Comprehensive Comprehensive tutorialtutorial

Internal Medicine 2007

Kraisorn(P’lek) ,MDKraisorn(P’lek) ,MD

1.Rx brain edema1.Rx brain edema

ข้�อสั�งเกต strok จะซึ มเม��อเป็�น brain stem stroke หรื�อ lesion ใหญ่�

จนเก�ด brain edema หรื�อ herniation แล้�วกด brain stem

Sign brain herniate : Cushing’s response Rx brain edema

ABCD ซึ ม GCS < 8 ใสั� tube Hyperventilation Mannital Restrict fluid นอนห�วสั�ง -2030° ไม�เอ"ยงคอ

Rx in strokeRx in stroke

IschemicThrombosis

Within 3 hrs →thrombolytic (t-PA)Long term →ASA

EmbolismAnticoagulant →warfarin

Hemorrhagic surgery : large, post fossa, cerebellum,IVH

2.Cause of dyspnea2.Cause of dyspnea

CVS RS Musculoskeletal system Psychiatric Metabolic : Kussmaul’s respiration

Wide GAP metabolic acidosis ; SALUD S = salicylic, starvation A = alcoholic L = lactic U = uremic D = diabetic KA

3.Chronic headache3.Chronic headache

4.Abdominal pain4.Abdominal pain

Referred pain patterns

Visceral pain patterns

5.Adrenal insufficiency5.Adrenal insufficiency

Primary : adrenal gland (Addison's disease) Secondary : pituitary gland (exogenous steroid)

predict to occur when 20 mg prednisolone more than 3 wk Cushing apperance

Tertiary : hypothalamus

6.UGIB6.UGIB

Gastritis : NSAID, AlcoholicPeptic ulcer : GU,PUVariceal : EV, GV, DV

Sign of portal hypertension Portosystemic collateral

Superficial v. dilate EV, hemorrhoid

Splenomegaly & hypersplenism ascites

7.Diabetic nephropathy7.Diabetic nephropathy

When to screening Type 1 : 5 yrs after dx Type 2 : once dx DM

What to screen Spot UA first Urine 24 hr for microalbumin if urine alb- Repeat yearly

How to Rx ACEI or ARB Control BP keep < 130/80 or 125/75 if proteinuria > 1

gm/d

8.Occupational lung dz8.Occupational lung dz

Inorganic dustAsbestosis : malignant mesotheliomaSilicosis : TB

Organic dust Byssinosis : cotton, flax(ล้�น�น)

9.Acute coronary syndrome9.Acute coronary syndrome

Base on clinical ,EKG, cardiac enz

ACS

Myocardial infarction Myocardial ischemia

STEMI NSTEMI Unstable angina

highintermedLow

• TNT +• CKMB +• STE or Q STE or Q

• TNT +• CKMB +• STST↓ or invert T↓ or invert T

• TNT +/-• CKMB -• ST↓ or invert T

Time course of markerTime course of marker

10.COPD10.COPD

Chronic bronchitis & emphysema Dx : FEV1 / FVC < 70 % Rx : depend on stage (FEV1)

Bronchodilator ß2-agonist : short (salbutamol) ,long

(salmeteral,formoteral) Anticholinergic : short (ipratropium br.) ,long (tiotropium) Xanthine derivative : sustain release theophylline

Steroid : ICS & systemic ไม�ชะล้อการืล้ดข้อง FEV1 แต�ล้ด exacerbation

อ��นๆ H. influ vaccine, home o2 therapy

( room air o2 sat < 88% ,Pao2 < 55, corpulmonale) การืหย(ดบุ(หรื"�เป็�นว�ธี"เด"ยวที่"�ชะล้อการืล้ดข้อง FEV1

11.Lesion Localization 11.Lesion Localization

Motor weaknessUMN

Cortical lesion : cortical lobe signSubcortical lesion : basal ganglion, internal capsuleBrain stem lesion : long tract sign + CN invovement

Midbrain : 3,4 Pons : 5,6,7,8 Medulla : 9,10,11,12

Spinal cord lesion : weak ด�านเด"ยวก�บุlesion sensory loss เป็�น level

11.Lesion Localization 11.Lesion Localization

Motor weaknessLMN

Anterior horn cell : pure motor,fasiculation(poliosis)

Nerve root, plexus Peripheral nerve : involve motor and sensoryNMJ : fatigability , opthalmoplegiaMuscle

13.Hyponatremia13.Hyponatremia

Na < 135 True : Posm < 280 Pseudohyponat

Hyperosmotic Posm > 280 : hyperglycemia correct Na = Na + ([(BS-100)/100] X 1.6) Isoosmotic hyponat : hyperprotein, hyperTG

True hyponatremia : ป็รืะเม�ณ ECFV Hypovolumic : เสั"ยน-.า เสั"ยเกล้�อ → renal loss, GI loss Euvolumic : SIADH, 1° polydipsia Hypervolumic : น-.าค��ง → CHF, CKD, cirrhosis

Rx depend on cause Hypovolumic : NSS Na = จ-านวน Na ที่"�ต�องการืแก�

x0.6xBW ไม�ควรืแก�เก�น12 meq ใน24 hr , 18 meq ใน48 hr

14.Febrile neutropenia14.Febrile neutropenia

Definitionssustained BT >38ºC for more than 1hrabsolute neutrophil count (ANC) <500 cells/µL or <1,000 cells/µL with a predicted nadir of

<500 ANC = %(PMN+BAND) X WBC

Most G- septicemiaEmpirical ATB = Ceftazidime + Amikin

15.Gout 15.Gout

Acute ,intermittent, 1st MTPChronic tophaceous goutDef dx

Monosodium urate crystal in PMNTophi

Rx acute attackColchicine : within 6-12 hr, S/E = diarrheaNSAID : รืะว�ง contraindication ; อาย( แพ้� ไต ห�วใจ

กรืะเพ้าะSteroid : intra-articular (mono), systemic (poly)Allopurinal** : กรืณ"ย�งไม�เคยได� ห�ามให�ข้ณะม" acute

attack

17.Wheezing 17.Wheezing

AsthmaAsthma Dx

AsthmaAsthmaTest

AsthmaAsthma

Rx acute exacerbations Inhaled beta agonists ± anticholinergics

MDI(4 puff via spacer) Nebulizer 1 NB q 20 min x 3

Systemic corticosteroidsIf not respond initiallyPrednisolone 2*3 short course

O2 therapy keep O2 sat ≥ 90%Rx precipitating

18.HBV18.HBV

Serologic diagnosis of HBVSerologic diagnosis of HBV

19.Proximal muscle weakness19.Proximal muscle weakness

Myopathy : myositis, e’lyte, endocrine

Peripheral neuropathy : GBSNMJ : MG

Hyperthyroid**

20.Anemia 20.Anemia

Normal Ranges of Erythrocyte Measurements in Adults

Females MalesHemoglobin (g/dl) 12 - 16 13 - 17Hematocrit (%) 36 - 48 40 - 52Red blood cells (x 106/ul) 4.0 - 5.4 4.5 - 6.0Mean cell volume (MCV ; fl) 80 - 95 80 - 95

แบ่�งชนิ�ด แบ่�งชนิ�ด AnemiaAnemia ตาม ตามOnsetOnset

Acute anemia ( ภายใน 1 สั�ป็ดาห1 ) Acute blood loss Acute hemolysis

Chronic anemia Iron def. anemia, megaloblastic anemia Anemia of chronic disease, CRF Primary marrow disorders

Thalassemia, PNH

Hemolytic anemiaHemolytic anemiaIntracorpuscular defects

Hereditary - Membrane defects : hereditary

spherocytosis → OF test

- Enzyme defects : G-6PD deficiency → G6PD assay

- Globin defects : Thalassemia, Hemoglobinopathy

Acquired : PNH → Ham test

Extracorpuscular defectsImmune hemolysis : AIHA, hemolytic transfusion reaction → DCT

Infections : malaria, clostridial infectionMicroangiopathy : TTP / HUS

21.Polyuria21.Polyuria

Definition Urine > 3,000 cc/day

CauseWater diuresis (Uosm/Posm < 0.9)

Primary polydipsia (hypo Na)Diabetic insipidus (hyper Na)

Solute diuresis (Uosm/Posm > 0.9)Organic : glucosuriaE’lyte : renal loss from diuretic

22.Chronic cough22.Chronic cough

DDxPost nasal dripping and postviral bronchitisAsthmaBronchiectasisChronic bronchitisChronic infection : TBCA lungDrug : ACEI

Pulmonary TBPulmonary TB

Dx Clinical :Cough, low grade fever, wt. loss

hemopthysis, fatigue, sweatingCXR : reticulonodular upper lobe, hilar LNSputum : acid fast + , short rod beat likeCulture Tuberculin skin test : screen latent infectionTissue patho PCR

Pulmonary TBPulmonary TB สั�ตรืยารื�กษาว�ณโรืค

CAT 1 ใช�สั-าหรื�บุผู้��ป็5วยใหม� ว�ณโรืคเสัมหะบุวก หรื�อผู้��ป็5วยหน�ก เช�น TB meningitis, TB spine

2 (3) HRZE (S) / 4 HR CAT 2 ใช�สั-าหรื�บุผู้��ป็5วย relapse, ไม�ตอบุสันองต�อการืรื�กษา

failure หรื�อtreatment after default 2 HRZES/ 1 (2) HRZE/ 5 HRE

CAT 3 ใช�สั-าหรื�บุผู้��ป็5วยใหม�ว�ณโรืคเสัมหะล้บุ 3 ครื�.ง หรื�อว�ณโรืค นอกป็อดที่"�ไม�รื(นแรืง เช�น ว�ณโรืคต�อมน-.าเหล้�อง

2 HRZ/ 4 HR CAT 4 ใช�สั-าหรื�บุ chronic case ใช�ยาที่"�เหล้�อรื�วมก�นอย�างน�อย

3 ต�ว หรื�อใช� INH ต�วเด"ยว

ขนิาดของยาให้�ตามนิ��าห้นิ�กเม��อเริ่��มขนิาดของยาให้�ตามนิ��าห้นิ�กเม��อเริ่��มต�นิริ่�กษาต�นิริ่�กษา

Drug Daily dose (mg)

30-39 kgs 40-49 kgs 50 kgs up

INHRMPPZAEMBSM

300300

1000800500

300450

15001000750

300600

200012001000

ผลข�างเคี�ยงจากการิ่ใช�ยาริ่�กษาวั�ณโริ่คี

INH : hepatitis, neurotoxicity paresthesia Rx pyridoxin (Vit B6 )5-10 มก./ว�น, Pellagra-like syndrome, Skin rashes

RMP : hepatitis, Flu syndrome, Cutaneous syndrome, ป็6สัสัาวะ อ(จจารืะ น-.าล้าย เสัมหะ น-.าตา แล้ะเหง��อม"สี�สี�ม, dyspnia,

shock PZA : hepatitis**, Hyperuricemia, Hypersensitivity reaction,

anorexia, nausea, vomiting EMB : optic neuritis, red-green colour blindness,

Hyperuricemia SM : vestibular damage, renal toxic, Hypersensitivity reaction

สี%ตริ่ยาในิผ%�ป่'วัยที่��แพ้�ยา 2 HRE/7 HR หรื�อ 2 HRZE/6 HE หรื�อ 2 HES/10-16 HE หรื�อ 2 HEO/10-16 HE หรื�อ 2 OES/10-16 OE หรื�อ 2 HTS/10-16 HT หรื�อ 12 HE หรื�อ 12 HT หรื�อ

23.Constipation 23.Constipation

Definition : < 3 per week

24.Hemophilia24.Hemophilia

A : FVIII , B : FIX - X linked recessive inheritance

Sex of affected : males only usually All affected males must be related

through female relatives

- X linked recessive- X linked recessive inheritance inheritance

พ้�อเป็�นโรืคพ้�อเป็�นโรืค

X’Y XX

X’X X’X XY XY แนะน-าให�ม"ล้�กชาย

แม�เป็�นพ้าหะแม�เป็�นพ้าหะ

X’X XY

X’X X’Y XX XYแนะน-าให�ม"ล้�กสัาว

25.Melioidosis 25.Melioidosis

Gram –ve bipolar staining (safety pin) Route of infection : หายใจ ผู้�วหน�ง เล้�อด ก�น Risk : DM cirrhosis CKD thalassemia immunocompromized (steroid,CMT) Infection form : pneumonia , hepatosplenic

abscess (multiloculated microabscess) Dx C/S ,melioid titer >1:160 or 4 fold Rx : initial→ Ceftazidime ± bactrim 2 wk

maintain→ bactrim + doxy 20 wk

27.Metabolic syndrome27.Metabolic syndrome

Definition Increased waist circumference

Male > 90 cm , female > 80 cm

plus 2 of the followingTriglycerides >150 mg/dL HDL <40 in men or <50 mg/dL in womenBP > 130/85FPG >100 mg/dL

ObesityObesity

Definition (asia)Under wt BMI < 18.5Normal 18.5-22.9Over wt ≥ 23 -24.9Obesity ≥ 25

28.Chronic cough28.Chronic cough

DDxPost nasal dripping and postviral bronchitisAsthmaBronchiectasisChronic bronchitisChronic infection : TBCA lungDrug : ACEI

29.Hypocalcemia29.Hypocalcemia

Trousseau's sign induction of carpal spasm by

sphygmomanometer above SBP for 3 min

Chvostek's sign contraction of the ipsilateral facial muscles

elicited by tapping the facial nerve just anterior to the ear

The EndThe End