White plaque in mouth that cannot be removed.

Leukoplakia. 

• Candidiasis can be removed and may bleed.  
• Leukoplakia may leed to squamous cell carcinoma.
• Biopsy to exclude cancer.

Otosclerosis.  

• Tx: Amplification or surgery.  
• Stapes is stuck in window.

1. Vomiting (also causes contraction alkalosis)
2. NG Suction
3. Renal Hydrogen Loss (Aldosterone or Contraction Alkalosis)

• Winter's Formula:

1.5(HCO3)+8 

Ethylene Glycol Toxicity

• Also increases risk of calcium-oxalate calculi. 
• Conjugation of calcium to oxalate->Hypocalcemia.
• Tx: Fomepizole (or alcohol)

• Sx: Tinnitis and fever.  
• AG Acidosis (mudpileS)
• Respiratory alkalosis as compensation

1. Distal (Not secreting H)
2. Proximal (Not reabsorbing HCO3)
3. Type 4: Hypoaldo 

Post-ictal lactic acidosis

• Resolves on its own without treatment.  
• Redraw labs in 2 hours.

• Exaggerated reflexes, cramps and seizure.  
• Commonly occurs after surgery where blood products are given (citrate in blood binds calcium).
• Also see in ethylene glycol toxicity.

• Causes high K release (by leaving receptors open).
• Don't use if hyperkalemia, burn or crush injury.

Anion Gap Metabolic Acidosis (Lactic Acidosis)

• CO stops oxygen from being delivered to tissues.

Agranulocytosis.  

• Also true of clozapine.
• Suspect in anyone on these drugs who presents with sore throat and fever.  
• If present, stop drug and get WBC.  
• Methimazole is the drug of choice, except for the first trimester.  

• Non-Compliance
• Physiologic Stress (Illness) 

• Tx: NS, Insulin.  Add D5 when glc 250-300. Watch K.
• Arterial pH (ABG) or AG are the most reliable indicators of recovery.  

1. Insulinoma (look for MEN1)
2. Exogenous Insulin (Insulin > C-Peptide)
3. Sulfonylurea (Sulfonylurea Level)

• Renin Tumor: Aldo is sky high, so Na and BP is elevated.
• Barter/Gittelman's: Na is being lost in these conditions (Loop, Thiazide diuretics).  Na is usually normal (ENaC compensates mostly).

• Vitamin D deficiency (Rickets in Kids/Osteomalacia in Adults).
• Low calcium-->Elevated PTH-->Low phosphate (but cannot fully compensate for calcium loss).
• -->Defective bone mineralization (And cartilage mineralization, also, in children).

Anti-Thyroid Peroxidase

• Extremely elevated risk of Lymphoma (60x).
• Hypothyroid patients are also at risk for:
• Bone loss (increased osteoclastic activity)
• AFIB

• Elevated ESTROGEN and testosterone.
• Esterogen is a precursor to testosterone.

• TCAs; GAbapentin.

• Worsening ophthalmopathy.  
• Risk may be decreased with pre & post-tx teroids.

• Usually asymptomatic (only finding is elevated AlkP is typical presentation).
• Hat size is getting bigger (asymmetric bone remodeling).  May cause headaches.
• Hearing Loss.
• Leg Pain.
• Due to abnormal bone remodeling.
• Xray: Areas of sclerosis and resorption.
• Labs: Elevated ALKP, normal GGT.  Normal Ca (to differentiate from osteoblastic prostate cancer). Elevated urinary hydroxyproline. 

• Is DELAYED.  
• This tells you that this isn't the persons height at the appropriate age, that it's their height at a younger "body" age and thus when their bone age matures, so will their height.

• Intestinal Angina with meals --> Weightloss.
• Without weight loss, consider an alternative diagnosis.
• 50% will have abdominal bruit.

• Cancer can cause a pseudoachalasia.  
• Do an endoscopy on:
• Anyone >60.
• Weight loss.  

• Chest pain brought about by hot or cold food.  
• Dx: Manometry.
• Tx: Nitrates or Peripheral CCBs.  

1. Na and water restriction (decrease hydrostatic forces).
2. Spironolactone.
3. Loop Diuretics.
4. If all else fails, frequent paracentesis.

• VIPoma. 
• Symptoms of watery diarrhea, and a pnancreatic head mass.  
• Other symptoms are hypokalemia (leg cramps) and low stomach acid (alkalosis).

Can cause drug-induced pancreatitis.  

• Mild; tx with supportive care.

• IV Steroids, fluids.  
• Colectomy if no resolution.

• Ischemic colitis (watershed areas-Splenic Flexure). 
• Abdominal Pain.
• Exam is usually benign.

• BUN/Creatinine. 
• Bacterial breakdown of Hb, with subsequent urea reabsorption into blood.

• Heart disease
• Renal failure

• Pilonidal Cyst

20 minute feeds q3 hours.

4-6 wet diapers a day

• GERD.  
• Tx: Thicken feeds, and have the child sit up for 30 minutes after feeds.  

1. Coin-Can observe for 24 hours.
2. Battery-Can cause ulceration.  Immediate removal with flexible endoscopy.

• Renal Cell carcinoma

Inpatient if systemic manifestations (vomiting, hypotension)

• Get blood culture if SIRS criteria is met as this can cause sepsis.

• Increased oxalate absorption (fat binds calcium, allowing free oxalate).
• Conditions:
• Celiacs
• Short Bowel 
• Chronic Diarrhea

• Vasculitis (palpable purpura)
• Glomerulonephritis
• Neuropathy
• Common in patients with Hepatitis C

• Urethritis.  
• Chlamydia is the most common cause.

1. Renal Vein Thrombosis: Acute onset fever, abdominal pain, gross hematuria.
2. Hypercoagulation (increased risk of stroke, MI)
3. Hypercholesterolemia (Tx with Statin)

1. HTN Nephropathy: Arteriolosclerosis
2. Diabetic: GBM thickening via nodular glomeruloSCLEROSIS.

• Goodpasteurs disease.
• Tx: EMERGENCY plasmaphoresis (to decrease extent of kidney disease).

• Amyloidosis.
• Will show deposits under polarized light (congo red stain shows green deposits).

• Lactic acidosis if renal/hepatic failure or sepsis.
• Tx: d/c drug until condition improves.

• Dehydrated patients
• DIABETICS

• Posterior urethral valve with distended bladder.
• Dx: Voiding cystogram.

• Turner SYndrome.  
• Dx: Karyotype.  
• Other Sx: Streak ovaries (high FSH, but no ovaries to stimulate); webbed neck, bicuspid aortic valve, coarctation.  

• Autoimmune hemolytic anemia.
• Dx: Positive Coombs test (dominant hereditary disease has positive osmotic fragility test).

• Young?  Look at old xrays.  
• Old? CT scan.

• Low in CML
• High in Leukemoid Reaction

• Should have a normal reticulocyte count unless aplastic crisis (not same as aplastic anemia; only effects RBCs).

• Sideroblastic anemia.  Tx with PLP (b6).
• If target cells are seen-thalassemia (normal RDW).

• B12 Deficiency.
• Both macrocytic anemias cause elevation in homocysteine.

• Will cause respiratory distress and sludging.
• Hematocrit > 65%.  
• Tx: Hydration.  exchange transfusion if sx.  

• PLP Deficiency (causes NEUROPATHY)-thats why TB treatment includes pyridoxine (PLP;B6).
• Hepatitis.

• Primary sclerosing cholangitis. 
• pANCA

• Octreotide + SCLEROTHERAPY.
• Band ligation is for elective.

• Primary biliary sclerosis.  

• Patients with normal enzymes and chronic dx only need to be watched. 
• Symptomatic patients are treated with  INF and Ribaviran (R comes after L).  
• Porphyria Cutanea Tarda a complication-Painless blisters on the back of hte hand.  Onycholysis, hyperpigmentation and hypertrichosis. 
• Tx with chloriquine (can cause retinitis).

• Swelling with clear demarcation.
• Acute in onset (vs. slow and indolent)
• Face involvement
• Always caused by Group A Strep.

• Malignant otitis externa-pseudomonas.
• May cause abscess in TMJ causing asymmetric jaw.

• Interferon and Lamivudine (L comes before R).

• Attempt diuretics.  If no work, get TIPS.

• NOT alcohol.
• Smoking, hyperlipidemia (and rest of metabolic syndrome).  Chronic pancreatitis.

Two Types:

1. Hemolytic Transfusion Reaction (within first 30 minutes):
1. Fever, DIC, Shock.  

TMP-Sx

Add Prednisolone if PaO2<70.

• Weekly acid fast, gram positive branching rod.
• TMP-Sx.

• Vaccination against:
• Pneumococcus
• Influenza
• Hepatitis B
• TMP-SX ppx against PCP PNA.

• None is needed if diagnosis is obvious.  Tx with doxy.
• If not obvious, like HIV.  Do ELISA and Western Blot.
• Use amoxicillin if <8 or pregnant/breast feeding.
• Bells Palsy is very common; if you see bells palsy, look for Lyme disease.

• PPx: 9 months of INH and pyridoxine (to avoid neuropathy).
• Tx: 2 months of 4 drugs, 4 months of INH and Rifampin.