Sandbox:DAMI

RESIDENT SURVIVAL GUIDE

Resident Survival Guide
Introduction
Team
Guide
Page Template
Examine the Patient Template
Navigation Bar Template
Checklist
Topics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

References

Template:WikiDoc Sources |}

Causes

Life Threatening Causes

• Central Diabetes Insipidus
• Nephrogenic Diabetes insipidus
• Psychogenic Diabetes insipidus
• Gestational Diabetes insipidus
• Autoimmune Diabetes insipidus

Common Causes

• Common cause 1
• Common cause 2
• Common cause 3
• Common cause 4
• Common cause 5

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[disease name]] according the the [...] guidelines.

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

Template:WikiDoc Sources

Differentiating Protein energy malnutrition from other Diseases

Differentiating kwashiorkor from marasmus

Distinguishing Features	Kwashiorkor	Marasmus
Cause	Deficiency of protein in the diet of child	Deficiency of protein as well as energy nutrients (that is carbohydrates and fats) in the diet
Age	Occurs in children in the age group 1-5 years	Typically occurs in children below the age of 1 year
Association	More common in villages where there is small gap period between successive pregnancies	More common in towns and cities where breast-feeding in discontinued quite early
Edema	Presence of edema	Absence of edema
Muscles	Wasting of muscles	Wasting of muscles is quite evident. The child is reduced to skin and bones
Skin changes	Dermatitis and Hyperpigmentation noticed	Dry and atrophic skin but no changes in color
Serum cortisol	Decreased/Normal	Increased
Fasting blood glucose	Decreased	Decreased
Growth retardation	Mildly retarded in growth	Severely retarded in growth
Facial appearance	Moon-like face	Elderly man face
Abdomen	Protuded	Shrunken
Vitamin deficiency	Present	Present
Weight	60-80% of normal weight for age	<60% of normal weight for age

Differential diagnosis of childhood malnutrition

Kwashiorkor
Marasmus
Vitamin A deficiency
Iron deficiency
Iodine deficiency
Congenital heart disease
Dehydration
Sepsis
Shigella and campylobacter
Inflammatory bowel diseases

Causes in Alphabetical Order

Amikacin Amphotericin B Amyloidosis Anophthalmia -- hypothalamo-pituitary insufficiency Anophthalmia -- hypyothalamo-pituitary insufficiency Anorexia nervosa Apoplexy Autoimmune Diabetes Insipidus Autoimmune Hypophysitis Brain aneurysm Carbamazepine Congenital hypopituitarism Craniopharyngioma Diabetes insipidus, congenital nephrogenic DIDMOAD syndrome Erdheim-Chester disease Familial CDI Familial hypopituitarism Genetic diseases - pit-1 mutation Hand-Schuller-Christian Syndrome Head injury

Hemochromatosis Histiocytosis Hypercalcaemia Hypokalaemia Hypothalamic radiation Hypoxic encephalopathy Idiopathic Infections Infiltrative lesions Pituitary, hypothalamu Inherited genetic kidney disorders Interstitial nephritis Intracranial bleeding Intracranial space-occupying lesion Ischemic stroke Kanamycin Langerhans cell histiocytosis Lithium Lymphocytic hypophysitis Malignant tumors infilterating hypothalamus from lung, breast Mass lesions hypothalamus Meningoencephalitis

Netilmicin Neurosurgery Panhypopituitarism pituitary adenomas Pituitary Cancer Pituitary radiation Pituitary surgery Pituitary cysts Pituitary tumour Post-supraventricular tachycardia Radiation - for CNS and nasopharyngeal malignancies Sarcoidosis Septo-optic dysplasia Sheehan syndrome Sheehan syndrome Sicca syndrome Sickle cell disease Subarachnoid hemorrhage Trauma - fracture of skull base Tuberculous meningitis Wolfram syndrome

Causes by Organ System

Cardiovascular	Hypovolemic shock
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Amphotericin B, Demeclocycline, Lithium , Radiation - for CNS and nasopharyngeal malignancies , Pituitary radiation , Netilmicin , Kanamycin, Carbamazepine , Amikacin
Ear Nose Throat	No underlying causes
Endocrine	Ischemia of the pitutary gland , Sheehan syndrome , Pituitary tumour , Panhypopituitarism , lymphocytic hypophysitis , Familial hypopituitarism , congenital nephrogenic , Congenital hypopituitarism , Apoplexy , pituitary cysts
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	Inherited genetic kidney disorders , Genetic diseases - pit-1 mutation
Hematologic	Sickle cell disease , Langerhans cell histiocytosis
Iatrogenic	Neurosurgery , Pituitary surgery
Infectious Disease	Tuberculous meningitis , Meningoencephalitis , Infections
Musculoskeletal / Ortho	No underlying causes
Neurologic	Dipsogenic diabetes insipidus , Ischemic encephalopathy , Subarachnoid hemorrhage , Mass lesions hypothalamus , Ischemic stroke , Intracranial space-occupying lesion , Intracranial bleeding , Hypoxic encephalopathy , Hypothalamic radiation , Brain aneurysm
Nutritional / Metabolic	Hypercalcemia , hemochromatosis , Anorexia nervosa
Obstetric/Gynecologic	Gestational diabetes insipidus
Oncologic	Pituitary Cancer , pituitary adenomas , malignant tumors infilterating hypothalamus from lung and breast , Histiocytosis , Craniopharyngioma
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	Polycystic kidney disease, Renal failure , Interstitial nephritis , Hypokalaemia , Hypercalcaemia
Rheum / Immune / Allergy	Sarcoidosis , Autoimmune Hypophysitis , Autoimmune Diabetes Insipidus
Sexual	No underlying causes
Trauma	Head injury , Trauma - fracture of skull base
Urologic	Partial blockage of the ureters
Dental	No underlying causes
Miscellaneous	Dehydration , Wolfram syndrome , Sicca syndrome , Septo-optic dysplasia , Infiltrative lesions , Idiopathic , Hand-Schuller-Christian Syndrome , Familial CDI , Erdheim-Chester disease , DIDMOAD syndrome , Anophthalmia -- hypyothalamo-pituitary insufficiency , Anophthalmia -- hypothalamo-pituitary insufficiency , Amyloidosis

Table for HV

• The table below summarizes the classification of the herpesviridae family

	Classification	Clinical manifestations
Subfamily alphavirinae	Herpes simplex type 1	Perioral vesicular rash Rarely encephalitis Meningitis
	Herpes simplex type 2 varicella-zoster virus	Disseminated vesicular rash at acquisition (chicken pox) Localized vesicular rash with reactivation(zoster)
Subfamily betavirinae	Cytomegalovirus	Mononucleosis like illness in healthy adults Fever Pneumonia Hepatitis in immunocompromised adults
	Human herpes virus 6	Acute febrile illness sometimes with rash (roseola infantum)
	Human herpes virus 7	May cause febrile illness sometimes with rash ( roseola-like)
Subfamily gammavirinae	Epstein-Bar virus	mononucleosis, lymphoma, nasopahryngeal carcinoma and hodgkins disease.
	Human herpes virus 8	Kaposi's sarcoma in immunocompromised.

Watery diarrhea

• Osmotic diarrhea
  • Mg2+, PO43-, SO42- ingestion
  • Carbohydrate malabsorption
• Secretory diarrhea
  • Laxative abuse (nonosmotic laxatives)
  • Congenital syndromes
  • Bacterial toxins
  • Ileal bile acid malabsorption
  • Inflammatory bowel disease
    • Ulcerative colitis
    • Crohn’s disease
    • Microscopic (lymphocytic and collagenous) colitis
    • Diverticulitis
  • Vasculitis
  • Drugs and poisons
  • Disordered motility
    • Postvagotomy diarrhea
    • Postsympathectomy diarrhea
    • Diabetic autonomic neuropathy
    • Hyperthyroidism
    • Irritable bowel syndrome
  • Neuroendocrine tumors
    • Gastrinoma
    • VIPoma
    • Somatostatinoma
    • Mastocytosis
    • Carcinoid syndrome
    • Medullary carcinoma of thyroid
  • Neoplasia
    • Colon carcinoma
    • Lymphoma
    • Villous adenoma
  • Addison’s disease
  • Epidemic secretory diarrhea
  • Idiopathic secretory diarrhea

Fatty diarrhea

• Malabsorption syndromes
  • Mucosal diseases
  • Short-bowel syndrome
  • Postresection diarrhea
  • Mesenteric ischemia
• Maldigestion
  • Pancreatic insufficiency
  • Bile acid deficiency

Inflammatory diarrhea

• Inflammatory bowel disease
  • Ulcerative colitis
  • Crohn’s disease
  • Diverticulitis
  • Ulcerative jejunoileitis
• Infectious diseases
  • Ulcerating viral infections
    • Cytomegalovirus
    • Herpes simplex
• Ischemic colitis
• Radiation colitis
• Neoplasia
  • Colon cancer
  • Lymphoma

Cause			Osmotic gap	History	Physical exam	Labs		Gold standard	Treatment
						Osmotic gap	Other Labs
Watery	Secretory	Crohns
		IBS
	Osmotic
	FunctionL

Watery

• Secretory (often nocturnal; unrelated to food intake; fecal osmotic gap < 50 mOsm per kg*)
  • Alcoholism
  • Bacterial enterotoxins (e.g., cholera)
  • Bile acid malabsorption
  • Brainerd diarrhea (epidemic secretory diarrhea)
  • Congenital syndromes
  • Crohn disease (early ileocolitis)
  • Endocrine disorders e.g., hyperthyroidism
  • Medications (see causes section)
  • Microscopic colitis (lymphocytic and collagenous subtypes)
  • Neuroendocrine tumors (e.g., gastrinoma, vipoma, carcinoid tumors, mastocytosis)
  • Nonosmotic laxatives (e.g., senna, docusate sodium)
  • Postsurgical (e.g., cholecystectomy, gastrectomy, vagotomy, intestinal resection)
  • Vasculitis
• Osmotic (fecal osmotic gap > 50 mOsm per kg*)
  • Carbohydrate malabsorption syndromes (e.g., lactose, fructose)
  • Celiac disease
  • Osmotic laxatives and antacids (e.g., magnesium, phosphate, sulfate)
  • Sugar alcohols (e.g., mannitol, sorbitol, xylitol)
• Functional (distinguished from secretory types by hypermotility, smaller volumes, and improvement at night and with fasting)
  • Irritable bowel syndrome

Table showing watery causes of chronic diarrhea (Table 1)

Cause			Osmotic gap		History	Physical exam	Gold standard	Treatment
			< 50 mOsm per kg	> 50 mOsm per kg*
Watery	Secretory	Crohns	+	-	Abdominal pain followed by diarrhea	Abdominal tenderness when palpated in severe disease Blood seen on rectal exam Fever Tachycardia Hypotension	Colonoscopy with biopsy	Topical mucosamine and corticosteroids are prefferd Mesalamine and sulfasalazine are used for remission
		Hyperthyroidism	+	-	Excessive sweating Heat intolerance Increased bowel movements	Lump in the neck Proptosis Tremors Increased DTR	TSH with T3 and T4	Carbimazole and methimazole Beta blockers like propylthiouracil Iodine-131
		VIPoma	+	-	Watery diarrhea Dehydration (thirst, dry skin, dry mouth, tiredness, headaches, and dizziness) Lethargy, muscle weakness Nausea, vomiting Crampy abdominal pain Weight loss Flushing	Tachycardia Rash Facial flushing Abdominal distention Abdominal tenderness in the right upper abdominal quadrant	Elevated VIP levels Followed by imaging	Sandostatin or chemotherapy for malignant tumors Surgical removal of the tumor
	Osmotic	Lactose intolerance	-	+	Abdominal pain Bloating Diarrhea Flatulence	Abdominal tenderness	Intestinal biopsy	Avoidance of dietary lactose Substitution to maintain nutrient intake Regulation of calcium intake Use of enzyme lactase
		Celiac disease	-	+	May be asymptomatic Vague abdominal pain Diarrhea Weight loss Malabsorption / steatorrhea Bloatedness	Abdominal pain and cramping Abdominal distention Tetany Mouth ulcers Dermatitis herpetiformis Signs of the fat-soluble vitamins A, D, E, and K deficiency	IgA tissue transglutaminase Ab	Gluten-free diet
	Functional	Irritable bowel syndrome	-	-	Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following: Improves with defecation Onset associated with change in frequency of stool Onset associated with change in appearance of stool 25% of bowel movements are loose stools History of straining is also common	Abdominal tenderness Hard stool in the rectal vault	Clinical diagnosis ROME III criteria Pharmacologic studies based criteria	High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodic drugs (e.g. anticholinergics such as hyoscyamine or dicyclomine)

Template:WikiDoc Sources

Fatty (bloating and steatorrhea in many, but not all cases)

• Malabsorption syndrome (damage to or loss of absorptive ability)
  • Amyloidosis
  • Carbohydrate malabsorption (e.g., lactose intolerance)
  • Celiac sprue (gluten enteropathy)–various clinical presentations
  • Gastric bypass
  • Lymphatic damage (e.g., congestive heart failure, some lymphomas)
  • Medications (e.g., orlistat Xenical; inhibits fat absorption, acarbose Precose; inhibits carbohydrate absorption])
  • Mesenteric ischemia
  • Noninvasive small bowel parasite (e.g., Giardia)
  • Post-resection diarrhea
  • Short bowel syndrome
  • Small bowel bacterial overgrowth (> 105 bacteria per mL)
  • Tropical sprue
  • Whipple disease (Tropheryma whippelii infection)
• Maldigestion (loss of digestive function)
  • Hepato-biliary disorders
  • Inadequate luminal bile acid
  • Loss of regulated gastric emptying
  • Pancreatic exocrine insufficiency

Table showing fatty causes of chronic diarrhea ( Table 2)

Cause	Osmotic gap		History	Physical exam	Gold standard	Treatment
	< 50 mOsm per kg	> 50 mOsm per kg*
lactose intolerance	-	+	Bloating, Flatulence Abdominal pain, and/or chronic diarrhea after ingestion of lactose	Abdominal tenderness when palpated in severe disease Fever Hypotension Tachycardia Nausea and vomitting	Lactose breath hydrogen test	Restriction of lactose and maintain calcium and vitamin D intake.
Celiac sprue	-	+	Diarrhea with bulky, foul-smelling stools Growth failure in children, Weight loss, Anemia, Neurologic disorders Osteopenia	Neuropsychiatric disease Dermatitis herpetiformis Arthritis Iron deficiency Metabolic bone disease Hyposplenism Kidney disease Idiopathic pulmonary hemosiderosis	Immunoglobulin A (IgA) anti-tissue transglutaminase (TTG) antibody followed by upper ebdoscopy with biopsy.	Dietary counseling, elimination of gluten in the diet.
Whipple disease	-	+	Arthralgias Weight loss Diarrhea Abdominal pain	Leukocytopenia Thrombocytopenia Skin hyperpigmentation	Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction [PCR] testing, and immunohistochemistry)	Doxycycline and hydroxychloroquine was bactericidal

Inflammatory or exudative (elevated white blood cell count, occult or frank blood or pus)

• Inflammatory bowel disease Crohn disease (ileal or early Crohn disease may be secretory)
  • Diverticulitis
  • Ulcerative colitis
  • Ulcerative jejunoileitis
• Invasive infectious diseases
  • Clostridium difficile (pseudomembranous) colitis–antibiotic history
  • Invasive bacterial infections (e.g., tuberculosis, yersiniosis)
  • Invasive parasitic infections (e.g., Entamoeba)–travel history
  • Ulcerating viral infections (e.g., cytomegalovirus, herpes simplex virus)
• Neoplasia
  • Colon carcinoma
  • Lymphoma
  • Villous adenocarcinoma
• Radiation colitis

Table showing inflammatory causes of chronic diarrhea ( Table 3)

Cause	History	Laboratory findings	Diagnosis	Treatment
Diverticulitis	Bloody diarrhea Left lower quadrant abdominal pain Abdominal tenderness on physical examination Low grade fever	Leukocytosis Elevated serum amylase and lipase Sterile pyuria on urinalysis	Abdominal CT scan with oral and intravenous (IV) contrast	bowel rest, IV fluid resuscitation, and broad-spectrum antimicrobial therapy which covers anaerobic bacteria and gram-negative rods
Ulcerative colitis	Diarrhea mixed with blood and mucus, of gradual onset. Signs of weight loss Rectal urgency Tenesmus Blood is often noticed on underwear Different degrees of abdominal pain	Anemia Thrombocytosis A high platelet count Elvated ESR (>30mm/hr) Low albumin	Endoscopy	Induction of remission with mesalamine and corticosteroids followed by the administration of sulfasalazine and 6-Mercaptopurine depending on the severity of the disease. See ...
Entamoeba histolytica	Abdominal cramps Diarrhea Passage of 3 - 8 semiformed stools per day Passage of soft stools with mucus and occasional blood Fatigue Intestinal gas (excessive flatus) Rectal pain while having a bowel movement (tenesmus) Unintentional weight loss	cysts shed with the stool	detects ameba DNA in feces	Amebic dysentery ; Metronidazole 500-750mg three times a day for 5-10 days Tinidazole 2g once a day for 3 days is an alternative to metronidazole Luminal amebicides for E. histolytica in the colon: Paromomycin 500mg three times a day for 10 days Diloxanide furoate 500mg three times a day for 10 days Iodoquinol 650mg three times a day for 20 days For amebic liver abscess: Metronidazole 400mg three times a day for 10 days Tinidazole 2g once a day for 6 days is an alternative to metronidazole Diloxanide furoate 500mg three times a day for 10 days must always be given afterwards.

==Gestational Diabetes insipidus

Differentiating Diabetes insipidus based on the levels of ADH and the response of the body to the level of hyponatremia

• Disorders in which ADH levels are elevated
  • Reduced effective arterial blood volume
    • True volume depletion
    • Heart failure
    • Cirrhosis
  • Syndrome of inappropriate ADH secretion, including reset osmostat pattern
  • Hormonal changes
    • Adrenal insufficiency
    • Hypothyroidism
    • Pregnancy

• Disorders in which ADH levels may be appropriately suppressed
  • Advanced renal failure
  • Primary polydipsia
  • Diabetes mellitus
  • Sickle cell disease

• Hyponatremia with normal or elevated plasma osmolality
  • High plasma osmolality (effective osmols)
    • Hyperglycemia
    • Mannitol
  • High plasma osmolality (ineffective osmols)
    • Renal failure
    • Alcohol intoxication with an elevated serum alcohol concentration
  • Normal plasma osmolality
    • Pseudohyponatremia (laboratory artifact)
      • High triglycerides
      • Cholestatic and obstructive jaundice (lipoprotein-X)
      • Multiple myeloma
    • Absorption of irrigant solutions
      • Glycine
      • Sorbitol
      • Mannitol

Template:WikiDoc Sources

Question on Roseola

• A woman brings her 14 month old baby to the physician for the evaluation of a rash. He was in a good state of health until about 3 days ago when he developed a very high fever. The mother says the temperature was as high as 40C (104F) when she measured it with her thermometer at home. She gave him some tylenol and the fever subsided after which the rash developed. It started as a non itchy pink rash with rose spots on the head and is now generalized all over the body. Today the boy's temperature measured in the clinic is 37 C( 98F), pulse 88/min and respirations are 16/min. His immunizations are up to date and the boy is in no apparent distress. What is the most likely diagnosis in this patient?
• A. Scarlet Fever
• B. Rubella(German measles
• C. Roseola (sixth disease)
• D. Rocky mountain spotted fever
• E. Measles
• F. Kawasaki disease
• G. Erythema infectiosum (fifth disease)