ABRUPTIO PLACENTA- 4 vaginal bleeding, ABDOMINAL PAIN, and uterine tenderness and the absence of hemorrhage. DOES NOT rule out this Dx DDx: Placenta Previa, absence of bleeding RULES OUT PP. ****Risk factors: 1-HTN and PRE-ECLAMPSIA, 2-Placental abruption in previous pregnancy, 3-trauma, 4-short umbilical cord, 6-COCAINE abuse. AP MCC of DIC in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation. ****Risk Factors: Smoking and Folate def. It can progress rapidly so careful monitoring is mandatory. Once dx is made, large-bore IV and Foley catheter. Pts with AP in LABOR -- managed aggressively to insure rapid vaginal delivery, this will remove the inciting cause of DIC and hemorrhage. ***If stable: Tocolysis with MgSO4 is considered, but remember Ritordin is C/I in pt with HTN. *** Once we dx the next step: Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is C/I à EMERGENT C-SECTION. If there is Dystocia (narrowing birth passage) then Forceps can be used. ABCD of HOMEOSTASIS 1-AIRWAY: An airway is needed for all unconscious pts *** ER = OROTRACHIAL INTUBATION (Best method) *** In the field = NEEDLE CRICOTHYOIDECTOMY *** Conscious pt = CHIN LIFT w/FACE MASK 2-BREATHING: Cervical spine injury should be analyzed but 1st step is to establish ABC. 3-CIRCULATION: Needs control of bleeding and restoring the BP. ***Most External Injuries -- PRESSURE is enough to stop bleeding ***Scalp Laceration -- SUTURING is needed. All pts with HYPOTENSION receives rapid infusion of isotonic fluid (e.g. RINGERS LACTATE) to prevent life-threatening hypotension. If IV line is not good for ADULTS do saphaneous vein cut down and CHILDREN -- intraosseous membrane cannulation. ABSENCE SEIZURES - 3 Tx: Ethosuxamide or VALPROATE. Classic EEG: Symmetric 3 MHz spike and wave ***Phenytoin and Carbamazapine are 1st line for primary generalized tonic clonic seizure or partial seizures, both work by blocking Na channels voltage dependent ***Phenytoin is a 2nd line for myoclonic and tonic clonic seizure, FORMS: IV and oral SE: Gingival hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoin & Carbamazepine can cause Steven-Johnson and Toxic Epidermal Necrolysis. ACARBOSE SE Blocks carbohydrate breakdown in the intestinal tract. Most significant SE: GI disturbance d/t increased undigested CHO in the stool. ACE INHIBITORS SE Resp, 6/2 CAPTOPRIL (Cough, Angioedema, Pregnancy, Taste change, hypOtension, Proteinuria, Rash, Increase renin, Lower AII) and HyperK. Cough is caused by accumulation of Kinins possibly by activation of arachadonic acid PW. Kinins are degraded by ACE, when there is no ACE they increase. *****Angioedema that is seen in ER. Pt presents with non-inflammatory subcutaneous edema and laryngeal edema due to bradykinin stimulation. ACETAMINOPHEN TOXICITY - 2 ***Acute alcoholic intake: Can reduce the risk of hepatic injury by Acetaminophen b/c it competes w/CYP2E1, so there is less production of toxic metabolites. ***Chronic alcohol intake increases risk of hepatic injury by stimulating P450 system and decreasing the amount of Glutathione (used for metabolism of acetaminophen). Management: 1) 4-hr post ingestion Acetaminophen levels are determined to decide whether the pt will benefit from NAC or not. 2) If ingested >7.5 g and levels will not be available w/in 8 hrs of ingestion, the antidote should be given ACETAZOLAMIDE TOXICITY Causes normal anion gap metabolic acidosis due to renal loss of bicarbonate. Anion Gap is 140-(114+116) =10 which is normal anionic gap metabolic acidosis. ACHALASIA - 3 Dx 1-Barium studies 2- Esophagoscopy 3-Manometry. **CONFIRMATION is Manometry; also need to do Endoscopy to rule out malignancy. ACL INJURY It prevents gliding of tibia under femur. Injury is seen after Hyperextension. A popping sensation is felt at time of injury. Commonly assoc w/ Medial Meniscus and Medial Collateral Ligament (TRIAD). Lachman test --- for ACL tear. Flex and pull tibia. Drawer sign also tests ACL but it’s less sensitive. Posterior Drawer sign tests PCL. McMurry's sign tests Meniscus injury. Valgus test is for MCL. ACNE - 2 1-Comedones (black/white heads): minimal inflammation and tx is topical retinoids. If reactivation occurs add topical Erythromycin or Benzoyl peroxide 2-Papular and inflammatory: w/ moderate-severe inflammation: Oral Doxycycline. 3-Nodular or scaring: Oral Isotretinoin. ACROMEGALY ACTINOMYCOSIS Cervicofacial actinomycosis presents as slowly progressing, non-tender, indurated mass, which evolves into multiple abscesses, fistula, and draining sinus tracts with sulfur granules, which appear yellow. Actinomyces israelii is the agent Tx: High dose IV penicillin x 6-12 weeks. Surgical debridement after penicillin therapy. ACUTE ADRENAL INSUFFICIENCY Acute onset of nausea, vomiting, abd pain and hypoglycemia and hypotension after a stressful event (surgery) in a pt is steroid dependant is typical. ***CLUE: Pre-Operative steroid use. Exogenous steroids depress pit-adrenal axis and a stressful situation can precipitate AAI. DDx: Insulin-induced hypoglycemia r/o b/c doesn’t cause N and V, abdominal pain and hypotension. ACUTE ALKALI INGESTION When a pt takes Lye (alkali substance for suicide), UPPER GI CONTRAST STUDIES--ASAP to assess the damage and possible perforation of esophagus. Normal XR doesn’t R/O a perforation. Once you know there is no perforation then do DIAGNOSTIC PERONEAL LAVAGE if necessary. But 1st rule out perforation. ACUTE APPENDICITIS - 3 Pt who comes to hospital after 5 days of initial symptoms must be hospitalized w/IV hydration and IV CEFOTETAN. If there is abscess w/CTà PERCUTANEOUS DRAINAGE is an option ****Most pelvic abscesses are due to perforation of AA. Pt might have a 24 hr RUQ pain that resolves spontaneously and then in a few days he may come with anal abscess symptoms. Tx of choice: Drainage of the abscess **** When resection of part of ascending colon is required (e.g. right hemicolectomy w/ileo-transverse anastomosis has best postoperative results); and that is when pt has shown gangrenous rupture of appendix with questionable necrotized colon. ACUTE BACTERIAL PROCTATITIS MCC in young is Chlamydia and Gonococcus, in elderly = E. Coli. Dx: Culture of mid-stream urine sample & start empiric therapy. Prostate massage is C/I due to septicemia chance. ACUTE GI BLEEDING There are 3 causes: 1-Diverticulosis (Painless. can be r/o with Barium Enema), 2-Angiodysplasia (Painless. maybe seen as cherry-red spots that maybe coagulated, Dx: Labeled erythrocyte scintigraphy). 3-PUD (Painful) Dx: Endoscopy, if there is Hematochezia, bright red blood, d/t lower GI bleed, no need for endoscopy, the blood is from lower UGI bleeding). ACUTE RENAL TRANSPLANT REJECTION Renal transplant rejection in the early post-op stage can be explained by urethral obstruction, acute rejection, Cyclosporine toxicity, vascular obstruction and ATN. To determine the cause do U/S, MRI and Bx. If Bx shows infiltration of lymphocytes & vascular swelling and increased CR and BUN and oliguria, then the cause is Acute Rejection. Tx: High dose IV steroids. ACUTE TUBULAR NECROSIS Prolonged hypotention due to any reason (Hypovolemic shock) can lead to ATN. Hallmark on U/A is Muddy brown granular cast. DDx1: RBC cast, GN DDx2: WBC cast, Interstitial Nephritis & Pyelonephritis DDx3: Fatty cast, NephrOtic Syndrome DDx4: Broad and Waxy cast: Chronic renal failure ACYCLOVIR TOXICITY Can cause crystalluria with renal tubular obstruction during high dose parenteral therapy, especially in inadequately hydrated pts. ADDISON’S DISEASE - 2 MM-101. Aldosterone deficiency: non-anion gap hyperK+, hypoNa+, metabolic acidosis. ***80% of pt have primary adrenal deficiency due to Autoimmune adrenalitis. These pts also present with autoimmune involvement of other glands as well, like thyroid, parathyroid, ovaries. *** 70% of Causes of Primary Adrenal Insufficiency is autoimmune, mostly in developed countries. In underdeveloped countries MCC: TB, Fungal infection and CMV infection. Adrenal Calcification is a typical feature of TB PAI. Presents w/NO RISE IN SERUM CORTISOL AFTER COSYNTROPIN (ACTH analog); CT shows calcification of adrenal glands. Tx of TB does not result in normalization of adrenal gland. PAI in HIV is common, MCC is CMV. Sometimes Ketoconazole can cause it. PAI is very rare with adrenal tumor metastasis; even then calcification is not seen. ADENOMYOSIS Presence of endometrial glands in uterine muscle. MF in women > 49, presents w/severe dysmenorrhea, and menorrhagia. The typical exam reveals enlarged symmetrical uterus. If Adenomyosis is in one side of uterus then enlargement is ASSYMMETRICAL & SOFTER consistency DDx: Myomatous Uterus, Leomyoma, Endometrial carcinoma. Women age> 35, MANDATORY to perform Endometrial curettage or even hysterectomy to rule out endometrial cancer. DDx1: Endometriosis: a benign condition, where foci of endometrial glands are found OUTSIDE of endometrium. They increase in size throughout menstrual cycle. Assoc w/Adenomyosis occurs in 15% of cases. DDx2: Leomyomas: are difficult to distinguish from Adenomyosis, except consistency of Uterus is softer in Adenomyosis. DDx3: Endometrial Carcinoma : occurs in women after menopause. DDx4: Endometritis: fever, and enlarged and tender uterus, assoc with vaginal discharge. It usually occurs after a septic abortion, and the MCC is Strep. ADHD Short attention span, impulsivity, hyperactivity >6mo. Tx: Methylphenidate or Pimoline, SE: Decreased