3 “Foto navegable”
3.3 Análisis de las herramientas a utilizar
effect immediately. Long term tx: SSRI or TCA with cognitive or behavior therapy. ALSO according to Valia, Panic attack is assoc with Mitral Valve Prolapse. ***Of the 2 drugs for PA: Alprazolam has a Seizure attack due to withdrawl that happens in a few days of not taking the medication. But Diazepam, does not give you
seizure that quickly. So if pt comes with Seizure and didn’t take panic drug for a few days Alprazolam is the drug. ****Pts suffering from Panic dz are at increased risk for DEPRESSION, agoraphobia, GAD and substance abuse.
PARANOID PERSONALITY:
Cluster A (odd, eccentric), distrust and suspicious to others. Negatively interpret actions and words. Hold grudges for long time.
PARALYTIC ILLEUS
Absent bowel sounds with gaseous distention of both small and large bowels are indicative.
PARANEOPLASTIC SYNDROMES (PNS)
Hypercalcemia is the MCC of PNS (confusion, lethargy, fatigue, anorexia,
constipation, polyuria) it is assoc with Squamous cell carcinoma of the lung . The classical pathophys responsible for hypercalcemia of the malignancy is the
production of PTH-related peptide (PTHrP), which is homologous with PTH. Serum Ca is Increased and Phosphate is decreased *****Myopathy in assoc with PS: PS can manifest as muscular weakness. Proximal muscles are typically affected and strength is diminished symmetrically. Reflexes are normal and no sensation abnormality is detected. Elevated CK and myopathic EMG help to confirm Dx. Pathology in PS is in the muscle membrane, in MG is in Postsynaptic membrane, and in Lambert-Eaton is in the Presynaptic membrane.
PARENCHYMAL BRAIN HEMORRAGE
Always suspect it when pt has hx of uncontrolled HTN and then presents to ER unconscious with focal neuro signs.
PARINAUD'S SYNDROME
Consists of paralysis of vertical gaze that maybe assoc with pupillary disturbances and eyelid retraction (Collier sign). MCC by Pinealoma. Pt (10 yo) presents with facial hair and 2ary sex characteristics, plus vertical gaze and Collier sign. DDx: Craniopharyngioma that does not cause the Collier sign.
PARKINSON’S - 2
The most effective symptomatic therapy is L-Dopa. *** 1ST Drug for tremor and rigidity is Benztropine. *****assoc with Seborrhea dermatitis.
PAROXYSMAL SUPRAVENTRICAULAR TACHYCARDIA Test-1, Q-43. See picture. DOC is IV Adenosine
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH)- 2
A red cell membrane defect causes increasing binding of complement to the red cell à increased intravascular hemolysis resulting marked anemia. Since RBC is more
susceptible to hemolysis in acidic environment and serum is more acidic at night, lysis occurs at night and morning urine shows red urine. Thrombosis of Hepatic vein is a CC of death. Lab: Increased LDH, bilirubin and reticulocyte. Test specific to PNH is sugar-water test and the Acidified Hemolysis test (HAM test), which determines increased susceptibility to cell lysis by C’. DAF (Decay Activating Factor) is
diminished in PNH.
DDx1: RBC Enzyme Def (G6PD def): results in sudden hemolysis after drugs or infection.
DDx2: Peripheral destruction of RBC is seen in Hereditary Spherocytosis. ****Is an acquired disorder that should be considered in ALL CONFUSING cases of hemolytic anemia. Hemolysis is intravascular with low serum haptoglobin, and elevated LDH. Urinary Loss of Iron may lead to iron def anemia. Congestive splenomegaly is a complication. BM maybe hypocellular. Flow cystometry is better choice for dx vs. Ham test, it shows absence of CD59.
DDx1: Aplastic Anemia: BM is hypocellular, but peripheral blood smear does NOT show abnormal cells. RBC are normo- or macrocytic.There is NO hemolysis or Splenomegaly. SUGER test is for dx of PNH.
PARVOVIRUS INFECTION - 2
Parvovirus infection involves joint: symmetrical, hands, wrist, knee and feet are mostly affected. Rash may or may not present. Pt has Arthralgias or arthritis, MC in females. Pt presents with pain in small joints, arthralgia and arthritis. **** School teacher gets it. Anti-B19 IgM is the dx of choice.
PASSIVE AGGRESSIVE BEHAVIOR
An immature defense which an individual expresses aggression toward other person with repeated, passive failure to meet the other person's demand. A secretary won’t let you talk to the doctor because she had an argument with you.
DDx: Acting Out: A child throws a temper tantrum. PATIENT CONSENT
If pt needs transfusion and wife says it’s against his beliefs, go ahead with transfusion. Now if Pt himself is awake and tells you that he doesn’t want transfusion then you use other alternatives, Plasma.
PCP toxicity 3 Poison 6/3
Characterized by violence, vertical nystagmus, confusion, ataxia. DDx: Cocaine: causes tachycardia, HTN, sweating, mydriasis.
****LSD is like PCP but agitation and aggression is worse in PCP. Visual Hallucinations (Flashbacks) are hallmarks of LSD.
PEDIATRIC CNS TUMORS
Infra-tentorial tumors are more common. MCC type: Benign astrocytomas. MC solid tumor: CNS tumors and are 2nd MC malignancy after Leukemias. 2nd MC tumor in posterior fossa: Medulloblastoma, 90% arise from Vermis.
PEDIATRIC IMMUNOLOGY:
IgG and IgA and poor specific response to immunization. HIM presents with recurrent sinopulmonary infections and PCP. The unique susceptibility to opportunistic infections and neutropenia
DDx: it from XLA and other conditions.
2-Bruton’s X-linked Agammaglobinemia: characterized by 4 findings, a) Onset of recurrent bacterial infections in 1st 5 years of life, b) IgG, IgM and IgA are very low, c) Poor response to vaccination, d) <2% CD19+ B cells in peripheral
circulation.
3-Common Variable ID: presents low IgG, IgM and IgA levels, but normal B cells. Clinically they present with recurrent sinopulmonary infections like XLA. Most pts don’t become symptomatic until 15-35 yo.
4-Selective IgA deficiency: MC well-defined ID disorder. Infections occurs
predominantly in respiratory, GI and U-G tract. Serum concentrations of other Ig are normal. Dx is IgA <50 with no other immune defects.
5-Selective Subclass IgG Def: Recurrent infections despite normal IgG levels. 6-Severe Combined Immunodeficiency (SCID): is a life threatening synd. Presents w/recurrent sinopulmonary infection, oral candidiasis, persistent diarrhea,
opportunistic and viral infections. Dx: Absent LNs and tonsils, lymphopenia, and abnormal B & T cells. CXR: Absent thymic shadow.
7-Wiskot Aldrich Syndrome: is an X-linked recessive, caused by a defective gene encoding for WAS protein. Classic presentation: young boy with eczema,
thrombocytopenia, and recurrent infections w/ encapsulated bugs. Initial
manifestation: At birth: petechiae, bruises, bleeding from circumcision, or bloody stools. Low IgM levels, high IgA and IgE levels reduced T cells and platelets.
8-Chronic Granulomatous Disease: a defect of phagocytic cells, due to dysfunction of NADPH oxidase enzyme complex, leading to recurrent and uncontrolled
infections w/catalase positive organisms (Staph, Serratia, Klebsiella, Aspergillus) and not susceptible to catalase negative (Strep and H Influenza). MC infections: are lymphadenitis and abscesses of skin and viscera. Lymphocytes are normal. Dx is by Nitro Blue Tetrazolium test. Tx is prevention: DAILY TMP=SMX & Gamma Interferon 3x/wk BMT is Curative.
9-Transient Hypogammaglobinemia: Characterized by decreased IgG levels, normal IgA levels, and variable IgM levels. These Igs normalize by 6-11 month of age. 10-Di-George Syndrome: Typical of an infant with hypocalcemia seizures. Pathology is defect of 3 & 4th pharyngeal pouch leading to hypoplastic or aplastic thymus and parathyroid glands.
11-Chediak Higashi Syndrome: characterized by decreased granulation, chemotaxis. It’s a multi-system disorder: peripheral and central neuropathy, hepatosplenomegaly, pancytopenia, **partial albinism, infections w/aureus. Dx: finding neutropenia and giant lysosomes in neutrophils.
Tx is prevention: DAILY TMP-SMX and daily ascorbic acid.
12-Leukocyte Adhesion Defect: result from failure of innate host defenses against bacteria, fungi due to adhesion targeting. Pt has hx of delayed separation of umbilical cord, recurrent bacterial infection, necrotic skin lesions, severe gingivitis. 13-Job’s Syndrome or Hyper IgE syndrome: Chronic pruritic dermatitis,
recurrent Staph infections (resp and skin), markedly elevated IgE, eosinophilia and coarse facial features.
PEDIATRIC JAUNDICE
1-1 ST 24 hrs : requires immediate attention, maybe due to erythroblastosis fetalis, concealed hemorrhage, sepsis or infection.
2-2 ND & 3RD day : is usually physiologic.
3-3 RD day to 1 week : suggests bacterial sepsis or UTI and requires prompt and aggressive attention. Sepsis in neonate rarely causes neck stiffness or boging frontal or shock. Clues: Poor feeding, lethargy, vomiting, or alteration of activity. MERCK: Diminished spontaneous activity, less vigorous sucking, apnea,
bradycardia, and temperature instability (hypo- or hyperthermia) are particularly common. Fever is present in only 10 to 50% but, when sustained (e.g., > 1 h), generally indicates infection. Other symptoms and signs include respiratory distress, neurologic findings (e.g., seizures, jitteriness), jaundice (especially occurring within the 1st 24 h without Rh or ABO blood group incompatibility and with a higher than expected direct bilirubin concentration), vomiting, diarrhea, and abdominal distention. Anaerobic infection is often indicated by foul-smelling
amniotic fluid at birth.
The first step is to do a blood culture and a lumbar puncture. PEDIATRIC MENIGITIS
1-Group B Strep: MCC meningitis in infants. Usually acquired from mother during childbirth; no rash and very unlikely for a 18mo child.
2-Meningococemia: Suspect it in a neonate with petechial rash: trunk, wrist, ankle (75%).
3-H. Influenza: 6-48mo, no rash involved. Antigen is in CSF.
4-Listeria: Meningitis in newborn vaginally, NO rash. Another mode of transmission is unpasteurized milk.
MC in DM mothers.
5-Aseptic: Always viral cause. CSF shows: lymphocytosis, WBC<250, protein <150 and normal glucose. Typical pt: Alert and cooperative but uncomfortable and ill. ****
1-Newborns: Group B Strep(70%), then Listeria (20%) and S. Pneumonia (10%) 2-One month to 2 years: S. Pneumonia (50%), Neisseria (30%), Group B Strep (20%).
3-2-18 years: Neisseria (60%), S. Pneumonia (25%) and H Influenza (10%). 4-Adults >18yo S. Pneumonia (MCC) 60-70%.
PEDIATRIC RHEUMATIC FEVER
Suspect in children with low grade fever, pericarditis, sore throat, arthritis, chorea, and subcutaneous nodules, erythema marginated, elevated ESR and prolonged PR. Caused by GA Strep. Dx: 2 major or 2 minor and 1 major Jones Criteria. 5 major criteria PECCS (Polyarthritis, Erythema marginatum, Carditis, Chorea,
Subcutaneous nodules) and 3 minor FAR (Fever, Arthralgia and Previous RF). Tx: Benzathine Pen G. If (+) chorea, give antiepileptic, (+) Pericarditis give
salicylates, and (+) Arthritis give codeine. PEEP - 2
Positive End Expiratory Pressure: Development of positive pressure inside the thorax resulting in decreasing venous return. Decreased venous return leads
to decreased cardiac output, which ultimately leads to hypotention. The increased ventilate rate causes development of auto PEEP by not allowing enough time for expiration. Thus, the ventilator delivers a tidal volume, in addition to that is still in the lung at the end of the expiration, which is already inside the lung. This produces positive pressure.
***The most appropriate step: when Hypotension happens is to decrease the respiratory rate, to allow the lung to deflate in b/w respirations. ****When PEEP is increased its major drawback is decreased CO. Pts who are maintained on PEEP should be monitored with Swan Ganz catheter. PEEP has no direct effect on Systolic BP or Systemic Vascular Resistance. ****If Tidal Volume is too high, 800, REDUCE Pressure support and INCREASE ventilation rate not to increase pCO2.
PERITONSILAR ABCESS - 2
Fever, sore throat, dysphagia, trismus (inability to normally open mouth CN V), pooling of saliva and muffled voice. Management: Needle drainage (in
trendelenberg position) close monitoring and IV antibiotics. PELLAGRA
***** MC corn diet, also Alcoholics people w/ Carcinoid tumor. Characterized by 4Ds: 1-Diarrhea, Dementia, Dermatitis, (skin rash in sun exposed areas) Death.
PELVIC ABSCESS
Percutaneous drainage is the procedure of choice. If it fails then Laparotomy with debridement and drainage is indicated.
PELVIC TRAUMA:
XR do for ALL pt w/trauma to pelvis to screen for pelvic injury. Not CT. PEMPHIGUS VULGARIS Derm 6/3
Mucocutaneous blistering with flaccid bullae, with IgG deposits in intracellular in dermis. Autoantibodies against desmogelin. 1ST see in Oral mucosa. Easy separation of epidermis on superficial pressure (Positive Nikolsky sign) is characteristic. Tx: steroids.
DDx: Bullous Pemphigoid: Tense blisters, IgG and C3 in dermal-epidermal junction.
PENILE FRACTURE:
From women on top. Surgical exploration (tx of choice) but it should always preceded by retrograde urethrogram to r/o urethral injury
PEPTIC ULCER DZ - 3
If perforation occurs the 1 ST step : Upright abdominal XR. Now although the symptoms might suggest that pregnancy is a DDx, 1ST do XR to r/o the most dangerous possibility. ***** PUD can lead to gastric outlet obstruction, unceasing vomiting and dehydration resulting in Hypochloremic Met Alkalosis à Tx:
0.9%NaCl. This kind of Alkalosis is usually accompanied with HypoKalemia. K+ Supplementation is indicated whenever NG suction is done, Tx: Potassium
Chloride. ****MC complication is Hemorrhage. ***PUD causes: Sudden onset of severe epigastric pain that spreads to the whole abdomen, and upright filmsà AIR UNDER DIAPHRAGM.
DDx: Cholecystitis and Diverticulitis: NO sudden onset and short clinical course. DDx: Biliary Cholic: More localized pain w/o rebound.
PERICARDIAL CYST
Diagnosed with CT. Located at the middle mediastinum and are benign. The fluid can be aspirated and the cyst will shrink. Surgery is NOT indicated. Other medial mediastinum masses are Bronchogenic cyst, lymphoma, and aortic aneurysm.
PERICARDIAL TAMPONADE (PT)
Presents: Beck's triad: Hypotension, elevated JVD and muffled heart sounds. DDx: In case of hypotension due to BLEEDING, JVD will be decreased compare to PT or Tension Pneumothorax (TP). In TP mediastinum is deviated, but in PT its not. ****Pulsus paradoxus (NARROW PULSE PRESSURE) is a dx clue.
PERICARDITIS, ACUTE
When combined with renal failure is Nephritic Syndrome that leads to Uremic pericarditis, which is an indication for Hemodialysis. If vascular access is not possible then do Peritoneal dialysis. *****Severe constant pain that localized to anterior chest, radiates to arm, back, shoulder, epigastrium, is intensified with respiration, relieved by sitting up or leaning forward. MCC by Coxsackie virus. A hx of current viral illness is common. EKG shows: 1-Diffuse ST elevation with
concavity at "J" point, 2-PR elevation. Uremia can cause Pericarditis and this may represent an indication for dialysis.
*****Uremic Pericarditis: chronic renal failure pts (10%). UP is an absolute indication for Dialysis. Pericardial fluid in UP is most often Hemorrhagic. Clinical features are same as Pericarditis, but BUN is >60 and anemia. Most pts respond rapidly to dialysis with resolution of chest pain, and decrease in size of pericardial effusion.
*****Once you dx PC the next step: Start Hemodialysis not NSAIDS. Indications of Dialysis:
INDICATIONS of
Dialysis ABSOLUTE indications RELATIVE indications C/I to dialysis 1-Refractory
HyperKalemia
2-Volume overload & Pulmonary Edema not responding to diuretics. 3-Refractory metabolic acidosis (pH<7.2) *Fluid overload not responsive to tx * HyperK not responsive to tx * Refractory metabolic acidosis *GFR<10 *Serum CR <8 *severe uremic symptoms (Seizure & coma are
indication of immediate dialysis) *Debilitating chronic dz *Severe irreversible dementia
4-Uremic Pericarditis 5-Uremic Encephalopathy or neuropathy 6-Coagulopathy due to renal failure
Remember NSAID (sometimes corticosteriods) are 1st line tx for Pericarditis. Also for Pericardial Tamponade Pericardiocentesis is indicated.
PERIPHERAL ARTERY ANEURYSM:
Manifests as a pulsatile mass that can compress adjacent structure (nerve, vein) and can result in thrombosis or ischemia. MC PAA: Popliteal and femoral aneurysms, frequently assoc with AAA. Pt has all the atherosclerotic risk factors.
PERIPHERAL ARTERY DZ
Goal of therapy for occlusive arterial dz of lower extremity: Relieve pain, prevent limb loss & maintain gait. Most pts with Intermittent claudication remain stable with conservative management. Majority should be given exercise and ASA. Over 75% remain stable. Angiogram is not required if there’s no evidence of
ischemia, infection, gangrene or loss of pulse. If surgery is not planned a duplex arterial study may suffice.
PERITONITIS, PRIMARY
Abdominal pain with guarding and fever in a pt with ascites is suspect. Most likely peritonitis 2ND to paralytic ileus. If pt has signs of peritoneal fluid (shifting dullness) then diagnostic Paracentesis is the simplest test to
perform. May reveal signs of Exudate: Turbid fluid >250 Leukocytes, Protein >2.5, Serum to Ascitic albumin gradient <1.1, and Specific gravity >1.016.
PERITONSILAR ABSCESS (QUINSY)
Unilateral sore throat, neck pain, referred ear pain, dysphagia with swollen tonsils, Trismus is characteristic. *****It is a suppurative complication of Acute Tonsillitis. Scenario: a pt with sore throat, dysphagia, trismus, pooling of
saliva and muffled voice. PE: Unilateral and cervical lymphadenitis and deviation of uvula. Management: Needle drainage (in Trendelberg position), close
monitoring and IV antibiotics. PERNICIOUS ANEMIA
PA is the MC megaloblastic anemia. B12 def is caused by intrinsic factor deficiency 2nd to gastric atrophy. There is also basophilic stippling. Dx: Achlorhydria, decreased IF, decreased B12, extremely elevated LDH. ***DDx: Lead poisoning since they both have basophilic stippling. Lead poisoning presents like Iron deficiency anemia, MCV<80.
PESTICIDE POISONING
remove clothes to remove source of poison). PHARYNGITIS, STREP
A 7 yo with fever, erythema of pharynx has Pharyngitis, if Rapid dx test for Strep is positive the Next step: One IM dose of IM Benzathine Pen G, not IV aqueous crystalline Pen G or 10d oral Pen V. If allergy then Erythromycin is used. PHENCYCLIDINE INTOXICATION
Causes psychotic symptoms. PHENELZINE C/I
An MAO inhibitor and is use is C/I with SSRI (Paroxetine). Is called SEROTONIN SYNDROME: hyperthermia, rigidity and altered mental status. Is given to Depressed pts with SIGECAPS. Another SE: Hypertensive Crisis that occurs with wine and chocolate.
PHENYTOIN SE
causes Folate deficiency. (megaloblastic anemia) PHEOCHROMOCYTOMA - 2
Always 1ST give alpha blocker, followed by beta blocker. If you do it the wrong