Pain Management:
Pt with excruciating pain, even if in rehab for drug abuse, should be getting IV Morphine. Once the bolus morphine is given, the pt can be maintained on PCA (Pt Controlled Analgesics). The advantage is high quality analgesia, Pt and nurse satisfaction and freedom from painful injections. PCA can be used both at home and in the hospital by IV or SC. PCA is used mostly in post operative conscious pt for initiation of parenteral opiod therapy, treatment of incidence pain (trauma) and short term home care intractable pain like cancer pain.
Paget's Dis of Bone - 3
Hx of hearing loss, increased hat size and occasional headahces and elevation of Alkaline phosphatase. Pthophysiology is impaired bone remodeling. Initially increased osteoclastic activity is observed, with following osteoblasts and immature bone remodeling. Eventually, sclerotic bone is formed. Osteoporosis: Bone demineralization. Vit D deficiency: increased osteoid deposition. Primary hyperparathyroidism: Fibrous replacement of the bone. Hypervitaminosis A: Abundant mineralization of the periosteum. *The MCC of Asymptomatic increase in Alkaline Phospatase in an elderly is Pagets, with normal Ca,Phosphorous,normal ALT and AST. *Indication for tx of pts are:1-Bone pain, 2-Hypercalcemia, 3-Neurological defect, 4-High output cardiac failure, 5-preparation for orthopedic surgery, 6-involvement of weight bearing bones. Tx of Asymptomatic pts is not required. Biphosphonates are DOC for Paget's, they inhibit bone resorption(loss of bone tissue which is soaked up by blood), and last for years. Cacitonin also inhibits osteoclastic bone resorption, however its efect on osteoclasts is much weaker than biphosphonates.Tx with Calcium and Vit D has no effect.***PD is characterized by excesive Bone destruction and repair. Its generaly asymptomatic and may be suspected by elevated Alk Phosphatase. Serum Calcium is normal. Overtime 1/3 of pts may develop OSTEOSARCOMAor SACROMATOUS CHAGNGES. This will manifest as Marked bone pain, Lytic lesions and a sudden increase in ALk Phosphate. Bone remodeling is constant in Pagets, both osteoclasts and psteoblast are involved in process but BY ITSELF IS NOT A CAUSE OF PAIN.
Paget's Dis of Breast
Peristent dermatitis of nipple. Red, oozing crusted lesion non responsive to antibiotics or steriods. Biopsy reveals large cells surounded by halo like area invading the epidermis. This disorder is a breast cancer and almost always there is an underlying breast carcinoma present. Most commonly this is an infiltrating Ductal cell carcinome but occasionally ductal carcinoma in situ.
Pancoast Tumor
In a smoker with arm pain, cough and weight loss, mass in the lung apex is PT unless proven otherwise.
Pancreatic Carcinoma -5
Risk factors are: Family hx, Chronic pancreatitis, smoking, DM, Obesity and a diet high in fat. Alcohol is not a risk factor. *****Abdominal US is initial choice in pt with Jaundice. However they are usually not clear so the next step is CT has higher sensitivity for suspected pancreatic cancer. ****Anorexia,weight loss, painles jaundice in a smoker with increased Alkaline phosphatase and abscence of gallstones is suggestive. CT of abdomen is the next best thing, its very sesitive for PTtumor.Then we can do ERCP to get biopsy or refer to a high volume surgery unit to do Whipple’s procedure and remove tumor. Percutaneous Transhepatic Cholangiogram (PTC) is to asses biliary duct not PT. CA-19 is good for PT not for Dx of PT. Amylase is good for Pancreatitis no PT.
Pancreatitis, Acute - 8
Hypertriglyceridemia > 1000 mg/dl can cause AP. If its due Acute Cholesystitis, once the pt is stabalized perform cholesystectomy. Management is conservative, pain med, iv fluid, npo, nasogastric sucction.****Development of palpable mass in epigastrium 4 weeks after theacute pancreatitis is Pseudopancreatic Cyst. They are not true cyst, they lack epithelial lining. Collection of fluids,tissue,and necrotic debris. Amylase rich fluid leaks out so Amylase is increased. USG is dx of choice. THey should be drained ONLY if they persist after 6 weeks and are >5cm.*****Serum Lipase and Amylase is the first step in confirming dx and the most sensitive and specific test for AP, not ERCP(its used for CBD and Chronic pancreatitis). CT is used only if the pt is not responsing to management and we need to see if there are any complications. *****The 2 mcc are Alcohol and gallstones. If pt isnt alcohoic then cause is Gallstones. So the next step is to do US to llok for stones. CT cant help with Gallstones, but its good for necrosis and Cysts. CT is indicated when pt has WBC>20000 and Necrotizing pancreatitis is suspected. HIDA is for calculus or acalculus Cholecystitis. ****Cyst+Fever = Abscess. In AP the abscess needs to be drained EXTERNALY. Abscess needs to be drained, Pseudocyst can be managed conservatively .****In severe pancreatitis and 2ary paralytic ileus , naturalization of acidic pH with antacids should be considred, for severly illpts, to prevent gastric stress erosions.
Pancreatitis, Chronic - 5
Admit to hospital is pt has weight loss, pain, steatorrhea (malabsorption, best test to confirm it is 72hr fat in stool collection, if >7g/d its positive), malnutrition. CT to rule out pseudocysts and dialatation of the duct, when duct is dialated a cm the best tx is lateral pancreaticojejunostomy. This relieves the pain and improves nutrition.****PseudopancreaticCysts: are untouched for 6 weeks if they are <5cm. If it doesnt ersolve then either do percutaneous drainage or gastrostomy.****Surgical intervention is needed in case of chronic pseudocyst and debiliating pain (due to compaction of stones in pancreatic duct). Tx is ERCP with removal of stone and stent insertion. Partial panreatectomy is the last result, if ERCP didint work.**** Pt with recurrent pancreatitis after US is done should go under ERCP and BYPASS CT because CT is not good for pancreatic and billiary bile ducts and would miss microlithiasis.*****Lateral Pncreaticojejunectomy can provide relief for chronic pain.
Panic Disorder - 3
Women 20-40. Sense of IMPENDING DOOM. Acute tx is Benzodiazepine, takes effect immediately. For long term tx use SSRI or TCA with conginitve therapy or behavior. ALSO according to Valia, Panic attack is asso with mitral valve ProlaPs.***Of the two drugs for PA, Alprozolam has a Seisure attack due to withdrawl that happens ina few days of not taking the medication. But Diazepam, does not give you seisure that quckly. So if pt comes with Seizure and didnt take panic drug for a few days Alprozolam is the drug.****Pts suffering from Panic dis are at increased risk for DEPRESSION, agorophobia, GAD and substance abuse.
Paranoid Personality:
Cluster A (odd, eccentric), distrust and suspicious to others. Negatively interpret actions and words. Hold grudges for long time.
Paralytic Ileus
Absent bowel sounds with gaseous distention of both small and large bowels are indicative.
Paraneoplastic Syndromes
Hypercalcemia is the mcc of PNS (confusion, lethargy, fatigue, anorexia, constipation, polyuria) it is asso with Squamous cell carcinoma of the lung . The classical pathophys responsible for hypercalcemia of the malignancy is the production of PTH related peptide (PTHrP), which is homologous with PTH. Serum Ca is Increased and Phosphate is decreased *****Myopathy in asso with PS: PS can manifest as muscular weakness. Proximal muscles are typically affected and strength is diminished symmetrically. Reflexes are normal and no sensation abnormality is detected. Elevated Ck and myopathic EMG help to confirm Dx. Pathology in PS is in the muscle membrane, in MG is in Postsynaptic membrane, and in Lambert-Eaton is in the Presynaptic membrane.
Parenchymal Brain Hemorrhge
Always susprct it whn pt has hx of uncontrolled HT and then prewtns to ER unconscious with focal neuro signs.
Parinaud's Synd
Consists of paralysis of vetical gaze that maybe asso with pupilary disturbances and eyelid retraction (Collier sign). Most commonly caused by Pinealoma. Pt ( 10 yo ) prestns with facial hair and 2ary sex characteristics, plus vertical gaze and Collier sign. DDX is Craniopharyngioma that does not cause the Collier sign.
Parkinson's - 2
The most effective symptomatic therapy is L-Dopa.*** First drug to use for tremor and rigidity is Benztropine.*****asso with Seborrheic dermatitis.
Parox Supra vent tachycardia
Test-1, Q-43. See picture. DOC is IV Adenosine
Paroximal Nocturnal Hem.- 2
PNH. A red cell membrane defect causes increasing binding of complement to the red cell leading to increased intravascular hemolysis resulting marked anemia. Since RBC is more suseptable to hemolysisi in acidic environment and serum is more acidic at night, lysis occurs at night and morning urine shows red urine. Thrombosis of Hepatic vein is a cc of death in these pts. Lab shows increased LDH, bilirubin and reticulocyte. Test specific to PNH is sugar-water test and the Acidified Hemolysis test (HAM test), which determines increased suseptibility to cell lysis by complement . DAF (decay Activating factor) is diminished in PNH. DDX1:RBC enzyme def (G6PD def) results in suden hemolysis after drugs or infection. DDX2:Peripheral destruction of RBC is seen in Hereditary Spherocytosis.****Is an acquired disorder that should be considered in ALL CONFUSING cases of hemolytic anemia. emolysis is intravascular with low serum haptoglobin, and elevated LDH. Loss of Ironin urin may lead to iron def anemmia. Congestive splenomegaly is a complication. BM maybe hypocellular. Flow cytometry is a better choice for dx vs Ham test, it shows absence of CD59. DDX1:Aplastic Anemia,BM is hypocelllular, but peripheral blood smear does NOT show abnormal cells. RBC are normo or macrocytic.There is NO hemolysis or Slenomehaly. SUGER test is for dx of PNH.
Parvo Virus infection - 2
Parvo virus infenction involves joint. , its symetrical, hands, wrist, knee and feet are mostly affected. Rash may or may not preent. Pt has Arthralgias or arthritis, mc in femlaes. Pt presents with pain in small joints, arthralgia and arthritis. **** School teacher gets it. Anti-B19 IgMis the dx of choice.
Passive aggressive behavior
A mature defense which an individual expresses aggression toward other person with repeated , passive failure to meet theother person's demand. A secretory wont let you talk to the doctor because she had an argument with you.DDX is acting out. A child throws a temper tantrum.
Patient consent
If pt needs transfusion and wife says its agianst his believes, go ahead with transusion. Now if Pt himself is awake and tells you that he dosnt want transfusion then you use other alternatives, Plasma.
PCP toxicity –3. Poison 6/3
Characterized by violence, vertical nystagmus, confusion, ataxia. DDXCOCAINe causes tachycardia, ht, sweeating, mydriais.****LSD is like PCP but agitation and agression is more in PCP. Visual Hallucination (Flash backs) are hallmarks of LSD.
Pediatric CNS tumors:
Infratentorial tumors are more common. And benign astrocytomas are the mcc type. CNS tumors are the mc solid tumors & 2nd mc malignancy after Leukemias. Meduloblastoma is the 2nd mc tumor in posterior fossa, 90% arise from Vermis.
Pediatric Immunology:
1-Hyper IgM syndrome: Characterized by high levels of IgM, w deficiency of IgG and IgA and poor specific response to immunization. HIM presents with recurrent sinopulmonary infections and PCP. The unique suseptability to opportunictic infections and neutropenia DDX it from XLA and other conditions.
2-X-link Agamaglobinemia or Bruton’s: characterized by 4 findings, a-onset of recurrenct bacterial infections in 1st 5 years of life, b-IgG, IgM and IgA are very low, c-poor response to vaccination, d- <2% CD19+B cells in peripheral circulations.
3-Common Variable ID: presents with low IgG, IgM and IgA levels, but normal B cells. Clinically they present with recurrent sinopulmonary infections like XLA. Most pts don’t become symptomatic until 15-35 years.
4-Selective IgA deficiency: is the mc well defined ID disorder. Infections occu predominantly in respiratory, GI and urogenital tract. Serum concentrations of other IG are normal. Dx is IgA <50 with no other immune defects.
5-Selective subclass IgG def: Its seen in pts with recurrent infections despite normal IgG levels.
6-Severe Combined ID: is a life threatening synd. Presents w recurrent sinopulmonary infection, oral candiasis, persistant diarrhea, opportunistic and viral infections. Dx is confirmed by absent lymph nodes and tonsils, lyphopenia, absent thymic shadowon Cxr. And abnormal B & T cells.
7-Wiskot Aldrich Synd: is an X-linked recessive dis, caused by a defective gene encoding for WAS protein. Classic presentation is young boy with eczema, thrombocytopenia, and recurrent infections w encapsulated germs. Initial manif is at birth and consist of petechia, bruises, bleeding form circumcision, or bloodt stools. Low IgM levels, high IgA and IgE levels reduced T cells and platelets.
8-Chronic Granulomatous Disease: a defect of phagocytic cells, due to dsfunction of NADPH oxidase enzyme complex, leading to recurrent and uncontrolled infections w catalse positive organisms (Staph, Seratia, Klebsiela, Aspergillus) and not susceptible to catalase negative (Strep and H Influenza). The mc infections are lymphadenitis and abscesses of skin and visera. Lymphocytes are normal. Dx is by Nitro blue tetrazolium test. Tx is prevention with DAILY Trimeta-Sulfa and Gamma Interferon three times a week BMT is Curative.
9-Transient Hypogamaglobinemia: is characterized by decreased IgG levels, normal IgA levels, and variable IgM levels. These Igs normalize by 6-11 month of age.
10-Di-George Syndrome: Typical of an infant with hypocalcemic seizures. Pathology is defect of 3&4th pharyngeal pouch leading to hypoplastic or aplastic thymus and parathyroid glands.
11-Chediak Higashi Syndrome: characterized by decreased granulation, chemotaxis. It’s a multisystem disorder , peripheral and central neuropathy, hepatospleenomegaly, pancytopenia, partial albinism, infections w Aureus. The fiding of neutropenia and giant lysosomes in neutrophils will confirm Dx. Tx is prevention with Tri-Sulfa daily and daily ascorbic acid.
12-Leukocyte Adhesion Defect: result from failure of innate host defenses against bacteria, fungi due to adhesion targeting. Pt has hx of delayed seperation of umbilical cord, recurrent bacterial infection, necrotic skin lesions, severe gingivitis.
13-Job’s Syndrome: or Hyper IgE syndrome. Characterized by chronic pruritic dermatitis, recurrent Staph infections (resp and skin), markedly elevated IgE, eosinophilia and coarse facial features.
Pediatric Jaundice:
1-1st 24 hrs: requires immediate attention, maybe due to erythroblastosis fetalis, concealed hemorrhage, sepsis or infection.
2-2nd & 3rd day: is usually physiologic.
3-3rd day to one week: suggets bacterial sepsis or UTI and requires prompt and aggressive attention. Sepsis in neonate rarely causes neck stiffness or boging frontal or shock. The clues are poor feeding, lethargy, womiting, or alteration of activity. The first step is to do a blood culture and a lumbar puncture.
Pediatric Meningitis:
1-Group B Strep: mcc of meningitis in infants. Usually acquired form mother duting childbirth. Its not asso w rash and very unlikely for a 18mo child. 2-Meningococemia, suspect it in a neonate with petechial rash. 75% present with rash in trunk, wrist, ankle. 3-H. Influenza, 6-48mo, no rash involved. Antigen is in CSF. 4-Listeria can cause meningitis in newborn vaginally, it doesn’t cause rash. Anotehr mode of transmission is from unpasterized milk. Mc in DM mothers. 5-Aseptic; Always due to viral cause. CSF shows, lymphocytosis, WBC<250, protein <150 and normal glucose. Typical pt is alert and cooperative but uncomfortable and ill.****1-New Borns: Group B Strep is 70%, then Listeria 20% and S. Pneumonia 10%. 2-From one month to 2 years S. Pneumonia is 50%, then Nisseria 30%, then Group B Strep 20%. 3-From 2-18 years Nisseria 60%, then S. Pneumonia 25% and H Influenza 10%. 4-In Adults >18yo S. Pneumonia is the mcc 60-70%.
Pediatric Rheumatic fever:
Suspect it in children with low grade fever, pericarditis, sore throat, arthritis, chorea, and subcutaneous nodules. Erythema marginatum, elevated ESR and prolonged PR. Its caused by GroupA Strep. Dx is made w two major or two minor and one major Jones Criteria are satisfied. Five major criteria PECCS (Polyarthritis, Erythema marginatum, Carditis, Chorea, Subcutaneous nodules) and three minor FAR (Fever, Arthralgia and Previous RF). Tx is Benzathin PenG. . If chorea give antiepileptic, Pericarditis give salicylates and Arthritis give codeine.
PEEP - 2
Positive End Expiratory Pressure, refers to develpoment of positiv epressure inside the thorax resulting in decreasing venous return. Decreased venous return leads to decreased cardiac output, which ultimately leads to hypotention. The increased ventilate rate causes development of auto PEEP by not allowing enough time for expiration. Thus, the ventilator delivers a tidal volume, in addition to that is still in the lung at the end of the expiration, which is already inside the lung. This produces positive prssure. The most appropriate step when Hypotension happens is to decrease the respiratory rate, to allow the lung to deflate in b/w respirations.****When PEEP is increased its major drawback is decreased CO. Pts who are maintained on PEEP should be monitored with Swan Ganz cathater. PEEP has no direct effect on Sytolic BP or Systemic Vascular Resistance. ****If Tidal Volume is too high, 800, reduce Pressure support and increase ventilation rate to not to increase pCO2.
Peitonsilar abscess - 2
Fever, sore throat, dysphagia, trismus, pooling of saliva and muffled voice. Management includes needle drainage(trendelenberg position) close monitoring and IV antibiotics.
Pellagra
4Ds.*****Most commonly in people with corn diet. Also in Alcoholics and people with Carcinoid tumor. Characterized by 4Ds: 1-Diarrhea, Dementia, Dermatology (skin rash in sunexposed areas), Death.
Pelvic Abscess
Percutanous drainage is the procedure of choice. If it fails then Laparotomy with debridment and drainage is indicated.
Pelvic Trauma:
Xray should be doen in ALL pt with trauma to pelvic to screen for pelvic injury. Not CT.
Pemphigus Vulgaris. Dermo. 6/3
Mucocutaneous blistering with flaccid bullae, with IgG deposit in intracellular in dermis. Autoantibodies against desmogelin. First appears in Oral mucosa. Easy seperation of edidermis on superficial pressure (Positive Nikolsky sign) is characteristic. For tx use steroids. DDX:Bulous Pemphigoid, tense blisters, IgG and C3 in dermal-epidermal junction.
Penile Fracture:
From women on top. Surgical exploration is the tx of choice but it should always preceded by retrograde urethtogram to rule out urethral injury
Peptic Ulcer Dis - 3
If perforation occurs the first step is Upright abdomnal Xray. Now although the symptoms might suggest that pregnany is a DDX, do xray first to rull out the most dangerous possibility. ***** PUD can lead to gastric ouotlet obstruction. , unceasing vomiting and dehydration resulting in Hypocholeremic Met Alkolosis. Corrected with 0.9%NaCl. This kind of Alkolosis is usually accompanied with Hypokalemia. POTASIUM supplementation is indicated whenever NG suction is done.SO tx is Potasium Chloride.*****MC comlication is Hemorrhage.***PUD causes sudden inset of severe epigastric pain, spreads to the whole abdomen, and upright films show air under diaphram. DDX is Cholecystitis and Diverticulitis, which wont have such sudden onset and short clinical course. DDX Biliary Cholic will give more localized pain w/o rebound.
Pericardial cyst:
Diagnosed with CT. Located at the middle mediastenum and are benign. The fluid can be aspirated and the cyst will shrink. Surgery is NOT indicated. Other medial mediastinum masses are Bronchogenic cyst, lymphoma, and aortic aneurysm.
Pericardial Tempnade
Preents with Beck's triad, Hypotension, elevated JVD and muffled heart sounds. DDX: In case of hypotension due to bleeding, jvd will be decressed compare to PT or Tension Pneumothoras. In TP mediastinum is deviated, but in PT its not. ****Pulsus paradoxus is a dx clue.
Pericarditis, Acute
When combined with renal failure is Nephritic Synd that leads to Uremic pericarditis, which is an indication for Hemo dialysis. If vascular access is not possible then we do Peritoneal dialysis. *****Severe constant pain that localized to anterior chest, radiates to arm, back, shoulder, epigastrium, is intensified with respiration, releived by sitting up or leaning forward. MCC by Coxackie virus. A hx of current viral illness is common. EKG shows, 1-Diffuse ST elevation with cncavity at "J" point, 2-PR elevation. Uremia can cause Pericarditis and this may represent an indication for dialysis. *****Uremic Pericarditis: Its seen in 10% of chronic renal failure pts. UP is an absolute indication for Dialysis. Pericarial fluid in UP is most often Hemorrhagic. Clinical features are the same as Pericarditis, but BUN is >60and there is Anemia. Most pts responde rapidly to dialysis with resolution of chest pain. as well as decrease in size of pericardial effusion. Indications of Dialysis are :1-ABSOLUTE indications are fluid overload not responsive to tx, HyperKalema not responsive to tx, UP, Refractory metabolic acidosis. 2-RELATIVE indications are GFR<10, Serum Creatinin <8, severe uremic symptoms (Seizure and coma are indication of immediate dialysis). 3-CI to dialysis are Debiliating chronic dis, and severe irreversible dementia. Remember NSAID (and sometims corticosteriods) are 1st line tx for Pericarditis. Also for Pericardial Temponade Pericardiosenthesis is indicted. *****Once you dx PC the next sep is to start Hemodialysis not NSAIDS. Indications for dialysis are: 1-refractory hyperkalemia, 2-Volume overload and pulmonary edema not responding to diuretics. 3-Refractory metabolic acidosis (pH<7.2). 4-Uremic pericarditis, 5-Uremic encephalopathy or neuropathy, 6-Coagulopathy due to renal failure.
Peripheral Artery Aneurysm:
Manifests as a pulsatile mass that can compress adjacent structure (nerve, vein) and can result in thrombosis or ischemia. Popliteal and femoral aneurysms are the mc PAA. Frequently asso with AAA. Pt has all the atherosclerotic risk factors.
Peripheral Artery Disease
Goal of therapy for occlusive arterial dis of lower extremity is to relieve pain, prevent limb loss and maintina gait. Most pts
with Intermittent claudication remain stable with conservative management. Majority should be given exercise and aspirin. Over 75% remain stable. Angiogram is not required if pt has no evidence of ischemia, infection, gangrene or loss of pulse. If surgery is not planned a duplex arterial study may suffice.
Peritonitis, primary
Abdominal pain with guarding and fever in a pt with ascites is suspicous. Most likely pt has peritonitis secondary to paralytic ileus. If pt has signs of peritoneal fluid (shifting dillness) then diagnostic Parecenthesis is the simplest rest to perform. It may reveal signs of Exudate: Turbid fluid, >250 Leukocytes, Protein >2.5, Serum to Ascitic albumin gradient <1.1, and Specific gravity >1.016.
Peritonsilar Abscess ( Quinsy ):
Unilateral sore throat, neck pain, refered ear pain, dysphagia with swollen tonsils, Trismus is characteristic. *****It is a supporative complication of Acute Tonsilitis. Senario involves a pt with sore throat, dysphagia, trismus, pooling of saliva and muffled voice. Uilateral and vervical lymphadenitis and deviation of uvula. Management includes needle drainage (in Trendelberg position), close monitoring and IV antibiotics.
Pernicious Anemia
PA is the mc megaloblastic anemia. B12 def is caused by intrinsic factir def 2ary to gastric atrophy. There is also basophilic stippling. Dx is with achlorhydria, dec IF, dec B12, extremely elevated LDH. ***DDX is with Lead poisening since they both have basophilic stippling. Lead poisening presents like Iron def anemia, MCV<80.
Pesticide poisoning
First step in mgmt is to remove the source of poison ( if pt vomited the poison remove cloths to remove source os poison).
Pharyngitis, Strep
A 7 yo with fever,erhythema of pharynx has Pharyngitis, if Rapid dx test for Strep is positive the next step is to give him One IM dose of Bezatin PenG (which is IM), not IV aqueous crystalite PenG. Or 10d oral Pen V (which is Oral). If allergy then Erythromycin is used.
Phencyclidine intoxication
Causes psychotic symptoms.
Phenelzin CI
It’s a MAO inhibitor and its use is CI with SSRI (Paroxetine). Its called serotonin synd and presents ith hyperthermia,rigidity and altered mental status. Its given to Depresed pts with SIGECAPS. Another SE is Hypertensive Crisis that occurs with wine and chocolate.
Phenytoin SE
causes Folate def. (megaloblastic anemia)
Pheochromocytoma - 2
Always give alpha blocker first, followed by beta blocker. If you do it the wrong way you can precipitate a very dangerous increase in BP. ***Sudden attack of palpitation, HA, prophuse sweating.
Physiologic jaundice
Is seen in ALL new borns. Begins on the 2-3 day and resolves w/I the first week. Pathophys is increased billirubin production, decreased billirubin, clearance and increased enterohepatic circulation. DDX:Naeonatal Sepsis, jaundice after the 5th day and w/i one week. DDX:Breast milk , jaundice that starts afte the first week. Cessation of breast milk and replacement with formula will reverse it. *****Jaundice after 5th day and w.i 1st week is Neonatal Sepsis. Jaundice notices after the 1st week is Breast milk jaundice. Jaundice w increased at birth or w/I 24hrs is due to Erythroblastosis fetalis.
Pick's Dis
Fronto-Temporal dementai. Personality change (disinhibition, apathy, euphoria), compulsive behavior(peculiar eating habits, hyperoraliry) and impaired memory. May be positve famly Hx. DDX1:LEWY BODIES:fluctuating cognitive impairment. Bizzr visual hallucinations may occur. Parkinsonism may occur. DDX2:MULTI-INFARCT:congnitive dysfunction with motor and sensory dysfunction. DDX3:NEUROSYPHLIS:Pt maybe psychotic and personality change but NO family Hx..
PID - 2
Is suggested by triad of abdominal pain, uterine and adnexal tenderness, and cervical motion tenderness. Other criteria are fever, cerviac/vaginal mucopurulent discharge. Criteria for hospitalization include: pregnancy, outpatient treatment not responding, noncompliance, severe illness and abscess. A common regimen for severe PID is Cefotetan (2gr IV every 12hrs), or Ceftriaxone (2gr IV every 6 hrs)+ Doxycycline (100mg PO or IV every 12hrs). ***** severe PID presents with nausea nd vomiting and high fever (103), so admit pt. Mild PID just single IM Ceftriaxone and 7 day PO doxycycline or Azithromycin.
PKU
Auto rec. In fair skin,blue eye, rash, musky oddor pts with vomiting in a month old neonate. Dx is Guthri test , a qualitative test for colr, shows metabolites of phenulalanin in the urine. Tx is low phenulalanin, low protein diet.
Placenta Previa - 2
PP presents with painless vaginal bleeding in the 3rd trimester. Dx is with US, accuracy of 90% transabdominally and 100% transvaginally. Pelvic exam is CI. Risk factors are: multi parity, advanced age, multiple gestation. If the bleeding continues, C-section has to be done ASAP. Even if pregnancy is not term yet. In cases of extended bleeding surgeon might discover A Placenta Acerta. Now if the mother is stable and fetus is at term, scheduled C is choice. However, until then pt has to be monitored closely. If both mother and fetus are stable IM steriod are used to mature the lungs. Forcepts are not used in complete PP.*** In any case Vaginal delivery is not an option for any kind of PP. If both mothe and fetus are OK and there is no more bleeding and mother has access to close hospital then she can be sent home and monitored at home until 36week, then schedule c-section is done.***** Pt with complete PP, after bleedng is controlled and both baby and mohter are fine, Schedule Elective C-section.
Pleural Effusion
When the lung is dull, Cxr shows half of lung is white its due to effusion, too much fluid in pleural space causes collapse of partial lung. , the first step is to find the cause , so managmnt starts with whether its exudate or transudate. Diagnostic Thoracocenthesis is the preliminary procedure of choice, EXCEPT in CHF pts where a diuretic is used. Thoracocenthesis is a bed side, minimal invasive. If its Exudate furhter procedure is followed. Learn what causes transuddate vs exudate. (ie Cancer causes exudate). Now Bronchoscopy is an alternative, but since its very invasice TC is donr first, if its inconclusive then next step is Bronchoscopy. *****MCC of PE is CHF. Transudate effusion. The important diagnostic criteria for separating pleural fluid into transudate and exudates are : measurement of serum and pleural fluid protein & LDH levels. At least one must be present for exudates. If non is present its Trans. Pleural Fluid Protein/ Serum is >0.5, PF LDH/S LDH >0.6. Determination of pH is important in parapneumatic effusions in which a value of <7.2 requires a chest tube aspiration to prevent empyema. Normal PF is 7.46. Pleural pH <7.3 is inflammation. PH of 7.35 is transudate PE.
PMS
A menstural diary for at least 3 months is a useful aid for confirming PMS. PMS is confirmed when one or severl particular symptoms occur repeadedly at the same cylce interval. Like anxiety, mood swing, bloating,decreased libido, difficulty concentrating. Tx depends on the pt and problems. Decrese caffein may help with anxierty, SSRI is the DOC for mood change
Pneumomediastinum:
May accompany spontaneous pneumothorax: the air from ruptured alveoli or bulla dissects along the vessel into the hilum and mediastinum. Pneumomediastinum asso w SP usually respondsd to chest tube drainage and doesn’t need surgical decompression, unless its very massive and causes cardio-vascular compromise.
Pneumococcus Vaccine:
Recommended for 1-adults >65. 2-Chronic dis like CV and COPD. 3-Immunocompromised and DM. Chronic alcoholics. A one time booster is given 5 years after primary vaccine in elderly.*****It’s a T cell independent B cell response mechanism.
Pneumonia - 10
1- Community acquired(mcc Strep P. in nursing homes). 2-Legionella: Any elderly pt w pneumonia, abdominal pain, confusion and hyponatremia should be suspected. Also if beta lactam antibiotics fail. The definite dx is ELISA and tx is hig doze Erythromycin or Azithromycin. 3-Nosocomal : Pseudomona is the mc considered G- aerobic bacili in ddx of G- infections and is a cc of G- Nosocomal pneumonia.Its seen in mechanically ventilated pt and intubated pts. Tx is IV 4th generation cephalos like Cefepime or Ceftazidime. The new generation Quinolones (Levofloxacine and gatifloxacine) is being used for inpatient Community Acquired Pneumonia, for outpatient Azithromycin or doxycycline are used.**** Klebciella is an encapsulated gram negatie bacili can cause pneumonia in Alcoholics (3-4 ounces daily). Friedlander's penumonia affects UPPER lobe and presents with fever, productive cough and copious CURRANT jelly sputum. Klebsiella grows in MUCOID colonies.****Pneumonia pt present with fever, sweats and productive sputum, cxr shows consolidation. Antibiotics are best given IV. Two weeks after agressive tx of a consolidation you have to ensure the pt that there is no bronchhial obstruction by a tumor and that lung abscess has not developed. If pt has a tumor it might block the bronchus resulting in failure of antibiotic therapy. Thus if a pt fails to resolve after two of antibiotics, a Bronchoscopy is indicated. It will help obtain cultures, visualize the brunchus, and do a drainge. CT is indicated if a mass or abscess in llung is indicated. CT will also help to see if an Empyema has setin. Empyema at early stages can be tx with antibiotics and drainage. Abscess requires antibiotics for 4-6 weeks. Do CT first and then Bronchoscopy.****1-Mycoplasma:is common in teens. mostly it causes Pharyngitis or bronchtis only. in few cases hay fever,cough,chills, sorethroat, rhinorrhea. cxr appears worst. Erythema Multiform is one of the extrapulmonary signs, characterized by TARGET shaped lesions. It does not stain because has no cell wall. 2-Pneumococcus is rusty sputum. Gram stain reveals lancet shaped diplococci. 3-H. Influenza occurs in children, vacination prevents it. URT invovment is unlikely. It shows Gram negative staining. 4-Legionella occurs in smokers and alcoholics, water sourse. may be diarrhea. Gram stain fails to reveal it.****All pt suspected of bacterial pneumonia should have a cxr doen as first step. ****Paraneumonic effusions occur in penumonia. The fluid maybe steril in initial stages and resovlve with antibiotic therapy, however in a few cases the pt will continue tohave elevatred twmperatures, pleuritic chest pain and dypnea. CT will identify the fluid collection. The fluid may be aspirated to see is Empyema has set in. The fluid should be analysed for protein content, gam stain, cell count, cytology(rule out malignancy) and glucose level (low in RA, TB, Empyema, malignancy, esophageal rupture). pH should be assessed, Low pH (<7.2) ALWAYS indicative of Empyema and indictes removal of fluid by thoracostomy. Glucose of <60 is ALWAYS indicative of Tube thoracostomy. So the lab test most helpful in placing tube in parapenumonic effusion is Pleural fluid pH.
Pneumothorax - 5
Pneumo Mediastinum may accompany Spontaneous Pneumothorax: the air from ruptured alveoli in the hila and mediastinum. Pt may present with facial subcutaneous emphysema, breath sounds are absent on the affected side and crushing sounds are heard over pericardium. It usually responds to chest tube drainge and doesn not need surgical decompression. Now PM along with Mediastinitis would need surgical drainage of mediastinum. **** TENSION P: This is an EMERGENCY, once you suspect it dont even do CXR the FIRST thing to do is needle thoracotomy. Its due to air in pleural space, it creates a one way valve that allows only entery of the air and no exit. Pt prestns with Severe chest pain, shortness of breath, tachycardia,tachypnea, deviation of trachea, JVD, absence of breath sounds. TP is a clinical dx so dont wait for cxr needle it.****Spontaneous Pneumothorax occurs when there is no provoking factor. When you see a tall thin male think of this. Death from it very rare. Dx is best made with Cxr. ****Tension Penumothorax: after head on accicent and hemothorax. FIRST thing to do is not oxygen mask (it doent hep ), it is CHEST TUBE. ****Spontanous Penumothorax which occurs in young males is almost always due to rupture of SUBPLEURAL BLEBS. Cxr shows deviation. ****Tension P is a possible complication of mechanical ventilation when high PEEP is applied. The barotrauma causes rupture of the lung parnchyma and leaks air into pleual space. Rapid collaps of lung leads to RV filling failure. This results in Hypotension. Remember in Spontaneous P where there is shiftng of trachea, the main prblem is with Oxygenation and Cardiovascular problem becomes secondary not like Tension P which CV is primary.*****In Tension P. even if the Pt presents with severe hypotension (50, 0) the cause is still TP not Cardiac Temponade. Remember Hypotension+shortness of breath+JVD+Decreased breath sounds. And if you do thoracocenthesis and hypotension is resolved then it wasn’t Temponade. ****DDX b/w TP & Hemothorax?
Polycystic Ovarian Dis - 2
Insulin-resistant hyperinsulinemia is a common finding in patients with PCOD. PCOD is an important risk factor for development of DM-2 in women. About 10% of diabetes in premenstural women is POS related. Thus a glucose tolerance test is needed in all POS pts. A two hour test with > 140 is Dx and needs furthur action. Lifge style modification and Metformin is then indicated. Metformin helps in following ways: 1-prevents DM, 2-Causes anorexia and prevents obesity, 3-corrects hirsutism mildly, 4-menstural irregularity and infertility. Clomiphene Citrate induces ovulation and is used for infertility.*****This condition should be suspected in any pt who has mentrural irregularities, and evidence of Hyperandrogenism(facial hair). Presence f these establishes the dx.50% of pts are obeseand are at risk of DM-II. The next step is to do Oral glulcose tolerance test as mentioned above. *****Characterized by unbalanced Estrogen secretion resulting in Endometrial Hyperplasia.
Polycythemia Vera - 3
A12-**** Persistently elevated Hct and spleeno and hepato megally is highly suggestive of PCV. Pts are at risk of hepativ vein occusion (Budd Chiari synd) which is characterized by tender congestive hepato megally with ascites. Hepatic vein thrombosis in these pts is due to hypercoagulability. In cases of tender congestive hepatomegally the first step is to rule out right sided heart failure. If RS heart filaure and Constrictive pweicarditis are ruled out then the next best step is to do a Hepatic Venogram or biopsy.****Its distnguished from pther kind of Myeloproliferative dis by the marked increase inRBC mass and total blood volume. A typical pt is an old Plethoric male who complains of prurites after bathing. Both thrombosis and bleeding can occur due to elevated platelet count and impaired platelet funciton . They have granulocytosis, thrombocytosis and splenomegaly. BM is always hypercellular. There is an elevated Leukocyte alkaline phosphatase, normal oxygen saturation andlow erythropoetin level. A urinary erythropoetin assay reveals of ABSENCE OF MEASURABLE ERYTHROPOETIN in urine. ESR will be low in PCV.
Polymyalgia Rheumitica
Tx is Low dose prednisone. Pt has STIFFNESS rahter than pain. Morning stiffnes last >30minutes, for more than a month and include shoulder,hip, neck and torso. Pt says "Doc my should hip and neck are stiff". ESRis >40.
Polymyositis
An inflmmatory muscle dis of unknown etiology. Presens as proximal weakness, characterized by difficulty Ascending and Descending stairs, combing hair and kneeling down. There are no Skin rach or pathces like Dermatomyositis. These pt has dysphagia due to weaknes of straied muscle . MUscle biposy is the best Dx study. It shows ENDOMYSIAL infiltration.
Polyps
Classified as 1-Hyperplastic: the mc non-neoplastic. No follow up work is needed. 2-Hamartomatous: Include Juvenile polyp and Peutz Jeghers(non-malignant lesion). 3-Adenoma: the mc polyp found in colon. Presents in 30-50% of elderly. Only >1% become malignant. Most are asymptomatic, <5% have positive occult stool test. Probability of adenoma becoming malignant is judged clinically according to size histology and appearnce. A-Adenoma can be sessile or stalked (pedunculated). Cancer is usually in sessile.
B-Histologically, adenoma are villus, tubular and tubulovillus. Villus, which are sessile, are more likely to be malignant. 2nd is tubulovillus and 3rd is tubule.
Porcelaine Gallblader
A13-
Porphyria Cutanea Tarda
Pinless blisters, Hypertrichosis and hyperpigmentation, and increased skin fragility of hands. Asso with HepC. It can be trigered by ingestion of OCP(Etrogen) or Etanol. Elevated urinary porphyria confirms Dx. Phlebotomy or Hydroxychloroquine provides releif.
Post-Exposure Prophylaxis:
For Chicke Pox can be provided with VZIG ro acyclovir. VZIG is preferred and indicated in high risk people exposed w/I 72 hours of exposure. If its longer than that its tool late and the child will get it, warn the mother for the rash
Post traumatic Dis Synd
PTDS and Acute Stress Disorder are identical except that ASD cant last more than 4 weeks and PTDS lasts for months.***AVIOD Benzodiazpine in these pts since PTDS is asso with substance abuse and Benzos are addictive, tx is best with SSRI and exposureor cognitive therapy.
Posterm pregnancy - 2
Is pregnancy age > 42 weeks resulting in macrosomia. Assos syndromes are anencephaly and trisomy 18. Mgmt depends on well being of the baby. Follow biweekly with non-stress test and BPP, if baby is in danger(oligohydamniotics or spontaneous deceleration) deliver. If not labor should not be induces if cervix is not favorable. If the term is .34 weeks then delivery is mandated. If baby is >42 weeks and cervix is flavorable then deliver.
Post operative Endophthalmitis
is the mc endophthamitis. It occurs w/I 6 weeks of surgery. Pt has pain and decreased visual acuity. Conjuntiva & eye lids are swollen. Send Viterous for culture, and based on severity intravitreal antibiotic injection or vitrectomy is performed.
Post strepGN - 2
Its seen 10-20 days after throat or skin infection. Features include periorbital swelling, hematuria and oliguria. Pt may show hematuria with RBC Cast and proteinuria. Serum C3 complement are low. DDXrug induced intertitial Nephritis, occurs with penicillines, cephalos, sulfas. Pt prestns with fever,rash,arthralgia, esosiniphilia, hematuria, pyuria, and eosiniphiluria. WBC cast may be present but NO RBC Cast. ****There is increased ASO titers, decreased C3 and CH50. Renal function goes back to normal in 1-2 weeks. C3 goes back to noraml 8-12 weeks. ASO returns to normal 3-4 months.
Post Term Pregnancy:
Is pregnancy more than 42 weeks gestation. Fetus has long nails, abundant hair and dry skin. Mngmt is based on well being of the baby. The non stress test and Biophysical profile should be performed twice weekly and if there is oligohydamnion or decelerations If all favorable delivery should not be induced until cervix is favorable, fetus is macrosomic. If pregnancy goes over 43 weeks then delivery is mandatory. If its more than 42 weeks, cervix is favorable and head is in pelvis labor should be induced.
Prador-Willi Synd
Deletion in arm of Ch15. It presents Genomic Imprinting where genetic disposition depends whether its inherited from mother or father. Narrow bifrontal diamond shaped eyes, down turned mouth, and he has to be restrained from eating so they are obese. Also Hypogonadism.
Precocious Pubarche:
Its important to ddx b/w Precocious Puberty that is caused by premature activation of the hypothalamic-Pit-Gonad axis and Precocious pseudopuberty that is caused by gonadotropin-independent process, typically an excess of sex steroids. If pt presents with severe acne and severe growth acceleration, its pseudopuberty. It can be cused by LATE CAH.The axis PP is not so dramatic. Its sequence is testicular enlargement, penis enlargement, pubic hair growth, and then growth spur is absent.
Precocious Puberty, Idiopathic
it represents 40% of cases of PP in females and resuts from premature activation of Pit-Hypothal-ovarian axis. It chaaracterizes by simiar cases in family and a normal sequence of secondary characteristics. GnRH stimulation test may be performed to confirm the activation of axis, leads to release of LH. Pt should be tx with GnRH agonist in order to ingibit the secretion of estrogen, preventing, thus, premature epiphyseal plate fusion. Althought parents need to know that this is benign, but they need to also know tat action needs to be taken.****DDX with precocous PUBArche, which is sign of severe androgen excess , caused by gonadotropin independant process like exces sex steriod due to 21-hydroxylase def.*****Etiology of PP can be divided into 1-true isosexual PP 2ary to activation of axis, 2-pseudosexual PP oncrease in steriod hormones and resultant 2ary sexual characteristics, mostly due to ovarian tumors, also adrenal tumos and exogenous esterogen exposure, hypothyroidism and Mc-cune Albright syn. In GnRH stimulation test, a significant release of LH indicates activation of pit gland, therefore true isosexual PP.
Prednisone SE
Insomnia, Nervousness, indigestion,hirsutism, DM, Arthralgias, Epistaxis and Osteoporosis.***** Chronic use can cause Myopathy and pt presents with acidosis due to decreased pulmonary function, next step is PFT.
Pre-Eclampsia - 7
Sever preeclampsia is defined as > or = 190/110 or one or more of the following: 1-oligurea, blures visio, Epigastric pain. Pts are at risk of Eclapmsia, It results from cerebral vasospasm and resultant cerebral hypoxemia. It’s a generalized Tonic-Clonic seizure that manifest like grand mal. It occurs 25% before labor, 50% DURING LABOR 25% after delivery. ****Depresed DTR is the first sign for Magnesium Sulfate toxicity which requires stoping it and administer Calcium Gluconate. The second sign is respiratory depression, then coma, then cardiac arrest and death. In pt with MILD PE the prophylaxis is performed during labor, delivery and w/i 24 hrs after delivery. In pt with SEVERE dis the prophylaxis is started on admission, and carried out though out the period of evaluation and observation. Now if pt iis also taking Hydralazine, it needs tobe stopped and c-section started if BP drops abruptly. *****If the HT presesnts before 20week gestation its either Mole, or Chronic HT. If US does not show "snow storm" then its Chronic HT***** Transient HT occurs in 2nd half of pregnancy during labor or delivery. Proteniuria may be present but doesn’t exceed >300mg/24hr, if it does then it is Preeclampsia. ****The mcc of death in ECLAMSIC pt is Hemorhagic stroke due to HT and thrombocytopenia.****Its a miltisystem dis asso with HT and Proteinuria. Rarely presents before 20week. Proteinuria is >2gr/24hr and asso with creatinin increase. Risk factors are:first conception, DM, renal failure and extreme age.****Its important to ddx b/w PE and SLE in pregnancy because they respond to two different therapies. HT in a pregnant woman in the setting of massive proteinuria , malar rash, and positive ANA titer is most likely due to SLE which causes Glomerulonephritis. Now SLE very rarely STARTS in prgnancy, and it usualy exists prioe to pregnancy, so there is Chronic GN. ****The most effective tx for Preecclampsia and Eclampsia is delivery and evacuation of placenta. Most times it cant be done because its too far from delivery date. Guidlines are:1-MILD Preecalmpsia, If at term deliver, if not bed rest,salt restriction adn close observation. Dexamethasone is given b/w 24-34 weeks and once the maturity is achieved baby is delivered. 2-SEVERE Preeclamsia, pt needs to be stabalized and evaluated before making decisions. Bed rest and salt reduction is mandatory, pt with > 160/110 requires antihypertensive therapy.It pt is stabalize, the decisionis then made according to the term, is mature deliver, if not wait till 34 week and deliver. If pt doesnt responde to therapy or if mother or baby are at risk, delivery is promptly required, wich is accomplished vaginally after induction of labor, if vaginal is not possible then a C-section is done. Now HT therpay guide lines are: If pt is near term or already in labor, Hydrazaline or Labetolol, short acting, are used. In pts far from term Oal agents lilke Methydopa(doc) is used. Calcium Chanel blockers are 2ndline agents, and ACE is CI. Nitropruside is used when BP is extremly high, avoid it before birth bacuase it causes cyanosis in fetus. For SEIZURE prophylaxis and Tx: the most effective agent is Mg Sulfate. For prophylaxis its given IM to all severe preecmpsic pt from admission, and milder pts get it during labor and w/i 24hr of delivery. For Seizure tx, IV injection is used.
Pregnancy early detections
1-Chorionic Villus Sampling: is done in 10-12 weeks gestation. Its indicated in women >35 directly after abnormal US appearance. Serum screening in this age group is less accurate. It detects chromosomal abnormalities. 2-Amniocenthesis is done 16-18 week of gestation. Cordocenthesis or Percutaneous Umbilical Blood Sampling (PUBS) is used for rapid karyotype analysis or Rheusis isoimmunization is suspected. MSAFB is routinly done in 2nd trimester. for Neural tubes and abdominal wall defects.
Pregnancy problems - 12
Screening for gourpB strep should be done 36-37 week gestation and positive cases should be tx with Penicilline G during labor, even in the absence of risks.*****Low back pain is very common in thrid trimester. Its caused by lumbar lordosis and relaxation of ligament to the joints.*** Both Graves dis and Migrain will improve in Pregnancy. ***Excessive use of oxytocin may cause water retention (acts like ADH), hyponatremia and seizures (water intoxication).****ACE inhibitors and Oral hypoglycemic agents (Glibenclamide) are CI in pregnancy. Stop them and give Insulin for DM, and Methyldopa(most comonly used), Hydralazine and Labetalol for HT control in pregnancy. ***Pregnancy hasa protective efect on both MS and PUD. ****Pt 6week gestation has positive FTA-ABS for syphlis, alergic to peniciline, the best tx is Desensitize her to penicililn since Erytromycin cant cure syphlis.****In pregnancy both BUN and Creatinin are decreased to half of prepregnancy levels. Amoxicilin has no effect on them.****Asymptomatic Bacteriuria of Pregnancy, increases risk of developing cystitis and pyelonephritis. E coli is the cause 70% of the times. tx is 7-10 days of Nitrofurantoin, Ampicillin or first gen Cephalos.****Neonates of pts with graves dis treated with with surgery are at risk for Thyrotoxoicosis.because of the passage of throid stimulating immunoglobin across the placenta.*****Hypotension is a comon se of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling.****In pregnancy its recommended to CONYINUE excercise ust as you were doing before, like an aerobic instructor.*****Edema of lower extremities (Bilateral) in pregnancy is most commonly a benign problem. Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria, no need to do ECG or DVT (presents unilateral and fever).***** Oxytocin is like ADH so it causes water retention and Water toxicity due to decrease in Na concentration ( 123 ). So it could cause seizure post partum.***** Screening cultures should be performed at week 36-37 and positive cases should be treared with IV penicillin therapy during labor to prevent the new born from getting infected.***** If hypertension sets in before 20 weeks, its either Mole or CHRONIC hypertension. If it sets in after 20 weeks, its either Preeclampsia (Proteinuria, >300mg) or TRANSIENT hypertension (not accompanied by proteinuria, <300mg)*****Antibodies to ABO antigens belong to IgM antibody class so they don’t cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies that are responsible for Rh alloimmunization belongto IgG class and do cross placenta.
Premature Adrenarche
Isolated apprearance of axillary hair before agee of 6. Results from androgen secretion from Adrenal gland. Its benign and has no clinical significance. But Premature Pubarche (pubic hair growth before 8) is in 50% of cases asso with CNS disorder.
Premature labor
Premature labor must be managed agressively, and tocolysis has to be instituted at once. Magnesium Sulfate is the DOC for tocolysis therapy, but its not FDA approved (but Ritordine is). We also need to administer steriod for speeding up lung maturity.
Premature Ovarian Failure:
It refers to a failure of estrogen production by the ovaries of a a woman <35. Its most commonly idiopathic. But it could also be due to adhesion, Hashimotos’s, irradiation or chemo. Pt presents with few months of amenorrhea, Atrophy of vagina, increased FSH, previously had a child. The only way to treat infertility is Egg Donation.
Premature Rupture Of Membrane:
It’s a rupture that happens before labor at anytime of gestation. Premature PROM is a rupture that happens before term whether there is contraction or not. In PE there is amniotic fluid in vagina, confirmed with Nitrazine paper. In case of PPROM, amniotic sampling to measure lung indices is mandatory. Also do US to measure aniotic volume and determine fetal anomalies. If fetal has congenital anomay let vaginal delivery proceed. If fetus is viable then prolong pregnancy to mature lungs. REMEMBER if there is no contraction, no need to do tocolysis.
Premature Vent contractions
Require no tx, just observation.
Presby-cusis
In older people, it’s a high frequency hearing loss in both earswith difficulty in speech differentiation. "Acoustic neuroma is a unilateral hearing loss asso with rotational vertigo
Presby-opia
Normal aging loss of accomodative capacity.
Preterm labor
Defined as labor prior ro 37 week and is dx by 1-occurance of contractions, 2-cervical change or effacement of 80% or dialtation of >2cm. Preterm birth is delivery b/w 20-37 weeks. Low socioeconomic have higher incident. RDS is a common problem in premature births. If both mother and baby are stble, FIRST thing is to try bed rest and hydration. Eventhough there is effacement and dialation. Its succesful in 20% of times. Hydration is a negative feedback on the secretion of ADH and Oxytocin (post pituitary) , which is responsible for induction of labor. If this doesnt work, NEXT STEP is tocolytic therapy is initiated with Magnesium Sulfate. Pt should also be cultures for GroupB strep and antibody considered. Steriods are necessary for thi sstage of labor, when administered b/w 24-34 week they accelerate lung maturation. Agent used is Dexamethasone IM.
Preventative Medicine
1-DRE and hemoccult (PSA option) >50yrs, annualy. 2-Colonoscopy >50yrs every 10 years. 3-Pap is not needed for women who have had regular check up until age 65. 4-Mamogram should be done yearly from 50-75. 5-Routine Chlamydia infection screening for all sexually active women over 25 and younger. 6-If LDL Cholesterol is = or >100 for a DM risk factor then start life style modification. 7-Women who have had CIN ii or iii should have annualy pap smear even if the result is negative 3 years in a row. 8-Hormone replacement therapy is still the best therapy for osteoporosis in postmenopausal women. 9-Influenza vaccine on annual basis for all adults above 65 and adults of any age at risk of Influenza. 10-MMR is highly recommended for all HIV infected pts who are asymptomatic and are not severly compromised. 11-HIV infected pt should receive Tetanus and Diphteria immunization according to normal dosing schedule (meaning a booster every 15 years). DTP is only required for children since individuals >5years are highly unlikely to get Pertussis. 12-HepA vaccine is recommended for travelling to developing countries. 13-Yellow fever vaccination if necessary for Africa and south America travelers. 14-Menigococcial Meningitis is recommended for Hajj. ****Pneumococcus vacine is given at age 65.***Pap smear must be performed 3 yearsin a row before it could be left alone. *****If child develops zeizure after DTP vaccince, it is CI, so next time, Dont give Pertusus and just give DT.*****people with pancolitis and Ulcerative Colitis have in creased risk of colon cancer and should do colonoscopy 8 years after surgery and then every1-3 years after that to identify recurrent cancer in early stages.
Priapism
MC drug that cuases it is Prazosin, but in boards Terazodone is mostly associated with it
Primary billiary cirrhosis - 3
Although no specific tx is indicated, Ursodeoxycholic Acid is recommended to reduce itching and slow prrogression of dis. And untimately Liiver transplant. ***Presents in midle age and 90% are female. Its asso with Sjogren, RA and CREST. Liver biopsy is pathognomic with granlulatatose destruction of bile ducts in portal triad. Def tx is liver transplant.
Primary Dysmenorrhea
Pt present with hx of lower abdominal pain, that radiated to upper thighs and back. The pain is colicky and starts a few hours prior to menses, lasting 3-4 days. It usually appears 6-12 months after menarche. Tx is NSAID, so are OCPs. The pathology here is that menstural fluid has higher levels of prostaglandins.
Primary Hyperaldosteronism - 6
Parathyroidectomy is the only effective tx. Know how to ddx from Renovascular hypertension based on low renin activity in PHA and high renin activity in RVHT. Characterized by Hypertension, hypokalemia, and suppressed renin , The mcc is aldosterone producing adenoma (Adrenal Adenoma). ****The mcc of combination of hypokalemia+HT is PHA. *****The mineralocorticoid activity of Aldosterone results in increased salt & water retension, followed by nautriuresis (Aldosterone escape phenomenon). So there is MILD hypernatremia and NO EDEMA. ****Suspect it in a young pt with muscle weakness, and numbness and HT. The most specific lab value is high aldosterone / renin ratio .
Primary Hypoparathyroidism - 2
A7. *Increased serum calcium+decreased serum phosphate+increased PTH is the hallmark. DDX:Familian Hypocalciuric Hypercalcemia. In PHPT, urinary calcium excretion is normal or elevated, in FHHC calcium excretion is decreased, below 200 and creatinin is normal.
Primary Ovarian Failure:
It could be caused by chemotherapy and will cause premature menopause. Thr diagnostic blood test is increased FSH levels. Chemo, especially of Alkaline agents, causes failure of follicular cells of the ovary reaulting in decreased production of estrogen and inhibin. This results in loss of feedback inhibition of estrogen in LH & FSH, causing their high levels. Inhibin cuases the feedback inhibition of FSH only, so in the absence of inhibin the absence of inhibin FSH levels are higher than LH levels, which is pathognomonic for ovarian failure. Clinically, pts have Amenorrhea, hot flashes. They might develop anxiety, depression and irritability. Loss of estrogen results in atrophy of breast, vagina, myometrium.
Primary Polydypsia
Or Psychogenic Polydypsia. Characterized by primary increase of water intake. . In contrast with DI and DM , it’s the polyuria which is the driving force of increased water intake. This is seen mostly in anxious women young, . Pts taking Phenothiazine have this problem because dry mouth caused by anticholinergic effect of the drug. Promary Polydypsia can also be caused by hypothalamic lesions affecting the thirst center.
Primary Sclerosing Cholangitis
Its an inflamatory destruction of both intra and extrahepatic bile ducts. Its asso with IBD especially UC in 70% of cases. Hay jaundice, pruritis, RUQ pain, or acute cholangitis. It may progress to complete obstruction, 2ary billiary scirrhosis, hepatic failure or portal HT. ERCP is investigation of choice. Cholangiography shows characteristic 'Beading' due to stricture and dilations of intra and extra hepatic ducts. LFT shows very high Alk Phosphatase, mild ALT & ALT, <300. Other findings are Hypergamaglobinemia, increased serum IgM, P-ANCA. Tx is directed towards refleif of obstruction & trx against infectious complications. Liver transplantation is indicated in cure.*****CholangioCarcinoma is a complication of PSC especially in smokers with recurent UC. One of the early manifestations of CC is a severe STRICTURE in the billiary tree leading to Cholangitis characterized by Fever,jaundice,Leukocytosis. CC can happen in 20% of PSC pts. So ERCP shows the stricture, the next step is to do BIOPSY of the stricture to rule out CC. Ursodeoxycholic acid can be used in pts with PSC to lower liver enzymes.
Prolactinoma - 2
Another nmae is Lactotroph adenoma, the mcc pituitary tumor. A pituitary tumor <10mm is called a Microadenoma. Microprolactinoma is a prolactin producing microadenoma. In females it presents with galactorrhea and in males with hypogonadism. Dopamin agonist such as Bromocriptine or Carbegoline are the mainstay of Tx. If that didnt work for both Micro and Macro adenomas, then do MRI and then surgery is indicated.
Propylthiouracil
MC SE is allergic reaction. But the most serious SE is Agranulocytosis. Routine monitoring of WBC is not helpful, but majority of pt revocer.
Prostate cancer - 4
Radiation is usful in managing bone pain with prostate cancer who have undergone orchiectomy. *Acute Cord Compression could happen secondary to metastasis of cancer. Its also called Cauda Equina. First symptom is back pain asso with tenderness at the site of the metastasis. Tx step are: 1- IV Dexamethasone, 2-MRI of spine, if MRI is CI (Pace maker pt) or CT myelogram. 3-If confirmed, then radiotherapy.****Screening is : 1-Men 40-50 , do yearly digital exam. 2-age>50 do yearly digiral plus PSA. If either recta of PSA (>4) is suggetive the next step is transrectal USG, followed by niddle biopsy and then staging. For stagin, do bone scan to see metastasis.***When the cancer is in late stages (metastasized) surgery is not performed unless needed for palliation. Palliative radiation along with antiandrogen thrapy is the tx of choice. Leuprolid (LHRH analog) is doc, Flutamide is not as good.
Prostatitis, acute bacterial
In Younger pt its caused by STD, ini older pt by E Coli. First get a mid stream urine sample to cultrure and then give antibiotics empirically. Pt presents with chills and fever, urge to urinate and pain in urination, prostae is tender and boggy.
Prostatitis, non bacterial
Pts are afebrile and have irritable voiding symptoms, like frrequency, irgency and suprapubic discomfort. Urin analysis in normal. Expressed prostatic secretion show a leukocyte count greater than 10WBC/HPF and the culture is negative. We need to Rule out bladder cancer on all elderly pt with urinary cystology and cystoscopy.
Prostatodynia
Pt is 30-40 yo, afebrile, have irritative voiding syptoms. Expressed prostatic secretions show normal leukocytes (DDX with non.bact prostatitis), and culture is negative for bacteria. No hx of UTI.
Pseudocyesis - 2
a condition that a woman presents with all symptoms of pregnancy, owever, US reveals a normal endometrial stripe.*** All pts need Psych evaluation.
Pseudodementia - 2
Asso with Deppresion.***** SSRI ix tx.
Pseudogout - 3
Positive bifringent crystals. *****Asso with aging, trauma, , Hyperparathyroidism, Hemochromatosis. Pt complains of constipation, polyuria, fatigue and joint pain. His serum calcium level is high and phosphate is low, this suggests hyperparathyroidism. The joint aspirate under light microscopy shows Rhomboid shape, calcium pyrophosphate positive bifringent crystals. Gout has Needle shape negative bifringent. Struvite srytals in Nephrolithiasis have Cofin lid shaped crystals.
Pseudomembraneous colitis – 2, GI, 6/2
tx, Stop offending drug and start Metro. ****Clostridium difficile is the cause. Suspect a pt with diarrhea who has been taking antibiotics for a while. The most sensitivd test is Cytotoxin assay in the stool. Tx of choice is Oral/IV metronidazole. Or ORAL not iv Vancomycin.
Pseudotumor Cerebri - 4
Risk factors include medication(steriods and OCP), trauma and increased weight. Initial sign is a headache that is pulsatile and awakens thept from sleep. Then increased ICP occurs. Also nausea, vomiting, back pain, double vision, Papil edema, palsy . First things to do is CT/MRI to rulle out mass occupying lesion, most pt have empty sella in CT. Only then LP is indicated . CSF reveals increased P and normal cells. Sufficient CSF should be removed to lowerr P to 150mm/H2O. Following are criteria for DX:1-Presence of features of ICP in an alert pt. 2-Absence of focal neuro signs except 6th nerve palsy. 3-Normal CSF exept icreased opening presure. 4-Absence of any ventricular abnormality other than enlagement caused by ICP. ***Vitamin A and its derivatives taken in large doses could cause PC, like an acne pt taking Isotretinoin.***If LP didnt reduce the ICP, then the first line of therapy is Acetazolamide that inhibits Choroid plexes CA Inhibitor. If that filaed then Surgery, optic nerve sheath decompression or lumboperitoneal Shunt, is indicated.
Psoas Abcess
Pt presents with RUQ pain, fever, and positive psaos sign, he is also having furuncles which means he is having infectious sysmptoms. The infection has lead to Psaos abcess and the nest best thing to do is CT of abdomen to look for it. If suspcion is high and CT is negative the next step is Lapraroscopy. Tx is drainage and systemic antibiortics.
Psoriasis
Lithium can precipitate it.******Silvery scale skin.
Psoriatic Arthritis
Is Asymetric and oligo-articular. Pt has silvery scales on eryhtomatous plaques on flxural surfaces. Think of PA when pitting nails is in the hx. Othe rfeatures are spondyloarthropathy, DIP involvement. DDX with OA: OA is not inflammatory. DDX with RA: RA is not in DIP.
Puerperal Fever:
Is defined as T of >38 more than 2 days w/I 10 days after delivery. Occurs in 6-7% vaginally deliveries. The mcc is Endometritis. In assition, gnital tract infection may secondary evolve into pelvic Thrombophlebitis, abscess or schock. . It suspected if hay persistant spiking fever that wont responde to antibiotic therapy. Add HEPATIN to antibiotics for 2-3 weeks. If a rapid response is not noted then suspect abscess.
Pulmonary Contussion
Cx presents within first 24 hrs of tauma , tachypnea, tachycrdia, and hypoxia are charcersitc. PE reveals chest wall bruising, and decresed breath sounds. Cxr shows patchy irregular alveolar infiltrates. ABG sows hypoxia and ,iteslef, is an indication to suspect PC in trauma pts.
Pulmonary Embolism (Pulmonary Vascular Diseas) - 14
There is no pulmonary edema in PE. Think of PE in a post operative pt with JVD and new onset RBBB. * PE occurs when there is a sudden dislodgment of blood clot from DV in to the pulmonary artery. Risk factors are prolonged bes rest, obesity , trauma, malignancy, inherited def of prothrombin-III, protein C and S and use of Estrogen. Symptoms include dyspnea, chest pain, cough and hemoptysis, tachycardia, hypotension, and pain in the leg. The most typical feature of PE in seen in the blood gas. Aterial Hypoxemia is ALWAYS present. . Dx involves V/Q mismathc or Venous Duplex Ultrasound of the legs. Pulmonary angiogram is the gold sandard. Tx is Oxygenation and anticoagulant. Low molecular weight Heparin, thrombolytic therapy, inferior vena cava filter may be required. *Pt in whom anticoagulation is CI, require placmeent of IVC filter when they are diagnosed with DVT, for prevention of PE. * A pt with PE and hx of recurent unexplained DVT , factor V Leiden is a common cuase of it. factor V Leiden is the result of a point mutation in a gene coding for the coag factor V, because of mutation factor V becomes resistant to inactivation by protein C, an important counter balance in hemostatic cascade. *The initial symptom maybe sudden onset of hypoxia, tachycardia, and tachypnea, hypotensive. The Cxr maybe normal, if that is the case Pneumonia, Atelectasis and Pulmonary edema are rulled out and the next step is Ventilation/Perfusion scan.*****A truck driver sitting all the time with tachpnea,tachycardia and dyspnea and right axis deviation has PE. The next sep is perfusion/ventilation. You should expect larg area of perfusion defect w/o ventlation defect.****Tx steps: If the pt is hemodynamically compromised and the clot is situated in main pulmonary artery, the best tx option is pulmonary Embolectomy. Now Heparin is a good choice but it doesnt dissolve the clot, so give him heparin and take him to surgery for embolectomy. Fibrolytic therapy is an excellent choice but not in a post operatve pt, it may cause diffused bleeding. So to summ it up, When an acute PE occurs, with hemodynamic compromise, the best tx is Fibrolytic therapy. if the pt has CI to it (has surgery a few days ago), an embolectomy id the tx of choice.****In PE pt the cxr is NORMAL.****Sudden onset shortness of breath with clear lung is the clue. Put the pt on O2, and bed rest. Heparin should be started immediately, if the index of suspition id high, for 10 days. After you do cxr, ABG and EKG Then do V/Q ro rule out PE. Angiogram is gold but is rarely done. Doppler US is choice for DVT. Spiral CT is done if emboli is large and Cxr is abnormal, in that case its better than V/Q. Thrombolytics are used in pt with hemodynamic instability or if after iv filter pt is worst. If pt has CI to prolonged anticoag therapy or has another embolization while in the hospital, placemnt of IVC filter should be considered. Embolectomy is done in pt who is hemodynamicaly Unstable and has CI for thrombolytic use. So bottomn line is if you suspect PE clinicaly, and Cxr, ABG and EKG ruled out other ddx then you should being Heparin w/o waiting for V/Q to confirm your Dx. ****PE is the same as "Pulmonary Vascular Dis". dont mistake it for "Pulmonary Septic Emboli: which is caused by release of emboli from right heart due to IE of IV drug users.****When the suspicion is established V/Q is the next step,no need to rule out MI by doing CKMB. But if one of the options is Start coag tx , then that is the first step and then do v/q.
Pulmonary HT
T13Q39. Its defined as mean pulmonary arteial presure >25mmhg at rest and >30mmhg with exercise. Pt presents with dyspnea on excertion, Cxr shows enlargement of pulmonary arteries, enlargement of the right ventricle. EKG shows right axis deviation. Untreated PHT leads to Core PUlmonale.
Pulmonary Regurtitation:
Early diastolic murmur, decresendo, high pitched, blowing, best heard around the left sternal borderand usually develops secondary to pulmonary hypertension. Becomes more prominent with inspiration.
Pyelonephritis - 7
Urine and blood cultures must be obtained prior to obtaining antibiotics. After 48-72 hours of parenteral therapy (IV Ceftriaxone) the pt can be switched to an oral agent (TMP-SMX). Dipstick is positive for both Nitrites(indicates Enterobacteriaciae) and Esteras (indicates Pyuria). Its a risk factor in pregnant woman, soits important to treat UTI before it progresses to full disease. When there is no responde to 72 hr therapy with antiobiotics, US or CT is recommended to rind out other pathology like obstruction or Abscess.* Tx is empiric therapy w IV antibiotics. ****CHRONIC Pyelonephritis is characterized by focal parenchymal scaring and blunting of Calysis in IVP.
Pyloric stenosis - 2
Surgery is tx but first hydrate and give K to infant.****4 Week old infants has sudenly started to vomit after feding for the past 2 days. Its PS. Don’t be fooled by no mass being palpated. You need to do US to dx, it'll show hypertrophied pylorus.****Presents in 4-8 weeks with non bilous projectile vomiting. *****1st order of tx is to correct hydration and electrolytes and after that do surgery.
Quinidine Toxicity
Tinnitus, diarrhea, torsade de pointes, prolonged QT, hemolytic anemia.
R. A.
Pts with erosive joints need Disease Modifying Anti-Rheumatic Drugs (DMARD). Indomethacin or other NSAID may be used as joined therapy. These drugs slow down progression of erosions and cartillage lost. If conservative mngt didn’t work then steriods are used. DMARDs include Methotrexate, Hydroxtchloroquine, sulfasalazine, azathioprine. Methotrexate is the doc.****Methotrexate works by inhibiting DHF reducatase, so Microcytis anemia is a side effect. Hydroxychloroquin SE is GI stress, visual disturbances. and hemolysis in G6PD def. Prednisone may cause iatrogenic Cushings. Azathioprine may cause Pancreatitis, liver tox and BM supression. Cyclosporine is used in ttansplantation and may cause Nephrotoxicity.
Rabies
Try to capture the dog to see if he has rabies, if the dog was not captures assume he had rabies and tx is both actve and passive immunization.If dog is captures, observe for 10 days,if there is suspicion then do brain autopsy if its confirmed then the post oxposure prophylaxis (both pasive and active immun) is given.
Radial fracture:
Fractures of shaft of humerus present with tender, swollen, crepitus and shortend arm. Xray confirms Dx. The recommended tx in isolated diaphyseal humeral fracture is closed reduction followed by hanging cast
Raloxifene
Is a Selective Estrogen Receptor Modulator (SERM) used for prevention of osteoporosis. Unlike Estrogen, it doesn’t increase risk of Endometrial cancer. It decreases risk of Breast cancer. It has noeffect on Ovarian cancer. Ts most important SE is it increases the risk of Pulmonary Thromboembolism and is CI in pt with a hx of DVT. It may also worsen hot flashes and vaginal dryness.
Ramsay Hunt synd
A facial nerve palsy, caused by Herzes Zoster. Pt presents with lesions of external ear w or wo invlvement of tympanic membrane, vertigo, tinitus, and deafness due to geniculate ganglion involvement.
Rationalization
When a pt ignores a breast cancer and does not go to doctor, when asked why? Her rationalization is that because there is no family hx of breast cancer in my family.DDX is Denial , when a pt dx with terminating diseae but he denies it. DDX Intelectualization allows someone to talk about his dis in a detached manner.
Reaction formation
When a women who hates foreigners volunteers to help them in a center. DDX is Alturism, which is when a rape victim establishes a rape center to help other raped people, in order to help her own anxiety.
Reflex Sympathetic Dystrophy
Is a syndrome of Pain and swelling aso with vasomotor instability. Usually asso with move resriction of shoulder. Xray shows Osteopenia. Physical therapy is done to restore function. Prednisone is used in resistant cases.
Reiter's Synd or Reactive Arthritis
Arthritis, Conjunctivitis and Urithritis. Typical skin lesion is Keratoderma Blenorrhagicum on palms ans soles. Clear vesicels on red bases that later develop into macules and papules. Other lesion is Circinate Balanitis on penis, shallow painful ulcer. ****Its grouped under "Seronegative Spondyloarthropathies" and these pts have NEGATIVE RF. HLA/B27 is found in ONLY 80% of white pts and 60% of blacks.*****Its Arthritis reactive to genitourinary infection due to Chlamydia, might develop heel pain and sausage digits. Tx of choice is NSAID, if disease is due to infection with Chlamydia add Tetracycline.
Relapsing polychondritis
an idipathic disorder characterized by recurrent inflammation of catilagenous structures and other internal organs
Renal Arteery stenosis
In a pt with multiple risk factors for atherosclerosis (hypercholestrolemia, DM, smoking, HT), RESISTANT HT should make yo thnk of RAS. Continuous murmur (Systolic and Diastolic) in the periymbilical area or in flanks, is characteristic of RAS.
Renal Calculi
Excessive use of Vit C in pt with renal insufficienct can cause Oxalate stones (Radioopaque) (Gout stones are Radiolucent). The mc renal stones are calcium, CT of the abdomen w/o contrast is the dx procedure of choice, it can detect radioopaque(calcium) and radiolucent(uric acid) stones, KUB or abdominal xray is not the best test, the dietry recommendation for pts with renal calculi is 1-Decreased dietry protein and oxalate, 2-decrease sodium intake, 3-increase fluid intake, 4-increase dietry calcium. *****Renal stones in pregos require special care. Since there is no radiation with renal and pelvic US, this is the procedure of choice.
Renal cell carcinoma
Classic triad (flank pan, hematuria,palpable mass) in uncommon, but whne present it means metastasis has occurred. No matter what the vignette says if it mentions VARICOCELE fails to empty in recumbent position, it is RCC. So the next step is Abdominal CT.
Renal Laceration:
Presents with hematuria and retroperitoneal extravasation. CT, with contrast, will visualize both kidney and spleen. CT is the best study to evaluate solid organ damage in a stable pt.
Renal Tubular Acidosis
RTA results in impaired ammonia excretion which is the principle mechanism of met acidosis in CRF. Suspect RTA-type4 if hay DM pt +Hyperkalimia. *RA presents with decreased pH, then looking at PaCO2 we see increase and then HCO3 is a little elevated to compensate. Common causes are: 1-Pulmonary diseases. 2-Neuromuscular disease, any condition that weakens or paralysis respiratory muscles (MG, Polimyolitits, MS and Kyphoscoliosis.). 3-Primary CNS dysfunction like a brain lesion. ******RTA is a term used to describe conditions in which normal AG metabolic acidosis occurs from decreased net renal acid secretion. 3 types:
1-RTA-1: Distal tubular acidosis- characterized by decreased distal tubular capacity for hydrogen ion secretion and therefore inability to generate new bicarbonate. Suspect it in a pt with AG MA and a urine pH>5.5. Serum K is classically low in pts with distal RTA. Causes are Sjogren, SLE, Amphotericine toxicity, Wilson’s, Sickle cell, Fabry;s. Its asso w Nephrolithiasis.
2-RTA-2: Proximal tubular acidosis- Hallmark is impairment in proximal HCO3 reabsorption leading to excretion of excessive urinary HCO3. Pt has urinary pH<5.5. Normo or hypokalemia The mcc are heavy metal poisoning, Wilson’s, Multiple Myeloma, Amyloidosis. Suspect it when pt has normal AG MA and HCO3 around 15 and urine pH <5.0. Asso with osteomalacia.
3-RTA-4: Hyperkalemic RTA- This is the mc form in adults and results form Aldosterone resistance or deficiency. Almost everyone shows Hyperkalemia which is asymptomatic. Some causes are DM and Cyclosporine. Suspect it in pt w non AG MA and hyperkalemia.
Renal Vein Thrombosis
Is a complication of NephrOtic Synd. Antithrombin III is lost in urine. Pt presnts with sudden onset of abdominal pain, fever and hematuria. It can occur from any Nephrotic synd but MCC is Membraneous GlomeruloNephritis
Respiratory Alkolosis - 4
Increased pH and decreased PCO2. Due to hyperventilation. Homeostasis of 3 forms of palsma Calcium is dependant on extracellular pH. An increased extracellualar pH levels causes an increase in the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound calcium and consequesntly decreasing the levels of ionized calcium. Ionized calcium is the only physiologically active calcium, so decreased level lead to hypocalcemia(crampy pain, paresthesiaa and carpodedal spasm)
Restrictive Lung disease
DoMerck. A-a in increased in interestitial lung disease due to poor oxygenation. In restrictive lung disease TLC, FRC, and RV are all reduced. But FEV1/FVC is either normal or increased.
Retinal artery occlusion,cental
Painless loss of monoocular vision secondary to embolism. Embolism of retinal artery is the mcc of ocular stroke. Its commonly asso with Amorousis Fugax before the occulsion. Fundoscopy reveals ischemic retinal whittening and red cherry spots. Its an ophthalmology emergency, delay in tx may result in blindness. Immediate intervention includes ocular massage (which moves the emboli) and high flow oxygen therapy.
Retinal Detachment
Sudden onset & mostly unilateral of photophobia and floaters, the most classic descritpion is "a curtain coming down over my eyes".Tx is laser and cryotherapy.
Retinal necrosis, Acute
Most commonly by HSV and VZV in HIV pts. Asso with pain keratitis, uveitis and peripheral pale lesions. In CMV retinitis is painless, not asso with keratitis and conjunctivitis, but fundoscopy shows hemorrhages and fluffy or granular lesions around retinal vessels.
Retinitis, CMV
T9Q13. Occurs in HIV pts when CD4 falls below 50. It presents as yellowish-white patches of retinal opacification and retinal hemorrhages. Tx is ganciclovir or Foscarnet.
Retinoblastoma
Highly malignant tumor and failure to dx and tx early may lead to death from liver and brain metastasis. It’s the mc intraocular tumor of the childhood. Every case of LeukoCoria (white reflex) is considered retinoblastoma until proven otherwise, although the mcc is congenital cataract. So these pts shoud be refered to Ophtamologyst. Other signs are strabismus, decreased vision, ocular inflamation, eye pain, glaucoma.
Retro Pharyngeal Abscess
Fever and cervical adenopathy, POSTERIOR pharyngeal edema and nuchal rigidity.Tx is IV broad spectrum antibiotics or drainage.
Rhabdomyolysis - 2
Characterized by break down of muscles. MCC is alcoholism. Risk factors are crush injuries, strnous exercise and seizures. Dipstick testing reveals Hematuria, but microscopic analysis of urine does not show RBC. Serum creatinine is disproportiany elevated compare to BUN. ATN can occur due to ischemia or toxins. Hb or Myoglibin are endo or exogenous nephrotoxic substances which can accumulate in the kidney due to break down of muscles, and leading to ATN. Tx include aggressive IV hydration, and alkalinization of urine. In some cases, forced diuresis with Manitol may be required. ***In crush injuries tx is IV fluids, osmotic diuretics and Sodium Bicarbonate (to alkalinize urine). After crush injury in accidents, it might show with mypglobinemia, myoglobinuria and eventual renal failure, urine dipstick test is positive for hematuria. Hyperkalemia is common showing tall T waves on EKG. The best Dx test is Creatin Kinase. The best initial management is osmotic diuretics and bicarbonate (to alkaline urine) to prevent renal failure.
Rhesus Isoimmunzation
It happens when there is contact of Rhesus-positive fetal blood and Rhesus negative of maternal blood. This results in mother's antibodies to cross over to baby's circulation and cause hemolysis of baby blood. In sever cases it causes Hydrops Fetalis. In mild cases it causes, jaundice, w/i the first 24hr after birth. Any incident that causes bledding can cause this (amniocentesis,CV Sampling, Abortion, ectopic pregnancy, labor and delivery. The best tx is to prevent mother's immune system to be in contact with fetus blood cells, the best thig is AntiD-gamaglobin (Rho-GAM)wich prevents contact by decreasgin availablity of fetal RBC in maternal circulation. In case mother was not sensitized (antibody titers < 1:6) RhoGAM is still indicated. It should be given to ALL Rh-negative women at 28 weeks and w/i 72 hours after any procedure of incident (abortion) and delivery. In case the mother is already sensitized (antibody =>1:6) administration of RhoGAM is useless and close fetal monitoring for hemolysis is required. Methods used for this is Amniotic Fluid Spectrophotometry, it measured bilirubin in amniotic fluid. US is used in conjunction with it to detect Hydrops fetalis.
Rheumatic fever - 3
The mcc of Mitral stenosis is RF. Principle symptoms are dyspnea, pulmonary edema, and precipitated by exercise fever, anemia, sexul intercourse, tachycardia and pregnancy. In MS the left atrium gets very large and pushes up the left main stem bronchus. Occassionaly pressing the phrenic nerve causes persistant cough. Other findings are loud S1, opening snap and a diastolic murmur. ECG reveals atrial fibrilation. Echo will confirm dx. All pt should receive Endocarditis prophylaxis. Tx is mitral valve surgery. *Prevention os recurrent attacks of RF might slow down progression of MS, so Penicilline prophylaxis with monthly IM injection of Benzathine Penicilline is recommended in adulescent. Pts with or W?O Carditis need prophylaxis, with carditis need 10 yr and w/o 5 yrs. If there is a hx of embolic events anticoag is indicated.
Rib Fracture
MCC is auto accidents. Comlications are atelectasis, pneumonia and respiratory arrest. It could be deadly in elderly, this is due to painwhich causes hypoventilationand atelectasis/penumoina. Pain management is the PRIME priority in these pts. Local nerve block is used if oral or systemic analgesics are not helpful.
Ritordine SE, OBGYN, 6/2
Beta 2 agonist(Ritordine, for Tocolysis) may increase edema by decreased water clearance, tachycardia nd increased myocardial work load. They also increase Gluconeogenesis in liver and muscle resulting in increase demand for insulin in DM pts.
Rocky mountain spot fever
Characterized by fever,myalgias, HA, and petechial rash. It’s the mc and fatal Tick born dis in US. A delay in Dx can lead to Shock and systyemic signs. If shock is there (BP reduced a lot) then IV hydration is to be done prior to anything else. Then Tetracycline, oral or IV.
Rosacea
In pt of 30-60 yrs, light skin and eye color, telangiectasia over the cheeks, nose and chin. Flushing of these areas is precipitated by hot drinks, heat , motion and rapid body T changes. Tx is aimes at papules, pustules and erythema by topical Metronidazole.
Rotator Cuff Tear
Pt presents with shoulder pain aggrevated by movements like pushing, pulling, and positioning the arm above shoulder. If limitation of abduction or external rotationd does not reverse with Lidaocaine injection rules out Tendenitis and focuses on RCT. Def Dx of RCT is with MRI or Arthrography. If that is the case then surgery will fix the problem.
Rotor's Synd
Presents with Conjugated bilirubin in urin (urine dipstick show is). If billirubin is in urine it must be congugated since uncongugated can be excreted.
Rubella - 5
Macupapular rash, posterior cervical and posterior auricular lymphadenopathy and polyarthralgia. Pt can be tx with acetaminophene for symptoms. Pt can be infectious 1 week prior to the onset of the rash and 15 days after. Live attenuated vaccine os the best protection. Rash starts on the face and then progress to trunk. Arthritis that develops in adult females is a clue for rubella.***Most cases of postnataly acquired rubella are asymptomatic. Classic Rubella presents with Rash, low grade fever, lymphadenopathy. Lymphadenopathy and fever appear about 14 days after initial infection and prior to rash. Rash is in distinguishable from Measles. DDX1:Scarlet fever, pharyngitis, fever, sandpaper like rash. DDX2:Chicken pox has vesicular rash. DDX3:Erythema Infectiousum, has Slapped cheek appearing rash. Roseola Infantum Herpes virus 6, abrupt high grade fever, and then maculopapular rash on trunk and then periphery. Pt is no longer febrile whne rash appears.***After rubela vacicantio its recommended that no pregnancy for 3 months. But so far there are no reported fetal transmission in this regard, so if it does happen and the is then gets pregnant, just reassure the mother nothing else needs to be done.****Congenital Rubella Syndrestns with triad of sensorineural deafness, cardia malformation(PDA,ASD) and Cataracts (White reflex)ery muffin spots and thrombocytopenia. Pt also has 'blub. transmission in 4th week of pregnancy. Maternal infection manifest as Rash, arthralgias and lympgadenopathy. If it is at the begning of pregnancy its worst, might lead to spontaneous abortion or CRS (risk is 50% if transmited in 4week, and 1% if in last trimester). Matrenal infection is confirmed by antibody to rubells virus In infant, there is IgM antibody or persistant IgG beyond 6 mo. Prevention of Rubella is by viccination of ALL femlaes of child bearing age. If immunstatus is unknown, titers should be obtained first trimester. Vaccination should not be given in pregnancy. DDX1:Sturg-Weber:neurocutanous dis, port wine stain in distributin of trigeminal nerve, mental retardation,seisure and galucoma.DDX2:RetinoblastomaMay present with unilaterl or bilateral White reflex, HOWEVER hay No deafness or PDA as is is CRS. DDX3:Congenital CMV and Toxiplasma, both manifest with Hydrocephalus, cerebral calcification,chorioretinitis, and microcephaly. but no deafness or cardiac anomaly.
Salicylate tox
mixed respiratory alkolosis and metabolic acidosis.
Salmon patch:
A flat salmon colored lesion over eyelids and neck. It’s a vascular lesion that disappears early in childhood.
Sarcoidosis - 4
Systmic steriods are the DOC for Sarcoidosis. Its indicated in pt with disabling systems (visual disturbances,cough,shortness of breath) and Organ dysfunction. Pt has Hilar lymphadenopathy(organ derangment). Sterids suppress activated T-induced cell process at disease site. Asymptomatc pts need no tx. ****Cxr shows granular Hillar opacity in lungs bilaterally( midiastinum adenopathy). One midiastinum adenopathy is seen on Cxr, the next step is to perform mediastinal bronchoscopy and obtain tissue for biopsy . Ca is increased and Steriods are tx of choice for SYMPTOMATIC pts.****Pt with no symptoms but dyspnea that has gotten worst and joint pain with cxr showing hilar adenopahty and non-caseating granuloma.****Skin manifestation os rash is found in 30% of pts, to Dx Scintigraphy, to Confirm biopsy and NC Granulomas.
Scabies
Tx for adults is 5% permethrin cream
Scaphoid Fracture
Common in adults, after a fall on a outstretched hand. Pt presents with pain at wrist movement. Tenderness in Anatomical sniffbox. It might not show on xray for 2 weeks. So if signs are there but xray is negtive tx as if it is fracture. 10% go to have avascular necrosis due to tx error. Cast immobilization is recommended in the treatment of all Non-displaced scaphoid fractures (fractures <2mm displacement and no angulation). Open reduction and internal fixation if initial Xray shows displacement fracture. *****If fracture is suspected even if the xray doesn’t show it (cause it takes a few weeks) then the best mngmnt is long arm cast and treat it as if there is a fracture.
Scarlet fever
Presents with fever, toxicity, pharyngitis(Grey-white exudate), sanpaperlike rash and strawberry tongue and 'circumoral pallor'. By GroupA strep, because of erythrogenic toxins. tx is PenicilinV. If allergic, Erythromycin and Clindamycin are alternatives.DDX1:Kawazaki, due to pharyngitis, strawbery tongue, Lyphadenopathy and rash. However, it must hace either change is peripheral extremity or conjunctival injection, to make the dx. Its difficult to DDX but response to Penicilline makes the dx.
Schizoaffective disorder
Combination of Schizophrenia and mood disorder. So pt hears voices, but is not violent and just wana be alone.
Schizophrenia - 10
Fluphenazine & Haloperidol (both long acting and injectable) are the tx of choice in pts who suffer relapses due to tx non-compliance. Injection can be dome outpatient and intervals (twice per month). ******The symptoms are 2 types, + & - . The + symptoms include, hallucination, delusion, disorganized behavior and speech. The - symptoms include the Five "A"s, Affective Flatening (diminished emotional responsiveness), Alogia (poverty of speech), Apathy (impaired grooming, unwilingness to perform activities), Asociality (social detachment) and Attention (impaired attention when interviewed). Positive symptoms respond well to typical antipsychotics. The Negative symptoms responde to Atypical antipsychs, Risperidone.***** 1-Schitsoid personality:social detachment and restricted range of expressed emotions. 2-Schizotypal: Eccentric behavior and a reduced capacity for close relationship. They might believe in magical thinking and might have bizzar fantasy or believe in telepathy,or sixth sense. 3-Avoidant personality:hypersensitive to critisim. They fear ridicule. 4-Borderline personality has Splitting. 5- Schizofreniform:hallucinations, delusion, disorganized speech, catatonic or flattened affect. Symptoms must be there for at least one month but less than 6 months. 6-Schizophrenia is like number 5 but sysmptoms last more than 6 months.***Subtypes of Schizophrenia are: 1-Paranoid:Preoccupation with delusion,auditory halluciantion w/o disorganized speech or inappripriate affect, they rsponde to pharmacotherapy. 2- Disorganizedisorganized behavior & speech, and flat or inappropriate affect. 3-Catatonichysical symptoms including immibility or excessive motor activity and assumption of bizar postures. 4-Undifferenciated:mixed symptoms that dont meet the critetia of other subtypes.***Schizotypal is presents with odd behavior (like saying I have some powers) and no close friends. DDX is Schizoid are those hace social detachment but no odd behavior (powers and things). DDX is Avoidant are those who want to be socially involved but are afraid of rejection.****Schizophrenic pts have enlarged ventricular size, Decreased cerebral mass, hippocampal mass, temporal mass and no change in cerebellar mass.****The following s&S are indication for hospitalization of schzophrenic pts: Homocidal ideation, suicidal ideation, grave disablity, gross disorganization, agitaed or threatend behavior. ****Catatonic pts are tx with Benzodazepine. Pts dont move,talk, and there is rigidity. so Lorazepam ix doc.****remember DDX b/w Schizophrenia dn scizpphreniform is duration of more then 6months.
Scleroderma
CREST syndrom. Asso with anti scl-70 antibodies.Wegener asso with C-ANCA. Polymyositis and dermatomyositis are asso with ANA and Anti Jo 1 antibody.
Scoliosis
Types are:1- Idiopathic ( the mc), has three types infantile(<3yr), juvenile <10 and adult >10yr. 2-Neuromuscular , 3-Congenital. Dx is by bending over and Cobb's angle of scoliosis. Tx is aimed at control of curve progression. Careful obervation and follow up with mild (<20) curve. If first time notic is >30 give bracelets. If initial notic is >40 degree then Surgery is required.
Seborrheic Dermatitis
Dry scales and underlying erythema of scalp central face, interscapular areasumbilicus and body folds. Asso w Parkinson's Disease. Suspect HIV with a young pt with SD. Suspect Hepatitis C in pt with Lichen Planus.
Seborrheic Keratosis
Refered to as "barncles of old age". Benign. Welvety or warty, greesy, with stuck on appearance. Color from pink to black. Anywhere except palms and soles. Dx is shave biopsy. Remove for cosmetic reasons.
Secondary to the spine
Metastasis from carcinoma is the mc malignant tumor of the skeletal system. In pts w hx of malignancy, back pain raises suspicion for bone metastasis. Progresive low back pain not relieved by rest and worst at night suggets vertebral body metastasis. Secondaries to th ebone mainly arise from priamries f the prostate, breast, lung, lymphoma multiple myeloma. Technetium 99 scinti scanning is the method of choice.
Seizures - 2
1-Generalized (involving all brain) Tonic Clonic: Characterized by aura (lights), followed by stiffness and lost of consiousness. The next step is tonic-clonic jerky moves, biting the tongue, incintinence and postictal confusion. 2-Status epilepticus: multiple epileptic seizures one after the other. 3-Absence seizure, last a few seconds and no postictal confusion. and no loss of consiousness. 4-Simple partial seizure: focal motor sensory or autonomic symptoms and no loss of consiousness. 5-Complex partial seizure: focal seizure followed by transient or incomplete impaired consiousness.****CT of the head WITHOUT contrast is the initial Dx of choice when a pt is presented with impaired consciousness or seizures. CT WITH contrast is usually indicated if brain tumrs or other masses (Toxoplasma,lymphoma) is suspected. If the NON contrast CT excludes the hemorhage then MRI or CT WITH contrast is the next step.***Tods palsy is a transient hemiplasia that occurs after a seizure.
Selective IgA/IgG def
Pt presents with recurrent sino-pulmonary infections and diarrhea chronica, due to bacerial infection. Quantitavive measurment of serum Ig will help determine Dx.
Septic Abortion
Is to be suspected in ALL abortions outside hospital who come bcack with pain and vaginal discharge. Its managed with cervical and blood sampling, IV antibiotics and gentle suction cuertage.
Septic arthritis - 2
Acute inflamatory monoarticular arthritis in a previously damaged joint suggest SA. Leukocyte cont of >50K or 100K in synovial fluid.****Like Osteomyelitis in a child, SA is also hematogenous in origin and occurs after URI , The mc organism in children is Aureus and strep. Charcterized by severe pain,leukocytosis,elevated ESR. Pt refuses to walk,keeps the limb externally ROTATED. US guided aspiration shoould be done immediately. Fluid >100,000 is dx. Empiric antibiotics shoul dbe given immediately. In Infants Nafcillin+3rdgen cephalos, and for >5yo Nafcilliln alone. Its a true surgical emergency and needs surgery and drainage immediately, a delay of 4-6 hors can lead to Avascular necrosis.
Septic shock
To treat the induced metabolic acidosis, IV normal saline+Vasopressin+antibiotics is the tx. Use Sodium Bicarbonate is only recommended for pH<7.2, and then its only given to raise pH to 7.20 and then we use other means to normalize it.
Serous otitis media
is the mc middle ear pathology in pts with AIDS. Its charachterized by hearing difficulty, dull tympanic membrane, air bubbles. DDX with Chronic OM is that COM has purulent aural discharge. Tympanic membrane is thickended with calcific pathches and perforation. Otosclerosis occurs in 3rd decade of life and there is absence of stapedial reflex. Its limted to temporal bone.
Severe Combind I D
A lifethreatning syndrome. Presents with recurrent sinupulmonary infection, oralcandidiasis,persistant diarrhea,opprtunistic and viral infectins. Dx is confirmed by: Asence lymph node and tonsils, lymphopenia, absent thymic shadow on cxr, and abnormal T & B cells & natural killer cells. DDX1:Common Variable ID, or Acquiired Hypogamaglubinemia is similar to Burtons, however less sever symtoms and at a later age like 15-35, Ig A/G/M/E may be decreased but no absence of B cells. DDX2:Bruton's Agamaglubulinemia, X-linked, Pt is a male infant asyptomatic until 6mo of age, then recurent pyogenic infection ( S. penuonia, H.inf), Dx is Decreaed Ig A/G/M/E along WITH decreased B cells. DDX3:Wiskott Aldrich, X-linked, Pt is a young boy with Eczema, thrombocytopenia and recurrent infection with capsulated germs. Initail manifestation is at birth with petechia,bruises, bleeding from circumcision or bloody stools. Low Ig M/A/E levels, redueces T cells and platelets. DDX4:Chronic Granulomatous Dis, Defet of phagocytic cells due to dysfunctin of NADPH oxidase enzyme complex, leading to recurrent and uncontrolled infection with catalase positive organism, the mc infectin are lymphadenitis, abscesses of skin adn liver, Lymphocytes are normal, Dx is by Nitro Blue Tetrazolium test
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