Medicine Flashcards
(291 cards)
1
Q
Cor Pulmonale findings and Dx
A
GPE: loud P2, PSM, JVD, peripheral edema, hepatomegaly, ascitis
CXR: enlarged central pulmonary ateries and loss of retrosternal air space
ECG: right axis deviation, R BBB, RV hypertrophy, RA enlargement.
R heart catheterisation: elevated central venous pressure, RV end diastolic press and mean pulm artey press >=25mmHg
2
Q
Pulmonary Thromboembolism treatment
A
Immediate anticoagulation unless contraindicated.
Normal pts- RIVAROXABAN(immediate action and hence no need of bridging with heparin) EXNOXAPARIN, FONDAPARINUX.
Pts with renal insufficiency- UNFRACTIONATED HEPARIN followed by WARFARIN
3
Q
Pulmonary infarction S/S
A
Pleuritic chest pain
Hemoptysis
4
Q
Bronchiectasis s/s, causes and Dx
A
Signs & symptoms:
Cough with daily mucopurulent sputum production
Rhinosinusitis, dyspnea, hemoptysis
Crackles, wheezing
Etiologies:
Airway obstruction (eg, cancer)
Rheumatic disease (eg, RA, Sjögren), toxic inhalation
Chronic or prior infection (eg, aspergillosis, mycobacteria)
Immunodeficiency (eg, hypogammaglobulinemia)
Congenital (eg, CF, alpha-1-antitrypsin deficiency)
Evaluation:
1. HRCT scan of the chest (needed for initial diagnosis)
2. Immunoglobulin quantification
3. CF testing, sputum culture (bacteria, fungi & mycobacteria)
4. Pulmonary function testing
5
Q
Bronchiectasis due to CF findings
A
- Pseudomonas aeruginosa in sputum(in almost all bronchiectasis)
- Upper lung lobe involvement - bronchiectasis due to CF.
- Mutation of CF transmembrane conductance regulator gene results in DEFECTIVE CHLORIDE AND SODIUM TRANSPORT.
6
Q
Asbestos exposure is seen in..
A
Plumbers electricians carpenters pipefitters Insultation workers plastic/rubber manufacturing Ship-building Construction
7
Q
Ischemic chest pain (CAD)- type of pain
A
Substernal squeezing pain
8
Q
Progressive dyspnoea on exertion in the setting of morbid obsesity
A
Obesity Hypoventilation Syndrome (OHS)
9
Q
Patho of OHS
A
- Hypoxia or hypercapnia leads to bicarbonate retention-> decreased chloride reabsorption-> COMPENSATORY METABOLIC ALKALOSIS
- Chronic hypoxia-> pulmonary hypertension-> cor pulmonale-> PERIPHERAL EDEMA
- Chronic hypoxia -> increased erythropoietin-> COMPENSATORY ERYTHROCYTOSIS
- Chronic hypoxia-> chronic hypoventilation-> INCREASED pCO2
10
Q
Pleural fluid pH
A
Normal: 7.60
Transudate: 7.4-7.55
Exudates: 7.30-7.45
pH <7.30 : Empyema (increased acid production by cells or bacteria)
OR
Decreased H ion efflux from pleural space ( pleuritis, tumor, pleural fibrosis)
11
Q
Auscultation finding in COPD and ILD
A
COPD- wheezing
ILD- crackles
12
Q
ARDS diagnosis
A
New worsening respiratory distress within 1 week of insult
CXR- b/l lung opacities
Hypoxemia with PaO2/FiO2 ratio < 300mmHg
PAP increased
Pulmonary capillary wedge press (or left atrial press) normal
13
Q
ARDS treatment
A
Mechanical ventilation ( low TV, high PEEP, high FiO2, permissive hypercapnia)
PaO2: 55-80mmHg (SpO2: >88-95%)
14
Q
Central Respiratory Depression Dx & TX
A
ABG- primary respiratory acidosis( low pH and high PaCO2)
TX- increase minute ventilation ( mainly by increasing the respiratory rate)
15
Q
Diagnostic tests for pulmonary embolism
A
- CT angiography of chest
- Ventilation- Perfusion scan (alternate to CTA)
- transthoracic ECHO
- D-diner assay
16
Q
COPD Tx
A
Smoking cessation Supplemental O2 Inhaled bronchodilators (Ipatropium and Tiotropium) Anti-muscarinic agents + SABA(albuterol) Inhaled steroids LABA Lung reduction Surgery
17
Q
Reactivation of latent TB finding
A
CXR- apical cavitatory lesion
Chronic low grade fever, nigh sweats, WY loss, cough with blood tinged sputum
18
Q
Aspiration pneumonia findings
A
Fever, cough
Leukocytosis
CXR- lobar infiltrates
19
Q
Difference between Chr Bronchitis and Emphysema
A
Bronchitis:
DLCO- normal
CXR- prominent bronchovascular markings and mildly flattened diaphragm
Emphysema:
DLCO- decreased
CXR- decreased vascular markings and hyperinflated lungs
Hypoxemia is more in bronchitis
20
Q
Pneumothorax findings
A
Hyper resonance to percussion
Diminished breath sounds
Decreased tactile fremitis
Hypotension (decreased venous return)
21
Q
Criteria for initiation of Long term supplemental oxygen therapy (LTOT)
A
Resting PaO2 55%
22
Q
Histoplasma capsulatum findings
A
H/o exposure to bird/bats
CXR- mediastinal hilar lymphadenopathy with focal reticulonodular/miliary infiltrates
Dx- histoplasma antigen testing of urine or blood
Serology
Tissue diagnosis- granulomas with narrow based budding yeasts
23
Q
Hypersensitivity pneumonitis (Bird Fanciers disease) h/o and Dx
A
CXR- ground glass opacities/ haziness of lower lung fields
H/o bird or mould exposure which usually resolves within 24 hours
24
Q
Acute exacerbation of COPD findings and Dx
A
Change in >=1 of the following:
- cough severity /frequency
- sputum volume/ character
- level of dyspnea
GPE- wheezing, tachypnea, prolonged expiration, use of accessory muscles, JVD(during expiration)
CXR- hyperinflation
25
How to differentiate between AE of COPD from Heart failure
B-type Natriuretic Peptide
| Normal: <100pg/ml
26
Community acquired pneumonia s/s, Dx and Tx
```
S/s- dyspnea
Productive cough
Fever
Pleuritic chest pain
Tachypnea
Tachycardia
```
PE- focal increased breath sounds and crackles
CXR- lobar/ interstitial/ cavitatory infiltrates
Consolidator alveolar filling process
TX- Ceftriaxone + azithromycin (hospitalised pts)
Azithromycin (opd pts)
27
Hypovolemia S/S and Dx
S/s- diarrhoea, poor appetite, flat neck veins
Old pts- orthostatic hypotension
& orthostatic syncope
```
Increased hematocrit
Decreased serum sodium and potassium
Decreased urine urea nitrogen levels
Urine osmolality increased
Decreased Brain natriuretic peptide
```
28
Idiopathic pulmonary fibrosis- s/s and Dx
S/s- slowly progressive dyspnea
Dry cough
Fine bibasilar crackles
Advanced- end inspiratory squeaks, digital clubbing, abnormal S2(loud P2, fixed, split S2)
CXR- non specific reticular infiltrates
CT chest- peripheral/bibasilar reticular infiltrates and honeycombing
VQ mismatch
Increased A-a gradient
Decreased TLC, Residual Volume and Functional Residual Capacity
29
ARDS TX
Mechanical ventilation- either increasing FiO2 (<60%/0.6) or increasing PEEP
30
Pulmonary Function Test interpretation
FEV1/FVC - <70%- obstructive
>70% -restrictive
FVC- N/reduced- obstructive
<80%- restrictive
31
Oropharyngeal cobblestoning and rhinorrhea seen in
Upper Airway cough syndrome
32
Mechanical Ventilation settings
TV should be ~6ml/kg of ideal body weight
| I’m case of hyperventilation(^ pH & low pCO2 ) - RR has to be decreased.
33
Chest Physiotherapy is done for which diseases?
Pneumonia
Atelectasis
Bronchiectasis- long term
34
Interstitial lung disease- causes, s/s and Dx
Etiology:
- Sarcoidosis, amyloidosis, alveolar proteinosis
- vasculitis
- Infections
- occupational & environmental agents
- connective tissue disease
- IPF, interstitial pneumonia
S/S:
- Progressive exertions dyspnea/ persistent dry cough
- Findings from other underlying conditions
- >50% have smoking history
- Fine crackles during mid-late inspiration, possible digital clubbing
Inv:
CXR- reticular/nodular opacities
HRCT- fibrosis, honeycombing or traction bronchiectasis
PFT- N or increased FEV1/FVC, decreased DLCO, decreased TLC, decreased Residual Volume
ABG- N or mild hypoxemia at rest and severe hypoxemia on exertion
35
CHF exacerbation findings and Dx
Bibasilar crackles
Decreased breath sounds at base (due to pleural effusion)
Occasional wheezing
ABG- hypoxia, hypocapnia, resp alkalosis
BNP- > 100
Pulm capillary wedge pressure
36
SIADH causes, s/s and Dx
```
Causes:
CNS- stroke, hemorrhage
Meds- carbamazepine, ssri, nsaid
Lung disease - pneumonia
Ectopic ADH secretion- small cell lung cancer
Pain/ nausea
```
S/S-
Nausea, forgetfulness
Seizures, coma
Or euvolemia
```
Inv:
Hyponatremia
Serum osmolality <275 mOsm/kg H2O
Urine osmolality >100mOsm/kg H2O
Urine sodium >40 mEq/L
```
37
Serum osmolality calculation
(2 x serum Na + serum glucose /18) + ( serum BUN/2.8)
38
Factitious hyponatremia
Evidence of hypovolemia is seen :
| Dry mucus membrane , decreased skin turgor, serum BUN/creat ratio >20
39
Pleural fluid showing moderate lymphocytosis,
very high protein and
increased LDH , it is ...
Tubercular effusion
40
Chylothorax
- increased triglycerides
- milky white in colour
- exudative
Disruption of thoracic duct
- malignancy
- trauma
Fever and chest pain uncommon
41
Catheterisation(heart) interpretation
Increased PA and RA pressure > pulmo hypertension
Increased PCWP and RA and PA pressure > left sided heart failure leading to right sided heart failure
Normal PCWP and increased PA pressure > intrinsic pulmonary process (eg: pulmonary embolism)
42
Theophylline toxicity s/s and drugs/conditions which increase toxicity
S/S:
CNS - insomnia, seizures, headache
GI disturbance- nausea, vomiting
Cardiac toxicity- arrhythmia
Drugs which reduces clearance - Ciprofloxacin, cimetidine, erythromycin, clarithromycin, verapamil
Concurrent illness which increases toxicity-
Cirrhosis, cholestasis, respiratory infections
43
Myasthenic crisis- causes and Tx
```
Causes:
Infection/ surgery
Pregnancy/ childbirth
Drugs ( amino glycosides, fluoroquinolones, beta blockers, CCB, magnesium)
Tapering of immunosuppressants
```
```
Treatment:
Elective intubation
Plasmapheresis and IVIG
High dose corticosteroids
Azatgioprine
Pyridostigmine (for mild to mod disease)
```
44
LTOT criteria
1. Resting PaO2 55%
45
ICS adverse effects
```
Oral thrush,
cataract,
adrenal suppression,
decreased growth in children,
interference with bone metabolism and
purpura
```
46
Chronic pulmonary thromboembolism PFT
Normal Fev1, FVC, fev1/FVC ratio but decreased DLCO
47
Endocarditis
Valvular dysfunction
Left sided heart FAilure
Increased PCWP
Bibasilar crackles
48
Exercise induced bronchoconstriction s/s and Tx
Coughing, wheezing and breathlessness following exercise
Tx:
Beta agonists (Saba 10-20 mins prior to exercise)
Mast cell stabilisers
Antileukotriene agents ( if can not tolerate beta agonists)
Steroid inhalers for everyday athletes
Ipatropium inhalers + beta agonists for acute exacerbations
49
Granulomatosis with polyangiitis findings
```
ANCA: PR3 ~70% and MPO ~20%
Biopsy:
Skin- leukocytoplastic vasculitis
Kidney- pauci-immune glomerulonephritis
Lung- granulomatous vasculitis
```
Increased creatine
50
GPA treatment
High dose corticosteroids
Cyclophosphamide or
Rituximab
51
Pulmonary embolism findings
ECG- prominent S in lead I , Q in lead III and inverted T in lead III (S1Q3T3)
CXR- Hampton hump
Westermark sign
CT scan- wedge shaped, pleural based opacification
CECT- filling defect in the pulmonary artery
Atrial fibrillation and low o2 saturation is bad prognosis
52
Pneumonia common cause
CAP- streptococcus pneumoniae
| Hospital acquired- Pseudomonas aeruginosa
53
Löfgren syndrome
Erythema nodosum
Hilar lymphadenopathy
Migratory polyarthralgia
Fever
Seen in sarcoidosis
54
Sarcoidosis
```
S/S-
Fever
Dry cough
Dyspnea
Fatigue
Weight loss
```
CXR- hilar lymphadenopathy
Biopsy- non-caseating granulomas
55
Diamond classification for Acute coronary syndrome
For angina
1. Substernal/left chest pain
2. Worse on exertion
3. Relieved by nitroglycerin
3/3- Typical angina
2/3- Atypical angina
0-1/3- not angina
56
Treatment for Acute Coronary Syndrome
MONA BASCH
```
Morphine
Oxygen
Nitrates
Aspirin
Beta blockers
ACE inhibitors
Statins
Clopidogrel
Heparin
```
57
Treatment of choice for heart failure
2D ECHO
58
Treatment for heart failure
```
Base on NYHA classification: (goes on adding)
I- Beta blockers + ACE -inhibitors/ARB
II- Loop diuretics
III- ISDN-hydralazine, spironolactone
IV- Ionotropes(dobutamine, milrinone)
LV assist device/ transplant
```
I-III: AICD if EF <35%
If ischemic - aspirin and statin
Limit fluid intake <2L/day
Limit salt intake <2G/day
Smoking cessation
59
Symptoms of GERD
Heartburn
Usually after lying down after eating food
Abdominal or chest pain
60
CHF treatment
```
LMNOP
Lasix
Morphine
Nitrates
Oxygen
Position
```
61
Murmurs
Mitral stenosis- diastolic, with opening snap
aortic regurgitation- diastolic, rumbling
Aortic stenosis- Systolic, Harsh crescendo decrescendo
Mitral regurgitation- systolic, holosystolic, high pitched.
The above murmurs increase on squatting and leg lift.
HOCM- systolic
Mitral Valve prolapse- systolic
These decrease on squatting/leg lift
62
Pericarditis diagnosis
ECG- diffuse ST elevation and depressed PR segment(pathognomonic)
MRI- best test
63
pericarditis treatment
NSAIDs+ colchicine
NSAIDs
Colchicine
Steroids
64
Becks triad
Seen in pericardial tamponade:
1. JVD
2. Hypotension
3. decreased heart sounds
65
Pericardial effusion treatment
```
NSAIDs+ colchicine
Pericardial window (if fluid still present)
```
66
Pericardial tamponade immediate management
Pericardiocentesis
67
Pericardial effusion/ constrictive pericarditis diagnosis
ECHO
68
Vasovagal syncope Tx
Beta blockers
69
Orthostatic syncope Tx
IV fluids
70
criteria to start statins in pts with cholesterol
1. Vascular disease
2. LDL> 190
3. LDL 70-189 + age(>40) + DM
4. LDL 70-189 + age(>40) + calculated risk ( age, HTN,
Obesity, smoking)
remember everyone gets statins except LDL <70 and no other disease
71
Statin side effects
Statin-induced myositis: elevated CK
| Statin-induced hepatitis: elevated LDH
72
Drugs that can be used in cholesterol
Statins
Fribrates(second-line)
Not really used:
Ezetimibe
Bile acid resins
Niacin
73
Hypertension Tx
Heart failure, CAD- beta blockers(metoprolol, carvedilol,
labetolol), ACE-inhibitors
Stroke- ACE-inhibitors, HCTZ
Kidney disease- ACE-inhibitors (except stage IV)
Diabetes- ACE-i
Lifestyle modifications:
Diet- salt <2.4g/day, DASH diet, potassium
supplementation
Exercise- ~30min/day (2hr/week)
Weight loss- if overweight/obese (BMI >25)
74
Dilated cardiomyopathy S/S
S/S of systolic CHF-
orthopnea, OND, dyspnea on exertion:
Crackles, pulm edema
75
Dilated cardiomyopathy Tx
Tx of CHF-
Beta bockers, ACE-inhibitors, Loop diuretics
Transplant
Stop alcohol/chemotherapy if thats the cause
76
Cardiomyopathy Dx
ECHO:
dilated chambers- dilated cardiomyopathy
Asymmetric hypertrophy of ventricle- HOCM
Concentric hypertrophy- concentric cardiomyopathy
Restrictive pattern- restrictive cardiomyopathy
77
HOCM S/S and Tx
S/S- young athlete with syncope on exertion/shortness of breath
```
Tx-
avoid dehydration
Dont get the HR up > no exercise
beta blockers, CCB
remove obstruction: alcohol ablation/ myomectomy
AICB
Transplant
```
78
Restrictive cardiomyopathy S/S and Tx
signs of diastolic CHF
```
Rx-
Tx diastolic CHF
beta blovkers and CCb
Gentle diuresis
Transplant
```
79
general ECG changes in arrhythmia
Fast:
narrow QRS- SVT, A fib
wide QRS- Torsades, V Tachycardia
Slow:
Narrow qrs- Sinus bradycardia, 1 degree AV block, 2 degree I, 2 degree II AV block
Wide- 3 degree AV block, Idioventricular rhythm
80
SVT ECG changes
No P waves
| HR >150, regular
81
A fib ECG changes
```
No P waves
Irregularly irregular
HR <150
Chaotic background
Sawtooth
```
82
Torsades de pointes ECG changes
Changing amplitude
83
Ventricular tachycardia ECG changes
Monomorphic
| Fast rhythm
84
AV block ECG changes
Prolonged PR interval
| Dropped beats in 2 degree
85
ACLS- stable Tx
ECG:
fast, wide- Amiodarone
fast, narrow- adenosine
slow- atropine and then beta blockers and ccb
86
ACLS- unstable Tx
ECG:
fast- shock( synchronised cardioversion)
slow- pace
87
ACLS- no pulse Tx
2 mins of CPR> check pulse, rhythm> shock if indicated> repeat
ECG:
V tach/ V fib- shock, epinephrine, amiodarone
PEA, asystole- epinephrine
88
Cholelithiasis S/S
4Fs- Fat, Female, forty, Fertile
| Colicky pin in the RUQ- radiates to shoulder ( worse with fatty food)
89
4Fs- Fat, Female, forty, Fertile
| Colicky pin in the RUQ- radiates to shoulder ( worse with fatty food)
RUQ USG- gallstones
Rx:
Cholecystectomy( elective )
Ursodeoxycholic acid
90
Cholecystitis S/s
Constatnt RUQ pain
Murphy's sign positive
Fever, leukocytosis
91
Cholecystitis Dx and Rx
Dx:
RUQ USG- inflammation
HIDA scan
```
Rx:
NPO
IV fluids
Antibiotics- cipro+MTZ
Cholecystectomy (urgent)
Cholecystostomy -in non surgical candidates)
```
92
Choledocolithiasis S/S
PAINFUL JAUNDICE
Murphy's sign +
Fever, leukocytosis
93
Choledocolithiasis Dx and Rx
Dx:
RUQ USG- stones in CBD, obstruction, dialted ducts
MRCP
Rx:
NPO, IV fluids, IV Abx- cipro+MTZ
ERCP (urgent)
Cholecystectmy (electively)
94
Cholangitis S/s
```
Charcot's triad/ reynold's pentad:
RUQ pain
Painful jaundice
Fever
Hypotension
Altered mental status
```
95
cholangitis management
IV fluids, IV abx(cipro+mtz), NPO
ERCP emergently- diagnostic+therapeutic
Cholecystectomy (urgently)
RUQ USG- obstruction
96
Infetious esophagitis management
Candida- fluconazole
HSV- acyclovir
CMV- gancyclovir
If HIV opportunistic inf- add HAART
97
esophagitis Dx
Endoscopy+biopsy
Bx: >15 eosinophils/hpf- eosinophilic esophagitis
In case of caustic esophagitis- to see severity
98
Achalasia s/s and Dx
Pt- knot/ball of food stuck mid-sternum
Dx:
MANOMETRY (contracted LES)
Barium swallow- bird beak appearance
EGD+ Bx- to r/o cancer
99
Achalasia Tx
MYOTOMY
Botulinum - done only in bad surgical candidates
Pneumatic dilatation
100
Scleroderma s/s
```
C alcinosis
R eynolds
E sophageal dysmotility
S clerodactyly
T elangiectasia
```
Systemic Sclerosis( involving kidnery, heart and lungs)
Relentless GERD
101
Scleroderma Dx and Tx(for GERD symptoms)
```
Manometry- (no contractions at LES)
Barium swallow
EGD+ Bx
Serology- CREST- anti-centromere
SS- anti-scl-70
```
Tx- PPIs
102
Diffuse esophageal spasm s/s
Symptoms of MI- crushing chest pain, retrosternal, gets better with nitrates and CCB.
(without swallowing)
103
Diffuse esophageal spasm Dx and Tx
Dx:
Manometry- random contractions
Barium swallow- corkscrew esophagus
EGD+Bx
Tx:
CCB -> Nitrates
PPIs
104
Schatzki's ring s/s and Dx
"steakhouse dysphagia"
Dx:
Barium swallow- narrow lumen
EGD+Bx- to r/o cancer
105
Schatzki's ring Tx
Lyse the ring during EGD- open it up
106
Esophageal webs s/s
female
Dysphagia
iron def anemia
Webs->cancer
107
Esophageal webs Dx and Tx
Dx:
Barium swallow- webs
EGD+Bx
Tx:
Iron
EGD+Bx- to screen for cancer
esophagectomy if cancer develops
108
Zenker's diverticulum s/s
HALITOSIS
Older men
Regurgitation of undigested food
Coughs and gags on swallowing
109
Zenker's diverticulum Dx and Tx
Dx:
Barium swallow- diverticulum
EGD+Bx
Tx:
Surgery
110
Esophageal stricture s/s
Long standing GERD
Progressive dysphagia
Wt loss
111
Esophageal stricture Dx and Tx
Dx:
Barium swallow- symmetric, circumferential narrowing of lumen
EGD+Bx- no cancer
Tx:
PPIs
Dilatation
112
Esophageal carcinoma s/s
Long standing GERD
Progressive dysphagia
Wt loss
113
Esophageal carcinoma Dx and Tx
Dx:
Barium- asymmetric narrowing of lumen
EGD+Bx- cancer
Tx:
Chemo/ radiation
Surgery
114
GERD s/s
Typical-
burning chest pain- worse on lying down/eating spicy food
Atypical-
Hoarseness
Coughing, stridor
NOCTURNAL ASTHMA
115
GERD Dx
```
PPI+ lifetsyle mod for 6 weeks
I
if doesnt work
I
24 hr pH monitoring
EGD+Bx- if alarming symptoms(wt loss) and also to check for Barett's esophagus
```
116
GERD Tx
PPIs > H2 blockers > liquid antacids
Metaplasia- higher dose of PPIs
Dysplasia- local ablative therapies(RFA, laser, cryo)+ surveillance EGDs
Surgical:
Nissen fundoplication
117
Peptic ulcer Disease common causes
```
H. pylori
NSAIDs
Malignancy
Curling ulcers- in burn pts
Cushing ulcers- in raised ICP, steroids, ventilator
Gastrinoma
```
118
Peptic ulcer Disease s/s
Asymptomatic- 70%
Gnawing epigastric pain
Food- worse: gastric ulcer
better: duodenal ulcer
119
Peptic ulcer Disease Dx and Tx
EGD+Bx
Multiple, shallow- NSAIDs
Single- H. pylori
Necrotic, heaped margins- cancer
Tx:
Stop smoking, alcohol, NSAIDs
PPIs
120
H. pylori Dx
```
EGD+Bx-
1. rapid urease test
2. HISTOLOGY
3. Culture
Serology
Urea breath test
Stool antigen
```
121
H. pylori Tx
TRIPLE THERAPY-
Clarithromycin
Amixicillin
PPis
If allergic to penicillin- Metronidazole instead of amoxicillin
122
ZE Syndrome (Gastrinoma) s/s ,Dx and Tx
s/s- diarrhea
refractory
```
Dx:
Big virulent refractory ulcers
Gastrin level >1600- gastrinoma
250-1600- secretin stin test
SOMATOSTATIN RECEPTOR SCINTIGRAPHY (SRS)
CT abdomen
```
Tx- resection
123
Gastroparesis s/s
abdominal discomfort
chr. nausea and vomiting
Bloating
Peripheral neuropathy if diabetic
124
Gastroparesis Dx
Auscultation- splash heard while moving pt
EMPTYING STUDY
EGD+Bx- to r/o GOO, PUD, cancer
125
Gastroparesis Tx
```
Prokinetic agents:
metaclopramide PO
erythromycin IV -in acute flare
Low-fiber, small-vol diet
Avoid opiates
Blood glucose control
```
126
Cyclic vomiting syndrome s/s and Tx
S/S:
Nausea and vomiting after many weeks of smoking weed
Dx: clinical
Tx: Stop THC
Metaclopramide
Erythromycin
127
Gastric adenocarcinoma s/s
Early satiety
Wt loss
Obstructive symptoms
128
Gastric adenocarcinoma Dx and Tx
Dx:
EDG+Bx- Signet ring cells
PET CT/ Pan CT
Tx:
resection+ chemo
129
Acute diarrhea- organism/type based on history
```
ENTEROTOXIC- watery diarrhea
C. diff- recent Abx use
ETEC- traveller's diarrhea
V. cholerae- no boiled water, 3rd world country
S. aureus- potato/eggs kept out for long
B. cereus- reheated rice
giardia- fresh water /camping
Cryptosporidium- a/w AIDS
```
```
INVASIVE- bloody diarrhea+fever+leukocytosis+ feca; leukocytes
Shigella- HUS
Salmonella- uncooked eggs/poultry
EHEC- HUS, uncooked meat
Campylobacer- MC
```
130
C. diff / Abx associated diarrhea s/s
recent Abx use
watery diarrhea
smelly
severe:
fever+leukocytosis
megacolon
renal failure
131
C. diff / Abx associated diarrhea Dx
Dx:
C. diff NAAT
C. diff toxin
Colonoscopy- pseudomembrane
132
Dx:
C. diff NAAT
C. diff toxin
Colonoscopy- pseudomembrane
Only diarrhea:
oral vancomycin
3rd time- oral vanco or oral fidaxomycin
Refractory: fecal transplant
Severe: admit+ oral vanco
Fulminant (^ creat, ^WBC, VERY SICK):
admit+ higher dose oral vanco(PO/PR)+ IV metronidazole
133
Hemolytic Uremic Syndrome s/s
^ in children
Bloody diarrhea ( after eating uncooked meat)
^ BUN / creat (renal failure)
Anemia
134
Hemolytic Uremic Syndrome Dx and Tx
Dx:
Smear- MAHA+ schistocytes
Shiga-like toxin assay
Tx:
Supportive
Plasma exchange
135
How to calculate Stool osmolar gap
Measured Osm (290) - calculated Osm [2*(Na+K)]
<50- secretory diarrhea
>100- osmotic diarrhea
136
How differentiate b/w Secretory,osmotic and inflammatory diarrhea (i/c/o chronic diarrhea)
Secretory- No change with NPO, nocturnal symptoms present
Osmotic- ^ fecal osmotic gap, stops with NPO
Inflammatory- fecal RBC, WBC and mucus +
Malabsorptive- fecal fat present
137
Secretory diarrhea + pancreatic mass =
VIPoma
138
Secretory diarrhea + liver mass =
Carcinoid tumor/syndrome
139
Carcinoid syndrome s/s
intermittent diarrhea
flushing
wheezing
Right heart problems
140
Carcinoid syndrome Dx and Tx
Dx:
5- HIAA (hydroxyindoleacetic acid) urine test
CT scan- to stage
Tx:
resection
141
Celiac sprue s/s
```
Gluten allergy
diarrhea
wt loss
bloating
Skin- dermatits herpetiformis
Iron def anemia
Osteoporosis
```
142
Celiac sprue Dx and Tx
Antibodies- ttG (tissue transglutaminase)- 1st test
anti-endomysial Ab
EGD+Bx- flatteing of villi
Tx: Avoid gluten
143
Tropical sprue Dx and Tx
Same as celiac sprue but doesn't get better with avoiding gluten
Tx: Antibiotics- ciprofloxacin followed by TMP/SMZ
144
Whipple's disease s/s
```
Malabsorption
Arthitis
ocular findings
neurologic- dememtia, seizures
lymph nodes
```
145
Whipple's disease Dx and Tx
EGD+Bx-
PAS + macrophages (on light microscopy)
organism seen (on electrn microscopy)
Tx:
TMP-SMZ
Doxycycline
146
Diverticulosis s/s
```
> 50 yoa
low fiber diet
diet rich in red meat, fat
has constipation for a long time
Mostly asymptomatic
```
If pain- post-prandial pain in LLQ
relieved by bowel movement
147
Diverticulosis Dx and Tx
Dx:
Usually incidental
Colonoscopy
CT scan
Tx:
None if asymptomatic
High fiber diet
148
Diverticular hemorrage s/s and management
Painless hematochezia
>50yoa
Immediate Tx- IV fluids, PPI
(all immediate Tx for massice GI bled)
Dx:
Colonoscopy- if bleeding stops
Arteiogram- if bleeding persists -> emboloisation
Tx: Embolisation
149
Constant LLQ pain + tenderness + fever/leukocytosis =
Diverticulitis
150
Diverticulitis Dx
KUB (upright) to r/o perforation
| CT (IV contrast)
151
Diverticulitis Tx
```
Mild- liquid diet, oral Abx
Severe- NPO, IV Abx
Abscess- NPO, IV Abx, dran
Perforation- NPO, IV Abx, surgery (ex lap)
Refractory (>/= 2 times)- hemicolectomy
```
Antibiotics:
Cipro + MTZ
Gentamycin/ampicillin + MTZ
152
Colon cancer s/s
Asymptomatic screening -> polyp
Iron def anemia
change in caliber of stool / alternating bowel movts
```
>50 YOA
alcohol/smoking
obesity
processed red meats
IBD, PSC
family history
```
153
Colon cancer Dx and screening
Dx:
Colonoscopy+ Bx
Barium enema = "apple core"- late stage
Screening:
Colonoscopy at age 50 -> every 10 yrs till age 75-85
Sigmoidoscopy + FOBT at 50 -> q5yrs
FOBT g1yr
```
1 family history- at age 40 -> q5yr
321(HNPCC)- at age 25 -> q1-2yr
FAP- sigmoidoscopy at age 12 - q1yr
previous polyp -> q3-5yr
previous colon cancer-> at 1yr -> 3yr -> q5yr
```
154
Familian Adenomatous polyposis s/s and Tx
young
Thousands of polyps - by age 20
cancer by 30yoa
death by 40 yoa
Tx:
Prophylactic colectomy
155
Colorectal CA + endometrial CA + ovarian CA
| 3 family members + 2 generations + 1 premature
HNPCC(Hereditary Non-poluposis colorectal cancer) / Lynch synd
156
Brain tumor + colon CA
Turcot syndrome
157
colorectal CA + osteomas (or jaw tumor) + soft tissue tumors
Gardner syndrome
158
melanotic spots on lips/ skin + small bowel CA
Peutz-Jeghers syndrome
- ^ frequency of breast CA
- ^ gonadal and pancreatic CA
159
Causes for cirrhosis
VW HAPPENS
```
Viral hep
Wilson's disease
hemochromatosis
alpha 1 -antitrypsin def
PSC
PBC
Ethanol
NASH/NAFLD
Somethin else
```
160
Hep A Dx
IgM for Hep A- infected
| IgG- immune
161
Hep B Dx and Tx
```
HBsAg- infected
HBeAg- infectious
IgM-HBsAg- early infection
IgG- HBsAg- immune
IgG-HBcAg- immunity through eposure
```
Tx:
no specific Tx
always only ONE drug is given
162
Hep C Dx
Hep C PCR RNA viral load
Ab + HCV RNA+ = infected
Ab - HCV RNA+ = acute
Ab+ HCV RNA- = treated
163
Hep C Tx
Tx:
| Protease inhibitors- Boceprevir, sofosbuvir, etc
164
Wilsons disease s/s
Liver cirrhosis
hepatic insufficiency
CNS symptoms- chorea, psychosis, ataxia etc
Eyes- KF rings
165
Wilsons disease Dx and Tx
S. ceruloplasmin
LIVER BIOPSY
Slit-lamp exam- KF rings
Urine copper following Pencillamine administration
```
Tx:
PENICILLAMINE
Zinc
Trientine
Transplant
```
166
Hemochromatosis s/s
```
Bronze diabetes (pigmented skin + diabetes)
Fatigue, joint pain
Erectile dysfunction
Amenorrhea
Cardiomyopathy
```
167
Hemochromatosis Dx
```
S. FERRITIN >1000
S. Iron
LIVER BIOPSY
Transferrin >50%
ECHO- dilated and restricted cardiomyopathy
```
168
Hemochromatosis Tx
PHLEBOTOMY
| Deferoxamine
169
Young adult + COPD (emphysema) + cirrhosis
alpha 1- antitrypsin deficiency
170
alpha 1- antitrypsin deficiency Dx and Tx
Dx:
Biopsy- PAS + macrophages
Family h/o COPD at early age
Tx:
Enzyme replacement
Liver transplant
171
Male + pruritis + jaundice + 30-50yoa
| + IBD
Primary Sclerosing Cholangitis
172
Female + pruritis + jaundice + 30-50yoa
Primary Biliary Cirrhosis
173
Primary Sclerosing Cholangitis Dx and Tx
Dx:
Alk Phos, GGTP and bilirubin - elevated
MRCP- strictures/narrowing/beading of biliary system
Tx:
Ursodeoxycholic acid
Transplant
174
Primary Biliary Cirrhosis Dx and Tx
Elevated alk phos but normal bilirubin
LIVER BIOPSY
Anti-mitochondrial Ab
Tx:
Ursodeoxycholic acid
Transplant
175
LFT:
| AST >> ALT
Alcoholic Liver diasease
| or any other drug related liver disease
176
LFT:
| ALT >> AST
Viral hepatitis
177
Non-alcoholic + Biopsy (microvesicular fatty deposits) + mildly abnormal LFT
NASH / NAFLD
178
Liver disease + confused + altered mental status + asterexix
hepatic encephalopathy
179
hepatic encephalopathy Dx and Tx
Dx: clinical
NOT ammonia level
Tx: Lactulose
Rifaximin
Zinc
180
Varices s/s and management
s/s:
hematemesis or melena
Dx:
NG tube
Endoscopy -> banding
```
Tx:
banding
Octreotide
Antibiotics
Propanolol/nadolol
TIPS
Balloon tamponade
```
181
Ascitis Dx
Paracentesis -> SAAG and Biopsy
SAAG >1.1 : Portal HTN, cirrhosis, CHF, Hepatic vein thrombosis, Constrictive pericarditis
SAAG <1.1: Infection, cancer, nephrotic synd
182
Ascitis Tx
Furosemide + spironolactone
limit salt & water intake
paracentesis
183
Spontaneous Bacterial Peritonitis Dx
neutrophil count >250 -> immediate Tx
| Culture (dont wait for report)
184
Spontaneous Bacterial Peritonitis Tx
Ceftriaxone / cefotaxime
Prophylaxis- norfloxacin or TMP/SMZ
185
HCC Dx and Tx
screen- RUQ USG
AFP
Triple phase CT (confirmatory)
```
Tx:
Resection -if small
Transplant -if big
Radiofrequency ablation - if multiple/ too big
Chemo embolization
```
186
GI bleed immediate management
```
Stabilize:
2 large bore IV
IV fluids
IV PPIs
Type+cross
Call GI
```
Octreotide + ceftriaxone - if cirrhotic
187
hemetemesis following vomiting a lot all of a sudden
| eg: weekend alcohol drinking
Mallory-Weiss tear
Tx: self limiting
188
Hemetemesis in pt who vomits often (alcoholics/ bullemia)
Booerhav syndrome
189
Booerhav syndrome Dx and Tx
```
Pt: febrile, dyspnia
Auscultation- crunch in chest
Dx:
Gastrograffin swallow
CXR- air in mediastinum
EGD
```
Tx: Surgery
190
Dieulafoy's lesion
Pt: Brisk painless GI bleed
Dx: EGD
Tx: resect
191
Hemorrhoids S/S
Internal: Bleeds, no pain
External: Pain, does not bleed
Blood will be on toilet paper
192
Hemorrhoids dx and Tx
Dx: clinical
Tx: Sitz bath
Hemorrhoidectomy
193
Mesenteric ischemia s/s
Pain out of proportion to physical exam
H/o pain while eating -> decreased eating -> wt loss
Might have Afib( embolisation)
194
Mesenteric ischemia Dx and Tx
Dx:
Angiogram
Colonoscopy
Tx:
Resect
Revascularisation
195
Ischemic colitis s/s
Hypotensive
| Painfull hematochezia
196
Ischemic colitis Dx and Tx
Dx:
Colonoscopy = dead tissue
Tx: Supportive
197
Pancreatitis causes
I GET SMASHED
```
Idiopathic
Gallstones
Ethanol
Trauma
S
M
Autoimmune
Scorpion sting
Hypertriglyceridemia, hypercholesterolemia
ERCP
Drugs
```
198
Pancreatitis s/s
Epigastric pain - radiates to back(positional)
nausea/vomiting
anorexia
O/E:
Tenderness +
Grey Turner sign- flank discoloration
Cullen sign- umbilical discoloration
199
Pancreatitis dx
S. LIPASE >3xULN
S. Amylase (amylase-P)
CT SCAN
Prognosis- BUN
200
Pancreatitis Tx
```
NPO
IV fluids
Analgesics
Refeeding on demand
ERCP - if due to gallstones
```
201
Pancreatitis complications
```
Early:
ARDS
Hypocalcemia (means calciponification)
Pleural effusion
Ascites
```
Mid:
SIRS
late:
Abscess
Pseudocyst
202
Ulcerative colitis s/s
```
Bloody diarrhea (sudden onset)
20-30yoa
```
Extraintestinal- PSC, p-ANCA
203
Ulcerative colitis Dx
EGD: continuous lesions from the rectum
(stays within the colon)
Bx: only superficial layer
crypt abscesses
204
Ulcerative colitis Tx
Colectomy
screening for colon CA- at 8th year -> q1yr
205
Crohn's disease s/s
20-30yoa or 50-75yoa
Watery diarrhea (insidious)
Wt. loss
Extraintestinal- fistulas
206
Crohn's disease Dx and Tx
EGD- skip lesions
anywhere in GI tract
Bx- transmural
non-caseating granulomas
Tx: Sx only for complications
207
IBD Tx
Mild: 5-ASA compounds- mesalamine
Mod: Immune modulators- azathioprine, 6-mercaptopurine, MTX
Severe: CD- TNF-inhibitors: infliximab
UC- Surgical resection
Flares- STEROIDS
Abx- Cipro / MTZ
If perianal disease- drain
208
Prehepatic jaundice Dx and causes
^ Unconjugated (indirect) bilirubin (fat-soluble, crosses BBB)
Urine is not dark
causes:
hemolysis
hematoma
209
Posthepatic jaundice Dx and causes
^ Conjugated (direct) bilirubin (does not cross BBB)
DARK URINE
Causes: OBSTRUCTION
Painfull- gallstones
Painless- Stricture, cancer, PSC, PBC.
210
Intrahepatic jaundice Dx and causes
If ^unconjugated B= Criggler-Najjar synd, Bilberts synd.
If ^conjugated B= Dubin-Johnson synd, Rotors.
If mixed- Hepatits, Cirrhosis
211
Types of stroke
Ichemic-
Thrombotic - brain distal to the vessel dies
Embolic
Hemorrhagic- intracerebral / subarachanoid h.
212
Focal neurological deficits + Scenarios-
1. Vasculopathies (HTN, DM, smoking, etc)
2. Young girl with neck pain following trauma.
3. Afib/ prosthetic valve (not on anticoagulation)
4. Thunderclap headache
Ichemic stroke
213
Management of Ichemic stroke
```
tPA
Non-contrast CT head
ECG - Afib/Aflutter- Warfarin, NOAC
ECHO- Thrombus - Anticoagulation -
Warfarin, NOAC
Carotid duplex USG- Carotid artery stenosis
>70%-CEA, stenting
```
214
Ischemic stroke Tx
Supportive-> airway, O2, IV fluids.
```
Acute phase-
<3hrs (<4.5hrs if non diabetic)- tPA
ASA 325 mg
DM- controlled but not too low
Permissive HTN (220/120)
```
```
Chronic phase-
If on prophylaxis for DVT, etc - Heparin
If Afib/ prosthetic valve - anticoagluation
ASA 81 + dipyridamole (or)
Clopidogrel
High potent statins
HbA1c <8%
HTN- ACE-i, diuretics
```
215
TIA s/s
Ipsilateral blindness (amaurosis fugax) - “shade pulled over one eye.”
Unilateral hemiplegia
Hemiparesis
weakness or clumsiness that lasts less than 5 minutes.
216
TIA Dx and Tx
Carotid duplex scan -to look for carotid stenosis.
Tx:
Aspirin and antiplatelet medications.
Carotid endarterectomy- if the degree of carotid stenosis is 70% to 99%.
217
Types of seizures
- Simple partial
- Complex partial
- Tonic-clonic
- Absent
- Febrile
- Secondary
218
Causes of seizures
VITAMINS
Vascular
Infection (meningitis, encephalitis, toxoplasmosis, cysticercosis)
Trauma
Autoimmune
Metabolic (hypoglycemia, hypoxia, phenylketonuria, hyponatremia)
Ingestion/wIthdrawal (lead, cocaine, carbon monoxide poisoning)/ (alcohol, barbiturates, benzodiazepines, withdrawing anticonvulsants too rapidly)
Neoplasm
pSych/ Stroke
219
seizures s/s
LOC
Jerking
Tongue biting
Post-ictal state
220
Status epilepticus management
```
ABCs (airway, breathing, circulation)
Roll the patient on his or her side to prevent aspiration.
Benzo (Lorazepam/ diazepam) IV
Fosphenytoin
Phenobarbital
Midazolam
Propofol
```
221
Antiepileptic drugs:
```
Valproate
Lamotrigine
Levetiracetam
Carbamazepine
Ethosuximide
```
222
Atonic epilepsy Dx & Tx
no LOC, loss of tone +
| Tx- Valproate
223
Myoclonic epilepsy Dx & Tx
no LOC, uneccessary tone +
| Tx- Valproate
224
Absence epilepsy Dx & Tx
Brief (10–30 seconds in duration) generalized seizures
Loss of consciousness, often with eye or muscle fluttering.
No postictal state
Tx- Ethosuximide
225
Simple partial (also presents as trigeminal neuralgia) s/s
(local or focal) seizures-
- may be motor (e.g., Jacksonian march) or sensory (e.g., hallucinations),
- psychic (cognitive or affective symptoms).
- Consciousness is not impaired.
226
Simple partial Tx
Carbamazepine
lamotrigine
oxcarbazepine
levetiracetam
227
Complex partial (psychomotor) seizures S/s
Any simple partial seizure followed by impairment of consciousness.
228
Complex partial (psychomotor) seizures Tx
Valproate
lamotrigine
levetiracetam.
229
Tonic-clonic (grand mal) seizures s/s
- Associated with an aura.
- Tonic muscle contraction is followed by clonic contractions.
- Usually lasting 2–5 minutes.
- Associated symptoms may include incontinence and tongue lacerations.
- Postictal state
230
Postictal state
Characterized by drowsiness, confusion, headache, and muscle soreness.
231
Tonic-clonic (grand mal) seizures Tx
Valproate
lamotrigine
levetiracetam
232
Febrile seizure s/s
- Children between the ages of 6 months and 5 years may have a seizure caused by fever.
- Always assume another cause outside this age range.
- Usually of the tonic-clonic, generalized type.
233
Febrile seizure Tx
No specific seizure treatment is required, but you should treat the underlying cause of the fever
Acetaminophen to reduce fever.
234
Parkinsons disease S/s
Usually above age 60.
Classic tetrad.
1. Bradykinesia + mask like facies
(hypomimia)
2. Cog-wheel / Lead-pipe deformity
3. Abnormal gait- shuffling gait and festinant
4. Resting tremors ( pill-rolling tremors) which improves with movement
Micrographia
Postural instability due to orthostatic hypotension
May have dementia or depression also.
235
Parkinsons disease Dx and Tx
```
If >70 and loss of function -
LEVODOPA + CARBADOPA
MAO-B inhibitors : selegiline, rasagiline
COMT inhibitors: entacapone, tolcapone
Deep brain stimulation
```
If <70 yr and no loss of function -
Dopamine agonists: Ropinirole, Pramipexole - Anticholinergics - benztropine, trihexyphenidyl
- Amantadine
236
parkinsonism + dementia
Lewy body dementia
237
parkinsonism + orthostasis
Shy-Drager synd
238
Essential tremors s/s
↑ in males.
40- 60 yoa
Family history present
Tremor not present at rest -> begins when tries to move
239
Essential tremor Dx and Tx
Dx: clinical
Tx: Propanolol
240
Intention tremors s/s
Pt:
No tremor at rest
Tremor increases in amplitude as he goes closer to the target.
241
Intention tremors Dx and Tx
Dx: clinical
CT/MRI brain
Tx: None
242
Huntington's chorea s/s
Involuntary
Ballistic movements
Purposeless movts
Starts with fidgetiness or restlessness progressing to dystonic postural, rigidity and akinesia.
Psychiatric- psychosis, depression, dementia, etc
Most of them commit suicide.
243
Huntington's chorea Dx and Tx
Dx: Genetic analysis- CAG trinucleotide repeat sequences + the triad ( movement / memory / mood)
Tx: No specific tx.
Tetrabenazine - for dyskinesia
Haloperidol, quetiapine- for psychosis.
244
Restless leg syndrome s/s
Uncomfortable sensation in the legs - "creepy and crawly " at night.
Worsened by caffeine
Relieved by moving the legs.
Can even happen during sleep.
245
Restless leg syndrome Dx and Tx
Dx: clinical
Tx: Dopamine agonists - pramipexole.
246
Tourette disorder s/s
Vocal tics, grunts, coprolalia
Motor tics ( sniffing, blinking, frowning)
OCD
247
Tourette disorder Tx
```
Tx: Fluphenazine
Clonazepam
Pimozide
Methylphenidate
ADHD tx.
```
248
Causes for parkinsons disease
- Repeated head trauma from boxing
- use of antipsychotics (thorazine)
- Encephalitis
- Reserpine
- metoclopramide
249
Tension Headache
Pt:
Usually bilateral
Front radiating to the neck
Vice-like pain
Dx: clinical
Tx: NSAIDs
250
Analgesic rebound
Path: Withdrawal of analgesics (opiates, tryptans, etc)
Pt: Takes analgesics >10 times/ month -> stops -> headache
Dx: clinical
Tx: Withdrawal
251
Cluster headache s/s
Asymptomatic for a long time/ months
Suddenly develops headache which comes in clusters (8-10 times/ day or >3 times/ week)
severe, and tender
Unilateral eye pain, red eye.
A/w Horner's synd - lacrimation, rhinorrhea, lip sagging, nasal congestion, etc
252
Cluster headache Dx and Tx
Dx: Clinical
Tx: Supplemental oxygen
Triptans (Sumatriptan)
Prophylaxis- CCB- Verapamil, Prednisone, valproate.
253
Migraine s/s
Ages of 10 and 30 years.
Unilateral pulsatile headache
Debilitating - photophobia, phonophobia, nausea/vomiting
Aura
Trigger (which they usually know and avoid it)
Lasts for 4-72 hrs
Sleep -> aborts -> hangover
254
Migraine Dx and Tx
Dx: Clinical
```
Tx: Mild- NSAIDs
Mod- severe - Triptans
Ergotamine
Antiemetics
Prophylaxis- Propanolol , Valproate, Topiramate
```
255
Idiopathic intracranial hypertension (IIH)/ Pseudotumor cerebri S/S
Young females, obese
Headaches frequently
Symptoms of raised ICP- Nausea/vomiting, papilloedema
FND
Worrisome sequela is vision loss, diplopia
256
Idiopathic intracranial hypertension (IIH)/ Pseudotumor cerebri Dx
Dx:
CT brain - shows nothing
Lumbar puncture- Opening press. >25cm of H2O and relief
257
Idiopathic intracranial hypertension (IIH)/ Pseudotumor cerebri Tx
```
Acetazolamide
Wt loss
Repeated LP
CSF shunt/ VP (ventriculoperitoneal) shunt
Fenestration of optic nerve
```
258
Giant cell (temporal) arteritis s/s
Tenderness of the temporal area
Unilateral vision loss/ disturbance
Systemic symptoms- fatigue, muscle pain and weakness.
Jaw claudication
259
Giant cell (temporal) arteritis Dx and Tx
Dx: Biopsy
ESR- markedly elevated
Tx: Steroids- prednisone
260
Postherpetic neuralgia Tx
- TCA, gabapentin, pregabalin, carbamazepine or phenytoin.
- Acyclovir, famicyclovir, or valgancyclovir may reduce its incidence.
Prevention of Herpes zoster- Zoster vaccine to all people >60yoA.
261
Extracranial causes of headache
• Eye pain (optic neuritis, eyestrain from refractive errors, iritis, glaucoma)
• Middle ear pain (otitis media, mastoiditis)
• Sinus pain (sinusitis)
• Oral cavity pain (toothache)
• Herpes zoster infection with cranial nerve involvement
Nonspecific headache (e.g., malaise from any illness)
262
Disc Herniation s/s
older men
Heavy lifting
Sciatica
SLR test +
263
Disc Herniation Dx and Tx
Dx: X-ray
MRI
Tx: Sx > conservative management if < 6 months
Sx = conservative management >1yr.
264
Osteophytes s/s
older man
No heavy lifting
Sciatica +
SLR test +
265
Osteophytes Dx and Tx
Dx: X-ray
MRI
Tx: Surgery
266
Compression fracture spine s/s
older women
h/o fall on coccyx
Pin-point tenderness +
Vertebral step-off +
267
Compression fracture spine Dx and Tx
Dx: x-ray / MRI
Dexa scan
Tx: Surgery
Tx for osteoporosis
268
Spinal stenosis s/s, Dx and Tx
Pt: >50yoa
Pseudoclaudication - positional (present only while straight and walking)- In butt and thighs
Dx: x-ray
MRI
Tx: Laminectomy
269
Delirium
Acute, dramatic
Reversible
Global memory impairment
Causes: illness(sepsis), intoxication, etc
Attention- poor
Arousal- fluctuates
270
Dementia
Chronic, insidious
Usually irreversible
Remote memory impairment
Causes: Alzheimer's, multi-infarct stroke
Attention- unaffected
Arousal-normal
271
Reversible causes for dementia and Dx
```
TSH, T4 - hypothyroidism
Creat , BUN- kidney
LFTs - cirrhosis
Vit B12 deficiency- B12 level , methylmalonic acid level.
RPR / VDRL- neurosyphilis
```
Depression screening (pseudodementia)
272
Alzheimer's disease Path and s/s
Path: Plaques + tangles
Chromosome 21 association
Pt: memory impairment (recent)
Social distancing
Might be a downs synd pt.
Personality changes later
273
Alzheimer's disease Dx and Tx
Dx: clinical
CT - diffuse atrophy
```
Tx: Supportive
Family education
Mild- Ach-E inhibitors - donepezil,
rivastigmine, galantamine, tacrine
Severe- memantine
```
274
Pich's disease ( Frontotemporal degeneration ) s/s
```
Personality changes (emotional and social appropriateness lost)
Memory retains ( but later deteriorates)
Loss of filter
```
275
Pich's disease ( Frontotemporal degeneration ) Dx and Tx
Dx: clinical
CT - Frontotemporal degeneration
Tx: Supportive
Ach meds.
276
Lewy-Body dementia s/s
Parkinsonian symptoms
| VISUAL HALLUSINATIONS
277
Lewy-Body dementia Dx and Tx
Dx: clinical
MRI- loss in substantia nigra
Tx: supportive
Levodopa/carbidopa
278
Vascular dementia
Pt: Stepwise decline with each stroke
Dx: CT- multiple infarcts
Clinical
Tx: supportive
279
Creutzfeldt-Jakob Disease (CJD) s/s
```
Undercooked meat
Sporadic mutation
Young (30-40)
Rapidly progressive dementia
MYOCLONUS
```
280
Creutzfeldt-Jakob Disease (CJD) Dx and Tx
Dx: MRI/CT - normal
CSF protein : 14-3-3
Biopsy
Tx: supportive
281
NPH ( normal press hydrocephalus) s/s
Wet - urinary incontinence
Wobbly - gait ataxia
Weird- dementia
282
NPH ( normal press hydrocephalus) Dx and Rx
Dx: CT- hydrocephalus
Lumbar puncture - improvement
Tx: VP shunt
283
Posterior fossa insults causes
MS, tumor, stroke
Abscess
Seizures
Migraines
284
Posterior fossa insults s/s and Dx
FND- cerebellar signs
Vertigo
No ear s/s
Dx: MRI
285
BPPV ( Benign paroxysmal positional vertigo)
| s/s
Recurrent
Reproducible
Lasts for <1min
286
BPPV ( Benign paroxysmal positional vertigo) Dx and Tx
Dx: Dix-Hallpike manoeuvre - nystagmus
Tx: Epley manoeuvre
287
Vastibular Neuritis s/s
h/o URI 4 weeks back
Vertigo lasting 1-10mins
Hearing loss +/-
Nausea / vomiting +
288
Vastibular Neuritis Dx and Tx
Dx: clinical
Tx: Steroids (acutely)
Meclizine (long-term)
289
Meniere's disease s/s
Triad - Vertigo
Tinnitus
Hearing loss
Lasts for >30 mins but < 1hr
290
Meniere's disease Dx and Tx
Dx: clinical
Tx: Salt restriction
Thiazide diuretics
Anti-vertigo meds (Meclizine)
291
Most common causes of syncope
- Vasovagal syncope(most common)- classically seen after stress or fear.
- Arrhythmias
- Orthostatic hypotension
- Hypoglycemia
