pain, vomiting) may also present with lung mets) associated with %eckwithweidemann and denys-drash syndromes) neuroblastoma (ne&roendocrine t&mor$ will present with pain, ever, weight loss, hepatomegaly and hypertension, and the crosses midline3 tetralogy of fallot has *$ overriding aorta +$ right vent) hypertrophy $ pulmonary stenosis single sA6 and =$ "! (pansystolic m&rm&r$ in esodeviation which is a type o stra%ism&s, cover the &nafected eye) ntreated it %ecomes the preerred eye leading to %lindness o the deviated eye) do cover test ? child 14es sight on a target and e4aminer covers eye and checks or movement) the misaligned eye wo&ld shit to re14ate) >ibo#a%in 8A6 de(ciency gives yo& sore throat, hyperemic and edemato&s oropharyngeal m&co&s mem%ranes, cheilitis, stomatitis, glossitis, normocyticnormochromic anemia, se%orrheic dermatitis and photopho%ia) epiglottitis is ca&sed %y Haemop"ilus infuenza type b) presentation incl&des a%r&pt onset o ever, sore throat, dysphagia, drooling) can have airway o%str&ction, signs pointing to this incl&de a muRed hot potato %oice) keep neck hyperextended pro%ides some relief ) myotonic muscular dystrophy is autosomal dominant transmission) involves all types o m&scle (smooth, striated, cardiac$) slowly develop m&scle weakness and wasting) upper lip will %e in shape o an “ in%erted %G3 celiac disease can ca&se kwashiorkor-like clinical eat&res associated with dermatitis herpetiformis (erythemato&s vesicles symmetrically distri%&ted over e4tensor s&races o el%ows and knees$) hyper8gM syndrome gives recurrent sinopulmonary infections and poor speci(c antibody responses to immunizations) will have high 8gM and low other anti%odies and 0 cells) iron de(ciency anemia is common in inantstoddlers who drink excessi%e cow0s milk ) i child swallows a %attery and 4-ray shows itHs in the esophagus immediately remo%e via endoscopy) edward0s syndrome (trisomy *N$ has micrognathia, microcephaly, rocker %ottom eet, overlapping 1ngers and a%sent palmar creases) most common congenital heart pro%lem is ,SD) S. pneumoniae and H. in!uenzae are the most common ca&ses o acute bacterial rhinosinusitis) treat with amoxicillin $ cla%ulanate) immune thrombocytopenia in children ater a %iral illness presents with isolated thrombocytopenia) relatively %enign condition and will resolve most o
the time) i symptoms are se%ere and platelets M ?2k then give corticosteroids) (in ad<s, 8D, t4 with 8"8., plasmapharesis$ 77. +D+)S7B? do plasma exchange6 mumps gives bilateral parotitis and orchitis is a serio&s complication) cholesteatoma is an ear lesion with continued ear drainage despite appropriate anti%iotics) chronic middle ear disease leads to the ormation o a pocket in the tympanic mem%rane which can 1ll with granulation tissue and skin debris) complications incl&de hearing loss and C6 palsies, vertigo, and inections) eczema herpeticum is a orm o primary "S, that is associated with atopic dermatitis) &m%ilicated vesicles over healing atopic dermatitis are typical) associated with ever and lymphadenopathy) give acyclo%ir as soon as possi%le %eca&se this condition is life threatening) neuroblastoma arises rom neural crest cells which are prec&rsor cells o sympathetic chains and adrenal med&lla) calci(cations and hemorrhages are seen on W# and CD scan) le%els of serum urine catecholamines and their metabolites will be increased ) cystic calci(ed parasellar lesion on M#8 in a yo&ng %oy who has increased intracranial pressure (headache, vomiting$ bitemporal hemianopsia is a craniopharyngioma) %aginal foreign bodies sho&ld %e s&spected in children with purulent foul smelling %aginal discharge and bleeding, and is treated with irrigation with warmed #uids retropharyngeal abscess is a deep neck space inection seen most commonly in children that ages range J mo ? J years) a%scess orms %y direct spread of infection rom pharyngitis, tonsilitis, otitis, sin&sitis or other inections o the pharyn4) recent history of Q>* ollowed %y constit&tional symptoms and sore throat, dysphagia, muRed or hot potato %oice , and neck stiness) congenital syphilis- cutaneous lesions on palms, soles, hepatosplenomegaly, jaundice, anemia, rhinorrhea) congenital toxoplasmosis has chorioretinitis, intracranial calci(cations, hydrocephalus, congenital rubella has sensorineural hearing loss, cataracts, heart defects, microcephaly, congenital C), 8.#, petechia or purpura, chorioretinitis and peri%entricular calci(cations increased gastric residual %olume in pre-term neonate is highly s&spicio&s or necrotizing enterocolitis) &s&ally presents - *9 days ater %irth and is d&e to %owel wall inF&ry res<ing rom perinatal asphyxia) sepsis in a neonate oten presents with hypothermia, Fa&ndice, lethargy and poor eeding) do %lood c<&res and a l&m%ar p&nct&re or all %a%ies s&spected o sepsis recogni'e kawasaki0s disease2 *$ fe%er for @ ' days and = o the ollowing2 +$ bulbar conjuncti%al injection $ des;uamation of (nger and toe tips , edema =$ erythema 1ss&ring and cr&sting o lips, strawberry tongue, dif&se m&cosal inFection o orpharyn4 <6 truncal rash J$ cer%ical lymphadenopathy polycythemia in an inant maniests with respiratory distress, poor eeding and neurological manifestations) decreased p&lmonary %lood Low d&e to hyper%iscosity of the blood leads to respiratory distress) hypoglycemia is also seen in polycythemic inants)
manage idiopathic central precocious puberty with n>" agonist (le&prolide, -relin$ therapy to pre%ent premature fusion of epiphyseal plat es, which wo&ld lead to short stat&re) Fa&ndice d&e to unconjugated hyperbilirubinemia can %e d&e to *$ increased prod&ction o %ilir&%in (hemolysis$, +$ decreased clearance o %ilir&%in (crigler-naFFar and gil%ert$ or $ increased enterohepatic circulation ) in breast feeding jaundice there is increased enterohepatic circulation %eca&se they are not getting eno&gh milk) treatment is %etter %reasteeding techniK&es) + year old child has a voca%&lary o +99 words with <9G o their speech %eing &nderstanda%le, three year old has a voca% o aro&nd *999 words and
neonatal tetanus is seen in developing co&ntries in inants %orn to &nimm&ni'ed mothers reK&ently ollowing umbilical stump infection d&e to poor o%stetric proced&res, inadeK&ate postnatal care or c<&ral practices) onset is within 1rst two weeks o %irth and is characteri'ed %y poor suckling and fatigue, ollowed %y rigidity, spasms, and opisthotonus) trisomy +* (down0s syndrome$ is associated with congenital aganglionic megacolon (hirschsprung disease$) s&spect hirschspr&ng disease in any neonate with delayed passage o meconi&m as ;;G o &ll term inants stool within =N ho&rs o %irth) ailed development o enteric nervo&s system o a portion o the distal g&t and most commonly involves rectosigmoid) afected segment cannot rela4 and is chronically contracted) new%orns present with poor eeding, abdominal distention, failure to pass meconium , and biliary emesis) rectal e4am prod&ces an explosi%e expulsion of gas and stool Hs;uirt signG6 rom temporary relie rom the o%str&ction) gold standard is rectal %iopsy demonstrating a%sence o ganglionic cells) in tetralogy of fallot s;uatting increases systemic %ascular resistance decreasing the right to let sh&nt across the "!, making more blood go to the lungs) treat intussusception with an air contrast enema) int&ss&sceptions are o&nd at the ileocolic F&nction with the ile&m telescoping into the colon) presents with colicky abdominal pain , vomiting, and red currant jelly stools) sausage shaped mass is oten palpated) a%dominal radiographs will show air #uid le%els due to obstruction ) <raso&nd shows a targetoid lesion where one %owel segment is nested inside another %owel segment) s&spect growing bone pain in a child with nocturnal pain and no o%vio&s physical or la%oratory 1nding) in all cases the pain resolves in the morning) Chlamydia is the most common ca&sative agent o infectious neonatal conjuncti%itis) chlamydial pneumonia can develop in inected inants) (give oral, not topical anti%iotic$ midgut %ol%ulus presents in a child : * month o age as bilious %omiting, abdominal distension , and passage of blood stained stools ) anemia of prematurity is the most common anemia in premature and low birth weight infants) diminished >8C producion , shortened >8C life span , and %lood loss) normocytic normochromic anemia ) constitutional growth delay is the most common ca&se o short stat&re and p&%ertal delay in adolescents) afected individ&als have a normal birth weight and height, %&t %etween / months and ? years of age the height and growth %elocity slows ) aro&nd years o age the child regains a normal growth velocity) p&%erty and the adolescent growth sp&rt are delayed, %&t event&ally occ&r) self destructi%e beha%ior is &s&ally associated with lesch-nyhan syndrome) fragile x syndrome has clinical eat&res o a&tism, mental retardation, an elongated face and large testes ) ju%enile myoclonic epilepsy starts o&t with absence seizures aro&nd the age o *9 to myoclonic seizures at age B' ) then generalized tonic-clonic seizures) %iral infection is most common cause of pharyngitis in the pediatric pop&lation) low-grade ever makes streptococcal pharyngitis &nlikely) a%sence o cer%ical lymphadenopathy makes 8, and group a streptococcus S. pyogenes$ &nlikely) entero%iruses like coxsackie a %irus are capa%le o producing %esicles on the palate and tonsillar pillars herpangina$ henoch-schonlein-purpura is known as leukocytoclastic %asculitis) preceded %y #8) has palpa%le non-%lanching symmetric purpuric lesions in the buttockslower extremities) also joint pain which is oligoartic&lar in the knees
and ankles) abdominal pain and renal failure) skin %iopsy shows leukocytoclastic %asculitis in post-capillary %enules with extensi%e deposition of *g+ ) cough coryza and conjuncti%itis with koplik0s spots in measles (paramyxo%irus$) erythemato&s mac&les and pap&les %eginning on the ace and spread down to involve rest o %ody) roseola infantum is known as exanthem subitum or /th disease, ca&sed %y "",/$"",F) presents with high fe%er, periorbital edema and palatal or pharyngeal erythema3 lasts - < days and patients can get febrile seizures) skin er&pts as ever s&%sides 3 rose colored macules and papules that begin on the neck and trunk and spread to the face and extremities ) meconium ileus and hirschsprung disease sho&ld %e considered in any neonate with delayed passage o meconi&m as ;;G o inants stool within =N ho&rs o %irth) meconi&m ile&s is o%str&cted at ile&m with inspissated thick congealed6 consistency of meconium ) hirschsprung disease is o%str&cted at rectosigmoid F&nction with normal meconium consistency ) meconi&m ile&s is diagnostic or cystic (brosis ) the meconium will be thick as glue and dicult to propel , res<ing in obstruction at ileum and a narrow &nder&sed colon) a child who accidentaly takes li;uid alkali (oven cleaner$ sho&ld %e managed %y 1rst ens&ring there is airway patency) the ne4t step is doing upper gastrointestinal endoscopy to assess the extent of injury and to dictate &rther management) &pper .8 endoscopy ---3 gastrogra(n i perforation is s&spected (water sol&%le as 0ari&m will irritate the mediastin&m$ neonatal jaundice with ( direct6 conjugated hyperbilirubinemia is s&ggestive o neonatal cholestasis) biliary atresia can ca&se neonatal cholestasis) >ill have pale stools dark &rine) edwardHs syndrome patients have inde4 digit overlapping the rd and the < th digit overlapping the = th, rocker %ottom eet, prominent occip&t, micrognathia and microcephaly) ,SD is a pansystolic murmur lo&dest at let lower sternal %order) they can also have diastolic murmurs at the ape4 %eca&se o increased #ow across the mitral %al%e) (%lood rom right ventricle ret&rns %ack to let atri&m$ think epiglottitis in a - year old with acute respiratory distress , toxic appearance, drooling, stridor and high grade fe%er) tachycardia and tachypnea are also present) manage with endotracheal intubation, %&t also set&p or possi%le tracheostomy) pre-vaccination it was ca&sed %y H. in!uenzae type b (hi%$ respiratory distress syndrome hyaline membrane disease $ is a respiratory syndrome ca&sed %y immat&re l&ngs and s&ractant de1ciency) most important risk actor or #! is premat&rity) other risk actors incl&de male se4, c-section witho&t la%or, perinatal asphy4ia, and maternal dia%etes) c4r will show dif&se retic&logran&lar pattern and air %ronchograms) presents with tachypnea, retractions, and physical e4am will show signs o distress (gr&nting, retractions, tachypnea, nasal Laring, cyanosis$ bacterial sinusitis presents with nasal drainage, congestion, cough) patients appear ill and have high evers 3 ;C*9+)+/ and purulent nasal discharge) the most common predisposing factor or ac&te %acterial sin&sitis is a %iral Q>*) contaminating %acteria cannot %e cleared %y m&cociliary clearance d&e to m&cosal inLammation rom viral inection, leading to secondary %acterial inection) (S. pneumoniae" H. in!uenza" M. catarrhalis$ acute otitis media can present with boggy nasal mucosa and post-nasal drip) ear-drainage and diculty hearing are highly suggesti%e of acute otitis
media) con1rm with otoscopic examination which typically reveals erythema, retraction, or decreased mobility of the tympanic membrane ) congenital rubella inection maniests as 8.#, deafness, cardiac malformations (A, A!$, micropthalmia, cataracts, retinopathy, hepatosplenomegaly, thrombocytopenia, and CNS involvement) chronic inection may res< in growth retardation, radiol¢ %one disease, Fa&ndice, throm%ocytopenia and p&rple skin lesions (“ blueberry mun spots”$) classic triad is *$ sensorineural deafness +$ cardiac malformations and $ cataracts de%elopmenta dysplasia of the hip DD"6 is a dislocation o the emoral head rom the acetal%&l&m) %reech presentation, emale se4, white ethnicity, and amily history o 5 increase the risk, most patients have no risk actors) barlow and ortolani mane&vers sho&ld %e perormed to assess Foint sta%ility) ing&inal skin olds sho&ld also %e inspected as e4tension %eyond the anal ori1ce s&ggests dislocation o the ipsilateral emoral head) at age A weeks / months do hip ultrasound) after &-/ months do x-ray of hip ) shows %etter %eca&se o ossi1cation) s;uatting increases systemic peripheral resistance , decreasing the right to let sh&nt, and impro%es the cyanosis of tetralogy of fallot 7o!6 ) tet spells can %e %ro&ght on %y inection, crying, and e4ercise) severe tet spells may precipitate sei'&res and loss o conscio&sness) immediate treatment is administration of oxygen and placing child in a knee-chest position, ollowed %y L&ids, morphine and propanolol) %iral uri are the most common predisposing factor o acute bacterial rhinosinusitis) &ncomplicated ac&te %acterial rhinosin&sitis sho&ld %e treated with oral amoxicillin-cla%ulanic acid ) eat&res incl&de *$ persistent symptoms 3 *9 days witho&t improvement O# +$ severe symptoms (ever3;C*9+/$, p&r&lent nasal discharge, ace pain 3 days, O# $ worsening symptoms 3 < days ater initially improving viral &ri) fetal alcohol syndrome is characteri'ed %y pathognomonic acial dysmorphisms2 B6 small palpebral (ssures A6 smooth philtrum %ertical groo%e abo%e upper lip6 ?6 thin %ermilion border) fragile x has a long narrow ace with large ears and macrocephaly and macroorchidism) infections after / months of age s&ggestive of genetic b-cell de(ciency %eca&se thatHs when maternal anti%ody levels start to drop) predisposed to rec&rrent sinopulmonary infections with encaps&lated organisms like H. in!uenzae and S. pneumoniae) de(ciency in *g+ which inha%its the gastrointestinal tract predisposes to 'iardia infection) patients with SC*D have both 8- and 7- cell de(ciencies and wo&ld get bacterial, fungal and %iral infections as well) digeorge thymic hypoplasia6 is a D-cell de1ciency only, wo&ld get %iral$fungal infections) patients with x-linked agammaglobulinemia (bruton0s agammaglobulinemia$ have low 8 cells cdB4 lymphocytes6 ) patients sho&ld receive intra%enous immunoglobulins) neuro(bromatosis B has cafe-au-lait spots , axillary freckles, lisch nodules o the iris, neuro(bromas and bony lesions) sturge weber has port wine stains in ,B face region , angiomatous malformations of the brain , seizures, hemiparesis tuberous sclerosis has ash leaf hypopigmentation, cardiac rhabdomyomas, kidney angioleiomyomas , mental retardation, retinal hamartomas, and seizures) do guthrie test coloration $ to detect the presence o metabolic products of phenylalanine in the &rine) phenylketonuria has a phenylalanine hydro4ylase
de1ciency, leads to the accumulation of phenylalanine) &rine will have a mousy odor , and will %e fair skinned) friedreich ataxia is a&tosomal recessive condition characteri'ed %y e4cessive trin&cleotide repeat seK&ences) associated with necrosis and degeneration of cardiac muscle (bers leading to myocarditis, myocardial (brosis , and cardiomyopathy) 7-wa%e in%ersion2 myocardial inarction, myocarditis, old pericarditis, myocardial cont&sion, digo4in to4icity) sturge-weber syndrome is a neurocutaneous syndrome that is characteri'ed %y a congenital unilateral ca%ernous hemangioma along the trigeminal ner%e distribution and radiographic evidence o intra-cranial calci(cations that resem%le a tramline) seizures are the normal ne&rological presentation) mongolian spot is common among dark skinned races ) the ca&se is entrapment of melanocytes in the dermis d&ring their migration rom the ne&ral crest into the epidermis in etal development) the lesion is a %l&e, %l&ishgray, %l&ish-green or %l&e-%lack, Lat skin markign that &s&ally appears at %irth) mostly located at %ase o spine, lower %ack, and on the %&ttocks) painless rectal bleeding in a yo&ng child is often meckel0s di%erticulum) do a technetium-44m pertechnate scan milk protein intolerance may present with vomiting and bloody diarrhea) stool may show #0Cs and eosinophils and there may %e amily history o an atopic disorder) itHs a hypersensiti%ity reaction to cow0s milk proteins and &s&ally occ&rs in %a%ies who are ed with cows milk) however may occ&r in %reasted %a%ies as the motherHs milk may contain proteins rom ingested cows milk) meconium ileus is characteri'ed %y bilious %omiting, failure to pass meconium at birth, history o polyhydramnios, amily history o cystic 1%rosis, and a ground glass appearance on abdominal xr ) a possi%le complication o meconi&m ie&s is intestinal perforation) i the perforation occurs after birth pneumoperitoneum will %e seen on a%dominal 4r) i it occurs before birth , intraabdominal calci(cations will be seen ) meconi&m pl&g syndrome is the same thing %&t in %a%ies witho&t cystic 1%rosis and intestinal peroration does not occ&r) iron supplementation in the orm o oral erro&s salts or iron orti1ed milk orm&la is warranted in premature infants to pre%ent anemia of prematurity) metatarsus adductus is a congenital oot deormity) most reK&ent in 1rst-%orn inantsR attri%&ted to the molding efect o the primigravid &ter&s) internal ti%ial torsion is also a physiological 1nding in new%orns) reassurance is all that is needed) know when to give reass&rance V tricuspid atresia (no tric&spid valve$ presents with a cyanotic infant with left axis de%iation) a%sent connection %etween the right heart cavities, and a hypoplastic or absent right %entricle) "! (holosystolic m&rm&r$ occ&rs in ;9G o cases) there is left %entricular hypertrophy and since the let ventricle is getting all the %lood rom the right atri&m) %lood goes rom ra --3 la --3 lv --3 rv --3 p&lmonary --3 %ack to la) treatment is .B and balloon atrial septostomy) legg-cal%e-perthes disease is characteri'ed %y osteonecrosis of the femoral head) typically presents in =-*9 yo with insidio&s-onset hip andor knee pain and an antalgic gait) idiopathic avasc&lar necrosis thrombocytopenia with eczema and a history o bacterial infections is characteristic o wiskott-aldrich syndrome (>A!$) decreased platelet production is the primary pathophysiologic cause of thrombocytopenia in patients with was)
idiopathic thrombocytopenic purpura *7.6 is an imm&ne-mediated disorder ca&sed %y antibodies that bind to platelets and facilitate their remo%al from the circulation) preceded %y a viral inection) 7reat *7. with steroids or 8"8. i severe) %on gierke0s disease (type BO glucose-/-phosphatase de(ciency $ is ?-& months o age with hypoglycemia , lactic acidosis , hyperuricemia, and hyperlipidemia) the characteristic is a doll-like face (fat cheeks$, thin extremities, short stature, and a protuberant abdomen (enlarged li%er and kidneys$) hypoglycemic seizures may occ&r) pompe0s disease type AO acid maltase6 have hepatomegaly, and present as a H#oppy babyG with feeding diculties, macroglossia, and heart failure d&e to hypertrophic cardiomyopathy ) type iiiglycogen debranching enzyme, with a similar presentation as type B, however their la% 1ndings difer) they have ele%ated transaminases, fasting ketosis, and normal blood lactate and uric acid concentrations ) splenomegaly %&t normal kidneys) type & is amylopectinosis ) presents in the (rst B< months o lie with hepatosplenomegaly and failure to thri%e) progressi%e cirrhosis o the li%er) ewing0s sarcoma is a highly malignant t&mor o&nd in the lower extremity more oen than &pper) most common sites are metaphysis and diaphysis of femur, ollowed %y ti%ia and h&mer&s) aggresive and mets early to lungs and lymph nodes) white males in their *9s-+9s) patients may initially be diagnosed with osteomyelitis %eca&se o intermittent evers, le&kocytosis, anemia, and elevated !#) %&t radiologically is characteri'ed with a lamellated appearance or Honion skinG periosteal reaction ) lesion is &s&ally lytic, central, and accompanied %y endosteal scalloping ) onion skin appearance is oten ollowed with a moth-eaten or mottled appearance and extension into soft tissue) treatment is s&rgery, radiation, and m<i dr&g chemo) inter%entricular hemorrhage is commonly seen in premature and low birth weight infants) bleeding from the germinal matrix ) incidence o 8"5 is inversely proportional to %irth weight) patients may present with pallor, cyanosis, hypotension, sei'&res, ocal ne&rological signs, bulging or tense fontanelle, apnea, and %radycardia) many cases remain asymptomatic mandating transfontanelle ultrasound for all newborns with predisposing risk factors) children w selective m&tism are ver%al and talkative at home %&t re&se to speak in select settings) erythema toxicum neonaturm is a benign, sel limited condition in new%orns characteri'ed %y an e%anescent rash with red haloes, and eosinophils in the skin lesions) erythemato&s pap&les and vesicles s&rro&nded %y patches o erythema) urine dipstick can be positi%e for protein in B25 of school aged children ) can %e transient, orthostatic, or persistent) transient can %e ca&sed %y ever, e4ercise, sei'&res, stress, vol&me depletion) orthostatic has increased protein when patient is upright that ret&rns to normal when patient is rec&m%ent) i &rinalysis shows no hemat&ria and is otherwise normal repeat dipstick xA ) i negative then itHs transient protein&ria) &s&ally %enign condition) i protein&ria persists then take to pediatric nephrologist) maternal 58" inection is a%sol&te contraindication to %reasteeding) hospitali'e patients with anore4ia nervosa when there is evidence o medical complications (amenorrhea$ andor when they weigh M F'5 of a%g body weight for age sex and height )
Scarlet fe%er ca&sed %y group a streptococcus S. pyogenes$ that makes erythrogenic exotoxins) may follow strep pharyngitis , wound infections, %&rns, or strep skin infection) ever, chills, abdominal pain, pharyngitis) the rash initially appears on the neck , axillae, and groin within BA &< hours and generalizes within A& hours) p&nctate or (nely papular texture which is sometimes readily palpa%le “ sandpaper like”) pharynx is erythematous swollen and may have gray-white exudates) area aro&nd mouth appears pale in comparison with the extremely red cheeks giving the appearance o “circumoral pallor” slipped capital femoral epiphysis is characteri'ed %y displacement of femoral head on the femoral neck d&e to disr&ption o the pro4imal emoral growth plate) seen in obese adolescent boys ) groin or knee pain and limping) as the hip is Le4ed the thigh goes into e4ternal rotation) knee pain is also a common presentation) treat with surgical pinning of the slipped epiphysis in order to decrease the risk of a%ascular necrosis ) medulloblastoma is the + nd most common inratentorial t&mor in children and arises from the %ermis ) posterior %ermis syndrome ca&ses truncal dysataxia) characteristic eat&res o neuro(bromatosis B lisch spots in eyes incl&de cafe-au-lait spots , macrocephaly, eeding pro%lems, short stature and learning disabilities) patients may later develop 1%romas, ne&ro1%romas or diferent t&mors) neuro(bromatosis type A has bilateral acoustic neuromas and cataracts) >eye syndrome micro%esicular changes6 is seen in children : *< years old who were treated with salicylates or a viral inection) hyperammonemia, normal or slightly elevated %ilir&%in and AB, prolonged D, hypoglycemia, and moderate to se%ere ele%ations in +S7$+L7$LD" ) croup is ca&sed %y parain#uenza %irus and commonly presents in children : with hoarseness, a barking cough,, and varying degrees o respiratory distress) lateral 4r shows ( steeple sign$ subglottic narrowing) give nebulized epinephrine c is a%ove e in alpha%et) steeple (the top o %&ilding$ is a%ove th&m% (seen in epiglottitis$ turner syndrome sho&ld %e considered in new%orns with a we%%ed neck, high palate, short o&rth metacarpal and nail dysplasia) lymphedema reK&ently occ&rs d&e to abnormal de%elopment of the lymphatic system3 all patients with a cla%icular fracture sho&ld have a care&l ne&rovasc&lar e4amination to r&le o&t inF&ry to the &nderlying brachial plexus and subcla%ian artery) midshat ract&re E radial nerve epicondylar ract&re E %rachial artery anterior sho&lder dislocation E a4illary nerve clubfoot is initially managed with stretching and manipulation o the oot, followed by serial plaster casts malleable splints, or taping) surgical treatment is indicated i conservative management gives &nsatisactory res<s and is preera%ly perormed between ?-/ months of age ) emale inants : months o age sometimes develop vaginal spotting or %leeding) maternal estrogens crossing placenta entering etal %loodstream ca&sing a p&%ertal efect in the new%orn which disappears when the hormone is cleared rom the inants circ&lation) i have a high lead on 1ngerstick, do ser&m testing to con1rm or lead poisoning) inant with ail&re to thrive, bilateral cataracts, Fa&ndice, hypoglycemia and hepato$splenomegaly most likely has galactosemia) ca&sed %y galactose-Bphosphate uridyl transerase de1ciency, leading to elevated levels o galactose) alactokinase de(ciency W only cataracts respiratory syncytial %irus inection may increase the risk of asthma later in lie) #!" ca&ses %ronchiolitis)
in pyloric stenosis a mass will not always be palpable ) do <raso&nd of the abdomen to esta%lish diagnosis in an inant who is having projectile %omiting that is non %ilio&s) niemann-pick0s diseasesphingomyelinase) presents with hypotonia, hepatosplenomegaly, cervical lymphadenopathy, protruding abdomen and a Xcherry red spot0 on retinal e4amination) tay sachs disease hexosaminidase + ) characteri'ed %y hyperacusis, hyperreLe4ia, M#, seizures, cherry red macula, %&t not hepatosplenomegaly or cervical lymphadenopathy) glucocerebrosidase de(ciencygaucher0s disease) hepatosplenomegaly, anemia, leukopenia, and thrombocytopenia, %&t no cherry red mac&la) galactocerebrosidasekrabbe0s disease ) hyperacusis, irrita%ility and seizures) (the gHs donHt have cherry red mac&la) 6iemann picks his nose so he has hepatosplenomegaly$ in chronic granulomatous disease there is a de(ciency o the N+D." oxidase enzyme so yo& get rec&rrent inections o catalase1 organisms 2 S. aureus, Serratia, Bur("olderia, )lebsiella, 6eisseria, candida, pse&domonas, nocardia, D0, cepacia, diphtheria, *spergillus) most common clinical 1ndings are lymphadenopathy, hypergammaglobulinemia, hepatosplenomegaly, anemia o chronic disease, chronic diarrhea, gingivitis and dermatitis) the diagnosis can %e made %y the nitroblue tetrazolium nbt6 test which will %e negati%e abnormal6) treatment is tmp-smx prophyla4is and gamma-interferon) 0one marrow transplant can %e c&rative )ccune-+lbright syndrome is a rare condition characteri'ed %y *$ precocious puberty, +$ cafe au lait spots and $ multiple bone defects (polyostotic (brous dysplasia$) may %e associated with other endocrine a%normalities like hyperthyroidism, prolactin" secreting pituitary adenomas , adrenal hypercortisolism) three s2 precocio&s p&%erty, pigmentation, polyostotic 1%ro&s dysplasia bed wetting is normal upto & - ' years ) ater that &se %ed alarms, and then desmopressin
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pseudodementia in elderly patients with severe depression) treatment is SS>* inK&ire a%o&t stressors in hypochondriacs N)S has ever, encephalopathy, autonomic instability, very high CK rigidity, &se bromocriptine or dantrolene) alcohol withdrawal has hallucinations, hypertension, hyperthermia, agitation) treat with long acting benzodiazepines s&ch as chlordiazepoxide Librium6) &se !!#8 as 1rst line treatment or OC (Do&retteHs is associated with it$ schi'ophrenia has = types *$ paranoid (del&sions and hall&cinations$ +$ disorganized (early onset and worst prognosis, wears weird hats, disinhi%ited %ehavior$ $ catatonic (st&porrigidity, %&t can also %e highly e4cited and
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1gitidy$ =$ undierentiated and residual (mostly negative symptoms$ when they are no longer actively psychotic) Ac&te pyschosis2 treat with 8M olan'apine (less side efects than 5aldol$ or 'iprasidone Bong acting inFecta%le2 &se risperidone or panic attacks &se benzodiazepine or acute treatment, and SS>* or long-term relief ) delayed sleep phase syndrome is a circadian rhythm disorder characteri'ed %y ina%ility to all asleep at normal %edtimes) all asleep late) lithium toxicity presents with tremor, hyperre#exia, ataxia, seizures) phenytoin toxicity presents with horizontal nystagmus, cerebellar ataxia, and confusion) %en'odia'epine overdose does not have nystagm&s) restless leg syndrome presents with &ncomorta%le sensation in the legs alleviated %y moving yo&r legs (can happen at night where yo& canHt all asleep$) treated with dopamine agonists (pramipexoleropinerole$ in altruism there is no o%ercompensation o the persons response with the opposite reaction o how they act&ally eel) reaction formation is the complete opposite response o what they act&ally eel, %&t in altr&ism they wish to help people in a positive way) when patients ha%e renal dysfunction &se carbamazepine or %alproic acid instead o lithi&m for bipolar disorder ) antipsychotic meds like risperdone are dopamine antagonists and can ca&se hyperprolactinemia, leading to symptoms s&ch as galactorrhea, gynecomastia, menstr&al dys&nction, and decreased li%ido) olanzapine can %e &sed or long-term maintenance o bipolar disordermania) haldol can %e &sed or acute mania) (in patients with renal dys&nction &se car%ama'epine or valproic acid$ treatment or adF&stment disorder is cognitive or psychodynamic psychotherapy) the e4trapyramidal side efects o antipsychotics can %e treated with anticholinergics like benztropine) a single manic episode reK&ires long-term maintenance o lithium for a period of at least B yr ) ? or more relapses reK&ires treatment with lifelong maintenance therapy) all atypical antipsychotics (incl&ding olan'apine$ can ca&se weight gain, hyperglycemia, dyslipidemia and hypertension) risperidone (atypical antipsychotic$ is a dopamine and serotonin antagonist that can ca&se weight gain and hyperprolactinemia the latter o which can lead to amenorrhea and galactorrhea) antipsychotics ca&se hyperprolactinemia %y blocking dopamine activity along the tuberoinfundibular pathway) an important side efect o buproprion is decreased seizure threshold) a%sol&tely contraindicated in people with seizure disorders) individ&als with anore4ia or %&limia reK&ently develop electrolyte abnormalities that can precipitate seizures) opioid into4ication presents with miosis, depressed mental stat&s, decreased respiratory rate, decreased %owel so&nds, hypotension, %radycardia) social phobia is %est treated with assertiveness traininggrad&al e4pos&re therapy and an SS>*) risperidone is Bst-line atypical antipsychotic or schi'ophrenia) clo'apine is reserved or patients who have had serio&s side efects rom andor who have not responded to trials o other antipsychotics) atypicals work %y blocking dopamine and '-"7A receptors and have less ! efects %&t more endocrine efects (dm, weight gain$) clo'apine can ca&se agran&locytosis)
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altered levels o the ne&rotransmitter serotonin play an important role in the development o obsessi%e-compulsi%e disorder ) (ocd is treated with !!#8$ tourette0s syndrome is %est treated with traditional antipsychotics like haloperidol or risperidone atypical antipsychotic6 or pimozide) +D"DO treat with atomoxetine lithium toxicities incl&de2 nephrogenic diabetes insipidus , hypothyroidism, and ebstein0s anomaly in the et&s) SS>*s and SN>*s are the * st line medications or treating generalized anxiety disorder can use 8uspirone and ,enlafaxine6 a%r&pt cessation o a short acting benzodiazepine Janax alprazolam6 is associated with signi1cant withdrawal symptoms s&ch as generalized seizures and confusion) arents are 6OD allowed to re&se lie saving treatment in a child) .o get a co&rt order or those assholes
p&lmonary lo%ar pne&monia E increased tactile fremitus, bronchial breath sounds, dullness to percussion ple&ral ef&sionhemothora4 E decreased tactile fremitus , decreased breath sounds, dullness to percussion pne&mothora4copd E decreased tactile fremitus , decreased breath sounds , hyperresonant to percussion •
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in C9.D yo& get chronic hypoxemia -3 pulmonary %asoconstriction -3 pulmonary hypertension -3 right %entricular hypertrophy -3 right %entricular failure -3 hepatosplenomegaly$ascites$ele%ated j%p$peripheral edema acute pulmonary embolism ca&ses hypoxia and respiratory alkalosis) se%ere asthma exacerbation will ca&se respiratory acidosis d&e to air trapping and C9A retention) aspirin into4ication ca&ses a mi4ed respiratory alkalosis and meta%olic acidosis) hypoventilation gives respiratory acidosis with high CO+ C9 toxicity ca&ses anion gap meta%olic acidosis lactic acidosis ) decreased delivery o O+ to tiss&es sarcoidosis has anterior &veitis (w%c in anterior cham%er$, hilar adenopathy and retic&lonod&lar in1ltrates, can also ca&se !8A5 +>DS has intrapulmonary shunting, and the hypo4ia is typically refractory to oxygen administration i moderate to high s&spicio&s o "D, do <raso&nd 1rst %eore anti-coag&lation) i low s&spicion (want to r&le o&t$ do d-dimer) i d-dimer is negative yo& can r&le o&t clot) high sensitivity) sn-o&t S. aureus can ca&se post-%iral Q>* necrotizing pulmonary bronchopneumonia with multiple nodular in(ltrates that can ca%itate to cause small abscesses )
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1nger cl&%%ing is not associated with CO) s&spect malignancy in C9.D I (nger clubbing s&%ac&te : -N weeks and chronic 3 N weeks co&gh seen reK&ently in ad<s) *$ postnasal drip +$ .# $ asthma ca&se ;9G o co&gh w no p&lmonary disease) i co&gh ater #8 most likely post nasal drip ) treat with *st gen anti-histamine2 chlorpheniramine in a parapne&monic ef&sion, i the p" M F3A the pro%a%ility is very high that this L&id needs to %e drained, it is an empyema ) glucose M /2 is also an indication or this) laryngeal edema presents with acute-onset dyspnea ) d&e to allergies, similar to asthma attack %&t with dysphagia pulmonary contusion presents with tachypnea tachycardia, and hypoxia) will have decreased breath sounds on the side o the cont&sion) CJ> will re%eal patchy irregular al%eolar in(ltrate) A0. will show hypoxemia) (A#! wo&ld %e %ilateral patchy alveolar in1ltrates$ complications o ventilation with high incl&de2 alveolar damage, tension pne&mothora4 and hypotension) tension pne&mothora4 will present with s&dden onset shortness o %reath, hypotension, tachycardia, tracheal de%iation and unilateral absence of breath sounds ) as%estosis is a pne&moconiosis and presents as dyspnea, digital clubbing and bibasilar end-inspiratory crackles ) can develop cor p&lmonale) CJ> can show pleural pla;ues) will have decreased BCO (interstitial l&ng disease$ in patient with ac&te e4acer%ation o CO which is reractory to management with o4ygen, corticosteroids, %ronchodilators, try non-in%asi%e positi%e pressure %entilation %eore yo& try to int&%ate and mechanically ventilate i the patient is not crashing) normal .C9A indicates a se%ere asthma attack ) it indicates C9A retention %eca&se o airway o%str&ction (air trapping$ andor respiratory m&scle atig&e) also silent l&ngs, cyanosis, and altered sensori&m indicate this) CO+ sho&ld %e low %eca&se o hyperventilation and respiratory alkalosis right atrial pressure @ B2mmhg and systolic press&re 3=9mmhg are &sed to diagnose massi%e .) septic shock has decreased right atrial press&re and warm e4tremities) sarcoid has hilar adenopathy and non-caseating granulomas) treat with steroids) BightHs criteria2 *$ ple&ral proteinser&m protein 3 9)< +$ ple&ral B5ser&m B5 3 9)J $ ple&ral L&id B5 3 + &pper limit o normal or ser&m B5 e4&dative ef&sions are d&e to2 inection, malignancy, p&lmonary em%olism, connective tiss&e disease, and iatrogenic bronchoal%eolar la%age 8+L6 is &se&l or malignancy and opportunistic infections) 3;9G sensitive or C, %&t not as diagnostic in other l&ng diseases like sarcoid, interstitial p&lmonary 1%rosis, or connective tiss&e diseases) car%on mono4ide poisoning presents with headache, na&sea, di''iness and has high hematocrit d&e to no &nloading o o4ygen, so %ody makes more red %lood cells hypersensitivity pne&monitis is inLammation o l&ng parenchyma ca&sed %y antigen e4pos&re) ac&te episodes present with co&gh, %reathlessness, ever, and malaise) chronic exposure can ca&se weight loss, clubbing, and honeycombing of the lung) D42 remove so&rce, sho&ld go away low glucose concentration in exudati%e eusions is d&e to high metabolic acti%ity of leukocytes within the ple&ral L&id) p5 : )+, gl&cose : 9 s&ggests
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empyema or rhe&matic ef&sion) .l&cose val&es o 9-<9 s&ggests malignancy, l&p&s, esophageal r&pt&re, or t%) cardiomyopathy d&e to hemochromatosis can be re%ersed if caught early , however sarcoid, scleroderma and amyloidosis can not) criteria or long term 9A s&pplementation in C9.D patients are2 .a9A M '' , Sa9A M << , hematocrit @'', or e%idence of cor pulmonale ) shown to prolong s&rvival acute exacerbation of C9.D treated with2 inhaled nebulized bronchodilators and systemic steroids) in an ac&te CO e4acer%ation al%eolar hypo%entilation leads to hypoxia and hypercapnia) a%oid sedati%es as they can e4acer%ate alveolar hypoventilation, which can ca&se CO+ retention leading to lethargy, somnolence, sei'&res, coma, and death) anti-pne&mococcal ;uinolones like levoLo4acin or mo4iLo4acin are dr&gs o choice or in-patient treatment o community ac;uired pneumonia ) or o&tpatient therapy &se azithromycin or doxycycline) patients with severe o%esity (0M8 3 <<$ and alveolar hypoventilation d&ring wake&lness have obesity hypo%entilation syndrome (.ickwickian syndrome$) A0. will reveal respiratory acidosis, hypercapnia and hypo4emia) d&e to a conseK&ence o decreased chest wall compliance ) adenocarcinoma o the l&ng has the least association with smoking ) this is the most common type of lung cancer even in smokers) located peripherally and consists o columnar cells growing along the septa ) it presents as a solitary nod&le and may %e detected incidentally) large lung %olumes and diaphragmatic #attening in C9.D make it more dicult to decrease intrathoracic pressure d&ring inhalation and thus increasing the work of breathing) secondary pneumothorax sho&ld %e s&spected in C9.D patients presenting with worsening of their respiratory symptoms and is &s&ally d&e to dilated al%eolar blebs that rupture air into the pleural space ) symptoms incl&de ac&te onset o unilateral chest pain, shortness of breath , and on the aected side breath sounds are markedly reduced and the chest is hyperresonant to percussion) &se lightHs criteria to determine i ple&ral L&id is e4&date or trans&date) then determine i the L&id is complicated or &ncomplicated) complicated #uid has a 1 gram stain , 1 culture, ph M F3A , and glucose M /2 and reK&ires chest tube drainage %eca&se it is &nlikely to resolve spontaneo&sly with anti%iotic therapy) complicated eusions can progress to empyema ) inection (pne&monia$ is a m&ch more likely ca&se o complicated parapne&monic ef&sions than p&lmonary em%olism) the de%elopment of clubbing and sudden-onset joint arthropathy in a chronic smoker is s&ggestive o hypertrophic osteoarthropathy) this condition is oten associated with lung cancer, so do a CW#) massi%e pulmonary embolism leads to syncope, right bundle branch block due to acute right heart strain, F&g&loveno&s distension) right heart strain will progress to right ventric&lar dys&nction, decreased CO, left pump failure, res<ing in bradycardia) res<s in cardiogenic shock and C6! efects like dilated p&pils and &nresponsive mental stat&s) s&spect lung cancer in smokers who present with "orner0s syndrome) do a CW# ca&ses o exudati%e pleural eusion 2 empyema, malignancy, rheumatoid arthritis, esophageal rupture, pancreatitis, pulmonary infarction, and tuberculosis) only 78 is associated with a %ery high total protein @ &g$dl )
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tension pne&mothora4 has lack o %reath so&nds on one side, tracheal deviation to the opposite side) leads to rapid development o hypotension %eca&se o high intrathoracic pressures decreasing %enous returndecreasing preload) treatment consists o placing a large-bore needle in the A nd intercostal space in mid-cla%icular line o the afected side to rapidly decompress the pne&mothora4 and improve veno&s ret&rn) know how to identiy tension pneumo on CW#) faint white line %isceral pleura$ near the midline %eyond which no p&lmonary vasc&lat&re or l&ng parenchymal markings are apparent) also &s&ally #attening of the ipsilateral hemidiaphragm) hemothorax and pleural eusion have similar appearances on c4r2 blunting of costophrenic angle and opacify the entire ipsilateral chest) apical lung tumor in thoracic inlet can compress cervical and thoracic nerve roots that contri%&te to the ulnar ner%e ca&sing pain, numbness, and weakness in ipsilateral arm ) (look or radioopaK&e lesion in the ape4$ granulomatosis with polyangiits wegener0s6 is a orm o granulomatous %asculitis) renal and pulmonary symptoms are seen with goodpasture0s and wegener0s %&t upper airway and sinus are only seen with the latter ) can have systemic symptoms o weight loss, anore4ia, and arthralgias as well) churgstrauss has asthma and eosinophilia) in a patient with rapid ongoing massi%e hemoptysis 3*99-J99ml in a +=ho&r period, intubate the patient to protect the airway and place the %leeding l&ng in the dependent position to preserve gas e4change in the non-%leeding l&ng) then give L&ids and perorm an emergent %edside %ronchoscopy to %oth vis&ali'e the lesion and control the %leeding) int&%ate ---3 L&ids ---3 %ronchoscopy or %leeding control exudati%e eusions are ca&sed %y increased capillary permeability) trans&dates are ca&sed %y increased hydrostatic or decreased oncotic pressure) patients with obstructi%e sleep apnea have episodes o short-term hypo4emia which is sensed %y the kidneys and stimulates erythropoietin production) this drives creation o more #0Cs and res<s in polycythemia) chronic and rec&rrent co&gh with mucopurulent expectoration most likely d&e to bronchiectasis) will have rec&rrent inections prod&cing co&gh responding to anti%iotics) chronic bronchitis has non-purulent expectoration) highresolution C7 of the chest is the %est imaging modality or diagnosing bronchiectasis) criteria or asthmamild intermittent2 daytime symptoms : +week, nighttime awakenings :+ month, no limit on daily activites treatment is prn al%<erol mild persistent2 symptoms 3 + daysweek %&t not daily, nighttime awakenings -=month, minor limit on AB treatment is prn al%&terol I inhaled corticosteroid moderate persistent2 daily symptoms, weekly nighttime awakenings, moderate limit on AB and /"* J9-N9G treatment2 daily inhaled corticosteroid or cromolyn$nedocromil or methylxanthine or antileukotriene se%ere persistent2 symptoms thro&gho&t the day, reK&ent nighttime awakenings, e4tremely limited ABs, /"* :J9G treatment2 long acting %etaagonist and high-dose inhaled corticosteroids and systemic corticosteroid emphysema is a pathological diagnosis characteri'ed %y permanent and destructi%e enlargement of airspaces distal to the terminal bronchioles with loss o normal architect&re) patients are generally severe and dyspneic pink puers$ and have hyperinLation o the chest, decreased vasc&lar markings, decreased DLC9 (d&e to destr&ction o alveoli$) panacinar
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emphysema is typical or alpha-B-antitrypsin de(ciency ) centriacinar is more characteristic or CO) DLC9 is normal in chronic bronchitis) chronic %ronchitis is a clinical diagnosis o chronic prod&ctive co&gh or at least months over + consec&tive years) most common adverse efect o inhaled corticosteroid therapy is oropharyngeal thrush (oral candidiasis$ ever, con&sion, decreased ood intake, and Ic<&res points toward sepsis) sepsis can cause +>DS ) A#! ca&ses hypoxemia refractory to high inspired oxygen concentrations ) adeK&ate o4ygenation in A#! oten reK&ires positive end-e4piratory press&re ( ..$ delivered via mechanical ventilation) try to keep inspired 9A below &25 ) tension pneumothorax presents with decreased %reath so&nds, tachypnea, tracheal deviation) treat with needle thoracostomy emergently) o%esity hypoventilation syndrome (O5!$ is a long-term conseK&ence o severe o%esity and &ntreated o%str&ctive sleep apnea) chronic hypercapnichypo4ic respiratory ail&re, secondary erythrocytosis, and p&lmonary hypertension) will have respiratory acidosis , leading to an increased bicarbonate retention and decreased chloride reabsoprtion in a compensatory efort to maintain a normal p5) a (xed upper airway obstrution (s&ch as laryngeal edema$ will show a distincti%e #ow-%olume loop ) there is a #ow limitation with both inspiration (%elow the hori'ontal line$ and expiration (a%ove the hori'ontal line$) looks like an oval sideways) %$; mismatch ca&sed %y2 pulmonary embolism, obstructi%e lung disease, atelectasis, pulmonary edema, pneumonia) shunt ca&sed %y intracardiac shunt ,SD6) shunt doesnt get better with 9A ) (n in sh& nt and n in not %etter$ they both ha%e increased +-a gradient ) hypoventilation and decreased inspired O+ do not ca&se an increased A-a gradient) in a steady resting state the respiratory K&otient (#S$ near *)9 s&ggests car%s are the maFor n&trient %eing o4idi'ed) when the ratio rises itHs d&e to e4cess car%s) protein gives #S o 9)N and ats gives 9) solids in the l&ng make so&nds travel aster so consolidation (lo%ar pne&monia$ has increased tactile remit&s) air or L&id o&tside the l&ng interr&pts this transmission o so&nd) patients with consolidated l&ngs have %ronchial %reath so&nds d&e to over-transmission o so&nd over the chest wall) %reath so&nds are a%sent or diminished over ple&ral ef&sion, pne&mothora4 and CO) moving rom s&pine to sitting can increase the !>C by A2 ?'53 increasing the /#C can help pre%ent post-op atelectasis ) inhaled anti-muscarinic agents s&ch as ipratropium are the mainstay o symptom management in C9.D) lung consolidation ca&ses bronchial breath sounds, d&llness to perc&ssion, increased remit&s, %ronchophony, egophony, and whispered pectoriloK&y on physical e4am) %ronchial %reath so&nds have a &ll e4ipratory phase) aspiration pneumonia has foul-smelling sputum and is ca&sed %y excessi%e alcohol intake) other risk actors are altered conscio&sness, dysphagia, ne&rologic disorders, and sedative proced&res) ca&ses o restricti%e lung diseases incl&de interstitial lung disease, neuromuscular disease, al%eolar edema , pleural (brosis and chest wall abnormalities3 restrictive pattern may %e ca&sed %y ankylosing spondylitis) inLammation leads to fusion of the costo%ertebral joints res<ing in restriction o chest wall motion) will have normal or increased /#C d&e to (xation of the chest wall in an inspiratory position )
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the ne4t step in investigational step o a solitary pulmonary nodule detected on CJ> is &s&ally a C7 scan) i CD is s&spicio&s or malignancy or indeterminate then do further in%estigation with a biopsy or .7 scan) carbon monoxide poisoning presents with headache, na&sea, a%dominal discomort) pinkish-red skin h&e is noted on e4amination and diagnosis is con1rmed %y carboxyhemoglobin le%els ) in ventilated patients respiratory alkalosis can res< rom hyperventilation) i the tidal vol&me is appropriate (J mgkl o %ody weight$ the respiratory rate should be lowered ) red&cing the tidal vol&me can trigger increased ventilatory rate) C9.D can lead to cor pulmonale3 will have ele%ated I,., hepatomegaly and peripheral edema with clear lung sounds) loop di&retics are oten &sed to lower right ventric&lar 1lling vol&mes and reduce peripheral edema (in patients with CO e4acer%ations$) loop diuretics can ca&se decreased C9 in patients with cor p&lmonale, leading to pre-renal azotemia (elevated 06Cr$ and %icar%onate will go down secondary to a meta%olic acidosis rom &remia lambert eaton can %e associated with small cell carcinoma of the lung ) a&toanti%odies to presynaptic voltage gated calci&m channels) +>DS patients typically are given .. and high !i9A <25ish6 %&t then the ventilator settings sho&ld %e adF&sted to decrease !i9A to nontoxic %alues ? slowly lower %elow J9G the +-a gradient is increased in interstitial lung disease d&e to reduced diusion capacity and ,$= mismatch) CW# in idiopathic pulmonary (brosis (8/$ will show airway (brosis giving a “ honeycombG pattern, and pulmonary %ascular congestion most evident in the hil&m) &se lights criteria to determine i trans&date or e4&date) ph of F3?' is consistent with transudati%e pleural eusion) pleural pla;ues are seen in <9G o as%estosis cases on W#) helps to disting&ish rom other cases o p&lmonary 1%rosis) most common malignancy in as%estosis is bronchogenic carcinoma) pleural mesothelioma can also occ&r d&e to as%estosis e4pos&re %&t it has a lower incidence and occurs in the pleura, not in the l&ng 1elds)
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pain relief and respiratory support are important in rib fracture trauma to pre%ent hypo%entilation and atelectasis %l&nt a%dominal tra&ma can ca&se splenic injury) let sho&lder pain (reerred rom diaphragm, kehrs sign$) do abdominal ct with contrast rhinoplasty can ca&se nasal septum perforation leading to a whistling noise while breathing) in %l&nt a%dominal tra&ma i hemodynamically unstable, do #uid resuscitation and ultrasound (/A!D$) i blood found intra-peritoneally on /A!D then do laparotomy) post-operative atelectasis has hypoxemia and respiratory alkalosis (hyperventilation, not deep eno&gh %reathings$
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inLammation o diaphragm and peritonitis reers to the &pper let sho&lder post-op cholestasis happens in s&rgeries with hypotension and blood transfusions) *$ increased pigment load d&e to the trans&sion +$ decreased liver &nction d&e to hypotension $ decreased renal %ilir&%in e4cretion %eca&se o t&%&lar necrosis) +S7$+L7 normal or only mildly elevated) +L. can be high pilonidal cyst is ac&te pain and swelling o the midline sacrococcygeal and subcutaneous tissues) when patient has blunt abdominal trauma (0AD$ 1rst step is to determine i need e4ploratory laparotomy) assess or intraperitoneal ree L&idhemorrhage with !+S7 (oc&sed assessment with sonography$ scaphoid fracture has pain in anatomical snubox ) can take &p to *9 days to show ract&re on 4-ray i compressed or minimally displaced) s&pracondylar ract&re o h&mer&s can lead to ac&te compartment syndrome) common in yo&ng children alling on o&tstretched hand) pain, pallor, p&lselessness, paralysis, paresthesias) %olkmannEs ischemic contracture is the 1nal seK&ence o comparment syndrome where dead muscle has %een replaced with (brous tissue to ;uickly re%erse warfarinEs eects gi%e !!. ) &sed in need o s&rgery) %itamin k wo&ld take too long %eca&se it works via post-translational modi(cations) prolonged placement o central line can lead to subcla%ian %ein thrombosis ) Dhe patient will have a swollen and pale arm) remove catheter and do d&ple4 ca&ses o ever post-op are the < >s *$ wind (pne&moniaatelectasis$ *-+ days +$ water D8 -< days $ walking "D =-J days =$ wo&nd <- days <$ wonder medications 3 days dehydrated and elderly post op patients are prone to acute bacterial parotitis presenting with pain&l swelling o involved parotid gland, aggravated %y chewing) most common inectio&s agent is S. aureus) to prevent this complication do adeK&ate hydration and oral hygiene) motor vehicle accident ca&ses splenic rupture) will %e hypotensi%e, tachycardic, and have abdominal wall ecchymoses ) or upper gastrointestinal bleed that is ongoing &se packed >8C transfusion) in patient with heart disease a hgb @ B2 should be maintained meniscal tears in the knee associated with a popping sensation) s&%seK&ent Foin swelling develops grad&ally in conrast to a ligamentous tear which is a rapid joint swelling d&e to hemarthrosis) in patients with li%er dysfunction and renal dysfunction &se atracurium %eca&se it is spontaneo&sly hydroly'ed in the plasma) succinylcholine may ca&se hyperkalemia and apnea in patients with renal dysfunction) in pulmonary contusion patients develop hypoxia and respiratory distress ho&rs later ater p&lmonary edema has set in 3 if gi%en lots of *, #uids this may happen ;uicker ) CJ> will show patchy, irregular al%eolar in(ltrates3 transtentorial herniation of the uncus can occ&r d&ring head tra&ma and leads to ipsilateral hemiparesis, ipsilateral mydriasis and strabismus, contralateral hemianopsia, and altered mentation) acute ruptured appendicitis can ca&se pel%ic abscess ) typically presents as lower a%dominal pain, malaise, low-grade ever, and tender pel%ic mass on rectal examination)
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post-op atelectasis is a common s&rgical complication res<ing rom shallow breathing and weak cough due to pain ) most common on days +- ollowing a%dominalthoracoa%dominal s&rgery) weak co&gh predisposes to small airway m&co&s pl&gging and shallow %reathing limit recr&itment o alveoli at l&ng %ases) will %e hypo4emic and have respiratory alkalosis) 8n a patient with minor head tra&ma with loss o conscio&sness, the patient can %e discharged i CD is normal) T&st monitor or signs o altered mental stat&s at home all tra&ma patients with suspected spinal injuries sho&ld %e hemodynamically sta%ili'ed and have a sec&re airway and then have a urinary catheter placed to assess for urinary retention) all hemodynamically &nsta%le patients with penetrating abdominal trauma m&st &ndergo immediate exploratory laparotomy to diagnose and treat so&rce o %leeding as well as to diagnose and treat peroration o any a%dominal visc&s in an efort to prevent sepsis) circ&merential &ll-thickness %&rn involving e4tremities may ca&se an eschar to orm, and escharotomy may %e necessary to prevent vasc&lar compromise) will have compartment syndrome presenting like arterial throm%osis) (pallor, paresthesia, pain, p&lseless$ at em%olism presents with dyspnea, con&sion, and petechiae in the upper part of the body and occ&rs ater long %one ract&res) #ail chest is ca&sed %y three or more adFacent rib fractures that %reak into two places and create an &nsta%le chest wall segment that mo%es in a paradoxical motion with respiration) patients with Lail chest will remain tachypneic and hypotensi%e despite continuous #uid resuscitation ) peripheral artery aneurysms maniest as a pulsatile mass that can compress adjacent structures and res< in throm%osis and ischemia) popliteal and femoral artery ane&rysms are the most common peripheral artery ane&rysms) fe%er with chills and deep abdominal pain s&ggests a retroperitoneal abscess) blunt abdominal trauma can compress neck%ody o pancreas ca&sing retroperitoneal abscess or pseudocyst) a%dominal CD scans done early may ail to detect a pancreatic inF&ry) !plenic inF&ry wo&ld %e seen on CD, and delayed splenic r&pt&re wo&ld ca&se BS a%dominal pain and hypotension %&t no septic signs (ever$) gastric peroration more likely in penetrating (instead o %l&nt$ tra&ma and wo&ld show free air under diaphragm) blunt aortic injury has mediastinal widening on CW#) de%iation of the trachea or nasogastric t&%e to the right, or depression o the let main stem %ronch&s may also %e seen) signs o necrotizing surgical infection are intense pain in wo&nd, ever, hypotension and tachycardia, decreased sensitivity at edges o wo&nd, cloudygray discharge, subcutaneous gas with crepitus ) treatment is early surgical exploration to assess e4tent o process and debride the necrotized tissue) positi%e pressure mechanical %entilation increases intrathoracic pressure, which decreases %enous return to the heart and decreased preload) in patients with hypo%olemic shock this may cause circulatory collapse i the patients intravasc&lar vol&me is not replaced %eore mechanical ventilation is attempted) patients s&fering rom rapid deceleration %l&nt chest tra&ma are at high risk for aortic injury) 1ndings s&ggestive o aortic inF&ry incl&de a widened mediastinum, large left-sided hemothorax , de%iation of mediastinum and disr&ption o normal aortic conto&r) diagnose with C7 scan and treat with anti hypertensi%e therapy (rst line is 8eta 8lockers6 )
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patients can get high-o&tp&t heart ail&re rom arterio%enous (stulas) symptomatic A"/ creates an a%normal connection %etween the arterial and veno&s system that %ypasses capillary %eds) shunting of a large amount of blood through the (stula decreases systemic vasc&lar resistance increases cardiac preload , and increases cardiac output ) widened p&lse press&re, strong peripheral arterial pulsation (%risk carotid &pstroke$, systolic Low m&rm&r, tachycardia, and #ushed extremities) the let ventricle %ecomes hypertrophied and point o ma4imal imp&lse is displaced to the let) ischemia-reperfusion syndrome is a form of compartment syndrome ) ater &-/ hours of ischemia tissues can s&fer %oth intracellular and interstitial edema &pon reperfusion) when the e4tremities are invovled this creates a risk or compartment syndrome) compartment syndrome is de1ned as an increase in press&re within an enclosed ascial space ca&sing ischemia o m&scles and nerves) patients will have severe pain that is o&t o proportion to the physical e4am 1ndings and can %e remem%ered %y the < s2 pain, paresthesia, pallor, p&lselessness, paresisparalysis) in case o amp&tation inF&ry, amp&tated parts sho&ld %e wrapped in salinemoistened gauze, sealed in a plastic %ag, placed on ice, and %ro&ght into the ) in #ail chest, m<iple contig&o&s ri%s are ract&red res<ing in an isolated segment o the thoracic wall that e4hi%its paradoxical motion d&ring normal respiration) the instit&tion o positi%e pressure mechanical %entilation causes the #ail segment to mo%e normally ) pain control and supplemental oxygen are the most important early steps in managing Lail chest) tracheal de%iation can %e ca&sed d&e to opposite-side pneumothorax , hemothorax, or same side lung collapse ) distended neck %eins are d&e to either pneumothorax or cardiac tamponade ) &ntreated tension pneumothorax can lead to pulseless electrical acti%ity (A$ andor asystole) in s&spected tension pne&mothora4 with hemodynamic insta%ility 1rst do immediate needle thoracostomy prior to int&%ation, as positi%e %entilation following intubation usually exacerbates an existing pneumothorax) (same with hypovolemic shock) positive press&re mechanical ventilation decreases preload, decreases CO, so replace vol&me then do "$ most common and eared complication o 7.N is catheter tip infection ) D6 can also ca&se electrolyte a%normalities and meta%olic dist&r%ances) hypokalemia, hypophosphatemia and hypomagnesemia when rapidly given in a chronically nutrionally depri%ed patient) known as refeeding syndrome increase insulin use up all the body0s already low stores of K . )g leading to arrhythmias and death6 esophageal rupture is the most eared complication o esophageal dilation proced&res) patient will have post-procedure chest pain, hematemesis, and shortness of breath ) an accompanying left-sided pleural eusion is common) pneumomediastinum is another typical CJ> (nding and is s&ggestive o mediastinitis which is &s&ally caused by esophageal rupture ) patients who have had gastric bypass surgery have a higher incidence o developing gallstones d&e to an increase in bile concentration ) prophylactic treatment with ursodeoxycholic acid extrahepatic cholestasis can %e ca&sed %y obstruction of the common bile duct %y carcinoma o the head o the pancreas) Dhe patient will have pr&ritis, and Fa&ndice) >C. placement of a C8D stent wo&ld relieve the o%str&ction and cholestasis) i there is no inection o a oot &lcer and does not involve %one, can de%ride the necrotic tiss&e as s&Ucient treatment
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work&p widened mediastinum on CW# with a transesophageal echocardiograph or C7 scan of chest ) when hemorrhage$hypo%olemia occ&rs, tachycardia and peripheral %ascular constriction are the (rst physiological changes3 tension pne&mothora4 is an emergency sit&ation which needs immediate needle thoracostomy) will have rapid onset shortness o %reath, tachycardia, tachypnea, hypotension, and distension o neck veins d&e to s&perior vena cava (!"C$ compression) glasgow coma scale has components) *$ eye opening +$ ver%al response $ motor response in a patient with upper gastrointestinal bleeding who has a depressed level o conscio&sness and ongoing hematemesis, intubate (rst to protect the airway) then endoscopic treatment with band ligation or sclerotherapy to stop %leeding) int&%ate ---3 L&ids ---3 %ronchoscopy early dumping syndrome is a common postgastrectomy complication ) &p to <9G o patietns with partial gastrectomy may e4perience this syndrome) rapid emptying of hypertonic gastric content into the d&oden&m and small intestine) leads to L&id shit rom intravasc&lar space to the small intestine, release o intestinal vasoactive polypeptides, and stim&lation o a&tonomic reLe4es) treat with dietary modi(cation ) persistent pneumothorax and signi1cant air leak ollowing chest t&%e placement in a patient who has s&stained %l&nt chest tra&ma s&ggests tracheobronchial rupture) other 1ndings incl&de pneumomediastinum and subcutaneous emphysema) #accid paralysis after aortic surgery is consistent with spinal cord ischemia with possi%le inarction, a rare complication o vasc&lar s&rgery) the thoracic spinal cord is partic&larly dependent on these radic&lar arteries and the most v&lnera%le to inarction) surgery to repair thoracic and thoracoa%dominal aortic aneurysms is the most common ca&se o spinal cord ischemia and inarction) present with anterior spinal artery syndrome consisting o #accid paralysis, bowel$bladder dysfunction, sexual dysfunction, possi%le hypotension and loss of deep tendon re#exes ) worsening chest pain accompanied %y shortness o %reath, tachycardia and tachypnea after an endoscopy is concerning or iatrogenic esophageal rupture) common radiographic 1ndings incl&de a pleural eusion, pneumomediastinum and pneumothorax) do a water-soluble gastrogra(n6 esophagram to diagnose esophageal perforation ) .astrograUn %eca&se %ari&m will ca&se irritation and possi%le 1%rosis any g&nshot wo&nd %elow = th intercostal is considered to involve the a%domen and reK&ires an exploratory laparotomy in &nsta%le patients) patients with esophageal perforations most commonly present with a cuteonset se%ere substernal pain ) physical e4am sometimes shows subcutaneous emphysema in the neck or a characteristic HcrunchingG sound on auscultation of the heart d&e to mediastinal emphysema hamman0s sign$) chest 4-ray will show air in the paraspinal muscles , a widened mediastinum, pneumomediastinum mediastinal air6 or pleural eusions with or witho&t pne&mothora4) the diagnostic st&dy or esophageal peroration is gastrogra(n-contrast esophagography which will show contrast leakage at the site o the peroration) patients with cervical spine inF&ries sho&ld 1rst have sta%ili'ation o the c-spine) orotracheal intubation with rapid se;uence intubation is the preerred way to esta%lish an airway in an apneic patient with a c-spine inF&ry) acute mediastinitis is a complication o cardiac surgery &s&ally d&e to intraoperative wo&nd contamination) mediastinitis can complicate &p to
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sternotomies) patients typically present post-op with ever, tachycardia, chest pain, le&kocytosis, and sternal wound drainage or purulent discharge) CW# will show a widened mediastinum in non-postoperative mediastinitis %&t this can also %e seen in postoperative mediastinitis ater cardiac s&rgery) postoperative mediastinitis re;uired drainage, surgical debridement and prolonged antibiotic therapy ) a morton neuroma commonly occ&rs in r&nners and is a mechanically ind&ced neuropathic degeneration with symptoms incl&ding n&m%ness and %&rning o the toes, aching, and %&rning in the distal oreoot that radiates orward rom the metatarsal heads to the third and o&rth toes) physical e4am typically shows pain %etween the third and fourth toes on the plantar surface and a clicking sensation (m&lder sign$ when simultaneously palpating this space and sK&ee'ing the metatarsal Foints) treatment involves &sing metatarsal s&pport with padded shoe inserts ) do s&rgery or people where conservative treatment ails) diaphragmatic rupture is more common on the left side %eca&se the right side is protected %y the liver) patients tend to have respiratory distress %eca&se o leakage of the intraabdominal contents into the chest ca&sing compression of the lungs and mediastinal de%iation ) elevation o the hemidiaphragm on CW# might %e the only a%normal 1nding, %&t <raso&nd or CD scan o the chest is sometimes reK&ired i the CW# does not vis&ali'e well) the small %owel is sometimes present in the thoracic cavity) nasogastric tube in pulmonary ca%ity indicates a diaphragmatic hernia) donHt &se succinylcholine in a patient with hyperkalemia or high risk or it (%&rn cr&sh inF&ry patients$ and patients with prolonged demyelination like guillain barre syndrome, or with tumor lysis syndrome -=G o patients with spinal cord injuries will develop post-traumatic syringomyelia) whiplash is oten the inciting inF&ry) symptoms de%elop months to years later ) condition involves enlargement o the central canal of the spinal cord d&e to cere%rospinal L&id retention, res<ing in impaired strength and pain$temperature sensation in upper extremities ) )>* used to diagnose) (same thing as central cord syndromeZ$ compartment syndrome may %e ca&sed %y direct trauma hemorrhage $, prolonged compression of an extremity , or ater re%ascularization of an acutely ischemic limb ) m&scles o the e4tremity are encased in ascial compartments that do not allow or e4pansion o tiss&e) hemorrhage or edema within the m&scles ca&ses increased press&re within the non-distensi%le ascial compartment) this increased press&re intereres with per&sion %y disallowing passage o %lood rom the arterial system into the capillary %eds o the afected m&scles) this event&ally leads to m&scle necrosis) patients with compartment syndrome classicaly complain o severe pain that is worsened on passive range o motion, paresthesias, pallor, and paresis o the afected lim%) pressures @ ?2 mm"g may res< in cessation of blood #ow through the capillaries and sho&ld %e treated emergently by fasciotomy ) acute adrenal insuciency$addison0s can ca&se na&sea, vomiting, abdominal pain, hypoglycemia, and hypotension after a stressful e%ent (s&rgical proced&re$ in a patient who is steroid-dependent (patient with systemic l&p&s erythematos&s$) posterior urethral injury is associated with pelvic ract&res) patients present with %lood at the &rethral meat&s, a high riding prostate, scrotal hematoma, inability to %oid despite sensing an urge to %oid , and a palpa%ly distended %ladder) anterior &rethral inF&ries will not have a high riding prostate) more common with straddle inF&ries)
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air under diaphragm indicates perforated %iscus, a surgical emergency) get a s&rgical cons< or e4ploratory laparotomy) duodenal hematomas most commonly occ&r ater direct blunt abdominal trauma and are more commmon in children) ollowing tra&ma %lood collects between the submucosal and muscular layers of the duodenum ca&sing obstruction) most resolve spontaneo&sly in *-+ weeks and intervention o choice is nasogastric suction and parenteral nutrition) postoperati%e ileus ollows most s&rgeries where the peritoneal cavity is entered) morphine and other opiates compo&nd this pro%lem %y decreasing gastrointestinal motility) signs and symptoms of post-op ileus incl&de na&sea, vomiting, abdominal distention, failure to pass #atus or stool , and hypoacti%e or absent bowel sounds on physical e4am) mechanical bowel obstruction ca&ses hyperacti%e HtinklingG bowel sounds) all patients with smoke inhalation sho&ld %e s&spected to have acute carbon monoxide poisoning and treated with B225 oxygen %ia a nonrebreather facemask ) traumatic rupture of the diaphragm may ollow %l&nt or penetrating tra&ma) W# will show a de%iated mediastinum with a mass in the let lower chest) symptoms may %e chest pain radiating to the sho&lder, shortness o %reath, and a%dominal pain ollowed %y respiratory distress) do a barium swallow or C7 scan with oral contrast ) immediate management o splenic trauma ca&sed %y %l&nt a%dominal inF&ry depends on patients hemodynamic stat&s and response to intraveno&s L&ids) i &nsta%le %&t becomes stable with #uids the ne4t %est step is C7 scan ) i stays unstable after #uids then do exploratory lapaparotomy3 hypotension not responsi%e to #uid administration ollowing tra&ma is s&ggestive o ongoing occult blood loss ) do exploratory laparotomy to (nd bleeding i a%dominal tra&ma in an &nsta%le patient if the !+S7 (oc&sed assessment with sonography or tra&ma$ is inconclusi%e do diagnostic peritoneal la%age (B$, then do laparotomy i deemed necessary %y the B)
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pain with relie o ele%ation of the testicle helps in epididymitis) in testic&lar torsion there is a lack o a cremasteric reLe4) in the treatment o a patient with erectile dys&nction and 05 remem%er to give sildena(l and alpha-blocker at least & hours apart to red&ce risk o hypotension) sildena(l is contraindicated in patients with nitrates) ater diagnosis o solid testic&lar mass has %een made (a painless hard mass in testicle I s&ggestive <raso&nd$ the initial management is orchiectomy, do 6OD do /6A or needle %iopsy (risk o seeding the cancer cells$ in ac&te prostatitis do a c<&re of mid-stream urine sample to direct anti%iotic therapy) donHt massage the prostate as it may lead to %acteremia) urge incontinence is known as o%eracti%e bladder) &ninhi%ited %ladder contractions reerred to as detrusor instability$hyperacti%ity) res<s in invol&ntary leakage o &rine accompanied %y a severe sensation o &rgency)
