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Lecture Notes for Internal Medicine
Weill Bugando School of Medicine
Bugando Medical Centre
Students Version
1st edition (2012)

Introduction
The following lecture notes are based on the topics described in the official curriculum of the Weill
Bugando School of Medicine
...
These lecture notes contain the basic concepts of internal medicine
that every medical student should know by the time of graduation
...
Students are still encouraged to consult one of
the recommended textbooks of internal medicine for in depth explanations
...
We have attempted
to adapt these lecture notes and clinical cases to the diseases and resources that are commonly
available at Bugando and in East Africa
...

We believe that the best setting for learning medicine is at the bedside of a patient, and that this
material would be best taught at the bedside
...
When an illustrative patient is not available, the
teaching cases may be used to cover the most salient clinical details for each condition
...
Sessions
on the physical examination of the major body systems are included with the expectation that these
can be taught and modeled at the bedside
...

These lecture notes are a labor of love that has been completed over the course of the past 5 years
...
In particular we would
like to thank our Vice Chancellor (Prof
...
Charles Majinge) , Dean
(Prof
...
B
...
Samuel Kalluvya)
...
Hyasinta Jaka, Dr
...
Bahati
Wajanga, Dr
...
Mubarak Janmohamed
...

Those who have prepared these notes have used a variety of resources
...
, Glynn M
...

22nd ed
...
[for physical examination topics]
Eddleston M, Davidson R, Brent A, Wilkinson R
...
3rd ed
...
[for clinical topics]

Sincerely,
Drs
...
1
HISTORY, EXAM, AND PROCEDURES
...
6
GENERAL EXAMINATION
...
11
CARDIOVASCULAR SYSTEM EXAM
...
17
GASTROINTESTINAL SYSTEM EXAM
...
24
CARDIOLOGY
...
29
CHEST PAIN
...
34
VALVULAR HEART DISEASE
...
38
INFECTIVE ENDOCARDITIS (IE)
...
43
INTRODUCTION TO HYPERTENSION
...
48
SHOCK & HYPOTENSION
...
53
RENAL
...
57
NEPHRITIC & NEPHROTIC SYNDROMES
...
62
ELECTROLYTE & ACID-BASE DISORDERS
...
67
ACUTE AND CHRONIC DIARRHEA IN ADULTS
...
72
GI BLEEDING
...
76
PORTAL HYPERTENSION
...
81
NUTRITIONAL DEFICIENCIES
...
85
INTRODUCTION TO ANTIBIOTICS
...
91
HIV/AIDS
...
94
TUBERCULOSIS (PULMONARY AND EXTRA-PULMONARY)
...
99
MALARIA
...
105
SEXUALLY TRANSMITTED INFECTIONS
...
109

3

SYSTEMATIC METHOD FOR READING CHEST X-RAYS
...
113
DYSPNEA AND RESPIRATORY DISTRESS
...
118
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
...
124
PULMONARY EMBOLISM
...
129
STROKE
...
133
SEIZURES
...
137
ENDOCRINE
...
141
ACUTE COMPLICATIONS OF DIABETES MELLITUS IN ADULTS
...
145
HEMATOLOGY & ONCOLOGY
...
151
BLEEDING DISORDERS
...
156
LYMPHOMA AND LEUKEMIA
...
161
MISCELLANEOUS
...
169
BONE DISEASE
...
175
MEDICAL OPHTHALMOLOGY
...
The answer to the patient’s problem is in
the history 90% of the time! The other 10% of the time, you will need to use investigations to help
you figure the answer out
...
Fore example:
Luke Smart, 32 year old male, self referral to Bugando Medical Centre
...
Ask the patient, “Why did you come to the
hospital?” It is normally, one complaint, but can contain up to two or even three main complaints
...
For example: disturbance in breathing for two weeks
...
Use the patient’s own words as much as
possible
...
Usually a patient will say “chest pain” instead of “angina
...
For example: “The patient described
chest pain when walking up a hill four weeks ago
...

Eventually the chest pain subsided and the patient began to experience shortness of breath when
walking short distances
...


Review of Other Systems (ROS)
Review the systems that are not involved in the chief complaint
...
Usually the ROS is done from head to toe
(neurological, cardiovascular, pulmonary, gastroenterology, renal, genitourinary, and
musculoskeletal)
...
For example, if the patient has abdominal pain, then the gastroenterology system will be
reviewed in the HPI, and the cardiovascular, renal, and genitourinary systems ought to be specifically
mentioned in the ROS
...


Past Medical/Surgical History (PMSHx)
This includes past admissions, chronic medical problems, medications, allergies, immunizations,
prior surgeries, prior blood transfusions, and for women gynecological history
...
For example, if the patient presents with
chest pain that started one month ago and was admitted two weeks ago for this complaint, then it
should be included in the HPI
...
For some past medical
problems it is important to include more than just a diagnosis
...
For
6

the allergy section, ask specifically what kind of reaction they had
...
You can also ask if it was a pill or an intravenous medication
...


Family/Social History (FSHx)
A complete social history includes marital status, number of children, the location of their home
(region/village), type of home, number of children, occupation, level of education, alcohol use,
tobacco use, illicit drug use, and sexual history
...
This is reported in pack years
...
If the patient smoked one pack per day for ten
years, then they have a ten pack-year history of smoking
...
Also report the type of cigarettes
used
...

The sexual history should include the number of current partners (or the number of partners in the
past month), the total number of past partners in the patient’s life, any history of sexually
transmitted infections, the age at first intercourse, and whether the patient uses protection when
having sex
...


Summary #1
This is one sentence that summarizes the important parts of the history
...
For example: “This is a 30yo new diagnosis of IDS, who presented with at 2 week history of
difficulty breathing which was associated with chest pain, fever, weight loss, night sweats, and a TB
contact
...
More detailed information about how to perform the
different sections of the physical exam can be found in other lectures, and in Hutchison’s
...
At the end of the general exam, report the vital signs
...
The vital
signs are temp of 37
...
”
After reporting the general exam, report the systemic exam
...
If the patient presents with diarrhea, present GI first, then go on to other organ systems
...


7

Each organ system ought to be examined in the same order: I
...
P
...
– inspection,
palpation, percussion, auscultation
...
The only
exception to this rule would be for the central nervous system
...
P
...
A
...
Report the vital signs twice: once during
the general exam, and then the appropriate vital signs for each of the organ systems that are
investigated (e
...
you report BP and pulse with the CV exam even though they were already
reported during the general exam)
...
The first one is a repetition of Summary #1
...
You do not need to repeat the specifics of the exam
findings if you are able to summarize them in a brief way
...


Impression
Your impression should take into account the chief complaint and all abnormal findings on the
history and physical
...
The
differential diagnosis should include other possibilities, but not things that you are fairly certain the
patient has
...
g
...
You should give your
reason for each impression and then give 3-5 good differential diagnoses for each impression
...
It is best to organize your plan by stating what investigations and treatments you
want for each of your impressions, e
...
for IDS I want to send a cd4 count and get baseline ART labs
(RFT, FBP, LFT); for TB I want to get sputum for afb, check FBP, and get a chest x-ray
...


8

General Examination
Introduction



The general examination is usually done in either sitting or lying position
...

Move from general observation to specific inspection of different parts of their body

Mental and emotional state



What is their mental state? (confused, delirious, agitated, somnolent)
What is their emotional state? (anxious, depressed, apathetic)

Physique




Is appearance consistent with their age? (younger or older than stated age?)
What is their body habitus? (tall, short, fat, thin, muscular, asthenic, wasted)
Are there obvious deformities or scars? (kyphosis, scoliosis, pectus excavatum/carinatum)

Face






Is there any asymmetry?
Do they have any swelling? (general puffiness, parotid swelling)
What is their color? (pale, red, bluish, facial plethora)
Do they have any rashes? (telangiectasias, naevi, malar rash)
Are their eyes or eyelids irregular?

Skin





What is its color? (pallor, jaundice, central cyanosis, peripheral cyanosis)
What is its temperature? (cool, pyrexia)
What is its appearance? (dry, pitting edema, scratch marks, bruising, spider naevi)
If there is edema, what is its distribution? How far up the leg does it go? How severe is it?

Hands/Feet







What is the appearance of the fingers/joints? (redness, swelling, deformity, Dupuytren’s
contracture)
What is the appearance of the nails? (clubbing, splinter haemorrhage, koilonychia)
What is the appearance of the palms/pads? (Osler’s nodes, laneway lesions, palmar erythema)
Any abnormal movements? (hepatic flap, tremor)
o Checking for hepatic flap: When the hands are arms are fully extended and the wrists
extended with palms facing forward perpendicular to the ground, the patient will be
unable to sustain the hands in extension and will periodically flap his hands
...
Inspect
the neck for the pulsations of the internal jugular vein
...
It should normally be less than 3 cm above the sternal angle
...
Pulsus paradoxus is an abnormally large decrease in this normal variation
...
Slowly
deflate the cuff until you hear the first Korotkoff sound only during expiration and note the
blood pressure
...
Subtract this from the first pressure
...


Respiratory







What is the quality of the voice? (strong, weak, hoarse)
Are they breathless? If so, to what degree? (speaking in full sentences, speaking in one word
sentences, unable to speak, dyspnoea, Cheyne-Stokes breathing)
Are there any abnormal chest movements? (symmetri/asymmetric, subcostal, intercostal,
supraclavicular, or suprasternal recessions)
Are they using accessory respiratory muscles? (sternoclaidomastoid, intercostal)
Are they coughing? (weak, dry, wet, productive sounding, or paroxysmal cough)
What is the rate of respiration? (tachypnoea, apnoea)

Chest



Observe chest, pulses, and body surface for abnormal pulsations
Observe any breast irregularities (asymmetry, peau d’orange, gynaecomastia)

Gastrointestinal






The patient should be supine with arms loosely by his or her sides, with head and neck
supported by a pillow so that the abdomen can be relaxed
...
In severely ill patients,
the nervous system exam can be completed in the lying position
Always perform the neurological exam systematically so that you do not omit anything
...
Always report all 6 parts of the nervous
system examination – higher centers, cranial nerves, meningeal signs, motor/reflexes, sensation,
coordination/gate/balance –even if you need to report that some part “could not be assessed
...

For the an internal medicine doctor, you should at the very least observe the level of
consciousness and orientation
Level of Consciousness: In extremely ill patients consciousness can be quantified with the
Glasgow Coma Scale (GCS)
...
Do they know who
they are (their name, age, date of birth), where they are (city, hospital, floor), and when it is
(year, month, day, time)
Speech: Do they have dysarthria, expressive aphasia, or receptive aphasia?
Memory: assess both short term and long term memory
...
This is
often omitted during a brief bedside exam
...

CN III, IV, VI (Oculomotor, Trochlear, Abducens): Have patient track with eyes as you trace an ‘H’
1m away
...
Test pupils by shining light into
eyes and checking for direct and symmetric reaction
...


11












CN V (Trigeminal): Check sensation to light touch and pin prick in all three branches of the
trigeminal nerve on both sides of the face
...
Palpate masseter and temporalis
muscles as patient clenches teeth to assess motor function
...
Check movement of the lower face
by having the patient smile, bare teeth, and hold air in the cheeks while you tap on them
...

CN VIII (Vestibulocochlear): Test hearing with different volumes of speaking (normal, whisper),
and with rubbing your finger near their each ear individually
...
Check the vestibular function at the end of the neuro exam during the
coordination, gait and balance assessment with the Romberg test, heel to toe walking, and DixHallpike test
...
Ask the patient which is louder
...
Ask the patient whether the sound is heard in the midline or whether it is
louder on one side
CN IX (Glossopharyngeal): Test for motor function by having patient stick their tongue out
...

CN X (Vagus): As the patient says ‘ah,’ confirm soft palate elevates and the uvula stays midline
...
Check for sternoclaidomastoid
strength by placing hand on cheek and having patient turn their head against it
...

Kernig’s Sign: With the patient supine on the bed passively extend the patient’s knee on either
side when the hip is fully flexed and look for patient spasm
...


Motor/Reflexes




Bulk: Note any muscle wasting, fasciculations, or hypertrophy and their distribution
...

Tone: Move the limb passively back and forth at different rates
...


Power
0 – Complete paralysis
1 – A flicker of contraction only
2 – Cannot resist gravity, but moves on the
bed

3 – Resists gravity, but cannot resist examiner
4 – Resists gravity and examiner, but not
normal
5 – Normal power

12

Deep Tendon Reflexes
0 = absent
1 = present (as a normal ankle jerk)


2 = brisk ( as a normal knee jerk)
3 = very brisk
4 = clonus

Superficial Reflexes
o Abdominal reflex: with patient supine, drag stick across the abdomen from loin toward
midline causing contraction
o Plantar (Babinski) reflex: scratch the outer edge of the sole of the foot with a stick from
the heel to the toe, and watch for flexion of the toes
o Cremasteric reflex: Stroke the upper inner part of the thigh
...

o Anal reflex: gently scratch skin on either side of the anus and it will contract

Sensory System







Pinprick (small fibres/spinothalamic pathway): use a pin, start distal and move proximally
...

Light Touch (Moderately myelinated fibres/combined pathways): use finger or cotton
...

Joint position sense (large myelinated fibres/dorsal column pathway): Test a finger and toe on
each limb
...

Two Point Discrimination: Normally 2mm separation can be recognized as separate stimuli on
the finger tips, but only 1cm separation on the bottoms of the toes

Coordination, Gait, and Balance






Coordination: Test when concerned about cerebellar injury
o Finger to nose test: ask the patient to touch his nose and then the tip of your finger, held
at arm’s length in front of the patient’s face using their index finger
...
Then have patient walk heel to toe with their eyes first open, then closed
...

o Romberg’s: Standing with feet firmly together, have the patient close his or her eyes
and see if balance worsens (do they sway or fall)
...


Inspection of the Hands
This would normally be done and reported as part of the general examination unless ONLY a focused
cardiovascular examination is done
...


Arterial Pulses







Rate: Palpate the right radial artery
...

Rhythm: Note whether the rhythm is regular (no missed or extra beats) or irregular
...

Character: Palpate the right carotid artery on the neck at the angle of the right mandible
...
Check for symmetry between the right and left side, and for
delay between the brachial and femoral pulses
...


Blood Pressure





Blood pressure should be checked first in the sitting position in both arms
...

Place the bell of the stethoscope over the brachial artery on the ventral surface of the elbow
...
Normally it is less than 4cm
vertically above the angle
...


Palpation
Place your right hand on the patient’s left chest with the butt of the hand at the sternum and the
fingers extending into the axilla





Apex beat: the lowest most lateral point at which the cardiac impulse can be palpated
...

Double Thrust: A palpable 3rd and 4th heart sound
Left Parasternal Thrust: Thrust appreciated just to the left of the sternum
Thrill: Palpable vibrations on the chest wall

Auscultation
Technique
 Diaphragm of the stethoscope for high-pitched sounds
 Bell of the stethoscope to hear the low-pitched sounds
...

Sounds
 1st sound (S1) – closing of the mitral and tricuspid valves
 2nd sound (S2) – closing of the aortic and pulmonary valves
...

 3rd and 4th sounds (S3, S4)
o Low frequency sounds
...
Either one is called a ‘gallop
...
This can be low-pitched, medium pitched, or high-pitched
...

o Radiation: what direction does the sound travel to? (neck, axilla, back?)
o Timing: describes what phase of diastole or systole the murmur is heard
 Systolic: midsystolic, pansystolic, late systolic
 Diastolic: early diastolic, mid-diastolic, or presystolic
 Continuous: audible in both phases of the cardiac cycle
Innocent murmurs: always mid-systolic, rarely greater than grade 3
Positioning/Maneuvers: Some murmurs are louder when the patient is positioned differently
o Lying on the left side: helps with mitral regurgitation
o Inspiration: helps to hear tricuspid regurgitation
o Leaning forward: helps to hear aortic regurgitation or pulmonic regurgitation
Friction and venous hums
o Best heard in maintained expiration with the patient leaning forward
o High-pitched scratching noise audible during any part of the cardiac cycle and over any part
of the left precordium
o Hyperkinetic venous hum can be heard at the base of the heart, and is particularly common
in infants and usually disappears when lying flat

Other organs to examine during a focused cardiac exam




Auscultation and percussion of the lung bases to look for pulmonary edema
Palpation of the liver to examine for tender hepatomegaly or, hepatojugular reflux
Examine extremities for edema
...

Note any areas of swelling or tenderness
Note the position of the trachea: Feel with your second and fourth fingers on each edge of the
sternal notch
...
(midline, deviated to the right or left)
Note the apical impulse of the heart, both its location (is it displaced from the 5th intercostals
space, midclavicluar line?) and its quality (is it bounding, is there a heave)?
Note any asymmetry during chest expansion: Face the patient and place the fingertips of both
hands on either side of the lower ribcage, so that the tips of the thumbs meet in the midline in
front of – but not touching – the chest
...

Check tactile fremitus: Place the hands on the front of the chest with one hand on each side of
the sternum
...
Repeat on the back of the chest
...


Percussion








Note any hyperresonance (increase in resonance) or dullness (reduction in resonance) as well as
any pain or tenderness on percussion
...

Use the tip of the right middle finger to strike the distal interphalangeal joint of the left hand
Move your right hand at the wrist
Make sure the right middle finger is bent so that it strikes the left finger at a right angle in a
tapping motion
Percuss on the two sides of the chest, moving back and forth between the
Percuss over the clavicles, then three of four areas on the anterior chest wall, in the axillae, and
three or four areas on the back of the chest

17

Auscultation







Use correct technique
o Use the diaphragm of the stethoscope (not the bell)
o Ask the patient to take deep breaths through an open mouth
o Listen in comparable positions on each side and compare them to each other
Describe the breath sounds?
o Intensity (loudness): normal, loud or diminished
o Quality (vesicular, bronchial)
...

 Compare each point with a corresponding point on the other side of the chest
...

1
...

3
...

5
...

7
...
Make sure to inspect the genitals after the abdomen
...


Inspection








Shape: Is it distended (generalized/local, symmetric/asymmetric) or sunken (scaphoid)
Umbilicus: Is it abnormally everted?
Movements of the abdominal wall
...

o Skin:
 Smooth and shiny with marked abdominal distention
 Striae atrophica/gravidarum: white or pink wrinkled linear marks
 Purple striae: purple linear marks
o Veins: Is there a Caput medusae? (distended veins around the umbilicus)
o Pigmentation: is there a linea nigra, striae purpura, striae atrophica?
Groin, penis, and scrotum: Note any swelling or abnormal position
...
Use gentle firm pressure
...
Use a logical sequence to avoid missing anything
...
If the lower pole is felt,
it is rounded firm swelling between the right and left hands (bimanually palpable) and can be
pushed from one hand to the other
Spleen: Not normally palpable, unless it is enlarged two to three times its size
o Minor enlargement: firm swelling with smooth, rounded borders
o Considerable splenomegaly: firm swelling, beneath left subcostal margin, in the left
upper quadrant of the abdomen, moves downwards on inspiration, is not bimanually
palpable, upper border cannot be felt, notch sometimes felt in the lower medial border
Right kidney: Lower pole is commonly palpable in thin patients, smooth, rounded swelling which
descends on inspiration and is bimanually palpable
...

o Determine how the surface of the liver feels (Soft, smooth, and tender OR firm and
regular, OR hard, irregular, panless and nodular)
o Does the liver pulsate?
19
















Gallbladder: The normal gallbladder cannot be felt
...
At the height of inspiration the breathing stops with a gasp as the
mass of an acutely inflamed gallbladder is palpated which is exquisitely tender
o Courvoisier’s Law: in the presence of jaundice a palpable gallbladder makes gallstone
obstruction of the common bile duct unlikely
Urinary bladder: Normally not palpable
...
Note the width
of the aorta
...
They can only be felt if they are
enlarged and are rounded, firm, often confluent fixed masses in the umbilical region and
epigastrium along the left border of the aorta
Common femoral vessels: Just below the inguinal ligament at the midpoint between the anterior
superior iliac spine and the symphysis pubis
o Note the strength and character of the pulsation
o Compare the right side to the left side
o Note any inguinal lymph nodes
Confusing Findings in Abdominal Palpation
o Stool filled colon
o Sigmoid colon: firm tubular structure, 12cm long, in the left iliac fossa, parallel to the
inguinal ligament
o Caecum: in the right iliac fossa, soft, rounded swelling, indistinct borders
o Transverse colon: palpable in the epigastrium, softer and larger than pelvic colon,
distinct upper and lower borders and convex anterior surface
Rectus abdominis muscle belly, between the tendinous intersections
o See if this contracts when the patient flexes the abdominal muscles
Abdominal Masses: Make sure it is not a normal structure or an enlarged organ
...
Does this pulsation come from the mass or is it transmitted
by the mass?
Feel for any guarding
o Involuntary reflex contraction of the muscles of the abdominal wall
o Determine if this is truly involuntary, or if it is voluntary contraction
Feel for rigidity
 Board-like abdomen
Feel for rebound tenderness
o Palpate slowly and deeply over the abdomen
o Release the palpating hand, and observe to see if the patient experiences severe pain

Percussion
Define the boundaries of abdominal organs and masses







Liver
o
o
o
o
o

Start anteriorly, at the 4th intercostal space in the midclavicular line
...

Move vertically downward the chest wall as you percuss
The note will become dull at about the intercostal space as you move over the liver
The dullness extends down to the lower border at or just below the right subcostal
margin
o Normal liver height is 12cm to 15cm
Spleen: Normally not able to discern splenic size based on percussion
...

Urinary bladder: Normally not able to find with percussion
...

Other Masses: Use percussion and the change from resonance to dullness to measure the size of
masses in the abdomen
...

o Abnormal bowel sounds
 Excessive or exaggerated sounds
 Frequent, loud, low-pitched gurgles
 High pitched tinkles occurring in a rhythmic pattern with peristaltic activity
 Silence
o Succussion splash
 place the patient supine and place the stethoscope over the epigastrium
 roll the patient briskly from side to side
 if the stomach is distended with a fluid, a splashing sound will be heard
 Can be normal up to three hours after a meal
Vascular Bruits: listen for turbulent flow
o Listen lightly above and to the left of the umbilicus for the aorta
o Listen over the iliac fossae for the iliac arteries
o Listen over the epigastrium for the celiac and superior mesenteric arteries
o Listen laterally in the mid-abdomen for the renal arteries
o Listen over the liver for increased blood flow in liver tumors

The Groins




Inspection
o Ask patient to cough and observe for expansile impulse in the inguinal canal
o If a mass is present, does it extend into the scrotum?
o If there is a hernia present, observe the relationship of the hernia sac to the pubic
tubercle
Palpation
o Ask the patient to cough loudly and feel for an expansile impulse in the inguinal area
o Palpate along the femoral artery for enlarged inguinal lymph nodes
o Examine any lumps in the groin with the patient both supine and erect
o If swelling is present in the groin or scrotum, is it tender or nontender?
o If a hernia sac is present, determine whether it is reducible
22



Auscultation
o If there is a sac protruding into the inguinal canal or scrotum, listen for bowel sounds

The Anus and Rectum





Correctly position the patient: have them lie in the left lateral position
Inspection: Separate the buttocks, inspect perianal area and anus
...

Palpation (the digital rectal exam)
o Place lubricant on the gloved index finger of the right hand
o Place the pulp of the finger (not the tip) flat on the anus
o Press firmly and slowly, flexing the finger in a slightly backwards direction
o Feel the tone of the sphincter
...
After you
finish, document the procedure in the patient’s file: date, time, procedure, indication, site,
technique, quantity and quality of specimen, complications
...
A lumbar puncture was performed to rule out meningitis
...
5mL of clear fluid was removed, normal pressure
...
No complications occurred
...
cryptococcal meningitis) Patient presents with 2/4 of the following symptoms
should have an urgent LP performed: (1) fever (T>38
...

Contraindications: Skin infection over puncture site, increase intracranial pressure due to a mass
(papilledema, CT scan with mass), bleeding disorders
Technique:
 Position the patient in either the lateral decubitus or upright sitting position
...
Positioning is very important for LP
...
Palpate the top of the iliac crest and the vertebral interspace located
at the same level (L4-L5)
...
Conus Medullaris is at L1-L2
...

 Using a sterile 20g needle (or spinal needle) and sterile gloves, enter at the middle of the
interspace
...

 Once CSF is obtained, estimate the opening pressure based on the flow rate
...
Only the 2nd bottle needs to be sterile to be sent for
microbiology
...

 Place one drop of CSF on a urine dipstick and record results
...
Send the 2nd bottle (5mL) to
microbiology for gram stain, culture, sensitivity and AFB (if indicated)
...

Complications: Post LP Headache (common, treat with caffeine), nerve root injury (shooting pains,
transient), tonsillar herniation/spinal hemorrhage (rare but severe)

Thoracentesis
Indications: 1) Diagnostic: should be performed for any patient with a moderate-large pleural
effusion who have not had a previous diagnostic thoracentesis
...
Have them sit on the edge of their bed while leaning forward over a
bedside table
...

 Identify the puncture site by reviewing the CXR and percussing the level of the effusion
...
Do not enter below the 8th intercostal space to avoid the abdominal organs
...

 Using a sterile 16 or 18g needle attached to a sterile syringe (5 or 10mL) and sterile gloves, insert
the needle at the puncture site above the rib to avoid the neurovascular bundle below the rib
...
Stop inserting the needle when fluid
starts to flow
...
Send 1mL to chemistry for total
protein and 4-5mL to microbiology for gram stain, culture, sensitivity and AFB
...
Consider sending fluid for cytology if concerned for malignancy
...
Never drain more than 1 liter at a time to prevent reexpansion
edema
...
This process can be repeated several times if necessary
...

 Note: Patients with empyema or loculated pleural effusion should have chest tubes or surgical
drainage
...
2) Therapeutic: Only for patients with severe respiratory distress
or abdominal compartment syndrome due to massive ascites
Contraindications: Acute abdomen, skin infection at puncture site, pregnancy
...

Technique:
 Position the patient either sitting up in bed or lying in the left lateral decubitus position
...
Use either 2cm below the umbilicus (lower risk of bleeding) or
McBurney’s point in the LLQ (to prevent cecal perforation)
...
Confirm by percussion that there is fluid at the puncture site
...

25







Using a sterile 22g needle (18g for therapeutic paracentesis) attached to a sterile 5-10mL syringe
and sterile gloves, enter the skin at the puncture site while pulling the skin 2cm caudal in
relation to the deep tissue (Z line tract approach)
...

Advance the needle slowly while drawing back on the syringe
...

For diagnostic tap, remove 5-10mL of fluid in the syringe
...
Drain 2-6L as necessary to
remove the patient’s symptoms
...
Send blood for albumin at the same time
...
If concerned
for SBP, send 1mL to hematology for cell count and differential
...


Complications: Bowel/bladder perforation, hemorrhage, hypotension (if too much fluid
withdrawn), skin leak

Arthrocentesis
Indications: Any patient with a joint effusion who has not had a previous arthrocentesis and whose
effusion is not obviously due to osteoarthritis
...
Place the knee in the extended position (with patient lying supine)
and palpate the joint line and the lateral border of the patella
...

 Sterilize the puncture site
...
Draw back on the syringe while advancing until fluid is
withdrawn (usually after 1-1
...
Remove 10mL
...

 Send 1mL to chemistry for glucose
...
Send
5mL to microbiology for gram stain, culture, sensitivity and AFB (if indicated)
...

Complications: Rare
...
Characterized by
shortness of breath, fatigue and signs of fluid retention
...

This leads to stimulation of the cardio-respiratory centre in the brains, increased ADH release
(causing peripheral vasoconstriction and increases renal salt and water absorption) and increased
sympathetic stimulation (activating renin - angiotension system, promoting more water retention
and peripheral vasoconstriction)
...

Most patients present with left heart failure which can progresses to right heart failure
...
Heart failure can be either
compensated (when the patient is stable) or decompensated (when the patient suddenly gets
worse)

Etiology of CHF
Systolic Dysfunction (inability to expel blood)








Diastolic Dysfunction (abnormal filling)








Hypertension*
Ischemic heart disease
Idiopathic cardiomyopathy (like HIV)*
Valvular disease*
Alcoholic cardiomyopathy
Drug-associated cardiomyopathy
Myocarditis

* The most common causes in our setting

29

Hypertension
Fibrosis
Ischemia
Aging process
Constrictive pericarditis (like TB)*
Restrictive pericarditis (like EMF)*
Hypertrophic cardiomyopathy

The New York heart association (NYHA) functional classification





Class I- no limitation in physical activity
Class II- slight limitation of physical activity (fatigue, SOB)
Cass III- marked limitation of activity( comfortable at rest but slight exertion causes symptoms)
Class IV- symptoms at rest

Diagnosis





History and clinical examination
Echocardiography -wall thickness, cavity dimensions, ventricular function ( systolic and
diastolic), can reveal underlying aetiology
ECG-Commonly abnormal, Q waves, ST/T changes, LVH, arrhythmias and axis change
Chest Xray - Cardiomeglay, pulmonary congestions ( upper lobe diversions, fluid in the fissures,
Kerley B lines, pleural effusions)

Framingham Criteria for CHF




Validated CHF with 2 major criteria or 1 major and 2 minor
Major : PND or orthopnea, Elevated JVP, Pulmonary rales, S3, Cardiomegaly on chest xray
...
5 kg in 5 days with diuresis

Causes of CHF exacerbation/decompensation: FAILURE
F: forgot to take medication, ran out of medication
A: arrhythmias (especially atrial fibrillation)
I: ischemia / infarction / infection
L: lifestyle (poor diet)
U: up-regulation (high cardiac output states i
...
pregnancy, thyroid)
R: renal failure (fluid overload)
E: embolism / endocarditis

Treatment









Counseling
o Weight loss in obese patients, dietary sodium restriction ( < 2 grams a day), fluid
restriction, administration of oxygen if needed, exercise as tolerated for class I and II
Vasodilator therapy: mainstay of chronic therapy; reduces mortality
o ACE inhibitors (1st line) – but must follow renal function
o Hydralazine (rarely used)
Beta-blockers: for chronic therapy in patients with non-valvular CHF; not acute, decompensated
heart failure; reduces mortality
o Carvedilol (best), metoprolol, atenolol
Digoxin
o for Class II-III
o improves symptoms, does not reduce mortality
Diuretics
o Loop diuretics (lasix) for diuresis are the primary treatment of decompensated heart
failure but do not reduce mortality
o Aldactone – useful in chronic therapy of patients with Class III-IV; reduces mortality but
also greatly increases risk of hyperkalemia in patients who are also taking ACE inhibitors
...
Full characterization of the pain with regard to quality (squeezing,
tightening, pressing, burning), quantity, frequency, location, duration, radiation, aggravating or
alleviating factors and associated symptoms can help to distinguish the cause
...
**The life-threatening causes that must be considered and ruled out in all patients
with severe, persistent chest pain
...
pylori test
Biliary disease
 With RUQ pain, nausea/vomiting
 Aggravated by fatty foods
 Needs RUQ ultrasound, liver tests
Pancreatitis
 Epigastric or back discomfort
 Increased amylase and lipase, has risk factors

Musculoskeletal and other Causes
Costochondritis
 Localized sharp or dull pain, tenderness to palpation
Herpes zoster
 Intense unilateral pain often precedes rash, dermatomal rash and sensory findings
Cervical spine disease or arthritis
 Precipitated by motion, asts seconds to hours
 X-rays to confirm

33

Ischemic Heart Disease (IHD)
Definition
Due to insufficient oxygen supply to the heart
...
This is usually caused
by a narrowing of the coronary artery either due to plaque accumulation or vasoconstriction
...
e
...


Pathophysiology
Most commonly IHD is due to atherosclerotic plaque build-up
...
This narrowing prevents adequate oxygen supply from reaching the heart and
ischemia occurs
...


Predisposing conditions
Diabetes, HTN, and smoking are all risk factors for atherosclerotic plaque formation, which puts
someone at increased risk for ischemic heart disease and a myocardial infarction
...
This is likely because the
population of East Africa is younger (due to shorter life spans) as well as less diabetes mellitus,
hypercholesterolemia and number of cigarettes smoked by smokers
...
The chest pain is usually a squeezing
pain that often radiates to arms or neck
...
Other symptoms include: diaphoresis, nausea, vomiting, palpitations, or
lightheadedness
...
Abdominal pain is a common complaint for women having MIs
...
Key changes on ECG include: ST elevation, ST depression, T wave inversion,
or new LBBB
...






Lead I and aVL: lateral MI (left circumflex is affected)
Leads II, III, and aVF: inferior MI (right coronary artery is affected)
Leads V3-V6: anterior MI (LAD if affected)
Leads V1-V2: septal MI ( either distal LAD, left circumflex or right coronary are affected)

Management
This can be divided into care that needs to be given immediately and long term care that will
continue after the patient leaves the hospital
...

The distribution of disease varies greatly based on population and risk factors
...
Most common cause of valvular heart disease
in Tanzania is Rheumatic heart disease
...

 Exam: AS is a harsh crescendo/decrescendo midsystolic (ejection) murmur
...
It is heard best with the diaphragm when
the patient sits forward
...
The phase
during systole which the murmur peaks can help to determine the severity of the disease
...
This occurs because as the valve become more stenotic it takes the left ventricle
longer time to generate enough pressure to overcome the stenosis
...
As the AS progresses the valve will become progressively
become less mobile and stenotic causing the S2 to be quieter or even absent
...
Surgery is definitive treatment
...
Control HTN
...

Aortic Insufficiency/Regurgitation
 Pathophysiology: In diastole, blood flows from aorta into LV due to incompetence of aortic valve
which increases End Diastolic Volume and Stroke Volume
...

 Etiology: 1) rheumatic fever, 2) endocarditis, trauma, connective tissue disease, congenital
bicuspid aortic valve, HTN
 Symptoms: angina / CCF
 Exam: High pitched early diastolic murmur
...
The murmur radiates from the aortic area to the left lower sternal
edge, where is best heard
...
The Murmur is associated with a wide pulse pressure (fall in
diastole pressure due to the regurgitating blood) and displacement of apex beat
...
Medical therapy includes hydralazine, ACE inhibitors for severe
disease and digoxin for CCF
...
These elevated pressures lead to atrial dilatation and often
atrial fibrillation
...

 Etiology: most common rheumatic heart disease, congenital
 Symptoms: SOB, palpitations, dyspnea on exertion, atrial fibrillation or features of CCF
...
It is best heard at the apex beat with
the bell of the stethoscope while the patient lying on the left side
...
Can use beta blockers
...
Murmur increases
with handgrip and decreases with valsalva
...
Decrease preload with diuretics

37

Acute Rheumatic Fever and Rheumatic Heart Disease
Acute Rheumatic Fever
Definition
It is a nonsuppurative consequence of a pharyngeal infection by group A Beta hemolytic
streptococcus (Strep pyogenes)
...
This is disease
of the poor, the overcrowded and the poorly housed
...
In most patients with carditis, if the recent attacks
could be prevented they would eventually lose their murmur and the heart would return to normal
or near normal
...
Rheumatic heart disease is the
most common cause of valvular heart disease in the world
...

Diagnosis:
Generally a clinical diagnosis with laboratory confirmation is needed
...

Major Criteria
 Carditis: Occurs in about 50% of the cases and is the most serious manifestation of RF
...
This acute presentation is different from the later sequelae of rheumatic heart
disease (mitral stenosis)
...

 Arthritis: Occurs in 80% of the cases
...
each affected
joint inflamed for less than one week and typically over 6 joints involved
 Chorea: also called Sydenham chorea or St
...
It’s
abrupt, purposeless, nonrhythmic, involuntary movements, usually worse on one side
...
This presentation is rare
...

Heat brings lesions out
...

Minor criteria
 Fever
 Arthralgia
 Previous rheumatic fever or rheumatic heart disease
Laboratory Diagnosis

38





Increase titres of antistreptolysin O**(ASO, most common antibody test used) or strep
antibodies
Positive throat culture for Group A beta-hemolytic strep
Recent scarlet fever

**Antibodies are better than culture because the culture is often negative
...
Cannot use titers as indicator of disease activity after initial
illness
...
2
million IM once
...
2 million units every 2-4 weeks for
approximately 5 years
...
Lifelong prophylaxis is
recommended for patients with carditis and residual heart disease
...
Aspirin 20-25mg/kg PO
QDS 3-6 weeks if no cardiac involvement
...
In these severe cases prednisolone 0
...

 Heart failure: as standard
 Chorea: Sodium Valproate 10mg/Kg PO BD or haloperidol for 3 months
...
This is why the peak incidence of
rheumatic heart disease is 15 – 30 years of age (since the peak age for acute rheumatic fever is at 49 years of age)
...
Severe rheumatic heart disease usually only occurs after multiple episodes of acute rheumatic
fever
...
This is why antibiotic prophylaxis after a first episode of acute rheumatic fever is so
important
...
Over time fibrin deposition occurs
and valves thicken or fuse (fibrosis)
...
A subclinical inflammatory process caused
by the stress of chronic turbulent flow due to the deformed valve contributes to the progression of
stenosis
...

Valve findings and when they occur
Mitral stenosis is most common finding, followed by aortic stenosis
...
Even though stenosis occurs 10-20 years after infection symptoms may
be delayed as late as 40 years
...
more
virulent strains causing earlier adhesion of leaflets), onset of symptoms often occurs earlier
...
Can do closed or open commisurotomy, percutaneous
balloon valvulotomy, or valve replacement
...

 Atrial fibrillation: occurs in over 45% of mitral stenosis patients
 Pulmonary HTN: mean survival without surgery 2
...
Either
subacute (often due to Strep viridians) or acute (less common, often due to Staph aureus)
...
The bacteria on the valve can form a mass or vegetation
...
Immune complexes form with the bacteria
...


Predisposing conditions



Abnormal valve: prior endocarditis, h/o rheumatic heart disease, valvular heart disease,
congenital heart disease, prosthetic valves
...

Abnormal risk of bacteremia (valves may or may not damaged): poor dentition, tooth
extraction (or other GI/GU procedures breaking mucosal barriers like endoscopy), IV drug use,
hemodialysis (organism tend to be more virulent such as Strep
...
In
our settings post-partum pelvic infection and an acute pyomyositis are important are important
sources
...
(Nonspecific symptoms)
...

Septic emboli may cause stroke, renal or renal infarcts, infected joints and pulmonary emboli
...

Remember: Fever + regurgitant murmur = IE until proven otherwise

Signs










General - Finger clubbing, Splenomegaly, pallor ( anaemia)
New regurgitant murmurs due to valvular disfigurement- AR and MR are most common
...

Vasculitic events ( Due to immune complexes formed)
Splinter hemorrhages in nailbed
Roth spots (retinal hemorrhage + pale center)
Osler’s Nodes (tender nodules on tips of fingers and toes)
Glomerulonephritis

Diagnostic studies






3 sets of blood cultures from different sites, ideally >1 hour apart, should be drawn before
starting antibiotics! In some resource limited settings, obtaining 2 sets of blood cultures may be
more feasible
...
0 C
 Predisposition (like rheumatic heart disease)
 Embolic phenomena (arterial emboli, septic
pulmonary infarct, mycotic aneurysm,
intracranial hemorrhage, conjunctival
hemorrhage, laneway lesion)
 Immunologic phenomena
(glomerulonephritis, Osler’s nodes, Roth
spots, + rheumatoid factor
 Blood cultures that don’t meet criteria (only
1 positive)

Microbiology



Native valve endocarditis, Strep viridans, Staph aureus and Enterococcus most common
The organisms that cause endocarditis are different in:
o IV drug abusers – Staph aureus most common
o Prosthetic valve endocarditis - Staph epidermidis most common <6mo after surgery
o Immunosuppression – fungi more common

Treatment





Empiric antibiotics, adjust according to organism and sensitivities, continue for at least 6 weeks
after last positive blood culture
Start with penicillin 1
...

Antibiotics used:amoxicillin 3g PO 60 min prior to procedure OR Clindamycin 600mg if PCN allergy
or > 1 course of penicillin in the last mont use of antibiotics
...

Sinus bradycardia: sinus rate of less than 60 beats/minute
...
Etiology: increased vagal tone, hypothyroidism, ischemia,
medication such as digoxin, beta blockers, calcium channel blockers
AV Block
 1st degree: conduction delay within AV node, with prolonged PR interval on ECG > 200 msec
...
No therapy needed
...
Etiology: medication, electrolyte abnormalities, ischemia
...

 2nd degree Type II: abrupt AV conduction block without evidence of PR prolongation
...
Etiology: ischemia, conduction system disease
...

 3rd degree: dissociation of atrial beats and ventricular beats
...
And ventricle is beating on its own with a slower rate
...
Need pacemaker
...
Etiology: pain, fever, hypovolemia, hypoxia, anemia, anxiety, thyroid
disease; rate not greater than 220-age
o AV nodal reentrant tachycardia (AVNRT): reentrant circuit using AV node and accessory
pathway, rate can be > 150
...
This is an irregularly
irregular rhythm in which the atria depolarize chaotically and are not able to properly contract
...
e
...

Types

43









Valvular atrial fibrillation: usually associated with rheumatic heart disease due to MS or MR with
left atrial enlargement; *the most common type in our setting*
Isolated atrial fibrillation: secondary to another illness (hyperthyroidism, PNA, PE, etc
...
The loss of
atrial contraction then leads to heart failure
...
Symptoms include fatigue, syncope, chest pain,
palpitations
...
Many patients have no symptoms
at all
...
Look for
Signs: There are 2 important signs of atrial fibrillation are: Irregularly irregular pulse
...
Make sure to do thorough cardiac and
pulmonary exams
Evaluation
 ECG
 CXR
 Echocardiogram to look for valvular disease, presence of thrombus, left ventricular function
 Thyroid function tests (TSH), creatinine
Treatment
 If patient is hemodynamically unstable, consider electrical cardioversion in the ICU (consider
heparin drip if doing cardioversion)
 If low TSH and symptoms of hyperthyroidism, do complete thyroid workup (T3/T4, thyroid
ultrasound) and treat atrial fibrillation as below
 *Rate Control (goal heart rate 60-80) – best treatment for most patients
44

o
o
o






Beta blockers (atenolol, propranolol)
Calcium channel blockers (verapamil)
Digoxin for heart failure patients if blood pressure is low or if severe valvular heart
disease is present (but beware of renal dysfunction)
Rhythm Control – used only for severely symptomatic patients
o Amiodarone
*Anticoagulation to reduce risk of stroke
...
Consider simultaneous peptic ulcer disease prophylaxis
...
5)
o Aspirin (if monitoring of INR is not feasible) – technically an antiplatelet drug
*Thromboembolism prevention: Keeping the INR 2-3 with warfarin reduces risk of stroke by 66%
in patients with above risk factors
...


45

Introduction to Hypertension
Definition
HTN is simply defined as a persistently abnormal elevation in blood pressure, < 140/90mmHg
...
We treat HTN
because it is a major risk factor for stroke, MI, CCF, CKD, retinopathy and peripheral vascular disease
...


Physiology of HTN
HTN is caused by a combination of cardiac output, peripheral vascular resistance and sodium
retention (regulated by the renin-angiotensin system)
...
All
treatment of HTN targets these factors
...
Early studies indicated HTN was rare in Africa but
several recent studies have shown that the prevalence of HTN is now 5-15% (higher in urban areas)
...
, 2000)! The average blood pressure
in this group was higher than studies from America and Europe!

Types of HTN




Essential (Primary) HTN – most common (95%) and due to a combination of genetic,
environmental factors (salt intake, weight, exercise etc) and age
...

Secondary HTN – HTN due to other causes
...

o Renal – most common; can be related to CKD or renal artery stenosis
o Cushing’s syndrome – hypercortisolemia
o Conn’s syndrome - hyperaldosteronemia
o Coarctation of the Aorta
o Pheochromocytoma – catecholamine producing tumor
o Hyperthyroidism or hypothyroidism
...
Was called
malignant HTN in the past
...
The only reliable sign of HTN is the blood pressure
...


Diagnosis
HTN is diagnosed if BP is elevated on 3 separate occasions
...


47

Treatment of Hypertension
Treatment of Chronic HTN
When to Treat?
 See new WHO guidelines for Prevention of Cardiovascular Disease!
 In general, any patient with severe (Grade 3) HTN and/or signs of complications (stroke, CKD,
CAD, CCF, retinopathy etc) should be started on antihypertensive treatment immediately
 Patients with mild to moderate (Grade 1-2) HTN should be given 3 months to see if they respond
to behavioral modification first
...

Counseling
 lose weight (>5kg) if overweight by BMI > 25
 reduce salt intake – no added salt in cooking or at table
 increase physical activity
 Smoking cessation!
 Reduce alcohol intake (<3 units/day)
Patient should also be counseled that, if they start antihypertensives, they will likely need to take
medications every day for life to prevent complications
...
If they have side effects they should come directly to see the doctor and not stop the
medications until they are seen
...

o Use with caution in patients with DM and gout as bendrofluazide can cause
hyperglycemia and hyperuricemia
...

 In patient with CAD, beta blockers are the best first antihypertensive as they reduce the risk of
death from CAD
 Of note, most antihypertensives take 2-4 weeks to reach maximal effect so it is good to wait 1
month before increasing the dose of a medicine or adding another one
...

 Monitor for side effects
o ACE inhibitors – monitor creatinine
o Thiazide diuretics – monitor electrolytes
o Beta blockers – monitor heart rate
48



If the BP remains elevated despite maximal dose of a first drug, add another drug and then
titrate this to its maximal dose
...


What is the goal BP?
 In most patients the goal BP is < 140/90
 In patients with DM or CKD we use a goal BP of < 130/85

Treatment of Hypertensive Urgency and Emergency
In any patient with BP > 220/120 (“Very Severe Hypertension”), assess for signs of end organ
damage and consider admission to the hospital
...
Keep in mind that urgency is much more common than emergency
Signs of End Organ Damage
 Hypertensive Encephalopathy (confusion, headache)
 Acute retinal hemorrhage (sudden onset of blurry vision, massive hemorrhage on
ophthalmoscopy)
 Myocardial ischemia or infarction (chest pain, ECG changes)
 Pulmonary Edema (shortness of breath, CXR with pulmonary edema)
 Acute Kidney Injury (recent onset of oliguria or anuria, elevated creatinine, blood on UA)
Treatment Goals
If Hypertensive Urgency (no signs of end organ damage)



Aim to lower MAP by 25% over 2-3 days using oral medications
Start with Nifedipine 20mg BD and add other meds as necessary

If Hypertensive Emergency (+ signs of end organ damage)





Aim to lower MAP by 25% over 1-2 hours using IV medications
Currently we are using IV Hydralazine drips titrated to goal BP
Labetalol drips (+ other meds) are better when available
Once the BP improves, patients can be transitioned to oral medications

49

Shock & Hypotension
Hypotension is state of low blood pressure with systolic blood pressure <90 mmHg (relative
hypotension with >30mmHg below baseline, or mean arterial pressure <65
...
g
...

2
...

4
...

6
...

Low blood pressure is due to inadequate cardiac output or low peripheral resistance
...

Stroke Volume abnormalities: failure to receive (preload), failure to eject (contractility &
afterload), inadequate volume
Low peripheral vascular resistance is due to inappropriate vasodilatation
...

Oliguria –From shunting of renal flow to other vital organs, intravascular volume depletion, or
both
...

Cool, clammy skin – Compensatory peripheral vasoconstriction redirects blood from the
periphery to the vital organs (heart, brain, splanchnic)
...


Once the diagnosis of shock has been made, the most important next step is to quickly determine
the type of shock
...
Some basic investigations may be helpful
...
Often limited due to confusion or
obtundation
...


Examination








General: Ill-appearing? Pale? Confused? Lethargic? Unresponsive? Temperature >38C or <36C?
Neurologic: Meningismus? Focal neurologic deficits?
Cardiac: Tachycardic (HR>100)? Hypotensive (SBP<100)? Dizziness? Orthostatic hypotension?
S3? Murmurs? Extremities warm/well-perfused or cold/blue? Capillary refill brisk or slow? Chest
pain?
Pulmonary: Evidence of pneumonia? Using accessory muscles of respiration? RR>30? Oxygen
saturation <95%?
Gastrointestinal: Abdominal pain? Tense/rigid abdomen (may indicate perforated viscus,
hemorrhage, peritonitis)? Rebound? Guarding? Melena or blood on rectal exam?
Renal: Flank tenderness (pyelonephritis)? Urine output <0
...

Ultrasound – focused assessment with sonography for trauma (FAST)

Management
In schock, the management depends entirely on the type of schock!!! Shock is ALWAYS an
emergency and must be treated rapidly
...
Usually need:






**2 large IV cannulas – 18 gauge (green) or greater**
**Aggressive colloid (NS or LR) fluid resuscitation for hypotension – especially in hypovolemic +
septic shock (may require > 10L!!!)**
**Packed red blood cells if bleeding/hypovolemic shock**
Foley catheter and monitoring of urine output
Frequent monitoring of vital signs
51











Intubation if in respiratory distress
Stop any antihypertensives or diuretics
...
Give IV
fluids
If hypovolemic: IV fluids, check electrolytes, fix underlying condition (e
...
diabetic ketoacidosis),
send for type & crossmatch for urgent transfusion if hemorrhage (hemorrhage is the most
common cause of hypovolemic shock)
...
g
...

If outflow obstruction suspected: IV fluids, urgent ECG, CXR to confirm, thrombolysis for PE,
chest tube for tension pneumothorax, percardiocentesis for tamponade
...
3ml 1:1000 solution if severe,
antihistamines, & corticosteroids may help
...

Any patient with irregular cardiac rhythms or abnormal rate should have EKG to determine
the type of arrythmia
...


How to Perform
Place leads on the patient as seen in diagram:

Basic EKG Interpretation:
**You Must have a systemic approach (FOLLOW SAME PROCESS EVERY TIME)
...
RATE
2
...
AXIS
4
...
CHAMBERS

Some Basic Measurements
--one small box is 1mV
--one small box is 40ms (0
...
ST CHANGES AND Q WAVES

1
...
Rhythm
 Is the patient in sinus rhythm or not?
 Is the R-R interval regular or irregular?
 Is there a P for every QRS and a QRS for every P?
 Is the P upright in II and downward deflection in V1?
3
...

 Normal is –30 to 90
...

 Left Axis is less than –30
...

4
...
2 sec) one big box
 What is the QRS interval – normal is less than 100ms
o incomplete block is 100-120ms
o complete block is greater than 120ms
 What is the QT interval – this is rate dependent but should be less than ½ of RR interval
...
Chambers
 What size are the atria?
o LAE – look for biphasic P in V1 or notched P in II
o RAE – look for tall P in II (>2
...
Look for ST Segments and Q Waves

54

Renal

55

Acute Kidney Injury (AKI) and Chronic Kidney Disease (CKD)
Acute Kindey Injury
Definition
 Increase in the serum creatinine concentration from baseline (>26 mmol/L within 48 hours)
 Percentage serum creatinine increase >50%
 Oliguria of less than 0
...

Normal UOP is approximately 1mL/kg/hour = 1500mL/day for a 60kg adult
...
Remember, kidney injury in the hospital is often tied into
another problem (infection, heart failure, medications)
...
e
...
e
...

 BUN and creatinine
...

 Electrolytes if available
 Abdominal ultrasound (rule out obstruction, assess size and echotexture of kidneys)
...
Strongly consider catheterization, especially in setting of enlarged
prostate or full bladder on exam
...

Treatment Options
 Consider fluid boluses if you think the patient is dehydrated and has prerenal AKI
...

 Monitor for uremia (i
...
mental status changes, vomiting), and electrolyte drerangement
 Stop all nephrotoxic agents, such as NSAIDs or aminoglycosides, and adjust meds to GFR
...
23 x ( (140-age) x weight (kg) ) / Creatinine (umol/l) )
For women

= 1
...

Either syndrome can be caused by a number of different diseases processes
...
This is often the best you can do in a setting where kidney biopsy is not
available
...
Minimal change disease has the usual findings of heavy
proteinuria, no red blood cells in the urine
...
In addition the proteinuria in minimal change disease is often selective: it will only be
albumin
...
You can begin tapering once the
proteinuria has resolved (usually within 10-20 days)
...
When tapering the prednisolone, aim to stop it by 3-6 months
...
You can say they are nonresponders if there is no improvement after two
full months of steroids
...
Up to 50% of patients who respond will have a relapse
within the first year of treatment
...

Focal Segmental Glomerulosclerosis (FSGS)
FSGS is the most common type of nephrotic syndrome in adults in Africa
...
They usually require much
longer courses of steroids for improvement (6-9 months)
...
For most other causes of nephrotic syndrome, they will likely
progress to renal failure and uremia
...
The final 1/3 will progress to renal failure
despite treatment
...

Diagnosis
 Check urine dip:
 + blood, +RBCs suggests true hematuria
 +blood, -RBCs suggests myoglobinuria (such as from rhabdomyolysis)
Three important questions:
1
...
Are there any clues from the history or physical exam?
 concurrent pyuria and dysuria, consider UTI
 recent URI, consider post-infectious glomerulonephritis
 family history of renal disease, consider hereditary nephritis, polycystic kidney disease, sickle
cell disease
 unilateral flank pain radiating to groin, consider ureteral obstruction (kidney stone, clot,
cancer)
 hesitancy/dribbling, consider BPH
 history of bleeding disorders or bleeding from multiple sites, consider DIC
 cyclic in a woman, consider menses or endometriosis
 living in endemic area, consider Schistosomiasis haematobium
 sterile pyuria with hematuria, consider renal TB
 elevated creatinine consistent with renal failure
3
...

mansoni, S
...
haematobium and occasionally S
...
inercalatum
...

haematobium causes genitourinary disease
...
mansoni is the most common in Africa but S
...
S
...
mekongi are only found in Asia
...

Schitosome cercariae released from the snails penetrate human skin and enter blood vessels, pass
through the lungs into the liver and from there mature into adults
...
Other eggs embolize in the blood to various sites such as the lung,
liver and CNS where they stimulate a strong immune response causing immunopathological disease
...
Features include portal hypertension,
hepatospelnomegaly, ascites, esophageal and gastric varices
...

Genitourinary disease: classically “terminal hematuria”, schistosomiasis can causes macroscopic
and microscopic hematuria, frequency and dysuria; chronic fibrosis and calcification of bladder
can lead to hydroureter and hydronephrosis; chronic inflammation can lead to squamous cell
carcinoma of bladder; immune complex deposition can also lead to proteinuria, nephrotic
syndrome
Pulmonary disease: Rare
...


Management
Chronic disease can be treated with praziquantel 40mg/kg po as a single dose or 20mg/kg PO BD for
1 day
...
Some patients require a second dose
...

History & Physical Exam
 The patient may be asymptomatic or may present with confusion, lethargy, muscle cramps or
nausea
...
Treat with volume repletion with normal saline
...
Treat SIADH with free water restriction
+/- loop diuretics, and treat underlying cause
...

Hypervolemic hyponatremia: From CHF, cirrhosis, nephritic syndrome, and advanced renal
failure
...

Remember: Avoid rapid correction of hyponatremia as it can lead to central pontine myelinolysis
(spastic quadriplegia, dysarthria, dysphagia)
...
If the pt is asymptomatic, aim for Na correction at a rate of <=
...

If they are symptomatic they will need initial rapid correction of Na (2meq/l/hr for the first 2-3
hours) util their sxs resolve
...


Hypernatremia
A deficit of water relative to sodium (Na >145 mEq/L)
History & Physical Exam
 Pts may report thirst and oliguria or polyuria (depending on the etiology) as well as mental
status changes, weakness, focal neurologic deficits and seizures
...
Correction should occur gradually over 48-72 hours to
precent neurologic damage secondary to cerebral edema
...
Cardiac arrest resuscitation with NaHCO3)
 Mineralcorticoid excess: usually presents as mild hypernatremia caused by ADH suppression
 treat with D5W and a loop diuretic

Hypokalemia
Serum potassium is <3
...
B-agonists, alkalosis, periodic paralysis (Ca channelopathy), acute
increase in hematopoiesis (megaloblastic anemia txd with B12, AML crisis)
 GI losses plus metabolic acidosis: diarrhea, laxative abuse, villous adenoma
 Renal potassium losses: diuretics, primary mineralocorticoid excess or sevondary
hypoeraldosteronism, DKA, RTA, hypomagnesemia
History & Physical Exam
 May present with nausea/vomiting, fatigue, muscle weakness or cramps, ileus, hyporeflexia,
paresthesias, flaccid paralysis
Workup
 24 hour or spot urine potassium can help differentiate renal from GI losses

65



EKG may reveal T-wave flattening, U waves, and ST depression followed by AV block and
subsequent cardiac arrest

Treatment
 Potassium repletion: KCl 4 mEq po q4-6h if non-urgent, KCl 10 meq/h IV if urgent; recheck K
frequently
 beware of excessive potassium repletion if transcellular shift is the cause of hypokalemia
 treat underlying cause
 replete Mg as necessary

Hyperkalemia
Serum potassium >5 mEq/L
Etiologies
 Transcellular shifts: acidosis, insulin deficiency, B-blockers, dig toxicity, massive cellular necrosis
(tumor lysis, rhabdo, ischemic bowel) hyperkalemic period paralysis (Na channelopathy)
 Decreased GFR: any cause of oligo- or anuric acute renal failure or any cause of end-stage renal
disease
 Normal GFR but with decreased renal K excretion: CHF, cirrhosis, nephropathy (diabetic, HIV),
chronic interstitial nephritis, primary adrenal disorders, drugs (NSAIDS, ACEI/ARBSm potassium
sparing diuretics, bactrim), systemic disorders that cause tubulointerstitial disease (sickle cell,
SLE, amyloid)
 Iatrogenic (over-repletion of hypokalemia)
History & Physical Exam
 pts may be asymptomatic or may present with nausea, vomiting, weakness, paresthesias,
palpitations
 PE may reveal areflexia, flaccid paralysis, paresthesias
Workup
 Verify hyperkalemia with repeat blood draw (unless already have high index of suspicion)
 Check EKG: findings may include tall peaked T waves, PR prolongations, wide QRS, loss of P
waves and eventual progression to sine waves, v fib and cardiac arrest!
Treatment
 values of >6
...
Major causes are infectious agents, toxins, and drugs
...
Can be with or without increased frequency

History
Onset (sudden or gradual), duration, pattern (during fasting, day or night), characteristics, volume,
relieving factors, fecal incontinence, fever, weight loss, pain, exposures, travel history, dietary
history, antibiotic use, contact with diarrhea, immunopression, family history and risk factors for HIV
infection
...

Person to person contact or ingestion of contaminated food
...
Treatment: ampillicin in severe disease
...
Most common Ecoli O157:h7
...
Occur in summer mostly,
contaminated food
...
No antibiotics indicated
...
Coli
...
Self limiting disease,
usually lasts 5-7 days
...
Among wild and domesticated animals,
*associated with malaria and HIV
...
*patients with schistosomiasis are prone to salmonella bacteremia
...
Treatment: supportive, if severe: ciprofloxacin, amoxicillin,
chloramphenicol
Amoebic dysentery: entamoeba histolytica, parasite
...
Asymptomatic or
fulminant colitis with perforation in severe infection
...

Treatment: metronidazole x 5 days, then diloxanide furoate x 10 days
...

Trichuriasis (whipworm): trichuris trichuria
...
Can have vomiting, abdominal distention, blood diarrhea, weight loss
...


69

Viruses (Rotavirus, Norovirus etc): Rotarvirus is most common cause of non-bloody diarrhea in
children and can occur in adults (though less common
...
Causes severe dehydration from voluminous diarrhea, described as rice
stool, vomiting, can lead to electrolyte imbalance
...
Occurs in
outbreaks
...
2 types of disease simple diarrhea or nectroic
enterocolitis
Giardia: Giardia intestinalis
...

Watery diarrhea is most common symptoms, usually resolves in 2-4 weeks, accompanied with
abdominal pain, weight loss

Causes of Chronic Diarrhea
Infections
 Giardia, E
...

 HIV related diarrhea – Cryptosporidium, Cyclospora, Isospora
 Tuberculosis of ileocecal area
 Intestinal works/flukes: common in Asia
Medications
 Increased secretion, increased gut motility, change in bacterial flora in the gut and inflammation
...
Intraluminal mucosal or obstructive malabsorption may
cause steatorrhea
...

Diarrhea improves with fasting
...
Loss of villi and absorptive area
...
whipplei
Lactulose intolerance
o Symptoms: bloating, flatulence, epigastric discomfort with eating
o Treat: lactose free diet, lactase enzyme replacement

Inflammatory
Presents with fever, bloody stool, abdominal pain (acute or chronic)
...
Ischemic colitis, diverticulitis, colon cancer, lymphoma
70

Secretory
 No change in diarrhea with fasting, nocturnal diarrhea is frequently described
 Hormonal diarrhea: gastrin (Zollinger-Ellison), thyroxine, serotonin (carcinoid)
 Neoplasm: carcinoma, lymphoma, villous adenoma
...
For chronic diarrhea, all patients should
have rapid test for HIV and stool culture/fecal leukocytes sent
...





negative fecal leukocytes->secretory diarrhea
positive fecal leukocytes->inflammatory diarrhea (inflammatory bowel disease)
if diarrhea decreases with fasting->malabsorptive process

71

Abdominal Pain and Peptic Ulcer Disease
Abdominal Pain
Definition
Abdominal pain describes a broad general process with numerous etiologies
...
It is important that, as a student, you should learn
the differential diagnoses for abdominal pain in different regions of the adomen
...
Clarify the exact sequence of pain and
other symptoms
...
All
female patients should get a pelvic exam if complaining of lower abdominal pain
...
You can order an abdominal x-ray
...

 Right lower quadrant pain: acute appendicitis, duodenal ulcer, pyelonephritis, kidney stone,
acute pancreatitis, inflammatory bowel disease, Yersina enterocolitica infection, biliary
peritonitis
 Left upper quadrant pain: acute pancreatitis, perforated gastric ulcer, splenic rupture, splenic
infarct, perinephric abscess, pyelonephritis
 Left lower quadrant pain: diverticulitis, inflammatory bowel disease, kidney stone, appendicitis
 Mid-lower abdominal pain: perforated appendix, perforated sigmoid diverticulum, large bowel
obstruction, colitis
...
Men and women are at
equal risk
...

Pathophysiology: Normally they gastric acid is suppressed by a negative feedback loop
...
In
PUD there is too much gastric acid
...

H
...
H
...

Signs/Symptoms
 Wide range of presentation from asymptomatic iron deficient anemia to perforation
 Epigastric abdominal pain: relieved with food (duodenal) or worsened with food (gastric)
 Usually dull pain, but may be sharp or burning
...

 Gastric outlet obstruction can occur with duodenal ulcers
 Can present with upper GI bleed if ulcer is actively bleeding
 NSAID ulcers can present has painless bleeding
Etiology
* H
...
Ask about NSAID, asa, alcohol use, history of Hpylori infection and
weight loss
...
Upper endoscopy is the
preferred method for diagnosing peptic ulcer disease, can also get tissue sampling to evaluate for
malignancy and Hpylori
...
Hpylori
stool antigen is useful in detecting eradication after antibiotic therapy
...

 lifestyle changes: stop alcohol and tobacco use
 critically ill patients in ICU should get acid suppression therapy prophylaxis to prevent stress
ulcers: usually ranitidine 150 mg BD
PUD Complications
GI bleeding, gastric outlet obstruction, perforation, pancreatitis
...

Hematochezia: bright red blood per rectum from rapid upper gi bleed, or very distal lower gi
bleed
...
Can be anywhere in gi
tract
...
Other causes:
Esophagitis/gastritis, Mallory-Weiss tears, Arteriovenous malformations, tumors and erosions,
Erosive esophagitis ( in HIV patients consider CMV, HSV, candida), Dieulafoy’s lesions (submucosal
artery), gastric vascular ectasis
...

LGIB: The most common cause of LGIB is UGIB with passing of blood in stool
...


Signs/Symptoms





Acute upper GI bleed: Will see bright red bloody vomitus
...
As the blood passes through the GI tract, the
patient will produce dark, tar like stool called melena and this often time suggest an upper GI
source but can also be from other intestinal lesions
...
Patients
are often hemodynamically unstable
...

General: nausea, epigastric pain, syncope, lightheadedness, dizziness, fatigue

Evaluation










First determine if bleed is acute or chronic
...
Check blood pressure and heart rate
...

Check orthostatic vital signs, will be positive is patient with significant blood loss
...
For severe bleeding
give vitamin K 5 mg IV stat
upper/lower endoscopy if available

75

Liver Disease
Classify by duration of abnormalities: acute (< 6 months) or chronic (>6 months)
...
The liver acts as a filter for the
blood coming from the portal circulation and is exposed to many microbes and toxins
...


Function of the liver
Connected to to the gut by the billary system and portal venous system and to the systemic
circulation by the hepatic arteries and veins
...

Storage of glycogen, vitamins and minerals
Detoxification and inactivation of endogenous and exogenous substances
Secretion of bile
Synthesis of coagulation factors
...
Upper border defined by percussion which is normally at the 5th
Intercostal space and lower border below the costal margin in the midclavicular space
...

Due to large reserve, tests may be normal in early liver disease
...
ALT more specific for
liver than AST (also found in heart, skeletal muscle)
...
AST: ALT ratio > 2:1, suggets of alcoholic hepatitis
...

Alkaline phosphatase: enzyme bound in hepatic canicular membrane
...

If from liver GGT will also be increased
...

Albumin: marker for liver protein synthesis
...
Increased levels found in
severe acute injury or chronic injury
...


76

Bilirubin: product of heme metabolism in liver
...

Indirect/Unconjugated high in hemolysis and decreased conjugation by the liver
...
AST and ALT > 1,000 is indicative of severe viral hepatitis, acetominophen toxicity or
ischemic hepatitis
Cholestasis: increased alk phos and direct bilirubin +/- mild increases in AST and ALT
Jaundice: a clinical sign when bilirubin levels are high > 2
...


Clinical Presentation:
1
...
Signs of Portal Hypertension: splenomegaly, ascites, caput medussae (distended abdominal
veins)
Of note, cirrhosis will present with both #1 and 2 whereas schistosomiasis will present with only #2
...
malaria, HUS, sepsis, pneumococcal pneumonia, sickle cell disease
Hepatic causes
Viral Hepatitis:
 Acute: From asymptomatic to fulminant liver failure
...

 Chronic: From subclinical persistent to progressive with cirrhosis +/- hepatocellualr carcinoma
...
Increased AST/ALT first, bilirubin rises later in
disease course
...
Can
be a mild illness in children
...
Treatment is supportive
 Hepatitis B: most common in Tanzania, parenteral and perinatal -transmission
...
Hep B surface antibody positive: immune to infection
...
High rate of progression to hepatocellular cancer
...
Can have co-infection with Hep D (needs hep B in order to
infect)
...
Serology: anti Hep C antibody
positive
...
More common in southeast asia
...
Serology: IgM anti HEV
 EBV, CMV
Alcoholic Hepatitis
77





Usually an acute exacerbation of symptoms in a patient with chronic and excessive alcohol
ingestion from
...
If severe injury with hepatic encephalopathy, can treat with
steroids x 1 month with taper

Vascular Hepatitis
 Ischemic hepatitis: “shock liver” from severe hypotension (low cardiac output state) from septic
shock, cardiogenic shock, AST/ALT > 1000
 Congestive hepatitis: from any cause of right sided heart failure -> passive congestion leading to
ischemia and necrosis of liver
 Budd-Chiari Syndrome: occlusion (thrombosis) of the hepatic veins leading to sinusoidal
congestion and portal hypertension -> passive congestion and ischemia of liver, necrosis of
hepatocytes
Toxin induced Hepatitis
 Paracetomol- usually ingestion > 10 grams to cause clinical syndrome but can occur at 2-6 grams
in malnourished and alcoholics
...
Treatment: n-acetylcysteine
 Isoniazid, rifampin, fluconazole, phenytoin
 HIV medications: zidovudine, didanosine, nevirapine
 All statins for hyperlipidemia (stop drug is AST/ALT reaches 3-4 x upper limit)
Genetic Causes of Liver disease
 Hemochromatosis: iron overload with deposition in liver, heart, pancreas
...
Diagnosis: increased iron saturation
(iron/TIBC x 100% > 45%), increased ferriton
...
Signs/symptoms: neurological manifestatinos (copper
toxicity in brain), movement disorder, psychiatric, Kayser-Fleischer rings (copper deposits in
cornea)
...

Biliary origin
Primary biliary cirrhosis: autoimmune destruction of intrahepatic ductsPrimary sclerosing
cholangitis: cholestasis with fibrosis, stricturing of intra and extra hepatic ducts

78

Portal Hypertension
Definition
It is established by determining the pressure difference between the hepatic vein and the portal
vein
...


Etiology
Most common etiologies in Tanzania for portal HTN are schistosomal portal fibrosis and cirrhosis:
other causes include splenic and portal vein thrombosis
...
PRE-sinusoidal portal hypertension
...
Most common feature is portal
hypertension, severe hepatosplenomegaly, ascites, esophageal or gastric varices
...

Treatment: high rate of reinfection so total cure is difficult and retreatment is often necessary
...


Complications Portal Hypertension:
Esophageal Varices
 Pathophysiology: Occurs from development of portal-systemic collateral channels through
esophageal veins
 Signs/symptoms: upper GI bleed, high mortalitiy
 Treatment: IV access, packed red blood cells, somatostatin analogues or esophageal balloon if
available, endoscopy with banding if available
 Prevention of upper GI bleed in patients with portal HTN is non-selective beta blockers (titrate to
goal heart rate less than 25% of baseline)
...

Nitrates can be added if necessary
...

 Pathophysiology: portal hypertenion leads to leakage of fluid into peritoneum, thus leads to a
decrease in plasma volume and this leads to sodium retention (via aldosterone)
...
Abdominal ultrasound will detect fluid if >
100 cc
...
1-> portal HTN as etiology of
ascites (cirrhosis, schistosomiasis, heart failure, budd chiari)
...
1 -> peritonitis (TB), peritoneal cancer, pancreatitis
Treatment:
o decrease sodium intake (less than 2 grams a day)
o diuretics: combination of spironolactone and lasix (can increase slowly until goal diuresis
of 1 liter a day is obtained)
o therapeutic paracentesis (large volume): If diuretics are not working and respiratory
compromise present
...
In most cases, therapeutic paracentesis is not indicated
as the benefit is only temporary since the ascites will usually recur almost immediately
...
A health spleen measures 11cm in length and lies between the 9th and 11th ribs on the
left hand side behind the ribs
...
The presence of splenomegaly implies an active inflammatory process for which the
underlying course must be determined
...


Three Main Functions of the Spleen





Filter damaged cells from the blood
Antibody production
Provides protection against infection by the process of phagocytosis
...

Proliferation of the splenic tissue -particular the plasma cells as a result of antigenic stimulation
leading to antibody production
Portal Hypertension- Common in the context of chronic schistosoma mansoni infection or
Hepatitis B
Space occupying lesions within the splenic capsule - usually an abscess
...

Chronic splenomegaly-More firmer and fibrous
...


Examination
The size of the spleen should be expressed in centimeters below the left costal margin and should be
measure diagonally from the left mid-clavicular line to the tip of the spleen
...
There are 5 clues on physical examination that can differentiate splenomegaly
from other abdominal masses
...
Spleen moves downwards with respiration and medially with respiration
2
...
If the spleen is enlarged it is not possible to delineate its upper border which is covered by the
lower ribs
4
...
The spleen is dull to percuss
...
The spleen is not palpable bimanually in the loin where is kidney can be
...
There are
only a limited number of diseases that cause massive splenomegaly
...
Look for HIV wasting,
anaemia, Lymphanopathy, Ascities, Stigmata of chronic liver disease
Examination
 Determine size - Centimeters below the left costal margin (mid-clavicular line) as measure
diagonally toward the umbilicus
...
abcess
 Low grade fever and a murmur may indicate Infective endocarditis
 Asses for any ascities and the liver
Investigations
 Blood film for malaria - Interpret with caution especially in high endemic areas
 Full blood picture, liver function test, HIV test, Sickle cell test, blood cultures
 Pheirpheral blood smear to asses cell morphology
 Sputum for fast acid bacilli, bone marrow culture if salmonellae is suspected, Lymph node
aspiration/biopsy
 Abdominal USS( periportal fibrosis in schistosomiasis) , echocardiogram is infective endocarditis
is suspected
...
The
primary reason for malnutrition is a negative balance between dietary intake and physical needs
...
These elements seldom occur in isolation and they often reinforce each other
...
The malnourished become
immunosuppressed and so the infections last longer and are more severe
...
Infections deplete body stores of vitamin A, C, E
...

Indicators used are: wasting (decreased body mass index), stunting (decreased height fore age),
wasting and stunting combined (weight for age)
...
If <18
...


Classes of Beta Lactams
 Penicillins: Effects gram positives without beta-lactamase, mainly strep and staph
...

 Amino-penicillins (Ampicillin, Amoxicillin) amino group makes drug more hydrophilic, allowing
passage through GN cell wall, so covers Gram negatives and Enterococcus
...
Effective against
Pseudomonas
...
e
...

 Monobactams (i
...
Aztreonam) only effective against Gram negatives
...
e
...

Resistance to Beta Lactams
 Decreased penetration (outer membrane of Gram negative bacilli = effective barrier)
 Alteration of target site (altered PBPs in pneumococci, MRSA, gonococci, enterococci)
 Inactivation by bacteria (beta-lactamase, now extended-spectrum beta lactamase)
Adverse Effects
 Allergy:
o Immediate (within 60 minutes) urticaria, angioedema, bronchospasm, anaphylaxis
o Accelerated (1-72 hours) urticaria
o Late (>72 hours) rash, serum sickness (rash, fever, arthritis, adenopathy), drug fever
 Derm: morbilliform, erythema multiforme (target lesions), Stevens Johnson Syndrome (mucosal
involvement), exfoliative dermatitis
 Other: neurotoxicity (LOC, hyperreflexia, seizures), drug-induced lupus, diarrhea, AIN
 PCN allergy has 15% cross-reaction with cephalosporins, NO cross-reaction with aztreonam

Cephalosporins
Related to beta-lactams, and contain a beta-lactam ring, but is heavily modified
...

87

Third Generation: (Ceftriaxone) improved gram negative, but weak against staphylococcal species
...

Resistance
Inactivation by Beta-lactamases or cephalosporinases, can be constitutive or inducible
...
Has some degree of cross-reactivity with penicillins, estimated 510%
 Can also cause some GI distress
...
Diff
...
Most common in enterococcal species
...

Adverse Effects
 Possible nephrotoxicity, ototoxicity
 Redman syndrome

Fluoroquinolones




Ciprofloxacin, Levofloxacin, Gatifloxacin, Moxifloxacin, Norfloxacin, Lomefloxacin,
Directly inhibit bacterial DNA synthesis (inhibit DNA gyrase and topoisomerase IV)
Covers Gram negative bacteria, some Gram positives, mycobacteria (some coverage may select
for resistant TB), atypicals

Resistance
Mutation in chromosomal gene alters target mechanism (encoded subunits of gyrase and
topoisomerase) and regulates expression of cytoplasmic membrane efflux pumps or proteins that
constitute OM diffusion channels
Adverse Effects
 GI (diarrhea, nausea
...
Diff/PMC in North America

Aminoglycosides





Includes drugs such as Gentamicin, Amikacin, Streptomycin
Function by binding the 30S Ribsomal subunit, preventing bacterial protein synthesis
...

Very broad spectrum, with gram positive, gram negative, and cell-wall deficient mechanisms of
action, has a very narrow TI requiring careful drug level monitoring
88

Resistance
Plasmid mediated enzymes that phosphorylate the AG, inactivating it
...

Wide range of efficacy, are primarily bacteriostatic
...

Adverse Effects
 GI Distress and CDAD/PMC
 Photosensitivtiy
 Hepatotoxicity with higher doses, Nephrotoxicity as well
 Tooth discoloration, as it binds to forming bone

Macrolides






Includes Erythromycin, Clarithromycin and Azithromycin
Binds 50S subunit of Ribosome, causing inhibition of protein synthesis
...

Can also affect intracellular organisms as well
...

Adverse Effects
 Most commonly associated with GI distress, including N/V, diarrhea (improved with taking the
medication with food
...

 Ototoxicity

Trimethoprim & Sulfamethoxazole




Available as a fixed combination pill, with a ratio of 1:5
Both affect bacterial folic acid synthesis at different points
...


Resistance
Unclear mechanism, is increasing
Adverse Effects
 Hypersensitivity- rash, ranging from mild to severe
89



Hematologic effects include potential marrow supression

Metronidazole



Initially used only for parasitic infections, including Trichomonas, Entamoeba, and Giardia
...
also effective against C
...


Resistance
In vitro only, no known clinical significance
...
gonorrheae,
N
...
catarrhalis, H
...
coli, Klebs, Enterobacter, Salmonella, Shigella,
does not cover any anaerobes

Resistance
Missense mutation in rpoB gene
Adverse Effects
 Hepatitis, Orange discoloration of urine

90

Fever



Temperature > 37
...
3C usually indicates
and infectious etiology [T>38 (neutropenic pts)]
Fever of unknown origin (FUO): T>38
...


91

HIV/AIDS
AIDS is defined as HIV infection with a CD4 count <200 OR HIV infection with an WHO clinical stage
IV opportunistic infection/malignancy regardless of the CD4 count
...
Most with HIV-1—more virulent and
widespread
...
HIV transmitted through unprotected intercourse
(heterosexual and homosexual), from mother to fetus (before, during or after birth (via breast milk),
infected blood products, or injections/treatments with unsterile needles/syringes
...


WHO Clinical Stages
The presence of these opportunistic diseases, infections and malignancies parallels the decline in the
patient’s CD4 count
...
Most specific 
PCR (viral load) – test for presence of HIV virus; qualitative or quantitative
CD4 count – normal is >800; determines degree of immunosupression

Progression of HIV
At the time of infection the CD4 count drops drastically and the viral load is very high
...
The set points determines how fast it will progress
...
After 5-10 years the CD4 count starts to decline
...


Initial approach to HIV+ asymptomatic patient:





History: ask about fever, anorexia, weight loss, night sweats, lymphadenopathy, pruritis or
rashes, cough, dysphagia/odynophagia, diarrhea, headaches, visual symptoms, seizures
Physical Exam: temporal wasting, fever, lymphadenopathy; rashes or vesicles (examine the
perianal and genitals); oral findings (thrush, hairy leukoplakia), signs of lung consolidation or
crepitations; hepatosplenomegaly; peripheral neuropathies or focal neural deficits, cognitive
impairment
Labs: check CD4 and viral load, also consider CBC, creat, LFTs, PPD, CXR; other diagnostic tests
as history requires

Work-up of Common Symptoms and OIs in HIV/AIDS
Acute retroviral illness: Occurs in some patients 10-30 days post-exposure
...
Symptoms last 3-21 days
...
This stage often missed
...

Fever: Fever in HIV+ patient can have a variety of causes, some very serious and lethal
...
Diagnostic studies for fever
should be guided by CD4 count and history but at minimum the following should be done: Blood
smear for malaria, blood and urine cultures, CXR, UA, FBP, AFB
Cough and Dyspnea: Persistent cough and/or dyspnea may be caused by bacterial or viral PNA, PCP,
pulmonary TB, cardiac failure, bronchitis/asthma, malignancy (pulmonary KS); initial workup should
include the following with consideration of further diagnostic tests based on the results
...
PE may reveal white curd-like lesions in the oral cavity (thrush) or
ulcerations
...
Bacterial etiologies
include bacterial infection with salmonella, shigella, campylobacter, yersinia, and c diff
...

Other etiologies to consider include CMV, MAC, and AIDS enteropathy
...

Investigations should include: LN aspiration with AFB stain and biopsy, CXR, FBP with differential,
ESR
Skin rashes, sores and pruritis: HIV+ patients are prone to numerous dermatologic conditions
...

A diagnosis can often be made based on the physical exam however you can also consider: skin
scraping and microscopic examination (for fungal elements), culture of any discharge
Altered Mental Status/Severe Headache: Neurological complaints or findings in an HIV+ patient
should be taken very seriously as they can have devastating complications however often have
treatable etiologies
...
Neurosyphillis can also present with meningitis as well as cranial nerve palsies and
dementia
...
Again, if you have a high index of suspicion
for a certain diagnosis do not wait for the lab results to return before starting empiric treatment
...

Initiation of HAART should be considered in the following patients:
 Those with CD4 count of <200/mm3
 WHO stage IV
 WHO stage 3 and CD4 < 350
As of 2012, the HIV guidelines are being changed and will recommend initiation of ART for all
persons with CD4 <350 or WHO clinical stage III or IV

Regimens
HAART regimens usually will consist of an NNRTI + 2 NRTIs or a PI + 2 NRTI
...
Tenofovir + Emtricitabine (FTC) + Efavirenz (EFV) or Nevirapine (NVP)
2
...

Efavirenz is preferred for patients on anti-TB
...

*stavudine (d4t) has been removed from the first line regimens due to severe peripheral neuropathy
but is still being used in some parts of Tanzania as Triomune (d4t+3TC+NVP)

Monitoring




Pt’s should be seen 2 weeks after initiation of HAART to check for adverse effects and to have
the LFTs and CBC checked
...

Treatment failure (WHO criteria):
o Clinical - Occurs of new or recurrent stage 4 disease after 6-12 months of ART
...

o Virologically-Plasma HIV RNA >5000 copies/ml after 3 months of ART
...


Prophylaxis against OIs

94




PCP Prophylaxis: Cotrimoxazole should be started in patients with a CD4 < 350 or any WHO
Clinical Stage II-IV or unknown CD4 or those with TB or a histor of TB across all CD4
counts
...

TB: All HIV+ patients with a positive PPD who are not on HAART and have no signs of active TB
are eligible for TB preventative therapy
...
Treatment consists of INH 5mg/kd QD + vitamin
B6 x 9 months
...
Oral
candidiasis can be treated with nystatin oral suspension
...
At BMC, we typically give cotrimoxazole 1920mg PO TDS x
3/52 for all adults
...
7mg/kg/day x 2
plus Flucytosine 50mg/kg/day x 14 days, however, in our setting, this is often not available
...
2g/day x 2 weeks followed by 400mg po od x 8 weeks
...

HSV: mild/moderate cases can be txd with Acyclovir 400mg po tid x 7 days
...

VZV: Treat with Acyclovir 800mg 5 times a day for 7 days unless suspect disseminated VZV or
ophthalmic nerve involvement in which case treatment should be started with IV acyclovir,
1mg/kg q8h x 7 days
Toxoplasma encephalitis: Ideal treatment is with a combination of Pyrimethamine and
Sulfadiazine but this is often not available in our setting
...
Life long prophylaxis is recommended
...
The most frequent clinical
presentation is pulmonary disease
...

Most cases are a result of reactivation of prior infection
...


Epidemiology





Thought to cause ¼ of preventable adult deaths in developing countries
Causes 2-3 million deaths worldwide per year
Risk factors (environment): close quarters, low light, crowded, low ventilation
Risk factors (host): T-cell deficiency, steroid use, malnutrition

Microbiology





Mycobacteria are slender, curved, aerobic bacilli whose cell wall components make them acidfast on Ziehl-Neelson staining
...
Disease due to M
...

Cell wall with high lipid content that stains red (“acid-fast”)
Replication time=15-20 hours (compared with <1hour for other bacteria), so visible growth of
colonies in culture takes 4-12 weeks

Transmission
M
...
Overcrowded, close proximity contact and
poorly ventilated conditions increase the risk of transmission
...
tuberculosis enter alveoli and initiate a non-specific
response
...
The
may either be contained there or spread via the lymphatics or bloodstream to other organs
...
Granulomas heal in the
immunocompetant
...

Active TB disease: on average, about 5-10% of adults infected with M
...
HIV is an important risk factor
for developing active TB, as is recent infection, diabetes, poverty
...

Reactivation TB: Immune reaction (delayed-type hypersensitivity) leads to tissue destruction at site
of replicationcavitating caseated lesions (large numbers of multiplying bacilli encircled by rim of
giant cells and granulomas)
...
Cavitations
96

grow into airways, allowing bacilli now to be aerosolized in droplets and to be spread to outside
world
...

Signs of fever, malaise, cough, particularly in setting of recent TB exposure
...
CXR may show enlarged hilar or paratracheal lymph nodes with or without
lung consolidation in lower lung zones
...

In HIV negative adults, pulmonary TB is the most common presentation
...
TB may affect any organ in
the body resulting in organ specific signs and symptoms
...

Pulmonary TB: involves the lung parenchyma
...
A cough of
long durations > 2 weeks is indication for sputum smear for AFB
...
A patient may
present looking ill and wasted with fever and tachycardia or look well
...
Sputum smear is usually positive in HIV negative patients but
often negative in HIV positive patients
...

TB lymphadenitis: The second most common manifestation of TB
...
Nodes may initially be rubbery and nontender, become fluctuant and can
sometimes progress to chronic draining abscesses
...
TB is the most common cause of perstistent effusion in Africa in the absence of
some other obvious cause
...
Pleural biopsy can confirm the diagnosis
...
Vertebral collapse may ultimately
produce a characteristic angular deformity and gibbus
...

Miliary TB: most commonly affects HIV patients
...
Physical
findings often non specific, can find hepatomegaly, splenomegaly, tachypnea
...
Sputum smear is usually negative
...

*TB meningitis: is commonly seen in children or HIV patients
...
History is less acute
97

than bacterial meningitis, meningismus may be mild at first
...
Diagnosis rests on CSF examination with lymphocytosis, raised protein and decreased
glucose
...

It can occur at any site in the GI tract, common in terminal ileum
...
*Adrenal TB occurs when the adrenal
glands are infected and eventually destroyed
...

*Pericardial TB: often first suspected on the basis of globular enlargement of the cardiac silhouette
on chest xray in patients with cariorespiratory symptoms
...

A pericardial rub or clinical features of cardiac tamponade (elevated JVP, pulsus parodoxus,
hypotension) may be present
...

Constrictive pericarditis risk can be reduced by adding steroids for the first 6-12 weeks of anti TB
treatment
...
Presentation is
subacute and diagnosis requires TB culture or biopsies
...
The urine contains pus cells but the culture is negative for common
bacteria
...

Epididymal swelling is most common presentation of genital TB in men
...
Treatment is
intubation, steroids (to decrease the swelling), and anti-TB
...
Patients should submit 3 specimens within 24 hours: 1 sputum at first presentation (spot),
the 2nd the next morning (morning) and the 3rd during following day (spot)
...




looking for acid fast bacilli via Ziehl-Neelsen staining: specific, but not sensitive, particularly if
disease has not cavitated
diagnosis of sputum negative TB: if 3 samples are negative and your suspicion is high, reassess
the patient and repeat sputum exam after 1-2 weeks, following a trial of antibiotics and obtained
chest xray
...
Cavitations are
fairly specific for TB, but are often absent particularly in HIV
Tuberculin skin testing (TST): Indicates exposure to TB but not necessarily active disease
...

Culture of M
...

ESR: nonspecific and should not be used as a routine diagnostic tool

Categories





Category I – New smear positive PTB or new patients with severe forms of EPTB
Category II – Relapse, treatment failure, or sputum smear positive after default
Category III – New sputum smear negative PTB or less severe forms of EPTB
Category IV – Chronic cases
o Severe forms EPTB – meningitis, military, pericarditis, bilateral or large effusions, spinal,
intestinal, GU tract
o Relapse – smear positive after cure
o Treatment Failure – a patient who remains smear positive after 5 months of therapy
o Default – a patient who stopped therapy for > 2 months

Treatment:
Aims of treatment: to cure the patient, to prevent transmission in the patient’s family and
community, and to prevent development of resistant bacilli
Principles of anti TB therapy
 use at least 2 drugs to which the organism is presumed to be sensitive
 administer treatment for 6-9 months (for pulmonary and extrapulmonary TB)
 ensure the patient completes the full course of therapy

99

Anti-TB
 Izoniazide (H) – very potent; Major side effect liver toxicity
...
Resistance to both INH and rifampin (so called MDR
TB – Multi Drug Resistant TB) occurs in 1%
...


TB Preventative Measures








Early diagnosis and treatment*
DOT to assure that medications are taken*
Isolation of sputum positive patients in the first 2 weeks of treatment (when possible)
BCG immunization in infants
Screening families and close contacts of smear positive patients to detect other cases of TB
...
TB is the most common cause of
death in patients with HIV and the mortality of TB in the setting of HIV is much higher than TB in the
absence of HIV
...

Primary TB is also possible
...

Differences in TB among HIV positive patients
Presentation: extra pulmonary TB is more common in this population (50% vs 10% in the general
population) so symptoms/signs are often nonspecific
Diagnosis The diagnosis of TB in HIV+ patients is difficult due to 3 main reasons:
1
...
More commonly have hilar adenopathy, effusions, miliary disease or
opacities in lower/middle lobes
...
Sputum for AFB is often negative, particularly if CD4 < 350
3
...

Treatment: same drug regimen in HIV patients and non HIV patients





recurrence rates and re-infection is higher in HIV patients
mortality during and after treatment is also higher in HIV patients
rifampin lowers serum levels of most protease inhibitors and nevirapine; for this reason,
patients on NVP should be switched to EFV if starting anti-TB
if TB and HIV are diagnosed at he same time, anti-TB should be started immediately and ART
should be started after 2 weeks (if CD4<50) or 2 months (if CD4>50) to prevent IRIS
...
falciparum, P
...
ovale and P
...

The majority of malaria infection in Africa is caused by P
...
vivax infection is more
commonly seen in Central America, the Middle East and India
...
falciparum can be associated with
severe morbidity and symptoms can progress to coma or death very rapidly
...


Tramsmission
Malaria transmission is predominantly via the bite of a female Anopheles sp
...
“Autochthonous” malaria can result if a mosquito
feeds on a malaria-infected individual and transmits the infection by biting someone else
...
When these mature(6-16
days) they rupture into the blood stream releasing the merozoites
...
Finally, new
daughter merozoites are released from the red blood cells which then infect new red cells
...

vivax and ovale infections, some parasites may lay dormant in the liver(formation of hypnozoites)
and can cause late relapse after reactivating after many months; this does not occur with P
...
Some of the merozoites that enter the RBC do not develop into schizonts but
develop into gametocytes
...
The female mosquito will then ingest these and the cycle will restart
...

As the most death occur due to falciparium the below section will focus on its the pathogenesis
...
Falciparium has a short erthyrocytic cycle of 48
hours causing large destruction of red cells and a rapid increase in the merozoites
...
Falciparum
...
There parasitic cells adhere to one another, to non-parasitized cells and to capillary
endothelial through cytoadherence receptors
...

102

Cytokine activation
There is a significant increase in a number of pro inflammatory cytokine factors in particular
TNF
...
The
mechanism of damage are likely to include direct effects on cellular metabolism and stimulation of
the release of other toxins
...

Immunity
Immune responses occur following infection with malaria and individuals living in endemic areas
may develop partial immunity to disease following repeated infections
...
This partial protection wanes quickly
after leaving an endemic area
...
Natural immunity is found in those with sickle
cell trait and G6PD deficiency
...
Signs and
symptoms are varied but typically include fever, chills, sweats, headache, myalgias, fatigue, nausea,
vomiting, abdominal pain, diarrhea and cough
...
Anemia, thrombocytopenia,
splenomegaly, hepatomegaly and jaundice can develop and splenic rupture can occasionally occur
...
It is universally fatal if untreated and even with treatment has a 20% mortality rate
with most of the death happening in the first 24 hours
...
Risk factors for cerebral malaria include age (children and older
patients), pregnancy, poor nutritional status, HIV infection, transmission intensity and h/o
splenectomy
...
faliciparum infection include renal failure, pulmonary
edema/ARDS, hypoglycemia, anemia and bleeding and gastroenteritis
...
First smear is postive in 95% of
the cases
...
The thick smear is more sensitive in diagnosis malaria and the thin smear
allows examination of the morphology of the parasite (for species identification) and
quantification of the percent of parasitized red cells
...

Other lab abnormalities that can be seen with malaria include evidence of anemia, hemolysis,
thrombocytopenia, hyperbilirubinemia, abnormal renal function, mildly elevated transaminases,
elevated LDH, and sometimes evidence of DIC
...
2

Abnormal spontaneous bleeding Metabolic acidosis ( HCO3 < 15)
multiple convulsions

severe anaemia < 5

Pulmonary edema

Hyperparasitemia >5%

respiratory distress

serum lactate >2

impaired consciousness

renal impairment Cr > 265

Shock

Heamoglobinuria

Treatment
Treatment of malaria involves supportive measures as well as specific anti-malarial drugs
...
falciparum malaria should have their treatment commenced without delay and generally
should be admitted to the hospital so that they can be observed for any evidence of complications
...
Thick and thin smears should be examined routinely to monitor
the efficacy of therapy until the parasitemia is below 1%
...

Uncomplicated/non severe malaria
 First line -ACT bases therapy- 3/7 (In TZ, ACT = ALu (Artemether/Lumefantrine)
 Pregnancy - 1st trimester quinine, 2nd and 3rd ACT (although Quinine given in all 3 trimesters
according to current TZ guidelines)
Complicated/severe malaria
 IV Artesunate or
 IV Quinine
 With both cases there should be follow up oral ACT for 7/7

104

Meningitis
This is a clinical syndrome that results from the inflammation of the meninges which can be caused
by a wide range of organisms- Bacterial, viral, years helminths and rarely in some cases due to non
infected causes such as SLE, sarcoid and Behcets
...


Acute Bacterial Meningitis
Definition
Bacterial infection of the subarachnoid space
Microbiology
S
...
meningitidis and H
...

Listeria can be seen in the elderly, alcoholics, or patients with immunosuppression or malignancy
...

Clinical Manifestations
 fever
 headache, stiff neck and photosensitivity
 altered mental status
 seizures
 Focal neurology - localising signs - often CN V1palsy
 2 out of 4 of these symptoms will be present in 95% of patients presenting with meningitis
however keep in mind that the elderly and immunocompromised (ie: HIV+) may have an atypical
presentation with lethargy and confusion as their primary symptoms and no fever
 Also bear in mind that those present comatose often have a poor prognosis
...

Physical Exam
 nuchal rigidity, kernig’s and brudzinski’s sign
 focal neuro findings
 fundoscopic findings (papilledema, absent venous pulsastions)
 rash: maculoapular, petechial or purpuric (may be associated with N
...
However it should be noted
that in pts with mass effect herniation may occur even without LP and may not occur even with
LP
...

 If the patient is HIV positive or you have any suspicion that they are HIV + you may have to
broaden your empiric coverage dramatically
...
You may also want to consider treatment for cerebral malaria, toxo, neurosyphillis
...

Etiologies
 Viral: enterovirus, HIV, HSV, VZV, mumps, viral encephalitis, adenovirus, polio, CMV, EBV
 Tuberculosis
 Parameningeal focus of infection (ie: brain abscess, epidural abscess)
 Fungal, spirochetal, rickettsial
 Partially treated bacterial meningitis
 Medications: bactrim, nsaids, pcn, INH
 Systemic illness: SLE, sarcoid, Bechet’s, Sjogrens, RA
 Neoplasms: intracranial tumors, lymphomatous or carcinomatous meningitis
Empiric Treatment
 no abx if suspect viral etiology (unless you suspect HSV/VZV); otherwise start empiric
antibiotics and wait for the CSF culture data
 anti-TB meds if suspect TB meningitis

Chronic Meningitis
Definition: Meningitis with symptoms lasting > 7 days
...

Etiologies: Usually aseptic
...

Treatment: Evaluate for cryptococcal meningitis
...


106

Sexually Transmitted Infections
Treatment of STIs reduces transmission of HIV
...


Males
Urethral discharge: Confirm presence of discharge, evaluate gram stained specimen under
microscope
...
Treatment:
Ciprofloxacin 500mg PO STAT or Ceftriaxone 125mg IM STAT (Gonorrhea) PLUS Doxycycline 100mg
PO BD x 7 days or Azithromycin 1 gram PO STAT (Chlamydia)
Penile ulcers: Confirm presence
...
4 million IU IM STAT (2
injections into separate sites) or Procaine penicillin G 1
...
ducreyi gram negative rods)

Females
Vaginal discharge: Distinguish between vaginitis and cervicitis
...

Treatment: Ciprofloxacin 500mg PO STAT or Ceftriaxone 125mg IM STAT (Gonorrhea) PLUS
Doxycycline 100mg PO BD x 7 days or Azithromycin 1 gram PO STAT (Chlamydia)
Vaginitis: Caused by Trichomonas vaginalis, Candida albicans and Gardnerella
...
0oc
o Cervical Motion Tenderness
o Vaginal discharge
 PID caused by Neisseria Gonorrheae, Chlamydia trachomatis, anaerobic bacteria
Treatment (inpatient): Ceftriaxone 250mg IM OD PLUS Doxycycline 100mg PO/IV BD PLUS
Metronidazole 500mg PO/IV BD for at least 3 days after patient improved and then Doxycycline
100mg PO BD for 14 days
...


Types of X-Rays





Posterior-Anterior (PA) – best for most patients
Anterior-Posterior (AP) – for patients who can’t get out of bed (as in the ICU)
Lateral – useful when combined with PA film to determine 3 dimensional positions of pathology
Lateral Decubitus – an PA film performed with the patient lying on side; useful in determining
size and flow of pleural effusions

Sysematic Method for Reading Chest X-rays
Always follow the same method (so that you don’t miss anything)
...
Identify the patient: make sure this is the correct patient and correct date
2
...
The medial ends of the clavicles should be equal distances
from the spinous process
...
External hardware: Look for central lines, chest tubes, NG tubes (should be in stomach and below
diaphragm), or endotracheal tubes (should be 2-4cm above the carina)
Airway: Identify the position of the trachea and carina and whether it is shifted to one side or
another
Bones and soft tissues: Evaluate external structures first that might get overlooked



Bones- look for fractures, lytic bone lesions (cancer), dislocations
Soft tissues- look for subcutaneous emphysema

Cardiac shadow
 Mediastinum- assess the size (if wide, consider aortic dissection), rule out pneumomediastinum
(thin line of air around heart)
 Heart- assess the size (cardiomegaly- heart should be <1/2 total chest width, 2/3 of heart should
be on L side)

111




Heart borders- R border is RA, L border- From Diaphragm to to left hilum is LV
...
Above this is is the Pulomanry artery and aorta
...
Note left hilum is approxiamelty 2
...


Diaphragms and pleura: look at borders before the lungs




Diaphragms – shaped like domes, flat suggests emphysema, R should be higher than L (elevated
L could mean phrenic nerve paralysis), air below diaphragm suggests pneumoperitoneum
Costophrenic angles – should be clear and sharp (if blunted, pleural effusion)
Pleura- thickened pleura (suggests prior TB)

Everything else: Finally look at lung parenchyma





Parenchyma- evaluate for alveolar process vs
...
diffuse infiltrate (viral, PCP)
PTX- if no lung markings, consider PTX (tension PTX will have mediastinal shift)
Nodules- consider cavitary lesions, tumors
Vasculature- large vessels suggest vascular congestion

112

Pleural Effusion & Pneumothorax
Pleural Effusion
Anatomy
Pleura is the serous membrane that covers the lung parenchyma, the mediastinum, the diaphragm,
and the rib cage
...

Physiology
Where does the fluid come from? It enters the pleural space from several different souces:





Pleural capillaries
Interstitial spaces of the lung
Intrathoracic lymphatics/blood vessels: disruption of the thoracic duct, injury to the blood
vessels, etc
...

How is the fluid absorbed again? Reabsorbed normally by pleural lymphatics
What are the effects of the pleural effusion?




Effects on diaphragm: Diaphragm cannot be depressed
Effects on lung: Lung volume is decreased unless the thoracic cavity is made larger to
accommodate the lung + the extra fluid
...
For free flowing fluid, peural fluid accumulates in the depend part of the thoracic cavity
...

2
...

3
...

You need at least 200cc of fluid to be present for the lateral costophrenic angle to be blunted on a
CXR
...

What is a loculated Effusion? When there are adhesions between the visceral and the parietal pleura
and the pleural fluid becomes encapsulated
...
Caused
yby pleural inflammation
...


113

What is the significance of an air fluid level? Suggests bronchopleural fistula, pneumothorax,
rupture of the esophagus into pleural space, gas forming organisms
Symptoms
Shortness of breath, pleuritic pain, dry non-productive cough
Signs
 Abnormal chest excursion with inspiration
 Decreased tactile fremitus
 Percussion note is dull or flat
 Decreased breath sounds
 At the superior border of the fluid, there may be bronchial breath sounds-may be secondary to
increased conductance of breath sounds through a partially collapsed lung
 Pleural rub
 Tracheal deviation (if effusion large)
Differential diagnosis
 CHF – cardiomegaly, JVD, LE edema
 Collagen/Vascular – joint disease, rashes (lupus, rheumatoid arthritis)
 Malignancy – lymphadenopathy, masses
Diagnosis
 Systemic factors (increased hydrostatic pressure, decreased oncotic pressure) -> transudate
 Local factors (increased pleural surface permeability) -> exudates
 Light’s criteria: EXUDATE if ANY of the following 3 are found
o Total protein effusion / total protein serum > 0
...
6
o LDH effusion > 2/3 upper limit of normal of LDH serum
In resource limited settings where LDH is often not available: total protein effusion > 2
...
2

low

<10,000

Normal

<100,000 Normal

Normal
or low
Normal

<100,000 Normal

Normal

>100,000 Normal
<10,000
Very low

Normal
Low

Needs
drainage!
+AFB
+cytology

Hct ratio
High amylase

Pneumothorax
Definition
Accumulation of air or gas in the pleural space
Etiology
 Frequently caused by trauma
...

Chest pain on the affected side with dyspnea is the typical presenting complaint
...
It occurs more freuqnently in med than women, and
especially in young men (20-40 years old)
 Secondary spontaneous pneumothorax occurs in associationwith underlying lung disease
...

Clinical features and diagnosis
 The major symptoms are chest pain and dyspnea
...
If
the pneumothorax is large enough to impair right heart filling/function, then there will JVD and a
pulsus paradoxus and you may also find deviation of the trachea to the contralateral side
...
If the patient is upright, air rises to the apex
...
May see a deep sulcus sign: anterior costophrenic angle is sharply delineated
...
5 ml
of air is detectable
...

 If the pneumothorax is larger than 15%, it is managaed by direct aspiration or tube
thoracostomy
...

Because of a ball-valve mechanism, air enters the pleural space but cannot leave
...

Spontanous pneumothorax has a tendency to recur
...


116

Dyspnea and Respiratory Distress
Shortness of breath or dysnpea is the sensation of difficulty the breathing
...
When did the shortness of breath start, how
long does it last, any exacerbating or alleviating factors
...
Ask about orthopnea and
paroxysmal noctual dyspnea (PND)
...

However, if the patient has severe pneumonia, or can't tolerate PO, then give Ceftriaxone
...

Pathophysiology: A medium airway disease with 3 major contributors: 1) mucosal
inflammation with increased TH2 lymphocytes, eosinophils, mast cells and mucus production, 2)
bronchial hyper-reactivity to allergens/irritants, and 3) smooth muscle contraction
...


Epidemiology: Prevalence in US and Europe: 5-10%
...
Prevalence in SSA
is increasing, especially in higher socio-economic classes and cities
...
Over 40yo, prevalence is higher in females
...


Subtypes
1
...

2
...

3
...
Likely to persist for life
...
Occupational Asthma – associated with occupational exposure
...
Often symptoms only improve
during long vacations (> 2 weeks)
...

5
...
Pretreatment with betaagonist is recommended
...

6
...

7
...
Often associated with nasal polyps
...
The cough is typically paroxysmal, productive of scan sputum
and worse at night
...
All
symptoms of asthma are generally worse at night because of the diurnal variation of smooth airway
contraction in the airways
...
Patients
often appear anxious
...
On ascultation, diffuse expiratory wheezes with an increased expiratory time are
often heard
...

Atelectasis often causes decreased breath sounds in the bases
...
Physical examination often normal between episodes
...


Investigations:









Oxygen saturation – <93% indicates hypoxia
...
If personal best is not known PFR should be compared to
predicted PFR by age and weight
...
In asthma, PFR should improve by 15% after dose of
beta agonist
...

Streaky atelectasis often also present
...

Sputum for AFB x 3 – if productive cough > 2wk with fever, night sweats or wt loss
...
In
severe asthma patients will be unable to speak in full sentences, RR>25, HR>105, PFR<50%
predicted
...
The following should be given immediately:







Oxygen (4-10L/min)
Salbutamol 2 puffs every hour (or 5mg via nebulizer or spacer, if available)
Prednisolone 60mg PO OD x 5/7 or
If unable to take PO, hydrocortisone 200mg IV Q6H
No sedatives!
If pt still has symptoms of severe asthma:
o Amophylline 250mg IV over 20 minutes then 1g over 24 hours
...

o Consider intubation but only if all other treatment has failed
...
In all patients with asthma
...

Encourage smoking cessation or abstinence as smoking worsens all forms of asthma
...
The following medications should be used:




Salbutamol 2 puffs (100ug each) as needed for symptoms
Pt must be educated on how to correctly use inhaler!
Inhaled corticosteroid, increase dose until patient has symptoms < 2x/wk (“step up”)
...

Most asthma can be controlled with inhaled corticosteroids alone if used correctly
...


Subtypes
There are many subtypes of COPD including:
Chronic bronchitis – chronic productive cough for three months in each of two consecutive years in
a patient in whom other causes of chronic cough have been excluded
...

Emphysema – abnormal or permanent enlargement of the airspaces that are distal to the terminal
bronchioles
...
More
common in smokers, those exposed to indoor cooking with biofuels and in the elderly
...
Bronchiectasis is much more common in
Africa tha in the US/Europe due to higher incidence of pulmonary infections
...
Bronchiectasis
usually presents with chronic cough productive of copious sputum and/or hemoptysis
...


Symptoms – COPD should be considered in any patient with chronic respiratory complaints such
as dyspnea on exertion, cough, or acute exacerbations of respiratory complaints such as wheezing,
cough, or dyspnea
...
During acute exacerbations the mucus will
often turn purulent and the patient may have a fever
...
Many patients will have a history of smoking or exposure to smoke from indoor cooking
with biofuels
...
Mild disease will sometimes have prolonged expiration and
wheezes on forced exhalation
...

Anteriorposterior diameter of the chest may be increased
...
Accessory respiratory muscle use (neck and
shoulder), pursed lip breathing, paradoxical retractions of the lower interspaces during inspiration,
cyanosis, signs of right heart failure (cor pulmonale) including enlarged tender liver, neck vein
distention especially during expiration
...


Diagnosis: Check pulmonary function tests (PFT’s)
...
70 indicates
obstruction
...

Arterial blood gas (in severe exacerbations) - look for hypoxemia and hypercapnea
CXR – only 50% sensitive for diagnosis of chronic disease, but needed to rule out other diseases
...
In
acute exacerbation want to rule out pneumonia, acute heart failure, and pneumothorax
CBC
HIV test
Sputum for culture and sensitivity – if fever and sputum
...


Treatment
Acute exacerbation
 increase in symptoms including one of the three cardinal symptoms (cough, sputum production,
and dyspnea)
 Patients should be admitted to the hospital if they have high risk comorbidities (pneumonia,
cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, liver failure), inadequate
improvement of symptoms with initial therapies in casualty, marked increase in dyspnea,
inability to eat/sleep due to symptoms, worsening hypoxemia or hypercapnea
 In a severe exacerbation patients will be unable to speak in full sentences, RR>25, HR>105, silent
chest, cyanosis, bradycardia, hypotension, feeble respiratory effort or confusions and these
patients should be admitted to the ICU
...


Stable Chronic Disease (Outpatient)
 Mild COPD
o Salbutamol 2 puffs (100ug each) as needed for symptoms
o Pt must be educated on how to correctly use inhaler!
 Moderate COPD
o Add one or more a long-acting bronchodilator
 Severe COPD
o Add an inhaled glucocorticoid if needed for better control
 Very Severe COPD
o Consider long term oxygen therapy
o If still having frequent symptoms can add theophylline BD
o Rarely if frequent symptoms despite maximum therapy can add low dose oral steroids

123

Hemoptysis and Pneumonia
Hemoptysis
Definition
 hemoptysis is the expectoration of blood > 100-600 ml over 24 hours
 Be careful to distinguish hemoptysis from hematemesis or blood from gums, throat or nose
 Massive hemoptysis is a medical emergency
...

 Top 3 causes of massive hemoptysis in Africa: TB, bronchiectasis and carcinoma
 Always remember the 3 principles of management 1) maintain airway patency and oxygenation
2) localize the source of bleeding 3) control hemorrhage
Vascular Anatomy
The pulmonary circulation: carries deoxygenated blood from the right ventricle across the
pulmonary capillary bed and returns oxygenated blood via the pulmonary veins
...
Blood originating from the pulmonary
parenchyma can be from an infection such as pneumonia, lung abscess or TB or from diffuse process
such as Goodpasture’s syndrome
...
Bronchial
arteries branch from the aorta and are at systemic pressure
...

History
 ask about tobacco history, prior lung, cardiac or renal disease
 ask about any prior episodes of hemoptysis
 productive cough, infection, skin rash, travel history
 ask about chest pain and shortness of breath
 any bleeding disorders
Physical Exam
 examine skin: look for signs of Kaposi’s sarcoma, vasculitis
 look for splinter hemorrhages as sign of endocarditis
 listen for cardiac bruits or murmurs (large AVM)
 listen for cardiac sounds such as loud P2, TR as signs of pulmonary hypertension
 look for clubbing (nonspecific sign)
 examine legs for signs of DVT
Etiology
 Acute: pneumonia, bronchitis, pulmonary embolism
 Chronic: tuberculosis, lung cancer, bronchiectasis
Airways disease
 Bronchiectasis: is due to destruction of the cartilaginous support of the bronchial wall by
infection or bronchial dilatation owing to parenchymal retraction from alveolar fibrosis
...
Vast majority of primary lung cancers associated with
hemoptysis are squamous in origin
...

Foreign body and Airway Trauma

Parenchymal Disease
 Bacterial Pneumonia
 Tuberculosis: may cause hemoptysis either in active disease (cavitary lesions, rupture of
pulmonary artery aneurysms) or as late sequelae (rupture of aneurysms or secondary to
bronchiectasis)
...
It occurs when there is rupture of ectatic portions of the pulmonary arteries traversing
thick-walled cavities
...
Hemotysis occurs at same
time as patients menstrual cycle
Management
 consider TB in anyone with chronic cough and hemoptysis
 Maintain airway patency: asphyxiation is the most frequent complication of massive
hemoptysis
...
Moniter patient in the ICU
...

 Obtain IV access
 Obtain routine lab date: FBP, BUN/creatinine, PT/PTT and urinalysis
 Localize the source of bleeding: if there is any doubt, the source of the bleeding (pulmonary
versus GI versus ENT) should be investigated
...

 in general, bronchoscopy is the diagnostic procedure to identify source of bleeding
 Control the hemorrage: correct coagulopathy, for severe hemoptysis give vitamin K 1 mg IV
...
Bronchoscopy can control hemorrhage through vasoconstrictive
agents
125

Pneumonia
Definition = acute infection of lung parenchyma
Clinical manifestations
 Cough, fever, tachycardia, pleuritic chest pain, shortness of breath, sputum production
 CXR: infiltrate (can be different patterns i
...
lobar, interstitial, cavitary)
Microbiological Differential Diagnosis
1
...
influenzae, Staph aureus, Moraxella catarrhalis
2
...
Atypical bacteria: Legionella, Chlamydia pneumoniae, Mycoplasma pneumoniae,
4
...
Fungal: PCP*, cryptococcal, histoplasmosis
6
...
If pt has PCP + hypoxia
(“severe PCP), add prednisolone 40 mg bd x 5 days, then 40 mg daily x 5 days then 20 mg daily x
5 days then 10mg daily x 5 days
 For suspected TB pneumonia, add anti-TB

126

Pulmonary Embolism
Definition
Pulmonary embolism (PE) is an obstruction of the pulmonary artery or one of its branches by
material that originated elsewhere in the body
...
We will focus on today
...
Massive – causes hypotension (systolic blood pressure < 90mm Hg or a drop in the systolic of
>40mm Hg from baseline) for >15 minutes
...
Submassive – All PE’s not meeting the definition of massive
...
Saddle PE – lodges at the bifurcation of the main pulmonary artery into the left and right
...
The majority of DVT’s come from the lower extremities,
although they can come from other deep veins
...
Untreated PE has a mortality rate of
30%
...
),
pneumothorax, myocardial infarction, acute decompensated CCF, aortic dissection pneumonia,
COPD exacerbation
...
If < 24 hours, it is called a transient
ischemic attack (TIA)
...
Main risk factors for stroke in Africa are hypertension (#1), DM,
hypercholesterolemia, smoking, atrial fibrillation, rheumatic heart disease, sickle cell anemia, and
HIV
...
Usually
occurs in elderly patients except in cases of sickle cell anemia or rheumatic heart disease
...

Etiologies
 Thrombotic – usually related to atherosclerosis
 Embolic – as with atrial fibrillation, rheumatic heart disease or endocarditis
Symptoms and Signs: The most common symptoms/signs of stroke are hemiparalysis, aphasia and
coma
...
For example:





Anterior Cerebral Artery - Hemiplegia (leg>arm); Confusion, urinary incontinence, primitive
reflexes
*Middle Cerebral Artery* (Most Common) - Hemiplegia (face/arm>leg); hemianesthesia; aphasia
(if dominant hemisphere)
Posterior Cerebral Artery - Thalamic syndromes with contralateral hemisensory disturbance
Lacunar (involving internal capsule)- Pure hemiplegia

Physical Exam: Perform a close cardiovascular exam for rhythm, murmurs, carotid and subclavian
bruits; look for signs of peripheral emboli such as Janeway lesions or splinter hemorrhage
...

Diagnostic Studies
 Most important: urgent noncontrast head CT if available (will help differentiate between
ischemic vs hemorrhagic stroke)
 blood work should include at least a HIV Test, CBC, creatinine, lipids, glucose and electrolytes (to
r/o electrolyte imbalance or hypoglycemia as cause of symptoms); PT/PTT if you are considering
a hemorrhagic stroke as you may want to reverse coagulopathies
 Consider EKG
 Consider carotid dopplers if available
 Consider TTE if available (to look for vegetations or thrombus)
131

Treatment
 Consider thrombolysis (if available) if onset of symptoms is within 3 hours, there is a large
deficit, and there is no evidence of hemorrhage or other contraindications to lysis
 We usually do not perform lysis in our setting
...

It should be started early and continued for at least 2-3 months
...
Usually occurs in elderly patients or middle
aged patients with severe hypertension
...
Otherwise, symptoms are similar to ischemic stroke (see above)
...
More of these patients will be referred to hospitals like BMC due to the severity of
their stroke
...


Subtypes





Delerium: alteration of both level of arousal and thought content (comprehension, coherence,
reasoning) that is acute in onset and fluctuates (waxes and wanes), frequently induced by
physiologic derangement (infection, stroke, metabolic disorder, drugs, toxins, etc
...
)
Pychosis: psychiatric disease accompanied by visual or auditory hallucinations
Dementia: slowly progressive degenerative process affecting primarily memory and impairs
performance of activities of daily living, much more common in the elderly, sometimes impairing
other mental faculties

Distinguishing features
Feature
Onset
Course
Consciousness
Orientation
Attention
Hallucintations/delusions
Thinking
Sleep-wake cycle
Response to questions

Dementia
Insidious
Stable in short term
Clear until late disease
Decrease
Normal until late disease
±paranoid delusions
Impoverished, vague,
perseverative
Often fragmented
‘Near misses’

Delirium
Acute
Fluctuating
Impaired
Fluctuating
Distractible, hypo- or hyperalert
±visual hallucinations, paranoid
delusions
Disorganized, incoherent
Always disrupted
Incoherent

Etiologies
The differential diagnosis for causes of altered mental status and acute confusional state are very
broad
...
Vital Sign Abnormalities: temperature, blood pressure, pulse rate, oxygenation
2
...
Infectious: malaria, meningitis from TB/fungus/virus/bacteria, encephalitis, bacteremia/sepsis,
HIV, local infection that has become systemic
4
...
Seizures
6
...
)

History (Symptoms)


Very important/helpful for distinguishing the diagnosis or cause of the recent changes
133






Usually gathered from a family member or friend
Focus on the onset, duration, tempo, and progression of symptoms
Assess medications the patient takes and any changes (changed dose, cessation, new meds)
Ask about family and social history, diet, alcohol, tobacco,

Exam (Signs)




Will vary depending on the cause
...
5-3mg po tds
...


134

Seizures
Definition




Seizures are defined as excessive abnormal electrical activity of the brain leading to a clinical
event
Epilepsy is a condition where a person has recurrent seizures due to a chronic,
underlying
process
Status epilepticus: patient has recurrent seizures for > 15 minutes without regaining
consciousness between each episode, can be fatal

Etiology








Idiopathic
Infections of the CNS: bacterial meningitis, fungal meningitis, herpes encephalitis
Structural abnormalities: primary or metastatic CNS tumors, toxoplasmosis, AVM
CNS inflammatory process: CNS lupus, CNS vasculitis
Cerebral infarction: more common in embolic stroke
Acute or preexisting brain injury: trauma, hemorrhage (subarachnoid hemorrhage, subdural
hematomas)
Nonstructural precipitants include: electrolyte abnormalities (hyponatremia, hypocalcemia,
hypoglycemia), uremia, liver failure, hypoxia, fever (mostly in children), medication (alcohol
withdrawal, illicit drugs, cyclosporine)

History




Ask about: biting of tongue, urinary or fecal incontinence, aura, postictal confusion
Ask about: Prior history of head trauma, stroke, tumor, vascular malformation
Evaluate for: Sleep deprivation, systemic disease, electrolyte derangements, acute infection,
drugs that lower seizure threshold, alcohol use

Types of seizures
Partial/Focal: involves discrete areas of the cerebral cortex, affects one part of the body (can
secondarily generalize
Simple Partial: Clinical presentation: no altered consciousness, present with motor, sensory or
psychic symptoms
...
Impaired recollection or awareness of ictal phase
...
Child can present like he/she is “daydreaming” or has
a decline in school, will also have mild automatisms, no post-ictal state

135

*Tonic/clonic (grand mal): tonic phase with contraction of muscles (causing expiratory moan,
cyanosis, pooling of secretions, tongue biting)  clonic phase with intermittent relaxing and tensing
of muscles
...

Atonic: sudden loss of postural tone lasting 1-2 seconds, no postictal confusion
...

obtain random blood glucose
obtain FBP
obtain a CT scan of head if possible
if patient has history of HIV  perform lumbar puncture after looking for papilledema
if patient has meningeal signs (nuchal rigidity, fevers)  perform lumbar puncture

Treatment









lower patient to the ground or a flat surface, onto their side to decrease risk of aspiration
protect head to prevent head trauma
start oxygen therapy by facemask
make sure there is nothing in the mouth, suction the mouth if there are any contents
give diazepam 10 mg IV immediately if actively seizing
status epilepticus: if patient continues to seize, can give another dose of diazepam  if seizing
continues, give phenytoin  if seizing continues, give Phenobarbital, consider intubation
remember that when giving phenytoin to control seizures, you have to give a loading dose of 1
gram then 300 mg OD after that
once resolved, consider the following chronic medications for at least 12 months (and often
lifetime)
...


Seizure type
1st line drug
2nd line drug
Partial
Carbamezepime or Valproate
Phenytoin
Tonic-clonic (grand mal)
Phenytoin
Phenobarbital
At Bugando, diazepam, phenytoin, phenobarbital and carbamazepime are primarily available
...


136

Headache
Causes of Headache: There is a very broad differential for headache but you can narrow it
down with a good history and physical exam
...
Your differential should include:






Infectious etiologies: Malaria, meningitis, encephalitis, brain abscess, malaria, typhoid fever,
arboviral infection, sinusitis
Hypertension
Vascular etiologies: Stroke, subarachnoid hemorrhage (SAH), subdural hematoma etc
...
The primary headache syndromes are much more common than the
life-threatening causes:




Migraine: unilateral or bilateral, retro-orbital, throbbing or pulsitile, lasts 4-72 hours, often
accompanied by nausea, vomiting, photophobia, can be preceded by a visual aura
...
This is the most common cause of headache

Clinical Evaluation
History
 Quality, severity, location, duration, time of onset, precipitants/relieving factors
 Associated symptoms (visual changes, nausea, vomiting, photophobia)
 Focal neurological symptoms
 Head or neck trauma, constitutional symptoms
 Medications, substance abuse
Exam
 Vital signs
 General and neurological exam, optic/fundoscopic exam
Labs and studies
Only done if indicated by the history and physical
...


Warning Signs that would make you want to do more investigations including possibly CT
scan of the Brain:
137







worst headache ever
pain wakes pt up from sleep
vomiting
fever
abnl neurological exam

Treatment


Treatment should be based on the underlying condition
...
Type 2 DM is caused by insulin resistance in combination with relative insulin deficiency
...
0mmol/l or random glucose >11
...
Start with a short-acting/long-acting mix of insulin at
...
Should be given 20 min before breakfast
and evening meal
Risk Factor Control
 encourage weight reduction, diet, exercise
 should be on daily ASA unless contraindicated (eg: h/o GI bleed)
 start ACE-I if + microalbuminuria
 strict BP control: goal <130/80, start ACE-I as first line as nephro-protective
 lipid control: goal LDL <100, TG <150, HDL >40; there is a benefit of statins in all diabetics even
w/o overt CAD

Diabetic Follow-Up
Clinic check list: every 6 months check









Treatment compliance and glucose control
BP
Injection sites
Feet: pulses, numbness, sores, nail care
Eyes: acuity, cataracts, retinopathy
Urine dipstick for albumin
+/- serum creat
Regularly screen for TB as risk is high

142

Acute Complications of Diabetes Mellitus in Adults
Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS)
Definitions
HHS: extreme hyperglycemia w/o ketoacidosis, but with hyperosmolar state and altered mental
status in type 2 diabetics
...

DKA: a triad of hyperglycemia, anion gap metabolic acidosis, and ketonemia
...
Hyperglycemia develops from decreased glucose uptake into the cells, increased
gluconeogenesis
...

Precipitating events (VERY similar for both)
HHS: Inadequate insulin intake (under treated OR noncompliant), DEHYDRATION, infection
(pneumonia, UTI, sepsis), acute illness (myocardial infarction, stroke, acute pancreatitis, acute renal
failure, mesenteric ischemia, cholecystitis, etc), mediations (steroids)
DKA: Inadequate insulin intake (under treated OR noncompliant OR newly diagnosed diabetes [2025%]), infection (pneumonia, UTI, sepsis), acute illness (myocardial infarction, stroke, acute
pancreatitis, acute renal failure mesenteric ischemia, cholecystitis, etc), medications, steroids

Clinical Presentation
HHS: Usually insidious (subacute) presentation of polyuria, polydipsia, and weight loss a few days
before hospital admission
...
Usually sugar > 600
but even > 1000!
DKA: Usually acute presentation over 24 hours
...

Usually sugar >500 but < 800
Physical Exam
HHS: Signs of volume depletion (low skin turgor, hypotensive, tachycardic, dry mucous membranes),
altered mental status
DKA: Signs of volume depletion (low skin turgor, hypotensive, tachycardic, dry mucous membranes),
+/- altered mental status, Kussmaul’s respirations (deep and fast) to compensate for metabolic
acidosis, fruity odor of breat from acetone
Laboratory investigations
Hyperglycemia and hyperosmolality are the two primary laboratory findings in patients with DKA or
HHS; patients with DKA also have a high anion gap metabolic acidosis (Na – [Cl +HCO3] )Most
patients: acute increase BUN and creatinine ( reduction in glomerular filtration rate induced by
hypovolemia)
...
016 * (Serum glucose - 100),
anion gap, urine ketones, serum ketones if urine ketones +, CBC, urinalysis, ABG (if available)
Treatment: Fluid + Insulin Infusion + Frequent reassessment
DKA: rule out possible precipitants, AGGRESSIVE hydration with normal saline, frequently requires 36 liters, insulin bolus of 10 units followed by 0
...
Give potassium as needed
...
1 units/gk/hr insulin infusion until
ketones negative, RBG every 2 hours, when glucose < 14…add dextrose to the IVF and continue
insulin drip to metabolize ketones, change to SC insulin when ketones are negative
...


144

Thyroid Disease
Introduction
Thyroid disease is common and can mimic many other diseases so it should be considered in the
differential diagnosis of many conditions
...
Nodular and diffuse goiter can also occur without hypothyroidism or hyperthyroidism
...
Self-limiting but may require
treatment
...

 Non Goitrous: surgical, s/p radioactive iodine/radiation, drugs like amiodarone
Secondary (decreased TSH, decreased T4) Hypothalamic or pituitary failure – very rare
Diagnostic Tests
 TSH, FT4
 anti-thyroid peroxidase and anti-thyroglobulin antibodies if available (Hashimoto’s)
Treatment
 Thyroid replacement with levothyroxine, start with 50-150mcg OD (1
...
5ug/kg/day) if pt at risk for ischemic
heart disease as levothyroxine can cause ischemia
 If due to iodine deficiency, give Schiller’s iodine (1:30 dilute Lugol’s iodine) 2 drops OD x 6mo

145

Hyperthyroidism
Clinical Manifestations
 Restlessness, insomnia, heat intolerance, sweating, moist warm skin, fine hair, tachycardia,
palpitations, AF, weight loss, increased freq of bowel movements, menstrual irregularities,
hyperreflexia, osteoporosis, lid lag
 Thyroid Storm: (seen with stress or surgery) delirium, fever, tachycardia, systolic hypertension
(wide pulse pressure and low MAP), diarrhea (20-50% mortality)
Etiologies
Primary (decreased TSH, increased T4)
 Goitrous (enlarged thyroid):
o Toxic multi-nodular goiter – common; thyroid has multiple nodules
o Graves disease – common in women 20-40yo, Genetic predisposition leads to antibodies
to TSH receptors
 Unique Sx: diffuse, nontender goiter, proptosis (check sclera visibility above
pupil), diploplia, pretibial myxedema
 Dx: thyroid stimulating antibodies
o Thyroiditis (see above)
o Toxic Adenomas: nodule producing T3/T4
 Non Goitrous: iodine-induced, struma ovarii (T3/T4 producing ovarion tumor)
Secondary (increased TSH, increased T4) - TSH-secreting pituitary tumor
Diagnostic Tests
 Increased FT4/FT3; Decreased TSH (except for tumors)
 Thyroid ultrasound – to assess for nodules
 Radioactive iodine uptake scan
o Homogenous uptake—Graves
o Hetergeneous increase—multinodular goiter
o Single “hot nodule” —toxic adenoma
o No uptake—thyroiditis, iodine load, struma ovarii
Treatment
 Start with B-Blockers (Propranolol): control tachycardia and decrease T4->T3 conversion
 Graves/Thyroiditis: anti-thyroid medications or radiation
o PTU/methimazole/carbimazole (inhibit T3/T4 synthesis)
o Radioactive iodine
 Nodular Hyperthyroidism: often treated with surgery but can also be treated with antithyroid
medications or radiation

Thyroid Nodules


The most common cause of thyroid nodules in our setting is multi-nodular goiter which is
benign and common in areas of recently treated iodine deficiency
...

Thyroid carcinoma is a rare but deadly cause of thyroid nodules
...
Seen in severe illness
...
Does not require treatment but needs to be followed up

147

Hematology & Oncology

149

Anemia
Anemia is a disorder of the red blood cell
...


Symptoms
Depends on acuteness and severity of anemia
...
Symptoms which relate to the underlying cause include
non-specific complaints such as fatigue, headache, faintness, dyspnea, palpitations, intermittent
claudication, tinnitus
...


Laboratory Findings
Red cell values: vary according to age, sex, pregnancy state




normal hemoglobin in men 13-18 g/dl normal MCV 76-96
normal hemoglobin in women 11
...
5 normal MCV 76-96
in adults, severe anemia is defined by a hemoglobin of < 7 g/dL
...
If pancytopenia, bone
marrow aspiration/biopsy should be considered as the problem is usually in the bone marrow
...
A lower
reticulocyte index in the face of anemia suggests: impaired bone marrow function, deficiency of iron,
vitamin b12 or folate; lack of erythropoietin (renal failure); ineffective erythropoiesis
Peripheral Blood Blood smear: very useful in pointing towards specific types of anemia
...


Classification of anemia by size
Microcytic anemia
Iron deficiency anemia: most common worldwide
...
Etiology: poor diet, chronic blood loss (schistosomiasis, worms, GI loss from
esophageal varices, peptic ulcer)
...
Treatment: iron replacement ferrous sulfate 200 mg tds
Anemia of chronic disease: associated with chronic inflammatory or malignant disease
...
Clinical features: normocytic anemia, reduced serum iron and TIBC, normal or raised
ferritin
...

Thalassemia: heterogeneous group of genetic disorders which result from a reduced rate of
synthesis of alpha (4 chains) or beta chains (2 chains) of hemoglobin
...
Thalassemia minor: often asymptomatic
...
Diagnosis;
severe hypochromic microcytic anemia with raised reticulocyte count, target cells
Normocytic Anemia
Anemia of chronic disease: see above
Hypothyroidism: treatment is thyroid replacement
Acute blood loss: can be normocytic before iron stores are reduced
Pure red cell aplasia: destructive antibodies or lymphocytes leading to ineffective erythropoiesis
...
Diagnosis: lack of erythroid precursors on bone marrow
biopsy
...
Clinical features neurologic changes (numbness, paresthesias,
decreased vibratory and positional sense, ataxia)
...

Treatment: replacement of B12
Folate deficiency: Etiologies include malnutrition (alcoholics, elderly), decreased absorption (sprue),
impaired metabolism (methotrexate, trimethoprim, antimalarials)
...
Bone marrow is able to compensate
5 times the normal rate
...

Labs: increased reticulocyte count, indirect hyperbilirubinemia, shistocytes on blood smear
Treatment: treatment underlying cause of hemolysis

***Sickle cell disease: a severe hemolytic anemia caused by inheritance of a point-mutated gene
...
When deoxygenated, the HbS molecules polymerize
into long fibers and cause the red blood cells to sickle
...
Typically hemoglobin levels are 6-8 g/dl,
reticulocytes 10-20%
...
Shortness of breath, chest
pain with infiltrate on chest xray is called acute chest syndrome
Crises: painful vascular-occlusive crises precipitated by infection, dehydration, deoxygenation
...

Complications of sickle cell include renal failure, bone necrosis, infections (Salmonella
osteomyelitis), splenomegaly
...

Laboratory findings: hemoglobin levels of 6-8 g/l, sickle cells on blood smear
...
Give folic acid, improve hygiene
...
In sickle cell crisis: give IV fluids with normal saline, give antibiotics for signs of
infections
...
Give oxygen and transfuse blood for severe
anemia
...
Consider colonoscopy/endoscopy, urinalysis/ urine cytology for hematuria, pelvic
ultrasound for fibroids
...
Initiation of hemostasis involves the vascular endothelium and
platelets
...


Pathophysiology: All bleeding disorders are due to 1 of the following 3 things:
1
...
This is can present with splenomegaly and anemia
...
Defective Platelet Function: Purpura from this cause can be seen in hemorrhagic fevers
(lassa, dengue), alcoholism, hepatic cirrhosis, uremia, and leukemias
...
Rarely it is inherited as with VonWillebrand’s Disease
...
Clotting Factor Deficits: congenital or acquired (due to liver dyfunction, Vitamin K
deficiency, DIC etc
...
A profound acquired thrombocytopenia that affects
young people in southern africa
...
Treatment: transfusions and possible
splenectomy
154





Secondary: infection (HIV, malaria, dengue), lymphoproliferative disorders
(lymphoma), drugs (heparin, quinine, sulfonamides), autoimmune disease
o non immune mediated:
 DIC (disseminated intravascular coagulation) is the widespread or uncontrolled
deposition of fibrin in the circulation, followed by increased activation of
fibrinolysis
...

 HUS/TTP: HUS (hemolytic uremic syndrome: microangiopathic hemolytic anemia
+ thrombocytopenia + renal failure) TTP (thrombotic thrombocytopenic purpura:
microangiopathic hemolytic anemia + thrombocytopenia + alerted mental status
+ fever + renal failure)
 Splenic sequestration
Disorders of Platelet Function:

Coagulopathies:
These occur in 2 forms: congenital (hemophila A, hemophilia B, and von Willebrand’ disease
...

Examine the skin and joints carefully looking for purpura, examine for splenomegaly




obtain FBP, PT/PTT and look at blood smear
obtain reticulocyte count
treatment is based on underlying cause of bleeding disorder

155

Lymphadenopathy
Definition: lymph node enlargement
Signs/Symptoms
Patient may complain of swollen glands or mass
...


Physical Exam
The major lymph nodes to inspect and palpate include cervical nodes, axillary nodes (enlarged in
breast cancer), epitrochlear nodes (enlarged in syphillus), and inguinal nodes
...
Take note if the enlarge lymph node is unilateral or
bilateral, tender or nontender, whether it is mobile and whether it is erythematous
...
Lymph node
enlargement from malignancy can be nontender and fixed
...
Also ask the patient the duration of time the lymph nodes have been
enlarged
...
Enlarged lymph nodes can also be a sign of HIV related illness such as
tuberculosis, histoplasmosis, CMV infection, Kaposi’s sarcoma, lymphoma, dermatological
conditions such as seborrhoeic dermatitis
...
This illness is defined as follow: 1) more
than 3 separate lymph node groups affected 2) at least 2 nodes > 1
...
If the lymphadenopathy is severe (i
...
very large or painful
or associated with B symptoms), the patient should have the following investigations
...
It is important to guide
your evaluation based on the patient’s history and physical exam and most likely diagnosis
...
You can also guide your bloodwork based on physical exam, such as, if patient
complains of abdominal pain and distention -> order abdominal ultrasound and liver function tests
also
...

***If a node is rapidly enlarging or there is nodal asymmetry and systemic complaints not otherwise
explained-> the lymph node should be biopsied to exclude Kaposi’s sarcoma, lymphoma, infiltrative
tuberculosis or fungal disease

Treatment
Treatment is guided by underlying diagnosis that is causing lymphadenopathy
...


Pathophysiology



Dysregulation of hematopoiesis, the development of all blood lineages
This dysregulation is often related to specific chromosomal abnormalities
...

Acute leukemias are often characterized by rapid replacement of marrow with blast cells, i
...

immature forms
...


Lymphomas consist of malignant transformation of cells living in lymphoid tissues
...
Both usually involve malignant growth of the spleen and
lymph nodes
...
Low grade lymphomas indolent
but incurable
...
High-grade NHL more common in Asia
and Africa, and strongly associated with malaria (as in Burkitt’s lymphoma) and HIV infection
...

Lymphadenopathy common but extra nodal spread occurs early
...
Often symptomless, systemic symptoms similar to hodgkin’s
lymphoma
...
Staging is less important in the low
grade NHL since 70% have spread at presentation, but may be more important in high grade
tumors
...
Symptomless low grade tumors may go into
remission without therapy
...
Splenectomy may help with severe splenomegaly
...

Optimum treatment for high grade tumors is 6 weeks of chemotherapy (doxorubicin,
cyclophosphamide, vincristine, bleomycin, and prednisolone)
...
There is a peak incidence at 5-10 years, with a male predominance
...


Clinical Presentation
 often with tumors of the jaw, but may involve other bones and also solid organs, GI involvement
 Histology: “starry sky” (isolated histiocytes on a background of abnormal lymphocytes)
Diagnosis: aspirates of tumor show large blasts with deeply basophilic cytoplasm and
numerousvacoules
Management
 Highly curable
...
The
chemotherapy regimens used vary between sites
...
HL is not common
...
EBV exposure has been linked to etiology (EBV DNA has been found in some
Reed-Sternberg cells)
...
25% have general symptoms of malaise,
fever, weight loss, nightsweats (B symptoms)
...
Radiation for low stages + chemotherapy for higher stages

Leukemias
Acute Lymphoblastic Leukemia (ALL)
 Epidemiology: most common malignancy among young children (usually 2-5 years)
 Definition: neoplastic proliferation of lymphoblasts
 Clinical features: due to malignant infiltration, will see lymphadenopathy, hepatosplenomegaly,
bone pain
...
WBC is raised
in many patients to an abnormally high level
...

 Management: Curable
...

Prevention of infection with antibiotics ant antimalarials
...
Maintenance chemo
required for 2-3 years, may see relapse in blood, CNS and testes
Acute Myeloblastic Leukemia (AML)
 Epidemiology: more common in elderly patients
 Definition: neoplastic proliferation of blast cells derived from myeloid cells in bone marrow
 Clinical features: similar to ALL
...
Gum hypertrophy can be seen with some subtypes
 Diagnosis: peripheral smear looking for blasts, bone marrow biopsy
 Management: Poorer prognosis
...
Chemotherapy requires special centers
...
90% are B cell variants
incuding: hairy cell leukemia
 Clinical features: slow onset with bleeding, weight loss, infection, anorexia
...
Spleen is enormous in areas with malaria
...
Bone marrow biopsy
 Managemetn: Very slowly progressive so chemotherapy is not always needed, prednisolone
helps
...

Patients uniformly will enter a blast phase at some point during their course
...


160

Solid Tumors
Intro to Cancer
Cancer is a common condition worldwide; Lung cancer was the most common cancer worldwide,
followed by stomach, liver, colon, and breast
...
5
180
...
2
Breast
19
...
8
Uterine
4
...
4
Liver
21
...
5
Esophageal
17
...
8
Oropharyngeal
16
...
4
Gastric
14
...
3
Bladder
8
...
5
Lymphoma
7
...
5
Colon
6
...
9
Lung
5
...
3
Melanoma
5
...
3

Most common cancer types, by sex
Male
Female
Prostate
Cervical
Liver
Breast
Esophageal
Gastric
Oropharyngeal
Oropharyngeal
Gastric
Liver

Esophageal CA and hepatocellular carcinoma are considered to be particularly endemic to Africa
...
These differences are
thought to be related to environmental differences, including exposures to infectious (S
...


Basic Cancer biology
Cancer is a result of gene mutation, either in:
1
...
tumor suppressor genes (genes that usually regulate cell cycle and apoptosis that may become
mutates, removing the “brakes” from the cell cycle
161

3
...


Basics on the management and evaluation of cancer patients
Cancer requires early intervention
 cancer should be suspected in any elderly patient with unexplained illness
 before treatment of a cancer patient, all patients should have a diagnosis of cancer based on
tissue pathology
...

 Weight loss: due to involvement of GI track (obstruction, metastatic liver involvement) or to
increased cell turnover and metabolic rate
...

 Fever: may be a feature of certain cancers, such as renal cell cancer or liquid tumors
...

 Anemia: Usually normocytic normochromic, due to malabsorption
...
Also you can have marrow involvement related to the cancer
3 questions to ask during the initial evaluation of patients with cancer:
1
...
Do we know where it has spread
3
...

The Bosl 4:
1
...
If it is cancer, it is curable until proven otherwise
3
...
If the cancer itself is not treatable, the patient always is
...
You need a sample to diagnose the cancer
...
Helps to determine overall prognosis as well
...

side effects include fibrosis, marrow disorders, lung disease etc

Chemotherapy often works better against tumors that are dividing quickly and always in the cell cycle
...

 Definition: Tumor of the endothelial cells, caused by HHV-8, a sexually transmitted herpesvirus
...
Two other forms are recognized: 1st is classic KS (in
equatorial Africa), slowly progressive in adults, limited to one region, espeically the feet
...

 Presentation: multiple nodular, pigmented lesions
...

Small, macular, erythamtous early on, difficult to see
...
Can
occur on all parts of the body
...
Visceral disease may
occur without skin involvement—the only visible lesion may be within the oral cavity
...

 Kaposi’s sarcoma commonly involves lymph nodes, GI tract (stomach, duodenum, rectum), and
lungs (cause dyspnea, cough, chest tightness, hemoptysis, bronchoconstriction)
 Diagnosis: can be made clinically in most cases; a punch biopy is otherwise needed
 Treatment: the clinical course of KS is slow, patients normally die from HIV related infections
...

 The lesions may respond to chemotherapy, relapse is common
...
Subsequent combination therapy is required for more complicated lesions
...
Can also presents on the mucosal surfaces or on the retina
...
Chemotherapy is of limited utility
in metastatic disease
...
Increasing in frequency in northern
Presentation: cough, change in cough, hemoptysis, weight loss, shortness of breath, hoarseness,
asymptomatic
Small cell cancer
o responsible for paraneoplastic syndromes, produce ectopic hormones such as ACTH or
ADH -> causing SIADH hyponatremia
o can also secrete PTHrP, cause Eaton-Lambert Syndrome
o centrally located
o treated with chemotherapy, radiation
...

Also requires a Head CT
Treatment: early NSCLC can be treated with surgical resection +/- chemotherapy
...

 Presentation: expanding mass in the upper nasopharynx with subsequent neck swelling, cranial
neuropathies, hoarseness, difficulty swallowing
 Treatment: Radiation therapy, 5 yr survival ~ 50%
...

Breast Cancer
 Risk Factors/Epidemiology: Risk factors include unopposed estrogen exposure (early menarche,
late child-bearing, HRT), family history (BRCA1/2), radiation exposure
...

 Presentation: lump in the breast
...
Also feel for axillary lymphadenopahy since the tumor can
metastasize there first
 A younger women age < 30 with a breast mass should be monitered for 1 month to note any
change in mass
 Evaluation: Mammography
...
Masses should undergo mammography -> Biopsy
...


164



Treatment: Surgery (Modified radical mastectomy with axillary lymph node dissection, or
lumpectomy if RT is available), if Stage II or more, use adjuvant chemotherapy
...


Esophageal cancer
 Epidemiology: Very common in some parts of Africa, thought to be related to environmental
exposures- Seen in Kenya, Ethiopa, and Zimbabwe, as well as Uganda
...
Most often Sq Cell CA
...
Presentation: Present with
dysphagia, odynophagia and weight loss
 Treatment: Surgical procedures, RT for palliation, chemotherapy is usually ineffective
Colon cancer
 Epidemiology: relatively uncommon in Africa, thought to be mostly due to dietary issues, but
incidence may increase with urbanization
...
Any elderly patient with iron deficiency anemia should
have colon cancer on their differential
...

 Presentation: Can present with RUQ or ascites, recent weight loss
...
Often found on US of the abdomen for other reasons
...
Abdominal ultrasound may
be able to see mass
...
Techniques also available include
HAE (Hepatic artery embolization), HAI (Hepatic artery infusion), cryoablation
...
Treatment is surgery
Bladder Cancer:
 Epidemiology: Squamous Cell Cancer of the bladder is associated with Schistosoma
Haematobium, due to highly inflammatory response to eggs in bladder wall
...
Pts can also present with necroturia, or the passing of
pieces of inflamed dead tissue
...

 Treatment: Radical Cystectomy
...

Prostate Cancer:
 Epidemiology: Disease of old men
...

165






Presentation: Classically an older male who presents with increasing urinary hesitancy,
frequency, or ejaculatory problems
...
Exam usually involves a firm, often
enlarged nodular prostate
...
Also available are TURP,
brachitherapy, RT, and systemic chemotherapies; Hormonal therapy is extremely important,
involves Anti-androgens followed by an LHRH Agonist
...
One of the most
common cancers in Africa
...

 Presentation: can present with vaginal bleeding, discharge or asymptomatic
...


Complications of Solid Tumors
Spinal Cord Compression
 presents with lower extremity weakness, deceased sensation, decreased rectal tone, saddle
anesthesia (decreased sensation along buttocks), loss of bowel or bladder control
 need to start steroids IV immediately with suspicion of cord compression
 obtain spinal xrays
 delay in treatment will result in paraplegia
Pleural effusions
 often large unilateral effusions, exudative
 will reaccumulate

166

Miscellaneous

167

Dermatology Exam & Skin Disorders
Dermatology Exam
Skin
 Color: cyanosis, jaundice, changes in melanin
 Moisture: moist, dry, oily
 Temperature: cool, warm
 Texture: smooth, rough
 Mobility: decreased in edema
 Turgor: decreased in dehydration
Describing Lesions:
 Anatomic location
 Arrangement: linear, clustered, dermatomal
 Type: macule, papule, pustule, bulla, tumor
 Color: red, white, brown, blanching
Nails:
 Color: cyanosis, pallor
 Shape: clubbing
Hair:
 Quantity: thin, thick
 Distribution: patchy loss or total alopecia
 Texture: Fine vs coarse

Types of Skin Lesions:
Primary lesions
 Macule: Circumscribed, flat, nonpalpable spots <1cm (freckles, tattoos)
 Patch: same as a macule but >1cm in size
 Papule: palpable, elevated, solid mass, <1cm (wart, acne)
 Plaque: same as papule but >1cm and flat topped (psoriasis)
 Nodule: palpable, solid lesion >1cm and not flat-topped (lipoma)
 Wheal: relatively transient, superficial area of local skin edema
 Vesicle: circumscribed superficial elevation of skin filled with serous fluid, up to

...
5cm
 Pustule: vesicle filled with pus rather than serous fluid
 Wheal: itchy, transiently edematous area
Secondary lesions
 Erosion: loss of superficial epidermis leaving a moist area that does not bleed
 Ulcer: deeper loss of surface that may bleed and scar
 Fissure: a linear crack
169




Crust: dried residue f serum, pus, or blood
Scale: thin flake of exfoliated epidermis

Skin Disorders
Contact Dermatitis
This is an inflammatory reaction of the skin that may occur as a response to an external irritant
...
Skin lesions are erythematous, weepy, crusted
patches or plaques with sharp angles and straight borders
...
Infection causes small itchy papules and linear
burrows, particularly in the finger webs and flexor wrist surfaces
...
Itching is worse at night
...
Treatment should be given not only to the
symptomatic patient but also to household members even if they are not symptomatic
...
5%, permethrin 5% cream, or benzylbenzoate 25% cream
...
Malathion and
permethrin are applied twice, 1 week apart, and benzylbenzoate is applied on 3 consecutive days
...
PE reveals 2-5mm discrete, dome-shaped, shiny
papules with central umbilication
...
Lesions are asymptomatic unless inflamed or irritated
...

Leg/foot ulcers
Common causes of leg or foot ulcers include complications from diabetes (both from peripheral
vascular disease as well as neuropathy leading to decreased sensation/increased trauma), peripheral
vascular disease, sickle cell disease, tropical ulcers (ulcer 2/2 mixed bacterial infection following
minor trauma), and chronic osteomyelitis
...
Management consists of identifying and if possible
eliminating the source of the ulcer, elevating the legs, protection against weight-bearing, and
dressing the wounds with clean bandages
...

Erythema multiforme (Stevens-Johnson syndrome)
Erythema multiforme is an immune-mediated disorder that is due to drugs (typically penicillin,
sulfonamides, phenytoin), infections (especially herpes simplex and mycoplasma) or malignancy
...
SJS is a life-threatening disease
...
Lesions
may be found anywhere but typically are on the extremities, palms and soles
...
Other therapeutic
170

maneuvers are directed to symptoms and may include hydration, antihistamines, analgesics and wet
dressings
...
Systemic corticosteroids are often used but
their efficacy is unproven
...
It is often fatal without appropriate
immunosuppressive drugs
...
Erosions often start in the oral
mucosa progressing from localized skin blisters to generalized bullae
...
PE will reveal flaccid vesicles and bullae containing serous fluid with a predilection for the
scalp, face, axillae, groin and back
...
Pressure on the bullae may cause
lateral extension of blisters (Nikolsky’s sign)
...

Leprosy
Leprosy is a chronic inflammatory disease caused by mycobacterium leprae infecting macrophages
and peripheral Schwann cells
...
leprae and will develop clinical leprosy
...

Ulceration and digit loss seen in leprosy is due to secondary damage in neuropathic hands and feet
and is not an intrinsic disease feature
...


171

Bone Disease
Osteoporosis
Definition
 reduction in bone density or presence of a fragility fracture
 (T-score of -2
...
5 = osteopenia)
 Bone density = amount of bone mineral per unit area
 T-score indicates number of standard deviations from peak bone mass
Epidemiology:
 Very prevalent in the elderly in Western countries
...

Why is osteoporosis a problem?
 Decreased bone density (mineral & matrix) leads to increased fractures, resulting in increased
morbidity and mortality
...

Pathophysiology:
 Bone remodeling: Bones are dynamic organs that undergo constant remodeling to adapt to
physical stress placed upon them
...

 Osteoclasts: cause resorption of bone and release calcium into blood
 Osteoblasts: formation and mineralization of new bone
 Balanced osteoblastic & osteoclastic activity results in maintenance of a stable bone mass/density
...
After this point, increased
osteoclastic activity & reduced osteoblastic activity result in imbalanced bone remodeling and
increased overall bone resorption relative to formation (normal = 1-2% per year)
...

Pathophysiology: Progressive decrease in glomerular filtration rate (GFR) causes inability to
excrete phosphorous
...
Decreased vitamin D levels cause decreased absorption of calcium
...
Renal phosphorous excretion is limited by the
reduced function of damaged kidneys which causes continuation of PTH stimulating cycle
...

 Radiographic signs: erosive defects, pseudocysts
 Laboratory evidence: high serum phosphorous, high serum PTH, low/normal calcium
173

Treatment:
 Not removed through dialysis because the vast majority of phosphorous is intracellular
 Phosphate binders - Calcium carbonate, calcium acetate, sevelamer hydrochloride
 Avoid calcium citrate due to high aluminum content
 Calcitriol (vitamin D)

Osteoarthritis
Definition: non-inflammatory arthritis characterized by deterioration of articular cartilage &
reactive formation of new bone at articular surface
Clinical manifestations:
 joint pain, most commonly in knees, hips, spine, hands
 Bony enlargement of DIP joints = Heberden’s nodes
 PIP joints = Bouchard’s nodes
 Symptoms of deep ache, joint stiffness (worse with activity)
Labs: synovial fluid WBC < 2000 (mononuclear predominance), normal/slightly elevated ESR
Radiologic findings: narrowed joint spaces, osteophytes, subchondral sclerosis & bony cysts
Treatment: physical therapy, weight-loss, acetaminophen, NSAIDS, intra-articular steroid injections

174

Approach to Arthritis
Definition: Athritis vs
...
Arthritis is an objective finding of inflammation of the joint on exam
...
Be careful to distinguish arthritis from inflammation of surrounding structures (burisitis,
tendonitis, etc
...
Arthritis is a
commonly divided into the following categories based on presenting symptoms
...
SLE: systemic lupus erythematous
...
Acute monoarticular pain is usually caused by crystal
deposition (gout, calcium pyrophosphate deposition), but it is very important to rule out infectious
causes of joint disease
...


Clinical Manifestations Acute Joint Pain
Infection
Fever

Trauma
History of injury

Red, hot swollen joint
More commonly large
joints
Poly or monoarthritis
Neisseria,
Haemophilus, and
streptococcus

Rapid swelling of knee

Crystal Deposition
Recurrent
exacerbations
Monoarticular
Red, hot, swollen joints
Gout often affects 1st
metatarsophalangeal
joint

175

Reactive
Preceding infectious
illness
Swelling and pain (but
no redness)
Uveitis, urethritis,
conjunctivitis,

Clinical Manifestations of Chronic Joint Pain
Rheumatoid arthritis

Osteoarthritis

Age varies considerably
Stiff after resting (morning
stiffness)
Metacarpohalangeal
Proximal interphalangeal
Heberden’s nodes absent
Joint soft, warm, tender
Symmetric joint involvement

Usually > 40 years old
Stiff after effort (evening
stiffness)
Disatal interphalangeal
Carpometacarpal, knee, hip,
spine
Heberden’s nodes frequently
present
Joint hard and bony
Assymetric joint involvement

Scleroderma, polymyositis,
dermatomyositis, SLE
Vary according to disease

Investigations











Rapid test for IDS
Erythrocyte sedimentation rate (ESR)
Rheumatoid factor (RF) titers
Evaluation of synovial fluid (cell count, differential, culture, gram stain, crystal analysis)
Radiographic study of affected joints
Brucella serology
Full blood picture
Blood culture
Creatinine
Urine dipstick

Arthrocentesis – Analysis of Joint Fluid
Appearance

Normal
clear

Noninflammatory
clear, yellow

WBC/mm3

<200

<2000

Inflammatory
Clear-opaque, yellowwhite
>2000

Neutrophils
Culture
Glucose
Conditions

<25%
negative
≈serum

<25%
negative
≈serum
OA, trauma

≥50%
Negative
25RA, crystal, CTD, seroneg

Treatment
Treat the underlying disease process
...
Gradual and progressive
decrease in visual acuity
...
Fundoscopic exam shows
opacity of the red reflex with obscuration f the fundal detail
...
They are treated surgically under local anesthesia
...
Appears as a white opacity on cornea usually obscuring the
pupil
...
If both eyes affected,maybe corneal transplant or optical iridectomy
 Glaucoma: Causes 10-20% of all blindness
...
Early diagnosis difficult without proper equipment;
late glaucoma seen on fundoscopic exam cupping of the optic disc and poor pupil reaction to
light
...
Tx does not
restore sight but is given in effort to preserve remaining vision
...
Use antibiotic ointment and eye pad for 1 day
 Corneal abrasions: Scratche to the cornea removes epithelial cells
...
Dx confirmed by applying florescein to stain
...
Level of blood (hyphaema) visible
between cornea and iris
...
Avoid anticoagulants (ASA or
NSAIDS)
...


if no h/o trauma, consider
 Conjunctivitis: Infective (bacterial or viral) or allergic
...
Chlamydial conjunctivitis (trachoma) will discussed below
...
Sx: Usually severe pain and blurred vision
...
In severe cases fluid
level of pus inside the eye (hypopyon)
...
Treat herpes simplex with acyclovir
ointment
...
Treat
fungal infections with antifungals
...
Treat exposure
ulcers (i
...
from leprosy causing eyelids to stay open) with antibiotics and by taping eye closed
...
Posterior = choroiditis
...
Sx: mild to severe pain, usually with blurred vision and photophobia
...
Mgt: dilate the pupil and use
topical anti-inflamatory agents
...
A white inflammatory lesion on retina
...

 Acute glaucoma: If the IOP increases suddenly over hours or days then the eye becomes red and
very painful with severe loss of vision
...
Spontaneously or complication of old
cataract
...
Tx: acetazolamide
500mg stat and then 250 qds
...


Other Eye Conditions






Trachoma: chronic conjunctivitis caused from repeated infection with Chlamydia trachomatis
...
Eyelashes to turn in and cause corneal ulceration,
scarring and blindness
...
Tx: either azithromycin 20mg/kg po as
a single dose or tetracycline 1% topical ointment bd x 6 weeks
...
See
nutritional deficiencies lecture
...
Causes keratitis,
corneal scar, iritis, chorioretinitis, night blindness, optic neuritis and secondary optic atrophy
...
CMV retinopathy is the most
common OI of the eye and the major cause of blindness
...

Appearance is one of red hemorrhages and yellow necrotic tissue
...


178



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