Vitamins

Vitamin A

Night blindness, conjunctival dryness, corneal keratinization

Vitamin D

Ricketts - kids, long bone bowing; Osteomalacia-adults, demineralization

Vitamin K

Clotting deficiency with prolonged PT

Thiamine (B₁)

Beriberi - peripheral neuropathy, Cardiomyopathy - dry or wet (high output failure)
Wernicke-Korsakoff - Alcoholics, confabulation, nystagmus, confusion

Niacin

Pellagra - Diarrhea, dermatitis, dementia, death

Pyroxidone (B₆)

Rare, neuropathy, Cheilosis (swollen cracked bright red lips)

Cobalamin (B₁₂)

Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test

Folate

Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics

Vitamin C

Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic.

Failure to Thrive

Org.= decr. wt gain w/ other disease; Nonorg.=growth failure due to neglect ßstimulation
< 80% wt for Ht

Obesity

mild 20-40%, moderate 41-100, severe <101%; age, black women, low income
BMI= body wt (kg)/Ht (mm²) Normal 20-25
Pickwickian Syndrome = obesity, dyspnea, hypovent, CO₂ retention, hypoxia

Boerhaave's Syndrome

esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion

Dysphagia 

Obstructive - solids 1^st; Motor -solids = liquids

Infectious Esophagitis

Candida (thrush), HSV, CMV, immunocomp, diabetics, Dysphagia & odynophagia

Esophageal Atresia

Proximal esophagus, blind pouch

Trachesoph Fistula

Congenital defect, distal esoph, coughing & cyanosis when feeding, abd distention

Achalasia

Dysphagia for solids & liquids, nocturnal cough, aspiration; Absent peristalsis & tight LES, "Beak" esoph on x-ray, 20-40 yrs old

Esophageal Cancer

squamous 90% Dysphagia solids 1^st, Cough & hoarse = laryngeal nerve, constricting bands = annular lesion, Risk factors= smoking, alcohol, GERD, Barretts Esoph = adeno CA

Gastritis

Antral Creep=fundal tissue replaced by antral mucosa, Not preCA,
Risk Factors = NSAIDS, Alcohol, H.Pylori

PUD

Gastric = NSAIDS, eating no help, COPD,blood type A; 25%
Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Blood type O ; 75%

Cullen's Sign

Periumbilical cyanosis d/t hemoperitoneum = hemorrhagic pancreatitis, ruptured ectopic, ruptured spleen

Zollinger-Ellison Synd.

Gastrinoma ( incr. gastrin); recurrent ulcers, ½ are malignant

Gastric CA

Adeno, H.Pylori gastritis, Virchow's Nodes, Types = ulcerating (shallow edges); polyploid (intraluminal late mets); superficial (early CA) ; Linitus Plastica (all layers decr. elasticity) Mets to ovary = Krukenberg Tumor

Diarrhea

Osmotic = incr. H₂O lumen incr. solutes in bowel; Secretory = electrolytes & H₂O secreted not absorbed; Malabsorption; Exudative secretion of blood plasma & mucus (mucosal inflammation); decr. transit time (short bowel); incr. transit (bact. Proliferation)

Ischemic Colitis

Vascular compromise (atherosclerotic or embolic); abrupt abd pain after eating, bloody diarrhea, systemic sx.; Barium X-Ray - Thumbprint = pseudo tumor

Irritable Bowel Synd.

Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, antidiarrheals, TCA

Colonic Polyps

villous>tubular ; sessile>pedunculated for being CA; familial adeno polyps autodom.

Lactose Intolerance

Lactase deficiency, bloating & explosive diarrhea after milk; Ages 10-20

Celiac Sprue

Gluten sensitivity (wheat, rye, barley); amenorrhea 1^st sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of bowel with thin mucosal folds; most common cause of malbsorption

Tropical Sprue

nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline

Whipple's Disease

Infectious; middle aged men; multi-organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent)

Intestinal Lymphangiectasia

Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic
Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement

Toxic Megacolon

Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, incr. temp, abd pain, rebound, leukocytosis; X-ray - intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation

Inguinal Hernia

Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig.
Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's

Ulcerative Colitis

Colon & Terminal Ileum w/o skip lesions, w/ rectal bleeding, "lead Pipe" on X-ray (shortened, narrowed, loses haustrations) Tx: Sulfasalazine, steroids, Immunosuppresents; Complications=perf, hemorrhage, Toxic Megacolon, Colon CA

Diverticular Disease

Diverticulosis = false diverticulae, pearl sign on xray
Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack

Crohn's Disease

Granulomatous colitis; No bloody stools, 1^st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative

Colon CA

Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CA-hematochezia

Volvulus

Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery

Intussusception

Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = omit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery

Necrotizing Enterocolitis

Premature, decr. birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part

Cholera

Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline

Shigella Dysentery

Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin

Staph Enteritis

Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA, fever recovery w/in 24 hrs

Salmonella Enteritis

Undercooked Poultry; nausea & cramps => watery &/or bloody diarrhea; No antibiotics prolongs excretion of the organism

Viral Enteritis

Norwalk = yr round, Rota (kids) = winter; Coxsackie A1; echo, adeno

Botulism

Clostridium Botulinum, neuromuscular; onset 12-36 hrs; N/V/D, cranial nerve palsy, fixed dilated pupils, resp failure, no fever, Wound induced = neuro w/o gi sx
Infants constipation 1^st=> cranial nerve sx => cranial nerve Sx => Neuromuscular

Hemorrhagic Colitis

E coli 157, cramps, => watery diarrhea => bloody diarrhea Complications= Hemolytic-Uremic Syndrome, thrombotic thrombocytopenic pupura

Pseudomembraneous Colitis

Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases

Acute Pancreatitis

Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase incr. ;
Ranson's Criteria: 3 or more = incr mortality
Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000
Within 48 hrs: Hct decr. 10%, BUN incr. >5, Ca< 8, PaO₂ < 60, Base Def > 4, Fluid Seq>6L

Chronic Pancreatitis

ERCP to Dx; Alcoholics, Malabsorption & diabetes are results

Hepatitis

Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected
Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life
HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA
Hep C Most common post transfusion hepatitis
Hep D = Co infection with B; Hep E = fecal oral

Cholelithiasis

Female, fertile, fat, forty; Ultrasound, RUQ pain after fatty meals, Calcified = preCA

Cholangitis

Charcot's Triad = Biliary Colic, Jaundice, Fever; Leukocytosis, incr. Alk Phos

Hepatocellular CA

Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V.
Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites)

Benign Hep Adenomas

oral contraceptives

Exocrine Pancreatic CA

Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices

Insulinoma

Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still incr. after fasting
Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting

VIPoma

Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx

Glucagonoma

tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities

Pompe's Disease

a 1,4 glucosidase deficiency; fatal by age 2

VonGierke's Disease

glucose-6-phosphatase def.; big liver & kidneys, growth retardation, electrolyte prob.

McArdles Disease

musclephosphorylase is absent, muscle cramps & incr. myoglobin after exercise

Jaundice

Prehepatic = hemolysis, gilbert's disease, Crigler Najjar; Hepatic = hepatocellular or cholestatic; Post Hepatic = Biliary obstruction, AST & LDH also incr. ;
incr. unconj prehepatic; incr. conj = intrahepatic cholestasis or post hepatic disease ; incr. all fractions = hepatocellular, hyperbilirubinuria = conj bili water soluble

ETOH Hepatic Disease

Fatty liver => ETOH hepatitis => cirrhosis; AST incr. > ALT incr. ; incr. PT; decr. II, VII, IX, X Clot

Cirrhosis

necrosis and fibrosis, decr. serum albumin, anemia incr. PT, Not curable or reversible

Esophageal Varices

veins that expand to circumvent congested hepatic flow; Tx: vasopressin, balloon tamponade, endoscopic sclerotherapy, transjugular hepatoporto shunt (TIPS

Hepatic Encephalopathy

altered consciousness, incr. ammonia incr. glutamine in CSF, EEG abnormal

Ascites

Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if incr. albumin = malignant; incr. LDH > 60% of serum = malig or infective;
incr. WBC = infection

GI Bleeding

Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) decr. Lig Trietz

Intestinal Obstruction

Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS.
X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel

Ileus

Paralytic obstruction of bowel due to loss of peristalsis

Pyloric Stenosis

Projectile vomit in neonates, visible peristaltic wave, String Sign

Meconium Ileus

Abnormal thick Meconium with undigested protein, associated with CF

Hirschsprung's Disease

No autonomic nerves in colon, Obstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, Colostomy

Contraindications to BP meds

Asthma/COPD = Bblockers, DM = Thiazides & Bblockers, Cardiac Failure = Bblockers & Ca Channel Blockers; Pregnancy = Thiazides & ACE

Rheumatic Fever

post strep infection, migratory arthritis, endocardits, subcutaneous nodules on extensor surface, chorea, erythema marginatum, incr. Sed, WBC & ASO

ASD

L=>R; Wide split & fixed S2; patent foramen ovale

VSD

L=>R; pansystolic murmur left sternal border, thrill; most common defect; Eisenmenger's Syndrome = shunt direction reversed due to incr. pulm vasc resistance

Patent Ductus Arterio

L=> R; Continuous machinery murmur; Indomethacin inject may close

Tetralogy of Fallot

VSD, RVH, Pulmonic Stenosis, Overriding Aorta

Pulmonic Stenosis

R=>L, Early systolic click, High pitched systolic ejection murmur, soft or absent S2

Coarction of the Aorta

HTN arms but not legs, murmur heard on back, X-ray scalloping of ribs,

Bacterial Endocarditis

Acute: S.aureus, Group A strep, N Gonh., Sub acute: Strep Viridans; New heart murmurs, petechia over incr. half of body, Splinter hemorrhages on fingernails, Osler's Nodules (nodules on fingertips) Roth's Spots (retinal hemorrhages)

Noninfective Endocarditis

Libman Sacks Disease associated with SLE

Aortic Aneurysm

Abdominal = pulsatile mass on exam, atherosclerosis, smoking HTN >4 cm = surgery Thoracic =Marfan's & syphilis >7c = surgery; Dissecting =split between medial & adventitial layers "ripping in chest" Normal EKG vs abnormal in MI

Peripheral Vascular Disease

Weak pulses, Atrophic skin, Little Hair growth, Nonhealing ulcers, intermittent claudication 5P's = pallor, pain, pulseless, parathesia, paralysis

Raynaud's Phenomenon

Pallor, cyanosis, erythema of fingers, most are idiopathic, others related to collagen vascular disease Tx vasodialators

Heart Dysfunction

Diastolic = difficulty filling ventricles; Systolic = problem ejecting blood from ventricle

Polyarteritis Nodosa

inflamed medium arteries->ischemia in tissues; men 3x> women, usually 40-50; Dx confirmed by biopsy or angiography showing aneurysm of medium arteries

Giant Cell Arteritis

Temporal Arteritis; women >50; severe temporal or occipital HA, Amaurosis Fugax (temp blindness 1 eye) Temporal artery swollen & tender, Dx confirmed by biopsy

Cor Pulmonale

COPD most common cause; Dyspnea & syncope on exertion, S/Sx Rt heart failure

Mitral Stenosis

Mitral facies = red rash on cheekbones, Loud S1 and opening snap after S2; Right heart failure TX with diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca Channel Blockers to decr. HR & preload; Progressive Dyspnea

Mitral Regurge

Midsystolic click; Harsh blowing holosystolic murmur; MVP; LAH & LVH; wide S2 that widens more with inspiration; Bblockers for Sx Valve replacement

Aortic Stenosis

Triad = Angina, Syncope & Dyspnea on exertion; Cong bicuspid valve, weak long pulse, LVH T wave invesions; Left sided failure; Bblockers decr. HR & incr. coronary flow

Aortic Regurge

Decrescendo murmur, widened pulse pressure, "Water Hammer Pulse" (rapid up & down stroke); "Pistol Shot over femoral Artery; 2^o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP

Supraventricular Tachycardia

Sudden attacks due to reentry rhythm, P on T on EKG; #1 AV Nodal Reentry #2 Wolff Parkinson White = reentry thru accessory muscle bundle, can cause V fib in a Pt with Afib; Torsades De Point is drug induced

Left Sided Failure

Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, LVH

Right Sided Failure

Most common cause is Left sided failure; Neck vein distention, Liver big, Edema

MI

ST elevation, T wave inversion; CPK-MB 12 - 40 hr for peak; LDH peaks 3-6 days

Congestive Cardiomyopathy

Alcohol = chronic; Infection Coxsackie B or Trypanosoma cruzi (Chagas Disease)

Hypertrophic Cardiomyopathy

Cong or acquired VH with normal afterload; incr. venous pressure, JVD, ascites, edema, edema, pleural effusion, S4 on exam

Chronic Pericardtis

Causes right sided failure; Kussmaul's Sign ( incr. neck vein distention on exertion) Dyspnea on exertion and Orthopnea; pulsus paradoxus; Surg removal of pericardium is curative.

Pericardial Effusion

Friction rub, distant heart sounds, "water bottle" on x-ray; acute pericarditis = exudate; neoplasm or fibrosis =transudate; symmetrically enlarged cardiac silhouette

Cardiac Tamponade

Pulsus paradoxus, Kussmauls Absent; pericardial fluid compresses heart, Becks Triad = Hypotension, (ß decr. pulse pressure), JVD, Muffled heart signs

Heart Murmurs

AI: precordium, early diastolic, >S2, + heave; AS: 2^nd R ICS & radiates to carotids, harsh, < S2; Diastolic = r/o malignancy, check BP both arms; MR: Apex radiates to axilla, + heave, assoc w/ sever anterior MI, endocarditis prophylaxisis; MS: Apex, late diastolic, opening snap after S2; MVP: Apex, blowing, holosystolic, incr. w/ valsalva; PR: 2^nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR: 4^th L ICS, incr. loud w/ inspiration; bounding JVD, pulsatile liver; VSD: loud holoystolic, assoc w/ Down's

Peritonsillar Abscess

uvula away; Head tilted toward, Trismus (can't open mouth)Strep or Bacteroides

Epiglottitis

H.flu type B, Insp. Stridor, Dysphagia with drooling, Thumbprint sign on xray

Larengitracheitis

Croup; Paraflu #1, RSV, Flu, barking cough, stridor hoarse, r/o epiglottitis

Acute Bronchitis

non smokers = M. pneumonia; smokers=S.pneumonia & H.flu

Bronchiolitis

Circumoral cyanosis (blue around mouth) RSV; kids < 2

Strep Pneumonia

Red-brown sputum, lobar pneumonia, most common adult community acquired
Pneumovax vaccine = >65, immunocompromised, chronic disease

H.Flu Pneumonia

COPD, children, slow onset with URI sx 1^st, patchy bronchial infiltration on xray

Viral Pneumonia

Most common cause in kids, flu like prodrome, patchy infiltrates; WBC not incr. a lot

Klebsiella Pneumonia

Alcoholics, aspiration, Currant Jelly Sputum, Encapsulated gram neg rod

Staph Pneumonia

Salmon colored sputum, Nosocomial, pneumatoceles on xray are pathognomic

Mycoplasma Pneumonia

atypical no cell wall to stain, young adults in close contact; xray worse than pt looks

Pseudomonas Pneum.

hospital acquired, CF, immunocompromised

Legionella Pneumonia

atypical, CNS & GI sx; confusion & ataxia, aerosolized water (air conditioning)

TB

fever, night sweats, wt loss, bloody sputum, Miliary = disseminated; Acid fast stain, PPD>10mm nonimmunocompromised; ppd>5mm AIDS; Extrapulmonary manifestations= meningitis, pericarditis, bone invasion (Pott's Disease)

Bronchiectasis

chronic destructive; dilation of bronchial tree, cough with incr. incr. incr. sputum, dyspnea, hemoptysis, Xray = incr. bronchial markings, "honeycombing"

Emphysema

Destroyed alveolar walls, Risks: smoking, alpha 1 antitrypsin deficiency;
PFTS: ß decr. FEV1; decr. VC, FEV1/FVC < 60% normal

Blue Bloaters

Bronchitis>Emphysema; cough w/ mucous 3mos/yr x 2y; cyanosis, pulm HTN

Pink Puffers

Emphysema >Bronchitis; gradual dyspnea not hypoxic, underweight

Cystic Fibrosis

auto recessive, COPD, Pancreatic insufficiency; meconium illeus, incr. sweat chloride

Sarcoidosis

non caseating granulomatous, increased Calcium, ground glass, bilateral hilar & paratracheal adenopathy is pathognomic

Asbestosis

Increased risk of lung CA & mesothelioma, gradual dyspnea, nonproductive cough; no wheeze; diffuse linear opacities on xray

Silicosis

increased risk of TB, SiO₂ inhalation; metal mining; multiple small nodules & calcification of hilar lymph nodes

Resp Failure

ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg

Laryngeal CA

squamous cell, smoking & alcohol, hoarsness for several weeks

Lung CA

squamous>adeno>small(oat) cell; Squamous = hilar; Adeno = peripheral; Horner's Syndrome=invasion of the cervical symp. Ganglion= miosis, ptosis, anhydrosis
Pancoast tumor = Horners + pain in arm or shoulder on affected side

Asthma

PFTs decr. FEV1; ABG resp alkalosis, decr. CO2; If CO2 incr. or normal resp failure imminet

Massive Hemoptysis

>600 ml blood in 24 hrs; trauma; PE, aortic aneurysm, heart failure

Pneumothorax

Spontaneous = 15-35 y/o males; Tension = pressure in pleural spaces; displaces heart & lungs (mediastinal shift) = surgical emergency

ARDS

acute lung injury with non-cardiogenic pulm edema, ABG =acute resp alkalosis (ßO2 & ßCO2; Xray =pulm edema with normal cardiac silhouette, Positive pressure or PEEP ventilatory support

Pleural Effusions

decr. tactile fremitus; dull; egophony (incr resonance; chg voice to high pitched)
Transudates: <3g protein, Plasma/serum protein<0.5; Plasma/serum LDH <0.6 caused by CHF, cirrhosis, nephrotic syndrome
Exudates:Reverse labs; neoplasms & infections; incr. triglycerides = chylous effusion; Pus = empyema (s. Aureus); Meiggs syndrome = pleural eff, ascites pelvic tumors)

Pulmonary Edema

Pink, frothy sputum, Kerley B lines on xray; Incr cardiac silhouette if cardiac origin

Pulmonary Embolism

DVT (iliac & femoral) V/Q useful, angiography is god std for dx

RDS

<37 wks gestation, Lung maturity: L/S ratio >2, + PG; Beclomethasone hastens maturity; artificial surfactant for kid

Pulm HTN

Primary = dx of exclusion; secondary valvular heart disease, L=>R shunt, chronic ateletasis (localized collapse of alveoli)

Hypothyroid

Weight gain, Lethargy, Coarse hair & dry skin, irregular menses, cold intolerance, myxedema; Acquired = Hashimoto's; Congenital = cretinism, severe I deficiency = hoarse cry; resp distress, cyanosis, poor feeding, decr bone growth, ßT4 incr. TSH
Wolff Chaikoff effect = inhibition of thyroid hormone release due to high doses of I during thyroid scan

Hyperthyroid

1. GRAVES: most common, autoimmune, antibodies bind to TSH receptors; incr thyroid hormone, pretibial myxedema, Incr radio I uptake
2. SUBACUTE THYROIDITIS: tender, enlarged, Decr Radio I uptake, Sed Rate up, maybe followed by period of hypothyroid
3. SILENT LYMPHOCYTIC THYRODITIS: transient, postpartum, no pain or fever, Radio I uptake decr, lymphocytic infiltration, Tx Bblockers
4. TOXIC ADENOMA: multinodular goiter; nodules function autonomously, Excess T3 & T4; Scan shows a few hot spots with cold background
5. THYROTOXICOSIS FACTITIA: exogenous thyroid hormone, no goiter
6. PLUMMERS : multinodular goiter, nodules become autonomous and secrete thyroxine

Sick Euthyroid

acutely ill patients; T3&T4 decr due to chgs in hormone metabolism; TSH not decreased => not truly hypothyroid

Thyroid CA

Papillary = most common, best prognosis, Follicular = older, hematogenous spread to bone, lung, brain, liver; Anaplastic = worse prognosis, local invasion, hoarse & dysphagia; Medullary= Calcitonin producing Cells, MEN Type II(parafollicularC cells)

Diabetes

Dx: elevated random glucose sx, fasting BS > 140 x 2 days; Oral challenge >200 after 2 hrs; Type I: alpha islet cells, HLADR3, HLADR4, HLADQ, ketoacidosis
Type II: insulin resistance; no HLA association, endogenous production enough so no ketoacidosis but do get hyperosmolar coma(dehydrated, glucose 600-2000

Parathyroid Hormone

incr. Ca mobilization from bones, incr. Vit D production decr. phos reabsorption in distal tubules = decr. serum phos.

Hypoparathyroidism

ßPTH, ßCa, incr. Phos, Tingling, tetany, Chvostek's sign (tap on face & get muscle spasm) ; Trousseau's Sign (BP cuff up 3min => carpal tunnel sx; decr. Mg in alcoholics can lead to decr. Ca due to ßPTH secretions

Hyperparathyroid

Bones, stones, abd. Groans and psychic moans; 1^o = excess PTH; 80% benign adenoma; 2^o due to decr. serum Ca=> vit D defic, renal tube prob and Ca loss

Diabetes Insipidus

Lack of ADH, polyuria and polydypsia

Kallman's Syndrome

Male, anosmic, small testicles, azospermic d/t head trauma; decr. FSH & LH, no GNRH

SIADH

Excess ADH, Tumor, trauma, pulm disease, drugs; Hypoatremia, Conc. urine;

Acromegaly

Excess GH; bone & tissue enlargement; glucose intolerance, osteoarthritis

Addison's Disease

Decreased cortisol (aldosterone) Wt loss, fatigue, skin pigmentation, eosinophilia; Decr aldosterone, decr Na, incr K; Give ACTH if cortisol doesn't increase Dx made

Cushing's Syndrome

Incr cortisol, Buffalo hump, moon facies, central obesity, Osteoporosis, #1 Cushing disease due to pit. Adenoma, #2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical tumor- incr. cortisol, ACTH suppressible, cortisol not #4 Chronic glucocorticoid Tx

Waterhouse Friedrickson Syndrome

hemorrhagic infarct of adrenals, assoc w/ meningococcemia

Pheochromocytoma

Episodic HTN, Dx by urinary catecholamines

Familial Hypercholesterolemia

Autosomal dominant, Xanthomas (lipid on tendons) Xanthelasmas (lipids on eyelids) MI's in 40's, Homozygous usually has incr. total cholesterol

Familial Hypertriglyceridemia

Trig incr. , LDL normal, Autosomal dominant, Pancreatitis, milky serum

Familial Combined Hyperlipidemia

Auto dominant, incr. trig and cholesterol; no xanthomas

Familial Dysbetalipo-proteinemia

rare, problem with lipoproetin catabolism; palmar or tuberous xanthomas, incr. risk periph vasc disease & CAD, Abn VLDL, cholesterol & triglycerides

MEN I

Parathyroid , pituitary & Pancreatic tumors

MEN II

Pheochromocytoma, Parathyroid & medullary thyroid tumors

Hemochromatosis

Auto recessive, incr. GI absorption of Fe; Excessive Fe, incr. Ferritin, incr. Transferrin saturation, cirrhosis, diabetes, bronze skin

Wilson's Disease

Auto recessive, excessive Cu accumulation, ataxia & dementia, Kayser Fleisher rings on cornea

Hyperaldosteronism

Aldosterone works on distal renal tubule to facilitate incr. Na retention and incr. K loss
excretion due to decr. Na, decr. BP (renin angio), incr. K
1^o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone
2^o incr. renin angiotensin system activity => decr. BP

Neurogenic Bladder

Bladder control requires: intact sensation(full) motor function (start void) Cerebral control (timing)
Atonic, distended with overflow= acute spinal cord injury or sensory impaired
Motor defect = sense full bladder but can't start emptying
Autonomous = spinal cord injuries after acute; bladder fills & empties reflexively

Hydronephrosis

dilation of renal pelvis, incr. pressure in urinary system w/ or w/o ureter dilation

Fanconi's Syndrome

renal tubule defect; Urinary excretion of glucose, phos, AA; Tx: Vitamin D

Pyelonephritis & Pyelitis

Pyelonephritis = dilation of renal parenchyma, pyelitis = dilation of renal pelvis; E. coli; Different from cystitis since there are WBC casts not just WBC's

Cystitis

WBC in spun sample, E. coli, freq, urge, dysuria & suprapubic pain

Bladder Ca

transitional cell CA; Risk factors = smoking, schistosomiasis, aniline dyes

Renal Artery Stenosis

Cause of 2^o HTN; Fibromuscular dysplasia (young women) Atherosclerosis (older)

Urolithiasis

incr. Ca = Calcium stones; Struvite Stones = post UTI w/ urea splitting bact (proteus or pseudo) when urine basic MgNH₄PO₄ (struvite) stones ppt.

Uremic Syndrome

Symptomatic renal failure = GFR< 20 ml/min; CNS chgs, asterixis (flapping tremor) pericarditis, N/V, yellow-brown skin (uremic frost) Normochromic, normocytic anemia due to decr. erythropoietin; incr. Phos & decr. Ca = renal osteodystrophy

Glomerulonephritis

Hematuria, proteinuria, RBC casts: Post strep = give Antibiotics only if still strep +, steroids no help; Goodpastures- autoimmune, high dose steroids, uremia 3-9 mos.

Nephrotic Syndrome

Proteinuria > 3g/day, Edema, hypoalbuminemia & hyperlipidemia (milky serum); minimal chg disease in kids; idiopathic Glomerulonephritis in adults

Acute Tubular Necrosis

most common cause of acute renal failure; ischemia or toxins; resolves in several weeks may need dialysis

Polycystic Kidney Disease

Auto dominant; multiple bilateral renal cysts; gross hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic until adult; 15% have associated subarachnoid hemorrhage

Alport's Syndrome

X-linked, Type IV collage, deafness & renal failure in males

Wilm's Tumor

nephroblastoma, kids < 4yrs commonly, hematuria, abd mass; resection & chemo

Renal CA

adenocarcinoma; Triad: hematuria, abd mass & flank pain

Chronic Renal Failure

>90% glomeruli destroyed; uremia incr. K, ßNa incr. phos, ßCa = renal osteodystrophy

Hypernatremia

> 155 mEq/L; due to dehydration, CNS depression (neuronal shrinkage); Diabetes Insipidus= decr ADH = lots of dilute urine = dehydration = urine output incr.

Hyponatremia

<135 mEq/L; pseudo if lipids are incr. incr. incr. high to displace polar Na; Osmotic = diabetes incr. Na 1.6 for 100 mg/dl glucose value is above 140.; SIADH, Central Pontine Myelinosis if corrected to fast

Hyperkalemia

> 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met acidosis, oliguria, K sparring diuretics

Hypokalaemia

<3.5 mEq/L; muscle weakness, cardiac arrhythmias, resp failure, GI or renal loss

Urethritis

GC (gram - rodds in WBC, + thayer martin culture); nonGC = chlamydial; coinfection, Ceftrixone for GC, Doxycycline for Chlamydia

Epididymitis

Induration & tenderness of spermatic cord; support relieves pain

Torsion of the Testes

adolescents, swelling & tenderness, superior displacement, support does not relieve pain, Emergent SURGERY

Hydrocele

Painless lump, can be transilluminated; congenital process vaginalis remains in communication w/ abdomen = indirect inguinal hernias

Varicocele

"bag of worms", assoc w/ infertility

Seminoma

Painless lump; does not transilluminate, most common testicular neoplasm in men < 30; Undescended testes at greater risk even after surgical correction

Prostatitis

Nonbacterial > bacterial (GI organisms); recurrent UTIs; Rectal - warm, tender, boggy prostate; Tx TMP/SMX

BPH

Enlarged rubbery prostate on rectal; Urinary retention, a blockers; TURP, transrectal US more sensitive for Dx; PSA can be falsely elevated

Prostate Ca

Firm, nodular irregular prostate, Bone mets; Alk Phos and PSA are incr.

Bacters Syndrome

pre-auricular skin tag and kidney agenesis

Fever

most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis

Fever of Unknown Origin

> 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune

Inflamation

Rubor, Tumor, Calor, Dolor

Types of Immunity

Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk)

Bacteremia

bacteria in blood but asymptomatic

Septicemia

bacteria in blood with symptoms

Immunizations in Kids

HEP B = mom + HbsAG = HBIG & 1^st Hep B vaccine at birth
DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis
H FLU = not in kids > 5
POLIO = IPV if immunocompromised
MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart.

Adult Immunizations

TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle
FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test

HIV/AIDS

RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm³; Flu-like illness, antibodies 1 - 6 months after infection

AIDS related infections

CMV, HSV, VZV, EBV, TB, mycoplasma avium-intracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis

DeGeorge's Syndrome

Thymic aplasia, Absent T cells, congenital heart disease, craniofacial abnormalities

Wiskcott- Aldrich Syndrome

X linked, no antibodies against encapsulated bacteria, eczema, decr. platelets,

Chronic Granulamatous Disease

Autosomal recessive, defect in phagocytic enzymes, recurrent bacterial & fungal infections

Chediak-Higashi Syndrome

Autosomal recessive, recurrent strep & staph infections

Bruton's Disease

x-liked, agammaglobulinemia, N B cells or antibodies

Ataxia Telangectasia

Auto recessive, lymphopenia & IgA deficiency; gait abnormal, telangiectasia

Severe Combined Immunodeficiency

Deficits of B & T cells, IgA deficiency, recurrent infections esp resp & GI, IG administration contraindicated

Microcytic Anemia

MCV < 80; IRON DEFICIENCY = decr. ferritin; CHRONIC DISEASE decr. Fe, decr. Transferrin, incr. Ferritin; LEAD POISONING; THALASSEMIA

Normocytic Anemia

MCV 80 - 100; Hemolysis, Chronic disease, Bone marrow suppression (drugs, leukemia) (aplastic)

Macrocytic Anemia

MCV > 100; FOLATE DEF. = most common cause, decr. folate normal B12;

B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx,

Alpha Thalassemia

Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = a chain missing; Asians, Dx by Hb electrophoresis,

Beta Thalassemia

Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous

Sickle Cell Anemia

sickled cells, decr. Hct & incr. reticulocyte count, electrophoresis HbS + HbA neg. Salmonella osteomyelitis, S. pneumonia sepsis.

Hemophilia

X linked factor VIII (A) or IX (B) deficiency; Prolonged PTT, Joint & soft tissue bleeding; Tx cryoprecipitate & FFP

Von Willebrand's Disease

autosomal dominant deficiency of VIII & vWF, epistaxis, menorrhagia, bruising, increased PTT & bleeding time

Eosinophilia

Allergic Drug Reaction; NAACP = neoplasm, asthma/allergies, Addison's disease, connective tissue disorders, parasites

Thrombotic Thrombocytopenic Pupura

adults > kids, women > men; platelets consumed in clotting reactions, Fluctuating neurologic defects, decr. platelets, decr. HCT, incr. retic count, incr. incr. incr. LDH, acute onset not autoimmune

Idiopathic Thrombocytopenic Pupura

kids > adults, autoimmune destruction of platelets, Purpurea & Petechia , Platelets<10000, Epistaxis, menorrhagia

Hemolytic Uremic Syndrome

Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2^o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased

Hodgkin's Lymphoma

Painless cervical lymphadenopathy, Reed Sternberg cells (multinucleated reticular cells), 80% survival

Burkitt's Lymphoma

B cell lymphoma, Associated with Epstein-Barr virus, children & young adults

Hereditary Spherocytosis

dominant deficit in RBC membrane proteins, damaged cells get trapped in spleen. Spherical RBC & reticulocytosis on smear. Coombs neg.

G-6-PDase Deficiency

X linked hemoglobin accumulates in RBC (Heinz bodies) hemolysis occurs after ingestion of oxidant

Agranulocytosis

neutrophils = decr production or incr destruction

DIC

wide spread activation of coagulation cascade. decr. platelets, fragmented RBC, incr. PT & PTT ; decr. fibrinogen, Pregnancy, malignancy, infections, massive trauma

Acute Lymphocytic Leukemia

80% childhood leukemia, peak age 3 - 7; usually B cell origin; incr. lymphoblasts, few other cells on bone marrow biopsy

Acute Myelocytic Leukemia

affects myeloid cells (N,B,E,erythrocytes, megakarocytes) adults > kids; DIC possible, gram neg and fungal infections, Auer Rods (red staining intracellular inclusions.

Chronic Myelocytic Leukemia

Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; incr. uric acid, incr. B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal
Blast crisis transforms it to acute leukemia

Chronic Lymphocytic Leukemia

Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis

Hairy Cell Leukemia

B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated

Multiple Myeloma

Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones)

Waldenstrom's Macroglobulinemia

single B cell line = monoclonal IM over production; decr. RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders

Mycosis Fungoides

Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions

Polycythemia Vera

overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsy- hypercellular with absent Fe stores; R/O spurious polycythemia = incr. RBC due to dehydration; R/O 2^o polycythemia = RBC mass incr. due to decr. oxygenation.

Eaton Lambert

90% assoc w/ small cell CA, decr. presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function incr. w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare

Seborrheic Dermatitis

Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap

Psoriasis

HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails

Pilonidal Cyst

Hair lined tract in sacral area = "Jeep Seat"

Actinic Keratoses

Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA

Skin CA

Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure

Malignant Melanoma

Change in size, shape or color of a mole, Usually superficial spreading, Mets incr. as invasion goes deeper than 0.76 mm; itchy & ulcerated

Contact Dermatitis

1^o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1^st exposure
Allergic = type IV hypersensitivity, T cell medicated, Never 1^st exposure

Carbuncle

Abscess of skin caused by several boils coming together

Dermatopytoses

TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp;

NEVI

PIGMENTED: (Benign) sun exposed areas in children & adolescents
DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial incr. risk of melanoma

Hemangiomas

NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade
CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5
CAVERNOUS: Raised red or purple, enlarged vascular spaces

Osteoarthritis

incr. morning stiffness, bone spurs, osteophytes, DIP = heberdon's nodes, PIP = Bouchard's nodes, also affects hips, knees, spine

Rheumatoid Arthritis

Symmetric, PIP & MCP joints NOT DIP, Subcutaneous nodules, 70% +RF

Gout

Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks

Pseudo Gout

Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent

Phocomelia

Hands & feet attached to trunk, Thalidomide

Slipped Capital Femoral Epiphysis

Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis

Lyme Disease

Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ central clearing = erythema chronicum migrans, CNS chgs 1 month after exposure

Osteoporosis

decr. mass of bone; hip & wrist fx most common; decr. estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate - inhibits osteoclast activity, used for men & women who can't take estrogen

Systemic Lupus Erythematosus

Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = incr. BUN incr. Cr, + protein = immune complex glomerulonephritis

Polymyositis & Dermatomyositis

inflammation of skeletal muscles; violet discoloration of eyelids (heliotrope rash), elevated muscle enzymes (CPK, SGOT, SGPT, LDH) symetric proximal muscle weakness; hips & shoulders 1^st

Ankylosing Spondylitis

"Bamboo shoots" = vertebral squaring w/ bony outgrowths, paraspinal lig. Calcifications on xray; sacroiliac involvement is diagnostic; HLA-B27; incr. ESR

Shoulder Hand Syndrome

Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease

Bone Mets from Primary

breast, lung, prostate, kidney, thyroid

Paget's Disease

Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; incr. alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure

Congenital Hip

Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and decr. pressure; ORTOLANI'S: reduces dislocation by abduction and flexion

Osteochondritis

Inflammation of bone & cartilage; Osgood Schlaters - teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon

Osteomyelitis

Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella - sicklers; S. aureus; pseudomonas; incr. ESR; incr. WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics

Septic Arthritis

S, aureus = most common; N. Gon most common sexually active; synovial fluid = incr. WBC and + culture; Ceftriaxone NG infection; Nafcillin for others

Degenerative Disk

Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise;

CaudaEquina Syndrome

Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness

Polymyalgia Rheumatica

older women; assoc w/ temporal arteritis; Morning stiffness; swelling 1-2 joints; no weakness; incr. ESR; neg. Rheum factor; steroid response immediate

Fibromyalgia

"Trigger Points" reduce pain, IBS, depression, anxiety

Osteosarcoma

teenage boys, distal femur & proximal tibia; mets to lungs

Eosinophillic Granuloma

20-40; granuloma w/ histiocytes, eosinophilic infiltrate & fibrosis; multifocal = poor prognosis

Blindness

visual acuity 20/400 with best possible correction

Open Angle Glaucoma

Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; decr. amt aqueous humor produces

Closed Angle Glaucoma

Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention

Diabetic Retinopathy

Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates

Cataracts

Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex.

Senile Macular Degeneration

Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane)

Conjunctivitis

Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria

Uveitis

Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis

Central Retinal Occlusion

sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins

Central Vein Occlusion

unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins

Retinoblastoma

Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye.

Hearing Loss

Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear

Presbycusis

normal loss of hearing associated with age, sensorineural

Mastoiditis

Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics

Meniere's Disease

Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo

Acoustic Neuroma

Vestibular Schwannoma; tumor of CN VIII; Hearing loss, dizziness, tinnitus;

Migraine

2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity;

Cluster Headache

Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine

Tension Headache

cause unknown, most common type; bilateral, occipital, constant; muscles tight

Tumor Associated Headaches

progressive, increasing, dull, nonthrobbing, worse w/ postural chgs, exertion. Disrupt sleep, assoc w/ N/V

Trigeminal Neuralgia

Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts
Tx: carbamazepine & phenytoin; Surgical decompression of CN V

Partial Seizures

Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2^o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion

Generalized Seizures

Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal
Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal

Status Epilepticus

continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan)

TIA

sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities

Aneurysm

localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta

Subarachnoid Hemorrhage

between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.

Intracerebral Hemorrhage

Chronic HTN or local thrombus 2^o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs.

Stroke

Middle Cerebral: most often, contralateral limb weakness, sensory loss, homonymous hemianopsia, dominant hemisphere = aphasia, nondominant = sensory neglect & apraxia
Posterior Cerebral: contralateral homonymous hemianopsia & sensory loss, thalamic pain, hemiballistic movement disorder
Vertebrobasilar artery: fatal, unilateral occlusion = ipsilateral CN abnormalities, contralateral weakness; Complete occlusion = opthalmoplegia, defective pupil constriction, bilateral weakness, paralysis, decreased consciousness, dysphagia & dysarthria; completed = neuro stable; Evolution = progressive signs over 1-2 days
CT positive 48 - 72 hrs after onset.

Cavernous Sinus Thrombosis

CN palsies, fever, exophthalmos, papilledema, HA, decr. consciousness, occasional seizures; IV antibiotics immediately

Acute Subdural Hematoma

rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ incr. DTR. LP is contraindicated because may lead to herniation

Chronic Subdural Hematoma

Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis

Epidural Hematoma

Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs

Concussion

Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction

Toxic Vestibulopathies

Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion
Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-2 wks after ending tx
Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss
Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating
Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy

Toxic Neuropathies

Lead: multi motor neuropathy; acute encephalopathy in children
Organophosphates: delayed motor neuropathies, cholinergic crisis
Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy

Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy

Bacterial Meningitis

1^st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia
N. meningiditis at any age = 50% have petechial rash
Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion
Kernig's Sign: extension of knee in pt w/ flexed hip is painful
CSF: decr. glucose, incr. neutrophils, incr. protein, incr. opening pressure; Tx: ampicillin & cefotaxime = infants; 3^rd generation cephlosporin in kids > 3mos and adults

Aseptic Meningitis

nonbacterial meningeal irritation; CSF = incr. lymphocytes, normal glucose, neg gram stain & bacterial cultures, mild incr. protein, normal opening pressure; supportive Tx

Fungal/TB Meningitis

CSF: incr. lymphocytes, decr. glucose, incr. protein, incr. opening pressure; AIDS = cryptococcal meningitis

Encephalitis

Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days

Reye's Syndrome

follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce
Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx.

Neurosyphillis

Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs.

Rabies

Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1^st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine

Polio

Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV

Primary Neoplasms

Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids

Huntington's Disease

Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset, atrophy of caudate nucleus & cerebral cortex, Tx D2-receptor antagonists (haloperidol)

Parkinsonism

Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic)

ALS
(Lou Gehrig's Disease)

Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, incr. DTR, extensor plantar reflexes

Tay Sachs Disease

Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4

Multiple Sclerosis

Progressive demyelinating, women>men; Peak onset 20 - 40; Gradual & variable CNS sx suggest dx; CSF = mild incr. proteins, mild lymphocytes , oligoclonal bands, MRI = multi plaques in white matter

Guillain-Barre Syndrome

polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = incr. protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated

Cerebral Palsy

CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, incr. DTR, incr. tone, weakness, toe walking, scissors gait

Myasthenia Gravis

autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, incr. women, age 20 - 40; Ptosis, diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx

Muscular Dystrophy

Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK incr. before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1^st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles;

Coma

dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary

Gait Abnormality

Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn
Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral
Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing
Motor System = Footdrop - anterior tibial; Calf muscle - can't toe walk; Pelvic muscle - waddling gait.

Arnold Chiari Syndrome

Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40

Cold Calorics

Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component

Trichomonas Vaginitis

Yellow green discharge, Strawberry patches, Motile flagellated, Tx: Metronidazole