COMLEX Level 2

Management of GERD

>50yo M, Sx >5yr, Cancer RF, Alarm sx? - Yes? *EGD* --> Esophagitis? Treat the type you find. --> Not clear? *Manometry* - No? *PPI qd x8wks* --> Still have sx? *PPI bid x8wks* (or dif PPI) ...Still no improvement with that? Then *EGD* v. Manometry

Zinc deficiency

Absorbed in duodenum and jejunum Alopecia *Pustular* skin rash (perioral and extremities...unlike Niacin) Hypogonadism Impaired wound healing Impaired taste Immune dysfunction

Intention to Treat Analysis (ITT)

All patients allocated to one arm of a RCT are analyzed in that arm, whether or not they completed the prescribed treatment/regimen (opposite of Per-Protocol Analysis)

Werdnig-Hoffman Disease

Also known as infantile spinal muscular atrophy. Path: Autosomal-recessive inheritance, DEGENERATION OF ANTERIOR HORNS - LMN involvement only Pt: - Presents at birth as a "floppy baby", - Tongue fasciculations, - Median age of death 7 months.

Milia Rubra

Also known as prickly heat; acute inflammatory disorder of the sweat glands resulting in the eruption of red vesicles and burning, itching skin from excessive heat exposure.

Pseudofolliculitis

Also known as razor bumps; resembles folliculitis without the pus or infection. - MC in individuals with tightly coiled hair and frequent shaving

Light Criteria

EXUDATE - Pleural protein/Serum protein ratio >0.5 - Pleural LDH/Serum LDH ratio >0.6* - Pleural LDH >2/3 upper limit of normal of serum LDH TRANSUDATE - Doesn't meet above criteria Tuberculosis? Lymphocytic exudate RA? High LDH, Low glucose

Hydatid Cyst

Echinoccocus granulosus Path: Humans are close and intimate with dogs - Unilocular cystic lesion in any organ (w/*Eggshell calcification* of liver cysts) Control / prevention - Proper disposal and incineration of offal - Avoid feeding offal to dogs - Treat dogs with cestocides on a regular basis - Humans - good sanitary habits - Diagnosis - eggs in fecal flotation - ELISA test

Familial Chylomicronemia

Elevated Chylomicrons Milky serum Pancreatitis Hepatosplenomegaly Eruptive skin xanthomas Autosomal Recessive

Familial Hypercholesterolemia

Elevated LDL Tendon xanthomas Xanthelasmas Premature CAD Autosomal Dominant

EMTLA (Emergency medical treatment and Labor Act)

Emergency physicians are required to: - Provide screening examination - Patient has to be appropriately treated and stabilized before transferring to another unit. - Transfer patient only after patient has been stabilized

Motivational Interviewing

Engaging Focusing Evoking Planning

Major Pathologic Mechanisms of Foodborne Illness

Enterotoxin Ingested (vomiting dominant) - Staph aureus - B. Cereus Enterotoxin made in Intestine - C. perfringens - ETEC/STEC - Vibrio cholera Bacterial Epithelial Invasion - Campylobacter - Nontyphoidal salmonella - Listeria

Common Skin Infections

Erysipelas: STREP pyogenes: superficial infection of dermis and lymphatics - raised, sharply demarcated edges Cellulitis (NON-purulent): STREP/ MSSA - deep dermis and sub-cu fat - flat edges with poor demarcation - indolent Cellulitis (purulent): MSSA/MRSA - purulent drainage - folliculitis; infected hair follicle

Benign Neonatal Rashes

Erythema Toxicum - Filled with *Eosinophils* Milia Milia Rubra Neonatal Pustular Melanosis - Filled with *Neutrophils* Neonatal Cephalic Pustulosis

Number needed to harm (NNH)

Excess risk in a population explained by exposure to a particular risk factor. *NNH = 1/AR* - Attributable Risk = AR

Timeline of Infant Nutrition

Exclusive breast feed until 6mo --> *+ Vitamin D + Iron* --> If mom is strict vegetarian? *+ Vitamin B12* @ 6mo introduce pureed foods @ 1yr introduce cow's milk

Hyper IgE Syndrome (Job Syndrome)

FATED: - coarse *F*aces, - *A*bscesses (Staph) --> Cold abscesses - retained primary *T*eeth, - Elevated Ig*E*, - *D*ermatologic problems (eczema) - Pulmonary infections - Autosomal DOMINANT

Burn Injury

FIRST DEGREE: EPIdermis INTACT - "Sunburns" - Erythema, warmth, pain SECOND DEGREE: Partial thickness, EPIdermis BROKEN - Increased pain - *BLISTERS* THIRD DEGREE: Full thickness, Burn skin away, THROUGH DERMIS. - *NO pain!* - White, charred flesh - Always surrounded by 2nd degree ------------------------------------- CHEMICAL BURNS - Alkali worse than Acid - NEVER buffer (thermophilic reaction which can burn patient again) - Tx Skin: *Irrigate* - Tx Ingestion: *Serial Exams*....eventually EGD RESPIRATORY BURN - Hot stuff down resp tract - Closed fire, Explosion, Inhalation of smoke or chemicals - Edema can close off airway (Stridor) - Look for soot at nares, or singed nares - Dx: *ABG + O2 + Monitor Peak flows* - Tx: Intubate ELECTRICAL - Struck by lightening - Entrance and Exit wounds - Die from arrhythmia. - Muscle burn but skin looks fine - POSTERIOR dislocation of shoulder - Dx: CK, Creatinine, Rhabdo! - Tx: If rhabdo? *IVF + Mannitol* CIRCUMFERENTIAL - Compromises vascular supply - Dx: Clinical - Tx: Cut the eschar, Send to burn center (Encourage movement so they don't scar up, Early graft, Control pain, Infection prophylaxis w/Topical Abx [Mupirocin v. Silver Sulfadiazine]) -------------------------------------- PARKLAND FORMULA: *4ml x %TBSA x body weight* - Give 50% of fluid back in first 8hr - Other 50% give back in next 16hr Rule of 9's (2nd and 3rd degree ONLY) - Head = front 9, back 9 - Chest = front 9, back 9 - Abdomen = front 9, back 9 - Arms = 9 total (for each arm...so x2) - Legs = front 9, back 9 (for each leg...so x2) +9 - Genitalia = 1 Tx: Fluid resuscitation with *Lactated Ringers* + *FOLEY CATHETER* (to accurately monitor output) - Bc Normal Saline can cause Hyperchloremic Metabolic ACIDOSIS

Malignant Testicular Neoplasms

GERM CELL - Seminoma (Placental ALP, "Fried egg") --> Mcc in men 15-35yo - Nonseminoma --> Yolk Sac (AFP, Schiller-Duval) --> Embryonal Carcinoma --> Teratoma --> Choriocarcinoma (b-hCG) SEX CORD STROMAL - Leydig (increased Testosterone OR *Estradiol*, FSH/LH suppression) --> Men more commonly present w/gynecomastia!!! - Sertoli

VACTERL Syndrome

- *V*ertebral anomalies - *A*nal atresia - *C*ardiac anomalies - *T*racheo*E*sophageal fistula - *R*enal anomalies - *L*imb anomalies

Vaccines for Adults with HIV

!!!!LIVE vaccines only if CD4>200!!!! --> MMR, VZ !!!!*Inactivated* Influenza vaccine for all patients regardless of CD4 count.!!!! They should receive all vaccines an otherwise healthy person receives - Childhood vaccinations (if not then give them) --> !!!!LIVE vaccines only if CD4>200!!!! (x. MMR, VZ) - Hep A for International travel, Men-sex-men, Liver dz - Pneumonia: PCV13...then PPSV23 8wks later...then again in 5yr...then at 65 - *Inactivated* Flu shot - Tetanus: Td q10yr (or if has been 5yr and had high-risk trauma) - Tuberculosis: PPD or Interferon Gamma Quantiferon Assay --> PPD may have false negative though if CD4 counts are low...but not IGQA (NO BCG vaccine!!) - NO HPV >45yo

Adenocarcinoma of the Lung

"A"denocarcinoma Path: NONsmokers, "A"sbestosis Location: Peripherally (w/Puckering and Pain because involves Pleura) Paraneoplastic: *Hypertrophic osteoarthropathy* (digital clubbing + sudden onset arthropathy of wrists and hands) Tx: Chemo/rad/resection depending on stage

Hypersensitivity Reactions

"ABCD" Type I: Anaphylactic, Atopic, IgE mediated Type II: AntiBody mediated Type III: Immune Complex mediated Type IV: Delayed, T-Cell mediated

Speed's Test

"BiSPipital tendonitis" (SP for Speed) Indicates biceps tendon stability in the bicipital groove if no pain when arm flexed, elbow extended, and palm supinated. Isometric force between operator pushing down and patient pushing up.

Spurling Test ("Compression test")

"Bone SPUR in the neck causes radiculitis" TESTING: cervical nerve root compression POSITION: sitting, head side bent to uninvovled side, apply pressure through head straight down, repeat with head bent toward involved (+) TEST: pain and/or paresthesia in dermatomal pattern down arm

Boca's Area

"Broken Boca" - Lesion in *DOMINANT* (usually left) *FRONTAL LOBE* - Broca's aphasia - Broken speech system - Contralateral weakness of face and extremities Between Broca and Wernicke, location is alphabetical, with Broca in the FRONT, and Wernick behind that at TEMPORAL lobe

Features of Malabsorption in Celiac Disease

"Bulky, foul smelling, floating stools" Fat Protein Fe Ca Vitamin D Vitamin K Vitamin A

DiGeorge Syndrome

"CATCH-22" Path: Maldevelopment of 3 and 4 pharyngeal pouches - Chromosome 22q11 deletion Pt: - *C*ardic abnormality (Truncus arteriosus) - *A*bnormal fascies (wide-set eyes, low set ears, micrognathia) - *T*hymic aplasia (absent thymic shadow) - *C*left palate - *H*ypocalcemia/Hypoparathyroidism (tetany/seizures/arrhythmias) - 11;*22* translocation - Lack of T-cells - Underdeveloped Paracortex - Recurrent infection w/FUNGI & PCP Dx: Clinical - CBC w/reduced absolute lymphocytes Tx: IVIG Bridge to *Thymic transplant* - TMP-SMX prophylaxis

Apley Scratch Test

"Can they scratch their back?" Ask pt to touch scapula arm behind back and then over shoulder Difficulty with these motions suggests rotator cuff disorder or adhesive capsulitis

Disseminated Intravascular Coagulation (DIC)

"Consumptive coagulopathy" Path: Significant bleeding causes activation of *Thromboplastin (TF)*, which activates the coagulation cascade. Fibrin clot (being built with platelets) causes bleeding and thrombosis and organ damage. - Can be caused by trauma, sepsis, malignancy, obstetrical complications - *Can see with HEAT STROKE*!!! Pt: Sick as shit (sepsis, ICU, shock) --> Bleeding ("at venipuncture sites") - But also signs of thrombosis --> Clots - Signs of ORGAN DAMAGE (x. reduced urine output) - Associated with *MAHA* --> Anemia --> Elevated LDH --> Elevated Bilirubin --> Schistocytes on peripheral smear - Chronic DIC has time to compensate and produce more coagulant factors (see pic) --> assoc w/PANCREATIC CANCER Dx: CBC w/ low platelets --> Smear w/Shistocytes (after this is how we differentiate from TTP) - ELEVATED PT/PTT - LOW Fibrinogen - ELEVATED D-Dimer Tx: Supportive - Fix underlying disease - Consider *Cryoprecipitate* (clotting factors + fibrinogen + vWF)

Friedreich Ataxia

"Friedreich is Fratastic: he's your favorite FRAT brother, always stumbling, staggering and falling, but he has a BIG SWEET HEART" Path: Autosomal RECESSIVE trinucleotide repeat of GAA causing issue with Frataxin protein (in brain, heart, pancreas) Pt: Progressive symptoms starting in *young adulthood* - DM - HYPERtrophic cardiomyopathy - Degeneration of the spinal tracts (spinocerebellar tracts and posterior columns) - Progressive gait and limb *ataxia* - Loss of *position and vibratory sense* - *Scoliosis* - *Pes cavus* (high-arched feet) - Loss of DTRs - *Cervical spinal cord atrophy* - Dysarthria Dx: Genetic testing Tx: PT & Psychological support ...bc no cure :( - Death by age 40 d/t cardiomyopathy - Survival rarely exceeds 20 years after dx

GLASCOW Coma Scale (GCS)

"Glascow <8, intub8" Eye Opening Response (4pts) Verbal Response (5pts) Motor Response (6pts)

Vertical Supranuclear Palsy

- Dementia - Parkinsons - Inability to look superiorly - Postural instability

False Negative Tuberculin Skin Test (TST)

- HIV *CD4 <200* --> Treat with Anti-retrovirals and then retest - *CKD* --> Negative TST does NOT rule out TB infection!!

Mixed Cryoglobulinemia

"Kind of looks like Henoch-Schonlein but for older, immune compromised patients" Path: Vasculitis characterized by immune complex deposition in small- and medium-sized vessels --> Strongly associated w/*HepC* infection!!!!!, HepB, HIV, Autoimmune diseases, Lymphoproliferative disorders - "Leukocytoclastic vasculitis" Pt: - *Palpable purpura* on LE - Arthralgias - Weakness - Peripheral neuropathy (*Hyporreflexia*) - Elevated LIVER transaminases - *Glomerulonephritis* (HTN, Renal failure, Hematuria, Proteinuria, RBC casts) - Systemic symptoms - *HYPOCOMPLEMENTEMIA* Dx: Assay for *Cryoglobulins* w/ *RF & Polyclonal IgG* - Tissue bx w/*Small vessel leukocytoclastic vasculitis* Tx: Directed at underlying disease (x. HepC)

Korsakoff's Syndrome

"Korsakoff's Konfabulation" Path: Complication of Wernicke's encephalopathy (acute disorder of THIAMINE/B1 deficiency) Pt: (more of the behavioral sx of being drunk) - RETROGRADE *and* ANTEROGRADE amnesia - Intact LONG-TERM memory - *CONFABULATION* - Apathy - Lack of insight - History of alcohol use disorder Dx: Thalami and Corpus callosum involved on brain imging Tx: Basically *IRREVERSIBLE* (unlike Wernicke's) - Recovery is RARE w/Thiamine

Congenital Dermal Melanocytosis (Mongolian Spots)

"Mongolian spots" Path: d/t presence of melanocytes in the skin's dermis Pt: Benign *Flat, blue-gray patches* - over the LOWER BACK and BUTTOCKS - African, Asian, Hispanic - NONtender Dx: Clinical - Nontender - NOT bruises...bruises would be TENDER Tx: Reassurance - Spontaneously resolves over first 10yrs of life.

Neonatal Cephalic Pustulosis

"Neonatal acne" Face and scalp only Pustules Erythematous base Tx: Gentle cleansing with soap and water - Severe? Ketoconazole v. Steroids

Trisomy 18 (Edwards Syndrome)

"PRINCE Edward" *P*rominent occiput *R*ocker bottom feet *I*ntellectual disabiltiy *N*ondisjunction *C*lenched fists w/overlapping fingers Micrognathia low-set *E*ars Horseshoe kidneys 90% die by age 1 Congenital heart disease - MR - *VSD* (holosystolic murmur at left lower sternal border) - ASD - PDA

Spelnomegaly

"Palpable liver edge and spleen tip"

Acute Limb Ischemia

"Requires emergency vascular surgery intervention." Path: ACUTE - Cath? Cholesterol embolism. - A. fib? Embolism. - PVD? Thrombus. Pt: SIX P's - Pain - Pallor - Pulselessness - Paresthesias - Paralysis - Poikilothermia (limb is cold) Dx: GO STRAIGHT TO TREAT!!! - No ABI unless much more mild sx (like claudication w/activity) Tx: - 1st *Heparin* infusion - Then, *Thrombolysis (x. Alteplase)* v. *Surgery* or Embolectomy ABI > 0.9 = normal ABI < 0.5 = severely impaired flow Thrombotic (plaque rupture) more common than embolic (a. fib) cause.

Reye Syndrome

"Reyes and SHINE" Steatosis of liver/hepatocytes (*MICROvesicular*) Hypoglycemia/Hepatomegaly Infection (VZV, Influenza) Not Conscious (Coma) Encephalopathy Path: Aspirin use for VIRAL infection in children --> Encephalopathy and Acute liver failure - Microvesicular fat deposits in liver - Cerebral edema Pt: Hepatomegaly WITHOUT jaundice - Encephalopathy - Cerebral edema - Vomiting - Lethargy - Seizure - Coma - Elevated liver enzymes - *Prolonged PT and PTT* - *HYPERAMMONEMIA* (how you dif from inborn errors of metabolism) - Metabolic acidosis Tx: Supportive

Small Cell Lung Cancer (SCLC)

"S"mall Cell Path: "S"moking Location: "S"entrally - Often presents as HILAR MASS w/LND (see pic) Paraneoplastic: - *ACTH (Cushing)* , - *ADH (SIADH)*, - *Lambert-Eaton* Tx: Chemo + radiation - very responsive compared to other cancers

Squamous Cell Carcinoma

"S"quamous Cell Path: "S"moking Location: "S"entrally - Though ~40% are peripheral - Can make a *Cavitary lesion* on CXR (see pic)!!! Paraneoplastic: *PTHrp (hypercalcemia)* - Hypercalcemia of malignancy - "SCa++amous" Tx: Chemo/rad/resection depending on stage

Modified Well's Criteria

"SHIT PMH" Symptoms of DVT - 3 History of DVT - 1.5 Immobilization >3 days or post OP >4wks - 1.5 Tachycardia - 1.5 PE being #1 dx or equally likely -3 Malignancy - 1 Hemoptysis - 1

Scarlet Fever

"Sandpaper" rash Sore throat. Strawberry tongue not specific (also seen in Kawasaki disease) Anterior lymphadenopathy

Interpretation of Weber & Rinne Tests

"Sensorineural makes sense...." --> Meaning Weber heard best in good ear, and Rinne has "normal" pattern. Normal - Weber midline - Rinne AC>BC bilaterally Conductive Hearing Loss - Weber to *BAD* ear - Rinne BC>AC in bad ear. - Rinne AC>BC in good ear. Sensorineural Hearing Loss - Weber to *GOOD* ear - Rinne AC>BC bilaterally Mixed Hearing Loss - Weber to *GOOD* ear. - Rinne BC>AC in bad ear. - Rinne AC>BC in good ear.

Osteosarcoma

"Think of an osteocod (bonefish) swimming in the sun" Path: MC primary bone tumor in YOUNG BOYS - METAPHYSES of long bones - Associated with *Rb gene* (& Retinoblastoma) - & *TP53* (associated w/Li Fraumeni) Pt: Focal, Atraumatic bone pain - Tender *soft tissue mass* on physical exam - NO fever, weight loss, malaise - Elevated Alk Phos & LDH - *Sunburst pattern* - *Codman's triangle* - "Destruction of the trabecular and cortical bone, with formation of new periosteal bone" - "Periosteal elevation next to an osteolytic lesion" Dx: XRay, MRI, Bx - "Lytic lesion with ill defined margins surrounded by concentric layers of reactive bone" Tx: EXCISION & Chemo

Wallenberg Test

"VALlenberg tests Vertebral artery insufficiency" *Test vertebral artery insufficiency* - supine position flexion pts neck, holding it for 10 sec. then extends the neck holding it for 10 sec, then try rotate left, rotate right, etc. (+) test = pt complains of dizziness, visual changes, lightheadedness, or eye nystagmus occurs *Underberg's test: same thing neck extended w/ head fully rotated to either side, if pt has neuro/vascular symptoms then HVLA contraindicated

Normal Pressure Hydrocephalus (NPH)

"Wet, Wacky, Wobbly" Path: Abnormal accumulation of CSF (often idiopathic) Dx: MRI (shows ventriculomegaly out of proportion to the sulci) - Confirmed w/LP --> Normal!!! opening pressure Pt: - UMN signs - 1st, Wide-based, slow gait... "magnetic gait", like the feet are stuck to the floor - then, Cognitive impairment - Finally, Urinary incontinence (often Urgency) Tx: *High volume CSF removal* - Ventriculoperitoneal shunt is definitive

Wernicke's Area

"What" Wernicke's - Lesion in *DOMINANT* (usually left) *TEMPORAL LOBE* - Difficulty comprehending - Difficulty following commands - Able to speak fluently, though often ramble without concrete meaning Between Broca and Wernicke, location is alphabetical, with Broca in the FRONT, and Wernick behind that at TEMPORAL lobe

Pertussis

"Whooping Cough" Path: Vaccine in early childhood, Booster at 11-12yo - Acquired immunity wanes 5-10 years post-vaccination...so vaccine reduces risk of infection but *can still get infected around 16-22yo* Pt: THREE PHASES Inspiratory whoop, Paroxysmal cough, Post-tussive emesis - PHASE I = Catarrhal phase (looks like a cold...*Low grade temp, Rhinorrhea, Cough*) - PHASE II = Paroxysmal phase (*Intense cough, Inspiratory wheeze*, Hemoptysis from denudation of resp epithelium) - PHASE III = Resolution Dx: Clinical - *Nasopharygneal PCR* testing - *LYMPHOCYTE* predominant leukocytosis!!!! Tx: Supportive + *Erythromycin* - Post exposure prophylaxis? *Macrolide for EVERYONE!! no matter vaccination status*

Calciphylaxis

"calcific uremic arteriolopathy" Path: - Systemic arteriolar calcification - Soft tissue *calcium deposits* w/ local ischemia and necrosis Pt: ESRD on dialysis vs. renal transplant vs. Warfarin use - "painful subcutaneous plaques and nodules that can be violaceous or purpuric" --> progress to ischemic ulcers - mortality is high d/t risk of sepsis - INTACT peripheral pulses (unlike atherosclerotic ischemia) Dx: Calcium x Phosphorus *>55* (think ESRD pattern with tertiary hyperparathyroidism) - HIGH serum PTH - HIGH serum Phosphate - HIGH serum Ca2+ Tx: *IV sodium thiosulfate*

Pemphigus Vulgaris

(+) Nikolsky sign Anti-desmoglein (anti-desmosome) 40-60yo Involves oral mucosa (unlike Bullous Pemph) PAINFUL (not pruritic like Bullous)

Negative Likelihood ratio

(1-sensitivity)/specificity or... FN rate/specificity The likelihood that a negative test result will be obtained in a patient/client with the condition of interest as compared to a patient/client without the condition of interest

Anthracyclins

(Doxorubicin) "*Cardiomyocyte replacement by fibrous tissue*" --> Decline in LV systolic function - Overt clinical heart failure!! - Less likely to be reversible (vs. Trastuzumab which is asymptomatic, d/t "stunning" of cardiac myocytes, and is reversible)

Zollinger-Ellison Management

(Gastrinoma) 1. EGD w/*"Multiple stomach ulcers and thickened gastric folds"* 2. Gastrin level (off PPIs) x1wk - <110? Normal - Between? *Secretin stim test* (inhibits in normal cells, stimulates gastrin release in Gastrinomas) --> Positive? Gastrinoma confirmed. Localize tumor. - >1000? *Gastric pH x1wk* --> <4 pH? Gastrinoma confirmed. Localize tumor. --> >4 pH? No gastrinoma.

Struvite kidney Stones

(Mag, Ammon, Phos) Radioopaque. Caused by urea splitting bact. - *Proteus Mirabilis (mc) --> urine pH >8* - Klebsiella pneumonia Prevent w/Abx. Tx w/surgery bc staghorn and typically huge.

Active Phase Arrest

(aka Prolonged Active Phase) - Stuck in Active Phase of Stage 1. - "Active phase" = 6-10cm dilation with cervical dilation (≥1cm q2h, normally) Path: Taking too long to get from 6cm-10cm dilated - Macrosomia (causes cephalopelvic disproportion) - Epidural does NOT cause Stage 1 arrest, it causes Stage 2 arrest (at 10cm dilation) Pt: Dx: Cervix is UNCHANGED for *≥4 hours* in active phase, despite adequate contractions (*≥200 Montevideo units*) - OR no cervical change for *≥6 hours*, with inadequate contractions Tx: *C-Section*

Human Factors Engineering Strategy

(from most effective to least) Forcing Functions Computerized Automation Environment & Physical Layout Standardization & Simplification Human-Machine Redundancy Reminders, Alerts & Double Checks

Pyelonephritis

*10 DAYS ABX* Path: GNR Pt: - Urinary urgency - Frequency - Dysuria - FEVER - CHILLS - CVA TENDERNESS Dx: UA --> look for WBC CASTS + URINE CULTURE!! (bc course of tx is long) Tx: CEFTRIAXONE IV (for hospitalized pts) - if ambulatory can give CIPRO p.o. - After 48hr with symptomatic improvement can be switched to *Culture guided Abx* *make sure they don't have an abscess after!! via CT!*

US Preventative Task Force Recommendations for Breast Cancer Screening

*50-75yo, q2yr* The USPSTF recommends BIENNIAL screening mammography for women aged 50 to 74 years. † Grade B

Normal Urine Osmol

*<300* = DILUTE Urine specific gravity *<1.006* = DILUTE

Indications for Urgent Dialysis

*AEIOU* Acidosis - I. metabolic acidosis w pH<7.1 refractory to medical therapy Electrolyte abnormalities - sx hyperkalemia: ECG changes or ventricular arrhythmias Ingestion - toxic alcohols (methanol, ethylene glycol) - salicylate - lithium - sodium valproate, carbamazepine Overload - volume overload refractory to diuretics Uremia - Sx - encephalopathy (test q presented with asterixis), pericarditis, bleeding (PLATELET AGGREGATION DEFECT W/ONLY INC BLEEDING TIME IN UREMIA)

No Palpable Presenting Fetal Part

*Abd USD* to determine what's going on - Could be normal d/t contractions, or abnormal and baby is in the wrong position --> Determines route of delivery

Drugs that Effect Warfarin Metabolism

*Acetaminophen* causes interrupt recycling of Vitamin K in the Liver and INCREASE effect of Warfarin (increase INR)

Active vs. Latent Error

*Active*: occurs at level of frontline provider and has immediate impact (e.g. misprograming a pump) --> Fixing targets *Individual* *Latent*: occurs in processes indirect from provider, but does have impact on PT care (e.g. different types of IV pumps used in the same hospital) --> Fixing targets *System*

Brain Lesions & Clinical Presentation

*Anterior Cerebral Artery (ACA)* - Contralateral lower extremity *Middle Cerebral Artery (MCA)* - Contralateral face and upper extremity *Posterior Limb of Internal Capsule* (aka *Lacunar Infarct*): Pure motor hemiparesis, Pure sensory stroke, Sensorimotor, Dysarthria-clumsy hand, Ataxia hemiparesis *Vertebrobasilar System* (brain stem)

Glioblastoma Multiforme (GBM)

*Anterior fossa for ADULTS* Posterior fossa for PEDS Path: Highly aggressive brain tumor in the parenchyma, is a *Stage IV* Astrocytoma (which is staged by degree of anaplasia) - Eats the brain away... - Highly microtic and mitotic - *Ring enhancing lesion* - *Bat's wing deformity* .... is THE ONLY brain cancer that CROSSES MIDLINE!!! Tx: dismal prognosis. <1yr life expectancy.

Warm knee?

*Arthrocentesis*!!!! - You still want to dx it before you treat, even if you think it's Pseudogout. Even if there is no erythema or other sign of infection.

Neurogenic Orthostatic Hypotension

*Autonomic dysfunction* - d/t degenerative changes to autonomic ganglia and CNS nuclei - Seen in patient's with neurodegenerative disease (Parkinson's, Lewy body, etc)

Primary Immunodeficiency Syndromes

*B-Cell Disorders* --> After the first 6 months when mom's Ab's wear off - X-Linked Agammaglobulinemia - Common Variable Immunodeficiency - Severe Combined Immunodeficiency (B&T) - Wiskott-Aldrich Syndrome (B&T) *T-Cell Disorders* - DiGeorge Syndrome - Severe Combined Immunodeficiency (B&T) - Wiskott-Aldrich Syndrome (B&T) *Phagocyte Disorders* - Chronic Granulomatous Disease - Leukocyte Adhesion Deficiency *Complement Disorders* - C1q Deficiency - Terminal (C5-C9) Complement Deficiency - EARLY childhood? SLE, Recurrent sinopulmonary infections - LATE childhood? Neisseria meningitidis *B&T Cell Disorders all get treated with STEM CELL TRANSPLANT*

Maternal Estrogen Effects in Newborns

*Breast hypertrophy* (girls + boys) *Swollen labia* *Physiologic leukorrhea* (whitish vaginal discharge) *Uterine withdrawal bleeding* Tx: *Routine care + reassurance*

Histrionic Personality Disorder

*CLUSTER B* (wild) Path: - MC in women. Pt: - Theatrical - Attention seeking - Hypersexual, - Use of physical appearance to get what they want - Need to be center of attention. - Dramatic - Exaggerated but superfluous emotions (rapidly shifting emotions) - Superficial - Impressionistic speech - Think their relationships with people are more intimate than they really are. - Have trouble when they get older because they can't use their looks. Dx: Persistent pattern of behavior since early adulthood Tx: - Set rules. Insist they are followed.

Borderline Personality Disorder

*CLUSTER B* (wild) Path: Defense mechanism of *SPLITTING* (think self or people are either the absolute best or the worst) - MC in women. - Prior history of childhood trauma common —> esp *Insecure attachment* to primary caregiver Pt: - Frantic efforts to avoid abandonment - Unstable and intense interpersonal relationships - Marked and persistently unstable self-image - Impulsivity - Recurrent suicidal behaviors or threats or self-mutilation - Mood instability - Chronic feelings of emptiness - Chronic loneliness - Inappropriate and intense anger - Transient stress-related paranoia, psychosis, or dissociation (last minutes to hours long) Dx: Pervasive pattern of unstable relationships, self image and affects and marked impulsivity. - *≥5 of features above* - Impulsivity in *≥2 areas* that are self-damaging. Tx: *DBT* (helps w/emotional regulation, mindfulness, distress tolerance) - Set rules and insist they follow (patients will try to change rules and be demanding). - Suicidal attempts may be successful... - Inpatient? See patient as *Treatment Team* to avoid splitting.

Minor Head Trauma

*CT w/o contrast* if... - Altered mental status - LOC - Vomiting - Severe headache - Severe MOI - Signs of basilar skull fracture - Symptoms worsen during observation

Psoriatic Arthritis

*DIP* + PIP joint involvement, Morning stiffness >30min Rash w/ silvery scale on elbows and knees, Nail pitting!!! (>90% of patients) Oncholysis Swollen fingers. --> Dactyitis "Sausage fingers" Pencil in cup deformity Enesthitis (pain at tendon insertion sites) Tx: NSAIDs, Methotrexate, TNF-alpha-i

Solid Liver Masses

*Focal nodular hyperplasia* - Young women - Asymptomatic -aw/anomalous arteries -imaging: arterial flow @ central scar *Hepatic adenoma* -women @ long term Oral contraceptives -+/- hemorrhage/malignant transformation *Regenerative nodules* -acute/chronic liver injury - cirrhosis *Hepatocellular carcinoma* -systemic sx -chronic hepatitis/cirrhosis -high AFP *Liver mets* -single OR multiple lesions -known extrahepatic malignancy

Contraceptive Methods

*HORMONAL IUD* - Thickens cervical mucus and impairs implantation, causes amenorrhea (good for anemia) - Progestin only (Levonorgesterel) - Can last 3 years (Skyla) - v. 5 years (Mirena) - CI in unexplained, abnormal vaginal bleeding *COPPER IUD* - Can last 10 years - Causes heavy menstrual bleeding & cramping - CI in unexplained, abnormal vaginal bleeding *NEXPLANON/IMPLANON* - Can last 3 years *DEPO SHOT* - q3 months - Worse weight gain (~10lbs) - Risk for *loss of bone mineral density*!!! - Medroxyprogesterone *PATCHES* - "Ortho/Evra" - q1 month - Increased risk of DVT/PE *NUVARING* - q1 month - Vaginally inserted *COMBINED OCP* - Good for pathologic states (treating something else) - Not good for patients with medication compliance issues - NO weight gain - Breakthrough bleeding is mc adverse effect - CI if patients have migraines w/AURA (bc increased risk of ischemic stroke) --> dc immediately! - CI if smokes >15 cigarettes per day - Not recommended if smokes <15 cigarettes per day *MINI PILL* - Progesterone only. - Requires daily compliance down to the HOUR!!!

Clinical Characteristics of Major Stroke Subtypes

*Ischemic (THROMBUS)*: Atherosclerotic risks (uncontrolled HTN, diabetes) - Stuttering progression with periods of improvement - Carotid w/>30% stenosis (even greater risk w/>50%) *Ischemic (EMBOLIC)*: A Fib, Endocariditis - Abrupt symptoms - Max at the start *Intracerebral hemorrhage*: Hx of HTN, Coagulopathy, Illicit drugs - Mins --> Hrs - FND --> Increased ICP (how you dif from Ischemic strokes) - *Lacunar infarcts* mc = Putamen (Basal Ganglia, esp *Internal capsule*), Cerebellar nuclei, Thalamus, Pons --> Internal Capsule infarct? Contralateral hemiplegia and hemianesthesia, w/gaze deviation towards lesion *Spontaneous Subarachnoid*: Ruptured berry aneurysm from AVM - Severe HA at onset of neuro symptoms - Meningeal irritation (neck stiffness) - NO FNDs

Rett Syndrome

*MECP2* mutation on X-chromosome GIRLS, 6-18mo *Normal development, then REGRESS* Progressive neurological developmental disorder *Hand-wringing* Intellectual disability --> Autistic features Impaired motor skills Microcephaly Seizures Breathing abnormalities (alternating hyper- then hypo-ventilation) Sleep disorders

Pertussis Postexposure Prophylaxis

*Macrolide for EVERYONE!! no matter vaccination status*

Penetrating Abdominal Trauma

*NIPPLE DOWN* Lower threshold to take someone to surgery for *Laparotomy* than for Blunt Abdominal Trauma... - Anyone w/one or more of the following... --> Hemodynamic instability --> Peritonitis --> Evisceration --> Impalement --> Peritoneal penetration and significant organ injury (based on imaging or wound exploration) --> Blood in rectum --> Blood in NG tube Basically they all go to SURGERY unless clearly stable. --> Even if there is a very small peritoneal puncture and they are otherwise completely stable with good imaging, labs, etc. you can do *Serial abdominal exams*

Congenital Infections

*NONSPECIFIC*!!!! findings (can be seen in any congenital infection): - Hepatosplenomegaly - Jaundice - Blueberry muffin rash - Growth restriction Toxoplasmosis Syphilis - Desquamating rash involving palms and soles, buttocks, legs - Snuffles - Long bone abnormalities Rubella CMV (mc) Herpes HIV Varicella

Pap Smear

*Normal* = Polygonal w/small nucleus - "Glands" w/simple epithelium *Atypical Glandular Cells* --> *≥35yo*, or <35 with risk factors (Obesity, Anovulation)? *Colposcopy + Endocervical curettage + Endometrial Bx* (check everything! Ectocervix, Endocervix, Endometrium) *Endometrial Cells*? - *<45yo* = NORMAL (esp w/menses) - *≥45yo* = ABNORMAL! Need *Endometrial bx* *Atypical Squamous Cells of Undetermined Significance* (ASCUS) = Sign of *HPV* infection!!!, Koilocytes, Bilobed nucleus, Perinuclear halo --> *HPV Cotesting* --> then *Colposcopy* if High-risk HPV (same process as LSIL) *LSIL* = Mild dysplasia, Increased nuclear:cytoplasm ratio, Visible nuclear envelope, Pleomorphism, Dysplasia --> *HPV Cotesting* --> then Colposcopy if High-risk HPV *HSIL* = All the same as LSIL...but worse. Leaning more towards star-shaped. --> NOT preggo? *LEEP* --> Preggo? *Colposcopy* --> then LEEP Abnormality on PAP but normal Colposcopy? Think *Vaginal Cancer* *Carcinoma* = Star shaped, look like "aliens"

Risk Based Ovarian Screening and Management

*OCPs* are PROTECTIVE - Bc they decrease ovulation

Endometrial Polyp

*P*ALMCOEIN Path: Proliferation of *stroma* of endometrium...and glands "go along for the ride" (unlike Adenomyosis or Leiomyoma) Pt: - Women in their 30s-40s - Infertility - Abnormal vaginal bleeding - Intermenstrual bleeding - Regular monthly menses - Physical exam is normal Dx: Saline infused *transvaginal USD* Tx: *Hysteroscopic polypectomy*

Hematologic Manifestations of SLE

*PANCYTOPENIA* (anemia, thrombocytopenia, leukopenia) --> d/t *Peripheral immune-mediated destruction*

Thyroglobulin used as a tumor marker

*PAPILLARY* = mc 85%, Orphan Annie Nuclei, produces *Thyroglobulin* --> Tx: Resection *FOLLICULAR* = looks like normal thyroid tissue, produces *Thyroglobulin*. Spreads hematogenously. --> Tx: Radioactive Iodine Ablation Giving them levothyroxine to replace thyroid also helps promote regrowth of tumor!

Hyperparathyroidism

*PTH likes to rescue calcium from bones and kidneys and ditch Phos* Primary= from autonomous adenoma - PTH secreting adenoma - Pt: Hypercalcemia + pathologic fractures, decreased bone density, brown tumors, HYPERTENSION - Labs w/ increased PTH and Ca2+, and decreased Phos ("kidney" pattern bc PTH elevated) Secondary= Early CKD appropriate response, Malabsorbtion - Impairment of Vit D formation (so can't absorb Ca2+ and Ph, triggering PTH release) - CKD? Labs w/increased PTH, decreased Ca2+ (or normal d/t effects of PTH), *INCREASED* Phos (d/t decreased renal clearance) - Malabsorption? Labs w/increased PTH, decreased Ca2+ (or normal d/t effects of PTH), *DECREASED* Phos Tertiary= from MULTIPLE autonomous adenomas - Inability to make Vit D Dx: Sestamibi parathyroid scan - Primary? ONE large parathyroid gland, other atrophied - Secondary? Creatinine...BUN...eGFR - Tertiary? MANY large parathyroid glands Tx: - Primary & Tertiary? RESECTION...then watch out for HYPOca2+ - Secondary? Ca2+ + VITAMIN D + *CINACALCET* (which mimics Ca2+ so you can decrease PTH)

Seizure vs. Syncope

*Tongue biting* is the most reliable finding to differentiate Epileptic Seizure & Syncope - esp if LATERAL (frontal tongue biting is extremely rare but the may occur with syncope) Long post-ictal period also helps differentiate the two (Seizure has, Syncope does not) Syncope CAN have convulsive arm movements....

Antidepressant Management

*Try a dose for 4-6 WEEKS* *ANXIETY DISORDER*? They're extra sensitive to activating effects of antidepressants. - Start at *half dose* and increase gradually. *EFFECTIVE DOSE*? (length of tx depends on how many MDE they have had, how long episodes have been, suicide attempts, family history, etc) - Only *1 lifetime episode*? treatment for *6 months*, then if remission achieved can taper and stop. - *≥2 lifetime episodes, early onset ≤18yo*? Maintenance antidepressant therapy for *1-3 years*. - *≥3 lifetime episodes, chronic episodes, suicide attempts, severe episodes, strong family history*? *Lifetime* antidepressant therapy. *PARTIAL RESPONSE (25-50%)*? *ADD* "aka augment"... - Antidepressant w/different MOA - 2nd Gen Antipsychotic - Lithium - Triiodothyronine - Pyschotherapy. *ADVERSE EFFECTS* (nausea, diarrhea, headache, increased anxiety, insomnia, somnolence) - During first few weeks of treatment? *Temporarily decrease dose*...these ae often resolve. - If clear they are not tolerating then switch. Become *MANIC*? - STOP MED! --> If they continue to have mania/hypomania when off med, then *Bipolar* and start treatment for this. *FAILED ≥2 medications* from same class? - Switch to different class. *Stop medication for ≥2 WEEKS before starting another one* (avoid Serotonin Syndrome) - FLUOXETINE you must stop *5 weeks* before starting another one!!!! (d/t longer half life) "Flu-Fly-Five"

Breast Feeding Jaundice

*UNCONJUGATED* Path: Decreased feeding --> Decreased activity of bowels --> Reabsorption of bilirubin Pt: Jaundice *<7 day* (how you tell diff from breast milk jaundice) - Decreased stools and urination - Signs of dehydration Tx: Feed MORE (frequency and duration) - q2-3hr, 10-20 minutes at a time for first month of life - Total bili *>20*? Phototherapy - Total bili *>25*? Exchange transfusion Hard to tell apart from Breast MILK jaundice and treatments are different...

Breast Milk Jaundice

*UNCONJUGATED* Path: Milk INHIBITS conjugation for some reason (enzymes in milk) Pt: Jaundice *>7 day* (how you tell diff from breast feeding jaundice) - They are stooling and urinating well - No signs of dehydration Tx: Keep feeding + *HYDROLYZED FORMULA* Hard to tell apart from Breast FEEDING jaundice and treatments are different...

Approach to Adult Cardiac Arrest (ACS)

*WITH PULSE??* If NSR or sinus tachy? --> relax If anything else and NO SX? --> Do nothing...fluids, O2, monitor If anything else and +SX - STABLE? --> Tx: Drugs (Fast&wide w/Amiodarone, Fast&narrow w/Adenosine, Slow w/Atropine, *Afib+CHF w/Amiodarone or Digoxin*, Afib alone w/CCB v. BBlocker) - UNSTABLE? --> Tx: V. Fib w/Shock, FAST hr w/cardiovert & SLOW hr w/pace! *Don't use Amiodarone and Digoxin together, causing Digoxin AE (N/V, cardiac arrhythm, confusion, change in color vision). Decrease Digoxin dose by 25-50%* if plan to use Amiodarone. *WITHOUT PULSE??* 1) 2min CPR 2) Check pulse and rhythm. Shock if Vtachy. 3) etc. (repeat) *Every 2min CPR you do ONE drug.* Rhythms to be concerned about - Vtachy (even if pulseless) or Vfib --> Can shock!!, and alternate between EPINEPHRINE & AMIODARONE - Pulseless electrical activity (PEA) or Asystole --> NO shock, and alternate between EPINEPHRINE & NOTHING....Can look like A.Fib. The key sign is the lack of palpable pulse! - If there is an option to do CPR it is ALWAYS the right answer. Most critical factor determining survival rate is *Elapsed time to effective resuscitation* --> *CPR* (COMPRESSION!!! >> Rescue breaths....untrained individuals are actually advised to do compression-only CPR bc it is shown to be the critical factor here for outcomes) --> *Rhythm analysis* --> *Early defibrillation* (if indicated

Vaccines During Pregnancy

- INACTIVATED Influenza at initial prenatal visit barring allergy to any of its components - Tdap between 27 and 36 weeks regardless of prior vaccination status --> If haven't been vaccinated and already delivered, give in immediate postpartum period. --> Also give to family members who will be in close contact. - Rhogam (Rho(D) Immunoglobulin) ONLY if Rh NEG - Pneumococcal vaccine recommended only if have comorbidities (immunodeficiency, chronic heart or lung disease). - Varicella, MMR, and live attenuated intranasal influenza are NOT advised during pregnancy - Rubella non-immune mothers should receive rubella vaccination AFTER delivery of infant and avoid sick individuals during pregnancy - Women with negative varicella history should undergo serologic testing to confirm IgG. if non-immune should avoid exposure during pregnancy and offered vaccine postpartum.

Congenital Rubella

- Sensorineural hearing loss, - Cardiac defects (Patent Ductus Arteriosis) - Cataracts, - Microcephaly (symmetric growth restriction) - Hepatosplenomegaly. All women tested for rubella immunity at initial prenatal visit. - If nonimmune do NOT give MMR when preggo bc live vaccine and could cause CRS....GIVE MMR POSTPARTUM!

Evaluation of Hyperthyroidism

- most common cause of hyperthyroidism is GRAVES DISEASE I. cause: autoAb to TSH receptor - see diffuse goiter + ocular abnormalities (proptosis, periorbital edema) - understand in radioactive iodine uptake testing: I. low iodine uptake indicates that the hyperthyroidism is occurring due to release of *preformed T4* ii. high iodine uptake indicates that the hyperthyroidism is occurring due to *creation of new T4* - causes of thyroid toxicosis with reduced radioactive iodine uptake - causes of which are differentiated by [thyroglobulin] I. *thyroglobulin high causes include: a. subacute lymphocytic (PAINLESS) thyroiditis b. *subacute granulomatous thyroiditis* (De Quervain's - PAINFUL) c. iodine induced thyrotoxicosis d. struma ovarii - ovarian teratoma - extremely rare ii. thyroglobulin low causes include: a. exogenous levothyroxine uptake*

Palpable Breast Mass

<18yrs: Reassurance + Reevaluation after 1-2 cycles - If persists, *USD* <30yrs: *USD* ...maybe later Mammo - Simple cyst? *FNA*...then RTC in 2 mo for breast exam --> Nonbloody & resolves? No additional management --> Nonbloody & persists? *Core Biopsy* --> Bloody? *Core Biopsy* --> Turbid or purulent? *Culture* - Complex cyst/solid mass? *Core Biopsy* - Large/Suspicious mass? *Excisional Bx* >30yrs: *Mammo* ...maybe later USD - Suspicion for malignancy? *Core Biopsy*

NORMAL JVP

>3cm above sternal angle

CHA2DS2-VASc

0? *NO* anticoagulation 1? Can *consider* Oral anticoagulation or ASA 2? Oral anticoagulation is *recommended*. --> Options include *warfarin, dabigatran, rivaroxaban and apixaban* (NOT heparin or LMWH)!!!!

Management of Patients Leaving AMA

1. Assess decision making capacity -Clearly inform patient of risks of leaving prematurely 2. Provide options for continued care -Provider should continue to act in patient's best interest, including offering appropriate (even if less effective) alternate treatment options

Ocular Manifestations of HIV

1. Cataracts (MC) 2. CMV retinitis 3. HSV Keratitis 3. Uveitis 4. Neuroophthalmic complications

When to Amputate

1. Critical limb ischemia without the ability to perform revascularization (d/t anatomy or comorbidity CI) 2. Unsalvagable lower extremity soft tissue 3. Life-threatening infection (x. gangrene, necrotizing soft tissue)

Evaluation of Thyroid Nodules

1. Get *TSH & Thyroid USD* 2a. NORMAL or ELEVATED TSH (Hypo)? - Consider FNA 2b. *LOW TSH* (Hyper)? - Get *Radionucleotide Thyroid Scan* --> Cold? Consider FNA --> Warm? Treat for Hyperthyroidism Cold/Hypo is more likely to be cancerous. Malignancy signs on USD = Microcalcifications, Irregular margins, Internal vascularity - All nodules *>1cm* with above features get FNA - All nodules *>2cm* should get FNA

Evaluation of Suspected Unstable Aortic Aneurysm

1. Hemodynamically UNSTABLE 2a. AAA known? *Emergency repair* 2b. AAA NOT known? *FAST* USD - You MUST confirm dx before taking them to operating room! If Hemodynamically STABLE can get CT of Abd

Approach to Hypocalcemia

1. Low serum calcium - Confirm with repeat measurement IF ASX (SAME AS W/HYPERCALCEMIA) - *Correct for serum ALBUMIN* or measure ionized calcium (Hypoalbuminemia will cause Hypocalcemia) --> Corrected calcium = serum calcium + 0.8 * (4 - serum albumin) 2. Low magnesium level? (HypoMg2+ causes *resistance to PTH*) - Due to a drug? - Due to recent blood transfusion (Citrate binds Ca2+ and chelates..., Increased volume makes appear low)? - Alcoholic (they have dec Mg2+) i. if yes - treat underlying cause, replete magnesium, IV Ca2+ if sx severe ii. if No - *measure serum PTH* a. if NORMAL or LOW PTH - hypoparathryoidism - surgical (MOST COMMON): parathyroidectomy, thyroidectomy, radial neck surgery - autoimmune: polyglandular autoimmune syndrome - infiltrative disease - mets cancer ,Wilson dz, hemochromatosis - genetic: PTH gene or Ca2+ sensing receptor gene mutations b. if HIGH PTH - Get *Serum 25-Hydroxyvitamin D* - metabolic: Vit D defic, CKD - inflammatory: pancreatitis, sepsis - oncology: tumor lysis syndrome - PTH resistance: pseudo hypoparathyroidism ______________________________________________________ - understand that alcoholics - have HYPOMAGNESEMIA i. hypocalcemia due to hypomagnesemia - refractory to tx w/calcium unless Mg2+ replaced as well. ii. understand that hypomagnesemia - DECREASES PTH SEC + CAUSES RESISTANCE TO PTH FOR unknown reason iii. although PTH levels inc. rapidly after Mg2+ replacement, hypocalcemia takes longer to improve b/c PTH resistance persists despite improvement in Mg2+ levels iv. also oddly enough: despite PTH deficiency, when deficiency is due to Mg2+ deficiency, PHOSPHORUS LEVELS ARE NORMAL OR LOW - understand that hypophosphatemia in presence of hypomagnesemia is a result of that hypomagnesemia and does non itself cause hypocalcelmia

Management of Traumatic Brain Injury

1. Maintain CPP!!! (MAP - ICP) - Maintain MAP (fluids, vasopressors) - Reduce ICP (elevate head, hyperventilate, hypertonic saline, mannitol, sedate) 2. Prevent Intracranial Hemorrhage - Antifibrinolytic therapy (eg. *Tranexamic acid*) --> Within first *3hrs* --> *GCS must be 9-12* - Reversal of preexisting anticoagulation 3. Prevent seizures, control blood glucose, maintain normothermia

Classification of Angina

1. Typical Location (Substernal), Quality (pressure like), Duration (>20 min) 2. Provoked with exercise and emotional upheaval 3. Relieved with Nitro or rest - Classic (3/3) - Atypical (2/3) - Non-Anginal (0-1 / 3)

Splitting of S2

1st Aorta, 2nd Pulmonic Wide Splitting? Delayed RV emptying. - Pulmonic Stenosis - RBBB Fixed Splitting? - ASD Paradoxical Splitting? Delayed LV emptying. - Aortic Stenosis - LBBB

Lithium Toxicity

2 or more: - IRREGULAR COARSE tremor - Siezure - Fasciculations - Altered mental status - Metallic taste - Severe diarrhea - Vomiting Tx: - Mild? *IVF + Electrolytes* - Toxicity and Lithium level *>2.5*? *Hemodialysis* - Lithium level *>4* or Creatinine *>2*? Hemodialysis ADVERSE EFFECTS - HYPOthyroidism (sometimes HYPER) --> Tx: *Levothryroxine* (NOT by dc'ing lithium!!) - Hyperparathyroidism (high Ca2+) - Nephrogenic DI - Kidney injury - Ebstein's anomaly When prescribing, get *UPT, BMP, Ca2+, Cr, Thyroid function test...and ECG if CVD*. --> Then follow *TSH q6-12mo*

Developmental Milestones

2mo - Lift head, Social smile, Coos 4mo - Roll over, Turns to voice 6mo - Sit up, Stranger danger, Responds to name 1yr - Walk, Separation anxiety, 1 word sentences 2yr - Steps, 2 words sentences, 50-200 words, 2-step commands 3yr - Tricycle, 3 words sentences, Draw circle 4yr - Hop, 4 words sentences, Draw cross 5yr - Skip, 5 words sentences, Draw triangle Around 4-5yo develops ability to *Understand other's perspectives*

EKG Rate Interpretation

300, 150, 100, 75, 60, 50

Neonatal Abstinence Syndrome

48-72hr after birth (for heroin) Tx: Try supportive first - Then give Morphine, Methadone, Buprenorphine later as needed

OCP us and Hypertension

5% of patients have elevation in BP on *OCPs* and leads to *OVERT HYPERTENSION* - Risk increases with duration of OCP use. - Risk elevated in those w/Fam hx of HTN, or HTN during prior pregnancy Tx: Try switching to another form of birth control FIRST before trying diet, exercise, meds.

NORMAL LVEF

55-70%

Leukemoid Reaction

A benign leukocytosis (> 50,000) that occurs in response to underlying severe infection/hemorrhage, malignancy, or acute hemolysis. Smear can show - increased bands, - early neutrophil precurors (myelocytes, and metamyelocytes) - granules (Döhle bodies) in the neutrophils. *Increased LAP* (how you differentiate from CML) *Metamyelocytes* > Myelocytes

Acne Mechanica

A form of acne that results from heat, pressure, occlusion, and friction.

Failure Mode and Effects Analysis (FMEA)

A method to analyze reliability problems proactively to avoid negative outcomes - Can be done BEFORE problems arise - Evaluated CAUSES of failures and EFFECTS of failures - Flowcharts of steps necessary to solve hypothetical problems - Something that is developed by the whole healthcare team

Avoidant/Restrictive Food Intake Disorder (ARFID)

A problem with eating/feeding d/t sensory experience of food or concerns of vomiting or choking - Not due to body image concerns - Results in inadequate nutrition or calorie consumption. - Poor growth - Weight loss

Confounder

A third factor that can make it appear that an observed exposure causes an outcome. An unobserved exposure that is both associated with an observed exposure and is an actual cause of an outcome. x. Ice cream sales associated with risk of drowning...They both increase during summer, so summer is the true cause.

Misclassification Bias

A type of bias that occurs when an individual is classified into the wrong category (ex. classifying an individual as a case when in actuality he/she is a control and vise versa).

Mitral Regurgitation

ACUTE MR: - Left Atrial Size = NORMAL!!! - Left Ventricle Size = Normal - Left Ventricular Ejection Fraction = Normal/Increased --> bc takes into consideration ejection forward into aorta and backwards into LA (overall EF is increased because volume is increased) - Left Ventricular Filling Pressure = Increased CHRONIC MR: - Developed countries? mcc is *MVP*!!!! --> "Myxomatous degeneration of mitral valve leaflets and chordae" - Underdeveloped countries? *Rheumatoid arthritis MR/MS* - Left Atrial Size = Dilated - Left Ventricle Size = Dilated - Left Ventricular Ejection Fraction = Decreased --> bc increased wall stress causes contractile dysfunction - Tx: *Surgery if LVEF 30-60%*, REGARDLESS OF SX....also consider if *>60% EF and asymptomatic and just good candidates for surgery* --> If LVEF <30% only do surgery if good candidate for REPAIR (not replacement) --> If MR is secondary to dilated cardiomyopathy, could consider treatment w/BBlocker *Lower threshold for surgery than other valve diseases (x. MR <60% v. Aortic Stenosis <50%) bc regurgitant flow from MR causes OVERESTIMATION of LVEF*

Oxytocin has a similar amino acid sequence to _____ and excessive doses can lead to hyponatremia

ADH --> Can lead to fluid reabsorption --> Cerebral edema & Seizure! Tx: Stop oxytocin & give *3% NaCl slowly*

Transfusion Reactions

ANAPHYLAXIS - d/t IgA - NO FEVER! --> Don't get this confused with other anaphylactic responses, which are usually IgE induced. ACUTE HEMOLYTIC FEBRILE NONHEMOLYTIC URTICARIAL - Preformed IgE against soluble allergen in donated plasma - Onset in hours - Hives - Itching - Tx: Immediate cessation of transfusions + Antihistamines TRALI (Transfusion Related Acute Lung Injury) TACO (Transfusion Associated Circulatory Overload) - Acute dyspnea - Diffuse bilateral infiltrate - JVD PRESENT!!!! (unlike TRALI) - Crackles, rales - EF decreased (unlike TRALI) - BNP HIGH (unlike TRALI) --> basically like TRALI but with signs of fluid overload DELAYED HEMOLYTIC *HYPOCalcemia* can occur d/t *CITRATE* in blood products chelating calcium.

Mediastinal Compartments, Structures, & Masses

ANTERIOR MEDIASTINUM - Thymus - LNDs - Germ Cell Tumors MIDDLE MEDIASTINUM - Pericardium - Heart & Great vessels - Trachea & Main Bronchi - Esophagus - LNDs POSTERIOR MEDIASTINUM - Neural Tissue - Vertebrae - LNDs

Attributable Risk Percent (ARP)

ARP = (risk in exposed - risk in unexposed)/risk in exposed or... *ARP = (RR-1)/RR*

AST / ALT

AST: Found in many places in the body, including Liver, Heart, Kidney, and Skeletal muscle ALT: Found in Liver predominantly, but also Heart Kidney and Skeletal muscle in smaller quantities General rule of thumb... (AST>ALT = Alcohol) (ALT>AST = NAFLD) If they are *elevated*? Get more history. - Medications - Drugs - Alcohol - Recent travel - Sexual contacts - Blood transfusions Tx: Discontinue drugs & alcohol. - *Repeat testing in 6mo*. --> If they persist, you then do further work-up for viruses, NAFLD, Hemochromatosis

NSAIDs during pregnancy?

AVOID in *1st and 3rd* trimesters

Common Measures of Therapeutic Efficacy

Absolute Risk Reduction (ARR) Relative Risk Reduction (RRR) Relative Risk (RR) Number Needed to Treat (NNT)

Relative Risk (RR)

Absolute risk (treatment)/Absolute risk (control) *USE THE "TOTAL" FOR DENOMINATORS on top and bottom*!!!! Used in Cohort studies.

Negative Predictive Value (NPV)

Individuals WITHOUT disease who had NEGATIVE test TN/(TN+FN) *Will INCREASE with DECREASED prevalence of disease*

Skin Conditions & Associated Disease

Acanthosis Nigricans Multiple Skin Tags Porphyria Cutanea Tarda Cutaneous Leukocytoclastic Vasculitis Dermatitis Herpetiformis Sudden Severe Psoriasis Recurrent Herpes Zoster Disseminated Molluscum Contagiosum Severe Seborrheic Dermatitis Explosive Seborrheic Keratoses Pyoderma Gangrenosum

Evaluation of subacute (3-8 weeks) or chronic (> 8 weeks) cough.

Ace-i? Stop Ace-i UACS? Give H1-Blocker Asthma? PFT GERD? PPIs None of the above worked? CXR

Breastfeeding Contraindications

Active untreated TB Maternal HIV infection Herpetic breast lesions Active varicella infection Chemo or radiation therapy Active substance use (tobacco, cocaine, opioids, alcohol) Galactosemia HepB/HepC w/*CRACKED or BLEEDING* nipples --> Otherwise, totally ok to breastfeed

Suicidal Risk Assessment

Active? Plan? Method & Lethality? Preparations? Access? Consider recent stressors. Consider social support.

Antipsychotic Extrapyramidal Effects

Acute Dystonia Akathisia --> *Dose dependent*!! How you dif from psychotic agitation, because akathisia will be worse with increased dose and psychotic agitation will improve with increased dose. Parkinsonism Tardive dyskinesia

Lung Cancer

Adenocarcinoma SCC SCLC Large Cell Carcinoma

Causes of Heavy Menstrual Bleeding

Adenomyosis Endometrial Cancer/Hyperplasia Endometriosis Uterine Leiomyomas (Fibroids) Coagulopathy

Types of Stress Tests

Adenosine --> Causes VASODILATION of coronary arteries, in stenosed arteries this occurs to a lesser extent, so you notice relative decrease in radioactive isotope uptake Dobutamine --> Used in patients who require pharmaceutical stress testing but have CI to vasodilation (x. HYPOtension, Obstructive lung disease)

Community Acquired Pneumonia (CAP)

Admit or not? (MEMORIZE!!!) - CURB65 = Confusion, Uremia (BUN >20), RR>30, BP<90, 65 Age > 65. ...If 0-1, consider outpatient management ...if >1, inpatient management. If was not in hospital or >90 DAYS outside of medical building. - Strep. Pneumo (mcc) - M. Catarrhalis or H. Flu (COPD) - Klebsiella (alcoholics) - Staph. Aureus (post-viral) - Legionella (immunosuppressed) CAP If treating in hospital? CEFTRIAXONE + AZITHROMYCIN If treating at home? AZITHROMYCIN v. DOXY Life threatening B-lactam allergy? MOXIFLOXACIN If worried about MRSA or psuedomon? VANC + PIPTAZO - If can't do Vanc, then LINEZOLID - If can't do Piptazo, then MEROPENAM HCAP/HAP (<90 days from hospital exposure or <48hr admission) --> Tx PIPTAZO + VANCO If HIV+ suspect PCP --> Tx TMP/SMX ± STEROIDS (if low PaO2)

Toilet Training

Age 2-4 Premature initiation can prolong duration of training They're ready to do it when they can: - Walk - Imitate other's actions - Follow 2-step commands - Remove pants - Communicate need to pee or poop - Voluntarily control sphincters Nocturnal Enuresis = Urinary incontinence in children *≥5*

Infection Control Isolation

Airborne Contact Droplet

Immune Thrombocytopenia (ITP)

Aka "Idiopathic Thrombocytopenic Purpura" Path: Autoantibodies are directed against platelet membrane antigens --> destruction of antibody platelet complexes in the spleen - Preceded by *VIRAL* infection - Can be sign of Hep C or HIV (mc secondary causes) Pt: - Mc in children 2-5yo - May be woman w/autoimmune disorder and low platelets. - Low platelets (<100,000) - Purpura - Mucosal bleeding if severe - Prolonged bleeding (skin/mucosal) - Ecchymosis - Petechiae Dx: Dx of exclusion...*When signs and symptoms of other disorders are present, you must r/o those first!* - Thrombocytopenia - PBS is normal (maybe w/some *large platelets*!!! d/t high turnover) - Leukocyte count is normal - Erythrocyte count is normal - Coagulation studies are normal Tx: - Only cutaneous sx? *Observation*, they recover spontaneously in 3 months. - Severe (x. mucosal bleeding)? *Glucocorticoids + Anti-D IG + IVIG* --> "IVIG for ITP" - Intracranial bleeding? *Platelet transfusion* - Chronic, refractory ITP? *Splenectomy*

Upper Airway Cough Syndrome (UACS)

Aka "Postnasal Drip" Path: Cough starts after recent URI Pt: - Cough primarily at night - NONproductive Tx: *Oral H1-Blocker* (even though sedating, have best evidence)...NOT intranasal steroids. That used to be the answer but it has changed. - If don't respond after 2-3wks try imaging, or empiric sequential therapy for GERD, Asthma, etc.

Juvenile Idiopathic Arthritis (JIA)

Aka "Still's Disease" Path: Chronic autoinflammatory condition of childhood - Think of it like RA for kiddos. Pt: - Intermittent joint pain - Swelling - Morning stiffness in joints *worse in AM* (mc knees or ankles, hips are rarely involved) - Present for *≥6wks* - SYSTEMIC: --> Adolescent girls. --> Evanescent rash (pink or *salmon colored*) --> >2wks fever, --> Hepatosplenomegaly, --> Lymphadenopathy --> Arthritis ≥1 joint. NOT migratory arthritis (like Acute Rheumatic Fever) - POLYARTICULAR: --> Toddlers or adolescents (bimodal) --> ≥5 joints (Ankles, Knees, Wrists, Elbows, Joints of hands) --> Symmetric --> Maybe *UVeitis* - OLIGOARTICULAR: --> <5 joints --> Toddler --> Maybe *UVeitis* Dx: - Positive ANA - Elevated WBC - *Elevated Platelets* (thrombocytosis) - Elevated ESR - Decreased RBC Tx: First line = *Naproxen* - Second line = *Methotrexate* - Maybe DMARD - Consider Joint injections (steroids)

Ureteral Stones (Kidney Stones)

Aka Kidney Stones Aka Nephrolithiasis Pt: - Colicky flank pain, - Radiates to groin, - Microscopic hematuria, - NO fever Dx: UA w/hematuria!!! --> then *NONCONTRAST CT* --> stone or hydroneph seen? then KIDNEY STONE! - Preggo? *USD of kidneys and ureters* Tx: Stone? --> then STRAIN URINE (to find out what type of stone) --> then MODIFY RISK FACTORS (based off type of stone) --> RTC 6 weeks for screen --> - <10mm? (home) *PO Fluids + Pain Meds + Tamsulosin* - ≥10mm, or do not pass in 4-5wks? *Urology consult* - Fever, Acute renal failure, Complete obstruction, Pain, N/V? *Hospitalize + Urology consult*. Types: - *Calcium oxalate (80%)* - Struvite (Mag, Ammon, Phos) - Uric acid - Cysteine

Renal Tubular Acidosis (RTA)

All cause Non-Anion Gap Metabolic Acidosis d/t loss of HCO3 TYPE 1 RTA - Distal tubule (so acidification is off) - Impaired H+ excretion --> *Urine pH is >5.5* (characteristic!) - HYPOK+!!!! d/t reduced reabsorption (rare situation where K+ and H+ are not moving together) - Associated w/*Sögrens Syndrome* TYPE 2 RTA - "Fanconi Syndrome" - Proximal tubule (so distal acidification intact) --> Think of sketchy drawing with mario-looking cart and two tubes --> Urine pH is <5.5 - Impaired HCO3 reabsorption - HYPOK+!!! (spent banana peels on the ground) TYPE 4 RTA - Reduced Aldosterone activity - Impaired H+ and K+ excretion in the Collecting duct - HYPERK+ - Urine pH is <5.5

Differential Diagnosis of Dementia Subtypes

Alzheimer: early, insidious, short term memro loss - Language deficits, spatial disorientation - later= personality changes Vascular: stepwise decline, early executive dysfunction - deep white matter changes on neuroimaging Frontotemporal: early personality issues - apathy, disinhibition, compulsive behavior - frontotemporal atrophy on imaging Dementia with lewy bodies: VISUAL hallucinations, spontaneous parkinsonism, fluctuating cognition NPH: ataxia, incontinence, dialted ventricles Prion Disease - Rapid - Behavioral changes - Myoclonus

Amikacin

Aminoglycoside - Bactericidal, irreversible inhibitor of 30s ribosomal unit. - Useful for G- AEROBES - *Renal TOXIC* so must monitor - AE: Ototoxicity, Nephrotoxicity, NM blockade - CI: Pregnancy & Myasthenia gravis

Medications to Avoid in Myasthenia Gravis

Aminoglycosides Fluoroquinolones Magnesium *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* Muscle relaxers THEY TRIGGER MYASTHENIC CRISIS

Per-Protocol Analysis

An analysis of patient outcomes based only on those subjects who completed ALL aspects of the protocol. Also called on-treatment analysis. - If pt's drop out early you don't include them in study (Opposite of Intention to Treat Analysis)

Subgroup Analysis

An analysis that examines whether statistical results are consistent for different subsets of the sample (e.g., for males and females). - Happens AFTER study is complete

Informed Consent

An ethical principle requiring that research participants be told enough to enable them to choose whether they wish to participate. - When life saving procedure is necessary in an emergency setting and person not able to give consent, can give treatment. --> (x. Bicycle courier in major MVA says "No tube" then becomes unconscious) - Ideally you want informed consent, and informed refusal. "Informed" Discussion: - Diagnosis - Recommended treatment & risks and benefits - Treatment alternatives & risks and benefits - Risk of no treatment

Basic Criteria to Establish Causality

Analogy Biological gradient Biological plausibility Coherence Consistency Experimental evidence Specificity Strength of association Temporality

Common Cognitive Errors in Medicine

Anchoring Availability Confirmation Framing

Eating Disorders

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Cerebral Stroke Patterns

Anterior Cerebral Artery (ACA) - Contralateral lower extremity Middle Cerebral Artery (MCA) - Contralateral face and upper extremity Dx: CT of the head w/o Contrast + CTA of Head/Neck - If negative then MRI.

Myocardial Infarction Location Based on Coronary Vessel Location

Anterior MI ("widow-maker") - LAD - ST elevation in V1-V6 (some or all) Inferior MI - RCA (or LCX...less common) - ST elevation in II, III, AVF Remember: Reciprocal (opposite) leads from infarct may have ST depression.

Hashimoto's thyroiditis

Anti-TPO Abs

Absolute Contraindications to Combined OCPs

Antiphospholipid Antibody Syndrome --> NO estrogen or systemic progesterone (x. Depot)!!! - Give *Copper IUD* Same applies to other High Risk patients. - Even Progesterone can be too much of a risk.

Speech Sound Disorder

Articulation and phonemic based speech disorder when speech errors persist beyond a certain age, the errors can be segmental or super segmental

Yergason's Test

Assess the stability of biceps tendon in bicipital groove - pt flexes elbow to 90 while physician grasps elbow w/ one hand and wrist other pull and physician resists supination of forearm + external rotation of shoulder (+) Test = pain as biceps tendon pops out of bicipital groove --> *SLAP Lesion* v. *Biceps Tendon*

Chronic Hepatitis C

Associated w/ PORPHYRIA CUTANEA TARDA (PCT) - Skin rash in sun exposed areas Extrahepatic manifestations: - Arthralgias - Fatigue - PCT - Elevated Transaminases - Mixed cryoglobulinemia syndrome --> Palpable purpura --> Glomerulonephritis --> Low complement - Lichen planus

Radial Nerve

At risk to damage with *MIDSHAFT HUMERUS* fractures, as it sits in the spiral groove along the humerus --> causes Wrist drop

Postoperative Pulmonary Complications

Atelectasis Bronchospasm Pneumonia PREVENT? - PREoperative *Physical therapy* (to strengthen inspiratory muscles) - Smoking cessation *<8 weeks before surgery* - PPV for COPDers POSTop - POSTop pain control, Deep breathing exercises, Directed coughing, Early mobilization, Incentive spirometry

Pulmonary Auscultation Examination Findings

Atelectasis, trachea TOWARDS - think of condensed lung tissue pulling trachea Tension pneumothorax & pleural effusions, trachea AWAY

Neurofibromatosis Type I

Autosomal DOMINANT - Mutation in NF1 tumor supressor gene *Neurofibromin* - Chromosome 17 Cafe au last spots (not on face), --> "Darkly pigmented macules with smooth borders" Lisch nodules multiple Neurofibromas (nerve sheath tumors) Pheochromocytoma *Optic gliomas* - can cause blindness *Seizures* Learning disabilities Clustered freckles, especially in the axillary and inguinal

Water Soluble Vitamins

B1 (Thiamine) B2 (Riboflavin) B3 (Niacin) B6 (Pyridoxine) B9 (Folate) B12 (Cobalamin) C (Ascorbic acid)

Benign Breast Disease

Breast cysts - solitary well circumscribed mobile mass - +/- tenderness - Simple and asymptomatic? Observe - Simple and tender? *FNA* --> Nonbloody & resolves? No additional management --> Nonbloody & persists? *Bx or image* --> Bloody? *Bx or image* Fibrocystic changes - multiple, diffuse nodulocystic masses (*cord like thickening*) - *bilateral, nonfocal premenstrual tenderness* - common in *women of reproductive age* *due to fluctuating estrogen + progesterone during menstrual cycle* - *NSAIDs + OCPs = tx* - cyclic premenstrual tenderness Fibroadenoma - solitary, mobile, and well circumscribed mass - cyclic premenstrual tenderness Fat necrosis (can look like cancer on imaging and PE!!) - *post trauma/surgery* - *firm + irregular mass* "spiculated" "calcifications" - +/- ecchymosis, skin/nipple retraction - Bx w/*Fat globules and foamy histiocytes*

Fetal Heart Rate (FHR)

BASELINE - Average FHR rounded to increments of 5 beats/min observed during a 10 minute period of monitoring - Baseline variability? Fluctuations of >2 cycles per minute --> Minimal = < 5 BPM --> Moderate = 6 to 25 BPM (*reassuring*) --> Marked = > 25 BPM - Causes: --> Fetal metabolic acidosis, --> CNS depressants, --> Fetal sleep cycles, --> ongenital anomalies, --> Prematurity, --> Fetal tachycardia, --> Preexisting neurologic abnormality, --> Normal, --> Betamethasone - *Persistently minimal or absent FHR variability appears to be the most significant intrapartum sign of fetal compromise* FETAL TACHYCARDIA - Mean FHR *>160* bpm - Causes: --> Maternal fever (mc intraamniotic infection) --> Fetal HYPERthyroidism --> Fetal tachyarrhythmia (usually > 200 BPM with abrupt onset little to no variability), or SVT (200-240 BPM) --> Beta AGONISTS --> Fetal anemia FETAL BRADYCHARDIA - Mean FHR *<110* bpm - Causes: --> Heart block, (La/SSB, Ro/SSA) --> Fetal HYPOthyroidism --> Beta BLOCKERS --> Occiput posterior or transverse, --> Fetal compromise ACCELERATIONS - Prolonged acceleration: Increase in HR lasts for 2-10min. - Absence of accelerations for more than 80 minutes correlates with increased neonatal morbidity. - Episodic patterns: NOT associated with uterine contractions . - Periodic patterns: Associated with uterine contractions. DECELERATIONS - EARLY Deceleration: Occurs WITH contraction (≥30s) - LATE Deceleration: Occurs AFTER contraction (≥30s) - VARIABLE Deceleration: Shorter deceleration, may be with or after contraction (<30s) --> Tx: *Amnioinfusion* (CI with prior hx of uterine surgery!!!!) --> If signs of Uterine Rupture? Skip Amnioinfusion and go straight to *C-Section* - Prolonged deceleration: Lasts ≥2 min --> Causes: Maternal hypotension, uterine hyperactivity, cord prolapse, cord compression, abruption, artifact (maternal heart rate), maternal seizure - Tx: *Place patient on side, DC oxytocin, Correct hypotension, IV hydration.* --> Associated with tachysystole (>5 contractions in 10 minutes)? *Terbutaline + O2* --> If late decelerations persist for more than 30 minutes despite the above maneuvers, fetal scalp pH is indicated. - Scalp pH > 7.25 is reassuring - pH 7.2-7.25 may be repeated in 30 minutes. - Deliver for pH < 7.2 or minimal baseline variability with late or prolonged decelerations and inability to obtain fetal scalp pH. --> Consider *immediate C/S* for late decelerations, not improving on conservative measures, and not 10cm dilated. *VEAL-CHOP* - *V*ariable deceleration: *C*ord compression - *E*arly deceleration: *H*ead compression - *A*cceleration: *O*K! (we like this) - *L*ate deceleration: *P*lacental insufficiency

Causes of Hyperandrogenism in Pregnancy

BILATERAL ovarian masses or NONE? Observe, should resolve after pregnancy. UNILATERAL ovarian mass? Surgery in 2nd trimester. Placental Aromatase Deficiency Luteoma (*solid*) Theca Lutein Cyst (*cysts*) --> Hydatidiform mole v. Multiple gestation Sertoli-Leydig Tumor

Management of Breast Pain

BILATERAL, CYCLIC, DIFFUSE? - Mass? Imaging - No? Observe (Supportive bra + NSAIDs) UNILATERAL, NONCYCLIC, FOCAL? - Mass? Biopsy - No? Imaging --> Bx if abnormal --> Observe if not

Immunization Schedule

BIRTH: Hep B 2 MONTH: Hep B2, RV, DTaP, Hib, PCV, IPV 4 MONTH: RV, DTaP, Hib, PCV, IPV 6 MONTH: Hep B3, RV, DTaP, Hib, PCV, IPV + Hep B + Influenza Yearly 12-15 MONTHS: DTap, Hib, PCV, MMR, Varicella, Hep A1 4-6 YEARS: DTaP, IPV, MMR, Varicella 11-12 YEARS: TDaP, 3 dose HPV, Dose I meningococcal (booster at 16) HIGH RISK - MCV4 at 9 months, PPSV at 2-3 years

Weight Loss Medication

BMI ≥30 BMI 25-29 w/weight related complications Tx: - Orlistat - Liraglutide - Bupropion/Naltrexone - Phentermine/Topiramate

Norovirus v. Rotavirus

BOTH cause diarrhea and vomiting Norovirus? Adults Rotavirus? Unvaccinated kiddos <2

Bacterial Causes of Diarrhea

Bacillus cereus Staph aureus Clostridium difficile Clostridium perfringens Salmonella Vibrio vulnificus Escherichia coli - EHEC? Dx: Shiga toxin in stool (yes, Shiga) Shigella Campylobacter

Torus Palatin

Benign bony growth on the midline suture of the hard palate. - CONGENITAL ABNORMALITY Tx: Surgery for those who are symptomatic

Galactocele

Benign milk retention cyst - "Soft mobile nontender subareolar mass" Dx: *USD* Tx: *Ice packs + Supportive bra* - If symptomatic can consider Drainage

Acute Myeloid Leukemia (AML)

Blasts, Neutrophils, Cancer of blood Pt: Acute presentation (bone pain, fever, infection), ~67 years old, w/exposure to BENZENE or RADIATION - May have had CML and is now experiencing BLAST CRISIS - "You can get AML from CML, so CML must come first in age" - Can just have fatigue and sx related to ≥ 1 cytopenia (d/t bone marrow infiltration) --> Leukocytes can vary widely and may be LOW or >100,000. - *APL* associated w/DIC (thrombocytopenia) --> *PANCYTOPENIA* - Elevated *LDH* Dx: Blood Smear (shows BLASTS!!!!!!!....not just myelocytes or promyelocytes, that would be CML) --> Bone Marrow Bx (w/ >20% *myeloBLASTS*) --> *(+) MPO* Tx: *ATRA (Vit A) if M3 variant (Auer rods)* - If not? Chemo!!

Subgaleal Hemorrhage

Bleeding between the periosteum of the skull and the galea aponeurosis. - CAN CROSS suture lines. (compare to cephalohematoma) - See swelling on top of baby's head. - maybe BRUISING present on skin Rupture of the *emissary veins* (can occur during delivery) Can be fatal. Monitor serial HEMOGLOBIN for continued bleeding

NO NSAIDs with

Blood thinners!!!! - ASA - Clopidogrel - NOVAC - LMWH - Warfarin - Heparin

Hypothermia

Bradycardia can be symptom of hypothermia. Tx: Treat HYPOTHERMIA first!! Should resolve the other abnormalities. - MILD: Passive external heating (remove wet clothes, give blankets) - MODERATE: Active external heating (warm blankets, warm baths, warm IV infusion) - SEVERE: Active internal heating (warmed pleural or peritoneal fluid, warmed humidified oxygen)

Breast Feeding Benefits and Contraindications

Breastfed infants have LOWER rates of *otitis media, gastrointestinal, urinary tract, and respiratory infections* - Improved OVERALL immunity Mothers should exclusively breast feed until *6 MONTHS*

Differential Diagnosis of DSM5 Psychotic Disorders

Brief Psychotic Disorder Schizophreniform Schizophrenic Schizoaffective Delusional Disorder

Central vs. Peripheral Cyanosis

CENTRAL - Seen on lips, tongue, nail bed - Warm extremities - D/t significant amount of deoxygenated hemoglobin in the blood --> In neonate indicates possible congenital heart dz PERIPHERAL - Bluish discoloration on extremities only - Cool extremities - D/t increased O2 extraction from sluggish blood flow (oxygenation is normal)

Approach to Hyperbilirubinemia in Adults

CONJUGATED bilirubinemia - Hepatitis (various kinds) - Dubin-Johnson - Rotor Syndrome - Cholestasis - Malignancy - PBC - PSC - Choledocholithiasis UNCONJUGATED bilirubinemia - Crigler-Najar - Gilbert Syndrome - Reduced uptake - Overproduction NORMAL AST/ALT/Alk Phos? --> Inherited bilirubin metabolism disorders (Gilbert, Crigler-Najar, Rotor, Dubin-Johnson) ELEVATED AST/ALT, Normal Alk Phos? --> Intrinsic liver disease (Viral hepatitis, Hemochromatosis) ELEVATED Alk Phos, Normal AST/ALT? --> Intrahepatic cholestasis, Biliary obstruction

Criteria for extubation readiness

CRITERIA - pH >7.25 - Adequate oxygenation (PaO2≥60) on minimal support (FiO2 ≤40%) and PEEP ≤5cm H2O!!!!!! - Intact inspiratory effort and sufficient mental alertness to protect the airway Spontaneous breathing trial should be attempted prior to extubation - If maintain normal ABG can extubate. Want to extubate as soon as possible bc ventilation associated w/adverse effects etc If prolonged intubation (>7-10days), consider tracheostomy...

Cerebrospinal Fluid Analysis

CSF Findings/Analysis of CSF BACTERIA - High protein - Low glucose - SUPER high WBCs (>1000) neutrophils FUNGUS (& TUBERCULOSIS) - High protein - Low glucose - High WBCs lymphocytes VIRUS (& RMSF, Lyme's) - Mild protein - Normal glucose - Elevated WBCs lymphocytes HERPES ENCEPHALITIS - HIGH protein - Normal glucose - Elevated WBCs lymphocytes - *HIGH RBCs*!! (reflects temporal lobe hemorrhage) GUILLAIN-BARRE - SUPER high protein - Normal glucose - Normal WBCs

Pneumonia on steroids

CXR may be negative d/t immune suppression If you have strong suspicion, get *CT of Chest*

Causes of Hemoptysis

CXR to r/o Malignancy

Abortion Types

Can ONLY be considered abortion if *<20 weeks gestational age*!!!!!!!!!!!!!!!!!!!!!! MISSED abortion - Baby died but mom's body isn't recognizing - NO passage of contents - OS is CLOSED - USD w/DEAD BABY - Tx: *MISOPROSTOL* --> then OXYTOCIN to induce delivery and/or D&C - F/up *Fibrinogen* weekly bc coagulation issues can develop THREATENED abortion - *a little vaginal bleeding* - NO passage of contents - OS is CLOSED - USD w/LIVE baby INEVITABLE abortion - NO passage of contents yet - OS is OPEN - USD w/DEAD baby...but could be living and on its way out - Tx: --> Hemodynamically unstable? *D&C* --> Hemodynamically stable? *Misoprostol* v. *Expectant* INCOMPLETE abortion - (+) passage of contents - OS is OPEN - USD w/RETAINED PARTS - Tx: Gently remove products of conception with forceps (if you can see them), then D&C COMPLETE abortion - (+) passage of contents (previously passed) - OS is CLOSED - USD is EMPTY RECURRENT abortion - *≥3* spontaneous abortions *in a row*. *Decreasing* B-hCG indicates FETAL DEMISE - NOT mole. *All Rh- mothers need to be given RHOGAM at 28 weeks (and within 72 hours of delivery if baby Rh+)* If there are retained products of conception after abortion or D&C, a UPT will be (+)!!

Nonhodgkins Lymphoma (NHL)

Can achieve remission but returns in 10 years :( - Die from lymphoma related illness (-) B-Symptoms Stage IIB or WORSE Spreads hematogenously *Burkitt's Lymphoma* --> STARRY SKY pattern Extranodal disease... Tx: *Rituximab alone v. RCHOP*

Infective Endocarditis (IE)

Can mimic practically any disease. Path: 75% of patients with IE have valvular disease (Mitral, MVP particularly, is mc). Intravascular catheters and IVDU can also cause. - HEALTHCARE? *Staphylococcus aureus* --> even w/IV drug users, NOT STAPH EPIDERMIS!!! - INTRAVASCULAR CATHETER? *Staph epidermidis* - DENTAL WORK or Respiratory tract incision and Bx? *Streptococcus viridans* (Mutans, Sanguinis, Mitis, Oralis, Sobrinus) --> Must have underlying valve defect like mitral stenosis - RECENT UTI or BILIARY INFECTION? *Enterococcus faecalis* - COLON CANCER or IBD? *Strep Bovis* --> Follow up with *Colonoscopy* afterwards!! Pt: - New holosystolic murmur at apex (any of the above bugs can cause) --> If IVDU then systolic murmur at lower left sternal border (Tricuspid) ACUTE? probably *Staph or Strep*!!! - Pt: --> CHF --> Bacteremia --> Toxic --> NO Rheum features bc too soon - Dx: Abx w/ Blood cultures until (-) SUBACUTE? probably *Strep Viridans, HACEK*!!! - Pt: --> Fevers on and off, --> Weightloss --> Malaise --> Myalgias --> Arthralgias (looks like Rheumatoid) --> Positive RF --> Elevated ESR --> Normocytic anemia --> New regurgitant murmur --> Glomerulonephritis d/t immune complex deposition --> Janeway lesions --> Osler nodes --> Roth spots (hemorrhages) on retina --> Septic emboli (lungs, spleen, brain) .....can see "Cavitary lesions" d/t *Staph Aureus* etc. ......can see "Multiple ring enhancing lesions" in brain - Stroke-like symptoms (from emboli in brain) - Osteomyelitis - Septic arthritis - Kidney infarction - Dx: Blood cultures until (+) --> then Abx Dx: *Blood cultures (x3 from three dif spots) + TEE* - MRI w/Multiple Ring-enhancing lesions *UNILATERALLY* (how dif from Toxoplasmosis) *DUKE'S CRITERIA* Definite dx? *2 MAJOR* or *1 MAJOR + 3 MINOR* or Possible dx? *1 MAJOR + 1 MINOR* or *3 MINOR* MAJOR - Sustained bacteremia (Strep, Staph, HACEK) - Endocardial involvement by echo (vegetation present) - New valvular regurgitation MINOR - Risk factors (IVDA, Hx of endocarditis, Prosthetic valves), - Fever (>38C, or >100.4F) - Vascular complications (R Heart = Pulm emboli. L Heart = Janeway lesions, Splinter hemorrhages, Septic emboli, Acute limb ischemia) - Rheumatologic complications (Roth spots, Osler's nodes, Glomerulonephritis) Tx: 4-6 weeks abx (think about everything in terms of Vanc + Gent) - Native valves? *Vancomycin* (no Gent) - New (<60d) prosthetic? *Vanc + Gent + Cefepime* - Old (>60d) prosthetic? *Vanc + Gent + Ceftriaxone* - Inbetween aged prosthetic? *Vanc + Gent* - Subacute? *Gent + Ceftriaxone* (no Vanc) ...do *SURGERY* when... - CHF (Mcc of death!!!) - Vegetation >15mm - Vegetation >10mm + embolism (most of the time stroke and MI are contraind for surgery, but NOT in IE) - High risk of embolism - Abscess - Difficult to treat pathogens (x. Fungus) - Localized extension of infection *NO Abx Prophylaxis* for people with valve abnormality undergoing dental procedures. Unless.... - Prosthetic valve - Prior hx of IE - Heart transplant

Durable Healthcare Power of Atorney

Can only make decisions on patient's behalf if patient is comatose, or severely cognitively impaired

Hypokalemic, Hypochloremic Metabolic Alkalosis

Caused by - Severe vomiting Labs - Serum: *INCREASED HCO3*, Decreased Cl- - Urine: Decreased Na+, Decreased Cl- Initiated by loss of gastric H+, worsened by hypovolemia-induced activation of RAAS, and perpetuated by profound total Cl- depletion leading to hypochloremia and impaired renal HCO3- excretion (bc without H+ there isn't a buffer to convert HCO3-) Volume loss leads to increased aldosterone secretion, which reabsorbs Na+ at expense of excreting K+ and H+, worsening Alkalosis and causing HYPOKalemia. Tx: *NORMAL SALINE* - Repletion of volume and Cl- w/ normal saline corrects metabolic alkalosis (saline responsive)

UNILATERAL Watery Rhinorrhea

Caused by *CSF Rhinorrhea* --> Evaluate for prior hx of head trauma (esp skull base) - Tends to increase with bending over, bearing down - Salt or metallic taste - Tx: Inpatient (conservative tx) bc at risk for meningitis UWorld doesn't think anything else can cause unilateral watery rhinorrhea...not even cocaine.

Cranial Nerves and their locations

Cerebrum - Olfactory nerve (CN I) - Optic nerve (CN II) originate Midbrain - Trochlear nerve (IV) comes from the posterior side of the midbrain. Midbrain-pontine junction - Oculomotor (III). Pons - Trigeminal (V). Pontine-medulla junction - Abducens (VI), - Facial (VII), - Vestibulocochlear (VIII). Medulla oblongata - Posterior to the olive: glossopharyngeal (IX), vagus (X), accessory (XI). - Anterior to the olive: hypoglossal (XII).

Characteristics of Ulcerative Sexually Transmitted Diseases

Chancroid (H. Ducreyi) - Makes you "cry" (painful) - Multiple deep ulcers - *Gray-yellow exudate* - LNDs that produce *PUS* Genital Herpes (HSV) - Painful - No exudate - Tender LNDs - Vesicles --> MULTIPLE Ulcers - *Sterile pyuria* - Painful urination as urine flows over ulcers Granuloma Inguinale - PainLESS, beefy red, friable ulcers - NO swollen lnds!!. - Tx: Azithromycin Syphilis - If suspect encephalitis need CSF RPR - PainLESS ulcer - PainLESS LNDs Lymphogranuloma Venereum - Small, painless ulcers - PainFUL coalesced LNDs ("buboes")

Nephrotic Syndrome

Characterized by: 1. Proteinuria 2. Hypoalbuminemia 3. Edema 4. Hyperlipidemia & Lipiduria 5. *HYPERCOAGULATION*! Risk of thromboembolic complications!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Tara, Remember for God's sake. (d/t loss of Protein C, S, and Antithrombin III in the urine) --> *Renal Vein Thrombosis*, Pulmonary Embolisms, DVTs MC Diseases: - Minimal Change Dz (kiddos) - *Amyloidosis* (d/t Rheumatoid Arthritis, Multiple Myeloma, etc.) - Focal Segmental Glomerulosclerosis (AA, Hispanics, HIV, heroin) - Membranoproliferative Glomerulonephritis (tram track, complement overactivation, Hep B and C) - Membranous Glomerulopathy (MC for caucasians, SLE, Hep B and C, NSAIDs) - Mesangial Proliferative Glomerulonephritis

Differential Diagnosis of Chest Pain

Coronary Artery Disease Pulmonary/Pleuritic Aortic Gastrointestinal/Esophageal Chest Wall/Musculoskeletal

Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication: adults aged 40 to 75 years with no history of cvd, 1 or more cvd risk factors, and a calculated 10-year cvd event risk of 10% or greater

Check Lipid Panel *50-75yo, q3-5yr* The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when ALL!!! of the following criteria are met: 1) they are aged 40 to 75 years; 2) they have 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. - Just being diabetic makes you meet this criteria.... *** If they're YOUNG and DO NOT meet any of the CVD concerns above but have HYPERLIPIDEMIA, can treat them with meds OTHER THAN STATIN if they seem to be more tailored to that person's lipid issue!!! (x. Fenofibrate - for super high TG reduction!) Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults aged 40 to 75 years. See the "Clinical Considerations" section for more information on lipids screening and the assessment of cardiovascular risk. Grade

Twins

Chorion = Placenta Amnion = Sac Zygote = Baby Dif sex? *Dizygotic* (came from two eggs) w/Dichorionic and Diamniotic - Associated risks: Preterm, Malpresentation, C/S - It is possible to have dizygotic twins of same gender but on the test, this is how they will differentiate, bc in real life you won't know until birth --> *LAMBDA SIGN* Same sex? Look at # of placentas. - 2 Placentas? *Monozygotic* (one egg) *Dichorionic* (two placenta) and *Diamniotic* (two sacs) --> Associated risks: Identical, Preterm, Malpresentation, C/S --> *LAMBDA SIGN* - 1 Placenta? Look at presence or absence of septum. -- Septum (2 sacs)? *Monozygotic* (one egg) *Monochorionic* (one placenta) and *Diamniotic* (two sacs) --> Associated risks: Twin-twin transfusions (one twin takes more of the blood and becomes bigger but has more bilirubin so does poorer), Identical, Preterm, Malpresentation, C/S --> *T SIGN* -- NO septum (1 sac)? *Monozygotic* (one egg) *Monochorionic* (one placenta) and *Monoamniotic* (one sac) --> Associated risks: Conjoined twins, Cord entanglement, Twin-twin transfusions, Identical, Preterm, Malpresentation, C/S --> Manage INPATIENT at *28 weeks* onwards, --> Delivered PRETERM at *32-34 weeks* More than 50% of all twin deliveries deliver before week 37!!

Clinical Manifestations of Trace Mineral Deficiencies

Chromium Copper Iron Selenium Zinc *Zinc and Copper compete for absorption in GI*

Thyroiditis

Chronic Autoimmune Thyroiditis Painless Thyroiditis Subacute Thyroiditis

Hypertensive Nephrosclerosis

Chronic HTN can cause hyaline arteriolosclerosis (also more common in DM, and African American individuals) - *SHRUNKEN kidneys*!!! (how dif from AA amyloidosis) - mild proteinuria - Otherwise bland UA - Elevated Cr and BUN Irreversible azotemia, anemia, CKD develop over time. - In contrast to bilateral renal artery stenosis, which can be treated

Common Causes of Steatorrhea

Chronic Pancreatitis Pancreatic Cancer Small-bowel Crohn Bacterial Overgrowth PBC PSC Surgical resection of ileum Celiac Disease AIDS Giardiasis Whipple Disease Zollinger-Ellison Medication

Hypertensive Disorders of Pregnancy

Chronic hypertension (before 20wk) Gestational hypertension (after 20wk) Preeclampsia (after 20wk) Eclampsia (after 20wk) Preeclampsia superimposed on chronic HTN

Venous Ulcer

Chronic lower extremity edema and stasis dermatitis - MC *Pretibial* or *Above medial malleolus*

Diabetic Ulcer

Chronic unnoticed trauma due to peripheral neuropathy, and poor wound healing. - MC on *SOLES of feet under metatarsal heads* and at the *tops of the toes*

Chronic Myelogenous Lukemia (CML)

Chronic, Mature cells, Neutrophils Pt: Asymptomatic w/elevated WBC, ~47yo - "You can get AML from CML, so CML must come first in age" - PRIAPISM!!!! in men Dx: Differential --> Bone marrow bx --> *Philadelphia Chromosome (9:22) aka BCR-ABL* - *Myelocytes* > Metamyelocytes - Elevated WBC >100,00 - Thrombocytosis *LAP score LOW* (how you differentiate from leukemoid reaction)...d/t cytochemically abnormal neutrophils Tx: *Imatinib* - Cancer will eventually escape drug and cause BLAST CRISIS (CML --> AML)

Platinum-Based Chemotherapy

Cisplatin Carboplatin AE: (dose dependent) - *Irreversible* Sensorineural hearing loss --> d/t loss of hair cell on organ of corti - Tinnitus - Imbalance - Peripheral neuropathy

Muscular Dystrophies

Classic Myotonic Becker (is "better") Duchenne With *WADDLING* gait (d/t gluteal muscle weakness)

Temporality of Different Study Designs

Clinical Trial Prospective Cohort --> Uses *Relative Risk*, Starts with RF and works forwards to Dz Retrospective Cohort --> Uses *Relative Risk* Case-control (starts with *Dz or No Dz* ONLY one that does this! and works backwards to RF) --> Uses *Exposure Odds Ratio* Cross-sectional (starts with RF or No RF and works forwards to Dz, or looks at them all simultaneously) --> Uses *Prevalence Odds Ratio*

Seborrheic Keratosis (SK)

Clinical: • Tan to dark black papules -Middle-aged to older pts- head, neck, and trunk • 1 mm to several cm in diameter/sharp demarcation • Smooth to verrucoid texture Histopath: • Benign squamoid and basaloid proliferation with acantosis, hyperkeratosis, papillomatosis, and horn pseudocysts • Basal layer hyperpigmentation -Infiltrating lymphocytes in the dermis and epidermis Note: • Most common human neoplasm • Sign of Leser-Trelat- sudden eruption of SKs in persons with concomitant cancer, most commonly adenocarcinoma of GI tract

Childhood-Onset Fluency Disorder (Stuttering)

Communication disorder of childhood marked by frequent and pronounced verbal dysfluencies, such as repetitions of certain sounds.

Sternal Dehiscence

Complication of cardiac surgery - Two approximated edges of the bony sternum separate - Patient has clicking with chest movement, mild pain, and instability Tx: URGENT *Surgical exploration* + *Sternal fixation* - You worry about loose bone or wires damaging heart!!!

Pressure Ulcer

Constant pressure causes necrosis of the overlying skin - Nonblanchable erythema - MC over *BONY PROMINENCES* - When unstageable, can look similar to arterial ulcer, but location will be how you differentiate Tx: Readjust patient positioning every few hours. - Heels? *Place pillow under legs* to relieve pressure - Open ulcer? *Moist* dressings

Progestin Source During Pregnancy

Corpus Luteum is the source of progesterone up *until week 8-10* - After that, Hcg from placenta takes over If corpus luteum has to be removed *BEFORE WEEK 10*?? --> You have to supply mom with *progesterone*, otherwise pregnancy is at high risk of loss - This can be dc'd AFTER WEEK 10

Common Causes of Diarrhea in Patients with AIDS

Cryptosporidium (also seen in non-HIV patients w/traveler's diarrhea) - Spread through water, animal contact, person-person - *CD4 <180* - Prolonged *Severe watery diarrhea*, low grade fever, weight loss - Dx: O&P w/Modified acid-fast stain Microsporidium/isosporidium - *CD4 < 100* - *Fever is rare*, weight loss, crampy abdominal pain, watery diarrhea Mycobacterium Avium Complex (MAC) - *CD4 < 50* - Watery diarrhea - COUGH - *HIGH FEVER > 102.2* - Weight loss CMV - *CD4 < 50* - *Frequent, small volume diarrhea* - *Hematochezia (only AIDS diarrhea w/blood)* - *Abdominal pain* - Low grade fever, weight loss - *Tx = Ganciclovir* UWORLD STATEMENT: *any patient with HIV who has bloody diarrhea + CD4<50 should have COLONSCOPY WITH BX to look for CMV. ANY PT WITH ACTIVE CMV NEEDS OCULAR EXAM TO R/O CONCURRENT RETINITIS*

Direct Inguinal Hernia

D/t *Weakness of conjoint tendon* or *Weakening of the inguinal canal floor* During repair you worry about injury to - Ilioinguinal nerve - Genitofemoral nerve

Laparoscopic CO2 Insufflation

D/t *peritoneal stretch receptors* response is *increased VAGAL tone* Pt: - Bradycardia - AV Block - Asystole - HYPERtension

Cardiorenal Syndrome (CRS)

DECREASED CO means DECREASED fluid going to kidneys, which activates RAAS system --> Aldosterone increases Na+ uptake and therefore water a well (increase PRELAOD) --> Angiotensin II causes *EFFERENT* renal arteriole constriction (increases AFTERLOAD)

Disclosing Medical Errors

DO NOT use medical jargon. Apologize.

Medications to Avoid in G6PD Deficiency

Dapsone Mesalamine Methylene Blue Nitrofurantoin Pegloticase Phenazopyridine Quinine Rasburicase Sulfa Drugs

Obstetric Complications of Hypertension

Decreased placental perfusion seems to be at the root of it all... MATERNAL - Superimposed preeclampsia - Cesarean delivery - Abruptio placentae - Postpartum hemorrhage - Maternal mortality FETAL - Fetal growth restriction ± *oligohydramnios* - Preterm delivery - Intrauterine fetal demise - Perinatal mortality

Postpartum Encephalopathy

MC w/cardiac surgery Onset in the *immediate* post-operative period

Duke's Criteria

Definite dx? *2 MAJOR* or *1 MAJOR + 3 MINOR* or Possible dx? *1 MAJOR + 1 MINOR* or *3 MINOR* MAJOR - Sustained bacteremia (Strep, Staph, HACEK) - Endocardial involvement by echo (vegetation present) - New valvular regurgitation MINOR - Risk factors (IVDA, Hx of endocarditis, Prosthetic valves), - Fever (>38C) - Vascular complications --> R Heart = Pulm emboli. --> L Heart = Janeway lesions, Splinter hemorrhages, Septic emboli, Acute limb ischemia - Rheumatologic complications (Roth spots, Osler's nodes, Glomerulonephritis)

Epidural Anesthesia

Delivered to L2-L5 Causes *HYPOtension* d/t VASODILATION and VENOUS DILATION - Prevent w/aggressive IVF prior to placement

Basophilic Stippling

Deposits of lead in RBCs Seen in: - Lead poisoning - Thalassemia - Alcohol abuse

Grave's Disease

Diffusely enlarged goiter TRAbs

Active Phase Protraction

Dilation *<1cm/2hr* - MCC *Cephalopelvic disproportion* (Late-term, Malposition, Maternal obesity) --> Or Inadequate contractions... - Active phase is 6-10cm, with normal dilation ≥1cm/2hr - Epidural does NOT cause Stage 1 arrest, it causes Stage 2 arrest. Tx: *Oxytocin* if contractions <200MVEs

RAAS System (Renin-Angiotensin-Aldosterone System) Medications

Direct Renin Inhibitor (Aliskiren) - Prevents conversion of Angiotensinogen to Angiotensin I - Decreases serum Angiotensin II concentration - Decreases Aldosterone production Angiotensin Converting Enzyme Blocker (ACE-i, "-pril") - Prevents conversion of Angiotensin I to Angiotensin II - MOA: *Reduces glomerular hydrostatic pressure* by vasodilating the efferent arteriole....but the reducing of hydrostatic pressure part is what prevents damage to the kidney (x. DM) Angiotensinogen II Receptor Blocker (ARBs, "-sartan") - Serum Angiotensin II concentration is NORMAL, but blocked from causing effects on receptor

Berkson Bias

Disease studied using only hospital-based patients may lead to results not applicable to target population

Psoriasis Nails

Distal onycholysis/nail pitting.

Clinical Trial Phases

Does the drug *SWIM* - Preclinical: No humans. - Phase I: Safe (Toxicity, Max tolerated dose, AE, Pharmacokinetics, Pharmacodynamics) --> SMALL study - Phase II: Work (Efficacy, Optimal dosing, AE) --> SMALL study - Phase III: Improvement (compared to another med OR placebo) --> LARGE study - Phase IV: Market (Longterm AE after being on market) --> LARGE study

Drug-Induced Immune-Mediated Hemolytic Anemia

Drug coats RBC and causes IgG mediated hemolysis in spleen (EXTRAVASCULAR) Drug triggers immune complexes and causes complement-mediated hemolysis (INTRAVASCULAR) Called the "hapten model" - *Penicillin, cephalosporins* mcc - hydrocortisone Pt: Would have no prior hx of anything like this and drug triggers. - Anemia, - Indirect bilirubin w/jaundice, - Splenomegaly, - Abdomen or back pain - Dark urine - (+) Coombs test Tx: Discontinue offending drug

Postmenopausal Bleeding

Dx: - *TransVAGINAL USD* (not Transabdominal USD) --> >4mm endometrial lining is abnormal - OR *Endometrial Bx* (equally acceptable) - AND!!! *Pap testing for cervical cancer*

Causes of Hyperandrogenism in Women

Dx: *Serum DHEAS + Testosterone* --> Elevated Testosterone? Ovary --> Elevated DHEAS? Adrenal - THEN AFTER chemically confirmed, can get *CT* PCOS Nonclassic CAH Ovarian/Adrenal Tumor Hyperprolactinemia Cushing Syndrome Acromegaly

Congestive Heart Failure Exacerbation

Dx: CXR, ECG, BNP, Troponin, PCWP - If neg? Not HF, think of something else - If ECG + Troponin positive? MI --> MONABASH Tx: LMNOP Lasix Morphine Nitrates O2 Position

Treatment for Hypertension (JNC8 Guidelines)

Dx: First, get *Ambulatory home measurements* if possible. Then treat that. - Ambulatory readings monitor for 24-48hr - Home device BP monitor for 1 week, bid (morning and evening). - If can't do any of the above, then in-office readings x3, each a week apart. - If LVH, signs of end-organ damage, or systolic BP >180, or diastolic >120, can make diagnosis on the spot. Tx: Heart Failure w/reduced Ejection Fraction (CHF)? - *Beta blocker (metoprolol, carvedilol, bisoprol), Acei/Arb, Eplerenone*!!! --> BBlockers are CI only in bradycardia (<60), Symptomatic hypotension, Second or third degree heart block, Asthma, or Hx of reactive airway disease - They all have mortality benefit! Stroke? Acei/Arb + HCTZ

Acute Liver Failure

Dx: Requires three things.... - Grade 3 *hepatic encephalopathy* (asterixis, somnolence, disorientation) - *INR > 1.5* (PT >100s) - *Liver enzymes in 1,000s* Signs of kidney failure and rising bilirubin can also be sign but are not diagnostic

Infectious Bloody Diarrhea

E. Coli (O157:H7) Shigella --> *Seizures*!! Campylobacter Salmonella (may not be bloody) Tx: *Supportive care*!!! - Unless they appear really sick, then give them Abx like Ciprofloxacin (increases risk of HUS so we try to avoid)

Pseudothrombocytopenia

EDTA-dep Ab against platelets *in vitro* normal pt (asymptomatic) But platelet count is LOW --> bc they clump together in the dish accurate platelet counts can be obtained in tubes without EDTA

Duty to Treat

EMERGENCY DEPARTMENT SETTING (EMTALA) A code of medical ethics that provided guidelines for the physician-provider relationship, emphasizing the duty to treat a patient - If patient has a *life-threatening condition* they MUST be treated...even if they are racist and offensive and there is another provider who could take over.

Antipsychotics

FIRST GENERATION: (D2 blocking = *mesolimbic* system --> Dopamine seems to cause Positive symptoms) - *Haloperidol* is considered FIRST LINE!! --> High risk of extrapyramidal symptoms (EPS = acute dystonic reaction, akathisia), consider *LONG ACTING INJECTABLE if issues with compliance and tolerate oral well*, Strongest - *Fluphenazine* --> High risk of EPS, Stronger - *Chlorpromazine* --> Cholestatic jaundice, Weaker - *Thioridazine* --> Weaker. SECOND GENERATION (serotonin 2a and D2 blocking --> Serotonin seems to cause Negative symptoms) - *Ziprasidone* --> Low metabolic risk profile (consider for DM patients), Low risk of EPS, *QTc prolongation* at higher doses. - *Aripiprazole* --> Partial AGONIST and full ANTAGONIST at dopamine receptors, so has Low metabolic risk profile (consider for DM patients), Low risk of EPS, Lowest risk of hyperprolactinemia - *Lurasidone* --> Low metabolic risk profile (consider for DM patients), Low risk of EPS - *Risperidone* --> Strongest dopamine blocking effects of the second generations (EPS!!), highest risk of hyperprolactinemia, therefore strongest *teratogenic, galactorrhea, and menstrual irregularity* effects. - *Quetiapine* --> Lowest potency dopamine blocking effects of the second generations, Lowest risk of hyperprolactinemia, Prolonged QTc (>450ms), Somnolence. - *Olanzapine* --> Highest risk of weight gain and metabolic ae!! - *Clozapine* --> MOST effective, Decreases SI, High metabolic risk profile, Virtually NO risk of EPS, *Seizures*, Myocarditis, and pt Must have *failed ≥2 other antipsychotics d/t risk of agranylocytosis* Dopamine blocking... *Nigrostriatal* pathway? EPS *Tubuloinfundibular* pathway? Gynecomastia, Galactorrhea, Amenorrhea, Infertility *Mesolimbic* pathway? Reward center. Formulations: - *ORAL* (if compliant): Any atypical - *INTRAMUSCULAR* (if noncompliant and agitated): *Olanzapine v. Haloperidol* - *DEPO*...LONG ACTING! (injection if chronically noncompliant): *Haloperidol, Fluphenazine, Risperidone, Paliperidone, Olanzapine, Aripiprazole* - *ORAL DISSOLVING TABLETS* (if unable to swallow): *Olanzapine v. Risperidone* LABS - Get *BMI monthly* - Get *Fasting plasma glucose and lipids, BP, waist circumference at baseline, 4mo, and then annually*.

Complications of Infant of Diabetic Mother

FIRST TRIMESTER (makes sense bc this is when these major components of development occur) - Congenital Heart Disease - Neural Tube Defects - Small Left Colon Syndrome - Spontaneous Abortion SECOND/THIRD TRIMESTER - In utero? Fetal hyperglycemia & Fetal hyperinsulinemia - By the time of birth? --> Increased metabolic demand --> Fetal hypoxemia --> Erythropoiesis increased --> *POLYCYTHEMIA* (d/t increased fetal metabolism and mom's poor perfusion of placenta) --> Organomegaly --> Neonatal HYPOglycemia (bc all the extra sugar from mom is no longer there and the pancreas is trained to work overdrive) --> Macrosomia --> Shoulder dystocia --> Brachial plexopathy --> Clavicle fracture --> Perinatal asphyxia --> *HYPOCALCEMIA* d/t transient PTH suppression

Antidepressants

FIRST-LINE - *Bupropion* --> Norepinephrine and dopamine reuptake inhibitor, Stimulating effects, Smoking cessation, Weightloss, No sexual ae, CI in seizures and eating disorders. - *Mirtazapine* --> Serotonergic and noradrenergic activity, Sedating, Increases appetite (weight gain) - *Fluoxetine* --> Stimulating effects, longer half life. 5 week wash out period when switching meds. Used for kids and Bulemia. "Flu-Fly-Five" - *Citalopram* --> Dose-dependent prolongation of QT*c* (avoid w/recent MI) - *Sertraline* --> Low risk of adverse drug interactions. Used for preggo. - *Venlafaxine* --> Tachycardia, Hypertension (not recommended after recent MI), acts like SSRI at low doses and SNRI at high doses. - *Vortioxetine* --> Serotonin modulator TREATMENT RESISTANT OPTIONS - *Phenelzine* --> For *atypical depression*, MAOI. AE include Weight gain, Dietary restrictions, Hypertensive crisis, Increased risk of serotonin syndrome - *Amitriptyline* --> TCA, Sedating, Cardiotoxicity, Danger with overdose - *ECT* --> For *Psychotic features, Emergency* (pregnancy, refusal to eat or drink, imminent risk for suicide). NO absolute CI!! AE include increased risk of CVD, MI, Stroke, Brain aneurysm, Space-occupying lesion. *<25yo? Associated w/increased risk of suicidal THOUGHTS* which needs to be weighed against the risk of COMPLETED SUICIDE in untreated patients - Benefits for moderate to severe depression outweighs the risks - Closely monitor pts

Neonatal Pustular Melanosis

Face White PUSTULOUS spots Become hyperpigmented macules No erythematous base

Milia

Face White keratin-filled spots No erythematous base

Type II Error (beta)

False *NEGATIVES* - The SMALLER the sample size the smaller the *POWER* (and larger the confidence interval range) and the MORE likely you will identify Type II error (fail to see a connection between things when there is one). - Study does not find statistically significant difference, even though one exists Smaller sample sizes are less likely to find differences between groups.

Type I Error (alpha)

False *POSITIVES* - The GREATER the sample size the greater the *POWER* (and smaller the confidence interval range) and the MORE likely you will identify Type I error (see connection between things when there is not one). - Study finds statistically significant difference even though one does not exist Larger sample sizes are more likely to find differences between groups.

Inherited Hyperlipoproteinemias

Familial Chylomicronemia Familial Hypercholesterolemia Familial Dysbetalipoproteinemia Familial Hypertriglyceridemia

Prescription Drug Misuse

Features - Age <45 - Psychiatric disorder - Personal or family hx of substance use disorder - Legal hx Tx: Reduce risk by - *Checking prescription drug monitoring* before each appointment - *Random UDS* - *Frequent follow-up visits*

Influenza

Fever + Cough + *Myalgias* - Myalgias is what separates flu from other similar diseases Dx: Flu swab Tx: - For NO risk factors? SYMPTOMATIC v. OSELTAMVIR if <2 days of sx - For RISK FACTORS (*>65yo, chronic medical problems, preggo*)? *OSELTAMIVIR* no matter how many days of sx - Do not give influenza vaccine until sx abate

Atrioventricular Block

First Degree - PR prolongation - Tx: Observation Mobitz Type I Second Degree (Wenkiiiiibach) - Can be seen in endurance athletes - Prolonging PR interval, then dropped QRS (longer longer longer drop) - ASYMPTOMATIC - Tx: Observation Mobitz Type II Second Degree - Constant PR interval w/randomly dropped QRS - SYMPTOMATIC (Fatigue, Chest pain, Dyspnea, Light headedness, Syncope) - Risk of cardiac arrest. - Tx: Pacemaker Third Degree - No relation between P and QRS waves - Tx: --> Unstable? *Atropine* --> Still unstable? *Transcutaneous Pacemaker* --> Still unstable? *Dopamine* --> Signs of heart failure? *Dobutamine*

Intubation

For UPPER AIRWAY (when closing, or can't be controlled) NOT for Lower Airway (x. Bronchospasm from allergic reaction)

Medical Interpretor

Formal service preferred. If patient is clearly sick, formal service is not working, and staff speak language? can use them. Children can only act as interpretor in urgent situations.

Resumption of Postpartum Menstruation

Formula feeding? 8-14 weeks postpartum Exclusively breast feeding? >6mo postpartum

Differential Diagnosis of Regurgitation & Vomiting in Infants

GERD (Physiologic v. Pathologic) Milk Protein Allergy Pyloric Stenosis

Skin Conditions and Associated Diseases

GI malignancy - Acanthosis Nigricans - Explosive onset of Seborrheic keratoses Insulin resistance - Multiple Skin Tags - Acanthosis Nigricans HepC - PCT - Cryoglobulinemic vasculitis - Lichen planus Celiac's Dz - Dermatitis Herpetiformis HIV - Sudden severe Psoriasis - Recurrent Herpes Zoster - Disseminated Molluscum - Severe seborrheic dermatitis - Sudden severe Tinea Corporis Parkinson Dz - Severe seborrheic dermatitis IBD (Crohn/UC) - Pyoderma gangrenosum

Myopathy Differential

GLUCOCORTICOID-INDUCED MYOPATHY POLYMYALGIA RHEUMTICA (PMR) INFLAMMATORY MYOPATHIES (Polymyositis/Dermatomyositis) STATIN-INDUCED MYOPATHY HYPOTHYROID MYOPATHY (or HYPERthyroid) POLYMYALGIA RHEUMATICA

Lower Extremity Alignment

Genu Varum NORMAL until 2yo

Elderly woman w/new onset abdominal pain and normal colonoscopy?

Get *Abdominal USD* to r/o Epithelial Ovarian Cancer

Confidence Interval (CI)

Given a sample from a population, the CI indicates a range in which the population mean is believed to be found. Usually expressed as a 95% CI, indicating the lower and upper boundaries. - Larger range of CI indicates larger range of possible effects - Smaller range of CI indicates smaller range of possible effects USING ODDS RATIO OR RELATIVE RISK? - CI that includes 1? --> No difference between groups - CI that does not include 1? --> Significant DIFFERENCE between the groups COMPARING AVERAGE BETWEEN GROUPS? (x. ANOVA) - CI that includes 0? --> NO difference between groups - CI that does not include 0? --> Significant DIFFERENCE between the groups

Enteral Nutrition

Giving nutrients into the GI TRACT through a feeding tube Promotes gut integrity (delay 72hr if hemodynamically unstable d/t concerns of perfusion of gut)

Total Parenteral Nutrition (TPN)

Giving nutrients through a catheter inserted into a VEIN - Use for those who do not tolerate EN or can't get enough nutrients from EN Associated w/liver dysfunction and increased mortality in burn patients GREATEST RISK? *Central-Line Associated Blood Stream Infection* - Staph epidermis (Coag-neg staph) --> May not cause fever!!! - Staph aureus - Klebsiella - Pseudomonas

Post-Strep Glomerulonephritis (PSGN)

Glomerulonephritis Hematuria after an upper respiratory infection *10-20 days* after URI *Serum complement levels are LOW* (unlike IgA Neph) --> *Hypocomplementemia* Subepithelial humps of C3

Hawthorne Bias

Group being studied changes behavior d/t knowledge of being studied

Local Vascular Complications of Cardiac Catheterization

HEMATOMA - May or may not have mass - *NO* BRUIT!!! PSEUDOANEURYSM - Bulging, *pulsatile* mass - *SYSTOLIC* bruit ARTERIOVENOUS FISTULA - *NO* mass. - *CONTINUOUS* bruit - *Palpable THRILL* - Weak distal pulses of the extremity --> Worry about HIGH OUTPUT HEART FAILURE!!! (bc blood is shortcutting the circulation back to heart), limb ischemia, limb edema - Dx: Duplex *USD*

Hazard Ratio

HR = (Hazard rate in intervention group)/(Hazard rate in control group) HR < 1? Intervention is LESS likely to experience adverse event than control. HR = 1? Hazard rate of event is same in both groups. HR > 1? Intervention is MORE likely to experience adverse event than control.

Infectious Genital Ulcers

HSV - Painful - No exudate - Tender LNDs - Vesicles --> MULTIPLE Ulcers - *Sterile pyuria* - Painful urination as urine flows over ulcers Chancroid (H. Ducreyi) - Makes you "cry" (painful) - Multiple large, deep ulcers - *Gray-yellow exudate* - LNDs that produce *PUS* - Tx: Azithromycin Treponema Pallidum - If suspect encephalitis need CSF RPR - PainLESS ulcer - PainLESS LNDs Lymphogranuloma Venereum (C. Trachomatis) - Small, painless ulcers - PainFUL coalesced LNDs ("buboes")

Where POTASSIUM GOES...

HYDROGEN GOES...

Brain lobes: major functions

Hemineglect --> D/t lesion in *NONDOMINANT PARIETAL* Lobe. (i.e if right handed, lesion is on RIGHT)

Risk Factors for Colon Cancer

Hyperinsulinemia (DM, Obesity) increases IGF-1, which inhibits colorectal epithelial cell *?

Elevated B-hCG (x. Hydatidiform Mole, Multiple gestation) can cause ______.

Hyperthyroidism --> Labs look like subclinical Hyperthyroidism (elevated Free T, Low TSH....but still in normal range) (B-hCG directly stimulates TSH Receptors to produce more free T) Elevated estrogen also stimulates synthesis of TBG, causing less Free T, so body produces more.

Uric Acid Stones

Hyperuricemia Gout, High-purine diets, Cancer chemotherapy Acidic urine (x. chronic diarrhea) Tx: *Alkalinizing urine* (potassium bicarb v. potassium citrate)

Hemodynamic Measurements in Shock

Hypovolemic Cardiogenic (Think: Right ventricular failure) Obstructive (Think: PE) Distributive When L-sided PRELOAD and PCWP are discordant (i.e. Preload decreased and PCWP increased) think *Cardiac Tamponade*

Radioactive Iodine Uptake Patterns

INCREASED RAIU Graves Toxic Multinodular Goiter Toxic Nodule DECREASED RAIU Painless (Silent) Thyroiditis Subacute (de Quervain) Thyroiditis Amiodarone-induced Thyroiditis Surreptitious Intake Struma Ovarii Iodine-Induced Thyroid Cancer Mets

Routine Prenatal Care

INITIAL VISIT - *INACTIVATED INFLUENZA VACCINE* (safe during every trimester and during breastfeeding --> increased morbidity d/t flu while preggo, so vaccinate them!!) - Tetanus vaccine - RhD - Hgb/Hct, MCV - HIV, VDRL/RPR, HBsAg - Rubella, Varicella immunity - Urine culture - 24hr urine collection for protein ONLY if at risk for preeclampsia (HTN, DM, multiple gestation) - Trichomonas ONLY if HIV (+) - Gonorrhea/Chlamydia screening *ONLY* if *high risk* - Pap test ONLY if indicated - EARLY GTT if BMI >25 AND!!!, prior hx of GDM or 1st degree relative w/GDM - Start Aspirin (12-16wks) if at risk for preeclampsia 24-28 WEEKS (2nd trimester screen "blood, sweat, and tears") - Hb/hct (blood) - Glucose (sweat) 50mg - Rh ab screen in Rh (-) (tears) 36-38 WEEKS - Group B Strep

Diaper Dermatitis

IRRITANT CONTACT DERMATITIS - Skin breakdown from exposure to urine, stool - MC diaper rash - "Erythematous papules and plaques" - *SPARES* skin folds - Tx: *Topical barrier* CANDIDA DERMATITIS - Yeast superinfection of irritant contact dermatitis - Second mc diaper rash - "Beefy-red confluent rash" - *INVOLVES* skin folds w/satellite lesions - Tx: *Topical antifungal* (x. nystatin)

Management of HSIL

If *PREGNANT* you will do COLPOSCOPY!!!! - Then after consider LEEP if not satisfactory...but try not to (see pic?) - You don't go straight for LEEP (like you would if she was not preggo and had HSIL/CIN3) If PREGNANT and HIGH GRADE FEATURES on cervix? - You can go straight for *Cervical Bx* Unsatisfactory Colposcopy? (entire transformation zone not visualized, or glandular cells visualized) *Endocervical Curretage* (DO NOT do this while preggo) NEGATIVE margins w/cervical conization? *Cotesting at 1 & 2 yr* POSITIVE margins w/cervical conization? *Repeat conization* v. *Hysterectomy* (depending on what fertility is preferred)

Benign vs. Pathologic Murmurs

If intensity *Grade >1-2*, it's pathologic If DIASTOLIC murmur, it's pathologic If HOLOsystolic, it's pathologic. Benign maneuvers are early or mid-systolic in timing and they decrease with maneuvers that decrease venous return. Dx: *Echocardiogram*

Ascites

If new onset.... "SANGUINEOUS" = Bloody "SEROUS" = Straw color "SEROSANGUINEOUS" = Both bloody and yellow Dx: Paracentesis w/ - *Cell count & differential* --> to r/o spontaneous bacterial peritonitis (confirmed w/ PMN cell count >250) - Fluid color assessment - Total protein count - *Serum-ascites albumin gradient (SAAG)* --> Serum albumin - ascites albumin --> SAAG >1.1 indicates PORTAL HTN --> Increased hydrostatic pressure --> Ascites! - Cytology --> if concerned about malignancy - Bilirubin --> if concerned about perforated biliary duct or bowel - Glucose & LDH --> can indicate malignancy, bowel perf., or infection (but are less specific than Cell Count & DIff.) If d/t *CIRRHOSIS*? Usually clear, yellow-tinged, with low protein (<2.5g), and high SAAG (>1.1g/dL) - Tx: *Furosemide + Spironolactone*, Alcohol abstinence, Sodium restriction

Approach to Patient with Pulmonary Embolism

If patient has LIKELY PE based on Well's Criteria, and are in *MODERATE TO SEVERE DISTRESS* --> Give *Heparin or LMWH* BEFORE you do diagnostic imaging

Foodborne Disease

If symptoms take *>1 day* to develop, likely d/t bug that causes diarrhea via toxins (x. ETEC, STEC, C. Perfringens) Giardia incubation takes *7-14 days* before symptoms develop. Staph takes *1-6 hours* to develop, is vomiting predominant!!! and may or may not have diarrhea. Don't forget about parasitic causes: (profuse, prolonged, watery) - *Cryptosporidium* (don't have to have AIDs to get) - Cyclospora

Asthma

IgE type mediated - See other IgE type mediated dz (eczema, allergies) OBSTRUCTIVE dz that is REVERSIBLE (unlike COPD) Ominous signs: Decreased lung sounds and hyper-resonance (means air trapping) *Can present as NOCTURNAL COUGHING* Dx: PFTs (decreased FEV1/FVC) - If normal? Induce w/Methylcholine (Ach agonist) --> if negative then not asthma. If + then asthma. - If shows obstructive disease? Rescue w/ albuterol --> If reverses then asthma. If not then not. ** Could also try 2-4wks of ICS, if cough improves then asthma dx made Stage I: <2x/week day sx, <2x/mo night sx, 80% FEV1 Stage II: <1x/day day sx, <1x/week night sx, 80% FEV1 Stage III: ≥1x/day day sx, ≥1x/week night sx, 60-80% Stage IV: ≥1x/day day sx, frequent night sx, ≤60% Stage V: REFRACTORY Stage I tx: SABA - Esp used 10-20min before exercise Stage II tx: SABA + (Inhaled Corticosteroid (ICS) or LTA) Stage III tx: SABA + (ICS or LTA) + LABA Stage IV tx: SABA + (INCREASE DOSE of ICS or LTA) + LABA Refractory: Steroids P.O. Exacerbation? - *SABA + SAMA + IV Magnesium* AND!!! - Send home with *Oral Steroids* to prevent late-phase-reaction from causing respiratory collapse *Never treat with LABA alone!! It can cause asthma-related death* *Cromolyn sodium: only used when it's clearly athletic asthma and they know they'll be exposing themselves to the cause.*

Vitamin A Deficiency

Impaired adaptation to darkness --> May progress to night blindness Photophobia Dry scaly skin Dry conjunctiva Dry cornea Wrinkled, cloudy cornea Bitot spots (dry silver-grey plaques on the bulbar conjunctiva) Follicular hyperkeratosis (shoulders, buttocks, extensor surfaces)

Infectious Complications of Atopic Dermatitis

Impetigo Eczema Herpeticum Molluscum contagiosum Tinea corporis

Indications for Cystoscopy

In ABSENCE of glomerular disease or infection, do cystoscopy for all patients w/ - Gross *hematuria* - Microscopic *hematuria* associated with other risk factors for bladder cancer (x. cigarette smoking) 1. Gross hematuria with no evidence of glomerular disease 2. Microscopic hematuria with no evidence of glomerular disease or infection but increased risk of malignancy 3. Recurrent UTIs (those NOT d/t menopause) 4. Obstructive sxs suspicious for stricture, stone 5. Irritative sxs w/o urinary infection 6. Abnormal bladder imaging or urine cytology

Attrition Bias

In longitudinal research, this bias occurs when certain participants are more likely to drop out of the study than others, leading to a final sample that differs from the initial sample in important ways.

Surveillance Bias

Increased monitoring leads to increased disease diagnosis relative to the general population.

Positive Pressure Ventilation in Cardiogenic Pulmonary Edema

Increasing thoracic pressure via *PPV*.... - DECREASES venous return to heart!!! = DECREASED PRELOAD - Increases pulmonary capillary pressure = Increased RV afterload and decreased LV preload - DECREASES MAP (bc aortic compression signals baroreceptors to lower BP) = DECREASED AFTERLOAD - Decreases transmural pressure, so lungs don't have to compress heart as much to oxygenate, so heart is able to contract more effectively = Enhanced STROKE VOLUME This is how it helps CHF patients offload fluid!!!

Cutt Off

Increasing value of cutoff? - Decreased TP --> Decreased Sensitivity - Increased TN --> Increased Specificity Positive Predictive Value would decrease with decreased cutoff because (TP increases on numerator, but both FP and TP increase on denominator)

Groin Hernias

Indirect Direct Femoral

Positive Predictive Value (PPV)

Individuals WITH disease who had POSITIVE test TP/(TP+FP) Will INCREASE with increased PREVALENCE of disease - "PPV increases with Prevalence"

Otitis Externa (Swimmer's Ear)

Infection of the OUTER ear Pathology: - Swimmers ear (pseudomonas) vs. - Digital trauma from picking or cleaning (staph) - Headphone earbuds worn while sweating Patient: - Unilateral ear pain *WORSE* with pulling the pinna. - *Erythem and angry canal*, w/normal TM. - Necrotizing? It's spreading to bone...GRANULATION tissue in canal is characteristic --> Can lead to cranial neuropathy (CN7 facial weakness, CNX vagus, CNXI accessory) Dx: Clinical - Elevated ESR Tx: Nothing, resolves spontaneously. - Abx ear drops if looks bad (CIPRO!!!) + Steroid drops --> Could even be IV Cipro if really severe

Acute Otitis Media

Infection of the TM ... considered middle ear Path: URI bugs (Strep, Moraxella, H. flu) - RF = Young age (6-18mo), *Smoking* in household, Lack of breastfeeding, Day Care attendance - With perforation (increased ear pressure causes perforation)? STREP. Pt: Unilateral ear pain *BETTER* w/ pulling of the pinna. - Loss of light reflex - Swelling of TM - May be perforated - *Erythematous, BULGING TM* (only dif from Otitis Media with Effusion, which you do NOT treat) - Fluid behind ear Dx: Pneumatic insuflation (TM stays rigid when air puffed) Tx: *Amoxicillin* + Galbreath technique - Recur? *Amox-clav* - Recur recur recur if (3x/6mo or 4x/1year)? *Tympanoplasty* w/tympanocentesis & culture - If Penicillin allergic and reaction NOT anaphylaxis, then okay to use Cephalosporin! - If pen allergic and anaphylaxis then Azithromycin or Clindamycin! *If baby is fussy with erythem TMs but no other sx of ear infection DO NOT TREAT w/abx.*

Risk Factors for Cervical Cancer

Infection w/HPV 16 & 18 (most genital lesions appear within 3MO of infection) Tobacco use Multiple or High-risk sexual partners Early onset of sexual activity History of STDs HIV positive or immunocompromised OCP use Low socioeconomic status

Hypertension

Initial evaluation of HTN? - Identify complications & comorbid conditions of HTN (bc may influence management) --> Get: *CMP + Hgb/Hct + UA + ECG + TSH + Lipid panel + HgbA1c*!!!!! - Further diagnostic evaluation of HTN only needed for atypical presentation: Onset <30yr, Resistant HTN, or S/Sx specific to etiology. <130/<80 = Elevated BP --> Tx: Lifestyle modifications (LSM) & rtc 6 mo to see changes (see pic) - DIET --> #1 DASH diet --> #3/4 <2.4g salt/day --> K+ Supplementation (unless contraindicated - ex. CKD) --> #5 Alcohol (2 for men, 1 for women) - EXERCISE --> #2 30 min/day 5+ days, or 2hr/week - WEIGHT --> #3/4 Obese or overweight? LOSE WEIGHT (≥ 25BMI) <140/<90 = Stage I --> Tx: LSM alone (rtc 3 mo), LSM + antihypertensive meds if have other risk factor for CAD (smoking, diabetes, dyslip, obesity, family history, etc. then rtc 1 mo w/ home blood pressure monitoring) *STAGE ONE = ONE MED* ≥140/≥90 = Stage II --> Tx: LSM but more importantly TWO MEDS selected based on comorbid conditions (w/rtc 1 mo every time you start a new one and home blood pressure monitoring) *STAGE TWO = TWO MEDS* ≥220/≥120 = Urgency --> Tx: IV medications followed by oral medications Signs of end organ damage = Emergency --> Tx: Drip and ICU, then oral meds once MAP decreases by 25% or more.

Arterial Ulcer

Insufficient blood supply that leads to tissue necrosis - MC at *DISTAL* parts of extremities where blood is lowest (x. tips of fingers or toes)

Effect of Exercise on Insulin & Glucose

Insulin is cleared by the KIDNEYS!!! - CKD causes increased risk of hypoglycemia Those on insulin have increased risk of hypoglycemia with exercise, bc insulin dose remains the same while the patient decreases their BG through exercise.

Factorial Design

Involves *2 or more* experimental INTERVENTIONS Each with *2 or more* VARIABLES which are studied independently.

Iron Studies in Microcytic Anemia

Iron Deficiency Thalassemia - Increased IRON! (d/t high RBC turnover) - Increased Ferritin - Decreased TIBC - Increased Transferrin (Serum Iron/TIBC) Anemia of Chronic Disease

Iron Deficiency Anemia & Thalassemias

Iron Deficiency Anemia (pencil RBCs) --> Decreased reticulocytes Alpha-Thalassemia Minor Beta-Thalassemia Minor

Microcytic/Hypochromic Anemia

Iron-deficiency anemia (mc) --> get *Iron Studies* Thalassemias Anemia of chronic disease Myelodysplasia/sideroblastic anemia

Causes of Hemiplegia in Children

Ischemic Stroke Intracranial hemorrhage Seizure (*Todd paralysis*) Hemiplegic Migraine

NSAID Induced Acute Kidney Injury

Kidneys usually compensate for volume depletion by secreting vasodilatory prostaglandins - If you give NSAIDs you prevent this from happening --> renal afferent arterial vasoconstriction --> Prerenal azotemia with BUn:Cr 20:1 Tx: Stop NSAID, IVF

LMWH v. NOAC

LMWH? *Enoxaparin, Fondaparinux* NOAC? *Rivaroxaban, Apixaban, Dabigatran*

Community Acquired Pneumonia in School Age Children

LOBAR? - Strep Pneumo BILATERAL? - Mycoplasma - Chlamydia - Virus

Evaluation of Chest Pain in Outpatient Setting

LOW pretest probability? - No additional dx testing needed INTERMEDIATE pretest probability? - Can exercise? *ECG* --> ECG Normal? Send for *Exercise Stress ECG* --> ECG ABnormal? Send for *Exercise Imaging Test* ....If any of those are positive you send for *Coronary Angiography* - Can't exercise? *Pharm Stress Imaging Test* --> Positive? Send for *Coronary Angiography* HIGH pretest probability? - Start on *CAD meds, Refer to expert*

Management of Type 2 Diabetes in Heart Disease

Lifestyle Glycemic Management Lipid Lowering Therapy Blood Pressure Control Antiplatelet Therapy

Normal Postpartum Lochia

Lochia Rubra (bloody) --> Birth - 4th day Lochia Serosa (old blood) --> 4th day - 14th day. Lochia Alba (creamy) --> 11th day - 6 weeks

Malrotation

Look at gas pattern to differentiate from Intestinal Atresia, Duodenal Atresia, and Annular Pancreas!!!! Path: - Failure of normal embryonic gut rotation (Malrotation) - Twisting of gut around SMA Pt: Biliary Emesis (one of the four), DOUBLE BUBBLE on XRAY, Abdominal distention, Tympani, Shock - *NORMAL Gas* (suggests when baby was born air was initially able to get through) Dx: Abdominal XRay w/dilated bowels, Pneumoperitoneum, Air-fluid levels - Ligament of Treitz on right - Corkscrew or Bird's beak duodenum Tx: Laparotomy w/*Ladd procedure* - Surgical Emergency!!

Uterine Surgical History and Vaginal Birth

Vaginal Delivery is CONTRAINDICATED if... - Prior *Classical Cesarean Delivery* - Prior *Abdominal myomectomy WITH uterine cavity entry* --> Deliver them via C-Section at 36-37wks

Malrotation with Midgut Volvulus

Look at gas pattern to differentiate from Intestinal Atresia, Duodenal Atresia, and Annular Pancreas!!!! Path: Failure of normal embryonic gut rotation, Twisting of gut around SMA - At risk for perforation!!! Pt: - Previously normal feeding and stooling patterns with sudden onset of bilious emesis and no stools. (how you dif from any of the other causes of bilious emesis) - Biliary Emesis (one of the four), - Can mimic DOUBLE BUBBLE on XRAY (like duodenal atresia...) - Abdominal distention, - Tympani, - HYPOvolemic hock - *NORMAL Gas* (suggests when baby was born air was initially able to get through, unlike Duodenal atresia) Dx: Abdominal XRay w/dilated bowels, Pneumoperitoneum, Air-fluid levels - *Ligament of Treitz on right* - *Corkscrew or Bird's beak duodenum* Tx: Laparotomy w/*Ladd procedure*

Duodenal Atresia

Look at gas pattern to differentiate from Intestinal Atresia, Malrotation, and Annular Pancreas!!!! Path: Associated w/ - Down's Syndrome - VACTERL (Vertebral anomalies, Anal atresia, Cardiac anomalies, TEF, Renal anomalies, Limb anomalies) Pt: Biliary Emesis (one of the four), - *Double bubble* on XRAY (how dif from Jejunal Atresia) - *NO GAS* (unlike malrotation) - *Down Syndrome* --> Associated w/*VSD* if Down's - Polyhydramnios - Fluid filled stomach - Fluid filled proximal duodenum Tx: Surgery (even if it hasn't been 48hr yet, if you know you'll send them to surgery) (same as Annular Pancreas)

Aspergillosis

Looks a hell of a lot like tuberculosis...esp in it's Chronic form. Path: Ubiquitous fungus most people encounter daily which is inhaled and can convert to potentially pathogenic hyphae - IMMUNOCOMPROMISE (x. tuberculosis, HIV, sarcoidosis, malignancy) - Fungus will go into preexisting lung cavity made by Tuberculosis, etc. Pt: Invasive has classic Triad... - *Hemoptysis* - *Pleuritic chest pain* - *Fever* - Cough - Dyspnea - Thick sputum - "Cavitary mass with air in the periphery" - Pt's will also have a history of some similar looking dz...bc thats what the fungus needs to infect the way it does - *Eosinophilia*!!! - Elevated IgE Dx: Often need to get a *BAL* to dx... - INVASIVE? --> *"Halo Sign"* on CT = *Nodular lesions w/surrounding ground glass opacities* --> Positive cultures - CHRONIC? (needs all 3) --> *>3mo* of symptoms --> *Fungus ball* within a cavity (usually apical, sometimes there may not be a fungus ball in there) --> (+) Aspergillus *IgG Serology* Tx: *Voriconazole* x 1-2wks + Echinocandin - Then prolonged oral Voriconazole - CHRONIC? *+ Resection of fungus ball* - Mortality rate >50%

Magnesium Toxicity

Loss of DTRs Difficulty with respiration Somnolence Hypocalcemia (Mg temporarily suppressed PTH) Reverse w/*Calcium gluconate* Primarily excreted by kidneys!!! So will see toxicity easily in patients w/renal failure (x. Preeclampsia, Eclampsia)

Spinal Stenosis

Low back pain w/NEURO SX WORSE w/EXTENSION (STANDING)

Common Hereditary Cancer Syndromes

Lynch Syndrome Family Adenomatous Polyposis (FAP) Von Hippel-Lindau Multiple Endocrine Neoplasia Type 1 Multiple Endocrine Neoplasia Type 2 BRCA1 and BRCA2

Acute Lymphoblastic Leukemia (ALL)

MC Cancer in Children Path: Blast cells (big angry nasty cell, churn up bone marrow, crowd out bone marrow so no good cells can be made, lose platelets, lose blood, lose good leukocytes) Pt: - 2-5yo - Fever - Fatigue - Weight loss - Bone pain (means leukemia infiltration of bone marrow)...how you dif from aplastic anemia --> Worse at night!!! --> Kiddos may refuse to walk - PANCYTOPENIA --> Though classically see Leukocytosis - *NONTENDER lymphadenopathy* (how you dif from Sickle Cell aplastic crisis which would have no nodes at all) - Hepatosplenomegaly - Pallor (anemia) - Petechiae (thrombocytopenia) Dx: Gold standard is *BONE MARROW Bx* (need >25% BLASTS, could also confirm this w/Peripheral blood) - Abnormal CBC but WBCs may not be elevated Tx w/*Chemo*, but prophylax the CNS PMNs? AML. Tx w/*ATRA (Vit A)* if M3 variant (Auer rods), if not then *Chemo*

Metronidazole

MC adverse effect? *NEUROPATHY* - May become HYPORREFLEXIVE - Motor function is spared "Loss of pain, touch, and vibration sensation" often in bilateral fingers and toes.

Focal Segmental Glomerulosclerosis (FSGS)

MC in AFRICAN AMERICANS Rapidly progressive *Nephrotic* syndrome Cause: - HIV - Heroin - Obesity

Membranous Nephropathy

MC in CAUCASIANS *Nephrotic* syndrome Causes: - Hep B - Hep C - SLE - Solid tumors - NSAIDs

Diabetic Ketoacidosis (DKA)

MC in TYPE I Path: *INFECTION* often precipitates, bc body increases release of cortisol, glucagon, and catecholamines, causing HYPERGLYCEMIA - Body doesn't have access to sugars in blood bc no insulin, so breaks down fats for energy in the liver --> KETONES - All the sugar in urine causes massive osmotic diuresis Pt: - Polyuria - Polydypsia - Abdominal pain - Fatigue - *Kussmal respirations* - ANION GAP METABOLIC ACIDOSIS - Ketones - Diabetic coma - *HYPERK+* (Falsely elevated!!!!! bc lack of insulin causes K+ to go out of cells. Watch as you treat because should go back into cells w/insulin and normalize on own and you will actually need to add K+ because when giving Insulin drops K+ further) - *NET TOTAL LOSS!!!! OF BODY K+* bc it goes out with glucose in the urine - Bc of elevated glucose in blood, body tries to get rid of all the electrolytes in the urine and then reabsorb fluids w/ADH Dx: *BG 300-500* - Urine w/(+) Ketones (sufficient) - *SERUM (+) Ketones* best answer! - ABG w/anion gap metabolic acidosis - BMP (to check gap and Ca2+) Tx: Why did go into DKA? Treat that (infection, etc) - FIRST? Give *Saline bolus (10mL/kg)* over first hour - THEN *IV Insulin drip + Potassium* --> watch GLUCOSE: When BG<200 switch to *5%D5*, once gap is closed bridge w/*long acting insulin* --> watch POTASSIUM: Make sure *K+ >4* before giving insulin...*add back K+ when <5.3* --> watch GAP (most effective way to monitor resolution of DKA) "INsulin makes K go INside" (so do B-Agonists)

Hyperglycemic Hyperosmolar State (HHS)

MC in TYPE II Path: Can be triggered by prednisone use in a DM2 patient, or by infection Pt: - Diabetic coma - Hypotension - Dry mucous membranes - Altered mental status - Dysarthria - Seizures - Elevated BUN/Cr - No ketones - No acidosis - HYPOnatremia (bc hyperosmolar blood from sugar pulls fluid in and dilutes sodium) --> "Translocational Hyponatremia" Dx: *BG 800-1000* - UA w/o ketones - ABG w/o acidosis - BMP w/o gap Tx: Why did go into HHS? Treat that (infection, etc) - FIRST? Give *Saline bolus (10mL/kg)* over first hour - THEN *IV Insulin drip + Potassium* --> watch GLUCOSE: When BG<200 switch to *5%D5*, once gap is closed bridge w/*long acting insulin* --> watch POTASSIUM: Make sure *K+ >4* before giving insulin...*add back K+ when <5.3* --> watch GAP (most effective way to monitor resolution of DKA) - As you treat the sugars, the sodium will normalize. "INsulin makes K go INside" (so do B-Agonists)

Drowning

MCC injury-related death in children 1-4yo Path: Water can cause *atelectasis, noncardiogenic pulmonary edema, decrease lung compliance, and impair O2 exchange* (RESPIRATORY INSUFFICIENCY) by... - Wash out surfactant and cause lung collapse - Chemicals can do their own damage via inflammation. - Mess up the osmotic gradient in alveoli and capillaries causing increased permeability - Also can cause CEREBRAL EDEMA (more likely w/submersion >5min) - ARRHYTHMIAS (seen at initial presentation if they'll be seen at all) Pt: Poor swimmers, Young, Drunk - Worry about Tubs, Pools, Buckets. Prevent: - Limit access (Gates, Fences) - Supervise - Life jacket Tx: Immediate rescue breaths in field & Supplemental O2. You have to watch them in the ED.... SYMPTOMATIC? - Dx: CXR, ECG, CBG, CBC, Electrolytes, UDS - Tx: *Supplemental O2 (noninvasive positive pressure) ± Bronchodilators* + Continuous pulse Ox --> Consider *Intubation* prn if can't protect airway ASYMPTOMATIC? - Dx: CXR at END of observation ± ECG, CBG, CBC, Electrolytes, UDS. - Tx: *Observe ≥8hr*

Multiple Endocrine Neoplasia (MEN)

MEN 1 (AUTOSOMAL *DOMINANT*) - Parathyroidism - Pancreatic (or Gastric) Cancer - Pituitary Cancer MEN 2A (RET mutation) - Medullary Thyroid Carcinoma - Parathyroid Hyperplasia - Pheochromocytoma MEN 2B (RET mutation) - Medullary Thyroid Carcinoma - Pheochromocytoma - Mucosal Neuromas - Marfanoid Habitus

Hematuria in Children

MICROSCOPIC? - Blunt trauma? --> CT Scan - Otherwise watch and wait MACROSCOPIC? --> look at Urine Micro - Dysmorphic or RBC casts? Glomerular disease --> UA, Kidney Bx - Normal RBCs and NO casts? NONglomerular cause (*UTI*!!!!, kidney stones, malignancies, trauma, stones, cancer) --> USD, Cystoscopy, CT, MRI --> If UTI (leuk est) then give Abx If... - Brown urine - Edema - HTN - Proteinuria - RBC Casts --> THEN *Cr, Complement levels, CBC* (consider glomerulonephritis)

Cancer Pain Management

MILD (Non-opioids) - Acetaminophen - NSAIDs MODERATE (Weak opioids ± Nonopioids) - Codeine - Hydrocodone - Tramadol SEVERE (Opioids) - First? Short-acting --> Morphine --> Hydromorphone - Later? Long-acting (once have MME from short-acting use) ± Short-acting for breakthrough pain --> Fetanyl patch --> Oxycodone

Transient Synovitis

MIMICS SEPTIC ARTHRITIS but less severe Path: Benign inflammation of tissues surrounding the joint, Usually occurs after *VIRAL* infection or post-traumatic (x. gymnastics) - Resolves within 2 days or so Pt: Hip pain after viral illness - Children 3-8 - Well-appearing - WBCs are NORMAL (unlike Septic arthritis) - *LOW grade fever or NORMAL* (unlike Septic arthritis) - *ABLE* to bear weight (unlike Septic arthritis) - Limited hip mobility (extension & internal rotation) - Bilateral hip *effusions* - Hip pain or pain referred to knee Dx: Clinical - Normal or mildly elevated WBC - Normal or mildly elevated CRP - Normal or mildly elevated ESR Tx: NSAIDs + Conservative

Pregnancy & Exercise

MODERATE activity OK *20-30 minute session* most days of week. See list for safety

Blunt Abdominal Trauma

MOST COMMONLY INJURED ORGANS? - Spleen - Liver --> Both would produce large amount of intraabdominal fluid if vessels are damaged, which would be seen on *CT* Intraperitoneal FREE AIR seen on imaging? --> *Lap* Hemodynamically UNSTABLE? (*Systolic <90*) --> Mostly straight to surgery unless imaging is unconcerning --> Give *IV Fluids ASAP and transition to blood products as soon as you can*!!! Basically take them straight to surgery. - Peritonitis (x. rigidity)? *Lap* - No peritonitis but free fluid on FAST? *Lap* - No peritonitis and No fluid (or equivocal) on FAST? *CT Abd Pelv* (preferred) or *Diagnostic peritoneal lavage* (invasive, rarely used) - Preggo? Place in left lateral decubitus to relieve pressure of IVC. Hemodynamically STABLE? - Peritonitis? *Lap* - No peritonitis but free fluid on FAST? *CT-AP* - No peritonitis and No fluid on FAST? Consider CT Abd Pelv (esp if tachycardic or abd pain) or Serial abdominal examinations

Trisomy 13 (Patau Syndrome)

MR Cleft lip/palate *Cutis aplasia* *Polydactyly* Urogenital abnormalities Congenital heart disease Holoprosencephaly 96% die in 1st 6 months

High Anion Gap Metabolic Acidosis

MUDPILES (Accumulation of unmeasured acidic components) - methanol - uremia - DKA - paraldehyde/propylene glycol - INH, iron - lactic acid - ethylene glycol (oxalic acid) - salicylates

Mean, Median, Mode

Mean: Arithmetic average --> Extremely sensitive to outliers. Median: Middle number (if even # of values take average of middle two) Mode: Number which occurs most often

"Randomized"

Means confounders have been evenly distributed amongst groups.

Chronic Low Back Pain

Mechanical (x. Muscle Strain, Disk Degeneration) Radiculopathy (x. Herniated Disk) Spinal Stenosis Inflammatory (x. Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, IBD Arthritis) Metastatic Cancer Infectious (x. Osteomyelitis, Discitis)

Failure to Pass Meconium (FTPM)

Meconium Ileus Hirschsprung Disease

Common Causes of Vertigo

Meniere Disease BPPV Vestibular Neuritis Migraine Brainstem/Cerebellar stroke

Complications of Graves Disease Treatment

Methimazole PTU Radioiodine ablation Surgery

Disease-modifying Antirheumatic Drugs (DMARDs)

Methotrexate Leflunomide Hydroxychloroquine Sulfasalazine TNF-i (x. Etanercept)

Sunburn

Minor/Moderate? Conservative treatment (NSAIDs, Aloe Vera, etc) Severe (blisters)? IVF --> Prevent superinfection w/Mupirocen or Silver sulfadiazine Prevent w/SPF *≥30*

Acute Abdominal/Pelvic Pain in Women

Mittelschmerz Ectopic Pregnancy Ovarian Torsion Ruptured Ovarian Cyst Pelvic Inflammatory Disease

Trisomy 21 (Down Syndrome)

Mom has: "arrange alphabetically and then down-up-down-up" - DECREASED AFP - INCREASE beta-HCG - DECREASED Estriol - INCREASED Inhibin-A Pt: - Atlantoaxial instability (clumsiness, lack of coordination, ataxic gait, neurogenic bladder, sensory deficits, UMN signs) - Duodenal atresia - Protruding tongue - Upslanting palpebral fissures - Hirschsprung disease - ASD - VSD - Hypothyroidism - Hypotonia (weak suck) - AML - Fixed split S2 - Soft holosystolic murmur if defect is large - Diaphoresis with feeds and crackles (d/t failure of pulmonary vascular resistance)

Adson Test

Monitor pts pulse the arm extended pt asked to breathe in and turn head toward IL arm (+) Test = severely DEC/absent radial pulse Indicates compression btw anterior + middle scale of the neurovascular bundle = THORACIC OUTLET SYNDROME (TOS)

Causes of Recurrent Pneumonia

Most concerning cause of recurrent pneumonia (not necessarily most common though) is *bronchogenic carcinoma* --> *Smoking* is the primary RF - Next step in patient with smoking hx & recurrent pneumonia is *CT* (due to suspicion of bronchogenic carcinoma) - Then, if CENTRAL? *Bronchoscopic biopsy* - If PERIPHERAL? *CT-Guided Biopsy*

Poor Outcome Factors of Witnessed Out of Hospital Cardiac Arrest

Most critical factor determining survival rate is *Elapsed time to effective resuscitation* --> *CPR* (COMPRESSION!!! >> Rescue breaths....untrained individuals are actually advised to do compression-only CPR bc it is shown to be the critical factor here for outcomes) --> *Rhythm analysis* --> *Early defibrillation* (if indicated)

Neurofibromatosis Type II

Mutation in NF2 tumor supressor gene *Merlin* - Chromosome 22 - Autosomal DOMINANT BILATERAL vestibular schwannomas (hearing loss, difficulties with balance) Hearing loss Tinnitus *Intracranial meningiomas* (NOT subependymal nodules) Cataracts

Key Defense Mechanisms

NEUROTIC - *Isolation of affect* = Unconscious limitation to the affective expression of emotion. IMMATURE - Acting Out - Denial - Displacement - Intellectualization (avoid anxiety by focusing on the nonemotional aspects) - Passive aggression - Projection - Rationalization - Reaction formation (does NOT give them pleasure to do it) - Regression - Splitting MATURE - Sublimation (putting negative feelings into something socially acceptable and positive) - Suppression - Altruism (gives them pleasure to do it)

Indications to Image Cervical Spine

NEXUS Criteria: Cervical spine imaging (*CT w/o contrast*) is necessary if any *1+* of the following are present: - Neurologic deficit - Spinal tenderness - Altered mental status (i.e. intoxication) - Intoxication - Distracting injury (i.e. painful injury elsewhere) - Also want to get any time there is a *HIGH-ENERGY MECHANISM OF INJURY* *If none of the above present THEN can do NEURO EXAM to r/o C-spine injury* - You DO NOT do this first in any of the cases above! They just go straight to CT. !!!! If ONE vertebra is fractured, this is indication to get *CT* of the *whole spine* !!!! --> Likelihood that there is more than one vertebra fractured is high

Hematuria

NON-GLOMERULAR --> Gross hematuria, Normal appearing RBCs, NO Protein - Cancer (Renal cell, Prostate) - Infections (Cystitis) - PCKD - Nephrolithiasis --> Symptoms help to differentiate between causes GLOMERULAR --> Gross hematuria, Dysmorphic RBCs or RBC casts, YES protein - IgA Nephropathy - Poststreptococcal - Alport Syndrome --> Nonspecific sx, so *Renal bx* helps to differentiate between causes

Lymphoma

NONTENDER, fixed, firm lymph node (esp supraclavicular) w/lymphadenopathy ± B symptoms Dx: *EXCISIONAL BIOPSY* (not FNA) - HODGKINS? --> *Reed-Sternberg Cells* - NONHODGKINS? --> No Reed-Sternberg cells, *Starry sky*, Burkitt's - If other cancer? METS--> Find primary - If nothing? Make sure not REACTIVE--> Gram Stain, Culture, Acid Fast Bac, Fungal (would usually be tender if this but not always) *CXR* (mediastinal mass seen in majority of HL pts) --> CT C/A/P to stage --> If still neg then BONE MARROW BX Staging: - I: 1 LN, SAME side of diaphragm - II: ≥2 LN, SAME side of diaphragm - III: ≥2 LN, OPPOSITE side of diaphragm - IV: Mets Tx: - Hodgkin's? Combination Chemo has good prognosis.

Acid Base Disturbances

NORMAL - pH 7.35-7.45 - CO2 35-45 - Bicarb 22-26 #1 LOOK AT pH <7.4 (acidemia) >7.4 (alkalemia) #2 LOOK AT CO2 (norm 40) - Resp Acid will have high CO2...If acidosis and CO2 not high, then you have Metabolic Acid - Resp Alk will have low CO2...if alkalosis and CO2 not low, then you have Metabolic Alk - If CO2 inappropriate then Metabolic....do *WINTER'S FORMULA (1.5 x bicarb + 8 ± 2)* --> If CO2 greater than expected, coexisting Resp Acid (x. Hypoventilation). If less than expected, coexisting Resp Alk. #3 are there other disturbances going on? 3a. Anion Gap (>12 abn) 3b. Acute or chronic *For every change of 10 CO2, pH changes by 0.8 if acute, and 0.4 if chronic* 3c. BICARB appropriate (norm 24)? If too much then coexisting Metabolic Alk! If too little then coexisting Metabolic Acid! Resp Acid: *For every change of 10 CO2, BICARB changes by 1 if acute, and 3 if chronic* Resp Alk: *For every change of 10 CO2, BICARB changes by 2 if acute, and 4 if chronic* Metabolic: Add back method... (Anion Gap - 12) + Bicarb - Respiratory Acidosis = HYPOventilation - Respiratory Alkalosis = HYPERventilation - Metabolic Alkalosis --> next step is to get *URINE CHLORIDE (if LOW <10* then are VOLUME RESPONSIVE "CONTRACTION ALK", bc when volume low aldost causes Na & Cl retention) - Metabolic Acidosis --> next step is ANION GAP (*Na - Cl - HCO3*) Unless kidneys are damaged, they will try to compensate during Metabolic Alk/Acid as well... Via - Ammonium buffer (excreting it serves to decrease H+ and thus compensate for Acidosis) - Bicarb buffer

68-95-99.7 rule

NORMAL DISTRIBUTION About 68% of values fall within *1* standard deviation of the mean. About 95% fall within *2* standard deviations of the mean About 99.7% fall within *3* standard deviations of the mean

5-Alpha Reductase Deficiency

NOT Aromatase Deficiency!!! Get it together, Tara. Path: Affects *MALES*; Inability to convert testosterone to DHT - Testosterone causes development of male INTERNAL genitalia - DHT causes development of male EXTERNAL genitalia - Autosomal Recessive Pt: - Female EXTERNAL and Male INTERNAL until puberty --> puberty causes virilization d/t increased testosterone (Clitorus w/hood, Bilateral palpable masses in labia majora) - Acne - NO breast development (unlike AIS)!!! Dx: *Elevated Testosterone/DHT ratio* Tx: Depends on age and gender identity

Rectus Abdominis Diastasis

NOT palpable while supine Weakening of linea alba

Blunted response to infection?

Neutropenia (x. chemotherapy, cancer) DM Steroids

Nail Melanoma

Nevi at nail matrix produces brown pigmented band. - "Longitudinal melanonychia" Dx: Bx Tx: - Observe if <3mm wide, involves multiple nails, or has been stable for years. - *Melanoma* if pigment extends onto nail folds, has been changing, or has irregular borders.

Metabolic Alkalosis

Next step is to get *URINE CHLORIDE --> if LOW <10* then are VOLUME RESPONSIVE/"CONTRACTION ALK", bc when volume low aldost causes Na & Cl retention (which means less excreted in the urine) - UChloride <10: Diuretics, Dehydration, Emesis/NG Suction = *Saline responsive* - UChloride >10: Look for HTN --> Yes? Hyperaldosteronism (H+ goes where K+ goes) --> No? Genetic diseases like Bartter & Gitelman = NOT Saline responsive

Clues in the Etiology of Syncope

Vasovagal Carotid hypersensitivity Autonomic dysfunction Hypovolemia LV outflow obstruction Ventricular tachycardia Conduction impairment

Vaginal Cancer

Non-Keratinized Stratified Squamous Epithelium + HPV 16,18 --> Vaginal Intraepithelial Neoplasia (VaIN) --> Squamous Cell Carcinoma (SCC) - VaIN is NONINVASIVE - Vaginal Carcinoma is INVASIVE Path: HPV 16,18, tobacco use, others. - E6 inhibits P53 - E7 inhibits Rb Pt: - Vaginal bleeding - Malodorous discharge - Pelvic pain - Urinary symptoms (hematuria, represents mets) - Constipation (mets) PREINVASIVE - Asymptomatic - *Recurrent (+) PAP, but (-) Colposcopy* - Risk factors for HPV INVASIVE - Pruritis - Post-coital or menopausal vaginal bleeding Dx: *Biopsy* - INVASIVE SCC is usually in *upper 1/3* of vagina in posterior fornix and is *Clinically* staged Stage 1 = Contained to vaginal wall Stage 2 = Subvaginal Stage 3 = Through vaginal wall Stage 4 = Mets, Outside pelvis Tx: PRE-INVASIVE (VaIN) - LSIL? HPV! Will clear. - HSIL? *Wide local excision* v. topical *5-FU*. INVASIVE? (SCC) - Surgery if *small, upper 1/3 vagina, early stage*...if not, then *Chemoradiation* + Hysterectomy/Vaginectomy/Pelvic LND

Reversing Warfarin Anticoagulation

Non-urgent? Vitamin K --> Takes 12-24 hr to be effective Urgent? *Prothrombin Complex Concentrate (PCC)* --> takes minutes to be effective and can last for hours - Could also consider *FFP* but takes longer to prepare and requires more volume infusion Platelet transfusion --> correct ASA or Clopidogrel *Protamine sulfate* --> urgently corrects *Heparin*

Noninvasive Positive Pressure Ventilation (NPPV)

Noninvasive positive-pressure ventilation (NPPV) is a technique using positive pressure to keep alveoli open and improve gas exchange without the need for airway intubation. NPPV is now being used to manage - Dyspnea, - Hypercarbia - *Acute exacerbations of chronic obstructive pulmonary disease (COPD)* - Cardiogenic pulmonary edema - Acute asthma attacks.

Antepartum Fetal Surveillance

Nonstress Test (NST) - High false positive rate...requires f/up with BPP or CST Biophysical profile (NST + USD = BPP) Contraction Stress Test (CST) - CI's are anything that CI labor! (x. placenta previa) Doppler sonography of the umbilical artery If NST is nonreactive? Get *BPP* or *CST* BPP Score (out of 10) - 0-4? *Fetal hypoxia d/t placental dysfunction* (HTN, DM, tobacco, advanced maternal age)

Crying in Young Infants

Normal Colic GERD Infection Intussusception Torsion Trauma

Tetanus Prophylaxis

Normal Vaccination Schedule - Found in Metal, Dirt, Feces, Soil, Saliva - DTaP = KIDS --> Big D, Big P, means bigger dose --> Kids get *5 doses* (2m, 4m, 6m, 12m, 4yr) - Tdap = ADULTS --> Little d, Little p, means smaller dose --> Adults get *1+ dose*, then *Booster q10yr* - Pregnant women get EVERY pregnancy Prophylaxis - MINOR wound --> ≥3 vaccines in childhood? *Tetanus Toxoid vaccine (Tdap)* if last dose was *≥10yr* ago --> <3 vaccines in childhood or uncertain? *Tetanus Toxoid vaccine (Tdap)* - MAJOR wound (human, dog, cat bite) --> ≥3 vaccines in childhood? *Tetanus Toxoid vaccine (Tdap)* if last dose was *≥5yr* ago --> <3 vaccines in childhood or uncertain? *Tetanus Toxoid vaccine (Tdap)* + *IV IG* ...also give Tetanus IG if patient is SYMPTOMATIC

Renal Changes in Normal Pregnancy

Normal pregnant Cr = 0.4-0.8 --> Monitor renally excreted med doses closely bc pregnant women will process them faster

Joint Fluid Characteristics

Normal: <200 Noninflammatory: 200-2,000 Inflammatory: 2,000-100,000 Septic: 50,000-150,000

Number Needed to Treat (NNT)

Number needed to treat with new treatment to reduce one death with old treatment *NNT = 1/ARR* - Absolute Risk Reduction = ARR ARR = %placebo - %treatment = x%....convert to decimal for 1/ARR equation or... ARR = (Risk of control) - (Risk of treatment)

Nummular Eczema

Nummular = "Coin" Path: Idiopathic pruritic inflammatory dz Pt: - "Pruritic scaly fissured plaque with intermittent exudate" - Young, old - Worse in Fall/Winter, - Coin-shaped plaques - Pruritus - *Extremities*!! Tx: Topical steroids

Bariatric Surgery

OK if.... BMI ≥40 BMI ≥35 w/serious comorbidity (DM2, HTN, OSA) BMI ≥30 w/resistant DM2 or metabolic syndrome *Medication failure is not required for surgery!*

Odds Ratio

OR = (Odds of exposure in cases)/(Odds of exposure in controls) or... OR = (a/c)/(b/d) *DO NOT USE THE "TOTAL" FOR DENOMINATORS on top and bottom*!!!! (that would be RR) - Think of it like rolling a dice OR < 1? Protective factor OR = 1? No association OR > 1? Risk factor Used in *Case-Control* studies

Diabetic Retinopathy

Occurs in both insulin-dependent and non-insulin dependent diabetics. - DECREASED VISUAL ACUITY & IMPAIRED COLOR VISION Three types... - Background/Simple: *Microaneurysms*, hemorrhages, exudates, retinal edema (visual impairment w/edema) - Pre-proliferative: *Cotton wool spots* (HTN retinopathy has this too) - Proliferative/Malignant: Newly formed vessels. Tx: ARGON LASER PHOTOCOAGULATION for prevention!

Lumbar Disk Degeneration

Often asymptomatic Older folks Can have - Mechanical back pain - Lumbosacral radiculopathy - Pain WORSE w/movement Dx: MRI - Straight leg raise is (+) Tx: Conservative first - Later consider surgery

Metabolic Acidosis

Once determined (pH <7.4, CO2 normal or low), next step is get ANION GAP (*Na - Cl - HCO3*) - Anion Gap > 12: MUDPILES (methanol, uremia, DKA, propylene glycol, iron, lactic acid, ethylene glycol, salicylate) - Anion Gap < 12 (Nongap) --> Check URINE anion gap (*Na + K - Cl*) --> If pos? RTA. --> If neg? Diarrhea (you lose bicarb) *Metabolic ACIDOSIS* is common in FICTITIOUS DIARRHEA (laxative abuse) --> Melanosis Coli (dark spots in colon) seen w/scope

Premenopausal Adnexal Mass

Ovarian Mass Ovarian Cyst Ovarian Cancer Mcc Follicular cyst v. Sex Cord Stromal tumor (<11 yo) v. Germ Cell tumor (young to early 20s) Dx: w/*Transvaginal USD* + *UPT* COMPLEX? - *≥10cm* if reproductive age (≥7cm if not) - Multiple septations - Thick wall - Calcifications - Irregular contour - Hypervascular on Doppler - Multiple echogenicities...heterogeneous SIMPLE? (looks like a follicle) - *≤10cm* if reproductive age (≤7cm if not) - No septations - Thin wall - Smooth, round contour - No hypervascularity on Doppler - Homogeneous - Anechoic - No solid components Tx: - *<3cm*? Ignore - *<10cm, or Simple*? Repeat imaging q3-6mo, if still there then laparoscopic cystectomy - *>10cm, or Complex*? Laparoscopic cystectomy - Malignant features? *Surgery*

Differentiation of Conjunctivitis

Viral Bacterial Allergic

Distinguishing Features of Common URI

Viral Upper Respiratory Syndrome Influenza Streptococcal Pharyngitis

Postmenopausal Adnexal Mass

Ovarian Mass Ovarian Cyst Ovarian Cancer Postmenopausal women are less likely to have benign cause of adnexal mass!! 1. *USD* - If it looks malignant (Complex)? *Laparoscopy* - It not (Simple)? *Risk stratify* w/*CA-125* level!!! (falsely elevated in premenopausal women bc released from stimulation to uterus, fallopian tubes) --> NORMAL CA-125? Benign. Tx w/*Observation + Serial USDs* --> ELEVATED CA-125? Likely malignant. Dx further w/*CT*...then Exploratory *Laparoscopy/Laparotomy* (to stage, debulk) ± Chemotherapy

Adenomyosis

P*A*LMCOEIN Path: Proliferation of stroma *and* glands INTO the myometrium (unlike Polyps or Leiomyoma) - If placenta implants into myometrium and then tears off, stratum basale gains access to myometrium Pt: - Older women (>40yo) - Hx of multiple pregnancies - Symmetrically tender uterus - *Uniform "boggy" uterus* - Heavy, *painful, regular* menses --> Progresses to *Chronic pelvic pain* with increased accumulation of endometrial glands in myometrium Dx: Transvaginal USD Tx: *Hysterectomy* - If not surgical candidate then *Contraceptives* or *GnRH analogs*

Causes of Hirsutism in Women

PCOS --> Elevated T --> Elevated LH --> Normal or elevated DHEAS Idiopathic --> Everything normal Nonclassic CAH Androgen Secreting Adrenal Tumor --> Elevated DHEAS --> Elevated Testosterone (bc DHEAS gets converted) --> Decreased LH (bc elevated T) Androgen Secreting Ovarian Tumors --> Normal DHEAS --> Elevated T --> Decreased LH Ovarian Hyperthecosis Cushing Syndrome

Tuberculosis

PRIMARY infection --> Bacteria goes into MIDDLE or LOWER lobes of lungs and looks just like any other lobar pneumonia + *HILAR ADENOPATHY*!! (which other normal pneumonias won't have) + *Cavitation (w/caseating granulomas)* --> MILIARY TB = Uncontrolled primary infection (d/t immunocompromise, making IFN-gamma falsely negative), goes into Lungs, Liver, Spleen, Bone w/"Micronodules" SECONDARY infection (immunocompromise can cause) --> Reactivation --> *Gohn complex*/*Apical lesions* bc lower O2 tension up there - Subacute *fever* - Cavitary lesions - Infiltrates - Pulmonary effusions - Hemoptysis (bc body attacks the lesions and gets lung instead) - Night sweats - Weight loss - Anemia - Spondylitis - Arthritis - Osteomyelitis - Monocytosis (bc macrophages lead the charge against TB) - Hypergammaglobulinemia (elevated total protein) - Hyboalbuminemia Dx: (≥5mm if severely immune compromised or close contact of positive; ≥10mm if healthcare workers, prison, homeless, travel; ≥15mm for everyone else) "RIPE tx = 2mo of 4 meds, then 4mo of 2 meds" - (-) Test? No further management - <5yo? (+) PPD - >5yo? (+) Interferon Gamma Assay (also for BCG vaccinated patients) - Then...*CXR*!!!! EVEN IF PREGNANT!!!! Safe w/appropriate screening. You give them usual tx as well. - If have been EXPOSED but CXR (-), they are *latent* --> Tx: *Isoniazid + B6 (x9 mo)* or 12wks *Isoniazid + B6 + Rifapentine* - If CXR (+), then get *Acid Fast Bacillus smear (AFB) x3!!!* - If CXR (+) but AFB (-), they are *latent* --> Tx: *Isoniazid + B6 (x9 mo)* or 12wks *Isoniazid + B6 + Rifapentine* - If CXR (+) but AFB (-), at HIGH RISK for exposure, and Symptomatic --> *RIPE* and isolate. - If CXR (+) and AFB (+), they are *active* --> Tx: *RIPE* (~2mo), then *Isoniazid + B6 (x9 mo)* *If signs/sx of TB --> jump straight to CXR...+AFB* FALSE NEGATIVES w/TST!!!!!!!!!! : - HIV CD4 <200 --> Treat with Anti-retrovirals and then retest - *CKD* --> Negative TST does NOT rule out TB infection

Patellar Tendinitis (Jumper's Knee)

Pain at INFERIOR pole of patella (unlike Osgood-Schlatter's which is at tibial tuberosity)

Varicocele

Painless --> Or "Dull ache" after standing too long *Bag of worms* Does not transilluminate SURGICALLY CORRECT to avoid *INFERTILITY & TESTICULAR ATROPHY* PRIMARY: Compression of left renal vein between SMA & Aorta - *L sided* - Decompress when supine - Increases with standing and with valsalva (like indirect hernia) - NOT reducible (unlike indirect hernia) - Dx: USD SECONDARY: Venous thrombus or compression of IVC by abdominal mass (x. Wilm's tumor in kiddos)....consider when - Prepubertal - *R sided* - DOES NOT decrease in size when supine - Dx: *Abd USD* Tx: - Concerns of infertility? *Surgery* - Older w/o interest in fertility? *Scrotal support + Analgesics*

Incisional Hernia

Palpable while supine (unlike rectus abdominis diastasis) Increases with bearing down

Breast Conserving Therapy (BCT)

Partial Mastectomy/Lumpectomy + Axillary SNL Bx - (+) Margins? *Excision of involved margins* - ≥3 Positive Nodes? *Axillary LN Dissection* --> Once margins are (-) can begin *RT*

COPD (chronic obstructive pulmonary disease)

Path/Pt: *Air is trapped during EXPIRATION* & *Destruction of the alveolar capillary membrane* - Severe COPD? Pulmonary cachexia (poor prognosis)...from increased work of breathing burning calories. --> BMI <20, weight loss >5% --> Impaired balance, increased susceptibility to infections Two flavors... Emphysema and Bronchitis EMPHYSEMA "pink puffers" - CO2 retention - No change in O2, no cyanosis - Increased AP diameter - Prolonged exhalation - Pursed lips BRONCHITIS "blue bloaters" - Inflammation of airways - Decreased O2, CYANOSIS - Decreased O2 --> Pulm artery vasoconstriction --> PULMONARY HTN --> R HEART FAILURE --> Edema Dx: FEV1/FVC <70% - Severe? FEV1/FVC <50% - CT w/*enlargement of the airspaces distal to the terminal bronchioles* - Decreased vital capacity - Increased lung distensibility - Increased functional residual volume - Increased total lung capacity Tx: 1. SABA (beta AGONIST!! - not antag...) --> unchanged sx usually 2. SABA + LAMA (Long acting muscarinic antagonist x. tiotropium) 3. SABA + LAMA + LABA 4. SABA + LAMA + LABA + ICS 5. SABA + LAMA + LABA + ICS + PDE4i 6. SABA + LAMA + LABA + ICS + PDE4i + Steroid "COPD-ER" C = Corticosteroids (ICS if stable, p.o. steroids if really bad, IV steroids if exacerbation) O = Oxygen (if *SpO2<88*% or PaO2<55. OR SpO2<89% cor pulmonale, right HF, or hematocrit >55%. Goal 88-92%, THEY NEED THEIR HYPOXIC DRIVE!!!) --> O2 prolongs survival when needed P = Prevention (Flu vaccine, PNA vaccine, smoking cess) D = Dilators (SABA, LABA, LAMA, orals) E = Experimental (forget about this) R = Rehab (doesn't change mortality though) *LIFE PROLONGING MEASURES:* - STOP SMOKING!!! - SUPPLEMENTAL O2 (*if ≤88% SpO2* or *≤89% w/erythroctosis HCT>55%, cor pulmonale, or evidence of RHF*)!!!! ALSO GIVE VACCINATIONS - *Influenza vaccine* - *Pneumococcal vaccine*

Female Sexual Interest/Arousal Disorder

Path/Pt: Lack of or significantly reduced sexual interest/arousal, not better explained by medications or another medical disorder - They're distressed by the decreased interest

Erectile Dysfunction (ED)

Path/Pt: Sympathetic control is T11-T12, Parasympathetic control is S2-S4 (point + shoot) - ORGANIC (hypogonadism, DM, Smoking) --> initially intermittent or slowly progressive, mc with advancing age, NO nocturnal erections - PSYCHOGENIC (interpersonal conflict, performance anxiety, underlying emotional disorder) --> *persistence of nonsexual nocturnal erections*, normal erections with masturbation, sudden onset, situational ED Dx: Clinical Tx: ORGANIC? - Tx medical condition - Stop smoking - Stop BBlocker, Thiazide diuretic, Spironolactone, SSRI, Cimetidine (NOT ranitidine!) PSYCHOGENIC? Therapy + Sildenafil

Polycystic Ovarian Syndrome (PCOS)

Path: - Hyperandrogenism (Testosterone increased, DHEAS normal) --> increased androgens from theca cells, no granulosa cells to convert it to estrogen via aromatase - Insulin resistance (increased risk of GDM) - Failure of maturation of ovarian follicles - Elevation of LH relative to FSH bc elevated estrone d/t peripheral androgen conversion (fat) causing more dramatic pulses of GnRH which preferentially creates LH --> Lack of LH surge --> *Anovulation* - Because they have anovulatory cycles, they have *decreased progesterone*, which means more unregulated estrogen --> Increased risk for Endometrial cancer. Pt: - Physical or biochemical hyperandrogenism - Polycystic ovaries - Anovulation (Intermenstrual bleeding, w/heavy menstrual bleeding whenever ovulation occurs) - Prediabetes - Obesity - Hyperlipidemia - NO VIRILIZATION Dx: *Anovulation* + one of the following... - *LH/FSH > 3:1* (this means extra LH is converted to estrone which gets converted to testosterone) - ....though LH or testosterone levels may be normal and it is just a "relative imbalance" - USD with lots of follicles in BILAT ovaries *Can have hirsute female w/ LH/FSH >3:1 and still not meet criteria for PCOS! Need signs of ANOVULATION.* Dx: ...Could use *Progestin challenge* --> which should cause menses Tx: 1. Exercise and weight loss but never used as monotherapy, add... 2. *METFORMIN*!! (helps with diabetes and ovulation!) + *OCPs* - If trying to get preggo...Weightloss. But really, CLOMIPHINE v. *Letrozole* (causes LH surge resulting in ovulation) - For hirsutism? SPIRONOLACTONE

Foreign Body Ingestion

Path: - If something sharp & in *esophagus, stomach, or proximal duodenum*? Retrieve. Worried about perforation. - *Battery* ingestion? Super dangerous....can cause corrosion and necrosis --> esophageal ulceration, perforation, death - *Magnets*? Retrieve --> Can consider observation for single magnet though. - *Sharp object*? Retrieve - Coin? Less scary. Can let pass unless... - Resp issues or obstruction? Retrieve. Pt: Asymptomatic - Nausea - Vomiting - Anorexia - Chest pain - Fever - Hematemesis - Shock Dx: CXR - CT if object not identified Tx: - Symptomatic or Dangerous item? *Endoscopic removal* --> Can give honey soon after ingestion to help protect, but still needs to be removed. - Asymptomatic and Benign item? Can watch and monitor movement of item with q24hr XRays. If it stops moving you can retrieve it.

Transient Hypogammaglobulinemia of Infancy

Path: - Prolonged decreased physiologic IgG. Pt: - Recurrent respiratory infections and GI infections - Eczema or Food allergies - Normal Ab response to vaccines - Normal B and T lymphocytes - Decreased IgG - Variable IgM - Normal IgA & IgE Tx: Observation. Self resolves at 9-15mo.

Hepatocellular Carcinoma (HCC)

Path: Pt: Dx: - *Bloody ascites* (doesn't decrease on repeat paracentesis) --> Get *Abd imaging* + *AFP* (High in HCC) + *Cytology* Tx: - Systemic sx - Chronic hepatitis/cirrhosis - High AFP

Adenocarcinoma of the Rectum

Path: Pt: - Hematochezia - Bright red blood on toilet paper Dx: *Colonoscopy* - Then CT of abdomen to stage - Can follow CEA marker Tx:

Temporomandibular Joint Disorder

Path: Pt: - Otalgia during chewing - Worn & smooth teeth (signs of Bruxism) - Normal ear examination - Tenderness at TMJ - Headache - Neck stiffness - Ear pain Dx: Clinical Tx: Education + Soft diet + Avoidance of triggers + NSAIDs - Could consider TMJ PT maneuvers - Muscle spasm? Give muscle relaxer

Internal Hemorrhoids

Path: Pt: - Purplish anal bulge ABOVE dentate line - Bleed!! - Don't hurt usually Dx: Clinical Tx: *High fiber diet + oral Fluids + Reduce fat + Reduce alcohol + Exercise* - Can consider *Sitz baths + Lidocaine + Stool softeners* - Refractory? *Banding* v. Infrared coagulation

Growth Hormone Deficiency

Path: Pt: - Short - Delayed bone age - Delayed puberty - *Falling off growth charts ≥2 major percentiles* (unlike Constitutional growth delay which would be tracking NORMAL) Dx: Tx:

Fibrocystic Changes

Path: Pt: - Young women - *Multiple* - Diffuse, nodulocystic masses - Premenstrual TENDERNESS Dx: Tx: Reassure

Tourette Syndrome

Path: Pt: Exacerbated by stress. - Tics occur throughout the day in bouts - MOTOR? Grimacing, Eye blinking, Nose twitching, Head jerking, Shoulder shrugging. - VOCAL? Barking, Grunting, Squeaking, Coughing, Throat clearing, Coprolalia (aka obscenities, in minority....). - May wax or wane in intensity Dx: *MULTIPLE motor &!!! ≥1 verbal tics BEFORE 18yo* (not necessarily all at once) - Duration? *≥1 year* (of at least one of the tics) - If you ONLY have vocal OR motor tic, then considered "Persistent Motor (or Vocal) Tic Disorder"...which is a dif diagnosis Tx: *Habit reversal training* (NOT exposure/response training, that's for OCD) - Severe, Interfere w/social or academic function? (+) *Dopamine antagonists* (esp second gen antipsychotics) v. *Alpha agonists* - F/up *ADHD* and *OCD*...also can develop Anxiety, Depression, Substance abuse

Premenstrual Syndrome (PMS)

Path: Pt: Recurrent episodes of - Fatigue - Bloating - Mood swings - Anxiety - Headaches - Hotflashes - Breast pain ~day 14 of cycle Dx: *Symptom diary* (to differentiate from MDD, or Hypothyroidism) - Need evidence of sx correlating w/*LUTEAL PHASE (1-2wks before menses)* - Need *>5 sx* - Over *≥2 cycles* Tx: Continuous vs. luteal phase only (starting day 14) *SSRIs*

Amyloidosis

Path: - *AA*? RHEUMATOID ARTHRITIS, IBD, any *Inflammatory disease* really... - *AL*? Multiple Myeloma Pt: NEPHROTIC syndrome - Edema - Proteinuria (severe) - Facial swelling - Enlarged kidneys Dx: Bx w/Glomerular deposits on Congo Red staining that show apple-green color Tx: Treat underlying condition - *Colchicine for prevention*

Anterior Cord Syndrome

Path: - *ANTERIOR Spinal Artery* occlusion, - *Aortic Dissection*, - *FLEXION* injury. Pt: Loss of everything but PCML - HAVE proprioception and sense of vibration - LOSE pain & temperature (Spinothalamic tract) - LOSE motor (Lateral corticospinal tract) Dx: Imaging Tx: - If HIGH cervical or respiration unstable? Intubate - If lower? Bladder *Catheterization*

Esophageal Cancer

Path: - *SCC* = Upper 1/3rd, Hot liquids, Alcohol, Smoking - *Adenocarcinoma* = Lower 1/3rd, GERD, Barrett's Pt: Dysphagia - Progressive difficulties with smaller and smaller foods and eventually water - Weight loss - Iron deficiency anemia - Vomiting Dx: *EGD w/bx* Tx: Resection

Primary Amenorrhea

Path: - *≥15 and no menses* but has thelarche - or *No thelarche or menses at ≥13yo* - or *No menses ≥3yr after thelarche* Dx: 1. NO secondary sexual characteristics? *Delayed puberty* --> Check *USD* --> If normal, check *FSH, LH, Estradiol*... - Central causes have LOW to normal FSH/LH/Estradiol - Peripheral causes have HIGH FSH/LH/Estradiol HYPERgonadotropic HYPOgonadism - If FSH, LH HIGH then ovaries are problem (get USD) - If Normal then brain is problem (get MRI) HYPOgonadotropic HYPOgonadism - If FSH, LH LOW then brain is problem...*get SMELL TEST* (r/o Kallman's), then MRI - MRI abnormal? If pituitary issue patient would also have s/sx of increased ICP (Dx: w/ LH, FSH, TSH, ACTH, IGF-1; Tx: replace all hormones v. resect) 2. YES secondary sexual characteristics? --> Check *USD* --> Then if normal check *UPT, TSH* - Positive UPT? IUP - Elevated TSH? Hypothyroidism (Tx: Levothyroxine) - USD w/o uterus? *Mullerian Agenesis*

Urinary Tract Infection in CHILDREN

Path: - <2yo are at increased risk of complications from UTIs Pt: - Abdominal pain - Dysuria - Fussiness - Poor feeding - Fever (suggests pyelonephritis) Dx: UA - Leukocyte esterase - Nitrites (indicates E. Coli) - Pyuria (≥5 WBCs) - Bacteriuria (≥50,000 colony forming units) - E. Coli on urine culture Tx: *1-2 weeks of Cefixime* (or other 3rd gen ceph) - If FIRST FEBRILE UTI & E. Coli? *Renal & Bladder USD* to r/o anatomical abnormalities - Fever? *Renal USD* - If OTHER bug, Recurrent (*≥2 febrile UTIs*), or Scarring? *Voiding cystourethrogram*

Routine Newborn Care

Vitamin K IM Erythromycin eye ointment Hep B Vaccine Newborn screen (Metabolic/Genetic disorders) Hyperbilirubinemia Hearing Screen Pre & Post-ductal pulse Ox --> Screens for Congenital Heart Disease - Ductal dependent and Cyanotic conditions need to be corrected in the FIRST YEAR of life. Hypoglycemia

Atrial Fibrillation

Path: - A Fib: ECTOPIC FOCI originates from *PULMONARY VEINS* --> PE can cause!!! - A Flutter: Ectopic foci originates from *TRICUSPID ANNULUS* Pt: - Initially paroxysmal --> then persistent - *Left ventricular hypertrophy and Left atrial enlargement.* - No P-waves - Varying R-R intervals - FAST *HR < 150* (how you tell diff from SVT) - *IRREGULARLY* irregular - Narrow QRS (<three boxes or <0.12) - Chaotic background - Sawtooth if A. flutter Tx: - If not currently in A. Fib, but you suspect? --> *Holter monitor (v. Z-patch)* - If you're seeing them after recent ED visit w/A. Fib? --> Use CHA2DS2VASC to determine whether need anticoagulant or not (doesn't matter if it was just one episode that self-resolved). - If SYMPTOMATIC/STABLE? --> Rate=Rhythm Control ... *BBlockers v. CCBs* - If UNSTABLE (chest pain, SOB, hypotension, signs of poor perfusion)? --> *Cardiovert* Work-up: 1) Assess stability ...if unstable (hypotensive, MI, pulm edema) --> shock ...if stable --> rate control (BBlocker v. CCB) 2) Assess duration ...If <48hr old then "new" onset --> cardiovert (drugs if stable, shock if not) ...if >48hr old or unknown then --> TTEcho - if Valvular --> WARFARIN w/LMWH bridge - If NONvalvular --> Warfarin v. NOAC 3) If goal is cardioversion (young, no CAD, no structural heart issues) then *Anticoagulate for 3wks* --> then TEE --> then Cardioversion --> then Anticoagulate 1mo (WARFARIN) 4) If OLD, CAD, etc. then leave them alone and do RATE CONTROL. Clot risk: CHADS2VASC (CHF, HTN, >75yo, DM, Stroke x2) Score 0 (male) to 1 (female) = No anticoagulation needed Score 1 (male) = Consider Warfarin v. NOAC (dabigatran, apixaban, rivaroxaban) Score 2+ = Recommend Warfarin v. NOAC (dabigatran, apixaban, rivaroxaban)

Hepatitis B

Path: - ACUTE HepB infection in adults is self-limited Pt: - If symptomatic and recently infected (HBsAg, HBeAg, IgM Anti-HBc) - Window phase (IgM Anti-HBc) - If asymptomatic, suggests cleared infection "Recovery" (HBsAb, IgG Anti-HBc, Anti-HBe) - Resolved infection (HBsAb, IgG Anti-HBc) - If symptomatic and diagnosed a while ago (HBsAg, IgG Anti-HBc) - Vaccinated (HBsAb) Dx: - HepB surface Ab = Immune through vaccine OR *exposure* - HepB core Ab = Immune through exposure - HepB (any) Ag = Currently infected - HepB envelope Ag = Infectious Tx: - Exposure & UNVACCINATED? *IV HepB IG + Vaccine* - Exposure & VACCINATED? *Nothing*!!!! or HepB Booster (depends on who you ask)

Drug Induced Acne

Path: - Associated w/*Steroids*, Azathioprine, Cyclosporine, - aka Steroid-induced folliculitis, Steroid acne, Anticonvulsants, Antituberculous drugs Pt: - Acute pappular inflammatory rash - Monomorphic papules w/o associated comedones - Upper back, shoulders, arms Dx: Clinical Tx: DOES NOT respond to typical acne agents!! *Discontinue offending drug* that caused (x. steroids)

Primary Adrenal Insufficiency (Addison's Disease)

Path: - Autoimmune destruction of bilateral adrenal cortex (GFR. Salt, sugar, sex), - *Infection (TB)*, - *Metastasis*!!! (common for lung, breast, kidney, skin primary) - *Chronic Glucocorticoid therapy* (x. SLE) --> Suppresses HPA axis, so when steroids are removed or stress occurs where more stress is needed, there is adrenal crisis. - ADH release is increased as a result of the hypovolemia, which further dilutes sodium. Pt: - *Hyperpigmentation in palmar creases* - & *mucous membranes* (mouth) - Vitiligo - Mineralocorticoid def: --> Hypotension --> HypoNa+ --> Salt craving (only in PRIMARY AI) --> HyperK+ - Glucocorticoid def: --> Fatigue --> Anorexia --> Psych manifestations --> Hyperpigmentation (only in PRIMARY AI), --> *EOSINOPHILIA*....(weird. Like Hodgkins. Apparently d/t loss of cortisol) - Androgen def: --> Loss of libido --> Reduced pubic hair (usually only in women bc men produce androgens from testes) - NORMOCYTIC anemia - Abdominal pain - Diarrhea - HYPERCHLOREMIC Metabolic Acidosis - ACUTE CRISIS? --> Hypotension (often unresponsive to anything but steroids) --> Shock --> Hypoglycemia - PRIMARY ADRENAL INSUFFICIENCY? *Low, or Low-Normal* Cortisol & High ACTH (bc pituitary is producing, adrenals just aren't responding) - SECONDARY (pituitary) or TERTIARY (hypothalamus) ADRENAL INSUFFICIENCY? *Low* Cortisol & Low ACTH Dx: Similar to dx for Cushing! But focused on ACTH. - 1st: *Early AM Cortisol* + *Serum ACTH* (low is central, high is peripheral) - 2nd: *Cosyntropin (synthetic ACTH) stim test* --> If cortisol rises (may even be a blunted response d/t adrenal atrophy from chronic low ACTH) then *PITUITARY* cause... confirm w/MRI... Tx: w/*Cortisol* alone! (aldosterone via RAAS increases salt and regulates BP) --> If cortisol DOES NOT rise then *ADRENAL ISSUE*... confirm w/CT/MRI... Tx: w/*Cortisol + Fludrocortisone* Tx: Corticosteroid replacement therapy (x. *Hydrocortisone* for short acting and better controlled, *Dexamethasone* for long acting) + *IVF* - (+) Mineralocorticoid replacement therapy if needed (x. *Fludrocortisone*) --> Seen w/peripheral adrenal insufficiency

Fanconi Anemia

Path: - Autosomal RECESSIVE Pt: - *Pancytopenia*, - *Hypoplastic thumb and radius* (unlike Diamond-Blackfan which is triphalangeal) - Hyperpigmentation, - Abnormal facial features - Short stature - Developmental delays - NAGMA --> Proximal tubule issue, excrete bicarb. --> HYPOK+

X-linked Agammaglobulinemia (Bruton)

Path: - BTK gene - X-linked recessive (Boys only) - No *B-Cell* maturation --> Decreased ANTIBODY production --> Infected w/*Enterovirus*, Encapsulated organisms, GI bugs. Pt: ~3-6mo old (when mom's antibodies wear off) --> GI & URI bugs....usually *encapsulated* (bc require Abs to opsonize capsule) - Recurrent Bacterial or *Enteroviral infections* - Recurrent Sinopulmonary infections *Strep Pneumo & H. Flu* - Prolonged diarrheal illnesses (Giardia) d/t low IgA - NO TONSILLAR OR ADENOIDAL TISSUE - Low CD19 - Low IgG, IgM, IgA Dx: Quantitative Immunoglobulin w/decreased *Ig of ALL classes* - Could also do flow cytometry (w/low B-cell count) Tx: *Ig Replacement therapy*

Pyogenic Liver Abscess

Path: - Biliary tract obstruction--> obstruction of bile flow allows bacterial proliferation - Other causes: Diverticulitis, Appendicitis - Causative organisms: E.coli, Klebsiella, proteus, enterococcous, anaerobes Pt: - Fever - RUQ pain - Hepatomegaly - Leukocytosis - Elevated LFTs - If in hepatic dome can irritate diaphragm and cause *sterile pleural effusion*, or can eventually rupture into pleural space and cause empyema Dx: US or CT scan (w/ well defined, hypoattenuating, rounded lesion) Tx: *IV abx* and *Percutaneous drainage of abscess*

Respiratory Burn Injuries

Path: - Burn patients are at high risk of RESPIRATORY COMPROMISE (supraglottic airway swells/blisters from heat, smoke, inflammation) Pt: - *Carboxyhemoglobin >10%* - Stridor - Tachypnea - Oropharyngeal inflammation - Carbonaceous sputum - Burns on face - Singeing of eyebrows Dx: Tx: *HIGH FLOW O2* via non-rebreather....but *INTUBATE* if there is evidence of thermal damage to the upper airway (*≥1 of the above sx*) - If thermal skin wounds? IV LR

Toxoplasmic Encephalitis

Path: - CD4<100 Pt: Dx: MRI w/Multiple *BILATERAL* ring enhancing lesions (how you dif from Infective Endocarditis) Tx: *Sulfadiazine + Pyrimethamine + Leucovorin* - then RE-SCAN in 6mo!

Germ Cell Tumors

Path: - Can be a testicular primary - or Mediastinal mass Pt: Dx: *Bx* + *Testicular USD* (to determine primary) SEMINOMA (males), DYSGERMINOMA (females) - "Fried egg" - Elevated Placental-ALP - Maybe elevated B-hCG or LDH - NORMAL AFP NONSEMINOMA (Yolk Sac, Choriocarcinoma, Embryonal carcinoma) & MIXED - Elevated *AFP* - Elevated *B-hCG* Tx: Type and location determines treatment

Degenerative Disc Disease (DDD)

Path: - Can lead to acute disc herniation - NOT associated with spinal fractures Pt: - CHRONIC pain - Low back pain - Worse w/activity - Relieved by rest Dx: Tx:

Varicella Zoster Virus

Path: - Chicken pox (kiddo) - Shingles (adult) typically --> ....but any age can get shingles so long as they have had chicken pox first. --> Can be brought on by stress, *CHEMO*, *SURGERY*, trauma, etc. - Vaccination can cause very mild form (mild rash, no fever) Pt: Rash, *NO fever* - Diffuse pruritic vessels on erythematous base in DIFFERENT STAGES of healing (along unilat. dermatome and PAIN if shingles) - Shingles? PAIN may PRECEDE onset of vesicular rash by several days!! (will have severe tenderness just on lightly brushing skin in that area) --> Post-herpetic neuralgia (continues hypersensitivity of afferent nerves) Dx: Clinical Tx: Supportive - *Acyclovir* if they're at risk of complications OR PRESENT EARLY! Can shorten duration and decrease risk of postherpetic neuralgia - Avoid HIGH RISK individuals *Prevent w/MMRV vaccine, NOT pox parties* *Shingles if had chickenpox before & >60 (should be giving those patients the vaccine)*

DSM-5 Personality Disorders

WEIRD - Paranoid - Schizoid - Schizotypal WILD - Borderline - Histrionic - Narcissistic - Anti-social WORRIED - Avoidant - Dependent - Obsessive compulsive

Emergency Contraception

Path: - Effectiveness decreases the longer you wait. Eligibility for Emergency Contraception? - NO positive UPT (if positive then implantation has already occurred) Tx: - MOST EFFECTIVE? *Copper IUD* (w/in 5 days) - Second most effective? *Ulipristal* pill!! (one time pill can be taken w/in 5 days) - For hormonal options? Levonorgestrel (Progesterone-heavy) is better bc does not cause as much nausea as it would if you used OCPs (estrogen causes nausea)

Alcohol Withdrawal Syndrome

Path: - GABAb receptor Pt: - Tachycardia - Hypertension - Dilated pupils - Tremors - Anxiety - *Alcoholic hallucinosis*/*Seizures* at 12-48hr - *Delirium Tremens* at 48-96hr Dx: Clinical - CIWA protocol can guide treatment, score >8 typically indicates treatment w/Benzo - Watch K+ and Mg+ Tx: "LOT" - "Lorazepam is safe for the Liver" v. Oxsazopam v. Temazepam - If goes untreated can develop DTs (2-4 days after cessation) - Banana bag to replace K+, Mg2+, and B1 (thiamine)...always do before giving anything with glucose. If withdrawal symptoms overlap with opiate withdrawal, priority goes to treating alcohol withdrawal since it is deadly!

Sheehan Syndrome

Path: - High estrogen levels during pregnancy cause enlargement of the pituitary gland without a proportional increase in blood supply. - Peripartum hypotension (*BLOOD LOSS*) can cause *ischemic necrosis* of the pituitary leading to panhypopitutiarism. Pt: Hypotension, Weight loss, Failure of lactation, Amenorrhea, Fatigue - Decreased Prolactin - Decreased TSH - Decreased LH - Decreased FSH - Decreased GH - Decreased ACTH Tx: Replace deficient hormones - No treatment for restoring lactation :( LYMPHOCYTIC HYPOPHYSITIS: Is autoimmune infiltration of pituitary in peripartum or postpartum women NOT triggered by blood loss.

Hypercalcemia

Path: - Immobilization can cause (*Hypercalcemia of immobilization* --> d/t osteoclastic bone resorption) after ~4weeks. - Hydrochlorothiazide use can cause MILD hypercalcemia - Hypercalcemia of malignancy causes more EXTREME hypercalcemia (*>14*) - Primary Hyperparathyroidism would cause high calcium and LOW phosphorus. - Excess VitaminD consumption would cause High calcium and High phosphorus - Milk-Alkali Syndrome would cause High calcium, Low phosphorus, Metabolic alkalosis, and renal injury. Pt: Bones, stones, groans, psychic moans. - "Fatigue, Constipation, Depression" - Polyuria Dx: *Correct for albumin* (low albumin lowers Ca2+, so reality is increased...and high albumin falsely elevates Ca2+ *Pseudohypercalcemia*) - FIRST? get *PTH* --> If High/Normal or High, then Primary Hyperparathyroidism, FHH, or Lithium --> If DECREASED? Get *PTHrp, 25-hydroxyvitamin D, 1,25-Dihydroxyvitamin D* - SYMPTOMS? Go to treat. - NO SYMPTOMS? *Recheck Ca2+*...if still elevated go to treat. Tx: FLUIDS!!!!! Dilute it!!!!!!!! (don't just go straight to furosemide). then.... - for IMMEDIATE phase: *Calcitonin*...if screaming high Ca2+ - for LONG TERM phase: *Bisphosphonates* (inhibit resorption of bone)...most of the time this will be right answer w/IV fluids. - if they're volume UP: Diuretics (really want to avoid this unless in CHF)

HIV Management During Pregnancy

Path: - Increased viral load means more infectious risk Dx: - First? *ELISA* - Then? *Western Blot* to confirm - Then? Get *Viral load + CD4* Tx: All pregnant women w/HIV should take *ART as soon as possible!!* esp. *Zidovudine* which lowers transmission rte to baby during delivery! --> *2+1* (2NRTi + 1NNRTi) or (2NRTi + 1Pi+Ritonovir) --> *Tenofovir + Emtricitabine + Nevirapine* or *Zidovudine + Lamivudine + Atazanavir + Ritonovir* - Regardless of CD4 count or viral load - Minimizes maternal risks of infection - Reduces perinatal transmission Give *postexposure ART prophylaxis* to neonate - Two NRTI (Tenofovir + Emtricitabine) + integrase inhibitor (v. protease inhibitor v. NNRTI) If *≤1,000 copies* viral load and on HAART? - May deliver *VAGINALLY* If *>1,000 copies* viral load, or NOT on HAART? - Need *intrapartum AZT* and delivery via *C/S* If in USA, no breastfeeding w/HIV --> formula feed instead

Left Ventricular Aneurysm

Path: - LATE complication of MI - Can occur *MONTHS* after - d/t scarring and fibrosis of LV wall after injury of MI Pt: Progressive LV enlargement - Heart failure - Refractory angina - JVD - Pulmonary crackles - Shortness of breath - Secondary mitral regurgitation - Ventricular arrhythmias - Worry about mural thrombus Dx: EKG w/ *PERSISTENT ST-ELEVATION* & *DEEP Q WAVES* in the SAME LEADS would be unchanged from study done at MI, months prior. - Confirm w/*Echo* (shows thinned and dyskinetic myocardial wall)

Tinea Capitis

Path: - MC in African Americans - Contagious via direct contact or fomite (shared combs) Pt: Itchy, scaly patch on head w/hair loss - Lymphadenopathy may be present - Black dots in affected areas Dx: Clinically - Can use KOH to confirm Tx: Griseofulvin + Terbinafine

Optic Nerve Injury

Path: - Mcc indirect during trauma --> *shearing forces* of injury are transmitted to the optic canal causing contusion or avulsion of the nerve Pt: - Acute vision loss - *Inability to perceive light* - Color vision may be impaired - Relative AFFERENT pupillary defect Dx: *Emergency CT of orbit* Tx: 50% improve with conservative management - Other 50% need surgery

Gastric Outlet Obstruction

Path: - Mcc malignancy, Peptic Ulcer Disease, Crohn Disease, secondary to Caustic agents, Gastric bezoars. Pt: - Postprandial pain - Postprandial vomiting of *partially digested* food - Early satiety - Nausea - *Succussion splash* (place stethoscope on upper abdomen, rock patient back and forth...represents retained gastric material >3hr after meal) Dx: Upper Endoscopy Tx: Surgical

Obsessive Compulsive Disorder (OCD)

Path: - OBSESSIONS --> anxiety forming (internal, intrusive, unwanted, THOUGHTS/preoccupations or URGES or IMAGES) - COMPULSIONS --> anxiety reducing Pt: Time-consuming, Ego*DYSTONIC* (they know is wrong but do anyways) - OBSESSIONS --> Safety, Contamination, Symmetry - COMPULSIONS --> Checking locks, Cleaning, Counting - Postpartum? Fears of contaminating or harming baby. - Intrusive thoughts - Repetitive behaviors Dx: Clinical - Time consuming *>1 hour/day* - Brain imaging w/structural abnormalities in the *orbitofrontal cortex* and *basal ganglia* Tx: *CBT* >> SSRIs - Therapy focuses on EXPOSURE and RESPONSE PREVENTION (make do thing they fear without allowing them to do compulsion) - Last line could use *Clomipramine* (TCA)

Late Term Pregnancy / Post Term Pregnancy

Path: Late term pregnancy = *≥41 wk gestation*. Post-term pregnancy = *≥42 wk gestation*. - Decreased placental fx due to age related placental changes (infarction, calcification) --> blood preferentially distributed to the brain rather than peripheral tissue --> *Oligohydramnios* - Complications = Uteroplacental insufficiency, Chronic fetal hypoxemia. - RF = Increasing gestational age Tx: Frequent fetal monitoring (NST, amniotic fluid index) - *Late decelerations or Oligohydramnios*? *Delivery* (to prevent intrauterine fetal demise) --> Could be vaginal or C/S depending on other features

Epithelial Ovarian Carcinoma

Path: - Presents advanced most commonly, bc sx are nonspecific - Often found incidentally - RF = BRCA, Endometriosis, Infertility, Hormone replacement...cumulative estrogen exposure - OCPs, Multiparity, Breast feeding protect Pt: Usually asymptomatic - Postmenopausal women - Firm, nonmobile pelvic mass --> with nodularity? Mets - Constipation - Bloating - Dyspnea - Pleural effusion (mets to pleura) - "ALARM FEATURES" --> Onset constipation ≥50yo --> Early satiety --> *Constant pain unrelated to bowel movements* Dx: - FIRST? *USD* (mass w/thick septations and increased vascularity) --> Elevated *CA-125* - Then *CT* to assess for mets - If no mets? *Laparotomy* for surgical staging and tumor debulking - DO NOT biopsy the mass, could rupture it and spread mets throughout the abdomen. Tx:

Penile Cancer

Path: - RF = (similar to other scc genital cancers) *HPV*, *Smoking*, Phimosis Pt: - Men >60yo - PAINLESS penile nodule or ulcer (often for several months)...can look like a Chancre, but lasts longer - LNDs Dx: Bx Tx:

Hemorrhoids

Path: - RF = Constipation, Increasing age, Straining Pt: LOW VOLUME bleeding - INTERNAL? Painless, Bright red rectal bleeding - EXTERNAL? Painful, Pruritic, usually do NOT bleed Dx: - External? Clinical - If young, otherwise healthy, with typical sx? *Anoscopy* - Otherwise, *Colonoscopy* Tx: Increased intake of *FLUID & FIBER*, decreased consumption of fat and alcohol, and increased exercise. - Then PrepH (aka phenylephrine) and/or Sitz baths ...If still no improvement? - INTERNAL? Banding - EXTERNAL? Hemorrhoidectomy (>50% circumference of anus is bad idea)

Pulmonary Embolism (PE)

Path: - RF = Malignancy, HIV, Immobility, Hemoconcentration (losing fluid), Pregnancy - *FEMORAL VEIN* is MC source of PE!!! Though calf veins are mc source of DVT. Pt: - Chest pain (esp *pleuritic*) - Hemoptysis, --> More commonly caused by infarction of peripheral pulmonary artery - TACHYCARDIA, - TACHYPNEA, - *Normotensive*, --> Unless is a MASSIVE PE...in which case it is defined by *HYPOtension* and/or signs of *Right heart strain* - LE swelling - Pleural effusion (EXUDATIVE, bloody, painful) - Low grade fever - JVD - Mild leukoctyosis - Elevated troponins - ABG = Increased pH b/c decreased CO2 - CXR = Mc *NORMAL* (or wedge shaped infarct) - CT = "Pulmonary artery filling defect" - EKG = Pulm HTN w/R heart strain pattern (S1Q3T3) --> May also see A. Fib ("no organized p-waves") - V/Q mismatch --> 100% ventilation and 0% perfusion, body then vasodilates to try and get more O2 --> fluid leaks out --> larger diffusion barrier for O2 Dx: Well's Criteria Symptoms of DVT - 3 History of DVT - 1.5 Immobilization >3 days or post OP >4wks - 1.5 Tachycardia - 1.5 PE being #1 dx or equally likely -3 Malignancy - 1 Hemoptysis - 1 Still "SHIT PMH" - Score <2? LOW PROB --> DDIMER - Score ≥4? HIGH PROB (when considering CT) --> *CTA* (but kidneys must be good) - Score ≥6? HIGH PROB (when considering V/Q) --> *V/Q Scan* (for bad kidneys, morbidly obese pts, contrast allergy...but need normal CXR first) - Pregnant? *V/Q* --> High probability? It's a PE. --> Low probability? If their pretest was low probability it's ruled out. If not, get *CTA* (yes, even if preggo) to confirm. --> Normal? RULES OUT PE. !!!!!!!!! If patient has LIKELY PE based on Well's Criteria, and are in *MODERATE TO SEVERE DISTRESS* --> Give *Heparin or LMWH* BEFORE you do diagnostic imaging !!!!!!!!!! Tx: - FIRST!!! Heparin bridge! (5 days or until INR is 3...whichever is LONGER). Then...Warfarin (once PTT is 1.5-2x normal) - or NOAC (no need for bridge!) --> can't use unless GFR>30!!! Same w/LMWH. - Pregnant? *LMWH* is ideal. Could use *Heparin* if kidneys suck. - CI to anticoagulants? *IVC Filter* - if MASSIVE PE w/HYPOTENSION? --> tPA - if CANCER? --> LMWH for rest of life..

Myocardial Infarction (MI)

Path: - RF = Smoker, Estrogen therapy, Fam hx, CVD, Hyperlipidemia Pt: - Retrosternal chest pain - Radiates to Left arm - Diaphoresis - Nausea - Vomiting Dx: ECG + Troponins Tx: MONABASH STAT.... - Morphine - O2 (if <90%) - Nitrates (NO if R-sided MI, bc R heart is PRELOAD dependent...*AVF, III, II*) - Aspirin (asap) CAN WAIT.... - Beta-blocker - Ace-i - Statin - Heparin (caution w/HTN) - Clopidogrel (for stents! drug eluting = 1yr of clopidogrel, bare metal stent = 1mo)

Pancreatic Cancer

Path: - RF = Smoking (reversible) is #1, Chronic pancreatitis, First degree relative, Obesity, Low physical activity, Longstanding DM (metformin lowers risk of pancreatic cancer, sulfonylureas increase risk), BRCA, Peutz Jeghers syndrome Pt: - Men - Smokers - Middle aged - Sudden onset DM - "Gnawing, constant epigastric pain" - Succession splash if Gastric Outlet Obstruction - *Pancreatic cancer in BODY or TAIL* --> Constant back pain (*T5-T10*) worse when SUPINE at NIGHT, Normal spinal XR, Normal PE - *Pancreatic cancer in HEAD (MC) --> Obstruction...jaundice, STEATORRHEA, epigastric pain* - *Migratory thrombophlebitis* (inflammation of vein and then thrombus, seen along distribution of the nerve) Dx: *CT of Abd* (NOT ercp........TARRAAAAAA...thats for ducts) - If jaundice present indication head of pancreas, and they're on a budget, can do *USD* Tx: - Pruritus? *Endoscopic stent placement* (routes Common Bile Duct and jejunum)....for symptomatic relief

Laryngeal Squamous Cell Carcinoma

Path: - RF = Smoking, Alcohol Pt: - Persistent, constant hoarseness (>30d) - Fungating laryngeal mass - Dysphagia - Airway obstruction - Referred otalgia (d/t CN XI or X irritation) - Hemoptysis - Cervical LNDs Dx: *Laryngoscopy* Tx:

Atherosclerotic Cardiovascular Disease (ASCVD)

Path: - RF = Smoking, Hyperlipidemia, Male, Age >40 Dx: HIGH RISK IF.... - *LDL ≥190* - *CHA2DS2* w/10-year risk of *>7.5-10%* - Age *≥40 w/DM* Tx: *Lifestyle modification* - If at *CHA2DS2* w/10-year risk of *>7.5-10%*, *≥40yo w/DM*, or *LDL ≥190*? *Atorvostatin* v. *Rosuvastatin* (either preferred bc they are stronger) - If HIGH RISK and *>50yo*? *+ ASA*

Psychotic Disorder

Path: - Reaction to trauma or stressor - Pregnancy induced psychosis - Postpartum psychosis - Medication induced (x. steroids) Pt: POSITIVE symptoms 1. Delusions (persecution, grandiosity) 2. Hallucinations (auditory) - more common than delusions in pediatric cases. 3. Disorganization of SPEECH 4. Disorganization of BEHAVIOR NEGATIVE symptoms 5. Flat affect 6. Poverty of speech and movement 7. Anhedonia 8. Cognitive delay (becomes more impaired with each cognitive break) Dx: FIRST r/o *OTHER MEDICAL CONDITION, DRUGS, etc* which may cause (urine toxicology, CMP, CBC, TSH, Vitamin B12, Syphilis, ANA) - *≥1 symptoms* - Duration *>1 day, <1 month* w/full return to function Tx: Antipsychotics (*1 MONTH*) - If caused by other medical condition? Fix that. - Caused by a med? Stop that.

Pericardial Effusion

Path: - Recent URI (viral pericarditis often causes), - Recent thoracic surgery (esp heart) Pt: - Pleural effusions, - JVD, - Muffled heart sounds, - Tachycardia - Tachypnea - Borderline low blood pressure Dx: Echocardiogram - EKG w/ *Electrical alternans* - CXR w/ *Enlargement of cardiac silhouette*

Herpes Simplex Virus

Path: - Recurrence becomes less frequent in time due to improved immunity Pt: - Painful - Multiple pustules, vesicles, small ulcers on erythematous base - Tender lymphadenopathy - Fever - Headache - *Urinary retention* - Sterile pyuria - Signs of congenital infection? IUGR, Preterm delivery, Blindness Dx: *HSV PCR* - NO tzanck test anymore. Tx: *Acyclovir v. Valcyclovir* (reduce symptom severity and frequency of recurrence but doesn't stop outbreaks entirely) - If left untreated? Would resolve spontaneously in the next week. - Pregnant? See pic. *Prophylactic Acyclovir* starting at *36 wks* until delivery --> decreased risk of vertical transmission - Active lesions at delivery? *C-section*

Dissociative Amnesia

Path: - Stressor or event can cause - WITH v. WITHOUT *FUGUE* (unexpected travel/more severe, with invention of new identity) Pt: Amnesia - Can lose every day occurrences or routines (x. loss of memory of an event) - or can lose entire autobiography (don't know who they are or any prior personal hx) Dx: - r/o Neurological condition - r/o Drugs Tx: *Psychodynamic psychotherapy*

Cervical Lymphadenitis in Children

Path: - Unilateral? MCC Staph or Strep - Bilateral? MCC Virus Pt: Unilateral or Bilateral (look at pic) LYMPHADENOPATHY Tx: - Unilateral? *Clindamycin*

Hereditary Angioedema

Path: *C1 esterase inhibitor deficiency* --> elevated bradykinin - Autosomal DOMINANT - Acquired mc d/t *Ace-i* - Emotional stress or trauma can cause!!! Pt: - Recurrent edema of face, limbs, genitalia - Laryngeal edema (less common but life threatening) - Bowel wall edema --> diarrhea, colicky abdominal pain, vomiting Dx: - Low C4 - Low C1 inhibitor function Tx: - If d/t stress or trauma? Self resolves....but could give *C1 inhibitor* - If d/t Ace-i? Stop med. - If airway obstructed or vasomotor instability? *EPINEPHRINE* - If airway does not respond to Epi? *Emergency tracheostomy*

Stress Induced Cardiomyopathy (Takotsubo)

Path: "Broken heart syndrome" - Thought to be d/t a catecholamine surge brought on by severe physical or emotional stress --> Microvascular spasm causes ischemia and myocardial stunning which leads to impaired contraction Pt: - Postmenopausal women - Intermittent mid-sternal pressure-like chest pain - Dyspnea - LE swelling - Segmental left ventricular dysfunction which gives heart characteristic shape --> Mid- and Apical HYPOkinesis --> Basilar HYPERkinesis Dx: *Echo w/Balloon shaped heart* --> Hence the name "Takotsubo" which means "octopus trap" - ECG w/*ST changes* and *T-inversions* - Troponin may be elevated - Coronary angiogram shows absence of CAD Tx: Supportive, resolves on its own in several weeks

Retinal Artery Occlusion

Path: "Eye stroke" - AMAUROSIS FUGAX is the Eye TIA. Pt: Painless acute loss of vision - UNILATERAL - No other FND - NOT transient (amaurosis fugax) - *Cherry red spots on fovea* - *Central pallor* Dx: Clinical Tx: *Intra-arterial tPA* - If you don't have this then can Hyperventilate v. Global pressure (push eye)

Delusional Disorder

Path: "Fixed false belief". Persistent delusions and no other psychotic symptoms. - Non bizarre delusion - *NO* impairment Pt: - Behavior not obviously bizarre (aside from delusions appears normal) - Ability to function apart from delusion's impact - Subtypes: Erotomaniac, Grandiose, Jealous, Persecutory, Somatic (x. thinking eczema on skin means they are being poisoned) Dx: - *≥1 delusion* - Duration of *≥1 month* Tx: *Antipsychotics* v. *CBT*

Sturge-Weber

Path: "Tram on rails with sturgeon fish over web logo. The tram is shaking. A turtle sits at a table inside trying to drink wine but it spills on the three gems he's examining" Pt: - Intellectual disability - Port wine stain over TRIGEMINAL nerve distribution --> Associated *Leptomeningeal capillary venous malformation* affecting the brain and the eye behind - Seizures (focal at first, then generalized) --> Hemiparesis contralateral the intracranial malformation present at time of seizure onset - Visual impairment d/t *capillary venous malformations* - Glaucoma - Tram track sign on skull radiographs Dx: *MRI* w/*intracranial vascular malformation* seen Tx: Reduce seizures & reduce intraocular pressure - Could try laser therapy for the port wine stain

Factitious Diarrha

Path: (Factitious disorder) Intentional falsification of illness without external reward Pt: - Vitals normal - PE normal (or tender in all 4 quadrants) - Lab results normal - Colonoscopy normal or Melanosis Coli - No signs of weight loss, malnourishment etc - Goal of sick role! May take illness and exacerbate/dramaticize Dx: *Stool osmolality* v. *Stool electrolytes* v. *Stool osmolar gap* (osmotic laxatives cause this)

Nonclassic Congenital Adrenal Hyperplasia

Path: *21-hydroxylase deficiency* --> shunts to producing androgens (increased 17-hydroxyprogesterone) - Autosomal recessive Pt: - Acne - Early hair - Hirsutism in girls w/onset in adolescence - NORMAL gluco- and mineralocorticoids!!!! (unlike CLASSIC CAH) - NO virilization (clitoromegaly). - Elevated DHEAS Dx: *Exaggerated 17-hydroxyprogesterone response w/ACTH stim test* Tx: *Hydrocortisone* - NO mineralocorticoids needed!!

Interventricular Septum Rupture

Path: *3-5 days* following MI Pt: - Hypotension - Dyspnea - JVD - *Harsh holosystolic murmur at the lower left sternal border* - *Palpable THRILL* Dx: Pulmonary artery cath or TEE

Opiate Withdrawal

Path: *6-12hr* after last dose - Peak at 36-72 hours - Can last for several days - Norepinephrine is the primary cause of withdrawal symptoms Pt: *FLU-LIKE SYMPTOMS* - INCREASED bowel sounds - Restlessness - Anxiety - Diaphoresis - Tachycardia - Elevated BP - Nausea - Vomiting - Cramping - Lacrimation - Rhinorrhea - Yawning - Piloerection - Arthralgias - Myalgias Dx: Clinical Tx: *Low-dose methadone v. Buprenorphine* - Anxiety, Restlessness, HTN? *Clonidine* - Diarrhea? Loperamide - Myalgias? Ibuprofen - Muscle cramps? Baclofen - If pregnant and trying to get off opiates? *Methadone* v. *Buprenorphine*

Conduct Disorder

Path: *<18 yo* version of Antisocial personality disorder - Must have shown symptoms *BEFORE 15yo* Pt: Aggression to people and animals, destruction of property, serious violations of rules. 1. Often bullies, threatens, or intimidates others 2. Often initiates physical fights 3. Has used a dangerous weapon that can harm others 4. Has been physically cruel to others 5. Has been physically cruel to animals 6. Has stolen while confronting a victim (mugging) 7. Has forced someone into sexual activity 8. Has deliberately set fires with intention to cause serious damage 9. Deliberately destroyed the property of others Deceitfulness or theft 10. Broken into someone else's house or car 11. Often lies to obtain goods or favors, or to avoid obligations 12. Steals items of a nontrivial value without confronting the victim. 13. Stays out at night despite parental objections (beginning before age 13) 14. Has run away from home at least twice for an extended period of time 15. Often truant from school (beginning before age 13) Dx: Clinical - *≥3* of above symptoms Tx: Juvenile detention - F/up Antisocial personality disorder

Acute Hemolysis

Path: *ABO Incompatibility* of blood transfusion Pt: *MINUTES TO HOURS* after transfusion - ACUTE!! - Fever - Flank pain - Hemoglobinuria - Renal failure - DIC Tx: Stop Transfusion

Neuroleptic Malignant Syndrome (NMS)

Path: *ANTIPSYCHOTIC medication induced* (dif from Malignant catatonia & Malignant hyperthermia) - Onset over *days* (vs hours in Serotonin syndrome) Pt: - Fever - Tachycardia - Hypertension (or labile blood pressure) - DELIRIUM (often first sx) - Altered mental status - Autonomic dysregulation (HTN, then hypotension, diaphoresis, etc) - *Lead pipe rigidity* (how you tell dif from serotonin syndrome) - Tremor - Elevated CK - *Myoglobinuria* (UA w/blood but few RBCs) _ *Leukocytosis w/left shift* (....weird)!!! - Normal DTRs Dx: Clinical Tx: Stop antipsychotic + *BENZO!!!* + Supportive care - Refractory? *Bromocriptine* v. *Amantadine* v. *Dantrolene*

Alopecia Areata

Path: *Autoimmune* attack on hair bulb cells - Genetic predisposition - Develops over weeks in discrete patches Pt: - Painless - Patchy - Scalp underneath smooth and hairless - NO erythema, scaling, scarring Dx: Positive hair pull test (*>5-6 hairs extracted) - Narrowing of hair shaft close to scalp (*Exclamation point hairs*) Tx: Most have regrowth over time - Mild/Moderate? *Topical or intralesional corticosteroids* - Extensive? *Topical immunotherapy + Oral corticosteroids*

Prognostic Factors in Schizophrenia

WORSE PROGNOSIS - Early age of onset - Negative symptoms (bc antipsychotics are better at treating positive sx....we don't have great way to treat the negative ones) - Gradual - Fam hx - Long duration untreated - Male

Benign Prostatic Hyperplasia

Path: *CENTRAL* (TRANSITIONAL ZONE) portion of prostate becomes hyperplastic w/age. - This is the part that surrounds urethra, so causes the urinary obstruction sx. Pt: - Male - Age >50 - Urinary frequency - Urinary urgency - Pushing with urination Dx: Clinical - Get *PSA* to r/o cancer --> Would be normal or mildly elevated if BPH, and significantly elevated if cancer Tx: *Tamsulosin* provides immediate sx relief - Could also start *Finasteride* which takes several months to start working but helps to reduce risk of prostate cancer.

Tertiary Hyperparathyroidism

Path: *Chronic kidney disease* causes HYPOCALCEMIA and hyperphosphatemia. (d/t Vitamin D deficiency), which triggers release of PTH (Secondary Hyperparathyroidism) ......If this goes on for long enough it causes *Hyperplasia of the parathyroids* --> Then begins to release PTH even if Ca2+ is NORMAL!! = TERTIARY HYPERPARATHYROIDISM Pt: - High PTH levels - Hypercalcemia (d/t bone resorption, though serum value is often normal) - Hyperphosphatemia (d/t renal retention) Dx: Tx:

Postthrombotic Syndrome

Path: *Chronic venous insufficiency* following DVT - 50% of patients develop this within 2 yrs of DVT d/t *Venous HTN* distal the site of prior thrombus Pt: - Progressive unilateral LE pain - Edema (pitting) - Fatigue - Superficial venous dilation - NO erythema - NO calf pain or tenderness Dx: Doppler USD to r/o DVT Tx: *Exercise + Compression stockings*

Dementia with Lewy Bodies (DLB)

Path: *Eosinophilic cytoplasmic inclusions of alpha-synuclein* (aka Lewy Bodies) - Primarily effects the extrapyramidal motor system that has NO DTR response Pt: - Visual hallucinations - Parkinsonism - Fluctuating cognitive impairment - Autonomic dysfunction (HR, orthostatic hypotension) - REM sleep behavior disorder - Depression - Postural instability --> Frequent falls Dx: Dementia + *≥2 features* (see above) with onset of *dementia FIRST or AT THE SAME TIME as parkinsonism*. - Brain Bx would show LEWY BODIES *Eosinophilic intracytoplasmic inclusions*, which are inclusions of *alpha synuclein* - If Parkinsons develops FIRST *>1yr*? Then *Parkinson Disease Dementia*, even if has dementia and hallucinations later on... - If Dementia + 1 of the above? NOT DLB!!! Is PARKINSON'S!! Tx: - Parkinsonism? *Carbidopa-Levodopa* - Cognitive impairment? *Cholinesterase-inhibitors* (x. Rivastigmine) - REM sleep behavior disorder? *Melatonin* - Impairing hallucinations? *Anti-psychotic* (x. Quetiapine) --> *USE WITH CAUTION*! DLB patients are very sensitive to these (associated w/confusion, worsening parkinsonism, and autonomic dysfunction)

Medulloblastoma

Path: *HIGHLY MALIGNANT* tumor which develops in the *vermis of the CEREBELLUM* --> Can compress 4th ventricle and cause obstructive hydrocephalus - Anterior fossa for ADULTS - *Posterior fossa for PEDS* (MC) - Seeds arachnoid space....can have distal lesions in spinal cord - Concerned about Obstructive hydrocephalus (progressive headaches, N/V) Pt: - Cerebellar dysfunction, issues with balance and gait - Ataxia - Wide based gait - Increased ICP - Headache - Vomiting - Papilledema - Bilateral *ABDUCEN (CNVI) PALSIES* w/issues looking laterally Dx: MRI Tx: Surgery + Chemo + RT

Warts

Path: *HPV* enters the skin through tiny cuts or abrasions and then direct contact w/individual w/HPV - Could be in plantar, palmar, or genital areas - MC in young adults and immune compromised Pt: - "Hyperkeratotic papules" - Painful when walking or standing Dx: Tx:

Neonatal Indirect Hyperbilirubinemia

Path: *INDIRECT* hyperbilirubinemia occurs in varying degrees in ALL NEWBORNS --> ALL Fetal RBCs are increased at birth and have shorter lifespan (= increased turnover) --> Hepatic bilirubin clearance is decreased bc *UGT* activity doesn't reach adult levels until 2wks!!! --> Enterohepatic recycling is increased bc immature gut flora can't convert it to urobilinogen for excretion Also consider ABNORMAL causes. Such as.... - Increased production: --> Rh isoimmunization, --> ABO incompatability, --> Spherocytosis, --> G6PD Deficiency, --> *Cephalohematoma* (bc RBCs in the space are broken down and resorbed), --> Polycythemia. - Decreased clearance: --> Gilbert Syndrome, --> Crigler-Najjar Syndrome - Increased enterohepatic circulation? --> Lactation failure jaundice, --> Breast milk jaundice. - RF = Exclusive breast feeding, Prematurity, Jaundice <24hr, Family hx Pt: - Jaundice - Liver margin >3cm in an infant is ABNORMAL Dx: Total Serum Bili Tx: Phototherapy - If physiologic? Benign. Resolves in 1-2wks. Recommend frequent feeding.

Sideroblastic Anemia

Path: *Iron* gets stuck in the mitochondria, so marrow throws more iron at them causing elevated Fe in blood - Reversible causes? Drugs, alcohol, *lead* - Irreversible causes? B6 deficiency, myelodysplastic syndrome Pt: Ringed sideroblasts Dx: - ELEVATED Fe - NORM Ferritin - NORM TIBC

Cauda Equina Syndrome

Path: *L3 and LOWER* spinal segments Pt: - MORE SEVERE pain (compared to Cona Medullaris) - Saddle anesthesia (inner thigh, anus, genitalia) --> Patchy sensory loss - ASYMMETRIC paresis of legs - HYPOreflexive (how dif from Cona Medullaris, bc involves nerves just outside of cord) - Erectile dysfunction - Urinary retention LATER - Rectal sphincter dysfunction - Gradual onset Dx: MRI Tx: *EMERGENT Surgical Evaluation* (within 24-48hr to prevent permanent nerve damage)

Wallenberg Syndrome (lateral medullary syndrome)

Path: *Lateral medullary* infarction. D/t occlusion or dissection of ... - *Posterior inferior cerebellar artery* - *Vertebral artery* (can dissect from head tilting back and left) Pt: - Nystagmus - Vertigo (falls to side of lesion) - Nausea - Loss of pain and temperature on IPSILATERAL face - Loss of pain and temperature on CONTRALATERAL body - Ipsilateral Horner syndrome (miosis, ptosis, anhidrosis) - Dysphagia - Dysarthria - Hoarseness Dx: MRI Tx: - Occlusion? IV thrombolytics

Bronchopulmonary Dysplasia (BPD)

Path: *Long term* consequence of RDS (decreased surfactant). De-recruitment of alveoli, can't get O2 into the blood --> *Scarring* - Causes = Mechanical ventilation, Prolonged O2 exposure (you'd given them O2 for *>28 days*), Inflammation. - RF = Prematurity, Low birth weight, RDS. Pt: Premature infant w/increased O2 demands. - Tachypnea - Ronchi Dx: XRay w/*Ground glass opacities* - "NEW" (premature)? *Alveolar hypoplasia with decreased septation* - "OLD" (on ventilator for long time)? *Coarse lung markings with cystic changes* Tx: *Surfactant* POST-natal - *Steroids* ANTE-natal - F/up Diffuse Pulmonary Lung Disease (diseased lungs from scarring)

Pellagra

Path: *Niacin (B3)* deficiency - Can be synthesized from tryptophan Pt: "the D's" - Diarrhea, Abdominal pain, Nausea - Dementia (d/t neuronal degeneration) - Dermatitis (sun exposed areas, rough and scaly) - Death - Atrophic glossitis

Anti-NMDA Receptor Encephalitis

Path: *Ovarian teratoma* (or other tumor...) induces AUTO-IMMUNE ENCEPHALITIS Pt: (may look like Serotonin Syndrome) - Anxiety - Psychosis - Insomnia - Autonomic instability (hyperthermia, hypertension, tachycardia) - Rigidity - *Hyperreflexia* - Dystonia - Focal seizure after flu-like prodrome Dx: Clinical - Confirm w/*CSF antibodies to GluN1 subunit of NMDAR* Tx: *Immunosuppressive therapy* ± *Tumor removal* (if applicable)

Dupuyten's contracture

Path: *PALMAR FASCIA* "balls" up and *FIBROSIS* - RF = DM, Alcohol use, Tobacco use Pt: Alcoholics and Scandinavian men - Can't EXTEND - Palpable fascial nodules on palm (usually at base of ring finger) --> Eventually become fibrotic cords - Contracture Dx: Clinical Tx: Needle disruption of cords v. Glucocorticoid injections - SURGERY for refractory cases

Cruetzfeldt-Jakob Disease (CJD)

Path: *Prion* disease (misfolded proteins cause other proteins to misfold, creating neurotoxic fibrils) - Fatal transmissible spongiform encephalopathy - MC sporadic!!! But can be iatrogenic, hereditary, or from consumption of infected neural tissue. - 10 year incubation period!!! But rapid death once sx develop... Pt: Typically *RAPID and SUDDEN* development (over course of couple months) - Sleep disturbances - Mood symptoms - Rapidly progressive dementia - Myoclonus (provoked by *startle*) - *UMN* signs - Hypokinesia (slow movement) - Cerebellar dysfunction - Hypersomnia Dx: *EEG* w/*PERIODIC SHARP TRIPHASIC WAVE COMPLEXES* - Confirm? *MRI* w/widespread ATROPHY of cerebrum and cerebellum, cortical enhancement (cortical ribboning) and enhancement caudate and putamen (*hockey stick sign*) - CT is NORMAL! - Increased *14-3-3 protein* in CSF - Increased Tau (like Frontotemporal dementia) - CSF w/*real-time quaking-induced conversion testing* (RT-QuIC) POSITIVE --> you take abnormally folded proteins from CSF and isolate w/normal ones and watch conversion (misfolding) via fluorescence --> Otherwise, CSF is "noninflammatory". Tx: None....*death within 1 year* regardless of treatment.

Atraumatic Splenic Rupture

Path: *Recent viral infection* (x. EBV, CMV) or malarial infection causes splenomegaly, then blunt abdominal trauma occurs and ruptures it. - Contact sports should be avoided until *3-4 weeks* after infection. Pt: - Hypotensive - Tachycardia - Pale - Sweating - Abdominal pain - FAST w/intraperitoneal fluid --> Referred Left Shoulder pain - Anemia

Bacterial Conjunctivitis

Path: *STAPH AUREUS* Pt: - MUCOPURULENT discharge - Bilateral - *NO* lymphadenopathy - Otitis media. Tx: Azithromycin v. Erythromycin v. Polymyxin-trimethoprim - Contacts? Fluoroquinolone drops.

Vascular Dementia

Path: *Stroke or cerebrovascular disease* - Large vessel atherosclerosis (anterior cerebral artery could cause deficits of the frontal lobe --> executive function, personality, memory.) - Small vessel disease (x. Arteriosclerosis) - Cerebral amyloid angiopathy Pt: - CORTICAL TYPE (large artery infarction) --> Usually associated w/stroke --> S/sx reflect the cortical region effected --> Follow *stepwise* worsening course - SUBCORTICAL TYPE (small arterial distribution infarctions) --> Focal motor deficits (x. reflex asymmetry, abnormal gait, urinary sx, psych sx) --> Follow *gradual* declining course - EARLY prominent *executive dysfunction* (much more severe then issues with memory, how you differentiate from Alzheimers) - Cardiovascular risk factors - Behavioral changes - Memory loss Dx: Single strategic infarcts (abrupt decline in fnx) vs. Multiple infarcts - Cortical infarcts - Subcortical lacunar infarcts - White matter hyperintensities Tx: - Risk factor modification - Cholinesterase inhibitor - Antiplatelet therapy

Ataxia Talengiectasia

Path: *T-cell deficiency associated with defective DNA repair* - Autosomal RECESSIVE - Mutation in ATM gene (critical role in repair of dsDNA breaks, activation of NF-kB and cell cycle progression) Mutation causes defective: - TCR and Ig rearrangement - T-cell activation - Lymphocyte proliferation Pt: Can look like SCID but with talengiectasias - *Ataxia* due to cerebellar Purkinje cell degeneration - *Telangiectasias* (dilated small blood vessels) - Recurrent sinopulmonary infections (decreased serum Igs, poor T-cell function) - Predisposition to *Leukemia and Lymphoma* Dx: - Decreased T-cells - Decreased B-cells - Decreased Immunoglobulins

Cona Medullaris Syndrome

Path: *T12 to L2* spinal segments Pt: - LESS severe pain (compared to Cauda Equina) - Perianal numbness - SYMMETRIC paresis of legs - HYPERreflexive (bc involves cord, how dif from Cauda Equina) - Erectile dysfunction - Urinary & fecal incontinence EARLIER - Sudden onset Dx: MRI Tx: *EMERGENT Surgical Evaluation* (within 24-48hr to prevent permanent nerve damage)

Bladder Cancer

Path: *Transitional cell* - RF = Smoking, Aniline dyes, Family hx Pt: - >40yo raises suspicion - Male - Smoker - Dysuria - Urgency - Frequency (tumor reduces bladder volume) - Suprapubic pain (tumor has penetrated muscle and invaded soft tissue and nerves) - PAINLESS hematuria THROUGHOUT micturition --> Or *AT END* of micturition (indicates bleed from bladder, prostate, or posterior urethra....v. hematuria at beginning which indicates urethral bleed) --> *CLOTS* also indicate bladder (nonglomerular) source - Obstructive symptoms Dx: UA w/RBCs...then *Cystoscopy* - Then CT Urography to look for mets Tx: Transurethral resection + BCG (Bacillus Calmette-Guerin) + Chemo (w/Cisplatin) - Cystectomy if recurrent or invasive - USPSTF does NOT recommend screening, even in high risk individuals (doesn't improve outcomes)

Fragile X Syndrome

Path: *Trinucleotide repeat* of CGG repeat expansion of FMRI - X-linked dominant Pt: - Long face w/prominent forehead and jaw (chin) - Large protruding ears - Deep set eyes/"Hooded" eyes - Macroorchidism - Macrocephaly - Joint hypermobility - Speech and motor delays - ADHD - Mental retardation - Autistic features (hand flapping, hand biting) - Social deficits - *NORMAL life expectancy*!!! - FEMALES tend to have less severe sx bc can have one normal X Dx: *FMR1 DNA Analysis* followed by Southern Blot to measure the length of repeat

Meniscal Tear

Path: *Twisting* injury Pt: - *CLICKING*, - *Popping* - *LOCKING*, - Joint "giving-away" - Crepitus - *EFFUSION* (may develop slowly over next day) - Tenderness at the joint line Dx: MRI - Then arthroscopy - Thessaly or McMurry Test Tx: - Mild? Rest + Activity modification - Persistent? Surgery

Ramsay Hunt Syndrome

Path: *VZV facial neuritis*...(unlike Bell Palsy which is HSV) Pt: - Ear pain - *Vesicular eruption in the external auditory canal* (how you dif from Bell Palsy) - Ipsilateral upper and lower facial paralysis - Can spread to involve *CNVIII as well*!! --> Tinnitus --> Hyperacusis --> Hearing loss --> Vertigo --> Nausea --> Vomiting Tx: *Corticosteroids* + antivirals (*acyclovir v. valacyclovir*)...same as Ramsey - If face is paralyzed protect eyes w/artificial tears

Acute Myocardial Infarction

Path: *Ventricular fibrillation* is the mc underlying arrhythmia responsible for sudden cardiac arrest. --> IMMEDIATE phase (<10m) after infarction? Reentry Ventricular Arrhythmia is common. --> DELAYED phase (10-60m) after infarction? Abnormal automaticity. - Asx CAD = 50% occlusion, DONT STENT - Stable Angina = 70% occlusion - Unstable Angina = 90% occlusion (EKG w/ST depression) - NSTEMI = Biomarkers elevated, 90% occlusion - STEMI = Biomarkers elevated, 100% occlusion In acute phase of MI will hear *FOURTH HEART SOUND* because ventricle will be stiff and not contracting as well Pt: Obese, HTN, DM, Smoker, HLD, Women >55yo, Men >45yo 1. Substernal pain 2. Worse w/exertion 3. Relieved by Nitroglyc (3/3=typical, 2/3=atypical, 0-1/3=nonanginal) Dx: New ST-segment elevation in *2 contiguous leads* Also, *New LBBB is suggestive of Acute MI*!!!! Get ECG --> if ST elevation get to CATH LAB - if NO ST elevation get TROPONINS (v. CKMB if reinfarction) --> if elevated go to CATH LAB - if NO ST elevation and NO cardiac markers then STRESS TEST ((only for STABLE ANGINA!!! if it looks like ACS then this could kill them) via ecg if baseline ecg is normal, echo if baseline ecg not normal, nuclear med if previous CABG) w/exercise v. adenosine or dobutamine if they can't exercise --> if positive then ELECTIVE CATH LAB -- in Stress Test, looking for areas that move fine at rest but don't move at stress -- 3+ vessels involved or Big and proximal? CABG -- 1+ vessels involved? Stent Tx: *MONA BASCH* (see pic) - Morphine (only if have pain) - Oxygen (standard) - Nitrates (NOT to R-sided MI = II, III, AVF) - *HIGH DOSE* Aspirin (standard) - Beta blocker (NOT if pulmonary edema) - Ace-i (standard) - Statin (standard) - Clopidogrel (standard) - Heparin (or tPA....depends on whether can do PCI or not) - ...Furosemide (if pulmonary edema) - ...Atropine (if bradycardic) Early reperfusion is critical for outcomes. - If can get to cath lab in 90m? *PCI* - If can't? *TPA* within 120m.

Rickets

Path: *Vitamin D* deficiency - *Exclusive breast feeding* W/O!!! VitD supplement. This is needed bc breast milk alone does not contain Vitamin D, and we shield young babies from sun bc decreases risk of skin cancer later. Pt: - *WIDENED WRISTS* (d/t growth plate enlargement, aka epiphyseal plate enlargement) - *Metaphyseal fraying with widened physes* - Craniotabes (skull bones that depress w/pressure) - Radial/ulnar/femoral/tibia bowing (Genu Varum) --> Seen once kiddo is weight bearing - Delayed fontanelle closure (frontal bossing) - *Rachitic rosary* (costochondral junction enlargement) - Fractures - Dental enamel hypoplasia Dx: *Calcium + Phosphorus + PTH* levels Tx: VitD + *Calcium* supplementation

Recurrent Pregnancy Loss

Path: *≥3* spontaneous abortions *in a row* - Structural - Genetic - Endocrine - Antiphospholipid antibody syndrome (APS) --> Hypercoagulable state leading to venous or arterial thrombosis Pt: - If APS? Transient ischemic attack Dx: Work up w/*USD + Karyotype + Thrombophilia tests* Tx: - Fibroids? Even if not significant size, *Hysteroscopic myomectomy* - APS? *LMW Heparin* if preggo, Warfarin if not.

Absence Seizures

Path: 100-1000s of seizures daily Pt: "ADHD" - Kids ONLY!! - Episodes last *<30s* - LOC - NO loss of tone! - Generalized - NO postictal state (unlike Focal Seizures with Impaired Awareness) Dx: EEG w/*3 Hz waves* Tx: *Ethosuximide* - or + Valproic acid prn - MOST OUTGROW!!

Pyoderma Gangrenosum

Path: 30% of cases are triggered by local trauma Associated w/ - *CROHN'S DISEASE* > UC - Arthropathies (x. Rheumatoid Arthritis) - Hematologic Conditions (x. AML) - Granulomatosis w/ Polyangiitis (Wegner's) Pt: - Inflammatory papule, pustule or nodule --> then forms *expanding ulcer w/purulent base and irregular violasceous border* - On trunk or LE - Multiple lesions or single lesion Dx: Skin bx of ulcer margin w/*Mixed cellular infiltrate* and dermal and epidermal necrosis Tx: *Glucocorticoids* (local or systemic)

COPD Exacerbation

Path: 50% are caused by acquisition of bacterial respiratory infection Pt: Change in *≥1 symptoms* - Wheezing, - Cough, - Sputum production - Dyspnea - Altered mental status? F/up on Symptomatic Hypercapnia (dx ABG) - RESPIRATORY ACIDOSIS d/t CO2 retention - Neck veins may be distended on expiration Dx: CXR, ABG, EKG Tx: - *O2* to keep sats between 88-92% --> If too high and becomes lethargic get *ABG* to r/o hypercapnia - *Bronchodilators* q30min (Albuterol+ipatropium = DUONEB) - *Steroids* (po vs. IV) - *Abx* (Levofloxacin/Moxifloxacin v. Azithromycin v. Amoxacillin-Clavulanate) for 3-7 days If BETTER after all of this? --> Send home (w/ po steroids and meter-dose inhalers) If WORSE? --> Go to ICU (w/ IV steroids, continuous nebulizers, *NPPV* (BiPAP/CPAP) --> ET tube if they fail NPPV If need more time? Floor (w/ po steroids and nebulizers)

Prolactinoma

Path: A benign tumor of the pituitary gland that causes it to produce too much prolactin Pt: - Women: Amenorrhea + Galactorrhea. bc notice sx typically have MICROadenoma and so no compression of optic chiasm yet - Men: Loss of libido. bc no obvious sx typically present w/MACROadenoma w/bitemporal hemianopsia - *GnRH LOW* (low LH and FSH) - *TSH NORMAL/LOW* (depending on compressive effect of tumor) Dx: - 1st? Look at meds. - Then? TSH --> HYPOthyroidism can produce HYPERprolactinemia (so TSH should be high if cause of prolactinoma) - Then? Check prolactin (*>200*) - Then? MRI Tx: *Cabergoline* > Bromocriptine - F/up w/surgery or radiation

Ovarian Hyperstimulation Syndrome

Path: A rare but life-threatening complication of ovulation induction for fertility treatment - Over-expression of VEGF causes increased vascular permeability and leakage --> Third spacing Pt: - 1-2wks after ovulation induction - Positive Beta-hCG - Bilateral enlarged cystic ovaries with multiple follicles - Ascites - Abdominal distention - Abdominal pain - Nausea - Vomiting - Pleural effusions - Intravascular volume depletion - Hemoconcentration - Extreme cases: Thromboembolism, Renal failure, Death. Dx: Tx:

Esophageal Stricture

Path: A significant narrowing of the esophagus - Associated w/BARRETTS (5-15% of GERD patients have stricture) Pt: - Difficulty swallowing SOLIDS - Circumferential ring in distal esophagus - Temporary resolution of acid reflux sx Dx: *BIOPSY* to r/o cancer... Tx: EGD w/balloon dilation

Miller Fisher Syndrome

Path: A variant of Guillain-Barre Syndrome with antibodies directed at a ganglioside in peripheral nerves Pt: - RAPID ONSET Ophthalmoplegia can be unilateral (characteristic of Miller Fisher and not of GBS) - ATAXIA (also characteristic of Miller Fisher and not GBS) - Lower extremity weakness (not paralysis, like you see in GBS) - Arreflexia (rather than the Hyporreflexia seen in GBS) Dx: *Antibodies to GQ1b* & LP w/*Albuminocytologic dissociation* - NORMAL WBCs - Elevated Protein - Gram stain w/o organisms - MRI is NORMAL. Tx: *IV IG* vs. *Plasmapheresis*

Cryptococcus Neoformans Meningitis

Path: AIDs w/low CD4 count (*<100*) - Replicates in the CNS and clogs the arachnoid villi --> CSF outflow obstruction & increased ICP - Longer more indolent course than usual meningitis, which comes on acutely Pt: They may LEAVE OUT the classic signs of meningitis (neck pain, photophobia) and you will have to figure this out... - *Umbilicated skin lesions* that look like molluscum contagiosum - *Lateral Rectus palsy* (CN6) - Signs of *ELEVATED ICP* - Progressive headaches - Nausea - Vomiting - Confusion - Diplopia - Fever - Malaise - Signs of opening pressure w/papilledema - Photophobia - Neck pain Dx: *CSF* w/*India Ink* (not sensitive enough) or *Cryptococcal antigen* (preferred) testing - High protein - Low glucose - High WBCs (*LYMPHOCYTIC* predominance) - *Enlarged ventricles* on brain imaging (Ventriculomegaly) Tx: *Amphotericin B + Flucytosine* IV - Then home w/*Fluconazole* (first High dose for ≥8wks, then Low dose until CD4>100 and on ART therapy for >3mo) - Delay treatment for ART until 2 wks after tx begins for Cryptococcus (worry about Immune Reconstitution Syndrome) - May need to do repeated CSF punctures to drain fluid and decrease pressure

Urinary Tract Infection in PREGNANT WOMEN

Path: ALL women are screened for UTI at *INITIAL PRENATAL VISIT* - Pregnant women have an INCREASED RISK of --> Pyelonephritis --> Preterm delivery --> Low birth weight - MC E. Coli - RF = Pre-pregnancy DM Pt: Asymptomatic...or symptomatic - One of the ONLY timesterm-1021 we treat asymptomatic bacteriuria Dx: UA w/Nitrites & Leuk esterase - F/up w/*Rescreen UA* after treatment!!!!! You want Tx: *Amoxicillin* - Could consider Fosfomycin ...ONLY Nitrofurantoin if penicillin allergic (recent studies question safety) - Repeat culture after treatment to ensure clearance

Ethylene Glycol

Path: ANTIFREEZE Pt: - AKI - *Calcium Carboxylate crystals* in urine (square envelopes) - Flank pain - Hematuria - Oliguria - Anion gap metabolic acidosis - High osmol gap (350 - 2xsodium + Glucose Tx: Fomepizole

Osler-Weber-Rendu syndrome

Path: AUTOSOMAL DOMINANT mutation of genes involved in angiogenesis --> Leading to mucocutaneous talengiectasias and visceral organ AVMs. Pt: - Hemoptysis - Recurrent epistaxis - Gastrointestinal angiodysplasia (acute and chronic GI bloodloss) - Anemia (Microcytic) - Pulmonary bruit (bc AVM bloodflow is turbulent) - *Nodular lung lesions (Pulmonary AVMs)*: "multifocal well circumscribed smooth round nodules on CXR without calcifications" - Iron deficiency anemia Tx: - Hemoptysis? *Pulmonary angiography*, then *Embolization* - Iron transfusions

High Output Heart Failure Hemodynamics

Path: AVMs, Arteriovenous Fistulas, Hyperthyroidism, Severe anemia, Obesity, Paget Disease - Afterload: DECREASED (bc blood bypasses arterioles by going straight from arteries to vein) - Preload: INCREASED (bc blood goes more easily into veins) - CO: INCREASED --> Puts at risk for high output heart failure Pt: - Pulmonary edema - Peripheral edema - *Warm extremities* - *Widened pulse pressure* - *Brisk carotid upstroke* - Tachycardia - Eccentric left ventricular hypertrophy - Systolic flow murmur from the high blood flow

Paralytic Ileus

Path: Abdominal surgery, Trauma - *Opiates* contribute to the continued "stunning" of the bowel - >3-5 days postpartum? *Prolonged Postoperative Ileus* Pt: - N/V, - Failure to pass gas or stool ("Obstipation") - *Absent bowel sounds* (how dif from SBO) - CONSTANT pain (how dif from SBO) - Abdominal distention Dx: Abd XRay or CT Abd - Gastric dilation - Gas-filled loops of small and large bowel Tx: *K+* + IVF + Get patient to move - Bowel rest - Supportive care - Treatment of secondary causes

Incisional Hematoma

Path: Abnormal collection of blood at the incision site d/t inadequate surgical hemostasis - RF = Obesity, Anticoagulants Pt: - Hours to days after surgery - Pain at incision - Fluctuant mass --> May become large enough that it opens incision site as it grows Dx: Clinical Tx: *Open incision, remove clot, obtain hemostasis, reclose*

Meniere Disease

Path: Abnormal condition within the labyrinth of the inner ear causing *endolymph hydrops (endolymph accumulation)* that can lead to a progressive loss of hearing. - Increased fluid in the cochlea Pt: - Dizziness or vertigo - Hearing loss - *Tinnitus* (ringing in the ears). - *Aural fullness*

Meconium Aspiration Syndrome

Path: Abnormal inhalation of meconium (first stool) produced by a fetus or newborn - Associated with *PPHN*, but meconium is also known to destroy surfactant Pt: - *Tachypnea >60RPM* - Cyanosis - Increased work of breathing Dx: CXR w/*HYPERinflation & Patchy infiltrates*

Urethral Diverticulum

Path: Abnormal localized urethral mucosa d/t recurrent periurethral gland infection in the ANTERIOR vaginal wall - Outpouching can collect and store urine Pt: - *Postvoid dribbling* - Recurrent lower UTIs - Dysuria - Dyspareunia - Tender anterior vaginal wall mass - Purulent or bloody urethral discharge Dx: *Pelvic MRI* Tx: *Surgical excision*

Benign Paroxysmal Positional Vertigo (BPPV)

Path: Abnormal positioning of otoliths in semicircular canals "Calcium debris in semicircular canals" Pt: EPISODIC <1min - Fleeting episodes of vertigo when the person changes direction of head (x. looking up, looking down) - worse in morning - When rolling over in bed - Episodes are *recurrent & brief* (how you dif from other types of vertigo) --> caused by head movement Dx: *Dix Hallpike* --> DIAGNOSE "D and D" Tx: *Epley* --> TREATS - Attempts to move the otolith out of the semicircular canal

Antidepressant Discontinuation Syndrome

Path: Abrupt discontinuation of antidepressant causes *flu-like symptoms* - Symptoms begin *2-4 days* after abruptly stopping antidepressant - Greater risk w/antidepressants w/SHORTER HALF-LIFE (x. *Venlafaxine, Paroxetine*) - Higher doses & longer duration of treatment are associated w/increased risk Pt: FLU-LIKE SYMPTOMS - Fatigue - Myalgias - Rhinorrhea - Chills - Headache - Dizziness - Nausea - *Neurosensory disturbances* (electrical shock sensations, vivid dreams) - Psychological symptoms - Insomnia - Tremor - Anxiety - Depression Dx: Clinical Tx: Prescribe another *SSRI* and taper slowly if intent is to discontinue. - Consider using SSRI w/LONGER HALF-LIFE

Disinhibited Social Engagement Disorder

Path: Abuse and neglect in infancy, or being bounced around in foster care Pt: Pair TOO MUCH - Bond too quickly - Attach on to everyone - Overfamiliarity - Lack of appropriate boundary setting Dx: *<5yo* - r/o Autism Tx: Caregiver (teach to parent better) - F/up MDD, Anxiety, Substance abuse - F/up Learning disability

Reactive Attachment Disorder

Path: Abuse and neglect in infancy, or being bounced around in foster care - Normal development of emotional bonding to caregivers is disrupted by inconsistent or inadequate care Pt: Pairs TOO LITTLE - Hx of physical abuse, neglect - Social withdrawal (Socially inhibited) - Lack of response to positive affirmation - Don't seek reassurance - Emotional outbursts - Emotionally inhibited - Lack of positive emotions (constricted affect) - Unexpected irritability and aggression Dx: *<5yo* - r/o Autism Tx: *Consistent and nurturing caregiving* - F/up MDD, Anxiety, Substance abuse - F/up Learning disability

Vasa Previa

Path: Accessory lobe plants across OS, blood vessels tear when cervix dilates or w/rupture of membranes - If baby bleeds from these they are dead quick - Obstetric emergency - RF = IVF, Placenta previa Pt: - PainLESS minimal vaginal bleeding (bc "previa", baby's blood) - Baby w/bradycardia - Baby w/sinusoidal heart pattern (fetal anemia) - Fetal exsanguination and demise Dx: *Fetal anatomy USD 18-20wks* - Non-Stress Test v. Contraction Stress Test (would see fetal distress) Tx: Third-trimester inpatient management, with *scheduled delivery at 34-35 wks* (before contractions and ROM) - If too late? *URGENT C-SECTION* *Anything w/PREVIA means painLESS for mom and is BABY's BLOOD.*

Septal Hematoma

Path: Accumulation of blood between the perichondrium and septal cartilage. - Most offen d/t nasal trauma - Worry about... --> Septal abscess (infection). --> Avascular necrosis of septum. Pt: - Soft, fluctuant swelling of the nasal septum - Hx of trauma - Nasal obstruction Dx: Clinical Tx: *Incision & Drainage* - Then...Anterior nasal packing + Ice packs + NSAIDs + Abx - Assess via Otolaryngology once packing has been removed a few days later

Wernicke's Encephalopathy

Path: Acute disorder of THIAMINE/B1 deficiency - Alcohol use disorder - Anorexia - Hyperemesis gravidarum Pt: Classic triad...(more of the physical sx of looking drunk) - Encephalopathy - Ataxia - Oculomotor dysfunction Dx: - Imaging w/Mammillary body atrophy & Dorsomedial thalamic neuron loss Tx: *Thiamine supplementation*

Acalculous Cholecystitis

Path: Acute inflammation of the gallbladder in the absence of gallstones. - Associated w/Severely ill patients, Post-surgery, Hospitalized, Trauma, burns, sepsis, shock, prolonged fasting, intubation. --> Causes gallbladder stasis or ischemia with local inflammation, which leads to secondary infection by enteric organisms, causing edema and necrosis of gallbladder - Scary!!! Pt: - Unexplained FEVER! - Diffuse RUQ pain - Jaundice - RUQ mass - Leukocytosis - Abnormal liver function tests - Can have elevated LIPASE - Usually NORMAL Alk Phos - May be associated w/*ILEUS* w/dilated large and small bowels, and quiet bowel sounds. Dx: USD w/signs of cholecystitis (x. distended gallbladder, thickened wall, pericholecystic fluid) but NO STONES - If not clear, try CT or HIDA Tx: *Abx* --> then percutaneous cholecystOSTOMY - Later? Cholecystectomy (when stable)

Small Bowel Obstruction

Path: Adhesions (if have hx of surgery) - or *Incarcerated hernia* can cause (if dont have hx of surgery) Pt: *Colicky abdominal pain* (how dif from ileus) - *Borborygmi* = high pitched crescendo sounds - Tympany - *HYPERactive bowel sounds* (vs perforation which is HYPOactive) - Flatus & BMs at first, as dz progresses get *obstipation* - Abdominal distention - Metabolic acidosis and Hemodynamic instability should be concerning. Dx: KUB (look for air-fluid bubbles/levels) - then confirm w/CT w/contrast (shows whether complete or incomplete) Tx: - INCOMPLETE? (Bowel lumen narrowed but not completely obstructed, air in colon) *NG Tube + Electrolytes + Serial abdominal examinations* --> *Small bowel follow through* (evaluates intestinal function and motility) can help dx this. - COMPLETE, UNSTABLE, Perforation, or signs of Necrosis? (No flatus, NO air in colon, Air outside bowel loops, elevated lactate, fever, leukocytosis) *Surgery!!!!* - If they're poor surgical candidate? Treat conservatively (NG tube, Decompression, watch K+ x3 days), if no improvement then SURGERY. If PERITONEAL SIGNS (rebound tenderness, etc) at any point --> Tx EMERGENT SURGERY

Menopause

Path: Age-related ovarian follicle depletion and decreased estrogen levels - Cessation of menses *≥12 months* in women with previously REGULAR menstrual cycles Pt: - Dyspareunia - Vulvovaginal atrophy - Decreased libido - Hotflashes Dx: Cessation of menses *≥12 months* in women with previously REGULAR menstrual cycles - Women W/O previously regular menstrual cycles (or hx of hysterectomy, endometrial ablation, etc)? Would need *Elevated FSH and LH* (bc no neg feedback from ovaries) to confirm. Tx: - Mild hot flashes? Behavioral changes. - Moderate/Severe hot flashes, has uterus, & *CI* to estrogen? *SSRI* (x. Paroxetine), Clonidine, Gabapentin - Moderate/Severe hot flashes & *NO* CI to estrogen but HAS UTERUS? *Estrogen + Progestin* i.e. COMBO pill - Moderate/Severe hot flashes, *NO* CI to estrogen, & NO uterus? *Estrogen ONLY* i.e. Transdermal Estrogen patch (bc the combo of estrogen+progestin comes with increased risk of breast cancer, and they don't need to worry about endometrial hyperplasia with solo estrogen)

Inflammatory Breast Cancer (IBC)

Path: Aggressive breast cancer characterized by invasion into *dermal lymphovascular spaces*, causing lymphatic obstruction which gives it the characteristic appearance. - Rapid tumor growth and metastasis --> Patients commonly have metastasis at presentation - NOT Paget's of breast TARA!!!!!!!!!!!! Jesus. Pt: - Rapid onset - Unilateral, pruritic breast rash - Skin edema and fine dimpling (*peau d'orange*) - Breast erythema and edema - Axillary lymphadenopathy - Usually ER/PR (-) Dx: Mammography v. USD - Then *Breast BX* & *Full thickness skin Bx* showing dermal lymphatic invasion Tx: Aggressive bc metastasizes quickly.. - *(Neoadjuvant) Chemotherapy ± Mastectomy ± Radiation*

Choriocarcinoma

Path: Aggressive form of gestational trophoblastic neoplasia - Arises from placental trophoblastic tissue - Secretes B-hCG - MC follows a hydatiform mole, but can also occur after spontaneous abortion OR normal gestation - Presents *<6mo after pregnancy* - LUNGS are most frequent site of mets Pt: - Irregular vaginal bleeding - Enlarged uterus - Pelvic pain - "*Red vascular nodule in posterior fornix of vagina that bleeds when touched with a cotton applicator*" --> Vaginal mets - If pulmonary mets? Chest pain, Hemoptysis, Dyspnea Dx: *Quantitative B-hCG* - CXR for suspicion of lung mets Tx: - Low risk (lungs or uterus mets)? *Methotrexate* (95-100% cure) - High risk (many mets)? *Methotrexate + ActinomycinD + Etoposide + Carboplatin* (50-75% cure) - F/up Reliable contraception --> treat until Hcg is 0, then Hcg q1m for 12m

Bronchial Mucus Plug

Path: Airway obstruction creates distal air trapping in the alveoli --> because no air can enter they become devoid of matter and collapse - Causes *atelectasis* - RF = Surgery, Smoking Pt: - Hypoxemia - Respiratory distress - Tachypnea - Dyspnea - Tachycardia Dx: CXR w/structures pulled TOWARDS atelectasis (unlike effusions which pull AWAY) - Dullness to percussion on that side - Absence of breath sounds on that side - Narrowed intercostal spaces on that side Tx: *Bronchoscopy* to remove plug - Prevent? Chest physiotherapy

Prepatellar Bursitis

Path: Aka "Housemaid's knee". Usually from doing a lot of kneeling. Pt: - Acute pain and tenderness anterior to the knee - Swelling anterior to the knee - Erythema - PainFUL ACTIVE range of motion - PainLESS PASSIVE motion (causes less pressure on bursa) Dx: *Bursal fluid aspiration* (can be infectious in 33% - skin bugs) Tx: NSAIDs - Infectious? Drainage + Abx

Nonallergic Rhinits

Path: Aka "Vasomotor rhinitis", often triggered by smells and exposure to cold air. - Classically DO NOT improve with antihistamines - Patients have a hard time identifying triggers - Negative testing for aeroallergens Pt: - Clear rhinitis - Nasal mucosa are boggy and erythematous - Worse w/BEHAVIOR (x. eating, walking into cold air) - NO sneezing or conjunctivitis (unlike allergic rhinitis) Dx: Clinical Tx: *Intranasal Steroids*

Fetal Alcohol Syndrome (FAS)

Path: Alcohol consumption by mom when baby is in-utero. - It is unclear still what amount of alcohol is required for this to develop. Pt: - Midface hypoplasia --> Small eye openings / Short palpebral fissures --> Sunken nasal bridge --> Thin upper lip / Smooth philitrum --> Low set ears - Growth retardation - CNS involvement (structural or behavioral issues) --> ADHD --> Issues w/impulse control and emotional regulation - *VSD* - Small placenta and shrunken cord

Delirium Tremens (DTs)

Path: Alcohol withdrawal - *48-96*hr after last drink Pt: - Tremor - Increased psychomotor activity - Delusions - *Hallucinations* - Illusions - Disorientation - Confusion - Tachycardia - Hypertension - Diaphoresis - Mydriasis - Hyperhydrosis - Hyperthermia (*fever*) - Feeling of insects crawling on skin - Agitation Dx: Clinical Tx: IV Benzo

Allergic Conjunctivitis

Path: Allergies Pt: - Watery - Bilateral - ITCHY - Bumpy & edematous conjunctiva Tx: OTC antihistamine/decongestant drops - More frequent? Mast cell stabilizer (olopatadine)

Secondary Amenorrhea

Path: Amenorrhea *≥3 months* in previously regular menses, or *≥6 months* in previously irregular menses - MCC = Pregnancy, Hypothyroidism, Prolactinemia, Medications (dopamine antagonists) - Breast Feeding: Increased prolactin *inhibits GnRH* --> Decreases FSH and LH --> Decreases Estrogen --> No menses ...Once the above have been ruled out, can evaluate the HPO axis. Dx: *UPT + FSH + TSH + Prolactin*!!!! Every time. --> *INCREASED TRH* (HYPOthyroidism) increases prolactin!

Aminoglycoside Ototoxicity

Path: Aminoglycosides.... Pt: - Oscillopsia (sensation of objects moving) - Hearing loss - Imbalance - Nystagmus Dx: POSITIVE head thrust test...where you have them look at something and turn head side to side --> Issues with this let's you know is peripheral vestibulopathy...unlike Vertebrobasilar Insufficiency or Cerebellar stroke Tx: Stop med.

Amniotic Fluid Embolism

Path: Amniotic fluid enters the maternal circulation through endocervical veins, placental insertion site, or areas of uterine trauma - Inflammatory response Pt: - Vasospasm - Cardiogenic shock (HYPOtensive, Tachypneic, Tachycardic) - Hypoxemic respiratory failure - DIC - Advanced maternal age - High gravida - Seizures - Loss of consciousness Dx: Clinically Tx: Supportive (O2 + Intubate + Vasopressors) - High incidence of neurological damage

Synthetic Cathinones (bath salts)

Path: Amphetamine analogs...increase release or inhibit uptake of serotonin, dopamine, norepinephrine. Pt: Like PCP but *PROLONGED DURATION* (may last up to a week!!) - Severe agitation - Combativeness - Psychosis - Delirium - Myoclonus - Hyperreflexia - Seizures - Tachycardia - Hypertension Dx: *NEGATIVE UDS*! Tx:

Plantar Fasciitis

Path: An inflammation of the plantar fascia (plantar aponeurosis) on the sole of the foot from excessive pronation (runners, athletes) or high heels. - RF = Obesity, Pes cavus (arched foot) Pt: - Heal pain - Worse w/WEIGHT BEARING - Worse w/FIRST FEW STEPS of morning - Gets better during day - Worse w/*Long periods of standing or walking* - *Tenderness at insertion site of plantar fascia into calcaneus* --> Worse with passive dorsiflexion of toes - *Heel spurs* = Calcifications of the proximal plantar fascia Tx: - Arch supports & supportive shoes - Daily icing - NSAIDs - Stretching + CS if there is a tender point.

Cervicofacial Actinomyces

Path: Anaerobic Gram Positive Filamentous bacterium of oral cavity that causes invasive disease w/dental infections or trauma - Risk increases if immunocompromised (DM, etc) - Direct extension of infection into tissue planes Pt: - Slow growing indurated mass - Recent hx of dental procedure - Erythematous mass at mandible - Yellow granules produced, "sulfur granules" - Eventually forms sinus tracks in skin - typically NO FEVER - typically NO LNDs Dx: *Needle aspiration w/culture* Tx: *Penicillin*

Lung Abscess

Path: Anaerobic bacteria - Parkinson's...bc has swallowing dysfunction w/worsening of disease --> aspiration --> lung infection - Substance abuse - Poor dentition - Recumbency Pt: - 1-2week onset - Fever - Nght sweats - Cough w/*FOUL* sputum - *HYPONATREMIA* (d/t SIADH) Dx: *Cavitary lesion(s)* on CXR!! --> Confirm w/CT - Mild hyponatremia (SIADH) Tx: *Ampicillin + Sulbactam* - Rash to penicillin? *Ceftriaxone + Clinda* - Severe allergy? Clindamycin alone

Androgen Insensitivity Syndrome (AIS)

Path: Androgen receptors malfunction in genetic males, impeding the formation of male EXTERNAL genitalia; - Child may be born with FEMALE external genitalia Pt: - Primary amenorrhea (≥15yo w/secondary sexual characteristics) - Genotypically Male (XY) - Phenotypically Female. - Absent uterus and upper vagina. - Tall stature. - Breast development bc pubertal testosterone is aromatized to estrogen - *Minimal axillary or pubic hair d/t androgen resistance* (unlike Mullerian Agenesis) Dx: *Karyotype analysis* Tx: *Elective gonadectomy procedure* (bc undescended testes at risk for testicular cancer) - Then supply w/replacement hormones for rest of life

Androgen Abuse

Path: Androgens are anabolic steroids - High intensity athletes tend to abuse Pt: - *Erythrocytosis* - Hepatic failure - Cholestasis - Dyslipidemia - Increased libido MALES - Testicular atrophy - Reduced spermatogenesis - Gynecomastia - Mood disturbances aggressive behavior - NO hairloss FEMALES - Acne - Hirsutism - Deepening of voice - Menstrual irregularities Dx: Fake testosterone inhibits GnRH leading to... - Decreased FSH - Decreased LH - Normal Testosterone (bc tests can't differentiate between real deal and fake) - Low sperm counts Tx:

Acute Urinary Retention

Path: Anesthetics, Opioids, Anticolinergics can all precipitate Pt: - Male - Elderly - Tachycardia - Suprapubic tenderness - Hx of BPH - Hx of neurologic disease (x. dementia) --> Agitation --> Confusion - Hx of Surgery Dx: *Bladder USD w/≥300mL urine* - If obese and unable to get a good reading, *Foley cath* can be both diagnostic and therapeutic Tx: Foley catheter - + UA to r/o infection

Anti-glomerular Basement Membrane Disease (Goodpasture Syndrome)

Path: Antibodies against *alpha-3 chain of type IV collagen* (in glomerular and alveolar basement membrane) - Mc in young adult males Pt: - NephrITIC-range proteinuria - Acute renal failure - Urinary sediment w/dysmorphic red cells & red cell casts - SOB - Cough - Hemoptysis d/t pulmonary hemorrhage - Fever, weight loss, arthralgias are uncommon! Dx: Renal bx w/*Linear IgG deposition* along glomerular basement membrane - c-ANCA (only way you can tell dif from Microscopic polyangiitis, which is p-ANCA) Tx:

Pernicious Anemia

Path: Antibodies against intrinsic factor (protein carrier for B12 absorption) - Associated with increased risk of *Gastric adenocarcinoma* or *Gastric carcinoid* tumors Pt: - Macrocytic anemia - Mild thrombocytopenia/Leukopenia - Glossitis - Older patients w/other autoimmune conditions (*vitiligo*, *autoimmune thyroid disease*) Dx: *Anti-intrinsic factor Abs* Tx: *Vitamin B12 supplementation*

Autoimmune Metaplastic Atrophic Gastritis (AMAG)

Path: Antibodies towards parietal cells (*Pernicious Anemia*), resulting in... --> Atrophy and metaplasia of the gastric corpus --> Hypochlorhydria --> Unchecked gastrin production --> Vitamin B12 deficiency - RF = Other autoimmune conditions (x. Hypothyroidism) - Increased risk for *Gastric Adenocarcinoma* and *Neuroendocrine tumors* (SCLC, Carcinoid, Neuroblastoma) Pt: - Women > Men - *Chronic postprandial abdominal pain* - Bloating - Nausea - Heartburn - Regurgitation - *Macrocytic anemia* - *Elevated serum GASTRIN* levels Dx: Tx: - Routine *Surveillance endoscopy* (d/t increased risk of cancer)

Jimson Weed Poisoning

Path: Anticholinergic toxicity Pt: "Mad as a hatter, hot as a hare, blind as a bat, dry as a bone, red as a beet" - Hallucinations/delirium - Hyperthermia - Tachycardia - Nonreactive mydriasis - Dry, red skin

Selective Mutism

Path: Anxiety disorder - Refusal to speak in school impairs ACADEMIC and SOCIAL development Pt: - Refusal to speak in a SPECIFIC social situation - Normal communication in situations where they feel comfortable Dx: *≥1mo* refusal to speak in situations where it is expected Tx: *CBT* w/graded exposure to social situations, family therapy, SSRIs - f/up Social Anxiety Disorder

Gestational Trophoblastic Neoplasm (GTN)

Path: Arises any time there is successful placentation - RF = Advanced maternal age, History of prior GTD, AA/Asian/NativeAm. - Three main causes: --> Invasive Mole = MCC, edematous chorionic villi --> Choriocarcinoma = neoplastic synctiotrophoblast & cytotrophoblast (no villi) --> Placental Site Trophoblastic Tumor = proliferation of intermediate trophoblasts (no villi) Pt: Asymptomatic patient treated for GTD (mole or partial mole), who then has rise in Hcg. - or s/sx of metastasis (locally invasive v. choriocarcinoma) - Choriocarcinoma likes to metastasize to the lungs and cause *hemoptysis* - Abnormal bleeding *>6wks* should be evaluated w/B-hCG Dx: - If AFTER GTD (mole or partial mole)? *NO workup required* - If new? *Transvaginal USD, then D&C* Tx: Imaging required to stage - Low risk (lungs or uterus mets)? *Methotrexate* (95-100% cure) - High risk (many mets)? *Methotrexate + ActinomycinD + Etoposide + Carboplatin* (50-75% cure) - F/up Reliable contraception --> treat until Hcg is 0, then Hcg q1m for 12m

Aromatase Deficiency

Path: Aromatase converts *ANDROGENS (DHEAS) to ESTROGEN (Estradiol)*, when not working properly, *androgens* (DHEAS) builds up Pt: Seen in infancy - Normal internal genitalia - External virilization - *Undetectable serum estrogen levels* (how you tell dif from CAH) - *Elevated DHEAS* levels - Adolescence? *Delayed puberty, osteoporosis, high levels of gonadotropins causing PCOS* - Transient masculinization of mother that resolves after preggo

Renal Vein Thrombosis

Path: Assoc w/ *NEPHROTIC syndrome* (MC)....bc nephrotic syndromes are HYPERcoagulable. Remember? - Left gonadal vein drains into the left renal vein, so you see signs of kidney injury AND varicocele in gonads. - Also compression, tumors, chemo, transplants, trauma Pt: - *Hematuria* - *Left sided flank pain* - Left gonadal vein dilation (Varicocele) - Left-sided edema - Sonographically: dilated thrombosed vein, enlarged hypoechoic kidney, increased RI (biphasic) Tx: *Thrombolysis*

Toxic Megacolon

Path: Associated w/C. dif, UC - RF = Recent hospitalization, Recent Abx use Pt: - Watery or bloody diarrhea - Abdominal distention - Diffuse tenderness - NO REBOUND tenderness usually - Leukocytosis (>15,000) - Fever - Systemic toxicity (fever, hypotension, tachycardia) Dx: Radiographic evidence of *LARGE BOWEL DILATION* (to r/o mechanical obstruction) - *>6cm* colon dilation - Loss of haustra - Irregular mucosal pattern Tx: - FIRST? Conservative!! *Bowel rest + NG tube + Abx (IV Metronidazole + ORAL Vanco) + IVF + Electrolytes* - d/t IBD? *+ IV glucocorticoids* (NOT sulfasalazine, doesn't respond) - Subtotal Colectomy if no response to this

Hodgkin Lymphoma

Path: Associated w/EBV in the immunocompromised - 80% become cured or are in remission - Chemo & RT are what causes most of the long term adverse effects... can cause --> NONHodgkins, --> *Constrictive pericarditis*, (& CAD) --> *Radiation induced HYPOthyroidism*, --> *Secondary malignancy* (>30%, >10yr after tx) - Radiation causes increased risk of SOLID ORGAN MALIGNANCY (leading cause of death of those who have been cured) Pt: - Painless peripheral lymphadenopathy in cervical and supraclavicular nodes (~50%) - MEDIASTINAL MASS (~50%) --> Cough, SOB, Retrosternal pain - B-Symptoms - Most of tumor burden is in area of origin - *Pel Epstein* --> CYCLICAL FEVERS - *EtOH Lymph Nodes* --> NONTENDER LNs become TENDER w/Alcohol - *Eosinophilia* - Pruritis - Fatigue Dx: - NORMAL CBC & - NORMAL Peripheral Blood Smear!!! - *Reed-Sternberg* cells on LN bx --> "Hedgehog, sounds like Hodgkin, and the Reed-Sternberg cells kind of look like Hedgehogs" - Elevated LDH & Eosinophilia Tx: *ABVD* + Radiation - If really severe? *BEACOP

Optic Neuritis

Path: Associated with *Multiple Sclerosis* Pt: - Young women - *Monocular vision loss* --> May initially begin as *CENTRAL SCOTOMA* "smudge" in center of vision which progressively enlarges (like macular degeneration) - *Afferent pupillary defect* in effected eye!!! - Colors appear washed out Dx: MRI Tx: *Steroids*

Acute Splenic Sequestration Syndrome

Path: Associated with SICKLE CELL DISEASE seen only in CHILDREN - Sickle cells become trapped in the splenic sinuses - Life threatening complication of SCD - Once splenic infarction occurs they are functionally asplenic, and at risk for infection by *Encapsulated* organisms (mcc of sepsis is *Strep Pneumo*!!!) --> Prophylactic *Penicillin* until 5yo --> H. Flu & N. Meningitidis also possible if unvaccinated Pt: - Jaundice - Anemia - Tachycardia - Fatigue - Pallor - Hypotension - Left sided abdominal tenderness - Enlarged spleen - NORMAL liver - Increased reticulocytes Dx: *Hemoglobin electrophoresis* Tx: IVF + *PRBC transfusion* (most SS patients have Hgb of 7-8 at baseline, don't transfuse to number! Transfuse to symptoms --> Later may consider Splenectomy but this is often unnecessary d/t patients auto-infarcting the spleen on their own.

Biliary Cyst

Path: Associated with an anomalous connection of the pancreatic and biliary ducts, where it is back in the pancreas and not as close to the duodenum. --> More likely to obstruct!!! - Cyst mc evolves from the *Common Bile Duct* - Can be complicated by --> Pancreatitis --> Cholangitis --> Stone formation --> *Increased risk for malignancy* (gallbladder, pancreatic) if uncorrected Pt: <10 years old...most are asymptomatic (looks like acute pancreatitis) - ACUTE onset (how dif from pancreatic pseudocyst) - Acute abdominal pain (esp RUQ) - RUQ mass - Vomiting - Elevated amylase & lipase - Jaundice - Hyperbilirubinemia Dx: USD w/*Extrahepatic cystic mass* Tx: Surgery to prevent malignancy (x30 greater risk of pancreatic and gallbladder cancers)...even if asymptomatic - Treat OBSTRUCTIVE conditions FIRST before surgery

Restless Leg Syndrome (RLS)

Path: Associated with central and peripheral nervous system changes. - PRIMARY = Idiopathic - SECONDARY = Associated by accompanying disease or medications (x. DM, CKD, Diphenhydramine) Pt: - Dysesthesia (crawling, itching feelings) - Irresistible urge to move the legs - Sx in evenings or at night - Partially relieved by movement - NO numbness - NO sensory deficits (unlike peripheral neuropathy) Dx: Clinical - Check SERUM FERRITIN on all patients Tx: - Iron deficiency or serum *Ferritin ≤75*? Supplement iron. - Intermittent or mild? Leg massage, Heating pads, Sleep hygiene - Persistent moderate or severe (impairing sleep)? *Pramipexole* v. Ropinirole v. *Gabapentin*

AA Amyloidosis

Path: Associated with chronic inflammatory conditions - RA is the mcc Pt: - Amyloid deposits in kidney causing *Nephrotic syndrome* (renal signs at mc seen) - Cardiomyopathy - Hepatomegaly - Dysmotility - Peripheral neuropathy - Dementia - Stroke - Thickening of skin - Easy bruising - Normocytic anemia - Elevated ESR Dx: Presence of amyloid on *fat pad* bx (Not kidney) - "Amorphous hyaline material that stains Congo red" with "Apple green birefringence"

Diffuse Alveolar Hemorrhage

Path: Associated with inhaled drug abuse (x. crack), which causes ... --> Thermal damage --> Intense pulmonary vasospasm --> Ischemia-reperfusion injury --> Direct cellular toxicity - Results in widespread alveolar capillary bleeding Pt: - Rapid onset hypoxemia (w/in 48hr of inhalation) - Tachypnea - Hemoptysis (50%) - *INSPIRATORY CRACKLES* (unlike bronchospasm which would be wheezing) - Diffuse bilateral alveolar opacities (usually reflects fluid, cells, or blood) - Crack use? --> Burns on fingertips --> Mydriasis --> HTN --> Tachycardia Dx: Imaging w/*Diffuse bilateral alveolar opacities* and suspicion of inhaled drug use - OR positive UDS - BAL w/subsequently bloody vials (dif from aspirated blood which would decrease with subsequent vials) Tx:

Peripheral Arterial Disease

Path: Atherosclerosis of the peripheral arteries - RF = Smoking, HTN, Hyperlipidemia - Symptoms can come on more SLOWLY than acute limb ischemia bc body has developed compensatory vasculation d/t the chronic disease that supplies the area Pt: - Shiny, hairless legs - Pain AT REST --> Improves w/dangling - Ruptured plaque? (Acute on chronic limb ischemia) --> *Mottling* --> Coolness --> Prolonged capillary refill --> Paresis Dx: - ABI > 0.9 = normal - ABI < 0.5 = severely impaired flow Tx: Limb Ischemia? Skip Dx and go straight to tx. - 1st *Heparin* infusion - Then, *Thrombolysis or Surgery* or Embolectomy Thrombotic (plaque rupture) more common than embolic (a. fib) cause.

Eczema Herpeticum

Path: Atopic dermatitis (eczema) causes skin barrier and immune dysfunction, then patient will either encounter someone with Herpes or have latent reactivation. - Concern for disseminated disease involving the eyes or visceral organs. Pt: - Hx of atopic dermatitis - Painful vesicular rash "painful vesicles on an erythematous base" --> Evolves into "punched out erosions" and then "hemorrhagic crusts" - Face, neck, trunk - Fever - LNDs Dx: Clinical Tx: *Acyclovir*

Immune Thrombocytopenic Purpura (ITP)

Path: Autoantibodies (IgG) to platelet surface glycoproteins - Primary = w/no discernable cause - Secondary = d/t HIV or Hep C Pt: Prolonged bleeding (skin/mucosal), ecchymosis, and petechiae - Usually woman w/autoimmune disorder and low platelets. - Normal liver span - NONpalpable spleen - Normal PT - Normal PTT - Normal Fibrinogen Dx: Dx of exclusion...*When signs and symptoms of other disorders are present, you must r/o those first!* - PBS is normal (maybe w/some large platelets d/t high turnover) - Leukocyte count is normal - Erythrocyte count is normal - Coagulation studies are normal Tx: - Acute flair? *Steroids* - Critically low platelets? *IVIG* - Refractory? *Splenectomy* --> *Rituximab to rescue* *Treat ITP w/IVIG*!!!!!!!!!!!!! The I's go together.

Myasthenia Gravis

Path: Autoantibodies to postsynaptic NMJ endplate (acetylcholine receptors) - Women of childbearing age - RF (have increased risk): *Pregnant*, *Postpartum* - Associated w/*Thymomas* - *CRISIS* is an acute exacerbation triggered by infection, surgery, emotional distress, overdose or inadequate medication. Pt: Fluctuating, fatiguable muscle weakness - WORSE w/repeated movements - Worse later in day - PROXIMAL muscle involvement (arms, hips) --> difficulty rising from chair, lifting arms above head - Bulbar weakness --> difficulty chewing - Occular dysfunction --> ptosis, blurred vision - ABSENT reflexes Dx: - AchR-Abs - Edrophonium? - CT of chest (thymoma) Tx: *Pyridostigmine* - Crisis? *IVIG* v. *PLASMAPHERESIS* + CORTICOSTEROIDS.......NO!! PYRIDOSTIGMINE (bc increases secretions during intubation) - *Thymectomy* provides clinical recovery for those with thymoma AND WITHOUT!

Dermatomyositis

Path: Autoimmune condition causing proximal muscle inflammatory myositis - Associated with increased risk of *Malignancy* (only dermatomyositis, not polymyositis) Pt: - Women - Proximal muscle weakness - *Violaceous poikiloderma* following *Shawl* distribution --> Causes Periorbital edema = *Heliotrope sign* --> Flat, scaly, violaceous *Grotton papules* on MCPs, PIPs, Elbows, Knees. - Interstitial Lung Disease - Elevated CPK - Anti-Mi-2 and Anti-Jo-1 "MiJositis"

Sympathetic Ophthalmia

Path: Autoimmune condition when T-cells become sensitized to previously sequestered eye antigens - Exposed by way of *EYE TRAUMA* usually --> Inflammatory response agains the injured AND uninjured eye Pt: Dx: Tx: - If eye is injured (by trauma) and there is no chance for recovery? *Remove the eye* (limits the likelihood of T-cells then blinding the remaining, normal, eye) - If recovery is possible? Keep eye and give *Corticosteroids* if sx develop

Multiple Sclerosis

Path: Autoimmune demyelination, typically young women of child-bearing age. - Associated with decreased *VITAMIN D* - *EBV* - Smoking - Cold climates!! can exacerbate - HOT climates can exacerbate (Uhthoff Phenomenon) Pt: FND lasts for days or weeks (unlike TIA) - Optic neuritis ("optic disk appears hyperemic and swollen") - Diplopia - Unilateral vision loss - Fatigue - Motor weakness - Imbalance - Gait disturbance - Asymmetric weakness - Vertigo - Bladder loss - HYPER-reflexive - Transverse Myelitis symptoms - Intranuclear ophthalmoplegia - Cerebellar dysfunction (ataxia, intention tremor, nystagmus, etc) Dx: *MRI* (Multifocal ovoid hypo-/hyperintense lesions in white matter, or "Demyelinating plaques disseminating space and time" --> How you differentiate from TIA!!!) - Confirm w/LP (*IgG "oligoclonal" bands in CSF*) Tx: - Acutely/Symptomatic? *IV Steroids* v. *Immunoglobulins* v. *Plasma exchange* - Maintenance/Prevention? *DMARDs* - f/up *DEPRESSION* (66% develop)

Vitiligo

Path: Autoimmune destruction of melanocytes - Associated w/ other AUTOIMMUNE dz (esp thyroid...x. Hashimoto's, Grave's) - Slowly progressive Pt: - Well demarcated - Depigmented macules - Face & Distal extremities Dx: Clinical Tx: - Limited? *Topical corticosteroids* - Extensive? *Oral corticosteroids* v. topical calcineurin inhibitors v. PUVA - F/up thyroid disorders

Autoimmune Encephalitis

Path: Autoimmune encephalitis to *NMDR-Receptors* - Multistage syndrome with characteristic features Pt: - Median age of onset is *21* - 4x more common in WOMEN - Anxiety - Psychosis - Insomnia - Hyperthermia - Hypertension - Tachycardia - Cognitive impairment - Rigidity - Hyperreflexia - Dystonia Dx: CSF antibodies to *GluN1* subunit of NMDR - Imaging to find tumor (usually *teratoma* >50%) Tx: *Immunosuppressive treatment* + Remove tumor

Primary Sclerosing Cholangitis (PSC)

Path: Autoimmune fibrosis of *INTRA- & EXTRA* hepatic ducts - At risk of developing = Cholangiocarcinoma, Cholangitis, Colon cancer Pt: - Fatigue - MEN mc (but can be women) - Cholestasis (elevated Alk Phos, jaundice, pruritis) - Ascending cholangitis (fever, jaundice, hypotension, mental status changes) - NO PAIN!!!! (how you dif from cholelithiasis) - IBD = 90% have *UC* - Elevated ALT/AST - Elevated AlkPhos & GGT (Cholestatic pattern) Dx: best is *MRCP* w/"strictures and focal dilations within intra- and extrahepatic biliary ducts" - But you will probably start with *ABD USD* for investigation of cholestatic pattern Tx: - F/up on *Ulcerative Colitis* & *COLON CANCER* (should get screening colonoscopy YEARLY!!)

Huntington Disease

Path: Autosomal *DOMINANT* trinuclear repeat of *CAG* --> Abnormal huntingtin protein - Anticipation effect...develops younger in subsequent generations Pt: - "Random jerking movements throughout the extremities and face"...aka CHOREA/Choreoathetosis - Also described looking like they are drunk. - DEPRESSION - Psychosis - Behavioral change - Cognitive impairment - Delayed saccades (eyes) - Motor impersistence (inability to hold grip) - Hyperreflexia - CHOREA --> Early on this my appear like restlessness --> Patients may subconsciously associate it into purposeful movements, like smoothing their hair Path: Loss of *GABA-ergic* neurons in *CAUDATE & PUTAMEN* (atrophy of caudate and putamen)

Tuberous Sclerosis

Path: Autosomal DOMINANT - Mutation in TSC1 or TSC2 Pt: <2yo - *Angiofibromas* (face!!) - *Ash-leaf spot* ("elliptical hypopigmented macules") - CNS lesions (*subependymal tumors*!!!!) - Shagreen patches - Seizures - Cardiac rhabdomyoma - Renal angiomyolipoma - Retinal/brain hamartomas --> Seizures --> ADHD Dx: Neuroimaging - Echocardiogram for cardiac rhabdomyoma Tx: Supportive - F/up Mental Retardation

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

Path: Autosomal DOMINANT, onset of symptoms in ADulthood - Bending over and doing physical activity can result in cyst rupture (flank pain, hematuria). Pt: - Recurrent *Flank pain* (cyst rupture or nephrolithiasis) - *Hematuria* - Palpable abdominal mass - Polyuria - Polydipsia - Progressive renal dysfunction - HYPERTENSION --> thought to be from cyst expansion leading to localized renal ischemia, which activates RENIN release - "SECONDARY HYPERALDOSTERONISM" - Eventually ESRD - Nephrolithiasis (uric acid stones) - Liver cysts - Berry aneurysms Dx: *USD* Tx: *Ace-i, ARB* - Control risk factors for CKD

Cystic Fibrosis

Path: Autosomal RECESSIVE disorder, CFTR gene (deltaF508) - Associated with *DM* - Milder variants may present w/sx in adulthood Pt: Prenatal screen showed it or they're older and it wasn't completed, - Growth delay/Failure to thrive (because CF effects pancreas so they can't digest food), - Fat malabsorption - *ADEK malabsorption* --> Bruising, Bleeding d/t no VitK (*"Absent coagulation factor activation*") - Diabetes - Steatorrhea - Jaundice - Meconium ileus (tx: Water enema) - Delayed passage of meconium - Recurrent pulmonary infections (*Staph* when <20yo, *Pseudomonas* when >20yo!!!!!!!!!!!!!) - Salty baby. - *Absence of the vas deferens* - *Cor Pulmonale eventually* (Pulm HTN, JVD, Hepatomegaly, Ascites, Elevated liver enzymes) --> Bronchiectasis and enlarged, scarred airways, cause chronic hypoxemia --> Pulm HTN --> RVH & Right-sided Heart Failure! Dx: Screen. - Confirm w/Sweat chloride test >40 infant, >60 older. Tx: - Lung = pulmonary toilet to move secretions, Staph + *Pseudomonas abx*!! - Pancreas = pancreatic enzymes, fat soluble vitamins ADEK *Infertile b/c men don't have VAS DEFRENS, and women have excessively THICK cervical mucous.*

Chediak-Higashi Syndrome

Path: Autosomal Recessive, defect in LYST = Lysosomal Trafficking - Staph & Strep infections Pt: - *Albinism* - Peripheral neuropathy - Lymphohistiocytosis - Pyogenic infections - *Neutropenia* (rather than neutrophilia) - Skin infections Dx: *Giant Granules in Neutrophils*

Posterior Hip Dislocation

Path: Axial load on hip while hip is flexed and adducted (car accident w/knee on dashboard) Pt: - Hip FLEXED, - ADducted, - INTERNALLY rotated - Limb appears shortened - Look out for injury to *SCIATIC NERVE* --> Weakness of knee flexion (Sciatic nerve) --> Weakness of ankle dorsiflexion (Common fibular nerve) --> Decreased ankle reflex (Tibial nerve) Dx: XR Tx: *Reduction w/in 6 hr* of injury!! in the ER - No fracture? Can be CLOSED reduction - If fracture? ORIF (open)

Beta Blocker Toxicity

Path: BBlocker overdose Pt: - Hypotension - Bradycardia - Wheezing Tx: *Atropine* - If this doesn't work? *Glucagon* IV

Osteoid Osteoma

Path: BENIGN bone tumor in adolescent boys - MC in PROXIMAL FEMUR! Pt: - Night pain - Responsive to NSAIDs!!! Dx: "Small round lucency with sclerotic margins" on XRay Tx: NSAIDs - Monitor w/serial XR (most spontaneously resolve over several years)

Biophysical Profile (BPP)

Path: BPP = Biophysical profile = NST + USD = NST + (Amniotic Fluid Index + Fetal Movements + Fetal Tone) - Has replaced Stress Test - Done without contractions Assesses fetal oxygenation through USD observation and the Nonstress Test (NST) = 10 pts total - Measure amniotic fluid (up to 2pts) - Observation of fetal tone (up to 2pts) - Breathing movement (up to 2pts) - Gross body movement (up to 2pts) Pt: Failed NST +/- VAS Dx: Score of... - 0-4 = *Fetal hypoxia* due to *placental dysfunction/insufficiency* (advanced maternal age, tobacco use, HTN, DM) --> *Emergency C/S*!!!! - 8-10 = Normal

Bullous Pemphigoid

Path: BULLOw the BM --> IgG autoantibodies against hemidesmosomes - Furosemide, NSAIDs, captopril, penicillamine - Associated with Parkinson's Disease Pt: - (-) Nikolsky's sign (sideways rub on skin doesn't tear it) --> unlike PEMPHIGUS VULGARIS (flacid blisters) - Autoimmune blistering disorder. - Often in elderly patients on numerous meds. - >60yo - Pruritus - Tense bullae - Urticarial plaques Dx: Skin biopsy, immunofluorescence: - *subepidermal bullae with eosinophils*, - *linear IgG/C3 deposits along basement membrane zone* Tx: *Clobetasol* (or other high potency topical steroid)

Infantile Vitamin-K Deficient Bleeding

Path: Baby did not receive *Vitamin K* shot at birth (they are deficient bc does not cross placenta, immature liver, and intestinal flora is not yet synthesizing it) - *Reduced coagulation factor carboxylation* (II, VII, IX, X) --> Pt: - Presents on *Day 2-7* after birth - Bruising - Mucosal bleeding - GI hemorrhage - Intracranial hemorrhage Dx: Prolonged PT & PTT - Confirm w/resolution following Vitamin K administration Tx: *Vitamin K*

Pediatric Traumatic Brain Injury (PECARN Rule)

Want to avoid unnecessary radiation exposure... HIGH RISK features? (Get *CT*) - Altered mental status - LOC - Severe MOI (>5ft fall, High impact hit, MVA) - Vomiting - Headache - Signs of basilar skull fracture

Spinal Epidural Abscess

Path: Bacteria gets into spinal cord and causes compression, usually at multiple different levels. - Epidural block, - LP, - Spinal surgery, - IVDU, - Endocarditis - Overlying cellulitis - MCC is *Staph Aureus* Pt: Triad - *Fever* - *Spinal pain* - *FND* - (mc) Progressive neurological deficits = Focal pain --> Radicular pain --> Motor weakness, Sensory changes, Bowel or bladder disreg. --> Paralysis - Low grade FEVER - Malaise - Lumbar back pain - Lower extremity neuro sx (weakness, tingling, numbness) Dx: *MRI of spine* Tx: Surgical drainage + *Vancomycin + Ceftriaxone*

Necrotizing Fasciitis

Path: Bacteria spread rapidly through subcutaneous tissues and deep tissues. - Often d/t hx of minor trauma - *Group A. Strep* (mcc), also Staph, C. Perfringens, Polymicrobial Pt: - Cellulitis... - Toxic, - Rapidly spreading, - Pain out of proportion of PE, - Erythema - Fever - Hypotension - Swelling - May have loss of sensation - *Crepitus* (like Gas Gangrene), - "Blue-grey discoloration" - Purulent discharge - Bullae - Necrosis Dx: *XRay* w/GAS bubbles!!! (also like Gas Gangrene) - "Air in the tissue bed" Tx: Surgical debridement + *3rd gen ceph + Clindamycin + Ampicillin*

Brain Abscess

Path: Bacterial rhinosinusitis (which presents >10 days after a URI) goes *UNTREATED* and extends into periorbital space and/or intracranially. - D/t otitis media, sinusitis, dental infection - MC organisms are *Viridans Strep* & *Staph Aureus* Pt: - Focal headache (usually unresponsive to pain meds) - HIGH fever (in 50%, others may be normal) - Early MORNING VOMITING (d/t increased ICP in recumbent position) - Mental status change - Focal neurological deficit - Neck pain - Seizures if tx delayed Dx: CT or MRI w/ Cerebtritis initially, and later on will see a SINGLE *RING ENHANCING LESION* with central necrosis (how you dif from Toxo, in addition to history) Tx: IV Abx (Metronidazole + Ceftriaxone + Vancomycin) If FOCAL HA, HIGH FEVER (>100.4), EARLY AM VOMITING, mental status change, focal neuro deficit, neck pain --> Get CT FIRST!! to confirm NO BRAIN ABSCESS from spread to FRONTAL sinus (then can do LP) --> ring-enhancing lesion if positive. - Tx: IV Abx

Catscratch Disease

Path: Bartonella, a fastidious gram (-) bacteria carried in the majority of cats. - D/t cat scratch, bite, or flea Pt: - Cat owner - SLOW onset (1-2wks)...unlike Pasteurella (1-2d) - Most patients don't recall specific bite or scratch - Localized papule - Regional ipsilateral LNDs --> Enlarged, tender, w/overlying erythema - Fever Dx: Clinical Tx: *Azithromycin*

Uncal Herniation

Path: Basal ganglia hemorrhage is mcc - Brain herniates down below tentorium cereblli Pt: - Nonreactive ipsilateral pupil - Contralateral extensor posturing - Coma - Respiratory compromise

Meconium Ileus

Path: Basically *CYSTIC FIBROSIS* - removes water from lumen causing meconium PLUG - In newborn baby with failure to pass meconium it is either this, or Hirschsprung Pt: Failure to pass meconium - Either had prenatal screen and you know they have CF - or they did NOT have prenatal screen Dx: XRay w/*Transition point* v. *Gas filled plug* - Contrast enema w/"microcolon" Tx: *Water-contrast enema* (Gastrograffin)...because issue is that they aren't lubricating enough so this will help dissolve the plug and diagnose. - F/up on Cystic Fibrosis w/*Sweat chloride test* if you didn't know about it (Give ADEK, Pancreatic enzymes, and Pulmonary toilet)

Vulvar Cancer

Path: Bc it is SKIN and there IS keratinized layer that cannot get infected w/HPV unless there is chronic inflammation (x. lichen sclerosis) --> HPV 16, 18, others - It's essentially skin cancer, so you may see melanoma (black), basal cell (waxy), squamous (variable) - *Chronic tobacco use* or HIV makes harder to clear HPV infection - RF = LICHEN SCLEROSIS Pt: Unifocal *FIRM, WHITE, FRIABLE MASS/PLAQUE* (usually on labia majora) PREINVASIVE - Asymptomatic - Risk factors for HPV - Focal color change INVASIVE - Pruritis - Fungating mass Dx: Biopsy - Invasive vulvar scc is *surgically* staged Tx: PRE-INVASIVE - LSIL? Will clear on its own - HSIL? *Resection/Ablation* (unlike Cervical cancer where you excise). Can use *Imiquimod*. - F/up Vaccinate INVASIVE - Surgery: *Vulvectomy + Inguinal nodes*

Trichotillomania (Hair-Pulling Disorder)

Path: Behavioral disorder characterized by compulsive hair pulling - Automatic (don't realize are doing) v. Preceded by tension followed by relief. Pt: - Irregular, patchy hair loss - Irregular areas of hair loss (x. eyebrows, eyelashes) - Areas of uneven hair (hairs of different lengths) - If they consume (trichophagia) they may develop trichobezoars and abdominal pain Dx: Clinical - Lack of other findings --> erythema (tinea capitis), total hair loss (alopecia areata) Tx: *CBT*

Trichotillomania

Path: Behavioral disorder characterized by compulsive hair pulling - Automatic (don't realize are doing) v. Preceded by tension followed by relief. Pt: - Irregular, patchy hair loss - Irregular areas of hair loss (x. eyebrows, eyelashes) - Areas of uneven hair (hairs of different lengths) - If they consume (trichophagia) they may develop trichobezoars and abdominal pain - Will see NEW GROWTH in bald patches Dx: Clinical - Lack of other findings --> erythema (tinea capitis), total hair loss (alopecia areata) Tx: *CBT*

Acromegaly

Path: Benign GH secreting tumor by pituitary somatrotroph adenoma - Increased release of *GH and IGF-1* causes growth of tissues, bone, cartilage, and visceral organs --> *IGF-1* is primarily what causes the clinical features of Acromegaly!!! - Can cause decreased secretion of other hormones Pt: - Kids? *Gigantism* d/t growth of long bones - Adults? Acromegaly *W/O* growth of long bones but.. --> Coarse facial features --> Increased interdental space --> Macroglossia --> Large hands --> Large feet --> Large visceral organs --> *Hyperglycemia* --> Increased metabolic rate (Hyperhidrosis) --> Diastolic CHF (concentric left ventricular hypertrophy) --> *Hypogonadism* - Joint pain - Finger swelling - Sweaty palms - Oily skin - Doughy - Poorly controlled HTN - Carpal tunnel syndrome - Pituitary mass effect symptoms (headache, visual field deficits) Dx: 1) *IGF-1* (hormone made from LIVER d/t GH stimulation) 2) If IGF-1 is elevated then? *Glucose-suppression test* --> bc elevated BG should LOWER GH (since high BG causes neg feedback), if doesn't change then tumor! 3) If glucose-suppression test (+)? MRI We don't use GH to Dx because it varies widely throughout the day. Tx: *Surgery* - f/up w/*Octreotide v. Pegvisomant* (or use these if not surgical candidate) - Skeletal and joint abnormalities are largely irreversible, but treatment works on several other features (x. Hyperglycemia) - Cardiovascular disease is the leading cause of death in these patients.

Keratosis Pillaris

Path: Benign condition of retained keratin plugs. Pt: - MC on *posterior surface of upper arm* - Small painless papules - Rough skin texture - Mottled perifollicular erythema - May be pruritic in cold, dry weather Dx: Clinical Tx: *Emollients* v. *Topical keratolytics* (x. salicylic acid)

Febrile Seizures

Path: Benign convulsions that occur in the setting of a fever (>100.4F) in children *6mo-5yr* - RF = High fever (usually viral), Recent immunization, Fam hx of febrile seizures Pt: - SIMPLE? Generalized tonic-clonic movements <15min --> May have postictal period but return to baseline within minutes. --> Normal neuro exam. --> DO NOT RECUR within 24hr Dx: Clinical Tx: *≥5 min* = *Benzo* - SIMPLE? Can be discharged home + Reassurance + Supportive care (antipyretics) --> Inform parents risk of repeated febrile seizures is increased, and risk of epilepsy is increased but still overall low.

Hepatic Adenoma

Path: Benign epithelial liver tumor, Solitary solid liver tumor - Can transform into malignant tumor - May RUPTURE and cause HEMORRHAGIC SHOCK! Pt: - Women - Long term Oral contraceptives Dx: - USD shows well-demarcated HYPERechoic lesions - CT shows CENTRIPETAL ENHANCEMENT - NO needle bx, just take to surgery Tx: - Asymptomatic & <5mm? STOP OCPs - Symptomatic & >5mm? SURGERY - If burst? URGENT SURGERY and Circulatory support

Cholesteatoma

Path: Benign growth of squamous epithelium with accumulation of keratin debris in the middle ear - Chronic middle ear disease can cause --> *Retraction pocket in TM* which can fill with Granulation tissue and debris - Cleft palate increases risk, bc increases risk of middle ear disease Pt: Continued *EAR DRAINAGE* for several weeks despite Abx treatment - CONDUCTIVE hearing los - Cranial nerve palsies - Vertigo - Life threatening infections - *Pearly white mass* at anterosuperior aspect of TM Dx: Clinical (ear exam) - Maybe CT of head Tx: *Surgical excision*

Familial Hypocalciuric Hypercalcemia (FHH)

Path: Benign mutation of the CaSR - Higher calcium levels are required to suppress PTH release - Autosomal DOMINANT disorder Pt: Asymptomatic - HYPERcalcemia - NORMAL renal function - *HYPOcalciuria* (how you dif from Primary Hyperparathyroidism - which has increased release of Ca2+ in urine d/t increased release of Ca2+ from bones) - *Normal PTH* or possibly ELEVATED (dif from Hypervitamin D which would be low in response to hypercalcemia) Dx: Clinical - Confirm w/Urine Calcium Creatinine Clearance Ratio Tx: None if asymptomatic - F/up Pancreatitis, Chondrocalcinosis

Keratocanthoma

Path: Benign neoplasm d/t UV exposure or prior trauma - Some undergo malignant transformation to *SCC* Pt: - Rapidly growing nodule w/ulceration and central keratin plug - Fair skinned - Elderly Dx: *Excisional Bx* Tx: Reassurance. - Usually resolves spontaneously over several months

Congenital Melanocytic Nevus

Path: Benign proliferation of melanocytes which present within the first few months of life. Pt: - Solitary hyperpigmented lesion - Increased density of overlying coarse HAIRS - Initially homogeneous --> May grow during infancy and appear heterogeneous and raised Dx: Clinical Tx: Fade with age

Vestibular Schwannoma

Path: Benign tumor of Schwann cells on cochlear and vestibular nerves of CN VIII. - SLow growing Pt: - Causes SENSORINEURAL hearing loss (Weber localizes to GOOD ear, Rinne w/AC>BC bilaterally) - CN 8 (hearing loss and imbalance), and - CN 5 (facial numbness) within the internal auditory meatus --> indicates tumor has grown to Cerebellopontine angle - Can compress CN 7 (facial paralysis), Dx: AUDIOGRAM v. MRI Tx: Observation ...OR... surgery v. RT

Intraductal Papilloma

Path: Benign!!! papillary projections of epithelial and myoepithelial cells - Aka *Papillary carcinoma* Pt: - Unilateral bloody nipple discharge - NO BREAST MASS!!! (or if it's there it is a very small mass...how dif from Intraductal carcinoma) - NO LNDs Dx: *Mammography v. USD* Tx:

Giant Cell Tumor (Osteoclastoma)

Path: Benign, but locally destructive. - MC at EPIPHYSIS of long bones. Pt: Young adults Dx: XR w/*"Soap Bubble appearance"* Tx: Surgery

Group B Streptococcus (GBS)

Path: Benign, normal flora for Mom. - Can lead to Preterm delivery, Premature rupture of membranes, Chorioamnionitis. Dx: UA + Urine Culture - Perform rectovaginal culture on all preggo's at *10 weeks* and then again at *36-38wks gestation* --> Screen *3-5wks* before estimated delivery date Tx: *Give all those listed below INTRAPARTUM prophylactic abx*.....*Penacillin v. AMPICILLIN* --> Pen ALLERGIC? *Cefazolin* --> SEVERE Pen ALLERGY? *Clindamycin* OR!!! *Vanocmycin* if sensitivities show resistance to Clinda or Erythromycin (even if just resistance to Erythromycin we always also assume resistant to Clinda as a result!) - GBS (+) at any point during pregnancy (even if treated already) + additional observation - GBS status uncertain - GBS Bacteriuria or GBS UTI in current pregnancy - Prior delivery w/early onset neonatal sepsis - Intrapartum fever - Rupture of membranes for ≥18hr (PROLONGED ROM) - <37 week gestation ONLY PERSON WHO DOES NOT get prophylactic abx = C/S w/o ROM

Craniopharyngioma

Path: Benign, slow growing, 5-14yo - Remnant of *Rathke Pouch* (evaginates from the mouth to give rise to Anterior Pituitary) Pt: Worsening headaches, waking up from night, papilledema. OPTIC CHIASM COMPRESSION --> Bitemporal hemianopsia PITUITARY STALK COMPRESSION --> Endocrinopathies - Growth failure (decreased TSH or GH) - Pubertal delay in children (decreased LH and FSH) - Diabetes insipidus (decreased ADH) Dx: MRI/CT w/*Calcified or cystic suprasellar mass* Tx: Surgical resection or radiation therapy

Subarachnoid Hemorrhage (SAH)

Path: Berry aneurysm ruptures ....Because the blood causes meningeal irritation there are a lot of overlapping symptoms with Meningitis. - RF = HTN, Smoking, ADPK, AVMs, Alcohol - Complications? --> *24HR* = *REBLEEDING* (once surgically repaired this risk is virtually eliminated) --> *3-10DAYS* = *VASOSPASM* (Dx w/CTA, Tx w/Nimodipine) --> Remember sketchy pic with person at topping stand "Need mo' dippin'" by berries . Pt: *RAPID ONSET*!!!!! How you dif from Meningitis - Thunderclap headache - Nausea - Vomiting - Photophobia - Seizures - Neck stiffness (from blood on meninges) - FEVER - Focal neurologic deficits (60%) --> *Occulomotor (CNIII) nerve palsy* ("down, out, blown" = ptosis + mydriasis + loss of somatic) @ PCA --> CNII palsy @ ACA or Internal Carotid --> CNIII palsy @ PCA --> CNIV palsy (SO4) @ Superior cerebellar --> CNVI palsy (LR6) @ AICA - Coma Dx: CT *WITHOUT contrast* (Bleeding into the cisterns and brainstem seen) - *MRA or CTA to confirm* location!!! - If CT NEGATIVE but you still think SAH? *LP* --> Would show Elevated opening pressure + *RBCs* or *Xanthochromia* (yellow color from OLD blood in csf) --> *If RBCs do not clear w/subsequent* samples drawn then it is evidence for SAH and NOT traumatic tap! Tx: EARLY (w/in 48hr)? - Bleeding...Tx: *BP <140/90* or Coil or Clipping - Hydrocephalus...Tx: Serial LPs or VP Shunt - Doing really poorly with increased ICP?....Tx: Craniotomy, then Clipping or VP Shunt - Headache or aneurysm and NOT going to do craniotomy?....Tx: Coil and Serial LPs - Seizures...Tx: Levetiracetam LATE (5-7 days)? - Vasospasm...Prevent w/CCB (x. *Nimodipine*) or *INCREASE BP* (counter-intuitive, but need to perfuse the brain)

Bulimia Nervosa

Path: Binge (uncontrolled eating)...then PURGE (emesis v. laxative abuse v. fast v. exercise v. diet pills, etc) bc feels shame about binging - *YES* INSIGHT - Many ways to "PURGE", does NOT need to be just vomiting or diarrhea. Pt: - Female to male 10:1, - Typically normal BMI or overweight EMESIS? - Dental erosions - Dorsal hand scars - Parotid swelling - Metabolic *ALKALOSIS* - Low H+, K+, Mg2+ LAXATIVES? - Metabolic *ACIDOSIS* - Low Bicarb (bicarb out the butt) Dx: Binge + Compensatory behavior must occur *≥1x/week* for *≥3 months* - Confirm w/*Hypokalemic Hypochloremic Metabolic alkalosis* Tx: *SSRI/SNRI* (esp. Fluoxetine) + CBT

Behavioral Regression

Path: Birth of new baby causes older child to seek out attention from parents in negative ways Pt: - Loss of toilet training - Loss of acquired words - Increased separation anxiety - Increased tantrums - Aggressive behavior towards newborn Tx: Spend *one-on-one time* with child (to reinforce importance and sense of security) + Reward positive behavior + Give toddler supervised responsibilities --> If this doesn't work then Child Psychologist

Bisphosphonate Related Osteonecrosis of the Jaw

Path: Bisphosphonates inhibit the resorption of bone, which impairs bone remodeling. - Classically presents in an area of exposed, necrotic bone following tooth extractions or other dental procedures. Pt: Often asymptomatic - Presents for months or years - Local swelling - Mild pain - Exposed bone Tx: Supportive + Oral hygiene + Abx rinses

Human Rabies

Path: Bit by an animal - Fatal neurotropic viral disease - Death within weeks of sx onset Pt: Symptoms *1-3mo after* exposure - Fever - Chils - Sore throat - Malaise - Pain, tingling, numbness of bite wound - Hydrophobia - Aerophobia - Pharyngeal spasms - Hypersalivation - Grimacing - Opisthotonos Tx: - Unprovoked SMALL WILD animal attack? Low risk. No PEP. - Unprovoked MID-SIZED+ WILD animal attack? *Catch and kill* to run tests, PEP if positive. - Provoked DOMESTIC animal bite? *Observe* for 10 days. No PEP if healthy. *If can't observe, then PEP*. - Human gets sx of rabies? *Rabies Ig + Vaccine*

Mitral Stenosis

Path: Blood can't get through mitral valve as well so backs up into L ATRIUM and then into LUNGS - *Rheumatic Heart Disease* Pt: - Younger w/CHF symptoms - *Dyspnea on exertion* (mc sx) - Cough - PND - Vascular congestion - Enlarged cardiac silhouette - A fib/A flutter - Diastolic murmur best heard at cardiac apex (5th ICS, midclavicular line) - *Opening snap* at beginning of diastole - *Rumbling* during mid-diastole (like aortic regurg) --> The more severe this is, the earlier you hear it (this is opposite aortic stenosis, where severe murmurs are heard later) - Upward displacement of left mainstem bronchus on CXR Dx: Clinical Tx: *Balloon valvuloplasty* (less invasive) - Replacement (but will need to repeat this throughout thier life, so not as ideal) - Routine anticoagulation, independent of CHA2DS2-Vasc score

Anterior Shoulder Dislocation

Path: Blow to *abducted* and/or *raised* arm, Violent muscle contraction (x. seizure) --> Worry about *Axillary nerve* injury (innervates teres minor and deltoid...which cause shoulder ABduction and lateral shoulder sensory innervation) Pt: - Arm held in *ABduction/External rotation*

Blunt Cardiac Injury

Path: Blunt cardiac trauma can cause edema, hemorrhage, necrosis capable of causing a spectrum of structural, ischemic, or electrical complications Pt: - History of chest trauma - Persistent tachycardia despite interventions - New onset arrhythmia Dx: *TEE* is preferred but more invasive....so when hemodynamically stable can do *TTE* instead!!! Tx: 24-48hr of continuous cardiac monitoring

Bronchial Rupture

Path: Blunt chest trauma causes bronchial rupture, where large quantity of air escapes with each breath. - Or air is leaking from well-sealed chest tube. Pt: - *Persistent* tension pneumothorax/pneumomediastinum despite appropriate treatment (needle or tube thorocostomy) - *Subcutaneous emphysema* - Rapid, large air leak into the chest tube drainage system Dx: *Bronchoscopy* - CT is OK but misses smaller injuries. Tx: *Operative repair*

Pulmonary Contusion

Path: Blunt force to the chest wall can injure the underlying lung, resulting in *alveolar hemorrhage and edema* (noncardiogenic pulmonary edema) - Subsequent fluid resuscitation can injure the underlying lung Pt: HUGE trauma Day 1? - NO symptoms!!! Later? - *Dyspnea* - Tachypnea - Tachycardia - Hypoxia Dx: Initial CXR often negative. Later *CT* w/... - *Ground-glass opacities* in the lung *adjacent to the injured chest wall*!!!! --> "Irregular nonlobular infiltrates" - Unilateral v. Bilateral Tx: Pain control + Pulmonary hygiene + Supplemental O2 & Ventilatory support

Lyme Disease

Path: Borrelia burgdorferi (spirochete) bite - Patient's develop disease 7-14 days after transmission - 48-72 hours of feeding by tick is required before transmission of spirochete occurs. Pt: Flu like illness + ... - Erythema migrans (because rash migrates outwards into the bulls eye appearance) - Fever - Headache - Myalgia - Fatigue - Later? Carditis/Bells Palsy/Migratory Arthritis --> Bells palsy is often *Bilateral*!!!! - *Lymphocytic meningitis* --> Pain with neck flexion!!!! Dx: Go straight to treatment!!!!! (Serology early on will often be negative) - If you need to, you can test for *Lyme Ab's* to confirm - Joint aspiration w/Moderately high WBCs (~25,000). Gram stain and culture are negative. Tx: - If tick is STILL ON SKIN? *Remove as close to skin as possible by using forceps* --> If attached for *≥36hr*, give *Prophylactic Doxy* --> If *<36hr*, reassure. - If no tick but erythema migrans? *Doxycycline* - Later/Severe? *Ceftriaxone* - Preggo?? *Amoxicillin*

Wound Botulism

Path: Botulinum toxin contaminates a puncture wound, germinate in the anaerobic environment and release botulinum toxin in-vivo. - Impairs PRESYNAPTIC release of Ach at the neuromuscular junction - RF = *IVDU* Pt: - Ptosis - Mydriasis - Descending paralysis (begins with the CN's) - Diaphragmatic paralysis causing progressive respiratory compromise - Autonomic dysfunction (ileus, orthostatic hypotension, urinary retention) - Fever (only seen when infection in WOUND!!!) - Leukocytosis (only seen when infection in WOUND!!!) Dx: Botulinum in culture v. Toxin in serum Tx: *Equine Botulinum Antitoxin*

Sphincter of Oddi Dysfunction

Path: Can develop following any inflammatory process (x. surgery, pancreatitis) - Dyskinesia and Stenosis of the Sphincter of Oddi Pt: Mimics a structural lesion - Recurrent episodic pain in the RUQ - AST & ALT elevations (or not) - Alk Phos elevations - Dilation of Common Bile Duct *w/o stone!!!!* - Elevated total bilirubin Dx: *Sphincter of Oddi manometry* Tx: *Sphincterotomy* - Opiates WORSEN sx - cause sphincter contraction!!!

ARDS CXR

White/cloudy CXR with pulmonary infiltrates

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Path: Brain lesion, Lung lesion, Meds (SSRIs!!!, *Carbamazepine*, NSAIDs, Excessive Desmopressin), *Pulmonary infections* - ADH causes renal reabsorption of pure water from urine, so concentrates urine and dilutes blood. - If hx of smoking think *Small Cell Lung Cancer* Pt: Nausea, Forgetfullness, Seizures, Coma (all d/t hypoNa+), Euvolemia - Drugs can cause (x. Desmopressin, Lithium, etc) Dx: *Euvolemic HYPOTONIC HYPONa+* - Urine osmol >100 - Urine Na+ elevated - Serum Na+ low - Serum osmol <270 Tx: 1. *Fluid restriction* +/- salt tablets --> If severe (Na+ *<120mEq*), give *HYPERTONIC saline*!!!! (don't correct too rapidly, worry about Osmotic Demyelination Syndrome) 2. Then gentle diuresis. 3. Then *Demeclocycline* if all else fails. - can be due to SSRIs!, NSAIDs, pain, nausea, lung disease, ca

Breech Presentation

Path: Buttocks or Feet are closest part to maternal cervix - RF = Prematurity, Multiparity, Multiple gestation, Uterine anomalies, Leiomyomas, Placenta previa, Fetal anomalies Pt: - Subcostal pain - Hard mass near uterine fundus - Lack of fetal presenting part on digital cervical examination Dx: *USD* Tx: - *FOOTLING or INCOMPLETE BREECH*? *External Cephalic Version* if *≥37 weeks* and no CI to vaginal delivery...consider C-Section next --> risk of prelabor rupture of membranes, abruptio placentae, preterm labor - *FRANK or COMPLETE BREECH*? Can consider *Vaginal delivery* - Prior hx of C-section (w/o low transverse incision)? *C-Section* (at 37wks, if had prior c-section delivery)

Peripheral Vascular Disease

Path: CAD (smoking, DM, HTN, HLD, female) Pt: Limb claudication (ischemia for the limb), Shiny shins, Loss of hair, Diminished pulses, Cooler to touch - Nonhealing wounds - Severe? Pain at rest or when change position. - R/o spinal stenosis (pain which improves w/leaning forward or seated and worse with standing) Dx: ABI - >1.4? Need *TBI* (Toe-brachial index) - 1-1.4? Normal. - 0.9-1? Equivocal. Need to follow-up with *Exercise ABI* - 0.8-0.9? Mild. - 0.4-0.8? Moderate. - <0.4? Severe. ......if ABI is (+), then get *USD Doppler* to confirm location. Tx: BBlocker, or Ace-i, or A1c<7, or Smoking cessation, or Statin, or Aspirin v. Clopidogrel. - *Supervised graded exercise* is the best for reducing claudication. - If will effect their lifestyle or Failed medical therapy? *STENT* (ABOVE the knee and SMALL) v. *BYPASS* (BELOW the knee and LONG). - If NOT surgical candidate? *Cilostazol* v. Pentoxyphylline (usually these are wrong answer on test)

Secondary Hyperparathyroidism

Path: CKD or ESR causes Low Ca2+ d/t impaired production of VitaminD, and also cause High Phos d/t impaired excretion --> This triggers increased PTH --> Goes to bone and resorbs bone to try and increase Ca2+ (metabolic bone disease, osteopenia) --> Hyperplasia of the parathyroids!!! Pt: Asymptomatic - Calcium --> ...if Ca x Ph>55 then at risk for calciphylaxis. - Phosphorus - Bone pain - Increased risk of fracture. - Worry about developing *Tertiary Hyperparathyroidism* (where adenoma of parathyroid tissue causes independent oversecretion of PTH) Dx: BMP (Ca & Ph) Tx: - *Low phosphate diet* - *Sevelamer* (Phosphate binder) or - *Calcium-Carbonate* or - Replace Ca2+ & Vitamin D

Osteogenesis Imperfecta

Path: COL1A1 gene defect (Type *ONE* collagen) "bONE", important component of musculoskeletal system, skin, and sclera. - Autosomal DOMINANT Pt: - Frequent fractures (decreased bone strength and flexibility) - Short stature - Blue sclera - Gray, translucent teeth (Dentinogenesis imperfecta) - Joint hypermobility - Conductive hearing loss --> Results in Speech delay - TYPE II (lethal): Stillborn fetus often born with... --> Hypoplastic thoracic cavity --> Multiple limb fractures (unlike Potter sequence which would be club foot, etc) --> Shortened femur --> Growth restriction

Infant Constipation

Path: Can be NORMAL or sign of serious issue - Normal? D/t failure to coordinate increased abdominal pressure or inadequate muscle tone - Serious issue? w/severe abdominal distention, abnormal rectal tone or sacral findings, failure to pass meconium, failure to thrive Pt: - Straining during defecation >10min - Face turns red - Abdominal distention - Crying prior to or during passing stool Dx: Well appearing? *Look at stool*!! - Normal? *Reassure* - Pellets? *Functional constipation* - Loose? *Food-induced* Tx: - Normal? Resolves at 9 months - Pellets? *Lactulose* - Loose? *Switch to soy formula if breastfed*

Polymyositis

Path: Can be a paraneoplastic syndrome.... - NON-Hodgkin, Lung, and Bladder cancers Pt: - Positive ab's to *ANA & Anti-Jo*, Anti-Mi...."Mi-Jo-sitis" - May have diffuse myalgias or muscle tenderness... (usually we think of it as NO pain) - PROXIMAL MUSCLE WEAKNESS - Dysphagia - Difficulty going up stairs - Difficulty lifting arms above head - Elevated CK, - Elevated ESR - Elevated ALDOLASE, - Elevated AST Dx: *Muscle biopsy* w/ mononuclear infiltrate surrounding muscle fibers, - or EMG, or CK Tx: Steroids + Glucocorticoid-sparing agent to minimize longterm AE of steroid use - Do age appropriate CANCER SCREENING to r/o

Mesenteric Ischemia

Path: Can be chronic (similar in concept and pathophysiology to cardiac angina) or acute (similar in concept and pathophysiology to MI). D/t.... - Atherosclerosis, - Embolic source, - Hypercoagulable disorders Pt: - Urge to defecate (Tenesmus) - Periumbilical pain - Nausea - Early satiety - Vomiting - Diarrhea - Bloating - Postprandial epigastric pain - Food aversion - Weight loss - Abdominal bruit - Leukocytosis w/bands - HIGH Hgb (Hemoconcentration) - DECREASED bowel sounds - If INFARCT occurs? --> POOP (Pain Out of Proportion) --> Focal abdominal tenderness, --> Peritoneal signs, --> Hematochezia, --> Sepsis --> Anion gap metabolic acidosis (d/t lactic acidosis) Dx: *CT mesenteric angiography* of abd (preferred) or MRA - Leukocytosis - Elevated Amylase & Phosphate - Elevated Lactate (metabolic acidosis) Tx: NG decompression + IVF + Abx (+ maybe anticoagulation if not bleeding) - Embolectomy w/vascular bypass in some cases

Intrauterine Fetal Demise

Path: Can be d/t maternal, fetal, or placental causes - Cause requires *Autopsy*, until then you cannot state why you think baby died. - Up to 50% of cases have NO identifiable etiology - MUST be *≥20 weeks* Pt: - Absent fetal movements - Absent fetal cardiac activity Tx: - 20-23wks? *D&C* OR *Vaginal Delivery* - ≥24wks? *Vaginal delivery* (regardless of presentation, i.e. breech etc) --> You'll want to induce as soon as they're ready either way, bc retention of dead fetus can cause coagulopathy

Plaque Psoriasis

Path: Can be prompted by skin trauma (x. kneeling) or medications - EXPLOSIVE ONSET? Think HIV! Pt: - Well demarcated - Hyperkeratotic plaques - Silvery scale - Extensor surfaces - Psoriatic arthritis Dx: Clinical - Could bx if difficult to dx Tx: - Mild? --> Body? *Topical steroids* --> Face? *Vitamin D derivatives, Calcineurin inhib, Topical retinoids* - Severe? *UV Phototherapy v. Methotrexate v. TNF-a inhib* - Psoriatic arthritis? Systemic tx (though NOT w/steroids)

Pleural Effusion

Path: Can happen *after cardiac surgery*, which is benign as long as Early onset, Small to moderate in size and not enlarging, Not associated with respiratory symptoms. - If criteria not met could be serious complication which needs investigation - Light Criteria helps determine cause... TRANSUDATE caused by: - CHF - Nephrosis - Gastrosis - Cirrhosis EXUDATE (*protein ratio >0.5, LDH >0.6*) caused by - Malignancy - Pneumonia - TB Dx: Lateral decubitus CXR Tx: - If *<1cm* then too small, can't tap? WATCH/WAIT - If after CABG and asymptomatic? WATCH/WAIT - If new and large enough to tap? *THORACENTESIS* - If *Parapneumonic effusion*? *Abx* --> If COMPLICATED (signs of bacterial invasion into effusion)? *+ Chest Tube* to drain --> If UNCOMPLICATED? *+ Serial CXRs* to monitor - If *loculated* (septations/lobes)? THORACOSTOMY (and put tPA through tube to help drain!!!) --> if this doesn't work then THORACOTOMY - If they have CHF? Diurese... --> If that fails then THORACENTESIS PMNs in fluid? --> PNEUMONIA Lymphocytes in fluid? --> TB/MALIGNANCY RBCs in fluid? --> HEMOTHORAX v. CA (stage 4) TGs in fluid? --> CHYLOTHORAX

False Labor

Path: Can occur d/t mild dehydration or other benign causes. - All patients w/contractions must be evaluated, bc sometimes the cause is NOT benign - Aka Braxton-Hicks Pt: - IRREGULAR contractions - NO dilation or cervical change Dx: *NST* Tx: If NST reactive (normal), then *Observation + Discharge home w/labor precautions*

Basal Cell Carcinoma (BCC)

Path: Cancer of basal layer. - Associated with *sun exposure* - Mc on face, chest, extremities. - NO METS - (+) Local invasion - If pt is immunocompromised think SCC!!!! Pt: *Light or pearly pink nodules with talengiectasia and ROLLED BORDERS* on HEAD or NECK - Non-healing lesion that bleeds easily - Can also have CENTRAL ULCERATION OR CRUSTING (like SCC) - MC and least severe type of skin cancer - RARE on lip, and when seen is on *UPPER LIP* (remember is opposite from if you were to match B with B) - NO NEURO SX (less common at least...) Dx: EXCISIONAL Bx (w/palisading nuclei) - "Invasive clusters of spindle cells surrounded by palisaded basal cells" Tx: - Nodular? *Excision w/NARROW margins* - Face? *Moh's Procedure* - Limb & Mild? *Excisional Bx w/WIDE margins* - Limb & Aggressive? Amputate limb

Squamous Cell Carcinoma (SCC) of the SKIN

Path: Cancer of keratinocytes - YES can METS - (+) Local invasion - Sun exposure or *Chronic wounds* or *Scars*, *Immunosuppressive therapy*, RT, Tobacco use Pt: *Well defined red papule* or *KERATINIZED nodules/lesions (thick, rough surface), can ULCERATE w/crusting and bleeding*. - Hyperpigmented spot on *BOTTOM* lip = SCC - *Marjolin Ulcer* if from chronic wound or scar (enlarging non-healing ulcer, rolled over, granulation tissue, bleeds easily) - SUN EXPOSED areas - NEUROLOGICAL symptoms (numbness, paresthesias) can occur. --> How you can dif from BCC!!!!! - SCC on BOTTOM lip!!! (opposite from if you were to match b with b for bcc) - >60yo Dx: *EXCISIONAL Bx* (keratinocytes w/keratin "pearls") - "Invasive cords of squamous cells with keratin pearls" Tx: - Face? *Moh's Procedure* - Limb & Mild? Excisional Bx w/wide margins - Limb & Aggressive? Amputate limb *ACTINIC KERATOSIS is a PRECURSOR lesion* *BOWEN DISEASE = SCC-IN SITU*

Melanoma

Path: Cancer of melanocytes - (+) METS - (+) Local invasion Pt: Jet black lesion (like mole) but WITHOUT HAIR - Asymmetric - Irregular Borders - Different or changing colors - Diameter *>5mm* - Evolving over time - Can be *NODULAR*, which grows vertically and presents w/few of the ABCDE criteria... --> Darkly pigmented --> Firm --> Continued growth over month Dx: - Large or Low suspicion? *Punch Bx* - Small or High suspicion? *Excisional Bx* Biopsy appropriate when.... - 1-2 of ABCDE - Inflammatory changes (itching, crusting, bleeding, numbness) - *Ugly duckling sign* (significantly different from other lesions on same patient) --> doesn't need to meet full ABCDE criteria in this case! - Thickening or nodularity Tx: Based on depth of lesion... - <0.5mm? *Excisional Bx* w/0.5cm margins - 1-2mm? *Excisional Bx + SLND* w/1cm margins - 2-4mm? *Excisional Bx + SLND* w/2cm margins - >4mm? Basically mets at this point...*Chemo + Radiation & Debulk for palliative care*

Medullary Thyroid Cancer

Path: Cancer of the *PARAFOLLICULAR CELLS* in thyroid, which produce *Calcitonin* (decreases Calcium) - Most are sporadic - 25% Associated w/MEN2A and MEN2B (RET mutation) Pt: - Asymptomatic thyroid nodule - Some have HYPOcalcemia (diarrhea, flushing) but most are NORMAL Dx: *FNA* w/ Tx: *Thyroidectomy* - Give *Levothyroxine* after - Check *Calcitonin* levels for tumor recurrence

Tumor Lysis Syndrome

Path: Cancer patient started on chemo. Malignant cells release abnormally high amounts of - *PHOSPHATE*, which causes compensatory release of calcium by the kidneys (HYPOCALCEMIA), causing KIDNEY STONES which damage the kidney. --> Acute renal injury - *POTASSIUM* (usually intracellular, which is then released as the tumor is lysed) --> Cardiac arrhythmia - *URIC ACID* from purine nucleotides released during tumor lysis, which then cause URIC ACID STONES, damaging the kidney. --> Acute renal injury Pt: - Nausea, - Vomiting, - Seizures, - Arrhythmias, - Muscle cramps, - Tetany - All ultimately from electrolyte abnormalities --> HYPER K+ --> HYPER Phosphate --> HYPER Uricemia --> HYPO Ca2+ Tx: *IVF* + *Allopurinol, Rasburicase, Febuxostat*

Intertrigo

Path: Candidal infection of the skin folds. - RF = Steroids, DM Tx: *Topical -azoles*

Carotid Sinus Hypersensitivity

Path: Carotid sinus receptors become overly sensitive, triggering an exaggerated vagal response to pressure (putting on shirt, tie, shaving, etc). Pt: - Elderly man - Atherosclerotic disease - Syncope or presyncope Dx: Carotid massage Tx: Placement of pacemaker

Sickle Cell Trait

Path: Carrier mutation with Hemoglobin AS - African, Mediterranean, Middle Eastern - Sickling occurs d/t physiologic stress, esp. that with LOW O2, Dehydration, or Acidosis Pt: Usually asymptomatic (HEMATURIA mc sx) - Anemia w/appropriate reticulocytosis - Renal papillary necrosis (increased renal medullary echogenicity on USD) --> Gross *HEMATURIA* w/*Blood AND RBCs* (unlike rhabdo which is just blood and no RBCs), NO CASTS --> Acute flank pain - Splenic infarction only in high altitudes (so not very common) Dx: Hemoglobin electrophoresis w/HbA > HbS

Ecthyma Gangrenosum

Path: Cutaneous infection associated with *PSEUDOMONAS* (remember the spots on the Dalmatian?). - Seen in immunocompromised patients - Symptoms progress RAPIDLY Pt: - Cutaneous or mucous membrane lesions - Begin as painless red macules - Become indurated pustules or bullae w/punched out gangrenous ulcers - Fever Dx: Cultures Tx: Abx that cover Pseudo

Preeclampsia

Path: D/t *abnormal cytoplast invasion* (during implantation of placenta) --> low flow, high resistance vessels (vs high flow low resistance vessels which are normal) --> Decreased placental perfusion - Symptoms *≥20 weeks* - Third trimester is when demands of fetus outpace abilities of placenta - Severe features has worse outcomes (eclampsia, *abruptio placentae*, fetal demise) - Can present up to *6 wks after delivery* - Patients are at increased risk of *hemorrhagic or ischemic STROKE* (d/t endothelial damage) - *Distention of the hepatic capsule* causes RUQ pain. - RF: Multiple gestation, DM1, SLE, HTN, Prior hx of preeclampsia Pt: - Uteroplacental insufficiency - Wide-spread maternal vasoconstriction (HTN) - Signs of end-organ damage (headache, visual changes, proteinuria, thrombocytopenia, hemolysis) - Maternal thrombocytopenia - Vascular microthrombi --> *acute ischemic stroke* - Decreased fetal growth (bc limited blood supply to fetus) --> SGA - Pulmonary edema (d/t arterial vasoconstriction) - Hyperreflexia, clonus Dx: All symptoms must be sustained at *≥20 weeks* - FND? *CT of head* to r/o hemorrhage or ischemia NOT SEVERE? - New onset hypertension (≥140/*≥90*) - Proteinuria (24 hour urine protein test >3.5g/day, or >300ng/dL) --> get at initial visit. SEVERE? Diagnosed when *≥1*!!! of the following is present...so can have BP of 140/90 and Cr of 1.5 and meet criteria for Severe Preeclampsia (unless better explained by SLE flair) - HTN ≥160/≥110 at ≥20 weeks - Proteinuria *>500g/dL* or *protein:cr ratio of >0.3* or *2+* --> DO NOT need evidence of proteinuria if they already have signs of other organ dysfunction. You go straight to *Delivery* if >34wks - Platelets <100,000 - Creatinine >1.1 - Elevated transaminases 2x - RUQ pain - Pulmonary edema - Headaches - Vision or cerebral symptoms - *PULMONARY EDEMA* (d/t increased SVR & vascular permeability, and decreased albumin & renal function) Tx: PREVENT (*CKD, DM, HTN, Preeclampsia in prior pregnancy, Multiple gestation*)? *Low dose aspirin* starting at 12-16wks ideally, but could start up to 28wks NOT SEVERE? - <37 weeks? *Expectant* - ≥37 weeks? *Delivery* - F/up frequently to look for alarm symptoms SEVERE? - ≥34 weeks? *Delivery* - Severe BP? *IV Labetolol* (watch HR bc drops) v. *IV Hydralazine* (watch HR bc increases) v. *PO Nifedipine* - *Magnesium* (for seizure prophylaxis) + *Delivery* (can induce usually) --> f/up on DTRs bc don't want to suppress everything so much that there are resp issues...give Ca2+ to correct. --> Remember Mg2+ excreted by kidneys, so impaired function can cause easy toxicity

WAGR Syndrome

Wilms tumor Aniridia (absence of iris) Genital/gonadal tumors Retardation (mental and motor)

Pheochromocytoma

Path: Catecholamine secreting ADRENAL tumor - Anesthesia triggers catecholamine release!!! - Associated with... --> RET mutations in MEN2a and MEN2b (Autosomal DOMINANT) --> Neurofibromatosis I (Autosomal Dominant) --> Von Hippel Lindau (Autosomal Dominant) Pt: Only 50% have sx, EPISODIC - Paroxysmal - Headache - HTN (intermittent or sustained...often drug resistant) - *Pallor* (d/t - Tachycardic - Perspiration - NO Confusion or Impaired consciousness!!! That would indicate hypoglycemia Dx: - If crisis now? *Plasma Free Catecholamines* - If not sure? *24-hr Urine Metanephrines* (VMA) - Then... CT Abd to confirm - Then... Adrenal vein sampling to determine unilateral or bilateral involvement Tx: (Pre-operative measures! bc you will ultimately resect) "Follow the alphabet" 1st: *Alpha-Blockade* w/Phenoxybenzamine 2nd: *Beta-Blockade* 3rd: *Resect*

Urethritis

Path: Caused by STD (*gonorrhea, chlamydia*) Pt: - Young, sexually active - May have discharge - Dysuria Dx: FIRST? *UA + Urine culture* - UA w/ Leukoctye Esterase, WBCs, and NO organisms!!! (*Sterile pyuria*) - Urine culture is also often negative THEN? *NAAT* Tx: CEFTRIAXONE x1d + AZITHROMYCIN x1d - or CEFTRIAXONE x1d + DOXY x7d if Azithro cant be used. *Give all HIV screen*

Lead Poisoning in Adults

Path: Causes *IMPAIRED HEME SYNTHESIS* (microcytic anemia) d/t inhibition of enzymes for heme and RNA synthesis Pt: - Fatigue - Abdominal pain - Constipation - Anorexia - Sensorimotor neuropathy - Headaches - Short term memory loss - Hypertension - Nephrotoxicity - HYPERuricemia - Foot drop - Wrist drop Dx: - PBS w/*basophilic stippling* on RBCs Tx: *Dimercaprol*...."put a dime on lead"

Sickle Cell

Path: Cells sickle d/t HgbSS --> Vasooclusive crisis (provoked by hypoxemia, acidosis, or dehydration) - Autosomal *RECESSIVE* - Once splenic infarction occurs (by *4yo*) they are functionally asplenic, and at risk for sepsis d/t *Encapsulated* organisms --> Mcc of sepsis is *Strep Pneumo*!!! (which can cause DIC and therefore petechiae, making it confusing with other bugs that cause rash)!!! - At risk for osteomyelitis infections with *Staph* and *Salmonella* (unless it's clearly a bone infection, Salmonella and Staph ARE NOT involved) Pt: - *Acute Chest* --> looks like MI w/ CHF exacerbation - *Acute Brain* --> looks like STROKE - PRIAPISM!! for males - *Macrocytic anemia* d/t folate deficiency which can easily occur w/o adequate supplementation bc of the increased demand for erythropoesis in SS patients. - Splenic sequestration --> only occurs in CHILDREN --> Severe normocytic anemia --> Thrombocytopenia --> INCREASED reticulocytes --> Tachycardia --> Hypotension --> Jaundice --> Splenomegaly - Aplastic Crisis (think Parvo) --> Anemia --> Platelets NORMAL --> LOW reticulocytes Dx: *Hgb electrophoresis* ONCE usually as kids to dx --> check *BLOOD SMEAR* if you think they are in crisis, would show sickle cells or *Howell-Jolly bodies* Tx: *Hydroxyurea* (induces formation of hemoglobin F or fetal Hgb which helps because beta gene has the bad gene in HgbSS) + IVFluids, O2, Pain control - If Acute Chest, Stroke --> *Exchange Transfusion* (most SS patients have Hgb of 7-8 at baseline, don't transfuse to number! Transfuse to symptoms) - Splenic sequestration? *IVF + Blood + Splenectomy* - Priapism? *Aspirate blood from corpora cavernosa*, then intracavernous phenlyephrine injection - Iron overload? Deferoxamine. - Sepsis? *Ceftriaxone + Vancomycin*

Physiologic Leukorrhea

Path: Cervical mucus + Normal vaginal flora + Vaginal squamous epithelium - Increased amounts occur 10-14d after prior menses Pt: - Odorless - White or clear - *Mucoid* - May see *"RARE polymorphonuclear leukocytes"* (normal, noninfectious) Dx: Tx:

Sudden Infant Death Syndrome (SIDS)

Path: Child that dies for NO REASON Prevention: - Sleep on BACK (but this flattens occiput, so turn head onto cheek) - Don't share a bed - *SMOKING CESSATION* Higher risk? - Premature infants - Congenital defects

Velocardiofacial Syndrome

Path: Chromosome 22q11 deletion Pt: - Cleft of soft palate - Elongated face - Retrognathia - Prominent nose - "Almond eyes" - Hypernasal speech - Cardiac defects - Learning disability - Schizophrenia - Paranoia

Hairy Cell Leukemia

Path: Chronic B-cell neoplasm --> Manifestations arise from infiltration into bone marrow, spleen, peripheral blood - Rare Pt: - Males - >50yo - Recent episodes of pneumonia - MASSIVE red pulp *SPLENOMEGALY*, - Bone marrow infiltration w/fibrosis and PANCYTOPENIA (unusual for leukemias)...anemia, thrombocytopenia, Leukopenia - IF!! they have Leukocytosis, it is MILD Dx: PBS w/Hairy lymphocytes - *Bone marrow bx* and flow cytometry confirms (Dry tap) and stains + (TRAP) Tx: *2-CDA* (adenosine deaminase inhibitor)...cladrabine

Onchomycosis

Path: Chronic dermatophyte infection of the toenails by Trichophyton rubrum - Can get into interdigital spaces between toenails Pt: - Itching - Erythema - Scaling - Thickening of toenails - Discoloration of toenails Dx: Clinical - Confirm w/KOH prep of nail scrapings Tx: *Terbinafine* (oral) v. Topical antifungals. - Treatment failure is common

Pseudogout

Path: Chronic inflammatory arthritis d/t *Ca2+ pyrophosphate* crystal deposition - Mc at knees and ankles, can be UE - Can be multiple joints - Attacks triggered by trauma, overuse, surgery, medical illness - Associated w/*Primary Hyperparathyroidism, Hypothyroidism, Hemochromatosis* Pt: - MC older pts >60 - Seen equally in both genders - MONOARTICULAR (knee, ankle, wrist) - *Calcification of joint cartilage* aka "Chondrocalcinosis" Dx: *Synovial Fluid Analysis* w/ (+) Birefringent, Rhomboid crystals - Inflammatory effusion w/15,000-30,000 cells (neutrophil dominant) - XRay w/*Chondrocalcinosis* Tx: *Colchicine*, NSAIDs, Intra-articular steroids

Vulvar Lichen Planus

Path: Chronic inflammatory condition in postmenopausal women Pt: Pruritic, purple-hued plaques - Sometimes associated with "thin, white striae" around the labia and vulva (*Wickham striae*) - Erosive variant: Desquamation and erosion of mucosal surfaces - Vulvar pain - Pruritis - Dyspareunia - Serosanguinous vaginal discharge Dx: *Vulvar punch biopsy* Tx: High potency *Topical corticosteroids*

Hidradenitis Suppurativa

Path: Chronic inflammatory condition with recurrent occlusion of hair follicles in intertriginous areas. - RF = Obesity, Tobacco use, Family history Pt: - Women 20-40yo - INITIALLY? Solitary painful nodule --> later becomes Spontaneously draining abscess - Sinus tract and scar formation Dx: Clinically Tx: *CLINDAMYCIN* v. *DOXYCYCLIN*

Uremic Encephalopathy

Path: D/t acute or chronic renal failure, or CO2 retention!!! - Reduced renal clearance of uremic toxins leads to high levels of BUN Pt: - Lethargy - Somnolence - Confusion - Asterixis Dx: Clinical Tx: URGENT *Hemodialysis*

Lichen Sclerosis

Path: Chronic inflammatory disease in postmenopausal women or prepubertal girls - CHRONIC lichen sclerosis causes inflammation and hyperplasia of vulvar epithelium and results in malignant transformation --> Associated with *Vulvar cancer* - RF = DM1, Allopecia areata, Autoimmune conditions Pt: Multiple white papules that converge into plaques - Vulva thins --> Hypopigmentation & Skin sensitivity - Vulvar itching - Vulvar burning - Loss of labia minora (if severe) - Sclerotic plaques on labia majora - Typically *NO vaginal* involvement - Severe itching, may see excoriations - "Thin, white, wrinkled skin" - Painful defecation - Anal fissures - "Figure 8 pattern" (involves vaginal introitus and *perianal area*, which is how you can dif from vuvlvovaginal atrophy) Dx: *Vulvar punch bx* (to confirm dx and r/o Vulvar Cancer) - UNLESS they are a kid...then no risk of Vulvar Cancer so can be diagnosed clinically Tx: - Lichen Sclerosis? *Topical corticosteroids* - VIN? *Imiquimod* v. *laser ablation* - Vulvar cancer? Wide local excision, LND, Chemorad

Ulcerative Colitis (UC)

Path: Chronic inflammatory disorder of the colonic mucosa. - Cancer risk increased, so colonoscopy starting at yr8 and repeated q1yr - Pregnancy can worsen or trigger (d/t placental cytokines that cause inflammation) Pt: - 20-30yo, - Watery BMs daily (sometimes BLOODY but rare), - Abdominal pain relieved by BMs, - WEIGHT LOSS, - FEVER - Normal ESR & CRP if mild. May be elevated if severe. - May have anemia if severe. - Extra-intestinal: --> Primary Sclerosing Cholangitis (and therefore *Cholangiocarcinoma*) --> P-ANCA --> *Arthritis* (mc extra-intestinal manifestation) that improves w/activity and is worse in morning....spine or peripheral Dx: - *Colonoscopy* w/CONTINUOUS lesions involving rectum and colon - Bx w/Superficial lesions w/CRYPT ABSCESSES - "Erythematous friable mucosa with small, shallow ulcers" - Elevated *CRP & ESR* - Stool positive for fecal *Calprotectin* Tx: - Mild (*<4 BMs qd*)? *Mesalamine enema or suppository* (or oral Sulfsalazine if more severe). - Moderate/Severe (*>6 BMs qd*)? *TNF-alpha inhibitors* (Infliximab) ....all of the above txs are safe for preggo - Corticosteroids for flairs - Colectomy is curative (if refractory and severe!!)

Celiac Disease

Path: Chronic malabsorption disorder of the small bowel d/t immune-mediated hypersensitivity to gluten. - Associated w/other *autoimmune diseases* (x. DM1...w/recurrent hypoglycemic episodes bc sign not able to absorb nutrients) - Associated w/Down Syndrome - Increased risk of SMALL BOWEL adenocarcinoma and lymphoma Pt: - Growth delay often first sign in peds population - Abdominal discomfort - Diarrhea - Bloating - Gas ("Borborygmi" sound of gas gurgling in intestine) - Foul smelling - Greasy or floating stools - Atrophic *Glossitis* ("Tongue is red and smooth") - *Peripheral neuropathy* - Poor energy - Joint pains - Weight loss, - Malabsorption --> *IRON DEFICIENCY ANEMIA* (Microcytic) --> *VIT D DEF w/ HYPOCa2+, HYPOPhos, HYPER-PTH* (calcium may be NORMAL d/t help from PTH) --> Osteoporosis, Osteopenia, Ricketts - *Dermatitis herpetiformis* (pruritic rash) --> "Grouped intensely pruritic papules and vesicles on extensor surfaces" - *Thyroiditis* Dx: *IgA anti-endomysial*, *IgA anti-ttg*, OR *Duodenal Bx* (w/ Villous atrophy) --> *If IgA test is negative, STILL ABLE TO MAKE THE DIAGNOSIS*!!!!! bc Celiac has IgA deficiency. - If Dermatitis Herpetiformis (w/ *Microabscesses* at tips of dermal papillae) - Fecal Fat would be positive Tx: Gluten-free Diet. - *DAPSONE* for Dermatitis Herpetiformis

Primary Biliary Cholangitis

Path: Chronic progressive liver disease w/Cholestasis and Autoimmune destruction of INTRAlobular bile ducts - *Anti-Mitochondrial Ab* (as opposed to Autoimmune Hepatitis which is Anti-sm Ab) - Mc in Middle aged Women Pt: - Pruritus, - Fatigue, - Jaundice, - Steatorrhea, - Hepatomegaly, - *Eyelid xanthelasma* from severe hyperlipidemia, - Portal HTN, - Osteopenia ....Later w/ - Malabsorption, - Osteomalacia, - Osteoporosis, - Hepatocellular carcinoma Dx: - NORMAL ALT/AST - ELEVATED ALK PHOS - Presence of *Anti-Mitochondrial Ab* Tx: *Ursodeoxycholic acid* (Ursodiol) - Even if asymptomatic, would give ASAP to prevent sx --> improves sx and possibly survival - Eventually may require liver transplant

Alcoholic Neuropathy

Path: Chronic severe alcohol use. Alcohol ALONE!!!! is neurotoxic and results in decrease in number of myelinated and demyelinated fibers - May be associated with THIAMINE (B1) deficiency - NOT D/T B12 or Folate deficiency!!! (Though this can be associated and the symptoms would overlap making them hard to tell apart) Pt: - Symmetric distal polyneuropathy (stocking glove pattern) - Paresthesia - Burning - Pain - Numbness - Loss of light touch - Loss of vibratory sense - Gait ataxia - *Loss of DTRs* (often starts with the ankle reflex) Tx: Stop alcohol + Thiamine - Can consider Gabapentin, TCAs for refractory pain

Rosacea

Path: Chronic skin disorder of the face with red inflamed areas appearing mostly on the nose and cheeks - Triggered by heat, spicy food, sun, alcohol Pt: - Erythematous pustular rash effecting the central face - Papulopustular - Phymatous - *Ocular* involves cornea, conjunctivae and lids Tx: - Papulopustular? *Topical METRONIDAZOLE* (think of the mountains out the window of the Metro on Sketchy) - Severe or Refractory disease? Oral Tetracyclines - Mild? Behavioral changes (avoid sun, hot/spicy food, etc) - Talengiectasias? Brimonidine - Irregular thickening? Isotretinoin NO STEROIDS! They cause rebound worsening!!!

Giant Cell Temporal Arteritis

Path: Chronic vasculitis effecting medium and large vessels Pt: - Women - ≥50yo - Fatigue - Fever - Weight loss - *Headache* - *Lateral scalp tenderness* - *Transient vision loss* (aka Amaurosis Fugax) --> then *Monocular vision loss* - *Anterior ischemic optic neuropathy* which presents as *"pale edematous disc with blurred margins"*!!!!!!!!!!!!!!!!!!!!!!!!!! (d/t occlusion of the posterior ciliary artery) --> Can lead to blindness... - *Jaw claudication* - Thickening and tenderness along TEMPORAL ARTERY (lateral scalp) - Asymmetric loss of distal pulses - Associated w/PMR in 50% of patients (Proximal muscle pain and stiffness) - *Elevated ESR* Dx: *Temporal artery Bx* AFTER starting steroids Tx: - Uncomplicated? Higher dose oral prednisone - Vision loss? *HIGH DOSE* Glucocorticoids, then oral therapy with a slow taper

Generalized Anxiety Disorder (GAD)

Path: Chronic, Insidious Pt: Constant state of worry about MOST things (*everyday concerns*), on MOST days. - *Distress or functional impairment* - Restlessness, feeling on edge - Anxiety - Worries - Fatigue - Difficulty concentrating - Irritability - Muscle tension - Sleep disturbance - Headaches, Stomachaches - Nonspecific physical symptoms (muscle aches, fatigue, sleep disturbances) - CHILDREN? Perfectionism Dx: Clinical - Duration *≥6 months* - *≥3 somatic complaints* in ADULTS - *≥1 somatic complaints* in CHILDREN Tx: *PSYCHOTHERAPY >> Meds (SSRIs/SNRIs v. Buspirone)* - SSRI? Fluoxetine - SNRI? Venlafaxine v. Duloxetine

Chronic Lymphocytic Leukemia (CLL)

Path: Chronic, Mature cells, Lymphocytes - Bone marrow infiltration of abnormal cells Pt: Asymptomatic w/elevated WBC, ~87yo - DRAMATIC LYMPHOCYTOSIS (how you dif from Hodgkin, which would be normal) - ANEMIA (bc of immune dysregulation causing *extravascular hemolysis*, hence splenomegaly...may also see jaundice, etc) - THROMBOCYTOPENIA - LYMPHADENOPATHY - SPLENOMEGALY (extravascular autoimmune hemolytic anemia) - "L's are the extremes of age, ALL pediatric, CLL geriatric" - associated w/ Warm (IgG) Autoimmune Hemolytic - (+) B-symptoms Dx: Differential --> Bone marrow bx - *PBS w/Mature lymphocytes* (how you dif from Hodgkin, which would be normal) - CLL = "Crushed Little Lymphocytes" --> smudge cells Tx: 10yr life expectancy - If old (>65yo) and asymptomatic? *Do nothing* (treatment is not beneficial if the patient is asymptomatic) - If >65yo and sx (HA, bleeding, fever, LNDs, cytopenia, splenomegaly etc)? *Rituximab* (CD20 antigen monoclonal Ab) - If young <65yo and has donor? *Stem cell transplant*

Chronic Myelogenous Leukemia (CML)

Path: Chronic, Mature cells, Neutrophils - Bone marrow infiltration of abnormal cells Pt: Asymptomatic w/elevated WBC, ~47yo - DRAMATIC LYMPHOCYTOSIS (how you dif from Hodgkin, which would be normal) - Dramatic SPLENOMEGALY (extravascular autoimmune hemolytic anemia) - "You can get AML from CML, so CML must come first in age" - *Thrombocytosis* (w/elevated Platelets) --> PRIAPISM!!!! in men - Anemia Dx: Differential --> Bone marrow bx --> *Philadelphia Chromosome (9:22) aka BCR-ABL* - *Myelocytes* > Metamyelocytes --> May also see Promyelocytes. - Elevated WBC >100,000 - Thrombocytosis - Anemia - *LAP score LOW* (bc neutrophils are cytochemically abnormal...how you differentiate from leukemoid reaction) Tx: *Imatinib* - Cancer will eventually escape drug and cause BLAST CRISIS (CML --> AML)

Alcoholic Hepatitis

Path: Chronic, heavy alcohol abuse *>7 drinks/day* Pt: - Fever - Jaundice - Anorexia - Tender hepatomegaly - MCV >100 - Elevated AST/ALT 2:1 - Elevated *GGT* - Elevated *Ferritin* - Elevated Bilirubin - Elevated INR - Thrombocytopenia Dx: Clinical Tx: Abstinence + Supportive care + Acid suppression

Dysthymia

Path: Chronic, indolent MDD Pt: - Depressed mood - Poor appetite or overeating - Insomnia or hypersomnia - Low energy or fatigue - Low self-esteem - Poor concentration or difficulty making decisions - Feelings of hopelessness Dx: Depressed mood more days than not for *≥2 years* - *≥2* of the above sx - No symptom free period for *>2 months at a time* - Specifiers: w/"persistent" v. "intermittent" MDE. - Children? Depressed mood more days than not for *≥1 year* - r/o hypothyroid Tx: *CBT ± Antidepressants*

Dysthymia (Persistent Depressive Disorder)

Path: Chronic, indolent MDD Pt: - Depressed mood - Poor appetite or overeating - Insomnia or hypersomnia - Low energy or fatigue - Low self-esteem - Poor concentration or difficulty making decisions - Feelings of hopelessness Dx: Depressed mood more days than not for *≥2 years* (≥1 in children) - *≥2* of the above sx - No symptom free period for *>2 months at a time* - Specifiers: w/"persistent" v. "intermittent" MDE. - Children? Depressed mood more days than not for *≥1 year* - r/o hypothyroid Tx: *CBT ± Antidepressants*

Interstitial Cystitis

Path: Chronic, painful bladder of unknown etiology. - Associated with Fibromyalgia, Endometriosis, IBS, Sexual dysfunction, Psychiatric illness. Pt: - Women >40yo - Bladder pain exacerbated by filling - and RELIEVED by voiding! - Urinary frequency - Urgency - Chronic pelvic pain - Dyspareunia Dx: Clinical - NORMAL URINALYSIS!!!!!! - R/o other diseases w/Postvoid residual, STI Tx: - Analgesics - Bladder training - Fluid management - Avoidance of caffeine, alcohol, artificial sweeteners

Chronic Bronchitis

Path: Cigarette smoking Pt: Chronic productive cough *≥3mo total over course of 2yr* - White sputum Dx: CXR w/prominent *thickened bronchovascular markings* - Normal DLCO

Cushing Reflex

Path: Classic hemodynamic response to increased *ICP* (attempts to restore cerebral perfusion) - Hypoxic ischemic brain injury can cause...leads to edema which leads to increased ICP Pt: *Cushing Triad* - Hypertension - Bradycardia (d/t baroreceptors sensing hypertension) - Irregular respirations --> Poor prognostic sign, indicates cerebral herniation is imminent.

Polycythemia Vera (PV)

Path: Clonal myeloproliferative disorder - Proliferation of WBCs, RBCs, Platelets Pt: - Acquagenic pruritus (Itching after warm shower) - Facial plethora (Ruddy face) - Splenomegaly - Transient visual disturbances - Hypertension - Thrombosis - Gouty arthritis (from high RBC turnover) - Normal O2 sat - *Low EPO*!!!!!!!!!!! (made from kidneys, triggers production of RBCs) - *JAK2 mutation* Dx: CBC Tx: *Phlebotomy* - *Hydroxyurea* if increased risk of thrombus

Dementia (Major Neurocognitive Disorder)

Path: Cognitive deficits interfere with independence. Several types... - Alzheimer's Disease (mc) - Vascular Dementia - Frontotemporal Dementia - Dementia with Lewy Bodies Pt: - *Getting lost in familiar places* (most SPECIFIC) - Difficulties with bathing - Difficulties with personal hygiene - Difficulties with food acquisition and intake - Can't administer own meds - Impaired social interactions - Difficulty operating common appliances Dx: ALL PATIENTS should undergo workup for reversible causes... - FIRST!!! get *Vit B12 + CBC + CMP + TSH + Neuroimaging* - *MOCA ≤25* strongly suggests - *MMSE ≤23* strongly suggests Tx:

Pneumothorax

Path: Collapsed lung (x. subclavian central venous cath) displaces mediastinal structures and causes cardiopulmonary function compromise - Positive Pressure Ventilation can induce, especially in COPD patients --> Would see increased peek and plateau pressures on the ventilator machine Pt: - HYPOtension (compression of mediastinal structures) - Tachycardia - Decreased breath sounds - HYPERresonance - Trachea pulling AWAY from collapsed side - Distended neck veins Risks: - Positive pressure mechanical ventilation --> people with ARDS, pneumonia, obstructive lung disease are at higher risk d/t comprised lung tissue Dx: CXR (if hemodynamically stable). If NOT, see Tx... Tx: - Hemodynamically unstable? *Needle thoracostomy* ASAP (physical exam dx all that is needed)...try 2nd ICS and then 5th ICS if that fails - ....Then follow w/*Emergency tube thoracostomy*

Traumatic Hyphema

Path: Collection of blood in the anterior chamber of the eye - Intraocular pressure increases acutely w/impact --> ruptured blood vessels in iris and ciliary body Pt: - Eye pain - Blurry vision - Unequal pupils (anisocoria) - Sluggish puil response - *Intraocular hypertension* --> leads to *Optic nerve injury* Dx: Blood between cornea and lens on PE. Tx: Eye shield, Bed rest, Glucocorticoid eye drops (all prevent rebleeding) - Small? Self resolves in days - *Monitor intraoccular pressure* bc untreated HTN can lead to optic nerve injury

Delirium

Path: Common IMMEDIATELY post-operatively in elderly patients. Associated with an underlying condition or medications. - If stable for a few hours and then develop delirium? Worry about another cause!!! (x. hemorrhagic shock) - Risk increases w/risk factors (advanced age, dementia) & surgical complexity - If have delirium in setting of medical illness, they are at increased risk of Dementia later or may have underlying dementia. --> Accelerates progression of cognitive decline d/t neuronal injury from inflammation, decreased cerebral blood flow, impaired neurotransmitters, etc. - Psychosis secondary to another medical condition (x. hallucinations d/t brain tumor) CANNOT BE DIAGNOSED!!!!!!!!!!!!! when Delirium is present!!!!!!!!!!! Pt: - *Fluctuating cognitive impairment* (poor attention and disorientation) - ACUTE ONSET - Confusion - Disorientation - Agitation - Hallucination Tx: Treat underlying cause +.... - Mild? *Bedside sitter* --> Personal interaction (reassurance, physical touch) reduces risk of agitation (familiar people are best, but professional sitter could also work) --> Constant observation (to avoid restraints) --> Control of behavioral symptoms --> Treatment of underlying causes - Severe agitation (will interfere with treatment)? *Haloperidol v. Quetiapine* - F/up *Increased risk of cognitive decline* later on.

Bile Leak

Path: Common complication after cholecystectomy - 2-10 days after surgery Pt: - RUQ tenderness - Vomiting - Diarrhea - Leukocytosis - Obstructive-appearing liver enzymes - Bilious ascites (if large leak) Dx: Imaging will be normal Tx: Surgical consult

Behcet Syndrome

Path: Common in middle eastern origin Pt: - Recurrent - Oral apthous ulcers - Genital apthous ulcers - Uveitis - Erythema nodosum - Vasculitis - Venous arterial thrombosis - Ulcerating skin response following minor injuries Dx: Clinical

Osteoarthritis (OA)

Path: Common progressive disorder that commonly effects the hands and weight-bearing joints - RF = Obesity, Advanced age, DM, Prior joint injury Pt: - >40yo, - Joint swelling (hands and large, weight bearing joints) --> DIP (w/ Herberden nodes) --> PIP (w/ Bouchard nodes) --> 1st MCP - Rest pain - Brief periods of morning stiffness (<30m) - Joint effusions (common in older patients) - HIP pain may radiate to the GROIN, buttock, or lateral hip - Creptius when knee flexed and extended (dif from click on extension w/meniscal tear) Dx: XR w/*joint space narrowing and osteophytes* - Fluid aspiration would reveal NONinflammatory pattern (WBCs <2000) Tx: - FIRST *EXERCISE* (low impact, aerobic, *"quad strengthening exercises"*) + WEIGHT LOSS --> decreases inflammation and joint loading. - THEN... *NSAIDs* (topical or oral) --> Could consider Steroid injections vs. HA injections - THIRD you try SURGERY or CHRONIC PAIN MANAGEMENT

Avascular Necrosis (Legg-Calve-Perthes Disease)

Path: Commonly seen in the femoral head d/t disrupted circulation to bone via micro-occlusions, endothelial dysfunction, increased intra-osseous pressure - AKA *Osteonecrosis of Femoral Head* - Associated with Alcohol abuse, *Sickle Cell*, *SLE* and other conditions treated with glucocorticoids. - Can be *IDIOPATHIC* RF = *SLE*, *Corticosteriod use*, Chronic alcohol abuse, Smoking (coagulopathy), HIV/AIDs Pt: Initially PE may be normal........... 1) Pain localized to the groin. 2) Deep/throbbing pain 3) May be worse w/ movement. May have a catching or popping sensation w/ motion. Dx: XR & Labs will appear normal --> get *MRI* Tx: Non-weight bearing + (Bracing or Splinting) + NSAIDs - Consider Surgery (Decompression of femoral head w/ subcutaneous drilling. Hip replacement after collapse and persistent pain)

Multifocal Atrial Tachycardia (MAT)

Path: Commonly seen with *PULMONARY DISEASE*, Right atrial enlargement, Sepsis, Electrolyte imbalance. - Can look like A. Fib but is NOT d/t presence of p-waves. - NO increased risk of thrombus!! Pt: - *YES!!! P-waves* w/3+ different morphology (how you tell dif from A. Fib) - FAST *HR <150* - Narrow QRS - Irregularly irregular Tx: - FIRST? *Correct underlying Pulm Dz* - If SYMPTOMATIC use *BBlocker v. CCB* --> Amiodarone and Cardioversion are NOT appropriate for MAT. They are for A Fib. - NO anticoagulation needed!!!

REM Sleep Behavior Disorder

Path: Complex motor behaviors that occur during REM sleep. - Absence of muscle atonia - Degeneration of brainstem nuclei responsible for inhibiting spinal motor neurons Pt: - Older men - Dream enactment - LATTER half of night (like nightmare disorder) - Awake EASILY - Are ALERT & ORIENTED when awakened. Dx: Clinical Tx: - If frequent and recurrent? f/up Parkinson's v. Dementia w/Lewy bodies

Papillary Muscle Rupture

Path: Complication *3-5 days* post-MI --> Acute & Severe MITRAL REGURGITATION Pt: - Hypotension - Pulmonary edema - Cardiogenic shock Dx: Tx:

Septic Pelvic Thrombophlebitis

Path: Complication associated with pelvic surgery or the postpartum period. - Thrombosis of the deep pelvic or ovarian veins that then becomes infected - Hypercoagulable state of pregnancy contributes, pelvic venous stasis and dilation, endothelial trauma from infection or trauma during delivery Pt: Endometritis that does not resolve with treatment... - Persistent fever - Negative infectious evaluation Dx: Diagnosis of exclusion Tx: *Anticoagulation + Broad spectrum Abx*

Arteriovenous Fistula

Path: Complication following CABG - D/t catheter insertion site --> Worry about HIGH OUTPUT HEART FAILURE!!! (bc blood is shortcutting the circulation back to heart), limb ischemia, limb edema Pt: - *NO* mass. - *CONTINUOUS* bruit - *Palpable THRILL* - Weak distal pulses of the extremity Dx: Duplex USD Tx: Observation v. UDS-guided compression v. Surgical repair depending on severity

Acute Rheumatic Fever

Path: Complication of *Strep A* infection - Symptoms appear *2-4 weeks* after resolution of the initial infection. Pt: *JONES Criteria* = MAJOR criteria NEED *2 Major* OR *2 Minor and 1 Major* - Migratory polyarthritis - Carditis - Subcutaneous nodules - Erythema marginatum - Chorea (*autoimmune attack of basal ganglia*) - Elevated CRP - Elevated ESR Dx: Need *2 Major* OR *2 Minor and 1 Major* of JONES - Positive strep antigen test ..or... - *Antistreptolysin O* titer Tx: At risk for progression if not treated. (see pic)...basically *IV Penicillin G* q4wks - Monitor q6-12mo for left ventricular dysfunction

Bronchogenic Cyst

Path: D/t anomalous budding of the foregut during congenital development of the tracheobronchial tree - Most common benign cystic tumor Pt: - Become symptomatic in infancy OR adulthood! - Chest discomfort - Nonspecific respiratory symptoms - Recurrent coughing - Frequent respiratory infections Dx: *CT w/contrast* Tx:

Short Interpregnancy Interval

Women who are breastfeeding have continued nutritional demands which prevent repletion of... - Folate - Iron ...causes prolonged anemia --> Increased risk of pregnancy complications - Low birth weight - Preterm ROM - Preterm labor

Osteomalacia

Path: Complication of *Vitamin D* deficiency --> Impaired intestinal absorption of CALCIUM --> PTH increases to try and increase Ca2+ levels by resorbing from bone, but causes decreased Phosphate absorption (kidney pattern) = *Secondary Hyperparathyroidism* - Associated w/*Malabsorptive* disorders (x. Celiac disease, Crohns disease) - Calcium or phosphate deficiency impairs BONE MINERALIZATION Pt: - Fatigue - Bone pain - *HYPOphosphatemia* - *Calcium levels LOW or NORMAL* - *Increased AlkPhos* (d/t increased activity of osteoblasts) - Muscle weakness - Waddling gait - Increased risk of fracture - Bone density decreased Dx: Serum *25-Hydroxyvitamin D levels* (NOT!!!!!!! 1-25 dihydroxyvitamin D, which would be for PTH levels or renal function) Tx:

Hepatorenal Syndrome (HRS)

Path: Complication of End-Stage Liver Disease, where *splanchnic arterial dilation* occurs in response to Cirrhosis, decreasing the systemic vascular resistance, which leads to activation of the RAAS system. - Characterized by significant *decrease in GFR* in the absence of other signs of kidney disease Pt: - Decreased GFR - Elevating Cr - Minimal hematuria - Lack of improvement with volume resuscitation Tx: *Hepatic recovery* (abstinence from alcohol) v. *Transplantation* - Not surgical candidate? *Octreotide* (or other splanchnic vasoconstrictors)

Soft Tissue Dehiscence

Path: Complication of cardiac surgery - Superficial separation of skin at site of incision - Worry about infection going deeper and causing *Mediastinitis* Pt: - Purulent drainage Dx: *Chest and sternal imaging* Tx: (get IMAGING FIRST) - Then Surgical drainage prn, tissue cultures, IV *ABX*

Hemobilia

Path: Complication of hepatic or biliopancreatic interventions (Liver bx, ERCP, Cholecystectomy) - Upper GI bleeding - Massive? Sx immediately after procedure. - Intraductal hematoma? Causes sx ~5 days after, when clot dissolves. Pt: - RUQ pain - Jaundice - Melena (maybe even hematemesis) - DIRECT hyperbilirubinemia (bile duct obstruction) - Anemia - Leukocytosis Dx: Abd CT v. USD Tx: IVF + Blood transfusions prn (manage conservatively)

Diabetic Gastroparesis

Path: Complication of long standing hx of DM (>10yr), which causes autonomic neuropathy... --> Esophageal motility disorders --> Delayed gastric emptying (uncoordinated smooth muscle contractions and peristalsis) --> Intestinal dysfunction Pt: - Nausea - Vomiting - Early satiety - Postprandial fullness - Delayed intestinal absorption of glucose makes treatment with insulin difficult. Dx: *Gastric emptying study* Tx: Small, frequent meals + *Metoclopramide* + DM control

Mastitis

Path: Complication of untreated mastitis (d/t incomplete emptying of the breast) - Staph aureus, usually Pt: - Fever - Localized erythema (may have improved on abx but patient still has systemic sx) - Pain - Axillary lymphadenopathy - *Unilateral fluctuant, tender, palpable mass* - OR *Tender breast nodularity* and NO discrete mass Dx: Clinically - Use *USD* if they have *tender breast nodularity but no discrete mass* to r/o mastitis Tx: *Drain abscess w/needle* + *Abx* (Dicloxacillin v. Cephalexin) - Continue breast feeding!!

Bile Acid Diarrhea

Path: Complication that effects ~10% of patients following cholecystectomy. - D/t bile acids entering the gut more rapidly, overwhelming the resorptive ability of the terminal ileum. --> Bile acids entering the colon cause *mucosal irritation* and *secretory diarrhea*. Pt: - Recurrent watery brown stools - Several times daily - *Persists w/fasting* (nocturnal diarrhea!!) - Labs are unremarkable Dx: Tx: *Cholestyramine*

Carpal Tunnel Syndrome

Path: Compression of the *MEDIAN NERVE* as it runs through the Carpal tunnel. - Innervates first three fingers (sensation and motor) - d/t HYPOTHYROIDISM? Bilateral, bc of deposition of *mucinous material* into nerve sheath. - d/t ESRD? Unilateral (on side of dialysis) bc of *amyloid deposits* and *calcifications*. - d/t RHEUMATOID ARTHRITIS (can be presenting sign) Pt: PAIN --> Paresthesias --> Paralysis - Flexion makes worse (Phalen's) - Tapping on median nerve makes worse (Tinnel) - Can eventually get *atrophy of thenar eminence* Dx: *Nerve Conduction Study* Tx: 1) *Nocturnal Wrist Splinting + NSAIDs* (keep out of flexion) --> Preggo? Just *Splint*, resolves after childbirth 2) *Intra-articular steroids* 3) SURGERY if all else failed.

Meralgia Paresthetica

Path: Compression of the *lateral femoral cutaneous nerve* under the inguinal ligament. - RF = obesity, postural changes, tight clothing, pregnancy Pt: - Pain & tingling sensation - NO motor loss Dx: Clinical!! - Nerve conduction studies if you absolutely must. Tx: *Conservative* (lose weight, avoid tight clothing, etc)

Tarsal Tunnel Syndrome

Path: Compression of the *tibial nerve* in the tarsal tunnel at medial ankle as it passes under the *Flexor retinaculum* - D/t overuse, trauma, inflammation. - RF = *Pes planus* (flat foot) Pt: - Pain, numbness, paresthesia of DISTAL *PLANTAR!!!* surface (bc Tibial nerve goes down posterior leg) - At toes, sole, heel, medial ankle - Worse with weight baring - Relieved by rest Dx: Clinical - *Tinel sign on medial malleolus* to reproduce sx. - or maneuvers that stretch the nerve (should reprodyce sx) Tx: modify activity, NSAIDs, orthotics, surgical release, steroid injections

Spinal Cord Compression

Path: Compression of the thecal sac. - Cancers involved: --> Prostate --> Multiple Myeloma --> Breast --> Lung - If these same sx develop but there is FEVER and it's possible it's a Epidural abscess? Give *Abx* ASAP! NOT steroids. Pt: Pain for 1-2mo.....then - Thoracic is MC, then lumbar - Sx may be progressive (x. epidural abscess) or acute (x. fracture) - Pain worse in recumbent position (when lying) --> Wakes them up from sleep - SYMMETRIC *Lower extremity motor weakness* - Loss of sensation below a spinal level - *Hyperreflexia* - *Bladder dysfunction* (late finding seen w/lesions above S2) - *Ataxia* - Parapalegia (late finding) Dx: MEDICAL EMERGENCY!! Skip!!!! and go straight to Tx. - then confirm w/*MRI* Tx: *IV Glucocorticoids* ASAP - w/URGENT NEUROSURGICAL EVALUATION - If these same sx develop but there is FEVER and it's possible it's a Epidural abscess? Give *Abx* ASAP! NOT steroids.

Diamond-Blackfan Anemia

Path: Congenital erythroid aplasia --> increased apoptosis of RBCs - *PURE RED BLOOD CELL APLASIA* (unlike Fanconi Anemia which has pancytopenic bone marrow failure) Pt: - Craniofacial abnormalities - *Triphalangeal thumbs* (unlike Fanconi which are hypoplastic) - Increased risk of malignancy - Short stature - Cleft palate - Webbed neck - In infancy? Pallor and Poor feeding are often presenting symptoms Dx: Blood labs w/ - *MACROcytic* anemia - Reticulocytopenia - Normal platelets - Normal WBCs Tx: *Corticosteroids* (weird...) + Transfusion therapy

Fracture of the growth plate?

Worry about *growth arrest*

Coarctication of the Aorta (CoA)

Path: Congenital narrowing of the descending aorta just distal the left subclavian artery --> Proximal arterial pressure load to upper body - PDA helps in newborns bc supplies LE with O2 rich(er) blood, when closes, sx may arise --> *~Day 5* - Aortic constriction leads to *increased LV afterload* Pt: - Asymptomatic HTN (in UE) - Epistaxis - Headaches - *Brachial-femoral pulse delay* - Poor distal perfusion - LE claudication - Systolic murmur at Left Infraclavicular v. Left Infrascapular region, Continuous if collateral vessels - 4th Heart Sound - Left-sided cardiac enlargement - Signs of CHF (hepatomegaly, pedal edema) --> Neonates? Sweating, pallor, resp distress when feeding - Decreased urine output - Lactic acidosis Dx: *Echo* - CXR w/*notching* "erosions of inferior costal surfaces" (ribs 3-8) d/t pressure induced enlargement of the intercostal arteries - *3 sign* d/t indentation of the aorta with pre- and post-stenotic dilation Tx: *Prostaglandin E* keeeeps the PDA open --> Treatment is aimed at R to L shunting to improve systemic blood flow

Laryngomalacia

Path: Congenital soft, floppy laryngeal cartilages, esp epiglottis - Worse w/feeding, URI Pt: - *INSPIRATORY Stridor when supine, - Improved when prone* - Able to feed without cyanosis Dx: Flexible Laryngoscopy - Omega shaped epiglottis Tx: *GER treatment* improves sx (random, we dont know why) - Spontaneous resolution by 18mo

Colovesical Fistula

Path: Connection between the bowel and bladder. - Can be caused by.. --> Diverticulitis, --> Crohn disease, --> Malignancy. Pt: - Fecaluria - Foul smelling urine - Pneumaturia (air in urine)...esp at end of stream since gas rises in bladder - Recurrent UTIs w/mixed flora (E. Coli, Proteus, Klebsiella) Dx: CT w/*ORAL or RECTAL contrast!!!* (NOT IV!) - Later can do Colonoscopy to r/o malignancy. Tx: *Surgery* after the infection resolves.

Digital Clubbing

Path: Connective tissue proliferation at the nail bed and distal phalanx --> Megakarocytes become trapped in the distal fingers d/t size, and release VEGF and PDGF which lead to clubbing - Associated w/Hypertrophic Osteoarthropathy (painful joint enlargement, periostosis of long bones, synovial infusions) - d/t Pulmonary or Cardiovascular diseases (*Malignancy, Cystic Fibrosis, Left to right cardiac shunts*) HYPOXEMIA alone does not cause digital clubbing....if you see this in a patient esp w/COPD and smoking hx you should think cancer

Iron Toxicity

Path: Consumption of too many iron pills, etc. Iron damages GI mucosa by free radical production and lipid peroxidation. - MIDPILES --> ANION GAP Metabolic Acidosis (Na+ - (Cl + Bicarb)) Pt: - *Small opacities in the stomach and intestines* - Abdominal pain, - Hematemesis ("coffee ground") - Melena --> May be *Green/Black* from disintegrating iron tablets - Tachypnea - Tachycardia - Hypotension - Look out for *Hepatic Necrosis* (1-2d after ingestion) - or SBO from scarring Dx: Elevated serum iron levels Tx: *IV Deferoxamine* - If untreated can lead to shock, hepatic necrosis, death

Legionella pneumophila

Path: Contaminated water supplies associated with travel (cruise ships, hotels) Pt: - Fever > 102.2 - Unilobular patchy infiltrates - *HYPONa+* - Bradycardia!!!! - Neuro sx - *Diarrhea* - Cough - Hepatic dysfunction (elevated ALT/AST) - Gram stain w/neutrophils but no organisms Dx: *URINE antigen testing* + Culture Tx: Macrolide v. Fluoroquinolone (x. Levofloxacin) - Fluoroquinolones preferred bc have coverage of Strep pneumo and Mycoplasma

Adhesive Capsulitis

Path: Contracture of GH Joint capsule d/t chronic inflammation, fibrosis, and contracture. - RF = DM, Thyroid dz, Chronic immobility Pt: - Progressive weakness (in *ALL* movements of shoulder joint) - Pain with movement of joint - Reduced *ACTIVE & PASSIVE ROM*!! (shoulder arthropathy has reduced active rom only) - Deltoid muscle atrophy common. Dx: No imaging needed for Dx. Tx: ROM EXERCISES, NSAIDs, corticosteroid inj. *Not to be confused* w/ - Dermatomyositis/Polymyositis (bilateral weakness w/o pain) - PMR (bilat stiffness, no weakness, tx oral steroids)

Wilson Disease (hepatolenticular degeneration)

Path: Copper deposition in liver, basal ganglia in brain, corneas. - Autosomal RECESSIVE Pt: - <40yo - Psych changes, --> Academic decline --> Depression --> Irritability - Hepatomegaly, - Hyperreflexia, - Dysarthria, - Mouth held slightly open (also seen in dystonia & parkisonism) - Hemolytic anemia (Coomb's negative) - Kayser-Fleischer rings on slit lamp exam (corneal copper deposition) Dx: LOW!!! serum *ceruloplasmin* (d/t impaired hepatocellular transport) - Increased urinary copper excretion - LOW!!! Alk Phos Tx: lifelong chelation (*D-penicillamine*)

Exertional Heat Stroke

Path: Core body temperature ≥104F - Otherwise healthy person exercises in heat or high humidity --> Interferes with body's ability to cool off (evaporate sweat) - RF = Obesity, Antipsychotics, Anticholinergics Pt: - Hyperthermia (~105F!!) - Hypotension - Tachycardia - Hyperventilation - Flushing - Diarrhea - CNS dysfunction (how dif from heat exhaustion) - Rhabdomyolysis - DIC - End organ dysfunction Dx: Tx: - FIRST? *Ice water immersion* (morbidity and mortality are related to duration of hyperthermia)....unlike Nonexertional Heat Stroke where you would use evaporative techniques. - THEN? Consider IVF + Electrolytes

Subconjunctival Hemorrhage

Path: Coughing spells, rubbing eyes, hypertensive episodes, coagulopathy Pt: - Red eye - Painless - Otherwise asymptomatic Dx: Clinical Tx: *Observation* - Resolves within 24-48hr

Heparin Induced Thrombocytopenia (HIT)

Path: Could be d/t *Heparin* OR!!! *LMWH* (enoxaparin) TYPE 1 Nonimmune direct effect of Heparin on platelets. - Presents within first 2 days of treatment. - Resolves on own. - Can continue heparin use! TYPE 2 Development of IgG antibodies against heparin- bound platelet factor 4 (*PF4*). - Antibody-heparin-PF4 complex activates platelets leading to thrombosis and thrombocytopenia (*platelets drop >50%* or *new thrombus w/in 5-10 days*) (rest of this applies to Type 2 ONLY) Pt: - Thrombocytopenia - Thrombotic!!! complications (*ARTERIAL & Venous*) - Skin necrosis at site of abdominal injection --> "Purple black patches are seen in the periumbilical area, surrounded by erythema" Dx: (to confirm only!!! should go straight to treat first) *Serotonin release assay* Tx: DISCONTINUE HEPARIN ASAP --> *Nonheparin meds* (dabagatran, argatroban, fondaparinux) - Once platelets >150,000 can switch to Warfarin.

Colic

Path: Crying for no apparent reason *≥3hr, ≥3days/week, <3mo* Pt: - Crying (usually around same time of day) - Otherwise healthy - No signs/sx of another disease Dx: Clinical (dx of exclusion) Tx: *Reassurance + Support + Soothing techniques*

Open fracture with disruption of skin above?

Worry about *osteomyelitis*

Pill-Induced Esophagitis

Path: D/t direct effect of certain medications (x. Tetracyclines, Potassium Chloride, NSAIDs) on the esophageal mucosa Pt: *Sudden onset*!!! - Retrosternal pain - Odynophagia - Mc in *Mid-esophagus* (d/t compression by aortic arch or left atrium) Dx: Endoscopy w/*discrete ulcers and relatively normal surrounding mucosa* Tx: Stop meds

Reactive Arthritis

Path: D/t infection (*Salmonella, Yersinia*, Chlamydia, etc) Pt: Can't see, can't pee, can't climb a tree" - UVeitis - Arthritis - Enesthitis (pain at tendon insertions) - Oral ulcerations - Follows an infection Dx: Joint aspiration (-) - WBCs normal - No bacteria --> then try and find infection elsewhere Tx: If you find infection then treat - Doxy or Azithro - Ceftriaxone --> if you DONT find infection then DO NOT treat w/abx. Do NSAIDs and time.

Potter Sequence

Path: D/t oligohydramnios. - RF = Gestational HTN, ARPK, *Posterior Urethral Valves* (PUV) Pt: - Flat faces - Limb deformities (club foot, etc) - Hypoplastic lungs - Hypoxia - PUV? --> Mc in boys --> Midline suprapubic abdominal mass (bladder distention from PUV's causing bladder outlet obstruction) --> Distention of ureters and kidneys as well --> Weak stream --> Renal failure Dx: Tx:

Neonatal Acute Kidney Injury

Path: D/t several different prerenal, intrinsic, or postrenal causes (see pic) - Normal urine output in a neonate is *≥1 void/day of life*. --> If neonates do not have 2 voids by 48hr, this is *OLIGURIA* and indicates Neonatal Acute Kidney Injury. Pt: - Oliguria Dx: *Renal and Bladder USD* - Assess Risk factors. - Assess Volume status.

Generalized Convulsive Status Epilepticus (GCSE)

Path: D/t underlying brain anomaly (tumor, etc), metabolic abnormality, drug withdrawal, or infection - Prolonged seizures are associated with neuronal injury and death --> *Cortical necrosis* Pt: - Seizure lasting *≥5 minutes* OR - *≥2* seizures between which patient does not completely regain consciousness. Dx: Clinical - Obtain Blood Glucose Tx: Immediate *IV Benzos* (for termination) - PLUS!!! *NON-Benzo* (prevents recurrence) --> x. Fosphenytoin, Phenytoin, Levetiracetam, or Valproic acid. - If patient DOES NOT regain consciousness *10-20 min* after appropriate treatment? Get *EEG!!!* (will differentiate between ongoing non-convulsive seizures, or sedation effect of benzos) --> If still having seizures can do continuous infusion of *Benzo* (or propofol v. pentobarbitol in refractory cases) - F/up when stable w/neuroimaging

Hypertriglyceridemia

Path: D/t... - Inherited disorder (Autosomal DOMINANT) - Acquired condition (DM, Obesity, Alcoholism, Hypothyroidism, Nephrotic syndrome) - Adverse effect to medication (Tamoxifen, BBlocker, Corticosteroids, Antiretroviral medications) Pt: - Eruptive xanthomas (see pic - "yellowish red papules on arms and shoulders") - Acute pancreatitis (if serum triglycerides >1,000) Dx: Fasting Serum Lipid Profile Tx: - MILD (150-500)? *Statin + Lifestyle adjustments* (alcohol, weight loss) - MODERATE/SEVERE (500-1000)? *Statin + Gemfibrozil*

Diabetic Autonomic Neuropathy

Path: DM >10yr - RF = Poor glucose control, Other vascular risk factors - Can be associated with other microvascular complications (retinopathy, nephropathy, peripheral neuropathy) Pt: - Neurogenic bladder w/decreased ability to sense a full bladder, incomplete emptying, urinary retention, and distended bladder (pee = parasympathetic)

Aplastic Anemia

Path: Damage to multipotent cells in bone marrow, Bone marrow infiltration of atypical cells - Reduced production of *precursor cells* that generate the blood cell lines. - Minimal reticulocyte production in setting of significant anemia (seen in kidney disease d/t lack of EPO, but if Cr is normal then bone marrow failure) --> "Decreased megakaryocyte production" - Can be Idiopathic!!!, or d/t Drugs, Infections, RT Pt: Anemia + Leukopenia + Thrombocytopenia - Hematuria - Ecchymosis - Petechiae - Low reticulocytes!!! - NO Hepatosplenomegaly - NO Jaundice - Morphologically normal cells on PBS (how dif from Myelodysplastic anemia) Dx: *Bone marrow evaluation* w/hypocellular marrow - If blast cells? Leukemia Tx:

Oligohydramnios

Path: Decreased amniotic fluid index *≤5cm* - Consider limited urine output (x. Renal agenesis, etc) - Normal index is >5cm Pt: Potter sequence - Underdeveloped lungs - Flat ears - Flat face - Limb abnormalities Dx: Single deepest pocket *<2cm*, or *amniotic fluid index ≤5* Tx:

Dilated Cardiomyopathy

Path: Decreased contractility - Viruses - Wet beriberi - *Alcohol* - Ischemia - Some chemo meds Patient: Systolic CHF --> Orthopnea, DOE, crackles, edema Dx: Echo --> Dilated Tx: BBlocker, Ace-i, Loop diuretic - Stop alcohol, Stop chemo meds - ...eventually maybe Transplant

Von Willebrand Disease (vWD)

Path: Decreased vWF & Factor 8 (bc is carrier protein for Factor 8) causes impaired platelet-endothelial binding. - vWF = "Binds *platelets with endothelial components*" --> Prolonged bleeding time - Factor 8 = Responsible for Intrinsic pathway effects --> Prolonged PTT - Autosomal DOMINANT (vWD) Pt: - Mucocutaneous bleeds - Epistaxis - Heavy menstrual bleeding - PTT prolonged *or NORMAL*!!! if mild dz or increased production (x. pregnancy, OCP use, hyperthyroidism, stress), - PROLONGED BLEEDING TIME adhering to - Normal platelet count, - Normal PT - MC inherited Dx: *vWF Assay* - Ristocetin cofactor assay - Factor VIII levels Tx: DDAVP (desmopressin) - If acute hemorrhage need factor 8 infusions

Common Variable Immunodeficiency (CVID)

Path: Defect in *B-Cell differentiation* into plasma cells (basically mild form of Bruton's) --> Infected w/*Enterovirus*, Encapsulated organisms, GI bugs. Pt: *TEEN or ADULTHOOD* onset!! - Can have Autoimmune disease (Rheumatoid arthritis) - Bronchiectasis, - Lymphoma, - Recurrent Sinopulmonary infections - Decreased plasma cells - Atopy (asthma, eczema) - NO response to vaccines (unlike Transient Hypogammaglobulinemia of infancy)!!! - CHRONIC? *Pulmonary fibrosis and scarring* & *Bronchiectasis* Dx: *Quantitative Immunoglobulin panel* w/decreased *Ig of 2/3 classes or ALL classes* but not as bad as Brutons) - *CD19* levels are NORMAL!!! (how you dif from Brutons) Tx: *Ig Replacement therapy*

Tracheoesophageal Fistula (TEF)

Path: Defective division of FOREGUT into Esophagus and Trachea - MC = Proximal esophageal pouch & Fistula between Distal Trachea and Esophagus Pt: - Coughing, Choking, Vomiting with feeding - Excessive oral secretions - Course lung sounds and respiratory distress (from pooled secretions in oropharynx). - Think VACTERL - POLYHYDRAMNIOS on prenatal USD (bc neonate can't swallow amniotic fluid) Dx: Can't pass *NG tube* into stomach - XRay confirms, w/coiled enteric tube in proximal esophagus Tx: Surgery - VACTERL? *Echocardiogram + Renal USD*

Phenylketonuria

Path: Deficiency in *Phenylalanine hydroxylase* --> Inability to metabolize *Phenylalanine* into *Tyrosine* - Autosomal RECESSIVE Pt: Asymptomatic initially... - Increased Phenylalanine - Absent Tyrosine - Eczema - Seizures - Intellectual disability - Fair complection - Musty/mousy body odor Dx: *Tandem mass spectrometry* (standard part of newborn screening) - IF suspected later? *Quantitative amino acid analysis* w/elevated phenylalanine levels Tx: Diet LOW in Phenylalanine (avoid foods high in protein) - If started early enough they can have normal development and a normal life span!

Hyper IgM Syndrome (CD40 Ligand Deficiency)

Path: Deficiency of B-Cells. Can't convert IgM-->IgG - IgM fights everything kind of well, but IgG is super specific for a bug and kicks ass. - No CD40 ligand = no class switching Pt: Nonspecific immune deficiency Dx: Quantitative Immunoglobulin w/ - *INCREASED IgM* - *DECREASED IgG and IgA* Tx: NOTHING

Lactose Intolerance

Path: Deficiency of intestinal lactase, which usually metabolizes lactose (*Carbohydrate malabsorption*). Intestinal bacteria instead metabolize lactose and release gas in the process. - Mc in Asian, African - *Celiac dz, Crohn Dz, Infectious gastroenteritis* may precipitate bc damages gut wall! --> "Secondary Lactase Deficiency" Pt: - Postprandial - Abdominal discomfort - Hypertympanic abdomen - Diarrhea ("Bulky, malodorous stools") - Gas - Nausea - Slightly distended abd - Benign abd exam - Normal labs - No overnight symptoms Dx: *Lactose hydrogen breath test* Tx: - Primary? Use lactose-free products - Secondary? Resolves on own

Solitary Pulmonary Nodule (SPN)

Path: Defined as... - Rounded opacity - ≤3 cm in diameter - Surrounded by pulmonary parenchyma - No associated LN enlargement Malignancy RF: - Size (*>0.8 cm* requires additional work-up/surveillance) --> *Size is STRONGLY correlated with malignancy* - Location of nodule - Borders (x. *Irregular* or Spiculated) - Low density - Calcifications - Smoking hx - Age - Family history Dx: *CXR* ....& compare to prior studies - Stable for *>2yr*? No further work-up needed. - Possible growth or no prior studies? *Confirm w/CT* --> Benign features? *Serial CTs* --> Indeterminate or Suspicious? *Bx (Bronchoscopy if central, CT-guided if peripheral) or PET* --> Highly suspicious? *Surgical Excision* Tx: - *>0.8cm* and RF? *Bx or Surgical excision*!!!! - *>0.8cm* and NO RF? Surveillance w/repeat CT in 3mo

Cervical Radiculopathy

Path: Degeneration and osteophyte formation in the facet and uncovertebral joints lead to intervertebral foramen narrowing and compressive nerve root symptoms. - Mcc is *Spondylosis* of the cervical spine (degenerative spine disease) Pt: - Older patients - Progressive neck, shoulder, arm pain - Weakness along a myotome - Sensory loss along a dermatome Dx: *MRI of the cervical spine* Tx: NSAIDs + PT

Cervical Myelopathy

Path: Degeneration and thickening of the lateral vertebral bodies and posterior longitudinal ligament - Mcc is *Spondylosis* of the cervical spine (degenerative spine disease), which narrows the spinal canal and compresses the cord. Pt: - Symmetric (how we tell dif from ALS) - Slowly progressive gait dysfunction - Extremity weakness - Vibratory/pain sensation changes - LMN signs AT the level of the lesion!!! (how dif from ALS) - UMN signs BELOW the level of the lesion!!! (how dif from ALS) Dx: MRI v. CT Tx: *Surgical decompression*

Amyotrophic Lateral Sclerosis

Path: Degeneration of UPPER & LOWER motor neurons of spinal cord causes ASYMMETRIC muscular weakness and atrophy. - Commonly called Lou Gehrig disease (think of Stephen Hawking) Pt: - Elevated CK may be seen - NORMAL SENSORY!!! - Dysarthria - Dysphagia - Corticobulbar tract damage w/dysarthria, dysphagia, inappropriate laughing or crying) - *ASYMMETRIC* LMN and UMN signs (how we dif from Cervical Myelopathy!!!) - UMN signs --> Spasticity, --> Increased muscle tone --> Exaggerated DTRs, --> Upward going Babinski - LMN signs --> Weakness, --> Atrophy, --> *Fasciculations* Dx: Clinical - Could get EMG & MRI of brain and spinal cord to r/o other causes - Electrodiagnostic/Electrophysiologic studies w/"LMN dysfunction with denervation in multiple muscle groups resulting in widespread fibrillations and positive sharp waves" Tx: Ri"lou"zole (slows progression) + Edaravone - Palliation introduced early. - Universally fatal :(

Multiple System Atrophy (Shy-Drager Syndrome)

Path: Degenerative disease. - ALWAYS CONSIDER WHEN PARKINSONS PATIENT EXPERIENCES AUTONOMIC SYMPTOMS!!!!! - May be fatal if there is bulbar dysfunction or larygeal stridor. Pt: - *Parkinsonism* - *Autonomic Dysfunction* --> Postural hypotension --> Abnormal sweating --> Disturbance of bowel or bladder control --> Abnormal salivation --> Abnormal lacrimation --> Impotence --> Gastroparesis - *Widespread neurological signs* (x. cerebellar, pyramidal, LMN) Dx: Tx: *Intravascular volume expansion* (Fludrocortisone, Salt supplementation, Alpha agonists, Constrictive garments on LE) - Parkinsons drugs are INEFFECTIVE

Pericarditis

Path: Delayed coronary reperfusion following STEMI are at increased risk. Causes include.... - *Peri-Infarction* (from local inflammation *<4 DAYS* after MI causing necrosis) - *Post-Infarction* = "Dressler Syndrome" (immune-mediated pericarditis *SEVERAL WEEKS* after MI...d/t antibodies to myocardial antigens) - Viral - *Uremia* (Kidney failure) Pt: - CHEST PAIN (unlike pericardial effusion!) - Pleuritic chest pain (hurts w/breath, unlike MI) - Positional (improved by leaning forward) - Pain radiates to Bilateral lower scapulae, Shoulder, or beneath Breast - LOW GRADE FEVER (unlike MI) - High frequency grating or squeaking sound heard at left sternal border. - *Pericardial friction rub* "Scratchy sound between S1 and S2" - Dyspnea (reduced lung expansion d/t the pain) Dx: EKG w/*diffuse ST elevations* which evolves to *T-wave inversions* and/or *depressed PR segment* (unlike MI)!! (except w/uremic pericarditis) - "Best" imaging would technically be MRI. - NOT echo!! Tx: - SLE? *NSAIDs* - Viral, uremia, or *POST*-Infarction (within weeks of MI)? *NSAID + Colchicine* - *PERI*-Infarction (within days of MI) you would *Avoid NSAIDs* bc weakens the wall!! Could give *ASA* though. - Uremia? Hemodialysis!

Preterm Birth Prevention

Path: Delivery <37 weeks - Assess RF for pre-term delivery, if at risk then see below Pt: RF - *Cold knife conization* - Prior spontaneous preterm delivery - Tobacco use - Multiple gestation - Prior cervical surgery Dx: - NO prior preterm delivery? *Cervical length measurement* at *16-24* weeks (*≤2.5cm at <24 weeks*) via *TVUS* Tx: - NO prior preterm & SHORT cervix? *Vaginal progesterone* (decreases prostaglandin and maintains uterine relaxation) - Prior PRETERM & NO prior painful contractions? *Cerclage* (put in at week 14 & take out at week 36) - Prior PRETERM & Prior PAINFUL CONTRACTIONS? *IM 17-Hydroxyprogesterone*

Systemic Lupus Erythematosus (SLE)

Path: Deposition of anti-dsDNA immune complexes in tissues Pt: It can basically effect any organ system... - Migratory symmetric polyarticular arthralgias (MORNING STIFFNESS, prefers LARGE joints) - Facial rash (even if it just says 'pink cheeks', like a**holes) - Oral ulcers - Lymphadenopathy - *PANCYTOPENIA* (anemia, thrombocytopenia, leukopenia) --> d/t *Peripheral immune-mediated destruction* - *Rheumatoid-like arthritis* (but NO erosions, etc. on imaging...how you dif from RA) - Seizures - Serositis - Lupus glomerulonephritis (hematuria/proteinuria) --> Anti-dsDNA deposits on GBM. --> w/decreased C3 and C4 levels since they are activated --> Hematuria w/RBC CASTS - *Membranous Nephropathy* --> Immune complex deposition under GBM. - Libman-Sacks endocarditis - Thromboembolic events - Accelerated atherosclerosis - Premature cardiovascular disease - OSTEONECROSIS OF FEMORAL HEAD - Psychosis - Preggo? Fetal heart block, destruction of AV node via Abs, & subsequent fetal bradycardia --> Fetal hydrops d/t cardiac output failure Dx: ANA --> then Anti-dsDNA, Anti-Smith, Anti-U1 ribonucleoprotein - Need *4/11* "MD SOAP BRAIN" sx - *Anti-dsDNA = Lupus Nephritis (deadly) --> Dx w/BIOPSY* - Anti-Smith - Anti-Histone = Drug Induced Lupus - CRP (preferred) ± ESR - If FEVER --> check C3 and C4...*LOW COMPLEMENT* when FLAIR!! - *Hypocomplementemia* - Anti-Ro (SSB) & Anti-La (SSA) Ab's cross placenta Tx: - Hydroxychloroquine (everyone gets) - Steroids (for Flairs!! --> get off asap though) - *IV Cyclophosphamide*, then later *PO Mycophenolate mofetil*. (For lupus Nephritis!! when you make dx, prescribe)

Pancreatogenic Diabetes Mellitus

Path: Destruction of Beta cells of pancreas (which secrete insulin) causes DM, but further destruction of *Alpha cells* of pancreas causes inability to produce *Glucagon*. D/t.... - Long standing DM1 - Cystic Fibrosis - Chronic pancreatitis Pt: - More susceptible to *HYPOglycemic* episodes Dx: Tx: *Conservative insulin management + Emergency glucagon kit + Frequent BG checks*

Urgency Incontinence (Overactive Bladder)

Path: Detrusor over-activity Pt: - Urgency - Frequency - Nocturia - Constantly wet Even if there is prolapsing bladder, if there are signs of URGE incontinence, you will treat with those measures (bladder training, anti-muscarinics, lifestyle) Tx: - FIRST? *Bladder training* - Then can try *Antimuscarinics* v. Beta-adrenergic agonists

Pancreatic Pseudocyst

Path: Develops SLOWLY over several months in patients with history of acute or chronic pancreatitis Pt: - Early satiety, - Weight loss, - Abd pain - Vomiting - Sometimes elevated bilirubin and lipase Tx: - <6cm & <6wks? Uncomplicated! *Expectant management* + *NPO* - >6cm & >6wks? Complicated! *Drain*

Specific Learning Disorder

Path: Difficulty acquiring and using core academic skills (x. reading, writing, math) - Worsens as academic expectations increase (Kindergarten to Elementary school, etc) Pt: - Effects ability to follow directions --> *Behavioral problems* --> Reluctance to engage in learning d/t negative self concept :( Dx: Standardized testing Tx:

Neonatal Respiratory Distress Syndrome (NRDS)

Path: Diffuse alveolar collapse due to *surfactant deficiency* and immature lungs --> Atelectasis - RF: Premature, Perinatal distress, *DM in mom* (high levels of circulating insulin antagonize cortisol production), CS. - Intrauterine stress (x. IUGR, vaginal birth) STIMULATES early lung maturity Pt: Premature, Perinatal distress - Tachypnea, - Increased work of breathing, - Cyanosis - Hypoxia equal in arm and leg - Cyanosis starting within minutes of birth Dx: CXR w/*diffuse reticulonodular ground-glass pattern* - Lungs *HYPOextended w/Atelectasis* - Diffuse alveolar collapse causes *air bronchograms* (patent air filled bronchioli surrounded by opacified alveoli) Tx: *Intubation* - Severe? *+ Surfactant* - Prevent w/prenatal steroids, however, this only decreases risk it is NOT a guarantee

Paget Disease of Bone

Path: Disordered *osteoclastic* bone resorption of uncertain etiology, followed by increased osteoblastic activity to rebuild bone - Result is focal enlargement AND weakening of bone "Mosaic pattern" - At risk for developing Giant Cell Tumors and Osteosarcoma Pt: - Bony pain - Bone deformity - *Mixed lytic/sclerotic lesions* on XR - *Bowing of long bones* - Cortical thickening - Arthritis in adjacent joints - *Frontal bossing* "hat can't fit" - Headaches - Cranial nerve dysfunction - *Hearing loss* Dx: - Elevated AlkPhos (d/t bone turnover) - NORMAL Ca2+ - NORMAL Phos - Elevated urine *hydroxyproline* (from breakdown of collagen) Tx: Bisphosphonates

Neonatal Displaced Clavicular Fracture

Path: Displaced clavicular fracture, which can occur during vaginal birth - RF = Birth weight >4kg, Maternal GDM, Shoulder dystocia, Vacuum delivery Pt: - Crepitus over the clavicle - Asymmetric Moro reflex - Pain with passive movement of the upper extremity Dx: XRay Tx: They heal rapidly on their own (*Reassurance + Gentle handling*)

Beckwith-Wiedemann syndrome

Path: Disregulation of gene on chromosome 11p15 - Increased risk for *Wilms Tumor* & *Hepatoblastoma* Pt: - Macroglossia - Omphalocele or umbilical hernia - Macrosomia - Hermihyperplasia (asymmetric growth of one side of the body) - Rapid growth - HYPOGLYCEMIA (d/t Hyperinsulinemia) Tx: - *Monitor BG* - *AFP q3mo until 4yo* (monitor for Hepatoblastoma) - *Renal USD q3mo from 4-8yo* (monitor for Wilms)

Syringomyelia

Path: Disruption of CSF drainage from the central canal causes formation of a fluid-filled cavity *Syrinx* that compresses the surrounding tissue. - Can enlarge over time and destroy adjacent portions of the spinal cord - Associated with *Arnold-Chiari Type I* Malformation, Meningitis, Inflammatory disorders, Tumors, Trauma. Pt: - Symptoms may present months to years after the inciting event - MC involves cervical or thoracic spine - Loss of *Pain & Temperature* in a cape-like distribution (d/t destruction of the crossing fibers of the Spinothalamic tract) - May also have loss of *Flaccid paralysis* function in cape-like distribution as enlarges - NO issues w/Touch, Vibration, Proprioception Dx: *MRI* w/Intramedullary cavity Tx: *Surgery* (shunt placement)

Lambert-Eaton

Path: Disrupts the NMJ via autoantibody-mediated removal of Ca2+ channels. - Associated with SCLC!! Pt: - PROXIMAL!!!!!! muscle weakness (can look like polymyositis....which presents in a remarkable similar manner....but if the pt has hx of SMOKING they want you to think Lambert-Eaton) - Legs > Arms (dif from Myasthenia Gravis which is Arms > Legs) - BETTER w/increasing activity --> "Postexercise facilitation" - LOSS OF REFLEXES (how dif from Myasthenia Gravis) Tx: *Guanidine* v. 3,4-Diaminopyridine - Refractory? IVIG or corticosteroids - Look for cause via CT of chest. "Lambert eats an iguana"

Decompression Sickness

Path: Dissolved gas forms bubbles within the body, leading to pain and obstruction of blood flow - Descent causes increased pressures which allow nitrogen and oxygen to diffuse into the bloodstream --> *Rapid ascent* does not allow these gases to be exhaled out as they would with a slow ascent. Pt: - Hx of scuba diving - "The bends" = Type 1, MSK involvement --> Worsening joint pain --> Nontender to palpation --> Normal ROM - "The staggers" = Type 2, --> Ataxia --> Dizziness --> Visual disturbance --> Spinal cord involvement - Pruritus - Erythema Tx: IVF + O2 + *Hyperbaric O2 therapy* - Avoid flying for 12hr after scuba diving

Congenital Dacryostenosis

Path: Distal duct fails to canalize completely, so membrane blocks tear flow from NLD to the nose. - The most common cause of eye discharge in infants Pt: - Increased tearing - Matting and crusting of the eyelashes - Clear conjunctivae Dx: Clinical - May use Fluorescein dye testing, with dye that persists and flows down the cheek rather than draining Tx: *Lacrimal sac massage* - Spontaneous resolution common in the first few months of life.

Greenstick Fracture

Path: Distal forearm fracture, where fracture involves only one side of bone and the other side "bends" - D/t fall onto outstretched hand - Commonly seen in kiddos Pt: - Pain - Swelling - Limited range of motion of the wrist Dx: XR prior to cast removal to confirm bony union Tx: *Prompt reduction & immobilization* (potential for refracture or displacement) - No long term complications

Cutaneous Larva Migrans (Creeping Eruption)

Path: Dog or cat hookworm larvae (Ancylostoma) infects human as they are walking on contaminated sand or soil. - Larvae are unable to penetrate deeply as humans are incidental hosts, and so cutaneous infection results. Pt: - Serpinguinous reddish-brown cutaneous tracks - Intense pruritus Dx: Tx: Most clear in a few weeks - Can give *Ivermectin* to aid clearance

DRESS Syndrome

Path: Drug Reaction w/ Eosinophilia and Systemic Symptoms (DRESS) syndrome is a drug-induced condition. - Onset = *2-6 wks* after drug initiation w/a mortality rate of 10-20%, w/most fatalities d/t *liver failure* - x. Allopurinol, Epileptics Pt: - Drug - Rash (*generalized morbilliform eruption* that starts on face and trunk and then spreads) --> Facial edema commonly seen - Eosinophilia - Systemic Symptoms --> Fever >38°C --> Lymphadenopathy --> Hematologic abnormalities --> Hepatitis --> Involvement of at least one internal organ --> Malaise Tx: Stop drug + Supportive

Tubulointerstitial Nephritis

Path: Drug-induced chronic renal failure, "Analgesic nephropathy" (ASA, Naproxen) Pt: - Polyuria - Sterile pyuria (WBCs and *WBC casts* w/o bacteria, nitrites, leuk est) - Hypertension - Mild proteinuria - Impaired urinary concentration Dx: UA Tx:

Gestational Diabetes Mellitus (GDM)

Path: During SECOND trimester (*>20wks*) fetus has increased demand for glucose and other nutrients due to increased growth (esp in THIRD trimester too) --> INCREASED human placental lactogen (hPL), a placental somatomammotropin, causes Mom to develop pancreatic *beta cell hyperplasia*, increased insulin secretion, and increased insulin resistance - Increased risk of Fetal *Respiratory Distress Syndrome*, Macrosomia, LGA, C-section, Preeclampsia, Gestational HTN, *Polyhydramnios* (unlike HTN which causes Oligohydramnios) --> In contrast, FIRST TRIMESTER DM (Pre-Gestational) causes cardiac defects, limb, and neural tube defects (makes sense bc this is when these major components of development occur) Pt: - BMI >30 - Prior hx of GDM - Pre-diabetic - Neonate w/BG *≤40* Dx: Screen w/*1hr 50mg* glucose tolerance test at *24-28wks* (*≥140 mg/dL means ABNORMAL*) - Confirm w/*3hr 100mg* GTT (need 2 or more of following: Fasting ≥95, 1hr ≥180, 2hr ≥155, 3hr ≥140) - NOT HgbA1c!!!!!!! Bc tests period of time during FIRST TRIMESTER when mom would be considered Diabetic, NOT GDM. Tx: - 1st line? *Diet* (low carb, small meals, light snacks between) - 2nd line? *Insulin*...or could do *glyburide or metformin* - Postpartum? Fasting at *24-72hr post*, then 2hr 75g GTT at *6-12wk* f/up TARGET - Fasting <95 - 1hr ≤140 - 2hr ≤120

Monoclonal gammopathy of undetermined significance (MGUS)

Path: Early myeloma Pt: >85yo, NO CRAB!!!! (HyperCa, Renal failure, Anemia, Bone pain seen in Myeloma)) Dx: - SPEP (+) - UPEP (-) - Skeletal survey (-) --> Bone Marrow Bx w/*<10% PLASMA* cell (how we differentiate from Waldenstrom's, in addition to being asymptomatic) Tx: - *Watch & Wait* --> Monitor for conversion to Myeloma (2%/year) w/Skeletal Surveys

Familial Dysbetalipoproteinemia

Path: Elevated Chylomicrons and VLDL remnants Pt: - *Milky serum* ("Grossly lipemic serum") - *Palmar xanthomas* - Severe hypertriglyceridemia - Repeated bouts of pancreatitis --> Triggered by alcohol consumption Tx: - Isolated hypertriglyceridemia and no other atherosclerosis RF? *Fenofibrate* - Atherosclerosis RF (LDL ≥190, CHA2DS2 w/10-year risk of >7.5-10%, Age ≥40 w/DM)? *Statin*

Familial Hypertriglyceridemia

Path: Elevated VLDL Pt: - *Eruptive xanthomas* (see pic - "yellowish red papules on arms and shoulders") - Acute pancreatitis (if serum triglycerides >1,000) - Autosomal dominant - Presents young!!! Dx: Fasting Serum Lipid Profile Tx: - Isolated hypertriglyceridemia and no other atherosclerosis RF? *Fenofibrate* - Atherosclerosis RF (LDL ≥190, CHA2DS2 w/10-year risk of >7.5-10%, Age ≥40 w/DM)? *Statin*

Breastfeeding Hormonal Effects

Path: Elevated prolactin suppresses GnRH release --> Low FSH, LH, Estrogen - Low estrogen levels inhibits ovulation and causes menopausal-like symptoms Pt: - vulvovaginal atrophy - dyspareunia Tx: Nonhormonal lubricants & moisturizers - Refractory cases may require topical estrogen

Ectopic Pregnancy

Path: Embryo implants in the fallopian tube - High risk of fallopian tube rupture and hemorrhage - Most common site is *AMPULLA* - RF = Prior ectopic pregnancy, PID, Chlamydia, Hx of tubal ligation, IUD Pt: - Asymptomatic - or Normal signs of pregnancy - Amenorrhea - Vaginal bleeding - Abdominal pain - Tubal rupture? Hemoperitoneum causes urge to defecate Dx: *UPT* --> Pelvic USD w/*thin endometrial stripe* & pregnancy outside uterine cavity Tx: MEDICAL - *Methotrexate* if <3.5cm or B-hCG <5,000 (NOT Misoprostol = for abortions) + follow B-hCG 1x/week --> CI if Breastfeeding, Hematologic abn, Active pulmonary dz, Hepatic or renal dz, Hemodynamically unstable --> Relative CI: Adnexal mass ≥3.5cm, Fetal cardiac activity, B-hCG ≥5,000) v. SURGICAL *IF UNSTABLE* (x. acute abdomen, hemoperitoneum, hypotension, tachycardia)

Opiate Use Disorder

You can treat their ACUTE pain the same way as you would anyone else. If they underwent trauma and are in pain...Tx: - First? Ketorolac --> Peak effectiveness at 3hr, can dose every 4-6hr - Then can give IV Morphine! - Close follow-up for them to avoid relapse.

Thyroglossal Duct Cyst

Path: Embryologic anomaly --> Thyroid tissue which develops from the tongue fails to completely descend - Most noticeable after *respiratory tract infection* Pt: - MIDLINE neck mass - Moves SUPERIORLY when swallowing or w/tongue protrusion Dx: Thyroid imaging (to confirm it is not only piece of thyroid tissue...if it is we won't remove it) Tx: If it is NOT only piece of thyroid tissue then it can be *surgically removed* d/t risk of infection

Vascular Ring

Path: Encompasses a variety of congenital malformations of the aortic arch system, encircles the trachea or esophagus and compresses ("congenital vascular malformation") - EXTERNAL trachea compression --> Fixed airway obstruction Pt: - Sx usually seen when patient starts to eat solid foods >6mo - Trachea affected? --> *Biphasic* stridor --> Worsens with increased work of breathing --> *EXTENDING NECK* helps - Esophagus affected? --> Vomiting and solid food dysphagia --> Compression of posterior esophagus on imaging --> Middle lobe pneumonia from aspiration Dx: *Direct Laryngoscopy + Bronchoscopy + Echocardiogram* (bc malformation can involve other aspects of thorax) Tx: *Surgery*

Pseudohypoparathyroidism

Path: End organ resistance to PTH, "insensitivity" Pt: Labs will look like low PTH (Low Ca2+, HIGH Phos), but PTH levels will be HIGH

Coccidiomycosis

Path: Endemic mold of the SOUTHWEST (esp Arizona or California), aka "Valley Fever" with URI *>1wk* - Inhalation of a single spore can cause illness 1-2wks later Pt: Subclinical. If symptomatic lasts weeks or months. - Fever - Chest pain - Productive cough - Lobar infiltrate - *Arthralgias* - *Erythema nodosum* - Erythema multiforme Dx: Clinical - Confirm w/*Serologic testing* and cultures Tx: - Healthy, Moderate or Mild sx? *No treatment* - Severe sx or Immunocompromised? *Ketoconazole* or *Fluconazole*

Aortic Regurgitation

Path: Endocarditis, Infarction, Dissection - Developing Country? Rheumatic Heart Disease - Developed Country? Bicuspid Aorta v. Aortic Root Dilation Pt: Inherited or sporadic. - mcc in developed countries is BICUSPID AORTA!!! (also associated w/aortic stenosis though...) - DIASTOLIC murmur (helps differentiate from HCM) --> Best heard w/patient *sitting up and leaning forward on EXHALE* - Valvular cause (Bicuspid aorta)? Best heard at LEFT STERNAL BORDER @ *4th ICS* (bc regurgitation reverberates backwards into the ventricle) - Dilation cause? Best heard at RIGHT STERNAL BORDER!!! --> Need to think about aortic aneurysm as possible cause. - Decrescendo, Blowing - *Water hammer pulse* --> Higher Systolic bc all that extra blood is being pushed forward --> Lower Diastolic bc regurgitated blood causes low diastolic pressure --> Pulsation in the fingertips or nail beds Dx: Echocardiogram Tx: Replacement - F/u w/CABG

Abdominal Aortic Aneurysm (AAA)

Path: Enlargement of the abdominal aorta - *SMOKING* is the strongest modifiable influence for AAA development and progression --> Disrupts the arterial wall elastin matrix - Usually ruptures POSTERIORLY into the retroperitoneum, which delays hemodynamic instability --> If ruptures ANTERIORLY you see rapid hemodynamic instability and shock - RF = Smoking, HTN, Atherosclerosis, Family hx Pt: - >60yo, - Male, - Smoked in lifetime or currently smoking, - Asymptomatic pulsatile mass - Could be older person w/TENDER pulsatile mass and BACK PAIN --> surgery bc about to burst - Flank pain - Flank hematoma - Umbilical hematoma - Nausea - HYPOTENSION - Pale - Anxious - Diaphoretic Dx: U/S - Screen once via Abd USD in men *65-75* who have ever smoked Tx: Rupture? *Surgery* ASAP >3.5cm = AAA, screen q12m + Lifestyle modification >4.5cm = AAA, screen q6m + Lifestyle modification >5.5cm or growing >0.5cm/6mo = SURGERY (endovascular repair same as open)

Spontaneous Bacterial Peritonitis (SBP)

Path: Enteric bacteria translocate through the abdominal wall and seed the ascitic fluid - Associated w/Cirrhosis Pt: - FEVER - Ascites - HYPOtension - Tachycardia - Paralytic ileus - *Diffuse abdominal pain* !!! - Subtle mental status changes - Connect the numbers test abn Dx: *Paracentesis* w.... - *SAAG >1.1* - Low protein - Ascites PMNs *≥250* Tx: IV Abx (3rd Gen Ceph v. Fluoroquinolone)

Congenital Adrenal Hyperplasia (CAH)

Path: Enzyme deficiency causes Can be caused by... - 21-Hydroxylase deficiency (mc) --> Which would include signs of salt wasting - 11-Hydroxylase deficiency --> Which would NOT have signs of salt wasting Pt: - XX neonate - Viri lization of female genitalia --> Clitoral enlargement, hypospadias, or underdeveloped phallus --> Gonads would not be palpable in a female. - Hypotension (if salt wasting) Dx: Elevated *17-hydroxyprogesterone* - Abd USD - Electrolytes Tx: *Glucocorticoids + Mineralocorticoids*

Homocystinuria

Path: Errors in methionine metabolism secondary to Cystathione synthase deficiency - Autosomal RECESSIVE Pt: Looks like MARFANS but... - Fair complexion - Thromboembolic events - *Intellectual disability* (unlike Marfans) - Marfanoid habitus (tall stature, long thin limbs, hyperlaxity) - *Cerebrovascular accidents* - *DOWNWARD* Lens dislocation (key dif from Marfans) Tx: *B6 + B9 + B12* + Anticoagulation

Eosinophilic Esophagitis (EoE)

Path: Esophageal inflammation triggered by food allergy - DOES NOT respond to usual Antacids Pt: - 20-30yo male - Other eosinophilic disorders like eczema or asthma. - *Abdominal pain with eating* (unlike vascular ring) - Mid-epigastric pain - Dysphagia - Vomiting - Food impaction - Drooling - Hypersalivation - Inability to swallow liquids - Food refusal or preference for soft liquids is common in children - *Refractory heartburn* despite PPIs - Weight loss Dx: EGD shows w/"circular rings and thickened linear furrowing of the esophagus" - FAILED *2 month trial of PPI* - then can do EGD w/*Bx* showing *Eosinophilia (>15/hpf)* Tx: *Dietary changes* + *Topical (swallowed) fluticasone* + PPI

Amaurosis Fugax

Path: Essentially an *Eye TIA*. D/t ischemia... - Embolized plaque from carotid artery (mcc) - Cardioembolic source (A. Fib) - RF = HTN, HLD, Smoking - Increased risk of stroke!!! Pt: - Acute painless monocular vision loss - Transient temporary episodes of "curtain falling over eye" (*<10min*) Dx: *USD of carotids* Tx: - Revascularization - Anticoagulation - Statin

Appendicitis

Path: Fecalith Pt: - INITIALLY? Periumbilical pain - THEN RLQ pain - Pain at McBurney's Point - Anorexia - N/v - If *PSOAS SIGN*, (pain when right leg extended) then indicates abscess POSTERIOR to appendix - Leukocytosis - *Microscopic Hematuria* d/t proximity of appendix and right ureter. Dx: *CT Scan*!!!!!! (we don't do "no imaging" anymore even if PE and Hx is screaming appendicitis d/t the widespread availability of imaging) - If Preggo or Kiddo then *USD...then MRI prn* Tx: *Surgery + Abx*!!! - Perforation? *NPO + Abx + (I&D or Percutaneous drain)* - If posterior & *"contained"* abscess they have high risk immediate surgery rate so....Tx: *IV Abx, Bowel rest, I&D of abscess*....then maybe consider *Interval Appendectomy* 6-8 weeks later

Fetal Growth Restriction (FGR)

Path: Estimated fetal weight *<10th percentile* for gestational age - *SYMMETRIC*? Infection, Chromosome abnormalities - *ASYMMETRIC*? Maternal malnutrition, or Complication of maternal vascular disease (HTN, DM1) --> placental vasoconstriction and ischemia --> uteroplacental insufficiency - These babies have risk for *Growth failure, Childhood obesity, Metabolic syndrome, ADHD, Delayed cognitive development* ....May also just be *Constitutionally small* (d/t genetic predisposition) --> Have NORMAL neonatal course and NO risk for adverse long-term outcomes --> Umbilical artery USD would be normal, and they would have appropriate interval growth. Pt: - Oligohydramnios (amniotic fluid index ≤5) - Intrauterine fetal demise (high risk) Dx: *Umbilical artery doppler USD* + Serial USDs (to assess growth) - Asymmetric? Biparietal diameter and abdomen circumference will be different Tx: Possibly *Urgent delivery*

Intrauterine Growth Restriction (IUGR)

Path: Estimated fetal weight <10th percentile for gestational age - *SYMMETRIC*? Infection, Chromosome abnormalities - *ASYMMETRIC*? Maternal malnutrition, or Complication of maternal vascular disease (HTN, DM1) --> placental vasoconstriction and ischemia --> uteroplacental insufficiency Pt: - Oligohydramnios (amniotic fluid index ≤5) - Intrauterine fetal demise (high risk) Dx: *Umbilical artery doppler USD* - Asymmetric? Biparietal diameter and abdomen circumference will be different Tx: Possibly *Urgent delivery*

Fibroadenoma

Path: Estrogen sensitive (so size and tenderness change with menses) *fibroepithelial tumor* - BENIGN - Self-limited - OCPs can trigger Pt: - Women <30 - Usually *Single* (how dif from Fibrocystic changes) - Unilateral, firm, well-circumscribed masses - Upper outer quadrant - Size and tenderness changes w/menses - Usually *NONtender* (how dif from Fibrocystic changes) Dx: - Adolescents (<18yo) & no concerning features? *Repeat exam in 6 weeks* - Adults or persistent mass? *USD <30yo* v. *Mammogram >30yo* Tx: Reassure

Genitourinary Syndrome of Menopause

Path: Estrogen withdrawal w/vaginal epithelium regression - Menopause or BSO cause estrogen deficiency which causes atrophy of tissues. - RT and Chemo to the area can deplete ovarian follicles --> Low estrogen Pt: "Atrophic vaginitis" - Vaginal dryness - Dyspareunia - Inability to penetrate - Pelvic organ prolapse - Increased risk for UTI (d/t increased vaginal pH) - Wiping with TP can cause light bleeding - *Urgency incontinence* (d/t Urogenital atrophy) Dx: Clinical - R/o disease and malignancy - Vaginal *pH ≥5* Tx: *Water based lubricants + Topical estrogen + Kegels/Bladder training* - Prevention? HRT+timing - CI to estrogen?

Antisocial Personality Disorder

Path: Evidence of conduct Disorder in childhood, now grown up (>18yo) Pt: - Criminals. - No regard for others. - Impulsive - Unstable employment history - Lack remorse - Manipulative. - Physically aggressive. - Failure to accept responsibility Dx: - >18yo. - Had Conduct Disorder in childhood and did not get fixed. Tx: - Is this person able to be rehabilitated? Often learn how to appear to be better in order to be better at manipulating, and retain antisocial tendencies.

Cushing Syndrome

Path: Excess cortisol. ACTH Dependent v. ACTH Independent. - ACTH is a *polypeptide hormone*, which increases the release of cortisol, a steroid hormone. (ACTH is NOT a steroid hormone) Pt: - Weight gain - Buffalo hump - *Proximal muscle weakness* - *Ruddy appearance* - Depression, Anxiety - Insomnia - Fatigue - Memory defecity - HTN - DM - Hyperglycemia - Easy bruising - Dermal atrophy - Wide purple striae - Cutaneous infections (x. tinea versicolor, onchmycosis) - Hypokalemia (d/t mineralocorticoid effects of cortisol) - Alkalosis (d/t mineralocorticoid effects of cortisol) - Hyperpigmentation (only seen in ACTH-dependent!!!, bc POMC is cleaved into MSH and ACTH) - Hyperandrogenism (only seen in ACTH-dependent!!! bc it increases androgen production from ZR in adrenals) --> Menstrual irregularities --> Acne --> Hirsutism Dx: s/s of Cushing's "Low THen High" - 1st: LOW dose Dexamethasone suppression test --> if FAILS to suppress cortisol then *Cushing's SYNDROME*....CONFIRM w/24hr urine cortisol or late-night salivary cortisol (doesn't matter which one you pick)....then go to step 2. - 2nd: Check ACTH levels --> if LOW/NORMAL then *Primary Hypercortisolism* (adrenal tumor)...confirm w/CT or MRI, and renal vein sampling....Tx: Surgery --> if HIGH then then ACTH-dependent & go to step 3 - 3rd: HIGH dose Dexamethasone suppression test --> if suppresses cortisol then *Cushing's DISEASE* (pituitary cancer)...Tx: *Metyrapone* until they can get to surgery. --> if does NOT suppress cortisol then *Ectopic source* (Pan-scan CT, super rare)

Obstructive Sleep Apnea (OSA)

Path: Excess tissue or Obstructed airway --> Intermittent periods of hypoxia causes kidneys to produce more EPO (& therefore RBCs) - Obesity w/BMI >35 has greatest risk Pt: - Daytime somnolence - Obese - Snoring - Large tongue - Short neck - *Depression* - *Erectile dysfunction* - *Increased HEMATOCRIT & HEMOGLOBIN* - Pulmonary HTN - Systemic HTN - Kiddos? Hyperactivity, Inattention, Emotional lability, *Adenotonsillar hypertrophy*, Poor growth If also have Obesity Hypoventilation Syndrome? (OHS) - Hypoxia - Increased pCO2 - Bicarb retention - Decreased Chloride - Resp Acidosis w/compensatory Metabolic alkalosis Dx: Sleep study (*Polysomnography*) - *≥15 apneas/hr* - OR *≥5 apneas/hr w/snoring* Tx: *CPAP* (same as PEEP) - If obese, lose weight - Kiddo? *Adenotonsillectomy* - If you don't treat you see RIGHT SIDED HEART FAILURE (bc hypoxemic)

Staphylococcal Scalded Skin Syndrome (SSSS)

Path: Exfoliative toxin in Staph - Neonates? Infection from circumcision or umbilicus - Older children? Nasopharyngeal, or Skin lesion Pt: - Fever - Irritability - Generalized erythema w/blisters (especially in flexor regions) - Epidermal shedding w/gentle sliding of finger *(Nikolsky sign)* - NO Mucocutaneous involvement (how dif from SJS/TENS) Dx: Clinical Tx: Nafcillin v. Vancomycin *Bullous Impetigo* = the localized form of this

Age-related Sicca Syndrome

Path: Exocrine output from lacrimal and salivary glands declines with age and is associated with atrophy, fibrosis, and ductal dilation of the glands. - RF = Female, Thyroid disorders, DM, RT, Graft V Host Dz, Pt: Basically looks like Sjögrens. - Dry eyes - Dry mouth - Xerostomia - Dental carries - Impaired vision (from corneal epithelial erosions) Dx: - Negative ANA - No Anti-Ro/Anti-La Tx: *Artificial tears*

Parotid Gland Neoplasm

Path: Exposure to RADIATION is significant RF for disease - RF = Primary parotid neoplasms, Lymphomas, Mets - Neural invasion may occur - >80% are BENIGN (if in Submandibular gland or Salivary would have higher rate of malignancy) Pt: Concerning signs for metastasis? - Facial droop - Facial numbness Dx: CT or MRI Tx: *Surgical resection* w/sparing of facial nerve

Breast Cancer

Path: Exposure to estrogen (women with more cycles or more estrogen are at higher risk) - RF = *Increasing AGE* (biggest one), Early menarche, Late menopause, Nulliparity, Hormone replacement therapy (ORAL estrogen/progesterone, *NOT topical estrogen*), Radiation, Genes (BRCA1&2) Pt: Dimpling, Fixed nodes, Breast mass - Asymptomatic screen (w/ Mammogram!!! or MRI if super risk factors...self breast exam and MD breast exam are no longer recommended) --> *50q2yr* Pt: - Dimpling - Nipple Discharge - Fixed nodes - Breast mass Dx: Screen *50-75yo, q2yr* Breast mass <30yrs? *USD*...maybe later mammo - Simple cyst? FNA...then RTC in 2 mo for breast exam - Complex cyst/solid mass? Core Biopsy Breast mass >30yrs? *Mammo* ...maybe later USD - Suspicion for malignancy? Core Biopsy Breast mass in adolescence? *Wait 6 weeks and check again* Tx: LOCAL THERAPY - Radiation - *SLNBx* (if positive LN then do Axial LN Dissection w/surgery) - Surgery (Lumpectomy + Radiation = Mastectomy in terms of outcomes) SYSTEMIC THERAPY - Chemo: Doxorubicin + Cyclophosphamide + Paclitaxel - Targeted: --> Trastuzumab if Her2+ --> Tamoxifen/Raloxifen if ER/PR+ and PREmenopausal --> Aromatase-i if ER/PR+ and POSTmenopausal *If BRCA1/2 --> Prophylactic bilat. Mastectomy & Oophorectomy*

Melanosis Coli

Path: FICTITIOUS DIARRHEA (laxative abuse, especially *Senna*) - Seen after several months of abusing laxatives - *Metabolic ACIDOSIS* (bicarb out the butt) Pt: - Melanosis Coli (dark spots in colon) seen on Colonoscopy Tx: Resolves w/dc of laxatives

Cavernous Sinus Thrombosis (CST)

Path: Facial/Ophthalmic venous system is valveless, so infection of skin, sinuses, and orbit can spread to cavernous sinus - Leads to life-threatening Cavernous Sinus Thrombosis - & Intracranial HTN - CN III, IV, V, VI pass through cavernous sinus, so can cause respective sx Pt: - Headache - Periorbital edema - Fever - Vomiting (d/t ICP) - Papilledema (d/t ICP) - Binocular palsies (Can't move eyes) - Hypoesthesia or Hyperesthesia Dx: Tx: Broad spectrum IV Abx - Prevent on reverse brain herniation prn

Deep Wound Dehiscence

Path: Failure of *fascia* but no emergence of abdominal contents yet.... Pt: - Hernia (ventral mc), - *Salmon colored Serosanguioneous drainage* Dx: Clinical - May need USD or CT Tx: *Binders + Reduced straining* (to prevent evisceration) + Re-operate eventually - If was superficial wound dehiscence? Wound care.

Evisceration

Path: Failure of *whole wound* post-surgery. - Or trauma to abdomen which causes bowels to come out. Pt: Loops of bowel popping out of surgical wound Dx: Clinical Tx: *Emergent surgery* + Apply warm saline dressing to gut to keep hydrated in mean time. - DO NOT put back in abdomen immediately

Hirschsprung disease

Path: Failure of INHIBITORY neurons to migrate to the DISTAL colon (muscle can't relax) "failed neural crest cell migration" - No Auerbach plexus - No Myenteric plexus Pt: - SEVERE? *Failure to pass meconium* in first 48hr (explosive diarrhea w/DRE) - MILD? Toddler with *Overflow incontinence* --> May also present in infancy with chronic, refractory constipation or *poor growth* --> Thin stools - Distal colon sphincter cannot relax, - Palpable colon. - Poor feeding - Abdominal distention - Bilious emesis - *EXPULSION of stool and gas* with exam of anal sphincter Dx: ABD XRAY....Proximal colon dilated (looks "bad" but is really "good") v. Distal colon looks "normal" (but is really bad) - then, *CONTRAST ENEMA* (w/"rectosigmoid transition zone") - If Overflow incontinence? *ANAL MANOMETRY* (w/increased tone) - Confirm w/*Rectal Suction Biopsy* (w/o plexus) Tx: Surgery - remove bad colon

Nonunion

Path: Failure of fracture to achieve clinical or radiographic evidence of fusion in an adequate time period (x. 6mo for long bones) - RF = DM, Smoking, Atherosclerosis, Steroids, Hypothyroidism, Infection

Cryptorchidism

Path: Failure of in-utero testicular descent from abdomen to scrotum. - At increased risk for INTRA-ABDOMINAL TORSION --> surgical emergency - RF = Prematurity, IUGR, SGA Pt: - Empty, poorly rugated scrotum - Testes may be palpated in the inguinal canal or undetectable Dx: - Unilateral? See tx... - Bilateral? *Karyotype + Electrolyte monitoring* (indicates may be d/t CAH, etc) Tx: Often descends spontaneously in the first few months of life. - IF HAVE NOT DESCENDED BY *6 months* --> ORCHIOPEXY (before 1yo) to avoid association w/cancer, infertility, torsion --> Surgery resolves risk of infertility and torsion, but are still at relatively increased risk for CANCER (better than when undescended though)

Infertility

Path: Failure to achieve pregnancy after *12 months* of unprotected intercourse for couple where woman is *<35yo* - ...after *6 months* of unprotected intercourse where woman is *≥35yo* - 25% is d/t male. Dx: Check *MALE problems FIRST* via *Semen Analysis*. Then check Female problems. - If female is ovulating/menstruating normally, with normal anatomy? *Semen analysis* - Abnormal menstruation? *Basal body temp v. Mid-luteal phase progesterone level (Cycle day 22)* --> to see if ovulating, if she is? *Hysterosalpingogram v. Hysteroscopy*. If normal? *Laparoscopy* - If risk factors for tubal blockage (x. PID, endometriosis)? *Hysterosalpingogram* Tx: They more than likely will get preggo in the next year, BUT... - Timing intercourse with ovulation (have sex ON day of ovulation and *five days BEFORE*) - Clomiphene - If male problem with low count or mobility? *IUI* - If done entire work-up (including laparoscopy) and is unexplained? *Adoption*

Specific Phobia

Path: Fear of objects or specific situations or events (x. spiders, snakes, flying, heights) Pt: Exaggerated and/or irrational fear response Dx: Clinical - Duration *>6 months* Tx: *CBT (exposure therapy)* + Benzos - FLOODING = works less well but works quickly (overload w/thing that is feared while calmed w/benzo) - DESENSITIZATION = longer lasting but takes longer (introduce to thing that is feared and slowly increase exposure over time, while calmed w/benzo)

Social Anxiety Disorder

Path: Fears of scrutiny and negative evaluation results in embarrassment in social and performance situations Pt: - Poor eye contact - Persistent anxiety in social settings - Anticipatory anxiety about social settings - Turns red - Sweaty palms - Heart races - Voice cracks - Declines promotions (example of functional impairment) - Self medicate with alcohol Dx: Clinical - Marked anxiety about *≥1 social situation* - Duration *≥6 months* Tx: *SSRI/SNRI* v. *CBT* (w/focus on Social skills training, Cognitive reframing of anxious thoughts, Systemic desensitization) - Performance anxiety-ONLY? *Propanolol v. Nadolol*...could use Benzos as well if patient does not have personal or family history of addiction.

Large Local Reaction

Path: IgE reaction - Less life threatening Pt: - Rapid onset, within 24hr --> Peak at 48hr - *>10cm or more* swelling - Erythema - Warmth Tx: *Antihistamines + Steroids* - Self resolve within several days

Appendicitis in Pregnancy

Path: Fecalith obstruction of appendix Pt: - D/t gravid uterus, pain is in FLANK (right mid- to upper- quadrant) - *Fever* (helps dif from Preeclampsia) - Nausea - Vomiting - May be hypertensive from pain - *Peritoneal signs* (helps dif from Preeclampsia) - *NO proteinuria* (helps dif from Preeclampsia) - Fetal tachycardia (another sign of infection v. Preeclampsia) Dx: USD Tx: Surgery

Idiopathic Pulmonary Fibrosis

Path: Fibrosis can be caused by connective tissue disease or exposure to chemicals (x. asbestos), in the absence of this it is Idiopathic. - Alveolar injury followed by inappropriate repair Pt: - Dyspnea - *Inspiratory crackles* - Restriction on PFT Dx: CT w/*subpleural honeycombing and reticular opacities* (How you dif from Hypersensitivity pneumonitis which is diffuse) - "Velcro" inspiratory crackles PFT w/ - TLC = Decreased - FEV1/FVC = Normal or increased (>80%) - DLCO = Decreased Tx: *Antifibrotic drugs* (inhibit fibroblasts to slow the rate of FVC decline and are first-line therapy) - Devestating dx....People die in 2-3 years

Urethral Stricture

Path: Fibrotic narrowing of the urethra most commonly in the bulbar portion - Usually idiopathic - Can be caused by trauma (pelvic trauma, iatrogenic instrumentation), infection (STD/STIs), radiotherapy Pt: Young male - Decreased urinary flow - Sensation of incomplete emptying - Elevated Postvoid residual volume - Urine retention - Can cause UTIs Dx: elevated postvoid residual volume - Can confirm w/Cystourethroscopy Tx: - Mild? Observe cautiously - Moderate/Severe? Urethral dilation v. Urethroplasty

Cyanide Poisoning

Path: Fires or Occupational exposure, or *NITROPRUSSIDE*!!! - Combustion of nitrogen-containing synthetic polymers --> Smoke inhalation injury --> HCN + CO - Symptoms develop within minutes or seconds - Potent inhibitor of *cytochrome oxidase* (reduces Fe3+ to Fe2+) which is then unable to bind oxygen --> Functional anemia bc oxygen is not able to be delivered to tissues Pt: - Headache - Vertigo - Dizziness - Hyperventilation - Tachycardia - Nausea - Vomiting - Lactic acidosis bc cells have to use anaerobic metabolism (*METABOLIC acidosis*) Dx: Can't - blood levels are unreliable, you treat impirically Tx: *Hydroxocobalamine* - Or as an alternate could use *Sodium Thiosulfate*

Hypospadias

Path: First, picture erect penis. EPI = Dorsal (top) and HYPO = Ventral (bottom). - 10% are associate w/Cryptorchidism Pt: Varies Dx: Clinical Tx: *Never circumcise* (need skin to rebuild urethra) - Urologic evaluation for surgery - SEVERE? *Karyotype* (can be indication of disorder of sex development)!!!! --> Androgen receptor mutation, Virilization of an XX, or Undervirilization of an XY, Mosaicism

Otitis Media with Effusion (OME)

Path: Fluid accumulation of the middle ear *WITHOUT TM INFLAMMATION* - Viral infection can cause - Following episode of Acute Otitis Media - Cleft palate increases risk Pt: Asymptomatic - Sometimes discomfort --> Ear tugging and pulling - Air-fluid levels posterior TM, - Poor mobility of TM on insufflation, - *Translucent and Grey* (NOT erythem or bulging, how you dif from Acute Otitis Media, which you treat!!!) - Effusion limits TM vibration --> *Conductive hearing loss* Dx: Clinical Tx: NONE!!! Resolves on own in week - F/up for resolution, if none? *Tympanostomy tube*--> >3months of OME causes Speech Delay and Hearing Loss

Telogen Effluvium

Path: Follicles undergo a widespread shift into the rest/shedding phase d/t a stressful event - Stress, Nutrition, Illness, Pregnancy, Distress - mc cause of hair loss in adults Pt: DIFFUSE hair loss Dx: Hair pull test (>10% is abnormal, or >6 hairs) Tx: Reassurance

Myositis Ossificans

Path: Following trauma, a calcium mass forms within a muscle *3-4 weeks* AFTER muscle injury - Formation of lamellar bone in extracellular tissue Pt: Painful, firm, mobile mass w/swelling Dx: XRAY w/*Calcification and radiolucent zones* - Elevated Alk Phos, ESR, CRP Tx: ROM exercises + NSAIDs - Surgical excision

Postconcussive Syndrome

Path: Follows a traumatic brain injury induced concussion. - A few hours or days later, can lead to post concussive syndrome. Pt: - Headache - Confusion - Amnesia - Difficulty concentration - Difficulty multitasking - Vertigo - Mood alteration - Sleep disturbance - Anxiety Dx: Tx: Most resolve w/supportive treatment - Some patients have sx *≥6mo* after

Secondary Bacterial Pneumonia

Path: Follows viral pneumonia. Often caused by... - STREP pneumo - STAPH aureus (rapid onset, severe, necrotizing, rapidly progressive, high risk of death) Pt: - Worsening fever - Pulmonary symptoms (productive cough, dyspnea) - Follows flu sx. - HYPOXIA - Lobar or Multilobar infiltrates Tx: Broad spectrum Abx (Vanco, Pip-Tazo, Levofloxacin) in ICU

Campylobacter

Path: Foodborn GI illness of campylobacter (Gram negative) bacteria mc caused by undercooked poultry - Also caused by contact w/contaminated water, or infected animal Pt: - Fever - Abdominal pain - *MUCUS* filled diarrhea - Bloody stools mc in children - Nausea - Vomiting Dx: Stool cultures. Tx: Self limited! Develops ~3days after exposure. - ONLY patients w/*SEVERE* dz (Infected >7days, Bloody stools, High fevers) get antibiotics --> *Azithromycin* v. *Levofloxacin* Remember, Amoxicillin could work depending on sensitivities (good for gram negatives and positives)

Colonic Volvulus

Path: Forms a *Closed loop obstruction* - *Cecal* volvulus is mc - RF = Constipation, Advanced age Pt: - Progressive abdominal pain - Slowly progressive abdominal distention - Nausea - Vomiting - Single dilated loop of LARGE bowel on Abd XR - Cecal? Younger, Prior self-resolving episodes, d/t *Congenital mobile cecum* Dx: *Abd CT* Tx: _ Cecal? *Emergency laparotomy w/Resection of R colon* - Sigmoid? Detorse bowel

Sigmoid Volvulus

Path: Forms a *Closed loop obstruction* - RF = Elderly patients with neurological dysfunction, Chronic constipation Pt: - Progressive abdominal pain - Slowly progressive abdominal distention - Nausea - Vomiting - Constipation - Single dilated loop of LARGE bowel on Abd XR - No gas in rectum. Dx: *Abd CT* w/INVERTED U-SHAPE (no haustra!!) - aka "Bean sign" Tx: *Endoscopic DETORSION* (unlike Cecal volvulus where you resect bowel)

Brown Recluse Bite

Path: Found in warm, dry areas (woodpiles, cellars, attics). Venom from bite causes ISCHEMIA and resulting damage to tissues. - MC in southern states Pt: - Initially painless - Become painful a few hours after - *Bite --> Blueish blister --> Ulcer --> Necrosis* Dx: Clinical Tx: Conservative!!! *Wound care* + Pain control + Clean site + Cold compress - Surgical debridement once wound stops spreading.

Correlation Coefficient

a statistical index of the relationship between two things (from -1 to +1) -1 = inverse relationship 0 = no relationship +1 = positive relationship

Colles Fracture

Path: Fracture of the distal radius at the wrist d/t fall on outstretched hand Worry about - *RADIAL ARTERY* --> Absent radial pulse --> Delayed cap refill - *MEDIAN NERVE* --> Sensation to lateral 3.5 fingers --> Motor innervation to thenar muscles Pt: Little old lady with osteoporosis Dx: XRay w/"Dinner fork deformity" (see pic) Tx: - Neurovascular compromise? *Immediate fracture reduction* - If still neurovasc comp after reduction? Immediate CTA v. Emergent Orthopedic referral

Spondylolisthesis

Path: Fracture of the pars interarticularis, followed by forward slippage of the vertebra. - MC during adolescent growth spurts (10-19yo) d/t increased lordosis and decreased bone mineralization. - Athletes with repetitive back extension and rotation (gymnasts, divers) Pt: - Pain worse with EXTENSION - Palpable *Step-off* - Pain may radiate to buttocks or legs Dx: XR Tx: *Conservative* - Warning signs (persistent pain, progressive vertebral displacement, weakness, incontinence)? *Surgery*

Vibrio vulnificus

Path: Free-living gram negative bacteria that lives in brackish *water and marine* environments that can cause OSTEOMYELITIS - Get from *raw oysters*, *open wound contamination*, raw seafood handling. - Worse in summer. - RF = *LIVER DZ* (esp Hemochromatosis bc iron acts as catalyst) Pt: - Cellulitis - Immunecompromise? Necrotizing fasciitis w/"hemorrhageic bullous lesions" --> Septic shock Dx: Blood & wound cultures Tx: IV Abx

Frostbite

Path: Freezing of tissue causing disruption of cell membranes, ischemia, vascular thrombosis, inflammatory changes. Pt: - Stiff or waxy texture to tissues - Superficial pallor - Anesthesia - Blistering - Eschar formation - Deep tissue necrosis - Mummification Dx: Tx: Rapid rewarming of REGION with *Warm WATER* + Analgesics. - SYSTEMIC Hypothermia? *Infusion of warmed fluids*

Acute Tubular Necrosis

Path: From renal ischemia (if hypoperfusion persists), HYPOvolemic shock, Crush injury, etc. - Pt: MUDDY BROWN Granular Casts Dx: Because tissue is damaged and not able to reabsorb... - *Urinary Na+ >20* (unless contrast induced, then <20) - BUN:Cr Ratio of *10-15:1* (prerenal azotemia is >20:1) - Urine Osmols 300-350 - FeNa >2%

Perforated Peptic Ulcer

Path: Full thickness erosion of peptic ulcer through stomach or duodenal wall --> gastric secretions in the peritoneal cavity Pt: - Postprandial epigastric pain followed by acute onset severe pain - Tachycardia - Tachypnea Dx: Intraperitoneal free air under diaphragm on CXR Tx: Urgent *Surgical exploration* + IV Abx + IV PPI + NG tube + IVF

Intraamniotic Infection (Chorioamnionitis)

Path: Fulminant polymicrobial infection of the amniotic sac, fetus, cord, and placenta from ascending vaginal infection - Common in patients with PREMATURE RUPTURE of membranes (PPROM) Pt: - Maternal Fever - Nausea - Vomiting - Uterine fundal tenderness - Fetal Tachycardia (>160 for 10 min) - Maternal leukocytosis - Maternal tachycardia - Purulent amniotic fluid Dx: Tx: *Broad spectrum IV Abx + INDUCTION OF LABOR!!* - GET THAT BABY OUT! No matter how old :( Mortality of infection outweighs mortality associated with prematurity

Acute Colonic Pseudo-Obstruction (Ogilvie syndrome)

Path: Functional - d/t Electrolyte imbalance (HypoK, HypoMg) - d/t Autonomic disruption Pt: Elderly, Colon ONLY - NO fever, tachycardia, leykocytosis, diarrhea, etc. Dx: KUB (small bowel normal, LARGE bowel dilated) - How you differentiate from others is that there will be *No normal colon* Tx: Rectal tube - *Neostigmine* if this fails!!! --> Colonoscopy later to r/o cancer

Pseudo-obstruction (Ogilvie syndrome)

Path: Functional. Thought to involve disruption of the autonomic nervous system. - *Electrolyte imbalance* (HypoK, HypoMg) --> from severe diarrhea - Autonomic disruption of colon - Other causes: Trauma, Severe infection, Major surgery, Neurological disorders, Pt: Elderly, Colon ONLY - Severe abdominal pain - Nausea - Vomiting - Obstipation - Tympanic abdomen - Hypoactive bowel sounds - NO fever, tachycardia, leukocytosis, diarrhea, etc. (that would be seen in Toxic Megacolon) Dx: KUB (small bowel normal, LARGE bowel dilated) - How you differentiate from others is that there will be *No normal colon* Tx: NPO + Rectal tube - If this fails, consider *Neostigmine* after 48hr or if cecal diameter exceeds 12cm --> Colonoscopy later to r/o cancer

Pneumocystis Pneumonia (PCP)

Path: Fungus causing pneumonia - Immune compromised at risk (esp CD4 <200) Pt: - Progressive dyspnea - Acute Respiratory Failure - Tachypnea - Hypoxia - Dry cough - Fever - Bilateral diffuse pulmonary *reticulonodular* infiltrates on CXR - LDH elevated Dx: *BRONCHOALVEOLAR LAVAGE* w/specialized stains - Cannot be cultured Tx: *TMP-SMX + Steroids* (bc lysed organisms are inflammatory, esp if *O2 <92%, pO2 <70, or Aa gradient >35*) - If sulfa allergy? *Pentamidine* - Start *Antiretroviral therapy* within 2 weeks!! to prevent AIDs progression

Blastomycosis

Path: Fungus found in the CENTRAL and MIDWESTERN USA - LONG incubation period --> *3-6 weeks* Pt: - "Left upper lobe consolidation" - Fever - Night sweats - Productive cough - *Lytic lesions on bone* - *Ulcerated lesions on skin* --> "Warty, heaped up skin lesions w/violaceous hue and sharply demarcated border" - *PROSTATITIS*...& - *EPIDIDYMO-ORCHITIS* Tx: Itraconzaole v. Amphotericin B

G6PD Deficiency

Path: G6PD usually protects from oxidant, when deficient will pass through cell and damage. - Oxidants = Dapsone, TMP-SMX, Nitrofurantoin, Primaquine, *Infection*, Fava beans. - Mc in African Americans, Mediterranean, Asian, Middle Eastern - *X-linked RECESSIVE* (mc in Males) Pt: - Jaundice (elevated indirect bili) - Back pain - *Hematuria* - Fatigue - Anemia - Elevated LDH - Decreased *Haptoglobin* - NO Splenomegaly (or very rare) Dx: Blood Smear (*Bite cells & Heinz bodies*) - Best? *G6PD level 3MONTHS!! after the attack* (would be normal during the attack bc older RBCs would be hemolyzed and younger ones would not yet) - Coombs testing would be NEG (bc not Ab mediated hemolysis!!) Tx: Supportive, avoid stressor

Galactosemia

Path: GALT (Galactose-1-phosphate UDT) deficiency --> Galactose accumulation after lactose or galactose ingestion - Autosomal RECESSIVE Pt: - Jaundice --> increased INDIRECT or DIRECT bili - Hepatomegaly --> increased Liver enzymes - Cataracts - Vomiting, poor feeding, failure to thrive - Hemolytic anemia - Increased risk for *E. Coli sepsis* - Metabolic ACIDOSIS - Hypoglycemia - Accumulation of galactose Dx: Absent RBC GALT activity Tx: Galactose-free diet (use soy-milk instead!)

Response Bias

a systematic pattern of incorrect responses in a sample survey x. medical students being surveyed for smoking frequency, they will give desirable responses

Cholecystitis

Path: Gallstone blocking the CYSTIC duct --> Ingestion of fatty food causes contraction of gallbladder against stone in cystic duct (Cholelithiasis w/colicky pain) --> inflammation! (and pos infection) - Pericholecystic fluid - Thickened gallbladder wall - Gallstones - RF = Rapid weight loss, Hemolytic anemia, Hypertriglyceridemia, Female, Fat, Forty Pt: - *CONSTANT* RUQ pain (or EPIGASTRIC!!) - Fever, - Elevated WBCs, - (+) Murphy's - AST/ALT, Bilirubin, Amylase may be mildly elevated d/t passage of sludge or puss in common bile duct!!! - Guarding (if peritoneal irritation) - NO elevated AlkPhos (thats seen w/cholangitis or choledocholithiasis) - NO jaundice!!! Dx: RUQ USD --> if unrevealing then *HIDA Scan* (shows perfusion via dye W/O filling of gallbladder) - "gallbladder wall thickening, edema, pericholecystic fluid" Tx: NPO, IV fluids, IV Abx (*Cipro+MTZ v. Amp/Gent+MTZ*) - & urgent cholecystectomy (w/in *72 hours*. If nonsurgical candidate do cholecystostomy) - emergent cholecystectomy if perforation or gangrene

Choledocholithiasis

Path: Gallstone blocks the COMMON BILE duct. - Depends where the stone gets stuck...elevated ALT/AST for liver, elevate Amylase/Lipase for pancreas. Pt: *PAINFUL jaundice* (obstructive), (+) Murphy's, Mild fever, Mild leukocytosis, *Elevated ALK PHOS* - Maybe has pancreatitis - Maybe has hepatitis Dx: RUQ USD (would see dilated ducts) --> if unrevealing then *MRCP* - During HIDA scan radiotracer does not reach small intestine Tx: NPO & IV Fluids ... - & IV Abx (*Cipro+MTZ v. Amp/Gent+MTZ*) - ....get ready for *ERCP (urgently)* - ...then do *cholecystectomy (electively)*. If liver enzymes go up and down this is "ball-valve" effect and should be treated the same.

Peptic Ulcer Disease (PUD)

Path: Gastric (mostly d/t H. Pylori) v. duodenal (always d/t H. Pylori) - H. Pylori (mc) --> Can cause Maltoma! - Cancer - NSAID - Curling (burn) - Cushing (increased ICP - steroids and ventilators) - Zollinger-Ellison Pt: - Postprandial nausea - Upper abdominal pain --> *Immediate* pain suggests GASTRIC (or pain WITH food is GASTRIC) --> *2 hours later* suggests DUODENAL (or pain RELIEVED by food is DUODENAL) - Recent hx of NSAID use - Positive stool guaiac - Can be complicated by PERFORATION --> Peritonitis --> Fever --> Tachycardia Dx: Clinical - Confirm w/*XR* of chest and abdomen - If negative get CT w/contrast Tx: Avoid NSAIDs + *PPI* - Signs of perforation? *Surgery* (you would NOT do scope because could further worsen perforation)

Pyloric Stenosis

Path: Gastric-outlet obstruction - Onset 3-6weeks AFTER BIRTH (when hypertrophy of pylorus has developed) Pt: Projectile vomiting - Nonbilious - First born male - Visible peristalsis - *Olive shaped mass* Dx: USD w/Donut Sign Tx: - FIRST!!!! Correct *Electrolytes* + *IVF* (improves all outcomes) - Then, once stable, *Pyloromyotomy*

Zollinger-Ellison Syndrome

Path: Gastrinoma (benign) - Increased Gastrin >1000 - Decreases gastric pH <4 - *Deactivates pancreatic enzymes* --> Steatorrhea Pt: - Multiple duodenal and sometimes jejunal ULCERS - Big, virulent, refractory ulcers - Steatorrhea d/t gastrin deactivating pancreatic enzymes Dx: EGD w/*"Multiple stomach ulcers and thickened gastric folds"* --> Gastrin-level --> then location w/*Somatostatin Receptor Scinctography* or CT Gastrin level (off PPIs) x1wk... - <110? Normal - Between? *Secretin stim test* (elevates gastrin levels if Gastrinoma. Normally, would turn off parietal cells and therefore decrease gastrin levels) --> Positive? Gastrinoma confirmed. Localize tumor. - >1000? *Gastric pH x1wk* --> <4 pH? Gastrinoma confirmed. Localize tumor. --> >4 pH? No gastrinoma. Tx: Resection + High dose PPIs - Increased gastrin is a grow stimulator for HCl producing parietal cells, so can induce gastric malignancy (NOT benign) - F/up *MEN1* screening, bc associated with (Parathyroid, Pituitary, Pancreas)

Glanzmann Thrombocytopenia

Path: Genetic GPIIB/IIIA deficiency; ("the other one") - bc Glanzmann kind of looks like GPIIB/IIIA...if you squint. - Platelet *AGGREGATION* is impaired - Autosomal RECESSIVE Pt: - NORMAL platelet counts - No clumping on PBS - Mucocutaneous bleeding

Retinitis Pigmentosa (RP)

Path: Genetic condition that causes progressive retinal degeneration, beginning with the *RODS* (help with vision in low lighting) - Can be sporadic, but most have family hx Pt: - Onset in early adulthood - Initial presentation is *Night blindness* - Visual field deficits in *Midperiphery* --> with progressive loss of peripheral vision - Flashing lights (Photopsia) - Blind spots (Scotomas) - Advanced disease? Degeneration of *Cones* causes decreased visual acuity. Dx: Fundoscopy w/... - *Retinal vessel attenuation* (d/t decreased metabolic demand) - *Waxy, pale optic disc* - *Pigment deposition* in a BONE-SPICULE pattern (late finding d/t degeneration of retinal pigment) Tx: Most patients legally blind by 40yo

Juvenile Myoclonic Epilepsy

Path: Genetic epilepsy syndrome that effects otherwise healthy adolescents - More common in those with family history of seizures - 33% have history of Absence Seizures in childhood Pt: - Myoclonic (limb jerking) - Generalized tonic-clonic seizures - More common in MORNING - Sleep deprivation can trigger - Postictal state (confusion) - Urinary incontinence Dx: *Bilateral polyspike and slow wave activity* on EEG Tx: *Valproic Acid* - Avoid triggers

Malignant Hyperthermia

Path: Genetic mutation of Ryanodine Receptors - *ANASTHETIC medication induced* (dif from NMS)....especially halothane - Autosomal DOMINANT Pt: Usually DURING anesthesia, but can occur MINUTES AFTER anesthesia cessation - Fever (late manifestation) - Muscle rigidity - Tachycardia - Tachypnea - Dyspnea - *Rhabdomyolysis* - Dark urine - *HyperK+* - Hypercarbia (CO2) Dx: Tx: Resp/Vent support + Stop anesthetic + *Dantrolene*

Preterm Labor Management

Path: Gestation *<37 wks* (and usually >24wks) with *REGULAR* contractions - If IRREGULAR, no cervical change, and normal NST you can DC!!!!!!! - More interventions are required the earlier baby is - RF = Cigarette smoking, Young maternal age, Multiple gestations, Preterm ROM, Anatomical Pt: - *REGULAR* Contractions - Cervical change - Preterm Dx: Clinical Tx: SEE PIC Fetal distress/Maternal instability/Intrauterine infection? - Immediate delivery Emergent c-section? *Forget about giving steroids*, bc that baby is coming out NOW and steroids take hours to have an effect <32 WEEKS? *Steroids + Abx + Tocolysis + Magnesium* - Steroids: *Betamethasone* - Abx: *Penicillin* (for GBS if positive, unknown, or Prolonged ROM) - Tocolysis: *Indomethacin* --> Can cause oligohydramnios d/t decreased renal perfusion with PDA closure - *Magnesium sulfate* (decreases risk of cerebral palsy <32wks, don't give if older) 32-34 WEEKS? *Steroids + Abx + Tocolysis* - Steroids: *Betamethasone* - Abx: *Penicillin* (for GBS if positive, unknown, or Prolonged ROM) - Tocolysis: *Nifedipine* >34 WEEKS? - Steroids: *Betamethasone* - Abx: *Penicillin* (for GBS if positive, unknown, or Prolonged ROM) - Tocolysis: *NO*!!! Just let them have baby.

Presbycusis

Path: Gradual loss of SENSORINEURAL hearing that occurs as the body ages, or d/t mechanical or metabolic overload - RF = Excessive occupational noise - SENSORINEURAL means INNER EAR is effected (*cochlear hair cell* loss --> decreased hearing of high frequency sounds, or tinnitus... can also be caused by medications, meniere, schwannoma) Pt: - Harder to hear when there are loud noises - Loss of HIGH FREQUENCY hearing - Weber is doesn't localize to any side (normal) - Rinne w/AC>BC (normal) - Tinnitus Tympanosclerosis = conductive hearing loss, caused by repeated infections of middle ear Osteosclerosis = conductive hearing loss, caused by abnormal bone deposition in younger patients. Fixation of stapes. Autosomal dominant w/incomplete penetrance

Clenched Fist Bite Injury ("Fight Bite")

Path: Gram Negative, Anaerobes Pt: Sex acts, Fist fights - If FEVER and SEVERE PAIN when moving joint? Septic! Dx: Clinical Tx: *Amoxicillin-Clavulanate* (or Ampicillin/Sulbactam) + Leave wound open to heal by secondary intention - Septic? Surgical *Irrigation + Debridement* --> ≥3 vaccines in childhood? *Tetanus Toxoid vaccine (Tdap)* if last dose was *≥5yr* ago --> <3 vaccines in childhood or uncertain? *Tetanus Toxoid vaccine (Tdap)* + *IV IG*

Nocardiosis

Path: Gram POSITIVE aerobic acid-fast bacteria with branching, filamentous growth that is found in soil and can inoculate humans via inhalation or cutaneous contact - Seen in *Immunocompromised* Pt: - Fever - Weight loss - Malaise - Dyspnea - Cough - Pleurisy - *Nodular or cavitary lesions in the UPPER lobes* on imaging (confused w/tuberculosis or malignancy) Dx: *BAL* - Gram stain w/filamentous *gram positive bacteria that are weakly acid-fast* Tx:

Hypersensitivity Pneumonitis

Path: Granulomatous reaction to inhaled organic antigens (e.g., "pigeon breeder's lung") --> Exaggerated immune response to inhaled antigen - RF = Atopy, Eczema, Asthma Pt: Variable depending on dose and chronicity of epxosure - Fevers - Malaise - Nonproductive Cough - Dyspnea - Fatigue - Leukocytosis Dx: PFT w/*RESTRICTIVE pattern* (FEV1/FVC >80%) - DECREASED DLCO - CXR w/bilateral interstitial opacities "*honeycombing*" (how you dif from Idiopathic Pulmonary Fibrosis which is only subpleural) - "*Bilateral scattered micronodular interstitial pattern*" - "Patchy interstitial inflammation" - "Diffuse fine crackles heard throughout both lungs" Tx: Self resolves, remove exposure - Glucocorticoids if not

Hereditary Hemochromatosis

Path: HFE mutation causes excessive intestinal absorption of *IRON* and deposition in tissues (x. pituitary), leading to multisystem end organ damage - Autosomal RECESSIVE (think of a little bronze, liver-shaped car with a candy on top) - "Bronze diabetes" Pt: - <40yo. --> WOMEN present LATER d/t losing iron in MENSTRUATION - Fatigue, - Hypogonadism --> Impotence (Erectile dysfunction) - Hepatomegaly, - Bronzed skin - *Arthropathy of 2nd and 3rd MCP* w/"chondrocalcinosis" (calcium pyrophosphate depositions) --> *Pseudogout* - RESTRICTIVE or dilated Cardiomyopathy - Cirrhosis - Diabetes - *Hepatocellular carcinoma (HCC)* (causes 45% of HH deaths) Dx: - *HIGH Serum Iron*, - *HIGH Transferrin saturation* - *HIGH Ferritin* levels, - Confirm w/*HFE* genetic test, Tx: *Phlebotomy* (reduces risk for HCC and Cirrhosis) - Urgent if Ferritin >1000 - If Ferritin <500 can monitor labs and give phlebotomy once becomes worse or signs of end organ damage

Roseola Infantum

Path: HHV-6 Pt: - <2yo - VERY HIGH fever (>104) - *THEN* RASH 3-5 days after! --> "Rose-colored blanching maculopapular rash" - Begins on NECK/TRUNK and then spreads to FACE/Extremities (unlike Measles, Rubella, etc. which start on face and spread down) Dx: Clinical Tx: Supportive - Be aware of febrile seizures (abort with benzos), - Treat fever with ACETAMINOPHEN

Head and Neck Squamous Cell Carcinoma (HNSCC)

Path: HPV16 (more responsive to tx) & tobacco exposure can cause. - MC at tonsil or base of tongue Pt: - Ulcerates lesion on tonsil or base of tongue - Cervical LNDs --> Persistent, painless, firm cervical LND is often the presenting (and only) sign!! - Halitosis - Dysphagia - Pharyngitis - Hearing loss --> d/t tumor at base of tongue where CN8 is, or in neck where CN10 is (both of which also innervate ear)!!! Dx: *FNA* of lesion + *Laryngopharyngoscopy* - Stage w/CT of neck Tx:

Bell Palsy

Path: HSV facial neuritis (mcc of facial nerve palsy)...virus causes edema and inflammation of CNVII - Also associated w/Lyme's disease Pt: ACUTE ONSET - Ear pain or sound distortion may be prodrome --> There is NO rash in ear (unlike Ramsey Hunt) - Unilateral upper and lower facial drooping - Drooping of mouth corner - Inability to raise eyebrow or close eye - Disappearance of nasolabial fold Dx: When classic presentation? *No further workup* necessary. Tx: High dose *Corticosteroids* + antivirals (*acyclovir v. valacyclovir*)...same as Ramsey - Resolves within a few weeks

Herpetic Whitlow

Path: HSV inoculates a cutaneous defect in the hand - Usually HSV2 (from genitals) Pt: - Systemic symptoms (x. FEVER, Malaise) differentiate this from other similar rashes - Clustered erythematous vesicles "Focal area of grouped vesicles on an erythematous base" - Typically on hand or finger - Tingling - Burning - Pain - Epitrochlear or axillary LNDs Tx: Resolves spontaneously in a few weeks, so can *Reassure* - Immunocompromised? *Acyclovir*

Aortic Dissection

Path: HTN, Bicuspid aorta (Turner's), Coarctication of the aorta, Marfan's, Syphylis. Pt: - TEARING chest pain radiates to back, stomach, *R shoulder* --> Numbness and tingling in extremity - ASYMMETRIC BP arm to arm, - WIDENED mediastinum - Symptoms depend on where dissection is occurring - Hypotension - Aortic regurgitation (diastolic murmur heard best at 4th ICS left of sternal border) - May see ST, T-wave changes on EKG.....(confuses things) - Type A = Ascending, before great vessels (can cause Vertebral artery dissection --> Posterior Cord Syndrome) - Type B = Descending, after great vessels (can cause descending aorta dissection --> Anterior Cord Syndrome) Dx: - Hemodynamically STABLE and good kidneys? *CTA (with contrast)* --> Look for "false lumen" - Hemodynamically UNSTABLE or can't do contrast? *TEE* Tx: - Type A, or B w/malperfusion? *OPERATE* & eval for need to replace A-valve - Type B w/o organ malperfusion? Get BP and HR down w/*IV BBlockers*

Intraparenchymal Hemorrhage

Path: HTN, Crack cocaine use - *Basal ganglia* is most common site!!! --> Can lead to Uncal Herniation Pt: - FND (depends on wherever they're bleeding into) - HA - N/V - Coma Dx: CT scan Tx: - Decrease ICP - Craniotomy - Evacuate F/u w/CT Scan (look for expanding hematoma, which can force brain DOWN through FORAMEN MAGNUM = *Uncal Herniation*)

Bipolar Type II

Path: HYPOMANIA + Major Depressive Episodes - Hypomanic symptoms are less severe and functioning is improved or only slightly impaired (compared to mania) Pt: HYPOMANIA = - ≥4 days of elevated, irritable mood - *+ ≥3 of following*: grandiosity, decreased sleep, talkativeness, distractibility, racing thoughts, risky behavior, hyperactivity - Functioning while hypomanic is improved or only mildly impaired (in contrast to Bipolar I where functioning is severely impaired) Dx: - Duration of HYPOMANIA *≥4 days* - Duration of MDE *≥2 weeks* - *≥1* MDE - *≥4 mood episodes/year*? "RAPID CYCLING" - R/o Catatonia --> BP1 - R/o Psychosis --> BP1 Tx: *Lithium* or *Valproate* (second line is Lamotrigene) for maintenance for the rest of their life (d/t high risk of recurrent episodes) - Severe? *Lithium + Quetiapine* - Currently in MDE? *Lurasidone* v. *Quetiapine* v. *Lamotrigene* - Looks like MDE and already on Lithium? *Check TSH FIRST!!!* before changing any meds. --> Even if Lithium level is therapeutic, can still cause AE. --> Tx hypothyroidism w/Levothyroxine (don't dc lithium if it's working). - Pregnant? *Lamotrigene* - Agitated in ED? *Benzo* (esp if acute) v. *Quetiapine* (esp if psychotic) - NOT "B52" (aka Haloperidol + Lorazepam + Diphenhydramine)...bc too extreme If they are having MDE and you tx w/anti-depressant and they become manic, or their depression resolves abnormally rapidly? *Bipolar Spectrum* --> *Discontinue the med*

Vitreous Hemorrhage

Path: Head trauma - Associated w/*DIABETIC RETINOPATHY* Pt: - *Sudden loss of vision with floaters* - Leakage of blood into vitreous - Relative afferent pupillary defect Dx: *ABNORMAL RED REFLEX* - "Loss of fundus details, floating debris and a dark red glow"

Concussion

Path: Head trauma w/NO BLEED on CT (usually always sports injury) leads to diffuse neuronal depolarization, decreased cerebral blood flow, localized lactic acidosis --> Causes *" Transient Neuronal functional disturbance"* - Axonal sheering from rotation of brain within skull Pt: Mild vs. Severe - Look for Focal Neurological Deficit (+ if severe) - Duration of LOC (<60s if mild, >60s if severe) - HA (- or getting better if mild, + or worsening if severe) - Amnesia - Dizziness - Sleepiness - Difficulty concentrating Tx: Physical and cognitive rest for *24-48hr*, then return to play in a stepwise fashion. - MILD? No CT, No treatment, go home and be monitored - SEVERE? Get CT, Admit. - Return to play in stepwise fashion (Min of 1 week) ---> Light aerobic activity --> Noncontact sports --> Contact sports (you step up to next level after 24hr of no sx) - If becomes symptomatic return to last level was asymptomatic at

Hypertrophic Cardiomyopathy

Path: Heart walls become thick in a way that covers the opening of the aortic valve. Left ventricular outlfow tract obstruction. When dehydrated they lose stretch to show part of aorta opening --> DEATH - SARCOMERE MUTATION (genetics) - Autosomal DOMINANT Patient: YOUNG ATHLETE w/shortness of breath and/or syncope on exertion. - Fatigue - Palpitations - Lightheadedness - Chest pain - Dizziness on exertion - Systolic murmur at left sternal border - Family history of sudden cardiac death Dx: Auscultation...sounds like AORTIC STENOSIS - BUT more blood makes sound weaker - *ASYMMETRIC* Hypertrophy on ECHO!! - Has systolic anterior motion of the mitral valve Tx: AVOID DEHYDRATION + *BBLOCKER* (or Verapamil) - Consider alcohol ablation or myectomy, defibrillator (for those at increased risk of death), or Transplant *FIRST DEGREE RELATIVES SHOULD BE SCREENED*

Hypertrophic Cardiomyopathy (HCM/HoCM)

Path: Heart walls become thick in a way that covers the opening of the aortic valve. When dehydrated they lose stretch to show part of aorta opening --> DEATH - SARCOMERE MUTATION (genetics) - Autosomal DOMINANT inheritance - "Cardiomyocyte hypertrophy and disarray" Patient: YOUNG ATHLETE w/shortness of breath and/or syncope on exertion. - Mc in African Americans - Carotid pulse with dual upstroke Dx: Auscultation...sounds like AORTIC STENOSIS - BUT more blood makes sound weaker - *ASYMMETRIC* Hypertrophy on ECHO!! - Has systolic anterior motion of the mitral valve Tx: AVOID DEHYDRATION + BBLOCKER (or CCB) - Consider alcohol ablation or myectomy, defibrillator (for those at increased risk of death), or Transplant *FIRST DEGREE RELATIVES SHOULD BE SCREENED*

Ovarian Torsion

Path: Heavy ovarian cyst causes ovary to twist --> Suspensory ligament (*Infundibulopelvic ligament*) gets twisted/tangled cutting off veins --> Ovary engorges and enlarges - But uterine anastomoses provide venous drainage and arterial supply to ovary, so it does not infarct - Those with prior history of torsion are more likely to have it recur!! Pt: Asymptomatic and previously undiagnosed ovarian mass, twists without provocation - Sudden onset pelvic pain - Nausea - Vomiting - NOT fever or leukocytosis (if has this then sign of necrosis) - Partial torsion? Can have intermittent sx w/normal blood flow, which progresses Dx: Transvaginal USD w/HUGE ovary and *whirlpool sign* - NO Doppler flow in ovarian vessels Tx: SURGICAL EMERGENCY --> *Laparoscopy* - Untwist and leave it in!!! (unlike testes where you'd remove depending on what it looked like)

Myelodysplastic Syndrome

Path: Hematopoietic stem cell neoplasm that interferes with the production of functional blood cell lines. --> Leads to dysplasias and cytopenias - RF = Advanced age, Prior hx of chemo or RT Pt: Often asymptomatic.....Pancytopenia.... - Anemia (Normocytic or *Macrocytic* "Ovalomacrocytosis") --> Weakness --> Fatigue --> Dyspnea --> Conjunctival pallor - Granulocytopenia --> Infection --> *Leukopenia w/immature granulocytes* ("neutrophils with reduced segmentation") - Thrombocytopenia - Rarely may see Hepatosplenomegaly and lymphadenopathy - Deficient reticulocytes!!! Dx: *Bone marrow Bx* w/Hypercellular marrow Tx: Transfusions, Chemo, Stem Cell

Stroke

Path: Hemorrhagic v. Ischemic Pt: SUDDEN ONSET - SAH --> Thunderclap headache, temporary LOC - ICH --> Progressive, may see symptoms of ICP - Confusion - Somnolence - Headache - Cerebellar? Ataxia, Falling to one side, Vertigo, Headache, Unilateral dysmetria. Dx: Ischemic v. Hemorrhagic - Get *CT of head W/O CONTRAST* to r/o hemorrhage (SAH or ICH) --> Hemorrhagic has "Hyperdense fluid collection with irregular margins" --> Ischemic is often Normal!! - If NORMAL then consider ISCHEMIC stroke --> May have "Hypoattenuation with surrounding edema" Tx: - Ischemic? *TPA* if *w/in 4.5hr of onset*!! - Hemorrhagic? *Elevate head of bed + Hyperventilate* + *BP 140-160* + Surgery - If d/t ENDOCARDITIS!!!!!!!!!! (clot thrown off by vegetation on valve), *DO NOT* use Aspirin, Heparin, Thrombolytics as they INCREASE risk of intracranial hemorrhage ---> Tx: IV Abx, consider surgery

Testicular Torsion

Path: Insufficient fixation of testis to tunica vaginalis (*bell-clapper deformity*) - >12hr causes NECROSIS Pt: - Abrupt onset scrotal pain, - Testicular swelling, - N/V - NO cremasteric reflex - *Heterogeneous testicular echotexture (indicates necrosis) with small hydrocele* - Worry about ischemia and necrosis Dx: Clinically - Can confirm w/Doppler USD - Cremasteric reflex ABSENT Tx: Urgent surgical consult

Nonalcoholic Fatty Liver Disease (NAFLD)

Path: Hepatic steatosis in the absence of other secondary causes of hepatic fat accumulation (alcohol) - *Insulin resistance* leads to increased peripheral lipolysis, triglyceride synthesis, and hepatic uptake of fatty acids. --> This further leads to insulin resistance bc it impairs insulin-dependent glucose uptake and increases hepatic gluconeogenesis. Pt: - Metabolic syndrome - Obesity - DM - Hyperlipidemia - Mild AST/ALT elevation (ratio <1) - Mild AlkPhos elevation - Hepatomegaly - NO hx alcohol abuse Dx: Labs + Imaging (USD) - Could do bx to confirm - ALT > AST (<1 Ratio!!!) Tx: *Weight loss*

Pancreatic Leak

Path: High drain output of pancreatic fluid after Post-operative procedure involving pancreas - Non-anion gap METABOLIC ACIDOSIS (bc exocrine pancreatic fluid is HIGH in *bicarb*!!, which is lost, to neutralize the acidic chyme from the stomach) - Hyperchloremic bc body increases Cl- to maintain negative balance

Supracondylar Fracture

Path: High impact fall onto an outstretched arm, with elbow hyperextended - MC type of pediatric elbow fracture (esp 2-7yo) Pt: Risk damaging - Brachial artery - & Median nerve - Worry about Compartment syndrome! --> increasing swelling and pain, NOT responsive to analgesics --> 4 P's: Pallor, Pulselessness, Paresthesia, Paralysis Dx: XR w/"fracture line and displacement of the humerus" - Occult fracture? You just see displacement of the fat pad Tx: - Nondisplaced? *Cast* - Displaced? *Surgery* - Compartment syndrome? Emergency fasciotomy

Mycoplasma Pneumoniae

Path: High infectious low virulence organism common among young individuals who share close quarters - Peak prevalence in fall or winter - INDOLENT onset (v. Strep Pneumo which is rapid) Pt: - *Macular/Vesicular rash*!!!!!!!!!!!! - Headache - Malaise - Fever - Dry cough - Nonpurulent pharyngitis - Subclinical hemolytic anemia (d/t cold agluttinins) Dx: CXR w/*interstitial infiltrates*, may also have pleural effusion Tx: *Azithromycin*

Stimulant Intoxication

Path: High school, College, student, etc - Can be hard to tell apart from NMS, Serotonin Syndrome Pt: - Hypertension - Tachycardia - Mydriasis - Hyperthermia (fever)!! - Diaphoresis - Restless - Irritability - Insomnia - Prolonged QT Dx: Clinical Tx: *Benzos* (blunt catecholamine release) - NO antipsychotics bc can also prolong QT, impair heat dissipation, and lower seizure threshold.

Open Globe Injury (OGI)

Path: High velocity projectile injury to the eye causes traumatic breakdown in the integrity of the wall of the eye (sclera or cornea). - Also associated with Pt: - Most often characterized by *Teardrop Pupil* - Can have loss of vision - Decreased intraocular pressure - Absent afferent pupillary response - Pain - Tearing - Foreign body sensation - May see extrusion of the vitreous or iris Dx: Fluorescein drops (helps differentiate between OGI and corneal abrasion) Tx: Shield eye + Emergent opthalmologic consultation - Worry about infection, posttraumatic cataract, vision loss

Mucormycosis

Path: Highly destructive fungal infection d/t molds ubiquitous in environment which convert into hyphae in nasal turbinates and resp tree - Rhizopus species - Esp seen in DM patients Pt: - Fever - Nasal congestion - Purulent nasal discharge - Headache - Sinus pain - Necrotic spread to palate, orbit, brain Dx: *Sinus endoscopy* w/cultures and bx Tx: Amphotericin B + Surgical Debridement + Glucose control - Mortality rate is 60% :(

Cholangiocarcinoma

Path: Highly lethal malignancy of the bile duct epithelium - RF = Ulcerative Colitis, PSC, Fibropolycystic liver disease Pt: - Subacute RUQ pain - Weight loss - Biliary obstruction (jaundice, elvated Alk Phos, dilated intrahepatic ducts) - Hyperbilirubinemia - Dark urine - Pruritus - Biliary mass - Typically NO common bile duct dilation (unlike pancreatic cancer which would definitely have if the other sx are present!) Dx: *ERCP* - Elevated *CEA* & *CA 19-9* (like pancreatic cancer) - NORMAL AFP (unlike hepatocellular cancer) Tx:

Congenital Diaphragmatic Hernia

Path: Hole in diaphragm, Bowel in chest - *LUNG is HYPOplastic* bc can't develop fully - Posterior (aka Bochdalech) - Anterolateral (aka Morgagni) Pt: *Scaphoid abdomen* & *Barrel chest* - Respiratory distress - Cyanosis - Unilateral breath sounds - Deviation of heart to the right Dx: XRay Tx: - First? *Intubate* (avoid barotrauma) + *Corticosteroids* (for lung development) + G-tube w/suction (avoid GI distention) - Later? Surgical repair

Thrombotic Thrombocytopenic Purpura (TTP)

Path: Hyaline clots --> Clog vessels and shred up RBCs and platelets - ADAMTS-13 autoantibody attacks ADAMTS-13 (which usually cleaves *vWF*, cleaving platelets off vessel walls, so in it's absence they stick in areas with high shearing force and lead to formation of thrombi) Pt: Classic Pentad "FATRN" - Fever - Anemia (MAHA) --> Jaundice - Thrombocytopenia - Renal failure - Neuro changes (possibly can have stroke) Dx: CBC w/low platelets (after this is how we differentiate from DIC) - Smear w/Shistocytes - NORMAL PT/PTT - NORMAL Fibrinogen - NORMAL D-Dimer Tx: EMERGENT *Plasma Exchange Transfusion* (removes autoantibodies and replenishes ADAMTS-13) "Plasma Exchange for TTP" - NEVER transfuse platelets.. - W/o treatment, fatality rate is 90%

Allergic bronchopulmonary aspergillosis (ABPA)

Path: Hypersensitivity to inhaled aspergillus. Mechanism not well understood. - Cystic Fibrosis patients - Asthma patients Pt: The classic triad - Hemoptysis - Fever - Pleuritic chest pain - Central bronchiectasis results - Eosinophilia Dx: CXR w/ Segmental atelectasis or scattered infiltrates Tx: Steroids and ITRACONAZOLE

Overflow Incontinence

Path: Hypotonic detrusor OR bladder outlet obstruction Pt: - Parapalegic - Complete spinal cord transection - Dribbling throughout the day - Incomplete bladder emptying - No urge or pain. Dx: USD --> Increased post-void residual volume, large, distended thin walled bladder. Tx: *Bethanacol* (M3 agonist) if medical (not spinal cord transection) v. Timed ins and outs (x. q6h they cath themselves) if parapalegic/spinal cord transection

High-Altitude Illness (HAI)

Path: Hypoxia d/t low partial pressure of inspired O2 at high altitude - High altitude = >8,000ft, or >2500m - Happens in 1-2 days of arriving - Respiratory suppressants worsen ventilatory response and worsen HAI Pt: Low O2 causes HYPERVENTILATION --> RESPIRATORY ALKALOSIS - Fatigue - Nausea - Headache - Lightheadedness - Dyspnea Dx: Tx: *Acetazolamide* (helps remove BICARB so normalize pH) - Body will compensate on own in *3 days*

Acute Urticaria

Path: IgE mediated allergic reaction to something causes mast-cell activation in the superficial dermis - Usual allergic causes.... - But also can be IDIOPATHIC and come on for no reason Pt: - Intensely pruritic - Well-circumscribed erythematous plaques Dx: Clinical Tx: *H1-blocker*

Otosclerosis

Path: Imbalance of bone resorption and deposition --> Stiffening of the *stapes* predominantly, along with malleus and incus - *AUTOSOMAL DOMINANT* w/incomplete penetrance Pt: - Younger (~30), - Women, - Asymmetric often - CONDUCTIVE hearing loss --> Weber better in bad ear --> Rinne w/BC > AC --> Paradoxically *Hear better when NOISY than when QUIET* (feature of conductive hearing loss) - *Reddish hue behind TM* (bony resorption exposes underlying blood vessels) Dx: Clinical Tx: Hearing Aids v. Surgical reconstruction of stapes

Immaturity of the hypothalamic-pituitary-ovarian (HPO) axis

Path: Immature axis fails to produce appropriate quantities and ratios of GnRH to produce ovulation Pt: Abnormal uterine bleeding in a female who recently began menstruating - Anovulatory menstrual cycles (so no progesterone and endometrium cont to proliferate on estrogen) - Painless, irregular, HEAVY bleeding (bc endometrium outgrows blood supply) Tx: Progestins ONLY v. Combo OCP - To stabilize endometriums and regulate the menstrual cycle

Hepatic Encephalopathy

Path: Impaired CNS function in patients with CIRRHOSIS in part d/t *neurotoxicity from ammonia* in the setting of impaired liver function - Can be induced by Diuretic therapy and low oral intake --> Lead to HYPOKALEMIA which causes increased production of NH3 by renal cells. - Can be induced by METABOLIC ALKALOSIS --> Converts NH4 to NH3, which is then taken into the brain. - TIPS (for ascites/cirrhosis) increases risk bc NH3 rich blood bypasses the liver. Pt: - Lethargy - Confusion - Asterixis Tx: 1st = FIX CAUSE FIRST!!!! (x. *Replace K+* + IVF) 2nd = *Lactulose* 3rd = Rifaximin (also used for SBO) NOT Neomycin...This was in FA but it is NOT THE RIGHT ANSWER.

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

Path: Impaired absorption of CSF by the arachnoid villi - RF = OCPs, Steroids, Vitamin A Pt: - OBESE WOMEN of CHILDBEARING age (also prepubertal kiddos....) - Holocranial headache, worse when lying FLAT - Increased ICP in an ALERT patient - No focal neurologic deficits except maybe *6th nerve palsy (lateral rectus)* (bc of its long course through the skull to the muscle) --> Diplopia --> Impaired eye abduction - No evidence of other causes of ICP on imaging - PAPILLEDEMA (optic disc edema) --> Blurry vision --> Enlarged blind spot --> Momentary vision loss when bending over, leaning forward, etc. - Pulsatile tinnitus (Whooshing sound in the ears) - *BLINDNESS* is the only significant complication that can occur!!! Dx: First, *MRI or CT* to rule out bleed, mass lesion, etc. (should be normal) - Then, *Lumbar puncture* w/INCREASED CSF OPENING PRESSURE w/o any other abn - DO NOT due Tonometry Tx: *Acetazolamide* + Weight loss - Can add *Furosemide* to this as needed

Cystinuria

Path: Impaired transport of *cystine* and other dibasic amino acids (ornithine, lysine, arginine) by renal tubular and intestinal epithelial cells Pt: - Recurrent stones since childhood - Family history of nephrolithiasis - HEXAGONAL crystals on UA (Radiolucent) Dx: UA w/radiolucent hexagonal crystals - Urinary *cyanide-nitroprusside test* to confirm Tx:

Septic Shock

Path: In response to widespread infection, peripheral vasodilation with leaking of blood vessels. Pt: Bounding pulses (early, hyperdynamic phase), hypotension, tachycardia --> eventually cool and clammy extremities as blood is shunted to organs Dx: Hemodynamic monitoring will show: - Decreased PCWP (left atrial pressure) - Decreased Right Atrial pressure - Cardiac Index and SV increase (to compensate for hypovolemia) --> this makes up the bounding pulses Tx: *Abx + LR* - Give fluid in IV Boluses (500-1000mL) until systolic >90 - Add *Epinephrine* if no evidence of improvement w/fluid resuscitation

Fetal Hydantoin Syndrome

Path: In-utero exposure to an antiepileptic (x. *Phenytoin, Carbamazapine, Valproate*) - Cross placenta and cause low folate and high oxidative metabolites in the fetus Pt: - Cleft lip - Cleft palate - Wide anterior fontanelle - Distal phalange hypoplasia - Microcephaly - Developmental lay - Poor cognitive outcomes Dx: Clinical Tx: - Prevent? *Titrate to LOWEST DOSE for seizure control + Folic Acid*

Phimosis

Path: Inability to retract the prepuce (foreskin) - Physiologic in infants and young children. --> If it is forcefully retracted it can entrap the prepuce and cut circulation off Pt: - Infant w/foreskin - Edema and tenderness of glans penis and prepuce Dx: Clinical Tx: Emergency!! *Prompt reduction of foreskin*

Postpartum Urinary Retention

Path: Inability to void *≥6 hours* after vaginal delivery or ≥6hr after catheter removal post C/S - Causes *overflow incontinence* - RF = Epidural, *Pudendal nerve* injury from prolonged labor, Primiparity Pt: - Inability to sense the need to void - Loss of micturition reflex - Bladder atony - Urinary retention - Dribbling of urine (Overflow incontinence) - Lower abdominal pressure Dx: *Urethral catheterization* - Postvoid residual volume *≥150mL* Tx: *Urethral catheterization* - Most patients regain control/function after this (<1 week)

Oppositional Defiant Disorder (ODD)

Path: Incongruent parenting Pt: - Lie, cheat, steal - Fights authorities - Violates rules - Defiant - Pattern of angry/irritable mood - Temperamental - Hostile - Defiantly break rules - Argumentative/defiant behavior towards authority figures - *DO NOT* hurt people - *DO NOT* hurt animals - NO cruelty or torture Dx: Clinical Tx: Parenting... - Give kid the idea that there is an authority figure

Physiologic Hydronephrosis of Pregnancy

Path: Increase in maternal blood volume requires increased filtration - Then uterine enlargement compresses the ureters at the pelvic brim, causing proximal dilation and hydronephrosis Dx: Renal USD w/*dilation of proximal ureters and bilateral hydronephrosis* R>L Tx: No additional management

Polyhydramnios

Path: Increased amniotic fluid index *≥24cm* - Consider issue with GI tract...unable to swallow fluid (x. esophageal atresia, TEF, etc) - Could be d/t DM - Normal is >5cm Pt: - Uterine size larger than dates - Fetal malposition (x. breech) - Umbilical cord prolapse - Preterm labor - Preterm premature rupture of membranes Dx: Tx: - Mild, asymptomatic, at-term EGA? *Expectant management* - Severe or symptomatic, preterm? *Amnioreduction via amniocentesis*

Type 1 Diabetes Mellitus

Path: Insulin deficiency from autoimmune destruction of the pancreatic beta cells - Common children - Recent illness or hypovolemia can exacerbate the onset Pt: - Polyuria, Nocturia, Enuresis - *Polydipsia* (unlike Addison's) - *Hyperventilation* (unlike Addison's) - Weight loss - Fatigue - Blurred vision - *Abdominal pain* - Diabetic gastroparesis (if has had DM for *>10yr*) - *KETONES* in urine (how we dif from DM2) Dx: Elevated serum glucose OR Glucosuria on UA - If an adult, can get GAD-65 Ab to confirm DM1 (75% have). Tx: *Insulin*

Intrahepatic Cholestasis of Pregnancy (ICP)

Path: Increased estrogen and progesterone levels during pregnancy cause hepatobiliary tract stasis - Increases risk of fetal complications bc bile acids can cross placenta - RF = Prior ICP, Maternal age ≥35, Multiple gestation Pt: *THIRD TRIMESTER* - Pruritus *most severe in palms and soles* (how you dif from basically every other rash in preggo) - RUQ Pain - Alk Phos may or may not be elevated - Fetus? Intrauterine fetal demise :( Preterm delivery, Meconium-stained amniotic fluid, Neonatal respiratory distress syndrome Dx: - Elevated aminotransferases - *Elevated total bile acids ≥10* Tx: *Ursodeoxycholic acid* + Delivery at *37wks* - Antihistamines for symptomatic relief

Venous Stasis

Path: Increased intraluminal pressure with loss of vessel wall tensile strength leads to venous vessel dilation and failure of venous valves. Pt: - Older - Obese - Hx of venous thrombosis, - Erythema - *Warmth* (but BILATERAL unlike cellulitis which is UNIlateral), - Woody induration, - Red/brown discoloration - Fibrosis - Scaling - Weeping - Superficial erosions - Pitting edema - Ulcers at the medial malleolus Dx: Clinical - Confirm w/*Venous Doppler USD*. Tx: Compression stockings, leg elevation, exercise, avoidance of prolonged standing

Compartment Syndrome

Path: Increased pressure within an enclosed fascial space that limits perfusion of muscles and nerves (trauma w/fracture, crush injuries, severe burns, arterial reperfusion) - Blood thinners put at increased risk Pt: - Pain out of proportion (does not respond well to narcotics) - Pain on passive stretch - Paresthesias - Loss of sensation - Motor weakness - Diminished pulses - "wood-like" - Tissue tension - Pallor Dx: - *Measure compartment pressures* --> *Delta pressure <30* (Diastolic BP - Compartment pressure) - If high risk patient, diagnosis can be made on clinical grounds alone Tx: *Urgent fasciotomy* - If full circumference burn? *Escharotomy* - Time to fasciotomy is the most pertinent prognostic indicator

Gender Dysphoria

Path: Individual's internal sense of gender does not match assigned gender at birth. - Results in *DISTRESS or IMPAIRMENT* Pt: Intense persistent desire to be another gender, throughout adolescence. - Desire to be or be treated like opposite sex. - Desire to be rid of secondary sexual characteristics. - Believes they are the opposite sex. Dx: Clinical - Duration *≥6 months* Tx: *Psychotherapy* ± *Hormonal therapy* ± *Gender-affirming surgery* "Multidisciplinary support services and care" - Evaluate patient's safety - Provide nonjudgmental support - Offer further consultations with specialists (gender reassignment)

Orbital Cellulitis

Path: Infection involves intraorbital structures - Staph v. Strep - Bacterial sinusitis (esp Ethmoid or Maxillary) can spread up to the orbit Pt: - Cheek pain - Eyelid erythema - Eye swelling - Chemosis - *Pain w/EOM* - *Proptosis* - *Opthalmoplegia* Dx: *CT scan of orbit* Tx: IV Abx - Consider SURGERY to drain purulent material if present

Emphysematous Cholecystitis

Path: Infection of gallbladder with GAS FORMING ORGANISMS (x. Clostridium) - RF = DM, >50yo, Immunesuppression, Vascular compromise - Worry about gangrene or perforation (would see peritoneal signs) Pt: - Gas in gallbladder WALL and lumen - Air-fluid levels in gallbladder - Maybe pneumobilia (air in ductal system) - Maybe crepitus in RUQ - UNCONJUGATED Hyperbili (d/t Clostridium induced hemolysis) Tx: Emergency Cholecystectomy + *Pip-Tazo*

Meningococcal Meningitis

Path: Infection w/Neisseria Meningitidis - RAPID PROGRESSION (<12hr)!! - Watch out for *Waterhouse-Friderichsen* syndrome Pt: - *Fever*, - Headache, - Vomiting, - *Myalgias*, - *Sore throat* - <12hr = EARLY sx often DO NOT include typical signs...(headache, vomiting, photophobia, nuchal rigidity, petechial rash, etc) - 12-24hr = Petechiae/Purpura, Meningeal signs, *Mottled skin or Pallor* - Complications = Shock, DIC, Adrenal hemorrhage, Death - Adrenal hemorrhage? (Waterhouse-Friderichsen) --> Sudden vasomotor collapse unresponsive to IVF --> Skin rash (large purpuric lesions on the flanks) Dx: Blood cultures + *Lumbar Puncture* Tx: - Infant (<1mo)? *Ampicillin + Gentamicin* - Kiddo (>1mo)? *Cefotaxime + Ampicillin + Vancomycin* ± Steroids - Adult? *Ceftriaxone + Vancomycin* ± Steroids

Human Immunodeficiency Virus (HIV)

Path: Infection with HIV, transmitted by through sexual contact. - Start ART therapy ASAP!! --> Decreases immunosuppression (and therefore risk of infectious diseases) --> Decreases inflammatory diseases caused by viral inflammation (HIV nephropathy, malignancy, neurological disease) --> Decreases oncogenic viral reactivation (Lymphoma, Kaposi sarcoma) --> Reduces risk of transmission to others Pt: Looks like Mono but they have Diarrhea... - Presenting symptom may be *THROMBOCYTOPENIA* with nothing else wrong....in 10% of patients - Fever - Myalgias - Arthralgias - Fatigue - *Rash (Pink/red macular oval lesions that resolve w/in week)* --> "Maculopapular" on trunk, neck, face. --> NO palms/soles. - *Painful oral ulcerations* - Diffuse lymphadenopathy - Sore throat - Headache Dx: Test for HIV!!! Usually this is done before checking for anything else Tx: - If no immunity to HepA or HepB yet, *Vaccinate* - PCP prophylaxis when CD4 <200: *TMP-SMX* - Toxo prophylaxis when CD4 <100: *TMP-SMX* - Post-exposure prophylaxis? Two NRTI (Tenofovir + Emtricitabine) + integrase inhibitor (v. protease inhibitor v. NNRTI) --> Start w/in first few hr of exposure + HIV serology immediately, then at 6wks, 3mo, 6mo Continue for 28 days (4wks)

Histoplasmosis

Path: Infection with Histoplasma, a fungi found in the Midwestern and Central US (Ohio & Mississippi River Valley) - Bird or bat droppings - Commonly seen in immunocompromised patients --> CD4 *<100* Pt: - Fever, - Fatigue, - Chills, - Headache, - Myalgias, - Dry cough, - Weight loss - *Mucocutaneous* lesions - Hepatosplenomegaly - *Pancytopenia* (d/t bone marrow infiltration) - Hx of spelunking/caves in Midwest & NORTH EAST - Elevated Liver enzymes - Elivated LDH Dx: *Histoplasma URINE Antibody Testing* - Bronchoscopic Bx w/ "Non-caseating granulomas with *Narrow Based Budding* yeast forms" (Coccidio is spherules w/endospores) - CXR w/ Bilateral alveolar opacities or Interstitial infiltrates (Reticulonodular or Miliary) & Mediastinal and Hilar lymphadenopathy Tx: Usually resolves on own - Mild or limited disease? *Itraconazole* - Severe? *Amphotericin B* --> then after two weeks, switched to Itraconazole for one year

Bronchiectasis

Path: Infectious insult followed by delayed clearing --> Irreversible dilation and destruction of bronchi ...then they can be easily infected again and the process repeats. - d/t Recurrent respiratory infections - Associated with *Cystic Fibrosis* Pt: - Chronic cough - Inadequate mucus clearance - Copious mucopurulent sputum --> May have streaks of blood - Fever - Hemoptysis - Crackles on Physical Exam --> If *Upper lobes*? Think CF - Digital clubbing - Weight loss Dx: HRCT w/*Destruction and dilation of the airways* (definitive diagnosis made this way) - CXR w/*Bronchial dilation and irregular peripheral opacities* Tx: - Exacerbation? Abx

Tethered Cord Syndrome

Path: Inferior end of spinal cord becomes attached to spine during development, and fails to rise with growth. - Closely associated with other issues involving closure of the spinal cord --> x. *Spina bifida occulta* (aka Closed Spinal Dysraphism) Pt: - Stretch-induced dysfunction of the spinal cord. - Butt/Back/leg pain progressively worse with activity (or with growth spurts) - Weakness in LE - Muscle atrophy - Hyporeflexia in LE - *New onset scoliosis* - *Lumbosacral cutaneous abnormality* (x. subcutaneous lipoma) - Pes cavus - Hammer toe - Footdrop .......looks like Charcot-Marie-Tooth but with autonomic dysfunction. - *Bowel/bladder dysfunction* (how dif from Charcot-Marie-Tooth) Dx: *MRI* Tx:

Right Ventricular Myocardial Infarct

Path: Inferior wall infarct (*II, III, AVF*) causes contractile dysfunction --> "T-wave inversion" in those leads with normal setup - D/t occlusion of the *right coronary artery* (5x mc) or Left circumflex artery Pt: - *Atypical EPIGASTRIC pain*, rather than substernal - Nausea - No SOB, bc right ventricle - *BRADYARRHYTHMIA* bc right coronary artery supplies SA and AV nodes - *HYPOTENSION* - Second degree AV Block Mobitz II (normal P-QRS for a couple beats, then P with dropped QRS) Dx: *RIGHT-Sided Precordial ECG*!!!!! - Will see *ST-segment elevation in lead V4-46R* Tx: *IVF* - RV is highly sensitive to preload under these conditions so we *DO NOT give Nitrates*!!!!.

Blepharitis

Path: Inflammation at the eyelid margin, most prominent at the opening of the meibomian glands. - RF = *Seborrheic dermatitis*, Rosacea, Allergies, Bacterial infection, Viral infection, Demodex mites Pt: - Burning or itching of the lids - Discharge, with crusting of eyelashes in the morning - Foreign body sensation in the eye - Redness and swelling of lid margin - Scaling of lid margin - Conjunctiva may or may not be inflamed - Lipoid plugs at lid margin (dif from Allergic Conjunctivitis bc would see irritation of the eye, rather than the lid margin) Dx: Clinical Tx: *Warm compress*, Gentle scrubs, Lid massage

Pes Anserine Bursitis

Path: Inflammation of the pes anserine bursa located at the MEDIAL aspect of the knee. - The pes anserine bursa is a fluid filled sac acts as a cushion for the tendons of the.....at their distal point of insertion on the shin bone (tibia). --> Sartorius, --> Gracilis, and --> Semitendinosus muscles - Typically caused by overuse or a contusion (x. *Running*) - RF = Obesity, DM, Knee osteoarthritis, Angular deformity of the knee Pt: - Medial knee pain - Focal tenderness just distal joint on tibia - Painless, normal ROM (characteristic of bursitis) - Hx of overuse Dx: Clinical Tx: NSAIDs + Quadriceps & Hamstring training exercises

Thromboangiitis Obliterans (Buerger Disease)

Path: Inflammation of the small & medium-sized arteries and veins because of nonatherosclerotic thrombotic occlusion, ischemia, and infarction. Pt: - Young patients - Smokers - Distal extremity ischemia and gangrene. Dx: Diagnosis of exclusion.....everything is usually normal - *Angiography* confirms occlusion of small and medium sized arteries. Tx: Complete smoking cessation

Dacrocystitis

Path: Inflammation of the tear sac, can be seen in babies and elderly. Pt: - Inflammation of the tear duct - Warmth - Redness - Swelling - Crusting of eyelid - Purulent eye drainage (how dif from tear duct obstruction)

Idiopathic Transverse Myelitis

Path: Inflammatory cells infiltrate a segment of the spinal cord leading to death and demyelination - Usually follows *recent infection* of no particular organism - RAPIDLY PROGRESSIVE Pt: Sudden onset - Motor *weakness* that goes from flaccid LMN to spastic UMN signs (how you dif from Guillain-Barre Syndrome) - *SENSORY DYSFUNCTION* severe and at a distinct sensory level (how you dif from Guillain-Barre Syndrome). - *Autonomic dysfunction* - NO electric shock sensations ....Think of it as GBS but acute and with more sensory sx Dx: MRI w/T2 hyperintensity and NO masses or lesions Tx: *High dose IV glucocorticoids* - If doesn't work or severe motor sx? Plasmapheresis - Persistent defects are common

External Hordeolum (Stye)

Path: Inflammatory disorder of *eyelash follicle or tear gland* - Often d/t infection w/Staph, but can also be sterile Pt: "Hordeolum is a wh*re" - Erythematous tender nodule at the lid margin - PAINFUL (compared to painless chalazion) Tx: Warm compress - I&C if does not resolve

Internal Hordeolum (Chalazion)

Path: Inflammatory disorder of *meibomian gland* - Less common Pt: - Tender nodule at the palpebral conjuctiva - PainLESS (compared to painful hordeolum) Tx: Warm compress - I&C if does not resolve

Shigella

Path: Ingestion of contaminated food or water - Low infectious dose required for person to person spread Pt: - Fever - Abdominal pain/intestinal cramping - Watery diarrhea turns bloody, mucus - *Seizures* - Rectal prolapse - Bacteremia - HUS Dx: *Stool culture* Tx: *IVF* + *Abx* - Symptoms usually resolve in one week

Carbon Monoxide Poisoning

Path: Inhalation of car exhaust or victim of fire - CO binds to hemoglobin with greater affinity than O2 - Left shift with decreased O2 unloading to tissues - O2 disrupts oxidative phosphorylation in mitochondria Pt: - Anion Gap Metabolic acidosis d/t lactic acidosis from tissue hypoxia - *Pulse oximetry is NORMAL* (bc cant differentiate between oxyhemoglobin and carboxyhemoglobin) - Bilateral *hyperintensity of globus pallidus* (most sensitive to hypoxia) - Headache - Dizziness - Confusion - Seizures - Pulmonary edema - Signs of cardiac ischemia (troponin, ECG changes) - Bright cherry lips (also seen in cyanide poisoning) Dx: *ABG* w/carboxyhemoglobin level Tx: *High flow O2*...monitor for ≥4hr, if no improvement, hospitalize

Vaginal Hematoma

Path: Injury to the uterine artery (supplies 30% of blood to uterus) during operative vaginal delivery, or birth of infant >4kg - Potentially life-threatening postpartum complication - RF = Large infant, Operative vaginal delivery, Pt: - Hypovolemic shock - Hypotensive - Tachycardia - Pale - Diaphoretic - "*Large purple*" Protruding vaginal mass (blood collects w/in paravaginal tissue) - Minimal vaginal bleeding Dx: Clinical Tx: - Not expanding? *Observe* - Expanding? *Uterine artery embolization*

Orthostatic Hypotension

Path: Insufficient constriction of blood vessels in the LE upon standing - Some *Baroreceptor sensitivity* is LOST w/age Pt: - Hypotensive upon standing - May be lightheaded, dizzy Dx: Postural decrease in BP by *≥20 systolic* and *≥10 diastolic* Tx: Increase fluids

Chronic Bacterial Prostatitis

Path: Intraprostatic reflux of urine allows bugs (E. Coli mc) to reflux to prostat - RF = Smoking, DM Pt: - Young/middle aged men - Recurrent sx of UTI (that improve w/Abx) - Pain with ejaculation - Pyuria - Bacteriuria - Prostate swelling or tenderness, OR NORMAL!!! Dx: Clinical - Confirm w/*Prostate massage*, then evaluate fluid (bacteria before massage < bacteria after massage) Tx: *6 or more weeks* of Abx (x. Fluoroquinolone)

Sydenham Chorea

Path: Involuntary, unpredictable contractions of the limbs and face d/t abnormal signaling within the basal ganglia - Kiddos? d/t *Group A Strep* infection --> Antistrep Abs and host neuronal antigens cross react. Pt: - MC in GIRLS - Onset months after GAS infection - Abnormal, jerky movements - Disappear during sleep - Hypotonia - Behavioral changes --> Irritability --> OCD behaviors Dx: Throat culture + *Antistreptolysin O* titers + *Anti-DNAse* titers - Titers can be detected for months after the infection - Get Echo + ECG to r/o rheumatic fever Tx: Self-resolves within months

Posterior Urethral Valves

Path: Irregular thin membranes of tissue located within the male posterior urethra that do not allow urine to exit the urethra - Mcc of urinary tract obstruction in MALE newborns - "like BPH for babies" Pt: - Baby *gaining weight* in first few days (urine) instead of losing it. - Reduced urine output. - Distended bladder ("suprapubic midline mass") - Distended abdomen - Weak urinary stream - Grunt w/urination - LUNG HYPOPLASIA (d/t oligohydramnios)!!! --> Respiratory distress Dx: *Renal & Bladder USD* - If dilated bladder and bilateral hydroureters and hydronephrosis then *Voiding Cystourethrogram* to r/o reflex Tx: SURGERY to fix. - Catheter for symptomatic relief

Brain Death

Path: Irreversible cessation of all cerebral brainstem activities - The legally acceptable definition of death - Mcc in adults is Traumatic Brain Injury Pt: - No cranial nerve reflexes - No motor responses originating from the brain - Movements from *spinal cord* (x. monosynaptic DTRs) may still be observed!! Dx: Neuro exam shows brain death + *Apnea test* (remove from ventilator and no respiratory response)

Thalassemia

Path: Issue w/GLOBIN (not heme, so labs are normal) - Mediterranean? *BETA* - S/E ASIA? *ALPHA* - MINOR? Asymptomatic - MAJOR? Transfusion dependent Dx: Since all normal....*get Hgb ELECTROPHORESIS* - Target cells - NORM/increased Fe - NORM/increased Ferritin - NORM/decreased TIBC - *Elevated RBC counts* (how you dif from iron deficiency) HgbA1 = 2 alphas & 2 betas BETA THAL: Has 2 alphas w/something else in place of beta ALPHA THAL: alphas can't be anything else...so Hgb electrophoresis looks NORMAL (diagnosis of exclusion) -->"Gamma tetramers"? *Hemoglobin Barts* (usually not compatible with life) Tx: - MINOR? *None* - MAJOR? *RBC Transfusions* --> if develop iron overload then tx w/ *Deferoxamine* (not phlebotomy, thats for hemochromatosis)

Developmental Hip Dysplasia

Path: Issue with acetabulum growing around the femur - RF = Breach, Female, Caucasian, Family history Patient: NEWBORN Dx: Clicky hip vs. Leg length discrepancy vs. Asymmetric inguinal skin folds - Asymmetry w/o clunk could return in 2-4wks - *USD at 4weeks* CONFIRMS!!!! Tx: *Harness* before 6 months has favorable prognosis - F/up XRay at 4 months

Renal Artery Stenosis (RAS)

Path: Kidney thinks it's volume down so tries to reabsorb more volume. D/t two flavors - Atherosclerosis - FMD Pt: Old man w/atherosclerosis v. Young woman w/FMD - Severe, persistent HYPERtension - Failed 2+ strong antihypertensives --> After addition of *Ace-i or ARB* the kidneys tank!!! - HYPOK+ - Lateralizing abdominal bruit - Recurrent flash pulmonary edema Dx: *Renal Doppler USD* (to locate) - Confirm w/*Aldosterone:Renin <10* - Best? Angiogram Tx: - FMD? *Stent* - Atherosclerosis? *Ace-i/Arb ± Aldosterone antagonist* (even if 80% occlusion, can still use them!!!, just monitor closely) --> Then if refractory to that, recurrent flash pulm edema, or recurrent CHF? *Stent*

Achalasia

Path: LES that won't relax Pt: Knot or ball of food stuck at LES junction Dx: *Manometry* - Next step? *Barium swallow* (w/BIRD'S BEAK esophagus) - Then *EGD + Bx* (to rule out pseudo-achalasia which is cancer!!!) Tx: *Heller Myotomy* --> Muscles of LES are cut allowing for passage of solids and liquids - If bad surgical candidate? Botox

Postpartum Thyroiditis

Path: LIKE *SILENT/PAINLESS THYROIDITIS* but following childbirth. - Can occur within *12 MONTHS* of delivery!!!!! - Inflammation of the thyroid gland following childbirth (7-8% of women) Pt: FIRST 6 MONTHS post-birth (or within 12 mo) - Painless - *Enlarged thyroid* (how you dif from exogenous intake) - Can be hyper then hypo, just hyper, or just hypo - HYPO? --> Hypercholesterolemia --> Hyponatremia Dx: *(+) TPO-Ab assay* (like Hashimoto's) - Decreased TSH - Increased T3 - Increased T3 - LOW radioactive iodine uptake (bc not making new thyroid, is releasing it) Tx: Self-limited (unlike Hashimoto's) and returns to normal after a few months. - So can tx symptomatically with *Propanolol* (if hyper)

Narcolepsy

Path: LOW CSF levels of *orexin/hypocretin* Pt: - Excessive daytime sleepiness with lapses into sleep - *Hallucinations while falling "GOing" asleep* (hypnoGOgic hallucinations) - *Hallucinations upon waking* (hypnopompic) - Cataplexy (loss of muscle tone in response to intense emotion) - Decreased sleep latency - Sleep paralysis - *Wake up feeling refreshed after passing out* (bc they go straight into REM sleep) Dx: LOW *Orexin/Hypocretin-1 levels in CSF* - Confirm w/*Polysomnography* (specifically, *multiple sleep latency test*) - Frequency of *≥3x/week* - Duration for *≥3 months* Tx: *Modafinil*

Congestive Heart Failure (CHF)

Path: LV systolic or diastolic dysfunction - RF = Smoking, HTN, CAD, Cardiorenal syndrome (renal disease w/fluid overload), Renal artery stenosis. Pt: - S3, - Displaced PMI - Dyspnea - Orthopnea - Paroxysmal nocturnal dyspnea, - JVD, - Bibasilar Crackles, - Peripheral edema, - Weight gain, - Hepatosplenomegaly, - Abdominal pain. Dx: 1. *BNP* - Could consider also PCWP 2. Echo (EF - elevated means diastolic dysfunction, decreased means systolic dysfunction) 3. Left Heart Cath (determines whether ischemic or not) - if ISCHEMIC then give *ASA + STATIN* + (other meds below) Tx: CHF STAGES Stage I: No sx - Limit fluid (<2L), Limit salt (<2g), BBlocker, Ace-i/Arb Stage II: No Sx w/ADL - Limit fluid (<2L), Limit salt (<2g), BBlocker, Ace-i/Arb, Loop diuretics Stage III: Sx w/ADL - Limit fluid (<2L), Limit salt (<2g), BBlocker, Ace-i/Arb, Loop diuretics, ISDN + Hydralazine, Spironolactone Stage IV: Sx ALL THE TIME - Limit fluid (<2L), Limit salt (<2g), Inotropes...won't live more than year...inotropes to get them through to Heart Transplant. DO NOT give BBlockers if CHF!! *If EF <33% and NOT Stage IV HF, then get AUTOMATED INTERNAL CARDIAC DEFIBRILLATOR (AICD)* Exacerbation? Dx: CXR, ECG, BNP, Troponin, PCWP - If neg? Not HF, think of something else - If ECG + Troponin positive? MI --> MONABASH Tx: LMNOP Lasix Morphine Nitrates O2 Position

Aortic Stenosis

Path: LVH (concentric becomes eccentric w/time d/t limited O2 supply to walls) - *>70yo*? Degenerative calcification of the valve leaflets - *<70yo*? Bicuspid aortic valve!!!! (also cause Aortic Regurgitation) - Rheumatic heart disease can cause - Atherosclerosis Pt: Old men w/atherosclerosis, chest pain, CHF, EXERTIONAL syncope - Not symptomatic (including LVH) unless valve area *<1cm* - *Pulsus parvus and tardus* (delayed and diminished carotid pulse) --> Parvus means decreased amplitude --> Tardus means delayed - Murmur radiates to CAROTID ARTERIES - Systolic ejection murmur at BASE of heart - Left ventricular hypertrophy - MILD/MODERATE? *Early-peaking systolic murmur* - SEVERE? *Late-peaking systolic murmur* or *Soft and single S2 during inspiration* (combo of stenosis and increased volume during insp delay puts A2 at same time as P2) Dx: Auscultation --> SYSTOLIC, 2nd intercostal space on right, *Crescendo-decrescendo* murmur w/radiation to carotid arteries Tx: - SYMPTOMATIC? *Replace*!!! - ASYMPTOMATIC? --> SEVERE (w/Valve area *<1cm*)? *Serial echo q6-12m* once they become symptomatic you replace it --> LVEF *<50%* or undergoing other *Cardiac surgery*? *Replace*

Chronic Granulomatous Disease (CGD)

Path: Lack of *NADPH oxidase activity* (oxidative burst) --> impotent phagocytes (*NEUTROPHILS*!!!!...would be low despite signs of infection) - X-linked Recessive Pt: Susceptible to *catalase (+) organisms* (x. Staph, Serratia, Burkholderia, Aspergillus, Nocardia) - Recurrent SKIN, SOFT TISSUE, LUNG infections - Normal lymphocytes - Normal Ig, B cells, T cells Dx: *Dihydrorhodamine (DHR) oxidation test* Flow cytometry w/COLORLESS results (green is normal) - "Organism-filled segmented neutrophils" (d/t ineffective intracellular killing) Tx: 1) *Prophylactic TMP-SMX* 2) *IFN-gamma* or bone marrow transplant?

Primary Ovarian Insufficiency

Path: Lack of menses for *≥3 months* in those with previously regular cycles - Accelerated ovarian primordial follicle depletion (decreases estrogen) - Unknown cause - RF: Turner Syndrome, *HYPOthyroidism*, Fragile X Syndrome Pt: - *<40yo* (if >40yo then menopause!!) - *Elevated FSH* (no feedback inhibition from estrogen) - Minimally rugated vagina - Secondary amenorrhea - Could be a fragile X gene carrier - Hot flashes, etc Dx: No response to Progesterone challenge test (indicates there is no estrogen) & Elevated FSH Tx: Estrogen-containing therapy (to protect bones, etc) - If trying to get preggo? *In-vitro Fertilization v. Ovum donor*

Takayasu Arteritis

Path: Large vessel vasculitis w/mononuclear infiltrates and granulomatous infiltration of the vascular media. --> Leads to *arterial wall thickening with aneurysmal dilation, or narrowing and occlusion*. - Aka "Pulseless disease" Pt: - Asian women <40yo - Fever - Arthralgias ("Fleeting joint pains") - Weight loss - Arterio-occlusive manifestations (mc in UE) --> Claudication --> Distal ulcers - Blood pressure discrepancies - Pulse deficits - Bruits - Anemia - Elevated ESR, CRP Dx: - CXR w/widened mediastinum - MRI or CT w/thickened large artery walls and narrowing of the lumen Tx: *Glucocorticoids*

Macular Degeneration

Path: Leading cause of blindness in industrialized countries. Atrophic v. Exudative types... - Atrophic/DRY: Sores on macula region - Exudative/WET: New vessels that leak, bleed, scar retina - RF = Cigarette smoking, Increasing Age Pt: - DRY? --> Slowly progressive vision loss in one or both eyes --> Starting with *Central vision loss* "Central SCOTOMA" - WET? --> Unilateral aggressive vision loss --> Starting with *straight line distortion* "wet and wiggly" - Issues with driving and reading Dx: *Drusen* seen in retina Tx: ANTIOXIDANTS - Quit smoking - Control BP

Folic Acid Deficiency (B9)

Path: Leafy greens, increased demand for pregnancy - 3-6wk store in human body Pt: Tea + Toast diet - Megaloblastic anemia Dx: Low folic acid - But if equivocal, get Methylmalonic acid (should be LOW/NORMAL) Tx: 1mg Folic Acid po qd - If prior hx of neural tube abnormality or other RF, women take 4mg before pregnancy (needs to be taken at least *3mo* before getting pregnant). *If Folate COMBO deficiency w/B12* --> Megaloblastic anemia will IMPROVE!! w/Folate treatment --> BUT NOT improvement w/neuro issues from B12 deficiency (they can actually be precipitated or worsened by giving Folate)

Uterine Fibroid Degeneration

Path: Leiomyomata uteri (fibroids) grow rapidly during pregnancy d/t increased estrogen and progesterone - D/t increasing blood supply to baby, they outgrow blood supply and cause fibroid infarction and necrosis Pt: - *Contractions* (bc degenerating fibroids release prostaglandin) - Fundal tenderness - Tender mass - Severe abdominal pain - Leukocytosis Dx: USD Tx: Conservatively managed w/*acute pain control* (Indomethacin <32 weeks)

Lens Dislocation

Path: Lens detaches from the ciliary body - Blunt force trauma can induce - Associated with *Marfans* (upward) and *Homocystinuria* (downward) Pt: - Poor vision - Tremulous iris during eye movement Dx: Lens displacement on slitlamp Tx: Glasses v. Surgery

IgA Vasculitis (Henoch-Schonlein purpura)

Path: Leukocytoclastic vasculitis characterized by the deposition of IgA immune complexes in small vessels - Often preceded by mild upper respiratory infection Pt: - "Nonblanching palpable purpura on the buttocks and LE" --> Coalesces and darkens over days, NOT associated with thrombocytopenia or coagulopathy - Arthritis/Arthralgia (hips, knees, ankles) - Abdominal pain (bowel wall inflammation) --> Intussusception (Ileoileal) - GI bleeding --> Anemia - Renal disease (can present delayed by days or months!!!) --> Hematuria --> Red cell casts --> Nonnephrotic proteinuria - LE edema - Scrotal pain and swelling - ESR is NORMAL Dx: *Urinalysis*....possibly Serial UA's to monitor development of renal injury. Tx: Supportive - Severe? *Glucocorticoids*

Sertoli Leydig Cell Tumor

Path: Leydig cells make testosterone - Elevated testosterone (how you dif from Adrenal causes) suppresses LH and FSH. Pt: - Precocious puberty - Virilization (voice deepening, clitoromegaly, hair thinning, facial hair) - Abnormal uterine bleeding - Amenorrhea Dx: - Elevated testosterone (like PCOS, but more extreme!!!) --> Causes suppression of GnRH and therefore FSH/LH - USD of ovaries Tx: *Unilateral salpingoophorectomy* - If in puberty? f/up GnRH analog

Fournier Gangrene

Path: Life threatening *Necrotizing Fasciitis* that quickly progresses to sepsis and death without intervention - Mc d/t cutaneous breakdowns in the perineal or genital region --> Polymicrobial colonic or genital organs then infect and cause microthrombi in cutaneous vessels = gangrene - RF = Poorly controlled DM, Obesity Pt: RAPID!!!!!!!!! - Swelling, tenderness, *crepitus* in the perineum, scrotum, lower abdomen - High fever - Hypotension - Leukocytosis - Acidemia - Renal insufficiency - Coagulopathy Tx: *Broad spectrum IV Abx* + *IVF* + *URGENT SURGERY*

Progressive Multifocal Leukoencephalopathy (PML)

Path: Life threatening neurologic disease caused by reactivation of the *JC Virus* - Virus spreads to the CNS and lyses oligodendrocytes --> *White matter demyelination* Pt: - Poorly controlled HIV --> *CD4 <200* - AMS - Motor deficits - Ataxia - Vision abnormalities Dx: CT w/*Nonenhancing hypodense asymmetric white matter lesions* with NO surrounding edema - Confirm w/*LP* (CSF w/JC virus) Tx: *Antiretroviral meds* can sometimes prolong life

HSV Encephalitis

Path: Life-threatening inflammation of the brain parenchyma - Symptoms develop acutely, *<1 wk* - Commonly caused by *HSV* --> Primary infection? Spread from olfactory bulb --> Reactivated infection? Spread from trigeminal nerve Pt: - Fever - Headache - Seizure - Altered mental status - FNDs - Hyperreflexia Dx: *PCR* from CSF - HSV? *Temporal Lobe* hemorrhage or edema Tx: - HSV? *Acyclovir*

Thyroid Storm

Path: Life-threatening thyrotoxicosis in patients with undiagnosed or inadequately treated hyperthyroidism. - *Surgery* (doesn't have to be on thyroid), Trauma, Childbirth, Infection can trigger. Pt: - Tachycardia - Hypertension - Cardiac arrhythmias (x. A Fib) - *Fever* (up to 104-106F) - Anxiety - Altered mentation - Seizure - Nausea - Vomiting - Hepatic dysfunction - Tremor - *Lid lag* - Goiter - *Elevated CK* Dx: Thyroid function studies w/HYPERthyroidism Tx: *Propanolol + PTU + Glucocorticoids* - *+ Iodine solution* (must be given >1hr after PTU administration)

Caustic Ingestion

Path: Local contact with a caustic substance Pt: - Erythematous oropharynx - Ulcerated oropharynx - Drooling - Pain - Hoarsness - Airway compromise - If full thickness, can perforate and cause mediastinitis or peritonitis Dx: Tx: Assess A, B, C --> Remove clothes --> Hospitalize --> EGD w/in 24hr (not too soon though and not too late, risk not seeing anything or a perf) - F/up Esophageal or Gastric strictures - F/up SCC (33%)

Diabetic Foot Ulcer

Path: Long standing DM with poor diabetic control. Risk is greatest in those with... - Diabetic neuropathy (reduces ability to sense ulcer) - Peripheral vascular disease (reduces immune recruitment and ulcer healing. - Bugs = Pseudomonas, Aerobic gram positives cocci, Enterococci, Anaerobes - Can be complicated by underlying *Osteomyelitis* --> Can arise WITHOUT evidence of infection!!! Bc DM patient's have a suppressed response to infection Pt: Dx: - *XR v MRI v. Bone Biopsy* to r/o osteomyelitis IF.... --> Deep ulcer (probe to bone) --> Longstanding (>1wk) --> Large (>2cm) --> ESR/CRP elevated --> Signs of soft tissue infection --> Sinus drainage (purulent fluid coming out of wound) Tx: - Osteomyelitis? *Surgical debridement + Abx* --> Amputation only if there are significant complications such as ischemia, necrosis

Tardive Dyskinesia

Path: Long term antipsychotic use (worse with first generation and clozapine) causes dopamine receptor *SUPERSENSITIVITY* from chronic blockade. - Often IRREVERSIBLE (unlike Dystonia) - Commonly first appears after dose reduction or discontinuation of antipsychotic Pt: - Facial grimacing - Foot tapping - Inversion movements - Trunk, Limb, Face dyskinesia Dx: Clinical - Usually after PROLONGED (*>6mo*) course of anti-psychotics Tx: *Taper and stop antipsychotic* if possible OR switch to antipsychotic w/less EPS (x. Quetiapine, Clozapine) - Second line: Try *Valbenazine* or *Deutetrabenazine* (recently approved by FDA for TD) - Screen them along the way via *AIMS scale* to see if they are starting to develop sx so you can STOP rx

Ectocervical Cancer

Path: Long term tobacco use, HPV 16, 18, others - E6 inhibits P53 - E7 inhibits Rb - AIDS increases risk --> Is an AIDS DEFINING ILLNESS in HIV+ folks --> cervical dysplasia rapidly progresses to cancer Pt: Unvaccinated and Unscreened - Repeat infections v. Chronic (bc over 90% of women clear HPV infection over 2 years) - Vaginal discharge - Ulcerative lesion on cervix - Intermenstrual bleeding - Perimenopausal v. Postmenopausal - Post-coital bleeding - Fungating mass on speculum exam - Lower back pain - "Lower uterine segment mass that extends laterally" - Bilateral hydronephrosis Dx: PapSmear v. Colposcopy v. Biopsy - If you see a frank lesion on cervix go ahead and just *Biopsy* it. - Histology? look for Ki96, P16 or mitosis --> CIN1 (LSIL) --> CIN2 (precancerous) --> CIN3 (HSIL) - Cancer? Stage clinically (a's go down, b's go out) --> Stage 1 = Ectocervix alone --> Stage 2a = Upper 2/3 of vagina --> Stage 3a = Lower 1/3 of vagina --> Stage 2b = Out transverse cervical ligament --> Stage 3b = Onto pelvic sidewall --> Stage 3c = Lymphatic spread --> Stage 4b = Encroaching on nearby organs - w/*Endometrial Cells*? --> *<45yo* = NORMAL --> *≥45yo* = ABNORMAL! Need *Endometrial bx* Tx: - Squamocolumnar not sufficiently visualized on COLPOSCOPY? *Endocervical curretage* if high likelihood of dysplasia - LSIL/CIN1? *HPV co-testing* - Early? *LEEP* if CIN2-3 - Late? Surgery, Chemo, RT - Prevent? Vaccine, screen (*21yo q3yr*, or co-testing *30yo q5yr*...don't continue after 65yo) --> Depending on risk of cancer you return more or less frequently - Preggo? You will do COLPOSCOPY!!!! Then after consider LEEP if not satisfactory...but try not to

Diabetic Nephropathy

Path: Long-standing DM2, high serum glucose causes hyaline arteriosclerosis of EFFERENT arteriole > AFFERENT, so GFR increases and microalbuminuria occurs (*Hyperfiltration* at first) - Then as disease progresses GFR falls and creatinine rises. - Protein losses leads to increased *Albuminuria* Pt: - Nephrotic syndrome - LE edema - Facial edema - Periorbital edema - Nephrotic range proteinuria - Glomerular hyperfiltration Dx: Screen w/*Urine ALBUMIN:CREATININE ratio*!!!!!! - Screen AT DIAGNOSIS for DM2, then YEARLY - Screen 5 YEARS AFTER diagnosis for DM1, then YEARLY - Renal bx w/longstanding changes in kidney at *GLOMERULAR BASEMENT MEMBRANE* (from NEG and reactive oxygen species) --> Glomerular basement membrane fibrosis & thickening, --> Interstitial fibrosis and mesangial thickening, --> Nodules (Kimmelstiel-Wilson) Tx: If *30-300*!!!! *Albumin:Creatinine ratio* (moderately increased) then tx w/*ACE-i/ARB* or SGLT-2i to *<130/80* --> Prevents progression to ESRD - And tight glucose control with HgbA1c *<7*

Methotrexate Induced Lung Injury

Path: Looks like fibrotic lung disease, adverse effect of methotrexate --> Similar mechanism to Hypersensitivity Pneumonitis - *Granulomatous lymphocytic lung infiltration* - Idiosyncratic (not dose dependent) Pt: - Exertional dyspnea - Hypoxemia - Pulmonary infiltrates - Reticular thickening (fibrosis) Dx: *BAL w/Lymphocytic pleocytosis* - R/o infection - Overlapping patterns on imaging (Groundglass, Fibrosis, Consolidations) Tx: Corticosteroids - F/up by confirming improvement after Methotrexate cessation

Angelman Syndrome (AS)

Path: Loss of MATERNAL Chromosome 15 (15q11) - "Mom's lost, but she's an angel" Pt: Also known as the "Happy puppet" Syndrome - Short stature - Intellectual disability - Frequent smiling - Laughter - Hand flapping - Ataxia - Seizures - Fascination with water and shiny objects

Prader-Willi Syndrome

Path: Loss of PATERNAL Chromosome 15 (15q11) - "Prader lost his Papa" Pt: - Poor suck and feeding problems in infancy - Almond eyes - Hypogonadism - Hypotonia - Compulsive binge eating - Obesity problems Dx: *Karyotype* & Methylation studies, then FISH and satellite probes Tx: Structured eating environment + Strict limitation of food intake - Screen for OSA and DM

Cirrhosis

Path: Loss of liver function (three categories) - *Synthetic* = Clotting factors, Cholesterol, Proteins - *Metabolic* = Metabolism of drugs and corticosteroids, Detoxification - *Excretory* = Bile - Activation of RAAS causes retention of *sodium* and water. - Increases risk for HCC Pt: - Caput medusae - Splenic enlargement - Splanchnic vasodilation --> Causes "Hyperdynamic circulation", where SVR is decreased so heart increases CO and HR in response - *Hepatic Hydrothorax* (pulmonary effusion d/t protein poor fluid passing through diaphragmatic defects) METABOLIC (don't metabolize estrogen) - Spider hemangiomas - Palmar erythema - Gynecomastia - Testicular atrophy - Decreased body hair EXCRETORY - Jaundice SYNTHETIC - Decreased production of clotting factors - Edema d/t decreased production of proteins Dx: USD w/FibroScan Tx: - Ascites? *Furosemide + Spironolactone + Salt restriction + ↑Protein* --> DO NOT give Ace-i or ARB because the RAAS system is the only way these patients maintain organ perfusion. - F/up HCC w/*q6mo Abd USD* - Varices? *BBlocker* (nadolol v. propanolol)

Hyperkalemia

Path: Low ALDOSTERONE state (Ace-i, ARB, Aldo-i), Iatrogenic, Ingestion + CKD, ESRD, Artifact (Hemolysis!!) Pt: Muscle weakness, flaccid paralysis, decreased DTRs Check EKG! - First? see Peaked T - Then? Progressive lengthening of the PR interval (*High-degree AV block*) - Then? Absent/flattened p-waves - Then? Wide QRS (Prolonged QT --> also caused by HYPOCa2+) - Finally? *Sine wave pattern* (see pic) --> HYPERKALEMIC EMERGENCY! Work-up - Recheck K+ - If still elevated then, EKG - EKG changes or *K>6.5*? Emergent!! --> Step... 1. Stabilize!!! (IV *CaCl* or *CaGluconate*) --> protects from cardiac arrhythmias while you start #2 and #3. 2. temporize (*Insulin + D50...to shift K+ into cells*!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!), 3. reduce total body K+ (loop diuretics v. Kayexalate v. hemodialysis) - No EKG changes or *K<6.5*? Urgent --> Reduce total body K+ (loop diuretics v. Kayexalate v. hemodialysis) "C-BIG-K-DI" --> see big k+ die! - CaCl/CaGluconate - Bicarb or B2 agonist - Insulin + Glucose - Kayexalate - Diuretics/Dialysis

High Altitude Pulmonary Edema (HAPE)

Path: Low partial pressure of inspired oxygen at high altitude causes lungs to undergo *hypoxemic vasoconstriction* to optimize gas exchange. - Some individuals are genetically predisposed to unevenly distributed hypoxemic vasoconstriction. --> Leads to patchy bilateral *noncardiogenic pulmonary edema* Pt: - Symptom onset within few days of arriving at high altitude (~>8,000ft) - SOB - Headaches - Dizziness - Hypoxemia - Bilateral lung crackles - *Fever* - Mild *Leukocytosis* (if >15,000 or there are bands, think pneumonia) Dx/Tx: *Rapid improvement of Hypoxemia w/supplemental O2*

Hyponatremia

Path: Low serum tonicity results in influx of water into brain cells, causing swelling and cerebral edema (elevated ICP). - HYPOvolemic HypoNa+? Urine sodium *<20* (bc trying to keep fluid in blood) - HYPERvolemic HypoNa+? Urine sodium *>20* (bc trying to get rid of fluid in urine) - EUVOLEMIC (x. SIADH, Primary polydypsia)? Urine sodium *>20* (bc not trying to pull Na+ and thus water back into blood) Pt: - Symptomatic when Na <125mEq --> Nausea --> Malaise --> Headache --> Confusion --> Seizure --> Coma --> Respiratory arrest MILD = Asymptomatic - Tx: Oral H2O MODERATE = N/V, confusion, HA - Tx: IV Fluid NS SEVERE = Coma, seizure - Acute (<48hr)? Symptomatic w/Na+ *<130* - Chronic (>48hr)? Symptomatic w/Na+ *<120* - Tx: 3% NaCl --> Correct Na+ *4-6 mEq* over period of several hours, with 8 mEq being the MAX for 24hr period (worry about OSMOTIC DEMYELINATION SYNDROME) "From low to high, your pons will die" (osmotic demyelination syndrome) "From high to low, your brains will blow" (cerebral edema/herniation) Work-up 1. Patient presents hyponatremic 2. Calculate serum Osmolality = (2 x (Na + K)) + (BUN / 2.8) + (glucose / 18) = *280* 3. - If osmols are Normal --> ISOTONIC HYPONA - If osmols are Elevated --> HYPERTONIC HYPONA (means Na, BUN, and/or glucose is elevated) --> *for every 100BG above 100, you give 1.6 Na* (x. BG 500 means 4x1.6 Na) - If osmols are Low --> HYPOTONIC HYPONA --> If volume overloaded? Diuresis. If volume deficient? IV fluids. If euvolemic? (RTA, Addisons, Thyroid, SIADH) SIADH Tx: Fluid restriction and or *hypertonic saline*. - Then gentle diuresis. - Then demeclocycline if all else fails. can be due to SSRIs!, pain, nausea, lung disease, ca *** DO NOT PICK -VAPTANS!!!!

Sjögren Syndrome

Path: Lymphocytic inflammation of the exocrine glands - Associated with RA - Associated with *RTA TYPE 1* = impaired H+ excretion from DISTAL conv tubule (metabolic acidosis w/o anion gap) --> HYPOK+ --> Urine pH >5.5 (can't acidify)!!!!!! characteristic - Increased risk for Non-Hodgkin lymphoma Pt: ~50yo - Dry eyes (discomfort, grittiness, foreign body sensation) = *Keratoconjunctivitis Sicca* - Dry mouth = *Xerostomia* - Decreased tear production makes them at risk for *CORNEAL ULCERATIONS* - THRUSH - FIRM SUBMANDIBULAR NODULES (salivary glands) - Dental caries - Raynaud phenomenon - Chronic urticaria - Cutaneous vasculitis - ILD Dx: - Evidence of lymphocytic infiltration of salivary glands - OR!!! Anti-SSA (Ro)/Anti-SSB (La) abs --> Most also have positive ANA - PLUS Schirmer test (measure tears on paper after 5min) Tx: Artificial tears + Humidifiers + Eyeglasses with barriers

Diabetes Insipidus

Path: MCC Hereditary CENTRAL DI (hypothalamic or post pituitary --> deficient ADH secretion)? - Responds to Desmopressin - Does NOT respond to water deprivation test - *High Serum Na+* (d/t impaired thirst mechanism) NEPHROGENIC DI (ADH resistance)? - Does NOT respond to Desmopressin - Does NOT respond to water deprivation test - Lithium causes this by accumulating in *collecting ducts* - *Normal Serum Na+* (d/t intact thirst mechanism, so they drink water to dilute it) Pt: Usually see - *LOW urine osmols* - *LOW urine specific gravity* - *HIGH serum osmols (Serum HYPERNa+)* For reference.... - NORMAL Urine Osmol *>300* - NORMAL Urine Specific Gravity = *>1.006* Dx: - Older kids/Adults? *Water deprivation test* - Younger kids? *Desmopressin* (bc we worry about causing severe hypernatremia in them w/water deprivation) Tx: Depends on cause - Central? *Desmopressin*

Wiskott-Aldrich Syndrome (WAS)

Path: Mutation of WAS gene, which means leukocytes and platelets are unable to reorganize their actin skeleton - X-linked RECESSIVE "Eczematous boy coughing and sneezing in a floatie on water, wearing small cross" - B & T cell deficiency Pt: "WAITER" - Wiskott-Aldrich - Immunodeficiency - Thrombocytopenic purpura (smaller platelets) - Eczema - Recurrent infections Dx: CBC w/*DECREASED WBCs and PLATELETS* "W is an upside down M so low IgM, A and E are right side up so high IgA and IgE" - Quantitative immunoglobulin w/ --> Decreased to normal IgG and IgM, --> Increased IgE and IgA (vowels) Tx: *Bone marrow transplant*

Bipolar Type I

Path: MANIC-predominant Bipolar Disorder - More severe, Functioning is impaired Pt: "DIGFASTER" - *D*istractability - *I*nsomnia - *G*randiosity - *F*light of ideas - *A*gitation - *S*exual exploits - *T*alkative - *E*levated mood or Irritability - *R*acing thoughts - Can have *Catatonia* and *Psychosis* (unlike BP2!!!) Dx: Elevated Mood? ≥3 sx. Irritable Mood? ≥4 sx. - Duration of MANIA *≥1 week* - Any *psychosis* automatically makes MANIC episode (vs. Hypomanic) - *≥4 mood episodes/year*? "RAPID CYCLING" - R/o Stimulants - R/o BP2 and Cyclothymia - DOES NOT require hx of depressive episode Tx: *Lithium* or *Valproate* (second line is Lamotrigene) for maintenance for the rest of their life (d/t high risk of recurrent episodes) - Mild/Moderate Mania? Lithium v. Valproate. Second line is Carbamazepine v. Oxcarbazepine. - Severe Mania? *Lithium + Quetiapine or Olanzapine* (bc can be given IM) - Currently in MDE? *Lamotrigene* v. *Lurasidone* v. *Quetiapine* - Looks like MDE and already on Lithium? *Check TSH FIRST!!!* before changing any meds. --> Even if Lithium level is therapeutic, can still cause AE. --> Tx hypothyroidism w/Levothyroxine (don't dc lithium if it's working). - Pregnant? *Lamotrigene* --> Try for 3-6mo, if stable then can attempt pregnancy. --> If stable on lithium when conceive may elect to continue lithium as risk of Ebstein is low, but lamotrigene is better of two for pregnancy - Agitated in ED? *Benzo* (esp if acute bc takes a while for lithium to start working) v. *Antipsychotics* (esp if psychotic) - NOT "B52" (aka Haloperidol + Lorazepam + Diphenhydramine)...bc too extreme If they are having MDE and you tx w/anti-depressant and they become manic, or their depression resolves abnormally rapidly? *Bipolar Spectrum* --> *Discontinue the med*

Autism Spectrum Disorder

Path: MC associated heritable syndrome is Fragile-X, a *Trinucleotide repeat expansion* (CGG repeat expansion on FMR1 gene) Pt: - *Absence of JOINT ATTENTION* --> Spontaneous attempts to share interests with others by eye gazing and pointing at objects - Insistance on routines - Fixated interests (playing with one toy) - Repetitive behaviors - Rigid adherence to routines --> May become aggressive when someone tries to divert them from this - *Delayed language development* (odd word choices, odd pitch, lack of functional pitch) - Unresponsiveness to name - Solitary play - Impaired social communication and interaction - Fascination with certain sights, sounds, textures - Not reacting to pain or extreme temperatures Dx: Structured assessment of social, language, intellectual development + hearing, vision, genetic (Fragile X) testing. Tx: EARLY INTERVENTION - Speech therapy, - Behavioral therapy, - Educational interventions, and - Occupational therapy in preschool or early education significantly improves functioning VS. *Isolated Intellectual Disability*, which would be socially responsive in appropriate way for age VS. *Global Developmental Delay*, which would be socially responsive and make efforts to communicate.

Burn Wound Sepsis

Path: MC cause of death in severe burn patients Pt: - *Temp >102.2* (how you dif from post-op ileus) - Pulse >90 - Respirations >30/min - Refractory hypotension <90 systolic - CBC abnormalities - Evidence of *organ hypoperfusion or dysfunction* (x. oliguria or new onset feeding intolerance) Dx: *Blood cultures* + *Wound cultures* Tx: *Abx*

Retroperitoneal Hematoma

Path: MC complication following CABG - D/t catheter insertion site --> If is FEMORAL and above INGUINAL LIGAMENT can extend into retroperitoneal space --> Less common w/RADIAL ARTERY approach - Hemorrhage and hematoma formation *w/in 12hr* of catheterization Pt: - HYPOtension - Tachycardia - Flat neck veins - BACK PAIN - Flank pain Dx: *Noncon CT of Abd/Pelvis* Tx: Supportive - No heavy lifting for ONE WEEK following catheterization

Mature Cystic Teratoma (dermoid cyst)

Path: MC in PREmenopausal women - Solid components - *Calcifications* - Multiple thin echogenic bands (hair) Do NOT have multiple septae or cause ascites (how dif from epithelial ovarian cancer)

Gilbert Syndrome

Path: MC inherited disorder of bilirubin glucuronidation d/t deficiency of hepatic *UDP Glucosuronyltransferase* (more benign version of Crigler-Najjar) - Triggers include: Illness, Stress, Dehydration, Fasting, Exercise, Menstruation, Surgery Pt: - Episodic jaundice - Scleral icterus - *UN*conjugated bilirubin Dx: Persistent INDIRECT bilirubinemia, in absence of other lab abnormalities Tx: Reassurance (benign condition)

Asthma in Pregnancy

Path: MC pulmonary disorder in pregnancy. 1/3 get worse, 1/3 get better and 1/3 are stable - RF = Prior hx of asthma or uncontrolled or severe asthma - Worse in second trimester - Associated with Preterm delivery, Low birth weight, Antenatal hypoxia Pt: - Intermittent cough (dif from Dyspnea of Pregnancy) - Chest tightness - Shortness of breath - Worse at night (reduced anti-inflammatory effects at night...cortisol etc) Tx: *Albuterol* for acute sx - If persistent? *+ Inhaled Corticosteroids*

Splenic Abscess

Path: MC seen following *infective endocarditis*. Then gets to spleen hematogenously or via septic emboli. - Staph, Strep, Salmonella are mcc - RF = Immunocomprised (x. DIABETICS following laparoscopic Upper GI surgery) Pt: TRIAD - *Fever* - *Leukocytosis* - *LUQ* pain - Enlarged spleen - Radiates to back - Weight loss - *Left-sided pleural effusion* from irritation to diaphragm!! Dx: CT ABD Tx: *SPLENECTOMY* - Studies have shown treatment with Abx alone has 50% mortality... Compare to - Splenic infarction: would have hx of clotting disorder or embolisms - Splenic venous thrombosis: from portal HTN. NO fever or weightloss.

Alcohol Use Disorder

Path: MC substance abused - Men more than women Pt: - Disinhibition - Slurred speech - Cerebellar dysfunction - Wernicke's - Korsakoff's - Cirrhosis - Gastritis - GI bleed - Coma Dx: Breathalyzer *>0.08* - BAC decreases by *0.03/hr* Tx: - Acute? *IVF + Time* - Coma? *Thiamine* THEN *D50* - Chronic? *AA* + (*Naltrexone* v. *Acamprosate*) --> Acamprosate (safe for LIVER dz, not for kidneys) is for *MAINTAINING ABSTINENCE*, so can't be given if they're still drinking --> Naltrexone (safe for KIDNEYS dz, not for liver) can be given even if they're still drinking

Viral Conjunctivitis

Path: MC, *ADENOVIRUS* - Children and caregivers - Late summer and early fall Pt: - Pharyngitis, - WATERY discharge, - Unilateral, - *Lymphadenopathy* - Rhinorrhea Tx: *Warm or Cold compress*

Acute Bacterial Rhinosinusitis (ABR)

Path: MCC = *Nontypable H. Influenza*!!!!!!!! Taraaaaaaa arghhhhhhhhhhhhh - 2nd MC = Strep v. Moxarella - MC risk factor is VIRAL URI Pt: - Cough - Fever - Nasal discharge (purulent) - Facial pain - Headache Dx: only need ONE of below to dx... - Symptoms >10days without improvement - Severe (*102.2F* + drainage) *>3days* - Worsening symptoms Tx: Amoxicillin +/- Clavulanate - If mild can be Observed! - If don't respond to usual Abx, get *Sinus aspiration* and culutre.

Osteomyelitis

Path: MCC Staph - Sickle cell? Salmonella - Penetrating wound/IVDU? *Pseudomonas* - Diabetic foot? Polymicrobial (Pseudomonas and MRSA) - "Oyster/Water" or "Liver Dz" (x. Hemochromatosis)? Vibrio...kills people - Gardening? Sporothrix Pt: Can probe to bone, recurrent or refractory cellulitis - ESR & CRP will be elevated (you see this with infection inflammation, or autoimmune diseases) - Chronic osteomyelitis? --> Sinus tract with persistently draining wound Dx: XRay (often negative unless had infection for 2+wks) - If early and you are convinced is osteo, *MRI* - "Best?" *Bone Bx*, ideally before Abx, but if they are too sick then given Abx first, then Bx. - Chronic? Necrosis and fragmentation of the bone and ragged, irregular fracture lines. Tx: Debridement + 4-6 weeks of Abx (ideally tailored to sensitivity of bact) - Regular ol' Staph? *Nafcillin/Oxacillin or Cefazolin* - MRSA? *Clindamycin or Vancomycin* - Salmonella (sickle cell)? *Staph coverage + CEFTRIAXONE*

Perianal Fistula

Path: MCC is ruptured perianal abscess that forms a residual sinus tract - Can occur as a complication of Crohn's disease, radiation proctitis, atypical infections, or trauma. Pt: - Pain on defecation - Chronic anal discharge - Inflamed perianal lesion - External terminus with indurated tract leading to the rectum. Dx: Clinical (you can often see the terminus in the anus) - Could use imaging to confirm Tx: *Fistulotomy*

Minimal Change Disease

Path: MCC of NephrOtic syndrome in kiddos - T-cell mediated *CYTOKINE* damage to capillary wall of glomerulus, leading to epithelial podocyte injury - Unclear why happens... - Associated with Hodgkin Lymphoma Pt: - Edema - Fatigue - Hypoalbuminemia - Proteinuria Dx: UA w/Proteinuria...CLINICAL DX!! - Renal Bx to confirm (NORMAL!!!) --> Only do this in rare circumstances - EM w/*diffuse effacement of foot processes* of podocytes Tx: Corticosteroids

Alzheimer's Disease (AD)

Path: MCC of dementia (usually >65yo) - Early onset (<65yo) more heritable than late onset. - Impaired acetylcholine synthesis Pt: First memory, then behaviors (dif from Frontotemporal dementia) EARLY - Short-term memory loss (recent events first, word finding) - Executive dysfunction - Impaired visuospatial skills (getting lost) LATER - Personality changes - Behavioral changes (apathy, disinhibition, suspiciousness) - Psychotic features (delusions, hallucinations) - Language difficulties - Apraxia (inability to perform familiar movements on command, even though the command is understood and there is a willingness to perform the movement) - Urinary incontinence secondary to severe cognitive dysfunction Dx: Clinical - Imaging shows *Advanced cortical atrophy* - R/o other diseases w/Neuropsych testing, Brain imaging, Laboratory testing - Degeneration of *Locus coeruleus* (produces *Norepinephrine*) Tx: Death within 10yr of dx, regardless of tx :( PREVENTION - Aggressive treatment of cardiovascular risk factors (Hypertension, Diabetes, Obesity - Cognitively stimulating activities - Maintaining social relationships

Adenoid Hypertrophy

Path: MCC of persistent *nasal obstruction* during childhood!!!! Pt: - Persistent nasal obstruction - Recurrent otitis - Recurrent sinusitis - Mouth breathing - Sleep disturbances or snoring d/t apnea --> Hyperactivity, Inattention, Emotional lability, Poor growth - Elongated/flattened facial features - Postnasal drip - Mucopurulent discharge - Concurrent tonsillar hypertrophy is common Dx: Not easily visualized...

Glucagonoma

Path: Malignancy of the α-islet cells causes glucagon producing tumor. Pt: - *Migratory necrolytic dermatitis* (presenting feature in >70% of patients) --> "Painful itchy red spots that enlarge and begin to crust" --> "Erythematous plaques with central clearing and eroded borders" - *DM* (elevated glucose, sometimes just mild, rarely needs insulin) - Diarrhea - Weight loss - Venous thromboembolism - Depression - Psychosis - *Normocytic, normochromic ANEMIA* Dx: *Glucagon-level* (>500) --> then MRI or CT scan to locate Tx: Resect

Neuroblastoma

Path: Malignant tumor of *NEURAL CREST CELLS* (sympathetic ganglia, adrenal glands if in abdomen) Pt: Occurs most commonly in infants <2yo - *Opsoclonus Myoclonus* (dancing eyes dancing feet) - Periorbital ecchymosis (d/t orbital metastases) - Abdominal mass - Spinal cord compression (*dumbbell tumor*) - Ptosis, Miosis, Anhydrosis (Horner's) Dx: *Tissue Bx* - Urine & Serum catecholamines will be elevated

Congenital Toxoplasmosis

Path: Maternal contact with cat feces, or through *undercooked meat, unwashed produce, etc* - Mom is usually asymptomatic when infected, or could have fever, myalgias, LND, or rash. Pt: - Microcephaly (like CMV)...OR - Hydrocephalus (w/*Macrophaly*...unlike CMV) - Diffuse cerebral calcifications - Chorioretinitis Dx: *Amniocentesis* for toxo PCR Tx: *Pyrimethamine + Sulfadiazine + Folinic acid* may decrease risk of neurologic sequelae

Major Depressive Disorder (MDD)

Path: May occur in response to a variety of stressors, including loss of loved one - Marked social and occupational dysfunction Pt: *Depressed mood* + "SIGECAPS" - *S*leep (typical has LESS, atypical has MORE) - *I*nterest (aka anhedonia) - *G*uilt - *E*nergy - *C*oncentration - *A*ppetite (typical has LESS, atypical has MORE) - *P*sychomotor changes (slowing or agitation, like fidgeting) - *S*uicidal ideation - Low mood (or *Irritability* if adolescent!!!!) - *Mood reactivity* (ability to become transiently euthymic when exposed to positive events --> ATYPICAL only) - May present with physical symptom d/t lack of psych awareness or stigma of mental health issues (x. headache, fatigue, insomnia, aches and pains) Dx: - Duration *≥2 weeks* - *≥5/9 symptoms* (see above) - *Patients with ≥1 MDE and no history of mania or hypomania are diagnosed with MDD* - *Increased CORTISOL levels* d/t hyperactivity of the hypothalamic-pituitary-adrenal axis (think of it as a sign of stress, which also causes elevated cortisol) - DECREASED REM sleep latency (quicker to dream) - DECREASED slow-wave sleep (deep sleep) Tx: - ADULT? *Psychotherapy* + *SSRI v. SNRI v. Bupropion v. Mirtazapine* --> treat for *1-2 months*, then reassess about dose etc. - KID? *Pyschotherapy* (+ SSRI if severe, esp. *Fluoxetine*....NOT Bupropion.) - Only *1* lifetime episode? treatment at successful dose for *6 months*, then if remission achieved can taper and stop. - *≥2 lifetime episodes, early onset (≤18yo)*? Maintenance antidepressant therapy for *1-3 years*. - *≥3 lifetime episodes, chronic episodes (≥2yr), severe episodes, severe psychosocial stressors, strong family history*? *Lifetime* antidepressant therapy. - Suicidal ideation + plan? Hospitalize - Suicidal ideation, NO plan? Contract for safety - Best/Refractory/Catatonia/Psychosis? *ECT* w/sedation

Calcaneal Stress Fracture

Path: Occurs due to repetitive trauma Characterized by sudden onset pain in plantar-calcaneal area, pain in morning (mimics plantar fasciitis but becomes WORSE w/activity) - Obese women at higher risk Dx: Calcaneal squeeze test + confirm w/XR - if negative then MRI as needed. Tx: Analgesics, reduction of weight-bearing activities

Ventricular Tachycardia

Path: Mc after MI, bc increases risk of ventricular arrhythmias --> Especially associated w/*AV dissociation* - REGULAR - WIDE complex - TACHYCARDIA - Two flavors: Monomorphic v. Polymorphic (Torsades) Pt: - Cannon A waves seen in JV (intermittent), d/t right atrial contraction against closed tricuspid valve (signify AV block, AV dissociation, PVCs) - Headache - Dizziness Dx: Tx: - If SYMPTOMATIC/STABLE --> Tx: Amiodarone - If UNSTABLE (chest pain, SOB, hypotension, signs of poor perfusion) --> *Cardiovert* - Pulseless? *Cardiovert + Epinephrine* (only case where you shock a pulseless patient) - Torsades? *Magnesium* --> If that doesn't work then *Pacemaker*

Vertebral Compression Fracture

Path: Mc d/t decreased bone density d/t *Osteoporosis* (lifting, twisting, coughing, or trauma) - Type I: postmenopausal - Type II: elderly man or woman - Multiple/recurrent vertebral compression fracture is common Pt: - Point tenderness - Midline - Localized - WORSE w/movement, coughing, etc - May persist at night - NO neuro deficits - NORMAL Labs (PTH, Ca++ etc) Dx: *XR*

Rotator Cuff Tear

Path: Mc d/t fall on outstretched arm Pt: - >40yo - Shoulder pain (worse w/abduction, external rotation) - Limited *ACTIVE* abduction (weakness) --> Unlike Rotator Cuff Tendinopathy, which would be painful but not cause weakness!!! - Intact *PASSIVE* movement - *Drop arm sign* (can't smoothly control shoulder) - NO sensory loss (that would be sign of Axillary nerve injury) Dx: *MRI* Tx: *Surgery* (esp if done within 6wks of injury)

Nonexertional (Classic) Heat Stroke

Path: Mc in elderly patients bc have impaired thermoregulatory response - RF = Obesity, Alcohol, High humidity (impairs sweat's ability to cool body) Pt: - Temp *≥104F* - CNS dysfunction (how dif from Heat exhaustion) - Tachycardia - Tachypnea - Hypotension - DIC - Pulmonary edema - Renal failure - Hepatic failure Dx: Tx: *Evaporative techniques* (unlike EXERTIONAL heat stroke where you would do ice water immersion) + IVF

Traumatic Macrovascular Hemolysis

Path: Mc seen in dysfunctional *MECHANICAL VALVE* (x. Aorta) or *Severely calcified* valve - High pressure gradients cause shearing forces on passing erythrocytes and platelets (*intravascular hemolysis*) - Damaged RBCs left over are then destroyed in the spleen by macrophages (*extravascular hemolysis*) Pt: - Anemia (fatigue, dyspnea) - Hepatosplenomegaly - Jaundice - Dark urine - Thromboctyopenia - Reticulocytosis bc bone marrow is trying to help Dx: *Transthoracic ECHOCARDIOGRAM* to check valve function - PBS w/Schistocytes Tx:

Bacterial Meningitis in Children

Path: Mcc *Streptococcus pneumonia* or *Neisseria meningitidis* Pt: - *>1 month* old - Irritability - Fever - Bulging fontanelle - Lethargy - Poor feeding - Inconsolable - If older child, signs of intracranial pressure: Headache, Vomiting, Altered mental status Dx: - Hemodynamically stable? *Lumbar puncture* (don't worry about brainstem herniation bc fontanelles not yet closed), then Abx!! - Not stable? *Abx first*, then *LP* Tx: *Cefotaxime + Ampicillin + Vancomycin* ± Steroids

Enterotoxigenic E. coli (ETEC)

Path: Mcc of "Traveler's diarrhea" - Resource limited areas w/poor sanitation - Fecal-oral transmission (contaminated food or water) Pt: - Water diarrhea - *LOW GRADE* fever - Abdominal cramping - Nausea, maybe even vomiting Tx: Self-limited, usually last <5 days. Supportive care w/rehydration. - SEVERE (temp or diarrhea severely limits activities)? *Azithromycin* v. *Ciprofloxacin*

Congenital Hypothyroidism (Cretinism)

Path: Mcc worldwide is *THYROID DYSGENESIS* (aplasia, hypoplasia, ectopic gland) - Commonly asymptomatic at birth because mom's T4 passes through the placenta - NOT D/T MATERNAL HYPOTHYROIDISM Pt: Most are asymptomatic - Failure to pass meconium (>48hr to first stool) - Large fontanelle - Large tongue - Weak cry - Poor feeding - Hypotonia - Constipation - *Umbilical hernia* (not to be confused w/Beckwith-Wiedemann syndrome) - Jaundice (bc unable to stool out their bili like normal babies) - Neurodevelopmental injury if not recognized and treated immediately. Dx: - Elevated TSH - Decreased T4 Tx: *Levothyroxine* - Endemic goiter? Than d/t iodine deficiency --> give Iodine.

Serum Sickness-Like Reaction

Path: Medications (Penicillin, TMP-SMX) - MC in *CHILDREN* (how dif from SS) Pt: Sx 5-14 days after - *LOW* fever (how you tell difference from SS) - Urticarial rash (intensely pruritic), spares mucous membranes (how you dif from Steven Johnsons, TENS - Arthralgia - Diffuse lymphadenopathy Tx: Spontaneously resolves - Discontinue medication if you haven't already

Premenstrual Dysphoric Disorder (PMDD)

Path: Menstruating female - Symptoms compromise quality of life Pt: Worsen prior to menstruation, resolve for a few weeks at a time - Overeating - Mood swings - Irritability - Sadness - Anger - Irritability - Decreased interest - Fatigue - Bloating - Physical discomfort Dx: *Symptom Diary* - Patient must report ≥2 cycles w/symptom free follicular phase (before ovulation), and symptoms during *Luteal phase* (1-2wks before menses) Tx: *SSRIs*

Refeeding Syndrome

Path: Metabolic alterations that may occur during nutritional repletion of starved patients (denotes a prolonged phase of malnutrition, not just several days of not eating) - Refeeding causes increased release of *INSULIN*, which leads to cellular uptake of electrolytes and increases the *use of phosphate for ATP* --> Massive fluid and electrolyte shifts Pt: - *HYPOphosphatemia* (primary deficient electolyte bc used for ATP) - *HYPOkalemia* & (causes arrhythmia) - *HYPOMagnasemia* (causes arrhythmia) - Arrhythmias - Volume overload - Edema - Heart failure - Muscle weakness - Seizures. - Rhabdomyolysis - Neurologic dysfunction - Diarrhea - Elevated transaminases Tx: Parenteral *phosphate* ---> Can develop acute weakness, hyporeflexia, rhabdomyolysis, hemolysis, arrhythmias, CHF when given fluid and electrolyte treatment

Acute Fatty Liver of Pregnancy (AFLP)

Path: Microvesicular fatty infiltration of hepatocytes - Develops in the *THIRD TRIMESTER*!!!, especially with multiple gestations - Defective maternal fatty acid metabolism Pt: Looks really similar to HELLP but is more obvious liver failure - Hypertension - Hepatic inflammation (RUQ pain, leukocytosis, elevated liver enzymes) - Encephalopathy - Liver failure (scleral icterus, hyperbilirubinemia, *HYPOGLYCEMIA*)...unlike HELLP - *Prolonged PT/PTT*...unlike HELLP - Vomiting - Jaundice - Abdominal pain - Can develop DIC & AKI - Fetal hypoxemia --> death Dx: Tx: Maternal stabilization and *immediate delivery* - Regardless of gestational age

Transient Ischemic Attack (TIA)

Path: Minor stroke; where neurological function is regained quickly with time - Patients have risk factors for stroke (x. Hypertension, Hypercholesterolemia, Smoking) - Increased risk w/prosthetic valves (esp Mitral) Pt: - Transient FND which resolves *<24hr* (dif from MS) Dx: Clinical (Brain imaging would be negative/normal) Tx: *Aspirin + Statin + BP control + Stop smoking + Exercise* - For ASYMPTOMATIC patients treat as above (w/ <80% occlusion. If >80% occlusion then consider CEA) - For SYMPTOMATIC patients, consider a *CEA (CAROTID ENDARTECTOMY)* if SEVERE (70-99%) occlusion...if persistent disabling side effects, total occlusion, or <5yr life expectancy then not worth it.

Cholelithiasis (Biliary Colic)

Path: Mixed usually.. - Cholesterol (Female, Fat, Forty, Fertile, Native american) - Pigmented (hemolysis) Pt: *COLICKY* RUQ pain (though may be constant), Radiates to shoulder, Worse w/food - RESOLVES w/in 4-6hr (unlike cholecystitis) - Dull pain - Postprandial - RUQ or epigastric - Radiates to *SHOULDER* - Nausea - Vomiting - Diaphoresis - VITALS & LABS NORMAL Dx: RUQ USD (w/gallstones) Tx: *Cholecystectomy electively* - If not surgical candidate can use *Ursodeoxycholic acid*.

Neonatal Varicella-Zoster Infection

Path: Mom gets varicella infection *5 days BEFORE delivery....to 2 days AFTER delivery* - Contagious through aerosolized droplets - Post-exposure prophylaxis (PEP) is recommended for those who are not immune (immunity would have been via *TWO* vaccine doses or prior hx of immunity) Tx: *VZ IG* (good for neonates, preggo, or immuncompromised) - If >1yr old and immunocompetent? Can give normal *VACCINE* as PEP.

ABO Incompatability

Path: Mom is blood type O and baby is A, B, or AB. Mom makes antibodies (IgG) to antigen on baby's blood. - Can happen with FIRST BABY (bc mom has already developed Abs to A and B from food, etc) Pt: - Bc A and B are on other tissues in body, not just blood, there are more MILD signs of hemolytic disease (anemia) --> Jaundice - or ASYMPTOMATIC Dx: Direct Coomb's at birth to test - Indirect Coomb's to screen Tx: Phototherapy

Congenital CMV

Path: Mom may have gotten infection with CMV from close contact with young children - Maternal contact with infected bodily fluids (x. saliva) Pt: - *Periventricular* calcifications - Intrahepatic calcifications - intrauterine growth restriction - Hepatosplenomegaly - Jaundice - Blueberry muffin spots - Hydrops fetalis - Microcephaly (unlike Toxo which could be Mico or Macro) - Sensorineural hearing loss - Seizures - Developmental delay Dx: Amniocentesis for baby, Serology for mom Tx: Expectant management

Multiple Myeloma

Path: Monoclonal Plasma Cells --> So make IgA, Light Chains, and IgG (how dif from Waldenstrom's) - *Bence Jones Proteins* which deposit in kidneys --> causing AKI!!! - Osteoclast stimulating factor (*osteoLYTIC* lesions & pathologic atraumatic fractures) --> hence the Hypercalcemia Pt: >70 w/ "CRAB" - *HyperCa2+* - *Renal failure* - *Anemia* - *Bone pain* (lytic lesions) - Recurrent infections - Protein gap - Bilateral upper respiratory infections and UTIs Dx: - SPEP *(+)* w/M-spike - UPEP *(+)* w/M-spike - *SKELETAL SURVEY* (+) (w/multiple xrays) not!! bone scan. w/*Osteolytic lesions* (hence the hypercalcemia) --> Bone Marrow Bx (w/*>10% plasma cell*) - *PBS* w/rouleaux - *Serum Free Light Chain Analysis* - Can then confirm dx w/bone marrow bx - UA has little proteinuria bc does not pick up monoclonal proteins Tx: - >70yo & NO donor? Chemo (*Melphalan + Steroids + (Thalidamide v. Bortesamib)) - <70yo & donor? Stem cell transplant

Schizoaffective Disorder

Path: Mood episodes w/psychotic features that also occur in the absence of mood episodes. - Psychosis predominates but there is a little bit of mood (dif from Bipolar w/Psychotic features where mood predominates and there is a little bit of psychosis) Pt: - Major depressive or manic episode concurrent with symptoms of schizophrenia. - Mood episodes are prominent and recur throughout illness. Dx: - Duration mood episodes with sx of schizophrenia for *≥6 months* - Lifetime history of delusions or hallucinations *≥2 weeks in the ABSENCE* of major depressive or manic episode. Tx: - First? Treat MOOD.

Methanol

Path: Moonshine Pt: - *Blindness* - Optic disc hyperemia - Anion gap (MUDPILESSS) - Osmolar gap - Abdominal pain - Vomiting Tx: *FOMEPIZOLE* (or ETOH)

Chikungunya

Path: Mosquito borne viral illness (*aedes* type) - S america / *Caribbean* Pt: - High fever - *SYMMETRIC polyarthalgias*, - *Low WBC* - Low platelets - Elevated LFTs - *Maculopapular rash* - Cervical LAD Dx: *Serology* Tx: *Supportive* - Can rarely cause persistent arthritis

Urinary Tract Infection in INFANTS

Path: Most common bacterial infection in febrile infants. - RF = Female, Uncircumcised males, *Constipation* Pt: - Fever - Fussiness - Poor feeding - Abdominal discomfort - Decreased urine output - Dysuria - Frequency - Suprapubic pain - Flank pain Dx: UA + Urine Culture (via straight cath, unless toilet trained) - WBCs & >50,000 cfu's makes diagnosis. Tx: Abx

Focal Seizures with Impaired Awareness

Path: Most common manifestation of *temporal lobe epilepsy* - Focal seizure originates in a single hemisphere Pt: - Often ADULTS (how dif from Absence Seizures) - Blank stare (not responding to environment) - Automatisms (repetitive movements, such as hand rubbing, chewing, swallowing or walking in circles) - LOC - Have postictal confusion!! (unlike Absence) - Episodes last *30-90s* (how dif from Absence Seizures) Dx: EEG w/epileptiform changes over temporal region

Febrile Nonhemolytic Transfusion Reaction

Path: Most common transfusion reaction, BENIGN - D/t *cytokine release* from leukocytes within the donor blood product (they try to remove all the leukocytes from blood donations but sometimes bits make it in there) --> Leukocytes release cytokines during storage Pt: - *1-6hr* after transfusion initiation - Transient fevers - Chills - Malaise Prevent w/: *Leukoreduced blood products*

Marfan Syndrome

Path: Mutation of *Fibrillin-1* gene - Autosomal DOMINANT Pt: - Joint hypermobility - Skin hyperelasticity - Long fingers - Arachnodactyly (thumb sign) - Pectus excavatum - Scoliosis/Kyphosis - *UPWARD* Lens dislocation (key dif from Homocystinuria) - Iridonesis - Face long - High palate - Crowded teeth - MVP - Aortic root dilation (Aortic regurg murmur) or dissection Dx: - *Echocardiogram* to look at mitral valve & aorta

Sleep Terrors

Path: Occurs during *NON-REM* sleep, - occurs in FIRST THIRD of night. Pt: - Incomplete awakenings - Flushed face - Sweating - Tachycardia - *UNRESPONSIVE* to comfort (dif from Nightmare disorder) - *DOES NOT* remember dream (dif from Nightmare disorder) Tx: *Reassurance* - Low dose Benzo at bedtime if frequent, persistent and depressing. - Resolve spontaneously in 1-2 years

Acute Pancreatitis

Path: Most commonly caused by GALLSTONES. - Causes: *THIAZIDES & FUROSEMIDE*!!!, Alcohol use - SEVERE (pancreatitis w/failure of ≥1 organ)? Active pancreatic enzymes are released into vascular system and cause increased permeability and widespread inflammation. Pt: - Epigastric pain, --> Improves when *Leaning forward* or sitting up - Back pain - Nausea, - Elevated Lipase - HYPOcalcemia (possibly from binding panc fat) - Example given was patient s/p cardiac cath and cholesterol emboli blocked off panc - SEVERE? (may look like internal bleed!!!) --> HYPOTENSION --> Tachycardia --> Dyspnea, basilar crackles --> Abdominal distention --> Cullen sign (greyish color around umbilicus) --> Grey-Turner sign (red brown color around flanks) Dx: ≥2 of the following... - *Amylase and/or Lipase >3x upper limit of norm* (see this within 2hr of sx onset)...Lipase is more specific... - Severe epigastric pain - MRI, USD, or *CT* of Abd (see changes w/in 48hr of onset) --> this is first step to dx if CHRONIC PANCREATITIS. Look for necrosis if severe pancreatitis. --> Suspect Gallstone pancreatitis (elevated AlkPhos, ALT, AST)? First step is RUQ USD!!!! and if that is unrevealing, then *ERCP* --> Suspect other cause of pancreatitis? First step is CT!!!! Tx: Supportive care for uncorrectable causes (self-limiting) --> *IVFluids + Pain control + NPO* - If d/t gallstones? Cholecystectomy (once recovered) - If d/t meds? DC them - Severe? Aggressive IVF

Toxic Epidermal Necrolysis (TEN) / Steven Johnson Syndrome

Path: Most commonly drug induced (Allopurinol, Antibiotics, Anticonvulsants, NSAIDs, Sulfasalazine), though can be associated with infections (x. Mycoplasma) - Sulfonamide drugs are commonly involved (*TMP-SMX*) - Onset of rash *4-28 days* after exposure - TEN = *>30%* of body surface - SJS = *<10%* of body surface - SJS/TEN overlap = 10-30% Pt: - Acute influenza-like prodrome - Rapid onset erythematous macules, vesicles, bullae - Necrosis and sloughing of epidermis - *Mucosal involvement* - Skin slides off with light pressure - Fever - Tachycardia - Hypotension - Altered consciousness Tx: Supportive wound care (similar to burns)

Esophageal Spasm

Path: Motor disorder of the esophagus Pt: - Regurgitation - Chest pain that radiates *intrascapularly* --> can last up to a couple hours (which r/o pinzmetal angina) - Stress, hot or cold foods can induce spasm - Women. Dx: *ESOPHAGEAL MANOMETRY* --> repetitive nonperistaltic, high-amplitude contractions (can use ERGONAVINE to stimulate) Tx: *NITRATES and CA2+ CHANNEL BLOCKERS* (which relax the muscles...just like angina!)

IgA Nephropathy

Path: Mucosal infection triggers pathogenic IgA which is then deposited in the mesangium. - Onset of sx is *Less than 5 days* after URI (unlike PSGN which is weeks later) - Mc in young adults Pt: - Asymptomatic microscopic hematuria v. Gross hematuria w/nephritic syndrome --> Can also present as nephrotic syndrome - *RBC casts* may be present - Hypertension - Proteinuria - Creatinine may be elevated - NORMAL complement (unlike PSGN) Dx: Clinical - Confirm w/kidney bx prn Tx:

Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)

Path: Mullerian Duct system defect - Abnormal development of *Uterus, Cervix, UPPER THIRD of vagina* - Like AIS but *with pubic hair* Pt: - Primary amenorrhea - *Bilateral FUNCTIONAL ovaries* - Normal SECONDARY sexual characteristics (breasts, hair, stature) --> from normal hormones (FSH, Estrogen, Testosterone) - **Normal axillary and pubic hair** (unlike AIS) - Normal female EXTERNAL genitalia - *BLIND VAGINAL POUCH*/Vaginal dimple - Absent or rudimentary uterus Tx: - Evaluate for *Renal tract abnormalities* - Vaginal dilation

Whipple's Disease

Path: Multisystem disease caused by Tropheryma Whippeli, but route or mechanism of infection is still of unclear etiology Pt: - Chronic - Steatorrhea - Flatulance - Protein-losing enteropathy - Weight loss - Abdominal distention - Migratory, nondeforming arthritis - Lymphadenopathy - Low grade fever - Damage to Heart, CNS, Eye Dx: *Intestinal Bx + PCR* - Bx w/*PAS positive macrophages containing non-acid fast gram-positive bacilli* (unlike MAC which would have acid-fast staining bacilli, and would cause similar sx!!!) Tx: *Ceftriaxone* or *Meropenem* x14d - Then *TMP-SMX* for 3-12mo

Rhabdomyolysis

Path: Muscles are broken down due to prolonged stress, contraction, or injury. Heme pigment from myoglobin is released into blood stream and causes renal damage. - Statins, - Colchicine!!, - Alcohol - Crush injury, - Immobilization, - Exercise in the heat - Seizures Pt: - Muscle pain & weakness, followed by dark urine, oliguria, - AKI --> can become ATN (with true hematuria, muddy brown casts) - *Hyperkalemia* (released from lysed muscle cells) - *Hyperphosphatemia* (released from lysed muscle cells) - *HYPOCalcemia* (bc is deposited in muscles) - Elevated AST>ALT bc AST is released from muscles Dx: UA w/Blood elevated (~2-3+), and *RBCs NOT*!!!!!! (1-2 rbc) - Elevated CK will confirm! - *Hyperkalemia and Hyperphosphatemia* (released from lysed muscle cells) - *HYPOCalcemia* (bc is deposited in muscles) Tx: Aggressive fluid resuscitation, CAREFULLY to avoid Compartment Syndrome

CHARGE Syndrome

Path: Mutation in *CHD7* Pt: - *C*oloboma (abnormal development of eye) - *H*eart defects - *A*tresia of the choanae (NG tube won't go down) - *R*enal anomalies/Genitourinary anomalies - *G*rowth impairment - *E*ar abnormalities/deafness - Anosmia - Hypotonia - Cleft lip or palate ..."C" and "A" are how you differentiate from VACTERL. Dx: Genetic testing Tx: Oral airway for respiratory support

Acute Intermittent Porphyria (AIP)

Path: Mutation in *Porphobilinogen Deaminase* that often presents in puberty and causes build up of neurotoxic heme pathway intermediates - Discrete attacks after exposures to *tobacco, alcohol, surgery, fasting, progesterone-meds* - Autosomal *DOMINANT* - ↑Porphobilinogen - ↑ALA - ↑Coporphobilinogen (urine) - ↓Heme Pt: "5 P's" - Painful abdomen (diffuse) --> *Neuropathic*, so NOT tender upon palpation - Purple (wine) urine (red urine that darkens when exposed to light)....unlike Wilson's which would be liver pain in RUQ - *Polyneuropathy* (esp proximal upper extremities)...how you dif from Wilson's bc would be issues w/movement, not neuropathy - Psychological disturbances, - Precipitated by Puberty, drugs (P450 inducers), alcohol, starvation - Tachycardia - Diaphoresis - Tremor - Hyponatremia (SIADH) Dx: *Urobilinogen* will be elevated in UA - *Urinary Porphyrin* (confirms) Tx: *Glucose, Heme*, which inhibit ALA synthase

McCune-Albright syndrome

Path: Mutation in the GNAS gene --> G-protein over-activation of pituitary hormones Pt: - Cafe au Lait spots - Precocious puberty (boys <8 and girls <9) - Fibrous dysplasia of bone - Thyrotoxicosis - Acromegaly - Cushing syndrome Dx: PERIPHERAL precocious puberty - LOW LH & FSH - Advanced bone age Tx:

Pseudoachalasia

Path: Narrowing of distal esophagus, NOT d/t denervation - RF = Tobacco use (Adenocarcinoma and SCC), Alcohol use (SCC), Pt: - Dysphagia to solids and liquids - Dilated esophagus with smooth taper of distal esophagus - *Weight loss* - *Rapid symptom onset* - Presentation at age >60yo - "Widened mediastinum" represents tumor mets Dx: *EGD* to differentiate between Achalasia and Pseudoachalasia - Easier to pass scope through LES in achalasia than in pseudoachalasia - Then *CT* for staging Tx:

Lumbar Spinal Stenosis

Path: Narrowing of spinal canal and compression of nerve roots - Mcc is *Degenerative disc disease* where disc herniation and facet osteophytes impinge upon the spinal cord Pt: Compressive forces worsen - Pain in the low back and legs - WORSE when STANDING (extended) or walking downhill - BETTER when SEATED or bent (flexed) or walking uphill May see - Weakness - Sensory loss - Numbness/Tingling - Neuro exam may be normal, some may have (+) Straight Leg raise test Dx: *MRI* Tx: NSAIDs + OMT > Steroid injections

Angle Closure Glaucoma

Path: Narrowing of the anterior chamber causing decreased aqueous outflow and elevated intraocular pressure - MC in Women, Asians - Pupillary dilation triggers bc closes posterior chamber (*Anticholinergics, Sympathomimetics, Low ambient light*) Pt: - Headache - Nausea - Vomiting - Red eye - Decreased visual acuity - *Mydriasis/"Sluggish dilated pupil"* (how you dif from Cluster Headache) - Lacrimation - Palpable firmness to eyeball - Elevated ESR - Permanent vision loss can occur in 2-5hr of sx onset if not treated! Dx: *Tonometry* (or Gonioscopy) w/elevated pressure Tx: *Timolol + Pilocarpine + Acetazolamide + Apraclonidine* - Urgent ophthalmologic evaluation for laser peripheral iridotomy

Granulomatosis with Polyangiitis (Wegener)

Path: Necrotizing vasculitis effecting small to medium sized vessels. - Vasculitis induced blood vessel damage causes occlusion, localized ischemia, and necrosis Pt: we"C"ener - Upper Respiratory --> Chronic sinusitis (bloody/purulent nasal discharge) --> Saddle nose deformity --> Oral or auditory canal ulcers --> *Otalgia* --> *Hearing loss* - Lower Respiratory --> Trachea narrowing --> Ulceration --> Dyspnea --> Cough --> Hemoptysis --> Lung nodules w/cavitation!!! like TB or cancer.... - Kidney --> Glomerulonephritis --> Renal insufficiency - Skin Manifestations --> *Leukocytoclastic angiitis* (purpura on lower extremities that ulcerate) --> Urticaria --> Livedo reticularis --> Pyoderma gangrenosum (also associated w/IBD) - White - 30-50yo - Weight loss - Low grade fever - Malaise - Leukocytosis Dx: c-ANCA (aka "Proteinase 3-ANCA") = *Qualitative serum antibodies* - Could also bx effected tissue, but NOT nose bc has high rate of false negatives Tx: High dose steroids + (Cyclophosphamide or rituxumab)

Lumbosacral Radiculopathy (Sciatica)

Path: Nerve root compression d/t *Herniated disc* - Older patients or those w/prior traumatic injury can also develop it d/t *Lumbar spondylosis* - Also could be caused by Infections, Mass lesions, Vascular disorders, Developmental anomalies Pt: - Shooting or burning pain in LOW BACK - Radiates to CALF and FOOT - Minor weakness Dx: Positive *Straight leg raise* test (reproduces pain) - Neuroimaging (MRI) *NOT*!!!! recommended unless severe, progressive, bilateral, or suspect cancer or abscess Tx: *NSAIDs* - Consider *PT* if persists for >2wks - Most patients experience spontaneous improvement

Acute Respiratory Distress Syndrome (ARDS)

Path: Non-cardiogenic pulmonary edema...*NEUTROPHILIC* lung inflammation...Capillary gets leaky and lets fluid into alveolar-capillary membrane...can be triggered by Pneumonia, Pancreatitis, etc. - O2 is DIFFUSION limited and so is affected by this most --> HYPOXEMIA - CO2 is PERFUSION limited and so is less affected by this - Alveolar collapse d/t loss of surfactant Pt: - Sick as shit (septic shock, transfusion-related acute lung injury, near drowning, pneumonia, pancreatitis, etc), - Hypoxemic (PaO2/FiO2 ratio <200, PaO2 decreases and FiO2 increases) - Decreased *Lung Compliance* - Increased *Pulmonary Arterial Pressure* - Respiratory distress - Diffuse crackles - Bilateral alveolar infiltrates - V/Q mismatch w/increased Alveolar-arterial oxygen gradient Dx: CXR (pulm edema) - They will try and make you compare with CHF pulm edema!! If BNP is high then is CHF. if Echo indicates LV failure then CHF. Basically, PCWP elevated (bc fluid backs up into pulm veins) & decreased LV function in CHF. - in ARDS *LV function is normal or elevated* & *PCWP decreased or normal (bc fluid is not backing up into L atria)* Tx: Intubation + Treat underlying disease + Diuretics. "*Low Tidal Volume Ventilation*" (a lung protective strategy) --> GOAL IS TO *PREVENT OVERDISTENTION OF THE FEW ALVEOLI WHICH ARE OPEN AND FUNCTIONING*!!!! - CO2: *Keep tidal volume low* and *RR high* so you dont accumulate CO2 (high tidal volume will damage the alveoli) - O2: increase *PEEP* (maintains recruitment of alveoli since they are being crushed by fluid)!! Not O2 (FiO2). --> would see bilateral alveolar opacities if need PEEP increased --> Want FiO2 >60% initially but this is toxic (<60% is nontoxic)! So if stats look good, should turn it down - Prone position may help open up some of the alveoli collapsed dorsally. - *Conservative fluid strategy* --> Help keep FLUID OUT (bc their capillaries are leaky so it will only contribute to the issue you are treating)

Adjustment Disorder

Path: Non-life threatening STRESSOR resulting in mood change. - CANNOT be defined by bereavement!! Pt: MOOD CHANGE that doesn't quite fit criteria of other mood disorders - Marked *distress* out of proportion of the stressor --> Patient seeking help counts as sign of distress (if physician brings up patient looks "down" this doesn't count) - and/or Marked *functional impairment* --> Impaired social or occupational functioning Dx: Symptoms *within 3 months* of stressor - Resolves w/in *6 mo* of end of stressor - Diagnosis of exclusion Tx:*PSYCHOTHERAPY*

Fibromuscular Dysplasia (FMD)

Path: Noninflammatory and nonatherosclerotic condition caused by abnormal cell development in the arterial wall --> Vessel stenosis, Aneurysm, Dissection - Renal, Carotid, Vertebral arteries are the most commonly involved Pt: Young women of childbearing age w/severe HTN RENAL ARTERY (mc)? - Secondary HYPERTENSION --> causes Secondary hyperaldosteronism - Flank pain - String of beads appearance of renal artery - Abdominal bruit CAROTID ARTERY? - Recurrent headache - Pulsatile tinnitus - Neck pain - TIA - Stroke (including fam hx) - Monocular vision loss (amaurosis fugax) - *SUBAURICULAR (behind ear) systolic bruit* or *Carotid bruit* Dx: Duplex USD, CTA, MRA - Decreased perfusion to kidneys causes *Increased Renin & Aldosterone* (<20, ~10) Tx: Antihypertensives (ACE-I v. ARBs) - then PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY if needed --> and SURGERY if this doesn't work

Senile Purpura

Path: Noninflammatory disorder mc in elderly d/t loss of elastic fibers in perivascular connective tissue --> Minor trauma causes extravasation of blood - RF = Anticoagulants, NSAIDs, Corticosteroids Pt: - Mc on dorsum of hands and arms (vulnerable places) - Skin fragility - Ecchymosis - Normal labs (CBC, Coagulation, etc) Dx: Clinical Tx: Reassurance

Constitutional Growth Delay

Path: Normal variant of growth, d/t slowed linear growth velocity between 6mo-3 years. - Then after that grow normally but are behind. Pt: - Short - *Delayed bone age*!!! (unlike Familial Short Stature which would be NORMAL) --> But they are otherwise tracking normally. - Puberty is also usually delayed (unlike FSS which would be NORMAL) Dx: Growth charts Tx: Reassure. They will catch up to normal adult height.

Postpartum Blues

Path: Normal, self-limited condition that *occurs within a few days* postpartum - PEAK AT *5 DAYS*!!! - RESOLVES w/in *2 WEEKS*!! --> Beyond 2 weeks meets criteria for *Postpartum Depression (aka MDD w/Postpartum onset)*!!! - This means by the time the baby is brought in for first well child visit the symptoms have already resolved. - They are at INCREASED RISK of postpartum depression though (sx >2weeks or suicidal intention)... - And prior hx of MDD increases risk Pt: *MILD* depression that appears *2-3 days* following delivery (compared to Postpartum Depression which is full postpartum MDE). - Tearfulness - Irritability - Dysphoria - Anxiety - Insomnia - Impaired concentration Dx: Clinical Tx: *Reassurance*

Mediastinitis

Path: Occurs following *CARDIAC SURGERY* or Boerhaave syndrome. - Surgical stuff or GI stuff gets into the medistinum and causes infection - Post-Operative <14days Pt: 10-50% Mortality even w/correct treatment! - Fever - Tachycardia - Chest pain - RETROSTERNAL pain - Leukocytosis - Sternal wound drainage/*Purulent Discharge* "cloudy fluid" Dx: - CXR w/ *Widened mediastinum* Tx: *Surgical debridement + Drainage + Abx*

Ventilator Associated Pneumonia (VAP)

Path: Nosocomial pneumonia that develops *≥48hr* after endotracheal intubation. Usually aspiration of organisms from oropharynx or stomach. - Mcc aerobic/gram (-), and gram (+)s. RF: - Acid SUPPRESSION (you want the acid to kill the bacteria, so keeping it is good) - Supine position - Pooled subglottic secretions - Paralysis & EXCESSIVE sedation (prolongs days on ventilator and suppresses gag reflex) - Excess movement while intubated - Frequent ventilator circuit changes Prevent: - Head of bed to *45Degrees* - Suction of subglottic secretions - Limit use of gastric acid inhibitors Pt: - Fever - Purulent secretions - Difficulty with ventilation - Leukocytosis - Tachycardia - New infiltrates on CXR - Worsening oxygenation Dx: *CXR* w/abnormal findings (alveolar infiltrates, air bronchograms, silhouetting of adjacent solid organs) - Then *Endotracheal tube sample* (culture & microscopy) v. *BAL* Tx: *Vancomycin + Piptazo* ASAP (need coverage for Gram positives, Gram negatives, MRSA, and Pseudomonas) - If improves? Narrow abx to culture results - If not? Intensify or broaden abx - If cultures (-)? Look for other cause

Endometriosis

Path: Not clear...normal, ectopic, mullerian ducts, or derived endometrium - Typically worsens with time - MC in pouch of douglas and uterosacral ligaments - "Endometrioma" = Chocolate cyst Pt: - *INFERTILITY* (NOT miscarriages) --> d/t recurrent inflammation causing fibrosis and distort anatomy and impair implantation - Perimenstrual pain (in abdomen or in chest) - Pain with sex - Pain with defecation - Chronic pelvic pain - Fornix tenderness - *Uterosacral ligament thickening* - Heavy, painful menses - Pain THROUGHOUT menses (unlike primary dysmenorrhea which resolves in first couple days) --> Pain may even begin a day or two BEFORE menses - Immobile uterus - Anatomic distortion (x. lateral cervical displacement) - Cervical motion tenderness - Implants in bladder? --> Cyclical bladder pain --> Hematuria --> Dysuria --> Leukocytosis --> Anterior vaginal wall tenderness or nodularity Dx: Clinical - *Laparoscopic* confirmation - USD may show *Endometrioma* w/*homogeneous ovarian cyst with a ground-glass appearance* Tx: - First line? *Oral Contraceptives v. systemic progestin v. GnRH analog* + *NSAIDs* - If conservative management doesn't work? *Laparoscopy to ablate*! - Asymptomatic and doesn't desire fertility? *Observation*

Attention Deficit Hyperactivity Disorder (ADHD)

Path: Not sure what causes. Three types: - Inattentive - Hyperactive/Impulsive - Combo Pt: - Poor frustration tolerance - Impulsive behavior that results in conflicts with peers, parents, authority figures, etc. --> Leads to low self esteem, depression, or anxiety if untreated. IMPULSIVITY - Blurts out inner thoughts - Interrupts - Fidgets - Can't wait INATTENTION - Talks really fast - Easily distracted - Fails to finish tasks - Loses things - Can't follow directions Dx: Clinical - "At least some symptoms" BEFORE *12yo*. - Sx in *≥2 settings*!! - Duration of *≥6 months*. Tx: *Stimulants* if patient is *≥6 years old* - <6 years old? *Parent-child behavioral therapy* (parent management training) - NONSTIMULANTS? *Atomoxetine* v. Bupropion v. Guanfacine v. TCAs

Hydronephrosis

Path: OBGYN surgeries put at risk!!!! --> *Ureteral injury* is easy to do as the ureters run right next to the cardinal ligament (w/uterine artery) and infundibulopelvic ligament which are cut during hysterectomy BSO. Pt: - Postoperative unilateral back pain - Nausea - Vomiting - CVA tenderness - NORMAL renal function (bc OTHER kidney is functioning normally) Dx: Renal USD Tx: Surgical Correction

Bartholin Gland Cyst

Path: Obstruction d/t mucus, trauma, edema, idiopathic - Located at *4 o'clock* and *8 o'clock* positioning of vulvar vestibule posteriorly - D/t MRSA or E. Coli Pt: - Soft, mobile, nontender mass at the base of the labium majus that protrudes into the vagina - If large enough can cause discomfort with sex, walking, etc Dx: Clinical Tx: - Asymptomatic? *Observation* - Symptomatic or Abscesses? *I&D, then Word Catheter*

Bartholin Duct Cyst

Path: Obstruction of Bartholin Gland Duct d/t mucus, trauma, edema, idiopathic - Located at *4 o'clock* and *8 o'clock* positioning of vulvar vestibule posteriorly - "Behind the posterior labium majus" Pt: - Soft, mobile, nontender mass - If large enough can cause discomfort with sex, walking, etc Dx: Clinical Tx: - Asymptomatic? *Observation* - Symptomatic or Abscesses? *I&D*, then *Word Catheter*

Acne Vulgaris

Path: Obstruction of the pilosebaceous follicle with abnormal proliferation of keratinocytes and accumulation of sebum. --> This is then colonized by C. ACNES (recently renamed from p. acnes), causing inflammation Pt: Acne. - Comedonal type w/blackheads and whiteheads - Inlammatory type w/erythema and pustules - Nodular type w/cystic (usually painful) Dx: Clinical Tx: - COMEDONAL? --> *Topical retinoids v. Salicylic acid* - INFLAMMATORY? --> Mild? *Topical retinoids + Benozyl peroxide* --> Moderate? *+ Topical Abx* --> Severe? *+ ORAL Abx* - NODULAR? --> Moderate? *Topical retinoids + Benozyl peroxide + Topical Abx* --> Severe? *+ ORAL Abx* - Refractory to treatment? *ORAL Isotretinoin* monotherapy + (if female)... --> Needs negative *UPT x2* before starting tx, and then *UPT monthly*!!! --> AND Needs to either agree to not have sex with men OR use *Two forms* of effective contraception

Avascular Necrosis (Legg-Calve-Perthes Disease)

Path: Occlusion of end arteries supplying the femoral head, causing avascular necrosis. - Aka "Osteonecrosis of Femoral Head" - RF include... --> *SLE* --> *Corticosteriod use* --> SS Anemia --> Chronic alcohol abuse --> Smoking (coagulopathy) --> HIV/AIDs Pt: - Progressive hip pain (may localize to GROIN) - Limited INTERNAL rotation and ABDUCTION. - Deep/throbbing pain - May be worse w/ movement. - May have a catching or popping sensation w/ motion. - Inflammatory markers are NORMAL. Dx: XR & Labs will appear NORMAL!!! --> get *MRI* Tx: Decompression of femoral head w/ subcutaneous drilling. Hip replacement after collapse and persistent pain.

Nightmare Disorder

Path: Occurs *during REM* sleep, - mc in SECOND HALF of night Pt: - Recurrent awakenings with disturbing dreams - Fully alert when awakened - No motor activity - No sleep-related injury. - *REMEMBERS* dream (dif from Sleep Terrors) - *RESPONSIVE* to comfort (dif from Sleep Terrors)

Postdural Puncture Headache

Path: Occurs after neuraxial anesthesia --> Unintentional dural puncture --> CSF leakage causes headache --> slight herniation of brain stem Pt: Like migraine but - Occipital headache - Worse with sitting or standing d/t CSF leakage, improved when supine - Neck stiffness - Photophobia, Diplopia - Hearing loss, Tinnitus - Nausea - Vomiting - NO FND or HTN (if you see this think preeclampsia if delivered sometime in past *6 weeks*) Dx: Clinical Tx: *Epidural blood patch*

Tuberculosis Meningitis

Path: Occurs in 5% of those with extrapulmonary TB - Risk increased in those with malnutrition, substance abuse, HIV, etc. - Nidi of infection cause hypersensitivity reaction which causes gelatinous substance to coat basilar region of the brain and block CSF outflow. Pt: Slowly progressive sx over weeks (how you dif from other bacterial meningitis) - Subacute fever - Vomiting - Nuchal rigidity - Stroke Dx: CT w/"*Moderate hydrocephalus & Basilar meningeal enhancement*" or *CSF acid-fast bacilli* Tx:

Infant Botulism

Path: Occurs in children *<1yo* following ingestion of C. botulinum spores. - Their GI lacks the protective microbiota that adults have, so spores are able to colonize. - Inhibits *presynaptic Ach release at the NMJ*. Pt: - Constipation - Poor feeding - Irritability - Muscles innervated by CNs --> Ptosis --> Impaired pupillary constriction --> Absent gag reflex - Descending paralysis - Respiratory failure - Absent DTRs - Hypotonia Dx: C. botulinum toxin or spores in stool Tx: IVIG Botulism

Nonbullous impetigo

Path: Occurs secondarily d/t skin trauma - Usually STREP or STAPH --> BULLOUS IMPETIGO has bullae and is caused by STAPH!!! - RF = Warm, Humid, Poor hygiene, - *Can get PSGN, but NOT RF* (treatment of impetigo does not decrease risk) Pt: - Kiddos - First? Papules and pustules - Then? Honey-crusted lesions Tx: Topical *Mupirocin* - Cephalexin po if severe or bullous!! - Clindamycin if pen allergic

Ischemic Colitis

Path: Occurs when part of the large intestine is partially or completely deprived of blood (x. atherosclerosis) - mc in splenic flexure - A form of Mesenteric Ischemia Pt: - Abdominal pain - BLOODY diarrhea - WEIGHT LOSS - Colonic strictures Dx: - CT w/pneumatosis (air and edema) in bowel wall - Colonoscopy w/ cyanotic mucosa and hemorrhagic ulcerations --> Bx w/"*Mucosal atrophy and granulation tissue*" Tx: IVF + Bowel rest + Abx

Ulnar Neuropathy

Path: Often compressed at the *elbow* - Cubital tunnel (holding cell phone) - Epicondylar groove (leaning on elbow) Pt: - Predominantly sensory loss of medial hand - May have weakened grip Tx: Avoid repeated provoking movements - Then try *Intra-articular steroid injection* - Then Surgery

Brief Psychotic Disorder

Path: Often develop d/t a marked STRESSOR (Think of the guy who almost got hit by the beam and then develops paranoid delusions and bizarre behavior, hypervigilant, agitated, suspicious) - Reaction to trauma or stressor - Pregnancy induced psychosis - Postpartum psychosis - Medication induced (x. steroids) Pt: POSITIVE symptoms 1. Delusions (persecution, grandiosity) 2. Hallucinations (auditory) - more common than delusions in pediatric cases. 3. Disorganization of SPEECH 4. Disorganization of BEHAVIOR NEGATIVE symptoms 5. Flat affect 6. Poverty of speech and movement 7. Anhedonia 8. Cognitive delay (becomes more impaired with each cognitive break) Dx: - *≥1 symptoms* - Duration *>1 day, <1 month* w/full return to function Tx: Antipsychotics (*1 MONTH*)

Atelectasis

Path: One of the most common post-operative pulmonary complications (esp after abdominal surgery) - 2-5 days after surgery - d/t *Mucus plugging* --> Can be seen with asthma as well Pain & Changes in lung compliance --> *Impaired cough & Shallow breathing* - Shallow breathing leads to limited alveoli recruitment at base of lungs --> Decreased O2 - Impaired cough leads to mucous plugging --> Decreased O2 Pt: "Bibasilar crackles that clear with coughing" Dx: DECREASED O2 leads to increased respiratory rate which causes DECREASED CO2 - *Respiratory Alkalosis* w/decreased O2 & CO2 - CXR w/Trachea TOWARDS (think of condensed lung tissue pulling trachea) - "Opacification of the affected lung area with ipsilateral mediastinal shifting and rib space narrowing" Tx: CPAP ± Chest physiotherapy and suctioning - PROPHYLAXIS? *Pain control, Deep breathing exercises, Directed coughing, Early mobilization, Incentive spirometry*

Open Angle Glaucoma

Path: Optic neuropathy characterized by atrophy of the optic nerve head - RF = *DM*, African American, Fam hx Pt: Insidious, slowly progressive course...pt's often asymptomatic until condition is advanced - Loss of *PERIPHERAL VISION* in all fields (tripping over objects, near MVAs Dx: - Enlarged optic cup "Cupping of the optic disc" - Increased Cup:Disc ratio - Tonometry w/*Increased intraoccular pressure* Tx: *Bimatroprost* - Could consider adding *Timolol* (watch w/asthma) - Then last, Surgery.

Glaucoma in Children

Path: Optic neuropathy d/t increased intraoccular pressure from impaired drainage of intraocular fluid - *Sterge-weber* (usually seen on side of port-wine stain) --> Anterior chamber angle anomaly Pt: - Enlarged cornea and globe - Conjunctivitis - Clear tearing - Conjunctival erythema - Photophobia - Blepharospasm (twitching of eye) - Cupping of the optic nerve - NO issues w/eye movement Dx: *Tonometry* Tx: *SURGERY*!!!! To preserve vision. We don't try conservative options with kiddos

Osgood-Schlatter disease

Path: Osteochondrosis (abnormal growth, injury, or overuse of the developing growth plate) of the TIBIAL TUBERCLE (unlike Patellar tendinitis which is at distal patella) Pt: Teenage athletes - Knee pain and *TIBIAL SWELLING* - Worse pain with RUNNING and JUMPING Dx: Clinical Tx: Sit it out = Curative - Work through it

Listeria Monocytogenes

Path: Outbreaks via ingestion of contaminated food (x. deli meats, milk, cheeses) - Replicates at cold temperatures - Invades intestinal mucosa when infected Pt: Immunocompetent patients are self-limited. Immunocompromised patients (x. PREGGO) have increased risk of invasive disease (can cross placenta). - Watery diarrhea - Fever - Vomiting - If fetus infected in FIRST or SECOND trimester, can cause *granulomatosis infantiseptica* --> FETAL DEMISE (hydrops fetalis) - If fetus infected in THIRD trimester can cause fetal distress, neonatal sepsis, preterm delivery Dx: Tx: - Pregnant women should avoid raw meats and raw vegetables, unpasteurized dairy products, and processed meats - Wash hands after handling soil and *unwashed produce*

Zenker Diverticulum

Path: Outpouching of pharyngeal mucosa through an acquired defect in the muscular wall (false diverticulum) - *IMPAIRED CRICOPHARYNGEAL RELAXATION* - Pulsion (internal force rather than external) creates diverticulum Pt: - Malodorous breath - Regurgitation of undigested food - WITHOUT dysphagia Dx: Barium Swallow Tx: *Cricopharyngeal myotomy*!!!!

Ruptured Ovarian Cyst

Path: Ovarian cyst ruptures - Sexual or strenuous activity may cause Pt: - Unilateral lower abdominal pain - Adnexal mass - Peritoneal irritation - Pain may radiate to shoulder (phrenic nerve irritation) Dx: Pelvic USD w/free fluid - CBC - UPT Tx: - Uncomplicated? Conservative - Complicated (Fever, Hypotension, Tachycardia, Peritoneal signs)? Surgery

Calcaneal Apophysitis (Sever Disease)

Path: Over-use injury at the growth plate via repetitive microtrauma to the place where the achilles attaches to the calcaneus. - Athletic children - *Running and Jumping* sports (like Achilles tendinopathy) Pt: - Bilateral heel pain - Worse with activity - Tenderness when squeezing the heel - Tenderness at *base of heel* or within first 2cm of Achilles tendon insertion into heel (how dif from Achilles tendinopathy) - Limited ankle dorsiflexion d/t tight Achilles tendon and decreased Gastrocnemius flexibility Dx: *Calcaneal compression test* Tx: Stretching, ice, NSAIDs, heel cup insert

De Quervain's Tenosynovitis

Path: Over-use syndrome causing tendonitis of the *ABductor pollicus longus* and *Extensor pollicus brevis* - RF = 4-6wk postpartum Pt: - Thumb pain - Tenderness at radial side of wrist at base of hand - Mom cradling baby - Guy lifting weights Dx: Clinical - Finkelstein's test Tx: 1) Splinting + NSAIDs (keep out of flexion) 2) Intra-articular steroids NO SURGERY

Salicylate Toxcicity

Path: Overconsumption or even excessive topical salicylate use (Aspirin/ASA) - MUDPILES Pt: *MIXED ACID-BASE DISTURBANCE*!!!! --> PH is usually NORMAL!!! - Immediately after consumption? Tinnitus, N/V, vertigo, Tachypnea --> PRIMARY *RESP ALKALOSIS*. - Several hours later? Obtunded, hyperpyrexia (high fever) --> *ANION GAP Metabolic ACIDOSIS* Dx: SALICYLATE LEVEL Tx: - If w/in 2hr of ingestion? *Activated charcoal* - If caught later and kidneys are good? *Na Bicarbonate* (requires large volume though) - If caught later, severe, or other signs of organ failure? *Hemodialysis* (N-Acetylcysteine is for ACETAMINOPHEN!)

Lateral Epicondylitis

Path: Overuse of the *Extensor muscles* causes noninflammatory angiofibroblastic tendinosis at the common extensor origin on the *Lateral epicondyle*. - Disorganized tissue and neovessels (tendinopathy and degeneration, NOT inflammation) - "Tennis elbow" Pt: - Pain with PASSIVE wrist FLEXION at wrist - OR....RESISTED wrist EXTENSION - Tenderness at the lateral epicondyle Dx: Pain with wrist extension or making fist. Tx: Counterforce elbow brace + Activity modification + NSAIDs

Patellofemoral Pain Syndrome

Path: Overuse, malalignment, acute injury (NOT peripatellar or intraarticular disorders) Pt: - Female MC, - Hurts with stairs, - Worse w/prolonged sitting, - Atrophy of quads, - Varus/valgus deform, Dx: Clinical Tx: Exercises for quads and hip abductors, NSAIDs

Methemoglobinemia

Path: Oxidation of iron from 2+ to 3+, which is then unable to bind oxygen --> Functional anemia bc oxygen is not able to be delivered to tissues - D/t drugs like *Dapsone, Anesthetics, Nitrates* Pt: Cyanosis + Resp depression - Lactic acidosis bc cells have to use anaerobic metabolism (*METABOLIC acidosis*) Tx: *Methylene Blue*

Cataract

Path: Oxidative damage to the lens causes opacification of the lens. - RF = DM, Smoking, Sunlight, Steroids, Uveitis, Scleritis, Penetrating traumatic injury. - Slowly progressive course Pt: - Typically >60yo but can be younger if associated w/HIV - Painless blurring of vision - Loss of acuity, - Glare, - Halo around lights - Clouding of the lens - Early on red reflex may be RED, and then will lose this as time goes on Tx: SURGERY --> *lens replacement*

Primary Hyperparathyroidism

Path: PRIMARY= from *autonomous adenoma* - PTH secreting adenoma Pt: "Bones, Stones, Abdominal groans, Psychic moans" - Renal stones - Osteoporosis w/pathologic fractures - *Pseudogout* (d/t Calcium-pyrophosphate deposition) - Constipation - Psychosis/Depression - Brown tumors - HYPERTENSION - Increased PTH - Increased Ca2+ - Decreased Phos ("kidney" pattern bc PTH elevated) - *HYPERCalciuria* (how you dif from Familial Hypocalciuric Hypercalcemia) Dx: Sestamibi parathyroid scan - Primary? ONE large parathyroid gland, other atrophied Tx: Primary? RESECTION (if <50yo, are symptomatic, have osteoporosis, nephrolithiasis, CKD, etc.) - Then watch out for HYPOca2+ (Perioral tingling, Trousseou's sign, Rovsing's sign) bc other glands have atrophied --> Tx w/IV Ca2+

Mittelschmerz

Path: Pain in the middle of the menstrual cycle d/t ovulation (day 10-14) - Rupture as follicle releases egg Pt: - Unilateral abdominal pain - Lasts less than a day Dx: Clinical - USD w/*large cyst with multiple smaller cysts* --> May be a small amount of fluid which is what irritates the peritoneum - R/o other more concerning things Tx: Reassurance

Breath Holding Spells

Path: Pain or fear can cause breath holding spell Two subtypes... - CYANOTIC --> d/t tantrum - PALLID/pallor --> d/t trauma Pt: LOC <1min Risk factors - Family history - Age 6mo-2 years - Iron deficiency anemia Dx: Clinical Tx: Reassurance + Iron supplementation (if deficient) - Resolves by 5yo

Necrotizing Pancreatitis

Path: Pancreatic inflammation causes uncontrolled release of pancreatic enzymes which digest the pancreas and peripancreatic tissues Pt: All the signs of pancreatitis + sick as shit (sepsis) - Fever - Hypotension - Tachycardia - Confusion - Enteric pathogens can infect the necrotic pancreatic tissue Dx: CT w/necrotic pancreas - If gas? Then infected. (usually 7-10 days after) Tx: *Necrosectomy* (but have to wait until later so it is encapsulated and you can scoop it out) - IF!!! FNA proven bx w/infection? *Carbapenem*

Croup

Path: Parainfluenza virus which spreads through nasopharyngeal mucosa to larynx and trachea --> Edema and narrowing of the PROXIMAL trachea Patient: - 3mo-3yr, - Viral prodrome - Low grade fever - Rhinorrhea first...then - Hoarseness - barking seal-like cough, "harsh cough" - INSPIRATORY STRIDER (upper airway obstruction differentiates from bronchiolitis/RSV) Dx: Improvement with RACEMIC EPINEPHRINE. (XR w/steeple sign is also seen with bacterial tracheitis) Tx: - Mild (stridor when crying)? Single dose of *Dexamethasone* (to reduce airway edema) - Moderate (stridor at rest)? Dexamethasone + Nebulized *Racemic epinephrine* + O2. - Severe? Ongoing O2 + Racemic epi.

Measles (Rubeola)

Path: Paramyxovirus - Highly infectious - AIRBORNE (Spread by infectious respiratory particles) - LIVE vaccine at *12-15mo* --> If international travel they should get earlier (6-11mo) Pt: Fever & Rash simultaneously (at *SAME* time) - Begins on FACE and then spreads down (just like Rubella) --> Spares palms and soles - HIGH TEMPT 104 - Different from Rubella via *4 C's*: !!! *Cough,* *Coryza (runny nose),* *Conjunctivitis,* *Koplik spots* (small white lesions in buccal mucosa) Dx: Clinical Tx: *Supportive* - Severe or Immunocompromised? *Vitamin A* (reduces morbidity and mortality of patients w/infection) - Think of the "A" hat on the weasle - Later on in life can develop *Subacute Sclerosing Panencephalitis* - There's a vaccine (MMRV), so if someone gets they'll have a reason why weren't vaccinated...12-15 MONTHS OLD!!! - Can cause mild measles reaction 1-3wks after vaccine --> RESOLVES ON OWN, so reassure and have avoid immunocompromised.

Humoral Hypercalcemia of Malignancy (HHM)

Path: Paraneoplastic syndrome, where malignant SQUAMOUS cells release *PTHrP* (which simulates PTH) --> Bone resorption & Reabsorption of Ca2+ from distal renal tubule - Smoking hx? *SCC of lung* - "SCa++amous" - Mcc of PTH-independent Hypercalcemia Pt: SUDDEN onset - Severe, *rapid onset* HYPERcalcemia - *HYPOphosphatemia* (how you dif from Osteolytic malignancy which would be NORMAL) - Weakness - Diminished reflexes - Decreased GI motility - Weight loss - Temoporal wasting - Vitamin D (1,25) levels are NORMAL or LOW (unlike Primary hyperparathyroidism) Dx: Clinical...*Ca2+ is usually >14*!!! (rare for any of the other causes to get it this high) - Confirm w/*elevated PTHrP* and *decreased PTH* Tx: Aggressive *IVF* + *Calcitonin* - Can consider adding bisphosphonates later as needed.

Nonaccidental Trauma

Path: Parent figures who were abused as children often repeat the pattern with their own children. - RF = Single parent home, Domestic violence, Unstable family situation Pt: - Femur fractures in nonambulatory infants - Metaphyseal corner fracture - Posterior rib fractures - Skull fractures Dx: *Skeletal survey* w/fractures of varying age or stages of healing - Consider also Fundoscopy or CT of head to assess for intracranial bleeding.

Atrioventricular Nodal Reentrant Tachycardia (AVNRT)

Path: Paroxysmal supraventricular tachycardia Pt: - Regular rhythm - Adolescents/Young adults - Palpations - Dyspnea - Syncope/Presyncope

Dog/Cat Bite

Path: Pasturella + oral anaerobes. - Cat bites are more likely to cause infection than dog or human bites! Dx: Clinical Tx: Irrigation + *Amoxicillin-Clavulanate* - Leave wound open to heal by secondary intention --> ≥3 vaccines in childhood? *Tetanus Toxoid vaccine* if last dose was *≥5yr* ago --> <3 vaccines in childhood or uncertain? *Tetanus Toxoid vaccine* + *IV IG*

Ankylosing Spondylitis (AS)

Path: Pathogenesis driven by inflammatory cytokines, *ESPECIALLY TNF-alpha*!!!!! which eventually destroys articular cartilage - Immune response mediated primarily by T-Cells Pt: - UVeitis - IBD - Tenderness at the SI joint - *Enthesitis* (tenderness at tendon insertion sites) --> Heels, Shoulders, Elbows, Hips, Costosternal junctions, Iliac crests, Tibial tuberosities, etc. - Dactylitis (swelling of fingers and toes) - Aortic regurgitation (early diastolic murmur) - Osteopenia/Osteoporosis (increased osteoclast activity d/t chronic inflammation) - *Vertebral fractures* (d/t spinal rigidity) - Thoracic wedging - Hyperkyphosis - Reduced chest expansion causes *RESTRICTIVE lung disease* pattern --> Both decreased but ratio increased (FEV1/FVC >80%, & FEV1 alone <80%)) - Ribs get fixed into *INSPIRATORY* position ... --> FRC and RV are normal or high!!! (obstructive pattern) Dx: *XR of SI joint* - Could consider MRI - ESR elevated - CRP elevated - HLAB27 association Tx: *NSAIDs (esp Indomethacin) + Local steroids* - Maybe even *TNF-alpha-inhibitors* (Etanercept, Infliximab) - Exercise regimen w/postural and ROM exercises - Supervised PT - NOT DMARDS!!!

Sinus Bradycardia

Path: Pathologic causes include *Sick sinus syndrome*, MI, OSA, Hypothyroidism, increased ICP, Medications. - Can occur NORMALLY in athletes, young individuals, during sleep, etc. (asymptomatic) Pt: Most are asymptomatic - Fatigue - Dizziness - Lightheadedness - Syncope - Hypotension - Angina - CHF Dx: Tx: Identify and treat reversible causes. - Symptomatic? *Atropine* IV - Then can try *Epinephrine* v. *Dopamine* v. *Transcutaneous pacing* --> Only use Glucagon if suspect BBlocker or CCB toxicity

Separation Anxiety Disorder

Path: Pathologic when separation anxiety becomes persistent, impedes development, or causes functional impairment. - Normal 9-18mo old - Starting school or transitioning in some way can trigger - Traumatic life events can trigger Pt: Usually <12yo, but can occur at any age - Fear of separation - Reluctance to leave - Excessive concern that something bad will happen - Somatic symptoms (stomach ache) - Impedes development or causes functional impairment - At 9-18 MONTHS old this is normal - NO issues with making decisions for self (i.e. dependent personality), more concern about other person specifically Dx: Clinical Tx:

Phantom Limb Pain

Path: Patient with amputation now has *neuropathic* pain in the absent part of the limb - Extremely common in amputees Pt: - Shooting, burning pain - Innocuous triggers (x. urination, defecation) Dx: Clinical Tx: *Multimodal therapy* (with pharmacotherapy and adjuvant therapy...CBT, mirror therapy, biofeedback etc.)

Contrast Induced Nephropathy (CIN)

Path: Patients undergoing imaging with IV CONTRAST who have prior hx of CKD - Esp Diabetic Nephropathy Pt: - ATN w/Muddy brown granular and epithelial casts - Renal vasoconstriction causes PRERENAL injury despite adequate volume - *Urinary Na+ <20* Because tissue is damaged and not able to reabsorb (other causes of ATN is >20) - BUN:Cr Ratio of *10-15:1* (prerenal azotemia is >20:1) - Resolves in 3-5 days. Prevent: - Lowest dose possible - IVF - NO NSAIDs

Achilles Tendinopathy

Path: Patients who abruptly increase their physical activity (esp running or jumping) - RF: Athletic activity, Fluoroquinolone use, Psoriasis, Ankylosing spondylitis, Reactive arthritis, Glucocorticoids. Pt: - Ankle pain - Swelling - Tenderness - Stiffness - Most prominent *2-6 cm ABOVE the posterior calcaneus* along achilles tendon (how dif from Sever's) Dx: POSITIVE *THOMPSON TEST* (calf squeeze) Tx: - Acute? Decrease activity, ice, NSAIDs - Chronic? ECCENTRIC exercise resistance (*Calf-strengthening exercises*)

Esophageal Perforation

Path: Pedestrians struck by vehicle in MVA w/THORACIC TRAUMA, Mom w/Hyperemesis gravidarum Pt: - Pneumothorax --> then *Turbid green (or yellow) pleural effusion* (*w/high amylase and low pH*) - Retrosternal chest pain - Pain radiating to back - Widened mediastinum on CXR - Pneumomediastinum/Subcutaneous emphysema "Crunching" - Dyspnea - Sepsis - Odynophagia Dx: Esophagography or CT w/water soluble contrast Tx: Surgical emergency + IV PPI + IV Abx + NPO

Posterior Urethral Injury

Path: Pelvic fracture can cause - Involves prostatic or membranous urethra, superior to the urogenital diaphragm. - Most common site is bulbomembranous junction Pt: - Blood in meatus - Inability to void - *High-riding prostate* on DRE - Perineal/scrotal hematoma. Dx: *Retrograde urethrogram* (XR of urethral tract after injection dye into urethral meatus....as such no cath is required) Tx: *Suprapubic catheter* until it heals --> Delayed repair (compared to anterior urethral injuries, which have urgent surgery)

Persistent Pulmonary Hypertension of the Newborn (PPHN)

Path: Persistence of elevated fetal pulmonary resistance - RIGHT to LEFT shunt across ductus arteriosus --> *high O2 in UE and lower O2 in LE* - ASSOCIATED WITH lung injury (x. *MECONIUM ASPIRATION*) Pt: - PREductal (UE) O2 sat NORMAL, - POSTductal (LE) O2 sat LOW - Respiratory distress (some infants are asymptomatic) - Cyanosis - Prominent S2 Dx: CXR is often *NORMAL* Tx: Oxygenation + Ventilation + *Inhaled NO* (pulmonary vasodilator)

Gambling Disorder

Path: Persistent and maladaptive gambling that results in impairment or distress - Nonsubstance behavioral addiction Pt: - Anticipatory craving - Chronic relapsing course - Preoccupation with gambling - Frequent return to gambling to recover losses - Tendency to damage relationships or employment - Reliance on others to make up for financial losses - Gambling when distressed, depressed, anxious - Increased gambling to achieve desired excitement - Irritability/distress when trying to cut back - Repeated unsuccessful attempts to cut back and conceal behaviors Dx: *≥4 characteristics* related to problematic gambling behavior Tx: *CBT* + *Self-help programs*

Condylomata Acuminata (Genital Warts)

Path: Persistent infection with *low-risk HPV strains 6 & 11* - RF = Chronic tobacco use or immunosuppression (x. pregnancy) Pt: - Clusters of "soft PINK or fleshy skin colored lesions" --> May be somewhat *friable and bleed*!!! - Exophytic - Dry appearing - *Verrucous* (looks like Cauliflower) or are flat - *Pruritic* - Asymptomatic otherwise, and nontender - Friable with manipulation Dx: Clinical Tx: *Tricholoracetic acid* v. *Imiquimod* v. or surgical excision - Preggo? *Tricholoracetic acid* --> Neonates at risk for Respiratory Papillomatosis, but you still deliver them vaginally!! bc risk does not decrease w/C-section - High recurrence rates regardless of treatment - In kid? They should resolve on own without treatment. Evaluate for sexual abuse.

Chronic Suppurative Otitis Media

Path: Persistent non-healing perforation of the tympanic membrane. - Eustachian tube dysfunction or Cholesteatoma weakens the TM and then perforates, allowing external bacteria into middle ear. - Mcc *Staph aureus* & *Pseudomonas* - Cleft palate increases risk Pt: - CHRONIC EARACHE, though pain is uncommon - DEAFNESS (conductive hearing loss) - persistent DISCHARGE from EXTERNAL AUDITORY MEATUS. - Normal external canal Dx: Clinical Tx: *Ototopical fluoroquinolone drops* (oral meds don't work bc the middle ear is now poorly vascularized from scarring)

Heat Exhaustion

Path: Person exercises in heat or high humidity --> Interferes with body's ability to cool off (evaporate sweat) - RF = Older age, Obesity, Poor physical fitness, Illness, CF (bc have higher concentration of Na and Cl in sweat) Pt: - Temp *<104F* (how we dif from Heat Stroke) - Nausea - Presyncope - Hyperthermia - Tachycardia - Tachypnea - Hypotension - Weakness - Dizziness - Profuse sweating - Headache - N/V - ABSENCE of CNS dysfunction (how dif from Heat Stroke) Dx: Tx: Cool patient (air conditioning, cold shower) + Salt-containing fluids

Acute Glenohumeral Dislocation

Path: Physical trauma causes shoulder to pop out of place. - ANTERIOR dislocation: Arm held in *ABduction/External rotation* --> Blow to *abducted* and/or *raised* arm, Violent muscle contraction (x. seizure) --> Worry about *Axillary nerve* injury (innervates teres minor and deltoid...which cause shoulder ABduction and lateral shoulder sensory innervation) - POSTERIOR dislocation: Arm held in *ADduction/Internal rotation* --> Fall on *outstretched* hand Pt: - Shoulder pain - "Guarding" w/limited willingness to move shoulder Dx: Shoulder XRay - Anterior? *Inferomedial displacement of humeral head in relation to coracoid and glenoid* Tx: *Closed reduction* v. *Surgical repair* - F/up w/*Immobilization & Progressive rehab* - Patients are at risk for further dislocation d/t *Labral tears, Ligamentous laxity, Multidirectional joint instability*, etc.

Exercise Associated Postural Hypotension

Path: Physiological adaptations in endurance athletes w/higher CO d/t hypertrophy and hyperplasia of LV - D/t abrupt cessation of exercise, muscles are no longer supplying same venous return as they were before so you see decreased preload, --> Heart hasn't caught up with that yet so initial response is postural hypotension and temporary collapse Pt: - Transient postural HYPOtension - HYPERthermia (elevated temp) - Collapse - NO LOC or mental status changes (unlike exertional heat stroke) Dx: Clinical Tx: Trendelenberg + oral Fluids

Abruptio Placentae

Path: Placenta tears off endometrium d/t large insult (HTN, cocaine, tobacco, MVA, polyhydramnios) --> sudden loss of volume (ROM) or vasoconstriction of maternal placental vessels causes shearing. - When placenta tears off = COMPLETE - When bleed goes into placenta and is hidden = CONCEALED - RF = Multiple gestation, Polyhydramnios (bc overdistention can cause sudden loss of volume when water breaks) Pt: - Vaginal bleeding - Tender, hypertonic (firm) uterus - PainFUL, severe abdominal pain (bc mom's blood) --> may present as back pain if placenta is posterior - Polyhydramnios - High frequency contractions - Mom may get *DIC* - "Rigid, diffusely tender uterus" Dx: USD, Contraction Stress Test or Non-Stress Test - check mom's Hgb, vitals, mentation. Tx: C-SECTION - Consider transfusion (1:1:1) in mom FIRST if signs of hypovolemic shock (hypotension, tachycardia, cool extremities)

Hepatic Hydrothorax

Path: Pleural effusion d/t the ascites caused by cirrhosis and portal HTN (low albumin levels and abnormal extracellular fluid regulation) going through defects in the diaphragm. - TRANSUDATIVE effusion Pt: - RIGHT sided pleural effusion - Hx of cirrhosis, portal HTN, ascites - No cardiac or pulmonary indication for cause - Dyspnea - Cough - Pleuritic chest pain - Hypoxemia Dx: CXR - R/o other causes Tx: *Diuretics* + *Salt restriction*

Asbestosis

Path: Pneumoconiosis from exposure (x. mining, shipbuilding, insulation, pipe work) - Latency period ≥20yr - RF = *SMOKING* (when added to asbestos exposure creates 59x increased risk of Bronchogenic Carcinoma) - Bronchogenic Carcinoma (mcc) >>> Mesothelioma Pt: - Progressive dyspnea over period months - Cough - Sputum production - Wheezing - *Digital clubbing* - *Bibasilar end-inspiratory crackles* Dx: CXR w/*Interstitial thickening of lower lung fields in reticular (net like) pattern*, *Cavitary mass* (Bronchogenic carcinoma) & *Pleural plaques* (could be Mesothelioma or just Asbestosis) - "Supleural linear densities and parenchymal fibrosis" - PFT w/Restrictive Pattern (FEV1/FVC >80%) - Decreased DCLO - Decreased pulmonary compliance Tx:

External Hemorrhoids

Path: Venous hypertension within the hemorrhoidal venous plexus. Pt: - Purplish anal bulge BELOW dentate line - Severe pain if thrombosed - Mucosal ulceration if thrombosed - NO bleeding usually (that's internal) Dx: Clincial Tx: - Mild? *Sitz baths + Lidocaine + Stool softeners + Nitroglycerine cream* - Severe pain or Refractory to tx? *External hemorrhoidectomy*

Irritable Bowel Syndrome

Path: Poorly understood, likely involves visceral hypersensitivity and abnormal GI motility - Associated w/Anxiety, Depression, Fibromyalgia Pt: - Young women - Diarrhea AND/OR constipation - Abd pain relieved w/defecation...sometimes worse w/defecation - Bloating - Flatulance - Nausea - Tenesmus - FOB negative - NORMAL ESR - *>1day/week for ≥3mo* (or 12 weeks in last year) Dx: Exclude organic disease w/*CBC + Inflammatory markers (ESR) + Fecal Calprotectin* - Diarrhea subtype? r/o CELIACs w/*Serum IgA Anti-TTG* --> FURTHER TESTING NOT REQUIRED (x. colonoscopy) unless ALARM FEATURES are present. Tx: - Constipation subtype? LOW FODMAP diet - Diarrhea subtype? LOPERAMIDE

Esophageal Varices

Path: Portal HTN from cirrhosis Pt: Cirrhotic, GI bleed Dx: EGD - *SCREENING EGD* should be completed upon Dx of Cirrhosis to check for varices!! Tx: - Stable? *BBlockers + Oxygenation* --> then *Banding* - Bleeding? *Vasopressin + Somatostatin + Abx* --> then Endoscopy to complete *Variceal ligation or Sclerotherapy* --> then *Balloon tamponade* if all this unsuccessful --> Lastly, consider *TIPS* (increases risk for Hepatic Encephalopathy) - Massive bleed/Altered mental status/Persistent hematemesis (risk for aspiration)? *Intubate*!!! Prophylaxis? *Propanolol v. Nadolol*

Dumping Syndrome

Path: Post-GASTRECTOMY - Loss of normal action of the PYLORIC SPHINCTER --> Rapid emptying of hypertonic gastric contents into the duodenum, drawing fluid into small intestine Pt: - HYPOtension - Stimulation of autonomic reflexes --> Abd pain, --> Nausea, --> Diarrhea, --> Dizziness, --> Tachycardia, --> Hypotension, --> Diaphoresis) Dx: Clinical Tx: *DIETARY MODIFICATION* - Frequent, SMALL meals - Eat slowly - Avoid simple sugars - Increase fiber and protein - Drink fluids between meals

Congenital Torticollis

Path: Postural deformity from intrauterine crowding (x. breech presentation, multiple gestation, oligohydramnios) Pt: - *Neck mass* (even if they just say "Firm mass on inferior portion of SCM" like jerks.....represents muscle fibrosis apparently)!!! - Ipsilateral head tilt, - Contralateral rotation, - Flattening of head on one side posteriorly. Dx: Clinical Tx: Positioning (x. tummy time), Passive stretching, PT

Viral Myocarditis

Path: Potentially lethal disorder of the myocardium. Myocyte necrosis via direct viral injury and autoimmune inflammation causes systolic and diastolic dysfunction. Mcc are... - COXSACKIE B or A. - Adenovirus. - Parvo B19. - HHV6 - Influenza - HIV Pt: - <55yo - Viral prodrome - Chest pain - Respiratory distress - Then signs of CHF (d/t *Dilated cardiomyopathy* aka Eccentric Cardiomyopathy) --> Bilateral pleural effusions --> Dyspnea --> Paroxysmal nocturnal dyspnea --> LE edema - Cervical lymphadenopathy - S3 and holosystolic murmur - ECT w/*nonspecific ST changes* - CXR w/CARDIOMEGALY - Hepatic congestion (from Heart failure) Dx: *Endomyocardial bx w/PCR* Tx: Supportive. Treat CHF. - Some patients recover cardiac function - Complete resolution, but may leave fibrosis and dilated cardiomyopathy. - Patchy necrosis with CD8 (MI would have PMN, macrophage, fibroblast)

Oral Leukoplakia

Path: Potentially malignant or premalignant lesion in mouth. - RF = *Tobacco use*, Alcohol use (synergistic effect) --> Similar RF to SCC Pt: - Painless - White mucosal lesion - Lateral and/or inferior tongue - CANT be scraped off (unlike candida) Dx: *Bx* Tx: - Benign? Stop tobacco & alcohol, frequent oral exams, come in if changes

Myasthenic Crisis

Path: Precipitated by *infection, surgery, meds* Pt: - Severe respiratory muscle weakness - Respiratory failure - Bulbar muscle weakness Dx: Clinical Tx: *Intubate* + (*IVIG* v. *PLASMAPHERESIS*) + *Corticosteroids* - NO!! PYRIDOSTIGMINE (bc increases secretions during intubation)

Eclampsia

Path: Preeclampsia w/new onset seizure - Abnormal placenta releases anti-angiogenic factors causing maternal endothelial dysfunction Pt: - Hypertension - *Seizure(s)* (tonic-clonic, generalized, brief) - Hyperreflexia - Signs of other organ failure Dx: Clinical - White matter edema seen on CT Tx: *Delivery* (usually emergency C/S, removal of the placenta is curative) - *Magnesium* for seizures (f/up on DTRs bc don't want to suppress everything so much that there are resp issues...give Ca2+ to correct) --> If have Myasthenia? Use *Valproic acid* (...odd choice d/t teratogenicity)

Systemic Lupus Erythematosus in Pregnancy

Path: Pregnancy and postpartum period have increased risk for flares. - RF = d/c Hydroxychloroquine, Active disease prior to conception - Difficult to differentiate from preeclampsia, but would have additional *s/sx specific to SLE* (x. malar rash, joint pain, RBCs on UA, decreased complement, increasing ANA) - Increases risk of = Preeclampsia, Preterm birth, C/S, Fetal growth restriction, Fetal demise. Pt: - Edema - Joint pain - Malar rash - Proteinuria - Hypertension - RBC casts Dx: *Renal bx* Tx:

Premature Atrial Complexes (PACs)

Path: Premature activation of the atria originating from somewhere other than the SA node. - Benign arrhythmia - RF = Tobacco, Alcohol, Caffeine, Stress Pt: Usually asymptomatic - Sometimes can cause "skipped" beats or palpations Dx: ECG w/early p-wave Tx: Lifestyle changes - Symptomatic? Low dose Beta-Blocker

Body Dysmorphic Disorder (BDD)

Path: Preoccupation w/skin, hair nose, breast Pt: - Check appearance frequently - Time-consuming repetitive behavior - Unnecessary surgery Dx: *≥1 perceived physical defect* Tx: *SSRI*(significantly high doses) vs. *CBT* - They lack insight, so you want to *gently assess their level of insight* by exploring their perceptions of what other people think of them

Labial Adhesions

Path: Prepubertal girls d/t *low estrogen*, inflammation from poor hygiene, infection, irritation, or trauma. - Fused labia MINORA Pt: - PARTIAL --> Often asymptomatic --> Vaginal pain --> Vaginal "pulling" --> Abnormal urethral stream --> Increased risk of UTI - COMPLETE Dx: Clinical Tx: - Asymptomatic? No treatment. - Symptoms? *Topical estrogen*

Psychogenic Non-Epileptic Seizures (PNES)

Path: Present similarly to epileptic seizures but are not associated with increased synchronous neuronal activity. - Women are more susceptible - Occurs in front of witness Pt: - *Eye closure or fluttering* during the spell - *Side to side* head shaking - *Asynchronous* limb movement - Lack of postictal period - Absence of self injury - Absence of incontinence - Memory recall of the event Dx: *Continuous video EEG* - If preggo? r/o Eclampsia Tx: *CBT + Neurologic f/up* - Appropriate communication (nonjudgmental explanation of what is occurring) improves symptoms

Complete Mole (Hydatidiform Mole)

Path: Product of *dispermy* - *EMPTY* ovum (unlike partial mole) --> 46 chromosomes = normal number bc egg was empty and two sperm - NO evidence of an embryo - Hydropic (full of fluid) - Tumor of the *Syncytiotrophoblasts* --> makes Hcg!! (unlike partial mole) - "Heterogeneous mass of cystic structures" - RF = Vitamin A deficiency Pt: - Elevated Hcg - Hyperemesis gravidarum - Ketosis from excessive vomiting - *Bilateral theca-lutein cysts* (bc increased Hcg increases LH) - *HYPERthyroidism* (from elevated B-hCG) - Abnormal vaginal bleeding - Grows fast - Increased size for dates - Grape-like mass coming out of the cervical OS - Signs of EARLY preeclampsia (<20wks!) Dx: Hcg (*>100,000*) + *Transvaginal USD* w/*Snowstorm appearance* - Best? D&C Tx: Worry about *GESTATIONAL TROPHOBLASTIC NEOPLASM* (GTN) - No fertility requested? Hysterectomy - Fertility requested? *D+C + Reliable contraception (NOT IUD) + Serial Hcg's* --> treat until Hcg is 0, then Hcg q1m for 12m --> If Hcg does NOT reach 0 and instead plateus or increases, give *Methotrexate* or *Hysterectomy* bc is GTN.

Partial Mole

Path: Product of *dispermy* - *NORMAL* oocyte (unlike complete mole) + 2 sperm = 69 chromosomes - There CAN be an embryo!! (unlike complete mole) - Partially hydropic - Tumor of the *Cytotrophoblasts* --> DO NOT produce Hcg!!! (unlike complete mole) Pt: - Asymptomatic - "Normal" pregnancy - Abnormal vaginal bleeding - Absent fetal heart tones Dx: *Transvaginal USD* w/*Snowstorm* - Best? D&C Tx: - No fertility requested? Hysterectomy - Fertility requested? *D+C, Reliable contraception (NOT IUD), Serial Hcg's* - F/up gestational trophoblastic neoplasm --> If plateau or rise in Hcg after removal of mole, then cancer!!

Dyspnea of Pregnancy

Path: Progesterone induced stimulation of medullary respiratory center - Worsens during second trimester - *Persistent* (unlike asthma which is intermittent) - NO diurnal variation (unlike asthma)

Interstitial Lung Disease (ILD)

Path: Progressive fibrosis of pulmonary interstitium, alveoli, and conducting airways. - Causes = Chronic inhalation of organic/inorganic dust, drug toxicity, radiation, systemic connective tissue disease - Pleural calcifications seen in asbestosis DOES NOT cause respiratory compromise, it is the pulm fibrosis that does Pt: - Progressive dyspnea - Nonproductive cough - Fine *INSPIRATORY* crackles, "velcro" Dx: PFT w/Restrictive pattern (FEV1 decreased, FVC decreased, Ratio normal or increased) - DECREASED DLCO d/t pulmonary fibrosis - then!!!!! *HIGH RESOLUTION CT* of chest --> "Subtle reticulation or honeycombing in the dorsal dependent lung" Tx:

Biliary Atresia

Path: Progressive fibrotic obliteration of the EXTRAHEPATIC bile ducts - Bile plugs in the bile and canalicular ducts - Portal tract edema - Fibrosis Pt: Worsening jaundice at *~7-14 days* (ASYMPTOMATIC AT BIRTH! Then becomes jaundiced!) - *DIRECT* hyperbilirubinemia - *Elevated GGT and Alk Phos* (bc of destruction to bile ducts) - *Pale stools* - Dark urine - Hepatomegaly --> Eventually can develop splenomegaly from progressive cirrhosis and portal HTN - Absent gallbladder Dx: *USD (shows no ducts or gallbladder)* - CONFIRM w/*HIDA + Phenobarbital* (should show dye in liver and nothing below in ductal area) - THEN *Liver Bx* --> w/intrahepatic bile duct proliferation & portal tract inflammation, edema, and fibrosis Tx: Divert bile to small intestine (*Kasai procedure* = Hepatoportoenterostomy) >2mo - Most require liver transplant :(

Rheumatoid Arthritis (RA)

Path: Progressive inflammatory disorder - If it looks like SLE but ANA is negative, it's probably RA. Pt: - Women - 30-60yo - MORNING STIFFNESS in Hands, Feet, Wrists, Knees (small joints), Symmetrical - Fever - Weight loss - Fatigue - Periarticular erosions - Rheumatoid nodules at pressure points (elbows, forearms) - *OSTEOPENIA/OSTEOPOROSIS* (d/t inflammatory cytokines) - *Erosions of joint margins* - Associated w/*Atlantoaxial subluxation* (can be deadly) - *Tricuspid stenosis* - Coronary atherosclerosis - Pulmonary nodules - *Pulmonary fibrosis* - *Pleural effusions* (EXUDATIVE!!! w/super HIGH LDH, and LOW glucose which is unusual) - *AA Amyloid Nephrotic syndrome* (the type of amyloidosis that occurs in chronic inflammatory conditions...mc seen in RA) - Sjogren Syndrome - NO pericardial effusions (unlike SLE) - NO pancytopenia (unlike SLE) PULMONARY SX *Interstitial Lung Disease* *Pulmonary nodules* Can cause *Pleural Effusions*: - EXUDATIVE - w/LOW glucose (when you see this is either RA, empyema, TB, or malignancy) - w/HIGH LDH Dx: Positive *RF* - 50% have positive ANA - If you Bx rheumatoid nodules they are CHOLESTEROL Tx: (see pic) Start DMARDS as soon as possible to prevent joint damage... - 1st w/*MTX* --> Consider adding or using instead: *Leflunomide* v. Hydroxychloroquine v. Sulfsalazine --> If persistent sx *>6mo*, ADD *TNF-a-i* - Preggo? Hydroxychloroquine - Acute flair? Steroids - Severe? *TNF-a-i* (Infliximab, Rituxumab, Etanercept)...but make sure are vaccinated, get TB, and dont live in endemic area w/fungi - Osteoporosis? Avoid steroids, Encourage exercise, Vitamin D, Calcium intake.

Uterine Fibroids (Leiomyomas)

Path: Proliferation of *myometrium* (unlike Adenomyosis or Polyps) forms sphere of cells. "Monoclonal myometrium proliferation". - ESTROGEN responsive - Intramural v. Transmural v. Submucosal - Submucosal can become intracavitary fibroid and *Prolapse* --> presses on cervix --> painful labor-like contractions and cervical dilation Pt: Mc neoplasm in women of REPRODUCTIVE age - African Americans - Cyclic pain - Infertility (prevents implantation) - Abnormal uterine bleeding - Heavy, prolonged, REGULAR periods - NONUNIFORM, FIRM, RUBBERY, Enlarged, Irregular uterus - Thickened endometrium (submucosal fibroids) - Abdominal girth - Pelvic pressure - Impaired urinary, GI and sexual function Dx: *Pelvic USD* Tx: *OCPs v. IUD* - v. GnRH analogs (shrinks them) --> Surgery (myomectomy if fertile, hysterectomy if not) - v. Uterine Artery Embolization (if not worried about having kids) - Pain? NSAIDs...but cause bleeding so you have to watch out for that - Prolapsed fibroid? *Surgical removal*

Pancoast Tumor

Path: Prolonged hx of smoking causes *Adenocarcinoma or SCC* in the apical pleuropulmonary groove - Tumor then grows and compresses into surrounding structures Pt: - *Smoker* - Shoulder pain - Arm/hand pain (esp of Ulnar distribution) - Horner's Synd: Ptosis, Miosis, Anhydrosis - Neurologic manifestations along ulnar distribution - Hoarseness - Superior Vena Cava Syndrome (plethora and edema in head and UE) - Weight loss ....bc in sulcus, normal lung ca signs appear later! - Dyspnea - Hemoptysis - Dry cough Dx: CXR...then staging imaging + Bx

Staphylococcal Toxic Shock Syndrome (TSS)

Path: Prolonged or continuous tampon use, or Surgical or Postpartum wound infection - D/t toxic shock syndrome *toxin-1* (exotoxin that acts as super antigen) Pt: - High fever - Hypotension - Tachycardia - Diffuse red *macular rash involving palms and soles* --> *Sudden onset* is how you differentiate from Syphilis!!!! They will try to trick you!!! - Nausea - Vomiting - Profuse diarrhea - Leukocytosis - Shock - Multi-organ failure (bilateral crackles, altered mentation) Dx: Clinical Tx: *IVF + Clindamycin + Vancomycin + Remove foreign body*

Malaria

Path: Protazoal disease called by Plasmodium (intracellular RBC), transmitted by mosquitos - Protective? Sickle Cell TRAIT, Prior hx of malarial infection (they develop partial immunity) - P. Vivax is dominant species OUTSIDE of Africa --> Has a *Dormant hepatic phase*!!! - P. Falciparum is dominant species IN Africa Pt: - *COLD phase --> then HOT phase --> then SWEATING phase* then resolves for a day or two and happens again --> Fever correlates with parasites being released from liver into the blood stream - *Anemia* - *Thrombocytopenia* - *Hepatosplenomegaly* - Headache - Malaise - Myalgias - Vomiting - Diarrhea Cerebral? - Seizures - Delirium - Coma Dx: *THICK AND THIN Blood smear* w/intracytoplasmic circle Tx: *Prophylaxis* INDIA = very chloroquine-resistant...so give one of the below + Primaquine - *Atovaquone-proguanil* - *Doxycyclin* - *Mefloquin* (2wks before trip until 4wks after) CENTRAL AMERICA/CARRIBEAN = chloroquine-sensitive... so give*Chloroquine + Primaquine*

Food Protein Induced Allergic Proctocolitis

Path: Proteins in *Soy Milk, Cow's Milk, Breast Milk (if mom drinks Cow's or Soy milk), or Formula*!!!!!!!! causes eosinophilic inflammation in distal colon and rectum - *Non-IgE Mediated Reaction* Pt: - Infants only!!! (Arises at *1-4 weeks old*) --> Do NOT see >1yo - Well appearing infant - Painless - *Bloody stools* - *Loose stools* - Mucus in the stool Dx/Tx: *Maternal elimination of Soy and/or Cow's milk* (if resolves is diagnostic) - If infant is formula fed? Switch to *Hydrolyzed formula* - Spontaneously resolves by 1 year

Antiphospholipid Antibody Syndrome

Path: Prothrombotic autoimmune disorder associated with SLE (30%) Characterized by autoantibody against proteins bound to phospholipids (*Lupus anticoagulant*) Pt: Need *1 CLINICAL* & *1 LAB* criterion for dx Usually asymptomatic but can lead to... - arterial/venous thrombosis including DVTs, - hepatic vein thrombosis, - PE, - placental thrombosis (recurrent pregnancy loss) --> >3 consecutive unexplained fetal losses before wk 10 --> >1 unexplained fetal losses after wk 10, --> >1 premature birth of neonate before 34 wk d/t eclampsia preeclampsia or placental insufficiency - *stroke* - Mild thrombocytopenia - ANA positive - *Anti-Cardiolipin --> false positive syphillis test* - Anti-B2-glycoprotein-1 - *Falsely elevated PTT!!!!* Dx: *Mixing Test* (w/plasma)....would fail to resolve coagulation issue. - If resolves coagulation issue then is d/t FACTOR DEFICIENCY *Positive serology should be repeated at 12 weeks* Tx: Lifelong anticoagulation w/*Warfarin* - *LMWH* if preggo

Entamoeba Histolytica

Path: Protozoal infection from sexual contact (MSM) or drinking dirty water and food in developing nations. Pt: - Bloody diarrhea - Amebic liver abscess --> "Singly subcapsular low density lesion in R lobe of liver" --> RUQ pain --> Hepatomegaly --> Elevated liver enzymes --> *Neutrophilia* (bc protozoas do this.....NOT eosinophils) - Anorexia - Weight loss - Cough - Flask ulcers in colon Dx: *Stool & Ova* - Liver abscess? Serology Tx: Metronidazole

Aspirin-Exacerbated Respiratory Disease (AERD)

Path: Pseudoallergy....seems to be d/t overproduction of Leukotrienes (rather than IgE). Pt: Suspect w/*SAMTER TRIAD* - *Asthma* - *Chronic rhinosinusitis w/nasal polyps* --> Bland tasting food and recurrent nasal discharge/congestion - *NSAID or ASA induced respiratory reactions* Dx: Clinical - Confirm w/*ASA Challenge* Tx: Inhalers + Intranasal saline + Glucocorticoids + Leukotriene-modulating agents - ASA desensitization can be attempted prn

Hospital Acquired Pneumonia (HCP)

Path: Pt develops pneumonia *≥48hr* after admission, and did not have it before. - NG tubes *increase risk*!!! - PPIs *increase risk*!!! Need to cover MRSA & Pseudomonas!!! w/VANC + PIPTAZO - If can't do Vanc, then LINEZOLID - If can't do Piptazo, then MEROPENAM If immunosuppressed need to cover TB/FUNGUS/PCP w/TMP+SMX ± STEROIDS

Hereditary Spherocytosis

Path: RBC membrane protein issues (Spectrin, Ankrin, Pallidin) causes spherular RBC which can't fit through spleen vasculature so gets destroyed by macrophages --> Anemia - Autosomal DOMINANT Pt: - Hemolytic anemia - Jaundice - Splenomegaly - Reticulocytosis - Spherocytes - Low to normal MCV - Family history of anemia or gallstones - Pigmented gallstones!! d/t recycling of RBCs Dx: Blood smear - Best? *Osmotic fragility* (Acidified glycerol lysis test) - (-) Coomb's Tx: - Conservative? *Folate + Fe* (d/t chronic hemolysis) + Transfusions prn - Severe? *Splenectomy*

Panic Disorder

Path: RECURRENT, UNEXPECTED attacks (ONE panic attack would be a "Panic ATTACK", NOT disorder) - Negative medical work-up - DOES NOT need to have a trigger!!!! - Resolves w/in MINUTES. Pt: "STUDENTS PANIC" - *S*OB - *T*rembling - *U*nsteady - *D*epersonalization - *E*xcessive heart rate/Tachycardia - *N*umbness - *T*ingling - *S*weating - *P*alpitations - *A*bdominal pain - *N*ausea - *I*ntense fear - *C*hest pain - Anticipatory anxiety can lead to chronic anxiety. - May become preoccupied with possibility of undiagnosed illness (makes difficult to differentiate from Somatic Symptom Disorder) Dx: Recurrent attacks + *≥4 of the above* - *≥1 month of worry* about future attacks - At least some attacks are *untriggered* and *unexpected* - r/o ACS --> ECG, Troponins - r/o HYPERthryoidism --> TSH - r/o Asthma --> Would be wheezing Tx: - Maintenance? *SSRI/SNRI >> COGNITIVE BEHAVIORAL THERAPY (CBT)* - Acute? Benzos (do NOT use if substance abuse or frequent use of alcohol, marijuana, etc) - f/up Agoraphobia

Dysruptive Mood Dysregulation Disorder (DMDD)

Path: REQUIRES DX *<10yo*!!!!!!!! Otherwise basically looks like Intermittent Explosive Disorder Pt: - Frequent temper outbursts - Persistent irritability and anger BETWEEN episodes. (unlike Intermittent Explosive Disorder) - Inconsistent w/development level

Anorexia Nervosa

Path: RESTRICTION (reducing caloric intake & increasing caloric expenditure). - Poor self-image. - Fear of becoming or being fat. - *NO* insight (can't see that she is underweight). Pt: Adverse effects... ("Hypothyroid but THIN") - Dry skin - Cold intolerance - Lanugo - Edema - Abdominal distention (Gastroparesis) - HYPERcholesterolemia - *HYPERcortisolism --> Decreased bone density* - Growth hormone resistance - Amenorrhea - Arrhythmias - Seizures - Low T3 and T4 ("Euthyroid sick syndrome") Dx: Anorexic if BMI !!!!!!*<18.5*!!!!!!! w/ fear of weight gain or distorted body image Tx: 1. first goal is to restore nutritional state (may need hospitalization) --> *Nutritional rehabilitation* 2. *COGNITIVE behavioral therapy* 3. ANTIPSYCHOTICS (x. *OLANZAPINE*) are first line (NOT antidepressants unless OCD or MDD present) HOSPITALIZE if... - BMI <15 - Hypotensive - Bradycardic - Electrolyte imbalance - Leukopenia - Tx: Force-feeds + IVFluids

Perinatal Hepatitis B Viral Infection

Path: Vertical transmission of HepB through pregnancy - 90% of vertical transmissions progress to Chronic infection in baby (Cirrhosis, Hepatocellular carcinoma, Liver failure) Pt: Dx: Tx: - *IVIG + HepB Vaccine* (w/in 12 hr of birth)

Anterior Cruciate Ligament Tear

Path: Rapid deceleration or direction changes, pivoting on lower extremity with foot planted Pt: - Rapid severe pain - *Joint instability* (how dif from meniscus tear) - Significant swelling - "Popping" at time of injury (how dif from mensicus tear) Dx: *Lachman's test* (more sensitive/specific) - Could also do Anterior drawer test (but less specific) - MRI to confirm Tx: *RICE* (rest + ice + compression + elevation) - Consider surgery

Cardiac Tamponade

Path: Rapidly accumulating fluid (can be caused by *aortic dissection*), or fluid alot over a long period of time - D/t blood in pericardial space, or a pericardial effusion - Can be provoked by *Viral URI* turned viral pericarditis Pt: - CHF symptoms (bc R heart is crushed by fluid) --> *JVD*, - *Hypotension*, - *Decreased heart sounds*...Beck's Triad - Clear lungs!!!! (how you dif from LHF causes of hypotension, dyspnea, and JVD) - *Pulsus paradoxus* > 10mmgh (fall in BP during inspiration) - *Nonpalpable point of maximal impulse* - Widened mediastinum Dx: Clinical - EKG w/ *Electrical Alternans* (peak of QRS varies...see pic), - *Low-voltage QRS complexes* (<10mm in precordial leads) - CXR w/*Large, globular cardiac silhouette* Tx: Emergency *PERICARDIOCENTESIS* - IV Fluids to start if you can't get pericardiocentesis fast enough

Ludwig Angina

Path: Rapidly progressive cellulitis of the submandibular and sublingual spaces d/t contiguous spread of *dental infection* - Floor of mouth displaces tongue posteriorly --> AIRWAY OBSTRUCTION - D/t Strep Viridans & oral anaerobes Pt: Looks intense but it's really just a tooth....still have to be careful about airway obstruction though - Neck that is *Woody* or *Brawny* - Fevers - Chills - Malaise - Mouth pain - Drooling - Dysphagia - Muffled voice - Airway compromise - Tender and indurated submandibular area - Floor of mouth elevated - Tongue displaced - Tripod positioning - Inability to lay flat - No LDN - Anaerobes may cause crepitus Dx: *CT of neck* r/o abscess Tx: (*Ampicillin-Sulbactam v. Clindamycin*) + Remove tooth + Secure airway prn - Drainage and surgery are usually NOT needed...

Uterine Sarcoma

Path: Rare but aggressive malignancy - RF = Tamoxifen (has estrogen agonist effects on the uterus), Prior hx of pelvic radiation Pt: - Bulk symptoms - Postmenopausal bleeding

Postpartum Psychosis

Path: Rare condition which occurs within the first *1-2 weeks* following delivery - MC in patients w/hx of bipolar disorder --> High risk of recurrence in future pregnancies Pt: - Depressed or manic mood - Agitation - Insomnia - Delusions - Psychosis - Hallucinations Dx: Clinical Tx: *Hospitalize* so they don't hurt the baby + Antispychotics

Angiosarcoma

Path: Rare malignant tumor derived from vascular endothelial cells, spreads within the vasculature. - RF = Breast cancer having underwent RT or axillary LN dissection, Chronic lymphedema. --> Onset 4-8yr after therapy Pt: - Rapidly progressive - Red plaque without distinct borders - *Purple papules* on top Dx: Bx Tx: Resection

Cerebral Venous Thrombosis

Path: Rare, potentially life threatening condition caused by clots forming in the *Dural sinuses* --> Venous congestion, decreased cerebral perfusion, disruption of the blood-brain barrier, impaired CSF resorption - RF = Prothrombotic states, *Postpartum period*, Inherited thrombophilias Pt: - Elevated ICP - Headache (worse in morning) - Vomiting - Papilledema - Seizures - *Ischemic OR hemorrhagic stroke* can occur, which DO NOT follow normal arterial patterns Dx: *CT of head* which can be NORMAL (33%) - If high suspicion, get *MR Venography* Tx: Anticoagulation

Choroid Plexus Papilloma

Path: Rare, slow growing, benign overgrowth of choroid plexus that *overproduces CSF* Pt: - Infant - Hydrocephalus - Enlarging head circumference - Ventriculomegaly - Intraventricular mass - Increased ICP (bulging fontanelles) - Poor feeding - Irritability - Vomiting upon waking Dx: USD of head w/enlarging ventricles and intraventricular mass - MRI confirms Tx: Resection

Retinoblastoma

Path: Rb gene mutation, which inactivates RB1 (tumor suppressor) - With the tumor suppressor knocked out they are at *increased risk of CANCER* - Mc intraoccular tumor of childhood Pt: - Child <2yo - *All white retina* (aka "Leukocoria") --> Sporadic? UNILATERAL --> Inherited? BILATERAL (if bilateral you have to r/o other causes of congenital cataracts such as CMV, Rubella) - Strabismus - Nystagmus - Vision impairment - Occular inflammation Dx: Clinical... - Confirm w/*MRI* of brain and orbits - DO NOT XRAY!! This would be "second hit" for Rb and would cause cancer!! Tx: Send to *Ophthalmology*!!! - Surgery - F/u for OSTEOSARCOMA

Constrictive Pericarditis

Path: Recurrent pericarditis (scars heart) causes pericardial fibrosis and obliteration of pericardial space --> Impaired ventricular filling during diastole --> Venous overload - Can be caused by *TB*, Viral, RT, Surgery, Connective tissue dz, Idiopathic Patient: DIASTOLIC heart failure - *Pericardial knock* (early heart sound after S2) - Fatigue - Dsypnea on exertion - JVD - Ascites - Pedal edema Dx: Echo - *"ring of calcifications around the heart"* Tx: Pericardiectomy

Porphyria Cutanea Tarda (PCT)

Path: Reduced activity of hepatic enzyme required for HEME BIOSYNTHESIS - Accumulation of porphyrins - Associated w/Hep C Pt: - Fragile vesicles and bullae - Sun exposed areas Dx: Clinical - Confirm w/Plasma and Urine Porphyrin levels Tx: *Phlebotomy + Hydroxychloroquine* - F/up *HCV* --> Start antivirals

Prerenal Acute Kidney Injury

Path: Reduced effective arterial blood volume - Sepsis w/hypotension - Acute heart failure exacerbation (where there is decreased ejection fraction) --> *Cardiorenal Syndrome* (decreased renal perfusion and activation of the RAAS system, causing vasoconstriction and increased preload) - NSAIDs (cause afferent arteriole constriction) Dx: NO casts - *Urinary Na+ <20* --> Because RAAS is activated. - BUN:Cr Ratio of *>20:1*--> Because urea reabsorbed w/Na+ Tx: Two totally opposite treatments, depends on cause... - Cardiorenal syndrome? *Diuretics* - Everything else? *Fluid resuscitation w/IV crystalloids* - HOLD Nephrotoxic treatments (Metformin, NSAIDs, etc)

Necrotizing Enterocolitis

Path: Reduced mesenteric oxygen delivery causes wall of gut to be invaded by bacteria...local infection and inflammation destroys the gut "dead gut" - RF = Hypotension, Congenital heart disease (bc low O2 delivery to gut), *Prematurity*, *Very low birth weight*, Formula feeding Pt: Premature infant FIRST FEW WEEKS of life - Characteristically w/*Bloody BM* (but may not have in early stages, yellow seedy stools are NORM) - Abdominal distention - Feeding intolerance - Bilious emesis - Lethargy - Temperature instability (hypothermia) - Leukocytosis - Metabolic acidosis Dx: XRay w/*Pneumatosis Intestinalis* (air in wall of bowel) - Air in the portal venous system may be seen Tx: *NPO, TPN, IV Abx against gram (-)* - Pneumoperitoneum? *Surgery*!! - F/u Surgery

Colonic Ischemia

Path: Reduction in intestinal blood flow causes ischemia (ACUTE HYPOTENSION ...unlike mesenteric ischemia which would be d/t thrombi or emboli). - MC site is *Splenic flexure*, followed by Rectosigmoid junction Pt: - Crampy abdominal pain - Followed by Hematochezia. - Fever - Nausea - Leukocytosis - Elevated lactic acid - Commonly occurs at watershed areas (*Splenic flexure* & *Rectosigmoid junction*). - Typically affects elderly. Dx: *ABD CT w/Thumbprint sign* on imaging due to mucosal edema/hemorrhage. - Colonoscopy to confirm (pale mucosa with petechial bleeding, bluish hemorrhagic nodules) Tx: IV fluids + Bowel rest - Resection if damaged bowel

Acute Bacterial Prostatitis

Path: Reflux of bugs in urine (mostly E. Coli, Proteus) Pt: - Flu-like illness (*Fever*, chills, malaise, myalgia), - Dysuria - Urinary frequency - Urgency - Pelvic/suprapubic pain - Urinary retention - DRE w/tender swollen prostate Dx: Urine culture Tx: *TMP+SMX v. Levofloxacin* x 6wks - Suprapubic catheter for urinary retention (urethral catheters can causes sepsis or prostatic rupture)

Meckel's Diverticulum

Path: Remnant of the vitelline duct which contains GASTRIC CONTENTS which can secrete acid that causes small bowel ulceration and bleeding. - TRUE Diverticulum - Sometimes made of *Pancreatic* tissue - If this had failed to involute completely the belly button would leak gastric fluid Pt: ASYMPTOMATIC - Painless, intermittent hematochezia (GI bleed, bloody stool, bloody BM) - Anemia - NO abdominal pain, diarrhea, vomiting etc. - Associated with Intussusception (can act as a lead point) RULE OF 2's - Kids <2yo - <2% of population - 2' from ileocecal valve - 2" in size - 2x mc in males than females Dx: *Technician-99 scan*!!! - If Teenager? *CT Scan* Tx: Resection

Wilms Tumor

Path: Renal cancer arising from METANEPHROS - Can be associated with WAGR --> Wilms tumor --> Aniridia --> Genitourinary abnormalities --> mental Retardation) - Associated w/Beckwith-Wiedemann Syndrome Pt: Child 2-5yo - *UNILATERAL* ASYMPTOMATIC abdominal mass (does NOT cross midline) - HYPERTENSION (renin secretion, compression of renal vasculature) - Fever - Maybe abdominal pain - Lungs are mc site of metastatic spread Dx: Abd USD - f/up with *CT of chest* to stage (bc lungs are mc mets) Tx: Surgery + Chemotherapy +/- RT - Survival rates are excellent (90%) esp if treated early

Hypokalemia

Path: Renal losses (Iatrogenic, Hyperaldosterone x. FMD, RAS, Conn's syndrome) v. GI losses (V/D) Pt: weakness & hyporeflexia (similar to HYPERK+), a. fib, rhabdo, vomiting, cramps Dx: Check EKG! --> broad flat T-waves, U-waves, ST-depression, premature ventricular beats Work-up 1. Recheck K+ 2. If still low then, EKG 3...but no matter results will *REPLETE K+* - *PO > IV* (bc w/Peripheral IV can only go 10mEq/hr , or 20mEq/hr if Central IV) 4. If you are repleting K+ and it doesn't do anything, CHECK THE *Mg2+* (often d/t alcohol abuse)!!! And replace it (this is the same for Hypocalcemia) *10mEq of K+ will change K+ by 0.1*

Pelvic Inflammatory Disease

Path: Repeated cervicitis d/t ascending infections from vagina. Either STD/STIs or polymicrobial infections. - Encompases Endomyemometritis, Salpingitis, Tubo-Ovarian Abscess and Perihepatitis (Fitz-Cugh-Hertis) Pt: Varies widely....Vague pelvic pain to septic shock - Irregular intermenstrual bleeding - Pelvic pain (constant) - Bilateral adnexal tenderness - Cervical motion tenderness, and/or something is tender above the cervix (uterus, ovarian tubes, ovaries, adnexa) - May have fever >100.9F - May have mucopurulent cervical discharge - RUQ pain if perihepatitis (Fitz-Hugh-Cutis) --> Vomiting --> PLEURITIC (d/t fibrosis on anterior liver) Dx: Clinical - Can use USD to r/o TOA - Purulence? do NAAT to r/o Gonorrhea or Chlamydia Tx: INPATIENT (fever = septic, pregnant, TOA) - *Cefoxitin + Doxycycline* - If TOA? *+ Metronidazole* OUTPATIENT - *Ceftriaxone 1x IM + Doxycycline 100mg bid x14 + Metronidazole 100mg x14* - If test of cure, you can discontinue the 14 day business F/UP - Fitz-Hugh-Curtis - Ectopic pregnancies (worse w/gonorrhea)

Apnea of Prematurity (AoP)

Path: Repeated episodes of apnea (periods *>20s* without respiration!) - D/t *immature central respiratory centers* in the brainstem - At risk for CEREBRAL PALSY (d/t repeated hypoxia) Pt: - First few days postnatal - Episodic respiratory pauses - Bradycardia - Desaturation - Preterm neonate - Physical exam otherwise normal - Appears well between episodes Dx: Clinical - CXR should be NORMAL (if only AoP) Tx: *Caffeine therapy* v. *Noninvasive respiratory support* --> Given until respiratory drive is developed (34-37wks postmenstrual age)

Bing Eating Disorder

Path: Repeated episodes of eating an excessive amount of food in discrete period - All BINGE, no purge. Pt: - Loss of control - Physical discomfort - Distress - Often overweight - Absence of inappropriate compensatory behaviors (dif from Bulimia) Dx: Clinical Tx: *CBT* - If fail psychotherapy or prefer meds? *SSRIs* v. Lisdexamfetamine v. Topiramate

Binge Eating Disorder (BED)

Path: Repeated episodes of eating an excessive amount of food in discrete period - All BINGE, no purge. Pt: - Loss of control - Physical discomfort - Distress - Often overweight - Absence of inappropriate compensatory behaviors (dif from Bulimia) Dx: Clinical Tx: *CBT* - If fail psychotherapy or prefer meds? *SSRIs* v. Lisdexamfetamine v. Topiramate

Enuresis

Path: Repeated urination on bed or clothes - Voluntary - Anatomic - Disease states - Medications - Regression (new sibling v. abuse) Pt: Wets self, bed. - #1 risk factor is FAMILY HISTORY Dx: Urinary incontinence in children *≥5yo* --> GET *UA* first to r/o medical cause!!! - Positive UA and Negative USD? *Infection*. - Negative UA and Positive USD? *Anatomic* - Negative UA and Negative USD? *Regression* Tx: - If WERE dry and now not? Functional issue... - If <7 and NEVER dry? Potty train (w/positive reinforcement) v. Water restriction v. Alarm blankets v. Voiding Diary

Female & Male Pattern Hair Loss (FPHL/MPHL)

Path: Replacement of terminal hairs with smaller Vellus hairs (follicular maturization) - Hair loss in men is driven by androgens - FPHL has NORMAL androgens! (unlike PCOS, etc) Pt: - Gradual thinning of hair at the vertex and midline - Females? Hairline is preserved. Dx: Clincial Tx: - Women? *Minoxidil* (vasodilator, increases blood flow to the scalp) - Men? *Minoxidil v. Finasteride*

Intermittent Explosive Disorder

Path: Stressor can be anything. Onset often >10yo (unlike DMDD) - Mild = NO harm --> *2 outbursts/week* and continues for *3 months* - Severe = HARM!!! --> *3 times/ever!* and continues for *12 months* Pt: Men > Women, Decreases w/age - Verbal or physical aggression out of proportion to the provocation - Impulsive outburst - Episodes *<30 minutes* - Immediate relief - Followed by remorse, dysphoria, embarrassment - Significant functional impairment (jobs, schools, legal) - NO persistent anger or irritability between episodes (unlike DMDD) Dx: Clinical Tx: - Mild? None - Severe? *CBT + SSRIs*

Primary Dysmenorrhea

Path: Results from increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline - No actual pelvic pathology Pt: - Pain begins *WITH* menstruation (Dif from secondary dysmenorrhea which begins mid-cycle, or Endometriosis which begins *BEFORE* menses) - Pain ends after first couple days of menses (unlike endometriosis, which is painful the duration of menses) - Severe? Diarrhea, Nausea, Fatigue, Dizziness - NORMAL pelvic exam Dx: Tx: *NSAIDs* + *OCPs* - If sexually active? Start with OCPs (NO evidence of weight gain w/OCP use) - Not sexually active? NSAIDs - Most women have decreasing symptoms with increasing age

Intubation of the Right Mainstem Bronchus

Path: Right mainstem bronchus diverges from the trachea at a fairly non-acute angle, - Ideal location of distal tip of the endotracheal tube is 2-6cm above the carina Pt: - Overinflation of right lung - Underventilation of left lung (decreased lung sounds) - Asymmetric chest expansion - Markedly decreased or absent breath sounds on left immediately after intubation - Hemodynamically stable (unlike pneumothorax which would cause hypotension d/t compression) Dx: CXR Tx: Pulling tube back slightly to place between carina and vocal cords.

Cor Pulmonale

Path: Right sided heart failure secondary to *Pulmonary HTN* - Pulmonary HTN can be due to COPD, ILD, OSA, Pulmonary vascular disease, Kyphoscoliosis Pt: - Dyspnea - Angina - Syncope - JVD - Loud P2 - Tricuspid regurgitation murmur - Peripheral edema - Hepatomegaly - Ascites - Hypotension - Tachycardia - d/t COPD? --> Distant heart sounds --> Decreased breath sounds Dx: *Right heart catheter* w/elevated CVP and right sided pressures, and no sign of left sided disease. - CXR w/Enlarged central pulmonary arteries and loss of retrosternal space d/t RVH - ECG w/Right axis deviation, RBBB, RVH, Right atrial enlargement Tx: *Supplemental O2 + Diuretics + Treat underlying disease (+ IV inotropes prn)*

Abdominal Compartment Syndrome

Path: Rising abdominal pressure causes reduction in organ perfusion --> Organ dysfunction - Ex. Pancreatitis causes inflammation which increases abdominal pressure Pt: - Tensely distended abdomen - Difficulty breathing - Basilar atelectasis (diaphragmatic elevation) - Decreased urine output (increased intra-abdominal pressure reduces renal perfusion) - Increases CVP d/t pressure, which also decreases preload --> Decreased CO --> Tachycardia & Hypotension - Peripheral edema (from decreased venous drainage) Dx: Tx: - Avoid over-resuscitating with fluids - Decrease intraabdominal volume (x. NG tube) - Increase abdominal wall compliance (x. sedation) - Surgical decompression prn

Preterm Prelabor Rupture of Membranes (PPROM)

Path: Rupture of membranes *<37 weeks prior to the onset of labor* (premature = prelabor) - Risk factors: Prior PPROM, conditions that overextend or weaken the membranes (polyhydramnios, genitourinary infections, antepartum bleeding), esp. BV infections - Bacterial enzymes induce contractions and increase membrane fragility Pt: - <17 or >35 - Decreased amniotic fluid volumes --> maternal uterine decompression --> shearing of vessels --> *Placenta abruption* - Intraamniotic infections - No true contractions yet, or preterm labor - Umbilical cord prolapse Dx: Nitrazine positive amniotic fluid w/ferning Tx: - PPROM <34 weeks? Inpatient expectant management w/*Prophylactic Abx + Corticosteroids + Fetal surveillance* - Anticipate delivery *at 34 weeks* unless complications --> Deliver if *Uterine tenderness* or *Fetal tachycardia* or *Fetal or maternal deteriorating status* - Watch for placental abruption (from loss of fluid) --> Immediate C-Section - GBS (+) or questionable? Just give *Ampicillin* - F/up *Test of Cure* for infections

Penile Fracture

Path: Rupture of the *fibrous tunica albuginea* that envelops the corpus cavernosum - Blunt trauma to an erect penis Pt: Snapping sound, sudden onset pain - Blood in meatus - Hematuria - Dysuria - Urinary retention (inability to urinate) - Penile shaft hematoma Dx: *Retrograde urethrogram* if it looks possible that urethral injury has occurred (~20% it does) Tx: Urological emergency!!! *SURGERY* (if urethral injury will repair then and place catheter at that time) - If was POSTERIOR urethral injury (i.e. during pelvic fracture) would do suprapubic catheter

Neonatal Intraventricular Hemorrhage

Path: Ruptured germinal matrix vessels, in fragile part of brain that gives rise to neurons and glial cells during fetal development - *PREMATURITY <32wks* is the greatest risk factor, bc lack supportive structure around matrix vessels --> Germinal matrix involutes after 32wks. - IVH in first few days of life Pt: 50% are asymptomatic - Bulging fontanelle - Anemia - Apnea - Seizures Dx: - All neonates born *<32 wks* get *Screening HEAD USD* Tx: Symptomatic (blood pressure stabilization, seizure management)

Acute Stress Disorder

Path: SAME AS PTSD Severity of stressor (actual death, threatened death, combat, sexual assault, abuse), Exposure (experienced, witnessed, learned, repeated exposure) - Some resolve before becoming PTSD Pt: SAME AS PTSD - Intrusion (memories, flashbacks, nightmares) - Mood change (depressed) - Dissociation (depersonalization) - Avoidance (not going to place it happens, not talking about it) - Arousal (irritability, hypervigilence) - Anxiety - Insomnia - Impaired concentration - Dissociative symptoms Dx: Clinical --> *>3days - <1 month* - PTSD = *>1 month* Tx: *CBT* - If not ready to talk about therapy, discuss common *physical and emotional response to trauma* - If have panic attacks? Benzo - Follow-up on mood disorders and substance abuse

Diffuse Axonal Injury

Path: SEVERE Head trauma, - Acceleration/Deceleration causes *shearing of white matter tracts* (grey-white matter junction most at risk) - Can be seen in shaken baby syndrome Pt: *Glasgow <8* - *LOC --> COMA* Dx: - Head CT is unremarkable - MRI w/*minute punctate hemorrhages in white matter* or *blurring of the gray/white interface* Tx: Supportive, ICP management

Neisseria gonorrhoeae

Path: STD Pt: - Fever - *Pharyngitis or tonsilitis* if orogenital contact... - Nontender cervical LNDs - Abdominal pain from PID - Cervical tenderness (Chandelier sign) - Mucopurulent cervical discharge - Arthritis and tenosynovitis - Papulopustulous rash (only a few lesions usually on the LE) Dx: NAAT Tx: Ceftriaxone (+ Doxycycline if culture not yet confirmed)

Tricyclic Antidepressant Overdose

Path: Tricyclic (TCA) antidepressants cause *prolonged QRS* d/t Na+ channel blockage, (similar to quinidine) - Also *prolonged QTc* - Hypotension and Arrhythmia are what makes this DEADLY Pt: Three C's: *C*oma, *C*onvulsions, *C*ardiotoxicity. - Mental status changes (x. Hallucinations) - Seizures - Tachycardia - *Hypotension* - Cardiac conduction delay - Anticholinergic effects (see pic) hyperthermia, mydriasis, flushed skin, bowel ileus Dx: *EKG* Tx: - Hypotensive? *Saline boluses* - QRS *>100msec*? Worry about ventricular arrhythmia & seizures --> *Sodium Bicarb*

Cervicitis

Path: STIs (Gonorrhea & Chlamydia) - All sexually active women <25 should be screened, or if older and at high risk Pt: Often have NO symptoms - Purulent cervical discharge + Cervical motion tenderness (Chandelier sign...preggo patient's often DO NOT have cervical motion tenderness!!!) - Friable cervix that bleeds easily - Dysuria (Urethritis) - Dyspareunia - Vulvovaginal pruritus - NO fever - NO leukocytosis - NO sign of PID Dx: Clinical - Confirm w/NAAT (aka PCR) to cervical discharge confirming for either gonorrhea or chlamydia. Tx: - Gonorrhea? *250mg IM 1x Ceftriaxone* + *1g PO 1x Azithromycin* (to cover chlamydia, regardless of test results) - Chlamydia? *100mg PO x7 Doxycycline* or *1g PO 1x Azithromycin* (no Doxy if preggo) - Preggo? Ceftriaxone + Azithromycin - F/up *TEST OF CURE* for all pregnant women bc associated w/obstetric and neonatal complications when not treated adequately. - Treat partners

Erysipelas

Path: STREP infects the skin superficially, limited to epidermis and superficial dermis Pt: - Dark red well defined indurated climbing lesions - *RAISED, SHARP BORDERS* (how dif from Cellulitis) - Severely erythematous - ADULTS Tx: Amoxicillin - Clindamycin if pen allergic

Scabies

Path: Sarcoptes Scabiei infection spread through person to person contact. - Mites burrow into skin and cause Type IV HSR to eggs, feces, mite. Pt: - Intensely pruritic - WORSE AT NIGHT!!!! - Itchy fingers - Webs of hands - Burrows - 2-3mm erythematous papules and vesicles - MC on distal extremities, waistband, creases Dx: Clinical - Could confirm w/Light microscopy on skin scrape Tx: *Promethrin* (topical) or *Ivermectin* (PO) - Treat household contacts and wash linens - Place bedding clothes, etc in bag for ≥3 days (mites can only live off humans for 2-3d)

Allergic Rhinitis

Path: Seasonal or Perinneal - Chronic IgE mediated Type I Reaction - Trigger --> Cross-linking Mast Cells degranulate --> Histamine release Pt: - Shiners salute, - Pale, boggy, mucosa, - Polyps, cobblestoning Dx: Clinical Tx: *Intranasal Steroids* - "Best" = Avoid trigger (but most people want their cats)

Functional Hypothalamic Amenorrhea

Path: Secondary amenorrhea in an athletic or calorie restricting patient - Suppression of HPO axis Pt: - NO estrogen withdrawal sx!!! (hotflashes, etc) - Decreased bone-mineral density - Low calorie intake/Excessive physical activity - Normal Prolactin - Normal TSH Dx: *Progestin challenge* w/medroxyprogesterone acetate --> would normally cause menses, but would NOT if Functional Hypothalamic Amenorrhea bc not sufficient estrogen to have built up a uterine lining Tx: Increasing caloric intake and/or decreasing excercise

Acute Cerebellar Ataxia

Path: Secondary to autoimmune issue following *viral infection* (x. Varicella, EBV) Pt: Acute onset (w/in hours or days) - *Ataxia* - *Nystagmus* - *Dysarthria* - DTRs normal - NO!! issues w/proprioception/vibration (unlike Freidreich Ataxia) - NO!! Myoclonus (unlike Neuroendocrine tumor...and nystagmus is dif from opsoclonus) Dx: Clinical Tx: Self-limited (~2 weeks), Supportive care

Subacute Thyroiditis (de Quervain's)

Path: Self-limited HYPERthyroidism, may be followed by a few months of hypothyroidism. - Often following a flulike illness (*viral infection*). Pt: - Fever, - Very TENDER thyroid - Neck pain - Goiter - Early inflammation. Dx: DIFFUSELY enlarged - Elevated ESR & CRP Tx: - *BBlockers* for sx (usually hyperthyroid) - *NSAIDs* for pain relief --> Glucocorticoids if does not respond to NSAIDs (compare to *Suppurative Thyroiditis* - which is also TENDER w/FEVER, but is UNILATERALLY enlarged d/t abscess and pts are EUTHYROID.)

Vestibular Neuritis

Path: Self-limited disorder of the vestibulocochlear nerve - Follows Viral *URI* - If paired with HEARING LOSS? *Labyrinthitis* Pt: - Constant (unlike BPPV) - Nausea - Vomiting - Impaired gait - Horizontal nystagmus - Hearing loss (= labyrinthitis) Dx: *Head thrust test* w/horizontal saccade Tx: Expectant (bc self limited)

Transient Tachypnea of the Newborn (TTN)

Path: Self-limiting, MC in C-Sections, Delayed reabsorption of alveolar fluid - Baby wasn't squeezed through the birth canal right, which would trigger contractions to help them breathe Pt: Term or NEAR term baby - Expiratory *Grunting* - Intercostal/Subcostal retractions - Nasal flaring - Clear lungs Dx: CXR w/lungs *HYPERextended & WET* - *Interstitial infiltrates with prominent interlobar fissures* (white streaks) - Perihilar streaking - Fluid in the interlobular fissures Tx: *PPV* ...or Partial pressure ventilation (usually goes away in first 6hr but can go until 48hr)

Distal Symmetric Polyneuropathy

Path: Sensory loss in a distal stocking-glove pattern. - CHRONIC? Systemic disease (HIV, DM) - ACUTE? Medications (*Metronidazole*) Pt: - "Loss of pain, touch, and vibration sensation" often in bilateral fingers and toes. Dx: Clinical Tx: DC med or treat diseases - Gabapentin for chronic cases

Serotonin Syndrome

Path: Serotonergic medication use ae - Watch out for things like Tramadol, Linezolid, Dextromethorphan as they have serotonergic activity and can cause, esp when added to SSRI/SNRI. - Onset over *hours* (unlike NMS which is over days) Pt: - Jitteriness - Diaphoresis - Hyperthermia - Tachycardia - Hypertension - Hyperthermia - Altered mental status - Myoclonus - *Hyperreflexia* (how you tell dif from NMS, Caffeine intoxication, Stimulant intoxication) - *Increased muscle tone* (how you tell dif from Caffeine intoxication, Stimulant intoxication) - *GI symptoms* (vomiting, diarrhea.....also how you tell dif from NMS) - Leukocytosis - Elevated CPK Dx: Clinical Tx: *BENZOS!!!!!* + Supportive measures - If not responsive to this? *Cyproheptadine*

Severe Combined Immunodeficiency (SCID)

Path: Several Types --> Deficiency of *T-Cells*, leading to severe *B-Cell* dysfunction - IL-2R (MC, X-linked recessive) - *Adenosine deaminase* deficiency (Autosomal recessive) "deaaaam it's SCID!" Pt: Recurrent viral, bacterial, fungal, protozoal infections ("Bubble baby" = MegaAIDS) - Failure to thrive - *Lymphopenia* (low lymphocytes) - Chronic diarrhea - Thrush - Absence of Thymic shadow, Germinal centers, and T-cells - Decreased CD4 and CD8, CD19 (B-cells), CD3 (T-cells) Dx: CBC w/o WBCs - Quantitative Immunoglobulin w/decreased *Ig of ALL classes* Tx: *Stem Cell Transplant* - TMP+SMX for PCP prophylaxis

Pancytopenia

Path: Several causes. See pic. - Bone Marrow Aplasia (ex. Aplastic Anemia --> Most cases are IDIOPATHIC!!!!!) - Bone Marrow Infiltration - Mature Blood Cell Destruction Pt: - Signs of Leukopenia - Signs of Anemia - Signs of Thrombocytopenia - Low reticulocytes Dx: Hypocellular bone marrow Tx:

Postpartum Period

Postpartum chills and shivering - D/t decreased estrogen and progesterone - Low grade fever normal Lochia - Vaginal bleeding with small clots - Normal up to 6wks Firm contracted uterus

Pulmonary Hypertension

Path: Several different causes... - Primary (intimal hyperplasia) - Left sided heart disease (causes irreversible vascular remodeling) - COPD, ILD, chronic lung disease (causes narrowing and obliteration of small arterioles and alveolar capillaries) - Thromboembolic disease - Sarcoidosis (CREST and systemic) Pt: - Dyspnea - Fatigue - Weakness - Right Ventricular heave (or parasternal heave) on PE --> indicates RV enlargement to push blood into lungs - Loud pulmonary component of second heart sound (A2 first, then P2) --> NOT fixed splitting! May be *WIDE*, but NOT "fixed", that would be a septal defect. Dx: Echo measuring pulmonary artery pressure (*≥25mmHg* at rest) - We don't do Swan-Ganz anymore Tx:

Acute Erosive Gastropathy

Path: Severe hemorrhagic lesions following exposure of gastric mucosa to various injurious agents that reduce blood flow. - Cocaine, Aspirin, Alcohol Pt: - Hematemesis (but not as much as you would expect from Mallory-Weiss tear) - Abdominal pain - Partier Dx: Tx:

Major Depressive Disorder with Psychotic Features

Path: Severe subtype of depression characterized by delusions and/or hallucinations - Psychotic features have depressive themes (guilt, worthlessness, dying) Pt: - Severe depression (SIGECAPS) - Delusions and/or hallucinations Tx: *Antidepressant + Antipsychotic* - Severe suicidality or refusal to eat or drink? *ECT*

Dissociative Identity Disorder (DID)

Path: Severe, chronic condition of *≥2 distinct identities* - Caused by severe, prolonged childhood trauma - Personalities are typically connected to the childhood trauma Pt: - Gaps in memory - Behavior suggestive of different personality states - Transition between personalities is sudden and can be caused by stress - Auditory hallucinations (voices INSIDE head, dif from psychotic disorders with voices outside head) Dx: Clinical - *≥2 distinct identities* Tx: *Psychotherapy* (long-term, trauma focused)

Post-Traumatic Stress Disorder

Path: Severity of stressor (actual death, threatened death, combat, sexual assault, abuse), Exposure (experienced, witnessed, learned, repeated exposure) Pt: - Intrusion (memories, flashbacks, nightmares) - Mood change (depressed) - Dissociation (depersonalization) - Derealization - Avoidance (not going to place it happens, not talking about it) - Arousal (irritability, hypervigilence) - Startle response - Sleep disturbance - Nightmares - Impaired concentration - Negative mood Dx: Clinical --> *>1 month* - *Acute Stress Disorder* = *>3day - <1 month* Tx: *CBT ± SSRIs* - If have panic attacks? Benzo - Nightmares? *Prazosin* (alpha-1 antagonist) or CBT (w/image rehearsal therapy) - Follow-up on mood disorders and substance abuse - If have panic attacks? Benzo

Granulosa Cell Tumor

Path: Sex-cord stromal tumor that releases estrogen and causes precocious puberty in girls and menstrual abnormalities in women Pt: - Peripheral precocious puberty (early onset breast development, vaginal bleeding) - Breast tenderness - Bloating - Irregularly thickened endometrial lining - Advanced bone age - Large adnexal mass - HIGH *Estradiol* (converts Testosterone to Estradiol via aromatase) - HIGH *Inhibin* Dx: *Pelvic USD* - Then follow/up with *Endometrial bx* bc elevated estrogen increases risk of endometrial hyperplasia/cancer Tx: *Unilateral Salpingoophorectomy*

Slipped Capital Femoral Epiphysis (SCFE)

Path: Shearing at the proximal femoral physis - Anterosuperior displacement of the proximal femur diaphysis Pt: ~13yo obese or growth spurt w/nontraumatic joint pain - Obese (typically but not always) - Chronic >3weeks dull thigh pain - Decreased ROM - Leg EXTERNALLY rotated (limited internal) - Exacerbated by activity - Atrophy of quadriceps and gluteal muscles - (+) Trendelenberg's - Hip pain - Referred thigh or knee pain Dx: Bilateral hip *FROG LEG XR* w/POSTERIORLY displaced humeral head Tx: SURGERY

Hemolytic Uremic Syndrome (HUS)

Path: Shiga Toxin (EHEC O157:H7) - Vascular damage and microthrombi formation Pt: *MAHA + Thrombocytopenia + AKI* - Bloody diarrhea - Fatigue, pallor - Bruising, petechiae - Oliguria, edema - Thrombocytopenia - Hemolytic anemia (Schistocytes, Increased bilirubin) - AKI Tx: Dialysis (bc primarily disorder of renal system) + Fluid + Electrolyte management + Blood transfusions (if Hgb <6) +

Priapism in Sickle Cell Disease

Path: Sickling of blood in the corpora cavernosa makes blood unable to exit the veins - Sickle Cell Disease alters the blood viscosity and causes venous obstruction - Precipitants = Fever, Cold, Alcohol, Medications, Dehydration, Cocaine Pt: - Can see "Stuttering priapism" in the weeks before (repeated shorter episodes) - Persistent painful erection in the absence of sexual stimulation Dx: Erection lasts ≥4hr Tx: *Aspirate blood from corpora cavernosa* --> then intracavernous phenlyephrine injection

Somatic Symptom Disorder

Path: Significant focus on physical symptoms that results in major dysfunction. Pt: - Preoccupied with some SOMATIC SYMPTOM (generally pain or fatigue) - May actually have medical disease, but pain is disproportionate. - Ego*DYSTONIC* (they don't want to feel these feelings...) - Risk factors: Childhood trauma or adult sexual abuse, Female sex, low education level, personal hx or exposure to chronic illness. Dx: - *>1 symptoms* causing distress, impairment - Duration *≥6 months*!!!! Tx: *SSRI* v. *Psychotherapy* - Focus on coping and functional improvement - Try to keep to ONE provider - Set boundaries (number of tests they'll get, etc) - Can also be advocate for new, significant complaints.

Superior Vena Cava Syndrome

Path: Something obstructs the SVC... - SCLC - SCC lung cancer - NHL - Pancoast tumor - Histoplasmosis - TB Pt: - Plethora & edema in head and UE - Conjunctival congestion - Headache worse when *leaning forward* - *JVD* but NO peripheral edema! Dx: CXR Tx: *Endovenous stunting + RT* (Palliative only)

Breast Abscess

Path: Staph aureus enters ducts through the nipple and multiplies in *STAGNANT* milk - Mom's not breastfeeding enough - RF = Nipple excoriations, Rapid weaning Pt: - Erythematous breast (though this may improve on Abx) --> Will still have *Nodularity* or a fluctuant mass though - Tender - Firm - Swollen - Mom has fever - Myalgias - LNDs!!! (axillary) Dx: Clinical - USD if has "Tender nodularity" and you're not sure if it's severe mastitis v. abscess Tx: *Breast feed* + Analgesics + *Dicloxacillin* + *USD guided needle aspiration* - Possible it's MRSA? *Clinda, Vanco, TMP-SMX*

Pediatric Septic Arthritis

Path: Staph, Strep - Can present following URI w/Staph or Strep - *Juvenile Idiopathic Arthritis* is a RISK FACTOR Pt: Acute! Flair of SINGLE joint. - Fever >101.3 - Hot, Swollen knee - Won't bare weight - Pain wakes up at night - Elevated ESR - Elevated CRP Dx: Aspirate knee (aka *Arthrocentesis*) - >50,000 WBCs, 80-90% PMNs - Cultures Tx: Drainage + IV *Vancomycin* - If does not improve on Vanco? *+ Ceftriaxone* (to cover Gram negs)

Cervical Insufficiency

Path: Structural weakness of the cervix causing second-term loss - RF = Collagen abnormalities (EDS), Uterine abnormalities, Prior obstetric trauma, Cervical conization Pt: - Increased vaginal discharge - Light or NO vaginal bleeding - Pelvic pressure - Spontaneous painful cervical dilation - Potential second trimester loss Dx: Clinical..."All the 2's!!" - *≥2* prior consecutive painLESS, *2nd trimester* losses - OR....*2nd trimester* cervical length *≤2.5cm* PLUS prior preterm delivery - OR...painless cervical dilation in CURRENT pregnancy Tx: *Rescue cerclage* (a suture around the cervix, put *in at week 14 & take out at week 36*) recommended UNLESS membranes already bulging...then delivery is imminent --> ONLY do if PRIOR HISTORY of second-term losses - If NO prior preterm & SHORT cervix? *Vaginal progesterone*

Cellulitis

Path: SubQ infection - Strep (likes to go OUT; NO abscess, NONpurulent) - Staph (likes to go IN; w/ABSCESS, Purulent) Pt: - Erythematous - Warm - Tender - *Flat, indistinct borders* (how dif from Erysipelas) Dx: Clinical (DO NOT need to swab!!) Tx: If redness doesn't start to recede then you have wrong abx...usually question will want you to tx Staph. - Strep: *1st gen Ceph* (if nontoxic) v. *Pip-Tazo or Amp-Sulbactam* (if toxic) - Staph: *Clindamycin or TMP-SMX* (if nontoxic) v. *Vanco or Linezolid or Clindamycin* (if toxic) ONLY choose to treat Strep, or choose to treat Staph, UNLESS Diabetic or Osteomyelitis --> Tx: Pip-Tazo + Vanco

Angiodysplasia

Path: Submucosal dilation of venules...seen w/ - Renal disease, - *Aortic stenosis* --> Damaged valve is thought to destroy vWF multimers, and trigger bleeding this way. Pt: - >60yo - RIGHT COLON mc, but can also see in the SMALL BOWEL - Cause of PAINLESS hematochezia or melena Tx: Cauterize if bleeding

Myoclonus Status Epilepticus

Path: Sudden involuntary muscle contractions which occur acutely after inciting event. - D/t Genetic disorders, Seizures, Medications, Prolonged hypoxia Pt: - Movements of limbs, joints, face - Intermittent eye opening - Upward gaze deviation - Swallowing Dx: EEG Tx: *Antiepileptic agent* - Poor prognosis

Venous Air Embolism

Path: Sudden onset respiratory distress during *Removal of central venous catheter* or *Placement of IJV catheter* - Air embolism travels to right ventricle and can go into pulmonary arteries Pt: - V/Q mismatch - HYPOXEMIA - Obstructive shock - Cardiac arrest Tx: *Left lateral decubitus* position (or Left lateral Trendelenberg) + *High Flow O2* - Traps air emboli against lateral wall of right ventricle so it can't obstruct outflow

Waldenstrom's macroglobulinemia

Path: Super high IgM!!!!! Pt: - Hyperviscosity syndrome (bc IgM is so big compared to the other Ig's that when it is in super high quantities it impedes circulation) --> Bleeding from mucosal surfaces, --> visual disturbances due to retinopathy and CNS manifestations (nonspecific), --> diplopia, --> tinnitus, --> headache - Hepatosplenomegaly - Anemia - Thrombocytopenia - Leukocytosis!!! - Lymphadenopathy - Constitutional Sx Dx: "Gamma gap" (large dif between total protein and albumin) should prompt... - SPEP (+) - UPEP (-) - Skeletal survey (-) --> Bone Marrow Bx w/*>10% LYMPHOMA cells* (how we differentiate from MGUS in addition to having sx) Tx: - *Rituximab* chemo - Hyperviscosity? *Plasmapheresis*

Non-Suicidal Self-Injury (NSSI)

Path: Superficial cutting behavior used to cope with distressing affective states. - Seen in Borderline personality disorder, Eating disorders, Dissociative disorders, Developmental disabilities Pt: - Cutting - No suicidal intent - Increased long-term risk of suicide attempts Dx: *Psych eval* to find underlying condition Tx: *Therapy* - Determine if require hospitalization (suicidal, psychotic). - If teen can keep information private from parent (if kid requests) so long as they are not in immediate danger.

Mallory-Weiss Tear

Path: Superficial tear in mucosa...NOT full thickness (compared to Boerhaave's which is transmural) Pt: Weekend warriors - Self limiting bc bleeds and then stops on its own Dx: EGD Tx: Supportive

Asherman Syndrome

Path: Surgical removal of stratum basalis, causing scarring and secondary amenorrhea - "Endometrial cavity adhesions and fibrosis" Pt: - Secondary amenorrhea OR very light menses Dx: No withdrawal bleeding on progesterone challenge test (d/t absent endometrium) - but NORMAL FSH & TSH (unlike Primary Ovarian Insufficiency) Tx: *HYSTEROSCOPY* to lyse adhesions (also diagnosis)

Alpha-1-Antitrypsin Deficiency

Path: Suspect when see COPD signs at young age and smoking history doesn't match. --> Intrahepatic accumulation of AAT molecules leading to panacinar emphysema and cirrhosis. - PAS stain + - CODOMINANT inheritance Pt: - Young --> If smoke will present ~30yo --> If don't smoke will present ~40yo - Signs of COPD (esp common in *LOWER*/basilar lobes, unlike smokers who have it prominently in upper lobes) --> Dyspnea on exertion --> Decreased breath sounds --> Cough with mucoid sputum - Liver disease (may be asymptomatic up until endpoint of disease) - Fam hx of cirrhosis or emphysema - Panniculitis (skin) Dx: Measure AAT levels + Liver function panel --> Could just be VERY MILDLY elevated liver enzymes!!!!!!! (like 45...when normal is up to 40) Tx: *IV AAT* + (Bronchodilators + Corticosteroids prn) - Severe? Lung and/or liver transplant

Cephalohematoma

Path: Swelling caused by bleeding between the osteum and periosteum of the skull. - RF = Operative vaginal delivery (forceps or vacuum) - Benign Pt: - Firm - Nonfluctuant - Nontender - DOES NOT cross suture lines. (compare to subgaleal hemorrhage) Tx: Resolves spontaneously - Monitor w/*Serial bili levels* (as hematoma breaks down bili increases and may require phototherapy)

Orbital Compartment Syndrome

Path: Swelling or hemorrhage within the enclosed orbit space causes increased intraorbital pressure (x. trauma, coagulopathy, infection, surgery) --> Ischemia of the optic nerve and globe. - Can lead to permanent vision loss if not treated Pt: - Proptosis, - Resistance to retropulsion (pushing eye in) - Tight orbit - Rock hard eyelid - Tight eyelids, - Tenting of globe on CT scan - Afferent pupillary defect - Periorbital edema - Impaired eye movements d/t extraoccular muscle compression Dx: MRI (after surgery!!) Tx: immediate lateral/inferior cantholysis (emergency surgical decompression) - Elevate head in bed - Pain control

Postpartum Depression

Path: Typically with ≥2nd child Pt: Mom DOESN'T care about baby --> neglect - SIGECAPS symptoms Dx: - SIGECAPS 5/9sx. - Starts *<1 month* of birth. - Duration *≥2 weeks* (if less than that is Postpartum Blues) - Suicidality. - Ongoing. TX: *SSRIs* (esp. Sertraline bc breast milk levels are undetectable)

Stages of Change Model

Precontemplation Contemplation Preparation Action Maintenance Identification

Sarcoidosis

Path: Systemic granulomatous disorder of uncertain etiology Pt: "Facial droop is UGLIER" - Bells palsy (*Facial droop*) - Uveitis - Non-caseating Granulomas - Lupus pernio (lupus like facial rash) - Interstitial fibrosis (Restrictive lung disease) (High/Norm FEV1/FVC (FEV1/FVC >80%, & FEV1 alone <80%)) - Erythema nodosum (bx w/septal panniculitis) - Rheumatoid-arthritis-like arthropathy - *Hypercalcemia*!!!! (bc granulomas have 1-alpha-hydroxylase activity which increased 1-25-dihydroxyvitamin D and therefore increases Ca2+ absorption from the gut) --> Urinary frequency --> Hypercalciuria (w/Nephrolithiasis) - Cardiac effects: AV nodal block, restrictive or dilated cardiomyopathy (granulomas can invade the heart) - Bilateral parotid gland swelling (weird...) - Bilateral LNDs (x. cervical) - Centralized diabetes insipidus - Generalized seizures Dx: >50% are asymptomatic! - FIRST *Bx most accessible lesion* - Restrictive lung disease pattern --> Decreased/Normal FEV1 --> *INCREASED FEV1/FVC* (High/Norm FEV1/FVC (FEV1/FVC >80%, & FEV1 alone <80%)) - Decreased TLC - Decreased DLCO (bc scaring impedes alveolar gas exchange --> if this was obesity induced restrictive lung disease would be normal) - CXR w/*Hilar Lymphadenopathy* = "mediastinal fullness and scattered reticular opacities" - ACE is elevated Tx: - Asymptomatic? Follow w/o treatment - Symptomatic? *Prednisone*

HELLP Syndrome

Path: Systemic microangiopathy and platelet consumption. --> Placental release of antiangiogenic factors causing widespread maternal endothelial dysfunction - *Distention of the hepatic capsule* (Glisson capsule) causes RUQ pain. Pt: - *H*emolysis - *E*levated *L*iver enzymes - *L*ow *P*latelets - MAHA --> Elevated indirect bilirubinemia - RUQ pain - NORMAL PT/PTT (how dif from AFLP) - Nausea - Vomiting - Headache - Hypertension -....may or may not have proteinuria Dx: Tx: Same as eclampsia - *Magnesium* + *Delivery* (f/up on DTRs bc don't want to suppress everything so much that there are resp issues...give Ca2+ to correct)

Kawasaki Disease

Path: Systemic vasculitis, MC in Asian population Pt: Prolonged fever *≥5 days* (would be uncommon for Adenovirus) - Conjunctivitis - Oral mucosa erythematous, Strawberry tongue, Fissured lips - Polymorphous rash in perineal area - Erythema and edema of hands and feet - Often UNILATERAL *Cervical lymphadenopathy w/node >1.5cm* - Coronary artery aneurysms LABS - Neutrophilia (~75%) - Normocytic anemia - Elevated transaminases Dx: - *≥4* of the above sx - *≥5 days of fever* Tx: Self-limited, resolve w/in 2 weeks - *IVIG* (decreases risk of coronary aneurysms) + *ASA* - F/up w/*Echocardiogram* (bc of risk of aneurysm)

Tricyclic Antidepressant Toxicity

Path: TCA's inhibit the *FAST* sodium channels in the purkinje system and myocardium, decreasing conduction velocity and prolonging QRS Pt: "Coma, Convulsions, Cardiotoxicity" - Coma - Cardiotoxicity --> QRS prolongation (>100ms) --> V tach/V fib - Convulsions - Anticholinergic effects --> Hyperthermia --> Dilated pupils --> Intestinal ileus --> Dry mouth - Hypotension - Tachycardia Tx: *Sodium Bicarbonate* if QRS >100msec, or there is a ventricular arrhythmia in the setting of TCA toxicity!!! - Increasing serum pH deactivates TCA so it is unable to bind sodium channels - Also improves HYPOtensio (#1 cause of death when combined with cardiac toxicity)

Prostate Cancer

Path: TESTOSTERONE (5-DHT) causes growth - *PERIPHERAL* zone of prostate is mc where it is - RF = *Advanced age*, Pt: Older men >70yo - OBSTRUCTIVE symptoms - Back pain if mets - Mets to bone (usually LUMBAR, Vertebral bodies)? *OSTEOBLASTIC LESIONS* ("Sclerotic")!!! Unlike basically any other mets to bones!! --> Hypocalcemia, Elevated AlkPhos Dx: DRE w/*Firm, Nodular prostate* - Get PSA (significantly elevated) - Bx (Transrectal) --> Take multiple samples, the WORST TWO are added together - *Bone scan* for mets Tx: Resection = Radiation = Brachytherapy - Then, to suppress, use *Antiandrogen therapy (x. Flutamide) or GnRH therapy (x. Leuprolide)* - Consider orchiectomy if they are older and refractory F/up with PSA's - If PSA elevated and NO sx? Tx: *Antiandrogens* - If PSA elevated and YES sx? Tx: *Radiation therapy*

Biliary stasis

Path: TPN (d/t Small bowl resection, etc) OR Prolonged fasting cause decreased release of CCK (usually stimulated by proteins and fatty acids in the duodenum) which would cause gallbladder to contract. --> As a result, causes biliary sludge and cholesterol heavy stones to build up Decreased enterohepatic recycling of bile acids is also seen small bowel resection, further promoting stone formation

Neurocysticercosis

Path: Taenia solium transmitted due to ingestion of undercooked, contaminated pork - Ingested eggs spread to GI and then go hematogenously to brain, muscle, liver and encyst Pt: Asymptomatic usually - Seizures - Later signs of increased ICP Dx: CT/MRI w/≥1 *cysts* and surrounding edema, calcified nodules - "Enhancing, Nonenhancing, and Calcified lesions" Tx: *Antiepileptics* (x. Phenytoin) + *Albendazole* + *Corticosteroids* (for inflammation)

Second Stage Arrest

Path: Taking too long to get from *10cm dilated* to baby OUT (*>3hr in nullgravid, >2hr in multi*). - D/t fetal malposition (*occiput anterior* w/baby's face facing anus is preferred!!!) --> causes *cephalopelvic disproportion* Dx: - Nullgravid or prior pregnancies C-sections? Should be over in *3hr* (add an hour if epidural) - Multi? Should be over in *2hr* (add an hour if epidural) Tx: - *Oxytocin* --> If this fails, and NEGATIVE STATION then *C-Section* --> If POSITIVE STATION (*2+* or closer and *fully effaced*) then *Forceps v. Vacuum* ("Operative Vaginal Delivery")

Milk-Alkali Syndrome (Burnett's syndrome)

Path: Taking too much Calcium and absorbable Alkali (x. Osteoporosis meds, Antacids) - Concurrent use of THIAZIDE diuretics, Ace-i, NSAIDs may exacerbate!!! Pt: *HyperCa2+ + AKI + Metabolic alkalosis* - Anorexia - Dizziness - Fatigue - Headache - Confusion - Psychosis - Dry mouth - Polydypsia - Polyuria - Metabolic alkalosis - Renal insufficiency - HYPERcalcemia (causes renal vasoconstriction, which causes renal insufficiency) --> The level of Hypercalcemia you see with Milk-Alkali is far more extreme than you'd see with Thiazides alone!!!!!!!!! - *HYPOphos* (how you dif from thiazide-induced hypercalcemia) - HYPOmg - Normal K+ (unlike thiazides) - DECRESED PTH - Can look like Diabetes Insipidus!!!!!! Dry mouth, Polydypsia, Polyuria....but these are apparently just signs of hypercalcemia (you will also see abdominal pain, constipation, etc) Tx: Isotonic Saline + *FUROSEMIDE*

Acute Subdural Hematoma

Path: Tearing of *Bridging veins* - RF = Alcoholics, Elderly (bc brain volume decreases and bridging veins have to go further), Anticoagulant use Pt: - Young (Shaken baby, Young adult w/Superman syndrome) - Elderly - Hx of trauma, falls - Gradual symptoms 1-2 days after injury - Impaired consciousness - Confusion - ICH (Nausea, Vomiting, Headache) - *LOC --> Die* Dx: CRESCENT SHAPED hyperdensity on CT - Crosses suture lines Tx: Reduce ICP...they will probably still die - *Hyperventilate* - Raise head of bed 30degree - Mannitol - Large? Urgent Surgery

Intussusception

Path: Telescoping of bowel - Overlapped bowel has blood flow cut off to it - 90% of patients DO NOT have a lead point - Recent viral infection or rotavirus infection - Usually ileocecal junction - Recurrent, Unusual age, Unusual location? Think *MECKELS DIVERTICULUM*, Polyps, Cysts, Tumors, Hematomas Pt: - Sudden abdominal pain lasting ~15-20 minutes that increases in severity and frequency - *Episodic inconsolable crying* (d/t intermittent contraction of the bowel) - Knee-Chest position relieves the pain - Lethargy may be presenting sign in infants - "Sausage-shaped mass" - *Currant-jelly diarrhea* Dx: *Abd USD* w/*Target sign* Tx: *Air-contrast enema* - SURGERY if... --> Frank peritonitis --> Perforation --> Failure of air enema *CAN'T RECEIVE ROTAVIRUS VACCINE!!* if have hx of Intussusception

Chlamydia & Gonorrhea

Path: The USPSTF recommends screening for *gonorrhea and chlamydia* in *sexually active* women age *24 years and younger* ANNUALLY - And in older women who are at increased risk for infection. - And in those with illicit drug use Pt: Often have NO symptoms!!! - Mucopurulent vaginal discharge - Friable cervix Dx: NAAT Tx: Ceftriaxone + Doxycyline - Preggo? Ceftriaxone + Azithromycin

Acute Bronchitis

Path: There was a preceding URI (usually *VIRUS*) Pt: - Dry cough - Mild wheezing - Mild dyspnea - Chest wall discomfort - Purulent yellow or green sputum d/t sloughing and not a sign of bacterial infection - *Audible crackles in lungs that clear with coughing* (unlike pneumonia) - NO fever (if you see this think pneumonia) Dx: Clinical Tx: Supportive (Throat lozenges + Cough suppressants) - If underlying asthma? Give *SABA* - NO ABX!!!

Schizophrenia

Path: Thought disorder w/genetic component - POSITIVE symptoms caused by *excess DOPAMINE* - NEGATIVE symptoms caused by *excess SEROTONIN* - Develops <18yo? "Early-onset schizophrenia", associated with more SEVERE course of illness (usually have prodromal phase of social withdrawal and academic decline before onset of psychotic symptoms). Pt: Typically present with a psychotic break in early 20's following major stressor... POSITIVE symptoms (confer better prognosis) 1. Delusions (persecution, grandiosity) 2. Hallucinations (auditory) - more common than delusions in pediatric cases. 3. Disorganization of SPEECH 4. Disorganization of BEHAVIOR NEGATIVE symptoms 5. Flat affect 6. Poverty of speech and movement 7. Anhedonia 8. Cognitive delay (becomes more impaired with each cognitive break) Dx: - *≥2 symptoms, one must be from 1-3* or *≥1* symptoms if delusions are bizarre, AH provides running commentary on thoughts, or AH is two voices conversing. - Duration *≥6 months* - Brain imaging w/*loss of cortical volume and ventricular enlargement* (esp. *lateral ventricular enlargement*) - R/o drugs Tx: Antipsychotics (*LIFELONG*) - Family stressors (critical, hostile, overinvolved)? *+ Family therapy* (to educate them) - Compliant & wants to take meds? Atypicals (x. *Quetiapine, Olanzapine, Risperidone*) - Combative in ED? *Haloperidol* (bc IV) v. Olanzapine (ok answer for wards but not for boards) - Noncompliant? *Haloperidol* (depot injection - month-long) - When all else fails? *Clozapine* (watch agranulocytosis) - Anxious? Continue meds and add *CBT* - *HOSPITALIZE* if: Danger to self or others, or grave disability (inability to care for self, decompensating)

Collagenous Colitis (Microscopic Colitis)

Path: Thought to be an abnormal immune response in genetically predisposed individuals. - Two flavors: Collagenous v. Lymphocytic - RF = Female, Smoking, NSAIDs Pt: - Usually in middle-aged and older women - Chronic watery diarrhea - Urgency - Incontinence - Nocturnal diarrhea - Abdominal pain (50% of patients) Dx: Colonoscopy - COLLAGENOUS COLITIS? --> Bx w/*Dense subepithelial collagen layer* - LYMPHOCYTIC COLITIS? --> Bx w/"*Mononuclear infiltrate*" (increased intraepithelial lymphocytes) Tx: *Antidiarrheals* - Avoid NSAIDs - Refractory? Budesonide

Jejunal Atresia

Path: Thought to occur d/t a vascular accident in utero, causing necrosis and reabsorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine. - RF = Maternal use of *Vasoconstrictive medications* (x. cocaine, tobacco) Pt: - *Triple bubble sign* (how dif from duodenal atresia) - Bilious emesis - Abdominal distention Dx: XR w/Triple bubble Tx: *Resuscitation & Stabilization* (correct electrolytes, give fluid etc) --> Then *Surgery*

Thyroid in Pregnancy

Path: Thyroid hormone production increases in FIRST TRIMESTER to keep up with metabolic demands. Does so by... - Estrogen stimulates synthesis of Thyroid Binding Globulin --> Patient's body then increases production of Thyroid hormone to maintain free levels - hCG directly stimulates TSH, which then produces Thyroid hormone that then suppresses TSH release. - Can look like *Subclinical Hyperthyroidism*.... Pt: - CLINICALLY EUTHYROID!!!! - Increased circulating T3 and T4 - Normal FREE T4 - Suppressed TSH Tx: Reassure Normal - However, *HYPOTHYROID patients* will need their Levothyroxine dose increased during pregnancy bc they are unable to keep up with the increased demand.

Rocky Mountain Spotted Fever (RMSF)

Path: Tick bite transmits Rickettsia bacteria, seen throughout the untied states, mc in places that are woody or grassy - Bacteria attacks the vascular endothelial cells Pt: - Viral prodrome for few days (Nonspecific fever, headache, myalgia, arthralgia) - Maculopapular rash to Petechial rash --> Starts on extremities, classically involves palms and soles - Noncardiogenic pulmonary edema ("Bilateral rales") - Signs of shock - Thrombocytopenia - Leukopenia in some cases - HYPONATREMIA (d/t ADH release in response to hypovolemia) - Children often have severe *ABDOMINAL PAIN* - *Increased AST/ALT* - CSF w/"Viral Pattern" (*Normal glucose, Elevated protein, Mildly elevated WBCs*) Tx: Doxycycline (ok in kids for the short ~7 day course needed)

Human Monocytic Ehrlichiosis

Path: Tick-born infection caused by ticks in the South Eastern and South Central United States - "Like Rocky Mountain Spotted Fever, without the rash" Pt: - Acute febrile illness - Malaise - Altered mental status - *NO rash* - *Leukopenia* --> w/increased *Monocytes* - *Thrombocytopenia* - Elevated aminotransferases (how dif from Lyme) - Elevated LDH (how dif from Lyme) - HIGH FEVER (how dif from Lyme) Dx: Clinical - Could confirm by seeing intracytoplasmic morulae in WBCs or PCR Tx: *Doxycycline*

HIV-Associated Dementia

Path: UNTREATED HIV patients (CD4<200) Pt: Predominantly subcortical symptoms... - Apathy - Early impairments in attention - Subcortical motor symptoms

Femoral Neck Fracture

Path: Usually d/t fall backwards. - Worry about... --> Avascular necrosis --> Malunion --> Secondary instability --> Degenerative changes in the femoral head Pt: - Mc 65yo - Hip pain - Shortening of extremity - External rotation of extremity Dx: XR w/*Shortening of the neck, disruption of the normal cortical contour, and irregular lucency at the fracture plane* Tx: - Ambulatory pt? *Surgical repair w/ORIF* - Nonambulatory? Can do nonoperative management

Hypothyroidism

Path: Too little thyroid. - Autoimmune? Hashimoto's - Many sx of HYPOthyroidism is d/t deposition of *MUCINOUS MATERIAL* (glycosaminoglycans, hyaluronans, & mucopolysaccharides) Pt: - Myalgias - Constipation - Dry skin - Fatigue - Memory issues - Cold intolerance - Weight gain - Edema - HYPOreflexia - *Galactorrhea* (low thyroxine stimulates TSH & PROLACTIN!!!!!!!!!!!!!!!! production in the pituitary, prolactin then suppresses FSH, LH, and estrogen) - Amenorrhea - *Primary ovarian insufficiency* - *Pseudogout* - Lipid abnormalities (Total Cholesterol, LDL, and Triglycerides) - *BILATERAL CARPAL TUNNEL SYNDROME* (d/t median nerve infiltration by mucinous material) - *Diastolic HYPERtension* (>90) - *HOARSENESS* (d/t glycosaminoglycan deposition in tissue interstitial spaces) - Depression - *Myxedema madness* (paranoia or hallucinations) Dx: - Elevated TSH - Decreased T4 Tx: *Levothyroxine* - Estrogen (x. for menopause, or during pregnancy) causes increased TBG, which binds Free T4 and T3, so you have to INCREASE THE DOSE of Levothyroxine

Transfusion Related Acute Lung Injury (TRALI)

Path: Transfusion reaction d/t *Donor Antileukocyte Abs* which cause neutrophils to damage pulmonary microvasculature. - Within *minutes to hours* of transfusion - RF = Smoking, Alcohol abuse, Critical illness Pt: - Fever - *HYPO*tension - Hypoxia - Dyspnea - Tachycarida - Noncardiogenic pulmonary edema (inflammatory pulm edema) --> Bilateral crackles and pulmonary infiltrates Dx: Tx: Respiratory supportive care

Physiologic Anemia of Infancy

Path: Transient decline in hemoglobin due to downregulation of EPO (*reduced production of EPO*) secondary to sudden increase in oxygenation at birth. - Physiologic hemoglobin nadir at *11 g/dL at 2-3m* Pt: ASYMPTOMATIC - Normocytic anemia

Stress Hyperglycemia

Path: Transient elevation in blood glucose caused by metabolic stress in patients without preexisting DM --> Cortisol and catecholamines act on liver to release glucose into blood - Sepsis, Burns, Major trauma or hemorrhage Pt: - Recent trauma - Elevated BG - Normal HgbA1c Tx: - Mild/Moderate? Observe. Normal. - Severe (>180-200)? *Short acting insulin* d/t increased mortality, w/target of 140-180

Todd Paralysis

Path: Transient hemiplegia following a loss of consciousness (occurs during postictal period) - Gradual return to baseline - NORMAL imaging - Thought to be d/t neuronal exhaustion Pt: - Hx of seizure - Flaccid focal weakness or paralysis - Extremities on SAME SIDE of body Dx: Clinical - Imaging to r/o other causes of parlysis Tx: Self-limited, sx resolve in 36hr

Hepatitis A (HAV)

Path: Transmission via *fecal-oral* route - RF = Overcrowding, Poor sanitation, International travelers, MSM, Drug users, Infected household, Unvaccinated Pt: - Fever - Nausea - Vomiting - RUQ pain - Jaundice (ADULTS ONLY) - Pruritus .....after a few days - Dark urine - Acholic stools Dx: Anti-HAV IgM antibodies - ALT/AST in the *several-thousands!!* Tx: Most patients completely recover in 3-6 weeks - Close contacts? Post-exposure prophylaxis w/*HAV vaccine* or *HAV IG*

Diaphragmatic Rupture

Path: Trauma may cause defect in the diaphragm which allows the bowels to pass through. - MC on L side bc R is protected by the liver. - Worry about bowel strangulation and hernia formation Pt: - Children can present months or years after injury - Dyspnea - Chest discomfort - Bowel loops within thoracic cavity - Mediastinal shift Dx: *CXR*, then *CT* to confirm Tx: *Surgical correction*

Blunt Chest Trauma

Path: Trauma to the chest Pt: - Anterior chest wall pain and tenderness Dx/Tx: - Hemodynamically UNSTABLE? Resuscitation + *Chest CT + FAST + ECG + Stabilizing interventions* --> Becomes stable? Additional tests, then consider discharge if normal. --> DOES NOT become stable? *Thoracotomy* - Hemodynamically STABLE? --> High risk MOI? Resuscitation + *Chest CT + FAST + ECG + Stabilizing interventions* --> NO high risk MOI? *Evaluation, ECG, CXR* (NO FAST!!!!) (if normal then can discharge, if NOT then get further imaging, if that's abnormal then Thoracotomy)

Corneal Abrasion

Path: Trauma, foreign body, contacts - Cornea sensation is detected by CNV1 (nasociliary nerve) Pt: - Severe eye pain - Photophobia - Inability to open eye - Foreign body sensation - Drop in visual acuity Dx: *Fluorescein* examination w/corneal staining defect Tx: - Refer to Ophthalmology if... --> pus, --> ulceration, --> drop in visual acuity, or --> lack of healing in 3-4 days

Cryptosporidium Parvum

Path: Traveler's diarrhea - Contaminated water sources (drinking, swimming) - HIV patients are at risk for severe, chronic infection Pt: - Prolonged profuse watery diarrhea Dx: *Microscopy w/specialized stains* - STOOL O&P DOES NOT WORK Tx: *Nitazoxsanide* - Healthy? Resolves within 10-14 days

Common Fibular Neuropathy

Path: Travels near fibular head, susceptible to compressive injury (cast, bedrest, leg crossing, squatting) - "When your foot goes numb" Pt: *Transient* symptoms, resolve w/in hours - Unilateral foot drop - Numbness/tingling over dorsal foot/lateral shin - Impaired ankle dorsiflexion (walking on heels) - Preserved plantarflexion (walking on toes) Dx: *EMG* or *Nerve conduction* Tx: Reduce pressure on nerve, Splint, PT

Syphilis

Path: Treponema pallidum Pt: Unprotected intercourse...30 days later single painLESS ulcer - "Papule --> Ulcer with nonexudative base, and raised indurated margin" - PainLESS LNDs - Condylomata Lata ("raised grey-white lesions on mucosal surfaces") - During pregnancy? IUGR - Baby exposed in FIRST trimester? Dead baby - Baby exposed in THIRD trimester? Snuffles, Saber shins, Saddle nose, Hutchinson teeth, Desquamating rash involving palms and soles, buttocks, legs, Long bone abnormalities Dx: *RPR + FTA-ABS* (need BOTH!!! unless...) - If *Classic Clinical Presentation*? Just treat! Tx: *Penicillin G* - If severely allergic? *Doxycycline* - If allergic & Pregnant? *Penicillin skin test* (for IgE-mediated response) then desensitize to Penicillin so can receive it. *Penicillin* IM x1 - Late Latent Syphilis? *Penicillin* IM qWeek x3 - Tertiary Syphilis (neuro)? *Penicillin* IV q4h for 7-10days

Tinea Corporis

Path: Trichophyton fungus...Like to live in warm, humid places. Once get in one place can self innoculate elsewhere (autoinnoculation). Foot = Athletes foot (Tinea pedis) Groin = Jock itch (Tinea cruris) Body = Ring worm (Tinea corporis) Nails = Onychomycosis Hair = Tinea capitus --> May have associated LNDs - When there is sudden onset, *think HIV*!!! (like basically any other normally benign rash thing which then suddenly explodes uncontrollably) Pt: - "Confluent annular scaly plaques" Dx: KOH Tx: - Foot, Groin, Body? *TOPICAL antifungals* (x. miconazole, clotrimazole) --> If diffuse can give ORAL. - Nails? *Terbinifine* - Hair? *Griseofulvin*

Migraine

Path: Trigeminovascular activation of CGRP pain signaling - Triggered by stress, fasting, dehydration, menses, sleep deprivation - Episodic headaches lasting several hours or days Pt: May have prodrome - Episodic unilateral headaches (in kids can be *BIFRONTAL* pain) - Throbbing or pulsatile quality - Nausea - Vomiting - Photophobia - Phonophobia - Visual auras (mc scintillating scotoma, flashing lights) - Facial weakness or numbness - Unilateral extremity weakness or numbness Dx: Clinical Tx: Supportive care - ABORTIVE therapies = Triptans, NSAIDs, Acetaminophen, Antiemetics, Ergotamines --> NEVER give Triptans and Ergotamines together!!!!! (causes prolonged vasoconstriction, MI, stroke) - PREVENTIVE therapies = Topiramate, Divalproex, TCAs, Venlafaxine, BBlockers, CCBs --> Use when FREQUENT (*>4/month*), LONG (*>12hr*), have DISABLING SX, Refractory to abortive tx

Insomnia

Path: Trouble sleeping Pt: - Problem FALLING asleep - Problem with REAWAKENING - No mood disorder - <6hr sleep per night despite good sleep hygiene Dx: - Frequency of *≥3x/week* - Duration for *≥3 months* Tx: *Diphenhydramine* v. *Trazodone* v. *Quetiapine* v. *Zolpidem*

Nasopharyngeal Carcinoma

Path: Tumor associated with *EBV* common in Asians (esp Southern China) - Genetic predisposition - Salty foods and salt cured foods Pt: Tumor obstructs the nasal cavity and oropharynx - Nasal congestion - Epistaxis - Headache - Facial numbness (para-cavernous sinus infiltration, CN5) - Serous otitis media (eustachian tube infiltration) - Mets to bilateral cervical lymph nodes Dx: Nasopharyngoscopy --> then *Endoscope guided bx of primary tumor* Tx: *Radiation therapy + Chemotherapy*

Tricuspid Regurgitation

Path: Two main SECONDARY causes (90% of TR) d/t right ventricular cavity enlargement (i.e. volume or pressure overload). Tricuspid valve is considered *Anatomically NORMAL* - *Dilation of tricuspid valve annulus* (mc)...from dilated cardiomyopathy - Flailing of tricuspid valve leaflet d/t tethering of cordae tendinae for same reason. Also seen w/ - Permanent placemaker, bc right ventricular lead can damage valve leaflets (10-20% of pts) - IV drug use can cause INFECTIVE ENDOCARDITIS (staph aureus mc) w/vegetations on tricuspid Pt: - Progressive dyspnea - LE edema - Ascites - JVD distention w/*Prominent V-waves* - Holosystolic murmur at lower left sternal border --> Increases with inspiration - Infective endocarditis? May see septic pulmonary embolisms --> "Numerous round pulmonary lesions in peripheral lung fields bilaterally" Dx: Echocardiogram Tx: 4-6 weeks abx (think about everything in terms of Vanc + Gent) - Native valves? *Vancomycin* (no Gent) - New (<60d) prosthetic? *Vanc + Gent + Cefepime* - Old (>60d) prosthetic? *Vanc + Gent + Ceftriaxone* - Inbetween aged prosthetic? *Vanc + Gent* - Subacute? *Gent + Ceftriaxone* (no Vanc) ...do *SURGERY* when... - CHF (Mcc of death!!!) - Vegetation >15mm - Vegetation >10mm + embolism (most of the time stroke and MI are contraind for surgery, but NOT in IE) - High risk of embolism - Abscess - Difficult to treat pathogens (x. Fungus) - Localized extension of infection

Lichen Planus

Path: Two main flavors.... - CUTANEOUS: Pruritic, purple, polygonal planar papules and plaques (6 P's) - ORAL: Wickham striae seen (lacy white markings) --> Oral has *prolonged* course w/many relapses - Associated w/... --> Hepatitis C (test for when you see this w/elevated LFTs) --> ACE-I --> THIAZIDE diuretics --> Beta-blockers --> Hydroxychloroquine Pt: - Flexor surfaces, Genitals, Oral mucosa - Oral mucosa is WHITE PAPULES AND PLAQUES w/MUCOSAL ATROPHY AND ULCERS (looks like aphthous ulcers but apthous ulcers are acute...) !!!! - Can cause longitudinal fissuring and thinning of nails - VULVAR & VAGINAL INVOLVEMENT --> "Multiple glazed brightly erythematous erosions bordered by white striae" --> "Stenotic vaginal introitus" from prolonged inflammation (can be confused with Lichen Sclerosis) --> Serosanguinous discharge Dx: *Vulvar punch bx* (to r/o cancer) Tx: TOPICAL *HIGH POTENCY GLUCOCORTICOIDS* Spontaneously resolves in 2 yrs

Myotonic Dystrophy

Path: Type 1 is mc and is *adult-onset* - CTG repeat on the DMPK gene - Autosomal DOMINANT - Life expectancy reduced d/t cardiac or respiratory failure Pt: Progressive weakness of skeletal, cardiac, and smooth muscle. - Testicular atrophy - Balding - Cataracts in adulthood - Hypotonia and poor feeding in childhood - Lower motor neuron signs (atrophy, weakness, decreased DTRs) - Elevated CK Can look like MYASTHENIA GRAVIS because has - Bilateral ptosis - Flat affect - Dysarthria - Muscular weakness BUT!!!!! - Weakness is *CONSTANT and NOT FATIGUABLE* - Grip myotonia (hard to let go) in DISTAL musculature (hands)

Anaphylaxis

Path: Type I Reaction....IgE-mediated. - Trigger --> Cross-linking Mast Cells degranulate --> Histamine release - Can have Biphasic (w/two separate peaking of sx) or Protracted (where sx last hours or days, far longer than normal) course. Pt: - Urticaria (rash), - *Hypotension*, - Wheezing - Respiratory distress - Cardiovascular compromise - Tachycardia - Tachypnea - Hypotension Dx: Clinical - Allergic symptoms effecting ≥2 systems Tx: *Epinephrine (1:1000 IM)* (immediate) + H1 Blockers + Steroids (take hours to work) - Oral pharyngeal edema, Stridor, Voice alteration? *+ Airway management* (only if Upper Resp signs) - If minimal response to first dose of Epi, *GIVE AGAIN* --> Can give *3x* Epi doses IM total before switching to IV infusion of Epi as needed (worry about arrhythmias) - Hypotensive? *Crystalloid + Trendelenberg* - Bronchospasm? *Albuterol* - DO NOT EVER give NSAIDs or BBlockers, worsens anaphylaxis - Recurrent anaphylaxis to Bees? *Bee Venom Immunotherapy*

Allergic Contact Dermatitis (ACD)

Path: Type IV hypersensitivity (Delayed Hypersensitivity Reaction) = *T-Cell Mediated* - *POISON IVY* --> Produces *Urshiol* - Nickel rash - Topical medications - Skin care products Pt: 4-96hr after exposure - Rash limited to exposed skin - Pruritus, - Erythema, - Edema, - Vesicles/Bullae Tx: Avoid allergen - Oral or topical *Corticosteroid*

Bacterial Vaginosis

Path: Type of VULVOVAGINITIS. Lactobacillus are loss (d/t abx or something else) and *Gardnerella Vaginalis* takes over. Pt: Copious, thin, *grey-white* vaginal discharge - *Amine odor* = fishy - NO pruritis or erythema (bc "vaginosis", not "vaginitis") - Elevated vaginal pH *>4.5* Dx: *Clue cells* on *Wet/Saline prep* - Can confirm w/positive *whiff test* (KOH sample) Tx: Metronidazole or Clindamycin (both safe to give anytime during preggo)

Vulvovaginal Candidiasis

Path: Type of VULVOVAGINITIS. Lactobacillus is lost (d/t abx or something else) and *Candida Albicans* takes over. - HIV, Steroids, Estrogen, DM can precipitate Pt: *Thick, white, chunky* vaginal discharge ("cottage cheese") - Loosely adherent pseudomembrane - Pruritus (bc "vaginitis") - NO change in pH (*3.8-4.5* NORMAL) Dx: *KOH prep* w/*pseudohyphae, hyphae, budding yeasts* Tx: Topical Miconazole (otc) v. oral Fluconazole (1x) - If recurrent, f/up w/*HgbA1c*

Septic Arthritis

Path: URI or skin infection can allow hematogenous spread of bacteria into the joint space. - MCC? *Staph* - Sexually active teenager? Gonorrhea - Kiddo? Staph or Strep - RF = (joint inflammation, injury) RA, OA, Prosthetic joint, Gout, DM, IVDU - If it goes untreated for >4-6hr may develop *Avascular necrosis of femoral head*!!! Pt: - *ABRUPT*, Acute!! (how you tell dif from RA flare) - Monoarticular arthritis (how you tell dif from RA flare) - Fever - Hot - Swollen - Decreased ROM - Progressive (ex. over 3 days...unlike gout which peaks at *12-24hr*) - underlying joint disorders (like gout, pseudogout, osteoarth) increase risk - Elevated ESR & CRP - Children prefer to keep the hip *Externally rotated* d/t pus in the joint space Dx: Synovial fluid analysis - Gram stain - Fluid white count >50,000 (90% neutrophils) Tx: *IV Abx* (big guns until cultures come back) + *Surgical drainage* - Gram positive? *Vancomycin* - Gram negative? *Third generation Cephalosporin* - Negative microscopy? *Vanc (+ 3rd Gen Ceph if immune compromised)* - ASAP!!! If it goes untreated for >4-6hr may develop *Avascular necrosis of femoral head*!!!

Pyelonephritis in Pregnant Women

Path: UTI involving the kidneys Pt: - Fever - Chills - CVA tenderness - Can be complicated by ARDS!!! Dx: - (+) UA (look out for epithelial cells bc have bacteria on it, so would be false positive) - WBC casts - >100,000 colonies Tx: ADMIT!!! and give *Ceftriaxone* (only IM or IV) - Usually you could consider treating with Cipro under these circumstances but it is a teratogen so NOT in pregnancy - Treat for *5-14 days* - If there is clinical improvement (asymptomatic for 48hr) you can switch to ORAL abx (*Penicillins, Cephalosporins, Fosfomycin*) --> if *improved*, then tx for *10 days* --> if NOT improved, then worry about *perinephric abscess*, so *USD* to confirm and tx for *14 days* --> They will remain on oral abx prophylactically for the rest of pregnancy - F/up on TEST OF CURE

Felty Syndrome

Path: Uncommon, serious complication of long-standing, erosive *Rheumatoid Arthritis*, where *AUTOANTIBODIES* are formed against *Neutrophil components* & *GCSF* (Granulocyte colony stimulating factor) Pt: - Swollen, deformed hand joints - Inflammatory polyarthritis - *Splenomegaly* (d/t neutrophils coated with Abs getting trapped) - *Neutropenia* (absolute neutrophil count <2000) - *Recurrent bacterial infections* (esp skin and sinuses) - Lymphadenopathy - Rheumatoid nodules - Necrotizing skin lesions Dx: - Anti-RF - Anti-CCP (*Anti-Citrullinated peptide antibodies*) - Elevated ESR - R/o other causes w/Bone Bx and Peripheral Smear Tx:

Selective IgA Deficiency

Path: Unknown defect. IgA deficiency --> Can't fight MUCOSAL defenses - Most common 1° immunodeficiency. - Ig*A* gets *A*naphylaxis! Pt: Ear, Nose, Throat, Gut. - Majority Asymptomatic. - Get anaphylaxis to IgA-containing products (x. BLOOD!!!! transfusions, Platelets, FFP) --> Don't get this confused with other anaphylactic responses, which are usually IgE induced. - Sinopulmonary infections - Gastroenteritis (x. *Giardia*) - Autoimmune disease (SLE, Celiac) - Atopy (*asthma, eczema*) - *Decreased IgA* - Normal IgG - Normal IgM Dx: Quantitative Immunoglobulin w/*ONLY decreased IgA, and normal everything else* Tx: Medical alert bracelets + wash plasma

Disseminated Gonococcal Infection

Path: Unprotected sexual intercourse Pt: - Young patient - Sexually active - Fever - Migratory joint pain v. Single joint - PRIMARY INFECTION CAN BE SILENT!!! (no vaginal discharge, cervical tenderness) - May or may not have rash (two flavors) EITHER - *Purulent monoarthritis* or... TRIAD of - *Pustular rash* (2-10 pustular or vesiculopustular lesions on LE) + - *Migrating polyarthritis* (asymmetric) + - *Tenosynovitis* (pain along flexor tendon sheaths) Dx: Joint aspiration looks inflammatory rather than infectious...but it is actually infectious - WBCs *<50,000* - NO BACTERIA!!! - NAAT Tx: *IV Ceftriaxone* - If purulent joint, *Drain* NOT!!!! REACTIVE ARTHRITIS! Which should have other symptoms! "Can't see, can't pee, etc"

Secondary Syphilis

Path: Untreated primary syphilis (Chancre) develops into secondary syphilis within weeks to months - Can cross placenta Pt: - Maculopapular rash, begins at skin cleavage lines of the trunk and spreads to extremities (*involves palms and soles!!!*) - Targetoid lesions - Fetal growth restriction - Congenital infection - Intrauterine fetal demise Dx: Screen all preggos at INITIAL prenatal visit w/*RPR* - Confirm w/*FTP-Abs* - Repeat at THIRD trimester for high risk (HIV, etc) Tx: *Penicillin* - If allergic & Pregnant? *Penicillin skin test* (for IgE-mediated response) then desensitize to Penicillin so can receive it.

Varicella Post-exposure Prophylaxis

Path: Up to 90% of susceptible individuals will develop infection after exposure - Usually receive vaccine at 1yo and 4yo Pt: - NO fever - Diffuse pruritic vessels on erythematous base in DIFFERENT STAGES of healing (along unilat. dermatome and PAIN if shingles) - Severe infection (mc in adolescents, adults, immunocompromised, preggo)? CNS disease, Pneumonia, Aggressive Skin disease Tx: - Infants <1yo outside neonatal period? Observe - Immunocompromised, Preggo, Neonates? *Varicella IG* - Not vaccinated and Not immunocompromised? *Varicella Vaccine* (live) - Completely vaccinated or prior infection? Observe

Gout Attacks

Path: Uric acid build up - Can be incited by trauma, surgery diet, red meat, *Diuretics* Pt: - Super acute, peaks at 12-24 hours. - Erythematous - Warm - Painful - First toe Dx: Joint aspiration with *Uric acid* - Will have WBCs 2,000-100,000 w/NEUTROPHILIC predominance Tx: *Lifestyle changes* FIRST (Decreasing WEIGHT, EtOH, Red meat, Fructose, Change med that caused).......unless repeated disabling attacks, Tophi, XR w/signs of gouty joint disease, Uric acid stones, Renal insufficiency.....Then can prophylax - Acute attack? *Colchicine, NSAIDs, Steroids* --> Avoid NSAIDs when CI to use (on ASA, clopidogrel, blood thinners) --> Avoid Colchicine in elderly patients and those with renal dysfunction - Prevention? *Allopurinol* v. Febuxostat --> If these don't work? *PROBENECID* - Tumor Lysis Synd? *Rasburicase* --> Prophylax w/IVF + Allopurinol

Primary Hyperaldosteronism (Conn Syndrome)

Path: Usually d/t adrenal adenoma --> Excessive unregulated excretion of ALDOSTERONE (increases serum Na+ = HTN and increased volume, & *secretes H+* to balance it = Metabolic alkalosis) Pt: - Polyuria, - Polydipsia, - Muscle cramps, - LOW renin activity (in response to HTN) - Refractory HTN, - *HypoK* - *Hypertension* - Hypernatremia (mild d/t aldosterone escape = increased renal filtering + BNP) - *Metabolic alkalosis* Dx: *Aldosterone:Renin >20* - 1st: *Oral saline load* --> adrenal suppression - 2nd: Failure to suppress aldosterone? get *Abd CT* - 3rd: Then *Venous sampling to figure out if unilateral or bilateral* Tx: - Unilateral? Resection - Bilateral or Not surgical candidate? *Epleronone v. Spironolactone*

Upper Extremity DVT

Pt: Unilateral arm or forearm edema, erythema - Athlete - PICC line or Central line - Thoracic outlet obstruction - RF = Malignancy Dx: *Duplex USD* Tx: *3mo* of anticoagulation

Hypoparathyroidism

Path: Usually iatrogenic (thyroidectomy or parathyroidectomy), sometimes autoimmune Pt: Signs and sx of HYPOCa2+... - Tetany - Perioral tingling - Headache - *Deposition of calcium in the basal ganglia* --> Extrapyramidal manifestations (x. resting hand tremor, increased muscle tone) - Dry skin - Blurry vision - Optic cup fullness - Nephrocalcinosis - Cataracts - Decreased PTH - Decreased Ca - Irrelevant or increased Phos Calcium-Phosphorus product (calcium x phos) *>55* increases the risk of soft tissue calcification!!! - x. *Calciphylaxis* Tx: Oral Calcium + Calcitriol (VitD)...but watch Phos!!! - Phos too high? Avoid phosphate-rich foods, consider phosphate binders

Vitamin B12 Deficiency (Cobalamine)

Path: Usually obtained from animal products, used in body to make DNA. - 3-10yr worth store in human body - Neuro symptoms (subacute combined degen of cord) - B12 + Intrinsic Factor absorbed at TERMINAL ILEUM --> Why *Crohn's disease* can be associated - RF = Vegetarians, Vegans, Alcoholics Pt: Strict uneducated vegan or compromised absorption - Pernicious anemia (autoimmune attack of parietal cells) - Crohn's disease (inflammation of terminal ileum) - Gastric bypass (remove parietal cells w/stomach) - *Lower extremity paresthesia* often presents FIRST - *Proprioceptive issues* - *Loss of vibratory sense* - Memory deficits - Irritability - Dementia - *PANCYTOPENIA* can be seen (bc can't make DNA) --> Megaloblastic anemia --> Mild THROMBOCYTOPENIA --> Mild LEUKOPENIA - Intramedullary hemolysis can cause JAUNDICE & Indirect hyperbilirubinemia --> Elevated LDH Dx: Low B12 - But if equivocal, get Methylmalonic acid (should be HIGH) - High MCV (*may even be borderline-normal!!!* esp if concomittent iron deficiency anemia from blood loss) Tx: B12 (oral v. IM) - ORAL if *nutritionally deficient* - IM if *impaired absorption* - Schilling's test will confirm whether nutritional or impaired...give oral B12, if found in urine then proof are able to absorb so nutritional def is issue. If not found in urine then proof not absorbed, so that is issue. *B12 deficiency can cause DORSAL COLUMN degen --> tissues w/two point discrim, proprioception, vibratory sense (can present like syphilis)* *If B12 COMBO deficiency w/Folate* --> Megaloblastic anemia will IMPROVE!! w/Folate treatment --> BUT NOT neuro issues from B12 deficiency

Vertebral Osteomyelitis

Path: Usually spread hematogenously (*UTI*, IVDU, etc) --> If spreads into epidural space becomes *Epidural abscess* Pt: - Fever (may or may not be present) - Back pain - *FOCAL SPINAL TENDERNESS* - WBCs may be NORMAL - UTI or recent hx of infection or IVDU Dx: *Blood cultures + ESR + CRP + Spinal XR* - ESR/CRP elevated - XR NORMAL --> Get *MRI* Tx: *CT Guided needle aspiration/Bx* + Abx

Uterine Inversion

Path: Uterus births itself...contracts so hard it goes through the cervix top-first. - Oxytocin makes contract excessively - or During placenta removal you pull uterus out too - RF = Fetal macrosomia, Rapid labor and delivery, Placenta accreta Pt: - Severe abdominal pain - Postpartum hemorrhage (500cc vaginal, 1000cc C/S) - *CAN'T FEEL* uterus, "ABSENT" uterus, *not palpable at umbilicus*!! (how you dif from vaginal hematoma) - Hypotension - Paradoxical bradycardia d/t pull of surrounding peritoneum Dx: Clinical Tx: DO NOT try and remove placenta until after uterus is back in place. 1. *Manually try replacing it* FIRST 2. If this doesn't work then use *Tocolytics* (though associated with increased risk of bleeding and bogginess which is why you hold off on this) -->Manually replace-->*Tonics* (so it contracts into place) 3. If unexplained & ongoing? *Uterine artery* ligation (via OB), *Uterine artery embolization* (via IR), *Total abdominal hysterectomy* (via OR)

Von Hippel Lindau Disease

Path: VHL gene mutation - Autosomal DOMINANT Pt: - Retinal and CNS *Hemangioblastomas* - *Pheochromocytomas* (adrenal medulla) & Paragangliomas (sympathetic ganglia) - *Renal cell carcinoma* - *Endolymphatic tumors of the middle ear* (HEARING LOSS!!!!!) Dx: Tx:

Endometritis

Path: Vaginal flora ascends into Mom's sterile uterus if baby is OUT (polymicrobial) - Infection of the uterine decidua - If baby is IN, flora ascends to Amniotic Sack (Chorioamnionitis) - RF = Prolonged ROM, Prolonged labor, Operative vaginal delivery, C/S Pt: - Maternal fever (usually >24hr after surgery) - Intermenstrual bleeding - Cervical motion and/or uterine tenderness - Purulent lochia - Intrauterine adhesions (but NOT lateral cervical displacement like Endometriosis) Dx: - r/o other source of infection Tx: Abx for Gram (-) and anaerobes (*Ampicillin + Gentamicin +/- Clindamycin*) - Continue treatment until afebrile for >24hr - If does not resolve with treatment? Consider *Septic Pelvic Thrombophlebitis*

Vasovagal & Situational Syncope

Path: Vagus nerve is stimulated somehow --> Ach is dumped (parasympathetic stimulus) --> Bradycardia + Vasodilation - "Increased parasympathetic output to the heart" vs. "Decreased sympathetic output to the heart" - Vagus nerve stimulated by... --> VISCERAL ORGAN STIMULATION (x. cough) --> CAROTID BODIES --> PSYCHOGENIC (emotions) - Triggered by emotional or painful stimuli - *"Bradycardia and sinus arrest"* Pt: Situational, reproducible - Syncopal prodrome --> Nausea --> Diaphoresis --> Pallor --> Lightheadedness --> Dizziness --> Abdominal pain - Rapid recovery of consciousness - Cough, micturation, hair combing etc can also cause Dx: Clinical Tx: *Counterpressure manuever education* (supine with legs raised, crossing legs with tensed muscles, hand grips) + *Avoid triggers*

Trigeminal Neuralgia

Path: Vascular compression of *Trigeminal Nerve* root as it enters the PONS leads to atrophy and demyelination of the nerve. - D/t vascular loop, neoplastic growth, or multiple sclerosis plaque Pt: - Unilateral, intermittent stabbing *ear pain* that radiates along *V2 or V3* distribution of Trigeminal nerve --> Last a few seconds to a few minutes - Worse when touched, chewing, light stimuli Dx: *MRI* Tx: *Carbamazapine v. Oxcarbazepine*

Kaposi Sarcoma

Path: Vascular tumor caused by co-infection with *HHV8* - AIDs defining illness Pt: - Elliptical violaceous skin lesions - Papules at first, then plaques or nodules - Go from light brown to purple - Found on legs, face, genitalia, GI tract, Lungs - NO FEVER (how you dif from Bacillary Angiomatosis, caused by Bartonella) Dx: Clinically - May Bx to confirm Tx: *Antiretroviral therapy* - If systemic or severe may consider Chemotherapy

Snakebite Envenomation

Path: Venomous snake bite has toxins which cause local tissue toxicity and swelling, coagulation abnormalities, neuro/myotoxicity, cardiovascular collapse, Pt: - Two puncture marks - Swelling - Ecchymosis - Oozing from bite site - Decreased capillary refill - Hypotension Dx: *CBC + CK + PT/PTT + INR + Fibrinogen* Tx: - MILD? Observe. - Pronounced sx, coagulation or CV compromise? *Crotalidae polyvalent Fab* (works for all North American snake bites) --> Want to avoid if you can bc there is high risk for anaphylaxis

Mumps

Path: Very contagious viral illness by Mumps - Prevented by vaccinations Pt: More severe sx in adults or adolescents - Fever - Myalgias - Fatigue - Pubertal males. - Parotid swelling (can be *UNILATERAL or BILATERAL*!!!) - Orchitis. - Can cause aseptic meningitis Dx: Clinical Tx: Supportive - MMRV vaccine so a patient would have hx & why they're not vaccinated

Herpes Encephalitis

Path: Viral encephalitis caused by Herpes Pt: (over a few days) - Fever - Headache - Altered mental status - FND - Seizures - Stupor - Anosmia - Gustatory hallucinations - Pyschosis Dx: CT, MRI, EEG --> *Hypodense lesions in the TEMPORAL lobe* (or frontotemporal lobe) - *CSF* w/ (think of fit as viral pattern but w/elevated RBCs) --> HIGH protein --> Normal glucose --> Elevated WBCs --> *HIGH RBCs*!! (reflects temporal lobe hemorrhage)

Deep Venous Thrombosis (DVT)

Path: Virchow's triad 1) Venous stasis 2) Endothelial injury 3) Hypercoagulable state Pt: - UNILATERAL LEG SWELLING (not calf tenderness) Dx: *Compression USD* Tx: *Anticoagulants* (for board test, we only start these after confirming w/compression USD!!!!) - Preggo? *Heparin v. LMWH* for >3mo - CI (significant bleeding, recent surgery, hemorrhagic stroke) to anticoagulation? *IVC Filter* - Failed tx w/anticoagulants or recurrence? *IVC Filter* - PE or *Massive* proximal DVT w/limb ischemia? *Thrombolytics*

Vitamin K Deficiency

Path: Vitamin K is a PROCOAGULANT...activates clotting factors 2, 7, 9, 10. When deficient causes bleeding. - Body usually stores 30 days of this, but if alcoholic or liver injury and malnourished can drop down to ~7 day supply - Deficiency seen in Cystic Fibrosis (pancreas issues means can't absorb ADEK) - Found in leafy greens Pt: - Easy bruising - Epistaxis Dx: - FIRST prolonged *PT & INR* - THEN prolonged PTT (severe) - Deficiency of Factors 2, 7, 9, 10, Protein C, Protein S

Clostridioides difficile (C. dif / C dif)

Path: Watery diarrhea following RECENT antibiotic use (does not need to be current) - RF = Recent hospitalizations, Age >65, *Gastric acid suppression with PPIs* - Unexplained leukocytosis even in the absence of diarrhea should raise suspicion Pt: - Abdominal cramping - Watery diarrhea - Fever - Leukocytosis - Toxic megacolon (colonic diameter ≥6cm) - Increased Lactate indicates possible ischemia Dx: *Stool TOXIN testing* - Test for cure not needed...would be positive for weeks after clinical recovery Tx: *Vancomycin* ORALLY (bc better delivery to gut) - ...+ MTZ (if fulminant w/ megacolon, or unable to take vanco) - If 3rd recurrence? *Fidaxomycin* (but expensive) - If still not responsive? *Fecal transplant* - Peritoneal signs? *Laparotomy* (think necrosis or perforation)

Gastroesophageal Reflux Disease (GERD)

Path: Weakened LES --> Acid reflux Pt: Retrosternal burn - Sx worse when flat & w/spicy food - Sx better when upright & w/antacids - *Nocturnal asthma* = Wheezing, coughing, hacking at night - Can awaken from sleep - Prolonged chest pain lasting *>1 hour* - Maybe dysphagia - Cough - Hoarseness Dx/Tx: >50yo M, Sx >5yr, Cancer RF, Alarm sx? - Yes? *EGD* --> Esophagitis? Treat the type you find. --> Not clear? *Manometry* - No? *PPI qd x8wks* --> Still have sx? *PPI bid x8wks* (or dif PPI) ----> If still no improvement with that? Then *EGD* v. Manometry. - *1* episode of sx per week? *Lifestyle changes* (Weight loss, avoid coffee, chocolate, peppermint, alcohol, elevate head of bed at night) - Barrett's Metaplasia? HIGH DOSE PPI. - Dysplasia? Ablation. - Adenocarcinoma? Resect.

Organophosphate Poisoning

Path: Weapons of terror, Myasthenia gravis meds, Pesticides - Acetylcholinesterase is blocked, so excessive acetylcholine Pt: DUMBELS - Diarrhea - Urination - Miosis - Bronchospasm/Bradycardia - Emesis - Lacrimation - Salivation Dx: Clinical - Could confirm w/*RBC Acetylcholinesterase Activity* test Tx: - FIRST? *Remove clothes and irrigate skin*!! --> Do this to prevent continued absorption of chemicals into the skin!! Healthcare workers must wear PPE. - NEXT? *Atropine* (works for muscarinic symptoms, x. bronchospasm, but not for nicotinic) - THEN *Pralidoxime* (works for nicotinic and muscarinic symptoms, but can worsen muscarinic if not given before atropine)

Subfalcine Herniation

Path: When the cingulate gyrus is pushed beneath the falx cerebri - D/t unilateral frontal, parietal, or temporal lesion Pt: - Ipsilateral *anterior cerebral artery* compression causes contralateral *LE weakness* - NO pupillary involvement, irregular respirations, or coma (unlike Uncal, Tonsillar herniations) Dx: CT Tx: Decrease ICP + Correct cause of mass effect

Leukocyte Adhesion Deficiency

Path: White blood cells can't leave the blood stream - Defect of *LFA-1 integrin* --> *No CD18 on neutrophils* - WBCs are unable to travel into sites of infection - Staph areus and Gram negative bugs are mc seen Pt: "LAD" - *L*ate separation of cord - *A*bsent puss (infected tissue lacks purulence or neutrophils) - *D*ysfunctional neutrophils (*recurrent skin and mucosal bacterial infections*!!!!! --> Staph, Strep, Gram negs) - FEVER - Leukemia-like HIGH WBCs (*neutrophilia*) bc they're stuck in the blood vessels - Recurrent bacterial infections - *Severe periodontitis* - Chronic infection can lead to ulceration and necrosis Tx: *Bone marrow transplant*

Acute Cellular Rejection (ACR)

Path: Within *FIRST 3 MONTHS* of transplant - Patient's own immune system targets the allograft Pt: Asymptomatic or... - Fevers, - Malaise, - Lethargy, - Liver transplant? Elevated ALT, AST, AlkPhos, Bili - NO HYPOTENSION, TACHYCARDIA, or Significant LEUKOCYTOSIS (these would be signs of *Sepsis*!!!! Not ACR.) Dx: Bx w/ - *Mixed inflammatory infiltration* (eosinophils, neutrophils, lymphocytes), - *Interlobular bile duct destruction* and - *Endotheliitis* (subendothelial invasion) --> MOST RELIABLE sign of ACR Tx: Increased dose of immunosuppressants (x. *High dose corticosteroids*)

Recurrent Urinary Tract Infection

Path: Women are at increased risk - Esp. *postmenopausal* women because *estrogen deficiency* causes... --> Vulvovaginal atrophy --> Decreased bulk of bladder and urethra w/increased risk of ascending infection --> Decreased vaginal lactobacilli levels and elevated vaginal pH (E. coli can colonize better) Pt: - Urgency - Urinary frequency - Leakage of urine (d/t bladder spasm) - Dysuria Dx: Leukocyte esterase & Nitrites on UA, w/NO CVA tenderness (or maybe even just Leukocyte Esterase...Nitrites is caused by E. Coli but not Staph Sap) - *≥3 episodes in a year* of simple cystitis - OR *≥2 episodes in 6 months* Tx: - Asymptomatic? Don't treat. - Postmenopausal? *Increased fluid intake* + *Vaginal estrogen*...can consider daily or postcoital prophylaxis w/abx - Pregnancy? *Amoxicillin*...ONLY Nitrofurantoin if penicillin allergic (recent studies question safety)

Transient Global Amnesia

Think *50 First Dates* - She always remembers who she is ANTEROGRADE amnesia for time and place. NO loss of personal identity (unlike Dissociative amnesia). Memory loss resolves within *24hr*

Solid Organ Transplant

Path: Worry about opportunistic infections (*PCP*, *CMV*, Aspergillus are the mc!) Pt: - CMV? in *FIRST YEAR* after transplant. --> ACUTE, Febrile, Diffuse interstitial pneumonia. --> Crackles --> TX: Valganciclovir - PCP? --> INDOLENT, Febrile, Diffuse interstitial pneumonia --> Crackles --> Tx: TMP-SMX. - ACUTE CELLULAR REJECTION --> Respiratory dysfunction, Febrile, New infiltrates. --> Can be precipitated by infection and occur concurrently w/CMV or PCP - CHRONIC GRAFT REJECTION --> *>1yr* post-transplant --> Progressive airflow fibrosis --> Obstruction & Wheezing Dx: *Bronchoscopy + Lung bx* Tx: *TMP-SMX* --> Covers PCP, Listeria, Toxo, and many other URI, GI, and urinary bugs. - Can often stop 6-12mo after transplant when immunosuppressives are tapered. - *Pneumococci* and *HepB* vaccines given BEFORE transplant - *Inactivated influenza vaccine* given yearly

Lesch-Nyhan syndrome

Path: X-linked RECESSIVE deficiency of HGPRT (involved in purine metabolism) - Accumulation of Hypoxanthine and Uric acid in urine, serum, CNS - Dopaminergic pathways effected Pt: Self-mutilation, Gouty arthritis INFANCY - Delayed milestones - HYPOtonia AGE >3 - Dystonia - Chorea - Spasticity - Self-mutilation (biting hands, fingers, lips) - Banging head and limbs - HYPERreflexia - Gouty arthritis - Obstructive nephropathy

Duchenne Muscular Dystrophy (DMD)

Path: X-linked RECESSIVE disorder causing reduced or absent dystrophin in muscle fibers Pt: Severe, progressive *PROXIMAL muscle weakness* - Don't walk independently until *>18mo* - Gower sign - Calf enlargement (pseudohypertophy) by childhood --> can have 5/5 calf strength and weakness in THIGHS!!! - DILATED CARDIOMYOPATHY is leading cause of death --> 20-30yo - Respiratory failure is second leading cause of death - Scoliosis - Pes planus (flat feet) Dx: *CREATININE KINASE* is elevated!!! - Dystrophin gene mutation on Genetic Analysis to confirm - Then ECHO to check for dilated cardiomyopathy Tx: Glucocorticoids (...weird) only if have muscle pain

Hemophilia A & B

Path: X-linked RECESSIVE disorder. ...Factor VIII deficiency = A ...Factor IX deficiency = B - Mom's pass it on. Pt: Delayed or prolonged bleeding after minor trauma - Hemophilic arthropathy - Joint pain and swelling - Skeletal muscle hematoma Dx: Coagulation studies or CBC - Prolonged PTT - Normal PT and platelets. Tx: *Recombinant factor VIII or IX infusions* - Watch for inhibitor development (where body recognizes infusions as foreign and develops Abs to it)...happens in 25% of pts --> Recurrence of sx (Bleeding, prolonged PTT)

Turner Syndrome

Path: XO --> Gonadal dysgenesis Pt: - Bicuspid aortic valve (mc) - Coarctation of aorta (second mc) - Increased risk for *Aortic Dissection* - Horseshoe kidneys - *Congenital lymphedema* (>50% of patients - hands, feet, neck fill w/protein-rich fluid --> NONPITTING edema) - Short stature - Scoliosis - Nail dysplasia - Streak ovaries (estrogen deficient = amenorrhea, no breast development, *osteoporosis*) - *ELEVATED FSH and LH* (Hypergonadotropic Hypogonadism) --> bc no negative feedback loop from Estrogen --> *Primary ovarian insufficiency* --> *Osteoporosis* (d/t decreased estrogen protection) - Have PUBIC and AXILLARY HAIR! --> bc adrenals not effected - NORMAL cognitive abilities.... Dx: Karyotype Tx: *Estrogen + Progesterone* replacement therapy

Klinefelter Syndrome (XXY)

Path: XXY is associated with testicular fibrosis, which causes Primary Hypogonadism, so compensatory increase in gonadotropins causes increased expression of aromatase (testosterone --> estradiol) - Elevated estrogen:androgen ratio Pt: - Infertility (Seminferous tubule dysgenesis --> hypogonadism --> increased LH and FSH) - Tall stature - Gynecomastia (would be *BILATERAL*) - Low libido (how you tell dif from anabolic steroid use) - Decreased body hair (how you tell dif from anabolic steroid use) - Increased risk for male breast cancer (would be *UNILATERAL*) - NO cognitive impairment (unlike FragileX), though there may be some behavioral issues Dx: Karyotype analysis - *FIRM BREAST MASS*? Get IMAGING!!!!!!!!!! Low threshold compared to other men d/t their increased risk. Tx: *Exogenous Testosterone*

Illness Anxiety Disorder

Path: aka "Hypochondriasis" Pt: - NO SX - Preoccupation with acquiring an ILLNESS despite repeated reassurance - Ego*DYSTONIC* (they don't want to feel these feelings...) Dx: Clinical Tx: *Psychotherapy* - Try to keep to ONE provider - Set boundaries (number of tests they'll get, etc) - Can also be advocate for new, significant complaints.

MALT of the Stomach

Path: aka Extranodal marginal zone B-Cell Lymphomas, associated w/*H. Pylori* infection, the inflammation from which stimulates large numbers of B and T cells in the gastric lamina. - Eventually results in a monoclonal B-cell proliferation that doesn't need normal stimulatory pathway Pt: - Upper abdominal pain - Nausea - Loss of apetite - Epigastric pain worse w/NSAIDs - Epigastric tenderness - Mass in body of stomach Dx: H. Pylori testing Tx: - Early? *Quadruple therapy* (PPI + Tetracycline + Metronidazole + Bismuth salt) - Advanced or H. Pylori negative? RT v. Immunotherapy v. Chemo

Morton Neuroma

Path: caused by mechanically induced neuropathic degeneration of the interdigital nerves. - Mc cause of pain in forefoot in women 25-50 usually b/c shoes (high heels) Pt: - Runner or wears high heels - Numbness, aching, burning in distal forefoot - Pain bw *3rd and 4th toes* on plantar surface --> MASS Dx: Mulder sign (clicking sensation when simultaneously palpating this space and squeezing metatarsal joints) Tx: shoe inserts to decrease pressure on metatarsal head - surgery last case scenario

Crohn's Disease

Path: crypt inflammation and abscesses Pt: 20-30 yo & 50-75 yo, Watery diarrhea, multiple BMs daily, abdominal pain, nutritional deficiencies, WEIGHT LOSS. INSIDIOUS. - No cancer risk - *Arthritis* (mc extra-intestinal manifestation) that improves w/activity and is worse in morning --> Spine or peripheral - Skin disorders (Erythema Nodosum, Pyoderma Gangrenosum) - Nephrolithiasis - Oral ulcers (aphthous ulcers) - Uveitis - Fat malabsorption --> Increased oxalate reabsorption (bc Ca2+ binds to fat instead of oxalate) = KIDNEY STONES!!! - *Fibrotic STRICTURE at TERMINAL ILEUM* --> Causes SBO - Extra-intestinal: --> FISTULAS, --> Terminal ilium intestinal deficiencies = B12 & fats (leads to *Bile salt malabsorption, and therefore chronic diarrhea*) --> Duodenal intestinal deficiencies = Fe2+ & osteopenia. Dx: - *Colonoscopy* or EGD w/Skip lesions in ENTIRE GI tract (esp. TERMINAL ILEUM) - Bx is TRANSMURAL w/NONCASEATING GRANULOMAS - Elevated *CRP & ESR* - Stool positive for fecal *Calprotectin* Tx: *Budesonide* (or other steroids) - Surgery is Reserved for complications (fistulas and abscesses). "think of a fat granny and an old crone skipping down a cobblestone road away from the wreck (rectal sparing)"

Guillain-Barre Syndrome

Path: d/t *INFECTION* (can be *Viral, URI, or Campylobacter!!!*) causing an immune-mediated polyneuropathy which demyelinates peripheral nerve fibers Pt: Ascending symmetrical paralysis over DAYS to WEEKS. - Paresthesia, neuropathic pain - Back pain w/o!! tenderness at spine --> May radiate down to buttocks in electric shock sensation - Radicular pain d/t nerve root inflammation - Decreased/*absent* DTRs - Autonomic dysfunction (tachycardia, urinary retention, arrhythmias) --> Not seen in tick-borne paralysis! - Electric shock sensations - Follows infections (viral, campylobacter, URI) - *Rapid onset ophthalmoplegia* (Associated w/variant "*Miller Fisher Syndrome*" ONLY) Dx: LP w/*Albuminocytologic dissociation* - NORMAL WBCs - Elevated Protein - Gram stain w/o organisms - MRI is NORMAL. Tx: *IV IG* vs. *Plasmapheresis* - Assess pulmonary function w/*Spirometry* FIRST!!!! --> THEN a decrease in FVC *(≤20)*, Respiratory distress, Dysautonomia, or widened pulse pressure indicate reason for *Intubation*

Chemical Conjunctivitis

Path: d/t *Silver nitrate* which was thought to prevent vertical transmission Pt: - Onset w/in *24 hr* of birth - BILATERAL - NONpurulent Tx: - Prophylax? *topical Erythromycin* instead! (takes care of everything but chlamydia)

Chlamydial Conjunctivitis

Path: d/t Chlamydia Pt: - Onset w/in *5-14 days* - *UNILATERAL* turns *BILATERAL* - *Mostly mucoid* then turn *Purulent* Tx: ORAL!!!!!!! *Erythromycin* - No prophylaxis :( The topical stuff doesn't work.

Gonorrheal Conjunctivitis

Path: d/t Gonorrhea... Pt: - Onset w/*2-7 days* - BILATERAL - *Purulent* Tx: *Ceftriaxone* - Prophylax? *topical Erythromycin* at birth! (takes care of everything but chlamydia) --> We do this for all babies

Rectovaginal Fistula

Path: d/t Third or Fourth degree perineal lacerations during birth, with inadequate wound repair or wound infection and breakdown. Pt: - "Dark red, velvety lesion" on posterior vaginal wall - Malodorous tan-brown discharge Dx: Clinical Tx: Surgical repair

Variable Decelerations

Path: d/t UMBILICAL CORD COMPRESSION - Seen WITH or AFTER contraction. - From onset of deceleration to nadir (peak) of deceleration is *<30s*!!! - Must be seen in *≥50%* of contractions Tx: - FIRST: *Maternal repositioning* (on side, on all fours) - THEN if not resolved: *Amnioinfusion* - Recurrent or Category III FHR: *C-section*

Cytomegalovirus (CMV)

Path: ds-DNA viral infection which looks very similar to EBV (Mono) in adults, and looks similar to Toxoplasmosis in neonates. - Transplant patients - AIDs patients w/*CD4<100* Pt: - PNEUMONITIS: Meat guy coughing is *CMV pneumonia* --> "Bilateral interstitial infiltrates" --> "Small amount of fluid at the bilateral lung bases" - GASTROENTERITIS: Conveyor belt is *ulcerated colon* --> first watery diarrhea from inflammation, then bloody diarrhea. - HEPATITIS (elevated liver enzymes) - Mono-like infection but MORE MILD (Fever, fatigue, malaise, absolute lymphocytosis w/*atypical lymphocytes*, may or may not have splenomegaly, pharyngitis, and tender LNDs) - CYTOPENIA (x. PANcytopenia) can be seen from bone marrow involvement - Chorioretinitis --> *Yellow-white exudates immediately adjacent to the fovea and retinal vessels* ("Perivascular", unlike Toxo which has "Nonvascular" distribution) --> Progressive blurred vision --> Floaters --> Photopsia (sensation of flashing lights) - Paraventricular calcifications - Seizures - Mental retardation - Blueberry muffin rash Dx: Clinical - *Bx the affected organ* - Can confirm w/*CMV IgM* Serology - Negative heterophile Ab test (would be positive in Mono/EBV) Tx: *Ganciclovir* + Discontinue or reduce immune suppressants - Lesions near fovea or optic nerve? *Intravitreal injections* (prevent retinal detachment) - Start HIV treatment ~2wks after initiating CMV tx

hCG Secreting Germ Cell Tumor

Path: hCG Secreting Germ Cell Tumor, found in gonads Pt: - Elevated B-hCG level - Elevated Estradiol --> Gynecomastia - Low/normal testosterone Dx: *USD* of gonads Tx: Resection

Chronic Pancreatitis

Path: mc d/t chronic alcohol abuse Pt: - Chronic epigastric pain relieved by LEANING FORWARD, - Diarrhea, - Steatorrhea, - Weight loss - can have pain free intervals lasting year - or can be continuous - glucose intolerance or overt diabetes eventually Dx: *CT* --> pancreatic calcifications, patchy inflammation, fibrosis - DECREASED fecal *Elastase* - NOT amylase or lipase (bc they will be normal!) Tx: Lifestyle adjustments + *Panc Enzymes*

Unilateral Cervical Lymphadenitis

Path: mcc *Staph & Strep* - Recent URI - Or poor dental hygiene (would cause Gram NEG infection) Pt: - Children *<5yo* - *Fever* - Unilateral swollen lymph node, TENDER (3-6cm) - Erythema over LN - Fluctuance indicates it has progressed to abscess Dx: Clinical Tx: *Clindamycin* v. *Amoxicillin-Clavulanate* - Surgical drainage prn

Choanal Atresia

Pathology: Blockage from nose to throat (completely atretic or stenosis) Patient: - Baby is BLUE with feeds and - PINK with crying, - childhood snoring. - In childhood presents w/chronic nasal discharge. Dx: Catheter fails to pass, look up there with fiberoptic wire Tx: Surgically open up - Maintain airway and do orogastric tube feedings until surgery

Epiglottitis

Pathology: H. Flu (less common now b/c vaccine) - Strep - Staph Patient: - 3-7yo, - High fever, - Tripodding, "leaning forward with chin thrust forward" --> Hyperextending neck - Accessory muscle use, - Drooling - Hot potato voice (like retropharyngeal abscess and peritonsillar abscess) Dx: Visualize CHERRY-RED swollen epiglottis (NOT XR, which would show thumbprint sign) Tx: *ET tube* in OR - then IV Abx (*Ceftriaxone + Vanco*).

Mastoiditis

Pathology: Infection of mastoid air cells w/URI bugs. - Consider in anyone with otitis media, otitis externa, esp. w/ear tubes. Patient: - Acute otitis MEDIA appearance - Swelling of the mastoid bone, - *ANTERIORLY ROTATED* ear, - Fever, - Otalgia. Dx: Clinical Tx: *Surgical decompression* (tympanostomy v. mastoidectomy) + IV Abx. - Check for EXTRACRANIAL extension (Facial nerve palsy, Labyrinthitis, Hearing loss) - Check for INTRACRANIAL extension (*Nocturnal headaches, Morning vomiting*)

Foreign Body Aspiration

Pathology: Kids like to stick things places. Then infection can develop. Patient: UNILATERAL bacterial infections, or swallowed item on CXR - Inspiratory stridor or wheeze, focally diminished breath sounds Dx: Clinical v. Imaging Tx: Retrieve object and treat infection - If small, blunt, and <24hr can let pass - If small blunt and seems stuck higher up than it should be given time that has passed, it's obstructed and needs to be retrieved - If sharp, retrieve

Peritonsillar Abscess

Pathology: Oral flora Patient: - >10 years, - Fever - Hot potato voice & Drooling (like epiglottitis and retropharyngeal abscess), - Sore throat (pharyngeal pain) - Dysphagia, - Earache - UVULAR DEVIATION (unlike tonsillitis) - Prominent unilateral LNDs Dx: Clinical Tx: - IMMEDIATELY? *Drainage* of peritonsillar abscess - THEN? *IV Abx* (cover Strep & Resp anaerobes) - May need to consider surgery if the prior steps do not work.

Acetaminophen toxicity

Pathology: Tylenol. --> Causes DRUG INDUCED LIVER INJURY Patient: INTENTIONALLY vs. UNINTENTIONALLY - Max dose 2-3mg/day Dx: - If AST/ALT >1000? *ACETAMINOPHEN LEVEL* @ 4hr & 16hr after ingestion and compare to nomogram (this determines treatment) Tx: - If ABOVE nomogram? Give *N-ACETYLCYSTEINE* - If BELOW nomogram? OBSERVE

Pharyngitis

Pathology: Viral (mcc) vs. Group A Strep Patient: - Sore throat - Odynophagia. - If viral s/sx (conjunctivitis, rhinorrhea, etc), think Herpangina (Coxsackie A) --> Small vesicles on the uvula, soft palate, tonsillar pillars. "CENTOR" criteria (+1 for ea...see pic) .....Not useful in children and preadolescents!!! - Cough (-) = no cough - Exudates - Nodes - Temperature ≥ 38c (100.4F) - OR (<14yo = +1 vs. >44yo = -1) Dx/Tx: CENTOR *≤1* = VIRAL, do nothing 2-3 = Rapid strep (if neg and you think false, then culture. --> If neg and you think true then do nothing --> If neg and you think false, and there are risks associated w/possible infection (care taking after infant, etc) get *Throat culture* *≥4* = Abx (*Amoxicillin vs. Penicillin*)

Bronchiolitis

Pathology: Virus...mcc RSV - Older children? URI (rhinorrhea, nasal congestion) - Younger children? URI + LRI - Looks like baby walking pneumonia clinically. Patient: - <2yo - Cough, - Wheezing, - Dyspnea, - Fever (may be high...but you still don't give Abx) - Otherwise generally look well. - O2 sats not terrible - Winter months, - *Apneic episodes* which scare parents but are benign. - *EXPIRATORY WHEEZE* (lower airway obstruction. helps differentiate from croup) --> Can be recurrent throughout childhood - *Crackles bilaterally* Dx: You really don't need anything to dx. - CXR w/*increased interstitial markings and peribronchial cuffing* (can look like Neonatal RDS CXR, but these babies are older) --> Absence of focal consolidation Tx: Discharge w/*Close follow-up* (can progress to AHRF, or ARDS) - If premature or <2mo? *IVF + O2* --> *Palivizumab* if high risk (see pic)

Cross Cultural Care

Patient Centeredness --> Identify patient's values and align care with their priorities. Cultural Sensitivity --> Explore their beliefs and understand how they may effect health decisions. Enhanced Communication --> Address language barriers and tailor communication style to patient's preferences.

Ethics: Meningitis Refuses Hospitalization

Patient w/Meningitis declines to be treated in hospital - *Hospitalize and Isolate against patient's wishes* --> You're allowed to do this for public safety reasons He can decline treatment if he wants, but he has to be isolated.

Scaphoid Fracture

Patient: *Fall on outstretched hand*, w/pain at anatomic snuff box. - MC carpal bone fracture - Worry about avascular necrosis and nonunion bc fracture can disrupt proximal segment of *RADIAL ARTERY* Dx: Clinical at first!! *Tenderness at anatomic snuff box* - XRAY is NORMAL on DAY 1 ...if need confirmation can use *CT or MRI*, bc you don't want to miss avascular necrosis!!! - XRAY be show fracture on DAY 7 Tx: *CAST EVEN IF XR NORMAL! Then XRAY on day 7-10* (lower cost approach) - Or if need immediate proof, CT v MRI on day 1 (more expensive but may allow for earlier return to activity)

Ureterolithiasis (Kidney Stones)

Patient: Colicky flank pain, radiates to groin, hematuria, (without fever or mass) Dx: UA w/hematuria!!! --> then *NONCONTRAST!!!!!! SPIRAL CT* --> stone or hydroneph seen? then KIDNEY STONE! - *USD* if preggo Tx: Stone? --> then STRAIN URINE (to find out what type of stone) --> then MODIFY RISK FACTORS (based off type of stone) --> RTC 6 weeks for screen --> - <5mm? IV Fluids + Pain Meds - <7mm? IV Fluids + Pain Meds + Medical Expulsive Therapy (CCB v. Alpha-Blocker *Tamsulosin* for men and women!) - >7mm and <1.5cm? *Lithotripsy if PROXIMAL. Ureteroscopy if DISTAL* - >1.5cm? *Percutaneous Anterograde Nephroliotomy if PROXIMAL. Lap surgery if DISTAL.* - Septic? *Nephrostomy if PROXIMAL. Stenting if DISTAL.* WHEN TO REFER TO UROLOGY? Septic Anuria Acute kidney injury Refractory pain >1cm Stone hasn't passed in 4-5weeks

Social (Pragmatic) Communication Disorder

Persistent difficulties in the social use of verbal and nonverbal communication (eye contact, body language) w/ Impairment evident in multiple settings

Tremors

Physiologic Tremor - Meds can provoke (x. SSRIs, steroids, caffeine, stimulants, *LITHIUM* etc.) - NOT distractible - Worse w/STRESS - LOW amplitude, HIGH frequency (fine) Cerebellar Tremor - HIGH Amplitude, LOW Frequency (coarse) - WORSE w/movement Essential Tremor - WORSE w/movement, better w/rest. Parkinson's - Resting tremor - BETTER w/movement Functional Tremor - MOST COMMON TREMOR!! - Aka "Psychogenic" - *HIGH* Amplitude, *LOW* Frequency (coarse) - DISTRACTABLE - Inconsistent tremor - Abrupt onset and cessation - No other neurological findings.

Quality Improvement (QI)

Plan-Do-Study-Act Plan-Do-Check-Act 1. Identify issue 2. PLAN: Identify contributing factors, Set objective, Put a plan in place to get there 3. DO: Implement the plan, Collect data, Document problems and observations 4. CHECK/STUDY: Compare data collected to objective 5. ACT: Identify changes that need to be made or lessons learned and act on them 6. Repeat prn.

Control Charts

Plot data over time and set upper and lower limits (x. infection rates in an ICU), so you can identify whether a problem needs to be investigated further (x. infections are occurring more frequently than normal)

Recommended Prophylactic Treatment for Asplenic Patients

Pneumococcal, meningococcal, and Haemophilus influenzae (Hib) Inactivated influenza vaccine q1yr HBV HAV Tdap, then Td q10yr Should be received *≥14 days BEFORE* Splenectomy OR *≥14 days AFTER* Splenectomy If become sick? Take *Amoxicillin-Clavulanate* and proceed to nearest emergency center

Epididymitis

Posterior testicular pain and swelling, improvement in pain with elevation, normal cremasteric reflex Dx: NAAT + UA - UA shows normal or mild wbc w/mild urinary sx (STD), or high wbc w/urinary sx (E.coli) Tx: - *<35yo*? Likely *Gonorrhea/Chlamydia* (from sex) --> *Ceftriaxone + Doxy* - *>35yo*? Likely *E. Coli* (from BPH) --> *Levofloxacin*

Postpartum -blues -depression -psychosis

Postpartum Blues (typically w/in days) Postpartum Depression (typically w/in 4-6wks) Postpartum Psychosis

Mechanical Prosthetic Valve Thrombosis

Prevention - Aspirin 75-100 mg/day - WARFARIN --> *Mitral valve*: warfarin with target INR 2.5-3.5 --> *Aortic valve*: warfarin with target INR 2-3 (like A. Fib goal) Clinical features: - Mitral valve risk > Aortic valve risk - Obstructive thrombus mimics valvular stenosis!!! - Heart failure, cardiogenic shock - Systemic thromboembolic events (eg, stroke) Tx: - Small thrombus and mild HF? *Heparin* - Large thrombus or severe HF? Surgical valve replacement

Accuracy

Probability that an individual is correctly identified by the test. (TP+TN)/(TP+TN+FP+FN) Total area under the curve is = to the accuracy!!

Photosensitivity Drug Reactions

Production of *REACTIVE OXYGEN SPECIES* by the reaction of drug metabolites with UV rays. --> Damages cell membranes and DNA --> Less sun is required to be "burnt" (1hr) --> Severity and longevity of burn may be more than a usual sunburn

Traveler's Diarrhea

Prolonged, profuse and watery? Cryptosporidium (not just HIV patients!!!) Cyclospora Giardia ETEC (watery) Entamoeba (can be watery then bloody) Shigella (bloody)

Specificity

Proportion of *TRUE NEGATIVES* TN/(TN + FP) (1-Specificity) = FP rate "SP-P-IN" - When *P*ositive, rules *IN* disease - Better for *CONFIRMATORY TESTS*

Sensitivity

Proportion of *TRUE POSITIVES* TP/(TP + FN) (1-Sensitivity) = FN rate "SN-N-OUT" - When *N*egative, rules *OUT* disease - Better for *SCREENING TESTS*

Thyroid Nodules

Pt risk factors for malignancy: - Radiation to head/neck. - Prior hx of cancer. - Family hx of cancer. - Hoarseness (indicates tumor has invaded nerve) PE risk factors for malignancy: - "Fixed firm, hard nodule with non-tender surrounding lymphadenopathy" Dx: USD w/solid HYPOechogenic nodule, >2cm, micro-calcifications, irregular borders --> get TSH - If low? "Hyperthyroid" and therefore Low risk --> get RAIU --> if hot then hyperfunctioning (tx as such), if cold then nonfunctioning and probs cancer --> USD --> FNA - If normal or high? High risk. --> USD --> if >1cm then FNA, if <1cm then repeat in 6-12m *PAPILLARY* = mc 85%, Orphan Annie Nuclei, produces *Thyroglobulin*--> Tx: Resection *FOLLICULAR* = looks like normal thyroid tissue, produces *Thyroglobulin*. Spreads hematogenously. --> Tx: Radioactive Iodine Ablation *MEDULLARY/PARAFOLLICULAR* = C-cells and *calcitonin* (HYPOCa2+), MEN2A/2B (RET oncogene, pheochromocytoma). *ANAPLASTIC* = Elderly, locally invasive. Fatal bc grows into tissue of neck.

Vitamin C Deficiency (Ascorbic Acid)

Pt: - Coiled hairs - Petechiae - Bruising - Gingival bleeding - Arthralgias - Weakness - *Poor wound healing* (d/t fragility of capillary walls)

General Manifestations of Hyperthyroidism

Pt: - *MYOPATHY* (w/proximal muscle weakness!!!) --> Muscle atrophy - Fatigue (from chronic hyperstimulation) - Hyperreflexive DTRs (though are often NORMAL) - Lid lag - Proptosis - Periorbital edema - Extraoccular muscle weakness - Tremor - A. Fib - HTN - Weight loss - Menstrual irregularities - Wide pulse pressure (from peripheral vasodilation paired with increased cardiac contractility and SV) - Pretibial myxedema - Hair loss - Onycholysis (nail detaching from nail bed) - *Nail clubbing* - Hypercalcemia (d/t increased bone turnover)

Phencyclidine Use Disorder (PCP)

Pt: - *Miosis* - Aggression - Diminished pain perception - Psychotic symptoms (hallucinations) - *Nystagmus* (vertical or horizontal, rotatary) - Hypertension - Tahycardia - Rigidity - Seizures Tx: 1. *Lorazepam/Benzos.* 2. Haloperidol is second line - NOT urine acidification

Ascariasis

Pt: - Abdominal pain - Nausea - Vomiting - Diarrhea - Cough - Can cause *SBO*!!!, biliary colic, cholangitis, pancreatitis --> Bc larvae mature into egg-laying adults in the small bowel - *Eosinophilia* - Anemia - Other signs of vitamin deficiency Dx: Visualization of worms or eggs in sputum or stool Tx: Albendazole v. Mebendazole

Hypertensive Retinopathy

Pt: - Arteriovenous nicking - Copper wiring - "Flame hemorrhages" - "Cotton wool spots" - Optic disc edema Pt: *BLURRED* vision

Polymyalgia Rheumatica (PMR)

Pt: - Bilateral - morning STIFFNESS, not really muscle pain. - NO WEAKNESS. Dx: - Elevated CRP - Elevated ESR - CK is NORMAL Tx: *LOW DOSE* Glucocorticoids *Associated with Giant Cell Temporal Art*

Cocaine Intoxication

Pt: - Dilated pupils - Hypertension - Tachycardia - Chest pain (Prinzmetal) - Pyschomotor agitation - Necrotic nasal tissue - Hypertension - Unilateral clear rhinorrhea - Seizures INTOXICATED? - Sympathetic nervous system stimulation (dilated pupils, tachycardia, sweating, tremors) - Mood swings - Irritability - Anxiety - Panic attacks - Grandiosity - Impaired judgement - Psychotic symptoms (paranoia, hallucinations) WITHDRAWAL? - Depression, - Lethargy, - Hypersomnia, - Hyperphagia, - Increased dreaming, - Impaired concentration. Tx: - ACUTE w/MI? *Benzo* + O2 + Antiplatelet therapy + Nitrates + PCI (as indicated)

Atopic Dermatitis (Eczema)

Pt: - Erythematous papules and vesicles, with weeping, oozing, and crusts. - Lesions usually on scalp, forehead, cheeks, forearms and wrists, elbows, backs of knees. - Paroxysmal and severe pruritus. - Family history of allergies. Tx: Emollients - First line: Topical steroids - Second line: Topical Calcineurin inhibitors - F/up Infectious complications which can arise --> Impetigo (Tx w/*Mupriocen* abx) --> *Eczema Herpeticum* (Tx w/Acyclovir) --> Poxvirus --> Trichophyton Rubrum

Obstructive Uropathy

Pt: - Flank pain - Low volume voids w/ or w/o occasional high volume voids (as fluid volume and pressure overcomes obstruction) - Renal dysfunction - Potassium wasting - Weakness Dx: UA fairly benign....w/ some protein, some WBCs, some RBCs, NO CASTS

Testicular Cancer

Pt: - Hard ovoid mass within the tunica albuginea --> "Firm nontender nodule which does not transilluminate" - Unilateral PAINLESS mass - Does not transilluminate - Males 15-35yo Dx/Tx: DO NOT Bx or FNA!!!! This spreads cancer through lymphatic system and worsens prognosis. - FIRST? Scrotal USD w/solid HYPOechoic mass in testicle. - THEN? *Radical inguinal orchiectomy* = TAKE THE BALL OFF!!! (Can Tx as well) - Serum tumor markers (LDH, Alpha-Fetoprotein, Beta-HCG)

Arterial Insufficiency

Pt: - Intermittent claudication, - Dermal atrophy, - ABSENT DISTAL PULSES (skin discolor & present pulses indicates venous insuff) Dx: Ankle Brachial Index (ABI) - *≤0.9*? Peripheral Arterial Diseae - *≤0.4*? Severe ischemia - *≥1.3*? Calcifications (DM can cause)

Hemorrhagic Shock

Pt: - Losing blood, - Heart normal, - Lungs normal, - Hgb LOW, - Hypotensive (Systolic <90) - HR FAST Dx: *FAST* = USD Tx: Apply pressure --> OR - On the way to OR can type & cross, IVF, PRBC - If unstable (systolic <90)? *Don't wait and just give O-Type Blood*!!! --> If doesn't respond, start *Massive Transfusion Protocol* (1:1:1 = RBC, Platelets, FFP) "Blood on the floor and 4 more" - External bleeding (on the floor, up to entire blood volume) - Chest (40% blood volume) - Abdomen (up to entire blood volume) - Pelvis (up to entire blood volume) - Thigh

Headache Warning Signs

Pt: - Neurologic findings: Seizures, Specific deficits, - Changes in consciousness - Change in frequency - Change in intensity - Change in characteristics - New at age >40yo - Sudden onset - Trauma - Present on Awakening Dx: *MRI of the brain*

HSV

Pt: - Painful - No exudate - Tender LNDs - Vesicles --> Ulcers - *Sterile pyuria* - Urinary retention (d/t pain or lumbar neuropathy that can complicate) - Painful urination as urine flows over ulcers

Femoral Artery Aneurysm

Pt: - Pulsatile groin mass below inguinal ligament - Anterior thigh pain due to compression of the femoral nerve that runs lateral to the artery - Femoral artery aneurysm is the second most common peripheral artery aneurysm after popliteal - May be associated with AAA

Lacunar Infarct

Pt: - Pure motor hemiparesis - Pure sensory stroke - Sensorimotor - Dysarthria-clumsy hand - Ataxia hemiparesis

Herniated Disk

Pt: - RADICULAR PAIN (down leg to knee, x. sciatica) - POSITIVE STRAIGHT LEG TEST Dx: No imaging needed unless warning signs Tx: NSAIDS, self resolves. Maybe PT.

Disc Herniation

Pt: - RADICULAR PAIN (down leg to knee, x. sciatica) - Worse with FLEXION - Dermatomal numbness - Possible weakness of the leg - POSITIVE STRAIGHT LEG TEST - Usually NO vertebral tenderness Dx: NO IMAGING ... unless warning signs Tx: NSAIDS, self resolves. Maybe PT.

Parkinson Disease

Pt: - Resting tremor, IMPROVES w/movement (unlike Essential Tremor!!! opposite!!)...often be asymmetrical - 5-7Hz - Typically involves one hand before the other (asymmetrical) - *HYPOKINETIC*, "Festinating" shuffling gait (narrow based, limited arm swing) - Rigidity - *Neurogenic orthostatic hypotension* (autonomic dysfunction d/t degenerative changes to autonomic ganglia and CNS nuclei) - *Psychosis* (can be easily confused w/Lewy Body, but doesn't meet all the DLB criteria - Dementia + 2sx - or parkinsons symptoms occur *>1yr* BEFORE DLB sx) - *Dementia* (w/onset AFTER Parkinsons sx) = *Parkinson Disease Dementia* --> Executive and Visuospatial dysfunction - *REM Sleep Behavior Disorder* (90+ min after sleep onset) - Loses balance - Hard to get out of bed Dx: *≥2 of 3 sx* on PHYSICAL EXAM - Resting tremor - Rigidity - Bradykinesia Tx: - Mild? *Selegeline* (MAO-B inhibitor) - Moderate to Severe? *Levodopa* ± Entacapone (to help stabilize levodopa levels) - <65yo? *Pramipexole* - Younger w/tremor dominant? *Trihexphenidyl* + *Amantadine* (to prevent anticholinergic effects of Trihex in older pts) - Impairing hallucinations? *Anti-psychotic* (x. Quetiapine) - Dementia? *Donepezil* - f/up *Depression* (up to 20% develop) *Essential Tremor: 4-6Hz, worse w/movement, bilateral, can involve head, autosomal dominant. Tx w/PROPANOLOL*

Frontal Lobe Tumor

Pt: - Seizures - Papilledema - Headache - Personality changes - Language changes - Memory impairment - Motor changes - Issues w/Executive planning - Depressive symptoms

Congenital Zika Syndrome

Pt: - Severe microcephaly - *Thin cerebral cortices* (unlike toxo) - Intracranial calcifications - *Closed anterior fontanelle* (unlike toxo)

Carotid Artery Dissection

Pt: - UNILATERAL headache (loss of sympathetic supply) - Ptosis - Miosis - Anhydrosis

Intraductal Carcinoma

Pt: - Unilateral bloody nipple discharge - Palpable, irregularly shaped *MASS* present (how you tell dif from Intraductal Papilloma) - Overlying skin contraction (d/t involvement of suspensory ligaments) - LNDs

Stress Fracture

Pt: - Weekend warrior not used to higher level of physical activity, - Forced march, - PINPOINT tenderness on anterior shin or forefoot - Commonly w/FEMALE ATHLETE TRIAD (oligo-/amenorrhea, decreased calorie intake, osteoporosis) Dx: XRAY can be NORMAL, or show *Hairline fracture* --> Similar to scaphoid fx, you will still cast (if NOT on a metatarsal). Will be positive later, sometimes after weeks. Tx: - Metatarsal #2-4? *Rest + Analgesia* (bc other toes act as splints, you do not need to cast) - Elsewhere? Rest + Analgesia + Stabilization w/*CAST* (to prevent nonunion)....Then CRUTCHES. *Not to be confused with SHIN SPLINTS w/DIFFUSE tenderness on anterior shin. Commonly OVERWEIGHT and casual runners.*

Nausea and Vomiting during Pregnancy Masking an Underlying Eating Disorder

Pt: - Weight loss with an already relatively low BMI - Unpredictable appetite with skipping meals followed by overeating - Distorted view of body weight/shape ("looking pregnant" despite early gestational age) Tx: - Nutritional counseling - Setting expectations for normal changes during pregnancy - Psychotherapy

Fibromyalgia

Pt: - Young to middle aged women - Widespread pain, --> Worse after exercise - Fatigue, - Cognitive/mood disturbances - Normal PE...but --> have *TRIGGER POINT* pain (mid-trapezius, lateral epicondyle, costochondral junction, greater trochanter) - ESR, CRP, ANA, RF are NORMAL Tx: - FIRST w/ Regular aerobic exercise (or low impact exercise regimen) & Sleep health - IF conservative measures fail, can try TCA's

Breast Cyst

Pt: - solitary well circumscribed mobile mass, smooth - Thin walls, anechoic - +/- tenderness Dx: - <30? *USD* - >30? *Mammo* (MRIs are sensitive for cancer and therefore not used for screening) Tx: - Complex? *Bx* - Simple and asymptomatic? *Observe* - Simple and tender? *FNA* (then assess fluid) --> Nonbloody & resolves? No additional management --> Nonbloody & persists? *Bx* or *USD v. Mammo* --> Bloody? *Bx* or *USD v. Mammo* --> Turbid or purulent? *Culture*

Congenital Syphilis

Pt: EARLY - Snuffles (copious clear rinorrhea) - Rash (maculopapular or bullous that later desquamates) --> palms, soles, buttocks, legs - Long bone abnormalities (metaphyseal lucencies) LATE - Saddle nose deformity - Hutchinson's teeth Dx: *RPR*, VDRL, Darkfield microscopy Tx: Penicillin

Scleroderma

Pt: LIMITED? "CREST" - Calcinosis cutis - Raynaud's - Esophageal dysmotility - Sclerodactyly - Talengiectasias (GI bleeds, Iron def anemia) - Pulmonary HTN w/"hyperplasia of intimal smooth muscle layer" (FEV1/FVC and FEV1 are all totally NORMAL!!!) SYSTEMIC? (CREST +....) - Pulmonary ILD --> mcc from Interstitial Lung disease w/*FIBROSIS* (FEV1/FVC increased or normal and FEV1 decreased) - Pulmonary HTN --> Important to note you also see PHTN in CREST (Limited Sclerosis) but lungs look NORMAL, versus Systemic Sclerosis which has ILD so they DO NOT look normal but also have PHTN. - *Scleroderma Renal Crisis* --> Acute Kidney Injury, sudden onset --> Headache, blurry vision, nausea, marked HTN --> Blood smear w/ MAHA v. DIC & schistocytes & thrombocytopenia - *Right ventricular heave* (from pulmonary HTN) - Loud P2 (from pulmonary HTN) Dx: - Anti-*C*entromere Ab --> seen in *C*REST - Anti-Topoisomerase I (Anti-*S*cl-70) Ab --> seen in *S*ystemic Sclerosis - ANA - Anti-RNA Polymerase III Ab Tx: Symptomatically (DO NOT give steroids!) - Sclerodactyly? Penacillamine - Raynaud's? CCB - Scleroderma renal failure? Ace-i

Meningitis

Pt: *SLOWER ONSET!!!!* How you dif from SAH.... - Headache - Nausea - Vomiting - Neck stiffness - Fever - Photophobia Dx: BACTERIA - High protein - Low glucose - SUPER high WBCs (>1000, neutrophils) FUNGUS - High protein - Low glucose - High WBCs (lymphocytes) VIRUS (Lyme's, RMSF) - Mild protein - Normal glucose - Elevated WBCs (lymphocytes) GUILLAIN-BARRE - SUPER high protein - Normal glucose - Normal WBCs Tx: If showing warning signs such as loss of consciousness, etc. DO NOT DELAY TREATMENT FOR A LUMBAR PUNCTURE!!!! --> 1. Blood cultures. 2. Abx (see pic) + *Dexamethasone* until Strep Pneumo ruled out! If seems somewhat stable? --> 1. Blood culture. 2. LP. 3. Abx (see pic) + *Dexamethasone* until Strep Pneumo ruled out! If immunocompromised, w/central nervous system dz, papilledema, new onset seizures, focal neuro deficits, or altered mental status --> 1. Blood cultures. 2. Abx (see pic) + *Dexamethasone* until Strep Pneumo ruled out! 3. CT (to r/o intracranial mass) 4. LP.

Cluster Headaches

Pt: Attacks usually come on at night, can last *90m*, up to *8xdaily for 6-8wks*, then experience period of remission - Unilateral - Behind one eye - Erythematous conjunctiva - Tearing - *Miosis* (how you dif from Angle Closure Glaucoma) - Ptosis - Sweating - Nasal congestion or rhinorrhea - Males - Come on at NIGHT - Peak rapidly (tearing, nasal congestion, rhinorrhea, is how you dif from Carotid Artery Dissection) Tx: - Acute? *100% O2* v. subcutaneous sumatriptan - Prophylactic? !!!!*Verapamil* v. *Lithium*!!!!...start as soon as possible after the attack

Management of Carotid Atherosclerotic Disease

Pt: CAD risk factors - Smoker - Diabetic - Hypertensive - Obese Tx: *ASA + Statin + BP control* - + Stop smoking + Exercise - Annual duplex carotid USD monitoring ASYMPTOMATIC? - <50% occlusion? Tx as above. - 50-79% occlusion? Generally just Tx as above....can consider CEA (carotid endartectomy) in select patients with low preoperative risk. - >80% occlusion? *CEA*. SYMPTOMATIC? - <50% occlusion? Tx as above. - 50-69% occlusion? Consider *CEA* in MEN and medical therapy in WOMEN. - 70-99% occlusion? *CEA* ...if persistent disabling side effects, 100% occlusion, or <5yr life expectancy then not worth it.

Autoimmune Hepatitis

Pt: Can be asymptomatic...but if not we see - fatigue, - anorexia, - nausea, - jaundice, - comorbid autoimmune disease Dx: - *Anti-smooth muscle (anti-sm)* - ANA - Anti-liver/kidney microsomal type 1 - Elevated LFTs --> ALT, AST, AlkPhos, hypergammaglobulinemia (increased protein seen) - NO elevated bilirubin!! Tx: *PREDNISONE* +/- AZATHIOPRINE

Chronic Subdural Hematoma

Pt: Elderly, EtOH - Headaches --> Dementia - Confusion - Headaches - Insomnia - Progresses over a period if weeks!! Path: Tearing of *Bridging veins* Tx: Craniotomy - Correct anticoagulation... --> Warfarin? PCC or FFP --> Heparin? Protamine sulfate --> Thrombocytopenia? Platelets

Precocious Puberty

Pt: Obese children are at increased risk bc insulin stimulates adrenal glands to produce excess hormones GIRLS "tits, pits, mits, lips" 1. Breasts (8) 2. Axillary hair (9) 3. Growth spurt (10) 4. Menarche (11) Hypothalamus (GnRH) --> Ant Pituitary (LH/FSH) --> Ovaries (Estrogen/Progesterone) --> ENDOMETRIUM bleeds w/Estrogen <-- Adrenals (DHEAS/Testosterone) Dx: If secondary sex characteristics and <8yo... 1. WRIST XRAY for *BONE AGE*!! If looks *>2yr* of their chronological age then pathologic! 2. you then do *GNRH (LEUPROLIDE*) STIM TEST 3. if LH increases, then CENTRAL condition --> MRI!! 4. TUMOR? resect. Nothing? CONTINUOUS LEUPROLIDE (cont = turns off axis, pulsatile = stim) 3. if LH DOES NOT increase, then PERIPHERAL condition --> USD ABD/ADRENAL/OVARIES, test for DHEAS & TESTOSTERONE, 17-OH-PROGEST (if considering CAH) 4. if CAH? STEROIDS. If tumor? RESECT. CYST? Reassure.

Gas Gangrene

Pt: Penetrating wound, Contaminated, Crepitus (like Nec Fasc) Dx: - 1st = *XRay* w/ GAS (also like Nec Fasc) Tx: Debridement + *PCN + Clinda*

Epidural Hematoma

Pt: Strike to the head (x. baseball, skiing) - *Walk, talk, die*. --> LOC but they WAKE UP and then DIE (some will stay awake and then just die) Path: Tearing of the *Middle meningeal artery* Dx: LENS SHAPED on CT - Midline shift (aka Subfalcine Herniation).....neurosurgical emergency Tx: Craniotomy - Lower ICP

Tension Pneumothorax

Pt: Super pneumothorax - No matter whether L or R sided, it *Crushes the IVC --> No blood flow can return to the heart --> Engorged veins* (treatment improves *venous return* to the heart by relieving this pressure) - HYPOtension!! - Normal Heart - Decreased breath sounds - Hyperresonance - Tracheal deviation Dx: *DO NOT* get CXR!!!! If they have Hyperresonance you just go for Needle decompression.... - THEN after that can get CXR...then Tx w/Thoracostomy - If are stable and/or dx is uncertain you can get imaging first. Tx: *Needle decompression* (14 gauge needle over top of 2nd rib, then over top of 5th as needed) - ...then later Thoracostomy (which is definitive treatment for pneumothorax) - *DO NOT* give PEEP!!! (that's for ARDS) If you give peep to someone with tension pneumo it worsens the one-way valve effect and worsens the pneumothorax

Hypocalcemia

Pt: Tetany, perioral tingling - Trousseau's sign (bird beak hand when cuff inflated) - Chvostek's sign ("ChvosTAPS sign" tap facial nerve and face twitches) - *Jitteriness* in newborn (think Ca2+, esp if BG≥40) - Respiratory symptoms (Dyspnea, Wheezing) - Seizures Adverse effects: "CATs go numb" - Convulsions - Arrhythmias (*prolonged QT*) - Tetany - Numbness (symmetrical and only w/tetany) Work-up 1. If hypocalcemia, then check ALBUMIN (bc might correct w/calcium correction) 2. If still low when corrected, check ionized Ca2+. 3. If ionized Ca2+ low, then give IV Ca2+!!! *Hypomagnesemia causes resistance to PTH, causing Hypocalcemia*, so fix HypoMg! (same for HypoK) *Pancreatitis can cause HYPOCa2+* via sequestration *Phosphate typically does OPPOSITE of calcium*

Statistical Technique

Qualitative Independent/Qualitative Dependent - Chi-Square (used when there are *2 variables*) - Logistic regression Quantitative Independent/Qualitative Dependent - Logistic regression Qualitative Independent/Quantitative Dependent - T-test (when there are *2 independent groups*) --> *Dependent Samples T-Test/Paired T-Test* = When groups are *dependent or matched* (i.e. same groups are assessed twice, OR groups are matched based on age, sx, etc) --> *Independent Samples T-Test* = When groups are *independent* - ANOVA (when there are *≥3 independent groups*, and *several dependent variables*) - Linear regression (used when there is *one dependent* variable) Quantitative Independent/Quantitative Dependent - Correlation (uses correlation coefficient to assess linear relationship between two quantitative variables) - Linear regression (used when there is *one dependent* variable)

Management of Unilateral Facial Weakness

RED FLAGS? - Progressively worse over several weeks - Facial spasms - Sparing of the forehead - *HEARING LOSS* - Rash --> Get *MRI of head* + Audiogram

Pulmonary Function Testing

RESTRICTIVE PATTERN - FEV1? Normal or High - FVC? Decreased - FEV1/FVC? Increased or Normal (>80%) - DLCO? Depends on disease. Decreased in ILD. Normal in chest wall weakness (Obesity Hypoventilation). OBSTRUCTIVE PATTERN - FEV1? Decreased most - FVC? Decreased - FEV1/FVC? Decreased (<70%) - DLCO? Depends on disease. Decreased in COPD. Normal or increased in Asthma.

Comparison of Right Ventricular vs. Left Ventricular Myocardial Infarction

RIGHT VENTRICULAR INFARCT - Inferior wall infarcts (II, III, AVF) --> "T-wave inversion" --> Dx: Follow this up with *RIGHT-Sided Precordial ECG*!!!!! - *Atypical EPIGASTRIC pain*, rather than substernal - Nausea - No SOB, bc right ventricle - *BRADYARRHYTHMIA* bc right coronary artery supplies SA and AV nodes - *HYPOTENSION* - RV is highly sensitive to preload under these conditions so we DO NOT give Nitrates. --> Tx: Give *IVF* instead

Relative Risk Reduction (RRR)

RRR = (Absolute Risk (control)- Absolute Risk (treatment))/Absolute Risk (control) or RRR = ARR/Absolute Risk (control) or RRR = 1 - RR

Calcium oxalate kidney stones

Radioopaque. Caused by increased Ca2+ and increased oxalate. MC Flavor of kidney stone Tx/Prevent w/thiazides - increase DIETARY Ca2+ - decrease SUPPLEMENT Ca2+ - increase K+ - limit Na+ - decrease fructose - decrease oxalate consump (red meat, chocolate, peanuts, tea) - increase citrate consump (fruits/veggies) - decrease Vitamin C

Neyman Bias

Rapidly fatal diseases cause patients to die before a study can be conducted on them. (x. hospital based study of snow shoveling and MI, miss patients who die in their driveway)

Anal & Perianal Masses

Rectal prolapse External hemorrhoid Internal hemorrhoid Perianal abscess Anogenital wart Anorectal cancer Skin tags

Indications for Imaging in Low Back Pain

Red Flag Features: - Sudden onset of pain w/spine tenderness - History of cancer - Constitutional symptoms - Trauma - Significant or progressive neurological deficits - Elevated risk of spinal infection - Nocturnal pain that wakes them up Dx: *Plain film XRays + ESR + CRP* - Confirm w/*MRI* --> Can go straight to MRI if infection, significant neuro deficits, or cauda equina syndrome

Intracranial pressure (ICP)

Regulated via three things: 1. Brain parenchyma (constant) 2. CSF (constant in most cases) 3. Cerebral blood flow (regulated by *PaCO2*!!!) - *When PaCO2 increases, blood flow increases* Can also try lowering ICP via... - *HYPERventilation = LESS PaCO2 = Vasoconstriction = Decreased ICP*!!!!!!!!! - *Hypertonic saline* (Preferred over Mannitol, which causes volume depletion) - *External ventricular drain* (LP would cause a pressure gradient, so we don't use)

Reporting Bias

Reluctant to report an exposure due to stigma about the exposure

Ascertainment Bias

Results from an atypical population are extrapolated into the entire population.

Root Cause Analysis

Retrospective analysis tool that identifies ALL causes of an adverse event - Assess via *5 Why's* - Mcc are failures in *Communication* or *Teamwork* Prevent via: Redundancy, Teamwork, Sufficient staffing

Rib Fracture Location & Associated Injuries

Ribs 1-3 - Subclavian vessels - Brachial plexus - Mediastinal vessels Ribs 3-6 - Cardiovascular Ribs 9-12 - Spleen (L) - Liver (R) - Kidney (ribs 11&12) Any level - Pulmonary

Mechanical Complications of Acute Myocardial Infarction

Right Ventricular Failure (Acute) Papillary Muscle Rupture (3 - 5d) Interventricular Septum Rupture (3 - 5d) Free Wall Rupture (5d - 2wk after) Left Ventricular Aneurysm (SEVERAL MONTHS!!! after) -->

Placenta Previa

Risk Factors: Multigravid, multi-gestations - "oil well" analogy where placenta implants where it can find nutrients if wall has been tapped elsewhere leaves limited options - RF: Prior C-section, Multiple gestation, Prior placenta previa, Advanced maternal age (>35) Path: Placenta implants across the OS ("Marginal" v. "Partial" v. "Complete"), cervix dilates and tears babies blood Pt: - Heavy, persistent vaginal bleeding bc mom's blood - PainLESS (bc "previa") - Reassuring fetal monitoring initially - Signs of maternal hemorrhagic shock (hypotension, tachycardia) - Intercourse may trigger bleeding Dx: *Transabdominal USD* (w/"transverse baby lie") v. Non-Stress Test or Contraction Stress Test (w/fetal distress) - If positive? Do *Transvaginal USD* to confirm!!! (bc Transabdominal USD has a high false positive rate) Tx: Pelvic rest + Routine care --> 90% resolve on their own - If hasn't resolved? SCHEDULED C-SECTION at *36-37wks* - NO intercourse - NO digital cervical examination *Previa means painless for mom*

Brachial Artery Cannulation

Risk damaging the *Median Nerve* - compressed by hematoma --> Decreased sensation of touch and pain along median nerve distribution - or lacerated by seeker needle --> Motor issues as well

Thoracic Aortic Injury

Risk: Rapid deceleration Pt: - Widened mediastinum - Abnormal aortic contour - Left sided effusion (hemothorax) - If INCOMPLETE RUPTURE may be *NORMOTENSIVE or even HYPERTENSIVE* (if pseudocoarctication - obstructive intimal flap that impedes flow) - *Hoarse voice* d/t compression or stretching of surrounding structures Dx: - If Hemodynamically stable? *CTA* - If Unstable? *TEE*

Blunt Thoracic Aortic Injury

Risk: Rapid deceleration - Full thickness rupture? They usually die immediately, UNLESS contained by a hematoma or surrounding tissues. - Incomplete rupture? May survive long enough to make it to the ED. Pt: - *Widened mediastinum* - Abnormal aortic contour - Left sided effusion (hemothorax) - Pale - Tachycardic - Neck veins collapsed - FULL thickness rupture? HYPOtensive. - INCOMPLETE RUPTURE? *NORMOTENSIVE or even HYPERTENSIVE* (if pseudocoarctication - obstructive intimal flap that impedes flow) - *Hoarse voice* d/t compression or stretching of surrounding structures Dx: - Hemodynamically STABLE? *CTA* --> Determines whether surgery should be endovascular or an open approach - Hemodynamically UNSTABLE? *TEE* (NOT!!! TTE) in operating room + *Thoracotomy* Tx: Hemodynamic support, then *Surgery* - Keep systolic BP *<100* to prevent injury extension/rebleeding before surgery

Gastric Cancer

Risks: - Eastern asians - Associated with salted foods and nitroso compounds - H. Pylori infection - Smoking - Pernicious anemia Pt: - Mid-epigastric abdominal pain, WORSE w/eating (bc acid is irritating to cancer) - Prostprandial N/V - Dysphagia if proximal - Weight loss - Microcytic anemia (iron deficiency from blood loss) - Mets to LIVER --> Hepatomegaly w/elevated liver enzymes Dx: *EGD* - Stage w/CT

Dopaminergic medications that can cause mania/psychosis

Ropinirole Pramipexole

Common Causes of Shoulder Pain

Rotator Cuff Impingement or Tendinopathy - pain with ABDUCTION, EXT ROTATION - subacromial tenderness - normal range of motion with (+) impingement tests (eg, NEER, Hawkins) i. NEER test - internal rotate at humerus, stabilize pt scapula with one hand, passively raise arm through forward flexion @ humerus to see for pain - this indicates impingement between greater tuberosity of humerus + inferior acromion ii. Hawkins test - elbow + shoulder are flexed passively and at this point, arm rotated at humerus - same meaning as NEER test - repetitive activity above shoulder height (e.g., painting ceilings) - supraspinatus is most susceptible *** - impingement syndrome - characteristic of RCT - refers to compression of either supraspinatus tendon or subacromial bursa Rotator Cuff Tear - similar to rotator cuff Tendinopathy - weakness with external rotation - age > 40 Adhesive Capsulitis (frozen shoulder) - decreased PASSIVE + ACTIVE ROM - more stiffness than pain Biceps Tendinopathy/rupture - ANTERIOR shoulder pain - pain with lifting, carrying, overhead reaching - weakness is LESS COMMON Glenohumeral osteoarthritis - uncommon + usually caused by trauma - gradual onset of anterior or deep shoulder pain - dec active + passive abduction + external rotation

Ewing Sarcoma

SECOND MC primary bone tumor in YOUNG BOYS - CENTRAL osteolytic lesion - *Onion skin appearance* --> *Cortical layering* of new bone - *Moth eaten appearance* - Translocation 11:22 - *MIDSHAFT* (vs. Osteosarcoma which is end of bones....epiphysis or metaphysis) Pt: Focal, Atraumatic bone pain - maybe Fever - maybe Leukocytosis - Early metastasis - Pain at night - Elevated ESR - Pain DOES NOT respond to NSAIDs (unlike Osteoid Osteoma) Dx: XRay, MRI, Bx Tx: EXCISION - Chemo

Deliberate Scalding Injury

SPARED flexural creases NO splash marks Uniform depth Sharp lines of demarcation

Sun Protective Measures

SPF >30 - Anything is fine. Going too big make no real difference in skin protection.

Neural Tube Defects

Screening for NTDs at 15-20 wks Neural tube closure complete at 5-6 wks Elevated AFP seen in - NTDs - Multiple gestations - Ventral defects - Incorrect gestational age - *Anencephaly* if severe Dx: USD Tx: Folic acid >1mo prior to pregnancy --> taking it after 5-6wks won't make difference because tube is already formed - Average risk? 0.4mg - High risk? 4mg

Diabetes Mellitus (DM)

Screening: ≥45yo ≥25 BMI HTN Pt: Remember, *diabetic patients often CANNOT MOUNT INFECTIOUS RESPONSE when septic* d/t leukocyte dysregulation from hyperglycemia. - Reason why we take diabetic foot ulcers so seriously. --> Tx: Give aggressive IVF & big gun Abx when infected. - *Diabetic cheiroarthropathy* (thickened skin of hands, sclerosis of tendon sheaths, stiffness of joints) - *Carpal tunnel syndrome* - Diabetic neuropathy (nephrotic syndrome w/kimmelsteil wilsen nodules) --> Hyperfiltration at first! Dx: - *HgbA1c ≥6.5 (DM) or ≥5.7 (PreDM)* - Random BG ≥200...(x1) - Fasting BG ≥125 (DM) or 100 (PreDM)...(x2) - 2hr glucose tolerance ≥200 (DM) or 140 (PreDM) Type I = Polyuria, Polydipsia, High BG - Dx: *GAD Abs* - Tx: *Insulin* PreDM - Tx: Lifestyle + Metformin (unless CKD, CHF, Liver Dz...bc can cause lactic acidosis) DM - Tx: Lifestyle + Metformin (unless CKD, CHF, Liver Dz...bc can cause lactic acidosis) --> add a second agent --> add Insulin - Treatment goal is HgbA1c *≤7* (higher in older adults and those with comorbidities) --> Repeat check q3m - If A1c >9 go straight to insulin - Albumin:Cr *30-300*? Start *Ace-i or ARB* (goal <130/80) - Cardioprotective? *-tides*, *-flozins* -gliptins = weight neutral -tides = weight loss

Abnormal Uterine Bleeding & Secondary Amenorrhea Evaluation

Secondary Amenorrhea: - *≥3mo* w/o period in women w/previously REGULAR periods - *≥6mo* in women w/previously IRREGULAR periods. <45yo? - *UPT + FSH + TSH + Prolactin* --> Low thyroxine stimulates TSH & PROLACTIN!!!!!!!!!!!!!!!! production in the pituitary, prolactin then suppresses FSH and LH. - If all neg or normal? OCP's - If no response to OCP's (or obese, or hx of tamoxifen tx)? *Endometrial Bx* >45yo? - *Transvaginal USD* (Endometrial stripe >4mm is ABNORMAL) v. *Endometrial bx* - AND!!! you obtain a *PAP* (no matter when her last one was)

Warfarin Induced Skin Necrosis

Seen in the first few days of treatment with Warfarin. D/t it's inhibitory effects on Protein C and S (anticoagulants) --> Transient hypercoagulable state leads to excessive thromboembolism --> Skin necrosis In patients with pre-existing Protein C deficiency skin necrosis can be very pronounced. Tx: *Stop Warfarin* + *Give Protein C*

Humoral Immunodeficiency Syndromes

Selective IgA Deficiency Job Syndrome CD40 Ligand Deficiency (Hyper IgM) Common Variable Immunodeficiency X-Linked Agammaglobulinemia

Positive Likelihood Ratio

Sensitivity/(1-Specificity) or Sensitivity/FP rate The confidence that a positive test result came from a person with a disorder rather than a person who does not.

Carcinoid Tumor

Serotonin related Path: None Location: - In LUNG...RIGHT sided CARDIAC FIBROSIS w/R HF. (but also has flushing, wheezing, diarrhea) - Carcinoid tumor in INTESTINES that mets to liver does not cause carcinoid sx. Paraneoplastic: Serotonin syndrome Dx: *5-HIAA in URINE* Tx: *Octreotide* - Surgery if liver mets

Thymus Pediatric CXR

Sharp, shelf-like looking thing in the RUL is the *THYMUS* in kiddos *<3yo* - "Sail sign"

Assessment of Decision Making Capacity (DMC)

Should ask *WHY* not receiving treatment is patient's preferred choice. --> You need the rationale - Helps you better understand DMC - Helps you know how you can help them (x. declining cancer tx d/t depression or fear of surgery) Even if Schizophrenic and hallucinating, if they are able to communicate understanding then you must give patient autonomy. - If they DO NOT understand, then give *Antipsychotics* and address whatever it is they want done once stable.

Electrophoresis Patterns in Sickle Cell Syndromes

Sickle Cell Trait Sickle Cell Anemia Sickle Cell Anemia on Hydroxyurea Hemoglobin SC Disease

Optic Disc Edema

Sign of Idiopathic Intracranial HTN

Somatoform Disorders

Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder Factitious Disorder Malingering

Spina Bifida

Spina bifida occulta = "*Closed Spinal Dysraphism*" - At risk for Tethered Cord Syndrome Prophylaxis: 4 mg of folic acid daily BEFORE conception - Neural tube closure is complete by 28 days post-conception, so initiating folic acid after the first 28 days has no prophylactic value. - A couple who has had one affected child has an increased risk of approximately 3% of having another similarly affected child.

Surveillance After Colon Cancer Resection

Stage I (Localized): confined to mucosa/submucosa - Colonoscopy 1 yr after resection - Then Colonoscopy q3-5 yr Stage II (Involves serosa)/III (involves LNDs): - Colonoscopy 1yr after resection - Then Colonoscopy q3-5 yr - CT A/P/C q1yr - Periodic CEA testing Stage IV: - Individualize

Lung Cancer Screening

Start at 55-80yo + >30pack year history + quit <15yr ago Stop at 80 or >15yr quit. Screen w/low dose CT q1yr ***55yo + >30py + <15yr quit, q1yr low dose CT*** - Dan would need this yearly

Colon Cancer Screening

Start screening at *45* - *IF first degree family member w/adenoma or cancer <60yo, then or start screening 10 YEARS before fam hx (x. 42 if dad was 52 at dx) OR at 40yo!!!! WHICHEVER COMES FIRST.* --> Then *q3-5yr* - Screen earlier (30-40yo) if hx of abdominopelvic radiation If first degree family member w/CRC <60, or TWO first degree family members with CRC at any age? - *q3-5yr* Stop screening at 75 (or 85 if they're really healthy) How to screen - Colonoscopy q10yr (unless fam hx of dx <60yo (q5yr), or adenomatous polyps found (depends on size, number)) - Flex sigmoidoscopy q5yr + FOBT q3yr - FOBT q1yr *if during colonoscopy have a couple hyperplastic polyps that are removed, can repeat in 10yr* IBD? - Start *8yr post-dx* - Then *q1-2yr* HNPCC? - Start *20-25yo* - Then *q1-2yr* FAP? - Start *10-12yo* - Then *q1-2yr*

Aggressive Patient

Stay close to door Keep door open Have security present Offer patient food and drink, blanket DO NOT just administer meds or restrain if they are refusing unless the prior steps have failed and they are violent

Urinary Incontinence

Stress Urgency Overflow Mixed Tx: First line for any urinary incontinence is *Bladder training + Pelvic floor muscle exercises* - If doesn't respond to first-line treatment consider *Meds* - Mixed? *Voiding Diary* to determine predominant type

Indicators Used in Quality Assessment

Structural Indicators Process Indicators Outcome Indicators Balancing Indicators

Anesthetics

Succinylcholine - Neuromuscular blocking agent that binds to postsynaptic ACH receptors and depolarizes --> Na+ goes into cell, K+ goes out - Rapid onset and offset - Can cause *CARDIAC* arrhythmias from electrolyte derangement --> Esp worry about this if something else that could increase serum potassium is going on (Crush injury, GBS, etc) Propofol - Causes severe hypotension from cardiac depression Etomidate - Inhibits 11-beta-hydroxylase --> Adrenal insufficiency (immunocompromised at risk) Nitrous Oxide - Inactivates Vitamin B12 and therefor methionine synthase --> Peripheral neuropathy Vecuronium/Rocuronium - NONdepolarizing neuromuscular agents (they just block) - No risk of HYPERKalemia like with Succinylcholine

Ecological Study

Uses *POPULATIONS* rather than Individuals (how you dif from Cross-Sectional) x. Life expectancy for certain communities and the altitude at which those communities live - *Ecological fallacy* is when life expectancy appears to be longer at higher altitudes, when it is actually shorter for certain individuals (such as those with COPD)

Differential Diagnosis of Postpartum Hemorrhage

Uterine Atony Retained Product of Conception Genital Tract Trauma Inherited Coagulopathy

Gout

Super ACUTE!!!, peaks at 12-24 hours. Can be incited by trauma, surgery Pt: Episodic monoarticular arthritis - Podagra (big swollen first toe) - Chronic gout causes TOPHI (looks like osteoarth but they tend to be younger), nontender. - Acute gout is TENDER - Feet MC first! Then hands,. etc - *Punched out erosions in bone* Dx: Joint aspiration... Inflammatory effusion w/*Uric acid* crystals - Monosodium urate crystal deposition - Negatively birefringent crystals - If have tophi? Dx can be clinical and based on that and prior hx of monoarticular arthritis - Also, if have typical s/sx of gout w/pre-established dx of gout then DO NOT need aspiration. Can tx. Tx: - Increased production: Colchicine, NSAIDs, Steroids (CKD, EtOH, Thiazide) --> Prophylax w/Decreasing EtOH, Red meat, Fructose, Change med that caused....or *Allopurinol* - Tumor Lysis Synd: Tx w/Rasburicase --> Prophylax w/IVF + Allopurinol - Under excreter: *PROBENECID* (like they have perfect diet but still develop gout)

Hospice Care

Symptom relief and Quality of life - Rather than Prolonging life. Must - Have prognosis *≤6 mo* - DO NOT have to be actively dying - Discontinue curative or life-prolonging treatments - CAN continue palliative treatments - DNR is NOT REQUIRED

Salmonella

THERE ARE TWO KINDS, TARA!!!!!! Please remember this. *NONtyphoidal Salmonella*!!!! - Undercooked poultry and eggs (think America) - Vomiting, Fever, Maybe bloody diarrhea - Dx: Stool culture - Tx: Supportive (Abx only for severe or invasive dz). Prevent with properly cooking food. *Typhoidal Salmonella* - Developing countries, contaminated food or water - Rose spots, Fever, Bacteremia, Bloody diarrhea - Dx: Blood culture - Tx: Prevent w/Vaccine

Quadruple Screen

TRISOMY 21: ("arrange alphabetically and then down-up-down-up") - DECREASED AFP - INCREASE beta-HCG - Decreased Estradiol - INCREASED Inhibin-A TRISOMY 18: - DECREASED AFP - DECREASED beta-HCG - DECREASED Estradiol - NORMAL Inhibin-A NEURAL TUBE/ABD WALL DEFECT/Twins: - INCREASED AFP - NORMAL beta-HCG - NORMAL Estradiol - NORMAL Inhibin-A If Quad screen is (+) --> Offer *Cell Free Fetal DNA* testing

Calcineurin Inhibitors

Tacrolimus Cyclosporine (both are hepatically excreted and sensitive to P450 system) Adverse Effects: - Nephrotoxicity (via vasoconstriction) --> AKI --> *Hyperkalemia* &Hyperuricemia - Hypertension --> Vasoconstrictive properties - Neurotoxicity --> *Tremor* (resting or intention), Visual disturbances, Seizures - Glucose intolerance - Gingival hypertrophy - Hirsutism - Allopecia - GI (Anorexia/N/V/D) - Increased risk of infection & malignancy

Selective Estrogen Receptor Modulators (SERMs)

Tamoxifen - Breast: Estrogen ANTAGONIST - Endometrium: Estrogen AGONIST Raloxifene - Breast: Estrogen ANTAGONIST - Bone: Estrogen AGONIST

Systemic Inflammatory Response Syndrome (SIRS)

Temp >1.00.4 or <96.8 Pulse >90 Resp >20/min WBCs >12,000 or <4,000 or >10% bands As opposed to be Burn Wound Sepsis criteria which is completely different.

Wright Test

Tests for Thoracic Outlet Syndrome (TOS) "Think of a kid sitting in class raising their hand like 'IM RIGHT" test is performed in sitting or supine. The therapist moves the pt's arm overhead in the frontal plane while monitoring the radial pulse. - Positive is decreased or diminished radial pulse and may be indicative of compression at the costoclavicular space.

Syphilis Infection in Pregnant Women: Screening: pregnant women

The USPSTF recommends early screening for syphilis infection in all pregnant women. Grade A

Syphilis Infection in Nonpregnant Adults and Adolescents: Screening : asymptomatic, nonpregnant adults and adolescents who are at increased risk for syphilis infection

The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection - MSM - >1 partner in past 6mo Grade A

Effect Modification

The change of one factor alters the outcome involved. x. effect of smoking (additive) on Estrogen's therapy's association with DVT.

Absolute Risk Reduction (ARR)

The difference in risk (not the proportion) attributable to the intervention as compared to a control ARR = (Absolute Risk (control)- Absolute Risk (treatment))

Prevalence

The number or proportion of TOTAL CASES of a particular disease or condition present in a population at a given time.

Incidence

The number or rate of NEW CASES of a particular condition during a specific time. "Incident"

Selection Bias

The sample is not representative of the population being studied, so that some conditions are over- or underrepresented x. Loss to follow up x. Mortality rate in patients treated with PCI vs Medical therapy (PCI patients tend to be more sick to begin with and hence have higher likelihood of mortality)

Maternal Cardiopulmonary Adaptations to Pregnancy

There are normal changes during pregnancy: - leg/ankle/foot edema - SOB with exertion (increased tidal volume but not resp rate, elevated diaphragm with decreased FRC) - appearance of innocent systolic ejection murmurs due to increased blood volumes.

Primary Biliary Cholangitis (PBC)

Think of it as Primary Biliary Cirrhosis....which is what it used to be called. - This makes more sense bc it involves ducts within the liver Path: Chronic liver disease characterized by autoimmune destruction of the *INTRAhepatic bile ducts* - Associated w/other autoimmune diseases (Celiac's, Hashimoto's, Rheumatoid) - WOMEN mc (but can be men) Pt: - NO PAIN!!! (how dif from choledocholithiasis) - Cholestasis - Nonconjugated bili - Elevated AST/ALT - Elevated Alk Phos, - Jaundice, - Pruritis - Hepatomegaly - Severe *Hyperlipidemia* w/Xanthelasmas (HDL>LDL, does not increase risk for atherosclerosis) - Steatorrhea - Portal HTN - Metabolic bone disease (Osteomalacia) - NO cholangitis (seen in PSC) - Increased risk of hepatocellular carcinoma Dx: *ABD USD* then will probably get *MRCP (would be normal) or ERCP* - Confirm w/*Anti-mitochondrial Abs* Tx: *Ursodeoxycholic acid*

Sail Sign

Thymus shadow on pediatric CXR (<3yo)

ARDS Management

Tidal Volume <6 ml/kg Increase PEEP Decrease FiO2

Toddler's Fracture

Toddler ≤3yo Twisting injury during low impact fall *Spiral fracture of tibia* Pain, limp, refusal to walk or bear weight Lower extremity bruises (common in toddlers, not sign of abuse) Dx: XRay Tx: Immobilization + Pain control

Common Causes of Neonatal Respiratory Distress

Transient Tachypnea of Newborn Respiratory Distress Syndrom Persistent Pulmonary Hypertension

Erythema Toxicum

Trunk and extremities Eosinophils

Cervical Spondylosis

Two Flavors: - CERVICAL MYELOPATHY (more general) --> LMN at site of lesion, UMN below. --> Tx: Surgery - CERVICAL RADICULOPATHY (more specific) --> Weakness at myotome, Sensory loss along specific dermatome. --> Tx: NSAIDs + PT

HPV Vaccination

Two types: Cervarix covers types 16, 18; Gardasil covers types 6, 11, 16, and 18. *≥15yo*? Requires *THREE* doses. *<15yo*? Requires *TWO* doses 6 mo apart. Previous or current HPV infection is NOT contraindication to HPV vaccine bc it can provide protection to different strains.

Chronic Liver Failure

Tx: - Ascites? Albumin + Furosemide + Spironolactone. Consider paracentesis. - Hepatic encephalopathy? Treat cause. Could use lactulose.

Intimate Partner Violence

Tx: - FIRST Support their courage in coming forward. - THEN Validate that threatening or abusive behavior is undeserved and wrong. - THEN *Assess for safety* and *Establish a safety plan* - Assure them you will not abandon them no matter their choice. - Never pressure the patient into action.

Morning Sickness

Tx: - Small scheduled meals - *Vitamin B6* - Medications w/food and at night

Unstable Angina/NSTEMI

Tx: *ASA* + *Clopidogrel* + *Heparin* + BBlocker + Statins + Ace-i/ARB - (+) *Aldosterone antagonists* if *DM or LVEF <40%* --> Limits platelet aggregation and adhesion which worsens cardiac death from NSTEMI, or could cause complete STEMI - DUAL ANTIPLATELET therapy (ASA + Clopidogrel) decreases risk of recurrent MI and cardiovascular death - NO Nitrates in asymptomatic patients. They may keep on hand for when become symptomatic, but is not part of regular regimen for Unstable Angina.

Management of Migraines in Pregnancy

Tx: *Acetaminophen* - No improvement? Acetminophen-codeine, Promethazine, Caffeine-butalbital. - To prophylax? *Propanolol* or even CCBs Ibuprofen is avoided in 1st and 3rd trimesters

Unconscious & Hypoglycemic?

Tx: *Bolus of 50% Dextrose*

Infantile Hemangioma

Tx: Observation...Consider BBlocker if - Large, Face, or rapidly growing - Periorbital (visual impairment) - Subglottic (airway compromise) - Hepatic (high output heart failure)

Cardiovascular contraindications to pregnancy

Tx: These should be corrected PRIOR TO pregnancy if possible (d/t 50% increased CO by second trimester) - If they're even slightly symptomatic now it will be dangerous by mid-pregnancy!!! - Stenotic valvular disease is more poorly tolerated then regurgitant valvular disease Symptomatic *MITRAL STENOSIS* --> Get *Percutaneous Mitral Balloon Valvotomy* PRIOR to preggo Symptomatic *AORTIC STENOSIS* (one of the highest risk abnormalities to have) --> Get *SURGICAL* correction PRIOR to preggo Symptomatic HF w/*LVEF <30%* (can't be corrected) --> *Avoid *pregnancy. *Pulmonary arterial HTN* (can't be corrected) --> *Avoid* pregnancy *Mitral Regurgitation* or *Aortic Regurgitation*? --> Manage w/*MEDS* during pregnancy *Bicuspid AV w/ascending aortic enlargement*

Endometrial Carcinoma

Type 1 endometrial carcinoma - "Endometrioid" - mc type - Proliferative Type 2 serous endometrial carcinoma - More rare - Almost always fatal - Estrogen independent - Early mutations in TP53 - Atrophic Type 2 mucinous endometrial carcinoma - Proliferative Risk Factor: Cumulative estrogen exposure - Early menarche - Late menopause - Nulliparity - Obesity - Anovulation - Tamoxifen (inhibits in breast but stims in uterus). Protective Factors: - Late menarche - Early menopause - Multiparity - Breast feeding - Progestins (IUD, etc) Pre-Cancer: Endometrial hyperplasia Path: PTEN --> Kras --> PIC3KA --> TP53 - Increased risk of developing w/ MLH1/MSH2, BRCA1/2, HNPCC Pt: Below is true UNLESS SEROUS endometrial carcinoma (which has NO vaginal bleeding) - PERImenopausal w/increased menses, intermenstrual bleeding, or heavy menstrual bleeding - POSTmenopausal w/vaginal bleeding - *>4mm* endometrial lining (if <3mm then normal!) Dx: - PERImenopausal? *Endometrial Bx* (D&C) - POSTmenopausal? *Transvaginal USD* w/large endometrial stripe...then Endometrial Bx (D&C). --> Look for increased gland:stromal ratio on bx - If Hyperplasia? WITHOUT atypia - If Carcinoma? Atypia!! - If Dysplasia? Pleomorphism w/increased nucleus:cytoplasm ratio --> Staging (a's go down, b's go out) - Stage 1 = Endometrial lining - Stage 2 = Cervical OS (2a), Myometrium (2b) - Stage 3 = Vagina (3a), Perimetrium (3b), Nodes (3c) - Stage 4a = Rectum or Bladder - Stage 4b = Distant mets Tx: - Endometrial hyperplasia *WITHOUT atypia*? *Progestin therapy*!!! (repeat bx in 3-6mo)...or *TAH+BSO* - Endometrial hyperplasia *WITH atypia*? *TAH+BSO* - Carcinoma? TAH + BSO (staged surgically) and Carboplatin + Paclitaxel - Follow-up: *Ca-125* for remission and relapse BRCA1/2? Prophylactic TAH+BSO at 35-50yo HNPCC? Prophylactic TAH+BSO at 4045yo

Endometrial Hyperplasia

Type 1 endometrial carcinoma - "Endometrioid" - mc type - Proliferative Type 2 serous endometrial carcinoma - More rare - Almost always fatal - Estrogen independent - Early mutations in TP53 - Atrophic Type 2 mucinous endometrial carcinoma - Proliferative Risk Factor: Cumulative estrogen exposure - Early menarche - Late menopause - Nulliparity - Obesity - Anovulation - Tamoxifen (inhibits in breast but stims in uterus). Protective Factors: - Late menarche - Early menopause - Multiparity - Breast feeding - Progestins (IUD, etc) Pre-Cancer: Endometrial hyperplasia Path: PTEN --> Kras --> PIC3KA --> TP53 - Increased risk of developing w/ MLH1/MSH2, BRCA1/2, HNPCC Pt: Below is true UNLESS SEROUS endometrial carcinoma (which has NO vaginal bleeding) - PERImenopausal w/increased menses, intermenstrual bleeding, or heavy menstrual bleeding - POSTmenopausal w/vaginal bleeding - *>4mm* endometrial lining (if <3mm then normal!) Dx: - PERImenopausal? *Endometrial Bx* (D&C) - POSTmenopausal? *Transvaginal USD* w/large endometrial stripe...then Endometrial Bx (D&C). --> Look for increased gland:stromal ratio on bx - If Hyperplasia? WITHOUT atypia - If Carcinoma? Atypia!! - If Dysplasia? Pleomorphism w/increased nucleus:cytoplasm ratio --> Staging (a's go down, b's go out) - Stage 1 = Endometrial lining - Stage 2 = Cervical OS (2a), Myometrium (2b) - Stage 3 = Vagina (3a), Perimetrium (3b), Nodes (3c) - Stage 4a = Rectum or Bladder - Stage 4b = Distant mets Tx: - Endometrial hyperplasia WITHOUT atypia? *Progestin therapy*!!! (repeat bx in 3-6mo)...or *TAH+BSO* - Endometrial hyperplasia WITH atypia? *TAH+BSO* - Carcinoma? TAH + BSO (staged surgically) and Carboplatin + Paclitaxel - Follow-up: *Ca-125* for remission and relapse BRCA1/2? Prophylactic TAH+BSO at 35-50yo HNPCC? Prophylactic TAH+BSO at 4045yo

Ovarian Cancer

Types: - SEX CORD STROMAL (prepubertal) = Granulosa-theca, Sertoli-Leydig, Fibrothecomas --> If female w/thelarche? *Granulosa-theca* (Call-exner bodies) --> If female w/masculinization? *Sertoli-Leydig* (Reinke crystals) --> If female w/weight gain? *Fibrothecoma* - GERM CELL (postpubertal) = Dysgerminoma, Yolk Sac, Choriocarcinoma, Teratoma, Mixed --> *Yolk sac* (Shiller-duval, AFP) --> *Choriocarcinoma* (B-hCG) --> *Dysgerminoma* (Fried egg, LDH, Estrogen, B-hCG) ---> *Teratoma* (three germ layers) *Serous* cystadenocarcinoma --> from Type 2 serous endometrial carcinoma - Essentially UTERINE TUBE on ovary (Pseudostratified columnar w/serous fluid) - Mcc of epithelial ovarian tumors *Mucinous* cystadenoma (benign) or Mucinous cystadenocarcinoma (not) --> from Type 2 mucinous endometrial carcinoma - Essentially ENDOCERVIX on ovary (Simple columnar epithelium w/mucinous fluid) - Second mcc of epithelial ovarian tumors. *Endometrioid* carcinoma --> from Type 1 endometrial carcinoma - Essentially ENDOMETRIUM on ovary (Simple columnar epithelium) - Third mcc of epithelial ovarian tumors. Risk Factor: Cumulative estrogen exposure - Early menarche - Late menopause - Nulliparity - Obesity - Anovulation - Tamoxifen (inhibits in breast but stims in uterus). Protective Factors: - Late menarche - Early menopause - Multiparity - Breast feeding - Progestins (IUD, etc) Path: PTEN --> Kras --> PIC3KA --> TP53 - Increased risk of developing w/BRCA1/2, HNPCC, MLH1, MSH2 Pt: NO screen...tend to be asymptomatic until late stage - Pelvic pain - Pelvic mass - Ovarian torsion - ±Ascites Dx: *Transvaginal USD* w/mass --> Get *CA-125* if post-menopausal. - CA125 elevated? *Resect!* to get path (DO NOT FNA or tap ovary!!!) Tx: - Sex Cord Stromal? *UnilateralSO* (if fertility desired) v. TAH+BSO (if not desired) - Germ cell? *Cystectomy* (if fertility desired) v. USO+Staging (if malignant). If do chemo then *BEP* (Bleomycin + Etoposide + Cisplatin) - Epithelial? *TAH+BSO* (staging), Carboplatin + Paclitaxel - F/up w/pulsed GnRH analog to allow pubertal development to continue

Evaluation of Red Urine

UA w/*HIGH Blood & NORMAL RBCs*? - Rhabdomyolysis.....or - Hemoglobinuria (x. intravascular hemolysis)

Parapneumonic Effusion Management

UNCOMPLICATED (sterile) ...and/or, No Resp Distress or Hypoxia? - *Oral Abx* COMPLICATED (infected = Low pH, Low Glucose, Leukocytes >50,000, or LDH >1,000) ...and/or, Large Effusion, Resp Distress OR Hypoxia? - *USD + IV Abx + Drainage* *EMPYEMA*? - *Abx + Drainage* - If this does not work then *VATS* NEVER GET CT. You don't need it unless suspect malignancy/necrosis.

Breast Discharge Evaluation

UNILATERAL - <30yo? *USD ± Mammogram* - ≥30yo? *Mammogram + USD* BILATERAL --> *UPT* + TSH + Prolactin

Evaluation of Bilious Emesis in the Neonate

UNSTABLE or Free air (on XR)? Emergency *Laparotomy* STABLE? *Abd XRay* - Double bubble? *Duodenal atresia* - Normal, or Dilated loops of bowel w/normal rectum? *Upper GI series* --> R-sided ligament of Treitz? *Malrotation* - Dilated loops of bowel & FTPM or increased rectal tone? *Contrast enema* --> Microcolon? *Meconium ileus* --> Rectosigmoid transition zone? *Hirschsprung*

Chest Pain Evaluation in ED

UNSTABLE? --> Stabilize hemodynamics STABLE? --> EKG + CXR + *Aspirin* - EKG w/NSTEMI? Anticoagulate - EKG w/STEMI? Cath lab v. Thrombolysis - EKG Normal? Treat CXR. - CXR Normal? Look for another cause (x. PE)

Parapneumonic Effusion

Uncomplicated - Sterile exudate in pleural space !! - pH >7.2 (normal) - Glucose is normal - Relatively low leukocyte and LDH levels Complicated - Bacterial invasion of pleural space - pH is LOW - Glucose LOW - Gram stain and culture are often FALSELY NEGATIVE due to low bacterial count Empyema - Bacterial colonization, fluid is grossly purulent - pH is LOW - Glucose LOW - Protein HIGH - Neutrophil predominant LEUKOCYTOSIS (>50,000) - Elevated LDH - Gram stain and culture are POSITIVE

Weight gain in Pregnancy

Underweight: Recommend 28-40lbs gain Normal: Recommend 25-35lbs gain Overweight: Recommend 15-25lbs gain Obese: Recommend 11-20lbs gain Normal pregnancy requires an increase in daily caloric intake of *300 kcal*. - Eat 5x daily and never skip breakfast *Continue exercise during preg* - Any type of exercise involving the potential for loss of balance or even mild abdominal trauma should be avoided.

Management of Suspected Ectopic Pregnancy

Unstable? Surgery Stable? *TVUS* (we don't usually see anything unless B-hCG >3500) - Adnexal? *Methotrexate* - Intrauterine? Depends on pt/provider preference - Nondiagnostic? --> *Serum B-hCG* (if viable preggo will increase 35-50% q48hr, if ectopic or anembryonic will increase <35%, if aborted will decrease) ----> *>1500*? *B-hCG + TVUS* in 2 DAYS ----> *<1500*? *B-hCG* in 2 DAYS

Sodium Bicarb

Used for - Acidosis ONLY if *pH <7.2* - *TCA Overdose* - Ventricular arrhythmias (V. Tac)

Digoxin Toxicity

Used for A Fib w/CHF - Narrow therapeutic index - Renally excreted (problem for older people) - *HYPOKalemia* exacerbates toxicity! (think of sketchy pic with bananas locked out in another room and everything being crazy in there) - *Amiodarone* increases serum levels of digoxin AE: - Arrhythmias!! - *Atrial Tachycardia w/AV block* (considered diagnostic of toxicity) --> D/t variation of beat foci in atrium and increased vagal activity. - Hyperkalemia ACUTE? - Nausea, - Vomiting, - Diarrhea, - Fatigue - Lethargy CHRONIC? - Confusion - Blurry yellow vision (think van Gogh), Tx: Stop drug + IVF - Severe or not responsive to prior step? *Digoxin Fab* (specific antibody)

Amiodarone

Used to treat ventricular arrhythmias in patients with HF and/or systolic LV dysfunction.

Frontotemporal Dementia

aka "Pick Disease" - "Pick your tau-nail in the front" Path: *Pick bodies* (tau protein accumulations) in hippocampi, temporal lobes, frontal lobes - 25% Autosomal DOMINANT - Degenerative process progresses more rapidly than other dementing syndromes - 5-10 year survival following dx Pt: First behaviors, then memory (dif from Alzheimers) EARLY - 50-60yo - Family hx of disease in 40% - Behavioral changes (x. *Disinhibition*) - Compulsive behavior (consuming same meal daily, hoarding) - Hyperorality (even just increased cigarette consumption) - Lack of insight - Apathy LATER - Executive dysfunction (memory loss more MILD, then progresses - unlike Alzheimers) Dx: Clinical --> Frontotemporal atrophy on brain imaging Pt: *SSRI v. Trazodone*

Periorbital Cellulitis

aka "Preseptal Cellulitis" Path: Break in periorbital skin causes infection. - Mc bugs are Staph and Strep. Pt: - Inflammation around the eye. - CAN move eye without issue - NO proptosis Can they move eye? Is there Proptosis? - YES? Periorbital cellulitis --> Tx: *Abx* (cover Gram positive skin bugs...x. Clindamycin) - NO? Worry about Orbital cellulitis --> *Dx: CT scan. Tx: I&D + Abx* *Diabetes? Consider MUCOR MYCOSIS* --> Tx: Amphotericin B

Factitious Disorder

aka Munchausen & Munchausen-by-proxy Path: Intentional production of false symptoms to assume the SICK ROLE. - NO secondary gain. - Imposed on self v. Imposed on another - Intent to deceive. Pt: - History of major childhood illness or abuse - Motivated by internal factors (validation, psychosocial stressors, final examinations) Dx: Clinical Tx: *Psychotherapy* - Evaluate for other comorbid conditions (cause for SI, psychosocial stressors, etc) - By-proxy? They're doing to someone else

Painless Thyroiditis

aka silent thyroiditis mild, brief hyperthyroid phase spontaneous recovery small, nontender goiter variant of hashimoto's + TPO antibody!!!!!!!!! low radioiodine uptake

Unicameral Bone Cyst

children and young adults. proximal femur or humerus. pathological fracture. cystic lesion with well defined margins.

McMurray Test

compression of the meniscus of the knee combined with internal and external rotation while the patient is face-up to assess the integrity of the meniscus Lateral Meniscus? - Provide VARUS force at knee (recreate force that caused injury) & - INTERNALLY rotate leg by using foot Medial Meniscus - Provide VALGUS force at knee (recreate force that caused injury) & - EXTERNALLY rotate leg by using foot Painful click = meniscus tear

Finklestein's Test

identifies deQuervain's tenosynovitis (parentendonitis of abductor pollicis longus (APL) and/or extensor pollicis brevis (EPB) "An APpLe tastes good with Every Precious Bite"

Drop Arm Test

identifies tear and/or full rupture of rotator cuff

Femoral Nerve

innervates quadriceps and skin of anterior thigh and medial surface of leg - Saphenous nerve supplies medial surface of leg L2-L4

Direction and Strength of a Linear Relationship

r < 0 - As one variable increases, the other decreases r > 0 - As one variable increases, the other increases - OR as one variable decreases, the other decreases

Supraventricular Tachycardia

rate varies btwn 160-250 bpm, regular rhythm, originates from a location above AV node, will start and stop w/o cause. common causes: mitral valve prolapse, cor pulmonale, digitalis toxicity, and rheumatic heart disease Tx: Adenosine

Tetralogy of Fallot (TOF)

set of 4 congenital heart defects occurring together - pulmonary valve stenosis, - over riding aorta, - RVH - VSD