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Terms in this set (171)

are the most common carpal bone fracture and occur while falling on an outstretched hand with a dorsiflexed wrist (The scaphoid spans both the proximal and distal carpal row. In this position it is quite vulnerable to high-impact injuries, such as a fall on an outstretched hand, and is the most commonly fractured carpal bone.).
↓Range of motion in the wrist + point tenderness over the radial aspect of the wrist/ the scaphoid within the anatomic snuffbox (snuffbox tenderness)+ ↓grip strength
It can take up to 2weeks to show the fracture in X-ray. The current guidelines recommend MRI or CT of the wirst to distinguish between fracture and ligament injuries. Patients should be referred to an orthopedic surgeon if they have a scaphoid fracture displaced >1mm, association with tilf of the lunate, nonunion during follow-up, osteonecrosis or scapholunate dissociation. If not meet surgical indications and have a nondisplaced fracture should be placed in a short-arm thumb spica cast (with wrist deviated radially and neutrally flexed) and have follow-up X-rays every 2 weeks to monitor healing. Immobilization should be continued until there is radiographic union. Scaphoid fractures are most commonly complicated by nonunion骨折不愈合 and avascular necrosis (proximal fractures of the scaphoid has less blood supply and require longer immobilization, 12weeks for adequate healing,)
Malunion骨连接不正is more commonly seen in physeal fractures of the distal forearm in children due to injury of the growth plate and growth arrest → a growth disparity between the radius and ulna wrist deformity
DD
1. Colles fracture: occurs after a blow to the wrist while falling on an outstretched hand and has the appearance of a dinner fork on lateral view of the wrist due to the ulnar styloid separating from the rest of the bone (A Colles fracture is a fracture of the distal radius at the metaphysis, which is displaced dorsally and often angulated. It is the most common wrist fracture in adults. The ulnar styloid is often involved, and there may be intraarticular involvement as well.)
1. Hamate fracture: occur while falling on an outstretched hand, near the hook of the hamate containing the ulnar artery and nerve, pain/swelling in the hypothenar eminence and ulnar aspect of the wrist
2. Radial styloid fracture (Hutchingson /chauffeur fracture) occurs due to a direct blow to the styloid while falling on an outstretched hand with ulnar deviation and supination - a fracture dislocation of the radial styloid and either lunate or scaphoid
3. Wrist sprain of the ligaments: mild pain/stiffness with normal range of motion, resolve with conservative/supportive care. Worse pain with flexion and extension of the ligaments rather then severe point tenderness with palpation
纤维瘤
A locally aggressive benign tumor arising from fibroplastic elements within the muscle or fascial planes with very low potential for metastasis/differentiation due to abnormal wound healing or clonal chromosomal abnormalities causing a neoplastic behavior, has variable clinical course.
Rare but increased in familial adenomatosis polyposis (Gardner syndrome)
Typically present as deeply seated painless/painful masses in the trunk/extremity, intraabdominal bowel and mesentery and abdominal wall. They can cause intestinal obstruction and bowel ischemia and have a high rate of recurrence even after aggressive surgery
Treatment: surgery or radiation
DD
1. Dermatofibroma
A benign proliferation of fibroblasts that usually occurs after trauma or insect bite or idiopathic, a firm hyperpigmented nodule located on the lower extremities rather than the abdomen
2. Epidermoid像表皮的cyst
A discrete nodule that is usually located on the skin and a result of the normal epidermal keratin becoming lodged in the dermis. It can be seen in Gardner syndrome but are usually located on the extremities, can resolve spontaneously without treatment
3. Lipoma
An asymptomatic and benign subcutaneous collection of fat cells. Soft without rapid enlargement or recurrence after resection.
4 Pyogenic granuloma (granuloma telangiectaticum)
Caused by capillary proliferation after trauma
Dome-shaped papule with recurrent bleeding, more commonly seen in pregnant women


In digital injuries, tendons are more likely to be injured than arteries, veins or nerves due to their relative, vulnerable anatomic location. Digital arteries, nerves and veins run on the sides while the flexor tendons run on the anterior surface of the phalanges. Attempting to grab a knife with a hand is likely to injure the tendons.
Excruciating pain + swelling in the anterior part of the knee + inability to maintain passive extension of the knee against gravity
Treatment: early surgical repair of the ruptured patellar tendon, delayed treatment can lead to quadriceps muscle atrophy, contracture formation and limited range of motion of the knee →significant disability
DD
1. Anterior cruciate ligament tear (ACL)
Popping sensation/sound at the time of injury
Anterior drawer test +: A difference of 1cm compared with the opposite side suggests a complete tear of the ACL
Lachman test is most sensitive for ACL insufficiency (80-95%)
2. Meniscal injury
A twisting force with the foot fixed on the ground, commonly seen during football/basketball games, McMurray's maneuver + with an audible /palpable click or popping sensation during extension of the involved knee
3. Medial collateral ligament injury
Tenderness/pain along the medial joint line. \
It is most frequently caused by an injury involving valgus (abductor) stress to the partially flexed knee with the foot fixed. Such injury can occur while skiing or during contact sports when another person falls across the knee from the lateral to medial direction
Did the patient or someone else hear a pop?
If yes, suspect ACL tear (80%), meniscal injury (15%), and rarely a fracture.
When did you notice swelling?
If 0-12 hours after the injury, suspect ACL tear or patellar dislocation/subluxation;
if 12-24 hours, suspect meniscal injury.
If there is hemarthrosis on aspiration,
suspect ACL injury (>75%), patellar subluxation, or intraarticular fracture.
Acute onset of severe abdominal pain+ unmatched PE with the severity of pain + metabolic acidosis is generally mesenteric ischemia unless proven otherwise.
Leukocytes, Hb, serum amylase, LDH , creatine phosphokinase or alkaline phosphatase can be ↑ in mesenteric ischemia
The most commone cause is superior mesenteric artery(SMA) occlusion secondary to an embolism. SMA runs off at a minimla angle from the aorta and has a wide diameter.
Risk factors are cardiac arrhythmia, recent MI and abdominal malignance.
60% mortaility rate (untreated mesenteric ischemia → bowel infarction, sepsis and death)

Cardiac arrest due to lightening injuries usually present with asystole and should be treated with prompt and sometimes prolonged cardiopulmonary resuscitation.
Defibrillation is effective for ventricular fibrillation and pulseess ventricular tachycardia but not aystole.
Epinephrine and then atropine should be given for asystole.
The most common injuries from lightning include cardiac(sudden cardiac arrest), renal (rhabdomyolysis), nervous system (autonomic dysfunction → fixed/dilated pupils, ruptured eardrum and vitreous hemorrhage) and skin (thermal burn)

Numerous complications can occur from iv nutrition in critically ill patients. The most dangerous metabolic complication, hyperglycemia, is most commonly caused by too rapid initiation of the infusion. It is best prevented by initiation of the infusion at 40-60cc/hour, and slowly increasing the rate at 20 cc/hour every 24 hours, while monitoring the patient's glucose level. Patients with normal glucose intolerance may manifest glycosuria for the first 48hours of parenteral nutrition. Before initiating insulin, one must verify that the glucose level is high and that glycosuria is not secondary to a reduced threshold for glucose.
The most common cause of sudden hyperglycemia is sepsis and hyperglycemia may antedate other signs of sepsis within 24 hours. The sudden appearance of hyperglycemia should initiate a thorough search for the source of infection.

Dumping is a common complication of gastrectomy: abdominal pain + diarrhear+ N/V+dizziness, generalized sweating, dyspnea
Treat: a high protein diet, low in carbohydrate
Fractionated, smaller, more frequent foot portions


14% of pregnant women in the 2nd trimester can have premature delivery when affected by appendicitis while around 33% of those in the 1st trimester may experience abortion. During the third trimester the main complication is appendix perforation with peritonitis and subsequent pylephlebitis (infectious thrombosis of the portal veins) 门静脉炎. These complications are rare but feasible, especially if therapy is not offered within the first 24 hours of the initiation of symptoms)
visible, palpable and tortuous superficial veins of the legs. Most are asymptomatic. Some may complain of leg cramping, heaviness, fatigue and swelling. The symptoms are generally worse in the evening with prolonged standing and improve with leg elevation.
1. conservative measures: leg elevation, weight reduction and ↓venous pressure in the lower extremities by direct compression (compression stocking should not be used in arterial insufficiency)
2. Injection sclerotherapy (sclerotherapy → endothelial damage + sclerosis of the involved vein→ prevent further vein filling) for patients with symptomatic, small, varicose veins who have failed at least 3-6 months of conservative treatment.
3. surgical ligation + stripping : large symptomatic varicose veins + ulcers, bleeding, recurrent thrombophlebitis of the veins.
external laser treatment: particular veins and/or telangiectasia , not for varicose


The patients with blunt chest trauma requires further evaluation for blunt cardiac injury (BCI). Patients with BCI can have varying degrees of severity including transient dysrhythmias, cardiac wall motion abnormalities, cardiogenic shock and free wall rupture. Cardiac contusion is the most common injury.
The first step after initial stabilization of the patient is to do a chest x-ray to evaluate for fractures, pneumothorax, hemothorax and widened mediastinum indicating possible aortic injury. A patient can either be asymptomatic or manifest various symptoms of cardiac injury ranging from mild chest pain (dull or pressure-like pain) to severe heart failure and cardiovascular collapse.
If the chest x-ray is abnormal or the patient is hypotensive, further testing by focused assessment with sonography in trauma (FAST) examination or CT scan of the chest can be done to evaluate for aortic injuries or hemopericardium心包积血.
All patients should have a 12-lead ECG especially if there is anterior chest trauma(bruise), are elderly or have a h/o coronary artery disease. 12-lead ECG is the single most important screening test for BCI. Patients with possible BCI and normal ECG require no further treatment or investigation. Abnormal ECG in CBI include a new bundle branch block, persistent sinus tachycardia, ST depression or elevations and other arrhythmias.


An individual who suffers severe traumatic injury should be given narcotics for pain relief, regardless of addiction history
is a type of non-scarring hair loss that can affect any hair-bearing area. It is an autoimmune process.
Well-demarcated, round, non-scarred patch of complete hair loss. "Exclamation point hairs"(hairs which are tapered near the insertion into the scalp, especially at the periphery of an alopecic plaque) is considered pathognomonic of but not necessary for the diagnosis. Areas of involvement may be single or multiple. Nail pitting is a common associated finding.
Self-limited but may be relapsing and remitting or chronic and progressive.
↑risk for other autoimmune conditions including autoimmune thyroid disease, vitiligo白癜风and pernicious anemia
DD
1. Medication-related hair loss
Diffuse non-scarring thinning
Telogen effluvium静止期脱发usually begins 3 months after some precipitating event such as an illness, stressor or new medication (beta-blocker, anti-coagulants, systemic retinoids, anti-convulsants and anti-thyoid medications are frequently implicated causes of telogen effluvium)
Chemotherapeutics can cause anagen effluvium生长期脱发which usually begins within 1-2w of chemotherapy initiation.
2. scarring alopecia
tinea capitis (erythema + scaling + "black dot" alopecia), folliculitis, + inflammation + hyperkeratosis
3. Androgenetic alopecia: treat with low-dose Finasteride indefinitely
4. Metabolic conditions: hypothyroidism, hyperthyroidism, iron deficiency
5. Trichotillomania: psychiatric impulse control disorder
Treatment: Intralesional corticosteroids
there is a high chance of recurrence of hair loss even after successful treatment.
Papillary carcinoma-most common, excellent prognosis, "ground-glass" nuclei (Orphan Annie) psammoma bodies, nuclear grooves. ↑risk with childhood irradiation.
Nearly total thyroidectomy (NTT) is the preferred treatment for patients with papillary thyroid cancer. By taking out most of the thyroid tissue, it becomes easier to destroy the resideul thyroid tissue (small thyroid tissue left after surgery) by giving high-dose radioactive iodine.
Throglobulin is used as a tumor marker for following patients after NTT and radioactive iodine treatment. Detectable serum thyroglobulin following NTT and radioactive iodine treatment suggests residual disease.
Staging of papillary thyroid cancer is not performed preoperatively even when metastase. Most papillary thyroid cancers are slow growing and the prognosis is usually very good.
In patients with thyroid cancer in remission, the dose of levothyroxine is adjusted to suppress the TSH below normal range, usually between 0.1 and 0.3uU/mL. For patients with distant metastasis, even lower levels of TSH are required. Patients being treated with suppressive doses of levothyroxine are at an increased risk for bone loss and atrial fibrillation.
Levothyroxine suppression
For high risk patients (Stage III and IV disease), we recommend full levothyroxine therapy (TSH <0.1 mU/L) . For low-risk patients (Stage I and II disease), we suggest levothyroxine suppression of TSH to slightly below the lower half of the reference range (0.1 to 2.0 mU/L)
The presence of heart disease or low bone density may necessitate a lower level of TSH suppression with smaller doses of thyroxine. The dose also may be decreased to allow the TSH to rise into the normal range in low risk patients who remain disease-free for 5 to 10 years after primary therapy
Metformin is contraindicated in patients with alcoholism, congestive heart failure and renal failure.
Pioglitazone is an insulin sensitizer and should be carefully used in patients with congestive heart failure because it can cause salt and water retention, which can worsen the cardiac failure. Pioglitazone is contraindicated in patients with NYHA class III and class IV congestive heart failure.
Glyburide increases insulin release and is useless in patients with beta cell loss secondary to chronic pancreatitis.
When renal failure, stop metformin and sulfonylureas (glyburide) that are metabolized exclusively by the kidneys
Insulin:Patients with type I diabetes are managed with a combination of basal insulin (Type I DM requires either 2 injections of NPH or one dose of a long-acting insulin like glargine to provide basal insulin delivery) and meantime boluses of regular or ultrarapid acting insulin (lispro or aspart)
NPH has its peak actions after 4-6 hours of injection, and its effects can last up to 16-18 hours. Hypoglycemia episode (glucose < 60 mg/dL) during exercise in type I DM can be managed by lowering NPH in the morning, avoiding injections of insulin in the excercising limbs and eating before excercising.
Regular (rapid onset of action, short duration of action) and NPH (slower onset of action, longer duration of action) human insulin are the most commonly-used preparations. Regular insulin has an onset of action (begins to reduce blood sugar) within 30 minutes of injection, reaches a peak effect at 1-3 hours, and has effects that last 6-8 hours.
NPH insulin is an insulin with an intermediate duration of action. It has an onset of action starting about 2 hours following injection. It has a peak effect 4-12 hours after injection, and a duration of action of 18-26 hours.

Chronic pancreatitis → islet damage → type I DM
Patients with type 2 DM are likely to have higher plasma C-peptide and insulin levels compared to patients with islet damage
Patients with DM secondary to chronic pancreatitis are more prone to develop hypoglycemic reactions with insulin use due to the associated loss of both alpha and beta cells (in type I DM, there is selective loss of beta-cells). Alpha cells in the islets secrete the counterregulatory hormone glucagon, which is important in increasing blood glucose levels during hypoglycemia, therefore, loss of alpha cells due to chronic pancreatitis will result in a poor glucagon response to hypoglycemic episodes.
Kava(for anxiety) --- liver injury, hepatitis, cirrhosis, liver failure 卡瓦根(旧时用作利尿药)
Gingko --- bleeding, Stevens-Johnson syndrome - psychosis
Aconite --- cardiotoxic: arrhythmia, hypotension 乌头毒草;从乌头草的根中所提炼的强心止痛剂


Stable and otherwise healthy adults who present with jaundice + ↑ALS + ↑AST can be evaluated on an outpatient basis. Admission to the hospital for observation is appropriate only if there is concern that the pt's condition will worsen rapidly in the near future.
Acute hepatitis B virus infection is a subclinical or anicteric syndrome in 70% of pt, with the remaining 30% complaining of symptoms such as anorexia, nausea, jaundice, and RUQ discomfort. Treatment of acute hepatitis B consists of supportive measures.
Fewer than 5% of adults stricken with acute hepatitis B infection will go on to develop chronic hepatitis B whereas 90% of infants that acquire acute hepatitis B perinatally will go on to develop chronic hepatitis B.


Triple drug therapy with a PPI, clarithromycin and amoxicillin/metronidazole (metronidazole in case of penicillin allergy) X 2w is the regimen of choice for the eradication of H. pylori infection. There is a high prevalence of H. pylori resistance to clarithromycin and metronidazole in the US.
1. use different combination of drugs/antibiotics for another 2w
2. Quadruple therapy: PPI+bismuth+tetracycline+metronidazole, take with meals for 2w
Confirmation of H. pylori eradication is recommended for pt with ulcers or ongoing dyspepsia. Either urea breath or fecal antigen testing can be used after 4w to confirm H. pylori eradication (urea breath test is more accurate than fecal antigen testing). 1w is too soon for urea breath test and may result in a false positive test. H. pylori serology should not be used since it may remain positive a year or more after eradication.
Management of adenocarcinoma arising in a polyp is usually different from other forms of colonic adenocarcinoma. If the invasive adenocarcinoma is in the head of the polyp, the margins are uninvolved, the lesion is well-differentiated, and there is no lymphovascular invasion then the pt can undergo nonoperative management, however consultation is typically required with the pt on a case by case basis. In pt who are managed nonoperatively, follow up colonoscopy should be performed in 3 months to exclude residual/recurrent disease. Subsequent follow ups should be obtained at 1, 4, and 9 years following the initial polyp resection as these pt are at an ↑risk of having colonic adenocarcinoma in the future.
Colonic polyps: Masses protruding into gut lumen →sawtooth锯齿appearance. 90% are non-neoplastic. Often rectosigmoid. can be tubular or villous. Adenomatous polyps are precancerous. Malignant risk is associated with ↑size, villous histology, ↑epithelial dysplasia. Precursor to colorectal cancer (CRC). The more villous the polyp, the more likely it is to be malignant (VILLous = VILLainOUS) .
Polyp symptoms- often asymptomatic, lower G I bleed, partial obstruction, secretory diarrhea.

Studies have shown that 30-50% of pt with one adenoma will have at least one another adenoma at a different site (synchronous adenoma). All pt with adenomatous polyps found on screening sigmoidoscopy should have a complete colonoscopy for detection of synchronous adenomas. Examination of the complete large bowel and removal of all the adenomas is an important step in reducing the risk of subsequent cancer, therefore the pt should be screened with a complete colonoscopy to detect and resect all synchronous adenomas.
No further treatment is necessary if all the following criteria are fulfilled:
1. The polyp is considered to completely excised
2. There is accurate determination of the depth of invasion, grade of differentiation and completeness of excision of the carcinoma
3. The cancer is not poorly differentiated
4. There is no vascular or lymphatic involvement
5. The margins of the excision and the stalk of a pedunculated adenoma are not involved. Invasion of the stalk of a pedunculated polyp is not an unfavorable prognostic finding, as long as the cancer do not extend to the margin of the stalk resection.
A three-year interval for surveillance colonoscopy is safe and cost-effective for the majority of pt with adenomatous polyps (> 2 adenomas, > 1cm adenoma, a villous adenoma or and adenoma with high-grade dysplasia). The surveillance intervals can be extended to 5 years if no adenomas are detected at the three-year follow-up colonoscopy.
Number/Size/Histopathology Surveillance colonoscopy
Hyperplastic polyps 10 years
1 or 2 small (< 1cm) tubular adenomas with no high-grade dysplasia 5 years
➢ > 2 adenomas
➢ High-grade dysplasia
➢ Villous features
➢ Any adenoma > 1cm in size 3 years
Adenomatous colon polyps are neoplastic lesions which have the potential to develop into colonic adenocarcinomas, make up 2/3 of polypoid lesions in the colon
Hyperplastic polyps rarely if ever develop into malignancy and should NOT affect recommendations for future colonoscopic surveillance.

Colonoscopy is the initial test of choice in pt with iron-deficiency anemia and + fecal occult blood test. Barium enema has lower sensitivity and do not offer the option of simultaneous diagnostic and therapeutic intervention (biopsy or polyectomy). In pt with no obvious pathological findings on colonoscopy, upper GI endoscopy should be performed.
The most common cause of massive lower GI bleeding in elderly pt is angiodysplasia or diverticulosis (the two entities frequently coexist). Angiodysplasia is associated with aortic stenosis, Von Willebrand disease and ESRD. The cause of angiodysplasia may be related to degenerative changes associated with aging and to intramuscular hypertrophy that obstructs submucosal veins.
Angiodysplasias are composed of ecstatic 扩张的, dilated, thin-walled vessels that are lined by endothelium alone or endothelium along with small amounts of smooth muscle.
Angiodysplasia is usually diagnosed by endoscopy being done to evaluate GI bleeding, but in some cases, radiographic imaging or surgery may be required for detection.
DD
Diverticulosis 憩室病is also a common cause of massive colonic bleeding (erosion of artery) and this has been attributed to ruptured vasa recta wither at the apex or neck of a diverticulum. The bleeding is generally painless and can be massive. Diagnosis can be made by colonoscopy.
Diverticulitis can also cause bleeding as a result of superficial mucosal ulcerations but usually the bleeding is mild, fever + abdominal pain + mild bleeding. It was diagnosed with a CT scan (colonic wall thickening and stranding of mesenteric fat, complications of diverticulitis such as perforation, fistulas and abscesses, determine the need for surgery or percutaneous CT-guided drainage). A change to a diet rich in fiber is recommended to prevent recurrences. A colonoscopy is contraindicated in the acute condition.
Colon cancer: occult GI bleeding + anemia
Ulcerative colitis: bloody diarrhea + mucus + mild abdominal cramping, dx is made by endoscopy and barium enema
Popcorn/concentric/laminated/central/diffuse homogenous calcification
Popcorn calcifications are characteristically seen on radiographic imaging in pt with pulmonary hamartoma

Schematic representation of different patterns of benign calcification. In clockwise orientation from top left: target, diffuse, popcorn, and lamellated calcification.


Schematic representation of different patterns of malignant calcification. In clockwise orientation from top left: reticular, psammomatous (punctate), eccentric, and amorphous calcification.

Schematic representation of different patterns of the margin of pulmonary nodules. In clockwise orientation from top left: smooth, scalloped圆齿状的, corona radiata辐射冠, and spiculated.

Benign pattern of calcification in a solitary pulmonary nodule with characteristic popcorn configuration suggestive of a hamartoma.


Spiculated border in a malignant solitary pulmonary nodule located in the right middle lobe. Smoker with obvious centrilobular emphysema.

A review of all available old chest X-ray is an important initial part of the diagnostic workup of pt with a solitary pulmonary nodule. A high-resolution CT scan is extremely useful in defining the morphology, margin and border of the lesion. It demonstrates the pattern of calcification within the nodule and identified any mediastinal lymph node involvement and small pleural effusions. An irregular/speculated border and the presence of eccentric, reticular or punctuate calcifications within the lesion. Video-assisted thoracoscopic surgery (VATS) with excisional biopsy should be performed for the removal and definite diagnosis of a peripheral located pulmonary nodule suspicious for malignancy.
It is important to perform preoperative pulmonary risk assessment in all pt who will be undergoing major surgical procedures (reduce postoperative pulmonary complications and length of stay in the hospital). A detailed history and PE is the first step (most important tools) in the evaluation of these pt. Significant risk factors (Age, Chronic lung disease, Asthma, Smoking General health status, Obesity, Obstructive sleep apnea, Pulmonary hypertension, Heart failure, Upper-respiratory infection, Metabolic factors) should be identified. Any history suggesting unrecognized chronic lung disease or heart failure, such as exercise intolerance, unexplained dyspnea, or cough, requires further consideration. In a pt with a known , stable, COPD and no evidence of exercise intolerance, routine testing with arterial blood gas analysis, pulmonary function testing, or spirometry is not indicated.
All candidates for lung resection should have preoperative pulmonary function tests performed.
A careful history and physical examination are the most important tools for preoperative risk assessment in evaluating patients for potential postoperative pulmonary complications. Attention should be paid to symptoms that suggest the possibility of occult underlying lung disease, including exercise intolerance, cough, and unexplained dyspnea. In addition, the clinician should seek a history of the risk factors summarized above. The Canet risk index is also a promising tool for risk assessment. A high risk patient will benefit from aggressive strategies to reduce pulmonary complications (algorithm 1). (See "Strategies to reduce postoperative pulmonary complications".)
In addition to the history and physical examination, a chest x-ray should be obtained in patients undergoing high risk surgery who are over age 50 years, or if cardiac or pulmonary disease is suggested by the clinical evaluation, unless one has been obtained in the past six months. Pulmonary function tests should be reserved for patients with uncharacterized dyspnea or exercise intolerance and for those with COPD or asthma where clinical evaluation cannot determine if airflow obstruction has been optimally reduced. The benefit of PFTs in other situations is unproved. There is no role for preoperative arterial blood gas analyses to identify high risk patients or to deny surgery.
Stroke pt are often at risk for oropharyngeal dysphagia,and possibly aspiration, particularly those with symptoms of dysarthria. In the setting of acute stroke, such pt should not be given anything by mouth until a swallow evaluation can be performed.
Dysphagia is very common after stroke and is a major risk factor for developing aspiration pneumonia. Bedside swallowing evaluation with speech therapy followed by barium swallow study if needed.
The upright supine position is thought to be the most protective and is used most frequently to prevent the risk of aspiration in pt with impaired consciousness or dysphagia due to neurological disorders. The recumbent position平卧的 predisposes the pt to a high risk of aspiration and should be avoided if possible.
DVT and subsequent PE is a common cause of morbidity and mortality in pt with acute stroke, particularly in pt with dense hemiparesis. Subcutaneous low-dose heparin or LMWH for >2w should be used for prophylaxis in most pt with acute stroke.
HTN up to a blood pressure of 220/120 should generally be permitted in pt with acute ischemic stroke.
After the dx of an acute stroke is make and appropriate treatment is started, further evaluation is necessary to determine the cause of the cerebral infarct
1. MRA, CTA: evaluate the carotids and intracranial vasculature , duplex U/S: evaluate the carotids alone
2. ECG: Dx MI → intracardiac thrombus → embolus
3. TTE/TEE/cardiac MR: detect intracardiac thrombus
Medical management of TIA consists of aggressive treatment of atherosclerotic risk factors as well as antithrombotic medication. Treatment with either aspirain or clopidogrel is comparable. Warfarin or an aspirin/clopidogrel combination have not been proven to be more efficacious than aspirin or clopidogrel alone but have a much higher bleeding risk. There is evidence to suggest that clopidogrel may be superior to aspirin in the secondary prevention of stroke.
The initial presentation of MS with multiple sclerosis with cranial nerve involvement especially optic neuritis or sensory symptoms , onset at an early age, female sex and a relapsing form of disease carries a good prognosis.
An initial presentation due to involvement of cerebellum, brainstem or pyramidal system signifies a poor prognosis. Internuclear ophthalmoplegia, nystagmus and hemiparesis represent involvement of the brainstem, cerebellum and pyramidal system respectively and are bad prognostic features.
Acute exacerbations of MS are treated with iv corticosteroids, Treatment is indicated when there are disabling symptoms. Mild sensory symptoms generally do not require steroids. High dose iv methylprednisolone is used for this purpose, Long-term treatment with steroids provides no benefit and does not prevent future relapses. Oral steroids should NOT be offered to pt who have evidence of optic neuritis.
Pt with relapsing MS should be treated with either beta-interferon or glatriamer acetate, The best way of monitoring the disease activity is with a repeat MRI scan 3m after the initial scan.
Relapses are decreased during pregnancy and increased in postpartum. Contraception is important if pt are taking disease-modifying agents (both beta-interferon and glatriamer acetate are teratogenic, pt should be advised to stop these medications several months before attempting to conceive, if pt becomes pregnant by chance, the medication should be stopped immediately), however therapeutic abortion is not indicated if they become pregnant with early exposure.
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