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_________________________________
. ANEMIA presentations:
_______________________
. Mild -> Fatigue - loss of energy - tiredness - malaise.
. Severe -> Shortness of breath - lightheadedness - confusion.
. Diseases with similar presentations (Hypoxia - CO poisoning - Methemoglobinem
ia).
. Pallor - flow murmur - pale conjunctiva.
. MICROCYTIC ANEMIA:
____________________
____________________
(1) IRON DEFECIENCY ANEMIA:
____________________________
. The most common cause is chronic blood loss (Bleeding ulcer).
. ++ platelet count.
. Dx -> Best initial test -> IRON STUDIES:
- ____________________________________________
- | -- iron.
.|
- | -- ferritin.
.|
- | -- iron saturation.
.|
- | ++ TIBC (Total iron binding capacity).
.|
|--------------------------------------.|
- | ++ Red cell distribution of width (++ RDW).|
- ____________________________________________
. Dx -> Most accurate test -> Bone marrow biopsy.
. Tx -> Ferrous sulfate orally (May turn the stool BLACK but Guaiac test -ve).
. PICA -> Appetite for non-nutritive substances (ice - clay - dirt).
(2) ANEMIA OF CHRONIC DISEASE:
_______________________________
. Rheumatoid arthritis.
. End Stage Kidney Disease (ESKD).
. Any chronic infectious, inflammatory or connective tissue disease.
. . Dx -> Best initial test -> IRON STUDIES:
- _______________________________________
- | -- iron.
.|
- | ++ ferritin.
.|
- | Normal or -- iron saturation.
.|
- | -- TIBC (Total iron binding capacity).|
|--------------------------------------.|
- _______________________________________
* IRON IS LOCKED IN STORAGE OR TRAPPED IN MACROPHAGES OR IN FERRITIN.
. Osteoarthritis doesn't cause anemia of chronic disease !
. Exclude anemia of chronic disease if there is NORMAL ESR !
. The only form of anemia that responds to erythropoietin is ESKD.
. Tx -> tt the underlying cause e.g. (METHOTREXATE or INFLIXIMAB for RA).
. Although iron concentration is low, Iron supplementation is not benificial.
. IRON IS LOCKED IN STORAGE OR TRAPPED IN MACROPHAGES OR IN FERRITIN.
(3) THALASSEMIA:
_________________
. Very small MCV with few or no symptoms. (55 - 75 ml).
. TARGET cells.
. Dx -> NORMAL iron studies.
.
.
.
.
.
.
.
. N.B. (5):
___________
. Anemia of chronic kidney disease is due to erythropoietin defeciency.
. One must be careful to ensure adequate iron stores prior to erthropoietin rep
lacement,
. Bec. the erythropoietin induced surge in RBCs production may consume much iro
n,
. precipitating an iron defecient state.
. N.B. (6):
___________
. A case of microcytic hypochromic anemia with -- iron & ferritin,
. The most common cause of iron defeciency anemia is GIT blood loss.
. Dietary iron defeciency & malabsorption of iron are rare causes.
. Iron supplementation helps to restore iron reserves but u must detect the cau
se !
. So .. perform test for occult blood in the stool.
. N.B. (7):
___________
. The most common cause of folic acid defeciency is NUTRITIONAL.
. Either due to poor diet or Alcoholism.
. May be caused by some drugs either by impairing its absorption (PHENYTOIN),
. or antagonizing its physiologic effect (Methotrexate - Trimethoprim).
. N.B. (8):
___________
. PERINICIOUS ANEMIA:
______________________
. Most common cause of vit. B12 defeciency.
. Auto-antibodies against the gastric intrinsic factor required for B12 absorpt
ion.
. More in Northern Europeans.
. Associated other auto-immune diseases e.g. Autoimmune thyroiditis & Vitiligo.
. Shiny tongue due to atrophic glossitis.
. Shuffling broad-based gait ataxia.
. Neurological abnormalities with loss of pain & vibration sense.
. Peripheral blood smear -> Macro-ovalocytes, megaloblasts & hyper-segmented ne
utrophils.
. Dx -> Detection of Anti-intrinsic factor Abs.
. N.B. (9):
___________
. Total body stores of Vit.B12 in humans are 2-5 mg with min. daily requirement
6-9 micg.
. Animal products (meat & dairy) are the only dietary sources of vit. B12.
. It would take 4-5 years of a pure vegan diet to cause dietary defeciency.
. In contrast, Folate stores are smaller, clinical defeciency occur within 4-5
months.
. N.B. (10):
____________
. SCHILLING TEST:
__________________
. Used to detect the cause of vit. B12 defeciency.
. Used to differentiate dietary defeciency from perinicious anemia & malabsorpt
ion.
. In dietary defeciency,
. Oral radiolabelled Vit B12 is absorbed in the gut & excr. by kidneys in NORMA
L amounts.
. But In Malabsorption,
. Oral radio-labelled Vit B12 is excreted in sub-normal amounts.
. HEMOLYTIC ANEMIA:
___________________
___________________
. SUDDEN ONSET of hematological manifestations.
. Dx -> Hemolysis ->
-> ++ indirect bilirubin.
-> ++ reticulocyte count.
-> ++ LDH level.
-> -- Haptoglobin.
. Dx -> Intravascular hemolysis ->
-> Abnormal peripheral smear (schistocytes - helmet cells - fragmented cells).
-> Hemoglobinuria.
-> Hemosiderinuria.
(1) SICKLE CELL ANEMIA:
________________________
. Very severe pain in the back, chest & thighs.
. Retinal infarction.
. Flow murmur from anemia.
. Splenomegaly in children & asplenia in adults.
. Rales or consolidation from lung infection or infarction.
. Skin ulcers.
. Aseptic necrosis of hip.
. Neurological strokes.
. Cause of Osteomyelitis in sickle cell anemia is SALMONELLA !
. Cause of BM suppression in sickle cell anemia is PARVO B19 !
. Tx -> OXYGEN - HYDRATION with NORMAL SALINE - Pain relief.
. If there is fever -> (Emergency - No spleen) -> Ceftriaxone -levofloxacin.
. Tx -> EXCHANGE TRANSFUSION if ->
-> Eye -> Visual disturbance from retinal infarction.
-> Lungs -> Pulmonary infarction with pleuritic pain.
-> Penis -> Priapism from infarction of prostatic plexus of veins.
-> Brain -> Stroke (weakness & aphasia due to sludging & occlusion of cerebral
vessels).
. N.B. -> SUDDEN DROP IN HEMATOCRIT can be caused by FOLATE DEFECIENCY or PARVO
B19 INF:
. Folate defeciency in SCD due to ++ RBCs turnover & consumption of folate in t
he BM.
. Daily folic acid supplementation is recommended in all SCD.
. If the pt is already on Folate replacement -> The cause is PARVO B19 viral in
fection !
. PARVO B19 may invade the bone marrow & causes aplastic anemia.
. Detect Parvo B19 infection by PCR for DNA of Parvo B19.
. On discharge -> Give folate replacement - Pneumococcal vaccine.
. Hydroxyurea (++ Hb F) is given to prevent further crisis.
(2) HEMOGLOBIN SICKLE CELL DISEASE:
____________________________________
. African American pt.
. Family H/O of blood disrder.
. Mild version of sickle cell anemia.
.
.
.
.
.
.
Stage
Stage
Stage
Stage
Stage
0
1
2
3
4
->
->
->
->
->
++ WBCs.
Enlarged LNs.
Enlarged Spleen.
Anemia.
-- platelets.
.
.
.
.
.
Anemia.
Hypercalcemia.
Renal insuffeciency.
Lytic lesions in bones.
Serum monoclonal protein > 3
. MGUS require METASTATIC SKELETAL BONE X-RAY to exclude lytic lesions sugesting
MM !
. LYMPHOMA:
___________
. ENLARGED LNs (Mostly CERVICAL).
. Anemia due to BONE MARROW INFILTRATION by CANCEROUS CELLS !
. Two types_________________________________
|
____________________________________________________
|
.HODGKIN's LYMPHOMA
|
.NON-HODGKIN's LYMP
.__________________
.__________________
HOMA
_____
. Best initial test -> EXCISIONAL LN BIOPSY.
. SAME.
. REED STERNBERG CELSS.
. NO !
. STAGING by Contrast CT & CXR & BM biopsy:
. SAME.
-> 1 -> Single LN group.
-> 2 -> 2 LN groups on one side of diaphragm.
-> 3 -> LN invovement on both sides of diaphragm.
-> 4 -> Wide-spread disease = B symptoms (fever - weight loss - Night sweats).
. 90 % of cases present with Stages 1 & 2.
. 90 % of cases present with sta
ges 3 & 4.
. Tx -> Stages 1 & 2 with no B symptoms -> radiotherapy.
. Tx -> Stages 3 & 4 with B symptoms ----> chemotherapy.
. "ABVD" ->
. "CHOP" ->
- Adriamycin.
- Cyclophosphamide.
- Bleomycin.
- Hydroxyadriamycin.
- Vinblastine.
- Oncovin.
- Dacarbazine.
- Prednisone.
. TUMOR LYSIS $YNDROME:
_______________________
. Ass. with tumors with high cell turn-over.
. Ex: Poorly differentiated lymphoma "Burkitt's lymphoma" & Leukemias "ALL".
. HYPER {phosphatemia - kalemia - uricemia}.
. HYPO {Calcemia}.
. Both potassium & phosphate r intra-cellular ions, so cell break down -> their
release.
.
.
.
.
____________________________
. Hemoarthrosis - Hematoma.
. A -> PLATELET TYPE BLEEDING:
______________________________
. 1 . IDIOPATHIC IMMUNE THROMBOCYTOPENIA (ITP):
________________________________________________
. Immune destruction of platelets.
. Platelets count < 50000.
. Ig G auto-antibodies against the paltelet membrane glycoproteins 2B & 3A rece
ptors.
. Mostly occur in children.
. Pt may be asymptomatic.
. Mucocutaneous bleeding, ecchymosis & or petichiae.
. May follow acute viral infection.
. Dx -> ISOLATED THROMBOCYTOPENIA < 100000/ml.
. Dx -> Peripheral smear sh'd be done to exclude other causes e.g. TTP.
. Dx -> Bone marrow -> ++ Megakaryocytes (platelet precursors).
. Dx -> U/$ -> NORMAL SPLEEN.
. Dx -> Check for hepatitis C & HIV infections.
. Dx -> Diagnosis of exclusion.
. Tx -> Platelets > 30000 , without bleeding -> Observe !
. Tx -> Platelets < 30000 , or bleeding -> Corticosteroids Prednisone (1st line
therapy).
. Tx -> Platelets < 20000 ! with eistaxis, melena & intracranial hemorrhage ->
IVIG.
. IVIG: INTRAVENOUS IMMUNOGLOBULIN -> when platelet < 20000 & life threatening
condition.
. Recurrent episodes -> SPLENECTOMY.
. No response to splenectomy -> Romiplostim.
. N.B. HCV & HIV tests as ITP may be the initial presentation of HIV infection.
. 2 . UREMIA INDUCED PLATELET DYSFUNCTION:
___________________________________________
. Uremia prevents palatelets from degranulation.
. NORMAL PLATELET COUNT + PLATELET TYPR BLEEDING + RENAL FAILURE PT.
. NORMAL Ristocetin test & VWF level.
. Tx -> Desmopressin - DDAVP.
. B -> FACTOR TYPE BLEEDING = COLTTING FACTOR DEFECIENCIES:
___________________________________________________________
* FACTOR 8 = HEMOPHILIA A:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma on a MALE child.
. Dx -> Mixing study then specific factor level.
. Tx -> Minor defeciency -> DDAVP.
. Tx -> Severe defeciency -> Factor 8 replacement.
* FACTOR 9 = HEMOPHILIA B:
___________________________
. Joint bleeding (Hemarthrosis) or hematoma (less common than factor 8 def.).
. Dx -> SAME.
. Tx -> Factor 9 replacement.
* FACTOR 11:
_____________
. Rare bleeding with trauma or surgery.
. Dx -> Same.
. Tx -> FFP Fresh frozen plasma.
. FACTOR 12:
____________
. No bleeding.
. Dx -> Same.
. Tx -> No ttt necessary.
. SENILE PURPURA:
_________________
. occurs in areas susceptible to traumas in elderly (Dorsum of the hands & fore
arms).
. Due to PERIVASCULAR CONNECTIVE TISSUE ATROPHY .
. Lesions rapidly resolve leaving a brownish discolouration from hemosiderin de
position.
. Requires no ttt.
. HEPARIN INDUCED THROMBOCYTOPENIA (HIT):
___________________________________________
. HEPARIN exposure > 5 days then,
. Platelet count reduction > 50 % from baseline.
. Despite -- platelet count ->HIT is highly thrombogenic -> Arterial & venous t
hrombosis.
. Necrotic skin lesions at heparin injection sites.
. Acute systemic anaphylactoid recation after heparin.
. Dx -> SEROTONIN RELEASE ASSAY (GOLD STANDARD).
. TTT is started on clinical suspicion before serotonin assay.
. Tx -> CESSATION OF ALL HEPARIN PRODUCTS !
. Tx -> Start Argatroban (direct thrombin inhibitor).
. WARFARIN INDUCED SKIN NECROSIS:
_________________________________
. More common in females.
. Common sites: breasts , buttocks, thighs & abdomen.
. Initial complaint is PAIN FOLLOWED BY BULLAE FORMATION & SKIN NECROSIS.
. Occurs within weeks after starting therapy.
. Tx -> Discontinue warfarin - Give heparin to continue anticoagulation - Give
Vit. K.
. Acetaminophen, NSAIDs & Amiodarone may potentiate the anticoagulant effect of
warfarin.
. VITAMIN K DEFECIENCY BLEEDING:
________________________________
. Pt kept NPO NOTHING PER ORAL for a prolonged period of time & receiving Antib
iotics.
. OR Newborn hadn't received prophylactic vit. K (Home-born) for prevention of
hemorrhage
. ++++ PT > ++ PTT.
. THROMBOPHILIA = HYPERCOAGULABLE STATES:
_________________________________________
_________________________________________
(1) LUPUS ANTI-COAGULANT or ANTI-CARDIOLIPINS ANTIBODIES:
__________________________________________________________
. Venous thrombosis.
. ++ aPTT (PROLONGED PARTIAL THROMBOPLASTIN TIME).
. Normal PT, BT, platelet count & VWF.
. Spontaneous abortion. (Due to promotion of arterial & venous thrombosis).
. False +ve VDRL & True -ve FTA-ABS (Excluding $yphilis as a cause of recurrent
abortions
. Dx -> Mixing study.
. Dx -> Russel Viper venom test (Most accurate).
. Tx -> Heparin (LMWH) followed by warfarin.
(2) PROTEIN C DEFECIENCY:
__________________________
. Skin necrosis with the use of Warfarin.
. Dx -> Ptn C level.
. Tx -> Heparin followed by Warfarin.
(3) FACTOR 5 LEIDEN MUTATION:
______________________________
. Most common cause of thrombophilia.
. Dx -> Factor 5 mutation test.
. Tx -> Heparin followed by Warfarin.
(4) ANTI-THROMBIN DEFECIENCY:
______________________________
. No change in the aPTT with a blous of IV heparin !
. Dx -> Anti-thrombin 3 level.
. Tx -> Large amounts of heparin or direct thrombin inhibitor followed by warfa
rin.
. DIC = DISSEMINATED INTRAVASCULAR COAGULATION:
_______________________________________________
. Doesn't occur in healthy pts.
. Ass. with sepsis - burns - snake bites - cancer - Abruptio placenta or AF Emb
olism.
. BLEEDING related to CLOTTING FACTORS DEFECIENCY & THROMBOCYTOPENIA !!
. ++ both PT & PTT.
. -- platelet count.
. ++ D-dimer & FDP (fibrin degradation products).
. -- fibrinogen level (consumed).
. Tx -> REPLACEMENT by FFP FRESH FROZEN PLASMA (Contains both palatelets & clot
.factors).
. TRANSFUSION REACTIONS:
________________________
________________________
. 1 . ABO INCOMPATIBILITY:
___________________________
. Acute symptoms of hemolysis WHILE the transfusion is occuring.
. Ex -> DURING a transfusion, the pt becomes hypotensive & tachycardic.
. Back & chest pain & dark urine.
. ++ LDH & bilirubin.
. -- Haptoglobin.
. 2 . TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) = LEUKO-AGGLUTINATION REACT
ION:
________________________________________________________________________________
____
. Acute Shortness of breath from antibodies in the donor blood against the repi
ent WBCs.
. Ex -> 20 mins after a pt. receives a blood transfusion, the pt becomes short
of breath.
. Transient infiltrates on CXR.
. All symptoms resolve spontaneously.
. 3 . IgA DEFECIENCY:
______________________
. presents with anaphylaxis !
. In the future, use blood donations from an IgA defecient donor or washed RBCs
.
. Ex -> As soon as the pt. received transfus., he becomes SOB, hypotensive & ta
chycardic.
. NORMAL LDH & BILIRUBIN.
. 4 . MINOR BLOOD GROUP INCOMPATIBILITY:
_________________________________________
. To kell, Duffy, Lewis or Kidd antigens or Rh incompatibility !
. Delayed jaundice.
. No specific therapy.
. Ex -> A few days after transfusion, the pt becomes jaundiced.
. The hematocrit doesn't rise with transfusion & he is generally without sympto
ms.
. 5 . FEBRILE NON-HEMOLYTIC REACTION:
______________________________________
. Small rise in temperature.
. No ttt required.
. Reaction against donor WBCs antigens.
. prevented by using filtered blood transfusions in the future to remove WBCs a
ntigens.
. Ex -> A few hours after transfusion, the pt becomes febrile with rise 1 degre
e in temp.
. No evidence of hemolysis.
. N.B. HYPOCALCEMIA MANIFESTATIONS (PARESTHESIA) AFTER BLOOD TRANSFUSION:
_________________________________________________________________________
. Occurs in pts who receive more than one blood volume of blood transfusion or
packed RBCs over 24 hours may develop ++ plasma level of CITRATE (A SUBSTANCE AD
DED TO STORED BLOOD) -> CHELATION of Ca & Mg by citrate -> -- Ca -> Paresthesia.
. MIGRATORY SUPERFICIAL THROMBOPHLEBITIS = TROUSSEAU's $YNDROME:
________________________________________________________________
. Hypercoagulable disorder.
. Un-explained superficial venous thrombosis at un-usual sites e.g. arm & chest
area.
. Associated with OCCULT VISCERAL MALIGNANCY !
. Ex. Cancer involving the pancreas "most common".
. The tumor releases mucin that react with platelets forming platelet rich micr
o-thrombi.
. H/O of heavy smoking - abdominal pain - migrattory thrombophlebitis.
. Dx -> CT Abdomen -> searching for an occult tumor (pancreatic carcinoma).
. GLUCAGONOMA:
______________
. Necrolytic migratory erythema:
---------------------------------> Erythematous papules / plaques on face, perineum & extremities.
-> Enlarge & coalese with central clearing & blistering & crusting & scaling.
. Diabetes Mellitis:
---------------------> Mild hyperglycemia easily controlled with diet & oral agents.
-> Don't require insulin !
. GIT symptoms:
----------------> Diarrhea - anorexia abdominal pain - occasional constipation.
. Other findings:
------------------> Weight loss.
-> Neuropsychiatric (ataxia - dementia - proximal ms weakness).
-> Associated wih venous thrombosis !
. Dx -> Hyperglycemia with ++ GLUCAGON > 500 mg/dl.
. Dx -> Normocytic Normochromic anemia.
. Dx -> CT or MRI to detect the tumor.
. SMOKER + HORNER's $ = LUNG CANCER:
____________________________________
. Horner's $ -> Miosis, ptosis & anhydrosis.
. Simple CXR is the best next step to detect lung cancer.
. SMALL CELL (OAT) LUNG CARCINOMA:
__________________________________
. associated with $yndrome of inappropriate ADH secretion & ACTH production.
. SIADH (Hyponatremia & -- serum osmolality & ++ urine osmolality).
. Metastasis is already present at the time of diagnosis !
. Tx of SIADH -> Mild (Fluid restriction) or Severe (Hypertonic saline).
. ++ ACTH -> Hypertension - Hypokalemia - Metabolic alkalosis - Hyperpigmentati
on.
. e'out other manifests of Cushing $ (Moon face - Dorsal hump - central obesity
- striae)
. SQUAMOUS CELL CARCINOMA OF THE LUNG:
______________________________________
. Significant smoking H/O.
. HYPERCALCEMIA ++ Ca -> (sCa++mous) !
. Hilar mass.
. ADENOCARCINOMA OF THE LUNG:
_____________________________
. Least association with smoking.
. Located peripherally.
. Consists of columnar cells growing along the septa.
. Presents as a sloitary nodule !
. May be detected incidentally.
. FEBRILE NEUTROPENIA:
______________________
. Single temperature > 38.3c or sustained temp. > 28 c for > 1 hour in a neutro
penic pt.
. Neutropenia = Absolute neutrophil count < 1500 cells/ml.
. Mild (<1500) - Moderate (<1000) - Severe (<500).
. All require antibiotics.
. Moderate & severe neutropenia require hospitalization.
. The most common invading organism is PSEUDOMNAS AERUGINOSA.
. Tx -> HOSPITALIZATION,
. BLOOD CULTURES followed by IV CEFEPIME or PIPERACILLIN TAZOBACTAM.
. SQUAMOUS CELL CARCINOMA OF THE MUCOSA OF THE HEAD & NECK:
___________________________________________________________
. ALCOHOLIC SMOKER.
. HARD UNILATERAL NON-TENDER CERVICAL OR SUBMANDIBULAR lymph node.
. Dx -> Best initial -> PAN-ENDOSCOPY.
. Tx -> Radical neck dissection.
. TESTICULAR TUMOR:
___________________
. Painless hard mass in testicle.
. Suggestive ultrasound.
. Tx -> Orchiectomy (Removal of the testicle & its associated cord).
. FNAC or trans-rectal biopsy are contr'd bec. the risk of spillage of cancer c
ells.
. FIBROCYSTIC DISEASE OF THE BREAST:
____________________________________
. Rubbery, firm, mobile & pinful mass in a young pt.
. More pain during menses.
. Aspiration of the cyst -> Clear fluid with diasppearance of the mass.
. Tx -> Observation of the pt 4 - 6 weeks.
. Only send the fluid for cytology if their is blood or foul smelling.
. INVASIVE DUCTAL BREAST CARCINOMA:
___________________________________
. TNM staging is the single most important prognostic tool for breast cancer.
. Prognosis is best detected using ONCOGENE AMPLIFICATION by FISH !
. FISH = Fluorescent in situ hybridization.
. Over-expression of the oncogene HER2 can be detected by FISH = (Worse prognos
is).
. Positivity predicts a +ve response to TRASTUZUMAB & ANTHRACYCLINE chemotherap
y.
. ER +ve & PR +ve are GOOD prognostic features.
. Tx -> TRASTUZUMAB (Herceptin) is used to ttt breast cancer that is HER2 +ve.
. Trastuzumab side effect -> CARDIOTOXICITY.
. ECHOCARDIOGRAPHY is recommended before ttt to assess the ejection fraction.
. INFLAMMATORY CARCINOMA OF THE BREAST:
_______________________________________
. Breast cancer sh'd be considered whenever a pt. without a prior H/O of skin d
isease,
. develops a breast rash that is non-responsive to standard ttt !
. When invasive ductal carcinoma is severe, it can infiltrate into the dermal l
ymphatics,
. resulting edema - erythema - warmth of the entire breast (inflammatory carcin
oma).
. When the rash is localized to the nipple & has an ulcerating eczymatous appea
rance,
. the primary cosideration should be PAGET's DISEASE of the breast.
. 5 % of pts with PAGET's disease have an underlying breast cancer "ADENO-CARCI
NOMA".
. Skin biopsy -> Large cells surrounded by clear halos.
. TAMOXIFEN:
____________
. Has mixed agonist & antagonist activity on Estrogen receptors.
. It is used as an adjuvant therapy for early stage breast cancer,
. It reduces the risk of recurrence of the original cancer,, BUT,,
. ++ risk of developing of another cancer in the other breast !
. Estrogenic effects ++ risk of ENDOMETRIAL cancer & Venous thrombosis.
. SQUAMOUS CELL CARCINOMA of the SKIN:
______________________________________
. Any scar that develops into a non-healing, painless, bleeding ulcer.
. Sun-exposed or burned areas are typically involved.
. Rough scaly nodules that can ulcerate & metastasize.
. Tar derivatives (tobacco smoke) & chronic radiation exposure are predisposing
.|
(-)
(+)
.|
.|
|
-)
|
. Un-likely to have DVT ! (TTT with Heparin & Warfarin) (Contrast V
enography)
. Dx -> X-ray -> Expansile & eccentric lytic area with SOAP & BUBBLE APPEARANCE
.
. Benign but locally aggressive skeletal neoplasm.
. Young adults.
. pain, swelling & -- range of motion at the involved site.
. Pathologic #s are common due to thinning of the bone cortex in weight bearing
areas.
. Affect the epiphysis of the long bones (distal femur & proximal tibia).
. MRI -> Tumor containing both cystic & hemorrhagic regions.
. Tx -> Surgery.
. COMPRESSION OF THE THECAL SAC or SPINAL CORD by a TUMOR:
__________________________________________________________
. Ex -> H/O of prostatic cancer + Acute onset back pain.
. Rapid recognition is crucial to avoid paralysis.
. Point tenderness over the spine process L5 & S1.
. Imbalance, ms weakness & week rectal sphincter tone.
. Dx -> MRI spine BUTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
. Initial management with glucocorticoids (dexamethasone) is crucial to -- swel
ling,
. as an attempt to preserve neurological function while awaiting the results of
imaging.
. POST-SPLENECTOMY RECOMMENDATIONS:
___________________________________
. Risk for sepsis after splenectomy is present UP TO 30 years & more !
. Anti-pneumococcal, Haemophilus & meningococcal vaccine sh'd be given,
. several weeks before splenectomy.
. Daily oral penicillin prophylaxis for 3 - 5ys following splenectomy.
. CANCER OVARY:
_______________
. NO screening tests !
. Serum CA 125 & pelvic U/$ may help in diagnosis.
. ++ HOMOCYSTEINE levels -> HYPERCOAGULABILITY:
_______________________________________________
. Vit. B6, Folate & Vit. B12 are involved in the metabolism of homocysteine.
. Vit. B6 lowers homocysteine levels by acting as a cofactor for cystathionine
B-synthase
. which metabolizes homocysteine to cystathionine.
. PAIN CONTROL IN CANCER PATIENTS:
__________________________________
. Give the appropriate pain medication to cancer pts e.g. Ibuprofen.
. If no response .. Use a narcotic drug if it is the most appropriate.
. Use SHORT ACING IV MORPHINE.
. MANAGEMENT OF CHEMOTHERAPY INDUCED NAUSEA & VOMITING:
_______________________________________________________
. Volume repletion + SEROTONIN ANTAGONIST (Block 5HT3 recptors).
. MANAGEMENT OF CANCER RELATED ANOREXIA & CACHEXIA:
___________________________________________________
. PROGESTERONE ANALOG -> ++ Appetite & ++ weight gain.
. PROSTATE CANCER with BONE METASTASIS:
_______________________________________
. Tx -> FOCAL EXTERNAL BEAM RADIATION (If the pt under-went orchiectomy !).
. BRAIN METASTASIS:
___________________
. SOLITARY -> SURGICAL RESECTION followed by whole brain radiation.
. Multiple -> Palliative whole brain radiation.
. MANAGEMENT OF HYPERCALCEMIA DUE TO UNDERLYING MALIGNANCY:
___________________________________________________________
. Asymptomatic or mild -> Ca < 12 mg/dl:
_________________________________________
. Just avoid thiazides, lithium use, volume depletion or prolonged bed rest.
. Severe -> Ca > 14 mg/dl:
___________________________
. Immediate ttt -> Normal saline hydration + Calcitonin.
. Long term ttt -> Biphosphonate (Zoledronic acid).
. D.D. of ANTERIOR MEDIASTINAL MASS (4 Ts):
___________________________________________
. Thymoma - Teratoma - Thyroid neoplasm - Terrible lymphoma.
. Germ cell tumors are classified into seminomatous & non-seminomatous.
. Non-seminomatous (Yolk sac tumor - choriocarcinoma - embryonal carcinoma).
. A mixture of all types of non seminomatous germ cell tumors = MIXED GERM CELL
TUMOR.
. Seminoma -> ++ B-HCG & Normal AFP.
. Non seminoma (MIXED) -> ++ B-HCG & ++ AFP.
. HEMOCHROMATOSIS:
__________________
. NEW-ONSET DIABETES MELLITUS + ARTHROPATHY + HEPATOMEGALY.
. Due to abnormal ++ intestinal absorption of iron -> ++ iron deposition in tis
sues.
. Damage to organs ex. liver, pancreas , heart & pituitary.
. Liver -> Hepatomegaly -> Liver cirrhosis -> Hepatocellular carcinoma.
. Pancreas -> Bronze D.M.
. Pituitary -> Hypogonadism.
. Heart -> Restrictive heart failure.
. Joints -> Arthropathy.
. Skin -> Hyperpigmentation.
. Dx -> Iron studies -> ++ fe, ++ ferritin, ++ transferrin saturation.
. Dx -> Liver biopsy -> confirm the diagnosis.
. LEAD POISONING:
_________________
. Lead bind to erythrocytes & disrupts hemoglobin synthesis -> Microcytic anemi
a.
. Due to chronic lead exposure & toxicity.
. Acute exposure -> Abdominal pain & constipation.
. Chronic exposure -> Fatigue, iiritability & insomnia.
. Hypertension - Sensori-motor neuropathies - Neuropsychiatric disturbances - N
ephropathy
. OCCUPATIONAL HISTORY IS VERY IMPORTANT !
. BATTERY MANUFACTURING - PLUMBING - MINING - PAINTING - PAPER HANGING & AUTO-R
EPAIR.
. Dx -> Blood Lead level.
. Dx -> Peripheral smear -> BASOPHILIC STIPPLING.
. Tx -> CHELATION THERAPY.