IMPORTANT POINTS Australian Medical Council (AMC) EXAM

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IMPORTANT POINTS Australian Medical Council (AMC) EXAM
SOME IMPORTANT POINTS have 2 know

GASTROENTEROLOGY

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 , more in Strict Vegitarian.

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 1st; 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 1st, 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 ***.; 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.

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

Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1st *** 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; ***: 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, 1st 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

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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 ***
Infants constipation 1st=> cranial nerve *** => cranial nerve *** => 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 ***; 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

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

VIPoma Makes Vasoactive peptide (VIP); *** 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



To Be Contin.....

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CARDIOVASCULAR
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/*** 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 *** 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; 2o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP

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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: 2nd 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: 2nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR: 4th L ICS, incr. loud w/ inspiration; bounding JVD, pulsatile liver; VSD: loud holoystolic, assoc w/ Down's

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RESPIRATORY
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 *** 1st, 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 ***; 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)

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ENDOCRINOLOGY
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 ***, 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 ***; decr. Mg in alcoholics can lead to decr. Ca due to ßPTH secretions

Hyperparathyroid Bones, stones, abd. Groans and psychic moans; 1o = excess PTH; 80% benign adenoma; 2o 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
1o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone
2o incr. renin angiotensin system activity => decr. BP

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GENTOURINARY
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 2o 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

[dr_raja143]

INFECTIOUS DISEASES & IMMUNOLOGY
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 & 1st 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

HEMATOLOGY & ONCOLOGY
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 ***,

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, 2o 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 2o 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