The Medical student Review

[جوري]

picking up where we left off

A man is admitted to the hospital with renal failure developing over a few days
his cr has risen from 0.8mg/dl to 2.5 mg/dl. His bun has risen even more, going from 15 to 54. his serum bicarbonate is slightly low. the urine sodium is low and the urine osmolality is high..

1-Blood pressure 92/56 and pulse is 124.
2-serum albumin is 2.2 and the PT is elevated. there is splenomegaly
3-Ha has an ejection fraction of 24% with edema. a diuretic was recently started.
4-a bruit is present at the flanks and he has just started an ACE inhibitor.



1- pre-renal azoremia from any cause leads to an elevation of the BUN and CR, wit the BUN rising more than the CR in a ratio greater than 15:1. The tachycardia and hypotension in the first case suggest hypovolemia or any other form of chock. FeNa <1% also indicated a pre-renal etiology.

2- low oncotic pressure for any reason results in pre-renal azotemia because of decreased renal perfusion. In addition, liver dz such as cirrhosis can lead to hepatorenal syndrome, which is renal failure entirely based on liver failure.
3-CHF from any cause leads to rpe-renal azotemia. It can become suddenly worse with the volume depletion from a diuretic. pre-renal azotemia leads to low urine sodium and high urine osmolality
4- Renal artery stenosis is associated with decreased renal perfusion. ACE inhibitors can precipitate acute renal failure. Think about fibromuscular dysplasia in a young woman.

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pt with worsening renal function over the past few days. His cr is 3.5md/dL and the BUN is 28 units. The urine Sodium is 45meg/L and the urine osmolality is 290 mosm/L. His serum bicarbonate is low.

1- pt has been on gentamicin for last 8 days
2-he was on pipercillin for a few days. but stopped yesterday. He has fever and rash and there are eosinophils in his urine.
3-Chemotherapy for lymphoma was started 2 days ago
4- there is an empty bottle of anti-freeze by his bedside..

1-aminoglycoside induced RF generally occurs after 5-10 days of exposure to the medication. As with all forms of acute tubular necrosis, the BUN and CR will rise in about 10:1 ratio.
the urine sodium will be high (>40) and the urine osmolality will be low (<350) because of the inability of the damaged kidney tubules to concentrate urine . Amphotercin and any other renal toxic meds will result in the same numbers.
2- Allergic interstitial nephritis presents with fever, rash and eosinophils in the urine. The presence of esosinophils in the urine is more frequently than in the blood.
3- Hyperuricemia from tumor lysis syndrome will lead to acute RF
4-Antifreeze contains ethylene glycol, which leads to acute RF from oxalic acid accumulation in the kidney tubule. Look for 'envelope shaped oxalate crystals' in the urine. Formic acid accumulates with methanol ingestion and causes blindness.
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a man comes to the ER dept after sustaining a prolonged seizure. He has dark urine which is strongly positive on the dipstick for blood but in which no red cells are seen on microscopic exam. His serum bicarb level is low.

Rhabomyolysis presents after crush injury or severe exertion of any kind with dark urine in the absence of visible red cells. This is indicative of urine myoglobin. Rhbdomyolysis leads to metabolic acidosis, hyperkalemia and eventually renal failure.
2- Urine myoglobin is the most specific diagnostic test for rhbadomyolysis. The potassium level and EKG are probably the most urgent diagnostic steps because they determine who is most likely to die. the CPK level will be significantly elevated. admin of IV fluids and alkalinazation of the urine are important. an elevated CPK is not specific ofor indicating the cause of renal failure.
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pt with confusion. His sodium is at a low 122 mEq/L he has no edema, clear lungs, and no JVD. There is no orthostasis.

1- pt has lung ca with mets to brain. Urine Sodium is 70 (high) and urine osmolarity is 450 high.
2-the pt is bipolar, with frequent urination all day and less at night. urine sodium is 10 low and urine osmolarity is 75 low.
3- the pt has diabetes with a glucose level of 850 (NL 80-110)
here are some lab values for reference

Albumin 3.2 - 5 g/dl
Alkaline phosphatase (Adults: 25-60) 33 - 131 IU/L
Adults > 61 yo: 51 - 153 IU/L
Ammonia 20 - 70 mcg/dl
Bilirubin, direct 0 - 0.3 mg/dl
Bilirubin, total 0.1 - 1.2 mg/dl
Blood Gases

Arterial Venous
pH 7.35 - 7.45 7.32 - 7.42
pCO2 35 - 45 38 - 52
pO2 70 - 100 28 - 48
HCO3 19 - 25 19 - 25
O2 Sat % 90 - 95 40 - 70
BUN 7 - 20 mg/dl
Complete blood count (CBC) Adults

Male
Female

Hemoglobin (g/dl) 13.5 - 16.5 12.0 - 15.0
Hematocrit (%) 41 - 50 36 - 44
RBC's ( x 106 /ml) 4.5 - 5.5
4.0 - 4.9

RDW (RBC distribution width) < 14.5
MCV 80 - 100
MCH 26 - 34
MCHC % 31 - 37
Platelet count 100,000 to 450,000
Creatinine kinase (CK) isoenzymes
CK-BB 0%
CK-MB (cardiac) 0 - 3.9%
CK-MM 96 - 100%
Creatine phosphokinase (CPK) 8 - 150 IU/L
Creatinine (mg/dl) 0.5 - 1.4
Electrolytes

Calcium 8.8 - 10.3 mg/dL
Calcium, ionized 2.24 - 2.46 meq/L
Chloride 95 - 107 mEq/L
Magnesium 1.6 - 2.4 mEq/L
Phosphate 2.5 - 4.5 mg/dL
Potassium 3.5 - 5.2 mEq/L
Sodium 135 - 147 mEq/L
Ferritin (ng/ml) 13 - 300
Folate (ng/dl) 3.6 - 20
Glucose, fasting (mg/dl) 60 - 110
Glucose (2 hours postprandial) (mg/dl) Up to 140
Hemoglobin A1c 6-8
Iron (mcg/dl) 65 - 150
Lactic acid (meq/L) 0.7 - 2.1
LDH (lactic dehydrogenase) 56 - 194 IU/L
Lipoproteins and triglycerides

Cholesterol, total < 200 mg/dl
HDL cholesterol 30 - 70 mg/dl
LDL cholesterol 65 - 180 mg/dl
Triglycerides 45 - 155 mg/dl (< 160)
Osmolality 289 - 308 mOsm/kg
SGOT (AST) < 35 IU/L (20-48)
SGPT (ALT) <35 IU/L
Thyroid Function tests

Free T3 2.3-4.2 pg/ml
Serum T3 70-200 ng/dl
Free T4 0.5-2.1 ng/dl
Serum T4 4.0-12.0 mcg/dl
TSH 0.25-4.30 microunits/ml
Total iron binding capacity (TIBC) 250 - 420 mcg/dl
Transferrin > 200 mg/dl
Uric acid (male) 2.0 - 8.0 mg/dl
(female) 2.0 - 7.5 mg/dl
WBC + differential

WBC (cells/ml) 4,500 - 10,000
Segmented neutrophils 54 - 62%
Band forms 3 - 5% (above 8% indicates left shift)
Basophils 0 - 1 (0 - 0.75%)
Eosinophils 0 - 3 (1 - 3%)
lymphocytes 24 - 44 (25 - 33%)
Monocytes 3 - 6 (3 - 7%)
Laboratory test
Values if prerenal cause of acute renal failure
Values if intrarenal cause of acute renal failure

FENa, percent*
<1
>1

BUN to creatinine ratio
>20:1
10 to 20:1

Urine specific gravity
>1.020
1.010 to 1.020

Urine osmolality, mOsm per kg
>500
300 to 500

Urine sodium concentration, mEq per L (mmol per L)
<10 (10)
>20 (20)

Urine sediment
Hyaline casts
Granular casts

FENa = fractional excretion of sodium; BUN = blood urea nitrogen.

*-FENa is calculated as follows:

FENa =
Urine sodium ÷ plasma sodium X 100

http://www.globalrph.com/labs.htm

SIADH is caused by an abnormality of the brain or the lungs. This can be a cancer, infarction or infection. SIADH is associated with an inappropriately high urine sodium and osmolarity. The normal response to a low serum sodium should be a low urine sodium and low urine osmolarity. SIADH is a case of euvolemic hyponatremia. Free water restriction is the treatment .

2-psycogenic polydipsia is associated with bipolar disorder. there is a normal urinary response to hyponatremia. The normal response is low urine sodium and osmolality. decrease in sx at night is the key to the dx. when he goes to sleep he stops drinking, so he stops urinating.
3- pseudohyponatremia is from an elavted glucose for any reason. For every increase in glucose of 100 above normal there is a 1.6pt decrease in sodium.

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[جوري]

on with nephrology
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on routine screening, a pt is found to have low sodium of 127. He has no SX of the hyponatremia, and the neurologic exam is normal

1- pt has CHF with peripheral edema
2-he has 7g of protein every 24hrs and the serum albumin is 2.4 (normal is 3.5-5.5)
3- the potassium level is elevated at 6.2mEq/L (normal (3.5-5.2) and there is mild metabolic acidosis

1- CHF results in hyponatremia because of a decreased intravscular volume. The same effect occurs in cirrhotic pts. This is an appropriate increase in ADH because of decreased intravascular volume.

2-Nephrotic Syndrome results in hyponatremia because of a decrease in intravascular volume from low oncotic pressure. Nephrotic syndrome here is the most likely DX because of the low serum albumin levels as well as the marked increase in protein in the urine.

3-Addison's disease or hypoadrenalism of any cause results in hyponatremia. the loss of aldosterone results in th urinary loss of sodium and the retention of both potassium and hydrogen ions.

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a pt with severe hypernatremia is admitted to the ICU for confusion, there is polyuria despite increase in serum sodium. The pt is dehydrated.

1- the urine volume markedly decreases in response to the admin of vasopressin
2- there is no response to the adminstration of vasopressin. The urine volume remains high and the urine osmolality remains low.
3- the pt has diabetes and the glucose level is markedly elevated, but the serum bicarbonate is normal


1- Central diabetes inspidus is an insufficiency of antiduiuretic hormone ADH due to damage to either hypthalamus or posterior pituitary. There is a marked response in urine volume to the administration of vasopressin

2- with nehrogenic diabetes inspidus, there is no response to the admin of ADH. NDI is often from hypokalemia or hypercalcemia. There may a HX of lithium admin

3-Nephrotic hyperosmolar coma results in severe hypernatremia when there is a marked osmotic diuresis from hyperglycemia.

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A patient is seen because of Muscular weakness. There is also an elevated serum bicarbonate of 30. The potassium level is decreased at 2.9

1-vomiting is severe
2-the pt is on a loop diuretic because of CHF


vomiting from any cause can cause hypokalemia. This is because the metabolic alkalosis from vomiting causes a transcellular shift of potassium intracellularly. This is also because the loss of chloride from the stomach leads to an increase in bicarbonate resorption from the kidney. This state is hypochloremic hypokalemic metabolic alkalosis.

2- Diuretics cause hypokalemia because the volume depeltion leads to increased aldosterone secretion. All volume contractions lead to metabolic alkalosis by this mechanism. All cases of hypokalemia result in Muscular weakness.

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A man has mild proteinurea found on routine urinalysis

1- he is a healthy athlete undergoing intensive physical training.
2-he is a waiter. when split 24 hour urine is measure, the morning urine has no protein but the afternoon urine shows trace proteinuria
3-He is generally healthy and the repeat urinalysis shows no protein

Mild proteinuria can be found in healthy young athletes undergoing physical training. this is a benign finding and needs no further testing.

2-orthostatic proteinuria can occur in those who stand up all day long. when urine is split into morning and evening protein measurement. there is more in the first 8 hrs of the day. this is benign

3-between 1 and 10% of the population can have transient mild proteinuria. if protein is not found on repeat testing it needs no further follow up. if it persists, a 24 hour urine measurement of protein/ creatinine ratio is performed. Only if the proteinuria is persistent or the ratio is elevated should a renal biopsy be performed.

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a woman is in your clinic because of edema developing over months. she has a normal echo. her urinalysis shows 4+ protein and the spot protein/creatinine ratio is 7:1. triglycerides are elevated.

1- there is a hx of diabetes and htn. the eyes show background retinopathy.
2-she has been an injection drug user of heroin in the past.
3-she was recently diagnoses with lymphoma

Nephrogenic syndrome is a combination of edema, a 24 hr urine protein greater than 3.5g and hyperlipidemia. A spot protein/creatinine ratio greater than 3.5 is the same as a 24 hour urine protein. Diabetes and HTN are the most common causes of nephrotic syndrome. A ratio of protein to creatinine is equal of the amount found on a 24 hr urine.

2- injection drug use and heroin both cause focal segmental glomrulonephritis. HIV is also associated with focal/segmental disease.

3-the most common cause of nephrotic syndrome is a primary disease limited to the kidney is membranous glomerulonephritis. Membranous glomerulonephritis is also associated with cancer such as lymphoma.

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A man comes to see you because of persistent hematuria. The urinalysis shows red-cell casts and a 1+ proteinuria. The urine sodium is low.

1- the pt is asian with recent viral infxn. there are no systemic manifestations.

2- he has had lifelong eye probs and ear probs with deafness.
3- he had pharyngitis a week ago and has periorbital edema
4-he has multiple systemic probs such as petechiae, joint pain, abdominal pain, and GI bleeding. There is neuropathy and lung involvement.

1- IgA nephropathy, or Bergers disease presents as isolated hematuria at the same time as a viral illness. It is more common in Asians. and is the most common cause of acute glomerulonephritis.

2- Alport's syndrome presents with glomerulonephritis in association with eye and ear probs. Such as deafness. All forms of glomerulonephritis give red cell casts and mild proteinuria.

3- poststreptococcal glomerulonephritis leads to tea or cola colored urine which is proteinuria and hematuria. perorbital edema is characteristic. The blood will show anti-streptolysin O antibodies as a sign of strep infection,

4-Polyarteritis nodosa (PAN) presents as a systemic vascuilitis with skin, joint, GI, CNS and neurologic probs. PAN spares the lung.

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a pt is in your office for evaluation of blood in his urine x a few days

1- he has burning on urination and must urinate frequently
2- he also has pain going from his sides to his groin. the pain is extremely severe.
3- Red cell casts and protein are found in the urine as well. urine sodium is low.
4- has recently undergone chemo

1- Urinary tract infxn of any kind such as cystitis or pyelonephritis, can lead to hematuria. Definitive diagnosis on the location of the pain described in the question. urinalysis and urine culture should still be obtained.
2-Nephrolithiasis, or kidney stones, present with severe flank pain radiating to the groin, also known as renal colic.
3-Glomerulonephritis of any kind can present with hematuria. when red cell casts. red cells and mild proteinuria are present the most likel diagnosis is glomerulonephritis. the urine sodium is low because of vasoconstriction of te afferent arterial, which is present in all forms of glomerulonephritis.
4- cyclophosphamide leads to hemorrhagic cystitis.

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a pt comes with hematuria, joint pains and purpuric skin lesions. urinalysis reveals red cells, red cell casts, and mild proteinuria. the spot protein ratio is 1.2

1- hx of hep c and an IgM present in the blood
2- a child with abdominal pain

Cryoglobulinemia is most often associated with chronic hep c. Cryoglobulinemia leads to renal dysfunction. skin lesions and joint pains. Neuropathy is common, both Cryoglobulinemia and cold agglutin disease are from IgM antibodies in blood. Cold agglutinin disease however, leads to hemolysis, not renal dysfunction, an is associated with mycoplasma

3-Henoch-Schönlein purpura, is the most likely dx when the pt is an adolescent or a child. presenting with GI sx in a combination with renal, joint and skin findings. Palpable purpura of the lower extremities is key. The most accurate test is a skin biopsy with IgA deposited in the skin, but routine biopsy is not necessary.

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a 27 year old woman comes because of hematuria and flank pain as well left lower quadrant abdominal pain with diverticuli found on colonoscopy. Auscultation shows a mid systolic click. There are cysts found on the ovary as well as the liver

polycystic kidney disease presents with hematuria and can present with kidney stones that occur with increased frequency. In addition to kidney disease, there are also cysts of the liver and ovary with diverticulosis, mitral valve prolpase, and aneurysmal disease in the circle of willis.

The most common cause of death from kidney disease is renal failure. renal failure occurs from chronic repeated infections such as pyelonephritis. in addition there are recurrent kidney stones secondary to significant anatomic abnromalities. Aneurysms rupture is not the most common cause of death in polycystic kidney disease.

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a patient comes in with sudden onset of flank pain and hematuria
1- there is a hx of sickle cell disease. the patient has taken extra doses of multiple pain meds, including NSAIDS. there is some necrotic material in the urine.
2-the pain radiates to the groin in an otherwise healthy person.

1-papillary necrosis occurs in pts who have underlying kidney disease such as sickle cell disease or chronic pyelonephritis. The presentation is similar to nephrolithiasis in that there is sudden flank pain and hematurua. However, it often occurs from the use of extra NSAID medications and is associated with necrotic material in the urine. The most accurate test is a CT scan. There is no specific therapy.

2-Nephrolithiasis presents with sudden flank pain radiating to the groin. the most accurate test is a spital CT scan. kidney stones do not need contrast material to be visible on x rays of the abdomen have poor sensitivity. the IVP is always wrong, it is slow and associated with potential for renal insufficiency and allergy from contrast.

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Man comes to the office, and is found to have casts in his urinalysis.
1- white cell casts
2-red cell casts
3-eosinophil casts
4-hyaline casts
5-muddy brown or granular casts

pyelonephritis is associated with white cell casts, if they are there , they are specific for the disease, generally, casts ass little to help the diagnosis, which is usually obvious in the presence of fever and dysuria, and flanl pain and tenderness.

2- red cell casts are specific to glomerulonephritis.

3- Eosinophil casts are specific to allergic interstitial nephritis. they are not present as often as individual eosinophils.
4-Hyaline casts are found on dehydration or any other form of pre-renal azotemia. They are the accumulation of normal protein which sludges because of decreased renal flow.
5-granular or muddy brown cast are found in acute tubular necrosis, the 'granules' are sloughed off, necrotic epithelial cells from the kidney tubules..
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Neurology

a pt comes to the office for evaluation of headache
1- woman with unilateral headache that is throbbing at the time of menses. she is nauseated and sees bright flashes of light. Light hurts her eyes and sounds are painful.
2- bilateral squeezing pain like a belt tied around her head
3- a man with unilateral tearing and redness and nasal stuffiness, there are several short headaches..

1- migraine headaches are common, but not always unilateral with autonomic probs such as nausea and vomiting. Visual problems such as bright flashing lights, zigzags of lights or visual field defects occur. there may be photophobia and phonophobia, migraines can be precipitated by mensuration, physical or emotional stress or lack of sleep.

2- tension headaches are bilateral and bandlike, there are no associated neurologic probs.

3- cluster headache are ten times more common in men, there are multiple short hedaches in a limited period of time, they are very severe with redness of the eye, lacrimation, rhinorrhea and nasal stuffiness. Horner syndrome sometimes occurs...

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Man comes with severe facial pain that occured while his wife was gently stroking his face. the pain is extremely severe, started at one side of his face, and is like a nail being driven in his cheek..

trigeminal neuralgia or 'tic douloureux' is an idiopathic disorder of the fifth cranial nerve. there is sudden severe pain of the face brough on by touch, chewing or movement. the pain is lancinating and unilateral.

2- trigeminal neuralgia is treated with carbamezepine. if medical therapy is not effective, surgical resection of the nerve may be necessary.

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an elderly man is brought to the er with a sudden onset of weakness over the right side of his body, dysarthria, and loss of his right visual field. his head CT scan is normal

1- the sx began with unilateral loss of vision on the left side. All sx resolve within 6 hrs. MRI os the head is normal

2- sx persist. MRI of the head is normal in 24 hrs

TIA begin with loss of sensory and motor function that resolves in <24 hrs. All imaging studies are normal, TIAs often begin with 'Amurosis fugax" which is a transient loss of vision. The visual loss is on the contralteral side from other sensory and motor loss. this is from a carotid embolus on the same side as the visual loss.

2-stroke is a permanent neurologic loss, often from a non hemorrhagic embolic or thrombotic episode of the middle cereberal artery. There is loss of motor ad sensory function on the opposite side from the lesion. This is frequently accompanied by a 'homonymous hemianopsia' which is the loss of the optic radiation of fibers through the parietal lobe. A stroke on the left eliminates the visual field on the right. pts look toward the side of the lesion.

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a man presents to the ER with severe vertigo, he is found to have hemifacial anesthesia, dysarthria, dysphagia, and sensory loss of his body on the opposite side from the hemifacial anesthesia. He is ataxic and there is Horner's syndrome present.

this is Wallenberg or lateral medullary syndrome is a stoke of the posterior inferior cerbellar artery (PICA). this results in ipsilateral facial sensory loss, contralateral body sensory loss , vertigo, atazia, dysarthria, dysphagia, and horner's syndrome.

2-MRI of the brain is the most accurate way to assess the cerebellum and brain stem. CT scanning does not effectively look at the posterior fossa or the brain stem.

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a pt comes in with sudden onset of weakness. the weakness is unilateral and is worse in the lower extremity compared to the arm. Sensory loss is also present that is worse in the leg, he is confused and there is urinary incontinence.

Anterior cerebral artery stroke presents with unilateral loss of motor and sensory function. These sx are worse in the lower extremity compared to the upper extremity. There is also confusion and urinary incontinence.

MRI of the brain is the msot accurate method of determining the presense of a stroke. Echo and carotis doppler studies are used to determine the etiology of the origin of the stroke, specifically looking for evidence of vegetation or intra cardiac thrombus.

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[جوري]

Neurology
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A man comes to the ER with sudden, extremely severe headache, the first such episode he has ever had

1- there is photphobia and neck stiffness, fever, and a loss of consciousness from which he recovers.

2- he has unilateral loss of vision which persists.

1- subarachnoid hemorrhage (SAH) results in a sudden severe headache with meningeal signs such as nuchal rigidity, fever and photphobia. The two key features is the most likely dx would be the loss of consciousness in 50% of ts. CT scan without contrast is 95% sensitive in detection of SAH. Lumbar puncture will detect the rest, showing blood and/or xanthochromia the yellow appearance of cerebrospinal fluid (which envelops the brain) (this headache is described as a thunderclap headache)

2- temporal arteritis leads to severe unilateral headache associated with loss of vision as well as tenderness of the scalp and the artery. The answer is always to give steroids rather than wait for a temporal artery biopsy, there maybe Jaw claudication and onset is in the elderly.
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a woman comes in with severe back pain
1- hx of cancer, spine tenderness, hyperreflexia, urinary incontinence, los of sensation in the lower extremities.
2-no tenderness and no focal neurologic defecits.
3- spinal tenderness, leukocytosis, and fever.

1- Spinal cord compression from metastatic disease is thought to be present when back pain is accompanied by tenderness, hyperreflexia, sensory loss below the level of the comrpession, and sometimes urinary or fecal incontinence, steroids are critical to prevent worsening sx.
2- low back pain or lumbosacral strain has no accompanying focal neurologic probs. the straight leg raise may elicit pain suggesting disc herniation. This doesn't chanfe the answer for initial management, which is to give analgesics and not perform routine imagine testing. Do not advise of bed rest.
3-Spinal epidural abscess is the answer when there is fever, leukocytosis, and spinal tenderness. Imaging such as an MRI should be performed if there is spine tenderness. which suggests compressive mass.
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a child is brought for eval of mental subnormality and seizures

1- there is a port wine stain on the face and leptomeningeal angiomas.
2-facial adenoma sebaceum, renal lesions, and 'Shagreen patches' are present, with leathery plaques of subepidermal fibrosis, usually situated on the trunk. retinal hamratomas are present, pale hypopigmented 'ash-leaf' patches are present.

1- Sturge-weber syndrome presents with seizures and mental subnormality in association with port wine stain and leptomeningeal angiomas.

2-Tuberous sclerosis gives hamartomas of the retina in association with ash leaf hypopigmented areas. there are also lesions of the heart and kidneys. Adenoma sebaceum is reddened nodules on the face.

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a pt comes in with loss of pain and temp sensation of the lower extremities
1- the loss of pain and temp is bilateral, there is also loss of bilateral motor function. There is striking sparing of position and vibratory sensation bilaterally.
2-a knife wound is sustained to the back. the loss of pain and temp is on the opposite side from the injury. there is loss of position and vibratory sensation of the same side as the injury

1- Anterior spinal artery infarction results in the bilateral loss of all pain, temp and motor function below the level of the infarction. There is sticking preservation of position and vibratory sensation which has another vascular supply on the posterior portion of the spinal cord..

2-Brown Sequard syndrome is a hemisection of the spinal cord. Pain and temp are not lost on the opposite side from the lesion. Position and sense are lost on the same side as the injury.

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a pt comes in some time after being involved in a motor vehicle accident, there was spine trauma the patient has lost pain and temp sensation in a capelike distribution across the neck and down both arms. Touch, position and vibratory sensation are intact. Over time, there is motor loss below the level of the injury

1- syringomyelia presents with the loss of pain and temp in a capelike distribution across the neck and arms. There is sparing of tactile sensation, position and vibratory sense. Reflexes are lost. There maybe lower motor neuron manifestation at the lesion with upper motor neuron signs below the lesion enlarges. Syringomyelia is caused by tumor and trauma.
MRI is the most accurate test.
Surgery is the rx.
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an obese young woman comes in for an eval of severe headache and double vision. she has recently started OCP. on PE she has six cranial nerve palsy and papilledema. Head CT is normal

Pseudotumor cerebri is an idiopathic increase in intracrnial pressure that occurs more often in obese women who are using OCP or teracycline antibiotics. the key to the answer is the presence of a headache in association with diplopia, papilledema, sixth cranial nerve palsy and a normal CT.
Lumbar puncture is the most accurate diagnostic test.
treatment is with the loss of weight combined with actazolamide and diuretics. Steroids and surgical shunting are sometimes necessary.
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pt with multiple bruises on her legs. she is accompanied by her husband. whom she insists is kicking her every night. he denies this, he does say his legs are uncomfortable at night and that this discomfort is relieved by moving his legs. His legs feel 'creepy crawly'. he tries to avoid the prob by drinking cofee.

restless leg syndrome is an idiopathic disorder of discomfort in the legs at night relieved only by movement. it is worsened by restlessness and caffeine use.
Dopamine agonists such as ropinirole or pramipexole are the rx of choice.

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A man comes to office for progressive muscular weakness. the weakness is diffuse and accompanied by dysarthria and difficulty chewing and handling saliva, with a decreased gag reflex. there is spasticity, hyperreflexia, muscle wasting and fasciculations

Amytrophic lateral sclerosis (ALS) is the only disease to combine uppr and low motor neuron dysfunction. Pts come with progressive motor weakness, dysarthria, dysphagia, loss of gag reflex and difficulty handling oral secretions. Only yhe motor system is affected. Upper motor findings are sasticity and hyperreflexia. Lower motor neuron findings are wasting and fasciulations. Mental function remains intact.
Death results in inability to handle oral secretions and recurrent pneumonia progressive respiratory insufficiency etc etc..
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[جوري]

A man comes to the ER with a seizure Head CT scan shows a 'ring' or contrast enhancing lesion. there is surrounding edea and modest mass effect..

1- HIV negative Pt.
2-HIV positive pt. CD 4 count is <100. the repeat CT shows a smaller lesion after two weeks of pyrumethamine and sulfadiazine
3-HIV positive pt. CD4 count is <100. the repeat CT shows the lesion is unchanged after two weeks of Pyrimethamine and sulfadiazine..

1- Ring or contrast enhancing lesions can be either neoplastic or infections. in HIV negative a brain biopsy must be preformed to confirm the dx.. there is no clear way to determine a precise histological type without a biopsy.

2- toxoplasmosis occurs in HIV positive pts with <100 CD4 cells. the response to RX wih pyrimethamine and sulfadiazine for two weeks is sufficiently specific to confirm the dx.

3- lymphoma presents as a constant contrast enhancing lesion in HIV positive pts with <100 CD4 cells. There will be no response to therapy for toxoplasmosis. A brain biopsy must be performed to confirm.

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A man comes to the office for eval of a tremor

1- the tremor is in the hands and occurs both at rest and when he is moving them. it is worse with caffeine. An alcoholic drink improves it.

2- he is an older pt. the tremor is only at rest and does not occur when he is reaching for an object.

3- there is no tremor at rest. When he reaches for something. his hands wobble considerably


1- Benign essential tremor occurs both at rest and when reaching for objects. caffeine and beta agonists make it worse. Alcohol improves the treatment. treatment with propranolol.

2- parkinsonian tremor occurs at rest and isn't present on intention such as when reaching for objects.

3- cerebellar disorders such as a stroke result in a tremor only when reaching for things. This is similar to an abnromal finger to nose test. There is no tremor at rest.

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A man is being evaluated for dementia. He has poor short term memory

1- He has parkinsonian features such as tremor, rigidity, and gait abnormalities in addition to the dementia.
2-The dementia has been rapidly progressive over several months. He has myoclonus.
3- there is gait ataxia and urinary incontinence.
4-Social inappropriateness and emotional lability preceded the loss of memory.

1-Lewy body dementia is accompanied by features of the movement disorder of parkinson's disease.
2-Creutzfeldt-Jakob disease is characterized by rapidly progressive dementia and myoclonus jerks.
3-Normal pressure hydrocephalus is the triad of dementia, gair ataxia and urinary incontinence.
4-Frontotemporal dementia or pick's disease, starts with abnormalities of social appropriateness and emotional lability prior to the loss of memory. There is inappropriate anger, laughing or crying. MRI of the brain shows focal 'lobar' atrophy of the brain. Alzheimer's disease is slowely progressive loss of memory with no focal neurologic abnormalities.

__________________________________

A man in his 30's is brought by his fam for cognitive abnormalities. He has developed progressively worsening emotional outbursts such as anger, depression, and paranoia. There is a profound movement disorder similar to chorea. He is now showing memory loss

Huntington's disease consists of personality changes such as emotional instability, paranoia and depression combined with a movement disorder and dementia. the disease is AD
the diagnostic test is for a specific DNA sequence abnormality consisting of CAG trinucleotide repeat sequences.
there is no therapy.
________________________________

A man is brought to the ER for weakness. the weakness begins in his feet and has progressed to bilateral severe weakness of both legs. Knee jerk and ankle reflexes are absent. He recently has an episode of gastroenteritis

Guillain Barre syndrome consists of ascending weakness that progresses from the feet upward. The weakness may involve the diaphragm, at which time the respiratory failure develops. Deep tendon reflexes are lost in an ascending fashion. There is an association of Guillain Barre after an episode of campylobacter gastroenteritis.
the diagnosis is most accurately confirmed with nerve conduction studies which sow a decrease in conduction velocity. CSF shows an elevated protein with no cells. PFT test are crucial to determine who is most likely to develop respiratory paralysis.
treatment is with IV immunoglobulins or plasmophoresis.
________________________________

an alcoholic man is brought to the er dept with confusion, agitation. on exam there is paralysis of the extraocular muscles and gait ataxia

Wernicke's encephalopathy is characterized by the development of confusion, gaze plasies, and nystagmus as well as ataxia of the gait. It is most commonly found in Alcoholic pts. It is caused by a thiamine deficiency.
rx is admin of thaimine
______________________________

72 year old man is evaluated in the office for rigidity, tremor, micrographia and hypomimia (reduced degree of facial expression)
1- orthostatic hypotension is the most significant abnormality
2- vertical gaze plasy is striking
3-Ataxia such as an abnromal heel to shin and finger to nose tests is the chief complaint.

1- Shy-drager syndrome: parkinson's disease with orthostatic hyptonsion as the main finding.
2- supranuclear palsy: vertical gaze plasy is the most important feature
3-olivopontocerebellar atrophy: Ataxia is the main feature
_____________________

A man with metastatic prostate ca. comes in for eval of pain and motor weakness of the lower extremities. There is bilateral leg weakness and sensory neuropathy. "saddle" anesthesia or loss of sensation in the perineal area is striking. Bowel and bladder abnormalities are present

cauda equina compression is a peripheral nerve injury that presents with urinary retention, saddle anesthesia and progressive leg weakness. Saddle anesthesia is numbness in the perineum, genitals, buttocks, and upper inner thigs. Urinary retention with over flow incontinence may occur. Anal sphincter tone is decreased in 60-80% of pts.

MRI is the most accurate diagnostic test. Surgical resection of the compressive lesion should be ASAP ..
____________________________

A chronic smoker comes in with an abnromal X-ray with a lesion in the superior sulcus. On PE, he has dropping of his eyelife on one side. the pupils are unequal in size (anisocoria) the pupil remains constricted in dark light. He doesn't sweat on one side of the face.

Horner's syndrome is unilateral presence of ptosis, with diminished elevation combined with anisocoria from the inability to dilate the pupil; as well as anyhydoris, which is the loss of the ability to sweat on one side. Horner's is the combination of miosis, ptosis and anyhrodsis
Horner's syndrome is from loss of sympathetic stimulation. This can be congenital or from cervical adenopathy, from carotid dissection of from a pancoast tumor or superior sulcus tumor.

________________________________________

A pt comes in with weakness of the legs progressive over several months, there is loss of bladder control and abnormalities of the deep tendon reflexes. Hyperintense lesions of the white matter of the spine seen on MRI

1- the pt from the caribbean motor defects are limited to the legs. There are antibodies to HTLV-1 in the serum
2- Motor defects are present in the arms as well. She has an episode of optic neuritislast year. MRI of the brain shows lesions as well

1- Tropical spastic paraparesis (TSP) is from an unclear effect of HTLV-1 on the white matter of the thoracic spine. Defects of the motor and sensory system are limited to the legs. urinary abnormalities are present as well. There is no proven treatment. Resolution does not occur, and the condition is chronic and progressive. There are no ocular abnormalities in TSP.

2- Multiple sclerosis presents with multiple motor, sensory, urinart and autonomic abnormalities of the entire nervous system. Defects tend to relapse and recur. They occur in different areas over time. the most common abnormality is optic neuritis ...

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[جوري]

still on neurology

A man comes in with muscular weakness. the weakness makes it difficult for him to chew his food, and he has difficulty swallowing.
1- the weakness is worse at the end of the day. repetitive exercise makes it worse.

2- He has lung cancer and repetitive exercise makes it better .

3- the weakness occurred only after an infusion of gentamicin.

Myasthenia gravis with worsening weakness with repetitive exercise. There is ptosis and difficulty swallowing. The best initial test is antibodies to ACH receptors. The most accurate test is an electromyogram. Tensilon (edophonium) test confirms the DX

2- Eaton Lambert syndrome is a mysthenia like syndrome to in association with small cell lung ca. Repetitive exercise makes it better..

3- Aminoglycoside use can provoke muscle weakness by inhibiting the neuromuscular junction.

________________________________

An HIV positive man with 25 CD4 cells comes in for eval of Multiple motor, sensory and cognitive defects. MRI reveals white matter lesions in multiple places. the lesions don't enhance with contrast. There is no mass effect and no surface edema

1- progressive multifocal leukoencephalopathy (PML) results in multiple white matter lesions wth no ring enhancement and no mass effect. PML is a viral infection that causes disease only for those with the most profound immunosuppression. such as AIDS with CD4 cells <50. toxoplasmosis and lymphoma both give mass effect and contrast enhancement. PML is from the polyoma virus knows as the JC virus.

2- there is no specific antiviral therapy known to be effective for the JC virus causing PML. the lesions will resolve if antiretroviral terapy is used that raises the CD4 cell count.

______________________________

A man comes to the ER because of a sensation of the room spinning around him as well as nausea. Nystagmus is present on examination.

1- changes in position of his head precipitates the vertigo. Hearing is normal and there is no tinnitus or ataxia.
2- hearing loss, tinnitus and ataxia are present.
3-Hearing loss and tinnitus are present this is the first episode.
4-There are multiple episodes of hearing loss and tinnitus in his ears.
5- there has been recent head trauma

1- benign positional vertigo is isolated vertigo brought on by changes in the position of the head, there are no other findings

2-acoustic neuroma or eight nerve tumor can have prominent ataxia in addition to hearing loss and tinnitus.
3- labrynthitis is a viral infection of the inner ear that leads to a single episode of hearing loss, tinnitus and vertigo
4-Ménière's Disease presents with recurrent and persistent episodes of hearing loss, tinnitus, and vertigo, this is like persistent or recurrent labyrinthitis.
5- perilymph fistual occurs from head trauma resulting in anatomic damage to the inner ear. all forms of vertigo are associated with nystagmus.
_________________________________________

ob?gyn

a woman comes in for eval of pelvi pain that began several days before her period and continues until the menstrual flow slackens. she also has dyspareunia. Pelvic exam shows some tender nodules in the cul de sac.

endometriosis presents with pelvic pain related to the timing of mensuration. the pain begins a few days before the period and continues until the flow stops. Dyspareunia and infertilit are often associated with it.
Ultrasound or MRI can be done as the best initial test. the most accurate test is a laproscopy.
treatment for endometriosis is with combination estrogen/progesterone contraceptives. Androgens such as danazol can also be effective. GnRH agonsts such as leuprolide or nafarelin can be used to inhibit ovulation. Mild discomfort is best treated with NSAIDS.
___________________________________________

a primigravid woman comes to L&D because of abdominal pain she is found to have a blood pressure of 150/92 proteinuia and a headache peripheral smear shows schistocytes and fragmented cells. The AST, ALT and bilirubin are 3 times the upperr limit of normal. plt count is 87,000

HELLP syndrome.. is comprised of hemolysis, elevated liver function tests and low plts. in a woman in her second or third trimester o pregnancy. Eighty five percent of pts have HTN and proteinuria, hence it is a variant of preeclampsia. Many pts will complain of abdominal pain. Look for abnormal blood smear, elevated transminases, and thrombocytopenia.
delivering the baby is the mainstay therapy. there is no doubt that rapid delivery is the best management if the pt is >34 weeks of pregnancy. for those at earlier stages of pregnancy, steroids should be given.

________________________________

A woman comes in because of abnormal vaginal bleeding, she has not had a period for 16 weeks. there is no fetal movement or heart sounds. the uterus is considerably larger than it would be at 16 weeks of gestation. She has passed grapelike clusters of material from her vagina. Her HCG level is >40,000

Gestational trophoblastic dz or hydatidiform mole presents with abnormal uterine bleeding. Vomiting and a uterus enlarged to a size greater tha would be expected 10-16 weeks of gestation.. the HCG level is markedly elevated and there can be passage of grapelike clusters.
sonography is the most accurate test.
surgical evacuation is the best initial therapy.
___________________________

37 year old woman in her 7th month of pregnancy comes in because of vagina bleeding. she is a smoler with a HX of HTN
1- the uterus is painful and tender, there is no fetal distress noted on the monitor. abnormally increased numbers of uterine contractions are present, sonography is inconclusive.
2- the uterus is not tender or painful, there is no abnormal uterine contractions. abdominal sonography confirms the diagnosis

1- Abruptio placenta is painful, late trimester bleeding. the uterus is ender. abruption is the separation of the placenta from the uterine wall. mild abruption will have no fetal abnormalities. More severe cases will present with fetal distress. If there is no fetal distress, the patient can be managed with conservative in hospital observation. More severe cases with fetal distress requires delivery of the child. Sonography will ot confirm the dx of abruption. HTN and smoking are risk factors for abruption,

2- Placenta previa is painless later trimester bleeding. sonogram confirms the diagnosis. Do not do a digital pelvic or speculum exam for abnromal bleeding without a sonogram to exclude placenta previa. the uterus is nontender.
___________________________

a pregnant woman in her 27th week of pregnancy comes t the hospital for edema and HTN protein is present in her urine

1- blood pressure is 148/96 there is 2 g of protein in a 24 hr urine.

2- blood pressure is 162/112 and 7 g of protein are present in 24 hrs. PLT count is 85,000. she developed a seizure

preeclampsia presents with mild HTN, edema, and moderate proteinurea. plt count is normal. the management is conservative. rapid delivery is not necessary. Magnesium sulfate doesn't need to be given immediately.

2- Eclampsia is characterized by seizures, severe HTN, marked proteinuria and possibly thrombocytopenia. Rx is with Magnesium sulfate, labetolol, or hydralazine to control BP and urgent delivery of the baby. Diazepam can be used to manage seizures.

_________________________________

Opthalmology

a pt comes to the ER with the sudden loss of vision in one eye. the eye isn't red, painful or tender

1- visual loss occurs 'like a curtain coming down' in from of his eyes, there are bright flashes of light.
2-pale milky retina wit a 'cherry red macula' the arteries have areas of pallor interspersed with blood in a 'boxcar' pattern
3-collections of blood are visible in the retina
4-Headache and jaw claudication on chewing
5-examination is normal. Visual loss resolves in a few hours

1- retinal detachment presents 'like a curtain coming down' with flashes and floaters. The Question may describe a hx of head trauma.
2- retinal artery occlusion gives pale retina with a cherry red macula the eye is not red or painful
3-retinal vein occlusion presents the same way as retinal artery occlusion, but acute hemorrhages are present on retinal examination .
4-Giant cell or temporal arteritis gives headache, jaw claudication and tenderness of the temporal area. occurs in pts older than 50.
5-Amurosis fugax from an embolus gives a normal physical examination. the eye is not red, painful or tender.
___________________________

A man comes to the ER dept with sudden onset of a painful red eye.
1-a pupil is nonreactive and is fixed at mid dilation. Visual acuity is decreased.
2- a discharge is present. Lymph nodes are enlarged.
3-Photophobia is present there maybe hx of sarcoidosis or Reiter's syndrome.
4-He sustained ocular trauma earlier today. he feels like 'Sand caught in his eyes'

1- Acute angle closure glaucoma gives a painful tender, hard eye with a noreactive pupil fixed at the midpoint, Tonometry shows increased pressure and the cup-to-disc ratio is >0.3
2- conjunctivitis is the only form of 'red eye' that gives an ocular discharge. viruses cause bilateral disease. enlarge the pre-auricular nodes, and cause itching of the eyes. Bacteria cause unilateral disease
3-Uveitis is associated with photophobia, the diagnosis is confirmed with slit lamp exam, and the best initial therapy is with topical steroids. Inflammatory bowel dz may be described in the case.
4-Corneal abrasion gives a feeling of foreign body sensation from trauma. the most accurate test is a fluorescin staining. contact lenses are likely described in this case..

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[جوري]

before I go on with tonight's stuff let me get out of the way a brief caveat on how to handle hyponatremia! electrolyte/acid/base imbalances in the human body is a biggie and you need to know proper algorithm on how to handle a pt in such states.

someone comes in with hyponatremia measure their serum osmolality see if it high, low or normal

if it is high, the problem is glucose remember for every hundred over glucose is you lose 1.6 sodium
if it is normal, the problem is lipids or proteins
if it is low you must figure out their volume status
how do you check out for volume status? you'll check out their state, if they have edema it is high, check for orthostatic hypotension tachycardia to see if high it is an edematous condition like heart failure, liver failure or nephrotic syndrome ..
if the extracellular fluid volume is low, they are fluid depleted then you must measure urine sodium
if the urine sodium is low i.e <10 then they are probably losing fluid from the skin or the GI tract..
if the urine sodium is high >20 they are probably losing fluid from their kidneys
if the extracellular fluid volume is normal, it is almost always SIADH or one of the drugs causing SIADH, could be water intoxication, could be a thyroid problem

 

[جوري]

a bit about acid base disorders


Let's talk about acid base disorders
specifically
Alkalosis = High Ph
Acidosis = Low PH
then move on to renal tubular disorders
definitions for starters, Alkalosis is a situation when the Ph is high
first step is to determine whether this is alkalosis or acidosis
first start by looking at PH
so if PH = 7.4 +/- 0.3 that is normal
PH < 7.37 = acidosis
PH > 7.43 = alkalosis

then once you know whether acidosis or alkalosis
you need to determine whether it is respiratory acidosis or alkalosis or whether it is metabolic acidosis or alkalosis
arterial blood Gas will give PH
PCO2 normal value is between 35 and 45 very dependent on your breathing rate, the faster you breathe the lower your PCO2 will be, the slower you breathe or if you hold your breath the higher your PCO2 will be these change very rapidly..
then there is the bicarbonate level NL (20-28) it is a metabolic buffer, so changes slowly... thus if you get acidotic and your bicarb is set to change that, it will happen slowly compared to PCO2 in mins
the next thing you get is Oxygen level which can vary depending on which altitude you live at and O2 sat level typically in the mid nineties
we mostly however focus on PH, HCO3- and CO2
respiratory alkalosis for starters
is caused by multiple reasons
hyperventilation, rapid, acute fast breathing
also anxiety, from acute pain, panic disorders
the PCO2 will go down but O2 will be normal
can happen in acute respiratory disorders, acute pneumonia or PE, also early ASA toxicity --
in an acute there is no time for metabolic compensation
PH High
PCO2 Low
and HCO3 will be unchanged (typical of respiratory)
24 year old female feeling suffocating, tightness of throat and chest
RR 36
ABG =
PH =7.52
O2=99% (no lung probs)
PCO2 low
HCO3= unchanged
alkalosis because high PH PCO2 low, breathing fast alkalosis respiratory alkalosis
Another case:
24 year old female comes to the ER feels like she is suffocating, RR 36 tightness in throat and chest
ABG
PH= 7.52
o2 sat = 72%
PCO2= 25 (very low) normal is (35-45)
Hco3- 27 (normal)~
not anxiety or panic, case of something wrong with lung, maybe has BCP acute respiratory alkalosis lung disease
________________
now metabolic alkalosis

the problem is that you are either gaining HCO3- or losing H+
how does this happen?
lose acid, with prolonged vomiting, or other NG tube for instance sucking fluid along with stomach content
or diuretics and make them alkalotic,
or rather than losing acid, you gain alkali
like with antacids, milk alkali syndrome build up of bicarb.
metabolic alkalosis is a slow chronic process, losing acid, or eating bicarb as slow gradual, as ou start to become alkalotic the body will have you correct by having you breathe slower, so PH falls from alkali closer to normal
PH increases
HCO3- increases
and respiratory rate slows

typical case
67 year old with HTN on HCTZ complains for fatigue, with orthostatic hyptenion
she is hypokalemic K down, Hyponatremic Na+ down and hypochloremic Cl is down
Ph 7.42 (a little alkali)
PCo2 is high
HCO3- is high
alkaline, highbase in her blood
metabolic alkalosis, body is trying to compensate, by raising PCO2 higher and higher
high PH, High bicarb, high PCO2 for respiratory comp.



____________________

Now Acidosis


Hypovnetillation could be acute could be chronic
unable to blow off PCO2.. hold your breath
or COPD, can;t exhale all the air all the time
do it long enough breathe poorly because of chronic obstructive lung disease
kidneys will retain bicarb to lessen the acidosis
Acute respiratory acidosis, taking narcotics, lowering respiratory rate, or acute asthma
on chronic basis, with chronically elevated
pickwikian syndrome, PCo2 rise get startles awaken
manifestations of high PCO2
blood gases are
decreased PH
High PCO2 breathing slow or poorly not ventilating well
if acute bicarb won't have time to rise, in time it will rise but will never be completely normal
typical
27 year old RR 7
needle tracks pupils are small narcotic overdose
Ph =7.28
O2 sat low
PCo2 =High not breathing
bicarbonate hasn't compensated it is normal

72 year old woman with COPD, comes in with gradually SOB
PH 7.37
O2 90% borderline of normal
PCo2 high 56
HCO3 at 32 also high
she is acidotic because breathing ineffectively
in attempt to correct bicarb rises to bring Ph toward normal

Ph 3.37
O2 Sat = 90%
PCO2 high at 56
HCO3- 32 high
not primary?
___________
metabolic acidosis most complicated
a whole bunch of causes but in general
relative increase to the quantity of acid due to the following
1- addition of acid
2-inability to excrete acid
3-loss of base Hco3-
mechanism low PH
HCO3- low (decreased)
RR increased for compensation in effort to blow off PCO2, thereby increasing PH back to normal, occurs rapidly.
sudden acidosis it will kick in right away..

typical case 17 year old with diabetes hasn't been taking his insulin -- presents with altered mental status
ABG
PH =7.29
O2 sat = 97%
PCO2 = 29
HCO3= 17
metabolic acidosis both PH and bicarbonate are low, as compensation body has been breathing fast to bring down PCO2 to bring that number down
metabolic acidosis
first step look at
metabolic acidosis with high anion gap or with normal anion gap
anion gap adding sodium and potassium subtracting from them the two engatives in blood
so
[NA+ + K] - [cl + HCO3-]
normal anion gap is 11+/-3 that is between (8-14)
high anion gap higher than 11 +/-3
some other acid has been added to the body
if normal anion gap excess HCL or loss HCO3 base
high anion gap acidosis
a few causes
anion gap is >14
acid other than HCL
chloride is unaffected
1- ketoacidosis (due to alcoholic or diabetic, starvation)
lactic acidosis, renal failure, intoxication
ethyelene glygol, salicylates
lactic acidosis
aspirin
methanol
uremia
DKA
Proylene glycol
Isopropyl
ethlene glycol
(La Mud pie )

high anion gap
ketoacidosis over production of ketone bodies
in RF unable to excrete organic acids
normal anion gap
all have in common, pt is losing bicarbonate from GI or urine
or can't excrete acid in urine
common causes are diarrhea from loss of HCO3-
or RTA inability to excrete acid in urine

normal anion gap acidosis
RTA several types
all of these types have one thing in common the inability to effectively acidify the urine.
the kidney ought to be rid of acid -- urine could even be alkalotic overtly wrong

type I- occurs in distal tubules of kidney, the primary defect, Urine PH high, seen in bunch of conditions
kidney stones, Amphotercin B toxicity
lithium use, Sickle cell disease
diagnose with acid challenge,
expecting to spill over in urine
still can't acidify then in urine so give bicarbonate
RTA II in proximal renal tubules
problem to absorb bicarbonate until the levels are very low and eventually when urine goes to distal tubules some will be resorbed, lots of bicarb in urine even when having acidic blood
this occurs in a bunch of conditions
like meyloma, fanconi syndrome, wilson's disease
so basic defect inability to absorb bicarb, this is diagnosed bicarbonate is lost in the urine even in the face of acidic blood, and the way you treat is, is by volume restriction-- volume restrict, enhances ability to absorb bicarbonate
type IV due to hypoaldosteronism due to adrenal insufficiency or diabetes, presents with hyperkalemia, restrict salt, urine sodium is still high must treat with fludacortisone, mineralcorticoid agent
essential basis about RTA
RTA- I
Defect: Distal tubule can't excrete acid
result urine is alkaline even when the blood is acidic
the potassium will be low
the test to do is acid load test-- the urine remains alkaline even when given an acid load
treat it: by giving oral bicarbonate

RTA II
defect: proximal tubule can't absorb bicarbonate
result: urine remains alkaline except in very low flow state
potassium here is :low
test for this: bicrabonate load test, renal tubules don't absorb the bicarbonate and urine remains alkaline
treat: volume restriction

RTA IV

Defect is adrenal or aldosterone deficiency, results in high urine sodium, aldsterone causes you to retain sodium and lose potassium, so if you have an aldosterone deficiency you'll lose sodium and retain potassium
when you lose sodium, sodium exchanges with hydrogen and potassium, you build hydrogen concentration in blood -- hydrogen is an acid will also retain potassium which makes this different from the other two states
test: salt restriction test urine sodium remains high because you don't have mineralocorticoid activity, the treatment is to replace mieralcorticoid with fludrocortisone

 

[جوري]

opthalmology

an elderly man comes for eval of visual loss over last several months, peripheral vision is in tact. central vision is lost. Doesn't have DM or HTN. lesions are visible on the retina.

1- Multiple Drusen ( an eye disease resulting from small accumulations of hyaline bodies underneath the retina) are visible. they are dry without new vessels

2- straight line appear wavy or curves. there is sudden deterioration in vision over weeks.

1- Age related macular degeneration can be either dry or wet . Dry ARMD presents with loss of central vision and multiple yellow drusen on eye exam. This is very slowely progressive. no clear therapy

2- wet ARMD can have sdden, rapid prgression over several weeks to months. subretinal fluid hemorrhge, and lipid exudate are visible. neovascularization appears as grayish discoloration in the macular area. Flurescin angiography reveals the choroidal new blood vessles being formed. treatment is with vascular endothelila growth factor inhibitors such as ranibizumab or pegaptanib. they are given by intravitreal injection.

_________________________________

a 34 year old man comes in for evak of visual loss and eye pain developing over one to two weeks. he has diminished perception of red colors. The optic disc is swollen on examination. eye pain is worsened by movement of the eyes. The pupil constricts only when light is show in the unaffected eye

Optic neuritis presents with unilateral loss of vision peaking in one to two weeks. there is swelling of the optic disc and pain on movement of the eyes. color desaturation is a partial form of color blindness. the normal eye will see an object as dark red, the affected eye wil see it paler, such as pink. an afferent pupillary defect is present. An afferent pupillary defect is present. the affected eye will not constrict when light is shown directly into it, but it will constrict when a light is show directly into it. but it will constrict when light is shown in the normal eye. this is known as marcus gunn pupil

multiple sclerosis is the most common cause of optic neuritis, encephalitis and lupus also cause optic neuritis

most cases will respond to steroids.

___________________________________________

a pt comes in for a sudden onset of double vision and a headache. he has severe sinusitis that didn't respond to antibiotics. extrocular movements are markedly impaired. cranial nerves III, IV, and VI are paralyzed. There is ptosis, chemosis ( edema of the mucous membrane of the eyeball and eyelid lining) and proptosis

cavernous sinus thrombosis is an acute thrombosis of the venous sinus surrounding the sphenoid sinus. usually from a sinus infection. the key to the dx is the presence of opthalmoplegia from plasy of the third, fourth and sixth cranial nerves. there is marked redness and swelling of the eye, and bulging forward of the eye, proptosis. ptosis occurs from impairment of the third cranal nerve, which normally lifts the eyelid. when black materka is present on the palate in a diabetic the diagnosis is mucormycosis.
MRI is the most accurate test.
surgical debridement is critical in the management, in addition to atibiotics, without surgery mucormycosis is rapidly fatal.
________________________________

pediatrics

a child comes in with several days of cough, coryza and a low grade fever
1- barking, spasmodic cough and stridor is present. the voice is hoarse

2- after 7-10 days of upper respiratory tract infxn, paroxysms of coughing occur. there is striking gasp or whoop after the paroxysm of cough. there are typically five or mroe cough per episode.

1- croup is a viral infection of the upper respiratory tract that results in a barking cough and inspiratory stridor. the white cell count and temperature maybe mildly elevated. An anterior posterior neck xray will show sublottic stenosis. RX is with inhaled epinephrine and dexamethasone.

2- Pertussis or whooping cough presents with paroxysms of coughfollowed by high pitched inspiration, or whoop. the diagnostic test is a culture or PCR secretions for botdetella pertussis. Erythromycin and azithromycin are the antibiotics of choice. A hx of lack of vaccination maybe given..

_______________________

a chlld comes in with sudden onset of high fever, sore throat, drooling, dysphagia, and inspiratory stridor. swallowing is painful. the sx cause the child to sit up and lean fwd and hyperextend the neck. voice is muffled, cough is absent

epiglottitis is a respiratory emergency with a very ill, irritable appearing child with high fever, drooling and both pain and difficulty swallowing. the child leans fwd with a muffled voice to aid in handling oral secretion. difficulty breathing is common and may suddenly worsen. Cough is absent.

sudden aiway obstruction may occur with oral examination, venipunctur, or any cause of anxiety. for the msot critical intial step is to transfer the pt to an operating room or an area where emergency trachostomy can be perfomed.
Lateral neck x-ray may show swollen epiglottis as a thumbprint as the first test. direct visualization of the epiglottis should occur only after an airway is secure.
Intubation and ceftriaxone are the initial therapy after guaranteeingairway will not close off. Dexamethasone is useful.

__________________________________

a two year old child is brought in fo eval of shortness of breath resulting in irritability. the child squats to releive the SOB. A systolic ejection murmur is heard at the upper left sternal border. the S2 is single. A right ventricular heaven is present

Tetralogy of fallot is a common congeital heart defect. the pt may present at birth of later in life if the degree of pulmonary outflow tract stenosis is milder. toddlers will squat in order to increase venous return to the heart and improve sx of SOB. The S2 is single becase the P2 is not heard. right ventricular enlargement occurs because of pulmonic stenosis. the PS drives unoxygenated blood through a ventricular septal defect. transposition of the great vessles becomes symptomatic immediately after birth and soon as ductus arteriosus closes. The murmur of PS is heard at the upper left sternal border.

2- Echocardiography and cardiac cathe are the most accurate diagnostic tests.
Surgical closure is the rx
tetraology of fallot has a ventricular septal defect, pulmonary valve stenosis, over-riding aorta and a right ventricular hypertrophy.
______________________________

one Y/O child is brough with abdominal pain, blood is passed per rectum. there is nausea and vomiting.

1- the pain originally occured 15-20 mins apart, but has now become constant, lethargy has eveloped. A sausage shaped mass is palpable in the abdomen. the blood is mixed with mucus so it looks like currant jelly

2- there is repeated episodes of bleeding. tenderness is present to the left of the umblicus. upper and lower endoscopy are normal


1- intussusception is an idiopathic obstruction that occurs in the firsr year of life . the key to dx is abdominal pain progressing from episodic to constant combined with bloody stool and palpable abdominal mass.
Ultrasound or contrast enema are most accurate tests. Barium on air enema will successfully reduce 90% of pts intussusception. surgery is seldom needed.

2- Meckle's diverticulum presents with repeated episodes of lowe GI bleeding. it can mimic appendicitis. the dx is based on technetium bleeding scan/. surgical resection is necessary.

__________________

A male child comes in with hypogonadism. testosterone levels are low

1- at puberty extra long bones develop with gynecomastia and diminished sperm count. FSH and LH levels are abnromally high. the testes are atrophic.

2- A male infant has no testes palpable in the scrotum

3- Anosmia is present. there is renal agensis. The LH and FSH are markedly diminished
1- klienfelter's syndrome is hypogonadism associated with an abnromal karyotype. the pt is XXY. LH and FSH levels are elevated but the testes are nonfunctional with markedly low testosterone. these pts are normal until puberty. they develop extra long bones and gynecompastia. RX is with testosterone replacement.

2- cryptorchidism is usually apparent much younger when ne of both testes are missing from the scrotum. sperm and testosterone will be normal RX is surgically pull the testes down from the abdomen and attach them to the scrotum. this is important to do as early as possible because of increased risk of testicular cancer.

3- Kallamann's syndrome is a genetic defect resulting in low gonadotopin levels from hypothalmic deficiency og GnRH. Kallamann's syndrome is associated with anosmia and renal agensis.

_________________________________

a girl is brought in because of failure to achieve menarche. the pt is short in stature compared to her sis with a webeed neck and wide spaced nippled, she is hypertensive and has a murmur of a bicuspid aortic valve.

Turner's syndrome is a karyotypic abnromality with absence of a second second X chromosome in a phenotypic female. there is webbed neck, short stature, cardiac abnromalities.
Karyotype is X,O
treatment is growth hormone and estrogen replacement.

________________________________

a pt comes in with pain in his testicles

1- one testicle is higher than the other and lies in an abnormal horizontal axi. the entire testicle is tender and edematous and there is nausea and vomiting. the cremasteric reflex is absent

2- there is relief of pain with elevation of testis. fever and sx of dysuria are present. there is point tenderness on part of the testis.

testicular torsion presents as a surgical ER with sudden severe pain and swelling of the entire tests. the cremaster reflex is a absent. sonogram may help confirm the dx. surgical reduction of the testis is the rx.

2- epididymitis presents with painful testis that may show relief with elevation of the testis. both testis are at the same heigh and there maybe be fever and irritating sx on urination. there maybe redness of the testis. dx is with gram stain of urethral content. the most accurate test is a DNA probe or culture.
Ofloxacin or levofloxacin are useful.

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an infant is noted to have copious secretions shortly after birth. there is drooling, choking and respiratory distress, and inability to feed. Air is present n the Gi tract

traceoesophageal fistula and esophageal atresia presents with drooling and respiratory distress along with choking and cyanosis
DX is initially determined by inability to pass an orogastric tube. Contrast studies will confirm the dx.

rx is with surgical ligation of the fistula. if atresia is present, the ends of the esophagus maybe surgically re-anastomosed.

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[جوري]

1- a child comes with pain in his leg and a limp unrelated to trauma

1- a five year old child with progressive limp pain that is relieved by rest. X-ray of the hip shows widening by rest. X-ray of the hip shows widening of the articular space.

2- an adolescent pt who is obese, has groin pain radiating to the knee and thigh. X ry shows medial displacement of the epiiphysis and wide growth plates

!- Legg-Calvé-Perthes disease presents with a pain in the anterior thigh that is relieved by rest. the child is typically 5 and walks with a limp. pain is relieved by rest. This is probably from avascular necrosis of the femoral head. X-ray is the best initial test. the disorder is self limitin. range of motion exercises are appropriate

2- Slipped capital femoral epiphysis presents in older children who are obese. radiographic images show medial displacement of the epiphysis. surgical pinnin or external fixation are often necessary.

________________________________

2-A two year old Asian child presents with fever that isn't responsive to antibiotics. bilateral conjunctivitis is present with a rash, strawberry tongue, lips that are dry and cracked and cervical adenopathy. there is edema of the dorsum of the hands and feet. the superficial layer of the skin comes off in large sheets

Kawasaki disease, or mucocutaneous lymph node syndrom, begins with fever and progresses to bilateral conjunctivitis, rash, edema o he dorsum of hand and foot. Mucous membrane involvement is common. although sedimentation rate, C-reactive protein and plt count are all elevated, there is no specific test for Kawasaki's dz.
Coronary artery aneurysm and myocarditis with decreased myocrdial contractility are the most dangerous complications of therapy.
rx. IV immunoglobulin and ASA in order to prevent cardiac involvement.

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3-A child comes in with markedly enlarged lymph nodes in his elbow, axillary and cervical areas. the nodes are tender, there is fever, the child has a kitten and a turtle, and fishes as pets

cat-scratch fever is the development of painful, tender nodes a few days or weeks after a scratch or bite from a cat. fever isn't always resent. a small number of pts develop ocular involvement, encephalitis, or seizures.
serologic testing is often helpful. the most accurate test is aspiration f a lymph node with PCR or warthin starry staining of the materla.
nor rx necessary if limited to lymph nodes.

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4-a six year old child comes in with joint pain, there is also fever, multiple joints are red, swollen and painful. in addition there is a new heart murmur. the anti-strptolysin O titer is elevated. EKG shows a prolonged PR interval. throat culture is negative

Acute rheumatic fever is diagnoses with the presence of two of the major criteria (carditis, arthritis, subcutaenous nodules, chorea, and eryhema marginatum) the dx is also determines with the presence of one major criteria ( fever, arthralgias, high ESR, and prolonged PR interval on EKG) the diagnosis requires confirmation of the presence of recent streptococcal infection, such as a throat culture or anti-streptolysin I titer.

treatment is with antibiotics (PCN, erythromycin) for streptococcus and ASA. prophylactic pcn is used until the age of 21
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5- a 12 year old child comes to the office for evaluation of progressive leg weakness. he is unable to keep up in running with his peers and has frequent tripping. PE shows a high arched foot (pes cavus) and hammer toes. he has relatives with the same foot shape abnormality

Charcot Marie-tooth syndrome is progressive peroneal muscle atrophy. It presents with progressive weakess of the muscles of the legs with a high arches foot pes cavus and hammer toes. vibratory sense and general sensation are also lost in a glove and stocking pattern. reflexes are lost, gait abnormality such as steppage gait develops
nerve conduction studies show marked slowing of conduction. biopsy of a peripheral nerve, such as the sural nerve, shows marked axonal degeneration.

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6- a newborn with a fam hx of CF comes in with billious vomiting, abdominal distension, and failure to pass meconium. the pain is worst in the right lower quadrant. there is weight loss and poor appetite

meconium ileus occurs mostly in those with a HX of CF with tenacious meconium obstructs the terminal ileum.
pts present shortly after delivery with vomiting and right lower quadrant pain and distension.
Xray of the abdomen shows a soap bubble appearance f air bubbles mixed with meconium.
treatment is with enemas. Acetylcystine can be combined with the enema. if this isn't effective, surgery (such as a laparotomy) is performed.

_____________
7- a child is brought in with confusion, lethargy and intermittent episodes of disorientation. the pt had a recent viral synrome, and was given ASA. five days later, severe vomiting developed, followed by altered mental status. AST and ALT are 2-3 times normal. Bilirubin and CSF are normal

Reyes syndrome is enecphalopathy combined with fatty infiltration of the liver. a child who has had recent ASA for a viral episode, specifically chicken pox. clinical manifestations can be extremely severe, with deepening stage of coma manifested by progressive unresponsiveness, seizures, pupils that are fixed and dilated and respiratory arrest. SIADH and diabetes melitus can occur.
the dx is made based on enecephlopathy cmbined with fever, hepatic steatosis and recent ASA use. livr biopsy is the most useful test. blood CSF and glucose levels are frequently low. the bilirubin is normal but the PT time is often elevated.
there is no specific therapy for reye syndrome.

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8- A 12 year old boy comes in because of pain just below the knee. he is very active in sports and is generally healthy. there is tenderness and swelling of the tibial tuberosity a few inshces below the kneee at the patellar tendon insertion site

Osgoog-Schlatter dz is a chronic traction injury at the insertion pt of the paterllar tendon on the tibial tuberosity. the key is pain and swelling and tednerness on the exam below the knee. Osgood Schlatter is probably the most frequent cause of knee pain in children.. characterized by activity related pain. child rubbing his shinbones.
rx of osgood Schlatter dz is rarely necessary beside some analgesics, it resolves spontaneously over several weeks or months.

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9- a 12 year old child is brough in for eval of abnromal movements of hs face, and shoulders. there is facial grimacing and head jerking, and blinkin. he also produces cocal sounds that are barkin or grunting in quality, and seem involuntary, occasionally yells out obscene words

Tourette's syndrome is combination of motor tics which can be accompanied by involuntary use of foul language and barking and grunting sounds.
RX for tourette is with clinidine, or anti-psychotic meds such as haloperidol or risperidone.
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10- a man with HX of depression is brought to the ER with muscular rigidity, myoclnus, fever, ataxia, confusion, tremor and sweating, he was recently started on paraoxetine . meperidine was used yesterday for pain. dextromethorphan was used yesterday for a cough

sertonin syndrome is a colelction of sx and PE findings such as muscular rigidity, mycolonus, fever, ataxia, confusion, tremor, sweating. tere is no specific test to confirm the dx. the clue is recent initiation of SSRU, dextromepthrophan and mepridine increase the level of sertonin. can preciptate the syndrome.

There is no specific therapy.. stop all med...
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[جوري]

pulmonary..
1- pt comes in for evaluation for SOB over the last several months. His physical exam and chest xray can't determine a clear diagnosis. Pulmonary function testing is performed

1- FEV1 52%, FVC 54%, DLCO 40%, TLC 58%
2-FEV 1 44%, FVC 70%, DLCO 45%, TLC 128%
3- FEV 1 94%, FVC 92%, DLCO 110% FEV 1 decreases by 25% with methcoline

FEV1= forced expiratory volume in one second
FVC, forced vital capacity
DLCO, diffusion capacity of the lung for carbon monoxide
TLC =total lung capacity

1- restrictive lung disease to interstitial disease gives decrease in both the FEV1 and the FVC but the proportion between them is normal. Everything is decreased, but it is decreased equally. Because of interstitial fibrosis, the DLCO is decreased. Carbon monoxide can't adequately diffuse across the membrane.

2- Obstructive lung dsease (COPD) decreased both the FEV1 an the FVC, but the FEV1 decreases far more. The TLC is increases bu the volume is not usable because it is residual volume that participates in gas exchange. Increasing the RV is what leads to flattened diahragms and a barrel chest. The DLCO is decreased in COPD, the parenchyma is destroyed in the lung and you can't exchange gas if the lung is destroyed.

3- Asthma appears similar to COPD except that there is reversibility with bronchodilators. if the pt is normal at rest, methacholine is used to provoke a >12% decrease in FEV1 to confirm the diagnosis. Because te lung parenchyma has not been destroyed. The DLCO is normal, it can also be increased due to hyperventillation.

___________________________

2- A man comes to the office for evaluation of persistent asthma despite the use of inhaled bronchodilators. in addition to eisodes of SOB of breath he has sputum with brown plugs, transient infiltrates on chest x-ray and eosinophilia on CBC. there are 'tram-track' markings on chest x ray

Allergic bronchopuloonary asergillosis (ABA) presents with many qualities similar to asthma. thee is SOB, hemoptysis and wheezing. In addition, the chest xray shows recurrent transient infiltrates and 'tram-tack' lines in the bronchi. these track tram lines are indicative of edema of the bronchial wall and bronchiectasis. An elevated esosinophil count is the main clue for dx.

the most accurate diagnostic are elevated level of IgE, Aspergillus precipitans in the serum, Aspergillus-specific IgE and IgG. And sometimes increases skin test reactivity to Aspergillus. Aspergillus can sometimes be grown from sutum.

treatment is with prednisone and itraconazole.
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an obese, middle aged man comes to the office for excessive daytime sleepiness. He also notes impaired concentration. His wife says he snores alot. on PE exam he is obese and hypertensive

obstructive slee apnea is defined as the presence of excessive daytime somnolence combined with several additional findings, such as snoring, frequent nocturnal awakening, unrefreshing sleep and impaired consciousness. HTN is found is 50% of pts but is not part of the diagnostic criteria of the dz.

the most accurate test is polysomnography. this is the most accurate way to document periods of desaturation as well as periods of apnea and hypoapnea. By defintion, obstructive sleep apnea is a combination of the sx just described combined with >5 eisodes per hr of apnea and hypopnea.
treatment with continuous CPAP

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A man comes to the office with several month of cough productive of large volumes of sputum. he has fever and hemoptysis

1- fat malabsorption, intestinal obstruction and azoospermia. There are episodes of SOB as well

2- poor dentition, intoxication, seizures, stroke, or intubation. the sputum is foul smelling.

3- episodes of coughing and sputum production come and go it is chronic long term disease


1- Cystic fibrosis is charcterized by pancreatic insufficiency, leading to fat malabsorption, infertility from azoospermia, and intestinal obstruction. the azoospermia happens from imperfectly formed ducts in the male as well as blockage of sperm transport from insipisated secretions. the sputum ic colonized by multiple organisms.

Lung absecess occurs in tose with poor dentition and a reason for increased aspiration, such as seizures, stroke, intoxication or emergenc intubation. All of these impair the gag reflex.
Bronchiectasis is characterized by long term recurrent episodes of cough sputum production, infection. the dx is confirmed by high resolution CT scan.
____________________
a pt is on his third postoperative day when he is found t be suddenly short of breath, his lungs are clear to ausculaation. His pulse is 115 and his blood gas shows hypoxia

pulmonary emboli PE presents with sudden SOB with normal lung exam. there are no definite phusical findings conclusive of the dx of PE. pneumothoraz does not always give abnormalities on chest exam if it is small. that is why the best initial test is a chest xray.. chest xray is often normal on PE.

te most accurate test for a P is an angiogram. although this rarely is done. Spiral CT scan has become the standard of care in terms of testing. however the sensitivity of the est isn't ideal. low probability pts are often best tested with a D-Dimer tes by EliSA. the negative predictive valie of this test is greater than a negative spiral CT scan.

Starting with treatment with heparin is more important than waiting for a definitve diagnostic test such as the CT V/Q sca or angiogram. the presentation of the sudden onset of SOB with clear lungs is critical to the dx. CHF and asthma give clear abnormalities on exam.. pneumonia isn't sudden .
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38 year old AA woman comes for sevral months of SOB, dry cough and tender patches on her skin, just below the knees. thre are crackles on lung exam. the x ray shows hilar adenopathy

sarcoidosis is characterized by SOB with dry nonproductive cough. Sarcoidosis is far more common in AA wmen. Sarcoid is characterized in almost all cases by some form of abnromal lung finding on chest xray. this can be hilar, paratracheal, or mediastinal adenopathy alone or in combination with parenchyma involvement. Although systemic sx such as fatigue, fever, weight loss can occur, the diagnostic question is strongly base on seeing a woman with chronic dry cough. enrlarged lymph nodes on xray is the most characteristic finding on sarcoidosis.
the most accurate diagnostic test i a lung hilar node biopsy looking for noncaseating granulomas.
predinsone is the rx of choice.

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60 year old man with alcoholic cirrhosis has been admitted to the hospital with SOB. there is an increased alevolar arterial gradient. his SOB and hypoxia bexome worse when he sits upright. the chest xray and D dimer are normal

hepatopulmonary syndrome is a triad of cirrhotic liver dsease, hypoxia and worsening SOB upon sitting upright. worse dyspnea of being upright is referred to as orthdeoxia. It is presumed to be from vasodilatory substances that are not cleared by the diseases liver. This leads to abnromal pulmonary vascular dilation and right to left shunting.

hepatopulmonary syndrome can be confirmed by contrast echo. Technetium laveled albumin as a perfusion study can be diagnostic...

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[جوري]

A man comes to the office for progressive worsening SOB and cough, he has a barrel shapes chest. on CXRAY there are flattened diaphragms and bullae. Blood gas shows retention of carbon dioaxide and an elevated bicarbonate level

1- He is an elderly, long term smoker
2- he is youner than 40 and has never smoked. He also has unexplained liver disease

1- COPD generally occurs in long term smokers, particularly those over 60. all forms of COPD are associated with progressively worsening SOB. Cigarettes markedly accelerate the usual loss of lung function as the pt ages.

2- Alpha-1-antitrypsin deficiency results in premature emphysema in a nonsmoker under the age of 45. the findings can be identical to COPD that occurs in older smokers. There can also be evidence of unexplained cirrhosis as well.

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A pt comes with slowly progressive SOB over the last year or two. He has a dry cough, dry crackles on exam and a loud P2 heart sound. His CXRAY shows bilateral interstitial disease

1-He worked as a rock blaster being a glass manufacturer
2-He makes underwear. His SOB is worse on monday and improves by the end of the week
3-He was a shipbuilder an he has pleural plaques on XRAY
4-He manufactured electronic equipment and he has granulomas that respond to steroids.

1-Silicosis is a form of interstitial lung disease that occurs in those exposed to sand. glassmaking, rock blasting or raw quartz. It presents with a ry cough, SOB, and interstitial infiltrates on CXRAY and chest CT scan. there is no therapy.
2-Byssinosis occurs in those exposed to raw cotton, such as in the manufacture of fabrics. It is a type of fabrics. It is a type of reactive airways disease that is worse on the first day of the work week.
3-Asbestosis is classically found in shipbuilders. it is associated with pleural plaques. The most common cancer in asbestosis is lung cancer, not mesothelioma.
4-Berylliosis is a rare cause of granulomatous lung disease in association with the manufacture of recycling of electronic equipment and fluorescent light bulbs in the past. Steroids have been effective ..

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A man is brought to the ICU with acute SOB and hypoxia. he has been placed on mechanical ventilation. He has a stroke and you presume that he aspirated gastric content, resulting in pneumonia. he has bilateral infiltrates and his wedge pressure is normal. The ratio of PaO2 to inspired oxygen is <200

Acute ARDS is a disease of diffuse lung injury that results from sepsis, aspiration, trauma, pancreatitis. There is diffuse capillary leak. the CXRAY shows bilateral infiltrates, and there is marked hypoxia. The chest x-ray looks like CHF but the pressures are normal.

there is no specific diagnostic test for ARDS. it is presumptive diagnosis. the ratio of the arterial O2 to the fraction of inspired oxygen (paO2/FiO2) is <200

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A usually sedentary 50 year old man comes to the office for evaluation of painful arms and legs with thickened, erythmatous, edematous skin. Limb movement is restricted by pain and skin thickening. There is an orange tinge to the skin that resembles an orange peel 'peau d'orange' this began just after he started a vigorous exercise program. the white cell count is elevated with 45% eosinophils

this patient has esosinophilic fascitis. which is characterized by thickened, edematous skin that can restrict movement and looks like scleroderma. the skin color is orange tinged. the key to the dx is skin changes combined with blood eosinophilia. It often begins with a sedentary person who being a new vigorous exercise program. The skin is thick to the point of resembling an animal's hide. less common features are joint pain and carpal tunnel syndrome.
most accurate test is a skin biopsy
scleroderma has shiny skin, usually has raynaud's phenomenon and esophageal involevement. Scleroderma doesn't give eosinophilia.
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a 40 year old woman comes in with progressive musclar weakness occurring over months. She can't rise from seated position without using her hands. the muscles are tender There is a purplish perioribital rash and scaly lesions over the extensor surfaces of her knuckles. The CPK level and aldolase are relevated. the ANA is positive

polymyositis and dermatomyosistis present with proximal muscle weakness that makes it difficult to rise from a seated position or to walk on stairs. Half of the pts also have muscle pain. Dermatomyositis is associated with a helitoe rash. a purplish periorbital rash. Gottron papules are scaly lesions over the metacarpophalangeal joints. Elevation of the levels of CPK and aldolase are expected. A positive ANA is present in 80% of pts.

the most accurate test is a muscle biopsy. Antibodies to Jo-1 are resent in 30% of pts and are extremely specific for dermatomyositis. abnormalities in the EMG are expected.
Polymyositis gives an increased risk of malignancy and cardiac involvement.
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a middle ages woman comes in with several months of dry eyes and difficulty chewing and swalloing, particularly with dry ood. She feels constantly thirsty and also has dysareunia. she feels like there is a 'sand under her eye lids' physical exam revealed markedly enlarges parotid glands and multiple dental caries
Sjögren's Syndrome is an autoimmune disorder caused by lymphocytes attacking the lacrimal and salivary glands. Pts complain of dry eyes and dry mouth. it is also known as Sicca syndrome. Vaginal dryness leads to dyspaeunia. Saliva is necessary to physically leads to severe dental caries as well as loss of taste and smell.
the diagnosis is confirmed with a schrimer test, in which filter paper is placed in the eye. A normal person can moisten 15mm of the paper. Those with Sjögren's Syndrome moisten <5mm. Anti SS-A and anti SS-B antibodies are present in 65-70%. The ANA is present in 90-95% and the rheumatoid facor is 80%. The ANA and rehumatoid facto are non-secific. Biopsy of the gland is rarely necessary.
pt with Sjögren's Syndrome are at risk for lymphoma..
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A 24 year old woman comes in foe eval for recurring joint pain and a rash on her face, she has had episodes of fever that have never been diagnoses in addition to fatigue and some weight loss. she also reports intermittent chest pain that changes with respiration. the urinalysis shows red cells and proten

Systemic Lupus erythematosus is a multiorgan disease that is most commonly presents with joint pain and skin lesions. Nonspecific sx such as weight loss, fever, fatigue are common but are not part of specific diagnostic criteria. Even without lab testing. this pt has four manifestations of SLE, arthraligia, hematuria/proteinuria, serositis such as CP and rash. four of eleven criteria are the standard for dx of SLE

the full criteria is
Mala rash
discoid rash
photo sensitivity
oral ulcers
arthritis
serositis
renal disorder
Leukopenia (<4000/uL), lymphopenia (<1,500/uL), hemolytic anemia or thrmbocytopnia (<100,000/uL)
Neurologic disorder
Positive anti-DNA or anti smith antibodies or positive for antiphospholipid antibodies
antinuclear antibodies in raised titer..
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A woman comes to your office for substernal CP suggestive of reflux dz and dysphagia. she complains of episodes of severe pain in her fingers, associated with changes. On PE you note thickening of the skin and immobility of joints

1-Systemic sclerosis or scleroderma is characterized by thickening of one the skin that leads to immobility and pain in the joints. Raynaud's phenomenona is pain in the fingers with color changes from white to red to blue. Raynaud's phenomena is present in virtually all cases of scleroderma. Esophageal disorders are common. this can either be esophageal disorders are common. this can be either reflux, dysphagia or both.
The CREST syndrome is calcinosis, Raynaud's, esophageal dysmotility and telengiectasia.
there is no diagnostic test for scleroderma. the ANA is positive in 90% f ases of more. The anti-Scl-70 antibody is present in one third of cases and is directed against topoisomerase.
scleroderma results in death from involvement of the heart, lung, and kidney. pulmonary fibrosis and pulmonary HTN develop over time slowly

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[جوري]

Salaamz I needed to add this bit about FiO2 to accompany the last post

FiO2
From Wikipedia --yes


The FiO2 is expressed as a number from 0 (0%) to 1 (100%). The FiO2 of normal room air is 0.21 (21%).

A patient's FiO2 may be varied through the use of different Venturi masks, in combination with varying oxygen flow rates. In addition, most mechanical ventilators have controls for adjusting FiO2. An increased FiO2 is necessary in managing adequate oxygenation in patients who are critically ill due to causes such as major surgery, acute lung injury, sepsis, pneumonia, congestive heart failure, or other cardiopulmonary disease. The oxygenation to a patient on a ventilator can be manipulated by changing not only Fio2, but also the tidal volume,the respiratory rate and having a Positive end-expiratory pressure (PEEP). Generally the FiO2 is maintained at less than 40%. Higher settings can lead to oxygen toxicity.

Another common misconception is that the FiO2 changes with elevation. It remains at 0.21 at all altitudes within the atmosphere. What changes is the barometric pressure of air. At altitude, therefore, the partial pressure of oxygen delivered by that 21% of oxygen is lower. The partial pressure is the driving force to oxygenate the blood and therefore a lower partial pressure makes it that much harder to get O2 delivered to the tissues that require it, resulting in hypoxia.

It is important to note that the PaO2/FiO2 ratio:
The ratio should be greater than 286.
and anything below <200 could be considered ARDS
if you wish to know how to calculate oxygen needs etc in a patient then this is a good website

http://classes.kumc.edu/son/nurs420/unit2/calculating_oxygen_needs.htm

will follow up with high yeild notes later this evening insha'Allah

 

[جوري]

a woman comes in with months of fatigue and tiredness, and sleep disturbances. She also complains of headache.

1- young woman with muscle tenderness in the neck and shoulders. Alla tests are normal. Eleven trigger pts in the neck, shoulders and hips are tender.
2-older woman with an elevated sed rate and normal CPK, she has temporal arteritis. All sx respond to steroids
3-fatigue for longer than 6 months with normal tests. there are no physical findings

1- fibromyalgia gives multiple trigger pts of excessive tenderness in characteristic areas around the neck, trapezius, hips and kneees. Alla tests in fibromylagia are normal. the pt is under 50 pain is more prominent than lassitude. tricyclic antidepressants and exercise help.

2- polymyalgia ehumatica (MR) gives pain withiut trigger point tenderness. PMR is in older women and is associated with giant cell temporal arteritis. the CPK is normal but the ESR is markedly elevated. Normocytic anemia is often present. there is an excellent response to steroids.
3- CFS is defined as more than 6 months of tiredness. it is often associated with headache, sleep disturbance, muscle and joint pain and tender lymph nodes. there are no physical exam or lab abnromalities. there is no proven therapy.

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A man comes to the ER dept with the sudden onset of pain, redness and swelling of a joint

1- the pain occurs after an alcoholic binge. the metatarsal phlangeal joint is involved.
2-the pt has a hx of hemochromatosis or hyperparathyroidism. the knee is affected.

1- gout occurs most often in the first metatasophalangeal (Podagra). it can occur after binge drinking. aspiration of the joint is the most accurate diagnostic test. Gout is from uric cid crystals, which are needlelike with strongly birefringence under polarized light..
2-psudogout of calcium pyrophosphte dihydrate (CPPD) deposition disease is more common with hemochromatosis, hyperparathyroidism and acromegaly. the knee is most commonly affected joint CPPD crystals are rhomboid in shape, are blunted and have weakly positively birefringence.

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A man of middle eastern origin comes in with shere recurrent oral lesions of unclear etiology, he also has geintal lesions and erythema nodosum like lesions. he develops a sterile skin abscesses whenever he has a needle stick

Behçet syndrome is an idopathic disorder that occurs in pts of middle eastern or eastern origin. consisting or recurrent oral and genital lesions. ocular lesions such as uveitis, optic neuritis, or retinal vasculitis. skin and joint lesions are frequent.
there are no specific tests for this syndrome
the worst complication of Behçet syndrome is blindness. Neurologic involvement occurs in 20% of pts. this consists of chronic meningioencephalitis and may also lead to brain stem lesions and psychiatric disturbances. peripheral neuropathy isn't a feature.
mild Behçet dz responds to colchicine. severe dz is treated with steroids.
pathergy phenomenon (PP) is ofen used as a criteria for Behçet syndrome. it refers to the hypersensitivity to needle sticks..

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a 12 year old comes in with pain in multiple joins, fever and a salmon colored rash

1- there is also splenomegaly, tender lymphadenopathy, and pericarditis. the ESR is elevated. Iridocyclitis develops later. Joint fluid yields 8,000 white cells

2- the pt has a normocytic anemia, a profoundly low retic count, and giant pronormoblasts on the bone marrow. Generalized flulike sx are also present.

Jevenile RA presents with high fever, multiple large joint involvement, tender lymph nodes, splenomegaly, and complications of JRA such as pleuritis or pericarditis. iridocyclitis is a complication if JRA that may lead to blindness. A mildly elevated synovial white cell count is common.

2- parvovirus B19 presents wit a diffuse rash, flulike sx, and aplastic crisis. the alastic crisis is more common in those with a hemoglobinopathy such as sickle cell dz. parvovirus can also present as an isolated rash known as erythema infectiosum, or fifth dz. it looks like 'slapped cheeks'

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a pt with a hx of osteoarthritis comes in with pain in the back of the kneww on exam there is palpable fluids filled mass, that is felt when the leg is in full extension

A baker's cyst is an outpocketing of the synovium of the kneww that causes pain in the back of the kneww. these cysts are often easy to dx by palpation. when they rupture, pain extends into the calf. and may mimic a deep venous thrombosis. they occur in pts with hx of arthritis.

on PE, including transillumination is not diagnostic. Baker's cyst is detected by sono or MRI
Most baker's cysts don't need specific therapy. severely symptomatic cysts can be treated with aspiration or steroid injection surgery is often not necessary.

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a 53 year old man has had several month of cough, SOB, fever, and weight loss. there is hemoptysis, joint pain and sinusitis. last month he has his first episode of otitis media. the chest xray shows a cavitation. there urinalysis shows red cells, red cell cass, and potein. there is no response to antibiotics, and all sputum testing including TB is repeatedly negative

the most likely dx is Wegner's granulomatosis.
wegner's is characterized by upper and lower respiratory tract infxns, as well renal abnormalities, such as hematuria an proteinuria. the upper respiratory probs are sinusitis and otitis. in addition wegner's is a systemic vascuilitis with involvement of the brain (stroke) skin (purura/petichiae) eye (uveitis/iritis) GI tract bleeding and joint pain and neural tissues.

the best initial test is c-ANCA. the most accurate test is a biopsy of the involved organ. CHurg-Strauss syndrome would present only with lung and renal sx and would not affect the body diffusely, as does wegner's...

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a woman comes in with several month of progressive worsening joint pain and swelling in more than three of the joints in her wrist and metaxarpophalangeal joints.

the pain improves over several hours as the day progresses. the xray of the hand is normal

RA is characterized by a least four of the following

1- morning stiffness for at least one hr and present for at least six weeks of three or more joints.
swelling of wrist, metacarpophalangeal, or proxima intephalangeal symmetric joint swelling.
hand xray changes typical of RA include erosions or unequivocal bony decalcification
ra subcutaenous nodules
positive RA factors

RA is also associated with pericarditis, lung nodules and effusion, anemia, vascuilitis, and peripheral neuropathy.
the RA factor is nonspecific. the most specific blood test for RA is antibody to cyclic citrullinated peptide (specificity 95%)
___________________________

a man comes in with pain in several joints in an asymmetric distribution. he has back pain and sacroiliac SI joint is involved, he has pain in the knee and ankle as well. his RA factor is negative but he is ositive for HLA-B27 antibodies
1- an adolescent with decreased lumbar spinal mobility and back pain. He also has uveitis. X ray shows that he has fusion of the SI joint.
2there is nonspecific urethritis, circinate balanitis, and conjunctivitis. A skin lesion knows as keratoderma blennorrhagicum is present
3- psoriasis with nail pitting is present. the distal interphalangeal joints are especially affected.

all three of these cases are seronegative sondyloarthropathies. the RA factor is negative and antibodies to HLA-B27 are frequently present. the first case is ankylosing spondylitis. which is present in a young man with back pain and decreasing spinal flexibility. exercise improves sx. 30% have uveitis and 3% aortisis. A fused SI join on X ray or MRI is required for the DX

2-reactive arthritis orr Reiter's syndrome is a triad of nonspecific urethritis, conjunctivitis and asymmetric arthritis. Skin lesions are common.

3-Psoriatic arthritis occurs in 10% of thosw with psoriasis, Nail pitting is characteristic. as is involvement of the distal interphalangeal joints (DIPs) RA does not give sacroilitis or DIP involvement.

___________________________

a young asian woman comes in with fever, fatigue, weight loss, arthralgia and night sweats. these sx resolve, she later has an episode of syncope and amaurosis fugax. Arm pain is present on exertion. pulses are diminished in upper extremities

Takayasu's arteritis is an inflammatory polyarteritis of unclear etiology that occurs most often in Asian women before the age of 50. after an initial period of nonspecific inflammatory sx such as fever, fatigue, and weight loss. the pt develops an occlusive vascuilitis of the aorta and subclavian artery. Lesions proxima to the branching off of the verterbral artery. Lesions proximal to the branching off of the verterbral artery can result in retrograde flow from the brain. these subclavian steal sx may result in syncope and transient ischemic attacks. HTN is present in 25%. Arm pain develops from vascular insufficiency, as does diminished and eventually absent pulses.
the most accurate test to examine the vasculature by CT, MRI or angiogram.
corticosteroids improve sx.
_________________________

a pt comes in with a hx of connective tissue dz , he has recurrent episodes of pain in his external ears. Hearing is normal, but the cartillage of the ear is red, inflmmed and deformed. He has recently developed the same problem in his nose. Joint pain, hoarseness, and ocular sx are present as well.

relapsing polychondritis is an idiopathic inflammation of the cartilage of the ears, nose, larynx and trachea . the episodes are recurrent and ofen occur in those with other connective tossue disorders. Such as SLE or RA. the nose can ebcome severely deformed. Laryngeal involvement presents as hoarseness. iritis is part of the syndrome. after the acute attacks subside, the cartillage becomes deformed.
Some pts develop aortic root dilation and aortic regurgitation
relapsing polychondritis is treated with corticosteroids.
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>>>>>>>>>>>>>>>>>>>>>>>.

 

[جوري]

a 53 year old man has had several months of cough SOB, fever, weight loss. here is hemoptysis. the CXRAY shows cavitation . urinalysis shows red cell casts and protein. there is no response to antibiotics, and all the sputum testing is negative repeatedly, including TB.

1- upper and lower respiratory tract involvement. there is also multi-organ involvement such as joint, skin, eye, CNS and GI

2-Eosinophilia and asthma with wheezing

3- Only lung and renal involvement with no additional organs

Wegner's granulomatosis is a systemic vasculitis with upper and lower respiratory tract involvement. there is renal involvement as well, but this isn't unique. Wegner's also has joint pain, purpuric skin lesions, iritis and uveitis, GI lesions, sroke, and neurologic involvement.


2-Churg strauss syndrome also a systemic vascuilitis but it is unique in that it is characterized by eosinophilia and asthma .

3- Goodpasture syndrome is not a vascuilitis, although there is ling and renal involvement, the dz is limited to these two organs.

_________________________

A woman comes to the ER with right lower quadrant abdominal pain. she has a temp of 101 F and an elevated white count of 14,000

1- the pain started around the umblicus and is worse on passive extension of the right leg

2- there is cervical motion tenderness on pelvic exam

appendicitis presents with periumblical pain that progresses to pain at the right lower quadrant midway between the umblicus and the anterior superior illiac spine of the hop (McBurney's point) there may also be additional pain with passive extension of the right leg. CT scanning can help confirm dx.

Pelvic inflammatory dz and salpingitis presents with lower abdominal pain in women. both of these are associated with cervical motion tenderness (CMT), ectopic pregnancy can also lead to these findings.

_______________________________

a man is in the hospital several days after abdominal surgery. he is nauseated with abdominal pain and is unable to tolerate feeding. He has not passed stool or gas. He his bloated and there are no bowel sounds on auscultation

A dynamic ileus can occur with any form of abdominal surgery that penetrates the peritoneum. Normally, peristalsis should return within 24 hrs. prolonged ileus produces abdominal pain, bloating, absent bowel sounds and the inability to pass gas or stool.

an abdominal xray will show multiple air/fluid levels
there is no specific therapy to restore bowel motility. Decompression of the stomach should be performed with nasogastric suction.

___________________________________________

an elderly man comes to the ER dept with left lower quadrant abdominal pain

1- he has a fever elevated white count. there is tenderness in the left lower quadrant. the dx is best made with CT scan

2- he has rectal bleeding and the diagnosis is best made with a colonoscopy


1- diverticulitis presents with left lower quadrant abdominal pain and tenderness in an older person, because it is an infection, there is fever, leukocytosis. because of an increased risk of perforation with colonoscopy, the dx is best made with CT scan. Antibiotics such as ciprofloxacin and metronidazole are standard care.

Ischemic colitis is a type of chronic intestinal ischemia. it presents with pain and rectal bleeding. colonoscopy best confirms the dx. there is no specific therapy.

____________________________________

an infant suffers nonbilious projectile vomiting after almost every feeding. He is dehydrated. A firm, nonmobile, olive-sized lesion is palpated in the abdomen. There are fewer stools that are smaller. a wavelike motion is visible on the abdomen after eating. Metabolic alkalosis is present

pyloric stenosis is an idiopathic narrowing of the pyloric sphincter of the stomach. an infant between two and eight weeks of age develops progressively worsening projectile vomiting. the stenotic sphincter may be palpable in the abdomen, about the same size as an olive. After eating, peristaltic waves maybe visible on the abdomen. Dehydration and metabolic alkalosis may occur from vomiting
the most accurate diagnostic test is first an ultrasound and best with barium studies of the abdomen
surgical correction is best therapy with a myotomy.

___________________

a 36 year old man presents to the Er dept with severe pain in the back of his lower lef from the heel to the back of the calf. This hapened with a 'popping sound' as he started a game of basektball, which he plays every few weeks. He has been on cipro for the last 6 weeks for prostatitis

Achilles tendon rupture presents as a sudden 'pop' or 'snap' but apparently no crackle

:haha:.. just checking to see you are awake.. anyhow, this happens upon exercise or when vigorously dorsiflexing the foot. this is seen more often in those who engage in viperous activity after prolonged periods of inactivity without adequate stretching or preparation. there is severe pain n the back of the foor and up into the calf
quinolones predispose to achilles tendon rupture becaise of their ability to inhibit chondroblasts and osteoblasts
surgical reattachment is necessary.

___________________

a man comes to the Er because of intoxication. he is disoriented with an unsteady gait and an alcohol odor on his breath. he has metabolic acidosis with respiratory alkalosis as a compensation.
1- He has visual disturbance. his retina is hyperemic on exam and the anion gap is elevated.
2-Envelope shaped crystals are found on urinalysis. his serum calcium is low. the aion gap is elevated
3- his anion gap is normal

1-methanol intoxication is associated with an elevated anion gap metabolic acidosis and intoxication. methanol is metabolized to formic acid which leads to optic nerve toxicity and visual disturbance.

2-Ethylene glycol intoxication results most often from ingestion of antifreeze. it forms calcium oxalate crystals in the kidney and they appear as 'envelopes' in the urine

the formation of calcium oxalate crystals results in a low serum calcium level. both methanol and ethylene glycol lead to elevated anion gap.

3- Isopropyl alcohol is rubbing alcohol and ingestion leads to metabolic acidosis with a normal anion ap. the osmolar gap is elevated in all three scenarios indicating ingestion of an abnormal substance.
______________________________

A man is snowed in during a storm. He has a wood burning stove. the patient and his family have been having lightheadedness, fatigue, SOB and headaches, he feels better when he is shoveling snow.

carbon monoxide poisoning presents with lightheadedness, shortness of breath, headache, faitgue, when it is more severe there will be confusion and CP. the two most important clues to answering the dx question is either a woodburning stove in a contained area, or pt rescued from burning building. 60% of deaths from fires on the first day are from smoke inhalation and CO poisoning.

carboxyhemoglobin levels are the most accurate diagnostic test. the blood gas will show metabolic acidosis with respiratory alkalosis as compensation.
the best therapy is 100% Oxygen. Hyperbaric Oxygen is an answer if there is cardiac of CNS abnormalities.

______________________________

a man with severe CHF is brought in because of confusion, blurry vision, vomiting, diarrhea and color vision abnormalities. His potassium level is elevated. EKG shows ventricular ectopy and paroxysmal atrial tachycardia

digoxin toxicity most commonly presents with GI disturbances, such as nausea, vomiting, and diarrhea. Neurologic toxicity includes confusion, blurry vision, yellow halos around objects, and color vision mispreception. Hyperkalemia occurs from inhibition of the sodium/potassium ATPase. the earliest EKG abnormalities include atrial or ventricular tachycardia. and or atrial trachycardia with variable block.

treatment for digoxin toxicity is with digoxin binding antibodies. the strongest indication for digoxin binding antibodies is cardiac or CNS toxicity.

_______________________________________

a man who works in the demolition/construction business comes in with abdominal pain. He has HTN, anemia, renal insufficiency. PE exam shows foot drop. Peripheral smear shows basophilic stipling

lead poisoning in adults presents with abdominal pain or 'lead colic' there is a direct renal toxicity against the renal tubules. lead blocks the production of heme, resulting in sideroblastic anemia and basophilic stippling on blood smear HTN develops for unclear reasons. Neurotoxicity takes the form of wrist or foot drop.

the free erythrocyte protoporphyrin levels is elevated. lead level is the most accurate diagnostic test.
rx is with chelating agents such as succimer, EDTA, or dimercaprol. Succimer is an oral agent.

___________________________

an elderly woman with osteoarthritis comes in with hyperventillation, tachycardia and nausea. she also complains of tinnitus. Blood gas shows a PH of 7.45, pCO2 of 22, and serum bicarb of 14. Cxray shows pulmonary edema

Salicylate tox presents with nausea, hyperventillation, tinnitus and metabolic acidosis as well as primary rspiratory alkalosis.
ASA is also renal toxic both from direct toxicity to the renal tubules and from inhibition of prostaglandins that dilate the afferent arteriole. Non-cardiogenic pulmonary edema may be visible on chest xray.

Alkalinzation of the urine is performed in order to increase urinary excretion.
___________________________

a depressed pt comes in aftr a suicide attempt confused and disoriented. he is unable to offer a coherent hx. His mouth is dry, and there is urinary retention, dilated pupils and decreased peristalsis.

tricyclic antidepressant OD presents with signs of anticholinergic side effects of the meds. which include dry mouth, flushed skin, twitching muscles, dilated pupils, tachycardia, and diminished bowel sounds, seizures can occur.

the most urgent step is to do an EKG to check the presence of widening QRS. seizures and arrhythmias are most common cause of death.
RX of cardiac tox is with bicarbonate.

______________________________

a police officer has just been exposed to a nerve gas. he comes in with excessive salivation, lacrimation, urination and diarrhea. in addition there is wheezing and bradycardia

organophosphate toxicity most commonly results from insecticide exposure, in addition, it is the basis of nerve gas. pts presents with signs of ACH toxicity, such as salivation, lacrimation, urination, defectation, bronchospasm and bradycardia.

Atropine is the most important initial step in addition, to remove the pts clothing and wash him to decontiminate his skin.
Pralidoxime is the specific antidote for organophosphates .

___________________________________

thank you for reading..

 

[جوري]

approach to the patient with incontinence: most people believe they have this down (myself included) but have no clue how to approach the proble.. thus

the best thing to do is work systematically and develop a differential

1- irritatative incontinence
2- Genuine stress incontinence
3-hypertonic (urge incontinence)
4- Hypotonic (overflow incontinence)
5- Fistula or bypass incontinence


Now for your diagnostic plan:

cheapest first -- urinalysis looking for irritative incontinence -- what causes irritation of the bladder cause it to contact?
1- infection
2- tumor
3- foreign body
4- stones

your findings on urinalysis with an infection, white cells, and offensive agent.. with a tumor you'd find red cells (microscopic hematuria) as well with a foreign body-- if you have a urinalysis that doesn't show these three, then you've ruled out irritative incontinence .

Next cheap test is the Q tip test before cystometric studies..
Q tip test. pt lays supine put a lubricated cotton tip applicator in the urethra and have pt. increase intrabdominal pressure, if there is loss of support for the bladder, as the bladder goes down, the Q tip goes up, an increase in angel more than 40-45 degrees you have a positive Q tip suggesting increased mobility of the proximal urethra.

Now cystometric studies : ask the patient to empty as much urine as s/he can, then do a residual volume to see how much is left, leave the catheter in and infuse saline into the bladder, as the saline goes in, it empties from the cath into the tube and you can see the level of the fluid, see how high it goes and look for involuntary contractions by level of fluid going up and down and you'll instruct the patient on when the sensation of bladder fullness occurs, called the sensation of fullness volume, as well the sensation of wanting to void

the normal values for those:
a normal residual volume is <50cc
a sensation of fullness >250cc
sensation of wanting to void >400cc

dx genuine stress urinary incontinence:
loss of support of the urethral vesicle junction, so the proximal urethra is no longer an intrabdomionl structure

looking at plevic floor you can see that the pelvic urethra is an abdominal structure -- during coughing the intravesicle pressure goes up and the urethral pressure goes up as well = no loss of urine

however, with loss of support of the proximal urethra of the bladder neck, during coughing, the bladder pressure goes up but can't be transmitted to the urethra because it is no longer an abdominal organ.. the bladder doesn't contract, only the pressure.. so now coughing, running, sneezing jumping incontinence..
RX medical therapy, kiegel excer. strengthen the pelvic diaphragm is post menopausal maybe estrogen or elevate with urethropexy to become again an intraabdominal organ..


if there is a prpblem in bladder do cystoscopy..
if no urine lost at night then for sure stress incontinence..

involuntary bladder contraction.. is urge hypertonic bladder (irritable bladder syndrome) only 150cc and need to go.. you suppress contraction with anticholinergics...

if overflow hypotonic from multiple sclerosis or meds.. not a surgical rx, self cath. if non fixable neurological problem..

if continuious leakage because of a fistula because of pelvic radition or radical surgery because of a tumor, you put a tampon in and inject indigo carmine dye, the tampon turns blue.. fix that with surgery......

 

[Musaafirah]

You know one thing that annoyed me so much.
I revised so much for acid base disorders, memorising the equations where necessary, with the possible chance of the topic coming up in this years clinical chemistry exam, as it wasn't in last years paper. I didn't however give too much thought to the renal functions, nor liver as they were in last years paper.
However, I went in to the exam to find that the paper was very similar to last years.
How awful that lecturers have no pattern to what they do!
Alas.
Do you have to continually take exams, even though you're qualified?

 

[جوري]

If you want, I'll cover renal acid/base disorders here in in the upcoming couple of weeks in a really simple fashion.. one super wonderful book that was of much use to me, though it might go into things that aren't necessary for your purposes right now, is this one














anyhow, the answer to your question, is yes, you could be on the verge of retiring and still have to take exams to maintain your license.. but it is for the patient's own good and yours....imagine you are a pathologist or a radiologist or even a GP who has early dementia and continue to diagnose, manage and pass out surgical cases... yearly exams are made so you'd maintain your license and just about anyone in health care has to take them.. pharmacists have to do it to keep up with latest drugs, it is called CE credits.. you need a certain number per year.. once you graduate studying isn't over .. and I'd be worried about inertia in health care, I wouldn't want folks with dated info working on me... that as an aside, the exams aren't as tenuous as the licensure exams which are at least 9 hours long, and there is 4 of them..
step I, step II, CSA (clinical skills assessment with simulated patients) and step III which has a CCS component.. you take yearly exams during your residency to get to the next year, and once you specialize you have to take the board exam in your specialty and then yearly to maintain your CE (continuing education) and licensure ....

 

[جوري]

childhood immunizations are another chapter most like to skip because they seem tenuous but we'll take the generalist's approach and make them simple:

1- Hepatitis B vaccine, initially given at birth, 2nd dose one month later, 3rd dose at 6 months of age-- if the mother is hepatitis B surface antigen positive, then that is a red-flag, the mother most likely has a chronic hepatitis, the baby has been exposed to that in utero, the child is vertically exposed, you must therefore not only give a hepatitis B vaccine because with active immunization it takes a while to make antibodies and mount and immune response you must also give the hepatitis B immunoglobulin. which is called HBIG -- this must be administered within the first 12 hrs of life -- if don't know the mother's status, you must get a surface antigen and if positive give HBIG along with the immunization in the first week of life.
2- DtaP (the acellular component invented by the japanese)
3- HIB.. three types of vaccine, different people making it, like toothpaste consider crest, Colgate and pepsodent for instance all different names to toothpaste.. how do I administer certain types from different company like PEDvax, or comvax, can be used in infancy 2m, 4m, but a dose also required at 6 months... however if you used Dtap + hib combo you can never use the combo products for primary immunization. manufature put different components into one syringe, you can never use combo in the first month of life.
4- inactivated polio, all children need four doses of IPV at 2m, 4 m and then one between 6 and 18 months, and then another booster before starting school from at 4~6 years.
5- MMR... important thing to remember is that you need to give a booster dose between 4~6 yrs of life, however if you miss it you can give it aferr that, you need a 2nd MMR.. if you have missed it between four and six yrs complete it by 11~12 yrs old
6- varicella at any visit after 12 months of age.. make sure the pt doesn't have a hx of varicella don't give it if they have had it.
7-if negligent parents, try to find out if pt had a varicella vaccine, or if 13 and never had a hx of varicella they'll need two doses four weeks apart.
8-pneumococcal vaccine we've two types heptaovalent PCV recommended to children between 2-23 month of age.. high risk pts like with sickle cell or nephrotic, they should also receive the peunmoccocal polysaccharide they need two types, especially sickle cell, because they are susciptible to various strains. by using the two you have a chance of broader protection.
as far as heptatis A only in areas that are endemic.

lastly, flu A vaccine, often confused with HIB, influenza vaccine isn't the same as hemophilus... who would get flu A, children greater than 6m with certain risk factors, if they had asthma, diabetes, lung dz like cystic fibrosis, sickle cell, etc
other things, vaccine is age appropriate. need two doses separated by four weeks.

_____________________________________

 

[جوري]

On Bartter's syndrome:

patient with Bartter' syndrome defect in the ion transport protein in the thick ascending limb of the loop of Henle, such as the apical loop diuretic sensitive sodium potassium chloride cotransporter (NKCC2, Na-K-2CL) the failure to reabsorb NACL in the loop of Henle causes defects in the urinary concentrating abilities, NACL wasting, Hypercalciurea, hypomagnesemia, and decreased intravscular volume .. similar to the effects seen with loop diuretics such as Ethacrynic acid, furosamide and bumetanide. The renal response to decreased intravascular volume, sensed by decreased stretch in the afferent arteriole, is the increased production and release of renin by the juxtaglomerular cells -- increased renin increases the activity of angitensin II and aldosterone and downstream affects. increased aldosterone increases potassium and hydrogen ion wasting in the distal tubule and the collecting duct, causing hypokalemia and metabolic alkalosis, respectively. In the light of concomitant chloride loss in the urine , the resulting metabolic alkalosis is of the hypochloremic variety .. might get a metabolic panel like so
NA+ 130
K 3.2
ca2+ 7.8
HCO3- 30

 

[Nσσя'υℓ Jαииαн]

Sis I'm taking Organic Chemistry and Genetics, would that be a smart move to do at the same time? And will these notes help me in them?