UDAN Concepts: Medical and Surgical

Congestive Heart Failure

● Right-sided CHF (RCHF)
- Venous back-up
- Systemic manifestations

● Left-sided CHF (LCHF)

- Pulmonary edema (Left-lungs)
- Cellular hypoxia
- RAAS activation (HPN, hypoK+)

Anemia

Different Types of Anemia

● Iron deficiency Anemia (IDA)
● Folate Deficiency Anemia
● Pernicious anemia
● Aplastic Anemia
● Thalassemia

Signs and Symptoms of Anemia:

 Signs & Iron Folate Pernicious Aplastic Thalassemia
Symptoms Deficiency Deficiency

Macrotic, ✔ ✔
Normochromic
anemia

Pancytopenia ✔

Microcytic/ ✔
Hypochromic
anemia

Cheilosis ✔

Beefy red tongue ✔

Koilonychia ✔

Intrinsic factor ✔
deficiency

Abnormal hgb,
short lifespan of ✔
rbc

Cyanocobalamine
deficiency ✔
(B12)

Vinson- Plummer’s ✔
Syndrome

Iron overload ✔
 Arterial/ Venous Insufficiency

● Arterial Insufficiency
- Low/ no oxygen in the legs

● Venous Insufficiency
- Blood pooling in the legs

Signs/Symptoms Arterial Venous

Insufficiency Insufficiency
(blood pooling)

Elevation of legs relieves edema ✔

Absence of pulse ✔

Thin, shiny, hypopigmented skin in ✔

the legs
Thickened, hyperpigmented skin in ✔
the legs

Ulcers in the toes ✔

Edema ✔

Cold, cyanotic skin in the leg ✔

Ulcers at the ankle ✔

Warm, reddish skin in the leg ✔

Leg pain on walking ✔

(intermittent claudication)

Lowering of legs improves blood flow ✔

Gangrene develops ✔
Leg pain relieved by walking ✔
Intermittent claudication ✔

Calf pain (Homan’s sign) ✔

Thrombophlebitis ✔

Raynaud’s disease ✔

Aneurysm ✔

Breath sounds
A. Vesicular E. Crackles
B. Bronchovesicular F. Rhonchi
C. Bronchial G. Stridor
D. Wheeze H. Pleural friction rub

Description Breath Sounds

1. Rustling like the sound of wind in the Vesicular

trees
2. Harsh, hollow, tubular Bronchial

3. Heard over mainstem bronchi Bronchovesicular

 4. Burst of popping bubbles Crackles

5. High- pitched hissing/ musical sound Wheeze

on expiration

6. Heard over trachea Bronchial

7. Low- pitched musical sound on Rhonchi

inspiration

8. Musical wheeze over trachea Stridor

9. Sounds like 2 pieces of sandpaper Pleural friction rub
rubbing together
10. Heard at the periphery, apex, and Vesicular
base of the lungs
11. Inspiration longer than expiration Vesicular
12. Inspiration equals expiration Bronchovesicular

13. Inspiration shorter than expiration Bronchial

SIADH/ Diabetes Insipidus (D.I)

➢ SIADH (Syndrome of Inappropriate ADH)
- Water retention
- Low serum sodium (dilutional hypoNa+)
➢ Diabetes Insipidus (D.I.)
- Water loss

ADH (Vasopressin)
- Retains water in the renal tubules
- vasoconstriction

➔ Hypersecretion: SIADH
➔ Hyposecretion: D.I.

Osmolarity
- Concentration of fluids
- High osmolarity - concentrated (less water)
- Low osmolarity - dilute (more water)
 ➔ Blood: Urine (opposite direction)
↓ dilute ↑ concentrated
↑ concentrated ↓ dilute

Urine SP GR (1..010 - 1.025)

● High SP GR - Urine is CONCENTRATED
- (1.03 and above)
● Low SP GR - Urine is DILUTE
- (1.001 and above)

SIGNS/SYMPTOMS SIADH D.I.

1. Urine output= 4 to 6 L/ day ✔

2. Highly- colored urine ✔

3. Urine specific gravity= 1.050 ✔

4. Weight gain ✔

5. Weight loss ✔

6. Dehydration ✔

7. Serum sodium = 120 mEq/L ✔

8. Constipation ✔
9. Fluid intake= 4L/day ✔

10. Low urine specific gravity ✔

11. Hemoconcentration ✔

12. Low hematocrit ✔

13. Polydipsia ✔

14. Hypertension ✔

15. Pulmonary edema ✔

 16. Decreased blood osmolarity ✔

17. Water intoxication ✔

18. Water- like urine ✔

19. Growth retardation ✔

20. Urine sp gr = 1.004 ✔

Hyperthyroidism/Hypothyroidism

❖ Hyperthyroidism
- Everything is high, fast and wet
- Eye manifestations
- Hypocalcemia
↑ T3 ↑ Metabolism
↑ T4 ↑ Body heat production
↑ Thyrocalcitonin

Eye manifestations
➔ Exophthalmos
➔ Von graefe’s sign (lid lag)
- Pt looks down - long & deep palpebral fissure
➔ Jeffrey’s sign
- Pt looks up, forehead remains smooth
➔ Dalyrimple’s sign (thyroid stare)

❖ Hypothyroidism
- Everything is low, slow, and dry
- hypercalcemia
↓ T3 decreased metabolism
↓ T4 decreased body heat production
↓ Thyrocalcitonin = hypercalcemia

Thyroid gland
1. T3 (Triiodothyronine)
- Metabolism, growth
 2. T4
- Catabolism, body heat production
3. Thyrocalcitonin
- Regulates serum Ca levels

● Thyrocalcitonin: Serum Calcium (opposite direction)

↑ hyperthyroidism ↓ hypoCa+
↓ hypothyroidism ↑ hyperCa+

BMR (BASAL METABOLIC RATE)

● Normal (euthyroid)
+20% to -20%
● ↑ +20% hyperthyroidism
● ↓ -20% hypothyroidism

Antithyroid drugs
● Tapazole
● PTU
● Lugol’s solution
Taken on full stomach
Start with HIGH dose then gradually taper

Thyroid Preparations
● Synthroid
● Cytomel
Taken on empty stomach
Start with LOW dose, then gradually increase
Check pulse rate and BP before administration

Signs and symptoms:

Signs/symptoms Hyperthyroidism Hypothyroidism

1. Anorexia ✔

2. Cold intolerance ✔
3. Diarrhea ✔

4. Fatigue ✔

5. Obesity ✔

6. Exophthalmos ✔

7. Thin ✔

8. Restlessness, Nervousness ✔

9. Fine, oily hair ✔

10. Dry, sparse hair ✔

11. Serum Calcium= 12 mg/ dL ✔

12. Serum Calcium= 3.5 mEq/ L ✔

13. Fine tremors ✔

14. Lid lag ✔

15. Pulse rate= 55 to 60 bpm ✔

16. BP= 140/90 to 159/ 94 ✔

mmHg

17. Serum cholesterol= 280 ✔

mg/dL

18. Thickened, hyperpigmented ✔

skin in the pretibial area

19. Dry, scaly skin ✔

20. Diarrhea ✔

21. Sweaty skin ✔

22. tachycardia ✔

23. Slow physical and mental ✔

reaction
24. Hypercalcemia ✔

25. Elevated body temperature ✔

26. BMR = (-)30 % ✔

27. Treated with Synthroid ✔

28. Treated with Tapazole ✔

29. Treated with PTU ✔

30. Treated with Lugol’s ✔

solution

31. Dull look ✔

32. Exophthalmos ✔

33. Von Graefe’s sign ✔

34. Jeffrey’s sign ✔

35. Dalyrimple’s sign ✔

36. Treated with Cytomel ✔

37. Requires high calorie diet ✔

38. Requires low fiber diet ✔

✔
39. Requires cool, quiet
Environment

40. Requires warm environment ✔

during cold climate

41. Tendon of Achilles Reflex ✔

(+1)
 ❖ Hyperparathyroidism
- Everything is low and slow except BP (BP is high)
- Hypercalcemia, hypophosphatemia

Hyperparathyroidism/Hypoparathyroidism

❖ Hyperparathyroidism
- Everything is low and slow except BP (BP is high)
- hypercalcemia , hypophosphatemia

❖ Hypoparathyroidism
- Everything is high and fast except BP (BP is low)
- Hypocalcemia, hyperphosphatemia

Calcium - Regulates cell membrane permeability

 Hypocalcemia
↓
Increased cell membrane permeability
↓
Increased neuromuscular irritability
(Everything is HIGH & FAST except BP)

Hypercalcemia
↓
Decreased cell membrane permeability
↓
Decreased neuromuscular irritability
(Everything is LOW & SLOW except BP)

Hypercalcemia
● Polyuria → polydipsia
● Dehydration
● Urinary stones
● Fracture

Hypoparathyroidism
● Hyposecretion of PTH
● Hypocalcemia
● Hyperphosphatemia

Hypothyroidism & hypoparathyroidism

● Dry skin
● Dry hair
● Brittle nails

Signs/Symptoms Hyperparathyroidism Hypoparathyroidism

Hypercalcemia ✔

Hypocalcemia ✔

Dry, scaly skin ✔

Dry, brittle hair and nails ✔

Muscle cramps ✔

Muscle weakness ✔

Hypophosphatemia ✔

Low BP ✔

Seizures ✔

Increased urine output ✔

Polydipsia ✔

Tingling lips, fingers, toes ✔

Fracture of long bones ✔

+ Chvostek’s ✔

+ Trousseau’s ✔

Hypertension ✔

Laryngospasm ✔

Types of diabetes:
❖ Type I
❖ Type II

Signs and symptoms:

Type 1 Type 2

Lifelong insulin therapy Associated with heredity

Brittle DM/ Unstable DM ketosis - resistant

Prone to DKA Treated with oral hypoglycemic

agents (OHA)
 Thin Obese

Occurs among children Prone to HHNC

Onset before age 30 years Associated with obesity

Associated with autoimmune Pancreas secretes insulin but

disorders demands are increase

Insulin Dependent Non-insulin Dependent

Absence of Islets of Langerhans

Best managed with diet, activity,

exercise, insulin

Hyperglycemia/ Hypoglycemia

❖ Hyperglycemia
- 3P’s
- Dehydration (due to polyuria)
- ketoacidosis

❖ Hypoglycemia
1. Decrease glucose supply to the brain
2. SNS stimulation
3. Feeling hungry

Signs and symptoms:

Signs/Symptoms Hyperglycemia Hypoglycemia

Blurred vision ✔

Headache, dizziness ✔

Pallor, diaphoresis ✔

Urine output 300mls/hour ✔

Acetone odor of breath ✔

Fluid intake 4L/day ✔

Kussmaul’s breathing ✔

Cold, clammy skin ✔

Sunken eyeballs ✔

Restlessness ✔

Excessive hunger ✔

Weakness, shakiness ✔

Faintness ✔

Urine (+) for glucose and ketones ✔

pH = 7.31, HCO3 ✔

Hunger pangs ✔

Yawning ✔

Blood glucose ✔

Warm, flushed, dry skin ✔

Inability to concentrate ✔

Hypokalemia ✔

Needs insulin ✔

Needs glucose ✔

Memory lapses ✔

Urine (+) for glucose and ketones ✔

 Fruity odor of breath ✔
(ketoacidosis)

Polydipsia ✔

Polyphagia ✔

Addison’s Disease/ Cushing’s Disease

★ Addison’s Disease
- Everything is low except K+, Ca+, pulse rate
- Dark skin
★ Cushing’s Disease
- Everything is high except K+, Ca+, pulse rate

Adrenal Glands
★ Adrenal cortex - secretes hormones that regulate the 3s
➔ SUGAR - glucocorticoid
➔ SALT - mineralocorticoid (e.g. Aldosterone)
➔ SEX - estrogen, testosterone

★ Adrenal Medulla - secretes catecholamines (Epinephrine and

Norepinephrine)

Similar manifestations of Hypok+ and Hyperk+

● Anorexia
● Nausea and vomiting
● Muscle weakening
● Fatigue
● Paralysis
● Dysrhythmias
● Renal damage
 Effects of adrenal cortex hormones/ Signs and symptoms of
cushing’s disease/ Side effects of steroids

Cushing's disease BOTH Addison’s disease

Hypertension Loss of appetite Hypotension

Hypernatremia Fatigue Hyponatremia

Sodium & water Muscle weakness Eternal tan

retention (edema, appearance of the
weight gain) skin (DARK)

Loss of appetite to eat Nausea, vomiting Dehydration

Osteoporosis Hyperkalemia

Delayed/Poor wound Depression

healing

Obese trunk, thin Weight loss

arms & legs

Moon face

Thinning of scalp hair

Bradycardia

Hirsutism

Edema

Purple striae on the

abdomen

Hypoglycemia &
Hyperglycemia

Hirsutism in females

Hypocalcemia

Increased virilism in
 females

Gynecomastia in
males

Buffalo hump

Sex hormones imbalances

- Males: feminization
- (gynecomastia, decreased libido, impotence)
- Females: MASCULINIZATION
- (hirsutism, thinning of scalp hair, acne, increased virilism)
- Purple striae on the abdomen

Cranial nerves:
a. Olfactory g. Facial
b. Optic h. Acoustic
c. Oculomotor i. Glossopharyngeal
d. Trochlear j. Vagus nerve
e. Trigeminal k. Spinal accessory
f. Abducens l. Hypoglossal
signs/symptoms/tests

Signs/ Symptoms/ Tests Cranial Nerve

1. Blurred vision Optic (II)

2. Protrusion of the tongue Hypoglossal (XII)

3. Tic douloureux Trigeminal (V)

4. Vertigo Vestibular/ Acoustic (VIII)

5. Unequal pupils Oculomotor (III)

6. Papilledema Optic (II)

7. Rolling of the eyeballs Trochlear (IV)

8. Loss of sense of taste,anterior ⅔ of Facial (VII)

the tongue

9. Inability to shrug shoulders Spinal accessory (XI)

10. Loss of hearing Trochlear (IV)

11. Parasympathetic stimulation Vagus (X)

12. Loss of sense of smell Olfactory (I)

13. Dysphonia Glossopharyngeal (IX)

14. Ptosis of the eyelids, diplopia Abducens (VI)

15. Bell’s palsy Facial (VII)

16. Inability to smile and show the teeth Facial (VII)

17. Inability to stick out the tongue Hypoglossal (XII)

18. Loss of gag reflex Glossopharyngeal (IX)

Vagus (X)

19. Scotoma (blind spots in the visual field) Optic (II)

20. Slowing and slurring of speech Vagus (X)

(dysarthria)
Neuromuscular Disorders
a. Parkinson’s Disease (PD)
- Tremors, rigidity
b. Myasthenia gravis (MG)
- Muscle weakness
c. Multiple sclerosis (MS)
- Demyelination of CNS
d. Guilain Barre’ syndrome (GBS)
- Demyelination of the peripheral nervous system

Signs/ symptoms Disorders (PD, MG, MS, GBS)

Pill Rolling tremors PD

Muscle weakness associated with MG

activity

Ascending paralysis GBS

Tiptoe walking PD

Ataxic gait MS

Shuffling gait PD

Ptosis, strabismus, diplopia MG

Treated with levodopa PD

Treated with mestinon MG

Treated with cogentin PD

Bradykinesia PD

Cogwheel rigidity PD

Decreased dopamine production PD

Decreased acetylcholine receptor MG

sites

Resting tremors PD
 Intention tremors MS

Sticky skin PD

Positive tensilon test MG

Soft, monotonous voice PD

Scanning speech MS

Treated with baclofen MS

Treated with cholinergic MG

Treated with anticholinergic PD

Flattened affect PD

Stooped posture PD

Small, shaky handwriting PD

Associated with swine flu vaccine GBS

Bladder and bowel dysfunction MS

Chacot’s triad MS

Absence of arm swing when PD

walking

Lhermitte’s sign MS

Different types of Arthritis

● Rheumatoid
● Osteoarthritis (OA)
● GOUT
 RA (Rheumatoid ) OA (Osteoarthritis) GOUT

Autoimmune disorder Degenerative Metabolic disorder

disorder

More common in men = women; More common in

females obese males

Systemic inflammation Localized Localized

inflammation inflammation

Symmetrical affection Unilateral Unilateral

of joints

Synovial membrane Cartilage of joints

affected wear off (crepitus)

Joints of finger most Weight - bearing Big toe commonly

commonly affected joints most affected
commonly affected

Subcutaneous nodules Herberden’s nodes Tophi

Bouchard’s nodes

Pain on non-use of Pain-on-use of joints

joints
Morning stiffness

Sjogren’s syndrome
(excessive dryness of
eyes, mouth, vagina)

Felicity’s syndrome
(leukopenia-decreased
resistance to infection)
(splenomegaly-severe
hemolytic anemia)
Signs and Symptoms
Signs/ Symptoms Type of Arthritis
(RA, OA, GOUT)

Degenerative disorder OA

Metabolic disorder GOUT

Autoimmune disorder RA

Males more commonly affected GOUT

Females more commonly affected RA

Obese elderly commonly affected OA

Subcutaneous nodules RA

Localized inflammation OA and RA

Cartilage of joints wear off OA

Synovial membrane affected RA

Joints of fingers commonly affected RA

Weight- bearing joints most commonly OA
affected
Big toe commonly affected GOUT

Tophi GOUT

Bouchard’s nodes OA

Heberden’s nodes OA

Ulnar drift of the hand RA

Cock- up toe RA

Crepitus OA

Morning stiffness RA

Pain-on-use of joints OA
 Pain-on-nonuse of joints RA

Excessive dryness of eyes, mouth, and RA

vagina (Sjogren’s syndrome)

Leukopenia, splenomegaly RA
(Felty’s syndrome)

Hemolytic anemia RA

Elevated urine and serum uric acid GOUT

Unilateral affectation of joints OA and GOUT

Inflammation affects both side of the body RA

Sympathetic Nervous System/Parasympathetic Nervous System

● Sympathetic Nervous System (SNS)

- Everything is high and fast, EXCEPT GI and GU
SNS: Anticholinergic
- Beta agonists (ex. Bronchodilators)

● Parasympathetic Nervous System (PNS)

- Everything is low and slow, EXCEPT GI and GU
PNS: Cholinergic
- Beta Adrenergic blockers (ex. antihypertensive)

SNS PNS

Dilate: Dilate:
- Pupils - peripheral blood vessels
- Bronchial tree
- Coronary blood vessels Constrict:
Constrict: - Pupils
- peripheral blood vessels - Bronchial tree
- Coronary blood vessels
 Signs and symptoms:
SNS PNS

Peripheral vasoconstriction Peripheral vasodilation

Hypertension Hypotension

Tachycardia Bradycardia

Bronchodilation Bronchoconstriction

Dilatation of pupils Constriction of fluids

Constipation Diarrhea

Urinary retention Urinary frequency

Dryness of mouth, thirst Increased salivation

Hyperglycemia Hypoglycemia

Decreased peristalsis Increased gastric acid secretion

Pallor Wheezing

Increased heart rate Slow respiration

Increased respiratory rate

Cold, clammy skin Flushed skin

Increased force of myocardial Decreased cardiac output

contraction

Diminished bowel sounds

Diaphoresis

Abdominal distention

Elevated body temp

Coronary vasodilatation

Restlessness
 Signs and Symptoms SNS PNS

Restlessness ✔

Tachycardia ✔

Peripheral vasodilation ✔

Peripheral vasoconstriction ✔

Hypotension ✔

Hypertension ✔

Bradycardia ✔

Bronchoconstriction ✔

Bronchodilatation ✔

Dilation of pupils ✔

Constriction of pupils ✔

Diarrhea ✔

Constipation ✔

Urinary retention ✔

Urinary frequency ✔

Dryness of mouth, thirst ✔

Increased salivation ✔

Diaphoresis ✔

Pallor ✔

Cold, clammy skin ✔

Hypoglycemia ✔

Hyperglycemia ✔
 Increased gastric acid secretion ✔

Decreased peristalsis ✔

Wheezing ✔

Diminished bowel sounds ✔

Increased heart rate ✔

Increased respiratory rate ✔

Slow respiration ✔

Abdominal distention ✔

Elevated body temp ✔

Flushed skin ✔

Coronary vasodilation ✔

Increased force of myocardial ✔

contraction

Decreased cardiac output ✔

SNS: Anticholinergic
- Beta agonists (ex. Bronchodilators)

PNS: Cholinergic
- Beta Adrenergic blockers (ex. antihypertensive)
Answer Drugs/Conditions Antidotes

K 1. Morphine A. Mucomyst
(acetylcysteine)

B 2. Magnesium sulfate B. Calcium gluconate

B 3. Hyperkalemia C. Digibind

D 4. Beta adrenergic blockers D. Glucagon

 D 5. Calcium channel blockers E. EDTA

A F. Methadone
6. Acetaminophen poisoning
E 7. Lead Poisoning G. Disulfiram

I 8. Heparin H. Vitamin K

H 9. Coumadin I. Protamine sulfate

F 10. Opiate addiction J. Cholinergic

C 11. Digitalis toxicity K. Naloxone

G 12. Alcohol abuse L. At SO4

J M. Desferal
13. Myasthenic crisis
L 14. Cholinergic crisis N. Romazicon

N 15. Diazepam

M
16. Hemosiderosis

Critical thinking: Position

Situations/ Conditions Position

After thoracentesis, left lung Right side lying

After right modified radical Semi- Fowler’s, right arm abducted,

mastectomy elevated

Patient with COPD

Upright, leaning forward (orthopneic
position
During liver biopsy Left side- lying

After liver biopsy Right side- lying

Patient with increased ICP Semi- Fowler’s, HOB elevated at 15-

30 degree,maximum of 45 degree

After kidney biopsy Supine

After tonsillectomy Lateral

After pantopaque (oil-based) Flat/ supine

myelography

After metrizamide (water-based) Semi- Fowler’s

myelography

After UGI endoscopy Lateral/ side- lying

During colonoscopy Left lateral

After incisional cholecystectomy Semi- Fowler’s

Patient with MI Semi- Fowler’s

Patient with CHF High Fowler’s

Patient who had supratentorial Semi- Fowler’s

craniotomy

Patient who had infratentorial Flat

craniotomy

During gastrostomy feeding Semi- Fowler’s

During change of IV tubing Trendelenburg

During insertion of TPN catheter into Trendelenburg

the subclavian vein

Patient with arterial insufficiency Legs lower than level of the heart

Patient with leg varicosities Legs higher than the level of the
heart

Patient with autonomic hyperreflexia Upright/ Sitting

Patient with spinal cord injury Flat

Patient who had lumbar laminectomy Flat

During enema (adult) Left lateral

Catheterization of female patient Dorsal recumbent

Woman in labor with prolapsed Trendelenburg

umbilical cord

During cystoscopy Lithotomy