08-06-2008, 03:07 PM
Abrupta Placenta - 4
Pt presents
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ic Keratosis is a recursor to SCC.**** When ulcer dosnt heal, suspect SCC, nest step is PUNCH biopsy. If SCC, WIDE excision is the Tx of choice.****Actinic Keratosis turns into SCC.
Statin intolerance/Toxicity
CPK elevation of more than 10 times in presence of myalgias/myopathy. Rhabdomyalysis in an Acute renal failure could be a consequence. Tx is stop the drug and supportive therapy for Rhabdo.
Status Epilepticus
An emergency. Mgmnt step are: 1-Place pt lateral with mandible pushed forward. 2-medication started. 3-if medication failed after 30 min , then general anesthesia and intubation is indicated.
Stevens Johnson's
Target shaped mucocutanous lesions and systemic signs of toxicity. Pathology involves immune complex mediated hypersensitivity.
Still's dis, Adults
Is a variant of RA. Pt presents with 20-30yo, high spiking fevers with CHARACTERISTIC salmon colored rash, arthralgias, arthritis, Leukocytosis. DDX1
arvovirus (Slapped cheek dis), malar,eryhtomatous rash, arthralgia or arthritis. DDX2:Henoch-Schonlein purpura, in children, rash,abdominla pain,arthralgias and renal dis. Rash is pruritic and involves lowerlegs or Buttucks.DDX2:RF, PECCS. Erythema Marginatum is Evanescent(tending to vanish)erythomatous non pruritic mostly on the trunk.
Stomach cancer
The only malignany that has decreased universaly. The reason is not known.
Strabismus:
The mcc of amblyopia (decreased visual acuity) is strabismus. The mc type of strabismus is esodeviation (medial deviation of th eye). Tx is to cover the normal eye.
Stranger Anxiety
When a child is left in unfamiliar places (day care). From 6-8 months and peaks in 12-15 months. DDX:Seperaion aniety is with older childs when seperated from a love one.
Stress Fracture
Bone pain at rest, worsens with exercise, swelling and point tenderness, Xray is normal at initial stage and MRI is dx, Tx is restrictive weight bearing along with short leg cast, healing takes 3-4 weeks. It occurs in young dancers's legs.
Stroke - 6
Stroke can be 2 types, Hemorrhagic (intercerebral or subarachnoid) or Ischemic (secondary to thrombosis, embolism, or systemic hypoperfusion). Blood supply of the brain is 1-Anterior vasculature, internal carotid A and its branches Anterior and Middle cerebral A. 2-Posterior vasculator, paired Vertebral A and they join to make Basilar artery, which divides to make Posterior cerbral Artery. Now Deficiencies produce: 1-ACA:Contralaterla motor and sensory deficit wich is more pronounced in the lower rather than upper limbs.Urinary incontinence, gait ataxia. 2-MCA: Contralateral motor and sensory deficitwhich are more pronoucedin the Upper rather than lower limbs, and homonomous hemianopia. If the dominant lobe (left) is involves hay aphasia, and if non-dominant (right) is involved hat neglect syndrome and anosognosia(pt cant tell is there has been an injury to the body). 3-PCA: Homonomous Hemianopia, ataxia w/o agraphria, visual hallucination(Calcarine cortec), sensory symptoms (thalamus), third nerve palsy with paresis of vertical eye movement and motor deficit (mid brain). 4-LACUNAR infarcts: are small non cortical infarcts caused by occulsion of a branch of a cerebral artery. Risk factors are hypertension, DM or Polycythemia. They usually dont produce both motor and sensory symptoms but rather have well recognized syndromes, like pure motor hemiparesis, pure sensory stroke, dysarthria-clumsy handor ataxic hemiparesis. *If a pt presents w/i 3 hours of ischemic attack, thrombolytic therapy with tPA (after CT scan) should be started. Dont try to regulate BP first, it might impair autoregulation and make it worst. Streptokinase does not help either. tPA is tx of choice. * THALAMIC stroke:Involves VPL part of thalamus that transmits sensory info from contralateral part of body. Presents with hemianesthesia accompanied by hemiparesis, ahtetosis. Dysesthesia (numbness and tingling burning feeling) of the area affected by the sensory loss is chracteristic, and is called thalamic pain phenomenon.****HT has the highest risk factor for Stroke, more than smoking,alcohol,hyppercholesterol.....****If pt presents with hemiparesis and speech difiulty like broken words then its Expressive aphasia related to Dominant frontal. But if he cant understand what is being said to him then it is Parietal dominant(Dyscalculia,Dysgraphia). ****If a pt comes in with hemiplasia, you need to first ddx b/w Hemorrhagic and Ischemic stroke and then give medication. To DDX you need to do CT WITH OUT contrast, if its ischemic (thrombi) then we give aspirin and then we do carotid Doppler and TEE to evaluate source of embolism.
Stuge-Webber Synd:
A neurocutanous condition. Its auto dominant therefore doesn™t affect multiple generations. Pt will have a cerebral lesion on the same side as facial nevus. Also exopthalmus due to ICP. Dx is CT. The cerebral lesions are nevi involving the leptomeninges and are thus similar to the facial lesions.*****Caverness unilateral hemangioma is another presentation. Skull Xray after the age of 2 years shows gyriform intracranial calcifications that resembles the tramline. Tx ia aimed at controlling seizure and reducing ICP. Laser therapy w Argon to remove skin lesions.
Subacromial bursitis
It refers to inflamation of the subacromial bursa. It occurs in athlets as pat of impingment syndrome. Its characterized by shoulder pain, which is absent at rest but present at overhead activity. Range of movement is limited by pain. Neer sign (pain on passive internal rotation and forward flextion at shoulder) is present. US or MRI confirms Dx. Tx is conservative with NSAID, physical therapy. DDx is Tear of long head of bicept tendon, which will lead to bulging muscle mass in the middle of the arm.
Subacute Combined Degen
T9Q42. Tx is B12
Subarachnoid hemorrhage “4. 6/3
Rupture of aneurysm is the most frequent cause. Hypertension is the mcc for Intracerebral Hemorrhage. They are most prone to rupture when they™re >7mm. Pt should be evaluated with cerebral angiography and treated surgically. Pt should be evaluated by cerebral angiography and treated surgically. AVM is the mcc of SAH in children, the hx of seizure and migrain like headache is characteristic.****Vasospasm is the major cause of morbidity and mortality in pts with SAH. Calcium channel blockers (Nimodipine) are used to prevent spasm in these pts.****SAH or "cerebral-salt wasting syndrome". Patholgy involves 1-SIADH (inappropriate vasopressin secretion) which causes water retention. 2-an increased secretion of an atrial/brain natriuretic peptide. SIADH also results in hyponatremia for which water restriction is the tx of choice. So Hyponatremia is one of the important complications of SAH.
Subcunjuctival hemorrhage. Ophthalmo. 6/3
Redness in the eye, due to hard rubbing or trauma. Its benign and heels spontaneously.
Subdural hematoma
Tear of bridging veins. Picture shows semi lenticula rhematome. MC in Elderly & Alcoholics. Tx is conservative if no midline shift is present in CT. Tx is centered on prevention of ICP by head elevation, hyperventilation (causes vasoconstriction and thus decreases cerebral blood flow), and if needed acetazolamide and mannitol. If there is a midline shift then Craniotomy is indicated but its asso with grave prognosis. DDX1:Epidural hematoma where Middle Meningeal A. is injured. Biconvex hematoma in CT, non contrast. Lucid interval. DDX2:Hypertensive hemorrhage, putamen & thalamus. DDX3:Subarachnoid hemorhage, rupture of aneurysm.
Sublimation:
A mature defence mechanism that allows for unacceptable impulses to be channeled into more acceptable activities. Like aman w fiery temper who channels his anger into athletic pursuits.
Sumatriptan Tox
CI include Printzmetal Angina, CAD, Pregnancy. So is a femlae of child baring age wants it make sure she is not pregnant.
Superficial thrombophlebitis:
Dull pain in the region of the affected vein, eryhtema, induration and tenderness along the vein. High fever and chills and rigor is suggestive of septc phlebitis. Presence of edema and deep calf tenderness is characteristis of DVT. ST is not risk factor for Pulmonary Embolism. Localized ST is treated wth bed rest, heat and NSAID
Superior Vena Cava Synd
Pt presents with Venous congestion of face and arms. The mcc of superior vena cava onstruction is Bronchogenic carcinoma(Small cell tumor) (smokers). Today Angioplasty with stenting is choice.
SVT:
Narrow QRS, HR>140, regular, loss of P wave. If pt is unstable, cardioversion. If stable, vegal maneuvers initially, if failed then IV Adenosine. Verapamil is 2nd DOC.
Supraclavicular fracture:
It compromises brachial artery resulting in bradial artery pulse loss.
Symptomatic Bradycardia
Pt has HR of 40, dizzy,lightheaded, clamy extremities, but no dyspnea or chest pain and no hypotention. He is having severe symptomatic bradycardia dn the tx is iv Atropine.If that didn™t work net step is Transcutaneous pacing. If pt has bradycardia AND Hypotension, then tx is Epinephrine. Reember Adenisine is used for SV tachycardia.
Syncope - 3
Know basic pathophys mechanism and different types of Syncope. The most common pathophysiologic basis for syncope is an acute decrease in cerebral blood flow (with resultant cerebral hypoxemia) secondary to decreased cardiac output; arrhythmias, including conduction abnormalities, are the most frequent cause. 1-Exertional (effort) syncope suggests cardiac outflow obstruction, mainly due to aortic stenosis. 2-Syncope of cardiac etiology typically begins and ends suddenly and spontaneously. It is most commonly due to an arrhythmia. 3-Vasovagal (vasodepressor) syncope is typically precipitated by unpleasant physical or emotional stimuli (eg, pain, fright, sight of blood), usually occurs in the upright posture, and is often preceded by vagally mediated warning symptoms. 4-Syncope due to seizures is abrupt in onset and is associated with muscular jerking or convulsions, incontinence, and tongue biting. 5-Syncope due to pulmonary embolism usually indicates massive pulmonary vascular obstruction and is often associated with dyspnea, tachypnea, chest discomfort, cyanosis, and hypotension. 6-Syncope of gradual onset (with warning symptoms) and slow clearing suggests metabolic changes, eg, hypoglycemia or hypocapnia of hyperventilation. ***7-Situational syncope, Typical senario would include a man middle age who looses consiousness immediately after urination or during coughing fits. The pathophysiology involves autonomic dysregulation, which can be explained by staining or rapid bladder emptying. ****Vasovagal syncope dx is with upright tilt table testing which includes Carotid sinus massage.
Synovitis of the hip joint
Bed rest with the hip joint in a comfortable position is the tx of choice.
Syphilis - 4
Once Dark field microscopy shows the spirochet and its positive, no need to do VDRL or FTA-ABS. But since the pt is at risk of HIV we need to do Elisa for HIV screening.****PRIMARY: Presnts with Painless, shallow CHANCRE ulcer WITH PUNCHED OUT BASE AND ROLLED EDGES and painless bilateral lymphadenopathy. The best dx test is Dark field microscopy. **Secondary: presents with Condylomata lata, highly contagious.****** In pt who is allergic to Penicillin, give Oral Doxycycline.
Syringomyelia
Suspect in a pt with upper extremity areflexia weakess and associated anesthesia in a "cape" distribution. When syringomyelia is associated with Arnold-Chiari malformation, there is caudal displacement of cereberal tonsilsthrough the foramen magnum
Systemic Sclerosis
The cause of pulmonary complication is interestitial fibrosis not tighning of the skin. Prolonged oral administration (> 1.5 yr) of penicillamine (0.5 to 1.0 g/day) can reduce skin thickening. For renal disease, ACE inhibitors are the drugs of choice.
Tachycardia, Vent
Regular (Wide Complex) Ventricular tachycardia has 2 types of tx. 1-If pt is hemodynamically stable (BP is normal, K normal, no bleeding) then DOC is IV Amiodarone, or alternative is Lidocaine. If pt is not stabalized then cardioversion is choice. Digoxin is CI in VT, Its used for Atrial Tachy. For SVT Carotid massage is chioce.
Tamoxifen - 3
An antiestrogen drug used for breast cancer. When used as adjuvent therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma. ***It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, ITS PROVEN. SEE RALOXIFEN.****It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.
Tay-Sachs dis:
Def of Hexosaminase and accumulation of GM2 gangliosidase, particularly in CNS. Pt presents with hyperacusis, MR, seizure, chery red macula but NOT hepatomegally or lymphadenopathy.
TB -2
1-Induraation of 5 or > is + in: Close contacts of TB pt, HIV pt, Organ trnasplant, chronic steriod therapy. 2-Induration of 12 or > is + in : Immigrants recent, IV drug users, homeless person, prisoners and healthcare workers. Once PPD is positive, it does not mean pt has TB, they have to undego Cxr. If TB is diagnosed then full therapy, if TB is excluded then 9 months of Isoniazide prophylaxis. TB is the mcc of Constrivtive pericarditis in immigrants. It should be considered in pt with unexplained elavation of JVP and hx of predisposure.*****Erythema induratum are nodules in the sheen and calves. They are small tender erythomatous nodules.
TCA intoxication - 4
T9Q15. tx is sodium bicarbonate prevents arrythmia by alleviatng cardio-depressant action on sodium channel. Asso with QRS widening on EKG. It also helps correct acidosis. If pt presents with seizures that need tx we give Diazepam.
Tennnis Elbow
Or Laterla Epicondylitis, is condylitis about the origin of extensors of forearm. Characterized by point tenderness over the lateral epicondyle of humerus and exacerbation of pain by extention of the wrist agaisnt resistance (hitting the ball). DDX with Radial tunnel syndrome which could coexist, pain is produces by simultaneously extending the wrist and ringers while the long finger is passively flexed by the examiner.
Testicular cancer - 2
1-Seminoma: elevated Placenta Alkaline Phosphatase. 2-Embryonal: elevated Alpha Feto Protein (AFP). 3-Choriocarcinoma: elevated beta-HCG. Once the dx of carcinoma is made, US shows solid nodule, then initial mngmt is Orchiectomy. Trans scrotal biopsy and FNA is CI becauseit might spread lymphatically or hemotgenously. ****Leydig cell tumors are the mc type of testicular sex cord stromal tumor. Testosteone and Estrogen are markedly increased with 2ary inhibition of FSH & LH. Pt prestns with Bilateral Gynecomastia. DDX1:Choriocarcinoma, bHCG is increased. DDX2:Seminomas contain Syncytiotrophoblastic giant cells.DDX3:Yolk sac tumors show increased AFP.
Testiclar feminization:
Defect of absence of androgen receptors resulting in feminine phenotype with 46XY genotype. The MIF is produced by the gonads, so th euterus, vagina and tubes are absent. Breasr develop due to peripheral production of estrogen, whereas axillary and pubic hair does not. Tx is to resect testicles and make Vagina.
Tetanus guideline
Hx of Tetanus Immun Clean Wounds Dirty looking wounds
=3 dose of tet toxoid in past TT:Yes if last dose >10y ago, TIg:No TT:yes if last dose>5y ago, TIg:No
Tetracycline Toxicity
A5- Photosensitivity.
Tetralogy of Falot - 2
Most prominent feature is cyanosis that rarely improves with oxygen. A Classid presentation is Squanting that improves cyanosis. "Tet" spells are hypoxic episodes characterized by rapid breathing. Immediate tx is Oxygen and put the child in a Knee-Chest position. followed by fluids,morphine,propranolol. TOF is a Cyanotic (early) condition. ASD & VSD aren't cyanotic (late).****Pansystolic murmur, Hepatomegally.
Tetsticular feminization
defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so urtus and vagina are absent. Breat develop because peripheral production of estrogen , whereas axillary hair and pubic hair does not. Tx is testicular resection at puberty and creation of aneo vagina. Pt prestns with amenorrhea, developed breasts, absent pubic and axllary hair , absent internal reproductive organs and a 46XY karyotype.
Theophyline toxicity
1-CNS stimulation (headache, insomnia), 2-GI (Nasea, Vomitting), 3-Cardiac toxicity (arrhythmia).
Thiazide SE
Hyper GLUC= Hyper 1-Glycemia, Lipidemia, Uricemia, Calcemia. HypoK and HypoNa.
Thioridazine toxicity - 2
Unlike other antipsychotics, thioridazine is asso with cardiac arrythmias. Symptoms of thio overdose include deep sleep, coma, abnormal involuntary movements, hypotension, tachypnea and arrhythmias. EKG reveals prolong QRS. Pt needs sodium bicarbonate.****Antipsychotics like Thioridazine, galactorrhea 2ary to Dopamine blocking effect. Pt presents with lactation and menturation irregularity.
Thoracic outlet synd
refers to compresion of neuro-vascular structures supplying upper extremity. Pain wakes up the pt from sleep. There is paresthesias ans weakness of fingers. Vascular involvement presents with palor pulslessness and coldness.Cxr, MRI and angiography helps to dx the cause f compression. Conduction velocity studies identify the site of compression and overhead pully excercise helps to releif the compression.
Threatened abortion - 3
Hemorhage before 20week . Cervix is closed,no fetal tissue pasage,feal heart if normal, 25% of women have this. When th pt comes to you first step is to make sure fetus is alive. Once that is fullfiled, mngmt is reassurance and performance of USG one week later. Tx is Reassurance and outpatint follow up. DDX1:Incomplete abortion,sometissue is evacuated, cervix is dialated. DDX2:Complete abortion,whole concep passes theough cervix. Cervix is closed. USG shows empty uterus. DDX3:Inevitable abortion, low abdominal cramp radiated to the back, dialated cervix. USG shows ruptures or collapsed gestational sac with absence of fetal cardiac motion.****Complete abortion is when produce has come out and cervix is closed with blood in vaginal vault.****Cerclage is used to tx or prevent first trimester abortions when the cause is incompetent cervix.
Thrombophlebitis:
Characterized by palpable, indurated, cord-like, tender, subcutaneous venous segments, low fever.
Thymoma - 2
Is seen with CT in ANTERIOS midiastinum. All Neurogenic tumors (Neuroblastoma, are in POSTERIOR mediastinum. Pericardial cyst is in the MIDDCLE mediastinum. Esophageal Leomyomas are in POSTERIOR midiastinum.****Is asso with Red cell aplasia which is eveything except RBC,ESR,Hct,Hb and reticulocyte are normal.
Thyroid carcinoma
MC cancers 1-PAPILLARY(Papillary carcinoma is the most common thyroid cancer (60 to 70% of all thyroid cancers). Females are affected two to three times more often than males. It is more frequent in the young, but is more malignant in the elderly. It is more common in patients with a history of radiation. Hurtle cells exist. Psammomma bodies are characteristic.FNAB shows large cells with groung glass cytoplasm, and the pale nuclei with central bodies and central grooving. The prognosis is excellent even with metastasis.). 2-FOLLICULAR cancer(Follicular carcinoma accounts for about 15% of thyroid cancers and is more common in the elderly. ddx with ADENOMA is that cancers demonstrate invasion of capsul and blood vessels. It is more malignant than papillary carcinoma, spreading hematogenously with distant metastases.). 3-MEDULARY(Medullary (solid) carcinoma may occur as sporadic (usually unilateral) or as familial (frequently bilateral), transmitted as an autosomal dominant trait. Pathologically there is a proliferation of parafollicular cells (C cells) that produce excessive amounts of calcitonin, a hormone that can lower serum Ca and phosphate (PO4), Total thyroidectomy is indicated, even if bilateral involvement is not obvious. Hurtle cells exist.). 4-ANAPLASTIC(Anaplastic carcinoma accounts for 10% or less of thyroid cancers and occurs mostly in elderly patients and in women slightly more than in men. The tumor is characterized by rapid and painful enlargement, and about 80% of patients die within 1 yr of diagnosis). Do FNA for Dx, but FNA cant ddx b/w Follicular cancer and Follicular Adenoma.
Thyroid Nodules - 2
The mc is COLLOID (benign), 2nd mc is FOLLICULAR adenoma (benign). The first step in Dx of a thyroid nodule is is measurement of TSH, the subsequesnt steps (T4, T3) are all dependent on TSH levels. ***** FOLLICULAR Adenoma:histologically demonstration of invasion of the capsul and blood vessels is required. FNAB shows large numbers of normal-appearing follicular cells. Its almost impossible to ddx Follicular ADENOMA from Follicullar CANCER. Unlike PAPILLARY cancer, FOLLICULAR cancer is encapsulated and doesnt have dstinctive nuclear features. Lymph node involvement in Follicular cancer is rare, unlike papillary.
Thyrotoxicosis
one of the mc causes of thyrotoxicosis with reduced thyroid uptake is Subacute lymphocytic (painless) thyroiditis. Leakage of thyroid hormones into the circulation due to inflamatory damage to the thyroid follicales results in Thyrotoxicosis. Most cases happen postpartum. Other causes of TT with low radioactive iodine uptake are 1-Subacute granulomatous (De Quervain)thyroiditis (Asso with intense pain in thyroid), TX is just NSAID. 2-levothyroxine overdose, 3-Iodine induced TT.
TIA - 4
1-Embolic TIA are prolonged and single, they last for hours. EKG shows Atrial Fibrillation or MI. Tx includes avoidance or correction of risk facor like smoking, HT and Hypercholesterolemia. Anticoagulation is considered when TIA is caused by Emboli that arose from the heart. Heparin is administered followed by Warfarin. Transesophageal Echi is performed to clots or vegetations. 2-Atherothrombotic TIA are recurrent and shorter in duration., minutes. MRI and CT shows the site of injury. All pt should get antiplatelet therapy if there is no CI. Aspirin is the initial agent of choice. Clopidegrol is used if pt is intolerant of aspirin. Aspirin is used in combinatinon with Dipyridamole if pt has a hx of TIA despipte being on Aspirin.**** Presents as focal neurologic deficits (right-sided weakness, expresive aphasia) (MS might show same way but CT shows it). There are 3 pathophy for TIA, 1-Blood vessel abnormality(atherosclerosis, inflamation), 2-Embolic source(heart), 3-inadequate cerebral blood flow. Atherosclerosis & Emboli are the mcc in Elderly pt. in Young pt Emboli is the mcc. usually from the heart, due to arrythmia, IE, valvular dis or Myxoma. Less common are venous emboli that reach arterial circulation via ASD or patent foramen ovali. Transatlantiv flights increse the risk for Venous Thrombosis.. To identify the cause Transthoracis Echo is performed. If Echo is normal work up for hypercoagulable conditions should follow. ****All pt with atherothrombotic TIA should get antiplatelet tx if there is no CI to it. Aspirin is the initial agent of choice. If CI exists, Clopidegrol. If CI still exist then Ticlopidine.Now if TIA was caused by Emboli from the heart then anticoagulants ar considered.****In TIA asso focal symptoms resolve in 40, SPLENECTOMIZED, or immuncompromised. Parasyte enters RBC and cuases hemolysis. . Progression is Jaundice, hemoglubinuria, renal failure and death. Unlike othe rtick diseases RASH IS NOT a symptom.. Hay intravesculr hemolysis, anemia, abnormal LFT, elevated ESR. Dx is with blod smear. Tx is either Quinine-Clidamycin or Atovaquone-Azitromycin.
Tinea Corporis
Ring shaped scally patches with central clearing and distinct borders, topical tx with 2% antifungal lotions and creams (terbinafine) or systemic tx with Griseofulvin (for extensive disease).
Tinea Versicolor
Velvety pink or whitish, hypopigmentaed macules that don™t tan and don™t appear scally, but scale on scraping. Agent is Malasezia furfur. On KOH shows "spagetti and meatballs", Topical Selenium sulfide lotion or Ketokonazole shampoo is recommended.
TMJ Dysfunction
Always think of refered talgia when pt presents with ear pain and no hx. TMJD is a cc of refered otalgia, and pain aggravated by chewing, with psychogenic grinding (bruxism).
Torret Synd - 2
Tx is TYPICAL antipsychotics, like Haloperidole or Pimozide. *** Pts are at risk of developing OCD (keep repeating the same gestures and obsessed about counting the same numbers).
Torsade de pointes - 2
Could be caused by Quinidine. Tx is first stop the drug, then increase the heart rate by Magnesium. Torsade de pointes (see Fig. on DT), or twisting of the points, causes symptoms and death in patients with the rare congenital long QT syndromes. Its importance in everyday practice is its provocation by drugs (especially antiarrhythmics, which are contraindicated in its further management) or electrolyte imbalance. Management is to stop all cardioactive drugs (eg, antidepressants, antiarrhythmics, phenothiazines), normalize electrolytes (particularly K and Mg). ***TDP is also termed Polymorphic VT. its a very rapid VT characterized by gradulay changing QRS, prolonged QT. The mcc is Quinidine. In the acute setting Mg replacemnet is the tx.
Torus palatinus
is a benign bny mass on the palate. Its basically an outgrowth of the hard palat. No medical or surgery is required. Cause is unknown. So in a young person who present with a fleshy immobile mass on his hard palateits most likely Torus Palatinus
Toxic Adenoma - 2
Increased thyroid hormones with suppressed TSH are indicative of Thyrotoxicosis. Furthermore if radioactive Iodine uptake increased only in one lobe, that confirms Toxic Adenoma. DDX with Grave's is that in Graves iodine uptake is diffusly increased not just a specific area, also have exophthalmos. DDX with Multinodular goiter, uptake is patchy. DDX with Painless Thyroiditis, uptake is markedly reduced.***** Increased hyperthyroid pt like TA are at increased risk of rapid bone loss. Direct effect of thyroid hormone on th ebone cells eventually leads to increased OsteoClastic bone resorption.
Toxic epidermal necrolysis
A life-threatening skin disease in which the epidermis peels off in sheets, leaving widespread denuded areas. Primary manifestation is an erythomatous morbilliform eruption that rapidly evolves into exfoliation of the skin. Patches of skin slides off with slightest pressure (Positive Nikolsky sign). Oral mucosa shows painful blisters. Could be caused by Sulfanamides, barbituates, phenytoin, NSAIDS. Tx is supportive. Sulfanamides could also cause Stevens Johnson's syndrome (Erythema multiform major), but typical lesions are "target" shape. Same with Erythema multiform minor.
Toxic shock Syndrome
symptoms include sudden onset of flu-like syndrome, high fever, hypotension, erythomatous rash. 1-2week after onset skin peels. Tx: Pt should be hydrated and debridment of the wound should be performed. All source of infection should be removed and anti staph antibiotics should be started.
Trachoma
MCC of blindness in the world. Dx by presents of lymphoid follicales on the conjunctiva , scarring and limbal follicles. Tx is erythromycin or tetracycline.
Transient Sinovitis of the Hip:
Inflammation and swelling around the hip joint. Cause is unknown but could be due to virus. Bed rest with the affected joint in a comfortable position is the treatment of choice. Pt gets better in 3-4 days. DO NOT give aspirin due to the fear form Reyes Syndrome.
Transplantation
Oral Trimethoprine-Sulfamethoxide is the DOC for preventing PCP in transplant pts. If hay allergy then Dapsone.
Transposition of great vessels
The mc cyanotic heart disease that presents with cyanosis w/I the first 24hr of life. TOF chows cyanosis after few years.
Trichomonas Vaginalis
T. vaginalis is a flagellated protozoan found in the GU tract of both men and women. The organism is usually pear-shaped .Copius Malodoros vaginal Greyish-green color, thin and frothy. Also vaginal pruritis, dysurea and dyspareunia. Petechial pathes on the cervix show "strawbery cervic". Dx by microscopic obervation of flagellad organism in wet mount preparation. Tx is either one dose 2000mg or 250mg 3X a day for 7 days, for both partners. Metronidazole is teratogenic avoid using in 1st trimester.
Tricuspid Atresia:
Is a cyanotic congenital heart disease characterized by cyanosis early in life and left axis deviation. Most cases, 90% , are asso with VSD. DDX is TOF.
Tricuspid Regurgitation
A pansystolic murmur at the left sternal border
Tricuspid Stenosis:
A mid diastolic rumble, best heard along the left lower sternal border
Tricyclic Antidepressant drug tox:
Is the mcc of hospitalization and death due to excessive ingestion of prescription drugs. Pt with TCA overdose presents with anticholinergic, CV and neurological symptoms. CV se is proonged QRS and AV block. Also dry mouth dilated pupils, decreased bowel sounds, urinary retention, constipation, tachycardia, flushed skin and hyperthermia. Its been realized that QRS interval more reliably predicts the level of toxicity than the serum or urine drug levels.
Trigeminal Neuralgia - 2
At surgery or autopsy, intracranial arterial and, less often, venous loops compressing the trigeminal nerve root where it enters the brain stem have been found, suggesting that the tic is a compressive neuropathy. Paroxysmal lightning pain on the face, tx is carbamazepine.
Trimeta-Sulfa Toxicity
In African-Americans it cann cause acute hemolysis, back pain due to G6PD deficiency. NOTE:vigniette says that "G6PD I snormal", Don™t fall for that because in these pts it is normal but the cuase is still G6PD def. This also happens with Primaquine.
Torus Palatinus:
Is a benign bony mass on the hard palate. No medical or surgery is required. Cause is unknown. Tx is reassurance.
Tropical Sprue
Blunting of the villi and hx of travel is DDX with CELIAC disease. A common presentation is the triad of sore tongue, diarrhea, and weight loss. All features of a malabsorption syndrome may develop. Steatorrhea is common, and D-xylose absorption is abnormal in > 90% of cases. Folic acid and vitamin B12 deficiencies lead to megaloblastic anemia. shortening of the villi and lengthening of the crypts, with changes in the surface epithelium and an inflammatory cell infiltrate of lymphocytes, plasma cells, and eosinophils. The best treatment is tetracycline
TTP
presents with Pentad of 1-severe thrombocytopenia, 2-Microangiopathic hemolytic anemia (RBC fragments), 3-Neurological signs, 4-Renall failure, 5-Fever. LDH is elevated, PT & pTT are normal. HUS is like TTP w/o neuro signs. Both need Emergent Plasmaphoresis. DDX:I T P, a dx of exclusion, pt presents with isolated decreased in platelet count. Hb and WBC are normal, Pt & Ptt are normal. DDX3
IC, RBC fragments, PT,PTT and BT are elevated. Renal failure is not a feature.
Tuberous Sclerosis:
Initial presentation is seizures. The cutaneous anomaly is called adenoma sebacum, which appears b/e 5-10 yrears of age. TS occurs in first year of life with clusters of brief symmetrical contractions of the neck , trunk and extremities known s ˜infantile soasms, demonstrating EEG patterns. There is also hyperpigmented lesions (Ash leaf) and cortical tubers on head CT. The DOC is IM ACTH.
Tubo-varian abscess
Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , drainage should be considered. If there is doubt re Dx we do Laparoscopy. If hay rupture we need to do exploratory Laparotomy.
Tumor Lysis Synd - 2
Is characterized by Hypreuricemia. Seen in pt undergoing chemotherapy, with high nucleic acid turn over such as Leukemia dn Lymphoma. Prophylactic Allopurinol is the most effective method to prevent gout in these pts. Hysration is also good but alone is not enough, it should be used with Allopurinol.****Tumors which have high cell turn over are frequently ass with TLS, like Burkitts, ALL and AML. There is Hyperphosphatemia, Hypercalcemia, HyperKalemia and Hyperuricemia. The reason is both K and PO4 are intracel so they increase, PO4 causes HypoCa and Degradation of cellular protein causes increased Uric acid.
Turcot synd
It refers to an asso b/w brain tumors (primarily medulablastoma and gliomas) and FAP ( Familial Adenomatous Polyposis) or HNPCC (Hereditary Non Polyposis Colorectal Cancer. Its autosomal recessive and occurs mostly in teens. DDX1: Gardner, An auto Dominant, colonic polyps are seen with extraintestinal lesions, like Desmoid tumors, sebacious or epidermal cysts, lipomas, osteomas (mandible) gastric polyps and nasopharyngeal angiomas. DDX2: Peutz-Jeghers, an auto dominant dis, intestinal hamatomatous polyps with cutanous melanocytic macules. DDX4:Multiple Hamartoma synd, asso of GIT hamartomas and breast cancer, thyroid cancer and gingiva hyperplasia.
Turner synd
Since all ova are lost by atresia before menarchi, pts have streaked ovaries. There are no estrogen production, as there are no functinal filicular cells in streak ovaries. Absence of follicular cells results in absence of estrogen and inhibin from the ovaries as a result of loss of feedback inhibition of estrogen on LH & FSH causing their elevation. Inhibin only causes feedback inhibition of FSH, so in the absence of inhibin, serum FSH are more than LH, which is pathognomonic for Primary Ovarian Failure. **** Variation are possible, as in one X and one Y Ch. In this case the pt needs a bilateral gonadectomy due to increase risk for gonadoblastoma.*****Cxr shows rib notching due to coarcation of the aorta.
Ulcerative colitis - 3
Toxic Megacolon is a complication of UC. Its an emergency and prompt admin of IV steriods, nasogastric decompression& fluid management is required. Pt presents with diarrhea and bloddy stools, Dx is established clinically and colonoscopy. As it progresses, the rectum looses its elasticity and lumen collapses. Once tx is sarted some pt remit but some go on and manifest wieght lost and fever, when this acute colitis symptoms are associated with radiologic evidence of coloninc dialatation its called toxic megacolon.****Pts with UC that have pancolitis, should begin surveilance colonoscopy after eight years of diease.
Ulcerative Esophagtis
CMV is the most frequent cause in HIV pt. Triad of focal substernal burning pain with Odynophagia, shallow superficial ulceration and intracellular incluisons are dx of CMV (tx is gancyclovir). If ulcers are caused by HSV(tx is Acyclovir) they are multiple, well circumscribed and look like Volcanos.
Ulnar Nerve entrapment
Decreased sensation to 4 & 5 digits, and weak grip. The mc site is the elbow, in medial epicondyl groove.
Umbilical cord compression
is asso with Variable deceleration. Fetal sleep presents with decreased logn term variability. Fetal Head compression is asso with EARLY deceleration. Uteroplacential insufficiency presents with LATE deceleration. Intrauterine infection presents with tachycardia.
Umbilical Hernia
Is due to imperfect closure or weakness of the umbilical ring. Commonin low weight and Black infants. Its covered with skin and is easily reduced. > most disappear by one year. Surey is advised if hernia persists to the age of 3-4, exceeds 2cm in diameter, causes symptoms, becomes strangulated or progresily enlarges after 1-2 years.
Urethral injury, posterior - 2
Hallmark of Urethral injury is triad of 1-Blood at urethral meatus. 2-Inability to void, 3-Distended bladder. We have two types of UI: 1-Anterior, urethral inury anterior to perineal membrane. AUI are mc due to blaunt trauma to perinuem (saddle injuries). An immediate surgert is tx. 2-Posterior urethra, consists of prostate urethra and membaneous urethra. PUI are mc asso with pelvic fracture and high riding prostate. Initial mgmnt is retrograde urethrogram and then suprapubic catheterization. Remember Urethrogram with post void film is for Bladder injuries.
Urethritis
A/01/03. Tx for uncomlicated infections, Tetracycline, Azithromycin. For Pregnant women Erythromycin.
Uric acid stones
Are visualized via CT of abdomen, or IV pyelography.*****Needle shape crystals on urine analysis indicate urc acid stones. Uric acid stones which are radiolucent have to be evaluated with either CT of abdomen ar IVP. The stone can cause Ileus, possibly due to vagal reaction due to ureteral colic. The result will be absent bowel sounds, constipation, signs of obstruction, no gas passing. Ileus will be over once ureterolithiasis is tx. Stones
Uterine Rupture - 2
Presents with intense abdominal pain asso w vaginal bleeding, ranging from spotting to massive hemorrhage.****Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more children, total hysterectomy is the Tx of xhoice. If she wants more kids then Debridment and closure is indicated.****difficult to ddx from abrupta placenta. UR is preceeded by agitation, rapid breathing, tachycardia.
UTI in females - 3
The mcc in order are: 1-Shorter urethra compare tomen, 2-Contraceptives, 3-wt periuretral envoronment, 4-close proximity to anus.*****E.Coli is the mcc but it dos not produce uease so it doesn™t alter the normal Acidic pH of urine. Proteus is a urease producing bacteria and a frequent cause of UTI. Protease makes the urine Alkaline. ****In a female that there is no response to trimetasulfa and yellow/green mucopurulent endocervical dischage and edematous friable cervix, suspect C.Trochomatis. Dx is cervical culture. Asingle doze of Azithromycin for both partners is tx of choice. DDX is Chlamydia Urethritis, suspect in sexulay active pt with prolonged dysuria (7-10) days unresponsive to therapy for Chlamydial CYSTITIS. In Chlamydia, Gonocoal prophylaxis in not needed, but in Gonococal infection, empiric tx of chlamydia is recommended. Hospitalization and IV tx is recommended for severe PID (abdomial pain, uterine.adnexal tenderness on bimanual exam, and cervical motion tenderness).
Uveitis
Is the mcc of red eye in pt with Ankylosing spondolytis.
Vaginismus - 2
Involuntary spasm of the perineal musculature that interferes with sextual intercourse.****Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases its due to ignorant of women's anatomy, ahuge apprehention about penetration, and an uncontrolable fear of pain. Tx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dialation (penetration).
Vaginitis, Candida
Its not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritis, burning and dysparunia. Discharge has cottage cheese appearance. Its NOT malodorous and pH is 4-4.5. Dx is by KOH wet mount preparation and visualization os pseudohypha and spores. Tx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect anoterh oraganism and culture on Sabourausd. 50% of reccurence is due to other organism like like T.Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy. DDX1:Trichomonas (Metro) DDX2:Gardenella Vaginitis (Metro).
Varicose Veins
Symptoms are fatigue, tiredness in the leg, aching swelling. They are worsend by prolonged sittingor standing.The sweeling and pain rapipdly goes away when leg is elevated. The edema is asso with perforator incompetence. Ulcers occur in medial aspect of the leg. DDX Arterial insufficiency:presents with claudication that is worsened by leg elevation. Pulse is weak or absent and the ulcers are deep and at the distal parts of the leg. There is NO SWELLING in arterial insuff but hair loss and muscle atrophy is noted. DDX2 DM ulcers are like arterial but they are at the pressure points. DDX3 DVT related ulcers take years to develop and they are unlikely in active pts.
Vasa Previa - 2
Hemorrhage w fetal heart rate changes, progresing from tachycardia to bradycardia to a sinusoidal pattern. "Apt" test distinguishes maternal from fetal blood. Mortality risk is 75%. Dx w transvaginal US in combination w Doppler. VP necessitates emergency C section.
Ventricular Tachycardia
When a pt has recurrent VT first thing to do after stabilization(Amiodarone) first thing to do is to look for the cause, Most probabelt its due Diuretics (ie Furesamide causes HypOkalemia). So order electrolytes and correct them if needed.
Ventriculat Fibrilation.
Tx is defibrilation with 200-360 joules. If it fails, lidocaine or Amiodarone (DOC) can be loaded and pt shocked again. Epinephrine can sensitize and lower the treshold for conversion.
Verapamil poisoning
May cause bracardia, hypotension, AV block and cardiac arrest. Like hypotension caused by other poisons, IV saline is the first thing. Then Calcium Chloride is useful in reversing the effect of Calcium channel blocker including bradycardia, AV block and hypotension.
Vesicoureteral Reflux:
Is retrograde flow of urine from bladder to ureter and renal pelvis. It™s a risk for recurret UTI and renal scarring ultimately. Renal scaring is the major cause of end stage disease in children. Reflux exists in all children with renal scars and renal scars are in 60% of children with gross reflux. Dx is made with voiding cystourethrogram.
VIPoma
Is a Pancreatic tumor. Produce Vasoactive Intestinal Peptide. It causes diarrhea, hypokalemia resulting in leg cramp, and decrease in amount of acid in stomach. Woman are more affected. Other symptoms include weight loss, facial flushing and redness. Dx is high VIP in blood. CT or MRI find location. Tx: first goal is to treat dehydration. Next is to slow the diarrhea with Octreotide. If tumor has not metastasized, surgery is indicated.
Vitami K def - 2
Vit K def presenting as hemorrhagic dis of the new born occurs in infants born at home with no prenatal care. Its given to all infants after birth. Newborns are suseptible due to low fat stores, low vit K breast milk and liver immaturity. It can present as intracranial bleeding as well as skin and GI. In adults it is seen in pts with chronic small bowel disease, after small bowel resection or prolonged anbiotic therapy. Dx is elevated Pt or decreased clotting factors. BT is normal. Platelet in normal, PTT may or may not be elevated. DDX1:Von Willerbrand, Auto Dom, BT & PTT are elevated, PT is normal. Factor VIII is low. DDX2:Hemophilia ia X-link, PTT is elevated, BT and Pt are normal. DDX3:Liver disease, Pt is elevated, PTT & BT are normal. DDX4:ITP, platelets are low.
Vitamin D Def
Most commonly due to MALABSORPTION causes reduced plasma Calcium and Phosphorous. DDX w Hyperparathyroidism and Pseudoparahypothyroidism is that they cause decreased in Ca but increase in phosphate.****In infants: presents with bone abnormality like softness or deformity. Typical pts ar low birth weight, Unsupplimented dark skin infants, infants with inadequate exposure to the sun, and breast fed infants.Pthology is defective mineralization of the bone.*****Rickets is developed due to Vit D def in children who stay indoors all the time and eating is not blanced. Presents with costochondral junctions are enlarged, wrist and ankle are thick and xray shows cupping and frying of the distal end of radius and ulna, large anterior fontanel.
Vitamin D Toxicity, Misc. 6/2
Confusion, HA, nausea from hypercalcemia. Mental status changes. Constipation is the mc GI SE. Renal SE is nephorolithiasis, ARInsiff and CRI. Tx is stopping the vitamin, low Ca diet, keep urine acidic and giving corticosteriods.
Vitamine Def
1-Riboflavin Def (B2) is unusual in industrialized nations. Symptoms are Photophobia, Dermatitis and Anemia. 2-Vit C : Ecchymosis, petechia, bleeding gums, Hyperkeratosis, Sjogren's. 3-Niacin (B3) presents with Diarrhea, Dementia, Dermatitis. 4-Thiamin def (B1) asso with infantile and adult Beri Beri as well as Werneki-Korsakoff. Dry beri beri is symetrical peripherla neuropathy with sensory and motor involvment. Wet beriberi is includes neuropathy in addition to cardiac involvment.
Vitiligo - 2
Presents with pale patches of skin, symetrically around themouth and areola. Borders are well circumscribed and hyperpigmented. Pathology is destruction of melanocytes. Few experience spontaneous remission. ***Its asso with Pernicious anemia, Grave's dis, DM-I, alopecia areata.
Vitreous Hemorrhage -2
Sudden loss of vision with floaters in the visual field. Diabetic Retinopathy is the mcc. Fundus is hard to visualize. Basically there are 3 types of Ophtalmological Hemorrhages:1-Conjunctival, cause is minor trauma,cough, sneeze or strain, no tx needed, resolves w/i 2 weeks. 2-VH, produces blavk reflex in exam, cause is DM and retinal vein occulsionretinal tears,its absorped slowly, bleeding is controlled with photocoag. 3-Retinal Hemorrhage which is flame shaped in HT and dot&blot in DM or septic infarction, its always significant.
Volkman™s Ischemic Contracture:
Displaced anterior fat pad is a radio-G sign of Supracondylar fracture which may be complicated by VIC
Volvulus, midgut
Present in a child
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ic Keratosis is a recursor to SCC.**** When ulcer dosnt heal, suspect SCC, nest step is PUNCH biopsy. If SCC, WIDE excision is the Tx of choice.****Actinic Keratosis turns into SCC.
Statin intolerance/Toxicity
CPK elevation of more than 10 times in presence of myalgias/myopathy. Rhabdomyalysis in an Acute renal failure could be a consequence. Tx is stop the drug and supportive therapy for Rhabdo.
Status Epilepticus
An emergency. Mgmnt step are: 1-Place pt lateral with mandible pushed forward. 2-medication started. 3-if medication failed after 30 min , then general anesthesia and intubation is indicated.
Stevens Johnson's
Target shaped mucocutanous lesions and systemic signs of toxicity. Pathology involves immune complex mediated hypersensitivity.
Still's dis, Adults
Is a variant of RA. Pt presents with 20-30yo, high spiking fevers with CHARACTERISTIC salmon colored rash, arthralgias, arthritis, Leukocytosis. DDX1
arvovirus (Slapped cheek dis), malar,eryhtomatous rash, arthralgia or arthritis. DDX2:Henoch-Schonlein purpura, in children, rash,abdominla pain,arthralgias and renal dis. Rash is pruritic and involves lowerlegs or Buttucks.DDX2:RF, PECCS. Erythema Marginatum is Evanescent(tending to vanish)erythomatous non pruritic mostly on the trunk.Stomach cancer
The only malignany that has decreased universaly. The reason is not known.
Strabismus:
The mcc of amblyopia (decreased visual acuity) is strabismus. The mc type of strabismus is esodeviation (medial deviation of th eye). Tx is to cover the normal eye.
Stranger Anxiety
When a child is left in unfamiliar places (day care). From 6-8 months and peaks in 12-15 months. DDX:Seperaion aniety is with older childs when seperated from a love one.
Stress Fracture
Bone pain at rest, worsens with exercise, swelling and point tenderness, Xray is normal at initial stage and MRI is dx, Tx is restrictive weight bearing along with short leg cast, healing takes 3-4 weeks. It occurs in young dancers's legs.
Stroke - 6
Stroke can be 2 types, Hemorrhagic (intercerebral or subarachnoid) or Ischemic (secondary to thrombosis, embolism, or systemic hypoperfusion). Blood supply of the brain is 1-Anterior vasculature, internal carotid A and its branches Anterior and Middle cerebral A. 2-Posterior vasculator, paired Vertebral A and they join to make Basilar artery, which divides to make Posterior cerbral Artery. Now Deficiencies produce: 1-ACA:Contralaterla motor and sensory deficit wich is more pronounced in the lower rather than upper limbs.Urinary incontinence, gait ataxia. 2-MCA: Contralateral motor and sensory deficitwhich are more pronoucedin the Upper rather than lower limbs, and homonomous hemianopia. If the dominant lobe (left) is involves hay aphasia, and if non-dominant (right) is involved hat neglect syndrome and anosognosia(pt cant tell is there has been an injury to the body). 3-PCA: Homonomous Hemianopia, ataxia w/o agraphria, visual hallucination(Calcarine cortec), sensory symptoms (thalamus), third nerve palsy with paresis of vertical eye movement and motor deficit (mid brain). 4-LACUNAR infarcts: are small non cortical infarcts caused by occulsion of a branch of a cerebral artery. Risk factors are hypertension, DM or Polycythemia. They usually dont produce both motor and sensory symptoms but rather have well recognized syndromes, like pure motor hemiparesis, pure sensory stroke, dysarthria-clumsy handor ataxic hemiparesis. *If a pt presents w/i 3 hours of ischemic attack, thrombolytic therapy with tPA (after CT scan) should be started. Dont try to regulate BP first, it might impair autoregulation and make it worst. Streptokinase does not help either. tPA is tx of choice. * THALAMIC stroke:Involves VPL part of thalamus that transmits sensory info from contralateral part of body. Presents with hemianesthesia accompanied by hemiparesis, ahtetosis. Dysesthesia (numbness and tingling burning feeling) of the area affected by the sensory loss is chracteristic, and is called thalamic pain phenomenon.****HT has the highest risk factor for Stroke, more than smoking,alcohol,hyppercholesterol.....****If pt presents with hemiparesis and speech difiulty like broken words then its Expressive aphasia related to Dominant frontal. But if he cant understand what is being said to him then it is Parietal dominant(Dyscalculia,Dysgraphia). ****If a pt comes in with hemiplasia, you need to first ddx b/w Hemorrhagic and Ischemic stroke and then give medication. To DDX you need to do CT WITH OUT contrast, if its ischemic (thrombi) then we give aspirin and then we do carotid Doppler and TEE to evaluate source of embolism.
Stuge-Webber Synd:
A neurocutanous condition. Its auto dominant therefore doesn™t affect multiple generations. Pt will have a cerebral lesion on the same side as facial nevus. Also exopthalmus due to ICP. Dx is CT. The cerebral lesions are nevi involving the leptomeninges and are thus similar to the facial lesions.*****Caverness unilateral hemangioma is another presentation. Skull Xray after the age of 2 years shows gyriform intracranial calcifications that resembles the tramline. Tx ia aimed at controlling seizure and reducing ICP. Laser therapy w Argon to remove skin lesions.
Subacromial bursitis
It refers to inflamation of the subacromial bursa. It occurs in athlets as pat of impingment syndrome. Its characterized by shoulder pain, which is absent at rest but present at overhead activity. Range of movement is limited by pain. Neer sign (pain on passive internal rotation and forward flextion at shoulder) is present. US or MRI confirms Dx. Tx is conservative with NSAID, physical therapy. DDx is Tear of long head of bicept tendon, which will lead to bulging muscle mass in the middle of the arm.
Subacute Combined Degen
T9Q42. Tx is B12
Subarachnoid hemorrhage “4. 6/3
Rupture of aneurysm is the most frequent cause. Hypertension is the mcc for Intracerebral Hemorrhage. They are most prone to rupture when they™re >7mm. Pt should be evaluated with cerebral angiography and treated surgically. Pt should be evaluated by cerebral angiography and treated surgically. AVM is the mcc of SAH in children, the hx of seizure and migrain like headache is characteristic.****Vasospasm is the major cause of morbidity and mortality in pts with SAH. Calcium channel blockers (Nimodipine) are used to prevent spasm in these pts.****SAH or "cerebral-salt wasting syndrome". Patholgy involves 1-SIADH (inappropriate vasopressin secretion) which causes water retention. 2-an increased secretion of an atrial/brain natriuretic peptide. SIADH also results in hyponatremia for which water restriction is the tx of choice. So Hyponatremia is one of the important complications of SAH.
Subcunjuctival hemorrhage. Ophthalmo. 6/3
Redness in the eye, due to hard rubbing or trauma. Its benign and heels spontaneously.
Subdural hematoma
Tear of bridging veins. Picture shows semi lenticula rhematome. MC in Elderly & Alcoholics. Tx is conservative if no midline shift is present in CT. Tx is centered on prevention of ICP by head elevation, hyperventilation (causes vasoconstriction and thus decreases cerebral blood flow), and if needed acetazolamide and mannitol. If there is a midline shift then Craniotomy is indicated but its asso with grave prognosis. DDX1:Epidural hematoma where Middle Meningeal A. is injured. Biconvex hematoma in CT, non contrast. Lucid interval. DDX2:Hypertensive hemorrhage, putamen & thalamus. DDX3:Subarachnoid hemorhage, rupture of aneurysm.
Sublimation:
A mature defence mechanism that allows for unacceptable impulses to be channeled into more acceptable activities. Like aman w fiery temper who channels his anger into athletic pursuits.
Sumatriptan Tox
CI include Printzmetal Angina, CAD, Pregnancy. So is a femlae of child baring age wants it make sure she is not pregnant.
Superficial thrombophlebitis:
Dull pain in the region of the affected vein, eryhtema, induration and tenderness along the vein. High fever and chills and rigor is suggestive of septc phlebitis. Presence of edema and deep calf tenderness is characteristis of DVT. ST is not risk factor for Pulmonary Embolism. Localized ST is treated wth bed rest, heat and NSAID
Superior Vena Cava Synd
Pt presents with Venous congestion of face and arms. The mcc of superior vena cava onstruction is Bronchogenic carcinoma(Small cell tumor) (smokers). Today Angioplasty with stenting is choice.
SVT:
Narrow QRS, HR>140, regular, loss of P wave. If pt is unstable, cardioversion. If stable, vegal maneuvers initially, if failed then IV Adenosine. Verapamil is 2nd DOC.
Supraclavicular fracture:
It compromises brachial artery resulting in bradial artery pulse loss.
Symptomatic Bradycardia
Pt has HR of 40, dizzy,lightheaded, clamy extremities, but no dyspnea or chest pain and no hypotention. He is having severe symptomatic bradycardia dn the tx is iv Atropine.If that didn™t work net step is Transcutaneous pacing. If pt has bradycardia AND Hypotension, then tx is Epinephrine. Reember Adenisine is used for SV tachycardia.
Syncope - 3
Know basic pathophys mechanism and different types of Syncope. The most common pathophysiologic basis for syncope is an acute decrease in cerebral blood flow (with resultant cerebral hypoxemia) secondary to decreased cardiac output; arrhythmias, including conduction abnormalities, are the most frequent cause. 1-Exertional (effort) syncope suggests cardiac outflow obstruction, mainly due to aortic stenosis. 2-Syncope of cardiac etiology typically begins and ends suddenly and spontaneously. It is most commonly due to an arrhythmia. 3-Vasovagal (vasodepressor) syncope is typically precipitated by unpleasant physical or emotional stimuli (eg, pain, fright, sight of blood), usually occurs in the upright posture, and is often preceded by vagally mediated warning symptoms. 4-Syncope due to seizures is abrupt in onset and is associated with muscular jerking or convulsions, incontinence, and tongue biting. 5-Syncope due to pulmonary embolism usually indicates massive pulmonary vascular obstruction and is often associated with dyspnea, tachypnea, chest discomfort, cyanosis, and hypotension. 6-Syncope of gradual onset (with warning symptoms) and slow clearing suggests metabolic changes, eg, hypoglycemia or hypocapnia of hyperventilation. ***7-Situational syncope, Typical senario would include a man middle age who looses consiousness immediately after urination or during coughing fits. The pathophysiology involves autonomic dysregulation, which can be explained by staining or rapid bladder emptying. ****Vasovagal syncope dx is with upright tilt table testing which includes Carotid sinus massage.
Synovitis of the hip joint
Bed rest with the hip joint in a comfortable position is the tx of choice.
Syphilis - 4
Once Dark field microscopy shows the spirochet and its positive, no need to do VDRL or FTA-ABS. But since the pt is at risk of HIV we need to do Elisa for HIV screening.****PRIMARY: Presnts with Painless, shallow CHANCRE ulcer WITH PUNCHED OUT BASE AND ROLLED EDGES and painless bilateral lymphadenopathy. The best dx test is Dark field microscopy. **Secondary: presents with Condylomata lata, highly contagious.****** In pt who is allergic to Penicillin, give Oral Doxycycline.
Syringomyelia
Suspect in a pt with upper extremity areflexia weakess and associated anesthesia in a "cape" distribution. When syringomyelia is associated with Arnold-Chiari malformation, there is caudal displacement of cereberal tonsilsthrough the foramen magnum
Systemic Sclerosis
The cause of pulmonary complication is interestitial fibrosis not tighning of the skin. Prolonged oral administration (> 1.5 yr) of penicillamine (0.5 to 1.0 g/day) can reduce skin thickening. For renal disease, ACE inhibitors are the drugs of choice.
Tachycardia, Vent
Regular (Wide Complex) Ventricular tachycardia has 2 types of tx. 1-If pt is hemodynamically stable (BP is normal, K normal, no bleeding) then DOC is IV Amiodarone, or alternative is Lidocaine. If pt is not stabalized then cardioversion is choice. Digoxin is CI in VT, Its used for Atrial Tachy. For SVT Carotid massage is chioce.
Tamoxifen - 3
An antiestrogen drug used for breast cancer. When used as adjuvent therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma. ***It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, ITS PROVEN. SEE RALOXIFEN.****It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.
Tay-Sachs dis:
Def of Hexosaminase and accumulation of GM2 gangliosidase, particularly in CNS. Pt presents with hyperacusis, MR, seizure, chery red macula but NOT hepatomegally or lymphadenopathy.
TB -2
1-Induraation of 5 or > is + in: Close contacts of TB pt, HIV pt, Organ trnasplant, chronic steriod therapy. 2-Induration of 12 or > is + in : Immigrants recent, IV drug users, homeless person, prisoners and healthcare workers. Once PPD is positive, it does not mean pt has TB, they have to undego Cxr. If TB is diagnosed then full therapy, if TB is excluded then 9 months of Isoniazide prophylaxis. TB is the mcc of Constrivtive pericarditis in immigrants. It should be considered in pt with unexplained elavation of JVP and hx of predisposure.*****Erythema induratum are nodules in the sheen and calves. They are small tender erythomatous nodules.
TCA intoxication - 4
T9Q15. tx is sodium bicarbonate prevents arrythmia by alleviatng cardio-depressant action on sodium channel. Asso with QRS widening on EKG. It also helps correct acidosis. If pt presents with seizures that need tx we give Diazepam.
Tennnis Elbow
Or Laterla Epicondylitis, is condylitis about the origin of extensors of forearm. Characterized by point tenderness over the lateral epicondyle of humerus and exacerbation of pain by extention of the wrist agaisnt resistance (hitting the ball). DDX with Radial tunnel syndrome which could coexist, pain is produces by simultaneously extending the wrist and ringers while the long finger is passively flexed by the examiner.
Testicular cancer - 2
1-Seminoma: elevated Placenta Alkaline Phosphatase. 2-Embryonal: elevated Alpha Feto Protein (AFP). 3-Choriocarcinoma: elevated beta-HCG. Once the dx of carcinoma is made, US shows solid nodule, then initial mngmt is Orchiectomy. Trans scrotal biopsy and FNA is CI becauseit might spread lymphatically or hemotgenously. ****Leydig cell tumors are the mc type of testicular sex cord stromal tumor. Testosteone and Estrogen are markedly increased with 2ary inhibition of FSH & LH. Pt prestns with Bilateral Gynecomastia. DDX1:Choriocarcinoma, bHCG is increased. DDX2:Seminomas contain Syncytiotrophoblastic giant cells.DDX3:Yolk sac tumors show increased AFP.
Testiclar feminization:
Defect of absence of androgen receptors resulting in feminine phenotype with 46XY genotype. The MIF is produced by the gonads, so th euterus, vagina and tubes are absent. Breasr develop due to peripheral production of estrogen, whereas axillary and pubic hair does not. Tx is to resect testicles and make Vagina.
Tetanus guideline
Hx of Tetanus Immun Clean Wounds Dirty looking wounds
=3 dose of tet toxoid in past TT:Yes if last dose >10y ago, TIg:No TT:yes if last dose>5y ago, TIg:No
Tetracycline Toxicity
A5- Photosensitivity.
Tetralogy of Falot - 2
Most prominent feature is cyanosis that rarely improves with oxygen. A Classid presentation is Squanting that improves cyanosis. "Tet" spells are hypoxic episodes characterized by rapid breathing. Immediate tx is Oxygen and put the child in a Knee-Chest position. followed by fluids,morphine,propranolol. TOF is a Cyanotic (early) condition. ASD & VSD aren't cyanotic (late).****Pansystolic murmur, Hepatomegally.
Tetsticular feminization
defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so urtus and vagina are absent. Breat develop because peripheral production of estrogen , whereas axillary hair and pubic hair does not. Tx is testicular resection at puberty and creation of aneo vagina. Pt prestns with amenorrhea, developed breasts, absent pubic and axllary hair , absent internal reproductive organs and a 46XY karyotype.
Theophyline toxicity
1-CNS stimulation (headache, insomnia), 2-GI (Nasea, Vomitting), 3-Cardiac toxicity (arrhythmia).
Thiazide SE
Hyper GLUC= Hyper 1-Glycemia, Lipidemia, Uricemia, Calcemia. HypoK and HypoNa.
Thioridazine toxicity - 2
Unlike other antipsychotics, thioridazine is asso with cardiac arrythmias. Symptoms of thio overdose include deep sleep, coma, abnormal involuntary movements, hypotension, tachypnea and arrhythmias. EKG reveals prolong QRS. Pt needs sodium bicarbonate.****Antipsychotics like Thioridazine, galactorrhea 2ary to Dopamine blocking effect. Pt presents with lactation and menturation irregularity.
Thoracic outlet synd
refers to compresion of neuro-vascular structures supplying upper extremity. Pain wakes up the pt from sleep. There is paresthesias ans weakness of fingers. Vascular involvement presents with palor pulslessness and coldness.Cxr, MRI and angiography helps to dx the cause f compression. Conduction velocity studies identify the site of compression and overhead pully excercise helps to releif the compression.
Threatened abortion - 3
Hemorhage before 20week . Cervix is closed,no fetal tissue pasage,feal heart if normal, 25% of women have this. When th pt comes to you first step is to make sure fetus is alive. Once that is fullfiled, mngmt is reassurance and performance of USG one week later. Tx is Reassurance and outpatint follow up. DDX1:Incomplete abortion,sometissue is evacuated, cervix is dialated. DDX2:Complete abortion,whole concep passes theough cervix. Cervix is closed. USG shows empty uterus. DDX3:Inevitable abortion, low abdominal cramp radiated to the back, dialated cervix. USG shows ruptures or collapsed gestational sac with absence of fetal cardiac motion.****Complete abortion is when produce has come out and cervix is closed with blood in vaginal vault.****Cerclage is used to tx or prevent first trimester abortions when the cause is incompetent cervix.
Thrombophlebitis:
Characterized by palpable, indurated, cord-like, tender, subcutaneous venous segments, low fever.
Thymoma - 2
Is seen with CT in ANTERIOS midiastinum. All Neurogenic tumors (Neuroblastoma, are in POSTERIOR mediastinum. Pericardial cyst is in the MIDDCLE mediastinum. Esophageal Leomyomas are in POSTERIOR midiastinum.****Is asso with Red cell aplasia which is eveything except RBC,ESR,Hct,Hb and reticulocyte are normal.
Thyroid carcinoma
MC cancers 1-PAPILLARY(Papillary carcinoma is the most common thyroid cancer (60 to 70% of all thyroid cancers). Females are affected two to three times more often than males. It is more frequent in the young, but is more malignant in the elderly. It is more common in patients with a history of radiation. Hurtle cells exist. Psammomma bodies are characteristic.FNAB shows large cells with groung glass cytoplasm, and the pale nuclei with central bodies and central grooving. The prognosis is excellent even with metastasis.). 2-FOLLICULAR cancer(Follicular carcinoma accounts for about 15% of thyroid cancers and is more common in the elderly. ddx with ADENOMA is that cancers demonstrate invasion of capsul and blood vessels. It is more malignant than papillary carcinoma, spreading hematogenously with distant metastases.). 3-MEDULARY(Medullary (solid) carcinoma may occur as sporadic (usually unilateral) or as familial (frequently bilateral), transmitted as an autosomal dominant trait. Pathologically there is a proliferation of parafollicular cells (C cells) that produce excessive amounts of calcitonin, a hormone that can lower serum Ca and phosphate (PO4), Total thyroidectomy is indicated, even if bilateral involvement is not obvious. Hurtle cells exist.). 4-ANAPLASTIC(Anaplastic carcinoma accounts for 10% or less of thyroid cancers and occurs mostly in elderly patients and in women slightly more than in men. The tumor is characterized by rapid and painful enlargement, and about 80% of patients die within 1 yr of diagnosis). Do FNA for Dx, but FNA cant ddx b/w Follicular cancer and Follicular Adenoma.
Thyroid Nodules - 2
The mc is COLLOID (benign), 2nd mc is FOLLICULAR adenoma (benign). The first step in Dx of a thyroid nodule is is measurement of TSH, the subsequesnt steps (T4, T3) are all dependent on TSH levels. ***** FOLLICULAR Adenoma:histologically demonstration of invasion of the capsul and blood vessels is required. FNAB shows large numbers of normal-appearing follicular cells. Its almost impossible to ddx Follicular ADENOMA from Follicullar CANCER. Unlike PAPILLARY cancer, FOLLICULAR cancer is encapsulated and doesnt have dstinctive nuclear features. Lymph node involvement in Follicular cancer is rare, unlike papillary.
Thyrotoxicosis
one of the mc causes of thyrotoxicosis with reduced thyroid uptake is Subacute lymphocytic (painless) thyroiditis. Leakage of thyroid hormones into the circulation due to inflamatory damage to the thyroid follicales results in Thyrotoxicosis. Most cases happen postpartum. Other causes of TT with low radioactive iodine uptake are 1-Subacute granulomatous (De Quervain)thyroiditis (Asso with intense pain in thyroid), TX is just NSAID. 2-levothyroxine overdose, 3-Iodine induced TT.
TIA - 4
1-Embolic TIA are prolonged and single, they last for hours. EKG shows Atrial Fibrillation or MI. Tx includes avoidance or correction of risk facor like smoking, HT and Hypercholesterolemia. Anticoagulation is considered when TIA is caused by Emboli that arose from the heart. Heparin is administered followed by Warfarin. Transesophageal Echi is performed to clots or vegetations. 2-Atherothrombotic TIA are recurrent and shorter in duration., minutes. MRI and CT shows the site of injury. All pt should get antiplatelet therapy if there is no CI. Aspirin is the initial agent of choice. Clopidegrol is used if pt is intolerant of aspirin. Aspirin is used in combinatinon with Dipyridamole if pt has a hx of TIA despipte being on Aspirin.**** Presents as focal neurologic deficits (right-sided weakness, expresive aphasia) (MS might show same way but CT shows it). There are 3 pathophy for TIA, 1-Blood vessel abnormality(atherosclerosis, inflamation), 2-Embolic source(heart), 3-inadequate cerebral blood flow. Atherosclerosis & Emboli are the mcc in Elderly pt. in Young pt Emboli is the mcc. usually from the heart, due to arrythmia, IE, valvular dis or Myxoma. Less common are venous emboli that reach arterial circulation via ASD or patent foramen ovali. Transatlantiv flights increse the risk for Venous Thrombosis.. To identify the cause Transthoracis Echo is performed. If Echo is normal work up for hypercoagulable conditions should follow. ****All pt with atherothrombotic TIA should get antiplatelet tx if there is no CI to it. Aspirin is the initial agent of choice. If CI exists, Clopidegrol. If CI still exist then Ticlopidine.Now if TIA was caused by Emboli from the heart then anticoagulants ar considered.****In TIA asso focal symptoms resolve in 40, SPLENECTOMIZED, or immuncompromised. Parasyte enters RBC and cuases hemolysis. . Progression is Jaundice, hemoglubinuria, renal failure and death. Unlike othe rtick diseases RASH IS NOT a symptom.. Hay intravesculr hemolysis, anemia, abnormal LFT, elevated ESR. Dx is with blod smear. Tx is either Quinine-Clidamycin or Atovaquone-Azitromycin.
Tinea Corporis
Ring shaped scally patches with central clearing and distinct borders, topical tx with 2% antifungal lotions and creams (terbinafine) or systemic tx with Griseofulvin (for extensive disease).
Tinea Versicolor
Velvety pink or whitish, hypopigmentaed macules that don™t tan and don™t appear scally, but scale on scraping. Agent is Malasezia furfur. On KOH shows "spagetti and meatballs", Topical Selenium sulfide lotion or Ketokonazole shampoo is recommended.
TMJ Dysfunction
Always think of refered talgia when pt presents with ear pain and no hx. TMJD is a cc of refered otalgia, and pain aggravated by chewing, with psychogenic grinding (bruxism).
Torret Synd - 2
Tx is TYPICAL antipsychotics, like Haloperidole or Pimozide. *** Pts are at risk of developing OCD (keep repeating the same gestures and obsessed about counting the same numbers).
Torsade de pointes - 2
Could be caused by Quinidine. Tx is first stop the drug, then increase the heart rate by Magnesium. Torsade de pointes (see Fig. on DT), or twisting of the points, causes symptoms and death in patients with the rare congenital long QT syndromes. Its importance in everyday practice is its provocation by drugs (especially antiarrhythmics, which are contraindicated in its further management) or electrolyte imbalance. Management is to stop all cardioactive drugs (eg, antidepressants, antiarrhythmics, phenothiazines), normalize electrolytes (particularly K and Mg). ***TDP is also termed Polymorphic VT. its a very rapid VT characterized by gradulay changing QRS, prolonged QT. The mcc is Quinidine. In the acute setting Mg replacemnet is the tx.
Torus palatinus
is a benign bny mass on the palate. Its basically an outgrowth of the hard palat. No medical or surgery is required. Cause is unknown. So in a young person who present with a fleshy immobile mass on his hard palateits most likely Torus Palatinus
Toxic Adenoma - 2
Increased thyroid hormones with suppressed TSH are indicative of Thyrotoxicosis. Furthermore if radioactive Iodine uptake increased only in one lobe, that confirms Toxic Adenoma. DDX with Grave's is that in Graves iodine uptake is diffusly increased not just a specific area, also have exophthalmos. DDX with Multinodular goiter, uptake is patchy. DDX with Painless Thyroiditis, uptake is markedly reduced.***** Increased hyperthyroid pt like TA are at increased risk of rapid bone loss. Direct effect of thyroid hormone on th ebone cells eventually leads to increased OsteoClastic bone resorption.
Toxic epidermal necrolysis
A life-threatening skin disease in which the epidermis peels off in sheets, leaving widespread denuded areas. Primary manifestation is an erythomatous morbilliform eruption that rapidly evolves into exfoliation of the skin. Patches of skin slides off with slightest pressure (Positive Nikolsky sign). Oral mucosa shows painful blisters. Could be caused by Sulfanamides, barbituates, phenytoin, NSAIDS. Tx is supportive. Sulfanamides could also cause Stevens Johnson's syndrome (Erythema multiform major), but typical lesions are "target" shape. Same with Erythema multiform minor.
Toxic shock Syndrome
symptoms include sudden onset of flu-like syndrome, high fever, hypotension, erythomatous rash. 1-2week after onset skin peels. Tx: Pt should be hydrated and debridment of the wound should be performed. All source of infection should be removed and anti staph antibiotics should be started.
Trachoma
MCC of blindness in the world. Dx by presents of lymphoid follicales on the conjunctiva , scarring and limbal follicles. Tx is erythromycin or tetracycline.
Transient Sinovitis of the Hip:
Inflammation and swelling around the hip joint. Cause is unknown but could be due to virus. Bed rest with the affected joint in a comfortable position is the treatment of choice. Pt gets better in 3-4 days. DO NOT give aspirin due to the fear form Reyes Syndrome.
Transplantation
Oral Trimethoprine-Sulfamethoxide is the DOC for preventing PCP in transplant pts. If hay allergy then Dapsone.
Transposition of great vessels
The mc cyanotic heart disease that presents with cyanosis w/I the first 24hr of life. TOF chows cyanosis after few years.
Trichomonas Vaginalis
T. vaginalis is a flagellated protozoan found in the GU tract of both men and women. The organism is usually pear-shaped .Copius Malodoros vaginal Greyish-green color, thin and frothy. Also vaginal pruritis, dysurea and dyspareunia. Petechial pathes on the cervix show "strawbery cervic". Dx by microscopic obervation of flagellad organism in wet mount preparation. Tx is either one dose 2000mg or 250mg 3X a day for 7 days, for both partners. Metronidazole is teratogenic avoid using in 1st trimester.
Tricuspid Atresia:
Is a cyanotic congenital heart disease characterized by cyanosis early in life and left axis deviation. Most cases, 90% , are asso with VSD. DDX is TOF.
Tricuspid Regurgitation
A pansystolic murmur at the left sternal border
Tricuspid Stenosis:
A mid diastolic rumble, best heard along the left lower sternal border
Tricyclic Antidepressant drug tox:
Is the mcc of hospitalization and death due to excessive ingestion of prescription drugs. Pt with TCA overdose presents with anticholinergic, CV and neurological symptoms. CV se is proonged QRS and AV block. Also dry mouth dilated pupils, decreased bowel sounds, urinary retention, constipation, tachycardia, flushed skin and hyperthermia. Its been realized that QRS interval more reliably predicts the level of toxicity than the serum or urine drug levels.
Trigeminal Neuralgia - 2
At surgery or autopsy, intracranial arterial and, less often, venous loops compressing the trigeminal nerve root where it enters the brain stem have been found, suggesting that the tic is a compressive neuropathy. Paroxysmal lightning pain on the face, tx is carbamazepine.
Trimeta-Sulfa Toxicity
In African-Americans it cann cause acute hemolysis, back pain due to G6PD deficiency. NOTE:vigniette says that "G6PD I snormal", Don™t fall for that because in these pts it is normal but the cuase is still G6PD def. This also happens with Primaquine.
Torus Palatinus:
Is a benign bony mass on the hard palate. No medical or surgery is required. Cause is unknown. Tx is reassurance.
Tropical Sprue
Blunting of the villi and hx of travel is DDX with CELIAC disease. A common presentation is the triad of sore tongue, diarrhea, and weight loss. All features of a malabsorption syndrome may develop. Steatorrhea is common, and D-xylose absorption is abnormal in > 90% of cases. Folic acid and vitamin B12 deficiencies lead to megaloblastic anemia. shortening of the villi and lengthening of the crypts, with changes in the surface epithelium and an inflammatory cell infiltrate of lymphocytes, plasma cells, and eosinophils. The best treatment is tetracycline
TTP
presents with Pentad of 1-severe thrombocytopenia, 2-Microangiopathic hemolytic anemia (RBC fragments), 3-Neurological signs, 4-Renall failure, 5-Fever. LDH is elevated, PT & pTT are normal. HUS is like TTP w/o neuro signs. Both need Emergent Plasmaphoresis. DDX:I T P, a dx of exclusion, pt presents with isolated decreased in platelet count. Hb and WBC are normal, Pt & Ptt are normal. DDX3
IC, RBC fragments, PT,PTT and BT are elevated. Renal failure is not a feature.Tuberous Sclerosis:
Initial presentation is seizures. The cutaneous anomaly is called adenoma sebacum, which appears b/e 5-10 yrears of age. TS occurs in first year of life with clusters of brief symmetrical contractions of the neck , trunk and extremities known s ˜infantile soasms, demonstrating EEG patterns. There is also hyperpigmented lesions (Ash leaf) and cortical tubers on head CT. The DOC is IM ACTH.
Tubo-varian abscess
Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , drainage should be considered. If there is doubt re Dx we do Laparoscopy. If hay rupture we need to do exploratory Laparotomy.
Tumor Lysis Synd - 2
Is characterized by Hypreuricemia. Seen in pt undergoing chemotherapy, with high nucleic acid turn over such as Leukemia dn Lymphoma. Prophylactic Allopurinol is the most effective method to prevent gout in these pts. Hysration is also good but alone is not enough, it should be used with Allopurinol.****Tumors which have high cell turn over are frequently ass with TLS, like Burkitts, ALL and AML. There is Hyperphosphatemia, Hypercalcemia, HyperKalemia and Hyperuricemia. The reason is both K and PO4 are intracel so they increase, PO4 causes HypoCa and Degradation of cellular protein causes increased Uric acid.
Turcot synd
It refers to an asso b/w brain tumors (primarily medulablastoma and gliomas) and FAP ( Familial Adenomatous Polyposis) or HNPCC (Hereditary Non Polyposis Colorectal Cancer. Its autosomal recessive and occurs mostly in teens. DDX1: Gardner, An auto Dominant, colonic polyps are seen with extraintestinal lesions, like Desmoid tumors, sebacious or epidermal cysts, lipomas, osteomas (mandible) gastric polyps and nasopharyngeal angiomas. DDX2: Peutz-Jeghers, an auto dominant dis, intestinal hamatomatous polyps with cutanous melanocytic macules. DDX4:Multiple Hamartoma synd, asso of GIT hamartomas and breast cancer, thyroid cancer and gingiva hyperplasia.
Turner synd
Since all ova are lost by atresia before menarchi, pts have streaked ovaries. There are no estrogen production, as there are no functinal filicular cells in streak ovaries. Absence of follicular cells results in absence of estrogen and inhibin from the ovaries as a result of loss of feedback inhibition of estrogen on LH & FSH causing their elevation. Inhibin only causes feedback inhibition of FSH, so in the absence of inhibin, serum FSH are more than LH, which is pathognomonic for Primary Ovarian Failure. **** Variation are possible, as in one X and one Y Ch. In this case the pt needs a bilateral gonadectomy due to increase risk for gonadoblastoma.*****Cxr shows rib notching due to coarcation of the aorta.
Ulcerative colitis - 3
Toxic Megacolon is a complication of UC. Its an emergency and prompt admin of IV steriods, nasogastric decompression& fluid management is required. Pt presents with diarrhea and bloddy stools, Dx is established clinically and colonoscopy. As it progresses, the rectum looses its elasticity and lumen collapses. Once tx is sarted some pt remit but some go on and manifest wieght lost and fever, when this acute colitis symptoms are associated with radiologic evidence of coloninc dialatation its called toxic megacolon.****Pts with UC that have pancolitis, should begin surveilance colonoscopy after eight years of diease.
Ulcerative Esophagtis
CMV is the most frequent cause in HIV pt. Triad of focal substernal burning pain with Odynophagia, shallow superficial ulceration and intracellular incluisons are dx of CMV (tx is gancyclovir). If ulcers are caused by HSV(tx is Acyclovir) they are multiple, well circumscribed and look like Volcanos.
Ulnar Nerve entrapment
Decreased sensation to 4 & 5 digits, and weak grip. The mc site is the elbow, in medial epicondyl groove.
Umbilical cord compression
is asso with Variable deceleration. Fetal sleep presents with decreased logn term variability. Fetal Head compression is asso with EARLY deceleration. Uteroplacential insufficiency presents with LATE deceleration. Intrauterine infection presents with tachycardia.
Umbilical Hernia
Is due to imperfect closure or weakness of the umbilical ring. Commonin low weight and Black infants. Its covered with skin and is easily reduced. > most disappear by one year. Surey is advised if hernia persists to the age of 3-4, exceeds 2cm in diameter, causes symptoms, becomes strangulated or progresily enlarges after 1-2 years.
Urethral injury, posterior - 2
Hallmark of Urethral injury is triad of 1-Blood at urethral meatus. 2-Inability to void, 3-Distended bladder. We have two types of UI: 1-Anterior, urethral inury anterior to perineal membrane. AUI are mc due to blaunt trauma to perinuem (saddle injuries). An immediate surgert is tx. 2-Posterior urethra, consists of prostate urethra and membaneous urethra. PUI are mc asso with pelvic fracture and high riding prostate. Initial mgmnt is retrograde urethrogram and then suprapubic catheterization. Remember Urethrogram with post void film is for Bladder injuries.
Urethritis
A/01/03. Tx for uncomlicated infections, Tetracycline, Azithromycin. For Pregnant women Erythromycin.
Uric acid stones
Are visualized via CT of abdomen, or IV pyelography.*****Needle shape crystals on urine analysis indicate urc acid stones. Uric acid stones which are radiolucent have to be evaluated with either CT of abdomen ar IVP. The stone can cause Ileus, possibly due to vagal reaction due to ureteral colic. The result will be absent bowel sounds, constipation, signs of obstruction, no gas passing. Ileus will be over once ureterolithiasis is tx. Stones
Uterine Rupture - 2
Presents with intense abdominal pain asso w vaginal bleeding, ranging from spotting to massive hemorrhage.****Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more children, total hysterectomy is the Tx of xhoice. If she wants more kids then Debridment and closure is indicated.****difficult to ddx from abrupta placenta. UR is preceeded by agitation, rapid breathing, tachycardia.
UTI in females - 3
The mcc in order are: 1-Shorter urethra compare tomen, 2-Contraceptives, 3-wt periuretral envoronment, 4-close proximity to anus.*****E.Coli is the mcc but it dos not produce uease so it doesn™t alter the normal Acidic pH of urine. Proteus is a urease producing bacteria and a frequent cause of UTI. Protease makes the urine Alkaline. ****In a female that there is no response to trimetasulfa and yellow/green mucopurulent endocervical dischage and edematous friable cervix, suspect C.Trochomatis. Dx is cervical culture. Asingle doze of Azithromycin for both partners is tx of choice. DDX is Chlamydia Urethritis, suspect in sexulay active pt with prolonged dysuria (7-10) days unresponsive to therapy for Chlamydial CYSTITIS. In Chlamydia, Gonocoal prophylaxis in not needed, but in Gonococal infection, empiric tx of chlamydia is recommended. Hospitalization and IV tx is recommended for severe PID (abdomial pain, uterine.adnexal tenderness on bimanual exam, and cervical motion tenderness).
Uveitis
Is the mcc of red eye in pt with Ankylosing spondolytis.
Vaginismus - 2
Involuntary spasm of the perineal musculature that interferes with sextual intercourse.****Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases its due to ignorant of women's anatomy, ahuge apprehention about penetration, and an uncontrolable fear of pain. Tx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dialation (penetration).
Vaginitis, Candida
Its not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritis, burning and dysparunia. Discharge has cottage cheese appearance. Its NOT malodorous and pH is 4-4.5. Dx is by KOH wet mount preparation and visualization os pseudohypha and spores. Tx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect anoterh oraganism and culture on Sabourausd. 50% of reccurence is due to other organism like like T.Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy. DDX1:Trichomonas (Metro) DDX2:Gardenella Vaginitis (Metro).
Varicose Veins
Symptoms are fatigue, tiredness in the leg, aching swelling. They are worsend by prolonged sittingor standing.The sweeling and pain rapipdly goes away when leg is elevated. The edema is asso with perforator incompetence. Ulcers occur in medial aspect of the leg. DDX Arterial insufficiency:presents with claudication that is worsened by leg elevation. Pulse is weak or absent and the ulcers are deep and at the distal parts of the leg. There is NO SWELLING in arterial insuff but hair loss and muscle atrophy is noted. DDX2 DM ulcers are like arterial but they are at the pressure points. DDX3 DVT related ulcers take years to develop and they are unlikely in active pts.
Vasa Previa - 2
Hemorrhage w fetal heart rate changes, progresing from tachycardia to bradycardia to a sinusoidal pattern. "Apt" test distinguishes maternal from fetal blood. Mortality risk is 75%. Dx w transvaginal US in combination w Doppler. VP necessitates emergency C section.
Ventricular Tachycardia
When a pt has recurrent VT first thing to do after stabilization(Amiodarone) first thing to do is to look for the cause, Most probabelt its due Diuretics (ie Furesamide causes HypOkalemia). So order electrolytes and correct them if needed.
Ventriculat Fibrilation.
Tx is defibrilation with 200-360 joules. If it fails, lidocaine or Amiodarone (DOC) can be loaded and pt shocked again. Epinephrine can sensitize and lower the treshold for conversion.
Verapamil poisoning
May cause bracardia, hypotension, AV block and cardiac arrest. Like hypotension caused by other poisons, IV saline is the first thing. Then Calcium Chloride is useful in reversing the effect of Calcium channel blocker including bradycardia, AV block and hypotension.
Vesicoureteral Reflux:
Is retrograde flow of urine from bladder to ureter and renal pelvis. It™s a risk for recurret UTI and renal scarring ultimately. Renal scaring is the major cause of end stage disease in children. Reflux exists in all children with renal scars and renal scars are in 60% of children with gross reflux. Dx is made with voiding cystourethrogram.
VIPoma
Is a Pancreatic tumor. Produce Vasoactive Intestinal Peptide. It causes diarrhea, hypokalemia resulting in leg cramp, and decrease in amount of acid in stomach. Woman are more affected. Other symptoms include weight loss, facial flushing and redness. Dx is high VIP in blood. CT or MRI find location. Tx: first goal is to treat dehydration. Next is to slow the diarrhea with Octreotide. If tumor has not metastasized, surgery is indicated.
Vitami K def - 2
Vit K def presenting as hemorrhagic dis of the new born occurs in infants born at home with no prenatal care. Its given to all infants after birth. Newborns are suseptible due to low fat stores, low vit K breast milk and liver immaturity. It can present as intracranial bleeding as well as skin and GI. In adults it is seen in pts with chronic small bowel disease, after small bowel resection or prolonged anbiotic therapy. Dx is elevated Pt or decreased clotting factors. BT is normal. Platelet in normal, PTT may or may not be elevated. DDX1:Von Willerbrand, Auto Dom, BT & PTT are elevated, PT is normal. Factor VIII is low. DDX2:Hemophilia ia X-link, PTT is elevated, BT and Pt are normal. DDX3:Liver disease, Pt is elevated, PTT & BT are normal. DDX4:ITP, platelets are low.
Vitamin D Def
Most commonly due to MALABSORPTION causes reduced plasma Calcium and Phosphorous. DDX w Hyperparathyroidism and Pseudoparahypothyroidism is that they cause decreased in Ca but increase in phosphate.****In infants: presents with bone abnormality like softness or deformity. Typical pts ar low birth weight, Unsupplimented dark skin infants, infants with inadequate exposure to the sun, and breast fed infants.Pthology is defective mineralization of the bone.*****Rickets is developed due to Vit D def in children who stay indoors all the time and eating is not blanced. Presents with costochondral junctions are enlarged, wrist and ankle are thick and xray shows cupping and frying of the distal end of radius and ulna, large anterior fontanel.
Vitamin D Toxicity, Misc. 6/2
Confusion, HA, nausea from hypercalcemia. Mental status changes. Constipation is the mc GI SE. Renal SE is nephorolithiasis, ARInsiff and CRI. Tx is stopping the vitamin, low Ca diet, keep urine acidic and giving corticosteriods.
Vitamine Def
1-Riboflavin Def (B2) is unusual in industrialized nations. Symptoms are Photophobia, Dermatitis and Anemia. 2-Vit C : Ecchymosis, petechia, bleeding gums, Hyperkeratosis, Sjogren's. 3-Niacin (B3) presents with Diarrhea, Dementia, Dermatitis. 4-Thiamin def (B1) asso with infantile and adult Beri Beri as well as Werneki-Korsakoff. Dry beri beri is symetrical peripherla neuropathy with sensory and motor involvment. Wet beriberi is includes neuropathy in addition to cardiac involvment.
Vitiligo - 2
Presents with pale patches of skin, symetrically around themouth and areola. Borders are well circumscribed and hyperpigmented. Pathology is destruction of melanocytes. Few experience spontaneous remission. ***Its asso with Pernicious anemia, Grave's dis, DM-I, alopecia areata.
Vitreous Hemorrhage -2
Sudden loss of vision with floaters in the visual field. Diabetic Retinopathy is the mcc. Fundus is hard to visualize. Basically there are 3 types of Ophtalmological Hemorrhages:1-Conjunctival, cause is minor trauma,cough, sneeze or strain, no tx needed, resolves w/i 2 weeks. 2-VH, produces blavk reflex in exam, cause is DM and retinal vein occulsionretinal tears,its absorped slowly, bleeding is controlled with photocoag. 3-Retinal Hemorrhage which is flame shaped in HT and dot&blot in DM or septic infarction, its always significant.
Volkman™s Ischemic Contracture:
Displaced anterior fat pad is a radio-G sign of Supracondylar fracture which may be complicated by VIC
Volvulus, midgut
Present in a child