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Posted by Care from IP 173.215.213.226 on September 17, 2010 at 17:24:33:

1. What is the earliest evidence of renal involvement in diabetes mellitus?
The earliest renal changes in diabetes consist of an increase in GFR of 25-50% and a slight enlargement of the kidney that persists for 5-10 years. At this stage, there may be a slight increase in albumin excretion rate (microalbuminuria), but the total protein excretion remains in the normal range. Studies indicate that patients with this "microalbuminuria" (> 20 μg/min of albumin) are more likely to develop overt diabetic nephropathy than those who do not exhibit microalbuminuria. The clinical phase starts with the appearance of proteinuria (corresponds to > 300 mg /day) on urine dipstick.

2. Diphenhydramine overdose manifests as anticholinergic symptoms. Patients have neurologic symptoms such as confusion and delirium. They complain of abdominal pain, nausea, vomiting, and their mucous membranes are usually exceptionally dry. Diphenhydramine is commonly found in over-the-counter sleeping aids. Diphenhydramine is correct. Diphenhydramine overdose manifests as anticholinergic symptoms. Patients have neurologic symptoms such as confusion and delirium. They complain of abdominal pain, nausea, vomiting, and their mucous membranes are usually exceptionally dry. Diphenhydramine is commonly found in over-the-counter sleeping aids. Physostigmine is a reversible cholinesterase inhibitor that is used for the treatment of diphenhydramine overdose.

3. A new diagnostic test for latent tuberculosis infection, known as the quanta-feron test (QFT-G), is now available. This is a blood test that measures interferon response to specific M. tuberculosis antigens. The test is FDA approved and is available in some large TB centers and state health departments. It may assist in distinguishing true positive reactions, from individuals with latent tuberculosis, from PPD reactions related to: non-tuberculous mycobacteria; prior BCG vaccination; or difficult-to-interpret skin test results from persons with dermatologic conditions or immediate allergic reactions to PPD. The diagnostic utility of the test as a replacement or supplement to the standard PPD is not yet fully determined.


4. Pulmonary Embolism. The diagnosis of pulmonary embolism is based on a combination of clinical symptoms and diagnostic imaging. The gold standard is pulmonary angiography (3 hours), however the use of spiral CT (30 minutes) has become an excellent modality for diagnosing PE. Other imaging modalities include the ventilation-perfusion scan (2 hours) and doppler venous ultrasound of the lower extremities (2 hours). The following guidelines are generally accepted based on pretest probability.
Criteria for determining pretest probability
1. PE more likely than alternatives: 3.0 points
2. Deep Vein Thrombosis (DVT) suspected: 3.0 points
3. Tachycardia (pulse >100 beats per minute): 1.5 points
4. Surgery or immobilization in last 4 weeks: 1.5 points
5. Prior DVT or Pulmonary Embolism: 1.5 points
6. Hemoptysis: 1.0 points
7. Active malignancy: 1.0 points
Interpretation of pretest probability
1. Score 0-2 points: Low PE Probability (4% risk)
2. Score 3-6 points: Intermediate PE Probability (21% risk)
3. Score >6 points: High PE Probability (67% risk)
• If high pretest probability - obtain spiral computed tomography of the chest. If positive treat; If negative,  obtain pulmonary angiography
• If intermediate pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, treat.
• If low pretest probability - obtain ventilation-perfusion (V/Q) scan and D-dimer. If both negative,  eliminate diagnosis. If V/Q scan intermediate, obtain pulmonary angiography. If V/Q scan high probability, obtain pulmonary angiography.

5. Acetaminophen poisoning - Treatment
• As first-choice therapy, particularly if a significant ingestion occurred within the preceding hour, activated charcoal may be administered.


6. KEY POINTS: SENSITIVITY, SPECIFICITY, AND PREDICTIVE VALUE
1. Sensitivity = TP/(TP + FN)
2. Specificity = TN/(TN + FP)
3. Positive predictive value = TP/(TP + FP)
4. Negative predictive value = TN/(TN + FN)
5. Predictive value depends on the performance of the test, combined with the prevalence of the condition in the tested population.

7. Hepatitis B panel
Chronic hepatitis B infection.  (+) HBsAg and (+) anti-HBc.
Acute Hepatitis B infection  (+) HBsAg, (+) anti-HBc, (+) IgM anti-HBc
Immunity due to vaccination  (+) anti-HBs
Immunity as a result of natural infection  (+) anti-HBs and (+) anti-HBC

8. Neonatal jaundice is first visible on the face. As bilirubin levels rise, jaundice progresses caudally. Jaundiced feet are an indication to obtain serum bilirubin levels.

9. Incidence of re-expansion pulmonary edema increases in patients whose chest tubes have been placed 3 or more days after the pneumothorax occurred. A chest tube very likely was placed to treat this patient’s spontaneous pneumothorax.

10. The hCG molecule is first detectable 6 to 8 days after ovulation. A titer of less than 5 IU/L is considered negative, and a level above 25 IU/L is a positive result. Values between 6 and 24 IU/L are considered equivocal, and the test should be repeated in 2 days. A concentration of about 100 IU/L is reached about the date of expected menses. Most qualitative urine pregnancy tests can detect hCG above 25 IU/L.
It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines.

11. Anginal pain at rest with a circadian rhythm particularly when occurrence is in the early morning is highly suggestive for variant (Prinzmetal) angina. Documentation of ST segment elevation correlating with symptoms is almost pathognomonic. Variant angina usually responds to treatment with calcium channel blockers

12. A University of Michigan study in 2000 found as many as one-third of patients with epilepsy have undiagnosed obstructive sleep apnea. Logically there seems good reason to suspect a causal relationship, with hypoxia associated with apneic episodes predisposing to epileptic seizures.

13. Therapeutic options
Summary of therapies
Hashimoto's thyroiditis:
• Many patients do not require treatment
• Treat hypothyroidism and/or goiter with levothyroxine
Subacute thyroiditis:
• Treat thyroid/neck pain with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
• Treat hyperthyroid symptoms with beta-blocker
• In severe cases, corticosteroids such as prednisone will improve constitutional symptoms and shorten the duration of illness
• Transient hypothyroidism later in the disease course may require levothyroxine therapy
Painless thyroiditis:
• Treat hyperthyroid symptoms with beta-blocker
• Transient hypothyroidism later in the disease course may require levothyroxine therapy
• Corticosteroids are not necessary
Suppurative thyroiditis:
• Treat with broad-spectrum antibiotics to cover both Gram-negative and Gram-positive organisms
• Because of the high frequency of infection with Stapylococcus aureus and other Gram-positive cocci, nafcillin, along with gentamicin or a third-generation cephalosporin would be appropriate as initial therapy
• Prompt evaluation by specialist is required to assess the need for drainage/biopsy
Riedel's thyroiditis:
• Surgery may be required if patient has compressive symptoms
• Levothyroxine therapy is necessary if hypothyroidism develops
Clinical pearls
• Decision to treat with levothyroxine during the hypothyroid phase should be made on a clinical basis. Some patients tolerate hypothyroidism extremely well; others are ill with only mild elevations of TSH
• The hypothyroid phase of subacute and painless thyroiditis is often shorter than the time required to achieve steady-state levels of levothyroxine (4-6 weeks)
• Patients with Hashimoto's thyroiditis may develop TSH receptor antibodies and present with Graves' disease
• Radioactive iodine uptake and scan is pivotal during the hyperthyroid phase to rule out Graves' disease

14. Corticosteroids are the only recommended medication for the treatment of alcoholic hepatitis. Prednisolone has been shown to reduce short-term mortality in severe acute alcoholic hepatitis.

15. The ECG findings most commonly seen in myocarditis are diffuse T-wave inversions without shifts in the ST segment


16. In the first few days, the ECG in acute pericarditis shows ST elevation, concave upwards, with upright T-waves in most leads. Classically it is more obvious in lead II than in III or I. In the later stages of pericarditis, the T-waves become inverted in most leads.

17. Intravascular volume contraction and dehydration due to third spacing and poor oral intake in small bowel obstruction often causes an increase in BUN.


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