-
Bordatello pertussis: -paroxysmal cough, inspiratory whoop, postussive emesis -lymphocyte predominat leukocytosis -Tx: MACROLIDE -Confrm with bacterial culture or PCR rom nasopharyngeal secretions in !st month -"erology ater ! month Hereditary angioedema: C! inhibitor defciency or dysunction # leads to elevated levels o edema producing actors C$b and rady!inin
Characteri%ed by: Rapid onset o: -nonin&ammatory edema o ace limbs and genitalia -laryngeal edema # can be lie threatening -edema o intestines -' colicky abdominal pain -"O e#idence o$ urticaria "eonatal tetanus: -born to unimmuni%ed mother -(re)uently ollowing umbilical stump inection -present in frst two weeks o lie with: poor suckling and atigue ollowed by rigidity, spasms, and opisthotonus -*igh mortality: -frst week apnea, second week sepsis "eimann pic!: "phingomyelinase defciency +uto rec +ge $- months oss o motor milestones *yptonia (eeding di.culties Cherry red macula Hepatosplenomegaly Are%e&ia
'ay-sachs: /-hexoaminisidase + de +uto rec oss o motor milestones *ypotonia (edding di.culties Cherry red macula H()ERre%e&ia
Do*n syndrome second trimester +uadruple screen : ow 0"+(P1maternal serum a etal protein2, low estriol, increased /-hcg, inc inhibin +
P+PP-+: pregnancy assoc plasma protein is a glycoprotein produced by the trophoblast3 4uring (5R"T trimester P+PP-+ can be measured with /-hcg and 6" nuchal transluceny with detection rate o 789 or down syndrome ot used in second tri
Hypercalcemia: 0ainestations o Ca '!$mg;d: -constipation $;$ altered intestinal smooth m tone -anorexia -vomiting -weakness -polyuria $;$ deect in concentrating ability o renal tubules 1nephrogenic diabetes insipidus2 -conusion;lethargy
Medullolastoma: $nd 0Cinratentorial tumor in children -highly radiosensitive -can met through C"( '<=9 develop in cerebellar vermis -Posterior vermis syndrome: -truncal dystaxia -unbalanced gait -hori%ontal nystagmus
+strocytoma: 0C inratentorial tumor in children -develop in Cerebellar hemispheres -*emispheric syndrome: -arm, leg and gait ataxia with ipsilateral cerebellar signs ------>/" screening at ?8-?@ weeks gestation3 Results are valid or A8weeks3
+nti-4 5g +B+ Rh antibody testing: done between $7-?$ >+
-hal lie o anti-4 abs is Aweeks, covers any potential exposure through maDority o ? rd trimester
Mi&ed cryogloulinemia cryogloulinemia -seen in ?=9 o pts with Hepatitis C -arthralgia o miced cryoglobulinemia a;w a chronic chronic vasculitic syndrome characteri%ed by palpable purpura, lymphandenopathy, nephropathy, and neuropathy T/ is a common cause cause o chronic chronic primary primary adrenal adrenal insu.ciency insu.ciency
Primary adrenal insuE: Ftiology: +utoimmune, inection 1T/, *5G, ungal2, hemorrhagic inarction1meningococcemia2, metastatic C+1lung2 Presentation: +cute: shock, abd tenderness, unexplained (, n;v, anorexia *yponatremia, hyperkalemia, hypercalcemia, and eosinophilia Chronic: atigue, wt loss, n;v, abd pain, hyperpigmentation H()O'E",IO" , hyponatremia, hyperB, hyperCa, anemia, eosinophilia +ll adrenal insu.ciencies will have "on-anion gap metaolic acidosis 4x: 0easure +CT* and serum cortisol with high dose +CT* stim test Primary adrenal insuE: low cortisol, high +CT* "econdary adrenal insuE: low cortisol, low +CT* *5G tx side eEects: 4idanosine # pancreatitis +bacavir # hypersensitivity syndrome +ny RT5s- lactic acidosis, "teven Dohnsons syndrome evirapine #liver ailure 5ndinavir1protease inhibitor2 # crystal induced1needle shaped2 nephropathy Crystal induced nephropathy: Common etiologies: +cyclovir 15G 'oral2 # low urine solubility -' precipitates in tubules -' renal tubular obstruction "ulonamides 0ethotrexate
Fthylene glycol Protease inhibitors Flevated creatinine w;in !-@ days o starting drug 6rinalysis can show: hematuria, pyuria, crystal >ive 5G &uids with drug to reduce risk o +B5
+4PB4: H'" is common early fnding, oten present beore decline in renal unction -+ce inhibitors are preerred *T tx in +4PB4 +lso present with: hematuria, proteinuria, palpable renal masses, or progressive renal insuE3 0ay have &ank pain due to renal calculi, cyst rupture or upper 6T5 "hock Fpinephrine+lpha - ! agonist to increase vasoconstrict vasoconstriction ion /eta # $ agonist to relax bronchial smooth muscle and decrease vascular permeability 4opamine # can be used as additional vasopressor or persistent hypotension *igh dose acts on beta # ! and alpha -! 4oes not help respiratory symptoms due to lack o signifcant beta # $ activity +dult smoker with hard, non-tender, submandibular or cervical nodes is highly concerning or head and neck C+3 Gast maDority o head and neck C+ is ")uamous Cell C+ /rain death reers to a total loss o brain unction and is a legally acceptable defnition o death3 (amily permission is HT legally re)uired to discontinue lie support *erediatary spherocytosis: -auto dom3 4isorder o spectrin that provides scaEolding or R/Cs -R/Cs are not &exible and get trapped in enestrations o spleens red pulp fndings: positive amily hx, splenomegaly, spherocytosis with increased retic count Thalassemia minor minor -hetero%ygous or /-thalassemia
-typically asymptomatic -microcytic target cells on peripheral smear >P4 de -I linked rec ->P4 re)uired to create +4P* necessary to create glutathione and prevent oxidation o hgb3 -Rxn occurs in response to oxidant stress1antimalarial drugs, sulas2 ava beans, inection -bite cells -hein% bodies ater crystal violet staining "uccinocholine is a depolari%ing neuromusc blocker oten used during rapid se)uence intubation -rapid onset J8-= seconds -rapid oEset -!= minutes -Can cause signifcant potassium release and lie threatening arrhythmias -should "O' be used in pts at high risk or hyper!alemia -crush or burn inDury '7hrs old 1high risk o rhabdo2 -pts with demyelinating syndroms 1guillain-barre2 -pts with tumor lysis syndrome "ick euthyroid syndrome +B+ Klow T? syndromeL: +ny pt with an acute, severe illness 105, shock, etc2 may have abnormal thyroid unc tests3 -likely $;$ caloric deprivation and increase in cytokine levels15-! and 5-2 -0ost common hormone pattern: -low total and ree T?, $;$ decreased peripheral conversion o TJ'T? -normal TJ and T"* -5 non-thyroidal illness persists, TJ and T"* levels also decrease -Hn recovery, may see transient increase in T"*3 Hten misinterpreted as subclinical hypothyroid3 -Thereore, Thyroid unction test should not be perormed in pts recovering rom maDor illness /en%o overdose symptoms: "lurred speech, drowsiness, unsteady gait 4istinguish rom: -Hpioid H4 by lack o respiratory depression and lack o pupillary constriction -+lcohol intoxication by lack o nystagmus 0yasthenia >ravis:
Can aEect muscles anywhere in the body, most common sx ptosis and double vision Acettlcholine receptor A test 4I: F0> and Acettlcholine CT o the chest to look or thymoma should be done in all newly diagnosed 0> pts --Thymectomy is useul in such cases, results may not be seen or ?-Jyears acunar stroke 0aDor risk actors: *T, 40, hyperlipidemia, smoking Pathology: likely $;$ combination o microatheroma and lipohyalinosis -inarcts are usually o thrombotic origin -$;$ small si%e, lacunes are oten missed on noncontrast CT scans during or shortly ater event3 -0C site or lacunar inarct is posterior limb o the internal capsule leading to a pure motor stroke aEecting the contralateral $ace arm and leg e+ually -other lacunar stroke syndromes: ataxic hemiparesis, clumsy-hand dysarthria, pure sensory stroke and mixed sensory-motor stroke Creut%feld Dakob disease: Prion proteins cause rapid neuronal loss and death within !yr -should be suspected in pts 8=-@=yrs old with rapidly progressing dementia and myoclonus -other sx: insomnia, apathy, behavioral changes, impaired vision 4x: "pongiorm changes on postmortem brain biopsy >enetic testing or )"R) protein gene /i or tri phasic sharp *a#e comple&es on FF> Flevated !J-?-? proteins on C"( samples Bey eatures o ds: -long incubation period -characteristic spongiorm changes -lac! o$ in%ammatory response1no change seen on cbc2 Prin%metal angina1variant angina2 : chest pain $;$ coronary vasospasm -risk actor: smoking -pts oten lack CG risk actors -episodes characteristically occur at night !$+-7+ and can be assoc with transient "T elevations -egative cardiac en%yme panel -Tx: CCB # diltia%em -+void aspirin and /-blockers bc they can promote vasoconstriction
ewy body dementia: ey bodies M eosinophilic intracytoplasmic inclusion made o alpha synuclein protein Two Two o three three essential or or 4x: -%uctuating cognition with pronounced variations in attention and alertness hallucinations that are typically well-ormed and -Recurrent #isual hallucinations detailed -spontaneous motor eatures o parkinsonism Tx o psych symptoms: symptoms: acetylcholineste acetylcholinesterase rase inhibitors inhibitors -' Rivastigmine Rivastigmine Bey to distinction between /4 and parkinsons is the early appearance o dementia in /4 and o motor symptoms in parkinsons Chronic pancreatitis is assoc;w increased risk o pancreatic C+ +bd 6" preerred intial test i Daundiced # can detect biliary tract dilation and obstruction +bd CT w; contrast preerred initial test without Daundice # CT is more sensitive or pancreatic C+, delineating tumor extent and staging tumor ormal C+ !<-< values do HT r;o pancreatic C+ -used as a marker o longitudinal ds in known pancreatic C+ pts *ypoxia in P+ occurs $;$ alveolar and interstitial in&ammation which causes areas o G;N mismatch -0aniests as increase in alveolar#arterial gradient >iardiasis: (ood borne, water borne, or p$p Troph Tropho%oites o%oites ahere ahere to mucosal mucosal suraces suraces y adhesi#e dis!s producing malasorption -generally chronic duration o sx -Tx metronida%ole met ronida%ole >lucagonoma: rare pancreatic tumor -mild 40 or hyperglycemia with necrotic migratory erythema 0F: erythematous pla)ues or papules that coalesce to orm large painul in&ammatory blister and or crustingwith central clearing3 -typically on ace, perineum, extremities -diarrhea and wt loss
-anemia: normocytic normochromic likely $;$ anemia o chronic ds or glucagons direct eEect on erythopoesis -4I: .lucagon le#els / 011 "tepwise approach to Tx o +scites: !3 "odium "odium and and water restri restrictio ction n 1$;day2 1$;day2 $3 "pir "piron onol olact acton one e ?3 oop diuretic diuretic when max dose o spironolacto spironolactone ne not enough a3 ot mor more e than than ! ; day o diur diuresis esis J3 (re)ue re)uent nt abd paracen paracentesi tesis s 1$-J ;day2 ;day2 a3 atch or or hepator hepatorenal enal syndr syndrome ome
Psoriatic arthritis: -8-?=9 o pts with psoriasis -Classically involves involves DI) Doints -0orning stiEness, deormity, dactylitis1sausage fngers2 -nail involvement ie onycholysis -well demarcated red pla)ues with silver scale Tx: "+54", methotre methotrexate, xate, anti-T( anti-T( agents 4ermatomyositis: -can present with >ottronOs papules: violaceous pla)ues, slightly scaly, over the 0CP Doints C: -0C leukemia in adults -/-cell leukemia -Ksmudge cellsL on pathology: Kleukocytes that have undergone partial breakdown during prep o stained smear bc o greater ragilityL -Thrombocytopenia is a poor prognostic avor # "tage 5G -characteristic -characteristic fndings: -lymphadenopathy, splenomegaly, anemia, thrombocytopenia -+vg lie span 7-!= years TC+ overdo overdose: se: C", cardiac, anticholinergic fndings -TC+s inhibit ast sodium channels in his-purkinDe system, decreasing conduction velocity, increasing duration o repolari%ation and prolonging reractory periods -' hypotension 2R, *idening #entricular arrhythmias - Tx: "odium bicarb to reduce reduce cardiac cardiac toxicity toxicity 1p* goal goal @382 -increased p* decreases drug avidity or a channels -increased extracellular sodium increases electrochem gradient across cardiac cells and aEects ability o TC+s to bind ast sodium channels
Clopidogrel: anti-platelet, acts by antagoni%ing +4P -appropriate alternative or those who cannot tolerate aspirin -Clop aspirin better than apirin alone (ollowing pts post unstable angina;"TF05: -clopidogrel or at least !$m +"+ indefnitely Percutaneous coronary interventions 1PC52: -Clop +"+ better than +"+ alone or frst ?= days, helps prevent subacute stent thrombosis -4rug-eluting stents re)uire longer duration bc epitheliali%ation occurs slowly -?= days or bare metal stents -up to ! yr drug eluting stents )olycythemia #era: Clonal myeloprolierative d% o the pluripotent hematopoietic stem cell3 Characteristic eatures: -increased R/C mass -mild granulocytosis -elevated platelets -low FPH
0ay be present: -H'" as a result o expanded blood volume -increased incidence o peptic ulcer # histamine release rom basophils -gouty arthritis # increased cell turnover
0ultiple myeloma: 0onoclonal prolieration o plasma cells '?g;d 0 protein on "PFP '!=9 plasma cells in bone marrow CR+/: Calcium 1hypercalcemia2 Renal impairment +nemia /ones 1bone pain, lytic lesions, ractures2 5ncreased risk o in$& due to a total decrease in unctional antibodies and leukopenia secondary to bone marrow crowding with malignant plasma cells
----0>6" monoclonal gammopathy o undetermined signifcance Q ?g;d 0 protein on "PFP Q!=9 plasma cells in bone marrow !9 per year risk o progression to 00
Trigemin Trigeminal al neuralgia neuralgia tx o choice: choice: Carbama%epine Carbama%epine /ronchiecstasis: 4ilated bronchi with thickened walls Present with chronic cough and are oten treated with repeated courses o antibiotics -C' is best method to confrm 4x -hemoptysis is re)uent complication "pider angiomas: -bright red central arterioles surrounded by radiating vessels -BLA"CH with pressure -estrogen dependent, common in pregnancy, HCP use, and cirrhosis related hyperestrogenemia ,3, 4 'E" Q!=9 o body surace area: "" !=-?=9 /"+: "" TF overlap '?=9: TF 5-67 days a$ter e&posure to trigger 1$ days ater repeat exposure2 +cute in&uen%a like prodrome Rapid onset erythematous macules, vesicles, bullae ecrosis S sloughing o$ epidermis Mucosal in#ol#ement
"igns: (, tachycardia, hypoT, +0", conDunctivitis, sei%ures, coma 4rugs: +llopurinol +ntibiotcs 1eg sulonamides2 +nticonvulsants 1carbama%epine, lamotrigne, phenytoin2 "+54" "ulasala%ine 03 pneumonia
Gaccination >rat vs host disease INFECTIOUS ENDOCARDITIS: A microbial process of the endocardium, usually
involving the heart valves. Serial blood cx most cx most important part of Dx The following peripheral lesions are only present in 25% of cases JANEWAY LESIONS: Painless hemorrhagic macules on the palms and soles that are
consistent with infectious endocarditis. Osler nodes (tender nodules on the finger or toe pads) pads)
ROTH SPOTS: Hemorrhagic retinal lesions with white centers, due to infectious
endocarditis. Highly virulent species, such as Staphylococcus aureus, produce acute infection, and less virulent organ- isms, such as the viridans group of streptococci, tend to produce a more suba- cute illness, which may evolve over weeks
(ever is present in <89 o cases HACEK organisms (Haemophilus aphrophilus/paraphrophilus, Actinobacillus actinomycetemcomitans, actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae)
Pericardial tamponade: /ecks triad # !2 *ypoT poT $2 G4 ?2 4ista 4istant nt heart heart soun sounds ds 0ost sensitive physical fnding: )ulsus parado&us- decrease in "/P Pulsus paradoxus in tamponade: 4uring inspiration increased systemic venous return to R heart causes interventricular septum to shit into the let ventricular cavity, reducing ventricular end diastolic volume -' decreased stroke vol -' reduced "/P Pulsus paradoxus also seen in severe asthma and CHP4: drop in intrathoracic pressure is greatly exaggerated3 egative pressure leads to pooling o blood in pulmonary vasculature decreasing G preload
*5G pt: Hnly live vaccines that can be administered ar 00R and varicella i: -C4J count ' $== -no history o +54" defning illness +cute glaucoma: (irst line tx: 5G mannitol +lso can administer: +ceta%olamide # carbonic anhydrase inhibitor, decreases a)ueous humor production Pilocarpine # opens canals o schlemm, allowing drainage o a)ueous humor Timolol Timolol # /-blocker, /-blocker, decreases decreases a)ueous a)ueous humor production production +void mydriatic agents such as atropine >lucocorticoid induced myopathy: -Hne o most common drug induced myopathies -typically *ee!s to months a$ter starting t& -)AI"LE,, pro&imal muscle *ea!ness 1F beore 6F2 maniests as di.culty in +4 such as getting out o chair, climbing stairs, brushing hair, -"o muscle in%ammation normal E,R normal C8 -likely $;$ increased muslcle catabolism and decreased anabolism as a direct eEect o the steroids -improves with discontinuation o steroid therapy Polymyalgia Rheumatic: -seen in up to 8=9 o pts with temporal9giant cell arteritis -aching and morning stiEness -)ain and decreased range o$ motion in shoulders, neck and hip girdle -normal muscle strength -E,R / 51 -"ormal C8 -"ymptoms improve rapidly with glucocorticoids 0etabolic eEects o *CT: -4ecreased glucose tolerance -' hyperglycemia -increased 4 -increased triglycerides -hyponatremia -hypokalemia -hypercalcemia Dacrocystitis: inx o lacrimal sac
-occurs in inants and pts 'J=yo -sudden onset o pain and redness in medial canthal region -ever, prostration, elevated leukocyte count -may express purulent &uid rom lacrimal duct -"3 aureus and >+" common organisms Episcleritis : inx o episcrleral episcrleral tissue -+cute onset o mild to mod discomort, photophobia and watery discharge Hordeolum: abscess on upper or lower eyelid -0C cause "3 aureus -Red, tender swelling over the eyelid Chala;ion: chronic granulomatous inx o meibomian gland -Hard painless nodule -presents as lid discomort
Rabies: Pts exposed to high risk wild animals # raccoons, bats, skunks # should receive post exposure prophylaxis i animal is unavailable or testing3 -i animal can be tested, pt should start PFP but may discontinue i animal tests negative "ubarachnoid hemorrhage: 0ost commonly $;$ ruptured berry aneurysm "evere *+ at onset 0eningeal irritation 1neck stiEness2 (ocal defcits uncommon Complications: Rebleeding # frst $J hrs
