Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

STEP 2 Board Studying

No description
by

Rebekah Crawford

on 15 November 2015

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of STEP 2 Board Studying

Main mneumonics
IM
OMM
others
OBGYN
Peds
FP
Psych
Neuro
Surgery
STEP 2 Board Studying
cardiology
Respiratory
GI / liver
Nephrology
Endocrinology
MS
Hematology
OBGYN
Psych
Psych axis:
I. Major
psych
health disorders, schizo, anxiety disorders, opiate overdose
II.
PD/MR
III.
Medical issues
: HTN, > blood sugars
IV. Social
stressors
(break up)
V. Global assessment of
function
- Severely disturbed (0-10)
- Hospitalized (0-40)
- Stressed, very tired (50-60)
- Normal (80)
- Perfect, no psyche frustration (100)

Neuro
FP
Peds
Derm
EM
underlined in book, quick review

antidotes---voice sms
Ethics/Law
sticky notes:
- 2x2 table & terms
Opthalmology
Radiology
- X-ray:
Lucent-b/sclerotic-w, radiolucent-b/radiopaque-w
- CT: hypodense-b/hyperdense-w
- Table 10.2

Derm
Opthalmology
Radiology
EM
Ethics/Law
7- petaled flower = IM
10 floater-subjects
MDD: ddx hypothyroidism, esp in elderly
- ETC Tx: if refractory, main SE memory loss
Dysthymic disorder: steady Sx for min 2 yrs
Bereavement: > 2 mo < 6 mo
Bipolar: young people, > E, < need sleep, pressured speech, < attn span, impuls, hypersex, spend lots money.
- DDx: coc/amphet use, PD, schizo, hypomania
- Sx > 1 wk and abrupt
- Rapid cycling: 4 episodes/yr---may be precitated by antidepressants
- Tx: 1st valproate, 2nd lithium
- valp and carbamazepine = SE blood dycrasias
- Li toxicity = tremor + polyuria from nephro DI
Drug induced mania: EKG arrhythmia, ischemia in young people
- Tx: Ca ch blockers for acute ANS, drug Tx programs
Psychotic disorders:
-schizo: late teens-20s (slightly later in women), very strong
- positive symptoms = hallucinations (normally > audit than visual) and delusions
- negative Sx = lack of affect, alogia (lack of speech)
- lastst > 6 continuous months
Schizophreniform 1-6 mo
Brief Psychotic Disorder 1 day-1 mo
schizoaffective = mood disorder + schizophrenia
delusional disorder = non-bizarre delusions

delirium: Pt not AOx3, severity waxes and wanes within same day
Yersinia enterocolitis
= DDx from appendicitis, labs: fecal culture
Ectopic pregnancy
= > hCG, culdocentesis with blood
PID = TOA
= salpingitis (similars): purulent vaginal discharge, cervical motion tenderness, adnexal mass. + chlamydia or gonorrhea
Meckel's Diverticulum
: melena, hematochezia, insussuception, Littre's hernia...
intussusception
: infants 5-10 mo, crying infant pulling legs up to abd, dark red currant jelly stool, vomiting, shock. On Barium or air contrast enema = Dx "coiled spring" sign
Splenic rupture
: tachy, broken ribs, Hx trauma, hypotension.
Kehr's Sx
(LUQ pain, refers to shoulder), X-ray medially displaced gastric bubble, Dx preferred via CT
Sigmoid volvulus
: X-ray = inverted U, contrast enema = bird's beak deformity
Pyelonephritis
: high fever, rigors, CVA tenderness, Hx of UTI
Pancreatitis
: Grey turner's Sx (flank) or Cullen's Sx (periumbilical), sentinel loop. CT: phlegmon, pseudocyst, necrosis, abscess
Achalasia
: motility disorder, no LES relax cuz of ganglionic degeneration or Chagas Dz. dysphagia both solids and liquids, foul odor, > risk esophageal CA cuz of dev to Barrett esophagus
Zenker's diverticulum
: pulsion diverticula, only the mucosa, b/t thyropharyngeal and cricopharyngeous muscle fibers (m dysfunction/spasms). Tx: myotomy + removal of diverticulum


Eosphageal CA
: apple-core lesion, endoscopy + Bx
- squamous cell: men, 60's, alcohol, tobacco
- adenoCA: chronic reflux = Barrett's esophagus (squamous to collumnar metaplasia)

Gastric CA
: most malignant, most common men >50 y.o.
- linitis plastica = invariably dead within months
- mets: virchow's node, Krukenberg's tumor, sister Mary Joseph sign, blumer's shelf
Hernias
- inguinal: direct (medial)/indirect (lateral) to inferior epigastric artery, through Hesselbach's triangle = inguinal lig + inf epigastric art + rectus abdominis
- combined (pantaloon), sliding, richter, littre, reducible/incarcerated, strangulated, incisional
Liver CA ---dx via U/S,
CT
benign
- hemangioma = most common benign
- hepatic adenoma----relat to OCPs, Dx via CT
- peliosis hepatis (rare), little lakes of blood cysts throughout liver, Tx Abx and monitor
- adenomas may rupture = severe intraperitoneal bleed
malignant
- mets = most common
- hepatocellular CA (most common 1ary), most common in world = SE Asia and Sub-saharan Africa---assoc with HepB, HepC, cirrhosis, alcoholism, hemochromatosis, Wilson's Dz. Very high AFP. Tx: surgery, liver transplant, chemo-Sorafenib
- hemangiosarcoma: toxic exposure to polyvinyl chloride, Thorotrast, and arsenic. Tx: surgical resection
Gallbladder:
-
cholelithiasis
= Gallstones, 4Fs: female, forty, fertile, fat.
if < 20 y.o. workup for congenital spherocytosis or hemoglobinopathy
-
porcelain
gallbladder (esp. Native American)
-
biliary

colic
---U/S, HIDA scan, EF < 20% = highly suggestive of acalculous cholecystitis
-
cholecystitis=
2ary to ifxn of obstructed gallblader. Tx: NPO, IV hydration, Abx, demerol for pain (cuz morphine=spasm sphincter of Oddi), surgical resection if needed
-
choledocholithiasis
: normal CBD > 9mm diam (normal CBD 3-4mm, > by 1 mm per 10 yrs over 50 y.o.) 5mm--50, 6mm--60
-
ascending

cholangitis
: 2ary to strictures, foreign bodies, and parasites. life threatening. Tx: NPO... Abx, IV hydration, ERCP or PTC to decompress, later cholecystectomy
-
Charcot's triad
: jaundice + RUQ pain + fever
-
Raynold's pentad
: altered mental status + hypotension
-
gallbladder

CA
: 1ary is adenoCA, freq in Far East cuz Clonorchis sinensis (liver fluke) infestation
- if confluence hepatic ducts-common bile duct = Klatskin's tumor
- Courvoisier's law = gallbladder big if obstructed by pancreatic CA, but not when obstructed by stone
-
bile duc CA
: mort 90% at 5 yrs. risk factors: clonorchis sinensis infxn, UC, sclerosing cholangitis.
Exocrine pancreas:
- acute pancreatitis: common causes gallstones and alcohol.
- others: infxn, trauma, radiation, drug (thiazides, AZT, protease inhib), hyperlipidemia, hyperCa, vascular events, tumors, scorpion sting
- Sx:
Grey-Turner's Sx, Cullen's Sx
- use TPN if NPO for > 7-10 days
- prognosis via Ranson's Criteria (table 2.11)

Pancreatic CA: most adenoCA, > AA, smokers, males. Sx: painless jaundice, weight loss, abd pain, classic Sx =
Trousseau's Sx
= migratory thrombophlebitis (10% pts). > CA19-9 but not Dx

Endocrine Pancreas CA
- insulinoma (beta-cell)
- glucagonoma (alpha-cell: hyperglycemia, exfoliative dermatitis, most malignant tumor cuz 70% mets rate)
- somatostatinoma (delta cell)
- VIPoma: watery diarrhea + electrolyte prob
-ZES (gastrinoma), assoc with MEN 1
Small bowel neoplasms:
- Leiomyoma (benign)
- carcinoid tumors
- malignant Ca:
adenoCA > carcinoid > lymphoma > sarcomas


Colonic polyps:
- neoplastic: most commonly adenomas, mean age 55, > incidence with age, intermitt rectal bleeding. Tx: colonoscopic polypectomy or laparotomy
- tubular adenoma
- tubulovillous adenoma
- villous adenoma (greatest malig potential)
- hamartomas (just weird skin)
- inflammatory
- hyperplastic: benign unless malig in hyperplastic polyposis Sx
-
Familial polyposis Sx
-
FAP
: auto D inherit APC gene, multiple polyps begin @ puberty. congenital hypertrophy of retinal pigment epith (97% predictor)
-
Gardner's Sx
: polyposis + desmoid tumors + osteomas of mandible or skull + sebaceous cysts
-
Turcot's Sx
: polyposis + medulloblastoma or glioma
-
Peutz-Jeghers Sx
: auto D, nonneoplastic hamartomatous polyps in stomach, sm int, hyperpigmentation (colon, skin, mucous membrane---freckles on lips). > risk CA in other tissues (breast, pancreas...). Tx: careful regular monitoring
-
Juvenile Polyposis Sx
: juvenile polyposis coli, generalized juvenile GI polyposis, Cronkhite-Canada Sx. Hamartomatous polyps

Diverticulitis:
- fistula = colovesicular = recurrent UTIs, pneumaturia
- NO Ba enema and colonoscopy, unless obstruction or fistula = contrast enema
- colonoscopy 4-6 wks post resol Sx to see if CA
- Tx: abscess = CT or U/S percutaneous drainage. Sigmoid colectomy (elective). Perforation/obbstruction: temp divert colostomy + Hartman pouch + reanastomosis 2-3 mo later. OR sigmoid colectomy + colocolonic anastamosis with proximal loop ileostomy

Massive lower GI hemorrhage causes: diverticular Dz, angiodysplasia, UC, ischemic colitis, solitary ulcer.
Dx: 1st proctoscopy, unstable still = angiogram, stable = colonoscopy
Breast
- mastalgia: breast pain not cuz lumps. Tx: Danazol (induce amenorrhea, SE: hirsutism + weight gain)
- Tietze Sx = costochondritis (if worse with respiration)
- Mondor's Dz = thoracoepigastric vein phlebitis

- CA risks: auto D = BRCA-1, BRCA-2, Li-Fraumeni Sx, Cowden's Dz, Peutz-Jeghers

-
Fibrocystic changes:
not assoc with > risk CA unless epith hyperplasia with atypia = 4-5x risk
-
Fibrous Pseudo-Lump
: parenchymal atrophy in premenopause, multiple nodules
- I
ntraductal papilloma
= serous/bloody niple discharge, solitary = ok, multiple > risk CA
-
Intraductal hyperplasia:
> 2 cell layers in ducts, with atypia = > risk CA in either breast. NOT premalignant, but MARKER for future malig, may not be in same place
-
DCIS
: usually non-palpable, irregularly shaped ductal calcific on mammography. Comedonecrosis common in her2/neu + (c-erbB-2 +) Dz. True premalignancy = will lead to invasive ductal CA. roman bridge cells. Tx estrogen R + with tamoxifen for 5 yrs
-
LCIS
: not detect easy. NOT precancerous, IS marker for future IDC risk in both breasts. mucinous cells, sawtooth and clover-leaf in duct
-
intraductal CA
, most common, 35-55 y.o., solid tumors. tumor size. cribiform or pap intraduct origin vs. comedo origin (bad)
-
invasive lobular CA
: only 3-5% of invasive CA, 45-55 y.o., look vague on mammogram, single file growth pattern within a fibrous stroma
-
paget's breast Dz
. nipple/aola, underlying ductal CA
-
inflamm CA
: inflamed breast, rapidly progressive breast CA, almost always widely metastatic at presentation, poor prognosis
Urology
- testicular torsion: no cremasteric reflex on affected side
- epididymitis: gonorrhea or chlamydia
- appendix testis torsion : blue dot Sz on superior pole of testicle, yes cremasteric reflex. Supportive Tx, resolve 2 wks
- Fournier's Gangrene: necrotizing fasciitis of genital area----Tx emergently wide surgical debridement and Abx
Intracranial

hemorrhage
: CPP = MAP + ICP ----1st HTN and tachy------then
Cushing's

response
= HTN, bradycardia, tachypnea----compression on vagus
-
epidural
: biconcave disk (lens), middle meningeal art, Tx burr holes
lucid period, trauma to temporal, young, fixed dilated pupil
-
subdural
: crescentic, cortical bridging veins, can't cross suture lines.Tx burr holes
elderly, alcohol, or on anticoags. Sx: HA, drowsiness
-
subarachnoid
: severe sudden HA, maybe CN III palsy, worst HA of my life, nuchal rigidity, focal neuro deficits, confusion. photophobia and meningismus Eventually decerebrate rigidity and coma. circle of willis at branch for middle cerebral artery. CT: texaco start ----Tx surg excision Berry aneurysm or fill with metal coil. Tx nimodipine to prevent vasospasm and 2ary infarcts
-
parenchymal
= basal gangila, internal capsule, thalamus. from HTN, trauma, AV malformation, coagulopathy. > ICP, Tx mannitol, hyperventilate, steroids, maybe ventricular shunt


Fluid and electrolytes:
3 x vasc deficit = effective 2/3 intracell
table 2.1
good vol = urine output > 0.5 cc/kg/hr or typical Pt > 30 cc/hr

Blood Product Replacement:
- 1u pRBCs = > Hg by 1g/dL and > Hct by 3%
- sig bleed if Plt < 50,000/microL
- FFP
- cryoprecipitate
-*alloimunization

Perioperative Care
- ASA d/c 2 wks prior
- CV = Goldman cardiac risk index
- before dye = IV uids, NAC or Na bicarb to avoid CAN (nephropathy)
- Postop ARF > 50% mortality despite hemodialysis
- Abx: within 1 hr start surgery, stop prophylaxis within 24 hrs post-surgery
- DVT prophyl = SubQ heparin
- if on corticosteroids = give hydrocortisone (before, during, and after surgery)----cuz if not = may have adrenal crisis (unexplained < BP and tachy despite fluid and vasopressor use)
- Malignant hyperthermia: anesthesia (halothane, isoflurane, succinylcholine). Tx: dantroline, cooling, ICU
- Postop fever = 5 W's.... bugs in infxn= strep and clostridium
wind, water, wound, walking (DVT), wonder drug
Trauma
- general survey = ABCDE
- if alrey thoracostomy---indic for thoracotomy = 1,500 cc initial output or 250 cc/hr x 4 hrs
- neck = 4 vessel angiography (all zones I, II, III)
- Esophageal injury = gastrografin swallow or direct visualization
- sonography = FAST -----to DDx intraperitoneal hemorrhage or pericardial tamponade
- perihepatic (hepatorenal space)
- perisplenic
- pelvis
- pericardium
- LOC = causes = AEIOU TIPS
alcohol, epilepsy, environ (temp), insulin, overdose, uremia (electrolytes), trauma, infxn, psychogenic, stroke
Tx: coma cocktail = dextrose, thiamine, naloxone, O2
*Glasgow coma scale: eye opening 4, verbal 5/motor response 6

> ICP = Cushing's triad (HTN, bradycardia, bradypnea)

2ary trauma survey = stable ---Dx peritoneal lavage, Abd U/S or CT
unstable = surgical lap


blood @ urethra = retrograde urethrogram before catheter
hematuria = sig retroperitoneal injury = CT


Compartment Sx: tense, pale, paralyzed, paresthetic, painful. Tx = fasciotomy

Shock:
- hypovol: 2 large bore IV crystalloid/colloid. 3L for 1L loss
- cardiogenic: 1st Dobutamine, 2nd add dopamine/NE, O2
e.g. pericardial tamponade, or tension pneumothorax, CHF
- septic: NE = vasoconstric periph-----prevent MODS, resist Abx, O2
- neurogenic: blood pooling in muscles and spleen
- anaphylactic

Burns: Parkland formula
%BSA x weight (kg) x 4 = vol crystalloid
1/2 given in 1st 8 hrs, rest over next 16 hrs
check blood, ABG, electrolytes, UA
Tx: irrigate and debride wound, topical Abx (silver sulfadiazine, mafenide, polysporin). Prophylaxis: tetanus, stress ulcer
*Marjolin's ulcer: sq cell CA from ulcer/burn
*Curling's ulcer: acute duodenal ulcer in burn Pts

*Neck mass DDx: table 2.8
Esophagus: Dx: Ba swallow (see variations in anatomy)

Fitz-Hugh-Curtis Sx = perihepatitis ---post PID
> leuks but nml bili, nml LFTs
Colangitis: life-threatening. Charcot's triad/Raynold's pentad. Dx: ERCP or PTC
Hepatitis: DDx rule out by U/S
Prego = Sx = amenorrhea, > urine freq, breast engorgement and tenderness, nausea, fatigue, Chadwick's Sx (blue discolor vagina)
Hegar's Sx (softening of cervix)
- home preg kit detect 12-15 days after, beta-hCG
- U/S: gest sac (5 wk), fetal image (6-7 wk), cardiac activity (8 wk). U/S to det gestational age
- EDC = estimated date of confinement = Nagele's rule = LMP + 7 days + 9 mo
- first visit post-conception: do all blood test, OB Hx, infxn tests, give supplements
- fetal fibronectin = risk for preterm labor

*teratogenic drugs, and safe mom's take care (audio file)

Timeline:
1st trimester (1-12 wks)
screen for Down's Sx: U/S nuchal translucency, blood test triple-marker screen (AFP, beta-hCG, estriol). inhibin. PAPP-A (>85% detect DS)
Down's Sx: < AFP, >beta-hCG, < estriol, > inhibin
>AFP in multiple gest and NT defects
chorionic villus sampling wks 9-11 (fetal karyotyping) risk limb reduction, less likely but fetal loss, and can't detect neural tube prob
2nd trimester (13-28 wks)
U/S = eval fetal heartbeat at each visit
wks 17-19 quickening, document move
amniocentesis (15-20 wks) for > risk moms (>35 y.o. or Hx)
glucose screening at 24 wks (1 hr Glucola)
Repeat Hct at 25-28 wks
3rd trimester (29-40 wks)
PTL Sx: vaginal bleeding, contractions, ROM
PIH
screen for GBS at 35-37 wks
RhoGAM 28-30 wks if indicated
SLE= Anti-dsDNA = active lupus nephritis = flea-bitten kidney on its cortical surface
anti-Ro/SSA = neonatal SLE, causing congenital complete heart block = bradycardia, with gallops and murmurs. also + with other autoimmune rheumatic disorders
RA= anti-citrullinated peptide Ab = ACPA (against keratin and other CT components). also + in SLE and Sjogren's Sx with arthritis, or even in active TB
Scleroderma = Anti-scl-70 Ab = anti-topoisomerase I
limited scleroderma = CREST Sx, affects hands, arm, and face
diffuse = organ + skin involvement, sometimes < ventialtion and perfusion capacity cuz barrier to exchange
MCTD = anti-U1 RNP Ab. Sx varied, e.g. = myalgias, raynaud's and hypergammaglobulinemia
- HTN
-
urgency
>170/>100
Tx:
enalopril
or
clonidine
-
emergency
>210/>150 or CHF >130
nitroprusside
(powerful vasodil... arteriolar, and venous, SE: reflex tachy
- other options
diaxoxide
= arteriole dil, SE reflex tachy
labetalol
= powerful alpha1 block (vasodil) and beta1 block (< BP by < force contractions) no reflex tachy
-
malignant
: any HTN with end-organ damage
sudden > BP over baseline can = blood vessel and organ damage, most come from HTN emergency. brain/retina/kidney.
look for focal neuroSx, fundoscopic, UA, retinal hemorrhage, papilledema
- Do not < BP by >1/4 within the 1st hour
- never drop > 40% w/in 24 hrs

- stages of HTN: normal/preHTN/stage I/stage II
-
2ary HTN
: CV, Renal, Endo, Drug induced
drugs:
ping P O N G
phenylephrine, OCPs, NSAIDs, glucocorticoids
- CV: aortic regurg (wide pulse P), aortic coarct (HTN arms, < BP in legs)
- Renal: glomerular Dz (proteinuria), RAS (refractory HTN, often from atherosclerosis in older men or fibromuscular dysplasia in young women), polycystic kidneys
- endo: Cushing's and Conn's (> aldost, > steroids, HTN and hypoK), Pheochromocytoma (episodic autonomic Sx), hyperthyroidism (isolated systolic HTN)

- CAD: Risk: HOPE F U L SSS
(ldl)(Hx)(DM)(sedentary, sex, smoking)
TIMI risk score for unstable angina/STEMI
age > 65, >3 CAD risks, known CAD, ASA use last wk, severe angina, ST dev, + enzymes
- risk > 3 = enoxaparin (vs. unfractionated heparin), glycoprot IIb/IIIa inhib, and early angiography
- stable/unstable angina (at rest, changing)/Printzmetal's (EKG show, no enzymes)
- NSTEMI (>20 min) heparin. STEMI tPA
angiography/angioplasty (within 24h)
> enzymes = cath + clopidogrel + Gp II-IIIa inhib (eptifibatide, tirofiban)
Sx > 12 hrs ---CABG

myocarditis: chronic, vague and mild pain, fever
pericarditis: positional, worse with laying down, pleuritic, sharp, EKG abnormalities
1st line anti-HTN:
- thiazides: normal HTN and osteoporosis
DCT block Na reabs, > Na and H2O output in urine, causes vasc Sx a new and < set point for BP
- ACE inhib (NOT for RAS, prego, Cr > 1.5)
DM (arbs too), CHF (arbs too), MI (beta-blocker too, but not for COPD)
save kidney, no > filtration P
in DM glucosuria and drags H2O cuz osmotic P, so RAA Sx < = dil renal efferent arteriole (good)
- alpha-blockers: for prostate
- beta1-selective blockers: act on HR and JG cells (RAA Sx), also on islet cells of pancreas = < insulin (cuz < funct cells)----problem for DM type II= relative CI, block symp response to hypoglycemia as well
- alpha-methyldopa: prego-safe
- amlodipine (Ca block): Prinzmetal's anginal
- diltiazem/verapamil (NOT for CHF), for Afib/A flutter
- Clonidine: for refractory HTN, renal failure Cr> 1.5, or drug use
- Nitroprusside (powerful: arteriolar vasodil and venodil), can cause reflex tachy
other options:
- diaxocide (arterliole dil, reflex tachy),
- labetalol (powerful, alpha1 blocker = vasiodil, beta1 block = < BP force heart, no reflex tachy

Hypercholesterrolemia Tx:
- HMG-CoA Red Inhib (simvastatin, atorvastatin) SE: rhabdo...
- Fenofibrate
- Niacin: SE: cutaneous flushing, > insulin resist
- Ezetimibe
- Gemfibrozil: < VLDL prod. for isol > triglyceridemia, SE: rhabdo
EKG
Heart sounds and murmurs
cardiomyopathies
endocarditis
RHDz
Pericarditis
PAO2 = FiO2 (Pbreath + PH20) - (PaCO2/R)
COPD: most smoke or alpha1-anittrypsin
- Emphysema (pink puffer): alveolar wall destruction, SOB
- Chronic bronchitis (blue bloater): productive cough on most days at least 3 mo, during 2 consec yrs
- Asthma: reversible bronchoconstriction
- Bronchiectasis: perm abn dilation bronchiloes, tram-track lung markings

○ By the time dyspnea happens: 1/2 lung function and had COPD for years
○ Dx: spirometry for lung function ----Ratio of FEV1 to FVC < 0.7 = airway obstruction
§ If reversible: increase in FEV1 > 12% or 200 mL
○ Staging:
§ 0 --at risk, normal spirometry
§ I ---mild: meets definition, with or without Sx ---Tx: short-acting bronchodilators
□ Albuterol (beta2-agonists) and anticholinergics (ipatropium)
§ II ---moderate: FEV 50-80%, Tx: long-acting bronchodilators
□ salmeterol, tiotropium, or oral methylxanthines (aminophylline, theophylline: but narrow therapeutic window, high toxic, multiple interactions)
§ III ---severe: FEV 30-50%, Tx: inhaled steroids
□ Fluticasone, triamcinolone, mometasone
□ Not for long term: complic = myopathy, osteoporosis, glucose intolerance…
§ IV-----very severe, FEV< above, chronic hypoxemia (<88% at rest), Tx: long-term O2, worn for at least 15h/day + maybe surgeries
○ Acute exacerbations = sick with Pneumococcus, H flue, Moraxella catarrhalis
§ If severe: klebsiella, pseudomonas

RESTRICTIVE lung Dz
- < lung tissue
- parenchymal Dz
- interstitial fibrosis ----honeycomb, PEEP
- extrapulmonary
- Pleural effusion: transudate/exudate (prot):
Tx: thoracentesis
PE: Virchow's triad
- Pleural edema and ARDS
- PE
- Pulm HTN
RRR, axis
Rate: 60-100 = 3-5 boxes
300 - 150 - 100 - 75 - 60 - 50

PR = 3-5 small boxes = 0.08-0.10 sec
QRS = 2.5 small boxes

- Sinus rhythms:
○ Normal
1. P has QRS, QRS has P
- P wave w/o QRS
- Afib: no discernable P waves ------irregularly irregular rhythm
- Aflut: "sawtooth pattern", flutter waves are regular to each other
-2nd AV block
◊ Mobitz Type I = Wenckebach
◊ Mobitz Type II -----Sx, could be drug induced
- 3rd AV block = P-P regular, R-R regular, each doing their own = no more communication AV
◊ Normally have some sort of pathology and need pacemakers
- QRS w/o P
- PJC ----QRS still normal width = narrow (travel normal conduction way, except start at AV or around there)
◊ Happens early in the cycle (earlier than you would expect it) with a compensatory pause
- PVC-----wide QRS (irritable Purkinje fibers, through myocytes instead of normal conduction way)
◊ Unifocal ----all look the same
◊ Multifocal---post MI, post thrombolytics, post-stent, irritable myocardium
◊ Single/coupled
◊ Bigemini/trigemini: every 2 or every 3 beats is PVC
- AVNRT = SVT = P waves hidden in QRS -----cuz has to have a T (ventricles NEED to repolarize) rate above 130
◊ Afib
◊ Aflut ----often in HR = 150
◊ reentry
- Vtach = 3 or > QRS together, fairly regular
◊ Monomorphic = all complexes same shape ----non-sustainable rhythm----degenerates into Vfib
◊ Polymorphic = Torsades de pointes (awake), alcoholics, poor nutrition, electrolyte deificient -------MgSO4 2g----also Tx preeclampsia
- Vfib -------CRAZY! (not awake), disorganized
◊ Coarse
◊ fine
- Idioventricular rhythm: wide QRS, bradycardia
2. Cte P-P and R-R intervals
- PAC = premature atrial contraction (didn't come from SA node = P wave inverted)
3. P upright in I, II, and aVF
- Atachy = not from SA node, fast rate
- MAT = multifocal (P waves look different than each other between them)
- Junctional rhythm ----no P wave or inverted P wave, RATE= 50
- If faster = tachy junctional
4. # boxes PR and QRS
- WPW = short PR, delta wave (wide QRS, like you're dragging a leg)
- 1st degree AV block (long PR but cte), can live normal lives ----esp see in Pts on beta-blockers
- Wide QRS: several, some of them…. Need all 12 leads to see it
- BBB = RSR' wave = bunny ears!
◊ L: V5 and V6
◊ R: V1 and V2
◊ Ventricular PACED rhythm, with pace spikes
5. Rate
- Sinus bradycardia (slow)
- Sinus tachy (fast) ---e.g. exercise 100-120 RATE, can see P wave still
- Hypovolemic, pain, fever, anxiety, hypoxia
○ Brady
○ Tachy
- SVTachy
○ Afib
○ Aflut
○ Atachy

Asystole: 99% dead
PEA: no pulse, any of the rhythms. ----need P of about 50 (not conscious)
WPW: d waves and short PR interval

Q waves = > 1 small box deep and 3/4 box wide
- In V2 and V3 = always pathologic


http://www.skillstat.com/tools/ecg-simulator
I: inferior ----II, III, aVF ------R coronary art
See: septal--V1, V2 ------------LAD
All: anterior-V3, V4-------------LAD
Leads: lateral: I, aVL, V5, V6- L circumflex

people with atypical (or silent) MIs = women, DM, elderlyand postortho heart transplant
weird Sx with inf infarction = brady, diarrhea, lightheaded, cuz L vagus nerve runs right behind

Enzymes 2-4-6-8 days T(CAL)
Mediastinal tumors
- MS
- MVP
-MR
-TS
-TR
-AS
-A Sclerosis
-AR
-HCM
hypoxemia: 5 methods = high altitude, hypoventilation, diffusion impairment (fibrosis, anemia), V/Q mismatch (PE), shunt (resp edema or chronic liver Dz)
Lung CA
- AdenoCA
*pancoast tumor: Horner's Sx and SVC Sx
- bronchoalveolar CA
- large cell CA
- squamous
- small cell (oat cell)
- bronchial carcinoid tumors
-lymphangio leiomyomatosis
TB
Penumonia
- most community
- typical bact
- strep pneumo
- H flu
- Moxarella catarralis
- Klebsiella
- S. aureus
- atypical bact
- legionella
- mycoplasma
- chlamydophila
- chlamydia
- fungal
- p jiroveci
- Coccioides immitis
- histoplasma
- blastomycosis
-cryptococcus
- anaerobes: oral flora
- viral: Influenza

- hospital/healthcare related
- resistant GNR
- pseudomonas
- acinetobacter
- MRSA
Gastroesophageal Dz:
- dyspepsia
-GERD
- Chronic= atrophic gastritis
type A = autoimmune, pernicious anemia
type B= H pylori infection or NSAIDs
triple Tx = amox, clarithomycin, omeprazole
H2 R antag = cimetidine, ranitidine
PPIs = omeprazole, lansoprazole
- gastric ulcer
- basophilic esophagitis
Intestines:
- diarrhea >200 g feces/day, > freq or < consistency stool
-acute <2 wks Sx, usually infxn and self-limited
- preformed toxins (s aureus, bacillus cereus)
- noninvasive bact (ETEC, v cholerae, c diff)
- invasive bact
(EIEC, salmonella, shigella, campylobacter
, yersinia)
- parasites (giardia, entamoeba histolytica)
-opp org (cryptosporidium, isospora, microsporidia, CMV)
- ped in winter = Rotavirus
-chronic > 4 wks
- > secretion (carcinoid, VIPomas)
- malabs/osmotic (bact overgrowth, pancreatic insuf, mucosal abnml, lactose intol)
- IBD
- alt motility = IBS
-duodenal/peptic ulcer
- SBO = causes: adhesions, hernias, neoplasms, intussusception, gallstone ileus, stricture from IBD, volvulus, CF. Tx = NPO, surgery if need + 2nd look surgery 18-36 hrs later
- gallstone ileus = radiopaque material at cecum
- ileus = loss peristalsis without struct obstruction
- IBD---Caucasians and Ashkenazi Jews, 30-50's
Tx: 5-ASA agents (sulfasalazine, mesalamine)
- Chron's
- U/C
- Carcinoid Sx

Liver:
- Jaundice:
- congenital >bilirubinemia
indirect: Crigler-Najjar/Gilbert
direct: Dubin-Johnson/Rotor
- hemolytic anemias
- hepatocellular adenoma
- extrahepatic
- choledocholithiasis
- sclerosing cholangitis
- biliary sclerosis
- 1ary
- 2ary
- CA biliary Sx or pancreas
- Hepatitis:
- fulminant
- ischemic
-viral:
- HepA: vaccinated for when go overseas, spread thru shellfish or infected food handlers, fecal-oral too. self-limiting
- HepB: uses reverse transcriptase
acute infxn (core Ab IgM), chronic (core Ab IgG), window (core Ab IgG---then IgM), resolved infxn (core Ab IgG + surface Ab), vaccine (surf Ab)
Sx: acute viral, or chronic = cirrhosis, hepatocellular CA
- HepC: thru blood or sex, no vaccine. 80% = chronic hep. Tx: pegylated IFN, maybe ribavarin
coats itself with LDLs to enter liver
- HepD: req coexistant HepB infxn
- HepE: thru fecal-oral route, high infant mort in pregos
- granulomatous
- alcoholic
- autoimmune
- type 1
- type 2
- Cirrhosis: ascites DDx with/out portal HTN
- hepatic encephalopathy ---Tx = lactulose
- alcohol withdrawl
- NASH
- Hemochromatosis = > Fe absorpt, hemosiderin deposits liver, pancreas, heart, adrenals, testes, pituitary, and kidneys. auto r. males NEuropean descent.
- secondary in chronic transfusion Tx (e.g. alpha-thalassemia), alcoholics
Tx: weekly phlebotomy, maintenance 2-4 mo. Deferoxamine
- Wilson's Dz (ABCD): asterixis, basal ganglion deterioration, <ceruloplasmin, cirrhosis, >copper, hepatocellular CA, chorea, dementia
15-30 y.o. Kayser-Fleischer rings cornea, jaundice
Tx: avoid shellfish, liver, legumes. Penicillamine + pyridoxine, oral Zn
- Hepatic abscess
- Portal HTN
- Budd-Chiari Sx
- Pancreatic CA = abd pain, etc. Courvoisiers Sx (palpable, non-tender gallbladder), Trousseau's Sx (migratory thrombophlebitis). Classic sx = painless, progressive jaundice. Whipple procedure, chemo with 5-FU, bad Px
Renotubular and interstitial
- ARF
- ATN
- Drug-induced AIN
- RT funct disorder
- RTA
I
II
IV
- DI: central/nephrogenic
- SIADH
- CRF
Glomerular Dz
- nephritic:
- PSGN
- RPGN = crescentic
- Berger's Dz (IgA nephrop)
- HSP
- MM
- nephrotic:
- MCD
- FSGS
- Membranous
- Membrano-proliferative
- Systemic Dz
- DM
- HIV
- Renal amyloidosis
- SLE
type I
type II
type III
type IV
type V
- RAS
- Nephrolithiasis
Kidney CA
- Renal cell CA
- Wilm's tumor
- HPA
- prolactinoma
- acromegaly
- Metabolic Sx = insulin resist Sx or Sx X. abd obesity, > BP, impaired glycemics, dyslipidemia. Tx: intensive weight loss, control rest
- DM---assoc with HLA-DR3, DR4
complications
- acute
DKA = type 1 DM, stress or noncompliance, Sx: abd pain, vomiting, Kussmal resp, fruity acetone breath odor. severely dehydrates, electrolyte abnml, MS changes. Tx: fluids + K + insulin + Tx underlying Dz
HHS = hyperosmolar hyperglycemic state = profound dehydration, MS changes, hyperosm, ext high plasma glucose >600 without acidosis. type 2 DM, acute stress, often fatal. Tx: aggressive fluid and electrolyte replacement + insulin
- chronic
reinopathy (DM for 3-5 yrs). Tx: laser photocoag for retinal neovasc
DM nephropathy = hyperfilt injury + microalbuminuria. Prevent ACEIs and BP and glucose control
Neuropathy = periph, symmetric, sensorimotor. Tx preventative foot care and analgesics. late complic = auto dysfunction = delayed gastric empty, esoph dysmotility, impotence, ortho hypotension
macrovascular = CV, cerebrovascular, periph vasc Dz, start on low dose ASA
drugs
- Metformin = inhib liver gluconeogenesis, > sensitive to insulin. SE: weight loss, GI upset, rarely lactic acidosis. CI: elderly and renal Dz
- Sulfonylureas: glipizide, glyburide, glimepiride (insulin secretagogues. SE hypoglycemia and weight gain)
- meglitinides = repaglinide and nateglinide (short-acti similar to sulfonylureas)
- Thiazolinediones = "glitazones" = > insulin sensit. SE: weight gain, edema, pot hepatotox
- alpha glucosidase inhib = < int absorp carbohydrates. SE: flatulence
- peptide analogs
- amylin analog

- Gonads
- Klinefelter's Sx
- XXY Sx
- testicular feminization Sx
- 5-alpha reductase defic
- CAH
- Prader-Willi Sx
- Laurence-Moon-Biedl Sx
- Kallman's Sx


Thyroid CA very common, > older, most are benign
- Hot/Cold
- Papillary CA =
most
Popular, women>, Papillae (branching), Palp LN, "pupil" nuclei = Orphan Annie eyes, Psammomma bodies, Positve Px. slow growing, TSH prod cells. same prog as folliclar CA
- Follicular CA = TSH prod cells, 90% surv 10 yrs or >, Px worse elderly or large tumors
- Medullary CA: calcitonin, Px depends on degree of vascular invasion. 80% 10 yr surv
- Anaplastic CA 2%, rapid enlarge and mets. only 10% surv 3 yrs
- MEN
I = Wermer's Sx
IIa = Sipple's Sx
IIb ---marfanoid habitus
- Metabolic Bone Dz
- osteoporosis
- rickets/osteomalacia/scurvy
- osteitis deformans = Paget's Dz of the bone
- non- metabolic Bone Dz
- Fibrous Dysplasia
- osteomyelitis
Bone tumors:
- *MM = most common
- osteochondroma = 2nd most common
metaphysis of dist femur or prox tibia. 20-30 y.o., > men, pain worse at night, B Sx, Codman's triangle, sunburst pattern
- Giant cell
- osteosarcoma
- Ewing's sarcoma: onion skin
Arthropathies and CT disorders:
-
RA
: 30-55 y.o., women > men
○ + RF (rheumatoid factor), anti-CCP, elevated CRP, anemia, thrombocytosis, low albumin (correl with Dz severity)
○ Tx: DMARDs (sulfasalazine and methotrexate), anticytokines (imatinib and etanercept), and topical analgesics

-
OA
: 65 y.o.+ (trauma, repet joint use, obesity)----x-rays usually normal at first: later bone sclerosis, subchondral cysts, and osteophytes
-
DeQuervain
's synovitis: anatomical snuff box + Finkelstein's test. Tx: NSAIDs or corticosteroids
-
SLE:
AA women childbearing, Criteria Dz (have 4): DOPAMINE RASH (discoid rash, oral ulcers, photosensitivity, arthritis, malar rash, immuno criteria, neuro sx (SLE cerebritis, seizures), >ESR, renal Dz, ANA +, Serositis, Heme abnml
Dx: ANA (highly sensitive), Anti-dsDNA and Anti-Sm Ab (highly specific), neonatal SLE = + anti-Ro Ab
Sx maybe: antiphospholipid Ab, anemia, leukopenia, thrombocytopenia, proteinuria, casts.
Tx: NSAIDs, steroids acute. refractory: steroids, hydroxychloroquine, cyclophosphamide, azathioprine
-
Sjogren's
- Behcet's Sx
-MCTDz
-PMR
-
Ankylosing
spondylitis: + Schober test (< spine flexion)
-
Reactive

arthritis
= Reiter's Sx: can't see, can't pee, can't climb a tree. usually post infxn campylobacter, shigella, salmonella, chlamydia, or ureaplasma
- psoriatic arthritis: oligoarthritis, DIP included. psoriatic skin and dactylitis (sausage-shaped digits)
- scleroderma = progressive systemic sclerosis
- sarcoidosis
- gout: men 30-50y.o., postmenopausal women 50-70y.o., normal WBC (<60,000) in joint aspirate
○ Crystals:
- MSU (strong negative birefringence needles)
- Ca pyrophosphate dehydrate (rod, weak positive birefringence)----------pseudogout
- Ca hydroxiapatite (EM, cytoplasmic inclusions, not birefringent)
- Ca oxalate (bipyramidal, strong positive birefringence, end-stage RF)
- Tx: (NSAIDs e.g. indomethacin, colchicine, and/or steroids) acute, maintenance allopurinol (overprod) or probenecid (undersecretors)
- septic arthritis
Mucle Dz:
-
DMD
: x-linked r, defic dystrophin, onset 3-5 y.o./life expect teens, axial and proximal m > , progressive clumsiness, fatigability. Gower's maneuver, waddling gait, pseudohypertrophy of gastrocnemius m, MR. Dx: M Bx. Mort from pulmonary congestion (high output Card F, F = RespF and pneumonia)
-
Becker

MD
: onset 5-15 yrs, life-expect 30-40s, uncommon MR, dystrophin lvls nml but abnml prot on Western Blot
-
Polymyositis
= progressive CT disoder, inflamm in striated muscle, 50-70 y.o., females >, symm proximal m weak, pain, diff breathing/swallowing (adv Dz)--may be assoc with underlying Breast or Lung CA. Labs = > CK, > aldolase, + Anti-Jo-1 Ab
-
Dermatomyositis=
polymyositis + heliotrope rase (violaceous periorbital rash, shawl sign, or Gottron's papules (dorsa of hands, over bony prominences) Labs: + CD4 + cells, + Anti-Jo-1 Ab
-
*Scleroderma
: chronic systemic autoimmune Dz, limited (CREST) and diffuse (organ + skin). Raynaud's, > risk lung Dz, anti-centromere Ab specific, Anti-Scl-70 = anti-topoisomerase I Ab (poor prognosis), may have eosinophilia. Tx: acute steroids, skin: penicillamine. Raynauds---Ca+ ch blockers, ACEIs for renal Dz and malignant HTN
Mort: pulm HTN
- MG
- Lambert-Eaton Sx
- Felty's Sx = RA + splenomegaly + neutropenia
- Know the H's and T's = what can cause cardiac arrest
○ H's
§ Hypovolemia, hypoxia, H+, hyper/hypokalemia, hypothermia
○ T's
§ Tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary), thrombosis (coronary)

Vtach, v fib
- No pulse = unsynchronized cardioversion
- Pulse = synchronized
PEA or asystole= unshockable, can add on IV atropine right away (1 mg), up to x3

- 1st Epi 1 mg
- Epi or vasopressin 40 U
- 3rd: can use amiodarone 300mg, or IV Mg 2 g(torsades), IV lidocaine 1.5 mg/kg

­ Respiratory arrest ---normal BLS or ABCD ACLS
­ VF or pulseless Vtach(CFR and AED---shock therapy ASAP)
○ Best result: 1st event = 1ary Vfib, and rapid shock therapy
§ If not chance of survival < 7-10%/min, but with CPR only < 3-4%/min
○ Use AED: no response + no breathing + no pulse
○ Drugs:
§ Epi
§ Amiodarone
□ shock
­ VF/Pulseless VT
­ PEA (asystole)
○ Tx: CPR, airway
○ Drugs:
§ Epi 1 mg every 3-5 min
§ Any therapies based on H's and T's
­ Asystole
­ ACS = acute coronary Sx
­ Bradycardia
○ Stable ---can decide not to Tx, just observe if no Sx, maybe all prepped and ready, but don't need to intervene yet
○ Unstable: electrical therapy
§ Cutaneous pacemaker
§ Meds:
□ Atropine 0.5 mg (max dose 3 mg---Receptors maxed out)
□ Epi, Dopamine, NE drip
­ Unstable Tachycardia
­ Stable Tachycardia
­ Acute Stroke ---see if eligible for fibrinolytics, neuro exam
Stroke: give O2, see if DM or seizure, facial droop, pronator drift, "you can't teach an old dog new tricks"
- Rapid intervention (eval within 10 min)
- Rapid CT w/out contrast----within 25 min or arrival
- Know when started
- BP monitored and Tx ----so okay to Tx with thrombolytics
- Thrombolytics before 3-4 1/2h

8 D's of stroke:
- Detection: quick
- Dispatch
- Delivery
- Door---appropriate triage---assess within 30 min (ABCs, baseline VS, oxygen, IV patency, blood tests, 12 lead ECG)
- Data---quick ED evaluation and management (CT scan----if hemorrhagic no fibrinolytics!), if not, go through fibrinolytic check list
- Decision---stroke expertise and choose therapy
- Drug---fibrinolytic therapy (rTPA or if not aspirin), intra-arterial strategies
- Disposition ----admit to CCU

NIH stroke scale: 0-32 (the lower, the fewer the Sx, the benefits of thrombolytics go down)
- Up till 17 = benefits from thrombolytics
- > 17 = > likely to have a hemorrhagic stroke

Vascular problems:
- AAA: if smoker men 65-75 y.o. -----atherosclerosis
- Aortic dissection = HTN, men 40-60 y.o.
- classification
- DeBakey Sx = I, II, III
- Stanford Sx= A, B

Virchow's triad = DVTs = venous stasis + endothelial trauma + hypercoagulable
Beck's triad = cardiac tamponade = JVD + hypotension + distant heart sounds

6 P's of acute ischemia = pain, pallor, pulselessness, paralysis, paresthesia, poikilothermia

IBS
○ Tx:
- Antidiarrheal:
□ Bismuth salicylate (pepto-bismol)----warning, turns stool black
□ Imodium (loperamide + simethicone)
- Special: aldansetron, for diarrhea
- Bleeding/anti-ulcer = hyoscyamine
- Terrible cramps = antispasmodic: levsid and bentyl (TID or QID)
- Constipation predominant: linzess, or amitiza
- Laxative + antidiarrheal: polycarbophil

l DM
○ Tx: (somewhere in there, insulin if needed)
§ First Metformin
§ Second: sulfonylureas
§ Third: GLP-1s

Fourth: the other options
l
Osteoporosis
: DEXA scan, T score, Z score < 2.0
○ 2ary causes: alk P, Ca, vit D
○ If Sx: addn testing: thyroid, liver, kidney (rule out hyperthyroidism, chronic liver Dz, renal insufic), cbc for bone marrow malig or malabsorption Sx
○ If Dx: then Tx: hormones (calcitonin--nasal spray), (teriparatide: PTH, CI in osteosarcoma), Denosumab (monoclonal antibody), SERMs (raloxifene), and biphosphonates (aldronate, risedronate, ibandronate---inhib osteoclast activity)

Acromegaly
= benign pit GH adenoma = gigantism if in kid
Sx: enlarged jaw, hands, feet, coarse facial features. may have carpal tunnel, diastolic dysf, HTN, arthritis, bitemp hemianopia, glucose intol or DM.
- Dx: MRI pit, IGF-1 > and confirm with oral glucose suppression test
- Tx: transsphenoidal surgical resection or extrnal beam radiation, ocreotide (suppress GH secret), pegvisomant (block GH R if refractory)

Prolactinoma
= most common funct pit tumor. Sx: hypogonadism, infertility, oligomenorrhea/amenorrhea. galactorrhea, gynecomastia, bitem hemianopia, prolactin > 200mg/mL.
- Tx: dopamine agonists (1st line Tx): cabergoline, bromocriptine, or pergolide. Surgery if other Tx failed, or when want pregnancy, or if visual field defects.

l Palpitations
○ 12-lead EKG
○ Age over 50 = always suspect CAD
○ 24-72h Holter monitor (ambulatory): if Pt has freq palpitations/30-day event monitor: if infreq
○ Hypertrophic cardiomyopathy (healthy, sports, adolescent): systolic heart murmur: increases intensity on Valasalva
§ Restrict activity until echocardiogram, LHF, Pulm HTN, infective endocarditis
○ Midsystolic click: consider Mitral valve prolapse (most common valvular defect in the US)---some progress into mitral regurg and a fib
○ Primary rhythm disorders:
§ Sinus brady/tachy
§ WPW Sx (delta wave) ---sometimes with PSVT ----Tx: if needed stop hyperactive foci via electrical ablation
§ SSS (sick sinus Sx)
§ PAC (premature atrial contractions)
§ SVT
§ PVC
§ Vtach
○ Tx:
§ Beta-blockers, digoxin, carotid sinus massage, valsalva maneuver, diver's reflex (cold appl to the face), adenosine, electrical cardioversion, antiarrhythmics (amiodarone [lidocaine instead if allergic to iodine], sotalol, or class 1C like flecainide and propafenone)
§ TEE prior to cardioversion (if non-emergent)
§ Anticoagulation: with warfarin
○ Brugada Sx: ion channel disorder in Asian males, RBBB pattern---can cause dangerous arrhythmias = sudden death
○ Long QT = auto dominant, risk sudden death, more common in females (QT > 500 msec)
○ Lab studies for other things: CBC, Tsh
○ Meds affecting: alcohol, caffeine, cocaine, tobacco, decongestants, diuretics, digoxin, beta-agonists (e.g. albuterol), theophylline, phenothiazine

- Stroke
- 90% ischemic = hypoechoic
□ Thrombolic
□ Embolic = wedge-shaped infarction area
□ Lacunar (subtle, fewer neuro deficits, small vessel)
- 10% hemorrhagic = hyperechoic
□ Subarachnoid hemorrhage (worst HA of my life) Berry aneurysms
- Risk factors: SHAME: smoking, HTN, Adult polyposis Dz, atherosclerosis, Marfan's Dz, Ehlers-Danlos Sx
- Tx:
Pre-knowing stroke management:
- ER Tx before labs: O2, beta-blocker, Tx hypoglycemia, Tx fever
During stroke management:
- Ischemic
□ Tx: nicardipine (< BP under 160), if Pt is on warfarin give FFP, vigilant for seizures, and keep Pt inclined at 30 degrees to keep ICP in control
- Hemorrhagic
□ Tx: see if eligible for thrombolytic Tx via rtPA (alteplase)----there is no benefit from heparin, warfarin, or antiplatelet admin in ongoing stroke
CI to rtPA/ If eligible---admin rtPA within first 90 min, max before 3 hours
Post-stroke management:
- ASA (or clopidogrel or dipyrandamole)
- Order seizure prophylaxis to have on hand for nurse if needed, if not don't give. 5 mg lorazepam or diazepam IV
- If Afib = warfarin (INR 2-3) + Ca channel blocker (diltiazem)
- Echocardiogram
- Carotid angiography (surgery if > 70% blockage)
- Lifestyle modific
- Anticoag: heparin/LMWH, warfarin, factor X blockers
- Rehab

- Wernicke's = wordy, Broca's broken boca
- decorticate posture = flexion arms/ decerebrate (midbrian or lower) = extension arms

Macule/papule/plaque/vesicle/wheal/bulla/lichenification/keloid/petechiae/purpura/cyst/hyperkeratosis/parakeratosis/acantholysis/spongiosis
Infections:
-
acne
: propionibacterium acnes (open/closed comedones) Tx: topical Abx, Retin-A, benzoyl peroxide, systemic Abx e.g. erythromycin, if scarring: isoretinoin (Accutane) or spirololactone (in females)
-
impetigo
= honey-crusted, superficial skin infxn, often kids around nose and mouth, cause:
staph aureus
or
strep pyogenes
, Tx: topical oral Abx against both for 7-10 days (e.g mupirocin ointment)
-
bullous
: fragile blisters, break = red, tender skin w/ ragged edge, esp on buttocks ---from staph aureus and its exfoliative toxin A (exotoxin that targets desmoglein), can go into SSS
-
non-bullous
: blisters/scabs, then yellow crusts. Nose/face, arms/legs.sometimes nearby swollen glands.
-
ecthyma
= ulcerative pyoderma (skin + dermis) = deeper form of impetigo
-
folliculitis
: s aureus,
"hot tub" = pseudomonas aeruginosa,
fungi, virus
furuncle and carbuncle
- pilonidal cysts = abscesses in sacrococcygeal region, abscess with bacteroides,20-40 y.o., can complic into perianal fistulas
-
SubQ

infxns
:
-
cellulitis
: (begins with a scratch or cut) rubor, dolor, calor, tumor. from staph and strep
(strep pyo)
. Tx: vanco, cefazolin, or clindamycin
- in burn Pts, sickle cell, IV drug users and DM: pseudomonas
-
abscess
: furuncle(small, one hair follicle, s. aureus)/carbuncle(extensive with a deep pocket), local collt of pus, often with fever, > WBC
Tx: incision and drainage + Abx: TMP-SMX, vanco, clinda
-
erysipelas
: infxn superficial dermal layer = edema right there. Sx= bright red skin with peau d'orange, classic = cheeks. from Group A strep =
strep pyo
, Tx: penicillin
-
paronychia
: infxn surrounding nail margin (can extend into surrounding skin and hand tendons) from s. aureus, candida. Tx: warm compress, I&D if pus, add Abx if severe
-
Nec

Fasc
: infxn skin layers down to fascia = severe pain, fever, > WBC, local inflamm deceptively missing, "pain out of prop to exam findings" from
strep pyogenes (GAS)
, clostridium perfringes, MRSA
- Tx: immediate extensive surgical debridement + penicillin or ceftriaxone (for strep and clostridium) + vanco (for MRSA) + clinda (shuts down toxins causing tissue necrosis)
-
Scarlet

fever=
GAS =
strep pyogenes.
"sunburn with goose bumps" rash, blanches with pressue, initially on trunk--hours later all over. Sandpaper rough skin, strawberry tongue, beefy-red pharynx, circumoral pallor. Pastia's lines = rash > intense in creases of axilla and groin, evental desquamation hands and feet. Sx: fevers, chills, delirium, sore throat, cervical lymphadenopathy. Complications = rheumatic fever and glomerulonephritis. Tx: penicillin
-
hidradenitis

suppurativa
: plugged apocrine glands = inflammed masses in groin/axilla, then infected. Tx: surgical debridement, ABx, and consider Retin A
-
erythrasma
: irreg red rash along major skin folds (axilla, groin, fingers, toes, and breasts), in adults with DM, from corynebacterium. Dx: Wood's lamp = coral-red fluoresecen. Tx: clindamycin topical, if > extensive = erythromycin oral
DDx: tinea versicolor: lighter spots, itchy, Dx: scrape + wood's lamp = yellow green color
-
scalded

skin

Sx
(
SSS
): from staph aureus, 2-5 y.o. widespread formation of thin walled fluid-filled blisters, Nikolsky's Sx = easy exfoliation of outer layer skin. from exfoliative toxins. lack of mucous membrane involvment.
-
topical

epidermal

necrosis
: same as SSS, but with mucous membrane involvement
-
Toxic Shock Sx
; superantigen, pyrogenic exotoxin
(strep pyo) =
cytokines and multisystem organ failure
-
Steven-Johnson Sx
: > fever, diffuse mucosal involve, blisters, and myalgias. + Nikolsky's Sx and necrosis. from HIV and drugs: allopurinol, carbamazepine, lamotrigine, phenytoin, sulfonamides, nevirapine

Topical steroids: Had To Find Dermatologist
(little flower)
- low potency = 1% hydrocortisone ---face, genitals, skin folds, kids
- moderate = 0.1% triamcinolone---body/extemities, or bad on face, genitals, skin folds
- high = Fluocinonide (Lidex)---thick skin (palms/soles) or bad body Dz. NOT face
- very high = Diflorasone---thick skin, very bad Dz on body
Major stroke regions:
- Anterior circ

Opthalmic
art - eyes
- Vision (
amaurosis

fugax=
monocular blindness) ---from carotid emboli
□ ACA - medial and ant frontal lobes, medial parietal lobes
- Lower body, pelvic floor musculature (urinary incontinence) =
hemiplegia
, sensory integration (less common Sx: anosmia--from olfactory bulb, homonymous hemianopsia or personality change---from frontal lobe)
- Contalat: body
hemiplegia
/sensory loss

□ MCA- lat frontal lobes, temporal lobes, lat ant parietal lobes
- Upper body, language
- Most common.
- Contralateral: lower facial paralysis + body hemiplegia/sensory loss (upper body, parts of homunculus thatMCA goes to)
- Affects CN III ipsilateral = bilat eye deviation towards side of infarct (cuz CN VI remains intact), may produce rarely contralat
homonymous

hemianopsia
- If on L = affects language (receptive or productive
aphasia
; verbal agnosia)
- if affects non-dominant side = apraxia

- Post circ
□ PCA - occipital lobes, post temp lobes, post parietal lobes, midbrain, various CN ganglia (III, VII, X, XII)
- Vision, balance, sensory integration, CN function
- Most notable Sx: visual = halluc, agnosia, and if 1ary visual cortex affected = contralat homonymous hemianopsia
- (if truly PCA, never motor Sx)
- Deeper branches (beyond cerebrum) = rostral midbrain, level of oculomotor (CN III) = opthalmoplegia = CN III palsey = which innervates EOMS: superior rectus (elevates), inf rectus (depresses), medial rectus (adducts), and inf oblique (elevates at full med position), and also levator palpebrae superioris
- Muscles left: sup oblique (depresses at full med position), and lat rectus (adducts) = eye down and out

- Weber's Sx: ipsilateral opthamoplegia from CN III, corticospinal tracts (contralateral hemiplegia), subst nigra (gait distrubances, rare)
- Benedikt's Sx: Weber's Sx + > effects subst nigra and red nucleus
□ PICA - post inferior cerebellum, post lat medulla
- Facial sensation, pain sensation from body, CN X
□ Lateral medullary (Wallenberg's Sx)
- Ipsilat: facial sensory loss
- Contralat: body sensory loss
- Often also Sx: dizziness, ataxia, dysarthria, and Horner's Sx
- Yellow region affected: spinothalamic tract (P, temp, crude pain, sensory = contralateral)

□ Basilar artery - "Locked-in Sx" ---
vertebrobasilar
(embolic): affects
brainsetm
= Sx: drop attack/vertigo/CN palsy/
coma


-
Meningitis
: Meningismus (Pt can't touch chin to chest), + Kernig's Sx (knee), + Brudzinski's Sx (neck)
- Tx
- acute
neonates (
amp
+
ceftriaxone
)---vs strep agalactiae, listeria, E coli
kids-teens (
vanco
+ ceftriaxone)---vs. s pneumo, neisseria meningitidis
n mening: beware of Waterhouse-Friderichsen Sx (adrenal infarct)
adults (immuno compet): vanco + ceftriaxone---vs. s pneumo
>65 (Amp + vanco + ceftriaxone)---vs/ s pneumo and listeria (tumbling motility)
*viral: HSV---acyclovir, HIV----AZT, otherwise Tx= supportive

- Chronic: same, plus fungal, syphilis, etc..
- cryptococcus (AIDS), india ink. Tx: IV amphotericin +/- 5Fluorocytosine + fluconazole + serial LPs (< ICP), if need shunt
- coccidioides: Desert: AZ, CA. > risk AA, hispanic, filipino. Tx: > dose fluconazole
- TB meningitis: elderly (reactivation), grave Px. Dx: TB PCR of the CSF
- Tx: RIPE: Rifampin, INH, Pyrazinamide, Ethambutol + corticosteroids

-

-
- metab/nutrition disorders
- CO poisoning (new gas heaters) = bilat pallidal necrosis. Sx: HA, N/V, delirium, cherry-red lips. Dx: > carboxyhemoglobin. Tx: hyperbaric O2 or 100% O2
- thiamine defic= 2ary alcoholism
- Beriberi = peripheral neuropathy from Wallerian degeneration
- Wernicke's encephalopathy = confusion (confabulation) + opthalmoplegia + ataxia. lesion to mamillary bodies
- B12 defic: subacute degen of post column and lat CST = weakness, < vibration sense, paresthesias, hyperreflexia, ataxia, personality change, dementia (even if no heme changes present). Dx: > methymalonic ac and homocysteine
- Wilson's Dz (hepatolenticular degeneration) = defect copper metab = lesions in basal ganglia = extrapyramidal tremors, rigid, psosis, manic-depression, typically young people. Keyser-Fleischer ring around cornea. Dx: < serum ceruloplasmin
- Tx: penicillamine or liver transplant if needed
- hepatic encephalopathy: cirrhosis, 2ary to excess NH4 = hyperreflexia, asterixis, dementia, Sz, obtund/coma
- Tx: lactulose, neomycin, prot restriction
- Tay-Sachs Dz: hexosaminidase A defect = > ganglioside GM2,
Sx: cherry-red spot on macula, MR, paralysis, blind
Dx: Bx of rectum or enzymatic assay. NO Tx
- Lesch Nyhan Sx: self-injury, use soft restraints, mouth guard or edentulate
- Prader-WIlli Dz
- Neurofibromatosis
- type 1 = Von Recklinghouse's Dz

TUMOR BOARD
- Seizures: gen/part, simple/complex (LOC)---1st Tx all (except absence and status epilepticus): carbamazepine, phenytoin
- Generalized
- Absence (petit mal) < 30 sec unresponsive, blank stare, 3 Hz spike and wave on EEG
Tx: 1st line
ethosuximide
(SE: non-sedating, mild G, rare idiosyncratic blood dyscrasias), valproic acid.
2nd line: lamotrigine
- Tonic-clonic (grand mal): damatic convulsions, LOC< incontinence, post-ictal confusion
Tx: 1st line valproic acid, carbamazepine, phenytoin
2nd line: lamotrigine, phenobarbitol (stimulates GABA, highly sedating, addictive, CYP450 induction), primidone (metab to phenobarb, poorly tolerated)
- Partial
- simple partial: sensory or limited focal
- complex partial: starts as partial, then generalizes
Tx both : 1st line: carbamazepine, phenytoin
2nd line: gabapentin (GABA analog, adjunctive Tx, minor SE: dizziness, ataxia, Tx neuro pain Sx, few drug interactions),
lamotrigine
(may inhibit release of glutamate, adjunct Tx, really changes levels of other anti-epileptics, SE: HA, GI upset, rash), phenobarbital, primidone,
topiramate
(may relate to GABA, SE: slow thinking, tremor, GI upset, adj Tx), valproic acid
3rd line partial: felbamate: related to GABA, monotherapy or adjunctive, SE: blood dyscrasias and hepatotoxicity severe

- *status epilepticus: non-stop seizure > 5 min = respiratory compromise + rhabdomyolysis - medical emergency!
Tx: 1st line: IV benzos = lorazepam (long and slow), diazepam (quick, over) (both used also for alcohol withdrawal)
2nd line: phenytoin
3rd line: phenobarbital (coma)
- Epilepsy: habbit of seizures. 5-7 day continuous EEG. Tx: valproate
Encephalitis:
-
HSV
: temporal lobe, AMS, personality changes, olfactory halluc. CSF often blood. Dx confirm by HSV PCR in CSF. Tx: IV acyclovir
-
other

viral
: enteroviruses, arboviruses (eastern equine, calif, ) west nile. Sx overlap: AMS + focal neuro. Dx: combo Ab testing + PCR. NO Tx
-
toxoplasmosis
: in neoantes = congenital hydrocephalus + MR. In adults = reactivates in CSF when < immuno (#1 CNS lesions in AIDS), multiple ring-enhancing, basal ganglia = focal neuro prob. lesions shrink after 2 wks of Tx: sulfadiazine + pyrimethamine. 1ary prophylaxis TMP-SMX for AIDS CD4 < 200
-
PML
= progressive multifocal leukoencephalopathy: in AIDS, Ab against WBC for CA, autoimmunity, from JC polyomavirus = diffuse white matter Dz on MRI. Dx: CSF PCR for JC virus. Tx: Tx AIDS
- cysticercosis: from taenia solium = seizures (hispanic immigrant), MRI = cysts in brain, old Dz= calcified spots in brain. maybe CSF eosinophils. Dx: CSF Ab. Tx: Albendazole + steroids
anti-seizure meds:
- phenytoin: non-sedating
SE gingival hyperplasia, hirsutism, hypotension during IV load
major inducer of CYP450 ----can cause hepatic toxicity if liver Dz
- carbamazepine: SE blood dyscrasias (leukopenia/aplastic anemia), hepatotoxic, rashes, HA
- also Tx for trigem neuralgia and bipolar Sx
- CI in absence Sz
- valproate: SE blood dyscrasias (neutropenia, thrombocytopenia), hepatotoxic
-also Tx used for bipolar Sx
-*stop Tx if no Sz for 2 yrs + nml EEG
Tx: underlying cause: electrolyte, infxn, toxic ingestion, trauma, azotemia, stroke/bleed, delirium tremens, hypoglycemia, hypoxia
CAGE questions
Tremor, seizures, DT = > mort ----Tx: benzos
amphetamines
formication, heart arrhythmia, or infarction, or stroke, seizure, nose bleeds
Tx: benzos
Tx: benzos (seizures and BP/HR)
Ca channel block (ischemia) NOT beta-blockers---cuz already unopposed alpha-agonist from cocaine
Heroin
Triad: < consc, pinpoint pupils, Resp depres
intense, fleeting euphoria
N/V, pupil dilation, insomnia
- Tx overdose: naloxone (reverse acute intox)
- withdrawal tx: long methadone taper
Benzo's and barb's
Resp and cardiac depression
delirium
- intox Tx: control airway, charcoal?, flumazenil (careful cuz can precipitate seizures)
- withdrawal Tx: taper doses
drugs:
- LSD and PCP (violence)= visual, taste, tough, smell halluc
- coc and amphetamines = paranoid delusions + formication
- anabolic steroids: bodybuilder bad temper, acne, shrunken testicles
- corticosteroids: psychosis/mood disorders early in course of Tx

Antipsych: typical (high pot/low pot), and atypical
- clozapine (an atypical), for refractory dz, SE: no move disorders, agranulocytosis = weekly CBC
- move disorders
:
- a
c
ute dyst
onia (4hrs-4days): torticollis, jaw, or back (opisthotonos). Tx: immed IV diphenhydrami
ne
- parkins
onism (4days-4mo): cog-wheel rigidity, shuffling gait, resting tremor. Tx: benztropine (anticholinerg
ic
)
- TD (4 mo-4yrs): invol irreg mov head, tongue, lips, limbs, trunk. Tx: immed change
med
- ak
athesia (anytime): restles
snes
s
- NMSx (anytime): life-threat m rigidity. Tx: immed stop drug, give dantrolene, cool Pt
OCD: obsessions = recurrent thought, compulsions = recurrent action
PTSD: Tx: prolonged exposure Tx, or CProcessingTx
- DDx acute stress disorder (within 4 wks of event, only lasts < 4 wks)
GAD: worry for most days @ least 6 mo, irritability, unable to concentrate, insomnia, fatigue, restlessness. Dx req social dysfunction

PD: pervasive pattern of maladaptive behavior = functional impairment, consist behavior, traced back to childhood. usually ego-syntonic
CLUSTERS:
- A: wizards of odd (weird)
○ Paranoid = accusatory
○ Schizoid = aloof [droid]
○ Schizotypal = awkward, magical thinking
- B: bad to the bone (wild), dramatic, emotional, erratic
○ Antisocial = sociopath
§ Peds: oppositional defiant------CONDUCT disorder
§ Link to ADHD
○ Borderline = splitting (unstable relationships), disassociate: "forget" negative with over-exuberance. DBT, reduce impulses to self-mutilate,
○ Histrionic = whohoo, soap opera, use disassoc and repression
○ Narcissistic
- C: anxious/fearful (worried)
○ Avoidant (cowardly)
○ OCPD (compulsive)

○ Depende
nt (clingy)
Somatoform
= lack of conscious manipulation of somatic Sx, often female, < 30 y.o., Tx = continuity of care
- GI + neuro + sexua
l
Factitious disord
er = consciously faking, assume sick role, not for material gain
- Munchau
s
en
Sx = with predomin pysical (not psych) Sx
- Munchau
sen by proxy
Maling
ering = consciously faking Sx for material
gain
Conversion Dis
order: neuro Sx (not multisystem), not consciously faked ----sensory deficits fail to be any 1 known pathway-----indendify stressor that precipitated the Sx, or DDx: brain tumors, MS.
- Tx: supportive, resolve < 1 , do not tell Pt imagining Sx, but suggest Psychotherapy may help with the d
istress
Hypoco
ndriasis----do not tell Pt they're imaginin
g the Sx
Body dysmorphic
disorder

Psych tests:
- intelligence WAIS-R adults, WISC-R kids 6-16, WPPSI kids 4-6
- personality: MMPI, Rorsarch
- achievement: WRAT (content-specific knowledge)

Autism: prototypic pervasive dev disorder: language (rep phrases and made-up vocab), social interaction, emotional reactivity, responding to internal stimuli, Sx before age 3 y.o., no eye contact, abnormal behavior (fasc vacuum cleaners, sprinklers), ritualistic movement (spinning), inordinate need for constancy.
Asperger's Sx = autism without the language impairment

Depression in kids: preschool (hyperactive and aggressive), adolescents (boredom, irritability, openly antisocial behaviors), and usual depression Sx. Tx= family Tx

separation anxiety: desensitizing Tx and imipramine

oppositional defiant disorder (bark)/conduct disorder (bite) ----Tx both: setting with strict rules + expected consequences for violations

ADHD: Dx req Sx < 7 y.o., Tx: methyphenidate + amphetamine (ritaline, concerta, Adderal). concern about impeding kids growth = drug holidys. extremely structured environment with consistent rules + punishments

Tourette's Dx = noth motor tic + vocal tic for > 1 yr
- Tx: haloperidol (if mod-severe) + psychotherapy for the emotional stress

Anorexia: 85% < expected BMI, amenorrhea
Bulimia: > common, binge eating + active purging, nml appearing BMI, Russel's Sx: abrasions over nuckles + dental erosion
Tx both: monitor serum electrolytes, cardiac dysfunction, psychotherapy

Table 6.8

Multiple Personality Disorder = Dissociative Disorder
- Tx = gradual integration of these personalities
- Main DDx dissociative amnesia and dissociative fugue

Adjustment Disorder: Sx within 3 mo of stressor + disappear within 6 mo of stressor disappearance

Impulse control disorders: intermittent explosive disorder, kleptomania, pyromania, trichotillomania

Sleep:
- insomnia: can't fall asleep or stay asleep recurrently over 1 mo period, can be assoc with stress, anxiety, drugs, and various health/mental conditions. Tx: sleep routine, exercise, antihistamines, short course of benzos (< 2 wks to prevent rebound insomnia)
- hypersomnia:
- narcolepsy: cataplexy (sudden colapse from loss of all muscle tone). Tx: methylphenidate or pemoline (Provigil)
- sleep apnea: can lead to pulmonary HTN, assoc with hypothyroidism
- Pickwickian Sx (central alveolar hypoventilation) = Obesity Hypoventilation Sx: triad of somnolence, obesity, and erythrocytosis
Restless leg Sx: 1ary or 2ary to Fe defic, dopamine defic, or hypothyroidism. Tx: dopamine agonist + Tx underlying cause
Encephalitis
Demyelinating Dz
-
MS
: unknown cause, northern latitudes. relapsing-remitting asymm limb weakness, >reflexes, nystagmus, tremor, scanning speech, paresthesias, optic neuritis, + Babinski. Dx: Hx, MRI, LP
on MRI: periventricular plaques, multifocal demyel scattered in brain and spinal cord. on LP: > WBC = oligolonal bands.
- Tx: 3 diff parts: acute exacerb (steroids), Dz progression ( IFN-beta or glatiramer acetate), complications (m relaxers: baclofen, dantrolene, diazepam at night; fatigue and narcolepsy; pain; urinary urgency). Px: variable, if decline= death in a few years
-
GBS
: acute autoimmune demyelinating Dz of peripheral nerves. Ascending paralysis, <reflexes. Maybe had gastroenteritis before (c jejuni, mycoplasma, virus, immuniz, allergic rxn). Dx: CSF: albumin-cytologic dissociation (CSF prot >>> without > cells seen)
- Tx: plasmapheresis + IVIG + intubat (respirat fail)---be watching PFTs
- GBSx variant =
Miller
-
Fischer

Sx
[GQ1b Ab] = descending paralysis, ophthalmoplegia, ataxia, areflexia {bilat facial nerve palsy}
-
CPM
= central pontine myelnolysis---from too quick correct of hyponatremia = coma or death, no Tx once started
- Autoimmune nerves/muscles related
-
MG
[Ach R Ab] = Sx worse with exercise. Normal reflexes. Affects eye muscles and eye lids before other muscles
○ Or [MuSK Ab]
-
LEMS
= Lambert-Eaton Myasthenic Sx [voltage-gated Ca channel P/q-type Ab] = proximal weakness + absent reflexes. Sx improve with exercise ---assoc with small cell lung CA 50-70%. Autonomic Sx (dry mouth)
- Degenerative Dz
-
Dementias
: Alzheimers/Parkinson/CVJ/Lewy-body/Pick's Dz/Lacunar
parkinsons: TRAP = tremor + cog-wheel rigid + akathesia (bradykinesia + mask-like facies) + postural instab (shuffling gait). Tx: levodopa (sinemet), anticholinergics (benztropine/trihexyphenidyl), amantadine, Surgery
- Tx depression = e.g. venlafaxine (may be pseudodementia). Alzheimers: donepezil
-
Huntington
's chorea: progressive, demetia, 30-50's, autosomal CAG rep, anticipation, atrophy of striatum (esp. caudate nucleus and GABAnergic neurons---from glutamate toxicity). Tx: supportive. death inevitable
○ Early= hypotonia + hyperreflexia, abn eye movements
○ Late = rigid, parkinsonian state
-
ALS
(Lou Gehrig's Dz, motor neuron Dz)
-degen Dz upper and lower motor neurons from glutamate toxicity. Sometimes related to superoxide dismutase gene on chromosome 21. ONLY affects motor
○ Sx: UMN (spasticity + Babinski Sx) + LMN (m weakness, starts with atrophy of the intrinsic muscles of the hand, eventually to diaphragm = ventilator dependent)
○ Tx: glutamate antagonist = riluzole
○ Ave survival time 3-5 yrs
-
Cerebral
Palsy: 70% before birth. does not worsen over time
- types: spastic/athetoid or dyskinetic/ataxic= balance and coordination
Tx: botox in spastic m or baclofen. Selective dorsal rhizotomy

Classic Sx:
amblyopia
bitemporal hemianopsia
internuclear ophthalmoplegia
parinaud's Sx
Marcus Gunn Pupil (Afferent Pupillary Defect)
Argll Robertson Pupil
Lens Dislocation
Kayser-Fleischer Ring
Pterygium
Pingecula
Subconjunctival hemorrhage
retrobulbar neuritis
optic neuritis

palpebral inflammation:
chalazion
hordeolum (stye)
blepharitis
orbital cellulitis
Red eye: asses pain, visual acuity, type discharge, pupillary abnml in all Pts
bact conjunctivitis
viral conjunctivitis
allergic conjunctivitis
hyphema
xerophthalmia
corneal abrasion
keratitis
uveitis
angle-closure glaucoma
subconjunctival hemorrhage
Dacrocystitis (tear duct imflamm)
Eye colors:
- yellow eye
- yellow vision
- blue sclera
- blue vision
- opaque eye
Retina:
DM retinopathy
age-related macular degeneration
retinal detachment
retinitis pigmentosa
classic physical findings
leukocoria
Roth spots
copper wiring, flame hemorrhages, A-V nicking
papilledema
"sea fan"
wrinkles
cherry-red spot on macula
Hollenhorst plaque
brown raise macule on retina = malig melanoma (most common intraocular CA adults)
Glaucoma
- open
- closed
Orbital tumors:
adult
cavernous hemangioma
mets
lymphoid tumors
fibrous histiocytoma
mucocele
fibrous ysplasia
schwannoma
peds
capillary hemangioma
dermiod cyst
leukemia
rhabdomyosarcoma
lymphangioma
neuroblastoma
Orbital trauma
chemical burns
eyelid laceration
foreign body
ruptured globe
retinal detachment
hyphema
blowout fracture
traumatic optic neuropathy
retrobulbar hemorrhage
ocular melanoma
Opthalmic meds:
anesthetics
steroids (topical)
anticholinergics
short-acting
long-acting
adrenergics
decongestants
antibacterials
antiviral
NSAID
Glaucoma Tx
beta-blockers
parasympathomimetics
sympathomimetic
carbonic anhydrase inhib
Dry eye: artificial tears
Common disorders:
Psoriasis: red, from silver scaly patches on extensor surfaces, Auspitz Sx.--local irrit or trauma (Koebner's phenomenon), oil spots and onycholysis. Histo = Munro's microabscess in stratum corneum. Tx: topical corticosteroids + UV and MTX (SE hepatotoxicity) if severe
psoriatic arthritis = sausage fingers, lumbosacral, +HLA-B27
variations:
guttate psoriasis = chronic
pustular psoriasis---can be life-threatening if generalized = fever, electrolyte abnml, loss serum prot
inverse psoriasis
5%----seronegative arthritis
eczema
atopic dermatitis ---pruritus and lichenification
contact dermatitis (previous exposure = sensitized)
dyshidrotic eczema
seborrheic eczema
urticaria (hives)
hypopigmentation
vitiligo: depigmentation (autoimmune, neuro, ?), small, sharply-demarcated white spots, spread, Dz chronic and progressive---many have blood marker of autoimmune Dz, pts with malign melanoma may dev antimelanocyte immune response = vitiligo. Patho = total abscence of melanocytes. PUVA, suncreen...
albinism
pityriasis alba
hyperpigmentation
freckle = ephelis
lentigo
nevocellular nevus
blue
spitz
dysplastic
mongolian spot
melasma (Cholasma)
hemangioma
*port-wine stains
Xanthoma
Rosacea = inflamm, not infectious, middle-aged, abnml flushing, central facial erythema with telangiectasias----later, papules and pustules. ocular keratitis and rhinophyma. Tx: corticosteroids or metro
Pityriasis rosea: pink and scaly, HHV-7, mini-epidemics young adults. Herald patch, multiple fine papules with "cigarette paper", "Christmas tree pattern" on back, KOH -, DDx: syphilis (RPR), guttate psoriasis, drugs
erythema nodosum = pretibial, indurated and do NOT ulcer, from inflammed fat cells. causes = panniculitis from infxn, drugs, chronic inflamm Dz (sarcoid, Chron's)
erythema multiforme = targetoid lesions, recurrent HSV infxn lip, if severe can go into TEN or SJSx
seborrheic keratosis, > 40 y.o., skin tumor, may be part of a paraneoplastic Sx, no malignn potential. exophytic waxy brown papules and plaques, look as if could be scraped off, large numbers, Dx: histo: hyperplasia of benign, basaloid epidermal cells with horn pseudocyts. Tx: cut or ice off
Acanthosis Nigricans---intertriginous zones, velvety. Tx: topical steroids or retinoid. lose weight
Bronze diabetes = 1ary hemochromatosis
Warts (Verrucae)---HPV, 16 and 18 = sq malign
cauliflower like
verruca vulgaris
verruca plana
HPV
condyloma lata (from syphilis = treponema pallidum)
Tx = cutting, cryotherapy, acid keratolytics. genital =
Blistering Disorders:
pemphigus

vulgaris
= intraepidemal blister-----widesread painful erosions skin and mucous memb, antidesmoglein Ab (keratin can't adhere = loss cell attch) and stim proteinases and complement. 40-60 y.o. + Nikolsky's Sx, Skin Bx=acantholysis
bullous pemphigoid = acquired blistering Dz = sep at epidermal bm, chronic, 60-80 y.o. Ab to bullous pemphigoid antigen = complement and eosinophils. Stable blisters = Nikolsky -. IF. Tx = systemic corticosteroids
erythema multiforme ---HSV related
porphyria cutanea tarda

Vector-borne Dz
Peliosis hepatis (bacillary angiomatosis)
Lyme Dz: erythema migrans (3-30 days from bite), bullseye rash from Borrelia burgdorferi, carried by the Ixodes tick
DDx:
erythema multiforme: hypersensit rash, target lesions, rapidly progressive, come in crops, itchy, malaise, fever and burning
erythema nodosum: extensor surfaces LE, painful infalmm nodule preceded by fever, malaise, arthralgias. > women, sarcoidosis, IBS, TB, strep, or coccidiomycosis
Rocky Mountain Spotted Fever
Parasitic infxns: Tx: OTC pyrethin (RID), permethrin, or ivermectin
scabies, pruritus at night, track of red, excoriated papules
lice = head louse (pediculosis capitis)
pediculosis pubis ("Crabs")--anticoag in their saliva = bites turn blue
cutaneous larva migrans (creeping eruption)
larva currens
Fungal Cutaneous disorders:
tinea versicolor = pityrosporum orbiculare---Malassezia furfur. risk factors = Cushing's Sx, immunosuppression, hot, humid condit. small, scaly patches of varying color, usually chest or back, KOH prep = "spaghetti and meatballs" hyphae and spores. Tx = topical selenium sulfide
candida
onychomycosis (other summary)
dermatophytes = live only in tissues with keratin = mycrosporidium, trichophyton, epidermophyton ---from pets, DM, < periph circ, immunocompromise, chronic maceration of skin. KOH prep = mold hyphae
tinea corporis
tinea pedis/manuum = athletes foot
tinea cruris = jock itch
tinea capitis = ringworm
Developmental milestones
Puberty: tanner stages: I-V
Infections:
- ToRCHS
-
Toxoplasmosis
-
Rubella
= blueberry muffin, hearing loss
-
CMV
= microcephaly, IUGR, chorioretinitis
-
HSV
-
Syphilis
: perinatal deaths 40%, Hutchinson teeth, mulberry molars, frontal bossing, saber shins
-
Infant

Botulism
: honey spores, accute flaccid paralysis descending with clear sensorium, no fever, no paresthesias. 3wks-6mo. loss of head control and resp arrest. Tx: intubate, support care. no Abx or toxins needed in infants
-
Exanthems
-
Rubeola
= Measles = Paramyxovirus ---say hola! and see Koplick spots (white). 3 Cs = cough, coryza, conjunctivitis
-
Rubella
(German measles) = togavirus, suboccipital lymphadenopathy, rash starts on face, then all over
-
Coxsackie

A virus
= hand, foot, and mouth Dz, lasts 1 wk
-
Roseola
= exanthem subitum = HHV-6, several days high fever, then rash for 1d
-
Parvovirus B19
= Fifth Dz = Erythema infectiosum = Slapped Cheek Dz = reticular pattern. danger = sickle cell or anemias cuz aplastic crises, > fetal compl
-
VZV
= chickenpox : teardrop vesicles, lesions at all different stages. adult: zoster


Respiratory disorders:
Otitis

media
, young kids, strep pneumo, h flu, moraxella catarrhalis, viruses. Tx: amox or azithro, 2nd line aug pens or TMP-SMX, if chronic = P equaliz tubes
Bronchiolitis
---RSV 50%, others viruses. Sx: mild runny nose, fever, prog to cough, weeze with crackles, tachypnea, nasal flaring, < appetite. Tx: bronchodil, O2 as needed
URIs
Croup
: (laringotracheobronchitis): parainflu, influ, RSV, mycoplasma. fall-winter. barking cough, inspirat stridor, Sx worse at night. X-ray = steeple Sx. Tx:
Pertussis
: 3 stages: catarrhal (1-2 wks cough), paroxysmal (cough with whoops), colescent (1-2 wks persist chronic cough). Dx: Bordet-Gengou medium. Tx: macrolide to < infectious period, no effect on duration of Sx
Epiglottitis
: H flu B, Sx: med emergency! fulminant inspir stridor, drooling, sits forward, dysphagia, "hot potato" voice, Thumb print Sx on Lat X-ray, Tx: examine in OR, intubate as need, cefriaxone
Bacterial

tracheitis
: staph and strep, inspirat stridor, > fever, toxic look, Tx: vanco or cefriaxone
Foregin
-
body

aspiration
, usually after 6 mo, inspir strider, wheeze, < breath sounds, dysphagia, unresolved pneumo. CXR = hyperinfl on affected side. Tx: endoscopic or surgical removal
Stridor
---laringomalacia, croup, others.
Adenoiditis
: adenoid facies. freq OM, snoring, cte mouth breathers, hypernasal voice. Tx: surgery
Pneumonia
---chart in OneNote
MS
- genu valgum=knock-kneed/varum (bow-legged)
- limp
- painful
- septic arthritis: 1-3 y.o. from s areus most common, h flu, n gonorrhea, X-ray: joint space widening. Joint aspir and drainage
- toxic synovitis: boys 5-10 y.o. insidios pain onset, WBC and ESR nml, no tenderness warmth or joint swelling. Tc scan = > uptake epiphysis. rest and analgesis, 3-5 days
- aseptic avascular necrosis: < uptake epiphysis. Tx: < weight-bearing on affected side over long time
- Legg-Calve-Perthes Dz = head of femur, 4-9 y.o. boys
- Osgood-Schlatter = tibial tubercle
- Kohler's bone Dz = navicular bone
- slipped capital femoral epiphysis: obese male adolescents, dull achy pain hip or knee. X-ray: ice-cream scoop falling off cone. Tx: surgical pinning
- osteomyelitis: staph, strep. x-ray lags 3-4 wks, MRI gold standard. Abx = 4-6 wks
- painless
- from hip dysplasia
- from cerebral palsy
- from leg-length discrepancy
- collagen vascular Dz
- Juvenile RA ---Tx: NSAIDs, < dose MTX, prednisone only in acute febrile onset
- systemic = Still's Dz: spiking fevers, return to normal daily. rash with fever. 1/3 chronic disabling arthritis
- pauciarticular: < 4 joints, large joints, type 1 = girls < 4 y.o. ANA +, type 2 = boys > 8 yrs old, ANA +, > risk ankyl spondylitis or Reiter's
- polyarticular: > 5 joints, small and large, fever, anemia, lethargy, anytime kids
- Kawasaki's Dz (Mucocutaneous LN Sx) = large and med vessel vasc Jap kids. CRASH: conjunctivitis, rash, aneurysms, strawberry tongue, hands and feet induration. Tx: ASA, IVIG. NO prednosone
- Henoch-Schonlein Purpura (IgA small vessel vasculitis) ---related to IgA nephropathy (Berger's Dz), palpable purpura on buttocks of kids, abd pain, maybe intussusception. Tx: self-limited
- Histiocytosis X = langerhan's skin cells
- Letterer-Siwe Dz: acute, aggresive. hepatosplenomegaly, lymphadenopathy, pancytopenia, lung involv, recurrent infxns
- Hand-Schuller-Christian Dz: before 5 y.o., skull lesions, DI, exopthalmos
- Eosinophilic granuloma: skeletal + lung

Metabolic
- congenital hypothyroidism: 2ary to agenesis of thyroid, T4 essential 1st 2 yrs of life for nml brain dev. presents at 6-12 wks poor feeding, lethargy, hypotonia, coarse facial features, large protruding tongue, hoarse cry, dev delay, constip. If Dx: delayed > 6 wks, MR. Newborn screen mandatory by law
- Newborn jaundice (nml 24-48 hrs), AT BIRTH = pathologic. Tx: phototherapy with blue light, urgently stop MR 2ary to kernicterus (bilirubin precipit in basal ganglia)
- Reye Sx: salicylate in VZV or influenza illness, 4-12 y.o. prodromal fever, ASx interval, vomiting, delirium, stupor, hepatomegaly, may seizures, coma, death. Dx: > LFTs, nml CSF. Tx: control > ICP with mannitol, fluid restriction + glucose (cuz glycogen stores depleted)
- Febrile Sz: 3mo-5 y.o. fine if < 15 min with very high fever. Tx: antipyretics, parental counseling and reassurance
Genetic/congenital disorders
- FTT = failure to thrive. poor Px if in 1st yr of life cuz max postnatal brain growth
- Craniofacial abnormalities
- bifid uvula
- cleft lip
- cleft palate--interferes with feeding
- macroglossia: Down's Sx, gigantism, hypothyroidism, acq in amyloidosis or acromegaly
-
Patau
's Sx = trisomy 13 ---arrhinencephaly, holoprosencephaly, "Rocker Bottom Feet"
-
Edward
's Sx = trisomy 18---arrhinencephaly, corpus callosum agenesis, microcephaly, and micrognathia
-
Down
's Sx = trisomy 21---> risk if mom >35 y.o., cardiac septal defects, psychomotor retard, Down's facies (flattened occiput, epicanthal folds, up-slanted eyes, Brushfield spots on iris, protruding tongue, small backset ears, hypotonia, simian crease in palms), > risk leuk, premature Alzheimer's. Px: till 30-40s
-
Turner
's Sx = XO ---#1 cause 1ary amenorrhea. Neck webbing, lymphedema hands/feet, short, ptosis, coarct aorta, amenorrhea + present uterus, GI telangiectasias, no MR. Tx: hormone replace
-
Fragile

X
Sx = X-linked dominant, MR in boys. Long face, prominent jaw, large ears, enlarged testes, dev delay, MR
-
Arnold
-
Chiari

Malformation
: congenital, caudally displaced cerebellum ---into foramen magnum, meningomyocele, aqueductal stenosis. Death as neonate/toddler
-
Neural

Tube

defects
: (> AFP) spina bifida/meningocele
-
Fetal

alcohol

Sx
= smooth lip philtrum, MR, ASD
-
Tuberous

Sclerosis
= auto D multinodular prolif of multinucleated astrocytes = tubers, Sx: seizures, MR, "adenoma sebaceoum", assoc with rhabdomyosarcoma in kids
-
Congenital

Pyloric

stenosis
: from 2 wks-2 mo, palpable "olive"
-
Congenital

Heart

Dz
- ASD: wide fixed split S2, midsyst ejection murmur
- VSD: most common cong heart defect. small-med close on their own before 2 y.o. Eisenmenger's complex (R--L shunt 2ary to pulm HTN)
- Tetralogy of Fallot: tet spell, boot-shaped X-ray
- Transposition of the Great Arteries: marked cyanosis at birth, early digital clubbing CXR= egg-shaped heart
- Coarctation of the Aorta: cont murmur over collat vessels in back, CXR Sx = rib notching
- PDA: conti machine-murmur heard best at 2nd L interspace, wide pulse P, hypoxia. Tx: indomethacin
- Child abuse
- Poisonings: know severe + age and weight + time, type, amount, route exposure + PMHx
GP (TPAL)
Preme= delivery infant weight 500-2500 g
delivery between 20-37 wks
First Visit
- Sx: Chadwick's Sx, Hegar's Sx
- beta-hCG, commercial kit detects post 12-15 days
- U/S: gest sac--5 wk, fetal image--6-7wks, cardiac activity first--8wks. most accurate to det gestational age
- obstetrical Hx, menstrual Hx, contraceptive Hx
- MedHx: potential teratogens, smoking, etc ---audio
also multivit, recommend 25-35 lbs weight gain
- EDC ---Nagele's rule = LMP + 7 days - 3 mo + 1 yr
- pap smear for gonorrhea and chlamydia
- labs: CBC, blood type with Rh status, UA with culture, RPR for syphilis, rubella titer, TB skin test, can offer HIV Ab test
First-Trimester visits (1-12 wks), visit q 4 wks
fundal height at 12 weeks at the pubic symphisis
- trace glucosuria nml, but > trace prot abnml
-Screen for Down's Sx:
- U/S = NT = nuchal translucency
- blood tests = triple-marker screen (AFP, estriol, beta-HCG
- inhibin
- PAPP-A
Second-Trimester visits (13-28 wks), visit q 4 wks
at 16 wks = 1/2 symphisis to umbilicus. 20 wks = fundal height at umbilicus, later = + 1 cm per wk
- U/S to eval fetal heartbeat
- wk 17-19 fetal quickening = document fetal move
- amniocentesis for > risk mom's (> 35 y.o. and + Hx)
- glucose screen (1 hr glucola)
- rep Hct at 25-28 wk
Third Trimester visits (29-40 wks), q 4 till 32, then q2 till 36, then q week
- PTL Sx: vag bleeding, contract, ROM
- PIH (cause 15% mom deaths)
risk: nulliparity, >40 y.o., FHx, chronic HTN, chronic renal Dz, DM, twins
quick weight gain cuz edema, > reflexes and clonus. Tx = deliver baby
- Screen for GBS
- RhoGAM at 28-30 wks if needed

Changes in prego:
- blood: hypercoag, > Clotting factors, venous stasis. anemia of pre >vol, RBC mass comes later to 15% dilution
- cardiac output > 50%, S2 split with inspiration, JVD, systolic ejection murmur, S3 gallop = nml. Diastolic murmurs = NOT nml
- resp = TV and minute vent > 30-40%, FRC and RV < 20%, hyperventil = fetal PCO2 around 40 and still give off CO2. RR, VC and Insp Resverve = cte. TLC < 5%
- GI: < motility and < LEsoph sphincter tone---from progesterone. Hemorrhoids
- Renal: GFR > 50%, but NO signif > prot loss. Cr and BUN <
- Endo: fetus uses its own insulin starting 9-11 wks, TBG> = > T3 and T4. > cortisol and > CBG
- Skin: mimick liver Dz from > estrogen = spider angiomas, palmary erythema, hyperpigmentation
- weight gain: 25-35 nml, 15 overweight, >35 underweight
Medical conditions in prego:
- GDM---HPL antag insulin.
- Thromboembolic Dz---warfarin CI cuz teratogenic early, fetal bleeding later
- PIH: risk nulliparity, >40 y.o., FHx of PIH, chronic HTN, chronic renal Dz, DM, twins. Sx: hyperreflexia and clonus, edema weight gain
- preeclampsia: HTN >140/90, new onset proteinuria or edema, >20 wks
- severe preeclampsia: CNS disturb
- eclampsia: convulsions
-* HELLP Sx. Tx: delivery, transfuse blood, plts, FFP as needed. IV fluids and pressors = maintain BP
- Cardiac Dz (careful with pre-exist Hx)
- peripartum cardiomyopathy: risk > AA, multiparous, >30 y.o., twins, or preeclampsia. Tx = bed rest, digoxin, diuretics, possible anticoag, heart transplant if needed
- GBS: Tx = clinda or erythro. Check at 35-37 wks
- Hyperemesis Gravidarum: severe N/V after 1st trimester, ketosis and weight loss of >5% pre-pregnancy weight
- Pyridoxine + doxylamine (H1 R blocker)
- Odansetron
- IV fluids if severe dehydration and not tolerating oral liquids or solids for a time. If ketonuria = dextrose + vit
Fetal well-being
- fetal growth: fundal weight, U/S
- early: crown-rump length
- later: 4 measures: biparietal diam skull, abd circumference, femur length, cerebellar diam
- NST = Nonstress test
- FHR response to move (nml > by 15 bpm for 15 sec following fetal move) x 2 = nml
nml FHR = 120-160 bpm
variability:
- accel = :)
- early decel = mirrors contraction (P on vagus) = head compression on pelvis or vagus nerve
- variable decel = doesn't coincide, but rapid return to baseline, umbilical cord compression)
- late decel = dangergous = uteroplacental insuffic (placental abrupt, PIH, maternal DM, maternal anemia, maternal sepsis, postterm prego, hyperstim uterus)
- Biophysical profile (score 8-10 nml), <4 concerning
- fetal breathing: > 1 breath movem in 30 min lasting 30 sec
- gross body move >3
- fetal tone: extension/flexion
- qualitative amniotic fluid vol: 1 wih 1 cm in 2 perpendicular directions
- reactive FHR = reactive NST
Test fetal lung maturity (avoid neonatal RDS):
- L:S ratio (>2 = mature)
- phosphatidylglycerol present
causes nonreassuring getal assesment:
- uteroplacental insufficiency: placenta previa or abruption, placental edema from hydrops fetals or Rh isoimmunization, postterm prego, IUGR, uterine hyperstimulation
- umbilical cord compression
- fetal anomalies: IUGR, prematurity, postterm, sepsis, congenital anomalies
- isoimmunization---Tx RhoGAm within 72 hrs of delivery, and at 28 wks gestation
*Braxton Hicks contractions (false labor)
leopold maneuvers see fetal lie
vaginal exam: fetal station (-3 to +3)
LABOR:
- stage 1= onset to full cervical dil 10 cm, monitor FHR via doppler or fetal scalp electrode
- latent phase: till 3-4 cm
- active phase = contractions! monitor tocodynameter or IUPC, give analgesi (meperidine) or anesthetic (epidural block)
- stage 2: end dilation ----deliver baby
well controlled = protect the perineum, episiotomies, suction nose and mouth, watch for nuchal cord. push gently head down = 1 shoulder, pull up = other shoulder, test umbilical cord blood
- stage 3: delivery baby ---deliver placenta
- stage 4: immed postpartum (2 hrs) mom's body changes a lot
Abnml labor
- dystocia = difficult (power, passenger, or passage)
- arrest: active labor stopped for 2 > hrs
Postpartum hemorrhage:
- uterine atony: oxytocin, prostaglandins, massage
- retained placenta (accreta/increta/percreta)
- DIC
OB complication:
- abortion
- threatened
- inevitable
- completed
- incomplete
- missed
- recurrent
- ectopic prego
- 3rd trimester bleeding
- placenta previa (painless, placenta implated over internal cervical os)
- placental abruption (painful, premature separation of placenta from decidua) U/S not useful, besides seeing fetal distress
- PTL
delay via tocolysis = Mag Sulf, beta-2 agonist (terbutaline, ritodrine), Ca blockers (nifedipine or idomethacin)
steroids (betamethasone) = enhance fetal lung maturity if wks 34-37
check fetal fibronectin = marker assess likelihood preterm labor between 22-34 wks. if negative, < 1% chance deliver in the next 2 wks
- PROM: Nitrazine test (false + with semen, cervical mucus, trich infxn, blood, unusually basic urine), fern test, U/S = oligohydramnios
- Multiple gestations ---induced with clomiphene (SE: thromboembolism, multiple gestation, serious visual disturb, ovarian CA with long-term use)
postpartum care:
- lactation/breast feeding
- contraception
- immunizations
- postpartum blues
- postpartum uterine infxn (most common = metritis)
Cycle
Contraception
- OCPs
- alt: minipills, drosperidone and ethinyl estradiol, Depo-Provera, Norplant, Patch, IUD, vaginal ring, postcoital emergency...
Pap smear, atypia
colposcopy ---ECC----cone Bx --- excision
HPV
Vaginitis: candida/trichomonas/gardnerella
Endometriosis: 3Ds = dysmenorrhea, dyspareunia, dyschezia
Repro endocrinology and infertility:
- amenorrhea: prego, asherman's Sx, hypothalamic defic, pituitary dysfunct, ovarian dysfunct, genital outflow tract prob
- dysfunctional uterine bleeding
- hirsutism and virilization
- DDx: PCOD, Sertoli-Leidig cell tumor, CAH
- menopause (51 y.o. ave)
- infertility
- workup male semen
- basal body temp female
- anovulation
- anatomic disorder
Incontinence:
- stress
- urge
- neuropathic
- anatomical
TUMOR BOARD
Endometrial CA
- simple or complex hyperplasia
- atypical hyperplasia
- Endom CA

Uterine leiomyomas = fibroids


Leiomyosarcoma


Cervical CA


VIN = vulvar intraepithelial neoplasia

Vulvar CA


Vaginal CIS and CA = very rare



GTN = Hydatidiform Mole
- complete
- partial
Ovarian CA
- benign:
- cysts
- tumors
- epithelial cell
- germ cell
- stromal cell
- malignant:
risk factors
- epithelial cell
- germ cell
- stromal cell
Sacral decubitus ulcers: P ulcers. Tx wound care + hydrocolloid dressings
- stage I: area persistent non-blanchable erythema, usually over bony prominence
- stage II: ulceration thru dermis
- stage III: destruct tissue down to SubQ fat
- stage IV: shows underlying m, tendon, bone
Neuropathic ulcers: P points foot and toes, in DM, usually painless
Venous stasis ulcers: near lat/med malleolus, assoc with bilat LE edema. Tx: compression + elevation
Nail problems:
- koilonychia: Fe defic anemia= nails with raised edges and are thin + concave
- onychorrhexis: brittle nails, split vertically = "peeled" appearance. housecleaning prod exposure to nails
- onycholysis: painless separation of nail from nail bed. often in psoriasis.
- paronychia: infxn nail fold 2ary to bact, fungal or viral infxn
- pterygium: inward advance of skin over nail plate, usually from trauma
TUMOR BOARDS
-
seborrheic

keratosis
(benign)
-
actinic

keratosis
= precursor to SCC in situ, lesions caused by sunlight. face, arms, older pts, red, sharply demarcated, scale can be thick and crusted. Tx: ice off or 5-FU. Bx if CA suspected
- DDx: Bowen's Dz, another SCC in situ idiopathic or from carcinogen exposure (arsenic)
-
squamous

cell

CA
: (2nd most common) non-healing ulcer, sun-exposed area. inflamm and crusting. pot for mets and death. from UV light, chemical carcinogens, radiation tx, chronically draining infectious sinuses (osteomyelitis). Dx: Bx, graded histo, Tx surgery, maybe radiation/chemo
- SCC with cutaneous horn
- nodular---thick papule, often with central ulceration
- exophyic ---from Bowen's Dz, bleeds easy
-cerucous CA: low grade SCC, resembles a wart, on mucous memb and plantar surfaces
-
basal

cell

CA
= most
common malign
, but not usually fatalities, virtually no mets. slow larging lesion, pearly/waxy, translucent, doesn't heal, bleeds occasionally (telangiectasias). usually face, head, neck and hands. from chronic UV light exposure, arsenic exposure, or inherit BCC nevus Sx. Dx: Bx islands prolif epith like basal layer. Tx: surgical excision. cure rate > 95%
- nodular/ulcerated/sclerosing/superficial/pigmented/BCC nevus Sx from kids also + frontal bossing + jaw cysts + CNS tumors


Virus:
- molluscum contagiosum: (young kids and AIDS), discrete, non-tender, flesh-colored papules with central depression, small. On Giemsa or Wright's stain = large inclusion or molluscum bodies
- HSV= 1 oral-labial, 2 genital. epidermal cells fuse---giant cells on Tzank smear. Tx: acyclovir
- VZV= varicella (dewdrop on a rose petal), lesions all different stages, palms and soles are spared
in adults = systemic complic = pnmonia, encephalitis
-Shingles = dermatomal distrib, older Pts may dev postherpetic neuralgia
- Thyroid
-
hyperthyroid
: (hyperreflexia, weight loss, pretibial myxedema)
-
Graves
' Dz = (most common) TSH-R Ab, anti-thyroglobulin Ab. Sx: hyperthyroid, goiter (hoarseness/voice change), orbitopathy, sometimes dermopathy. often assoc with RA\ Tx: radioactive I2 thyroid ablation, thyroidectomy, antithyroid drugs (methimazole or propylthiouracil) and after give levothyroxine, for Sx = propanolol
-palp = diffusely large and symmetric
-
Plummer
's
Dz
=
toxic

multinodular

goiter
(2nd most common) from focal/diffuse hyperplasia. >age, > iodine defic. Sx: cough, dysphagia, dyspnea. radioactive I2 = patchy or localized uptake. Tx: surgery and radio I2. has palpable thyroid nodule
-
deQuervain
's
thyroiditis
=
subacute
granulomatous thyroiditis = subacute. (rare) starts from post-viral inflamm
hyperthyroid till wasted-hypothyroid--then regenerate
Sx: neck pain radiates to jaw, ear, upper throat, chest. maybe enlarged thyroid and tender. < TSH, nml T3, T4, > ESR
Tx: anti-inflammatory. TSH monitored q few weeks
-
Adenoma
-
thyrotoxicosis
: hypermetabolic state from infxn, CA, or hyperthyroidism, often 2-6 mo postpartum, palpit, nervous, fine resting tremor. transient. elderly = Afib, CF and dyspnea. Often progresses into hypothyroidism
-
subclinical

hyperthyroidism
: < TSH, nml T3, T4
> risk Afib, CV effects, < bone density
-
hypothyroid
:
- primary =
Hashimotos

thyroiditis
= anti-thyroid peroxidase Ab = anti-TPO + = anti-microsomal antigen, also anti-thyroglobulin Ab. Tx = levothyroxine
-
myxedema
coma = severe hypoth, < MS, hypothermia, other parasymp Sx. Mortality 30-60%. IV levothyroxine and IV hydrocortisone (if AI hasn't been excluded)
- Sheehan's Sx: pit infarction postpartum
- drug causes = Li, amiodarone, iodide
Balance/dizziness/vertigo: nystagmus
- Meniere's Dz : hearing loss
- cerebellar infarction: single, prolonged episode
- vestibular neuronitis: single, prolonged episode
- BPPV
- acoustic neuroma (if NF)
- SE drug (e.g. HCTZ)
Pre-syncope, lightheadedness
Spinal cord injuries/problems:
- hemi-section= Brown-Sequard Sx
ipsilateral motor and DCML, contralateral STT (temp and pain)
- complete transection of spinal cord
- bony impingement
- anterior cord
- post cord
- syringomyelia
Movement Disorders:
- Parkinson's: tremor at rest, invol resistance to move (rigid). Tx (normal, good balance, good gait, active = (anticholinergics) trihexyphenyldyl or benztropine if < 60, if > 60 Amantadine), carbidopa/levidopa, + adjunctive DA agonists (pramipexole, ropinirole)
- Benign Essential tremor: Tx: propranolol (if can't then primidone)
- Restless leg Sx: Tx pramipexole (DA)
- Wilson's Dz: neuro/psych + cirrhosis + tremor. Dx: slit lamp examination = Keyser-Flescher Ring, if neg, then check serum ceruloplasmin levels + = lo, most accurate test = liver Bx
Tx: D-penicillamine chelation
- Huntington's Dz: degradation of the caudate nucleus. abrupt personality changes + psych issues + chorea, athetosis, Parkinson's Sx (dementia), fidgety
Dx: chromosome analysis
Tx: tetrabenzine (reversible inhib VMAT2 = < uptake neurotransmitters into synaptic vessels = deplete stores)
- Friedrick's ataxia (mut GAA reps) = prog degen Dz of dorsal columns + SCT = Sx progressive gait abnrml and limb ataxia, dysarthria, loss joint posit and vibratino senses, absent reflexes LE, extensor plantar reflexes
Sympathetic
innervations
H+N = 1-4
heart and lungs = 1-6 cervicothoracic, middle and superior cervical ganglia

S 5-9 Greater Splanchnic------Celiac ganglion
L 6-9
P 5-11
S 9-11 Lesser Splanchnic------Sup mesenteric ganglion
K 10-11
B 12-L2
L 12-L2 Least and Lumbar Splanchnics ---Inf mesenteric ganglion
Parasympathetics
- CN III ---Edinger Westfal Nucleus ---Ciliary ganglion
- CN VII---sup salivatory nucleus----pterygopalatine or submandibular ganglion
- CN IX---inf salivatory nucl-----otic ganglion--parotid gland
- CN X----dorsal vagal nucl----sup and inf vagal ganglion

Pelvic splanchnics = S2-S4
Left colon, lower ureter, bladder, uterus/prostate, genitals
Freyette's Laws
1. Neutral
2. F/E
3. less motion

doesn't apply to cervicals:
- OA (yes) F/E [S & R
oppose
]
mostly translate to know
- AA (No) = rotate. retroorbital pain,
opposite
-upper cervicals = Rotate [S & R
same
]
mostly translate to know
- lower c's = sidebend
CI to HVLA
- Absolute (easy fracture bones)
- osteoporosis
- osteogenesis imperfecta
- bone CA/mets to bone
- in cervicals
- Down's (transverse lig laxity)
- RA
- V art dissect
- Relative
- whiplash
- prego
- post-op
- herniated disc
- hemophilia
- acute sprain
- anticoagulants
PRM = move it! = CRI 10-14 cycles/min
1. Bones cranium
2. membranes (RTM)
3. CSF
4. Brain and Spinal cord (moTility)
5. Saccrum (invol)
Ribs
- true 1-7
- false 8-12
- floating 11-12

motion
- pump handle
- bucket
- caliper

ME muscles for ribs:
- scalenes (ribs 1-2)
- pecs minor (3-6)
- serratus ant (6-10)
- lats dorsi (9-12)
- quad lumborum (rib 12 direct=inhalation/indirectly=exhalation)
- intercostals (forced inhalation/exhalation)
Lumbosacral angle = Ferguson's
Normal = 25-35 degrees

Carrying angle
male = 5 degrees
female = 10-12 degrees
Somatic Dysfunction
• Definition-impaired or altered function of related component of the somatic system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.
• Diagnostic Criteria-Tissue Texture Abnormality,
Asymmetry, Restriction of Motion, Tenderness (TART).

Acute/Chronic dysfunction

Rule of 3's : BUM BUL BUM
Cranial Somatic Dysfunctions Occur at the SBS:
1. Flexion (will not cycle into extension)
SBS forward, ext rot paired bones, inhalation, counter-nutation
2. Extension (will not cycle into flexion)
SBS backward, int rot paired bones, exhalation, nutation
3. Torsions (left and right)
4. Sidebending rotations (left and right)
5. Vertical Strains (superior and inferior)
6. Lateral Strains (left and right)
7. SBS compression

The Seven Stages of Spencer:
1.
Extension
of the upper extremity to 90 degrees.
2.
Flexion
of the upper extremity to 180 degrees.
3.
Circumduction
with glenohumeral joint
compression
. This tests the joint surfaces.
4. Circumduction with
traction
. This tests the joint capsule.
5.
Abduction
(not adduction) to 90 degrees.
6.
Internal

rotation
.
7.
Pump
, also called traction with caudal glide.

Tests of the UE
shoulder
Apley's Scratch test = eval ROM shoulder
Apprehension (Crank) test = detect chronic shoulder dislocation
Post apprehension test = Posterior Shoulder Instability or Dislocation
Adson's test = compression of subclavian art (thoracic outlet Sx)
Drop arm test = detect tears in rotator cuff m
"empty can" test = Detect Tears of the Supraspinatus Tendon or Muscle
Load & Shift test = Shoulder Instability, Anterior or Posterior
Sulcus Sx = inf shoulder instability
Yergason's test = bicipital tendonitis
Speed's test = Bicipital Tendinitis

hand
Phalen’s Test = Carpal tunnel Sx
Tinel's Sx = carpal tunnel Sx
Allen's test = collat circ of hand
Finkelstein’s test = DeQuervain’s Tenosynovitis (Abductor Pollicis Longus & Extensor Pollicis Brevis Tendons)
Somatic dysf knee: (ami ple-az!)
A-M- internal glide
P-L - external glide

Fibular head posterior dysfunction may cause compression of the common fibular (peroneal) nerve.

LE tests:
hip
- Barlow's test = hip stability
- Erichsen's test = SI pathology
- Galleazzi's (Allis) Test = Congenital Hip Dislocation Ages 3-18 mos.
- Ludloff’s Sign = Traumatic Separation of the Lesser Trochanter of the Femur
- Laseque Test = unilat straight leg raise, for herniated nucleus palposis or neural foraminal stenosis = indicates dural sheath involvement
- Well Straight Leg Raise test: eval vertebral disc damage (Sx radiopathy in opposite one than lifted)
- Ober’s Test = Iliotibial Band/Fascia Lata Dysfunction
- Ortolani’s Test = Congenital Hip Dislocation in a Newborn
- Patrick’s (FABER or FABERE) Test = hip joint patho
- Trendelenburg Test = Gluteus Medius Muscle (Superior Gluteal Nerve)
- Thomas Test = contraction Iliopsoas m
knee
- ant drawer test = ACL
- Lachman's test = ACL
- Post drawer test = PCL
- Apley's compression test = knee meniscal injury
- Apley's distraction test = knee ligamentous injury
- McMurray’s Test = meniscal tears
- Valgus Stress Test = Medial (Tibial) Collateral Ligament
- Varus Stress Test = Lateral (Fibular) Collateral Ligament
ankle:
- ant drawer test of ankle = ant talobibular and calcaneofibular lig
- Thompson’s Test = ruptured achille's tendon
leg in general:
- Babinski's = UMN dysfunct
- Homan's Sx = DVT
Testicular CA:
-
chorioCA
= most aggresive Germ Cell tumor, mets early and widespread. necrosis + hemorrhage. > 1000 beta-HCG
-
Leydig
cell = most common sex cord tumor, 40-50 y.o. give androgens = feminization. Gynecomastia, < libido, ED. If in kids = precocious puberty
-
Sertoli
cell= sex cord tumor, rare. Assoc with Peutz-Jegher's (intest polyposis and mucosal melanin spots) and Carney's Sx. most 45 y.o. gynecomastia, hyperestrogenism, rarely virilization
-
Teratoma
= germ cell tumor. Pure (< 2 y.o.)/mixed(young adults), mature/immature. Dx: U/S. heterogeneous, cystic or solid
-
Yolk

sac
tumor = endodermal sinus tumor (most common pre-pubertal). painless testic mass. AFP > 100 (correlates with Dz extent)
S2 splitting = wide, paradoxical, fixed
+ S3 (CHF)
+ S4 (LVH, infarction)
pericardial rub (likely pericarditis)

extremities:
- calf swelling (PE)
- absent pedal pulses (aortic dissect)
hyperlipidemia
-
LDL
>100, or > 70 in DM
statins! SE: m pain, rhabdomyelolysis
assoc with: familial hypercholesterolemia, >fat diet, obstruct liver Dz (PBS, PSC), thyroid Dz, nephrotic Sx, DM, anabolic steroid use, thiazide diuretics, OCPs
-
HDL
<60
-
Triglycerides
> 150

Antihyperlipidemics
-
HMG
-CoA reductase inhib (
statins
) = pravastatin, fluvastatin, atorvastatin, etc. use in kids > 8-10 y.o.
○ Reduces biosynth of cholesterol. Mostly lowers LDL ---assoc with > survival
○ 1st choice, check LFTs before use, CI: prego, liver Dz
§ SE: myalgia, rhabdomyolysis (esp if + niacin or + fibrate)
-
Fibrates
: gemfibrozil, fenofibrate, etc
○ > prod of lipoprot lipase, mostly < TGs
-
Niacin
= Vit B3. mostly > HDL
○ SE: flushing, pruritus, worsening of gout
-
Bile

acid

sequestrants
= cholestyramine, colestipol, colesevelam
○ < reuptake of bile acids, mostly < LDLs. only one to use in Liver Dz
- SE: bloating, GI upset, steatorrhea. CI: very > Triglycerides
-
Ezetemibe
= > cell absorpt of cholesterol, blocks transporter cholesterol in the intestine
○ Mostly < LDL, used in combo with statin
Few SE, CI: very > Triglycerides


AAA: common site = distal to renal arteries

blood supply adrenals:
arteries
- superior supraadrenal (from inf phrenic art)
- middle supraadrenal (from aorta)
- inf supraadrenal (from renal art)
veins
- L : suprarenal vein---to renal vein
- R: suprarenal vein --- to inf vena cava

Colon CA (2nd leading cause CA deaths)
- CEA if >, follow till normal
-
Lynch Sx I
= auto D, R sided (70% proximal to splenic flexure)
-
Lynch Sx II
= Lynch Sx I + extracolonic CA (endometrial CA, CA of the ovary, sm bowel, stomach, pancras, ureter, renal pelvis)
- Screening: age > 50 wihtout risk factors, yearly stool occult blood tests, flexible sigmoidoscopy q3-5 yrs or colonoscopy q10 yrs or Ba enema q 5-10 yrs
- Tx: surgery (resetion + regional LN dissection), adjuvant Tx for mets =
FOLFOX
(5-FU + leucovorin or levamisole + oxaliplatin)---30% > survival, bevacizumab (
Avastin
) can be added for distant Dz

Hemorrhoids: degree of prolapse 1-4
Anal
fistula
patnent =
FRIEND
= foreign body, radiation, infection, epithelializ, neoplasm, distal obstruction

Rectal CA: > in males, rectal bleeding, obstruction, altered bowel habits, and tenesmus
Anal CA = sq cell CA, or transit cell, adenoCA, melanoma, mucoepidermal. Tx: Nigro Protocol (
5-FU, mitomycin, radiation
)---for all except melanoma




Large Intestine Obstruction: 15% obstructions, common site is = sigmoid colon, from adenoCA, scarring from diverticulitis, volvulus, adhesions if prev abd surgery. Dx clinical + X-ray, consider Ba enema. NO Ba orally if suspected obstruction. Tx: emergency lap if cecal diam > 12 cm or severe tenderness, peritonitis, sepsis, free air
- Pseudo-obstruction
(Ogilvie's Sx
)--no evidence of obstruction, Tx: colonoscopy and rectal tube = decompression. Consider neostigmine for rapid bowel evacuation, beware of bradycardia

Volvulus: rotation large bowel on mesenteric axis = ischemic bowel, gangrene, and subsequent perfora
Full transcript