Causes of Urgency

-bacterial prostatitis (infection of the prostate)
-BPH (benign prostatic hyperplasia) where the prostate gets enlarged
-bladder cancer & bladder infections
-medication induced
-constipation
-incontinence

Constipation

Constipation

Diabetes

Diabetes

This is a very common condition that can be dangerous if not managed properly.  Here, we discuss the 2 main types of diabetes that involve regulation of blood sugar.

Type II Diabetes::

This is the more common type. There is no problem with making insulin.
Cause: Cells become resistant to insulin so you need more insulin to have the same effect.
Treatment: People with type II may be treated by simple weight loss, diet, and exercise (which will increase sensitivity to insulin), drugs that help your body secrete more insulin (like Metformin), and even insulin itself (in severe cases).

Type I Diabetes::

This is a more rare diabetes. It's a problem with making enough insulin.
Cause: The cells that make the insulin (beta cells of islets of langerhans in pancreas) are destroyed -- by an autoimmune process.
Treatment: People with type I are dependent on insulin injections.

Type I and type II fall under diabetes Mellitus.  Diabetes insipidus is a deficiency in Antidiuretic hormone and results in excessive dilute urination and has nothing to do with insulin.

Human Immunodeficiency Virus (HIV)

Human Immunodeficiency Virus

Pathogenesis -- HIV-1 infects lymphocytes with the CD4 marker.  CD4 lymphocytes are involved in cell-mediated immunity and their depletion also impairs B-cell activation.  --> AIDS

Transmitted by sexual contact, IV drug use, breast-feeding, needle-stick injuries

Clinical Manifestation:::
Acute HIV infection:  fever, fatigue, rash, headache, lymphadenopathy, pharyngitis, myalgia, GI upset, night sweats, aseptic meningitis, oral&gential ulcers.  within days to weeks after exposure.
Prolonged Asymptomatic Period:  body makes antibody to the virus in 3-4 weeks and enters a period with no symptoms (up to 12 yrs) but the HIV-1 RNA and antibody levels can be measured.
AIDS: immune deficiency, high levels of the virus, opportunisitic infections.

Physical Examination:
-look for weight changes, skin lesions (signs of opportunistic infections), fever.
-weight loss of more than 10%
-Pneumocystis carinii pneumonia most common cause of fever.  patients may have normal lung function even with active infection.
-Opportunistic infections:  sinusitis, oral thrus, CMV retinitis, toxoplasmosis, cryptococcal meningitis, Kaposi sarcoma, psoriasis, seborrheic dermatitis, molluscum contagiosum, herpes zoster

Diagnostic::
1) ELISA (enzyme-linked immunosorbent assay) & Western blot test. 
-a positive ELISA should be followed up with a Western  blot test which will react with 2/3 different antigens.  It is inacurate in first 3-4 weeks after HIV exposure.
2) PVL (plasma viral load): can detect as early as 11 days.  can determine the stage of disease by looking at CD4 count and PVL.

Treatment::
-Asymptomatic & CD4 count is above 350/mm³: don't treat it
-Asymptomatic but CD4 count is less than 350/mm³ or PVL is elevated (30k copies/mm³ by B-DNA or 50k copies/mm³ by PCR): retroviral therapy

-3 types of drugs:  NRTIs (nucleoside reverse transcriptase inhibitors), PIs (protease inhibitors), nNRTIs (nonnucleoside reverse transcriptase inhibitors).
-Regimen of 3 total drugs:  2 NRTIs (zidovudine+didanosine OR zidovudine+lamivudine) + 1 PI (indinavir) or 1 nNRTI (efavirenz)

- for pregnant mothers, C-section and Zidovudine therapy can reduce incident in child.  Babies will have positive test (Immunoglobulins cross placenta) and should be given ziduvidine for at least 4-6 wks with repeat tests every month until 2 negative tests.

Hypertension

Hypertension: 140/90 on 2 consecutive visits 2 weeks apart.
I. Primary (essential)
II. Secondary (exogenous substances, renal failure, sleep apnea, renovascular disease, primary aldosteronism, pheochromocytoma, Cushing syndrome)

• Onset of HTN befor 20 y.o. or after 50 y.o.
• hx of tachycardia, sweating, headache
• personal or family hx of renal disease
• HTN that is resistant (in a compliant patient)
• symptoms indicating sleep apnea
• drug use: amphetamine, cocaine, alcohol abuse
• medication use: oral contraceptives, estrogens, corticosteroids, NSAIDs
• hx of hirsutism or easy bruising

Lymphadenopathy

Lymphadenopathy:  enlarged lymph nodes (generally larger than 1 cm).  for inguinal, its larger than  1.5 cm.  for epitrochlear  (located above the elbow cease on the medial side), its larger than .5 cm.

How do lymph nodes get enlarged? 
3 main ways:
1) reactive hyperplasia (cells in the lymph node react to an antigen / inflammation)
2) cells in the lymph node transform
3) malignant cells invade the lymph node

HISTORY:

• 2 main types of lymphadenopathy:  regional and generalized
• if regional: ask about regional symptoms (ex: cervical --> any pharyngeal symptoms, dental problems, hoarseness?)
• if generalized:  could be a number of things (infection, immunologic, metabolic, malignant); is often associated with splenomegaly
• fever, weight loss --> cancer, systemic infection, connective tissue disease
• rashes, arthralgias, pharyngeal symptoms, pet exposure --> connective tissue disease, viral illness, cat scratch fever
• contact with sheep --> brucellosis
• location --> coccidioidomycosis (west texas, desert west), histoplasmosis (mississippi river valley)
• animal bites --> Franciesella tularensis (rabbits), Pasteurella (domestic pet bites).

PHYSICAL EXAM:

• malignant:  hard, fixed, nontender, greater than 3 cm
• infectious: warm, erythematous, fluctuant
• reactive: discrete, rubbery, mobile
• red streaks from an inflammed node --> lyphangitis and lymphadenitis

Diagnosing:

• most are self-limited / benign
• can do monospot or strep screen to start, CBC, serology
• if supraclavicular --> can be serious and may need to do a biopsy
• supraclavicular or pulmonary symptoms --> chest xray
• various titers: EBV, toxoplasomosis, CMV,
• other serologic tests:  HIV antibodies, ANA, rheumatoid factor
• inguinal:  can do urethral or cervical cultures
• unusual cases (bites):  blood cultures
• US, CT, MRI can be done later on to delineate involved area
• anemia, thrombocytopenia, malignant cells on peripheral smear --> bone marrow examination

 Treatment:

• Cat scratch:  TMP/SMX
• Atypical mycobacteria: surgical excision + antituberculosis meds (Isoniazid, Rifampin, ethambutol)
• Lymphadenitis: treat with antibiotics that take care of strep and staph (Cephalosporin, Erythromycin, Dicloxacillin)
•  

Proteinuria

Proteinuria: defined as more than 150 mg/24 hrs. 
-With nephrotic proteinuria, its more than 3.5 g / 24 hrs.
-normally, 100mg/mL can show up on the UA (trace proteinuria) but is considered normal.

Pathogenesis: can result from problems with...
-filtration:  glomerular diseases, function proteinuria (fever, seizures, surgery, CHF)
-resorption:  renal tubular diseases
-overflow proteinuria (bence-jones proteins in multiple myeloma):  production of abnormal proteins that can't be resorbed.

Type of protein in urine:
Glomerular disease --> albumin
Tubular disease --> low-molecular-weight proteins
Multiple myeloma or monoclonal gammopathy --> plasma proteins

Red Eye

Red eye -- very common and can be usually be treated by Family physicians except if life threatening (corneal ulceration, iritis, and glaucoma).\

Infections or occlusion: 
Internal Hordeolum--  infection of meiboian glands:

Sty (External Hordeolum):  infection of the gland of Zeis (the glands of eye-lashes).
Chalazion -- sterile inflammation of the meiobian glands
Blepharitis -- infection, inflammation, and scaling of the eyelid margins
Dacryocystitis -- occlusion of the nasolacrimal duct
Orbital or Periorbital cellulitis -- can spread from sinusitis
Iritis or Glaucoma -- from hyperemia of ciliary vessels
Subconjunctival Hemorrhage -- bleeding the small fragile vessels of the conjunctiva in response to minor trauma or straining.
 

Shortness of Breath (Dyspnea)

Causes of Dyspnea::

Acute:
-pneumonia (elevated WBC)
-MI (ST-segment changes on ECG)
-PE
-acites
-kyphoscoliosis
-obesity

Chronic:
-asthma (normal O2)
-COPD (smoker, barrel-chested, hyperinflation on xray)
-CHF (swollen legs/peripheral edema, murmurs, S3, pulmonary edema on xray, Elevated BNP)
-angina (will have chest pain, ST segment changes)
-PE (may have a swollen leg)
-anemia (signs of bleeding -- melena, uterine bleeding)
-anxiety (perioral numbness, stress, paresthesias)

more common in kids:
-upper airway obustrciton (foreign-body aspiration)
-asthma
-respiratory tract infections (pneumonia, bronchiolitis)

Shoulder Pain

Shoulder Pain -- more common in middle to older age people.

Treating Pneumonia

Treating Pneumonia

Some cases will need to be hospitalized: (just think of messed up vital signs, comorbidites, etc.)
-systolic pressure < than 60
-pulse > than 140
-PO2 < than 90% or 60 mmHg
-presence of an abscess or pleural effusion
-metabolic abnormalities
-other diseases also present: CHF, renal failure, malignancy, diabetes mellitus, COPD
-is oder than 65 y.o.
-social situation messed up
 

IF patient does not need to be hospitalized, you can give antibiotics::
Less than 60 y.o. and healthy adult: (young people EAD a lot)
-erythromycin
-azithromycin
-doxycycline
Over 60 y.o.: (old ppl listen to FM radio and are from a 2nd generation)
-fluoroquinolone
-macrolide
-2nd generation cephalosporin
Children (2 months - 5 yrs)  (little kids on high doses of sugar like to mock .. amox)
-high dose amoxicillin
Older children:  (macro = big = older kids growing up feeling big)
-macrolide

Vaccines