Tiki Taka AHMD
Tiki Taka AHMD
Tiki Taka AHMD
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===================================================== Cardiology
=============================================================================
. Myocarditis:
______________
. Is an inflammation of the myocardium, Caused by: infections, toxins, and autoimmune diseases.
. Viral infection ( enteroviruses in particular) the most common cause of myocarditis in children.
. Classically occurring in spring and summer, myocarditis develops more often in infants and young children than in
older children and adolescents.
. Leads to tissue necrosis, thereby worsening myocardial function, dilating the heart, and increasing end diastolic
volume with resultant pulmonary edema and CHF.
. Myocarditis typically presents as a flulike illness: fever, anorexia, lethargy, and irritability followed by respiratory
distress from acute heart failure.
. A holosystolic murmur may be identified secondary to dilated cardiomyopathy and the resulting functional mitral
regurgitation.
. Hepatomegaly can develop due to passive congestion Other features of heart failure include fatigue, tachypnea,
tachycardia, and decreased perfusion.
. Affected children should be monitored in the intensive care unit because of the risk of acute decompensation and fatal
arrhythmias.
. The workup for suspected myocarditis includes a (CBC) with differential, ESR and C-reactive protein, cardiac
enzymes, and blood and viral cultures.
. A chest radiograph demonstrates cardiomegaly and pulmonary edema.
. Electrocardiography most commonly shows low voltage QRS and sinus tachycardia.
. Echo.is the best means of evaluating myocardial function and often shows global hypokinesis, left vent. hypertrophy,
left vent. dysfunction & pericardial effusion.
. The gold standard for diagnosis is a myocardial biopsy, which also allows for disease stage classification.
. Ventricular septal defect (VSD):
__________________________________
. The most common congenital heart malformation.
. VSDs range from small and asymptomatic to large with significant left-to-right shunting.
. Indications of significant VSD is: left-to-right shunt First, he is symptomatic Second, he has the telltale murmur.
(Affected patients have pansystolic murmurs loudest at the left lower sternal border.
. There maybe also a diastolic murmurs at the apex because of increased flow across the mitral valve ).
. This patient should have an echocardiogram with a bubble study to evaluate his congenital heart defect.
. Most small ventricular septal defects close spontaneously and require no treatment, as long as there are no signs of
pulmonary vascular disease.
. Reassurance and surveillance via EKG and echocardiography are needed in most patients.
. Tetralogy of Fallot (TOF):
____________________________
. Is the most common cyanotic congenital disease in children less than 4 years.
. Patients often present with cyanotic spells.
. The classic tetrad includes:
(1) subpulmonary stenosis (single S2), (2) overriding aorta, (3) ventricularseptal defect (VSD) (pansystolic murmur),
and (4) right ventricular hypertrophy.
. Because a large unrestrictive VSD is always present, the right ventricular pressure is the same as the left ventricular
and aortic pressures.
. Pulmonary artery pressure and flow are inversely proportional to the degree of subpulmonary obstruction.
. The degree of cyanosis correlates precisely with the degree of pulmonary stenosis.
. Untreated patients with TOF are at risk for "hypercyanotic" or "tet" spells.
. These spells are often precipitated by exertion (such as feeding) and are characterized by irritability, cyanosis, and
tachypnea.
. The exact etiology of these episodes is unclear, it may be predisposed by peripheral vasodilation, hyperventilation,
and/or contractility of the Rt. ventricular outflow tract.
. Regardless of the etiology, however, an increased right to left shunt across the ventricular septal defect develops,
causing a decrease in pulmonary blood flow and
increased systemic venous return of deoxygenated blood leading to worsening cyanosis.
. If untreated, "tet" spells can lead to syncope or death.
. The treatment of a "tet" spell is to place the child in a knee to chest position, which increases systemic vascular
resistance resulting in
increased blood flow from the right ventricle to the pulmonary circulation.
. Morphine and an intravenous fluid bolus can also be given to increase pulmonary blood flow.
. Oxygen is of little benefit because the abnormality is decreased pulmonary blood flow, not insufficient oxygenation
. Atrial septal defects:
________________________
. Are relatively common among children and may cause symptoms.
. On exam, there is a widely split and fixed S2, systolic ejection murmur in the left upper sternal border, and,
if there is a large shunt, a diastolic murmur at the left lower sternal border.
. Transposition of the great vessels:
_____________________________________
. A cyanotic heart disease which presents with cyanosis in the first 24 hours of life.
. It is commonly seen in infants of diabetic mothers and in males.
. The aorta arises from the right ventricle, and the pulmonary artery from the left ventricle.
. As a result, deoxygenated blood coming from the body goes to the right atrium and ventricle and is cycled back to the
body through the aorta.
. Oxygenated blood from the lungs is returned to the lungs by the left side of the heart through the pulmonary artery.
. During intrauterine life, the fo ramen ovale and ductus arteriosus provide mixing of the deoxygenated and oxygenated
blood,
resulting in an almost normal oxygenation of the fetal circulation.
. A patent foramen ovale or ductus arteriosus can maintain life after birth, as seen in a patient with normal Apgar
scores.
. The foramen ovale and ductus arteriosus begin to close after birth, leading to decreased mixing and poor oxygenation.
. As the aorta is located in front of the pulmonary artery, the S2 aortic component is better heard than the S2 pulmonic
valve component and is audible as a single S2.
. There is usually no murmur because the foramen ovale and ductus arteriosus have closed.
. The neonate then presents with cyanosis and tachypnea within the first few hours of life.
. Chest x-ray can be initially normal but show some evidence of increased pulmonary blood flow after 1-2 weeks.
. Echocardiography confirms the diagnosis.
. Prostaglandin E1 can be intravenously given to stabilize the neonate by maintaining the patency of the ductus
arteriosus, which is important for survival.
. Surgical treatment is definitive.
.N.B:
- Prostaglandin E1 is a vasodilator used to prevent ductus arteriosus closure in such infants,
to increase or maintain pulmonary blood flow and improve oxygenation until definitive surgery can be performed.
- Closure of the ductus arteriosus in such patients would cause progressive hypoxia and metabolic acidosis.
. Coarctation of the aorta (COA):
_________________________________
. A congenital defect characterized by stenosis of the aorta, usually near the ductus arteriosus.
. present with hypertension in the upper part of the body (high BP in the arms) and relative hypoperfusion in the lower
part of the body (low BP in the legs).
. The prevalence of COA in patients with Turner's syndrome is approximately 7%.
. The clues to the diagnosis are occasional headaches and increased BP in both arms, leg muscle fatigability while
climbing stairs (due to lower body hypoperfusion).
. And a mild, continuous murmur heard all over the chest (due to the development of collaterals between the
hypertensive and hypoperfused vessels).
. Rib notching caused by the dilatation of the collateral chest wall vessels is specific for coarctation.
. Mitral stenosis:
__________________
. also causes a diastolic rumble but does not typically cause a pansystolic murmur at the left lower sternal border unless
there is tricuspid regurgitation as well.
. Other features to suggest rheumatic fever such as fever, arthritis, or skin lesions.
. Tricuspid atresia:
____________________
. Suspect tricuspid atresia in a cyanotic infant with left axis deviation.
. This condition is characterized by an absent connection between the right heart cavities, and a hypoplastic or absent
right ventricle.
. Ventricular septal defect (holosystolic murmur on auscultation) occur in 90 % of cases.
. Transposition of the great arteries occur in 30% of cases (which is not likely to be in a case where the chest x- ray
does not demonstrate pulmonary overcirculation).
. The associated heart defects, such as atrial septal defect (ASD), ventricular septal defect (VSD), or patent ductus
arteriosus (PDA), are necessary for survival.
. Venous blood passes through the ASD to reach the left cavities, and then through the VSD back to the outlet portion
of the right ventricle to reach the pulmonary circulation.
. Sometimes, there is an associated pulmonary stenosis, and the blood passes through the PDA to reach the pulmonary
circulation.
. Patients with normal arteries (without TGA) present in the first two weeks of life with progressive cyanosis,
tachypnea, easy fatigability, and poor feeding.
. EKG reveals left ventricular hypertrophy, which occurs since the left ventricle handles both pulmonary and systemic
venous returns.
. Echocardiography shows a fibromuscular membrane in the place of the tricuspid valve, a variably small right
ventricle, ventricular septal defect, and a large left ventricle.
. The treatment generally includes PGE1 (to keep the ductus arteriosus open) and balloon atrial septostomy
(if the ASD is not large enough to allow an adequate flow from the right to left atrium)
. postpericardiotomy syndrome:
______________________________
. It is reactive pericarditis with a pericardial effusion that present after surgery for congenital heart disease.
. Symptoms usually occur 1-6 weeks after surgery.
. Although the cause is not known, it is thought to be an autoimmune response, possibly to a viral infection.
. Most children develop mild symptoms which are self limited. In infants, pericardial effusions can present with
abdominal pain, vomiting, and decreased appetite.
. Older children may complain of chest pain Fever is often present On examination, findings are consistent with
pericardial and/or pleural inflammation,
including tachycardia, poor perfusion, pulses paradoxus, distant heart tones, and jugular venous distention.
. If the effusion is large enough to affect the function of the heart , pericardial tamponade can occur.
N.B:
- Most cardiac murmurs in childhood are benign (innocent) and require only observation. Know the following features
of a benign murmur:
systolic ejection quality.
varies with position;
Asymptomatic patient
Murmur intensity grade 2 or less
Normal S2
No audible clicks
Normal pulses
No other abnormalities.
- Pathological murmurs may indicate or lead to congenital heart disease, and are very likely when the patient has any of
the following:
symptomatic patient
Murmur intensity more than grade 2.
Pansystolic murmur
Murmur loudest at upper left sternal border
Absent or diminished femoral pulses
Murmur's quality is unchanged with position.
. Rheumatic fever:
__________________
. Suspect rheumatic fever in a child with sore throat, low-grade fever, pericarditis, arthritis, chorea and subcutaneous
nodules.
. Other features include erythema marginatum, elevated ESR and prolonged PR interval on EKG.
. Rheumatic fever is caused by is group A streptococcus.
. Diagnosis is made if two major or one major and two minor criteria (Jones criteria) are satisfied, in addition to
evidence of recent streptococcal infection (via detection of antistreptolysin antibodies, cultures and other various
antigen detection kits).
. Jones criteria:
----------------. The five major criteria are:
- Polyarthritis.
- Carditis.
- Chorea.
- Subcutaneous nodules.
- Erythema marginatum.
. The three minor criteria are:
- Fever.
- Arthralgia.
- Previous rheumatic fever.
. The treatment is benzathine penicillin G.
. Patients with chorea, pericarditis and arthritis may require additional therapy with anti-epileptics, salicylates, and
codeine, respectively.
. Jervell-Lange-Nielson syndrome:
_________________________________
. Is an autosomal recessive disease characterized by congenital deafness and QT interval prolongation on EKG.
. QT interval prolongation predisposes to a particular type of ventricular tachycardia called torsades de pointes.
. Torsades de pointes cause syncopal episodes and sudden death.
. The clue to the diagnosis is a syncopal episode without following disorientation (post-episode confusion is more
=============================================================== ENT
=============================================================================
. Epiglottitis:
_______________
. In unimmunized children H. influenza type B is the most likely cause.
. In Hib vaccinated patients:H. influenzae type A and nontypable strains, H. parainfluenzae, Streptococcus pneumoniae
. Sudden onset of; fever, sore throat, dysphagia and drooling.
. Airway obstruction is the most concerning complication of epiglottitis.
. This is a pediatric emergency and should be managed emergently with endotracheal intubation; however, since
intubation of such patients is difficult,
preparation for possible tracheostomy is also standardly performed.
. Allergic Rhinitis:
____________________
. Allergic rhinitis is characterized by an immunoglobulin E (lgE) mediated hypersensitivity to fo reign allergens.
. It may be acute or chronic, and can be confused with recurrent colds.
. It may present with itchy eyes and tearing, swollen mucosa, headaches and nasal obstruction,if the age of onset is in
the second decade of life.
. Diagnosis is by allergy testing and findings of eosinophilia in the nasal discharge.
.N.B:
- The most common predisposing factor for acute bacterial sinusitis is a viral upper respiratory infection.
. Choanal atresia: Extremely high yield question for USMLE.
__________________
. Suspect choanal atresia in an infant who presents with cyanosis that is aggravated by feeding and relieved by crying.
. Failure to pass a catheter through the nose 3-4 cm into the oropharynx is suggestive of the diagnosis.
. The diagnosis is confirmed by CT scan with intranasal contrast.
. First step in management consists of placing an oral airway and lavage feeding.
. Definitive treatment involves repairing the obstruction with surgery or endoscopy.
. Brain abcess after otitis media:
__________________________________
. An acute onset of headaches and focal neurologic symptoms after an episode of acute otitis media or sinusitis most
likely has a brain abscess.
. Hypothermia, hypotension.
. Ring-enhanc ing lesions are usually seen on CT or MRI scan.
. Acute bacterial sinusitis:
____________________________
. Streptococcus pneumoniae is the most common cause of acute sinusitis in childhood, followed by Haemophilus
influenzae and Moraxella catarrhalis.
. Staphylococcus aureus and anaerobes are common etiologic agents of chronic sinusitis, and are rarely seen in acute
cases.
. Diagnosis of acute bacterial sinusitis for children <6 years of age should be based on clinical rather than radiographic
criteria.
. The treatment is antibiotics, in uncomplicated sinusitis, the treatment of choice is amoxicill in 45-50 mg/kg/day.
. Cholesteatomas:
_________________
. Cholesteatomas in children can either be congenital or acquired secondary to chronic middle ear disease.
. Congenital cholesteatomas typically found in younger patients around the age of five.
. New-onset hearing loss or chronic ear drainage despite antibiotic therapy are typical presenting symptoms of acquire
cholesteatomas, and
granulation tissue and skin debris may be seen within retraction pockets of the tympanic membrane on otoscopy.
. Complications of cholesteatomas include hearing loss, cranial nerve palsies, vertigo, and life-threatening infections as
brain abscesses o rmeningitis.
. Should be referred to an otolaryngologist for a dedicated otologic exam, possibly accompanied by a CT and/or
surgical visualization to confirm the diagnosis.
. Acute otitis media:
_____________________
. The most common causative organism is Streptococcus pneumoniae (40% of cases), followed by non-typable
Haemophilus influenzae & Moraxella catarrhalis.
. Acute otitis media should be considered in any patient with symptoms of ear drainage and difficulty hearing.
. Ear pain is also common, but may be absent in young patients.
. Nonspecific systemic symptoms: fever, irritability, and diarrhea can sometimes be present.
. The first-line treatment is 10 day course of amoxicillin.
. juvenile angiofibroma (JNA):
______________________________
. Any adolescent with a nasal obstruction, visible nasal mass, and frequent epistaxis is considered to have a juvenile
angiofibroma (JNA) unless proven otherwise.
. This is typically found in the back of the nose or upper throat (nasopharynx) of adolescent boys.
================================================================= Ophthalmology
==================================================================
. Neonatal Conjunctivitis:
__________________________
. Gonococcal conjunctivitis: A copious amount of purulent drainage in newborns who are 2-5 days old is most
consistent with gonococcal conjunctivitis.
. Chlamydia trachomatis conjunctivitis: caused by Chlamydia trachomatis is usually milder and presents > 5 days after
birth.
. Chemical conjunctivitis can result from prophylactic silver nitrate eye drops, but it is usually fairly mild.
. viral conjunctivitis:
_______________________
. The conjunctiva is red with copious, watery discharge.
. Children are more commonly infected through contaminated swimming pools.
. It is mostly caused by adenovirus type 3.
. Chemical conjunctivitis:
__________________________
. It is the most common cause of a red eye that presents within the first 24 hours of life.
. Approximately 80% of patients who receive silver nitrate prophylaxis (to prevent gonococcal conjunctivitis)
experience mild conjunctival irritation and tearing that generally resolve within 24 hours.
. Gonococcal conjunctivitis:
___________________________
. is acquired through contact with infected genital secretions, and occurs 2-5 days after birth.
. It presents as a hyperacute and highly purulent conjunctivitis with copious, purulent eye discharge with swollen
eyelids and chemosis.
. It is the most destructive neonatal eye infection, since it may result in corneal perforation and permanent blindness if
left untreated.
. The treatment is ceftriaxone.
. Chlamydial conjunctivitis:
___________________________
. Develops a few days to several weeks after birth ( > 5 days after birth).
. Manifests with conjunctival congestion, edema, and mucoid or frank purulent discharge.
. Pneumonia usually appears 3 to 19 weeks after birth, and symptoms include cough, tachypnea, and rales; there is no
fever, and wheezing is rare.
. The latter two features permit to differentiate chlamydial pneumonia from RSV bronchiolitis.
. The treatment is oral erythromycin for 14 days, as topical agents are ineffective.
. Trachoma:
___________
. caused by Chlamydia trachomatis serotype A-C. It is a major cause of blindness worldwide.
. The active phase of the disease is characterized by follicular cionjunctivitis and pannus (neovascularization) formation
in the cornea.
. conjunctivitis usually presents on the 5th to 14th day of life as congestion and discharge that may be scant, mucoid or
frankly purulent.
. Concurrent infection occurs in the nasopharynx, leading to nasal discharge.
. The diagnosis can be made by Giemsa stain examination of conjunctiva! scrapings.
. Topical tetracycline or oral azithromycin should be started immediately.
. The treatment is erythromycin, which has to be administered systemically (oral) to decrease the risk of chlamydial
pneumonia.
. Repeated infections can lead to scarring of the cornea.
. Retinal hemorrhages:
______________________
. Common findings in child abuse. Multiple retinal hemorrhages that differ in size and color support the suspicion of
child abuse.
. A precipitating factor (stepfather/mother, financial issue) is usually present in the history In addition, there may be
bruises that usually have associated swelling and tenderness.
. In this case, nothing in the history and physical findings is suggestive of child abuse; therefore, reporting to the
authorities is not necessary.
. Herpes simplex keratitis:
___________________________
. Presents as pain, photophobia, and decreased vision.
. Dendritic ulcer is the most common presentation.
. There may also be minute clear vesicles in the corneal epithelium.
. Orbital cellulitis:
_____________________
. Is an infection that is posterior to the orbital septum which is unilateral and more common in children with paranasal
sinus infection.
. Patients present with an abrupt onset of fever, proptosis, restriction of extraocular movements and swollen, red
eyelids.
. Differentiating preseptal cellulitis and orbital cellulitis is important in any patient who presents with a swollen and
painful eye accompanied by fever.
. Pain with eye movement is more suggestive of orbital cellulitis it can occur in preseptal cellulitis as well.
. Both proptosis and decreased visual acuity are almost always seen in orbital cellulitis.
. CT can be used to confirm the extent of infection and to identify a potential abscess.
. Treatment requires intravenous broad-spectrum antibiotics.
. Preseptal cellulitis:
_______________________
. Is an infection of the soft tissue anterior to the orbital septum, that is most commonly caused by contiguous spread of
infection from local facial or eye lidtrauma.
. It is often present with: eyelid swelling, tenderness, erythema or discoloration.
. The presence of decreased eye movements, decreased visual acuity, proptosis or double vision is more suggestive of
orbital cellulitis.
. Case of leukocoria (white reflex):
____________________________________
. Every case of leukocoria is considered a retinoblastoma, until proven otherwise.
. So, this child needs prompt referral to an ophthalmologist.
. Retinoblastoma is the most common intraocular tumor of childhood.
. The underlying pathology involves inactivation of the Rb suppressor gene, which may be familial or sporadic.
. Retinoblastoma is a highly malignant tumor, and failure to diagnose and treat the disease early may lead to death from
liver and brain metastases.
. The other manifestations of the disease may include strabismus, decreased vision, ocular inflammation, eye pain,
glaucoma, and orbital cellulitis.
. The diagnosis is highly suspected with US or CT scan findings of a mass with calcifications.
. strabismus:
_____________
. an esodeviation (medial deviation of the eye), which is the most common type of strabismus, representing over 50% of
all cases.
. Strabismus is the most common cause of amblyopia.
. The cover test: asking the child to fix his sight on a target as the examiner alternately covers one eye while observing
the movement of the other.
. A normal eye keeps the same position and does not move, whereas a misaligned eye shifts to refixate the object when
the normal eye is covered.
. The standard of treatment is occlusion of the normal eye.
. This procedure forces the affected eye to correct itself in order to be properly functional, thus stimulating proper
visual maturation.
. In case the amblyopia is secondary to abnormalities of refraction, appropriate lenses should be prescribed so as to
have a well-formed retinal image.
. The normal or less severely affected eye is then covered.
. If the amblyopia is caused by an opaque media, surgical removal of the media should be performed .before occlusion
therapy.
========================================================================= Neurology
==========================================================
. Night Terrors:
________________
. Occurs in young children 2-12 years during Non-REM sleep.
. Characherized by fear, craying or screaming, decreased level of consciousness.
. and amnesia of the event next morning.
N.B.:
- Todd's palsy is characterized by transient hemiplegia that occurs after a seizure.
. Migraine headaches:
_____________________
. are the most common cause of headaches in the pediatric population, occurring in 50% of cases before the age of 20
years.
. The aura can be visual (e g , blurred vision, scotoma, photophobia, distortion of objects) or
sensory (e g perioral paresthesia, numbness of extremities, shoulder pain, abdominal pain, otalgia).
. Migraine headache is a clinical diagnosis, and further investigations are not usually indicated.
. Neuroimaging is required only when there are behavioral changes, decline in school performance, decline in growth
parameters,
early morning headaches, seizures, orabnormal neurologic findings.
. In complicated migraines, neurologic signs (e g , basilar signs, ophthalmoplegia, or hemiparesis) may be present,
although the work-up reveals nothing abnormal.
. These neurologic symptoms may last only during the headache or persist for several days or weeks.
. Brain abscesses:
_________________
. can present with fever, headache, focal neurologic changes, seizure, spasticity, or signs of increased intracranial
pressure.
. Congenital heart disease (particularly right-to-left shunts), head trauma, infections of the jaw or mouth, infections of
the face or scalp, meningitis, and
cranial instrumentation increase the risk of developing a brain abscess.
. Absence (petit mal) seizures:
_______________________________
. Characterized by a sudden cessation, without warning, of ongoing mental activity.
. Each episode rarely lasts longer than 30 seconds.
. A typical absence seizure is characterized by brief (typically lasting for a few seconds) periods of impaired
consciousness.
. Patients may also present with automatisms, but do not have a post- ictal state.
. Hyperventilation during the EEG reveals a generalized 3Hz spike-and-wave pattern on a normal background.
. Minor motor symptoms are common, but complex automations and clonic activities do not occur.
. Best diagnosed with EEG studies.
. An EEG with activation procedures (hyperventilation, photic stimulation, sleep) helps in further diagnosis and
classification of seizures.
. Ethosuximide is used almost exclusively for childhood absence seizures & valproic acid is the 2nd choice.
.N.B:
- An atypical absence seizure lasts longer.
- The characteristic EEG pattern is slow spike-and-wave activity with a frequency less than 2.5Hz
. Seizures:
___________
. Seizures are classified as partial or generalized:
A) Generalized seizures involve the brain diffusely from the beginning of the event.
B) Partial seizures arise from a discrete focus in the brain.
. In Partial seizures there are initial symptoms related to a specific focus in the brain e.g. an unusual smell could be
classified as an olfactory hallucination,
referred to as an "aura" which is indicative of a partial seizure arising from a specific focus in the brain.
. Partial seizures can be further classified into simple partial seizures, complex partial seizures, and partial seizures
with secondary generalization.
1. Simple partial seizures: No Loss of consciousness.
2. Complex partial seizure: Loss of consciosness (failure to respond to various stimuli during the episode) +
automatisms during their loss of consciousness
as chewing, picking movements of the hands, or lip smacking.
- The EEG pattern is usually normal or may show brief discharges.
. Partial seizure with secondary generalization: usually have tonic-clonic manifestations.
. A post-ictal state lasting several hours can be seen with both complex partial seizures and partial seizures with
secondary generalization so this is not
a helpful differentiating factor.
. The presence of blood-tinged sputum is suggestive that the patient bit his tongue and would make a partial seizure
with secondary generalization more likely.
. Loss of bladder or bowel control is also more likely in seizures with secondary generalization.
. Phenytoin & carbamazepine are used as first-line drugs for ttt of 1ry generalized tonic-clonic seizures or partial
seizures with or without 2ndry generalization.
. Todd's paralys:
_________________
. Represents a postictal condition that usually rapidly improves with restoration of motor function within 24 hours.
. May follow generalized as well as focal seizures.
. The exact pathophysiology of this condition is not well understood, but most probably involves alteration in neuronal
electrical activity.
. It indicates that a structural abnormality underlying the seizure is present.
. Cephalohematoma:
__________________
. Is a subperiosteal hemorrhage; hence, it is always limited to the surface of one cranial bone.
. There is no discoloration of the overlying scalp, and swelling is usually not visible until several hours after birth
because subperiosteal bleeding is a slow process.
. Most cases do not require any treatment and resorb spontaneously within 2 weeks to 3 months, depending on the size.
. Rarely, phototherapy may be necessary to improve the hyperbilirubinemia.
.N.B.: Caput succedaneum:
. The key to evaluating a child with an epidural hematoma is to search for the presence of clinical features that
necessitate an emergent craniotomy.
. which include any of the following: GCS < 8, signs of increased ICP, pupillary abnormalities, hemiparesis, or
cerebellar signs.
. Febrile seizure:
___________________
. Diagnostic Criteria of Febrile seizures:
- Seizure associated with a temperature >38C (1004F).
- Age <6 years.
- No CNS infection, No acute systemic metabolic cause of seizure & No history of previous afebrile seizures.
. classified as: simple or complex.
. A simple febrile seizure is a generalized tonic-clonic seizure that lasts <15 minutes and usually occurs once in a 24hour period.
. It does not cause permanent brain injury or significantly increase the child's future risk of epilepsy.
. Although febrile seizures can recur, children who experience simple febrile seizures are less likely to have a
recurrence.
. A complex febrile seizure is diagnosed if the seizure is focal, lasts >15 minutes, or occurs more than once with a total
duration of seizure activity >30 minutes.
. Children with complex febrile seizures are at increased risk for future febrile or afebrile seizures, especially if there is
family history of epilepsy in a parent or sibling.
. Febrile seizures are associated with viral or bacterial infections (e.g. otitis media) However, serious intracranial
infections (e.g. meningitis) must be ruled out.
. Once an intracranial infection has been ruled out, the patient can be treated for the fever and underlying infection.
. The patient can then be discharged home with parental education about the use of antipyretics and seizure precautions.
. Cerebral palsy:
_________________
. Cerebral palsy is a non-progressive disorder characterized by impaired motor functioning.
. The most common cause is cerebral anoxia.
. Present as: hypotonia, hyperactive deep tendon reflexes, learning disabilities, along with an intrapartum history of
prolonged labor and low APGAR scores at birth.
. Hydrocephalus:
________________
. Symptoms: Poor feeding, irritability, decreased activity, Vomiting.
. Physical examination: Tense and bulging fontanelle, Prominent scalp veins, widely spaced cranial sutures, rapidly
increasing head circumference.
. The best diagnostic approach in symptomatic children with rapidly increasing head circumference is to perform
diagnostic imaging.
. A CT scan of the brain is the best initial choice in an infant who is acutely symptomatic & will reveal ventricular
dilation as well as the infant's anatomy.
. In otherwise stable and asymptomatic infant, a sedated MRI could be considered to spare the child radiation exposure.
. Both CT and MRI provide greater detail than ultrasound, which requires a widely open anterior fontanelle and is most
useful in infants under 6 months.
. Treatment: a shunt that is placed from the ventricle to the peritoneum, pleura, or right atrium; which allows the excess
CSF to drain.
. Guillain-Barre syndrome:
___________________________
. Suspect Guillain-Barre syndrome in a child who presents with an ascending polyneuropathy one week after an
apparent viral infection (e.g. diarrhea).
. The underlying pathology involves mainly the peripheral motor nerves, although sensory and autonomic nerves may
also be affected.
. Friedreich Ataxia:
_____________________
. an autosomal recessive condition and genetic counsel ing is recommended for prenatal diagnosis for parents with one
affected child.
. FA is associated with necrosis and degeneration of cardiac muscle fibers leading to myocarditis, myocardial fibros is
and cardiomyopathy.
. Cardiac arrhythmia and congestive heart failure contribute to a significant number of deaths.
. Klumpke's paralysis:
_____________________
. is a brachial palsy that occurs in newborns following excessive traction on the arm.
. It consists of hand paralysis and ipsilateral Homer's syndrome (ptosis and miosis).
. It is secondary to injury to seventh and eighth cervical nerves and first thoracic nerve.
. Confirmation MRI, which demonstrates nerve root avulsion or rupture.
. Treatment depends on the severity of the injury and, generally, it consists of partial immobilization and appropriate
positioning to prevent contractures.
. Gentle massages and range-of-motion exercises can be started by 7-10 days of age.
. If by 3-6 months there is no improvement, neuroplasty, neurolysis, end-to-end anastomosis, and nerve grafting may be
attempted.
. Erb-Duchenne palsy:
_____________________
. is another type of brachial palsy in which the injury involves the fifth and sixth cervical nerves.
. It presents with: absent Moro reflex and intact grasp reflex of the affected arm.
. Patients present with a characteristic position, which consist of adduction and internal rotation of the arm with
pronation of the forearm.
. Subarachnoid hemorrhage (SAH):
________________________________
. SAH can be caused by an intraventricular hemorrhage, which is common in premature infants.
. Accumulation of the blood in the subarachnoid space may lead to destruction of the arachnoid villi and cisterns,
thereby blocking the flow or decreasing the
absorption of CSF, and leading to communicating hydrocephalus.
. SAH is the most common cause of communicating hydrocephalus.
. CT scan: dilation of the entire ventricular system with distinct enlargement of the subarachnoid space over the
cerebral cortex is very suggestive of nonobstructive
or communicating hydrocephalus secondary to a subarachnoid hemorrhage (SAH).
.N.B:
- Dandy-Walker anomaly and Chiari malformation will both reveal CT findings consistent with obstructive or
noncommunicating hydrocephalus.
. Dandy-Walker Anomaly will demonstrate a cystic expansion of the fourth ventricle, and Chiari malformation will
reveal protrusion
of the structures of the posterior fossa through the foramen magnum.
===============================================================================
Hematology ===========================================================
. Acquired aplastic anemia:
___________________________
. present by: Normocytic or macrocytic anemia, Leukopenia, reticulocytopenia and thrombocytopenia.
. B.M. biopsy (essential for diagnosis) --> profound hypocellularity in all cells with fatty infiltration.
. Result from B.M. supression due to acquired or congenital causes:
A) Acquired Causes of Aplastic Anemia:
- Idiopathic.
- Drugs (e.g, NSAIDs, sulfonamides, etc).
- Toxic chemicals (e.g. benzene, glue, etc ).
- Viral infections (e.g. HIV, EBV, etc ).
- Immune disorders.
- Thymoma.
B) Congenital causes of aplastic anemia --> Fanconi's anemia.
. Fanconi's anemia:
____________________
. are more common in children, and Fanconi anemia (FA) is the most common congenital cause.
. It is an autosomal recessive or X-linked disorder associated with the clinical manifestations summarized below.
. Most patients with FA are diagnosed by the age of 16 years and have a predisposition for developing cancer.
. Numerous genes, all believed to involve DNA repair, have been implicated.
. Bone marrow: Aplastic anemia and progressive bone marrow failure.
. Appearance: Short stature, microcephaly, abnormal thumbs, upper limb anomalies, renal malformations and
hypogonadism.
. Skin: Hypopigmented/hyperpigmented areas, cafe au lait spots, and large freckles.
. Eyes/ears: Strabismus, low-set ears, and middle ear abnormalities (e.g. hemorrhage, incomplete development, chronic
infections, deafness, etc ).
. Diagnosis of FA is made by chromosomal breaks on genetic analysis combined with the clinical findings.
. The patient likely has bleeding secondary to thrombocytopenia, fatigue from macrocytic anemia, and pounding in his
ears
from possible conduction deifects or chronic hemorrhage.
. The definitive treatment for aplastic anemia is hematopoietic stem cell transplantation.
. Blood counts start to decrease at the age of 4-12 years.
. Intial manifestations: Thrombocytopenia followed by neutropenia then anemia.
. Diamond-Blackfan anemia (DBA): congenital hypoplastic anemia
______________________________
. Congenital pure red cell aplasia.
. Macrocytic anemia, low reticulocyte count, and congenital anomalies.
. The majority of cases are sporadic, although dominant and recessive inheritance is found in 15 % of cases.
. The primary pathology is an intrinsic defect of erythroid progenitor cells which results in increased apoptosis.
. Present in the 1st 3 months with pallor and poor feeding.
. Congenital anomalies: Cleft palate, webbed neck, sheilded chest, triphalangeal thumbs and cardiac anomalies.
. The macrocytic anemia of DBS is distinct from that of megaloblastic anemia as there is no hypersegmentation of the
nucleus in neutrophils & other blood cells in the former.
. Electrophoresis reveals elevated fetal Hb levels
. Chromosomal studies are normal.
. Therapy is mainly corticosteroids. For unresponsive patients, transfusion therapy is indicated.
. CBC --> Normocytic or macrocytic anemia with reticulocytopenia.
. WBCs and Platelet counts are normal.
. Transient Erythroblastopenia of childhood (TEC):
__________________________________________________
. Acquired red cell aplasia which occurs in healthy children between 6 months and 5 years.
. Gradual onset of symptoms as pallor and dcreased activity.
. Lab. --> Normocytic normochromic anemia with Hb level 3-8 mg/dl and extremely low reticulocytic count.
. Glucose-6-phosphate dehydrogenase (G6PD) deficiency:
__________________________________________________
. The most common RBC enzyme deficiency causing anemia is (G6PD) deficiency.
. In affected patients, oxidant drugs (e g , antimalarials and sulfas) and infection can cause episodic hemolysis.
. Thalassemias:
_______________
. Autosomal recessive disorders of hemoglobin seen most commonly in people of Mediterranean descent.
. Clinical symptoms can range from minor to severe depending on the number of globin chains that are affected.
. Individuals with thalassemia trait usually have no symptoms and are diagnosed when routine laboratory studies reveal
a microcytic anemia with a normal RDW.
. Clinically, thalassemia is confused with iron deficiency anemia; If microcytic anemia does not respond to empiric oral
iron therapy, iron studies should be done.
. If the patient has normal iron studies, which rules out iron deficiency and makes thalassemia trait much more likely.
. Hemoglobin electrophoresis can be performed to confirm the diagnosis.
. For individuals with thalassemia trait, no treatment is usually necessary.
. Sickle cell disease:
______________________
. Characterized by chronic hemolysis of sickled cells, leading to a high RBC turnover and anemia.
. Patients with sickle cell anemia will have sickle cells and reticulocytes on their peripheral blood smear.
. Reticulocytes are present because the bone marrow is attempting to compensate for the chronic hemolysis
characteristic of sickle cell anemia.
. Painful crisis, the most common manifestation of sickle cell anemia.
. These episodes due to intermittent vasoocclusion in connective tissue & muscle, are characterized by severe acute
pain & tenderness, fever, tachycardia, and anxiety.
. Hemolysis is mainly extravascular and leads to reticulocytosis, hyperbilirubinemia and elevated serum LDH with low
serum haptoglobin.
. The hematocrit is generally 20-30 percent, owing to the decreased RBC volume.
. Iron deficiency anemia is not common in SCD as the hemolysis of RBC is extravascular, and the iron is usually
restored and reused;
. however, iron deficiency secondary to increased utilization or urinary iron loss can be present in up to 20% of
patients.
. Megaloblastic anemia occurs in vitamin B12 or folic acid deficiency, which is not usually seen with SCD;
although folate deficiency secondary to increased folate utilization can be seen in some individuals.
. Anemia of chronic disease may occur in SCD if iron reuptake and use is decreased due to infection, inflammation or
some chronic illness.
. Iron deficiency, folate deficiency, and anemia of chronic disease occur less frequently in SCD patients.
. Sideroblastic anemia is seen in inherited or acquired defects affecting the biosynthesis of heme within red cell
precursors not related to SCD.
. Salmonella and Staph aureus are the most common cause of osteomyelitis in patients with sickle cell disease.
. Pneumococcal vaccination plus penicillin prophylaxis can prevent almost all cases of pneumococcal sepsis in patients
with sickle cell anemia.
. Those with sickle cell trait have some protection against malaria.
. Complications of sickle cell disease:
-------------------------------------. Sickle cell disease is a chronic, well-compensated hemolytic anemia with appropriate reticulocytosis.
. An acute drop in hemoglobin is can occur secondary to a hyperhemolytic crisis, splenic sequestration, or an aplastic
crisis.
1. An aplastic crisis: a transient arrest of erythropoiesis that results in a severe drop in hemoglobin and virtual absence
of reticulocytes on peripheral smear (reticulocytes < 1%).
. It may be caused by infections such as parvovirus 819.
. Treatment generally consists of a blood transfusion.
. It is important to note that an aplastic crisis in sickle cell disease differs from aplastic anemia, which occurs in other
patients & characterized by pancytopenia.
2. A hyperhemolytic crisis: is a rare complication of sickle cell disease that is characterized by sudden, severe anemia
accompanied by an appropriate reticulocytosis.
3. Splenic sequestration: occurs in sickle cell patients who have not yet developed auto-splenectomy.
. This is caused by vasoocclusion and pooling of red cells within the spleen, which may lead to severe hypotensive
shock.
. It is characterized by a dramatic drop in hemoglobin concentration that is accompanied by persistent reticulocytosis.
. The classic physical examination finding is a rapidly enlarging spleen.
. Splenic sequestration carries a mortality of 10-15% and a 50% chance of recurrence, so splenectomy is usually
recommended after the first episode.
4. Acute chest syndrome: is characterized by the presence of fever, chest pain, and an infiltrate on chest X-ray.
. The etiology of acute chest syndrome is thought to be multifactorial and related to pulmonary infarction and infection.
. While a drop in hemoglobin may be seen, severe anemia without associated reticulocytos is is not seen in acute chest
syndrome
5. A vasoocclusive (painful) crisis: is characterized by acute onset of pain and is caused by vasoocclusion secondary to
the sickling of red blood cells.
. These crises may be precipitated by changes in weather, dehydration, or infection.
. Treated by adequate hydration and opioid analgesics.
. Hydroxyurea is indicated in sickle cell patients with frequent, acute, painful episodes, as it tends to increase the Hb F
levels.
. Hb F: retard sickling, so increased HbF levels lead to reduced sickling of red blood cells and consequently, decrease
episodes of vaso-occlusion.
. Severe anemia and a low reticulocyte count are not seen in vasoocclusive crises
.N.B:
- patient has sickle cell trait, which is characterized by a Hb S concentration ranging from 35-40% (sickle cell disease
Hb S > 40%).
- Individuals with sickle cell trait have a heterozygous genotype (AS) and are generally asymptomatic.
- Symptoms occur very rarely, and the most common of these is painless hematuria.s
- In a patient with a chronic hemolytic anemia and compensatory reticulocytosis, increased demand for folic acid can
lead to folic acid deficiency,
- For this reason, patients with sickle cell anemia should be on folic acid supplementation
- vitamin B12 is also required However, in contrast to folic acid, B12 stores can be adequately maintained by most
every patient via diet alone.
. Hereditary Spherocytosis:
___________________________
. Is a common cause of hemolysis and hemolytic anemia in the newborn.
. Indicators of hemolysis: reticulocytosis and hyperbilirubinemia.
. A positive Coombs' test points towards autoimmune hemolytic anemia, and a positive osmotic fragility test indicates
hemolysis confirms hereditary spherocytosis.
. The peripheral smear may reveal anisocytosis and polychromatophilic reticulocytes and spherocytes.
. Microcytic anemia:
____________________
. caused by iron deficiency can often be differentiated from thalassemia by an elevated RDW, which is typically greater
than 20% in iron deficiency.
. The reticulocyte count is low in patients with iron deficiency due to decreased erythropoiesis.
. N.B: Howell-Jolly bodies:
-----. These bodies are nuclear remnants within RBCs that are typically removed by the spleen.
. They are present on peripheral blood smear as single, round, blue inclusions on Wright stain.
. Their presence indicates physical absence of spleen or functional hyposplenism due to splenic autoinfarction,
infiltrative disorders of spleen, or splenic congestion.
. Leukemia:
___________
. Leukemic patients can present with numerous infections, diarrhea and failure to thrive.
. Although such patients present with more serious bacterial and fungal infections.
. Hepatomegaly and splenomegaly may be found.
. Laboratory studies reveal: leukocytosis, thrombocytopenia and anemia. Other findings may include
hyperuricemia,hyponatremia, elevated LDH and hypokalemia.
. Acute lymphoblastic leukemia:
______________________________
. Acute lymphoblastic leukemia is the most common leukemia in children.
. The first symptoms are nonspecific: anorexia, irritability and lethargy.
. Patients may have a history of viral respiratory infection or exanthem from which they do not fully recover.
. On physical examination, there may be pallor, hepatosplenomegaly, petechiae, and/or lymphadenopathy.
. Diagnosis of leukemia is suggested by presence of anemia, thrombocytopenia and blast cells on peripheral blood
smear, but is confirmed by B.M. examination.
. Lymphoblasts lack peroxidase positive granules but often contain cytoplasmic aggregates of periodic acid Schiff
(PAS) positive material.
. Immunostaining for terminal deoxynucleotidyltransferase (TdT) is positive in more than 95% of patients TdT is
expressed only by pre B and pre T lymphoblasts.
. Myeloblasts on the other hand contain peroxidase positive material.
. Acute myeloid leukemia (AML):
______________________________
. Seen more commonly in adults.
. It can present similarly to ALL with anemia, thrombocytopenia and high WBC count.
. The main differentiating and diagnostic factor is demonstration of greater than 25% of myeloblasts in the bone
marrow.
. Chronic lymphocytic leukemia (CLL):
__________________________________
. usually presents in elderly patients.
. with fatigue, lymphadenopathy and splenomegaly.
. Labs show lymphocyte count of greater than 5000/mm3, made of mature-appearing cells.
. Hodgkins' disease (HD):
_________________________
. The most common presenting sign is Painless, firm, cervical or supraclavicular adenopathy.
. Depending on the extent and location of nodal and extranodal disease, there maybe symptoms and signs of airway
obstruction, pleural or pericardial effusion,
hepatocellular dysfunction, or bone marrow infiltration.
. Although signs and symptoms are similar to ALL, presence of lymphoblasts makes ALL most probable.
. Burkitt lymphoma:
___________________
. It is a neoplasm of mature B cells. It is associated with the Epstein-Barr virus infection.
. Most patients present with either a mass involving the mandible or abdominal viscera.
. High mitotic index is typical. Histological examination shows characteristic "starry sky appearance".
. It is a very aggressive tumor but responds well to the high dose chemotherapy.
. Myelodysplastic syndromes (MOS):
__________________________________
. They are clonal stem cell disorders which may progress to acute leukemias.
. These are usually seen in elderly patients, and are characterized by pancytopenia.
. Henoch-Schonlein Purpura:
___________________________
. Is an lgA-mediated vasculitis of small vessels, affecting children more than adults.
. Many cases follow an upper respiratory tract infection.
. The clinical manifestations: a classic tetrad of rash, arthralgias, abdominal pain, and renal disease.
. The rash is typically purpuric and distributed symmetrically over the lower legs, buttocks and arms.
. Arthralgias most commonly affect the knees and ankles, these symptoms are always transient, and there is no
permanent damage to the joints.
. GIT symptoms most commonly colicky abdominal pain (mostly due to local vasculitis) that is frequently associated
with vomiting,
. Two common pathologies which should be ruled out emergently are GI bleeding and intussusception ( a surgical
emergency, and is treated with air/barium enema).
. Renal involvement relatively mild disease characterized by asymptomatic hematuria & proteinuria with a normal or
slightly elevated plasma creatinine; however,
. More marked findings may occur including the nephrotic syndrome, hypertension, & acute renal failure (treatment
includes steroids and monitoring of renal function).
. Other organs as the lung and central nervous system, may be involved.
. Confirmation of the diagnosis requires evidence of tissue deposition in the skin or kidney of lgA by
immunofluorescence microscopy.
N.B.:
1- Minimal change disease: electron microscopy uasually shows Podocyte fusion in the glomerulous.
2- Membranous nephropathy: electron microscopy shows Glomerular basement thickening & is considered the most
common cause of adult nephrotic syndrome.
3- focal segmental glomerulosclerosis: electron microscopy shows Focal and segmental sclerosis.
4- Goodpasture's syndrome: electron microscopy shows Linear deposition of lgG on the basement membrane is seen.
. Lymphadenitis in children:
_____________________________
. Cervical lymphadenopathy is common in children.
. Lymphadenitis is diagnosed when the lymph node becomes tender and erythematous in addition to being enlarged.
. Lymphadenopathy maybe acute or subacute/chronic, and unilateral or bilateral.
. Acute, unilateral lymphadenitis in children is usually caused by bacterial infection.
. Staphylococcus aureus is the most common followed by group A streptococcus.
. Patients with bacterial lymphadenitis are usually less than 5 years old and nontoxic appearing.
. The affected lymph node is tender, warm, erythematous, and usually 3 to 6 cm in size.
_______________________________________
. Is a defect of phagocytic cells due to dysfunction of the NADPH oxidase enzyme complex (impaired oxidative
metabolism within the phagocytes) leading to:
. Recurrent and uncontrolled infections with catalase-positive organisms, as S. aureus, Serratia marcescens,
Burkholderia cepacia, Klebsiella, and Aspergillus sp.
. Patients are not susceptible to catalase-negative organisms (Streptococcus pyogenes, Streptococcus pneumoniae, and
Haemophilus influenzae).
. CGD should be suspected in all patients presenting with unexplained infections caused by Aspergillus, Serratia
marcescens, and Burkholderia cepacia.
. The most common findings are lymphadenopathy, hypergammaglobulinemia, hepatomegaly, splenomegaly, anemia of
chronic disease,
underweight, chronic diarrhea, short stature, gingivitis, and dermatitis.
. Neutrophilic functions such as chemotaxis, phagocytosis and degranulation are intact in these patients; only
intracellular killing is deficient.
. Thus neutrophils filled with bacteria are a classic finding on Gram stain.
. The diagnosis is made by nitroblue tetrazolium (NBT) slide test, flow cytometry, or cytochrome C reduction.
. Treatment includes prevention of infection with daily trimethoprim-sulfamethoxazole and gamma-interferon three
times a week.
. Bone marrow transplantation is experimental but curative.
. Wiskott-Aldrich syndrome (WAS):
__________________________________
. An X-linked disorder characterized by the triad of thrombocytopenia, eczema, and recurrent bacterial infections.
. Recurrent infections are usually due to Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus
influenzae.
. The thrombocytopenia is caused by decreased platelet production, and the few platelets that exist are typically quite
small.
. Platelet counts in patients with WAS are typically less than 50,000/mm3 and the mean platelet volume is also usually
reduced.
. Decreased platelet production is the primary pathophysiologic cause of thrombocytopenia in patients with WAS.
. Idiopathic thrombocytopenic purpura ( ITP):
_____________________________________________
. An immune-mediated disorder caused by antibodies that bind to platelets and facilitate their removal from the
circulation.
. Affected children typically present with easy bruisability or bleeding.
. Intraventricular hemorrhage ( IVH):
_____________________________________
. IVH is most commonly seen in premature and LBW infants.
. Patients may present with pallor, cyanosis, hypotension, seizures, focal neurologic signs, bulging or tense fontanel,
apnea and bradycardia.
. However, many cases remain asymptomatic, thus mandating transfontanel ultrasound for all newborns with
predisposing risk factors.
. Studies have shown that the incidence of IVH is inversely proportional to birth weight (the lower the birth weight, the
greater the likelihood of IVH).
. Pelvic dystocia, prenatal infections, congenital anomalies, and macrosomia are not directly incriminated in IVH.
. Hemorrhagic disease of the newborn (HDN):
___________________________________________
. Routine perinatal care, includes parenteral injection of vitamin K after delivery.
. This shot is given to prevent hemorrhagic disease of the newborn (HON), a potential consequence of vitamin K
deficiency.
. Humans obtain vitamin K from two sources diet and via the gut flora.
. Deficiency in newborn babies is the result of poor placental transfer, absent gut flora, and inadequate levels in breast
milk.
. HDN results from deficiency of vitamin K-dependent clotting factors (II, VII, IX, X).
. Signs include bruising, bloody stools, and (less commonly) intracranial hemorrhage.
. Prolonged PT and PTI support the diagnosis, but the diagnosis is confirmed by reversal of symptoms with vitamin K
administration.
. Mild vitamin K deficiency may present with an elevated PT level and a normal PTT level.
. Polycythemia:
_______________
. Defined as a central venous hematocrit level greater than 65%.
. The most common cause of polycythemia in term infants is delayed clamping of the umbilical cord resulting in excess
transfer of placental blood.
. As the hematocrit rises, the viscosity of the blood increases as well as the arterial oxygen content, this change in blood
flow may affect various organs.
. In newborns, the hematocrit level peaks within 12 hours of birth and then decreases over the subsequent 12 hours.
. Not all infants with polycythemia become symptomatic However, symptomatic infants may present with
manifestations to any organ.
. The most common findings are plethora and CNS disturbances like lethargy, irritability, jitteriness, and seizures.
. Other common symptoms are respiratory distress, tachypnea, and cyanosis, caused by the decrease in pulmonary
blood flow due to the hyperviscosity of blood.
. Poor feeding, hypoglycemia, and hypocalcemia are also commonly seen in polycythemic infants.
. Treatment includes hydration and, if symptomatic, partial exchange transfusion.
. Purpura in children:
______________________
. The common causes of purpura in children: thrombocytopenia, clotting factor deficiencies, and vasculitis.
. Nearly 2.5% of the normal population have a platelet count of< 150,000/?L, and clinical manifestations of
thrombocytopenia (e g petechiae, purpura) usually do
not occur unless the platelet count is < 100,000/?L.
. Common clotting factor deficiencies causing purpura in children: van Willebrand disease, hemophilia A (factor VIII
deficiency) & hemophilia B (factor IX deficiency).
. These conditions do not usually cause abdominal pain and other renal findings (proteinuria).
. If there is no thrombocytopenia (paltelets > 100.000), then vasculitis should be high in suspecious, especially if there
is no abdominal pain or renal affection.
. Henoch Schonlein purpura (HSP): a small vessel vasculitis that usually presents with the classic tetrad
. lower extremity palpable purpura, arthritis/arthralgias, abdominal pain, and renal disease.
. HSP is the most common form of systemic vasculitis in children.
. 50% of patients develop HSP after upper respiratory infection & have other nonspecific symptoms as subcutaneous
edema, joint pains, bloody stools, and scrotal edema.
. Small bowel intussusception is a common complication of HSP.
. Laboratory testing is usually normal (including a normal platelet count), although hematuria or proteinuria may be
found.
. Diagnosis is usually based on clinical findings, and skin biopsy is rarely necessary.
. Treatment is usually supportive, but NSAIDS are sometimes given to abdominal pain.
.N.B: Purpura fulminans:
- seen with bacterial infections (e.g. N. meningitidis, S. pneumoniae) However, patients are usually very ill with fever,
hypotension, and evidence of DIC.
. Immune thrombocytopenia:
________________________
. usually occurs in children between 2 and 6 years of age.
. The pathogenesis involves antibodies that bind to platelets, and subsequent destruction of these complexes in the
spleen.
. The condition is usually preceded by a viral infection and presents with purpura, petechiae, hematuria or GI bleeding
& there is no adenopathy.
. Laboratory studies usually show no abnormalities, except thrombocytopenia.
. The course is self-l imited, and spontaneous recovery occurs in the majority of patients.
. There is controversy on treatment, but corticosteroids are drugs of choice in all age groups for thrombocytopenia less
than 30,000/mm3, and/or for severe symptoms.
. Patients with a platelet count of more than 30,000/mm3 usually have very few symptoms and do not require treatment
(Observation).
. Hemophilia:
_____________
. Presence of spontaneous hemarthrosis and soft tissue hematomas raise the suspicion for hemophilia, for which factor
VI 11 assay is diagnostic.
. Spontaneous hearthrosis is very unlikely with any other form of bleeding disorder, including Von Willebrand's
disease.
. The best next step is a complete set of coagulation studies followed by factor VIII and IX levels.
. Prolonged PTI, normal prothrombin time, normal bleeding time, normal fibrinogen level and low serum factor VIII
activity are the typical lab findings.
. The standard treatment for hemophilia is to replace the factor VIII.
. However, mild hemophilia may be treated with desmopressin (DDAVP), which causes release of factor VIII from the
endothelial cells.
. Leukocyte adhesion defect:
____________________________
. An immune deffeciency disease present with: recurrent bacterial infections and necrotic periodontal infection.
. Delayed separation of the umbilical cord (>3 weeks) is characteristic and presents an important clue to the correct
diagnosis.
. The leukocytes fail to express some adhesion molecules on their surface.
. The leukocyte number is increased, but the inter-leukocyte communication is defective; therefore, chemotaxis and
cytotoxicity are impaired.
. Normal lymphocyte count and gamma globulin concentration help to differentiate this condition from a variety of cell
and/or humoral immune defects.
. Hemolytic uremic syndrome: Extremely high-yield question for the USMLE!!!
____________________________
. It is usually preceded by an acute diarrheal illness due to the pathogens Escherichia coli serotype 0157 H7, Shigella,
Salmonella, Yersinia, and Campylobacter.
. It is less commonly preceded by an upper respiratory infection.
. GI bleeding is common, Physical examination frequently reveals purpura and hypertension.
. The hallmark finding is microangiopathic hemolytic anemia.
. Other typical features: acute renal failure, fever, oliguria (or anuria) and thrombocytopenia
. The peripheral smear reveal schistocytes (which represent fragmented RBCs) and giant platelets.
. lntravascular hemolysis results in elevated levels of (LDH) and indirect bilirubin, as well as reticulocyte count BUN
and creatinine levels are markedly elevated.
. Moderate leukocytosis may be present.
. The urine contains hemoglobin, hemosiderin, albumin, RBCs, WBCs, and casts.
. Suspect HUS when: a diarrheal illness and presents with acute R.F., microangiopathic hemolytic anemia, fever,
thrombocytopenia and peripheral smear of schistocytes.
.N.B:
- Howell-Jolly bodies: are nuclear remnants of RBCs present in sickle cell atients & are generally removed by a
functioning spleen.
- Their presence in peripheral smear suggests functional asplenia in sickle cell patients (Sickle cell patients usually have
infarcted spleens by the first 18 to 36 months of life).
- Heinz bodies: are aggregates of denatured hemoglobin & are commonly seen in patients with hemolysis due to G6PD
deficiency and thalassemia
- Helmet cells are fragmented red blood cells, their presence is suggestive of traumatic hemolytic conditions such as
DIC, HUS and TIP.
- Basophilic stippling are ribosomal precipitates which appear as blue granules & seen with thalassemias, as well as
lead or heavy metal poisoning.
=========================================================== Pulmonary
=====================================================================================
==
. Pseudomonas Aeruginosa :
________________________
. Is a common cause of severe pulmonary infection in patient with cystic fibrosis (CF).
. So the best treatment for a patient with severe exacerbation of cystic fibrosis is
combination of aminoglycosides (Tobramycine) and antipseudomonas penicillines (piperacillin).
.N.B.: Staphylococcal aureus is a frequent cause of mild pulmonary infection in patient with cystic fibrosis SO;
when pulmonary infection is mild (cough and mucous production only) oral anti-staphylococcal antibiotic is
preferred (Dicloxacillin).
.N.B.:
- Mothers with gestational diabetes mellitus (GDM) usually give birth to large babies with the most common
complications:
- Clavicular fracture which is usually greenstick fracture and heal rapidly without complications.
. The characteristic laboratory findings of:
____________________________________________
1) Iron deficiency anemia are: decreased serum iron, decreased percent of saturation (serum iron/ TIBC) & increased
TIBC.
2) Sideroblastic anemia: is characterized by increased serum iron levels and normal TIBC.
3) In dimorphic anemia: two distinct forms of red cells are circulating
4) Megaloblastic anemia is characterized by an elevated MCV, elevated MCH, and normal MCHC.
5) Anemia of chronic disease is associated with decreased TIBC.
. Cystic fibrosis:
________________
. Is an autosomal recessive disorder that is more common in Caucasian people.
. The cause is a defect in the CFTR (Cystic fibrosis transmembrane conductance regulator) protein, which leads to
impaired chloride transport in tissues
. and consequent multi-system involvement, particularly:
(1) increased salt content in sweat gland secretions.
(2) thick, viscous secretions in the lungs, pancreas, reproductive tract, and liver.
. Young child presents with recurrent upper respiratory tract infection, persistent nasal discharge and bilateral nasal
polyps.
. Also can be present with recurrent upper respiratory tract infections, bronchiectasis and failure to thrive.
. The patient may have pulmonary manifestations, which begins as a persistent, productive cough, and progresses to
obstructive airway disease.
. A deficiency of pancreatic enzymes leads to fat and protein malabsorption, thereby causing bulky, greasy, foulsmelling stools and
subsequent deficiency of fat-soluble vitamins (A, D, E and K).
. Vitamin A deficiency presents as dry skin, and Vitamin K deficiency presents as epistaxis.
. Vitamin K is an important cofactor of several coagulation factors factors II , VII , IX, and X as well as proteins C and
S.
. Failure to thrive is the result of chronic malabsorption from pancreatic insufficiency.
. Other possible presentations are meconium ileus at birth and infertility.
. Meconium ileus is virtually diagnostic for cystic fibrosis, an autosomal recessive disorder.
. A mutation of a single gene localized on chromosome 7 is responsible for this disorder.
. patient is suffering from an acute exacerbation of lung disease, and his presentation (shortness of breath, excessive use
of accessory respiratory muscles, hypotension) suggestive of severe attack.
. The most common etiologic agent is Pseudomonas aeruginosa.
. The three most common organisms that cause pneumonia in patients with cystic fibrosis are Haemophilus,
Pseudomonas, and Staphylococcus.
. The treatment is rapid administration of empiric antibiotics and the usual choice is a combination of two agents with
coverage against Pseudomonas aeruginosa,
(ceftazidime or a penicillin derivative such as ticarcillin + an aminoglycoside such as amikacin or gentamicin).
.N.B: It is essential to memorize the following for the USMLE
- Gram-positive diplococci - Streptococcus pneumoniae.
- Gram-positive cocci in clusters - Staphylococcus.
- Gram-negative cocci - Neisseria.
- Gram-positive rods - Listeria and Bacillus.
- Gram-negative rods - Pseudomonas, Haemophilus, Klebsiella, Legionella.
. Pertussis:
____________
. Caused by Bordetella pertussis infection.
. It is a highly contagious infection, but its incidence has dramatically decreased today because of immunization.
. It usually presents with severe bouts of coughing spells after an upper respiratory tract infection.
. The coughing spells can be so severe that they can cause rectal prolapse, epistaxis and pneumothoraces.
. These spells may last from two to ten weeks
. In patients with apparent subcutaneous emphysema secondary to severe coughing paroxysms, chest x-rays must be
obtained first to rule out pneumothorax(same mechanism).
. Presence of leukocytosis with predominant small and normal-appearing lymphocytes further supports the diagnosis.
. The recommended first line treatment is a macrolide antibiotic (erythromycin, azithromycin, or clarithromycin),
regardless of the age or the immunization status.
. Treatment is given whenever pertussis is suspected or confirmed, and regardless of the stage of the disease.
. For pertussis prevention, all close contacts should be given erythromycin for 14 days, regardless of age,
immunizations, or symptoms.
. Foreign body aspiration:
__________________________
. A sudden onset of respiratory distress may be caused by foreign body aspiration.
. Direct laryngoscopy & rigid bronchoscopy is the procedure of choice for both diagnostic and therapeutic purposes.
. It affects 50% of children in the 1st 2 years of life, especially those who are prone to airway reactivity, & there is
increased incidence of asthma later in life.
. The WBC count is normal, and the chest x-ray may show air trapping or atelectasis.
. The treatment is supportive care with humidified oxygen and bronchodilators.
. Ribavirin may be administered in high- risk children.
================================================================== Rheumatology
===============================================================================
. Septic Arthritis:
___________________
. Septic arthritis can occur following skin or upper respiratory tract infections.
. Arthrocentesis is both diagnostic and therapeutic, and is mandatory in all suspected cases.
. Blood cultures and synovial fluid cultures must be obtained prior to administering the antibiotics.
. Empiric antibiotic therapy ( IV nafcill in or IV cefazolin) should be started with pending synovial fluid cultures.
. Clubfoot (talipes equinovarus):
______________________________
. Presents with equinus and varus of the calcaneum and talus, varus of the midfoot, and adduction of the forefoot.
. This is a common foot deformity and may be congenital, teratologic, or positional (in utro).
. Initial treatment involves, stretching and manipulation of the foot, followed by serial plaster casts, malleable splints, or
taping.
. Because conservative treatment corrects the majority of cases, so Surgical treatment is indicated if conservative
management
gives unsatisfactory results, and is preferably performed between 3 and 6 months of age.
. Remember that the treatment of clubfoot should be started immediately.
. Spondylolisthesis:
____________________
. Is a developmental disorder characterized by a forward slip of vertebrae (usually L5 over S1 ) that usually manifests in
preadolescent children.
. In the typical clinical scenario, back pain, neurologic dysfunction (e g , urinary incontinence), and
a palpable "step-off" at the lumbosacral area are present if the disease is severe.
. Hemophilic arthropathy:
_________________________
. patients with coagulopathies (Hemophilia) --> Recurrent hemarthroses may then lead to a joint injury called
"hemophilic arthropathy".
. Although the exact mechanism underlying the joint damage is not known, iron deposition and synovial thickening
with fibrosis are characteristic.
. Iron deposition and cytokines released from the blood stimulate synovial proliferation, fibrosis and cartilage injury.
. Growing pains:
________________
. Common in children between the ages of two and twelve.
. It is usually poorly localized and common in the legs below the knees and bilateral.
. It awakens the child at night and responds to reassurance, massages or analgesics.
. In all cases, it resolves in the morning.
. The diagnosis of growing pain is a diagnosis of exclusion, all the physical and laboratory findings are negative.
. X- rays are not required if the physical exam is unremarkable.
. All such children are observed, and parents are assured that this condition will resolve with time.
. Transient synovitis:
______________________
. Is a frequent cause of hip pain in children, typically occurring in male children ages 3-10 years old.
. The cause of transient synovitis is unknown, but the condition usually follows mild trauma or viral infection.
. Transient inflammation of the joint synovium leads to pain and decreased range of motion.
. Patients usually have a history of a recent viral infection and present with a limp and/or unilateral hip or knee pain A
low grade fever may be present, but
patients are generally afebrile.
. On examination, the affected hip will be flexed, slightly abducted, and externally rotated, There is mild limitation of
motion.
. The patient may complain of pain with palpation or passive motion.
. Laboratory findings characteristic of transient synovitis include a slightly elevated white blood cell count and
erythrocyte sedimentation rate.
. Four clinical criteria have been shown useful in differentiating septic arthritis from transient synovitis;
white blood cell count > 12,000/mm3; temperature > 39C (102F); erythrocyte sedimentation rate > 40 mm/h; and
refusal to bear weight.
. If at least three of these four criteria are met, further work-up is indicated to rule out septic arthritis.
. Radiographs of the hip should be done to exclude bony lesions and Legg-Calve-Perthes disease.
. Widening of the joint space or an enhanced pericapsular shadow may be seen with transient synovitis.
. Additional work-up is not usually necessary, unless the diagnosis is uncertain.
. Treatment consists of rest and non-steroidal anti-inflammatory medications (NSAIDs).
. Most patients experience resolution of symptoms within several days, although transient synovitis may contribute to
the development of arthritis later in life.
. Compartment syndrome:
_______________________
. supracondylar humerus fractures may be complicated by neurovascular injury or compartment syndrome.
. Compartment syndrome is characterized by severe pain, pallor, poikilothermia, paresthesias, and the late findings of
pulselessness and paralysis.
. Patients with predisposing injuries should be continually monitored for the development of compartment syndrome,
particularly as swelling from the injury increases.
. Initial treatment includes removal of any bandages, measurement of compartment pressures, and emergent orthopedic
evaluation for possible fasciotomy.
. N.B.:
1- The United States Preventive Services Task Force (USPSTF) recommends vision screening for children aged 0-5
years,
primarily to identify those with strabismus, amblyopia, and refractive errors.
Early diagnosis and treatment are being emphasized, because poor visual acuity resulting from the above conditions
may impair
a child's future academic performance and selfimage,and may even lead to blindness.
2- Lead toxicity causes microcytic anemia and permanent neurologic damage, so identification of affected patients is
desirable at an early stage.
Risk factors for environmental lead exposure include minority race or ethnicity, low socioeconomic status, pre-1950
housing,
occupational exposure from parents, and recent immigration.
- The USPSTF recommends no screening for asymptomatic children aged 1-5 years at average (no) risk of lead
toxicity.
3- The Centers for Disease Control (CDC) recommend beginning the meningococcal vaccination series between 11-12
years.
Children who are at high risk of the disease (i.e , asplenic) may be vaccinated as early as 2 years of age.
4- The CDC recommends administering the rotavirus vaccine between 2 and 8 months.
_________________________________
. Differential diagnosis for a lytic bone lesion in a child:
- infectious (Brodie abscess from osteomyelitis), - endocrine (hyperparathyroid osteitis fibrosa cystica),
- neoplastic (Ewing sarcoma, Langerhans cell histiocytosis, metastases) and - idiopathic (benign bone cyst, aneurysmal
bone cyst).
. If there is concomitant hypercalcemia, it narrows the differential diagnosis to hyperparathyroid state versus lytic bone
neoplasm.
. Parathyroid adenoma is the most common cause of primary hyperparathyroidism, and typically occurs in patients over
50 years of age.
. A lytic bone lesion is most likely occurs in children.
. Langerhans cell histiocytosis (LCH, Langerhans cell granulomatosis, histiocytosis X) is known to causes solitary,
lytic, long bone lesions.
. Eosinophilic granuloma, the least severe form of histiocytosis X, generally presents in children and young adults as a
solitary bone lesion.
. This lesion may be painful, have overlying tender swelling, and cause pathological fractures.
. Though these tumors can be locally destructive, they typically resolve spontaneously and are therefore regarded as
benign and treated conservatively.
. Aseptic necrosis of the femoral head: Extremely high yield question for USMLE!!!
_______________________________________
. Osteonecrosis = A vascular necrosis.
. is a common complication of sickle cell disease.
. It involves occlusion of end arteries supplying the femoral head, bone necrosis, and eventual collapse of the
periarticular bone and cartilage.
. The femoral head has two main sources of blood supply - ascending arteries and the foveal artery, which lie within the
ligamentum teres.
. The foveal artery is patent early in life, but may become obliterated in older patients.
. This explains why aseptic necrosis of the femoral head is uncommon in children.
. Traction apophysitis (Osgood-Schlatter disease):
__________________________________________________
. is a common cause of knee pain, particularly in adolescent male athletes.
. During early adolescence (ages 13-14 for males, and ages 10-11 for females), there are periods of rapid growth in
which
the quadriceps tendon puts traction on the apophysis of the tibial tubercle where the patellar tendon inserts.
. This traction apophysitis is worsened by sports that involve repetitive running, jumping, or kneeling, and it improves
with rest.
. Approximately 1/4 of affected individuals have bilateral disease.
. Physical examination, there is edema and tenderness over the tibial tubercle,a firm mass can sometimes be felt due to
heterotopic bone formation.
. Pain can be reproduced by extending the knee against resistance.
. Radiographic findings are nonspecific: anterior soft tissue swelling, lifting of tubercle from the shaft, and irregularity
or fragmentation of the tubercle.
. Treatment consists of activity restriction, stretching exercises, and non-steroidal anti-inflammatory medications.
. Clavicular fracture in neonat:
_________________________________
. Clavicular fracture presents with irregularity, crepitus, and fullness over the fracture site, and decreased movements of
the arm.
. Predisposing factors are shoulder dystocia, traumatic delivery, and large size of the infant.
. Generally, no specific treatment is required (reassurance).
antibiotic therapy.
. Septic joint in a child is a true surgical emergency and needs immediate drainage.
. A delay of even 4-6 hours can lead to avascular necrosis of the femoral head.
. Lyme arthritis:
_________________
. occurs as a result of untreated Lyme infection. It is caused by Borrelia burgdorferi, a spirochete carried by the deer
ticks.
. It spreads via blood to various areas of the body, including the joints.
. The early symptoms are mild and are easily overlooked, arthritis is the hallmark of late disease.
. It tends to involve the knee in most patients Warmth, swelling from effusion and restriction of movements
differentiate it from arthralgias, which occur early in the disease.
. The first episode occurs within six months of having erythema migrans, the episodes gradually disappear in about ten
years, if left untreated.
. In United States, Lyme disease is prevalent in: Connecticut, Rhode Island, New York, Pennsylvania, New Jersey,
Delaware, Maryland and Wisconsin.
. Slipped capital femoral epiphysis (SCFE):
___________________________________________
. is a common hip disorder seen in adolescents.
. SCFE occurs when the capital femoral epiphysis displaces from the femoral neck.
. Boys > girls, and the usual age is 10 to 16 years old.
. Obesity is a significant risk factor, additional risk factors: hypothyroidism, panhypopituitarism, and growth hormone
deficiency or supplementation.
. Children with endocrine issues are more likely to have bilateral disease and to present at an earlier age.
. Commonly present with an insidious onset of knee or hip pain and a limp, usually without a history of trauma.
. Sometimes, minor trauma can increase the pain and bring the patient to medical attention.
. Patients tend to hold the hip in passive external rotation and exhibit decreased internal rotation, abduction, and flexion.
. Diagnosis is made with plain radiographs of the hip (AP and frog leg lateral views), which show the posteriorly and
inferiorly displaced femoral head.
. Treatment: emergent orthopedic consultation and surgical fixation at the current degree of slippage to avoid the risk of
avascular necrosis.
. Supracondylar fractures:
__________________________
. are the most common fractures in the pediatric population.
. The most common complication is entrapment of the brachial artery, resulting in loss of the radial artery pulse.
. therefore, all patients with a supracondylar fracture must have their radial pulse checked.
. After reduction of the fracture, the radial pulse must be reassessed.
. Duchenne muscular dystrophy:
______________________________
. should be suspected in a child under the age of 5 who presents with proximal muscle weakness (difficulty climbing
stairs),
Gower's sign (use his hands to "walk up" his legs in order to assume an upright position), diminished reflexes, and
pseudohypertrophy of the calf muscles.
. Mental retardation.
. Cardiomyopathy.
. Serum CK (and aldolase)levels are used for screening the muscular dystrophies.
. Muscle biopsy can confirm the diagnosis in most cases.
. The gold standard is genetic studies, which is required in atypical cases.
. Prognosis: most of patients are wheelchair bound by age of 12 years.
============================================================ GIT
==================================================================================
. Congenital abdominal wall defects:
____________________________________
. Diagnosis Congenital abdominal wall defects can be made antenatally with maternal serum-AFP measurements and
ultrasonography.
. The two types of abdominal wall defects are described in the table below:
* Gastroschisis:
----------------
. Bowel protrudes through a defect on the right side of the umbilical cord.
. Bowel is not covered by a protective membrane.
. Bowel looks "angry" and matted.
. Not typically associated with any other abnormalities outside the GI tract.
. If the diagnosis was made antenatally, management would begin with planned spontaneous vaginal delive ry at a
tertiary neonatal surgical unit,
. Caesarean section is performed only in the presence of the usual obstetric indications.
. After delivery, the next step in management is to immediately wrap the exposed bowel with sterile saline dressings
and
. Cover with plastic wrap in order to prevent insensible heat and large fluid losses.
. The neonate is then maintained in a thermo-neutral environment.
. Further steps in the management of gastroschisis include inserting an orogastric tube (to decompress the stomach),
establishing peripheral intravenous access (to
provide fluids), and administration of broad-spectrum antibiotics.
. Definitive treatment is surgical; however, surgery should be preceded by the above measures.
. Primary closure is successful in 70% of neonates, but if it is unsuccessful, staged closure with Silastic silo can be
used.
* Omphalocele:
-------------. Intra-abdominal contents protrude through the umbilical ring The abdominal herniat ion usually includes small bowel
and may include large bowel and liver.
. Bowel is covered by an amnioperitoneal membrane.
. This scenario is suggestive of celiac disease, which is also called gluten-sensitive enteropathy.
. It is due to abnormal hypersensitivity to gluten and presents characteristically at 12-15 months of age, when glutencontaining foods
such as wheat, rye or barley are introduced into the child's diet.
. Pyloric stenos:
_________________
. Is a common congenital anomally typical presentation is non-bilious projectile vomiting which gradually becomes
more frequent and
forceful in a 4-8 week old infant Pertinent physical findings are a palpable abdominal mass and visible peristaltic
waves in the upper abdomen.
. Hypokalemic alkalosis occurs due to the frequent episodes of vomiting.
. Abdominal ultrasound is the most useful tool for confirming the diagnosis, and shows a thick hypoechogenic ring in
the pyloric region.
. Additionally, the loss of large volumes of fluid via vomiting leads to contraction alkalosis due to the action of
aldosterone.
. In order to compensate for the metabolic alkalosis, the respiratory system responds via hypoventilation to create a
secondary respiratory acidosis.
. i.e. have a primary metabolic alkalosis with respiratory compensation.
. This is characterized by a plasma pH greater than 7.45, PaC02 greater than 40 mm Hg and HC03- greater than 24
mEq/L.
. Pyloric stenosis is treated su rgically; however, surgery should be undertaken only after the infant's hydration status
and electrolyte levels have been stabilized.
. Meckel's diverticulum:
________________________
. Typically presents with painless melena in 2 to 3-year-old children.
. It is present in 2-3% of the population, and is the most common anomaly of the GIT.
. It results from the failure of the vitelline duct to obliterate during the fetal development.
. Heterotropic gastric tissue may be present in the diverticulum, which results in ulcerations and bleeding.
. The diagnosis of a Meckel's diverticulum is best made with technetium-99m pertechnetate scanning (uptake by
heterotopic gastric mucosa).
.N.B.:
1- Peptic ulcer disease may present in preschool children with epigastric pain related to meals with a positive family
history.
2- Anal fissure is a painful condition associated with constipation it may occur in infancy, and presents with blood
streaked stools.
3- lntussusception may present in an infant or a young child with irritability, vomiting, red currant-jelly stools and
abdominal mass.
4- Inflammatory bowel disease may present in preschool children with diarrhea, abdominal pain, low-grade fever and
malaise.
. A choledochal cyst:
_____________________
. a congenital abnormality of the biliary ducts characterized by the dilatation of intra or extra-hepatic biliary ducts or
both.
. It has a multifactorial origin, but most of the cases are related to an anomalous pancreaticobiliary junction, which
. leads to weakness and dilatation of the biliary wall due to the reflux of alkaline pancreatic secretions into the biliary
tree.
. Various types of choledochal cysts are:
- Type 1: Most common type, features the dilatation of the entire common hepatic and common bile ducts or segments
of each.
- Type 2: Relative isolated protrusions or diverticulae from the common bile duct wall.
- Type 3: Cyst found in the intraduodenal part of common bile duct
- Type 4: Multiple dilatations in the intra and extra hepatic biliary tree.
- Type 5: Isolated dilatation of intrahepatic bile ducts.
.N.B.:
- Caroli's syndrome is a congenital disorder characterized by intrahepatic dilatation of bile ducts.
. Pseudo-pancreatic cyst:
________________________
. is a complication of acute or chronic pancreatitis characterized by retroperitoneal/epigastric mass and high amylase.
. However, it will rarely cause a right upper quadrant mass and very mild jaundice by compressing the common bile
duct.
. It is easily diagnosed by ultrasonogram.
. Intestinal atresia:
_____________________
. It can occur anywhere from the duodenum to the colon.
. Jejunal atresia is thought to occur due to an intrauterine vascular accident that causes necrosis and resorption of a
segment of bowel.
. The severity of the obstruction can vary from a membranous web to full atresia and loss of bowel length.
. Prenatal ultrasounds can diagnose intestinal atresia.
. If not discovered prenatally, the infant will develop vomiting and abdominal distention along with feeding intolerance
shortly after birth.
. Duodenal atresia appears as a "double bubble" on radiography.
. Jejunal atresia presents as a "triple bubble" on radiographs, indicating dilation of a larger amount of small bowel than
that seen in duodenal atresia.
. Treatment should initially be focused on resuscitation and stabilization of the patient, followed by surgical correction.
. Duodenal atresia usually presents with bilious vomiting a few hours after the first feeding.
. It is usually associated with other congenital anomalies, and can be a feature of Down's syndrome.
. Midgut volvulus:
___________________
. usually presents in a child less than one month old with bilious vomiting, abdominal distension and passage of
bloodstained stools.
. Volvulus is associated with malrotation of the gut, and can be complicated by perforation and peritonitis.
. lntussusception:
__________________
. is the most common cause of intestinal obstruction in the first two years of life.
. The classic presentation: is an infant with colicky abdominal pain, vomiting, and red currant jelly stools.
. The currant jelly stools are caused by bowel ischemia, which leads to bleeding and mucus production.
. Between episodes of abdominal pain, the child appears well.
. On physical examination, the abdomen is usually soft, nontender, and nondistended, A sausage-shaped mass is often
palpated.
. An abdominal radiograph may show air fluid levels due to obstruction.
. An ultrasound commonly shows a targetoid lesion in which one bowel segment is nested inside another bowel
segment.
. An air contrast enema is both diagnostic and therapeutic in the majority of cases.
. Emergent laparotomy is indicated for the treatment of intussusception when air contrast enema is unsuccessful.
. However, laparotomy becomes the treatment of choice if the child presents with peritoneal signs.
. The most common type of intussusception is ileocolic.
. Hirschsprung's disease:
________________________
. usually presents with failure to pass meconium within the first 24 hours.
. In this disease, an aganglionic segment of the colon causes the intestinal obstruction.
. Cyclical vomiting:
__________________
. Recurrent self-limiting episodes of vomiting and nausea in children in the absence of any apparent cause.
. The etiology of this condition is unclear; however, its incidence is high in children whose parents have a history of
migraine headaches.
. Complications that may arise from the condition are anemia and dehydration.
. Treatment consists of anti-emetics and reassurance of the parents.
. Infantile gastroesophageal reflux disease (GERD):
___________________________________________________
. The child typically has frequent vomiting, but maintains adequate weight gain.
. Symptoms usually begin in the first few months of life, peak around 4 months, and generally resolve by 1 year
. Conservative therapy is first-line management in these infants, and make sure that the feedings are the appropriate
volume and are given at regular intervals.
. Breast milk or formula can be thickened with rice cereal, which can decrease the frequency of vomiting.
. The infant should also be positioned to help decrease intraabdominal pressure by keeping the child's head elevated or
laying the child prone when awake.
. Parents should be reassured that most children will have resolution of their symptoms by 12 months.
. If infants develop respiratory symptoms due to GERO such as stridor, apnea, or failure to thrive, a more detailed
evaluation is necessary including
. an upper gastrointestinal series, pH probe monitioring, or endoscopy.
. These children may require pharmacotherapy if conservativetreatments do not improve their symptoms.
. N.B:
- Batteries lodged in the esophagus on x-ray should be removed immediately under endoscopic guidance to prevent
mucosal damage and esophageal ulceration.
- Batteries located distal to the esophagus pass uneventfully in most cases and need only to be observed with stool
examination and/or follow up x-rays to confirm excretion.
. Hemolytic-uremic syndrome (HUS):
__________________________________
. Caused by a toxin released from Escherichia coli.
. The toxin enters the systemic circulation and injures the endothelial cells in the kidney.
. When there is progressive elevation of BUN and creatinine, the chances for improvement of the kidneys' function is
poor.
. When the kidneys are damaged, the mortality is 5-10%.
. Turcot's syndrome:
____________________
. It is autosomal recessive and mainly occurs in teens.
. An association between brain tumors (primarily medulloblastomas and gliomas) & FAP (Familial Adenomatous
polyposis) or HNPCC (Hereditary nonpolyposis colorectal cancer).
. Gardner's syndrome:
_____________________
. is autosomal dominant where colonic polyps are seen with prominent extraintestinal lesions.
. Includes: desmoid tumors, sebaceous or epidermoid cysts, lipomas, osteomas (especially mandible), supernumerary
teeth & juvenile nasopharyngeal angiofibroma.
. Peutz-Jeghers syndrome:
_________________________
. An autosomal dominant inherited disorder characterized by intestinal hamartomatous polyps in association with
mucocutaneous melanocytic macules.
. Esophageal atresia:
_____________________
. The most common esophageal anomaly is esophageal atresia with a tracheoesophageal fistula.
. This is characterized by an atretic esophageal pouch that communicates distally with the trachea just above the carina.
. This anatomic arrangement allows air to enter the stomach, and this leads to gastric distention.
. The discontinuous esophagus prevents the infant from completely swallowing, thereby resulting in drooling or
regurgitation during feeding.
. In addition, gastric fluid ascends into the distal esophagus through the fistula, into the trachea and lungs, thereby
producing aspiration pneumonia Pneumonitis and atelectasis occur frequently, and rattles are heard during breathing.
. The inability to pass a feeding tube into the stomach is suggestive of esophageal atresia with or without
tracheoesophageal fistula.
. Infantile colic:
___________________
. is defined as excessive crying in an otherwise healthy infant for more than 3 hours a day, more than 3 days a week,
and more than 3 weeks in a month.
. Colic usually presents within the 1st 3 weeks of life and resolves spontaneously by four months of age.
. Most parents report that the crying occurs at the same time of day, typically in the early evening.
. The crying begins suddenly, and the child generally cannot be comforted.
. The cause of colic is not known, it maybe due to a digestive tract origin (eg, trapped gas) leading to abdominal pain.
. Because the etiology is not known, there is no accepted treatment (resolves spontaneously by four months of age).
. Proposed treatments: soothing measures, simethicone (which decreases the surface tension of gas bubbles), or
probiotics.
. Congenital diaphragmatic hernia:
__________________________________
. The first step is immediate placement of an orogastric tube & connecting it to a continuous suction, to prevent bowel
distension and further lung compression.
. Endotracheal intubation and mechanical ventilation are also priorities for all infants with severe CDH who present in
the first hours of life.
=============================================================== Neonatology
=====================================================================
. The Apgar score is measured in newborns at 0 and 5 minutes of life. It has five components, and is scored as follows:
A) Color of the newborn
----------------------0 body and extremities are blue/pale
1 body is pink and extremities are blue
2 body and extremities are pink.
B) Heart rate
------------0 heart shows no activity
1 HR <100 beats/min
2 HR > 100 beats/min
. Group B streptococcus is the most common cause of neonatal sepsis, it is part of the normal vaginal flora of women
and
is transmitted to infants during passage th rough the birth canal.
. In neonates, infection presents either as early-onset sepsis or late-onset sepsis.
. Early sepsis presents within the first week of life and usually involves several organs Symptoms include:
. Respiratory failure, meningitis, DIC, acute tubular necrosis and peripheral gangrene.
. It is usually refractory to therapy and quickly evolves to shock, coma and death.
. Late-onset GBS infection is usually a focal infection, most frequently meningitis (75%),
although arthritis, osteomyelitis, cellulitis and urinary tract infection may also occur.
. Meningitis presents with fever, lethargy, poor feeding, hypotonia, seizures and a bulging fontanel.
. The diagnosis is confirmed by positive blood or cerebrospinal fluid cultures,
although all newborns with fever and sepsis should have full workup for sepsis, including urine cultures.
. If the mother has already received antibiotics, culture results may be negative and a latex agglutination test may be
more helpful.
N.B.
1- Escherichia coli meningitis is less frequent than GBS meningitis It is the second most common cause of neonatal
meningitis.
2- Listeria is the third most common cause of neonatal meningitis It also tends to result in multiple abscesses and
pneumonia, in addition to meningitis.
3- Congenital toxoplasmosis classically presents with microcephaly, microphthalmia, hepatosplenomegaly and
chorioretinitis.
4- Herpes simplex virus encephalitis usually presents with focal neurologic signs. Herpes involves temporal lobes, so
patients may present with seizures.
. Neonatal sepsis:
__________________
. Sepsis in the neonate often presents with fever or hypothermia, jaundice, lethargy, and poor feeding.
. Infants with a serious bacterial infection such as meningitis rarely present with classic findings such as neck stiffness
or Kernig's or Brudzinski's signs.
. As a result, all infants with a suspected diagnosis of sepsis should be evaluated with blood cultures and a lumbar
puncture
. Jaundice in the newborn has a broad list of differential diagnoses including sepsis, breast milk jaundice, and
breastfeeding jaundice.
.N.B: Breast milk jaundice:
. Temporary cessation of breastfeeding is the most appropriate next step in an infant with suspected breast milk
jaundice.
. Breast milk jaundice, which is a caused by a factor in human breast milk, results from increased intestinal absorption
of bilirubin and generally peaks
around two weeks of age.
. Liver function tests (Albumin, AST, ALT, alklaline phopshatase) should be obtained in infants with a direct or
conjugated hyperbilirubinemia,
to assess for conditions such as biliary atresia.
. Milk protein intolerance:
___________________________
. Suspected in infant with vomiting, bloody diarrhea, RBCs and eosinophils in stool, and there may be a family history
of an atopic disorder.
. It is a hypersensitivity reaction to cow's milk proteins, and therefore usually occurs in babies who are fed with cow's
milk;
however, it may occur in breastfed babies, as the mother's milk may contain proteins from ingested cow's milk.
.N.B.:
- viral gastroenteritis: the associated diarrhea is usually non-bloody.
- Meckel's diverticulum typically presents as painless melena in a child who is approximately 2 years of age.
- Hirschsprung's disease may present with failure to pass meconium within the first 24 hours of life and/or failure to
thrive.
.N.B.: HIV testing in pregnant females:
--------------------------------------- It should be done to all pregnant women in the first trimester to prevent possible transmission to the infant.
- Persistent oral thrush, lymphadenopathy and hepatosplenomegaly & maybe intractable diarrhea, refractory infections
and fa ilure to thrive the presenting symptoms.
- In neonates, serologic testing is not useful for HIV diagnosis because of the passage of maternal antibodies to the fetal
circulation through the placenta.
- PCR, viral culture and p24 antigen testing are more appropriate; HIV infection is confi rmed if at least two of these
tests are positive.
. Contraindications to breastfeeding:
_____________________________________
1. Certain active maternal infections (HIV, tuberculosis, herpes simplex lesions on or near the nipple, malaria, sepsis,
typhoid fever),
2. Eclampsia, nephritis, substance abuse, and breast cancer.
3. Transmission of HIV by breastfeeding is well documented; therefore, the presence of maternal HIV infection is a
contraindication to breastfeeding.
N.B.: Situations that are not a contraindication to breastfeeding:
1- Mastitis --> we encourage breastfeeding since this prevents engorgement, along with other subsequent symptoms
such as fissures and cracking of the nipple.
2- Maternal rubella infection --> there is currently insufficient evidence regarding the associated risks.
3- Breast milk jaundice --> Mothers of such infants are instructed to switch their babies to formula-feeding for 1-2
days.
This allows the increased indirect bilirubin levels of the infant to return to normal values. After 2 days, the mother
resumes breastfeeding,
and further hyperbilirubinemia usually does not recur.
4- Hemolytic disease of the newborn (erythroblastosis fetalis) --> breastfeeding because antibodies in the mother's milk
are inactivated
in the intestinal tract and do not contribute to further hemolysis of the infant's RBCs.
. Physiological jaundice:
_________________________
. usually presents after 24- 36 hours of birth.
. The pathophysiology involves a combination of increased bilirubin production, decreased bilirubin clearance, and
increased enterohepatic circulation.
. Breastfeeding jaundice:
_________________________
. Breastfeeding jaundice is an exaggeration of physiologic jaundice caused by the relative dehydration that can occur in
breastfed infants in the first week of life.
. Breastfed infants usually breastfeed for about 15-20 minutes on each breast, 8 times/day, make about 4-6 wet
diapers/day mixed with 8-12 stools/day,
& lose 10% of their birth weight in the first week.
. Ineffective breastfeeding in the first few days of life causes inadequate enteral intake, prolongs the intestinal transit
time, and leads to increased absorption of
- A salmon patch is a flat salmon-colored lesion commonly seen over the glabella, eyelids, and neck.
. It is a vascular lesion that usually disappears in early childhood.
. Indications of the evaluation of neonatal jaundice include:
_____________________________________________________________
1. Conjugated hyperbilirubinemia (> 2 mg/dL)
2. Jaundice that appears in the first 24 - 36 hours of life.
2. Serum bilirubin rising at a rate faster than 5 mg/dl/24 hours.
3. Serum bilirubin greater than 12 mg/dl in full-term (especially in the absence of risk factors) or 10 - 14 mg/dl in
preterm infants.
4. Jaundice persists after 10 -14 days of life.
5. The presence of signs or symptoms.
N.B.: Conjugated hyperbilirubinemia (> 2 mg/dL):
- Association with light colored stools, hepatomegaly, and direct (conjugated) hyperbilirubinemia.
- Is indicative of neonatal cholestasis and impaired hepatic excretion of bilirubin, either by extrahepatic obstruction or
liver cell injury.
- With conjugated neonatal hyperbilirubinemia, priority should be given to conditions that require prompt diagnosis and
treatment, such as
sepsis, endocrinopathy (hypothyroidism). and nutritional hepatotoxicity caused by metabolic diseases (galactosemia,
tyrosinemia).
- After these diagnoses are ruled out, the final step is to differentiate biliary atresia from neonatal hepatitis.
. Breast-milk jaundice:
_______________________
. Appears in the second week of life; however, the hyperbilirubinemia is indirect (unconjugated).
. The unconjugated bilirubin levels may rise as high as 10-30 mg/dl Levels drop rapidly as soon as breastfeeding is
stopped,
and the infant is given milk formula for 1-2 days.
. After 2-3 days the breastfeeding can be resumed, and usually there is no return of the hyperbilirubinemia.
. Although it is a benign condition in some instances, phototherapy may be indicated.
. Physiologic jaundice:
_______________________
. Consists of moderate unconjugated hyperbilirubinemia (< 12-14 mg/dL) appears after the first 24 hours of life and
resolves before the end of the first week.
. It is a benign condition and is more common in preterm infants, infants of diabetic mothers, and infants of Asian or
Native American descent.
. Crigler-Najjar and Gilbert's syndrome:
________________________________________
. Are inherited deficiencies of UDP-glucuronyl transferase that result in unconjugated hyperbilirubinemia.
. In Gilbert's syndrome, the deficiency is mild, and patients are asymptomatic due to the mild indirect
hyperbilirubinemia.
. In Crigler-Najjar syndrome, the enzyme is absent; patients present early in life, and die within their first few years.
. Erythroblastosis fetalis:
___________________________
. is characterized by unconjugated hyperbilirubinemia and anemia.
===========================================================================
Endocrinology & Genetics ===========================================================
. Precocious pubarche (Puberty):
_________________________________
. It is very important to differentiate between precocious puberty that is caused by premature activation of the
hypothalamus-pituitary-gonad (HPG) axis,
and precocious pseudo-puberty that is caused by a gonadotropin-independent process, typically an excess of sex
steroids.
. In case of precocious pseudo-puberty: there is signs of severe androgen excess (i. e. severe cystic acne, significant
growth acceleration) which suggests precocious
pseudo-puberty It can be caused by late-onset congenital adrenal hyperplasia (21-hydroxylase defficiency).
. Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation Sequential
development of testicular enlargement, penis enlargement, pubic hair
growth, and then growth spurt is typically present.
. Severe hypothyroidism is a rare cause of precocious puberty, and is characterized by slowing (not acceleration) of
growth.
. Klinefelter's syndrome may present with a height that is higher than normal, but signs of androgen excess are not
typical.
. 47, XYY karyotype may manifest as severe acne, but precocious puberty is not characteristic.
. Premature adrenarche: Extremely high yield question for USMLE
_______________________
. characterized by the isolated appearance of axillary hair before the age of six years.
. This change results from premature androgen secretion of the adrenal glands.
. The condition is generally benign and has no clinical significance.
. On the other hand, premature pubarche (pubic hair growth before the age of 8 years) is more alarming, as it is
associated in 50% of cases with a CNS disorder.
. Congenital adrenal hyperplasia (CAH):
_______________________________________
. Congenital adrenal hyperplasia (CAH): is a group of syndromes characterized by a deficiency in one of the enzymes
responsible for steroid synthesis.
. The most common syndrome is 21-hydroxylase deficiency, which results in excess 17-alpha-hydroxyprogesterone
metabolite that is shunted to androgen,
thereby resulting in hirsutism or virilism.
. This deficiency also leads to a decreased production of mineralocorticoids and glucocorticoids, and consequent
hyponatremia and hyperkalemia.
. Complete deficiencies can present at birth with ambiguous genitalia, salt wasting and dehydration.
. In partial deficiencies, patients usually present during puberty or adulthood with virilism, which may or may not be
associated with salt wasting.
. The diagnosis is suggested by increased levels of 17-alpha-hydroxyprogesterone and confirmed with ACTH
stimulation test.
. Adolescent onset of hirsutism and virilism, with normal menstruations and elevated 17-hydroxyprogesterone, are
diagnostic of congenital adrenal hyperplasia.
N.B.:
1- Thyroid dysgenesis is the most common cause of congenital hypothyroidism in United States.
2- Iodine deficiency or endemic goiter is the most common cause of congenital hypothyroidism worldwide, but is
essentially not seen in the United States.
.N.B:
- Mammary gland enlargement and non-purulent vaginal discharge are common findings in newborn infants.
. These are transitory physiologic events due to infant's physiologic target-organ response to transplacentally acquired
maternal hormones (estrogens).
. Therefore, such infants only require observation and routine care.
. Primary amenorrhea:
_____________________
. The most common cause of primary amenorrhea is Turner syndrome, a 45,XO karyotype chromosomal disorder.
. It may also result from anatomic abnormalities (imperforate hymen, absent uterus), hypothalamic/pituitary
dysfunction, hyperandrogenism or pseudohermaphroditism.
. Turner syndrome is characterized by short stature, webbed neck, hypogonadism (streak ovaries), lymphedema, higharched palate,
congenitally bicuspid aortic valves, and coarctation of the aorta.
. Most commonly, ovarian failure in Turner syndrome manifests with delayed puberty, though at least 1/5 of patients
will have a normal puberty followed by early menopause.
. The decreased femoral pulses may indicate aortic coarctation, which occurs in approximately 10% of patients with
Turner syndrome.
. This clinical diagnosis should be confirmed by karyotype analysis.
.N.B.:
- A progesterone challenge: is used in the diagnostic evaluation of amenorrhea in patients with both a uterus and
normally developed breasts.
- Hyperprolactinemia can cause secondary amenorrhea as prolactin decreases GnRH production and release.
- 17-hydroxyprogesterone measurement is indicated when congenital adrenal hyperplasia is suspected as a possible
cause of primary amenorrhea.
. Serum 17-0H progesterone is elevated in 21- and 11-hydroxylase deficiencies and is decreased in 17-hydroxylase
deficiency
. McCune-Albright syndrome:
___________________________
. is a rare condition characterized by precocious puberty, cafe au lait spots and multiple bone defects (polyostotic
fibrous dysplasia).
. It is responsible for 5% of the cases of female precocious puberty, and may be associated with other endocrine
disorders,
such as hyperthyroidism, prolactin- or GH-secreting pituitary adenomas, and adrenal hypercortisolism.
. McCune-Albright syndrome is sporadic and has been recently attributed to a defect in the G-protein cAMP-kinase
function in the affected tissue, thereby resulting
in autonomous activity of that tissue.
. Remember the 3 P's of McCune-Albright syndrome precocious puberty, pigmentation (cafe au lait spots) and
polyostotic fibrous dysplasia.
.N.B.: Adrenal tumors result most commonly in heterosexual precocious puberty (i.e , premature development of male
the implication of GH deficiency accompanying PWS in the development of these features is still controversial.
.N.B:
- If you see a vignette with a child that is >2-years-old, it is unlikely that the diagnosis is Patau's or Edward's syndrome.
. Macrosomia secondary to maternal diabetes:
________________________________________
. Important differ. diag. of Beckwith-Wiedemann syndrome; but here infants do not present with dysmorphic features
as omphalocele, prominent occiput & macroglossia.
. Moreover, the prenatal and birth histories of the patient maternat D.M.
. The common congenital problems that in an 'infant of diabetic mother:
1. Caudal regression syndrome
2. Transposition of great vessels.
3. Duodenal atresia and small left colon.
4. Anencephaly and neural tube defects.
. WAGR syndrome:
________________
. Characterized by Wilms' tumor, aniridia, genitourinary anomaly and mental retardation.
. It is related to a deletion in chromosome 11 involving the gene WT1. (Wilms' Tumor 1 gene) and aniridia gene PAX6.
. Galactosemia:
_______________
. Is a metabolic disorder caused by galactose-1-phosphate uridyl transferase deficiency, eading to elevated blood levels
of galactose.
. Manifest a few days or weeks after the infant starts taking formula or breast milk.
. These include liver failure (hepatomegaly, direct hyperbilirubinemia, disorders of coagulation), abnormal renal
function, emesis, anorexia, acidosis & glycosuria.
. Present with: infant or newborn with failure to thrive, bilateral cataracts, jaundice and hypoglycemia.
. Other common manifestations: aminoaciduria, hepatic cirrhosis, hypoglycemia, and mental retardation.
. Such patients are at increased risk for E.coli neonatal sepsis.
. Galactosemia is NOT a self-limiting condition.
. Early diagnosis and treatment by el imination of galactose from the diet are mandatory.
. phenylketonuria:
__________________
. an autosomal recessive disorder.
. It occurs in approximately 1/10,000 births, and is more frequent in the Caucasian and Asian populations.
. Pathology: a deficiency in phenylalanine hydroxylase, that breaks down phenylalanine into tyrosine.
. This deficiency leads to the accumulation of phenylalanine and its metabolic products in the blood and body tissues
(particularly in the brain).
. If untreated, the defect can produce mental retardation and seizures.
. The most commonly used screening test is the determination of blood phenylalanine levels.
. Guthrie test, which is a qualitative (coloration) test, can also be used as it detects the presence of metabolic products of
phenylalanine in the urine.
. Treatment: a low-phenylalanine diet, since little amounts of phenylalanine are still necessary for growth and
development.
. Cereals, starches, fruits, vegetables, and phenylalanine-free milk formulas are recommended.
. High-protein foods should be avoided.
. Early diagnosis and treatment can improve the prognosis, with most (treated) patients having normal mental
development and a normal life span.
. Congenital hypothyroidism:
____________________________
. The most common cause is thyroid dysgenesis (ie , aplasia, hypoplasia, or ectopic gland).
. Other causes: inborn errors of thyroxin synthesis, and transplacental maternal thyrotropin- receptor blocking
antibodies.
. Infants initially appear normal at birth, but gradually develop apathy, weakness, hypotonia, large tongue, sluggish
movement, abdominal bloating & umbilical hernia.
. Other signs: pathologic jaundice, difficult breathing, noisy respiration, hypothermia, and refractory macrocytic
anemia.
. Infants initially appear normal due to the presence of moderate amounts of maternal hormones in the infant's
circulation.
. So, screening is mandated in all states at birth to allow for the early detection, treatment, and consequent improvement
of the prognosis.
. Screening is done by measuring serum T4 and TSH levels.
. The treatment is levothyroxine.
. Fragile X syndrome:
_____________________
. Male infant with a characteristic appearance (la rge head, long face, prominent forehead and chin, protruding ears),
joint laxity, and large testes.
. Behavioral abnormalities: hyperactivity, short attention span, and autism, are common.
. It results from a full mutation in the FMR1 gene caused by an increased number of CGG trinucleotide repeats
accompanied by aberrant methylation of the FMR1 gene.
. Turner syndrome:
__________________
. Presentation: short stature, short webbed neck and broad chest with widely spaced nipples and 45 XO karyotype.
. Other features: a low posterior hairline, gonadal dysgenesis, infertility and primary amenorrhea, which may occur as
the child grows.
. A higher incidence of cardiac anomaly: coarctation of the aorta (COA) and a bicuspid aortic valve.
. Physical findings of COA include upper extremity hypertension and a delay in the radial-femoral pulse.
. Congestive heart failure may be seen in infants with severe cases.
. The diagnosis is made with an echocardiogram and the treatment is surgery.
. There is higher risk of renal abnormalities, particularly horseshoe kidney, and should have a screening ultrasound after
the diagnosis is made.
. Swollen hands and feet due to congenital lymphedema, which is common in patients with Turner syndrome due to
abnormal development of the lymphatic network.
. Edema that is due to lymphedema is generally nonpitting on physical exam.
. Patients are prone to osteoporosis which increases the risk of bone fracture, this is due to low estrogen levels from
gonadal dysgenesis.
. Edward's syndrome:
____________________
. trisomy 18.
. The features: micrognathia, microcephaly, rocker bottom feet, overlapping fingers and absent palmar creases.
. Closed fists with index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, and rocker bottom feet.
. Congenital heart disease occurs in greater than 50 % of affected patients; ventricular septal defect is the most common
one.
. 80% of affected children die in the first month, 90% die by 1 year and remaining 5-10% are mentally retarded.
. Osteomalacia caused by vitamin D deficiency:
_______________________________________________
. Vitamin D deficiency leads to decreased intestinal calcium absorption and hypocalcemia.
. Hypocalcemia stimulates parathyroid glands & secondary hyperparathyroidism results, which brings serum calcium to
. Marfan syndrome:
__________________
. MSF is an autosomal dominant disorder that results from the mutations of the fibrill in-1 (FBN1) gene.
. It presents with tall stature, long and emaciated extremities, arachnodactyly, hypermobility of the joints, upward lens
dislocation, and aortic root dilation.
. Homocystinuria:
_________________
. An autosomal recessive disease caused by cystathionine synthase deficiency.
. Her features are characteristic of Marfan's syndrome (tall stature, long emaciated extremities, arachnodactyly,
hyperlaxity of the skin and joints).
. But her clinical presentation of a stroke is highly indicative of homocystinuria.
. Remember: Marfan's features + thromboembolic events = classic homocystinuria.
. Thromboembolic events at any age, due to the pathologic changes in the vessel walls and increased adhesiveness of
the platelets (commonly cerebral vessels).
. Lens dislocation (ectopia lentis): In Marfan's syndrome, the lens is dislocated upward, and in homocystinuria, it is
dislocated downward.
. Elevation of both homocysteine and methionine in body fluids confirm the diagnosis.
. The initial treatment: high doses of Vitamin B6.
. Restriction of methionine along with supplementation of cysteine is used for patients not responsive to Vitamin B6
therapy.
. Glucose-6-phosphatase deficiency:
___________________________________
. is also known as type I glycogen storage disease and Von-Gierkes' disease.
. As its name suggests, this condition is caused by deficient glucose-6-phosphatase in the liver, kidneys, and intestinal
mucosa.
. The typical patient, is 3-4 months of age with hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia.
. Hypoglycemic seizures may occur.
. The characteristic features: a doll-like face (fat cheeks), thin extremities, short stature, and a protuberant abdomen
(due to the enlarged liver and kidneys).
. The spleen and heart are normal.
=========================================================================== Nephrology
=================================================================
. Systemic Lupus erythematosus:
_________________________________
. Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is specific and confirmatory for the
diagnosis of systemic lupus erythematosus
. Transient proteinuria:
________________________
. A urine dipstick can be positive in up to 10% of school-aged children. Proteinuria in children can be transient
(intermittent), orthostatic, or persistent.
. Transient proteinuria is the most common cause of proteinuria and can be caused by fever, exercise, seizures, stress, or
volume depletion.
. Orthostatic proteinuria is very common in adolescent boys and is defined as increased protein when the patient is in an
upright position
that returns to normal when the patient is recumbent.
. If the urinalysis shows no hematuria and is otherwise normal, the urine dipstick should be repeated on at least two
additional specimens.
. If these subsequent tests are negative for protein, the diagnosis is transient proteinuria that are usually benign
conditions that require no further evaluation.
. Posterior urethral valves:
____________________________
. are the most common congenital obstructive urethral lesion in males.
. There is midline lower abdominal mass probably represents a distended bladder.
. The finding of a distended bladder indicates that the obstructive lesion is distal to the bladder neck.
. Posterior urethral valves are abnormal folds in the posterior urethral wall (distal prostatic urethra) that obstruct urine
flow out of the bladder.
. Affected infants may develop hydronephrosis, azotemia, and failure to thrive.
. A voiding cystourethrogram (VCUG) is the diagnostic test of choice.
. Bladder exstrophy:
____________________
. Results from a ventral defect of the urogenital sinus, which causes separation of the pubic rami, external rotation of
the hips,
and separation of the rectus abdominis muscles.
. The resulting ventral midline defect allows protrusion of a malformed bladder.
. This condition is associated with epispadias, recurrent urinary tract infections, and urinary incontinence.
. Hypospadias:
______________
. is a congenital abnormality where the penile urethra opens on the ventral surface of the penis rather than at the tip.
. It results from incomplete fusion of the urethral folds on the ventral penis.
. urachus:
__________
. is a tubular extension of the allantois that extends from the bladder to the umbilicus.
. It is normally obliterated during fetal development A patent urachus can result in an urachal fistula, cyst or sinus.
. None of these conditions would interfere with urine drainage from the bladder.
. An omphalomesenteric duct cyst:
_________________________________
. is a focal failure of vitelline duct obliteration.
. Such a vitelline cyst may cause a small midline mass deep to the umbilicus.
. The cyst could be attached to the umbilicus and the wall of the ileum by vitelline remnants and may cause small
intestinal volvulus.
. Cryptorchidism:
_________________
. is a fa ilure of one or both testes to descend from the abdomen through the inguinal canal(s) into the scrotum.
. Wilms tumor (nephroblastoma):
_______________________________
. Wilms tumor is usually diagnosed between the ages of two and five years.
. It is the most common primary renal neoplasm of childhood.
. 80% of the cases have an asymptomatic abdominal mass that is usually detected by the mother/caretaker while bathing
the child.
. The mass may be bilateral, symptoms may include hypertension, hematuria, abdominal pain, and vomiting.
______________________________
. Is the retrograde flow of urine from the bladder to the ureter and renal pelvis.
. Reflux is a risk factor for UTI & Repeated attacks of UTI can lead to progressive renal scarring,
which is the major cause of end stage renal disease and hypertension in children.
. It is a risk factor for UTI as it facilitates the transport of bacteria from bladder to the upper urinary tract,
. this explains why VUR is the most likely cause of acute UTI in children.
. VUR is present in 35-40 o/o of children with UTI.
. The diagnosis is made with voiding cystourethrogram (VCUG) followed by renal imaging.
. Diagnosis of VUR is best made with a voiding cystourethrogram or a radionuclide cystogram (RNC).
. Renal ultrasonography is less sensitive in detecting reflux nephropathy.
. The American Academy of Pediatrics recommends that all children aged 2 to 24 months with a first UTI should
undergo a VCUG or RNC to detect the presence VUR.
. N.B:
- Chronic pyelonephritis is characterized by focal parenchymal scarring and blunting of calices on IVP.
- Hydronephrosis is seen on IVP as dilation of the collecting system including the calyces, pelvis and ureter, depending
on the level of obstruction.
- Ureteropelvic obstruction would also lead to hydronephrotic changes in the kidney with IVP showing the level of
obstruction as a constriction in the flow of dye.
. Acute pyelonephritis:
_______________________
. usually present with fever, chills, nausea, vomiting and flank or suprapubic pain.
. Physical examination shows costovertebral angle tenderness.
. Urinalysis shows bacteriuria and pyuria.
. Therapy should be started with empiric antibiotics after withdrawal blood & urine for culture and sensitivity and
before its results are available.
. Severe disease with systemic manifestations warrants intravenous (IV) antibiotics.
. If patient is vomiting and hypotensive; therefore, IV antibiotics should be administered.
========================================================================= Infection
=====================================================================
. Measles (rubeola):
____________________
. It is caused by Paramyxovirus.
. Characterized by a prodrome of non-productive cough, coryza, non-purulent conjunctivitis, followed by
. Koplik's spots (pathognomonic): red spots with bluish specks over the buccal mucosa, opposite the premolar tooth &
sometimes on the inner conjunctivae & vaginal mucosa
. And maculopapular rash initially appearing on the face then spread to involve the entire body.
. Lab. findings: leukopenia, lymphopenia and Proteinuria may be seen.
. Diagnosis is mostly clinical and can be supported by a fourfold rise in hemagglutination inhibition antibody titer.
. Leukopenia (T-cell cytopenia) and thrombocytopenia can be seen with measles infection.
. Vitamin A has been shown to reduce the morbidity and mortality rates of patients with measles through immune
enhancement.
. It also helps the gastrointestinal and respiratory epithelium to regenerate.
. N.B.: - Atypical measles:
- Occurs in persons who have previously received inactivated measles vaccine (was available in the 1960's), (the
measles vaccine available now is a live one).
- This form is potentially life-threatening, and characterized by atypical rash (not maculopapular), the absence of
_______________________________
. The clinical manifestations of chickenpox in healthy children generally develop within fifteen days after the exposure.
. Include a prodrome of fever, malaise, or pharyngitis, followed by the development of a generalized vesicular rash,
usually within 24 hours.
. The lesions are commonly pruritic and appear as successive crops of vesicles over a three to four day period.
. Patients typically have lesions in different stages of development on the face, trunk and extremities.
. New lesion formation generally stops within four days, and most lesions are fully crusted by the 6th day in normal
hosts.
. Impetigo :
____________
. Is a superficial skin infection with multiple vesiculopustules on the exposed areas of the face and extremities.
. Is a contagious disease caused by Staphylococcus aureus, Streptococcus, or both.
. It presents as an erythematous macule, which rapidly evolves into vesicles and pustules.
. The pustules later rupture and leave honey-colored, crusted exudates.
. There are 2 forms of impetigo vesiculo-pustular and bullous types Bullous type is caused by Staphylococcus.
. These vesiculopustules eventually rupture, and then appear encrusted with a characteristic golden-yellow color.
. A history of skin trauma or insect bite is common, and local lymphadenopathy can be present.
. Impetigo is most commonly seen in children, and is associated with post-streptococcal glomerulonephritis.
. The etiologic agent is either group-A beta-hemolytic streptococci (GABS) or S. aureus, the clinical presentations of
these organisms are almost similar.
. Factors predispose to impetigo are warm and humid climate, poverty, crowding, poor personal hygiene, and carriage
of GABS or S . aureus.
. Nasal carriage of Staphylococci can cause recurrent impetigo.
. Topical mupirocin is the treatment of choice or oral erythromycin.
. Kawasaki disease or mucocutaneous lymph node syndrome:
________________________________________________________
. Criteria of Kawasaki's disease:
1. Fever for > 5 days, and
2. Four of the following symptoms:
Bulbar conjunctiva! injection.
Desquamation of the finger and toe tips, indurative edema.
Erythema, fissuring, and crusting of the lips, strawberry tongue, and diffuse mucosal injection of the oropharynx.
Morbill ifo rm truncal exanthem.
Cervical lymphadenopathy.
. Kawasaki disease is one of the most common causes of generalized vasculitis in children.
. It is usually self-limited, although it can be fatal because of giant aneurysm formation, thrombosis or rupture of the
coronary arteries, leading to MI.
. 2D echocardiography is used to assess cardiac function and coronary vasculature (Coronary artery aneurysms are the
most serious complication of Kawasaki disease).
. A baseline echocardiography is to be performed within 7 days of the disease onset, then repeated 6 to 8 weeks later.
. The laboratory of Kawasaki's disease: increased (ESR) and C-reactive protein, leukocytosis, normochromicnormocytic anemia, and thrombocytopenia.
. Thrombocytopenia is a non-specific finding and does not characterize this illness.
. Fever in Kawasaki's disease poorly responds to acetaminophen.
. All patients with suspected Kawasaki disease should be hospitalized and treated with intravenous immune globulin (
IVIG) and high-dose aspirin.
. The mainstays of systemic treatment of Kawasaki's disease are intravenous immunoglobulin (IVIG) and aspirin.
. Aspirin is useful for fever and arthritis.
. This is one of the conditions in which aspirin is recommended in children despite concerns about Reye's syndrome.
. Influenza vaccination is recommended in patients with Kawasaki's disease taking life long aspirin therapy.
. IVIG has been shown to reduce the incidence of coronary artery aneurysms and other complications.
. If untreated, up to 25 % of these patients may develop coronary artery aneurysms.
. Scarlet fever:
________________
. Caused by strains of Group A streptococcus that produce erythrogenic exotoxins.
. Has the same mode of transmission and age of distribution as streptococcal pharyngitis.
. The illness may follow a streptococcal pharyngitis, wound infections, burns, or streptococcal skin infection.
. It begins acutely after an incubation period of 1 to 7 days.
. Initial symptoms include fever, chills, toxicity, abdominal pain, and pharyngitis.
. The rash initially appears on the neck, axillae, and groin within 12 to 48 hours, and subsequently generalizes within 24
hours.
. The rash characteristically has a punctate or finely papular texture which is sometimes readily palpable; hence, the
"sandpaper-like" description.
. The pharynx is typically erythematous, swollen and possibly covered with gray-white exudates, strawberry tongue
may be present as in cases of Kawasaki disease.
. The area around the mouth appears pale in comparison with the extremely red cheeks, giving the appearance of
"circumoral pallor.
. Towards the end of the first week, desquamation begins in the face, progresses down the trunk, and finally extends to
the hands and feet.
. The most common condition with which Kawasaki's disease is confused is scarlet fever; however, scarlet fever will
have
a positive streptococcal throat test, and normal-appearing lips, as opposed to negative streptococcal throat test and
inflamed lips in Kawasaki's disease.
. Latex agglutination test is more rapid but less accurate in the diagnosis of scarlet fever.
. The treatment of choice for scarlet fever is a ten-day course oif penicillin V; however, in penicill in-allergic patients,
erythromycin or clindamycin can be used.
. Treatment of scarlet fever with penicillin doesn't prevent post-streptococcal glomerulonephritis.
. Staphylococcal scalded skin:
______________________________
. Caused by exfoliative strains of S. aureus, and is characterized by the development of superficial flaccid bullae
followed by an extensive exfoliation of the skin.
. It is most common in infancy, and rarely occurs beyond five years of age.
. Herpangina:
_____________
. is a throat infection caused by enteroviruses, especially Coxsackie A.
. It is characterized by a high fever and a severe sore throat that may result in a complete inability to swallow,
sometimes necessitating IV hydration.
. Ulcerative lesions are found on the palate, tonsils, and pharynx Sometimes,
. these lesions appear on the palms and soles & is called (hand-foot-mouth disease).
. It generally does not produce a rash after taking an antibiotic.
. Infectious mononucleosis:
____________________________
. caused by the Epstein-Barr virus.
. Sometimes detected only when the patient develops a characteristic polymorphous rash after taking ampicillin or
amoxicillin for an apparent URT infection.
. A prodrome of malaise, fever and adenopathy, the virus is spread via the saliva, and the condition usually resolves
after 2-3 weeks.
. can also present with exudative pharyngitis and lymphadenopathy.
.N.B.:
- Group A beta-hemolytic streptococci (not Group B) is responsible for 20-25% cases of pharyngitis in children.
. Group B streptococcus infections in the adult are serious. these are common in diabetics and those with peripheral
vascular disease.
. Complications include endocarditis, arthritis, pneumonia, empyema and meningitis.
. It does not present with a rash after taking amoxicillin.
. Toxic epidermal necrolysis:
_____________________________
. is another form of cutaneous hypersensitivity that is sometimes considered to be a variant of Stevens-Johnson
syndrome.
. Most cases are secondary to medications, such as sulfa drugs, anticonvulsants, and NSAIDs.
. Similar to staphylococcal-scalded syndrome, it presents with extensive erythema, tenderness, and blister formation,
followed by denudation of the epidermis.
. Mucous membranes are severely affected, and shedding of the nails may occur.
. Stevens-Johnson syndrome:
__________________________
. A severe variant of erythema multiforme.
. Characterized by skin lesions of erythema multiforme (target lesions), followed by inflammatory bullae of two or
more mucous membranes.
. Sometimes, the GI, respiratory, or GU tracts may also be involved.
. Rabies:
_________
. Fatal disease that is transmitted to humans by contact with saliva or nervous tissue from an infected animal through a
bite, open wound, or mucus membrane contact.
. Bats are a major reservoir for the rabies virus, Bat bites are often so quick and minor that the victim is not even aware.
. For this reason, any direct contact between bats and humans requires post-exposure rabies prophylaxis.
. People bitten by domestic animals suspected of being rabid or not available for observation, or
by wild carnivores like raccoons, skunks, and foxes should also receive prophylaxis.
. Rabbits and small rodents like squirrels, chipmunks, and rats are ra rely infected with rabies,so Post-exposure
prophylaxis following bites is not routine.
. Viral meningitis:
___________________
. usually self-limited inflammation of the leptomeninges caused by a viral infection.
. 90% of cases are caused by non-polio enteroviruses, such as echovirus and coxsackievirus.
. The incidence of viral meningitis decreases with increasing age Infants are most commonly affected, and disease
morbidity and mortality is highest in this group.
. Present with a viral prodrome of constitutional and upper respiratory symptoms with low-grade fever.
. Over the next 36-48 hours, the patient develops a high fever, headache, irritability, and nuchal rigidity.
. Focal neurologic signs are absent.
. The patient may also present with seizures. Other symptoms of enteroviral infection may also be seen such as
pharyngitis, rash, or herpangina.
. In viral meningitis, (CSF) will show pleocytosis with lymphocytic predominance, although neutrophils may
predominate early in the course.
. The protein level is normal to slightly elevated and the glucose level is normal, CSF gram stain will not show any
organisms.
. TORCHs infections:
___________________
. Toxoplasmosis, rubella, CMV, HSV and syphilis.
. cause a syndrome characterized by microcephaly, hepatosplenomegaly, deafness, chorioretinitis, and
thrombocytopenia.
. Standard prenatal care for high risk women (immegrants) in USA includes:
screening for infection with syphilis, chlamydia, gonorrhea, and HIV, as well as rubella and hepatitis B immunity.
. N.B.:
1- Folic acid supplementation prior to conception is important to prevent neural tube defects such as spina bifida and
anencephaly.
2- Zidovudine treatment early in pregnancy in women with confirmed HIV infection can reduce the risk of vertical
transmission of HIV to the fetus.
Also Caesarian delivery also reduces vertical transmission.
3- Malaria during pregnancy, causeS maternal anemia, also increases the risks of fetal loss and IUGR. Microcephaly is
not associated with malaria during pregnancy.
4- Smoking during pregnancy carries a risk of intrauterine growth retardation, as well as neurologic and developmental
defects. Microcephaly is not a feature.
. Congenital syphilis:
______________________
. Presents early on with hepatosplenomegaly, cutaneous lesions, jaundice, anemia, and rhinorrhea.
. Metaphyseal dystrophy and periostitis may be seen on radiography.
. Late manifestations: frontal bossing, high arched palate, Hutchinson teeth, interstitial keratitis, saddle nose, and
perioral fissures.
. These late manifestations can be prevented with early treatment of the infant
. Serologic testing: initial screening (VDRL), rapid plasma reagin (RPR), (EIA); confirmatory testing is with
treponemal tests as the (FTA-ABS) or (TPPA).
. Parenteral penicillin G is the treatment of choice for syphilis.
. Congenital toxoplasmosis:
___________________________
. Remember the classic triad of congenital toxoplasmosis: chorioretinitis, hydrocephalus, and intracranial calcifications.
. Microphthalmia, microcephaly, hepatomegaly, diffuse lymphadenopathy, jaundice and diffuse petechiae may be seen.
. Mumps:
________
. Parotitis secondary to mumps.
. Orchitis is one of the most frequent complications of mumps, developing in about 20% of cases.
. It is most common in postpubertal young men, ages 15-29. Because less than 15% of orchitis cases of are bilateral,
infertility is a rare complication.
. Treatment for mumps is supportive, with application of cold compresses to the parotid area or testes.
. Other common complications of mumps are aseptic meningitis and encephalitis.
. Eczema herpeticum:
____________________
. is a form of primary herpes simplex virus infection that is usually superimposed on healing atopic dermatitis lesions
after exposure to herpes simplex virus.
. Numerous umbilicated vesicles over the area of healing atopic dermatitis are typical.
. It is frequently accompanied with fever and adenopathy.
. In infants, the infection may be life-threatening, and acyclovir treatment should be initiated as soon as possible.
. Erythema toxicum:
___________________
. The healthy appearance of the neonate, the evanescent nature of the rash, and the distinctive red halo surrounding the
lesions support the diagnosis of erythema toxicum.
. The presence of numerous eosinophils in the pustules is diagnostic.
. Erythema toxicum is a benign, self-limited condition usually found in newborns after the first 2 days of birth.
. Treatment is not necessary.
.N.B.:
- Milia are small pearly white cysts, and are distinct from the rash of erythema toxicum.
- Sebaceous hyperplasia presents as little yellowish papules and are commonly found on the face.
- Vaccination against hepatitis B decreases the incidence of hepatocellular carcinoma, especially,
in regions with high levels of hepatitis B infection such as Asia (china) and Africa.
- The vaccination schedule for preterm infants should be conformed to the child's chronologic age, not the gestational
age.
- Because prematurity does not markedly change the immune response to vaccines, and the risk of infection and
complications in preterm infants is greater than term.
- The exception is that children should be 2 kg prior to receiving the first hepatitis B vaccine (which is at birth).
- Small for gestational age infants have a weight under the 10th percentile for gestational age at birth
- May have complications such as hypoxia, polycythemia, hypoglycemia, hypothermia, and hypocalcemia.
.N.B.:
- Albendazole or mebendazole is the first-line treatment for Enterobius vermicuLaris infection, Pyrantel pamoate is an
alternative.
- Urinalysis is a preliminary investigation that should be performed first in all patients with suspected renal disease.
- All children with recurrent episodes of nocturnal vulvar itching should be examined for pinworms and treated
empirically with mebendazole.
- Female infants less than 3 months of age sometimes develop vaginal spotting, discharge or bleeding.
Due to maternal estrogens crossing the placenta to the fetal blood before birth, causing a pubertal effect in the
newborn,
which disappears as soon as the hormone is cleared from the infant's circulation, so treatment is reassurance of the
mother.
. Lyme disease:
_______________
. The causative agent is the spirochete Borrelia burgdorferi, which is transmitted to humans by the bite of an infected
tick of the Ixodes species.
. The first clinical manifestation is the typical annular rash, named erythema migrans, at the site of the bite.
. The rash may be uniformly erythematous, or it may appear as a target lesion with central clearing.
. Erythema migrans may be associated with systemic features: fever, myalgia, headache or malaise.
. Individuals who are exposed to tick-infested areas should wear light-colored clothing so that ticks can be spotted more
easily and removed before getting attached.
. Wearing long-sleeved shirts and tucking pants into socks or boot tops can help keep ticks from reaching the skin.
. Applying insect repellents containing DEET to clothes and exposed skin, and applying permethrin to clothes, which
kills ticks on contact, also reduce the risk of tick attachment
. Tinea corporis:
_________________
. Is a superficial fungal infection mostly seen in hot, humid climates.
. The lesions are pruritic, erythematous, scaly, and have a red ring with central clearing.
. Exposure to infected animals, people, and public places are major risk factors.
. Tinea corporis is most common in preadolescents.
. It is diagnosed clinically or with a skin scraping and potassium hydroxide examination.
. Topical antifungals ( Terbinafine) are the preferred therapy.
. Reye syndrome:
________________
. also known as fatty liver with encephalopathy.
. A rare illness seen exclusively in children less than 15 years old who were treated with salicylates for a viral infection.
. Pathophysiology Reye syndrome is characterized by diffuse mitochondrial injury that leads to;
. Present with: vomiting, agitation, and irrational behavior, progressing to lethargy, stupor, and restlessness,
convulsions may occur.
. The liver is enlarged but there is no icterus.
. Laboratory findings: hyperammonemia, normal or slightly elevated bilirubin and alkaline phosphatase, prolonged
prothrombin time, hypoglycemia,
and moderate to severe elevations in AST, ALT, and lactate dehydrogenase levels.
. Histologically, extensive fatty vacuolization of the liver without inflammation is presen
. Biopsy of the liver, kidneys and brain reveals microvesicular steatosis.
. Treatment is supportive
. Aspirin is therefore generally contraindicated in children, except in the treatment of Kawasaki disease.
.N.B:
- Newborns of mothers with active hepatitis B infection should be passively immunized at birth with hepatitis B
immune globulin (HBIG) followed by
active immunization with recombinant HBV vaccine.
. Infant botulism:
__________________
. C. botulinum is the most common etiologic agent and is usually transmitted through food, especially honey, which is
the carrier in 1/3 of cases.
. In infantile form of botulism, the causative organism gains entry through the food and produces toxin in the GIT,
which subsequently triggers the symptoms.
. It is a protease that blocks acetylcholine release.
. Infants typically present between 2 weeks and 9 months with constipation and poor feeding.
. This is followed by progressive hypotonia, weakness, loss of deep tendon reflexes, cranial nerve abnormalities
(impaired gag reflex), and respiratory difficulties.
. Signs of autonomic dysfunction such as hypotension and neurogenic bladder can occur early in the course of the
disease.
. Staphylococcal scalded skin syndrome (SSSS):
______________________________________________
. is caused by exfoliative toxin-producing strains of S. aureus.
. It starts with a prodrome of fever, irritability, and skin tenderness, which is followed by generalized erythema and
superficial flaccid blisters.
. A positive Nikolsky sign (gentle lateral pressure on the skin surface adjacent to a blister causes slipping and
detachment of a superficial layer of skin).
. Scaling and desquamation follow, before resolution of the disease process SSSS usually affects children below age 10.
. but adults with kidney disease or immune compromise may also be affected.
. Cultures from intact bullae are usually sterile, because this is a toxin-mediated process.
. The goal of treatment is to eliminate any focus of infection with appropriate anti-staphylococcal antibiotics & provide
supportive wound care of all denuded areas.
. Rehydration:
______________
. The signs and symptoms of hypernatremia are mainly neurologic and include lethargy, altered mental status,
irritability, and seizures.
. Hypernatremia can also cause muscle cramps, muscle weakness, and decreased deep tendon reflexes.
. Hypovolemic hypernatremia develops secondary to renal losses (eg, diuretic use, glycosuria) or extrarenal losses (eg,
gastrointestinal upset, excessive sweating).
. Hypervolemic hypernatremia occurs due to exogenous sodium intake or mineralocorticoid excess (eg,
hyperaldosteronism).
. When treating a patient with hypernatremia, the sodium must be slowly returned to normal.
. In caseof hypernatremia and dehydration, the initial goal is to stabilize the infant with fluid resuscitation as needed.
. When giving intravenous fluid boluses, only isotonic solutions such as normal saline or lactated Ringer's should be
used.
.N.B:
- Half normal saline (45%) and 5% dextrose are hypotonic solutions, they should never be used for initial resuscitation.
. because they quickly exit the intravascular system and lower the sodium too rapidly Precipitating drop in sodium
levels can cause cerebral edema.
- Multiple studies have demonstrated that the expensive colloid solutions are no better than crystalloids at fluid
resuscitation.
. Developemental processes:
___________________________
- Age: 12 months:
---------------. Fine Motor: Tow finger pincer grasp & turns several pages of a book at a time.
. Gross Motor: Walks without assistance & - Waves bye & Climbs up on furniture.
. Language: Says 2-3 words & - Says "mama" and "dada" games (can identify each parent).
. Social: Imitates actions & - Plays reciprocal games (peek-a-boo) & indicates wants.
- Age: 2 year:
-------------. Fine Motor: Builds a twer of 6 cubes.
. Gross Motor: Walks up & down stairs
. Language: 200 word vocabulary & uses 2-word phrases
. Social: Follow 2 step commands.
- Age: 3 years:
---------------. Fine Motor: Copies a circle uses utenisles to feed self & stacks 9 blocks.
. Gross Motor: climbs stairs with alternating feet, rides a tricycle & kicks a ball.
. Language: uses 3 word sentences, stats first name & 3/4 (75%) of speech is intelligible.
. Social: wash/dry hands, helps with simple household tasks & group play.
- Age: 4 years:
---------------. Fine Motor: Copies a cross, draw a person, begins to use scissors & holds a crayon with a tripod grasp.
. Gross Motor: Hops on one foot with out losing balance & jumps over objects.
. Language: Counts to 10, tells stories & use lurals and prepositions.
. Social: Cooperative play, has imaginary friends & imitate adults role.
--------------------------------. Language development:
----------------------- Social smile 2 months
- Babbles 6 months
- 2 words, obeys 1-step command 1 year
- 2-3 word phrases, obeys 2-step command 2 years
. Gross motor development:
-------------------------- Holds head 3 months
- Rolls back to front and front to back 4 months
- Sits well unsupported 6 months
- Walks alone 12 months
- Walks up and down stairs without help 24 months
. Fine motor development:
------------------------- Raking grasp 6 months
- Throws object 12 months
- Builds tower of 2 blocks 15 months
- Builds tower of 6 blocks/turn pages of books 24 months
. Social development:
--------------------- Recognizes parents 2 months
- Recognizes strangers (stranger anxiety) 6 months
- Imitates action/comes when called 12 months
- Plays with other children 18 months
- Parallel play 24 months
N.B:
- Developmentally, a 12 month old should be able to walk holding onto a hand or object. He should have a neat pincer
grasp that allows him to grab small objects.
- Language development at 1 year old consists of mama and dada said specifically to his parents, and at least one other
word.
- Socially, a 12 month old can roll a ball and makes postural adjustments when being dressed
. Toilet training:
__________________
_______________________________
. Constitutional growth delay is the most common cause of short stature and pubertal delay in adolescents.
. Affected individuals have a normal birth weight and height, but between 6 months to 3 years of age, the height growth
velocity slows, and they drops percentiles on their growth curve.
. Around 3 years of age, the child regains a normal growth velocity and follows the growth curve at the 5th to 10th
percentile.
. Puberty and the adolescent growth spurt are delayed, but eventually occur.
. The child will have a normal growth spurt and reach a normal adult height.
. Bone age radiographs show a bone age that is delayed compared to the chronological age.
. Separation anxiety:
_____________________
. Separation anxiety is a normal behavior in young children between 9-18 months.
. usually manifests when parents leave the child or at night when the child is put to bed.
. The child responds by crying, clinging to the parent, and becoming upset Separation anxiety usually lasts 2-4 months
and gradually resolves as the child begins to
understand that his parents will return.
.The initial step in the management of children with speech delay is an audiology evaluation especially when there is
history of recurrent otitis media.
===================================================================== Miscellaneous
==============================================
. Autism:
_________
. patient is usually less than 3 years old and presents with impairment in social interactions and communication, delayed
language development,
repetitive activities, and stereotypical behaviors.
. Treatment include special education and behavioral modification techniques, No pharmacological agent has been
found to be useful in autism.
. Asperger syndrome:
____________________
. These kids are usually more socially aware and communicative. Although patients may have features of stereotypical
movements and
self-injurious behavior, their language development is normal.
. Attention-deficit hyperactivity disorder (ADHD):
__________________________________________________
. Children with ADHD have poor impulse control, inattentiveness, and motor overactivity.
. Multiple factors contribute to development of ADHD: genetics, pregnancy or birth complications, maternal drug use,
abnormal brain development or traumatic brain injury,
and psychological stressors.
. There are three subtypes of ADHD - predominantly inattentive, predominantly hyperactive-impulsive, or combined.
. To meet the diagnostic criteria for ADHD, a child must exhibit six or more symptoms of inattention or hyperactivityimpulsivity before age 7 years, with the symptoms present for at least 6 months.
. The symptoms must cause significant impairment in functioning and must occur in at least two different settings
. Many children with ADHD have a family history of ADHD. However, this is not necessary for the diagnosis.
. Educational testing may be appropriate, as many children with ADHD have coexistent learning disabilities however.
. Teacher evaluations must be obtained first to establish the diagnosis of ADHD.
. Children with ADHD can have sleep problems, which should be addressed if the diagnosis of ADHD is confirmed by
teacher evaluations.
Inattention Symptoms
Hyperactivity-lmpulsivity Symptoms
3- Acute vitamin D ingestion causes anorexia, nausea, vomiting, diarrhea, headache, polyuria and polydipsia.
4- Vitamin K may cause hyperbilirubinemia in premature infants.
5- Acute lead poisoning presents as vomiting, ataxia, colicky abdominal pain, irritability, seizures, encephalopathy and
cerebral edema.
6- Dimercaprol is the antidote for lead poisoning, as well as poisoning from other heavy metals (e g , gold, arsenic,
mercury).
7- Aspirin poisoning is characterized by lethargy, fever, hyperpnea, vomiting, tinnitus and metabolic acidosis,
abdominal radiographs are usually unremarkable.
. Lead poisoning:
_________________
. Risk for lead poisoning: live in an old house, especially if there is peeling paint or during renovation projects.
. Other risk factors: lead pipes, living near a battery recycling plant, having a parent who works with batteries or
pottery, or having a playmate or sibling
with a history of lead poisoning.
. Capillary blood specimens (using a fingerstick) are widely used in childhood screening for lead poisoning.
. Since false positive results are common, the first step after an abnormal fingerstick lead level is to confirm the
diagnosis with a serum (venous blood) lead level.
. If the serum lead level is >10 ?g/dL, then intervention is needed.
. Removing the child from the house would be the most important step in reducing exposure if the diagnosis of lead
poisoning is confirmed.
. Chelation therapy with either dimercaprol or dimercaptosuccinic acid (DMSA, succimer) is typically used when lead
levels are extremely elevated (>45 ?g/dL).
. Rechecking the lead level in one month is appropriate for children with mildly elevated lead levels (<20 ?g/dL) after
a thorough history is taken and counseling is done about removing the child from any potential lead exposure.
. Vaccination adverse reactions: Extremely high yield question for the USMLE!!!
_______________________________
. The adverse reactions to the DTaP vaccine are usually attributed to the pertussis component of the vaccine.
. Mild reactions consist of local redness and swelling, irritability , and fever < 105F (40 6C).
. Less common reactions include inconsolable crying for > 3 hours and a temperature of > 105F (40 6C).
. An immediate anaphylactic reaction, an encephalopathy, or any CNS complication within 7 days of administration of
the vaccine is a contraindication for further
administration of DTaP.
. In these instances, DT should be substituted for DTaP since the adverse reactions are usually attributed to the pertussis
component of the vaccine.
. varicella vaccine:
____________________
. Guidelines recommend active immunization with varicella vaccine for healthy adults & children exposed to varicella,
ideally within the first 3- 5 days of exposure.
. because efficacy is decreased beyond this period.
. Because this is a live virus, the vaccine is only recommended for immunocompetent individuals.
. Postexposure prophylaxis with varicella-zoster immune globulin product is indicated in susceptible high-risk persons
(lmmunocompromised patients, pregnant women)
exposed to varicella within 96 hours (preferably 72 hours) of exposure, it does not prevent infection but effectively
reduces disease severity.
. administration of any of these vaccines after these periods it will ineffective.
. Cat bites:
_____________
. Are of significant concern because these often result in deep puncture wounds, also infection of such wounds with
. The treatment for NAS: symptomatic care to calm the infant & help the infant sleep, such as swaddling, providing
small frequent feeds, &
keeping the infant in a low stimulation environment.
. Pharmacologic treatment used when supportive treatment does not control it; Morphine can be administered &
systematically weaned to help control opiate withdrawal.
.N.B.:
- Prenatal exposure to cocaine can result in jitteriness, excessive sucking, and a hyperactive Moro reflex.
- Withdrawal symptoms are usually not as severe as with opiates; Long-term effects on behavior, attention level, and
intelligence may be seen.
. Serum sickness-like reaction:
_______________________________
. It most commonly occurs in young children following the treatment of viral infections with antibiotic.
. May occur 1-2 weeks after administration of certain drugs, such as penicillin, amoxicillin or cefaclor in the setting of a
viral illness.
. Prominent symptoms: fever, urticaria! rash, polyarthralgia and lymphadenopathy.
. It derives its name from its similarities to true serum sickness, an immune-complex mediated hypersensitivity reaction
to non-human proteins.
. Serum-sickness like reaction is a clinical diagnosis, and should resolve with withdrawal of the offending agent; it does
not represent a true drug allergy.
. Deficiency of niacin (vitamin B3):
____________________________________
. leads to pellagra, which is characterized by diarrhea, dermatitis, dementia, and if severe, death.
. Pellagra is common in 3rd world countries where the main diet consists of cereal or corn, but can be seen in people
with bowel disease that interferes with vitamin absorption.
. Present with GIT complaints (nausea, abdominal pain, or epigastric discomfort) along with glossitis and watery
diarrhea.
. Dermatitis seen in pellagra occurs in sun exposed areas and resembles a sunburn; it is also typically bilateral and
symmetric.
. As the rash progresses, the skin becomes hyperpigmented and thickened.
. Mental status changes can range from poor concentration to irritability, aggressiveness, and dementia.
. Death can occur in severe niacin deficiency if untreated.
. Treatment of pellagra is niacin replacement.
.N.B:
----1- Deficiency of thiamine (vitamin B1 ) causes beriberi or Wernicke-Korsakoff syndrome
- These conditions are characterized by neurologic and psychiatric symptoms, and are often seen in alcoholics or
patients who have had weight loss surgery.
2- Deficiency of riboflavin (vitamin B2) can lead to cheilosis, glossitis, seborrheic dermatitis (often affecting the genital
areas), pharyngitis, and
edema and/or erythema of the mouth (Pure riboflavin deficiency is has been documented in regions of the world with
severe food shortages).
3- Pyridoxine (vitamin B6) deficiency causes irritability, depression, dermatitis, and stomatitis.
- It can also cause an elevated serum homocysteine concentration, which is a known risk factor for venous
thromboembolic disease and atherosclerosis.
4- Deficiency of cyanocobalamin (vitamin 812) causes macrocytic anemia and peripheral neuropathy.
. Vitamin A deficiency:
________________________________
. Suspect vitamin A deficiency in a 2 or 3-year-old child with impaired adaptation to darkness, photophobia, dry scaly
skin, xerosis conjunctiva,
xerosis cornea, keratomalacia, Bitot spots and follicular hyperkeratosis of the shoulders, buttocks, and extensor
surfaces
. Sudden infant death syndrome (SIDS):
______________________________________
. is the leading cause of mortality in infants aged between 1 month and 1 year in the United States.
. It is defined as the sudden, unexpected death of an infant that cannot be explained by the history and a thorough postmortem examination.
. It is recommended that infants be placed in a supine position while sleeping to reduce the risk of SIDS.
. Anaphylaxis:
______________
. is an acute, life-threatening, lgE-mediated type I hypersensitivity reaction.
. The most common inciting agents for anaphylaxis are insect envenomation, drugs and foods.
. Food allergies are the major cause of pediatric outpatient anaphylaxis, and peanut allergies account for the majority of
fatal and near fatal reactions.
. Signs include bronchoconstriction, hypotension and urticaria.
. Intramuscular injection of epinephrine is the first-line treatment for anaphylaxis in a patient with a patent airway.
. The most effective and potentially life-saving intervention in a patient with known anaphylaxis is
prescription of self-administrable epinephrine for use upon reexposure to the inciting allergen.
. Risperidone:
______________
. Is an atypical antipsychotic commonly used to treat schizophrenia and bipolar disorder.
. It is a dopamine & serotonin antagonist.
. It inhibits dopamine, which leads to elevated serum prolactin levels.
. The hyperprolactinemia causes: oligomenorrhea, amenorrhea, and galactorrhea, in premenopausal females.
. The resultant side effects can include the breast tenderness, amenorrhea, and galactorrhea.
. Risperidone has been found to increase prolactin levels to a greater extent than do many of the other antipsychotics.
. Cradle cap, or seborrheic dermatitis:
________________________________________
. is a common pediatric skin condition.
. This papular, scaly rash tends to affect the eyebrows, nasolabial folds, and scalp.
. Treatment: moisturizers, antifungals, and topical steroids.
. Atopic dermatitis:
____________________
. In infancy presents with pruritus and skin lesions typically distributed symmetrically over the face, scalp, chest and
extensor surfaces of the extremities.
. The diaper region is typically spared.
. Patients with exfoliative dermatitis (erythroderma):
_______________________________________________________
. usually have a prior dermatological condition such as psoriasis, atopic dermatitis or mycosis fungoides (Sezary
syndrome).
. Intraosseous access:
______________________
. Whenever intravenous access cannot be obtained in emergent pediatric cases, intraosseous access should be attempted
next.
. Intraosseous cannulation can be performed quickly in the ED, this technique does not require the precision required
for cannulation of small vessels& provides
a cannula large enough to deliver adequate fl uids.
. This route can be used in emergencies for 24 to 48 hours, at which point another intravenous route should have been
obtained.
. Associated complications such as osteomyel itis are rare.
=====================================================================================
====================================
. TRANSFUSION REACTIONS:
________________________
________________________
. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.
. 2 . TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) = LEUKO-AGGLUTINATION REACTION:
____________________________________________________________________________________
. Acute Shortness of breath from antibodies in the donor blood against the repient WBCs.
. Ex -> 20 mins after a pt. receives a blood transfusion, the pt becomes short of breath.
. Transient infiltrates on CXR.
. All symptoms resolve spontaneously.
. 3 . IgA DEFECIENCY:
______________________
. RHINITIS:
____________
____________
{A} ALLERGIC RHINITIS:
_______________________
. Watery rhinorrhea & sneezing with more prominent eye symptoms.
. Early age of onset.
. Identifiable trigger (animals - environmental exposure).
. Usually seasonal symptoms but can be persistent throughout year.
. Nasal mucosa can be normal, pale blue or pale on exam.
. Associated with allergic disorders e.g. eczema & asthma.
. Tx -> Allergen avoidance.
. Tx -> Topical intra-nasal glucocorticoids.
{B} NON-ALLERGIC RHINITIS = VASOMOTOR RHINITIS:
________________________________________________
. Nasal congestion - Rhinorrhea - Postnasal discharge (postnasal drip = dry cough).
. Late age of onset > 20 ys.
. Can't identify clear trigger !
. Symptoms throughout the year but sometimes worse with seasons change.
. Nasal mucosa may be normal or erythematous.
. Less commonly associated with allergic disorders e.g. asthma or eczema.
. Routine allergy testing isn't necessary prior to initiating empiric ttt.
. May respond to 1st generation oral H1 antihistaminics (Chloramphenicol),
. Never ever responds to antihistaminics without anticholinergic properties (Loratidine)!
. Tx -> TOPICAL INTRANASAL GLUCOCORTICOIDS.
. The 3 most common causes of CHRONIC COUGH (> 8 weeks):
________________________________________________________
{3} . URTICARIA:
_________________
. Sudden swellings of the superficial layers of the skin.
. Can be caused by insects or medications.
. May be caused by pressure, cold or vibration !
. Tx -> ANTI-HISTAMINICs (Diphenhydramine & koratidine).
. GRAFT VERSUS HOST DISEASE (GVHD):
___________________________________
___________________________________
. in pts with bone marrow transplantation.
. due to activation of the DONOR "T" lymphocytes.
. Skin ---> Maculopapular rash.
. Intestine ---> Bloody diarrhea.
. Liver ---> Abnormal LFTs & jaundice.
. PRIMARY IMMUNO-DEFECIENCY DISORDERS:
_______________________________________
_______________________________________
{1} COMMON VARIABLE IMMUNODEFECIENCY (CVID):
_____________________________________________
. ADULT with recurrent sino-pulmonary infections.
. NORMAL NUMBER OF "B" cells but don't make effective amounts of immunoglobulins.
. DECREASE in ALL subtypes of immunoglobulins (IgG, IgM & IgA).
. Frequent episodes of bronchitis, pneumonia, sinusitis & otitis media.
. CVID increases the risk of lymphoma.
. Dx -> Decreased immunoglobulins level & -- response to Ag stimulation of B-cells.
. Tx -> Antibiotics for infections.
. Tx -> Chronic maintainance with regular infusions of I.V. immunoglobulins.
. The clue to CVID is DECREASE in the OUTPUT of B-LYMPHOCYTES with,
. NORMAL NUMBER of B-cells & NORMAL amount of LYMPHOID TISSUE (LNs, adenoids & tonsils).
{2} X-LINKED (BRUTON) A-GAMMA-GLOBULINEMIA:
____________________________________________
. MALE CHILDREN with recurrent sino-pulmonary infections.
. DIMINISHED B-cells & LYMPHOID TISSUES.
. ABSENCE of tonsils, adenoids & lymph nodes & spleen.
. NORMAL T-cells.
. Tx -> Antibiotics for infections.
. Tx -> Chronic maintainance with regular infusions of I.V. immunoglobulins.
{3} SEVERE COMBINED IMMUNODEFECIENCY:
______________________________________
. Combined = Defeciency in BOTH B & T cells.
. -- B-cells -> -- immunoglobulin production -> Recuurent sinopulmonary infections at 6ms
. -- T-cells -> AIDS related infections e.g. PCP, varicella & candida.
. Treat the infections as they rise.
. BM transpalntation is curative.
. 3 . Pericarditis:
____________________
-> Pain worse with lying flat, better when sitting up.
-> ECG -> ST elevation in all leads with PR depression.
. 4 . Duodenal ulcer disease:
______________________________
. Epigastric discomfort - pian is better on eating.
. Endoscopy is confirmatory.
. 5 . Gastro-esophageal reflux disease "GERD":
_______________________________________________
. Bad taste, cough & hoarsness.
. Response to PPIs "Omeprazole".
. 6 . Pneumonia:
_________________
. Cough, sputum & hemoptysis.
. Dx -> CXR.
. 7 . Pulmonary embolism:
__________________________
. Sudden onset SOB, hypoxia, tachycardia.
. CxR -> Clear lungs.
. Spiral CT - V/Q scan - D-Dimer.
. Most accurate: Pumonary angiography.
. 8 . Pneumothorax:
____________________
. Sharp, pleuritic pain with tracheal deviation.
. CXR is diagnostic.
. 9 . Pancreatitis:
____________________
. Alcoholic pt with chest pain radiating to the back.
. Nausea & vomiting.
. Dx -> Check amylase & lipase levels.
. 10 . Cholecystitis:
______________________
. Right upper quadrant tenderness & mild fever.
. Dx -> Abdominal U/$ for gall stones.
. EVALUATION OF CHEST PAIN IN THE EMERGENCY DEPARTMENT:
_______________________________________________________
Focused H/O & P/E
Assess vital signs
Obtain venous access
|
_______ STABLE ______________UN-STABLE_______
|
|
. Obtain ECG & CXR
. Stabilize hemodynamics.
. Administer aspirin if
. Check for underlying causes
low risk of aortic dissection
|
ECG consistent with AC$ ?
|
_______________________________________________
|
|
YES
NO
|
|
_______________________
CXR diagnostic ??
|
|
|
STEMI
NSTEMI
__________YES_________NO___
|
|
|
|
Treat with emergency
Treat with Treat cause
Assess for Pulmonary embolism
catheterization or
appropriate
Assess for pericarditis
thrombolytics
anticoagulation
Assess for aortic dissection
. N.B.
. Further testing for coronary artery disease (CAD):
. sh'd NOT be done routinely in low risk pts as they frequently can've false +ve results.
. Exercise EKG or pharmacological stress testing is most useful in intermediate risk pts.
. High risk pts sh'd start pharmacological therapy & undergo coronary angiography,
. if they have stable angina.
. Physical examination findings:
_________________________________
. Distressed pt with SOB & clutching chest.
. S3 gallop = Lt ventricular dilatation.
. S4 gallop = Lt ventricular hypertrophy.
. Jugulo-venous distension.
. Bilateral basal lung rales.
. LL edema.
. Diagnosis:
____________
. Best initial test -> EKG.
. N.B. If the case is very clear with diagnosis of ischemic pain & the given choices are:
. EKG & (Aspirin - Nitrates - Oxygen - Morphine) ..
. CHOOSE TTT 1st !
. N.B. CK-MB is the best to detect RE-infarction a few days after the initial infarction:
__________________________________________________________________________________________
. Both CK-MB & troponin levels rise 3-6 hs after the start of chest pain.
. The main difference is that CK-MB only stays elevated 1-2 days.
. While troponin stays elevated 1-2 weeks.
. so, CK-MB is the best to detect RE-infarction a few days after the initial infarction.
. N.B. MYOGLOBIN is the 1st cardiac marker to rise after chest pain:
_____________________________________________________________________
. Myoglobin elevates 1-4 hours after start of chest pain.
___________ LAD
___________ RCA or LCX
. Posterior MI
. Lateral MI
{1} ASPIRIN:
_____________
. The best initial therapy for all AC$.
. ANTI-PLATELET drug.
. LOWERS MORTALITY.
. Given in addition to Nitrates, oxygen & Morphine.
. CLopidogreal or Prasugrel are given in case of containdication to Aspirin e.g. Allergy.
. They are also given in pts under-going angioplasty or there is acute MI.
{2} THROMBOLYTICS & ANGIOPLASTY (PCI):
_______________________________________
. Both lower mortality.
. Angioplasty must be performed within 90 minutes of arrival at the emergeny department.
. If it can't be performed within 90 mins -> The pt sh'd receive THROMBOLYTICS.
. Contraindications to thrombolytics (Major bleeding - Recent surgery - Severe HTN).
. Complications of angioplasty (Rupture of coronary artery - Restenosis - Hematoma).
{3} BB, ACEIs & ARBs:
______________________
. BB ALWAYS LOWER MOTALITY.
. ACEIs & ARBs lower mortality ONLY IF there is left ventricular dysfunction!
. ACEIs lessens ventricular remodelling following MI.
{4} STATINS:
_____________
. Given to all pts with AC$.
. Side effect -> Liver toxicity.
. Statins inhibit intracellular HMG-CoA reductase enzyme,
. prevent conversion of HMG coA to mevalonic acid & ++ NO of cell membrane LDL receptors
. Statins also -- coenzyme Q10 synthesis involved in muscle cell energy production,
. so .. It contributes to statin-induced myopathy.
. CPK levels sh'd be checked in any pt on a statin who presents with myalgias.
. If highly elevated, the 1st step is to discontinue the statin.
. N.B. High dose Niacin therapy may cause cutaneous flushing & pruritis.
. This side effect is due to PROSTAGLANDIN INDUCED PERIPHERAL VASODILATATION.
. Can be reduced by low dose aspirin.
. ACEIs sh'd be initiated within 24 hours of MIin all pts without contraindications.
. N.B.
. GERD is characterized by a retrosternal burning sensation after eating & lying down.
. It may be accompanied by hoarseness & chronic cough especially while recumbant.
. Initial ttt is an H2-receptor blocker or Proton pump inhibitor.
. N.B. Dihydropyridine CCB (Nifedipine) can worsen cardiac ischemia,
. Bec. they cause peripheral vasodilatation & reflex tachycardia.
. so they are contraindicated in pts with acute coronary $.
. N.B. NON-Dihydropyridine CCB (Diltiazem & Verapamil) can be used in STEMI after BB,
. BUT .. They do NOT improve mortality.
. N.B. Ischemic damage in MI may lead to diastolic dysfunction & stiff left ventricle,
. resulting in an atrial gallop (S4 4th heart sound).
. N.B. Pts presenting to the emergency department with chest pain & suspected AC$,
. should be administered ASPIRIN ASAP.
. Early anti-platelet therapy with aspirin reduces the rate of MI & overall mortality.
. COMPLICATIONS of Acute MI:
____________________________
{1} CARDIOGENIC SHOCK:
_______________________
. Dx -> Echo & SWAN-GANZ Rt heart catheterization.
. Tx -> ACEIs & urgent re-vascularization.
{2} VALVE RUPTURE:
___________________
. Dx -> ECHO.
. Tx -> ACEIs, Nitroprusside & intra-aortic balloon pump as a bridge to surgery.
{3} MYOCARDIAL FREE WALL RUPTURE:
__________________________________
. Mechanical complication of transmural ANTERIOR wall MI.
. Presents with profound chest pain & profound shock.
. Rupture of the Lt ventricle -> Hemopericardium & tamponade.
. Pericardial effusion & tamponade signs (Dyspnea, hypotension, JVD, Pulsus paradoxus).
. Tamponade compresses the Lt wall ventricle& decreases stroke volume -> -- BP & ++ HR.
. EKG -> Low voltage QRS complexes & Electrical alternans.
. Dx -> ECHO.
. Tx -> Pericardiocentesis & Supportive care & urgent surgical repair.
{4} INTERVENTRICULAR SEPTAL RUPTURE:
_____________________________________
. Around 5 days after infarction.
. Presents with profound chest pain & profound shock.
. Interventricular wall rupture causes a ventricular septal defect.
. Sudden onset of hypotension congestive biventricular failure (Right predominant).
. Loud holosystolic murmur heard best at the lower left sternal border.
. Dx -> Echo & SWAN-GANZ Rt heart catheterization.
. Toxicity -> (Anorexia, Nausea & vomiting) & Biventricular tachycardia & yellow vision.
. Most common arrhythmia due to Digitalis is ATRIAL TACHYCARDIA WITH VARIABLE AV BLOCK !
. Tx of Digoxin toxicity -> Na-K ATPASE, Lidocaine & Digibind (Abs against Digitalis).
. N.B. 6. DRUGS LOWERING MORTALITY IN CHF -> ACEIs - ARBs - BB - SPIRONOLACTONE & ASPIRIN
. Hydralazine & nitrates have been proven to lower mortality in CHF.
. Implantable defibrillator lowers mortality & prevents sudden death due to arrhythmia.
. N.B. 7. Digoxin & loop diuretics "Furosemide" DO NOTTTT lower mortality.
. N.B. 8. EJECTION FRACTION (EF):
. Best initial test -> TRANS-THORACIC ECHOCARDIOGRAPHY (TTE).
. Most accurate test -> MUGA scan or nuclear ventriculography.
. N.B. 9. A NORMAL BNP excludes CHF !
. N.B. 10. If their is hyperkalemia 2ry to ACEIs, don't give ARBs (Also cause ++ K)!
. Give HYDRALAZINE (DIRECT ACTING ARTERIOLAR VASODILATOR) instead.
. N.B. 11. A H/O of upper RTI followed by suuden onset cardiac failure in a healthy pt,
. is suggestive of dilated cardiomyopathy.
. It is the end result of myocardial damage due to toxic, metabolic or infectious agents.
. Viral myocarditis is most commonly seen following Coxsackie virus B infection.
. Viral myocarditis may cause dilated cardiomyopathy via direct viral damage.
. Dx -> Echocardiogram -> Dilated ventricles with diffuse hypokinesia.
. Low EF (Systolic dysfunction).
. N.B. 12. Mechanism of edema in congestive heart failure:
. In heart failure, there is defective circulating blood volume -> -- COP.
. -- COP -> Renal hypoperfusion -> Activation of Renin Angiotensin Aldosterone system.
. ++ in concentration of both Angiotensin 2 & Aldosterone.
. Angiotensin 2 -> -- Renal blood flow by constricting the efferent renal arteriole.
. Aldosterone -> ++ Na Reabsorption -> ++ water retention -> Edema.
. N.B. 13. HYPO-NATREMIA is a bad prognostic factor in pts with heart failure.
. It indicates the severity of heart failure i.e. high level of neurohumoral activation.
. -- Na is associated e' high levels of renin, aldosterone, vasopressin & norepinephrine.
. -- water intake (Not ++ Na intake) may correct the electrolyte imbalance.
. N.B. 14. HYPO & HYPER-KALEMIA are an imporatant electrolyte imbalance in HF.
. It reflects the activity of RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM.
. It may be due to drug interactions.
. Hyperkalemia due to ACEIs (Enalapril), Digoxin & K sparing diuretics (Spironolactone).
. Hypokalemia due to Thiazide diuretics (Furosemide).
. N.B. 15. AMYLOIDOSIS may cause congestive heart failure.
. It is extracellular deposition of excees proteins leading to organ dysfunction.
. Extra-cardiac manifestations (proteinuria & easy bruisability) are the key words!
. Common causes of amyloidosis include multiple myeloma (AL amyloidosis).
. Chronic inflammatory diseases e.g. rheumatoid arthritis (AA amyloidosis).
. Deposition of amyloid fibrils in the kidney -> proteinuria.
. Amyloid fibrils binding to liver-> -- coagulation factors synthesis-> Easy bruisability
. Amyloid fibrils deposition in the heart -> Restrictive cardiomyopathy.
. Restrictive cardiomyopathy is due to thickened ventricular wall & diastolic dysfunction . Systolic function is
. Valvular lesion _____ ++ VR (Squatting & Raising legs) ____ -- VR (Standing & Valsalva)
__________________________________________________________________________________________
. AS,AR,MS,MR, VSD ____
(+)
____
(-) Give diuretics !
. HOCM & MVP __________
(-)
____
(+)
. EFFECT OF CHANGE IN AFTERLOAD:
_________________________________
. Valvular lesion _____ ++ AFTERLOAD (HAND GRIP)
____ -- AFTERLOAD (AMYL NITRATE)
__________________________________________________________________________________________
. AS __________________
(-)
____
(+)
. AR __________________
(+)
____
(-) Give ACEIs !
. MR __________________
(+)
____
(-) Give ACEIs !
. VSD _________________
(+)
____
(-) Give ACEIs !
. HOCM ________________
(-)
____
(+)
. MVP _________________
(-)
____
(+)
. LOCATION & RADIATION OF MURMURS:
___________________________________
. AS -> Heard best at 2nd Rt intercostal space & radiates to the carotid arteries.
. AR, TA, TR, VSD -> Heard best at Lt lower sternal border.
. MR -> Heard best at apex & radiates into the axilla.
. DIANOSIS:
____________
. Best initial test -> ECHOCARDIOGRAPHY (Trans-Thoracic TTE > Trans-Esophageal TEE).
. Most accurate test -> Left heart catheterization.
{1} AORTIC STENOSIS (AS):
__________________________
. Chest pain.
. Old pt with H/O of HTN.
. Syncope & HF are less common presentations.
. Syncope due to left ventricular out flow obstruction.
. Associated CAD.
. AS becomes sympomatic when it is severe (Valve areas < 1 cm2).
. CRESCENDO DECRESCENDO SYSTOLIC MURMUR.
. Heard best at 2nd Rt intercostal space & radiates to the carotid arteries.
. PULSUS PARVUS ET TARDUS (Week & delayed pulse stroke).
. EKG & CXR -> Lt ventricular hypertrophy.
. Tx -> Best initial ttt -> DIURETICS.
. Tx -> Failed -> AORTIC VALVE REPLACEMENT. (Give Warfarin till INR 2-3).
. N.B.
. Aortic stenosis in young individual mostly due to CONGENITAL BICUSPID AORTIC VALVE.
. Pts with severe aortic stenosis often have large left ventricular mass, so..
. requiring additional oxygen.
. ++ myocardial oxygen demand -> Anginal pain.
. N.B.
. Aortic stenosis in old individual is mostly due to AGE DEPENDENT SCLEROCALCIFIC CHANGES
. They may present with exertional syncope due to restricted COP due to stenotic aorta.
. N.B.
. Indications for aortic valve replacement:
. LOUD S1.
. DIASTOLIC RUMBLE AFTER AN OPENING SNAP "Extra-sound in diastole".
. EKG & CXR -> LT atrial hypertrophy.
. CXR -> Lt border Straightening & Elevation of the left main bronchus.
. Tx -> Best initial therapy -> Diuretics.
. Tx -> Most effective therapy -> Balloon valvuloplasty.
. Pregnancy is not a contraindication to valvuloplasty.
. N.B. MS may be caused by INTRACARDIAC ATRIAL TUMOR (ATRIAL MYXOMA).
. Atrial myxoma may obstruct the mitral valve.
. Constitutional manifestations of the tumor (Low grade fever & weight loss).
. Presents as a mass on echocardiography.
. May be assocaiated e' neurological symptoms "side weakness" due to tumor embolization.
. Atrial myxoma is NOT equal to Myxomatous valve degeneration (COMMON MISTAKE) !!!
{4} MITRAL REGURGITATION (MR):
_______________________________
. Dyspnea on exertion is the most common complaint.
. Any disease leads to heart dilatation e.g. Hypertension, ischemic heart disease.
. HOLOSYSTOLIC MURMUR OBSCURING BOTH S2 & S2.
. S3 GALLOP due to volume overload.
. Tx -> Best initial therapy -> ACEIs, ARBs & Nifedipine.
. Tx -> Add loop diuretic (Furosemide).
. Tx -> Surgery (If EF < 60% or LVESD > 40mm).
. N.B.
. DIASTOLIC & continous murmur as well as loud systolic murmurs on auscultation,
. should always be investigated using TTE (Trans-thoracic Doppler Echocardiography).
. Mid-systolic soft murmurs in an asymptomatic young pt are usually benign,
. No further investigations are needed.
. N.B.
. AORTIC STENOSIS -> Trans-Thoracic TTE.
. AORTIC DISSECTION -> Trans-Esophageal TEE.
. N.B.
. Acute MR can occur due to papillary muscle dysfunction in pts with acute MI.
. Acute MR characteristically causes a rise in LEFT ATRIAL PRESSURE.
. NO CHANGE in (Lt atrial size - Lt ventricular size - Lt ventricular EF).
. MITRAL VALVE PROLAPSE (MVP):
______________________________
. Mostly a young female.
. Mostly asymptomatic.
. Absent symptoms of CHF.
. Mid-systolic click over the cardiac apex.
. An accompanying short systolic murmur if mitral regurgitation is present.
. Squatting -> ++ VR -> ++ cardiac preload -> -- or eliminates the prolapse.
. Prosthetic valves.
. Intravascular catheters.
. Implanted devices (pacemakers - Defibrillators).
. Injection drug users.
* STREPTOCOCCUS VIRIDANS:
__________________________
. Dental procedures.
. Incision & biopsy or respiratory tract.
* COAGULASE NEGATIVE STREPTOCOCCI:
___________________________________
. Intravascular catheters.
. Prosthetic valves.
. pacemakers - Defibrillators.
* ENTEROCOCCI:
_______________
. Nosocomial urinary tract infections.
* STREPTOCOCCUS BOVIS:
_______________________
. Colon carcinoma.
. Inflammatory bowel disease.
* FUNGI:
_________
. Immunocompromized host.
. Chronic indwelling catheters.
. Prolonged antibiotic therapy.
. SEPTAL DEFECTS:
_________________
_________________
.1. VENTRICULAR SEPTAL DEFECT (VSD):
_____________________________________
. HOLOSYSTOLIC MURMUR at the lower left sternal border.
. Mostly asymptomatic.
. Large defects may cause SOB.
. Dx -> ECHOCHARDIOGRAPHY.
. Dx -> Catheterization is used to determine the degree of Lt to Rt shunt.
. Tx -> Mild defects can be left without mechanical closure.
.2. ATRIAL SEPTAL DEFECT (ASD):
________________________________
. Mostly asymptomatic.
. Large defects may cause signs of Rt venticular failure (SOB - parasternal heave).
. FIXED SPLITTING of S2.
. Dx -> ECHOCARDIOGRAPHY.
. Tx -> Best initial -> Percutaneous or catheter devices.
. Tx -> Repair if the shunt ratio exceeds 1.5:1.
. CARDIOMYOPATHY:
_________________
_________________
{1} DILATED CARDIOMYOPATHY:
____________________________
. presents & managed in the same way as CHF.
. Most common causes (Ischemia - Viral - Alcohol - Adriamycin - Radiation - Chaga's dis).
. Dx -> Best initial test -> ECHOCARDIOGRAPHY to detect EF.
. Dx -> Most accurate test -> MUGA or nuclear ventriculography.
. Tx -> ACEIs, ARBs & spironolactone.
. Digoxin -- symptoms but doesn't prolong survival.
{2} HYPERTROPHIC CARDIOMYOPATHY:
_________________________________
. SOB on exertion.
. S4 Gallop.
. Dx -> ECHOCARDIOGRAPHY -> NORMAL EF.
. Tx -> BB & Diuretics.
. ACEIs may be used.
. Digoxin & spironolactone do NOT benifit !
. PERICARDIAL DISEASES:
_______________________
_______________________
{1} PERICARDITIS:
__________________
. Sharp & brief pleuritic chest pain (changes with respiration).
. Positional (Relieved by sitting up & leaning forwards).
. Viral in origin in most cases.
. Friction rub.
. Dx -> EKG -> ST segment elevation in ALL leads.
. Dx -> EKG -> PR segment is pathognomonic but isn't always present.
. Tx -> Best initial therapy -> NSAIDs (Indomethacin).
. Tx -> Add oral steroids (prednisone) in refractory cases.
. N.B.
. UREMIC PERICARDITIS (UP) occurs in 10 % of renal failure pts.
. Typically those with BUN > 60 mg/dl.
. Most pts do NOT present with the classic ECG changes of pericarditis (Diffuse ST elev.)
. Tx -> HEMODIALYSIS -> Rapid resolution of chest pain & -- size of effusion.
. N.B. Pericardial effusions appear as an enlarged, "water bottle" shaped on CXR.
. P/E of pericardial effusion without a tamponade -> Diminished heart sounds &
. Difficulty to palpate the point of maximal impulse.
{2} PERICARDIAL TAMPONADE:
___________________________
. SOB + Beck's triad (Hypotension + JVD + Muffled heart sounds).
. AORTIC DISEASES:
__________________
__________________
. AORTIC DISSECTION:
_____________________
. Dissection of the THORACIC aorta.
. Most common cause is SYSTEMIC HYPETENSION.
. Marfan's & Ehlers-Danlos $yndromes may cause dissection in YOUNG population.
. Tearing chest pain radiating to the back between the scapulae.
. Very severe "Ripping".
. Dissection may extend to:
. carotid arteries -> stroke & AMI.
. renal arteries -> Acute renal failure.
. aortic valve -> Aortic regurgitation: Early diastolic decrescendo murmur at the sternum
. ARRHYTHMIAS:
_______________
_______________
. INITIAL MANAGEMENT OF CARDIAC ARREST:
________________________________________
. The 1st step is to make sure that the pt is truely unresponsive.
. Exclude sleeping or syncopal episode !!
. Open the airway -> Head tilt, chin lift & jaw thrust.
. Five rescue breaths if not breathing.
. Check pulse & start chest compressions if pulseless.
. CPR doesn't restart the heart; it keeps the pt alive until cardioversion is performed.
. The most iportant factors in improving survival in pts with sudden cardiac arrest:
______________________
______________________
. Rarely associated with hemodynamic instability bec. COP is dependent upon ventricles.
. H/O of palpitations, dizziness or lightheadedness.
. H/O of exercise intolerance or dyspnea.
. H/O of embolic stroke.
. N.B. An irregularly irregular rhythm suggests Af even before an EKG is done !
. Af is the most common arrhythmia in the US.
{1} & {2} . ATRIAL FIBRILLATION (Af) & ATRIAL FLUTTER (AF):
____________________________________________________________
. Both have identical management .. Only 2 differences:
. 1 -> Flutter is a regular rhythm while fibrillation is irregular.
. 2 -> Flutter usually goes back into sinus rhytm or deteriorates into fibrillation.
{1} . Atrial fibrillation (Af):
________________________________
. IRREGULAR pulse (R-R interval) with ABSENT "P" waves & narrow QRS complexes.
. Af is a common complication after CABG.
. The most common cause of Af is HYPERTHYROIDISM.
. Tx -> Hemodynamically UN-stable -> Synchronized DC cardioversion.
. Synchronization helps to prevent deterioration into VT or VF.
. CHRONIC Af:
______________
. Af lasting more than 2 days.
. It takes several days to be a risk of clot formation.
. The majority of those who are converted to sinus rhythm will not stay in sinus.
. Af & AF are mostly caused by anatomic abnormalities of the atria from HTN or valve dis.
. Shocking the pt. into sinus rhythm doesn't correct a dilated left atrium.
. Over 90% will revert to fibrillation.
. SLOW THE RATE & COAGULATE "WARFARIN" are the STANDARD CARE for chronic Af.
. The best initial therapy is to control the rate with BB, CCB or Digoxin.
. Once the rate is under 100/min -> Give WARFARIN until the INR is between 2-3.
. CCBs used (Diltiazem & verapamil) -> Block the AV node.
. You need to use heparin only if there is a current clot in the atrium.
. N.B. Rate control drugs don't convert the pt. into sinus rhythm.
. N.B. Heparin is not necessary before starting a pt on warfarin.
. N.B. Controlling the rhythm or rate in pts with prolonged tachysystolic Af,
. usually improves the LV function significantly, sometimes even dramatically.
. Af CLASSIFICATION:
_____________________
. FIRST DETECTED -> Initial diagnosis, independent of duration.
. PAROXYSMAL -> Recurrent > 2 episodes that terminate spontaneously in < 7days.
. PERSISTENT -> Episodes lasting > 7days.
. LONGSTANDING PERSISTENT -> Persistent > 1 year duration.
. PERMANENT -> Persistent with no further plans for rhythm control.
. LONE Af:
___________
. LONE = paroxysmal, persistent or permanent Af with no structural heart disease.
. Pts e' low risk of stroke can safely prevent it e' using ASPIRIN alone e'out warfarin.
. Criteria of low risk of stroke from Af:
-> No cardiomyopathy, CHF or atherosclerosis.
-> No hypertension.
-> Age 75 or younger.
-> No DM.
-> No past stroke.
. When all the previous risk factors are absent, this is called "LONE Af".
. Tx of lone Af -> ASPIRIN & rate control with BB.
. CHADS2 SCORING:
__________________
. C -> Congestive heart failure.
. H -> Hypertension (BP > 140/90 mmHg).
. A -> Age > 75 ys.
. D -> DM.
. S -> Previous stroke or TIA.
. ANTICAGULATION ttt in Af according to CHADS2 score:
______________________________________________________
. CHADS2 score -> Stroke risk -> Anti-thrombotic ttt.
. 0
-> Low
-> No anticoagulation (preferred) or Aspirin.
. 1
-> Intermediate -> Anticoagulation (preferred) or Aspirin.
. 2
-> High
-> Anticagulation.
. N.B.
. Antiarrhythmic drugs are reserved for pts with recurrent symptomatic Af episodes,
. or those with Lt ventricular systolic dysfunction thought to be 2ry to uncontolled Af.
. Long term use of antiarrhythmic drugs has significant side effects.
. N.B.
. Amiodarone cause pulmonary toxicity & sh'd be avoided in pts with preexisting lung dis.
. So .. RESTRICTIVE lung disease pts can NOT be given Amiodarone.
. Amiodarone is ABSOLUTELY CONTRAINDICATED.
. N.B.
. BBs causes bronchoconstriction.
. So .. OBSTRUCTIVE lung disease (Asthma - COPD) pts can NOT be given BBs.
. BBs are RELATIVELY CONTRAINDICATED in obstructive lung diseases.
. BBs can be used SAFELY in RESTRICTIVE lung diseases.
. N.B.
. Af pts with past H/O of Wolf-Parkinson-White $yndrome,
. Should be treated with cardioversion or anti-arrhythmics like procainamide.
. AV nodal blockers (BB - CCB - Digoxin - Adenosine) should be AVOIDED,
. because they ++ conductance through the accessory pathway after AVN blockage.
. N.B.
. Pts e' new-onset Af sh'd've TSH & free T4 levels measured to rule out hyperthyroidism.
{3} . SUPRA-VENTRICULAR TACHYCARDIA (SVT):
___________________________________________
. Palpitations in a pt who is usually hemodynamically stable.
. No structural heart disease.
. Heart rate 160-220/min.
. Mechanism of SVT -> "RE-ENTRY into the AV NODE."
. Narrow QRS complex tachycardia.
. No regular P waves as they are burried within the QRS complexes.
. PSVT most commonly results from accessory conduction pathways through the AV node.
. Vagal maneuvers & medications that -- conduction through the AV node reslove the attack
. Cold water therapy affects the AV conductivity. (VVVVVVV. imp.).
. The best initial step is vagal maneuvers (carotid message, valsalva & ice immersion).
. ADENOSINE if vagal maneuvers don't work.
. BB (Metoprolol), CCB (Diltiazem) or Digoxin if adenosine is not effective.
. If hemodynamically UNSTABLE -> DC CARDIOVERSION.
. N.B. you sh'd differentiate bet SVT & sinus tachycardia due to panic attacks,
. Sinus tachycardia has normal P wave morphology & relationship with QRS complex.
. Tx of sinus tachycardia due to anxiet -> Alprazolam.
. N.B. You sh'd differentiate bet SVT & ventricular tachycardia (VT),
. Ventricular tachycardia has WIDE QRS COMPLEXES,
. while SVT have NARROW QRS complexes.
. Tx of VT if hemodynamically stable -> Amiodarone.
. N.B. You sh'd differentiate bet SVT & Af with rapid ventricular response (AF with RVR),
. SVT presents as sudden onset, REGULAR, narrow complex tachycardias.
. SVT HR 160 - 220 beats/min.
. Can be managed by vagal maneuvers as carotid massage or Adenosine.
. But Af with RVR has IRREGULARLY IRREGULAR RHYTHM with narrow complex tachycardia,
. in addition to absence of P waves.
. Af with RVR is managed by rate control (BB metoprolo or CCB Diltiazem),
. if hemodynamically stable (No hypotension).
{4} . WOLFF - PARKINSON - WHITE $YNDROME (WPW):
________________________________________________
. Anatomic abnormaily in the conduction pathway.
. Supraventricular tachycardia alternating with ventricular tachycardia.
. Supraventricular tachycardia that gets worse after diltiazem or digoxin.
. DELTA waves on EKG.
. Dx -> Most accurate test -> Cardiac electrophysiology (EP) studies.
. Tx -> Acute therapy -> Procainamide or Amiodarone. (Only if there is current WPW).
. Tx -> Chronic therapy -> Radiofrequency catheter ablation is curative.
. Digoxin & CCB are DANGEROUS "they block the normal pathway forcing abnormal conduction"
. N.B. Pts with Wolf-Parkinson-White $yndrome who develop Atrial fibrillation with RVR,
. Should be treated with cardioversion or anti-arrhythmics like procainamide.
. AV nodal blockers (BB - CCB - Digoxin - Adenosine) should be AVOIDED,
. because they ++ conductance through the accessory pathway after AVN blockage.
{5} MULTI-FOCAL ATRIAL TACHYCARDIA (MAT):
__________________________________________
. N.B.
. Absence of P waves is characteristic for Af.
. PULMONARY VEINS are the most common frequent origin of ectopic foci that cause Af.
. N.B.
. DELTA waves are characteristic for WPW $.
. N.B.
. FLUTTER waves are characteristic for AF.
. TRICUSPID ANNULUS is the most common frequent of ectopic foci causing AF.
. N.B.
. HIGH RATE REGULAR RHYTHM NARROW QRS COMPLEXES TACHYCARDIA = PSVT.
. It mostly involves formation of a re-entry circuit within AV node or accessory pathway.
. BRADYCARDIA & AV BLOCK:
__________________________
__________________________
. HR < 60/min.
. EKG is mandatory to detect the cause of bradycardia.
. {1} SINUS BRADYCARDIA:
_________________________
. HR < 60/min with REGULAR rhythm & constant PR interval.
. May be associated with exaggerated vagal activity, hypoglycemia & sick sinus $yndrome.
. May be induced by some medications (Digitalis, BB & CCB).
. Mostly asymptomatic.
. May be dizziness - lightheadedness - syncope - fatigue & worsened angina.
. No ttt if asymptomatic no matter how low the heart rate is.
. If symptomatic -> Atropine is best initial ttt & PACE MAKER is the most effective ttt.
. Atropine ++ HR by -- vagal input.
. {2} FIRST DEGREE AV BLOCK:
_____________________________
. Delayed impulse transmission from atria to ventricles.
. Prolonged PR interval > 0.20 seconds i.e. > 5 small squares i.e. > 1 big square.
. The PR interval remains constant.
. There is a QRS complex present for every P wave.
. Same management.
. {3} SECOND DEGREE AV BLOCK:
______________________________
. {a} MOBITZ "1" = WENCKEBACH BLOCK:
_____________________________________
. Intermittent AV nodal block.
. Progressively lenghtening PR interval that results in dropped beat.
. PR interval longer than previously conducted beat until dropped QRS.
. Grouped QRS complexes followed by dropped complex.
. Low risk for complete heart block.
. Normal sign in aging population.
. No ttt either symptomatic or asymptomatic !!
FUSION/CAPTURE BEATS?
_______________________
|
______YES_____________NO________
|
|
VENTRICULAR TACHYCARDIA
SUPRAVENTRICULAR TACHYCARDIA With ABERRANCY
_________________________ _____________________________________________
|
|
_________________________
_____________________________
|
| |
|
STABLE
UN-STABLE
STABLE
________
___________
_________
|
|
|
. IV AMIODARONE
. HYPOTENSION
. VAGAL MAEUVERS (Carotid massage)
. Altered mentation . Adenosin - BB - CCB - Digoxin.
. Respiratory distress
|
. SYNCHRONIZED CARDIOVERSION
. SYNCOPE MANAGEMENT:
______________________
______________________
. Management of syncope is based on 3 criteria:
________________________________________________
. Was the loss of consciousness sudden or gradual ?
. Was the regaining of consciousness sudden or gradual ?
. Cardiac examination normal or abnormal ?
{1} Was the loss of consciousness sudden or gradual ?
______________________________________________________
. Sudden -> Cardiac or neurologic etiology "seizures".
. Gradual -> Toxic metabolic problem - Drug toxicity - Hypoxia - Anemia - Hypoglycemia.
{2} Was the regaining of consciousness sudden or gradual ?
___________________________________________________________
. Sudden -> Cardiac etiology (Rhyhtm disorder or structural heart disease).
. Gradual -> Neuorologic "Siezures".
{3} Cardiac examination normal or abnormal ?
_____________________________________________
. Normal -> Ventricular arrhythmia.
. Abnormal -> Structural heart disease (AS - HOCM - MS - MVP).
. DIFFERENTIAL DIAGNOSIS OF SYNCOPE:
_____________________________________
.1. VASO-VAGAL = NEURALLY MEDIATED SYNCOPE = NEUROCARDIOGENIC SYNCOPE:
_______________________________________________________________________
. Most common type of syncope.
. Due to excessive vagal stimulation -> Profound hypotension & bradycardia.
. Triggers -> Prolonged standing - emotional stress - painful stimuli.
. Situations like medical needles & urination can precipiatate it.
SEIZURES
_______
SYNCOPE
. Upright position.
. Emotions.
. Heat.
. Crowded places.
* Sequelae
. Delayed return to baseline.
. Post ictal state (sleepy confused).
. N.B.
. Clonic jerks may occur during any syncope if it is prolonged due to brain hypoxia.
. Absence of previous H/O of seizure & presence of structural heart disease,
. excludes seizure & makes a diagnosis of syncope due to arrhythmia more reliable.
. SYSTEMIC HYPERTENSION:
________________________
________________________
. Systolic blood pressure > 140 mmHg.
. Diastolic blood pressure > 90 mmHg.
. A diabetic pt or chronic renal disease pt > 130/80 mmHg.
. Hypertension is the most common risk factor for MI (Death most common risk factor).
. 95% of cases of HTN has no clear etiology "Essential hypertension".
. Commonest cause of essential HTN is RIGIDITY OF ARTERIAL WALL "Atherosclerosis".
. 5 % of cases has definite etiology (Mostly YOUNG population) -> "Secondary HTN".
. Causes of SECONDARY HYPERTENSION:
-> Renal artery stenosis "systolic diastolic abdominal periumbilical bruit".
-> Glomerulonephritis.
-> Coarctation of the aorta "Upper extremity BP > Lower extremity BP".
-> Acromegaly.
-> Pheochromocytoma "Episodic HTN - flushing - Palpitations - Headache - Part of MEN 2".
-> Hyperaldosteronism "++Na,--K, Weakness, Metabolic alkalosis,-- Renin,++ Aldosterone".
-> Cushing $ (Central obesity - Abdominal striae - Facial plethora).
-> Exogenous therapeutic glucocorticoids.
____________________________________________
. Metabolic side effects -> Hyperglycemia, ++ triglycerides & ++ LDL cholesterol.
. Electrolyte side effects -> Hyponatremia, hypokalemia & hypercalcemia.
. DIRECT RENIN INHIBITOR:
__________________________
. Enhances natriuresis.
. -- serum angiotensin 2 concentration.
. -- Aldosterone production.
* PRIMARY HYPERPARATHYROIDISM:
_______________________________
. Hypercalcemia (Polyuria & polydipsia).
. Renal stones.
. Neuropsychiatric (Confusion, depression & psychosis).
* AORTIC COARCTATION:
______________________
. Differential hypertension with brachial femoral pulse delay.
. MISCELLANEOUS TOPICS:
_______________________
_______________________
. NOREPINEPHRINE INDUCED VASOSPASM:
___________________________________
. Caused by vasopressors used in emergency bleeding episodes.
. Norepinephrine is an alpha 1 agonist causing vasoconstriction.
. Norepinephrine causes ischemia of the distal fingers & toes 2ry to vasospasm.
. SYMMETRICAL duskiness & coolness of all fingertips.
. A similar condition may occur in intestines (Mesenteric ischemia) or kidneys (RF).
. BLUE TOE $YNDROME:
____________________
. Due to cholesterol emboli in pts with atherosclerosis.
. Affect the distal portions of the digits.
. ABSENCE of symmetry of digital involvement.
. SUBCLAVIAN VEIN THROMBOSIS:
_____________________________
. Used for total parenteral nutrition.
. Continous irritating hyperosmolar fluid can traumatize the veins leading to thrombosis.
. Prolonged placement of central lines can lead to subclavian vein thrombosis.
. It results in arm swelling & pallor.
. CATHETER REMOVAL IS MANDATORY.
. Duplex is ordered to document thrombus & the need for anticoagulation.
. HEAT STROKE:
______________
. Temperature above 40.5 c (105 F).
. Exertional heat stroke occurs in healthy individuals exercising in extreme heat.
. Dehydration, hypotension, tachycardia & tachypnea are common.
. Systemic effects like seizures, ARD$, DIC & hepatic or renal failure may occur.
. COCAINE USE:
______________
. Atrophic nasal mucosa.
. Sympathetic hyperactivity (Tachycardia, hypertension, dilated pupils).
. Chest pain due to coronary vasospasm.
. Psychomotor agitation & siezures.
. Complications (Acute MI - Aortic dissection - Intracranial hemorrhage).
_____________
. Bilateral.
. Congestive heart failure.
. Dyspnea & orthopnea.
. Jugular venous distension & hepatomegaly.
{2} HEPATIC:
_____________
. Bilateral.
. Hepatic cell failure.
. Ascites dominates over LL edema.
. Abnormal liver function tests (++ ALT & AST)
. Hypoalbunimea & hyperbilirubinemia.
. Spider nevi, gynecomastia, palmer erythema.
{3} RENAL:
___________
. Bilateral.
. Nephrotic $yndrome (Due to massive proteinuria).
. Nephritic $yndrome (Due to fluid retention).
. Proteinuria, hypoalbuminemia.
. Abnormal renal function tests (++ urea & creatinine).
{4} NUTRITIONAL:
_________________
. Bilateral.
. H/O of metabolic problems.
. Rare in adults.
{5} MEDICATIONS SIDE EFFECTS:
______________________________
. Bilateral.
. Ex. Dihydropyridine Ca channel antagonists (Amlodipine).
. Amlodipine dilate peripheral blood vessels.
{6} VENOUS INSUFFECIENCY:
__________________________
. Unilateral.
. Varicose veins.
. Skin changes & ulcers.
. N.B. TRICKY CASE:
___________________
. 53 ys old pt - 2 days H/O of Rt calf pain & swelling.
. Constant pain - exacerbated by knee flexion.
. H/O of past IV drug abuse, endocarditis & stroke.
. He is currently wheel-chair bound 2ry to stroke related Lt sided hemiparesis.
. BP 140/90 - HR 100/mon.
. No JVD - No hepato-jugular reflux.
. Clear chest on ausculatation.
. Enlarged abdomen with shifting dullness & fluid wave suggestive of ascites.
. Palpable liver 3 cm below the Rt. costal margin - splenomegaly.
. Rt sided calf swelling & tendrness.
. What is the cause of ascites ??
. HYPOVOLEMIC __ - __ + __ - __ + __ -
. SEPTIC
__ + __ - __ - __ + __ -
. NEUROGENIC
__ - __ - __ - __ + __ -
gangrene!".
. U can't differentiate bet. PERSISTENT CHALAZION & BASAL CELL CARCINOMA except through
HISTOPATHOLOGICAL exam.
. MOLLUSCUM CONTAGIOSUM is caused by POX VIRUS not HPV !!!!!!! (REPEATED FAULT) !!
. BASAL CELL CARCINOMA:
----------------------. Fair skinned individual.
. Prolonged sun exposure.
. Slowly growing nodule with rolled border.
. SHINY PEARL.
. Most common location is the lower eyelid margin.
. Seborrheic Keratosis:
----------------------. OLD AGE.
. WAXY - "STUCK ON" - well circumscribed lesion.
. Not pre-cancerous.
. No therapy is required.
. Surgical removal for cosmetic purpose.
. MELANOMA -----------> Excisional biopsy " FULL THICKNESS".
. Varicella Zoster virus = Shingles:
-----------------------------------. Vesicular eruption that occurs in a dermatomal distribution.
. Preceided by pain.
. The 1ry disease in children is termed "chickenpox".
. ANGIO-EDEMA:
-------------. H/O of ICU pt on ACEIs e.g ENALAPRIL.
. Edema in the face, mouth, lips.
. Laryngeal edema may occur causing airway obstruction.
. occurs due to BRADYKININ release.
. it may occur at any time not just at the start of drug intake.
. Dx----> Low levels of C2 & C4.
. Tx----> STOP ACEIs + FRESH FROZEN PLASMA + Secure the airway.
. HERIDITARY angioedema:
-----------------------. C1 esterase inhibitor defeciency.
. Drug induced PHOTOTOXICITY:
----------------------------. The most common drug is DOXYCYCLINE (TETRACYCLINE).
. Manifest as exaggerated sunburn reactions with erythema ,edema & vesicles over sun. WARFARIN induced skin necrosis:
--------------------------------. More common in females.
. Common sites: Breasts, buttocks, thighs & abdomen.
. Initial complaint is pain followed by bullae formation & skin necrosis.
. Occurs within weeks after starting therapy.
exposed areas.
. Tx: Discontinue WARFARIN & Give Vit. K & maintain anticoagulation using Heparin.
. Dermatitis Herpetiformis:
--------------------------. Pruritic papules & vesicles over the extensor surfaces.
. Presence of anti-endomysial antibodies.
. Tx----------------> DAPSONE.
. Dermatitis Herpetiformis:
--------------------------. Ass. with celiac disease.
. Erythematous papules, vesicles & bullae that occur bilaterally, symmetrically & in
arrangement.
. On the extensor sufraces of the elbows,knees,buttocks.
. Tx: Gluten free diet & DAPSONE.
groups "herpetiform"
. Pemphigus Vulgaris:
--------------------. Thin & fragile large wide bullae.
. +ve Nikolsky sign.
. Mouth is involved.
. H/O of ACE Is use.
. Deposition of IgG in the epidermis.
. Bullous Pemphigoid:
--------------------. Thick & intact small & narrow bullae.
. Bullae don't rupture easily.
. No mouth involvement.
. H/O of SULFA drugs use.
. Deposition of IgG & C3 in the epidermis.
. ROSACEA:
---------. 30 - 60 ys old pt.
. TELANGECTASIA over the cheeks, nose & chin.
. Flushing of these area is precipitated by hot drinks,heat,emotion.
. Tx: initial ttt is METRONIDAZOLE.
. Toxic Epidermal Necrolysis "TEN":
---------------------------------. Much more surface area involved.
. Higher mortality rate.
. +ve NIKOLOSKY sign.
. Although the most common cause of death is sepsis, Anitibiotics is not indicated.
. TEN has similar features to SSSS, however, TEN is DRUG INDUCED but SSSS is caused by a
. Vilitiligo (Leukoderma):
-------------------------. Young 20-30 ys.
. Pale whitish macules with hyperpigmented borders.
. Around body orifices.
. Auto-immine destruction of melanocytes.
toxin.
ENT
----. TEMPORO-MANDIBULAR JOINT DYSFUNCTION:
--------------------------------------. H/O of teeth grinding at night.
. Referred pain to ear.
. Worse with eating.
. Peri-tonsillar abscess:
------------------------. Muffled voice make one consider other diagnosis than simple tonsillitis or pharyngitis. . Deviation of the Uvula +
Unilateral lymphadenopathy = Peri-tonsillar abscess.
. Tx: URGENT NEEDLE ASPIRATION + IV Antibiotics.
. PRESBYCUSIS:
-------------. Old pt in 60s.
. Sensori-neural hearing loss.
. HIGH frequency BILATERAL hearing loss.
. Difficult hearing in noisy crowded places.
. OTOTOXIC drugs:
----------------. Aminoglycosides antibiotics.
. Loop diuretics e.g. Furosemide. NOT THIAZIDEs !!
. Aspirin.
. REMEMBER:
----------. SE of BBs -------> Bronchoconstriction - Bradycardia - fatigue - depression.
. SE of ACEIs -----> Cough - Hyperkalemia - Angioedema.
. SE of Aspirin ---> Tinnitus.
. SE of Thiazides -> Orthostatic Hypotension - photosensitivity - hypercalcemia.
. Serous O.M.
------------. is associated with HIV pts manifesting as middle ear effusion without infection.
. causing dull hypomobile tympanic membrane.
. NASAL POLYP:
-------------. is associated with chronic rhino-sinusitis, asthma.
. H/O of aspirin or NSAIDs induced broncho-spasm
. (ASPIRIN EXACERBATED RESPIRATORY DISEASE).
. Symptoms of bilateral nasal obstruction, nasal discharge & anosmia.
. LEKOPLAKIA:
------------. Hard to remove white patches in the floor of the mouth.
. due to chronic irritation by smoking or alcohol.
. May lead to squamous cell carcinoma.
. CANDIDIASIS:
-------------. Diabetic pt. with poor control.
. Whitish plaques with underlying erythema.
. Easily scrapped off with a tongue depressor.
. Epiglottitis:
--------------. High fever.
. Severe sore throat.
. Odynophagia.
. DROOOOOOOOOOOOOOOOLING.
. Progressive airway obstruction.
. HARSH SHRILL.
. Causative organisms: Haemophilus influenzae & Streptococcus pyogenes.
. Retro-pharyngeal space is the most common neck space susceptible to infection.
. Otosclerosis:
--------------. is the most common cause of conductive hearing loss in middle aged adults 20-30s.
. AMINOGLYCOSIDES - GENTAMYCIN is the most common cause of sensorineural hearing loss.
. Retro-pharyngeal abscess:
--------------------------. Fever & sore throat.
. Dysphagia & Odynophagia.
. Trismus (pain on mouth opening).
. Pain on neck EXTENSION (pain on neck flexion = Meningitis).
. H/O of local trauma to the pharynx e.g. FISH BONE.
. MENIERE's disease:
-------------------. Vertigo = Severe spinning sensation + nausea.
. The type of vertigo is peripheral not central as it last just for 1-2 hours with the
presence of ear fullness & H/O of
excessive cell phone use.
. EAR FULLNESS suggests Meniere's disease
. from an abnormal accumulation of endo-lymph within the inner ear.
. Meniere's dis. is an INNER ear disease.
. Simply exclude CEREBELLAR dis. by absence of inco-ordination or gait disturbances!
. MALIGNANT OTITIS EXTERNA:
--------------------------. caused by PSEUDOMONAS AERUGINOSA.
. Elderly with poorly controlled DM.
. Ear pain, discharge.
. GRANULATION TISSUE within the ear canal on otoscopy.
. Progression to the base of the skull may damaga the facial nerve causing facial palsy. . Dx: CT skull base.
. Tx: IV CIPROFLOXACIN. not surgery !!
. Meniere's disease:
-------------------. Vertigo + Ear fullness + Hearing loss.
. Young pt.
. Chronic diarrhea.
. Abd. pain.
. Weight loss.
. Mouth ulcers.
. Rt upper Q. tenderness without rebound.
. Gas in small & large intestines.
. Reactive thrombocytosis & anemia.
. DIVERTICULOSIS:
---------------. Old pt.
. is associated with constipation not diarrhea,
. with Left lower Q. pain.
. CANCER HEAD PANCREAS:
----------------------. Enlarged (NON TENDER) Gall bladder.
. Weight loss.
. evidence of biliary obstuction (++ALP disproportionate with +AST & +ALT).
. Dx: Abd. CT !
. The most common cause of iron defeciency anemia in an elderly pt is GIT bleeding.
----------------------------------------------------------------------------------. The next step is COLONOSCOPY.
. A single -ve occult blood test doesn't exclude GIT bleeding.
. DYSPHAGIA:
-----------. Both sloids & liquids = Motility disorder e.g. ACHALASIA.
. Solids then progressing to liquids = Obstructing lesion e.g. esophageal
perform BARIUM SWALLOW 1st before endoscopy.
. CARCINOID $ triad:
------------------. Flushing.
. Valvular heart disease.
. Diarrhea.
. Ass. e' hepatic metastasis.
. ++ Serotonin & 5 HIAA in blood & urine.
. The precursor of Serotonin is Tryptophan,
. which is also utilized in the synthesis of Niacin.
. -- Niacin ----> PELLAGRA 4 Ds (Diarrhea-Dermatitis-Dementia-Death).
. Neutrophilic cryptitis is seen on bowel biopsy in pts with IBD.
. CARCINOID $ = Flushing + secretory diarrhea + Wheezing + cardiac problem.
. Intra-abdominal malignancy obstructing the biliary system:
-----------------------------------------------------------. Painless jaundice.
. Conjucated hyper-bilirubinemia.
. Elevated Alkaline phosphatase.
. ex. pancreatic adenocarcinoma.
. Pancreatic choleraa = VIPoma.
------------------------------. The pancreas secretes vaso-active intestinal peptide.
. Hypokalemia (leg cramps).
. chronic diarrhea --> dehydration.
. Abd. pain.
. weight loss.
. facial flushing & redness.
. Dx: Abd. CT.
. FOLIC ACID DEFECIENCY:
-----------------------. A tea & toast type of diet is associated with folic acid defeciency.
. Folic acid is heat sensitive.
. Folic acid defeciency causes macrocytic anemia.
. Corn based diets -> NIACIN defeciency -> PELLAGRA (4Ds):
---------------------------------------------------------. Diarrhea + Dementia + Dermatitis + Death.
. DIVERTICULITIS:
---------------. H/O of costipation & little fiber in diet.
. Left lower quadrant pain & fever.
. Tx: IV Antibiotics.
. If no improvement ---> Abd. CT to detect complications.
. Tropical sprue:
----------------. Endemic tropical area e.g. Puertorico.
. Biopsy of S.I ---> Blunting of villi,
. with infiltration of chronic infl. cells e.g. lymphocytes, plasma cells & eosinophils. . Malabsorption to Vit. B12 &
. The condition may be complicated by systemic toxicity : fever & weight loss,
. with dilated colon on CXR "TOXIC MEGA-COLON".
. Tx: I.V. fluids + Antibiotics + Bowel rest + I.V. corticosteroids.
. If failed: Emergency surgery with sub-total colectomy with end ileostomy.
. Minimal bleeding per rectum or scant hematochezia:
---------------------------------------------------. Dx -> Office based ANOSCOPY or PROCTOSCOPY.
. GIARDIASIS:
------------. Foul smelling stool.
. Abd. cramps.
. Bloating = MALABSORPTION diarrhea.
. H/O of developing country e.g. South America.
. Tx: METRONIDAZOLE.
. MALIGNANT criteria of a colonic polyp:
--------------------------------------. Villous adenoma.
. Sessile adenoma.
. Size > 2.5 cm.
. MULTIPLE MYELOMA:
------------------. Back pain + Renal dysfunction + High ESR + Anemia.
. MM ----> ++ Ca Hypercalcemia.
. ++ Ca ----> Constipation.
. so .. The cause of constipation in a pt. with MM is ELECTROLYTE DISTURBANCE (++ Ca).
. NON-CASEATING GRANULOMA ----> PATHOGNOMONIC to CHRON's disease !
. N.B. UC always involves the rectum while it is spared in CD.
. Angiodysplasia:
---------------. Pt. > 60 ys. with anemia.
. Painless GIT bleeding.
. Murmur of Aortic stenosis.
. DIVERTICULOSIS:
---------------. The most common cause of painless GIT bleeding.
. Not associated with AS.
. Endoscopy: Multiple out-pouchings of the mucosa through the hypertrophied muscular
. ZOLLINGER ELLISON's $:
-----------------------. Multiple duodenal ulcers + Single jejunal ulcer resistant to H2 blockers & PPIs.
. GASTRIN producing PANCREATIC TUMOR.
. Un-controlled gastrin production
. ---> Parietal cell hyperplasia
. ----> +++ Stomach acid production
. ----> Inactivation of pancreatic enzymes
layer.
. ----> Steatorrhea.
. Inflammatory Bowel disease:
----------------------------. Bloody diarrhea + anemia + elevated ESR + Reactive thrombocytosis.
. The type of diarrhea is INFLAMMATORY.
. Newly diagnosed gastric carcinoma transformation in a gastric ulcer by an endoscopy
scan to evaluate the extent of the cancer.
warrants an abdominal CT
. ASIAN pt.
. H/O of very recent viral upper RTI.
. Dx: Best initial test: ++ IgA !
. Dx: Most accurate test: RENAL BIOPSY IS ESSENTIAL !
. Normal complement levels.
. Tx: Steroids.
* HENOCH - SCONLEIN PURPURA:
_____________________________
. Adolescent or child.
. Raised, non-tender purpuric skin lesions "buttocks".
. Abdominal pain.
. Possible bleeding.
. Joint pain.
. Renal involvement.
. Dx: Best initial test: CLINICAL SUSPENSE !
. Dx: Most accurate test: R. biopsy "Not necessary".
. Tx: No ttt - Resolves spontaneously.
* POST-STREPTOCOCCAL GLOMERULONEPHRITIS = PSGN:
________________________________________________
. Dark urine "Tea-colored or cola-colored".
. Periorbital edema & hypertension.
. H/O of Throat or skin infections 10 - 20 days ago.
. Dx: Best initial test: Anti-streptolysin O test "ASLO",
. Anti-DNase & Antihyaluronidase.
. Low complement levels.
. Dx: Most accurate test: R. biopsy sh'd n't be done bec. blood tests r suffecient.
. Tx: Antibiotics e.g. PENICILLIN.
. CONTROL HYPERTENSION & FLUID OVERLOAD with diuretics.
* CRYOGLOBULINEMIA:
____________________
. H/O of HEPATITIS "C" with renal involvement.
. Joint pain & pruritic skin lesions & Hepatosplenomegaly.
. Dx: Best initial test: Serum cryoglobulin componet levels,
. immunoglobulins & light chains, IgM.
. Low complement levels esp. "C4".
. Dx: Most accurate test: R. biopsy.
. Tx: Treat HEPATITIS C with INTERFERON + RIBAVIRIN.
* LUPUS (SLE) NEPHRITIS:
_________________________
. H/O of SLE !!
. N.B. Drug induced lupus spares the kidneys & the brain "V.V.V. imp.".
. Dx: Best initial test: ANA & Anti-Ds DNA.
. Dx: Most accurate test: RENAL BIOPSY.
. R. biopsy is v. imp. in cases of SLE to determine the extent of the disease & ttt.
. Tx:
----- Sclerosis only -------------------------------> No ttt.
----- Mild dis., early stage, NON proliferative ----> Steroids.
----- Severe dis. late stage, PROLIFERATIVE --------> MYCOPHENOLATE.
* ALPORT $YNDROME:
___________________
. CONGENITAL with family H/O of renal failure.
. Recurrent episodes of hematuria.
. Eye & ear problems e.g. deafness.
. No specific therapy.
* HEMOLYTIC UREMIC $YNDROME:
____________________________
. H/O of E-coli 0157:H7
. Intra-vascular hemolysis (fragmented cells on smear).
. ++ Creatinine.
. -- platelets.
* THROMBOTIC THROMBOCYTOPENIC PURPURA "TTP":
_____________________________________________
. HU$ +
. Fever +
. Neurological abnormalities.
. Tx: Plasmapharesis in severe cases.
___________________________
. ARF : PRE-RENAL AZOTEMIA:
___________________________
.. Presentation:
_________________
... Elderly pt with poor oral intake living in nursing homes taking medications e.g.,
... NSAIDs, ACE Is & diuretics causing intravascular volume depletion.
... leading to renal glomerular vasoconstriction.
.. Causes:
___________
. 1- Hypotension "SBP <90 mmHg".
. 2- Hypovolemia "dehydration or blood loss".
. 3- Low oncotic pressure " -- Albumin".
. 4- Congestive heart failure.
. 5- Constrictive pericarditis.
. 6- Renal artery stenosis.
.. Dx:
_______
... BUN:Creatinine ratio > 20:1.
... Urinary Na is low < 20.
... Fe Na < 1.
... Urine osmolality > 500.
___________________________________________________
. ARF : POST-RENAL AZOTEMIA = OBSTRUCTIVE UROPATHY:
___________________________________________________
.. Causes:
___________
. 1- Stone in the bladder or ureter.
. 2- Strictures.
_____________________
. Urinary infection most commonly arises by an ascending route.
. Sexual intercourse is one of the most imp. risk factors of un-complicated UTIs.
. due to its mechanical effect of introducing uropathogens into the bladder.
. RENAL CELL CARCINOMA:
_______________________
. Triad of flank pain, hematuria & palpable abdominal renal mass.
. Scrotal varicoceles "Lt sided" r seen in 10 % of pts.
. Varicoceles typically fail to empty when the pt is recumbent due to tumor obstruction.
. So presence of non emptying varicocele make you suspect mass obstruction by a tumor !
. Para-neoplastic symptoms e.g. Thrombocytosis, hypercalcemia & cachexia.
. Dx: Abd. CT .
. BENIGN PROSTATIC HYPERPLASIA = BPH:
_____________________________________
. Lower urinary tract symptoms e.g. frequency. nocturia, hesitancy & weak stream.
. Hypertrophy usually starts at the CENTRAL part of the prostate.
. Rectal exam: Smooth & firm enlargement of the prostate.
. N.B. prostate cancer rectal ex: (prostate nodules - induration - asymmetry).
. 1st initial step of management is placement of a FOLEY's catheter.
. Tx of BPH: Alpha blockers.
. Tx of severe cases: Surgery TURP.
. Current recommendations: All BPH pts sh'd have urinalysis & serum creatinine,
. to assess for urinary infection, obstruction or hematuria.
. If there is woresening of creatinine,
. Abdomial ULTRA$OUND is the initial test of choice to assess for HYDRONEPHROSIS.
. Hydronephrosis is caused by urinary obstruction & renal failure.
. HYPERKALEMIA (++ K > 5):
__________________________
. Drugs ++ K (ACE Is - NSAIDs - K sparing diuretics e.g. spironolcatone & Amiloride).
. Pseudohyperkalemia (Hemolyzed sample during venipuncture).
. Hyperkalemia (K > 6.5) may cause cardiac toxicity .
. EKG -> Peaked T waves & progressive widening of the QRS complex.
. Tx: IV CALCIUM GUCONATE.
. Tx: Insulin - B2 agonists.
. Tx: Na HCO3.
. Dialysis in severe cases.
. REMOVAL OF K FROM THE BODY -----> KAYEXALATE !
. The most common cause of death in RENAL DALYSIS & TRANSPLANTATION:
____________________________________________________________________
. is CARDIOVASCULAR complications.
. ANALGESIC NEPHROPATHY:
________________________
. Woman with chronic headaches on NSAIDs.
. Presenting with painless hematuria.
. NSAIDs -> VC of renal medulla vessels -> RENAL PAPILLARY NECROSIS.
. CHRONIC TUBULO-INTERSTITIAL NEPHRITIS.
. AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE (ADPCKD):
________________________________________________________
____________
. Initial "Beginning of urination" -----> Urethral lesion e.g. Urethritis.
. Terminal "At the end of voiding" -----> Prostatic or Bladder lesion e.g. cystitis.
. Total "during the entire process" ------> Ureters or kidneys lesion.
. The presence of clots in urine is more consistent with bladder not renal lesion.
_______________________
. URINARY TRACT STONES:
_______________________
1.CALCIUM OXALATE STONES:
__________________________
. Radio-opaque.
. envelope shaped on microscopy.
. Small bowel disease, surgical resection or chronic diarrhea,
. may lead to malabsorption of fatty acids & bile salts,
. which are important for chelating calcium,
. so, when Calcium is free, it binds with oxalic acid,
. forming Ca Oxalate stones.
2.CALCIUM PHOSPHATE STONES:
____________________________
. common in primary hyperparathyroidism.
3.URIC ACID STONES:
____________________
. When urine is acidic.
. When there is ++ cell turnover.
. Radio-lucent on X-ray.
. Tx: Hydration.
. Tx: Alkalinization of urine to pH > 6.5 by oral POTASSIUM CITRATE.
4.CYSTEINE STONES:
___________________
. ++ cysteine "Inborn error of metabolism".
. +ve family H/O.
. Recurrent stones since childhood.
. HARD & RADIO-OPAQUE stones.
. HEXAGONAL CRYSTALS on urine analysis.
. +ve Urinary cyanide nitroprusside test.
5.STRUVITE STONES:
___________________
. Formed when urine is ALKALINE.
. Bec. of infection with urease producing bacteria e.g. PROTEUS.
. H/O of recurrent UTI.
. NEPHROTIC $YNDROME:
______________________
. Proteinuria ( > 3- 3.5 g/day - most imp. criterion).
. Hypoalbuminemia.
. Edema.
. PSGN : begins 10-15 days after URTI with low serum complement.
. MEMBRANO-PROLIFERATIVE GLOMERULONEPHRITIS:
____________________________________________
. caused by persistent activation of the alternative complement pathway.
. Microscopy: Dense intra-membranous deposits that stain for C3.
. Dipsticks findings in case of UTI:
____________________________________
. Leukocyte esterase -> Pyuria.
. Positive nitrites -> Enterobacteriaceae.
. The most common culprit organism in UTIs is E-Coli.
. ERYTHROPOIETIN THERAPY in cases of ESKD:
__________________________________________
. ESKD presents with normocytic normochromic anemia due to -- erythropoietin.
. Tx of choice is recombinant erythropoietin.
. Started if Hb < 10 g/dl.
. Most common side effect is WORSENING OF HYPERTENSION.
. Other SE: Headaches & flu-like symptoms.
. ESKD ttt options:
___________________
. Dialysis or renal transplantation.
. Renal transplantation is more preferred due to better survival rate.
. A living related donor is always preferred.
. Management of CALCIUM OXALATE STONES:
_______________________________________
. 1- ++ fluid intake.
. 2- -- Na intake.
. 3- THIAZIDE DIURETIC.
. 4- -- protein & oxalate intake.
. GUESS WHAT ???!!------------> Calcium restriction is not required
. ACUTE EPIDIDYMITIS:
_____________________
. Fever.
. Painful enlargement of the testes.
. Irritative voiding symptoms.
. Two types of epididymitis: Sex-transmitted related & non-related.
. Sex-transmitted: more common in young pts & associated with urethritis.
. Sex-transmitted: pain at the tip of the penis & urethral discharge.
. Sex-transmitted: caused by Chlamydia trachomatis & Neisseria Gonorrhea.
. NON-sex-transm.: more common in elderly & associated with a UTI.
. NON-sex-transm.: No pain at the penile tip - No urethral discharge.
. NON-sex-transm.: caused by gram -ve rods e.g. E-coli.
. ACUTE PROSTATITIS:
____________________
. Fever, chills, ++ WBCs with bandemia.
______________________________________
. Reddish discolouration of urine, saliva, sweat & tears.
. Benign drug effect.
. Reassure the patient.
. UREMIC COAGULOPATHY:
______________________
. Complication of CRF.
. Echymosis & epistaxis are the most common presentations.
. The main cause is PLATELET DYSFUNCTION.
. PT,PTT,Platelet count -> NORMAL.
. Bleeding time is prolonged.
. Tx: DDAVP ++ the release of factor 8 (Von Willebrand f) from endothelial storage sites.
. PLATELET TRENSFUSION has NOOOOOO EFFECT as they quickly become INACTIVE.
. SICKLE CELL TRAIT:
____________________
. YOUNG BLACK MALE with PAINLESS HEMATURIA.
. Painless hematuria in EPISODES !
. Caused by PAPILLARY ISCHEMIA.
. Reassurance.
. DETRUSOR MUSCLE INACTIVITY:
_____________________________
. May be caused by 1st generation ANTI-HISTAMINICs due to their ANTI-CHOLINERGIC effects.
. They inhibit the action of Acetyl-choline on Muscarinic receptors.
. Urine retention occurs due to detrusor ms. failure of contraction.
. Other SEs: Dryness of eyes, oral mucosa & rspiratory passags.
. GROSS PAINLESS HEMATURIA in an ADULT = BLADDER MASS TUMOR:
____________________________________________________________
. Do a contrast CT abominal scan or IVP to detect the mass.
. The presence of erythrocytes in urine sh'd be confirmed microscopically,
. to exclude myoglobinuria, hemoglobinuria or porphyria.
. Other causes: BEETS large amounts ingestion or Rifampicin ttt.
(3) THALASSEMIA:
_________________
. Very small MCV with few or no symptoms. (55 - 75 ml).
. TARGET cells.
. Dx -> NORMAL iron studies.
. Most accurate test -> HEMOGLOBIN ELECTROPHORESIS:
- Beta -> ++ Hg A2 & Hg F.
- Alpha -> Normal (Most accurately diagnosed by DNA sequencing).
- Hg H has Beta 4 tetrads with 3 gene deleted Alpha thalassemia.
. B thalassemia major -> Both B hemoglobin are deffective.
. Characterized by severe anemia & transfusion dependence at an early age).
. B thalassemia minor occurs in people heterozygous for the B hemoglobin gene.
. The only microcytic anemia with a HIGH reticulocytic count is Hg H.
. Microcytic anemia non responsive to iron supplementation.
. No ttt !
(4) SIDEROBLASTIC ANEMIA:
__________________________
. Defect in heme-synthesis.
. Alcoholic pt.
. Isoniazid intake without Vit. B6 "pryridoxine" supplementation.
. Lead exposure.
. Dx -> Iron studies -> HIGH IRON & -- TIBC.
. Dx -> Bone marrow biopsy -> RINGED SIDEROBLASTs.
. Most accurate test -> PRUSSIAN BLUE STAIN.
. Tx -> Minor -> Pyridoxine replacement.
. Tx -> Major -> Remove the toxin exposure.
. "IRON DEFECIENCY ANEMIA" - "ALPHA THALASSEMIA MINOR" - "BETA THALASSEMIA MINOR":
______________________________________________________________________________________
. Hematocrit < 30 %
- Hematocrit > 30 %
- Hematocrit > 30 %
. RDW ++
- RDW normal
- RDW normal
. RBC count -- RBC count normal
- RBC count normal to ++
. No target cells
- TARGET cells on smear
- TARGET cells on smear
. -- serum iron & ferritin - Nor. to ++ iron & ferritin - Nor. to ++ iron & ferritin
. ++ TIBC
- Normal TIBC
- Normal TIBC
. Responds to iron supplem. - No response to iron supplementation
. Normal Hb Electrophoresis - Normal Hb Electrophoresis - ++ Hb A2 on Hb Electrophor.
. N.B. MECHANISMS OF ANEMIA IN MICROCYTIC HYPOCHROMIC DISEASES:
_______________________________________________________________
. -- fe intake & ++ blood loss -> IRON DEFECIENCY ANEMIA.
. Defective utilization of storage iron -> ANEMIA OF CHRONIC DISEASES.
. -- globin production -> THALASSEMIA.
. -- Heme synthesis -> LEAD POISONING & SIDEROBLASTIC ANEMIA.
. MICROCYTIC HYPOCHROMIC DISEASE -> FINDINGS IN IRON STUDIES:
_____________________________________________________________
. IRON DEFECIENCY ANEMIA -> -- fe, -- ferritin & ++ TIBC.
. THALASSEMIA -> Normal to ++ fe & ferritin levels.
. ANEMIA OF CHRONIC DISEASE -> -- TIBC.
. SIDEROBLASTIC ANEMIA -> Normal to ++ fe & ferritin levels.
. MACROCYTIC ANEMIA:
____________________
____________________
. Extravascular hemolysis occurs in spleen & liver so u can't see it on a smear !
. Caused by Vit. B12 or floate defeciency.
. Vit. B12 def. -> neurological findings (Mostly peripheral neuropathy- Least dementia).
. Folate defeciency is NOT associated with neurological findings.
. Suspect Vit B12 def. in STRICT VEGETERIANS with anemia & neurologic complications.
. METFORMIN blocks B12 absorption.
. B12 def. -> Smooth tongue (Glossitis) & diarrhea.
. -- B12 -> -- production of INTRINSIC FACTOR by gastric parietal cells,
. -- B12 -> Atrohic gastritis -> DOUBLE RISK of GASTRIC CANCER.
. Dx -> Best initial test -> CBC with peripheral smear -> HYPERSEGMENTED NEUTROPHILs.
. Dx -> Hypersegmented neutrophils + Large MCV = Megaloblastic anemia.
. Dx -> Anisocytosis - poikilocytosis - basophilic stippling.
. Dx -> ++ Bilirubin & LDH.
. Dx -> -- Reticulocytic count.
. Dx -> Most accurate test -> -- Vit. B12 & Folic acid levels.
. If u suspect B12 defeciency but B12 level is normal -> Order Methyl Malonic acid (MMA).
. Dx -> HOMOCYSTEINE is ++ in both Vit. B12 & folate defeciency.
. Dx -> Most accurate test -> Anti-parietal cell Abs & anti-intrinsic factor Abs.
. Tx -> REPLACEMENT of Vit B12 & folate.
. Tx -> Folic acid will correct the hematological problems.
. Tx -> Vit. B12 will correct the neurological problems.
. Watch for low potassium after ttt B12 def. !
. N.B. (1):
___________
. Folate & cobalamine (B12) are involved in the conversion of homocysteine to methionine.
. -- Vit. B12 or folic acid -> ++ Homocysteine level.
. N.B. (2):
___________
. Folic acid & vit. B12 defeciency can be distinguished by measuring Methyl Malonic acid!
. Vit B12 (Not folic acid) is involved in the conversion of MMA to succinyl coA.
. -- Vitamin B12 -> ++ MMA.
. -- Folic acid -> NORMAL MMA.
. N.B. (3):
___________
. Laboratory tests ------------> Prinicious anemia -------------> Folic acid defeciency
________________________________________________________________________________________
. Serum B12 level ------------->
(--)
-------------> Normal.
. Serum folic acid level ------>
(Normal) -------------> (--).
. Serum LDH level ------------->
(++)
-------------> Normal.
. Achlorhydria ---------------->
present -------------> Absent.
. Schilling test -------------->
+ve
-------------> -ve.
. Methyl malonyl acid MMA ----->
++
-------------> Absent.
. Neurological signs ---------->
++
-------------> Absent.
. N.B. (4):
___________
. Alcohol abuse is the most common cause of nutritional folate defeciency in USA.
. N.B. (5):
___________
. Anemia of chronic kidney disease is due to erythropoietin defeciency.
. One must be careful to ensure adequate iron stores prior to erthropoietin replacement,
. Bec. the erythropoietin induced surge in RBCs production may consume much iron,
. precipitating an iron defecient state.
. N.B. (6):
___________
. A case of microcytic hypochromic anemia with -- iron & ferritin,
. The most common cause of iron defeciency anemia is GIT blood loss.
. Dietary iron defeciency & malabsorption of iron are rare causes.
. Iron supplementation helps to restore iron reserves but u must detect the cause !
. So .. perform test for occult blood in the stool.
. N.B. (7):
___________
. The most common cause of folic acid defeciency is NUTRITIONAL.
. Either due to poor diet or Alcoholism.
. May be caused by some drugs either by impairing its absorption (PHENYTOIN),
. or antagonizing its physiologic effect (Methotrexate - Trimethoprim).
. N.B. (8):
___________
. PERINICIOUS ANEMIA:
______________________
. Most common cause of vit. B12 defeciency.
. Auto-antibodies against the gastric intrinsic factor required for B12 absorption.
. More in Northern Europeans.
. Associated other auto-immune diseases e.g. Autoimmune thyroiditis & Vitiligo.
. Shiny tongue due to atrophic glossitis.
. Shuffling broad-based gait ataxia.
. Neurological abnormalities with loss of pain & vibration sense.
. Peripheral blood smear -> Macro-ovalocytes, megaloblasts & hyper-segmented neutrophils.
. Dx -> Detection of Anti-intrinsic factor Abs.
. N.B. (9):
___________
. Total body stores of Vit.B12 in humans are 2-5 mg with min. daily requirement 6-9 micg.
. Animal products (meat & dairy) are the only dietary sources of vit. B12.
. It would take 4-5 years of a pure vegan diet to cause dietary defeciency.
. In contrast, Folate stores are smaller, clinical defeciency occur within 4-5 months.
. N.B. (10):
____________
. SCHILLING TEST:
__________________
. Used to detect the cause of vit. B12 defeciency.
. Used to differentiate dietary defeciency from perinicious anemia & malabsorption.
. In dietary defeciency,
. Oral radiolabelled Vit B12 is absorbed in the gut & excr. by kidneys in NORMAL amounts.
. But In Malabsorption,
. Oral radio-labelled Vit B12 is excreted in sub-normal amounts.
. HEMOLYTIC ANEMIA:
___________________
___________________
. SUDDEN ONSET of hematological manifestations.
. Dx -> Hemolysis ->
-> ++ indirect bilirubin.
-> ++ reticulocyte count.
-> ++ LDH level.
-> -- Haptoglobin.
. Dx -> Intravascular hemolysis ->
-> Abnormal peripheral smear (schistocytes - helmet cells - fragmented cells).
-> Hemoglobinuria.
-> Hemosiderinuria.
(1) SICKLE CELL ANEMIA:
________________________
. Very severe pain in the back, chest & thighs.
. Retinal infarction.
. Flow murmur from anemia.
. Splenomegaly in children & asplenia in adults.
. Rales or consolidation from lung infection or infarction.
. Skin ulcers.
. Aseptic necrosis of hip.
. Neurological strokes.
. Cause of Osteomyelitis in sickle cell anemia is SALMONELLA !
. Cause of BM suppression in sickle cell anemia is PARVO B19 !
. Tx -> OXYGEN - HYDRATION with NORMAL SALINE - Pain relief.
. If there is fever -> (Emergency - No spleen) -> Ceftriaxone -levofloxacin.
. Tx -> EXCHANGE TRANSFUSION if ->
-> Eye -> Visual disturbance from retinal infarction.
-> Lungs -> Pulmonary infarction with pleuritic pain.
-> Penis -> Priapism from infarction of prostatic plexus of veins.
-> Brain -> Stroke (weakness & aphasia due to sludging & occlusion of cerebral vessels).
. N.B. -> SUDDEN DROP IN HEMATOCRIT can be caused by FOLATE DEFECIENCY or PARVO B19 INF:
. Folate defeciency in SCD due to ++ RBCs turnover & consumption of folate in the BM.
. Daily folic acid supplementation is recommended in all SCD.
. If the pt is already on Folate replacement -> The cause is PARVO B19 viral infection !
. PARVO B19 may invade the bone marrow & causes aplastic anemia.
. Detect Parvo B19 infection by PCR for DNA of Parvo B19.
. On discharge -> Give folate replacement - Pneumococcal vaccine.
. Hydroxyurea (++ Hb F) is given to prevent further crisis.
(2) HEMOGLOBIN SICKLE CELL DISEASE:
____________________________________
. African American pt.
. Family H/O of blood disrder.
. Mild version of sickle cell anemia.
. Visual distrurbance is frequent.
. No painful crisis.
. RENAL problems are common,
. (Hematuria - Isosthenuria "inablility to dilute urine or concentrate urine" - UTIs).
. Isosthenuria due to RBCs sickling in the vasa rectae of the inner renal medulla.
. The pt have to wake to urinate 2 - 3 times per night despite restricting fluid intake.
. No ttt.
(3) AUTOIMMUNE HEMOLYSIS:
__________________________
. H/O of other autoimmune diseases e.g. SLE (peripheral immune destruction of all cells).
. H/O of CLL or lymphoma (Enlarged Non tender axillary LNs bilaterally!).
. H/O of penicillin - alpha methyl dopa - quinine or sulfa drug intake.
. Dx -> ++ LDH - ++ indirect bilirubin - ++ reticulocyte count - -- Haptoglobin.
. Dx -> peripheral smear -> spherocytes.
. Dx -> Most accurate test -> Coombs test. (WARM Abs = IgG Abs).
. Tx -> Best initial ttt -> Steroids e.g. prednisone.
. If there is recurrent episodes of hemolysis -> SPLENECTOMY is the most effective ttt.
. If no response to prednisone or splenectomy -> Give IVIG.
(4) COLD INDUCED HEMOLYSIS = COLD AGGLUTININs:
_______________________________________________
. H/O of mycoplasma or EBV infection.
. Coomb's test -> -ve.
. Complement test-> +ve.
. No response to prednisone, spenectomy or IVIG.
. Tx -> RITUXIMAB.
(5) GLUCOSE - 6 - PHOSPHATE DEFECIENCY (G6PD):
_______________________________________________
. X-linked disorder - Only MALE pt. (African American).
. ENZYME defeciency (Glucose 6-phosphate dehydrogenase).
. Sudden onset of hemolysis.
. INFECTION is the most common predisposing factor.
. H/O of intake of Oxidizing drugs (Sulfa - primaquine - Dapsone).
. H/O of ingestion of FAVA BEANS.
. Mechanism of cell damage -> OXIDATIVE STRESS.
. Dx -> Best initial test -> Heinz body test & BITE CELLs.
. +ve prussian blue is indicative of hemosiderin found in urine during hemolytic episode.
. Heinz bodies are collections of oxidized precipitated Hb embedded in the RBC membrane.
. Bite cells appear when pieces of the red cell membrane have been removed by the spleen.
. Most accurate test -> G6PD level after 2 months of symptoms !
. A normal level of G6PD immediately after an episode of hemolysis doesn't exclude it !
. Tx -> AVOID OXIDANT STRESS.
. N.B. PYRUVATE KINASE DEFECIENCY:
___________________________________
-> can lead to similar presentation as G6PDD .. BUT:
-> Hemolysis not precipitated by sulfa drugs !
-> No bite cells on peripheral smear !
(6) HERIDITARY SPHEROCYTOSIS:
______________________________
. Northern European descent.
. TRIAD of HEMOLYTIC ANEMIA + JAUNDICE + SPLENOMEGALY.
. Autosomal dominant disorder of spectrin (Ptn that provides scaffolding for RBCs).
. RBCs are not deformable -> Gets trapped in the fenesterations of the spleen's red pulp.
. Recurrent episodes of hemolysis.
. Splenomegaly.
. Bilirubin gall stones (pigmented Ca bilirubinate) -> Acute cholecystitis.
. Dx -> +++ MCHC (Mean cell hemoglobin concentration = RBC membrane loss & dehydration).
. Dx -> Peripheral smear -> Spherocytes.
. Dx -> -ve Coomb's test (+ve in AIHA = Autoimmune hemolytic anemia).
. Dx -> Most accurate test -> OSMOTIC FRAGILITY test.
. Tx -> SPLENECTOMY will prevent hemolysis as spherocytes are destroyed in the spleen.
. Folate supplementation is important.
. There is a risk for infection with Parvovirus B19 causing aplastic anemia.
(7) HEMOLYTIC UREMIC $YNDROME (HU$):
_____________________________________
. H/O of E-coli 0157:H7 infection.
. HUS TRIAD (ART):
-> Autoimmune hemolysis -> intravascular hemolysis (Anemia - indirect hyperbilirubinemia)
-> Renal failure -> ++ BUN & creatinine.
-> Thrombocytopenia -> -- platelets.
. Dx -> Peripheral smear -> Schistocytes.
. Tx -> Most cases resolve on their own.
. Tx -> Severe cases are ttt with plasmapharesis or plasma exchange.
. Steroids don't help !
. Antibiotics worsen the case !
. Platelet transfusion worsen the case !
(8) THROMBOTIC THROMBOCYTOPENIC PURPURA (TTP):
_______________________________________________
. H/O of TICLOPIDINE use.
. HUS TRIAD + FN (Fever & Neurolgical abnormailities).
. Dx -> Peripheral smear -> Schistocytes.
. Same ttt as HUS (PLASMAPHARESIS or PLASMA EXCHANGE).
(9) PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH):
_______________________________________________
. Pancytopenia.
. Recurrent attacks of dark urine "Specially in the morning !".
. Most common cause of death -> LARGE VESSEL VENOUS THROMBOSIS "PORTAL VEIN THROMBOSIS".
. PNH may transform to alpastic anemia or acute myelogenous leukemia (AML).
. PORTAL VEIN THROMBOSIS may be the key to answer PNH case !
. Dx -> Most accurate test -> Flow cytometry -> Cd 55 & CD 59 antibodies.
. Tx -> Best initial ttt -> Glucocorticoids (prednisone).
. Transfusion dependent pts may be ttt with Eculizomab -> inhibit C5 complement.
. Hemolytic anemia + Venous thrombosis = PNH.
(10) MACROVASCULAR TRAUMATIC HEMOLYSIS:
________________________________________
. ++ reticulocytes - ++ LDH - -- Haptoglobin ("intra-vascular hemolytic anemia).
. Fragmented RBCs.
. Chronic hemolysis -> iron loss -> Microcytic anemia.
. Due to mechanical trauma from artificial valves or calcified aortic valves.
. N.B. HERIDITARY SPHEROCYTOSIS & AUTOIMMUNE HEMOLYTIC ANEMIA:
______________________________________________________________
. Peripheral blood smerar in both conditions -> Spherocytes without central pallor.
. Both cause extravascular hemolytic anemia.
. Heriditary spherocytosis -> Autosomal dominant heriditary condition.
. AIHA -> Acquired condition.
. Spherocytosis -> +ve family H/O & -ve Coomb's test.
. AIHA -> -ve family H/O & +ve Coomb's test.
. N.B. PATHO-PHYSIOLOGIC MECHANISMS of ANEMIA in variable diseases:
___________________________________________________________________
. Impaired DNA & purine synthesis -> Vitamin B12 defeciency.
. RBC membrane instability -> Heriditary spherocytosis.
. Impaired Hb synthesis -> Iron defeciency anemia, sickle cell anemia & Thalassemia.
. Impaired glutathione synthesis -> G6PDD.
. Mechanical injury to RBCs -> Hemolysis with artificial heart valves.
. MET-HEMOGOLBINEMIA:
_____________________
. Shortness of breath for no clear reason.
. Clear lungs on examination.
. Blood locked up in an oxidized state that can't pick up oxygen.
. H/O of exposure to drugs such as nitroglycerin, amyl nitrate, nitroprusside & dapsone.
. H/O of exposure to anesthetic drugs e.g lidocaine.
. H/O of brown blood !!
. Tx -> Methylene blue !!
. CARBOXYHEMOGLOBINEMIA = CARBON MONOXIDE (CO) POISONING:
_________________________________________________________
. H/O of environmental risk (Pt working in an enclosed space -> underground parking lot).
. Present with headache, nausea & dizziness.
. Exposure to CO from automobile exhaust.
. CO binds Hb with an affinity app. 250 times that of oxygen.
. -- in blood carrying oxygen capacity.
. As a compensation -> the body ++ RBCs production (++ HCT).
. OBSTRUCTIVE SLEEP APNEA (OSA) -> ++ ERYTHROPOIETIN PRODUCTION:
________________________________________________________________
. Recurrent transient obstruction of the upper airway due to pharyngeal collapse.
. Obese or over-weight pts have excessive snoring, day time sleeping & morning headaches.
. Transient episodes of hypoxia -> sensed by the kidneys -> ++ Erythropoietin production.
. Erythropoietin ++ RBCs -> Polycythemia.
. OSA doesn't cause carboxyhemoglobinemia ! xxxxxxxxxxxxxx
. LEUKEMIA:
___________
___________
(A) ACUTE LEUKEMIA:
____________________
. Pancytopenia (Fatigue - bleeding - infections).
. Excess WBCS but don't work (Functional immunodefeciency).
. Dx -> Peripheral smear -> BLASTS.
. AUER RODS = AML ACUTE MYELOID LEUKEMIA.
. DIC is asscociated with M3 (Acute pro-myelocytic leukemia).
____________________________
. Hemoarthrosis - Hematoma.
. A -> PLATELET TYPE BLEEDING:
______________________________
. 1 . IDIOPATHIC IMMUNE THROMBOCYTOPENIA (ITP):
________________________________________________
. Immune destruction of platelets.
. Platelets count < 50000.
. Ig G auto-antibodies against the paltelet membrane glycoproteins 2B & 3A receptors.
. Mostly occur in children.
. Pt may be asymptomatic.
. Mucocutaneous bleeding, ecchymosis & or petichiae.
. May follow acute viral infection.
. Dx -> ISOLATED THROMBOCYTOPENIA < 100000/ml.
. Dx -> Peripheral smear sh'd be done to exclude other causes e.g. TTP.
. Dx -> Bone marrow -> ++ Megakaryocytes (platelet precursors).
. Dx -> U/$ -> NORMAL SPLEEN.
. Dx -> Check for hepatitis C & HIV infections.
. Dx -> Diagnosis of exclusion.
. Tx -> Platelets > 30000 , without bleeding -> Observe !
. Tx -> Platelets < 30000 , or bleeding -> Corticosteroids Prednisone (1st line therapy).
. Tx -> Platelets < 20000 ! with eistaxis, melena & intracranial hemorrhage -> IVIG.
. IVIG: INTRAVENOUS IMMUNOGLOBULIN -> when platelet < 20000 & life threatening condition.
. Recurrent episodes -> SPLENECTOMY.
. No response to splenectomy -> Romiplostim.
. N.B. HCV & HIV tests as ITP may be the initial presentation of HIV infection.
. 2 . UREMIA INDUCED PLATELET DYSFUNCTION:
___________________________________________
. Uremia prevents palatelets from degranulation.
. NORMAL PLATELET COUNT + PLATELET TYPR BLEEDING + RENAL FAILURE PT.
. NORMAL Ristocetin test & VWF level.
. Tx -> Desmopressin - DDAVP.
. B -> FACTOR TYPE BLEEDING = COLTTING FACTOR DEFECIENCIES:
___________________________________________________________
* FACTOR 8 = HEMOPHILIA A:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma on a MALE child.
. Dx -> Mixing study then specific factor level.
. Tx -> Minor defeciency -> DDAVP.
. Tx -> Severe defeciency -> Factor 8 replacement.
* FACTOR 9 = HEMOPHILIA B:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma (less common than factor 8 def.).
. Dx -> SAME.
. Tx -> Factor 9 replacement.
* FACTOR 11:
_____________
. Rare bleeding with trauma or surgery.
. Dx -> Same.
. Tx -> FFP Fresh frozen plasma.
. FACTOR 12:
____________
. No bleeding.
. Dx -> Same.
. Tx -> No ttt necessary.
. SENILE PURPURA:
_________________
. occurs in areas susceptible to traumas in elderly (Dorsum of the hands & forearms).
. Due to PERIVASCULAR CONNECTIVE TISSUE ATROPHY .
. Lesions rapidly resolve leaving a brownish discolouration from hemosiderin deposition.
. Requires no ttt.
. HEPARIN INDUCED THROMBOCYTOPENIA (HIT):
___________________________________________
. HEPARIN exposure > 5 days then,
. Platelet count reduction > 50 % from baseline.
. Despite -- platelet count ->HIT is highly thrombogenic -> Arterial & venous thrombosis.
. Necrotic skin lesions at heparin injection sites.
. Acute systemic anaphylactoid recation after heparin.
. Dx -> SEROTONIN RELEASE ASSAY (GOLD STANDARD).
. TTT is started on clinical suspicion before serotonin assay.
. Tx -> CESSATION OF ALL HEPARIN PRODUCTS !
. Tx -> Start Argatroban (direct thrombin inhibitor).
. WARFARIN INDUCED SKIN NECROSIS:
_________________________________
. More common in females.
. Common sites: breasts , buttocks, thighs & abdomen.
. Initial complaint is PAIN FOLLOWED BY BULLAE FORMATION & SKIN NECROSIS.
. Occurs within weeks after starting therapy.
. Tx -> Discontinue warfarin - Give heparin to continue anticoagulation - Give Vit. K.
. Acetaminophen, NSAIDs & Amiodarone may potentiate the anticoagulant effect of warfarin.
. VITAMIN K DEFECIENCY BLEEDING:
________________________________
. Pt kept NPO NOTHING PER ORAL for a prolonged period of time & receiving Antibiotics.
. OR Newborn hadn't received prophylactic vit. K (Home-born) for prevention of hemorrhage
. ++++ PT > ++ PTT.
. THROMBOPHILIA = HYPERCOAGULABLE STATES:
_________________________________________
_________________________________________
(1) LUPUS ANTI-COAGULANT or ANTI-CARDIOLIPINS ANTIBODIES:
__________________________________________________________
. Venous thrombosis.
. ++ aPTT (PROLONGED PARTIAL THROMBOPLASTIN TIME).
. Normal PT, BT, platelet count & VWF.
. Spontaneous abortion. (Due to promotion of arterial & venous thrombosis).
. False +ve VDRL & True -ve FTA-ABS (Excluding $yphilis as a cause of recurrent abortions
. Dx -> Mixing study.
. Dx -> Russel Viper venom test (Most accurate).
. Tx -> Heparin (LMWH) followed by warfarin.
(2) PROTEIN C DEFECIENCY:
__________________________
. Skin necrosis with the use of Warfarin.
. Dx -> Ptn C level.
. Tx -> Heparin followed by Warfarin.
(3) FACTOR 5 LEIDEN MUTATION:
______________________________
. Most common cause of thrombophilia.
. Dx -> Factor 5 mutation test.
. Tx -> Heparin followed by Warfarin.
(4) ANTI-THROMBIN DEFECIENCY:
______________________________
. No change in the aPTT with a blous of IV heparin !
. Dx -> Anti-thrombin 3 level.
. Tx -> Large amounts of heparin or direct thrombin inhibitor followed by warfarin.
. DIC = DISSEMINATED INTRAVASCULAR COAGULATION:
_______________________________________________
. Doesn't occur in healthy pts.
. Ass. with sepsis - burns - snake bites - cancer - Abruptio placenta or AF Embolism.
. BLEEDING related to CLOTTING FACTORS DEFECIENCY & THROMBOCYTOPENIA !!
. ++ both PT & PTT.
. -- platelet count.
. ++ D-dimer & FDP (fibrin degradation products).
. -- fibrinogen level (consumed).
. Tx -> REPLACEMENT by FFP FRESH FROZEN PLASMA (Contains both palatelets & clot.factors).
. TRANSFUSION REACTIONS:
________________________
________________________
. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.
. 2 . TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) = LEUKO-AGGLUTINATION REACTION:
____________________________________________________________________________________
. Acute Shortness of breath from antibodies in the donor blood against the repient WBCs.
. Ex -> 20 mins after a pt. receives a blood transfusion, the pt becomes short of breath.
. Transient infiltrates on CXR.
. All symptoms resolve spontaneously.
. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or washed RBCs.
. Ex -> As soon as the pt. received transfus., he becomes SOB, hypotensive & tachycardic.
. NORMAL LDH & BILIRUBIN.
. 4 . MINOR BLOOD GROUP INCOMPATIBILITY:
_________________________________________
. To kell, Duffy, Lewis or Kidd antigens or Rh incompatibility !
. Delayed jaundice.
. No specific therapy.
. Ex -> A few days after transfusion, the pt becomes jaundiced.
. The hematocrit doesn't rise with transfusion & he is generally without symptoms.
. 5 . FEBRILE NON-HEMOLYTIC REACTION:
______________________________________
. Small rise in temperature.
. No ttt required.
. Reaction against donor WBCs antigens.
. prevented by using filtered blood transfusions in the future to remove WBCs antigens.
. Ex -> A few hours after transfusion, the pt becomes febrile with rise 1 degree in temp.
. No evidence of hemolysis.
. N.B. HYPOCALCEMIA MANIFESTATIONS (PARESTHESIA) AFTER BLOOD TRANSFUSION:
_________________________________________________________________________
. Occurs in pts who receive more than one blood volume of blood transfusion or packed RBCs over 24 hours may
develop ++ plasma level of CITRATE (A SUBSTANCE ADDED TO STORED BLOOD) -> CHELATION of Ca &
Mg by citrate -> -- Ca -> Paresthesia.
. MIGRATORY SUPERFICIAL THROMBOPHLEBITIS = TROUSSEAU's $YNDROME:
________________________________________________________________
. Hypercoagulable disorder.
. Un-explained superficial venous thrombosis at un-usual sites e.g. arm & chest area.
. Associated with OCCULT VISCERAL MALIGNANCY !
. Ex. Cancer involving the pancreas "most common".
. The tumor releases mucin that react with platelets forming platelet rich micro-thrombi.
. H/O of heavy smoking - abdominal pain - migrattory thrombophlebitis.
. Dx -> CT Abdomen -> searching for an occult tumor (pancreatic carcinoma).
. GLUCAGONOMA:
______________
. Necrolytic migratory erythema:
---------------------------------> Erythematous papules / plaques on face, perineum & extremities.
-> Enlarge & coalese with central clearing & blistering & crusting & scaling.
. Diabetes Mellitis:
---------------------> Mild hyperglycemia easily controlled with diet & oral agents.
-> Don't require insulin !
. GIT symptoms:
----------------> Diarrhea - anorexia abdominal pain - occasional constipation.
. Other findings:
------------------
. TESTICULAR TUMOR:
___________________
. Painless hard mass in testicle.
. Suggestive ultrasound.
. Tx -> Orchiectomy (Removal of the testicle & its associated cord).
. FNAC or trans-rectal biopsy are contr'd bec. the risk of spillage of cancer cells.
. FIBROCYSTIC DISEASE OF THE BREAST:
____________________________________
. Rubbery, firm, mobile & pinful mass in a young pt.
. More pain during menses.
. Aspiration of the cyst -> Clear fluid with diasppearance of the mass.
. Tx -> Observation of the pt 4 - 6 weeks.
. Only send the fluid for cytology if their is blood or foul smelling.
. INVASIVE DUCTAL BREAST CARCINOMA:
___________________________________
. TNM staging is the single most important prognostic tool for breast cancer.
. Prognosis is best detected using ONCOGENE AMPLIFICATION by FISH !
. FISH = Fluorescent in situ hybridization.
. Over-expression of the oncogene HER2 can be detected by FISH = (Worse prognosis).
. Positivity predicts a +ve response to TRASTUZUMAB & ANTHRACYCLINE chemotherapy.
. ER +ve & PR +ve are GOOD prognostic features.
. Tx -> TRASTUZUMAB (Herceptin) is used to ttt breast cancer that is HER2 +ve.
. Trastuzumab side effect -> CARDIOTOXICITY.
. ECHOCARDIOGRAPHY is recommended before ttt to assess the ejection fraction.
. INFLAMMATORY CARCINOMA OF THE BREAST:
_______________________________________
. Breast cancer sh'd be considered whenever a pt. without a prior H/O of skin disease,
. develops a breast rash that is non-responsive to standard ttt !
. When invasive ductal carcinoma is severe, it can infiltrate into the dermal lymphatics,
. resulting edema - erythema - warmth of the entire breast (inflammatory carcinoma).
. When the rash is localized to the nipple & has an ulcerating eczymatous appearance,
. the primary cosideration should be PAGET's DISEASE of the breast.
. 5 % of pts with PAGET's disease have an underlying breast cancer "ADENO-CARCINOMA".
. Skin biopsy -> Large cells surrounded by clear halos.
. TAMOXIFEN:
____________
. Has mixed agonist & antagonist activity on Estrogen receptors.
. It is used as an adjuvant therapy for early stage breast cancer,
. It reduces the risk of recurrence of the original cancer,, BUT,,
. ++ risk of developing of another cancer in the other breast !
. Estrogenic effects ++ risk of ENDOMETRIAL cancer & Venous thrombosis.
. SQUAMOUS CELL CARCINOMA of the SKIN:
______________________________________
. Any scar that develops into a non-healing, painless, bleeding ulcer.
. Sun-exposed or burned areas are typically involved.
. Rough scaly nodules that can ulcerate & metastasize.
. Tar derivatives (tobacco smoke) & chronic radiation exposure are predisposing factors. . Dx -> PUNCH BIOPSY.
. Tx -> Surgical removal with wide excision of the skin around the tumor.
. No additional screening.
. ULCERATIVE COLITIS:
_____________________
. Colonoscopy once the diagnosis is established for 8 ys then repeated every 1 - 2 ys.
. MEN 1 = MULTIPLE ENDOCRINE NEOPLASIA 1:
_________________________________________
. Paratyhroid (>90%) -> parathyroid hyperplasia -> primary hyperparathyroidism -> ++ Ca.
. Pituitary -> prolactinoma.
. Pancreas / GIT -> Gastrinoma "ZE $" - insulinoma - VIPoma - Glucagonoma.
. KEY WORDS-> INTRACTABLE ULCERATION + HYPERCALCEMIA -> ZE$ & Hyperparathyroidism = MEN1.
. POST-SPLENECTOMY SEPSIS:
__________________________
. Asplenic pt have defective PHAGOCYTOSIS !
. impaired antibody mediated opsonization in phagocytosis.
. High risk of overwhelming infection by encapsulated organisms,
. e.g. Strept. pneumoniae, N. menengitidis & H. influenzae.
. DEEP VENOUS THROMBOSIS = DVT MANAGEMENT:
__________________________________________
. Presents with pain, swelling & discoloration.
. D.D. -> Ruptured Baker's cyst - venous insuffeciency - post-thrombotic $ & cellulitis.
. Failure to anti-coagulate the pt may lead to pulmanary embolism.
. Modified Wells criteria is a pretest propability of DVT:
-> Previous DVT.
-> Active cancer.
-> Recent immobilization.
-> Localized tendrness along vein distribution.
-> Swollen leg.
-> Pitting edema.
.
. Pre-test propability of DVT using WELLs criteria
.__________________________________________________
.|
._________________________________________
.|
.|
. Not likely
. Likely
.____________
.________
|
.|
. D-Dimer test (+)--------------->. Compression Ultrasonography
.______________
._____________________________
.|
.|
.|
._________________________________
.|
.|
.|
(-)
(+)
(-)
.|
.|
.|
. Un-likely to have DVT ! (TTT with Heparin & Warfarin) (Contrast Venography)
. Clinical features of METASTATIC BRAIN CANCER:
_______________________________________________
. Incidence -> Lung > Breast > Un-known primary > Melanoma > Colon.
. Primary solitary brain metastases -> BREAST - COLON - RENAL CELL CARCINOMA.
. Tx -> Surgery.
. COMPRESSION OF THE THECAL SAC or SPINAL CORD by a TUMOR:
__________________________________________________________
. Ex -> H/O of prostatic cancer + Acute onset back pain.
. Rapid recognition is crucial to avoid paralysis.
. Point tenderness over the spine process L5 & S1.
. Imbalance, ms weakness & week rectal sphincter tone.
. Dx -> MRI spine BUTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
. Initial management with glucocorticoids (dexamethasone) is crucial to -- swelling,
. as an attempt to preserve neurological function while awaiting the results of imaging.
. POST-SPLENECTOMY RECOMMENDATIONS:
___________________________________
. Risk for sepsis after splenectomy is present UP TO 30 years & more !
. Anti-pneumococcal, Haemophilus & meningococcal vaccine sh'd be given,
. several weeks before splenectomy.
. Daily oral penicillin prophylaxis for 3 - 5ys following splenectomy.
. CANCER OVARY:
_______________
. NO screening tests !
. Serum CA 125 & pelvic U/$ may help in diagnosis.
. ++ HOMOCYSTEINE levels -> HYPERCOAGULABILITY:
_______________________________________________
. Vit. B6, Folate & Vit. B12 are involved in the metabolism of homocysteine.
. Vit. B6 lowers homocysteine levels by acting as a cofactor for cystathionine B-synthase
. which metabolizes homocysteine to cystathionine.
. PAIN CONTROL IN CANCER PATIENTS:
__________________________________
. Give the appropriate pain medication to cancer pts e.g. Ibuprofen.
. If no response .. Use a narcotic drug if it is the most appropriate.
. Use SHORT ACING IV MORPHINE.
. MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA & VOMITING:
_______________________________________________________
. Volume repletion + SEROTONIN ANTAGONIST (Block 5HT3 recptors).
. MANAGEMENT OF CANCER RELATED ANOREXIA & CACHEXIA:
___________________________________________________
. PROGESTERONE ANALOG -> ++ Appetite & ++ weight gain.
. PROSTATE CANCER with BONE METASTASIS:
_______________________________________
. Tx -> FOCAL EXTERNAL BEAM RADIATION (If the pt under-went orchiectomy !).
. BRAIN METASTASIS:
___________________
. SOLITARY -> SURGICAL RESECTION followed by whole brain radiation.
. Multiple -> Palliative whole brain radiation.
. MANAGEMENT OF HYPERCALCEMIA DUE TO UNDERLYING MALIGNANCY:
___________________________________________________________
. Asymptomatic or mild -> Ca < 12 mg/dl:
_________________________________________
. Just avoid thiazides, lithium use, volume depletion or prolonged bed rest.
. Severe -> Ca > 14 mg/dl:
___________________________
. Immediate ttt -> Normal saline hydration + Calcitonin.
. Long term ttt -> Biphosphonate (Zoledronic acid).
. D.D. of ANTERIOR MEDIASTINAL MASS (4 Ts):
___________________________________________
. Thymoma - Teratoma - Thyroid neoplasm - Terrible lymphoma.
. Germ cell tumors are classified into seminomatous & non-seminomatous.
. Non-seminomatous (Yolk sac tumor - choriocarcinoma - embryonal carcinoma).
. A mixture of all types of non seminomatous germ cell tumors = MIXED GERM CELL TUMOR.
. Seminoma -> ++ B-HCG & Normal AFP.
. Non seminoma (MIXED) -> ++ B-HCG & ++ AFP.
. HEMOCHROMATOSIS:
__________________
. NEW-ONSET DIABETES MELLITUS + ARTHROPATHY + HEPATOMEGALY.
. Due to abnormal ++ intestinal absorption of iron -> ++ iron deposition in tissues.
. Damage to organs ex. liver, pancreas , heart & pituitary.
. Liver -> Hepatomegaly -> Liver cirrhosis -> Hepatocellular carcinoma.
. Pancreas -> Bronze D.M.
. Pituitary -> Hypogonadism.
. Heart -> Restrictive heart failure.
. Joints -> Arthropathy.
. Skin -> Hyperpigmentation.
. Dx -> Iron studies -> ++ fe, ++ ferritin, ++ transferrin saturation.
. Dx -> Liver biopsy -> confirm the diagnosis.
. LEAD POISONING:
_________________
. Lead bind to erythrocytes & disrupts hemoglobin synthesis -> Microcytic anemia.
. Due to chronic lead exposure & toxicity.
. Acute exposure -> Abdominal pain & constipation.
. Chronic exposure -> Fatigue, iiritability & insomnia.
. Hypertension - Sensori-motor neuropathies - Neuropsychiatric disturbances - Nephropathy
. OCCUPATIONAL HISTORY IS VERY IMPORTANT !
. BATTERY MANUFACTURING - PLUMBING - MINING - PAINTING - PAPER HANGING & AUTO-REPAIR.
. Dx -> Blood Lead level.
. Dx -> Peripheral smear -> BASOPHILIC STIPPLING.
. Tx -> CHELATION THERAPY.
++
........ ++ .........
--
--
++ ..........
(--)
--
. CHRONIC disease ---> Same as acute disease but based on persistance of HbsAg > 6 months
. Anti HBc Ig "G" Ab -> Denotes CHRONICITY !
. Best means of screening for HBV infection -> HBsAg & IgM Hbc Ab.
. N.B. ACUTE VIRAL REPLICATION indicators:
__________________________________________
. Hepatitis B DNA plymerase = e-Antigen = Hepatitis B PCR for DNA.
. CHRONIC HEPATITIS B TREATMENT:
________________________________
. Chronicity = More than 6 months with +ve serology.
. Tx -> Anti-viral therapy -> LAMIVUDINE + INTERFERON.
# HEPATITIS C:
______________
. HEPATITIS C DIAGNOSIS:
________________________
. Best initial test -> Hepatitis C antibody.
. Most accurate test ->
1 - Hepatitis C PCR for RNA:determine the degree of viral activity & response to therapy.
2 - Liver biopsy: determine the seriousness of the disease i.e. extent of liver damage.
. Chronic HCV classically presents with waxing & waning transaminases levels & few syms.
. Pts may complain of arthralgias or myalgias.
. Extra-hepatic sequlae: Cryoglobulinemia - porphyria cutanea tarda & glomerulonephritis.
. CHRONIC HEPATITIS C TREATMENT:
________________________________
. All chronic hepatitis C pts with ++ ALT, detectable HCV RNA & histologic evidence.
. Tx -> Anti-viral therapy -> RIBAVIRIN + INTERFERON.
. Chronic HCV pts with persistently NORMAL liver enzymes & MINIMAL histological findings,
. NO NEED TO BE TTT WITH INTERFERON OR ANTI-VIRAL DRUGS.
. JUST follow up with yearly liver function tests.
. All chronic HCV pts sh'd receive vaccinations to Hepatitis A & B if not already immune.
. Both vaccinations are safe during pregnancy.
. Incidence of vertical transmission is very low 2-5 % (No need for C.S. for pregnants).
. HCV infected mothers should NORMALLY BREAST-FEED their babies.
. SE of Ribavirin -> Anemia.
____________________________
. SE of Interferon -> Arthralgia - myalgia - flu-like $ - thrombocytopenia - depression.
________________________________________________________________________________________
. VACCINATION:
______________
. Vaccination for both hepatitis A & B are done universally in childhood.
. No vaccine & No post-exposure prophylaxis for hepatitis C.
. Middle-aged woman.
. ITCHING !
. XANTHELASMA (Cholesterol deposits).
. H/O of other autoimmune diseases.
. Best initial test -> ++ ALP Alkaline phosphatase with NORMAL BILIRUBIN level.
. ++ IgM.
. Most accurate test -> Anti-mitochondrial antibody (AMA) & Liver biopsy.
. Tx -> Ursodeoxycholic acid.
{3} PRIMARY SCLEROSING CHOLANGITIS (PSC):
__________________________________________
. Inflammatory bowel disease (IBD) accounts for 80% of causes (UC > CD).
. ITCHING !
. Best initial test -> ++ ALP Alkaline phosphatase with ++ BILIRUBIN level.
. Most accurate test -> ERCP -> BEADING of the biliary system.
. +ve ASMA (Anti-smooth muscle antibody).
. +ve ANCA.
. Tx -> Ursodeoxycholic acid.
{4} WILSON's DISEASE = HEPATO-LENTICULAR DEGENERATION:
_______________________________________________________
. -- Ceruloplasmin -> ++ Copper.
. Abnormal Copper deposition in liver, basal ganglia & cornea.
. Young pt < 30 ys.
. Cirrhosis + Choreiform movement disorder + Neuropsychiatric abnormalities.
. May present with hemolysis.
. Best initial test -> Slit lamp (Keiser Fleischer rings) & -- Ceruloplasmin level < 20mg
. Most accurate test -> Liver biopsy -> Copper level > 250 mcg/gram.
. Tx -> Penicillamine.
{5} HEMOCHROMATOSIS:
_____________________
. Genetic disorder -> over-absorption of copper.
. Iron deposits in various body tissues.
. Heart -> Restrictive cardiomyopathy.
. Skin -> Darkening & pigmentation.
. Joint -> Psedogout & CPPD.
. Pancreas -> Bronze Diabetes.
. Pituitary -> Panhypopituitarism.
. Genitalia -> Infertility.
. Infections -> LISTERIA, VIBRIO VULNIFICUS & YERSINIA ENTEROCOLITICA.
. Liver -> HEPATOMA & cirrhosis -> HEPATOCELLULAR CARCINOMA (Most common cause of death).
. Dx -> Best initial test -> ++ serum iron & ferritin levels & -- TIBC.
. Dx -> Most accurate test -> Liver biopsy - MRI liver - HFe gene mutation detection.
. Tx -> Phlebotomy.
{6} AUTO-IMMUNE HEPATITIS:
___________________________
. Young woman with other auto-immune diseases (Coomb's +ve AIHA, thyroiditis & ITP).
. Best initial test -> ANA & ASMA & Liver/kidney microsomal antibody.
. Serum protein electrophoresis (SPEP) -> Hyper-gamma globulinemia.
. Most accurate test -> Liver biopsy.
. Tx -> prednisone.
. Tumors of GIT, lung & breast are the most common culprits.
. May be asymptomatic & discovered accidentally.
. If symptomatic: Hepatomegaly, jaundice, cholestasis & ++ alkaline phosphatase (ALP).
. NORMAL ALPHA FETO-PROTEIN (AFP).
. Dx -> CT -> Multiple hepatic nodules of varying sizes.
. Confirmed by liver biopsy.
. Multiple liver masses are much more likely to be the result of a metastatic disease.
. Mostly -> CANCER COLON -> DO COLONOSCOPY.
* HEPATOCELLULAR CARCINOMA (HCC):
__________________________________
. Less common than metastasis.
. ++++ ALPHA FETOPROTEIN.
. CT -> SOLITARY large lesion.
* HEPATIC ADENOMA:
___________________
. Benign rare liver tumor.
. Young & middle aged women with H/O of OCP intake.
. Palpable liver mass.
. Liver biopsy -> Mildly atypical hepatocytes containing glycogen & lipid deposits.
. Normal liver finction tests.
. Normal AFP.
. ++ ALP & GGT.
. Complications -> Severe intra-tumor hemorrhage & malignant transformation.
. ALCOHOLIC LIVER DISEASES:
___________________________
. Females are more susceptible than males to alcoholic liver diseases !!
. Alcoholic fatty liver is reversible condition.
. AST:ALT -> 2:1.
. 80 % of alcoholics will develop fatty liver.
. 20 % of alcoholics will develop hepatitis.
. 50 % of alcoholics will develop cirrhosis.
. H/O of heavy alcohol use.
. Hepatomegaly (Liver span > 12 cm in MCL).
. ++ MCV.
. ++ AST : ALT = 2:1.
. Stages -> 1. Fatty liver "steatosis" - 2. Hepatitis - 3. Fibrosis "Cirrhosis".
. Fatty liver is due to short alcohol use.
. Hepatitis & cirrhosis require long term use.
. Alcohol Hepatitis is characterized by:
-> MALLORY BODIES.
-> Neutrophils infiltration.
-> Liver cell necrosis.
-> Peri-venular inflammation.
. On CESSATION of alcohol intake:
-> Steatosis & hepatitis & early fibrosis are REVERSIBLE.
-> True cirrhosis (with generation nodules) are IRREVERSIBLE, regardless of abstinence.
. HYPER-BILIRUBINEMIA APPROACH:
_______________________________
_______________________________
{A} MAINLY UN-CONJUGATED:
__________________________
. Over-production (hemolysis).
. Reduced up-take (drugs & porto-systemic shunt).
. Conjugation defect (Gilbert's $).
{B} MAINLY CONJUGATED -> EVALUATE LIVER ENZYME PATTERN:
________________________________________________________
. {1} Predominantly ++ AST & ALT:
__________________________________
. Viral Hepatitis.
. Autoimmune hepatitis.
. Drug induced hepatitis.
. Hemochromatosis.
. Ischemic hepatitis.
. Alcoholic hepatitis.
. {2} NORMAL AST & ALT & ALP:
______________________________
. DUBIN JOHNSON's $YNDROME.
. ROTOR's $YNDROME.
. {3} Predominantly ++ ALP -> Do abdominal imaging U$ or CT & Antimitochondial Abs:
____________________________________________________________________________________
. Cholestasis of pregnancy.
. Malignancy (pancreas - ampullary).
. Cholangiocarcinoma.
. Primary biliary cirrhosis.
. Primary sclerosing cholangitis.
. Choledocholithiasis.
. N.B. U/$ -> Biliary dilatation = Extra-hepatic cholestasis.
. N.B. U/$ -> No biliary dilatation = Intra-hepatic cholestasis.
. UN-CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:
_______________________________________________________
{1} GILBERT's $YNDROME:
________________________
. Disorder in conjugation.
. -- Glucuronyl transferase (enzyme that mediates glucuronidation).
. Mild jaundice.
. In-direct bilirubin < 3 mg/dl.
. Tx -> Un-necessary.
{2} CRIGLER NAJJAR TYPE - 1 $YNDROME:
______________________________________
. Disorder in metabolism.
. Severe jaundice.
. Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin 20 - 25 mg/dl. may reach 50 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> NO CHANGE in serum bilirubin.
. Tx -> Phototherapy or plasmapharesis the LIVER TRANSPLANT.
{3} CRIGLER NAJJAR TYPE - 2 $YNDROME:
______________________________________
. Disorder in metabolism.
. Severe jaundice (less severe than type 1).
. NOOOO Bilirubin encephalopathy (Kernicterus).
. In-direct bilirubin <<<< 20 mg/dl.
. Normal liver enzymes & liver histology.
. IV PHENOBARBITAL -> ----------- in serum bilirubin.
. Tx -> Not necessary (just phenobarbital to -- bilirubin).
. CONJUGATED HYPER-BILIRUBINEMIA FAMILIAL DISORDERS:
____________________________________________________
{1} ROTOR's $YNDROME:
______________________
. Defect in hepatic storage of conjugated bilirubin.
. Normal liver function tests.
. TTT is not necessary.
{2} DUBIN JOHNSON's $YNDROME:
______________________________
. Defect in hepatic bile secretion.
. Liver biopsy -> dark granular pigment in hepatocytes (Not seen in Rotor's $).
. PANCREATIC DISEASES:
______________________
______________________
. ACUTE PANCREATITIS:
_____________________
. Severe mid-epigastric abdominal pain radiating to the back.
. Vomiting without blood - Anorexia - Tendrness in the epigastric area.
. Main causes are ALCOHOLISM & GALL STONES.
. Other causes -> Hypertiglyceridemia - trauma - infection - iatrogenic ERCP.
. Dx -> Best initial test ->
* ++ Amylase & lipase (most sensitive & specific) -> ++ Amylase/lipase 3 times.
* ABDOMINAL ULTRA$OUND -> Diffusely enlarged hypoechoic pancreas.
. Dx -> Most accurate test -> Abdominal CT scan:
* Detect dilated common bile ducts.
* Comment on intra-hepatic ducts.
. Dx -> N.B. -> ++ ALT > 150 & ++ ALP -> Biliary pancreatitis.
. MRCP -> Detects causes of biliary & pancreatic duct obstruction not found on CT scan.
. ERCP -> If there is dilatation of the common bile duct without a pancreatic head mass.
. ERCP -> Detect stones or strictures in the pancreatic duct system & remove them.
. Tx -> NPO - Bowel rest - Hydration - pain medications.
. N.B. (1):
____________
. If the cause of acute pancreatitis was gall stones not alcoholism,
. Once the pt. recovers with normalization of the pancreatic enzymes & medically stable,
. CLOLECYSTECTOMY IS A MUST !
. N.B. (2):
____________
. Acute pancreatitis in pts without gall stones or a H/O of alcohol use.
. HYPER-TRIGLYCERIDEMIA > 1000 mg/dl -> Acute pancreatitis.
. Eruptive xanthoma on exam.
. Dx -> FASTING LIPID PROFILE.
. COMPLICATIONS OF SEVERE PANCREATITIS:
________________________________________
. 1 . Pseudocyst.
. 2 . Peri-pancreatic fluid collection.
. 3 . Necrotizing pancreatitis.
. 4 . ARD$.
. 5 . ARF.
. 6 . GIT bleeding.
. SEVERE PANCREATITIS:
______________________
. Pancreatitis with failure of at least 1 organ !
. Predisposing factors: Age > 75 ys, Alcoholism & obesity.
. CULLEN SIGN -> Peri-umbilical bluish coloration indicating hemoperitoneum.
. GREY-TURNER SIGN -> Reddish brown coloration around flanks = retroperitoneal bleeding.
. ++ CRP > 150 mg/dl in the 1st 48 hs.
. ++ Urea & creatinine in the 1st 48 hs.
. Severe cases -> (-- BP, -- Ca, -- O2, -- pH) & (++ WBCs, ++ glucose).
. Hypotension, Hypoxia, Metabolic Acidosis, Hypocalcemia, Leukocytosis & Hyperglycemia.
. Hypocalcemia due to fat malabsorption.
. severe pancreatitis may lead to release of activated pancreatic enzymes,
. that enter the vascular system & ++ the vascular permeability,
. so, large volumes of fluid migrate from the vascular system to surrounding peritoneum,
. resulting in widespread vasodilatation, capillary leak, shock & end organ damage.
. Dx -> CT or MRCP to detect pancreatic necrosis & extra-pancreatic inflammation.
. Tx -> Supportive with several liters of IV fluids.
. NECROTIZING PANCREATITIS:
___________________________
. Dx -> CT.
. Tx -> If > 30 % necrosis -> IV Antibiotics (Imipenem) & CT guided biopsy.
. If the biopsy showed infected necrotic pancreatitis -> SURGICAL DEBRIDEMENT.
. Surgical debridement is done to prevent ARD$ & death.
. PANCREATIC PSEUDOCYST:
________________________
. Palpable mass in the epigastrium 4 weeks after the onset of acute pancreatitis.
. Not true cysts as they lack an epithelial lining just walled by a thick fibrous capsule
. Best initial test -> ABDOMINAL U/$ -> DILATED BILE DUCTS & MASS IN HEAD OF PANCREAS.
. CT abdomen is more specific than U/$.
. If CT failed -> i.e. No mass lesion -> Do ERCP.
. If ERCP failed -> due to pancreatic duct obstruction -> Do MRI.
. GALL BLADDER DISEASES:
________________________
________________________
. GALL STONE DISEASE = CHOLELITHIASIS:
______________________________________
. Types of gall stones (Cholesterol - Pigment "Ca bilirubinate" - Mixed).
. Msot common is Cholesterol stone & least common is pigment "Ca bilirubinate".
. 80 % of stones are RADIO-OPAQUE.
. FAT - FERTILE - FEMALE - FORTY - FILTHY !
. Native American - DM - Obesity - OCP & pregnancy are common predisposing factors.
. Bloating & dyspepsia after eating fatty foods.
. RUQ abdominal pain.
. Dx -> Abdominal U/$.
. Tx -> LAPAROSCOPIC CHOLECYSTECTOMY.
. If refused the operation -> Give ursodeoxycholic acid & advise to avoid fatty foods.
. Asymptomatic gall stones should NOT be treated.
. Symptomatic gall stones -> LAPAROSCOPIC CHOLECYSTECTOMY.
. ACUTE CHOLECYSTITIS = ACUTE GALL BLADDER INFLAMMATION:
________________________________________________________
. CHARCOT's TRIAD -> Fever + severe jaundice + RUQ abd pain radiating to the Rt shoulder.
. REYNOLD's PENTAD -> + Confusion + Hypotension -> (Suppurative cholangitis).
. Most commonly due to obstruction of the common bile duct by stone.
. The original incinting event is a gall stone obstructing the CYSTIC DUCT (Not CBD) !!!
. MURPHY's SIGN -> pain on palpation of area of gall bladder fossa on deep inspiration.
. ++ WBCs & ++ ALP (cholestasis & obstruction).
. Dx -> U/$.
. Tx -> Supportive care & broad spectrum antibiotics.
. Most pts recover completely, but despite adequate fluids & antibiotics,
. Some pts continue to have persistent abd. pain, hypotension, high fever & confusion.
. This is an indication of URGENT BILIARY DECOMPRESSION by ERCP.
. ERCP -> Sphincterotomy & stone removal or stent insertion.
. Lap. cholecystectomy won't accomplish drainage of the biliary tree "main concern" !
. Pt will undergo cholecystectomy later on but drainage of the biliary tree is more imp.
. EMPHYSEMATOUS CHOLECYSTITIS:
______________________________
. Due to 2ry infection of the gall bladder with gas forming bacteria e.g. Clostridium.
. Mostly diabetic male pts aged 50 - 70 ys.
. Vascular predisposing factor e.g. obstruction or stenosis of the cystic artery.
. Right upper quadrant pain - nausea - vomiting - low grade fever.
. Crepitus in the abdominal wall adjacent to the gall bladder.
. Complications -> Gangrene & perforation.
. Dx -> Abdominal radiograph -> Air fluid level in the gall bladder.
. Dx -> Abdominal ultrasound -> Curvilinear gas shadowing in the gall bladder.
. Tx -> Immediate fluid & electrolyte resuscitation, cholycystectomy & antibiotics.
. A-CALCULOUS CHOLECYSTITIS:
____________________________
. Acute inflammation of the gall bladder in absence of gall stones.
. Most commonly seen in hospitalized pts wit the following conditions:
. Extensive burns - severe trauma - Prolonged TPN or fasting & mechanical ventillation.
. pathophysiology -> ischemia - biliary stasis - infection or external compression.
. Complications -> Gangrene - perforation - emphysematous cholecystitis.
. Dx -> U/$ -> Signs of cholecystitis but No gall stones.
. CT & HIDA scan are more sensitive & specific.
. PORCELAIN GALL BLADDER:
_________________________
. Due to chronic cholecystitis.
. Calcium laden gall bladder.
. Calcium salts are deposited intra-murally 2ry to chronic irritation from gall stones.
. RUQ. pain with firm non tender mass in the RUQ.
. X-ray -> Rim like calcification in the area of gall bladder.
. CT -> Calcified rim with central bile-filled dark area.
. Mostly develop to GALL BLADDER CARCINOMA.
. Tx -> CHOLECYSTECTOMY.
. GALL BLADDER CARCINOMA = CHOLANGIOCARCINOMA:
______________________________________________
. Rare malignancy.
. More in hispanic or Native american females who have H/O of gall stones.
. Typicallu diagnosed during or after chlecystectomy !
. Can NOT be easily diagnosed pre-operatively.
. CA 19-9 is NOT a specific marker.
. POST-OPERATIVE CHOLESTASIS:
_____________________________
. Benign condition developing after a major surgery.
. Major = Hypotension - extensive blood loss into tissues - massive blood replacement.
. Jaundice by the 2nd or 3rd post-operative day.
. Bilirubin peaks at 10 - 40 mg/dl by the 10th day.
. ALP may be elevated.
. AST & ALT NORMAL.
. POST-CHOLECYSTECTOMY $YNDROME:
________________________________
. Persistent abdominal pain, nause & dyspepsia after cholecystectomy.
. Biliary causes -> Retained common bile duct - cystic duct stone.
. Extra-biliary causes -> Pancreatitis - PUD.
. Dx -> U/$ followed by ERCP.
. POST-CHOLECYSTECTOMY PAIN:
____________________________
. Due to functional etiology e.g. SPHINCTER OF ODDI DYSFUNCTION or CBD stone.
. Normal ERCP & U/$ can rule out CBD stones.
. It is a diagnosis of exclusion.
. Tx of sphincter of Oddi dysfunction -> ERCP with sphincterotomy.
. VANISHING BILE DUCT $YNDROME:
_______________________________
_________________________
. Mild fever & hemolytic anemia.
. Within 2 - 10 days of transfuion.
. +ve direct Coomb's test & +ve new antibody screen.
. caused by ANAMNESTIC ANTIBODY RESPONSE.
. 4 . ANAPHYLACTIC:
____________________
. Rapid onset of shock, angioedema, urticaria & respiratory distress.
. Within a few seconds to minutes of the transfusion.
. Caused by RECEPIENT anti-Ig"A" Abs.
. 5 . URTICARIAL = ALLERGIC:
_____________________________
. Urticaria - flushing - angioedema & pruritis.
. Within 2 - 3 hours of transfusion.
. Caused by RECEPIENT Ig"E" Abs & mast cell activation.
. 6 . TRANSFUSION RELATED ACUTE LUNG INJURY:
_____________________________________________
. Respiratory distress & signs of non-cardiogenic pulmonary edema.
. Within 6 hours of transfusion.
. Caused by DONOR ANTI-LEUKOCYTE ANTIBODIES.
. N.B. Individuals who received blood transfusions before 1992 sh'd be screened for HCV.
. N.B. Individuals who received blood transfusions before 1986 sh'd be screened for HBV.
----------------. ARIZONA.
. Non specific lung syms + erythema multiforme + erythema nodosum + Arthralgia.
. Any dog bite .. An attempt to capture the dog is tried 1st.
------------------------------------------------------------. If the dog is not captyred .. It is assumed RABID .
. Give post-exposure prophylaxis.
. If the dog is captured .. but doesn't show any features of Rabies .
. Observe for 10 days .
. If it developed any Rabies features.
. Give post-exp. prophylaxis.
. If the bite involves the head & neck.
. Post exposure prophylaxis is indicated IMMEDIATELY.
. Viral (HSV) Encephalitis:
--------------------------. Fever + confusion.
. Hemiparesis + Hyperreflexia.
. Cranial n. palsies + focal deficits.
. CSF: ++ ptn , ++ WBCS , ++ Lymphocytes.
. Normal glucose.
. Dx: PCR.
. Tx: I.V. ACYCLOVIR.
. Rt. sided endocarditis:
------------------------. should be considered in pts. with H/O of I.V. drug abuse.
. Tx ----------------> VANCOMYCIN.
. directed against MRSA & Streptococci.
. BABESIOSIS:
------------. Tick borne disease.
. Parasite enters the RBC causing hemolysis.
. Symptoms: JAUNDICE .. HEMOGLOBINURIA .. RENAL FAILURE .. DEATH.
. Typical pt: > 40 ys .. without a spleen or immunocompromized.
. LABS: INTRAVASCULAR HEMOLYSIS:
................................ * -- RBCs,--WBCs,--Platelets.
................................ * -- Serum complement.
................................ * ++ ESR, ++ Lymphocytes.
. Dx: GIEMSA stain.
. Tx: ATOVAQUONE - AZITHROMYCIN.
. Any transplant pt. should have TMP-SMX for prophylaxis against (PCP) pnemo-cystis carinii pneumonia.
. "AIHI" Auto-immune Hemolytic Anemia is one of the complications of INFECTIOUS
. Empiric antibiotics for bacterial meningitis:
----------------------------------------------. VANCOMYCIN + AMPICILLIN + CEFEPIME + CORTICOSTEROIDS.
MONONUCLEOSIS.
. Recall of a tick bite is not the main stay of the diagnosis of LYME disease caused by BORRELIA BURGDORFERI !
. UTI INFECTION:
---------------. Acidic urine = E-Coli.
. Alkaline urine = Proteus.
. Rash of measles & Rubella r za same ... BUT:
---------------------------------------------. Measles is accompanied by KOPLIK's spots.
. Rubella is associated with ARTHRITIS.
. TRICHINELLOSIS:
----------------. GIT complaints.
. + Triad of ---> Peri-orbital edema + Myositis + Eosinophilia.
. other clues .. Splinter or sub-ungal hemorrhages.
. Actinomycosis:
---------------. Infection at the neck in a diabetic pt.
. Serosanguinous fluid draining from a defect in the center of the lesion.
. Culture : Gram +ve branching bacteria.
. Tx: I.V. Penicillin.
. Actinomycosis is a bacteria not a fungus so don't ttt it with Amphotericin !!
. Lesion: Slowly progressive non tender indurated mass
. evolving into multiple abscesses with draining sinus tracts.
. with sulfur yellowish granules !
. CMV Pneumonitis !!!!
--------------------. 45 days post Bone Marrow transplant recepients.
. CXR: Multi-focal diffuse patch infiltrates.
. Oral thrush.
. CMV colitis: Abdominal tenderness
. Toxic scock $yndrome:
----------------------. H/O of NASAL PACKING or MENSTRUATION TAMPOONS.
. Fever < 38.9 c.
. Hypotension < 90/60 mmHg.
. Rash & thrombocytopenia.
. Multisystem involvemet (Vomiting & Diarrhea & Myalgia).
. PCP = PNEUMOCYSTIS CARINII PNEUMONIA:
-------------------------------------. HIV pt. with CD4 < 200.
. Non prod. cough, dyspnea, fever, hypoxia.
. Bilateral interstitial infiltrates on CXR.
. Tx: TMP-SMX.
. Use steroids if: PaO2 < 70 mmHg or A-a gradient > 35 mmHg.
. NOCARDIOSIS:
--------------
. Crooked , branching , beaded , gram +ve partially acid fast filaments on microscopy.
. Tx: TMP-SMX.
. Symptomatic CAT scratch disease:
---------------------------------. Lymphadenopathy & Systemic symptoms.
. Tx: AZITHROMYCIN.
. PSEUDOMONAS AERUGINOSA:
------------------------. Gram -ve bacilli in the sputum of an intubated ICU pt. + fever + leukocytosis.
. Tx: CEFEPIME (4th g. cephalosporin) or PIPERACILLIN - TAZOBACTAM !
. Ceftriaxone is not effective against Pseudomonas.
. U should STOP it !
. Valvular diseases:
-------------------. MR is the most common valvular abnormality not related to IV drug abuse.
. If IV drug abuser .. TR is the the most common.
. D.M. pts with foot ulcer who developed osteo-myelitis:
-------------------------------------------------------. The route of infection is CONTAGIOUS SPREAD.
. A nail puncture wound resulting in Osteomyelitis in an adult:
--------------------------------------------------------------. is due to Pseudomonas Aeruginosa.
. Bacterial Meningitis with meningococcemia:
-------------------------------------------. Sudden onset fever + Neck stiffness + Nause + Headache + Myalgias.
. Hypotension + Tachycardia + Myalgia + Purpuric skin lesions.
. CSF findings of BACTERIAL cause:
=================================
** ++ WBCs .. 2000 (N: 0-5).
** Glucose .. 20 (N: 40-70).
** ++ Protein .. 175 (N: <40).
. Lyme disease:
---------------. is not associated with purpura.
. but associated with erythema migrans.
. with characteristic bull's eye appearance !
. INFLUENZA MANAGEMENT:
----------------------. Most pts with INFLUENZA r ttt with BED REST & SIMPLE ANALGESIA e.g. ACETAMINOPHEN.
. Anti-viral medications reduce the duration of influenza,
. but they r only effective if administered within 48 hours of the onset of illness. . Amantadine & Rimantadine r only
effective against type A.
. Zanamivir & Oseltamivir r only effective against both type A & B.
. INDINAVIR (Protease inhibitor):
---------------------------------
. Anti-retroviral therapy.
. causing high creatinine & hematuria.
. Needle shaped crystals in sediment : causing crystal induced nephropathy!
. BACILLARY ANGIOMATOSIS:
-------------------------. caused by BARTONELLA HENSELAE.
. Manifest as several cutaneous & visceral angioma like blood vessels.
. EXOPHYTIC PURPLE SKIN LESIONS.
. I.V. drug abusers r more prone to developing tricuspid endocarditis:
---------------------------------------------------------------------. caused by STAPHYLOCOCCAL AUREUS.
. Fragments of the vgetation can embolize to the lungs,
. causing the characteristic nodular infiltrate with cavitation.
. PID PELVIC INFLAMMATORY DISEASE :
----------------------------------. Any PID .. Give .. Chlamydia (Azithromycin) + Gonorrhea (Ceftriazone).
. Any PID pt sh'd be routinely screened for $yphilis .. HIV .. HBV .. PAP smear.
. 2ry SYPHILIS:
--------------. Maculo-papular rash involving the palms & soles + Generalized lymphadenopathy. . Spirochete infection.
. PNEUMONIAS:
------------. POST-INFLUENZA ---------------> STAPH. AUREUS.
. HIV---------------------------> PCP.
. D.M. & Alcoholics-------------> KLEBSIELLA.
. C.F. & Bronchiectasis---------> PSEUDOMONAS.
. Atypical $ dry cough----------> MYCOPLASMA.
. Aspiration--------------------> ANAEROBES.
. o"H"io----> "H"ISTOPLASMOSIS:
------------------------------. HIV pt with CD 4 cell count <100.
. T.B. like pulm. syms with FHMA & weight loss.
. HEPATOSPLENOMEGOLY + Palatal ulcers.
. CXR: Bilateral reticulonodular opacities.
. Dx: URINE ANTIGEN.
. Tx: ITRACONAZOLE.
Dr. Wael Tawfic Mohamed
-------------------------
----------------. ARIZONA.
. Non specific lung syms + erythema multiforme + erythema nodosum + Arthralgia.
. Any dog bite .. An attempt to capture the dog is tried 1st.
------------------------------------------------------------. If the dog is not captyred .. It is assumed RABID .
. Give post-exposure prophylaxis.
. If the dog is captured .. but doesn't show any features of Rabies .
. Observe for 10 days .
. If it developed any Rabies features.
. Give post-exp. prophylaxis.
. If the bite involves the head & neck.
. Post exposure prophylaxis is indicated IMMEDIATELY.
. Viral (HSV) Encephalitis:
--------------------------. Fever + confusion.
. Hemiparesis + Hyperreflexia.
. Cranial n. palsies + focal deficits.
. CSF: ++ ptn , ++ WBCS , ++ Lymphocytes.
. Normal glucose.
. Dx: PCR.
. Tx: I.V. ACYCLOVIR.
. Rt. sided endocarditis:
------------------------. should be considered in pts. with H/O of I.V. drug abuse.
. Tx ----------------> VANCOMYCIN.
. directed against MRSA & Streptococci.
. BABESIOSIS:
------------. Tick borne disease.
. Parasite enters the RBC causing hemolysis.
. Symptoms: JAUNDICE .. HEMOGLOBINURIA .. RENAL FAILURE .. DEATH.
. Typical pt: > 40 ys .. without a spleen or immunocompromized.
. LABS: INTRAVASCULAR HEMOLYSIS:
................................ * -- RBCs,--WBCs,--Platelets.
................................ * -- Serum complement.
................................ * ++ ESR, ++ Lymphocytes.
. Dx: GIEMSA stain.
. Tx: ATOVAQUONE - AZITHROMYCIN.
. Any transplant pt. should have TMP-SMX for prophylaxis against (PCP) pnemo-cystis carinii pneumonia.
. "AIHI" Auto-immune Hemolytic Anemia is one of the complications of INFECTIOUS
. Empiric antibiotics for bacterial meningitis:
----------------------------------------------. VANCOMYCIN + AMPICILLIN + CEFEPIME + CORTICOSTEROIDS.
MONONUCLEOSIS.
. Recall of a tick bite is not the main stay of the diagnosis of LYME disease caused by BORRELIA BURGDORFERI !
. UTI INFECTION:
---------------. Acidic urine = E-Coli.
. Alkaline urine = Proteus.
. Rash of measles & Rubella r za same ... BUT:
---------------------------------------------. Measles is accompanied by KOPLIK's spots.
. Rubella is associated with ARTHRITIS.
. TRICHINELLOSIS:
----------------. GIT complaints.
. + Triad of ---> Peri-orbital edema + Myositis + Eosinophilia.
. other clues .. Splinter or sub-ungal hemorrhages.
. Actinomycosis:
---------------. Infection at the neck in a diabetic pt.
. Serosanguinous fluid draining from a defect in the center of the lesion.
. Culture : Gram +ve branching bacteria.
. Tx: I.V. Penicillin.
. Actinomycosis is a bacteria not a fungus so don't ttt it with Amphotericin !!
. Lesion: Slowly progressive non tender indurated mass
. evolving into multiple abscesses with draining sinus tracts.
. with sulfur yellowish granules !
. CMV Pneumonitis !!!!
--------------------. 45 days post Bone Marrow transplant recepients.
. CXR: Multi-focal diffuse patch infiltrates.
. Oral thrush.
. CMV colitis: Abdominal tenderness
. Toxic scock $yndrome:
----------------------. H/O of NASAL PACKING or MENSTRUATION TAMPOONS.
. Fever < 38.9 c.
. Hypotension < 90/60 mmHg.
. Rash & thrombocytopenia.
. Multisystem involvemet (Vomiting & Diarrhea & Myalgia).
. PCP = PNEUMOCYSTIS CARINII PNEUMONIA:
-------------------------------------. HIV pt. with CD4 < 200.
. Non prod. cough, dyspnea, fever, hypoxia.
. Bilateral interstitial infiltrates on CXR.
. Tx: TMP-SMX.
. Use steroids if: PaO2 < 70 mmHg or A-a gradient > 35 mmHg.
. NOCARDIOSIS:
--------------
. Crooked , branching , beaded , gram +ve partially acid fast filaments on microscopy.
. Tx: TMP-SMX.
. Symptomatic CAT scratch disease:
---------------------------------. Lymphadenopathy & Systemic symptoms.
. Tx: AZITHROMYCIN.
. PSEUDOMONAS AERUGINOSA:
------------------------. Gram -ve bacilli in the sputum of an intubated ICU pt. + fever + leukocytosis.
. Tx: CEFEPIME (4th g. cephalosporin) or PIPERACILLIN - TAZOBACTAM !
. Ceftriaxone is not effective against Pseudomonas.
. U should STOP it !
. Valvular diseases:
-------------------. MR is the most common valvular abnormality not related to IV drug abuse.
. If IV drug abuser .. TR is the the most common.
. D.M. pts with foot ulcer who developed osteo-myelitis:
-------------------------------------------------------. The route of infection is CONTAGIOUS SPREAD.
. A nail puncture wound resulting in Osteomyelitis in an adult:
--------------------------------------------------------------. is due to Pseudomonas Aeruginosa.
. Bacterial Meningitis with meningococcemia:
-------------------------------------------. Sudden onset fever + Neck stiffness + Nause + Headache + Myalgias.
. Hypotension + Tachycardia + Myalgia + Purpuric skin lesions.
. CSF findings of BACTERIAL cause:
=================================
** ++ WBCs .. 2000 (N: 0-5).
** Glucose .. 20 (N: 40-70).
** ++ Protein .. 175 (N: <40).
. Lyme disease:
---------------. is not associated with purpura.
. but associated with erythema migrans.
. with characteristic bull's eye appearance !
. INFLUENZA MANAGEMENT:
----------------------. Most pts with INFLUENZA r ttt with BED REST & SIMPLE ANALGESIA e.g. ACETAMINOPHEN.
. Anti-viral medications reduce the duration of influenza,
. but they r only effective if administered within 48 hours of the onset of illness. . Amantadine & Rimantadine r only
effective against type A.
. Zanamivir & Oseltamivir r only effective against both type A & B.
. INDINAVIR (Protease inhibitor):
---------------------------------
. Anti-retroviral therapy.
. causing high creatinine & hematuria.
. Needle shaped crystals in sediment : causing crystal induced nephropathy!
. BACILLARY ANGIOMATOSIS:
-------------------------. caused by BARTONELLA HENSELAE.
. Manifest as several cutaneous & visceral angioma like blood vessels.
. EXOPHYTIC PURPLE SKIN LESIONS.
. I.V. drug abusers r more prone to developing tricuspid endocarditis:
---------------------------------------------------------------------. caused by STAPHYLOCOCCAL AUREUS.
. Fragments of the vgetation can embolize to the lungs,
. causing the characteristic nodular infiltrate with cavitation.
. PID PELVIC INFLAMMATORY DISEASE :
----------------------------------. Any PID .. Give .. Chlamydia (Azithromycin) + Gonorrhea (Ceftriazone).
. Any PID pt sh'd be routinely screened for $yphilis .. HIV .. HBV .. PAP smear.
. 2ry SYPHILIS:
--------------. Maculo-papular rash involving the palms & soles + Generalized lymphadenopathy. . Spirochete infection.
. PNEUMONIAS:
------------. POST-INFLUENZA ---------------> STAPH. AUREUS.
. HIV---------------------------> PCP.
. D.M. & Alcoholics-------------> KLEBSIELLA.
. C.F. & Bronchiectasis---------> PSEUDOMONAS.
. Atypical $ dry cough----------> MYCOPLASMA.
. Aspiration--------------------> ANAEROBES.
. o"H"io----> "H"ISTOPLASMOSIS:
------------------------------. HIV pt with CD 4 cell count <100.
. T.B. like pulm. syms with FHMA & weight loss.
. HEPATOSPLENOMEGOLY + Palatal ulcers.
. CXR: Bilateral reticulonodular opacities.
. Dx: URINE ANTIGEN.
. Tx: ITRACONAZOLE.
Dr. Wael Tawfic Mohamed
-------------------------
3- CEREBELLUM:
______________
* NO hemiparesis.
* GAIT ATAXIA.
* OCCIPITAL HEADACHE (+nausea & vomiting).
* Gaze palsy (6th CN. paralysis)
* Facial weakness.
4- "P"ONS:
__________
* COMPLETE PARAPLEGIA.
* Followed by deep coma in a few mins.
* (REACTIVE) "P"IN POINT PUPILS.
5- CEREBRAL:
____________
* May be associated with seizures.
* Eyes deviate AWAY from the hemi-paresis.
. GUILLAIN BARRE' $YNDROME:
___________________________
. Acute idiopathic polyneuropathy.
. Ascending paralysis (i.e. affects LL 1st then involve the rest of the ms upwards!).
. Preceided by infection or vaccination.
. weakness in both legs then ascends to involve the arms, respiratory ms & face.
. Reflexes are diminished or symptoms.
. Distal paresthesia may occur.
. Dx: CSF ANALYSIS -> HIGH PROTEIN CONCENTRATION with NORMAL CELL COUNT.
. ++ PROTEIN & NORMAL (WBCs - RBCs - GLUCOSE) !
. i.e. CYTO-ALBUMINOUS DISSOCIATION.
. Tx: Supportive care, IVIG (Intravenous immunoglobulins) & plasmapharesis.
. GB$ may lead to respiratory failure.
. LUNG VITAL CAPACITY is the best way to monitor the respiratory function.
. N.B. TICK BORNE PARALYSIS:
____________________________
. Progressive ascending paralysis.
. Over hours - days.
. NO fever.
. Normal sensations.
. Normal CSF analysis.
. Meticulous search & removal of the tick results in improvement & complete recovery.
# PARA-NEOPLASTIC $YNDROMES !
_____________________________
.1. MYASTHENIA GRAVIS:
______________________
. Female 18 - 25 ys.
. NEURO-MUSCULAR JUNCTION DISEASE.
. Muscle weakness after a period of muscle use.
. Dysarthria - Dysphagia.
. Drooping eyelids (Ptosis) - Diplopia (Double vision). {Extraocular ms involvement}.
# STROKE MANAGEMENT:
_____________________
1- NON contrast head CT to rule out hemorrhagic stroke.
2- Ischemic stroke -> Give fibrinolytic therapy (if the pt comes within 3-4 hs of onset).
3- Make sure that the pt. has no contraindications to the fibrinolysins.
4- If there is contraindication -> Give Antiplatelets (ASPIRIN).
. Clinical presentation "ischemic stroke case" -> Anti-platelet/Anti-thrombotic therapy:
________________________________________________________________________________________
. Presenting within 3 - 4.5 hs of symptoms onset with no cont'ds -> I.V. Alteplase.
. Stroke with no prior anti-platelet therapy -> Aspirin.
. Stroke on Aspirin therapy ->(Aspirin + dipyridamole) OR (Clopidogrel).
. Stroke on Aspirin therapy + intracranial large art. sclerosis -> Aspirin + Clopidogrel.
. Stroke with evidence of atrial fibrillation -> LONG TERM ANTICOAGULATION e.g. WARFARIN.
# THROMBOLYTICS = TISSUE PLASMINOGEN ACTIVATOR (t-PA) = ALTEPLASE:
___________________________________________________________________
# THROMBOLYTICS INDICATIONS & CONTRAINDICATIONS:
_________________________________________________
# THROMBOLYTICS INDICATIONS:
_____________________________
.1. Non hemorrhagic ischemic stroke.
.2. Symptoms onset < 3 - 4.5 hours before treatment initiation.
# THROMBOLYTICS CONTRA-INDICATIONS:
____________________________________
.1. Stroke or head trauma in the past 3 months.
.2. H/O of intracranial hemorrhage.
.3. Major surgery in the past 2 weeks.
.4. GI,GU or active bleeding in the past 3 weeks.
.5. Seizure at the onset of stroke.
.6. SBP > 185 mmHg or DBP > 110 mmHg.
.7. Platelets < 100000/mm3 , Glucose < 50 mg/dl , INR > 1.7.
__________________________________________________________________________________________
__________________________________________________________________________________________
. HEMI-NEGLECT $YNDROME = LESION in the (RIGHT PARIETAL LOBE CORTEX):
_____________________________________________________________________
. Lesion of the RIGHT (NON)-dominant hemi-sphere.
. which is responsible for spatial organization.
. So, In this disease, The pt ignores the left side of a space.
. Responds only to the stimuli coming from the RIGHT side.
. Pt may shave only the Right side of their face.
. Comb the Right side of his hair.
. Ignore the subject located in the left side of a space.
. Dx: Ask the pt to fill in the numbers o a clock !
. EXERTIONAL HEAT STROKE:
_________________________
. Severe exertion under direct sun light.
. DIABETIC NEUROPATHY:
______________________
. Symmetric peripheral polyneuropathy, mononeuropathy or autonomic neuropathy.
. Mononeuropathies either cranial or somatic.
. CN 3 (Oculomotor) is the most common affected.
. The cause of neuropathy is ISCHEMIC.
. Somatic & parasympathetic fibers in CN 3 have separate blood supplies.
. So .. Only somatic fibers are affected while the parasympathetic fibers are intact.
. Manifested by PTOSIS & DOWN & OUT GAZE.
. Accomodation & light reflex are intact.
. SPINAL CORD COMPRESSION:
__________________________
. isolated, symmetric, lower extremity symptoms.
. Loss of sensations & signs of upper motor neuron lesion.
. Weakness without fasciculations, hyperreflexia & +ve Babinski sign.
. Possible etiologies: (Disk herniation - Epidural absess & malignancy).
. It is a medical emergency !
. Dx: MRI Spine .. NOT CT !!
. ALZHEIMER's DISEASE:
______________________
* It is the most common cause of dementia.
* NO disturbance in consciousness.
* Age group > 60.
* EARLY FINDINGS:
__________________
. Anterograde memory loss (immediate recall affected, distant memory preserved).
. Visuospatial deficits (lost in own neighborhood).
. Language difficulties (difficulty finding words).
. Cognitive impairment with progressive decline.
* LATE FINDINGS:
_________________
. Neuropsychiatric (hallucinations & wandering).
. Dyspraxia (difficulty performing learned motor tasks).
. Lack of insight regarding deficits.
. Non-cognitive neurological deficits (pyramidal & extra-pyramidal motor, myoclonus).
. Urinary incontinence.
* Dx: CT -> Diffuse cortical & subcortical atrophy,
which is disappropriately greater in the temporal & parietal lobes.
. GLIOBLASTOMA MULTIFORME (GBM) = HIGH GRADE ASTROCYTOMA:
_________________________________________________________
. Symptoms of ++ ICT (Nausea-vomiting-headache worsening with change in position).
. ++ ICT = Space occupying lesion.
. Personality changes & strange behavior (Due to involvement of the frontal lobe).
. Dx: CT or MRI -> BUTTERFLY appearance with central necrosis,
. with HETEROGENOUS SERPIGINOUS CONTRAST ENHANCEMENT.
. CRANIOPHARYNGIOMA = Hypopituitarism signs + Headaches + Bitemporal blindness:
_______________________________________________________________________________
. Benign tumors arising from Rathke's pouch.
. Bimodal age distribution i.e. children & 55-65 ys age group.
. It is located above sella turcica.
. Consists of multiple cysts filled with oily fluid.
. Presents with symptoms of hypothyroidism.
. In children (Retarded growth due to -- GH & TSH).
. In adults (Sexual dysfunction).
. Women may present with amenorrhea.
. It compresses the optic chiasma -> BITEMPORAL BLINDNESS.
. Headaches occur due to ++ ICT.
. Dx: MRI or CT.
. Tx: Surgery or radiotherapy.
. CAUDA EQUINA $YNDROME:
________________________
. Compression of the spinal nerve roots.
. Causes (Tumor - Herniated disk - Abscess - Trauma).
. Low bk pain.
. Bowel & bladder dysfunction.
. Saddle anesthesia.
. Sciatica.
. Lower extremity sensory & motor loss.
. Dx: Emergent MRI.
# HIV associated lesions on MRI:
________________________________
.1. PRIMARY CNS LYMPHOMA:
_________________________
. Solitary.
. {WEAKLY} ring enhancing peri-ventricular mass.
. Altered mental status.
. Associated EBV DNA in the CSF.
.2. TOXOPLASMOSIS:
__________________
. Multiple.
. {Ring - enhancing} spherical lesions in the basal ganglia.
. +ve serology is not specific !
. TMP-SMX is preventive.
.3. PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY:
_______________________________________________
. {Non - enhancing}.
. No mass effects.
. Opportunistic viral infection (JC virus).
.4. AIDS DEMENTIA COMPLEX:
__________________________
. Cortical & sub-cortical atrophy.
. 2ry ventricular enlargement.
.5. ABSCESS:
____________
. Solitary.
. {Ring enhancing}.
. Isolated, round with smooth borders.
. H/O of known extra-cranial infections.
. Fluid collection in the maxillary sinus.
. The most common causative organisms are AEROBIC & ANAEROBIC STREPTOCOCCI & BACTEROIDES.
# CAROTID ARTERY STENOSIS:
__________________________
. May progress to embolic stroke or TIAs.
. May be silent with no symptoms.
. Symptomatic -> sudden onset of focal neuro. syms ipsilateral to the blocked artery.
. Dx: NECK DUPLEX U/$.
. Tx: CEA or CAS.
. CAROTID END ARTERECTOMY (CEA) is recommended if:
_________________________________________________
. * Symptomatic pts with carotid stenosis 70 - 99 %.
. * Low surgical risk.
. * Good 5 year predicted survival.
. * Surgically accessible carotid lesion.
. CAROTID ANGIOPLASTY WITH STENTING (CAS) is recommended if:
___________________________________________________________
. * High surgical risk.
. * Poor 5 year predicted survival.
. * Lesion not amenable to surgery.
# IMPORTANT CRANIAL NERVES & THEIR FUNCTIONS:
_____________________________________________
* OPTIC NERVE (CN 2):
_____________________
. VISION.
* OCULOMOTOR (CN 3):
____________________
. Eye movement (Most).
. Adduction with medial rectus.
. Elevation with superior rectus.
. Depression with inferior rectus.
. Eye lid opening.
. Pupil constriction.
* TRIGEMINAL (CN 5):
____________________
. Three branches with both motor & sensory fibers.
. The 1st branch is called the Ophthalmic nerve,
. It carries sensory fibers to the scalp, forehead, upper eyelid, cornea & nose.
* FACIAL (CN 7):
________________
. Facial movement.
. Taste in the anterior 2/3s of the tongue.
. Lacrimation.
. Salivation.
. Eye closing.
* VAGUS (CN 10):
________________
. Swallowing.
. Palate elevation.
. Monitoring baro & chemo receptors of the aortic arch.
. IMPAIRED DAILY FUNCTIONING:
_____________________________
. is essential to distinguish between dementia & normal aging.
. Pts with dementia have functional impairment.
. Normal aging is not ass. with impairment.
. ACUTE GLAUCOMA:
_________________
. Occurs when a pre-existing narrow anterior chamber angle is closed,
. in response to pupillary dilatation from medications or another stimiulus.
. PPt by direct bright light e.g. watching TV.
. ++ IOP may lead to nausea & vomiting & tearing pain.
. Complain of seeing halos around light.
. Damage of the optic nerve is common & may lead to visual loss.
. Sudden onset of photophobia, eye pain, headache & nausea.
. Palpation -> very hard eye.
. NON REACTIVE MID DILATED PUPIL.
. Dx: TONOMETRY.
# HEADACHES:
____________
.1. MIGRAINE HEADACHE:
_______________________
. Unilateral.
. Pulsating quality.
. Attacks last from 4 - 72 hs.
. Photophobia.
. Common in younger females.
. AURA of neurological syms preceiding headache.
. Tx: TRIPTANS (Efficient only before the start of the attack) + NSAIDs.
. I.V. Anti-emetics e.g. (PRO-CHLOR-PERAZINE) or Metoclopramide {SEVERE VOMITING CASES}.
.2. CLUSTER HEADACHE:
______________________
. Intense unilateral retro-orbital pain.
. Starts suddenly (usually at night).
. More common in men.
. Redness of the ipsilateral eye.
. Tearing eye pain.
. Stuffed or runny nose.
. Ipsilateral Horner's $.
. Attacks occur in clusers.
. Prophylaxis is the key to management (Verapamil - Lithium - Ergotamine).
. Tx of acute attack -> 100 % OXYGEN & S.C. Sumatriptan.
. ETHICAL PROBLEM:
__________________
. REGARDLESS OF H/O OF DRUG ABUSE,,
. Pts with acute severe pain sh'd receive the same standard of pain management !!
. IV MORPHINE is the best ttt for acute severe pain.
. Physicians sh'd NEVER undertreat pain even if there is a risk for abuse.
. SITE OF THE LESION ----> DEFICIT:
___________________________________
. UPPER THORACIC SPINAL CORD ---> Paraplegia - Bladder & fecal incontinence,
. ............................... + Absent sensation from the (NIPPLE) downwards.
. LOWER THORACIC SPINAL CORD ---> Absent sensation from the (UMBILICUS) downwards.
. PARKINSON DISEASE = TREMORS + RIGIDITY + BRADYKINESIA:
________________________________________________________
. Neurodegenerative disorder.
. Caused by accumulation of alpha synuclein within the neurons of SUBSTANCIA NEGRA.
. The most common presenting symptom is asymmetric resting tremor in the upper extremity.
.1 * TREMOR:
___________
. A resting 4 to 6 Hz tremor with a pill-rolling quality.
. Frequently first manifests in one hand.
. May slowly generalize to involve the other side of the body & the lower extremity.
.2 * RIGIDITY:
______________
. Baseline ++ resistance to passive movement (Lead pipe or cog wheel).
.3 * BRADYKINESIA:
__________________
. Difficulty initiating movements as when starting to walk or rising from a chair.
. Narrow based, shuffling gait with short strides without arm swing (FESTINATING).
. Micrographia (Small hand writing).
. Hypomimia (-- facial expression).
. Hypophonia (soft speech).
.4 * POSTURAL INSTABILITY:
__________________________
. Flexed axial posture.
. Loss of balance during turning or stopping.
. Loss of balance when pushed slightly.
. Frequent falls.
. NO SPECIAL TEST FOR EXACT DIAGNOSIS.
. ONLY PHYSICAL EXAMINATION CAN LEAD TO THE Dx.
. STATUS EPILEPTICUS:
_____________________
. Single seizure lasting > 30 mins.
. H/O of seizure disorder with no compliance to anti-convulsant therapy.
. A brain seizing > 5 mins is at ++ risk of permanent injury : CORTICAL LAMINAR NECROSIS.
. Tx -> BENZODIAZEPINE -> IV DIAZEPAM.
. Failed -> ADD FOSPHENOTOIN.
. CEREBELLAR TREMORS -> Intension tremors - low fequency 3-4 Hz - Nystagmus & ataxia.
. TRIGEMINAL NEURALGIA: LIGHTENING PAIN on the face - electric shock - Tx: CARBAMAZEPINE.
. GUILLAIN BARRE'$: Ascending paralysis - Pre.by infection - CYTOALBUMINOUS DISSOCIATION.
. TICK BORNE PARALYSIS: Ascending paralysi - NO fever - Normal CSF - Tx: Tick removal.
. MYASTHENIA GRAVIS: Ptosis,Diplopia RESOLUTION OF MUSCULAR WEAKNESS WITH REST.
. LAMBERT EATON $YNDROME: LUNG CANCER H/O, Auto-Abs against voltage gated Ca channels.
. N.B. MYASTHENIA GRAVIS: AutoAbs against (post)synaptic recs - INTACT DTRs.
. N.B. LAMBERT-EATON $: AutoAbs against (pre)synaptic receptors - LOST DTRs.
. DERMATOMYOSITIS: Sym. prox. ms weakness - SKIN (Gottron's papules & Heliotrope rash).
. STEROID INDUCED MYOPATHY: Prox. ms weakness (LL before UL) - No pain.
. SUB-ARACHNOID HEMORRHAGE: Rupture of "Berry" aneyrysm - WORST HEADACHE EVER.
. NEURO-FIBROMATOSIS "2": S.C. neurofibromas + Cafe' au lait spots + acoustic neuromas.
. PRONATOR DRIFT = UMNL.
. ESSENTIAL TREMOR: Tx: BB "Propranolol".
. MULTIPLE SCLEROSIS = Optic neuritis (painful loss of vision) & diplopia.
. MULTIPLE SCLEROSIS = INTER-NUCLEAR OPHTHALMOPLEGIA (INO).
. MULTIPLE SCLEROSIS = Dx: BRAIN MRI with & without GADOLINIUM.
. MULTIPLE SCLEROSIS = CSF analysis: OLIGOCLONAL IgG bands - Normal pressure.
. MULTIPLE SCLEROSIS = Tx of acute exacerbation -----> HIGH DOSE IV GLUCOCORTICOIDS.
. MULTIPLE SCLEROSIS = prevent future attacks -> B-interferon or Glatiramer acetate.
. MULTIPLE SCLEROSIS = YOUNG FEMALE with BILATERAL TRIGEMINAL NEURALGIA.
. AMYOTROPHIC LATERAL SCLEROSIS: UPPER + LOWER motor neuron lesions.
. CT$: MEDIAN N. - At WRIST - Thenar eminence atrophy - Paresthesia 1st 3.5 fingers
. ULNAR N. ENT. $: paresthesia of 4th & 5th fingers - ent.at medial epicondylar groove.
. VESTIBULO-TOXICITY by AMINOGLYCOSIDES: Gentamycin-Amikacin - Vertigo & gait imbalance.
. TORTICOLLIS: Example of FOCAL DYSTONIA.
. UN-PROVOKED FIRST SEIZURE -> HEAD CT WITHOUT CONTRAST is the 1st initial step done.
. LIMB ISCHEMIA: 5 Ps (Pain - Pallor - Paresthesia - Pulselessness & Paralysis).
. METOCLOPRAMIDE: Side effect Dystonia - Manifested by stiff painful neck.
. HEMI-NEGLECT $YNDROME: RIGHT PARIETAL LOBE CORTEX lesion - (NON)-dominant hemi-sphere.
. EXERTIONAL HEAT STROKE: Tx -> EVAPORATION COOLING (NOT immersion in cold water xxx).
head position.
diagnostic.
classic.
.. CMV :
-------... Pain-less.
... Not ass. e'keratitis or. conjunctivitis.
... Fundus: Hemorrhages & fluffy or granular lesions around retinal vessels.
. Neuro-fibramatosis type 1 = Axillary freckling + Cafe' au lait patches + Optic glioma.
--------------------------. Diabetic pt with blurry vision:
--------------------------------. Type 2 D.M. with HYPEROSMOLAR HYPERKETOTIC state without ketoacidosis.
. Glucose in urine with NO KETONES.
. NKHS = Non Ketotic Hyperosmolar $
so, the cause of blurring of vision is HYPEROSMOLARITY !
. Macular degeneration:
----------------------. Grid test: distortion of the straight lines that appear wavy !
------------------------Dr. Wael Tawfic Mohamed
-------------------------
. OPIOID INTOXICATION:
______________________
. -- RESPIRATORY RATE is the most reliable & predictive sign.
. -- Bowel sounds.
. -- BP.
. -- Temp.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Tx: NALOXONE.
. The goal of ttt is ++ RR from 6 to 12/min with improving Oxygen saturation.
. N.B. PUPIL EXAMINATION is NOT RELIABLE !!
. Opioid intoxication doesn't always present with miosis.
. Co-ingestions can lead to normal pupillary size or even mydriasis !!!
. OPIOID WITHDRAWAL:
____________________
. Symptoms develop within 6-12 hs after the last dose of short acting opioid.
. H/O of heroin injection (Needle marks on extremities by P/E).
. Nausea - vomiting - Abdominal pain - Diarrhea - Restlessness - Arthralgia & myalgia.
. Rhinorrhea - Lacrimation.
. Mydriasis - Piloerection & hyperactive bowel sounds.
. Tx -> METHADONE.
. METHANOL INTOXICATION:
________________________
. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -----> Vision loss & coma.
. Optic disc hyperemia.
. ++ ANION GAP METABOLIC ACIDOSIS { (Na) - (Cl + HCO3) }. (Normal AG 8-12).
. ++ OSMOLAR GAP.
. Very low HCO3.
. ETHYLENE GLYCOL INTOXICATION:
_______________________________
. "ALCOHOL's SUBSTITUTE".
. H/O of homeless man.
. 1st 24 hs -> Headache, nausea, vomiting & epigastric pain.
. Later -> Flank pain, hematuria, oliguria, Acute renal failure.
. Glycolic acid (Metabolite) injuries the renal tubules.
. Oxalic acid binds calcium & deposits in the kidneys.
. Tx: FOMEPIZOLE or ETHANOL to prevent ethylene glycol to its harmful metabolites.
. N.B. METHANOL & ETHYLENE GLYCOL MAY HAVE SIMILAR PRESENTATIONS ! BUT !!
_________________________________________________________________________
. METHANOL DAMAGES THE EYES.
. ETHYLENE GLYCOL DAMAGES THE KIDNEYS.
. BETA-BLOCKERS BB INTOXICATION:
________________________________
. -- HR.
. -- BP.
. AV BLOCK.
. BRONCHOSPASM -> WHEEZES (MOST SPECIFIC).
. Cardiogenic shock may occur (Cold & clammy extremities).
. Neurological effects (Delirium & seizures).
. 1st line TTT -> ATROPINE + IV FLUIDS.
. FAILED -------> GLUCAGON ++ c-AMP -> ++ Ca -> ++ cardiac contractility.
. CANNABIS = MARIJUANA INTOXICATION:
____________________________________
. +++++++ APPETITE.
. DRY MOUTH.
. CONJUNCTIVAL INJECTION.
. ++ HR.
. ++ BP.
. ++ RR.
. -- concentration & short time memory.
. -- reaction time & impairs attention.
. ++ the risk of vehicle accidents.
. ALCOHOL INTOXICATION:
_______________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Disinhibited behavior.
. Memory impairment.
. Nystagmus.
. ALCOHOL WITHDRAWAL:
_____________________
. Due to reflex hyperactivity of certain parts of the brain.
. Anxiety, insomnia, tremors & diaphoresis in the 1st 6-24 hs after alcohol cessation.
. Hallucinations & withdrawal seizures may occur.
. DELIRIUM TREMENS may occur in 5% of pts after 48 - 72 hs.
. Hypertension, agitation, tachycardia, hallucinations & fever.
. Tx -> CNS depressant -> Benzodiazepenes -> Chlordiazepoxide.
. BENZODIAZEPINE OVERDOSE:
__________________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. Respiratory compromise, stupor & coma.
. Distinguished from opioid overdose by lack of severe respiratory depression & miosis.
. Distinguished from alcohol & phenytoin toxicity by lack of nystagmus.
. BARBITURATE (SEDATIVES) INTOXICATION:
_______________________________________
. Slurred speech.
. Unsteady gait.
. Incoordination.
. COCAINE INTOXICATION:
_______________________
. SYMPATHETIC STIMULATION (++HR, ++BP, MYSRIASIS).
. Euphoria.
. Sense of self confidence.
. ++ arousal.
. improved performance.
. CAUSTICS "LYE" (SODIUM HYDROXIDE) INGESTION:
______________________________________________
. A strong alkaline solution.
. Mostly due to suicidal attempt.
. SEVERE ESOPHAGEAL DAMAGE due to LIQUEFACTIVE NECROSIS.
. May lead to perforation & mediastinitis.
. Retrosternal or epigastric pain - hypersalivation - Odynophagia & dysphagia.
. Tx -> HOSPITALIZATION + IV HYDRATION.
. ENDOSCOPY IS MANDATORY to determine the extent of esophageal damage !
. If perforation is suspected -> A gastrograffin study sh'd be performed.
. NEVER to neutralize the alkali with ana acid !!
. NEVER to induce vomiting !!
. Charcoal isn't effective !!
. N.B. NO ALTERATION IN CONSCIOUSNESS.
. CARDIOLOGICAL PROBLEM RELATED TO TOXICOLOGY !
_______________________________________________
. TORSADES DE POINTS -> Tx: MgSO4 !
____________________________________
. Polymorphic ventricular tachycardia.
. Occurs in the setting of a prolonged QT interval.
. Seen in pts with familial long QT $yndrome.
. Malnourished pts predisposed to hypomagnesemia (Alcoholics).
. Pts on TCAs (Tricyclic anti-depressants).
. Pts on anti-arrhythmics (Amiodarone - Sotalol).
. Anti-infective agents (Moxifloxacin - Fluconazole).
. Tx -> Cessation of the offending drug & MgSO4.
. PHENCYCLIDINE INTOXICATION:
_____________________________
. HALLUCINOGENIC STREET DRUG.
. VERTICAL NYSTAGMUS.
. VIOLENT BEHAVIOR.
. Agitation - confusion - Pupillary dilatation - tachycardia.
. Severe hypertension & hyperthermia may occur.
. Tx -> Benzodiazepines.
. CHEMICALS IN THE EYE:
_______________________
. FLUSH THE EYE WITH WATER (EYE UNDER A FAUCET OF RUNNING WATER FOR AT LEAST 15 mins) !
. DIPHENHYDRAMINE POISONING:
____________________________
. Anti-histaminic used in ttt of allergic rhinitis - insect bites & motion sickness.
. Mixture of anti-cholinergic symptoms.
. Drowsiness & confusion.
. Dry mouth - dilated pupils - blurred vision - Reduced bowel sounds & urine retention.
. Tx -> PHYSOSTIGMINE (Cholinesterase inhibitor).
. SALICYLATE INTOXICATION:
__________________________
. TINNITUS.
. Nausea & vomiting.
. Fever.
. Altered mental status & acid-base abnormalities.
. Tx -> ALKALINIZATION OF URINE with SODIUM BICARBONATE (Na HCO3).
. CARBON MONOXIDE (CO) POISONING:
_________________________________
. HISTORY is the most ipmortant clue to diagnosis.
. SMOKE INHALATION - BARBEQUE PARTY !!
. CO is a colorless - odorless gas.
. Emitted by automobiles, furnaces & charcoal grills.
. When inhaled, it prevents the body from utilizing Oxygen.
. Headache - Nausea - Vomiting - Abd. discomfort - confusion - coma.
. PINKISH RED SKIN HUE.
. Dx -> Obtain CARBOXYHEMOGLOBIN levels.
. Tx -> HYBERBARIC OXYGEN.
. ACETAMINOPHEN POISONING:
__________________________
. Rumack - Matthew Nomogram is a curve used to assess its hepatotoxic effects.
. It also provides the need for N-acetylcysteine as an antidote.
. The 1st data point on the curve is at 4 hours !
. The decision of whether or not to take the antidote can be made after 4 hours.
. Studies proved zat their is no correlation bet. z amount ingested & z toxicity level!
. So .. If a pt. came to u with H/O of ingestion of 14 pills 2 hours ago ,,
. You should wait 2 hours then obtain the acetaminophen level.
. ORGANO-PHOSPHATE POISONING:
_____________________________
. Organophosphates antagonizes acetylcholinesterase -> Cholinergic excess.
. -- HR - miosis - muscle fasciculations.
. Bronchorrhea - salivation - lacrimation - diarrhea - urination.
. Tx -> ATROPINE (Compete with acetylcholine at the muscarinic receptors).
. IMMEDIATE REMOVAL OF THE PT's CLOTHING (SOAKED with secretions),
. thus .. preventing continued absorption of organophosphates through the skin.
. TRI-CYCLIC ANTI-DEPRESSANTS (TCA) INTOXICATION:
_________________________________________________
. Hyperthermia - seizures - Hypotension.
. Anticholinergic effects (mydriasis - flushed dry skin - intestinal ileus).
. TCAs -> -- conductivity -> QRS prolongation -> Ventricular arrhythmia.
. THE BEST INDICATOR OF THE EXTENT OF THE OVERDOSE is the QRS COMPLEX DURATION.
. Tx -> NaHCO3 -> Narrows the QRS complex & -- the incidence of VT.
. NaHCO3 Mechanism -> Sodium load will alleviate the depressant action on Na channels.
-----------------------------------------------------------------------------------* It can be given to HIV pts with CD4 cells > 200 with no evidence or H/O of AIDS defining illness.
* Live vaccines e.g. BCG, Oral polio, Meningococcal vaccines are CONTRAINDICATED in HIV pts.
* TETANUS & DIPHTHERIA TOXOID booster doses every 10 ys can be given safely.
. INFLUENZA vaccine is recommended ANNUALLY !
-------------------------------------------. Pneumococcal vaccine:
----------------------. Pt < 65 ys --> Once followed by a booster every 5 years.
. Pt > 65 ys --> Once.
. Travelers to developing countries e.g EGYPT should be vaccinated against HEPATITIS A.
. CHLAMYDIA TRACHOMATIS infection:
---------------------------------. should be screened in all sexually active women aged 24 ys & younger.
. If a pt has DM with no vaccines except flu vaccine since childhood series,
--------------------------------------------------------------------------. he should receive TdaP "Tetanus + Diphtheria + Pertussis" ,
. annual IM influenza & pneumococcal vaccines.
. CHRONIC LIVER disease VACCINATIONS:
------------------------------------. HEPATITIS A & B.
. INFLUENZA. "ANNUALLY".
. PNEUMOCOCCAL. "Immunocompromized".
. TdaP "Usual Boosters".
. All adults:
-----------. should have TETANUS & DIPHTHERIA boosters every 10 ys,
. with a one-time tetanus, diphtheria & pertussis booster.
. require INFLUENZA vaccine ANNUALLY.
. Cervical cancer screening:
--------------------------. should be started at age 21 & repeated every 2 - 3 ys.
. Women aged 30-65 ys:
--------------------.. Either PAP smear every 3 ys.
.. Or COMBINATION of PAP smear & HPV testing every 5 ys.
. Vaccinations in pts with HIV:
-----------------------------. Pts with HIV shouldn't receive live vaccines,
. such as BCG,anthrax,oral typhoid,intranasal influenza & oral polio.
. The exceptions r the MMR & VARICELLA vaccines,
. which can be used in pts without evidence of immunity if their CD4 counts > 200.
* DELUSIONAL DISORDER:
-> Key is that delusions are NON-bizarre.
-> Delusions may occur normally in daily life.
-> Delusions are false beliefs in high functioning person.
* PERSONALITY DISORDERS (Especially SCHIZOTYPAL PERSONALITY DISORDER):
-> Prsents with peculiar thinking & social isolation.
-> No psychosis.
. The previous two types of pts (DELUSIONS & PERSONALTY DISORDERS):
-> Don't respond to anti-psychotics.
-> PSYCHOTHERAPY is the preferred therapy.
. N.B.
. A DELUSION is a fixed, false belief not consistent with cultural norms.
. Individuals with GRANDIOSE DELUSIONS typically believe they have
. special powers extraordinary accomplishments or a special relationship e' god.
. RULE OUT other forms of psychosis that are NOT schizophrenia:
-> Get a DRUG SCREEN to rule our SUBSTANCE ABUSE.
-> Look for signs & symptoms of SEIZURE !
-> TEMPORAL LOBE EPILEPSY can present with hallucinations (Auditory & Olfactory).
. N.B.
. Watch out for SUICIDAL IDEATION in schizophrenia pts & schizophreniform pts.
. 50 % of them attempt suicide & 10 % are successful.
. 1st stepin management is always to HOSPITALIZE if there is risk of suicide.
. The 1st step in management of any acute psychiatric condition is:
. to determine if the pt needs hospitalization !
. Hospitalize if the pt at risk of harm to self or to others.
. Hospitalize against the pt's will if the pt has suicidal or homicidal ideation.
. The greatest risk factor for progression to schizophrenia is SCHIZOFRENIFORM DISORDER.
. Prognosis:
-> Females have a better prognosis & respond better to ttt than males.
-> Pts e' paranoid schizophrenia are more responsive to ttt.
. The prognosis is poor if there is:
-> Early age of onset.
-> Negative symptoms.
-> Poor premorbid functioning.
-> Family H/O of schizophrenia.
-> Disorganized or deficit subtype.
. Treatment:
-> If there is bizarre or paranoid syms -> HOSPITALIZE the pt.
-> Give BENZODIAZEPINES for agitation & start ANTI-PSYCHOTICS.
-> Anti-psychotic medications are given for 6 months.
-> They are most effective to prevent further episodes.
-> Long term anti-psychotics are ONLy given if there is H/O of REPEATED episodes.
-> Initiate log-term psychotherapy.
. ANTI-PSYCHOTICS:
___________________
___________________
. Have an IMMEDIATE QUIETING EFFECT in acute atacks.
. Delay relapse.
. Used for sedation when benzodiazepines are cont'd or as an adjunct during anesthesia.
. Used for ttt of movement disorders (Huntington's disease & Tourette $),
. to suppress tics & vocalization
. N.B. In ttt of Tourette $ -> We use TYPICAL antipsychotics (Haloperidol & PIMOZIDE).
. N.B. Antipsychotics are chosen based on side effect profile, NOT efficacy !
. A . CONVENTIONAL (TYPICAL) ANTIPSYCHOTICS:
_____________________________________________
(1) HIGH POTENCY {FLUPHENAZINE DECANOATE - HALOPERIDOL}:
__________________________________________________________
-> Less sedating - Fewer anticholinergic effects - Less hypotension.
-> Useful as depot injections (Haloperidol decanoate) for non-compliant pts.
-> Give IM route for acute psychosis when pt is unable or unwilling to take PO.
-> GREATEST ASSOCIATION WITH EXTRAPYRAMIDAL SYSTEMS (EPS).
-> ++ PROLACTIN.
(2) LOW POTENCY {THIORIDAZINE - CHLORPROMAZINE):
_________________________________________________
-> Less likely to cause EPS.
-> Greater anticholinergic effects - More sedation - More postural hypotension.
. B . ATYPICAL ANTIPSYCHOTICS (RISPERIDONE - OLANZAPINE - QUETIAPINE - CLOZAPINE):
___________________________________________________________________________________
-> OLANZAPINE is the best.
-> Drug of choice in initial therapy.
-> Greater effect on negative symptoms.
-> Little or no risk of EPS.
. N.B. SIDE EFFECTS of ATYPICAL ANTIPSYCHOTICS:
________________________________________________
. Clozapine -> Agranuloctosis (Order CBC before initiatin ttt & one week after).
. Quetiapine -> Cataracts.
. Olanzapine -> Weight gain - Hyperglycemia - Dyslipidemia.
. Respiredone -> Hyperprolactinemia.
. N.B. Anti-psychotic medications -> Dopamine receptor blockage -> Hyperprolactinemia.
. ++ PRL > 200 ng/ml -> Gynecomastia - Galactorrhea - Menstrual dysfunction & -- libido.
. N.B. Antipsychotics -- dopamine activity in the TUBERO-INFUNDIBULAR pathway.
. NOOOOOOOOTTTTTTTTT the mesolimbic pathway xxxxxxxx !
. LOW potency antipsychotics have the highest risk of causing ORTHOSTATIC HYPOTENSION
. Due to (ALPHA BLOCKAGE).
. LOW potency antipsychotics have the highest risk of causing ANTICHOLINERGIC SYMPTOMS
. Acute urine retention - Dry mouth - Blurry vision - Delirium.
. Often irreversible.
. Circumoral movements.
. Tx -> Stop older antipsychotics.
. Tx -> Switch to newer antipsychotics (Clozapine).
. It can be ttt with BENZTROPINE.
. Symptoms commonly worsen after medication discontinuation.
. N.B.
. Chronic use of dopamine antagonists eg. antiemetics (Metoclopramide & Prochlorperazine)
. can result in tardive dyskinesia.
{5} NEUROLEPTIC MALIGNANT $YNDROME:
____________________________________
. Any time !
. Muscle rigidity - Hyperthermia - Volatile vital signs - Altered consciousness.
. ++ WBCs & ++ Creatinine kinase level.
. Tx -> Stop antipsychotics.
. Tx -> DANTROLENE (Muscle relaxant).
. Transfer to ICU for monitoring.
. Mortality rate 20 %.
. N.B.
. CLOZAPINE is the most effective anti-psychotic for schizophrenia.
. CLOZAPINE has NO incidence of movement disorders.
. CLOZAPINE is a 2nd line therapy bec. of the risk of seizures & agranulocytosis.
. Remember to monitor CBC to watch for bone marrow suppression.
. N.B.
. BENZTROPINE (Anticholinergic)
. is the 1st line ttt in management of acute dystonia & bradykinesia (parkinsonism).
. N.B.
. BBs (Propranlol) is the 1st line ttt of akathisia.
__________________________________________________________________________________________
. ANXIETY DISORDERS ( ):
_______________________________
_______________________________
. Anxiety that interferes e' daytime functioning not due to any other identifiable cause.
. Medical causes:
. Hyperthyroidism - Pheochromocytoma - Excess cortisol - Heart failure.
. Arrhythmia - Asthma - COPD.
. Drugs:
. Corticosterids - Cocaine - Amphetamines - Caffeine.
. Withdrawal from alcohol & sedatives.
{1} ADJUSTEMENT DISORDER ( ):
____________________________________
. Normal psychological reaction (anxiety - depression - irritability).
. occurs soon after profound changes in a person's life.
. such as divorce - migration - birth of handicapped child.
. In GAD, multiple life circumstances, not just one, are causing the anxiety.
. ANXIOLYTIC MEDICATIONS:
__________________________
__________________________
. Adjustment disorder with anxious mood:
. Tx -> Benzodiazepines with brief psychotherapy.
. Rapid onset to therapy.
. Panic disorder:
. Tx -> SSRIs, Alprazolam & Clonazepam.
. They -- intensity & frequency of panic attacks.
. GAD: Tx -> Venlafaxine (-- overall anxiety).
. OCD: Tx -> SSRI (-- obsessional thinking).
. Social phobia -> SSRIs (-- fear ass. e' social situations).
. Benzodiazepines:
-> Don't change dosages abruptly.
-> Use the lowest dose in the elderly.
-> Advise against using machinery or driving.
-> Half life -> ALPRAZOLAM < LORAZEPAM < DIAZEPAM.
. N.B.
. Abrupt cessation of Alprazolam (used in sleeping difficuties),
. which is a short acting benzodiazepine lead to withdrawal symptoms;
. in the form of generalized tonic clonic seizures.
. BUSPIRONE:
-> Therapeutic effect can take up to 1 week.
-> No sedation or cognitive impairment.
-> Best option for people with occupations where driving or machinery is involved.
-> No withdrawal syndrome.
__________________________________________________________________________________________
. MOOD DISORDERS ( ):
_____________________________
_____________________________
{1} MAJOR DEPRESSIVE DISORDER ( ):
__________________________________________
. Depressed mood or anhedonia & depressive symptoms lasting at least 2 weeks.
. Major depressive disorder = Depressed mood + SIGECAPS.
. S -> changes in (S)leep.
. I -> loss of (I)nterest.
. G -> thoughts of worthlessness or (G)uilt.
. E -> loss of (E)nergy.
. C -> trouble (C)oncentrating.
. A -> changes in (A)ppetite or weight.
________________
. History of suicide threats & attempts is the most important predictor of suicide.
. Family H/O of suicide.
. Perceived hopelessness (Demoralization).
. Scizophrenia, borderline or antisocial personality.
. Drug use, especially alcohol.
. Males.
. Age > 65 ys.
. Socially isolated, recently divorced or widowed.
. Chronic physical illness.
. Low job satisfaction or unemployment.
* EMERGENCY ASSESSMENT:
________________________
. Take all suicide threats seriously.
. Detain & hospitalize (Usually 2 weeks).
. Never transport patient to emergency depratment without medically trained personnel.
. Don't identify with the pt.
. Tx of choice -> PSYCHOTHERAPY + ANTIDEPRESSANTs (SSRIs are the 1st choice).
. For acute severe risk of self-harm -> Tx of choice is ECT.
. N.B.
. Minors with suicidal attempts must be admitted to hospital ,
. even against their parents will (Their consent is NOT mandatory).
* INDICATIONS FOR ELECTROCONVULSIVE THERAPY (ECT):
___________________________________________________
. Major depressive episodes that are unresponsive to medications.
. High risk of immediate suicide.
. Contraindications to using antidepressants.
. Good response to ECT in the past.
. The biggest complication of ECT is TRANSIENT MEMORY LOSS,
. which worsens with prolonged therapy & resolves after several weeks.
. Use of ECT is cautioned in pts with space occupying intracranial lesions.
. ECT ++ ICT.
* ANTIDEPRESSANTs & MOOD STABILIZERs:
______________________________________
. SSRIs are the 1st line of therapy.
. TCAs are avoided bec. of risk of toxicity (U sh'd monitor BP).
. MAOIs are more helpful in atypical depressive disorders.
. Switch to another antidepressant if there is no response after 8 weeks.
. Treat the pt for 6 months then taper the dose gradually.
. SSRIs are the 1st line of therapy in the following disorders:
-> Major depressive disorder.
-> Bipolar disorder.
-> Anxiety disorders (Panic disorder - OCD - Social phobia - GAD).
-> Bulimia nervosa.
. When the Q. describes a pt concerned about weight gain or sexual side effects,
. Give Bupropion (causes modest weight loss).
. MEDICATION OVERDOSES:
________________________
________________________
{1} LITHIUM TOXICITY:
______________________
. Elderly p who takes lithium with renal failure or hyponatremia.
. May be induced by diuretics, vomiting or dehydration.
. Nausea - vomiting - acute disorientation - tremors - ++ DTRs - seizures.
. Tx -> DIALYSIS.
{2} NEUROLEPTIC MALIGNANT $YNDROME:
____________________________________
. H/O of recent start with antipsychotics (Specially HALOPERIDOL).
. H/O of Parkinson's pt who has recently stopped Levo dopa.
. High fever - Tachycardia - Ms rigidity - Altered consciousness - Autonomic dysfunction.
. It is unrelated to dosage or previous drug exposure.
. 20 % mortality rate.
. Tx -> Transfer to ICU.
. Tx -> Discontinue antipsychotic.
. Tx -> Bromocriptine to overcome dopamine receptor blockage.
. Tx -> Ms relaxants (DANTROLENE or DIAZEPAM) to reduce ms rigidity.
{3} SEROTONIN $YNDROME:
________________________
. H/O of SSRIs use or migraine medication (triptans) or MAOIs.
. Agitation - Hyperreflexia - Hyperthermia - Muscle rigidity.
. Volume contraction 2ry to sweating & insensible fluid loss.
. Tx -> IV fluids.
. Tx -> Cryptoheptadine to -- serotonin production.
. Tx -> Benzodiazepine to -- muscle rigidity.
{4} MAOIs INDUCED HYPERTENSIVE CRISIS:
_______________________________________
. H/O of MAOI use with acute hypertension.
. H/O of antihistaminics or nasal decongestants may be a cause.
. H/O of consumption of tyramine rich foods (Cheeses - Pickled foods).
. May also be seen in pts who take a MAOI (Phenelzine) & a TCA concurrently.
. Tx -> As hypertensive crisis.
__________________________________________________________________________________________
. SOMATOFORM DISORDERS = :
______________________________________
. Physical symptoms without medical explanation.
. Severe enough to interfere with the pt's ability to function.
{1} SOMATIZATION DISORDER = :
_____________________________________
. 4 pain symptoms + 2 GIT symptoms + 1 Sexual symptom + 1 psudoneurologic symptom
. Tx -> Maintain a single physician as the primary care giver.
. Tx -> Schedule brief monthly visits.
. Tx -> Avoid diagnosting tests or therapies.
. Tx -> Schedule individual psychotherapy.
__________________________________________________________________________________________
. EATING DISORDERS = :
______________________________
______________________________
{1} ANOREXIA NERVOSA = :
_________________________________
. YOUNG FEMALE - UNDERWEIGHT.
. Food restriction & excessive exercise.
. No menstrual period for 3 months or more.
. H/O of purging ( ).
. N.B.
. REFEEDING $YNDROME:
-> Fluids & electrolytes shift -> Electrolyte depletion, arrhythmias & heart failure.
. N.B.
. ANOREXIA COMPLICATIONS:
-> Osteoporosis.
-> ++ Cholesterol & carotene levels.
-> Cardiac arrhythmias (Prolonged QT interval).
-> Euthyroid sick $.
-> Hypothalamic - pituitary axis dysfunction -> Anovulation.
-> Hyponatremia secondary to excess water intake.
-> Pregnants (Miscarriage - Hyperemesis gravidarum - postpartum depression - C.S.).
-> Fetus (IUGR - Prematurity).
{2} BULIMIA NERVOSA = :
______________________________
. YOUNG FEMALE - NORMAL WEIGHT RANGE.
. Frequent episodes of binge eating follwed by guilt, anxiety.
. Self induced vomiting, laxative, diuretics or enema use.
. Food restriction is NOT a feature of bulimia nervosa.
. Painless parotid gland enlargement.
. Dental enamel erosions.
. Metabolic alkalosis with hypochloremia & hypokalemia caused by emesis.
. Metabolic acidosis caused by laxative abuse.
. Risk of cardiomyopathy with excessice syrup of epicac use.
. MANAGEMENT of ANOREXIA NERVOSA & BULIMIA NERVOSA:
____________________________________________________
. HOSPITALIZE for IV hydration if electrolyte disturbance are present.
. OLANZAPINE in anorexia nervosa helps with weight gain.
. SSRI antidepressants (esp. FLUOXETINE) prevent relapses.
. Behavioral therapy.
{3} BODY DYSMORPHIC DISORDER = :
__________________________________________
. YOUNG FEMALE - Preoccupied with an imagined or slight defect in appearance.
. causing an impaired ability to function in a social or occupational life.
. Distress is most commonly related to facial features.
. The pt is often isolated & housebound.
. Tx -> High doses of SSRIs are the 1st line of ttt.
. N.B.
. If the only concern is body shape & weight -> ANOREXIA NERVOSA is more accurate Dx.
. If the only concern is sex characteristics -> GENDER IDENTITY DISORDER is more acc.
__________________________________________________________________________________________
. IMPULSE CONTROL DISORDERS = :
______________________________________________
______________________________________________
. People who are unable to resist impulses.
. Anxiety prior to the impulse that is relieved after the pt acts on it.
. Pts do NOT believe their actions or out of proportion.
. Pts lack insight (Unlike OCD).
{1} INTERMITTENT EXPLOSIVE DISORDER = :
_________________________________________________
. Episodes of aggression out of proportion to the stressor.
. H/O of head trauma.
. If there is a H/O of drug intake -> Intermittent explosive diorder is NOT the Dx !
. Tx -> SSRIs & mood stabilizers.
{2} KLEPTOMANIA = :
_________________________
. Individual who repeatedly steals items to relieve anxiety.
. The person doesn't steal because he needs the object.
. The person often secretely replaces the object after stealing it.
. Tx -> COGNITIVE BEHAVIORAL THERAPY.
{3} PYROMANIA = :
__________________________
. Individual who repeatedly lights fires.
. Pyromania is NOT the diagnosis if the motive is personal gain (insurance money),
. or when the motive is to show anger (Differenting it from CONDUCT DISORDER).
{4} PATHOLOGIC GAMBLING = :
___________________________________
. Obsession with gambling despite the consequences.
. Tx -> Group psychotherapy (GAMBLING ANONYMOUS).
{5} TRICHOTILLOMANIA:
______________________
. Uncontrollable urge to pull out the hair -> Alopecic areas.
. These areas still contain hair of varying lenghts.
__________________________________________________________________________________________
. TYPES OF ABUSE:
__________________
__________________
{1} CHILD ABUSE:
_________________
. Ex. 45 ys old singl man fears an upcoming social party being hosted by his parents.
. He dreads having to meet other people & doesn't feel comfortable speaking e' others.
. He is planning on staying at home to avoid speaking to others.
(2) DEPENDENT PD:
__________________
. Submissive & clinging behavior related to a need to be taken care of.
. They are always worry about abandonment.
. They feel inadquate & helpless & avoid disagreements with others.
. They usually focus dependency on a family member or a spouse.
. Ex. 28 ys old woman seeks counseling bec. of a recent relationship breakup.
. They were dating for 6 months.
. She continues to call her ex 15 - 20 times a day eventhough he doesn't pick up.
. She says she can't understand why they broke up bec. she never disagreed with him.
. She never left the house without him & she always asked his opinion.
. She can't imagine life without him.
(3) OBSESSIVE COMPULSIVE PD:
_____________________________
. They are preoccupied with orderliness, perfectionism & control.
. They are always consumed by details of everything & lose their sense of overall goals.
. They are strict & perfectionistic, overconscientious & inflexible.
. Associated with difficult interpersonal relationships.
. Ex. 38 ys old man presents with his wife for marital counseling.
. The wife reorts that he is inflexible & has unrealistic demands of orderliness.
. Both partners agree that his demands are causing marital problems.
__________________________________________________________________________________________
. SUBSTANCE USE DISORDERS:
___________________________
___________________________
(1) ALCOHOL DEPENDENCE = ALCOHOLISM:
_____________________________________
. Frequent use of alcohol -> Tolerance & physical & psycholical dependence.
. Alcohol abuse -> Failure to fulfill obligations, legal troubles.
. Tolerance is NOT included in the diagnosis of alcohol abuse.
. Dx -> CAGE QUESTIONNAIRE (Lab tests are never included in the diagnosis).
. CAGE -> An answer of YES to any 2 of the following Qs is suggestive of abuse:
-> Have you ever felt that you should CUT down your drinking ?
-> Have you ever felt ANNOYED by others who have criticized your drinking ?
-> Have you ever felt GUILTY about your drinking ?
-> Have you ever had an EYE-OPENER to steady your nerves or alleviate a hangover ?
. Order toxicology to look for another drugs: breath, blood & urine drug screens.
. Look for 2ry effects of alcohol use: ++ GGTP, AST, ALT & LDH.
. If there is suggestion of IV drug use (treack marks) -> Order HIV, HBV, HCV & PPD.
. Management of abuse or prevention of relapse -> ALCOHICS ANONYMOUS (AA).
. SUBSTANCE ABUSE:
___________________
___________________
{1} ALCOHOL:
_____________
. Intoxication syms -> Talkative, sullen, gregarious & moody.
. Intoxication ttt -> Mechanical ventillation if severe.
. Withdrawal syms -> Tremors, hallucinations, seizures & delirium.
. Withdrawal ttt -> Long acting benzodiazepeines (Chlordiazepoxide).
. No seizure prophylaxis.
. Disulfiram or naloxone for adjunct to supervised therapy after acute withdrawal.
{2} AMPHETAMINES & COCAINE:
____________________________
. Intoxication syms -> Euphoria, hypervigilance, autonomic hyperactivity & weight loss.
. Intoxication syms -> Pupil dilatation, disturbed perception, stroke & MI !
. Intoxication syms -> -- appetite (Picky eater).
. Intoxication syms -> Erythema of turbinates & nasal septum.
. Intoxication ttt -> Antipsychotics, benzodiazepines, inderal & vit C to ++ excretion.
. Withdrawal syms -> Anxiety, tremors, headache, ++ appetite, depression & suicide risk.
. Withdrawal ttt -> Antidepressants.
{3} CANNABIS:
______________
. Intoxication syms -> Impaired motor coordination, impaired time perception.
. Intoxication syms -> Social withdrawal, ++ appetite, dry mouth, tachycardia.
. Intoxication syms -> Conjunctival redness.
. Intoxication ttt -> NONE.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
{4} HALLUCINOGENS (LSD = LYSERGIC ACID):
_________________________________________
. Intoxication syms -> Visual hallucinations & intensified perception.
. Intoxication syms -> Ideas of reference, impaired judgment & dissociative syms.
. Intoxication syms -> Pupillary dilatation, panic, tremors & incoordination.
. Intoxication ttt -> Supportive counseling (talking down), antipsychotics & benzos.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
{5} INHALANTS:
_______________
. Intoxication syms -> Belligerence, apathy, assaultiveness & impaired judgement.
. Intoxication syms -> Blurred vision, stupor & coma.
. Intoxication ttt -> Antipsychotics if delirious or agitated.
. Withdrawal syms -> NONE.
. Withdrawal ttt -> NONE.
. If severe impairment -> Give antiandrogens or SSRIs to help reduce pt's sexual drive.
. TYPES OF PARAPHILIAS:
________________________
________________________
.1. VOYEURISM:
_______________
. Recurrent urges to observe an unsuspecting person who is engaging in sexual activity or disrobing.
. This is the earliest paraphilia to develop.
.2. PEDOPHILIA:
________________
. Recurrent urges or arousal toward prepubescent children.
. This is the most common paraphilia.
.3. EXHIBITIONISM:
___________________
. Recurrent urge to expose oneself to strangers.
.4. FETISHISM:
_______________
. Use of non-living objects usually associated with the human body.
.5. FROTTEURISM:
_________________
. Recurrent urge involving touching or rubbing against a non-consenting partner.
.6. MASOCHISM:
_______________
. Recurrent urge or behavior involving the act of humiliation.
.7. SADISM:
____________
. Recurrent urge or behavior involving acts in which ..
. physical or psychological suffering of a victim is exciting to the patient.
. PHARMACOLOGICAL AGENTS THAT CAUSE SEXUAL DYSFUNCTION:
________________________________________________________
________________________________________________________
. Alpha 1 blockers -> Impaired ejaculation.
. Beta blockers -> Erectile dysfunction.
. Neuroleptics -> Erectile dysfunction.
. SSRIs -> Inhibited orgasm.
. Trazodone -> Priapism.
. Dopamine agonists -> ++ Erection & libido.
. N.B. POOR SLEEP HYGIENE:
___________________________
-> can be associated with insomnia.
MINOR STATUS
|
______________________________________________
|
|
UN-emancipated
Emancipated
|
(Can consent for care)
|
|
. Age < 17 ys & must have consent
. Married
from parent or legal guardian
. In the military
. Lives separately from parents
& manages own financies.
. Once the baby comes out, she can't refuse ttt for the baby.
__________________________________________________________________________________________
. CONFIDENTIALITY:
___________________
. The pt has an absolute right to privacy concerning his own medical information.
. The following persons do NOT have a right to any of the medical information of the pt:
-> Relatives, employers, friends & spouses.
-> Other physicians -> U can't release it without the express consent of the pt.
-> Members of law enforcement: U can't release medical information to courts or
police without a court order or
subpoena.
. BREAKING CONFIDENTIALITY TO PREVENT HARM TO OTHERS:
______________________________________________________
. If a pt has a TRANSMISSIBLE disease, such as T.B. or HIV,
. the physician can violate the pt's confidentiality to protect innocent 3rd parties.
. If u have T.B., your doctr can contact your close associates with OUT your consent.
. If u have $, HIV or gonorrhea, your doctor can safely inform others e'OUT your consent.
. The classic ex. is of a pt e' a psychiatric illness who may be planning to harm others.
. The physician has the right to alert the person at risk to prevent harm.
__________________________________________________________________________________________
. END OF LIDE ISSUES:
______________________
______________________
. An adult with capacity can withhold or withdraw any form of therapy.
. If the pt begins ttt, he or she has the right to withdraw any form of ttt.
. The reasons for the withdrawal or withholding of care are not important.
. An advice directive is a set of instructions from an adult pt.
. with capacity directing the care of himself or herslf prior to losing capacity.
. HEALTH CARE PROXY:
_____________________
. The strongest advance directive is a health care proxy.
. The proxy is both a document describing the care the person desire,
. as well as the appointment of an agent to be the decision maker.
. The agent as a decision maker doesn't take hold until the pt loses the capacity.
. If I appoint a proxy but I'm still here, alert & communicative,
. you can't ask the agent for consent for my procedures.
. LIVING WILL:
_______________
. It is a writen document outlining the care desired by the patient.
. If a pt doesn't have a health care proxy, the living will can be very useful.
. If the pt writes out "I never want to be intubated", this is valid.
. If he writes "No heroic measures", this is not valid.
. To be useful, a living will must be clear & precise.
. If a pt's family members disagree with a living will,
. and demand care that contradicts the pt's written wishes,
. the best initial step is -> DISCUSS THE MATTER WITH THEM.
. If discussion fails o resolve the condition -> consult the hospital's ETHICS COMMITTEE.
. These are not the same as providing pain medications that may end the pt's life.
. It is ethical to give pain medication, even if the only way to relieve pain,
. may result in shortenening of life !
. The primary difference is clear:
-> In physician assisted suicide, the 1ry intent is to end life.
-> With a life shortened by pain medication, the 1ry intent is to relieve suffering.
. FUTILE CARE:
_______________
. There is NO obligation on the part of the physician to provide care that won't work !
. There is NO obligation to provide treatment without possible benifit.
. Ex. A pt with widely metastatic cervical cancer develops renal failure,
. the family members insist that dialysis be started. What do u tell them ??!
-> You don't have to provide dialysis to a person who will certainly die !!
. BRAIN DEATH:
_______________
. You are NOT obliged to provide care for a brain-dead patient.
. Brain death = Dead.
__________________________________________________________________________________________
. REPRODUCTIVE ISSUES:
_______________________
_______________________
. 1 . ABORTION:
________________
. A woman's right to an abortion varies by trimester of pregnancy:
-> 1st trimester -> A woman has UNRESTRICTED right to an abortion.
-> 2nd trimester -> A woman has access, but her rights are LESS CLEAR.
-> 3rd trimester -> NO CLEAR ACCESS to abortion (The fetus is potentially viable).
. N.B. YOU DO NOT NEED THE CONSENT OF THE FATHER FOR THE ABORTION.
. 2 . DONATION OF GAMETES:
___________________________
. Pts have UNRESTRICTED RIGHT to donate sperm & eggs.
. There is no ethical problem with being a PAID DONOR for sperm & eggs.
. Note that one can't be a paid donor for organs, such as the kidneys or the cornea.
__________________________________________________________________________________________
. HIV ISSUES:
______________
. A pt has a right to confidentiality of his HIV status.
. However, this confidentiality can be broken to prtect the uninfected,
. such as sexual & needle-sharing partners.
. No obligation for HIV +ve health care workers to disclose their HIV status.
. This include surgeons.
. A surgeon doesn't have to disclose her HIV status to patient.
-> Faculty -> Reported to the department chair or the dean of the medical school.
-> Those in practice -> Reported to the state medical board.
. The impairment must involve potential danger to medical care.
. If u c a physician stealing a car, behavior is NOT reportable to the department chair.
. If u c a physician at a bar dancing naked on the table top,
. but her medical performance is not impaired, this is NOT reportable.
__________________________________________________________________________________________
. TIPS & TRICKS:
_________________
_________________
. Tx of Alzheimer's dementia -> Acetylcholinesterase inhibitors (Donepezil, Rivostigmine)
. Pts with homicidal thoughts sh'd be admitted at the psychiatric ward.
. Pt with meningitis -> Admit him against his will & start ttt.
. PASSIVE AGGRESSIVE BEHAVIOR:
. Individual expresses his aggression toward another person,
. with repeated passive failures to meet the other person's needs.
. When dealing with an angry pt, the most appropriate response is to:
. encourage a discussion about the source of feelings.
. ex. You seem to be angry about something, May I ask what is bothering u so I can help?!
. If a pt is interested in alternative therapy, the physician sh'd 1st inquire as to why?
. If a pt refuses ttt after being informed about cancer, he sh'd be asked why u refuse ?
. DISPLACEMENT DEFENSE MECHANISM:
-> Shifting of emotions associated with an upsetting person to a safer alternate object,
-> that represent the original.
-> Ex. Husband angry with his wife, breaks the car she gave to him !
. INTELLECTUALIZATION DEFENSE MECHANISM:
-> Transformation of an unpleasant event into a purely intellectual problem - No emotions -> Ex. A doctor received the
results of his investigations & discovered that has cancer,
-> He went home & surfed the net for the most recent ways of ttt of cancer.
. REACTION FORMATION DEFENSE MECHANISM:
-> Transformation of unwanted thought or feeling into its opposite.
-> REACTION FORMATION is NEITHER a splitting, NOR a dissociation.
. Genito-pelvic pain (Vaginismus) -> Pain with intercourse or attempted penetration.
. Treatment response
-> When a pt demonstrates significant improvement with or without remission.
-> Generally defined as a 50 % reduction in base line of severity.
_________________________
___________________________________
. IPRATROPIUM or TIOTROPIUM INHALED (Most effective therapy to reduce syms in COPD).
. SABA ALBUTEROL INHALED.
. Pneumococcal vaccine -> Hepatavalent vaccine (Pneumovax).
. Influenza vaccine yearly.
. Long term home oxygen therapy (If pO2 < 55 or SO2 < 88%).
. N.B. Long term O2 therapy in a pulmonary hypertension pt or HCT > 55% -> PaO2 < 60 mmHg.
. N.B. Both smoking cessation & home oxygen therapy & vaccines lower mortality in COPD.
. N.B. SABA (Albuterol), Anticholinergic (Anti-muscarinic ipratropium),LABA & STEROIDS:
improve symptoms only without -- mortality rate.
. N.B. INHALED ANTI-CHOLINERGICS = INHALED MUSCARINIC ANTAGONISTS - INHALED
IPRATROPIUM
are the most effective in COPD.
. N.B. Cromolyn & Montelukast have no benefit in COPD.
. ACUTE EXACERBATION OF COPD TTT:
_________________________________
. Acute worsening of symptoms in a pt. with COPD.
. Caused by upper respiratory tract infection.
. May be preceided by cough & fever.
. Exam -> Bilateral wheezes.
. ABG -> Respiratory acidosis & hypoxia.
. Inhaled bronchodilators (B2 agonists = Albuterol).
. Inhaled anti-cholinergics (Ipratropium).
. Broad spectrum antibiotics.
. INHALED CORTICOSTEROIDS for 2 weeks then tapered gradually.
. Smoking cessation.
. Oxygen (If pO2 < 55 mmHg or SO2 < 88%).
. N.B. Pts with acute on chronic respiratory failure ttt with high flow supplemental O2,
. are at risk for developing worsening HYPERCAPNIA & CO2 NARCOSIS,
. due to a combination of reduced alveolar ventillation & ++ dead space ventillation,
. causing ventillation perfusion mis-match & -- Hb affinity for CO2.
. The goal oxy-hemoglobin saturation in these pts is 90 - 94 % (Not > 95%)!
. NON INVASIVE POSITIVE PRESSURE VENTILLATION (NIPPV):
_______________________________________________________
. Used in acute exacerbations of COPD REFRACTORY to ttt with B-agonist & inhaed steroids.
. Used before intubation to avoid its side effects e.g. infection.
. Recommended in pt e' respiratory distress with a pH<7.35 or pCO2>45mmHg or RR>25/min.
. It is contraindicated in septic, hypotensive or dysrhythmic pts.
. NIPPV will provide more O2 & wash out excess CO2.
. If the pt. is refractory to NIPPV -> Intubate with mechanical ventillation !
. SPONTANEOUS PNEUMOTHORAX (A complication of COPD):
____________________________________________________
. COPD pt presenting with catastrophic worsening of respiratory symptoms.
. Cigarette smoking markedly ++ risk of pneumothorax.
. Ascites.
. Dependent LL edema.
. Most commonly caused by COPD (Flattened diaphragm - prominent pulmonary vessels on CXR)
. CXR -> Prominent right ventricle & pulmonary artery.
. PULMONARY EMBOLISM:
_____________________
_____________________
. PERFUSION DEFECT & NO VENTILLATION DEFECT.
. ++++++++++++++++++++++++++++ A-a gradient.
. SUDDEN onset SOB + CLEAR LUNGs.
. Risk factors of DVT (Immobility - Malignancy - Trauma - Surgery - Thrombophilia).
. H/O of recent orthopedic surgery followed by bed rest.
. No specific physical finding for PE.
. MODIFIED WELL'S CRITERIA for PRE-TEST PROPABILITY of PE:
___________________________________________________________
-> Score + 3 points (Clinical signs of DVT).
-> Score + 1.5 points (Prev PE/DVT - HR>100 - Recent surgery <4wks - Immobilization>3ds)
-> Score + 1 point (Hemoptysis - cancer).
-> Total score for clinical propability (< 4 -> PE UN-likely .. > 4 -> PE likely).
.
.|
.|
.|
.|
. +ve PE
. -ve PE
. PE Un-likely . PE likely
.________
.________
.______________ .___________
.|
.|
.|
.|
. IVC FILTER
. No further tests
.| . START anticoagulation
.| .______________________
.|
.|
. D-DIMER TESTING for PE
.________________________
.|
._____________________________________________________________________
.|
.|
. +ve
. -ve
. Start or continue anticoagulation,
. STOP anticoagulation
. consider surgery or thrombolysis if indicated.
. PLEURAL EFFUSION:
___________________
___________________
. Best initial test -> CXR.
. Decubitus films (Pt lying on one side) sh'd be done next to assess the fluid mobility.
. Most accurate test -> THORAC-CENTESIS.
. Un-diagnosed pleural effusion is best evaluated with THORACOCENTESIS,
. To detect whether it is a transudate or an exudate.
. Except in pts with clear-cut evidence of congestive heart failure,
. Associated fluid overgain, pedal edema & bilateral lung base crackles.
. Diuretics & echo sh'd be done not thoracocentesis.
. COMPARISON BETWEEN EXUDATE & TRANSUDATE (VVVVVVVVVVV. imp.):
_______________________________________________________________
. EXUDATE PLEURAL EFFUSION ______________________ . TRANSUDATE PLEURAL EFFUSION
. Cancer & infection & Pulmonary embolism _______ . Congestive heart failure & cirrhosis.
. High ptn level > 50 % of serum level __________ . Low ptn level < 50 % of serum level.
. High LDH level > 60 % of serum level __________ . Low LDH level < 60 % of serum level.
. LDH > 2/3 upper limit of normal serum LDH (250) . < 2/3 !
. pH > 7.3 (Normal 7.6) ______________________ . pH < 7.3 (++ acid prod. by bacteria).
. NO CHANGE IN GLUCOSE OR AMYLASE LEVELS IN BOTH TYPES !
. Tx -> Small pleural effusions don't need therapy !
. Diuretics can be used for those caused by congestive heart failure.
. Larger effusions esp. those caused by empyema -> Drain by CHEST TUBE.
. Large recurrent effusion from an un-correctable cause -> PLEURODESIS.
. If pleurodesis failed -> Decortication.
. N.B. 1 -> EXUDATE -> MALIGNANCY OR INFECTION -> ++ Capillary permeability.
. N.B. 2 -> TRANSUDATE -> CONGESTIVE HEART FAILURE -> ++ HYDROSTATIC PRESSURE.
. N.B. 3 -> TRANSUDATE -> CIRRHOTIC LIVER FAILURE -> -- PLASMA ONCOTIC PRESSURE.
. COMPLICATED PARA-PNEUMONIC EFFUSION CRITERIA:
________________________________________________
. Exudative pleural effusion.
. Pleural fluid acidosis.
. Low pleural fluid glucose < 60 mg/dl(High metabolic activity of leukocytes or bacteria)
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:
________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.
. EMPYEMA = INFECTION OF THE PLEURAL SPACE:
___________________________________________
. Due to untreated pneumonia cased by bacterial invasion of a pleural effusion.
. or contamination of the pleural space by rupture of a lung abscess.
. Others: Bronchopleural fistula - penetrating trauma - thoracotomy or ruptured viscus.
. May complicate hemothorax, the residual blood is an excellent medium for bacteria.
. A mixed aerobic & anaerobic bacterial infection (Strept. - Staph. - Klebsilella).
. Low grade fever.
. Dx -> CT scan.
. Tx -> Drainage & antibiotics.
. Tx -> SURGERY (If localized - complex or having thick rim).
. SLEEP APNEA:
______________
. Obese pt complaining of daytime somnolence.
. The pt's partener will report severe snoring.
. Hypertension - Headache - Erectile dysfunction & fat neck.
. Obstructive sleep apnea from fatty tissues of the neck blocking breathing.
. Central sleep apnea due to -- respiratory drive from the CNS.
. Dx -> NOCTURNAL POLYSOMNOGRAPHY (GOLD STANDARD OF DIAGNOSIS).
. Mild sleep apnea -> 5 - 20 apneic periods per hour.
. Severe sleep apnea -> > 30 apneic periods per hour.
. Tx of obstructive sleep apnea -> Weight loss & CPAP:Continous positive airway pressure
. If not effective -> Uvulo-palato-pharyngo-plasty.
. Tx of central sleep apnea -> Avoid alcohol & sedatives.
. Medroxyprogesterone -> Central respiratory stimulant.
. OBESITY HYPOVENTILLATION $YNDROME (OH$) = PICKWICKIAN $YNDROME:
_________________________________________________________________
. Severe obesity (Greater then 150% of ideal body weight -> BMI = 55!).
. Thin neck & hypersomnolence.
. Obesity -> Distant heart sounds & Low voltage QRS complexes on EKG.
. Alveolar hypoventillation during WAKEFULLNESS !
. Polycythemia secondary to alveolar hypoventillation.
. ABG -> Hypoxemia & Hypercapnia & Respiratory acidosis.
. Due to DECREASED LUNG & CHEST WALL COMPLIANCE ! (Not resp. ms weakness xxx).
. Tx -> Weight loss - Ventilator support - Oxygen - Avoid supine posture during sleep.
. COMPLICATIONS of long-standing OSA or OH$:
____________________________________________
. Pulmonary hypertension with cor pulmonale.
. Secondary erythrocytosis.
. Hypoxia, chronic hypercapnea & respiratory acidosis (Due to chronic hypoventillation).
. N.B. Chronic hypercapneic respiratory failure due to OH$:
___________________________________________________________
. Marked acidosis should be the result of respiratory failure in OH$.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !
. HOW TO DIFFERENTIATE BETWEEN OBSTRUCTIVE SLEEP APNEA & OBESITY HYPOVENTILLATION $:
____________________________________________________________________________________
____________________________________________________________________________________
.{1}. OBSTRUCTIVE SLEEP APNEA:
_______________________________
. Air flow is impeded by AIRWAY OBSTRUCTION,
. due to POOR ORO-PHARYNGEAL TONE.
. NORMAL ABG !
.{2}. OBESITY HYPOVENTILLATION $:
__________________________________
. Air flow is impeded by diminished expansion of chest & abdominal wall due to obesity.
. ABG -> HYPO-ventillation -> Chronic hyoxia & hypercapnia.
. ALLERGIC BRONCHO-PUMONARY ASPERGILLOSIS (ABPA):
_________________________________________________
. Asthmatic pt with worsening asthma symptoms.
. Coughing of brownish mucous plugs with recurrent infiltrates.
. Peripheral eosinophilia.
. ++ Ig E levels.
. Central bronchiectasis may be seen.
. Tx -> ORAL (Not inhaled) corticosteroids.
. PULMONARY EDEMA:
__________________
. Hypoxia - SOB - Tachypnea.
. CXR -> Diffuse alveolar infiltrates.
. May be cardiogenic (LVF) or non cardiogenic (ARD$).
. Differentiate bet. the two types using pulmonary capillary wedge pressue (PCWP).
. PCWP > 18 -> Cardiogenic pulmonary edema.
. PCWP < 18 -> Non cardiogenic = ARD$.
. ACUTE RESPIRATORY DISTRESS $YNDROME (ARD$) = NON-CARDIOGENIC PULMONARY EDEMA:
_______________________________________________________________________________
. Sudden severe respiratory failure resulting from diffuse lung injury,
. secondary to a number of overwheming systemic injuries e.g.
. Confusion.
. Age > 65 ys or older.
. Co-morbidities eg. cancer, COPD, CHF & RF or liver disease.
. HYPOXIA & HYPOTENSION as single factors are a reason to hospitalize !
. Tx -> VENTILLATOR ASSOCIATED PNEUMONIA (VAP):
________________________________________________
. VAP -> Fever - Hypoxia - New infiltrate & ++ secretions.
-> Imipenim - Cefepime or Piperacillin/Tazobactam.
-> Gentamycin & Vancomycin.
. INDICATIONS OF TUBE THORACOTOMY in PARA-PNEUMONIC FLUID ACCUMULATION:
________________________________________________________________________
1- pH of the pleural fluid < 7.2.
2- Glucose < 60 mg/dl.
. SPECIFIC ASSOCIATIONS:
_________________________
* Recent viral infection -> Staphylococcus.
* Alcoholics -> Klebsiella.
* GIT syms & confusion -> Legionella.
* Young healthy pts -> Mycoplasma.
* Animal contact -> Coxiella Burnetii.
* Arizona construction workers -> Coccidioidmycosis.
* HIV with < 200 CD4 cells -> Pneumocystis carinii PCP.
. MYCOPLASMA PNEUMONIAE:
________________________
. Most common cause of atypical pneumonia.
. Non productive i.e. dry cough.
. Many extra-pulmonary symptoms (Headache - sore throat - skin rash).
. ERYTHEMA MULTIFORME -> Dusky red TARGET shaped skin lesions on extremities.
. CXR -> Lower lobe interstitial infiltrates.
. No cell wall (Only polymorphnuclear cells will appear on gram stain).
. MYCOBACTERIAL PNEUMONIA:
__________________________
. HIV pts have a higher risk of reactivation of tuberculosis.
. Non specific symptoms (Cough - Weight loss - Fatigue - Low grade fever & Night sweats).
. CXR -> UPPER LOBE INFILTRATES WITH CAVITATION.
. ASPIRATION PNEUMONIA = ANAEROBIC PNEUMONIA:
_____________________________________________
. Impaired swallowing due to IMPAIRED EPIGLOTTIC REFLEX is the most imp. predisp. factor.
. Aspiration of oro-pharyngeal secretions.
. May be a complication of upper GI endoscopy.
. Usually caused by ANAEROBES & Streptococcal viridans.
. Advanced age, poor dentition, dementia, alcohol addiction are predisposing factors.
. Pt presents with systemic syms e.g. fever & malaise & FOUL SMELLING SPUTUM.
. Tx -> CLINDAMYCIN.
. KLEBSIELLA PNEUMONIA = FRIEDLANDER's PNEUMONIA:
_________________________________________________
. Dry cough is most likely due to post-nasal drip associated with allergic rhinitis.
. Dx -> Confirmed by improvement of the nasal discharge & cough with H1 Anti-histaminics.
. Chlorpheniramine is an H1 receptor blocker that decreases the allergic response.
. Decrease in NASAL SECRETIONS is most likely to significally improve symptoms.
. ANAPHYLAXIS = ANAPHYLACTIC SHOCK:
___________________________________
. Type 1 hypersensitivity reaction.
. Pts usually have prior exposure to the offending substance.
. Pts have preformed Ig E -> Histamine mediated peripheral vasodilatation.
. Bee stings - food & medications are the most common allergens.
. Acute onset of hypotension & tachycardia.
. Dangerous allergic reaction may progress to respiratory failure & circulatory collapse.
. Allergen exposure -> Sudden onset of symptoms in more than one system,
. Cutaneous (hives - flushing - pruritis).
. GIT ( Lip / tongue swelling - vomiting).
. Respiratory (Dyspnea - wheezing - stridor - hypoxia).
. Cardiovascular (Hypotension).
. It is a medical emergency.
. Tx -> INTRA-MUSCULAR EPINEPHRINE into the THIGH.
. ASPIRIN SENSITIVITY $YNDROME:
_______________________________
. Aspirin ingestion - persistent nasal blockage - Episodes of bronchoconstriction.
. Pathogenesis -> Psudo-allergic reaction.
. Aspirin -> PGs/LKs imbalance.
. Tx -> Avoid NSAIDs & Leukotriene recptor antagonists (Drug of choice).
. MEDIASTINAL TUMORS:
_____________________
_____________________
. Dx -> Helical CT CHEST.
. ANTERIOR mediastinum --> THYMOMA & GERM CELL TUMORS.
. MIDDLE mediastinum ----> BRONCHOGENIC CYST.
. POSTERIOR mediastinum -> Neurogenic tumors e.g. Meningocele.
. GERM CELL TUMORS:
___________________
. Affect young adults.
. Present as large ANTERIOR mediastinal mass.
. Two types of germ cell tumors (Seminomatous & Non-seminomatous).
. Both types produce B-HCG (B-Human chorionic gonadotropin).
. ONLY "NON"-seminomatous type produces Alpha-feto protein (AFP).
. CHORIOCARCINOMA:
__________________
. Metastatic form of gestational trophoblastic disease.
. It may occur after molar pregnancy or normal gestation.
. The lungs are the most frequent site of metastatic spread.
. Any postpartum woman e' pulmonary sympotms & multiple nodules on CXR = CHORIOCARCINOMA.
. Dx -> ++++++ B-HCG levels.
. INCIDENTALLY DISCOVERED SOLITARY PULMONARY NODULE:
____________________________________________________
. May be BENIGN -> Infectious granuloma or hamartoma.
. May be MALIGNANT -> Bronchogenic carcinoma & metastasis.
. BIOPSY is the only way to definitively detect whether a nodule is benign or malignant.
. Clinical characteristics favoring malignancy:
. Age > 50 - H/O of smoking - Weight loss - Previous malignancy.
. Radiographic characteristics of malignancy:
. Large size - Low density - Spiculated borders - Absence of calcifications.
. Rate of lesion growth is an important parameter:
. Malignant nodules tend to double in size bet. one month & one year.
. OBTAINING PREVIOUS X-RAY if possible is the FIRST BEST STEP in management.
. If a previous x-ray demonstrates that the lesion has been stable in size > 2 ys,
. Malignancy is effectively ruled out & no further testing is necessary.
. LOW propability nodules are followed by serial high resolution CT CHEST.
. INTERMEDIATE propability nodules are followed by PET SCAN or BIOPSY.
. HIGH propability nodules are removed surgically.
. PULMONARY - RENAL ASSOCIATIONS:
_________________________________
.1. WEGENER's GRANULOMATOSIS WITH POLYANGIITIS:
________________________________________________
. SYSTEMIC VASCULITIS + UPPER & LOWER RESPIRATORY TRACT INFECTION +
GLOMERULONEPHRITIS.
. Age around 40s.
. URT symptoms (Bloody or purulent nasal discharge - oral ulcers - sinusitis).
. LRT symptoms (Dyspnea - cough - Hemoptysis).
. Renal symptoms (Microscopic hematuria - RBC casts).
. Granulomatous inflammation of nasopharynx (Epistaxis - Rhinorrhea - Otitis - sinusitis)
. Saddle nose deformity due to destruction of the nasal cartilage.
. Cutaneous manifestations (Painful SC nodules - palpable purpura - pyoderma gangrenosum)
. BEST INITIAL TEST -> +ve C-ANCA = serum anti-neutrophilic cytoplasmic antibody.
. CXR -> Bilateral multiple nodular opacities.
. Urinalysis -> RBCs casts - proteinuria & sterile pyuria.
. Tx -> CYCLOPHOSPHAMIDE & High dose corticosteroids.
.2. GOODPASTURE's DISEASE:
___________________________
. Due to renal basement membrane antibodies !
. Young male.
. Lungs (cough - dyspnes - hemoptysis).
. Kidneys (Nephritic proteinuria - ARF - Dysmorphic RBCs & red cell casts on urinalysis).
. Systemic symptoms are un common.
. Dx -> Renal biopsy -> LINEAR IgG antibodies along the glomerular basement membrane.
. EFFECTS OF ARTERIAL OXYGENATION & VENTILATION IN VARIOUS ENVIRONMENTS:
________________________________________________________________________
_____________________________ Example ________ A-a gradient ____ Pa CO2 ___ Corrects e' O2
. SPIROMETRY
.____________
.|
.____________________________________________________
.|
.|
. LOW FEV1/FVC
. NORMAL OR HIGH FEV1/FVC
.______________
._________________________
.|
.|
. OBSTRUCTIVE DISEASE
. RESTRICTIVE DISEASE
._____________________
._____________________
.|
.|
. BRONCHO-DILATOR CHALLENGE
. DLCO
____________________________
.______
.|
.|
._________
.________________
.|
.|
.|
.|
. ++ FEV1 . No ++ in FEV1
. NORMAL
. -- DLCO
._________ ._______________
._______
._________
. ASTHMA.
. COPD.
. CHEST WALL WEAKNESS . ILD.
.|
. DLCO
._____________________
.|
.|
. (--) -> Emphysema . (++) -> Chronic bronchitis.
_____________________________________________________
. 1 . Chronic hypercapneic respiratory failure due to COPD:
___________________________________________________________
. Marked acidosis should be the result of respiratory failure in COPD.
. But .. RENAL TUBULAR COMPENSATION occurs.
. Kidneys ++ HCO3 retention to compensate for ++ CO2 !
. Pts with chronic hypoventillation have gradual ++ in pCO2 -> Respiratory acidosis.
. To compensate, kidneys ++ HCO3 retention & -- Chloride reabsorption instead !
. BOTTOM LINE -> The body compensates for chronic hypercapnea by ++ bicarbonate retention.
. 2 . Mechanically vetillated pt following head trauma:
_______________________________________________________
. Hyper-ventillation (Due to ++ TV or RR) -> Excessive CO2 loss & Respiratory Alkalosis.
. Hypo-ventillation (Due to -- TV or RR) -> Excess CO2 Retention & Respiratory Acidosis.
. Respiratory alkalosis:
-> ++ pH (N = 7.4).
-> -- PCO2 (N = 40 mmHg).
-> -- HCO3 (N= 24) -> DECREASED due to attempted renal compensation for resp. alkalosis.
-> The kidneys retain increased amounts of Hydrogen H (protons)
-> & excrete ++ amounts of bicarbonate (HCO3) in attempt to normalize serum pH.
-> The ++ amount of HCO3 in urine ALKALIZES the urine.
. Valgus stress test -->-ve. "Ruling out Medial collateral ligament injury".
. NORMAL X-ray.
. Tx: Cortico-steroids injection into the bursa.
. Pre-patellar bursitis:
-----------------------. Pain & swelling directly over the patella.
. Disease ---> Specific Antibodies:
----------------------------------. Rhematoid Arthritis "RA" ------------> Anti-Cyclic Citrulinated Peptide "CCP".
. Systemic Lupus Erythematosus "SLE" --> Anti-Double Stranded DNA "DS DNA".
. Scleroderma -------------------------> Anti-topoisomerase "Scl 70".
. CREST $ -----------------------------> Anti-centromere.
. Sjogren $ ---------------------------> SS-A "Ro" & SS-B "La".
. Wegener's granulomatosis ------------> Anti-neutrophil cytoplasmic Antibody "C-ANCA".
. Chrug-Strauss -----------------------> Anti-myeloperoxidase antibody "P-ANCA".
. WHIPPLE's disease:
-------------------. H/O of malabsortion diarrhea (Steatorrhea, flatulence, abd. distension).
. Weight loss.
. Migratory arthritis.
. caused by Tropheryma Whippelii.
. Dx: Small intestinal biopsy ---> PAS +ve macrophages in the lamina propria.
. Celiac disease = Celiac sprue = GLUTEN SENSITIVE ENTEROPATHY :
--------------------------------------------------------------. Malabsorptive diarrhea.
. Anti-endomysial & Anti-transglutaminase Antibodies.
. Biopsy --> Effacement of SI villi.
. ANKYLOSING SPONDYLITIS & IBD are associated !
---------------------------------------------. Both are associated with HLA B27.
. Both are associated with P-ANCA.
. IBD (UC): Bloody diarrhea, anemia & -ve stool culture, erythema nodosum.
. AS: SACROILIITIS.
. REACTIVE ARTHRITIS = 3 Can't ( see, pee, climb a tree):
-------------------------------------------------------. Following infectious diarrhea,
. caused by shigella, salmonella, Yersinia, Campylobacter or C.dificile.
. Conjunctivitis "Can't see".
. Urethritis "Can't Pee".
. Arthritis "Can't climb a tree"
. POLY-MYALGIA RHEUMATICA (PMR):
-------------------------------. Age > 50 ys.
. Aching pain in neck, shoulders & pelvic girdle lasting at least 1 month.
. Morning stiffness > 1 hour !
. ESR < 40 mm/hr.
. No pain with active or passive range of movement.
. Nausea.
. Anemia.
. Hepatotoxicity.
. Tx: Give FOLIC ACID !
. RA:
---. MORNING STIFFNESS > 1 hour.
. Small joints (MCP & PIP).
. Spares DIP "Unlike OA".
. Tenosynovitis (Trigger finger).
. Rheumatoid nodules (Elbow).
. Cervical joint involvement ---> Spine sublaxation ---> Spinal cord compression.
. +ve Anti-CCP Abs.
. +ve RF.
. ++ CRP & ESR.
. X-ray: Soft tissue swelling , joint sapce narrowing & bone erosions.
. Both Obstructive & Restrictive lung disease cause -- in FEV & FEV 1 !
---------------------------------------------------------------------. But .. RESTRICTIVE lung disease cause much more -- in FEV 1 than Obstructive type.
. So .. In RESTRICTIVE lung dis. FEV 1 / FEV is > 80 %.
. Examples of RESTRICTIVE causes:
-------------------------------.. Interstitial lung disease.
.. Neuromuscular diseases.
.. Chest wall abnormalities.
. Ankylosing spondylitis -> costovertebral joint fusion -> chest wall motion restriction.
. ENTHESITIS:
-----------. Inflammation & pain at ligaments & tendons attached to bone.
. Associted with Negative spondylo-arthropathies,
. e.g. ANKYLOSING SPONDYLITIS, psoriatic arthritis & reactive arthritis.
. Associated with HLA B 27.
. Most common sites are shoulder & hip.
. REACTIVE ARTHRITIS = Seronegative spondyloarthropathy:
------------------------------------------------------. TRIAD of: CAN'T SEE, CAN'T PEE, CAN'T CLIMB A TREE !!
. 1- CONJUNCTIVITIS "CAN'T SEE".
. 2- NON GONOCOCCAL URETHRITIS "CAN'T PEE".
. 3- ASYMMETRIC OLIGOARTHRITIS "CAN'T CLIMB A TREE".
. Mucocutaneous lesions.
. Enthesitis "Achilles tendon pain".
. STERILE Synovial fluid analysis.
. Tx: NSAIDs.
. Pts with prolonged H/O of ANKYLOSING SPONDYLITIS:
-------------------------------------------------. are at ++ risk of VERTEBRAL #,
. due to -- bone mineral density & may occur with minimal trauma !!
. FIBROMYALGIA:
. SLE Arthritis:
--------------. Like RA but --------> NO PERMANENT DEFORMITIES.
. SEPTIC ARTHRITIS:
-----------------. H/O of PROSTHETIC joint.
. Red, hot, swollen, painful joint with limited range of motion.
. ++ WBCs > 50000.
. STAPH. AUREUS is the most common causative organism.
. Disseminated Gonococcemia:
--------------------------. H/O of recent unprotected sex with a new partener.
. A triad of Polyarthralgia + Tenosyvovitis + Vesiculo-pustular skin lesions.
. PAGET's disease of bone:
------------------------. Age > 40 ys.
. ++ bone turn over.
. ++ OSTEOCLAST ACTIVITY.
. Mosaic pattern of lamellar bone.
. Enlarged cranial bone --> ++ hat size.
. Entrapment of 8th cranial nerve --> Deafness.
. X-ray --> Femoral bowing.
. NORMAL CALCIUM & PHOSPHOROUS LEVELS.
. ++ ALKALINE PHOSPHATASE LEVEL.
. NEUROGENIC ARTHROPATHY = CHARCOT's JOINT:
-----------------------------------------. Due to DIABETIC NEUROPATHY.
. H/O of DM is the key word.
. -- pain, proprioception & temperature.
. caused by D.M., peripheral nerve damage, syringomyelia & B12 defeciency.
. X-ray ---> Loss of cartilage, osteophytes formation & loose bodies.
. Tx: ttt the cause & special shoes !
. GOUT X-ray ---> PUNCHED OUT EROSIONS + Overhanging rim of cortical bone.
Dr. Wael Tawfic Mohamed
-------------------------
. N.B.
. When hemorrhage occurs, tachycardia & peripheral vasoconstriction are the 1st changes.
. These responses act to maintain the blood pressure within normal limits.
. PULSE CHANGE IS THE FIRST INDICATOR FOR HYPOVOLEMIA.
-> Pericardial tamponade:
__________________________
. Cause distended neck veins & high central venous pressure.
. Enlarged heart on CXR (May be normal cardiac silhouette).
. Electrical alternans on EKG.
. Pulsus paradoxus on vital signs.
. Tx -> immediate pericardiocentesis tap or pericardial window.
. N.B.
. Acute cardiac tamponade:
. occurs due to a sudden rise in intra-pericardial pressure.
. Should be suspected in all adult pts with blunt chest trauma.
. Jugular venous distension, Tachycardia & Hypotension despite aggressive fluid resusc.
. CXR findings typically reveal a normal cardiac silhouette without tension pneumothorax.
-> Tension pneumothorax:
_________________________
. Cause distended neck veins & high central venous pressure.
. Respiratory distress, tracheal deviation, absent breath sounds.
. Hyperresonance to percussion.
. Tx -> immediate placing of a large-bore needle or IV catheter into the pleural space.
. Chest tube placement.
. Never wait for a CXR for diagnosis.
. N.B.
. Don't be distracted by head trauma or dilated pupils in a hypotensive trauma pt.
. Intracranial bleeds are never the cause of hypotensive shock.
. The 1st step in management is to identify & control the site of bleeding.
. N.B.
. Most causes of shock in the setting of trauma are 2ry to hypovolemia from blood loss.
. However, ++ CVP/PCWP or failure of hypotension to resolve after a bolus of IV fluids,
. should suggest an alternative diagnosis.
. Myocardial contusion sh'd be suspected in pts with evidence of injury to anterior chest
. MI can be confirmed with +ve cardiac markers & EKG changes.
. Tension pneumothorax is excluded if there is no tracheal deviation.
. Hypovolemia is excluded if there is failure to respond to an IV fluid bolus.
. N.B.
. High energy blunt trauma to the chest commonly causes aortic injury.
. In most cases of aortic rupture, death is the immediate result.
. Widened mediatinum, large left sided hemothorax & mediastinal deviation to right side.
. Disruption of the normal aortic contour..
. Bilateral COLLAPSED neck veins.
. Cardiac contusion & rupture cause pericardial tamponade only.
. If FAST exam is limited or equivocal -> A diagnostic peritoneal lavage (DPL) is done.
. DPL is done to evaluate for hemoperitoneum.
. Pts with +ve findings on either FAST or DPL -> should undergo exploratory laparotomy.
. Hemodynamically stable pts with -ve findings on FAST may undergo abdominal CT,
. to determine need for laparotomy.
. Hemodynamically un-stable -> FAST or DPL.
. N.B.
. Blunt abdominal trauma to the upper abdomen can cause pancreatic contusion,
. crush injury, laceration or transection to the pancreas.
. Pancreatic injuries may be MISSED by CT scan during the 1st 6 hours following trauma.
. Untreated pancreatic injury can be complicated by retroperitoneal abscess or pseudocyst
. N.B.
. The spleen is the most commonly injured organ following blunt abdominal trauma.
. Left upper quadrant abdominal pain.
. Abdominal wall contusion, Lt lower chest wall tendrness.
. Lt shoulder pain referred from splenic hemorrhage irritating phrenic nerve & diaphragm.
. It is called "KEHR" sign.
. Splenic rupture causes acute left upper quadrant abdominal pain.
. Delayed hypotension may result due to blood loss.
. No signs of sepsis will be present.
. Dx -> Abdominal CT with IV contrast.
. N.B.
. Blunt deceleration trauma (Motor vehicle accident or fall from > 10 feet):
. Blunt aortic trauma must be ruled out.
. CXR is the initial screening test -> WIDENING of the mediastinum.
. N.B.
. Duodenal hematoma:
_____________________
. mostly follow abdominal blunt trauma in children.
. The hematoma may cause duodenal obstruction with nausea & vomiting.
. Epigastric pain & vomiting due to failure to pass gastric secretions past obstruction.
. Tx -> NASOGASTRIC SUCTION & PARENTERAL NUTRITION.
. Most hematomas will resolve spontaneously in 1-2 weeks.
. N.B.
. Any gun shot wound below the 4th intercostal space (level of the nipple) is:
. considered to involve the abdomen & requires an exploratory laparotomy in unstable pts.
. N.B.
. All hemodynamically UN-STABLE pts with penetrating abdominal trauma,
. must undergo immediate exploratory laparotomy to diagnose & treat source of bleeding
. as well as to diagnose & treat perforation of any abdominal viscus to prevent sepsis.
. N.B.
. Abdominal CT used to detect intra-abdominal injury in hemodynamically stable trauma pts
. In hemodynamically un-stable pts, a FAST U/$ should be the initial test.
. DPL Diagnostic peritoneal lavage is used in hemodynamically unstable pts if -ve FAST.
. N.B.
. DIAPHRAGMATIC TRAUMA:
________________________
. Blunt abdominal trauma -> Mild respiratory distress & Abnormal CXR.
. Sudden ++ in intra-abdominal pressure -> Large radial tears in the diaphragm.
. Rupture is more common on LEFT side bec. the right side is protected by the liver.
. Dx -> CXR -> Hemi-diaphragmatic elevation.
. Dx -> CXR -> Naso-gastric tube in the pulmonary cavity = Diaphragmatic hernia.
. Dx -> CT is the next best step (to Confirm).
. The small bowel may be present in the thoracic cavity.
. Tx -> Surgical repair & exploration for other traumatic injuries.
. N.B.
. TRACHEO-BRONCHIAL RUPTURE:
_____________________________
. Due to rapid decceleration blunt chest trauma.
. 1st manage the ABCs.
. Dx -> CXR -> Persistent pneumothorax & pneumomediastinum despite chest tube placement !
. Subcutaneous emphysema (Palpable crepitus below the skin).
. The RIGHT MAIN BRONCHUS is the most commonly injured.
. Dx -> High resolution CT scan (Confirm).
. Tx -> Surgical repair.
. BLUNT ABDOMINAL TRAUMA MANAGEMENT:
_____________________________________
_____________________________________
. HEMODYNAMICALLY UN-STABLE PATIENT:
_____________________________________
-> Cervical spine immobilization.
-> Intravenous hydration.
-> FAST (Focused assessment with sonography for trauma).
-> If FAST is +ve for blood & pt is still UNSTABLE AFTER A TRIAL OF FLUID RESUSCITATION,
-> URGENT LAPAROTOMY with surgical repair is indicated.
. HEMODYNAMICALLY STABLE PATIENT:
__________________________________
-> CT scan abdomen with contrast (to detect the amount of bleeding & the site of injury).
-> The surgeon can then select either laparotomy or admission & observation.
. MANAGEMENT OF BLUNT ABDOMINAL TRAUMA
_______________________________________
. in HEMODYNAMICALLY UN-STABLE PT
__________________________________
|
FAST EXAMINATION
________________
|
____________________________________________
|
|
|
+ve
inconclusive
-ve
|
|
|
LAPAROTOMY <--POSITIVE--- DPL ----NEGATIVE---> Signs of
____________
_____
extra-abdominal
hemorrhage (Pelvic/long bone #)
|
___YES_____________NO_____
|
|
STABILIZE
STABILIZE
ANGIOGRAPHY & SPLINT
then CT ABDOMEN
* VASOMOTOR SHOCK:
___________________
. Hypotension & tachycardia in pts who are warm & flushed (Not pale & cold!).
. Look for a H/O of medication use (penicillin allergy).
. H/O of spinal anesthesia or exposure to allergen (bee stings).
* TRAUMA TO LOCALIZED SITES:
_____________________________
. All penetrating wounds with damage to internal organs will need to go to the OR.
. If the case describes an object embedded in the pt, NEVER to remove it.
. Never remove it in the ER or at the scene of the accident (Only in the operating room).
* HEAD TRAUMA:
_______________
. "No" surgical intervention is needed for ..
. an asymptomatic head injury with a closed skull # (No overlying wound) alone.
. The next step of management is to clean any lacerations.
. Surgery "Repair or craniotomy" is always done for ..
. COMMINUTED or DEPRESSED SKULL # even if the pt is asymptomatic !
. Send the pt to the OR.
. For head trauma & loss of cosciousness
. The 1st step of management is ordering a HEAD & NECK CT with "OUT" contrast.
. If the head CT & neurological exam are normal,
. he can go home if someone can closely observe him over the next 24 hours.
. i.e. wake him up frequently & watch for changes in mentation.
. Give tetanus toxoid & prophylactic antibiotics to all pts with open skull #s.
* BASAL SKULL #:
_________________
. Ecchymosis around both eyes (Racoon eyes).
. Ecchymosis behind the ear (Battle's sign).
. Clear fluid drippling from the ear or nose (CSF leak).
. CT scan of head & neck -> Basal skull #. "X-ray is a wrong answer".
. A CSF leak will stop by itself & requires no specific management.
. Prophylactic antibiotics are NOT indicated !!
. Facial palsy may occur 2-3 days later due to neuroapraxia (Use Steroids).
* EPI-DURAL HEMATOMA:
______________________
. Side head trauma & rupture of middle meningeal artery in the foramen spinosum.
. H/O of head trauma & SUDDEN LOSS OF CONSCIOUSNESS.
. Accumulation of blood in the potential space inbetween the cranium & dura matter.
. Honeymoon period (The period when the pt immediately awakes & appears normal).
. Pt typically has ipsilateral pupil dilatation due to oculomotor nerve compression.
. Then the pt quickly deteriorates, so .. It is important to manage quickly.
. Dx -> CT scan -> BICONVEX LENS shaped hematoma with or without midline deviation.
. Tx -> EMERGENCY CRANIOTOMY.
. If the pt is treated, the prognosis is good.
. If not, the prognosis is fatal within hours.
. Epidural hematoma results from rupture of middle meningeal artery,
. higher arterial pressure can rapidly expand the hematoma -> Compress the temporal lobe.
. Fluid resuscitation ++ the rate at which the epidural hematoma expanded.
. Hypertension, bradycardia & respiratory depression (Cushing's reflex) = ++ ICP.
. The uncus is the innermost part of the temporal lobe & herniated through the tentorium,
. leading to the following pressure effects:
. TRANS-TENTORIAL (UNCAL) HERNIATION:
______________________________________
______________________________________
. Compression of the contralateral crus cerebri against the tentorial edge:
____________________________________________________________________________
. Ipsilateral hemiparesis.
. Compression of the ipsilateral oculomotor nerve (CN 3) by the herniated uncus:
_________________________________________________________________________________
. Loss of parasympathetic innervation causes mydriasis.
. Loss of motor innervation causes ptosis & down-outwards gaze of the ipsilateral pupil,
. due to un-opposed trochlear (CN 5) & abducent (CN 6).
. Compression of the ipsilateral posterior cerebral artery:
____________________________________________________________
. causes ischemia of the visual cortex -> Contralateral homonymous hemianopia.
. Compression of the reticular formation:
__________________________________________
. Altered level of consciousness; coma.
* "S"UB-DURAL HEMATOMA:
________________________
. Low pressure bleeding from the "VENOUS SYSTEM".
. Accumulation of blood in the subdural space between the dura & arachinoid membrane.
. Head trauma with FLUCTUATING CONSCIOUSNESS i.e.
. gradual headaches, memory loss, personality changes, dementia, cofusion & drowsiness.
. Dx -> CT scan -> "S"EMILUNAR, CRESCENT shaped hematoma e' or e'out midline deviation.
. Tx -> CONSERVATIVE management with STEROIDS.
. Emergency craniotomy is done if there are lateralizing signs & midline displacement.
* DIFFUSE AXONAL INJURY:
_________________________
. Results from ACCELERATION-DECELERATION injuries to the head.
. The pt will be deeply unconscious.
. Dx -> CT -> Normal or diffuse small bleeds at the junctions of the grey & white matter.
. CT -> Numerous punctate hemorrhages.
. Prognosis is terrible !
. Surgery can't help.
. Therapy is directed at preventing further injury from ++ ICT.
* ELEVATED INTRACRANIAL PRESSURE (++ ICP):
___________________________________________
. Briefly depressed consciousness after head trauma.
. Improvement.
. Progressive drowsiness.
. ++ ICT is a medical emergency.
. GRADUAL DILATATION OF ONE PUPIL & DECREASING RESPONSIVENESS TO LIGHT is an imp. sign.
. It indicates clot expansion on the ipsilateral hemisphere.
. Dx -> Head CT -> Midline shift or dilated ventricles.
. Don't think about performing a lumbar tap in any pt before getting a head CT 1st !
. If you perform a lumbar puncture on a person with ++ ICT, you'' herniate the brain !
. Tx -> Head elevation - Hyperventillation - Avoid fluid overload.
. Tx -> Mannitol & furosemide (use very cautiously as they can reduce cerbral perfusion).
. Tx -> sedation & hypothermia may lower oxygen demand.
. N.B. Lowering ICP is not the ultimate goal; preserving brain perfusion is.
. Systemic hypotension or excessive cerebral vasoconstriction may be counterproductive.
. N.B. Steroids are good for cerebral edema 2ry to tumors & abscesses,
. But they have no role in head trauma pts !
. N.B. Pts with mild to moderate traumatic brain injury:
. can be discharged under the care of an adult if they have a NORMAL CT.
. The caretaker sh'd be given printed instructions detailing signs & symptoms that,
. warrant immediate return to the hospital.
__________________________________________________________________________________________
. ACUTE ABDOMEN:
_________________
_________________
. 4 main causes -> Perforation - Obstruction - Inflammation/Infection - Ischemia.
. When is "SURGEY" the answer ?
________________________________
1. Peritonitis (Exclude primary peritonitis).
2. Abdominal pain/tendrness + sepsis signs.
3. Acute intestinal ischemia.
4. Pneumoperitoneum.
. In all of the above cases, make sure pancreatitis is 1st ruled out !
. N.B. Primary peritonitis is spontaneous inflammation with nephrosis in children.
. or .. An adult with ascites & mild abdominal pain (even there is fever & leukocytosis).
. When is "MEDICAL ttt" the answer ?
_____________________________________
1. Primary peritonitis.
2. Pancreatitis.
3. Cholangitis.
4. Urinary stones (Look for stones on X-ray).
5. Things that can mimic an acute abdomen:
-> Lower lobe pneumonia (Look for infiltrate on CXR).
-> Myocardial ischemia (Look for EKG changes).
-> Pulmonary embolism (Look for immobilized pt).
6. Ruptured ovarian cyst.
. N.B.
. Cholangitis is a GIT medical emergency & intervention with ERCP is the ttt of choice.
. NON-surgical causes of an acute abdomen:
___________________________________________
1. Myocardial infarction - acute pericarditis.
2. Lower lobe pneumonia - pulmonary infarction.
3. Hepatitis - GERD.
4. DKA - Adrenal insuffeciency.
5. Pyelonephritis - Acute salpingitis.
6. Sickle cell crisis.
7. Acute porphyria.
. N.B.
. Be sure to differentiate GERD from peptic ulcer perforation (surgical emergency).
* 1 * PERFORATION:
___________________
___________________
(1) GASTRO-INTESTINAL PERFORATION:
__________________________________
. Acute abdominal pain that is sudden, severe, constant & generalized.
. Pain is excruciating with any movement (may be blunted in elderly pts).
. Most common causes of GIT perforations:
(a) Diverticulitis: Elderly pt with lower abdominal pain & fever.
(b) Perforated peptic ulcer: Epigastric pain waking up the pt at night.
(c) Chron's disease.
. Dx -> Supine & erect abdominal x-ray (free air under diaphragm).
. Tx -> Nothing by mouth (NPO) & IV fluid hydration.
. Tx -> IV antibiotics such as flagyl & gentamycin.
. Tx -> IV 2nd generation cephalosporins (Cefotetan or cefoxitin).
. Tx -> Emergency surgery.
. The contents of the vomitus are feculent with more distal obstructions.
. Hyperactive bowel sounds due to peristaltic rush.
. Dx -> Abd. x-ray -> DILATED BOWEL LOOPS with MULTIPLE AIR FLUID LEVELS.
. Tx -> Complete bowel rest - Decompression e' nasogastric tube.
. Tx -> Pain control - Fluid resuscitation.
. Tx -> If no improvement -> Surgical intervention to avoid strangulation.
. Strangulation signs (fever - tachycardia - leukocytosis - Metabolic acidosis).
. N.B.
. Immediate surgical intervention is indicated for pts with intestinal obstruction who,
. develop clinical or hemodynamic instability, fail to improve after conservative ttt,
. or develop syms of strangulation (fever-tachycardia-leukocytosis-Metabolic acidosis).
* 3 * INFLAMMATION:
____________________
____________________
. Causes (Acute diverticulitis - Acute pancreatitis - Acute appendicitis).
. Gradual onset of constant abdominal pain that slowly builds up over several hours.
. Initially ill defined pain that becomes localized to the site of inflammation.
. Note that signs of peritoneal irritation are ABSENT in pancreatitis.
(1) ACUTE DIVERTICULITIS:
__________________________
. Acute abdominal pain in the LEFT LOWER QUADRANT (LLQ).
. Middle age or older pt with fever, leukocytosis & peritoneal irritation in the LLQ.
. Palpable tender mass in the LLQ.
. In women, think about fallopian tubes & ovaries as potential sources.
. Dx -> CT -> Abscess & free air.
. Never order contrast studies or endoscopy in acute phase.
. Tx -> If there is no peritoneal signs -> Manage as outpatient with antibiotics.
. Localized peritoneal signs & abscess -> Admit pt - NPO - IV fluids - IV antibiotics.
. Generalized peritonitis or perforation -> Emergency surgery.
. Recurrent attacks of diverticulitis -> Elective surgery.
. N.B. When diagnosing acute diverticulitis,
. don't forget to order a urine pregnancy test on all women of childbearing age.
. Complicated diverticulitis: Associated e' abscess, perforation, obstruction or fistula.
. Fluid collection < 3cm -> IV antibiotics & observation.
. Fluid collection > 3cm -> CT guided percutaneous drainage.
. If no response within 5 days -> Surgery for drainage & debridement.
(2) ACUTE PANCREATITIS:
________________________
. Alcoholic pt who develops an acute (over several hours) upper abdominal pain,
. radiating to the back, with nausea & vomiting.
. It may be edematous, hemorrhagic or suppurative (pancreatic abscess).
. Late complications include pancreatic pseudocyst & chronic pancreatitis.
. Dx -> Serum or urinary amylase or lipase (serum 12 - 48 hs, urinary 3rd - 6th day).
. Dx -> CT if diagnosis is uncertain.
. Tx -> NPO, NG suction & IV fluids.
. N.B. Look out for the risk factors for acute pancreatitis:
-> Alcoholism.
-> Gall stones.
-> Medications (Didanosine, pentamidine, Flagyl, Tetracycline, Thiazides & Furosemide).
-> Hypertriglyceridemia.
-> Trauma.
-> Post-ERCP.
. N.B. COMPLICATIONS:
-> Abscess:
. Often appears 10 days after onset with persistent fever & high WBC count.
. Surgical drainage is the ttt.
-> Pseudocyst:
. Appears 5 weeks after initial symptoms.
. when a collection of pancreatic juice causes anorexia, pain & a palpable mass.
. If < 6 cm & present < 6 weeks -> OBSERVATION.
. If > 6 cm or present > 6 weeks -> Percutaneous drainage or endoscopic drainage.
-> Chronic damage:
. causes diabetes & steatorrhea.
. Treat with insulin & pancreatic enzyme supplementation.
. N.B. The most common causes of acute pancreatitis are gallstones & alcohol use.
. Identifying the underlying cause can prevent recurrent pancreatitis.
. ULTRASOUND is the preferred test to detect gall stones.
. Stable pts sh'd undergo cholecystectomy for biliary pancreatitis prior to discharge.
(3) ACUTE APPENDICITIS:
________________________
. Begins with anorexia.
. Followed by vague peri-umbilical pain.
. several hours later, it becomes sharp, severe, constant & localized to RLQ of abdomen.
. RIGHT LOWER QUADRANT PAIN.
. Tenderness, guarding & rebound tendrness are found on the right & below the umbilicus.
. Dx -> Fever, leukocytosis 10000 - 15000 with neutrophilia & immature forms.
. Dx -> Reactive thrombocytosis.
. Dx -> Abdominal U/$ or CT scan if clinically unclear.
. Tx -> IV antibiotics before appendectomy.
. Tx -> If appendix is perforated -> Continue IV until fever & WBC count normalize.
. N.B. APEENDICEAL PERFORATION complicated by PSOAS ABSCESS:
_____________________________________________________________
. Localized Rt lower quadrant findings > 5days after onset of appendicitis.
. perforation occurs with abscees formation.
. Psoas abscess -> Flexion of the hip against resistance (Psoas sign).
. Tx -> IV hydration - Antibiotics - Bowel rest - Interval appendectomy after 6-8 weeks.
. N.B. APPENDICEAL PERFORATION complicated by PELVIC ABSCESS:
______________________________________________________________
. Rupture of appendix with pelvic abscess formation.
. Drainage of fluid into the dependent recto-vesical pouch.
. Tender, fluctuant mass palpable only e' the tip of finger = recto-vesical pouch abscess
. SURGICAL JAUNDICE:
____________________
____________________
* OBSTRUCTIVE JAUNDICE CAUSED BY STONES:
_________________________________________
. Obese, fecund woman in her 40s.
. Recurrent episodes of abdominal pain.
. High alkaline phosphatase.
. Dilated ducts on sonogram.
. Non-dilated gall bladder full of stones.
. Dx -> Abdominal U/$.
. Dx -> Confirm e' endoscopic ultrasound (EU$).
. Dx -> Confirm e' Magnetic resonance cholangiopancreatography (MRCP).
. Tx -> Perform Endoscopic retrograde cholangiopancreatography (ERCP).
. Tx -> Cholecystectomy sh'd follow ERCP.
. N.B. ERCP & EU$ are never the 1st step in diagnosis.
. N.B. ERCP is mostly a management step on exam.
* OBSTRUCTIVE JAUNDICE CAUSED BY TUMOR:
________________________________________
. Progressive symptoms in the preceeding weeks & weight loss.
. Adenocarcinoma at the head of pancreas.
. Adenocarcinoma at the ampulla of Vater.
. Cholangiocarcinoma arising in the common bile duct itself.
. Dx -> Abdominal U/$.
. Dx -> CT scan.
. Dx -> For lesions on CT -> Obtain a tissue diagnosis via EU$.
. Dx -> If no lesions on CT -> Order MRCP.
. MRCP -> will show the ampullary or common bile duct tumors not seen on CT scan.
. Obtain tissue diagnosis via ERCP.
. Tx -> Surgical resection.
. GALL STONES:
_______________
_______________
(1) BILIARY COLIC:
___________________
. TEMPORARY occlusion of the CYSTIC DUCT.
. Colicky pain in the upper right quadrant RUQ.
. Radiating to the right shoulder & back.
. Often triggered by fatty food.
. Episodes are brief (20 mins).
. No signs of peritoneal irritation or systemic signs.
. Dx -> U/$.
. Tx -> Elective cholecystectomy.
. N.B. Ingestion of a fatty meal causes the gall bladder to contract.
. so .. it presses the gall stones against the cystic duct opening,
. increasing the intra gall bladder pressure causing VISCUS DISTENSION & colicky pain.
. Subsequent gall bladder relaxation alows the stone to fall back from the duct,
. causin the pain to resolve completely.
. Biliary colic pain may be referred to right shoulder.
. N.B. Pain of biliary colic is distinguished from that of acute cholecystitis by:
. its intermittent nature & relation to meals as well as absence of fever.
(2) ACUTE CHOLECYSTITIS:
_________________________
. PERSISTENT occlusion of the CYSTIC DUCT.
. Caused by a stone.
. Constant pain.
. Fver, leukocytosis & peritoneal irritation in the RUQ.
. Dx -> U/$ (Gall stones - Thick walled gall bladder - Pericholecystic fluid).
. Tx -> NG suction - NPO - IV fluids - IV antibiotics.
. Tx -> Followed by elective cholecystectomy after 6 - 12 wks.
. Tx -> Emergency cholecystectomy is needed if there is:
. generalized peritonitis or ephysematous cholecystitis (i.e. perforation or gangrene).
(3) ACUTE ASCENDING CHOLANGITIS:
_________________________________
. Obstruction of the COMMON BILE DUCT causes obstruction & ASCENDING INFECTION.
. High fever & very high WBC count.
. High levels of alkaline phosphatase.
. High levels of total & DIRECT bilirubin.
. Mild elevation of transaminases.
. Tx -> IV antibiotics.
. Tx -> Emergency decompression of the common bile duct is life saving !
. Decompression by ERCP or PTC (Percutaneous transhepatic cholangiogram) or surgery.
. Tx -> Cholecystectomy must follow.
. N.B.
. A pregnancy test sh'd be performed in any woman of childbearing period age before,
. ordering diagnostic tests such as x-rays or computed tomography scans.
. PRE-OPERATIVE & POST-OPERATIVE CARE:
______________________________________
______________________________________
* PRE-OPERATIVE ASSESSMENT:
____________________________
{1} CARDIAC RISK:
__________________
. Ejection fraction < 35 % -> Prohibits non-cardiac surgery.
. JVD (sign of CHF) -> Give ACEIs, BB, Digitalis & Diuretics prior to surgery.
. Recent MI -> Defer surgery for 6 months post MI.
. Severe progressive angina -> Cardiac catheterization for coronary revascularization.
{2} PULMONARY RISK:
____________________
. Smoking (Compromised ventillation = High pCO2 & FEV1 < 1.5):
-> Order PFTs to evaluate for FEV1.
. PEDIATRIC SURGERY:
_____________________
_____________________
. CONDITIONS THAT NEED SURGERY AT BIRTH:
_________________________________________
_________________________________________
. Congenital anomalies constitute the conditions that need surgery at birth.
. The most imp. step is to rule out other associated congenital anomalies.
. VACTER -> Vertebral, Anal, Cardiac, Tracheal, Esophageal, Renal & Radial anomalies.
{1} ESOPHAGEAL ATRESIA:
________________________
. Excessive salivation is noted shortly after birth.
. Chocking spells are noticed when 1st feeding is attempted.
. Confirm the diagnosis with an NG tube -> Coiled in the upper chest on CXR.
. Tx -> Primary surgical repair.
. If surgery needs to be delayed for further workup,
. perform gastrotomy to protect the lungs from acid reflux.
{2} IMPERFORATED ANUS:
_______________________
. ABSENCE of flatus or stools.
. Look for a fistula near by (to vagina or perineum).
. If present, delay repair until further growth (but before toilet training time).
. If not present, a colostomy needs to be done for high rectal pouches.
{3} CONGENITAL DIAPHRAGMATIC HERNIA:
_____________________________________
. Dyspnea is noted at birth !
. Loops of bowel in left chest are seen on x-ray.
. The primary abnormality is the HYPOPLASTIC LUNG with FETAL TYPE CIRCULATION.
. Tx -> Endotracheal intubation, low pressure ventillation, sedation & NG suction.
. Delay repair 3-4 days to allow lung maturation.
{4} GASTROSCHISIS & OMPHALOCELE:
_________________________________
* GASTROSCHISIS:
_________________
. The umbilical cord is NORMAL.
. The defect is to the right of the cord where is no protective membrane.
. The bowel looks angry & matted.
* OMPHALOCELE:
_______________
. The umbilical cord goes to the defect.
. The defect has a thin membrane (one can see normal looking bowel & little liver slice).
. Tx -> Small defects -> Close small defects primarily.
. Tx -> large defects -> Silastic "silo" to protect the bowel.
. Manual replacement of the bowel daily until complete closure (in about 1 week).
. Give parenteral nutrition (The bowel will not work in gastrochisis).
____________________________________________
____________________________________________
{1} CLAVICULAR #:
__________________
. # of the MIDDLE 1/3 -> Brace (Figure 8 sling), rest & ice.
. # of the DISTAL 1/3 -> Open reduction & internal fixation to prevent malunion.
. All pts sh'd've a creful neurovascular examination to rule out injury to:
. the underlying brachial plexus & subclavian artery.
. Hearing a loud bruit warrants an angiogram to rule out subclavian artery injury.
{2} COLLE's #:
_______________
. Closed reduction & casting.
. Elderly woman falling on an out-stretched hand.
. Painful wrist.
. Dinner fork deformity.
{3} DIRECT BLOW TO ULNE (MONTEGGIA #) or RADIUS (GALEAZZI #):
______________________________________________________________
. Combination of diaphyseal # & displaced dislocation of the nearby joint.
. Open reduction & internal fixation is needed for the diaphyseal reduction.
. Closed reduction for the displaced joint.
{4} SCAPHOID #:
________________
. Young adult with fall on an out-stretched hand.
. Persistent pain in the anatomical snuff box.
. Takes > 3 weeks to be seen on x-ray.
. If the initial x-ray is -ve, subsequent x-ray is done in 7-10 days.
. Wrist x-ray -> Fine radiolucent lines in nondisplaced scaphoid #.
. Tx -> Wrist immobilization for 6 - 10 weeks.
. Place thumb spica cast to help to prevent non-union.
{5} HIP #:
___________
. Any elderly pt who sustains a fall.
. Look for externally rotated & shortened leg.
. Femoral neck # -> High risk of avascular necrosis - Tx: Femoral head replacement.
. Intertrochanteric # -> Open reduction & pinning.
. Femoral shaft # -> Intra-medullary rod fixation.
{6} TRIGGER FINGER:
____________________
. Woman who awakens at night with an acutely flexed finger,
. that snaps when forcibly extended.
{7} DE QUERVAIN TENOSYNOVITIS:
_______________________________
. Young mother carrying baby,
. with flexed wrist & extended thumb to stabilize the baby's head.
. Steroid injection is the best therapy.
{8} DUPUYTREN CONTRACTURE:
___________________________
. Contracture of the palm & palmar fascial nodules.
. Surgery is the only ttt.
{9} POSTERIOR HIP DISLOCATION:
_______________________________
. H/O of head-on car collision where the knees hit the dashboard (Orthopedic emergency).
. Differentiate it from hip # by an internally rotated leg (The leg is also shortened).
. Emergency ruduction is needed to avoid avascular necrosis.
{10} KNEE INJURIES:
____________________
(a) Medial & lateral collateral ligament injury:
__________________________________________________
. Caused by a direct blow to the opposite side of the joint.
. Casting if isolated ligament injury.
. Surgical repair if multiple ligaments injured.
. Medial -> Due to abduction injury to knee - Dx -> VALGUS stress test.
. Lateral -> Due to adduction injury to knee - Dx -> VARUS stress test.
(b) Anterior & posterior cruciate ligament injury:
____________________________________________________
. Swelling & pain.
. Anterior / posterior drawer sign.
. Young athletes need arthroscopic repair.
. Older pts need immobilization & rehabilitation.
. Anterior -> H/O of forceful hyperextension injury to knee.
. Effusion is seen rapidly following injury.
. Dx -> Lachman's test, ANTERIOR drawer test & pivot shift test.
. Posterior -> H/O of dashboard injury.
. Forceful posterior-directed force on the tibia with knee flexed at 90 dgrees.
. Dx -> POSTERIOR drawe test, REVERSE pivot test & posterior sag test.
(c) Meniscal injury:
______________________
. Twisting injuries with the foot flexed.
. Medial meniscus is more commonly injured than the lateral meniscus.
. POPPING SOUND followed by severe pain at time of injury.
. Prolonged pain & swelling.
. Localized tendrness at the side of the knee.
. Catching & locking of knee koint on extension (BUCKET HANDLE TEARS).
. Palpable or audible snap while extending the leg from full flexion (McMurray's sign).
. Tx -> Arthroscopic repair.
{11} TIBIAL STRESS INJURY:
___________________________
. H/O of military or cadet marches.
. X-ray may be -ve initially.
. Tx -> Cast.
. Order the pt not to bear weight.
. Hyperflex the elbow with your thumb over he radial head to feel reduction.
. No post reduction films are needed.
. The child will resume the use of the previously unused extremity without crying.
* COMPARTMENT $YNDROME:
________________________
. Most frequent in the forearm or lower leg.
. H/O of prolonged ischemia followed by reperfusion, crushing injuries or other traumas.
. Pain & tightness & tenderness to palpation at the affected area.
. EXCRUCIATING PAIN with PASSIVE EXTENSION.
. Pulses may be normal !!
. Tx -> 1st step is emergent fasciotomy.
. N.B. When a pt complains of pain at the site of a cast,
. Always remove the cast & examine for compartment $.
. N.B. ISCHEMIA REPERFUSION $YNDROME:
. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of ischemia,
. suffer from intracellular & interstitial edema upon reperfusion (SOFT TISSUE SWELLING).
. When edema causes the pressure within a muscular fascial compartment to rise > 30 mmHg
. compartment $ occurs leading to further ischemic injury to the confined tissue.
. N.B.
. Escharotomy is indicated for circumferential full thickness burns of an extremity,
. with an eschar causing significant edema & constriction of the vascular supply.
. Pts sh'd be evaluated for clinical signs of adequate perfusion after escharotomy.
. Fasciotomy sh'd be done if there is NO signs of relef.
* NEURO-VASCULAR INJURIES:
___________________________
___________________________
. OBLIQUE DISTAL HUMERUS #:
____________________________
. Radial nerve injury.
. Inability to dorsiflex (extend) the wrist.
. Function regained after reduction.
. Surgery is indicated if paralysis persists after reduction.
. POSTERIOR KNEE DISLOCATION:
______________________________
. Popliteal artery injury.
. Decreased distal pilses.
. Doppler studies or arteriogram.
. Prophylactic fasciotomy if reduction is delayed.
. BACK PAIN:
_____________
_____________
{1} DISC HERNIATION:
_____________________
. Sudden onset severe back pain after lifting heavy object.
. Electric shock like pain shooting down the leg.
. Straight leg raising test gives excruciating pain.
. Mostly lumbar in origin L4, L5 & S1.
. Peak age 43-46 ys.
. Tx -> Anti-inflammatories & brief bed rest.
. Immediate surgical compression is needed if the H/O suggests Cauda equina $.
. (Bowel/Bladder incontinence - flaccid anal sphincter - Saddle anesthesia).
. MRI -> Confirm both disc herniation & causa equina.
. Trial of anti-inflammatories is always the 1st step in management.
{2} ANKYLOSING SPONDYLITIS:
____________________________
. Man in his 30s or early 40s.
. Chronic back pain.
. Morning stiffness improving with activity.
. X-ray -> Bamboo spine.
. Associated with HLA B-27 antigen (Screen for uveitis & IBD).
. Tx -> Anti-inflammatory agents & physical therapy.
{3} METASTATIC MALIGNANCY:
___________________________
. Elderly pt with progressive & constant back pain.
. Worse at night & unrelieved by rest.
. H/O of weight loss.
. X-ray -> Lytic lesions or blastic lesions.
. Blastic metastatic lesions -> Prostate cancer & breast cancer.
. Lytic metastatic lesions -> Lung, renal, breast, thyroid & multiple myeloma.
. Hypercalcemia & ++ ALP.
. 1st -> Order plain radiographs (Especially important in multiple myeloma).
. Bone scan is most sensitive in early disease.
. MRI shows the greatest amount of details.
. MRI -> test of choice if there are any neurologic syms to rule out cord compression.
. Bone scan will not be helpful in purely lytic lesions (Multiple Myeloma).
. Instead order plain radiographs or MRI.
* FOOT PAIN:
_____________
_____________
. PLANTAR FASCIITIS:
_____________________
. Older, overweight pts with sharp heel pain every time their foot strikes to the ground.
. Pain is worse with walking & in the mornings.
. X-ray -> Bony spur matching the location of the pain.
. Exquisite tenderness to palpation over the spur.
. Burning pain in nature.
. More common in runners with repeated microtrauma,
. who develop local point tendrness on plantar aspect of foot.
. However, surgical resection of the bony spur is not indicated !
. MORTON NEUROMA:
__________________
. Inflammation of the common digital nerve at the 3rd interspace.
. Between the 3rd & 4th toes.
. Mechanically induced neuropathic degeneration.
. Numbness & burning of the toes, aching & burning in the distal forefoot.
. Pain radiates forward from the metatarsal heads to the 3rd & 4th toes.
. PALPATION & SQUEEZING the metatarsal joints -> CLICKING SENSATION (MULDER SIGN).
. Caused by wearing pointy-toed shoes.
. The neuroma is palpable with very tender spot there.
. Management is analgesics & appropriate foot wear.
. STRESS # = HAIR LINE #:
__________________________
. Sudden ++ in repeated tension or compression without adequate rest.
. Sharp localized pain over a bony surface that is worse with palpation.
. The tibia is the most common bone in the body to be affected by stress #s.
. Occur in the anterior part of the middle 1/3 of the shin of tibia in jumping sport pts.
. Occur in the postero-medial part of the distal 1/3 of the tibia in runners.
. X-ray are frequently normal during initial evaluation.
. Stress # of the meta-tarsals are common in atheletes & military recruits.
. The 2nd metatarsal is the most commonly injured.
. Tx -> Rest, analgesia & a hrd soled shoe.
. TARSAL TUNNEL $YNDROME:
__________________________
. Compression of the tibial nerve as it passes through the ankle.
. Usually caused by a # of the bones around the ankle.
. Burning, numbness & aching of the distal plantar surface of foot or toes.
. Pain may radiate up to the calf.
__________________________________________________________________________________________
* UROLOGY:
___________
___________
. VARICOCELE:
______________
. Tortuous dilatation of pampiniform plexus of veins surrounding spermatic cord & testis.
. Results from incompetence of the valves of the testicular vein.
. Occurs most frequently on the left side, bec.
. Lt testicular vein enters Lt renal vein inferiorly at right angle -> impaired drainage.
. Dull or dragging discomfort scrotal pain that becomes worse on standing.
. Examination -> Bag of worms (Enlarge with Valsalva maneuver).
. NEGATIVE TRANSILLUMINATION.
. HYDROCELE:
_____________
. Due to fluid accumulation in tunica vaginalis.
. POSITIVE TRANSILLUMINATION.
. TESTICULAR NEOPLASIA:
________________________
_______________________________
. Due to an arteriosclerotic stenotic plaque at the origin of subclavian artery.
. This allows enough blood to reach the arm for normal activity, but,
. Not enough to meet the ++ demands of an exercised arm,
. resulting in BLOOD BEING STOLEN FROM THE VERTEBRAL ARTERY.
. Posterior neurological signs (Visual symptoms - Equilibrium problems).
. Claudication in the arm during arm exercises.
. Don't confuse this condition with thoracic outlet $!
. Thoracic outlet $ causes vascular symptoms only with-OUT neurological signs.
. Dx -> Angiography.
. Tx -> Bypass surgery.
{2} AORTIC ANEURYSM:
_____________________
. Size & symptoms are key to management of "ABDOMINAL" aortic aneurysm:
-> Aneurysms < 5cm -> Observe with serial annual imaging.
-> Aneurysms > 5cm -> Elective surgical repair.
. More urgent surgery is needed if:
-> A TENDER AAA will rupture within a day or two requiring urgent repair.
-> Excruciating back pain in a pt e' large AAA means that,
. the aneurysm is already leaking, necessitating emergency surgery.
. N.B. The following contributes to the development of "THORACIC" aortic aneurysm:
-> Chronic hypertension.
-> Hyperlipidemia.
-> Smoking.
-> Marfan $.
-> Untreated tertiary $yphilis.
. N.B. The most imp. modifiable risk to prevent worsening of existing aneurysms is:
-> UNCONTROLLED HYPERTENSION.
. N.B. Asymptomatic lesions -> BLOOD PRESSURE MANAGEMENT is the most important.
. N.B. Symptomatic lesions (including active dissection) -> Surgical intervention.
. (Look for sudden onset tearing pain in the back).
{3} ARTERIOSCLEROTIC OCCLUSIVE DISEASE OF THE LOWER EXTREMETIES:
_________________________________________________________________
. Pain in the legs on exercise that is relieved by rest (intermittent claudication).
. If the claudication doesn't affect the pt's life style -> No intervention is needed.
. The only management indicated is CESSATION OF SMOKING & THE USE OF CILOSTAZOL.
. If the pain is more severe,
. Dx -> Doppler studies (Pressure gradient ABI < 0.9).
. Dx -> Arterigram to identify stenosis.
. If there is DISABLING symptoms (Affect work or daily life activity),
. or there is impending ischemia to the extremity,
. Tx -> SURGERY (Angioplasty & stenting for stenotic segments).
. More extensive disease requires bypass grafts or sequential stents.
. N.B. PAIN AT REST indicates END STAGE DISEASE (Pt complains of calf pain at night).
. N.B. VVVVVVVVVVVVVVVVV. imp.
. The 1st step in evaluating a pt with suspected peripheral artery disease (PAD) is:
. to obtain an ANKLE-BRACHIAL INDEX (ABI) to confirm the diagnosis.
. Aspirin & cilostazol are antiplatelet agents that can be given after confirming PAD.
. They are not given upon clinical suspicion !
. Pts with significant symptoms & NORMAL ABI may have MILD diesase at rest.
. They sh'd undergo EXERCISE TESTING with pre & post exercise ABI measurment to confirm.
. ABI (1.0 - 1.3) -> Normal.
. ABI < 0.9 -> > 50 % occlusion of a major vessel.
. ABI < 0.4 -> Limb ischemia.
. N.B. ISCHEMIA REPERFUSION $YNDROME:
. A form of compartment $.
. Extremeties subjected to at least 4-6 hours of ischemia,
. suffer from intracellular & interstitial edema upon reperfusion (SOFT TISSUE SWELLING).
. When edema causes the pressure within a muscular fascial compartment to rise > 30 mmHg
. compartment $ occurs leading to further ischemic injury to the confined tissue.
. N.B. COMPARTMENT $ 5 "P"s:
____________________________
. May be caused by direct trauma (Hemorrhage), prolonged compression of an extremity.
. May be caused after revascularization of an acutely ischemic limb.
. Muscles of extremity are encased in fascial compartments preventing tissue expansion.
. The ++ pressure interferes with perfusion leading to muscle necrosis.
. Pressure > 30 mmHg leads to cessation of blood flow through capillaries.
. Tx -> EMERGENT FASCIOTOMY.
-> Pain
. Earlest symptom.
. ++ by passive stretch of the muscles in the affected compartment.
-> Paresthesia
. Burning or tingling sensation.
. occurs in the distribution of the affected peripheral nerve.
-> Pallor
. of the overlying skin
. result from tense swelling & compromised perfusion.
-> Pulselessness
. Late finding.
. Presence of a pulse on exam does NOT rule out compartment $.
-> Paresis/Paralysis
. Late finding.
. resilt from nerve & muscle ischemia & necrosis.
. N.B. ESCHAR !
. Eschar is a firm necrotic tissue formed on on exposed tissue following burn wounds.
. When eschar occurs circumferentially on an extremity,
. it restricts the outward expansion of the compartment as edema follows burn.
. Interstitial pressure increases -> compromise vascular flow to the limb.
. Deep pain out of proportion to injury, pulselessness, paresthesia, cyanaosis & pallor.
. Tx -> Escharotomy.
. N.B. Compartment $ 2ry to SUPRA-CONDYLAR # of humerus:
. 2ry to fall on out-stretched hand.
. Due to ++ pressure in a limited space.
. Pain, pallor, pulselessness, paralysis & presthesia.
. Tx -> Immediate fasciotomy.
. N.B. VOLKMANN's ISCHEMIC CONTRACTURE:
. is the final sequel of compartment $ (The dead muscle is replaced by fibrous tissue).
{4} ARTERIAL EMBOLIZATION OF THE EXTREMETIES:
______________________________________________
. H/O of Af or recent MI.
. Sudden onset painful, pale, cold, pulseless, paresthetic & paralytic lower extremity.
. Dx -> Doppler studies to locate the obstruction.
. Tx -> Thrombolytics (if early) & Embolectomy (if later) with fasciotomy.
. N.B. LERICHE $YNDROME = AORTO-ILIAC OCCLUSION:
_________________________________________________
. Arterial occlusion at the bifurcation of the aorta in the common iliac arteries.
. Triad of bilateral hip, thigh & buttock claudication, impotences &
. symmetric atrophy of the bilateral lower extremeties due to chronic ischemia.
. Absence of impotence excludes the condition.
. N.B. SPINAL CORD ISCHEMIA:
_____________________________
. Follows aortic vascular surgery due to anterior spinal artery $.
. The spinal cord derives its blood supply from the:
. anterior spinal artery & 2 posterior spinal arteries originating from vertebral artery.
. Presents with flaccid paralysis, bowel/bladder dysfunction, sexual dysfunction.
. Possible hypotension & loss of deep tendon reflexes.
. Spasticity & hyperreflexia develop over days to weeks.
. Vibratory & proprioceptive sensation is preserved as posterior circulation is preserved
. Dx -> Emergent MRI.
. Tx -> Supportive care & lumbar drains to reduce spinal pressure.
__________________________________________________________________________________________
. MISCELLANEOUS TOPICS:
________________________
________________________
. GASTRIC OUTLET OBSTRUCTION:
______________________________
. Can be caused by many diseases causing mechanical obstruction e.g.
. Gastric malignancy - Peptic ulcer disease - Chrons dis - Strictures e' pyloric stenosis
. Strictures 2ry to ingestion of caustics.
. Characterized by early satiety, nausea, non-bilious vomiting & weight loss.
. P/E -> ABDOMINAL SUCCUSSION SPLASH, elicited by placing the stethoscope,
. over the upper abdomen & rocking the pt back & forth at the hips,
. Retained gastric material > 3 hours after a meal will generate a splash sound,
. indicating the presence of a hollow viscus filled with both fluids & gas.
. In a pt with a H/O of acid ingestion, pyloric stricture is the most likely cause.
. H/O of a recent acid ingestion is a risk factor of developing pyloric stricture.
. Acid ingestion causes fibrosis 6-12 weeks after the resolution of acute injury.
. Dx -> Upper endoscopy.
. Tx -> Surgery.
. TOTAL BODY BURN & SYSTEMIC INFLAMMATORY RESPONSE $:
______________________________________________________
. Systemic inflammation & tissue injury.
. Burn -> Dysregulated host response,
. Massive uncontrolled release of proinflammatory substances -> extensive tissue damage.
. This is known as systemic inflammatory response $yndrome:
-> Temperature -> > 38.5 c (101.3 F) or < 35 c (95 F) !!!!!
-> Pulse -> > 90/min.
-> Respirations -> > 20/min.
-> WBC > 12000 or < 4000 or > 10 % bands !!!!
. SIR$ can follow pancreatitis, autoimmiune dis, vasculitis & burns.
. Sepsis (SIRS e' a known infection) is considered severe when there is end organ failure
. Oliguria - Hypotension (SBP < 90mmHg) - Thrombocytopenia (PLT < 80000).
. Metabolic acidosis - Hypoxemia.
. Hyperglycemia occur due to insulin resistance.
. Muscle wasting & protein loss & Hyperthermia.
. Sepsis with septic shock may occur in the 1st week post-burn.
. Main causes of sepsis are pneumonia & wound infections (Staph aureus & Pseudomonas).
. Criteria indicating sepsis -> Leukocytosis - Thrombocytopenia - Mild hypothermia < 36.
. Tachypnea & tachycardia due to associated pneumonia.
. Worsening hyperglycemia due to worsening insulin resistance.
. Bottom line:
. In pts with severe significant total body surface areas burns,
. The major cause of morbidity & mortality is HYPOVOLEMIC SHOCK.
. In case of adequate initial fluid resuscitation,
. Bacterial infection (Bronchopneumonia or burn wound infection) -> Sepsis & septic shock
. INTRA-PERITONEAL RUPTURE OF THE BLADDER:
___________________________________________
. Intra-abdominal pathology causing shoulder pain = Subdiaphragmatic peritonitis.
. Hyperextension injury in elderly pts with degenerative diseases of the cervical spine.
. Selective damage to the central portion of the spinal cord.
. specially the corticospinal & decussating fibers of the lateral spinothalamic tracts.
. Burning pain & paralysis in the UPPER extremeties e' relative SPARING of lower limbs.
. POSTERIOR CORD $YNDROME:
___________________________
. Bilateral loss of vibratory & proprioceptive sensation.
. BROWN SEQUARD $YNDROME:
__________________________
. Acute hemisection of the spinal cord.
. Ipsilateral motor & proprioception loss below the level of the lesion.
. Contralateral pain loss below the level of the lesion.
. ACUTE DISK PROPLAPSE:
________________________
. Severe radicular pain.
. +ve Straight leg raising test.
. CAUDA EQUINA $YNDROME:
_________________________
. Paraplegia.
. Variable sensory loss.
. Urinary & fecal incontinence.
. SYRINGOMYELIA:
_________________
. May follow spine cord trauma.
. Whiplash is often the incinting injury.
. Symptoms develop months to years later.
. Enlargement of the central canal of the spinal cord due to CSF retention.
. Impaired strenght & pain/temperature sensation in upper extremeties.
. Preservation of dorsal column function (Light touch - vibration - position sense).
. CAPE LIKE DISTRIBUTION.
__________________________________________________________________________________________
. # Mid-shaft humerus -> Radial nerve injury -> Wrist drop.
. # Supracondylar humerus -> Brachial artery -> pain, pallor, pulselessness, paresthesia.
. # Humerus -> Ulnar nerve -> Claw hand.
. ROTATOR CUFF TEAR:
_____________________
. Rotator cuff is formed by tendons of:
. (supraspinatous, infraspinatous, teres minor & subscapularis muscles).
. The supraspinatous is most commonly injured,
. due to repeated bouts of ischemia near its insertion on the humerus,
. induced by its compression between the humerus & the acromion.
. Common cause of tear is fall on out-stretched hand.
. Severe shoulder pain & edema following the trauma.
. Inability to abduct the arm at 90 degrees.
. When the pt's arm is abducted passively to greater than 90 degrees,
. And the pt is asked to lower the arm slowly; the pt's arm drops suddenly !
. N.B.
. D.D. for rotator cuff tear is "RUPTURE OF TENDON OF LONG HEAD OF BICEPS";
. POSITIVE POPEYE SIGN (The biceps muscle belly becomes prominent in the mid upper arm.
. PAGET'S DISEASE OF BONE = OSTEITIS DEFORMANS:
________________________________________________
. Disordered bone remodelling.
. ++ Osteoclast activity -> ++ bone resorption.
. Accelereated osteoblastic activity to rebuild the degraded bone.
. WOVEN BONE formation (Various stages of bone throughout the body).
. The woven bone is larger than normal bone & more liable to bowing & #.
. Most common presenting symptom is secondary arthritis of hip or knee.
. ++ ALKALINE PHOSPHATASE.
. NORMAL serum phosphorous & calcium levels.
. Enlargement of skull bones -> Bossing, ++ head size (Old hats no longer fits!).
. Headaches & cranial nerve palsies.
. Hearing loss is due to damage of the cochlear nerve,
. due to enlargement of the temporal bone & entrapment at the internal auditory meatus.
. VARICES:
___________
. NON-BLEEDING VARICES are managed with BB "Prporanolol".
. After 1st episode of bleeding -> Sclerotherapy, endoscopic band ligation & surgery.
. If not responsive to medical or endoscopic intervention -> Porto-systemic shunt (TIPS).
. RESPIRATORY QUOTE (RQ):
__________________________
. RQ is the ratio bet. CO2 produced to O2 consumed.
. Used to make assessmentsof metabolism taking place in the body.
. In mechanically ventillated pt, the RQ is 1.05.
. The ratio depends upon the major fuel being oxidized for ATP production.
. An RQ close to 1 indicates that CARBOHYDRATE is the major nutrient being oxidized.
. The RQ for protein & lipid as sole energy sources are 0.8 & 0.7 respectively.
. Massive atelectasis could affect ABG, but once a new steady state is achieved,
. the RQ value w'd still depend only upon the nature & proportions of metabolics used.
. TROCHANTERIC BURSITIS:
_________________________
. Unilateral hip pain in a MIDDLE-AGED adult.
. Inflammation of the bursa around the insertion of gluteus medius greater trochanter.
. Excessive frictional forces 2ry to overuse or trauma are common causes.
. Hip pain when pressure is applied (When sleeping) & external rotation or abduction.
. FEMORAL HEAD AVASCULAR NECROSIS = LEGG CALVE' PERTHES DISEASE:
_________________________________________________________________
. Boys between 4 & 10 ys with peak incidence bet. 5 & 7 us.
. Hip, groin or knee pain + Antalgic pain.
. RETRO-PERITONEAL HEMORRHAGE:
_______________________________
. An iatrogenic complication after cardiac catheterization.
. After cannulation of the femoral artery to access the cardiac vessels.
. A hematoma is formed at the upper thigh -> Extends into the retro-peritoneal space.
. Significant belleding with hypotension & tachycardia.
. Ipsilateral flank/back pain.
. Dx -> CT scan of ABDOMEN & PELVIS with-OUT contrast.
. Tx -> Supportive -> Blood transfusion - IV fluids - Bed rest.
. Tx -> Immediate surgical decompression if there are neurological deficits.
. PNEUMO-PERITONEUM:
_____________________
. AIR UNDER DIAPHRAGM = Intra-peritoneal air.
. Best seen bet. the liver & the diaphragm.
. Caused by PERFORATED VISCUS e.g. PERFORATED PEPTIC ULCER.
. PERFORATED PEPTIC ULCER (H/O of epigastric pain & discomfort with eating).
. Tx -> SURGICAL CONSULATATION IMMEDIATELY for EXPLORATORY LAPAROTOMY.
. CHILD ABUSE:
_______________
. Patterned scalds & burns = forceful immersion of hot object e.g. cigarette or hot iron.
. Incoherent or impropable explanation of the injuries.
. Delay in seeking care after injury.
. #s of long bones or ribs, #s in various stages of healing.
. Suspicious bruises include those on thighs, abdomen, cheeks & genitalia.
. Subdural hematoma & retinal hemorrhages in very young infants.
. Inaapropriate affect of the care giver.
. Physician should perform a thorough physical exam. & full radiographic skeletal survey.
. Report the case to child protective services.
. Admit the pt to ensure their safety.
. The child should never be sent home.
. The caregiver should never be confronted.
. Physicians are mandatory reporters.
. AMPUTATION INJURY:
_____________________
. Amputated parts sh'd be wrapped in SALINE-MOISTENED GAUZE,
. SEALED IN A PLASTIC BAG,
. PLACED ON ICE,
. brought to the emergency department with the patient.
. CAUSES OF HEMOPTYSIS:
________________________
. Pulmonary -> Bronchitis - Pulmonary embolism - Bronchiectasis - Lung cancer.
. Cardiac -> Mitral stenosis - Acute pulmonary edema.
. FAT EMBOLISM:
________________
. Common in pt with polytrauma with multiple #s of long bones.
. Severe respiratory distress, petichial rash, subconjunctival hemorrhage.
. Tachycardia, tachypnea & fever.
. May occur after 12-72 hs after trauma.
. CNS dysfunction -> Confusion - Agitation - Stupor - Seizures - Coma.
. Dx -> Fat droplets in urine.
. Dx -> Intra-arterial fat globules on fundoscopy.
. Dx -> CXR -> Diffuse bilateral pulmonary infiltrates.
. Tx -> Respiratory support.
. DUMPING $YNDROME:
____________________
. Common post-gastrectomy complication.
. Due to rapid emptying of gastric contents into the duodenum & small intestine.
. Post-prandial abd. cramps - weakness - lightheadedness - diaphoresis.
. Symptoms diminish over time.
. Symptoms result from fluid shift from intravascular space to small intestine.
. Stimulation of intestinal vasoactive peptides -> Stimulation of autonomic reflexes.
. Dietary changes are helpful to control symptoms.
. In resistant cases, octreotide sh'd be tried.
. Reconstructive surgery is reserved for intractable cases.
. HEMATOCHEZIA:
________________
. Bright red blood in stool.
. Due to lower GI bleeding (distal to ligament of Treitz).
. May occur in very brisk upper GI bleeding.
. Most common causes of lower GI bleeding in pts >50 ys-> DIVERTICULOSIS - ANGIODYSPLASIA
. Nasogastric tube placement with bile not blood = No active upper GI bleeding.
. Upper endoscopy sh'd be done next not to miss duodenal bleeding.
. In cases of hematochezia due to diverticulosis,
. The initial step is COLONOSCOPY.
. If -ve -> Radio-nuclide (Technetium 99 Labelled eryhthrocyte scintigraphy tagged RBCs).
. It is less invasive & more sensitive than angiography.
. It localizes the source of bleeding so that,
. the region can be further evaluated by colonoscopy or angiography.
. CENTRAL VENOUS CATHETERIZATION:
__________________________________
. A CXR sh'd be done to confirm proper placement & absence of complications.
. e.g. subclavian artery injury, pneumothorax, hemothorax, thrombosis & air embolism.
. To avoid myocardial perforation the catheter tip sh'd be located proximal to either:
. the cardiac silhouette or the angle between the trachea & right main stem bronchus.
. The catheter sh'd lie in the superior vena cava.
. DIABETIC FOOT ULCERS:
________________________
. Result from neuropathy, microvascular insuffeciency & immunosuppression.
. They occur on the plantar surface of the foot under points of greatest pressure,
. such as under the head of the 1st metatarsal bone.
. SOLITARY PULMONARY NODULE EVALUATION:
________________________________________
SOLITARY PULMONARY NODULE EVALUATION
______________________________________
|
CHEST CT WITH CONTRAST
________________________
|
__________________________
|
|
Benign features
Intermediate or suspicious for malignancy
_________________ ___________________________________________
|
|
SERIAL CT SCANS TO MONITOR FURTHER INVESTIGATION WITH BIOPSY or PET scan
. Diverticulae erode the bowel vasculature leading to profuse bleeding per rectum.
. Most common site is sigmoid colon.
. Dx -> CT Abdomen.
. N.B.
. Diverticulosis -> Non-inflammed diverticula -> Painless bleeding.
. Diverticulitis -> Abdominal pain & infectious syms 2ry to obstruction of diverticula.
. It is uncommon to see bleeding with diverticulitis !
. GASTRO-ESOPHAGEAL MURAL INJURY CHARACTERISTICS:
_________________________________________________
_________________________________________________
(A) MALLORY WEISS $YNDROME:
____________________________
. Upper gastro-intestinal MUCOSAL TEAR.
. Caused by forceful retching (++ pressure).
. Submucosal arterial or venule plexus bleeding.
. Vomiting, retching, hematemesis & epigastric pain.
. Dx -> EGD confirms diagnosis.
. Most tears heal spontaneously.
. Endoscopic therapy for continous bleeding.
(B) BOERHAAVE $YNDROME:
________________________
. Esophageal TANS-MURAL tear.
. Caused by forceful retching (++ pressure).
. ESOPHAGEAL AIR/FLUID LEAKAGE into nearby areas e.g. pleura.
. Vomiting, retching, chest & upper abdominal pain.
. Odynophagia, fever, dyspnea & septic shock may occur.
. Subcutaneous emphysema may be seen.
. Dx -> CT or CONTRAST ESOPHAGOGRAPHY e' GASTROGRAFIN (Water soluble) confirms diagnosis.
. CXR -> Pneumo-mediastinum & pleural effusion.
. Pleural fluid analysis -> EXUDATIVE, LOW pH, VERY HIGH AMYLASE > 2500 IU.
. Tx -> Surgery for thoracic perforations.
. Conservative measures e.g. antibiotics for cervical perforation.
. IATROGENIC esophageal perforation:
. CXR -> Pleural effusion, pneumomediastinum & pneumothorax.
. Dx -> Water soluble contrast esophagogram.
. Avoid endoscopy not to worsen the condition !
. MECHANISMS OF LOWERING INTRA-CRANIAL TENSION:
________________________________________________
. HEAD ELEVATION -> ++ venous outflow from the head.
. SEDATION -> -- metabolic demand & control of HTN.
. IV MANNITOL -> Extraction of free water out of brain tissue -> Osmotic diuresis.
. HYPERVENTILLATION -> CO2 washout -> Cerebral VASOCONSTRICTION.
. POST-SPLENECTOMY VACCINES:
_____________________________
. Following splenectomy, pts are at ++ risk for sepsis 2ry to encapsulated organisms
. Capsulated organisms (S. pneumoniae - N. meningitidis - H. influenzae).
. Vaccination against these organisms sh'd be administered.
. Pneumococcal vaccine boosters are required every 5 years.
. PAROTID NEOPLASM:
____________________
. The two lobes of the parotid gland are separated by the facial nerve.
. Parotid surgery involve the deep lobe of the parotid gland -> facial palsy.
. Facial palsy -> Facial droop.
. INJURY -> CULPRIT INJURED NERVE:
___________________________________
. HOARSENESS -> RECURRENT LARYNGEAL BRANCES OF VAGUS NERVE (Thyroid/Parathyroid surgery).
. TIC DOULOUREUX (TRIGEMINAL NEURALGIA) -> TRIGEMINAL NERVE.
. TONGUE PALSY -> HYPOGLOSSAL NERVE (Submandibular gland surgery).
. WINGED SCAPULA -> LONG THORACIC NERVE (Axillary lymphadenectomy surgery).
. PERIPHERAL ARTERY ANEURYSM:
______________________________
. Pulsatile mass that can compress adjacent structures (nerves - veins).
. May lead to thrombosis & ischemia.
. Most common are popliteal & femoral aneurysms.
. Associated with peripheral artery aneurysm.
. PENILE #:
____________
. Crush injury of an erect penis.
. Common during intercourse with female on top of male.
. Dx -> Emergent urethrogram to assess for urethral injury.
. Tx -> Surgical exploration to evacuate hematoma & mend the torn tunica albuginea.
. URIC ACID STONES:
____________________
. Ureteral colic -> Vagal reaction -> ILEUS.
. Urinalysis -> Needle shaped crystals = uric acid stones.
. Dx -> CT abdomen or IV pyelography.
. Tx -> Stones < 0.6 cm -> Pass spontaneously with hydration & analgesia.
. Tx -> Stones > 0.6 cm -> Surgical removal.
. NASOPHARYNGEAL CARCINOMA (NPC):
__________________________________
. Undifferentiated carcinoma of squamous cell origin.
. Higher frequency in people of Mediterranean or far eastern descent.
. Most NPC are metastatic at the time of diagnosis.
. Recurrent otitis media (Due to eustachian tube obstruction by tumor).
. Recurrent epistaxis or nasal obstruction.
. Associated with positive serology for EPSTEIN BARR VIRUS (EBV).
. It is associated with smoking & chronic nitrosamine consumption (Salted fish diet).
. PARALYTIC ILEUS:
___________________
. Abdominal pain after a traumatic injury.
. Associated with vertebral # or retro-peritoneal hemorrhage.
. Ileus is caused by an exagerrated intestinal reaction after abdominal surgery.
. Due to disruption of normal neurologic & motor control of the gastrointestinal tract.
. Failure to pass stool or flatus, abdominal distension, nausea & vomiting.
. Distended abdomen with tympany.
. Decreased or absent bowel sounds.
. Abdominal x-ray -> Air-fluid levels & distended gas-filled loops of small & large int.
. Tx -> Conservative with bowel rest & supportive care.
. LUDWIG's ANGINA:
___________________
. Infection of the submandibular & sublingual glands.
. Source of infection -> Infected tooth (2nd or 3rd mandibular molar).
. Most common cause of death -> Asphyxia.
. TORUS PALATINUS:
___________________
. CONGENITAL !
. Young individual.
. Fleshy immobile mass on the midline hard palate.
. No medical or surgical ttt is required unless the growth becomes symptomatic.
. i.e. interfering with speech or eating.
. NEURO-ANATOMY:
_________________
_________________
. FEMORAL NERVE:
_________________
. Motor to anterior compartment of thigh (Quadriceps femoris - Sartorius - Pectineus).
. Responsible of knee extension & hip flexion.
. Sensory to the anterior thigh & medial leg via saphenous branch.
. TIBIAL NERVE:
________________
. Motor to posterior compartment of thigh, posterior compartment of leg & plantar foot ms
. Responsible of knee flexion & digits & plantar flexion of foot.
. Sensory to the leg (except the medial side) & plantar foot.
. OBTURATOR NERVE:
___________________
. Motor to medial compartment of thigh.
. Responsible of thigh adduction.
. Sensory to the medial thigh.