unmanned iM

proximal muscle weakness

Stretch marks (classically purple abdominal striae

Hirsutism

depression

osteoporosis

insulin resistance, polyuria,

dyslipidemia

weight gain- central obesity, moon facies

secondary HTN

hyper - cortisol / cushing

symptom not seen in primary hypercortisolism

hyper pigmentation; seen in secondary

labs; cushing

BMP; Na, K, metabolic alkalosis

Blood glucose

serum cholestrol and triglycerides

urine free cortisol

low dose dexamethasone

serum cortisol

plasma ACTH level

CT/ MRI; adrenal or pituitary

why is cortisol checked at night

In healthy individuals, cortisol levels are low at night.

In Cushing's syndrome, this diurnal rhythm is lost, and cortisol remains inappropriately elevated at night.

"Cushing disease" refers specifically to

secondary hypercortisolism that results from excessive production of ACTH by pituitary adenomas.

Rx of cushing disease

Control hypertension (e.g., ACE inhibitors, calcium channel blockers)

Treat hyperglycemia (e.g., insulin, metformin)

Prevent/treat infections (risk ↑ due to immunosuppression)

Electrolyte correction: hypokalemia common in ectopic ACTH syndrome → give K⁺ and spironolactone

Osteoporosis treatment: bisphosphonates, calcium, vitamin D

first line(ACTH-independent) - adrenalectomy + steorid replacement

Cushing disease (ACTH-producing pituitary adenoma) - Bilateral adrenalectomy

Ectopic ACTH production; Common sources: small cell lung cancer, carcinoid tumors Locate and resect the tumor

Ketoconazole, Pasireotide, osilodrostate

causes of cushing

most common - prolonged glucorticoid therapy

adrenal adenoma, carrcinoma (primary/ acth independent)

pitutary adenoma; cushing disease

ectopic acth; paraneiplastic syndrome, small cell lung caricnoma, lung endocrine tumor, pheocromocytoma

what causes bilateral adrenal ATROPHY in cushing

excess glucocorticoid use

primary hypercortisolism casues

atrophy of contralateral gland

cushing disease/secondary causes

bilateral adrenal HYPERPLASIA

hypocortisolism is called

hypercortisolism is called

addisons

cushing

causes of addison

1. Autoimmune destruction

2. Infection (TB)

2. adrneal hemorrage; (Waterhouse-Friderichsen syndrome), sepsis, DIC

4. Mets to adrenal gland

5. adrenalectomy

6. sudden discontinuation of chronic glucocorticoid therapy

7. hypopituitaryism

symptoms of addison

Hypoaldosteronism

Hypotension

Salt craving

hypocorti; weigh loss, fatigue, GI issues, orthostatic hypotension

elevated ACTH > hyperpigementation

adrenal gland secretes

aldosterone,

cortisol,

epinephrine, norepinephrine

androgen

labs; addison

BMP

Na ↓, K ↑,

blood glucose; Hypoglycemia

morning cortisol

morning ACTH

short ACTH stimulation test

plasma renin (high cause aldost is low)

CXR; TB

MRI; pituitary

CT/MRI; adrenial gland

Rx. addison

Primary adrenal insufficiency: Replace

Glucocorticoids (e.g., hydrocortisone)

Mineralocorticoids (e.g., fludrocortisone)

± Androgens (e.g., DHEA, if needed)

100mg IV bolus of hydrocortisone is the first line for glucocorticoid replacement. not available, dexamethasone

intravenous saline & glucose

(fluid replacement) - then maintenance hydrocortisone & adequate saline intake oral

Secondary/Tertiary adrenal insufficiency: Replace

Glucocorticoids only

Stress-dose steroids: Increase glucocorticoids during illness/surgery to prevent adrenal crisis

Sick day rule: Double/triple glucocorticoid dose during stress/illnes

complication; addison

adrneal crisis

chronic fatigue

electrolyte distrubance

inferitlity adn menstrual irregularities

Fatigue, decreased physical activity,

cold intolerance, decreased sweating,

hair loss (Queen Anne sign),

brittle nails, cold dry skin,

weight gain despite poor appetite, constipation,

bradycardia,

puffy appearance

hoarse voice,

Hypo-thyroidism

Labs; hypothyoridism

Thyroid function test;

TSH, Free T4 and T3

Anti-thyroid antibodies (for autoimmune causes):

· Anti-thyroid peroxidase (anti-TPO) - hashimoto

· Anti-thyroglobulin antibodies - hashimoto

Lipid profile CBC

BMP

Creatine kinase:

Prolactin

Serum cortisol

Imaging; Thyroid ultrasound , nuclear medicine thyroid scan

Complications of hypothyroidism

myxedema coma,

primary thyroid lymphoma,

Rx; hypothyroidism

Levothyroxine

Overtreatment can lead to symptoms of thyrotoxicosis; heat intolerance, tremors, Tachycardia; arrhythmias, Weight loss

Drugs that reduce levothyroxine absorption include PPIs, calcium salts, ferrous sulfate, and bile acid sequestrants

differential; hypothyroidism

Euthyroid sick syndrome, Goiter, Myxedema coma, Anemia, Riedel thyroiditis, Subacute thyroiditis

causes of hypothroidism

autoimmune (hashi)

postopartum

viral infection, de quervein

iatrogenic,

pituitary

hypothalamic

Heat intolerance,

excessive sweating,

weight loss despite increased appetite, frequent bowel movements,

pretibial myxedema,

onycholysis,

thyroid acropachy,

lid lag, lid retraction,

exophthalmos

tachycardia

atrial fibrillation

fine tremor, proximal muscle weakness (hyperthyroid myopathy),

gynecomastia, decreased libido, glucose intolerance, anxiety, restlessness, insomnia, hyperreflexia.

hyper thyroidism

Labs; hyper thyroidism

- Thyroid Function Tests

o TSH ↓ in primary hyperthyroidism

o Free T4 and Free T3 ↑

o Thyroid-stimulating immunoglobulin (TSI) - specific for Graves

o TSH receptor antibodies (TRAb) - confirms Graves disease

o Anti-TPO antibodies - positive in autoimmune thyroid disease

o Thyroglobulin levels - helps detect thyroiditis or exogenous hormone use

- CBC, Fasting glucose/HbA1c Serum cholesterol

- ECG - tachyarrhythmia or atrial fibrillation

- Imaging; thyroid ultrasound, radioactive iodine uptake scan, Nuclear medicine thyroid scan

Rx, hyperthyroidism

All symptomatic patients

> First-line: Propranolol (for hyperadrenergic symptoms)

> If contraindicated; Verapamil or Diltiazem

Antithyroid Drugs

Most patients: Methimazole

Thyroid storm / 1st trimester pregnancy: Propylthiouracil (PTU)

Radioactive Iodine Ablation (RAIA); Toxic MNG, toxic adenoma

> Graves / toxic MNG: Near-total or total thyroidectomy

> Toxic adenoma: Lobectomy

causes of hyperthyroidism

1. Graves disease - most common cause overall (autoimmune)

2. Toxic multinodular goiter

3. Toxic adenoma

4. Subacute thyroiditis (De Quervain) - painful, post-viral,

5. Silent/postpartum thyroiditis - painless, transient

6. Excess iodine

7. exogenous thyroid hormone intake

8. Struma ovarii - rare ovarian teratoma

9. TSH-secreting pituitary adenoma

10. Hypothalamic TRH-producing tumors -

complications of hyperthyroidism

atrial fibrillation

thyroid storm

eye complications / graves opthalmopathy

Diffuse bilateral reticulonodular shadowing in both lungs

Miliary Tuberculosis:

Differentials for Miliary TB

Atypical Pneumonia

Pulmonary edema

ARDS

clinical features of miliary TB

non specific

Lymphadenopathy

Hepatosplenomegaly

Low-grade fever with night sweats

Weight loss

Decreased appetite

Malaise

examination findings; TB

Consolidation: dullness on percussion, crackles

Cavitation: hyperresonance on percussion, amphoric breath sounds

lab; TB

Sputum AFB smear (Ziehl-Neelsen stain)

Sputum culture for Mycobacterium tuberculosis

Nucleic acid amplification test

CBC

ESR/CRP

LFTs

HIV test

Chest XRYA,

CT chest

PCR

Spine X-ray / MRI Spine; Pott's disease (vertebral TB)

biposy in sever cases

Rx. TB

2 months; RIPE

4 months; RI

Adjuvant treatment: pyridoxine to prevent vitamin B6 deficiency

RIPE for TB

RIPE": Rifampin, Isoniazid, Pyrazinamide, and Ethambutol

Complications; TB

ARDS

Empyema

Pneumothorax

Disseminated tuberculosis infection (including tubercular meningitis)

Bronchiectasis

Aspergilloma

Hemoptysis

Mediastinal shift to the opposite side

Depressed diaphragm on affected side

Hyperlucent (dark) hemithorax on the affected side

no bronchovascular markings

Tension Pneumothorax

Rx. pneumothorax

Immediate Needle Decompression; 2nd / 5th intercostal space, midclavicular line

Chest Tube (Tube Thoracostomy); 4th or 5th intercostal space, mid-axillary line

Oxygen supplementation

IV fluids if hypotensive

Monitor vitals and repeat chest X-ray to confirm lung re-expansion

complications; penumothorax

Complete pulmonary collapse → respiratory failure

Tension pneumothorax → cardiac failure

Hemothorax

Pneumomediastinum

Pneumoperitoneum

examinations findings; pneumothorax

Reduced or absent breath sounds

Hyperresonant percussion

Decreased tactile fremitus

Reduced chest expansion

Distended neck veins

Bilateral hilar lymphadenopathy is seen

Sarcoidosis (classic cause)

Tuberculosis

Lymphoma

Fungal infections (e.g., histoplasmosis)

Silicosis

Other granulomatous diseases

labs; sarcoidosis

CBC and differential

ESR, CRP

CMP (including calcium levels)

Urinalysis

Serum ACE levels

Chest X-ray

High-resolution CT (HRCT)

Pulmonary function tests (PFTs)

Bronchoalveolar lavage (BAL)

Tissue biopsy (gold standard)

first line treatment; sarcoidosis

Observation: For asymptomatic or mild cases, especially Stage I.

Corticosteroids: First-line for symptomatic or progressive disease.

Supportive care: Treat organ-specific complications (e.g., supplemental oxygen for lung involvement).

What is the most common causative organism of lobar pneumonia?

Streptococcus pneumoniae.

pathophysiological stages of lobar pneumonia.

Congestion, red hepatization, gray hepatization, resolution.

Homogeneous consolidation confined to one or more lobes with air bronchograms.

chest X-ray findings in lobar pneumonia.

lab; pneumonia

CBC (leukocytosis)

CRP

ESR

Serum procalcitonin (PCT)

Blood cultures

Sputum culture and Gram stain

Imaging

Chest X-ray (posteroanterior and lateral)

Chest CT (usually without contrast)

Bronchoscopy (for suspected mass, pathohistology, inconclusive CT, poor treatment response)

how to decide for hospitalization of pneumonia

CURB 65

CURB 65

Confusion (disorientation, impaired consciousness)

Serum Urea > 7 mmol/L or BUN > 20 mg/dL

Respiratory rate ≥ 30/min

Blood pressure: systolic BP ≤ 90 mm Hg or diastolic BP ≤ 60 mm Hg

Age ≥ 65 years

CURB-65 score 0 or 1: The patient may be treated as an outpatient.

CURB-65 score ≥ 2: Hospitalization is indicated.

Rx. pneumonia

Outpatient (no comorbidities)

Amoxicillin or doxycycline or macrolide (e.g., azithromycin)

Outpatient (with comorbidities)

Amoxicillin-clavulanate + macrolide

OR respiratory fluoroquinolone (e.g., levofloxacin)

Inpatient (non-ICU)

IV ceftriaxone or cefotaxime + azithromycin

OR respiratory fluoroquinolone

ICU

Ceftriaxone + azithromycin or fluoroquinolone

Consider coverage for MRSA or Pseudomonas if risk factors

Oxygen therapy, 45 sitting degree postion , parentral antipyertics, analgesics, antibiotics acc to type of

Bronchodilators if wheezing antimucolytics (inccase of SOB exces sputum, mucolytics)

most common cause of atypical pneumonia in young adults?

Mycoplasma pneumoniae

first-line treatment for atypical pneumonia?

Macrolides (e.g., azithromycin) or doxycycline

Cavity with air fluid level

Lung abscess

Tuberculosis (especially reactivation TB)

Necrotizing pneumonia (due to Klebsiella, S. aureus, Pseudomonas)

Fungal infections (e.g., Aspergillus, Histoplasma)

Malignancy

causes of lung abscess

anaerobic bacterial infection

aspiration

bronchial obstruction

immunosupression

fungal infection

recent/unresolved pneumonia

Rx. lung abscess

Empiric Antibiotic Therapy

no risk factors for MRSA:; Ceftriaxone + Metronidazole

If MRSA suspected: Vancomycin

nterventional Therapy; Percutaneous drainage, Surgical resection

chest xray findings; pleural effusion

Large Homongenous (since its big ) opacity in the middle and lower lobes of right lobe

Blunted costophrenic border in the right side

Silhouette sign

meniscus sign

labs; pleural effusion

Serum protein LDH

blood culture

xray

ct

pleural fluid analyisis via thoracocentesis

how to differentiate pleural effusion type

lights criteria

Light's criteria

Pleural Effusion is likely EXUDATIVE if atleast ONE of the following exists:

1. Pleural Protein : Serum Protein > 0.5

2. Pleural LDH : Serum LDH > 0.6

3. Pleural LDH is > 2/3 the upper limits of normal for serum

Transudative causes of pleural effusion:

Congestive heart failure

Hepatic cirrhosis

Nephrotic syndrome

Protein-losing enteropathy

Chronic kidney disease (Na+ retention)

Exudative causes of pleural effusion

infection. *parapneumonic)

empyema

malignancy

PE

Autoimune disease; sle

trauma

pancreatitis

Rx; pleural effusion

Treatment of the underlying cause [6]

Acute congestive heart failure: loop diuretics

thoracocentesis

low glucose (less than 60) pleural effusion

MEAT has low glucose: Malignancy, Empyema, Arthritis (rheumatoid pleurisy), and Tuberculosis

causes of Cloudy, milky effusion

Chylothorax

Pseudochylothorax

causes of purulent effusion

Parapneumonic effusion

Empyema

•Pleural fluid lymphocytosis suggests

TB, sarcoidosis or malignancy.

•Neutrophil dominant effusions are associated with

empyema or pulmonary embolism.

how to classify effusion/ascites based on LDH

LDH less than 225 U/L = transudate

LDH > 225U/ L = exudate

Serum ascitic albumin gradient (SAAG);

measures portal pressure to determine if ascites is due to portal hypertension ;

SAAG = (serum albumin) – (ascitic fluid albumin)

Diagnostic tools for ascites include

ultrasound, paracentesis, ascitic fluid analysis, fluid culture

Aspirated ascitic fluid ; clinically detectable until there are at least -- mL of fluid present.

500

Clinical features; ascites

{Abdominal distension, discomfort, Weight gain, Shortness of breath, Reduced appetite

Rx. ascities

aspirate, gram stain, culture, empiric, broad-spectrum antibiotics immediately after peritoneal fluid is obtained, till culture results become available

Diuretics

Monotherapy with spironolactone

Combination therapy with spironolactone PLUS furosemide

paracentesis