Internal Med EOR
Internal Med EOR
HTN Hypertensive Urgency •Urgency: poorly controlled •CBC, CMP, UA; EKG, CXR Hypertensive Urgency: adjust medications
Urgency v. *>220/125 WITHOUT end- •CT if neuro sx in emergency -hospital: Clonidine, Captopril, Nifedipine
Emergenc organ damage •Emergency: identify organ -oral: labetolol, captopril, NTG, clonidine
y failure brain, kidney, heart Complications:
Hypertensive Emergency •Renal-nephrosclerosis Hypertensive Emergency: 1st line: BB, CCB
*>220/125 WITH end-organ •Eye-retinopathy, cotton wool -ischemic CVA: keep BP 180-200
damage •Vascular-atherosclerosis, aneurysm -hemorrhagic CVA: <130
•CVA (SPB); S4, heave -dissection: 100-110
Angina Substernal chest pain usually History: ALL: EKG and CXR Lifestyle modifications
Pectoris brought on my exertion •Chest pain: poorly localized, NSTEMI: high troponin, ST depressed
substernal Unstable: normal troponin, ST depressed Pharmacotherapy: M.O.N.A. (162-325mg)
•Class I: strenuous activity •Radiation: arm, teeth, jaw *goal is to increase supply and decrease
•Duration: Short (<30 minutes) Exercise Stress Test: demand on the heart
•Class II: more prolonged •Alleviating: rest, NTG • (+) if ST-depressions, hypotension/HTN, •NTG
rigorous activity •Aggravating: exertion arrhythmias, symptomatic •Beta-Blockers
•CCB (Diltiazem, Verapamil)
•Class III: daily activity Other SX: diaphoresis, dyspnea, Imaging Stress Test: •Aspirin: does not work with supply/demand,
fatigue, numbness, nausea •thallium-201 or technetium-99 but prevents progression of stable angina to
•Class IV: at rest •patient with baseline EKG abnormalities acute coronary syndrome
Exam: usually normal •Adenosine or Dipyridamole
•CI: asthmatics Classic TX: ASA, BB, NTG, statin
Endocarditis Cause: ORAL (dental, candy, brush) MC: 3 blood cultures, 1 hour apart Acute Endocarditis: Nafcillin +
-others: IVDU, EGD, TURP, cath, •fever (90%), chills, night sweats DUKE CRITERIA Gentamicin x4-6 weeks
•MSK pain (back) Major criteria
•Localization of the infection is •murmurs (80%) • (+) blood culture (2 are +) Subacute Endocarditis: PCN or
determined by turbulent blood flow •CHF (2/3 cases) •endocardial involved on echo (TEE) Ampicillin + Gentamicin
•new regurg murmur
•MC bug: S. aureus Peripheral Manifestations: Prosthetic valve: Vancomycin +
•MC on Left side, TV MC in IVDU •petechia *strep or staph Minor Criteria: Gentamicin + Rifampin
•splinter hemorrhages *strep, staph •heart condition or IVDU
•osler nodes *strep *PAIN (finger) •fever (>100.4F) Fungal: Amphotericin B
•Acute: infection of normal valves •Janeway *PAINLESS (palms) •vascular and embolic PNA
•Subacute: abnormal valve •Roth Spots (eyes on funduscopic) •immunologic phenomena Prophylaxis: Amoxi 2g 30-60min
•IVDU: MRSA, Pseudomonas •microbiologic evidence -prosthetic heart valves
•Prosthetic: Staph epidermis *1 normal, or 2+ abnormal -prior endocarditis
-cyanotic congenital heart disease
Interpretation: -cardiac transplantation
•Definitive: 2 major or
1 major + 3 minor, or 5 minor
Toxic: Alcohol, cocaine,
Doxorubicin
Other: pregnancy
Hypertrophic Inherited genetic disorder (autosomal •Dyspnea (MC complaint) Murmur: •Avoid volume depletion
Cardio- dominant) •Angina, Syncope, Arrythmias Harsh, mid-systolic crescendo-
myopathy mutation of sarcomeres •Sudden cardiac death decrescendo murmur, at 3rd/4th ICS •Beta-blockers or Verapamil (CCB)
louder with valsalva, quiet w/ squat *1st line!
•MC effects interventricular septum
LVH diastolic dysfunction •EKG: LVH (V5, V6, aVL) •Septal myetomy/alcohol septal
•Echo: DIAGNOSTIC-assymetrical ablation *inject alcohol-kill off part
•Impaired ventricular relaxation/filling wall thickeness
Restrictive •Ventricle is STIFF and has impaired •Right sided HF sx •Echo: non-dilated ventricles with •Treat underlying cause if known
Cardio- filling diastolic dysfunction •Pulmonary HTN normal wall thickness dilation of
myopathy •Normal ejection fraction both atria
Cause: Amyloidosis (MCC),
sarcoidosis, hemochromatosis, Exam: Kussmaul sign
scleroderma, fibrosis, cancer
Stress- •Can cause an ACS or STEMI • psycho or physiological stress Echo/LV angiography: •Recover in a few weeks
Induced *MC in postmenopausal women Systolic dysfunction of apex •LV apical ballooning •Beta Blockers for one year
(Takotsubo) and/or mid segments
Cardio 20% About Clinical Presentation Diagnostics Treatment
Pericarditis Inflammation in pericardial sac •PLEURITIC CHEST PAIN •Viral titers •FIRST LINE-NSAIDS
-worse with inspiration •Cardiac enzymes -Ibuprofen 600-800mg TID or
Causes: -worse when supine •Echo Indomethacin TID for 1-2 weeks
•Idiopathic *MC -relieved with sitting up and leaning *likely normal unless significant -ASA post MI
•Viral (enterovirus) (MC!) forward effusion present
•Systemic: thyroid, lupus, RA •CBC, BMP, ESR/CRP 2nd line: Colchicine
•Neoplasms: lung & breast CA •Fever -use for recurrence
•Drug Toxicity EKG: diffuse ST segment elevation
•Myocardial Injury Auscultation: pericardial friction -smiley face &diffuse
•Pericardial Injury rub *washing machine sound
Pericardial •Fluid in pericardial space Distant (muffled) heart sounds CXR: cardiomegaly Small/no tamponade: observe
Effusion EKG: low QRS voltage
•MCC: pericarditis Echo: increased pericardial fluid
•Others: infection, radiation, cancer
Cardiac Effusion causing significant pressure BECKS TRIAD: Echo: effusion + diastolic collapse of Pericardiocentesis
Tamponade on the heart restricted filling •JVD cardiac chambers
decreased CO •Muffled heart sounds
•hypotension EKG: electric alternans
Constrictive Thick, fibrotic and calcified heart •Dyspnea (MC sx) Echo: thickening of pericardium, Diuretics for sx improvement
Pericarditis diastolic dysfunction •RHF: JVD, edema, N/V
CXR: pericardial calcificiation Definitive: pericardiectomy
MCC=TB *underdeveloped Murmur: pericardial knock -if unresponsive to diuretics
-high pitched 3rd heart sound due to Cardiac CT/MRI: thickening
MC is radiation, surgery, and viral sudden cessation of ventricular filling
pericarditis *developed from thickened pericardium Cardiac Cath: *CONFIRMATORY
Varicose Veins •Varicose veins develop in LE •Dull, aching heaviness or feeling of •No diagnostic evaluation •Nonsurgical: Elastic compression
fatigue in legs brought on by periods of stocking (20-30mmHg), leg elevation
Dilated, tortuous superficial veins standing, relieved with elevation •Imaging needed for surgical
Increased intraluminal pressure intervention-duplex US •Surgical:
reverse venous flow •Itching , palpable -sclerotherapy: inject sclerosing agent
-laser therapy: wavelength
Hallmark: venous reflux & HTN -endovenous ablation
-vein stripping (last resport)
Cardio 20% About Clinical Presentation Diagnostics Treatment
Chronic Venous •Severe manifestation of venous Burning, aching, heavy leg pain Compression stockings, leg elevation
Insufficiency hypertension -worse with standing/sitting Regular exercise
-better with walking & elevation lipodermato
•Valve leaflets that do not coapt Ulcer: UNNA boot, wet to dry dressings
because thickened and scarred or Edema, hyperpigmentation,
in a dilated vein so impaired
function •Venous ulcers: medial malleolus atrophic blanche
legs develop venous
HTN and high •Lipodermatosclerosis
hydrostatic force -pigmented, swelling, red, “bowling pin”
corona
MCC-prior deep venous •Atrophie Blanche
thrombophlebitis -star shaped ivory-white depressed Trendelenburg test: elevate one
atrophic plaque; red dots within scar leg at 90 degrees, occlude great
saphenous vein, have patient
•Corona Phlebectatica stand for 20 sec slow ankle
-dilated veins around the ankle fillings suggests competency
Superficial •Inflammation of a vein due to Trousseau’s sign: •CBC: WBC may be elevated 1st line: supportive therapy
Venous clot in the superficial vein migratory thrombophlebitis associated -elevate, warm compression,
Thrombophlebiti -thrombotic or septic with malignancy •Venous Doppler US: non- compression stocking, NSAIDs
s complications compressible vein with clot
-great saphenous vein
Local phlebitis: tender, pain, edema, Septic state:
Causes: IV catheter, trauma, erythema, induration •PCN + Aminoglycoside
pregnancy, varicose veins •+/- palpable cord •Vanc + Rocephin
•Fever (if septic)
•MC pathogen-Staph Aureus
Chronic Causes: *Asymptomatic for years •Echo*diagnostic of choice •Valve Replacement (AVR): those with
Aortic •Aortic leaflets: •CHF, angina -monitors progression of disease symptomatic severe AR or with LV changes
Regurgitation rheumatic fever, congenital
abnormalities, endocarditis Murmur: •AR prior to LC dilation greater than 50mm
•Early diastolic, radiate to apex or reduction in EF to less than 50%
•Aortic root: •Decrescendo, blowing
dissection or dilation, •High pitch, 2nd and 4th L spaces •Vasodilator therapy-unload the ventricle
Marfan •Widened pulse pressure Arterodilation
•S3&S4 gallop Reduce afterload -> less pressure to
*LVH due to dilation from •Austin Flint Murmur maybe push back into the ventricle
accommodating regurg
volume
Acute Aortic Causes: •S/S of cardiogenic shock Echo *diagnostic study of choice SURGICAL EMERGENCY
Regurgitation •infective endocarditis •Pale, cool extremities -performed quickly and bedside
•trauma rupture of leaflet •Weak, rapid pulse Vasodilator and diuretic if BP is stable
EMERGENCY •aortic root dilation *LV in unable to accommodate the -Inotropic agents & vasopressors
•acute dysfunction of Murmur: increased diastolic volume -> increased
prosthetic valve •low pitch, early diastolic pressures and pulmonary congestion **Treatment of choice: Urgent AVR
Mitral Valve General Features Clinical Presentation Diagnostic Studies Management
Mitral Stenosis •2/3 are women •Dyspnea, orthopnea EKG: LAE, RVH, A-fib Mild to moderate: CONTROL HR
•Don’t develop sx until 20-40 •Atrial fibrillation *enlarged atria
years following disease ~30-40yo •Hemoptysis (rupture of dialted bronchi) Echo: *diagnostic of choice Moderate to Severe (NYHA III-IV):
•Blood tinged sputum *pulmonary edema •Rhematic deformitity-doming •Percutaneous balloon valvuloplasty
Causes: (hockey stick) *not common or definitive treatment
•Rheumatic fever is MCC! Additional findings: •Large LA compared to LV
•congenital abnormalities, •PE, edema, Ortner Syndrome (L recurrent -normal MV area: 4-6cm 2 Surgery is definitive treatment with
connective tissue disorders, left laryngeal nerve compression) bioprosthetic or valve replacement
-critical: <1cm 2
atrial tumors, aggressive surgical
repair of MR Murmur: •smoke in left atrium
•Diastolic, Low-pitch, rumbling
•Heard at apex in LLD position w/ bel Cardiac cath: measure CO
•Opening snap following S2
Mitral Valve •1-3% population; MC in women Nonspecific sx (MVP syndrome): DX: Echo •NO TREATMENT if mild prolapse
Prolapse •superior displacement in systole •chest pain, palpitations, dizzy, anxiety *diagnostic study of choice and asymptomatic
Chronic Abnormalities of mitral leaflets, •fatigue EKG: Reduce Afterload: *less mitral
Mitral annulus, chordae, papillary •dyspnea on exertion •LA enlargement, LVH, A-fib regurg
Regurgitation muscles •peripheral edema •vasoduilators (ACEI, hydralazine)
-MVP, LV dilation, posterior MI Echo: *Diagnostic of choice •diuretics
-rheumatic fever Murmur:
-endocarditis •blowing holosytolic murmur Cardiac Cath: Surgery: annuloplasty
•heard at apex & radiates to axilla/back •Assess function & filling pressures *DEFINITIVE
•Regurgitating blood flow from •mid-systolic click •should be performed before
LV to LA in systole irreversible myocyte damage and left
centricular remodeling occur
Causes:
•acute MI, trauma, endocarditis
•tachyarrhythmia w/ chronic MR
•MVP
Tricuspid •Regurgitating blood flow from RV •Well tolerated without pulmonary HTN CXR: •Treatment of underlying cause
Regurgitation to RA •As it progresses, may have RV failure:
-fatigue, abd bloat & peripheral edema •Repair TV with annuloplasty
•Secondary to dilation of the RV *persistent symptoms
and tricuspid annulus due to RV Physical Exam:
failure (pulm HTN or L failure) •JVD, hepatic congestion and palpable •TV replacement
systolic pulsation *pts with underlying primary leaflet
•Increased RA pressure -> increased pathologic condition
venous congestion & reduced RV Murmur:
output -> volume overload •High pitch, pansystolic, tricuspid post
•accentuated with inspiration or leg raise
Sinus Bradycardia Heart rate <60bpm •Increased vagal influence on the normal pacemaker •1st line-permanent pacemaker
Rate increases with exercise, atropine or organic disease of sinus node
- Fear, bearing down, SSS Acute setting: transcutaneous pacing, temporary
Causes: transvenous pacing, Atropine (ACLS protocol)
•Increased ICP: hemorrhage •Severe <45bpm-sinus node pathology
•Anterior MI: Inf. wall MI -> RCA supply SA
•OSA: decreased Hr <30bpm in apnea SX:
•Other: hypothermia, hypothyroidism •weakness, dizziness, confusion, syncope
Sick Sinus Syndrome •Commonly have recurrent supraventricular “When they go into AFIB its really fast then when Symptomatic Pacemaker (PPM)
arrhythmias and bradycardia “tachy-brady” they go out of afib they go into a really slow sinus
brady”
•MC in elderly
•Cause: medications
Sinus Tachycardia •HR >100bpm Symptoms: palpitations, lightheadedness Physiologic: none needed, try massage
•Onset & termination usually GRADUAL *usually related to the cause *usually a compensatory mechanism
Premature Premature depolarization originates *frequently in normal heart •Many are completely asymptomatic •Symptomatic: BB (Metoprolol)
Ventricular from the ventricles •caffeine, stress, alcohol •Palpitations MC complaint •2nd line: Class Ic or III AAD
Contractions - wide QRS complex w/ pause •electrolyte abnormalities
•thyroid •Significant burden: cath ablation
Prevention:
•Catheter Ablation: recurrent, sympt. PSVT
•Medication Therapy: BB & CCB are 1st LINE
Arrhythmias Definition
Ventricular •Not a sustainable rhythm IMMEDIATE UNSYNCHORNIZED
Fibrillation •Leading cause of sudden death DEFIBRILLATION
Right Bundle Receives blood supply from septal Conduction can be compromised by: Generally asymptomatic Do not require further dx or tx
Branch Block branches of the left anterior •Structural heart disease
(RBBB) descending •Functional factors
Bifasicular •Asymptomatic (BENIGN) Asymptomatic:
Block - no further dx tests •Screen carefully for symptoms and signs
suggesting occult cardiac disease
•Presyncope or syncope
- ECG monitor 24-48h Symptomatic:
- Echocardiography •Pacemaker if CHB is identified
PULM 15%
COPD Irreversible airflow obstruction •cough, dyspnea with exertion Screening: annual screen with Cat A (GOLD 1-2):
- Loss of elastic recoil of alveoli •excess sputum production CT in adults 55-80yo with 30yr •SABA, possible LABA
- Increased airway resistance pack history and currently smoke
or smoked within past 15 years Cat B (GOLD 1-2):
Risks •LABA or LAMA
•SMOKING (>15 pack years) CXR: hyperinflation
•secondhand smoke CT: better for emphysema Cat C (GOLD 3-4):
•alpha-1-antitrypsin deficiency •LAMA, + LABA, LABA +
Spirometry: inhaled steroids + SABA
FEV1/FVC <70%, FEV1 <80%
COPD •Productive cough x3mo for 2 consecutive years •Productive cough Cat D (GOLD 3-4):
(Chronic •cyanotic, edema, RHF A: mMRC 0-1, CAT <10, 0-1 •LABA/LAMA, triple
Bronchitis) •Chronic airway inflammation hypersecretion of •rales and rhonchi exacerbation
B: mMRC 2+, CAT 10+, 0-1
mucus, airway narrowing, increased airway SABA: Albuterol
exacerbation
resistance obstruction •respiratory acidosis C: mMR 0-1, CAT <10, 2+
LABA/ICS: “SAD”
•V/Q mismatch (normal in exacerbation, 1+ hospital LABA: Salmeterol,
emphysema) D: mMRC 2+, CAT 10+, 2+
exacerbation, 1+ hospital Combo LABA/LAMA: Bevespi
COPD •Irreversible enlargement of air spaces distal to •dyspnea with exertion GOLD 1: mild-FEV1 80%+ Triple (D): Trelegy
(Emphysema terminal bronchioles destruction of air spaces; •pink complexion GOLD 2: moderate-FEV1 50-70%
) loss of elastic recoil in acinus air trapping •thin, barrel chest, no edema GOLD 3: severe-FEV1 30-49% Others: Steroids, oxygen
GOLD 4: very severe-FEV1 >30%
•respiratory alkalosis *oxygen is only TX proven to
“lean forward w/ pursed lips” STOP SMOKING!!!!!!
decrease mortality in patient
Asthma Reversible; airway inflammation & •Dyspnea Pulmonary Function Test 1. SABA (all)
bronchoconstriction in response to trigger •Wheezing Spirometry *GOLD 2. +ICS
•Cough (worse at night) low FEV1/FVC and FEV1 3. +ICS/LABA or med ICS
Pathophys: •Chest tightness 4. +med ICS/LABA
1. airway hyperactivity (IgE T-cell) •Fatigue Bronchoprovocation: 5. +high ICS/LABA
2. bronchoconstriction: airway narrowing due to Bronchodilator FEV1
6. +high ICS/LABA or oral
smooth muscle contraction, edema, mucus, Physical Exam: increases by 12% and 200ml
hypertrophy air trapping •Prolonged expiration
3. inflammation •Hyperresonance to percussion Peak Expiratory Flow (PEFR) Admit if:
•Decreased breath sounds *assesses asthma exacerbation •PEFR <50%
Mild Intermittent: •Tachycardia, tachypnea severity and response •ER within past 3 days
•SX ≤2d/wk, night awake ≤2x/mo, FEV1 >80% •Accessory muscles •Normal is 400-600 •status asthmaticus
Mild Persistent:
Samter’s Triad: asthma, nasal Culture: curschmann’s spirals,
•SX >2d/wk, night 3-4x/mo, FEV1 >80% polyps, ASA or NSAID allergy Charcot-Leyden crystals
Moderate Persistent:
•SX daily, night awake >1x/wk, FEV1 60-80%
Severe Persistent:
•SX throughout day, awake nightly, FEV1 <60%
PULM 15%
Idiopathic *MC interstitial lung disease Clinical Findings: PFT: restrictive (low TLC, RV) Early referral for lung
Pulmonary •gradual dyspnea with nonproductive cough DLco: reduced transplant
Fibrosis Pathophysiology:
diffuse epithelial cell activation and PE: HRCT: ground glass opacities,
abnormal repair fibrosis •fine inspiratory crackles/rale traction bronchiectasis,
•maybe digital clubbing honeycomb
Asbestosis workers exposed to asbestos fibers Symptoms: CXR/HRCT: LOWER LOBES Supportive
pneumoconiosis over many years (old homes, ships) •after a latent period of 20 years + DOE -linear (reticular) opacities
-pleural plaques INCREASED RISK OF
Pathophys: PE: -honeycomb bronchogenic carcinoma &
macrophages ingest inflammation •bibasilar, fine end-inspiratory crackles malignant mesothelioma
fibroblasts fibrosis •clubbing Lavage: asbestos bodies
Sarcoidosis •Inflammatory Disease, immune Pulmonary: (MC) Labs: High Ca2+, ESR, ACE 1st line: watch and wait
•Noncaseating (non-necrotizing), •dyspnea & dry, non-productive cough x2-4wks *granulomas produce Vit D
granulomas involving 2+ organs •Fatigue, fever, night sweat, wt loss Standard: steroids
Pulmonary Function Tests: *reduce granulomas
•Organs: lungs (MC!); skin, eye Skin: (2nd MC organ) •DLco: <80% (most sensitive)
Granuloma: •erythema nodosum: bilat tender red nodules •restrictive disease (all low Second Line:
mass of immune •MC in black, N. European, females on anterior legs except ratio is normal or high) Immmunomodulators if no
cells made by •lupus pernio (pathognomonic): violaceous, improvement in 6 months
macrophages, Pathophysiology: raised discoloration of nose, ear, cheek, chin CXR:
epithelioid, giant T-cell response to variety of antigens •maculopapular rash (MC chronic) •Stage I: bilat hilar adenopathy Advanced: Lung transplant
cells immune activation and immune •Stage II: combo
depression granuloma formation Ocular: Anterior uveitis blurred vision, •Stage III: infiltrates *upper Follow-Up:
disrupt normal structure discomfort, photophobia, floaters •Stage IV: fibrosis -min yearly exam
-yearly PFTs, labs, CXR, EKG
Biopsy: noncaseating granuloma
PULM 15%
Cor Pulmonale Risks: pulm disease COPD, ILD, pulm HTN JVD, ascites, edema DX: echo, R cath •diuretics & oxygen, anticoag
Pulmonary Increased pulmonary vascular resistance RHF Symptoms: •Echo: *begin with echo Who Group 1:
HTN •dyspnea, chest pain •EKG: RHF, RVH, RAD 1st line CCB: Verapamil
WHO Group1: pulmonary arterial hypertension •cough
•muscle hypertrophy & endothelial dysfunction •fatigue, lightheadedm syncope •CXR: increased pulm arteries Other options:
•hemoptysis •PDE-5 (Sildenafil),
WHO Group 2: *lungs L heart disease •R Heart Cath (Swan-Ganz) •Prostacyclins (Epoprostenol),
-pulmonary venous hypertension (heart) Classification: NYHA 1-4 *GOLD STANDARD •Endothelin antagonists
1-no limitation -MAP >25, Wedge <15 (Bosentan)
WHO Group 3: secondary to lung disease 2-mild sx with normal activities
3-marked limitation •Vasoreactivity Testing Who Group 2: tx underlying
WHO Group 4: pulm HTN secondary to 4-severe sx with rest -vasodilator and measure
thromboembolism occludes pulm arteries hemodynamic response Who Group 3: Oxygen
Signs/Physical Exam: -Epoprostenol, Adenosine, NO
WHO Group 5: heme, systemic & metabolic -JVD, LE edema RHF (+) if pressure decreases <10 and Who Group 4: anticoagulant
(sickle cell, sarcoidosis) - S2 & P2; tricuspid regurg to a value <40
Hypoventilation Risks: obesity, structural, fhx, alc, hypothyroid •snoring, interrupted sleep •Polysomnography (sleep study) weight loss, exercise, nonsupine,
Syndrome •daytime sleepiness, fatigue, avoid alcohol and sedatives
(sleep apnea) 1. pharyngeal wall collapse repetitively •wake up with breath holding, •Alternative: home sleep apnea
2. failure of upper airway dilator muscle gasping, choking testing (HSAT) Mild/moderate: CPAP
3. sleep-related obstruction and breath cessation •HTN, CAD, DM, mood Severe: CPAP, surgery
PULM 15%
Solitary Nodule: <3cm; Mass: >3cm Benign: SLOW GROWTH Malignant: RAPID GROWTH Low (<5%): watch
Pulmonary -round, smooth -irregular, speculated “<50yo and no smoking”
Nodule Risks: Thymomas (MC) -calcifications “popcorn” -cavitation with thick walls Intermediate (5-60%): biopsy
-cavitation High (>60%): resect
Carcinoid Neuroendocrine tumor •Asymptomatic (25-40%) •Secrete serotonin, ACTH, ADH, Definitive: surgical excision
Tumor •Wheezing, cough, recurrent PNA, hemoptysis melanocyte stimulating hormone
MC sites: GI tract, lungs Carcinoid syndrome: diarrhea due to serotonin •Ocreotide may reduce SX
•Increased bradykinin and histamine flushing, Bronchoscope: pink-purple tumor
tachycardia, bronchoconstriction, acidosis *well vascularized MC complication: bleeding
Bronchogenic MCC cancer deaths SCLC: fast growing, starts in bronchi (central) CXR & CT Scan NSCLC:
Carcinoma •SVC syndrome, SIADH/hyponatremia, cushing •Surgical resection treatment of
Risks: cigarettes, asbestosis •lambert-eaton (weakness improves WITH use) Central lesions: sputum, bronchoscope choice
*squamous cell, SCLC
Adenocarcinoma (MC!!): slow, periphery SCLC:
Squamous: central (bronchial) Peripheral lesions: FNA biopsy •Chemo treatment of choice
•CCCP: central, cavitation, hypercalcemia, *large NSCLC, adenocarcinoma
Pancoast (shoulder pain, horners, hand atrophy)
PULM 15%
Bronchiectasi •Permanent, abnormal dilation and destruction of the •Chronic daily cough •Clinical diagnosis •ABX+ bronchodilator + chest PT
s bronchial walls of the large airway •copious, thick, foul- •CXR r/o PNA -Ampicillin, Amoxicillin, Bactrim
smelling sputum -FQ or Zosyn if Pseudomonas
MCC: H. flu, Pseudomonas (cystic fibrosis) •hemoptysis HRCT: STUDY OF CHOICE
•recurrent lung infection bronchial wall thickening (“tram-
inflammation, edema, cratering, ulceration, track”) and dilated airways
neovascularization abnormal dilation and PE: crackles
destruction of major bronchi & bronchial walls Sputum Culture: neutrophilia
Acute MC in the winter, self-limited ~5 days-3 weeks •non-productive cough CLINICAL *Reassurance and education
Bronchitis MCC: Adenovirus; Others: S. pneumo, M. cat, H. flu •Wheezing CXR: usually normal •rest and hydration, NSAIDs
•Rhonchi (clear with
Pathophys: infection inflamed exudate spasm cough) •Procalcitonin *bacterial AVOID ABX unless indicated!
•Pharyngitis >0.25 (non-ICU) •Atypicals: Macrolide, FQs
Two phases: •Fatigue/Malaise >0.5mcg (ICU)
1. direct inoculation of tracheobronchial epithelium •Fever (low-grade)
2. Hypersensitivity of airway receptors (persistent sx
1-3wks) increased sputum
Pneumonia rust: S. pneumo (MC) RLL •productive cough CXR (PA and Lateral) GOLD CAP Out: No comorbid/ABX:
(Bacterial) green: H, flu, pseudomonas •fever CT if unclear Azithro, Clarithro, Doxycycline;
red currant jelly: Klebsiella upper lung •dyspnea Comborbid/ABX: Levofloxacin,
Foul smell/bad taste: anaerobic •pleuritic CP Azithro+Rocephin
•chills Labs: hospital: cx, NP, CBC, CMP;
•tachypnea HAP: new infiltrate CAP Inpatient:
Ventilator: Pseudomonas, Acinetobacter •accessory muscles Non-ICU: Levo; Moxifloxacin;
PSI: >90=hospital Rocephin+Azithro
CAP: within 48 hours of hospital or outpatient Dullness to percussion CURB-65 (2+=hospital): ICU: Rocephin + Azithro or Levo
Increased TF confusion, urea >19 (>7mmol), RR
-S. pneumo, Mycoplasma pneumo
(+) egophony 30+, BP <90/60, age >65 HAP (low risk drug-resistant):
HAP/VAP/HCAP: develops 48hours AFTER Levofloxacin, Zosyn, Cefepime
-Pseudomonas, Klebsillea, S. aureus
HAP (high): Vanc +
1. Cefepime or Ceftazadime
2. Imipenem or Carbapenem
3. Zosyn+Cipro
4. Gent or Amikacin
Pneumonia •Influenza •Fever, chills •NP swab O2, rest, fluids, antipyretics,
(Viral) •adenovirus, parainfluenza, RSV, HMNV •nonproductive cough •CXR analgesics, IVF
•rhinorrhea, myalgia
•HA, sore throat
Pneumonia •Unicellular, Fungal pneumonia •Fever Labs: Elevated LDH & B-D-glucan •ART initiated if not already
(HIV/Fungal) •Associate with immunocompromised, esp HIV •dry cough, dyspnea
P. jivoreci •Person-person through airborne spread •respiratory failure CXR: diffuse, bilateral infiltrates •BACTRIM
CT scan: ground glass opacities •Prophlylaxis: CD4 <200
GI 12%
Hiatal Protrusion of the upper portion of •Type I: sliding hernia (MC) CXR •Type I: same at GERD
Hernia the stomach into the chest cavity
due to diaphragm tear •Type II: rolling hernia fundus protrudes •Type II: surgery
Esophageal Dilated submucosal veins due to •Acute gastrointestinal hemorrhage Emergent Endoscopy STABILIZE: IV, fluids, blood
Varices portal HTN •Retching, Dyspepsia (+) red wale markings and FFP or plts if INR >2.0 or plt <50,000
•Bright red bleeding in esophagus cherry red spots
Risks: CIRRHOSIS •Hypovolemia w/ postural vitals or shock Pharm:
Vasoconstrict: Ocreotide (Somatostatin)
ABX: IV Rocephin or Fluoroquinolones
Infectious *MC in immunosuppressed patients Candida: linear white plaques Endoscopy with biopsy and Candidal: Fluconazole
Esophagitis -Candida albicans, HSV, CMV CMV: large superficial shallow ulcers brushings CMV: Gangciclovir
HSV: small, deep ulcers HSV: Acyclovir
MCC non-infectious: GERD
Mallory UGI bleeding due to longitudinal •Hematemesis with or without melena Upper endoscopy: Superficial Supportive: fluids, transfusions
Weiss Tear mucosal laceration at the cardia or •H/o retching, vomiting, straining 50% cases longitudinal mucosal erosions
gastroesophageal junction Severe: epinephrine, sclerosing agent,
•Upper endoscopy after resuscitation band ligation, clipping
Due to increase in intragastric
pressure vomiting after ETOH
GERD Transient relaxation of lower •Heartburn (pyrosis) ~30-60min after meals Upper endoscopy 1st: lifestyle modificiations
esophageal sphincter (LES) •Reflux of sour/bitter contents (regurg) -elevate head, avoid lying down x3hr,
•Dysphagia (1/3) Complications: avoid acidic food and alcohol
*severity not correlated with degree •Asthma, cough, laryngitis, CP, altered sleep Esophagitis
of tissue damage Stricture Pharm: H2-blockers (Ranitidine), PPI
ALARM: Esophageal adenocarcinoma (Omeprazole),
dysphagia, odynophagia, weight loss, bleeding Barrett’s Esopagus
squamous to columnar
Esophageal Squamous cell: •Solid food dysphagia then fluids Endoscopy with biopsy Curable: surgery and chemo
Cancer -MC type worldwide •Odynophagia
-MC in upper 1/3 esophagus •Tracheo-esophageal fistula cough, PNA Incurable: chemo, palliative
-risk: smoking, alcohol •Chest or back pain (mediastinal estension)
Adenocarcinoma:
-MC type in US; MC in lower 1/3
-risk: GERD
GI
Gastritis Inflammation/irritation of the stomach •MC asymptomatic H. pylori: urea breath test, stool H. pylori: CAP: Clarithromycin,
mucosa with mucosal injury •Epigastric pain, N/V, anorexia Amoxicillin, PPI
EGD *MOST ACCURATE
Erosive: NSAIDs, alcohol, stress •biopsy CONFIRMS NSAID: PPI (Omeprazole),
Non-erosive: H. pylori, systemic Misoprostol, Sucralfate
Peptic Ulcer Decreased mucosal protective factors and •Epigastric Pain (dyspepsia) worse at night Endoscope: GOLD 1. Triple Therapy x10-14d
Disease increased damaging factors •Dull, aching, “hunger” CAP: Clarithromycin,
•Food relief (duodenum) *returns in 2-4h H. Pylori tests: Amoxicillin, PPI
MCC OF UGI BLEED •endoscopy with biopsy (GOLD)
•Nausea, anorexia •urea breath test; stool 2. Quadruple Therapy
Causes: •GI bleed (melena, coffee ground emesis) •antibodies PPI + Bismuth (pepto) +
H. pylori infection *MC in duodenum *may be asymp until bleed Tetracycline + Flagyl
NSAIDS *MC in stomach Complications:
Zollinger-Ellison syndrome Physical Exam: tenderness over epigastric Bleeding, perforation,
ETOH, smoking, stress, obstruction, malignancy
Gastroenteriti Causes: •Vomiting, anorexia, fever, diarrhea Labs: Viral: symptomatic, fluids
s •Virus v parasitic v bacterial •HA, Cramp, Myalgia •CBC: WBC, bands Bacteria: Cipro, Doxy, Azithro,
•Viral: norovirus (#1), adenovirus, •BMP/CMP: CO2, BUN/Cr Bactrim
enterovirus, rotavirus Timing: winter •Stool: SSYC, O&P, virus (GE
*norovirus is vomiting and muscle Transmission: fecal oral panel) Concerns:
cramps Incubation: 12h-4d, last 4-7d •UA: dehydration •presence of blood or mucus
•Parasitic: cryptosporidium, giardia Age: <5yo •weight loss
•Bacterial: campylobacter, e. coli, •low BP, sunken fontanelle, dry
clostridium, salmonella (reptiles) Exposures: foreign travel, playing in creek, mucous membrane
daycare, poultry *want to know if crying, peeing
•decreased UOP
Gastric Adenocarcinoma MCC worldwide Asymptomatic until advanced Iron deficiency anemia •Surgical resection: gastrectomy
Adeno- Other: lymphoma •Dyspepsia, vague epigastric pain
carcinoma •Anorexia, wt loss, early satiety Diagnostic: EGD & biopsy •Chemotherapy and/or radiation
Risks: H. pylori, high salt or nitrate foods
PE: •Palliative measures
•palpable mass (20%)
•left supraclavicular lymph (virchows)
•umbilical node (sister mary joseph)
•rigid rectal shift (Blumer shelf)
Zollinger- Gastrin-secreting neuroendocrine tumor •Multiple peptic ulcers •Fasting gastrin level HIGH Local: surgical resection
Ellison Associated with MEN1 •Refractory ulcers *best screening test
Syndrome •“Kissing” ulcers (each side of luminal Metastatic: PPIs
MC in duodenum, pancreas, lymph node wall touching each other) • (+) Secretin test: increase
•Abdominal pain, diarrhea gastrin release with secretin seen
in gastrinomas
GI
Celiac •Response to GLUTEN •Diarrhea, steatorrhea, flatulence Diagnostic work-up: *bloods! REMOVE GLUTEN!
Disease •Presents in childhood, early adulthood •Wt loss, weak, muscle wasting Serologic antibody tests •Sx improve in 1-2 weeks once
•IgA TTG (best!) most sensitive gluten is taken out of diet
Triggers autoimmune response that •Iron, B12 or folate deficiency •IgG DGB (gluten sensitivity)
damages proximal S.I. mucosa loss of •Osteoporosis, bone pain •IgA Endomysal SEVERE reactions:
villi malabsorption •Detmatitis herpetiforms (10%) •Prednisone 40-60mg/day
*severity depends on amount of SI affected *very confirmative of celiac after (+) blood test: •Fluids
•Confirm with EGD with duodenal
mucosal biopsy
Irritable •Idiopathic Rome IV Criteria: ALARM sx: •Food diary and dietary changes
Bowel •Chronic GI sx NOT explained by the •Crampy, abdominal pain 1x/wk x3mo •Severe progressive pain *avoid triggers, avoids gas
Syndrome presence of structural/biochemical abnorm. AND 2/3: pain with anorexia or wt loss producing, low FODMAP diet,
(IBS) -relieved with defecation! •severe constipation or diarrhea fiber supplementation
Causes: abnormal motility, visceral -Change in stool frequency •hematochezia
hypersensitivity, enteric infection, -change in stool form •weight loss Diarrhea: Dicyclomine or
psychosocial (functional dyspepsia) •fever Loperamide
Constipation: laxatives
GI
Crohns Transmural inflammation and skip •Crampy RLQ abdominal pain Labs: (+) ASCA Goal: *NOT curative!
Disease lesion •Diarrhea (intermittent, non-bloody)
malabsorptive, steatorrhea GOLD=Colonoscopy w/ biopsy •Diet
Can occur anywhere in GI •weight loss, fatigue skip lesions with cobblestone appearance •Stop smoking
*MC-ileum and cecum •Symptomatic medications
perianal disease: fistula, abscess Barium study: “string sign”
*see infectious s/s with fistulas barium flows through narrow 1st line: oral mesalamine
inflammaed/scarred area due to transmural
malabsorption: iron and B12 deficiency strictures Maintenance:
5-ASA (Asacol, Pentasa)
extra-intestinal manifestation:
•arthralgia, arthritis, iritis, uveitis
•skin: Pyoderma gangrenosum
erythema nodosum
Ulcerative Relapsing and remitting episodes of •Crampy lower LLQ abdominal pain Labs: H/H, ESR, albumin, (+) P-ANCA CURATIVE
Colitis inflammation, spreads proximally •BLOODY diarrhea, pus/mucus
*mucosal layer of colon ONLY, •Fecal urgency and tenesmus Imaging: Pharmacology
*can mimic rectum is always involved Gold Standard-COLONOSCOPY 1. Aminosalicyclates
diverticuliti Complications: uniform inflammation, ulceration, polyps (Sulfasalazine, Mesalamine)
s *smoking decreases risk for UC •Severe bleed -CI IN ACUTE COLITIS 2. Steroids *acute flares only
•fulminant colitis (>10BMs/day) 3. Immunomodulators
•toxic megacolon, perf Barium: “stovepipe sign” loss of haustra 4. Anti-TNF
GI
Anal Fissure •Linear tears/ulcerations around anus •Tearing pain with defecation Inspection •Proper toileting, Sitz bath, Fiber
*MC posterior midline •Bleeding
*small amount with bright red Chronic fissures:
•Due to trauma to anal canal during blood (streaking on TP) •Topical NTG, Botulinum injection
defecation constipation/hard, straining •Surgery- sphincterotomy
Perianal ½ perianal abscesses are caused by fistulas Abscess: swelling, pain Clinical rectal exam •Perianal Abscess: I & D, Antibiotics;
Abscess and MC in posterior rectal wall •worse with sitting, cough, poo sitz baths, high fiber
Fistula Fistula DX: US/CT
Fistula: open tract b/w two epithelium areas Fistula: anal discharge and pain •Fistula treatment: Fistulectomy
Hemorrhoids •Internal and/or external •Asymptomatic PE: Conservation (stage I and II)
•Engorgement of rectal and hemorrhoidal •peri-anal inspection •proper toileting & high fiber diet
veins Internal (superior vein) •Anoscopic evaluation
•Bleeding Medical (stage I & II with bleeding,
Causes: constipation, low fiber, straining, •Prolapse Staging: stage II-IV)
pregnancy, obesity •mucoid discharge •I: confined in anal canal, no •Preparation H, Anusol, Proctofoam
prolapse
Complications: External (inferior vein) •II: prolapse with straining Surgical (III-IV, recurrent bleed)
•Thrombosed external hemorrhoids *painful •perianal pain and bleeding •III: require manual reduction •band ligation (MC)
•sitz bath, topical ointments, clot evacuation •IV: always out, irreducible •sclerotherapy
Diverticulitis Infection/inflammation of diverticuli •Acute LLQ abdominal pain Labs: leukocytosis Diet:Clear liquid initially
•Fever, N/V, Bowel changes *eliminate seed, nuts, popcorn
Diverticuli: outpouching due to herniation of Imaging: CT abdomen/pelvis
the mucosa into the colon wall Physical exam: ***BEST TEST ABX:
*MC in sigmoid colon •LLQ tenderness, •Augmentin 875mg BID x7-10d,
•palpable mass Complications: peroration, bleed, •Flagyl + Cipro
abscess, stricture •Bactrim
Colon Cancer Causes: Proximal Screening Staging and Management: TNM
•Adenomatous polyp malignancy •Anemia •FOBT (yearly) colonography *tumor, node, metastasis
•Familial adenomatous polyposis •Weakness, fatigue •flexible sigmoidoscopy q5 years
•Melena, (+) FOBT •colonoscpy age 50-75 Treatment:
Risk factors: •Wt loss •Surgical resection: stage 1-II
•>50yo Diagnostic: •Chemotherapy/radiation: III +
•family hx Distal colon Colonoscopy with biopsy
•diet (red meat, fat) •Change in bowel habits diagnostic study of choice!
•smoking •Obstruction
•obesity •Hematochezia Barium enema: apple core lesions
•Urgency/tenesmus (rectal) Labs: HIGH CEA
Familial •Inherited mutation (APC gene) Soft tissue tumors in skin and Diagnosis confirmed with genetic Prophylactic colectomy
Adenomatous •Development of hundreds and adenomatous osteomas testing recommended!
Polyposis polyps
*stomach and duodenum
GI
Cholelithiasis Gallstone form from: Asymptomatic •Ultrasound Symptomatic (Biliary Colic):
•Ratio of cholesterol too high *procedure of choice •Laparoscopic cholecystectomy
•Ratio of bilirubin too high Symptomatic (biliary colic)
•Gallbladder not emptying bile •RUQ pain (hallmark) •CT No surgery:
-follow fatty meals Ursodeoxycholic acid
Types: Cholesterol gallstones (MC!) -may radiate to back and
right shoulder blade! Complications:
Risks: 5 Fs: fat, female, fertile, fair, choledocholithiasis, acute
forty *don’t typically see N/V, fever, chills cholangitis, acute cholecystitis
with biliary colic
Choledocolithiasi Choledocolithiasis: gallstones in Choledocolithiasis Choledocolithiasis •IV fluids, pain control, NPO
s and Cholangitis common bile duct (CBD); symptomatic •Intermittent RUQ pain Labs: normal •ERCP w/ stone extraction &
-passes are “uncomplicated” •Jaundice sphincterotomy
-typically symptomatic •Intermittent N/V Cholangitis
PE: normal Labs: •ABX with acute cholangitis
Cholangitis: gallstone lodged and •Leukocytosis -mild-moderate: Cipro + Flagyl
obstruction in CBD infection Cholangitis •high alk phos, GGT, bilirubin -severe: IV Zosyn + Flagyl
-Bacterial infection or hepatic injury •Charcot Triad
*when become a problem -RUQ pain, Fever, jaundice Diagnostics: Complications:
•Reynolds Pentad: •US/CT (FIRST!) •liver damage
-Charcot + low BP •ERCP-diagnostic test of choice •septic shock with acute
+mental status changes cholangitis
PE: RUQ pain & hepatomegaly
Cholecystitis Acute: •RUQ Pain Labs: Leukocytosis Management: NPO, IVF, ABX
•MC due to stone lodged in cystic duct -steady, sharp pain, continuous •Ceftriaxone +/- Flagyl
•Sudden onset, severe -precipitated by meal Imaging: •IV Morphine or Demerol for pain
•N/V & Fever •Ultrasound-1st line •Laparoscopic chole in 24-72hr
Bugs: E. coli, Klebsiella, Enterococci -thick gallbladder, sludge, stones
PE: Complications:
(+) Murphy Sign •HIDA scan: GOLD •Gangrene
(+) Boas: referred pain to R shoulder (+): no visualization of gallbladder •Chronic Cholecystitis
irritation of the phrenic nerve
GI
Hepatitis A •Fecal-oral route •Incubation ~30 days •Hep A Antibody (Anti-HAV) Symptomatic rest & fluids
•Crowding and poor sanitation -IgM peak in first week of sx *active Vaccine
•Contaminated food •Malaise, myalgia, N/V, anorexia infection
•Aversion to smoking (no craving) -IgG rises for months *previous, immunity
•RUQ abdominal pain, jaundice
•Mild hepatomegaly, liver tenderness Blood smear: Atypical large lymphocytes
GI
Acute Causes: •Epigastric pain that radiates into the back •Serum amylase & lipase Assessment of Severity:
Pancreatiti •gallstone *because retroperitoneal -elevated 3x normal •Ransons Criteria “LAAWG”
s •heavy alcohol -sudden, steady -lipase better for dx 3+ indicates severe course
-worse w/ activity & supine •CBC -age >55
Pathophysiology: -improve w/ leaning forward -leukocytosis -bld random glucose >200
•Edema/obstruction at ampulla of Vater •N/V •CMP -serum LDH >350
•acinar cell injury premature or over •Weakness, sweating, anxiety -elevated glucose -AST >250
activation of enzymes self-digestion -electrolyte abnormal b/c N/V -WBC >16,000
PE: *can dehydrate quickly •elevated alk-phos, LFTs
•Epigastric tenderness •High TGs Treatment:
•Distended abdomen •UA: proteinuria, glycosuria **Supportive: IVF, NPO, pain
•Absent BS if with ileus ABX: broad spectrum if severe
•Fever, Tachycardia, hypotension *baseline 3 tests are serum amylase
•Cullens & Grey Turners (side) sign and lipase, CBC, CMP
Chronic Chronic inflammation causing •Chronic, steady or intermittent epigastric X-ray: calcifications in pancreas Oral pancreatic enzyme
Pancreatiti parenchymal destruction loss of pain *often radiates to back replacements
s exocrine function, sometimes endocrine •Anorexia, weight loss CT (best): pancreatic enlargement,
•N/V, constipation pseduocysts, calcifications
Causes:
•Alcoholism –MC! Pancreatic insufficiency Endoscope US: honeycomb
•Recurrent biliary pancreatitis exocrine: malabsorption & steatorrhea
•Severe high TGs endocrine: glucose high or low
•Autoimmune
•Genetic mutations TRIAD: calcifications, steatorrhea, diabetes
•Idiopathic
GI
Acute •Double stranded DNA •Incubation 12-14wks (up to 6mo) •HBsAG (surface antigen)-infective state! •Rest, increase fluids,
Hepatitis B •Inner core protein and outer *first to elevate, first sign nutrition
surface coat •Flu-like: Malaise, myalgia, fatigue •Avoid activity, alcohol,
•Low grade fever, anorexia •Anti-HBs (+) and rest (-)= vaccine hepatotoxic
Causes: Bloodborne, sex, mother •Recurrent infections (URI)
Risks: IVDU, inmates, healthcare •Distaste for smoking •Anti-HBC (antibody to core antigen) •Hepatitis B Immune
•Mild RUQ pain and hepatomegaly - indicates diagnosis of Hep B Globulin (HBIG)
•Jaundice, enlarged lymph nodes *must give within 7d
•BEeAG (envelope antigen) *definitely infected
- indicates rapid viral replication & infectivity Prevent:
•Universal precautions
•HBV DNA: parallels presence of HBeAG •Safe sex
•Needle sharing education
•Elevated ALT/AST (LT > ST), bilirubin, ALP •Vaccination: 0, 1 and 6mo
GI
Chronic 90% of infants and Periods of remission with acute flares Elevated HBsAG and ALT/AST x6 months! •Antivirals: *1st LINE
Hepatitis B immunocompromised adults Increased risk of hepatocellular carcinoma -Tenofovir, Adefovir
Hepatitis C •Bloodborne, Sex, parenternal Incubation period 6 weeks Acute: (+) HCV RNA and +/- anti-HCV Interferon alpha 2-B AND
•Initially asymptomatic Resolved: (-) HCV RNA and +/- anti-HCV Ribavirin
Risk: IVDU, inmates, healthcare •Fatigue, myalgia Chronic: (+) HCV RNA and anti-HCV
•Jaundice wax and wane
Hepatitis D Hep B co-infection Increased risk of fulminant hepatitis •serum antibodies •Worse prognosis
GI
Cirrhosis •Fibrosis and nodular regeneration S/S: Insidious onset Minimal changes early •No cure w/o liver transplant
throughout the liver •Weakness, fatigue, sleep changes •Treat complications!
replaces functional hepatocytes •N/V, abdominal pain, ascites •AST/ALT & ALP elevated
with nonfunctioning nodules •Bilirubin elevated Avoid alcohol
•Portal HTN: esophageal varices, •Hypoalbuminemia •Strict dietary management: protein, low
Causes: splenomegaly •Anemia carb and sodium; reduce protein if
•Alcoholic hepatitis (MCC US) •WBC fluctuations encephalopathy
•Hepatitis C •Skin: spider angioma, palmar erythema, •Thrombocytopenia •Nutritional supplements
•NASH ecchymosis •Prolonged PT/PTT •Vaccinations
•Drug toxicity *May have normal AST/ALT but
•Autoimmune hepatitis •Menstrual abn, ED, gynecomastia craziness everywhere else Encephalopathy: Lactulose, Rifamixin
•Hemochromatosis Ascities: Diuretics
•Genetic, metabolic •Vitamin & nutrient deficiencies: Diagnostics: Pruritis: Cholestyramine
-anemia, glossitis, cheilosis •US/CT
•Biopsy: definitive DX Staging: Child-Pugh classification
•Jaundice, ascites, edema, effusion (late) •EGD: look for varices
Hepatocellula Types: Patient that has already had cirrhosis •Alk phos spike (higher then before) Screening:
r Carcinoma •Hepatocellular *parenchymal and now they are declining •Alpha fetoprotein HIGH Cirrhosis & chronic HBV/HCV patients
•Cholangiocarcinoma *ductal •Liver US & a-feroprotein q6mo
•Cechexia Imaging:
Risks: •Severe wt loss, anorexia •CT: 1st line imaging! Treatment:
•hepatitis B, C, D; Cirrhosis •Weakness, muscle wasiting •Liver biopsy: CONFIRMS! •resection if not invading vasculature and
•male gender, fhx •Bloody ascities *necrotic tumor preserved liver function
•Alcohol •Tender hepatomegaly Staging: TNM •other: transplant
ORTHO
Polymyalgia •Idiopathic inflammatory •Pain and stiffness of proximal joints •HIGH ESR! *characteristic 1. Prednisone 10-20mg/day po
Rheumatica condition neck, shoulder, pelvis •Elevated CRP *dramatic improvement in 72hr
(PMR) •MC in women >50 years old “difficulty putting on shirt/coat, comb hair” •Normocytic anemia
•symmetric & bilateral •ANA, RF, anti-CCP all (-) 2. DMARDs
•Associated with giant cell •worse in morning, resolve w/ movement
arteritis •fever, tired, weight loss Criteria for Chuang & 3. Calcium 1200mg and vitamin
Colleagues/Healy D 800 units daily
•Genes: HLA-DR4 *Healy-rapid response to Prednisone
Polyarteritis •Necrotizing inflammation of Constitutional: fever, myalgia, arthritis •Increased ESR and CRP Mild:
Nodosa medium/small arteries •ANCA (-) Prednisone 1mg/kg x4 weeks
•Systemic vasculitis Renal: HTN (increased renin), renal failure
P-pulmonary Definitive: biopsy necrotizing Moderate & severe:
A-arteries •NO glomerulonephritis CNS: neuropathy, mononeuritis multiplex inflammatory lesions AND…
N-not •Associated with hepatitis B Oral Cyclophosamide 1.5-2mg
involved “hePANitis B” Derm: livedo reticularis, purpura, ulcers, Renal angiography: microaneurysms with
gangrene, Raynauds phenomenon abrupt cut-off of small arteries
ORTHO
Systemic •Chronic, systemic multi-organ •Joint pain, fever, pericarditis, conjunctivitis • (+) ANA *initial test Sun protection
Lupus autoimmune disorder of connective tissues •malar “butterfly” rash *spares nasolabial
• (+) Anti-Smith and Anti-DNA Skin: topical steroids
•MC in females 20-40, minorities Discoid: annular, erythematous patches on *most specific test
face, scalp that heals with scarring Rash/joints: Hydroxychloroquine
Risks: sun exposure, estrogen, fhx (HLA)
Lupus profundus: firm, deep nodules Pain: NSAIDs or Tylenol
Drugs: Procainimide, Hydralazine, causing dented scars as fat cells destroyed
Isoniazid, Quinidine
Systemic: glomerulonephritis, retinitis, ulcer
Scleroderm Systemic connective tissue disorder •Tight, shiny thickened skin • (+) anti-centromere Raynauds: CCB, Prostacyclin
a (Systemic *associated with CREST
CREST Syndrome *spares trunk
Sclerosis) 2 types: Reflux: PPI, H2-blocker
•C-calcinosis cutis
1. limited (CREST) distal extremities • (+) anti-SCL-70
•R-raynauds
2. diffuse proximal extremities *associated with diffuse Nausea: Reglan
•E-esophagus motility disorder
•S-sclerodactyly (claw hand)
Pulm HTN: Sildenafil
•T-telangiectasias
Polymyositis •Idiopathic inflammatory muscle disease of •Progressive PROXIMAL muscle weakness •Increased aldolase and CK Prednisone 40-60mg
proximal limbs, neck, pharynx • (+) Anti-Jo 1 and Anti-Mi
Dermatomyositis: deep purple (heliotrope) • (+) Anti-SRP; Anti-155/140
•MUSCLE WEAKNESS rash of face, neck, shoulder, chest, back, eye
DX: 1st-MRI, definitive: biopsy
Sjogren •Autoimmune disorder of exocrine glands •Dry mouth (xerostoma) and dry eyes • (+) AntiSS-A and B (Ro/La) Eyes: artificial tears
Syndrome (keratoconjunctivitis sicca) • (+) RF and ANA Xerostoma: Pilocarpine
Types: primary (alone) v. secondary •Parotid enlargement & Thyroid dysfunction • (+) Schirmer test (low tears) -MOA: cholinergic
ORTHO
Reactive •Autoimmune response to infection •asymmetric arthritis (knees, ankles) • (+) HLA-B27 1. NSAIDs
Arthritis in another part of the body conjunctivitis/uveitis, urethritis
(Reiters Synovial Fluid: high WBC 2. DMARDs
Syndrome) •MCC: Chlamydia, gonorrhea, GI •mucocutaneous lesions: -bacterial culture (-)
infections (SSYC) balanitis, stomatitis 3. Anti-TNF
•Keratoderma blennorrhagicum:
hyperkeratotic lesions on palms & soles
Rheumatoid •Chronic inflammatory disease with •Symmetrical swelling •High ESR and CRP 1. NSAIDs *symptom control
Arthritis persistent symmetric polyarthritis •MC in PIP of fingers and MCP of 2. DMARDs (Methotrexate)
T-cell mediated wrists, knees, ankles• • (+) RF *best initial test 3. TNF-inhibitors
Worse in the morning, improves with • (+) anti-CCP *most specific
•Formation of pannus erodes movement *give NSAIDs with DMARDS; NSAIDS
cartilage, bone, ligaments, tendons X-ray: joint space narrowing don’t prevent disease course
Complications: ulnar deviation, swan
neck deformity, boutonniere deformity Joint fluid: inflammatory
Gout Uric acid deposition in soft tissue, •Joint pain, erythema, swelling X-Ray: “mouse bite” “punched-out” 1st line: NSAIDs
joints, bone •MC 1st MTP great toe (podagra) erosion -Indomethacin, Naprosyn
Cause: under-excretion of uric acid Tophi deposition: collection of uric acid Arthrocentesis: (-) befringement 2nd line: Colchicine
-purine rich foods: alcohol, liver, crystals *CHARACTERISTIC LESION
seafood, yeast Preventative: Allopurinol
-MOA: Inhibits xanthine oxidase
-meds: diuretics (thiazide, loop),
ACEI, pyrazinamide, ethambutol,
aspirin, ARBs
Pseudogout Calcium pyrophosphate deposition •Red, swollen, tender joint• X-ray: chondrocalcinosis 1st line: NSAIDS; joint injections
MC in the knee
•MC in elderly females >60yo Arthrocentesis: (+) befringement Propohylaxis: Colchicine
rhomboid shaped CPPD crystals
Fibromyalgi •Widespread muscular pain •Diffuse pain •Pain in 11/18 “trigger points” •Exercise
a •MC in middle aged women •Fatigue, sleep disturbances 3 MONTHS +
•depression Pharm:
•TCAs (Amitriptyline)
•SNRI (Duloxetine-Cymbalta)
•SSRI (Fluoxetine)
•Gabapentin
•Pregabalin
ENDOCRINOLOGY 8%
Adrenal Gland: Cortex = GFR-ACE outer inner: Glomerulosa (Aldosterone-Na+), Fasciculata (Cortisol), Reticularis (Estrogen/Androgens)
ENDO 8%
Addison’s Autoimmune disease *gluco & mineralcorticoid deficiency •CBC: Eosinophilia, lymphocytosis Chronic: Oral glucocorticoids
Disease •CMP: low Na, glucose; high K+, -Hydrocortisone 15-30mg daily
*Adrenal ↓ cortisol •skin and mucosal hyperpigmentation BUN/Cr 2/3 in morning, 1/3 later
Gland ↓ aldosterone •Anorexia, weight loss, fatigue, decreased •Culture: Blood, sputum, urine
stamina •Plasma Cortisol and ACTH •Glucocorticoid Stress therapy
Adrenal Crisis: •Hypotension, dehydration, dizzy, hypoglycemia, •Serum DHEA (<1000) -Increase dose by 50% with stressors
MCC: abrupt weakness, fever, lymphoid hyperplasia, N/V/D •Plasma Renin
withdrawal of •Rapid ACTH Stimulation •Mineralocorticoid: Fludrocortisone 0.05
steroids Chronic: *add Cosyntropin IM, test cortisol in 45
•vitiligo (10%) ACTH binds to melanocyte min, abnormal= increase <20 Acute Adrenal Crisis
•Changes in hair *loss CYP11+17, gain CYP21 •Hydrocortisone: Loading IV IV q6h
•Generalized pain Adrenal Crisis: for 24h oral when tolerate oral food
•Psychiatric: anxiety, irritable Low Na and glucose, high K+ •Fludricortisone, IVF (normal saline)
•Neurologic: gait, coma •Broad ABX, tx electrolytes/glucose
Cushing’s ↑ cortisol Cushing Syndrome/Disease CBC: leukocytosis, low eosinophils Cushing SYNDROME Management
Disease •Fatigue, reduced physical endurance CMP: elevated glucose •hydrocortisone=DOC
*Adrenal Cushing Syndrome: •Central obesity with protuberant abdomen,
Gland Cortisol excess plethoric “moon face”, supraclavicular fat Dexamethasone suppression test Cushing DISEASE Management
pads, “buffalo hump” 1mg @ 11pm then check cortisol at •surgical removal of pituitary tumor
Cushing Disease: •Large purple striae, thin skin 8am: (+) if cortisol >5 •Hyperandrogenism: Flutamide
Increased ACTH •Hirsutism, male hair loss •Hypercortisolism: Metrypone
secretion from •Muscle weakness 24 hour urine free cortisol •HTN: K+ sparing diuretics, CCB
anterior pituitary •Elevated BP, immune suppression (+) if increased 3x normal
Monitor/treat cortisol related conditions:
Causes: Late night salivary cortisol osteoporosis, psych, DM, hypokalemia,
•Iatrogenic (steroid muscle weakness, infections
therapy) Serum ACTH
•Pituitary adenoma <20 adrenal CT, >20 MRI
•Ectopic ACTH pituitary
•adrenal tumor
Pheo- Rule of 10s: Triad: episodic palpitations, HA, diaphoresis Plasma Free Metanephrines Management: resection of tumor
chromocytom •10% bilateral •Anxiety, pallor, syncope, tachycardia •sit 15min; elevated assess urine
a •10% extra-adrenal •Paroxysms <1hr Awaiting Surgery:
*Adrenal •10% malignant •emotions/physical stressors, change in position, 24h Urine Metanephrine and Creatinine •Maintain BP < 160/90
Gland urination, various medications • (+) if >2.2mcg/mg of creatinine •Alpha-Adrenergic Blockers:
Catecholamine Cardura, Minipress, Hytrin
secreting adrenal *triad + HTN is HIGHLY suggestive Imaging: CT/MRI with contrast
tumor NE and E Diet-high salt and water intake
ENDO 8%
Diabetes Primary central DI: •Polydipsia (thirst)-craving for ice •24hr urine for volume and creatinine Mild: no tx, consume fluids (WATER)
Inspidious •Genetic or autoimmune water Urine volume <2L/24hr without ↑Na
•Polyuria rules out DI Central AND Vasopressinase-induced DI:
Resistance or Secondary central DI: •large urine volumes •desmopressin nose sprays
↓Vasopression •Damage to hypothalamus/stalk, •Serum glucose, urea nitrogen, calcium,
hemorrhage, surgery If no access to water: Potassium, Na, and uric acid
*AD •Partial DI Hypotension should be normal Nephrology:refer to nephrology
* posterior Vasopressinase-induced DI: •dry skin *wont respond to Desmopressin
pituitary •3rd trimester •+/- ↑Na and dehydration •Central DI: Vasopressin challenge test
*circulating enzyme destroys *measure urine 12h before & 12h after
vasopressin *aggravated by STEROIDS people w/ DI have ↓ polyuria/thirst Psychogenic-resolves with water
If positive, then get an MRI! restriction
Nephrogenic DI:
Defect in tubules •Nonfamilial: MRI pituitary/hypothal
•Nephrogenic: measure vasopressin
Congenital DI:
•Defective vasopressin *usually vasopressin is high
•present from birth (X-link)
Acromegaly/ Gigantism: child (before fuse) •frontal bossing (frontal bone •increased IGF-I Goal: control GH and IGF-I
Gigantism Acromegaly: adult (after fuse) enlargement)
•soft tissue swelling CONFIRM DIAGNOSIS: •SURGERY transphenoidal
↑GH ↑IGF-1 *most commonly caused by •hyperhidrosis (deep voice) •glucose load does not cause a •Somatostatin analogues
somatotrope adenoma •kyphosis, macroglossia. suppression of GH <0.4 w/n 1-2h •Dopamine Agonists
*anterior sleep apnea, DM, polyps •Radiation
pituitary •Cardiomegaly, thyroid enlarge
Adrenocorticotopinomas
•Cushings disease
ENDO
Type I DM no insulin due to destruction of beta-cells (islet 3 Ps: Monitor: •insulin (multiple-dose basal bolus)
cells of the pancreas) *antibodies •polyuria (pee) •check glucose 3x daily -short acting: Humalog, Novalog
•polydipsia (thirst at home, increase fiber in -basal: Glargine, Lantus, Levemir
•Islets of Langerhans infiltrated by lymph •polyphagia (hunger) diet •Pramlitide (Symlin) *adjunct only
islet cell autoantibodies, T-lymph proliferate, •GFR and urine
release of cytokines within infiltrated islets albumin/year Dawn Phenomenon:
•Weight loss (low
•nml glucose until 2-8am
water)
preproinsulin (A, B, and C) proinsulin (A & Labs: •decreased insulin sensitivity & nightly hormones
B) insulin (C chain cleaves off) •postural hypotension •treat with bedtime injection of NPH
•weakness, blurred • glucose >200, fast>126
Insulin functions: glucose transport; stops vision, neuropathy, •A1C >6.5%, GGT Somogyi effect:
protein & TG breakdown, and gluconeogenesis fatigue •C-pep/Insulin ratio (low) •night hypoglycemia rebound hyperglycemia due
*longer t ½ then insulin to surge of GH
•treat with decreased night NPH dose
Incretin: hormone that stimulates the release of
insulin and decrease blood glucose (+)GAD-65 with type IA
Type II DM Risks: •polyuria, polydipsia •self-check glucose 1- 1st line-Metformin + diet + exercise
•(+) fhx; N. American, AA, Hispanics, Asians •blurred vision 2x/d 2nd line-GLP1 ag., SGLT-2, DPP-4
•overweight (obese), birth wt >9lbs •poor wound heal •weight loss (5-10%) GLP1: “-tide”, DDP4: “-gliptin” SGLT2: “-glifozin”
•hyperglycemia •neuropathy •caloric restriction *insulin 0.1-0.2U if A1C>9 or sig. sx
•dry and itchy skin •eye exam, neuropathy
DM Treatment: •A1C 2x/year
Hypoglycemia: Sulfon, Meglit, Pramlintide, Insulin
Affordable: Metformin, Sulfonylureas Yearly eye exams
Weight Loss: GLP-1 Agonists, SGLT2 inhibitors; Recheck meds q3mo
Weight Gain: Sulfonylureas, TZDs, insulin
Diabetic metabolic acidosis 1+ days of ↑ thirst with •Glucose: 350-900 1-Fluid: 1L/hr 0.9% NS or LR 1-2h
Ketoacidosis polyuria and polydipsia •pH: acidic (6.8-7.3) *if Na rises, change to 0.45%
•Relative/absolute insulin def.
•GI: N/V, fruity breath 2-monitor cap glucose/hr & BMP/4hr for 1st 24hrs
•Excessive counter hormones •Potassium nml or ↑
•↓ Bicarbonate b/c depleted by ketoacids •Cardio: ↓ BP, ↑ HR •Sodium ↓Bicarbonate ↓ 3-IV regular insulin 0.1U/kg/hr
•↓ Insulin, ↑Glucagon *due to volume *change to dextrose when glucose 200mg/dL
-↑ hepatic gluconeogenesis and glycogenolysis depletion •Renal: ↑BUN/Cr, ↓GFR Goal glucose: 150-200mg/dL
-↑ free FA release -> ↑ ketones
•Neuro: •Ketones: acetone, 4-Potassium 10meq if <5.2
*triggered during increased physiologic need
Mild-alert or drowsy acetoacetate, B-hydroxy 5-Bicarb if pH <7.0 (50meq/L/2hrs)
Severe-confusion, coma *serum checks B-hydroxy,
•Respiratory: kussmaul
Hyperglycemi Insulin deficiency and inadequate fluid intake polyuria, polydipsia, •Glucose: 600-1200 1-Fluid management
a weakness, decreased oral Infusion 1-3L/hr 0.9% NS 1-3h
•pH: nml or minimal acid
Hyperosmolar •Triggered by stress: intake, wt loss *if Na rises >150, change to 0.45%
State -infection, infarction, ↓ water •K+ and bicarb nml
2-monitor *same as DKA
•Neuro: altered mental
•Renal: ↑BUN/Cr, ↓GFR
3-IV regular insulin 0.1U/kg/hr *NO if K <3.3
•Cardio: ↓ BP, ↑ HR •Osmolality: 330-380 *change to dextrose when glucose 250mg/dL
*often >350 Goal glucose: 250-300mg/dL
4-Potassium-10meq/hr, ↑ if K+ <3.5
ENDO
Hyper- Causes: HIGH BMR Thyroid labs: Treatment: PTU
thyroidism •Graves Disease (MC) •Heat intolerance •Primary: ↓TSH, ↑ FT4
•Toxic multinodular goiter •Weight loss, hyperglycemia Hypercalcemia, ↑ alk phos, Anemia Thyroid Storm:
•TSH secreting pituitary adenoma •Diarrhea Decreased granulocytes •marked delirium, tachy, V/D,
•Excess intake •Warm, moist skin & hair dehydration, high fever
•Iatrogenic thyrotoxicosis •Hyperactive: anxiety, tremor, nervous, •Graves-(+) TSI,(+) anti-TPO, anti-Tg
fatigue, weakness increased RAI and vascularity •Thiourea Methimazole or PTU
•Tachycardia, high output HF •Iodinated contrast
•Scanty period •Thyroiditis: ↑ ESR •Beta Blocker
•Hydrocortisone
Graves Eyes: lid lag with downward
gaze, “staring” appearance Thyroid Storm Definitive tx:
radioactive iodine surgery
Graves dermopathy (pretibial
myxedema): red, rough plaques
Hypo- Causes: LOW BMR •serum TSH +/- FT: ↑ TSH, ↓ FT4 Treatment: Levothyroxine
thyroidism •Iodine deficiency (MC worldwide) •Cold intolerance
•Hashimotos thyroiditis (autoimmune) •Weight gain, hypoglycemia Hashimoto: Myxedema Crisis-
•Potpartum thyroiditis •Constipation • (+) (anti-TPO) *MC and (=) anti-Tg *triggered by infection, illness,
•Pituitary hypothyroidism •Dry, thick skin; brittle nails cold, drugs
•Hypothalamic hypothyroidism •Loss of outer 1/3 eyebrows Imaging:*not indicated in simple cases
•Hypoactivity: fatigue, sluggish, •thyroid US •Treament Myxedema:
Primary: failure of thyroid T3, T4 memory loss, depression •CT MRI views gland IV levothyroxine (LT4)
Secondary: failure of pituitary TSH •Bradycardia, decreased CO
Tertiary: Failure of hypothalamus TRH •Menorrhagia •Supportive Myxedema: blankets,
intubation, tx underlying
Thyroid papillary thyroid carcinoma *MC •Palpable, firm, nontender nodule/mass Serum Tg Surgery-First Line
Cancer •single thyroid nodule •↑-metastatic papillary and follicular >1cm cancer: total
•least aggressive, slow, confined for Symptoms: <1cm cancer: lobectomy
•Asymptomatic Serum Calcitonin <4cm inderterminate: lobectomy
Follicular Thyroid Carcinoma •Metastasis ~3% cases •↑-medullary thyroid carcinoma >4cm indeterminate: total
•metastasize, ↑ iodine uptake *MC sites-lymph, lungs, bone
Serum CEA RAI therapy
Medullary Thyroid Carcinoma •Anaplastic-s/s of metastasis •↑-medullary thyroid carcinoma CI-prego, nursing
•Secrete calcitonin, prostaglandins, 5HT, •Medullary-flushing, diarrhea *low iodine diet for 2wkbefore
ACTH, CRH, other chemicals *rare Cushing-like syndrome Thyroid US *size, location of mass
•Local mets, NO good iodine uptake Chemo: aggressive CA
RAI Scan *use after thyroidectomy
Anaplastic Thyroid Carcinoma •reveal metastatic tissue
•Most aggressive, worst survival High uptake: follicular
•Rapidly enlarging mass in MNG
•Does not have good iodine uptake CT or MRI: Distant metastases
*local resection and radiation
Malignant: COLD & LOW UPTAKE
ENDO
Hyper- Primary: increased PTH (MC) •Signs of hypercalcemia •Increased PTH and Ca2+, vit D Primary:
parathyroidism •parathyroid adenoma •Decreased DTR •Low phosphate •Parathyroidectomy
Hypo- Causes: •Signs of hypocalcemia •Low PTH and Ca2+, Calcium supplementation and Vit. D
parathyroidism •post-surgical thyroid/parathyroidectomy •Increased DTR •High phosphate (Ergocalciferol, Calcitrol)
•autoimmune
ENDO
Pagets of Bone •Abnormal bone remodeling and disorganized •MC asymptomatic-incidental finding Labs: Asymptomatic: none
(Osteitis osteoid formation HIGH ALP
Deformans) •Bone pain (MC symptoms) Normal Ca & Ph Symptomatic:
•Increased osteoclast bone resorption •Soft bones bowed tibia, kyphosis Calcitonin & Bisphosphonates
abnormal trabecular formation large, weak, less •Deafness X-ray: (Aldendronate, Risedronate)
compact bones with more vasculature and prone “blade of grass/ -MOA: inhibit osteoclasts
to fracture flame” lucency -take with water 1-2h before meals
-CI: nephrotoxic, thrombocytopenia,
•MC in western Europeans Skull: cotton wool atypical femure fx, jaw osteonecoris
Hypercalcemia Causes: “stones, bones, abdominal moans, psychic EKG: shortened Mild: no treatment
•hyperparathyroidism (high PTH & Ca, low Ph) groans” QT interval
•malignancy (low PTH) Severe/symptomatic:
IV saline Furosemide (Lasix)
NO HCTZ (increases Ca2+)
Hypocalcemia Causes: •Chovstek (touching cheek) EKG: prolonged Mild: oral calcium and vitamin D
•hypoparathyroidism (low PTH) QT internal (Ergocalciferol, Calcitriol)
•Renal disease (high PTH) •Trousseu (BP cuff), cramps, spasms,
•Hypomagnesemia tetany lower action potential Severe/sympatomatic: Calcium
threshold gluconate IV or calcium carbonate IV
Hypernatremi Causes: Body loss of water diarrhea, sweating, CNS dysfunction: confusion, lethargy, Na >145 Fluid replacement hypotonic fluids
a diuretics, hyperglycemia coma, muscle weakness (water, 0.45% NS, D5W)
Hyponatremia Hypertonic: increased solutes dilute out sodium- •CNS dysfunction: Na <135 hypovolemic: Isotonic 0.9% NS,
increased glucose-pull water into interstitial space *cerebral edema
Isotonic (normal free water): usually due to HA, AMS, seizure, decreased DTR, hypervolemic: hypertonic 3% saline
hypertriglycerides or hyperproteinemia
•GI: N/V
Hypotonic: kidney unable to excrete free water
-Hypovolemic: diuretic; •Other: muscle cramps, lethargy
-Hypervolemia: fluid overload (CHF, nephrotic),
-Euvolemia: SIADH, thyroid
NEURO 8%
Tension HA Trigger: STRESS; depression, anxiety •Band-like/vise-like or tight in quality Clinical diagnosis •NO TRIPTANS
•Pericranial tenderness, poor concentration •Analgesics (NSAIDs, Tylenol)
•Bilateral, generalized, non-pulsatile
•NO FOCAL/NEURO COMPLAINTS Relaxation:
massage, bath, behavior
Cluster HA •activation of cells in ipsilateral •Minutes -> hours, severe, unilateral, temporal •Typically occur at night & •100% O2 via non-rebreather
hypothalamus, triggering trigeminal HA in grouped attacks over a period of time awaken patient •Sumatriptan and DHE
autonomic vascular system
IPSITALERAL SYMPTOMS: •Clinical Diagnosis Preventative:
*MC middle aged men (30-40yo) •ptosis, miosis, lacrimation, conjunctival •lithium, verapamil, Topamax,
•Trigger: alcohol injection, rhinorrhea, congestion, horner Valprate, prednisone. Ergotamine
Migraine Neuronal dysfunction in the Classic migraine attack typically has 4 phases: Criteria without aura: •NSAIDS (FIRST!)
HA trigeminal system vasoactive 1. Prodrome (24-48h prior to HA) A. 5 attacks + B-D -ASA, Ibuprofen; Naproxen
neuropeptides such as calcitonin gene- •euphoria, depression, irritability, cravings, B. HA last 4-72h -Ketorolac (Toradol)-ER
related peptide leading to neurogenic constipation, stiffness, and yawning C. has 2/4 following: -IM/IV, give w/ Zofran
inflammation, sensitization, and HA -unilateral •Triptans (FIRST LINE)
2. Aura (75% don’t have) -pulsating •Ergotamines
•3x more common in women •attributed to cortical spreading depression -moderate or severe •Antiemetics (Zofran!)
•90% have a family history •transient neurologic sx -aggravated by activity
*MC visual; sensory, verbal, motor D. 1+ of following: *sx treatment: rest in quiet, dark
•MC type is WITHOUT an aura -nausea, vomiting, or both room until sx subside, cold cloth
3. Headache -photophobia or phonophobia
Triggers: •unilateral, throbbing, or pulsatile Prophylaxis indication:
stress, menstruation, visual stimuli, •anorexia, N/V, photophobia, phophobia, •Topiramate, valproic acid
weather, nitrates, fasting, wine, sleep cognitive treatment, cutaneous allodynia (touch •Propranolol (BB), CCB, TCA
disturbances, aspartame hurts), blurry vision, hyperalgesia, blurry vision
Giant Cell •Chronic vasculitis of large and •HA, jaw claudication, scalp tenderness, visual increased ESR, anemia, elevated •High dose corticosteroids
Arteritis medium sized vessels abnormalities CRP and alk phos
(Temporal)
•Varicella-zoster antigen is found in •Temporal artery may be normal to nodular, •Temporal artery biopsy
nearly 75% of temporal arteries tender, or pulseless *GOLD*
Concussion Mild traumatic brain injury •HA, vision changes, vomiting, LOC, confusion, CT: study of choice •Allowing brain to heal rest
dizziness, amnesia normal •No contact sports until cleared
NEURO 8%
Bacterial Acute infections of the arachnoid Adults: •Blood cultures x2 + stain, C/S GOAL: TX WIHTIN 60min
Meningitis mater and subarachnoid space •Fever, HA, Nuchal, Meningeal •PROMPT LP first, UNLESS:
Standard for all (3mo-55yo)
•N/V, photophobia, seizure -immunocompromised
1.Dexamethasone 0-20minutes
Adults: -history of CNS
2.Ceftriaxone (Cefotaxime <1mo)
•Community Acquired increased ICP: -new onset seizure
3.Vancomycin
-S. pneumo (adults >20), N. -papilledema, N/V, LOC change -papilledema
Meningitidis, GBS, Listeria -meningococcal rash -abnormal LOC PLUS ONE additional below:
Monoctogenes, H. flu -focal neurologic deficit •Acyclovir (HSV encephalitis)
Pediatrics: •Meet any above=CT first! •Doxycycline (tick season)
•Healthcare Acquired: Staph aureus
•Fever, lethargy, seizure *DO NOT DELAY ABX! •Ampicillin (<3mo or >55yo)
•Respiratory distress •Metronidazole (OM, sinus, mastoid)
Pediatrics:
•Jaundice, N/V/D Lumbar Puncture:
•Neonatal: GBS, E. coli, Gram (-) Rifampin prophylaxis if:
•Poor feeding/decreased appetite •low glucose
•Exposure H. flu, S. pneumo, N.mening
•Children >1 month: S. pneumo, N. •Restlessness/irritability •high protein & WBC
•GBS (+) 35-37 weeks gestation
meningitides, GBS, H. flu •Bulging fontanel (infants) •cloudy, pressure 200-300
•Neurosurgery
Viral Evidence of meningeal inflammation Present similar to bacterial meningitis Work-Up: same as bacterial •Most cases self-limited (7-10d) &
Meningitis with a negative bacterial cx; MCC- but less severe treatment is supportive: fluids, rest, sx
Enterovirus Lumbar Puncture control
•HA, nuchal rigidity •CSF analysis, Gram stain and
Risk factors:
•Photophobia •PCR amplification Specific treatments:
•Infants <1 month
•Constitutional symptoms •clear, pressure <200, rest •HIV refer; HSV Acyclovir
•Immunodeficient patient
•mildly diminished LOC nml/low
•Exposure to someone with viral
Empiric ABX: old & immunocomp
meningitis
*NO seizures or focal neuro CT scan
Historical features: -not needed in uncomplicated Indeterminate diagnosis on CSF:
•travel and exposure history indications: focal neuro, 1. administer ABX after cultures
•TB exposure immunocompromised OR
•ill contacts with similar sx/viruses 2. observe w/ repeat LP in 6-24h
•vaccination history
•sexual history (HSV, HIV, syphilis) Prevention: IPV, MMR, VAR/Zoster
Encephalitis •Inflammation of brain parenchyma •Altered LOC, Seizures Work-Up: Treatment: Supportive, control sx
•Fever, HA, NV •LP with CSF analysis •Seizure: IV Lorazepam
•Meningoencephalitis: meninges •Focal neurologic signs (focal) -CSF PCR amplification
•Encephalomyelitis: spinal cord/nerve -speech/hearing, CN deficits, Therapy:
involuntary movements, MRI •HSV/VZV/EBV: Acyclovir IV 21 days
Causes: muscle weakness, partial •MRI for sensitive than CT *first dose within 30 minutes
•MC=herpes (HSV, VZV, EBV) paraylysis, memory loss •HSV etiology-90%, EEG-75% *all cultures before antiviral!
•Enterovirus, MMR, rabies, HHV6, •Psychotic symptoms
Labs: Clinical Course:
History: Involvement of HPA: •CBC, CMP, PT/PTT •CSF analysis for PCR repeated at
•Travel/Exposure history •temp dysregulation, DI, SIADH •Blood cultures (no sepsis) completion of antiviral
-camping/hiking, animal bite •Culture any herpetic lesion for a •continue therapy until (-)
•Sexual history (HSV 1 or 2) •Tzanck smear
•Ill contacts
•Vaccine history
NEURO
Carpal •A set of neurologic symptoms resulting -dull, aching discomfort, paresthesia, weak •Electrodiagnostics 1st line! •Relief of pressure
Tunnel from compression of the median nerve -NCS/EMG -neutral position (cock-up)
Syndrom -Increased pressure in intracarpal canal •Aggravating: sleep, sustained hand/arm -confirm dx & assess severity wrist splints, esp at night x3mo
e -direct compression damages nerve positions, repetitive movements of hand/wrist -severity needed to know if -steroid injection
•Alleviating: posture change, shaking/ringing surgical candidate -OT, PT, chiropractic
•MC in women -surgical decompression
•MC mononeuropathy •inspection: atrophy of thenar eminence (late) US/MRI: identify structural
abnormalities Plan of care:
Causes: synovitis of flexor tendons, •Tinel Sign: wrist percussion over capral tunnel •mild CTS: conservative (splint,
anatomically small canal, mass lesion, injection) 4-12weeks
edema, inflammation •Phalen/”Prayer” Sign: flex/extend hands
•moderate/severe: conservative
•Carpal compression: pressure for 30 seconds while awaiting NCS/EMG test
-surgery referral
•Hand Elevation Test: hands above head x1min
*HIGHEST sensitivity & specificity; longest
Tarsal •Compression of the tibial nerve as it •Paresthesias involving sole of foot, distal foot, •X-ray and/or MRI of the foot 1. Conservative: NSAIDS, shoe
Tunnel passes under flexor retinaculum at ankle toes, and occasionally heel -evaluate for bony deformity modification, orthotics
Syndrom -worse at night, walking, standing, dorsiflex
e Causes: posterior tibial nerve passes - +/- tinels sign •NCS/EMG 2. Steroid injection if
through tarsal tunnel -sensory loss over plantar surface -may be helpful in confirming conservative fails
-MC=fracture or dislocation
Severe: atrophy of intrinsic muscle 3. Surgical decompression
Ulnar •Compression of ulnar nerve at one of •Sensory: paresthesias in 4th and 5th digits, Diagnostics: Conservative: (mild-moderate)
Nerve two locations: cubital tunnel, guyon canal aching elbow/wrist pain, worse at night •NCS: localize compression to -avoid leaning on elbows,
Palsy -triggers: sustained elbow flexion, elbow or wrist prolonged flexion
Causes: repetitive grip, leaning on, repeated -brace or wrap elbow at night to
•Cubital tunnel: trauma of distal pronation/supination •EMG: muscle weakness limit flexion
humerus or elbow, compression/friction
(osteophytes, arthritis, synovitis) •Motor: “claw hand” in 4th/5th digits •MRI/US: demonstrate •Surgical Options:
compression at elbow or wrist -decompress (elbow/wrist)
•Guyons canal: trauma (laceration, carpal Physical Exam: -MRI: nerve impingement -decompress w/ nerve
fracture, blunt), space occupying lesion •Tenderness, decreased sensation & increased signal intensity transportation (elbow)
•tinels sign at elbow or wrist -US: thickening of nerve and
Risks: occupation (lean on elbow) cycling, •atrophy of hypothenar (pinky) eminence altered echogenicity
baseball, karate •froment sign: thumb adductor weakness
Radial Compression of nerve at various sites: •Motor: weakness of wrist extensor (“wrist •Often made with H/P ALONE Acute-conservative
Nerve •axilla (crutches), humerus, proximal drop”), finger extensors, thumb abduction •cock-up wrist & finger splints,
Palsy forearm, wrist •Confirm with NCS or EMG if avoid compression
•Sensory: hand (radial distribution) atypical presentation
Severe secondary to trauma
Risks: crutches, position, frequent tight-
-surgical decompression
fitting straps or gloves, fractures
NEURO 8%
Guillain- •Acute inflammatory •Onset 1-4wks after respiratory of GI illness Labs: CMP, CK, ESR, thyroid, stool IMMUNOTHERAPY WITHIN
Barre polyradiculoneuropathy with culture for C. jejuni, rheumatologic, 4WK OF ONSET
resultant weakness with possible Symptoms: vit B12, folic acid, A1C,
paralysis and diminished •dyesthesias (finger/toes and move proximal) electrophoresis, metal •Plasmapheresis
reflexes •proximal muscle weakness of LE ascending -removes autoantibodies, immune
symmetrically Electrodiagnostic (EMG/NCS) complexes, cytotoxic constituents
•Age: bimodal •diminished or loss of DTRs early on •confirms polyneuropathy
(15-35yo, 50-75yo) •pain-throbbing, aching •IVIG: donated plasma
*shoulder, back, buttocks, thighs Lumbar Puncture -requires less time, once daily
Variants: •progression of weakness over hrs -> days •reveals albuminocytologic
•acute inflammatory -CN involvement dissociation high protein, normal •Pain: NSAIDS, Gabapentin
demyelinating polyneuropathy -respiratory: dyspnea, SOB, diminished WBC
(AIDP)=MC •ANS dysfunction (dysautonomia) •Motor Dysfunction: PT, OT
-tachycardia(MC), bradycardia, arrhythmias MRI with Gadolinium
•other neurological findings •spine: thick intrathecal spinal nerve •DVT Prophylaxis: LMWH
-neuro: unsteady to complete gait loss roots and cauda equine
-sensory: impaired proprioception •brain: enhanced CN III, VI, VII
Myasthenia •Autoimmune disorder with •Fluctuating skeletal muscle weakness and fatigue Ice Pack Test x 2 minutes 4 treatment option available:
Gravis progressively reduced muscle •worse later in the day/evening or after exercise •(+) if improvement 1. symptomatic therapy
strength with repeated use •Ocular (CN II, IV, VI): EOM weak diplopi anticholinesterase
-diplopia disappears when close one eye Serology: (Pyridostigmine)
•Females 20-30; Males 50-70 -unilateral or bilateral ptosis •AChR antibodies (85%)
•MuSK Antibodies (if AChR (-)) 2. Chronic immunomodulating
eye/face -> neck -> UE •Bulbar muscle weakness (CN IX-XII) -not likely to have thymic therapy glucocorticoids
-> hands -> LE -weakness with prolonged chewing •Seronegative MG (both (-))
-dysphagia, dysarthria(speech), dysphonia(voice) -purely ocular disease 3. immediate immunomodulating
•Antibodies are produced (by •Anti-striated Muscle(anti-SM) therapy Prednisone
thymus) against the ACH •Facial Muscles (CN VII) -(+) in about 80% w/ thymoma -Other immunomodulators:
nicotinic postsynaptic receptors -flat affect, cant smile or close eye Azathioprine, Mycophenolate
(AChR) at the neuromuscular Imaging: CT chest thymoma mofetil, Cyclosporine
junction •Neck Muscle Weakness *anterior mediastinal mass
AChR destruction and a -“dropped syndrome” later in day weak
loss of postsynaptic extensor muscles Electrodiagnostic Studies 4. Surgery (thymectomy)
folds •Repetitive Nerve Stimulation
Over release of Ach •Limb: proximal muscle weakness, UE>LE (RNS) *MC study for MG Rapid Immunomodulating
-repetitively stimulated the NMJ of a Therapy
Etiology: •Myasthenia Crisis (resp. muscles) specific muscle Indications: myasthenic crisis,
•Idiopathic derangement of -diaphragm and IC muscle weakness (+) test: smaller EPSPs due to pre-op, bridging meds, maintain
immune system regulation repetitive stimulation remission
-anti-AChR antibody (MC!) •Plasmapheresis
-anti-MuSK antibodies •Single-Fiber Electromyopgraphy •IVIG
•Thymic disease found in 75% *Most sensitive test for MG
•Various drugs -2 muscle fibers w/ same axon
-(+) if increased time frame between
1st and 2nd AP
NEURO 8%
Essential MC adult onset movement disorder •Rapid action/kinetic tremor of arms Clinical Diagnosis •1st line-Propranolol (off label)
Tremor -trouble writing, eating, fine motor skills •Primidone + Propranolol if no response
Defined by: •Head and arm tremor MC *speech *refer if 1st line options don’t work
-enhanced by emotional stress changes
-decreased with ETOH •NO tremor at rest •2nd-Alprazolam, Topiramate, Gabapentin
-fhx common (dominant)
-no other abnormal findings •3rd line-Deep brain stimulation, botox
Parkinson’s •Uncommon under age 40, increase after •resting tremor, rigidity, bradykinesia Clinical features from hx •Aim: blocking the effect of Ach or
Disease age 60 & PE administration of Levodopa
Tremor
•MC in men •resting tremor of distal muscles; “pill Must have bradykinesia •1st line: Levodopa & Carbidopa
roll” with either rigidity
•Reduced Risk: caffeine, coffee, ibuprofen, •less with voluntary movement and/or tremor •Dopamine Agonist: <65 and mild sx
statins, cigarette smoking, moderate alcohol •spreads unilaterally up the body -Bromocriptine (Cycloset)
-Pramipexole (Mirapex)
•Increased Risk: age, fhx, Rigidity -Ropinirole (Requip)
herbicide/pesticide exposure •unilat spread up then contralateral -Amantadine
• “cogwheel” rigiditiy & lead pipe
Pathophysiology: •Anticholinergic-Benztropine
Degeneration of the dopamine-producing Bradykinesia 80% of patients -young patient w/ tremor as primary sx
neurons in the pars compacta of the •generalized slow movement
substantia nigra and locus coeruleus in •starts distally: fingers loss of arm •COMT Inhibitors
brainstem Dopamine/Ach imbalance swing feet and legs (shuffling) -Talcapine, Entacapone
-extend life of Levodopa; adjunct tx
•Lewy bodies within neurons
Huntingtons •Incurable, inherited, autosomal •Characterized by motor, cognitive, and •History and PE *Symptomatic; No cure
dominant neurodegenerative disorder psychiatric deficits with cell loss in
neurons of basal ganglia and cortex •CT/MRI: cerebral & •Tetrabenazine for dyskinesia
•Chromosome 4 caudate nucleus atrophy -MOA: blocks Dopamine release
•Expanded & unstable CAG trinucleotide •Chorea, Dystonia -SE: extrapyramidal
repeat in HTT gene at 4P16 •Eye movement abnormalities •PET scan: reduced •Reserpine for chorea
•Wt loss and cachexia striatal metabolic rate •Haloperidol for behavior & chorea
•Psych: irritable, moody, antisocial •Amantadine for chorea
•Cognitive: judgement, memory •Genetic Testing •Supportive care
•Behavior changes: dementia *gradual
NEURO 8%
Multiple •MC autoimmune inflammatory Spinal cord CLINICAL Acute Attacks
Sclerosis demyelinating disease of CNS •sensory loss, weakness, numbness, •2+ attacks followed by •Methylprednisolone
sphincter (urgency, hesitancy, sexual) objective evidence on exam & •Plasma exchange if steroids CI
•Cause: autoimmune 2 lesions
•Women > Men brainstem: optic neuritis, diplopia, Symptomatic
lateral gaze, dysphagia McDonald Criteria •fatigue: Amantadine, Methypheidate
Pathophysiology: •clinical findings + MRI •Depression: SSRI
•lesions effect white matter in the optic psychological: cognitive disability, •2+ regions of central white •Spasticity: Baclofen, Diazepam
nerve, brainstem, basal ganglia and depression, euphoria matter (space) •Pain: TCAs
spinal cord •different times (time) •Optic Neuritis: Methylprednisolone
-demyelinating lesions (plaques) motor: unsteady, spastic, cramp, gait
-myelin loss, destruction of Imaging: Disease-Modifying
oligodendrocytes, reactive transient features T1/T2 MRI of brain/cervical RRMS, SPMS with exacerbations
astrogliosis (increase in astrocytes) •lhermitte sign: electric shock like cord relapse prevention 1st line
•lesions affecting signal in grey matter sensation that runs down back or limbs -T1: hypointense “black holes” •IFN B-1a (Avonex, Rebif)
upon neck flexion (looking down) showing axonal damage •IFN B1b (Betaseron or •Extavia)
Risks: far from equator, viral infections, -T2: high signal intesntity •Glatiramer acetate (Copaxone)
HLA on chromosome 6 •uhthoff phenomenon: worsening sx lesions associated with total # •Fingolimod (Gilenya)
when overheated of lesions, highlight active
inflammation •progressive MS
-SPMS: high dose IFN-B
LP: oligoclonal IgG -PPMS: Ocrelizumab (Ocrevus)
NEURO 8%
CVA A sudden onset of neurologic •hemi/mono/quadriparesis •Oxygen Saturation •Keep NPO IVF
deficit resulting from a loss of •hemisensory deficit •Finger stick blood glucose •Hypoglycemia: dextrose
blood flow to a part of the brain •visual loss; one or both eyes, diplopia •Blood pressure: Labetolol,
•dysarthria, facial droop, ataxia, vertigo •CT brain w/o contrast Nicardipine, Clevedipine
*cell death and irreparable damage •aphasia (Brocas or Wernickes) -GOAL: w/n 25min of arrival •Cerebral edema: Mannitol
to brain tissue w/n 5min •decrease in LOC •Seizure: Lorazepam
Other Immediate Studies:
Exam: •CBC, BMP, PT/PTT, troponin Ischemic Stroke
Types: ABCs and vitals •EKG/cardiac monitoring •goal of SBP < 185 + DBP < 110
Ischemia: thrombotic, emboli Skin: petechial, janeway, osler, livedo •TPA (Altepase): maintain BP
*MCC is atrial fibrillation reticularis, purpura <180/105 for 24 hours after
HEENT: trauma, funcoscope, mouth
Hemorrhagic: intracerebral Cardio: rhythm, M/R/G, bruit Intracerebral Hemorrhage
(HTN), subarachnoid (aneurysm, Respiratory: breath sounds -lower BP within one hour to 140
AV malformation) Neuro: CNs, NIHSS sale
Transient •transient episode of neurologic Assessing severity of symptoms ABCD2 scoring: 1. Order US of carotids (CAD)
Ischemic dysfunction caused by cerebral 3+ should be admitted 2. EKG, Echo (emboli)
Attack acute infarction 3. MRA/CTA (vessel disease)
(TIA) -most resolve within 1-2 hours
Pharm: Plavix, Control BP, Statin
Coma 1. lesions that damage the RAS in •Sleep-like state with no purposeful GCS: 3 When to intubate:
the upper midbrain or its projections response to the environment and which the •apnea upper airway obstruction,
pt cannot be aroused for >1hr hypoventilation, emesis
2. Destruction of large portions of -closed eyes, do not open •liable to aspirate because of coma
both cerebral hemispheres -lack verbal communication
-no purposeful movement Prognosis:
3. Suppression of reticulocerebral -verbal stimulation no response •rarely lasts more than several wks
function by drugs, toxins, or -painful stimulation may produce no •either recover or revolve into brain
metabolic derangements response or nonpurposeful reflex death or a persistent vegetative state
(hypoglycemia, anoxia, uremia,
hepatic failure) *MC
Delirium ACUTE onset & fluctuating Cognitive: rambling speech CBC, CMP, glucose, O2 stat Reorient, encourage family
over 24 hours Inattention: difficulty maintaining conversation, trouble involvement, avoid restrains,
with instructions Brain MRI or CT: if trauma, maintain mobility, glasses and
Risk factors: medications Disorganized thinking: memory FUO, new neurologic hearing aids
Altered LOC: Sleeping disturbances, symptoms, no obvious cause
hallucinations/illusions, delusions, emotional lability
Epidural •middle meningeal artery •LOC, HA, N/V, focal sx, CN III palsy •CT of brain: convex (lens) bleed •high ICP: Mannitol
Hematoma •MCC: temporal FX •LUCID INTERVAL coma -does NOT cross suture lines
Subdural •cortical bridging veins •varies, may have focal neuro sx •CT of brain: concave (cresecent) •evacuate with massive 5mm+ midline
Hematoma •MC in elderly -DOES cross suture lines shift
•MCC: blunt trauma
Subarachnoi •berry arterial aneurysm •”thunderclap” sudden HA •CT of brain •supportive tx: bed rest, stool soft
d •MCC: rupture, AVM •meningeal symptoms, no focal neuro •LP: CT (-) xanthrochromia, high CSF •lower BP: Nicardipine, Nimodipine,
Hemorrhage Labetalol
Intracerebral •intraparenchymal •HA, N/V •CT: intraparenchymal bleed •supportive treatment: +/- Mannitol
Hemorrhage •MCC: HTN, AVM, trauma •DO NOT PERFORM LP (herniation) •gradual BP reduction
UROLOGY/RENAL 8%
GU 8%
Epididymitis •Inflammation of epididymis •+/- urethritis, prostatitis, cystitis sx •UA-pyuria, bacteriuria, hematuria, •Bed rest, scrotal elevation, ice packs
•fever culture •NSAIDS
•STD: men <40 •pain and swelling in scrotum •Urethral swab
•Non-STD: men 40+ -late-hard to distinguish from testis -gonorrhea: G- diplococci •ABX (improve ~3d, resolution ~2-4wk)
•+/- retractive hydrocele -chlamydia: WBC w/o organism -STD: Ceftriaxone + Doxycycline
•+- inguinal lymphadenopathy •PCR for gonorrhea/chlamydia -unlikely STD: Levofloxacin 500mg
• (+) phrens sign •CBC: WBC with left shift
Hydrocele •peritoneal fluid between Communicating: patent processus vaginlais- DX: transillumination TX: supportive until about 1-2yo
layers of tunica vaginalis fluid into tunica vaginalis; fluctuates -scrotal US to check contents
•common in infants Surgery indications: not resolved by 1-
•resolves by 1yo Noncommunicating: processus vaginalis 2yo; sx; compromised skin
closed, fluid trapped, not reducible
Testicular •Twisting of spermatic cord •pain worse with activity, N/V DX: US •Urgent urological consult and surgery
Torsion •Red, tender, swollen scrotum with a tender •Orchipexy; Detorsion with in 4-6hr
Neonate: cord above insertion swollen, elevated testis
Manual Detorsion:
of tunica vaginalis •Absent creamsteric reflec, (-) phrens sign
-twisted clockwise/counterclockwise
•Exquisite pain on palpation from testis
Adolescent: bell clapper -successful= rapid return of blood
•Can compromise spermatogenesis in 4-6hr
Varicocele Dilated, engorged, tortuous •Scrotal enlargement or heaviness Labs: Rule out other disorders Asymptomatic: observe
veins w/n the pampiniform •Infertility as initial complain Conservative: scrotal support, NSAIDS
plexus of scrotal veins US: confirms DX
Physical Exam: Surgical:
*most surgically correctable •Dilated veins in sac “bag of worms” •Occlusion (balloon) or embolization
cause of male infertility •Increased with standing, valsalva •Injected ablation of vein
*MC on left side •Improve while supine •Surgical ligation of pampiniform plexus
Erectile 1. Failure to initiate erection Vasculogenic causes: MCC! PE: cardio, genital, neuro Psychogenic component:
Dysfunction *psych, endo, neuro •atherosclerosis, arterial disease, structural •behaviorally oriented sex therapy
Labs: lipids, glucose, T, prolactin •counseling, stress reduction
2. failure to fill penile tissue Neurogenic *target towards underline cause
*arteriogenic •surgery, radiation, spine, MS, neuropathy Organic component:
*esp w/ DM & alcohol Education: •medications:
3. failure to store adequate •diet and exercise -PDE-5 inhibitors
blood in lacunar network Endocrinologic: Low T, increased prolactin •avoid smoking, ETOH, drugs -injection therapy (prostaglandin)
*venoocclusive dysfunction -testosterone replacement therapy
Diabetic: Vascular, neuropathy Associated Factors:
>80% cases: DM, *Decreased NO •DM, obesity, BPH •surgery:
atherosclerosis, medication •HTN, CV disease, low HDL -vacuum devices
Psychogenic: •smoking, radiation, surgery -penile implants (prosthesis)
Meds: BB, thiazides, estrogen, •inhibit reflexogenic responses, increase •depression, anxiety, stress, anger -vascular surgery
GnRH, H2, TCA, SSRI smooth muscle tone
GU 8%
Acute •Gram – rods most common •Fever, chills, malaise Labs: •IV: fluroquinalone +/- aminoglycoside,
Bacterial •E. coli, Pseudomonas, Proteus •Pain-perianal, sacral, suprapubic •CBC: leukocytosis, left shift or amp/gent
Prostatitis •Irritative & obstructive voiding •UA: pyuria, bacteriuria, hematuria
MC route: ascent up urethra •Urine culture: + for bacteria •Oral (MC): Bactrim 800-160mg BID
•Digital rectal exam (DRE): *KEY! or Fluoroquinalone (Cipro)
Risks: hot, exquisitely tender prostate Imaging: rarely indicated
•catheter, prostate biopsy, stricture *prostatic massage CI due to sepsis
Chronic •Gram – rods most common •Dull, poorly located, in suprapubic, Labs: Fluoroquinolones or Bactrim x6wk
Bacterial •E. coli perineal or low back pain •Prostatic secretions: increased WBCs
Prostatitis •Pseudomonas, Proteus, Klebsiella, •Irritative & obstructive voiding (>10) with a (+) culture SE of prolonged use:
•Enterococcus •HX UTI or (+) cultures C. diff, CNS, tendinopathy
•UA: normal unless cystitis also present
MC route: ascent up urethra DRE: nml (MC), may see boggy Supportive: anti-inflam, sitz baths
*may be complication of ABP, but (spongy), tender, enlarged, and/or •Urine culture: negative; + for
most have no hx indurated prostate organism AFTER massage! Difficult to cure! Common relapses
Benign •MC benign tumor in men •Obstructive voiding-hesitancy, Labs: Mild (0-7 score): watchful waiting
Prostatic •More common with increasing age decreased force and caliber of •UA: normal, possible hematuria
Hyperplasi *become more sensitive to stream, sensation of incomplete Surgical Procedures:
a (BPH) androgens and GF bladder emptying, double voiding •PSA: screening for prostate CA •Transurethral Resection of the
•Increase in both glandular and (urinating within 2 hr), straining, *can be elevated in BPH Prostate (TURP) *MC!
stromal component post-void dribble *can cause retrograde ejaculation
Imaging: *often not needed •Transurethral Incision of Prostate
Risks: •Irritative voiding •US: if high serum Cr or UTI (TUIP)
•Genetics (blacks more likely, -urgency, frequency, nocturia •Open Simple Prostatectomy
Asians less likely) *secondary response of bladder to •Upper GU tract image: only if
increased outlet resistance complications arise or comorbid GI Minimally Invasive:
•Increase Risk: Higher PSA levels, *detrusor muscle hypertrophy and disease present •Laser Therapy (TULIP)
prostatitis, heart disease, BB use, hyperplasic, collagen deposit •Transurethral Needle Ablation of
lack of exercise, obesity 2 mechanisms of obstruction: Prostate (TUNA)
DRE: smooth, firm, symmetric, •Mechanical: narrowed urethral lumen •Transurethral Electrovaporization of
•Decreased risk: NSAIDS, ETOH, elastic enlargement of prostate Prostate
smoking, regular exercise *induration & asymmetric -> cancer •Dynamic: A-receptor stimulation •Hyperthermia
causing increased tone (constriction) •Implant to Open Prostatic Urethra
Prostate MC non-skin cancer in men DRE: focal nodules or induration •PSA Observation small, well-differentiated
Cancer most are adenocarcinomas
Large or locally extensive CA: •BUN/Cr: high if urinary Radiation: beam or pellets
Risks: •obstructive voiding retention/obstruction Chemotherapy: metastatic disease
•Black ethnicity
• (+) fhx of prostate cancer Axial skeleton metastasis: •Alk Phos/Calcium: high if bony mets Cryosurgery: liquid nitrogen in prostate
•high dietary fat intake •low back pain, fracture
•old age *MC 1st site of metastasis Imaging: Transrectal US: stage/biopsy Androgen Deprivation Therapy
•LNRH agonists (Leuoprolide)
Staging: Gleason system •LNRH antagonist (Degarelix)
•Ketoconazole or steroids
•Orchiectomy (remove testicles)
GU 8%
Acute E. coli •Irritative voiding (dysuria) Labs: Short term antimicrobial Therapy
Cystitis Proteus •Frequency urgency •Pyuria •Nitrofurantoin (Macrobid) 100mg po BID x5-7d
“Bladder Klebsiella •Suprapubic pain •Hematuria •Bactrim 800/160mg po BID x3d
Infection” Pseudomonas •+/- gross hematuria •Bacteriuria •Fosfomycin (Monurol) 3g po x1
“UTI” Staph •Leukocyte esterase •Fluoroquinalones, Augmentin, Cephalosporins
Exam: •Urinary nitrate
MC route: •Suprapubic tenderness •Urine culture + bacteria Urinary Analgesics: Phenazopyridine (Azo)
ascent up urethra •NO CVA!
•NO TOXICITY! COLONY COUNT >100,000 Non-Pharm: *in addition to antibiotics
*MC in women •Sitz baths, fluids +/- crandberry juice, probiotics
Autosoma 90% from autosomal dominant •Abdominal or flank pain Hematuria & Mild proteinuria •Vasopresssin receptor antagonists
l •+hx of UTI & HTN •Tx HTN, protein restriction
Dominant Two genes: •+fhx of PKD •US confirms DX; CT if unclear •Rest, analgesics, hydration, avoid caffeine
PKD •ADPKD-1 (MC!): more severe <30: 2+ renal cysts
(ADPKD) •ADPKD-2: slow progression Exam: 30-59yo: 2+ cysts in each kidney Infected: Floroquinalone, Bactrim 2wk IV
•large kidneys, +/- palpable 60yo+: 4+ cysts in each kidney
Autosoma Enlarged kidneys with small •Enlarged kidneys & HTN •Large, echogenic kidneys •No specific therapy
l Recessive cysts on collecting tubules only •Impaired urine •Cysts visible after birth •Manage HTN
PKD *most neonates die from concentration absence of cysts in parents •Dialysis & transplant
pulmonary hypoplasia •Metabolic acidosis
GU 8%
Prerenal Bad perfusion (hypoperfusion) •Uremia •↓GFR and ↑BUN/Cr *BUN: CR ratio >20:1 treat underlying!
Azotemia •Arrhythmia •Low excretion of Na+ (<20 •Maintain euvolemia
*most •Hypovolemia •Nonspecific diffuse abd •Normal urine osmolality (>500) •Correct electrolytes
common •Decreased CO pain & ileus •Avoid nephrotoxic drugs
•Changes in vascular resistance urinary sediment: Hyaline casts
Postrenal obstruction of urinary outflow •Anuria or polyuria ↓GFR and ↑BUN/Cr *BUN: CR ratio >20:1 Studies/Imaging:
Obstruction *get blood in, but no urine out urine backed up leak •Bladder Catherization,
•Na+ in urine varies •Abdominopelvic US
least common ↑ pressure damaged parenchyma •Lower abdominal pain •Urine osmolality <400 can be helpful to look for hyroureter and
obstruction
causes: BPH (MC), obstructed catheter, •Large prostate, distended Urine sediment: nml
anticholinergic meds bladder •maybe RBC, WBC, crystals due to underlying
Acute AKI from tubular damage •Underlying cause ↓GFR and ↑BUN/Cr *BUN: CR ratio <20:1 •Remove cause & avoid complications
Tubular 85% of intrinsic AKIs •Arrhythmia •↑K+ and Phosphate, •AVOID volume overload & ↑K+
Necrosis •abdominal pain •↑Na+ in urine (>20)
(ATN) 3 causes: •uremia •Urine osmolality <400 (250-300) volume overload-loops or dialysis
*intrinsic •Ischemia: inadequate GFR and blood •Oliguric or nonoliguric
renal injury •Nephrotoxins: endogenous, Urine sediment: diet: restrict protein, adjust Ph, Ca, Mg
exogenous(MC) •pigmented granular or “muddy brown” casts, renal
•Sepsis: hypoperfusion and direct injury tubular cells, epithelial cast cells
Glomerulo- Types: Classic presentation: •Serum Cr increases over days -> months •High dose corticosteroids
nephritis •Immune complex deposition •HTN *slows immune process
*intrinsic *complexes in glomerular BM •Edema •Hematuria, moderate proteinuria
renal injury causes: infections (strep), lubus, Bergers (scrotal, periorbital) •RBC casts •Cytotoxic agents if cell mediated
disease (IgA nephropathy) •Proteinuria
•RBC, WBC, RBC casts •Complement low in immune complex •Plasma exchange: Goodpasture disease
•Anti-GBM .*Goodpasture (renal & pulm) •ASO titers (post-infectious) and pauci-immune
•Anti-GBM antibodies
•Pauci-Immune *churg-strauss •ANCA levels (Pauci-Immune)
Acute Interstitial inflammatory response with Classic triad: Sediment-WBCs, RBCs, eosinophiluria, WBC casts •Remove cause, supportive care
Interstitial cell-mediated immune rxns •Fever •IV or oral corticosteroids if persists
Nephritis •Rash ↓GFR and ↑BUN/Cr *BUN: CR ratio <20:1
*intrinsic Causes: •arthralgia •Urgent dialysis ~1/3 pts
renal injury •Medication (70%) Renal biopsy: inflam cells w/n renal interstitium
•Infections (staph, strep, CMV…), •Peripheral blood
Immunologic (SLE, Sjogrens…) •eosinophilia Abdominal Pelvic US: enlarged kidneys
Nephrotic Usually due to DM ! Subnephrotic: •Hypoalbuminemia (<3g) & Hypoproteinemia (<6g) Protein loss
Syndrome •little to no s/s •Hyperlipidemia •IF >10g, then intake INCREASE
*low protein low osmotic pressure high lipids •ACE/ARB
Nephrotic: *low clearance of VLDL -> high TG
•peripheral edema •Elevated ESR Edema: salt restriction, diuretics
•dyspnea •Vit D, zinc, copper deficiency
•pleural effusions Hyperlipidemia: diet, exercise, statins
•ascities UA: Proteinuria 300mg/d or more
spot urine protein: urine Cr ratio Hypercoag *If albumin <2g
•loss of antithrombin, protein C & S
Sediment: oval fat bodies, grape cluster, maltese cross •anticoag for 2-6mo in pt with thrombosis
GU 8%
Chronic Epidemiology: Early: asymptomatic •↓ RBC, H/H SLOW PROGRESSION
Kidney •70%+ cases due to DM or Late CKD: waste build-up, uremia •↓ Ca, Na+, pH (acidosis)
Disease HTN/vascular •↓ GFR •HTN & proteinuria: ACE/ARB
(CKD) •Independent risk of cardio disease Stage I-II: no sx from low GFR •↓ vitamin D •Reduce further kidney damage
•possible edema, HTN •↓ HDL *obstruction, nephrotoxins, flare of
↑↓ Risk Factors: underlying disease
Patient demographics: old, AA Stage III and IV: all organs affected •↑ K+, Phosphate •Control bld glucose AIC <7%
•Anemia, fatigue, anorexia •↑ uric acid
Historical Factors: •Abnormal Ca, Ph, vit D, PTH •↑ BUN/Cr Dialysis Indications:
•previous AKI •Abnormal Na, K, water, acid/base •↑ PTH •GFR 10 or less
•fhx renal disease •↑ triglycerides •Uremic symptoms
•smoking Stage V/ESRD: uremia syndrome •metabolic disturbances
•lead exposure •Marked disturbance in ADL, well-being, Urinalysis: •Fluid overload unresponsive to
nutrition, water, electrolytes •broad, waxy cast (dilated nephron) diuretics
Comorbid Conditions: •proteinuria
•GU-structural, proteinuria, sediment Physical Exam:
•Metabolic-DM, HDL, obese, •MC=hypertension!
•Other-HTN, autoimmune •Uremic frost
Bladder 2nd most common urologic cancer Hematuria, painless Labs: Hematuria +/- pyuria, anemia Superficial (Ta and T1):
Cancer MC in men and older patients (~73yo) Weight loss •transurethral resection of tumor
+/- irritative voiding Cytology: epithleial cells
MC-epithelial cell malignancy Invasive (T2+): radical cystectomy
(urothlial cell carcinoma) Large: possible abdominal mass Imaging: CT, MRI, or US •+/- chemotherapy, radiation
Renal Cell •Peak incidences in 60s •Gross or microscopic hematuria Labs: •Surgical excision
Carcinoma •2x more common in males •Flank pain •Hematuria -standard: radical nephrectomy
*primary •MC cause=sporadic tumors •Abdominal mass •Anemia (MC!) or erythrocytosis - kidney & adrenal, lymph nodes
•Hypercalcemia
*most •most are clear cell carcinoma Classic triad: •Stauffer syndrome: hepatic •very limited effective chemotherapy
common arise from proximal tubules •flank pain dysfunction with elevated LFTs for RCC
renal •hematuria
cancer Risks: obesity, HTN, chronic •abdominal mass Imaging: Prognosis: 5 years survival rates
analgesics, environmental toxin •Solid renal mass •renal capsule only 90-100%
exposure, chronic HCV, Metastatic: cough, bone pain •Standard-CT abd/pelvis •beyond renal capsule 50-60%
nephrolithiasis, smoking •MRI-evaluates spread into IVC •lymph node involvement 0-15%
Renal Atherosclerotic occlusive disease •HTN (refractory new onset) Elevated BUN/Cr if ischemia don’t use ACE if BILATERAL
Artery 5% of pts with HTN have RAS •Pulmonary edema with poor HTN
Stenosis Imaging: •Medical management
*MC >45yo w/ atherosclerotic disease PE: •US: asymmetric kidney (unilat) or •Angioplasty +/- stent
*suspect if unexplained HTN in •HTN small hyperchoic kidney (bilat)
woman <45 year old •audible abdominal bruit •Surgical bypass
•Doppler US *BEST *more risks, no greater efficacy
•Renal angiography *GOLD
CRITICAL CARE 7% Angina Pectoris, Cardiac Arrest, Cardiac arrhythmias/blocks, cardiac failure, Tamponade, Coma, MI, HTN crisis, pericardial effusion, seizures
CRITICAL
Appendicitis Rectocecal: •dull periumbilical or epigastric pain RLQ •CBC, UA, pregnancy •Consult surgeon
abd and flank pain •N/V, anorexia; SX increase over 24h •Preoperative preparation
•CT scan: STUDY OF CHOICE IVF, ABX Zosyn
Pelvic: PE: McBurneys point & Appendicitis signs *don’t need contrast
tender abd and rectal pain Rovsing: RLQ, Psoas: SLR, Obturator: twist
Volvulus •Torsion bowel bowel Infants: bilious vomiting Complications: •Endoscopic decompression
obstruction • intestinal ischemia, gangrene •IV Fluids
•MC in elderly Adults: distention, abdominal pain, N/V
•Sigmoid (MC!) 80% Fever, tachycardia Imaging:
•X-ray: SBO, “double bubble”
•GI series & CT: “birds beak”
Acute Decrease of blood supply •Crampy, abdominal pain DX: CT angiogram •NPO, rest, fluids; SURGERY
Mesenteric to bowel •Bloody diarrhea •Pain control, anti-emetics
Ischemia MCC: emboli, thrombus •HALLMARK: pain out of proportion Labs: CBC, lactate
Ischemia Colitis MCC: hypotension or •LLQ pain •Colonoscopy •Restore perfusion and observe for
atherosclerosis •Bloody diarrhea perforation
Toxic Total/segmental non- •colitis present for at least 1wk prior to onset XRAY (best!): •Complete bowel rest & NG tube
Megacolon obstructive colonic •Severe bloody diarrhea, abd pain, distention Transverse or R colon is dilated, •DC all antimotility agents (opiates,
dilatation (>6cm) + •Malaise 6-15cm supine anticholinergics)
toxicity •prophylaxis PPI & DVT
PE: FAT BAT •IV steroids & surgical consult
Complication of IBD, •Fever, AMS, Toxic •Flagyl + Amp/Gent or Ceftriaxone
radiation, ischemia •BP low, (postural), abdominal pain, tachycardia
Acute GI bleed •Ligament of Treitz is Hematesmesis: bleed proximal to ligament •type and crossmatch Upper GI Bleed
defining location -coffee-ground: mild, frank blood: severe •CBC ALL GET ENDOSCOPY
seperating UGI from LGI -normocytic: acute
bleed Hemathochezia: maroon/bright red LGI -microcytic: chronic Stable: consult GI/surgery
•CMP: high BUN: CR >30-UGI Unstable: IVF, PRBC: FFP (4:1)
Medications: Melena: black, tarry stool (altered hgb from •PT/INR: endoscopy can not be
•NSAIDS, anticoags, digestive enzymes ) UGI performed until INR <2.5 Lower GI
antiplatelets, •consult GI/general surgery
•Iron (melena) •Pain, dixzzy, syncope, confusion, diaphoresis •EKG & cardiac enzymes •consider endoscopy to r/o UGI
•Beets (hematochezia) •discuss colonoscopy v angiography
signs of significant bleeding: hypotension, NG Tube (suspected UGI)
Social: tachycardia, low pulse pressure, tachypnea •visual inspection of gastric content Others:
•Alcohol gastris, liver •sign of shock: cool, pale, low cap refill MOST SENSITIVE PPI: acid suppression
•Pantoprazole 80mg IV bolus
hx similar sx: 60% UGI •hyperactive BS: UGI bleed •indicated for bleeding from PUD
from same lesions •tenderness: inflame/infectious
•non-tender: vascular Somatostatin analong
•ascites/hepatosplenomegaly: liver
•Ocreotide 50mcg bolus
Rectal exam: if LGI suspected guaiac test
•use for variceal bleeding
CRITICAL
Pneumo- spontaneous: Sudden chest pain-pleuritic, CLINICALLY Tension Pneumothorax:
thorax •primary: no lung disease unilateral, non-exertional Needle decompression
-rupture of subpleural apical bleb Dyspnea •PA CXR with expiratory view: •large-bore needle (14-16 guage) at 2nd ICS at
-tall, thin males 10-40yo diagnostic *stable pt midclavicular line-leave in until thoracostomy
•secondary: underlying lung dx Physical Exam: tube places
•diminished breath sounds & TF •Chest CT, bedside US *large •Oxygen 2-4L nasal cannula
traumatic: penetrating or blunt, •increased resonance to percussion
iatrogranic ((+) pressure) •mild tachypnea Small Primary (<15-20%): observe x6hr
•pneumothorax under tension
tension (EMERGENT) -resp. compromise & CV collapse Large: chest tube (thoacostomy) & admit
-air entering pleural sac -tracheal deviation, displaced PMI
-MCC: cardiopulm, (+) pressure
Pulmonary Thrombus of the pulmonary artery Symptoms: EKG: sinus tachycardia, S1Q3T3 1. Oxygen, IV Fluids if needed
Embolism or its branches •Dyspnea (sudden onset)
•Pleuritic chest pain CXR: Hamptoms Hump or westmark 2. Anticoagulation
Types: thrombus MC! •Hemoptysis (pulm infarction) •Anti-thrombin III: Heparin (renal), LMWH
•Cough, wheeze VQ Scan: poor perfusion, good vent •Factor Xa inhibitor: Xarelto, Eliquis
Risks (Virchows Triad): •DVT symptoms (Homans sign) *good for outpatient, no heparin
•venous stasis -dorsiflexion causing pain Spiral CT: BEST •Direct thrombin inhibitor: Pradaxa
•injury (to vessel wall) Pulmonary angiography: GOLD *requires Heparin for 5-10d
•hypercoagulability: medications PE: •Vitamin K inhibitor: Warfarin
-tachypnea, tachycardia Wells Score >6: high, 2-6: mod
-hypoxemia; rales +3: DVT, alt dx not likely TPA: *hemodynamic compromise
-hypotension and syncope +1.5: HR >100, VTE hx, •begin UFH or LMWH after infusion
-JVD & S3 and S4 sounds immobilization for 4 weeks
(+) homans: calf pain w/ dorsiflex +1: malignancy, hemoptysis Thromboembolectomy:
•pts with life-threatening PE and CI to TPA
Acute MC form non-cardiogenic •rapid onset of profound DYSPNEA •CXR: bilateral pulmonary infiltrates Non-invasive or mechanical ventilation
Respirator pulmonary edema within 12-48h after event -AIR BRONCHOGRAMS
y Distress -spares costophrenic angles PEEP ((+) end-expiratory pressure)
•acute hypoxemic respiratory •SOB, tachypnea, intercostal -prevents alveolar collapse
failure following systemic or pulm retractions, crackles •ABG: PaO2/FIO2 <200 and is NOT -give at lowest effective levels
insult WITHOUT evidence of HF •hypoxemia (no response to O2) responsive to 100% O2 (refractory -does not improve mortality
hypoxemia) -risks: barotrauma, pneumothorax, auto-peep
•inflammatory alveolar damage •multiple organ failure: kidney,
increased permeability of liver, CV, CNS •Swanz-Ganz cath: pressure <18
alveolar-capillary barrier *differentiates from pulm edema Treat underlying disease
pulmonary edema low O2 HALLMARK: diffuse alveolar
damage
Causes: MCC-sepsis
-critically ill, trauma, aspiration
CRITICAL
Acute “Addisonian Crisis” •Hypovolemic Shock (MC!) •BMP •IVF: normal saline (D5NS if
Adrenal •Sudden worsening of adrenal •Hypotension -hyponatermia hypoglycemia)
Insufficiency insufficiency due to “stressful” event •Hypovolemia -hyperkalemia
•Abdominal pain, N/V -hypoglycemia •IV HIGH dose Hydrocortisone
Triggers: surgery, trauma, volume loss, •Fever
hypothermia, MI, fever, sepsis, •Weakness, lethargy, confusion •Reversal of electrolytes
hypoglycemia, steroid withdrawal •Fludricortisone
Status •Episode of abnormal neurologic •Abrupt onset ALL: Glucose, hcg •insert nasopharyngeal airway
Epilepticus function caused by inappropriate •Memory loss of activity •DOC is Lorazepam x2
electrical discharge •Purposeless movement during HX seizure disorder: + serum drug - alternates: Diazepam, Midazolam
attack levels •monitor airway and oxygenation
•Seizure activity 5+ minutes or two + •Postictal confusion/lethargy
seizures without regaining NO HX: +CMP, magnesium •second line: Fospheytoin or Phenytoin
consciousness -phenytoin incompatible with benzos,
fluids glucose/dextrose
CT scan of the head w/o contrast
Refractory: peristant seizures despite IV -SE: cardiac arrhythmias, resp dep,
•indications: first-ever seizure, change
of two anti-epileptics hypotension w/phenytoin
in pattern of normal seizure activity,
concern for acute intracranial process
Refractory Status Epilepticus
•persistent seizure after first and second
Lumbar Puncture
line treatments coma and intubation
•Indications: febrile,
•Midazolam or Propofol or Pentobarbital
immunocompromised, suspicion for
subarachnoid hemorrhage
Eclampsia: IV Magnesium sulfate 4-6g
•CI: avoid during active seizing Alcohol use: benzos, educate on alcohol
Acute Angle •Obstruction of aqueous humor outflow •Sudden eye pain & HA •Supine position
•Increased IOP 60-80 (normal 10-20):
Closure due to the lens or peripheral iris •colored halos around light
Glaucoma blocking the trabecular network •peripheral “tunnel” vision loss •firm to palpation 1. Acetazolamide (lower pressure &
•N/V aqueous humor production)
History: dark room (movie), reading, •Fixed mid-position pupil, fundoscope: cupping of optic nerve
dilating, anticholinergics, coke hazy cornea, injection 2. Timilol (reduce pressure without
affectiving visual acuity)
CRITICAL
Hypovolemic •Loss of blood or fluid volume •pale, cool extremities •CBC: increased hgb and hct ABCDEs
Shock •slow cap refill *decreased in late shock
*circulatory Causes: hemorrhagic, GI, •low skin turgor •Volume resuscitation: NS or LR
shock pancreatitis, DKI, burn •Increased HR •Vasoconstriction •Blood: PRBCs
•Decreased BP and CO •Low wedge pressure
Neurogenic •Acute spinal cord injury •Bradycardia •Clinical •fluid and vasopressors
Shock blocks sympathetic system •Hypotension (alpha-activity to increase sympathetic tone)
*distributive increased vagal tone •Warm, dry skin
•WIDE pulse presure
HEMATOLOGY 5%
HEME/ONC
Iron •MCC blood loss •Fatigue, hair thinning •High TIBC, RDW Ferrous Sulfate
Deficiency •pallor, pica, cheilitis •Low iron, ferritin, transferrin *take with Vitamin C
Microcytic •koilycia, plummer vinson syndrome •Low MCV, low MCH, nml MCHC
Alpha •Decreased alpha-globin •¼-silent •Smear: target cells •Moderate: folate, avoid oxidative
Thalassemia •MC in Asians •2/4- minor (trait) stress, avoid iron supplementation
•¾- HbH •Electrophoresis:
Microcytic •4/4- hydrops fetalis all equal b/c all contain A •Severe: transfusions, splenectomy
iron chelation (IV Deferoxamine),
Beta •Decreased beta-globin •½: Minor (trait)-asymptomatic electrophoresis: Major: blood transfusions
Thalassemia •MC in Mediterranean •2/2: major (cooleys) •increased HbA2 and HbF,
-symptomatic around 6 months definitive=bone marrow transplant
Microcytic HbF=2a2y -Frontal bossing & maxillary growth smear: target cells, nucleated cells
HbA=2a2b, HbA2=2a2d X-ray: crew-cut skull appearance
Folate •MCC=diet leafy greens •Glossitis, cheilosis •high MCV and homocysteine Folate supplement
Deficiency •NO NEUROPATHY •normal MMA
Macrocytic
Smear: hypersegmented
neutrophils, macro-ovalocytes
B12 •MCC=pernicious anemia damaged glossitis, NEUROPATHY high MCV, homocysteine & MMA B12 Injections
Deficiency parietal cells lack of intrinsic factor *B12 needed to convert MMA to
Macrocytic SCoA Smear: hypersegmented, macro-
ovalocytes, basophilic stippling
Sick Cell •Autosomal resessive Jaundice, HSM, cardiomegaly •Electrophresis: HbS •PCN at 2 months, folic acid at 1 yr
Anemia •Abnormal substitution of B chain Ill appearing, poor healing, •Smear: Howell-Jolly •Hydroxyurea
Normocytic retinopathy •Labs: increased reticulocytes
•Unstable HbS abnormal shape vaso- Acute: HOP: hydration, oxygen, pain
occlusive episodes destroyed by spleen Triggers: SHITAE Definitive: stem cell
G6PD •X-linked recessive; MC in AA males •Jaundice, dark urine Smear: Prevent: avoid oxidative drugs,
Normocytic •Malaise, weakness, pain •Bite & Blister cells; Heinz Bodies triggers
•Deficit in G6PD enzyme
Labs: •Folic acid supplementation
•RBC is vulnerable to oxidative state Triggers: •Low hgb & hct
hgb denatures forms Heinz bodies infection, food (fava beans), ABX •High reticulocytes & High MCH
damages membrane destroyed by spleen •G6PD assay
HEME
ITP • antibodies against platelets •Bleeding, petechiae, bruising ISOLATED thrombocytopenia •Steroids
•MC after URTI •IVIG, splenectomy
TTP •deficiency in ADAMTS13 • “FATRN” fever/FFP, anemia, •increased vWF, low ADAMTS13 FFP
“Adults, fever, neuro, vWF” thrombocytopenia, renal(hematuria), •smear: shistocytes
neurp
DIC Pathologic activation of coagulation system •Widespread hemorrhage & •Increased PTT/PT/INR •Treat underlying cause
widespread microthrombi consumes thrombosis •Decreased fibrinogen •FFP if severe bleeding
clotting factors thrombocytopenia and •MC at venipuncture sites •Increased D-dimer
diffuse bleeding
vWF •Autosomal Dominant •recurrent nose bleeds, heavy •Decreased vWF, decreased VIII DDAVP
Disease periods •prolonged PTT and bleeding time
•family history
Hemophilia X-linked recessive •hemarthrosis (joints, MC ankle) •prolong PTT & bleeding time •Hemophilia A: Factor VIII or
MC in children •hemorrhage due to trauma •normal platelets DDAVP
A: factor VII B: Factor IX C: factor XI •possible purpura/petechiae •Hemophilia B: Factor IX
•Hemophilia C: Factor XI
HEME
Factor V Leiden Factor V: activated by thrombin and helps •DVT Activated protein C Anticoagulant
convert prothrombin to thrombin •PE resistance assay
•Clotting confirm with DNA test
MCC inherited thrombophilia
ONC
Multiple •Proceeded by a premalignant MC in the axial skeleton CBC: anemia, thrombocytopenia *INCURABLE
Myeloma plasma cells proliferative disorder- •bone pain-back, hips, ribs Smear: RBC rouleaux formation *refer to heme/onc
MGUS •spinal cord compression-median*
•pathologic fracture BM Biopsy/Aspiration: infiltration by Chemo, stem cell, radiation
*monoclonal=ONE CELL •hypercalcemia abnormal monoclonal plasma
•proliferation of plasma cells in the confusion, somnolence, bone pain, Complications:
BM decreased hematopoiesis constipation, nausea, and thirst Electrophoresis: (+) paraprotein (M) •fractures
24hr urine: Bence Jones protein •vertebral body collapse
•increased neoplastic cells bone •anemia, neutropenia, thrombocytopenia Quantitative Immunoglobulin: suppression •spinal cord: steroids
tumor and hypercalcemia •impaired renal, oliguria, proteinuria of IgG, IgA, IgM •hypercalcemia: Reclast
•radiculopathy •Renal impairement
•secrete M-proteins harm •plasmocytomas Beta-2 microglubin: elevated plasmapheresis to remove
kidneys, nerve, organs M-proteins
X-ray: COMPLETE skeletal survey
Hodgkins •Germinal B cells undergo •PAINLESS cervical/supraclavicular LAD •Staging: Ann Arbor Chemo
transformation •Mediastinal mass, fatigue, wt loss •CBC normal, elevated ESR
•MC in males •B SX: wt loss >10%, T >38C, sweats •Biopsy: Reed Sternberg cells
Non- Accumulate in lymph tissue (spleen, •Cough, dyspnea, edema Burkitt: BBBB Chemo
Hodgkins nodes, thymus) •Mediastinal mass, RLQ mass • boy, B-cells, belly, chromosome B
Lymphoblastic: TT “teen, T-cells” Large Cells: B and T cell
ALL MC malignancy in children •Fever, weakness, fatigue •CBC with diff: ANC <1000 Chemo
Leukemic BLASTS replace marrow •Bone pain, pallor, anemia •Smear: lymphoblasts (~25%)
•Petechia, purpura, infection •Marrow FNA & biopsy confirms
AML Risks: •Fatigue, infection, nodules, HSM •CBC: all WBC low Chemo
•radiation, chemo •Smear: auer rod
•downs, NF1, twins •CONFIRM with marrow biopsy
CLL MC LEUKEMIA IN US! Slow onset! Usually found incidentally CBC: WBC > 20,000 Immediately begin multi-
MC elderly •lymphadenopathy (MC!) Isolated lymphocytes (>5,000) drug chemo if high-risk
•recurrent infections (PNA, HSV, HZV) +/- decreased RBC, platelets
Complications:
•obstructive lymphadenopathy •hepatosplenomegaly FLOW CYTOMETRY: *confirms
upper abdominal discomfort/fullness Confirms abnormal B-lymphocytes
•transformation into aggressive large •anemia/thrombocytopenia
cell lymphoma (Richter syndrome) BM Aspiration/Biopsy: small lymphocytes
CML Single specific genetic mutation •Fatigue! *often first symptom CBC: WBC 100-150,00 w/ L shift Chronic:
(translocation) of gene 9:22 •Low-grade fever, night sweats, wt loss Alk Phos: low Tyrosine kinase inhibitor
PHILADELPHIA on PCR •abdominal fullness, bone tenderness
•pruritis, flushing, GI ulcers with elevated PS: Accelerated: blast cells, promyelocytes Accelerate or Blast:
First (Chronic): MC mature cells basophils due to histamine TKI + multidrug chemo
Second (Accelerated): cytogenic BM Aspiration/Biopsy: hypercellular with *possible stem cell
Third (Terminal Blast): immature PE: HSM, LAD increased granulocytes and progenitors
ID 5% About Clinical Presentation Diagnostics Treatment
Botuslism Clostridium botulinum 8 Ds: •toxin assay Antitoxin (EVERYONE)
(Gram +) •Endotoxin ingested or inhaled •Diplopia •drooping eyelids •dilated/fixed pupil
inhibition of Ach weak •dry mouth •dysphagia, dysarthria (speech), + PCN or Metronidazole if wound
dysphonia transmission
Transmission: canned goods (adult),
wound, honey (infants) •”floppy” baby syndrome
Tetanus Clostridium tetani •Early: local muscle spasms, neck/jaw stiffness, Clinical DX Antitoxin + Metronidazole or
(Gram +) trismus *DO NOT CULTURE Penicillin
Transmission: spores from soil
•Later: drooling, risus sardonicus (facial contraction)
Neurotoxin (tetanospasmin) block
neuron inhibition (ach) severe •increased DTR
muscle spasm
Diptheria Corynobacterium diphtheria •Tonsillopharyngitis with white/grey patch that •cllinical diagnosis •Antitoxin + Erythromycin or PCN
(Gram +) bleed when scrapped •PCR
Transmission: inhale drops •Bull neck due to enlarged cervical LAD •Culture Prevention: DtaP, Erythro
•myocarditis arrhythmias, HF
Chlamydi Chlamydia trachomatis Women: urethritis, cervicitis, PID; inflamed, friable, Nucleic acid test Azithromycin
a (Gram -) red cervix, conjunctivitis, cervical motion tenderness
MC STD in US Complication:
Men: urethritis, epididymitis, prostatitis PROM
-water, mucoid discharge, conjunctivitis Fitz-Hugh Curtis
Gonorrhe Neisseria gonorrhoreae Yellow-green purulent discharge, urethritis, Nucleic acid:Intracellular Rocephin + Doxycyline
a (Gram -) prostatitis, conjunctivitis (infants), septic arthritis gram (-) diplococci Azithromycin
Pertussis Bordatella Pertussis coughing spells, hemorrhage and petechiae; clinical, high suspicion Azithromycin, Bactrim
(Gram -)
Pathogenesis: A & B toxin Stages: children >2wk Vaccine: DTaP
A enters cells & inactivates cAMP 1. Catarrhal-MOST contagious, resp symptoms,
increase mucous 2. Paroxysmal (rapid cough whoop) GOLD-Culture
B cell surface (adenylate cyclase) 3. Convalescent: chronic cough x2-3 weeks definitive: cough >3wk
Transmission: droplets
Varicella Transmission: resp droplets, •“dew drop on a rose petal” clear vesicles on an Clinical diagnosis Acyclovir
Zoster (VZV) direct contact erythematous base, different phases
(Viral) •along dermatome Complication: PHN
-Gabapentin, TCAs
Epstein-Barr Transmission: “kissing •posterior cervical lymphadenopathy heterophile monospot test supportive NO CONTACT
Virus (EBV) disease”, saliva, blood •fever, fatigue, malaise, splenomegaly SPORTS
(Viral) •maculopapular rash (worse with Ampicillin!) Smear: atypical lymphocytes
Influenza Transmission: respiratory Sudden fever, chills, malaise, sore throat, HA, non- •rapid flu Tamiflu (neuramidase
(Viral) droplets, touching productive cough •RT-PCR (1-3d) inhibitors A & B) w/n 48hr
contaminated surfaces •NP viral culture (3-7d)
Hemaglutinin: bind to epithelium (cellular infection) Prevention: influenza vaccine,
3 types: A (most pathogenic), <9yo need two in one seasons
B&C Neuraminidase: cleaves bond holdings new virions
(spread of infection)
Rabies (Viral) Transmission: bats, S/S: initial=fever, chills, tingling & itching at site •negri bodies in the animal, ONE dose of immunogolublin
woodchucks, skunk, raccoon, clinically FOUR vaccines (day 1,3,7,14)
fox, coyote neurologic=behavior change, agitation, anxiety,
hallucination, hypersalivation, fear of water
•animal saliva nervous (hydrophobia)
system encephalitis
HIV (Viral) Retrovirus: changes RNA into Acute seroconversion: flu-like illness •ELISA western blot 2 NRTIs: nucleotide reverse
DNA via reverse transcriptase transcriptase inhibitor
AIDS: CD4 <200, diarrhea, wt loss, dementia •HIV RNA viral load -Zidovudine (Retrovir)
Transmission: sex, IVDU, -Tenofivir
mother, blood contact
Prophylaxis
<200: Bactrim
<150: Itraconazole
<100: Fluconazole
<50: Azithromycin;
Valgangcilovir
Histoplasmosis Histoplasmosis capsulatum acute pulmonary: •high LDH, ALP, ferritin mild/moderate=Itraconazole
(Fungal) fever, non-productive cough, myalgia
Source: Bird/bat poop, river CXR: severe=Amp B
areas (Ohio/Mississippi) disseminated: •acute/disseminated=mediastinal
flu-like, wt loss, HSM, bloody diarrhea LAN & infiltrates
•Ingested by macrophages
•CD4 <150 “Wear hats at the river so you don’t get pooped •chronic=apical cavities & infiltrate
on before the mediastinal Ice cave”
Oral Candida albicans Beefy, red edematous mucosa with white •KOH budding yeast and Nystatin, Fluconazole
Candidiasis papules that CAN be scraped off pseudohyphae
Esophageal Candida albicans Odonyphagia +/- oral thrush •Endoscope white plaques Fluconazole
Candidiasis
Vulvovaginal Candida albicans White “cottage cheese” discharge, burning, •KOH fish smell Monistat
Candidiasis itching
Intertrigo Candida albicans Itch, erythema, “satellite” papules and pustules •KOH Nystatin, Fluconazole
Tuberculosis Mycobacterium tuberculosis Pulmonary: productive cough, CP, hemoptysis •sputum cultures & acid-fast stain RIPE x6-12 months
(Atypical) Rifampin: orange fluids, low plt
Transmission: person to person Constitutional: night sweats, fever, chills, •Mantoux TB skin test Izoniazid: hepatitis, neuropathy
by airborne droplets fatigue, anorexia, weight loss Pyrazinamide: hepatitis, hyperuric
CXR: apical cavities Ethambutol: optic neuritis (E=eye)
Primary TB: active initial Extra-pulmonary: vertebral (Potts), lymph -reactivation: apical, upper lobes
infection contagious) nodes (scrofula) -primary: middle/lower lobe
Latent: Isosinizid + Pyridoxine
Chronic (latent): caseating *not contagious in latent period
granuloma formation not (+) 5mm+ HIV/immunosuppressed, (+) *no sx, (+) PPD, (-) CXR
contagious CXR, close contact
(+) 10mm+ high risk populations: IVDU,
Secondary (reactivate): apex of homeless, age <5yo, immigrant, travel
upper lobes contagious (+) 15mm+ no risk factors
ID 5%
Lyme Disease Deer tick Ixodes tick early localized: erythema migrans •ELISA test if (+) then Doxycycline; Amoxi (<8, prego)
(Spirochete) summer & spring confirm with Western Blot
early disseminated: arthritis, CN VII palsy, cardio Prophylaxis: <72hr of rick
Borrelia burgdorferi late: neurologic worsening, synovitis, arthritis removal if the tick present >36h
Rocky Wood/dog tick Blanching, erythematous macular rash on wrists/ankles •Clinical diagnosis Doxycycline
Mountain Dermancentor tick palms/soles centrally Chloremphalone (pregnant)
Spotted Fever •serology indirect
(Spirochete) Ricketssia ricketsii immunofluorescent antibody
Gram (-) obligate intracellular
Syphillis Trepenoma pallidum Primary painless chancre on genital, painless lymph •RPR/VDRL Pen G Benzathine
(Spirochete) •dark field microscopy
Secondary: mucous patch, condyloma, scaly papule
Tapeworms Taenia sainata (beef) Instetinal: vague abdominal sx Proglottids in stool BIltricide once
(Parasite- Taenia solium (pork) Brain: epilepsy Albendazole
Helmith)
Roundworms Ascariasis •Eosinophilic PNA Eggs in stool Albendazole
(Helmith) *MC helmith infection •Vague abdominal sx Mebendazole
Trichinosis Trichinella spiralis larvae •GI: abdominal pain, N/V/D •ELISA Albendazole
(Parasite- to intestine striated muscle •Muscle: myositis, muscle pain, periorbital edema •High CK/LDH Mebendazole
Helmith) •HALLMARK: eosinophilia
Transmission: Uncooked pork
Malaria Plasmodium falciparum •paroxysm=HIGH fever, chills, sweats okay •Giemsa stain on blood •Chloroquine
(Parasite) cyclical smear •Atovaquone + Doxy or Clinda
Vector: Anopheles mosquito •Effects RBCs •Low WBC, plts, anemia
Toxoplasmosis Toxoplasmosis gondii •primary (good immune): asymptomatic or mono-like PCR, IgG/IgM pregnancy=Spiramycin
(Parasite) •primary (bad): necrotizing lesion, encephalopathy
•Fecal oral, cat feces •congenital: retardation, hearing loss, chorioretinitis immunocompromised:
Pyrimethamine & Sulfa
“The toxic cat spiraled out of control with the sulfa pyramid
due to necrotizing brain lesion. This caused her retina to swell
& the marines/guards were called in.”