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RESIDENT SURVIVAL GUIDE

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

References


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Causes

Life Threatening Causes

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

Common Causes

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



Differentiating Protein energy malnutrition from other Diseases

Differentiating kwashiorkor from marasmus[1]

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

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

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 + -
Hyperthyroidism + -
  • TSH with T3 and T4
VIPoma + -
  • Elevated VIP levels
  • Followed by imaging
Osmotic Lactose intolerance - +
  • Avoidance of dietary lactose
  • Substitution to maintain nutrient intake
  • Regulation of calcium intake
  • Use of enzyme lactase
Celiac disease - +
  • IgA tissue transglutaminase Ab
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:

  • 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

  • Clinical diagnosis
    • ROME III criteria
    • Pharmacologic studies based criteria

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

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
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)

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
  • 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 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:

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





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)
  1. Müller O, Krawinkel M (2005). "Malnutrition and health in developing countries". CMAJ. 173 (3): 279–86. doi:10.1503/cmaj.050342. PMC 1180662. PMID 16076825.
  2. Danziger J, Zeidel ML (2015). "Osmotic homeostasis". Clin J Am Soc Nephrol. 10 (5): 852–62. doi:10.2215/CJN.10741013. PMC 4422250. PMID 25078421.
  3. Sterns RH (2015). "Disorders of plasma sodium--causes, consequences, and correction". N Engl J Med. 372 (1): 55–65. doi:10.1056/NEJMra1404489. PMID 25551526.
  4. Fenske WK, Christ-Crain M, Hörning A, Simet J, Szinnai G, Fassnacht M; et al. (2014). "A copeptin-based classification of the osmoregulatory defects in the syndrome of inappropriate antidiuresis". J Am Soc Nephrol. 25 (10): 2376–83. doi:10.1681/ASN.2013080895. PMC 4178436. PMID 24722436.

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