Prostate-Specific Antigen (PSA) Test

• Total PSA (tPSA):

o Measures overall PSA levels in the blood.

o Used as the primary screening test.

• Free PSA (fPSA): 

o Measures unbound PSA.

o Lower free PSA percentage suggests a higher cancer risk.

• PSA Density (PSAD): 

o Adjusts PSA levels based on prostate volume

o Helps differentiate BPH from cancer.

• PSA Velocity (PSAV): 

o Tracks PSA level changes over time.

o Rapid increase may indicate aggressive cancer.

• PSA Doubling Time (PSADT): 

o Measures how quickly PSA levels double.

o Faster doubling suggests more aggressive cancer.

• Pro-PSA & Prostate Health Index (PHI): 

o Includes p2PSA, total PSA, & free PSA

o To improve cancer detection & reduce unnecessary biopsies.

• 4Kscore Test: 

o Evaluates four PSA-related proteins along with clinical factors.

o To estimate the risk of high-grade cancer.

• PCA3 Test: 

o Urine-based genetic test detecting PCA3 mRNA.

o Highly specific to prostate cancer.

• IsoPSA Test: 

o Analyzes PSA structural changes to distinguish benign conditions from cancer.

 

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SIRS vs Sepsis

 

Systemic Inflammatory Response Syndrome (SIRS)

• Non-specific (infections vs non-infectious)

• ≥2 of the following:

o Temp >38°C or <36°C

o HR >90 bpm

o RR >20 or PaCO₂ <32 mmHg

o WBC >12,000/mm³, <4,000/mm³, or >10% bands

Sepsis

• Organ dysfunction due to dysregulated host response to infection.

• SOFA score increases by ≥2.

• qSOFA (≥2 indicates high risk):

o Altered mental status (GCS <15)

o RR ≥22/min

o SBP ≤100 mmHg

Severe Sepsis (Obsolete Term in Sepsis-3, 2016)

• Sepsis + tissue hypoperfusion/organ dysfunction.

Septic Shock

• Sepsis + circulatory failure

o Hypotension requiring vasopressors (MAP <65 mmHg).

o Lactate >2 mmol/L 

Management (Surviving Sepsis Campaign Guidelines)

• Early recognition & treatment (within 1 hour)

• IV fluids (30 mL/kg crystalloid in 1st 3 hours)

• Broad-spectrum antibiotics ASAP

• Vasopressors (norepinephrine) if MAP <65 mmHg

• Source control (drain abscesses, remove infected devices)

• Supportive care (oxygenation, ventilation, glycemic control, DVT/stress ulcer prophylaxis)

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Guillain–Barré syndrome (GBS)

(aka: Landry–Guillain–Barré–Strohl syndrome:

• Most common cause of acute flaccid paralysis
• Rapidly progressive ascending paralysis & areflexia
• Autonomic dysfunction, CSF albumin-cytologic dissociation.
• The sensory and motor systems may be equally affected. 
• The paralysis moves rapidly from lower to upper areas.

Differential diagnosis:

• Myasthenia gravis: Intermittent & worsened by exertion.
• Multiple Sclerosis: CNS demyelination, hyperreflexia, multiple lesions on MRI, oligoclonal bands in CSF.
• Botulism: Descending weakness fixed dilated pupils, food/wound toxin exposure & prominent cranial nerve dysfunction with normal sensation.
• Tick paralysis: Ascending paralysis but spares sensation.
• West Nile virus: Headache, fever, & asymmetric flaccid paralysis but spares sensation.
• Transverse myelitis: Pain, weakness, abnormal sensation, urinary dysfunction, sensory level, hyperreflexia, spinal cord lesion on MRI.
• CIDP: Chronic progression, relapses, requires long-term immunotherapy.
• Spinal Cord Compression: Hyperreflexia, sensory level, MRI shows mass or compression.

 

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Lower extremity edema

Lower extremity edema is a multifaceted clinical presentation characterized by the abnormal accumulation

 of interstitial fluid within the subcutaneous tissues of the lower limbs. This phenomenon often manifests

 as visible swelling, which may be pitting or non-pitting in nature, contingent upon its underlying etiology.

 The pathophysiology involves an intricate interplay of increased capillary hydrostatic pressure, reduced

 oncotic pressure, lymphatic obstruction, or enhanced capillary permeability. Etiologies are diverse,

 spanning systemic conditions such as congestive heart failure, chronic kidney disease, and hepatic

 dysfunction, to localized factors like venous insufficiency, lymphedema, or trauma. A meticulous history

 and physical examination, supplemented by diagnostic adjuncts including duplex ultrasonography or

 laboratory investigations, are imperative to delineate the causative mechanism and guide targeted

 intervention.

 

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Palm Rashes

Common features and patterns:

• Color:

1. Red or erythematous: Common in inflammatory or allergic reactions.
2. Purple or purpuric: May suggest vascular or hematologic issues, such as small blood vessel inflammation (vasculitis).
3. White or hypopigmented: Seen in fungal infections or depigmentation disorders.
4. Brown or hyperpigmented: May occur in chronic skin conditions or post-inflammatory hyperpigmentation.

• Texture:

1. Flat (macular): Rash appears as flat, discolored spots.
2. Raised (papular or nodular): Bumps that may be small or large.
3. Scaly or flaky: Seen in psoriasis or fungal infections.
4. Smooth or shiny: Can occur in viral rashes or early dermatitis.

• Moisture:

1. Dry and cracked: Common in eczema or chronic irritation.
2. Moist or oozing: May suggest infection, blistering, or acute contact dermatitis.

• Distribution:

1. Symmetrical: Seen in systemic causes like eczema, psoriasis, or drug reactions.
2. Localized: Often indicates contact dermatitis or insect bites.
3. Peripheral patterns: Rashes that concentrate around the edges of the palms can be seen in certain fungal infections.

• Associated Symptoms:

1. Itching: Common in eczema, scabies, or allergic reactions.
2. Pain or burning: Suggests irritation, infection, or vascular issues.
3. Blisters: Seen in contact dermatitis, hand-foot-and-mouth disease, or bullous skin conditions.
4. Peeling or desquamation: Seen after infections (e.g., scarlet fever) or in conditions like Kawasaki disease.

• Causes & Features:

1. Contact Dermatitis: Red, itchy patches, sometimes with vesicles or blisters.
2. Atopic Dermatitis: Chronic, itchy, scaly rash; may worsen with exposure to irritants.
3. Psoriasis: Thick, scaly, silvery patches, often with well-defined edges.
4. Hand-Foot-and-Mouth Disease: Small, red spots or blisters on palms, soles, and sometimes around the mouth.
5. Fungal Infections (Tinea Manuum): Asymmetric scaling and redness, often with peeling.
6. Scabies: Small, red papules with linear burrows, typically between fingers.
7. Drug Reactions: Diffuse rash that can affect the palms, often accompanied by systemic symptoms.

 

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Tremor

TREMOR

Involuntary, rhythmic, shaking movement of part of the body

Occur when muscles repeatedly contract and relax.

Classification:

• Physiologic (Normal)
• Abnormal (Pathologic)
• Essential (Hereditary disorder)
• Cerebellar (Damage to cerebellum)
• Secondary (medication, or substance use, etc.)
• Psychogenic (Psychologic factors)

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Chronic Kidney Disease (CKD)

 

Individualize BP-lowering therapy and treatment targets in people with frailty, high risk of falls, very

 limited life expectancy, or symptomatic postural hypotension.

Treatments that delay progression of CKD with a strong evidence base include RASi and SGLT2i. In

 people with CKD and heart failure, SGLT2i confer benefits irrespective of albuminuria.

Initial dips in eGFR are expected following initiation of hemodynamically active therapies, including both

 RASI and SGLT2i. GFR reductions of ≥30% from baseline exceed the expected variability and warrant

 evaluation.

CKD is not a contraindication to an invasive strategy for people with acute or unstable heart disease.

 Imaging studies are not necessarily contraindicated in people with CKD and the risks and benefits should

 be determined on an individual basis.

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Radio-opaque shadows on ABDOMINAL X-RAY

• A substance is more radiopaque if it contains atoms of high atomic number (AN) such as calcium, iodine, barium, or lead.
• Bone, which contains calcium (AN 20), is more radiopaque than soft tissue, which is made up mostly of carbon (AN 6), hydrogen (AN 1), and oxygen (AN 8). 
• Iodine (AN 53) is the key constituent of radiocontrast material and lead (AN 82) is an effective barrier to x-rays.

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What Do You See

The eye is very complex and contains various tissues and structures that work together to provide vision.

 Eye problems can range from benign, self-resolving processes to malignant, and possibly metastatic

 tumors. Eye disorders can be caused by various factors, resulting in various signs and symptoms. They

 can be as trivial as minor irritation or pain all the way to blurred vision or blindness. Strabismus is a

 visual disorder in which the eyes are misaligned and point in different directions. When the eyes are

 misaligned, typically one eye will fixate on objects of interest while the other eye turns in (esotropia), out

 (exotropia), down (hypotropia), or up (hypertropia).

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Management of DM in Patients With CKD

• Monitor for changes in BP, serum creatinine, & serum K+ within 2–4 weeks of initiation or increase in the dose of an ACEi or ARB. 

• Continue ACEi or ARB therapy unless serum creatinine rises by > 30% within 4 weeks following initiation of treatment or an increase in dose.

• FDA recommends, metformin should NOT be used with serum creatinine ≥ 1.5 mg/dl in men & ≥ 1.4 mg/dl in women or with decreased creatinine clearance in people > 80.

• Recommended is treating patients with T2D, CKD, & an eGFR ≥ 30 ml/min per 1.73 m2 with metformin.

ADA/KDIGO Consensus Statements:

All patients with Type 1 diabetes or Type 2 diabetes and CKD should be treated with a

comprehensive plan, outlined and agreed by health care professionals and the patient 

together, to optimize nutrition, exercise, smoking cessation, and weight, upon which are

layered evidence-based pharmacologic therapies  aimed at preserving organ function and 

other therapies selected to attain intermediate targets for glycemia, blood pressure, and lipids.

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Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS)

Myocardial Infarction:

Classified into 5 types based on etiology and circumstances:

• Type 1: Spontaneous MI caused by ischemia due to a primary coronary event (eg, plaque rupture, erosion, or fissuring; coronary dissection).
• Type 2: Ischemia due to increased oxygen demand (eg, hypertension), or decreased supply (eg, coronary artery spasm or embolism, arrhythmia, hypotension).
• Type 3: Related to sudden unexpected cardiac death. 
• Type 4a: Associated with percutaneous coronary intervention (signs and symptoms of myocardial infarction with cTn values > 5 × 99th percentile URL). 
• Type 4b: Associated with documented stent thrombosis. 
• Type 5: Associated with coronary artery bypass grafting (signs and symptoms of myocardial infarction with cTn values > 10 × 99th percentile URL).

Infarct location

• Right ventricular infarction usually results from obstruction of the right coronary or a dominant left circumflex artery; it is characterized by high RV filling pressure, often with severe tricuspid regurgitation and reduced cardiac output.
• An inferoposterior infarction causes some degree of RV dysfunction in about half of patients and causes hemodynamic abnormality in 10 to 15%. RV dysfunction should be considered in any patient who has inferoposterior infarction and elevated jugular venous pressure with hypotension or shock. RV infarction complicating LV infarction significantly increases mortality risk.
• Anterior infarcts tend to be larger and result in a worse prognosis than inferoposterior infarcts. They are usually due to left coronary artery obstruction, especially in the anterior descending artery; inferoposterior infarcts reflect right coronary or dominant left circumflex artery obstruction.

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Acute Cholangitis

Legend says that Cholangitis was first defined in 1877 by Jean-Martin Charcot, at which time the

 pathognomonic triad of fever, right upper quadrant pain, and jaundice was described. Today, cholangitis is

 defined as the presence of increased hepatic intraductal pressure with a concurrent infection of the

 obstructed bile.

Chole: Derived from the Greek word “cholē” meaning bile.

Angio: Comes from the Greek “angeion” meaning vessel.

Cholangitis: Bacterial infection of the biliary tree.

The pathogens identified as causative agents of acute ascending cholangitis are gram-negative and

 anaerobic organisms, the most common including Escherichia coli, Klebsiella, Enterobacter,

 Pseudomonas, and Citrobacter.  

Iatrogenic introduction of bacteria commonly occurs post- ERCP in individuals with biliary obstruction.

Charcot triad has a high specificity (95.9%), while sensitivity is low (26.4%).

Tokyo guidelines (2018) have a sensitivity of 100% and specificity of 87.4%.

 

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