USMLE step 2
Terms
undefined, object
copy deck
- PAGET'S DISEASE PATHOPHYSIOLOGY
- EXCESSIVE BONE TURNOVER BY OSTEOCLASTS +/- ASSOCIATED WITH PARAMYXOVIRUS INFECTION
- PAGET'S S/S
-
DEEP BONE PAIN
FREQUENT #
INCREASED CRANIAL DIAMETER (=FRONTAL BOSSING)
DEAFNESS D/T CN VIII COMPRESSION - PAGET'S LAB & XRAY FINDINGS
-
INCREASED ALP, URNIARY HYDROXPROLINE
NORMAL Ca, PO4
XRAY - MARKEDLY EXPANDED BONY CORTEX - INCREASED DENSITY, THICKENED TRABECULAE, CHARACTERISTIC "JIGSAW" OR "MOSAIC" BONE PATTERN - PAGET'S - Rx
- NSAIDS, CALCITONIN, ALENDRONATE
- Paget's - complications
- #'s, high output cardiac failure, deafness, secondary osteosarcoma
- heliotrope rash
- violacious periorbital rash in dermatomyositis
- Grotton's papules
- papules on dorsum of hand over bony prominences in dermatomyositis
- polymyositis lab and EMG findings
-
elevated serum creatine, aldolase, CPK
EMG - fibrillations - complications of polymyositis
- myocarditis, cardiac conduction defects, malignancy
- Felty's triad
-
hepatosplenomeagly
TCP
RA - Lab, synovial fluid and Xray findings in RA
-
rh factor = anti-Fc IgG Ab - elevated in >75% (not specific)
+/- ESR elevated
synovial fluid - turbbid, decreased viscosity, WBC 3000-50000 cells/microL
Xray - juxta-articular dimineralization (early) joint space narrowing and erosions (late) - JRA - most common type?
-
pauciarticular - <30% develop iridocyclitis
ANA type - most common - asymmetric involvement of large joints with iridocyclitis
RF type - poor Px - concurrent with AS in HLA-B27+ males - Systemic acute febrile JRA
-
least common
characteristic arthritis with daily high spiking fevers
evanescent salmon coloured rash
+/- hepatosplenomegaly and serositis - Scleroderma S/S
-
thickening of skin of face +/or distal extremities
CREST
severe form - pulmonary fibrosis, cor pulmonales, ARF, malignant HTN - Anticentromere Ab
- specific for CREST
- anti-Scl-70 = anti-topoisomerase 1
- specific for systemic scleroderma
- treatment for scleroderma
- glucocorticoids, penicillamine for skin changes, CCB for Raynaud's, ACEI for renal dz/HTN
- SLE criteria
-
DOPAMINE RASH =
Discoid rash
Oral ulcers
Photosensitivity
Arthritis
Malar rash
Immunologic criteria
Neurologic symptoms (lupus cerebritis, seizures)
Elevated ESR
Renal disease
ANA +
Serositis
Hematologic abnormalities - anemia, leukopenia, TCP - Anti-dsDNA, Anti-Sm Ab's
- highly specific, not sensitive for SLE
- drug induced SLE antibodies
- Antihistone Ab
- Anti-Ro Ab's
- neonatal SLE
- Anti-phospholipid Ab's
- hypercoagulability, thromboembolic disease, recurrent spontaneous abortions
- Rx for SLE
-
NSAIDs (initial)
Steroids for acute exacerbations
hydroxychloroquine, cyclophosphamide, azithroprine for progressive/refractory cases - SLE pathogenesis, epidemiology
-
90% female (esp. African American)
Antibody-mediated cellular attack with deposits of antigen-antibody complexes - Drugs inducing SLE
-
hydralazine
pencillamine
procainamide - Temporal arteritis pathogenesis
- subacute granulomatous inflammation of large vessels (includes aorta, ext. carotid - temp. br, vertebral a's)
- temporal arteritis S/S
-
new h/a uni/bilateral with scalp pain
temporal tenderness
jaw claudication
fever
transient/perm monocular blindness
+/- wt loss, myalgia/arthralgia - bx findings in temporal arteritis
- thrombosis, media necrosis, lymphocyes, plasma cells, giant cells
- HSP path and epi
-
immune mediated small vessel vasculitis
children 2-11 y/o - HSP S/S
-
palpable purpura on buttocks, legs
asym. migartory periarticular swelling
abdominal pain
preceding URTI (75%) - Complications of HSP
- GIB, intussusception, GN - degree of renal involvment determines Px
- Barlow's maneuver
-
for DDH
pressure on inner aspect of abd thigh, hip add - causes post. dislocation - Ortolan's maneuver
-
for DDH
thighs abdocuted from midline with anterior pressure on greater trochanter - +ve = soft click (femoral head reduced into acetabulum) - Allis'/Galeazzi's sign
-
for DDH
knees at unequal heights when baby's hips and knees flexed (dislocated side lower) - Evaluation of DDH
- clinical, U/S esp after 10 weeks old (not xray until >4m old)
- Monteggia's #
- diaphyseal # of prox ulna with subluxation of radial head
- Galeazzi's #
-
diaphyseal # of radius with dislocation of distal r/u joint - d/t direct blow to radius
Rx - ORIF radius, cast in supination to reduce r/u jt - clavicular #
-
most common #'d long bone in kids
can be associated with brachial plexus injuries - greenstick #
-
incomplete # - cortex of only one side of bone
Rx - reduction with casting, repeat Xray 7-10days - nursemaid's elbow
-
radial head subluxation secondary to child being pulled or lifted by the the hand
Rx - gentle supination of elb at 90 - Torus #
-
buckling of cortex of long bone secondary to trauma
- usually distal radius or ulna - Salter-Harris # type I
- physis
- Salter-Harris # type II
- metaphysis and physis
- Salter-Harris # type III
- epiphysis and physis
- Salter-Harris # type IV
- epiphysis, metaphysis, physis
- Salter-Harris # type V
- crush injury of physis
- Rx of Salter-harris #'s
-
Types I, II - conservative
III - V - Sx - Rx of DDH
-
Splint with Pavlik harness (maintains hip flexed, abd) if <6m old
6-15m old - spica cast
15-24m old - ORIF - DDx of limp in children
-
"STARTSS HOTT"
Septic joint
Tumor
AVN (LCPD)
RA/JRA
TB
SCA
SCFE
HSP
Osteomyelitis
Trauma
Toxic synovitis - osteosarcoma
-
2nd most common primary malignancy of bone (MM 1st)
metaphyseal region of distal femur, prox. tibia, prox. humerus - mets to lungs
males, 2nd-3rd decades - osteosarcoma vs Ewing's
-
Osteo
metaphyseal region distal femur, prox tibia/humerus
Xray - Codman's triangle, "sunburst" pattern
Ewing's
diaphyseal-metaphyseal regions of pelvis, femur, tibia
multilayered "onion-skinning" - Codman's triangle
- Osteosarcoma Xray finding = periosteal new bone formation at diaphyseal end of bone
- lesion of Broca's area
- Broca's aphasia - motor (expressive) - broken speech, normal comprehension
- lesion of Wernike's area
- sensory (fluent/receptive)aphasia - poor comprehension
- lesion to arcuate fasciculus
- conduction aphasia - poor repitition with good comprehension, fluid speech
- Lesion to amygdala bilaterally
- Kluver-Bucy syndrome - hyperorality, hypersexuality, disinhibited behaviours
- lesion to fronal lobe
-
frontal release signs - personality changes
deficits in concentration, orientation, judgement - right parietal lobe lesion
- spatial neglect syndrome - agnosia of contralateral side of the world
- Lesion to mamillary bodies bilaterally
- Wernicke-Korsakoff's encephalopathy - confabulations, anterograde amnesia
- CN XII lesion
- tongue deviates towards lesion side
- CN V lesion
- jaw deviates towards
- unilateral cerebellum lesion
- patient falls towards side of lesion
- CN X lesion
- uvula deviates AWAY from lesion side
- CN XI lesion
- head turns towards side of lesion
- R optic nerve defect
- right hemianopsia
- optic chiasm lesion
- bitemporal hemianopsia
- R optic tract lesion
- L homonymous hemianopsia
- R Meyer's loop lesion
- L upper quadrant anopsia = right temporal lesion
- R dorsal optic radiation lesion
- L lower quadrant anopsia = R parietal lesion
- R visual cortex lesion
- L hemianopsia with macular sparing
- anterior cerebral artery distribution
- medial surface of brain, leg-foot area of motor and sensory cortices
- middle cerebral artery distribution
- lateral aspect of brain, Broca's and Wernicke's areas
- Anterior communicating artery defects
- most common circle of Willis aneurysm, +/- visual field defects
- Posterior communicating artery defects
-
CN III palsy
common area of aneurysm - Lateral striae arteries distribution
- internal capsule, caudate, putamen, globus pallidus = "arteries of stroke"
- stroke of anterior Circle of Willis
- general sensory and motor dysfunction, aphasia
- Stroke of posterior Circle of Willis
- vertigo, ataxia, visual defects, coma
- Poliomyelitis/Werdnig-Hoffman disease spinal cord lesions
- LMN lesions only = flaccid paralysis
- MS spinal cord lesions
- mostly white matter of cervical region - random and asym lesions
- ALS
-
combined U/LMN deficits
NO sensory deficits - Anterior spinal artery lesion
- spares dorsal columns
- Tabes dorsalis
-
impaired propriocetion
locomotor ataxia
d/t tertiary syphilis - syringomyelia
- affects ventral white commissure and ant. horns
- Vit B12 neuropathy/Friedreich's ataxia
- affects dorsal columns, lateral corticospinal and spinocerebellar tracts
- Broca's aphasia
-
disorder of language production with intact comprehension - pts aware
impaired repitition
Associated with arm and face hemiparesis (right), hemisensory loss, apraxia of oral muscles
d/t L superior MCA stroke - Wernicke's aphasia
-
disorder of language comprehension
neologisms, paraphasic errors
pts unaware
no hemiparesis, dysarthria
L inf/post MCA embolic stoke
poor Px c/w Broca's - Locked in syndrome S/S, causes
-
awake and alert, unable to move except eyes and eyelids
central pontine myelinolysis
brain stem CVA
advanced ALS - Persistent vegetative state
-
normal sleep-wake cycles
most common - diffuse cortical injury
hypoxic-ischemic injury - 5 A's of dementia
-
Aphasia
Amnesia
Agnosia
Apraxia
disturbances in Abstract thought - Causes of dementia
-
"DEMENTIAS"
neuroDegenerative diseases
Endocrine
Metabolic
Exogenous
Neoplasm
Trauma
Infection
Affective disorders
Stroke/Structural - Peripheral vs central vertigo
-
Peripheral - intermittent, severe, constant nystagmus, always horizonal, unidirectional, associated with hearing loss, no brain stem S/S
Central - constant, less severe, +/- nystagmus (absent, uni/bidirectional, +/- vertical)Rare hearing loss, often brain stem S/S (ataxia, dysarthria, CN abN, motor dysfunctions) - Most common causes dysequilibrium
-
BPPV (50%)
Ménière's
Others - hypothyroid, aminoglycoside/furosemide toxicity, stroke, trauma, labyrinthitis, acoustic neuroma - Nylen-Barany Maneuver
-
= Dix-Hallpike maneuver
pt sitting to supine quickly turning head to side - +ve if reproduces vertigo +/or nystagmus = BPPV - BPPV S/S
-
transient episodic vertigo <1min
nystagmus triggered by changes in head position (classic - turning in bed/getting up in am)
N/V
Symptoms decrease with repetitive testing -
Meniere's disease S/S
(=endolymphatic hydrops) -
intermittent peripheral vertigo d/t distention of endolymphatic compartment of inner ear
N/V
ear fullness
hearing loss
tinnitus
episodes resolve hrs-days - Causes of Meniere's
-
head trauma
syphilis - audiometry findings in Meniere's
- low-frequency pure-tone hearing loss
- Treatment of Meniere's
-
low salt diet
acetazolamide
actue attacks - antihistamines, antiemetics, benzo's
surgical decompression if refractory - acute h/a causes
-
SAH
hemorrhagic CVA
meningitis
seizure
acutely increased ICP
hypertensive encephalopathy
post-LP
ocular dz (glaucoma, iritis)
new migraine - subacute h/a causes
-
temporal arteritis
intracranial tumor
SDH
pseudotumor cerebri
trigeminal/glossopharyngeal neuralgia
post-herptic neuralgia
HTN - chronic/episodic h/a causes
-
migraine
cluster h/a
tension h/a
sinusitis
dental dz
neck pain - Migraine h/a S/S
-
throbbing h/a >2hrs, <24hrs
N/V
photophobia
noise sensitivity
"Classic" - u/l, visual aura (scintillating scotomas or field cuts)
"common" - b/l, periorbital without associated symp - Treatment of migraine h/a
-
ASA/NSAIDS, triptans
prophylaxis - BB, TCA, CCB, valproic acid - Cluster h/a description
-
brief, severe, usually u/l periorbital h/a 30min-3hrs
affects same part of head, same time of day (night), same time of year
triggers - EtOH, vasodilators - Cluster h/a S/S
-
ipsilateral tearing of eye
conjunctival injection
Horner's syndrome
nasal stuffiness - Treatment of cluster h/a
-
acutely - high flow O2 (100% non-rebreather)
ergots
sumatriptan
intranasal lidocaine
corticosteroids - Prophylaxis of cluster h/a
-
ergots
CCB
prednisone
lithium
valproic acid
topiramate - SAH causes
-
ruptured aneurysm (berry)
AVM
trauma (most common) - Berry aneurysms associated with?
-
PcKD
coarctation of aorta - CN involvment in SAH
- CN III palsy with pupil involvement associated with Berry aneurysms
- Treatment of SAH
-
prevent rebleeding - most likely in 1st 48hrs
prevent vasospasm - nimodipine and IV fluids, maintain elevated BP
antiseizure meds - phenytoin
NO NSAIDs - Complications of SAH
-
rebleeding aneurysm>AVM
extension into brain parenchyma (AVM)
vasospasm (in 1/3 of aneurysmal SAH)
obstructive hydrocephalus - EDH CT findings
- lens-shaped CONVEX hyperdensity
- SDH CT findings
- cresent-shaped, CONCAVE hyperdensity
- parenchymal hemorrhage causes
-
HTN - usually in basal ganglia
tumor
amyloid angiopathy (elderly)
vascular malformations (AVM, cavernous hemangiomas) - Cushing's triad
- alterations in BP, HR, and respiratory patterns
- Parkinson's tetrad
-
resting tremor
bradykinesia
rigidity
postural instability - treatment of parkinson's
-
dopamine agoinsts - brompcriptine, levo/carbadopa
MAO-B inhibitors - selegiline (neuroprotective, decreases levodopa need)
COMT inhibitors - entacapone (increase levodopa availability, may decrease motor fluctuations)
(amandatine, antiAch - limited efficacy) - astrocytomas
-
Adults
S/S h/a, increased ICP
+/- u/l paralysis CN V-VII, X
slow, protracted course
Rx - resection, XRT - GBM
-
most common primary
h/a, increased ICP
rapid progression, poor Px (<1yr) - meningiomas
-
women>men
from dura or arachnoid
increased incidence with age - acoustic neuroma
-
ipsilateral hearing loss
tinnitus
vertigo
signs of cerebellar dysfunction
Derived from Schwann cells - Medulloblastoma
-
children
from 4th vent - increased ICP
highly malignant - can seed subarachnoid space
Rx - Sx + chemo + XRT - ependymoma
-
children
from ependyma of ventricle (4th) or spinal cord
hydrocephalus
Rx - Sx + XRT - Neurocutaneous syndromes
-
NF 1,2
Tuberous sclerosis - NF 1 mutation
- NFT-1 gene on 17q
- NF 2 mutation
- defective gene chrom. 22
- NF1 diagnostic criteria
-
>=2 of:
1) 6 cafe au lait spots (>5mm kids, 15mm adults)
2) 2 neurofibromas (any type)
3)feckling-axillary/inguinal
4) optic glioma
5) 2 Lisch nodules = pigmented iris hamartomas
6)osseus abnormalities
7) 1st degree relative - NF2 diagnostic criteria
-
bilateral acoustic neuromas
1st degree relative
unilateral acoustic neuroma
any 2 of:
neurobfibroma
meningioma
glioma
schwannoma
Other features (not criteria)
seizures, skin nodules, cafe-au-lait spots - Tuberous Sclerosis - characterized by:
-
seizures (begin <1y/o)
mental retardation
skin and eye lesions - Tuberous sclerosis - presentation
-
infantile spasms
ash-leaf hypopigmented lesions
(trunk and extremities) - Skin lesions in tuberous sclerosis
-
sebaceous adenomas (small red nodules over nose and cheeks like acne)
shagreen patch (rough papule in L/S region with orange peel consistency)
Ash-leaf hypopigmented lesions (trunk and extremities) - Retinal lesions in tuberous sclerosis
-
mulberry tumors (arise from nerve head)
phakomas (round, flat, grey lesions near disc) - Tests and findings in Tuberous sclerosis
-
calcified tubers in periventricular area (rarely transform into malignant asyrocytomas)
Skin lesions with Wood's lamp
ECG for rhabdomyoma (apex of LV in 50% pts)
Renal U/S - renal hamartomas, PcKD
Pulmonary - angiomyolipomas (cause generalized cystic or fibrous changes) - Thiamine deficiency
-
Wernicke's encephalopathy
Korsakoff's dementia - Wernicke's encephalopathy
- triad = encephalopathy, ophthalmoplegia (LR palsy,nystagmus, conjugate gaze palsy), ataxia (polyneuropathy, CB and ventricular dysfunction)
- Korsakoff's dementia
- Wernicke's (encephalopathy, ophthalmoplegia, ataxia) + amnesia, horizontal nystagmus
- Way to elicit Wernicke's encephalopathy
- Large dose glucose administration
- Cyanocobalamin deficiency
-
= B12 deficiency
Combined system disease or subacute combined degeneration - Cyanocobalamin deficiency S/S
-
gradual, progressive onset
symm. P/N
leg stiffness
spasticity
paraplegia
bowel/bladder dysfunction
Dementia - Folate deficiency
-
irritability
memory loss
personality changes without CSD of B12 - Seizure causes in infants
-
perinatal injury
infection
metabolic
congential - Childhood (2-10y/o) causes of seizures
-
idiopathic
infection
trauma
fever - Adolescent causes of seizures
-
idiopathic
trauma
drug withdrawl
AVM - Young adult (18-35y/o) causes of seizures
-
trauma
alcoholism
brain tumor - Adult (>35y/o) causes of seizures
-
trauma
stroke
metabolic disorder
alcoholism
brain tumor - Lab finding in epileptic seizure
- elevated prolactin
- Simple partial seizures
-
motor, sensory, autonomic, or psychic features without LOC
+/- post-ictal focal neuro
deficit resolves 1-2 days
Can evole into generalized
DDx from acute CVA with MRI - Complex partial seizures
-
temporal lobe (70-80%)
char by:
impaired LOC
auditory/visual hallucinations
deja vu
automatisms
post-ictal confusion/disorientation, amnesia
Symp can mimic schizophrenia/acute psychosis
Can evolve into generalized - Normal EEG in seizure
- Does NOT r/o epileptic sz disorder
- First line anti-convulsant in children
- phenobarbital
- 1st line treatment of idiopathic generalized seizures
-
Valproic acid
Adjuncts - lamotrigine, topiramate - treatment of secondary tonic-clonic seizures
- Same as partial seizures
- Absence seizures EEG finding
- 3/sec spike-and-wave discharges (classic)
- Absence seizures treatment
-
ethosuximide - 1st line
Valproic acid, zonisamide - West syndrome
-
Infantile spasms
Abnormal interictal EEG (v. high amplitude slow waves)
Arrest of psychomotor devt at age of sz onset - West syndrome S/S
-
begins 3-12m
sz - tonic, b/l, symm in clusters of 5-10 individual spasms - occur when drowsy or on awakening
MR in most pts - West syndrome Rx
-
ACTH
prednisone
anti-epileptics (clonazepam, valproic acid) - Status epilepticus definition
-
prolonged (>30min) or repetitive sz without a return to baseline
20% mortality - Status epilepticus causes
-
anticonvulsant withdrawl/non-comliance
anoxic brain injury
EtOH/sedative withdrawl
drug intoxication
metabolic - hyponatremia
trauma
infections - Treatment of Status epilepticus
-
ABC's
IV benzo + phenytoin loading dose
If sz continue - intubate + phenobarbital loading dose
glucose, thiamine, naloxone - Risk factors for CVA
-
non-modifiable - male, age, genetics, race (African-American, Hispanic, Asian)
Modifiable - HTN, DM, obesity, smoking, hypercholesterolemia, carotid stenosis, heavy EtOH, cocaine, IVDU, AFib - CVA most common etiology
- athlerosclerosis of extracranial vessels (internal and common carotids, basilar, vertebral)
- Underlying causes of lacunar infarcts
-
athlerosclerosis
HTN
DM - cardiac causes of CVA
-
Afib (risk increased 5-6x)
emboli - mural thrombi, diseased/prosthetic valves, paradoxic (venous) in R-to-L shunt (ASD, PFO) - MCA stroke S/S
-
aphasia (dominant hemisphere)
neglect (non-dominant)
contralat. hemiparesis, gaze preference, homonymous hemianopsia - ACA stroke S/S
-
leg paresis
amnesia
personality changes
foot drop
gait changes
cognitive changes - PCA stroke S/S
-
homonymous hemianopsia
memory deficits
dyslexia/alexia - Basilar stroke S/S
-
coma
CN palsies
apnea
visual symp
drop attacks
dysphagia - lacunar stroke S/S
-
pure motor or sensory
dysrthria-clumsy hand syndrome
ataxic hemiparesis - tPA contraindications
-
SBP >185 or DBP >110 despite aggressive antihypertensive Rx
prior ICH
CVA/head trauma in past 3m
recent MI
current anticoagulant Rx with INR >1.7
heparin in last 48hrs with increased PTT
platlets <100000
major Sx in last 14d
GI/GU bleed in past 21d
sz present at CVA onset
glucose <50/>400mg/dL
age <18 - 5 A's of Guillain-Barre
-
Acute inflammatory demyelinating polyradiculopathy
Ascending paralysis
Autonomic neuropathies
Arrhythmias
Albuminocytologic dissociation - Findings in Guillain-Barre
-
EMG/nerve conduction studies - diffuse demyelination
CSF - protein >55mg/dL with little/no pleocytosis - Myasthenia gravis antibodies
-
postsynaptic ACh receptor Ab (85-90%)
antistriational Ab (85% of pts with thymoma) - Labert-Eaton Syndrome antibodies
- autoantibodies to presynaptic Ca channels
- Myasthenia Gravis assoicated disorders
-
thymoma
thyrotoxicosis
autoimmune - SLE, RA - Myasthenia Gravis S/S
-
fatiguable ptosis/diplopia
dysphagia
proximal muscle weakness
symp worsen throughout day - "Myasthenic crisis"
- respiratory compromise and aspiration (rare)
- Drug induced myasthenic syndrome cause
- aminoglycosides
- Myasthenia Gravis findings
-
edrophonium - dramatic improvement (diagnostic)
Abnormal single fiber EMG +/or decremental response to repetitive nerve stim
ACh Ab (85-90%)
Antistriational Ab (85% of pts with thymoma) - Treatment of MG
-
anticholinesterases - neostigmine, pyridostigmine
immunosuppressants - prednisone
Resection of thymoma - can be curative - ALS pathogenesis
- loss of motor neurons in spinal cord, brain stem, and motor cortex
- ALS S/S
-
asymmetric, slowly progressive weakness of arms, legs, CNs
UMN and LMN signs - Diagnostic findings in ALSq
- Combination of U and LMN signs in >= 3 extremities
- Findings in ALS
- EMG/NCS - widespread denervation and fibrillation potentials
- treatment in ALS
-
supportive
aggressive pulmonary toilet
Riluzole - reduces presynaptic glutamate release, may slow progression - Risk factors for carpal tunnel syndrome
-
repetitive use injury
pregnancy
DM
hypothyroid
acromegaly
RA
obesity - MS possible pathogenesis
- T cell mediated autoimmune progression
- MS classic triad
-
scanning speech
intranuclear ophthalmoplegia
nystagmus - Most common presenting complaints in MS
-
limb weakness
optic neuritis
P/N
diplopia
urinary retention
vertigo - Exacerbating factors in MS
-
infection
heat
trauma
vigorous activity
(decreasing - pregnancy) - MRI findings in MS
-
multiple, asymmetric, often periventricular white matter lesions
Corpus callosum lesions ~pathognomonic
Active lesions enhance with gadolinium - CSF findings in MS
-
mononuclear pleocytosis (>5cells/microL) 25%
elevated IgG - 80%
oligoclonal bands (non-specific) albuminocytologic dissociation - Treatment for MS
-
Steroids - acute exacerbations
Immunomodulators - ABC
Avonex/Rebif (interferon-β-1a)
Betaseron (interferon-β-1b)
Copaxone (copolymer-1)
Symtomatic Rx for spasticity, pain, fatigue, depression - Closed angle glaucoma epidemiology
-
elderly
Asians - Causes of closed angle glaucoma
-
acute closure of narrow anterior chamber angle ==>
pupillary dilatation - prolonged time in dark, stress, meds
ant. uveitis
dislocation of lens - Closed angle glaucoma S/S
-
extreme pain and blurred vision, ~always u/l
eye hard and red
pupil dilated, non-reactive to light
N/V
increased IOP - Treatment of Closed angle glaucoma
-
lower intraocular pressure - acetazolamide
pilocarpine once pressure drops
laser iridotomy - curative - open angle glaucoma risk factors
-
>40 y/o
FHx
African-American
DM
myopia - Open angle glaucoma pathogenesis
- intraocular pressure increase d/t diseased trabecular meshwork that obstructs proper drainage of eye ==> gradual pressure increase causing progressive visual loss
- Open angle glaucoma S/S
-
frequent lens changes in pts >35y/o
mild h/a
visual disturbances
impaired adaption to darkness
visual loss begins peripherally - Fundoscopic findings in open angle glaucoma
- cupping of optic disc
- Treatment of open angle glaucoma
-
preventative - >40y/o see ophthalmologist q3-5yrs (annual if increased RFs)
topical α-blockers - timolol, betaxolol (decrease aqu. humor producation)
pilocarpine (increases aqu. outflow)
carbonic anhydrase inhibitors if eye drops insufficient control of IOP
laser trabeculoplasty - Macular degeneration risk factors
-
Caucasian
female
smokers
FHx - Macular degeneration types
-
atrophic - gradual visual loss
exudative - more rapid and severe visual loss - macular degeneration S/S
- painless loss of central vision
- macular degeneration fundoscopy findings
- pigmentary or hemorrhagic disturbances of macular region
- treatment of macular degeneration
-
limited
laser photocoagulation may delay loss of central vision in exudative type - CRAO S/S
-
sudden, painlesss, u/l blindness
pupil accomodates
sluggish pupil reaction to direct light - CRAO fundoscopy findings
-
cherry-red spot on fovea
arteries +/- bloodless appearance
+/- retinal swelling - CRVO S/S
-
rapid painless vision loss
elderly pts - fundoscopy findings of CRVO
-
retinal hemorrhages
cotton-wool spots
edema of fundus - sequelae of CRVO
-
macular degeneration
glaucoma - Treatment of CRAO
-
thrombolysis of ophthalmic artery within 8hrs of symp onset
IV acetazolamide -decrease IOP - increase drainage of aqu. humor - sequelae of CRAO
- untreated - retinal infarction, permanent blindness
- Treatment of CRVO
- laser photocoagulation - variable results
- Estrogen functions (8)
-
follicle growth
endometrial proliferation
myometrial excitability
hepatic synthesis of transport proteins
feedback inhibition of FSH
LH surge
smooth muscle relaxation - Progesterone functions (5)
-
endometrial gland secretions
spiral artery development
decreased myometrial excitability
increased body temperature
inhibition of LH, FSH - hCG functions (2)
-
maintians corpus luteum for T1 by acting like LH
detect pregnancy (in urine at 8 days) - physiologic changes in pregnancy - CVS (4)
-
increased CO (30-50%), HR (10-15bpm), SV
possible S3, syst. murmurs (Normal) (new diast. murmur never normal!)
decreased SVR
decreased BP T1, normalizes by 40 weeks
cardiomeagly on CXR d/t heart displacement upwards - physiologic changes in pregnancy - cervix (2)
-
softening and cyanosis ~4wks
bloody show = thick mucus clot - physiologic changes in pregnancy - endocrine (3)
-
high estrogen => ↑TBG, bound T3, T4, unchanged active unbound hormone
HPL - acts as insulin antagonist to maintain fetal glucose => prolonged post-prandial hyperglycemia, fasting hyperinsulinemia, triglyceridemia, exaggerated starvation ketone response
↑total and free cortisol - physiologic changes in pregnancy - GI (4)
-
N/V (<=70%) resolves by 14-16wks
↑acid reflux d/t ↓LES tone
constipation d/t ↓bowel motility,↑H2O absorption
↑biliary cholesterol - physiologic changes in pregnancy - hematologic
-
↑plasma V (50%), RBC mass (30%)=> ↓Hb, hct = 'physiologic anemia'
WBC count ↑s throughout X=10
pregnancy = hypercoagulable state - physiologic changes in pregnancy - pulmonary
-
↑tidal V (40%)
↓TLC, RV,ERV
RR same
↑minute vent. => ↑Pa/PAO2, ↓Pa/PACO2 = 'dyspnea of pregnancy' - physiologic changes in pregnancy - Renal
-
kidneys dilate
↑GFR (50%)
↑RPF (30%)
↑estrogen/progesterone => ↑RAAS = ↑aldosterone - physiologic changes in pregnancy - skin
-
↑estrogen - stigmata like liver disease
↑αMSH, steroids => hyperpigmentation - midline (linea nigra), face (chloasma), perineum - physiologic changes in pregnancy - vagina
-
thick acidic secretions
Chadwick's sign = violet colouration from ↑blood flow - Nagle's rule = EDD
- add 9m + 7d to 1st day of LMP
- Ways to determine GA
-
uterine size
quickening (17-18wks)
fetal heart tones (10wks)
U/S fetal crown-rump length (5-12wks) biparietal diameter (20-30wks) - Labs at initial visit for pregnancy
-
CBC, UA + culture, Pap, blood type, Rh + Ab screen, rubella Ab titer, HBsAg, syphilis screen, cervical gonoccocal & chlamydia
PPD
glucose teting
HIV - Labs at 15-19wks GA
-
MSAFP or triple screen (=MSAFP, estiol, β-hCG)
amnio if >35y/o - Labs at 26-28wks GA
-
glucose loading test
give Rhogam at 28 wks if mom Rh-ve - Labs at 32-36wks GA
-
cerval chlamydia + gonorrhea in high risk
GBS screen - causes of ↑MSAFP (MoM >2.5)
-
1. open NTD - anencephaly, SB
2. abdominal wall defects - gastroschisis, omphalocele
3. multiple gestation
4. incorrect dates
5. fetal death
6. placental abnormalities - abruption - causes of ↓MSAFP (MoM<0.5)
-
need amnio and karyotyping to r/o chromosomal abnormalities
- trisomy 18, 21 - pattern of triple screen with Down's
-
↓AFP, estriol
↑hCG - pattern of triple screen with trisomy 18
- ↓AFP, estriol, hCG
- Compare complications of amnio with CVS
-
amnio (15-17wks)
fetal maternal hemorrhage 1-2%
fetal loss 0.5%
CVS (10-12wks)
fetal loss 1%
inability to Dx NTD
limb defects if <9wks GA - Indications for percutaneous umbilical blood sampling
-
Ax/Rx Rh isoimmunization/erythroblastosis fetalis
karyotyping
fetal infection (CMV, toxo, rubella)
genetic dz
fetal acid-base status - Normal labour and deliver stages
-
first
latent - onset to 3-4cm
active - 4cm to 10cm (1.2cm/h primi, 1.5cm/h
multip)increased with CPD
2nd - complete dilatation to delivery
34d - delivery of infant to placenta - Factors affecting active phase of labour
-
3P's
power
passenger
pelvis - Normal NST
-
FHR monitored by doppler correlated with reported mvts by mom
- acceleration ≥15bpm above baseline for ≥15sec twice in 20min - positive contraction stress test
- repetitive late decels during ≥3 contractions in 10min
- Biophysical profile
-
"Test the Baby MAN" - give score of 0 or 2 for each
Tone
Breathing
Movement
Amniotic fluid volume
NST
"+ve test" = score 0-2 - Early decelerations
-
begin and end with contraction
caused by cephalic compression (no fetal distress) - Variable decelerations
-
at any time during contraction
Caused by:
umbilical cord compression (change maternal position) - Late decelerations
-
begin at peak of contraction and end after contraction has finished
- uteroplacental insufficiency
- fetal hypoxemia
- potentially d/t abruption or hypotension
- if repetitive and severe deliver ASAP - Hyperemesis Gravidarum
-
intractable N/V after 14-16wks
poor wt gain/wt loss
more common in G1P0, molar pregnancies
labs - ketonemia, ketonuria, hyponatremia, hypokalemic-hypochloremic m.a. - Diagnosis of GDM
-
fasting serum glucose >126mg/dL
random >200mg/dL
abnormal GTT
1hr (50g) >140gm/dL
3hr (75g)with any 2 of -
fasting ≥95,
1h ≥180
2h ≥155
3h ≥140