‘The three important clinical criteria for the diagnosis of ankylosing spondylitis are: 1, Presence of low back pain and stiffness for more than a three month duration that improves with exercise or activity. 2. Limitation of the range of motion of the lumbar spine. 3. Limitation of chest expansion relative to the normal values.The following radiographs are used in monitoring the disease progression of patients with ankylosing spondylitis: 1. Anteroposterior and lateral views of the lumbar spine 2. Lateral view of the cervical spine 3. Pelvic radiograph, including the sacroiliac joints and hipElectroconvulsive therapy Cond ns treated * Unipolar & bipolar depression * Catatonia * Bipolar mania Specific indications * Treatment resistance Psychotic features present Emergency conditions Indications © Pregnancy o Refusal to eat or drink o Imminent risk for suicide * Pharmacotherapy contraindicated due to comorbid medical illness or poor tolerability History of ECT response * No absolute contraindications Increased risk o Severe cardiovascular disease, recent Safety myocardial infarction o Space-occupying brain lesion o Recent stroke, unstable aneurysmManagement of generalized convulsive status epilepticus + 25 minutes of generalized convulsive seizure or + 22 generalized convulsive seizures without interval recovery of consciousness J Stabilize circulation, airway & breathing Evaluate for predisposing causes Gain IV access & administer: o Lorazepam, diazepam’, or midazolam? Administer adjunctive IV agent: + Fosphenytoin, phenytoin, or valproic acid No Seizure activity terminated Yes EEG monitoring for refractory status epilepticus || Continue supportive care + Initiate continuous infusion: o Midazolam, pentobarbital, or propofol ‘May also be administered perrectum. ?May also be administered intramuscularly. IV = intravenous; EEG = electroencephalogram OuWordManagement of symptomatic peripheral arterial disease Risk factor control Antiplatelet therapy (aspirin or clopidogrel) Blood pressure Diabetes Statin therapy Smoking cessation Exercise Supervised exercise program (30-45 minutes 23 times/week for 23 months) Medications If symptoms persist despite exercise Cilostazol (preferred over pentoxifylline) Revascularization Indicated for limb-threatening disease or persistent functional limitation on above therapy Endovascular: Angioplasty +/- stent Surgical: Autogenous or synthetic bypass graftFavorable prognostic factors in schizophrenia Female gender Older age at onset (> 40) Acute onset of symptoms (no prodrome) Identifiable precipitant Predominantly positive (rather than negative) symptoms Presence of mood symptoms. Good pre-morbid functioning No family history of schizophrenia Good family support Shorter duration of active symptoms.Anorexia nervosa BMI <18.5 Intense fear of weight gain Distorted views of body weight & shape Clinical features Cognitive-behavioral therapy Treatment Nutritional rehabilitation Olanzapine for severe cases Hypothermia Malnutrition Dehydration Orthostatic hypotension Arrhythmia Refeeding syndrome ComplicationsStarve catabolic state ¥ | Insulin } Glucagon + Cortisol Y | Ketone bodies use in muscle + Ketone bodies use in brain + Glycogenolysis 1 Lipolysis 1 Protein catabolism Depletion of fat, protein, vitamins, minerals & intracellular electrolytes inical manifestations * Arrhythmia * Congestive heart failure (pulmonary edema, peripheral edema) * Seizures * Wernicke encephalopathy ‘ Start refeedi anabolic state | Serum phosphorus, potassium, magnesium | Serum thiamine + Sodium & water retention 7 Glycogen synthesis 1 Protein synthesis 7 Intracellular uptake of phosphorus, potassium, magnesium & thiamine ‘ + Insulin ryConcentration Acute hepatitis B infection Symptoms HBs4g (as HbeAg HBV DNA [iii Total anti-HBe IgM anti-HBc Anti-HBs Anti-HBe 0 1 rs 3 4 5 6 12 24 Months after hepatitis B virus infection 36Management of DKA & HHS . High-flow 0.9% normal saline is initially recommended IV fluids Add dextrose 5% when serum glucose is £200 mg/dL. Initial continuous IV insulin infusion Switch to SQ (basal bolus) insulin for the following: Insulin Able to eat, glucose <200 mg/dL, anion gap <12 mEq/L, serum HCO3 215 mEq/L Overlap SQ & IV insulin by 1-2 hours Add IV potassium if serum K* $5.2 mEq/L. Potassium Hold insulin for serum K* <3.3 mEq/L Nearly all patients K* depleted, even with hyperkalemia Bicarbonate Consider for patients with pH <6.9 Consider for serum phosphate <1.0 mg/dL, cardiac Phosphate dysfunction, or respiratory depression Monitor serum calcium frequently DKA = diabetic ketoacidosis; HHS = hyperglycemic hyperosmolar nonketotic state; IV = intravenous; SQ ibcutaneous.Bacterial vaginosi Trichomoniasis Candida vaginitis Diagnosis (Gardnerella vaginalis) (Trichomonas vaginalis) (Candida albicans) Examination Thin, off-white * Thin, yellow-green, * Thick, “cottage discharge with malodorous, frothy cheese” discharge fishy odor discharge * Vaginal No inflammation * Vaginal inflammation inflammation Laboratory findings pH>4.5, «Normal pH (3.8 -4.5) Clue cells Motile trichomonads | * Pseudohyphae Positive whiff test (amine odor with KOH) Metronidazole or clindamycin Metronidazole; treat Treatment sexual partner FluconazoleIndications for testing for pheochromocytoma Family history of pheochromocytoma Episodic headaches, diaphoresis, or tachycardia Early-age onset of hypertension Refractory hypertension Familial syndromes (eg, MEN2, neurofibromatosis-1, von Hippel-Lindau) Adrenal mass discovered incidentally on imaging Idiopathic dilated cardiomyopathy Paroxysmal hypertension and/or tachycardia during common proceduresHigh index of suspicion for pheochromocytoma vy + 24-hour urine fractionated metanephrines and catecholamines + Plasma fractionated metanephrines: v High (2-3 x upper Recheck during spell limits of normal) CT or MRI of abdomen' High Recheck during spell + High ar ctca x upper limits of normal) CT or MRI of abdomen ‘Consider further imaging: + MIBG* scan + Octreotide scan + Whole-body MRI + PET scan *MIBG: 1231-metaiodobenzylguanidine Surgical evaluation Genetic testing aand B blockade prior to surgery MIBG scan if tumor >5 cm and suspicion of extraadrenal diseaseSurgical complications of adrenalectomy for pheochromocytoma Complication Mechanism Treatment Hypertensive Hypotension Hypoglycemia Cardiac tachyarrhythmias + Catecholamine release due to endotracheal intubation & adrenal gland manipulation ® + Serum norepinephrine with larger tumors (>4 cm diameter) | Catecholamines after tumor removal Persistent alpha blockade from preoperative long-acting alpha blocker (eg, phenoxybenzamine) { Insulin secretion following tumor removal (catecholamines suppress insulin secretion) t Catecholamine release from adrenal gland handling Intravenous, nitroprusside, phentolamine, or nicardipine Normal saline bolus, pressors if unresponsive Intravenous dextrose infusion Intravenous lidocaine or esmololNumber needed to treat & number needed to harm Disease present | Disease absent Exposed A 8 Non-exposed c D = tisk of disease among exposed; -& = risk among non-exposed Se If exposure leads to | risk of disease: ARE ace G0 a8 &NNT= 2. If exposure leads to f risk of disease: ARI Ac 1 Ao ENNH solute risk increase (also called atibutable risk); ARR = absolute risk reduction;This patient most likely has Fadiation induced cardiotoxicity. Long-term survivors of Hodgkin lymphoma are at risk of developing cardiovascular complications due to chemotherapy and/or radiation therapy. Radiation therapy causes diffuse fibrosis in the interstitium of the myocardium, along with progressive fibrosis of the pericardial layers, cells in the conduction system, and the cusps andior leaflets of the valves. It also causes injury to the intimal layer, with arterial narrowing typically involving the ostial parts of coronary vessels. These effects lead to: 1, Myocardial ischemia and/or infarction 2. Restrictive cardiomyopathy with diastolic dysfunction 3. Constrictive pericarditis 4. Valvular abnormalities (mitral or aortic stenosis/regurgitation) 5. Conduction defects (sick sinus syndrome or variable degrees of heart block)X-linked recessive inheritance Affected father Mother Xd All daughters are carriers Father Y All sons are normal Carrier mother Mother Daughters have 50% chance of becoming carriers Father Sons have 50% chance of being affectedNon-REM sleep arousal disorders Diagnosis Recurrent incomplete awakenings from non-REM sleep with 1 of the following Sleepwalking: Blank, staring face, relatively unresponsive to attempts to awaken Sleep terrors: Abrupt arousals from sleep (panicked scream, terror, autonomic arousal, unresponsive to comfort) Little or no dream recall Amnesia for episodes Differential diagnosis Prognosis and treatment Nightmare disorder (occurs during REM, detailed dream recall) REM sleep-related behavior disorder (occurs during REM, “acts. out dreams”) Sleep-related seizures Nocturnal panic attacks Mostly self-limiting Administer low-dose benzodiazepine at bedtime if episodes are frequent, persistent, and distressingNeonatal chlamydial infections Conjunctivitis Pneumonia Mode of transmission Direct vaginal contact during delivery Age at onset 5-14 days 4-12 weeks Thickened injected Staccato cough conjunctivae (chemosis) oe Watery, mucopurulent, or Clinical blood-stained discharge manifestations © Hyperinflation Eyelid swelling on chest x-ray Conjunctival pseudomembrane * Nasal congestion « Rales Treatment Oral erythromycin for 14 daysSensitivity Specificity Positive predictive value predictive value Positive likelihood ratio Negative likelihood ratio The probability of a diseased person testing positive The probability of a non-diseased person testing negative The probability that disease is present given a positive result The probability that disease is absent given anegative result A ratio representing the likelihood of having the disease given a Positive result Aratio representing the likelihood of having the disease given a negative result True positives Sensitivity = ———_____ True positives + False negatives True negatives Specificity = ——_—— True negatives + False positives True positives PPy = True positives + False positives True negatives NPV = True negatives + False negatives Sensitivity LR+= 1 - Specificity 1 - Sensitivity R= _ SpecificityMajor depressive episode Grief reaction (bereavement) Five of the following 9 symptoms Sleep disturbances, appetite change, low energy, psychomotor changes, low mood, anhedonia, guilt, focus/concentration difficulty, suicidal ideation Low mood or anhedonia must be present May occur in response to a variety of stressors, including loss of loved one Duration 22 weeks Social & occupational dysfunction Suicidality related to hopelessness & worthlessness * Normal reaction to loss Feelings of loss & emptiness Symptoms revolve around the deceased Functional decline less severe “Waves” of grief at reminders Worthlessness, self-loathing, guilt & suicidality less common Sad feelings are more specific to deceased Thoughts of dying involve joining the deceased Intensity decreases over time (weeks to months)Sample size needed Factors impacting sample size Expected Easier to identify large effect magnitude of effect size More difficult to identify small effect Lenient cutoff for statistical significance P-value (a) Stringent cutoff for statistical significance Power (1-8) Small Small Low ability to detect difference a = rate of type | error; B = rate of type Il error.Indications for stress ulcer prophylaxis Any 1 factor Coagulopathy © Platelets <50,000/uL or o INR>1.5 or o Partial thromboplastin time > twice normal control Mechanical ventilation >48 hours Gl bleeding or ulceration in last 12 months 22 factors Glucocorticoid therapy >1 week ICU stay Occult GI bleeding >6 days SepsisFeatures of non-accidental trauma History Examination Caregiver behavior Vague or changing details Injury inconsistent with child’s developmental stage Sibling described as responsible Injury inconsistent with history Multiple fractures or bruises in different healing stages Likely inflicted injuries (eg, cigarette bum) Poorly kempt child Bruises on neck, abdomen, or unusual sites Injury to genitalia, hands, back, or buttocks Argumentative or violent Lack of emotional interaction with child Inappropriate response to child's injury Inappropriate delay in seeking medical care Partial confession in causing injuryManifestations of cyanide accumulation & toxicity Skin: Flushing (cherry-red color), cyanosis (occurs later) Central nervous system: Headache, altered mental status, seizures, coma Cardiovascular: Arrhythmias Respiratory: Tachypnea followed by respiratory depression, pulmonary edema Gastrointestinal: Abdominal pain, nausea, vomiting Renal: Metabolic acidosis (from lactic acidosis), Tenal failureFeatures of tabes dorsalis Increased incidence of syphilis in men who oa have sex with men & HIV-infected patients Epidemiology HIV-positive patients develop neurosyphilis more rapidly Treponema pallidum spirochetes directly Pathogenesis damage the dorsal sensory roots Secondary degeneration of the dorsal columns Sensory ataxia Lancinating pains Neurogenic urinary incontinence Associated with Argyll Robertson pupils Clinical findingsMAT is usually secondary to the following conditions: 1) hypoxia 2) chronic obstructive pulmonary disease (COPD) 3) hypokalemia 4) hypomagnesemia 5) coronary/ hypertensive! valvular disease 6) medications (i.e, theophylline) aminophylline, isoproterend))Pharmacotherapy for smoking cessation Treatment Long-acting NRT (nicotine patch) Short-acting NRT (nasal spray, gum, lozenge, inhaler) Bupropion Varenicline Indications | Cravings & daytime withdrawal symptoms Long-acting may be combined with short- acting NRT (“patch plus”) Decreases post- cessation weight gain Good choice in patients with depression More effective than bupropion or NRT Adverse effects/contraindications No significant effects, safe in almost all patients Contraindicated in patients with seizure or eating disorders Increased risk of cardiovascular events Possible increased risk of depression or suicidal events NRT= nicotine replacement therapy.Contraindications to fibrinolysis with tPA include: Presence of active internal bleeding Bleeding diathesis (eg, platelets <100,000/uL) Hypodensity in >33% of an arterial territory on CT scan Presence of intracranial hemorrhage on CT scan Intracranial surgery in the last 3 months Blood pressure >185/110 mm HgEffect of intensive glycemic control in type 2 diabetes Macrovascular complications No change (eg, acute myocardial infarction, stroke) (possible long-term |) Microvascular complications \ (eg, nephropathy, retinopathy) No change (A1c 6%-7%) Mortality 1 (Alc <6%)Clinical features of type 2 heparin-induced thrombocytopenia Suspected with heparin exposure > 5 days AND any of the following: © Platelet count reduction > 50% from baseline Arterial or venous thrombosis Necrotic skin lesions at heparin injection sites Acute systemic (anaphylactoid) reactions after heparin Diagnostic Serotonin release assay: gold standard confirmatory test evaluation Start treatment in suspected cases prior to confirmatory tests Cessation of ALL heparin products. Start a direct thrombin inhibitor (eg, argatroban) or fondaparinux (synthetic pentasaccharide) TherapyCommon causes of hemoptysis Pulmonary Hematologic Bronchitis Pulmonary embolism Bronchiectasis Lung cancer Mitral stenosis/acute pulmonary edema Tuberculosis. Lung abscess Coagulopathy Vascular Systemic diseases Arteriovenous malformations Wegener granulomatosis Goodpasture syndrome Systemic lupus erythematosus, vasculitiside assessment in the emergency department Suicidal thoughts, definite plan & intent/recent suicide attempt Past suicide attempt(s) Presence of psychiatric illness/severity of illness. impulsivity Hopelessness Marked anxiety/agitation Psychosis Intoxication (disinhibition) or substance use disorder Recent stressors Family history of suicide Lack of social support/living alone