AANP FNP

I. Anatomy: Vascular Supply A. Ethmoid Artery (branch of ophthalmic artery) 1. Supplies anterior and superior nose 2. Supplies Kiesselbach's Area or plexus (Little's Area) a. Supplies *anterior septum* b. *Most common site for Epistaxis* II. Anatomy: Support A. Bony Support 1. Lateral: Maxilla 2. Superior: Frontal Bone nasal process 3. Central: Paired nasal bones B. Cartilage 1. Cartilage extends from inferior edge of nasal bones 2. Cartilage provides most of nasal pliable form

4 Arteries come together at Little's Area to form a vascular plexus called Kiesselbach's Triangle

I. Definition A. *Chronic loss of previously acquired mental function* II. Criteria A. Insidious, gradual onset (months) of deterioration 1. Mild to severe fluctuations 2. All higher cortical functions B. Long duration of symptoms C. Normal Level of Consciousness, but altered content 1. *Impaired memory* and 2. *One higher cortical function (e.g. Judgement)* D. Vital Signs typically normal III. (Cortical) Alzheimer's Disease: 60-70% of cases A. Short Term Memory loss B. Aphasia C. Apraxia

Alzheimer's Dementia

spironolactone=gynecomastia

Random Bits of Info

Causes of palm and sole rash: You drive CARS using your palms and soles. CA: Cocksackievirus A (hand, foot, and mouth disease) R: Rocky mountain spotted fever S: Syphilis

Rash on Palm and Soles (CARS)

I. Contraindications A. Absolute Contraindications 1. Angioedema history a. Regardless of cause (even if not due to ACE Inhibitor) 2. Pregnancy (serious Teratogenicity - black box warning) 3. Renal Artery Stenosis 4. ACE Inhibitor related Allergic Reaction B. Relative Contraindications 1. Aortic Stenosis 2. Hypertrophic Cardiomyopathy II. Indications A. Hypertension 1. Useless in low renin patients (esp. Black ethnicity) 2. Low renin patients respond better to Diuretics B. Myocardial Infarction 1. Early ACE Inhibitor in acute Myocardial Infarction a. Started within 24 hours of Anterior MI 2. Significant reduction in CHF and death 3. Significantly lower mortality at 1 year C. Congestive Heart Failure 1. Left ventricle Systolic Dysfunction D. Diabetic Nephropathy E. Renal Insufficiency III. Adverse Effects A. Cough (dry and irritating) 1. Characteristics a. Occurs in 5 to 20% of patients i. More common in women ii. More common in black patients b. Not dose related c. Stops within 4 days of medication cessation 2. Alternative medications a. Angiotensin Receptor Blocker (e.g. Losartan) 3. Inhalers may relieve cough a. Tilade 2 puffs inhaled four times daily b. Cromolyn 20 mg inhaled four times daily

ACE Inhibitors (-pril)

On examination of the eye, a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing.

AV Nicking (Gunn Sign)

-slightly rough, pink or flesh-colored lesion in sun-exposed area -pharmacological treatment: 5-fluorouracil (topical chemotherapy) -non-pharmacological treatment: chemical peel, cryotherapy, laser resurfacing

Actinic Keratoses

I. Signs A. Abdominal exam 1. Suprapubic tenderness if obstruction B. Digital Rectal Exam 1. *Avoid vigorous exam or Prostatic Massage* 2. Risk of bacteremia 3. *Prostate is warm, boggy, tender on palpation* II. Labs: Standard A. *Urinalysis* B. *Urine Culture* (negative in 35% of acute prostatis cases) C. STD Screening (if risk factors or in men under age 35 years old) 1. Neisseria gonorrhoeae PCR 2. Chlamydia trachomatis PCR III. Labs to Avoid A. Avoid CRP or ESR (unlikely to direct care) B. Avoid PSA 1. Expect PSA elevation for 2 months after acute infection

Acute Bacterial Prostatitis

C: Have you ever felt like you need to Cut down on your drinking? A: Have people Annoyed you by criticizing your drinking? G: Have you ever felt bad or Guilty about your drinking? E: Have you ever had a drink first thing in the morning, to 'get you going' or an 'Eye opener'?

Alcoholism Screening (CAGE)

Antibiotics to Avoid in Pregnancy: SAFE Moms Take Really Good Care S: Sulfonamides A: Aminoglycosides F: Fluoroquinolones E: Erythromycin Moms: Metronidazole Take: Tetracyclines Really: Ribavirin Good: Griseofulvin Care: Chloramphenicol

Antibiotics to Avoid in Pregnancy

I. Symptoms A. Presentations 1. Classic Claudication: 10% of cases 2. Atypical Leg Pain: 50% of cases 3. Asymptomatic: 40% of cases B. Classic Claudication 1. Cramp-like leg muscle pain with Exercise, better with rest a. *Calf pain typical* (pain may occur in thigh, buttock) 2. *Pain worse with exertion* 3. Pain relieved within 10 minutes rest 4. Pain relieved with rest and dependent position C. Critical Limb Ischemia (1% of presentations) 1. Tissue loss or gangrene 2. Chronic rest pain D. Timing of symptoms related to degree of stenosis 1. Exertional pain: 70% arterial pain 2. Nocturnal pain: 70 to 90% arterial stenosis 3. Ischemic rest pain: 90% arterial stenosis III. Signs A. Most reliable signs of Peripheral Vascular Disease 1. Posterior tibial artery doppler Ultrasound a. All 3 components present rules-out Peripheral Arterial Disease b. Only 1 of 3 components present is strongly suggestive of PAD (Positive Likelihood Ratio = 7.0) 2. *Dorsalis pedis AND posterior tibial pulse absent* 3. *Femoral artery bruit* 4. Atypical Skin Color (pale, red, blue) of extremity B. Local Signs of Peripheral Vascular Disease 1. Dry, scaly, shiny atrophic skin 2. Skin hairless over lower extremity (e.g. shin) 3. Dystrophic, brittle Toenails 4. Non-healing ulcers or other lower extremity wounds 5. Decreased skin Temperature (cool feet) 6. Decreased Capillary Refill Time 7. Distal extremity color change with position a. *Skin rubor when leg dependent* b. Skin pallor when leg elevated >1 minute i. Color returns within 15 seconds in mild cases ii. Delay >40 seconds suggests severe ischemia

Arterial Insufficiency

I. Epidemiology A. Inherited sensitive skin (Atopic Patient) B. Incidence 1. Affects 11% of children in U.S 2. Affects 17.8 Million people in U.S. 3. Most cases go undiagnosed C. Onset 1. Typically presents with first 2 years of life (most often within first 6 months) 2. Diagnosed in first 5 years in 90% of patients 3. Many cases remit by age 3-5 years II. Pathophysiology A. Disrupted Epidermis due to underlying filaggrin protein defect B. Allows for Dermis immune cell exposure to environmental antigens 1. *IgE Antibody response* 2. Increased T-helper 2 subtype activity 3. Antigen-specific T-Cells secrete IgE binding factors C. Leads to inflammatory response 1. Intense itching ensues due to a low itch threshold to provocative factors 2. Scratching leads to further inflammation, resulting in a spiraling itch-scratch cycle III. *Associated Conditions: Atopic Triad (Family History)* A. Eczematous Dermatitis (Atopic Dermatitis) B. Allergic Rhinitis C. *Asthma* 1. Lifetime asthma Prevalence in patients with Atopic Dermatitis: 30% IV. Signs: Infants and young children A. Dermatitis characteristics 1. Erythema and Edema 2. Exudate 3. Crusting 4. Scaling B. Dermatitis Location 1. Face (especially cheeks) 2. Scalp 3. Trunk 4. Extensor surface of arms and legs V. Signs: Older children and adults A. Dermatitis characteristics 1. Similar Eczematous skin changes as with infants 2. "Hot and sweaty fossa and folds" B. Dermatitis Location 1. Flexor wrists and ankles 2. Antecubital fossa 3. Popliteal fossa 4. Hands 5. Upper Eyelid Inflammation (erythema, fine scale and lichenification) 6. Anogenital area. VI. Management: Dermatology referral indications A. Diagnosis uncertain B. Pruritus and other symptoms refractory to treatment (especially if impacting sleep, school or work attendance) C. Facial Eczematous Dermatitis refractory to treatment D. Severe Atopic Dermatitis E. Frequent exacerbations of Eczematous Dermatitis F. Systemic medications required for maintenance or frequent exacerbations G. Allergic Contact Dermatitis (consider on face, Eyelids and hands) VII. Management: Topical Steroid for exacerbation A. Consider alternative agents (e.g. Tacrolimus Ointment) B. General 1. Limited use only for exacerbations 2. Avoid Under-treatment 3. Consider applying only at night 4. Start early for exacerbations 5. Treat all palpable areas 6. Ointments are preferred a. Better tolerated (less burning) b. Allergic Reaction to ointment base less common c. Helps moisten very Dry Skin C. Mild exacerbation 1. Use for 3-4 days only 2. Low potency Topical Steroid (e.g. Hydrocortisone 1%) D. Moderate exacerbation 1. Taper over 2 weeks a. Use twice daily for 7 days, then b. Use once daily for 7 days 2. For Face and Groin a. Limit to Level 5 Topical Corticosteroid or less b. Hydrocortisone (0.5%, 1%, 2.5%) 3. For Eyelid a. Tridesilon 0.05% or Aclovate 0.05% ointment or cream applied twice daily for 5-10 days b. Consider Tacrolimus 0.1% ointment or Pimecrolimus 1% cream for refractory cases i. Risk of malignancy with longterm use (see below) 4. For body a. Hydrocortisone valerate 0.2% (Westcort) b. Triamcinolone 0.1% (Kenalog) E. Severe exacerbation 1. High Potency Topical Steroids (e.g. Fluticasone) 2. Try to avoid Systemic Corticosteroids 3. Consider maintenance Topical Steroid a. Low potency Topical Steroid daily or b. High potency steroid (eg. Fluticasone) twice weekly F. Other Anti-inflammatory agents 1. Hydroxyquinolone 2. Tar Preparations

Atopic Dermatitis

EKG: does not show discrete P waves Causes: Classic Case: sudden onset of heart palpitations with weakness, dizziness, and dyspnea - chest pain, feeling like passing out - rapid and irregular pulse may be >110bpm with hypotension Management: Rate Control - CCB, BB, or digoxin; Antiarrhythmic - amiodarone; Anticoagulation - warfarin Patient Education: consistent daily Vitamin K consumption - only 1 serving per day of very high VitK foods ("greens" and spinach) Labs: INR 2.0-3.0 - therapeutic 3.0-5.0, no bleeding - skip one dose, decrease maintenance dose - check INR every 1-2 days until normal 5.0-9.0, no bleeding - omit a dose, give small dose of VitK, decrease maintenance dose - check INR daily until normal

Atrial Fibrillation

I. Pathophysiology A. Endocardial layer infection (typically Heart Valves) 1. Mitral valve and aortic valve are most likely to be involved 2. Starts with endothelial damage a. Turbulent flow (e.g. valvular stenosis or valvular regurgitation) b. Intravascular device-related injury (e.g. catheters) c. Chronic inflammation (e.g. IV Drug Abuse) 3. Injured endotholelium colonized with transient bacteremia (e.g. dental procedures, GI/GU surgery) a. Sewing cuff of prosthetic valves are most often affected B. Two factor combination predisposes to the development of endocarditis 1. Bloodborne pathogen a. Bacteria b. Fungi 2. Cardiac lesion: Intracardiac surface upon which the pathogens can adhere a. Prosthetic Heart Valve b. Native valve with congenital or acquired defect II. Symptoms: Typical Presentation A. Prodrome type symptoms 1. *Fever* (80-90% of cases) a. May be absent in elderly or immunosuppressed 2. Chills 3. Sweats 4. *Myalgias* (especially large muscle groups) 5. Fatigue 6. Weight loss 7. Anorexia 8. Arthralgia 9. Malaise 10. Pallor B. Non-productive cough 1. Present in up to 24% of cases 2. Better when supine, worse when upright C. Classic endocarditis symptoms as above 1. May only be present in severe Acute Endocarditis III. Signs: Classic Presentation (Osler) A. Congestive Heart Failure 1. Present in severe cases B. Systolic Murmur from Heart Valve 1. New murmur auscultated in 48% of careful examinations 2. Most often a valve regurgitation murmur 3. Characteristics change on serial exams 4. Absent in tricuspid valve involvement (rare outside of IV Drug Abuse) C. Petechiae on mucus membranes (mouth, Conjunctiva) D. *Splinter Hemorrhages* 1. Non-blanching linear lesions beneath nails E. Splenomegaly F. *Osler Nodes* 1. *Painful, raised, violaceous nodules affecting pulp of fingers and toes* G. Janeway Lesions 1. Blanching, erythematous, painless hemorrhagic Nodules on palms or soles H. Roth Spots 1. Retinal Hemorrhages with central pallor 2. Exudative, edematous Retinal lesions I. Digital Clubbing J. Multiple foci of infection 1. Example: Pneumonia, perinephric abscess 2. Cerebral emboli a. Focal Cerebrovascular Accident findings IV. Precautions A. Endocarditis Diagnosis is often missed initially due to non-specific symptoms and signs 1. Typically presents as a viral-like syndrome 2. Patients often appear non-toxic initially 3. Fever may not be present at visit (but reported at home) 4. Murmurs are often absent or only intermittently present 5. Consider Blood Cultures and close interval follow-up in undifferentiated fever with myalgias B. Red Flags for which Endocarditis should be considered 1. Endocarditis risk factors a. Prosthetic or malformed Heart Valve b. Intravenous Drug Abuse (IVDA) c. Hemodialysis 2. Unexplained symptoms a. Fever b. Night Sweats c. Systemic illness V. Treatment A. Antibiotics: Initial Empiric Treatment (IV Antibiotics 4-6 Weeks) 1. Protocol 1 - Native Valve a. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) AND b. Ceftriaxone 2 grams every 24 hours IV 2. Protocol 2 - Native Valve a. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) AND b. Gentamicin 1 mg/kg every 8 hours IV or IM 3. Protocol 3 - Prosthetic Valve a. Vancomycin 15-20 mg/kg every 8-12 hours IV (target trough 15-20 mcg/ml) AND b. Gentamicin 1 mg/kg every 8 hours IV or IM c. Rifampin 300 mg PO/IV every 12 hours

Bacterial Endocarditis

I. Pathophysiology A. Metaplasia 1. Columnar metaplasia of distal esophagus (from normal squamous cell lining) B. Response to chronic inflammation from gastric acidic fluid via lower esophageal sphincter 1. Gastroesophageal Reflux C. *Precancerous lesion* 1. Metaplasia progresses to esophageal adenocarcinoma in <0.33% of patients with Barrett Esophagus annually II. Management A. *Proton Pump Inhibitor (e.g. Prilosec, Protonix) Long-term* B. High grade dysplasia 1. Noninvasive methods a. Photodynamic therapy i. Systemic Photosensitizers administered followed by endoscopic exposure to laser light ii. Complete response in >78% of cases iii. Only treatment that significantly reduces Barrett Esophagus progression to cancer iv. Risk of Esophageal Stricture in 33% b. Radiofrequency Ablation i. Balloon placed adjacent to mucosal lesions and providers localized thermal ablation ii. Complete response in >91% of cases iii. Risk of Esophageal Stricture <8% c. Endoscopic mucosal resection i. Complete response in >76% of cases ii. Preferred method for endoscopic cancer staging iii. Risk of Esophageal Stricture in >50% (as well as bleeding and perforation) 2. Invasive methods a. Esophagectomy III. Evaluation (Endoscopy) A. Barrett's Esophagus without dysplasia 1. *Repeat endoscopy with biopsy in one year* 2. If no dysplasia x2 biopsies, then endoscopy every 3-5 years B. Low grade dysplasia 1. Repeat endoscopy with biopsy in 6 months 2. Then repeat upper endoscopy annually until no dysplasia on 2 biopsies (and then endoscopy every 3 years) C. High grade dysplasia 1. Repeat upper endoscopy every 3 months 2. Consider esophagectomy if able to undergo surgery 3. Consider endoscopic resection and ablation if not able to undergo surgery

Barrett's Esophagus

-painless, pearly, ulcerated nodule with overlying telangiectasis -found on sun areas

Basal Cell Carcinoma

Causes of bloody diarrhea: "Bloody diarrhea is not SEECSY" S: Salmonella E: EIEC/EHEC E: Enteroamoeba C: Campylobacter S: Shigella Y: Yersinia enterocolitica

Bloody Diarrhea (SEECSY)

I. Complete Blood Count A. Decreased Hemoglobin PLUS... 1. Decreased MCV/MCH (Microcytic) a. Iron Deficiency b. Thalassemia 2. Normal MCV/MCH (Normocytic) a. Anemia of Chronic Disease b. Haemolysis c. Acute Blood Loss d. Aplastic Anemia 3. Increased MCV/MCH (Macrocytic) a. B12/Folate Deficiency b. Alcoholism c. Thyroid Disease d. Chemotherapy

CBC

I. Findings: Suggestive of central causes A. Nystagmus 1. Vertical or torsional Nystagmus (pure Horizontal Nystagmus may occur with either peripheral or central cause) 2. No Nystagmus on Horizontal Head Impulse Test 3. Persists <6 seconds after Dix-Hallpike Maneuver 4. Fixation of eyes on object does not inhibit Nystagmus 5. Requires weeks to months to resolve B. Episodes last hours to days C. Severe imbalance impairs standing and walking D. No Hearing Loss or Tinnitus in most central cases E. Acute Vestibular Syndrome (Posterior Circulation in 25% of cases) 1. Rapid onset (<1 hour) of acute, persistent, continuous Vertigo or Dizziness 2. Associated with Nystagmus, Nausea or Vomiting, head motion intolerance, and gait unsteadiness F. Positive HiNTs Exam Criteria (at least 1 of 3 positive) are suggestive of cerebellar CVA or Brainstem CVA (100% sensitive, 96% specific) 1. Normal Horizontal Head Impulse Test (no saccade/correction on head rotation) OR 2. Nystagmus that changes direction (or Vertical Nystagmus or torsional Nystagmus) OR 3. Skew Deviation on Alternate Eye Cover Test in which uncovered eye demonstrates quick vertical gaze corrections III. Causes: Central Vertigo A. Non-Vascular Central Causes of Vertigo (CN 8 or CNS) 1. Tumor a. Acoustic Neuroma (Vestibular Schwannoma) b. Infratentorial ependymoma c. Brainstem glioma d. Medulloblastoma e. Neurofibromatosis 2. Migraine Headache 3. Multiple Sclerosis B. Vascular disease related transient cerebral anoxia 1. Specific anoxia to vertebrobasilar system a. Vessel specific i. Brainstem Infarct (associated with Hearing Loss) 1. Anterior Inferior Cerebellar Artery Infarction 2. Anterior Vestibular Artery Infarction ii. Brainstem Infarct (no Hearing Loss) 1. Posterior Inferior Cerebellar Artery infarction 2. Labyrinthine Artery Infarction b. Precipitating conditions i. Arteriosclerosis ii. Hypertension iii. Anemia iv. Atrial Fibrillation C. Other Causes 1. Postural Hypotension 2. Syncope

Central Vertigo

Cotton wool spots are caused by retinal nerve fiber layer microinfarcts. Exploded retinal ganglion cell axons extrude their axoplasm like toothpaste.

Cotton Wool Spots

Blue discoloration from subcutaneous *ecchymosis and edema in periumbilical area*.

Cullen's Sign

I. Indications A. Screening for co-morbid depression in patients with Dementia II. Definition A. Provider completed scale composed of 19 questions within 5 categories 1. Mood related signs (e.g. Anxiety, sadness, flat affect, irritability) 2. Behavioral disturbance (e.g. Agitation, slowed speech or movement) 3. Physical Signs (appetite, weight loss, low energy) 4. Cyclic functions (e.g. worse mood in morning, Insomnia) 5. Ideational disturbance (e.g. Suicidality, self-esteem, pessimism) B. Each question is assigned a 3 point score 1. Score 0: Unable to evaluate or absent 2. Score 1: Mild or Intermittent 3. Score 2: Severe

Depression Screening in Dementia

I. Findings: Red Flags suggestive of *Foot Osteomyelitis* A. Sausage toe (swollen, deformed red toe) B. Bone Visualized or Probe-to-Bone Test positive II. Findings: Red Flags suggestive of Skin Ulcer A. Infected ulcer with ESR >70 mm/h or unexplained Leukocytosis B. Non-healing ulcer despite several weeks of wound care and non-weight bearing C. Non-healing ulcer over bony prominences despite wound care D. Ulcer with underlying bony XRay changes E. Ulcer area >2 cm^2 F. Ulcer depth >3 mm

Diabetic Foot Laceration Risk Factors

These murmurs occur during diastole and after S2, before S1. They're caused whilst the ventricle is filling, meaning blood either goes: from the atrium into the ventricle via the mitral valve; or back from the aorta into the ventricle. *With regards to the pulse, if the murmur is not in time with the pulse, it is likely diastolic.* All diastolic murmurs are abnormal! MS. AR

Diastolic Murmurs

I. Definition A. Implantation of fertilized ovum outside of the Uterus II. Risk Factors A. Highest risk factors 1. Prior tubal surgery 2. Sterilization such as Tubal Ligation 3. Prior Ectopic Pregnancy 4. Intrauterine Device (IUD) 5. In-vitro fertilization 6. Diethylstilbestrol Exposure (DES Exposure) in utero B. Moderate risk factors 1. *Pelvic Inflammatory Disease or other tubal infection* 2. Infertility for 2 years or longer 3. Multiple sexual partners 4. Advanced maternal age >40 years old 5. Tobacco abuse (via impaired tubal motility C. Other risk factors 1. Endometriosis 2. Mini Pill use (Progestin only pill) 3. Vaginal Douching 4. Early age at first intercourse (age <18 years)

Ectopic Pregnancy

I. Pathophysiology A. Ascending infection via vas deferens from prostatic Urethra II. Labs A. *Urinalysis and Urine Culture* (first void urine samples are preferred) 1. Often normal despite Epididymitis 2. Pyuria (Urethritis) may be present in Epididymitis and absent in Testicular Torsion a. Leukocyte esterase positive b. Urine White Blood Cells present on microscopy B. C-Reactive Protein (CRP) 1. Increased in Epididymitis and Orchitis >24 mg/L in most cases a. C-RP is typically normal in Testicular Torsion 2. C-RP processing time may preclude use to triage Ultrasound C. Sexually Transmitted Disease testing (PCR Urethral swab or first-void urine) 1. Neisseria Gonorrhea PCR 2. Chlamydia trachomatis PCR

Epididymitis

I: PrePurberty II: Breast budding; areolar hyperplasia with small amount of breast tissue; long downy pubic hair near the labia. III: Further enlargement of breast tissue and areola, with no separation of their contours; increase in amount and pigmentation of pubic hair. IV: Separation of contours; areola and nipple form secondary mound above breasts tissue; adult pubic hair in type but not in distribution. V: Adult Pattern

Female Tanner Stages

Patients taking aledronate are instructed to take the medication when they get up in the morning, 30 minutes before eating and with a full glass of water. They should be instructed to remain upright to avoid esophageal irritation. If they take this medication with food, it will reduce the bioavailability by 40%. Taking alendronate with coffee or orange juice will reduce bioavailabiliy by 60%.

Fosamax

I. Symptoms: Classic A. Heartburn (Initial GERD symptom) 1. Location: Epigastric and retrosternal Chest Pain 2. Characteristic: Caustic or stinging 3. No radiation to the back B. Acid Regurgitation (Water Brash or Pyrosis) 1. Suggests progressing GERD 2. Provoked by lying supine or leaning forward 3. Regurgitation of digested food or clear burning fluid 4. Undigested food suggests alternative diagnosis a. Achalasia b. Esophageal Diverticulum C. Difficult swallowing (Dysphagia) 1. Mechanical obstruction of solid foods a. Suggests peptic stricture 2. Liquid obstruction suggests alternative diagnosis a. Neuromuscular disorder b. Neoplasm c. Esophageal diverticulum II. Red Flags: Symptoms Indicating Evaluation (e.g. Endoscopy) A. Dysphagia 1. Immediately assess for Barrett's Esophagus B. Odynophagia 1. Assess for Esophageal Ulcer C. Weight Loss (Suggests Dysphagia or Odynophagia) D. Early satiety or Vomiting E. Aspiration F. Wheezing or cough G. Gastrointestinal Bleeding H. Unexplained Iron Deficiency Anemia 1. Suggests esophageal ulcer I. High risk patients 1. Male over 45 years old with longstanding GERD symptoms 2. History of severe Erosive Gastritis 3. Tobacco abuse with weekly GERD symptoms in the last year (OR 51.4) 4. Obesity (BMI >30 kg/m^2) with weekly GERD symptoms in the last year (OR 34.4) 5. Elderly with reflux (use high level of suspicion) i. Even serious pathology may present as mild GERD III. Management: General Measures A. Drink 8 glasses (8 ounces) non-caffeinated fluid daily B. Decrease provocative foods 1. Decrease or eliminate Caffeine 2. Avoid spicy foods 3. Avoid milk products toward end of day 4. Avoid chocolate 5. Avoid fatty foods C. Tobacco Cessation D. No eating food 2-3 hours before bedtime E. Elevate head of bed to 30 degrees 1. Place 6-8 inch blocks under legs at head of bed 2. Place Styrofoam wedge under mattress F. Symptomatic therapy for mild intermittent symptoms 1. OTC Antacid medications (e.g. Maalox, Tums, Rolaids) IV. Management: Medications A. Institute general measures above B. *Proton Pump Inhibitor* 1. All Proton Pump Inhibitors equivalent in GERD 2. Initial treatment for 6 to 12 weeks a. Dose 30-60 minutes prior to meal b. Use high dose (twice daily) for severe or refractory symptoms 3. Taper to lower dose for 4 to 8 weeks 4. Trial off Proton Pump Inhibitor C. Consider H2 Blocker maintenance therapy 1. Consider concurrent with first week of Proton Pump Inhibitor use (until complete pump blockade) 2. *H2 Blockers are inferior to PPI for control of GERD symptoms* a. Starting with Proton Pump Inhibitor (instead of stepping up from H2 Blocker) is more cost effective D. Medications not found to be beneficial 1. Sucralfate (Carafate) offers minimal benefit in GERD

GERD

I. Symptoms and Signs: General A. Urinary Symptoms 1. Urinary frequency 2. Urinary urgency 3. Dysuria B. Copious Urethral discharge 1. Green, yellow, or sanguinous discharge C. Meatus and anterior Urethra inflammation D. Conjunctivitis 1. Direct inoculation 2. Copious exudate 3. Beefy Conjunctiva E. Serious complications 1. Corneal Ulceration or opacification 2. Visual loss 3. Globe Perforation E. Pharyngitis 1. Rarely the only site of infection a. Accompanies Cervicitis in 10-20% of cases 2. Usually asymptomatic or only mild in up to 90% of cases 3. Associated with anterior cervical adenopathy 4. More common in Men who have Sex with Men, HIV Infection or other STD F. Proctitis 1. Receptive anal intercourse (especially in Men who have Sex with Men) 2. Mild anal irritation or itching to Rectal Pain 3. Mucopurulent discharge 4. Painful Defecation or tenesmus 5. May cause Acute Diarrhea II. Symptoms and Signs: Women (asymptomatic in 95% of cases) A. Delayed diagnosis is common with risk of Pelvic Inflammatory Disease or Disseminated Gonococcus B. Mucopurulent Cervicitis (most common presentation) 1. Onset 5-10 days after exposure 2. Odorless Vaginal Discharge (observed from os) 3. Vaginal Bleeding or spotting (may present as Metrorrhagia) 4. Friable Cervix bleeds easily C. Bartholin's gland inflammation D. Skene's gland inflammation III. Symptoms and Signs: Men (symptomatic in 90% of cases) A. Symptom onset within 2-6 days of exposure (may be delayed up to 30 days after exposure) B. Dysuria C. Epididymitis (unilateral Testicular Pain) D. Purulent discharge from Urethra meatus IV. Labs A. Nucleic Acid Amplification Test (DNA probe) 1. Reliable alternative to culture (preferred for screening) 2. Sample a. Men: Urethra or urine b. Women: Cervical swab is preferred 3. Rapid: 30 minutes B. Gram Stain: Urethral or Cervical Smear 1. Numerous White Blood Cells 2. Gram Negative biscuit-shaped diplococci a. False positive Gram Stain (saprophytic Neisseria) C. Gonorrhea Culture and Sensitivity 1. Culture medium of chocolate agar or Martin-Lewis agar 2. Required for Disseminated Gonococcus testing a. Blood Culture b. Throat Culture c. Synovial Fluid V. Treatment A. Treatment of Gonorrhea in 2014 is limited to a few agents for dual therapy 1. *Eradication typically requires Ceftriaxone and either Azithromycin 1 gram or Doxycycline for 7 days* a. Cefixime resistant strains are often also resistant to Doxycycline B. *Treat for Chlamydia (30-50% coinfection) if Gonorrhea positive* 1. *Doxycycline 100 mg orally twice daily for 7 days OR Azithromycin 1 gram orally for 1 dose* C. Uncomplicated Gonorrhea in non-pregnant patient 1. *Use Azithromycin 1 gram orally in all cases to treat the Gonorrhea infection (regardless of Chlamydia status)* 2. Second agent (in addition to Azithromycin) a. *Ceftriaxone 250 mg IM for 1 dose (preferred option)* i. Cure rate: 99% ii. Previously dose was 125 mg D. Severe Cephalosporin allergy (e.g. Anaphylaxis or Toxic Epidermal Necrolysis) 1. Give Azithromycin 2 grams orally for 1 dose as only medication AND 2. Recheck for cure in 1 week 3. Consult infectious disease E. Agents to avoid 1. Cefixime (Suprax) 400 mg orally for 1 dose a. Not recommended due to increasing resistance in 2012 (see resistance above) 2. Quinolones should no longer be used for Gonorrhea in U.S. due to high resistance

Gonorrhea

I. Pathophysiology A. *Gout occurs when Uric Acid levels exceed solubility limits* 1. Monosodium urate crystals deposit in joints, Kidney, and soft tissues 2. Crystal deposition triggers a inflammatory response from cytokines and Neutrophils 3. Joint space is irreversibly injured with ongoing attacks II. Risk Factors A. Most common 1. Obesity 2. Alcohol use (especially beer) 3. High purine diet (red meats, turkey and wild game, organ meats, seafood) 4. Drinks sweetened with high fructose corn syrup 5. Diuretic therapy including Thiazide Diuretics 6. Other risks a. Diabetes Mellitus b. Hyperlipidemia c. Hypertension d. Atherosclerosis e. Renal Insufficiency f. Myeloproliferative disease III. Symptoms A. Associated Symptoms 1. Chills 2. Fever as high as 104 F (40 C) 3. Severity: Very severe pain a. Unable to bear weight b. Too painful to put on socks c. Intollerant to light touch from blankets B. Regions Lower extremities 1. *First Metatarsophalangeal joint of great toe* (most common) a. Known as *Podagra* i. Affected in 50% of first gout attacks Mid-tarsal joints 2. Ankle Joints 3. Knee Joints C. Regions upper extremities 1. Fingers 2. Wrists 3. Elbows D. Characteristics: Joint Pain 1. Excruciating, crushing type pain 2. Timing: Joint Pain 3. Acute onset of lower extremity Joint Pain 4. Wakens patient from sleep IV. Signs A. Acute 1. Joint Inflammation 2. Erythema, tenderness and swelling at affected joint a. Pain extends well beyond joint b. Entire foot involved in some cases 3. Asymmetric joint involvement a. May only involve one side with the first attack 4. Skin over joint is tense and shiny B. Chronic 1. Gouty Tophi (develop after 10 years) a. Subcutaneous Nodules of monosodium urate crystals and lipids, proteins and mucopolysaccharides C. Chronic Arthritis 1. Chronic deposition occurs with recurrent attacks

Gout

I: very soft II: mild to moderately loud III: loud, easily heard with stethoscope IV: louder, first time thrill is present V: very loud, thrill more obvious VI: extremely loud, heard with stethoscope off of chest, thrill easily palpated

Grading System: Heart Murmurs

Discoloration at the *flank with blue-red-purple or green-brown ecchymosis*. Results from tissue catabolism of hemoglobin.

Grey Turner's Sign

HIV is a virus spread through certain body fluids that attacks the body's immune system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so many of these cells that the body can't fight off infections and disease. These special cells help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells (T cells) in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases.

HIV

Stage 1 (Acute HIV Infection): Within 2 to 4 weeks after infection with HIV, people may experience a flu-like illness, which may last for a few weeks. This is the body's natural response to infection. When people have acute HIV infection, they have a large amount of virus in their blood and are very contagious. But people with acute infection are often unaware that they're infected because they may not feel sick right away or at all.

HIV Stage 1

Stage 2 (Clinical Latency (HIV Inactivity or Dormancy)): This period is sometimes called asymptomatic HIV infection or chronic HIV infection. During this phase, HIV is still active but reproduces at very low levels. People may not have any symptoms or get sick during this time. For people who aren't taking medicine to treat HIV, this period can last a decade or longer, but some may progress through this phase faster. People who are taking medicine to treat HIV (ART) the right way, every day may be in this stage for several decades. At the end of this phase, a person's viral load starts to go up and the CD4 cell count begins to go down. As this happens, the person may begin to have symptoms as the virus levels increase in the body, and the person moves into Stage 3.

HIV Stage 2

Stage 3 (Acquired Immunodeficiency Syndrome (AIDS)): AIDS is the most severe phase of HIV infection. People with AIDS have such badly damaged immune systems that they get an increasing number of severe illnesses, called opportunistic illnesses. Without treatment, people with AIDS typically survive about 3 years. Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands, weakness, and weight loss. *People are diagnosed with AIDS when their CD4 cell count drops below 200 cells/mm* or if they develop certain opportunistic illnesses. People with AIDS can have a high viral load and be very infectious.

HIV Stage 3

MR. ASH (Systolic Murmurs) MR= Mitral Regurgitation - axilla - best heard at apex of the heart - loud blowing and high-pitched ASH= Aortic Stenosis - neck - best heard at 2nd ICS on Right side of sternum - harsh and noisy Only systolic murmurs radiate: mitral regurgitation radiates to the axilla and aortic stenosis radiates to the neck! MS. ART (Diastolic Murmurs) MS= Mitral Stenosis - best heard at apex of the heart - low-pitched rumbling - use bell of stethoscope ART= Aortic Regurgitation - best heard at the 2nd ICS on Right side sternum - high-pitched blowing ALL diastolic murmurs are abnormal = indicative of heart disease! Benign murmurs do NOT have a thrill; only very loud murmurs will produce a thrill! AoRtic= Right side of sternum PuLmonic= Left side of sternum

Heart Murmur Tips (MR. ASH & MS. ART)

Clinical Description: An acute illness with a discrete onset of any sign or symptom consistent with acute viral hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain), and either a) jaundice, or b) elevated serum alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels. Labs: Immunoglobulin M (IgM) antibody to hepatitis A virus (anti-HAV) positive.

Hepatitis A

Clinical Description: An acute illness with a discrete onset of any sign or symptom* consistent with acute viral hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain), and either a) jaundice, or b) elevated serum alanine aminotransferase (ALT) levels >100 IU/L. Labs: HBsAg positive, AND Immunoglobulin M (IgM) antibody to hepatitis B core antigen (IgM anti-HBc) positive (if done).

Hepatitis B

Clinical Description: An illness with discrete onset of any sign or symptom consistent with acute viral hepatitis (e.g., fever, headache, malaise, anorexia, nausea, vomiting, diarrhea, and abdominal pain), AND (a) jaundice, OR (b) a peak elevated serum alanine aminotransferase (ALT) level >200 IU/L during the period of acute illness. Labs: A positive test for antibodies to hepatitis C virus (anti-HCV); Hepatitis C virus detection test: Nucleic acid test (NAT) for HCV RNA positive (including qualitative, quantitative or genotype testing); A positive test indicating presence of hepatitis C viral antigen(s) (HCV antigen).

Hepatitis C

I. Pathophysiology A. Reactivation of latent virus from dorsal root Ganglion 1. Occurs in 10-20% of people previously exposed to Chicken Pox B. Inflammation to acute viral ID in segmental nerve C. Contagious to non-immune persons 1. Avoid contact until rash heals II. Symptoms: Prodrome A. Timing 1. May be precede rash by 1-5 days B. Most common symptoms 1. Fever (variably present) 2. Headache 3. Photophobia 4. Paresthesias 5. Pain within dermatome occurs first a. Examples: itching, burning, hyperesthesia 6. Malaise III. Signs: Rash A. Timing 1. Develops after 48-72 hours (up to 5 days before rash) 2. Lesions crust and heal within 2-4 weeks B. Distribution 1. Follows 1-2 dermatomes and rarely crosses the mid-line 2. *Back and face are most commonly affected* C. Characteristics 1. Starts as erythematous, maculopapular rash 2. Clear Vesicles develop a. Vessicles turn cloudy within 3-5 days D. Associated Findings 1. Tender regional lymph nodes IV. Management: Antivirals A. Relative indications for antivirals (maximal benefit) 1. Onset within 72 hours of starting treatment 2. Facial involvement (due to associated risk of ocular involvement) 3. Age 50 years and older 4. More than 50 lesions 5. Patients are likely to see benefit if still having active vesicle eruptions, even if delayed beyond the 72 hour window B. Oral antiviral agents 1. *Acyclovir* a. *Dose: 800 mg orally five times daily for 7-10 days* b. *Reduces healing time, pain, and rash dissemination* c. *Least expensive of all antiviral options by an order of magnitude* d. Valacyclovir appeared more effective in over age 50 2. Valacyclovir a. Dose: 1000 mg orally three times daily for 7 days b. Equivalent efficacy to Famciclovir 3. Famciclovir a. Dose: 500 mg orally three times daily for 7 days b. Lesions healed faster, more brief virus shedding c. Reduces Postherpetic Neuralgia duration by 2 months V. Herpes Opthalmicus A. Symptoms 1. Prodrome (precedes rash by several days) a. Lancinating pain lateral to affected eye b. Fever c. Malaise d. Headache e. Neck stiffness 7. Dermatitis a. Vesicular erythematous rash b. Follows first Trigeminal Nerve division i. Forehead ii. Eyelid (Blepharitis) iii. Cornea c. Crusts develop after the sixth day of the rash 8. Eye Pain 9. Lacrimation 10. Visual changes 11. Unilateral Red Eye VI. Acute Management of Herpes Opthalmicus A. *Ophthalmology Consultation* B. Antiviral agents 1. General a. Reduces ocular complications (Keratitis, Uveitis) b. Best prognosis when started early (within 72 hours) c. Efficacious if used as late as 7 days after onset 2. Acyclovir oral or intravenous a. Dose: 800 mg PO five times daily for 7-10 days b. Intravenous dose for immunocompromised patients 3. Valacyclovir (Valtrex) a. Dose: 1000 mg PO tid for 7-14 days 4. Famciclovir (Famvir) a. Dose: 500 mg PO tid for 7 days 5. Valacyclovir 6. Anti-staphylococcal antibiotics a. Augmentin b. Zithromax 7. Prednisone a. Use per Ophthalmology Consultation

Herpes Zoster (Shingles)

I. Pathophysiology A. IgG Antibody develops against platelet membrane antigen B. Acute Idiopathic Thrombocytopenic Purpura 1. Acute onset follows Viral Exanthem or viral Infection 2. Occurs in otherwise healthy patients C. Chronic Idiopathic Thrombocytopenic Purpura 1. Insidious onset in patient with immune disorder 2. More common onset in teenage girls II. Signs and Symptoms A. Purpura B. Bleeding complications 1. Associated with severe Thrombocytopenia (Platelet Count <30,000 per uL) C. Mild Splenomegaly in 5 to 10% of cases D. Absent signs 1. No fever, lethargy, pallor or weight loss 2. No bone or Joint Pain 3. No Lymphadenopathy 4. No Hepatomegaly III. Management: First-Line Management A. Corticosteroids 1. Indicated for severe Thrombocytopenia a. Typically indicated with Platelet Count <50,000 per uL (especially <30,000 per uL) 2. Platelets increase within a week of starting Corticosteroids 3. Dosing a. Methylprednisolone 30 ml/kg/day over 20-30 min up to 1 g/day IV OR b. Prednisone 1-1.5 mg/kg orally daily B. Intravenous Immune globulin (IV IG) 1. Dose: 1 g/kg/day for 2-3 days C. Rituximab (Rituxan) IV. Management: Emergent management A. Indications for urgent or emergent management (uncommon) 1. Serious Hemorrhage 2. Urgent or emergent surgery required B. Treatment 1. Platelet Transfusion at dosing 2-3 fold greater than usual dose

Idiopathic Thrombocytopenia Purpura (ITP)

Hidradenitis Suppurativa is a bacterial infection of the sebaceous glands of the axilla (or groin) by Gram-positive Staphylococcus aureus. It is marked by flare-ups and resolution. It can be confirmed by a C&S of the purulent discharge. I. Pathophysiology A. Inflammation of the Apocrine Sweat Glands II. Symptoms A. Pain, itching, burning and erythema in area involved III. Signs A. Characteristic 1. Early: Inflammatory Nodule or abscess 2. Later a. Sinus tract formation b. Fibrosis c. Bridge scarring d. Hypertrophic Scar or Keloid e. Contractures f. Comedones B. Distribution 1. Axilla (more common in women) 2. Anogenital area (more common in men) 3. Breasts 4. Extension onto back and buttocks IV. Management: Mild (Single Nodules with minimal pain) A. Avoid exposure to heat and humidity B. Avoid shaving if it causes irritation C. Avoid synthetic tight fitting clothes D. Use antibacterial soaps or hibiclens E. Weight loss F. Apply warm compresses to affected area V. Management: Moderate (Recurrent Nodules, pain, abscesses) A. Antibiotics for 2 months or more 1. Axillary involvement a. Dicloxacillin b. Erythromycin c. Tetracycline d. Clindamycin Topically (Cleocin-T) 2. Anogenital involvement a. Augmentin or other broad spectrum antibiotic B. Other options 1. Oral Contraceptives (high Estrogen, low androgen) 2. Accutane 0.5 to 1 mg/kg PO daily a. Used before surgery 3. Corticosteroids (variable efficacy) a. Prednisone 70 mg tapered over 14 days b. Intralesional triamcinolone 4. Cryotherapy VI. Management: Late (abscesses, sinuses, scarring) A. Referral to Dermatology B. Extensive surgical excision of lesions

Hidradenitis Suppurativa

The expected outcomes of the preceding medications are as follows: Lipitor: LDL: 20-60% decrease HDL: 5-15% increase Triglyceride: 10-40% decrease Gemfibrozil: LDL: 5-15% decrease HDL: 14-20% increase Triglyceride: 20-50% decrease Nicotinic acid: LDL: 10-25% decrease HDL: 15-35% increase Triglyceride: 20-50% decrease Colestipol: LDL: 10-20% decrease HDL: 3-5% increase Triglyceride: May increase

Hyperlipidemia Medications

I. Technique A. Patient lies on their left side B. Hyperextend patients right thigh C. Positive test if results in Abdominal Pain II. Interpretation A. Indicates irritation of iliopsoas B. Examples 1. *Extrapelvic abscess as seen in Appendicitis* 2. Adnexal changes 3. Bowel adhesions

Iliopsoas Sign (Psoas Sign)

The fencing reflex (tonic neck reflex) is done by turning the head to one side with the jaw over the shoulder. This should cause the arm and leg on the side where the head is turned to extend and the arm and leg on the opposite side to flex. I. Reflexes A. Foot 1. Stroke Inner Sole (Grasp) a. Toes curl around ("grasp") examiner's finger 2. Stroke Outer Sole (Babinski) a. Toes spread, great toe dorsiflexion B. Walking Reflex 1. Hold baby up with one hand across chest 2. As feet touch ground, baby makes walking motion ("stepping") C. Rooting Reflex 1. Touch newborn on either side of cheek 2. Baby turns to find Breast 3. Sucking Mechanism on finger is divided into 3 steps: a. Front of Tongue laps on finger b. Back of Tongue massages middle of the finger c. Esophagus pulls on tip of finger D. Tonic Neck (Fencing) Reflex 1. If the Babies' head is rotated leftward a. The left arm (face side) stretches into extension b. The right arm flexes up above head 2. Opposite reaction if head is rotated rightward E. Moro Reflex (Startle Reflex) 1. Hold supine infant by arms a few inches above bed a. Gently drop infant back to elicit startle 2. Baby throws Arms out in extension and baby grimaces F. Hand-to-Mouth (Babkin) Reflex 1. Stroke newborns cheek or put finger in babies palm 2. Baby will bring his fist to mouth and suck a finger G. Swimmer's (Gallant) Response 1. Hold baby prone while supporting belly with hand a. Stroke along one side of babies' spine 2. Baby flexes whole body toward the stroked side

Infant Reflexes

Infectious mononucleosis, also called "mono," is a contagious disease. The Epstein-Barr virus (EBV) is the most common cause of infectious mononucleosis, but other viruses can also cause this disease. It is common among teenagers and young adults, especially college students. At least 25% of teenagers and young adults who get infected with EBV will develop infectious mononucleosis. S/S: Typical symptoms of infectious mononucleosis usually appear 4 to 6 weeks after you get infected with EBV. Symptoms may develop slowly and may not all occur at the same time. These symptoms include: *extreme fatigue, fever, sore throat, head and body aches, swollen lymph nodes in the neck and armpits, swollen liver or spleen or both, rash*. Enlarged spleen and a swollen liver are less common symptoms. For some people, their liver or spleen or both may remain enlarged even after their fatigue ends. Most people get better in 2 to 4 weeks; however, some people may feel fatigued for several more weeks. Occasionally, the symptoms of infectious mononucleosis can last for 6 months or longer. Transmission: Typically, these viruses spread most commonly through bodily fluids, especially saliva. However, these viruses can also spread through blood and semen during sexual contact, blood transfusions, and organ transplants. Complications: Because your spleen may become enlarged as a result of infectious mononucleosis, you should avoid contact sports until you fully recover. Participating in contact sports can be strenuous and may cause the spleen to rupture. Prevention: There is NO vaccine for mono; do not kiss or share drinks, food, or personal items, like toothbrushes, with people who have infectious mononucleosis. Treatment: Relieve symptoms of infectious mononucleosis by: drinking fluids to stay hydrated, getting plenty of rest, and taking over-the-counter medications for pain and fever. *Do NOT take amoxicillin or ampicillin*. Blood Work: Labs may show more white blood cells (lymphocytes) than normal, unusual looking white blood cells (atypical lymphocytes), fewer than normal neutrophils or platelets, and abnormal liver function.

Infectious Mononucleosis

A. Symptoms: 1. Fatigue 2. Generalized Weakness 3. Dyspnea on Exertion 4. Lightheadedness B. Signs: 1. Pale Conjunctiva or Mucous Membranes 2. Pallor at Nail Beds 3. Tachycardia 4. Melena (dark, tarry stool) 5. Hematochezia (grossly bloody stool) C. Labs: 1. CBC a. MCV <75 (microcytic) 2. Iron Studies a. Serum Ferritin b. TIBC c. Serum Iron D. Risk Factors: 1. Vegetarian 2. Gastrointestinal Disease E. Iron Food Sources: 1. Red Meat 2. Green Leafy Veggies 3. Dried Fruit 4. Nuts 5. Iron-Fortified Cereal F. Associated Symptoms: 1. Generalized Pruritis (itching) 2. Restless Leg Syndrome (crawling feeling in legs) 3. Glossitis (inflammation of tongue) 4. Angular Cheilitis (cracking at corners of mouth) G. Treatment: 1. Iron Supplement a. Iron absorption decreased 40% when taken with meals - *do not take with meals* b. Antacids or proton-pump inhibitor use will decrease iron absorption c. *Vitamin C aids in the absorption of iron - orange juice*

Iron Deficiency Anemia

I BS when in ROME - ROME criteria to diagnose IBS: R: Relief with BM O: Opposite/Alternating (constipation-diarrhea) M: Mucous E: 3 = thrEE months (continuous or recurring)

Irritable Bowel Syndrome (ROME)

They are small, white spots (often on a reddened background) that occur on the inside of the cheeks early in the course of *measles*.

Koplik Spots

I. Causes A. Untreated Thiamine deficiency from Alcoholism II. Pathophysiology A. Follows Wernicke's Encephalopathy B. Lesions develop in mammillary bodies and Thalamus III. Signs A. Severe Short Term Memory loss B. Intact Immediate Memory C. Confabulation IV. Management A. Thiamine (See Wernicke's Encephalopathy) V. Prognosis A. Life-long Impairment B. Improvement in 75% of patients with treatment

Korsakoff's Syndrome

I. Indications A. Assessment for *Anterior Cruciate Ligament (ACL)* Rupture II. Interpretation: Positive Test for ACL Rupture A. Lax endpoints on anterior translation

Lachman's Test

I. Epidemiology A. Children age 4-9 years old typically affected (may affect ages 3-12 years old) B. Boys affected 4-5 times more often than girls C. Familial in 20% of cases D. Incidence 1:1000 to 1:5000 E. Caucasian more often affected than african american F. Typical body habitus 1. Short to average height 2. Average weight to Overweight (but not typically obese as seen in Slipped Capital Femoral Epiphysis) II. Risk Factors A. Boys B. Low birth weight C. Abnormal birth presentation (e.g. Breech Presentation) D. Family History E. Higher birth order F. Lower socioeconomic status III. Pathophysiology A. Juvenile idiopathic avascular necrosis of femoral head B. Results from a partial interruption of the blood supply to the femoral head 1. Repeat episodes result in infarction and necrosis of the femoral head C. Subchondral Stress Fractures with remodeling over ensuing 2-4 years 1. Femoral head flattens and subluxes IV. Symptoms A. *Pain in area of hip and may be referred to knee* B. *Unilateral Hip Pain* in 84-90% of cases C. Insidious onset of pain V. Signs A. *Child walks with a limp* B. Decreased Hip Range of Motion 1. Limited hip abduction 2. Limited internal rotation C. Leg Length Discrepancy VI. Imaging: XRay A. Views 1. Anteroposterior Pelvis 2. Frog-leg lateral hip B. Findings 1. XRay may appear normal early in condition 2. Joint space widening 3. Proximal femur growth center with fragmentation, flattening, and sclerosis a. May demonstrate a subchondral Stress Fracture line 4. Crescent sign a. Subcortical lucency represents bony destruction C. Non-diagnostic results 1. Consider MRI Hip (gold standard) X. Management A. *Orthopedic Consultation in all cases (within 1 week)* B. NSAIDs may be used for pain C. Difficult management 1. Long-term treatment 2. Limited activity D. *Bracing and Casting for up to 1-2 years* E. Surgical reconstruction to improve Hip Joint congruity 1. Allows child back to activity in 4-6 months

Legg-Calve-Perthes Disease

L: superior Labial artery E: anterior Ethmoidal artery G: Greater palatine artery S: Sphenopalatine artery

Little's Area Arteries (LEGS)

I. Epidemiology A. Leading cause of central Vision Loss over age 65 years B. Age-related changes 1. Onset after age 50 years (mean onset: 75 years old) 2. Prevalence a. Sixth decade: 1% b. Ninth decade: 15% II. Symptoms A. Slow, insidious central Vision Loss III. Signs: Bilateral eye involvement A. Drusen 1. Debris within Retinal pigment basement membrane 2. *Appear with ophthalmoscope as yellow spots on Retina* 3. Small drusen <63 microns are seen on aging macula 4. Numerous, large drusen are consistent with ARMD B. Geographic atrophy C. Serous Retinal pigment epithelial detachment D. Choroidal neovascularization IV. Management: Visual aids A. Magnifiers B. Increased light sources in home environment V. Tests A. Amsler Grid Test

Macular Degeneration

I: PrePurberty II: Enlargement of testes; pigmentation of scrotal sac; minimal or no enlargement of penis; long downy hair. III: Further enlargement of testes; significant enlargement, especially in diameter of penis; increase in amount of pubic hair with curling. IV: Further enlargement of testes; further enlargement, especially in diameter of penis; adult pubic hair in type but not in distribution. V: Adult Pattern

Male Tanner Stages

I. Pathophysiology A. Severe Retching results in tear in esophageal mucosa B. Lesion occurs near esophagogastric junction II. Symptoms A. Hematemesis (vomiting fresh blood) follows episode of Retching or Vomiting III. Signs A. Melena (black, tarry stool) B. Shock IV. Diagnosis A. Endoscopy (EGD) 1. Mucosal tear directly visualized V. Management A. Generally heals spontaneously within several days B. Endoscopy for cauterization if needed C. Surgery rarely required

Mallory Weiss Syndrome

I. Etiology A. Defect in gene coding for fibrillin structure B. Connective tissue defect affecting multiple systems 1. Musculoskeletal disease 2. Ocular disease 3. Cardiac disease II. Signs A. Body habitus 1. *Tall (Height exceeds 95th percentile for age)* 2. *Extremely slender build* B. Cardiovascular signs and conditions 1. Mitral Valve Prolapse 2. Aortic root dilatation 3. Myocardial Infarction 4. Aortic Insufficiency 5. Congestive Heart Failure 6. Subacute Bacterial Endocarditis 7. Aortic Dissection C. Musculoskeletal signs and conditions 1. Arachnodactyly (Spider fingers) 2. *Pectus deformity (Pigeon Breast or Funnel Breast)* 3. High narrow Palate 4. Arm Span exceeds height 5. Leg length exceeds trunk length 6. Hyperextensible joints and ligaments 7. Pes planus 8. Hammer toes 9. Vertebral Column deformities (e.g. Kyphoscoliosis) 10. Inguinal Hernia 11. Striae Distensae D. Ocular signs and conditions 1. Upward ectopia lentis 2. Myopia 3. Iridodonesis 4. Glaucoma 5. Retinal Detachment III. Labs A. Homocystinuria IV. Radiology A. Echocardiogram 1. Enlarged aortic root B. Chest XRay 1. Deformed aorta and pulmonary artery

Marfan Syndrome

I. Indication A. Evaluation for *Knee Meniscus* Injury II. Interpretation: Positive Test Suggests Meniscal Injury A. *"Click" heard or palpated on above maneuvers*. B. Joint line tenderness on palpation.

McMurray's Test

Measles is caused by a single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of measles virus. S/S: It is characterized by a prodrome of fever (as high as 105°F) and malaise, *cough, coryza, and conjunctivitis -the three "C"s*, a pathognomonic enanthema (*Koplik spots*) followed by a *maculopapular rash*. The rash usually appears about 14 days after a person is exposed; however, the incubation period ranges from 7 to 21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do not develop the rash. Transmission: Measles is one of the most contagious of all infectious diseases; approximately 9 out of 10 susceptible persons with close contact to a measles patient will develop measles. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area. Complications: Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. Serious complications include acute encephalitis, which often results in permanent brain damage, death from respiratory and neurologic complications, and subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection Prevention: Measles can be prevented with measles-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Labs: Detection of measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR) are the most common methods for confirming measles infection. Healthcare providers should obtain both a serum sample and a throat swab (or nasopharyngeal swab) from patients suspected to have measles at first contact with them. Urine samples may also contain virus, and when feasible to do so, collecting both respiratory and urine samples can increase the likelihood of detecting measles virus. Treatment: 1) Post-exposure vaccination: Non-immunized people, including infants, may be given the measles vaccination within 72 hours of exposure to the measles virus to provide protection against the disease. If measles still develops, the illness usually has milder symptoms and lasts for a shorter time. 2) Immune serum globulin: Pregnant women, infants and people with weakened immune systems who are exposed to the virus may receive an injection of proteins (antibodies) called immune serum globulin. When given within six days of exposure to the virus, these antibodies can prevent measles or make symptoms less severe. 3) Vitamin A: People with low levels of vitamin A are more likely to have a more severe case of measles. Giving vitamin A may lessen the severity of the measles. It's generally given as a large dose of 200,000 international units (IU) for two days.

Measles

I. Pathophysiology A. Diminished Insulin response results in hyperinsulinemia 1. Fewer Insulin receptors on cells 2. Less Glucose transporter (Glut 4) in cells B. Hyperinsulinemia predisposes to cardiovascular disease C. Precursor to Type II Diabetes Mellitus II. Diagnosis: Three or more conditions below: A. Insulin Resistance 1. *Fasting Glucose of 110 mg/dl or higher* B. *Hypertension (Blood Pressure 130/85 or higher)* 1. Seen in up to 40% of Metabolic Syndrome patients C. Hyperlipidemia 1. *Serum Triglycerides >150 mg/dl* 2. Serum very Low Density Lipoprotein (VLDL) increased 3. *Serum HDL Cholesterol decreased* a. *Men <40 mg/dl* b. *Women <50 mg/dl* D. Coronary Artery Disease E. Polycystic Ovary Syndrome F. Acanthosis Nigricans G. HAIR-AN Syndrome H. Abdominal Obesity 1. *Men with Waist Circumference >40 inches or 102 cm* 2. *Women with Waist Circumference >35 inches or 88 cm*

Metabolic Syndrome

Metabolic Syndrome... You'll have metabolic syndrome when you eat a lot of drive-thru foods, which comes in a HOT BAG: H: HDL (low) O: Obesity T: Triglycerides (high) B: Blood Pressure (high) A: Abdominal Fat G: Glucose (high)

Metabolic Syndrome Mnemonic (HOT BAG)

I. Epidemiology A. Most common congenital foot deformity B. Incidence: 1-2 per 1000 live births C. More common in female infants D. Left-side more commonly affected than right II. Cause A. In-utero confinement III. Metatarsus Adductus A. Corrects spontaneously by age 3 months in 90% cases B. Flexible deformity 1. Forefoot can be rotated to neutral position C. Associated with medial foot soft tissue contractures IV. Associated deformities A. Congenital dislocation of the hip (2-10%) V. Prognosis A. *Mild or flexible improves during first 3 months of life* 1. Suggests Metatarsus Adductus 2. *Full resolution spontaneously in 85% of cases* B. Rigid deformity requires treatment 1. Prevents complications in adults 2. Adult Bunions and calluses at fifth Metatarsal VI. Management A. Category A: Mild/flexible deformity (Most common) 1. Parents Stretch child's foot a. Firmly stabilize heel b. Stretch forefoot laterally (everting foot) i. Hold for count of 5 (baby will wince, not cry) ii. Do for 5 repetitions at each diaper change B. Category B: Moderate/fixed deformity 1. *Evaluation by pediatric orthopedics* a. *Evaluation at age 2-4 months* b. Consider serial corrective casts i. Cast every 1-2 weeks for 3-4 casts c. Avoid Casting too late (after 4-6 months) i. Late Casting is more difficult due to stiff foot ii. Child also kicks more at older age

Metatarsus Adductus ("In-Toeing")

Bouchard's nodes are bony nodules on the proximal interphalangeal joints. Heberden's nodes are bony nodules on the distal interphalangeal joints.

Nodes on Interphalangeal Joints

I. Technique A. Patient lies supine with right thigh flexed 90 degrees B. Examiner immobilizes right ankle with right hand C. Left hand rotates right hip by: 1. Pull right knee laterally (hip external rotation) 2. Pull right knee medially (hip internal rotation) D. Left obturator/Pelvis examined in similar fashion II. Interpretation A. Indicates irritation of obturator muscle B. *Suggests pelvic abscess as seen in Appendicitis*

Obturator Sign

I. Pathophysiology A. Increased Aqueous Humor production B. Aqueous outflow obstruction by microscopic blockages C. Normal chamber angles II. Symptoms A. Bilateral eyes affected but asymmetrically B. Colored halos around lights C. Asymptomatic until severe visual field or central loss 1. Visual field loss irreversible unless caught early 2. Insidious painless Vision Loss a. *Peripheral Vision Loss progresses to blindness* b. Loss not symptomatic until 40% of nerve fibers lost III. Signs A. Pupil dilatation B. Increased Intraocular Pressure (by Tonometer) 1. IOP < 22 mmHg: Normal if optic disks normal 2. IOP 22-30 mmHg: Borderline 3. IOP >31 mmHg: Abnormal C. Progressive peripheral Vision Loss 1. Stages of Vision Loss a. Stage 1: Loss of nasal and superior visual field b. Stage 2: *Loss of peripheral visual field* c. Stage 3: Total blindness 2. Screen visual fields by confrontation 3. Perimetry offers computerized visual field evaluation D. Glaucomatous changes in the optic disc 1. General a. Focal thinning of neural rim i. Nerves at edge of cup and edge of disc ii. Thinning seen at temporal (lateral) disc margin b. Superficial Hemorrhage overlying disc edge 2. Diagnostic changes a. Symmetrically enlarged cup-to-disc ratio >0.5 or b. Cup-to-disc ratio difference between eyes >0.2 or c. Significantly asymmetric cup in one eye IV. Management A. General 1. Regular aerobic Exercise reduces Intraocular Pressure 2. Approach treatment in similar fashion to systemic Hypertension Management a. Start with initial first-line agents b. Advance first-line agents and then add additional medications as needed for persistent elevated pressures

Open Angle Glaucoma

I. Epidemiology A. Common in physically active children near Puberty (age range 10-14 years old) 1. Boys (more common): Age 13-14 years old 2. Girls: Age 10-11 years old B. More common in Running and cutting sports 1. Soccer 2. Basketball 3. Gymnastics 4. Volleyball II. Pathophysiology A. Repetitive traction of Patellar tendon on tibial tubercle ossification center (apophysis) B. Cartilage detachment from tibial tuberosity 1. Acute stress 2. Recent increase in athletic activity 3. Recent growth spurt III. Symptoms A. Waxing and waning anterior Knee Pain for months B. Bilateral in up to one third of patients C. Knee Pain aggravated by: 1. Running 2. Jumping or hurdling 3. Going up and down stairs 4. Direct pressure with kneeling 5. Squatting IV. Signs A. *Localized tenderness and swelling at tibial tuberosity (tibial tubercle)* B. No overlying erythema C. Knee range of motion is intact D. Provocative maneuvers 1. Knee extension against resistance 2. Passive knee hyperflexion to buttock a. *Results in exquisite pain at tibial tubercle* b. Diagnostic for Osgood Schlatter

Osgood Schlater

I. Causes A. Adult common causes 1. Alcohol Abuse (35% of cases) 2. Cholelithiasis (40% of cases) II. Symptoms A. Abdominal Pain 1. Pancreatitis may be painful in some cases 2. Mid-Epigastric Pain, Left Upper Quadrant Abdominal 3. Pain or Periumbilical Abdominal Pain 4. Radiation into the chest or mid-back 5. Worse with eating and drinking (especially fatty foods) and in supine position 6. Boring pain that starts episodically and advances to become constant III. Signs A. General 1. Low Grade Fever B. Abdominal 1. Abdominal tenderness and guarding in the upper quadrants 2. Peritoneal signs may be present (e.g. abdominal rigidity or Rebound Tenderness) 3. Bowel sounds decreased 4. Palpable upper abdominal mass 5. Cullen's Sign (periumbilical discoloration with subcutaneous Ecchymosis and edema) 6. Grey Turner's Sign (flank discoloration with Ecchymosis) IV. Labs A. Approach 1. Consider obtaining Serum Amylase and serum Lipase simultaneously on initial evaluation a. *Expect Serum Amylase and Lipase to be increased in Pancreatitis* (question diagnosis if only 1 increased) b. Serum Lipase to amylase ratio >4 (and especially >5) strongly suggests Alcoholic Pancreatitis B. Fasting Triglycerides 1. *Hypertriglyceridemia (>1500)*

Pancreatitis

I. Signs A. Early and mild Papilledema 1. Subtle gray peripapillary halo 2. Normal radial Optic Nerve head disrupted 3. Nerve fibers accentuated by grayish opacity 4. Concentric folds of the retinochoroid B. Moderate Papilledema 1. Borders of optic disc become obscure 2. Disc margins are progressively elevated 3. Nerve head diameter increases 4. Major blood vessels leaving the disc are obscured C. Severe Papilledema 1. Optic Nerve head protrudes 2. Peripapillary halo demarcated 3. Optic cup is obliterated II. Interpretation A. *Suggests Increased Intracranial Pressure*

Papilledema

EKG: tachycardia with peaked QRS complex with P waves present Causes: digitalis toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drug use Classic Case: abrupt onset of palpitations, rapid pulse, lightheadedness, SOB, anxiety - HR from 150-200bpm Management: hold breath and strain hard, carotid massage, or splashing ice cold water on face - Valsalva maneuvers

Paroxysmal Atrial Tachycardia (PAT) - also known as Paroxysmal Supraventricular Tachycardia (PSVT)

I. Pathophysiology A. Intra-abdominal spread 1. Cervix to endometrium and via salpinx to peritoneal cavity B. Lymphatic spread 1. Example: IUD related infection C. Hematogenous spread (rare) 1. Example: Tuberculosis II. Exam A. Bimanual exam and speculum exam in all suspected cases 1. Cervical motion tenderness 2. Uterine tenderness 3. Adnexal tenderness B. Clinical diagnosis alone is accurate (when compared with imaging and laparoscopy) III. Diagnosis: 2002 CDC Criteria A. Major Criteria (Required) 1. Uterine or Adnexal tenderness to palpation or 2. Cervical motion tenderness 3. No other apparent cause B. Minor Criteria (Supporting, but not required) 1. Fever >101 F (38.3 C) 2. Abnormal discharge per Cervix or vagina 3. WBCs on Gram Stain or Saline of Cervix swab 4. Gonorrhea or Chlamydia testing positive 5. Increased Erythrocyte Sedimentation Rate or C-Reactive Protein 6. PID findings on diagnostic study (see below) C. Most specific findings (not required and rarely indicated unless refractory to management or unclear diagnosis) 1. Laparoscopy findings consistent with PID 2. Endometrial Biopsy with histology suggestive of Endometritis 3. Imaging (Transvaginal Ultrasound or MRI) with classic findings a. Thickened, fluid filled tubes b. Free pelvic fluid may be present c. Tubo-ovarian complex d. Tubal hyperemia on doppler Ultrasound IV. Management: General A. Intrauterine Device (IUD) removal is controversial 1. IUD increases PID for only first 3 weeks following insertion a. Risks are similar between the Copper-T IUD and the Mirena IUD 2. Historically, IUD has been removed at time of PID diagnosis 3. No evidence supports removal of IUD in PID 4. Close follow-up is critical for those who developed PID with IUD in place B. Treat patient's sexual contacts within last 60 days 1. Abstain from sexual intercourse until patient and partner have completed treatment C. Start empiric therapy if minimal criteria present 1. Do not delay treatment 2. *Delay >3 days increases ectopic and Infertility risk* D. Antibiotic should cover Gonorrhea and Chlamydia V. Management Outpatient A. Step 1: Initial Treatment at Diagnosis (with step 2) 1. *Cefoxitin 2g IM and Probenecid 1g PO* or 2. *Ceftriaxone 250 mg IM for 1 dose* or 3. Other third generation Cephalosporin (e.g Cefotaxime, Ceftizoxime) B. Step 2: Outpatient 14 day antibiotic course 1. Select general antibiotic coverage a. *Doxycycline 100 mg PO bid for 14 days* (75% cure, preferred agent) or b. *Azithromycin 1 gram orally once weekly for 2 weeks (alternative option)* 2. Consider adding anaerobic coverage a. *Metronidazole 500 mg orally twice daily for 14 days* or b. *Clindamycin 450 mg PO four times daily for 14 days* 3. Agents to avoid a. Fluoroquinolones (e.g. Ofloxacin 400 bid or Levofloxacin 500 daily) are no longer recommended b. Cohorts at highest risk for Fluoroquinolone resistance i. Homosexual men and any female sexual contacts

Pelvic Inflammatory Disease (PID)

I. Findings: Suggestive of peripheral causes A. Pathognomonic for peripheral cause 1. Sudden onset with brief episodes often on awakening 2. Rotary Illusion with Nausea, Vomiting B. Nystagmus 1. Combined horizontal and torsional Nystagmus 2. Persists 5-20 seconds after Dix-Hallpike Maneuver 3. Fixation of eyes on object inhibits Nystagmus C. Moderate imbalance D. Nausea or Vomiting E. Associated findings 1. Hearing Loss 2. Tinnitus F. Tullio's Phenomenon 1. Nystagmus and Vertigo provoked by loud sounds II. Causes: Common (Peripheral Vertigo) A. Acute Vestibular Neuronitis B. Benign Paroxysmal Positional Vertigo C. Meniere's Disease III. Causes: Other (Peripheral Vertigo) A. Ear Infections 1. Serous Otitis Media 2. Chronic Otitis Media 3. Otitis Externa 4. Mastoiditis B. Other infections 1. Herpes Zoster Oticus (Ramsay Hunt Syndrome) 2. Acute Labyrinthitis (uncommon) a. Not synonymous with Vestibular Neuritis i. Labyrinthitis is much less common than neuritis ii. Labyrinthitis causes permanent Hearing Loss b. Types i. Viral Labyrinthitis ii. Bacterial Labyrinthitis (Rare) C. Structural disorder 1. Cholesteatoma 2. Perilymphatic Fistula 3. Otosclerosis D. Trauma 1. Temporal Bone Fracture 2. Labyrinthine Concussion

Peripheral Vertigo

A. Symptoms: 1. Initial: Generalized Weakness, Paresthesias 2. Next: Leg Stiffness, Ataxia 3. Late: Memory Impairment, Personality Change, Depressed Mood B. Signs: (Mnemonic: "The 5 P's") 1. Pancytopenia (decrease in all blood cell lines) 2. Peripheral Neuropathy 3. Posterior Spinal Column Neuropathy (Dorsal Column Degeneration, Decreased proprioception, Decreased Vibration Sense, Ataxia, Hyporeflexia {e.g. Decreased Ankle Jerk}) 4. Pyramidal Tract Signs 5. Papillary Atrophy of Tongue (Atrophic Glossitis) *red, beefy tongue* C. Labs: 1. CBC a. MCV >100 (macrocytic) b. Leukopenia (decreased white blood cells) c. Thrombocytopenia (decreased platelets) 2. Serum B12 a. Megaloblastosis (oval macrocytes) D. Risk Factors: 1. Strict Vegetarian 2. History of Gastrectomy (Gastric Bypass Surgery) 3. Recent History of Malabsorption (Diarrhea) E. B12 Food Sources 1. Organ Meat a. Liver 2. Dairy Products 3. Fortified Cereal 4. Shellfish a. Clam

Pernicious Anemia (B12 Deficiency)

I. Signs A. Herald Patch (initial presenting lesion in 80% of patients) 1. *Single oval Macule on trunk* 2. Diameter: 2 to 10 cm 3. Characteristics: Annular Lesion (oval) a. *Erythematous (rose colored) border with fine peripheral scale* b. *Central clearing* B. Christmas tree pattern rash 1. Onset occurs 7-14 days after herald patch 2. Symmetric bilaterally 3. Smaller than herald patch (<1 cm) 4. Rash follows skin Cleavage Lines (Langer Lines) 5. Individual lesions appear similar to herald patch a. Small fawn or salmon colored oval Macules b. *Peripheral scaly collarettes* c. *Central clearing*

Pityriasis Rosea

I. Definition A. Hearing Loss related to aging II. Epidemiology A. Onset in middle age, and slowly progressive 1. Most notable over age 65 years III. Pathophysiology A. *Slowly progressive sensorineural hearing loss* B. Typically due to atrophy of Organ of Corti and auditory nerve at basal end of cochlea IV. Symptoms A. Abrupt high frequency Hearing Loss B. Decreased speech discrimination 1. Poor understanding of speech even when loud enough C. Recruitment 1. Abnormal hypersensitivity to noise V. Evaluation A. Audiometry displays high pitched Hearing Loss B. Acoustic reflex testing

Presbycusis

I. Digital Rectal Exam A. Findings suggestive of Prostate Cancer 1. Asymmetry 2. Induration 3. Nodularity 4. Diffuse firmness B. Findings suggestive of* Benign Prostatic Hyperplasia (BPH)* 1. *Symmetric prostatic enlargement* 2. *Smooth* 3. *Firm but elastic* C. Findings suggestive of Prostatitis 1. Prostate tenderness 2. Fever

Prostate on Digital Rectal Exam

I. Signs A. Complete or patchy Tongue baldness B. Smooth, slick, sore Tongue with lost papillae C. Atrophied hyperemic papillae (small punctate red dots) II. Causes A. Diabetes Mellitus B. Anemia 1. *Folic Acid deficiency Anemia* 2. *Vitamin B12 Deficiency Anemia (Pernicious Anemia)* 3. Iron Deficiency Anemia C. Other possible Vitamin Deficiencies 1. Pyridoxine deficiency 2. Riboflavin deficiency 3. Niacin deficiency D. Anti-cancer drugs E. Riley-Day Dysautonia Syndrome III. Management A. Treat underlying cause (e.g. nutritional deficiency) B. Soft, bland diet

Red Beefy Tongue

T: Trauma U: Unexplained Weight Loss N: Neurological Symptoms A: Age >50 F: Fever I: Intravenous Drug User S: Steroid Use H: History of Cancer (Lung, Breast, Prostate, Renal)

Red Flag Symptoms in Back Pain (TUNA FISH)

Roseola is caused by the human herpes virus 6, but the cause also can be another herpes virus — human herpes virus 7. Usually affects children <2 years of age. S/S: *Roseola typically starts with a sudden, high fever — often greater than 103 F (39.4 C)*. Some children may also have a *slightly sore throat, runny nose or cough along with or preceding the fever*. Your child may also develop *swollen lymph nodes in his or her neck* along with the fever. The fever lasts three to five days. Once the *fever subsides, a rash typically appears* — but not always. The rash consists of many *small pink spots or patches. These spots are generally flat, but some may be raised. There may be a white ring around some of the spots. The rash usually starts on the chest, back and abdomen and then spreads to the neck and arms*. It may or may not reach the legs and face. The rash, which isn't itchy or uncomfortable, can last from several hours to several days before fading. Other signs and symptoms of roseola may include: irritability in infants and children, mild diarrhea, decreased appetite, and swollen eyelids. Transmission: Roseola spreads from person to person through contact with an infected person's respiratory secretions or saliva. Complications: Occasionally a child with roseola experiences a seizure brought on by a rapid rise in body temperature. Roseola is also of greater concern in people whose immune systems are compromised, such as those who have recently received a bone marrow or organ transplant. Treatment: Treat symptoms. *Do NOT use Aspirin*.

Roseola

I. Symptoms A. Characteristics 1. Lateral arm without radiation beyond elbow 2. *Associated with arm weakness* B. Timing 1. *Night pain interferes with sleep* C. Provocative 1. Exacerbated by throwing motion 2. Overhead work II. Initial Visit A. Evaluation 1. Shoulder Exam 2. *Shoulder Xray* B. Conservative Therapy 1. Modify Activity 2. Start Physical Therapy and Encourage Early Shoulder Mobilization 3. NSAIDS

Rotator Cuff Injury

Rubella, sometimes called German measles or three-day measles, is a contagious disease caused by a togavirus of the genus Rubivirus. S/S: *Rash that starts on the face and spreads to the rest of the body, low fever (less than 101 degrees)* - these symptoms last 2 or 3 days. Older children and adults may also have swollen glands and symptoms like a cold before the rash appears. Aching joints occur in many cases, especially among young women. Transmission: Spread by contact with an infected person, through coughing and sneezing. Complications: *Birth defects if acquired by a pregnant woman: deafness, cataracts, heart defects, mental retardation, and liver and spleen damage* (at least a 20% chance of damage to the fetus if a woman is infected early in pregnancy). Prevention: Rubella vaccine (contained in MMR vaccine) can prevent this disease. Children should get 2 doses of MMR vaccine: The first dose at 12-15 months of age and the second dose at 4-6 years of age. These are the recommended ages, but children can get the second dose at any age, as long as it is at least 28 days after the first dose. Treatment: Treat symptoms.

Rubella

S1 = MOTIVATED M (mitral valve) T (tricuspid valve) AV (atrioventricular valve) S2 = APPLES A (aortic valve) P (pulmonic valve) S (semilunar valve)

S1 and S2 (Motivated Apples)

Sign of congestive heart failure (CHF)

S3

Sign of left ventricular hypertrophy (LVH)

S4

Fractures through a growth plate; therefore, they are unique to pediatric patients. These fractures are categorized according to the involvement of the physis, metaphysis, and epiphysis. The classification of the injuries is important, because it affects patient treatment and provides clues to possible long-term complications.

Salter-Harris Fractures

I. Pathophysiology A. Occurs in Group A beta-hemolytic streptococcal (GAS) infection (typically Streptococcal Pharyngitis) B. Some GAS strains produce streptococcal pyrogenic exotoxin 1. Patients with hypersensitivity to the toxin may develop a rash II. Epidemiology A. Occurs in 10% of Streptococcal Pharyngitis cases III. Symptoms A. Fever 1. Peaks on Day 2 2. Returns to normal on Day 5-7 B. Chills C. Headache D. Vomiting E. Pharyngitis IV. Signs A. Forehead and cheeks appear flushed B. Circumoral pallor C. Pharyngitis 1. Tonsils are hyperemic and edematous, with exudate 2. Throat is inflamed and covered by a membrane 3. Palatal Petechiae may be present D. Strawberry Tongue 1. Fine Papules on Tongue surface 2. Tongue dorsum may appear with a white exudate and projecting edematous papillae E. Rash 1. Onset with 12-72 hours after fever 2. Coalescing, blanching erythematous Macules (may appear Sunburn-like) 3. Fine papular or punctate lesions a. Texture of coarse sandpaper 4. Rash distribution a. Starts on upper trunk b. Rash distribution generalizes within 24 hours 5. Rash may affect flexor creases (Pastia lines) in the axillae, groin and neck a. Pastia lines due not typically blanche 6. Rash spares the palms and soles a. However, Desquamation of palms and soles may occur F. Desquamation 1. Follows rash fading after several weeks 2. Desquamation of face, skin folds, hands and feet 3. Desquamation may last up to 6 weeks V. Labs A. Streptococcal Rapid Antigen Test B. Throat Culture 1. Used to confirm a negative rapid antigen test C. Antistreptolysin O titer (ASO Titer) 1. Confirms diagnosis, but not typically helpful in acute disease

Scarlet Fever

I. Pathophysiology A. Increases by 1.0-1.5 mg/dl/day if no Renal Function B. Often unchanged until 25-50% of Renal Function lost C. Doubled Serum Creatinine implies 50% Renal Function II. Increased Serum Creatinine A. *Renal Insufficiency* B. *Decreased renal perfusion* C. Urinary Tract Infections D. Skeletal muscle Trauma or Rhabdomyolysis E. Ketonemia F. Diabetic Ketoacidosis G. Creatine Supplementation >15-20 grams per day 1. May increase Serum Creatinine over 2.0 H. Medications (Inhibit tubular secretion of Creatinine) 1. Aminoglycosides 2. Cephalosporins a. Cefoxitin b. Cephalothin 5. Hydantoin 6. Diuretics 7. Methyldopa 8. Cimetidine 9. Trimethoprim III. Decreased Serum Creatinine A. *Decreased muscle mass* B. Pregnancy

Serum Creatinine

When there is vaginal bleeding and cramping but the cervix remains closed it is a threatened abortion. It is possible in this case that the pregnancy can be salvaged. In an inevitable abortion the cervix is dilated. In a complete abortion the placenta and fetus are expelled completely. In an incomplete abortion placental products remain in the uterus and the cervix remains dilated.

Spontaneous Abortions

Some red color changes on the tongue ("strawberry tongue") could be related to a vitamin deficiency, Kawasaki disease, or a strep infection (scarlet fever).

Strawberry Tongue

I. Causes A. Crush injury to nail II. Symptoms A. Severe, throbbing digital pain III. Signs A. Discoloration of nail B. Tip of digit swollen and tender IV. Management: *Drainage (Nail Trephination)* A. Contraindications 1. Phalanx Fracture 2. Nail Bed Laceration 3. Large Subungual Hematomas (>50% of nail) a. Requires Nail Bed Laceration suturing B. Technique 1. *Gently drill 2-3 small holes into nail* a. Number 11 blade or b. Spin 18 gauge needle between fingers or c. *Heated paper clip*

Subungual Hematoma

These are murmurs that occur during systole and after S1, before S2. Essentially, they're caused whilst the ventricle is contracting which means the blood either goes: into the aorta through aortic valve; or back into the atrium through the mitral valve. *The best way to confirm a murmur as systolic is to feel the pulse whilst auscultating. If the murmur is heard in time with the pulse, it is systolic.* MR. AS

Systolic Murmurs

I. Precautions: Renal Insufficiency (GFR <30 ml/min) A. Thiazide Diuretics are minimally effective when GFR falls below 30 ml/min B. Switch to Loop Diuretics at this level of Renal Insufficiency II. Contraindications A. Hyponatremia 1. Do not use Thiazide Diuretics in patients with a history of Hyponatremia III. Adverse effects A. Hyperuricemia 1. Occurs more often with doses over 25mg 2. Less of an issue if avoid Hypokalemia 3. Avoid Thiazide Diuretics in gout! B. Hyperglycemia C. Hyperlipidemia D. Hypokalemia 1. One banana a day is sufficient Potassium Replacement a. Each inch of banana supplies 1 meq of Potassium 2. Cost benefit is lost when Potassium supplement used E. Hyponatremia F. Hypomagnesemia

Thiazide Diuretic (-ide)

I. Pathophysiology A. Infection 1. Exposure to contaminated soil 2. Exposure to infected animals or people B. Growth and transmission facilitating factors 1. Warm and moist environments (showers and pools) 2. Shared towels or clothing II. Signs A. Location: Glabrous skin (skin that is normally hairless) (excludes palms, soles, groin) B. Characteristics 1. *Round, erythematous, Scaling, pruritic Plaques* 2. Annular Lesion (hence the name Ringworm) a. Raised, advancing border b. *Plaque with central clearing* i. No central clearing after Corticosteroid use 3. Postinflammatory pigmentation changes III. Management A. Prevent re-infection (see pathophysiology above) B. Topical Antifungal applied twice daily for 2-3 weeks 1. Technique a. Apply to infected and normal skin 2 cm beyond affected area b. Continue for 7 days after symptom resolution 2. First line: Imidazoles (e.g. Clotrimazole) 3. Refractory cases: Naftin, Lamisil, Loprox, Mentax

Tinea Corporis (Ringworm)

I. Etiology A. Protozoan infection II. Symptoms A. Asymptomatic in 25-44% of women B. Copious, yellow-green or grayish-green Vaginal Discharge (variably present) 1. Fishy odor to discharge (variably present) 2. Frothy discharge (Carbon dioxide bubbles) C. Vulvar and vaginal Pruritus with irritation and edema D. Dysuria (20%) III. Signs A. Vulvar edema and erythema B. Tender vaginal or vulvar ulcerations C. *Strawberry Cervix* (2-3% of cases) 1. Punctate Hemorrhages or Petechiae 2. Telangiectasia IV. Labs A. Vaginal pH > 5.0 B. *KOH Preparation* 1. Sniff Test positive a. Fishy odor to discharge when KOH added (often negative) C. *Wet preparation* (from vaginal vault, not endocervix) 1. Read slide immediately a. Motility wanes quickly, over minutes b. Trichomonad shape morphs from pear-shaped to round with slide drying 2. Motile pear shaped Trichomonads with flagella exiting from tapering end (70%) a. Twice the size of White Blood Cells (WBC) V. Treatment A. General 1. Treat Sexual Partner also a. Metronidazole 500 mg orally twice daily for 7 days is most effective for male partners b. Avoid treatment in first trimester of pregnancy c. Avoid intravaginal preparations of Metronidazole or Tinidazole due to low cure rates B. Non-Pregnant, Non-Lactating Patient 1. *Metronidazole (Flagyl) 2 g orally for 1 dose (preferred)* or 2. Metronidazole (Flagyl) 250 mg PO three times daily for 7 days or 3. Metronidazole (Flagyl) 500 mg PO twice daily for 7 days or 4. Tinidazole (Tindamax) 2 grams orally for 1 dose a. Teratogenic, Category D (do not use if any risk of pregnancy)

Trichomonal Vaginitis

I. Definition A. Inflammation of bursa overlying hip greater trochanter II. Symptoms A. Pain overlying greater trochanter B. May radiate into knee or ankle or into buttock C. Night pain occurs if lying on affected side D. Palliative and provocative factors 1. Worse when standing from seated or lying position 2. Improves initially on walking 3. Worse again after walking for >30 minutes III. Signs A. Point tenderness over lateral greater trochanter of hip B. Symptoms reproduced on hip adduction C. Adduction and internal rotation may also provoke IV. Management A. NSAIDs B. Modify activity C. Trochanteric Bursa Injection

Trochanteric Bursitis

I. Transmission A. Mycobacterium tuberculosis carried in airborne droplets B. Active Pulmonary or Laryngeal Tuberculosis transmitted 1. Sneeze, cough, speak, or sing II. Symptoms A. Latent Tuberculosis is asymptomatic B. Active Tuberculosis presentation often mimics cancer presentation 1. Non-specific presentation (most common) a. Fatigue b. Weight loss c. Cachexia d. Night Sweats C. Pulmonary Tuberculosis symptoms 1. Productive cough (typically 2-3 weeks) 2. Hemoptysis (uncommon) 3. Pleuritic Chest Pain 4. Dyspnea III. Signs A. Sites of Involvement 1. Primary infection: lung involvement B. Disseminated Disease IV. Management A. Latent Tuberculosis 1. Positive PPD without signs of Active Tb 2. Treatment indicated if risk of Tb Progression from latent to active disease B. Active Tuberculosis

Tuberculosis

Chickenpox is a very contagious disease caused by the varicella-zoster virus (VZV). S/S: The classic symptom of chickenpox is a *rash that turns into itchy, fluid-filled blisters that eventually turn into scabs*. The rash may first show up on the face, chest, and back then spread to the rest of the body, including inside the mouth, eyelids, or genital area. It usually takes about one week for all the blisters to become scabs. *Other typical symptoms that may begin to appear 1-2 days before rash include: high fever, tiredness, loss of appetite, and headache*. Transmission: The virus spreads in the air when an infected person coughs or sneezes. It can also be spread by touching or breathing in the virus particles that come from chickenpox blisters. Complications: Pregnant women and people with weakened immune systems are at higher risk for serious chickenpox disease. Prevention: CDC recommends two doses of the varicella (chickenpox) vaccine for children, adolescents, and adults. Children should receive two doses of the vaccine—the first dose at 12 through 15 months old and a second dose at 4 through 6 years old. Treatment: Treat symptoms.

Varicella-Zoster Virus (Chickenpox)

I. Pathophysiology A. Abnormal venous tortuosity and dilatation 1. Pampiniform venous plexus 2. Internal spermatic vein B. Associated Infertility may be due to 1. Elevated testicular Temperature 2. Results in decreased spermatogenesis and motility II. Signs A. *"Bag of worms" superior to the Testicle* B. Vein dilation and tortuosity 1. Decreased with patient supine 2. Increased with patient upright and with Valsalva Maneuver C. Left Varicocele most common (80% of cases) 1. Left testicular vein drains into renal vein III. Management: Surgical repair A. Indication 1. Abnormal Semen Analysis and Infertility a. Fails to Restore fertility by recent study 2. Persistant symptoms (Dull ache or heavy sensation) B. Procedures 1. Surgical ligation of pampiniform plexus 2. Injected sclerotherapy 3. Directed embolization via intervention radiology

Varicocele

I. Pathophysiology A. *Dementia associated with multiple strokes* B. Symptoms depend on infarction location 1. Cerebral cortex 2. Thalamus 3. Basal Ganglia 4. Hippocampus II. (Subcortical) Vascular Dementia: 10-20% A. Mental slowing B. Mood disturbance

Vascular Dementia

I. Pathophysiology A. Normal Venous valves prevent backflow 1. Distal to Proximal vein backflow 2. Superficial to Deep vein backflow B. Incompetent valves allow backflow when legs relax 1. Results in distal venous Hypertension 2. Primary etiology for Chronic Venous Insufficiency II. Symptoms and Signs A. Initial Changes 1. Varicose Veins 2. Tan or reddish brown Skin Color changes 3. Weeping and excoriated skin 4. *Pedal edema* B. Later Changes 1. *Lipodermatosclerosis* a. *Induration at medial ankle to mid-leg* C. Advanced Changes 1. Brawny Edema above and below fibrotic area 2. Ulcerations III. Diagnosis A. Duplex Ultrasonound (B-Mode and Directional Pulse) 1. Can accurately assess venous reflux 2. Can also be used to assess Arterial Insufficiency a. With Ultrasound ankle/brachial index IV. Management A. General Measures 1. Take regular walks a. Leg muscle activity promotes better venous return 2. Avoid prolonged standing in one place 3. Elevate Legs above Heart a. Perform 30 minutes each 3-4 times daily b. Elevate the foot of the bed to raise legs overnight 4. Graduated Compression stockings (Jobst Stockings) B. Intermittent Pneumatic Compression Pumps 1. Indications a. Obesity b. Moderate to Severe edema 2. Contraindications a. Uncompensated Congestive Heart Failure C. Diuretics 1. Short term use 2. Indications: Severe edema

Venous Insufficiency