8/12/13 8:11 AMClinical Symptom Integration Notes

8/12/13 - Chest Pain

9 month old child w/ cc of chest painVaginal delivery, no complicationsVaccinations up to dateExamNo distress, normal color, runny nose, tachypnea, mild wheezing, decreased air entry in the lungsDifferential DiagnosisURI, flu, trauma, septal defect, bronchitis, asthma, cystic fibrosis, Wolf Parkinson white syndrome, trauma, foreign body, GERD, acid reflux, pneumonia, pneumothorax, congenital heart defects, tumor, cancer, pertussis, pleuritis, pericarditis, esophagitis, hiatal hernia, lung abcess, dermatitis, inhaled or exhaled rib, borhoff syndrome, hepatitis, pancreatitis, gastritis, endocarditis, dissected aorta, colic

23 year old man with cc of chest painIn tears, no significant medical history, vital signs are stable, physical exam unremarkable, some tenderness in costosternal areaDifferential diagnosisAppendicitis, rib fracture, heart problems, illicit drug use, pneumoepigastrium, GSW, acid reflux/heart burn, carcinoma, bacterial infection, pericarditis, muscle strain, medication side-effect, anxiety attack, GERD, hiatal hernia, costochondritis, sickle-cell anemia, PE, drug-seeker, bulimia, gall bladder disease, appendicitis, peptic ulcer, aortic dissection, pneumothorax, tuberculosis, MI, coronary vasospasms, marfan syndrome, costochondritis, tumor, cancer, arrhythmia, cardiomyopathy, electrolyte abnormalities

32 year old female with cc of chest pain and SOBHad a child 2 weeks ago (normal vaginal delivery), 200 lbs, no diabetes, no HTNCoaurse breath sounds bilateral, decreased breath sounds bilaterally, tachycardicDifferential diagnosisPE, diaphragmatic defect due to birth, pleuritis, empyema, pneumonia, CHF, atelectasis, cardiogenic shock, infection secondary to skin lesion, cardiac tamponade, lupus, shingles, MI, acute coronary syndrome, angina, muscle strain, rheumatoid arthritis, valvular diseases, rheumatic vlavular disease, endocarditis, GERD, coronary artery disease

65 year old woman with severe chest pain (sharp, in tears and severe distress)Hx of diabetes, HTN, previous MI, CHF, smoking, alcohol, edema in legsTachycardic, tachypnicLungs clear, chest clearDifferential DiagnosisMI, pulmonary embolism, COPD, coronary artery disease, Risk factorsGenetic and non-genetic, preventable and non-preventable, COPD, pulmonary HTN, aortic aneurysm, drug interaction, neuropathy, bronchitis, pneumonia, esophageal spasm, esophageal diverticulitis, tumor, ulcer, asthma,

8/12/13 8:11 AM

08/13/13 Introduction to neurology and approach to the neurologic complaint

Case #1: John34 years oldCC: headacheHPI: old cartsHad headache 1x prior, started last night, around the whole head (headband distribution), no trauma, constant, tylenol helped, laying down helps, associated nausea, 5/10, no radiation, no temporal patterns, loud noises make it worse, no tearing or runny nosePMHAnxiety, no medications or supplements, drinks monster (2-4 per day; had caffeine yesterday), Differential diagnosis: vasodilated cerebral arteries migraine (doesnt have to be unilateral), HTN, tumor, aneurysm (ruptured), stroke (hemorrhagic - subarachnoid), concussion and post-concussion syndrome, tension or cluster headache, dehydration (d/t caffeine), electrolyte imbalance, hypoglycemiaAlways ask first headache, worst headache, or atypical

Case #2: MaryCC: DizzyHPI: onset of 2 hours ago, room is spinning, 67 years old, constant dizziness, staying still makes it better, no weakness or numbness, has happened 2 times before (6 months and 2 years), gets worse with movementDifferential diagnosis: hypotension, dehydration, vestibular dysfunction/vertigo, meningitis (stiff neck, fever, headache), otitis media (would be atypical)CT to look for posterior bleed (due to abnormal finger-nose test and high BP)You must be careful with dropping BP rapidly, because if its an ischemic stroke, lowering BP will result in growing of penumbra d/t inability of blood to diffuse to distant sites through secondary and tertiary vesselsWith true nuchal rigidity, the head, neck and upper back move in unison/as a single unit

Case #3: RudolphCC: WeaknessHPI: what kind of weakness (generalized or focal; if generalized it is probably not in the brain)Differential diagnosis: food poisoning, stroke, traumatic injury, malnutrition, dehydrationWatch out for cauda equina (presents with extremity pain, not back pain)

Case #4: YolandaCC: NumbnessHPI: where is it (hands and feet)DD: peripheral nerve compression, stroke, diabetic neuropathy, exposure to chemicals, nerve compression, tumor, anxiety, MSUse history/physical to determine if dizziness is a CNS or non-CNS problemCT is better than MRI to visualize bleeding (MRI better for ischemic stroke)Vertical nystagmus indicates brainstem injury and horizontal nystagmus indicates peripheral nervous injuryOther neurological complaintsSeizures due to hypoglycemia, fever (in children febrile seizures; due to rate of change of temperature), alcohol withdrawalCommon neurological complaintsHeadache, numbness, weakness, pain, dizziness, vision changesProblems with herbal supplementsDosages arent standardized/regulated, theyre often tainted with other medications, they arent FDA approvedADEK vitamins are non-soluble, so excess levels cant be excreted in urineWhat type of things outside the brain cause neurologic symptomsHypoglycemiaUremiaIt is unknown why these to causes lead to focal problems that mimic strokesNeuro exam summaryCNs, proprioception and cerebellar function, sensory, reflexes, muscle strength, mental statusThe 1-minute neurologic examAlertness and orientationSpeechDysarthria is mechanicalAphasia has to do with whether or not the words are coming out or notMotor functionExtremity movementAmbulationCranial nervesNeuro ROSDizziness/LOC, HA, language or speech problems, blurred vision, blindness, numbness, tingling, memory problems, seizures, weakness, heaviness, stiffness, mental status/personality changes/disoriented, coordination problems (writing, walking, eating, etc.)Make sure you can justify every test you orderMost common neurologic cause for loss of consciousness is seizureIf you lose consciousness d/t a tumor, you likely arent waking up (du to edema and pressure that is present as a result of it)Same with strokehemorrhagic8/12/13 8:11 AM

8/19/2013 Headache

Pt: Antonio GomezCC: headacheWhat can a headache representTension headache, cluster headache, migraine, dehydration, malnutrition, drug use (i.e. cocaine), caffeine withdrawal, alcohol abuse, trauma, subarachnoid hemorrhage, meningitis, stroke, influenza, cancer/tumor, meningitis, encephalopathy (encephalitis), hypoglycemia, too much loud noises, carbon monoxide poisoning, strep throatOLD CARTSO: slowly while at work (eliminates subarachnoid hemorrhage, which has fast onset)L: frontal portion of the head (could be cluster headache)D: 24 hoursC: throbbing (migraine)A: light makes it worse; nothing makes it betterR: no radiationT: constant since onsetS: 8/10Differential diagnosisTrauma, migraine, subarachnoid hemorrhagePMH: HTN; no surgeriesMeds: hydrochlorothiazide (25mg daily)Allergy: NKDASH: accountant; married to Maria; denies any tobacco or illicit drug use; social etohFamily Hx (FH): HTN and DMROS: visual system (visual changes), fever, vomiting, etc.Encephalitis vs meningitisM: lethargy and sicklyE: change in mental statusWhat is the most concerning symptom associated with headaches?Stiff neck*****Indicates meningitis, encephalitis, subarachnoid hemorrhage, somatic dysfunctionVomitingConcussion, increased intracranial pressure, migraine, influenza, aneurysmPhotophobiaMigraine, drug reaction, FeverMeningitis, influenza, subarachnoid hemhorrage, PE, pneumoniaPhonophobiaMigraineEasily bruises and bleedingMicrocytopenia, cancer, hemophilia, sepsis, anemiaLungs CTAB clear to auscultation bilaterallyWithout W/R/R wheezing, rales, ronchiSpasms in trapezius and splenius capitisWhat OMM techniques could be usedMyofascial releaseFPRStrain-counterstrainTypically use and indirect technique with an acute episodeTreatmentNSAIDS, control blood pressure,

Catamenial headachesMigraines that occur before a womans menstrual cycle

What are some shortcomings of CTIf subarachnoid hemorrhage has been going on for 24+ hours, bad for stroke detection

PapilledemaSwelling of optic disc indicative of increased intracranial pressure

Nuchal rigidityIndicative of meningitis; cant move head independently of body

Meingismus2/22/14 5:50 PMWhen nuchal rigidity, photophobia, and headache are present without an actual infection

08/20/13 TBI

How do we define TBIAn alteration in brain function or other evidence of brain pathology by an external forceHow do we diagnose TBITBI is a process, not an eventSecondary injury can be more damaging than primary injuryMain mechanisms of brain injuryBrain contusionIncreased intracranial pressure papilledemaDiffuse axonal injuryPrimary vs Secondary injuryPrimaryIrreversible cellular injury as a direct result of the injuryPrevent the eventSecondary injuryDamage to cells that are not initially injuredOccurs hours to weeks after injuryPrevent hypoxia and ischemia (hypotension increased ischemia)Mechanism 1: Brain ContusionA brain contusion is defined by cell death accompanied by hemorrhage (leakage of blood)The soft brain tissue is vulnerable to contusion in head traumaThe contusion often occurs at a site distant from the point of impactCountercoup injuryAn injury on the opposite side of initial impact of head due to brain being thrown backwards after initial impact against interior of calvaria (coup injury)Mechanism 2The volume of the intracranial vault is fixedIntracranial contents80% brain tissue10% blood10% CSFAn increase in the volume of any of these intracranial contents causes increased intracranial pressureThe brain can swell (edema)Excess blood can accumulate due to hemorrhageCSF can accumulate due to blockage of outflow There is only one way out of the intracranial vault (the foramen magnumWhen the brain is squeezed through the foramen magnum (herniation), the brainstem is compressed, the patient stops breathing, and the patient diesMechanism 3Diffuse axonal injuryOne of the major causes of unconsciousnessNormal physiology of headBrain consumes 20% of total O2Receives 15% of COBrain tissue perfusionCPP vs CBFCPP = MAP-ICPMAP = (SBP-DBP/3) + DBPAutoregulation50-150 mm Hgintracerebral pressureFacts and FiguresDont need to know statisticsMales 15-24 TBI cost is highest in Chicago due to gang violence and guns as well as sportsMales over 65 TBI cost is high due to fallsKey history in head injuryMechanism of injury (rely on family and police because pts judgment an mental integrity is compromised)Pts condition prior to incident (baseline)Co-morbid factorsHTN, arteriosclerosis could affect approach to treatment due to risk of exacerbating diseasePts immediate post trauma conditionConfusion, agitation, malaise, etc.Pts current medical conditionCould affect treatment choiceWhen it comes to medicine it is always better to due a commission than an omissionWhere are the other injuriesMechanism of injury can be a key determinant of other injuriesAlways consider a spinal cord or vertebral column injury in a pt with a TBIEspecially in pts that are unconsciousRemember: SCIWORASpinal cord injury without radiographic abnormalityAssume a spinal cord or cervical spine injury until proven otherwiseAlways gradually change levels (glucose, electrolytes, temp, etc.)Acute Neuro examAirway (while maintaining cervical spine stabilization)BreathingCirculationDisabilityExposurePrevent secondary brain injuryHy[oxemia, hyperglycemia, hypotension, evacuation of mass, anemiaAirway control with cervical spine immobilizationIf a definitive airway is needed orotrachealPupil assessmentMotor gross function (posturing)Decerebrate vs decorticalGlasgow coma scaleCan give you a subjective, universal measure of the patients conditionCan give you a baseline to compare progress or decline againstConcussionAny alteration of cerebral function caused by a force to the head with any or oneBrief LOC, headache, visual changes, personality change, fatigue, balance disturbances, light headed, concentration, disruptions, amnesiaHaving a concussion makes it easier to have subsequent concussionsInvolves a degree of diffuse axonal injury and necrosisScalp lacerationMay lead to massive blood lossExcessive vasculature that is pulled tight by scalp layersSmall galeal lacerations may be left aloneSkull fractureTemporal bone is most common bone fractured (petrous portion) (EAC and TM)Dural tearCSF testingShould be started on antibioticsEpidural hematomaRupture of middle meningeal arteryAssociated with fracture of temporal boneRapid expansion under systemic arterial pressureLucid intervalSubdural hematomaRupture of bridging veinsSeen in elderly, alcoholics, blunt head trauma, shaken babySlow development due to low pressure venous systemCan develop over days to weeksCT showsSubarachnoid hemorrhageRupture of an aneurysmUsually a Berry aneurysm or AVMCan be traumatic or atraumaticAtraumatic: hypertensionSpider hemorrhage near circle of willisIntraparenchymal hematomaTypically does not rapidly expand or cause significant edema or midline shiftUnless pt is on an anticoagulantDiagnosed by CT scanDiffuse axonal injury

2/22/14 5:50 PM

08/20/13 Spinal Cord Injuries

Always assume that the mechanism of injury was a bad one until proven otherwiseCervical vertebrae are the most susceptible to injuryLess musculatureLess associated structuresSupports head lack of balanceC7-T1 is most susceptibleComplete injuryThe complete absence of sensory and motor function below the level of injuryThis includes loss of function to the level of the lowest sacral segmentIncomplete injurySpinal shockTemporary loss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injuryThe lower the spinal cord injury, the more likely that all distal reflexes will be affectedAnterior cord syndromeLoss of motor function, pain and temp sensation distal to the lesionResults from damage to: corticospinal and/or spinothalamic pathways, contusion of the cord or bony-injury (flexion of cervical spine)Worst prognosis of all injuriesCentral cord syndromeDecreased motor function, pain and to a lesser exten temperature sensation, greater in upper than lower extremetiesDue to damage to corticospinal pathway and/or spinothalamic pathwayCauses: usually in older pts wtith pre-existing cervical spondylosis wo sustain a hyperextension injuryThrombosis of anterior spinal arteryLeads to Masses Brown-Segard syndromePatients will exhibit ipsilateral loss of:Motor function, proprioception, vibratory sensationContralateral loss of pain and temperature sensationResults from hemisection of the spinal cordCausesDisk protrusions, penetrating trauma (GSW), hematomas bone injury, tumorsBest prognosis for recoveryClinical approachAlways assume a spinal cord injury until proven otherwiseABCs are top priority but with assumption of cervical spine injuryKey historical componentsMechanism of injuryLoss of consciousnessNeurologic complaintsYou can use the cremasteric reflex to test for testicular torsionUse reflex testing to assess spinal shock (presence, extent, and/or location)RadiographsAdvantagesQuick and easyRapid turnaround on viewing/interpretationDisadvantagesLimited compared to other modalitiesCT scansAdvantagesMore info than radiographsMore sensitive than plain filmsGreat for detecting bloodDisadvantagesPt must be stableMuch more radiation than plain filmsUsually require interpretation by radiologistCannot give any info on spinal cordMRIAdvantagesGives lots of info about bones, cord, vasculatureMore sensitive than CT scansGreat for detecting spinal cord injury, ischemiaNo radiationDisadvantagesNot good for bloodPt must be stableTakes a long timeRequires interpretation by radiologistPts with metal cannot have studyH & PGCS, mental exam, intoxicants?Pt status (stable vs unstable)Capabilities of facilities (keep vs. transfer)Clinical Symptom Integration2/22/14 5:50 PMGet a good mechanism of injury

08/21/13

Vestibular systemIt is better to have a peripheral nystagmus than a central onePeripheral deals with the middle/inner ear and central deals with the brainMenieres diseaseCorrelates with a high salt dietCan be autoimmune as wellVestibular neuritisVs menieres diseaseThey cant do anything (non-functional); very debilitatingBenign paroxysmal positional vertigoProvoked by head movement (particularly rotation)r/o orthostatic hypotension by lack of effect of fluid administrationALWAYS BE CAREFUL WITH OLDER PATIENTS BECAUSE THEY OFTEN HAVE ABNORMAL PRESENTATIONS2/22/14 5:50 PM

08/26/13 Back Pain

CC: My back hurtsDifferential diagnosisHerniated disck, cholelithiasis, tumor, kidney stone, thight psoas, nephritis, AAA or dissection, pulled muscle, vertebral fractureHow does age affect diagnosisYoung, old, adult changes most likely causesPMH/PSHSurgeries, previous injuries, repeat problemsWhich of the following could be the most concerning symptom (no correct answer because it could be any of them)Blood in urineIndicates kidney stone, UTI, ant kind of infectionPain in the legsHerniated disk, sciaticaNumbnessCauda equina, nerve impingementFind out if its localized, dermatomal, etc.FeverAny kind of infection, psoas abscess, cholelithiasis, spinal meningitis, discitis, epidural abcessWeakness (paresis)OLD CARTSO: began abruptly while studying in the dormL: left lower backD: 2 hrsC: sharp and acheyA: nothing makes it worse or betterR: radiation to groinT: has been constant since onset with waxing and waningS: rates it as a 10/10Differential:Kidney stone, musculoskeletal, atypical appendicitis presentation (retrocecal appendices cause pain on left; pregnant females commonly have abnormal appendicitis presentation)PMH: noneMeds: denies any med useAllergies: NKDASH: student, single, roommat of jeff smith, denies any tobacco or illicit drug use, social etohFH: DMSexual Hx: sexually active, one or many partner, male female or both, do you use protection and if so what kind, have you been tested, have you or your partner ever been diagnosed with an STIROS:Hx of dysuria, hematuria, ROM in back, weight change (cancer), fever, cough and sputum (pneumonia), chest pain (MI, aortic dissection, AAA), abd pain, discharge (STI)Pain can be referred if its visceralTop three diagnosesKidney stones, UTI, STIPhysical exam findingsMusculoskeletal examAbdominal examGU examCould have UTI, STI, testicular torsion, kidney stoneWhat do you prescribeTordol (NSAID); better for collicy painOMTMorpheneTo differentiate between somatic and visceral pain, ask if they can find a comfortable position to sit or if theyre constantly uncomfortableIf yes, its likely visceral/peritoneal irritationYou can also do a heel tap

Musculoskeletal injuries tend to have reproducible pain

2/22/14 5:50 PMTesticular torsion tends to be a testicle and the associated vas deferens twisted around itself

09/09/13 Mental Status

- 86 y/o confused femaleHome Health Nurse said that she had slurred speech, was confused, and not her normal selfPerform a mini-mental exam, examine skin for bruises/lesions indicating a fall or infection, a/o to person and place (not time), does it hurt to urinate, any trouble holding coffee, is there a number they can reach the home health nurse, she takes insulin and some pills (doesnt know what they all are) nurse gave her insulin today, Ask paramedics (pt is confused, family and HHN are absent) for infoHPIHard to get d/t pt being confused- Altered Mental Status is the medical terminology for confusionMain task in these patientsDetermine if the cause is life-threatening or notDetermine the cause, in general- Hx of alcohol abuseEmpty liquor bottles near the kitchen sinkWill interact with aspirinShe denies use of alcohol PMHx Diabetic Blood sugar OK HTN Hyperlipidemia CAD/MI Thyroid disease (hypo) Medications Get from slides Lives in an assisted living Lives in assisted living Window of Erwin Mother of John Former smoker- Cincinnati test to assess stroke- Perform Physical examMost cost effective and yields great results- CT scan, alcohol level- you must determine if this is an organic process or if this is a functional psychiatric disorder- DeliriumAn acute state of confusion that often occurs in response to an identifiable trigger (alcohol in this case)- Dementia2/22/14 5:50 PMA progressive decline in intellectual function that affects social and occupational functioning

9/16/13 Red Eye

- CC: red eyeIs it painful?Scleral or corneal abrasionDoes he wear glasses or contactsNumber one infection associated with contacts is pseudomonasWhere do you workDay care, welding, animals- ROSheadaches, vision changes, photophobia, ataxia, nausea and vomiting (d/t/ increased intracranial pressure)- if it is relieved with topical anesthetics it is likely an injured surface structure (i.e. cornea)- visual acuity is a vital sign for the eye- normal intraocular pressure: 10-15, 12-16 (somewhere in that range)increased is indicative of glaucomaeye will be less reactive (will be dilated and sometimes somewhat fixed)loss of a red reflex- hyphemablood in the anterior chamber (head trauma, pts on blood thinners, sickle cell causes additional problems)- Anisocoriadifferent sized pupils can be physiologic but otherwise is indicative of increased ICP, pupillary defect- chemosisinflammation, allergic type reaction swelling of the sclera (self-limitinganti-histamines for treatment- corneal ulcerfluffy white spot- dendritic lesion2/22/14 5:50 PMfrom herpes; vision threatening

9/17/13 - Eye Case Studies

- Case 1 blurry vision, tired, weak, extreme thirsteye exam unremarkablenext step?Check for DMThere are symptoms other than those that affect the eye, but the eye component is a part of that systemic effects of this diseaseBlurry vision d/t diabetic retinopathy (usually takes time to occur)dehydrationThe lens in your eye attracts glucose attraction of water (osmotic pressure/gradient) into lens swollen lensThis will happen whenever the sugar goes high (non-developmental)Acute conditionPre-diabetes = glucose intolerancePlasma glucose between 120 and 200

- Case 2anemia can cause pale/white appearing conjunctivayou pt doesnt have to present with an eye complaint to have a eye-related signs/manifestation of a disease

- Case 3 Bikerforeign bodywhen motorbikers go at high speed, small particles are heading towards them very quickly that can go into the eyehave pt stay very still and use 25 gage needle to pick it outif pt cant stay still, use a swab

- Case 4fundoscopic exam indicates optic disc edemadiabetes doesnt cause optic disc edema/papilledema; also, no thirst, fatigue, increased urination, vision losspseudotumor cerebriincreased CSF pressure (d/t obstruction of flow or overproduction) optic disc edemawill present with non-specific headaches, nausea, vomitingCT head, if negative then do spinal tapCould have viral/aseptic meningitis causing increased ICPSpinal taps will also tell you the pressure of CSF as well as allow you to drain some CSFSpinal taps often cause headaches (spinal headaches); can also cause infections, diskitis, etc.

- Case 5hyperthyroidismexophthalmos presentyou can see the top of their iris

- Case 6CT of head without contrastDont give with contrast, because the contrast can be confused with a bleedAnisocoriaCan be normalCan be due to increased intracranial pressure herniation

- Case 7 Jail fightDo a CT of the head to r/o skull fractureRaccoon eyes are present (indicate skull fracture)

- Case 8Intracranial injury with possible orbital fracture, brain herniation

- Case 9spontaneous subconjunctival hemorrhage (often d/t thrombocytopenia)trauma can cause it8/12/13 8:11 AMnot hyphemia because theres no blood in the cornea

09/23/13 Sorethroat Cases

- basicshistory, history, historydetailed physical examappearanceare they eating, drinking, happy; or do they look miserableknow your anatomy wellrisk stratificationcreate a detailed differential list (most likely to least likely)diagnostic tests, if necessary, that can help in your diagnosisappropriate txmany parents come to office just for antibioticswhen antibiotics are contraindicated, you must educate them as to why- basics of oral examinationlook for redness; area between tonsils and uvula, uvula and toungue; pus; symmetrylook at hard and soft palate for lesions and symmetryuvula can naturally deviate to one side, so ask pt if it is normal for them- Case 1diff dx:viral pharyngitis (adenovirus), mononucleosis, rhinovirus, coronavirus, Influenza virus- Case 2red mucosa, pus from tonsils, swelling closure of throat, uvula in midline but with less space between it and tonsilsexudative tonsillitisif exudate was coming from post aspect of oral area (pharynx) it would by exudative pharyngitisby the bookadenovirus will present with rhinitis symptoms and strep pyogenes will present with abdominal pain, nausea and diarrhea, but in real life pts often present with mixed symptoms (often due to multiple infections)- Case 3diff dxmono, immunocompromised, viral syndrome (flu), incorrect antibiotic prescribed, pt didnt take antibiotic or took it incorrectly, antibiotic resistant agent, acute retroviral syndrome, oral STI, bacteremiaif multiple treatment attempts dont work, take a step back and re-work your differential diagnosisno sports/physical activity until symptoms resolve because of splenomegaly- mono diagnosismonospot testonce youve had mono you will test positive on a monospot test for up to a year (EBV titers), because youve already developed titerslymphocyte infiltration as opposed to PMN and/or macrophage (for bacteria or viruses)- Case 4differential dxmumps, pharyngitis, tonsillitis, viral infection, peritonsillar abscess (most likely bacterial, so give antibiotics)physical findingserythema, inflammation on left side uvula deviated to the right d/t swelling (tonsillar infection in peritonsillar space cellulitis abscess)- basicssymmetryuvula in midlinesig signs on one side vs other (or both)watch out for carotid artery if draining a peritonsilar abscess

- inflammation without pus is cellulitis, but prolonged cellulitis abscesses; do a CT to determine which it is- cut off/re-cap needle so it can only go in a small amount

- Case 5diff dxmeningitis, GI flora, bacteremia, pharyngitis, retropharyngeal abscess (you dont always see during physical exam)confirm via CTlook for tracheal deviation

8/12/13 8:11 AM- your eyes, physical exam, and imaging must confirm the diagnosis

09/30/13 Increased Thirst

- increased thirst (polydipsia)textbook definition: thirst unrelieved by drinking fluidsdrinking more water than normal with a more difficult time quenching ones thirst satietyyoure dehydratedcan signify an underlying diseaseresult of strenuous activitydry mouth

- Case 140 y/o female presents with severe thirst; family members state that she cant stop drinkingwhen did it start, how long has it been going on, how much is she drinking at a time, what are they drinking, what is the urine output like (urinating constantly or not at all), color of urine and is there any smell, relieving or aggravating factors, abrupt or gradual onset, any edema or swelling (do your shoes and rings feel tight or loose, weight gain >5 lbs/week), current medications (type, dose, and freq.), allergies, diarrhea, fatigue, dietary changes (salt intake), blurry vision, fever (brain infection can cause change in set points, blood loss, replacing dead cells requires fluids, could affect kidneys, fevers cause sweating), polyphagia (increased hunger), menstrual cycle (blood loss - menorrhagia), excess facial hair hiursutism or excess lactation (endocrine/pituitary dysfunction), hair loss alopecia, head trauma, GI blood loss, diabetes, liver (cirrhosis inflammation/degradation of hepatic cells; d/t hepatitis, chronic alcoholism, etc. electrolyte imbalances thirst)physical examdry lips, ulcerative/scabbed (means it has been going on)

- anticholinergic toxicity (IN POWERPOINT)

- edema

- skin turgorskin retraction test: pinch the skin on the dorsum of your hand and observe for tenting

- mental status is very important in evaluating a patient with increased thirstpts with hyper- or hyponatremia will have mental status changes, drug toxicity, could be hyperglycemic, psychogenic polydipsia

- main Qspolyuria, polyphagia, weight gain, recent water loss, Hx of acute blood loss, etc.

- main causes of polydipsiauncontrolled diabetes mellitus, diabeted insipidous (can be central d/t vasopressin/ADH depression or nephrogenic kidneys fail to recognize vasopressin/ADH), psychogenic polydipsia, anticholinergic toxicity8/12/13 8:11 AMto distinguish between DM and DI, do urine analysis (electrolytes - K+ and Na+ in particular, low osmolality in DI)

10/7/2013 Endocrine

- Larry BrownO: 6 monthsL: calves (L more than R)D: 7-9 minutesC: Tightness (like a charlie horse)A: running makes it worseA: urinates more freq since starting BP meds (hydrochlorothiazide 4 yrs ago)R: stretching and rubbing the back of the calfT: worse at nightS: 4/10 (feeling more sore at the moment)Diet: regular diet- Spinach has much more potassium than bananas- DifferentialDehydration, electrolyte imbalance, DVT- PMHxHTN, - medicationHCTZ, aleve- NKA- lives with wife and son; smokes pack of cigarettes a day and occasional beer; auto mechanic- what is a crampy, deep pain in an extremity after exercise caused by HCTZ and relieved with rest calledclaudication- Next stepget a D-dimer to check for DVT (if a woman is present she will always be D-dimer positive)BMB, urinalysis- step needed to confirm diagnosis- most urgent next stepEKGWill detect hyper- and hypokalemia- % body water in a 40-60 yr old is 55%- you can diagnose rhabdomyolysis if you find myoglobin in the urine- excessive amounts of running can cause compartment syndromemyelin breakdown, edema, rhabdo, - hypercalcemia does not cause leg cramps (hypomagnesemia, hypokalemia, and hyperphosphatemia do)- people on HCTZ lose Ca2+- read article posted on blackboard- quiz on Thursday (hypokalemia and hyperkalemia)8/12/13 8:11 AMknow clinical findings and treatments

10/21/13 Joint Pain

- 44 y/o male presents to the PMDs office with knee painOLD CAARRTS, one or both knees, what part of the knee, does it always hurt or does it come and go, what makes it worse (maybe give him suggestions like when going upstairs or downstairs or running), if nothing makes it better include the questions you asked/possible things that they tried to help it (i.e. meds, ice, rest), MOI (mechanism of injury), associated sound/pop, any rash associated, previous injuries or surgeries, recent infection/illness (i.e. diarrhea), if pt is older (74) cancer is a possibility (colon, lung and prostate are most common, hip pain gait compensation/abnormality dysfunctional knees, falls, osteoporosis,), if pt is younger (playing sports, growing pains, Osgood schauders/tibial epophysitis)- locationUnilateral (trauma) vs bilateral (systemic response)Anterior (Osgood schlauters, patellar tendonitis and dislocation) vs. medial (MCL, medial meniscus) vs. lateral (LCL, fibular head, IT band) vs. posterior (

DVT, bakers cyst)- McMurray is the test for torn meniscus- neer and hawkins are for rotator cuff injuries- pes anserineSartorius aids in knee and hip flexion, as in sitting or climing; abducts and laterally rotates thighIt means goose foot- trauma to kneeACL, PCL, LCL, MCL, meniscus injury, patella dislocation, fracture, sprain, subluxationDo a thorough history so that you dont always have to do an X-ray- infectionstrep throat, septic joint, lyme, cellulitis, osteomyelitis- inflammatoryarthritis, bursitis, hemophilias, rheumatoid arthritis, sickle cell, lupus, gout (vs pseudogouts)- ReferredSCFE (slipped capital femoral epiphysis)The ice cream is sliding off the cone (anatomical L on Xray slide)Very common in fat adolescent boys- VascularDVT- X-ray of kneejoint space is wider on lateral side (tibial plateau fracture)-X-ray of two kneesR knee has osteoarthritis- X-ray of kneeman comes in after shoveling knee painpatella is normal (it is usually above the knee joint space)osteoarthritis on tibial plateau (normal in older people) visible as increased opacitypt has fluid in his thigh (bursa is inflamed or there is inflammatory fluid leaking out of the joint space)physical exam will reveal a very inflamed kneewhat pain med would you givemorphine sulfate (will allow you to manipulate the joint to take an x-ray or provide treatment)- When draining a knee dont walk the syringe along the posterior border of the patella boneif you need to use multiple syringes, you can leave the needle in the knee while changing out syringes (fluid will be milky/non-clear if fluid is not normal (will be clear if normal)insert syringe at upper 1/3 mark of patellagive superficial and deep anaestheticsend fluid for culture (tests for organisms); microbiolook for WBCs (cytology) indicates infectionlook for gout crystals (chemistry section)pseudogout: sodium pyrophosphate?gout: sodium ureate?- when is it appropriate to give a steroid injection in the knee8/12/13 8:11 AMwhen there is just an inflammatory reaction in the knee (no infection, etc.)

10/23/13 Rheumatology

Dr. Weinerrheumforimprovement@yahoo.com

disease modifying drugs in rheumatoid arthritisSLEautoantibodiesRheumatoid arthritisDifferential dx of acute inflammatory oligoarthrisisOsteoarthritis

- muscles, joints, and rheumatic diseases (100+ diseases)- requires a good Hx because tests exist with very high sensitivity (i.e. MRI) so if you dont know what youre looking for youre going to be lost- Diarthrodial jointstwo bones with cartilage, surrounded by a capsule that is filled with synovial fluidmost pathology occurs at the articular surface, which is covered with articular cartilage (lubricates, pads/softens blow/absorbs shock)- Initial characterization of arthritisacute or chronicnumber of joints involved: monoarticular, oligoarticular (2-4), or polyarticular (5+)symmetric or asymmetric; additive or migratory (hurts in one joint for a couple of hours then moves to another joint)accurate delineation of joints involvedinflammatory (swollen, red, painful joint) or non-inflammatoryis it d/t an infectionjust because a certain area hurts doesnt mean that there is a dysfunction in that area; so Hx is importanti.e. shoulder pain could be d/t spinal nerve impingement, synovitis, bursitis, etc.i.e. hip pain/dysfunction can originate in posterior, groin, or knee- acute onset of one joint (monoarticular arthritis), think inflammatorymultiple joints, chronic onset, think of something like a tick bite lyme diseasespondyloarthropathies - Differential diagnosis of chronic noninflammatory monoarthritisosteoarthritiseveryone will develop this at some time (generally after 50)internal derangementsrefer to tendons and cartilagei.e. torn meniscusosteonecrosisthe bone diesd/t trauma, steroid useneuropathic (charcot) arthropathycauses pain in the joints- common cause of acute monoarthritismust always be concerned about a septic arthritis (i.e. staph, strep, gonococcal, gram neg., etc. make enzymes that degrade cartilage)severely painful joint, they have a fever, may be an inciting event, immunocompromised individualspeople with rheumatoid arthritis have a high risk of developing a septic jointgout (crystal-induced arthritis)increasing in incidence d/t hyperuricemia crystallization in joints phagocytosis by macrophages release of chemical mediators inflammation/crystal arthropathysecondary to poor dietgout (monosodium urate crystals) vs pseudogout (calcium pyrophosphate dehydrate crystals)more common in men (30-40), incidence in women increases after menopausehemearthrosis d/t traumad/t anticoagulants- Differential diagnosiss of chronic inflammatory monoarthritisLymes diseaseCommon in Lyme, CT; MN; WI- Differential diagnosis of acute polyarthritisSLEespecially in young womenskin rash, photosensitivity, reynauds phenomenonacute viral infections Hepatitis C (can positive rheumatoid factor)Parvovirus (children have rashes, adults dont; joint pain; looks like a hand slapped your face type or rash)Paraneoplastic polyarthritis (away from the malignancy the body has a rxn to the cancer cells, i.e. SIADH d/t small cell lung cancer)SarcoidosisAcute presentation, Locran? syndrome; erythema nodosum (inflammation of fatty tissue deep in sub-Q, pretibial, red lesion on legs) and hilar adenopathyStill disease (adult onset)Juvenile rheumatoid arthritis for adultsPresents as a fever of unknown origin (going on for 5+ weeks); many possible causesTemp spikes one time per day, joint pain, salmon colored rashAll other tests are neg. (i.e. Ig, etc.)Macrophage activation syndrome is a sequelae that has high mortalitySystemic autoimmune diseases and vasculitidesVascular problems that joint pain- Differential of oligoarthritisbacterial endocarditisfever, multiple aches and pains, heart murmurankylosing spondylitisHLA-B27Psoriatic arthritisThe skin disease (psoriasis) can hide (behind ears, in anal cleft, etc.)Asymmetric, causes sausage-shaped inflamed jointInflammatory bowel diseaseUsually a knee of ankleSimilar for ulcerative colitis or crohns disease (joints are often innocent bystanders/sequelae of other diseases)- Palpable purpura is indicative of vascular disease- Joint issues have many causes to them and can manifest in many different areas of the body- fever and arthritisreactive arthritis in many dysentery causing bugs- hydralazine, propanaline can cause a state that looks like lupus- synovial fluidhas nutrientsshould be clearsynovial fluid clarity is determined by the number of WBCs (will cause the fluid to be turbid)- Synovial Fluid ClarityClass I: Rheumatoid arthritisClass II: inflammatory (mild)Class III: infected/septic (severe; purulence)Hemorrhagic: pt may be on too much blood thinner2/22/14 5:50 PMGO TO SLIDES (STARTS AT 21)

12/9/13

- if you ever have a pt that is diaphoretic, it is not good; you cant fake iteven worse if theyre cool, pale, and diaphoretic (it means theyre in shock)- CPR and defibrillating when heart isnt beating8/12/13 8:11 AM-

Medical Ethics in Islam- if someone has no function other than being able to breathe on their own, they are not considered dead- if the person isnt breathing on their own and if there are no signs of life, then it is okay to stop life support (life support; even if the heart is beating)- if someone has a terminal condition and a new, life-threatening condition arises, it is okay to refuse treatment because they will eventually die anyways and it would just be postponing the inevitable- Against abortion (unless the mothers life is in danger, if the child is a product of rape or incest first ? days - or if child has a condition that is incompatible w/ life must be in first 120 days)- contraception is okay, so long as it isnt permanent (i.e. tubal ligation, etc.) unless the persons life is in danger- artificial insemination is only permitted if it preserves the lineage of the marriage (no sperm or egg donors, but in vitro fertilization is okay)surrogate mothers discouraged- adoption is highly encouraged for couples who are unable to have children (the child is supposed to keep their last name to preserve their lineage)maintenance of lineage is very important marriage is meant to preserve lineages- elective plastic surgery is NOT allowed, but if it is medically necessary or as a result of some trauma (burn, etc.) then it is allowed

Medical Ethics in Judaism- agrees with Islam with most all subjects- we see ourselves as being made in the image of God and are supposed to live trying to live as he wouldyou shall be holy for I, the lord am holy- choose life (the gift and the curse, life and death Deuteronomy)the preservation of life is the most important commandment (3 exceptions)murder (you should die rather than do it)incest and adultery (you deserve to die)an example of idolatry to the community- to save a life is to save the whole world- Life supportif the person is dead before you put them on life support, then removing it is not killing them, because they were already dead prior to its application- End of lifeold definitions/requirementscessation of heart beat (visual or audial)cessation of breathingthere was no permission for organ transplantation from a brain dead individualNew definitionsIf someone is brain dead, there is no spontaneous heart beat, so they are considered dead and can donate organsPeople are supposed to be buried whole, but since the organ transplants save lives, they are permitted- DNRsname has been changed to no emergency CPRpreserves the patient name so theyre not referred to as DNRwe keep the pt alive as long as possible, until the medical professionals determine that there is no real life and that the person can not be resuscitated (2 examples)Sve Merat: someone who is dying slowly in the hospitalSomeone who is going to die in the next hour- body should be buried whole in the earthautopsys used to be prohibited because it involves mutilating the body, but the stance has changed because the knowledge that can be attained from performing the autopsy can save lives (you cant do an autopsy if its exploratory)- Continuity of life is paramount- contraception and abortionsimilar to Islamif mothers life is in dangerPreservation of life is paramount- plastic surgery not a problem- saving life takes precedence over everything (including Sabbath, restrictions of food/kosher, etc.)- everything that you do should have a medical goal, so if there is no beneficial outcome to your treatment, you shouldnt do it

Christian (Protestant)- Body, mind, and soul are good (there is no one precedent over the other)you always try to affirm all three aspects; however, in medicine, there is often a give and take between these three - I am more than my body, but my body is part of the more that is mequote of paraplegic woman who refused to be a poster-girl for stem cell research, because she felt it would reduce her to her body- Glyduridepancreatic stimulant that can cause hypoglycemiashouldnt diminish quality of life, even in diabeticsyou just have to monitor it a little- Prozacreturns brain chemistry to normal, but takes away from a pts ability to express themselves (saves the body but diminishes from the soul)- They believe that they should love God with all of your mind, body and soul (the affirmation of the three main qualities)loving yourself, others, and God are encompassed in any one act of lovemake sure your medical decision maximizes their lovehave a conversation between the practitioner, pt, family, pasture, and God to choose a course of treatment that will maximize this trio of qualities- you must determine if life after death is better than what life currently is when trying to come to a decision on treatment- They believe that God can heal and some people want to do everything that they can to make a person well; but, you must confront the reality that death will comehelp them deal with pressing and important issues- a reasonable chance of success of a treatment must exist when determining a course of action in end of life caresuccess must be defined from the perspectives of the physical, pt, and familyyou should give them all information so that they can make a decision as to what will be best for their whole body

Roman Catholicism- hierarchical organization- the Holy father pope is infallible only in matters of faith and morals- life begins at conception and must be protected and respected absolutely from that moment onwardsagainst procured abortions of all kindschurch does not judge or condemn the mother or abortionist, but reaches out to extend their gods mercy towards themstem cell research is prohibited (because it destroys the embryo)adult stem cell and umbilical blood use is okay- Euthanasiamorally unacceptablethose whose lives are diminished or weakened should be respected and helpedEXCEPTIONIf medical intervention is futile, it is okay not to proceed with further treatmentThis does NOT include hydration and nutrition, which may NEVER be withheld in order to hasten death- organ donationokay after deathokay for a living person so long as it doesnt mutilate the body (i.e. eyes)- Afterlifethose who die in Gods grace, but imperfectly purified go to purgatory- the church condemns nobody, because only their god knows the state of their soul at deaththe church provides a sacrament at death to assist in the passing over into eternal life- the church tends not to make medical decisions, it will make its stance on certain medical conditions and treatments known, however

Religion and End of Life Care Issues8/12/13 8:11 AM- when asked if treatments are futile by a dying pts family, the physician should never say its up to you. It is up to the physician to educate them and help them to make a decision based on the medical state of the individual

8/12/13 8:11 AM

Odynophagia painful swallowing

Motility both solids and liquidsvariable presentation -acutely-chronic-after stroke-achalasia common on boards

In clinical practice rarely jump straight to barioum swallow. Pt having motility issues catn swallow!Boards -> barium swallow

Odynophagia KNOW, esp infectious causes!!! Test ?

Endoscopy will not help diagnose a motility problem, duh

pH helps to confirm non-GERD diagnosis

GERD:***Lifestyle changes are first line Tx. Least cost and most effective KNOW specific lifestyle changes that have been proven effective aka those on slide

Clinical Dx:Teat w PPI, if they get better, they have GERD

Proceed to GI doc if PPI s fail or pt has alarm Sx wt loss, FE def anemiapH testing useful to confirm NON-gerd Dx

Functional disorder=IBS

PPI keeps Barretts from progressing further

***BARRETTS Esophagus -slideHALO = radiofrequency ablation

GERD TxKnow PPI side effects bc we are responsible for adverse effects on ptsThese lifestyle mods less successfulLINX: magnets act as LES

Infectious EsophagitisHSV: often in immunocompromised but can affect healthy people

IMAGES:Top left candida biopsy top layerBottom left: CMV biopsy center - starts with C organism in CenterBottom right: HSV biopsy margin of uulcer

(Alendrolatre for osteoporosis)

Caustic Injury is a risk factor for squamous carcinoma which rare in esophagous

Mallory Weiss tears: alcoholics, bulimia

**Eosiniphilic EsophagitisYoung pt long hx allx asthmaProgressive dysphagia, food impactionFurrowingHistologoic Dx > 15 eosinophilsMust tx underlying issue: Flucacortisone, PPIs

Rings = corrugatedFurrowing = lines/grooves

Plummer vinson: common on boards

Zenkers: at Killians triangle(upper esophagus)Old undigested food in throat, may wake up with food on pillow etc

Neoplasms:Most common Leiomyoma

E ultrasound to dx

Esophageal varices -usually with portal htn-cirrhosisrupture->bleeding presents emergency

If you dx cirrhosis check for eso varices

Achalasia motility BOARDSWill try to confuse us on boards not hyperactive LESLook for aperistalsis, and LES FAILS TO RELAXOlder ppl with gradual onset progresvive dysphagiaBIRDS BEAK on esophagramBottom right: huge dilated esophagus

Commonly: Idiopathic, Chagas,

ANNA-1 may be on boards

Poor surgical candidates = commonly elderly

Heller myotomy The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact.

Bonus questions: will not be on testUpper(white) from FA 2013Obestity or GERD do not lead to cancer but obesity -> GERD -> Barretts -> carcinoma

Achalasia is a risk factor for squamous CA

Bottom othercauses sq CA esophagus- Caustic causes swalling lye8/12/13 8:11 AM

Alcohol direct toxin, drinking causes gastritis EXTERNAL Burn injuries very severe (curling ulcers)

Sever abdominal pain usually not gastritisGastritis by itself often doesn't cause bledding. Need ulcers, tear etc

(Sulcrafate = agent used during codes)

Best way to prevent gastritis = EAT, food absorbs acid/irritants

PPI gtt = PPI drip, usually in hospital setting

Portal HTN gastropathyChronic GI bleedingWatermelon stomachGAVE image= red lines = bleeding, looks like watermelon

***H pylori know slidesMust treat if Dx bc it leads to gastric adenoma, MALTomaBreath test in clinical practice more frequently used to confirm eradication

Stool Ab about 90% sensitiveSerology not helpful for dxHistology = gold standard for dx

Pernicious anemia + B12 def could be caused by carcinoma

B12 def in healthy person should always raise suspicion-takes years to deplete liver stores

Menetrier Ds BOARDS

Anasarca edema all over body often from protein deficiency

Biopsy margin of ulcers >2cm

Gastric

***PUD (particularly slide before PUD causes?)

Gatrinoma: Old pt, chronic diarrhea, PUD

Cimetidine: inhibits P450, many interactions warfarin, coumadin

Unusual Ulcers:Camerons: as stomach gets pulled back and forth in LES it rubs diaphragm

ZE: multiple duodenal ulcers

Duodenal ulcers: common unusual cause celiac

Complications (may be test question)

Reccurent ulcers -> inflammation->obstruction-pylorus is normally only 5mm, esily blocked with excessive inflame

ZE:Gastinoma: older, wt loss, chronic diarrhea -> do a secretin test (rise in gastrin >200 suggests ZE)image: diffuse ulcers throughout duodenumglucagonoma(in pancreas) may present with low glucose

Other causes high gastrin levelObstructionVagotomy vagus nerve cut during stomach surgxrenal failure gastrin no longer cleared at normal rate

***Benign Neoplasm of stomach - SLIDEchronic PPI use

Gastric CAIntestinalH pyloriSmoked food, menetrier, atrophic gastritisDiffuse:Much worseSignet rings on biopsyLinnitus plstica thick leathery

Testable stops at Gastric CA imageIBS All tests come back normalOften presents when under stress

Bonus questionsLab abnormality upper gi bleed: on CMB -> high BUN, with normal creatinine Blood makes nitrogen, normal kidney function

Abd pain, normal lipse(marker for pancreatitis), elevated amylase: duodenal ulcer could be aggravating pancreas

Gastric mass w spindle cells?: GIST, gastrointestinal tumor

Inhibition other than H2 blocker or PPI? acetylcholineGASTRITIS and Gastroenterology8/12/13 8:11 AM

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