1- Bronchitis: · DEFINITION: Inflammation of the trachea/bronchi WITHOUT

1-      Bronchitis:

·        
DEFINITION:
Inflammation of the trachea/bronchi WITHOUT evidence of pneumonia.  This often follows an upper respiratory
infection. 

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·        
ETIOLOGY/PATH:
most commonly caused by viruses such as adenovirus, parainfluenza, influenza,
coronavirus, coxsackie, rhinovirus, RSV. 
It is more rarely caused by bacterial infections such as Strep
Pneumoniae, H. Influenza, M. catarrhalis, mycoplasma.

·        
SIGNS
& SX’s: the main presenting symptom is a cough.  This can be productive but purulent sputum is
not an accurate indicator of bacterial infection or susceptibility to
antibiotics.  The cough usually lasts
from 1-3 weeks (must be >5 days).  The
symptoms could be similar to pneumonia.

·        
PE
Findings: Wheezing and rhonchi may be auscultated on physical
examination, although rhonchi usually clear with coughing.  No other notable findings on physical
exam.  Mainly looking to rule things out
like pneumonia with PE.

·        
DDX:  Viral URI- this could precede the bronchitis
and is often self-limiting; Bacterial URI like Pertussis you will hear the
inspiratory whoop in-between coughs. 
Pneumonia is a big one you have to rule out due to the necessity of
treatment with an antibiotic.  Listen for
consolidation on auscultation, increased HR, RR, temperature.  Asthma can be ruled out by giving a
bronchodilator if having trouble breathing and if it improves you can know it
is asthma.  Pulmonary embolism must be
ruled out as well due to presentation with cough as well.  You can use Virchow’s triad and Well’s
Criteria.  GERD must be suspected with
presentation of cough.  ACE inhibitor use
because a dry cough is a common side effect

·        
DX:  Diagnosis is clinical and rarely needs
imaging or cultures, unless pneumonia or PE is suspected.  Chest X rays are usually nonspecific and not
helpful with the diagnosis of bronchitis. 

·        
TX:  Treatment is symptomatic.  Rest, drink plenty of fluids, you can use a
bronchodilator if necessary, you can prescribe an antitussive for adults.  One that is commonly prescribed is
Promethazine with codeine.  Antibiotics
are not recommended unless immunocompromised or elderly, then they may be
considered. 

·        
PATIENT
EDUCATION: Make sure the patient understands the course of the
condition and that it is most likely self-limiting and will start to improve
after 7-10 days.  It is important for
them to understand that if the condition worsens they should return to the
clinic.  If a patient is requesting
antibiotics, it is important to have a discussion on the importance of not
using antibiotics when it is not necessary. 

·        
Prevention:
Prevention should include smoking cessation, avoiding individuals who have
URI’s.

 

 

 

 

2-      Gonorrhea

·        
DEFINITION:
Neisseria gonorrhoeae is a gram negative diplococci bacteria.  It is the second most common STI in the
United States.  Infects both males and
females.  Can be treated with antibiotics
but if left untreated can lead to serious complications.

·        
ETIOLOGY/PATH:
Rates of infection have declined since the mid 1970’s and reached an all-time
low of 98 cases per 100,000 people in 2009. 
In 2015 however, there was an increase of 124 per 100,000 people.  These numbers are probably much lower than
the actual number of infected people due to underreporting of symptoms.  Highest rates of infection are seen in
adolescents and young adults.  Infection
rates in the southern United States has consistently been higher throughout the
years.  It is strictly a human pathogen. It
attaches to the mucosal cell surface, goes through local penetration, then
local proliferation, and then a local inflammatory response. 

·        
SIGNS
& SYMPTOMS:  Symptoms depend
on where the infection is.  A common
symptom is abnormal vaginal or penile discharge.  Most women will be asymptomatic but can
present with cervicitis which consists of vaginal puritis and or a mucopurulent
discharge.  Also can present with
Urethritis and pelvic inflammatory disease. 
In men it can present with urethritis, epididymitis, proctitis,
pharyngitis, conjunctivitis.  There can
be an anal, vaginal, penile or pharyngeal discharge. 

·        
PE
Findings:  For PE findings you
may see the discharge.  Females may
present with cervical motion tenderness. 

·        
DDX:  Other pathogens that cause STI’s, including
C. trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium, herpes
simplex virus (HSV) and syphilis can present with similar symptoms as Gonorrhea.  There are a number of things that can cause similar
symptoms as gonorrhea such as genital pain, PID, etc.  The main thing about Gonorrhea and Chlamydia
is that you are going to treat for both if you see the symptoms for one of
them.  Gonorrhea will sometimes have a
thicker discharge than the watery discharge that accompanies a chlamydial
infection.

·        
DX: To
diagnose Gonorrhea you can due a culture and it will show gram negative
diplococci in polymorphonuclear leukocytes. 
Perhaps the most accurate way to diagnose this is with the NAAT or PCR
technique.

·        
TX: You
will treat Gonorrhea with Ceftriaxone 250 mg IM (single dose) plus Azithromycin
1g PO single dose.  If not able to take
Azithromycin you could do Doxycycline. 
The reason for the additional meds is you want to provide extra coverage
for Gonorrhea and coverage for potential Chlamydial co infection.

·        
PATIENT
EDUCATION/PREVENTION: Look out for symptoms of gonorrhea that can include
abnormal discharge from the vagina or penis, and pain with urination for either
men or women. Gonorrhea can be cured with antibiotics, but if it is not treated
it could lead to serious complications including infertility.  Gonorrhea spreads from person to person
during oral, vaginal/penile, or anal sex.  Your risk of getting gonorrhea is greater if
you have a new sexual partner, multiple sexual partners, or if you have another
STI.  If you are at high risk for STI,
you need to be checked frequently because many infections are
asymptomatic.  If you do have gonorrhea
it is important for your sexual partner to be treated as well.  Practice safe sex including using condoms,
not having sex with someone who has these symptoms etc.

3-      Cushing Disease:

·        
DEFINITION:
This is a disease that is caused by an excess of Cortisol (hypercortisolemia)
specifically caused by a corticotropin (ACTH)-producing pituitary tumor.

·        
ETIOLOGY/PATH:
Due to a benign pituitary adenoma or hyperplasia that cause an increase in ACTH
release which in turn causes the adrenal glands to release more cortisol than
is needed in the body. 

·        
SIGNS
& SYMPTOMS: Increased weight is the most common symptom.  You will see a redistribution of fat
including: Central trunk obesity, “moon facies”, buffalo hump, supraclavicular
fat pads.  There can be thin extremities,
skin atrophy, increased infections, and hyperpigmentation due to increased
breakdown of proteins.  Can present with
HTN, weight gain, hypokalemia, mental disturbances, hirsutism, increased libido
and amenorrhea. 

·        
PE
Findings:  On examination you will
notice the fat redistribution symptoms as mentioned above.  You also may notice acanthosis nigricans on
examination of the skin.

·        
DDX:
Ingestion of exogenous glucocorticoids. The most common cause of
hypercortisolism is ingestion of prescribed glucocorticoids.  Cushing’s syndrome should also be considered
because it will present the exact same. Pregnancy, malnutrition and intense
exercise can all cause hypercortisolemia. 
There could be a lung tumor that is producing ACTH this is called a
paraneoplastic Cushing’s. 

·        
DX:
Obtain a detailed history to exclude cause of hypercortisolemia that wouldn’t
require testing.  Give 1mg Dexamethasone
at 10 PM at night and record cortisol and ACTH levels at 9 AM the following
morning.  If this is positive, you will
continue with a higher dose test with 8 mg of Dexamethasone.  In Cushing’s disease this 8 mg is enough to suppress the
anterior pituitary and decrease cortisol levels.  If it is a problem with the adrenal gland you
will see a decrease in ACTH but will not see a decrease in Cortisol.

·        
TX: For
Cushing’s disease, the treatment of choice is a Tran sphenoidal surgery to
resect the pituitary adenoma with radiation as well.  If surgery is contraindicated you can try
medication therapy.  Adrenal enzyme
inhibitors are the most commonly used drugs, but adrenolytic agents, drugs that
target the pituitary, and glucocorticoid-receptor antagonists also have been
used.

·        
PATIENT
EDUCATION/PREVENTION: Make sure patients understand the side effects of
medications that can possibly cause increased cortisol for a prolonged amount
of time.  Prednisone is a common drug
that can cause Cushing’s symptoms.  When
taking these drugs for a prolonged amount of time they must be tapered off to
allow the pituitary and adrenals to resume normal functions.  If you have these symptoms, especially if you
are pregnant you should speak with your doctor.

 

 

 

 

 

4-      Polycythemia Vera

·        
DEFINTION:
Acquired myeloproliferative disorder with overproduction of all 3 myeloid
cell lines.  This will present primarily
with increased RBC’s but can include WBC’s and or platelets. 

·        
EPIDEMIOLGY/PATH:
Most common in men and peaks in ages 70-79. 
Caused by a JAK2 mutation.  Exposure
to radiation and toxins has been suggested as a risk factor, but the majority
of patients have no evidence of exposure.

·        
SIGNS
& SYMPTOMS:  Symptoms are due
to elevated hemoglobin and hematocrit and can include: headache, dizziness,
visual disturbances, pruritus
(especially after warm bath.. OFTEN THE CHIEF COMPLAINT), tinnitus, pruritus,
erythromelalgia, early satiety or serious complications such thrombosis,
bleeding.

·        
PE
Findings: Splenomegaly, Flushed face, engorged retinal veins, excoriation
of the skin, gouty arthritis and tophi.

·        
DDX:
The differential list is actually fairly short. 
It includes: essential thrombocythemia, primary myelofibrosis, EPO
receptor mutations and secondary polycythemia

·        
DX:
In order to Dx you need to have all 3 of the following MAJOR criteria OR the 1st
2 major + minor.  Major criteria includes
1- Increased RBC mass.  2- Bone marrow Bx
that shows hypercellularity.  3- Presence
of JAK2 mutation.  Minor criteria
includes decreased serum erythropoietin levels.

·        
TX:
Management of choice is phlebotomy and this is done until the hematocrit is