What are some common signs and symptoms of pneumonia (PNA)
Cough with purulent sputum, fever, chills, pleuritic chest pain
What are some common physical examination findings in a patient with pneumonia
Decreased breathing sounds, crackles, egophony, dullness to percussion, tactile fremitus on
the side of the pneumonia, fever
What studies should be ordered if a PNA is suspected
CXR, CBC, sputum culture and Gram stain, blood culture (in hospitalized patient)
What do you see on a CXR in a patient with pneumonia
Lobar consolidation
What would the CBC show
Leukocytosis
Name the most common organism causing pneumonia in each of the following cases:
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
What hormones are secreted from the anterior pituitary
Follicle-stimulating hormone (FSH), luteinizing hormone (LH), adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), prolactin, GH
What hormones are secreted from the posterior pituitary
Antidiuretic hormone, oxytocin, vasopressin
What is the action of each of the following hormones
What is the most common type of pituitary tumor
Prolactinoma
What type of tumor is a prolactinoma
A pituitary adenoma which secretes prolactin
What are the two mechanisms by which a prolactinoma causes symptoms
1. Endocrinal effect: due to hyperprolactinemia
2. Mass effect:pressure of the tumor on surrounding tissues
What are some signs and symptoms of a prolactinoma
Headache, diplopia, hypogonadism, amenorrhea, gynecomastia, galactorrhea,hypopituitarism
What cranial nerve (CN) can be affected by a prolactinoma
CN III
How is a prolactinoma diagnosed
Magnetic resonance imaging (MRI)/computed tomography (CT)
What is the first-line treatment for a prolactinoma
Dopamine agonist such as bromocriptine
What are other treatment options
Surgical resection or radiation therapy if tumor is very large or refractory to medical treatment
Other than a prolactinoma, what are other causes of hypopituitarism
Sheehan syndrome (postpartum pituitary necrosis), hemochromatosis, neurosyphilis, tuberculosis (TB), surgical destruction of pituitary
What disorder is seen with elevated levels of GH
Acromegaly
What is the most likely underlying cause of acromegaly
Pituitary adenoma secreting GH
When must there be an elevation in GH in order for acromegaly to result
Elevated levels of GH must be present after epiphyseal closure
What results if there is excess GH secretion before epiphyseal closure
Gigantism
What are the signs and symptoms of acromegaly
Coarse facial features, large hands and feet, large jaw, deepening of voice, decreased peripheral vision due to compression of optic chiasm, hyperhidrosis
How is acromegaly diagnosed
MRI/CT demonstrating pituitary tumor or nonsuppressible GH postoral glucose challenge
and elevtated IGF-1 (insulin-like growth factor)
What are the treatment options for acromegaly?
Surgery or radiation of pituitary tumor, or medical treatment with octreotide or somatostatin, which blocks GH or dopamine agonists
What malignancy are patients with acromegaly at increased risk for
Colon cancer
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
Increased secretion of thyroid hormones
In what sex is hyperthyroidism more common
Ten times more common in women than men
What is the most common cause of hyperthyroidism
Graves disease (80%–90% of U.S. cases)
What are some other causes of hyperthyroidism
Plummer disease (toxic adenoma); toxic multinodular goiter; subacute thyroiditis; amiodarone therapy
What are some of the signs and symptoms of hyperthyroidism
Autoimmune disease causing hyperthyroidism. It is due to antibody stimulation of TSH receptors causing excess secretion of free thyroid hormone.
What are the two symptoms only seen in Graves disease
1. Pretibial myxedema
2. Infiltrative ophthalmopathy
What is pretibial myxedema
Pruritic, non pitting edema found on shins that usually remits spontaneously
What is infiltrative ophthalmopathy
Exophthalmos that may not resolve despite treatment of Graves disease most likely due to
autoimmune damage in extraocular muscles
How is Graves disease diagnosed
All hyperthyroidism is diagnosed via measurement of TSH, free T4, and free T3. In Graves disease, since there is excess stimulation of the thyroid gland causing increased production of thyroid hormone, laboratory tests show high levels of free T4 and free T3, and low levels of TSH (because of negative feedback) Also, a radioactive iodine uptake scan should be done. If uptake is low, then thyroiditis or medication-induced hyperthyroidism is considered.
What is another name for toxic multinodular goiter
Plummer’s disease
What is the underlying cause of hyperthyroidism in Plummer disease
Multiple thyroid nodules develop autonomous T4 secretion and, therefore, more T4 is released.
How is Plummer disease diagnosed
Radioactive iodine uptake tests show “hot” nodules with the rest of the gland being “cold”;also, clinically ,nodules can sometimes be felt.
What is another name for subacute thyroiditis
de Quervain thyroiditis
What are the signs and symptoms of subacute thyroiditis
Prodrome of viral urinary tract infection (UTI) followed by rapid onset of thyroid swelling and tenderness as well as hyperthyroid symptoms that can later turn into a hypothyroid state.
What is the treatment for de Quervain thyroiditis
Usually self-limiting, but asprin and corticosteroids may be indicated to control inflammation
What are the treatment options for a hyperthyroid state
1. Medication: propylthiouracil (PTU) or methimazole
2. Radioactive iodine ablation
3. Surgery: subtotal thyroidectomy
What is the first-line treatment for Graves disease
Radioactive iodine ablation
What is radioactive iodine ablation
Radioactive iodine is concentrated in the gland and destroys tissue
What are the possible side effects of radioactive iodine ablation?
Hypothyroidism; thyrotoxic crisis secondary to the release of thyroid hormone into the blood stream
What is the mechanism by which PTU works
It inhibits the peripheral conversion of T4 to T3, decreases iodine uptake, decreases T4 synthesis
Do patients need to be on therapy for the rest of their lives
No. After a 1–2 year course of treatment about 50% no longer need to be treated.
What is the potential side effects of PTU?
Leukopenia, rash, nausea
What other adjunctive treatment is given to patients with hyperthyroidism
Beta-blocker,usually propranolol, to control symptoms
What is the most serious complication of hyperthyroidism?
Thyroid storm
What can induce thyroid storm
Infection, surgery, trauma, abrupt stop of antithyroid medication, serious acute medical problems such as cerebrovascular accident or myocardial infarction
What are the signs and symptoms of thyroid storm
Exaggerated symptoms of hyperthyroidism are tachycardia, high outputcongestive heart failure (CHF), abdominal pain, fever, altered mental status (ultimately coma)
What is the mortality rate of thyroid storm
Up to 50%
What is the initial treatment for thyroid storm?
It is an emergency so think of the ABCs:
Airway stabilization
Breathing/oxygen administration
Circulation (check pulse/blood pressure [BP]) and start IV fluids
After primary stabilization of the patient, what is the medical management of thyroid storm
Beta-blocker, PTU, or methimazole. Tylenol for fever, cold iodine about 2 hours after PTU, and glucocorticoids.
What are the signs and symptoms of hypothyroidism?
Cold intolerance, fatigue, lethargy, weakness , constipation, weight gain, arthralgias, hoarse voice, skin is dry, coarse, and with nonpitting edema, loss of outer third of eyebrows, delayed relaxation phase of deep tendon reflexes
What is primary hypothyroidism
Thyroid gland dysfunction
What are some examples of primary hypothyroidism
Hashimoto thyroiditis, thyroid ablation or neck radiation therapy in the past, subacute thyroiditis, iodine excess or deficiency, medication-induced
What medication can cause hypothyroidism
Lithium
What is the most sensitive lab test for primary hypothyroidism
Elevated TSH
What other lab results are present in primary hypothyroidism
Low T3 and T4
What is Hashimoto thyroiditis
Painlesschronic autoimmune thyroid inflammation of autoimmune etiology
What laboratory results can help diagnose Hashimoto thyroiditis
Elevated antithyroglobulin and antimicrosomal antibody titers
What is subacute thyroiditis
Tender,enlarged thyroid; often post-viral infection can begin with hyperthyroid symptoms, then hypothyroid symptoms
How can you distinguish Hashimoto from subacute thyroiditis
On clinical examination, in Hashimoto the thyroid gland isnot tender to palpation but in subacute thyroiditis it istender to palpation.
How can Graves disease and increased Hashimoto’s thyroiditis be distinguished
Radioactive iodine uptake is with Graves and decreased with Hashimoto.
What is secondary hypothyroidism
Hypothyroidism caused by pituitary dysfunction
What are some examples of secondary hypothyroidism
Sheehan syndrome, pituitary neoplasm, TB
What is Sheehan syndrome
Postpartum pituitary necrosis
What lab results indicate a secondary hypothyroidism
Low to normal TSH as well asnormal thyrotropin-releasing enzyme (TRH), low levels of T3 and T4
What is tertiary hypothyroidism
Deficiency of TRH
What is an example of tertiary hypothyroidism
Hypothalamic radiation
Other than TSH, TRH, T3, T4, what other abnormal lab tests may be found in a hypothyroid patient
Elevated serum cholesterol (TG , LDL,total cholesterol); elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT); anemia; hyponatremia
What is the treatment for hypothyroidism
Levothyroxine
What is subclinical hypothyroidism
Elevated TSH levels but with normal thyroid hormone levels and with no clinical symptoms
What is the life-threatening complication of hypothyroidism called
Myxedema coma
What are the signs and symptoms of myxedema coma
Severe lethargy or coma, hypothermia, areflexia, bradycardia
What causes myxedema coma?
Prolonged cold exposure, infection, sedatives, narcotics, trauma, or surgery
What is the treatment for myxedema coma
This is an emergency, so start with ABCs (airway, breathing, circulation); IV fluids, steroids, levothyroxine, treat any precipitating causes
What is the initial appropriate workup of a thyroid mass
Fine needle biopsy and TSH
What other studies are done to workup a thyroid mass?
Thyroid ultrasound to determine the number and sizes of masses; and thyroid technetium 99m scan
What is a hot nodule and a cold nodule on a thyroid scan
Hot nodule indicates a hyperactive nodule and isless likely to be malignant. A cold nodule indicates a hypoactive nodule that is more likely to be malignant
What is the most common type of thyroid cancer
Papillary cancer
What is the prognosis for papillary cancer
85%, 5-year survival
What is seen on pathology
Psammomabodies, Orphan Annie nucleus
Which type of thyroid carcinoma is associated with multiple endocrine neoplasia types 2 and 3 (MEN 2 and 3)
Medullary cancer
What can be used to monitor medullary carcinoma
Calcitonin, because it is a calcitonin-secreting tumor
Which type of thyroid carcinoma has the worst prognosis?
Anaplastic cancer
In what patient population is anaplastic carcinoma usually found
Older patients
What is the 5-year prognosis for anaplastic carcinoma
0% survival at 5 years
Which thyroid cancer has the second worst prognosis
Medullary cancer
Which thyroid carcinoma often has metastasis to the bone and lungs?
Follicular cancer
Name the tumors that are part of each of the MEN syndromes
MEN 1: Wermer syndrome. three P’s prolactinoma, parathyroid, pancreatoma
MEN 2: Sipple syndrome pheochromocytoma, medullary thyroid, parathyroid
MEN 3: same as MEN 2B pheochromocytoma, medullary thyroid, mucocutaneous neuromas
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
Air droplet transmission
Who is at high risk for becoming infected with TB
Immunocompromised, foreign-born, homeless, prisoner, low-income communities, intravenous (IV) drug users
What are the common signs and symptoms of TB
Productive cough, night sweats, weight loss, hemoptysis,fever, chills, chest pain,
How is latent TB detected
Positive purified protein derivative (PPD)(tuberculin) skin test
What is considered a positive PPD
> 15 mm in any person
> 10 mm in immunocompromised, IV drug user, foreign-born, prisoner, nursing home resident, people who work in the medical field (that means you), underserved community
> 5 mm: HIV, abnormal CXR, close contact had TB
How is a positive PPD treated
Isoniazid (INH) for 9 months with vitamin B6
What laboratory tests should be done when starting a patient on isoniazid (INH)
Liver function tests (LFTs) because of possibility of hepatotoxicity
What part of the lung does primary TB usually affect
Lower lobes
What is the radiographic finding of healed primary TB called
“Ghon complex,” which is a calcified nodule with calcified lymph nodes (Fig. 3-4)
What is secondary TB
Reactivation TB
Where is secondary TB usually found
Lung apices
What is extrapulmonary TB
TB that had disseminated to other organs
What is the most common extrapulmonary location for TB to spread
Kidneys
What are other locations where extrapulmonary TB can be found
Liver, central nervous system (CNS), vertebral bodies, psoas muscle, cervical lymph
nodes, pericardium
What is TB of the vertebral bodies called
Pott's disease
What is cervical lymphadenopathy secondary to TB infection called
Scrofula
How is active TB diagnosed
Clinical symptoms, CXR, and sputum acid-fast stain and culture
What is seen on CXR in active TB
Upper lobe infiltrates with scarring, cavitary lesions
What is the treatment for active TB
Four-drug therapy for a minimum of 6 months (remember the mnemonic RIPE ):
Rifampin
INH
Pyrozinamide
Ethambutol
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
What are the signs and symptoms of systemic lupus erythematosus (SLE)
Fatigue, malaise, malar rash, arthralgias,pericarditis, endocarditis, neurologic symptoms, polyarthritis
What is the sex distribution of SLE
90% female predominance
How is SLE distributed based on race
Black > white
What is the mnemonic for diagnosing SLE
DOPAMINE RASH
Discoid rash: raised, erythematous circular rash with scale
Oral ulcers
Photosensitivity
Arthritis > 2 joints
Malar rash: butterfly rash on cheeks
Immunologic criteria: anti-Sm Ab, anti-double stranded DNA, false-positive venereal
disease research laboratory (VDRL) test
Neurologic symptoms: seizures, psychosis
ESR elevated (not part of the 11 criteria)
Renal disease
Antinuclear antibody (ANA) positive
Serositis: pericarditis, pleurisy
Hematologic disorder: hemolytic anemia,leukopenia, thrombocytopenia, lymphopenia
How many of the criteria must be present to make the diagnosis of SLE
Four or more
What is the pathomnemonic heart disorder seen in SLE patients
Libman-Sacks endocarditis (LSE)
What autoantibodies is most sensitive for SLE
ANA (it is not specific)
Which autoantibody is most specific for SLE
Anti-double stranded-DNA (very high titers are associated with renal involvement), anti-SM antibody
What other autoantibodies are associated with SLE
Anti-La antibody
Anti-Ro antibody
What are lupus anticoagulant and anticardiolipin associated with
Thrombosis, central nervous system (CNS) lupus, thrombocytopenia, valvular heart
disease, fetal loss
What serologies can be falsely positive in patients with SLE
Rapid plasma reagin (RPR)/VDRL
Anticardiolipin can cause a falsely elevated result with which lab test
Elevated partial thromboplastin time (PTT), but in reality SLE patients are more likely to develop blood clots
What are the treatments for SLE
Avoid sun exposure, NSAIDs for joint pain,systemic steroids, immunosuppressives such as cyclophosphamide in refractory cases with more advanced development of disease
How is drug-induced lupus different from SLE
Symptoms resolve with discontinuation of the drug and anti-histone antibody positive
What drugs are known to cause drug-induced SLE
SIQ CHaMP
Sulfasalazine
Isoniazid (INH)
Quinidine
Chlorpromazine
Hydralazine
Methyldopa, minocycline
Procainamide, penicillamine
What is the most common drug to cause lupus-like symptoms
Procainamide
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
Autoimmune disease which causes proximal muscle weakness
How is polymyositis different from dermatomyositis
Dermatomyositis includes rash as a symptom, whereas with polymyositis there is no rash.
What sex is more likely to have polymyositis
Females are twice as likely.
What are the signs and symptoms of polymyositis
Symmetric proximal muscle weakness,dysphonia, and dysphagia; patients have difficulty standing up from a chair or brushing their hair
What are the classic signs of dermatomyositis
Symmetric proximal muscle weakness,heliotropic periorbital rash, shawl sign (erythematous macules on shoulders and upper back),Gottron papules (violacious papules on DIP joints)
What autoantibody is associated with polymyositis and dermatomyositis
Anti-Jo-1
What are the four criteria for polymyositis
1. Creatine phosphokinase (CPK)
2. Proximal muscle weakness
3. Low-amplitude potentials and fibrillations on electromyogram (EMG)
4. Muscle fiber size on muscle biopsy
What is the treatment for polymyositis and dermatomyositis
Corticosteroids and methotrexate or cyclophosphamide in refractory cases
التوقيع
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
اللهم إنك عفو كريم تحب العفو فاعف عنى
خللى بالكم يا شباب سادسة من الجرعات دى مهمة جدااااااااااااااااااااا فى النسا
Mg Sulfate as anticonvulsant in ttt of PET
IV 4-6 gm slowly (over 15-20 min) then 1-2 gm/hr by drip
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ,,,,,,,,,, Oxytocin as ecbolic
most commonly used in (saline , dextrose , lactated ringer)
start by small dose at slow rate then gradualy increase
.5 - 2 mIU /min then increase by 1-2 mIU/30-60min
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, دكتور أبو عمار
دكتور أبو عمار 
stal induced arthropathy
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