Step 2

TB meds

2 months of RIPE + continue with 4 months of rifampin and INH Extend treatment to 9 months if osteomyelitis, miliary tb, meningitis, pregnancy or any time pyrazinamide is not used If exposed to someone with active TB, give 9 months of INH An infant born to a mother with active TB is at high risk of exposure. :. give latent treatment despite negative PPD. INH= peripheral neuropathy with B6 depletion Ethambutol= optic neuritis Rifampin + pyrazinamide= hepatotoxicity

Centra lines

3 main approaches: internal jugular, subclavian and femoral IJ within carotid sheath, lateral to common carotid A and anterior to the vagus nerve.

Budd Chiari

Acute hepatic vein thrombosis --> centrilobular congestion and necrosis -> congestive liver disease (hepatomegaly, asites, abdominal pain) --> liver failure *no JVD** - associated with hypercoagulable states, pregnancy, HCC, polycythemia vera

Bronchiolitis

Acute inflammation of small airways in children <2yo Low grade fever, rhinorrhea, cough, apnea, tachypnea and wheezing

Aortic Regurgitation

Acute: rapid onset pulmonary edema, cardiogenic shock and severe dyspnea Chronic: dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea Blowing diastolic murmur at left sternal border with/ without mid-diastolic rumble (austin flint murmur) Austin Flint murmur= blood flowing backwards through aortic valve, hitting anterior leaflet of mitral valve. *Primary indication for valve replacement. De Musset's sign= head bobbing with heart beat Waterhammer/ Corrigan's pulse = bounding pulses. due widened pulse pressures in hyperdynamic circulation. rapid abrupt upstroke, followed by rapid collapse of peripheral pulse Quincke's pulse= pulsating nail bed with elevation of the nail. due widened pulse pressures in hyperdynamic circulation Duroziez's sign= femoral bruit (due to blood moving forward during systole and retrograde during diastole) Best test= TEE Tx= CCB/ ACE-I's until s/s severe enough for valve replacement Acute AR tx= nitrates and dopamine Cause: aortic root dilation (marfan, syphillis) - murmur radiates from left to right sternal border, post-inflammatory (rheumatic heart disease, endocarditis), congenital bicuspid aortic valve Path: - Backflow from aorta into LV --> increased left ventricular end diastolic volume. Compensatory myocardial hypertrophy and ventricular enlargment initially maintain SV &CO - Increased LV size brings ventricular apex close to chest wall= pounding sensation/ uncomfortable awareness of heartbeat in L lateral decubitus position - excessive LV stretching leads to decreased stroke volume, decreased forward blood flow and systolic heart failure - Increased left ventricular end diastolic pressure --> pulmonary congestion S/S: - diastolic decrescendo murmur - louder with sitting up/ leaning forward, bringing aortic valve closer to stethoscope - widened pulse pressure (increased systolic BP, decreased diastolic BP ) - collapsing/ water hammer pulse - heart failure signs and symptoms

Sarcoidosis

African Americans incidental on CXR, usually asymptomatic Fever, anorexia, arthralgias Cardiac involvement is underdx with infiltration of noncaseating granulmoas- -> inflammation and conduction defects (Complete AV block, DCM, valvular dysfunction and heart failure); may lead to sudden cardiac death - suspect in any young pt (age <55) with unexplained second- or third- degree heart block or when EKG changes occur in a pt with known/ suspected systemic sarcoidosis Stage 2= b/l hilar LAD + pulmonary infiltrates Labs= elevated ACE from non-caseating granulomas, or VitD --> hypercalcemia --> hypercalciuria Tx: corticosteroids (6 month of prednisone for lungs). If contraindicated or unresponsive, use chlorambucil Tetracyclines for cutaneous sarcoidosis

Acute intermittent porphyria

Attacks of epigastric, colicky abdominal pain lasting several days, predominantly motor/ autonomic neuropathies, psych (hysteria and depress), severe constipation without rash** Autosomal dominant defect of porphobilinogen-deaminase (catalyzes porphobilinogen to hydroxymethylbilane). Porphobilinogen and ALA accumuate Dx: increased urinary porphobilinogen secretion Tx: high dose glucose (400g/d) inhibits heme synth and reduces prophyrin precursors

Lichen Sclerosus

Autoimmune cond'n. White, atrophic papules that coalesce into plaques. Common in anogenital region, keyhole fashion. High risk of developing SCC. Do BX prior to treatment with steroid ointment- 1st line= topical corticosteroid clobetasol 2nd line= calcineurin inhibitor i.e. tacrolimus

Fanconi Anemia

Autosomal recessive/ X- linked inherited BM failure Children 6-9yo Present with aplastic anemia + progressive BM failure, congenital malformations (short stature, hypopigmented spots on skin, thumb abnormalities, microcephaly and hypogonadism). cafe au lait spots and large freckles. Strabismus, low-set ears and middle ear abnormalities (hemorrhage, incomplete development, chronic infections, deafness) Predisposed to developing cancer -genes involving DNA repair Labs: mild- moderate thrombocytopenia (can be misdx as ITP); mild macrocytic anemia Confirmed by chomosomal breakage in blood/ germline mutation Tx= hematopoietic stem cell transplant

Aplastic anemia

BM failure due to injury to plurippotent stem cell line Cause: CA, drug rxn (nsaids, sulfonamides), exposure to toxic chemicals (benzene, glue), viral infections (HIV, EBV), immune d/o, thymoma, idiopathic - easily develop infections from low platelet counts Labs: Pancytopenia and reduction of reticulocytes BM Bx= hypocellular marrow + fat cells and marrow stroma

Hypertensive emergency

BP >180/120 + end organ damage (CV, renal, CNS) by fibrinoid necrosis of arterioles. cerebral artereis dilate after normal autoregulation of cerebral blood flow is disturbed tx: admit to ICU +IV sodium nitroprusside. BP must not be lowered too abruptly due to risk of ischemia and infarction to coronary and cerebral vessels. Goal= reduce no more than 25% within minutes to 1 or 2 hours and then toward a level of 160/100 mmHg within a total of 2-6hrs. monitor Na. other options: fenoldopam- renal insufficiency

MS

Baclofen PO/ IT = symptomatic tx of spasticity recombinant IFB b-1a and beta-1b and glatiramer acetate= disease modifying therapy heat exposure exacerbates symptoms

Angiodysplasia

CC of colonic bleeding. MC abnormality of GI tract and lower GI bleeding in pts >60, second to diverticulosis. Occult blood loss may present as chronic iron deficiency anemia, hematochezia or melena. Mostly right sided with lesions in cecum/ ascending colon. Chronic intermittent submucosal venous obstruction leading to vascular ectasia. Associated with aortic stenosis (heyde's syndrome)

Benzodiazepine overdose

Decreased mentation, delirium, Headache, weakness, slurred speech. Mild respiratory depression, hypothermia, dilated pupils, hyporeflexia

AIDS prophylaxis

CD4 >250: vaccinate against hep A and B, HPV and influenza annually CD4 < 200: PCP (dry cough + dyspnea+ fever, high LDH, b/l infiltrate): Bactrim, if it doesn't work can tx with clinda+primaquine. Best test= bronchoscopy+ bronchoalveolar lavage In endemic areas, CD4 <150: Coccidiomycosis: Fluconazole CD4 <100: Toxoplasma gondii: Bactrim = multiple ring enhancing spherical lesions in basal ganglia on MRI CD4 <50: MAC : azithromycin; tx= clarithromycin

Hypocalcemia

Ca <8.5 or decrease in ionize calcium <4.2 due to massive soft tissue infections (necrotizing fasciitis, renal failure, pancreatic and small bowel fistulas), hypoparathyroidims, TSS, tumor lysis syndrome short bowel syndrome, intestinal bypass, vitamin D deficiency, sepsis, acute pancreatitis, osteoblastic mets, renal failure, rhabdomyolysis, hypomagnesemia, aminoglycosides, diuretics, hypoalbuminemia (40-45% protein bound). Correct calcium = (measure total calcium) + 0.8 (4-serum albumin) perioral parasthesias, increased DTRs, psychiatric disturbances, seizures, teany, Chvostek and trousseau. Tx: Acute symptomatic: IV 10% calcium gluconate to achieve 7-9mg/dL sever hypocalcemia: use calcium chloride instead since gluconate would require a higher dosage (3x more) Calcium chloride only appropriate for RAPID correction if acute and occured in short time frame; this can be fatal if the hypocalcemia has been chronic due to acclimitaizatiton. CaCl can also cause fatal arrhytmias and tissue necrosis. Mg, K, and pH must also be corrected -hypocalcemia will not be corrected if hypomagnesemia is present Chronic hypoPTH: req vitD, PO calcium supplemnts and AlOH gels to bind dietary phosphate in the intestine

Organic brain syndrome

Cognitive/ behavioural changes due to physical causes vs psychiatric. 2 subgroups: acute (delirium/ acute confusional state) and chronic (dementia) Delirium - caused by infections, medications, postop periods, alcohoism, electrolyte imbalances, stroke, heart disease, seizures, hepatic and renal d/o. Consciousness altered and fluctuating. hallucinations, disorientation and abnormal vital signs. Waxing and waning, rapid deterioration.

Acute Respiratory Distress (ARDS)

Collapsed alveoli cause: infection, lung injury i.e. sepsis, trauma, burns, IVDU, pancreatitis or post-CV bypass **does not resolve with 100% O2** due to Right to left shunt lung injury --> fluid/ cytokine leakage into alveoli Impairs gas exchange, decreased lung compliance, PHTN Must meet criteria: - hypoxemia - b/l interstitial infiltrates/ opacities on CXR NOT due to CHF/ fluid overload -symptoms must occur/worsen within 1 week of insult 3 phases: exudative (alveolar edema due to destrction), proliferative and fibrotic Tx: mechanical ventillation (low TV, high PEEP, permissive hypercapnia) Mild: PaO2/FiO2 <100mmHg or <300mmHg on ventilator Moderate; PaO2/ FiO2 <100mmHg or <200mmHg on a ventilator Severe: PaO2/FiO2 <100mmHg or <100mmHg on a ventilator

Medical records

Information in the medical record (physical document/ electronic record) belong to the patient, but the medical record is owned by the hospital.

Cervical Myeplopathy

Compression of spinal cord. MC spinal cord d/o in persons >55yo due to spinal stenosis. Heavy feeling in legs, slow gait and shooting pains in arms and legs. test: flexion of neck (Lhermitte's sign)

Short Stature

Continual since birth= normal, reasssure Concerning=Sudden drop in growth progression Delayed puberty in males= 14yo Constitutional short stature --> bone age= height age, both behind chronologic age Familial short stature --> bone age > height age and = chronological age.

Pericarditis

Coxsackie A, HIV, rickettsial, borrelial, chlamydial, mycoplasma infections, uremia or collagen vascular dz Tx: NSAIDs, maybe drainage, add colchicine if refractory if after acute MI, combo of ASA + colchicine If due to CT disease, give glucocorticoid

Cirrhosis

Diffuse fibrosis and nodular regeneration destroying normal architecture of liver. S/S: - can be asymptomatic or with nonspecific symptoms (anorexia, weight loss, weakness, fatigue, muscle cramps) - jaundice and pruritis - GI bleed (melena, hematemesis) - encephalopathy (confusion, sleep disturbances) - Women: amenorrhea or irregular menses due to anovulation - Men: hypogonadism (decreased libido, erectile dysfunction, loss of axillary and pubic hair), more common to cirrhosis due to alcohol or hemochromatosis - low thyroid hormones due to liver's decreased ability to make binding proteins Leading cause: alcohol Other causes: viral hepatitis, hemochromatosis and biliary disease PE: collateral vein formation -esophageal varices, caput medusae and hemorrhoids, hematemesis, melena, teelangiectasia, splenomegaly, ascites, jaundice and scleral icterus, spider nevi, gynecomastia, asterixis, testicular atrophy, palmar erythema, muehrcke/ Terry nails, Dubuytren's contracture, clubbin, hypoalbuminemia, edema and anemia, hepatic hydrothorax usually occurs on the right (ascitic transudate seeps through small defects of diaphragm into pleural space -->tx therapeutic thoracentesis and salt-restricted diet+ diuretics; next tx option = TIPS; ultimately liver transplant is best)

Idiopathic thrombocytopenic purpura

Dx of exclusion. - Isolated thrombocytopenia on routine blood work. - epistaxis - gingival bleeding - petechiae - ecchymoses Coag parameters, fibrinogen, FSP, d-dimer, haptoglobin, renal function are normal. peripheral smear= large platelets, but decreased

LBBB

EKG: supraventricular in origin. QRS > 120ms. complexes in V1-V6. risks: aortic stenosis, dilated cardiomyopathy, acute MI, extensive CAD presents with syncope/ near syncope

Bacterial meningitis

Elevate WBC (neutrophils) + elevated ICP + decreased glucose + elevated protein tx: ceftriaxone, vanco + steroids (lowers mortality in s. pneumo) BUT if immunocompromised, consider ampicillin for listeria coverage. ppx of close contacts= rifampin/ ciprofloxacin - if untreated, most common deficit= hearing loss/ damage of CN8 - seizure increases risk of mortality `` Indications for CT: immunocompromised state, previous CNS disease, new-onset seizure, papilledema, AMS or focal neurologic deficits

Pneumaturia

Enteroviscal fistula due to diverticulitis, colon cancer, Crohn's disease and radiation pneumonitis, emphysematous UTI

Acute Interstitial nephritis

Eosinophils in urine: penicillins, cephalosporins, rifampin, sulfa drugs, quinolones, NSAIDs, diuretics, allopurinol and phenytoin. Stop offending drug --> trial of steroids definitive test= Kidney bx

Legionella atypical pneumonia

Fever, non-productive cough, abdominal pain, diarrhea. Lab: High LDH Test of choice: Urine Antigen test

Eryhtromycin

GI distress, acute cholestatic hepatitis, eosinophilia, rashes

Acute Digoxin Toxicity

GI: pain, nausea, vomiting, anorexia, less severe in chronic toxicity Neuro: confusion, weakness; lethargy, fatigue, delirium, confusion and weakness in chronic toxicity Visual: yellow halos around lights, scotomas and blindness CV: arrhythmias with PVC, bradycardia, atrial tachyarrhythmia with AV block, ventricular bigeminy, junctional rhythms, AV nodal block, Vtach, V.Fib. EKG: 2:1**** AV nodal blockade with atrial tachy *** (atrial ectopy increases vagal tone and decreases AV nodal conduction) Renally excreted

Microscopic colitis

Painless watery diarrhea without bleeding Signs of dehydration Infiltration of lymphocytes into colonic epithelium/ thickened subepithelial colitis histologic inflammation in endoscopically normal appearing colonic mucosa. Hx of nocturnal/ large volume diarrhea. stool osmotic gap typically less than 50 mOsm/kg indicates secretory diarrhea

Fungal/ TB meningitis

High WBC (lymphocytes), high ICP, Low glucose, HIgh protein

Viral meningitis

High WBC (lymphocytes), high ICP, normal- slightly low glucose, normal- slightly high protein Viral prodrome = upper resp symptoms + low grade fever High fever, headache, irritability and nuchal rigidity, seizures May also have pharyngitis, rash, herpangina CSF: elevated WBC count no higher than 500 cells/uL, normal glucose and normal or mildly elevated protein. Lymphocytes predominate. MCC: HSV -acyclovir, non-polio enteroviruses i.e. echovirus and coxsackievirus Self limited, resolves in 7-10 days

Stevens- Johnson Syndrome

High fever, diffuse mucosal involvement, blistering and myalgias. +Nikolsky sign + epidermal sloughing and necrosis. causes: HIV, allopurinol, carbamazepine, lamotrigine, phenytoin, sulfonamides, nevirapine

Breast cancer

Hormone receptor positive pts tx: tamoxifen Negative receptor tx: chemo Her2/neuR= trastuzumab (cardiotoxic) ProgesteroneR positive= favorable disease course Aneuploidy= poor disease course

Sinding- Larsen- Johansson syndrome

Inferior pole of the patella rather than tibial tuberosity

Shigella dysenteriae

Lactose negative - H2S common in children who attend daycare/ pts in mental institutions Shiga toxin irreversibaly nicks 60S ribosome, inhibiting protein synthesis -> cell death and bloody diarrhea Propels itself through actin polymerization highly virulent toxin inhibits protein synthesis and kills enterocytes

Salmonella Enterica Typhimurium

Lactose-negative on MacConkey + hydrogen sulfide (black precipitate) Transmitted through contaminated food -undercooked chicken or fruits and vegetables; peanut butter; from reptiles, amphibians Makes enterotoxin that increases intracellular cAMP levels. non-typhi= fever, diarrhea with RBCs and abdominal cramps 12-72h after infectionl; erythematous rash on abdomen (rose spots). Diarrhea last several weeks. stool cx is diagnostic. Can involve brain, bone, kidney and jts if not treated typhi= directly transmitted between people causing constipation with bacteremia

Blood supply of the heart

Left coronary: anterolateral Left ventricle; >50% occlusion indicated for CABG Right coronary: SA +AV node, inferior L ventricle

Acute lymphoblastic leukemia

MC malignancy in children 2-10 years, male >female Peristent fever, bleeding/ bruising and infection, bone pain, LAD and organomegaly, hepatosplenomegaly, pallor, petechiae MSK pain in long bones due to leukemic involvement of periosteum. Pt= limp, refusal to bear weight, awakened by pain at night. Labs: anemia/ thrombocytopenia. normal-low WBC Immature cells contain cytoplasmic aggregates of PAS+ material. Lack peroxidase positive granules [vs. myeloblasts] Confirm--> BM bx with >25% lymphoblasts Immunostain for TdT (in preB and pre T cells) BM Bx: hypercellular with lymphoblasts

Neisseria Gonorrhea

MC sites of infection: cervix, urethra, rectum and pharynx

Juvenile Rheumatoid Arthritis

MCC chronic rheumatologic dz in childhood s/s: joint pain or abnormal joint use, spiking fevers and an evanescent rash on the trunk or extremities.

NMS

MCC: haldol + fluphenazine -Central dopamineR blockade

Beta blocker overdose

Mental status changes, seizures, orthostatic hypotension Severe bradycardia, hypotension, pulmonary edema and CNS depression. Tx= glucagon; atropine for heart block/ bradycardia, isoproterenol/ dopamine/ norepinephrine for severe hypotension, sodium bicarb for prolonged QRS on EKG

Hypomagnesemia

Mg <1.5mEq/L symptomatic causes: hypokalemia, hypocalcemia or metabolic acidosis. other causes: renal failure, diarrhea, vomiting, gastric suctioning Affects CV + PNS EKG: u waves, nonspecific T waves and prolonged QT May become Torsades. OR v.fib, premature v. fib and depolarization alternans. Severe <1mEq/L: tremor, hyperactive DTRs and tetany. May have chvostek and trousseau Tx: Mag sulfate

Optic neuritis

Monocular visual loss Pain with eye movement Central Scotomas Decreased pupillary reaction to light - first presenting symptom of MS (selective demyelination of CNS plaques scattered throughout white matter, at angles of lateral ventricles) Tx: high-dose IV corticosteroids

Rheumatoid Arthritis

Morning stiffness, polyarthritis (hands and feet), symmetric. Hands- metacarpophalangeal and proximal interphalangeal joints is common. Articular damage leads to joint subluxation and malalignment i.e. ulnar deviation, swan neck deformities/ boutonniere deformities. Positive inflammatory markers: RA, CRP, ANA, ESR early therapy: DMARDs (methotrexate- standard of care for 4-6w) to retard disease progression, but may induce more remissions *be extra cautious with ET intubation (C1-C2 spine fragile) Radiographic findings: soft tissue swelling, joint space narrowing, and bony erosions. Inflammatory arthropathies cause bony erosions that are periarticular or marginal (wherever hyaline cartilage is not covering)

Renal toxicity/ ATN

NSAIDs, Aminoglycosides, vancomycin, loop diuretics - make sure pts are not dangerously volume overloaded and correct electrolytes + supportive care

Hyponatremia

Na <135mEq/L. risks: CHF, renal/ liver failure, pneumonia; anything that retains water - primary polydipsia is common in those with psychconditions i.e. schizophrenia due to central defec in thirst regulation Tx: based on volume status. Hypovolemic= IV isotonic fluids. Euvolemic= free water restriction profound <125, presents as fatigue, lethargy, HA, coma, seizures, psychosis. Tx=IV infusion of hypertonic saline. If corrected too quickly, central pontine myelinolysis (confusion, spastic quadriplegia, horizontal gaze paralysis) Hypovoelmic- volume depletion (acute blood loss), primary adrenal insufficiency, GI losses (diarrhea), renal losses (diuretics) Euvolemic- SIADH (due to drugs, malignancy), primary psychogenic polydipsia, secondary adrenal insufficiency, hypothyroidism Hypervolemic- CHF, cirrhosis, CKD or nephrotic syndrome

Dependent personality d/o

Needy, want to be taken care of, can't make their own decisions and need others to tell them what to do and provide for their needs. Fears of being left alone, discomfort and helpless when alone . At risk of being abused/ manipulated with intense fear of losing relationship

Carcinoid Tumors

Neuroendcocrine cells in intestines and appendix. Can be slow growing and asymptomatic. 5HIAA is broekn down by the liver will not cause symptoms. Symptoms may arise once metastasized to liver: flushing, tachycardia, hyper/hypotension, diarrhea and bronchospasm. Can then metastasize to lung, bone, skin. Elevated 5HIAA is diagnostic. pathognomonic plaque like deposits of fibrous tissue on endocardium on right side of heart= tricuspid regurg and right HF

Large bowel obstruction

Obstructive neoplasm, diverticulitis, volvulus = multiple air fluid levels NOT coffee bean

Friedberg's infarction

Osteochondrosis of second metatarsal head, MC in adolescent and young adult women. - dull, achy pain on plantar aspect of metatarsal - difficulty walking barefoot. - TTP of affected area + swelling/ crepitus on passive ROM - imaging= widening of the metatarsophalangeal joint + flattening of metatarsal head, sclerosis of joint

Panner's disease

Osteochondrosis of the capitellum common in overuse in little league baseball players when epiphysis is growing 7-12 yo - tenderness to lateral aspect of elbow with decreased extension on PROM - swelling with possible effusion - fragmentation with sclerosis of capitellum and irregular appearance of joint surface

Kohler's Disease

Osteonecrosis of the tarsal navicular, frequent in childhood

Osgoode Schlatter Syndrome

Traction apophysitis at the insertion of the patella tendon at the tibial tuberosity that is secondary to the mechanical stress of the extensor mechanism. Pain with resisted knee extension. Tx: activity modification, hamstring stretching, NSAID, bracing/ strapping of the knee.

Thrombotic thrombocytopenia purpura

Pentad of microangiopathic hemolytic anemia (schistocytes, elevated LDH, indirect hyperbilirubinemia), thombocytopenic purpura, neurologic abnormalities (seizure, hemiplegia), fever and renal disease. Involves peripheral blood, CNS and kidneys. classic histologic lesion = bland thormbi in microvasculature of affected organs (platelts with little fibrin and RBCs) pts have unusually large multimers of VWF in their plasma. Lack plasma protease to breakdown multimer. Tx: plasmapheresis

Diverticulitis

Recurrent LLQ pain requiring hospitalization and tx with antibiotics - best treated with sx resection

Psoriasis

Salmon- coloured patches, silvery scales and peeling over the extensor surfaces (elbows, knees) and scalp Pruritis commonly present and worsens with dry weather. Nail changes i.e. pitting occur in up to half of pts. Arthritis in 1/3 of pts Tx: topical cortiosteroids, UV light, methotrexate (hepatotoxicity, especially in hyperlipidemia, obesity, DM, HepB/C, alcohol abuse)

Pulmonary fibrosis

Sarcoidosis, myositis and collagen vascular dz (Goodpasture, Wegener's, SLE, RA)

R sided heart failure

Secondary to increased pulmonary vascular resistance --> RVH and systemic venous stasis Risk factors: CAD, HTN, valvular disease, cardiomyopathy, COPD or alcohol use Presentation: dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, congestive hepatomegaly, ascites, edema and abdominal pain

Hypercalcemia

Serum Ca >10.5mg/dL. Calcium inhibits depolarization of sodium channels, raising the threshold for depolarization. Decreases concentration ability of distal tubule in the kidney Causes: primary hyperparathyroidism (asx, found with calcium nephrolithiasis), malignancy, hyperthyroidism, renal failure and vitD deficiency Fatigue, constipation and depression may arise in mild-mod hypercalcemia. Polyuria and kidney stones. profound muscle weakness, bone pain from reduced cortical bone mass, constpiation, anorexia (dec. SM tone), pancreatitis, peptic ulcers, anxiety, depression and cognitive dysfunction. Lethargy, coma and stupor. Short QRS interval and widened T wave. Management: Severe (ca >14) or symptomatic: Short term = normal saline + calcitonin; avoid loop diuretics unless volume overload (HF) exists Long term= bisphosphonate (pamidronate and zoledronic acid) Moderate (Ca 12-14): no immediate tx unless symptomatic; tx similar to above Asymptomatic or mild (Ca<12): no tx, avoid thiazides, lithium, volume depletion and prolonged bed rest If hypercalcemia is due to cond'ns like lymphoma and granulomatous disease that release extrarenal calcitriol, can use glucocorticoids

Hypomagnesemia

Serum Mg <1.5mEq/L. Most coexist with hypokalemia since Mg releases inhibitory effect on K efflux Common in alcoholics and diuretic intake Symptomatic causes: hypokalemia, hypocalcemia or metabolic acidosis Renal failure, diarrhea, vomiting and gastric suctioning. May occur with malabsorption, steatorrhea, small bowel bypass sx. Absorption can be affected by thiazides, loop diuretics, PPIs, immunosuppresants i.e. mycophenolate. Tremor, hyperactive DTRs, tetany, positive trousseau/ chvostek CV: nonspecific T wave changes (u wave) and prolonged QT. Torsades may result, vfib, premature ventricular fibrillation, depolarization alternans decrease in skeletal growth and increased skeletal fragility; impairs PTH release --> hypocalcemia Tx= IV mag sulfate, caution in childre n and those with renal failure -CV monitor Common in hospitalized alcoholics, inducing resistance to PTH and causing hypocalcemia. Due to urinary losses, malnutrition, acute pancreatitis and diarrhea. Phosphorus is low or normal, possibly due to intracellular phosphorus depletion. (decreased GI absorption and increased renal loss)

Renal artery stenosis

Severe HTN, often assoc. with flash pulmonary edema, resistant heart failure, CKD. Systolic- diastolic Abdominal bruit Other features of atherosclerosis Labs: elevated plasma renin, raising both systolic and diastolic BP Refractory HTN with use of antihypertensives. Test of choice= duplex ultrasonographic scan if pt has normal kidney fxn, CT angiography is test of choice. Screen with oral captopril challenge (increased renin with captopril given) MCC= 2ndary to atherosclerotic plaques Tx= ACE-Is first line for unilateral RAS, but contraindicated in BL RAS (causes renal failure) + HMG COA reductase inhibitor to prevent further plaque build up

COPD exacerbation

Triggered by respiratory infection/ environmental pollution. Use noninvasive mechanical ventilation -CPAP/ BiPAP- to reduce respiratory load and diaphragmatic work of breathing, increasing tidal volume. Can give antibiotics at the same time , especially if requiring hospitalization, ventilation or 2/3 symp.: dyspnea, sputum production or purulence.

G6PD

X- linked recessive look for heinz bodies + bite cells on smear Wait 1-2 months to check G6PD level after an attack

Laryngotracheobronchitis/ Croup

acute viral inflammatory disease of larynx within the subglottic space. RSV, influenza, adenovirs, parainfluenza. Bacterial superinfection --> tracheitis (inflammation of larynx and trachea) Age 6 months to 3 years Fall, early winter presents with prodromal URI -low grade fever, mild dyspnea, hoarse voice, barking cough and inspiratory stridor worse with agitation. AP neck= subglottic narrowing Tx - cool mist + fluids (mild= no stridor at rest) - O2, PO/IM corticosteroids + racemic epinephrine (moderate/severe = stridor at rest+ respiratory distress)) [epi constrict mucosal arterioles in upper airways, alters capillary hydrostatic P, decreasing edema and reducing secretions] - intubate if all medications fail

Zinc deficiency

alopecia, facial rash growth retardation, hypogonadism, infertility, dysgeusia, diarrhea, poor wound healing, impaired cell immunity Absorption impaired in pancreatic disease, malnutrition, malabsorption syndromes and those getting chronic TPN. Acrodermatitis enterpathica= AR disease when zinc absorption is impaired= diarrhea, dermatitis alopecia, poor growth and impaired cell immunity

Celiac disease

autoimmune, sensitivity to gluten --> mucosal inflammation, villous atrophy and crypt hyperplasia in small bowel bulky, foul-smelling floating stools, bloating, flatulence, chronic diarrhea with weight loss, loss of muscle mass and SQ fat and Fe defiency anemia, vitD, calcium defieicnies risks: first degree relative with celiac disease, autoimmune thyroiditis, type 1 DM, down syndrome, selective IgA deficiency Dx: anti-endomysial Abs and anti-transglutaminase Abs, duodenal bx Duodenal bx= increased intraepithelial lymphocytes and flattened villi - many pts with bx confirmed celiac disease are negative for IgA anti-transgluatminase Ab due to selective IgA deficiency which is common in celiac. :. do total IgA measurement if negative

TTP vs HUS

both: thrombocytopenia + microangiopathic hemolytic anemia TTP= neurologic impairment HUS= acute renal failure --> support with hemodialysis Tx: plasma exchange

Beta blocker OD

bradycardia, heart block and hypotension, hypoglycemia, bronchospasm

Hyperglycemia

can be acutely caused by stroke/ MI. Chronic = polydipsia, polyria, polyphagia + blurred vision, delayed wound healing, weight loss and erectile dysfunction. If left untreated, ketoacidosis can occur= deep and rapid breathing, confusion, fruity breath, mental obtundation, hyporeflexia, focal signs. Tx= insulin

Heyde's syndrome

combination of aortic stenosis and GI bleeding due to colonic angiodysplasia. AS causes type 2 von Willebrand synrome --> inefficient hemostasis in high flow areas. Results in bleeding from angiodysplastic lesions.

Thoracic outlet syndrome

compression of brachial plexus and subclavian artery between anterior scalene and middle scalene mm. + adson's

Vitamin B6 deficiency

convulsions, hyperirritability and peripheral neuropathy. MCC= isoniazid, OCP

Paroxysmal Nocturnal hemoglobinuria

defective phosphatidylinositol class A gene --> defective CD55 and CD59 or decay accelerating factor. Overactivtion of complement and sensitivity of RBCs to acidotic state Hemolysis due to hypoventilation during sleep --> fatigue, dark urine in the morning Venous thrombosis (intrabdominal, cerebral veins) Labs: CBC (hypoplastic/ aplastic anemia), pancytopenia (impaired hematopoiesis), elevated LDH and low haptoglobin, indirect hyperbilirubinemia, UA (hemoglobinuria), iron deficiency anemia and decreased CD55 & CD59 by flow cytometry* MCC of death= hypercoagulability causing thrombosis, especially mesenteric and hepatic veins = acute abdominal pain Tx: Iron and folate supplementation. Start with prednisone for symptomatic tx Eculizumab = anti-complement antibody targeting CD5/ complement inhibitor. Cure: allogeneic bone marrow (replace defective hematopoietic stem cells with normal ) -reserved for severe cases/ aplastic anemia/leukemia

Atrial Fibrillation

hemodynamic stability? - unstable if hypotensive, has CHF or angina. --> synchronized cardioversion -stable: treat with rate controlling medications and anticoagulate if indicated by CHADS2 CHADs estimates risk of stroke in AF: - CHF - HTN - age >75 - DM - ischemic stroke/ TIA (2 pts) low risk= 0 mod= 1-2 severe >3 Anticoagulate long term with warfarin in all pts with prior TIA/ stroke and in those with 1+ risk for VTE Antiarrhythmic considered if pt is unstable, AMS, signs of shock, ischemic chest discomfort, acute HF + new onset AF, or hard to control/ symptomatic chronic AF irregularly irregular rhythm+ narrow complex tachycardia= Afib + RVR. Symptoms of fatigue and palpitations due to fast ventricular rate --> rhythm control to maintain sinus

Inferior Trunk Root Avulsion

high energy traction injury to C8 and T1

IBS

in diarrhea predominant/ mixed irritable bowel syndrome: do routine serology test for celiac disease

Cardiac Catheterization

indicated for Acute Mi and unstable angina refractory to medical intervention. Measures blood flow and pressures within the cardiac chambers and coronary vessels. Uses IV contrast. May cause livedo reticularis due to dislodged cholesterol plaques from procedure forming emboli and travelling to extremities. Skin becomes mottled and discoloured due to ischemia May also cause acute kidney injury, pancreatitis (self limited)or mesenteric ischemia contraindicated in pts taking metformin --> IV contrast + metformin --> kidney failure and lactic acidosis Tx= supportive care (pain control, IV fluids, bowel rest)

Necrotizing fasciitis

infection extending through dermis into fascial layers and becomes limb threatening. pt may have fever, ams, severe pain and leukocytosis. MCC: strep pyogenes, staph aureus, c. perfringens Tx: immediate and extensive surgical debridement, IV antibiotics (vancomycin, penicillin, clindamycin)

confidence Interval

interval estimate of a population parameter used to indicate reliability of an estimate.

Proteus mirabilis

lactose negative +H2S Makes high levels of urease, alkalinizes the urine --> struvite (Mg ammonium phosphate) stone = "coffin lid" appearance on microscopy Large staghorn calculi need to be surgically removed to prevent recurrence

E.Coli

lactose positive on MacConkey - H2S

Struma ovarii

monodermal teratoma containing at least 50% thyroid tissue causing hyperthyroidism -abdominal pain, palpable pelvic mass with ascites - no goiter Ca125 high, low TSH, high free T4/T3 MRI: thick gelatinous colloid with no evidence of fat Tx: resect

Ottawa Ankle Rules

pain in the malleolar zone + bone tenderness along distal 6cm of posterior edge of fibula/ tip of lateral malleolus, or bone tenderness along distal 6cm of posterior edge of the tibia or tip of medial malleolus, or an inability to bear weight both immediately and in the ED for 4 steps OR pain in the midfoot + bone tenderness at the base of the fifth metatarsal, or an inability to bear weight immediately and in the ED for four steps.

Sulfonylurea overdose

persistent hypoglycemia: headache, dizziness, N/V. Seizures, diaphoresis, depressed mental status, tremors

Hyperkalemia

potassium >7 mEq/L Causes: impaired excretion i.e. CKD, drugs altering renin-angiotensin axis Skeletal muscle weakness (mimics GBS, but no resp failure) + cardiac abnormalities PE: ascending muscle weakness + areflexia --> flaccid paralysis EKG: shortened QT + peaked T wave. As it progresses, PR and QRS intervals will lengthen, will eventually lose p wave. If untreated --> sine wave. Can also cause type 1 brugada pattern -right bundle branch block, coved ST elevationa and marked QRS widening, AV block and bradycardia. emergent treatment indicated when K is >6.5 or EKG changes noted Tx: loops/ thiazide diuretics, IV calcium, IV glucose + insulin. Albuterol, NaHCO3 and dialysis can be used in urgent treatment Definitive measures to reduce total body potassium include: 1. reversal of correctable etiology (i.e. IVF for pre-renal azotemia) 2. Diuretics (Contraindicated in dehydrated pts) 3. exchange resins (sodium polystyrene sulfonate that remove potassium from GI tract) 4. hemodialysis

Stevens- Johnson syndrome

preceding hx of infection/ medication use (anticonvulsants, antibiotics and NSAIDs) + nikolsky sign Dx: clinical presentiaton, confirmed with skin bx Tx: d/c offending med and supportive measures (burn unit)

Power

probability of finding a statstically significant association in a research study when one truly exists. = 1- probability fo beta error

Beta error/ Type 2

probability that the null hypothesis is not rejected even though it is false

Alpha error/ Type 1

probability that the null hypothesis is rejected even though it is true False positive

Thyroid storm

pt appears toxic + extreme hyperthyroid symptoms: hyperpyrexia, hypertension, hyperreflexia, agitation tachycardia, N/V, tremulousness, possible coma. In elderly, manifests as weight loss, a.fib and weakness, HF, pulmonary HTN and angina. Tx: PTU, give iodine 1hr later to prevent release of preformed thyroid hormones.

Epiglotitis

rapid infection of supraglottic structures (epiglottis + aryepiglottic folds). HiB, strep, nontypable H.flu and viral agents Acute onset high fever, dysphagia, drooling, muffled voice. Pt sits in tripod position with neck hyperextended and leaning forward Lateral X-ray: thumbprint sign

Relative risk

risk of disease in people exposed to a given facto relative to the risk in people unexposed to the same factor. Determined through cohort studies.

Serotonin syndrome

triad: AMS (tremor, muscle rigidity, b/l babinski), autonomic hyperactivity , neuromuscular abnormalities (clonus, tremor, hyperreflexia) - may look like NMS, but will start off with diarrhea, restlessness and autonomic instability Tx: cyproheptadine

brucellosis

undulant fever after contact with farm animals

Immediate laparotomy indicaions

unstable pt, peritonitis, evisceration, blood on DRE or NG tube suggesting intrabdominal injury

Subacute thyroiditis/ deQuervain's

viral/post-viral, recent URI. inflammation and damage to thyroid; transient hyperthyroid state, once exhausted --> euthyroid --> hypothyroid until follicles regenerate Pain in neck, radiating. High ESR, Low TSH, normal- high T3/T4`