Rating of Pitting Edema and other Scales

Pitting Edema: scale of 0-3
0:none, the non-abnormal finding.
1+:pit returns to normal in under 30 seconds.

2+: " in 30 sec to 5 min.

3+:" in longer than 5 min.

Muscle strength: 0-5
0- no muscle mvmt at all
1/5-muscle flicker
2/5-able to move, but not vs gravity.
3/5-able to move vs gravity,  but not vs moderate physician force.
4/5 less strong than normal,  but able to move against moderate physician force.
5/5 full muscle strength. The non-abnormal finding.

Reflex strength:0-4
0-none
1+: hypoactive reflex
2+: the non-abnormal finding. Ordinary reflex response.
3+:hyperactive reflex.
4+:hyperactive reflex with sustained clonus.

Pulse strength:
0-none
1+: hypoactive pulse
2+: the non-abnormal finding. Ordinary pulse response.
3+:hyperactive pulse.
4+:hyperactive bounding pulse.

Differential Diagnosis for Vertigo Symptoms

Vertigo: Feeling like the room is spinning.

1. Meniere Disease: Recurrent episodes, Unilateral hearing loss and tinnitus (mechanical vibration with sound), feeling of ear fullness.
Caused by increased volume and pressure of endolymph with resulting vestibular and cochlear damage.
Tx: Restrict caffeine, sodium, nicotine, EtOH. Benzos, Antihistamines, antiemetics can relieve symptoms. Diuretics can also help for long-term management.

2. Benign paroxysmal positional vertigo (BPPV): Brief, intense episodes triggered by head movement, Dix-Hallpike maneuver causes nystagmus. Usually no tinnitus or hearing loss.

3. Vestibular neuritis: Acute, single episode that can last days, often follows viral syndrome, abnormal head thrust test.
Tx: None. Will resolve within several weeks.

4. Migraine: Vertigo associated with headache or other migrainous phenomenon (eg, visual aura), Symptoms resolve completely between episodes

5. Brainstem/Cerebellar Stroke: sudden onset, persistent vertigo; Usually other neurologic symptoms.

Less common:
6. Multiple Sclerosis: episodic vertigo, sensorineural hearing loss. Also paresthesias, weakness, visual disturbance, urinary incontinence.

7. Vestibular schwannoma: unilateral persistent, progressive sensorineural hearing loss. May also have tinnitus, imbalance.

Proteinuria

In children if proteinuria is detected on urine dipstick test, should be repeated twice more on two separate occasions, and if negative, deemed "transient" and benign. If either subsequent test is positive, patient has "persistent proteinuria" and should be referred to a pediatric nephrologist to work up the cause.

Lochia

Lochia is vaginal discharge containing blood and mucus. It is normal up to 8 weeks post-partum. Heavy bleeding that soaks >2 pads in an hour is deemed excessive and must be further worked up.

Common Lactation Problems

Engorgement: B/L, symmetric fullness, tenderness and warmth of breast tissue.
Tx: breast-feeding/pumping, cool compresses, NSAIDs.

Nipple injury: Abrasion, bruising, cracking and/or blistering from poor latch
Plugged duct: Focal tenderness and firmness and/or erythema; no fever
Galactocele: Subareolar, mobile, well-circumscribed, non-tender mass, no fever
Mastitis: Tenderness/erythema and fever
Abscess: Symptoms of mastitis + a fluctuant mass.

Neisseria ghonorrhea

Gram negative diplococci
Not encapsulated
Facultative intracellular in PMNs
Sexually transmitted
Chlamyida coinfection
White purulent discharge
Fitz-Hugh Curtis Syndrome, spread of PID to peritoneum
Violin-strings adhesions form to capsule of liver, after PID
Assymetric arthritis, often in knee
Newborns
	Early onset conjunctivitis
Rx: Ceftriaxone

commonly gonorrhea and The Clap

Neisseria meningitidis

Gram negative diplococci
Encapsulated: A,B,C,D: 4 capsules
	Vaccines to all except capsule B
IgA Protease: cleaves at hinge region
Transmission: college campuses
Colonizes nasopharynx first
LOS envelope proteins cause inflammatory response
Leaky capillaries
	Hypovolemia and Shock
	Waterhouse-Friderichsen Syndrome: Adrenal hemorrhage
Sickle cell susceptibility
Petichial rash from thrombocytopenia
	Risk of DIC
Dx: Ferments both maltose and glucose
Rx: Ceftriaxone
Rifampin prophylaxis for close contacts

Neisseria

Antigenically variable pili (different colored watch chains)

IgA Protease: cleaves at hinge region (The ace card in Mac's Hat)

Pts with C5-C9 complement Deficiency are susceptible to infections (Show airs 5-9pm)

Gram negative diplococci (purple handcuffs)

Dx: Oxidase Positive (Has an oxidase positive ring)

Dx: Grows on VPN Agar = Thayer Martin Agar (Thayer Martin plays a Vice City Private Nvestigator)

Dx: Grows on Chocolate Agar (Mac's chocolate Bar)

Nocardia

Found in soil (soil spilling out of broken pot)

Gram-positive branching filamentous rod (branching tree)

Urease Positive (Urease Positive Spray Bottle)

Obligate aerobe (bellows)

Pneumonia-like symptoms (coughing)

Cavitary lung lesions (also in actinomycosis, coccidioidomycosis)

Brain abscess (hat shot through)

Cutaneous Symptoms: indurated lesions, inflammatory reaction: "Nocardiosis"

Immunocompromised at risk (cane)

Dx: Mycolic acid, partially acid fast (fast shootin' pink gun)

Dx: Catalase Positive (bartender's cat)

Rx: Sulfonamides (Sulfurous eggs)

Actinomyces israelii

Found in soil

Gram-positive branching filamentous rod (branching tree)

Obligate Anaerobe (gas mask)

Formation of sinus tracts

Infection assoc. with Jaw Trauma

Dx: Yellow sulfur granules

Rx: Penicillin

Listeria monocytogenes

Facultative anaerobe
Thrives in cold
Transmitted via milk, cheeses
Motile by actin polymerization = "actin rockets"
	Tumbling motility
Beta hemolytic (unique among gram negative bacteria)
Can be acquired transvaginally by foetus.	Pregnant women shouldn't eat soft cheese
	Neonatal meningitis
Facultative anaerobe
Elderly at risk
Dx: catalase positive (unique among gram-negative bacteria)
Rx: Ampicillin

Corynebacterium diptheriae

Inactivated pertussis toxoid vaccine
Transmited via respiratory droplets
EF-2 ribosylation (same as Pseudomonas, accordion)
Club-shaped V or Y rods
Pseudomembrane on throat and tonsils
Demyelination causes nerve deficits in posterior pharynx
Bull neck
Cardiotoxic effects: Myocarditis, arrhythmia, Heart Block
Dx: Plated on Tellurite Agar/Hoyle's agar
Dx: Plated on Loeffler's medium
Dx: Elek's test

Clostridium perfringens

Spores found in soil
Causes gas gangrene
Infections associated with wounds
Obligate anaerobe
Alpha-toxin = lecithinase causes myonecrosis, disrupts cell membranes
	Red cell hemolysis
Gas gangrene
Double zone of hemolysis
Rx: IV Penicillin G
Slow onset watery diarrhea from spore ingestion

commonly C. perfringens and flesh eating bacteria

Clostridium difficile

Cause: Clindamycin kills normal gut flora (although any chronic Abx can cause)
Diarrhea
Gram Positive Obligate anaerobe
Exotoxin A
	Targets brush boarder enzymes
	Watery diarrhea
Exotoxin B
	Pseudomembrane formation
	Depolymerization of actin filaments
Anaerobic
Dx: Assay to detect toxin in stool
Rx: Oral vancomycin
Rx: Metronidazole		Commonly C. diff

Clostridium botulinum

Transmitted by improper canning of food

Transmitted in spore-form in honey to infants

Descending paralysis

Spore forming

Obligate anaerobe

Early symptoms ptosis and diplopia

Toxin targets nerves that release Ach

Commonly botulism and C. botulinum

Clostridium tetani

Risus sardonicus smile (smiling Rhesus Monkey)
Rigid paralysis
Spores Transmitted by rusty objects, dirt (Spores and dirt, nails, barbed wire around lab cage)
Obligate anaerobe (gas mask)
Gram Positive (Purple color) rod
Oposthotonuss: exaggerated extension and arching of back (background monkey in this position)
Tetanospasmin Toxin cleaves SNARE protein  (Snares being cut)
	Acts as a protease (Scissors)
	Inhibits release of GABA and Glycine inhibitory neurotransmitters (G&G Labs)
	Targets Renshaw Cells, inhibitory interneurons (Wrenches and saws)
Retrograde Transport
Toxoid vaccine (Researcher is holding it) Commonly Tetanus and C. tetani and lock jaw lock-jaw

Bacillus

Protein capsule Poly-D capsule (D-capsules around vikings)
Large Gram Positive Bacillus in CHAINS (chain of boats) Catalase positive (Cat)
B. cereus: Food poisoning, rice. Vomiting and diarrhea: The diarrheal syndrome: abdominal cramps and copious diarrhea, usually beginning 8 to 16 hours after ingestion, resolving within 24 hours. Emetic Syndrome: Symptom onset usually within one to five hours of ingestion, usually resolve in 6 to 24 hours. Caused by cereulide toxin.
B. anthracis
Obligate aerobe (bellows)
Black eschar Widened mediastinum (Widened sails of ship) Pulmonary Symptoms: Pulmonary hemorrhage 99% mortality
Spore-forming
Edema Factor (Adenylate cyclase increasing cAMP)
Black eschar
Sheep-shearers' disease
Rx: Doxycycline
Rx: Fluoroquinolones
Lethal Factor: destroys MAP (Mitogen-Activated Protein) Kinase, causing tissue necrosis

ranging in size from 3 by 0.4 microns up to 9 by 2 microns

Commonly Anthrax

Enterococcus

E. faecalis
	Resistant to 6.5% NaCl
	UTI
	Endocarditis
	Biliary Tree Infections
	More common than faecium (more protesters)
E. faecium
	More dangerous (Buffer dudes)
	Bile Resistant (Wearing the Bile resistant boots)
	Rx: Tigecylin (Tiger striped line)
	Rx: Linezolid (Police Line)
	Resistant to Vancomycin (won't go into the van)

Streptococcus pneumoniae and viridans

Alpha-hemolytic
S. pneumoniae
	Encapsulated with polysacharride
		Optochin sensitive
	Lancet-shaped gram positive diplococci
	Bile soluble
	Rust colored sputum in lobar pneumonia
	MOPS: Meningitis, Otitis Media, Pneumonia, Sinusitis (most common bacterial cause of each)
	IgA protease
	Sickle cell patients susceptible
	Rx: Macrolide, erythromycin, 60S subunit
	Rx: Ceftriaxone
	23 valent adult vaccine: only IgM response
	7 valent childrens vaccine: IgG response (long-lasting immunity)
S. viridans
	Optochin resistant
	Bile resistant
	Dental caries (especially Strep. mutans)
	Worsens previous valve damage, Mitral valve prolapse, most likely to be damaged
	Adheres to Platelets, using dextrans glue synthesized from glucose
	No capsule

Strep. agalactiae

Group B Strep
Dx: Positive hippurate test
Polysacharide capsule
Dx: CAMP Test Positive, increasing zone of hemolysis with Staph. Aureus
Beta Hemolysis
Bacitracin resistant
Pneumonia, Meningitis and sepsis in neonates
Transvaginal transmission to neonates
	Rx: Prophylactic penicillin if positive for colonization at 35 wks

Streptococcus pyogenes

Hyaluronic Acid
Group A Strep
Human antigen capsule
Beta hemolytic
Impetigo (also Staph aureus possible)
	Honey-crusted infection
Pharyngitis
Eresypela (very superficial cellulitis with firm demarcations) and Cellulitis
SPE= Streptococcal Pyrogenic Exotoxin
	A&C: Scarlet Fever
		Pharyngitis
		Strawberry tongue
		Widespread rash that spares the face
	A&C: Toxic-Shock-Like Syndrome from Super-Antigen
	SPE B: Necrotizing fasciitis
		Amputations
Rheumatic Fever
	Precipitated by only pharyngitis
	M Protein
		Antiphagocytic
		Highly Antigenic
	Mitral valve damaged: Mitral stenosis
	QT elongation
	JONES Criteria: Need 3 out of 5 to Dx RhFev.
		Arthritic joints: Polyarthritis
		Endocarditis
		Subcutaneous Nodules
		Erythema marginatum
		Sydenham's Chorea
PSGN: Post Strep Glomerulonephritis
	Facial puffiness
	Cola-colored urine
	2 wks after Strep throat or Impetigo
Rx: Penicillin
Streptolysin O: allows S. pyogenes to lyse RBCs
Streptokinase converts plasminogen to plasmin: thrombolytic
DNAase
Bacitracin sensitive
Dx: AntiStreptolysin ASO titer to tell how long after initial infection

Staph. Saprophyticus and Epidermidis

Urease Positive (Urea Spray Bottle)
Catalase Positive (Cat)
Coagulase Negative
S. Epidermidis
	Infects prosthetic joints: will need to be replaced
	Covers all skin normally
	Most common cause of artificial heart valve endocarditis
	Creates polysaccharide biofilms for attachment and protection
	Novobiocin sensitive
	Rx: Vancomycin
	Contamination of blood cultures
S. saprophyticus
	UTI infections in sexually active women
	Novobiocin resistant

Drug Contraindications

Bupropion- contraindicated in bulemia Patients (1st line antidepressant, preferred d/t no sex dysfxn or weight gain)

Clinical Interaction Algorithms

iCARE algortithm is for general patient interaction:

i Introduce
C Connect
A Anticipate what the patient will need/say/ask and prepare for it.
R Reinforce, including answering questions, giving patient options, asking them to Repeat it back, and summarize the case.
E End by setting expectations for next time and provide a business card and gesture of goodwill/gratitude on parting.

and for dissatisfied and unhappy patients, use the HEALS algortithm:

H Hear
E Empathize "I'm sorry. I can understand how that...", but NOT "I know what you're going through".
A Apologize in a way that does not place blame on any party.
L Look for a Solution. "I want to help. What I can do is..."
S Show gratitude "Thank you for letting me be part of your care."