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Folic Acid Deficiency: present with megaloblastic anemia. MCC is poor diet
an alcoholism. Phenytoin, primidone, phenobarbital inhibit folate absorption.
TMP an methotrexate inhibit DHFR causing folate deficiency.
Systemic Sclerosis: affects all organ systems. Cutaneous findings are that of
scleroderma. Thickening of the skin, edema -> obliteration of hair follicles an
sweat glans an flexion contractures. Mask like appearance to face.
Myofibroblast proliferation -> increased collagen an ground substance
production. Kidney involvement -> hypertension. Pulmonary hypertension ->
right heart failure. Esophageal an gastric dysmotility -> GERD. Find ANA an
anti-topoisomerase I antibodies.
Acute Limb Ischemia: sudden decrease in perfusion that threatens limb vitality
an presents 2 weeks of symptom onset. Pain, pulselessness, pallor,
parasthesias, paralysis. Due to embolism (MCC), thrombosis, trauma. Atrial
fibrillation -> embolism. Prevent with warfarin.
Rotator Cuff Tendonitis: shoulder pain with reaching or lifting arm overhead.
Due to repetitive activity at shoulder height (painters), MC in middle
Acute Cord Compression: back pain with associated tenderness at the site
of metastasis (usually prostate). Progressive or sudden compression with
neurological deficit can ensue. Medical emergency that needs prompt
treatment. First do neurological exam for signs of myelopathy (if so, give
steroids). Then do MRI or CT myelogram if no MRI. Radiotherapy to treat.
Respiratory Acidosis: decreased pH, primary increase in PCO2. Along with low
PO2
levels,
suggest
alveolar
hypoventilation
(MCC).
Causes:
pulmonary/thoracic (COPD, OSA, CF, obesity, scoliosis, ankylosis),
neuromuscular (MG, LE, poliomyelitis, muscular dystrophy, GBS, ALS), drug
induced (anesthesia, narcotics, sedatives), primary CNS (brainstem lesion,
infection, stroke).
of lung
growing
is most
early to
velocity -> wide QRS (best indication of extent of OD) -> ventricular
arrhythmia. Treat with NaHCO3 (narrows QRS).
Aortic Dissection: three clinical findings: abrupt onset tearing pain in chest
or back, variation in pulse/BP between arms, wide mediastinum on CXR. Tear
in intima -> subintimal hematoma. HTN, smoking, family history of CAD. May
extend into pericardium, CA, carotids -> tamponade, MI, stroke.
Testicular Cancer: AFP, beta-HCG, placental ALP are useful for diagnosis,
staging, monitoring patients. Seminoma: PLAP, embryonal carcinoma: AFP +
beta-HCG (50%), choriocarcinoma: beta-HCG. LDH an CEA have some use but
are non-specific.
Atypical Mycobacterium: HIV infected, unexplained fever, cough, CD4 < 50, no
history of or exposure to tuberculosis. If CD4 < 50, give azithromycin as
prophylaxis.
Acute Pain: all patients should receive same stanard pain management
regardless of drug history. Use IV morphine. Never undertreat pain even with
risk of abuse. Frequently reassess, outpatient follow up, referral to pain
specialist if abuse is suspected.
Chronic Wounds: until proven otherwise, suspect SCC in a chronic wound ->
non-healing, painless, bleeding ulcer. SCC is cancerous changes in the mid
epidermis -> extension into dermis. Skin an mucous membranes can be
affected. Sun-exposed or burn areas are involved. Rough scaly nodules ->
ulcerate -> metastasize. Tar derivatives, carcinogens, radiation predispose.
Immunosuppression increases risk. Punch biopsy confirms.
AAA: surgery if > 5 cm, rapid rate of growth, symptoms present. If smaller, do
periodic imaging. Atherosclerosis is precipitant. Smoking is major RF for
formation, enlargement, rupture. Cessation is best intervention to slow
progression.
HNPCC: Amsterdam Criteria I: at least 3 relatives with CoCa with one being
first degree of other 2, > 2 generations, one before 50 y/o, FAP excluded.
Lynch I is hereditary site specific CoCa. Lynch II is cancer family syndrome an
high rate of extracolonic tumors. MC is endometrial cancer (43% of affected
females).
Isoniazid: causes hepatits picture via idiosyncratic liver injury with histological
features similar to viral hepatitis.
Acute Bronchitis: common cause of blood tinged sputum due to virus. Lack of
history or physical indicating more severe disease. Have malaise, throat pain,
wheezing. No fever (rules out pneumonia). Weight loss or more blood suggest
TB or malignancy. Observe an follow.
False Negatives: patients with negative test who have the disease. When
cutoff levels are raised, FN increase.
Neurofibromatosis:
neurocutaneous
syndrome.
Autosomal
dominant,
chromosome 22. Type I has caf-au-lait spots, axillary freckles, Lisch nodules
of iris, neurofibromas, bony lesions. Type II has brain tumors especially BL
acoustic neuromas (diagnostic). Develop CNS, PNS, skin, visceral tumors.
Mutations: nonsense an frame shift mutations are typically more severe than
missense or splice site mutations. Silent (same sense) mutations do not affect
the protein structure.
Scatter Plots: useful for crude analysis. Can demonstrate association (linear or
non-linear) if one is present. If linear, correlation coefficient can be calculated.
Hemi Neglect: patient neglects one side an only senses the other. May only
shave, comb, ignore people on one side. Ask patients to fill in clock, will only
fill in one side. Caused by lesion in right (non-dominant) parietal lobe,
responsible for spatial organization.
Lipid Screening: start at age 35 in men, 45 in women. Risk factors are (+) FH,
smoking, HTN, low HDL, age. With 0-1, goal LDL < 160. With 2, goal LDL <
130. With known CAD or CAD equivalent (diabetes, AAA, symptomatic CVD, 10
year risk > 20%), goal LDL < 100.
Cushings Syndrome: high cortisol -> vasoconstriction -> secondary HTN. Also
enhance insulin resistance (hyperglycemia) an mineralocorticoid activity
(hypokalemia). Proximal weakness, central obesity, thin skin, psych problems.
Result from adrenal cortical hyperplasia, ACTH adenoma (Cushings disease),
ectopic ACTH, steroid administration.
Simple Renal Cyst: most commonly seen in patients > 50. Benign an
incidentally discovered. Usually asymptomatic. Sometimes can become
infected. Simply observe an no follow up needed. Make sure its not
multiloculated, does not have thick or irregular walls, thickened septae, or
contrast enhancement.
Anticholinergic Toxicity: red as beet, dry as bone, hot as hare, blind as bat,
mad as hatter, full as flask. Can have dizziness, headache, tachycardia. Can
precipitate acute glaucoma due to mydriasis. Trihexylphenidyl an benztropine
are used for Parkinsons an EPSEs.
Squamous Cell Carcinoma: ulcer that is solitary, not healed for a long time,
located in keratinized epithelium of the vermillion zone of lower lip. May also
be chronic infectious, chronic autoimmune. Will have invasive cords of
squamous cells with keratin pearls. Will have history of occupational sun
exposure. Major of lip cancers are well differentiated SCC.
Acute Back Pain: with positive straight leg raise -> herniated disk. With
neurological defecit an perianal anesthesia -> cauda equina syndrome.
Manage conservatively. Return to activities ASAP. Use NSAIDs an muscle
Case Control Study: retrospective study. Movement from effect to cause. Look
at population with outcome an subjects are either cases or controls. Looks for
presence of risk factors.
Cross Sectional Study: exposure an outcome are studied at one cross section
of time. Not possible to determine temporal association between exposure an
outcome.
Chemicals in the Eye: first priority is immediate flushing under running water
for at least 15 minutes. Call ER, 911, doctor after washing. Acid exposure has
likely full recovery. Alkaline will more likely have permanent corneal damage.
For foreign bodies or cuts/scratches, obtain medical care first.
Rotator Cuff Tear: present with shoulder pain an weakness. Occur as end
result of rotator cuff tendonitis or trauma (FOOSH). Aggravated by pushing,
pulling, lifting overhead, lying on affected shoulder. Limited arc abduction an
external rotation. Remains after lidocaine injection. Tendonitis resolves with
lidocaine injection. MRI is diagnostic.
Ventricular Remodeling: after MI, ventricle slowly dilates an walls thin -> CHF
which occurs over months to weeks. ACEs inhibit ventricular remodeling an
should be started within 24 hours of MI if no contraindication.
Tinea Corporis: ring shaped scaly patches with central clearing, distinct
borders. Trichophyton rubrum is MCC, other dermatophytes can also cause.
MC symptom is itching. KOH preparation shows hyphae. Treat with topical
terbinafine if local. If extensive, give systemic griseofulvin an investigate for
immunosuppresion (DM, HIV).
Vitamin B12 Deficiency: causes are strict vegetarian diet (more than 3-4
years), an pernicious anemia, autoimmune disease resulting in parietal cell
destruction -> measure intrinsic factor Ab an B12 levels.
DM: RF are AA race, positive FH in first degree relatives. Present with polyuria,
polydipsia, obesity. Measure fasting blood glucose (recommended screening
test). > 126 on 2 occasions is diagnostic. Between 100 an 125 is insulin
resistance or pre-diabetes.
Pleural Effusion: use Lights criteria: exudate will have fluid to serum protein
ratio > 0.5, fluid to serum LDH ratio > 0.6, or fluid [LDH] > 2/3 the upper limit
for serum LDH. Complicated will have positive gram stain & culture, pH < 7.2,
glucose < 60 an needs chest tube. Empyema is frank pus.
Zollinger Ellison: also called gastrinoma. Prominent gastric folds, ulcer located
beyond duodenal bulb on endoscopy. Measure serum gastrin levels. > 1000 is
diagnostic. If not, do secretin stimulation test.
Alcohol Withdrawl: first 6-24 hours -> anxiety, insomnia, tremors, sweating.
First 48 hours -> seizures, hallucinations. Delerium tremens -> after 48-96
hours -> HTN, agitation, tachycardia, hallucinations, fevers. Treat with BZD
like chlordiazepoxide (Librium).
Status Epilepticus: ongoing seizures activity for > 5-10 minutes or lack of
interictal return to baseline. Resistant to medications. First step is appropriate
oxygenation an blood pressure, with endotracheal intubation. Use BZD or
phenytoin as second line.
Warfarin: inhibits vit K dependent clotting factors II, VII, IX, X, protein C, S.
Protein C has half life of 9 hours -> early signs of protein C deficiency ->
hypercoagulabilty -> thrombus formation -> skin necrosis. Common in
patients with congenital protein C deficiency.
Test Cut Off Points: lowering cut-off point increases sensitivity. Increase true
positives an false positives. PPV = TP/TP+FP. PPV will decrease an false
negatives will also decrease.
CAD: risk factors -> men > 45, women > 55, HTN, smoking, HDL < 40, family
history of early CAD (men < 55, women < 65). HDL > 60 negates one risk
factor. Risk equivalents impart equal risk for MI as having a previous MI. They
are DM, symptomatic CVD, AAA, PVD, 10 year risk > 20%.
Risk Category
LDL Goal
CAD or Equivalent
2+ RF
0-1 RF
< 100
< 130
< 160
When
lifestyle
changes start
> 100
> 130
> 160
Diverticulitis: history of constipation with little fiber. LLQ pain an fever. Give IV
antibiotics until symptoms resolve. If fail to response, do CT to evaluate for
perforation, abscess, fistula.
Febrile Neutropenia: ANC < 1500. Susceptibility increases < 1000. Ability to
control own flora decreases < 500. Fever in these patients classified as one
temperature > 100.9, or > 100.4 for over an hour. Bacteria from skin an flora
are MC, mostly G(+). Start antibiotics that are broad spectrum an cover
Pseudomonas. Ceftazidime, cefepine, imipenem, meropenem, or combination
of aminoglycoside an anti-pseudomonal beta-lactam.
Septic Arthritis: acute onset painful swollen joint, limited ROM, fever > 104,
fluid WBC 50-150k. Crystal induced presents similarly but WBCs between 1050k an lower fever. Prosthetic joint increases risk. Knee is most commonly
affected by hematogenous distribution. Staph aureus is MCC in prosthetic joint
septic arthritis.
of
hypergranular
Graves Disease: insomnia, fatigablilty, weight loss, lid lag, tremor. Atrial
fibillation is common due to increased sensitivity of beta receptors. Best
choice for stable patients is a beta blocker. Controls atrial fibrillation an other
symptoms of hyperthyroidism.
Asthma: intermittent -> daytime symptoms < 2x/wk, nighttime awakenings <
2x/mo, use of beta agonists < 2x/wk, baseline FEV1/FVR ratio is normal, no
limitations of daily activities. Treat with short acting bronchodilator as needed.
Mild persistent -> symptoms > 2x/wk but < daily, nighttime awakenings 34x/mo, minor limitation, normal PFTs. Add low-dose inhaled steroid as a
controller. Moderate persistent -> daily symptoms, weekly nighttime
awakenings, FEV1 < 60-80% predicted. Add long-acting inhaled beta 2
agonist. Severe persisent -> symptoms throughout the day, frequently
nighttime awakenings, extremely limited activity, FEV1 < 60% predicted. Treat
with as needed albuterol inhaler, long acting inhaled beta 2 agonist, high dose
inhaled corticosteroids. Possible oral steroids.
Radioactive Iodine: preferred treatment for Graves disease. Takes about 6-8
weeks for improvement. Contraindicated in pregnancy an very severe
ophthalmopathy. No higher incidence of cancer.
Sideroblastic Anemia: defective heme synthesis, MC due to pyridoxinedependent impairment in early steps of protoporphyrin synthesis. Present with
microcytic hypochromic anemia but can see normochromic cells (dimorphic
population). Will have high iron an low TIBC. Isoniazid an alcoholism can be a
cause. Give B6 to treat. Bone marrow biopsy will show ringed sideroblasts.
Cervical Spondylosis: chronic neck pain. Limited neck rotation an bending due
to osteoarthritis an muscle spasm. Osteophytes -> radiculopathy -> sensory
abnormalities. X ray -> bony spurs, sclerotic facet joints, narrowed disc
spaces, hypertrophic vertebral bodies. These findings are of low specificity.
MEN I: non-beta cell pancreatic tumor like gastrinoma -> abdominal pain,
diarrhea. Endoscopy -> multiple ulcerations, prominent gastric folds. Also
have primary hyperparathyroidism, pituitary tumors, other neuroendocrine
pancreatic tumors.
HEV: RNA virus. Histology -> focal necrosis, ballooned hepatocytes, acidophilic
hepatic degradation. Transmitted through fecally contaminated water.
Commonly found in India, Africa, Asia, Central America. Diagnosed by
detection of HEV RNA by PCR in serum or feces or IgM Ab. Self limited, no
chronic carrier state. Fulminant hepatitis can occur, more common in pregnant
women, especially in 3rd TM, can be transmitted vertically.
TMJ Dysfunction: history of teeth grinding, interpret as ear pain. Pain is worse
with chewing. May have crepitus or clicks in the TMJ with movement. Exclude
all other ear conditions. Initial treatment is conservative, like nighttime mouth
guard. Surgery sometimes needed.
Hyperthyroid: plasma TSH is best initial test -> usually low unless TSH
secreting adenoma. Free T4 is usually elevated. Do EKG to rule out
arrhythmia. Do 24 hour radioiodine uptake to differentiate Graves from other
disease. Use propranolol for symptomatic relief.
ACE Cough: non productive cough occurs in 5-20%. Kinins are degraded by
ACE. Accumulation of kinins an some activation of the arachadonic acid
pathway are the cause. Discontinue drug. If cough persists, do CXR, PFT,
barium swallow, bronchoscopy.
Prevention of Back Injury: usually present with lumbar strain (relation to heavy
lifting, no radicular signs, good response to conservative therapy). Strengthen
supporting muscles (abdominals), avoid sleeping on stomach, learning proper
bending an lifting. No twisting an bending exercises. Bend at knees, not at
waist. Keep back straight. Do warm ups.
Lyme Disease: doxycycline is first line for early lyme. Also treats coexistant
ehrlichiosis. In pregnant/lactating women an children, treatment choice is
amoxicillin. Penicillin G is alternate for early localized during pregnancy or
disseminated. IV ceftriaxone or cefotaxine (3 rd generation) are used for early
disseminated or late.
Chest Pain: methods for diagnosing CAD are only helpful for those at
intermediate risk. A (-) non invasive test in a high risk patient is likely false (-).
A (+) test in a low risk patient is likely false (+). In young women, anxiety an
psychosocial issues are a common cause.
Colon Ulcer: on scope, questionable ulcer needs biopsy to rule out cancer an
distinguish UC from Crohns since treatment is different for both.
Elevated BUN/Cr Ratio: prerenal azotemia (elevated BUN with mild elevated
Cr), steroid administration, or GI bleed (bacterial breakdown of hemoglobin
with urea reabsorption).
Megaloblastic Anemia: due to folate or B12 deficiency. Smear shows large RBC
an hypersegmented neutrophils. Have elevated homocysteine (cant convert
to methionine). B12 converts methylmalonyl CoA to succinyl CoA. B12
deficiency -> elevated MMA.
Hypertension: has the strongest association with strokes. Increases the risk of
all types of strokes. Have 4x higher risk of strokes than non-hypertensives.
Smoking an DM are also risk factors. Hypercholesterolemia more associated
with CAD.
HTN
Management:
pharmacologic
an
non-pharmacologic.
Lifestyle
modification is necessary: smoking cessation, weight loss, sensible alcohol,
reduce salt in diet. With multiple readings of > 140/90, an not improved with
lifestyle, JNC guidelines are to put on medication. Best first line is a thiazide.
Asthma is a contraindication for beta blockers. D
Hypovolemic Shock: blood loss -> loss of intravascular volume -> decreased
CO, decreased PCWP (indirect measure of LAP) -> activation of SANS ->
vasoconstriction, increased HR.
GBS: ascending paralysis, areflexia, sensory changes 3-4 weeks after a URI or
GE. CSF albumino-cytologic dissociation is specific. Facial nerve paralysis an
autonomic dysfunction can occur. Treat with IVIG an plasmapheresis.
Myocarditis: otherwise healthy young people with acute onset CHF an lack of
CAD risk factors. Usually viral due to coxsackie B virus. May have preceding
viral type symptoms.
Central/Tertiary
Adrenal
Insufficiency:
low
CRH
due
to
chronic
supratherapeutic doses of steroids -> low ACTH an cortisol, normal
aldosterone levels (not under CRH control). MCC of adrenal insufficiency.
Dihydropyridine CCB: cause peripheral edema along with CHF, renal disease,
venous insufficiency. Cause peripheral vasodilation. If significant, discontinue.
Labs will be normal. Not an allergy!
Crohns Disease: involves entire GI tract an has skip areas. Can have apthous
ulcers in the mouth (non specific) an can see granulomas. Associating
abdominal pain with extra-intestinal manifestations can help diagnose. Can
have weight loss an anemia.
Frostbite: best initial treatment is rapid rewarming with warm water (40-44).
Results in less tissue damage than slow rewarming at room temperature.
Immerse in room water that is continuously circulated. Do not attempt to
debride initially. Dry heat is not effective.
S4: low frequency heart sound at the end of diastole just before S1.
Associated with LVH from long staning HTN, or restrictive cardiomyopathy.
Sounds like Tennessee. Results from atrial kick hitting stiff LV.
HBV Vaccination: decreases incidence of HCC especially areas with high HBV
like Africa an Asia (chronic HBV secondary to vertical transmission major
cause of HCC). In US, MC contracted due to contaminated blood. 7 th & 9th MCC
cancer death in men an women.
Morning Hyperglycemia: due to Somogyi effect (high NPH dosing with peaks 410 hours after injection -> overnight hypoglycemia -> epi, NE, glucagon
release -> glycogenolysis an gluconeogenesis -> morning hyperglycemia) or
Dawn phenomenon (decreased insulin sensitivity between 3 an 8 AM ->
hyperglycemia at 3 AM an 7 AM due to spikes of GH release which occurs
shortly after falling asleep) or waning circulating insulin (usually coexists with
Dawn phenomenon, 3 AM glucose is usually normal).
Cut Off Point: lowering cut off point will increase sensitivity.
Zinc Deficiency: result from chronic TPN (lacks zinc) or malabsorption due to
SB resection due to IBD. Causes alopecia, bullous/pustulous lesions around
orifices or extremities, abnormal taste, impaired wound healing. Normally
digested in the jejunum.
Survival in CHF: ACE I, ARBs, beta blockers, spironolactone all confer survival
benefit. Digoxin an furosemide can reduce symptoms an hospitilzations, but
do not help survival.
Essential Tremor: AD, heads an UE are often affected, worse when arms
outstretched at the very end of goal directed activities (intention tremor).
Treat with propranolol.
COPD: often have CO2 retention -> respiratory acidosis. Use diuretics to treat
cor pulmonale but caution is needed because they have a reduction in CO
with subsequent development of renal failure.
Influenza: acute onset fever, chills, cough, malaise, myalgias. Occurs in winter.
Febrile with wheezes, crackles, course breath sounds. CXR may be normal or
have interstitial pattern. Nasal swabs confirm. Start antivirals within 48 hours.
Neuraminidase inhibitors (oseltamivir an zanamivir) are used, rimantadine an
amantadine are only effective against influenza A.
PPD: detect patients with latent TB infection. Degree of induration required for
(+) test depends on pre-test probability. >15 mm is (+) for healthy patients
with no known TB risk factors. >10 mm is (+) in immigrants from endemic
area, IVDA, residents/employees of high-risk settings, patients with
diabetes/CKD/hematologic malignancies/fibrotic lung disease, children < 4 or
teens exposed to high risk adults. >5 mm is (+) in HIV, recent contact with TB,
signs of TB on CXR, organ transplant, patients on immunosuppression.
Pancreatic Cancer: 5th MCC of cancer related mortality. RF: male sex, >50
years, black race, smoking (most consistent reversible RF), chronic
pancreatitis, long staning diabetes, obesity, familial pancreatitis, an
pancreatic cancer in close relative. Alcohol, gallstones, coffee intake are not
RF.
Kidney Stones: colicky flank pain with radiation to the groin. MC are calcium
oxalate that are envelope shaped. RF are small bowel disease, surgical
resection, chronic diarrhea -> bile salt an FA malabsorption -> calcium
chelation -> reabsorption of oxalate.
DVT: presents with calf pain, swelling, discoloration (other DDx is Bakers cyst,
muscle strain, venous insufficiency, cellulitis). Decision to anticoagulate based
on history, physical, an non-invasive testing: compression ultrasound. If low
risk, do D-dimer. If negative, no anticoagulation. If positive, do ultrasound.
Aspiration Pneumonia: fever, cough with foul smelling sputum after endoscopy
or other instrumentation. Poor dentition also RF. Add antibiotic with anaerobic
coverage like clindamycin.
Atrial Myxoma: MC primary intracardiac tumor, usually in LA. Can cause fever,
weight loss, neurologic symptoms due to embolization, an mass on echo.
Usually in elderly patients.
Chronic Liver Disease: all patients should be vaccinated against HAV an HBV
unless already immune (look at Ab levels), due to high risk for acute hepatic
failure or cirrhosis.
NPH: abnormal gait (slow broad based shuffle), incontinence (urinary, fecal in
late disease), dementia due to increased ventricular size without increased
pressure. Treat with large volume LP an, if successful, VP shunt.
Central Line Thrombosis: prolonged placement -> thrombosis -> swelling (arm
if SCV). Remove catheter an duplex to document thrombus an need for
anticoagulation. Common with TPN lines which should be in RA. Hyperosmolar
fluid -> irritation of vein. Have swollen arm with present pulses. Swelling may
extend into head an neck with distended veins.
Dehydration: altered MS, dry mucosa, high electrolytes/Hct, BUN/Cr > 20.
Elderly patients are predisposed due to decreased thirst response, impaired
sodium retention, impaired renal concentration. Treat with NS, but caution: Na
loading unmasks subclinical CHF.
Hypercalcemia:
abdominal
pain/constipation,
polyuria,
psychiatric
disturbances (usually calcium > 12). Treat with normal saline an then loop
diuretic. Can be seen in MM with back pain an pancytopenia, due to osteoclast
activating factor -> lytic lesions an hypercalcemia.
Serum Sickness Like Reaction: can occur 1-2 weeks after administration of
penicillin, amoxicillin, TMP-SMX, or cefaclor after viral illness. Fever, urticarial
rash, polyarthralgia, LA. Distinct from immediate hypersensitivity reactions.
Discontinue offending agent.
Lumbosacral Strain: MCC of acute back pain usually after physical exertion,
absence of radiation, presence of paravertebral tenderness/contraction, (-)
straight leg raise, normal neurological exam. Treat with NSAIDS an early
mobilization.
ABCs: start in management of ANY patient coming into ER. Poor circulation
evidenced by hypotension, pallor, tachycardia, delayed capillary refill ->
volume resuscitate -> hemodynamically stable -> start with diagnosis.
Anal Fissure: slit like tears of anal canal usually on anterior or posterior anal
verge due to passage of large, hard constipated stools. Crypt abscesses,
explosive diarrhea, perianal dermatitis/infection, IBD, trauma, sexual abuse
can all be causes. Severe pain an bright red bleeding. Treat acute an chronic
with high fiber, lots of fluids, stool softener, local anesthetic.
GERD: patient with asthma like symptoms that occur only at night (especially
those who eat late or go straight to bed), sore throat, horseness, wheezing.
Start with lifestyle modification (avoid eating late, elevated head of bed), PPI.
Atrial Flutter: sawtooth pattern of atrial impulses on EKG with large P waves
that do not conduct all QRS complexes. Caused by re-entrant rhythm. Present
with palpitations, CP, SOB, lightheadedness. Ventricular rate determined by AV
node conduction. MC is 2:1 block, can have 3:1 or 4:1 (variable AV node
conduction).
White Out Lung: have opacification with mediastinal shift towards affected
lung due to atelectatic volume loss. MC due to obstruction due to mucus
plugging, tumor, foreign body, external compression. Causes dyspnea,
tachypnea, diaphoresis, confusion, cyanosis. Urgent bronchoscopy for
diagnosis an possible relief of obstruction.
Hyperkalemia: removal of K from the body only done via dialysis, diuretics, or
exchange resins like Kayexalate acts in GIT to exchange Na for K. Treatment
also uses calcium gluconate, bicarb, insulin with glucose/dextrose, beta
agonists.
are raised, transmission when dogs live close to humans an are fed viscera of
slaughtered animals. Human ingestion -> intestinal penetration ->
dissemination. Cysts are have germinal layer (can give rise to daughter cysts)
an laminated layer.
Case Control Study: pateitns with disease of interest (cases) an people without
disease (control) are asked about previous exposure an exposure odds ratio is
measured compared case rate to control rate.
Nitrates: venodilation -> improves cardiac chest pain by reducing preload ->
decreased myocardial O2 deman. Reduces ventricular volume an wall stress.
Also cause some arterial dilation -> some decreased afterload an myocardial
O2 consumption.
ARDS: endothelial injury -> fluid leakage from capillaries -> fills interstitium
an alveoli -> intrapulmonary shunting -> hypoxia refractory to O2. Acute
onset, PaO2/FiO2 < 200, bilateral infiltrates, Swan Ganz < 18/absense of
JVD/cardiomegaly (which indicates CHF).
Wilsons Disease: AR, abnormal copper deposits in liver, basal ganglia, cornea.
Liver disease (asymptomatic to fulminant), neuropsychiatric. Have low
ceruloplasmin, increased copper excretion, Kayser-Fleisher rings.
Liver Mass: isolated mass is more likely to be metastatic than primary. Primary
tumors of GIT, lung, breast are MC. Usually asymptomatic an present with
symptoms of primary malignancy. With chronic abdominal pain ->
colonoscopy.
Ventilation: RR x Vt. Respiratory alkalosis (pH > 7.4, decreased CO2) results
from hyperventilation. In setting of appropriate Vt, lower RR (decreased Vt ->
increased RR -> worsens situation). Normal Vt is 6 mL/kg ideal body weight.
Aortic Dissection: suspect with acute retrosternal pain an normal EKG. Check
BP in both arms an listen for diastolic murmur of AR. TEE is preferred diagnosis
to MRI (takes too long) or CT. HTN should be controlled before TEE.
PE: signs an symptoms are non specific an variable. Suspect in patient with
sudden onset SOB, pleuritic chest pain, low grade fever, hemoptysis,
tachypnea, tachycardia, hypoxia. Calf swelling an Virchows triad not always
present. Low O2 an atrial fibrillation = poor prognosis.
PE: patients with recent orthopedic surgery are at higher risk for DVT an PE an
anticoagulation will be needed. Will have elevated A-a O2 gradient due to
impaired gas exchange (also seen in interstitial disease, an other processes
that alter V/Q).
Minimal BRBPR: on toilet paper, drops in toilet bowl, some on outside of stool,
not intermixed. MCC hemorrhoids, anal fissure, polyps, proctitis, rectal
ulcers/cancer. If patient < 50 with no risk factors, do anoscopy or proctoscopy,
then colonoscopy if no etiology found.
Central Retinal Vein Occlusion: subacute monocular vision loss with blood an
thunder appearance on fundoscopy of optic disc swelling, retinal
hemorrhage, dilated veins, cotton wool spots. Caused by coagulopathy,
hyperviscosity, atherosclerosis, chronic glaucoma.
Central Retinal Artery Occlusion: sudden, painless loss of vision in one eye
with optic disc pallor, cherry red fovea, boxcar segmentation of blood in retinal
veins.
COPD: progressive expiratory airflow limitation -> air trapping, decreased VC,
increased TLC/residual capacity an FEV1 is disproportionately decreased.
Accompanied destruction of alveolar-capillary membrane.
MCA Infarct: with aphasia, usually cerebral cortex on the left. Brocas is
common an patients will have word finding difficulties. Rapid irregular rhythm
-> atrial fibrillation -> cardiogenic source of embolus (could be caused by MI
due to CAD).
for diagnosis of interstitial disease. Can use sputum induction with hypertonic
saline (high specificity, 50% sensitivity).
Serous Otitis Media: middle ear effusion without active signs of infection, dull
TM that is hypomobile. MC middle ear pathology in AIDS. HIV LA or obstructive
lymphomas -> auditory tube dysfunction. MC symptom is conductive hearing
loss.
Gonnococcemia:
triad
of
polyarthralgia,
tenosynovitis,
painless
vesiculopustular skin lesions. Can have fever an chills. History of recent
unprotected sex with new partner. Usually no symptoms of symptomatic
venereal disease.
Angioedema: ACE I are the MCC of acquired, usually one week after stopping
drug. Edema in the face, lips, tongue, glottis, larynx. Occurs due to
Male Incontinence: MCC in older men is bladder outlet obstruction due to BPH
or carcinoma of the prostate. Present with post void dribbling, poor stream,
hesitancy, urgency, nocturia, urinary retention. Will have enlarged prostate
with high PVRV.
T2DM: most patients require more than one oral agent, an some eventually
need insulin. Metformin plus sulfonylurea (glyburide) is good combination.
Assess renal status, metformin causes lactic acidosis. Also helps some weight
loss.
PE: proximal deep leg veins (iliac, femoral, popliteal) are MC source of
symptomatic PE. Calf, renal, pelvic, upper extremity, an right heart are also
possible locations.
Nasal
Polyps:
chronic
rhinosinusitis,
asthma,
ASA/NSAID
induced
bronchospasm (aspirin exacerbated respiratory disease, AERD). Symptoms of
bilateral nasal obstruction, nasal discharge, anosmia. Bilateral gray glistening
mucoid masses in nose.
Spinal Stenosis: MC caused by degenerative disk disease with low back an leg
pain. Also called neurogenic claudication. Pain worse with walking, but leg
pain is position dependent an persists when staning still. Claudication is
exertion dependent. Diagnosed by MRI. Treated conservatively or with
laminectomy.
Acid Base Status: pH an PaCO2 are best values to determine status. HCO3 is
calculated from Henderson-Hasselbalch equation. pKa of CO2/HCO3 pair is
6.1.
Ventricular Free Wall Rupture: occurs during remodeling post MI. MC presents
3-7 days after (along with papillary muscle rupture), upto 2 weeks. Rapid
onset PEA is a result of tamponade -> shock -> sinus tachycardia. Do
pericardiocentesis.
MI: ischemia -> diastolic dysfunction an stiff LV -> atrial gallop (S4).
Parvovirus B19: arthritis of MCP, PIP, wrist, ankle joints. Anti-B19 IgM is
diagnostic. Frequent contact with children is diagnostic. MCC of viral arthritis
(polyarticular an symmetric), also HIV, hepatitis, rubella. May not have other
symptoms, resolve in 2 months.
Airway Obstruction: always rule out first with sudden onset SOB. Will have
dyspnea, difficulty swallowing, may have history of food allergies, urticaria,
laryngeal edema. May have stridor an harsh respiratory sounds.
Flash Pulmonary Edema: usually due to acute heart failure (MI). Use diuretic
such as furosemide -> decreases preload an venodilates. Beta blockers are CI
because they can worsen heart failure. Also give morphine, nitrates, oxygen,
PTCA/thrombolysis, anticoagulation.
PAC: premature activation of atria from ectopic source. Early P wave, single or
bigeminy. Can cause palpitations. Can result in SVT. Treatment needed if cause
distress or SVT. Tobacco, alcohol, caffeine, stress can all precipitate. Beta
blockers are helpful in symptomatic patients.
Gluconeogenesis: main substrates are alanine, lactate, an glycerol-3phosphate. Pyruvate is an intermediate of alanine during the process (via
ALT).
Anserine Bursitis: localized pain over the anterior medial tibial plateau just
below the medial joint line. Valgus stress an x rays are normal. Can be caused
by abnormal gait, overuse, trauma. Pain may present overnight. Rest, ice,
steroid injections.
Iron Poisoning: disrupts basic cell processes (free radial an lipid peroxiation) ->
hematemesis, abdominal pain, shock, metabolic acidosis. Occurs in children of
Polycythemia Vera: increased RBC mass an totcal circulating volume. Old male
with pruritis after bathing. Hyperviscosity symptoms. Thrombosis an bleeding
due to elevated platelet count an low functionality. Reversible moderate HTN.
Granulocytosis, splenomegaly, hypercelluar bone marrow, elevated LAP,
normal O2 saturation. Low serum/urine erythropoietin.
PE: common cause of pleuritic chest pain. Young person with tachycardia,
dyspnea particularly if on OCP. Will have subsequent minor or massive
infarction.
CLL: see smudge cells on smear with small mature lymphocytes. Can have
splenomegaly, anemia, thrombocytopenia (associated with poor prognosis).
Nocardia: filamentous, aerobic, G(+) soil bacterium that is partially acid fast
an causes pulmonary or disseminated disease in immunocompromised hosts.
Treat with TMP-SMX. Can be confused with TB or Actinomyces. Have cough
with purulent sputum. Can have alveolar infiltrates with nodules an cavitation.
Can have SQ or brain abscesses.
G6PD Deficiency: can have positive Prussian blue stain in urine due to
hemosiderin due to hemolysis. Attacks precipitated by sulfa drugs,
antimalarials, nitrofurantoin.
3rd Degree Heart Block: complete independence of P waves from QRS. Needs
pacemaker placement due to risk of VT or VF. QRS usually > 120 msec. V rate
is usually low -> dizziness an hypotension.
TIA: cerebral ischemia -> focal neurological dysfunction < 24 hours. Always do
head CT to distinguish ischemia from bleed. If thrombosis is suspected, give
antiplatelet agent (ASA). Warfarin good for cardiogenic emboli. Treatment is
important due to high risk of another.
Sleep Apnea: morbidly obese middle aged man with daytime sleepiness,
morning HA, increased fatigability an snoring. Can see mild HTN which
improves with treatment. Treat with weight reduction, avoid sedatives/alcohol,
avoid supine sleeping as first step. CPAP an UPPP also help.
Atrial Fibrillation: patients are at risk for strokes an need anticoagulation. With
no other RF, use ASA. With CHF, HTN, age > 75, DM, previous stroke/TIA,
valvular disease, use warfarin.
ED: in the setting of pelvic fractures with urethral injuries, usually caused by
parasympathetic nerve injury an altered arteral supply. Failure to achieve
Cryptosporidium: major cause of chronic diarrhea in HIV patients with CD4 <
180. Modified acid fast stain of stool shows oocysts. Can occur in
immunocompetent an HIV with CD4 > 180 but is self-limited.
ESRD: treatment options are transplant or dialysis. Renal transplant has better
survival rates an QoL. Living related > living non-related > cadaver. Anemia,
bone disease, HTN persist with dialysis. Transplant patients have better return
to normal function. Autonomic neuropathy is worse with dialysis. Survival 95%
at 1 year, 88% at 2 years.
DKA: causes anion gap metabolic acidosis. Have polyuria, polydipsia, nausea,
vomiting, abdominal pain that may present like surgical abdomen.
Heat Stroke: defined as temperature > 105. Exertional type occurs in healthy
individuals exercising in extreme heat. Dehydration, hypotension, tachycardia,
tachypnea. Seizures, ARDS, DIC, hepatic/renal failure may also occur. High
humidity may prevent sweating, can be exacerabated by medications with
anticholinergic activity.
Amebic Liver Abscess: contain debris described as anchovy paste, but cyst
aspiration is not recommended. Treatment is oral metronidazole. Recent
immigration, RUQ pain, tender solitary abscess. Caused by Entamoeba
histolytica, can cause dysentery, brain, cardiac, pulmonary involvement. CT or
MRI plus leukocytosis an elevated ALP. Also serum testing.
DEXA scan: USPSTF recommends one time screening for all women > 65, > 60
with RF. T score compared to younger individual of same gender an race. -1.5
to -2.5 is osteopenia, < -2.5 is osteoporosis. High risk in post menopausal
women.
Diabetic Neuropathy: TCAs are DOC. Can worsen urinary symptoms an cause
orthostatic hypotension. Gabapentin is the alternative. Usually present at rest
an worse at night. As it progresses, pain subsides an disappears, whereas
sensory deficit stays. Small fiber is more pain an allodynia, large fiber is more
sensory loss, low proproceiption, no ankle jerk.
Acute Pericarditis: typically occurs in first several days after an MI. Sharp
pleuritic pain worse when lying down an better when sitting up an leaning
forward. Diffuse ST elevations with PR depression is common. Friction rub may
be heard.
Alpha 1 Antitrypsin Deficiency: non smoking adults < 45 years old with pan
lobular emphysema (centrilobular in smoking). Causes liver disease (may
present as neonatal hepatitis, cirrhosis, liver failure). Measure serum A1AT.
SAH: vasospasm is major cause of M&M. CCB (nifedipine) are used to prevent
vasospasm. Signs of ischemia appear 7 days after bleed.
Postictal Lactic Acidosis: transient anion gap metabolic acidosis that resolves
without treatment after 60 to 90 minutes after cessation of seizure activity.
Excess production of lactic acid an decreased hepatic uptake. Observe an
repeat chemistry panel in 2 hours.
Emphysematous Cholecystitis: secondary infection of the GB wall with gasforming bacteria. Typically older males. RF are vascular compromise,
immunosuppression, gallstones. Complications are gangrene an perforation.
Air fluid levels in GB. Treat with fluids, electrolytes, early surgery, an
antibiotics.
After NSAIDs, try short acting morphine until under control, then use long
acting patches or narcotics.
MS: patchy neurological problems, optic neuritis (painful loss of vision in one
eye with central visual defect. Do MRI to see cerebral or cerebellar plaques.
Precision: measurement of ranom error. Tighter the CI, the more precise.
Increasing sample size increases precision.
SCC: second most common non-melanoma skin cancer. Single most important
factor in development is sunlight. Have polygonal cells with atypical nuclei at
all levels of epidermis with zones of keratinization.
Endocarditis: viridans type strep (MC is strep mutans, also causes caries) is
MCC of endocarditis after dental procedures. Pre existing MS is RF. Other
viridans are mitis, sanguis, salivarius. Staph epidermidis causes prosthetic
valve endocarditis.
DKA: suspect in stuperous patients with rapid breathing, history of weight loss,
polydipsia, polyuria. Can be triggered by infection. Kussmauls respiration
(rapid deep breathing) due to acidosis. Measure glucose first. Then chemistry,
CBC, ABG.
Diabetic Foot Ulcers: RF are diabetic neuropathy (80%), PVD, poor glycemic
control, bony abnormalities, male sex, smoking, > 10 years, history of
previous ulcer or amputation. MCC of non traumatic amputations. Will have
loss of monofilament sensation.
External Hordeolum: also called stye. Staph abscess of eyelid. Localized small
swelling along margin of eyelid. Use warm compresses. I&D is done if no
resolution in 48 hours.
PVCs: common in post MI patients. Even though they may indicate worse
prognosis, should not be treated unless causing symptoms (can worsen
survival). Beta blockers are first line.
Osteomalacia: low to low normal calcium, low phosphorus, low 25 Vit D, high
PTH
(makes
calcium
near
normal
in
beginning
an
worsens
hypophosphatemia). Have symmetrical looser zones, pseudofractures,
blurring of the spine.
Torticollis: focal dystonia involving SCM. Can occur idiopathically, but can be
medication related (typical antipsychotics, metoclopramide, procholperizine),
congenital, secondary to trauma or inflammation. Dystonia = sustained
muscle contraction -> twisting repetitive movements or abnormal posturing.
Acute MS: usually treated with steroids. Usually used when patients have
disabling symptoms. Not used for mild sensory symptoms. To reduce
frequency
of
exacerbations,
use
interferon,
plasmapheresis,
cyclophosphamide, IVIG, glatiramer acetate.
Acute Limb Ischemia: consider in patient with 5 Ps. Angiography will show
abrupt cutoff in blood supply. Start IV heparin. Needs surgical embolectomy or
intra-arterial fibrinolysis/mechanical embolectomy. IV streptokinase is used for
STEMI.
SCC Lung: suspect in patient with smoking history, hilar mass, hypercalcemia
(may have symptoms). Due to production of PTHrP -> increased bone an renal
resorption of calcium. May be due to bone involvement in late cancer (serious
implication).
Situational Syncope: typical is middle aged or older male who has LOC after
urination (may have BPH symptoms an nocturia) or during coughing fits. Due
to autonomic dysregulation which can be explained by straining an rapid
bladder emptying. Can have cardioinhibitory an vasodepressor mechanisms
involved.
MS: total protein is usually normal, but have high Ig levels, usually IgG but
also IgM an IgA. Oligoclonal bans present in > 85-90%. Rest of CSF is normal.
Elevated Ig also seen in neuropathies, CNS infections or viral syndromes. Not
diagnostic for MS.
Warfarin: dose should be adjusted based on INR for condition. VTE (3 month
treatment) an atrial fibrillation should be between 2 an 3 for good
anticoagulation without bleeding risk. 2.5 to 3.5 in patients with prosthetic
valves.
Scleroderma: absence of peristaltic waves in lower 2/3 an low LES tone are
characteristic for esophageal dysmotility due to scleroderma. Sticking
sensation an dysphagia with heartburn.
Hyperthyroidism: untreated, are at risk for rapid bone loss due to increased
osteoclastic activity in bone cells. Also at risk for arrhythmias (atrial
fibrillaion). Will have hypercalcemia an hypercalciuria.
PE: CT angio is test of choice but V/Q scan is useful tool for those with contrast
allergy or renal disease. Will have large perfusion defect without ventilation
defect, called mismatched defect. < 50% have this.
Non Alcoholic Steatohepatitis: insulin resistance plays central role -> fat
accumulation by increasing rate of lipolysis an elevating circulating insulin
levels. FA oxidation -> increased oxidative stress -> inflammatory cytokines
-> inflammation, fibrosis, cirrhosis.
Folic Acid Deficiency: tea an toast diet predisposes. Folic acid is head sensitive
(dont get from cooked foods). Causes macrocytic anemia. Can deplete in 4-5
months.
PE: result in pulmonary hypertension with elevated RAP an PAP, can result in
shock. Normal RAP is 4-6, normal PAP is 25/15. Will have sudden onset. COPD
an L heart disease also cause pulmonary HTN.
Left Atrial Enlargement: due to mitral stenosis. Can cause persistant cough an
elevation of left main stem bronchus. MCC is rheumatic fever. Loud S1,
opening snap, diastolic murmur. ECG will have atrial fibrillation or LAE. Echo
confirms. Surgery to treat.
Brown Sequard Syndrome: damage to the lateral STT -> contralateral loss of
pain an temperature beginning two levels below the lesion. Fibers cross early
in the cord.
Nodulocystic Acne: give oral isotretinoin with moderate to severe acne that
is nodulocystic, those with scars, acne resistant to other therapy. Topical
retinoids are for non inflammatory comedones. Benzoyl peroxide an topical
antibiotic is for mild inflammatory acne.
Chest Pain: in a young person with RF, warrants cardiac workup. First drug to
give is ASA during suspicion of coronary event to prevent platelet
Toxoplasmosis: HIV patient with fever, HA, confusion, ataxia, ring enhancing
lesion. Can have seizures an focal neurological deficits due to mass effects.
Occurs < 100 CD4. Due to reactivation, look for Ab at diagnosis. Treat
prophylactically with TMP/SMX if have Ab.
Thiazides:
cause
hyperglycemia,
increased
LDL/TG.
Also
cause
hyponatremia, hypokalemia, hypercalcemia. Still have desirable affects on CV
mortality even in diabetics. Also causes hyperurecemia.
Influenza Vaccine: all individuals > age 50 should get it yearly. Younger adults
with medical problems, frequent exposure to small children, pregnant women,
healthcare workers should also get it annually. COPD needs pneumococcal as
well, but not annually.
MG: fatigable muscle weakness involving the ocular an bulbar muscles. 15%
have a thymoma which can be seen on CT chest, small % can be invasive.
Hepatitis B: (+) HBsAg & (-) HBsAb means active infection. HBeAg indicates
high infectivity. Needle stick in unvaccinated individual -> give HPV vaccine an
Ig. Has higher rate of seroconversion than HCV an HIV.
Photo Protection: important in high risk groups. Sun avoidance is best method
of protection. Sunscreens should be applied 15-60 minutes before. Avoid
outdoor activities between 10 AM an 4 PM.
Intracranial HTN: diagnosed when ICP > 20. Presents with HA, vision changes,
nausea, vomiting, changes in awareness, focal neurological defecits. Trauma,
space occupying lesions, hydrocephalus, impaired CNS venous outflow. Worse
in morning, unsteadiness, Cushings reflex (hypertension an bradycardia). Do
CT or MRI.
VTE: treat initially with heparin & warfarin combination. If INR is therapeutic,
heparin is discontinued after 5 days. Warfarin should be continued for 6
months for first clot an lifetime for second.
FFP: given to patients with bleeding disorders an liver failure. Vitamin K will
not work because of liver disease.
CNS Lymphoma: HIV infected patient with altered mental status. EBV DNA in
the CSF, an solitary weakly ring enhancing periventricular lesion on MRI.
Statin Induced Myopathy: CPK levels of anyone on statin with muscle pain. If
highly elevated, stop the statin. Can progress to rhabdomyolysis (kidney
failure). Also causes increased LFTs.
Endocarditis: first draw blood for culture then give empiric antibiotics. IVDA an
valvular abnormalities are RF. When culture is available, antibiotics can be
changed.
Solitary Pulmonary Nodule: first step is to find old x rays. Absence of growth
over time rules out malignancy. If not available, decide if high or low risk (age,
smoking). Low -> serial CT. Intermediate -> PET, or biopsy. High -> surgical
removal.
SVC Syndrome: malignancy is MCC (smoking, weight loss). Lung cancer (SC)
an NHL are usual causes. Fibrosing mediastinitis due to histoplasmosis or Tb
HIV Esophagitis: start first with oral fluconazole directed against canidiasis.
Failure to respond in 3-5 days needs endoscopy. Usually CD4 < 50. Painful
swallowing an substernal burning. HSV an CMV are both causes as well.
NFII: young patient with acoustic neuroma an caf au lait spots. MRI with
gadolinium is best way to diagnose. Gradual tinnitus an hearing loss.
Frequently bilateral.
BZD OD: slurred speech, unsteady gait, drowsiness -> BZD or opioid. BZD do
not have severe respiratory depression an no pupillary constriction. Alcohol an
phenytoin intoxication are similar but have nystagmus. Lithium has tremor,
hyperreflexia, ataxia, seizures.
Lye Ingestion: effects are instantaneous, effects are most pronounced in the
esophagus -> liquefactive necrosis. Early upper GI contrast studies an
endoscopy are critical for evaluating damage an deciding on treatment. Have
retrosternal pain, hypersalivation, dysphagia/odynophagia. Give IVH an
receive serial abdominal an chest x rays. Gastrograffin study if rupture is
suspected.
Primary Syphilis: dark field microscopy is good for evaluation. Patients may be
involved in high risk sexual activity so HIV counseling an screening with ELISA
should be offered.
HIT: seen in about 5-15% of patients with onset in 3-15 days an resolution 4-5
days after stopping. Elevated PTT is therapeutic, thrombocytopenia is adverse
effect. Can have paradoxical thrombosis.
Opioid Intoxication: does not always present with miosis. Coingestions can
have normal pupil size or even mydriasis. Meperidine an propoxyphene do not
cause miosis. Decreased RR, obtundation, hypothermia, decreased bowel
sounds, hypotension. Needle marks on extremities. Administer naloxone.
Otitis Externa: any diabetic patient with severe ear pain, otorrhea, evidence of
granulation tissue in ear canal. Pseudomonas is MCC. Pain radiates to TMJ an
worse with chewing. Worsening with antibiotics -> malignant.
Inferior MI: right ventricular infarction -> right heart failure. Hypotension, JVD,
clear lung fields, Kussmauls sign (increased JVD with inspiration). Preload
dependent -> treat with IVF an avoid nitrates an diuretics to decrease preload.
STE in II, III, aVF an STD in I, aVL. Can use right sided EKG leads. Low HR ->
possible SA node involvement.
Retroperitoneal Hematoma: can occur even with normal INR. Back pain an
signs of hemodynamic compromise. Greater risk of bleed on warfarin in
diabetics, age > 60, hypertension, alcoholism. CT will show isodense
collection anterior to psoas, displacing kidney.
Myoglobinuria: suspect with large amount of blood on dipstick but few RBCs
on UA. Usually caused by rhabdomyolysis -> ARF (high BUN, Cr, K). Seizures
can be a cause.
New HIV Patient: VDRL, PPD, HAV/HBV serology, Ab titer for Toxoplasma are all
indicated.
ED: in treating patient with sildenafil an an alpha blocker (usually zosin), give
drugs 4 hours apart to decrease risk of hypotension. Diabetics are at high risk
for ED. Vascular complications, neuropathy, medications are usual causes.
First line is PDE inhibitors. CI in people taking nitrates, precaution in conditions
with priapism, concurrent use with drugs that may increase life
(erythromycin, cimetidine).
Portal HTN: MCC of ascites. Usually due to cirrhosis from chronic liver disease
(alcoholic or viral). IVDA -> cirrhosis due to possibility of HBV/HCV infection.
GERD: retrosternal burning after eating an lying down. May have horseness an
chronic cough especially when recumbent. Initial treatment is H2 receptor
antagonist (ranitidine) or PPI. Refractory -> fundoplication or endoscopic
treatment. Barretts an adenocarcinoma. May be trigger for asthma (upto 75%
of cases). May have wheezing (all patients with asthma symptoms should be
asked about GERD symptoms as well).
Hypertriglyceridemia: can cause acute pancreatitis when levels > 1000. May
have eruptive xanthomas on PE. Diagnose with fasting lipid profile.
Hypercalcemia, recent ERCP, trauma, infection, medications also causes.
Euthyroid Sick: any patient with acute severe illness can have TFT
abnormalities. MC pattern is fall in total T3, normal T4 an TSH (low T3
syndrome). Due to caloric deprivation an cytokine release. More severe ->
lower T3. Longer sick -> T4 an TSH drop. Prognosis : severity of lab
abnormalities.
SBP: suspect in any patient with cirrhosis an ascites who presents with low
grade fever (cirrhotics may be hypothermic), abdominal discomfort, altered
mental status. Paracentesis with PMN > 250 an positive culture is diagnostic.
SAAG > 1.1 = portal HTN as cause.
Power: the power of a study is its ability to detect the difference between two
groups. Increasing the sample size -> more power -> makes CI of the point of
interest tighter.
Herpes Encephalitis: temporal lobe affected, may present acutely (< 1 week)
with focal neurological signs. Present with lymphocytic pleocytosis, increased
number of erythrocytes, elevated protein. Do HSV PCR is gold stanard for
diagnosis. Usually HSV-1 beyond neonatal period. Can present as seizures.
EEG -> intermittent high amplitude slow waves. IV acyclovir.
Parkinsons: three cardinal signs are resting tremor (resting pill rolling usually
focal to one han an generalizes), bradykinesia, rigidity (lead pipe or
cogwheel), postural instability. 2/3 signs on physical exam grounds for clinical
diagnosis. Accumulation of alpha synuclein in substantia nigra.
AS: three most common causes are senile calcific aortic stenosis, bicuspid
aortic valve, rheumatic heart disease. Bicuspid valve considered in anyone <
70. May have CHF signs, S4.
Papilledema: transient loss of vision for a few seconds with changes in head
position, confirmed by ophthalmologic examination. Caused by increased ICP
(morning HA, changes in HA intensity with position). When ICP increased ->
transmitted to optic nerve head -> swelling. Enlarging blind spot.
Pleural Effusion: CHF is the MCC. Pleural fluid will be consistent with
transudate. Normal pleural fluid pH is 7.64. < 7.3 indicates pleural
inflammation. 7.35 would be transudative. Glucose < 60 favors
parapneumonic effusion, TB, or RA.
Breast Cancer: single most important RF is age. Women > 40-50 years of age
need regular annual mammograms. Only 10% have family history. Rare before
age 30.
NPV: probability of being free of a disease if test is negative. NPV will vary
with pretest probability. High probability = low NPV an vice versa.
HUS: child who has recently recovered from diarrheal illness an presents with
ARF, MAHA, fever, thrombocytopenia, schistocytes an giant platelets on
peripheral smear. GI bleeding is common. Purpura an HTN. Elevated LDH an
indirect BRN an reticulocyte.
SCC: of the head an neck in alcoholic smoker who presents with palpable
cervical LN. Panendoscopy (esophagoscopy, laryngoscopy, bronchoscopy) to
find primary tumor.
Dipstick: test for nitrites an esterase in suspected cases of UTI. (+) LE signifies
significant pyuria an (+) nitrites indicate Enterobacteraceae.
OA: predominantly involves DIP joints. Major radiographic features are joint
space narrowing, subchondral sclerosis, osteophytes, subchondral cysts.
Bladder Cancer: screening is not recommended even in those who are at risk
of developing the disease. 2nd MC urologic cancer. Men > women. Smoking an
exposure to industrial chemicals are common causes.
Inferior Wall MI: most likely cause is RCA occlusion (could be left circumflex).
ST elevation in inferior leads (II, III, aVF). Bradycardia an hypotension
suggesting SA node involvement.
Acne: if patient has mild acne (non inflammatory comedones) use topical
retinoids. Topical antibiotics are used if mild to moderate inflammation. Oral
antibiotics are used if papular an inflammatory acne. Oral isotretinoin for
nodulocystic or scarring.
Acute Limb Ischemia: in a patient with an MI who develops a cold leg, one has
to get an echo to rule out a thrombus in the LV.
Seborrheic Dermatitis: also called cradle cap. Papular scaly rash tends to
affect eyebrows, nasolabial folds, an scalp. Treat with moisturizers,
antifungals, topical steroids, anti-danruff shampoo. Transparent yellow
papules. Severe cases may be due to immunodeficiency.
Pronator Drift: relatively sensitive an specific for UMN damage affecting upper
extremities. Supinators are naturally stronger but exaggerated with UMN
lesion. When people are feigning, they will tend to drop the affected arm
without pronating.
PCKD: heritable form of renal disease with multiple renal cysts an intermittent
flank pain, hematuria, UTI, an nephrolithiasis. Enlarged right kidney is easier
to palpate than enlarged left because its lower. Liver might be enlarged due to
cystic involvement.
BNP: measurement of serum BNP can help distinguish between CHF an other
causes of dyspnea. Released from ventricles in response to volume overload.
Usually levels > 100 for CHF.
Orbital Cellulitis: pain with eye movement, proptosis, decreased visual acuity.
CT used to define extent or presence of abscess. Preseptal cellulitis presents
similarly with swollen, painful eye an fever. Sinusitis can cause orbital. Treat
with broad spectrum antibiotics.
Clubbing: new clubbing in patients with COPD can indicate cancer. NOT a
feature of simple COPD. Thickening of the nail bed, loss of angle between nail
bed an nail fold.
Primary HIV Infection: present with mononucleosis type syndrome with fever,
night sweats, LA, arthralgias, diarrhea. Make the diagnosis in an early stage.
Usually 2-4 weeks after the exposure. Can have mucosal ulcerations an skin
rash. Prolonged diarrhea an weight loss.
HOCM: heart murmur at LLSB that decreases with increased preload (staning
to squatting) or intensifies with decreased preload (Valsalva). MC in AA. AD
disease inheritance.
Bacillus Cereus: causes nausea an vomiting after eating rice. Symptom onset
is 1-6 hours. Produces a heat stable toxin in inadequately refrigerated cooked
rice. Chemical irritants also cause abrupt onset nausea an vomiting.
Warfarin: vitamin K antagonist used for anticoagulation. Foods with high vit K
(dark green, vegetables) decrease efficacy while foods, supplements,
medications such as alcohol, vitamin E, garlic, ginko biloba, ginseng, St Johns
wort, antibiotics increase efficacy -> bleeding.
Crigler Najjar Type 2: AR with milder jaundice (< 20). Survival into adulthood
with no kernicterus or neurological impairment. LFT an histology are normal.
Phenobarbital decreases BRN level. Periodic phenobarbital or clofibrate can be
used if necessary.
Mallory Weiss Tears: increased intragastric pressure during vomiting -> tears
in cardial mucosa an sometimes esophagus. Account for upto 10% of GI
bleeds. Usually spontaneously stops but can use vasopressin, endoscopic
injection, electrocautery.
Coarctation: presents with rib notching on CXR. 3 sign is typically seen with
coarctation of longer duration implying proximal aortic dilatation, constriction,
descending aortic dilatation. MC location is at site of LA. HA, epistaxis, cold
extremities. Radiofemoral delay. Upper extremity may be preferentially well
developed.
Lactose Intolerance: positive hydrogen breath test, positive stool for reducing
substances, low stool pH, increased stool osmotic gap. No steatorrea. Osmotic
diarrhea, abdominal cramps, bloating, diarrhea. Breath test = positive
hydrogen level after ingestion = bacterial metabolism.
Pica: appetite for non nutritive substances like ice, clay, dirt, paper products.
Can be a cause of iron deficiency (suspect chronic bleeding), especially with
ice. May also be a manifestation of psychiatric disease.
WPW: if develop atrial fibrillation with rapid ventricular rate treat with
cardioversion or procainamide/quinidine. AV blockers like beta blockers, CCB,
digoxin, adenosine should be avoided since it can increase conductance
through accessory pathway.
Iron Deficiency: low serum iron, ferritin, transferrin saturation, high TIBC. Have
low MCV, MCH, reticulocyte count. Have anisocytosis, poikilocytosis,
hypochromia, microcytosis on smear.
Mitral Stenosis: left atrial dilatation with risk of atrial fibrillation an cardiac
emboli. Pressure is transmitted to pulmonary vasculature -> dyspnea, cough,
hemoptysis. Can present with stroke. Patient may have history of rheumatic
fever or be an immigrant.
Parapneumonic Effusion: when pH < 7.2, glucose < 60, probability is high that
fluid needs to be drained. Drained via a chest tube (tube thoracostomy).
Herpes Zoster: a painful reaction of the varicella zoster virus that causes
vesicular rash in dermatomal distribution. Acyclovir an other antivirals are
used to decrease duration an incidence of post herpetic neuralgia. Pain
precedes rash by 48 hours.
CMV Colitis: any HIV (+) patient with bloody diarrhea an normal stool
examination should have colonoscopy to look for CMV colitis. Bloody diarrhea
with abdominal pain. Colonoscopy shows multiple ulcerations an mucosal
erosions. Biopsy has characteristic cytomegalic cells with intracytoplasmic an
intranuclear inclusions.
Aortic Regurgitation: wide pulse pressure, felt as water hammer pulse. Lying
down an turning to the left brings the heart closer to the chest wall an makes
the patient more aware of forceful heartbeat. Aortic root an bicuspid aortic
valve are MCC. Rheumatic fever is CC.
PE: suspected in all patients at risk of DVT with acute onset tachypnea,
dyspnea, chest pain. Can have exudative (MC) or transudative effusion.
Diagnosed by helical CT of chest.
Acute Variceal Bleeding: first step is to establish vascular access with two
large bore IV needles or central line. Protect airway an decompress stomach
with NG to prevent aspiration. 50% stops spontaneously. Terlipression (analog
of vasopressin), octreotide, somatostatin can be used. Rebleeding is common
in 6 weeks following initial bleed.
Tuberculosis: most cases occur in people who have immigrated to this country
from endemic geographic regions. Have chronic low grade fever, sweats,
weight loss, cough productive of blood tinged sputum.
Sickle Cell Trait: suspect in young black male who presents with painless
hematuria. Thought to be due to papillary ischemia due to low local oxygen
tension -> sickling.
Ankylosing
Spondylitis:
seronegative
spondyloarthropathy,
HLA-B27
association. Young men with progressive inflammatory back pain an stiffness.
Reduced lower back ROM an sacroiliitis. MC extraarticular manifestation is
anterior uveitis (monocular pain, blurring, photophobia).
occur
rarely.
Treat
with
HIT: first step in management is to stop all heparin including LMWH. HIT I is
non immune -> direct heparin effect on platelets. HIT II is autoimmune, within
4-10 days. Give alternate anticoagulation like danaparoid an direct thrombin
inhibitor (argatroban, lepirudin).
Staph Endocarditis: IVDA are at increased risk usually on tricuspid valve. Also
those with skin infections, infected medical devices. Vegetations can embolize
to the lungs causing nodular infiltrate with cavitation.
by
preferentially
excreting
Coagulopathy: FFP contains all the clotting factors an first line treatment
(esophageal variceal bleeding in patients with hepatic disease). Also has
plasma proteins an fluid. Fluid resuscitation is more important that diagnosis
in unstable patients.
Ectopic ACTH: lung cancer can cause. Important cause of Cushings. Sexual
dysfunction can be presenting complaint. Can have hypokalemic acidosis. Also
caused by adrenal neoplasia, pituitary adenoma, exogenous intake.
TCA OD: sodium bicarb (if QRS > 0.1 seconds) narrows QRS preventing
development of arrythmia by alleviating cardio-depressent action on sodium
channel. QRS prolongation -> ventricular arrhythmias.
HIV Ophthalmologic Disease: HSV an VZV can both cause severe, acute retinal
necrosis associated with pain, keratitis, uveitis, peripheral pale lesions an
central necrosis on fundoscopy. CMV retinitis is usually painless an not
associated with keratitis or conjunctivitis. Hemorrhage an fluffy or granular
lesions around retinal vessels.
Acute Hepatitis B: testing for both HBsAg an anti HBc is best screening.
ALT>AST. HBsAg is the first marker detected an is detectable during entire
symptomatic phase. Anti-HBs is found after immunization or clearance of
HBsAg, detectable for life. Indicator of noninfectivity an immunity. Window
period between disappearance of HBsAg an anti-HBs. HBcAg not usually
detectable. Anti-HBc appears after HBsAg, IgM is indicative of acute disease
an is present during window period, so is important between clearance of
HBsAg an anti-HBs. HBeAg detectable shortly after HBsAg, indicates viral
replication an infectivity. Cleared before HBsAg an followed by presence of
anti-HBe. Anti-HBe suggests cessation of active replication an low infectivity.
CIN II/III: should have Pap smears with or without coloposcopy an ECC every 6
months until 3 (-) results. May resume stanard screening after that (annual
until 65 or 70). Can increase to every 2-3 years if 3 (-) results with same
monogamous partner.
Testicular Mass: after diagnosis of solid testicular mass is made (painless hard
mass in testicle + suggestive US), initial management is removal of the testis
an cord. Transcrotal biopsy is CI due to risk of spillage of cancer cells ->
spread through lymphatics an blood.
GBS: acute or subacute ascending paralysis. CSF has elevated protein with
normal glucose, WBC, RBCs. Acute idiopathic polyneuropathy. Motor > sensory
(can have distal parasthesias). Autonomic disturbances are rare & fatal. Treat
with IVIG an plasmapheresis.
Acute Otitis Media: consider in any patient with ear drainage an difficulty
hearing. Ear pain is also common, but may be absent in young patients. Fever,
irritability, diarrhea. Can have boggy nose an PND. Erythematous TM with
decreased motion.
PAC: benign an to not require any follow up or treatment. P waves that are
premature relative to the cardiac cycle an differ in morphology. Anxiety, CHF,
hypoxia, caffeine, electrolyte abnormalities.
AV Fistulas: cause high output cardiac failure -> increased cardiac preload.
Can be due to trauma. Circulation cannot meet O2 demans of the body. Wide
PP, brisk carotid upstroke, tachycardia. Flushed extremities, displaced PMI.
Thyrotoxicosis, Pagets disease, anemia, thiamine deficiency also cause high
output cardiac failure.
Cluster HA: acute severe retroorbital pain that wakes patient from sleep.
Accompanied by redness of ipsilateral eye, tearing, redness, stuffed or runny
nose, ipsilateral Horners syndrome. Occur in clusters, daily, for 6-8 weeks,
followed by remission for a year. Acute attack: treat with 100% O2 an SQ
sumatriptan.
Anemia: the most appropriate blood product is PRBCs. In patient with preexisting heart disease, you want to keep Hgb > 10. Oxygenation can be
maintained at Hgb > 7 in patients with normal cardiac function. Transfusion is
often necessary with active bleeding.
Back Pain: common symptom. Identify signs of serious etiology: pain not
relieved by rest, night pain, constant or dull pain, lack of exacerbation with
movement or palpation, presence of neurologic changes. Cancer pain often
not tender to palpation. MC are lung, breast, prostate, renal, thyroid. In older
man, get PSA.
MEN IIa: AD, chromosome 10. Genetic testing has replaced serum calcitonin
as recommended screening test. If (+) for RET proto-oncogene, total
thyroidectomy is indicated.
Fibrocystic Disease: treat with aspiration of the cyst which should yield clear
fluid an result in disappearance of the mass. Afterwards patients are observed
for 4-6 weeks. No cytology needed. Rubbery, firm, mobile, painful mass with
more tenderness during menses.
PJP: occurs when CD4 < 200. Fever, dry cough, exertional dyspnea. CXR
shows diffuse bilateral interstitial infiltrates. Use TMP-SMX an prednisolone
when PaO2 < 70.
Homocysteine: vitamin B6, B12 an folate all play role in metabolism. B12 used
by methionine synthetase to make methionine from folate an oxidize 5-MTHF
-> THF which is reduced back to 5-MTHF by MTHFR. B6 used by cystathione B
synthetase to convert homocysteine to cystathione to be converted into
cysteine. B6 lowers homocysteine levels. B12 can be added if patient is
deficient.
Usually boys > girl except early on when are they same. Occur in distal thigh,
proximal leg, proximal humerus. MC initial symptom is pain. Surgery to treat,
either limb saving or amputation.
PID: treat with appropriate antibiotics, council on safe sex practices, inform
any partners of the past 60 days so they can be treated. Also screen for HIV,
syphilis, HBV, cervical cancer (pap), HCV if have history of IVDA.
Gonococcal Arthritis: MCC septic arthritis in young sexually active adults. Can
present as asymmetric polyarthritis (with tenosynovitis an skin rash) or
isolated purulent arthritis affecting one or a few joints. Diagnosis may be
confirmed by gram stain of the synovial fluid, blood cultures, urethral cultures,
skin cultures.
Amiodarone: class III antiarrhythmic that causes lung fibrosis (total cumulative
dose). Thyroid dysfunction (85% hypothyroid), hepatotoxicity (stop only if >
2x normal), corneal deposits (benign), skin discoloration (blue gray
discoloration of the face) are also causes.
COPD: long term supplemental oxygen therapy has been shown to prolong
survival. PaO2 < 55, SaO2 < 88, erythrocytosis (Hcrt > 55), evidence of cor
pulmonale.
Vomiting: gastric contents are rich in acid, chloride, potassium. Vomiting ->
hypokalemic hypochloremic metabolic alkalosis. Bicarbonate levels rise due to
loss of hydrogen an activation of RAAS. Give isotonic NaCl with K to correct.
Hairy Cell Leukemia: type of B lymphocyte derived chronic leukemia. Fine hair
like irregular projections from cells. Can have dry tap bone marrow aspirates
due to fibrosis. TRAP staining (strong acid phosphatase reaction not inhibited
by tartaric acid) an CD11c.
Temporal Arteritis: suspected in patients > 50 with new onset temporal HA,
jaw claudication, vision loss, symptoms of polymyalgia rheumatica. Immediate
initiation of high dose steroids to prevent damage to the retinal artery an
other vessels. ESR is elevated.
Acute Glaucoma: suspect with sudden onset of eye pain, photophobia, middilated pupil, nausea, HA. Do ocular tonometry to diagnose. Damages the
optic nerve. Drugs that dilate pupil can cause.
MS: relapsing remitting form is well defined acute episodes with no significant
disease progression between episodes. Interferon beta decreases the
frequency of relapse an reduces disability in patients with this form.
PSGN: 10-20 days after skin or throat infection. Periorbital swelling, hematuria,
oliguria. May be hypertensive. UA will show hematuria with RBC casts an
proteinuria. Serum C3 levels are low.
Pancoast Syndrome: neoplasm in the pulmonary apex at the thoracic inlet can
compress inferior portion of the brachial plexus resulting in shoulder pain
radiating in the ulnar distribution. Causes Horners, hoarse voice, SVC
syndrome.
New Onset Seizures: CT scan of the head without contrast is the first
diagnostic test when patients presents with new unprovoked seizures. Exclude
intracranial hemorrhage.
Trachoma:
presents
with
follicular
conjunctivitis
an
pannus
(neovascularization) formation in the cornea. Caused by Chlamydia
trachomatis A-C. Concurrent nasopharyngeal infection -> discharge.
Diagnosed by Giemsa stain of conjunctival scraping. Topital tetracycline or
azithromycin. Repeated infections are due to corneal scarring.
Lacunar Stroke: if patient presents with limited neurological deficit. Pure motor
(posterior limb of IC), pure sensory (VPL thalamus), ataxic hemiparesis
(posterior limb of IC), dysarthria clumsy han syndrome (basis pontis). Principle
cause is HTN.
Lyme Disease: erythema migrans rash an facial nerve palsy. Can cause palsy
of any CN but VII is MC. EM rash may be present on arms, abdomen, moist
areas. Erythematous with central clearing or uniformly red.
Cor Pulmonale: term for right sided heart failure MC due to pulmonary
disease. Signs of right sided HF -> JVD, S3, RV heave, hepatomegaly, ascites,
dependent edema.
Acute Angle Closure Glaucoma: unilateral eye pain, redness, dilated pupil with
poor light response, photophobia, halos around things. Distinguish from
migraine, cluster headache, temporal arteritis, keratoconjunctivitis.
Colon Cancer: RF for polyps turning into colon cancer are villous adenoma,
sessile adenoma, size > 2.5 cm. Only adenomatous polyps are premalignant,
but < 1% turn into cancer. Hyperplastic are non neoplastic an do not require
further workup. Hamartomatous polyps are either juvenile or Peutz Jeghers.
Splenectomy: risk for sepsis present for > 30 years. Patients should receive
pneumococcal, meningococcal, Haemophilus vaccination several weeks
before operation an daily oral PCN for 3-5 years.
GBS: can cause respiratory muscle weakness -> failure. Best way to measure
is through serial measurements of VC. Risk for failure greatly increases when
VC < 15 mL/kg.
HIV Vaccinations: influenza, HBV, pneumococcus. HAV for MSM. Should not
receive live vacciation (BCG, varicella, anthrax, oral thyphoid, intranasal
influenza, oral polio, yellow fever). One exception is MMR, used if no evidence
of immunity an CD4 > 200 an no ADI.
Mohs Surgery: special surgery where microscopic shaving is done such that 12 mm of clear margins are excised. Highest cure rate for BCC. Indicated in
patients with high risk features, lesions in functionally critical areas (face).
Giant Cell Bone Tumor: soap bubble appearance in epiphyseal end of long
bone. 20-40 year old female with knee pain an some mass. Oval or spindle
shaped cells with multinucleated giant cells. Benign but locally aggressive.
Recurs even after local curettage. Refer to ortho.
HTN: most patients will require pharmacotherapy but lifestyle changes can
make a difference. Weight control is the most important, then physical
activity, salt restriction, moderate alcohol consumption. Smoking decreases
CV risk, but will not affect HTN.
ARF: catheterization is most critical first step. Can resolve post renal
obstructions in addition to monitoring urine output in pre-renal an intrinsic
renal failure. Urinary retention common after lower abdominal/pelvic surgery.
Cirrhosis: if signs of portal HTN are present, do endoscopy to look for varices.
May be asymptomatic until they rupture. All patients with cirrhosis should be
screened for varices. Primary prophylaxis is beta blockers.
Proteus: most likely cause of UTI with alkaline urine. Produces urease.
Common in patients of long term care facilities an chronic indwelling
catheters. Canida, Pseudomonas, Klebsiella also cause alkaline urine.
Massive PE: likely in post operative patient with JVD, new onset RBBB. PE
complicated by hypotension, right heart strain. Sycope occurs. Need
respiratory an hemodynamic support, along with fibrinolysis. Surgery in past
10 days is CI to fibrinolytics. > 50% die in 1 hour.
Acute Aortic Dissection: chest pain that is sudden, tearing, radiating to the
back. HTN is MC predisposing factor. Decrescendo diastolic murmur suggests
AR. Wide mediastinum.
Acute DVT: treat with combination warfarin an heparin for 5 days. After 5 days
heparin can be discontinued if INR is therapeutic. Warfarin should stay on for 6
months for first clot. Progressing clot with subtherapeutic INR needs bridging
heparin until INR is therapeutic.
Reyes Syndrome: found in children given ASA for viral induced fever. Can
cause fulminent hepatic failure. Elevation of ammonia levels, transaminases,
vomiting, mental status changes are common manifestations. Diffuse
mitochondrial disease -> extensive fatty vacuolization of liver. Treat with
glucose with FFP an mannitol to decrease cerebral edema.
bronchodilators,
systemic
Allergic Rhinitis: nasal eosinophilia is characteristic for allergic rhinitis, but not
specific. Absent in patients with infectious (neutrophils) or vasomotor rhinitis
(non allergic). Nasal polyposis (including ASA sensitivity) an non-allergic
rhinitis with eosinophilia.
HHNK: very high blood glucose, plasma hyperosmolarity, normal anion gap, (-)
ketones. Can get very dehydrated -> poor perfusion -> lactic acidosis. T2DM.
Enough endogenous insulin to suppress ketosis but not hyperglycemia. Serum
osmolarity is 2(Na)+(Glc/18)+(BUN/2.8).
Vaccinations: all adults should have Td every 10 years. Adults with close
contact with children 0-59 months should have influenza vaccine.
PJP: non productive cough, exertional dyspnea, fever, severe hypoxia, bilateral
interstitial infiltrates on CXR, normal white count. CD4 < 200. TMP-SMX is
DOC. Steroids decrease mortality. Indications for steroids are PaO2 < 70, A-a
gradient > 35.
Warfarin Induced Skin Necrosis: pain -> bullae formation -> skin necrosis.
Breast, buttocks, thighs, abdomen are commonly involved. Protein C
deficiency is commonly associated. Females are MC affected. Occurs within
weeks. Vit K should be given initially an warfarin discontinued if progresses.
Heparin should be used until heals.
Mitral Valve Prolapse: mid systolic click over the apex, with short systolic
murmur after the click. Squatting decreases the murmur. Associated with
chest pain, anxiety, palpitations, hyperventilation.
HTN in Diabetes: better to keep systolic < 130 to prevent slow end organ
damage in diabetes an CRF. Want to keep diastolic < 80.
Vitamin K Deficiency: seen in patients who are NPO for a long time an
receiving broad spectrum antibiotics. Labs show prolonged PT an then PTT. PT
elevated more than PTT. Fat soluble vitamin that serves as a cofactor for
S3: low frequency diastolic sound heard just after S2 that is associated with
LVF. IV diuretics provide symptomatic benefits to patients with decompensated
HF. Can be normal in younger individuals an athletes.
Transplant Patients: should be given oral TMP-SMX for prophylaxis against PJP.
Can prevent toxoplasmosis, nocardiosis, UTI, pneumonia. Vaccinate against
influenza, pneumococcus, HBV. Gancyclovir or valgancyclovir can be used to
prevent CMV infections.
Babesiosis: patient from endemic area (NE US) who presents with tick bite
especially if there is evidence of hemolysis an patient is splenectomized. Rash
is not a feature (unless thrombocytopenia is present). Jaundice,
hemoglobinuria, renal failure, death. Giemsa stained thick an thin blood
smear. Use quinine-clindamycin or atovaquone-azithromycin.
COPD: all patients with PaO2 < 55 or SaO2 < 88 are canidates for long term
O2 therapy. Signs of pulmonary HTN or hematocrit > 55, start on home O2
when PaO2 < 60. If become hypoxic during exercise or sleep can use O2.
CHF: elevated BNP an S3 are both signs of increased cardiac filling pressures.
Iron Deficiency Anemia: bone marrow iron stains is the most definitive way to
diagnose iron deficiency anemia.
PMR: pain an stiffness in the neck, shoulders, pelvic girdle in patient > 50 with
elevated ESR an morning stiffness > 1 hour. Treatment when not associated
with GCA is low dose steroids. If GCA is coming along with it, treat with high
dose prednisone.
Heat Stroke: temperature is usually > 105. Results from inefficiency cooling
mechanisms. Treatment involves induction of evaporative cooling to reverse
hyperthermia. Dunking in cold water may work but difficult to monitor the
patient.
Effect Modification: present when the effect of the main exposure on the
outcome is modified by the level of another variable. Not a type of bias!
Uric Acid: highly soluble in alkaline urine -> oral potassium bicarbonate or
potassium citrate to get urine > 6.5. Radiolucent stones. Usually due to acidic
urine. Also hydrate, try low purine diet.
Aortic Dissection: sudden tearing chest pain that radiates to the back.
Mediastinal widening is sometimes present. Leg weakness can occur if
dissection progresses to involves arteries of spinal cord. Severe HTN is a RF.
Can have pleural effusion. Do contrast CT or TEE.
Primary HIV: manifests similarly to IM. Rash an diarrhea are LESS common in
IM, tonsillar exudate is not common in HIV. Splenomegaly with splenic rupture
is worrisome. Heterophile Ab can distinguish. Arise within 1 week an can
persist upto a year. Anti-EBV Ab as well.
Hematuria: bladder tumors are the MCC of painless hematuria in adults. Could
be a kidney or ureter malignancy as well. Do contrast CT or IVP as well as
cystoscopy of bladder/urethra. Infections, trauma, nephrolithiasis, GN,
CMV Retinitis: when CD4 < 50. Patients may be asymptomatic. Yellow white
patches of retinal opacifiation an hemorrhage are diagnostic. Initially eye is
usually white an quiet. Treatment is ganciclovir or foscarnet.
SBE: one the causative agent is identified, the antibiotics can be narrowed
from empiric to specific. Strep viridans is highly susceptible to IV PCN G an IV
ceftriaxone. Progressive fatigue an waxing waning low grade fever.
Nitroglycerin: main mechanism for pain relief in patients with anginal pain is
dilitaiton of veins (capacitance) an decreased ventricular preload. This
decreases myocardial oxygen deman.
not needed if patient presents with classic EM (usually in moist areas, bulls
eye, asymptomatic).
Pericardial Effusion: electrical alternans when QRS varies from beat to beat an
is specific. Enlargement of cardiac silhouette. Echo will more definitively
diagnose. Recent URI usually precedes.
SLE: joint pain is common but not deforming. MC in hans or knees. Migratory
arthritis. Pain > physical findings. Lower incidence of joint erosion, synovial
abnormality, permanent joint deformity than RA.
Asymptomatic
Gallstones:
should
not
be
treated.
Laproscopic
cholecystectomy is only for symptomatic disease unless have high risk of GB
carcinoma or gallstone complications. 20% of these patients will develop
symptoms in 15 years.
AR: early diastolic murmur. Can also have hyperdynamic pulse (bounding,
water hammer, peripheral pulses).
Fibromyalgia: pain worse with exercise. Fatigue, IBS, depression are common.
Inflammation, joint swelling, muscle weakness are absent. No abnormal
studies. Women from 20-55. Disorder of pain regulation.
Urine Sediment: muddy brown granular = ATN, RBC = GN, WBC = interstitial
cystitis an pyelonephritis, fatty = nephrotic, broad waxy = CRF. Prolonged
hypotension -> ATN. Also have urine osm 300-350, urine Na > 20, FENA > 2%.
Hepatic Adenoma: benign tumor most often seen in young an middle aged
women who are taking OCP. Severe intra-tumor hemorrhage an malignant
transformation are dreaded complications. Sheets of enlarged adenoma cells
that contain glycocen an lipid.
Acute MR: occurs due to papillary muscle dysfunction in patients with acute
MI. Causes rise in LAP without significant increased LA size, LV size, or LV EF.
Also have pulmonary edema. PCWP shows increased pressure in LA.
HOCM: first line of treatment is beta blockers or cardiac acting CCB such as
diltiazem since they promote myocardial relaxation. Beta blockers also
prevent anginal pain.
Bacterial Pneumonia: all patients should have CXR done as first step an then
administer antibiotics without waiting for sputum gram stain or cultures.
Cervicofacial Actinomycosis: classically presents as slowly progressive, nontender, indurated mass, which evolves into abscesses, fistulae, draining sinus
tracts with sulfur granules, which appear yellow. High dose PCN for 6-12
weeks. Anaerobic G(+) branching bacteria.
Leukoplakia: hard to remove white patches in the oral mucosa an may lead to
SCC. Only associated with tobacco. Caused by chronic irritation to the mucosa
due to tobacco, alcohol, poorly fitting dentures. Risk of transformation to SCC.
Multiple Myeloma: any elderly patient with bone pain, renal failure,
hypercalcemia. 50% of patients develop some kind of renal insufficiency.
Likely due to obstruction of distal collecting tubules by large laminated casts
of Bence-Jones proteins.
Stable Angina: with HTN, treat with beta blocker. Decreases threshold for
anginal episode an controls HTN. Also are cardioprotective an can potentially
reduce the risk of major CV events by decreasing sympathetic output to the
heart.
RA: morning stiffness presents with inability to do things in the morning but
fine by afternoon time. Affects MCP, PIP, wrist. Disease of systemic
inflammation. ESR will be high. Mostly peripheral joints. If affects axial ->
cervical spine -> C1-C2 instability -> subluxation.
Pancreatitis: nausea, vomiting, epigastric pain that radiates to the back. Low
grade fever also common. History, physical, elevated amylase an lipase.
Gallstones an alcohol are MCC. Hypertriglyceridemia, anatomic abnormalities,
infection, medications also cause. Can have left sided pleural effusions when
amylase is high, abdominal compartment syndrome, intraabdominal
hemorrhage,
shock,
pseudoaneurysm.
Reactivation TB:
diabetes,
pseudocyst
formation,
abdominal