Frozen Shoulder
There is stiffnes and limited motion due to glenohumeral joint stifness. In PE range of motion in all directions is limited whether passive or active movement. This is as a result of Pericapsulitis. Majority are idiopathic. Arthroscopy establishes the dx by showing decreased joint space volume and loss of normal axillary pouch. Tx involves NSAIDa, steriods injection in the joint and physical therapy. Rotator Cuff Tear or Rotator Cuff Tendinitis presents with severe pain and weakness of shoulder abduction. Positionng arm above shoulder aggrevates the pain. Range of motion is only limited in active movement but is normal in passive flextion. A positive drop arm sign, with inability to actively maintain 90 degree of passive abduction maybe present in large tears. Tendinitis can be ddx from Tear by injecting Lidocain that would result in improvment in motion in Tendinitis but not in Tear.
Furosemide Tox:
Causes oto-toxicity. Aminoglycosides, vancomycin, quinine, and chloroquin also cause oto-tox. Aspirin causes Tinnitus.
Galactosemia
In a newborn or young infant with failure to thrive, bilateral cataracts, jaundice and hypoglycemia. Early dx and tx by removing galactose from diet are mandatory. It’s a metabolic disrorder causd by Galactose-1Phosphate Uridyl Transferace def. That leads to increse level of Galactose. DDX: galactokinase def, only have cataratct and otherwise asymptomatic.
Gallblader Carcinoma
It’s a rare tumor, found in pts with chronic Choledocholithiasis usually diagnosed intra or post operatively after cholecystectomy.*****Chronic Cholecystitis predisposes to carcinoma, in xray we can see Porceline gall bladder, due to calcium deposition in gall bladder.
Gastric Carcinoma
Pt might present with blood vomiting and Acanthosis Nigrans. Don’t be fooled into thinking that its Aspirin tox, becaseu aspirin tox doesn’t cause AN. AN is a diease that causes dark,thick areas on the skin. MC in arm pits and other folds. Its associated with being over weight and other tumors like GASTRIC carcinoma. so pt needs complete work up like endoscopy and bioposy.
Gastric MALT
H. Pylori has an important role in parhogenesis of Gastric Mucosa-Asso Lymphoid Tissue Lymphoma. These Lymphomas may regress after eradication of H. Pylori, IF THERE IS NO METASTASIS. If Pylori eradication fails then Chemotherapy is the choice (CHOP). In the old days they used to do radical gasterectomy. Tx Pylori with Omeprazole+Clarithromycin+Amoxicilline.
Gastroschisis:
Bowel protrudes through a defect. Bowel not covered with protective membrane. First thing is to cover the exposed bowel with sterile wrapping, then iv access for nutrition and then iv antibiotics, then surgery to fix the defect. Omphalocele: Bowel protrudes through unbilicla ring. Bowel covered with amnioperitoneal membrane. Asso with other congenital abnormalities. Management is first wrapping, then orogastric tube to decompress stomach. If <2cm repair with primary closure if bigger Silastic Silo.
Gaucher’s Dis:
Sphingolipidosis due to deficiency of glucocerebosidase. Characterized by Hepatomegaly, anemia, leukopenia, and thrombocytopenia, but NOT chery red macula.
General Anxiety Disorder
First line of tx is Buspirone, because it does not show the dependence and withdrawl symptoms asso with Benzodiazepines. If sexual performance is a problem use Nefazodone.
Gentamycin
causes nephrotoc and Ototoxicity, vestibular toxicity that causes the pt to feel dizzy w/I a couple of weeks of use.
GERD - 6
In neonates is regurgitation after eating and failure to thrive. The child assumes the position of tilted head and arched back. Dx is 24hr pH monitoring of esophagus. *****When its unclear whether the pt has nocturnal asthma or GERD, a trial of proton pump inhibitor (Omeprazole) before breakfast is both Dx and therpeutic. ***** Esophagoscopy is indicated when a pt fails to respond to antibiotics and or theye are signs of implications (weight loss in cancer).****Dx Process: once pt presents with cough, and the vigniette says esophagoscopy is normal, the next thing is 24 hour pH monitoring. Then Manometry will confirm dx.****GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barret esophagus and is a risk for Adenocarcinoma of esophagus.****When pt comes in with symptoms of GERD you need to differenciate b.w Barrets,PUD,Gastritis, or tumor. Endoscopy is the most informative procedure for all these. Now if the vingette says "he has no Dysphagia" then you can skip the normal Barium test that precedes endoscopy and go straight to endoscopy.*****Indications to endoscopy are: 1-Nausea/vomiting, 2-weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failre to responde to PPI. So here is the order, if there if Dysphagia first do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry, you can skip BS.
Giant cell arteritis - 3
Don’t wait for biposy start high dose Prednisone right away.***Lab may show elevated ESR and normochromic normocytic anemia. Thoracic aortic aneurysm is a complication of this dis, maybe due to disruption of collagen and elastin.
Giardiasis
Adheres to mucosal surfaces by adhesive disk and cause malabsorption, may lead to weight loss. The MC symptom is foul smelling sttol, fatty stool, bloating and flatulence, nausea, malaise, abdominla cramps. Empiric tx should be given w a course of Metronidazole.
Gilbert synd
Partial absecnce of enzyme leads to : 1-mild uncongugated hyperbilirubinemia, 2-More elevated values happen with stress, fasting, alcohol abuse. 3-normal cbc, 4-normal liver enzyme, 5-complete reversal of hyperbilirubinemia. DDX1:Crigler-Najar-I: cgaracterized by 1-Unconj.Hyperbilirubinmeia 8-30, 2-Normal liver enzymes, 3-High rates od Kernicterus, 4-No response to Phenobarbital. DDX2:C-N-2: characterized by 1-Unconj HyperB, 2-Normal liver enz, 3-No Kernicterus, 4-25% decrease of Bilirubin with Phenobarbital. DDX3:Rotor synd: Conjugated Hyperbilirubinemia.
Glascow coma scale - 2
EYE opening:Spontanous 4, to verbal command 3, to pain 2, none 1. VERBAL response:Oriented 5, confused 4, Inappropriate 3, Incomprehensive 2, non 1. MOTOR respopnse:Obeys 6, localization 5, Flexion 4, abnormal felxtion 3, extenstion 2, none 1. Total 15. Minor injury is GCS of >14. Moderate <13 and >9. Severe <8. ****Pt with GCS of 7 in an accident is having a severe head injury. All pts with sever head injury should be intubated, with mechanical ventilation,and admin of IV fluids,analgesics and sedatives.
Glaucoma
it’s the leading cause of blindness in North America. Its characterized by elevated ICP. Symptoms are sudden onset of photophonia., eye pain, HA nasea. Eye is hard to touch. A non reactive mid dialated pupil suggest Acute Glaucoma.The best Dx is Tonometry. OPEN angle glaucoma: has incidious onsert with gradual loss of peripheral vision and consequence tunnel vision. Intraoclar pressures are high. Opthalmoscopic exam shows cupping of the optic disk.*****once you suspect it do MAPPING VISUAL FIELDS to find out defects.
Glaucoma, Acute closure angle 2
Age 55-70, Acute onset of severe pain and blurred vision, nausea and vomiting. Anterior chamber is shallow with inflammatory changes. Tonometry reveals increased IOP. IV Acetozolamide, Manitol, Pilocarpin with subseq oral. Permanent cure is laser peripheral iridotomy. Avoid Atropine.
Glaucoma, Acute Open angle:
Its more common in blacks. Gradual loss of peripheral vision, tunnel vision. IOP is high. There is cupping of the optic disk with loss of peripheral vision. Beta blockers, Timilol are effective in initial mngmnt. Later on Trabeculoplasty. Its asso with Diabetes.
Glioblastoma Multiform
GBM or HIGH grade astrocytoma. CT shows butterfly appearnce in the frontal lobe of alesion (surrounded by white calcification, looks like cyst membrane but not round). DDX is Brain Metastasis, pt will have a duration of symptoms of <2months, the site is grey-white juunction or watershed zones, they are multifocal and round. DDX2:Lowgrade astrocytoma, prestns with seisure and longer duration os symptoms.
Glucagonoma
Triad of Hyperglycemia, necrotizing Dermatitis, and weight loss. It’s a tumor of islet cells in Pancrease . The excess glucagon causes symptoms like glucose intolerance, and hyperglycemia. It also causes a distint skin lesion called 'Necrolytic migratory erythema'. Dx is confirmed by fasting glucose elevation, elevated glucagon, and pancreatic tumor by CT. Surgery is the prefered tx. It doesnt respond to Chemotherapy.
Glucose 6 Phosphatase deficiency:
Also glycogen storage type 1 or Von Gierke Dis. Presents with hypoglycemia, lacic acidosis, hyperuricemia, & hyperlipidemia. Hypoglycemic seizure occurs. Hay hepato and renal megally. Doll face, fat cheeks, thin legs, and a protuberant abdomen.
Glucocorticoud SE
Long term use in asthmatic pt can lead to Neutrophilia by increasing BM release and mobilization of marginated neutrophil pool. Eosinophils and lymphocytes are decreased.
Glycogen storage diseases
1-Von Gierke, 2-Pompe, type 3 and type 4. Read on them.
Gonococcal arthritis
Urethral cultures have the highest yeled than synovial or blood or urine cultures in cases of suspected purulent gonococcal arhtritis.
Gonorrhea - 2
Commonly causes cervisitis, urethral discharge. It also causes Pharyngitis. *It also causes GA(arthritis), which is asymetric migratory polyarthralgia, followed by monoarticular arthritis and rash, palms and soles have multiple necrotic pustules.
Goodpasteur's synd - 3
Involves lung and kidney. There is lower respiratory problems (hemoptosis) and proteinuria (renal failure), there is antibodies against glomerular basement membrane. Sputum shows iron in form of hemosiderin . There is anemia and RBC cast in urine. DDX1:Idiopathic pulmonary Hemosiderosis: Like GP, but there is more copious hemoptasis and its for children. DDX2: Wegner's, involves Upper (rhinorrhea) and Lower (hemoptasis) and Kidney problems. And Granular granulomatosis. Cresent formation.****Caused by circulating antiglomerular basement membrane antibodies. Early removal is imperative in order to minimize the damage tokidney. Emergency Plasmaphoresis is indicated.***Pt presents with massive hemoptosis, weightloss, hematuria and proteinuria. To confirm measure anti glumerulat basement membrane antibodies.
Goughers Dis
Is due to deficient activity of the lysosomal enz, acid beta glucosidase. The typical pt is Ashkani Jew adulescent with chronic fatigue, easy bruisability, bone pain and pathological fractures. The dx is conformed with radiologic (Erlenmeyer flask deformity of the distal femur) and bone marrow studies (Gaucher cells with wrinkled paper appearance).
GOUT- 2
Fluid joint aspiration for dx.*****In pt with frequent attacksof gout not controlled by Colchicine, a 24hr uric acid level in urine is determined. This evaluates whether hyperuricemia id due to over production or under secretion. A value of <800 indicates under secretion, so use a Uricosuric agent (Probenecid) is needed. If its >800 indicates over production, so add a xanthin oxidase inhibitor (Allopurinol).
Gouty arthritis - 2
Very painful, mostly in toe but could happen in long term RA pt in the hands. Alcohol is metabolized to Lactate which competes with Urate for renal excretion leading to accumulation of urate in the body and gout.Cessation of alcohol is important. Acute attack give oral indomethacin, colchicine or steriods. Chronic Cholcicine.
Graft Vs Host Disease
By activated donor T lymphocytes. Targeted at Skin (maculopapular rash in palm,sole and face), Intestine (bloody diarrhea, Liver.
Granuloma Inguinale
Is an STD caused by Donovane granulomatis. Its uncommon in US and is mc in Balck population. It starts with a papule that rapidly develops into a painless ulcer characterized by irregular border and red beefy granular base. Inguinal lymphadenopathy occurs w/o Buboes. Advnced stage has scaring, depigmentation and keloids. Fibrosis may lead to vaginitis and elephantitis. Dx is by identifying Donovan bodies, visulized by giemsa or wright stain of tissue smears, and appear reddish, encapsulated bipolar bacteria found within Monocytes. Tx is tetracycline, 500mg, every 6hr, 10-21 days. DDX1:Ulcer of primary syphlis has roled edges and punched out base. DDX2:Ulcer in Chancroid is very painful and foul smelling, buboes form and are painful. DDX3:in Genital herpes many vesicles appear before they turn into ulcers. DDx4 Ulcer in Lymphogranuloma Veneruem is also painless but its shallow and asso w non-specific systemic symptoms, also lymphadenopathy is inflamatory and does not appear at the same time as ulcers.*****The first thing to do is stop Heparin. However, most pt need anticoag so two options are offered: -Danaparoid and a direct thrombin inhibitor such as Lepirudin or Argatruban.
Granulosa Cell Tumor
Are SOLID tumors. Bimodal distribution. If occur before puberty , Precociouspuberty is presented. It produces excess estrogen and causes pubic hair, hpertrophy of brest and hyperplasia of uterus. Usually removal of tumor reverses the problem. If its in postmenopausal women it causes bleedingand uterus shows myohyperplasia. DDX1ysgerminoma, in young women and children, unilateral and go under torsion. It doesnt produce any hormones. DDX2:Sertoli-Leydig,produces androgen and DEFEMINIZATION, followed by masculinization in childbearing years. DDX3:Mature teratoma or Dermoid cysts, benign and dont produce any hormones. DDX4;Serous cystadenomas, are the mc CYSTIC ovarian neoplasm. 25% are malignant,half cases are bilateral. They dont produce any hormones. Ovarian mass and abdominla pain are presenting features.
Grave's Disease - 3
Tx is radioactive iodine. Might cause hypothyroidism *** Sudden onset of Atrial Fibrilation (irregularly irregulat rhythm with tachycardia) in pregnant women should alert the doctor to look for Hyperthyroidism, GRAVES is the MCC of hyperthyroidism in pregnancy. Remember Dx is made by TSH, T3 & T4, BUT the best SCREENING is just TSH. So next step is ordering TSH. Now the vigniette may not even indicate other signs of Graves, but you must recognize it as well. DDX is Hydatiform Mole, but sonogram will easily show it.
Green stick fracture
Commonly seen in children because the bone is less brittle. Also see torus fracture and plastic deformation.
Growing Pain
Common in children from 2-12. Mostly at night, awakens the pt, responds to massage and NSAIDs. Obs/Reasur.
Guillain Barre - 4
The best way to monitor respiratory function is to measure serial bedside vital capacity, to make sure it stays above 15ml/kg.***DDX is Tick borne paralysis charcterized by rapidly progresive ascending paralysis, absence of feve , absence of sensory abnormality and normal CSF. ****Campylobacter Jejuni is the most frequent precipitant in GB. ***GB is characterized by Ascending paralysis , previous hx of infection, CSF shows albumino-cytologic dissociation(Elevated protein despite normal cell count). Tx is IVIG and plasmophoresis. DDX is Botulism which presents with desceing paralysis, tx is antitoxin.
Gun Shot wound:
If its below 4thrib, level of nipples, then exploratory laparatomy is done.
Hairy Cell Leukemia - 2
It’s a type of B-lymphocytic derived chronic leukemia. Tartrate resistant acid phosphatase stain is Dx.****Picture looks like hairy projections of large cells. BM may become fibrotic so BM aspirate are frequently unsuccessful (Dry Tap). Tx DOC is a purine analog, Cladribine.Its toxic to BM, it causes neurological and kidney damage. Remember CHOP is for Nonhodgkins, Chlorambucil+Prednisone are for CLL.
Hashimoto Thyroiditis - 2
Transient thyrotoxicosis can occur in initial stages due to thyroid-stimulating antibodies. Positive anti-thyroperoxidase antibodies with an enlarged rubbery goiter are virtually diagnostic. The risk of thyroid Lymphoma is 60times greater in these pts. CT shows elragemnt of thyroid around trachea, "Doughnut sign". US shows "psudocycst pattern". RAIU is decreased. Since FNA might miss dx, Core biopsy is prefered. * Anti Thyroid Peroxidase Antibodies are present in >90% of pts.
HCV
If pt is + but no sign and symptoms, just follow up w yearly tests. No Tx.
Head trauma - 2
always do spine xray in pt with falls or accidents leading to head trauma. **** Pt with increased ICP should be treated with hyperventilation , head elevation, and IV Manitol and diuretics. Hyperventilation works by causing vasoconstriction and decreasing the ICP by decreasing cerebral blood flow volume.
Heart Block - 2
1-First Degree: prolonged but constant PR >0.2s . No tx is neede. 2-Mobitz Type-1: or Wenkeback, narrow QRS and progressive increase in PR until a ventricular beat is dropped. It may occur with Digoxin, or Inferior MI. If pt is symptomatic Atropine is gven. 3-Mobitz Type-2: Fixed PR with occasional drop . QRS is wide. Its seen after MI. Its dangerous and all pts have to be monitored in ICU. It can progress to complete heart block and needs Pace maker. Atropine must be by bed side at all times until a permanant pacemaker is inserted. *****Third degree heart block, no atrail impulses will travel to ventricles. , Atrail rate is 80 and Vent is 30. Pts are at risk of suden cardiac death and they should be transmitted to ICU and PERMANENT pacemaker should be placed. Always have Atropine by bed side. B-blocker WILL KILL HIM IMMEDIATELY.
Heat Exhaustion
Characterized by volume depletion under the conditions of heat stress. DDX:Heat Stroke, has CNS symptoms and T>40. DDX2:Heat Syncope:breif syncope after exposire to heat. DDX3:Heat cramps: painful muscle cramps due to depletion of salt in muscles.
Heat stroke
Characterized by body T of >40.5, due to filaure of thermoregulatory center. Rapid Evaporation cooling is the tx of choice. Immersion in ice water is also useful but makes it difficult to monitor the pt.
HELLP Syndrome
Hemolysis & Hypertension (preeclampsia), Elevated Liver enzyme, Low platele(thrombocytopenia). DDX are DIC, Preeclampsia, TTp, HUS, and Acute Fatty Liver of Pregnancy. In AFLP tx is supportive with early dx and rapiddelivery, there is incresed PT & PTT. In HUS, thrombosis of the glomerular arteries, happens in children. Often preceeded by infection. . TTP is wide spread of HUS and it occurs in Adults and Asso with NEUROlogical symptoms. Tx is exchange transfusion or plasmaphoresis with FFP****Delivery is definitive tx for HELLP in women beyond 34 weeks, give Mg SO4 to reduce BP & VAGINAL deliver.
Hematochezia, scant
Pt see fresh blood on toilet paper. Most common causes are hemorhhoids, fistulas or even cancer. If pt is <50 chance for cancer very low. Do Anoscopy first and then if still nnot clea do sigmoidoscopy or colonoscopy is done.
Hemi Neglect Synd
Involves the Right (Non dominant ) parietal lobe.
Hemochromatosis - 3
Genetic disorder of iron absorption, increased aborption from intestine . Liver, pancrease, heart and joints are mc affected. Pt prsents with weakness, loss ob libido, skin pigmentation, weight loss, abdominal pain and symptoms of DM (polyuria& polydypsia). Trensferin saturation (>=50%) and Ferritin (>1000) is a simple reliable sreen test. Hepatoma(Hepatocellular Carcinoma) is the most serious complications. ***Hay increased Fe and Feritin. Its Auto Recessive causing increased iron absorp and deposition in skin (pigmentation), Testes(decreased libido), pancrease (Diabetes), Joints (Arthralgia), and liver (cirrhosis).*** Pts are at increased risk for Listeria Monocytogenes, maybe due to impaired phagocytosis. Iron overload is also a risk for Yersenia Enterocolitica and sepsis from Vibria Vulnificus which are iron loving bacteria.*** IF pt presents with Joint pain and Hepatomegally and no other sysmptoms suspect it and FIRST thing you do is CBC to check Fe level. It presents with hepatomegaly,hyperpigmentation,diabetes (BRONZE diabetes), arthropathy, heart failure and hypogonadism.
Hemolytic Uremic Synd - 4
When you get Thrombocytopenia (decreased platelet 56000), a MicroAngiopathic Hemolytic Anemia(MAHA) (Increasesd bilirubin, and schitzocytes and RBC fragments and abnormal renal function) in a pregnant woman DDX include HEELP(Hemolysis, Elevated Liver enzymes, Low platelet count), HUS, TTP, DIC, preecclampsia and Acute Fatty Liver of Pregnancy (AFLP). Oliguric renal failure+MAHA+Thrombocytopenia points to HUS. Its characterized by thrombosis of the glomerular arterioles and capilaries. It occurs more frequesntly in childhood and presents with fever, thrombocytopenia, MAHA, HT and renal failure. Usually preceded with viral infection and asso with E. Coli. TTP is a variant of HUS, the thrombosis is systemic and it obstructs microvascular of several organs. It presents with fever, altred level of consciousness, focal neurologic signs, renal failure, MAHA and thrombocytopenia. tx is exchange transfusion, or plasmophoresis with FFP. HELLP is a variant of preeclampsia, in women older than 25, multipara, before 36 weks gestation. DIC is a comsumptive coagulopathy, Presents with elevated PT, PTT, fibrin degradation product and decreased fibrin. ****Occurs in young children. Preceeded by a diarrheal disease. Hallmark is Microcangiopathic hemolytic anemia. Other features are renal filure, fever, oliguria, thrombocytopenia. GI bleeing is common. Purpura and HT. Schizocytes, which represent frabmented RBC. Also Giant Platelets. Intravasculat hemolysis results in elevated LDH, indirect bilirubin and reticulocyte count. BUN andCrt are markedly elevated. . Urine contains, Hb, Hemosiderin, albumin, RBC,WBC and casts.****Its caused by E.coli released toxin, it injures kidney epithelium. Pt prsents with abdomnal pain, young pt, decreased Hb,Hct and Platelets. , bloody diarhea and swollen face. When kidney is damaged mortality is 5-10%.*****Its caused by toxin released by E.Coli, it destroys epithelial lining and causes bloody diarrhea. Subsequesnt activation of coagulation system and red cell hemolysis causes Jaundice. Its mc in children adn initial presentation is abdomnal pain and diarrhea. The classis TRIAD is Uremia(Renal Failure), Thrombocytopenia, and Hemolytic Anemia. Tx is generally suportive and involves Plasmaphoresis and Dialysis if necessary and steriods. DDX it with Campylobacter jejuni, althought it causes bloody diarrhea, there is no Thrombocytopenia.
Hemophilia
Bruising since child hood, excessive bleeding in a tooth extration procedure and uncle having the same problem. In these pts recurrent Hemarterosis ma lead to injury called 'hemophilic arthropathy'. Iron (HEMOSIDERINE) deposition and synovial thickening with fibrosis is characteristic. ***** Its X-linked. PTT is elevated and PT & BT are normal.
Hemothorax
Collectin of blood in pleural cavity. Tachypnea,tahcycardia,hypotention, deviated trachea , dullness to percusion, elevated JVP, fluic in pleural cavity(seen in Cxr) and collapsed lung. . Lung is the usual bleeding source 2ary to rib fracture. Its very important to evacuate the blood in order to stop bleeding, which stops on its own. Best initial interventon is to insert a low anterior chest tube to remove blood. Surgical Thoracotomy is indicated when more than 1500ml blood recovered when tube is inserted, or if more than 600ml blood loss after 6 hour post tube insertion.
Henoch-Schonlein Purpura
A common vasculitic of childhood, its commonly seed after URT infection and is more common in males. Classis findings are palpable Purpura in buttucks and lower extrmity. Peripheral edema nd scrotal swelling. Renal finding are Hematuria dn proteinuria. Tx includes steriod and monitoring renal function. When pt prestns with Abdominla pain two pathologies should be rules out emergently, GI bleeding and Intussuseption. Intus is characerized by sudden onet of abdominlapain with large amount of blood in stool. This is a surgical emergency and is tx with Air/barium enema.*****HSP is an IgA mediated vasculitis of small vessels, which results in rashes, arthralgias, abdominal pain and renal disease. Immuno florescence microscopy reveals IgA deposition in the kidney.
HepA
Acute disease asso w travelling. If travel <4 weeks, give Ig. If >4 weeks give vaccine.
Heparin induced thrombocytopenia - 3
Its seen in 5-15% of of pt taking Heparin with onseet b/t 3-15 days and resolution in 4-5 days of discontinuation. While PTT is a therapeutic effect of heparin, the thrombocytopenia is an adverse effect. So PTT is increased and Platelets are decreased.****Hospitalized pt who develop DVT after a period of bed rest are standardly treated with Heparin. An adverse effect is Thrombocytopenia, along with thrombosis (causes stroke sysmptoms). The combination os Arterial/Vnous thrombosis and thrombocytopenia in pts receiving Heparin is suggestive of HIT. Antibodies against Heparin-Platelet factor 4 complex are responsible for this. The antibodies activete platelets which will cause their removal form circulation.
Hepatic Adenoma
Is a benign tumor seen in mieedle age females taking OCP . Intra tumor hemorhhage is a major comlication. Dx is by bipsy, atypical hepatocytes with glycogen deposits. Tx Superficial and large adenomas are resected. But smaller and asymptomatic onces are under surveilance with imaging.
Hepatic Encephalopathy – 3. Hepatology. 6/3
Characterized by reversal of sleep cycle, asterixis, porgreive coma, and Delta waves in EEG. It’s a CNS complication of liver failure secondary to accumulation of ammonia in blood becuase of inability of live to detoxify ammonia (that comes from intestine) into urea. Eliminating toxic enteric products is the other main therapy: (1) The bowels should be cleared with enemas. (2) Dietary protein should be eliminated, and oral or IV carbohydrate should be given. (3) Oral lactulose should be given. (4) Oral neomycin.****Pt with hepatic failure should be given vit K to correct PT and if they are bleeding in this setting, or he needs immediate surgey, then FFP is indicated.Platelet transfusion is only indicated if it falls below 20,000-30,000. Cryoprecipitate is requied for coag factor def like factor VIII. Packed RBC is indicated when RBC is <8 in asymptomatic pt or <10 in symptomatic pt.
Hepatitis B –8. GIT. 6/3
Hepatitis B virus Ig + Lamivudine is used to prevent recurrent HBV after liver transplant.For HepB Interferon+Lamuvidine. Vaccination criteria: if someone is exposed and has Documented response there is no need for furthur action. If vaccined but no response to vaccine must be vaccined again. If vaccined many times and still no response, give HBIG on exposure. If exposed to virus and never been vaccinated before, give HBIG w/i 24 hrs and start HBV vaccination. Best screening test to dx acute HepB is AntiHBcAg and HBsAg. **** HepB vaccine is a recombinant vaccine containing HBsAg, which stimulated Anti HBsAg, person who receives it will have immunity and thus be positive for Anti HBsAg and negative for HBsAg. Person with ACUTE HBV will have HBsAg, HBeAg and IgM Anti HBcAg. Chronic HBV will have HBsAg only, for >6months. Person with recovery phase HBV will have AntiHBsAg, HBsAg, Anti HBeAg and ABSENT HBeAg. ****If seroogy shows HBsAg, HBeAg positive and high titers of HBV DNA, he has Chronic HEpB. The 2 drugs approved are Inerferone and Lamuvidine. Either one is indicated for pt with positive HBsAg,HBeAg,HBV DNA and persistantly elevated ALT. Degree os elevation of ALT is important in deciding the Tx. Serum ALT of mor than two times the upper limit requires need for Lamuvidinr or alpha interferone. If less than that its not useful. Generally Lamuvidine has less SE and easier to administer (ORAL). Inteferone is not successful in young children and immunocompromised pts. NOW, if the pt has just been exposed to virus, POSTEXPOSURE and has never had response to vaccine, we give vaccine+Ig, and if did have response and has antibodies then we just give Ig. ****Of all acute Hep B cases 90% recover, minority go to chronic, out of those 1% goes to Fulminant hepatic failure, defined as hepatic encephalopathy that develops w/I 8 weeks of the onset of acute liver failure and evidence by marked increase in ALT. and signs of Hepatic encephalopathy. Liver transplantation is the only effective method for tx, so initial step in tx at this point is to put her name on the list****Newborn of mothers with active HebB should be passivly at birth with HepB immunoglobin followed by Vaccination. *****Transmission from mother w chronic dis & +HBs antigen and Hbe antigen to the fetus is 90%.****If given choice b/w Interferon and Lamuvidine in a depressed pt, pick Lamuvidine cause interferone is CI in Psych pts..
Hepatitis C - 4
Risk factors for rapid progression of liver fibrosis in chronic HepC are: 1-Male sex, 2-Acquire infection after age of 40, 3-Co-infection with HepB or HIV, 4-Alcohol intake. Complications of Chronic HepC: 1-Cryoglobulinemia (causes Membraneous glomerulonephritis), 2-B-cell Lymphomas, 3-Plasmocytosis, 4-Autoimmune dis like Sjogren and thyroiditis, 5-Lichen Planus, 6-Porphyrea cutanea tarda, 7-ITP. Management: All pt with mild Hep C(alevated ALT,HCVRNA, moderate bridgenecrosis) should get Interferone+Ribavirin. Liver transplantation is the last step and its done when Pt and Albumin levels are very affected. **** HCV RNA is the single most sensitive serological marker to screen HepC, HCV RNA antibody takes months to show up dont do that one. **** All pts with chronic HepC, including Pregnant women, should be tested for HepA and HepB and if not immuned should be vaccinated which is safe for pregnancy. Ribavirin & Interferone are teratogenic.****Transmission risk could be a steady sex partner but the chances are low.
Hepatitis E
Asso with pregnant women.Ocurs in India,Asia, Africa and central USA.Ther is no vaccin or Ig avaible for HepE.
Hepatocellular carcinoma- 2
Most are palpable mass. It accts for 80-90% of liver cancers. Occurs more often in men. Cause is unknown but contributing factors are Chronic liver disease, HepB & HepC, hemochromatosis. Dx is by abdominal CT. ***High serum AFP (>500) in an adult with liver disw/o an obvious GI malignany is HCC. Pt has a hx ox Chronic HepC. Dx is confirmed by biopsy, Tx is surgical resection.
Hepato-Renal Synd
Hypotension, Hyponatremia, Azothemia and oliguria with normal urine analysis with sever liver disease. No tx is available. Pathogenesis is not clear. Initial mgmt is careful volume loading and withholding of Spironolactone and Furesamide.
Hereditary Spherocytosis - 3
Osmotic fragility test is dx.***An auto RECESSIVE dis. Folic acid is encouraged in ALL pts. MCV is normal or Elevated. They rarely require transfusion unless they have Aplastic crisis. Splenectomy is usually curative.****The tx for most pt involves Folic acid oral and blood transfusion. during periods of extrmem anemia. Splenectomy is considered if htey are refractory to medication. The most feared long term complication is overwhelming sepsis with encapsulated bacteria Strep Pneumonia. The risk is present for up to 30 years and even longer after splencetomy. Current recommendations state that pt shuld receive anti-penumococcal,Haemophilus and Meningococci Vaccinces several weeks before the operation and daily oral Penicilline prophylaxis for 3-5 years following splenectomy.
Herion Withdrawl
Signs are muscle spasm, abdominla pain, rhinorrhea , lacriation, sweating. Dilated pupils. These are oppsit signs when pt is toxicated, pin point pupil, constipated, depressed respiration and bp. DDX is Cocain withdrawl:irritable, fatigue, HUNGRY(opped to anorexic when toxicated).
Hernia
Respiration and hemodynamics are altered after repair of large hernias. Because large hernia content is displaced inside the peritoneal cavity, the pressure inside the cavity increases. The diaphram is pushed upwards and this impaires respiration, causing hypoventillation. At least a week is needed for the pt to accomudate to its new state. Early physiotherapy and respiratory excercises (blowing against resistance) are mandatory to prevent , Atelectasis, mucus pluggung and possible subsequent penumonia development.
Herpes Simplex Encephalitis -2
Mainly affects the Temporal lobe, bizare behavior and gustatory hallucination. CSF show Lymphocytosis, low glucose, and elevated proteins. HSV PCR is the gold standard. Tx Acyclovir.
Herpes Simplex Keratitis or Herpetic Keratitis due to HSV-1
Simplex More common in young pt. Zoster is mc in old pt. DX is with Slit lamp. Common in health workers.
Herpes Zoster Ophthalmicus
DDX with Herpes simplex keratitis is addition of vesicular rash in Varicella-Zoster. "Bacterial keratitis" occurs w contact lenses.
Herpetic Whitlow
Is the mc viral infection of the hand. The appearance of vesicles on the volar or dorsal distal phalanx is diagnostic. Caused by type I or II herpes simplex and its self limiting. Dentist are at increased risk.
Hirshsprung dis - 2
Pts with Down, are more likely to present with Duedenal atresia, Hirshsprung, endocardial cushin defect and acute leukimia. Typically there is a "double buble sign" is seen in abdominla radioraph.****This is an emerrgency, so if the infant has it and mother refuses tx, then go ahead and treat the infant because court order will take a while.
Hirsutism
Women produce androgens. DHEA-s and Testosterone in adrenals and ovaries. DHEA-S is only in adrenals by adrenal tumors. See T2-Q16. ACTH increase in pts w hirsutism is seen with ectopic or pituitary dependant Cushings dis. ACTH increases the production of cortisol as well as angrogens from the adrenal glands, however, the adrenal glands show diffuse hyperplasia rather than a discrete adenoma.
Histoplasmosis - 3
Is a common and asymptomatic infection in endemic areas of Mississippi & Ohio. Found in bird or bat dropings. ***** It’s the mf endemic fungal infectinin USA. Disseminated histoplasmosis occurs in immuncompromised pts. Presnece of mucous membrane ulcers, hepatospleenomegally and pancytopenia are clues to Dx. **** Tx is IV amphotericine followed by lifelong Itraconazole. Histoplasmosis happens to HIV pt in OHIO.
HIV- 30
TB occurs in the course of HIV when the CD4 counts are >200. Uper lobe consolidation and cavitation is typical Xray fiding. Asso with Hairy Leukoplakia (white painless lesion that appears hairy, found on the tounge, caused by EBV). All HIV pt should have the following done: 1-Hx & PE, 2-routine chemistry and hematology, 3-two plasma hivRNA levels, 4-CD4 count. 5-VDRL for syphlis. 6-PPD test. 7-Anti Toxoplasma antibody titer. 8-MMSE. 9-Pneumococcal vaccine, unles CD4 is <200. 10-HepA&B serology. 11-HepA&B vaccine, if seronegative. 12-Counselling. 13-Help for those who have been infected by the subject. CMV Colitis is suspected in pt with CD4<50, bloody diarrhea and abdominal pain multiple ulcers and biopsy shows basophilic intracytoplasmic inclusions or owel eye effect, Tx is Gancyclovir or if intolerance Foscarnet. MAC (Micobacterium Avium Complex) presents with unexplpained fever and cough, Azithromycin is used for prophylaxis against MAC when CD4 falls below 50, now Clarithromycin with Ethambutol is used for tx of MAC. **** Breast feeding is CI in HIV. **** Prophylaxis for PCP in HIV pt w CD4<50 doc are Azithromycin or Clarithromycin. Prophylaxis for Histoplasmosis in CD<100 is Itraconazole, in endemic areas. Prophylaxis for CMV in CD<50 is Gancyclovir. ***HIV pt are at risk of 3 types of Esophagitis when their CD falls below 50. MC is Candida, so first we give Oral Fluconazole. If pt didt responde w/i 3-4 days, then we do esophagoscopy to check for Herpes or CMV causes. **** Once PPD is >5mm in HIV pt then Prophylactic theapy with Isoniazide + Pyridoxine is indicated for 9months. **** in a pt with bilateral interestitial pneumoni, the agent is PCP. Tx is Trimeta-Sulfa, in pt with moderate to severe infection adding corticosteriods has reduced mortlity. Indication for steriod is 1-PaO2<70 and 2-A-a gradient >35. *** Best screening test is Eliza, then confirmatory with Western bloting. *** Multiple ring enhancing lesionson on CT in aids pt, is tx w Sulfadiazine and Pyrimethamine which is both diagnostic and therapeutic. Remember trimeta-sulfa is for prophylaxis.**** If health worker is infected, right away get blood for serology and start him on 3 drug therapy while waiting for results. Blood serology should be repeated in 6 weeks, 3 and 6 moths. ***** HIV pts are at increased risk of TB which may cause collapse of vertebral bodies and intervertbral disk.*** DDX of Diarrhea in HIV pt with CD4=80. 1-Cryptosporidium :Modified Acid fast stain shows Oocytes in stool. It becomes persistent in CD<180, its self limited. 2-Isospora is dx like Cryptosporidiosis but its not as common. 3-Microsporidia organisms are asso with severe malabsorption and persistent diarrhea in pt with HIV(immunocompetent).In stool they are SPORES not Oocytes. So Cryptosporidium is the majot cause of persistant diarrhea in HIV pts with CD<180cells/mm3.****HIV pt with fever,ha, csf india ink shows encapsulated yeast, dx is Cryptococcus Meningitis, Tx is IV Fluconazole + IV flucytosin.***** PCP tx is IV Trimeta-Sulfa. Inhaled Pentamidine is for prophylaxis. Prednisone is used in combo with Trim-Sulfa when PaO2 is <70mm/hg.*** Role of BCG is not proven in HIV pts so dont give it to them. But Pneumococcal vaccine is recomended in pts with CD4>200. ******* PML (by JC virus) presents in HIV pt with CD4<100, CT shows multiple NON-ENHANCING lesions with no mass effect. DDX1:Toxoplasmosis, the mc RING enhancing mass lesion in HIV. MRI shows multiple spherical lesions in basal ganglia. Just because antibody is positive doesnt mean pt has it. DDX2:CNS Lymphoma,is the 2ns mcc of mass lesion in HIV pt. It also presnts with ring enhancing lesion in MRI but its usulaly SOLITARY and periventricular. Presnece of EBV DNA in CSF is Dx.***** Kaposi sarcoma is elliptical, arranged linearaly on legs arms, face, oral cavity and genitalia. Initilay papules and later develop into plaques or nodules, and their color changes from brown to violet. No necrosis of the skin. DDX:Bacillary Angiomatosis is caused by G- rod Bartonella and is cured with antibiotics. they are red papules r nodulesasso with fever, chills, malaise, HA and anorexia. They are highly vascular, initialy and smooth. Later on eroded and encrusted. **** BAL (Bronch Alveolar Lavage) is >90% effective in dignosinfg PCP in HIV pt, especially when CD<200.**** DDX of cough in HIV pt:1-Pneumococcus Penumonia, presents with acute, high grade fever, and plrutal effusion, Its still the mcc of penumoniain HIV pt. 2-TB, presents with Chronic coug, night sweat and weight loss. 3-Coccidiomycosis, presents with milliary pattern or nodular infiltrate on cxr, in southwest USA. 4-PCP, Presents with DRY cough, and dyspnea, NO EFFUSIONS.*** HIV pt with cavitation: posibilites are TB, NOCARDIA. Nocardia is partialy acid fast So if pt prestns with night sweat,feve and cough and has PPD of 3mm, and partial acid fast filmaents branching rods, its Nocardia. TX is trmeta-Sulfa.***Since diarrhea in HIV pt could be caused by a number of organisms, the first step is Stool exam and not Empiric anbibiotics.**** When HIV IV drug user comes with dry cough, regardless of having, diarrhea, iv drug user and other things, the MCC is PCP. If he is alergic to sulfa, then Pentamdine is DOC. ***Lymphoma in HIV pt presents with EBV DNA, SOLITARY ring enhancing mass in periventricular with MRI. DDX1:Toxoplasmosis, MRI shows MULTIPLE ring enhaned leiosn in basal ganglia. A positive toxoplasma serolog is common in US so its not specific. Also if pt is taking Trimeta-sulfa, this etiology in unlikely. DDX2:Progg Multifocal Leukoecephalopathy lesions are NON enhancing and dont produce mass effect.****Condylomata acuminata (anogenital warts) are skin colored or pink, verrucous or papiliform skin lesions present around the anus and Podophyline(antimitotic agent) is a tx option. Its CI in pregnancy. DDX is Condylmata Lata, due to 2ary Syphlis, tx is Pecnicilline, are flat or velvety. **** HIV EYE problems: 1-CMV Retinitis, occurs in HIV pt w CD4<50, presents with yellowish-white patches of retinal opacification & retinal hemorrhages. Tx is Ganciclovir or Foscarnet. 2-Ocular Toxoplasmosis, severe retinal choroiditis, >50% have encephalitis. Necrosis of inner retina as white flyffy lesions. 3-Herpes Simples Keratitis, pain, photophobia and decreased vision. Dendritic ulcer is the mc presentation. 4-Herpes Zoster Ophtalmicus, mostly in elderly, or HIV pt. Presents with fever, malaise, itching and burning around the eye. Vesicular rash following trigeminal nerve. If eye is involved hay conjunctivitis and dendriform corneal ulcers. 5-HIV Retinopathy, presents as benign cotton wool spots in retina which remits spontaneously. ****Tx for Condylomata Acuminata is Podophyline. *****Cryptococcal Meningitis infection in AIDS pts, tx ia iv Amphotericin+Flucytosine.
Hodgkin’s :
Tx is ABVD. Adriamycin SE is cardiomyopathy. Bleomycin SE is pulmonary. Dacabrazine is Ematogenic. Vinblastin SE is Neuropathy leading to constipation.
Homocystinuria
Marfan features+mental retardation+thromboembolic events+downward dislocation of the lens is suggestive. Tx is high dose Vit B6.
Hordeolum ( Stye)
a common staph abscess of the eyelid. Tx is warm compresses. Incision and drainage is performed if resolution does not begin in the next 48 hours.
Hormone Replacement Therapy:
According to 2005 studies HRP increases the risk for Cerebrovascular accident, CV disease, Breast Cancer and DVT. It Decreases the risk of Hip fracture, Colorectal cancer and vulvovaginal atrophy.
Human Bites
Tx of choice is Amoxicilline/Clavulanic.
Humeral Fractures
Tx of choice is closed reduction and hanging cast. In cases of Segmented fragtures, or open fracture in trauma, pathologic fracture and vascular structures, open reduction and internal fixation is done.
Huntington - 2
Atrophy of caudate nucleous is characteristic. Mood disturbance, Dementia, Chorea and family history.
Hyaline membrane dis
should be suspected in preerm infacnts. With respirtory distress and hypoxia, NOT responding to oxygen therapy. The characterisric cxy shows fine reticuar granularity of the lung parenchyma. Tx includes early ventillation and surfactant.
Hydatid Cyst of Liver
Is due to infection with Echinococcus ganulosis. Can be contacted from dogs. It can cause Cyst in lung,muscle,bone,liver. In most pts its asymptomatic. "Eggshel calcification" of a hepatic cyst on CT is highly suggestive. Aspiration is NOT indicated due to chance of anaphylactic shock. Tx is surgical resection under the cover of Albendazole.
Hydrocele
1-Non Communicating Hydrocele is refered to a fluid containing sac which is a remnant of processus vaginalis. The upper limits of the mass is easily identified. Most cases of NCHC will dispear spontanously by the age of 12 months. 2-Communicating Hydrocele, the upper limit cant be reached and it treated with surgery.
Hydrocephalus
Happens in infants. CT scan , dialation of entire ventricular system with distinct enlargment of subarachnoid space ofer the cerebral cortex), is very suggestive of non-communicating or commuicating hydrocephalus.Accumulation of blood in subarachoid space may destry Arachnoid villi and whose job is to absorb CSF and lead to hydrocephalus. SAH is the mcc od communicating hydrocephalus. Its very common in PREMATURE infants. Non-Communicating hydrocephalus examples are Dandy-Walker and Arnorld-Chiari. DW shows a cyctic exapansion of fourth ventricle, and AC will rreveal posterior protrusion of posterior fossa through foramen magnun.
Hydroxychloroquine
is the safest drug for SLE but rarely it may cause serious eye dis including Macular degeneration, so eye exam at 6mo to 1yr intervals should be performed. Remember the mc SE is Alegic skin reaction. Also CI is G6PD Def.
Hyperandrogenism
A female prsetns with virilization, balding and clitonegaly. What to do next? Rapidly developing hyperandrogenism with virilization is indicative of androgen-secreting neoplasm of OVARY or ADRENAL. So next measure serum Testosterone and DHEAS to determine the site of tumor. Elevated Testosteone level with noraml DHEAS indicate ovarian source, but Elevated DHEAS with normal Testtosterone indicate Adrenal source. Now dont try to measure 17-HO, because that is for Congenital Adrenal Hyperplasia and happen very early inlife.
Hypercalcemia - 8
Hypercalcemia due to metastatic tumor (Breast) cancer. In all womem w metastaic breast cancer and radiographic lytic bone disease who are receiving either hormone therapy or chemotherapy (Tamoxifen), IV Pamidronate (Biphosphonate) is recommended. * In acute severe hypercalcemia, its importnant to FIRST give IV 0.9% Saline before giving Furesamide. Its complicated read MERCKs. *** Constipation is the mc GI presentation in pt. The important renal manifestation is neprolithiasis. Chronic therapy with vitD is a major cause for Hypercalcemia. Tx is stopping vitD tx and low calcium diet, keeping urin acidic and give corticosteriods. ****Hypercalcemia is the mc Paraneoplastic syndrom that is asso with Squamous CC lung cancer. Hypercalcemia production is due to ectopic PTH related petide (PTHrP) production.*****Immobilization can lead to HyperCa. Prolonged bed rest can lead to accelerated bone resorption, OsteoClastic activation in increased bone turn over is established. Biphosphonate therapy is helpful. DDX:Rhabdomyolysis, HypOcalcemia (not HyperCa) is seen, normaly du eto increased binding of Ca to Phosphorous that was released by muscle. DDX2:Hypercalcemia due to Malignancy, Causes include local osteolytic metastasis, secretion of PTHrPand increased 1-25VitD. DDX3:Hypoalbuminemia, Any change in albumin levels will affect total serum Ca levels w/o affecting the ionized fraction. In pt with decreased albumin total serum ca is decreased.****Malignancy is a frequent casue, lilke Breast cancer. There are various mechanism by which cancer causes hypercalcemia. 1-Procuction of Cytokins:Tumors that are metastatic to bones cause local osteolysis by production of Cytokins like IL-1 and TNF. The mf tumors that produce hyperalcemi byt his method are lung and breast cancer. .2-PTHrH (related hormones):Themcc of Hypercalcemia in pt with non-metastatic solid tumors is production of PTHrH. in these pt PTH is low. 3-Calcitriol:Hypercalcemia in case of Hodgkins is due to Calcitrol 4-Ectopic PTH:Its very rare and has been reported in ovarian cancer, lung cancer and neuroectodermal tumurs.***Hypercalcemia 2ary to malignancy is dueto multiple reasons, including osteolytic metastasis, secretion os PTHrP, increased formation of 1,25-dihydroxyVitD, increased interleukins-6. Generaly, hypercalcemia due to malignancy(2ary HCa) is higher than primary HCa. *****Pt with Squamous cell carcinoma will have Hypercalcemia, now if he vomits, he will be at risk for Acute Hypercalcemic Crisis. Tx is first normal saline for hydration and 2nd Furesamide to maintian urine output at 200cc/hr. Biphosphonate Pamidronate would work too, but by givng saline you both take careof hypercalcemia and hydrate to prevent Azothemia (renal failure) in the pt.
Hyperemesis Gravidarum:
In a pregnant female in her first trimester, who presents with severe and persistant vomiting think of HG. It is severe enough that requires admission. Cause is unknown but related to elevated HCG, which maybe indicative of Hydatiform mole. Order HCG to confirm that levels are consistant with the stage of pregnancy.
HyperKalemia - 4
MC due to Rhabdomyolysis. Ekg shows Tall T waves. Calcium Gluconate is given first and then Insulin, glucose and Kayexalate. Insulin drives K in to the cell, its given with glucose to prevent hypoglycemia, and Kayexalate exchanges Na for K in GI and excretes K. * Caused by either Medication (K sparing diuretis, ACE inhibitors, NSAID) or PseudohyperKalemia (the lab sample is hemolysed), decreased renal K excretion, transcellular shift, increased K intake. The most serious SE is cardiac toxicity, so do an EKG in ALL pts. It shows peaked T waves, prolong PR and QRS, progressive widening of QRS leads to Ventricular Fibrillation or Asystole. The approach to Tx depends on EKG and degree of HyperKalemia. Immediate tx is needed if there is cardiac toxicity, muscular paralysis, or K>6.5. For these pts 10ml of 10% calcium gloconate stabalizes cardiac membrane. To lower K level , insulin or B2 agonist is used since they drive K into cells. Sodium Bicarbonate can also drive K into cells. Slower acting tx is loop or thiazide diuretics which excrete K. Dialysis is reseved for pts with renal failure and those with lilfe threating hyperlalemia wich wont respond to medication. So...If the pt is Asymptomatic and just non malignant hyperkalemia, just discontinue Amiloride ( to get rid of K ) for a weak and recheck. If the pt has evidence of cardiac tox or K is >6.5, then give Calcium Gloconate and IV Dextrose plus Insulin. **** best drug to excrete K from body is Kayaxelate.
Hyperparathyroidism - 3
Increaed Calcium, decreased phosphate, increased PTH. Could be Asymptomatic. While all pt with symptomatic HPTshould have parathyroidectomy, not all Asymptomatic pt need this surgery. Criteria is as follows: 1-Serum Ca level at least 1mg/dl above upper normal lilmit, 2-24hr urinary Ca above 400mg, 3-Young age<50, 4-Bone Mineral Density < T-2.5 at any site, 5-difficulty in follow up if the pt. *****Hyperparathyroidism s asso with Pseudogout, Joint fluid aspiration reveals rhomboid shape calcium pyrophosphate crystals with positive bifringent. Tx is Colchicine, Indomethacin often stops acute attacks promptly.****Primary HPT is the mcc of hypecalcemia in ambulatory pts. Its asso with elevated PTH and decreased phsphorous. Now CRF can lead to SECONDARY HPT, PTH levels are higher in 2ary than Primary HPT, Ca levels are normal to low in 2ary HPT because cause of elevated PTH level is hypocalcemia.Now in Sarcoidosis there is increased conversion of 25-hydroxy VitD to 1,25 hydroxy VitD. thereby increased absorption of calcium from GIT and hypercalcemia, PTH is supressed.*****Asympomatic Primary Hyperpara: HyperCa, HypoPO4, Elevated PTH. Its common in female >60, identified during routin lab work. While Parathyroidectomy is needed for all symptomatic pts, not all Asymptomatic pts need surgery. Criteria includes: 1-Serum Ca level at least 1mg/dL above the upper limit of normal. 2- 24hr urinary Ca level >400mg. 3-Young age <50. 4-Bone Mineral Density lower than T-2.5 . 5-Difficulty to follow up pt.
Hypertension - 7
In elderly HT leads to Benign Nephrosclerosis. HT is the 2nd mcc of renal dis in US. The process of kidney damage evolves from Nephrosclerosis to Glomerulosclerosis. Nephrosclerosis is characterized by hypertrophy and intimal medial fibrosis of renal arteries, whereas, GlomeruloSclerosis is progressive loss of glomerular capilary surface area and glomerular and peritubular fibrosis. Microscopic Hematuria and proteinuria occurs due t glomeriular lesions. So pt presents with Anemia (decreased Hb). DDXiabetic Nephropathy, is the leading cause of end stage renal disease in US. Increased extracellular metrix, , basement membrane thickening, mesangial expansion and fibrosis characterize DN. ***Isolated SYSTOLIC HT, is an importnat cause of HT in Elderly.Pathophys is decreased elasticity of arterial wall, leading to increased SYSTOLIC bp, w/o diastolic bp leading to wide pulse pressure.Hydrochlorothiazide is the DOC. DDX:Aortic Insufficiency can cause the same systems, Echo will differentiate.****Tx of choice for Pt with Intermittant claudication due to atherosclerosis and HT is Ca chanle blocker. ****OCPs are common causes of 2ary HT caused by Estrogen mediated increase in in teh synthesis of Angiotensinogen in the liver. So stop taking the OCP and HT should go back to normal. If it didnt then its Essential HT and life style modification can be tried. If that didnt work either, then the next step is Thiazides.****Alcohol is a risk factor for HT, Smoking is not.****The tx of choice for Isolated Systolic HT (150/70,160/78) is Thiazides low dose. ****Lifestyle modification should ALWAYS be a part of mngmnt. All pts should be encouraged to lose WEIGHT , reduce SALT, avoid excess ALCOHOL (3bottle a week is excess). and stop SMOKING. This is more important than DRUG MODIFICATION. REMEMBER.
Hypertensive Retinopathy -2
Don’t show any symptoms assos with visual loss. Initially hay focal spasm of arteriols followed by progressive sclerosis and narrowing. Fundoscopy may reveal AV nicking, coper or silver wiring, exudates and hemorrhages.*****Grade1=slight AV nicking. Grade2=Copper wiring, AV depression with humping heads. Grade3=Silver wiring, flame shaped hemorrhages, exudates. Grade4=Flame shape hemorrhages, exudates and papil edema.
Hyperthyroidism - 5
Hyperchlosterolemia (increased LDL) is the most frequent lipid abnormality in pts. *****High estrogedn levels in pregnancy result in increase TIBG production by liver. So production of T4 nd T3 is increased (but not Free ones) . This increase however does not result in clinical symptoms because excess T3&T4 are bound to excess TIBG. And since Free T3&T4 are the same TSH will be normal.*****Atrial Fibrilation is a common complication in hyperthyroidism, Graves disease. In pts with Hyperthyroidism related tachysystolic Atrial Fibrilation a beta blocker,propranolol, is the doc. **** Antithyroid drugs, PropylThioUracil and Methimazole are asso with Agranulocytosis. Immune destruction of granulocytes starts w/i 90 days post therapy. Fever and sore throat are indicative of Agranulocytosis. Monitering in ineffetive. Stop othe drug immediately.****Palpitation should make you think of it. Thne the 1st test is TSH, almost all pt have low TSH (only exception is TSH secreting pituitary Adenoma). If TSH is low then measure Free T4, if its elevated Dx is established. Then do 24-hr thyroid radioiodine uptake to ddx Graves form the rest. Propranolol is initially used for symptoms until definitive cause is known. Radioactive iodine is tx of choice for ALL Grave's pts, however, Propranalol is STILL best initial choice. PTU can be used but hyperthyroidism can recur w/i 6 months. So PTU is only used when Iodine tx is CI, like in Pregnancy. Subtotal Thyroidectomy is also curative but its not the INITIAL tx of choice.
Hypertrophic Osteoarthropathy
Characterized by chronic proliferative periostitis of long bones , clubing of fingers and synovitis, Its asso with Squamou cell carcnimoa and Adenocarcinoma of the lung.
HypoCalcemia
Plasma calcium exists in three forms: ionized calium (45%), ALBUMIN-BOUND (40%), and calcium bound to organic and inorganic anions. Homeostasis of these forms is significantly influenced by the extracellularpH level. An increased pH level causes an increase in the affinity of serum albumin to calcium, thereby increasing the level of albumin-bound calicium, and consequently decreasing the levels of ionized calcium. Ionic calcium is the only physio logically active form, which means the decreased levels of this form can result in clinical manifestations of hypocalemia (crampy pain, paresthesias and carpopedal spasm). Increased extracellular pH levels (Respiratory Alkolosis) can cause an increase in the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium, and consequently decreasing the levels of ionized calcium leading to hypocalcemia. *****Hay increased DTR. *****Hypocalcemia can occur during or right after SURGEY, especially if transfusion is involves. First manifestation is increased DTR. HypoMg manifest with Decreased DTR.
Hypochondiasis
Symptoms occur durng periods of stress (med student worried about intracranial hemorrhage), pt shoudlbe asked about current emotional stresses and then referd for a breif psychotherpay.
Hypogonadism
T9Q4. Re-read Merck highlights.
HypoKalemia - 2
A35. All Beta-2 agonist reduce serum K by driving it in to cells. In occasional pt they cause HypoKalemia. So any pt taking B2 and complaining of muscle weakness Hypokalemia must be rules out. PEFR (peek expiratory flow rate) and Cxr are not of any use. We need to do Serum Electrolyte panel. and EKG to see "U" waves. Beta-2 also produces a more common SE of Fine resting tremor of fingers and peripherla edema.
Hyponatremia
Is a bad prognostic factor for pt with heart disease.
Hypothermia
Fluphenazine causes hypothermia by causing vasodialation and inhibition of shivering. Hyperthermia is common in drug abusers.
Hypothyroidism - 5
Generalized resistance to thyroid hormones.***Its asso with wide spectrum of musle involvement ranging from astmptomatic elevation of CK to Myalgia, muscle hypertrophy, myopathy. So suspect it if hay elevated CK and Myopathy. *It’s the most common SE of radiation therapy for Graves. * Asso with Hyperlipidemia. So unexplained hyponatremia, hyperlipidemia ane elevated serum muscle enzymes are indication for thyroid function tests.****Always rule out Hypothyroidims in a pt with Major Deppresive Disorder.If this option, "ordering blood test" for TSH was offered pick it over other options. ***** Thyroid dysgenesis is the mcc of congenital hypothyroidism in US.
Iatrogenic Esophag perforax
Pt comes back w/I hours with problems. Do contrast study of esophagus, if perforation is present , priary closureof esophagus, , and drainge of mediastinum must be done w/I 6 hours to prevent development of Mediastiitis.
Ichthyosis Vulgaris(Lizard Skin)
Dry and rough skin with horny plates over the surfaces of the limb. Tx is minimizing bathing, Oral retinoids (CI in pregnant women)
Idiopathic Pulmonary Fibrosis
Presents in 4-5 decade of life, fatigue,anorexia,weightloss, rthralgia, cyanosis and clubbing. Xr shows bilateral interstitial involvement. Biopsy is done to rule out sarcoid. Tx is Steriods. Mean survival is 2-5 yr after dx. Pleurodesis (where visceral and parietal pleura are fused, is used to treat recurrent pneunomothorax and effusion) is not used here.
Iga Deficiency, Misc 6/2
Recurrent sinopulmonary and GI infections (diarrhea), and anaphylactic transfusion reaction. Dx is made if IgA serum concentration is <7mg/dl with normal IgG and IgM levels. Tx targets prophylaxis and prevention. Initialy a six month course of daily prophylactic Trimeta-Sulfa or Amoxicilline , if fails needs IVIG with least amount of IgA. Don’t confuse sinupilmonary recurrent infection with CF, CF doesn’t cause anaphylactic reaction.
IgA Nephropathy
Is the mcc of glomerulonephritis in adults. Pt have recurrent episodes of gross hematurea, beginning 1-3 days after upper respiratory infection. Serum complement levels are normal.
Immune Thrombocytopenia
Occurs in children 2/6 yo. Pathogenesis involves antibodies that bind to platelets and subsequent destruction of these complexes in spleen. Its preceded with viral infection, and presents with petechia,purpura,hematuroa,or GI bleeding. No adenopathy. Lab shows no abnormality ecept thrmbocytopenia (60000). The course is felf limited. It requires no TX. If thrombocytopenia is <30000corticosteriods are DOC.
Impetigo Bullous – 2 . Dermo. 6/3
Tx: Mupirocin ointment is choice for local impetigo. If no respose then treat systmicallly. Because most cases are caused by penicillinase-producing staphylococci, Cloxacillin or a 1st-generation cephalosporin is the drug of choice in severe cases. Penicillin-allergic patients should receive cefadroxil or cephalexin rather than erythromyc.
Incontinence - 4
1-STRESS incintinence: Occurs when there is a sudden increase in abdominla muscle. Pelvic muscle exercise (Kegel exercise) Urethropexy are rcommended tx. It’s a CC of incontinence in older women, HIGH PARITY is a major risk factor. A high number of vaginal deliveries may lead to pelvic floor weakness over a period of time. Urethra relapses outside the pelvic so whenrver there is increase intraabdominal pressure (cough,sneez,laugh) urine ensues. Aggrevating factors are Obesity, pregnancy, COPD and Smoking. Postvoid cystometry is normal. Tx include Kegel excercise, esterogen in post menopasusal women. Surgical tx is Burch and Sling procedures. 2-URGE Incontinenceetruser instability, blader irritation form neoplasm, and interestitial cyctitis result in UI, which causes sudden and frequesnt loss of moderate to large amount of urine. Often accomodated with Nocturia. 3-OVERFLOW: Diabetic Nephropathy causes OI. Characterized by loss of small amount of urine from an over extended bladder and a markedly increased residual volume. There is hx of DM which is not controlled. ****CC are certain medications (Ibuprofen), Diabetic nephropathy, MS and spinal cord injury. NSAIDs have an inhibitory action on the detruser, so the first step is to stop NSAID. Then cholinergic drug (Bethanechol) should be added afterwards to improve detruser action . Intermittent self catheterization can be used.****One of effects of epidural anesthesia is urinary retension due to denervation of bladder. When bladder presure is > sphingter pt urianates until balace is achieved again. This incontinence is transient. PE may show distended blader. Postvoidal vol is high. Tx is by Intermittant cathaterization until control is regained. Oxybutyrin is used for Urge incontinence. Urethroplexy is for stress incontinence.
Infantile SAH:
CT scan shows dilation of entire ventricular system with distinct enlargment of subarachnoid space over the cerebral cortex, is suggestive of nonobstructive or communicating hydrocephalus secondary to SAH. SAH is the mcc of communicating hydrocephalus. Accumulation of blood in subarachnoid space may lead to destruction of arachnoid villi and cisterns (that absorb CSF), SAH is caused by intracranial hemorrhage common in premies. DDX Arnord Chiari, non-communicating, protrusion of structures through foramen magnum. DDX Dandy –Walker, NC, cystic expantion of 4th ventricle.
Infectious Diarrhea
Classified into 2 types, bloody or non bloodt. Bloody is caused by E.coli O157:H7 most commonly, also by Shigella, salmonella, Campylobacter, E. Histolytica and Yersinia and C. difficile.
Infectious Mononucleosis - 7
Heterophil antibody test is sensitive and specif. If its negative and you're still suspitious, do EBV specific antibody test. Splenic rupture is a serious complication. So pts with splenomegally are advised bed rest and avoidance of contact sports until no more spleenomegally. Glucocorticoids are indicated if IM is complicated by upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia( and resultant petechia). *IM is caused by Ebstein Bar virus. Sometimes it is detected only after pt develops a characteristic polymorphic rash after taking Ampicilline for an apparant upper respiratory track infection. **** Is asso with Autoimmune Hemolytic Anemia.*****Blood smear with Atypical Lymphocytes ( Large basophilic Lymphocytes) should make oyu tink of it. It might also be in Toxoplasmosis by CMV is the mc organism.*****A negative Heterophile antibodies dont exclude IM, because sometimes they appear later in the course.
Infective Endocarditis – 14, Infx 6/2
Generally if the procedure involves bleeding, prophylaxis is recommended. For procedures that is low risk like, GI endoscopy, there is no need for prophylaxis. Tx inclludes: 1-For IV drug user is IV Vancomycin+ IV gentamycin, since the incidence of MRSA is increased in IV users Vancomycin is better than Nafcilline). 2-For non IV users IV Nafcilline+ IV gentamycin. If IE is due to Strep Bovis, he is at risk for Colon cancer, colocoscopy is recommended. Chordinae tendinea rupture occurs as a complication if IE. **** Pathophysiological consequesnces and clinical manisfestation od IE can be explained by:1-Cytokine production, responsible for fever. 2-Embolization of veg fragments that leads to Pulm and Spleen infarction. 3-Hematogenous infection of sites. 4-Tissue injury due to Immune complex and immune responses to the deposited bacterial antigens. ROTH spots, are due to immune vasculitis. They are oval retinal hemorrhages with pale centers, they have been noticed in pts with collagen vasculat dis and hemorrhagic disorders. OLSER NODES, violacious nodules founf at the pulp of the fingers and toes, due to immune complex deposition. Immune complex is also responsible for GN and Rehumatolic manifestation of IE. JANEWAY LESIONS, macular,blanching, non painful erythomatous lesions on the palms and soles, they are due to SEPTIC EMBOLI, revealing subcutanous abcesses.****Tricuspid Endocarditis is asso with IV drug abusers. S.aureus is the mc organism. Tricuspid murmurs are accentuated by inspiration and neck vein distention. Echo is the dx choice. Cxr shows peripheral Welll circumsribed lesion with cavitation, Surgery is required in majority of pts. Valve repair or replacement is therapeutic.*****Pt with IE who goes inder GU instrumentation for evaluation of microscopic hematuria could have an exacerbation post procedure with murmur and other symptoms of IE.****Subacute bacterial infective endocarditis (SABIE) is seen n pts with damaged valves. Strep Viridens is the mcc. Acute BIE is caused by S.Aureus in IV drug users. S.Epidermitis is seen in pt with Prosthetic valves. ***Strep Viridans (S. Mutans) are the mc responsible for endocarditis after dental work.****Decision to give prophylactic antibiotis depends on risk due to condition of the pt and also depends on the procedure being done. Risk classication are:1-HIGH risk pt are Prosthertic valves, previous hx of IE, Cyanotic pts. 2-MODERATE risk pt are congenial cadiac abonormmalies Acquired valve dis, MVP and regurgitation, and HCM. Now conditions that DONT REQUIRE prophylaxis are MVP w/o regorgitation, innocent murmurs, Pacemakers and defibrilators. ****IE in IV drug users is in right heart and caused by staph aureus with involvemtn of Tricuspid valve. The holosystolic mumur that intensifies with inspiration is Tricuspid Regurgitation. Vegetations can emboli to remote organs, so if pt have fever and hemoptysis this would be SEPTIC EMBOLI. DDX with Bronchiectasis is that there s a hx of CHRONIC productive cough. DDX of Abscess is foul smell and cavity in Cxr.****Prophylaxis medication guides: 1-Amoxicilline is the DOC in Dental, and Respiratory procedures. In pt with penicilline allergy, Cefazolin, Clindamycin or Clarithromycin is used. 2-In Genitourinary and GI procedures, other than esophageal, the doc is Ampicillin plus Gentamycin. If pt is allergic to penicillin Vancomycin Plus Gentamycin is used****Once you suspect it the next step is to give IV biotics after you draw blood. TEE comes afterwards. Positive blood cultures and vegetatin on the valve seen in TEE confirms dx.****Always suspect IE when a pt is febrile , hx of Rheumatic fever and hematuria. Hematuria in Bacterial Endocarditis is due to glomerlar injury caused by deposition of immune complex. *****If pt has FUNGAL endocarditis then the next step is surgery because they are very aggressive in the valves.
Infertility - 4, OBGYN, 6/2
The first step in WOMEN is to check Basal Body Temperature and mid luteal PROGESTERONE. The ovulatory factor involves defects in the hypo-thalamic pituitary ovarian axis, and related infertility maybe due to impairment of follicular maturation ovulation or endometrial development. BBT assess the DURATION luteal finction and MLP asseses LEVEL of lutal function. Endometrial biposy is done to confirm luteal phase defect. rather than initial evaluation. ****MALES: Male coital factor is responsible for 40% of all cases infertility, common conditions include varicocele, genital tract trauma or surgerydisruption of hypothalamic-pic axis, or Iatrogenic causes like smoking and occupational exposure. The first step in MALE evaluation is sperm count. if its normal then an endocrine hormonal evaluation is carried out. It includes: 1-TFT (since increaed TSH inhibits GnRH and then decrease FSH. 2-Testosterone levels to indicate the presene or not of Gonadism. 3-Gonadotropin to determine whether hypogonadism is central or testicular and 4-Prolactin lelevs. ****Causes of infertility in femlaes falls in 4 factors: 1-Peritoneal factor. 2-Ovulatory. 3-Cervical. 4-tubo-uterine. Peritoneal is the mc type and includes Endometriosis and peritoneal adhesions. Laparoscopy is the procedure of choice. for dx and tx. Mild forms of endometriosis usually respond to meds like GnRH agonists, Danazol and Medroxyprogesterone. 2-Ovulatory factor involves hypothalamus-pit-ovary axis. and infertility might be due to impairment of follicular maturation, ovulation,or endometrial development. ovulatory abnormality may initially be screened by Basal body temp and midluteal phase level of progesterone, the former asseses DURAtion and later LEVEL of luteal function. If luteal phase shows low progesterone, hence infertility, then tx is suppository progesterone deposition. 3-Tubo0uterine is seldom a cause. It onvolves Fibroids, endometrial polyps, tubal occlusion(2ary to IUD or endometriosis). Investigation is ainlt hysterosalpingography or laparoscopy. 4-Cervial involves cervial structure abnormalities and abnormal mucus production. In 5-10% infertility remains unidentified. Intrauterine insemination is the tx. *****Clomiphene Citrate is an antiesterogen that acts by competitively inhibiting esterogen receptors at hypo-thalamus, thus inhibiting the negative feed back esterogen has on GnRH production and consequesntly increasing LH & FSH secretion and improving ovulation. Along with HCG and HMC its indicated for chronic anovulaation. Side effects include large ovaries, hot flashes, abdominal bloating, breast discomfort and abnormal uterine bleeding. Major complications include Ovarian Hyperstimulation Synd and multiple gestations. Danazol is an androgen derivative having a gonadotropin inhibitory effect, indicated in endometriosis, fibroids and fibrocystic breast disease.
Inflamatory Bowel Disease - 2
Erythema nodosum, arthralgias, diarrhea, and positive PANCA ( 60-80% in UC and 10-25% in Crohn) in a young pt are highly suggestive of IBD. ***Any young pt with with bloody diarrhea should make you think of IBD. DDX would be infectious diarrhea, mostly Campylobacter. If pt presents with rectal tenderness and mucus and distended abdomen he might have UC with a fulminant course and Toxic megacolon. Fulminant colitis is a serious comlication, xray shows it. Proctosigmoidoscopy with biopsy establishes Dx.
Influenza
Presnts with, cough,coryza,fever,chills,malaise,sorethroat, muscle pain. Dx is made clinicaly, however a rapid lab test for Influenza antigens srom nasal swap is available. The infection is self limiting b/w 1-7 days. Treat with bed rest and acetaminophen. Two calsses of drugs for prvention and tx are 1-Amantidine (influ-A), 2-Oseltamivir for both A & B.
Influenza Vaccine:
Is recommended in annual basis for all adults over 65 and adults of any age at risk of developing influenza (1-Chronic dis like CV or COPD. 2-Immunocompromised. 3-Nersing home residents. 4-Pregos in 2nd trimeseter in influenza season). This is NOT Influenza B vaccine.
Insulinoma - 2
Pancreatic B-cell tumor. Whipple's triad of attack occurs in fasting, there is hypoglycemia and ingestion of CHO releives the symptom. Tx is surgery. 80-90% are single benign tumor. !0% is malignant.DDX with Sulfunyluria(The sulfonylureas lower plasma glucose primarily by stimulating insulin secretion. SE is hypoglycemia and increased Cpeptide and increased plasma sulfunyluria) and DDX2 is Exogenous insulin admin (normal Cpeptide).
Intellectualization
Helps the pt to be emotinaly detached from the wrong doing (murder) or unacceptable fact (cancer). DDX:Rationalization is a logical reasoning for an upsetting event rather than the true reason (students says they failed me).
Interestitial Lung Diseases
1-Extrinsic Allergic Alveolitis or Hypersensitivity Pneumonitis, due to exposure to organic dust like fungal sporres or actinomyces, Farmer's Lung and Bird Breeders are two examples. Features are fever, sypnea and non productive cough. Cxr shows interstitial infiltrates. PFT shows restrictive pattern (Reduces total lung volume). The best tx is aviodance. 2-Alveolar Proteinosis, accumulation of phospholipid rich material in alveoli. It presents with dyspnea and cough. Cxr shows Bilateral alveolar infiltrate and PFT shows restrictive pattern. Dx is lung bipsy and PAS positive material. Tx is total lung Bronchoalveolar lavage. 3-Acute Interestitial Pneumonia, an acute fatal disorder that rapidly progress to pulmonary fibrosis. It presents in >40 people, fever, breathlessness and cough. Pt has hypoxia and requires ventilation. Cxr shows diffused bilateral alveolar infiltrate. 4-Asbestosis, Its initial presentation may be Obstructive. Presents with Pleural Fibrosis. Its exposed to IN organic dusts.
Intermittant explosive disorde
Is an impulse control disorder. Characterized by multiple episodes of assault resulting from aggressive impulses, out of proportion to any stressor. Its asso with abnormality in serotonergic pathway of limbic system.
Internal carotid a. occlusion
most commonly manifest in ocular disturbances and ischemia in middle cerebral artery territory.
Interossseous access
whenever pediatric iv line cant be found, this is the best place for it.
Intestinal Obstruction:
If hay simple mechanical obstruction then both Barium enema and Naslgastric tube+IV fluids+NPO would be appropriate. But if hay obstruction with metabolic acidosis and shock, then laparotomy is the only way to go and Laparoscopy is CI due to shock & acidosis.
Intestinal perforation:
Best test is standing abdominal xray. Used for PUD rupture. If negative then US, Ctand DPL is indicated.
Intra abdominal bleeding
Once you know the pt is bleeding into the abdomen the next thing to do is either US or Diagnostic Peritoneal Lavage to find out the location of bleeding and then exploratory laparotomy.
Intracranial Pressure:
Increased ICP is indicated by 1-Bilat dilated pupils. 2-Anisocoria, pupils are non reactive to light. 3-Flacidity or decerbrate motor posturing. 4-Papiledema. Glascow is not anindication for increased ICP.
Intraductal Papiloma:
A benign tumor of lactiferous ducts. Clinically manifest as serous bloody discharge. Mamo wont show it, too small. Resection has to be done to relief pain guided by galactogram.
Intra parebchymal hemorhage -2
Due to hypertension, think of Straie arteries that cause bleed in parenchymal in Basal Ganglia.***** HT is the most important risk factor. 1-Cerebellar hemorhage: acts for 16% of cases. Pt presents with Ataxia,vomit,occipital HA, gaze palsy. NO HEMIPARESIS. Emegent decompresion may be life saving. 2-The mc site of hypertensive hemorhage is Putamen, 35%. Internal capsule is always affected thereby leading to HEMIPARESIS. Other signs are hemi-sensory loss, homonomous hemianopsia. stupor and coma. The eyes are deviated form paralytic side. 3-Pontine is accounted for 5-12%. Pt presents with DEEP COMA, and paraplegia that developed w/i minutes. Pupils are pinpoint and reactive to light. No horizontal eye movement.
Intrahepatic cholestasis of Preg
Jaundice in the third trimester of pregnancy should be evaluated for hepatic disorders specific for pregnancy. Marked pruiritis and elevation of bile acids should make you think of ICP. Tx includes Cholestyramine with or w/o Phenobarbital or Ursodeoxycholate. Fetal monitoing is mandatory. DDX is Primary Billiary Cirhosis, intense pruiritis, makredly elevated Alk phosphatase and cholestrol levels. DDX primary Sclerosing Cholangitis is asso with UC, presents with RUQ pain,Jaundice and pruritis.
Intratrochanteric Fracture
Of the femur is mostly seen in elderly fall. The extremity is shortened and rotated. Xray is Dx. Tx is internal fixation with sliding screw and plate and EARLY mobilization.
Intrauterine fetal demise
It’s the death of the fetus in utero that occurs after 20 weeks gestation and before the onset of labor. Its suspected when mother reports the disappearance of fetal movements, decrease or stagnation in the uterus size and no heart tones. The most appropriate to confirm is Real Time US, which will demonstarate the lack of movement and absence of fetal heart activity. After dx is established coagulation profile has to be determined to to detect an eventual DIC, which is a serious complication of IUFD early in the course.
Intra Ventricular Hemorrhage of the new born:
Occurs in low birth weight infants. Its most commonly seen in premature infants. Pt presnts with palor, cyonosis, hypotension, seizures, focal neurologic signs, bulging or tense fontanels. So transfuntanel US is mandatory for all infants with risk factors.
Intussusception
2-yr old child with abrupt onser of abdominal pain,nasea,vomit, red current jelly stool containing blood and mucus. 75% of pts are yonger than 1-yr old, the mc is in Ileiocolic. Sausage like abdominal mass and draws knees towards chest.
Iron Def Anemia - 8. Hemo. 6/3
Fe normal is b/w 50-170. Decreased Fe, increased TIBC (460), MCV=68 and hypochromic microcytic anemia. Infants are at increased risk of this disease due to lack of Fe in milk. [DDX1 is Sideroblastic Anemia, is apart of utilization anemia which is caused by inadequate or abnormal utilization of intracellular Iron for Hb sysnthesis despite increased amount of Iron, sometimes it help to give Pyridoxone (B6)]. IDA is the mcc of anemia, suspect it when a person is not eating well and lab shows microcytic hypochromic anemia. **** In elderly, blood loss from GI will lead to Fe def anemia. Since fecal blood test is NOT sufficient we need to do Colonoscopy because in elderly pt w/o GI complain, the cause is probabely cancer. ****Its the mcc of anemia in children. The early intruduction of Cow milk to infants diet clearly asso with iron def anemia, the larger the amount of milk consumed the higher the risk. Typical lab shows, low MCV, low Hb, Low hematocrit, low reticulocyte count, microcytosis, hypochromia, low serum Iron, elevated TIBC. Low serum feritin is diagnostic for IDA. Infants should receive breast milk for the first year or iron fortified formulas. iron fortified cereal should be added the first 4-6 months. DDX1:Thalasemia, High Ferittin and signs of extramedulary hemopoises (hepato/spleno megaly and widened bones.). *****Microcytic hypochromic anemia due to chronic blood loss (Iron def anemia) results in decresed serum Fe, Ferittin, Transferin Saturation, and increased TIBC. DDX:Sideroblastic naemia has, Increased Fe, noraml Ferritin, Increased TIBC, normal to incresaed Transferin saturation. DDX2 Anemia of Chronic DISEASE will show decreased Fe, increased Feritin, low TIBC and low Transferin saturation. ***The mc type of anema in elderly pts. This pt presents with Fatigue and palor. Another cause of IDA is cheronic diseases like infections, inflamatory dis, neoplasm. ****BMIron stain is the most definite way to dx IDA. Low feritin, increased TIBC, Low Iron are not as specific.
Iron Poisoning
Presents with N&V and Diarrhea and abdominal pain, GI bleeding and Metabolic acidosis. Fe accumulates in mitchochondria and resulting in cellular damage. Hypotensio nthen occurs due to increased vascular permeability and venodialation. Since Iron tablets are radiopaque they will be seen on Xray. Dx is confirmed by serum Fe levels. IV Defroxamine is tx. DDX is Aspirin Tox, presents with lethargy,fever,hyperpnea,vomit, tinnitus and metabolic acidosis. Abdomen Xray is unremarkable.
Ischemic Colitis
MC site is Splenic flexure because its supplied by end arteries, It’s a 'watershed' area b/w superior and inferior mesenteric A.*****Ischemic colitis is due to onstruction of IMA. After AAA repair, diarrhea and blood in stool should raise suspicion. If CT is inconclusive a sigmoidoscopy is recommended. Angiogram is not recommended. Barium enema could cause perforation in case of IC. It’s a good technique for detection of colonic masses.
Isolated Proteinuria
IP (w/o pyuria or Hematuira) can happen due to stress or any febrile illness. Evaluation of pt should begin by testing the urine on at least three occasions (dipstick testing).
Isoniazide Tox
It might cause elevation of AST ALT in the beginning, do nothing it will decline.
ITP - 2
Idiopathic thrombocytopenic Purpura is an autoimmnue disorder characterized by isolated thrombocytopenia absecence of splenomegally, absence of fever or other systemic signs normal BM with normal or incresed Megakaryocytes.. ITP is acute and self limiting in children, but becomes chronic in adults. It presents with skin or mucosal bleeding. Coagulation studes are normal. Autoimmnue destruction of platelets maybe primary or it may be 2ary to SLE or infection with CMV,Toxoplasma, HIV. Whnever pt is having Chronic ITP BM must be exam must be performed to rule out primary hematological disorder. Pt must also be screned for SLE by anti niclear antibody testing, as isolated Thrombocytopenia may be a presenting feature of SLE, especially in a young female. Now, if a pt shows hepatomegaly, lymphadenopathy,or atypical lymphocytes , 2ary causes of autoimmune thrombocytopenia like CMV, HIV, Hepatitis and toxoplasma should be cinsidred. ***The mc acquired bleeding disorder in childen. It follows after viral infection, with easy bruisability,and petechia. Thrombocytopenia and normal PT&PTT. DDX:HUS, combination of Thrombocytopenia,Microangiopatic hemolytic anemia and Acute renal failure.
IUGR - 2
IUGR is defined as birth weight below the 10% for a given gestational age, and refers to fetuses and neonates whose growth potential has been restricted by pathologic processes in utero. These fetusus are particulary prone to problems such as meconium aspirarion, asphyxia, polycythemia, hypoglycemia and mental retardation. IUGR maybe of maternal, , fetal or placental origin. Common maternal causes include poor nutrition, cigarette smoking, drug abuse, alcoholism, cyanotic heart disease, pulmonary insufficiency, and antiphospholipid syndrome. Placentall causes include conditions that result in a lack of decidualization of myoetrial arteries resulting in deficient perfusion of the fetus. Such conditions include Hyper Tension, DM, CRF, and Preeclampsia. Feal causes are TORCH and congenital abnormalies. IUGR maybe symmetrical, the insult to the fetus before 28 week leads to damage to both Head and Body. Its caused by fetal factors. Asymmetrical IUGR is a result of insult after 28 week, only abdominal circumference is small. Its usually caused by maternal factors like DM, Hypertention, Preeclampsia & CRF and it has a better prognosis****The moft effective parameter for estimation of fetal weight in cases of suspected IUGR is Abdominal circumference.****Is defined as birth weight below 10% for a given age. These fetuses are prone to Meconium aspiration, hypoglycemia, and mwntal retardation. Once IUGR is dx fetal well being has to be monitored, with NST and BPP twice weekly. Mother can contribute to this monitoring by assesment of the kick count. Delivery is usually indicated at 34 weeks or when lung is matured. If there is Oligohydramnios, AFI of 4, DELIVERY SHOULD BE STRONGLY CONSIDERED. At birth , neonates with UGR are prone to hypothermia and hypoglycemia. RDS also frequently occurs. So bottomn line is that eventhogh gestational week is 28, go ahead and deliver vaginally.
Jaundice Dx Procedure
Once the pt has jaundice (bilirubin>1, then the next step is to determine if its mostly conjugated or unconjugated. Conjugated hyperbilirubinemia is present when direct bilirubin cinstitues >50% of total bilirubin. Unconjugated Hyperbilirubinemia is present when in-direct bilirubin constitutes >90% of the total bilirubin. Normaly direct bilirubin constitutes <10% of bilirubin. Conjugated HBR occurs in a)Intrahepatic causes:1-intrahepatic obstruction(occurs in viral or autoimmune hepatitis, alcoholic hepatitis, drug reaction, third trimester pregnancy) or 2-Congenital defects in biliary excretion (Dubin Johnson and Rotor). b)Extrahepatic billiary obstruction. Now the next step in pt with Conjugated HBL is to study liver enzymes. Pts with dominant aminotransferase elevation have hepatocelllular dis, whereeas pts wth dominant Alkaline Phosphatase elevation have intra or extra hepatic obstruction. In the second group, its important to rule out extrahepatic obstruction with US or CT of abdomen. If these fail to show extra hepatic billiary dialation then the next step would be ERCP or PTC.
Jervel-Lang-Neilson
Or Congenital 'Q' synd. Syncopal episode w/o following disorientation, hearing impairent, normal PE, and familt hx os sudden cardicac death is characterictic of this syndrome. Tx is Beta blockers
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