Mineral

■ -Iron.. iodine Fluorine" Zinc Copper Sdeaiüm ■ Manganese'

DKHClKNCY SKiNi» AND SYMPTOMS (ALSO TOXtCITttS)

Microcytic anemia, Icollonychia (spXioti-shaped ftngcn'titils); toxicity ~ licniodunmnausfis Goiter,' erciimsin, hypothyroidism; toxicity also may cause "myxedema liensal caries (cavities);-tonicity = fluorosis widi mo.uling.of teeth and ¡»ne exostoses tlypogeusia (dccr«ised taste), rash, slow wound healing

Vtotke.'s disease (X-linked, kinky hair, and mental retardation); toxicity -Wilson's disease Cardiotnyo'pifhy and muscle pain; toxicity ~ loss of hair and nails ' Toxicity equals "manganese madness" in miners of ore- ' ■ Impaired glucose tolerance

Important points:

1. Deficiency of fat soluble vitamins {A, D, E, K) often is clue to malabsorption (e.g., cystic fibrosis, cirrhosis, celiac disease, sprue, duodenal bypass, bile-duct obstruction, pancreas insufficiency, chronic giardiasis). In such patients, parenteral supplements are required if high-dose oral supplements fail.

2. Alcoholics can have just about any deficiency, but check folate, thiamine, and magnesium.

3. Vitamin B17 deficiency most commonly is due to pernicious anemia, in which antiparietal cell antibodies destroy the ability to secrete intrinsic factor. Conditions associated with pernicious anemia include hypothyroidism and vitiligo. Schilling's test is used to diagnose the cause of B , ? deficiency. Removal of the ileum and the tapeworm Diphyllobothrium latum also cause B]? deficiency.

4. Isoniazid causes B6 (pyridoxins) deficiency. Patients taking isoniazid (especially young patients) are often given prophylactic B6 supplements.

Anticonvulsants (especially phenytoin) may cause folate deficiency.

6. Vitamin A is teratogenic and any female patient given one of the vitamin A analogs as treatment for acne (e.g., isotretinoin) must have a negative pregnancy test before medication. is started and must be put on some form of birth control as well as counseled about the risks of teratogenicity if they become pregnant. Periodic pregnancy tests also should be offered.

7. Rickets causes interesting physical findings: craniotabes (poorly mineralized skull and bones that feel like a ping-pong ball), rachitic rosary (costochondral beading with small, round masses on anterior rib cage), delayed fontanelle closure, bossing of the skull, kyphoscoliosis, bowlegs, and knock-knees. Bone changes first appear at the lower ends of the radius and ulna.

8. Vitamin K is given to all newborns as prophylaxis against hemorrhagic disease of the newborn. Vitamin K is needed for the synthesis of factors II, VII, IX, and X as well as proteins C and S. Chronic liver disease (cirrhosis) may cause prolongation of the prothrombin time (PT) because of inability to synthesize denting factors, even in the presence of adequate vitamin K. Treat with fresh frozen plasma; vitamin K is ineffective.

Definition of shock: a state in which blood flow to and perfusion of peripheral tissues is inadequate to sustain life. Although not included in a rigid definition of shock for board purposes, associated findings include hypotension and oliguria/anuria. Tachycardia is also usually present.

Pragmatically speaking, there are four clinical types of shock:

1. Hypovolemic

2. Cardiogenic

3. Septic

4. Neurogenic

Your job is to figure out why the patient is in shock while keeping him or her alive. Give fluids while you're thinking. If the patient doesn't respond to a fluid bolus and you are given the choice, use invasive hemodynamic monitoring (Swan-Ganz catheter) to help make diagnostic and therapeutic decisions:

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Associated fhidings help to differentiate the etiology of shock:

1. Neurogenic shock: history of severe cen tral nervous system trauma or bleed; flushed skin, Heart rate may be normal.

2. Septic shock: fever, white blood cell couni changes, skin flushed and warm to the touch, extremes of age. Use broad-spectrum antibiotics after pan-culturing the patient (get blood, sputum and urine cultures plus others if history dictates).

3. Cardiogenic shock: history of myocardial infarction, chest pain, congestive heart failure, or several risk, factors for coronary artery disease. The patient has cold, clammy skin and looks pale. Distended neck veins, pulmonary congestion (on exam and x-ray). Patients usually need diuretics—fluid may make? them worse!

4. Hypovolemic: history of fluid loss (blood, diarrhea, vomiting, sweati ng, diuretics, inability to drink water).The patient lias cold, clammy skin and looks pale. Fluid loss may be internal, as in a ruptured abdominal aortic aneurysm or spleen, pancreatitis, or after surgery. Other signs include orthostatic hypotension, tachycardia, sunken eyes, tenting of skin, and sunken fontanelle (in children).

I. Anaphylaxis: look for bee stings, peanuts, shellfish., penicillins, sulfas, and other medica tions. Treat with epinephrine and fluids, administer 0?1 intubate if necessary (do a tracheostomy or cricothyroidotomy if laryngeal edema prevents intubation). Antihistamines help only when the reaction is mild. Use corticosteroids when the reaction is prolonged or severe (not first-line drugs for treatment of anaphylaxis). Monitor all patients for at least 6 hours after initial reaction.

6. Pulmonary embolus: look for risk factors for deep vein thrombosis (Virchow's triad: endothelial damage, stasis, hypercoagulable state), history of recent delivery (amniotic fluid embolus), fractures (fat emboli), deep vein thrombosis (positive Homan's sign with painful, swollen leg), and recent surgery (especially orthopedic or pelvic surgery). Patients have chest pain, tachypnea, shortness of breath, parasternal heave, right-axis shift on EKG, and. positive V/Q scan, Hepariniz.e to prevent further clotting and emboli.

7. Pericardial tamponade: history of stab wound in left chest, distended neck veins. Do peri cardiocentesis emergency.

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