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Key Concepts:

Terms in this set (146)

ROSH: Phlebitis is the counterpart to vasculitis, in that phlebitis is inflammation of a vein. Thrombophlebitis is vein inflammation due to thrombus (blood clot). These commonly occur in the superficial veins of the lower extremities, whereas, deep venous thrombosus (DVT) is the term used when a clot lodges in the deep veins. ymptoms include painful, palpable cord-like veins, distal edema and possibly localized erythema. Causes include a predilection to clotting, vein injury, incompetent venous valves (varicosity), Behcet's syndrome and prolonged travel or immobility. Evaluation usually includes Doppler ultrasonography and blood clotting studies. The key to treatment is driven by where the disorder is located. Below-the-knee superficial thrombophlebitis is usually treated with NSAIDs, compressive support and leg elevation. Above-the-knee superficial thrombophlebitis is commonly associated with deep venous thrombus. As such, dislodgement of the deeper clot can cause a life-threatening pulmonary embolus. Therefore, it is important to ascertain whether or not an above-the-knee superficial thrombophlebitis occurs with a deep venous clot (via Duplex ultrasound). If it does, then anticoagulation is recommended as part of the treatment plan. If it isn't, the recommended treatment is less clear. Enoxaparin is a low molecular weight heparin (LMWH) that is used to prevent and treat deep vein thrombosis or pulmonary embolism.

Superficial thrombophlebitis is an inflammation of a vein and can be related to a septic condition. One risk factor for superficial thrombophlebitis is presence of an IV catheter, which this patient would have due to being an inpatient and post-operative.
Symptoms of congestive heart failure (S3, pulmonary edema, crackles, mitral regurgitation) or an ejection fraction < 40%.

ACE inhibitors are primarily used in the treatment of hypertension and congestive heart failure.

Overall, digoxin use usually is limited to CHF patients with left-ventricular systolic dysfunction in atrial fibrillation or to patients in sinus rhythm who remain symptomatic despite maximal therapy with ACE inhibitors and β-adrenergic receptor antagonists. Although digoxin does not confer a survival benefit, it has reduced the number of hospitalizations that occur as a result of worsening heart failure.

Those with congestive heart failure or pulmonary congestion may benefit from the cautious use of digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors.

Severe anemia, may result with progression of gastric ulcers, and is the only high-output cause of congestive heart failure among the choices offered

Congenital heart diseases, such as malformations of the heart—patent ductus arteriosus (D) and ventricular septal defects, are the most common causes of heart failure in infants-toddlers

Transthoracic echocardiogram, is usually necessary in patients demonstrating symptoms suggestive of congestive heart failure

Bicuspid aortic valve, would be the most likely finding on echocardiogram given the patient's history and physical exam findings. The patient is demonstrating symptoms suggestive of congestive heart failure at a relatively young age, with relatively few cardiac risk factors. A congenital bicuspid aortic valve does not usually cause symptoms until the fifth or sixth decade

Signs and symptoms of congestive heart failure can lead to hepatic congestion and hepatomegaly
Atrial fibrillation is the most common chronic arrhythmia, frequently developing in the course of hyperthyroidism. The initial steps in the management of atrial fibrillation is to control the ventricular response and prevent the risk of stroke. A short acting beta-blocker (e.g., esmolol) is a good choice for the rapid management of heart rate. Other drugs used in the management of atrial fibrillation include:

Calcium channel blockers (e.g., verapamil or diltiazem)
Digoxin when calcium channel blockers and beta-blockers are not suitable

Electric cardioversion should not be performed prior to anticoagulation in patients with atrial fibrillation that has been present for more than 48 hours.

Ibutilide is mainly used for the conversion of atrial fibrillation or flutter.

The initial management in a hemodynamically stable patient (i.e., no hypotension or angina) with atrial fibrillation involves control of ventricular rate (goal <100 beats/min) by administering diltiazem or other rate-controlling drugs (e.g., verapamil, metoprolol, esmolol, or propranolol). If there is spontaneous conversion to sinus rhythm, the patient can be discharged after assessment for the cause of AF; otherwise, the patient requires anticoagulation and electrical/chemical cardioversion at a later date.

Amiodarone and propafenone are the pharmacological agents used in chemical cardioversion.

AV nodal ablation and permanent pacemaker implantation are highly effective in improving symptoms in patients with AF who are experiencing symptoms related to a rapid ventricular rate, and who cannot be adequately controlled with anti-arrhythmic or negative chronotropic medications.
Erysipelas
● Superficial bacterial skin infection that involves lymphatics
● Classically on face, common on legs
● Organism: strep pyogenes
● Sharp, demarcated borders, edematous, indurated, pruritic, painful

First-line treatment is an oral penicillin such as amoxicillin. For patients with systemic symptoms, intravenous ceftriaxone or cefazolin is indicated.
Erysipelas is a cutaneous infection characterized by marked superficial dermal lymphatic involvement. The most common cause of erysipelas worldwide is Streptococcus pyogenes (group A beta-hemolytic Streptococcus).

Facial erysipelas is frequently associated with streptococcal pharyngitis. Another common location for this infection is the lower legs.

Clinical manifestations include raised, bright salmon-red colored lesions above the level of the surrounding skin with a clear line of demarcation between involved and uninvolved skin. Plaques may develop vesicles or bullae. In facial erysipelas, one or both eyes are frequently swollen shut.

Erysipelas is a soft tissue skin infection characterized by deeply erythematous, indurated skin with sharply demarcated borders. It typically involves the upper dermis, superficial lymphatics and the superficial subcutaneous tissue. Patients are often very young or 50- to 60-year olds presenting with a prodrome of fever, chills and malaise followed by the eruption of cellulitic skin changes. Erysipelas is most often seen on the lower leg (90%) followed by the arm (5%) and the face (2.5%).

Tx: Amoxicillin/Kelfex
CTX or Cefazolin if
First-line treatment is to prescribe an intranasal corticosteroid or antihistamine. Nasal corticosteroids shrink hypertrophic nasal mucosa. Patients should be educated that noticeable efficacy may take approximately two weeks. This patient could be started on an intranasal steroid spray now and use it seasonally for a few months each fall.

Although it likely would be effective for symptoms, it would be inappropriate to prescribe a first-generation oral antihistamine (such as diphenhydramine or chlorpheniramine). The patient gave a history of trying such medications (which are available over-the-counter) and experiencing excessive sedation. Some of the newer, second-generation antihistamines would be a preferable choice, especially if the patient was experiencing allergy symptoms in his eyes.

An over-the-counter nasal saline spray is often recommended for various nasal conditions. In cases of allergic rhinitis, these sprays can mechanically flush allergens out of the nasal cavity; however, their role is more of an adjunct treatment, not a primary treatment.

First-line treatment is with glucocorticoid nasal sprays including fluticasone, or second-generation antihistamines. Nasal decongestant sprays are not recommended as monotherapy in the treatment of allergic rhinitis as their continued use can lead to rebound nasal congestion, also referred to as rhinitis medicamentosa.

This condition typically exhibits nasal secretions that are rich in eosinophils, which are the specific type of leukocytes that are involved in allergic reactions.
Neutrophila would be seen in excess in the case of infection. Lymphocytes would be seen in excess in the case of an immune reaction.

Allergic rhinitis is a hypersensitivity reaction to specific allergens that is mediated by immunoglobulin (Ig)E antibodies in sensitized patients resulting in inflammation

Classic findings of pale, bluish nasal mucosa, enlarged or boggy turbinates, clear nasal secretions, and pharyngeal cobblestoning may or may not always be seen.

Antihistamines are the drugs that have major applications in treating the symptoms of allergic rhinitis and urticaria.

Seasonal (allergic) rhinitis (hay fever)
One important hallmark of a simple partial seizure is that the patient does NOT lose consciousness.

Focal seizures without dyscognitive features (formerly termed simple partial seizures) can cause motor, sensory, autonomic, or psychic symptoms without impairment of cognition.

Simple partial seizures are due to focal brain cortex stimulation. The seizure symptoms will be related to the specific region of the brain cortex involved, and may include motor, sensory, and autonomic changes. Partial seizures are differentiated as simple versus complex, based on the alteration or lack of alteration of consciousness,

A transient focal deficit (usually unilateral) following a simple or complex focal seizure is referred to as Todd paralysis, and it should resolve within 48 hours.

Simple partial seizures are seizures that usually affect the temporal lobes and/or hippocampi. Simple partial seizures are usually followed by larger seizures later in life; the abnormal electrical activity spreads to a larger area of the brain (usually), resulting in a complex partial seizure or a tonic-clonic seizure

Eye deviation with facial twitching that lasts 1-2 minutes' is the correct answer. Simple partial seizures can vary depending on what portion of the cortex has been effected. Patients may display isolated tonic or clonic activity or may have transient altered sensory perception. Clonic movements are jerks that may involve a specific body part or may spread to adjacent body parts, known as "Jacksonian march." Tonic activity is stiffening or sustained posturing, such as eye deviation in this case.
CRPS is indeed a complex syndrome often occurring in a limb; patients exhibit vasomotor and neurologic symptoms out of proportion with objective findings. It often occurs following some type of event, such as a surgery (note the patient's recent ipsilateral knee surgery), fracture, stroke, or myocardial infarction. Most of the time, there is no nerve lesion. CRPS is classified into 3 stages, and symptoms can vary depending on the stage. It is characterized by persistent burning and/or throbbing pain in an extremity. Swelling, redness, and increased hair/nail growth occur in stage I; it may progress to cool, pale skin and even osteoporosis in the latter 2 stages. Allodynia, the phenomenon in which a normally painless stimulus produces significant pain response, is a common finding. No single exam finding or test is diagnostic of CRPS, which is a clinical diagnosis.

Complex regional pain syndrome is a form of chronic pain in a body region, but it most commonly affects the extremities. It is characterized by pain, swelling, skin changes, vasomotor instability, limited range of motion, and patchy bone demineralization. It frequently occurs after a soft tissue injury, surgery, or vascular event such as a myocardial infarction or stroke. The pathophysiology of complex regional pain syndrome is incompletely understood and most of the time there is no definable nerve lesion. Symptoms of complex regional pain syndrome include pain that is described as burning, tingling, throbbing or aching. The pain can be quite severe and out of proportion to physical exam. Many patients experience allodynia, which is pain from a stimulus that does not usually provoke pain. Other symptoms include sensitivity to cold or touch, swelling, skin changes such as thickened, rough skin, or muscle atrophy. A diagnosis of complex regional pain syndrome requires the presence of regional pain and sensory changes following a noxious event. It is usually made clinically as there is no laboratory or radiologic testing that alone is diagnostic.
Clindamycin (B) is generally given for aspiration pneumonia

Anaerobic bacteria can cause pneumonia in patients with poor dental hygiene or aspiration.
An alveolar space infection resulting from the inhalation of pathogenic material from the oropharynx.

Aspiration Pneumonitis
Inflammatory chemical injury
Inhalation of gastric contents
Can lead to aspiration pneumonia
Depressed level of consciousness
Unilateral focal/patchy consolidations in dependent lung segments
Prophylactic antibiotics NOT recommended

Aspiration pneumonia.

Lung Abscess

Patient will be complaining of several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats
CXR will show area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion
Most commonly caused by aspiration pneumonia
Treatment is clindamycin

Aspiration pneumonitis is an inflammatory chemical injury of the tracheobronchial tree and pulmonary parenchyma produced from the inhalation of regurgitated gastric contents. Aspiration pneumonitis can lead to aspiration pneumonia due to the breakdown of the pulmonary defense mechanisms caused by the chemical irritation

The elderly and those patients with a history of stroke are also at increased risk for aspiration pneumonitis. Clinically, patients may have minor symptoms (nonproductive cough and tachypnea). With larger aspirations, patients may develop tracheobronchitis with bronchospasm, bloody or frothy sputum, and respiratory distress. The chest radiograph usually shows unilateral focal or patchy consolidations in the dependent lung segments.
The diagnosis can be made confidently from the clinical and radiological feature, and it can be confirmed histologically from the biopsy of a superficial lymph node or skin lesion

What is the most useful test to confirm a diagnosis of sarcoidosis?Biopsy of the affected organ.

African-Americans, females
Primary target organ: lungs
Parotid enlargement
Hypercalcemia
CXR: bilateral hilar adenopathy
Biopsy: noncaseating granulomas
Steroids
Sarcoidosis is an idiopathic inflammatory disorder that may cause noncaseating granuloma formation in the lungs. Some patients report symptoms such as cough but others are asymptomatic.

Elevated levels of serum angiotensin converting enzyme (ACE) are typically elevated in about 75% of patients with sarcoidosis.

Sarcoidosis is a multisystem granulomatous disease. Histologically, it is characterized by the presence of non-necrotizing granulomas and hilar lymph node involvement occurs in 100% of the cases. Any infection has to be ruled out. 30% of the patients of sarcoidosis are asymptomatic, and the disease is commonly detected by an abnormal chest radiograph revealing bilateral hilar lymphadenopathy in an asymptomatic patient. However, with extensive lung involvement, there may be exertional dyspnea or cough.

Erythema nodosum (EN) may occur in up to 39% of sarcoidosis cases, characterized by tender erythematous nodules most commonly located on the anterior tibial areas.

Sarcoidosis has a number of lab abnormalities associated with it including hypercalcemia. Sarcoidosis is a multisystem inflammatory disease that involves non-caeseating granulomas composed of collections of T-helper cells and other inflammatory cells. It predominantly affects the lungs and intrathoracic lymph nodes but can involve a number of systems including cardiac, skin and neurologic. Chest radiography often reveals hilar adenopathy in early stages and progresses to pulmonary fibrosis. Patients may present with a host of non-specific symptoms including fever, fatigue, weight loss and polyarthritis. Other symptoms depend on end organ involvement. The granulomas secrete 1,25 vitamin D leading to hypercalcemia and hypercalciuria.
Name two steroid-sparing alternative medications used for pulmonary sarcoidosis.
Azathioprine and methotrexate.
The earliest sign of the development of osteoarthritis of the hip is often the loss of internal rotation

Distal interphalangeal joints of the hand are rare locations for either gout or pseudogout, but are classic locations to see signs and symptoms of osteoarthritis.

Osteoarthritis is a progressive, irreversible disease that leads to loss of articular cartilage in the joints. Osteoarthritis can affect the weight bearing joints in the lower extremities and spine, but can also be commonly found in the hands and other joints. The occurrence and severity of the condition can be affected by history of past trauma to a joint, long-term wear and tear on a joint, as well as obesity, genetics, and progressive aging. The condition can produce pain, swelling, stiffness, decreased range of motion, joint deformity, crepitus and decreased ability to do tasks of daily living. Osteoarthritis does tend to lead to direct damage to tissues like fascia (which is a fibrous connective tissue that surrounds muscles), muscles or tendons (tendons connect muscles to bones). As osteophytes form and joints become distorted, this could have a secondary impact on ligaments that are responsible for providing joint stability, but ligaments are not primarily affected by osteoarthritis
Osteoarthritis can affect all of the joints mentioned, but generally has the highest prevalence in the DIP joints, especially the second DIP joint. Osteophyte formation at the DIP joints produce enlargements referred to has Heberden's nodes.
Recommendations for patients diagnosed with osteoporosis without a fracture is every 2-3 years (C). This guideline is approved based on age, risk factors, or previous fractures. A post-menopausal woman at age 64 without a presenting fracture can be followed every 2-3 years with bone density imaging (DXA scan). Performing a DXA at intervals less than two years has not shown of benefit

Recommendations for calcium carbonate are 1,000-1,500 mg once daily orally. Vitamin D increases calcium absorption in the gastrointestinal tract, making calcium more available for reabsorption and circulation.

Recommendations for Vitamin D are 800-2,000 international units once daily orally.

Z scores indicate how the patients bone density compares to peers and T scores compare the patient to young, health individuals.

Proximal humerus fractures are most commonly seen in elderly patients. The most common type of fracture occurs at the surgical neck (the epiphyseal-diaphyseal junction, just inferior to both tuberosities).

Osteoporosis is a condition characterized by low bone mass, which increases the fragility of bones and leads to an increased risk of fracture. Osteoporosis is defined as being either primary or secondary and primary osteoporosis is further broken down into Type 1 and Type 2. Type 1 is related to decreased hormone levels - estrogen in women and testosterone in men, and is sometimes referred to as "postmenopausal osteoporosis." It is six times more common in women and results in loss of trabecular bone. Type 1 primary osteoporosis often presents with vertebral compression fractures or fractures of the distal radius after a fall. Type 2 primary osteoporosis is sometimes referred to as "senile osteoporosis" and generally occurs in patients over 70 years of age. It is twice as common in women as men and occurs due to a diminished capacity to make new bone. The most common types of fractures found in this type of osteoarthritis are hip and pelvic fractures. Secondary osteoporosis occurs at a somewhat higher rate in men versus women and is caused by some other medical condition that produces bone loss. Common causes include long-term steroid use, various endocrine abnormalities, and neoplastic diseases such as multiple myeloma.
Sigmoidoscopy or colonoscopy are used to confirm the diagnosis, but are not used during an acute flare due to the risk of perforation or toxic megacolon. Rectal or oral 5-ASA medications (e.g. mesalamine or sulfasalazine) are used in maintenance treatment. Acute flares are treated with rectal or oral glucocorticoids.

Tests include colonoscopy with biopsy, and barium enema. The goals of treatment are to control the acute attacks and prevent recurrent attacks. Corticosteroids are prescribed to reduce inflammation. Sulfasalazine may decrease the frequency of attacks. Surgery may be indicated in refractory disease.

First line treatment for mild to moderate UC is 5-aminosalicylic agents. These agents achieve clinical improvement in 50-70% or patients and remission in up to 30% of patients.

Fine serrations (ulcers) and pseudopolyps suggest colitis ulcerosa (ulcerative colitis). It is usually limited to the colon but occasionally, as in this case, the terminal ileum is also affected (backwash ileitis). In addition to sulfasalazine or 5-amino-salicylacid, more severe ulcerative colitis cases require corticosteroids. Corticosteroids are also helpful in Crohn's disease involving the small bowel.

Pyoderma gangrenosum, which is a ulcerative skin lesion of an uncertain etiology; in more than 50% of cases, it is associated with systemic diseases, most commonly inflammatory bowel disease.

Primary sclerosing cholangitis (PSC) is commonly associated with patients who have ulcerative colitis.

What autoantibody is associated with ulcerative colitis?
Answer: p-ANCA (50%-70% of cases). ASCA (10%-15% of cases).

Lead pipe colon is the appearance on barium enema of a foreshortened, narrow colon with loss of redundancy and haustral markings.

Oral mesalamine is a 5-aminosalicylic acid (5-ASA) derivative used in the maintenance treatment of ulcerative colitis.
Mild preeclampsia can be monitored without treatment, but severe preeclampsia should be treated with antihypertensives and magnesium for seizure prevention until delivery can be safely achieved. Antihypertensives of choice for severe preeclampsia include intravenous labetalol, hydralazine, and nifedipine. Patients presenting to the ED with signs and symptoms of preeclampsia should always be co-managed with an obstetric consultant.

Preeclampsia has a classic triad of weight gain, elevated blood pressure, and proteinuria. A woman with this triad of symptoms has preeclampsia until proven otherwise.

The onset of preeclampsia occurs from 20 weeks gestation to 6 weeks postpartum. If symptoms occur before 20 weeks, consider a molar pregnancy as a cause of hypertension.

Preeclampsia is defined as gestational hypertension (>140/90 mm Hg) with proteinuria (>300 mg/24 hr) that occurs after 20-weeks gestation. Progression from preeclampsia to eclampsia (hypertension, proteinuria and seizures) is unpredictable and can occur rapidly. In preeclampsia, patients may be asymptomatic. In severe disease, typically defined as a blood pressure >160/110 mm Hg, patients may have associated epigastric or liver tenderness, visual disturbances or severe headaches. These patients should be admitted for further management. Treatment for these patients is the same as in eclampsia. The goal of treatment is prevention of seizures or permanent maternal organ damage. Magnesium should be given for seizure prophylaxis

Labetalol, hydralazine, and nifedipine are the drugs of choice for acute, severe hypertension associated with HELLP syndrome. Like in preeclampsia and eclampsia, delivery is the only definitive management of HELLP.