Week 1 Notes PDF

Week 1 Neuro #1 60% Criteria for narcolepsy: recurrent lapses into sleep/napping multiple times within the same day, occurring at least 3x weekly for 3 months - Must also have at least 1 of the following: o Cataplexy: sudden loss of muscle tones precipitated by emotions (laughing/jok...

Week 1 Neuro #1 60% Criteria for narcolepsy: recurrent lapses into sleep/napping multiple times within the same day, occurring at least 3x weekly for 3 months - Must also have at least 1 of the following: o Cataplexy: sudden loss of muscle tones precipitated by emotions (laughing/joking) or spontaneous, abnormal facial movements w/o emotional triggers. o Hypocretin-1 deficiency found in CSF analysis o REM sleep latency 70%), then you have symptomatic carotid artery disease. - Tx: carotid endarterectomy to reduce future risk of stroke. - Rec for people with >70-99% stenosis and a life expectancy of 5+ years - Not rec for poor surgical candidates, those with ipsilateral stroke + disabling neuro deficits, and those with 100% occlusion of the ICA. Closure of PFO to reduce cryptogenic strokes should be done only for pt < 60. The hallmark finding of increased ICP on examination is papilledema. - blurring of the optic disc margins Cardio 60% 25 Q B-blockers are contraindicated in acute decompensated HF bc it decreases heart contractility and HR, which worsens pulmonary edema. Nitrates decreases cardiac preload which provides relief for CP and pulmonary edema in those with acute decompensated HF. You don’t stop B-blockers for surgery. In patient with Afib, if they are rate controlled and is asymptomatic Commented [LD3]: Pre-op patients at Je@ Torresdale on their current BB dose, continue it despite surgery - If AFib is not controlled, control it and proceed to surgery as long as they’re stable. - The goal for preop management of AFib: o Ensure hemodynamic stability to avoid HF and MI o Manage anticoagulants to reduce surgical risk of bleeding while minimizing thromboembolic risk of stopping anticoagulants. When to stop anticoagulant and if bridging is needed depend on the class of the medications.  - Whether or not to bridge depends on how fast the drug takes eUect. Warfarin takes longer than DOACs to work, so you need to bridge. Reserved for high-risk patients (CHADVASC 7+, recent stroke, mitral valve) Exercise stress test can help in diagnosis CAD and provide prognostic info in patients with known or highly suspected CAD - If has high-risk EKG features (>1 mm ST depression, ST elevation without Q waves) during stress test likely has CAD. (Aid in diagnostic) - Negative stress test means a < 1% risk of CV events within the next year (prognostic). - Most patients with HCM has normal life expectancy with appropriate therapy. Nitroglycerin is helpful in Acute decompensated HF because it decreases the cardiac preload, improving pulmonary edema. (in general, you want to add an IV vasodilator) - IV vasodilator is indicated right away in patients with “flash” pulmonary edema d/t severe HTN (>180/120 mmHg) (hypertensive emergency) What does each extra heart sound mean? S3 is pathologic in patients > 40 Yo indicative of enlarged ventricular chamber When to atropine? Only in severe and UNSTABLE bradycardia. The tx for Mobitz Type II 2nd degree block in STABLE pt = pacemaker - You want to start pacemaker in Mobitz Type 2 because it has a high rate of progression to complete (3rd degree) AV block A right heart cath study measures the pressure of the heart and lung. Most accurate way to determine how well your heart is pumping and their pressures. Can also measure each chamber’s oxygen saturation. - When there’s an abnormal step up in O2% between chambers and vessels, you should suspect left-to-right shunt and its etiologies.  - Stent thrombosis is an uncommon but fatal complication of coronary artery stenting procedure. Patient should be on dual-antiplatelet therapy (DAPT) for at least 3-6 months following the procedure. - Patient can be oU DAPT sooner if they have a bare metal stent placed. - Drug-eluting stents are stents coated with medicine, considered better than bare metals bc they are less likely to get blocked, restenosis. The con is that pt has to be on DAPT longer - - - Stent thrombosis usually occurs within 30 days of stent placement. - The biggest risk factor of stent thrombosis is medication noncompliance Sinus bradycardia can occur in inferior MI bc of decreased blood supply to the SA node, which causes the RV wall triggering an increased in vagal tone. - Normally self-limiting, but severe sinus bradycardia can lead to cardiogenic shock in inferior MI. - If vitals are unstable (hypotension, cold extremities), give IV atropine 0.5 mg q3-5 mins. - If pt is unresponsive to atropine, next step is temporary pacing. - Epinephrine is contraindicated in MI because it leads to an increase in oxygen demand d/t its beta-1 and alpha-1 stimulation What is the physical exam sign for pulmonary edema? Bibasilar crackles Patient with previous MI or cardiomyopathy and suddenly passes out without warning likely had VT. Admit for cardiac telemetry for monitoring and have and ECHO. - Approach to syncope: generally, look for clues. Some types of syncope - Treatment for all syncope is treating the underlying causes. Sudden cardiac death is the leading cause of death in young (3 cm = “mass”) - Surrounded by pulmonary parenchyma - No associated lymph node enlargement - Approach: first step is to compare lung mass with previous XR or CT Chest. o If no previous imaging available or if SPN has changed in size/appearance à get CT Chest - Solid or spiculated (spikes radiating from surfaces) is more likely to be malignant - Ground-glass appearance is less likely to be malignant - If SPN has high malignancy probability, refer to surgical excision or biopsy.  o Thoracotomy or video-assisted thoracoscopy (VATS) = diagnostic and curative. - If SPN malignancy probability is unclear, do positron emission tomography (PET). o Mass with high metabolic activity on PET is more likely to be malignant o Warrant biopsy or surgical excision. In patients receiving chronic opioid therapy, increased respiratory drive (dyspnea, tachypnea) is abnormal and should alert clinicians and caregivers to an acute underlying non-opioid related disease. Pulmonary cachexia syndrome (PCS): you’re losing lean muscle mass associated with chronic lung disease, commonly chronic obstructive pulmonary disease. - BMI < 20 kg/m2 or weight loss > 5% in patient with COPD suggest the disease - Mechanism is multifactorial and include: o Increased work of breathing cause increased caloric use, resulting in significant energy imbalance (decreased appetite and low diet intake) o Systemic inflammation that may play a role in decreased appetite and catalyzing muscle breakdown o Skeletal muscle hypoxia o Glucocorticoid use in some patients. - Tx: optimizing lung function, exercise, and nutritional supplements. Enlarging fluid collection after a procedure is usually an expanding neck hematoma - Life-threatening bc it compresses the support structures of an airway and causing narrowing of the lumen - Also compress the lympho-vasculature à impaired venous drainage. This results in vascular congestion and intrinsic laryngeal mucosal edema that narrows the airway lumen. - Tx: o if expanding, evacuate surgically. o If obstructing airway, ETT first. If that fails, do tracheostomy. Tracheostomy should be the last resort bc it increases risk of bleeding. What are signs of airway obstructions? - Tracheal deviation and hoarseness - Patient in tripod positions, dysphagia, voice changes, and stridor o Goal to maintain a brain-dead organ donor is to maintain euvolemic, normotensive and normothermic state. Patient receives IVF, desmopressin, and pressor support - Dxs that threatens organ donor viability o Central diabetes insipidus à depletes volume o Systemic hypotension à d/t loss of sympathetic tone, volume depletion o Hypothermia Incarcerated patient with newfound HIV and lung pleural eUusion findings should be suspected for TB pleural eUusion - Pt with advanced HIV has increased risk of getting TB or reactivating latent TB. o Low CD4 count impairs the body’s ability to form cavities that lock up TB bacteria. Soo they presents with lobar, pleural, or disseminated infection. Pts with high CD4 will presents with cavitary lesions in the upper lobe. o Thoracentesis of TB pleural eUusion is: § Lymphocyte-predominant, exudative eUusion § Malignancy pleural eUusion has the same characteristic but does NOT have elevated adenosine deaminase. TB pleural eUusion does. o To confirm: do pleural biopsy Pneumocystis pneumonia does not present with lobar infiltrates and pleural eUusions. - Dx is first evaluated with induced sputum sample THEN bronchoalveolar lavage (2nd-line dx test). Silicosis is more common in miners, sandblasters, foundry workers, and masons - Foundry workers: those that melt medals - Masons: those that lay bricks with cement in constructions - Doesn’t have pleural eUusion nor pleural thickening - CXR: upper lobe nodules and lower lobe emphysema. Asbestosis more common in those who work with cement, tile, automobile brake pads, or shipbuilding - Associated with malignant mesothelioma. - Pleural eUusion is almost always present and is typically noted on PE and CXR - Has pleural thickening, calcifications, and or mass - Most accurate dx test is video-assisted thorascopic biopsy or open thoracotomy. - Tx is surgery, chemo, and/or radio - Prognosis is 9-13 months to live. Pulmonary artery filling defects on CTA is also a diagnostic sign of pulmonary embolism S1Q3T3 pattern and T-wave inversion in V1-4 shows right heart strain pattern associated with PE. Troponin may reflect myocardial strain but it is nonspecific. Can be elevated in ANY cause of myocardial strain. Acute PE can have elevated troponin. - To diUerentiate ACS, must have ST elevation or depression corresponding to coronary artery territory.  o Criteria for STEMI is >0.1 mm elevation in 2 contiguous leads or >0.2 mm in lead V2 and V3 or new LBBB. Therefore, T-wave inversion at ONE lead is NOT ACS After confirming pulmonary embolism (PE), you have to stratify the risk. Risk stratification depends on how the right ventricle tolerates increased afterload. - Massive PE: RV failure with obstructive shock presentation (SBP < 90) and requires vasopressor and inotrope support. Need immediate systemic thrombolytic agents. - Submassive: RV dysfunction without hypotension. Commented [LD4]: Dr. Samuel spoke of this today in ICU o Dx based on BNP and Troponin levels. Increased Troponin indicates cardiac ischemia. 9/16 BNP reflect acute myocardial stretch. § Elevation of both shows higher risk of deterioration, progressing to shock or overt RV failure. o Tx: tailored individually from AC à thrombolytic-based strategies. Hemoptysis after PE is usually non-life threatening as long as it doesn’t cause airway obstruction (asphyxiation on blood, impaired gas exchange, HDUS). - Anticoagulation may exacerbate the risk for hemoptysis in the setting of PE. But if the patient is clinically stable, you should continue therapeutic anticoagulation. o Stopping premature can cause recurrent PE , esp in the first 2 weeks. The most important clinical predictor of pulmonary embolism is right ventricular dysfunction. There’s a step-wise management approach to PE: - Everyone should be on anticoagulation unless they have specific contraindications o Unfractionated Heparin, LMWH heparin, DOACs - IVC filter if anticoagulation is contraindicated or they have low cardiopulmonary reserve - Thrombolysis: when there’s hemodynamic instability (SBP < 90) and has low risk of bleeding o tPa 100 mg/2hr- systemic o Catheter-directed therapy (for pts who are not candidates for systemic fibrolytic therapy or surgical thrombectomy) o Contraindications: intracranial neoplasm, prior hemorrhage, cerebrovascular abnormalities, active bleeding, and recent cranial trauma. - If all else fails, thrombectomy  Do this before ordering CT Angiogram for confirmation Patients with impaired kidney functions (High Cr) should not have CT Angiogram. Instead, do V/Q scan. Acute asthma exacerbation management - Put patient on bronchodilator therapy: inhaled or nebulized albuterol + inhaled ipratropium. o Albuterol: B-agonist -> dilates the bronchioles o Ipratropium: muscarinic receptor antagonist. Dilates the bronchioles. Last longer than B- agonists. § ACh causes bronchoconstriction (ACH stimulates constrictions of smooth muscles) o IV magnesium or terbutaline may be needed for refractory bronchoconstriction § Terbutaline: B2- agonist. - Put patient on systemic corticosteroids for patients with incomplete response to bronchodilators, high-risk asthma features, or breakthrough acute exacerbation despite taking controller meds. (Next step) - Supplement O2 should be given to maintain SaO2 > 95% in pregnant ( vs >90% in nonpregnant patients) - - Intubate for any patients with IMPENDING respiratory failures. Characteristics of a benign lung lesion: popcorn calcifications (seen in pts with pulmonary hamartoma on XR), concentric or laminated, central, and dihuse homogenous calcifications. Hyperventilation stimulates mast cell degranulation, triggering bronchoconstriction. Exercising- induced bronchoconstriction is linked with pre-existing asthma, but it can occur without asthma. Exclusively triggered by exercise. Parkinson’s disease patients tend to suUer from dysphagia, this can lead to aspiration pneumonia. Aspiration PNA is the leading cause of death in PD Aspiration pneumonia is definitively diagnosed with video-fluoroscopic swallowing study. - Initial management is blood and sputum culture and start abx with anaerobic coverage (clindamycin) - Stabilize the patient first BEFORE bed-side swallowing assessment. - Once confirmed and patient is stabilized, start dysphagia rehab program (dietitian, nursing, speech therapy). Specific intervention include thickened liquids and modified swallowing techniques Bronchoscopy is useful to rule out and biopsy endobronchial obstruction. First step to assess patient with hemoptysis is to get a CXR. This is to identify the site and cause of bleeding (cavitary lesion, lung mass, or stigmata of mitral stenosis) In patients with acute COPD exacerbation (productive cough of greenish-yellow sputum, dyspnea, wheezing + COPD hx), start antibiotics for patients with any of the two features: - Increased sputum purulence - Increased sputum volume - Increased dyspnea - Those that require mechanical ventilation - *** According ot the GOLD guideline (Global initiative for Chronic Obstructive Lung Disease) Surgery 15Q 60% Acute compartment syndrome can be diagnosed clinically. But a delta pressure (diastolic pressure – compartment pressure) < 30 mmHg = confirmatory as well. Desmoid tumors are slowing growing and locally aggressive benign neoplasm with a high rate of local recurrence, even after surgery - p/w abdominal mass (most common location) and mild pain. Deeply seated painless/painful masses in the trunk/extremities, intraabdominal bowel and mesentery, and abdominal wall. o Can cause obstruction/bowel ischemia - They arise from fibroplastic elements w/in the muscle or fascial planes. Has low potential for metastasis or diUerentiation. - Thought to be due to abnormal wound healing or clonal chromosomal abnormalities causing the neoplastic behaviors - Can have varying sizes - - CT Abdomen/Pelvis or MRI for diagnosis, biopsy for histology  - Tx: surgery or radiation therapy (for poor surgical candidates) if symptomatic. If asymptomatic, observe Dermatofibroma: benign proliferation of fibroblasts that usually occur after trauma/insect bite. Appears firm hyperpigmented nodule located on the lower extremities rather than abdomen. - Epidermoid cyst: discrete nodule that usually located on the skin and a result of normal epidermal keratin becoming lodged in the dermis. Also most commonly occur on the extremities rather than abdomen/trunk - Pyogenic granuloma (granuloma telangiectaticum): capillary proliferation after trauma and usually p/w dome-shaped papule with recurrent bleeding. More common in pregnant women. - Open globe injury signs: tear drop pupils, decreased visual acuity after some type of trauma. - - Management: IV Abx, eye shields, CT eye (to look for foreign bodies), and emergency optho consultation for surgery - MRI is contraindicated when an intraocular metal foreign body is suspected bc the magnetic waves can cause the metal to migrate, cause more damage. - - Most hernias p/w dull sensation of heaviness or discomfort that is more pronounced w/ prolonged standing/straining (d/t increased intraabdominal pressure) and relieved with lying flat. - Femoral hernia needs to be surgically repaired regardless of symptoms bc of high risk of strangulation - Inguinal hernia is only surgically repaired if symptomatic. Otherwise, watchingful waiting and reassurance.  o This is the orifices of the inguinal hernia is LARGER than femoral hernia. Smaller holes = higher risk of strangulation. In acute settings , bedside ultrasound has become the test of choice for diagnosing pneumothorax bc of its high sensitivity and specificity ( both > 90%) compared to CXR (~50%). Doesn’t have to move the patient. - On U/S, you need to visualize the parietal and visceral pleura. If there are no lung sliding (2 layers moving against one another), then that’s pneumothorax. - - - Seashore sign: normal lung sliding - CXR can be a good alternative when there is no U/S available. Hip fracture in an elderly patient should be surgically managed promptly. - If hemodynamically stable, do surgery within 24 hours. o Associated with decreased mortality, length of hospital stay, and time to full-weight bearing status + functional recovery  - If unstable, delay surgery briefly (< 72 hours) but still need to do surgery. Burn surface area Calculation to predict mortality for burn patient is the revised Baux score: - Age + TBSA + 17 (if inhalation injury is present). - Score > 140-150 = no hope of survival. Refer to hospice care - Greatest contributor to this equation is TBSA. Higher the number, the worse prognosis. You can get SIADH postoperative, which is commonly due to non-osmotic stimuli for ADH secretion (pain, nausea, physical and emotional stress). - Patient that has [Na] < 120 mEq/L and tonic-clonic seizure suggests development of cerebral edema and associated risk of brainstem herniation. SBO/partial SBO are initially managed conservatively. If fails to improve in the next 12-24 hours, early surgical intervention is recommended. Both cyanide and CO poisoning can occur during a house fire. - Cyanide is a poison that stops oxidative phosphorylation, halting aerobic metabolism and forcing a switch to anaerobic metabolism o You’d expect to see lactic acidosis + cellular hypoxia à neurological dysfunction and rapid cardiopulmonary compromise (hypotension, bradycardia) - Antidote to cyanide poisoning is hydroxocobalamin. o Hydroxocobalamin binds to cyanide, forming cyanocobalamin which can be excreted. - CO binds to hemoglobin more readily than O2. This leads to oxygen not being delivered to tissues. o Tx with 100% oxygen o Confirm poisoning first with carboxyhemoglobin level BEFORE treating because the level will guide further management. - Patients who recently had renal transplant are more likely to develop diabetes within the first few months - Immunosuppression drug side eUects o Most pts are placed on glucocorticoid, calcineurin inhibitors (tacrolimus), and antimetabolic agent (mycophenolate). § GC causes weight gain and decrease insulin sensitivity § Calcineurin causes toxicity to the pancreas, impair insulin secretion - Healthier kidney o Imporved kidney can increase insulin excretion + gluconeogenesis. When there is a functional contralateral kidney, AKI is rarely caused by unilateral renal obstruction (ureterolithiasis). The normal opposite kidney can filter shit well on its own. - Therefore, post-renal AKI obstruction must be bilateral. - Post-renal Aki can be due to bladder outlet obstruction d/t BPH (this is John Lieb at Rox) Femoral neuropathy can be due to compression from an iliopsoas hematoma. - In pregnant women, prolonged lithotomy positioning can cause this Common fibular nerve distribution - GI 25Q 64% DM Patients with gastroparesis often have labile DM control and frequent hypoglycemia bc it’s diUicult for them to time their insulin dose to correspond with the delayed intestinal absorption of glucose. - First step to evaluate gastroparesis is to rule out a mechanical obstruction. Done with upper GI endoscopy or barium swallow. CT AP and MRI AP can be added if extrinsic compression is suspected. - If no obstructions are found, THEN you do nuclear gastric emptying study to assess the gut motility AND confirm the diagnosis. - Management: first line is to have them eat small, frequent meals with decreased fat and fiber intake. o If that doesn’t work, then add mobility agents (erythromycin or metoclopramide). - Colon cancer screening: - - You have a higher risk of colon cancer if you have a first degree relative who was diagnosed with colon cancer at age < 60. o If your first degree relative was diagnosed with cancer at age > 60, then you can follow the routine screening schedule. Treatment for chronic Giardiasis is tinidazole or nitazoxanide. Treatment for nontyphoidal Salmonella is fluroquinolones (ciprofloxacin)  Angiodysplasia is most common in patients > 60 y.o. and are often discovered incidentally on endoscopy. - Appears as small, cherry-red lesions. - P/w occult GI bleeding - Most of the time, patients don’t have bleeding. But bleeding is increased with end-stage renal disease, aortic stenosis, and von Willebrand disease (vWD) o Uremia from ESRD can impair platelet function à more bleeding o Aortic stenosis can lead to acquired vWD d/t mechanical disruption during vascular flow. Tricuspid valve regurgitation is associated with carcinoid syndrome, which causes flushing and diarrhea. Nonalcoholic fatty liver disease is defined as hepatic steatosis (fat buildup) without a secondary cause of hepatic fat accumulation (alcohol use, chronic viral hepatitis). - Often co-exist with type 2 DM, obesity, and HLD. Look for those signs in question stems. - - Nonalcoholic fatty liver (NAFL): hepatitc steatosis with no inflammation and hepatic injury (such as ballooning). Low risk for fibrosis and cirrhosis - Nonalcoholic fatty steatohepatitis: fatty liver with inflammation and hepatic injury (ballooning). Carries higher risk for fibrosis and cirrhosis. o Need more aggressive management (pioglitazone and Vitamin E) o “-glitazone” = thiazolidinedione (TZD) DM drug. Increases insulin sensitivity  - Acute diarrhea is defined as < 14 days. - Acute bloody diarrhea is more likely due to bacterial infection - In healthy patients, this usually self-resolve. So no need for hospitalization - Empiric Abx is avoided to prevent increased risk for Abx resistance - Indications for Abx: o Infection that are severe (induce hypovolemia o Prolonged ( last >7 days) o Patients at risk for severe disease (elderly, immunocompromised) - Mainstay of treatment for HCV is direct-acting antiviral agents, such as sofosbuvir-velpatasvir. - If you have HCV, get vaccinated for HAV and HBV to prevent further liver damage  - Fibrates (fenofibrate, gemfibrozil) are the most eUective meds to lower TG and prevent hyperlipidemia-induced acute pancreatitis. - Apheresis is when you directly filter TG out of the blood. Only used in severe cases (fever, tachycardia, leukocytosis, lactic acidosis, and hypocalcemia) Dumping syndrome is a complication of gastrectomy. - - Because the liquids and food enter the jejunum faster, you’d get abdominal pain, diarrhea, n/v, some neurovegetative symptoms (dizziness, sweating, dyspenea). - Management: tell patients to eat small, frequent, high protein diet and low carbohydrates. Acute radiation proctitis - p/w diarrhea, mucus discharge, and tenesmus (ineUectual/painful straining on defecation) during or within 6 weeks of pelvic radiation. - Chronic radiation proctitis: similar symptoms but occur >9 weeks to years after radiation therapy. More associated with strictures, fistula formations, and rectal bleeding. - Diagnosis of exclusion - Treated with supportive measures (fluids, antidiarrhea agents). Chronic cases can be treated with sucralfate (anti-ulcer drugs) or glucocorticoid enema Elderly patient with multiple atherosclerotic risk factors (CAD) with bruit heard on physical exam, think of chronic mesenteric ischemia (“intestinal agina”). - Worsening dull, crampy epigastric pain after eating (post-prandial) = diagnostic. - Patient starts losing weight bc of avoiding to eat = supportive. - Dx: CT angiogram, MRI angiogram, and duplex ultrasound (non-invasive) - Angiography is the gold standard for confirmation - Tx: angioplasty (stent placement) Patient with any of the risk factors should have endoscopic screening (EGD) to look for cellular metaplastic changes - Chronic GERD (>5 years) - Age >50 - Male - White race - Hiatal hernia - Central obesity (waist circumference > 102 cm) - Current or former smoker - First-degree relative with BE or esophageal adenocarcinoma Patients with Barret should be on life-long PPI to prevent cancer and control reflux. Acute pancreatitis requires 2 of 3 critierias - Acute onset of persistent, severe epigastric pain - Increased lipase or amylase that x3 times the upper limit (lipase is more specific) - CT AP with contrast shows pancreatitis o Has low sensitivity in the first 72 hours of presentation though. Hence, imaging is reserved when lab is not conclusive. After managing pancreatitis supportively but the patient still deteriorates (fever, leukocytosis, hypotension) with ongoing abdominal pain. Evaluate for infected pancreatic necrosis - Can be sterile initially but can become infected typically > 7 days after initial presentation. - Gas within pancreatic necrosis = diagnostic - Best Dx with CT AP with IV contrast - Tx: IV Abx (meropenem, fluoroquinolone + metronidazole). If this fails, surgical debridement. - - To prevent fecal impaction, prescribe a maintenance bowel regimen. - Polyethylene glycol is first-line for older people - Bisacodyl is not recommended for long term use bc of increased protein-losing enteropathy and electrolyte imbalances (hypokalemia, salt loss) - Long term use of enema (esp sodium phosphate enema) is advised AGAINST in older people bc they can cause hypotension and electrolyte abnormalities (metabolic acidosis). Plus it’s inconvenient - Docusate is a stool softener. Doesn’t have a strong laxative eUect. Lactose intolerance vs celiac disease - Celiac disease does not experience temporal relation between mealtimes and GI symptoms. - Lactose intolerance doesn’t present with iron deficiency anemia Peptic stricture is a well-known complication of GERD that resulted from the healing process of ulcerative esophagitis. Dysphagia starts with solid followed by liquids. Audible splashing sound in the epigastric region during sudden movement of the patient = succussion splash. à sign of delayed gastric emptying - Remember, first step is to evaluate for obstruction. Do this with EGD - Then do nuclear gastric emptying - Gastroduodenal manometry can be used to distinguish between myopathic (amyloidosis) vs neuropathic etiologies. - Random 25 Qs 76% Cilostazol is contraindicated in patients with CHF Dysphagia (diUiculty swallowing) that involves both solids and liquids = neuromuscular disorders (motility) - Barium swallow/esophagram is the initial test. - Manometry is usually confirmatory. Dysphagia that starts with solid first followed by liquid = mechanical obstructions (structural) - Initial: nasopharyngeal laryngoscopy (most eUective). Allow you to visualize the upper GI tract - Barium swallow/esophagram can also help. o Barium swallow: XR exam that evaluate esophagus, throat, and back of the mouth. o Vs Video-assisted barium swallow: a modified version of barium swallow/esophagram that is used to assess oral cavity, pharynx, and cervical esophagus. - EGD is used after the nasopharyngeal laryngoscopy/barium swallow can’t find anything. EGD is the NEXT step because 1) you cannot visualize the upper esophagus upon insertion and 2) increased risk for perforation à Upper GI/esophageal bleed. SCC is more upper esophagus. Adenocarcinoma is more mid-distal/lower esophageal cancer. All patient with reduced EF (HFrEF < 40%) should be put on ACE-i/ARBs + Beta-blocker. ACE-i/ARBs first. Once you find the right dose of ACE/ARBs that doesn’t cause hypotension, put them on Beta- blockers. - Diuretics is NOT indicated for asymptomatic CHF (NYHA class I) - SCC skin cancer needs to be surgically excised (both diagnostic and curative). Excision can help confirm the diagnosis in low-risk SCC skin cancer - For patients who don’t want surgery, alternatives are cryotherapy, electrosurgery, and radiation therapy. - Radiation therapy may require multiple visits and can increase risk of future cancers. So they are typically reserved for old people who refuse surgery. BRAF gene therapy is used for melanoma (not squamous cell skin cancer). Acute Multiple sclerosis exacerbation is treated with either oral or IV corticosteroids. But for patient with acute optic neuritis, IV is preferred. Oral route is associated with increased risk for recurrent optic neuritis. - Plasmapheresis is used IF the patient does not respond to corticosteroid. - Long-term Tx for MS: beta-interferon, glatiramer acetate. They both decrease the frequency of relapse and reduce the development of brain lesions. Pramipexole is a dopamine agonist used as long-term treatment for Parkinson disease Rivastigmine is a cholinesterase inhibitor that may be used to treat mild-moderate Alzheimer dementia Topiramate is an anticonvulsant that is used for migraine PPx or seizure disorder. Pregnant women with MS are more likely to need C-section compared to those who don’t. - Acute exacerbation of MS in pregnant patient is treated with short-term IV corticosteroid like non- pregnant people Muscle spasm in MS is treated with baclofen or tizanidine. Dupuytren contracture is shown in 40% of patients with DM. This is Dupuytren contracture Transverse myelitis: immune-mediated disorder characterized by infiltration of inflammatory cells into segment of the spinal cord. - p/w rapidly progressive myelopathy localizing to 1+ contiguous spinal cord segments following recent infection (URI, gastroenteritis) - Sx: motor weakness, sensory loss with distinct sensory level (usually around T10/umbilical region), and autonomic dysfunction (bladder retention). - Tx: high-dose IV glucocorticoid/corticosteroid Unexpected rise in Cr after ACE-I is an important clue to diagnose renovascular disease/renal artery stenosis - Renal hypoperfusion triggers RAAS, which causes HTN and maintain GFR. ACE-I lowers angiotensin II in the RAAS system, leading to significant decrease in GFR and AKI (increased Cr) Hazard ratio is a measure of risk that describes the chance of events occurring in one study compared to another. - Measures the ehicacy of one treatment vs other. - Used frequently in drug trials to analyze survival or time-to-event data. - HR > 1 = increased risk - HR < = decreased risk Incidence = # of new cases/ total cases Relative risk = incidence of disease in exposed group / incidence of disease in unexposed group - Used as a measurement of association between exposure and outcome in observational or experimental follow up studies. - RR < 1.0 = decreased risk - RR > 1.0 = increased risk For a confidence value to be statistically significant, the interval must NOT include 1.0 (the null value for ratios) Odds ratio: measures association between exposure and outcome in case-control and cross-sectional studies Immune thrombocytopenia vs Thrombolytic thrombocytopenic purpura: - Isolated thrombocytopenia is ITP. - ITP is a diagnosis of exclusion  - TTP is thrombocytopenia and microangiopathic hemolytic anemia (manifest as schistocytes on PBS and elevated lactate dehydrogenase). More severe features: o Acute renal failure (look at Cr) o Fever o Neurologic abnormalities (AMS) - - If platelet is < 30,000 or you have bleeding in ITP à give Glucocorticoid, IVIG, or anti-D - ITP is due to platelet destruction by antiplatelet autoantibodies, which are directed against membrane proteins (GPIIb/IIIa) Interpretation of relative risk ratio depends on which group is used as a reference (the denominator). - RR = numerator/ denominator - Interpretation: RR of # in **numerator group as compared to the denominator group = X - To switch the reference group, simply invert the fraction (x à 1/x) In patients with poorly controlled DMT2, the excessive glucose can cause decrease in acuity of vision via osmotic fluid shifts in the lens. - In other words, too much glucose can cause can shift fluids/water into the lens. - Too much water in the lens can change the thickness, curvature, and refractive power of the lens. - The thicker lens will increase the refractive power à blurry vision Hyperthyroidism after within a year pregnancy is most likely postpartum thyroiditis - Pathophysiology; having preformed thyroid hormones being released - Radioactive uptake will be LOW (vs. Graves, which will be HIGH). - Random 25Q 64% Warfarin inhibits epoxide reductase by competing with Vit-K, which inhibits the production of Vit-K dependent coagulation factors - Biggest side eUect is increased bleeding (esp. intracranial hemorrhage) - If intracranial hemorrhage, warfarin must be reversed quickly - Prothrombin complex concentrate (PCC) contains Vit-K dependent clotting factors. o Normalizes INR < 10 minutes - IV Vitamin K can also reverse warfarin but takes 12-24 hours for full reversal. o Hence why PCC > IV Vit K in emergent situations - Fresh frozen plasma (FFP) is second line d/t large volume (often > 2L) required and the delay for blood compatibility tests. Use when PCC is unavailable Acute RV contractile dysfunction seen in RVMI abruptly causes increased RV preload with JVD and ventricle is unable to pump adequate blood through the pulmonary circulation to the left side of the heart (decrease left side ventricular preload). This cause reduced cardiac output and hypotension. - Hence, nitrates, diuretics, and opioids are avoided because they reduce RV preload, worsening hypotension - Tx: goal to treat hypotension in the setting of RVMI = give IV normal saline bolus to further increase RV preload. o IV normal saline bolus also provide additional hydrostatic pressure to push the blood through the pulmonary circulation. - Then follow the standard acute MI management: o CCB (amlodipine) most common side eUect is peripheral edema. Others are headache, flushing, and dizziness. Herpes zoster treatment - Oral valacyclovir for 7 days is the mainstay regimen - IV acyclovir is only used if the patient is immunocompromised - Oral acyclovir requires dosing 5 times a day. Oral valacyclovir is preferred because it is taken 3x a day People (healthcare workers) are immune if they have either: - Documented previous hx of varicella - Received 2 dose varicella vaccine - Those who are immune do not require postexposure prophylaxis (PEP) after working with pts with herpes zoster - Those who do NOT have immunity need to receive PEP with varicella vaccine within 5 days of exposure Varicella lesions are that dry and crusted cannot generally transmit VZV to other individuals via direct contact or aerosolization. - If the lesions are not completely crusted over, you should cover up the rash to avoid spreading to patients who are highly susceptible to illness, such as pregnant women who have never had varicella or the varicella vaccine, low-birth-weight infants, and immunocompromised individuals Huntington disease is caused by autosomal dominant CAG trinucleotide repeat expansion in the huntingtin (HTT) gene on chromosome 4p. - Chorea: core feature of HD. Identified by abrupt and involuntary movements of the face, limbs, and trunk (facial twitching, asymmetric jerking movements. - Other signs: inability to sustain simple voluntary acts, inevitable cognitive decline - Course is a progressive deterioration in cognitive and motor function over 10-20 years after symptom onset à death - No cure or disease-modifying therapy. - Alopecia areata: discrete, smooth and circular areas of hair loss. Develops over a few weeks and has a recurring pattern. Most of them will regrow over times - However, the disease can reoccur after a successful treatment - Tx choice: topical or intralesional corticosteroids. Also, patient education o Disease = benign o Can have multiple relapses in spite of tx o Most patients have normal hair growth within the next 1-2. Years even without treatment. Sensitivity analysis: you repeat the primary analysis after making changes to the criteria or ranges. - Goal is to see if changing the variables/range will aUect the results. - If the results/outcomes are similar before the changes, then the researchers can be more confident in their results. Holosystolic murmur with a palpable thrill = VSD This is a superficial basal cell carcinoma Apparently there are 3 types of basal cell carcinoma (BCC): - Nodular BCC: this your classic shiny, pearly, skin-colored nodule with telangiectasia - Superficial BCC is the 2nd most common type, presents with pink/red macules, patches, or thin plaques. Can appear atrophic (see above) - Morpheaform/infiltrative BCC, least common. Presents with pale, scar-like indentations. - Granuloma annulare presents with asymptomatic, firm, smooth, annular plaque with raised borders. - Hydralazine can cause drug-induced lupus, but drug-induced lupus does NOT cause renal failure. NSAIDs can cause renal failure/nephropathy by causing a reversible decline in renal blood flow and GFR due to inhibiting prostaglandin production (PG). PG causes the renal arteries to vasodilate. Dengue: mosquito-borne virus. - Endemic ares: Asia (India), Africa, South America, and the Pacific and Carribean Islands. o Look for recent travel history. - Sxs begin 4-7 days after transmission. High fever, retroorbital pain, severe arthralgia and myalgia (‘breakbone fever”). o Has hemorrhagic symptoms (petechiae, mucosal bleeding). Petechiae can be provoked by the tourniquet test. o Tourniquet test: applying blood pressure cuU to the arm and inflating midway b/n diastole and systole for 5 mins. o Labs: leukopenia, thrombocytopenia, hemoconcentration (high HCT), and transaminitis. - Dengue shock syndrome: o life-threatening condition marked by severe capillary leakage, pleural eUusion, ascites, circulatory collapse, and end-organ damage. o Need urgent resuscitation. - XR is ordered first to look for osteomyelitis bc it’s cheap and has low radiation profile. However, sensitivity of an XR is low (< 55%), so a negative XR cannot rule out osteomyelitis. - MRI is the confirmatory tool for osteomyelitis d/t high sensitivity and negative predictive value. - MRI can see osteomyelitis-related bone changes < 5 days after infection onset. - - Bone biopsy with culture is the gold standard for identify which organism is responsible for osteomyelitis - Tx: antibiotics x 6 weeks, glucose control (if DM), surgical debridement, revascularization Basal cell carcinoma rarely metastasizes, but can invade local structures (cartilage, bone, nerve). If at the eyelid, BCC can invade the orbit à blindness and exenteration - Exenteration: surgical procedure that removes organs from a body cavity - Orbital exenteration: removes the entire contents of the bony orbit, including eyeball, muscles, fat, and sometimes the eyelids. - Tx: Mohs micrographic surgery (if BCC is in face/high-risk tumors) - If you are not a patient of a physician and some recs were given in a casual, nonprofessional setting with no established physician-patient relationship, you are not liable for malpractice. Tumor lysis syndrome: excessive release of intracellular contents, including K/P/Purine nucleic acids are metabolized to uric acid; - Measurement of elevated serum uric acid would confirm the dx - Presents with AKI + electrolyte abnormalities in the setting of malignancies with rapid cell turnover (non-Hodgkin, acute leukemia). - AKI in TLS results from calcium-phosphate and uric acid stones à renal tubular obstruction. o Uric acid can reduces NO levels, which lead to renal vasoconstriction and encourages localized inflammation. - - Tx for TLS: IVF + rasburicase o Rasburicase: uric-acid reducing therapy. A recombinant analog of urate oxidase that can metabolize uric acid that has already accumulated. § Urate oxidase changes uric acid to allantoin, which is excretable through the urine.  - Functional iron deficiency means adequate iron stores (normal – high ferritin) that cannot be eUectively used for erythropoiesis. Absolute iron deficiency: has depleted iron storage. Lithium-induced hypothyroidism is NOT an indication to stop lithium. Continue lithium and add on levothyroxine