Internal Medicine.docx
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Internal Medicine.docx
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InternalMedicine
6.Pleuraleffusion
Separationofexudatesfromtransudates
AccordingtoLight'scriteria,apleuraleffusionislikelyexudativeifatleastoneofthefollowingexists.
1.Pleuralfluidprotein/serumprotein>0.5
2.PleuralfluidLDH/serumLDH>0.6
3.PleuralfluidLDH>2/3uppernormallimitforserumLDH
7.COPD
Homeoxygentherapy-MCQ
GroupⅠ(anyoffollowing)
1.PaO2≤55mmHgorSaO2≤88%takenatrestbreathingroomair,whileawake.
2.Duringsleep(prescriptionfornocturnaloxygenuseonly)
∙PaO2≤55mmHgorSaO2≤88%forapatientwhoseawake,resting,roomairPaO2is≥56mmHgorSaO2≥89%or
∙DecreaseinPaO2>56mmHgordecreaseinSaO2>5%associatedwithsymptomsorsignsreasonablyattributedtohypoxemia(e.g.Impairedcognitiveprocesses,nocturnalrestlessness,insomnia)
3.Duringexercise(prescriptionforoxygenuseonlyduringexercise)
∙PaO2≤55mmHgorSaO2≤88%takenduringexerciseforapatientwhoseawake,resting,roomairPaO2is≥56mmHgorSaO2≥89%and
∙Thereisevidencethattheuseofsupplementaloxygenduringexerciseimprovesthehypoxemiathatwasdemonstratedduringexercisewhilebreathingroomair.
GroupⅡ
PaO2=56-59mmHgorSaO2=89%ifthereisevidenceofanyofthefollowing
1.Dependentedemasuggestingcongestiveheartfailure
2.PulmonaryonECG(Pwave>3mminstandardleadⅡ,Ⅲ,oraVF)
3.Hematocrit>56%
8.Asthma
Asthma–Diagnosis(important)
∙Episodicorchronicsymptomsofairflowobstruction:
breathlessness,cough,wheezing,andchesttightness.Symptomsfrequentlyworsenatnightorintheearlymorning.
∙Prolongedexpirationanddiffuse(ormigrating)wheezesonphysicalexamination.
∙Demonstrationofvariableexpiratoryairflowlimitation(1of2ways)
1.LimitationofairflowonPFT(PulmonaryFunctionalTesting)+Completeorpartialreversibilityofairflowobstruction,eitherspontaneouslyorfollowingbronchodilatortherapy
2.Positivebronchoprovocationchallenge.
∙ExclusionofOtherdiagnosis
Differentialdiagnosis
Allthatwheezesisnotasthma
1.Upperandlowerairwaydisorder
∙Foreignbody
∙Trachealnarrowing,
∙COPD
∙Bronchiectasis
∙Pulmonaryedema(congestiveheartfailure)
∙Allergicbronchopulmonaryaspergillosis(ABPA)
2.Systemicvasculitides
∙Churg-Stausssyndrome
∙Systemicvasculitideswithpulmonaryinvolvement
3.Psychiatricdisorders
∙Conversiondisorder
∙Panicattack
SeverityClassification(important)
TreatmentStrategies
∙Routinemonitoringofsymptomsandlungfunction
∙Patienteducationtocreateapartnershipbetweenclinicianandpatient(naturalcourse,prognosis,medicineadministrationmaneuvers)
∙Controllingenvironmentalfactors(triggerfactors)andcomorbidconditionsthatcontributetoasthmaseverity
∙Pharmacologictherapy
StepwiseTreatmentStrategyforAsthma
ICS:
Inhaledcorticosteroid
LABA:
long-actingBagonists
SABA:
Short-actingBagonists
LAMA:
long-actingmuscarinicantagonist
LTM:
leukotrienemodifier
LRTA:
Leukotrienereceptorantagonist
14.Valvularheartdisease
Rheumaticfever
Diagnosis
Majorcriteria
•Polyarthritis
•Carditis
•Subcutaneousnodules
•Erythemamarginatum
•Sydenham'schorea(St.Vitus'dance)
Minorcriteria
•Feverof38.2–38.9 °C(100.8–102.0 °F)
•Arthralgia:
Jointpainwithoutswelling(Cannotbeincludedifpolyarthritisispresentasamajorsymptom)
•RaisedESRorCRP
•Leukocytosis
•ECGshowingfeaturesofheartblock,suchasaprolongedPRinterval(Cannotbeincludedifcarditisispresentasamajorsymptom)
•Previousepisodeofrheumaticfeverorinactiveheartdisease
16.CoronaryAtheroscleroticHeartDisease(CHD)
KillipClassandMortality
ReperfusionstrategyforSTEMI
19.CardiacArrhythmias
Atrialfibrillation:
CommonCauses(Multiplechoice)
∙Coronaryarterydisease
∙Hypertensiveheartdisease
∙Valvularheartdisease,mitralstenosis
∙Cardiomyopathy
∙Thyrotoxicosis
∙Occasionally,nostructuralheartdisease,especiallyparoxysmalatrialfibrillation
22.PepticUlcerDisease
Specialtypeofpepticulcer
∙Complexulcer
∙Ulcerofpyloriccanal
∙Postbulbarulcer
∙Macrosisulcer
∙Pepticulcerinagedpeople
∙Asymptomaticulcer
Stagesofulcer
∙Activestage–clearwithacleanbaseandinflammatorysurrounding
∙Healingstage–basedisappeared,inflammatorysurroundingpresent
∙Scarringstage–onlydeformationorscarofulcer
Differentialdiagnosis
GastricUlcer
GastricCancer
Size
Small
Larger
Baseofulcer
Clean
Shaggy
Border
Regular
Irregular
Surroundinginflammation
Lessprominent
Prominent
Biopsyisthemostreliablefordifferentialdiagnosis
Etiopathogenesis
Defensivefactors
∙Mucus-HCO3-barrier
∙ProstaglandinandEGFfromtheepithelialcell
Invasivefactors
∙Helicobacterpylori
∙NSAIDs
∙Gastricacidandpepsin
∙Smoking,diet,stress
ClinicalManifestation
EpigastricpaininbothDU&GU
DU:
painoccurringwhenfastingoratnight,relievedbyfoodorantaciddrugs
GU:
painoccurringaftermeal,relievedbyfasting
PhysicalExamination:
Epigastrictenderness
ComplicationofPUD
∙Bleeding
∙Perforation
∙Canceration
∙Obstruction
DiagnosisofPUD
∙Symptoms&signs
∙Endoscopy-Mostsensitive,accurateandvaluableexamsforPUD
∙Biopsy–Ifnecessary,especiallyfordifferentialdiagnosis
∙X-raybariummeal
∙Hpdetection-Rapidureasetestor13Cor14Cureabreathtest
Treatment
1.Generaltreatment
2.Anti-ulcerdrugs
3.Hperadication
1.GeneralTreatmentofPUD
∙Rest&diet
∙Smoking,alcohol&NSAIDs
2.Applicationofantiulcerdrugs
∙Relievesymptoms,facilitatehealingofulcer
∙OftencombinewithHperadicationtherapy
∙Insomecases,maintenancetherapyisnecessary
Types(atleast1drugfromeachtype)
∙Acidinhibitiondrugs
1.Antacid
Algeldrate,hydrotalcite
2.H2RA(H2receptorantagonist)
Cimetidine,Ranitidine,Famotidine
3.PPI(Protonpumpinhibitor)
Omeprazole,Lansoprazole,Rabeprazole
∙Gastricmucosaprotectiondrugs
1.Sucralfate-Sucralfate
2.Prostaglandins-Misoprostol
3.Bismuthcompound-Colloidalbismuthsubcitrate
3.Hperadicationtherapy
∙HpmustbeeradicatedinallHp-positivepepticulcer!
!
∙RegimenofHperadication(14days)
Acidsuppressor+twoantibiotics
Acidsuppressor–PPIorColloidalbismuthsubcitrate
Antibiotics-Amocicillin,clarithromycin,metronidazole
4.AntiulcertherapyafterHperadication
∙Ulcerpatientwithcomplications
∙Patientwithlargeulcerorrecurrentulcer
∙SymptomcannotberelievedafterHperadication
24.HepaticEncephalopathy
MechanismofHE–NH3intoxication
Clinicalmanifestations
1.Disturbedconsciousness:
∙Sleepdisturbance–Changeofsleeppatterntohypersomnia,ordrowsiness
∙Confusionincludingdelirium
∙Unconscious
2.Abnormalbehavior
3.Abnormalcognition
4.Abnormalnervereflexes–Flappingtremor(asterixis)
25.UlcerativeColitis
DefinitionofIBD
∙Inflammatoryboweldisease(IBD)ischronicintestinalinflammationwithunknownetiology,includingulcerativecolitis(UC)andCrohn’sdisease(CD).
∙UCisaninflammatoryprocessconfiningtothecolonwhichpresentswithbloodydiarrhea,mucusandbloodypurulentstool,abdominalpain,andweightloss.Thelesionissuperficial,continuesdiffuselyandoftenbeginsintherectum.
PathologyofUC
1.Inflammationbeginsintherectum,extendsproximallyacertaindistance.
2.Acleardemarcationexistsbetweeninvolvedanduninvolvedmucosa,andno"skipareas"arepresent.
3.Primarilyinvolvesthemucosaandthesubmucosawithinfiltrationofinflammatorycells.
4.Edemaandcongestionofthemucosawithfocalhemorrhage
5.Formationofcryptabscessesandmucosalulceration.
6.Themucosatypicallyappearsgranularandfriable.
7.Pseudopolypsform,inmoreseverecases.
Bariumenemaiscontraindicatedinpatientswithmoderatetoseverecolitis,asitincreasestherisksofperforationandtoxicmegacolon.(Evennormalsalinemaybeharmful)
DifferentialdiagnosisCD&UC
Treatment
1.EmergencyDepartmentCare
Initiatesupportivecarewith
(1)bowelrest,
(2)nasogastricsuction,and(3)intravenousfluidscontainingelectrolytes
2.Medication
1.Agentsforsymptomatictreatment-loperamide,anticholinergicagent,ironsupplement
2.Aminosalicylates
∙Salicylazosulfapyridine(sulfasalazine,SASP)
Sideeffects:
WBCandRBCdecrease(Moresideeffectscomparedtootherdrugs)
∙5-aminosalicylicacid(5-ASA)
3.Corticosteroids
4.Immunomodulators
5.Biologics
6.Antibiotics
3.Surgery-Proctocolectomy+ileoanalanastomosis
29.GlomerularDiseases
ClinicalpresentationofGlomerularDiseases
GlomerularDiseases
ClinicalPresentation
LatentGN
Microscopicorgrosshematuria(AbnormalRBC,SpikeRBC)
Proteinuria
NephroticSyndrome
Proteinuria>3.5g/d
Hypoalbuminemia
Hyperlipidemia
Edema
AcuteGN
Hematuria
Proteinuria1-3g/d
ARF
Edema
Hypertension
RBCcasts
RapidlyprogressiveGN
Rapidlyprogressivedeteriorationofrenalfunction
Hematuria
proteinuria
Progressiveoliguria,anuria
RBCcasts
Withorwithoutsystemicsymptoms
ChronicGN
Hematuria
Proteinuria
Highbloodpressure
Renaldysfunction
Manifestations(&definition)ofNephroticsyndrome
∙Insidiousonset
∙Manifestations(1sttwoareenoughfordiagnosis)
1.Proteinuria>3.5g/d
3.Hypoalbuminemia(albumin<30g/l)
4.Edema
5.Hyperlipidemia
Epidemiologyofnephroticsyndrome
PathogenesisandcomplicationsofNS
TreatmentforNS
AlbuminusedONLYwhen:
•Severeedemaun-responsivetodiuretics
•Loweffectivebloodvolume
Steroidstherapywithdosage
ThreetypesofrapidprogressiveGN
∙RPGNtypeIAnti-GBM+(Goodpasturesyndrome–Respira
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