Note Cards

PROM Premature Rupture Of Membranes

1

Defn: Rupture of the choriaoamniotic membrane before the onset of labor. 10-15% of all pregos. 1/3 of preterm pregos. Risk Factors: Smoking during prego  2x risk of PROM; short vagina, Hx of PROM, preterm delivery, hyramnios, multiple gestation, bleeding early in prego. Sequalae: Neuro probs eg cerebral palsy, leukomalacia, pulmonary hypoplasia Dgx: Leaking vagina pH>7.0, +fern test, U/S shows lots of amnio fluid around fetus DDx: ↑ vag secretions, exogenous fluids discharge from infx, vesicovaginal fistula. Tx: R/O infx and determine viability, nothing if full term, delivery & Abx if preterm and infx

2

Ectopic Pregnancies

3

Leading cause of maternal mortality in US. SSx: Abdominal pain, vaginal bleeding

4

Vulvar Cancer

5

Epidemiology: Uncommon. Post menopausal fem 65-70 5% of gyn cancer. Pts usually embarrassed to visit Dr.  delay in t(x). SSx: Vulvar pruitus, red or white ulcerative exophytic lesion usu from post 2/3 of lab. mjr. Bleeding, pain. Dgx: Bpx Etiology: Unk ?smoking, ?HPV. 90% of cases are Sq cell carcinoma. Extramammary, Bartholins, basal cell, melanoma, sarcoma or mets also found. Spread via lymph of superficial inguinal, deep femoral or external iliac nodes. Extension to upper vag can  deep pelvic spread. Tx: Vulvectomy and Lymphectomy

6

Induction of Labor

7

8

Defn: Stimulation of uterine contrx bf spontaneous onset of labor with the goal of achieving delivery. Usu w/ Oxytocin and when the cervix is ‘ripe’ Indications: benefits of delivery >> risks of inertia-less pregnancy/labor. Mother and fetus must be taken into account. Methods: To ‘ripen’ the cervix use PGE2 or Dinoprostone. PGE2 can  uterine hyperstimulation  placental insuffx or uterine rupture. PGE2 C/I if asthma Laminaria is seaweed stems that are inserted into cervix, then expand, via moisture, to dilate cervix. Complx=cervical lax, membr ruptx, infx. Prolonged latent phase managed w/ rest or augmentation of labor

Surgical Alternatives to Hysterectomy for Myomas

9

10

1. R/o endometrial hyperplasia or CA esp in perimenopausal fems. 2. If fibroids don’t cause any probs (anemia, social hinderence) then monitor and reassure 3. Myomectomy if pt wishes to stay potentially fertile, or if myomas are getting in the way of fertility. 4. Pharm inhibition of E2, GnRH agonists to inhibit HoTH-Pit-Ovar axis from releasing E2. Watch x rebound upon withdrawal. Danazol to ↓ ovarian E2. 5. Uterine AA Embolization (UAE) with polyvinyl alcohol particles. Complx=PE

Intrauterine Growth Restriction IUGR

11

12

Defn: a fetus or infant whose wt is in the lowest 10% of the nl population for it’s gestational age. Dgx via U/S using biparietal diameter, head C, abd C & femur length, amniocentesis x karyotype, & PCR. Prevalence is 10%-by defn. NOT ‘low birth weight’. ↑%x fetal death, neonatal death, asphyxia, fetal intolerance of labor; or meconium aspirax, hypoglycemia, hypothermia, resp distress s/p labor. Causes: ↓ fetal : placenta surface area. 1)Maternal causes-HTN bc of ↓ placental perfux, SLE, smoking, EtOH, cocaine, anticonvulsants, steroids, immunosuppressants, malnutrition, young/teen antiphospholipid Antibodies, thrombophilias 2)Fetal-infx from Ruella or CMV esp if in 1st trimester, bact infx, tri 13, tri 18. Usu Early onset (↓ cell division) or Delayed onset (↓ cell size) can be reversed w/ nutrition-Usu due to uteroplacental insuffx. Hx if prev IUGR Asymmetric vs Symmetric: Asymm-Abd C>head C. Seen in nutritional defx. Sym-Abd C≈head C. Usu anomaly Tx: Deliver the healthiest possible fetus at the healthiest possible time (maturity vs fetal compromise). Correct cause if poss (eg. nutrition). U/S q4wks to monitor progress. Bed rest.

Prevention Of Venous Thromboembolism

13

14

Prego is considered a hypercoagulable state (like CA)  ↑%x VTE up to 42days postpartum. Fibrinogen (factor I) increases to 500mg/dL. Factors VII, VIII, IX, and X are also increased. PT/PTT and clotting time do not change.

Uterine Cancer

15

16

Epidemiology: Menopausal fem SSx: Abnl Vag bleeding, discharge. Hematometra in older pts. Risk Factors: too much E2 (menopause, unopposed E2 tx, nulliparity, obesity, Tamoxifen, DM) ?: Mostly adenocarninoma +/- sq epith CA (if sq epith present then adenoacanthoma; or adenosquamous carcinoma if sq epith more malignant). 1) E2 Independent usu in menopausal pts. vs 2) E2 Dependent usu in perimenopausal pts. due to excessive E2 from wherever (testosterone, ovaries, OCPs)  endometrial growth. and is more common vs the former. R/o prego Dgx: Bpx after abnl uterine bleed esp if >35yo. Staging is Surgical taking into acct lymph nodes and lots of sampling. the higher the grade the less % of long term survival Spread: endometriummyometriumcervixlymphaticsadnexa. Tx: Surgery: radical TAH, BSO +/- periaortic nodes. Post surgery radiation. Estrogen/progestin if recurrence. Progesterone to reverse the E2 dependent growth.

Oxytocin

17

18

Uses: induce contractions of labor (esp latent phase) via IV after mechanical probs are ruled out. Postlabortal Syndrome (+Abx), Oxytocin challenge test to test for uteral contractions. Milk let down.

Benign Ovarian Cancer

19

20

Types: 1) Epithelial-Glandular type. ?derived from embryo GU tract (mullerian). Mostly Serous Cystadenoma which are multilocular, large. Tx is sgx bc of ↑%x malignancy. Unilateral if pt is young/fertile, or BL oophorectomy w/ hysterectomy if pt is past reproductive age. 2) Germ Cell arise in the ovary & may contain bones, hair w/ appendages etc. Most common type is Benign Cystic Teratoma (aka Dermoid cyst). Most occur ≈ 30yo found during routine pelvic exam. Mobile, NT, ↑ fat content, →↑%x ovarian torsion. Tx is surgical to prevent torsion 3)Stromal Cell-Derived from sex cord stroma and may → granulose theca cell tumor (E2), or sertoli-leydic cell tumor (Testosterone). Can lead to precocious puberty, thelarche, vaginal bleeding Epidemiology: More common vs malignant ovary stuff. ↑%x malignancy w/ ↑age. Tx is surgery to avoid malignancy or torsion. Dgx via pelvic exam, U/S.

MALIGNANT Ovarian Cancer

21

22

Epidemiology: 5th most common fem CA. 2nd most common Gyn CA. MOST DEADLY Gyn CA. Poor prognosis (40% 5yr survival rate). 50-60 yo White F. BRCA-1 →5%↑%. BRCA-1 AND BRCA-2 →45%↑%. Long term suppression of ovulation is protective eg OCPs Ssx: Abd fullness, distension, abd pain, LBP, ↑urinary Hz. Dgx: Psammoma bodies Spread via direct extension in pelvis/perineum due to ovarian sloughing/seeding. CA-125 not Dgx but used to follow suppression s/p Tx Types: 1) Epithelial Cell (most common), have Serous Cystadenocarcinoma, Mucinous (psudomyxomatous peritonei), Endometrial Tumors in the ovary. 2) Germ Cell – Produce βhCG, or αFetoProtein. Dysgerminoma (unilateral; Tx is chemo/radio sensitive) and Immature Teratoma (painful, hemorrhage, necrosis; Tx is oophorectomy) types. Spread via lymphatics. 3)Stromal Cell Mets TO Ovary: Krukenberg Tumor is a tumor that is met from another site eg GI, breast, endometrium. Infiltrative, mucinoius of signet-ring type. Tx is BSO + hysterectomy. Poor Prognosis. 5% 5yr survival rate.

Cervical Cancer

23

24

External Cephalic Version

25

26 Defn: version performed entirely by external manipulation Indications: Breech deliveries. Stats: Only works in about ½ of all cases. Eligible cases should benl fetus, good heart tracing, adequate amniotic fluid, presenting part not in the pelvis?, no uterine op scars, no labor?. ECV works best in parous fem.

SERMs Selective Estrogen Receptor Modulators

27

28

Example: Raloxifene, Tamoxifene, Evista MOA: estrogen agonists w/in some organs (bone, liver, CV) >> antagonists w/in other organs (uterine, breast)  ↓ bone resorption [designed to have less potential of druginduced uterine or breast cancer] Indication: Osteoporosis, women lacking estrogen (postmenopause, post-hysterectomy) [prophylaxis & treatment], Breast CA?, Adverse: hot flashes, venous thromboembolism, ovarian, breast & endometrium cancer, fetal death, teratogen CI: pregnancy, immobilization, thrombosis

Operative Vaginal Delivery

29

30

Cervical Cytology

31

32

β hCG

33

Source: Placental Sycntiotrophoblasts. 1st detectable @ 10 daysPEAK @ 9 weeks  falls to plateau @ 20 weeks Sx: α sub-u looks like FSH. β sub-u needed x pregnancy If levels are too high: multigestation, hydatidform mole, choriocarcinoma, embryonal carcinoma If levels are too low: ectopic prego, threatened prego, missed Ab Function: stimulate corpus luteum to produce Progesterone, until the placenta can take over; Regulate steroid biosyths in the placenta and fetal adrenal growth; Stimulate Testosterone in male fetal testes

34

Human Placental Lactogen

35

Function: similar to somatotropin

36

Effects: Antagonizes insulin cellular RE  ↓ gluc and insulin utilization  ↑ % x gestational DM

Progesterone

37

38 Structure Source: Corpus luteum luteal cells early on but declines after 9 weeks making way for placental progesterone Function: Early Prego-induces secretory uterine changes to favor blastocyst implantation. LATER Prego-Induces immune tolerance for prego and prevent myometrial contrx.

Estrogens

39

40 E2: Major estrogen in fertile NON-prego fems; made in the follicular granulose cells by aromatase from androgens. (the androgens are made in the follicular theca cells) E3: Main estrogen during prego. Made in the placenta by sulfatase from DeHydroEpiAndroSterone (DHEAS is secreted from the fetal adrenals) Eone: Main estro during menopause. Made in fat cells by from adrenal androstenedione.

Pregnancy

41

42 Signs: Fetal heart sounds, +β hCG, amenorrhea, softening of corpus and cervix 1st Trimester: <13 weeks. +NV, fatigue, breast tenderness, Spotting, 8lb wt gain. Complication is spont ab. 2nd Trimester: 13-26 wks; Round ligament pain; Braxton Hicks Contrx (contrx w/o pain); +1lb/wk; awareness of fetal mvmts; complications are cervical incompetency, PROM, and premature membrane 3rd Trimester: 26-40wks; ↓ libido; LBP, urinary Hz, fetal head descent into pelvis, bloody show from cervical dilation; complications PROM, premature labor, preeclampsia, UTI, gestational DM, anemia Nl Complaints: bleeding gums, bigger breasts, carpal tunnel, LBP, chloasma, linea nigra, dizziness, fatigue, fluid retention, hair and nail shedding (telogen effluviam), HA, leg cramps, vomiting, nosebleeds, stretch marks, stress incontinence, varicose veins Nl menstruation=21-38days

Pregnancy Complaints

43

Vaginal Bleeding Early on – Spont Ab; Late-Placenta Previa Vaginal Fluid leak-ROM or urinary incontinence Epigastric Pain-SEVERE preeclampsia Uterine Cramping-Preterm labor, Preterm Contractions ↓ Fetal Movements-Fetal Compromise Persistent Vomiting-Hyperemesis, hepatitis, pyelonephritis HA+Visual changes-SEVERE Preeclampsia Pain w/ Urination-Cystitis, Pyelonephritis Chills and Fever-Pyelonephritis, Chorioamnionitis

44

Safe Immunizations

45

Flu-in all women during flu season HepA-pre/post exposure HepB-pre/post exposure Pneumococcus-ONLY HIGH RISK fems Meningococcus-in outbreak areas Typhoid-

46

Unsafe Immunizations

47

MMR Polio Yellow Fever Varicella

48

Projects I can’t do cuz someone else is doing it

49

Ovarian Dermoids: Hari Cerv CA: Vanessa HIV and Prego: Katie Fitz-Hugh Kurtis SSx: Jessica Trauma in Prego: Chris Dysgerminoma: Adham Maternal Congenital Heart Disease: Linda Fistulas: Marianne Nl Prego/Isoimmunization/Infertility: ME

50

Infertility

51

52

Defn: inability to conceive x 1 year of unprotected sex. Causes: 1) Anovulation 2) anatomic defects 2) abnl spermatogenesis DDx: Endometriosis, low body wt, marijane, PID & its risk factors, salpingitis, Asherman’s SSx/intrauterine synechiae, leiomyoma, uterine septum, Diagnosis: 1) check basal body temp, endometriosis, luteal phase progesterone lvls; Urine LH to predict ovulation, androgen lvsl, PL, GnRH 2) do a hysterosalpingogram 7-11days of cycle to ↓%x retrograde menses (hysteroscopy x uterine health); endometrial bpx after ovulation 3) check semen Tx: 1) Antiestrogens (clomiphen), Progesterone, FSH/Pergonal if clomiphene fails 2) Surgery via Lysis of adhesions, Deobstruction, Path: Random Info: Repro ages 15-44; % of fertility is 1/2ed bw 37 & 45. Body temp falls at time of menses and PEAKS 2 days after the LH surge/somatic progesterone >4ml. Ovulation occurs about 1 day bf the 1st temp elevation. If hx of irreg Menses then no need x basal body temp check. Check FSH, LH, PL, TSH, DHESA. Implantation happens 3-5 days sp fertilization. redupulication of genital tract is associated w loss/recurrent preg NOT so much infertility

Danazol

53

54 Tx: Endometriosis, Fibrocystic Breast Changes, Hereditary Angioedema MOA: Suppresses LH and FSH surges from ant. pit.  no E2 from the ovary  no proliferation of endometrium SDFX: Amenorrhea, pseudomenopause, acne, spotting, hot flashes, oily skin, facial hair, deepening of voice, decrease libido, atrophic vaginitis, decrease in HDL and LDL cholesterol, C/I: PREGO, breast feeding, porphyria, liver, kidney heart dysfx, Misc: ↓ LH and FSH (menopause  increase LH and FSH)

2 Cell Theory Of E2 Production

55

Oocyte surrounded by Granulosa cells (lack 17-α so can’t make testosterone). Granulosa cells surrounded by Theca interna cells.

56

FSH from anterior pituitary acts on Granulosa cell to secrete E2. More E2 causes proliferation of Granulosa cells. The follicle with the most granulosa cells wins. LH from Ant Pit work on Theca cells to change cholesterol into Androstendione. FSH stimulates the Granulosa cells to change Androstendione via Aromatase into E2 or E3. As E2 lvls increase, E2 + FSH  granulosa cells to make LH receptors. The LH receptor’d Granulosa cells start secreting progesterone. LH surge causes ovulation. After ovulation Granulosa and Theca cells secrete E2 and progesterone in response to LH.

Lupron

57

MOA: Suppresses GnRH down regulate ant pit  decreased LH/FSH  decrease E2 and testosterone Treats: Endometriosis, Fibroids SDFX: effects of decreased estrogen (menopause) C/I: prego, breast feeding,

58

Placenta Previa

59

60 Defn: abnormal location of placenta near/over the internal cervical os. ≈ 1/250 pregos Path: Bleeding is caused by separation of part of the placenta from uterus possibly from contrx. Bleeding usu stops on it’s own. Types: 1) Total-the placenta covers the os 2) Partial-the placenta covers part of the os 3) Marginal-the placenta is w/in a few cm of the os SSx: Painless vag bleeding esp in 3rd trimester. Dgx: US Tx: Hemostabalization, rest, cs, induced delivery if amnio shows developed lungs Risk Factors: Multiparity, AMA, h/o cs Complx: associated with CNS probs and deformities so do an anatomic US of the fetus if placenta previa is suspected or dgx

Placenta Abrupto

61

Path: Hemorrhage into the dedidua basalis  Premature separation of the nl implanted placenta from the uterine wall SSx: Painful VB, abdominal discomort, Tx: Risk Factors: HTN, cocaine use, abdominal trauma, baring down, Complx:

62

Mood Disorders ≥≤

63

64 Common 3-5% of pop. Major Mood Disorders: Bipolar I, II, MDD. Other Specific Mood D/O: Minor Depression, Dysthymic D/O, Cyclothymic D/O. Mood Disorder Due to a Medical Condition, Mood Disorder Due to Substance-Induced Mood Disorder. Adjustment Disorder w/ Depressed Mood. Bipolar is further described as Manic, Depressed or Mixed, # episode, ?recurrent, ? post-partum,. Major Depression should be characterized as Minor Mood D/ocyclothymia, dysthymia, adjustment d/o w/ depressed mood. Usu due to childhood loss and manifesting in late 20’s

Bipolar I

65

66 Epidemiology: young poor fem. 1% of pop usu >30yo SSx: periods of depression w/ >1 episode of mania that compromised functioning. Mania = >3 of Distractability, Indiscretion, Grandiosity, Flight of ideas, Activity ↑, Sleep Deficit, Talk is pressured (DIGFAST). Manic episode develops over days may → psychotic/uncontrolled characteristic. 20% have hallucinations or delusions or both; or can be confused w/ organic delirium. Can Mania can take up to 4 mos to resolve if untreated. Mania  legal/social probs. Depression  ↑%x suicide in BPI pts. Tx: Manic Episode-Li to maintain, Maintain x1yr and then taper off. If no more ssx then no need to continue meds. If ssx come back start and continue x 2more years; ? Carbamazepine to stabilize or other anticonvulsant, or a BZD Depressed- Lamotrigine (MOA is to inhibit Na channels  decreasing Glutamate) Mixed- Zoprazidone, Risperidone, Olanzapine Rapid Cyclers – Li

Major Depression Disorder MDD ≥≤♀♂

67

68 Epidemiology: usu starts in late 20yo F; but evenly distributed in all age groups and becoming more prevalent in teens SSx: Vary-Agitation or irritability vs c/o unusual bodily feelings or inexplicable mind disturbances. Usu worse in the am getting better throughout the day. Most attacks begin gradually over a 3wk span and last to ≈8mos to indefinitely if untreated. There must be absence of: Mania, Hypomania or due to something else (eg schizoaffective) “Psychotic” if w/ hallucinations or delusions. Elderly may present w/ retardation, memory impairment or disorientation (pseudodementia). Atypical fts-mood reactivity+>2 of increased appetite, wt gain, hypersomnia, leaden paralysis, or rejection sensitivity. Tx here is MAOIs Melancholic fts-anhedonia, or decreased rxn to pleasurable stimuli Misc: these pts ↑%x suicide

Post-Partum Depression

69

“Post Partum” is a specifier for any Mood Disorder (BP, MDD etc). Severe depression <4 wks post partum esp after 2nd or 3rd baby. ↑%x recurrent episodes with following babies.

70

Dysthymia

71

72 SSx: Depressed mood for most of the day, more days vs not x >2yrs. Depression + 2 or more of: change in appetite, change in sleep, ↓ in E, ↓ self-esteem, ↓ concentration, hopelessness. Ssx have not been absent x >2mos in this 2 yr (1 yr for kids/teens) period; no MDD, mania or cannot be due to another cause (eg schizophr or subst abuse or hypothyroidism). The ssx cause social dysfx Specify: Early – <21 yo vs Late – > 21yo; if Atypical-wt gain, +mood w +events

Cyclothymia

73

74 SSx: ≥2yrs (1yr in kids/teens) w hypomanic and depressive ssx but NOT w/o ssx ≥2mos. Rule Out: MDD, other dss (schizo bipolar delusional), drugs, medical condition If manic during this 2/1 yr period than u can add BPI to the dgx. If MDD during this 2/1 period u can add BPII to the dgx

Seasonal Affective Disorder

75

A specifier which can be applied to BP, MDD. SSx: Regular temporal relationship bw onset of MDD, BP and a particular time of year (eg. MDD during winter) and full remissions during other times of the year. MDD episode in the last 2 years that correlate with seasonal change and no other time. Seasonal MDD episodes >> Non-seasonal MDD over pts lifetime Rule Out: Stressors eg. seasonal occupation

76

Bipolar II

77

78 SSx: Hx of ≥1 MDD episode + Hx of ≥1 hypomanic episode. Ssx cause marked distress or impair social/legal/job fux Rule out: Schizoaff, schizophr, delusional d/o, Specify: Hypomanic vs depressed; Mild vs Moderate vs Severe w/(o) Psychotic Ft; Chronic; w Catatonic, Melancholic, Atypical Fts or Post Partum; Partial vs Full Remission; w/(o) Rapic Cycling

Hypomania

79

SSx: ≥4 days of elevated, expansive or irritable mood clearly different from the usual nondepressed mood. ≥3 of DIGFAST Distractability, Indiscretion, Grandiosity (↑self-esteem), Flight of ideas, Activity ↑, Sleep Deficit, Talk is pressured. This episode is noticeable by others but does NOT cause social/job impairment and does NOT have psychotic fts. Rule Out: Drugs, or general med condition (hyperthyroidism, tumor etc), somatic RE to antidepressant tx.

80

Mania

81

SSx: ≥1 week of elevated, expansive or irritable mood clearly different from the usual nondepressed mood. ≥3 of DIGFAST Distractability, Indiscretion, Grandiosity (↑self-esteem), Flight of ideas, Activity ↑, Sleep Deficit, Talk is pressured. This episode is noticeable by others AND causes social/job/legal impairment, may have psychotic fts or may need hosbitalization. Rule Out: Drugs, or general med condition (hyperthyroidism, tumor etc), somatic RE to antidepressant tx.

82

Mood Disorder 2ry to General Medical Conditon

83

Depression is due to physiological response to illness (eg hypothyroidism, ) SSx: 1 or both of – Depressed mood or marked ↓interest or anhedonia; elevated/expansive/irritable mood. Rule out: Adjustment w/ depressed mood in RE to the stress of having a general medical condition

84

Substance Induced Mood Disorder

85

SSx: 1 or both of – Depressed mood or marked ↓interest or anhedonia; elevated/expansive/irritable mood. The ssx developed w/in 1mo of subst use or withdrawal and/or is etiologically related to disturbance. Rule out if: SSx occurred before the subst use; ssx last >1mo after use and withdrawal; MDD

86

Mood Stabalizers

87

88 Li x BP-mania; Valproic Acid DOC x BP-Depression; Carbamazepine BPdepresion; Lamotrigine BP-maintenance Gabapentin, Topiramate and Pregabalin are used if DOC’s are not tolerated

Lithium

89

90

Use: DOC x BP Mania. Monitor CBC, CMP Cr, BUN, UA, T3/4, EKG MOA: ? but causes ↑ in presynaptic 5HT transmission. ?↓ DA transmission. ↑Plasma NE lvls. NSAIDS inhibit renal clearance causing increased blood levels PhKinetics: absorbed From GI. Maintenace plasma lvls 1.0-1.5 meq/L. t ½ ≈ 18-36hrs SDFX: Renal: Polyuria, polydipsia 2ry to Vasopressin-resistant DI in 50% of new pts, reversible. Focal Interstital Cortical Fibrosis w Tubular atrophy/sclerotic Glomer, IRReversible. ↑Cr; Neuro: ↑ EEG amp, ↓Hz, HA, slurred speech, confusion, ↓concentration/consciousness, delirium, coma, death, dysarthriea, ataxia, nystagmus, discoordination, Parkinson ssx, choreiform movements; NeuroMusc: Tremor, hyperactive reflex, fasciculations, paralysis; Blood: Leukocytosis reversible, ↑ESR; GI: NV, switch to Li-Tartate; Heart: flat/inverted T-waves, MI, Sudden Death; Hypothyroidism tx w low dose thyroxin; Wt Gain via hypoglycemia; Prego-Ebsteins Anomaly (tricuspid displaced down and to the R), crosses milk barrier, decrease the dose prior to birth cuz clearance falls during prego and mother can become toxic after birth

Carbamazepine (Tegretol)

91

Use: Rapid Cycling Bipolar; 2ry choice x BP – mania and depression. Anticonvulsant. SDFX: Agranulocytosis, aplastic anemia, liver damage, allergic rash, sedation, dizziness, Tox can present with gum/mucous bleeding. Monitor CBC w every blood check.

92

Valproic Acid

93

Use: 2ry choice x BP – mania and depression; Rapid Cyclers; Less SDFX vs Carbamazepine SDFX: sedation, wt gain, GI upset

94

Lamotrigine (Lamictal)

95

Use: 3rd line tx x BP episode and BP maintenance SDFX: Steven-Johnsons Syndrome

96

Oxcarbazepine (Triliptal)

97

98 Use: MOA: blocks voltage sensitive Na channels, stabilizes neural membranes, inhibits repetitive firing and ↓synaptic impulse propagation. PhKinetics: Met in liver p450 to active metabolite, excreted in urine. t1/2 ≈ 9 hrs

Psychotic Disorders

99

100 Schizophrenia (disorganized, catatonic, paranoid, undifferentiated, residual); Schizophreniphorm; Brief Psychotic Disorder; Schizoaffective Disorder; Shared Psychotic Disorder; Delusional/Paranoid Disorder; Psychotic Disorder due to a Medical Condition; Substance induced psychotic Disorder; Psychotic Disorder NOS

Schizophrenia

101

102 Epidemiology: 1% of world pop ≈ 2million in US esp in urban and lower SES via downward drift. More pronounced in “poor environments”. 10% chance of developing if 1° relative has it. SSx: Rambling (loose associations, neologisms, overinclusivesness, blocking, clanging, echolalia, concreteness, lack of speech or speech content); Delusions (reference, bizarre, persecutory, grandiose insertion); Disturbance of perception (auditory hallucinations BL from outside head, illusions, derealizations); Disturbance of emotions (blunt, labile, inappropriate affect); Disturbance of Beahavior; Positive Symptoms-Things that SHOULD NOT be there but are eg hallucinations, delusions, paranoia, loose associations; Negative Symptoms-Things that SHOULD be there but are not (normal affect SHOULD be there but may be manifest as flat affect)

Residual Phase of Schizophrenia

103

104 Pt is withdrawn, isolated, peculiar. Being disinterested, odd → loss of jobs friends. May think mystically or that they have special powers. IQ=wnl, but w/ cognitive deficits in memory attention, frontal lobe function. Previously dgx as borderline, antisocial or schizotypal. The first “breakdown” happens around 20yo.

Dissociative Disorders

105

Amnesia, Fugue, Dissociative Identity Disorder, Depersonalization Disorder

106

Dissociative Amnesia

107

108 Predominate feature is/are episode(s) where the pt can’t recall personal info usu of a traumatic or stressful nature that is too extensive to be explained by ordinary forgetfulness. Ssx cause marked distress/impairment socially/job/home Rule Out: Dissociative Fugue, DID, PTSD, Acute Stress, Nero insults, Drugs

Dissociative Fugue

109

110 Main thing is that the pt suddenly/unexpectdedly travels away from home/work w inability to recall his/her past; confusion about personal ID or assumption of a new ID. SSx must cause marked social/job impairment Rule out: DID, drugs or Gen.Med condition

Dissociative Identity Disorder

111

112 The presence of 2+ distinct ID’s/personalities which each have their own way of behaving (ego, superego, id). These personalities recurrently take control of the persons behavior. The pt cannot recall important personal info that is too extensieve to be explained by ordinary forgetfulness. Rule out: Drugs, Szrs, GenMedCond, Imaginary friends

Depersonalization Disorder

113

114 Pt feels recurrent feelins of detachment from his/her body/mental process (feeling like one is in a dream). Reality testing remains intact. The episode causes clinically marked social/job dysfx Rule out: Schizophr, Panic D/o, Acute Stress, other Dissoc D/o, Drugs, GenMed Cond(eg. temporal lobe szr)

Somatoform Disorders

115

116 Somatization, Hypochondriasis, Conversion, Pain, Body Dysmorphic, Somatoform NOS

Somatization

117

118 Dgx: All of the following: 1) Pain in ≥4 sites, 2) ≥1 Neuro ssx eg conversion or dissociation, 3) GU complaint, 4) ≥2 GI ssx. SSx must be present ≥30yo Hallmarks: ssx wax/wane; negative lab/clinical tests; comorbid w/ other psych probs; Epidemiology: F>>M; anxiety, irritability, impulse, depression and suicide are Hz; lower IQ and SES; relationship probs w/ chaotic lifestyle; hx of antisocial personality d/o or others; or w/ EtOHism, esp in M pts; R/O: variably presenting med cond’s – SLE, lymphoma, sarcoidosis etc; Tx: Management, many visits, gradually focusing on stressors; if meds=SSRI; tx other psych probs separately

Pain Disorder

119

Hallmarks: Pain from unk source; comorbid w/ anxiety d/o or depressive d/o; Appears suddenly usu after stress and disappear in a few days-years Epidemiology: 10% of pop Tx: encourage the pt to participate in life or antidepressants

120

Hypochondriasis

121

122 Dgx: convinced he has a serious med prob despite evidence to the contrary; insists on tests, txs; doctor shopping, is only happy when illness is confirmed; temporarily feels better but sx return in days-weeks Epidemiology: <5% of pop, M=F, begins in adolescents or middle age esp in elderly; frequent in schizophr, MDD, dysthymia or organic brain ssx Hallmarks: Sees lots of kinds of doctors but never psychiatrists; hyperalert to ssx and present them compulsively (that is they repeat the ssx, not dramatize them); this preoccupation w/ illness can  social disfx; can display anxiety or depression; Tx: None help but try tx underlying depression or psychosis, reassurance that the condition is not fatal, schedule frequent regular appts; try placebos or vitamins

Body Dysmorphic Disorder

123

124 Dgx: Epidemiology: usu young ppl w/ preoccupation w/ imagined physical defect usu on face  seeking surg intervention; Hallmarks: usu comorbid w/ MDD or OCD; may become a delusional or psychotic severity; DON’T DO SRGY cuz it won’t help, make things worse and possibly get u sued Tx: ?SSRI or clomipramine;

Conversion Disorder

125

126

Dgx: 1) Loss of neurological fx eg szr, blindness, paralysis, anosmia, vomiting 2) the dysfx  a 1º (relief of some kind of stress) or 2º gain (something that pt wants eg $$) Hallmarks: La Belle Indifference; ¼ of pts have organic probs eg szr; ssx are acute usu after stress; usu a hx of conversion; usu first seen as teen/20’s usu in ppl w/ antisocial or passive-aggressive personality d/o; associated w/ anxiety and depression, pts usu w/ narcissistic tendenciesusu in Fem Specific Conversions: Szr – The pt usu cries or LOLs during the szr, is aware and has muscle tone during ‘szr’ tx=sit the pt up; Unconsciousness – pt does not completely lose consciousness and stays aware of surroundings – VS, pain stimuli & DTRs are wnl – and makes purposefule movements; Paralysis – usu a hemiparesis inconsistent with neuroanatomy, DTR variable but pathological reflxs (babinski) are not present, paralyzed part resists force of gravity and has little Ω to passive movement, mvmnt can occur if pt is startled or hurt; Astasia-Abasia – pts dramatically fall but usu rarely are ever hurt by this; Sensory Changes; Blindnes – usu c/o blurry, 2x vision, tunnel loss or complete, behavior is usu inconsistent w/ reprted loss of vision Tx=Amobarbital to temporarily relieve the conversion. If no change in ssx: Then: not conversion; psychotherapy, supportive tx, R/O: Depression, Schiozophre; Amytal inj relieves ssx

Benzodiazepine

127

128

Uses: Hypnotic, anxiolytic, antidepressant, acute stress d/o, alcohol intoxication and withdrawal, amphetamine abuse, delirium, hallucinogen abuse, insomnia from narcolepsy, mania, panic d/o, PTSD, Schizophrenia, belligerent pts, anticonvulsant, muscle relaxant MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity PhKinetics: lipid soluble if non-ionic and vv, GI absorption, prot bound, metb by p450 or conjugation, [CSF]=[blood] SDFX: HA, NVD, blurry vision, drowsiness, ↓ motor, nightmare, abuse, hyperactivity, ↓ resp rate?resp acidosis, vasodilation C/I: COPD, obstr sleep apnea, ↓ stomach acid secretion, ?ppl w/ szrs? Examples: Alprazolam, Clonazepam, Diazepam, Lorazepam,

Alprazolam (Xanax; Niravam)

129

130 MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity; short t1/2 DOC: Acute anxiety attacks USES: Anxiety, agoraphobia, abuse & dependence, SDFX: somnolence, fatigue, confusion, coma, ↓ reflxs Withdrawal: Paranoia, Seizures, anxiety, agitation, psychosis, hallucinations, Misc: MUST TAPER

Diazepam Valium

131

MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity; long t1/2 DOC: Amphetamine abuse/withdrawal, LSD abuse/withdrawal, bad weed trip, PCP abuse/withdrawal USES: Amphetamine abuse/withdrawal, LSD abuse/withdrawal, bad weed trip, PCP abuse/withdrawal, status epileptcus SDFX: PhKintcs: OH-ylated

132

Lorazepam Ativan

133

MOA: helps GABA bind to GABAA (Cl channel)↑ Cl/ion flux ↓ neuronal activity; long t1/2, short onset DOC: Status Epilepticus; Acutely Violent patient USES: Anterograde Amnesia; 3rd line x akathisia (pacing, fidgety); BZD w/d; 3rd line x GAD SDFX: withdrawal; sedation, decreased concentration, PhKintcs:

134

Clonazepam Klonopin

135

Use: acute exacerbation of Panic Disorder +/- Agoraphobia; Flashbacks of PTSD MOA: increase GABA effects  more inhibition DOC: BZD w/d; 3rd line x Panic d/o; Trichotillomania

136

Generalized Anxiety Disorder General Anxiety Disorder GAD

137

Etiology: W>M esp in higher SES SSx: palpitations, perspiration, mydriasis, dizziness, trembling, diarrhea Misc: increased NE, Decreased GABA, Decreased 5HT Tx: BZD’s; Zolpidem, Bispirone; Venlafaxine Propanolol

138

Anorexia Nervosa

139

140 Dx: 1) Body wt >15W%below nl wt 2) Refusal to maintain body wt at nl levels 3) Amenorrhea x 3mos 4) Body image distortion where pt sees him/herself as obese despite being thin 5) Fear of gaining wt or becoming fat despite being underweight Ssx: BMI well below nl; Binge and Purge type; or Fast and Exercise type Tx: CBT, Amitriptyline Mortality rate is 20%

Citalopram Celexa SSRI

141

MOA: SSRI SDFX: Impotence, delayed ejaculation, decreased libido

142

GCS Eye Opening 1=none 2=to pain 3=to speech/command 4=spontaneous Verbal Response 1=None 2=incomprehensible 3=inappropriate words 4=confused 5=oriented Motor Response-best indication of prognosis 1=none

143

144 2=Decerebrate/extended 3=Decorticate/flexion 4=withdraw from pain 5=localizes pain 6=obeys commands Mild Head Injury 13-15 Moderate Head Inj 9-12 Severe Head Injury 8> Coma 8> Any change in GCS >2 requires a CT. Unequal pupil size is indicative of ↑ ICP. Monroe-Kelley Doctrine-For ICP to be maintained the volume of blood, CSF and brain in the head must be constant. If one changes then the others must compensate. Epidural Hematoma-outside dura but w/in skull. Lens shape on CT. Lucid interval.

145 Slow pupil rxn to light is indication of temporal herniation usu on same side of lxn. CO has 240x more affinity for Hg vs O2 → left shift of O2 curve (carboxyHg). t1/2 of COHg on 100% O2 is ≈ 40mins. Fluid (LR or Crystalloids) Requirements x burn pts >10kg = TBSA burned(%) x Wt (kg) x 4mL (Give 1/2 of total requirements in 1st 8 hours, then give 2nd half over next 16 hours of burn event). DO NOT USE colloids or NS. Urine OutPut should increase upon resuscitation. -Burn Rules of 9’s= Chest, Abdomen, 1 Arm, 1 Anterior Leg, 1 Posterior Leg, Upper back, Lower Back; ea is ≈ 9% of body surface area. Trauma -Shock Ssx=low BP, Tachycardia, Tachypnea -All trauma cases need Airway (do they have access for air to get to lungs) Breathing (can they breath on their own) and Cicrulation (stop bleeding, and resume normal BP c 2L NS; if doesn’t work then 1L blood; use 14G needles in the arms). ABC’s

146 -It’s OK to do ABC’s even tho u don’t know the status of other vital organs (eg spine) - Penetrating wounds to the chest can cause tension pneumo, cardiac tamponade, hemothrx c massive bleeding -DPL is used to find abd bleeds or perfs. -Spine trauma should be to log roll the patient with Cspine precautions until the pt is stable/sober so they can get spine films. -CT, U/S, DPL are other ways to examine abdomen. FAST can also be used but will miss retroperitoneal bleeds -Seat belt sign should prompt concern for ruptured bowel I II

Loss of 15%> 15-30% Loss

Classes of Hemorrhage Tachycardia, 3sec capillary refill time ≈ 10% loss, nml BP cool clammy skin, ↓ catecholamine lvls → ↑ peripheral vascΩ → ↑ Diast, ↓ pulse pressure, Tachycardia, Tachypnea,

147 III 30-40% Hypotension, more severe Tachycardia/Tachypnea, oliguria, Loss confusion/agitation IV >40% ↓ in systol BP, cold pale skin, ↓/no urine output, ↓ conciousness or Loss LOC, tachyca tachypn hypotension -In trauma, hemorrhage is the assumed cause of shock -Tx for adults in trauma shock is 1-2L bolus of NS -“shed blood”=blood at the scene -Blood at the external urethral meatus mandates a retrograde urethrogram from tip of urethra -Blood loss can go into the: thorax, abdomen, pelvis, thigh and head -Indications for Laparotomy: >500WBC cells/mm3; 10cc blood from syringe; >120K RBC/mm3; +bact (≈ bowel perf). -pts w LOC or altered GCS should receive head CT -IV bolus of ped’s=20cc/kg crystalloid Nml Urine Lvls <1 yo 2ml/min

148 1-18 1ml/min yo Adult 0.5ml/min -Old ppl, athletes, pts on β blockers (HTN meds), pregos usu experience class III hemorrhage bf getting hypotensive -Clots, Ca2+, ↑ Cells (tumors), and Contrast, show up as dense on CT -Compartment syndrome=Poikilothermia, Pallor, Pain, Paraesthesia, Pulselesness; Tx=remove whatever is causing problem (cast, burns/eschars etc) -Methylprednisone is used in spine trauma cases, also C-spine and serial vitals -Hypothermia is tx w/ heted blankets, (active external warming and warm lavage if going to ER) -Scrotal hematoma is indicative of pelvic fx -Amaurosis fugax (loss of vision in 1 eye) can be caused by dissecting carotid. -Internal pelvic fixation is the definitive tx x pelvic fxrs but if that isn’t available just wrap a sheet around it til you can get to a hospital.

149 -When ordering tests/imaging be sure to order the safer faster ones first (e.g. u/s bf endoscopy) -Tx x Coccidioides immitus is Amphotericin B -#1 Hospital infx=UTI via E. coli; #1 Ventilator infx → pneumonia -Pay attn to age and sex of pt bf deciding dgx (eg CHF is proly not likely in a young pt) -MI is a common problem s/p surgery. β blockers are cardioprotective s/p surgery x 2wks -Crystalloids → ↓ pee -DffDgx x young ♀ RLQ pain radiating to shoulder are: acute appy; tubo-ovarian abscess; ruptured ovarian cyst; perf ulcer; -Consumptive coagulopathy can → Thrombocytopenia → bleeding esp if much blood loss or transfusion cuz whole blood is not allowed thus lack platelets. -Perf bowel disseminates E. coli -Hematuria w/o blood at meatus requires CT of Abd/pelvis c/ triple contrast -Hypercalcemia DDx-CHIMPANZEES

150 Calcium xcess; Hyperparathyroidism; Immobility; Mets; Pagets; Addisons; Neoplasms; Excess vit A; Excess Vit D; Sarcoidosis -After injury to chest, EKG should follow chest tube if possible tamponade -Sigmoid Volvulous-LLQ pain, constipation, ?fever, abd distension, tender LLQ, distended bowel on KUB. Imaging should be Rigid Sigmoidoscopy. -Charcot’s Triad-Jaundice Fever ↑ T-Bili. Indicative of Cholangitis -DVT prophylaxis s/p surgery is 40mg LMWHeparin (Lovenox/Enoxaparin) -Crohns-Creeping fat on laparoscopy, inflamed ileus. If you start and appendectomy but you find other pathology, you STILL TAKE OUT the appendix and proly fix whatever else you can. -Elective Surgery should be postponed 6mos after MI -Meckel’s Diverticulum -Pain>exam=acute bowel ischemia/necrosis. [Base deficit is usu (-#)] Mesenteric Ischemia -“Food Fear” ≈ chronic mesenteric ischemia. [food fear + wt loss + post prandial pain].

-Screen w U/S -Tx = bypass graft or operative revascularization eg from Iliac aa. -Risk Factors x CMI: athersclerosis, old age

151

-Acute Mesenteric Ischemia caused by aa occlusion of Celiac or SMA. Usu no hx of chronic ssx. -This Is An Emergency! -Screen via Arteriography but leads to delay in tx. -Laparotomy=dusky to necrotic bowel, non-mobile Abdomen -CV disease can cause thrombosis and emboli anywhere in the body (e.g. cystic aa → GB necrosis) -NON-life threatening conditions encountered during srgy should be consulted after the elected operation is completed. DON’T take anything out, and don’t just give up.

152 -1st test to run are Labs (CBC, BMP, LFT’s etc); UNLESS there is overwhelming evidence of a defintive dx (e.g. ?CA in a pt w FamHx and +Ssx. -Hernia’s are usu NOT pulsatile. -Most common cause of SBO in pts w/ + PSH=adhesions -Esophageal varices can be due to splenic vv thrombosis. SSx hematemesis and esophageal varices on EGD. Fixed with splenic excision. -Steroid OD can be tx w VitA and… -Hepatic Adenoma-SSx Abd pain, L shoulder pain, syncope, PMH of OCP/BCP. Images=free fluid. ?↓ HnH -ITP is tx w splenectomy -Pancreatic Pseudocyst-Tx is to do a cystogastrostomy AFTER the cyst has grown >1cm -Most common cause of SBO in pts - PSH- =hernia -Distended loops of Small Intestine can be Adhesions or strictures. Tx is conservative (NPO, IV hydration, AB’s, and NG tube) if known cause. Or Ex Lap if unk cause

153 -Perforated Duodenal Ulcer-SSx Epigastric pain, +N, +EtOH, +Coffee/stimulants. Abd is tender, rigid. Tx= -Colovesicular Fistula-SSx Fever, Bacturemia, Dysuria. Imaging = sigmoid Diverticula via contrast CT, pneumobladder. Tx=IV ABs, cystogram -Colonic Ischemia-SSx +N/V, ↓ BP. Dgx via sigmoidoscopy → purple areas in sigmoid. Tx=IV ABs, Hydration, repeat sigmoidoscopy in 24hrs. (NOT enema) -Tx x Crohns flare up=IV fluids, BMP, CBC, CT. NOT invasive imaging (eg – oscopy’s) -Toxic Megacolon-SSx Bloody diarrhea, -AB’s use, crampy abd pain. Imaging=Dilated Colon. Tx= -Suspected liver condition should be tested with labs: CBC, LFT’s, CMP -Post Op complications of Lap Chole=biliary leak from cystic duct. SSx= RUQ pain, tender, ≈ tachy ↑ bili, nl Alk Phos and nl AST/ALT -Ischemic Bowel Tx=IV hydration, serum lactate, angiogram of suspected vessel (SMV, SMA eg).

154 -Definitive Tx x UC=Total colectomy and anal mucosectomy and ileoanal anastamosis. -Abdominal pain w/ nl blood labs should be followed with CT and/or HIDA biliary scan. DDx=Gastric malignancy or Gastric ulcer. - Dieulafoy ulcer=SSx ulcerative gastroenteritis due to ↑ steroid hormones. Dx via endoscopy. Tx=vagotomy and actrectomy -Antrum Ulcer is associated w/ H. pylori, CA, NSAIDs, & atrophic gastritis (NOT ↑ H+) -Duodenal Ulcers are associated w/ H. pylori, ↑ [H+], NSAIDs, M>F (NOT CA) -Gastrin should be checked if; pt has recurrent ulcers after srgy, has many ulcers or in weird areas, has ssx of endocrine adenomatosis syndrome. -Duodenum aa supply=Common hepatic -Duodenal ulcers are harder to tx and require 4 quadrant bx vs Gastric ulcers. (both usu require total gastrectomy, are equally malignant and occur in older pts M>F)

155 -Acute pancreatitis is most commonly due to Alcoholism and Biliary tract dss. rarely but pimpy via scorpion bites of pacific tropic ares. SSx=nl serum amylase, +N/V, ARDS, ↓ Ca2+, Abd TTP. Tx=broad spec ABs -↑ Amylase due to: perf’d PUD, Bowel Obstrx, Acute Chole’it is. (Pancreatic trauma will have ↑ amylase in ≈ 24 hrs) -Pancreatic CA SSx=painless jaundice; abdominal pain only, ie w/o jaundice; pain w/ jaundice. Dx=ERCP or Percutaneous Transhepatic Cholangiography. Tx=resection w or w/o histo evidence; <20% or pancreas or 5% or tumors are resectable; biliary stent to relieve jaundice/itching due to biliary salts; excision of head requires excision of duodenum. PreOp/PostOp Considerations -ADH postop → ↓ serum Na -Trauma fluids=0.9%NS @ 125cc/hr -SSx of blood transfusion rxn due to WBCs=nl BP, clear urine, fever/chills. -MI is a common risk PostOp.

156 -Narcotic analgesics can cause ↓ mental status eg demerol, morphine. -Patchy infiltrates sp trauma can indicate pulmonary contusion. SSx ↓ breath sounds, tachypnea. -Fever Wind POD1 Water POD3 Wound POD5 Walking POD1-7 Wonder Drugs POD1-7 -Superficial hematuria w/o blood via cystoscopy is proly urethral injury -Fistulas can occur bw vessels and biliary tract. SSx=icterus, hematemesis, ↓ BP, ↑ pulse -↑ gluc can → DKA → ↑ RR -Diffuse abd pain +fever, ↑ pulse, ↑ RR, -wound contmx, can be acute mesenteric ischemia -Metabolic Acidosis pH, PCO2, PO2, HCO3, BE,

157 -Respiratory Alkalosis pH, PCO2, PO2, HCO3, BE -Metabolic Alkalosis pH, PCO2, PO2, HCO3, BE -Respiratory Acidosis pH, PCO2, PO2, HCO3, BE -Thyroidectomy can → ↓Ca2+ → paraesthesias, Chvostek or Trosseau sign -Necrotizing Fasciitis causes by Strep is foul smelling and hot to the touch. Soft tissue infx via Clostr perf shows air in soft tissues, under skin and wound crepitance. -Srgy of GI tract should receive a PNC + AG. Pts who can’t take PO should take Vancomycin and Gentamycin cuz they are IV. -Homans sign pain in calf when ankle is slowly dorsiflexed while knee is bent, indicative of DVT. Image DVT via duplex U/S -Clindamycin covers G- bact -SOB sp trauma of chest (eg broken ribs) is proly due to pneumothorax -Long bone fx can → SOB via fat embolism syndrome ≈ 8hrs sp trauma. -SOB days sp MVC/trauma w/ tachy is pulmonary embolism -Septic Shock=Fever, ↑ WBC, tachycardia, met acidosis, neg BE, ↓ BP, ?patchy lung infiltrates

158 Thoracic/Vascular -A/V fistula SSx=?Hx of vasc srgy, ↓ exercise toler, edema, palp thrill. Dx=. Tx=. -Lung CA SSx=blood tinged sputum, wt loss, usu Hx of smoking, Dgx=X-ray, Chest CT, Bronchoscopy if nodes<1cm. Tx=. Rule out TB and other pathogens. -Spinal Ischemia SSx=↓ limb movement, Hx of aorta repair -Arterial Steal Phenomenon SSx=extremity pain/numbness, thrill, ↓ pulse on affected side, ?Hx of fistula or injury. Dx=. Tx=. -Amarugis Fugax should be investigated via Carotid duplex U/S c/ color flow doppler. -Renal aa stenosis should be investigated by labs, followed by U/S of kidneys. -Claudication SSx=pain while ambulation. Due to vascular spasm causing ischemia. Dgx clinical, ABIndex>.5, Usu obese, Hx +smoking. Tx=stop smoking, ↑ exercise, ↓ wt, pentoxifylline, noninvasive vasc tests. -Boerhave Syndrome SSx=CP, vomiting, ?↓ lung sounds, ↓VS, Hx +EtOH. Dx=.incr amylase of pleural effusion, widened mediastinum Tx=.

159

-PeriOp MI risk is best tested w/ Myoview stress test -Symptomatic AAA should be managed via blood type/cross and srgy consult. -Suspicion of vascular insuffx should be managed via Duplex US, of aa and vv. -Pneumothorax –Hx trauma is usu due to pulmonary blebs. -Packed Red Blood Cells (PRBC)-Administer when pt is anemic, c active bleeding -Fresh Frozen Plasma-contains clotting factors and plasma proteins. Used to reverse coagulopathy eg to lower INR in a pt taking warfarin -Cryoprecipitate-Clotting factor rich product used in coagulopathy pts that are sensitive to volume -Platelet Transfusion-Plasmapherisis-Process of removing pts plasma and replacing it c IV fluid. Done when a destructive subs (eg Ig) is in pts body. Used eg in

Pancreatic Pseudocyst

160

161 What is it? encapsulated fluid w ↑ pancreatic enzx usu near/in pancr or somewhere in abd. Walls=inflx fibrosis of connective tiss. Does not have epith lining. Hx of acute pancreatitis. SSx: Epigastric mass and pain, fever, wt loss,↑WBC, ?jaunice, Failure to recover >1wk tx of acute pancrx. Palpable tender mass including surrounding tissues (phlegmon) Dx: CT or US x f/u, ↑ amylase, ↑bili, Tx: Excision, or anastamosis to duo or stomach after it has ‘matured’.

Acute Pancreatitis

162

163 Usu caused by alcohol abuse, gall stones, or scorpion bites (or trauma) SSx: Acute upper abd pain sp large meal, N/V, dehydration, ↑pulse, ?↓BP. ↓BS, blue/gray discoloration if bleeding Dgx: ↑amylase esp if EtOH, usu nl CMP, ↑lipase esp if biliary, ↑urine amylase, ↓Ca2+. KUB shows sentinel loop (isolated dilation) of large or small bowel near pancr, glandular calcification, CXR might show L pleural effusion Tx: ↓secretions and correct serum lvls (Ca2+, Mg2+, CBC), gastric suxn, CT if not resolved >2 days, ABs if severe (Imipenem ), O2 x insidious hypoxemia DDx: acute chole, perf’d PUD, upper SBO, acute appy, mesenteric infarx. Can cause ARDS secondary to acute pancreatitis.

Ransons Criteria For Pancreatitis Severity Criteria Present Initially Age>55yo WBC>16K/µL gluc>200mg/dL LDH>350IU/L AST.250IU/dL Critereia Developing w/in 24hrs Hct ↓ >10% BUN ↑ >8mg/dL Serum Ca2+ <8mg/dL aaPO2 <60mmHg BE >4meg/L ??? est free fluid >6L 0-2 criteria=2% mortx; 3-4 criteria=15% mortalx; 5-6 criteria=40% mortalx; 7+ criteria=100% mortalx

164

I

Loss of 15%> II 15-30% Loss III 30-40% Loss IV >40% Loss

Classes of Hemorrhage Tachycardia, 3sec capillary refill time ≈ 10% loss, nml BP

165

cool clammy skin, ↓ catecholamine lvls → ↑ peripheral vascΩ → ↑ Diast, ↓ pulse pressure, Tachycardia, Tachypnea, Hypotension, more severe Tachycardia/Tachypnea, oliguria, confusion/agitation ↓ in systol BP, cold pale skin, ↓/no urine output, ↓ conciousness or LOC, tachyca tachypn hypotension

166 TPN bypasses the GI Tract which bypasses stimulation of the GI hormones b/c there are no nutrients in the GI tract. Without this stimulation bile stays in the gall bladder causing pain and predisposes to gall stones.

Appendicitis

167

168 SSx: Achy epigastric pain evolving to RLQ sharp pain TTP and ambulation. NV, anorexia, indigestion, +rebound tenderness. Dx: ↑WBC w/ neutrophilia, +/- hematuria. CT/Imaging shows weird stuff on RLQ eg free air/fluid, ↑tiss density, calculus (R psoas shadow), fat stranding. Tx: appendectomy Complications: Perf from late dx → ↑ % infertility in fems, peritonitis if gangrenous →toxicity distension and adynamic ileus. DDx: PID, tubo-ovarian torsion

Crohn’s “Regional Enteritis”

169

170 Chronic progressive granulomatous inflmx dss aaprox 90/100K ppl suffer, esp 40yo’s. Path: Usu involves distal ileum and colon but can involve entire GI tract (mouthanus). Can also have skin lesions. SSx: Diarrhea, neg hematochezia, postprandial colicky pains relieved by pooping, wt loss, malaise, chronic anal fissures, cobblestone-ing ulcers, malnutruition Dx: ?↑sed rate, ↓ albumin, anemia, steatorrhea. Barium test  string sign, thickened bowel wall, ulcers; Non-caseating granulomas, skip lesions, cobblestone appearance, fistulas, fissures and anal disease. Tx: rest, ↓ stress, eliminate dairy, ↑ prot. Steroids, sulfasalazine, aminosalicylates, mercaptopurine. Surgery if obstrx, perf, internal or external fistula, abscess, perianal dss or developmental failure. Complxs: fistulas, abscess, pain, hepatobiliary dss, uveitis, arthritis, ankylosing spondylitis, aphtous ulcers, thromboembolism, GU complxs.

Gastric Cancer

171

172

incidence≈ 20K/yr. (10/100K). Main cause ?H. pylorichronic atrophic gastritisgastric adenoCA. ↑[Ab’s]H. pylori α ↑risk gastricCA. Also ↑starches/↓fruits n veggies in diet ≈ ↑%x gastricCA. Parts involved=body or antrum. SSx: Postprandial heaviness becoming more Hz and longer. Anorexia, wt loss, coffeeground emesis, dysphagia. Epigastric mass on PE, +guaiac, Virchow node (palpable supraclavicular lymph node), anemia, +CEA. Bx of >6 brush samples during gastroscopy to be useful. Gastrectomy shows rolled up margins. Tx: Surgical resection. ≈ ½ are curable. Complxs: Krukenberg (ovary) tumor, Blumer (anal) shelf, mets to lung, liver, brain or bone. Types: 1) Ulcerative CA-Deep penetrating ulcer possibly involving adjacent organs. Kinda looks like benign ulcers. 2) Polypoid CA-Large bulky intraluminal growths which mets later. 3) Superficial Spreading CA/Early Gastric CA is confined to mucosa and submucosa; 1/3 mets; good prognx if gastrectomy. 4) Spreading tumor involving all layers w/ marked desmoplastic rxn  ↓pliability and leather like consistency. Bad prognx. 5) Advanced CAAdvanced stages of the previous mentioned classes.

Ulcerative Colitis “Idiopathic Mucosal Ulcerative Colitis”

173

174

Onset age has bimodal distribution. Jews esp. SSx: Rectal bleeding, Diarrhea, watery purulent bloody stool usu w/ tenesmus (spasm) or anal incontinence. ?Fever, cramping, abd pain, vomiting or wt loss? Aggravated by dairy. Onset is variable and progressive. ?LLQ tenderness, anal fissures and tenderness, blood on rectal exam. UC is Confined to the Colon esp rectum c no cobblestone appearance. Dx: Sigmoidoscopy shows granular dull hyperemic and friable mucosa. Oozing blood on contact. Mucosa is purple/red/velvety, NO skip lesions. Anemia, leukocytosis, ↑ sed rate, hypoalbuminemia, dehydration, ↓BMP and vits, steatorrhea. Must rule out bact/parasites. KUB can show megacolon, lead pipe appearance (lack of haustra). DON’T DO Colonoscopy or Barium Enema. DDx: CA/lymphoma, diverticulosis, salmonellosis, dysentery, shigellosis, campylobacter jejuni, E coli, amebiasis, TB. Complxs: skin/mucous lesions, erythema nodosum, erythema multiforme, pyederma gangrenosum, dermatitis, uveitits, spondylitis, OA, hep/bili/pancr lesions, cirrhosis, anemia, malnutrition, pericarditis, colon perf, toxic megacolon, massive hemorrhage, strictures, Colon/rectal CA@ ≈ 10yrs Tx: qs Mesalamine x maintenance. Total colectomy w ileal anastamosis if chronic, or megacolon does not resolve in 24hrs, or ≈10yrs to avoid colon CA.

175 Urinary Tract Fistulas Vesicovaginal, Ureterovaginal, Urethrovaginal

176 Due to injury to urinary tract (eg during labor) or ischemic necrosis following radiation tx x CA SSx: Constant urinary leakage can be seen in vagina. ureto/vesico-vag fistulas are usu at the ‘vault’ closure; urethra-vag fistulas are usu @ anterior wall. DDx: Cytoscopy or xray can see the os. Sometimes complicated os’s exist. Tx: Srgy, self limiting, skin excoriation x UTIs; Ureterovaginal fists are fixed vaiureteroureterostomy or ureteroneocystostomy. Must maintain bladder pressure postop; Radiation fists usu require new blood supply eg from gracilis.

Recto/Sigmoido-Vaginal Fistulas

177

178 Usu due to Ob/Gyn injury, srgy probs, cervical CA, radiation, IBD or diverticulitis. SSx: Flatus incontinence, feces thru vagina, fould vaginal discharge w/(o) blood. Os can be seen on vag exam, or DRE Dx: Colonoscopy or retrograde dye studies. Tx: Fix edema/inflmx, low residue diet, ABxthen: diverting colostomy if proximal. NO SRGY if: Crohns, no response to mx management, CA

Zollinger-Ellisoin Syndrome

179

180 SSx: PUD, diarrhea, steatorrhea, relief from high dose PPI or H2 blockers, hemorrhage, perf, obstrx. Dx: ↑gastrinserum (>500pg/mL), antacid mx can cause rebound ↑gastrin  worse ssx. If mildly elevated: Then: secretin provocative test ↑gastrin>150pg/mL in 15mins. Upper GI seriesulcers in duodenal bulb to prox jejunum, dilated duodenum w hyperactive perstalsis; somatostatin receptor scintography locates the gastrinoma and mets. Ulcers in ectopic locations is pathognemnonic x ZES. Tx: H2 blockers x acid prodx. Gastrinomaectomy w streptozocin 5-FU, and Doxorubicin x CA. Complications: Metsdeath

Gastric Ulcer Classes

181

182 Type I: Most common. Usu older vs duod ulcer pts. Nl acid prodx. Usu 2cm distal in the pyloric area in the lesser curvature near incisura angularis. Type II: Prepyloric ulcers, usu associated w/ duodenal ulcers. low%xCA. acid secretion≈ duodenal ulcer Type III: In the Antrum due to NSAID use. Must differentiate bw benign vs malignant ulcer

Gastric Ulcers

183

184 SSx: Epigastric pain exacerbated by eating. Dx: Gastroscopy shows flat edges. 6 marginal bx sections. upper GI XRulcer usu on lesser curvature near pylorus. Malignant if: shallow ulcer, +meniscus sign (radiolucency around ulcer), ulcer>2cm. Rule out H. pylori. Complications: Bleeding, obstrx, perf Tx: Stop NSAIDs, endoscopy to track healing, H2 blockers, Omeprazole Amoxicillin or Clarithromycin Metronidazole if H. pylori

Mallory Weiss Syndrome

185

186 10% of UGI bleeds. 1-4cm longitudinal tear thru submucosa (not sm muscle). Usu associated w hiatal hernia. Appears after severe retching or CPR. Sequence: Vomit foodretchingbloody vomit Tx: Ice water lavage, e-cauterage. Srgy if bleeding doesn’t stop (high/proximal gastrotomy. Good prognosis

Small Bowel Obstruction (SBO) Simple vs. Strangulation

187

188

1. Mechanical/physical obstrx. 2. Parlytic Ileus-neurogenic failure. Etiology-a. Adhesions is most common cause. b. Neoplasms of the lumenintussusceptionchronic anemia; masses @ ileocecal jx can also present as SBO. c. Hernia eg into obturator foramen, or surgical defects. d. Volvulus e. Intussusception f. Foreign bodies eg swallowing toys g. Gallstone ileus gallstones can pass via GB/SB fistula. h. IBDobstrx inflmx i. Stricture due to ischemia j. Cystic Fibrosis k. Hematoma eg from anticoagulants SSx: I. Simple Emesis, upper abd discomfort, crescendo-decrescendo diffuse pain. The more distal the obstrx the ↑%x feculent emesis, ?obstipation, dehydration, ↑pitched ‘tinkles’ on auscultation. nl DRE. II. Strangulation Shock, fever, severe abd cramping, emesis w gross/occult blood. Dx: I. Simple Concentrated BMP, ↑amylase, Dilated loops in a ladder like pattern w airfluid lvls. Gas is absent in colon. II. Free fluid bw loops of dilated bowel indicate perf Tx: Decompression via NG tube. Correct any e-lyte imbalances prior to srgy. Srgy if >3days obstrx or complete obstrx. Complx: death following seemingly successful srgy

Thoracic Empyema

189

190 Pus in the pleural cavity usu thick and malodorous; usu due to srgy or suppurative lung dss or trauma. Starts as Acute Exudative is sterile fluid, low LDH, and glucFibrinopurulent is thicker, whiter, ↓gluc and pH and ↑LDH causing fibrin deposition causing trapping of the empyema and also the lung. Usu caused by Staphylcoccus, Bacteroides or Peptococcus, Fusobacterium, E coli, Pseudomonas… SSx: Random-Fever CP, chest discomfort, anemia, tachycardia/pnea, ↓breath sounds dull to percussion, pulmonary osteoarthropathy. Dx: CXR’D’ shaped density, shifted mediastinum away from affected side. Bronchoscopy to r/o bronchial obstrx. CT or US to r/o abscess. Thoracocentesispus Tx: 1o Abx x infx, removal of purulent material and sterilization, fix underlying dss. 2o Open drainage, re-thoracocentesis. Add fibrinolytic enzx. *Pts w/ cont sepsis, are inadequately drained, or need long-term tube drainage should have open drainage ≈14 days sp closed tube drainage to ↓lung collapse and max pleurae fusion.

Pleural Effusions

191

192 Can be caused by Hydrothorax, CV Dss, Empyema, Hemothorax or Chylothorax Dx: CXR usu shows mediastinum shift to affected side; decreased breath sounds, decreased tactile fremitus, decreased transmitted airway sounds Tx: Thoracocentisis.

Abscess

193

194 A circumscribed collection of purulent exudate frequently associated with swelling and other signs of inflammation. A cavity formed by liquefactive necrosis within solid tissue. Acute<6mos Chronic>6mos

Superior Vena Cava Syndrome

195

196 M>F usu caused by lung CA tumors, thymoma, or breast SSx: Nasal congestion, edema in the upper half of body, cyanosis or purple skin. NV, dizziness, change in vision, drowsiness, stupor, & convulsions, cough, hoarseness, dyspnea due to bronchio/tracheal edema, usu exacerbated by lying down or bends over. Long standing dss canesophageal varices. Dgx: Upper extremity pressure ≈ 200-500mmH2O; venography. CXR shows impinging mass. Tx: Diuretics, avoid hydration and lines, head elevation, radiation tx x tumor, fibrinolytics. Improvement w/in 10 days, Complx: fatal cerebral edema w/in mins, anticoagulants can cause brain rehemorrhage. Good progx

Esophageal Perforations

197

198 THIS IS AN EMERGENCY Hx of recent instrumentation in the esophagus or sp emesis. Cricopharyngeal perfs due to instruments are most common or near tracheal impingement. Caused by: instruments, Boerhaaves. SSx: Pain in: Chest, epigastric, or neck; signs of mediastinal or thoracic sepsis <24hrs. Dx: Esophageal leak via, Hammans sign (mediastinal crunch), CXRair in soft tissues, widening of mediastinum, ant displacement of trachea, pleural effusion w/ (o) pneumothx, esophagram w/ contrast then barium (if contrast=0) Tx: Abx, srgy <24hrs, Complx: Esophageal infx if not fixed fast, communication w pleural cavity. Prognosis is 90% if srgy <24hrs or 50% if >24 hrs.

Lung Abscess

199

200 1o abscesses due to aspiration of S aureus or K pneumo or fungi. 2o due to CA, bronch obstrx, mediastinal LAD, or infx spread. SSx: Cough, fever, SOB, pleuritic CP; malaise & wt loss if chronic; insidious; lobar consolidation Dx: CMP x diff, sputum cx, CXR, bronchoscopy if idiopathic, FNA Cx Tx: Abx (PNC+Clinda; Bactirim, AmphoB, or Erythromycin if immunocmprsd) x 5mos, good hygiene; percutaneous drainage if complex (eg >4cm). Prognx is good as long as pts don’t end up in ICU.

Duodenal Ulcer

201

202 M>W. Due to H. pylori infx 90%; NSAIDs 10%; sometimes ZES SSx: Epigastric pain relieved by eating, TTP, nl-↑acid secretion; back pain when pancreas is involved; +/- NV Dx: upper KUBduodenal deformities; Endoscopy x UGI bleeds or obstrx; basal acid output, serum gastrin. Tx: H2 blockers, Abx x H. pylori; Vagotomy, (gastrojujenostomy) Distal gastrectomy anastomosed to the duod (Bilroth I) or proximal jejunum (bilroth II); Subtotal gastrectomy (3/4 of distal stomach) Complx: Dumping syndrome-combo of palpitationssweating, wkness, dyspnea, flushing, nausea, abd cramp, belching, V/D; alkaline gastritis, anemia; post vagotomy diarrhea, chronic gastroparesis

Paraesophageal Hiatal Hernia

203

Part of stomach herniates thru diaphragmair bubble displacement and pressure phenomenon. SSx: burping, snese of pressure in lower chest after eating Tx: Srgical fix w suture to esophagus.

204

Sliding Esophageal Hernia

205

GE jx herniates up diaphragmGERDadenocarcinoma; Aspiration canpneumonia. SSx: Acid reflux while laying down, burping Dx: Upper GI series shows sliding hiatal hernia. Bxevidence of esophagitis; ↓ LES resting pressure; ↑acid prodx. Tx: None if assx; No late meals, no lying down after meals, elevate bed head, frequent sm meals; H2 blockers; Srgy x pts who are resistant to Rx via Nissen fundiplication

206

Umbilical Hernia

207

208

Primary Amenorrhea

209

FSHE2 (stimulates endometrial hypertrophy) at first then Prog by dominant follicle after ovulation

210

Primary: No period >16yo Causes: E2 defx (pale vaginal mucosa, lack rugal folds), Turner Syndrome (short, webbed neck, gonadal dysgenesis), PCOS (hirsutism, obesity, acanthosis, irregular), Kallman Syndrome (agenesis of olfactory bulbsno GnRH neurons), hormonal, congenital, chromosomal (no breasts, no uterus). Anatomic (usu have 2º sex characteristics). “Testicular Feminiziation” (have 2º sex characteristics). Gonadal Dysfx or HoTH(have uterus, no breasts),

Secondary Amenorrhea

211

FSHE2 (stimulates endometrial hypertrophy) at first then Prog by dominant follicle after ovulation

212

Secondary: No period >6months after previously having 6 regular cycles or 12 irregular cycles Causes: Pregnancy. Tumor (hyperprolactinemia, androgenic dysfx). Stress, chronic infx, systemic illness, anorexia, weight loss and too much exercise can inhibit HoTH. Thyroid dysfx (palpitations, fatigue). PCOS (irregular, hirsutism, ↑LH or LH:FSH=2.5) (-)β PL, TSH. If PL, TSH nlProg challenge test. If bleeding <1week after progesterone=HoTH, pit, ovarian, uterus are fxing=no ovulation or PCOS. No bleeding=↓E2 or anatomic abnlcheck FSH lvls. ↑FSH=ovarian dysfx. ↓/nl FSHhead CT. Outlet obstrx tx=Prog/E2 If Testosterone>200mg/dL or DHEA>7mg/dLCT to r/o adrenal/androgen stuff

Aortic Dissection

213

214 SSx: Tearing chest pain in the “back of the chest” or the back Dgx: CXR=widened mediastinum, discreprancy bw pulse:BP and BP of arms. CT shows double lumen aorta. EKG can be nl. Diastolic murmur of aortic regurg; HTN; hypotension can occur if tear extends into coronary aa or pericardium  impaired cardiac fx; If Trauma &/or coumadin/warfarin then suspect mediastinal hemorrhage Tx: IV β blockers to reduce BP& pulse, or vasodilators (NO), Ca channel blockers, or ACE-I’s. Radial aa cath to monitor BP F/U: CT <7days to r.o. re-expansion Management: Hx, physical, TEE,CT, ECG, Cardiac Enzx

Unstable Angina

215

SSx: Chest pain or pressure type discomfort, radiating to hand or jaw, pain alleviated by rest or decreasing O2 demand. Dgx: EKG (ST seg elevation/depression and/or T-wave inversion; MI have this PLUS elevated CK-MB Troponins), CXR, CBC, CK-MB, Troponin-T & I, electrolytes, Renal fx, PT, PTT, INR, glucose Tx: Immediate tx=EKG, CXR, MONA and antithrombotic. Morphine, O2, NO, Aspirin, β-Blocker, Glycoprotein IIb/IIIa inhibitors (MONA β Gentle). ACE-I’s reduce immediate mortality, and stop ventricular remodeling. Causes: Atherosclerosis, coronary spasm, cocaine, endocarditisembolus, Monitor: O2 sats. After dgx/tx do LFT’s, Mg, homocystein, UA & tox screen, myoglobin. Then tx CAD if applicapble Risk Factors: Hx or Fam hx of CAD, HTN, tobacco, obesity

216

Congestive Heart Failure CHF

217

218 Systolic: Dilated ventricle failure, increased TPR, decreased CO, increased LVEDV SSx: Dyspnea on exertion, paroxysmal nocturnal dyspnea, night cough, S3 gallop, pulmonary edema, pleural effusion, JVD, tachycardia, cardiomegaly, cyanosis, oliguria, nocturia, peripheral edema, wt loss, Cheyne-Stokes Respiration, pink frothy sputum, weakness, lightheadedness, wheezing. Hx of HTN, CAD, smoking. Dgx: Echo (decreased EF, valvular stenosis, regurgitation), CXR (cephalization, pulmonary edema/perihilar infiltrates, cardiomegaly, chamber enlargement), EKG, increased BNP (Brain/B-type Natriuretic Peptide). Check CBC, LFT, renal fx, cardiac enzx. Can be precipitated by infx or anemia. HypoNa=(-) prognosis Tx: Furosemide/loop diuretics (reduces fluid overload and causes bronchial vasculature vasodilation), ACE-I’s (ARB’s if cough, prego, hypotension, hyperkalemia, renal probs), β Blockers (only outpatient), O2, IV access Diastolic: can’t contract, relax or fill Risk Factors: >50yo, Hx of HTN, CAD, heavy alcohol abuse, smoking, Ca++ channel blockers, Amyloidosis

Palpitations

219

220 Work-Up: EKG, CBC, TSH, CMP, DDx: A-fib. A flutter-Saw tooth pattern on EKG due to re-entry, variable AV node conduction and 2:1 condu hyper/hypothyroidism, DM, MI, hyperadrenalism, substance abuse (caffeine, cocaine, fen-phen), anemia, hyperK+ familial long QT syndrome, mitral valve prolapse, wolf Parkinson white (δ waves), sick sinus syndrome. Tx: SVT-IV adenosine, β blockers, Ca++ channel blockers, digoxin, carotid massage. A Fib-warfarin, β blockers. V Tach-Defribillation, Pacemaker. PSVT-Cold water to suppress AV Node Deadly: Long Q-T ssx (syncope, QTc>470ms). Hypertrophic Cardiomyopathy (kids, chest pain, syncope, palps, murmur on valsalva) dgx w ECG.

Mitral Valve Stenosis

221

222 → an increased risk of stroke bc calcific nodules provide a Most Common Cause: Rheumatic Heart Disease (migratory polyarthiritis, carditis, subQ nodules, erythema marginatum, Sydenham chorea) decades earlier from Gp A Strep. SSx: Dilated Left atrium, mural thrombi, Right ventricular hypertrophy, a fib, pancarditis. Opening snap. Capillary pulse (alternating reddening/blanching of capillary area due to arteriolar dilation). Loud S1. Mid diastolic rumbling/murmur at at apex. Decreased atrial kick; L main stem bronchus is pushed upward/elevated Dgx: Aschoff bodies (swollen eosinophilic collagen, T cells, swollen MΦ[Anitschkow cells/caterpillar], enlarged multinucleated MΦs aka Aschoff giant cells Tx: Surgery

Aortic Stenosis

223

224 Most common of valv abnl. Usu due to old age/wear n tear. Rheumatic Aortic Stenosis is ~10%. SSx: BP >200, Angina. CHF. Syncope. Systolic Murmur at the right sternal border ? radiating to carotids. Aortic Stenosis in a young person is usually due to a Bicuspid Valve which → ↑ myocardial O2 demand. Path: Hypertrophied ventr myocard becomes ischemic due to decreased blood flow. Causes CHF Tx: Sgx

Mitral Valve Prolapse

225

226 most often young women. Valves are big and thin, the tendinous cords can be long and thin too. Concurrent tricuspid prolapse is common. Increased risk for infective endocarditis Path: Annular dilation, no fusion of leaflets, thin cords, ?congential/systemic defect, so common in Marfan’s. SSx: incidental find MID SYSTOLIC CLICK, usu seen on ECG, ?Systemic connective tissue probs, possibly: angina, dyspnea, psych probs, holosystolic murmur. Dgx: ECG, left sided ventr enlargement, holosystolic murmur. Murmur disappears with squatting/increased preload. Complxs: mitral insuffx requiring surgery, increased risk of infective endocarditis, stroke from emboli, fatal ventr and atrial arrhythmias

Infective Endocarditis

227

228 Acute IE starts and causes death w/in a few days by high virulence organisms Subacute IE affects abnl heart on previously deformed valves and are Path: mostly bacterial, hx of mitral valve prolapse SSx: FEVER, murmur on the L, fatigue, wt loss, flu like ssx, ?:petechiae, red streaks of the nail bed (hemorrhages) Acute-necrotizing, ulcerative invasive valve infx. Subacute- Strep viridans, Dgx: hx of RHD, mitral valve prolapse, Tx: Abx for tx and for prevention bf dental, surgical, invasive procedures Risk Factors: IV drug abuse predisposing to staph aureus, hx of RHD, prosthetic valves, oral bacteria (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella [HACEK]), Prosthetic Valve (staph epidermidis), Dental srgx,

Tetralogy of Fallot

229

VSD Pulmonis Stenosis Overriding aorta RVH SSx: Cyanosis

230

Hypertension HTN

231

Parathyroid Gland Disease-kidney STONES, BONES ache with hypercalcemia, GROANS of GI ssx, and PYSCHiatric Overtones

232

Myocardial Infarction MI

233

SSx: ST segment elevations, inverted T waves, S4, ?NV,?Sweating Reasons: Coronary aa occlusion, CAD from DM hyperlipidemia, Cocaine Tx: Restore Coronary Blood Flow!, MONA β G. Cocaine-BZDs, ASA, NO, α blockers (phentolamine). Post MI: ACE-I’s if low EF. β-blockers if nl EF Death is caused by cmplx ventricular arrhythmia, reentry. Ventricular free wall rupture can occur during remodeling (ssx=pulseless electrical activity/PEA, pericardial tamponade, hypotension, sinus tachycardia; Tx-percardiocentesis)

234

Double Aortic Arch

235

236 SSx: child wheezing not responding to steroids or bronchodilators. Ssx worse while supine, alleviated by neck extension. Dgx: Vascular ring occluding neck airway Tx: Surgery

Premature ventricular Complexes PVC

237

SSx: QRS >120ms, bizarre morphology, compensatory pause (dropped beat?) Tx: Observation if assx. β-blockers if +ssx

238

Pericardial Effusion

239

SSx: Distant heart sounds, non palpable PMI Dgx: CXR may appear as an enlarged globular appearing cardiac shadow “water bottle” shape.

240

Pericardial Effusion

241

SSx: Alternating QRS amplitude ( Hx: viral URI Dgx: Electrical Alternans on EKG-varying QRS amp’s from beat to beat

242

Amiodarone SDFX

243

244 Pulmonary toxicity eg lipoid pneumonia Thyroid dysfx-Hypothyroidism in 85% and HypeRthyroidism in 15% so check TSH q3-4mos Hepatotoxicity-AST/ALT elevations, assx, benign if <2x increase Corneal Deposits-caused by secretion by the lacrimal gland. Benign Skin changes-blue-gray skind discoloration esp in the face

Stable Angina Exertional Angina Angina of Exertion

245

Tx: β blocker x HTN if isolated. NO to control ssx

246

Grave Disease

247

248 SSx: fatigue, wt loss, LID LAG, tremor Path: Toxic Goiter hyperthyroidism caused by increased β receptor sensitivity to sympathetic stimuli Tx: Propanolol to control A fib and other hyperthyroid ssx.

Beta (β) Blockers

249

DOC: SDFX: vasoconstriction

250

Atroventricular Fistula AV Fistula

251

252 Path: high output cardiac failure by shunting blood from aa to vv side increasing cardiac preload SSx:

Prinzmetal Angina Variant Angina

253

SSx: young F, smoking nighttime chest pain not associated with exertion, ST elevations on ECG Tx: eliminate risk factors, Ca Ch blockers, NO Path: coronary vasospasm

254

Ascites

255

Most common cause is hepatic cirrhosis. HepatoSplenomegaly is strongly suggestive of Hep. Risk Factors: Hep, risk factors for hep

256

Wolf Parkinson White

257

258 Tx: Cardioversion, Procainamide Path: Accessory electrical pathway conducts depolarization directly from atria to ventricles

1st Degree Heart Block First Degree AV Block

259

Tx: Observation if no other ssx, stop offending drugs eg digitalis,

260

Hydorchlorothiazide

261

SDFX: Hyperglycemia, Hpyokalemia

262

Vasovagal Syncope Neurocardiogenic Syncope

263

264 Common in women. SSx: Nausea. Sweating, Tachycardia. Pallor. Warm feeling. Usu in response to pain, stress, strong emotions, peeing, pooping Dgx: Upright Tilt table testing

Statins HMG CoA Reductase Inhibitors

265

266 MOA: HMG CoA Reductase inhibitors → ↓ mevalonate → ↓ dolichol and CoQ10 → myopathy. SDFX: Myonecrosis

Pericarditis

267

SSx: chest pain worse with inspiration, alleviated on leaning forward; Dressler syndrome: recurrent pericarditis s/p acute MI; EKG shows diffuse ST elevation everywhere except in aVR Tx: NSAIDS

268

Digoxin

269

270 SDFX: NVD, blurry yellow vision, arrhythmias. Scooped ST segments, prolonged PR intervals, short QT intervals, T wave inversion. Renal failure, hypokalemia exacerbate dig toxicity. Monitor dig lvls closely

Hypertrophic Cardiomyopathy

271

272 SSx: heart murmur at the left lower sternal border that decreases with an increase in preload/squatting Autosomal Dom

Acute Respiratory Distress Disorder Adult Respiratory Distress Disorder ARDS Non-Cardiogenic Pulmonary Edema

273

274 Path: Release of inflammatory mediators due to local tissue injuryalveolar damageincreased alveolar capillary permeabilityleakage protein-aceous fluid into alveoli from capillaries SSx: Acute onsetPaO2/FIo2<200, CXR=bilateral infiltrates. Absent JVD. Absent Cardiomegaly, Sepsis; Diffuse injury to the pulmonary capillary endothelium and alveolar epithelium leakage of protein rich fluid into alveolar and interstitial spacehyaline membr  alveolar collapse and decreased pulmonary gas exchange Dgx: ABG-Hypoxia, hypercapnia, Respiratory acidosis; nl PaCO2; Pulmonary Capillary Wedge Pressure<18mmHg Tx: PEEP and increased FiO2; NOT Responsive to O2; Maintain PaO2>60 Tidal volume and RespRate affecte pulmonary minute ventilation which affect PaCO2.

Benign Essential Tremor

275

276 SSx: Postural Tremor alleviated by alcohol. May affect head, hands, arms, eyelids, voice, disappear during sleep. Tx: Propanolol

Chest Pain

277

If it’s not angina, and only precipitated by emotional stressors. The chest pain is likely psychosocial and just needs reassurance.

278

Pulsus Paradoxus

279

280 An abnl drop in systolic pressure with inspiration. The result of increased vv return to heart during inspiration impeding L ventricular filling. Dgx: Tamponade. Pericardial effusion. Tension pneumo. Asthma (caused by very elevated intrathoracic pressures during inhalation exacerbating the L ventr compresión) Tx: tx underlying condition

Asbestosis

281

Etiology: Non smokers with progressive dyspnea who work in shipyards or something like that SSx: Dyspnea w/o cought or sputum. Dgx: CXR=Lower Lung Field abnl’s like pulmonary fibrosis or pleural plaques. Consequences: Bronchogenic Carcinoma; Mesothelioma

282

Atypical Pneumonia

283

SSx: Dry cough, HA, sore throat, skin rash Bugs: Mycoplasma pneumoniae, Chlamydia pneumoniae, legionella, Coxiella, Influenza, Pnemocystis jirovici Etiology: Old; Immunocompromised

284

Blastomycosis

285

SSx: Low fever, night sweats, Productive Cough, wt loss, lytic bone lesions skin involvement; Where: Mississippi, Ohio, Wisconsin, Great lakes. Dgx CXR looks like TB

286

Flail Chest

287

What: Broken ribs that are still attached to the pleural connective tissue SSx: Positive Pressure Mechanical Ventilation correct paradoxical thoracic wall movement, tachypnea. Shallow breathing due to pain, hyperventilation; Inward motion of affected side

288

Deep Vein Thrombosis DVT

289

290 Tx: Acute Anticoagulation and Clot Stabilization-Heparin so that INR is 2.0-3.0; Long Term Anticoagulation-Warfarin Takes 4-5 days to become therapeutic so use Heparin until Warfarin starts to work; DVT Tx-Compression stockings to decrease the risk of developing post phlebitic syndrome CONTRAINDICATIONS: Recent surgery; Hemorrhagic stroke; Bleeding diathesis; Active bleeding

Hodgkins Disease Hodgkins Lymphoma

291

Complx: Post radiation 2ry malignancy esp if tx <30yo with chemo AND Radx

292

Pulmonary Embolism PE

293

294 SSx: Dyspnea, CP, cough, tachypnea, pain on inspiration; tachycardia Dgx: +D-Dimer; V/P Scanvv US to look for DVTSpiral CT angiogram of the chestPulmonary Angiography Tx: Hemodynamic instability or R ventr strain are indications for thrombolytic therapy, Heparin; INR should be 2-3 Risk Factors: hypotension, tachycardia, SOB, hx/predisposition of DVT Complx: R ventricular dilation and failure (secondary to obstructed outflow) Massive Pulmonary Embolism: Hypotension &/or acute R heart strain, syncope

Respiratory Acidosis

295

296 Caused by inadequate pulmonary ventilation or HYPOventilation  low blood pH from CO2 retention Dgx: Elevated pCO2, low pH

Chronic Obstructive Pulmonary Disorder COPD

297

SSx: Cough, Wheezing on auscultatoin, hypoxia,; Prominent use of Accessory Respiratory muscles; Acute exacerbations can be precipitated by URI; Tx: inhaled bronchodilators like ipratropium, β agonists c anti-muscinic, inhaled steroids and long acting β agonists, corticosteroids; if PaO2<55, SaO2>88%, Hct>55%, or cor pulmonale then Supplementary O2 for best long term survival rates; smoking cessation and O2 decrease mortality rates; Theophyline/bronchdilators are useless for COPD; Try NonInvasive Positive Pressure Ventilation before intubation COPD + Finger Cluibbing=Cancer Dgx: CXR shows flattening of diaphragm due to increased work of breathing

298

Factor V Leiden Deficiency

299

Point mutation for factor V leaving it inactivatable by Protein C. This causes hypercoagulability, predisposition to DVTs, thrombosis, etc.

300

Asthma

301

302 SSx: V/Q mismatch, tachypnea, decreased PCO2 due to hyperventilation or tachypnea PCO2 is the best indicator of asthma severity. The higher the PCO2, the worse the asthma; normal is also bad. Tx: Depends on severity: Intermittent-PRN albuterol; Mild PersistentRescue+inhaled steroids; Moderate Persistent-Rescue+Low Dose Inhaled Steroids+Long acting β agonist: Severe Persistent- PRN Albuterol+Long acting β agonist+High Dose Inhaled Steroids SDFX of treatmenthypokalemiamuscle weakness, arrhythmias, EKG changes; tremor, HA, palpitations

Acute Bronchitis

303

SSx: No fever, ; maybe blood-tinged sputum due to hard coughing Causes: usu viruses

304

Wegeners Granulomatosis

305

306 SSx: Systemic vasculitis, upper and lower airway granulomatous inflammation, glomerulonephritis; Nasal cartilage destruction; tender nodules, palpable purpura, ulerations

Community Acquired Pneumonia CAP

307

308 SSx: Fever, chills, cought, purulent sputum, CP; alveolar consolidation-decreased breath sounds, dullness to percussion, increased tactile fremitus, egophony, bronchophony; Tx: Levofloxacin; Ciprofloxacin; β lactam abx; Causes: H. flu, Strep pneumo, Moraxella respond to Abx; Legionella-Azithromycin, macrolides; fluoroquinolones; does NOT respond to β lactams; ssx-High Fever, GI ssx, neuro ssx, rales, CXR=focal lobar consolidation; Sputum cx=lots of neutrophils, no organisms; Dgx via growth on charcoal agar or UA

Emypema

309

310 Defn: Infx in the pleural space usu from parapneumonic effusions, contamination of pleural space by abscess rupture, bronchopleural fistula, infective trauma, nonsterile thoracotomy, s/p hemothorax SSx: Fever, dyspnea s/p trauma err wvr Dgx: CT scan shows loculation; can have a thick peel around it Tx: Surgery

Hypoxemia

311

312 Defn: PaO2<80 Caused by: 1) Hypoventiliation- elevated PaCO2 nl A-a Gradient; usu follows srgx 2) Low inspired O2-nl PaCO2 no A-a gradient 3) Shunting-nl PaCO2 elevated A-a gradient that does not correct with 100% O2 4) V/Q mismatch-nl PaCO2 elevated A-a gradient IS CORRECTED with 100% O2 A-a gradient =[PAO2] – [PaO2] =[FiO2(760-47)-PaCO2/0.8] – [usu given]

Histoplasmosis

313

Where: Mississippi

314

Aspiration Pneumonia

315

Dgx: Foul smelling sputum and lower lobe pneumonia Risk Factors: Decreased conciousness; Dysphagia eg GERD, DBO; Neurologic DO eg dementia, myasthenia; Sedation x procedures

316

Idiopathic Pulmonary Fibrosis

317

Chronic Inflx of alveolar wallsfibrosis and destruction of lung architecture SSx: Progressive dyspnea, nonproductive cough, Digital Clubbing; Dry End inspiratory crackles; Fever/Chest pain are Absent Dgx: PFT show decreased TLC, FEV1 and FVC; nl FEV1/FVC; Increased A-a gradient; CXR decreased lung volumes, airway fibrosis/Honeycomb pattern, and pulmonary vascular congestion in the hilum

318

Cardiac Tamponade

319

320 SSx: Becks Triad-JV Distension, HYPOtension, Decreased heart sounds, Pulusus Paradoxus

Cor Pulmonale

321

322 Right Sided Heart Failure due to: Acute-dilation and failure of R side of heart by PE or lung probs; Chronic-Hypertrophy of R ventricle from lung disease SSx: Wheezing, fatigue; SOB, ; Elevated JVP, hepatomegaly, ascites, edema; NO evidnence of pulmonary congestion (eg CXR); Severe-S3 R ventricular heave Dgx: CXR may show big R ventricle and pulmonary aa, and maybe lung disease Causes: Pulmonary disease

Sarcoidosis

323

324 Immune dss usu seen in black F. SSx: Fever night sweats, wt loss, dyspnea; erythema nodosa, skin probs, eye, liver, kidney, CNS involvement; Elevated Ca and ACE; Dgx: CXR shows mediastinal adenopathybronchoscopy and biopsy Tx: Steroids if ssx

Aspirin Sensitivity Syndrome

325

Pseudoallergic rxn from aspirin induced prostaglandin/leukotriene bisbalance in susceptible pts

326

Goodpasteurs Syndrome

327

328 SSx: Proteinuria <1.5g/day, acute renal failure, urine dseiment c dysmorphic RBC and red cell hemorrhage; Dgx: Renal Bpx shows linear IgG deposits on glomerular basement membr Affects young white male. Ig’s vs α 3 chain of type IV collagen

Bronchiectasia Bronchiectasis

329

330 Abnl dilated segments of bronchial treeimpaired clearance of secretionsairflow obstrx SSx: Cough, mucopurulent foul-smelling sputum, hemoptysis Dgx: HRCT is standard dilated bronchioles, thickened bronchiole walls; CXR shows dilated bronchioles, peripheral opacities, linear atelectasis Inheritied usu caused by CF. Acquired usu caused by TB

Obstructive Sleep Apnea OSA

331

332 Sleep ApneaHYPOventilationacidosisRenal retention of bicarbdecreased serum Cl (it’s shifted back into the cells)

Friedlander Pneumonia

333

Pneumonia caused by Klebsiella pneumo, an encapsulated G- bacilli SSx: Currant jelly sputum, tissure necrosis; alcoholic or baby Dgx: Cx=mucoid colony;

334

Indications for Chest Tube Placement

335

Glucose<60mg/dL, low pH, empyema

336

Theophyline

337

338 MOA: Sm muscle relaxant, bronchodilator, diuretic, cardiac stimulant, vasodilator SDFX: Phosphodiesterase Inhibition adenosine antagonism and stimulation of epinephrine release  CNS ssx: HA, palpitations, insomnia, GI ssx

Choriocarcinoma

339

340 Metastatic form of gestational trophoblastic dss. Can occur after molar prego or nl gestation. Lungs are most frequent site of mets. Dgx: CXR=pulmonary ssx and multiple nodules esp in postpartum F

Meniere Disease

341

342

Diverticulitis

343

344 SSx: LLQ or RLQ pain, maybe bleeding, aggravated by eatingfever, chills, NV, decreased appetite, constipation; massive GI bleed Dgx: CT Scan Tx: clear water, f/u; NPO IV fluids; clear liquids Abx, colonoscopy in 6weeks; hospitalization; surgery if abscess, stricture, DDf: Colon CA in the elderly; Ovarian cyst, endometriosis, ectopic prego, torsion; IBC infectious colitis; appendicitis

Iron Deficient Anemia Microcytic Hypochromic Anemia

345

346 SSx: Dgx: Microscopy shows small, pale RBC’s; Low Hg, MCV<80mcL; Decreased Fe, Decreased Ferritin, High TIBC (Total Iron Binding Capacity); Colonoscopy if GI blood loss suspected then Endoscopy; Capsule endoscopy if AV malformations are suspscted Tx: Path: Can be caused by GI bleeding, meatless diets; In old ppl it’s due to GI blood loss until proven otherwise; Peptic Ulcer Disease eg from NSAID use

Clostridium Difficile Diarrhea

347

SSx: Nausea, Vomiting, abdominal pain, Diarrhea after antibiotic use, increased WBC Dgx: Stool testing for cytotoxin Tx: Metronidazole Path: Abx kill most GI flora letting C. diff grow and wreak havoc

348

Dysphagia

349

Common Causes: Crico pharyngeal dysfunction (oropharyngeal dysphagia) achalasia, stricture, tumor. Dysphagia for solids AND liquids = motility problem Solid food dysphagialiquid food dysphagia= organic? cause SSx: Dgx: Barium Swallow to check for anatomical abnlEndoscopy or Video Fluoroscopy if cricopharyngeal dysfx is suspected Tx: Path:

350

Esophageal Cancer Esophageal Adenocarinoma or Esophageal Squamous Cell Carinoma SCC

351

352 SSx: Heartburn worse when supine; Antacids do not relieve pain Dgx: Tx: Path: Untreated GERD causes metaplasia  Barrett’s esophagus adenocarcinoma or SCC; Risk Factors x Adenocarcinoma Barretts, obesity, high dietary calorie and fat intake, smoking and GERD. SCC risk factors = smoking EtOH, dietary defx of β carotene, vitamin B1, zinc, selenium, environmental viral infx, toxin producing fungi, hot foods/beverages, Nitrate preserved foods

Whipple Disease

353

SSx: Diarrhea, abdominal pain, wt loss; bulky foul smelling stools, abdominal distenstion, flatulence, mal-absorption; arthralgia. Generalized LAD, skin hyperpigmentation; valve dysfx, heart problems, CHF Dgx: Sm bowel bpx = villous atrophy c numerous PAS + materials in the lamina propria Tx: Path: caused by Tropheryma whippelii infx esp in white 40-60yos

354

Peptic Stricture

355

356 SSx: Difficulty swallowing solids at first then solids and foods; NO wt loss, NO anorexia; Dgx: Endoscopy=symmetric circumferential narrowins Tx: Bpx to r/o adenoCA or SCC Path: caused by body’s attempt to repair chronic GERD or Barrett’s  peptic esophageal strictures which causes progressive dysphagia; as the strictures progress they can actually improve GERD ssx.

357 Achalasia

SSx: Dgx: Barium Swallow= “bird beak” narowing Tx: Path: Inability to relax the sphincter

358

359 Zenkers Diverticulum Pharyngoesophageal Diverticulum

SSx: Difficulty Swallowing Dgx: Barium swallow= Tx: Path: Upper Esophageal Motor dysfx and dysmotility herniation between the fibers of cricopharyneal muscle

360

361 Deficiency

SSx: Dgx: Tx: Path:

362

B Vitamins

363

B1 Thiamine B2 Riboflavin B3 Niacin-Pellagra-Diarrhea, Dermatitis, Dementia B5 Pantothenic Acid B6 Pyridoxine/amine B7 Biotin, Vitamin H B9 Folate, Folic acid, Vitamin M B12 Cyanocobalamin

364

Zinc Deficiency Zn

365

366 SSx: Derm lesions bullous pustulous on body or extremities, hair loss, change in taste sensation; hx of IBD, being NPO or Short Bowel Syndrome Dgx: Tx: Path: Zn is found in animal protein, whole grains, beans and nuts and absorbed in the jejunum

Chronic Pancreatitis

367

368 Path: Chronic inflmx of the pancreas due to EtOH; can lead to Pancreatic Cancer SSx: Chronic abd pain not relived by antacids; diarrhea due to fat mal-absorption; Hx of chronic EtOH abuse; DM due to β cell destrx Dgx: Stool Elastase levels are low; nl to high amylase and lipase; Tx: Abx, NPO, fluids

Endoscopy Esophagogastroduodenoscopy EGD

369

Used to dgx luminal defects of upper GI esp Peptic Ulcer Disease, gastritis, dysphagia or upper GI bleeds; chronic abd pains not due to pancreatitis

370

Carcinoid Tumor

371

372 Path: Small slow growing neoplasm made of rounded oxyphilic or spindle shaped cells c moderately small vesicular nuclei. Covered by mucosa c yellow cut surface. Very invasive. Found anywhere in GI or lungs esp appendix/ileum SSx: Abdominal pain, diarrhea, Flushing, Pruritus, wt loss (Carcinoid Syndrome) Dgx: +Urine 5-HIAA Tx: Surgical Resection

Tropical Sprue

373

SSx: Diarrhea; Malabsorption, glossitis, cheilosis, protuberant abdomen, pallor, pedal edema; Hx of living in endemic areas eg Puerto Rico, Latin America etc Dgx: Decreased B12, Folatemegaloblastic anemia; Small intestinal bpx=villi blunting and lots of WBC’s;

374

Pertonitis

375

Dgx: Paracentisis, culture Tx: Cephalosporins

376

Toxic Megacolon from Ulcerative Colitis

377

Path: As UC progresses it causes the Rectum to lose elasticity lumen collapsetenesmus (spasm) SSx: Abdominal pain, diarrhea wt loss, fever; 40 BM per day Dgx: diffuse tenderness and distension; Abd Xray=colonic dilatation Tx: IV fluids, Abx and NPO, IV steroids; Surgery=subtotal colectomy c end ileostomy if does not resolve This is a medical emergency b/c it can  colonic perforation. Other causes of Toxic Megacolon are ischemic colitis,k volvulus, diverticulitis infx

378

MEN 1 Multiple Endocrine Neoplasia 1 Wermer Syndrome

379

380 Path: Tumors on the pituitary gland, pancreatic islet cells and parathyroid; 3P’s are affected, Pancreas, Parathyroid and Pituitary. SSx: -Pancreas: Aggressive. Secrete pancreatic polypeptide. Usu seen c ZollingerEllison syndrome and insulinomas causing hypoglycemia and neurologic probs -Parathyroid: Primary hyperparathyroidism c hyperplasia and adenomas. Nephrolithiasis, hypercalcemia -Pituitary: most likely Prolactinomaacromegaly from somatotropin. Can also cause gastrinomas eg in the duodenum

MEN 2 Multiple Endocrine Neoplasia 2 Sipple Syndrome

381

382 Path: Pheochromocytoma, Medullary Carcinoma, Parathyroid Hyperplasia; thyroid medullary c-cell hyperplasia carcinoma; Amino acid mutation affects RET gene which tyrosine kinase catalytic domain. SSx: -Pheochromocytoma: usu BL or found in extraadrenal sites -Parathyroid Hyperplasia: Hypercalcemia or renal stones

MEN 3 MEN 2B Multiple Endocrine Neoplasia 3 (2B)

383

384 Medullary Thyroid Carcinoma, Pheochromocytoma, Neuromas or Ganglioneuroma of the skin/mucus membranes c marfinoid habitus

Ileus

385

Path: functional defect in bowel motility w/o physical obstruction. Usu due to surgery SSx: NV, abdominal distension, failure to fart or poo, decreased bowel sounds; Other causes include post-op increased sympathetic tone and post-op analgesics from disordered peristalsis

386

Heat Stroke

387

1) Exertional Occurs in healthy individuals doing hard physical work in extreme temp’s and humidityinability of thermoregulatory center to dissipate heat SSx: T>105 °, altered mental status, dehydration (concentrated Htc, dry skin/membranes), hypotension; tachycardia, tachypnea; high body temp can also cause rhabdomyolysis (UA=large blood c no RBC) and organ system damage 2) Non-Exertional

388

HELLP Syndrome Hemolysis, Elevated Liver enzymes, Low Platelets

389

390 Path: A type of SEVERE Preeclampsia; SSx: Dgx: Hemolysis, Elevated Liver enzymes, Low Platelets Tx: <34weeks=Termination if severe, ; >34weeks=Delivery via MgSO4 and labor induction

Hematuria

391

392 3 Types: 1) Glomerula-Proeinuria, RBC casts, dysmorphic RBC; Renal Parenchymal dss esp if >80% dysmorphic RBC 2) Renal – 2° to tubulointerstitial, renovascular and metabolic disorders. Has proteinuria sans RBC dysmorphia 3) Urologic – Caused by tumors, calculi, infx, trauma, BPH DDx: Cancer; STD; Chemical exposure; strenuous exercise; Drugs, Herbs; The chances of painless microscopic hematuria being cancer is very very very low. Workup/Dgx: Repeat UA; Urine Culture; Lower GU images via cytoscopy, cytology; Upper GU images via CT or IV pyelogram Risk Factors: Smoking, chemical exposure eg dyes, hx of gross hematuria, >40yo, hx of GU probs, chronic analgesic ab/use Gross Hematuria Should Always Be Worked Up

Chronic Renal Failure CRF

393

Chronic renal failure 

394

Jaundice

395

396

Metoprolol

397

398 SDFX: Worsening of PVD via β2 mediated vasoconstriction; AV node conduction blocker

Pneumothorax

399

SSx: Tachypnea, tracheal deviation away from affected side, neck vv distension; decreased breath sounds, hyperresonance Tx: Needle thoracostomy

400

Indications for Hemodialysis Reasons for Hemodialysis

401

1. Refractroy hyperkalemia 2. Volume overload orpulmonary edema not responding to diuretics 3. Refractory metabolic acidosis 4. Uremic pericarditis 5. Uremic encephalopathy 6. Coagulopathy due to renal failure

402

Tension Pneumothorax

403

404

Olanzapine

405

406 MOA: Atypical Antipsychotic. Blocks D2 receptors DOC: SDFX: Wt gain, hyperglycemia, dyslipidemia, HTN Montior: Fasting blood sugar, wt, BP regularly; CBC yearly for agranuloytosis or if ssx

Tourrette’s Tourrette

407

Tx: Traditional antipsychotics eg Haloperidol or Pimozide; Risperidone Misc: Do baseline EKG bc Pimozide causes long QTc

408

Haloperidol

409

MOA: D2 antagonist; Traditional Typical Antipsychotic; DOC: Tourrette; Acute and Chronic Schizophrenia; Alcohol Idiosyncratic Intoxication (pathological intoxication); MDD c Psychosis; Agitated PCP intoxication; Delirium or Agitated Amphetamine intoxication SDFX: Extrapyramidal (via Nigrostriatal pathway); Increased Prolactin (via Tuberoinfundibular pathway); Antipsychotic (via Mesolimbic); Anticholinergic; Sedation Misc: Prot bound; Other Uses: Acute Mania; Symptoms of Psychotic Dementia; Delirium esp if psychotic; Violent Psychosis; EtOHic w/d +chlordiazepoxide

410

Extrapyramidal Side Effects

411

412 Caused by: Typical (traditional) Antipsychotics (Haloperidol; Chlorpromazine) SSx: Dystonia-Sustained muscle contraction usu the jaw or neck muscels (lock jaw, torticollis, carpo-pedal spasms, oculogyric crisis) Parkinsonism-Tremor (at rest and movement; esp upper extremities); Rigidity starting in the upper limbs then spreading to rest of body; Akinesia a zombie like affect c slowness, fatigue, little facial expression (can be mistaken x depression) Akathisia-Fidgety constanly moving, rocking from the waist, pacing, dysphoria (mistaken for anxiety or agitation) Rabbit syndrome-involuntary chewing movements Tardive Dyskinesia- involuntary movements of the facial muscles and tongue; tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking Tx: Benztropine; Benadryl/Diphenhydramine C/I: TCA, SSRI,

Atypical Anytpsychotics

413

414 e.g. Riseperidone; clozapine; olanzapine; quetiapine; ziprasidone aripraprazole MOA: D4, D2 5HT2a receptor antagonists SDFX: Clozapine-seizure exacerbation, agranulocytosis wt gain, DM; Risperidonethe same as clozapine + elevated Prolactin DOC: Schizophrenia? 2nd line after Typicals have been tried

Clozapine Clozaril

415

416 MOA: D4 antagonist 5HT2a receptor antagonist; Atypical Antipsychotic DOC: none; Use in Schizophrenia pts who can’t tolerate other mx; esp if ssx of apathy, anhedonia and flat affect SDFX: Szrs; AGRANULOCYTOSIS WBC<3000; mouth watering; hypOtension; wt gain, DM

Risperidone Risperdal

417

418 MOA: D4 antagonist 5HT2a receptor antagonist; Atypical Antipsychotic; use depot inj for noncompliant pts DOC: none; chronic Schizophrenia SDFX: increased Prolactin; EPS; Orthostatic hypOtension; Tardive Dyskinesia

Thioridazine Mellaril Traditional Antipsychotic

419

MOA: D2 receptor antagonist DOC: Psychosis in Borderline Personality SDFX: impotence; Retinitis Pigmentosa

420

Paroxetine Paxil SSRI

421

MOA: SSRI DOC: Depression; OCD, GAD, social anxiety d/o; Premature ejaculation SDFX: Delayed orgasm, anorgasmia; Birth defects; MISC: Hard to discontinue because pts get HA, nausea dizziness, insomnia and nervousness when u try to taper

422

Fluoxetine Prozac SSRI

423

MOA: SSRI DOC: Mild-Moderate Depression Panic d/o, OCD, bulimia SDFX: GI upset, rashes, sexual inhibition, insomnia, restlessness Misc:

424

Adjustment Disorder

425

426 SSx: Marked distress or functional impairment to known stressor w/in 3mos of stressor; Not Bereavement; ssx alleviated within 6mos of disappearance of stressor; SSx do not last >6mos after insult Specifiers: c Depressed Mood-main ssx are depressed mood, tearfulness or feelings of hopelessness; c Disturbance of Conduct-main ssx are conduct which violates rights of others or age inappropriate norms (fighting, legal) Tx: supportive psychotherapy; group therapy

Schizophrenia Types

427

Disorganized-Disinhibited, poor grooming and organization, inappropriate emotional RE; Onset <25yo Catatonic-Bizarre posturing or extreme excitability Paranoid-Delusions of persecution; usu older age of onset, better fxing Undifferentiated-characteristics of more than one type Residual-dgx of schizophre but no psychotic ssx

428

Negative (lack of) SSx-flat affect, thought blocking, poor grooming, amotivational, social withdrawal, poor speech. Atypical Antipsychotics work well on these ssx Positive (Too much of) SSx-Hallucinations, delusions, agitation; Both classes of antipsychotics work well here

Oppositional Defiant Disorder

429

430 SSx: A) pattern of negative, hostile and defiant behavior >6mos where >4 of the following are present: 1) loses temper 2) argues with adults 3) refuses to cooperate c adults or defies requests 4) deliberately annoys ppl 5) blames others for his/her misbehavior 6) easily annoyed by others 7) often angry or resentful 8) spiteful or vindictive; B) Causes social/academic/etc dysfx C) doesn’t occur during a psychotic or manic episode D) Is not conduct disorder or antisocial personality disorder Tx:

431 Amitriptyline (Elavil)

MOA: TCA DOC: Anorexia SDFX:

432

Panic Disorder

433

SSx: Sudden onset of intense apprehension fear c CP palpitations, HA dizziness, faintness, paresthesias, trembling DSM: >3 attachis in a 3 week period; No obvious reason; peak w/in 10 mins and over in 30mins. Tx: SSRI for long term maintenance; BZD for acute episodes Misc: High association c depression, agoraphobia, GAD and substance abuse

434

Neuroleptic Malignant Syndrome NMS

435

SSx: Severe (lead pipe) rigidity, change in mental status, autonomic instability, elevated CPK (rhabdomyolysis), elevated WBC Dgx: Usu caused by antipsychotic Tx: Dantrolene

436

Phenelzine MAOI

437

MOA: MAOI; inhibits the enzyme that breaks down amines

438

Hypertensive Crisis

439

440 SSx: Hypertension, hyperpyrexia Caused By: Ingesting tyramine with MAOIs (eg cheese, pickled foods, yoguret, nondistilled EtOH, broad beans); Uppers Tx: phentolamine Dgx: MAO in the gut wall usually prevents tyramine from being absorbed. MAOIs inhibit this enzx  absorption of tyramine  HTN, fever

Mental Retardation MR

441

nl IQ >70 Mild MR 55-69 These pts can hold down simple jobs and be independent eg assembly workers. 6th grade academic skills Moderate MR 35-55 Severe MR 20-35 Will need to be cared for as they cannot protect themselves Proufound MR <20 Cuases: Fragile X; Downs Syndrome, Trisomy 21;

442

Mirtazipine SSNRI

443

MOA: α2 antagonist  increased synaptic 5HT lvls and NE release SDFX: wt gain sedation; NO SEX SDFX DOC: none Uses: Anxiety

444

Ziprasidone Atypical Antipsycotic

445

446 DOC: Since it doesn't cause wt gain like the other atypical antipsychotics it's good in MOA: 5HT and DA2 blocker; Atypical Antipsychotic; moderate inhibitor of NE and 5HT SDFX: rash; NMS, somnolence, ohrthostatic hypotension, rhinitis, wt gain; Torsads de Pointes; prolonged QT

Sertraline Zoloft SSRI

447

MOA: SSRI DOC: Panic disorder, GAD, depression, PMDD SDFX: nausea, diarrhea, tremor, insomnia, somnolence dry mouth, ejaculatory delay, SIADH

448

Perphenazine Typical Antipsychotic

449

MOA: DOC: SDFX:

450

Wernicke Encephalopathy

451

SSx: ACE (Ataxia, Confusion and Eye movement nystagmus) Delirium, ataxia, vertical and horizontal nystagmus, external rectus eye muscle weakness; due to thiamine defx Dgx: decreased B1 Tx: Thiamine! to prevent…

452

Korsakoff Syndrome

453

454 SSx: confusion, severe impairment of memory, anterograde amnesia, confabulation; delirium tremens may precede the syndrome; due to malnutrition moreso vs EtOH Etiology: chronic alcoholics Dgx: Mammilary bodies are atrophied/dysfunctional; amnesia suggests temporal lobe involvement Tx: Thiamine!

Delusional Disorder

455

456 SSx: Dgx: Non-Bizarre delusions; Usually specific delusions. Affect, and cognition are intact; no loose associations Tx: individual psychotherapy Etiology: M, 40's,

Antipsychotics Neuroleptics

457

458 Typical/Traditional: Haloperidol, Chlorpromazine, Thioridazine, Fluphenazine, Perphanazine, Atypical: Risperidone, Ziprasidone, Quetiapine, Olanzipine, Clozapine

Anticholinergic Syndrome

459

SSx: Dry mouth, constipation, blurred vision, urinary hesitancy, glaucoma exacerbation; Tx: water gum or neostigmine, stool softeners, physostigmine, urecholine, / Cuased By: Traditional Antipsychotics (Chlorpromazine, pluphenazine, Haloperidol, Perphenazine)

460

Malignant Hyperthermia

461

SSx: Rapid onset of fever with muscle rigidity usually due to halothane or succinylcholine or some inhaled anesthetic. Tx: Dantrolene

462

Flumazenil Romazicon

463

MOA: BZD Receptor Antagonist DOC: BZD overdose; BZD sedation reversal SDFX: szrs, withdrawal, arrhtythmia, resdation

464

Narcolepsy

465

466 SSx: Persistant daytime somnolence relieved by naps, hypnagogic hallucinations, cataplexy, sleep paralysis just before falling asleep or waking up.

TCAs

467

MOA: Seritonin and NE reuptake inhibitors Tertiary: Amitriptyline, Clomipramine, Dexepin, Imipramine, Trimipramine Secondary Amines: Sesipramine, Nortriptyline Protriptyline

468

Dialectical Behavioral Therapy

469

The patient wants to improve The patient is doing the best he can The patient is encouraged to take responsibility for his actions. The patient is encouraged to solve his problems despite whether or not he is responsible for them. The patient must believe that he cannot fail therapy

470

Zolpidem Ambien Sedative Hypnotic Benzodiazepine Like Drug

471

MOA: Potentiates GABA receptors making the inhibitory pathway easier

472

Serotonin Syndrome

473

SSx: Abdoninal pain, diarrhea, diaphoresis, hyperpyrexia, tachycardia, hypertension, myoclonus, irritability, agitation, seizures and delirium Causes: SSRI + other SSRI potentiating meds eg MAOI, Li or carbamazepine Tx: stop drugs, supportive care

474

Nefazadone Serotonin Norepenipherine Reuptake inhibitor SNERI

475

MOA: Selective Serotonin Norepeneprine Reuptake Inhibitor DOC: n/a; 3rd line antidepressant SDFX: Hepatitis, liver failure

476

Venlafaxine SNERI

477

MOA: SNERI DOC: Maintenance tx for Panic and General Anxiety Disorder SDFX: HTN at higher doses

478

Trazadone

479

MOA: SSRI DOC: use to tx insomnia in pts with liver damage or history of alcohol abuse

480

Fetal Alcohol Syndrome FAS

481

SSx: Microcephaly, short palpebral fissures, flat midface, thin upper lip and MR

482

Complex Partial Epilepsy

483

SSx: Hyperreligious thinking, preoccupation, with moral ehavior, altered sexual behavior, altered sexual behaviors, hyperphagia, overelaborative communication styles/viscosity and heightened experience of emotions Misc: Psychotic ssx occur in 20% of pts

484

Clonidine

485

MOA: α2 autoreceptor agonist DOC: Opioid withdrawal

486

Idiopathic Avascular Necrosis of the Femoral Capital Epiphysis Legg-Clave-Perthes Disease

487

Epidemiolgy: M 4-10yo SSx: hip, groin or knee pain, antalgic gait; decreased ROM Dgx: X-ray=collapse of bone structures Tx: 1° conservative tx c braces and observation; 2ry=surgery if femoral head not well w/in acetabulum

488

Breast Cancer

489

Epidemiolgy: SSx: Piel-d'-orange Dgx: Mammogram= ; FNA=blood, send bloody aspirates for cytology; Tx:

490

Fibrocystic Changes of Breast

491

Epidemiology: F <50yo SSx: Breast pain worse around menstrual period that occur and resolve rapidly; Cysts are tender and mobile Dgx: FNA=serous, non-bloody aspirate; cysts disappear after aspiration Tx: Reassurance and f/u w/in 2months; Bpx if recurrence

492

Osteosarcoma

493

494 Epidemiology: M <20yo; occurs most commonly at site of bone growth eg epiphysis or metaphysis SSx: persisting bone pain Dgx: high alk phos; X-ray=destructive lesion and periosteal new bone formation c periosteal elevation (Codman triangle), or a 'sunburst' profile of the tumor Tx: chemotherapy and surgery Prognosis: Limb saving tx is likely if not too advanced?

Normal Arterial Blood Gas Values ABG

495

pH 7.35-7.45 pO2 80-100 mmHg pCO2 35-45 mmHg HCO3-22-28 mEq/L 02Sat=>95%

496

Meniscial Tear

497

Epidemiology: M:F 1:1 30s-40s SSx: joint pain after exertion; 'popping' sensation of joints; Dgx: MRI; hemarthrosis is indicative of ligament tear Tx: conservative, NSAIDS,

498

Squamous Cell Carcinoma

499

Epidemiology: M>>F Path: Risk Factors: sun exposure; chronic wounds; radiation; venous ulcers SSx: non-healing wounds Dgx: Tx: Misc: Marjolin Ulcer is that arises from a burn

500