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With the recent US Pre rev venti entiv ve Serv Services ices Ta Task sk Force (US USP PST STF) F) guidelines guidelines,, PSA screening rec re commendations hav have become controv contro versial. The USP US PST STF F does not recommend any an y oulation screening using PSA SA,, but the American !ancer Society Socie ty and the American Urologic Urologi cal Association guideli guidelines disagree "ith this re rec commendation ommendation.. #ue #ue to the controv contro vers ersy y, PSA screening should be determined on a case$b y$case basis by b y the hy hysician and atient. Tumor burden is the single most imortant rognostic consideration in the treatment o% atients "ith breast cancer. &t is based on T' staging. A%ter the diagnosis o% a solid testicular mass has been made made,, (a ainless hard mass in testicle suggestiv suggesti ve ultrasound ultrasound)), the initial management is remo val o% the testis and its associated cord cord.. Acute bacterial rostatitis resents resents in a manner similar to other urinary tract in%ections, in%ections, but "ith the addition o% erineal ain, ronounced systemic symtoms (%ever, chills, acute illness), and a tender, boggy rostate on e*amination. Urine culture should be obtained to hel direct antibiotic theray. Anabolic steroid use by a man can roduce in%ertili in%ertility ty by suressing the roduction o% +n +n -, LH, and FSS-.. emember the common causes o% riaism riaism /. Sickle cell disease and leukemia $ usuall usually y in children or adolescents 0. Perineal or genital trauma $ results in laceration o% the ca cav vernous artery artery 1. 'eurogenic lesions $ such as sinal cord in2ury in2ury,, cauda e3uina comress comressiion on,, etc etc.. 4. edications $ such as tra5odone and ra5osin &% a atient resents "ith riaism, riaism, al al" "ays check his medications %irst. This sy s ymtom is o%ten drug$$induced drug induced..The most common drug that causes riaism is ra5osin, ra5osin , although %or the boards,, it is imortant to remember the association o% riaism "ith t razodone boards razodone !horio carcinoma is a metastatic %orm o% gestational trohoblastic disease. disease. &t may may occur a%ter molar regnancy regnancy or normal gestation gestation,, and the lungs are the most %re3uent site o% metastatic sread.. Susect choriocarcinoma in any sread any ostartum "oman "ith ulmonary sy symtoms and multile nodules on chest *$ray *$ra y. An ele elev vated beta h!+ hels to con%irm the diagnosis. diagnosis. Patients "ith non$in%lammatory non$in%lammato ry chronic rostatitis are a%ebrile and hav ha ve irritativ irritative voiding symtoms mtoms..6*ressed rostatic secretions sho" sho " a normal number o% leukoc leukocy/ y/es es and culture o% these secretions is negativ negati ve %or bacteria.
The most common cause o% urina urinary ry r etention etention in elderly elderl y males is an enlarged rostate,, "hich is usually rostate usuall y re rev vealed by by rectal e*amination and characteri5ed by b y a high ostv os tvoid oid residual volume olume.. An absent or decreased decreased Achilles Achilles tendon tendon re%le re%le* * can be a normal %inding in elderl elderly y atients atients.. 7n hysical e*amination, varicoceles tyically mani%est as a so%t mass (8bag o% "orms8) that "orsens "ith standing and 9alsalva maneuvers but decreases "hen suine. Patients may have no symtoms or a dull scrotal ache "hen standing. Potential comlications include in%ertility and testicular atrohy (due to increased
scrotal temerature. The mass does not transilluminate. Ultrasound is the imaging o% choice and may sho" retrograde venous %lo", dilation o% amini%orm le*us veins, and tortuous, anechoic tubular structures ad2acent to the testis. Treatment deends on the atient:s age and desire %or %ertility. 7tions include scrotal suort and nonsteroidal anti $in%lammatory drugs ('SA&#s) or surgical correction. -ydrocele is the accumulation o% %luid around the testis and sermatic cord and bet"een the arietal and visceral layers o% the tunica vaginalis. !ommunicating hydroceles usually resent in in%ancy and are %re3uently reducible but may also increase in si5e "ith the 9alsalva maneuver . 'oncommunicating hydroceles do not usually change in si5e "ith ositional changes. •
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9aricoceles are a tortuous dilation o% the amini%orm venous le*us surrounding the sermatic cord and testis in the scrotum. They usually result %rom le%t renal venous comression bet"een the aorta and suerior mesenteric artery. 6*amination sho"s a so%t le%t$sided scrotal mass (8bag o% "orms8) that "orsens "ith standing and 9alsalva maneuvers but regresses "hen the atient is suine. Antihosholiid antibody syndrome ( APS) is associated "ith a %alse ositive 9d;, rolonged PT&, and thrombocytoenia. APS can romote arterial and venous thromboses and a resultant tendency to"ard sontaneous abortions. Prohyla*is "ith lo" dose asirin and ;W- are recommended to avoid regnancy loss.
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!ushing:s syndrome is caused by corticosteroid e*cess. -yokalemia and hyernatremia are the electrolyte abnormalities most commonly observed. Primary hyerarathyroidism (P-P) or %amilial hyocalciuric hyercalcemia (F--) can cause hyercalcemia secondary to an ele vated or inaroriately 8normal8 arathyroid hormone level. Urinary calcium creatinine clearance ratio is usually ?@.@/ in FHH comared to @.@0 in P-P. The most common cause o% hyernatremia is hyovolemia. ild cases can be treated "ith BC de*trose in @.4BC saline. Severe cases should be initially treated "ith @.DC saline. -yocalcemia can occur during or immediately a%ter surgery in atients undergoing ma2or surgery and re3uiring e*tensive trans%usions. -yeractive dee tendon re%le*es ma y be the initial mani%estation. aid treatment "ith calcium gluconate is necessary in a atient "ith hyerkalemia "ho develos signi%icant 6E+ changes. Further treatment "ith agents such as insulin andor sodium olystyrene sul%onate "ill eventually be necessary as "ell to reduce the serum concentration o% otassium. Acyclovir can cause crystalline nehroathy i% ade3uate hydr ation is not also rovided. 7ne should susect myoglobinuria "henever test results demonstrate a large amount o% blood on urinalysis "ith a relative absence o% =!s on urine microscoy. yoglobinuria is usua#rug induced interstitial nehritis is usually caused by cehalosorins, enicillins, sul%onamides, 'SA&#s,ri%amin, henytoin and allourinol. Patients resent "ith arthralgias, rash, renal %ailure and the urinalysis "ill sho" eosinohiluria.lly caused by rhabdomyolysis, "hich %re3uently leads to acute renal %ailure. ;ong$ter m analgesic use "ith / or more analgesics (eg, nonsteroidal anti$in% lammatory drug such as asir in,can cause chronic kidney disease due to tubulointerstitial nehritis and hematuria due to aillary necrosis.
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!ontrast administration has the otential to cause contrast$induced nehroathy, articularly in atients "ith renal insu%%iciency (!r/ .B) andor diabetes. 'on$ionic contrast agents are associated "ith lo"er incidence o% nehroathy than the older ionic hyerosmolar agents. &n addition to using non$ionic contrast agents,ade3uate &9 hydration and acetylcysteine can decrease the incidence o% nehroathy. #iuretic abuse leads to increased e*cretion o% "ater and electrolytes by the kidneys. #ehydration, "eight loss, orthostatic hyotension as "ell as hyokalemia and hyonatremia result. Urinary sodium and otassium "ill be elevated. Patients "ith eating disorders sometimes abuse diuretics to induce "eight loss. -igh$dose intravenous acyclovir can cause crystallur ia "ith renal tubular obstruction. Administering intr avenous %luids concurrently "ith the dr ug can hel reduce the risk o% acute kidney in2ury.
Tuberculosis is a common cause o% chronic rimary adrenal insu%%iciency (Addison:s disease) in endemicareas. Addison:s disease causes aldosterone de%iciency and resents "ith a non$anion ga and hyerkalemic and hyonatremic metabolic acidosis. !hronic alcoholics tyically resent "ith multile electrolyte abnormalities such as hyokalemia,hyomagnesemia and hyohoshatemia. -yomagnesemia, causes re%ractory hyokalemiaG there%ore it is imortant to correct the magnesium along "ith the otassium levels to be able to correct the electrolyte abnormalities o% such atients. Arter ial - or anion ga is the most reliable indicator o% metabolic recovery in atients "ith diabetic ketoacidosis. 6lderly atients "ith imaired thirst resonse are redisosed to rerenal a5otemia due to intravascular volume deletion and oor renal er%usion. #iuretics "orsen volume deletion. 'onsteroidal anti$in%lammatory drugs and angiotensin //$converting en5yme inhibitors imair the normal hysiologic resonse o% renal arterioles, "orsening glomerular %iltration rate and renal %unction. Simle renal cysts are almost al"ays benign and do not re3uire %urther evaluation. Features concerning %or malignant renal mass include a multilocular mass, ir r egular "alls, thickened setae, and contrast enhancement. enal vein thrombosis is an imortant comlication o% nehrotic syndrome, "hich is most commonly cause by membranous glomerulonehritis in adults. enal translant dys%unction in the early ost$oerative eriod can be e*lained by a variety o% causes,including ureteral obstruction, acute re2ection, cyclosorine to*icity, vascular obstruction, and acute tubular necrosis. adioisotoe scanning, renal ultrasound, &, and renal biosy can be emloyed in conducting a di%%erential diagnosis. Acute re2ection is best treated "ith intravenous steroids. Screening %or bladder cancer is not recommended, even in atients "ho are at risk o% develoing the disease. Severe ain in a atient "ith a mild urinary obstruction, such as =P-, may cause urinary retention due to inability to 9alsalva. The classic %indings in atients "ith amyloidosis are renal amyloid deosits that sho" ale$ green bire%ringence under olari5ed light a%ter staining "ith !ongo red. Asirin into*ication should be susected in a atient "ith the triad o% fev er , tinnitus, and tachynea. Adults "ith asirin to*icity develo a mi*ed resiratory alkalosis and anion ga metabolic acidosis. A normal - in an acid$base disturbance tyically signi%ies a mi*ed resiratory and metabolic acid$base disorder. Gl omerul ar hyperfi hrat i on is the earliest renal abnormality seen in diabetic nehroathy. &t is also the ma2or athohysiologic mechanism o% glomerular in2ury in these atients. Thickening of t he g l omerul ar basement membrane is the %irst change that can be 3uantitated.
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!ardiovascular disease is the most common cause o% death in dialysis atients. &t accounts %or aro*imately B@C o% all deaths in this oulation. !ardiovascular disease is also the most common cause o% death in renal translant atients. -yerkalemia is a medical emergency. Theray involves three stes membrane stabili5ation "ith calcium,shi%ting otassium intracellularly, and decreasing the total body otassium content. &nsulinglucose administration is the 3uickest "ay to decrease the serum otassium concentration. &ntravenous normal (@.DC) saline is re%erred %or treating hyovolemic hyernatremia. The %luid can be s"itched to a hyotonic %luid (BC de*trose in "ater re%er r ed over @.4BC saline) %or % re e "ater sulementation once the atient is euvolemic Uric acid stones are o%ten radiolucent but may be seen on ultrasound or !T scan. They are highly soluble in alkaline urineG alkalini5ation o% the urine to - H.@$H.B "ith oral otassium citrate is the treatment o% choice. The most common renal vascular lesions seen in hyertension are arteriosclerotic lesions o% a%%erent and e%%erent renal arterioles and glomerular caillary tu%ts. #iabetes mellitus nehroathy is characteri5ed by increased e*tracellular matri*, basement membrane thickening, mesangial e*ansion, and %ibrosis
Trimethorim can cause hyerkalemia due to blockade o% the eithelial sodium channel in the collecting tubule. Trimethorim also cometitively inhibits renal tubular creatinine secretion and may cause an arti%icial increase in serum creatinine "ithout a%%ecting the glomerular %iltration rate.. Platelet dys%unction is the most common cause o% abnormal hemostasis in atients "ith !F. PT, PT&, and latelet count are normal. =T is rolonged. ## A9P is usually the treatment o% choice, i% needed. ## A9P increases the release o% %actor 9lll von Willebrand %actor multimers %rom endothelial storage sites. Platelet trans%usion is not indicated because the trans%used latelets 3uickly become inactive. 9olume resuscitation "ith normal saline "ill correct contraction alkalosis. -yokalemia should be treated as "ell. The nehrotic syndrome can result in alterations in liid metabolism. This dysliidemia uts a%%ected atients at increased risk %or accelerated atherosclerosis . This atherosclerotic tendency, along "ith intrinsic hyercoagulability, laces atients "ith nehrotic syndrome at risk %or comlications such as stroke and myocardial in%arction. Patients "ith diabetes %or / @ years can develo diabetic microangioathy, nehroathy, and glomerulosclerosis. isk %actors include oor glycemic control, elevated blood ressure, smoking, increasing age, and ethnicity (eg, A%rican American, e*ican American). !linical %indings include mild to moderate roteinuria and chronic kidney disease "ith elevated creatinine. &n any atient, the - and Pa!@0 are the t"o lab values that r ovide the best icture o% acid$ base statusG the -!@1$ can be calculated %rom these values using the -enderson$ -asselbalch e3uation. et%ormin should not be given to acutely ill atients "ith acute renal %ailure, liver %ailure, or sesis as these conditions increase the risk o% lactic acidosis. Adrenal insu%%iciency and adrenal %ailure are characteri5ed by nonseci%ic symtoms and signs including anore*ia, %atigue, +l comlaints, "eight loss, and hyotension. -yonatremia is the most common associated electrolyte abnormality. -yerkalemia is also common.
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!ontrast$induced nehroathy resents as a transient sike in creatinine "ithin 04 hours o% contrast administration, "ith a return to normal renal %unction "ithin B$I days. Patients "ith diabetes and elevated baseline creatinine are at esecially high risk. Ade3uate &9 hydration "ith isotonic bicarbonate or normal saline and administration o% acetylcysteine hel to minimi5e the risk o% contrast$induced nehroathy. 'ehrotic syndrome is a hyercoagulable condition "hich mani%ests as venous or arterial thrombosis, and even ulmonary embolism. enal vein thrombosis is the most %re3uent mani%estation. !omlications o% nehrotic syndrome include rotein malnutrition, iron$ resistant microcy/ic hyochromic anemia, increased suscetibility to in%ection, and vitamin # de%iciency.
The most common causes o% hyerkalemia include acute or chronic kidney disease, medications, or disorders imairing the renin$angiotensin a*is. !ommon o%%ending medications include nonselective betaadrenergic blockers, otassium$saring diuretics (eg, triamterene), angiotensin$converting$en5yme inhibitors,angiotensin && recetor blockers, and nonsteroidal anti$in% lammatory drugs. =ased on urinary chloride levels and e*tracellular %luid volume status, metabolic alkalosis can be classi%ied as saline$resonsive and saline$unresonsive. Saline$resonsive metabolic alkalosis is associated "ith lo" urinary chloride e*cretion and volume contraction, and corrects "ith saline in%usion alone.Saline$unresonsive metabolic alkalosis tyically resents "ith urinary chloride 0@ m63;. ethyl alcohol oisoning can cause visual changes (::sno"%ield vision8) and acute ancreatitis, but "ill not cause urine crystals and renal %ailure. !alcium o*alate crystals (rectangular , enveloe$shaed crystals) are seen in atients "ith ethylene glycol (anti$%ree5e) oisoning. 6thylene glycol, methanol and ethanol into*ication cause metabolic acidosis "ith both an anion ga and an osmolar ga. The most common causes o% hyerkalemia include acute or chronic kidney disease, medications, or disorders imairing the renin$angiotensin a*is. !ommon o%%ending medications include nonselective betaadrenergic blockers, otassium$saring diuretics (eg, amiloride), angiotensin$converting$en5yme inhibitors,angiotensin && recetor blockers, and nonsteroidal anti$in%lammatory drugs. Autosomal dominant olycystic kidney disease is a otential cause o% hyertension. -eatic cysts are the most common e*trarenal mani%estations. &ntracranial ber ry aneurysms are seen in B to /@ C o% the cases. Although such aneurysms are common and dangerous "hen couled "ith hyertension, routine screening %or intracranial aneu rysms is not recommended. -ydration is the cornerstone o% theray %or renal stone disease. A detailed metabolic evaluation is not needed "hen a atient resents "ith his %irst renal stone.
Ureteral calculi may cause %lank or abdominal ain radiating to the erineum, o%ten "ith nausea and vomiting.Ultrasonograhy or a noncontrast siral !T scan o% the abdomen and elvis are the imaging modalities o% choice to con%irm the diagnosis. Ultrasonograhy is re%erred in regnant atients to reduce radiation e*osure.
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embranoroli%erative glomerulonehritis, tye 0, is a uni3ue glomeruloathy that is caused by ersistent activation o% the alternative comlement ath"ay. -yonatremia can be classi%ied according to the atient:s volume status (hyovolemic, euvolemic hyervolemic). -yovolemia increases the activity o% the renin$angiotensin$ aldosterone and symathetic nervous systems, and stimulates antidiuretic hormone ( A#-) release %rom the ituitary. The elevated A#- increases renal "ater reabsortion to cause hyonatremia until correction o% the hyovolemia. Pulmonary$renal syndromes include a variety o% disorders "ith simultaneous involvement o% the lung and kidney. Juick di%%erential diagnosis is imortant because the management di%%ers er disease. 6mergency lasmaheresis is re3uired in atients "ith +oodasture:s syndrome. +ranulomatosis "ith olyangiitis (Wegener:s) is treated "ith a combination o% cyclohoshamide and steroids. 7bstructive uroathy causes %lank ain, lo" volume voids "ith or "ithout occasional high volume voids, and (i% bilateral) renal dys%unction. Succinylcholine is a deolari5ing neuromuscular blocker that can cause li%e$threatening hyerkalemia. &t should not be used in atients "ith or at high risk %or hyerkalemia, such as burn and crush in2ury atients and atients "ith rolonged demyelination.
Transrectal ultrasound o% the rostate is an outatient rocedure to hel guide rostate biosyG it is indicated in atients "ith rostate nodules or ersistently elevated PSA o% 4 ngdl. !urrent guidelines recommend evaluating all atients "ith robable benign rostatic hyerlasia based on history and rectal e*amination "ith a urinalysis to assess %or urinary in%ection and hematuria. Patients "ith li%e e*ectancy /@ years should also have rostate$seci%ic antigen measured to screen %or rostate cancer . •
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easures to revent urinary calcium stone %ormation include increasing %luid intake , %ollo"ing a lo"$sodium, lo"$rotein diet, maintaining moderate calcium intake, and taking thia5ide diuretics to lo"er urinary calcium e*cretion. Aminoglycosides are antibiotics used to treat serious gram$negative in%ections. They are otentially nehroto*ic and drugs levels and renal %unction must be monitored closely during theray. Analgesic nehroathy is the most common %orm o% drug$induced chronic renal %ailure. Papill ary necrosi s and chronic t ubul oi nterstiti a/ nephrit is are the most common athologies seen. Patients "ith chronic analgesic abuse are also more likely to develo remature aging, atherosclerotic vascular disease, and urinary tract cancer . uddy bro"n granular cast $Acute tubular necrosis =! casts $ +lomerulonehr itis W=! casts $ &nterstitial nehr itis and yelonehritis Fatty casts $ 'ehrotic syndrome =road and "a*y casts $ !hronic renal %ailure The common resentation o% cryoglobulinemia includes alable urura, glomerulonehritis, non$seci%ic systemic symtoms, arthralgias, heatoslenomegaly, eriheral neuroathy, and hyocomlementemia. ost atients also have -eatitis !.
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#isticks are commercially available kits that detect the resence o% leukocyte esterase and nitrite in the urine o% atients "ith susected UT&. Positive leukocyte esterase signi%ies signi%icant yuria and ositive nitrites indicate the resence o% 6nterobacteriaceae. Uncomlicated cystitis commonly occurs in other"ise healthy atients and has a lo" risk o% treatment %ailure.Urinalysis con%irms the diagnosis. Patients can be treated "ithout a urine culture, "hich may be done later in those "ho %ail initial theray. 7ral trimethorimsul%ametho*a5ole, nitro%urantoin, and %os%omycin are e%%ective %irst$line treatment otions. Uncomlicated cystitis commonly occurs in other"ise healthy atients and has a lo" risk o% treatment %ailure.Urinalysis con%irms the diagnosis. Patients can be treated "ithout a urine culture, "hich may be done later in those "ho %ail initial theray. 7ral trimethorimsul%ametho*a5ole, nitro%urantoin, and %os%omycin are e%%ective%irst$line treatment otions. !ollasing %ocal and segmental glomerulosclerosis is the most common %orm o% glomeruloathy associated "ith -&9. Tyical resentation o% %ocal segmental glomerulosclerosis includes nehrotic range roteinuria , a5otemia, and normal si5ed kidneys. !ystinuria is an inherited disease causing recurrent renal stone %ormation. ;ook %or a ersonal history o% recurrent kidney stones %rom childhood and a ositive %amily history. The characteristic stones are hard and radiooa3ue. Urinalysis sho"s tyical he*agonal crystals. The urinary cyanide nitrorusside test is "idely used as a 3ualitative screening rocedure .
&nterstitial cystitis (ain%ul bladder syndrome) is an idioathic, chronic condition characteri5ed by bladder ain that is "orsened by %illing and relieved by voiding. #ysareunia, urinary %re3uency and urgency can also be resent. 'ehrotic syndrome is de%ined as heavy roteinuria (1.B g04 hr K "ith hyoalbuminemia and edema. Focal segmental glomerulosclerosis (FS+S) and membranous nehroathy are the most common causes o% nehrotic syndrome in adults in the absence o% a systemic disease. FS+S is more common in A%rican American atients and in those "ith obesity, heroin use, and -&9. &nitial hematuria suggests urethral damage . Terminal hematuria indicates bladder or rostatic damage, and total hematuria re%lects damage in the kidney or ureters. !lots are not usually seen "ith renal causes o% hematuria. I@C o% cases "ith interstitial nehritis are caused by drugs such as cehalosorins, enicillins, sul%onamides,sul%onamide containing diuretics, 'SA&#s, ri%amin, henytoin, and allourinol. #iscontinuing the o%%ending agent is the treatment o% drug$induced interstitial nehritis. Asirin into*ication causes a mi*ed resiratory alkalosis and metabolic acidosis. esiratory alkalosis is due to increased resiratory drive. etabolic acidosis is due to increased roduction and decreased renal elimination o% organic acids (eg, lactic acid, ketoacids).
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Unilateral varicoceles that %ail to emty "hen a atient is recumbent raise susicion %or an underlying mass athology, such as renal cell carcinoma (!!K, that obstructs venous %lo". !T scan o% the abdomen is the most sensiti ve and seci%ic test %or diagnosing !!. #rugs "ith anticholinergic roerties can cause acute urinary retention by reventing detrusor muscle contraction and urinary shincter rela*ation. The treatment involves urinary catheteri5ation and discontinuing the medication. &ntravenous saline hydration is the immediate treatment o% choice %or atients "ith symtomatic moderate (calcium /0$/4 mgd;K or severe (calcium /4 mgd;K hyercalcemia. Saline hydration hels to restore intravascular volume and romote urinary calcium e*cretion. !alcitonin also reduces serum calcium concentration "ithin 4$H hours and should be administered along "ith saline hydration. =ishoshonates are recommended %or long$term management in addition to treatment o% the underlying cause. Agents used to shi%t otassium intracellularl y include insulin and glucose, sodium bicarbonate, and beta$0 agonists.
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;ung malignancies, cystic %ibrosis, and right$to$le%t cardiac shunts are the most common causes o% secondary digital clubbing. !hronic obstructive ulmonary disease ("ith or "ithout hyo*emia) does not cause digital clubbing, and the resence o% clubbing should romt a search %or occult malignancy.-yertrohic osteoarthroathy re%ers to digital clubbing along "ith ain%ul 2oint enlargement, eriostosis o% longbones, and synovial e%%usions. ight mainstem bronchus intubation is a relatively common comlication o% endotracheal intubation. &t causes asymmetric chest e*ansion during insiration and markedly decreased or absent breath sounds on the le%t side on auscultation. eositioning the endotracheal tube by ulling back slightly "ill move the ti bet"een the carina and vocal cords and solve the roblem. ild intermittent asthma, the least severe %orm, is de%ined as symtoms $ 0*"eek, $ 0 nighttime a"akeningsmonth, "ith a normal F69/ and no limitations on activity. For this %orm o% asthma, only a P' albuterol inhaler is re3uired. #aily controller corticosteroids are reserved %or ersistent asthma. ecurrent bacterial in%ections in an adult atient ma y indicate a humoral immunity de%ect. Juantitative measurement o% serum immunoglobulin levels hels to establish the diagnosis. Undiagnosed leural e%%usion is best evaluated "ith thoracentesis, e*cet in atients "ith clear$cut evidence o% congestive heart %ailure. 7% the main cell tyes o% lung cancer , adenocarcinoma is the most common in both smokers and nonsmokers. &t accounts %or most o% the rimary lung cancer in nonsmokers. &t is usually located eriherally and may resent as a solitary nodule, "ith or "ithout symtoms. Stage at diagnosis is the most imortant rognostic %a ctor , "ith survival determined rimarily by resectability. &n atients "ith acute asthma e*acerbation, an elevated or even normal arterial artial ressure o% carbon dio*ide suggests decreased resiratory drive (likely due to resiratory
muscle %atigue) and imending resiratory %ailure. &n these atients, treatment involves endotracheal intubation and mechanical ventilation,inhaled short$acting beta$0$agonist, inhaled iratroium, and systemic corticosteroids. •
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&dioathic ulmonary %ibrosis is due to e*cessive collagen deosition in eri$alveolar tissues. This leads to decreased lung volumes (lo" total lung caacity, %unctional residual caacity, and residual volume) "ith reserved or increased %orced e*iratory volume in / second%orced vital caacity ratio. Patients have imaired gas e*change resulting in reduced di%%usion caacity o% carbon mono*ide and increased alveolar $arterial gradient. +ranulomatosis "ith olyangiitis (Wegener:s) is a vasculitis a%%ecting small and medium$ si5ed arteries. Patients resent "ith a combination o% glomerulonehritis and uer and lo"er resiratory tract disease. #iagnosis is made by c$A'!A ositivity and tissue biosy. Treatment involves high$dose corticosteroids and cy/oto*ic agents. Acute resiratory distress syndrome (A#S) is associated "ith hyo*emia (Pa7) Fi@2 S1@@ mm -g) and bilateral alveolar in%iltrates. A#S is due to imaired gas e*change, decreased lung comliance (sti%% lungs),and increased ulmonary arterial ressure (ulmonary hyertension). itral stenosis is most commonly due to rheumatic heart disease and resents "ith gradual and rogressively "orsening dysnea or orthonea. Atrial %ibrillation is a common comlication and can cause raid decomensation in reviously asymtomatic atients. ;ongstanding mitral stenosis can cause severe le%t atrial enlargement leading to an elevation o% the le%t main bronchus on chest radiograh. &ndicators o% a severe asthma attack include normal to increased Pco0 values, seech di%%iculty, diahoresis,altered sensorium, cyanosis, and :silent: lungs.
War%arin dosing should be ad2usted to maintain a goaii' aroriate %or the condition being treated. For atients "ith idioathic 9T6 or atrial %ibrillation, a target &' o% 0.@ to 1.@ rovides ade3uate anticoagulation "ithout an e*cessive risk o% bleeding. alignancy is the most common cause o% S9! syndrome. ;ung cancer (articularly small cell lung cancer K and '-; are o%ten imlicated. 7ther ossible causes include %ibrosing mediastinitis (secondary to histolasmosis or Tb in%ectionK or thrombosis secondary to ind"elling central venous devices. When the history and hysical e*amination are suggestive, chest *$ray is "arranted. The kidney comensates %or resiratory alkalosis by re%erentially e*creting bicarbonate in the urine. The result is an alkalini5ed urine (increased urine -). When the - o% the leural %luid is less than I.0, the robability is very high that this %luid needs to be drained.+lucose o% less than H@mgd; in leural %luid is also an indication %or tube thoracostomy. &n%ected leural sace is usually initially drained "ith a chest tube. Short$acting beta$adrenergic agonists administered 0@ minutes be%ore e*ercise are the %irst$ line treatment %or isolated e*ercise$induced asthma. The inciting trigger in e*ercise$induced asthma is raid ventilation o% cold,dry air .
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Physical e*amination in atients "ith leural e%%usion usually sho"s decreased tactile %remitus, dullness to ercussion, and decreased breath sounds over the e%%usion. &n the U.S., sarcoidosis most commonly a%%ects young$ to middle$aged A%rican American %emales, causing insidious$onset dysnea and dry cough in the absence o% constitutional symtoms. Sarcoidosis also tyically a%%ects the skin (rotean mani%estations, most commonly erythema nodosum) and the eyes (uveitis). Theohylline to*icity can mani%est as central nervous system stimulation (eg, headache, insomnia, sei5ures),gastrointestinal disturbances (eg, nausea, vomiting), and cardiac to*icity (arrhy/hmia). &nhibition o% the cy/ochrome o*idase system by other medications, diet, or underlying disease can alter its narro" theraeutic "indo". =lood in the chest, i% it is not evacuated, can get in%ected. The ma2ority o% atients "ill resent "ith a lo"$grade %ever , dysnea, and chest ain. Surgery is re3uired to remove the clotted blood and %ibrinous eel. A negative #$dimer is very hel%ul in e*cluding the diagnosis o% ulmonary venous thromboembolism in lo"$risk atients. A ositive #$dimer , ho"ever , is %ar %rom diagnostic and must be %ollo"ed by more seci%ic studies. Secondary malignancy is common in atients "ith -odgkin lymhoma treated "ith chemotheray and radiation. The most common secondary solid tumor malignancies are lung (esecially in smokers), breast,thyroid, bone, and gastrointestinal (eg, colorectal, esohageal, gastr ic tumors). &n all atients "ith !7P#, the t"o modalities that have been sho"n to decrease mortality are home o*ygen theray and smoking cessation. Asirin$e*acerbated resiratory disease (A67K is a non$lg6$mediated reaction that results %rom asirin$induced r ostaglandinleukotriene misbalance. &t is most o%ten seen in atients "ith a history o% asthma or chronic rhinosinusitis "ith nasal olyosis. A67 is characteri5ed by bronchosasm and nasal congestion %ollo"ing asirin ingestion. Treatment includes avoidance o% nonsteroidal anti$in%lammatorydrugs ('SA&#s K, desensiti5ation i% 'SA&#s are re3uired, and the use o% leukotriene recetor antagonists ( eg,montelukastK.
P. 2iroveci is an oortunistic athogen, and an imortant cause o% neumonia in immunocomromised hosts.=ilateral di%%use interstitial in%iltrates beginning in the erihilar region is a characteristic %inding on chest *$ray. long$term sulemental o*ygen theray has been roven to rolong survival in atients "ith !7P# and hyo*emia. !riteria %or theray include Pa@0LBB, Sa@0LMMC, erythrocy/osis (hematocritBBC), or evidence o% cor ulmonale. !7P# is character i5ed by rogressive e*iratory air%lo" limitation "hich causes air traing, decreased 9! and increased total lung caacity. F69/ is disroortionately decreased as comared to 9!. Patients "ith a history o% recent orthoedic surgery %ollo"ed by bed rest are at risk o% develoing lo"er e*tremity dee venous thrombosis and ulmonary embolism. An elevated A$a gradient is commonly seen in atients "ith ulmonary embolism.
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=ronchogenic cysts are usually %ound in the middle mediastinum. Thymoma is usually %ound in the anterior mediastinum. All neurogenic tumors are located in the osterior mediastinum. The 1 most common causes o% chronic cough are uer$air"ay cough syndrome (ostnasal dri), asthma,and gastroesohageal re%lu* disease. The diagnosis o% uer $air"ay cough syndrome is con%irmed by the elimination o% nasal discharge and cough "ith the use o% -/ histamine recetor antagonists. Acute massive ulmonary embolism can resent initially "ith syncoe and shock. ight heart catheteri5ation in atients "ith massive ulmonary embolism "ill sho" elevated right atrial and ulmonary artery ressures,along "ith normal ulmonary caillary "edge ressure. Acute ancreatitis can cause adult resiratory distress syndrome ( A#S) in u to /BC o% atients. The %irst ste in the initial ventilator management o% A#S is usually to decrease the Fi@0 to relatively non$to*ic values(i.e. ? H@C). P66P may be increased as needed to maintain ade3uate o*ygenation a%ter the Fi@0 is lo"ered. Acute ancreatitis can cause adult resiratory distress syndrome ( A#S) in u to /BC o% atients. The %irst ste in the initial ventilator management o% A#S is usually to decrease the Fi@0 to relatively non$to*ic values (i.e. ? H@C). P66P may be increased as needed to maintain ade3uate o*ygenation a%ter the Fi@0 is lo"ered. 'ormal leural %luid - is aro*imately I.H@. Transudative %luid is usually due to systemic %actors (eg,increased hydrostatic ressure or hyoalbuminemia) and has a leural %luid - o% I.4$I.BB. 6*udate is usually due to in%lammation "ith a leural %luid - o% I.1@$I.4B. Pleural %luid - ?I.1@ ("ith normal arterial - and lo" leural glucose) is usually due to increased acid roduction by leural %luid cells and bacteria (eg, emyema) or decreased hydrogen ion e%%lu* % rom the leural sace (eg, leuritis, tumor , leural %ibrosis). =ronchiectasis resents "ith cough, mucourulent sutum, and hemotysis that o%ten antibiotics. !hest *$ray is %re3uently abnormal but is not as sensitive or seci%ic as high$ resolution comuted tomograhy scan %or de%initive diagnosis. =lastomycosis is a ulmonary %ungal in%ection endemic to the +reat ;akes, and ississii and 7hio iver basins. Systemic =lastomycosis may cause skin and bone lesions in addition to ulmonary mani%estations.=road$based budding yeast gro"n %rom the sutum con%irm the diagnosis. ltracona5ole or amhotericin B may be used to treat symtomatic disease.
The modi%ied Wells criteria can assess r etest ossibility o% acute ulmonary embolism (P6) as it can have variable resentations. Patients "ith likely P6 based on these criteria should be %urther evaluated "ith comuted tomograhy angiograhy (!TA). Patients "ith negative !TA are unlikely to have P6. Eno" the comlications o% ventilation "ith a high P66P alveolar damage, tension neumothora* and hyotension. Tension neumothora* may resent "ith sudden$onset shortness o% breath, hyotension,tachycardia, tracheal deviation, and unilateral absence o% breath sounds.
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All !7P# atients "ith Pa@0 ? BB mm-g or Sa@0 ? MMC are candidates %or long$term home o*ygen treatment. Patient "ith signs o% ulmonary hyertension or hematocrit BBC should be started on home o*ygen "hen the Pa@0 ? H@ mm-g.
Patients "ith imaired consciousness, advanced dementia, and other neurologic disorders are redisosed to asiration neumonia due to imaired eiglottic %unction. =ronchiectasis can be identi%ied on !T by the resence o% dilated bronchi "ith thickened "alls. &t can occur in any atient "here there is ulmonary in%ection accomanied by either decreased air"ay drainage or imaired immune de%ense. -emotysis is a otential comlication o% bronchiectasis. -istolasma casulatum is a common and usually asymtomatic in%ection in endemic areas like ississii and 7hio iver valleys and !entral America. &t is usually %ound in soil "ith a high concentration o% bird or bat guano droings. Patients "ith massive ulmonary embolism usually resent "ith signs o% lo" arterial er%usion ( eg,hyotension, syncoe) and acute dysnea, leuritic chest ain, and tachycardia. The thrombus increases ulmonary vascular resistance and right ventricular ressure, causing right ventricular hyokinesis and dilation, decreased reload, and hyotension. For anticoagulation, un%ractionated hearin is re%erred over lo"$molecular$"eight hearin, %ondaarinu*, and rivaro*aban in atients "ith severe renal insu%%iciency (estimated glomerular %iltration rate ?1@ mUmin/. I1m2} as reduced renal clearance increases anti$Na activity levels and bleeding risk. +erm cell tumors tyically a%%ect young atients and dislay aggressive biologic behavior . 'onseminomatous germ cell tumors tyically roduce both alha %etorotein and human chorionic gonadotroin tumor markers.
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Antisychotic medications can cause hyerrolactinemia secondary to their doamine blockade e%%ect. Prolactinomas tend to roduce very high levels o% rolactin (0@@ ngm;). Some o% the more serious adverse e%%ects associated "ith lithium include nehrogenic diabetes insiidus,hyothyroidism, and 6bstein:s anomaly in the %etus. The antideressant o% choice %or deressed atients "ho do not resond to %irst$line treatment "ith a selective serotonin reutake inhibitor is another medication in the same class. 'euroletic malignant syndrome is a otentially li%e$threatening condition that can occur a%ter administration o% antisychotic medications. Symtoms include %ever , rigidity, altered mental status, and autonomic instability. The most e%%ective strategy to revent %irearm in2uries is to remove all %irearms %rom the home. Families "ho choose to kee %irearms in the home should be advised to store unloaded %irearms and ammunition in searate , locked containers. Unlike atients "ith anore*ia nervosa, atients "ith bulimia nervosa maintain a normal body "eight and are not amenorrheic.
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Patients "ho are an acute threat to themselves should be hositali5ed (involuntarily, i% necessary) %or treatment and stabili5ation. This rincile also alies to minors, even "ithout arental or guardian consent.
The mechanism o% action o% antisychotic medications rimarily consists o% doamine$@0 recetor blockade.The added serotonin r ecetor binding o% atyical antisychotics reduces the likelihood o% e*trayramidal side e%%ects. iseridone is a doamine and serotonin antagonist that can cause "eight gain and hyerrolactinemia, the latter o% "hich can lead to amenorrhea and galactorrhea. #elusional disorder involves one or more delusions and the absence o% other sychotic symtoms in an other"ise high$%unctioning individual. =en5odia5eines are used %or the acute treatment o% anic attacks. &n anic disorder , a selective serotonin reutake inhibitor serotonin noreinehrine reutake inhibitor andor cognitive behavioral theray should be used %or long$term symtom relie% . Patients "ho have e*erienced 0 eisodes o% acute mania should be considered %or long$ term (years), i% not li%etime, maintenance treatment "ith lithium, esecially i% the eisodes "ere severe or there is a %amily history. Patients "ith a history o% 1 or more relases are recommended to have li%etime maintenance thera y. P!P and ;S# into*ication resent similarly, but agitation and aggression occur more o%ten in atients using P!P. 9isual hallucinations and intensi%ied ercetions are hallmarks o% ;S# use. Acute dystonia is a tye o% e*trayramidal symtom associated "ith antisychotic treatment. &t is most commonly seen "ith high$otency tyical antisychotics and is best treated "ith anticholinergics (ben5troine) or antihistamines (dihenhydramine).
For the general oulation, the li%etime risk o% develoing biolar disorder is /C . -o"ever , an individual "ith a%irst$degree relative ( eg, arent, sibling, or di5ygotic t"in) "ho su%%ers %rom biolar disorder has a B $/ @C risk o% develoing the condition in his li%etime. Somatic symtom disorder involves one or more somatic comlaints (including ain) that are distressing or result in signi%icant disrution o% daily li%e, "ith e*cessive thoughts, %eelings, or behaviors related to these symtoms and lasting months. Patients may have concurrent medical illness, or the symtoms may reresent normal bodily %unction. Schi5oa%%ective disorder is characteri5ed by a signi%icant mood eisode (deressive or manic) "ith concurrent sychotic symtoms in addition to a eriod o% sychosis "ithout mood symtoms o% at least 0 "eeks. ost antideressants must be taken %or 4$H "eeks be%ore they rovide symtomatic relie%. ~
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inimi5ing con%lict and stress in the home decreases the risk o% relase in atients "ith schi5ohrenia.Family sychosocial interventions are indicated %or atients "ith a recent sychotic eisode "ho have signi%icant ongoing contact "ith %amily members. Panic disorder is %re3uently associated "ith other sychiatric illnesses, including agorahobia, ma2or deression, biolar disorder , and substance abuse. &t is also linked to a higher rate o% suicide attemts or suicidal ideations. Antisychotic medications are %irst$line treatment %or sychosis. Second$generation antisychotics are generally re%erred due to a comaratively lo"er r isk o% e*trayramidal side e%%ects and tardive dyskinesia.#ue to the risk o% agranulocytosis, clo5aine is reserved %or atients "ho have %ailed at least 0 antisychotic trials. The dissociative disorders are characteri5ed by %orget%ulness and dissociation. #issociative %ugue is the only condition "ithin this grou that is associated "ith travel. +enerali5ed social an*iety disorder is characteri5ed by an*iety and %ear o% scr utiny in social situations,resulting in avoidance, distress, and social$occuational dys%unction. The re%erred harmacological treatment is a selective ser otonin reutake inhibitor or serotonin
noreinehrine reutake inhibitor . !ognitive behavioral theray can also be used as %irst$line treatment. !lassi%ication o% sychiatric illnesses by hase is necessary to determine the aror iate harmacotheray.Treatment r esponse occurs "hen a atient demonstrates signi%icant imrovement ("ith or "ithout aremission), generally de%ined as a B@C reduction in the baseline level o% sever ity. !ognitive$behavioral theray %ocuses on reducing automatic negative thoughts and avoidance behavior s that cause distress. &t is e%%ective as monotheray or in combination "ith medication %or a "ide range o% sychiatric disorders. -oarding disorder is resonsive to treatment "ith selective serotonin reutake inhibitors and cognitive behavioral theray. Persistent deressive disorder (dysthymia) re%ers to a deressed mood lasting most da ys %or at least 0years. Symtoms o% a ma2or deressive eisode may occur concurrently or intermittently in ersistent deressive disorder. 9s Patients "ith avoidant ersonality disorder desire social interaction but shy a"ay due to %eelings o% inade3uacy or %ear o% criticism, %ailure, or re2ection. This atient:s %ear o% re2ection by "omen relates to his mood symtoms (lo" sel%$esteem) and not general avoidance o% social situations. •
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'euroletic malignant syndrome ('S) is an unusual but otentially lethal side e%%ect %rom the use o% antisychotics (neuroletics). &t is treated rimarily "ith dantrolene sodium and suortive care. !ancer atients o%ten have a deressed mood secondary to normal grie ving. -o"ever , ma2or deression should be considered in atients "ith rominent somatic symtoms o% deression, guilt, %eelings o% hoelessness, or suicidal thoughts. There should be a lo" threshold %or beginning a selective serotonin reutake inhibitor given the lo" risk o% side e%%ects and large otential bene%it to the atient. The treatment o% choice %or ad2ustment disorder is cognitive or sychodynamic sychotheray. Schi5ohreni%orm disorder is di%%erentiated %rom schi5ohrenia by the duration o% symtoms. &n schi5ohreni%orm disorder , symtoms must last %or / month but ?H months. The diagnosis o% schi5ohreniare3uires symtoms to be resent %or at least H months. Serotonin reutake inhibitors and serotonin$noreinehrine reutake inhibitors are %irst$line medications %or treating generali5ed an*iety disorder that can also otentially treat comorbid ma2or deression.=en5odia5eines should be reserved %or nonderessed atients "ithout a history o% substance abuse "ho %ail to resond to or cannot tolerate antideressants. #isorgani5ed seech is common in schi5ohrenics. Patients "ith a circumstantial thought rocess deviate %rom the original sub2ect but eventually return to it, "hile those "ith a tangential thought rocess dri%t a"ay "ithout ever returning to the sub2ect. =ecause symtoms o% hyochondriasis usually develo during eriods o% stress, atients su%%ering %rom the condition should be asked about their current emotional stressors and then re%erred %or brie% sychotheray. The e*trayramidal side e%%ects o% antisychotics can be treated "ith anticholinergic medications like ben5troine. Susect heroin "ithdra"al in atients "ith uillary dilatation, rhinorrhea, muscle and 2oint aches, abdominal craming, nausea, and diarrhea. The symtoms are severe and out o% roortion to hysical %indings. Eletomania is characteri5ed by inability to resist the imulse to steal ob2ects that are o% lo " monetary value or not needed %or ersonal use. Treatment rimarily involves cognitive behavioral theray.
First$line treatments %or obsessive$comulsive disorder are selective serotonin reutake inhibitors or clomiramine. P7&S7'&'+ A'# &U'7;7+< The 01$valent neumococcal vaccine contains casular olysaccharides and induces a relatively T$cell$indeendent =$cell resonse. &n contrast, the /1$valent neumococcal vaccine contains casular olysaccharides con2ugated to a rotein antigen, "hich allo"s %or a more robust T $cell$deendent =$cell resonse. Tricyclic antideressant overdose can resent "ith central nervous system, cardiac, and anticholinergic %indings. Sodium bicarbonate is used to treat cardiac to*icity, "hich is characteri5ed by rolonged JS duration (/@@ msec) and ventricular arrhythmias. Sodium bicarbonate increases serum - and e*tracellular sodium , thereby alleviating the cardia$ deressant action on sodium channels. •
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Slurred seech, unsteady gait and dro"siness can be seen in the overdose o% multile drugs.=en5odia5eine overdose can be distinguished %rom oioid overdose by the lack o% severe resiratory deression and the lack o% uillary constriction. Furthermore, "hile alcohol and heny/oin into*ication also share similarities "ith ben5odia5eine overdose, they can be distinguished by the resence o% nystagmus. Fluhena5ine is a high otency 8tyical8 antisychotic medication that occasionally causes hyothermia by disruting thermoregulation and the body:s shivering mechanism. Patients taking antisychotics should be advised to avoid rolonged e*osure to e*treme temeratures. 7ioid into*ication does not al"ays resent "ith miosis. !oingestions can lead to normal uil si5e or even mydriasis and certain oioids (meeridine, roo*yhene) do not reliably cause miosis even "hen taken alone. As a result, uil e*amination is not as reliable as the recognition o% bradynea in oioid into*ication. T!A overdose is characteri5ed by !'S deression, hyotension, and other anticholinergic e%%ects including dilated uils, hyerthermia and intestinal ileus. &t can also cause JS rolongation on 6E+, leaving the atient suscetible to ventricular arrhythmias. Patients susected o% T!A overdose should %irst undergo the A=!:s and sodium bicarbonate should then be administered to imrove blood ressure, shorten the JS interval, and revent arrhythmia To revent cardioresiratory arrest and ermanent neurologic disability , victims o% smoke inhalation in2ury should be treated emirically %or cyanide to*icity "ith an antidote, such as hydro*ocobalamin or sodium thiosul%ate, or "ith nitrites to induce methemoglobinemia. Symtoms o% oioid "ithdra"al include nausea, vomiting, crams, diarrhea, dyshoria, restlessness,rhinorrhea, lacrimation, myalgias, and arthralgias. Physical e*amination signs include mydriasis, iloerection,and hyeractive bo"el sounds. 7ral or intramuscular methadone is the treatment o% choice to relieve the symtoms o% oioid "ithdra"al in deendent atients. !austic oisoning does not cause alteration in consciousness. &t resents "ith dyshagia, severe ain, heavy salivation and mouth burns. The damage is the result o% necrosis o% the tissue that lines the gastrointestinal tract. &n severe cases, er%oration o% the stomach or esohagus can occur , causing eritonitis or mediastinitis. 'euroletic alignant Syndrome ('S) is caused by the initiation o% doaminergic antagonists and tyically resents "ith %ever , muscle rigidity, autonomic instability and mental status change. An elevated creatine kinase, leukocytosis and electrolyte abnormalities are also common. 6thylene glycol is associated "ith hyocalcemia and calcium o*alate deosition in the kidneys. This leads to %lank ain, hematuria, oliguria, acute kidney in2ury, and anion ga metabolic acidosis. Treatment involves administration o% %omei5ole or ethanol to inhibit
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alcohol dehydrogenase, sodium bicarbonate to alleviate the acidosis, and hemodialysis in cases o% severe acidosis andor end$organ damage. 7ioid into*ication resents "ith miosis, deressed mental status, decreased resiratory rate, decreased bo"el sounds, hyotension and bradycardia. 7% these, decreased resiratory rate is the best redictor o% into*ication and is also a %re3uent cause o% mortality. The most severe conse3uences o% methanol into*ication are vision loss and coma. Physical e*am in methanol into*ication re veals otic disc hyeremia "hile laboratory studies reveal anion ga metabolic acidosis. An increased osmolar ga is o%ten seen as "ell.O All adults should have tetanus and dihtheria boosters at least e very /@ years, "ith a one$ time tetanus,dihtheria, and ertussis booster . All adults re3uire yearly in%luen5a vaccinations. !ervical cancer screening can start at age 0/ "ith either Pa smear every 1 years. For "omen age 1@$HB, screening is recommended "ith Pa smear every 1 years or "ith a combination o% Pa smear and human aillomavirus (-P9) testing every B years i% both initial tests are negative.
