References Bww
Dluhy RG, Lawrence JE. Williams GH. Endocrine hypertension. In Larsen PR. Kronenberg HM. Melnied S. Polonsky KS, eds. Williams' textbook of endocrinology, l th ed. Philadelphia. WB Saunders, 2003 555-562. O'Connor DT. The adrenal medulla, catecholamines, and pheochromocytoma. In Goldman L. Bennett JC. eds. Cecil's textbook of medicine, 21st ed. Philadelphia. WB Saunders. 2000 1259-1262. Pacak K. Linehan WM. Eisenhofer G, et al. Recent advances in the diagnosis, localisation. and treatment of...
ANSWERS TO CASE 38 Hemoptysis Lung Cancer
Summary A 68-year-old female smoker has coughed up a cupful of bright red blood. For the previous 3-4 months, she has had a chronic nonproductive cough and. more recently, some blood-streaked sputum. She reports increase fatigability, reduced appetite, and unintentional weight loss. She denies chest pain, fever, chills, or night sweats. On examination, her chest reveals scattered rhonchi bilaterally without wheezes or crackles. She has clubbing of the fingers. Next step Chest x-ray film,...
Approach To Hypertensive Emergencies
Hypertensive crises are critical elevations in blood pressure, which usually are classified as either hypertensive emergencies or urgencies. The presence of acute end-organ damage constitutes a hypertensive emergency, whereas the absence of such complications is considered hypertensive urgency. Examples of acute end-organ damage include hypertensive encephalopathy, myocardial ischemia or infarction associated with markedly elevated blood pressure, aortic dissection, and pulmonary edema...
Gallstones
Gallstones usually form as a consequence of precipitation of cholesterol microcrystals in bile. They are very common, occurring in 10-20 of patients older than 65 years. Patients often are asymptomatic. When discovered incidentally, they can be followed without intervention, as only 10 of patients will develop any symptoms related to their stones within 10 years. When patients do develop symptoms because of a stone in the cystic duct or Hartmann pouch, the typical attack of biliary colic...
Approach To Suspected Meningitis
Bacterial meningitis is the most common pus-forming intracranial infection, with an incidence of 2.5 per lO.OOO persons. The microbiology of the disease has changed somewhat since the introduction of the Haemophilus influenza type B vaccine in the 1980s. Now Streptococcus pneumoniae is the most common bacterial isolate, with Neisseria meningitidis a close second. Group B streptococcus or Streptococcus agalactiae occurs in approximately 10 of cases, more frequently in neonates or in patients...
Case 6
A 42-year-old man is brought to the emergency room by ambulance after a sudden onset of severe retrosternal chest pain that began an hour ago while he was at home mowing the lawn. He describes the pain as sharp, constant, and unrelated to movement. It was not relieved by three doses of sublingual nitroglycerin administered by the paramedics while en route to the hospital. He has never had symptoms like this before. His only medical history is hypertension, for which he takes enalapril. There is...
Approach To Polyarticular Arthritis
The first and most important step in evaluating a patient with polyarticular joint pain is determining whether or not synovitis arthritis is present, producing soft tissue swelling, joint effusion, tenderness, warmth of the joint, and limitation of both active and passive range of motion. If the only finding is pain without inflammatory changes, then the diagnostic considerations include noninflammatory diseases such as osteoarthritis OA , fibromyalgia, hypothyroidism. neuropathic pain, and...
Answers Vwg
29.1 A. This young man most likely has a viral meningitis given the modest CSF pleocytosis count with predominant lymphocytes. Given the high RBC count, it may be HSV. so acyclovir should be instituted until more specific testing can be done. However, because bacterial meningitis cannot be excluded based on the CSF analysis alone, empiric antibac-terials should be given until culture results are known, usually within 48 hours. 29.2 D. Tuberculous meningitis is extremely difficult to diagnose,...
Management
The goals of therapy include reductions in cardiovascular morbidity and mortality. improvement in quality of life by decreasing symptoms of claudication and eliminating rest pain, and preservation of limb viability. The first step in managing patients with PAD is risk factor modification. Because of the likelihood of coexisting atherosclerotic vascular disease such as coronary artery disease, patients with symptomatic PAD have an estimated mortality rate of 50 in 10 years, most often as a...
Approach To Hypertension
Essential hypertension Also known as idiopathic or primary hypertension. It has no known cause, yet it comprises approximately 95 of all cases of hypertension. Lifestyle modification A cornerstone in the treatment of hypertension, consisting of regular aerobic activity, weight loss, decreased salt intake, and increased intake of fruit and vegetables, while decreasing the amount of total fat. especially saturated fat, in the diet. Alcohol consumption should be moderated, no more than two glasses...
APPROACH TO PEPTIC ULCER DISEASE Definitions
Dyspepsia Pain or discomfort centered in the upper abdomen mainly in or around the midline , which can be associated with fullness, early satiety, bloating, or nausea. Dyspepsia can be intermittent or continuous, and it may or may not be related to meals. Functional nonulcer dyspepsia Symptoms as described for dyspepsia, persisting for at least 12 weeks but without evidence of ulcer on endoscopy. Helicobacter pylori A gram-negative microaerophilic bacillus that resides within the mucus layer of...
ANSWERS TO CASE 26 Acute Sigmoid Diverticulitis
Summary A 61-year-old man has 3 days of new-onset, worsening, left lower quadrant abdominal pain. He feels nauseated, and he has not had any bowel movements since the illness began. His temperature is 100.2 F and he has no pallor or jaundice. His abdomen is mildly distended with hypoactive active bowel sounds and marked left lower quadrant tenderness with voluntary guarding. Rectal examination reveals tenderness, and his stool is negative for occult blood. The WBC count is 11,800 mm3 with 74...
Clinical Approach 1
Diverticulosis is extremely common, affecting 50-80 of people older than 80 years. Diverticula are, in fact. j.ve i diverticula through a weakness in the muscle lining, typically at areas of vascular penetration to the smooth muscle. Therefore, their walls do not contain the muscle layers surrounding the colon. They are typically 5-10 mm in diameter and occur mainly in the distal colon in western societies. The development of diverticula has been linked to insufficient dietary fiber leading to...
Stages Of Diverticulitis
Stage I Small, confined pericolic abscess Stage II Distant abscess retroperitoneal or pelvic Stage III Generalized suppurative peritonitis from rupture of abscess noncommu- nicating with bowel lumen Stage IV Fecal peritonitis caused by a free communicating perforation diverticular neck, setting up for more inflammation and diminished venous outflow, as well as bacterial overgrowth, which ultimately leads to abrasion and perforation of the thin diverticular wall. It is classified into four...
Clinical Pearls Lks
The two most common causes of atrial fibrillation are hypertension and atherosclerotic heart disease. The other causes can be remembered with the mnemonic 1 SMART CHAP. Acute atrial fibrillation is treated with direct current cardioversion if the patient is unstable. If the patient is stable, initial management is ventricular rate control with an atrioventricular nodal-blocking agent, such as digoxin, beta-blockers, diltia .em, or verapamil. Patients with chronic atrial fibrillation generally...
Causes Of Atrial Fibrillation
Inflammatory disease pericarditis, myocarditis Surgery post-bypass surgery, post-valvular surgery Medications theophylline, caffeine, digitalis Atherosclerotic coronary artery disease Rheumatic heart disease especially with mitral stenosis Thyrotoxicosis Congenital heart disease atrial septal defect. Ebstein anomaly Hypertensive heart disease Alcohol consumption holiday heart syndrome, alcoholic cardiomyopathy Pulmonary disease, especially pulmonary embolus Many patients with AF cannot be...
ANSWERS TO CASE 29 Bacterial Meningitis
Summary A 20-year-old college student presents with a 3-day history of fever, headache, myalgias, and nausea. He has no respiratory or gastrointestinal symptoms, hut now has developed photophobia. He is febrile to I02.3 F. tachycardic. and normotensive. His physical examination is generally unremarkable with a nonlocal neurologic examination but some neck stiffness, suggesting meningeal irritation. He has no skin lesions as might be seen in meningococcemia. Condition most likely concern...
Spun Urine
RED CELL CAST OR DYSMORPHIC RBCs YES SEROLOGICAL TESTS C3, C4, ANA, ANCA, ANTI-GBM ASO HEPATITIS, PANEL. BLOOD CULTURE. Cryoglobulin GLOMERULAR IMMUNE COMPLEXES GRANULAR IF STAINING CIRCULATING ANTI-GBM LINEAR IF STAINING NO LUNG LUNG INVOLVEMENT CIRCULATING ANCA PAUCITY OF IF STAINING POST-INFECTIOUS GN ASO INFECTIOUS ENDOCARDITIS Cryoglobulin - HEPATITIS C B MPGN NORMAL C3 C4 ANTI-G BM GN ANTIBODY-MEDIATED i IgA IMMUNOSTAIN PRIMARY GN SYSTEMIC VASCULITIS
ANSWERS TO CASE 13 Cirrhosis Probable Hepatitis C Related
Summary A 49-year-old woman presents with new-onset abdominal swelling. Her history reveals a blood transfusion with postpartum hemorrhage and cocaine use. On examination, her temperature is I00.3 F, heart rate 88 bpm, and blood pressure 94 60 mmHg. Her sclerae are icteric. Her abdomen is distended, with mild diffuse tenderness, shifting dullness to percussion, and a fluid wave, consistent with ascites. She has no peripheral edema. Laboratory studies show the following levels Na 129 mmol L,...
Clinical Pearls 1
Congestive heart failure is a clinical syndrome that is always caused by some underlying heart disease, most commonly ischemic cardiomyopathy as a result of atherosclerotic coronary disease or hypertension. Heart failure can be caused by impaired systolic function ejection fraction lt 40-45 or impaired diastolic function with preserved systolic ejection fraction . Chronic heart failure is a progressive disease with a high mortality. A patient's functional class, that is, his or her exercise...
Selected Causes Of Congestive Heart Failure
Myocardial Injury Adriamycin Alcohol use Cocaine Ischemic cardiomyopathy atherosclerotic coronary artery disease Rheumatic fever Viral myocarditis Chronic Pressure Overload Aortic stenosis Hypertension Chronic Volume Overload Mitral regurgiation Infiltrative Diseases Amyloidosis Hemochromatosis sonic beta-blockers, such as carvedilol, metoprolol, or bisoprolol, have been shown to reduce mortality in patients with impaired systolic function and moderate to severe symptoms. In patients who cannot...
Causes Of Hyponatremia
3. Posttransurethral resection of prostate bladder tumor Primary Na loss secondary water gain 1. Integumentary loss sweating, burns 2. Gastrointestinal loss vomiting, tube drainage, fistula, obstruction, diarrhea 3. Renal loss diuretics, osmotic diuresis, hypoaldosleronism. salt-wasting nephropathy, postobstructive diuresis, nonoliguric acute tubular necrosis A. Primary water gain secondary Na loss 2. Decreased solute intake e.g beer potomania 3. AVP release as a result of pain, nausea, drugs...
Clinical Manifestation
Critical coronary artery sterosis gt 70 Unstable platelet thrombus on ruptured plaque Platelet thrombus begins to form and spasm limits blood tlow at rest Transient or incomplete vessel occlusion lysis occurs Non-ST elevation myocardial infarction Platelet thrombus on ruptured plaque Complete vessel occlusion no lysis There are no specific physical findings in a patient with an acute MI. Many patients are anxious and diaphoretic. Cardiac auscultation may reveal an S4 gallop, reflecting...
References Ihc
Daroff RB. Carlson MD. Nervous system dysfunction Syncope, faintness, dizziness, and vertigo. In Kasper DL. Braunwald E, Fauci AS, et al, eds. Harrison's principles of internal medicine, 16th ed. New York McGraw-Hill, 2005 126-133. Gregoratos G. Abrams J, Epstein AE. et al. ACC AHA NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices Summary article A report of the American College of Cardiology American Heart Association Task Force on Practice...
Serologic Markers Of Glomerulonephritis
Complement levels C3. C4 low in complement-mediated GN SLE. MPGN. infective endocarditis, poststreptococcal postinfectious GN, cryoglobulin-induced GN Antineutrophil cytoplasmic antibody levels p-ANCA and c-ANCA positive in Wegener, microscopic polyangiitis. Churg-Strauss ANA positive in SLE anti-dsDNA, anti-Smith Antiglomerular basement membrane anti-GBM antibody levels positive in anti-GBM GN and Goodpasture ASO titers elevated in poststreptococcal GN postinfectious GN Blood cultures positive...
Approach To Nephrotic Syndrome
Normally, the kidneys do not excrete appreciable amounts of protein lt 150 mg d because serum proteins are excluded from the urine by the glomerular filter both by their large size and their net negative charge. Thus, the appearance of significant proteinuria heralds glomerular disease, with disruption of its normal barrier function. Proteinuria in excess of 3-3.5 g of protein per 1.73 m2 body surface area normal adult male body surface area per day is considered to be in the nephrotic range....
Clinical Pearls Myr
The most common causes of acute pancreatitis in the United States are alcohol consumption, gallstones, and hypertriglyceridemia. Acute pancreatitis usually is managed with pancreatic rest, intravenous hydration, and analgesia, often with narcotics. Patients with pancreatitis who have zero to two of the Ranson criteria are expected to have a mild course those with three or more criteria can have significant mortality. Pancreatic complications phlegmon, necrosis, abscess, pseudocyst should be...
Approach To Monoarticular Arthritis
Almost any joint disorder may begin as monoarthritis, or inflammation of a single joint however, the primary concern is always infectious arthritis, because it may lead to joint destruction and resultant severe morbidity. For that reason, acute monoarthritis should be considered a medical emergency and investigated and treated aggressively. Monoarthritis may be a result of infection e.g., bacterial, fungal, Lyme disease, tuberculosis or crystal-induced arthritis e.g., pseudogout and gout less...
115 92 Blood Pressure
Amman EM. Anbe DT. Armstrong PE. ct al. ACC AHA guidelines for the management of patients with ST elevation myocardial infarction. Circulation 2004 110 588. Antman EM. Braimwald E. ST segment elevation myocardial infarction. In Kaspcr DL. Braunwald E, Fauci AS. et al., eds. Harrison's principles of internal medicine. 16th ed. New York McGraw-Hill. 2005 1434-1462. Kceley EC. Boura JA. Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction A...
Comprehension Questions Fos
22.11 A 72-year-old man develops severe pain and swelling in both knees, shortly after undergoing an abdominal hernia repair surgery. Physical examination shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid. Gram stain is negative. Which is the most likely diagnosis C. Calcium oxalate deposition disease 22.2 A 65-year-old man with a...
Causes Of Syncope
a. Sinus bradycardia, sinoatrial block, sinus arrest, sick sinus syndrome a. Supraventricular tachycardia with structural cardiac disease b. Atrial fibrillation associated with the Wolff-Parkinson-White syndrome c. Atrial flutter with 1 1 atrioventricular conduction B. Other cardiopulmonary etiologies 4. Myocardial disease massive myocardial infarction 5. Left ventricular myocardial restriction or constriction 6. Pericardial constriction or tamponade 7. Aortic outflow tract obstruction aortic...
Contraindications To Thrombolytic Therapy
Major surgery trauma within past 2 weeks Active internal bleeding excluding menses History of cerebral tumor hemorrhage arteriovenous malformation Prolonged, traumatic cardiopulmonary resuscitation Allergy to agent prior reaction Cerebrovascular accident known to be hemorrhage within past 12 months History of uncontrolled hypertension Recent hepatic renal biopsy Blood pressure gt 180 110 mmHg on gt 2 readings Diabetic retinopathy with recent bleed Stroke transient ischemic attack within past...
References Kuq
Brady HR. Brenner BM. Acute renal failure. In Kasper DL. Braunwald E, Fauci AS. et al, eds. Harrison's principles of internal medicine. 16th ed. New York McGraw-Hill. 2005 1644-1653. Lameire N, Van Biesen W. Vanholder R. Acute renal failure. Lancet 2005 365 417-430. Rose BD, Post TW. Hyperkalemia. In Clinical physiology of acid-base and electrolyte disorders, 5th ed. New York McGraw-Hill. 2001 913-919. A 27-year-old woman presents to the emergency room complaining of retrosternal chest pain for...
Comprehension Questions Vbe
14.1 A 43-year-old man who is an alcoholic is admitted to the hospital with acute pancreatitis. He is given intravenous hydration and is placed NPO. Which of the following findings is a poor prognostic sign B. Initial serum glucose level of 60 mg dL C. Blood urea nitrogen BUN level rises 7 mg dL over 48 hours 14.2 A 37-year-old woman is noted to have gallstones on ultrasonography. She is placed on a low-fat diet. After 3 months she is noted to have severe right upper quadrant pain, fever to...
Comprehension Questions
12.1 A 42-year-old woman presents to your office for her annual physical. On examination, you note neck fullness. When you palpate her thyroid, it is enlarged, smooth, rubbery, and nontender. The patient is asymptomatic. You send her for thyroid function testing her T4, free T4. and T, are normal, but her TSH is slightly elevated. What is the most likely diagnosis 12.21 What laboratory tests could be performed to confirm your diagnosis of the patient in Question 12.1 A. Repeat thyroid function...