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________________________________
. HYPER-SENSITIVITY REACTIONS:
______________________________
______________________________
. TRANSFUSION REACTIONS:
________________________
________________________
. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.
. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or
washed RBCs.
. Ex -> As soon as the pt. received transfus., he becomes SOB,
hypotensive & tachycardic.
. NORMAL LDH & BILIRUBIN.
. RHINITIS:
____________
____________
. ALLERGIC REACTIONS:
_____________________
_____________________
{2} . ANGIO-EDEMA:
___________________
. H/O of ICU pt on ACEIs e.g ENALAPRIL.
. Edema in the face, mouth, lips.
. Absence of pruritis & urticaria.
. Laryngeal edema may occur causing airway obstruction.
. occurs due to BRADYKININ release.
. it may occur at any time not just at the start of drug intake.
. Dx----> Low levels of C2 & C4.
. Tx----> STOP ACEIs + FRESH FROZEN PLASMA + Secure the airway.
. HERIDITARY angioedema:
________________________
. C1 esterase inhibitor defeciency.
. usually follows an infection, dental procedure or minor trauma.
. N.B. The most common cause of acquired isolated angioedema is ACE
inhibitors use.
{3} . URTICARIA:
_________________
. Sudden swellings of the superficial layers of the skin.
. Can be caused by insects or medications.
. May be caused by pressure, cold or vibration !
. Tx -> ANTI-HISTAMINICs (Diphenhydramine & koratidine).
. The most common cause of chest pain that is NOT CARDIAC in origin is
GERD ACID REFLUX !
_________________________________________________________________________
_________________
. Ex: pt comes to the ER with chest pain in the epigastrium & associated
e' sore throat,
. A bad metallic taste in th mouth & cough is present.
. A proton pump inhibitor (Omeprazole) trial sh'd be done.
. 1 . Costochondritis:
_______________________
-> Chest wall tenderness.
-> Do physical examination.
. 2 . Aortic dissection:
_________________________
-> Radiation to the back.
-> Un-equal B.P. between both arms.
-> CXR: Widened mediastinum.
-> Confirm with Chest CT or TEE (Trans-esophageal echocardiography).
. 3 . Pericarditis:
____________________
-> Pain worse with lying flat, better when sitting up.
-> ECG -> ST elevation in all leads with PR depression.
. 6 . Pneumonia:
_________________
. Cough, sputum & hemoptysis.
. Dx -> CXR.
. 7 . Pulmonary embolism:
__________________________
. Sudden onset SOB, hypoxia, tachycardia.
. CxR -> Clear lungs.
. Spiral CT - V/Q scan - D-Dimer.
. Most accurate: Pumonary angiography.
. 8 . Pneumothorax:
____________________
. Sharp, pleuritic pain with tracheal deviation.
. CXR is diagnostic.
. 9 . Pancreatitis:
____________________
. Alcoholic pt with chest pain radiating to the back.
. Nausea & vomiting.
. Dx -> Check amylase & lipase levels.
. 10 . Cholecystitis:
______________________
. Right upper quadrant tenderness & mild fever.
. Dx -> Abdominal U/$ for gall stones.
. N.B.
. Further testing for coronary artery disease (CAD):
. sh'd NOT be done routinely in low risk pts as they frequently can've
false +ve results.
. Exercise EKG or pharmacological stress testing is most useful in
intermediate risk pts.
. High risk pts sh'd start pharmacological therapy & undergo coronary
angiography,
. if they have stable angina.
. Diagnosis:
____________
. Best initial test -> EKG.
. N.B. If the case is very clear with diagnosis of ischemic pain & the
given choices are:
. EKG & (Aspirin - Nitrates - Oxygen - Morphine) ..
. CHOOSE TTT 1st !
. N.B. CK-MB is the best to detect RE-infarction a few days after the
initial infarction:
_________________________________________________________________________
_________________
. Both CK-MB & troponin levels rise 3-6 hs after the start of chest
pain.
. The main difference is that CK-MB only stays elevated 1-2 days.
. While troponin stays elevated 1-2 weeks.
. so, CK-MB is the best to detect RE-infarction a few days after the
initial infarction.
. N.B. MYOGLOBIN is the 1st cardiac marker to rise after chest pain:
_____________________________________________________________________
. Myoglobin elevates 1-4 hours after start of chest pain.
. When do you order a STRESS TEST ?
____________________________________
. When the case is NOT ACUTE.
. When the initial EKG & cardiac enzymes can't establish diagnosis.
. Angiography is the next best step in case of an abnormal stress test.
. N.B.
. Ischemic cardiac pain can sometimes be mistaken for epigastric pain,
. but should remain high on differential.
. especially in the setting of symptoms worsened with exertion.
. An exercise stress test e'out imaging (Exercise EKG) is the most
reasonable 1st step,
. if the baseline resting EKG is normal.
. N.B.
. Dipyridamole & coronary steal phenomenon:
. Dipyridamole can be used during myocardial perfusion scanning,
. to reveal the areas of restricted myocardial perfusion.
. The redistribution of coronary blood flow to "Non-diseased" segments
by Dipyridamole,
. is called "Coronary steal phenomenon".
{1} ASPIRIN:
_____________
. The best initial therapy for all AC$.
. ANTI-PLATELET drug.
. LOWERS MORTALITY.
. Given in addition to Nitrates, oxygen & Morphine.
. CLopidogreal or Prasugrel are given in case of containdication to
Aspirin e.g. Allergy.
. They are also given in pts under-going angioplasty or there is acute
MI.
{4} STATINS:
_____________
. Given to all pts with AC$.
. Side effect -> Liver toxicity.
. Statins inhibit intracellular HMG-CoA reductase enzyme,
. prevent conversion of HMG coA to mevalonic acid & ++ NO of cell
membrane LDL receptors
. Statins also -- coenzyme Q10 synthesis involved in muscle cell energy
production,
. so .. It contributes to statin-induced myopathy.
. CPK levels sh'd be checked in any pt on a statin who presents with
myalgias.
. If highly elevated, the 1st step is to discontinue the statin.
. N.B. High dose Niacin therapy may cause cutaneous flushing & pruritis.
. This side effect is due to PROSTAGLANDIN INDUCED PERIPHERAL
VASODILATATION.
. Can be reduced by low dose aspirin.
. N.B. The main mechanism for pain relief in pts with anginal pain ttt
with NITROGLYCERIN
. VENO-DILATATION (DILATATION of CAPACITANCE VESSELS) & -- in
ventricular pre-load.
. N.B.
. GERD is characterized by a retrosternal burning sensation after eating
& lying down.
. It may be accompanied by hoarseness & chronic cough especially while
recumbant.
. Initial ttt is an H2-receptor blocker or Proton pump inhibitor.
. N.B. Pts presenting to the emergency department with chest pain &
suspected AC$,
. should be administered ASPIRIN ASAP.
. Early anti-platelet therapy with aspirin reduces the rate of MI &
overall mortality.
. N.B.
. Acute MR can occur due to papillary muscle dysfunction in pts with
acute MI.
. Acute MR characteristically causes a rise in LEFT ATRIAL PRESSURE.
. NO CHANGE in (Lt atrial size - Lt ventricular size - Lt ventricular
EF).
. NON-STEMI MANAGEMENT:
_______________________
. No thrombolytic use.
. HEPARIN is uded routinely.
. LMW heparin is preferred to the IV form.
. Glycoprotein 2b/3a inhibitors lower mortality in those undergoing
angioplasty & stent.
. Thrombolytics are used only if there is ST segment elevation or new
LBBB.
. BB are the 1st line therapy for anginal syms, improves exercise
tolerance.
. BB relieve angina by -- myocardial contractility & heart rate.
. BB improve survival rate in those with MI.
. N.B. The main difference between saphenous vein grafts & internal
mammary artery grafts
. is that veins grafts start to become occluded after 5 years,
. but internal mammary artery grafts are often patent at 10 ys.
. LIPID MANAGEMENT:
____________________
. The single strongest indication for a "statin" in a pt with AC$ & an
LDL > 130mg/dl.
. The goal of therapy in this pt will be < 100 mg/dl.
. If there is associated DM, the goal will be < 70 mg/dl.
. N.B. High dose Niacin therapy may cause cutaneous flushing & pruritis.
. This side effect is due to PROSTAGLANDIN INDUCED PERIPHERAL
VASODILATATION.
. Can be reduced by low dose aspirin.
. N.B. 10. If their is hyperkalemia 2ry to ACEIs, don't give ARBs (Also
cause ++ K)!
. Give HYDRALAZINE (DIRECT ACTING ARTERIOLAR VASODILATOR) instead.
. N.B. 11. A H/O of upper RTI followed by suuden onset cardiac failure
in a healthy pt,
. is suggestive of dilated cardiomyopathy.
. It is the end result of myocardial damage due to toxic, metabolic or
infectious agents.
. Viral myocarditis is most commonly seen following Coxsackie virus B
infection.
. Viral myocarditis may cause dilated cardiomyopathy via direct viral
damage.
. Dx -> Echocardiogram -> Dilated ventricles with diffuse hypokinesia.
. Low EF (Systolic dysfunction).
. N.B. 21. Measurement of serum BNP can help distinguish bet. CHF &
other dyspnea causes.
. A value > 100 pg/ml diagnoses CHF with,
. a sensitivity, specificity & predictive accuracy of 90, 76 & 83 %
respectively !!!
. IMPORTANT CLUES:
___________________
. Young female -> MVP.
. Healthy young athlete -> HOCM.
. Immigrant, pregnant -> MS.
. Turner's $, Aortic coarctation -> Bicuspid Aortic valve (AS).
. Palpitations, Atypical chest pain not with exertion -> MVP.
. MURMURS:
___________
. SYSTOLIC -> AS - MR - MVP - HOCM.
. DIASTOLIC -> AR - MS.
. DIANOSIS:
____________
. Best initial test -> ECHOCARDIOGRAPHY (Trans-Thoracic TTE > Trans-
Esophageal TEE).
. Most accurate test -> Left heart catheterization.
. N.B.
. Aortic stenosis in young individual mostly due to CONGENITAL BICUSPID
AORTIC VALVE.
. Pts with severe aortic stenosis often have large left ventricular
mass, so..
. requiring additional oxygen.
. ++ myocardial oxygen demand -> Anginal pain.
. N.B.
. Aortic stenosis in old individual is mostly due to AGE DEPENDENT
SCLEROCALCIFIC CHANGES
. They may present with exertional syncope due to restricted COP due to
stenotic aorta.
. N.B.
. Indications for aortic valve replacement:
-> All symptomatic pts with AS (Syncope - Angina - Dyspnea).
-> Pts with severe AS undergoing CABG or other valvular surgery.
-> Asymptomatic pt with e' AS & either poor LV systolic function, LV
hypertrophy > 15mm.
. N.B.
. The 3 most common causes of aortic stenosis in the general population
are:
. senile calcific aortic stenosis - bicuspid aortic valve - rheumatic
heart disease.
. A bicuspid aortic valve is the cause of aortic stenosis in the
majority of pts < 70 ys.
. N.B.
. AR murmur is best heard along the left sternal border at the 3rd & 4th
interspaces.
. It may be heard in some pts only by applying firm pressure e' the
stethoscope diaphragm
. while the pt is sitting up, leaning forward & holding his breath in
full expiration.
. N.B.
. In DEVELOPED countries,
. Congenital bicuspid aortic valve is the most common cause of AR in
young adults.
. N.B.
. In DEVELOPING countries,
. Rheumatic heart disease is the most common cause of AR.
. N.B.
. AR causes widening of the pulse pressure, which can be felt as "water-
hammer" pulse.
. Lying down & turning to the left brings the heart closer to the chest
wall,
. making the pt more aware of the forceful heart beat.
. LOUD S1.
. DIASTOLIC RUMBLE AFTER AN OPENING SNAP "Extra-sound in diastole".
. N.B.
. DIASTOLIC & continous murmur as well as loud systolic murmurs on
auscultation,
. should always be investigated using TTE (Trans-thoracic Doppler
Echocardiography).
. N.B.
. AORTIC STENOSIS -> Trans-Thoracic TTE.
. AORTIC DISSECTION -> Trans-Esophageal TEE.
. N.B.
. Acute MR can occur due to papillary muscle dysfunction in pts with
acute MI.
. Acute MR characteristically causes a rise in LEFT ATRIAL PRESSURE.
. NO CHANGE in (Lt atrial size - Lt ventricular size - Lt ventricular
EF).
. INFECTIVE ENDOCARDITIS:
_________________________
_________________________
. Intermittent fever.
. New murmur.
. +ve blood culture.
. Tx -> Empiric vancomycin (Covering staph, strept & enterococci).
. VIRIDANS group streptococci (Strep. Mutans) are highly susceptible to
penicillin.
. Tx Strept viridans & mutans with INTRA-VENOUS AQUEOUS PENICILLIN G or
IV CEFTRIAXONE.
. IV Ceftriaxone is easier to administer at home due to once daily
dosing.
. Oral antibiotics are NOT recommended.
* STAPHYLOCOCCUS AUREUS:
_________________________
. Prosthetic valves.
. Intravascular catheters.
. Implanted devices (pacemakers - Defibrillators).
. Injection drug users.
* STREPTOCOCCUS VIRIDANS:
__________________________
. Dental procedures.
. Incision & biopsy or respiratory tract.
* ENTEROCOCCI:
_______________
. Nosocomial urinary tract infections.
* STREPTOCOCCUS BOVIS:
_______________________
. Colon carcinoma.
. Inflammatory bowel disease.
* FUNGI:
_________
. Immunocompromized host.
. Chronic indwelling catheters.
. Prolonged antibiotic therapy.
. SEPTAL DEFECTS:
_________________
_________________
. SPLITTING OF S2:
__________________
__________________
. WIDE (Delayed P2) --------> RBBB - PS - RVH - PHTN.
. PARADOXICAL (Delayed A2) -> LBBB - AS - LVH - SHTN.
. FIXED --------------------> ASD.
. CARDIOMYOPATHY:
_________________
_________________
. Tx -> BETA BLOCKERS ARE THE BEST INITIAL THERAPY for both HOCM & HCM.
. DIURETICS ARE CONTRAINDICATED in HOCM but they are useful in ordinary
HCM.
. N.B. Systolic anterior motion (SAM) of the mitral valve is classic for
HOCM.
. N.B. Septal Q waves in the inferior & lateral leads are common in HOCM
(Absent in MI).
. N.B. Surgical myomectomy is the therapy only if all medical ttt fails.
. PERICARDIAL DISEASES:
_______________________
_______________________
{1} PERICARDITIS:
__________________
. Sharp & brief pleuritic chest pain (changes with respiration).
. Positional (Relieved by sitting up & leaning forwards).
. Viral in origin in most cases.
. Friction rub.
. Dx -> EKG -> ST segment elevation in ALL leads.
. Dx -> EKG -> PR segment is pathognomonic but isn't always present.
. Tx -> Best initial therapy -> NSAIDs (Indomethacin).
. Tx -> Add oral steroids (prednisone) in refractory cases.
. N.B.
. UREMIC PERICARDITIS (UP) occurs in 10 % of renal failure pts.
. Typically those with BUN > 60 mg/dl.
. Most pts do NOT present with the classic ECG changes of pericarditis
(Diffuse ST elev.)
. Tx -> HEMODIALYSIS -> Rapid resolution of chest pain & -- size of
effusion.
. N.B. Pulsus paradoxus -> Exaggerated fall in blood pressure > 10 mmHg
on INSPIRATION.
. It is a frequent finding in cardiac tamponade.
. Other causes severe asthma & COPD.
. AORTIC DISEASES:
__________________
__________________
. AORTIC DISSECTION:
_____________________
. Dissection of the THORACIC aorta.
. Most common cause is SYSTEMIC HYPETENSION.
. Marfan's & Ehlers-Danlos $yndromes may cause dissection in YOUNG
population.
. AORTIC COARCTATION:
_____________________
. Narrowing of DESCENDING aorta distal to Lt subclavian artery at
ligamentum arteriosum.
. CXR -> Notching of the 3rd - 8th ribs due to erosion by enlarged
intercostal arteries.
. Classic 3 sign caused by indentation of the aorta at the site of
coarctation.
. with pre & post stenotic dilatation.
. N.B.
. ASCENDING aortic aneurysms are due to cystic medial necrosis or
connective tissue dis.
. DESCENDING aortic aneurysms are due to atherosclerosis.
. CXR can suggest thoracic (descending) aortic aneurysm by showing:
. widened mediastinal silhouette, increased aortic knob & tracheal
deviation.
. Smooth, shiny skin with loss of hair & sweat glands & loss of pulses
in the feet.
. PAIN + PALLOR + PULSELESSNESS = ARTERIAL OCCLUSION.
. Dx -> Best initial test -> ANKLE - BRACHIAL INDEX (ABI) "Normal ABI >
0.9".
. LL BP should be EQUAL to UL BP (Difference > 10 % = Obstruction).
. Dx -> Most accurate test -> ANGIOGRAPHY.
. Tx -> Best initial ttt (Aspirin - ACEIs for BP control - Exercise -
Cilostazole).
. Acute arterial embolus is very sudden in onset with loss of pulse & a
cold extremity.
. It is also quite painful.
. H/O of AS or Af is present.
. ARRHYTHMIAS:
_______________
_______________
. INITIAL MANAGEMENT OF CARDIAC ARREST:
________________________________________
. The 1st step is to make sure that the pt is truely unresponsive.
. Exclude sleeping or syncopal episode !!
. Open the airway -> Head tilt, chin lift & jaw thrust.
. Five rescue breaths if not breathing.
. Check pulse & start chest compressions if pulseless.
. CPR doesn't restart the heart; it keeps the pt alive until
cardioversion is performed.
. i.e. The most imp. item is TIME TO RHYTHM ANALYSIS & DEFIBRILLATION.
. (1) ASYSTOLE:
________________
. Besides CPR, therapy for asystole is with epinephrine & atropine.
. Vasopressin is an alternative to epinephrine (Both constrict bl. vs.
in tissues).
. This shunts blood into critical central circulation e.g. heart &
brain.
. Managaed with un-interrupted cardiopulmonary resuscitation CPR &
vasopressor therapy,
. in order to maintain adequate cerebral & coronary perfusion.
. Defibrillation or synchronized cardioversion has no role in management
!
. ATRIAL ARRHYTHMIAS:
______________________
______________________
. Rarely associated with hemodynamic instability bec. COP is dependent
upon ventricles.
. H/O of palpitations, dizziness or lightheadedness.
. H/O of exercise intolerance or dyspnea.
. H/O of embolic stroke.
{1} & {2} . ATRIAL FIBRILLATION (Af) & ATRIAL FLUTTER (AF):
____________________________________________________________
. Both have identical management .. Only 2 differences:
. 1 -> Flutter is a regular rhythm while fibrillation is irregular.
. 2 -> Flutter usually goes back into sinus rhytm or deteriorates into
fibrillation.
. CHRONIC Af:
______________
. Af lasting more than 2 days.
. It takes several days to be a risk of clot formation.
. The majority of those who are converted to sinus rhythm will not stay
in sinus.
. Af & AF are mostly caused by anatomic abnormalities of the atria from
HTN or valve dis.
. Shocking the pt. into sinus rhythm doesn't correct a dilated left
atrium.
. Over 90% will revert to fibrillation.
. SLOW THE RATE & COAGULATE "WARFARIN" are the STANDARD CARE for chronic
Af.
. The best initial therapy is to control the rate with BB, CCB or
Digoxin.
. Once the rate is under 100/min -> Give WARFARIN until the INR is
between 2-3.
. CCBs used (Diltiazem & verapamil) -> Block the AV node.
. You need to use heparin only if there is a current clot in the atrium.
. N.B. Rate control drugs don't convert the pt. into sinus rhythm.
. N.B. Heparin is not necessary before starting a pt on warfarin.
. Af CLASSIFICATION:
_____________________
. FIRST DETECTED -> Initial diagnosis, independent of duration.
. PAROXYSMAL -> Recurrent > 2 episodes that terminate spontaneously in <
7days.
. PERSISTENT -> Episodes lasting > 7days.
. LONGSTANDING PERSISTENT -> Persistent > 1 year duration.
. PERMANENT -> Persistent with no further plans for rhythm control.
. LONE Af:
___________
. LONE = paroxysmal, persistent or permanent Af with no structural heart
disease.
. Pts e' low risk of stroke can safely prevent it e' using ASPIRIN alone
e'out warfarin.
. When all the previous risk factors are absent, this is called "LONE
Af".
. Tx of lone Af -> ASPIRIN & rate control with BB.
. CHADS2 SCORING:
__________________
. C -> Congestive heart failure.
. H -> Hypertension (BP > 140/90 mmHg).
. A -> Age > 75 ys.
. D -> DM.
. S -> Previous stroke or TIA.
. N.B.
. Antiarrhythmic drugs are reserved for pts with recurrent symptomatic
Af episodes,
. or those with Lt ventricular systolic dysfunction thought to be 2ry to
uncontolled Af.
. Long term use of antiarrhythmic drugs has significant side effects.
. N.B.
. Amiodarone cause pulmonary toxicity & sh'd be avoided in pts with
preexisting lung dis.
. So .. RESTRICTIVE lung disease pts can NOT be given Amiodarone.
. Amiodarone is ABSOLUTELY CONTRAINDICATED.
. N.B.
. BBs causes bronchoconstriction.
. So .. OBSTRUCTIVE lung disease (Asthma - COPD) pts can NOT be given
BBs.
. BBs are RELATIVELY CONTRAINDICATED in obstructive lung diseases.
. BBs can be used SAFELY in RESTRICTIVE lung diseases.
. N.B.
. Af pts with past H/O of Wolf-Parkinson-White $yndrome,
. Should be treated with cardioversion or anti-arrhythmics like
procainamide.
. AV nodal blockers (BB - CCB - Digoxin - Adenosine) should be AVOIDED,
. because they ++ conductance through the accessory pathway after AVN
blockage.
. N.B.
. Pts e' new-onset Af sh'd've TSH & free T4 levels measured to rule out
hyperthyroidism.
. N.B. You sh'd differentiate bet SVT & ventricular tachycardia (VT),
. Ventricular tachycardia has WIDE QRS COMPLEXES,
. while SVT have NARROW QRS complexes.
. Tx of VT if hemodynamically stable -> Amiodarone.
. N.B. You sh'd differentiate bet SVT & Af with rapid ventricular
response (AF with RVR),
. SVT presents as sudden onset, REGULAR, narrow complex tachycardias.
. SVT HR 160 - 220 beats/min.
. Can be managed by vagal maneuvers as carotid massage or Adenosine.
. But Af with RVR has IRREGULARLY IRREGULAR RHYTHM with narrow complex
tachycardia,
. in addition to absence of P waves.
. Af with RVR is managed by rate control (BB metoprolo or CCB
Diltiazem),
. if hemodynamically stable (No hypotension).
. N.B.
. AMIODARONE SIDE EFFECTS -> pulmonary fibrosis - Hepatotoxicity -
Hypothyroidism.
. Always do pulmonary, liver & thyroid function tests.
. N.B.
. Amiodarone-induced hypothyroidism:
. progressively worsening fatigue - difficulty concentrating & ++
forgetfulness.
. Unintensional weight gain & dry skin.
. N.B.
. Pre-mature atrial beats are benign.
. Neither require follow up nor treatment.
. May be due to anxiety, CHF, hypoxia, Caffeine or electrolyte
imbalance.
. N.B.
. Don't ONLY reassure the pt without advising him !!
. Tobacco & alcohol are reversible risk factors for PACs.
. BBs are helpful in those who are symptomatic.
. N.B.
. Heriditary hemochromatosis > Abnormal iron deposition -> Multisystem
end-organ damage.
. Iron deposition within the myocardium can lead to Dilated
cardiomyopathy, heart failure
. May lead to conduction abnormalities e.g. Sick sinus $yndrome.
. Manifestations of hemochromatosis (DM, -- libido, hepatomegaly &
testicular atrophy).
. Sick sinus $ = Tachycardia-Bradycardia $ = Bursts of atrial tachy then
bradyarrhythmias
. N.B.
. Multiple premature ventricular complexes (PVCs)
. Identified by a wide QRS > 120 msec.
. Bizarre morphology.
. Compensatory pause.
. PVCs can be seen in normal individuals.
. They may follow a myocardial infections.
. No ttt indicated if pt is asymptomatic.
. BB are the 1st line of ttt in symptomatic pts.
. N.B.
. Grave's disease (insomnia - fatigability - weight loss - lid lag -
tremor).
. Atrial fibrillation is a common complication of hyperthyroidism.
. Best initial ttt is BB "propranolol".
. BB not only control Af, but alsodiminishes hyperthyroism symptoms.
. N.B.
. Ventricular premature beats (VPBs)
. If associated with Acute coronary $,
. You sh'd n't give LIDOCAINE (Class 1B anti-arrhythmic)!!
. Although Lidocaine use deceases the risk of ventricualar fibrillation,
. It may ++ risk of asystole !!
. Loidocaine is not used prophylactically in pts with AC$.
. Overall prognosis is not affected.
. N.B.
. Absence of P waves is characteristic for Af.
. PULMONARY VEINS are the most common frequent origin of ectopic foci
that cause Af.
. N.B.
. DELTA waves are characteristic for WPW $.
. N.B.
. FLUTTER waves are characteristic for AF.
. TRICUSPID ANNULUS is the most common frequent of ectopic foci causing
AF.
. N.B.
. HIGH RATE REGULAR RHYTHM NARROW QRS COMPLEXES TACHYCARDIA = PSVT.
. It mostly involves formation of a re-entry circuit within AV node or
accessory pathway.
. N.B.
. The most common cause of death in the 72 hours post AMI is VENTRICULAR
ARRHYTHMIA.
. Manage arrhythmia from ischemia by correcting the ischemia.
. Don't put in an implantable defibrillator for an arrhythmia u can fix
the its cause !
. N.B.
. To determine the risk of recurrence of arrhythmia, do
ECHOCARDIOGRAPHY.
. If the echo shows a normal EF, the risk of recurrnce of arrhythmia is
small.
. N.B.
. In pts with recurrent syncopes due to arrhythmia, Put an implantable
defibrillator.
. An implantable defibrillator will prevent the next episode of syncope
or sudden death.
. N.B.
. Torsades de pointes = polymorphic ventricular tachycardia + prolonged
QT interval.
. H/O of alcoholism + Recent fluconazole or Moxifloxacin ttt.
. Tx -> Mg So4 (Alcohol is associated with -- Mg).
. N.B.
. Loop diuretics "Furosemide" cause hypokalemia & hypomagnesemia.
. These electrolyte abnormalities can cause ventricular taachycardia.
. so .. You should measure serum electrolytes before treating
ventricular arrhythmia.
. N.B.
. Anti-arrhythmic medications with the property of use-dependence,
. are more effective at higher rates because,
. there is no time between heart beats for the medication to dissociate
from its receptor
. This phenomenon is seen with class 1C anti-arrhythmics e.g
"FLECAINIDE" & class 4.
. Class 1C prolong the QRS complex whereas class 4 don't.
AV DISSOCIATION ?
___________________
FUSION/CAPTURE BEATS?
_______________________
|
______YES_____________NO________
| |
VENTRICULAR TACHYCARDIA SUPRAVENTRICULAR
TACHYCARDIA With ABERRANCY
_________________________
_____________________________________________
| |
_________________________
_____________________________
| | |
|
STABLE UN-STABLE
STABLE
________ ___________
_________
| |
|
. IV AMIODARONE . HYPOTENSION . VAGAL MAEUVERS
(Carotid massage) . Altered mentation
. Adenosin - BB - CCB - Digoxin.
. Respiratory distress
|
. SYNCHRONIZED CARDIOVERSION
. SYNCOPE MANAGEMENT:
______________________
______________________
. Management of syncope is based on 3 criteria:
________________________________________________
. Was the loss of consciousness sudden or gradual ?
. Was the regaining of consciousness sudden or gradual ?
. Cardiac examination normal or abnormal ?
. N.B.
. Clonic jerks may occur during any syncope if it is prolonged due to
brain hypoxia.
. Absence of previous H/O of seizure & presence of structural heart
disease,
. excludes seizure & makes a diagnosis of syncope due to arrhythmia more
reliable.
. SYSTEMIC HYPERTENSION:
________________________
________________________
. Systolic blood pressure > 140 mmHg.
. Diastolic blood pressure > 90 mmHg.
. Hypertension is the most common risk factor for MI (Death most common
risk factor).
. Medications that are not considered as 1st or 2nd line therapy are:
-> Central acting alpha agonists (Alpha methyl dopa - Clonidine).
-> Peripheral acting alpha antagonists (Prazosin - terazosin -
doxazosin).
-> Direct acting vasodilator (Hydralazine - Minoxidil).
. N.B.
. Benign essential tremor are tremors occuring with posture "movement".
. They are unlike Parkinson's disease which is characterized by resting
tremors.
. It usually disturbs the fine motor tasks e.g. handling a newspaper or
pouring tea.
. Inhibition of the tremor by a small amount of alcohol is typical.
. Tx -> Propranolol.
. N.B.
. Isolated systolic hypertension (ISH) is an important cause of
hypertension in elderly,
. it is due to DECREASED ELASTICITY OF THE ARTERIAL WALL.
. It sh'd be ttt due to strong association with ++ risk of
cardiovascular events.
. Initial ttt -> Monotherapy with a low dose thiazide, an ACEI or long
acting CCB.
. N.B.
. Renovascular hypertension
. sh'd be suspected in all pts with resisant hypertension in addition to
. diffuse atherosclerosis - asymmetric kidney size - recurrent flash
pulmonary edema.
. or elevation in serum creatinine > 30 % from baseline after starting
ACEIs or ARBs.
. The presence of continous abdominal bruit has a high specificity for
renovascular HTN.
. N.B.
. POLYCYSTIC KIDNEY DISEASE (PKD) -> Autosomal dominant inheritance.
. Bilateral cystic dilatation of the renal tubules.
. Hypertension is one of the earliest manifestations.
. Hematuria is often present.
. Flank or abdominal masses with pain & 2ry eryhthrocytosis.
. PKD is associated with cerebral aneurysms.
. Family H/O of stroke or sudden death.
. Dx -> Abdominal U/$.
. HYPERTENSIVE CRISIS:
______________________
. Hypertensive crisis is not defined as a specific level of blood
pressure !
. It is defined as hypertension associated with END-ORGAN DAMAGE.
. End organ damage = CONFUSION - BLURRY VISION - DYSPNEA - CHEST PAIN.
* RENO-VASCULAR DISEASE:
_________________________
. Severe hypertension (> 180 mmHg systolic & 120 mmHg diastolic) after
age 55.
. Possible recurrent flash pulmonary edema or resistant heart failure.
. Unexplained rise in serum creatinine.
. Abdominal bruit.
* PHEOCHROMOCYTOMA:
____________________
. Paroxysmal ++ Blood pressure with tachycardia.
. Pounding headaches, palpitations & diaphoresis.
. Hypertension with adrenal incidentaloma.
* CUSHING's $YNDROME:
______________________
. Central obesity & facial plethora.
. Proximal muscle weakness.
. Ecchymosis, amenorrhea & erectile dysfunction.
. Hypertension with adrenal incidentaloma.
* HYPOTHYROIDISM:
__________________
. Fatigue, dry skin & cold intolerance.
. Constipation, weight gain & bradycardia.
* PRIMARY HYPERPARATHYROIDISM:
_______________________________
. Hypercalcemia (Polyuria & polydipsia).
. Renal stones.
. Neuropsychiatric (Confusion, depression & psychosis).
* AORTIC COARCTATION:
______________________
. Differential hypertension with brachial femoral pulse delay.
. MISCELLANEOUS TOPICS:
_______________________
_______________________
. HEAT STROKE:
______________
. Temperature above 40.5 c (105 F).
. Exertional heat stroke occurs in healthy individuals exercising in
extreme heat.
. Dehydration, hypotension, tachycardia & tachypnea are common.
. Systemic effects like seizures, ARD$, DIC & hepatic or renal failure
may occur.
. COCAINE USE:
______________
. Atrophic nasal mucosa.
. Sympathetic hyperactivity (Tachycardia, hypertension, dilated pupils).
. Chest pain due to coronary vasospasm.
. Psychomotor agitation & siezures.
. Complications (Acute MI - Aortic dissection - Intracranial
hemorrhage).
. Management of chest pain:
-> IV BENZODIAZEPINES for blood pressure & anxiety.
-> Aspirin.
-> Nitroglycerin & CCBs for pain.
-> BBs are CONTRAINDICATED.
-> Fibrinolytics are NOT PREFERRED due to ++ risk of intracranial
hemorrhage.
-> Immediate cardiac catheterization with reperfusion when indicated.
. CHAGAS DISEASE:
_________________
. A potozoal disease caused by Trypanosoma cruzi.
. It is endemic to Latin America "Brazil".
. Two primary manifestations -> MEGACOLON/MEGAESOPHAGUS & CARDIAC
DISEASE.
. Megacolon or megaesophagus (focal GI dilatation) is 2ry t destruction
of the nerves,
. controlloing the gastrointestinal smooth muscles leading dialatation.
. Congestive heart failure occurs (Pedal edema - JVD - S3 gallop -
cardiomegaly).
. ARD$:
_______
. Acute onset.
. Bilateral patchy airsapce disease on CXR.
. PCWP < 18.
. No ++ in LVEDP.
. PaO2/FiO2 < 200.
. S3
. Extra-sound heared just after S2.
. (ken-tuc-"KY") -> With S3 corresponding to the last syllabus.
. Result when inflow from Lt atrium strikes blood already in Lt
ventricle.
. It is a sign of Lt ventricular failure.
. Best initial ttt of LVF is IV diuretics.
. S4
. Additional diastolic sound just prior to S1.
. ("TEN"-nes-see) -> With S4 corresponding to the first syllabus.
. It is indicator of a stiff left ventricle.
. Causes: prolonged systemic hypertension or restrictive cardiomyopathy.
. AR MURMUR
. Early diastolic murmur.
. Associated clinical finding -> Water hammer pulse = Bounding pulse.
. MR MURMUR
. Holo-systolic murmur.
. Heard best over the apex with radiation to the axilla.
{1} CARDIAC:
_____________
. Bilateral.
. Congestive heart failure.
. Dyspnea & orthopnea.
. Jugular venous distension & hepatomegaly.
{2} HEPATIC:
_____________
. Bilateral.
. Hepatic cell failure.
. Ascites dominates over LL edema.
. Abnormal liver function tests (++ ALT & AST)
. Hypoalbunimea & hyperbilirubinemia.
. Spider nevi, gynecomastia, palmer erythema.
{3} RENAL:
___________
. Bilateral.
. Nephrotic $yndrome (Due to massive proteinuria).
. Nephritic $yndrome (Due to fluid retention).
. Proteinuria, hypoalbuminemia.
. Abnormal renal function tests (++ urea & creatinine).
{4} NUTRITIONAL:
_________________
. Bilateral.
. H/O of metabolic problems.
. Rare in adults.
{5} MEDICATIONS SIDE EFFECTS:
______________________________
. Bilateral.
. Ex. Dihydropyridine Ca channel antagonists (Amlodipine).
. Amlodipine dilate peripheral blood vessels.
. The pt's H/O of IV drug abuse ++ risk for cirrhosis 2ry to infection
e' HBV & HCV.
. The findings of hepatosplenomegaly & ascites point toward the
diagnosis.
. Most common cause of ascites is hepatic cirrhosis.
. The pt's leg swelling may be due to DVT resulting from impaired
mobility.
. ASCITES is NOT related to DVT !!
. N.B.
. Chronic venous insuffeciency is a common cause of peripheral edema.
. Sh'd be suspected in pts with isolated lower limb edema & or dilated
veins,
. with otherwise normal physical examination.
. Initial ttt -> Conservative measures with leg elevation, exercise &
compression therapy
. PATHO-PHYSIOLOGY of CAUSES of PERIPHERAL EDEMA:
_________________________________________________
. ++ CAPILLARY PERMEABILITY:
_____________________________
. Burns, trauma & sepsis.
. Allergic reactions.
. ARD$.
. Malignant ascites.
. SEPTIC __ + __ - __ - __ + __ - __ Fluids,
pressors & Antibiotics
. CELLULITIS:
------------
. Cellulitis with systemic manifestations e.g. fever,rigors,chills &
confusion is ttt by I.V. NAFICILLIN or Cefazolin.
. caused by staph or strept.
. Generalized swelling which is erythematous "linear streaks", warm,
tender but less well demarcated than Erysipelas.
. An associated fungal infection may acts as a portal of entry.
. Tinea Corporis:
-----------------
. Ring shaped scaly patches with central clearin & scaly borders.
. Dx: KOH -----> Hyphae. . Tx: Local Terbinafine or systemic
Griseofluvin.
. Tinea Versicolor:
-------------------
. Pale velvety pink or whitish hypopigmented macules that DON'T TAN !
. SCALE ON SCRAPING.
. Dx: KOH preparation ----> Spaghetti & meat ball appearance.
. Tx: Selenium sulfide.
. NECROTIZING FASCIITIS:
------------------------
. Severe pain & swelling.
. H/O of recent trauma.
. High fever > 39 c.
. Edematous limb with PURPLISH DISCOLORATION of the injured area
"denoting start of gangrene!".
. Surgical debridement of all necrotic tissue.
. Empiric IV Antibiotics e.g AMPICILLIN + SULBACTAM + CLINDAMYCIN.
. Bullae & seroanguinous discharge.
. Seborrheic dermatitis:
------------------------
. Fine loose waxy scales with underlying erythema.
. On scalp, eye brows.
. Associated with HIV or parkinsonism.
. CHALAZION:
------------
. Painful swelling that progresses to a nodular rubbery lesion.
. due to MEIBOMIAN gland obstruction.
. Recurrent chalazion may be due to meibomian gland carcinoma !
. U can't differentiate bet. PERSISTENT CHALAZION & BASAL CELL CARCINOMA
except through HISTOPATHOLOGICAL exam.
. Seborrheic Keratosis:
-----------------------
. OLD AGE.
. WAXY - "STUCK ON" - well circumscribed lesion.
. Not pre-cancerous.
. No therapy is required.
. Surgical removal for cosmetic purpose.
. ANGIO-EDEMA:
--------------
. H/O of ICU pt on ACEIs e.g ENALAPRIL.
. Edema in the face, mouth, lips.
. Laryngeal edema may occur causing airway obstruction.
. occurs due to BRADYKININ release.
. it may occur at any time not just at the start of drug intake.
. Dx----> Low levels of C2 & C4.
. Tx----> STOP ACEIs + FRESH FROZEN PLASMA + Secure the airway.
. HERIDITARY angioedema:
------------------------
. C1 esterase inhibitor defeciency.
. Dermatitis Herpetiformis:
---------------------------
. Ass. with celiac disease.
. Erythematous papules, vesicles & bullae that occur bilaterally,
symmetrically & in groups "herpetiform" arrangement.
. On the extensor sufraces of the elbows,knees,buttocks.
. Tx: Gluten free diet & DAPSONE.
. Pemphigus Vulgaris:
---------------------
. Thin & fragile large wide bullae.
. +ve Nikolsky sign.
. Mouth is involved.
. H/O of ACE Is use.
. Deposition of IgG in the epidermis.
. Bullous Pemphigoid:
---------------------
. Thick & intact small & narrow bullae.
. Bullae don't rupture easily.
. No mouth involvement.
. H/O of SULFA drugs use.
. Deposition of IgG & C3 in the epidermis.
. ROSACEA:
----------
. 30 - 60 ys old pt.
. TELANGECTASIA over the cheeks, nose & chin.
. Flushing of these area is precipitated by hot drinks,heat,emotion.
. Tx: initial ttt is METRONIDAZOLE.
. Vilitiligo (Leukoderma):
--------------------------
. Young 20-30 ys.
. Pale whitish macules with hyperpigmented borders.
. Around body orifices.
. Auto-immine destruction of melanocytes.
. RUBELLA:
---------
. Middle aged female.
. Maculo-papular rash starting on the face & extends to involve the
trunk & extremeties (Not involving th palms & soles).
. Tender lymphadenopathy (Post. auricular & post. cervical LNs).
. Poly-arthritis.
. Secondary $yhphilis:
----------------------
. Maculopapular rash (involving the palms & soles).
. The papules may coalese to form CONDYLOMA LATA in severe cases!
. Frost-bite injury:
--------------------
. Rapid re-warming with warm water.
. Dead Tissue debridement is WRONG.
. Rapid re-warming with fry heat or fan is WRONG.
. CHERRY HEMANGIOMA:
--------------------
. Small vascular bright red papular lesion.
. 30-40 ys & ++ in no with age "Senile hemangioms".
. Don't regress spontaneously.
. Sharply circumscribed areas of congested capillaries.
. ACTINIC KERATOSIS:
--------------------
. Erythematous papule with a central scaling.
. Sand paper like texture.
. H/O of chronic sun exposure.
. Pre-cancerous ----> may convert to squamous cell carcinoma.
. ACANTHOSIS NIGRICANS:
-----------------------
. Symmetrical, hyperpigmented, velvety plaques in the axilla, groin &
neck !
. Ass. with INSULIN RESISTANCE in YOUNG pts e.g. DM & PCO.
. Ass. with GIT malignancy in OLD pts.
ENDOCRINOLOGY TiKi TaKa
_________________________
. THYROID DISEASES:
___________________
___________________
. HYPOTHYROIDISM:
_________________
* PRIMARY Hypothyroidism * * Secondary Hypothyroidism * * TERTIARY
Hypothyroidism *
________________________ _________________________
_________________________
. -- T3 & T4. . -- T3 & T4. . -- T3 &
T4.
. ++ TSH. . -- or normal TSH. . -- or
normal TSH.
. Ex: Auto-immune Hashimoto's.
. HASHIMOTO's THYROIDITIS:
__________________________
. Hypothyroidism symptoms: Slow, tired, fatigued pt with weight gain.
. Anti-TPO Abs (Anti-thyroid peroxidase antibodies).
. -- T4 & ++ TSH.
. Tx -> T4 or thyroxine replacement.
. High risk of developing THYROID LYMPHOMA.
A . 1st step -> Cilinical evaluation - TSH level & thyroid ULTRA$OUND.
______________________________________________________________________
C . TSH LEVEL ??
________________
. Normal or ++ -> FNAB.
. -- Low -------> D. (I 123 scintigraphy).
D . I - 123 scintigraphy:
_________________________
. HYPER-functional (HOT) nodule -> Treat hyperthyroidism.
. HYPO-functional (COLD) nodule -> FNAB.
. FACTITIOUS THYROTOXICOSIS:
____________________________
. Due to exogenous thyroid hormone.
. H/O of psychiatric illness or attempted weight loss (Herbal remedy!).
. Thyrotoxicosis syms (Palpitations - sweating - weight loss -
hyperactivity & diarrhea).
. Lid lag may be present but NO exophthalmos (Excluding Grave's dis.).
. The ingested thyroid hormone disturbs the native thyroid axis !
. RAIU is decreased (-- Radio Active Iodine Uptake).
. Dx -> "LOW SERUM THYROGLOBULIN" is the main stay of diagnosis.
. Dx -> -- TSH & ++ T3 &/or T4.
. TOXIC ADENOMA:
________________
. ++ T4 & -- TSH levels.
. Symptoms suggestive of thyrotoxicosis.
. Radioactive uptake in the nodule & suppression of uptake ith rest of
the thyroid gland.
. No infiltrative ophthalmopathy.
# THYROID MALIGNANCIES:
_______________________
1 * PAPILLARY CARCINOMA:
________________________
-> MOST COMMON TYPE & BEST PROGNOSIS.
-> Slow infiltrative local spread.
-> Presence of PSAMMOMA bodies.
2 * MEDULLARY CARCINOMA:
________________________
-> CALCITONIN secretion.
3 * FOLLICULAR CARCINOMA:
_________________________
-> Invasion of the tumor capsule & blood vessels.
-> Early metastasis to distant organs.
* MEN TYPE 1:
______________
. Parathyroid adenoma.
. Pituitary tumor.
. Pancreatic tumor.
. {Mutation in the MEN 1 tumor suppressor gene}.
. DM SCREENING TESTS:
_____________________
. DKA MANAGEMENT:
_________________
.1. RAPID INTRAVENOUS NORMAL SALINE (0.9% SALINE).
.2. RAPID INTRAVENOUS REGULAR INSULIN.
.3. K correction.
.4. TTT of infections e.g. Abs.
_______________________________ ....................
________________________________
. DIABETIC KETOACIDOSIS (DKA) .................... HYPEROSMOLAR
HYPERGLYCEMIC STATE
________________________________ ....................
________________________________
. Type (1) DM usually. ____________________ . Type (2) DM.
. YOUNGER age. ____________________ . Older.
. LESS confusion. ____________________ . MORE confusion.
. Hyperventillation MORE common ____________________ . Less common.
. Abdominal pain MORE common. ____________________ . LESS common.
_________________________________________________________________________
_____________
. Glucose 250 - 500 mg/dl. ____________________ . > 600
. HCO3 < 18 meq/L. ____________________ . > 18
. +++++ ANION GAP. ____________________ . NORMAL.
. POSITIVE serum ketones. ____________________ . NEGATIVE.
. Serum osmolality < 320 ____________________ . > 320.
. DIABETIC NEPHROPATHY:
_______________________
. Begins with HYPERFILTRATION (++GFR) & MICROALBUMINURIA.
. If not ttt well .. Micro becomes Macroalbumiuria > 300 mg/dl.
. INTENSIVE BLOOD PRESSURE CONTROL to prevent worsenening of the
condition.
. Use ACE Is with blood pressure goal 130/80 mmHg.
. Most sensitive screening test is -> RANDOM URINE MICRO-
ALBUMIN/CREATININE RATIO.
. DIABETIC NEUROPATHY:
______________________
. DISTAL SYMMETRIC SENSORIMOTOR PLOYNEUROPATHY.
. STOCKING GLOVE pattern.
. It is the most common risk factor of foot ulcerations in diabetics.
. Tx -> TCAs (Amitriptyline - Gabapentin).
. DIABETIC GASTROPATHY:
_______________________
. Autonomic neuropathy of the GIT.
. Symptoms of delayed gastric emptying & gastroparesis.
. -- Esophageal dysmotility -> Dysphagia.
. -- Gastric emptying -------> Gastroparesis.
. Gastroparesis (Nausea - vomiting - early satiety - postprandial
fullness).
. -- intestinal function ----> diarrhea - constipation - incontinence.
. Tx -> DN control - SMALL FREQUENT MEALS - METOCLOPROMIDE (prokinetic &
Antiemitic).
. SEs of Metoclopromide -> Extrapyramidal syms -> Tardive dyskinesia
(Give Erythromycin).
. INSULINOMA:
_____________
. BETA CELL TUMOR.
. Normally, blood glucose < 60 mg/dl result in complete suppression of
insulin secretion.
. Hypoglycemia in the presence of inappropriately ++ serum insulin
levels = insulinoma.
. ++ C-peptide level.
. ++ Pro-insulin.
. DIABETES INSIPIDUS:
_____________________
. Due to ADH defeciency or resistance.
. Urine osmolality is < serum osmolality.
. Polyurea & polydipsia.
. H/O of tendency to COLD BEVERAGES to QUENCH THIRST.
. Exclude psychogenic polydipsia using water deprivation test.
. Differentiate bet. central & nephrogenic DI using ARGININE
VASOPRESSIN.
. Tx -> NORMAL SALINE.
. Tx -> CENTRAL -> INTRANASAL SPRAY DDAVP.
. Tx -> NEPHROGENIC -> NSAIDs & HCZ.
. BOTTOM LINE:
______________
* Diabetes insipidus:
______________________
. Polyurea - polydipsia - excretion of diluted urine with ++ serum
osmolality.
* SIADH:
_________
. Hyponatremia - LOW serum osmolality & inappropriately high urine
osmolality.
. HYPER-VITAMINOSIS "D":
________________________
. H/O of trials of weight loss with vitamin supplementations.
. Vit. D ++ Ca absorption -> Hypercalcemia.
. Constipation - Abd. pain - Polyurea - Polydipsia.
. METABOLIC $YNDROME:
_____________________
1- ABDOMINAL OBESITY -> Waist circumference (Men > 40 & Women > 35
inches).
2- DIABETIS MELLITIS -> Fasting glucose > 100 - 110 mg/dl.
3- HYPERTENSION ------> Blood pressure > 130/80 mmHg.
4- HYPERLIPIDEMIA ----> Triglycerides > 150 mg/dl & HDL (Men < 40 &
Women < 50 mg/dl).
. ACROMEGALY:
_____________
. ++ GROWTH hormone by SOMATOtroph PITUITARY ADENOMA.
. GH -> ++ IGF-1.
. IGF-1 ++ growth of bones & soft tissues.
. Coarse facial features - arthralgia - uncontrolled HTN - skin tags.
. Carpal tunnel $.
. Dx -> The MOST SENSITIVE TEST is -> IGF-1 level (GH level fluctuations
is deceiving).
. Suppression of GH by giving glucose excludes acromegaly.
. MRI -> Pituitary lesion.
. Tx -> Surgical resection with trans-sphenoidal removal.
. Tx -> Somatostatin - Cabergoline or bromocriptine.
. MOST COMMON CAUSE OF DEATH is CONGESTVE HEART FAILURE.
. Non cardiac causes of death: stroke - cancer colon - renal failure.
. PROLACTINOMA:
_______________
. Prolactin secreting micro-adenoma.
. Pituitary tumor < 10 mm in diameter is called micro-adenoma.
. Amenorrhea & galactorrhea in females.
. Hypogonadism in males.
. Its small size can't lead to mass effects of ++ ICT.
. Tx -> 1st line is medical ttt with Dopamine agonists (CABERGOLINE or
BROMOCRIPTINE).
. Cabergoline normalizes the prolactin level & shrinks the tumor's size.
# CALCIUM HOMEOSTASIS:
______________________
. 3 forms of calcium (ionized Ca 45% - Albumin bound Ca 40% - Inorganic
anions bound Ca).
. Albumin plays an imp. role !
. Pts with hypo-albuminemia can have a low level of total plasma ca,
. However ,, They may NOT present with clinical hypocalcemia,
. Because their level of ionized calcium (physilologically active form)
remained normal.
. So .. it is imp. to calculate the CORRECTED SERUM CALCIUM LEVEL.
. CORRECTED SERUM CALCIUM LEVEL = TOTAL Ca + 0.8 (4 - Serum Albumin).
. Another rough method,
. With every 1 g/dl change in serum albumin level from 4 g/dl,
. there is a change in total plasma Ca level by 0.8 mg/dl.
. PRIMARY HYPO-THYROIDISM:
__________________________
. Causes -> post-surgical- congenital absence - autoimmune.
. Post surgical may occur after thyroidectomy & removal of 3.5 out of 4
parathyroids.
. -- Ca -> perioral tingling - numbness - ms cramps - carpopedal spasms
- seizures.
. EKG -> prolongation of the QT interval.
# Causes of ++ Ca & + PTH: 1ry Hyperparathyroidism & familial
hypocalciuric hypercalcemia:
_________________________________________________________________________
_________________
. Differentiated by 24 hour urinary calcium:
____________________________________________
. Primary Hyper-parathyroidism ---------> > 250 mg.
. Familial hypocalciuric hypercalcemia -> < 100 mg.
. PRIMARY HYPER-PARA-THYROIDISM:
________________________________
. Causes -> Parathyroid adenoma (90%) - hyperplasia (6%) & carcinoma
(2%).
. Associated with MEN 1 & 2A.
. 80 % of pts are asymptomatic.
. Abdominal groans, renal stones, bones #s & psychic moans.
. ++ Ca & -- PO4 & ++ or normal PTH.
. 24 hours urinary calcium > 250 mg.
. Urinary calcium/creatinine > 0.02 (To rule out familial hypo-calciuric
hyper-calcemia).
. Dx -> 3Ds SESTAMIBI scan + U/$ to locate the hyperactive parathyroid
tissue presurgery.
. Tx -> Parathyroidectomy for symptomatic pts.
. Surgery indications:
_____________________
-> Serum Ca level > 1 mg/dl above the upper limit of normal (11mg/dl).
-> Young age < 50 ys.
-> Bone mineral density < T-2.5 at any stage.
-> -- Renal function (GFR < 60ml/min.).
. HYPERCALCEMIA of MALIGNANCY:
______________________________
. ++ Ca -> confusion - lethargy - fatigue - anorexia - polyuria &
constipation.
. Associated with SQUAMOUS cell lung cancer.
. CXR finding of lung cancer (lobar mass & perihilar lymphadenopathy).
. Malignancy produces PTH related peptide PTHrP -> ++ Ca & -- PO4.
.Immobilization
. PAN-HYPO-PITUITARISM:
_______________________
* Pituitary tumors are the most common cause by exerting pressure on
pituitary cells.
* HYPOTHYROIDISM (Central):
___________________________
-> Fatigue, cold intolerance, -- appetite, constipation & dry skin.
-> Bradycardia, delayed relaxation phase of DTRs & anemia.
* -- GONADOTROPINS:
___________________
-> Women -> Amenorrhea, infertility & hot flashes.
-> Men -> -- energy & libido.
. OSTEOPOROSIS:
_______________
. Postmenopausal woman.
. presenting with multiple bony #s.
. NORMAL serum Ca - PO4 & PTH.
. OSTEOMALACIA:
_______________
. Vit. D defeciency in ADULTS.
. Bony pain & tendrness.
. -- serum Ca & PO4.
. -- urinary Ca.
. ++ ALP & ++ PTH.
. -- 25 OH-D.
. X-ray -> BILATERAL SYMMETRIC PSEUDO-FRACTURES (LOOSER ZONES).
. PAGET's DISEASE:
__________________
. NORMAL serum Ca - PO4 & PTH.
. INCREASED ++ ALKALINE PHOSPHATASE.
. Tx -> BIPHOSPHONATES -> inhibit OsteoCLASTs asctivity.
.. CAUSES of HYPOKALEMIA & ++ BOTH ALDOSTERONE & RENIN -> (Check Cl):
_____________________________________________________________________
. SURREPTITIOUS VOMITING:
_________________________
. Scars & calluses on the dorsum of the hands & dental erosions.
. Result from chemical & mechanical injury as the pt uses his hands to
induce vomiting.
. Dental erosions result due to ++ exposure to gastric acid..
. May lead to hypovolemia & hypochloremia -> Low urine Cl level.
# ADRENAL DISORDERS:
____________________
____________________
_________________________________________________________________________
_______
. Sources of Cushing $ ------> Pituitary tumor - Ectopic - ACTH Adrenal
adenoma:
_________________________________________________________________________
_______
. ACTH ----------------------> HIGH - HIGH - LOW.
. High dose dexamethazone ---> Suppression - No - No.
. Specific tests ------------> MRI - CT - CT adrenals.
. Tx ------------------------> Removal - Removal - Removal.
.________________________________________________________________
.|
. Minimal response
._________________
|
._________________________________________________
.| |
. Basal cortisol LOW . Basal
cortisol LOW
. ACTH HIGH . ACTH LOW
.____________________
.____________________
.| .|
. PRIMARY AI . SECONDARY or
TERTIARY AI
.4. PHEOCHROMOCYTOMA:
_____________________
. Headache, palpitations, tremors, anxiety & flushing.
. Episodic elevations of blood pressue.
. Dx -> BEST INITIAL -> ++ catecholamines level in plasma & urine.
. Dx -> BEST INITIAL -> ++ metanephrines & VMA levels.
. Dx -> MOST ACCURATE -> CT or MRI or MIBG of the adrenal glands.
. Tx -> PHENOXYBENZAMINE (Alpha blocker) "FIRST" to control blood
pressure.
. e'out Alpha blockage, BB may lead to CATASTROPHIC ++ in BP due to
unopposed Alpha stim.
. Tx -> Propranolol is used "AFTER" an alpha blocker .
. Tx -> Surgical resection.
. N.B. It is a part of MEN type 2 A & B (DNA testing is imp. RET PROTO-
ONCOGENE).
. ERECTILE DYSFUNCTION:
_______________________
. Failure to achieve a spontaneous erection.
. Causes:
. * NEUROGENIC -> injury of the parasympathetic nerve fibers (# pelvis
or urethral tear).
. * VENOGENIC -> Disruption of tunica albuginea (# penis).
. * ENDOCRINOLOGIC -> ++ prolactin & -- Testosterone.
. * SITUATIONAL -> Anxiety (Nighttime & morning erctions are preserved).
. Peri-tonsillar abscess:
-------------------------
. Muffled voice make one consider other diagnosis than simple
tonsillitis or pharyngitis. . Deviation of the Uvula + Unilateral
lymphadenopathy = Peri-tonsillar abscess.
. Tx: URGENT NEEDLE ASPIRATION + IV Antibiotics.
. PRESBYCUSIS:
--------------
. Old pt in 60s.
. Sensori-neural hearing loss.
. HIGH frequency BILATERAL hearing loss.
. Difficult hearing in noisy crowded places.
. OTOTOXIC drugs:
-----------------
. Aminoglycosides antibiotics.
. Loop diuretics e.g. Furosemide. NOT THIAZIDEs !!
. Aspirin.
. REMEMBER:
-----------
. SE of BBs -------> Bronchoconstriction - Bradycardia - fatigue -
depression.
. SE of ACEIs -----> Cough - Hyperkalemia - Angioedema.
. SE of Aspirin ---> Tinnitus.
. SE of Thiazides -> Orthostatic Hypotension - photosensitivity -
hypercalcemia.
. Serous O.M.
-------------
. is associated with HIV pts manifesting as middle ear effusion without
infection.
. causing dull hypomobile tympanic membrane.
. NASAL POLYP:
--------------
. is associated with chronic rhino-sinusitis, asthma.
. H/O of aspirin or NSAIDs induced broncho-spasm
. (ASPIRIN EXACERBATED RESPIRATORY DISEASE).
. Symptoms of bilateral nasal obstruction, nasal discharge & anosmia.
. LEKOPLAKIA:
-------------
. Hard to remove white patches in the floor of the mouth.
. due to chronic irritation by smoking or alcohol.
. May lead to squamous cell carcinoma.
. CANDIDIASIS:
--------------
. Diabetic pt. with poor control.
. Whitish plaques with underlying erythema.
. Easily scrapped off with a tongue depressor.
. Epiglottitis:
---------------
. High fever.
. Severe sore throat.
. Odynophagia.
. DROOOOOOOOOOOOOOOOLING.
. Progressive airway obstruction.
. HARSH SHRILL.
. Causative organisms: Haemophilus influenzae & Streptococcus pyogenes.
. Otosclerosis:
---------------
. is the most common cause of conductive hearing loss in middle aged
adults 20-30s.
. AMINOGLYCOSIDES - GENTAMYCIN is the most common cause of sensorineural
hearing loss.
. Retro-pharyngeal abscess:
---------------------------
. Fever & sore throat.
. Dysphagia & Odynophagia.
. Trismus (pain on mouth opening).
. Pain on neck EXTENSION (pain on neck flexion = Meningitis).
. H/O of local trauma to the pharynx e.g. FISH BONE.
. MENIERE's disease:
--------------------
. Vertigo = Severe spinning sensation + nausea.
. The type of vertigo is peripheral not central as it last just for 1-2
hours with the presence of ear fullness & H/O of excessive cell
phone use.
. EAR FULLNESS suggests Meniere's disease
. from an abnormal accumulation of endo-lymph within the inner ear.
. Meniere's dis. is an INNER ear disease.
. Simply exclude CEREBELLAR dis. by absence of inco-ordination or gait
disturbances!
. Meniere's disease:
--------------------
. Vertigo + Ear fullness + Hearing loss.
. 1st line ttt ----> LOW SALT DIET.
. When the TF is placed on the middle of the forehead, she feals the
vibration better in her Rt ear than the Lt
-> Abnormal Weber test
-> The sound lateralizes to the diseased ear due to better bone
conduction.
-> CONDUCTIVE hearing loss.
. APHTHOUS ULCERS:
-----------------
. CROHN's disease can involve any part of the GIT from the MOUTH to the
ANUS.
. APTHOUS ulcers in the mouth can be seen as extra-intestinal
manifestation.
. Pathology: GRANULOMATOUS inflammation.
GASTROENTEROLOGY TiKi TaKa
----------------------------
. Mallory Weiss $:
-----------------
. is hematemesis due to ++ intra-abd. pressure with vomiting,
. leading to rupture of submucosal ARTERIES at the distal esophagus.
. Portal hypertension:
---------------------
. leads to hematemesis due to rupture of esophageal varices (submucosal
VEINS).
. Diverticulitis:
----------------
. LLQ pain + Constipation + Fevr + vomiting.
. The most appropriate test to confirm acute diverticulitis is Abd. CT.
. Sigmoidoscopy is contra-indicated for fear of perforation.
. ULCERATIVE COLITIS:
--------------------
. Young pt.
. Abd. pain.
. Bloody diarrhea.
. Rectal urgency.
. Anemia & reactive thrombocytopenia.
. Rectal tenderness.
. Stool mixed with mucous & blood.
. ++ WBCS with nausea ----> Toxemia.
. U should suspect TOXIC MEGACOLON.
. DO ABDOMINAL X-rays to search for Toxic Megacolon.
. Chron's disease:
------------------
. Young pt.
. Chronic diarrhea.
. Abd. pain.
. Weight loss.
. Mouth ulcers.
. Rt upper Q. tenderness without rebound.
. Gas in small & large intestines.
. Reactive thrombocytosis & anemia.
. DIVERTICULOSIS:
----------------
. Old pt.
. is associated with constipation not diarrhea,
. with Left lower Q. pain.
. DYSPHAGIA:
------------
. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g.
esophageal adenocarcinoma. . so .. You should perform BARIUM
SWALLOW 1st before endoscopy.
. CARCINOID $ triad:
-------------------
. Flushing.
. Valvular heart disease.
. Diarrhea.
. Ass. e' hepatic metastasis.
. ++ Serotonin & 5 HIAA in blood & urine.
. The precursor of Serotonin is Tryptophan,
. which is also utilized in the synthesis of Niacin.
. -- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).
. DIVERTICULITIS:
----------------
. H/O of costipation & little fiber in diet.
. Left lower quadrant pain & fever.
. Tx: IV Antibiotics.
. If no improvement ---> Abd. CT to detect complications.
. Tropical sprue:
-----------------
. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi,
. with infiltration of chronic infl. cells e.g. lymphocytes, plasma
cells & eosinophils. . Malabsorption to Vit. B12 & folic acid --->
Megaloblastic anemia.
. Other signs of malabsorption e.g. glossitis - cheilosis - pallor.
. WHIPPLE's disease:
--------------------
. PAS +ve material in the lamina propria of the small intestine is
diagnostic.
. Primary HIV infection:
------------------------
. can present with a mononucleosis like syndrome,
. consisting of fever, night sweats, lymphadenopathy, arthralgia &
diarrhea.
. JAUNDICE:
-----------
.Abd. U/S is the best initial investigation for JAUNDICE.
.But .. once u suspect pancreatic cancer , then the best inv. is Abd.
CT.
.Manif. of cancer include weight loss , pressure obstruction of CBD,
.leading to ++ direct bilirubin & ++ ALP.
. MEN 1 = 3 Ps:
---------------
. Primary Hyperparathyroidism.
. Pituitary tumors.
. Pancreatic tumors (insulinoma-gastrinoma-VIPoma).
. GASTRINOMA = ZOLLINGER ELLISON's $ (Non B-cell pancreatic tumor).
. Endoscopy--> Multiple ulcerations & prominent gastric folds.
. MEN 2 A:
----------
. Medullary thyroid cancer & Pheochromocytoma.
. MEN 2 B:
----------
. Neuromas & Marfanoid habitus & Pheochromoytoma.
. Pts aged > 55ys with new onset dyspepsia with ALARM SYMPTOMS: -------
--------------------------------------------------------
* weight loss.
* dysphagia.
* persistent vomiting.
* should be evaluated with UPPER ENDOSCOPY.
. CRYPTOSPORIDIUM PARVUM:
-------------------------
. HIV pt. with chronic severe diarrhea with CD4 cells < 100.
. Bacterial overgrowth:
-----------------------
. Malabsorption in a pt. with a H/O of abdominal surgery.
. Vit. D def. = Hypocalcemia.
. Vit. A def. = Night blinness.
. Vit. B12 def. = Neuropathy.
. LACTOSE INTOLERANCE:
--------------------
. Asian American.
. +ve Hydrogen breath test.
. +ve stool test for reducing substance.
. ++ stool osmotic gap.
. -- stool pH.
. No steatorrhea.
. ESOPHAGUS:
----------
. ADENO-carcinoma ------------> Chronic GERD & Barret's esophagus.
. Squamous cell carcinoma ----> Smoking & Alcohol.
. Acute Appendicitis:
-------------------
. VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS-VS Visceral followed by somatic pain
!!
. Mallory Weiss $:
------------------
. occur in the distal esophagus at the gastro-esohageal junction,
. after repeated bouts of retching & vomiting.
. Zinc defeciency:
------------------
. may result from total parenteral nutrition or malabsorption.
. Alopecia,skin lesions,abnormal taste,impaired wound healing.
. Ulcerative colitis:
---------------------
. presents as diarrhea & bloody stools.
. The condition may be complicated by systemic toxicity : fever &
weight loss,
. with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end
ileostomy.
. GIARDIASIS:
-------------
. Foul smelling stool.
. Abd. cramps.
. Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.
. MULTIPLE MYELOMA:
-------------------
. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.
. so .. The cause of constipation in a pt. with MM is ELECTROLYTE
DISTURBANCE (++ Ca).
. Angiodysplasia:
----------------
. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.
. DIVERTICULOSIS:
----------------
. The most common cause of painless GIT bleeding.
. Not associated with AS.
. Endoscopy: Multiple out-pouchings of the mucosa through the
hypertrophied muscular layer.
. ZOLLINGER ELLISON's $:
------------------------
. Multiple duodenal ulcers + Single jejunal ulcer resistant to H2
blockers & PPIs.
. GASTRIN producing PANCREATIC TUMOR.
. Un-controlled gastrin production
. ---> Parietal cell hyperplasia
. ----> +++ Stomach acid production
. ----> Inactivation of pancreatic enzymes
. ----> Steatorrhea.
. CHRONIC PANCREATITIS:
----------------------
. H/O of ALCOHOL use.
. Epigastric chronic abd. pain.
. Malabsorption (Steatorrhea & chronic diarrhea).
. Weight loss.
. Type 2 D.M.
. Amylase & Lipase may be normal (Not diagnostic).
. Dx: Abd. CT showing pancreatic calcifications.
.Duodenal ulcers:
------------------
. typically presents with epigastric pain that improves with eating.
. OVER 90% of duodenal ulcers are infected with H. Pylori.
. Tx of H. Pylori ass. ulcers is acid suppression & organism
eradication with antibiotis. . 1st line regimen is OCA = OMEPRAZOLE
+ CLARITHROMYCIN + AMOXICILLIN.
. Achalasia Manometry:
---------------------
. esophageal body peristalsis.
. Failure of relaxation of LES.
. Achalasia Ba Swallow:
----------------------
. Dilated esophagus.
. Bird's beak deformity of LES.
. Ulcerative colitis:
--------------------
. Bloody diarrhea + tenesmus + abd. cramps + weight loss + anemia.
. Extraitestinal manifestations:
------------------------------
.Sclerosing colangitis.
. Uveitis.
. Erythema nodosum.
. Spondyloarthropathy.
. Complications:
--------------
. Toxic Megacolon.
. Colon cancer.
. Yearly colonoscopies is recommended for pts with UC,
. beginning 8-10 ys after diagnosis for prevention of cancer colon.
. PEPTIC STRICTURE:
-------------------
. Slowly progressive dysphagia to solids without anorexia & weight
loss.
. As stricture progresses , it can actually block reflux,
. leading to improvement of heart burn symptoms.
. ENDOSCOPY --> SYMMETRIC circumferential narrowing.
. ADENO-CARCINOMA:
----------------
. Pt with GERD < 20 ys.
. Weight loss.
. ASYMMETRIC narrowing of the esophageal lumen.
. REMEMBER:
-----------
. Pt. with fever + chills + Lt upper Q. pain + splenic fluid collection
. = Lt. sided endocarditis with septic emboli to the spleen,
. causing splenic abscess.
. H/O of incarerated pt. with ++ liver enzymes (possible HCV),
. suggesting IV drug use as the cause of infective endocarditis.
. NERD FAULT !!
---------------
. Pt. with upper GI bleeding (Hematemesis)
. who have depressed conscioussness level should be intubated with ??
. ENDO-TRACHEAL tube not naso-gastric tube to secure the airway.
* WEGENER's GRANULOMATOSIS:
____________________________
. URT infections + LRT infections.
. URT infections -> sinusitis & otitis.
. LRT infections -> cough, hemoptysis, Abnormal CXR.
. It is a systemic vasculitis so it may involve the joint, skin, eye.
. Dx: Best initial test: C-ANCA "Anti-neutrophil cytoplasmic Ab".
. Dx: Most accurate test: Renal biopsy.
. Tx: Steroids & cyclophosphamide.
* POLYARTERITIS NODOSA:
________________________
. Systemic vasculitis.
. Involvement of all organs EXCEPT LUNGS !!!!!
. Renal - myalgia - GI bleeding - purpura - stroke - uveitis -
neuropathy.
. MULTIPLE MOTOR & SENSORY NEUROPATHY + PAIN.
. Dx: Best initial test: ESR & inflammation markers.
. Dx: Most accurate test: Renal biopsy or SURAL N. biopsy.
. Test for HEPATITIS B & C (Ass. e' PAN).
. ANGIOGRAPHY showing BEADING can spare the need for biopsy.
. Tx: Steroids & cyclophosphamide.
* CRYOGLOBULINEMIA:
____________________
. H/O of HEPATITIS "C" with renal involvement.
. Joint pain & pruritic skin lesions & Hepatosplenomegaly.
. Dx: Best initial test: Serum cryoglobulin componet levels,
. immunoglobulins & light chains, IgM.
. Low complement levels esp. "C4".
. Dx: Most accurate test: R. biopsy.
. Tx: Treat HEPATITIS C with INTERFERON + RIBAVIRIN.
* ALPORT $YNDROME:
___________________
. CONGENITAL with family H/O of renal failure.
. Recurrent episodes of hematuria.
. Eye & ear problems e.g. deafness.
. No specific therapy.
___________________________
. ARF : PRE-RENAL AZOTEMIA:
___________________________
.. Presentation:
_________________
... Elderly pt with poor oral intake living in nursing homes taking
medications e.g.,
... NSAIDs, ACE Is & diuretics causing intravascular volume depletion.
... leading to renal glomerular vasoconstriction.
.. Causes:
___________
. 1- Hypotension "SBP <90 mmHg".
. 2- Hypovolemia "dehydration or blood loss".
. 3- Low oncotic pressure " -- Albumin".
. 4- Congestive heart failure.
. 5- Constrictive pericarditis.
. 6- Renal artery stenosis.
.. Dx:
_______
... BUN:Creatinine ratio > 20:1.
... Urinary Na is low < 20.
... Fe Na < 1.
... Urine osmolality > 500.
___________________________________________________
. ARF : POST-RENAL AZOTEMIA = OBSTRUCTIVE UROPATHY:
___________________________________________________
.. Causes:
___________
. 1- Stone in the bladder or ureter.
. 2- Strictures.
. 3- Cancer of the bladder, prostate or cervix.
. 4- Neurogenic bladder "Atonic or non-contracting due to MS or DM".
.. Dx:
_______
... Similar to pre-renal azotemia.
... Distended bladder on exam.
... Large volume diuresis after passing a urinary catheter.
... Bilateral hydronephrosis on U/$.
______________________________________________________
. ARF : INTRA-RENAL AZOTEMIA = ACUTE TUBULAR NECROSIS:
______________________________________________________
.. Dx:
_______
... BUN/Creatinine ratio 10:1.
... Urinary Na > 40.
... Urine osmolality < 350.
* RHABDOMYOLYSIS:
__________________
. Large volume muscular necrosis.
. causes direct toxic effect of myoglobin on the kidney tubule.
. H/O of crush injury or seizure.
. H/O of prolonged immobility.
. H/O of recent start of STATIN for hyperlipidemia.
. Best initial test: Urinalysis -> Large amounts of blood with no cells.
. Relative absence of RBCs on urine microscopy.
. ++ CPK (MOST SPECIFIC FINDING).
. Most accurate test: Urine myoglobin > 20000.
. Rhabdomyolysis --> ++ K & -- Ca.
. In case of hyperkalemia .. Do EKG to exclude arrhythmia.
. Tx hyperkalemia with IV Ca gluconate, insulin & glucose.
. Tx: BOLUS OF NORMAL SALINE, MANNITOL.
. ALKALINIZATION OF URINE.
. INDICATIONS OF DIALYSIS:
__________________________
. Hyperkalemia.
. Metabolic acidosis.
. Uremia with encephalopathy.
. Fluid overload.
. Uremia with pericarditis.
. Toxicity with a dialyzable drug e.g. Lithium , ethylene glycol or
Aspirin.
. URGE INCONTINENCE:
____________________
. Pain followed by urge to urinate.
. Not related to coughing, laughing or standing.
. Dx: Urodynamic pressure monitoring.
. Tx: Behaviour modification + Anti-cholinergics.
. STRESS INCONTINENCE:
______________________
. NO PAIN.
. Follow coughing or laughing.
. Dx: Observe leakage with coughing.
. Tx: KEGEL exercise + Estrogen cream.
. SEVERE HYPERKALEMIA:
______________________
. Denoted by PEAKED T waves on EKG.
. Tx: I.V. CALCIUM GLUCONATE.
. NEPHROLITHIASIS:
__________________
. Sudden onset flank pain.
. Colicky, may be referred to the scrotum.
. Nause, vomiting.
. Cola colored urine.
. Dx: Non contrast CT Abdomen (Preferred to X-ray as it detects Radio-
lucent stones).
. Tx: Relieve the pain by NSAIDs.
. Tx: Stones < 5 mm -> pass spontaneously with conservative ttt.
. Best conservative ttt is FLUID INTAKE > 2 LITERS / day.
. DEHYDRATION:
______________
. Altered mental status.
. Dry oral mucosa.
. ++ Na & ++ K.
. BUN / Creatinine > 20 "Pre-renal azotemia".
. More common in old age due to -- thirst response to dehydration.
. Tx: I.V. sodium containing CTYSTALLOIDS = NORMAL SALINE = 0.9 % NaCl.
. CHLAMYDIAL URETHRITIS:
________________________
. Middle aged female.
. H/O of mutliple sex parteners.
. Dysuria & urinary frequency.
. Urinalysis: Absent bacteriuria.
. Urine culture < 100 colonies.
. HONEYMOON CYSTITIS:
_____________________
. Urinary infection most commonly arises by an ascending route.
. Sexual intercourse is one of the most imp. risk factors of un-
complicated UTIs.
. due to its mechanical effect of introducing uropathogens into the
bladder.
. ANALGESIC NEPHROPATHY:
________________________
. Woman with chronic headaches on NSAIDs.
. Presenting with painless hematuria.
. NSAIDs -> VC of renal medulla vessels -> RENAL PAPILLARY NECROSIS.
. CHRONIC TUBULO-INTERSTITIAL NEPHRITIS.
. OVER-FLOW IN-CONTINENCE:
__________________________
. May be due to DM autonomic neuropathy causing a denervated bladder ->
urine retention.
. The a-contractile hypotonic bladder gradually overdistends,
. When the bladder pressure rises above the urethral pressure,
. Urine is lost until the pressure equalizes !
. These events occur in a cyclic manner occuring at day & night.
. Exam may reveal a distended bladder.
. post-voidal residual urine volume is high.
. Associated other D.M. manifestations e.g. gastropathy, nephropathy &
retinopathy.
. D.M. is the 1st leading cause of nephropathy, kidney biopsy will show:
________________________________________________________________________
. GLOMERULAR HYPERFILTRATION is the EARLIEST renal abnormality detected.
(UW Q!).
. ++ extracellular matrix, basement membrane thickening, mesangial
expansion & fibrosis.
. DIABETIC MICRO-ANGIOPATHY. (UW Q!)
. Proteinuria & progressive -- in GFR.
. Glomerulosclerosis. (UW Q!).
. HTN is the 2nd leading cause of nephropathy, kidney biopsy will show:
_______________________________________________________________________
. Arterio-sclerotic lesions of the afferent & efferent renal arterioles
& capillaries.
. NO proteinuria.
. HEMATURIA:
____________
. Initial "Beginning of urination" -----> Urethral lesion e.g.
Urethritis.
. Terminal "At the end of voiding" -----> Prostatic or Bladder
lesion e.g. cystitis.
. Total "during the entire process" ------> Ureters or kidneys
lesion.
_______________________
. URINARY TRACT STONES:
_______________________
4.CYSTEINE STONES:
___________________
. ++ cysteine "Inborn error of metabolism".
. +ve family H/O.
. Recurrent stones since childhood.
. HARD & RADIO-OPAQUE stones.
. HEXAGONAL CRYSTALS on urine analysis.
. +ve Urinary cyanide nitroprusside test.
5.STRUVITE STONES:
___________________
. Formed when urine is ALKALINE.
. Bec. of infection with urease producing bacteria e.g. PROTEUS.
. H/O of recurrent UTI.
. NEPHROTIC $YNDROME:
______________________
. Proteinuria ( > 3- 3.5 g/day - most imp. criterion).
. Hypoalbuminemia.
. Edema.
. Hyperlipidemia & lipiduria.
. Pathology: Altered permeability of the glomerular membrane.
. Children : Minimal change disease.
. Adults : Membranous glomerulopathy.
. Complicated by HYPERCOAGULABILITY -> Thrombo-embolic manifestations.
. Accelerated atherosclerosis.
. Venous or arterial thrombosis & even pulmonary embolism.
. Other complications: Ptn malnutrition - iron resistant microcytic
hypochromic anemia.
. Other complications: ++ susceptibility to infections & vitamin D
defeciency.
. POST-OPERATIVE OLIGURIA:
__________________________
. Low urine out-put volume with lower abdominal pain.
. Most common cause is post-renal i.e. bladder out-let obstruction.
. Placement of a bladder catheter can rapidly improve symptoms "1st step
done".
. Never to start fluids before catheterization as it may worsen the
condition.
. ACUTE PYELONEPHRITIS:
_______________________
. Acute febrile illness.
. Costo-vertebral angle tendrness.
. Pyuria & bacteriuria.
. Initial ttt -> Blood cultures followed by Empirical I.V. Antibiotics.
. No response within 72 hours -> Do imaging e.g. U/$ or CT,
. to search for underlying pathologies (e.g.obstruction) or
complications (e.g.abscess).
. Both IgA Nephropathy & PSGN are major causes of hematuria after an
upper RTI:
_________________________________________________________________________
______
. IgA nephropathy: begins (1-5days) after URTI with normal serum
complement.
. PSGN : begins 10-15 days after URTI with low serum complement.
. MEMBRANO-PROLIFERATIVE GLOMERULONEPHRITIS:
____________________________________________
. caused by persistent activation of the alternative complement pathway.
. Microscopy: Dense intra-membranous deposits that stain for C3.
. ACUTE EPIDIDYMITIS:
_____________________
. Fever.
. Painful enlargement of the testes.
. Irritative voiding symptoms.
. ACUTE PROSTATITIS:
____________________
. Fever, chills, ++ WBCs with bandemia.
. Urinary urgency, dysuria & +ve leukocyte esterase.
. Pain in the perineal region.
. Tender boggy prostate..
. Obtaining a mid-stream urine sample is the 1st step sh'd be done.
. Prostatic massage sh'd be avoided as it may lead to infectious spread.
. CASTS in NEPHROLOGY:
______________________
. Muddy brown granular ca?sts -> Acute tubular necrosis.
21Broad & waxy casts ---------> Chronic renal failure.
. RBCs casts -----------------> Glomerulonephritis.
. WBCs casts -----------------> Interstitial nephritis & pyelonephritis.
. Fatty casts ----------------> Nephrotic $.
. RENAL AMYLOIDOSIS:
____________________
. H/O of Rheumatoid arthritis (predisposes to amyloidosis).
. Enlarged kidneys & hepatomegaly.
. Renal biopsy -> Amyloid deposits with APPLE GREEN BIREFRINGENCE under
polarized light.
. ACUTE CYSTITIS:
_________________
. Healthy, young, non-pregnant woman. " Un-complicated".
. Pregnant, v.young, v.old, D.M.,immunocompromized,anatomical
abnormality. "Complicated".
. Dysuria, frequency, supra-pubic pain & or hematuria (Hemorrhagic
cystitis).
. Tx of un-complicated cystitis: NITROFURANTOIN or Oral TMP-SMX.
. Tx of complicated cystitis: Levofloxacin or ciprofloxacin.
. HEPATO-RENAL $YNDROME:
________________________
. Complication of end stage LIVER disease (e.g. Cirrhosis).
. -- GFR in absence of shock, proteinuria or other causes of renal
dysfunction.
. Failure to respond to 1.5 liters of normal saline.
. Most common causes of death are infection & hemorrhage.
. Tx: LIVER "NOT KIDNEY" TRANSPLANTATION.
. UREMIC COAGULOPATHY:
______________________
. Complication of CRF.
. Echymosis & epistaxis are the most common presentations.
. The main cause is PLATELET DYSFUNCTION.
. PT,PTT,Platelet count -> NORMAL.
. Bleeding time is prolonged.
. Tx: DDAVP ++ the release of factor 8 (Von Willebrand f) from
endothelial storage sites.
. PLATELET TRENSFUSION has NOOOOOO EFFECT as they quickly become
INACTIVE.
. ANEMIA presentations:
_______________________
. Mild -> Fatigue - loss of energy - tiredness - malaise.
. Severe -> Shortness of breath - lightheadedness - confusion.
. Diseases with similar presentations (Hypoxia - CO poisoning -
Methemoglobinemia).
. Pallor - flow murmur - pale conjunctiva.
. MICROCYTIC ANEMIA:
____________________
____________________
(3) THALASSEMIA:
_________________
. Very small MCV with few or no symptoms. (55 - 75 ml).
. TARGET cells.
. Dx -> NORMAL iron studies.
. Most accurate test -> HEMOGLOBIN ELECTROPHORESIS:
- Beta -> ++ Hg A2 & Hg F.
- Alpha -> Normal (Most accurately diagnosed by DNA sequencing).
- Hg H has Beta 4 tetrads with 3 gene deleted Alpha thalassemia.
. B thalassemia major -> Both B hemoglobin are deffective.
. Characterized by severe anemia & transfusion dependence at an early
age).
. B thalassemia minor occurs in people heterozygous for the B hemoglobin
gene.
. The only microcytic anemia with a HIGH reticulocytic count is Hg H.
. Microcytic anemia non responsive to iron supplementation.
. No ttt !
. N.B. (1):
___________
. Folate & cobalamine (B12) are involved in the conversion of
homocysteine to methionine.
. -- Vit. B12 or folic acid -> ++ Homocysteine level.
. N.B. (2):
___________
. Folic acid & vit. B12 defeciency can be distinguished by measuring
Methyl Malonic acid!
. Vit B12 (Not folic acid) is involved in the conversion of MMA to
succinyl coA.
. -- Vitamin B12 -> ++ MMA.
. -- Folic acid -> NORMAL MMA.
. N.B. (3):
___________
. Laboratory tests ------------> Prinicious anemia -------------> Folic
acid defeciency
_________________________________________________________________________
_______________
. Serum B12 level -------------> (--) ------------->
Normal.
. Serum folic acid level ------> (Normal) -------------> (--).
. Serum LDH level -------------> (++) ------------->
Normal.
. Achlorhydria ----------------> present ------------->
Absent.
. Schilling test --------------> +ve -------------> -ve.
. Methyl malonyl acid MMA -----> ++ ------------->
Absent.
. Neurological signs ----------> ++ ------------->
Absent.
. N.B. (4):
___________
. Alcohol abuse is the most common cause of nutritional folate
defeciency in USA.
. N.B. (5):
___________
. Anemia of chronic kidney disease is due to erythropoietin defeciency.
. One must be careful to ensure adequate iron stores prior to
erthropoietin replacement,
. Bec. the erythropoietin induced surge in RBCs production may consume
much iron,
. precipitating an iron defecient state.
. N.B. (6):
___________
. A case of microcytic hypochromic anemia with -- iron & ferritin,
. The most common cause of iron defeciency anemia is GIT blood loss.
. Dietary iron defeciency & malabsorption of iron are rare causes.
. Iron supplementation helps to restore iron reserves but u must detect
the cause !
. So .. perform test for occult blood in the stool.
. N.B. (7):
___________
. The most common cause of folic acid defeciency is NUTRITIONAL.
. Either due to poor diet or Alcoholism.
. May be caused by some drugs either by impairing its absorption
(PHENYTOIN),
. or antagonizing its physiologic effect (Methotrexate - Trimethoprim).
. N.B. (8):
___________
. PERINICIOUS ANEMIA:
______________________
. Most common cause of vit. B12 defeciency.
. Auto-antibodies against the gastric intrinsic factor required for B12
absorption.
. More in Northern Europeans.
. Associated other auto-immune diseases e.g. Autoimmune thyroiditis &
Vitiligo.
. Shiny tongue due to atrophic glossitis.
. Shuffling broad-based gait ataxia.
. Neurological abnormalities with loss of pain & vibration sense.
. Peripheral blood smear -> Macro-ovalocytes, megaloblasts & hyper-
segmented neutrophils.
. Dx -> Detection of Anti-intrinsic factor Abs.
. N.B. (9):
___________
. Total body stores of Vit.B12 in humans are 2-5 mg with min. daily
requirement 6-9 micg.
. Animal products (meat & dairy) are the only dietary sources of vit.
B12.
. It would take 4-5 years of a pure vegan diet to cause dietary
defeciency.
. In contrast, Folate stores are smaller, clinical defeciency occur
within 4-5 months.
. N.B. (10):
____________
. SCHILLING TEST:
__________________
. Used to detect the cause of vit. B12 defeciency.
. Used to differentiate dietary defeciency from perinicious anemia &
malabsorption.
. In dietary defeciency,
. Oral radiolabelled Vit B12 is absorbed in the gut & excr. by kidneys
in NORMAL amounts.
. But In Malabsorption,
. Oral radio-labelled Vit B12 is excreted in sub-normal amounts.
. HEMOLYTIC ANEMIA:
___________________
___________________
. SUDDEN ONSET of hematological manifestations.
. Dx -> Hemolysis ->
-> ++ indirect bilirubin.
-> ++ reticulocyte count.
-> ++ LDH level.
-> -- Haptoglobin.
. Dx -> Intravascular hemolysis ->
-> Abnormal peripheral smear (schistocytes - helmet cells - fragmented
cells).
-> Hemoglobinuria.
-> Hemosiderinuria.
. MET-HEMOGOLBINEMIA:
_____________________
. Shortness of breath for no clear reason.
. Clear lungs on examination.
. Blood locked up in an oxidized state that can't pick up oxygen.
. H/O of exposure to drugs such as nitroglycerin, amyl nitrate,
nitroprusside & dapsone.
. H/O of exposure to anesthetic drugs e.g lidocaine.
. H/O of brown blood !!
. Tx -> Methylene blue !!
. CARBOXYHEMOGLOBINEMIA = CARBON MONOXIDE (CO) POISONING:
_________________________________________________________
. H/O of environmental risk (Pt working in an enclosed space ->
underground parking lot).
. Present with headache, nausea & dizziness.
. Exposure to CO from automobile exhaust.
. CO binds Hb with an affinity app. 250 times that of oxygen.
. -- in blood carrying oxygen capacity.
. As a compensation -> the body ++ RBCs production (++ HCT).
. LEUKEMIA:
___________
___________
. N.B. Acute leukemia can sometimes present with extremely HIGH WBCs
count,
. When the WBCs > 100000 -> sludging of WBCs in the blood vessels of eye
& lungs & brain.
. LEUKOSTASIS is ttt with LEKOPHARESIS (Removing of WBCs via blood
centrifugation).
. Hydroxyurea is used to lower the cell count.
(B) MYELODYSPLASIA:
____________________
. Mild slowly progressive pre-leukemia $.
. May progress to acute leukemia.
. MOST COMMON CAUSE OF DEATH -> INFECTION or BLEEDING.
. Elderly pt.
. Pancytopenia (Fatigue - bleeding - infections).
. ++ MCV (Macro-ovalocytes).
. -- Reticulocyte count.
. Dx -> Special neutrophil with 2 lobes (PELGER-HUET) cells.
. Tx -> Supportive with transfusions as needed & AZAcitadine.
. Those with 5q minus $ are ttt with Lenalidomide.
QSZA `
. MYELO-PROLIFEARTIVE DISORDERS:
________________________________
(D) MYELOFIBROSIS:
___________________
. Same as hairy cell leukemia -> BUT -> NORMAL TRAP level !
. Dx -> TEAR DROP shaped cells on smear.
. Tx -> LENALIDOMIDE or THALIDOMIDE , BMT.
. Two types_________________________________
|
____________________________________________________
| |
.HODGKIN's LYMPHOMA .NON-
HODGKIN's LYMPHOMA
.__________________
._______________________
. COAGULATION DISORDERS:
________________________
________________________
. TYPES OF BLEEDING:
____________________
____________________
* FACTOR 9 = HEMOPHILIA B:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma (less common than factor 8
def.).
. Dx -> SAME.
. Tx -> Factor 9 replacement.
* FACTOR 11:
_____________
. Rare bleeding with trauma or surgery.
. Dx -> Same.
. Tx -> FFP Fresh frozen plasma.
. FACTOR 12:
____________
. No bleeding.
. Dx -> Same.
. Tx -> No ttt necessary.
. SENILE PURPURA:
_________________
. occurs in areas susceptible to traumas in elderly (Dorsum of the hands
& forearms).
. Due to PERIVASCULAR CONNECTIVE TISSUE ATROPHY .
. Lesions rapidly resolve leaving a brownish discolouration from
hemosiderin deposition.
. Requires no ttt.
. TRANSFUSION REACTIONS:
________________________
________________________
. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.
. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or
washed RBCs.
. Ex -> As soon as the pt. received transfus., he becomes SOB,
hypotensive & tachycardic.
. NORMAL LDH & BILIRUBIN.
. GLUCAGONOMA:
______________
. Necrolytic migratory erythema:
---------------------------------
-> Erythematous papules / plaques on face, perineum & extremities.
-> Enlarge & coalese with central clearing & blistering & crusting &
scaling.
. Diabetes Mellitis:
---------------------
-> Mild hyperglycemia easily controlled with diet & oral agents.
-> Don't require insulin !
. GIT symptoms:
----------------
-> Diarrhea - anorexia abdominal pain - occasional constipation.
. Other findings:
------------------
-> Weight loss.
-> Neuropsychiatric (ataxia - dementia - proximal ms weakness).
-> Associated wih venous thrombosis !
. Dx -> Hyperglycemia with ++ GLUCAGON > 500 mg/dl.
. Dx -> Normocytic Normochromic anemia.
. Dx -> CT or MRI to detect the tumor.
. SMOKER + HORNER's $ = LUNG CANCER:
____________________________________
. Horner's $ -> Miosis, ptosis & anhydrosis.
. Simple CXR is the best next step to detect lung cancer.
. FEBRILE NEUTROPENIA:
______________________
. Single temperature > 38.3c or sustained temp. > 28 c for > 1 hour in a
neutropenic pt.
. Neutropenia = Absolute neutrophil count < 1500 cells/ml.
. Mild (<1500) - Moderate (<1000) - Severe (<500).
. All require antibiotics.
. Moderate & severe neutropenia require hospitalization.
. The most common invading organism is PSEUDOMNAS AERUGINOSA.
. Tx -> HOSPITALIZATION,
. BLOOD CULTURES followed by IV CEFEPIME or PIPERACILLIN TAZOBACTAM.
. TESTICULAR TUMOR:
___________________
. Painless hard mass in testicle.
. Suggestive ultrasound.
. Tx -> Orchiectomy (Removal of the testicle & its associated cord).
. FNAC or trans-rectal biopsy are contr'd bec. the risk of spillage of
cancer cells.
. FIBROCYSTIC DISEASE OF THE BREAST:
____________________________________
. Rubbery, firm, mobile & pinful mass in a young pt.
. More pain during menses.
. Aspiration of the cyst -> Clear fluid with diasppearance of the mass.
. Tx -> Observation of the pt 4 - 6 weeks.
. Only send the fluid for cytology if their is blood or foul smelling.
. TAMOXIFEN:
____________
. Has mixed agonist & antagonist activity on Estrogen receptors.
. It is used as an adjuvant therapy for early stage breast cancer,
. It reduces the risk of recurrence of the original cancer,, BUT,,
. ++ risk of developing of another cancer in the other breast !
. Estrogenic effects ++ risk of ENDOMETRIAL cancer & Venous thrombosis.
. ESOPHAGEAL CARCINOMA:
_______________________
. Heart burn - significant weight loss - Regurgitation of food - fatigue
- smoking H/O.
. Age > 50 ys.
. Histological types -> Squamous cell carcinoma & Adenocarcinoma.
. SCC -> Ass. with smoking & alcohol consumption.
. Adenocarcinoma -> Barret's esophagus (GERD complication).
. Dx -> BARIUM SWALLOW followed by ENDOSCOPY.
. MYASTHENIA GRAVIS:
____________________
. Ptosis & double vision by the end of the day.
. Dx -> EMG -> Decremental response in compound action potential.
. Dx -> Acetyl choline receptor antibody test +ve.
. Dx -> CT scan chest sh'd be done in all newly diagnosed MG pts
searching for a THYMOMA.
* ROUTINE:
___________
-> Colonoscopy at 50 ys then every 10 ys.
. ULCERATIVE COLITIS:
_____________________
. Colonoscopy once the diagnosis is established for 8 ys then repeated
every 1 - 2 ys.
. POST-SPLENECTOMY SEPSIS:
__________________________
. Asplenic pt have defective PHAGOCYTOSIS !
. impaired antibody mediated opsonization in phagocytosis.
. High risk of overwhelming infection by encapsulated organisms,
. e.g. Strept. pneumoniae, N. menengitidis & H. influenzae.
. TYPES OF THERAPIES !
______________________
. ADJUVANT -> TTT given in addition to standard therapy.
. INDUCTION -> Initial dose of ttt to rapidly kill tumor cells.
. CONSOLIDATION -> TTT given after induction therapy to -- the tumor
burden.
. MAINTENANCE -> Given after induction & consolidation ttt to kill
residual tumor cells.
. NEO-ADJUVANT -> Given before the standard therapy for a particular
disease.
. SALVAGE -> TTT for a disease when the standard ttt fails.
. ANDROGEN ABUSE:
_________________
. Atheletes commonly abuse androgen to enhance performance in
competetive sports.
. Ex: testosterone & synthetic androgen.
. ++ Muscle mass & strength & ++ physical exercise intolerance.
. Men SEs -> -- testicular function - -- sperm production - testicular
atrophy.
. Men SEs -> Gynecomastia - mood distaurbance - agrressive behavior.
. Women SEs -> ++ Acne - Hirsutism - deepening of voice - menstrual
irregularities.
. Labs -> Erythrocytosis & ++ HCT - Hepatotoxicity - Dyslipidemia ( --
HDL & ++ LDL).
. POST-SPLENECTOMY RECOMMENDATIONS:
___________________________________
. Risk for sepsis after splenectomy is present UP TO 30 years & more !
. Anti-pneumococcal, Haemophilus & meningococcal vaccine sh'd be given,
. several weeks before splenectomy.
. Daily oral penicillin prophylaxis for 3 - 5ys following splenectomy.
. CANCER OVARY:
_______________
. NO screening tests !
. Serum CA 125 & pelvic U/$ may help in diagnosis.
. BRAIN METASTASIS:
___________________
. SOLITARY -> SURGICAL RESECTION followed by whole brain radiation.
. Multiple -> Palliative whole brain radiation.
. HEMOCHROMATOSIS:
__________________
. NEW-ONSET DIABETES MELLITUS + ARTHROPATHY + HEPATOMEGALY.
. Due to abnormal ++ intestinal absorption of iron -> ++ iron deposition
in tissues.
. Damage to organs ex. liver, pancreas , heart & pituitary.
. Liver -> Hepatomegaly -> Liver cirrhosis -> Hepatocellular carcinoma.
. Pancreas -> Bronze D.M.
. Pituitary -> Hypogonadism.
. Heart -> Restrictive heart failure.
. Joints -> Arthropathy.
. Skin -> Hyperpigmentation.
. Dx -> Iron studies -> ++ fe, ++ ferritin, ++ transferrin saturation.
. Dx -> Liver biopsy -> confirm the diagnosis.
. LEAD POISONING:
_________________
. Lead bind to erythrocytes & disrupts hemoglobin synthesis ->
Microcytic anemia.
. Due to chronic lead exposure & toxicity.
. Acute exposure -> Abdominal pain & constipation.
. Chronic exposure -> Fatigue, iiritability & insomnia.
. Hypertension - Sensori-motor neuropathies - Neuropsychiatric
disturbances - Nephropathy
. OCCUPATIONAL HISTORY IS VERY IMPORTANT !
. BATTERY MANUFACTURING - PLUMBING - MINING - PAINTING - PAPER HANGING &
AUTO-REPAIR.
. Dx -> Blood Lead level.
. Dx -> Peripheral smear -> BASOPHILIC STIPPLING.
. Tx -> CHELATION THERAPY.
. LIVER DISEASES:
_________________
_________________
. ACUTE HEPATITIS:
__________________
__________________
# HEPATITIS B:
_______________
. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.
# HEPATITIS C:
______________
. HEPATITIS C DIAGNOSIS:
________________________
. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - Hepatitis C PCR for RNA:determine the degree of viral activity &
response to therapy.
2 - Liver biopsy: determine the seriousness of the disease i.e. extent
of liver damage.
. Chronic HCV pts with persistently NORMAL liver enzymes & MINIMAL
histological findings,
. NO NEED TO BE TTT WITH INTERFERON OR ANTI-VIRAL DRUGS.
. JUST follow up with yearly liver function tests.
. N.B. PROTHROMBIN TIME IS THE SINGLE MOST IMPORTANT TEST TO ASSESS LIVER
FUNCTION !
_________________________________________________________________________
____________
. HYPER-ESTROGENISM in Cirrhosis:
_________________________________
. Due to -- clearance of Estrogen due to ++ portosystemic shunt.
. -- sex hormone binding globulin synthesis.
. Gynecomastia - testicular atrophy - spider angiomata - palmar eryhtema
& -- body hair.
. ASCITES:
___________
. Paracentesis if (New ascites - pain, fever & tenderness).
. HEPATIC HYDRO-THORAX:
_______________________
. Transudative pleural effusions in pts with cirrhosis,
. who have no underlying cardiac or pulmonary disease.
. Results in a RT-sided pleural effusion.
. Tx -> Salt restrictions & diuretics.
. TIPS "Trans-jugular Intra-hepatic Porto-systemic Shunt" placement in
refractory cases.
{5} HEMOCHROMATOSIS:
_____________________
. Genetic disorder -> over-absorption of copper.
. Iron deposits in various body tissues.
. Heart -> Restrictive cardiomyopathy.
. Skin -> Darkening & pigmentation.
. Joint -> Psedogout & CPPD.
. Pancreas -> Bronze Diabetes.
. Pituitary -> Panhypopituitarism.
. Genitalia -> Infertility.
. Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA ENTEROCOLITICA.
. Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR CARCINOMA (Most common
cause of death).
. Dx -> Best initial test -> ++ serum iron & ferritin levels & -- TIBC.
. Dx -> Most accurate test -> Liver biopsy - MRI liver - HFe gene
mutation detection.
. Tx -> Phlebotomy.
. MANAGEMENT OF CIRRHOSIS:
__________________________
__________________________
{B} . COMPENSATED:
___________________
. U/$ surveillance for Hepatocellular carcinoma & Alpha feto-protein
every 6 months.
. Esophageal endoscopy for varices surveillance.
. COAGULOPATHY MANAGEMENT:
__________________________
. Bleeding disorders occur as the liver synthesizes all clotting factors
except factor 8.
. Chief among these are Vit. K dependent factors 1972.
. Acute bleeding is best ttt with FFP FRESH FROZEN PLASMA.
. FFP contains all clotting factors.
* HYDATID DISEASE:
___________________
. Hydatid cyst in liver.
. Caused by ECHINOCOCCUS GRANULOSUS.
. Defnitive host is DOG.
. Unilocular cystic lesions in liver, lungs, muscles & bones.
. Most pts are asymptomatic.
. Symptoms are due to compression of the surrounding tissues.
. CT -> EGG SHELL CALCIFICATION of hepatic cyst.
. Aspiration isn't indicated -> anaphylactic shock 2ry to spelling of
cyst contents.
. Tx -> Surgical resection under the cover of ALBENDAZOLE.
. LIVER MALIGNANCIES:
_____________________
_____________________
* LIVER METASTASIS:
____________________
. 20 times more common than HCC.
. Tumors of GIT, lung & breast are the most common culprits.
. May be asymptomatic & discovered accidentally.
. If symptomatic: Hepatomegaly, jaundice, cholestasis & ++ alkaline
phosphatase (ALP).
. NORMAL ALPHA FETO-PROTEIN (AFP).
. Dx -> CT -> Multiple hepatic nodules of varying sizes.
. Confirmed by liver biopsy.
. Multiple liver masses are much more likely to be the result of a
metastatic disease.
. Mostly -> CANCER COLON -> DO COLONOSCOPY.
* HEPATIC ADENOMA:
___________________
. Benign rare liver tumor.
. Young & middle aged women with H/O of OCP intake.
. Palpable liver mass.
. Liver biopsy -> Mildly atypical hepatocytes containing glycogen &
lipid deposits.
. Normal liver finction tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant
transformation.
. HYPER-BILIRUBINEMIA APPROACH:
_______________________________
_______________________________
. PANCREATIC DISEASES:
______________________
______________________
. ACUTE PANCREATITIS:
_____________________
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tendrness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic
ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++
Amylase/lipase 3 times.
* ABDOMINAL ULTRA$OUND -> Diffusely enlarged hypoechoic
pancreas.
. Dx -> Most accurate test -> Abdominal CT scan:
* Detect dilated common bile ducts.
* Comment on intra-hepatic ducts.
. Dx -> N.B. -> ++ ALT > 150 & ++ ALP -> Biliary pancreatitis.
. MRCP -> Detects causes of biliary & pancreatic duct obstruction not
found on CT scan.
. ERCP -> If there is dilatation of the common bile duct without a
pancreatic head mass.
. ERCP -> Detect stones or strictures in the pancreatic duct system &
remove them.
. Tx -> NPO - Bowel rest - Hydration - pain medications.
. N.B. (1):
____________
. If the cause of acute pancreatitis was gall stones not alcoholism,
. Once the pt. recovers with normalization of the pancreatic enzymes &
medically stable,
. CLOLECYSTECTOMY IS A MUST !
. N.B. (2):
____________
. Acute pancreatitis in pts without gall stones or a H/O of alcohol use.
. HYPER-TRIGLYCERIDEMIA > 1000 mg/dl -> Acute pancreatitis.
. Eruptive xanthoma on exam.
. Dx -> FASTING LIPID PROFILE.
. SEVERE PANCREATITIS:
______________________
. Pancreatitis with failure of at least 1 organ !
. Predisposing factors: Age > 75 ys, Alcoholism & obesity.
. CULLEN SIGN -> Peri-umbilical bluish coloration indicating
hemoperitoneum.
. GREY-TURNER SIGN -> Reddish brown coloration around flanks =
retroperitoneal bleeding.
. ++ CRP > 150 mg/dl in the 1st 48 hs.
. ++ Urea & creatinine in the 1st 48 hs.
. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).
. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, Leukocytosis &
Hyperglycemia.
. Hypocalcemia due to fat malabsorption.
. severe pancreatitis may lead to release of activated pancreatic
enzymes,
. that enter the vascular system & ++ the vascular permeability,
. so, large volumes of fluid migrate from the vascular system to
surrounding peritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end
organ damage.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic
inflammation.
. Tx -> Supportive with several liters of IV fluids.
. NECROTIZING PANCREATITIS:
___________________________
. Dx -> CT.
. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided
biopsy.
. If the biopsy showed infected necrotic pancreatitis -> SURGICAL
DEBRIDEMENT.
. Surgical debridement is done to prevent ARD$ & death.
. PANCREATIC PSEUDOCYST:
________________________
. Palpable mass in the epigastrium 4 weeks after the onset of acute
pancreatitis.
. Not true cysts as they lack an epithelial lining just walled by a
thick fibrous capsule
. The pseudocyst is compromized of inflammatory fluid, tissues & debris.
. The fluid contains high levels of amylase, lipase & enterokinase.
. Dx -> U/$.
. Tx -> Usually resolves spontaneously.
. Tx -> Drainage if persisting > 6 weeks or > 5 cm in diameter or
becomes 2rly infected.
. May be complicated by severe hemorrhage if eroded into a blood vessel.
. CHRONIC PANCREATITIS:
_______________________
. Due to alcohol abuse - cystic fibrosis (Children) - Autoimmune causes.
. Epigastric chronic abdominal pain.
. Intermittent pain free intervals.
. Malabsorption -> chronic diarrhea & steatorrhea.
. Weight loss & DM may occur lately.
. AMYLASE & LIPASE may be normal .. Non diagnostic.
. Plain film or CT scan -> Pancreatic calcifications. (DIAGNOSTIC).
. If x-ray & CT are -ve for calcifications -> ERCP or MRCP.
. Tx -> Pain management with frequent small meals & pancreatic enzymes
supplement.
. Alcohol & smoking cessation.
. PANCREATIC CARCINOMA:
_______________________
. More in males & black race & age > 50 ys.
. Risk factors -> Chronic pancreatitis, smoking & DM.
. CIGARETTE SMOKING is the MOST CONSISTENT RISK FACTOR.
. Dull upper abdominal pain radiating to the back, weight loss &
jaundice.
. Tumors located in pancreatic body or tail -> pain & weight loss.
. Tumors located in pancreatic head -> Steatorrhea, weight loss &
jaundice.
. COURVOISIER's sign -> Palpable, non tender gall bladder at the Rt.
costal margin.
. VIRCHOW's NODE -> Left supra-clavicular adenopathy.
. ++ serum bilirubin & ++ ALP.
. ++ CA 19-9 levels (Serum cancer associated antigen).
. Dx -> ABDOMINAL U/$ & CT (if U$ is not diagnostic).
. Tx -> Resection of the involved tissue.
. GUESS WHAT -> ALCOHOLISM & GALL STONES ARE NOT RISK FACTORS OF
PANCREATIC CANCER !!
. EMPHYSEMATOUS CHOLECYSTITIS:
______________________________
. Due to 2ry infection of the gall bladder with gas forming bacteria
e.g. Clostridium.
. Mostly diabetic male pts aged 50 - 70 ys.
. Vascular predisposing factor e.g. obstruction or stenosis of the
cystic artery.
. Right upper quadrant pain - nausea - vomiting - low grade fever.
. Crepitus in the abdominal wall adjacent to the gall bladder.
. Complications -> Gangrene & perforation.
. Dx -> Abdominal radiograph -> Air fluid level in the gall bladder.
. Dx -> Abdominal ultrasound -> Curvilinear gas shadowing in the gall
bladder.
. Tx -> Immediate fluid & electrolyte resuscitation, cholycystectomy &
antibiotics.
. A-CALCULOUS CHOLECYSTITIS:
____________________________
. Acute inflammation of the gall bladder in absence of gall stones.
. Most commonly seen in hospitalized pts wit the following conditions:
. Extensive burns - severe trauma - Prolonged TPN or fasting &
mechanical ventillation.
. pathophysiology -> ischemia - biliary stasis - infection or external
compression.
. Complications -> Gangrene - perforation - emphysematous cholecystitis.
. Dx -> U/$ -> Signs of cholecystitis but No gall stones.
. CT & HIDA scan are more sensitive & specific.
. POST-OPERATIVE CHOLESTASIS:
_____________________________
. Benign condition developing after a major surgery.
. Major = Hypotension - extensive blood loss into tissues - massive
blood replacement.
. Jaundice by the 2nd or 3rd post-operative day.
. Bilirubin peaks at 10 - 40 mg/dl by the 10th day.
. ALP may be elevated.
. AST & ALT NORMAL.
. POST-CHOLECYSTECTOMY $YNDROME:
________________________________
. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.
. Biliary causes -> Retained common bile duct - cystic duct stone.
. Extra-biliary causes -> Pancreatitis - PUD.
. Dx -> U/$ followed by ERCP.
. POST-CHOLECYSTECTOMY PAIN:
____________________________
. Due to functional etiology e.g. SPHINCTER OF ODDI DYSFUNCTION or CBD
stone.
. Normal ERCP & U/$ can rule out CBD stones.
. It is a diagnosis of exclusion.
. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.
. 1 . FEBRILE NON-HEMOLYTIC:
_____________________________
. Most common reaction.
. Fever & chills.
. Within 1 - 6 hours of transfusion.
. Caused by cytokine accumulation during blood storage.
. 2 . ACUTE HEMOLYTIC:
_______________________
. Fever, flank pain, hemoglobinuria, renal failure & DIC.
. Within 1st hour of transfusion.
. +ve direct Coomb's test & pink plasma.
. Caused by ABO INCOMPATIBILITY.
. 3 . DELAYED HEMOLYTIC:
_________________________
. Mild fever & hemolytic anemia.
. Within 2 - 10 days of transfuion.
. +ve direct Coomb's test & +ve new antibody screen.
. caused by ANAMNESTIC ANTIBODY RESPONSE.
. 4 . ANAPHYLACTIC:
____________________
. Rapid onset of shock, angioedema, urticaria & respiratory distress.
. Within a few seconds to minutes of the transfusion.
. Caused by RECEPIENT anti-Ig"A" Abs.
. 5 . URTICARIAL = ALLERGIC:
_____________________________
. Urticaria - flushing - angioedema & pruritis.
. Within 2 - 3 hours of transfusion.
. Caused by RECEPIENT Ig"E" Abs & mast cell activation.
. CEREBRAL TOXOPLASMOSIS:
-------------------------
. Multiple ring enhancing lesions causing headache & hemiparesis.
. Prohphylaxis = TMP-SMX = Trimethoprim - Sulfamethoxazole.
. Treatment = SDZ-PMT = Sulfadiazine - Pyrimethamine.
. HIV pt with un-explained fever & cough with CD 4 count < 50.
. AZITHROMYCIN is the best prophylaxis for HIV with MAV.
. FEBRILE NEUTROPENIA:
----------------------
. Fever > 38.3 + Neutrophils < 1500.
. Management: Admission + CEFEPIME I.V.
. Mucormycosis:
---------------
. caused by fungus RHIZOPUS.
. require aggressive surgical debridement + I.V. AMPHOTERICIN B.
. ASPERGILLOSIS:
----------------
. Immunocompromized pt. with pulmonary symptoms.
. CXR: consolidation in the upper lobe.
. CT: HALO sign.
. HISTOPLASMOSIS:
-----------------
. Pulm. symps.
. CXR: Hilar adenopathy.
. Triad of palatal ulcers + splenomegaly + Thrombocytopenia.
. COCCIDIODIOMYCOSIS:
--------------------
. Pulm. symps.
. erythema multiforme or erythema nodosum.
. BLASTOMYCOSIS:
----------------
. Immunodefecient pt. with pulm. symps.
. YEAST :)
. COCCIDIOMYCOSIS:
-----------------
. ARIZONA.
. Non specific lung syms + erythema multiforme + erythema nodosum +
Arthralgia.
. BABESIOSIS:
-------------
. Tick borne disease.
. Parasite enters the RBC causing hemolysis.
. Symptoms: JAUNDICE .. HEMOGLOBINURIA .. RENAL FAILURE .. DEATH.
. Typical pt: > 40 ys .. without a spleen or immunocompromized.
. LABS: INTRAVASCULAR HEMOLYSIS:
................................ * -- RBCs,--WBCs,--Platelets.
................................ * -- Serum complement.
................................ * ++ ESR, ++ Lymphocytes.
. Dx: GIEMSA stain.
. Tx: qunidine-clindamycin, ATOVAQUONE - AZITHROMYCIN.
. Any transplant pt. should have TMP-SMX for prophylaxis against (PCP)
pnemo-cystis carinii pneumonia.
. EHRILICHIOSIS:
----------------
. SPOTLESS RMSF.
. TICK BITE.
. Sysytemic symptoms.
. LEUKOPENIA & THROMBOCYTOPENIA.
. ++ ALT & AST.
. Tx: DOXYCYCLINE.
. ENTERO-HEMORRHAGIC E-COLI:
----------------------------
. Bloody diarrhea.
. Abd. pain.
. NO FEVER.
. No travel H/O.
. CRYPTO-COCCAL meningitis:
---------------------------
. caused by encapsulated yeast
. HIV pt. with meningitis
. Tx: IV Amphotericin + FLUCYTOSINE.
. Tx of primary syphilis:
-------------------------
. Single I.M. BENZATHINE PENICILLIN.
. If the pt is allergic to penicillin.
. Give either single dose of AZITHROMYCIN or 2 weeks course of
DOXYCYCLINE.
. Recall of a tick bite is not the main stay of the diagnosis of LYME
disease caused by BORRELIA BURGDORFERI !
. UTI INFECTION:
----------------
. Acidic urine = E-Coli.
. Alkaline urine = Proteus.
. TRICHINELLOSIS:
-----------------
. GIT complaints.
. + Triad of ---> Peri-orbital edema + Myositis + Eosinophilia.
. other clues .. Splinter or sub-ungal hemorrhages.
. Actinomycosis:
----------------
. Infection at the neck in a diabetic pt.
. Serosanguinous fluid draining from a defect in the center of the
lesion.
. Culture : Gram +ve branching bacteria.
. Tx: I.V. Penicillin.
. Actinomycosis is a bacteria not a fungus so don't ttt it with
Amphotericin !!
. Lesion: Slowly progressive non tender indurated mass
. evolving into multiple abscesses with draining sinus tracts.
. with sulfur yellowish granules !
. NOCARDIOSIS:
--------------
. Crooked , branching , beaded , gram +ve partially acid fast filaments
on microscopy.
. Tx: TMP-SMX.
. PSEUDOMONAS AERUGINOSA:
-------------------------
. Gram -ve bacilli in the sputum of an intubated ICU pt. + fever +
leukocytosis.
. Tx: CEFEPIME (4th g. cephalosporin) or PIPERACILLIN - TAZOBACTAM !
. Ceftriaxone is not effective against Pseudomonas.
. U should STOP it !
. Valvular diseases:
--------------------
. MR is the most common valvular abnormality not related to IV drug
abuse.
. If IV drug abuser .. TR is the the most common.
. Lyme disease:
----------------
. is not associated with purpura.
. but associated with erythema migrans.
. with characteristic bull's eye appearance !
. INFLUENZA MANAGEMENT:
-----------------------
. Most pts with INFLUENZA r ttt with BED REST & SIMPLE ANALGESIA e.g.
ACETAMINOPHEN.
. Anti-viral medications reduce the duration of influenza,
. but they r only effective if administered within 48 hours of the onset
of illness. . Amantadine & Rimantadine r only effective against type A.
. Zanamivir & Oseltamivir r only effective against both type A & B.
. BACILLARY ANGIOMATOSIS:
--------------------------
. caused by BARTONELLA HENSELAE.
. Manifest as several cutaneous & visceral angioma like blood vessels.
. EXOPHYTIC PURPLE SKIN LESIONS.
. 2ry SYPHILIS:
---------------
. Maculo-papular rash involving the palms & soles + Generalized
lymphadenopathy. . Spirochete infection.
. PNEUMONIAS:
-------------
. POST-INFLUENZA ---------------> STAPH. AUREUS.
. HIV---------------------------> PCP.
. D.M. & Alcoholics-------------> KLEBSIELLA.
. C.F. & Bronchiectasis---------> PSEUDOMONAS.
. Atypical $ dry cough----------> MYCOPLASMA.
. Aspiration--------------------> ANAEROBES.
. o"H"io----> "H"ISTOPLASMOSIS:
-------------------------------
. HIV pt with CD 4 cell count <100.
. T.B. like pulm. syms with FHMA & weight loss.
. HEPATOSPLENOMEGOLY + Palatal ulcers.
. CXR: Bilateral reticulonodular opacities.
. Dx: URINE ANTIGEN.
. Tx: ITRACONAZOLE.
. GAITS IN NEUROLOGY:
_____________________
. TREMORS IN NEUROLOGY:
_______________________
2. ESSENTIAL TREMORS:
______________________
* Familial in up to 50 % of cases.
* Starts with fine movement in the upper extremity.
* Worst at the end of the goal directed activity (e.g. reaching a pen).
* Involving the entire head.
3. CEREBELLAR TREMORS:
_______________________
* Intension tremors.
* low fequency 3-4 Hz.
* Affect the extremity & the Whole head.
* Nystagmus & ataxia are present.
. TRIGEMINAL NEURALGIA:
_______________________
. Paroxysmal, LIGHTENING PAIN on the face.
. Severe intense burning or electric shock like.
. Tx: CARBAMAZEPINE.
. CEREBELLAR TUMORS:
____________________
. Ipsi-lateral ataxia (The pt. falls towards the side of the lesion).
. Ipsi-lateral muscular hypotonia.
. Titubation (Forward & backward movement of the trunk).
. Nystagmus.
. Intention tremors.
. Dysdiadokokinesia (Difficulty in performing rapid & alternating
movements).
. INTRA-CRANIAL HEMORRHAGE:
___________________________
. HYPERTENSION is the most imp. risk factor.
. Focal neurological signs develop suddenly & gradually worsen over mins
to hours.
. The degree of symptoms is not maximal at onset (# SAH or embolic
stroke).
. Symptoms start during normal activity (may be ppt by sex).
2- "T"HALAMUS:
______________
* Hemi-paresis, hemi-sensory loss.
* Eyes deviate "T"owards hemiparesis.
* UP-GAZE palsy.
* (Non-reactive) miotic pupils.
3- CEREBELLUM:
______________
* NO hemiparesis.
* GAIT ATAXIA.
* OCCIPITAL HEADACHE (+nausea & vomiting).
* Gaze palsy (6th CN. paralysis)
* Facial weakness.
4- "P"ONS:
__________
* COMPLETE PARAPLEGIA.
* Followed by deep coma in a few mins.
* (REACTIVE) "P"IN POINT PUPILS.
5- CEREBRAL:
____________
* May be associated with seizures.
* Eyes deviate AWAY from the hemi-paresis.
# PARA-NEOPLASTIC $YNDROMES !
_____________________________
. N.B. LAMBERT-EATON $:
________________________
. Auto-antibodies against the (pre) - synaptic receptors.
. LOSS of deep tendon reflexes.
.3. DERMATOMYOSITIS/POLYMYOSITIS:
___________________________________
. MUSCLE FIBER INJURY.
. Symmetric & more proximal ms weakness.
. Ass. ILD, esophageal dysmotility, Raynaud's phenomenon &
polyarthritis.
. SKIN FINDINGS (Gottron's papules & Heliotrope rash).
. SUB-ARACHNOID HEMORRHAGE:
___________________________
. Caused by rupture of arterial saccular "Berry" aneyrysm.
. Sudden severe headache (WORST HEADACHE EVER).
. Meningeal irritation may occur (Neck stiffness).
. Dx -> NON CONTRAST HEAD CT.
. Dx -> is imp. to rule out SAH.
. Dx -> Xanthochromia in CSF confirms the diagnosis.
. Dx -> CT cerebral Angiography is imp. to identify the bleeding source.
. Tx -> Coiling or restenting (Endovascular therapy).
. Tx -> Nimodipine (CCB) to -- the vasospasm.
. Complications:
. ______________
. 1 - Re-bleeding (1st 24 hours).
. 2 - Vasospasm (after 3 days).
. 3 - Hydrocephalus (++ ICT).
. 4 - Seizures.
. 5 - HYPO-NATREMIA (--Na due to SIADH).
. NEURO-FIBROMATOSIS TYPE 2:
____________________________
. YOUNG pt.
. S.C. neurofibromas + Cafe' au lait spots + Bilateral acoustic neuromas
(Deafness).
. Family H/O.
. Autosomal dominant dis. caused by a mutation in chromosome 22.
. NON-SENSE or frame shift mutations are the cause.
. N.B. Silent (Same sense) mutations don't affect the structure of the
protein.
. Dx: MRI with GADOLINIUM.
. PRONATOR DRIFT:
_________________
. It denotes UMNL.
. When the pt. closes his eyes & extends his arms with the palms up,
. The affected arm will tend to pronate.
. Bec. UMNL causes weakness in supination with dominance of the pronator
muscles.
. ESSENTIAL TREMOR:
___________________
. ACTION tremor.
. Absence of other neurological signs.
. Suppressed at rest (# parkinsonism).
. Noticed when the pt. attempts a task that requires fine motor movement
!
. Tx: BB (Propranolol) is the 1st line of ttt.
. Primidone may be used (Anti-convulsant which may ppt acute
intermittent Porphyria,
. manifested as abdominal pain, neurologic & psychiatric abnormalities.
. MULTIPLE SCLEROSIS:
_____________________
. Affects women in child bearing peiod (15-50 ys).
. Multiple neurological deficits that can't be explained by single
lesion.
. "PATCHY" neurological manifestations.
. Optic neuritis (painful loss of vision) & diplopia.
. Sensory symptoms -> Numbness & paresthesia.
. Motor symptoms -> Paraparesis & spasticity.
. Bowel/bladder dysfunction.
. "UHTHOFF phenomenon" Exacerbated by hot weather or exercise !
. "LHERMITTE's sign" Electric shock-like sensation down the spine on
flexion of the neck.
. INTER-NUCLEAR OPHTHALMOPLEGIA (INO) is characteristic:
_______________________________________________________
* On attempted left gaze, the left eye abducts & exhibits horizontal
jerk nystagmus,
* but the right eye remains stationary.
* On attempted right gaze, the right eye abducts & exhibits horizontal
jerk nystagmus,
* but the left eye remains stationary.
* caused by demyelination of the MEDIAL LONGITUDINAL FASCICULUS.
. Dx: BRAIN MRI with & without GADOLINIUM.
. MRI:Multiple bilatreal asymmetric hyperintense lesions in
periventricular white matter.
. CSF analysis: OLIGOCLONAL IgG bands - Normal pressure.
. Tx of acute exacerbation -----> HIGH DOSE IV GLUCOCORTICOIDS.
. Tx to prevent future attacks -> B-interferon or Glatiramer acetate.
. N.B. YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA = MS.
. AMYOTROPHIC LATERAL SCLEROSIS:
________________________________
. UPPER + LOWER motor neuron lesions.
. UMNL (Spasticity - bulbar symptoms - exagerrated deep tendon
reflexes).
. LMNL (Fasciculations, wasting).
. Tx: RILUZOLE (Glutamate inhibitor) - Steroids are WRONGGGGGGGGGGGGGGG
!
. VESTIBULO-TOXICITY by AMINO-GLYCOSIDES:
_________________________________________
. Gentamycin & Amikacin.
. Vertigo & gait imbalance.
. due to damage of the motion sensitive hair cells in the inner ear.
. TORTICOLLIS:
______________
. Example of FOCAL DYSTONIA.
. Dystonia -> Sustained ms contraction.
. Focal -> Affecting one muscle.
. Involuntary head turning & fixation to one side.
. Hypertrophy of the opposite side sterno-cleido-mastoid ms.
. It is a common side effect of Anti-psychotic drugs.
. LIMB ISCHEMIA:
________________
. Mostly due to migration of arterial emboli from the heart.
. The emboli source may be Af or recent MI.
. 5 Ps (Pain - Pallor - Paresthesia - Pulselessness & Paralysis).
. Tx: IV HEPARIN BOLUS followed by continous heparin infusion.
. Referral for emergency vascular surgery.
. METOCLOPRAMIDE:
_________________
. It is a pro-kinetic agent used to treat nausea , vomiting & gastro-
paresis.
. Pts sh'd be monitored closely for the development of drug induced
extra-pyramidal syms.
. Ex: Tardive dyskinesia - Dystonic reactions & prkinsonism.
. Manifested by stiff painful neck.
_________________________________________________________________________
________________
_________________________________________________________________________
________________
. 1 . ISCHEMIC THROMBOTIC:
__________________________
-> H/O of previous TIAs (Transient ischemic attacks).
-> Atherosclerotic risk factors (Uncotrolled HTN & DM).
-> Local in-situ obstruction of an artery.
-> Symptoms may progress or regress with time.
. 2 . ISCHEMIC EMBOLIC:
_______________________
-> H/O of cardiac disease (Af, endocarditis or carotid atherosclerosis
"Bruit").
-> Onset of symptoms is ABRUPT & usually MAXIMAL at the start.
-> Multiple infarcts within different territiories.
-> NO headache or impaired consciousness.
. 3 . HEMORRHAGIC:
__________________
-> H/O of uncontrolled HTN, co-agulopathy, illicit drug use e.g
amphetamines & cocaine.
-> Sudden development of focal neurological signs.
-> Followed by ++ ICT symptoms (vomiting & headache).
-> Worsens gradually over mins to hours.
-> Symptoms may start with normal activity.
-> Hypertension is the most imp. risk factor.
# LACUNAR STROKES:
___________________
. Most common site is in the POSTERIOR LIMB OF THE INTERNAL CAPSULE.
. Most common cause is HYPERTENSION & DM.
. Lipo-hyalinotic thickening of the small vessels.
. Micro-atheromas.
. LIMITED neurological deficit.
. Pure motor or sensory stroke - Ataxic hemiparesis - Dysarthria with
clumsy hand $.
. May be missed on CT due to their small size.
3. ATAXIC HEMIPARESIS:
______________________
. Lacunar infarct in the ANTERIOR LIMB OF THE INTERNAL CAPSULE.
. Weakness more prominent in LL extremity.
. Ipsi-lateral arm & leg incoordination.
# STROKE MANAGEMENT:
_____________________
1- NON contrast head CT to rule out hemorrhagic stroke.
2- Ischemic stroke -> Give fibrinolytic therapy (if the pt comes within
3-4 hs of onset).
3- Make sure that the pt. has no contraindications to the fibrinolysins.
4- If there is contraindication -> Give Antiplatelets (ASPIRIN).
. Clinical presentation "ischemic stroke case" -> Anti-platelet/Anti-
thrombotic therapy:
_________________________________________________________________________
_______________
. Presenting within 3 - 4.5 hs of symptoms onset with no cont'ds -> I.V.
Alteplase.
. Stroke with no prior anti-platelet therapy -> Aspirin.
. Stroke on Aspirin therapy ->(Aspirin + dipyridamole) OR (Clopidogrel).
. Stroke on Aspirin therapy + intracranial large art. sclerosis ->
Aspirin + Clopidogrel.
. Stroke with evidence of atrial fibrillation -> LONG TERM
ANTICOAGULATION e.g. WARFARIN.
# THROMBOLYTICS INDICATIONS:
_____________________________
.1. Non hemorrhagic ischemic stroke.
.2. Symptoms onset < 3 - 4.5 hours before treatment initiation.
# THROMBOLYTICS CONTRA-INDICATIONS:
____________________________________
.1. Stroke or head trauma in the past 3 months.
.2. H/O of intracranial hemorrhage.
.3. Major surgery in the past 2 weeks.
.4. GI,GU or active bleeding in the past 3 weeks.
.5. Seizure at the onset of stroke.
.6. SBP > 185 mmHg or DBP > 110 mmHg.
.7. Platelets < 100000/mm3 , Glucose < 50 mg/dl , INR > 1.7.
_________________________________________________________________________
_________________
_________________________________________________________________________
_________________
. MALIGNANT HYPERTHERMIA:
_________________________
. Genetically susceptible pt during anesthesia.
. Ass. with halothane & succinyl choline.
. Uncotrolled efflux of calcium from the sarcoplasmic reticulum.
. WERNICKE's ENCEPHALOPATHY:
____________________________
. Alcoholic pt.
. Altered mental status + Gait instability + Nystagmus + Conjugate gaze
palsy.
. Due to Vit. B "1" defeciency 2ry to long term alcohol use.
. Triad of ecephalopathy, oculomotor dysfunction & gait ataxia is
diagnostic.
. DECUBITUS ULCER:
__________________
. H/O of old pt in a care giver facility.
. Continued pressure on a bony prominence for a long period.
. Ischemic necrosis of the overlying ms, S.C. tissue & skin.
. Preveted by repositioning of the pt every 2-4 hours.
# DEMENTIAS:
_____________
.7. PSEUDO-DEMENTIA:
____________________
. Major depressive episode may present as pseudo-dementia.
. Elderly pts who r severely depressed may present with memory loss.
. H/O of emotional situation with the pt. (e.g. Pt's son moving out !).
. Symptoms coincides with the emotional situation.
. Tx -> Anti-depressants e.g. SSRIs (SLECTIVE SEROTONIN RE-UPTAK
INHIBITORS).
. BRAIN DEATH:
_______________
. Irreversible cessation of the brain activities.
. Absent cortical & brain stem functions.
. Absent corneal reflex.
. Absent gag reflex.
. Absent oculovestibular rflex.
. FIXED DILATED PUPILS.
. No spontaneous breathing when the ventillator is off for 10 mins.
. Spinal cord may be still functioning, so, DEEP TENDON REFLEXES may be
STILL PRESENT.
. MUST BE CONFIRMED BY TWO PHYSICIANS.
. BELL's PALSY:
_______________
. Facial 7th cranial nerve peripheral neuropathy.
. Sudden onset of unilateral facial paralysis.
. Inability to close the eye on the affected side.
. Inability to raise the eye brow on the affected side.
. Drooping of the mouth corner with disappearnce of the nasolabial fold,
. so, the mouth is drawn to the spared side.
. Diminished tearing.
. Hyperacusis.
. Loss of taste sensation over the anterior 2/3s of the tongue.
. If the lesion in the CNS occuring above the facial nucleus,
. it will typically CONTRALATERAL LOWER FACIAL WEAKNESS SPARING THE
FOREHEAD.
. AMAUROSIS FUGAX:
__________________
. Painless loss of vision.
. Cholesterol particles may be seen in the eye.
. It is a warning sign of impending stroke.
. An underlying embolic disease is most always present.
. Emboli occur at the carotid bifurcation.
. Dx: NECK DUPLEX ULTRA$OUND.
. SUB-DURAL HEMATOMA:
_____________________
. Due to BLUNT or shearing trauma tearing the BRIDGING VEINS.
. causing them to slowly bleed into the subdural space.
. Headache & gradual loss of consciousness occur gradually.
. More common in older pts & alcoholics due to brain atrophy & vessel
fragility.
. NON contrast head CT -> WHITE CRESCENT..
. Mass effect with mid line shift may be seen.
. Emergent neurosurgical consultation for hematoma evacuation is
necessary.
. EPI-DURAL HEMATOMA:
_____________________
. Trauma to the TEPORAL bone.
. Injury to the MIDDLE MENINGEAL ARTERY.
. Non contrast head CT -> BICONVEX HEMATOMA.
. DIABETIC NEUROPATHY:
______________________
. Symmetric peripheral polyneuropathy, mononeuropathy or autonomic
neuropathy.
. Mononeuropathies either cranial or somatic.
. CN 3 (Oculomotor) is the most common affected.
. The cause of neuropathy is ISCHEMIC.
. Somatic & parasympathetic fibers in CN 3 have separate blood supplies.
. So .. Only somatic fibers are affected while the parasympathetic
fibers are intact.
. Manifested by PTOSIS & DOWN & OUT GAZE.
. Accomodation & light reflex are intact.
. ALZHEIMER's DISEASE:
______________________
* It is the most common cause of dementia.
* NO disturbance in consciousness.
* Age group > 60.
* EARLY FINDINGS:
__________________
. Anterograde memory loss (immediate recall affected, distant memory
preserved).
. Visuospatial deficits (lost in own neighborhood).
. Language difficulties (difficulty finding words).
. Cognitive impairment with progressive decline.
* LATE FINDINGS:
_________________
. Neuropsychiatric (hallucinations & wandering).
. Dyspraxia (difficulty performing learned motor tasks).
. Lack of insight regarding deficits.
. Non-cognitive neurological deficits (pyramidal & extra-pyramidal
motor, myoclonus).
. Urinary incontinence.
.2. TOXOPLASMOSIS:
__________________
. Multiple.
. {Ring - enhancing} spherical lesions in the basal ganglia.
. +ve serology is not specific !
. TMP-SMX is preventive.
.5. ABSCESS:
____________
. Solitary.
. {Ring enhancing}.
. Isolated, round with smooth borders.
. H/O of known extra-cranial infections.
. Fluid collection in the maxillary sinus.
. The most common causative organisms are AEROBIC & ANAEROBIC
STREPTOCOCCI & BACTEROIDES.
. ACUTE GLAUCOMA:
_________________
. Occurs when a pre-existing narrow anterior chamber angle is closed,
. in response to pupillary dilatation from medications or another
stimiulus.
. PPt by direct bright light e.g. watching TV.
. ++ IOP may lead to nausea & vomiting & tearing pain.
. Complain of seeing halos around light.
. Damage of the optic nerve is common & may lead to visual loss.
. Sudden onset of photophobia, eye pain, headache & nausea.
. Palpation -> very hard eye.
. NON REACTIVE MID DILATED PUPIL.
. Dx: TONOMETRY.
# HEADACHES:
____________
. HERPES ENCEPHALITIS:
______________________
. Caused by HSV-1.
. Mainly affects the TEMPORAL lobe of the brain.
. Acute onset < 1 week duration.
. Altered mentation - focal neuro. deficits - hemiparesis - dysphasia -
aphasia - ataxia.
. May present with seizures !
. FEVER is present in 90 % of cases.
. CSF analysis -> LYMPHOCYTIC PLEOCYTOSIS.
. .............-> ++ RBCs (Hemorrhagic destruction of the temporal
lobes).
. .............-> ++ Ptn level.
. .............-> -- Glucose level
. Dx : HSV POLYMERASE CHAIN REACTION IS THE GOLD STANDARD.
. Tx : IV ACYCLOVIR.
. ETHICAL PROBLEM:
__________________
. REGARDLESS OF H/O OF DRUG ABUSE,,
. Pts with acute severe pain sh'd receive the same standard of pain
management !!
. IV MORPHINE is the best ttt for acute severe pain.
. Physicians sh'd NEVER undertreat pain even if there is a risk for
abuse.
.1 * TREMOR:
___________
. A resting 4 to 6 Hz tremor with a pill-rolling quality.
. Frequently first manifests in one hand.
. May slowly generalize to involve the other side of the body & the
lower extremity.
.2 * RIGIDITY:
______________
. Baseline ++ resistance to passive movement (Lead pipe or cog wheel).
.3 * BRADYKINESIA:
__________________
. Difficulty initiating movements as when starting to walk or rising
from a chair.
. Narrow based, shuffling gait with short strides without arm swing
(FESTINATING).
. Micrographia (Small hand writing).
. Hypomimia (-- facial expression).
. Hypophonia (soft speech).
.4 * POSTURAL INSTABILITY:
__________________________
. Flexed axial posture.
. Loss of balance during turning or stopping.
. Loss of balance when pushed slightly.
. Frequent falls.
. STATUS EPILEPTICUS:
_____________________
. Single seizure lasting > 30 mins.
. H/O of seizure disorder with no compliance to anti-convulsant therapy.
. A brain seizing > 5 mins is at ++ risk of permanent injury : CORTICAL
LAMINAR NECROSIS.
. Tx -> BENZODIAZEPINE -> IV DIAZEPAM.
. Failed -> ADD FOSPHENOTOIN.
. Failed -> ADD PHENOBARBITAL.
. Failed -> ADD SUCCINYL CHOLINE.
. DELIRIUM:
___________
. Acute confusion state.
. Reduced oe fluctuating level of consciousness.
. Inability to sustain attention.
. Anxiety, agitation & hallucinations.
. Common ppt factors (infections: UTI).
. Polypharmacy, medication side effects, volume depletion & electrolyte
imbalance.
. SERUM ELECTROLYTES & URINALYSIS sh'd be done to detect the cause.
. Tx-> Typical & atypical anti-psychotics (HALOPERIDOL).
. Benzodiazepines (Lorazepam) are not recommended in old age.
. INTRACRANIAL HYPERTENSION:
____________________________
. ++ intra-cranial pressure > 20 mmHg.
. Causes: Trauma - space occupying lesion - hydrocephalus - impaired CSF
outflow.
. Symptoms: Diffuse headache worse in the morning - Nausea & vomiting.
. Vision changes - papilledema - cranial nerve deficis.
. Somnolence - cofusion - Unsteadiness.
. Cushing's reflex: Hypertension & bradycardia.
. Dx: CT or MRI.
_________________________________________________________________________
________________
. BENIGN IDIOPATHIC INTACRANIAL HYPERTENSION = PSEUDOTUMOR CEREBRI:
___________________________________________________________________
. Over-weight female in the child bearing period.
. H/O of OCPs intake or hypervitaminosis A.
. Headache - transient loss of vision - pulastaile tinnitus - diplopia.
. Dx: MRI & LP (CSF opening pressure > 250 mmHg with NORMAL analysis).
=========================
. KEY-WORDS to RE-MEMBER:
=========================
. GAITS
. FESTINATING = HYPOKINETIC = SHUFFLING -> PARKINSONISM.
. HIGH STEPPAGE -------------------------> TABES DORSALIS or L5
Radiculopathy.
. SEMI-CIRCLE ---------------------------> STROKE HEMIPLEGIA.
. WADDLING ------------------------------> MUSCULAR DYSTROPHY.
. WIDE BASED & SHUFFLING ----------------> NORMAL PRSSURE HYDROCEPHALUS.
. IPSILATERAL ATAXIA --------------------> CEREBELLAR ATAXIA.
. SPASTIC -------------------------------> UMNL UPPER MOTOR NEURON
LESION:
. STAGGERING ----------------------------> VESTIBULAR ATAXIA.
. TREMORS
. RESTING TREMORS (PARKINSON)-> At rest,imp. e' activity,High frequency
tremors 5-7 Hz.
. ESSENTIAL TREMORS-> Worst at the end of the goal directed activity
(reaching a pen).
. CEREBELLAR TREMORS -> Intension tremors - low fequency 3-4 Hz -
Nystagmus & ataxia.
. TRI-HEXY-PHENIDYL:
Red as beet, dry as bone, hot as hare, blind as bat, mad as hatter &
full as a flask.
. DEMENTIAS
. FRONTO-TEMPORAL : Personality changes (euphoria - disinhibition -
apathy).
. LEWY BODIES DEMENTIA: Bizarre visual hallucinations.
. ALZHEIMER's DISEASE: Progressive dementia - Impaired judgement &
personality changes.
. HUNTINGTON's DISEASE: Triad of mood disturbances + Choreiform
movements + Dementia.
. CREUTZFELDT - JAKOB DISEASE: EEG -> SHARP TRI-PHASIC SYNCHRONOUS
DISCHARGES.
. NORMAL PRESSURE HYDROCEPHALUS: Triad of Urine incontinence + Abnormal
gait + Dementia.
. PSEUDO-DEMENTIA: Tx -> SSRIs.
. NORMAL AGING: Absence of functional impairments.
. ACUTE GLAUCOMA: Palpation -> very hard eye - NON REACTIVE MID DILATED
PUPIL.
. HEADACHES
. MIGRAINE HEADACHE: female Unilateral Pulsating, AURA of neuro syms
preceiding headache.
. CLUSTER HEADACHE: unilateral 5tearing retro-orbital pain .. Tx -> 100
% OXYGEN.
. PSEUDOTUMOR CEREBRI: Obese female- Vit A - OCPs - Most common
complication is BLINDNESS
. SUB-ARACHNOID HEMORRHAGE: WORST HEADACHE EVER !!
. PAPILLAEDEMA:
---------------
. Transient loss of vision lasting few seconds with change in head
psition.
. caused by ++ ICT manifested by morning headaches or change in headache
intensity with head position.
. Optic neuritis:
-----------------
. Associated with multiple sclerosis.
. Unilateral eye pain & visual loss.
. Allergic conjunctivitis:
--------------------------
. Intense itching - hyperemia - tearing - conjunctival oedema & eye lid
edema.
. CATARACT:
-----------
. Progressive thickening of the lens.
. Blurred vision & glare.
. Tx: Lens extraction.
. Macular degeneration:
-----------------------
. Loss of central vision.
. More common in OLD AGE.
. Post-operative ENDOPHTHALMITIS:
---------------------------------
. H/O of recent ocular operation.
. symptoms manifest within 6 weeks of surgery.
. pain & -- visual acuity.
. swollen eyelids, corneal edema & infection.
. CMV Retinitis:
----------------
. HIV pt with CD4 < 50.
. Fundoscopy: Yellow - white patches of retinal opacification &
hemorrhages are diagnostic.
. Optic neuritis:
-----------------
. Central scotoma.
. Afferent pupillary defect.
. Change in colour perception.
. -- visual acuity.
. Ass. e' Multiple sclerosis.
. Vitreous hemorrhage :
-----------------------
. Sudden loss of vision.
. Floaters in the visual field.
. Diabetic retinopathy is the most common cause.
. Fundus is hard to be visualized with obscured details.
. Amaurosis Fugax:
------------------
. Curtain falling down.
. Whitened edematous retina following the distribution of the retinal
arterioles.
. caused by retinal emboli from the ipsi-lateral carotid artery.
. Vitreous hemorrhage:
---------------------
. Black curtain coming down infront of eyes = Retinal detachment.
. Photopsia (Flashes of light).
. Floaters (Spots in the visual field).
. Diabetic retinopathy:
-----------------------
. H/O of D.M.
. -- visual acuity in both eyes.
. Micro-aneurysms.
. Dot & blot hemorrhages.
. Hard exudates.
. Macular edema.
. Tx ARGON laser photocoagulation to prevent complications.
. Presbyopia:
------------
. Difficulty in near vision.
. Prespyobia is due to -- in lens elasticity not due to macular
degeneration !!
. A history of middle aged individual who has to hold books at an arms
length to read is classic.
. Multiple Sclerosis :
----------------------
. FEMALE with multiple neurological presentations.
. Associated optic neuritis can lead to blurring of vision & retro-
bulbar pain.
. Sympathetic Ophthalmia:
-------------------------
. Damage of one eye (sympathetic eye) after a penetrating injury to the
other eye.
. Due to UN-COVERING OF HIDDEN ANTIGENS !
. In HIV pts:
-------------
.. HSV & HZV :
--------------
... Pain-ful.
... Ass. with karatitis & conjunctivitis.
... Fundus: Peripheral pain lesions & central necrosis.
.. CMV :
--------
... Pain-less.
... Not ass. e'keratitis or. conjunctivitis.
... Fundus: Hemorrhages & fluffy or granular lesions around retinal
vessels.
. Macular degeneration:
-----------------------
. Grid test: distortion of the straight lines that appear wavy !
-------------------------
Dr. Wael Tawfic Mohamed
-------------------------
POISONING TiKi TaKa
_____________________
. OPIOID INTOXICATION:
______________________
. -- RESPIRATORY RATE is the most reliable & predictive sign.
. -- Bowel sounds.
. -- BP.
. -- Temp.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Tx: NALOXONE.
. The goal of ttt is ++ RR from 6 to 12/min with improving Oxygen
saturation.
. N.B. PUPIL EXAMINATION is NOT RELIABLE !!
. Opioid intoxication doesn't always present with miosis.
. Co-ingestions can lead to normal pupillary size or even mydriasis !!!
. OPIOID WITHDRAWAL:
____________________
. Symptoms develop within 6-12 hs after the last dose of short acting
opioid.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Nausea - vomiting - Abdominal pain - Diarrhea - Restlessness -
Arthralgia & myalgia.
. Rhinorrhea - Lacrimation.
. Mydriasis - Piloerection & hyperactive bowel sounds.
. Tx -> METHADONE.
. METHANOL INTOXICATION:
________________________
. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -----> Vision loss & coma.
. Optic disc hyperemia.
. ++ ANION GAP METABOLIC ACIDOSIS { (Na) - (Cl + HCO3) }. (Normal AG 8-
12).
. ++ OSMOLAR GAP.
. Very low HCO3.
. N.B. METHANOL & ETHYLENE GLYCOL MAY HAVE SIMILAR PRESENTATIONS ! BUT !!
_________________________________________________________________________
. METHANOL DAMAGES THE EYES.
. ETHYLENE GLYCOL DAMAGES THE KIDNEYS.
. BETA-BLOCKERS BB INTOXICATION:
________________________________
. -- HR.
. -- BP.
. AV BLOCK.
. BRONCHOSPASM -> WHEEZES (MOST SPECIFIC).
. Cardiogenic shock may occur (Cold & clammy extremities).
. Neurological effects (Delirium & seizures).
. 1st line TTT -> ATROPINE + IV FLUIDS.
. FAILED -------> GLUCAGON ++ c-AMP -> ++ Ca -> ++ cardiac
contractility.
. ALCOHOL INTOXICATION:
_______________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Disinhibited behavior.
. Memory impairment.
. Nystagmus.
. ALCOHOL WITHDRAWAL:
_____________________
. Due to reflex hyperactivity of certain parts of the brain.
. Anxiety, insomnia, tremors & diaphoresis in the 1st 6-24 hs after
alcohol cessation.
. Hallucinations & withdrawal seizures may occur.
. DELIRIUM TREMENS may occur in 5% of pts after 48 - 72 hs.
. Hypertension, agitation, tachycardia, hallucinations & fever.
. Tx -> CNS depressant -> Benzodiazepenes -> Chlordiazepoxide.
. BENZODIAZEPINE OVERDOSE:
__________________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Respiratory compromise, stupor & coma.
. Distinguished from opioid overdose by lack of severe respiratory
depression & miosis.
. Distinguished from alcohol & phenytoin toxicity by lack of nystagmus.
. COCAINE INTOXICATION:
_______________________
. SYMPATHETIC STIMULATION (++HR, ++BP, MYSRIASIS).
. Euphoria.
. Sense of self confidence.
. ++ arousal.
. improved performance.
. PHENCYCLIDINE INTOXICATION:
_____________________________
. HALLUCINOGENIC STREET DRUG.
. VERTICAL NYSTAGMUS.
. VIOLENT BEHAVIOR.
. Agitation - confusion - Pupillary dilatation - tachycardia.
. Severe hypertension & hyperthermia may occur.
. Tx -> Benzodiazepines.
. DIPHENHYDRAMINE POISONING:
____________________________
. Anti-histaminic used in ttt of allergic rhinitis - insect bites &
motion sickness.
. Mixture of anti-cholinergic symptoms.
. Drowsiness & confusion.
. Dry mouth - dilated pupils - blurred vision - Reduced bowel sounds &
urine retention.
. Tx -> PHYSOSTIGMINE (Cholinesterase inhibitor).
. SALICYLATE INTOXICATION:
__________________________
. TINNITUS.
. Nausea & vomiting.
. Fever.
. Altered mental status & acid-base abnormalities.
. Tx -> ALKALINIZATION OF URINE with SODIUM BICARBONATE (Na HCO3).
. ACETAMINOPHEN POISONING:
__________________________
. Rumack - Matthew Nomogram is a curve used to assess its hepatotoxic
effects.
. It also provides the need for N-acetylcysteine as an antidote.
. The 1st data point on the curve is at 4 hours !
. The decision of whether or not to take the antidote can be made after
4 hours.
. Studies proved zat their is no correlation bet. z amount ingested & z
toxicity level!
. So .. If a pt. came to u with H/O of ingestion of 14 pills 2 hours ago
,,
. You should wait 2 hours then obtain the acetaminophen level.
. ORGANO-PHOSPHATE POISONING:
_____________________________
. Organophosphates antagonizes acetylcholinesterase -> Cholinergic
excess.
. -- HR - miosis - muscle fasciculations.
. Bronchorrhea - salivation - lacrimation - diarrhea - urination.
. Tx -> ATROPINE (Compete with acetylcholine at the muscarinic
receptors).
. IMMEDIATE REMOVAL OF THE PT's CLOTHING (SOAKED with secretions),
. thus .. preventing continued absorption of organophosphates through
the skin.
. PSYCHOTIC DISORDERS:
_______________________
_______________________
. N.B. Atypical anti-psychotics are the most effective ttt for -ve
symptoms.
. BRIEF PSYCOTIC DISORDER: < 1 MONTH (Look for a stressful life event
precipitating it).
. SCIZO-AFFECTIVE DISORDER:
-> Distinguished from schizophrenia by the presence of mood symptoms
-> (mania or depression) during the course of the disease.
. N.B.
. Disorganized speech & CIRCUMSTANTIALITY is common in pts with
schizophrenia;
. They deviate from the original subject but eventually returns to it !
. N.B.
. Schizophrenic pts have ++ ventricular size on CT !!
. N.B.
. When there is H/O of syms for many years e' NO IMPROVEMENT OF BASELINE
FUNCTIONING,
. think of:
* DELUSIONAL DISORDER:
-> Key is that delusions are NON-bizarre.
-> Delusions may occur normally in daily life.
-> Delusions are false beliefs in high functioning person.
. N.B.
. A DELUSION is a fixed, false belief not consistent with cultural
norms.
. Individuals with GRANDIOSE DELUSIONS typically believe they have
. special powers extraordinary accomplishments or a special relationship
e' god.
. N.B.
. Watch out for SUICIDAL IDEATION in schizophrenia pts &
schizophreniform pts.
. 50 % of them attempt suicide & 10 % are successful.
. 1st stepin management is always to HOSPITALIZE if there is risk of
suicide.
. Prognosis:
-> Females have a better prognosis & respond better to ttt than males.
-> Pts e' paranoid schizophrenia are more responsive to ttt.
. Treatment:
-> If there is bizarre or paranoid syms -> HOSPITALIZE the pt.
-> Give BENZODIAZEPINES for agitation & start ANTI-PSYCHOTICS.
-> Anti-psychotic medications are given for 6 months.
-> They are most effective to prevent further episodes.
-> Long term anti-psychotics are ONLy given if there is H/O of REPEATED
episodes.
-> Initiate log-term psychotherapy.
. ANTI-PSYCHOTICS:
___________________
___________________
. Have an IMMEDIATE QUIETING EFFECT in acute atacks.
. Delay relapse.
. Used for sedation when benzodiazepines are cont'd or as an adjunct
during anesthesia.
. Used for ttt of movement disorders (Huntington's disease & Tourette
$),
. to suppress tics & vocalization
_________________________________________________________________________
_________________
. MOVEMENT DISORDERS:
______________________
______________________
. Extra-pyramidal symptoms (EPS) are the most common reason for failure
to comply e' ttt.
. Acute dystonia - Bradykinesia - Tardive dyskinesia - Neuroleptic
malignant $.
. Most common culprit atypical antipsychotic is RISPERIDONE -> Switch to
CLOZAPINE.
{3} AKATHISIA:
_______________
. Weeks to chronic use.
. Motor restlessness (Do NOt nistake for anxiety or agitation).
. Tx -> Reduce the dose.
. Tx -> Add benzodiazepines or BBs (Propranolol).
. N.B.
. Chronic use of dopamine antagonists eg. antiemetics (Metoclopramide &
Prochlorperazine)
. can result in tardive dyskinesia.
. N.B.
. CLOZAPINE is the most effective anti-psychotic for schizophrenia.
. CLOZAPINE has NO incidence of movement disorders.
. CLOZAPINE is a 2nd line therapy bec. of the risk of seizures &
agranulocytosis.
. Remember to monitor CBC to watch for bone marrow suppression.
. N.B.
. BENZTROPINE (Anticholinergic)
. is the 1st line ttt in management of acute dystonia & bradykinesia
(parkinsonism).
. N.B.
. BBs (Propranlol) is the 1st line ttt of akathisia.
_________________________________________________________________________
_________________
. Anxiety that interferes e' daytime functioning not due to any other
identifiable cause.
. Medical causes:
. Hyperthyroidism - Pheochromocytoma - Excess cortisol - Heart failure.
. Arrhythmia - Asthma - COPD.
. Drugs:
. Corticosterids - Cocaine - Amphetamines - Caffeine.
. Withdrawal from alcohol & sedatives.
. D.D. -> Post-traumatic stress diorder (PTSD) & Acute stress diorder
(AST);
. which have a HISTORY OF TRAUMATIC EVENT (Threat to life).
. N.B.
. Obsessive symptoms in psychotic disorders may be misdiagnosed as OCD.
. You can differentiate psychosis from OCD by looking for:
. a lack insight & loss of contact to reality.
. N.B.
. Pts with Tourette $ have a high risk of developing ADHD or OCD !
{5} ACUTE STRESS DISORDER (ASD) & POST-TRAUMATIC STRESS DISORDER (PTSD):
_________________________________________________________________________
. ACUTE STRESS DISORDER (ASD) -> ÇÖØÑÇÈ ÇáÊæÊÑ ÇáÍÇÏ
. POST-TRAUMATIC STRESS DISORDER (PTSD) -> ÇÖØÑÇÈ ãÇ ÈÚÏ ÇáÕÏãÉ
. ASD -> Symptoms last LESS THAN ONE MONTH & occur within 1 month of
stressor.
. PTSD -> Symptoms last MORE THAN ONE MONTH.
. N.B.
. GROUP COUNSELING is the most effective to prevent PTSD following a
traumatic event.
{6} GENERALIZED ANXIETY DISORDER (GAD):
________________________________________
. Excessive, poorly controlled anxiety that occurs daily for more than 6
months.
. No single event or focus is related to anxiety.
. It often coexists e' major depression, specific phobi, social phobia &
panic disorder.
. Tx -> SUPPORTIVE PSYCHOTHERAPY.
. Tx -> SSRIs, Venlafaxine, buspirone & benzodiazepenes may be used.
. N.B.
. Distinguish GAD from panic attack or social phobiaby what is causing
the anxiety.
. If the question describes persistent worry of a panic attack or social
encounter,
. then GAD is NOT the answer.
. In GAD, multiple life circumstances, not just one, are causing the
anxiety.
. ANXIOLYTIC MEDICATIONS:
__________________________
__________________________
. Panic disorder:
. Tx -> SSRIs, Alprazolam & Clonazepam.
. They -- intensity & frequency of panic attacks.
. Social phobia -> SSRIs (-- fear ass. e' social situations).
. Benzodiazepines:
-> Don't change dosages abruptly.
-> Use the lowest dose in the elderly.
-> Advise against using machinery or driving.
-> Half life -> ALPRAZOLAM < LORAZEPAM < DIAZEPAM.
. N.B.
. Abrupt cessation of Alprazolam (used in sleeping difficuties),
. which is a short acting benzodiazepine lead to withdrawal symptoms;
. in the form of generalized tonic clonic seizures.
. BUSPIRONE:
-> Therapeutic effect can take up to 1 week.
-> No sedation or cognitive impairment.
-> Best option for people with occupations where driving or machinery
is involved.
-> No withdrawal syndrome.
_________________________________________________________________________
_________________
. Look for other causes of depression where the 1st step in management
is different:
-> Hypothyroidism (Check TSH).
-> Parkinson's disease.
-> Medications (Corticosteroids, BBs, antipsychotics).
-> Substance abuse (Alcohol - Amphetamines).
. N.B.
. The antidepressant of choice for depressed pts who don't respond to
1st line ttt
. with an SSRI (e.g. Paroxetine) is another medication of the same class
(Citalopram).
. N.B.
. In management of single episode of major depression,
. the antidepressant sh'd be continued for a period of 6 months.
. MANIA SYMPTOMS:
-> Grandiosity - Less need for sleep - Excessive talking - Pressured
speech.
-> Racing thoughts - Flight of ideas - Distractability - Sexual
promiscuity.
-> Goal focused activity at home or at work.
. BIPOLAR TYPE (1) DISORDER: MANIC episodes; pts may or may not 've
depressive episodes.
. MANAGAEMENT:
. N.B.
. The long term therapy of bipolar disorder is mood stabilizer
(Lithium).
. Lithium is NEPHROTOXIC.
. If the pt has renal problems (++ urea & creat) -> Give VALPROIC ACID.
. N.B.
. Lithium in the 1st trimester of pregnancy is very dangerous.
. It causes cardiac malformations.
. Septal defects & Ebstein's anomaly (Atrialization of right ventricle).
. In 2nd & 3rd trimesters, it causes goiter & neuromuscular dysfunction.
. N.B.
. Choose electro-convulsive therapy (ECT) for 1st trimester pts with
manic episodes.
. LAMOTRIGENE may be used in 2nd or 3rd trimester.
. N.B.
. Pts who are extremely agitated, psychotic or manic, sh'd be initially
managed with
. an antipsychotic medication such as "Haloperidol".
. N.B.
. BEREAVEMENT is a normal reaction o the loss of beloved one !
. PERSISTENT COMPLEX BEREAVEMENT DISORDER -> Severe impairment >12
months after the loss!
. N.B.
. COMPLICATED GRIEF / EXTENDED BEREAVEMENT can present e' syms of major
depression.
. Bereaved pts who have at least 2 weeks of syms of depression,
. 6-8 weeks after a major loss, sh'd be considered for ttt with:
. BOTH PSYCHOTHERAPY & TRIAL OF ANTIDEPRESSANTs.
. N.B.
. Pts e' both mood & psychotic symptoms respond to both antidepressants
& antipsychotics.
. However, you must treat the worst symptoms first.
. N.B.
. Auditory hallucinations e'out other psychotic symptoms are normal in
grief reaction.
. B . POSTPARTUM DEPRESSION:
_____________________________
. Usually after 2nd birth.
. Many have thoughts about hurting the baby.
. Severe depressive symptoms.
. Tx -> Antidepressants.
. C . POSTPARTUM PSYCHOSIS:
____________________________
. Usually after 1st birth.
. Mothers have thoughts about hurting the baby.
. Psychotic symptoms along with severe depressive symptoms.
. Tx -> Mood stabilizers or antipsychotics & antidepressants.
. Avoid medications if the pt is breastfeeding; use ECT instead !
* RISK FACTORS:
________________
. History of suicide threats & attempts is the most important predictor
of suicide.
. Family H/O of suicide.
. Perceived hopelessness (Demoralization).
. Scizophrenia, borderline or antisocial personality.
. Drug use, especially alcohol.
. Males.
. Age > 65 ys.
. Socially isolated, recently divorced or widowed.
. Chronic physical illness.
. Low job satisfaction or unemployment.
* EMERGENCY ASSESSMENT:
________________________
. Take all suicide threats seriously.
. Detain & hospitalize (Usually 2 weeks).
. Never transport patient to emergency depratment without medically
trained personnel.
. Don't identify with the pt.
. Tx of choice -> PSYCHOTHERAPY + ANTIDEPRESSANTs (SSRIs are the 1st
choice).
. For acute severe risk of self-harm -> Tx of choice is ECT.
. N.B.
. Minors with suicidal attempts must be admitted to hospital ,
. even against their parents will (Their consent is NOT mandatory).
_________________________________________________________________________
_________________
. MEDICATION OVERDOSES:
________________________
________________________
_________________________________________________________________________
_________________
. N.B.
. Somatization disorder or conversion disorder are NEVER the correct
diagnosis if:
. symptoms are produced intentionally or feigned.
. Malingering:
-> When obvious gain results from feigned symptoms.
-> Ex: Shelter - medications - disability insurance.
-> Pts are more occupied with rewards or gain than alleviation of
presenting symptoms.
. N.B.
. Factitious disorder -> The pt wants sick role.
. Malingering disorder -> The pt wants secondary gain.
_________________________________________________________________________
_________________
. N.B.
. REFEEDING $YNDROME:
-> Fluids & electrolytes shift -> Electrolyte depletion, arrhythmias &
heart failure.
. N.B.
. ANOREXIA COMPLICATIONS:
-> Osteoporosis.
-> ++ Cholesterol & carotene levels.
-> Cardiac arrhythmias (Prolonged QT interval).
-> Euthyroid sick $.
-> Hypothalamic - pituitary axis dysfunction -> Anovulation.
-> Hyponatremia secondary to excess water intake.
-> Pregnants (Miscarriage - Hyperemesis gravidarum - postpartum
depression - C.S.).
-> Fetus (IUGR - Prematurity).
. N.B.
. If the only concern is body shape & weight -> ANOREXIA NERVOSA is more
accurate Dx.
. If the only concern is sex characteristics -> GENDER IDENTITY DISORDER
is more acc.
_________________________________________________________________________
_________________
{5} TRICHOTILLOMANIA:
______________________
. Uncontrollable urge to pull out the hair -> Alopecic areas.
. These areas still contain hair of varying lenghts.
_________________________________________________________________________
_________________
. TYPES OF ABUSE:
__________________
__________________
. MANAGEMENT OF ABUSE:
_______________________
1 - Complete physical examination.
2 - Radiographic skeletal survey.
3 - Coagulation profile (If multiple bruises).
4 - Report to child protective services.
5 - Admission of the child to hospital.
6 - Consultation with a psychiatrist & evaluation of family dynamics.
_________________________________________________________________________
_________________
. Ex. 30 ys old woman reports that she has been to many doctors,
. They were all wonderful until they started ignoring her or cutting her
visits short,
. then she realized what terrible doctors they were.
. She startes the visit saying that the assistant at the front desk is
the worst ever,
. because she didn't smile at her.
. The other assistant was just wonderful according to her !
. Ex. 45 ys old singl man fears an upcoming social party being hosted by
his parents.
. He dreads having to meet other people & doesn't feel comfortable
speaking e' others.
. He is planning on staying at home to avoid speaking to others.
. Ex. 38 ys old man presents with his wife for marital counseling.
. The wife reorts that he is inflexible & has unrealistic demands of
orderliness.
. Both partners agree that his demands are causing marital problems.
_________________________________________________________________________
_________________
. Order toxicology to look for another drugs: breath, blood & urine drug
screens.
. Look for 2ry effects of alcohol use: ++ GGTP, AST, ALT & LDH.
. If there is suggestion of IV drug use (treack marks) -> Order HIV,
HBV, HCV & PPD.
. WITHDRAWAL $ MANIFESTATIONS:
_______________________________
_________________________________________________________________________
_________________
. SUBSTANCE ABUSE:
___________________
___________________
{1} ALCOHOL:
_____________
. Intoxication syms -> Talkative, sullen, gregarious & moody.
. Intoxication ttt -> Mechanical ventillation if severe.
. Withdrawal syms -> Tremors, hallucinations, seizures & delirium.
. Withdrawal ttt -> Long acting benzodiazepeines (Chlordiazepoxide).
. No seizure prophylaxis.
. Disulfiram or naloxone for adjunct to supervised therapy after acute
withdrawal.
{3} CANNABIS:
______________
. Intoxication syms -> Impaired motor coordination, impaired time
perception.
. Intoxication syms -> Social withdrawal, ++ appetite, dry mouth,
tachycardia.
. Intoxication syms -> Conjunctival redness.
. Intoxication ttt -> NONE.
{5} INHALANTS:
_______________
. Intoxication syms -> Belligerence, apathy, assaultiveness & impaired
judgement.
. Intoxication syms -> Blurred vision, stupor & coma.
. Intoxication ttt -> Antipsychotics if delirious or agitated.
_________________________________________________________________________
_________________
. HUMAN SEXUALITY:
___________________
___________________
{1} HOMOSEXUALITY:
___________________
. It is NOT a mental illness.
{3} PARAPHILIAS:
_________________
. Recurrent, sexually arousing preoccupations which are usually focused
on humiliation,
. The use of non-living objects & non-consenting partners.
. Occurs for more than 6 months & causes impairment in pt's level of
functioning.
. Tx -> Individual psychotherapy & averse conditioning.
. If severe impairment -> Give antiandrogens or SSRIs to help reduce
pt's sexual drive.
. TYPES OF PARAPHILIAS:
________________________
________________________
.1. VOYEURISM:
_______________
. Recurrent urges to observe an unsuspecting person who is engaging in
sexual activity or disrobing.
. This is the earliest paraphilia to develop.
.2. PEDOPHILIA:
________________
. Recurrent urges or arousal toward prepubescent children.
. This is the most common paraphilia.
.3. EXHIBITIONISM:
___________________
. Recurrent urge to expose oneself to strangers.
.4. FETISHISM:
_______________
. Use of non-living objects usually associated with the human body.
.5. FROTTEURISM:
_________________
. Recurrent urge involving touching or rubbing against a non-consenting
partner.
.6. MASOCHISM:
_______________
. Recurrent urge or behavior involving the act of humiliation.
.7. SADISM:
____________
. Recurrent urge or behavior involving acts in which ..
. physical or psychological suffering of a victim is exciting to the
patient.
=========================================================================
=================
=========================================================================
=================
. AUTONOMY:
____________
. An adult e' capacity to understand his/her medical problems can refuse
any ttt or test
. It doesn't matter if the ttt or test is simple, safe & risk free.
. It doesn't matter if the person will die without the ttt or the test.
. Respecting autonomy is MORE IMPORTANT to do the right thing for a pt !
. CAPACITY:
____________
. Capacity is determined by physicians.
. Competence is a legal term & is determined by courts & judges.
. An adult who is alert & not mentally handicapped is deemed to have
capacity.
. PSYCHIATRY CONSULTATION:
___________________________
. is the answer when a pt's capacity to understand is NOT clear.
. It is NOT necessary if the pt is clearly competent or clearly in coma
!
_________________________________________________________________________
_________________
. MINORS:
__________
. Minors aren't determined to have the capacity to understand their
medical problems,
. until the age of 18.
. Emancipation means that although the pt is under 18, he can make his
own decisions.
. Emancipated minors are living independently & self supporting, married
or in military.
. Partial emancipation is considered for (Sex - Reproductive health -
Substance abuse).
. MINOR STATUS
|
______________________________________________
| |
UN-emancipated
Emancipated
| (Can consent for
care)
| |
. Age < 17 ys & must have consent . Married
from parent or legal guardian . In the
military
. Lives
separately from parents
& manages own
financies.
. INFORMED CONSENT:
____________________
. It is based on autonomy.
. Only a fully informed pt e' the capacity to understand the issues can
grant it.
. The pt must be informed of the benifits & the risks of the procedure.
. Alternatives of the procedure must be given.
. The information is in a language the pt can understand.
. The informed consent must be given for each procedure.
. Pregnant women can refuse therapy, even if the life of the fetus is at
risk !!
. Until the fetus comes out of the body, it is considered part of the
woman's body.
. Ex. A woman can refuse a blood transfusion while pregnant.
. She can refuse antiretroviral ttt during prgnancy, even if the fetal's
life is at risk.
. Once the baby comes out, she can't refuse ttt for the baby.
_________________________________________________________________________
_________________
. CONFIDENTIALITY:
___________________
. The pt has an absolute right to privacy concerning his own medical
information.
. The following persons do NOT have a right to any of the medical
information of the pt:
-> Relatives, employers, friends & spouses.
-> Other physicians -> U can't release it without the express consent
of the pt.
-> Members of law enforcement: U can't release medical information to
courts or police without a court order or subpoena.
. LIVING WILL:
_______________
. It is a writen document outlining the care desired by the patient.
. If a pt doesn't have a health care proxy, the living will can be very
useful.
. If the pt writes out "I never want to be intubated", this is valid.
. If he writes "No heroic measures", this is not valid.
. To be useful, a living will must be clear & precise.
. ETHICS COMMITTEE:
____________________
. The ethics committee is used for cases in which the following are
true:
-> The pt is not an adult with capacity.
-> There are no clearly stated wishes on the part of the pt.
. Also, the ethics committee is the answer if:
-> the caregivers, such as family, are split or in disagreement about
the nature of care.
-> If some family members say "He never wanted to be on a ventilator,
ever".
-> and some family members say "He might have wanted a ventilator
sometime",
-> then this a case for an ethics committee.
. COURT ORDER:
_______________
. It is the option when all the other options haven't given clarity.
. If their is disagreement after all the other steps, including an
ethics committee.
. You don't need a court order if the proxy clearly states wishes or
family in agreement.
. These are not the same as providing pain medications that may end the
pt's life.
. It is ethical to give pain medication, even if the only way to relieve
pain,
. may result in shortenening of life !
. FUTILE CARE:
_______________
. There is NO obligation on the part of the physician to provide care
that won't work !
. There is NO obligation to provide treatment without possible benifit.
. Ex. A pt with widely metastatic cervical cancer develops renal
failure,
. the family members insist that dialysis be started. What do u tell
them ??!
-> You don't have to provide dialysis to a person who will certainly die
!!
. BRAIN DEATH:
_______________
. You are NOT obliged to provide care for a brain-dead patient.
. Brain death = Dead.
_________________________________________________________________________
_________________
. REPRODUCTIVE ISSUES:
_______________________
_______________________
. 1 . ABORTION:
________________
. A woman's right to an abortion varies by trimester of pregnancy:
-> 1st trimester -> A woman has UNRESTRICTED right to an abortion.
-> 2nd trimester -> A woman has access, but her rights are LESS CLEAR.
-> 3rd trimester -> NO CLEAR ACCESS to abortion (The fetus is
potentially viable).
. N.B. YOU DO NOT NEED THE CONSENT OF THE FATHER FOR THE ABORTION.
. 2 . DONATION OF GAMETES:
___________________________
. Pts have UNRESTRICTED RIGHT to donate sperm & eggs.
. There is no ethical problem with being a PAID DONOR for sperm & eggs.
. Note that one can't be a paid donor for organs, such as the kidneys or
the cornea.
_________________________________________________________________________
_________________
. HIV ISSUES:
______________
. A pt has a right to confidentiality of his HIV status.
. However, this confidentiality can be broken to prtect the uninfected,
. such as sexual & needle-sharing partners.
. No obligation for HIV +ve health care workers to disclose their HIV
status.
. This include surgeons.
. A surgeon doesn't have to disclose her HIV status to patient.
. Once having accepted a pt, however, the physician can NOT simply
abandon the pt.
. The physician has an obligation to inform the pt that he must find
another physician,
. and the physician must render care until a substitute caregiver can be
identified.
. GIFTS:
_________
. Ethically acceptable -> Small gifts not tied to specific ttt or tests.
. Ethically UNacceptable -> Gifts given e' intention of getting a
specific prescription.
. SEXUAL CONTACT:
__________________
. Psychiatrists -> NEVER acceptable.
. Other physicians -> They must end the doctor-patient relationship
FIRST !
. ELDER ABUSE:
_______________
. Can be reported even against the will of the patient.
. Doesn't imply a specific age; it has to do e' the FRAGILITY of the pt.
. If the pt is frail & vulnerable, the abuse can be reported even
against the pt's will.
. IMPAIRED DRIVERS:
____________________
. Such as pts suffering from a seizure disorder,
. can NOT have their license taken away by a physician.
. Only the department of motor vehicles can remove or restrict a
license.
. TORTURE:
___________
. Physician participation in torture, on any level, is always WRONG.
. You can't even agree to certify the patient dead !
_________________________________________________________________________
_________________
. IMPAIRED PHYSICIANS:
_______________________
. Must be reported to an authority figure.
-> Physicians in training -> Reported to program director ar department
chair.
-> Faculty -> Reported to the department chair or the dean of the
medical school.
-> Those in practice -> Reported to the state medical board.
. Pt with meningitis -> Admit him against his will & start ttt.
. When dealing with an angry pt, the most appropriate response is to:
. encourage a discussion about the source of feelings.
. ex. You seem to be angry about something, May I ask what is bothering
u so I can help?!
. Treatment response
-> When a pt demonstrates significant improvement with or without
remission.
-> Generally defined as a 50 % reduction in base line of severity.
Dr. Wael Tawfic Mohamed
_________________________
PULMONOLOGY TIKI TAKA
_______________________
. BRONCHIAL ASTHMA:
___________________
___________________
. N.B. Any BA pt. with RESPIRATORY ACIDOSIS & CO2 RETENTION sh'd be
placed in the ICU.
-> Persistent resp. acidosis is an indication of INTUBATION & MECHANICAL
VENTILLATION.
. NON-ACUTE BA:
________________
-> Best initial -> INHALED BRONCHODILATORs (ALBUTEROL).
-> Not controlled -> ADD + INHALED STEROIDs.
-> Not controlled -> ADD + INHALED LABA (SALMETEROL).
. GERD is present in 75% of asthma pts & may be the trigger of many
cases.
. Adult onset asthma with GERD (Worsening syms after meals or with lying
down).
. Obesity, hoarsness, pharyngitis & laryngitis tend towards GERD.
. A trial of proton pump inhibitors (Omeprazole) can be both diagnostic
& therapeutic.
. N.B. All pts with SOB sh'd 've -> O2 - pulse oximeter - CXR & ABG.
. N.B. (1):
. ABG is critical in acute SOB due to COPD (No other way to assess for
CO2 retention !).
. N.B. (2):
. ABG is important to assess for CO2 retention.
. ABG is important to assess for the need for chronic home oxygen based
on pO2.
. N.B. (3):
. In moderate & severe cases of COPD, pts may become members of the
50/50 club !!
. Both pO2 & pCO2 are around 50s !
. Ex -> pH. 7.35 - pCO2 49 - pO2 52 - HCO3 32.
. N.B. Both smoking cessation & home oxygen therapy & vaccines lower
mortality in COPD.
. N.B. Pts with acute on chronic respiratory failure ttt with high flow
supplemental O2,
. are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS,
. due to a combination of reduced alveolar ventillation & ++ dead space
ventillation,
. causing ventillation perfusion mis-match & -- Hb affinity for CO2.
. The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not >
95%)!
. BRONCHIECTASIS:
_________________
_________________
. Cough - mucopurulent sputum - hemoptysis.
. Profound dilatation of the bronchi.
. due to anatomic defect in the lungs mostly due to infection in
childhood.
. Episodes of lung infection with high volume of sputum.
. Hemoptysis & fever may occur.
. Dx -> CXR -> Dilated bronchi (TRMA TRACKING).
. Dx -> CT Chest -> Most accurate test.
. Tx -> No curative therapy.
. Just ttt the infectious episodes with rotating antibiotics to avoid
resistance.
. CYSTIC FIBROSIS:
__________________
__________________
. Young pt.
. Mutation in the Chloride transporter protein CFTR.
. Abnormally thick secretions.
. Affect the respiratory tract - sinuses - pancreas - intestines &
reproductive systems.
. Respiratory tract -> Chronic cough e' frequent exacerbations &
superimposed infections.
. Most pts develop BRONCHIECTASIS leading to HEMOPTYSIS.
. Pancreas -> Fat malabsorption with bloating & greasy, floating stools.
. Dx -> CT -> Atrophic pancreas with calcifications.
. Shortness of breath.
. "DRY" = NON productive cough & chronic hypoxia.
. Dry rales - Bi-basilar end-inspiratory crackles.
. Loud P2 (Sign of pulmonary hypertension).
. Digital clubbing.
. NOOOO FEVER - NOOOO systemic findings.
. N.B. The most common type of cancer in ASBESTOSIS is LUNG CANCER not
mesothelioma.
. SARCOIDOSIS:
______________
. AFRICAN AMERICAN WOMEN.
. Age < 40s.
. SOB - Cough & fatigue over a few weeks to months.
. Lung - > Rales.
. Eye -> ANTERIOR UVEITIS (Sight threatening).
. Neural -> Facial palsy (7th cranial nerve).
. Skin -> ERYTHEMA NODOSUM.
. Joint -> Polyarthralgia.
. Heart -> RESTRICTIVE CARDIOMYOPATHY.
. HYPERCALCEMIA (2ry to Vit.D production by the granulomas).
. Tx -> STEROIDs.
. SYSTEMIC SCLEROSIS:
_____________________
. Pulmonary symptoms (Due to interstitial fibrosis).
. Dysphagia.
. Raynaud's phenomenon.
. Hypertension.
. Telangiectasia.
. PULMONARY HYPERTENSION:
_________________________
. Mean pulmonary arterial blood pressure > 25 mmHg.
. Overgrowth & obliteration of pulmonary vasculature -> -- outflow of
the Rt ventricle.
. SOB more often in young women.
. May be 2ry to (MS - COPD - PCV - ILD & chronic pulmonary emboli).
. Physical findings (Loud P2 - TR - RV heave).
. Dx -> TRANS-THORACIC ECHOCARDIOGRAM (TTE) -> Rt atrial & ventricular
hypertrophy.
. Dx -> EKG -> Rt axis deviation.
. Dx -> CXR -> Pulmonary arteries enlarg. & RVE & tapering of distal
vessels (Pruning).
. Most accurate -> RIGHT HEART SWAN GANZ CATHETERIZATION -> ++ PULMONARY
ARTERY pressure.
. Tx -> BOSENTAN -> Endothelial inhibitor.
. May be complicated by RVF (Rt ventricular heave - JVD - Tender
hepatomegaly - Ascites).
. COR PULMONALE:
________________
. Rt sided heart failure due to pulmonary disease.
. Jugular venous distension.
. Right sided S3 gallop.
. Right ventricular heave.
. Hepatomegaly.
. Ascites.
. Dependent LL edema.
. Most commonly caused by COPD (Flattened diaphragm - prominent
pulmonary vessels on CXR)
. CXR -> Prominent right ventricle & pulmonary artery.
. PULMONARY EMBOLISM:
_____________________
_____________________
. PERFUSION DEFECT & NO VENTILLATION DEFECT.
. ++++++++++++++++++++++++++++ A-a gradient.
. 1 . CXR:
___________
. Most common result -> NORMAL.
. Most common abnormailty -> Atelectasis.
. Wedge shaped infarction & pleural humps are rare.
. 2 . EKG:
___________
. Most common showing -> SINUS TACHYCARDIA.
. Most common abnormality -> NON-SPECIFIC ST-T WAVE CHANGES.
. Right axis deviation & Rt BBB are rare.
. 3 . ABG:
___________
. HYPOXIA -> ++ A-a gradient.
. Mild respiratory alkalosis.
._______________________________________________
.|
.|
. YES = Diagnostic tests to evaluate for PE . NO = MODIFIED
WELL's CRITERIA
.__________________________________________
._______________________________
.|
.|
._____________________
._______________
.| .| .|
.|
. +ve PE . -ve PE . PE Un-likely
. PE likely
.________ .________
.______________ .___________
.| .| .|
.|
. IVC FILTER . No further tests .| .
START anticoagulation
.|
.______________________
.|
.|
. D-DIMER
TESTING for PE
.________________________
.|
._____________________________________________________________________
.|
.|
. +ve
. -ve
. Start or continue anticoagulation, . STOP
anticoagulation
. consider surgery or thrombolysis if indicated.
. PLEURAL EFFUSION:
___________________
___________________
. High ptn level > 50 % of serum level __________ . Low ptn level < 50 %
of serum level.
. High LDH level > 60 % of serum level __________ . Low LDH level < 60 %
of serum level.
. LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !
. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod.
by bacteria).
. SLEEP APNEA:
______________
. Obese pt complaining of daytime somnolence.
. The pt's partener will report severe snoring.
. Hypertension - Headache - Erectile dysfunction & fat neck.
. PULMONARY EDEMA:
__________________
. Hypoxia - SOB - Tachypnea.
. CXR -> Diffuse alveolar infiltrates.
. May be cardiogenic (LVF) or non cardiogenic (ARD$).
. Differentiate bet. the two types using pulmonary capillary wedge
pressue (PCWP).
. PCWP > 18 -> Cardiogenic pulmonary edema.
. PCWP < 18 -> Non cardiogenic = ARD$.
. When you find a given ABF with pO2 55 mmHg = Low oxygenation. & FiO2 =
70%
. So .. You should add PEEP 1st to improve oxygenation.
. Don't decrease the FiO2 before adding PEEP or you will worsen the
condition !
. When you find a given ABG with pO2 105 mmHg = TOXIC OXYGEN LEVEL.
. You should decrease the fractionated oxygen level FiO2 to non toxic
value < 60% !
. PEEP may be ++ as needed to maintain adequate oxygenation but avoid
tension pneumothx.
. When you are given an ABG with respiratory alkalosis (pH > 7.4) &
hypocapnia (--CO2),
. With appropriate tidal volume < 6 ml/kg (pt. 70 kg -> 420 ml).
. With appropriate FiO2 (Ex. 40 %),
. With appropriate PEEP (Ex. 5 cm H2O),
. Look at the respiratory rate (If it is high e.g. 18),
. This respiratory alkalosis will be due to HYPER-ventillation.
. So .. Decreasing the respiratory rate is the most appropriate step.
. Ventillation = RR x TV.
. Respiratory alkalosis results from hyperventillation.
. The RR sh'd be lowered.
. -- in TV can trigger ++ in RR -> worsening the condition.
. PNEUMONIA:
____________
. Fever, cough & sputum.
. Severe illness -> SOB.
. Pts > 65ys with chronic dis. of lungs or liver are more prone to
respiratory failure.
. DM - HIV - Steroid use - Asplenia -> Worse prognosis.
. ELDERLY HYPOXIC PT WITH OR WITHOUT FEVER SHOUL BE ADMITTED !
. N.B. All pts with suspected pneumonia sh'd have a CXR done as the 1st
step.
. Antibiotics sh'd be adminstered ASAP without waiting for sputum gram
stain or culture.
. SPECIFIC ASSOCIATIONS:
_________________________
* Recent viral infection -> Staphylococcus.
* Alcoholics -> Klebsiella.
* GIT syms & confusion -> Legionella.
* Young healthy pts -> Mycoplasma.
* Animal contact -> Coxiella Burnetii.
* Arizona construction workers -> Coccidioidmycosis.
* HIV with < 200 CD4 cells -> Pneumocystis carinii PCP.
. MYCOPLASMA PNEUMONIAE:
________________________
. Most common cause of atypical pneumonia.
. Non productive i.e. dry cough.
. Many extra-pulmonary symptoms (Headache - sore throat - skin rash).
. ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on
extremities.
. CXR -> Lower lobe interstitial infiltrates.
. No cell wall (Only polymorphnuclear cells will appear on gram stain).
. MYCOBACTERIAL PNEUMONIA:
__________________________
. HIV pts have a higher risk of reactivation of tuberculosis.
. Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever
& Night sweats).
. CXR -> UPPER LOBE INFILTRATES WITH CAVITATION.
. LEGIONNAIRE's DISEASE:
________________________
. H/O of recent TRAVEL or trip (BAHAMAS).
. Linked to cruise ship & hotel water supplies.
. HIGH GRADE FEVER > 39 c.
. GIT symptoms (Nausea & vomiting & loose stools).
. Mild ++ LFTs.
. HYPONATREMIA (PATHOGNOMONIC for LEGIONELLA).
. CXR -> Focal lobular consolidation.
. Gram -ve stain rod & stains poorly (Intracellular organism).
. So.. Gram stain will show many neutrophils but no organisms is
chracteristic.
. Most accurate test -> Urine antigen test.
. Tx -> AZITHROMYCIN or Levofloxacin.
. N.B. ACUTE PNEUMONIA WITH CONSOLIDATION & PHYSILOGIC SHUNT:
______________________________________________________________
. -- Breath sounds, ++ Tactile vocal fremitus.
. Alveoli of the affected lung become filled with exudative fluid &
cellular debris.
. These alveoli may have persistent blood flow to areas with impaired
ventillation.
. Leading to a physiologic intra-pulmonary shunt & arterial hypoxemia.
. Positioning of the pt. with the affected lung in dependent position
can worsen the case
. i.e. his SO2 will drop for example from 94% when lying on one side to
84% on other side
. RECURRENT PNEUMONIA:
______________________
. TUBERCULOSIS (T.B):
_____________________
. Immigrants - HIV - Homeless - Prisoners & Alcoholics.
. Most important epidemiologic factor is FOREIGN BORN INDIVIDUAL (Not US
born: MEXICO!).
. Fever - cough - sputum - weight loss & night sweats.
. Dx -> CXR & Sputum acid fast stain & culture to confirm TB.
. LATENT T.B.
_____________
. PPD -> PURIFIED PROTEIN DERIVATIVE TEST:
___________________________________________
. PPD is a screening test for high risk groups.
. POSITIVE TEST IF:
-> 5 mm -> Close contacts, steroid users, HIV +ve.
-> 10 mm -> Homeless - Immigrants - Alcoholics - Health care workers &
prisoners.
-> 15 mm -> Those without any risks.
. RHINITIS:
___________
{A} ALLERGIC RHINITIS:
_______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms.
. Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year.
. Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma.
. Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids.
. MEDIASTINAL TUMORS:
_____________________
_____________________
. Dx -> Helical CT CHEST.
. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS.
. MIDDLE mediastinum ----> BRONCHOGENIC CYST.
. POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele.
. CHORIOCARCINOMA:
__________________
. Metastatic form of gestational trophoblastic disease.
. It may occur after molar pregnancy or normal gestation.
. The lungs are the most frequent site of metastatic spread.
. Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR =
CHORIOCARCINOMA.
. Dx -> ++++++ B-HCG levels.
* PNEUMOTHORAX EXAM:
____________________
. Percussion -> Hyper-resonance.
. Auscultation -> Decreased breath sounds (Will be absent entirely if
large pneumothorax)
. -- TVF.
. JVD, Hypotension & Tracheal deviation to the opposite side.
* EMPHYSEMA EXAM:
_________________
. Percussion -> bilateral resonance.
. Auscultation -> Vesicuar breathing with fine crackles at inspiration.
.1. HISTOPLASMOSIS:
___________________
. Asymptomatic pulmonary nodule.
. Residence in suburban Mississippi or o"H"io river valleys !
. Absence of any complaints.
. Absence of significant past H/O.
. Absence of any cavitary lesions.
. Calcified nodes in the lung may be seen.
. It is a dimorphic fungus found in soil with high concentration of bird
or bat droppings
. Infection through inhalation of the spores of Histoplasma capsulatum
fungus.
.2. BLASTOMYCOSIS -> ULCERATED SKIN LESIONS & LYTIC BONE LESIONS:
_________________________________________________________________
. Fungal infection of the lung..
. Residence in great lakes, Mississippi, Ohio river & Wisconsin.
. Pulmonary symptoms resembling T.B. & Histoplasmosis.
. ULCERATED SKIN LESIONS & LYTIC BONE LESIONS (Characteristic!).
. Skin lesions -> Multiple well circuscribed verrucus crusted lesions.
. Bone lesions -> Lytic lesions in the anterior ribs.
. Dx -> Sputum culture -> BROAD BASED BUDDING YEAST.
. Tx -> ITRACONAZOLE or Amphotericin B.
.3. COCCIDIOIDOMYCOSIS:
_______________________
. Fungal infection of the lung.
. Residence in Southwestern US.
. Fever, cough & night sweats.
. Extra-pulmonary -> skin, meninges & skeleton.
. PANCOAST $YNDROME:
____________________
. Apical lung tumor at the thoracic inlet.
. Compress the inferior portion of the brachial plexus.
. Shoulder pain radiating in an ulnar distribution.
. HYPERTROPHIC OSTEOARTHROPATHY:
________________________________
. Development of clubbing & sudden onset joint arthropathy in a chronic
smoker.
. Bilateral wrist tendrness, thickening of distal fingers & convex nail
beds.
. Associated with lung cancer.
. CXR is mandatory to rule out malignancy.
. FINGER CLUBBING:
__________________
. Thickening of the nail bed that causes a devrease in the angle bet the
nail bed & fold.
. In severe cluccing, the terminal parts of the fingers appear swollen
like drumsticks.
. It is NOT a feature of simple COPD.
. NEW CLUBBING in COPD pts indicates the development of lung cancer or
occult malignancy.
. GOLDEN SCHEME:
________________
________________
. . SPIROMETRY
.____________
.|
.____________________________________________________
.| .|
. LOW FEV1/FVC . NORMAL OR HIGH
FEV1/FVC
.______________
._________________________
.| .|
. OBSTRUCTIVE DISEASE . RESTRICTIVE
DISEASE
._____________________
._____________________
.| .|
. BRONCHO-DILATOR CHALLENGE . DLCO
____________________________ .______
.| .|
._________
.________________
.| .| .|
.|
. ++ FEV1 . No ++ in FEV1 . NORMAL .
-- DLCO
._________ ._______________ ._______
._________
. ASTHMA. . COPD. . CHEST WALL WEAKNESS .
ILD.
.|
. DLCO
._____________________
.| .|
. (--) -> Emphysema . (++) -> Chronic bronchitis.
. MITRAL STENOSIS:
__________________
. Most common cause is rheumatic fever.
. Pt. 40 - 50ys.
. presents with gradual & progressively worsening dyspnea on exertion.
. Orthopnea & hemoptysis due to pulmonary edema.
. Auscultation -> Loud S1 & Opening snap after S2 at apex.
. Low pitched diastolic rumble at apex (When pt lies on left side with
breath holding).
. Atrial fibrillation is a common complication.
. Af causes rapid decompensation in a previously asymptomatic pt.
. Long-standing MS can cause Left atrial enlargement -> Elevation of
left main bronchus.
. Respiratory alkalosis:
-> ++ pH (N = 7.4).
-> -- PCO2 (N = 40 mmHg).
-> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for
resp. alkalosis.
-> The kidneys retain increased amounts of Hydrogen H (protons)
-> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize
serum pH.
-> The ++ amount of HCO3 in urine ALKALIZES the urine.
. SLE:
-----
. Young, African American woman.
. Aged 20 - 40 ys.
. Fatigue "Anemia".
. Painful oral ulcers.
. Non deforming arthritis.
. Hematologic abnormalities "pancytopenia".
. Low grade fever.
. Weight loss.
. Malar or discoid rash.
. Lupus Arthritis as RA involves MCP & PIP BUT "NO DEFORMITIES".
. ERYTHEMA NODOSUM:
-------------------
. Painful S.C. pre-tibial nodules.
. Associated with SARCOIDOSIS.
. Ask for a CXR to detect sarcoidosis.
. CXR: Bilateral hilar adenopathy.
. AFRICAN AMERICAN FEMALE !
. Cough, Arthritis & uveitis.
.. Cellulitis:
--------------
... Infection of skin & S.C. tissue.
... Risk factors: Obesity & Tinea pedis !
... Red, edematous skin that is hot to touch.
... Regional lymphadenopathy.
... Caused by STAPH & STREPT Group A.
. OSTEO-ARTHRITIS (OA):
-----------------------
. Old age.
. Affects hands & weight bearing joints.
. Mild morning stiffness < 30 mins (RA > 1 hour).
. Pain ++ with exercise & -- by rest.
. Bony crepitus, bony enlargement.
. Painful & - range of motion.
. Synovial fluid analysis: 200-2000 WBCs,
. (Normal 0-200 & Inflammatory 2000-50000 & Septic arthritis >50000).
. X-ray: -> NARROWED JOINT SPACE.
. X-ray: -> OSTEPHYTE FORMATION.
. X-ray: -> SUBCHONDRAL CYSTS.
. GOUTY ARTHRITIS:
------------------
. Middle aged male.
. Acute joint pain (1st Metatarsophalangeal joint is the most common).
. Swelling & -- range of motion.
. Low grade fever.
. Synovial fluid analysis is cirtical for diagnosis,
. WBCs 2000-50000,
. NEEDLE shaped, NEGATIVELY bireferingent crystals under polarized
light.
. NEGATIVE gram stain & culture.
. ++ serum Uric acid is neither sensitive nor specific !!
. Tx of acute attack --> INDOMETHACIN (Cot'd in RF or GIT bleeding) &
COLCHICINE.
. TREATMENT ----> NSAIDs, Colchicine & steroids.
. PREVENTION ---> Allopurinol & probenicid.
. PSEUDO-GOUT:
--------------
. Calcium pyrophosphate dihydrate (CPPD) deposition.
. Acute onset, pinful , monoarthropathy affecting the knee.
. Synovial fluid ---> RHOMBOID shaped with POSITIVE +ve birefringence.
. Ass. with HYPERPARATHYROIDISM:
.. ++ Ca & -- PO4 --> constipation & excess urination.
.. Disease of GROANS (Abd. pain), STONES (urinary) & Psychic MOANS.
. OSTEO-ARTHRITIS:
------------------
. Narrowed joint space.
. Osteophytes.
. Suchondral sclerosis or cysts.
. Obesity is the most common risk factor.
. Weight loss is the best initial ttt.
. HERNIATED DISC:
-----------------
. Pain worsens with sitting.
. Low bk pain & sciatica.
. +ve stress leg test.
. VERTEBRAL METASTASIS:
-----------------------
. Low bk pain.
. H/O of malignancy.
. Weight loss.
. CONSTANT DULL PAIN.
. Failure to improve with conservative therapy.
. Osteomyelitis:
---------------
. Caused by STAPH. AUREUS.
. Tx-> Ox, Clox, Dicloxacillin.
. VIRAL ARTHRITIS:
------------------
. Secondary to PARVO-virus 19 infection.
. Similar presentation as Rheumatic arthritis !
. Arthritis --> PCP & PIP & wrists.
. Resolves within just 2 months !!
. H/O of frequent contact with children e.g. day care workers.
. SARCOIDOSIS:
--------------
. AFRICAN AMERICAN FEMALE.
. Lung involvement --> Cough & dyspnea.
. Erythema nodosum.
. Anterior uveitis.
. Acute polyarthritis.
. Parahilar adenopathy.
. ++ ACE enzymes (Give ACE Is)!
. Biopsy: Non caseating granuloma.
. Tx: SYSTEMIC GLUCOCORTICOIDs.
. FIBRO-MYALGIA:
----------------
. WOMEN 20-50 ys.
. Point tenderness in at least 11 - 18 points !!
. H/O of generalized musculoskeletal pain not related to another
illness.
. Disturbed sleep, easy fatiguability.
. Normal lab values.
. Tx: TCAs e.g AMITRIPTYLINE.
. DERMATOMYOSITIS:
------------------
. Proximal extensor ms inflammatory myopathy.
. Violaceous poikiloderma.
. Periorbital edema with rash "Heliotrope sign".
. Rash on chest & lateral neck "Shawl sign".
. Rash on the knuckles, elbows & knees "Gottron's sign".
. Lichenoid papules "Gottron's papules".
. Anti-Mi-2 Abs.
. Ass. with internal malignancies "Most common is OVARIAN CANCER" !
. POLYMYOSITIS:
---------------
. Slowly progressive proximal muscle weakness of the lower limbs.
. Difficulty with stair climbing.
. Difficulty with rising from a seat.
. Muscle tendrness.
. Best diagnostic test ---> MUSCLE BIOPSY.
. LUMBAR STRAIN:
---------------
. Follow twisting of the bk while lifting heavy objects.
. ++ by activity & -- by rest.
. No point tendrness.
. SPINAL STENOSIS:
-----------------
. Low bk pain at lumbar spine,
. ++ with activity.
. DISK HERNIATION:
-----------------
. LBP radiating down the buttock,
. +ve straight leg raise test.
. ANSERINE BURSITIS:
--------------------
. Anserine bursa is located antero-medially over the tibial plateau,
. just below the joint line of the knee.
. Inflammation may be due to overuse or trauma.
. LOCALIZED pain over the ANTEROMEDIAL tibia.
. Valgus stress test -->-ve. "Ruling out Medial collateral ligament
injury".
. NORMAL X-ray.
. Tx: Cortico-steroids injection into the bursa.
. Pre-patellar bursitis:
------------------------
. Pain & swelling directly over the patella.
. WHIPPLE's disease:
--------------------
. H/O of malabsortion diarrhea (Steatorrhea, flatulence, abd.
distension).
. Weight loss.
. Migratory arthritis.
. caused by Tropheryma Whippelii.
. Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina
propria.
. Disseminated Gonococcemia:
----------------------------
. Migratory polyarthritis.
. Skin lesions (Pustules) on the extremeties.
. Tenosynovitis.
. High fever & chills.
. Blood & pustule culture --> NEGATIVE (Need specific growth
requirements).
. SJOGREN $YNDROME:
-------------------
. Women 50 - 60 ys.
. Kerato-conjunctivitis sicca (Xerophthalmia & dry eyes).
. XEROSTOMIA (dry mouth).
. Lack of normal amount of saliva -> Dental carries & dysphagia.
. Enlargement & firmness of the salivary glands.
. Histology -> Lymphocytic infiltration of the salivary glands.
. +ve Anti-SSA(Ro) & or Anti-SSB(La).
. SYSTEMIC SCLEROSIS:
---------------------
. AFRICAN AMERICAN FEMALE.
. Widespread organ involvement.
. Esophagus -->GERD.
. Heart ------> Rt Heart failure.
. Kidney -----> hypertension.
. Most common cause of death is PULMONARY ARTERIAL HYPERTENSION.
. +ve Anti-topo-isomerase-I Abs = +ve Anti-Scl70.
. SUB-ACROMIAL BURSITIS:
-----------------------
. Subacromial bursa lies between the acromion & the tendon of the
supraspinatous ms.
. caused by chronic microtrauma to the supraspinatous tendon.
. e.g. overhead work or tennis playing.
. Tendrness hen the arm is internally rotated & forward flexed at the
shoulder.
. No signs of deltoid atrophy.
. De QUERVAIN TENO-SYNOVITIS:
-----------------------------
. NEW MOTHERS who hold their babies with out-stretched thumb (ABDUCTED &
EXTENDED).
. Affects tendons of abductor pollicis longus & extensor pollicis
brevis.
. Passive stretch of these tendons elicits pain.
. BEHCET's $YNDROME:
-------------------
. Recurrent oral ulcers.
. Recurrent genital ulcers.
. Eye lesions: Anterior uveitis.
. Skin lesions: Erythema nodosum.
. Tx: Corticosteroids.
. More common in TURKISH, ASIAN & MIDDLE EASTERN population.
. SLE ARTHRITIS:
---------------
. Cortico-steroid induced "AVASCULAR NECROSIS" of the femoral head.
. Progressive hip or groin pain.
. without restriction of motion range.
. Normal radiograph on early stages.
. Dx: MRI is the gold standard.
. LUMBOSACRAL STRAIN:
--------------------
. Most common cause of pain.
. Pain starts acutely after physical exertion.
. Pain concentrated in the lumbar area.
. No radiation to thighs.
. Paraspinal tendrness.
. Normal neurological exam.
. -ve straight leg raising test.
. Tx: NSAIDs & early mobilization.
. HERNIATED DISK:
----------------
. Pain radiation to thighs.
. +ve straight leg raising test.
. VERTEBRAL OSTEOMYELITIS:
-------------------------
. Lumbar spine.
. Back pain.
. Low grade fever.
. ++ ESR.
. Local tendrness on percussion.
. Paravertebral muscular spasm.
. Dx: MRI.
. CERVICAL SPONDYLOSIS:
----------------------
. Due to BONY SPUR.+999999
. Age > 50ys.
. H/O of CHRONIC NECK PAIN is TYPICAL.
. Limited neck rotation & Lateral bending.
. Sensory deficits due to osteophyte induced radiculopathy.
. X-ray --> ** BONY SPURS & sclerotic facet joints.
. X-ray --> ** Narrowing of disk spaces.
. X-ray --> ** Hypertrophic vertebral bodies.
. LUMBAR STRAIN:
---------------
. Related to lifting a heavy object.
. No radicular signs.
. Good response to conservative therapy.
. Pt education -----> KEEP THE BACK STRAIGHT WHILE LIFTING AN OBJECT !
.METHOTREXATE:
--------------
. inhibits dihydrofolate reductase.
. SE: Macrocytic anemia (MCV > 100 & -- Hb).
. Other SEs: Nausea, stomatitis, rash, hepatotoxicity, Alopecia.
. HYDROXYCHLOROQUINE:
---------------------
. GI distress.
. Visual disturbances.
. Hemolysis in G6PD defeciency.
. CYCLOPHOSPHAMIDE:
------------------
. Nephrotoxicity & Bladder carcinoma.
. SPINAL STENOSIS:
-----------------
. Bk pain radiating to the buttocks & thighs.
. Numbness & paresthesia may occur.
. Symptoms r worse during walking & lumbar extension,
. while lumbar flexion alleviates the pain.
. Dx: MRI.
. ANKYLOSING SPONDYLITIS:
------------------------
. Young men < 40 ys.
. Low bk pain & stiffness.
. Worse in the morning & improves as the day progress.
. Ass. e' anterior Uveitis (Monocular pain,blurring,photophobia).
. X-ray pelvis --> SACRO-ILIITIS.
. -ve RF & +ve ESR.
. +ve HLA B 27.
. Tx: Pain relief & TNF Alpha antagonists.
. VERTEBRAL OSTEOMYELITIS:
-------------------------
. Injection drug user.
. Pts with sickle cell disease.
. immunocompromized pts.
. STAPHYLOCOCCUS AUREUS.
. TENDERNESS to GENTLE PERCUSSION.
. Pain not relieved by rest.
. Fever & ++WBCs --> UN-RELIABLE !
. ++ Platelet count.
. ++ ESR > 100 mm/hr.
. Dx: MRI.
. Tx: Long term IV Antibiotics.
. EPIDURAL ABSCESS:
------------------
. Enclosed infection in the epidural space.
. Bk pain, fever, chills & leukocytosis.
. More common in injection drug users.
. It may cause SPINAL CORD COMPRESSION.
. LL weakness & Urinary incontinence.
. Acute epidural abscess requires immediate surgical debridement.
. COMPRESSION #:
---------------
. due to VERTEBRAL BODY DEMYELINIZATION.
. Intense focal pain.
. Without neurological symptoms.
. Occur in cases of osteomalacia or osteoporosis.
. RA:
----
. MORNING STIFFNESS > 1 hour.
. Small joints (MCP & PIP).
. Spares DIP "Unlike OA".
. Tenosynovitis (Trigger finger).
. Rheumatoid nodules (Elbow).
. Cervical joint involvement ---> Spine sublaxation ---> Spinal cord
compression.
. +ve Anti-CCP Abs.
. +ve RF.
. ++ CRP & ESR.
. X-ray: Soft tissue swelling , joint sapce narrowing & bone erosions.
. Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 !
----------------------------------------------------------------------
. But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than
Obstructive type.
. So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %.
. Examples of RESTRICTIVE causes:
--------------------------------
.. Interstitial lung disease.
.. Neuromuscular diseases.
.. Chest wall abnormalities.
. Ankylosing spondylitis -> costovertebral joint fusion -> chest wall
motion restriction.
. ENTHESITIS:
------------
. Inflammation & pain at ligaments & tendons attached to bone.
. Associted with Negative spondylo-arthropathies,
. e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis.
. Associated with HLA B 27.
. Most common sites are shoulder & hip.
. FIBROMYALGIA:
--------------
. Women 20 - 50 ys.
. Generalized musculoskeletal pain in absence of joint swelling or lab
abnormalities.
. Excessive tendrness on palpation of at least 11 of 18 soft tissue
locations.
. The sites include the upper quadrants of the buttocks & medial aspect
of the knees.
. As well as Sternocleidomastoid & Trapezius muscles.
. Absent of joint swelling or ms weakness.
. PSORIATIC ARTHRITIS:
---------------------
. DIP.
. Dactylitis --> SAUSAGE shaped digits = diffusely swollen fingers.
. Nail involvement: pitting & oncholysis "separation of nail bed".
. Well demarcated red palques with silvery scaling.
. Tx: NSAIDs & MTx.
. Steroids are contraindicated.
. PSEUDO-GOUT = CHONDRO-CALCINOSIS:
----------------------------------
. Acute arthritis.
. Due to CPPD Calcium pyrophosphate dehydrate crystals deposition.
. H/O of recent surgery or medical illness.
. Synovial fluid analysis --> RHOMBOID shaped, POSITIVELY birefringent
crystals.
. GOUT synovial fluid analysis --> NEEDLE shaped, NEGATIVELY
birefringent crystals.
. BAKER CYST:
------------
. Due to excessive fluid production by an inflammed synovium.
. Occurs in cases of Rheumatoid Arthritis.
. Excess fluid accumulates in the popliteal bursa which expands,
. creating a tender mass in the popliteal fossa.
. May burst & release their contents into the calf,
. resulting in an appearance similar to DVT.
. AMYLOIDOSIS:
-------------
. Ass. with Nephrotic $ (facial swelling, LL edema, massive
proteinuria).
. Palpable kidneys.
. Hepatomegaly.
. Cardiomegaly (Audible S4).
. H/O of chronic infections e.g. Bronchiectasis & recurrent pulm.
infections.
. Tx: COLCHICINE.
. OSTEO-ARTHRITIS:
-----------------
. Age > 50 ys.
. Morning stiffness < 30 mins.
. Bony tendrness.
. Bony enlargement.
. CREPITUS on active motion.
. No warmth i.e. COOL joint !
. SLE Arthritis:
---------------
. Like RA but --------> NO PERMANENT DEFORMITIES.
. SEPTIC ARTHRITIS:
------------------
. H/O of PROSTHETIC joint.
. Red, hot, swollen, painful joint with limited range of motion.
. ++ WBCs > 50000.
. STAPH. AUREUS is the most common causative organism.
. Disseminated Gonococcemia:
---------------------------
. H/O of recent unprotected sex with a new partener.
. A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin
lesions.
. TRAUMA:
__________
__________
(1) AIRWAY:
____________
. Establishing & securing the airway is always the 1st step in
management.
. Altered mental status is the most common indication for intubation in
a trauma pt.
. As an unconscious pt can't maintain his airway.
. The preferred method of securing an airway -> OROTRACHEAL INTUBATION.
. Trauma with cervical spine injury -> FLEXIBLE BRONCHOSCPE.
. Extensive facial trauma & bleeding into airway -> CRICOTHYROIDOTOMY or
TRACHEOSTOMY.
. N.B.
. Pts with cervical spine injury should 1st have stabilization of the
cervical spine.
. Oro-tracheal intubation with rapid sequence intubation is the
preferred way,
. to secure an airway in an apnein pt with a cervical spine injury.
. N.B.
. In burn victims, clinical indicators of thermal inhalation injury to
the upper airway,
. or smoke inhalation injury to the lungs include burns on face, singing
of eye brows,
. oropharyngeal inflammation & blistering, oropharyngeal carbon
deposits,
. carbonaceous sputum, stridor, carboxyhemoglobin level > 10 %.
. H/O of confinement in a burnung buiding.
. The presence of one or more of these indicators warrants early
intubation,
. to prevent upper airway obstruction by edema.
(2) BREATHING:
_______________
. Check oxygen saturation, if SpO2 < 90 %:
-> ++ oxygen concentration & flow rate.
-> Obtain an ABG.
-> Determine the likely cause of hypoxia from H/O.
(3) CIRCULATION:
_________________
. N.B.
. When hemorrhage occurs, tachycardia & peripheral vasoconstriction are
the 1st changes.
. These responses act to maintain the blood pressure within normal
limits.
. PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLEMIA.
. N.B.
. Acute cardiac tamponade:
. occurs due to a sudden rise in intra-pericardial pressure.
. Should be suspected in all adult pts with blunt chest trauma.
. Jugular venous distension, Tachycardia & Hypotension despite
aggressive fluid resusc.
. CXR findings typically reveal a normal cardiac silhouette without
tension pneumothorax.
. N.B.
. Don't be distracted by head trauma or dilated pupils in a hypotensive
trauma pt.
. Intracranial bleeds are never the cause of hypotensive shock.
. The 1st step in management is to identify & control the site of
bleeding.
. N.B.
. Most causes of shock in the setting of trauma are 2ry to hypovolemia
from blood loss.
. However, ++ CVP/PCWP or failure of hypotension to resolve after a
bolus of IV fluids,
. should suggest an alternative diagnosis.
. Myocardial contusion sh'd be suspected in pts with evidence of injury
to anterior chest
. MI can be confirmed with +ve cardiac markers & EKG changes.
. N.B.
. High energy blunt trauma to the chest commonly causes aortic injury.
. In most cases of aortic rupture, death is the immediate result.
. Widened mediatinum, large left sided hemothorax & mediastinal
deviation to right side.
. Disruption of the normal aortic contour..
. Bilateral COLLAPSED neck veins.
. N.B. PNEUMOTHORAX:
. Primary spontaneous pneumothorax -> No preceiding event & No H/O of
lung disease.
. Secondary spontaneous pneumothorax -> Complication of underlying COPD.
. Tx -> Small ( < 2cm between lung & chest wall on CXR) -> Observation &
oxygen.
. Tx -> Large (Stable) -> Needle aspiration or chest tube.
. Tension pneumothorax:
________________________
. Life threatening; trapped air with mediastinal shift.
. Compromised cardiopulmonary function.
. Chest pain or dyspnea.
. -- Breath sounds / -- TVF / -- chest movement.
. Hyperresonance to percussion on the affected side.
. Tachycardia, hypotension.
. Tracheal deviation away from the affected side.
. Imaging -> Notable visceral pleural line.
. Imaging -> Air in hemithorax -> Contralateral mediastinal shift.
. Imaging -> Radiolucent costophrenic sulcus.
. Tx -> Urgent needle decompression then chest tube placement (Tube
thoracostomy).
. Tx -> IV lines & fluid resuscitation follow urgent needle
decompression.
. N.B.
. ONLY TWO CAUSES OF DISTENDED NECK VEINS -> TENSION PNEUMOTHORAX &
CARDIAC TAMPONADE.
. N.B.
. In HEMOTHORAX -> Neck veins are COLLAPSED !
. N.B. HEMO-THORAX:
____________________
. After blunt chest trauma, hemorrhagic shock associated e'
. decreased breath sounds & dullness to percussion over one hemithorax.
. & contralateral tracheal deviation.
. COLLAPSED NECK VEINS.
. Most common cause is damage to intercostal or internal mmamary artery.
* ABDOMINAL TRAUMA:
____________________
. The 1st step in management is always to control the site of bleeding
if known.
-> Apply direct pressure when the site is visible (e.g. extremity).
-> Blind clamping & the use of tourniquet is NEVER the answer.
. N.B.
. Intraosseous cannulation in the proximal tibia is used in children
(generally < 6ys).
. Give an initial bolus of Ringer's lactate at 20 ml/kg of body weight.
. Pts with +ve findings on either FAST or DPL -> should undergo
exploratory laparotomy.
. N.B.
. Blunt abdominal trauma to the upper abdomen can cause pancreatic
contusion,
. crush injury, laceration or transection to the pancreas.
. Pancreatic injuries may be MISSED by CT scan during the 1st 6 hours
following trauma.
. Untreated pancreatic injury can be complicated by retroperitoneal
abscess or pseudocyst
. N.B.
. The spleen is the most commonly injured organ following blunt
abdominal trauma.
. Left upper quadrant abdominal pain.
. Abdominal wall contusion, Lt lower chest wall tendrness.
. Lt shoulder pain referred from splenic hemorrhage irritating phrenic
nerve & diaphragm.
. It is called "KEHR" sign.
. Splenic rupture causes acute left upper quadrant abdominal pain.
. Delayed hypotension may result due to blood loss.
. No signs of sepsis will be present.
. Dx -> Abdominal CT with IV contrast.
. N.B.
. Blunt deceleration trauma (Motor vehicle accident or fall from > 10
feet):
. Blunt aortic trauma must be ruled out.
. CXR is the initial screening test -> WIDENING of the mediastinum.
. N.B.
. Duodenal hematoma:
_____________________
. mostly follow abdominal blunt trauma in children.
. The hematoma may cause duodenal obstruction with nausea & vomiting.
. Epigastric pain & vomiting due to failure to pass gastric secretions
past obstruction.
. Tx -> NASOGASTRIC SUCTION & PARENTERAL NUTRITION.
. Most hematomas will resolve spontaneously in 1-2 weeks.
. N.B.
. Any gun shot wound below the 4th intercostal space (level of the
nipple) is:
. considered to involve the abdomen & requires an exploratory laparotomy
in unstable pts.
. N.B.
. All hemodynamically UN-STABLE pts with penetrating abdominal trauma,
. must undergo immediate exploratory laparotomy to diagnose & treat
source of bleeding
. as well as to diagnose & treat perforation of any abdominal viscus to
prevent sepsis.
. N.B.
. Abdominal CT used to detect intra-abdominal injury in hemodynamically
stable trauma pts
. In hemodynamically un-stable pts, a FAST U/$ should be the initial
test.
. DPL Diagnostic peritoneal lavage is used in hemodynamically unstable
pts if -ve FAST.
. N.B.
. DIAPHRAGMATIC TRAUMA:
________________________
. Blunt abdominal trauma -> Mild respiratory distress & Abnormal CXR.
. Sudden ++ in intra-abdominal pressure -> Large radial tears in the
diaphragm.
. Rupture is more common on LEFT side bec. the right side is protected
by the liver.
. Dx -> CXR -> Hemi-diaphragmatic elevation.
. Dx -> CXR -> Naso-gastric tube in the pulmonary cavity = Diaphragmatic
hernia.
. Dx -> CT is the next best step (to Confirm).
. The small bowel may be present in the thoracic cavity.
. Tx -> Surgical repair & exploration for other traumatic injuries.
. N.B.
. TRACHEO-BRONCHIAL RUPTURE:
_____________________________
. Due to rapid decceleration blunt chest trauma.
. 1st manage the ABCs.
. Dx -> CXR -> Persistent pneumothorax & pneumomediastinum despite chest
tube placement !
. Subcutaneous emphysema (Palpable crepitus below the skin).
. The RIGHT MAIN BRONCHUS is the most commonly injured.
. Dx -> High resolution CT scan (Confirm).
. Tx -> Surgical repair.
. BLUNT ABDOMINAL TRAUMA MANAGEMENT:
_____________________________________
_____________________________________
___YES_____________NO_____
|
|
STABILIZE
STABILIZE
ANGIOGRAPHY & SPLINT
then CT ABDOMEN
* VASOMOTOR SHOCK:
___________________
. Hypotension & tachycardia in pts who are warm & flushed (Not pale &
cold!).
. Look for a H/O of medication use (penicillin allergy).
. H/O of spinal anesthesia or exposure to allergen (bee stings).
* TRAUMA TO LOCALIZED SITES:
_____________________________
. All penetrating wounds with damage to internal organs will need to go
to the OR.
. If the case describes an object embedded in the pt, NEVER to remove
it.
. Never remove it in the ER or at the scene of the accident (Only in the
operating room).
* HEAD TRAUMA:
_______________
. "No" surgical intervention is needed for ..
. an asymptomatic head injury with a closed skull # (No overlying wound)
alone.
. The next step of management is to clean any lacerations.
. Give tetanus toxoid & prophylactic antibiotics to all pts with open
skull #s.
* BASAL SKULL #:
_________________
. Ecchymosis around both eyes (Racoon eyes).
. Ecchymosis behind the ear (Battle's sign).
. Clear fluid drippling from the ear or nose (CSF leak).
. CT scan of head & neck -> Basal skull #. "X-ray is a wrong answer".
. A CSF leak will stop by itself & requires no specific management.
. Prophylactic antibiotics are NOT indicated !!
. Facial palsy may occur 2-3 days later due to neuroapraxia (Use
Steroids).
* EPI-DURAL HEMATOMA:
______________________
. Side head trauma & rupture of middle meningeal artery in the foramen
spinosum.
. H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNESS.
. Accumulation of blood in the potential space inbetween the cranium &
dura matter.
. Honeymoon period (The period when the pt immediately awakes & appears
normal).
. Pt typically has ipsilateral pupil dilatation due to oculomotor nerve
compression.
. Then the pt quickly deteriorates, so .. It is important to manage
quickly.
. Dx -> CT scan -> BICONVEX LENS shaped hematoma with or without midline
deviation.
. Tx -> EMERGENCY CRANIOTOMY.
. If the pt is treated, the prognosis is good.
. If not, the prognosis is fatal within hours.
* "S"UB-DURAL HEMATOMA:
________________________
. Low pressure bleeding from the "VENOUS SYSTEM".
. Accumulation of blood in the subdural space between the dura &
arachinoid membrane.
. Head trauma with FLUCTUATING CONSCIOUSNESS i.e.
. gradual headaches, memory loss, personality changes, dementia,
cofusion & drowsiness.
. Dx -> CT scan -> "S"EMILUNAR, CRESCENT shaped hematoma e' or e'out
midline deviation.
. Tx -> CONSERVATIVE management with STEROIDS.
. Emergency craniotomy is done if there are lateralizing signs & midline
displacement.
. N.B. Lowering ICP is not the ultimate goal; preserving brain perfusion
is.
. Systemic hypotension or excessive cerebral vasoconstriction may be
counterproductive.
. N.B. Steroids are good for cerebral edema 2ry to tumors & abscesses,
. But they have no role in head trauma pts !
. ACUTE ABDOMEN:
_________________
_________________
. N.B.
. Cholangitis is a GIT medical emergency & intervention with ERCP is the
ttt of choice.
. N.B.
. Be sure to differentiate GERD from peptic ulcer perforation (surgical
emergency).
* 1 * PERFORATION:
___________________
___________________
. Dx -> Supine & erect abdominal x-ray (free air under diaphragm).
. Tx -> Nothing by mouth (NPO) & IV fluid hydration.
. Tx -> IV antibiotics such as flagyl & gentamycin.
. Tx -> IV 2nd generation cephalosporins (Cefotetan or cefoxitin).
. Tx -> Emergency surgery.
* 2 * OBSTRUCTION:
___________________
___________________
. Severe colicky pain.
. Absence of flatus or feces.
. Nausea & vomiting.
. Constant movement as the pt tries to find a comfort position.
. Abdominal hernia -> Perform elective repair for all abdominal hernias.
-> except umbilical hernia in pts < 2 ys.
-> except esophageal sliding hernia.
. N.B.
. In a pt with a hernia, immediate surgery is the answer if the case
describes:
. fever, leukocytosis, constant pain & signs of peritoneal irritation
(Strangulation).
. N.B.
. Complete small bowel obstruction
. Nausea - vomiting - Abdominal bloating - Dilated loops of bowel on
abdominal x-ray.
. Adhesions are the most common etiology.
. N.B.
. SMALL BOWEL OBSTRUCTION:
___________________________
. Colicky abdominal pain & vomiting.
. No bowel movement or passing gas (Obstipation), abd. distension &
diffuse tendernesss.
. The contents of the vomitus are typically bilious in proximal SBO.
. The contents of the vomitus are feculent with more distal
obstructions.
. Hyperactive bowel sounds due to peristaltic rush.
. Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MULTIPLE AIR FLUID
LEVELS.
. Tx -> Complete bowel rest - Decompression e' nasogastric tube.
. Tx -> Pain control - Fluid resuscitation.
. Tx -> If no improvement -> Surgical intervention to avoid
strangulation.
. Strangulation signs (fever - tachycardia - leukocytosis - Metabolic
acidosis).
. N.B.
. Immediate surgical intervention is indicated for pts with intestinal
obstruction who,
. develop clinical or hemodynamic instability, fail to improve after
conservative ttt,
. or develop syms of strangulation (fever-tachycardia-leukocytosis-
Metabolic acidosis).
* 3 * INFLAMMATION:
____________________
____________________
. Causes (Acute diverticulitis - Acute pancreatitis - Acute
appendicitis).
. Gradual onset of constant abdominal pain that slowly builds up over
several hours.
. Initially ill defined pain that becomes localized to the site of
inflammation.
. Note that signs of peritoneal irritation are ABSENT in pancreatitis.
. N.B. Look out for the risk factors for acute pancreatitis:
-> Alcoholism.
-> Gall stones.
-> Medications (Didanosine, pentamidine, Flagyl, Tetracycline, Thiazides
& Furosemide).
-> Hypertriglyceridemia.
-> Trauma.
-> Post-ERCP.
. N.B. COMPLICATIONS:
-> Abscess:
. Often appears 10 days after onset with persistent fever & high WBC
count.
. Surgical drainage is the ttt.
-> Pseudocyst:
. Appears 5 weeks after initial symptoms.
. when a collection of pancreatic juice causes anorexia, pain & a
palpable mass.
. If < 6 cm & present < 6 weeks -> OBSERVATION.
. If > 6 cm or present > 6 weeks -> Percutaneous drainage or endoscopic
drainage.
. N.B. The most common causes of acute pancreatitis are gallstones &
alcohol use.
. Identifying the underlying cause can prevent recurrent pancreatitis.
. ULTRASOUND is the preferred test to detect gall stones.
. Stable pts sh'd undergo cholecystectomy for biliary pancreatitis prior
to discharge.
* 4 * ISCHEMIA:
________________
________________
. Acute mesenteric ischemia in older pts.
. H/O of arrhythmia (Af -> Absence of P waves with irregular rhythm).
. Coronary artery disease.
. Recent MI.
. Severe acute onset abdominal pain that is out of proportion to exam.
. Dx is clinical but look for acidosis & sepsis signs.
. If ischemia is suspected, don't w8 for lab findings (acidosis or ++
lactate),
. Go straight to surgery or order angiography.
. If diagnosis is during SURGERY -> Perform embolectomy &
revascularization or resection.
. If diagnosis is during ANGIOGRAPHY -> Give vasodilators or
thrombolysis.
. Acute embolic mesenteric ischemia may progress to bowel infarction.
. SURGICAL JAUNDICE:
____________________
____________________
. N.B. ERCP & EU$ are never the 1st step in diagnosis.
. N.B. ERCP is mostly a management step on exam.
. GALL STONES:
_______________
_______________
. N.B.
. A pregnancy test sh'd be performed in any woman of childbearing period
age before,
. ordering diagnostic tests such as x-rays or computed tomography scans.
* PRE-OPERATIVE ASSESSMENT:
____________________________
. N.B.
. If a pt presents with an acute abdomen due to perforation of hollow
abdominal viscus,
. (Rebound tendrness & subdiaphragmatic free intraperitoneal air on
abdominal x-ray),
. the pt will require IMMEDIATE LAPARATOMY !
. Pre-operative naso-gastric tube decompression is a must.
. Give IV fluids & IV antibiotics.
. N.B.
. Moving from supine to sitting position ++ the functional residual
capacity FRC by 25%.
. ++ FRC prevents post-operative atelectasis.
{6} ASPIRATION:
________________
. SOB - Hypoxia - Infiltrates on CXR.
. Lavage & remove gastric contents.
. Bronchodilators & respiratory support.
. Steroids don't help.
. N.B.
. Post-operative oliguria & azotemia:
______________________________________
. Oliguria (< 400 cc) of urine output per day.
. Azotemia ( ++ BUN/Creatinine ratio > 20:1) = Acute Pre-renal failure
from HYPOVOLEMIA !
. Urinary catheter obstruction should be ruled out 1st.
. Next step is an IV FLUID CHALLENGE.
. N.B.
. Post-operative ileus:
________________________
. An ileus is a functional defect in the bowel motility without physical
obstruction.
. Following most abdominal surgeries.
. Nausea, vomiting, abdominal distension, failure to pass flatus or
stools.
. Hypoactive or absent bowel sounds.
. In contrast (Mechanical obstruction e.g. adehsions cause "HYPERactive"
bowel sounds).
. Causes of ileus:
-> ++ splanchnic nerve sympathetic tone following violation of the
peritoneum.
-> Local release of inflammatory mediators.
-> Postoperative narcotic (opiate) analgesics e.g Morphine causes
disordered peristalsis.
. N.B.
. Post-operative DVT:
______________________
. DVT occurs due to Virchow triad (Stasis - endothelial injury -
Hypercoagulability).
. Major surgery is a significant risk factor.
. Pts sh'd be ttt with LMW HEPARIN acutely & warfarin for several
months.
. Stable pts can be ttt with anticoagulation as early as 48 - 72 hours
after surgery.
. N.B.
. Transfusion reactions:
_________________________
. occur acutely during or immediately following transfusion of blood
products.
. They are immune mediated;
. preformed host antibody reacts with antigens on transfused blood
products,
. causing the release of inflammatory mediators & complement activation.
. They may be HEMOLYTIC -> Severe reaction that may cause death.
. or NON-HEMOLYTIC -> Dose dependent self limited reaction with fever &
rigors.
. N.B.
. CATHETER (CENTRAL LINE) ASSOCIATED INFECTIONS:
_________________________________________________
. Intra-venous catheters are one of the most common causes of nosocomial
infections.
. Femoral central venous catheters carry a higher risk of bacteremia
than subclavian cath
. IV catheter infections are mostly caused by cutaneous organisms such
as STAPHYLOCOCCI.
. Femoral catheters may also cause gram -ve bacteremia.
. N.B.
. POST-OPERATIVE MEDIASTINITIS:
________________________________
. May follow a cardiac surgery due ti intra-operative wound
contamination.
. Complicates 5 % of sternotomies.
. 14 days postoperative.
. Fever, tachycardia, chest pain, leukocytosis.
. Sternal wound drainage drainage of purulent discharge.
. CXR -> WIDENED MEDIASTINUM.
. Tx -> Drainage, surgical debridement with immediate closure &
prolonged antibiotic ttt.
. High mortality rate.
_________________________________________________________________________
_________________
. PEDIATRIC SURGERY:
_____________________
_____________________
* GASTROSCHISIS:
_________________
. The umbilical cord is NORMAL.
. The defect is to the right of the cord where is no protective
membrane.
. The bowel looks angry & matted.
* OMPHALOCELE:
_______________
. The umbilical cord goes to the defect.
. The defect has a thin membrane (one can see normal looking bowel &
little liver slice).
_________________________________________________________________________
_________________
. ORTHOPEDICS:
_______________
_______________
. CLOSED REDUCTION -> for #s that are not badly displaced or angulated.
. OPEN REDUCTION & INTERNAL FIXATION -> for severely displaced or
angulated #s.
{1} CLAVICULAR #:
__________________
. # of the MIDDLE 1/3 -> Brace (Figure 8 sling), rest & ice.
. # of the DISTAL 1/3 -> Open reduction & internal fixation to prevent
malunion.
. All pts sh'd've a creful neurovascular examination to rule out injury
to:
. the underlying brachial plexus & subclavian artery.
. Hearing a loud bruit warrants an angiogram to rule out subclavian
artery injury.
{2} COLLE's #:
_______________
. Closed reduction & casting.
. Elderly woman falling on an out-stretched hand.
. Painful wrist.
. Dinner fork deformity.
{4} SCAPHOID #:
________________
. Young adult with fall on an out-stretched hand.
. Persistent pain in the anatomical snuff box.
. Takes > 3 weeks to be seen on x-ray.
. If the initial x-ray is -ve, subsequent x-ray is done in 7-10 days.
. Wrist x-ray -> Fine radiolucent lines in nondisplaced scaphoid #.
. Tx -> Wrist immobilization for 6 - 10 weeks.
. Place thumb spica cast to help to prevent non-union.
{5} HIP #:
___________
. Any elderly pt who sustains a fall.
. Look for externally rotated & shortened leg.
. Femoral neck # -> High risk of avascular necrosis - Tx: Femoral head
replacement.
. Intertrochanteric # -> Open reduction & pinning.
. Femoral shaft # -> Intra-medullary rod fixation.
. Medial -> Due to abduction injury to knee - Dx -> VALGUS stress test.
. Lateral -> Due to adduction injury to knee - Dx -> VARUS stress test.
{15} FEMORAL #:
________________
. Femoral shaft # is an orthopedic emergency.
. Can result in massive blood loss & high rate of infection.
. Immediate surgery & cleaning within 6 hours is needed.
. N.B.
. Hip #s are common in the elderly,
. 1st -> Stabilization & treatment for pain control & DVT prophylaxis.
. Next -> Discover the etiology of the pt's fall with appropriate
investigations.
. Do EKG , CXR & cardiac enzymes !
. N.B.
. Acute shoulder pain after forceful abduction & external rotation at
glenohumeral joint,
. suggests an anterior shoulder dislocation -> AXILLARY NERVE INJURY.
* COMPARTMENT $YNDROME:
________________________
. Most frequent in the forearm or lower leg.
. H/O of prolonged ischemia followed by reperfusion, crushing injuries
or other traumas.
. Pain & tightness & tenderness to palpation at the affected area.
. EXCRUCIATING PAIN with PASSIVE EXTENSION.
. Pulses may be normal !!
. Tx -> 1st step is emergent fasciotomy.
. N.B.
. Escharotomy is indicated for circumferential full thickness burns of
an extremity,
. with an eschar causing significant edema & constriction of the
vascular supply.
. Pts sh'd be evaluated for clinical signs of adequate perfusion after
escharotomy.
. Fasciotomy sh'd be done if there is NO signs of relef.
* NEURO-VASCULAR INJURIES:
___________________________
___________________________
. BACK PAIN:
_____________
_____________
* FOOT PAIN:
_____________
_____________
. PLANTAR FASCIITIS:
_____________________
. Older, overweight pts with sharp heel pain every time their foot
strikes to the ground.
. Pain is worse with walking & in the mornings.
. X-ray -> Bony spur matching the location of the pain.
. Exquisite tenderness to palpation over the spur.
. Burning pain in nature.
. More common in runners with repeated microtrauma,
. who develop local point tendrness on plantar aspect of foot.
. However, surgical resection of the bony spur is not indicated !
. MORTON NEUROMA:
__________________
. Inflammation of the common digital nerve at the 3rd interspace.
. Between the 3rd & 4th toes.
. Mechanically induced neuropathic degeneration.
. Numbness & burning of the toes, aching & burning in the distal
forefoot.
. Pain radiates forward from the metatarsal heads to the 3rd & 4th toes.
. PALPATION & SQUEEZING the metatarsal joints -> CLICKING SENSATION
(MULDER SIGN).
. Caused by wearing pointy-toed shoes.
. The neuroma is palpable with very tender spot there.
. Management is analgesics & appropriate foot wear.
. STRESS # = HAIR LINE #:
__________________________
. Sudden ++ in repeated tension or compression without adequate rest.
. Sharp localized pain over a bony surface that is worse with palpation.
. The tibia is the most common bone in the body to be affected by stress
#s.
. Occur in the anterior part of the middle 1/3 of the shin of tibia in
jumping sport pts.
. Occur in the postero-medial part of the distal 1/3 of the tibia in
runners.
. X-ray are frequently normal during initial evaluation.
. Stress # of the meta-tarsals are common in atheletes & military
recruits.
. The 2nd metatarsal is the most commonly injured.
. Tx -> Rest, analgesia & a hrd soled shoe.
_________________________________________________________________________
_________________
* UROLOGY:
___________
___________
. VARICOCELE:
______________
. Tortuous dilatation of pampiniform plexus of veins surrounding
spermatic cord & testis.
. Results from incompetence of the valves of the testicular vein.
. Occurs most frequently on the left side, bec.
. Lt testicular vein enters Lt renal vein inferiorly at right angle ->
impaired drainage.
. Dull or dragging discomfort scrotal pain that becomes worse on
standing.
. Examination -> Bag of worms (Enlarge with Valsalva maneuver).
. NEGATIVE TRANSILLUMINATION.
. HYDROCELE:
_____________
. Due to fluid accumulation in tunica vaginalis.
. POSITIVE TRANSILLUMINATION.
. TESTICULAR NEOPLASIA:
________________________
. Painless testicular mass with negative transillumination.
. SPERMATOCELE:
________________
. Cystic dilatations of the efferent ductules.
. Painless fluif-filled cysts containing sperms.
. Located on superior pole of testis in relation to epididymis.
. +ve transillumination.
. TESTICULAR TORSION:
______________________
. Severe, sudden onset testicular pain.
. NO fever - NO pyuria.
. The testis is swollen & exquisitely tender.
. High riding testicle with transverse lie.
. Dx -> U/$.
. Tx -> Immediate surgical intervention with bilateral orchipexy.
. ACUTE EPIDIDYMITIS:
______________________
. Acute scrotal pain (may be referred to abdomen).
. FEVER & urinary symptoms.
. Dx -> Urinalysis & urine cultures & discharge culture if present.
. Tx -> Males < 35 ys -> Treat for gonorrhea & chlamydia ->
Ciprofloxacin & Doxycycline.
. Tx -> Older males -> Treat as UTI (E-coli) with Levofloxacin.
. UROLOGIC OBSTRUCTIONS:
_________________________
. Combination of obstruction & infection is a urologic emergency.
. It can lead to destruction of the kidney in few hours.
. Tx -> Immediate decompression of the urinary tract above the
obstruction.
. Tx -> IV antibiotics are given to prevent infection.
. Tx -> A ureteral stent or percutaneous nephrostomy is the most
important intervention.
. N.B.
. Urinary calculi present as flank or abdominal pain radiating to the
groin.
. Nausea & vomiting is common.
. Unlikepts with an acute abdomen, pts with urinary stones are WRITHING
in pain.
. Unable to sit still in exam room (No peritoneal irritation so
movements don't ++ pain).
. Dx -> A NON-contrast spiral CT of the abdomen & pelvis is the most
accurate test.
. Dx -> X-ray can miss radio-lucent urinary stones (15 % of stones).
. N.B.
. Nephrolithiasis
. Flank pain & hematuria accompanied by nausea & vomiting.
. Pts with Chron's disease or small bowel dis -> Fat malabsorption.
. Fat malabsorption -> predispose to hyperoxaluria.
. Oxalate is obtained from diet & is a normal product of human
metabolism.
. Symptomatic hyperoxaluria is the result of ++ oxalate absorption in
the gut.
. Under normal circumstances: Calcium binds oxalate in the gut
preventing its absorption.
. In pts with fat malabsorption, Ca is bound by fat leaving oxalate free
& unbound.
. Failure to adequately absorb bile salts in cases of fat malabsorption,
. leads to -- bile salt reabsorption in small intestine.
. Excess bile salts may damage colonic mucosa -> ++ oxalate absorption.
{2} HYDROCELE:
_______________
. Fluid collection within the processus vaginalis or tunica vaginalis.
. Peritoneal fluid accumulation -> hydrocele
. POSITIVE TRANSILLUMINATION.
. Tx -> REASSURANCE -> Will resolve spontaneously by the age of 12
months.
. Tx -> If not resloved by 12 months -> Surgical removal to avoid
inguinal hernia.
{3} HYPOSPADIUS:
_________________
. Urethral opening at the ventral side of the penis.
. Never to perform circumcision on this child.
. The prepuce will be needed for the plastic reconstruction.
_________________________________________________________________________
_________________
. VASCULAR SURGERY:
____________________
____________________
. Aspirin & cilostazol are antiplatelet agents that can be given after
confirming PAD.
. They are not given upon clinical suspicion !
. Pts with significant symptoms & NORMAL ABI may have MILD diesase at
rest.
. They sh'd undergo EXERCISE TESTING with pre & post exercise ABI
measurment to confirm.
-> Pain
. Earlest symptom.
. ++ by passive stretch of the muscles in the affected compartment.
-> Paresthesia
. Burning or tingling sensation.
. occurs in the distribution of the affected peripheral nerve.
-> Pallor
. of the overlying skin
. result from tense swelling & compromised perfusion.
-> Pulselessness
. Late finding.
. Presence of a pulse on exam does NOT rule out compartment $.
-> Paresis/Paralysis
. Late finding.
. resilt from nerve & muscle ischemia & necrosis.
. N.B. ESCHAR !
. Eschar is a firm necrotic tissue formed on on exposed tissue following
burn wounds.
. When eschar occurs circumferentially on an extremity,
. it restricts the outward expansion of the compartment as edema follows
burn.
. Interstitial pressure increases -> compromise vascular flow to the
limb.
. Deep pain out of proportion to injury, pulselessness, paresthesia,
cyanaosis & pallor.
. Tx -> Escharotomy.
_________________________________________________________________________
_________________
. MISCELLANEOUS TOPICS:
________________________
________________________
. Bottom line:
. In pts with severe significant total body surface areas burns,
. The major cause of morbidity & mortality is HYPOVOLEMIC SHOCK.
. N.B.
. A peptic duodenal ulcer causes periodic epigastric pain relieved by
meals.
. PILO-NIDAL SINUS:
____________________
. Acute pain & swelling of the midline sacro-coccygeal skin &
subcutaneous tissues.
. Due to infection of a dermal sinus tract originating over the coccyx.
. RIB #:
_________
. Pain relief is the prime objective in management of rib #.
. As it allow proper ventillation & prevent atelectasis & pneumonia.
. TETANUS PROPHYLAXIS:
_______________________
_______________________
_________________________________________________________________________
_________________
. BREAST PROBLEMS:
__________________
__________________
. 1 . INTRA-DUCTAL PAPILLOMA:
______________________________
. Benign breast disease.
. Most common in peri-menopausal women.
. Intermittent BLOODY discharge from one nipple.
. Most intraductal papillomas are situated beneath the areola.
. Difficult to palpate on physical examination due to their small sizes
(< 2 mm).
. Soft in consistency.
. U/$ will be normal because it can detect masses only greater than 1 cm
in diameter.
. 2 . FIBRO-CYSTIC DISEASE:
____________________________
. Very common in pre-menopausal women.
. Bilateral breast pain.
. Associated with cystic changes of the breast.
. Benign condition.
. Symptoms vary cyclically with the menstrual cycle.
. P/E -> Lumpiness of the breast.
. 3 . FIBRO-ADENOMA:
_____________________
. Solitary breast lesion.
. Painless, firm, mobile breast lump.
. Average size about 2 cm.
. Women ages 15 - 25 ys.
. Benign condition.
. Do NOT change with menstrual cycle.
. N.B.
. BREAST FAT NECROSIS
. shows clinical signs & radiographic findings similar to breast cancer
!
. Syms include (Skin or nipple retraction - Calcification on
mammography).
. Biopsy of the mass -> FAT GLOBULES & FOAMY HISTIOCYTES.
. No ttt is indicated (Self limiting condition).
_________________________________________________________________________
_________________
. SYRINGOMYELIA:
_________________
. May follow spine cord trauma.
. Whiplash is often the incinting injury.
. Symptoms develop months to years later.
. Enlargement of the central canal of the spinal cord due to CSF
retention.
. Impaired strenght & pain/temperature sensation in upper extremeties.
. Preservation of dorsal column function (Light touch - vibration -
position sense).
. CAPE LIKE DISTRIBUTION.
_________________________________________________________________________
_________________
. N.B.
. D.D. for rotator cuff tear is "RUPTURE OF TENDON OF LONG HEAD OF
BICEPS";
. POSITIVE POPEYE SIGN (The biceps muscle belly becomes prominent in the
mid upper arm.
. VARICES:
___________
. NON-BLEEDING VARICES are managed with BB "Prporanolol".
. After 1st episode of bleeding -> Sclerotherapy, endoscopic band
ligation & surgery.
. If not responsive to medical or endoscopic intervention -> Porto-
systemic shunt (TIPS).
. RESPIRATORY QUOTE (RQ):
__________________________
. RQ is the ratio bet. CO2 produced to O2 consumed.
. Used to make assessmentsof metabolism taking place in the body.
. In mechanically ventillated pt, the RQ is 1.05.
. The ratio depends upon the major fuel being oxidized for ATP
production.
. An RQ close to 1 indicates that CARBOHYDRATE is the major nutrient
being oxidized.
. The RQ for protein & lipid as sole energy sources are 0.8 & 0.7
respectively.
. Massive atelectasis could affect ABG, but once a new steady state is
achieved,
. the RQ value w'd still depend only upon the nature & proportions of
metabolics used.
. TROCHANTERIC BURSITIS:
_________________________
. Unilateral hip pain in a MIDDLE-AGED adult.
. Inflammation of the bursa around the insertion of gluteus medius
greater trochanter.
. Excessive frictional forces 2ry to overuse or trauma are common
causes.
. Hip pain when pressure is applied (When sleeping) & external rotation
or abduction.
. TRENDELENBURG SIGN:
______________________
. Drooping of the contralateral pelvis when the pt stands on one foot.
. Associated with TRENDELENBURG gait (Waddling) caused by the trunk
rocking,
. to compensate for the pelvic drooping !
. Caused by weakness or paralysis of the gletues medius & minimus
muscles,
. due to superior gluteal nerve trauma or inflammation or entrappment.
. The pt presents with unilateral intermittent knee pain.
. Physical activity e.g. stair clumbing exacerbates the pain.
. Hip tenderness is common.
. RETRO-PERITONEAL HEMORRHAGE:
_______________________________
. An iatrogenic complication after cardiac catheterization.
. After cannulation of the femoral artery to access the cardiac vessels.
. A hematoma is formed at the upper thigh -> Extends into the retro-
peritoneal space.
. Significant belleding with hypotension & tachycardia.
. Ipsilateral flank/back pain.
. Dx -> CT scan of ABDOMEN & PELVIS with-OUT contrast.
. Tx -> Supportive -> Blood transfusion - IV fluids - Bed rest.
. Tx -> Immediate surgical decompression if there are neurological
deficits.
. PNEUMO-PERITONEUM:
_____________________
. AIR UNDER DIAPHRAGM = Intra-peritoneal air.
. Best seen bet. the liver & the diaphragm.
. Caused by PERFORATED VISCUS e.g. PERFORATED PEPTIC ULCER.
. PERFORATED PEPTIC ULCER (H/O of epigastric pain & discomfort with
eating).
. Tx -> SURGICAL CONSULATATION IMMEDIATELY for EXPLORATORY LAPAROTOMY.
. CHILD ABUSE:
_______________
. Patterned scalds & burns = forceful immersion of hot object e.g.
cigarette or hot iron.
. Incoherent or impropable explanation of the injuries.
. Delay in seeking care after injury.
. #s of long bones or ribs, #s in various stages of healing.
. Suspicious bruises include those on thighs, abdomen, cheeks &
genitalia.
. Subdural hematoma & retinal hemorrhages in very young infants.
. Inaapropriate affect of the care giver.
. AMPUTATION INJURY:
_____________________
. Amputated parts sh'd be wrapped in SALINE-MOISTENED GAUZE,
. SEALED IN A PLASTIC BAG,
. PLACED ON ICE,
. brought to the emergency department with the patient.
. CAUSES OF HEMOPTYSIS:
________________________
. Pulmonary -> Bronchitis - Pulmonary embolism - Bronchiectasis - Lung
cancer.
. Cardiac -> Mitral stenosis - Acute pulmonary edema.
. Infectious -> Tuberculosis - Lung abscess.
. Hematologic -> Caogulopathy.
. Vascular -> Arteriovenous malformation.
. Systemic diseases -> Wegener's granulomatosis - Goodpasture's $ - SLE
- Vasculitis.
. HEMOPTYSIS MANAGEMENT
________________________
|
. H/O & P/E to rule out other causes (Oropharynx &
GIT)
________________________________________________________
|
_______________________________
| |
. MILD/MODERATE . MASSIVE (>600
ml/24hs)
________________
_________________________
| |
. CXR, CBC, COAGULATION STUDIES . SECURE AIRWAY, BREATHING &
CIRCULATION
. RENAL FUNCTIONS & URINALYSIS |
. RHEUMATOLOGY WORK UP . IF BLEEDING
| |
<----------------STOPS---------------------
CONTINUES
|
|
. CT SCAN + BRONCHOSCOPY
|
|
|
. treat the cause;persistent bleeding
|
treated via bronchoscopic interventions <-----------------------
--
embolization or resection.
. N.B.
. Massive hemoptysis = > 600 ml/24 hs.
. Greatest danger is asphyxiation due to airway flooding with blood.
. Establishing an adequate patent airway is the most imp. initial step.
. The pt should be placed with the bleeding lung un the dependent
lateral position,
. to avoid blood collection in the airways of the opposite lung.
. Bronchoscopy is the best to localize the bleeding site, provide
suction.
. Bronchoscopy is both diagnostic & therapeutic.
. FAT EMBOLISM:
________________
. Common in pt with polytrauma with multiple #s of long bones.
. Severe respiratory distress, petichial rash, subconjunctival
hemorrhage.
. Tachycardia, tachypnea & fever.
. May occur after 12-72 hs after trauma.
. CNS dysfunction -> Confusion - Agitation - Stupor - Seizures - Coma.
. Dx -> Fat droplets in urine.
. Dx -> Intra-arterial fat globules on fundoscopy.
. Dx -> CXR -> Diffuse bilateral pulmonary infiltrates.
. Tx -> Respiratory support.
. DUMPING $YNDROME:
____________________
. Common post-gastrectomy complication.
. Due to rapid emptying of gastric contents into the duodenum & small
intestine.
. Post-prandial abd. cramps - weakness - lightheadedness - diaphoresis.
. Symptoms diminish over time.
. Symptoms result from fluid shift from intravascular space to small
intestine.
. Stimulation of intestinal vasoactive peptides -> Stimulation of
autonomic reflexes.
. Dietary changes are helpful to control symptoms.
. In resistant cases, octreotide sh'd be tried.
. Reconstructive surgery is reserved for intractable cases.
. HEMATOCHEZIA:
________________
. Bright red blood in stool.
. Due to lower GI bleeding (distal to ligament of Treitz).
. May occur in very brisk upper GI bleeding.
. Most common causes of lower GI bleeding in pts >50 ys-> DIVERTICULOSIS
- ANGIODYSPLASIA
. Nasogastric tube placement with bile not blood = No active upper GI
bleeding.
. Upper endoscopy sh'd be done next not to miss duodenal bleeding.
. N.B.
. Diverticulosis -> Non-inflammed diverticula -> Painless bleeding.
. Diverticulitis -> Abdominal pain & infectious syms 2ry to obstruction
of diverticula.
. It is uncommon to see bleeding with diverticulitis !
. POST-SPLENECTOMY VACCINES:
_____________________________
. Following splenectomy, pts are at ++ risk for sepsis 2ry to
encapsulated organisms
. Capsulated organisms (S. pneumoniae - N. meningitidis - H.
influenzae).
. Vaccination against these organisms sh'd be administered.
. Pneumococcal vaccine boosters are required every 5 years.
. PAROTID NEOPLASM:
____________________
. The two lobes of the parotid gland are separated by the facial nerve.
. Parotid surgery involve the deep lobe of the parotid gland -> facial
palsy.
. Facial palsy -> Facial droop.
. PENILE #:
____________
. Crush injury of an erect penis.
. Common during intercourse with female on top of male.
. Dx -> Emergent urethrogram to assess for urethral injury.
. Tx -> Surgical exploration to evacuate hematoma & mend the torn tunica
albuginea.
. PARALYTIC ILEUS:
___________________
. Abdominal pain after a traumatic injury.
. Associated with vertebral # or retro-peritoneal hemorrhage.
. Ileus is caused by an exagerrated intestinal reaction after abdominal
surgery.
. Due to disruption of normal neurologic & motor control of the
gastrointestinal tract.
. Failure to pass stool or flatus, abdominal distension, nausea &
vomiting.
. Distended abdomen with tympany.
. Decreased or absent bowel sounds.
. Abdominal x-ray -> Air-fluid levels & distended gas-filled loops of
small & large int.
. Tx -> Conservative with bowel rest & supportive care.
. LUDWIG's ANGINA:
___________________
. Infection of the submandibular & sublingual glands.
. Source of infection -> Infected tooth (2nd or 3rd mandibular molar).
. Most common cause of death -> Asphyxia.
. TORUS PALATINUS:
___________________
. CONGENITAL !
. Young individual.
. Fleshy immobile mass on the midline hard palate.
. No medical or surgical ttt is required unless the growth becomes
symptomatic.
. i.e. interfering with speech or eating.
. NEURO-ANATOMY:
_________________
_________________
. FEMORAL NERVE:
_________________
. Motor to anterior compartment of thigh (Quadriceps femoris - Sartorius
- Pectineus).
. Responsible of knee extension & hip flexion.
. Sensory to the anterior thigh & medial leg via saphenous branch.
. TIBIAL NERVE:
________________
. Motor to posterior compartment of thigh, posterior compartment of leg
& plantar foot ms
. Responsible of knee flexion & digits & plantar flexion of foot.
. Sensory to the leg (except the medial side) & plantar foot.
. OBTURATOR NERVE:
___________________
. Motor to medial compartment of thigh.
. Responsible of thigh adduction.
. Sensory to the medial thigh.
. EYE OPENING:
_______________
4 -> Spontaneous.
3 -> To verbal command.
2 -> To pain.
1 -> None.
. VERBAL RESPONSE:
___________________
5 -> Oriented.
4 -> Disoriented/confused.
3 -> Inappropriate words.
2 -> Incomprehensible sounds.
1 -> None.
. MOTOR RESPONSE:
__________________
6 -> Obeys.
5 -> Localizes.
4 -> Withdraws.
3 -> Flexion posturing (Decorticate).
2 -> Extension posturing (Decerebrate).
1 -> None.