All of Medicine Flashcards

medicine 2 Study online at quizlet.com/_14lx0d 1.

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major risk factors for atherosclerotic heart disease

DM Hyperlipidemia hypertension cigarette smoking Age >45 M, >55 F family history of MI at young age high LDL level

CAD prognostic factors

LVF EFsubendocardial ischemia (ST depression on ECG) *stress echocardiography- shows wall motion abnormalities- akinesis or dyskinesis 3. cardiac catheterization

what is the advantage of stress echo vs stress ECG

LV size/function dx. valvular disease identifies CAD * if positive -->cardiac cath

what is a positive stress test

If during a stress test the patient experiences: ST depression chest pain hypotension arrhythmias

metabolic syndrome X

WE = waist expanded (>35in F, 40in M) IG = impaired glucose (>110mg/dl) H = hypertension (BP >130/85) H = HDL low ( hypercholesterolemia/low HDL hypertriglyceridemia - >150 impaired glucose tolerance >110 diabetes hyperuricemia HTN

syndrome X

exertional angina with normal coronary arteriogram stress test shows evidence of ischemia

indications for stress ECG

confirm angina DX evaluate therapy response in CAD pts identify pts with CAD

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types of stress test

* get the HR up to 85% (220age) exercise tolerance test (ST segment depression) exercise or dobutamine echocardiogram (wall motion abnormalities) exercise or dipyridamole (dec. uptake of thallium isotope in ischemic area during exercise)

how does dipyridamole/adenosine work for pharmacologic stress test

cause generalized coronary artery dilation *diseased coronaries are already maximally dilated so under dipyridamole/adenosine they receive relatively less blood

holter monitor 1. use

1. detect silent ischemia, evaluating arrhythmias, monitor pacemakers, evaluate unexplained syncope/dizziness

Cardiac catheterization 1. info gathered 2. coronary angiography/PCI/CABG eval 3. indications for cardiac cath

1. hemodynamics (CVP, PCWP, SVC, CI), intracardiac pressure, CO, oxygen saturation 2. performed during cath, visualizes the coronaries ~~~ can accomplish all of the above 3. positive stress test, angina with non-diagnostic non-invasive tests angina unresponsive to medical therapy severely symptomatic evaluation of valvular disease

coronary angiography 1. info gathered 2. what can be done

1. identifies CAD, delineates coronary anatomy 2. PCI, angioplasty/stenting, diagnosis

at what level of coronary occlusion does angina occur

>70% occlusion

stress echocardiography + follow up with positive result

echocardiography after exercise will show akinesis or dyskinesis ~ this is mores sensitive than ECG to detect ischemia - follow up with positive result is CARDIAC CATHETERIZATION

types of stress test

exercise tolerance test dobutamine echocardiogram dypyridamole thallium may also use adenosine

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thallium 201 stress test

use any type of stress test (exercise, dobutamine, or dypridamole)

give thallium - no uptake indicates ischemia

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secondary hypertension 1. renal causes 2. endocrine causes 3. medication causes - others include coarctation, cocaine, sleep apnea

1. renal artery stenosis, chronic renal failure, PKD 2. hyperaldo, thyroid/parathyroid, cushings syndrome, pheo, acromegaly 3. OCP****, decongestants, estrogen, steroids, TCA, NSAIDs

HTN effect on heart

inc SVR --> concentric LVH --> dec CO/sx of heart failure

what other conditions comorbid with HTN

accelerates atheroscloerosis --> accelerated CAD and peripheral vascular disease

what are is the end organ damage sites of HTN

heart - LVH, MI, CHF*, CAD, dissection Brain - stroke (ischemic/lacunar), TIA encephalopathy CKD - nephrosclerosis, arteriosclerosis dec. GFR PVD retinopathy

HTN effect on the eyes

*early - AV nicking, cotton wool spots=> hemorrhage and exudates *papilledema

cutoff for HTN in general pop vs diabetics

general - 140/90 diabetics/renal disease - 130/80

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cardiac complications of HTN

CAD, CHF, MI, PVD, aortic dissection

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CNS complications of HTN

intracerebral hemorrhage, TIA, ischemic stroke, lacunar stroke (2/2 small vessel hyalinosis + microatheromas)

renal complications of HTN

arteriosclerosis of afferent/efferent arterioles and glomerulus (nephrosclerosis)

what labs to evaluate target organ damage in HTN

urinalysis BMP (K/BUN/Cr) Fasting glucose lipid panel ECG

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when is a drug needed to treat hypertension

stage 1 or greater- patient should be treated with lifestyle + drug

stage 2 - lifestyle modification and 2 drug como

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pre-hypertension just treat with lifestyle modification

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lifestyle modifications for HTN

no-added salt or lowsodium diet weight loss avoid alcohol (pressor action) regular aerobic exercise low sat fat, lots of fresh produce stress management

best treatment for African Americans with hypertensino

thiazide diuretics (b/c they usually have saltsensative HTN) BUT* if there is also diabetes, ACE is best choice

why are ACE inhibitors prefered to treat HTN in diabetic patients

ACE inhibitors have a protective effect on the kidneys

drug choices to treat HTN

thiazides beta blockers ACE ARB CCB alpha blockeres vasodilators (hydralazine/minoxidil)q

what patients is alpha blockers useful to treat HTN

those who have both HTN and BPH

treatment of refractory HTN

vasodilators (hydralazine, minoxidil) + beta blockers + diuretics

what is the goal BP in patients with HTN

135/85 minimum goal for patients with diabetes or renal disease

what is first important test before starting an antihypretensive drug on a woman

pregnancy test contraindicatedthiazides, ACE, CCBs Safe - Beta blockers, hydralazine

which antihypertensives are associated with decreased risk of new-onset diabetes

ACE and ARB

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side effects of antihypretensive agents 1. thiazides 2. beta blockers 3. ace inhibitors

1. hypokalemia, hyperuricemia, hyperglycemia, hypertriglyceridemia, met.alk, hypomagnesemia 2. bradycardia, bronchospasm, insomnia, masked hypoglycemia 3. dry cough, ARF, hyperkalemia, rash, altered taste

cardiovascular risk factors

smoking, diabetes, DM, hypercholesterolemia, HDL60, male, HTN, family history

1. screening for hyperlipidemia 2. effect of high dietary sat.fat on lipid panel 3. effect of high calorie on lipid panel 4. effect of alcohol on lipid panel

1. every 5 years starting at age 20 with a fasting lipid profile 2. increases LDL and cholesterol 3. increase TG 4. increase TG and HDL

1. age effect on cholesterol 2. thiazides effect on lipid panel 3. beta blockers "" 4. estrogens "" 5. corticosteroids and HIV proteases ""

1. 2mg/dL per year increase 2. inc. LDL, cholesterol, TG 3. inc TG, dec. HDL 4. inc. TG 5. elevates serum lipids

1.goal levels for cholesterol, LDL, triglycerides 2. LDL goal for diabetic 3. LDL goal for diabetic and CAD 4. HDL goal

1. 2. nasal congestion, post-nasal discharge, pain/headache >2-3 months.

laryngitis 1. patho + clinical pres 2. treatment

1. viral, moraxella, h.flu --> hoarseness +/URI symptoms 2. self limiting

sore throat 1. patho 2. which can cause exudative tonsillitis 3. dx/tx

1. adeno, PIV, rhino, EBV, HSV, s.pyogenes*, chlamydia, mycoplasma, gonococcal, EBV, coryne.dip, candida --> 2. EBV, c.dip, s.pyogenes, candida 3. dx - throat culture, rapid strep, monospot tx - penicillin, erythromycin, viral, EBV (dont give amox)

treatment for EBV pharyngitis

acetaminophen, ibuprofen NOT amox

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dyspepsia 1. patho + clinical pres 2. dx 3. when to do endoscopy for dyspepsia

1. GERD, PUD, functional dyspepsia, (90%) gastritis, hepatobiliary, pancreatic, esophageal spasm, DM gastroparesis, IBS, -> epigastric symptoms , heartburn, bloating, nighttime awakening, 2. response to empiric therapy, endoscopy, h.pylori stool antigen/urea breath test 3. weight loss, anemia, dysphagia, obstruction, upper GI bleeding, nonresponders to empiric therapy,

dyspepsia 1. tx

1. avoid alcohol, caffeine, smoking, raise head of bed, avoid eating before sleep H2 blockers, PPI, endoscopy , h.pylori treatment

peptic stricture clinical presentation

dysphagia and GERD

GERD 1. pathogenesis 2. clinical pres

1. inappropriate relaxation of LES, dec. esophageal motility, gastric outlet obstruction, hiatal hernia 2. heartburn, dyspepsia (retrosternal burning after large meals) regurgittation waterbrash -reflex salivary hypersecretion chronic cough hoarseness, sore throat early satiety, post-prandial n/v

complications of GERD

erosive esophagitis, barrett's, peptic strictures, esophagitis, aspiration pneumonia (lipid laden macrophages), dental erosion,

diagnosis of GERD

24 hour esophageal monitor, Upper GI series (barium contrast) endoscopy with biopsy (if refractory) esophageal manometry

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when to screen for barrett's esophagus

after 5 years of symptomatic GERD

GERD treatment

behavior -avoid fatty foods, smoking, alcohol, orange juice, chocolate, H2 blocker PPI promotility agent - metoclopramide (dopamine antagonist), bethanechol nissen fundoplication (for stricture, intractability, hemorrhage, stricture, barrett's)

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acute diarrhea (2-3wks) 1. patho 2. common viral pathogens 3. common bacterial infections 4. common parasites infections 5. pathogens in elderly/immunosuppressed

1. viral, bacteria, parasites, food poisoning abx (c.diff), malabsorption Ischemic bowel disease 2. norwalk virus, rotavirus, calicivirus, astrovirus, enterovirus 3. watery - ETEC, staph aureus, c.perfringens bloody - shigella, campylobacter, salmonella, EHEC 4. giardia lamblia, entamoeba histolytica, cryptosporidium 5. MAC, cryptosporidium, cyclospora, CMV

chronic diarrhea 1. patho 2. pathogens that can cause chronic diarrhea

1. IBS, IBD, medications, bacterial, colon cancer, diverticula, celiac, panc. insuff, short bowel, bacterial overgrowth, post surgical, hyperthyroid, addisons, diabetes, gastrinoma, VIPoma, laxatives 2. shigella, salmonella, campylobacter, EIEC

important questions for patient with diearrhea

blood/melena other assc. sx sick contacts/travel assc. with certain foods other medical problems (AIDS etc) recent med changes

acute diarrhea 1. lab tests for suspicious cases (chronic, severe illness/fever, blood, IBD suspicion, volume depletion)

1. CBC (anemia/leukocytosis) stool sample - #1 fecal leukocytes/culture c.diff toxin (treat empirically if suspicious), ova/parasites, giardia ELISA, stool culture - very low sensitivity dont order routinely (only detect shig/salm/camp) flexible sigmoidoscopy with bx

1. which causes of diarrhea have fecal leukocytes 2. what electrolyte abnormality with diarrhea

1. campylobacter, salmonella, shigella, EIEC, c.diff 2. hypokalemic met alk.

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acute diarrhea 1. when to hospitalize 2. tx

1. dehydration, PO intolerance, profuse bloody diarrhea, high fever/toxic 2. stop cause (abx or food), rehydrate, monitor electrolytes, loperamide 5 day course of ciprofloxacin - if bloody, severe, + stool culture, traveler diarrhea c.diff- metronidazole

constipation 1. patho 2. what meds cause constipation 3. what neuromuscular causes ""

1. diet (fiber), meds, IBS, obstruction, ileus, hemorrhoids/fissures, hypothyroid, hypercalcemia, hypokalemia, uremia, dehydration, neuromuscular disorders, congenital 2. anticholinergics, antidepressants, narcotics, iron, CCB, aluminum/calcium antacids, 3. parkinsons, MS, CNS lesions, scleroderma, DM

constipation 1. dx 2. complications of chronic constipation 3. tx

1. H&P, abdoinal films, TSH, serum calcium, CBC, electrolytes, r/o obstruction!, rectal examination radio-opaque marker transit, anorectal motility study 2. hemorrhoids, rectal prolapse, anal fissures, fecal impaction 3. inc. physical activity, inc. fiber/fluid, enema, surgery

see page 450 for list of all diarrhea

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irritable bowel syndrome 1. patho + clinical pres 2. dx 3. tx

1. depression, anxiety, somatization --> abnormal resting activity of the bowel >3 months --> diarrhea, constipation, cramping relieved by defecation, bloating/distention 2. diagnosis of exclusion use dx modalities for diarrhea 3. loperamide/diphenoxylate, colace/psyllium/cisapride, tegaserod maleate (serotonin agonist)

nausea/vomiting 1. patho 2. bilious, feculent, undigested, projectile

1. viral/food, preg, DKA, addisonian crisis, uremia,electrolyte, PUD, GERD, SBO, ileus (hypercalcemia/hypokalemia), hyperthyroid, pancreatitis, appendicitis, pyelo, chole, MI, cisplatin/chemo, digitalis*, erythromycin/abx, 2. bilious - obstruction distal to vater feculent - distal intestinal obstruction, bacterial overgrowth, gastrocolic fistula undigested - esophageal problem projectile - inc. ICP, pyloric stenosis

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nausea/vomiting 1. dx 2. tx.

1. CBC, electro, LFT, B-HCG, abdominal films upright/supine (r/o obstruction). 2. self limiting, rehydration with 1/2 normal saline, prochlorperazine, promethazine, avoid large fatty meals,

hemorrhoids 1. external vs internal 2. causes 3. clinical pres

1. external = inferior hemorrhoidal plexus internal = superior rectal plexus 2. constipation, pregnancy, portal HTN,l obesity, prolonged sitting/standing 3. bleeding/rectal prolapse, BRB per rectum, external - painless unless thrombosed internal - painless mass when they prolapse

hemorrhoids 1. tx

1. sitz bath, stool softeners to reduce strain, high fiber, high fluid diet, topical steroids, rubber band ligation, surgical hemorrhoidectomy

lower back pain (acute >4 wk, chronic >12 wk) 1. risk factors - 90% of patients with lumbar herniation/sciatica improve with conservative care

1. smoking, obesity, old age, low edu, workers comp, dissatisfaction, psychological factors (depression, anxiety)

1. what exacerbates disc herniation pain 2. what exacerbates spinal stenosis pain

1. coughing/sneezing increase intraspinal pressure forward flexion, sitting, driving, lifting 2. standing, walking, relieved by bending or sitting (walking on a shopping cart)

cauda equina syndrome 1. patho 2. clinical pres 3. treatment

1. severe stenosis of the lumbar spine 2/2 disc herniation 2. leg pain, bladder dysfunction (retention/incontinence), saddle anesthesia 3. immediate MRI, surgical emergency

1. spondylolisthesis 2. lumbar herniation clinical pres. 3. lumbar disc herniation treatment

1. forward slippage of cephalad vertebrae at L4-L5, L5-S1 2. radicular leg pain/back pain 3. anti-inflammatory, physical therapy, epidural steroid, early mobilization, ONLY MRI AFTER 4-6 WEEKS OF CONSERVATIVE TREATMENT

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spinal stenosis 1. patho 2. clinical pres 3. dx/tx **differentiate from arterial claudication by checking pulses

1. degenerative changes (facet osteophytes/ligamentum flavum hypertrophy) --> narrowing of spinal canal 2. neurogenic claudication radicular or buttock pain, cramping, numbness, paresthesias- relieved by sitting, worse with walking/standing 3. good distal pulses, straight leg test negative epidural steroid injections

musculoligamentous back strain 1. patho

1. bending/twisting --> back "gives way" --> radiation to buttock/upper posterior thigh/knee due to muscle spasm

imaging in back pain

what is seen on MRI/X Ray does not necessarily correlate with what the patient experiences *psychosocial variables have a higher correlation

vertebral compression fracture 1. patho 2. tx

1. acute back pain from minor stress in elderly patients or pts on long term steroids pain @ level of fracture 2. bracing, analgesics, kyphoplasty/vertebroplasty,

physical exam test for radiculopathy

straight leg raise positive at 30-60 degrees with the patient supine

spine pain 1. when to get imaging/MRI

1. no imaging until 4-6 weeks of symptoms, or prog. neuro deficits, disability sx, osteoporosis, hx of malig, constitutional sx, recent trauma, IVDU when patient has failed rest/PT/NSAIDs for >3 mo

acute lower back pain 1. tx

1. AVOID PROLONGED INACTIVITY, ATTEMPT WALKING ROUTINE NSAIDS, acetaminophen, activity modification, slow return to activities PT if above fails surgery if >1 year of failed conservative tx

1. clinical presentation of cervical spondylosis 2. MCC acute neck pain

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1. axial neck pain, cervical radiculopathy, cervical myelopathy 2. cervical strain 117.

cervical radiculopathy 1. patho + clinical pres 2. dx/tx

1. spondylosis, herniation, impingement, carpal tunnel, cubital tunnel, thoracic outlet, zoster, pancoast tumor --> compression of spinal nerve --> arm pain, numbness, tingling, weakness, unilateral neck pain 2. dx = MRI of cervical spine tx = NSAIDs, time, PT, epidural injections

cervical myelopathy 1. patho + clinical pres

1. cervical stenosis --> spinal cord compression - unsteady gait, loss of hand dexterity, cane/walker use 2. surgical decompression

evaluation of gait unsteadiness in an elderly patient

always consider cervical stenosis/cervical myelopathy and order an MRI

how to differentiate shoulder impingement (C5 radiculopathy) from cervical stenosis

relief when inject subacromial space with cortisone

causes of arthritis

osteoarthritis, systemic autoimmune disease - RA, SLE, IBD, psoriatic arthritis crystal arthropathies infectious - septic arthritis/lymes disease trauam chargot joint congenital - hip dysplasia, legg-calve perthe, SCFE sickle cell, hemophilia (recurrent hemarthrosis) wilsons, hemochromotosis

patellofemoral pain 1. clinical presentation 2. tx

1. pain worse with stair climbing/descending, 2. PT focuses on quads/hamstring rehab

meniscal tears 1. dx 2. tx

1. knee effusions, tenderness along medial/lateral joint lines, McMurray+ 2. arthroscopic meniscectomy or repair

osteochondritis dissecans 1. patho + clinical pres 2. tx

1. necrotic area of bone and degeneration of the overlying cartilage leadign to a free body in the joint space --> catching, popping, pain 2. arthroscopy with removal of fragment

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causes of acute monoarticular arthritis

septic disseminated gonorrhea gout/pseudogout rheumatic fever lymes disease seronegative spondyloarthropathy

bakers cyst 1. patho

1. intra-articular pathology (RA, OA) --> cyst formation (MCC popliteal fossa --> rupture that causes pain/swelling extending into the calf when they burst they MIMIC thrombophlebitis (pseudothrombophlebitis), DVT

patellar tendinitis 1. patho 2. tx

1. jumpers knee- anterior knee pain in the inferior pole of the patella tx = activity modifications, quad/hamstring rehab

plica syndrome 1. patho

1. repeated injury such as what is seen in athletes --> feeling of snapping in the knee, pain along medial ptella 2. PT, anti-inflammatory meds, arthroscopy only if refractory

diagnosis of knee pain

radiographs if suggest degernative/truam MRI for soft tissue/ligmentous damage knee aspiration

ligaments on the lateral aspect of the ankle ligaments on the medial aspect of the grade 1,2,3 ankle sprains

ATFL, CFL, PTL deltoid Grade 1 - partial ATFL Grade 2 - full ATFL, partial CFL Grade 3 - full ATFL, full CFL

dx of ankle sprains

tenderness over ligmaents no radiographs if ottawa rules are met (patietn can walk four steps at time of injury/evaluation, no bony tenderness over distal 6cm of the malleolus)

treatment of ankle sprains

RICE, controlled weight bearing, gradual inc. to full weight bearing, PT

1. supraspinatus tendinitis + tx 2. rotator cuff tear + dx

1. impingement syndrome of the C5 root impingement of greater tuberosity on acromion, pt. will complain of pain with overhead activity tx = acromioplasty, steorid injections 2. if there is weakness with abduction - dx = MRI tx = PT, steroid injections, arthroscopic surgery

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lateral epicondylitis 1. patho 2. tx

1. inflammation/degeneration of forearm extensor tendons from excessive supination/pronation 2. PT, splinting, injections

medial epicondylitis 1. patho

1. pain @ medial epicondyle from flexor origin, from overuse of flexor/pronator muscles

de quervain's tenosynovitis 1. patho 2. dx 3. tx

1. abductor pollicis longus and extensor pollicis brevis tendon inflammation --> pain @ radial styloid, pain radiates to the elbow or into the thumb 2. finkelstein's test, pain at radial wrist when pinch gripping 3. thumb spica splint/NSAIDs, local cortisone injections

olecranon bursitis 1. patho 2. tx

1. trauma, overuses --> swelling over elbow, from effusion into olecranon bursa 2. conservative

trochanteric bursitis 1. patho 2. tx

1. trauma, overuse, weak hip muscles, --> pain over lateral hip from friction between gluteus medius and tensor fascia lata 2. NSAIDs, activity modification, local cortisone injections

ddx for hand numbness

cervical radiculopathy, peripheral neuropathy (DM), median nerve in forearm (carpal tunnel syndrome)

carpal tunnel syndrome 1. patho 2. dx 3. tx

1. median nerve compression in carpal tunnel causes numbness/pain in median nerve distribution --> severe atrophy of thenar muscles (later) 2. tinels sign - tap median nerve causes paresthesias phalen test - wrist flexion 1 min --> paresthesias 3. wirst splint @ night, NSAIDs, local corticosteroids, surgical release*

hip osteoarthritis clinical pres

groin pain that radiates to the anterior thigh

osteoarthritis 1. patho 2. clinical pres 3. dx

1. degeneration of cartilage from wear/tear of the weight bearing joints 2. pain worsens with activity, stiffness in the morning that gets worse during the day , NO swelling or warmth, NO TENDERNESS TO PALPATION progresses to limited ROM/bony crepitus* 3. plain radiograph - joint space narrowing, osteophytes, sclerosis of subchondral bony endplates, subchondral cysts

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osteoarthritis 1. tx

1. avoid excess movement, weight loss, PT (swimming), canes/walkers acetaminophen*, COX2 inhibitors, intraarticular injections of corticosteroids, viscoelastic supplementation, total joint replacement

heberden's nodes bouchard's nodes

bony overgrowth and osteoarthritic changes at DIP

bouchard's nodes - """ at PIP

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osteoporosis 1. patho Type 1 Type 2

1. failure to reach peak bone mass @ age 30 Type 1 - post-menopausla women- loss of trabecular bone - vertebral compression/colles fractures Type 2 - loss of trabecular/cortical >70yo, femoral neck, intertrochanteric prox. humerus, pelvis fractures

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secondary osteoporosis

2/2 steroids, immobilization, hyperthyroid, long term heparin, hypogonadism, D3 def.

osteoporosis 1. risk factors 2. tx

1. estrogen depletion, eating disorders,early menopause, hyperthyroid, hypogonadism, smoking/alcohol, steroids, heparin 2. 65 - use T scores (>50 yo)/Z scores (pre-meno) 2. Ca, phos, ALP, TSH, D3, PTH, Cr, CBC

osteoporosis tx

diet, Ca 1200mg/day, 800IU D3/day, weight bearing exercise 3x/wk, smoking/alcohol cessation, bisphosphonates (aldronate/risedronate inb. osteoclasts), PTH therapy, calcitonin, estrogen-progestin therapy `

ARMD 1. patho 2. risk factors 3. tx

1. non-exudative ARMD form drusen under RPE--> atrophy/degen of central retina exudative - sudden vision loss from serous fluid leakage CENTRAL VISION LOSS**** 2. HTN, caucasian, smoking, FH 3. anti-VEGF injections/laser photocoagulation (wet), OTC vitamins (dry)

MCC of vision loss in developed countries

diabetic retinopathy ARMD (age > 65) cataracts glaucoma

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glaucoma 1. patho 2. open angle 3. closed angle glaucoma 4. dx

1. inc. IOP, ON damage, cupping of ON, loss of ganglion cells 2. impaired outflow, silent progression 3. rapid IOP from obstruction of outflow by iris- CAN BE CAUSED BY DILATION DROPS**** 4. tonometry, ophthalmoscopy, genioscopy, visual field test

1. OA glaucoma clinical pres 2. CA """

1. painless IOP, peripheral scotoma 2. red painful eye, sudden dec. VA, N/V (mimics acute abdomen), headache, dilated non-reactive pupil***, halos around light

1. OA glaucoma tx 2. CA """"""

1. beta blockers,alpha agonists, CA inhibitors, prostaglandin analogs, laser/surgery 2. immediate referral, pilocarpine drops, IV acetazolamide, oral glycerin, laser/surgery

risk factors for cataracts

1. old age, cigarettes, glucocorticoids, UV, trauma, diabetes, wilsons, downs syndrome

red eye 1. MCC - refer if FFF, recent eye surgery, corneal opacification/ulcer/foreign body, chemical exposure, 2. subconjunctival hemorrhage 3. keratoconjunctivitis sicca 4. blepharitis

1. conjunctivitis 2. focal, unilateral rupture of small conjunctival vessels by valsalva, trauma, HTN 3. autoimmune, meds, CNV/VII, foreign body sensation 4. inflammation of eyelid, staph aureus

red eye 1. episcleritis 2. scleritis 3. anterior uveits

1. inflammation of episclera, autoimmune, include dull ache/discharge, self limited NSAIDs 2. pain with palpation of the eyeball 3. iris/ciliary body inflamm, circumcorneal injection, blurred vision, pain/photophobia, ipsilateral constrictionassc. with sarcoid, ank spondy, reiters, IBD

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HSV keratitis 1. clinical pres 2. tx

1. UNILATERAL similar to viral conj. irritation, photophobia, DENDRITIC ULCER 2. acyclovir, topical antivirals

viral conjunctivitis 1. patho + clinical pres

1. adeno is MCC, hyperemia of both eyes, palpable pre-auricular node

bacterial conjunctivitis 1. patho 2. tx - chlamydial = MCC blindness worldwide (tx = tetra,doxy,erythro)

1. s.pneumo or gram neg -irritation, hyperemia, tearing, mucopurulent exudate 2. broad spectrum abx

allergic conjunctivitis 1. patho 2. tx

1. seasonal--> redness, itching, tearing, rhinorrhea, 2. cold compress, topical antihistamines, systemic antihistamines, NSAIDS

amaurosis fugax 1. patho 2. dx

1. monocular vision loss 2/2 embolization from carotid 2. carotid ultrasound, cardiac workup (lipids, ECG)

OSA 1. patho 2. dx 3. tx

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1. obesity, structural abn. of hard/soft palate, FH, alcohol/sedatives, hypothyroid--> intermittent obstruction of airflow--> daytime sleepiness, snoring, personality change, systemic/pulm HTN, arrhythmias 2. polysomnography - measure apneas/hypopneas 5-15 = mild 15-30 = moderate >30= severe 3. 30 apneas/night - CPAP, uvulopalatopharyngoplasty, tracheostomy

complications of OSA

inc. pulmonary vascular resistance, inc. pulm HTN, cor pulmonale, systemic hypertension

narcolepsy 1. clinical pres 2. tx

1. inherited REM sleep regulation disorder -- >sleep attacks, excessive sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations 2. methylphenidate, planned napping

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Insomnia 1. transient insomnia 2. secondary insomnia 3. definition of insomnia 4. tx

1. psychological stress/time zone crossing 2. depression, anxiety, PTSD, mania, schizo, OCD, meds/substance abuse, alcohol, sedatives 3. difficulty initiating/maintaining sleep, non-restorative sleep >1 month, excessive worry about not being able to fall asleep 4. underlying cause, sedative hypnotics as short as possible

treatment for obesity

1. diet, exercise, lifestyle orlistat up to 4 years bariatric surgery

incontinence (urge, stress, overflow, functional) 1. usual causes in males 2.. usual causes in females 3. risk factors

1 BPH, neurologic disease 2. hormonal changes, or pelvic floor dysfunction 3. recurrent UTI, immobility, dementia, spine injury, DM, CHF, multiparity, BPH, prostate cancer, diuretics, beta blockers, anticholinergics/adrenergics (inc. retention), CCBs, alcohol

1. causes of conductive hearing loss 2. sensorineural hearing loss 3.. treatment for cerumen impaction

c1. cerumen, OE, TM perf, OM, otosclerosis, pagets disease 2. presbycusis (degen of sensory cells@cocholea, high freq->low freq), chronic loud noise >85db, infection, aminoglycosides, aspirin (reversible) infection, menieres disease, TORCH infections 3. carbamide peroxide, triethanolamine

menieres disease 1. clinical pres 2. patho 2. tx

1. triggers - alcohol, caffeine, nicotine, high salt foods --> fluctuating unilateral hearing loss, progressive hearing loss, vertigo, hearing loss, nystagmus, vomiting 2. distention of endolymphatic compartment of the middle ear 2. salt restriction***, meclizine

urge incontinence 1. patho 2. clinical pres 3. dx 4. tx

1. dementia, stroke, illness, parkinson's --> detrusor instability/involuntary contractions 2. sudden urge to urinate, large volume voids, with low residual 3. urodynamic study, 4. bladder training exercises, anticholinergics (oxybutynin), TCA (imipramine)

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stress incontinence 1. patho 2. clinical pres 3. tx

overflow incontinence 1. patho 2. clinical pres

1. multiparity --> pelvic diaphragm weakness/loss of bladder support+hypermobility of bladder neck allows proximal urethra to descend below the bladder floor 2. involuntary small volume urine loss during activities that inc. intrabdominal pressure (cough, laugh, sneeze, exercise) with small post-void residual 3. urinalysis (r/o infection), kegel exercises, estrogen replacement, urethropexy, 1. neurogenic bladder (DM, LMN lesions) anticholinergics, alpha agonists, BPH** (MCC), strictures, fecal impaction--> inadequate contraction (dec. detrusor contractility) causes overdistention --> leakage after overcoming urethral resistance 2. nocturnal wetting, freq. loss of small volume urine, large post vol residual 3. self cath, cholinergics (bethanechol), alpha blockers (terazosin prazosin),

reflex incontinence 1. patho

1. spinal cord injury, MS, DM, tabes, herniation, cord compression --> no sense of urinary urge

incontinence dx

1. urinalysis*, post void catheterization (normal is inflammation of myocardium 2. fatigue, fever, cx pain, pericarditis, CHF, arrhythmia, death 3. cardiac enzymes, ESR tx= supportive

acute pericarditis 1. causes (long list...)

1. idiopathic/infectious (cox*, echo, adeno, ebv, flu, HIB, hep A/B, TB*, fungal, toxo) Acute MI (within 24 hrs) uremia collagen dz - SLE, scleroderma, RA, sarcoid hodgkins lymphoma, breast/lung cancer drug lupus: procainamide, hydralazine Dresslers syndrome- weeks to months after MI post pericardectomy sndrome amyloid radiation trauma

acute pericarditis 1. treatment 2. complications

1. supportive 1-3 weeks 2. pericardial effusion, pericardial tamponade

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acute pericarditis 1. clinical pres

1. preceeding viral illness severe pleuritic chest pain, retrosternal, left precordial KUSSMAULS SIGN, PROMINENT Y DESCENT radiates to trapezius ridge/neck positional - worse when lying supine***, coughing, swallowing, deep breathing better when sitting up and leaning forward *Pericardial friction rub (3 components)

best positioning to hear a pericardial friction rub

seated upright during expiration

acute pericarditis 1. dx 2. tx

1. fever and leukocytosis pericardial friction rub ECG -- diffuse ST elevation, PR depression ST segment returns to normal in 1 week T wave inversion (then reverses later) echocardiogram often normal (unless effusion) 2. self limited treat underlying cause NSAIDS Colchicine glucocorticoids (avoid if possible)

constrictive pericarditis 1. patho 2. clincal pres 3. dx

1. post viral, uremia, radiation, TB, connective tissue disorders --> fibrous scarring and obliteration of pericardial cavity/LATE* diastolic filling restriction 2. edema, ascites, pleural effusion, hepatomegaly DOE, fatigue, exercise intolerance, cachexia, JVD kussmaul's sign 3. ECG: low voltage, T wave flattening Echo: inc. pericardial thickness, limited diastolic filling CT/MRI - pericardial thickening Cath - rapid y descent, dip and plateau (square route sign)

diagnostic modality of choice for pericardial effusion and cardiac tamponade

echocardiogram

constrictive pericarditis 1. tx

1. underlying condition* diuretics monitor/treat for coagulopathy

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pericardial effusion 1. pathogenesis 2. clinical pres 3. dx

1. ascites, pleural effusion, CHF, cirrhosis, nephrotic syndrome OR acute pericarditis --> leads to exudation of fluid into pericardial space 2. muffled heart sounds, soft PMI, dullness at left lung base, friction rub (+/-) 3. echo- see effusion (as little as 20mL) CXR- >250ml enlarged silhouette "water bottle" ECG - low voltage, flat T waves, electrical alternans CT/MRI pericardial fluid - glucose, cell count/diff, cytology, SG, Hct, gram stain, acid fast, fungal smear, cultures, LDH

pericardial effusion 1. tx

1. repeat echo 1-2 weeks, no pericardiocentesis unless there is tamponade

cardiac tamponade 1. patho 2. causes - note also interventricular septum bows into LV during inspiration further reducing LV filling

1. >200ml of rapid fluid accumulation, or 2 liters of slow fluid accumulation-> mechanical filling and diastolic impairment--> chamber pressure equalization-->dec. LV preload, dec. SV, dec. CO 2. trauma, malignancy, uremia central line placement, pacemaker insertion, pericardiocentesis pericarditis POST MI free wall rupture

cardiac tamponade 1. clinical pres 2. dx

1. elevated JVD*, narrow pulse pressure, pulsus paradoxus- >10 mmHg drop in arterial pressure during inspiration muffled heart sounds tachypnea, tachycardia, hypotension, cardiogenic shock 3. echocardiogram CXR - enlarged silhouette ECG - electrical alternans alternate variation in direction of ECG waves due to pendular heart swinging Pulsus paradoxus - >10mmHg decline in sys. pres with inspiration cardiac cath - equal chamber pressures, elevated right atrial pressure, loss of Y descent

becks triad

cardiac tamponade: hypotension, muffled heart sounds, JVD

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cardiac tamponade 1. tx

1. nonhemorrhagic and stable monitor with echo/CXR/ECG, dialysis (for uremia) hemorrhagic - emergent surgery*, pericardiocentesis

mitral stenosis 1. patho 2. clinical pres/PE

1. rheumatic heart dz** --> cross reactivity between streptococcal antigen and valve--> scarring, inc. LA pressure, pulm HTN, Afib** 2. DOE, orthopnea, PND, palpitations, CX pain, hemoptysis (bronchial vein rupture), thromboembolism murmur - S2 followed by OS (closer = mores severe) followed by diastolic rumble, loud S1 in LLD position with bell LATE: JVD, hepatomegaly, ascites, right vent. heave, loud P2 (pulm HTN)

mitral stenosis 1. dx 2. tx

1. CXR - left atrial enlargement echo - left atrial enlargement, thick mitral valve, fish mouth orifice 2. diuretics for pulm congestion/edema beta blockers - lower CO/HR endocarditis prophylaxis anticoagulation with warfarin percutaneous balloon valvuloplasty open commissurotomy/mitral replacement

aortic stenosis 1. patho 2. clinical pres 25% 3 year survival w/o treatment @ time of presentation with symptoms

1. senile aortic calcification, bicuspid aortic valve, rheumatic fever --> LV outflow obs, LVH, mitral regurg 2. angina (3 yr surv), syncope (2 yr surv), dyspnea/heart failure (1.5 yr surv.) * murmur - harsh crescendodecrescendo systolic murmur, @ right 2nd ICS, radiates to carotids, soft S2 parvus et tardus - delayed carotid upstrokes sustained PMI, precordial thrill

aortic stenosis 1. dx 2. tx

1. CXR - calcified aortic valve, dilatation of proximal ascending aorta, enlarged LV/LA ECG - LVH, LA abnormalities Echocardiogram - immobile thickened aortic valve, dilated aortic root, LVH 2. no sx = no tx sx = aortic valve replacement

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aortic regurgitation 1. causes/patho 2. symptoms

1. infective endocarditis, trauma, dissection, iatrogenic rheumatic fever, bicuspid, marfans, ehlers, syphilis. OI, behcets, reiters--> inadequate closure of aortic valve leaflets--> LV dilation/hypertrophy--> elevated pulmonary pressures 2. DOE, PND, angina orthopnea, palpitations worse with lying down, cyanosis,

aortic regurgitation 1. clinical presentation

1. decrescendo diastolic murmur at 3rd ICS left sternal border Widened pulse pressure corrigan's pulse (water hammer pulse)rapidly increase pulse that collapses suddenly decreases austin-flint murmur - low pitched diastolic rumble from competing retrograde flow, increases with handgrip S3, displaced PMI de Musset's sign (head bobbing), mullers sign (uvula bobbing, duroziez's sign (pistol shot sound over femoral arteries)

aortic regurgitation 1. dx 2. tx

1. CXR - LVH, dilated aorta ECG- LVH Echo- LV size/function/reversal of flow in aorta cardiac cath - severity of regurg, LV dysfunction 2. CCBs (nifedipine)***, salt restriction, diuretics, digoxin, ACE aortic valve replacement

mitral regurgitation 1. patho 2. clinical pres 3. dx 4. tx

acute (high mortality) - endocarditis(staph), papillary muscle rupture, chordae rupture chronic MVP, rheumatic fever, marfans, cardiomyopathy 2. DOE, PND, orthopnea, palpitations, pulmonary edema, holosystolic murmor @ apex, radiates to back or axilla, afib, S3, wide S2, palpable P2 3.CXR - cardiomegaly, dilated LV, pulm edema Echo - MR, dilated LA/LV, dec. LV function 4. afterload reduction w/ vasodilators anticoagulation IABP, mitral valve repair/replacement

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tricuspid regurgitation 1.causes 2. clinical pres

1. RV dilation 2/2 left ventricular failure, right ventricular infarction, inferior MI, cor pulmonale, tricuspid endocarditis rheum arthritis, ebstein's anomaly, carcinoid, SLE 2. RVF failure signs - ascites, hepatomegaly, edema, JVD, pulsatile liver prominent V waves and rapid Y descent blowing holosystolic murmur @LLSB worse with inspiration, reduced with expiration/valsalva

tricuspid regurgitation 1. dx 2. tx

1. echocardiogram 2. diuretics for volume overload treat underlying cause valve repair, tricuspid ring

mitral valve prolapse 1. patho 2. sx/clinical pres

1. myxomatous degeneration of the mitral leaflet/chordae leads to prolapse *common in marfans, OI, Ehlers danlos 2. usually asymptomatic mid systolic click and mid to late systolic murmur, standing and valsalva increase murmur (b/c they dec. LV chamber size), squatting decreases murmur

MVP 1. dx/tx

1. dx = echocardiogram tx = reassurance, beta blockers surgery rarely

rheumatic heart disease 1. patho 2. clinical pres 3. tx

1. GAS immunological reaction with valves 2.JONES CRITERIAMAJOR: migratory polyarthritis, erythema marginatum, carditis, chorea, subQ nodules (over tendons) MINOR: fever, ESR, polyarthralgias, hx. rheumatic fever, prolonged PR interval, evidence of strep infection 3. penicillin, erythromycin for strep pharyngitis NSAIDs for rheumatic fever erythro/amox* for dental/GI/GU prophylaxis

infective endocarditis 1. acute 2. subacute 3. native valve endocarditis 4. IVDU 5. prosthetic valves 6. pathogenesis 7. recent bladder instrumentation 8. colon cancer

1. s.aureus on a normal valve 2. on DAMAGED valves s.viridans, enterococcus on damaged valves 3. s. viridans, s. aureus, s. epidermidis, HACEK - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella 4. IVDU = s.aureus***, enterococcus, strep, candida, pseudomonas 5. s.epidermidis 6. --> cardiac failure, myocardial abscess, septic emboli, glomerulonephritis 7. enterococcus 8. s.gallolyticus/bovis

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MCC epiglottitis + CXR finding

haemophilus influenza (often beta lactamase producing), #2 is strep. pyogenes CXR - lateral neck xray shows THUMBPRINT SIGN

weil felix titer

antibody titer for rickettsial organisms ie. rocky mountain spotted fever

neisseria gram stain

gram negative diplococci

clinical presentation of mycoplasma pneumonia + dx

both upper (sore throat, otitits) and lower respiratory symptoms (CXR infiltrates), myringitis hemolytic anemia, no organisms on gram stain dx = IgM cold agglutination, positive complement fixation test

methenamine silver stain

pneumocystis

dx EBV

heterophile antibodies, and atypical lymphocytes on peripheral smear

amoebic liver abscess 1. dx/tx 2. clinical presentation

1. indirect hemagglutination and ultrasound tx = metronidazole 2. RUQ pain, possible history of diarrhea, history of travel or endemic region

Coxsackievirus can produce a morbilliform vesiculopustular rash, often with a hemorrhagic component and with lesions of the throat, palms, and soles.

...

stages of lymes disease

stage 1 - erythema chronicum migrans (bulls eye rash that enlarges) stage 2 - neurologic, cardiac, arthritic (migratory monoarticular) symptoms weeks to months after stage 1

what lab test detects both syphilis and lymes disease

VDRL

what toxin causes toxic shock

TSST 1 superantigen increases TNF, IL1 release from PMNs

treatment of influenza outbreak in a nursing home

oseltamivir and flu vaccines for the entire population

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what is sensitive and specific for diagnosis of vertebral osteomyelitis and what is the cause

MRI of the spine prior UTI is most common mechanism for bacteremia and vertebral seeding

causes of fever of unknown origin

infections, malignancies, collagen vascular disease, granulomatous disease

stills disease (juvenile RA) 1. clinical presentation 2. diagnostic blood test

classic presentation is the triad of persistent high spiking fever (FUO), joint pain and a distinctive salmon-colored rash

2. elevated serum ferritin**, RF is often negative

...

acute hepatitis A incubation period

1 month****- does not neccessarily happen immediatly after exposure

features of chickenpox rash

papules vesicles and scabs in variable stages of development

what patients are most likely to get anaerobic cellulitis

diabetics

what are the causes of non-gonococcal urethritis

ureaplasma urealyticum, trichomonas vaginalis , chlamydia trachomatis

infectious endocarditis 1. clinical presentation endocarditis 2. complications of infective endocarditis 3. tx

1. new heart murmur, unexplained fever 2. cardiac failure, myocardial abscess, solid organ damage from emboli, glomerulonephritis 3. parenteral antibiotics for 4-6 weeks if cannot isolate culture - vanc + aminoglycoside until organism is isolated

dukes criteria

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infective endocarditis diagnostic criteria Major - sustained bacteremia, endocardial involvement by echo, new valvular regurgitation Minor - predisposing condition, fever, septic or pulm emboli, mycotic aneurysm, intracranial hemorrhage, janeway lesions immune phenomenon glomerulonephritis, osler's nodes, roth spots, rheumatoid factor non major blood culture/echo

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endocarditis prophylaxis indications + tx

indications: prior history of infective endocarditis, prosthetic heart valves, untreated CYANOTIC congenital heart disease, s/p sterile deposits of fibrin/platelets that forms ALONG LINES OF CLOSURE OF VALVE LEAFLETS 2.embolizations of vegetations to brain or body

non-bacterial verrucous endocarditis (libman sacks) 1. patho 2. complications + tx

1. SLE --> warty vegetations on BOTH SIDES of the valve leaflets 2. embolization tx = treat SLE and anticoagulate

ASD 1. patho 2. clinical pres 3. dx physical, Echo, CXR, ECG

1. ostium secundum, ostium primum (low in septum), sinus venosus (high in septum) --> left to right shunt with RA/RV dilation --> pulmonary hypertension (late) 2. asymptomatic then develops into exercise intolerance, DriOE, fatigue @ age 40 3. systolic ejection murmur at LSB, wide fixed split S2* (inc. blood flow), RVF. Echocardiogram w/contrast bubble study CXR - large pulmonary arteries, inc. pulmonary markings ECG - RBBB

treatment of refractory c.difficile

switch to oral vancomycin*** metronidazole has a failure rate of 25%

treatment for hospital MRSA

linezolid, daptomycin, vancomycin TMP SMX

HIV treatment 1. raltegravir 2. maraviroc 3. basic treatment of HIV

1. integrase inhibitor 2. CCR5 antagonist 3. 2 NRTI + 1 NNRTI, or 2 NRTI + protease inhibitor

prophylaxis against malaria

atovaquone-proguanil, mefloquine, or primaquine, 2 days before trip starts based upon CDC sensitivities

catheter associated UTI

fungal, e.coli, other gram negatives

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cervicofacial actinomyces

fluctuant lesion and fistula over the mandible

blastomycosis clinical presentation

chronic respiratory infection, verrucous crusted skin lesions, osteolytic bone lesions

aspergillus related disease

disseminated in immunocompromised allergic bronchopulmonary young woman with asthma aspergilloma - bronchial plugs with hyphae

which diseases are associated with peeling of the skin

staph toxic shock kawasaki scarlet fever severe drug reaction

which diseases associated with peeling of the skin

meningococcus, gonococcemia, rickettsia, infectious endocarditis, atypical measles, DIC associated with sepsis

causes of dysphagia in HIV patients

candida***(empiric fluconazole), HSV, cytomegalovirus

risk factors for IV contrast induced nephropathy + avoidance of complications

1. volume depletion, diabetes, CHF, CKD, multiple myeloma 2. hydration*** with isosmolar fluids, and sodium bicarb, nacetylcysteine

treatment for COPD exacerbation

steroids - Bipap is better because is reduces CO2 retention, - NOT OXYGEN THERAPY because of haldane effect and hypoxia drives respiration in COPD patients

causes of delirium

medications (anticholinergics, antihistamines, TCAs), postsurgical, infection, electrolytes, benzos, fluoroquinolones.

healthcare associated pneumonia 1. associated settings 2. bacteria 3. tx

1. long term care, recent hospitalization, chronic dialysis 2. inc. risk for acinetobacter, s. aureus, pseudomonas 3. carbapenem, fluoroquinolone, vancomycin

what decreases risk of ventilator associated pneumonia

daily interruption of sedation (sedation holiday), oropharyngeal intubation, elevating head of the bed

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complications of ASD 2. when to treat ASD

1. pulmonary hypertension eisenmenger disease- irreversible pulmonary hypertension leads to shung reversal, heart failure, cyanosis right heart failure A.fib stroke (PARADOXICAL EMBOLI), Afib 2. when pulm:systemic > 2:1 or if symptoms

VSD 1. patho 2. clinical pres 3. complications 4. dx/tx

1. right to left shunt leads to pulmonary hypertension 2. holosystolic harsh murmur @ 4th left ICS decreases with valsalva/handgrip, prominent P2 3. CHF, growth failure, lower resp. infections, eisenmenger's, cyanosis, DOE, aortic regurgitation 4. ECG - ventricular hypertrophy CXR - PA echo - shows septal defect tx = surgical repair if pulm:sys pressure 2:1, no abx prophylaxis if uncomplicated VSD

coarctation of the aorta 1. patho 2. clinical pres 3. dx/tx

1. narrowing of aorta @ left subclavian origin near lig. arteriosum 2. brachiofemoral delay, underdeveloped lower body, leg fatigue, claudication, headache, turner's features 3. ECG - LVH CXR - rib notching, figure 3 from indentation of the aorta tx = surgical decompression, percutaneous balloon aortoplasty

coarctation of the aorta complications

HTN, cerebral aneurysms, infectious endocarditis,aortic dissection

clinical associations with PDA

congenital rubella syndrome, high altitude, premature birth

PDA 1. clinical presentation 2. tx

1. asymptomatic, heart failure continuous machinery murmur, wide pulse pressure, bounding peripheral pulses, LOWER EXTREMITY clubbing/cyanosis 2. indomethacin, PGE, do not correct if severe pulm htn.

TOF 1. patho 2. tet spells 3. dx

1. VSD, right ventricular hypertrophy, pulmonary stenosis, aortic override. 2. squatting after exertion increases SVR and increases blood flow from RV to lungs 3. echocardiography CXR - BOOT SHAPED HEART EKG shows enlarged RA/RV

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hypertensive emergency 1. definition 2. clinical findings

1. >220/>120 with end organ damage * requires immediate treatment 2. altered mental status, papilledema, hypertensive encephalopathy, renal failure, hematuria, unstable angina, MI, CHF, pulmonary edema, dissection

hypertensive urgency

>220/>120 without evidence of end organ damage

posterior reversible encephalopathy syndrome 1. patho 2. symptoms 3. dx

1. 2/2 hypertensive emergency autoregulatory failure of cerebral vessels leads to arteriolar dilation and extravasation of fluid into the brain 2. insidious onset headache, seizures, visual changes 3. posterior cerebral white matter edema

treatment for hypertensive emergency

1. lower the BP (hydralazine, esmolol, nitroprusside, labetalol, nitroglycerin) 25% in 1-2 hours and then reduce gradually (with less intensive therapy) 2. order CT to r/o intracranial bleeding 3. negative CT proceed with lumbar puncture

aortic dissection 1. risk factors 2. type A vs type B 3. clinical pres *****BE CAREFUL AND DO NOT GIVE THROMBOLYTIC IF PRESENTATION IS SIMILAR TO MYOCARDIAL INFARCTION

1. hypertension, smoking, cocaine, trauma, marfans, ehler danlos, bicuspid aortic valve, coarctation, third trimester pregnancy 2. type A includes the ascending aorta type B distal to the subclavian artery 3. severe tearing, ripping sensation anterior chest (type A), or interscapular (type B), diaphoresis, pulse asymmetry between limbs, aortic regurg murmur (A), neurologic (obstruction of carotid)

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aortic dissection 1. dx / tx***

1. CXR - widened mediastinum, right sided pleural effusion TEE*** (NOT TTE) CT*/MRI - disadvantage is it takes longer aortic angiography tx= ANTIHYPERTENSIVES FIRST*** IV beta blockers, IV nitroprusside immediately Type A - surgical emergency Type B - medical - lower bp, pain control, if symptoms persist treat surgically

AAA 1. patho 2. clinical pres 3. ruptured AAA clinical pres 4. dx/tx

1. trauma, HTN, vasculitis, smoking, syphilis, marfans (thoracic) --> dilatation of aorta between renal arteries and iliac bifurcation 2. usually ASYMPTOMATIC, throbbing hypogastric and lower back pain, severe pain in back or lower abdomen radiating to groin, buttocks or legs, grey turner sign, cullen sign 3.abdominal pain, hypotension, palpable pulsatile mass , syncope, n/v 4. ultrasound = diagnosis of choice*** CT scan = only if hemodynamically stable

AAA 1. tx

1. >5 cm in diameter, surgical resection with graft placement ruptured = open repair or endovascular

leriche syndrome

atheromatous occlusion of distal aorta above the bifurcation causing BILATERAL CLAUDICATION IMPOTENCE DEC. FEMORAL PULSES

PVD 1. associated conditions 2. common sites 3. risk factors

1. coexisting CAD, MI, diabetes, lung disease 2. superficial femoral (in hunter's canal), popliteal, aortoiliac 3. smoking**, CAD, HLD, HTN, DM**

PVD evaluation

ECG, CBC, BUN/Cr, coagulation profile (factor V, antithrombin III, protein S/C)

PVD 1. intermittent claudication 2. rest pain 3. clinical findings

1. leg pain reproduced by same walking distance relieved by rest 2. pain in distal metatarsals prominent at NIGHT awakens from sleep relieved by hanging legs over the bed 3. dec. pulse, atrophy, loss of hair, thick toenails, decreased skin temp, ischemic ulcers, infarction, gangrene, pallor of elevation, rubor of dependency (BUERGER'S TEST)

brodie trendelenburg test

...

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PVD diagnosis PVD tx

1. normal ABI between 1.0 and 1.3 ABI > 1.3 is due to noncompressible vessels and is an indication of severe disease claudication showers of cholesterol from proximal source (atherosclerotic plaque) from aorta, iliac, or femoral arteries 2. small discrete areas of tissue ischemiablack/blue toes, renal insufficiency, abdominal pain/bleeding 3. dx = Eosinophilia******* tx = supportive, DO NOT anticoagulate,control BP, AVOID amputation or surgical resection

mycotic aneurysm cause and treatment

infection of the wall of the aorta leads to damage of the aortic wall tx = IV abx and surgical excision

luetic heart 1. patho

1. syphilitic aortitis leads to retrograde extensionaortic regurgitation and stenosis of the aortic branches (coronaries) tx = IV penicillin and surgical repari

DVT 1. pahto 2 risk factors 3. clinical pres

1. virchows triad - endothelial injury, hypercoagulability, venous stasis 2. prior history, prolonged immobilization, cardiac disease, CHF, obesity, major surgery (esp. ortho), pregnancy and estrogen use, smoking 3. classic findings- unilateral leg swelling/pain better with elevation/rest HOMANS sign - calf pain with dorsiflexion, palpable cord, fever

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DVT dx tx

doppler analysis, doppler ultrasound good for proximal thrombi, not for distal Venography - best for calf veins impedance plethysmography D-dimer testing - high sens tx = if doppler is positive start anticoagulation, if non-diagnostic repeat every 2-3 days for up to 2 weeks - heparin bolus titrate up to 1.5-2x aPTT, start warfafarin for 3-6 months, thrombolytic therapy (massive PE and unstable) IVC filter - prevents PE

complications of DVT

PE post thrombotic syndrome (chronic venous insufficiency) phlegmasia cerulea dolens - severe leg edema that compromises arterial supply results in impaired sensory/motor function

how to prevent post-op DVT

leg elevation, compression stockings, early ambulation, pneumatic boots

heparin or LMWH + pneumatic compression = BEST COMBO

...

chronic venous insufficiency 1. pathogenesis

1. history of DVT destroys venous valves--> ambulatory venous hypertension --> edema and extravasation of RBCs/proteins into subQ tissue leads to pigmentation--> reduced capillary flow and ulceration with mild trauma

chronic venous insufficiency 1. clinical presentation 2. tx

1. swelling worse at end of day, standing, sitting, elevation provides relief brawny, atrophic, shiny, indurated, cyanotic skin venous ulcers - MEDIAL MALLEOLUS 2. leg elevation avoid prolonged standing, elastic stockings, wet to dry saline dressings, unna venous boot, skin graft

superficial thrombophlebitis 1. patho 2. clincal pres

1. upper extremities - IV infusion lower extremities - varicose veins 2. pain tenderness, erythema along course of vein, with tender palpable cord 3. tx = no anticoagulation, aspirin, severe with pain/cellulitis - rest, elevation, hot compresses, only use abx if suppurative

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septic phlebitis tx

remove the offending IV canula and treat with IV abx x

migratory superficial thrombophlebitis

2/2 occult malignancy especially pancreatic cancer

1. most common tumor of the heart 2. atrial myxoma 3. atrial myxoma clinical pres

1. metastasis from other primary tumors 2. MCC primary heart tumor - usually from intratrial septum near fossa ovalis 3/ fatigue, fever, syncope, positional murmur, DIASTOLIC TUMOR PLOP

shock 1. clinical presentation

1. lactic acidosis, anuria/oliguria, altered mental status

CO/SVR/PCWP for 1. cardiogenic shock 2. hypovolemic 3. neurogenic 4. septic

1. dec,inc, inc 2. dec, inc, dec 3. dec, dec, dec 4. inc, dec, dec

cardiogenic shock 1. patho 2. clinical pres 3. dx

1. post MI, tamponade, tension pneumothorax, arrhythmias, massive PE, cardiomyopathy, valve defects, VSD --> CO too low to maintain tissue perfusion 2. BP SIRS--> sepsis -> septic shock --> multi organ dysfunction syndrome 3. signs of SIRS, signs of shock, temperature, severe peripheral vasodilation, WARM FLUSHED SKIN 4. IV abx, including fungal coverage, fluid administration, vasopressors

1. SIRS 2. sepsis 2a. severe sepsis 3. septic shock 4. multiorgan dysfunction

2 or more of fever >38 or hypothermia 20 bpm, or PaCO290 Inc. WBC >12000 or 10% bands 2. positive blood cultures (2 different sites) before abx administration + SIRS 2a. sepsis with organ dysfunction, hypoperfusion or hypotension 3. hypotension induced by sepsis despite adequate volume resuscitation 4. altered organ function in acutely ill patient leading to death

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neurogenic shock 1. patho 2. clinical pres 3. tx

1. failure of nervous system ot maintain adequate vascular tone - results from spinal cord injury, severe head injury, spinal anesthesia, sympathetic blockade --> peripheral vasodilation and decreased SVR 2. warm skin, low UOP, bradycardia/hypotension 3. IV fluids, cautious use of vasoconstrictors, trendelenburg position, control body temp

COPD 1. chronic bronchitis diagnostic criteria 2. pathogenesis

1. chronic cough producing sputum for >3 months for >2 years 2. excess mucus production narrows airways--> productive cough--> scarring of airways, enlargement of mucus glands, smooth muscle hyperplasia

diagnostic test for sjogrens

schirmers test with anti-Ro antibodies

DMARDs

methotrexate, anti-TNFs, antimalarials, sulfasalazine

other associated conditions with ank-spondy

uveitis, other joint disease, crohns

1. what are the causes of reiters syndrome 2. clinical pres 3. clinical associations

gonorrhea,non-gonococcal urethritis, GI infections - yersinia, campylobacter, salmonella, shigella 2. oligoarticular arthritis, conjunctivitis, urethritis, keratodermia blennorrhagicum (looks like papular psoriasis), spondylitis 3. HLA B27,

Scleroderma systemic sclerosis,

systemicvasculopathy of small and medium-sized vessels, excessive collagen depositionin tissues, and an abnormal immune system. It is an uncommon multisystemdisease affecting women more often than men. There are two variants of scleroderma

polymyalgia rheumatic 1. patho + clinical association

1. proximal joint stiffness worse in the morning associated with giant cell arteritis (50% of patients with GCA have polymyalgia rheumatica),

radiological finding of psoriatic arthritis

pencil in cup deformity @ DIP

chondromalacia patellae

common problem in runners - pain is worse when walking down stairs - lateral displacement of the patella with knee extension

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dermatomyositis vs. polymyositis etiology

dermatomyositis is immune complex deposition

polymyositis is T cell mediated

...

emphysema 1. patho

1. alveolar wall destruction to to excess protease (from PMNs/macrophages), or lack of anti-protease enlargement of the air spaces distal to the terminal bronchioles

causes of COPD

tobacco smoke alpha 1 antitrypsin environment (2nd hand smoke) chronic asthma

how does tobacco smoke cause emphysema

increases number of activated PMNs/macrophages and also inhibits alpha 1 antitrypsin

centrilobular emphysema

destruction limited to respiratory bronchioles (proximal to acini) usually in upper lung zones] *** centrilobular is seen in SMOKERS**

panlobular emphysema

destruction involves proximal and distal acini in the lung bases **panlobular is seen in patients with alpha 1 antitrypsin deficiency**

COPD 1. clinical presentation 2. PFT findings that defines COPD

1. cough, sputum production, progressively worsening DOE, full exhalation >6 seconds, end expiratory wheezes, hyperresonance, 2. dec. FEV1 FEV1/FEV 300, mod 100-300, sev 20% with methacholine or histamine CXR- only mild hyperinflation ABGs - if in respiratory distresshypocarbia (LOW PaCO2), hypoxemia

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classification/treatment asthma 1. mild intermittent 2. mild persistent 3. moderate persistent

1. sx 2 or less times/week albuterol rescue inhaler 2. >2x/wk but not every day albuterol + low dose inhaled steroid 3. daily sx, freq exacerbations daily inhaled corticosteroid or cromoly, nedocromil, methylxanthine, or antileukotriene 4. daily high dose inhaled corticosteroid, long acting beta 2 agonist, or methylxanthine and systemic steroids

side effects of inhaled corticosteroids

sore throat, oral candidiasis, hoarseness

what to order in a suspected acute asthma exacerbation

PEF - decreased ABG - inc A-a gradient CXR - rule out pneumonia/pneumothorax

asthma complications

status asthmaticus (no response to standard meds), acute respiratory failure (respiratory muscle fatigue) pneumothorax, atelectasis, pneumomediastinum

aspirin sensitive asthma

seen in patients with asthma and nasal polyps, asthma is exacerbated by aspirin

bronchiectasis 1. patho 2. clinical pres 3. dx/tx

1. CF***, infection, humoral immunodeficiency, airway obstruction --> permanent dilation of bronchial wall, damaged cilia 2. chronic cough with foul smelling mucopurulent purulent sputum, dyspnea, hemoptysis, recurrent pneumonia 3. high res CT, obstructive PFTs, abnl CXR, bronchoscopy tx = abx for exacerbations, hydration, chest physiotherapy, bronchodilators

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cystic fibrosis 1. patho 2. clinical pres 3. tx

1. AUTOSOMAL RECESSIVE - defect in chloride proteins causing impaired chloride/water transport leading to thick secretions of respiratory tract, exocrine pancreas, sweat glands, intestines, GU 2. obstructive lung disease, chronic pulmonary infections (pseudomonas), pancreatic insufficiency, GI complications 3. pancreatic enzyme replacement, fat soluble vitamin supplement (ADEK), vaccinations (flu, pneumo), abx, inhaled rhDNase

lung cancer 1. types 2. risks 3. clinical pres - tends to present late 4. sites of mets

1. small cell (25%) squamous, adeno, large cell, bronchoalveolar (75%) 2. smoking - pack years, adeno has lowest association with smoking, asbestos, radon, COPD 3. cough, hemoptysis, obstruction, wheezing, dyspnea, recurrent pneumonia, constitutional symptoms 4. brain, bone, adrenals, liver

lung cancer clinical syndromes 1. SVC syndrome 2. phrenic nerve palsy 3. hoarseness 4. horners syndrome 5. pancoast tumor

1. facial fullness, facial/arm edema, dilated veins of anterior chest, JVD 2. destruction of phrenic nerve by tumor causes hemidiaphragm paralysis 3. due to involvement of recurrent laryngeal nerve 4. cervical sympathetic chain anhidrosis, ptosis, miosis 5. superior sulcus tumor involves C8-T2 causes radiation down the arm

1. which type of lung cancer associated with airway involvement 2. what kind of lung cancer associated with pancoast tumor 3. which type of lung cancer seen in women, nonsmokers

1. SCC 2. SCC 3. bronchoalveolar

paraneoplastic syndromes 1. small cell 2. squamous cell 3. adenocarcinoma

1. SIADH, ectopic ACTH, hypertrophic pulmonary osteoarthropathy, eaton lambert - similar to myasthenia gravis 2. PTHrp, hypertrophic osteoarthropathy 3. hypertrophic osteoarthropathy

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lung cancer 1. dx

1. CXR (stable >2 years = BENIGN) NOT A SCREENING TEST CT CHEST WITH CONTRAST - useful for staging sputum cytology - only diagnoses central tumors fiberoptic bronchoscope w/ bx - only diagnoses central tumors whole body PET scan - detects lymph node, thoracic, distant metastasis thoracic needle biopsy mediastinoscopy - identifies advanced disease and rules out surgery as treatment

lung cancer 1. tx

1. NSCLC - surgery + radiation adjuvant SCLC - chemotherapy and radiation, non-surgical

solitary pulmonary nodule 1. possible causes 2. features favoring benign 3. feature favoring malignant - page 80- algorithm

1. granuloma, hamartoma, adenoma, carcinoma 2. age 2cm,

1. radiographic features of SCC lung cancer 2. """""" adenocarcinoma 3. """""" large cell 4. """""" small cell

1. central location, cavitary 2. peripheral location, plerual, less associated with smoking 3. peripheral 4. central, extrinsically compresses bronchi

1. management for a SPN that is at new, or has changed within 2 years 2. """ 1cm or larger that has changed or is new or films are not available

1. serial CT scan 2. PET scan

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mediastinal mass 1. MCC in older patients 2. ant. mediastinal masses 3. middle mediastinal masses 4. posterior mediastinal masses 5. symptoms of mediastinal masses 6. dx

1. mets, usually lung 2. thyroid, teratogenic tumors, thymoma, lymphoma 3. lung cancer, lymphoma, aneurysms, bronchogenic cysts, morgagni hernia, pericardial cysts 4. neurogenic tumors, esophageal masses, enteric cysts, aneurysms, bochdalek hernia 5. cough, chest pain, dyspnea, dysphagia, SVC syndrome, hoarseness (RLN), horners (sympathetic ganglia), diaphragm paralysis (phrenic) 6. CT scan

1. transudative vs exudative pleural effusions 2. causes of """"

1. transudative - elevated capillary pressure in visceral or parietal pleura or dec. plasma oncotic pressure exudative - increased permeability of pleural surfaces 2. transudative - CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis, hypoalbuminemia, PE, atelectasis exudative - bacterial pneumonia, TB, malig, metastasis, viral infection, PE, collagen vascular disease

1. what tests should be performed on an exudative pleural effusion 2. lab findings that distinguish exudative vs transudative effusion

1. differential cell count, glucose, pH, amylase, triglycerides, microbiology, cytology 2. plerual protein:serum protein >0.5 pleural LDH: serum LDH >0.6 LDH > 2/3 upper limit of normal

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pleural effusion 1. dx 2. tx

1. CXR - blunting of costophrenic angle (~250ml) lateral decubitus better than PA and lateral CT scan is most reliable thoracentesis (only if >10 mm deep on lateral decubitus, complication = PTX ) --> SEND FLUID TO BE TESTED FOR THE 4 C'S chemistry (glucose, pH, LDH, protein), cytology, cell count, culture (and gram stain) 2. transudative - diuretics, sodium restriction , therapeutic thoracentesis if massive /dyspnea exudative - treat underlying disease parapneumonic - abx, chest tube, intrapleural thrombolytics, surgical lysis

special pleural effusions 1. elevated amylase 2. milky opalescent 3. frankly purulent 4. bloody 5. lymphocytic 6. pH empyema (pus) (ie. a complicated parapneumonic effusion) 2. thoracentesis, abx, rib resection/open drainage

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pneumothorax 1. patho 2.secondary pneumothorax 3. clinical pres 4. dx/tx

1. traumatic (transthoracic needle aspiration, thoracentesis, central line), or spontaneous (subpleural blebs) --> air in normally airless pleural space 2. complication of COPD, asthma, interstitial lung disease, neoplasms, CF, TB 3. ipsilateral chest pain, dyspnea, cough, dec. breath sounds, hyperresonance, dec. tactile fremitus, mediastinal shift toward PTX**** 4. CXR - visceral pleural line tx = small just observe large or with symptoms - administer oxygen and place a chest tube

fibromyalgia 1. clinical pres 2. dx

1. diffuse musculoskeletal pain (WITHOUT weakness), worsens with exercise,fatigue, non-restorative sleep, absence of joint swelling 2. 11/18 tender point sites,

tension pneumothorax 1. patho 2. clinical pres 3. dx/tx

1. mechanical ventilation, CPR, trauma --> air accumulate in pleural space through opening that acts as a valve leads to collapse of ipsilateral lung and medi 2. hypotension, distended neck veins, tracheal shift away from PTX, dec. breath sounds on affected side, hyperresonance to percussion on affected side 3. dx- DO NOT DO CXR IF SUSPECTED , decompress via large bore cx tube

malignant mesothelioma clinical association

asbestos exposure

define interstitial lung disease

inflammatory process of the alveolar wall with widespread fibroelastic proliferation/collagen deposition that can lead to irreversible lung damage

what drugs are known to be toxic to the lungs

chemotherapeutics, amiodarone, penicillamine, nitrofurantoin, bleomycin, phenytoin

end stage interstitial lung disease is referred to as

honeycomb lung

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sarcoidosis 1. patho 2. clinical pres

1. chronic systemic NONCASEATING GRANULOMAS of unknown etiology (more common in AA women 1,25D3) low PTH **transbronchial biopsy showed noncaseating granulomas** 2. dec lung volumes (VC and TLC), dec. DLCO, dec. FEV1/FVC 3. spontaneously improve in 2 years systemic corticosteroids, methotrexate

classic clinical presentation for sarcoidosis

constitutional symptoms respiratory complaints erythema nodosum blurred vision bilateral hilar adenopathy

CXR staging of sarcoidosis

stage 1 - bilateral hilar adenopathy without parenchymal infiltrates stage 2 - hilar adenopathy with parenchymal infiltrates stage 3 - diffuse parenchymal infiltrates without hilar adenopathy stage 4 - pulmonary fibrosis with honeycombing and fibrocystic parenchymal changes

histiocytosis x 1 patho 2. clinical pres 3. dx/tx

1. chronic interstitial pneumonia caused by proliferation of histiocytes 90% are cigarette smokers 2. dyspnea and nonproductive cough, lytic bone lesions, spontaneous pneumothorax, diabetes insipidus 3. CXR shows honeycomb with cystic lesions, reticulonodular appearance tx = corticosteroids or lung transplant

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wegeners granulomatosis 1. patho 2. clinical pres 3. dx/tx

1. necrotizing granulomatous vasculitis affects lungs/upper airway**, kidneys, and other organs 2. upper and lower respiratory infections, glomerulonephritis, pulmonary nodules, skin findings subQ nod, purpura, pyoderma gangrenosum 3. tissue biopsy positive for CANCA*** ~ anti proteinase 3 tx = glucocorticoids + cyclophosphamide

churg strauss syndrome 1. patho 2. clinical pres 3. dx/tx

1. granulomatous vasculitis in asthma patients, 2. pulmonary infiltrates, rash, eosinophilia 3. CBC - eosinophilia p-ANCA (myeloperoxidase positive tissue biopsy tx = systemic glucocorticoids

coal workers pneumoconiosis

inhalation of coal dust with carbon and silica can progress to fibrosis of the lungs

substances that cause pneumoconiosis

silica, berylium, asbestos, coal dust, graphite,carbon, aluminum, talc

asbestosis 1. patho 2. complications 3. dx/tx

1. diffuse interstitial lung fibrosis of the LOWER LOBES 2. bronchogenic carcinoma, malignant mesothelioma 3. CXR shows pleural plaques and hazy infiltrates with linear opacities

CXR findings for asbestosis/silicosis

asbestosis - pleural plaques silicosis - egg shell calcifications

silicosis 1. patho 2. clinical pres 3. dx

UPPER LOBES nodular, localized peribronchial fibrosis 2. DOE, cough with sputum 3. CXR, restrictive PFTs

diagnosis of berylliosis

beryllium lymphocyte proliferation test

hypersensitivity pneumonitis 1. patho 2. causes 3. clinical pres 4. dx / tx

1. inhalation of organic dusts, thermophilic actinomycetes, fungi, avian proteins--> serum IgG/IgA --> flu like features 2. farmers lungs (moldy hay), bird breeders lung (avian droppings), air conditioner lung, bagassosis, mushroom worker's lung 3. cough, dyspnea, fever, chills, myalgia 4-8 hours after exposure 4. IgG antibody to offending antigen tx = steroids*****, and avoidance-bronchodilators/antihistamines are INEFFECTIVE

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eosinophilic pneumonia 1. dx 2. tx

1. fever, peripheral eosinophilia, CXR with peripheral pulmonary infiltrates 2. systemic glucocorticoids

goodpasture's syndrome 1. patho 2. clinical pres 3. dx/tx

1. IgG anti-GBM and alveolar basement membrane --> pneumonitis/glomerulonephritis 2. hemoptysis, dyspnea, hematuria 3. tissue biopsy, IgG anti GBM tx = plasmapheresis*, cyclophosphamide, corticosteroids

pulmonary alveolar proteinosis 1. patho 2. clinical pres 3. dx/tx

1. accumulation of surfactant and phospholipids in alveoli 2. dry cough, dyspnea, hypoxia, rales 3. CXR - ground glass, bilateral alveolar infiltrates resembling a bat lung biopsy *** tx= lung lavage, GCSF, dont give steroids

idiopathic pulmonary fibrosis 1. patho 2. dx

1. gradual onset dyspnea, non-productive cough 2. CXR - normal or honeycomb lung biopsy*** PFTs - restrictive lung pattern (dec. TLC, FEV1/FVC normal, dec. FEV1, dec. FVC) tx = supplemental O2, corticosteroids with and without cyclophosphamide, lung transplantation

cryptogenic organizing pneumonitis 1. patho 2. dx

1. virus/meds/connective tissue disease -> inflammatory lung disease that presents similar to pneumonia 2. CXR similar to pneumonia, abx ineffective tx = corticosteroids

radiation pneumonitis 1 patho

1. thoracic radiation --> interstitial pulmonary inflammation--> 2 years later alveolar thickening, pulmonary fibrosis 2. low grade fever, cough, chest fullness, dyspnea, pleuritic chest pain, hemoptysis 3. normal CXR CT scan - diffuse infiltrates, ground glass densities, patchy consolidation, pericardial/pleural effusions tx = corticosteroids

respiratory failure 1. hypoxia definition 2. hypoxemic respiratory failure definition 3. causes of hypoxemic respiratory failure

1. PaO2 50 2. low PaO2 with PaCO2 either low to normal O2 saturation 0.6 3. V/Q mismatch, intrapulmonary shunting ex. ARDS, pneumonia, pulmonary edema ,

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ventilatory respiratory failure 1. definition 2. causes

1. hypercapnia**** and hypoxemia 2. dec. minute ventilation or inc. dead space leads to CO2 retention/hypoxemia ex. CNS depression, mechanical restriction, respiratory fatigue, COPD, asthma CF, severe bronchitis

how to change a patient's ventilation vs oxygenation

ventilation - PaCO2- inc. RR or tidal volume (minute ventilation = RR*TV) oxygenation - PaO2 - inc FiO2 or inc PEEP

two causes of respiratory failure 1. VQ mismatch 2. intrapulmonary shunting

1. hypoxia without hypercapnia, seen in chronic lung disorders, RESPONSIVE TO OXYGEN 2. no ventilation in perfused areas, venous blood shunted into arterial circulation without oxygenation - ex. atelectasis, pneumonia, pulmonary edema, NOT RESPONSIVE TO OXYGEN

what are causes of inc. CO2 production leading to hypercapnic respiratory failure

sepsis, DKA, hyperthermia

clinical pres. of respiratory failure

dyspnea, cough, inability to speak in complete sentence, use of accessory muscles, tachypnea, tachycardia, cyanosis, impaired mentation

evaluation of hypoxemic patient Pg 96 - evaluation of hypoxic patient

get ABG look at PaCO2 elevated or not look at A-a gradient look at response to oxygen 1. if PaCO2 is elevated and A-a is normal = hypoventilation 2. if PaCO2 is elevated and A-a is elevated = hypoventilation + another factor 3. if PaCO2 is normal, and A-a is normal = low inspired PAO2 4. if PaCO2 is normal, A-a increased, and response to supp O2 = VQ mismatch 5. if PaCO2 is normal, A-a increased, no response to supp O2 = shunt

treatment for respiratory failure

treat underlying cause - ex. bronchodilators, corticosteroids, abx provide supplemental oxygen at lowest possible concentration NPPV for conscious patients with possible impending respiratory failure

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ways to improve tissue oxygenation

inc. FiO2, inc. PEEP, inc. inspiratory time fraction, inc. CO, inc. hemoglobin, remove venodilators

NPPV 1. indications 2. requirements

1. attempt to avoid intubation in patient with impending respiratory failure 2. patient must be neurologically intact, awake and cooperative

ARDS 1. patho 2. causes

1. bilateral inflammatory lung processes --> inc. alveolar capillary permeability--> massive intrapulmonary shunting (atelectasis, surfactant dysfunction)/no improvement with supplemental O2, dec. pulmonary compliance, inc. dead space, inc. A-a gradient. 2. sepsis***(pneumonia, urosepsis, wounds etc), aspiration, severe trauma, pancreatitis, massive transfusions, near drowning, intracranial HTN

ARDS 1. clinical pres 2. dx 3. tx

complications of ARDS

1. dyspnea, tachypnea, tachycardia, hypoxemia hypoxemia unresponsive to oxygen PaO2/FiO2 thickening of arteriolar walls, most common in middle age women 2. cardiac cath*** CXR - enlarged central pulmonary arteries, enlarged RV, clear lung fields PFT - restrictive pattern ECG - right axis deviation tx = IV prostacyclins, CCBs (nifedipine or diltiazem), nitric oxide/adenosine/CCB trials anticoag with warfarin

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cor pulmonale 1. patho 2. clinical pres 3. dx/tx

1. COPD, PE, ILD, asthma, CF, sleep apnea, PPH --> right ventricular hypertrophy/failure 2. signs of RV failure, cyanosis, clubbing 3. treat underlying disorder, USE DIURETICS CAUTIOUSLY THESE PATIENTS ARE PRELOAD DEPENDENT, long term O2 therapy, digoxin for LV failure,

how does PE cause death

hypoxemic respiratory failure acute pulmonary hypertension and RV failure

pulmonary emboli sources

DVT fat embolism amniotic embolism air embolism septic embolism (IVDU) schistosomiasis

PE 1. patho 2. DVT sources 3. complications 4. risk factors

1. thrombus from other region of the body embolizes to the pulmonary vascular tree --> dead space, inc PulmVR- acute cor pulmonale 2. deep veins of the lower extremities and pelvis 3. recurrent PE, pulmonary HTN (66%) 4. age >60, malig, hx of DVT/PE, hereditary hypercoagulability, cardiac diseease, obesity, nephrotic syndrome, pelvic/ortho surg, major trauma, pregnancy, estrogen use

two important PE studeies

The PIOPED study, the Christopher study

clinical presentation of fat embolism

dyspne, altered mental status, petechiae over the chest

PE clincal pres PE mortality

dyspnea ***, pleuritic chest pain, cough, hemoptysis, sycope, S3/S4, inc. P2 tachypnea, SOB - due to inc. dead space--> hypoxemia/hypercarbia 30% mortality, 10% if diagnosed within 1 hour, if untreated 30% will die from recurrent PE treatment reduces mortality to 2-8%

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PE 1. dx 2. how to rule out PE 3. what patients cannot have spiral CT

1. ABG - low PaO2, low PaCO2, high pH elevated A-a gradient* CT scan - intraluminal filling defects in central/segmental or lobar pulmonary arteries Pulmonary angiogram**** definitive dx D-dimer 2. negative pulmonary angiogram, negative D-dimer assay, low prob VQ scan 3. patients with renal failure due to the IV contrast

PE 1. CXR findings 2. negative CTA but high clinical suspicion= what prob of PE 3. tx

1. atelectasis, or pleural effusion, westermark's sign (prom central pulm artery with local oligemia), hampton's hump (lung infarction) 2. 5% 3. supplemental O2, anticoag (START IMMEDIATELY with heparin and warfarin), continue for 3-6 months thrombolytics - TPA, streptokinase IVC filter

complications associated with IVC filters

higher risk for DVT perforation of the IVC wall IVC obstruction

indications for IVC filters

contraindication for anticoagulation complication of current anticoagulation failure of adequate anti-coagulation low pulmonary reserve at high risk for PE

wells criteria for acute PE

symptoms/signs of DVT - 3 alt diagnosis less likely than PE - 3 HR > 100 bpm - 1.5 immobilization >3 days or surgery in previous 4 weeks - 1.5 previous DVT or PE - 1.5 hemoptysis - 1.0 malignancy - 1.0

if 4 get spiral CT scan

...

pulmonary aspiration 1. anatomic location 2. clinical presentation 3. predisposing factors

1. lower portions of the right upper lobe upper portions of hte right lower lobe 2. symptoms of pneumonia 2-4 days after aspiration (in 40% of patients who aspirate) 3. reduced LOC, alcoholism, extubation, excessive vomiting, ileus, tracheostomy, anesthesia/surgery, NMJ diseases, esophageal disorders (achalasia, GERD, cancer)

what is the indication for an INR 2.5-3.5

recurrent MI, antiphospholipid antibody syndrome

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1. aspiration pneumonia clinical pres 2. dx 3. tx

1. initially asymptomatic, then cough, SOB, fever, tachypnea, hypoxemia, frothy sputum 2. CXR similar to bacterial pneumonia, atelectasis, collapsed areas 3. ABCs, clindamycin, early bronchoscopy for obstruction,

how to prevent aspiration pneumonia

keep head of bed elevated, NG tube

dyspnea 1. key history 2. most common causes

1. acute vs chronic, heart/lung disease, baseline level of activity, exertional component, smoking, sputum 2. CHF exacerbation, pneumonia, bronchospasm, PE, anxiety

dyspnea 1. cardiovascular causes 2. respiratory causes 3. psychiatric causes 4. chest wall causes 5. neuromuscular causes 6. systemic causes

1. CHF, ischemia, pericarditis/tamponade, arrhythmias, valve disease, congenital 2. COPD, asthma, PE, ARDS, pneumonia, TB, bronchitis, pleural effusion, pulmonary edema, PTX, airway obstruction, ILD 3. GAD, panic attacks, hyperventilation 4. kyphoscoliosis, rib fractures, ank spondy 5. myasthenia , muscular dystrophy 6. chronic anemia, sepsis, DKA, GERD, narcotics

dyspnea 1. dx

1. pulse ox - COPD may be chronically low ABG - indicated if pulse ox is low CXR - can show etiology CBC - anemia, infection ECG - ventricular hypertrophy/ischemia Echo- further eval VQ scan, bronchoscopy

what are the complications of aspiration

lung aspiration/pneumonia

what lab/studies used to distinguish between lung/heart disease

CXR, sputum gram stain, PFT, ABG, ECG, echocardiogram

what will a chronic COPD patient's blood gas show at baseline and during exacerbation

baseline - normal pH, elevated HCO3exacerbation - low pH, normal HCO3-

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hemoptysis 1. massive hemoptysis definition + most common causes 2. causes 3. dx

1. >600 ml in 24 hoursbronchiectasis ,and bleeding diathesis 2. bronchitis, TB, bronchiectasis, pneumonia, idiopathic, good pastures, PE with infarction, aspergilloma, mitral stenosis, hemophilia. 3. CXR - may show fungus ball, mass, granuloma, opacity fiberoptic bronchoscopy - if suspicious for lung carcinoma CT chest -

indication for home oxygen

O2 saturation 50 adenomatous polyps IBD - UC 20% at 30 years of age family history (first degree relatives

CRC 1. histological classes 2. morphology types

1. tubular, tubulovillous, villous (worst) 2. sessile, pedunculated

FAP

autosomal dominant APC mutation leads to hundreds of adenomatous polyps in the colon, and duodenum (90%), as well as stomach, jejunum, ileum tx = prophylactic colectomy

gardners syndrome

colon polyps, osteomas, dental abnormalities, soft tissue tumors, desmoid tumors, sebaceous cysts, epidermoid inclusion cysts

turoct's syndrome

AUTOSOMAL RECESSIVE colon polyps, cerebellar medulloblastoma, GBM

peutz jeghers

hamartomas of entire GI tract - small bowel, colon, stomach pigmented spots of the face, lips, oral mucosae, face, genitalia , palmar surfaces inc. incidence of stomach, ovary, breast, cervix, lung cancer intussusception

familial juvenile polyposis coli

many juvenile polyps, low risk of CRC

HNPCC 1. lynch 1

1. early onset CRC, absence of antecedent multiple polyposis 2. lynch 1 + early onset of other cancers female (endometrial 43%/ovarian) skin, stomach, pancreas, brain, breast biliary

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CRC 1. clinical presentation 2. right sided clinical pres 3. left sided clinical pres 4. rectal clinical pres

1. abdominal pain, large bowel obstruction, weight loss, blood in stool 2. no obstruction (large diameter), melena, occult blood, IDA, change in bowel habits, RLQ mass 3. obstruction, hematochezia, change in caliber of stools (pencil) 4. hematochezia, tenesmus, rectal mass/feeling of incomplete evacuation

what fraction of CRC patients are metastatic at clinical presentation

20%

CRC 1. tx 2. follow up

1. surgical resection of tumor and regional lymphatics, pre-op CEA, post op chemo/radiation 2. stool guaiac annual CT scan of pelvis + CXR for 5 years colonoscopy at 1 year and then every 3 years CEA every 3-6 months

non-neoplastic polyps

hyperplastic polyps, juvenile polyps (remove), inflammatory polyps (UC)

adenomatous polyps + histology, size, typia, and morphology

benign lesions with significant malignant potential (villous >tubulovillous > tubular), (large > small), (atypia > no atypia), (sessile >pedunculated)

Diverticulosis 1. patho 2. clinical pres 3. dx/tx

1. low fiber/constipation --> inner colon bulges through weakness 2. asymptomatic or incidental finding, LLQ pain, bloating, constipation/diarrhea 3. barium enema tx = high fiber foods, psyllium

diverticulosis 1. complications

1. painless rectal bleeding (5% is severe), diverticulitis

diverticulitis 1. patho 2. clinical pres 3. complications 4. recurrence rate

1. impacted feces in a diverticulum leads to erosion/microperforation 2. LLQ pain, leukocytosis, altered bowel habits, lower GI bleeding RARE (compare to diverticulosis) 3. abscess, colovesical fistula, obstruction, colonic perforation(peritonitis) 4. 30% of medically treated patients at 5 years

what is worse, rectal cancer, or colon cancer

rectal has higher recurrence rate, lower 5 year survival

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what is the indication for radiation in CRC

NOT indicated for colon cancer radiation IS indicated for rectal cancer

where are most colonic polyps found + most common symptoms of colonic polyps

in the rectosigmoid junction most common symptom is painless rectal bleeding

diverticulitis 1. dx 2. tx

1. CT abdomen with oral/IV contrast Ab XR - rules out ileus or obstruction (air fluid levels), and perforation (free air) BARIUM ENEMA/COLONOSCOPY ARE CONTRAINDICATED 2. IV abx (7-10 days) cipro/flagyl, bowel rest, NPO, IVF surgery if persists 3-4 days or complicated

angiodysplasia 1. patho + clinical pres 2. dx/tx 3. key clinical association (non-GI)

1. tortuous submucosal vein in the colon --> bleeding, 15% massive bleeding 2. colonoscopy (better than angiography) tx= 90% stops bleeding spontaneously, right hemicolectomy if persistent bleeding 3. AORTIC STENOSIS

acute mesenteric ischemia 1. patho (4) 2. mortality

1. arterial embolism (cardiac - afib, MI, valves), arterial thrombosis (atherosclerosis, may be 2/2 dec. CO from MI), non-occlusive (splanchnic vasoconstriction in critically ill/elderly), venous thrombosis (infection/hypercoagulable, portal HTN, malig, pancreatitis) 2. 60-70%, 90% if bowel infarction

acute mesenteric ischemia 1. clinical pres 2. dx/tx

1. abdominal pain disproportionate to physical findings, anorexia, GI bleeding, sepsis, shock, peritonitis 2. mesenteric angiography**, SERUM LACTATE*** plain film abdomen (rule out other causes thumbprinting on barium enema (edematous mucosal folds) tx = IVF, broad spectrum ABX papaverine vasodilator into SMA thrombolytics/embolectomy heparin (for venous thrombosis) surgery - for non-viable bowel if peritonitis symptoms AVOID VASOPRESSORS - WORSEN ISCHEMIA

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chronic mesenteric ischemia 1. patho 2. clinical pres 3. dx/tx

1. atherosclerotic occlusion of main mesenteric vessels 2. progressive *postprandial abdominal angina, weight loss 3. mesenteric angiography tx = surgical revascularization

ogilvie's syndrome 1. patho 2. causes 3 dx/tx

1. SIGNS/SYMPTOMS/RADIOGRAPH of large bowel obstruction without mechanical obstruction 2. recent surgery/trauma, serious medical illness, meds (narcotics, psychotropics, anticholinergics) 3. diagnosis of exclusion after mechanical obstruction ruled out tx = stop offending agents, IV fluids, electrolyte, decompression with enemas/NG suction, surgical decompression (with cecostomy/colostomy)

diagnostic test of choice for diverticulosis vs diverticulitis

diverticulosis - barium enema diverticulitis - CT scan with oral/IV contrast

comorbid condition with AVM

aortic stenosis

comorbid conditions with acute mesenteric ischemia

heart disease - CHF, coronary disease

clinical presentation of acute mesenteric ischemia 1. embolic 2. arterial thrombosis 3. nonocclusive ischemia 4. venous thrombosis

1. sudden onset, more painful 2. more gradual and less severe than embolic 3. occurs in critically ill patients 4. symptoms for days or weeks

signs of intestinal infarction

hypotension, tachypnea, lactic acidosis *****, altered mental status

when should colonic distension be immediately decompressed

when the colon diameter exceeds 10cm - RISK FOR RUPTURE AND DEATH

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pseudomembranous colitis (antibiotic resistant colitis) 1. patho 2. most common abx associated 3. clinical pres 4. compliations

1. abx treatment kills normal flora that inhibit growth of c.diff --> c.diff overgrowth/toxin formation 2. clindamycin, cephalosporins, ampicillins (but all abx can cause) 3. sx in the first week of abx treatment (or later) --> profuse watery diarrhea, crampy abdominal pain, toxic megacolon (risk of perf) 4. toxic megacolon, colonic perforation, anasarca

pseudomembranous colitis 1. dx/tx

1. c.diff stool antigen*** flexible sigmoidoscopy - shows pseudomembrane abdominal XR - rule out megacolon tx = stop offending antibiotic metronidazole, oral vanc if resistant recurrence in 2-8 weeks in 35%

colonic volvulus 1. patho 2. locations 3. risk factors 4. clinical pres

1. twisting of intestine loop around mesenteric attachment site causes obstruction and vascular compromise, necrosis, perforation 2. sigmoid 75%, colonic 25% 3. chronic illness, inc. age, institutionalization, CNS disease, chronic constipation, laxative abuse, anti-motility drugs 4. acute colicky abdominal pain, distension, obstipation, n/v

cecal volvulus pathogenesis

congenital lack of fixation of the right colon in younger patients

colonic volvulus 1. dx

1. Ab XR - sigmoid volvulus - omega loop sign cecal volvulus - coffee bean sign large air fluid level in RLQ sigmoidoscopy diagnostic/therapeutic for sigmoid volvulus barium enema (don't do if suspect strangulation) - shows narrowing at twist = bird beak tx = sigmoidoscopic decompression (sigmoid) emergency surgery (cecal)

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591.

592.

593.

cirrhosis 1. patho 2. causes

1. fibrotic replacement of normal liver architecture --> decreased hepatic blood flow (portal hypertension) impaired biochemical function - albumin, clotting factors, urea cycle. 2. alcoholic liver (20% of heavy drinkers), chronic hep B/C, acetaminophen, MTX, autoimmune, primary biliary cirrhosis, hemochromatosis, wilson's, right heart failure, alpha w antitrypsin,

Childs classification Childs 1 Childs 2 Childs 3

1: no ascites, no encephalopathy, bilirubin 3.5, good nutrition 2: controlled ascites, minimal encephalopathy, bilirubin 2-2.5, albumin 33.5, good nutrition 3: uncontrolled ascites, severe encephalopathy, bilirubin >3, albumin accumulation of peritoneal fluid due to portal hypertension/hypoalbuminemia 2. abdominal ultrasound (as little as 30ml), diagnostic paracentesis (cell count, albumin, gram stain, culture) ascitic fluid albumin >1.1 suggests portal HTN 3. tx = bed rest, low sodium diet, diuretics, therapeutic paracentesis, peritoneovenous shunt or TIPS

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595.

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597.

hepatic encephalopathy 1. patho 2. clinical pres 3. tx

1. ammonia + other toxic metabolites accumulate TRIGGERED BY alkalosis, hypokalemia, sedative drugs, infection, hypovolemia. 2. dec. mental function, confusion, poor concentration, asterixis (with arms extended, hands dorsiflexed), rigidity, hyperreflexia fetor hepaticus - musty breath 3. lactulose - prevents ammonia absorption (bacterial metabolism of lactulose forms NH4+ in lumen of gut) neomycin (oto/nephro toxic) or rifaximin - kills bowel flora dec. ammonia production limit protein to 30-40 g/day ornithine aspartate sodium benzoate BCAA

hepatorenal syndrome 1. patho 2. clinical pres 3. tx

1. progressive FUNCTIONAL renal failure in advanced liver disease, 2/2 renal hypoperfusion from renal vessel vasoconstriction TRIGGERED BY* diuretics/infection, large volume tap without albumin 2. RENAL FAILURE THAT DOES NOT RESPOND TO VOLUME RESUSCITATION azotemia, oliguria, hyponatremia, hypotension, low urine sodium ( inc. renin secretion

laboratory monitoring for patient with cirrhosis

CBC, renal function electrolytes, LFTs, coagulation studies EVERY 3-4 MONTHS ^ endoscopy to find varices CT guided biopsy for suspected HCC

compliations of liver failure

AC9H ascites, coagulopathy hypoalbuminemia, hypoglycemia, hyperammonemia, portal hypertension, hyperestrinism, hyperbilirubinemia, hepatic encephalopathy, hepatorenal syndrome, HCC.

spontaneous bacterial peritonitis 1. patho 2. clinical pres 3. dx/tx

1. infected ascitic fluid (e.coli, klebsiella, s.pneumo) *ONE ORGANISM (vs perforation is polymicrobial) 2. abdominal pain, fever, altered mental status, vomiting, rebound, sepsis 3. paracentesis - PMNs- >250, WBC >500, positive ascitic cultures, protein >2.5. SAAG 1.016 tx = abx cefotaxime or ceftriaxone, albumin, repeat paracentesis in 2-3 days, look for lower PMN/WBCs

1. hyperestrinism in liver failure clinical pres 2.coagulopathy in liver failure

1. spider angiomas (dilated cutaneous arterioles), palmar erythema, gynecomastia, testicular atrophy 2. inc. PT (vitamin K dependent factors)

treatment of cirrhosis

abstinence from alcohol interferons for hep B/C avoid acetaminophen, alcohol 6 months abstinence to be eligible for liver transplant

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wilsons disease 1. patho 2. clinical pres

1. AUTOSOMAL RECESSIVE deficiency of ceruloplasmin --> inability to excrete copper--> copper accumulation in liver, kidney, cornea, brain (basal ganglia) (hepatolenticular degen)r 2. acute hepatitis, cirrhosis/liver failure, kayser fleischer rings, EPS signs, (parkinsonism symptoms resting tremor, rigidity, bradykinesia), chorea, drooling, incoordination from copper in basal ganglia

wilsons disease 1. dx/tx

1. dec. serum ceruloplasmin inc. urine copper elevated LFTs, liver bx (shows elevated copper levels) tx = D- penicillamine (chelator) Zinc - prevents dietary copper uptake liver transplantation

hemochromatosis 1. patho 2. organs effected 3. clincal pres 4. complications

1. AUTOSOMAL RECESSIVE (HLAA3) defect in HFE gene --> inappropriate iron absorption and accumulation of iron in the intestines and other organs as ferritin/hemosiderin --> excess free oxygen radicals 2. liver, pancreas (DIABETES) , heart, skin (BRONZE) 3. liver disease, fatigue, arthritis, diabetes, arrhythmias, abdominal pain 4. cirrhosis, cardiomyopathy (CHF), DM, arthritis (2nd/3rd MCP, hyperpigmentation (BRONZE), hypothyroid, cardiac condution abnormalities *

secondary hemochromatosis

2/2 multiple transfusions or in chronic hemolytic anemia

signs of acute liver failure

coagulopathy jaundice hypoglycemia hepatic encephalopathy infection elevated LFTs

hemochromatosis 1. dx/tx

1. elevated serum iron, ELEVATED SERUM FERRITIN elevated transferring saturation (>50%), dec. TIBC liver biopsy - determines hepatic iron genetic testing tx = repeated phlebotomies, deferoxamine, liver transplant

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617.

hepatocellular adenoma 1. patho 2. clinical pres 3. dx/tx

1. females, OCP use, anabolic steroid use 2. asymptomatic, but can rupture causing hemoperitoneum/hemorrhage 3. CT, ultrasound, hepatic arteriography tx = dc OCP, resect tumors >5cm

cavernous hemangioma 1. patho 2. clinical pres 3. dx/tx

1. small vascular AVM liver tumors, inc. in size from pregnancy/OCP 2. asymptomatic, rupture/hemorrhage, obstructive jaundice, coagulopathy, CHF from large AV shunt 3. CT scan with IV contrast, NO BIOPSY WILL HEMORRHAGE tx = none required unless high risk for rupture

focal nodular hyperplasia

benign liver tumor with no malignant potential, no association with OCPs, no treatment required

HCC 1.two pathological types 2. risk factors 3. clinical pres

1. non-fibrolamellar (hep B/C) unresectable with short survival fibrolamellar (not associated with hep B/C) more often resectable 2. cirrhosis (alcohol, hep B or C 10% of patients get HCC)*** , aflatoxin, vinyl chloride, thorotrast, AAT, hemochromatosis/wilson's, schistosomiasis, hepatic adenoma (10%), cigarettes, type 1 glycogen storage disease, tyrosinemia 3. abdominal pain, weight loss, anorexia, fatigue, portal HN, ascites, jaundice, splenomegaly , paraneoplastic syndromes

paraneoplastic syndromes associated with RCC

erythrocytosis, thrombocytosis, hypercalcemia, carcinoid syndrome, hypertrophic pulmonary osteodystrophy, hypoglycemia, high cholesterol

HCC 1. dx 2. tx

1. liver bx hep B/C serology, LFTs, coagulation studies ultrasound, CT cx/ab/pelvis, elevated AFP (40-70% of patients) elevated alk phos 2. tx = liver resection, liver transplantation

most common malignant liver tumors

HCC and cholangiocarcinoma

nonalcoholic steatohepatitis 1. patho + risk factors 2. dx

1. no alcohol use, but have same changes to liver -risk factors = obesity, hyperlipidemia, DM, usually asymptomatic/benign 2. routine LFT shows mild elevation of ALT/AST macrovascular liver changes on liver biopsy

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624.

gilberts syndrome 1. patho 2. clinical pres 3. dx/tx

1. AUTOSOMAL DOMINANT - decreased uridine diphosphate glucuronyl transferase activity --> unconjugated hyperbilirubinemia*** 2. asymptomatic jaundice with fasting, fever, alcohol, infection 3. normal liver bx, no treatment necessary

hemobilia 1. patho/clincal pres

1. trauma, papillary thyroid carcinoma, surgery, tumors, infection -> blood draining into the duodenum --> melena, hematemesis, jaundice, RUQ pain 2. arteriogram, upper GI endoscopy (blood from ampulla of vater) tx = transfusion, resuscitation

polycystic liver cysts 1. patho

1. assc. with polycystic kidney disease, rarely progress to cirrhosis

hydatid liver cysts 1. patho 2. treatment

1. echinococcus granulosus, or echinococcus multilocularis --> CALCIFIED CYST****right lobe of the liver--> rupture into peritoneal cavity -- > fatal anaphylactic shock 2. surgical resection (don't spill), mebendazole after surgery

pyogenic liver abscess 1. patho 2. clinical pres 3. dx/tx

1. biliary obstruction/appendicitis/diverticulitis --> bacterial proliferation - ecoli, klebsiella, proteus, enterococcus, anaerobes 2. fever, malaise, anorexia, weight loss, nausea, vomiting, RUQ pain 3. CT scan, elevated LFTs tx = IV abx, percutaneous drainage

amebic liver abscess 1. patho 2. clinical pres 3. dx/tx

1. fecal oral - entamoeba histolytica --> hepatic portal vein --> liver 2. fever, RUQ pain, n/v, hepatomegaly, diarrhea 3. IgG assay, LFTs, E. histolytica stool antigen Ultrasound, CT scan tx = IV metronidazole , aspiration if abscess is large

budd chiari syndrome 1. patho 2. clinical pres 3. dx/tx

1. hypercoag, polycythemia, preg, inflammatory disease, cancer myeloproliferative --> occlusion of hepatic venous outflow --> hepatic congestion 2. hepatomegaly, ascites, abdominal pain, jaundice, variceal bleeding 3. hepatic venography, serum ascites albumin gradient >1.1g/dl tx = *balloon angioplasty with stent placement, portacaval shunts liver transplant anticoag, thrombolytics diuretics

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626.

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630.

three major causes of jaundice

hemolysis, liver disease, biliary obstruction

jaundice 1. what level is clinical observable 2. clinical finding unique to conjugated hyperbilirubinemia 3. sources of bilirubin 4. clinical findings unique to unconjugated bilirubin

1. total bili >2mg/dl 2. dark urine/pale stools b/c conjugated bili is loosely bound to albumin 3. hemoglobin, myoglobin, liver enzymes (--> unconj bilirubin in the spleen) 4. tightly bound to albumin, cannot be excreted in the urine, cross BBB and causes neurological damage/deficits

causes of conjugated hyperbilirubinemia 1. dec intrahepatic excretion of bilirubin 2. extrahepatic biliary obstruction

1. hepatocellular disease (viral or alcoholic hepatitis, cirrhosis), Dubin johnson, rotors syndrome, PBC, PSC 2. gallstones, head of pancreas carcinoma, cholangiocarcinoma, periampullary tumors, extrahepatic biliary atresia

causes of unconjugated hyperbilirubinemia 1. excess production of bilirubin 2. reduced hepatic uptake of bilirubin or impaired conjugation

1. hemolytic anemia 2. gilberts, crigler najjar, sulfonamides, penicillin, rifampin, radiocontrast agents, immature conj. system (physiologic jaundice of newborn), hepatitis, cirrhosis

what labs to order for 1. unconjugated hyperbilirubinemia 2. conjugated hyperbilirubinemia

1. CBC, retic, haptoglobin, LDH, peripheral smear 2. ultrasound or CT, ERCP, MRCP, liver biopsy

clinical presentation of cholestasis

jaundice gray stools, dark urine (conjugated) pruritus serum alk phos elevated cholesterol skin xanthomas

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Aminotransferases 1. which is more sensitive/specific for liver damage 2. what condition does ALT and AST not rise at same rate 3. mildly elevated LFTs 4. moderate elevated LFTs (100s-1000s) 5. severely elevated LFTs (>10,000)

1. ALT 2. alcoholic liver disease - AST:ALT 2:1 3. chronic viral hepatitis, acute alcoholic hepatitis 4. acute viral 5. ischema, shock liver, acetaminophen toxicity, viral hepatitis

why are LFTs not always elevated in patients with cirrhosis or metastatic liver disease

because the number of functioning hepatocytes is greatly reduced.

causes of elevated LFTs in asymptomatic patients

Autoimmune hepatitis, hep B/C, drugs, ethanol, fatty liver, growths(tumors, hemodynamic (CHF), iron (hemochormatosis), copper (wilsons, AAT)

alkaline phosphatase 1. what causes very high elevation 2. if levels are mildly elevated what should be the next step 3. what is possibility if ALP is elevated but GGT is normal

1. extra hepatic obstruction of bile flow, 2. get a GGT which will tell if elevated ALP is from a hepatic origin 3. pregnancy, bone disease

where is AST/ALT/ALP found in the body

ALT - LIVER ONLY AST - skeletal muscle, heart, kidney, brain ALP - bone, gut, placenta`

at what hemoglobin level will central cyanosis be present

> 4 g/dl desaturated ie. 80% saturation in a COPDer with hemoglobin 20 or 60% saturation in IDA patient with hemoglobin of 10

tachybradycardia syndrome 1. patho 2. tx

1. period tachycardia followed by sinus node suppression-2. pacemaker (prevents the tachycardia) medications for the bradycardia

contraindications to cardiac stress testing + what to do to test them for CAD

pre-existing ST depression, LVH ** do nuclear testing instead

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what conditions have low albumin

chronic liver disease nephrotic syndrome malnutrition inflammatory states -sepsis, trauma, burns

what clotting factors not synthesized by the liver

III, VIII, vWF

cholelithiasis 1. yellow/green stones\ 2. black stones 3. brown stones

1. obesity, diabetes, multi partum, OCP, cirrhosis, CF 2. hemolysis (SCD, thalassemia, spherocytosis, cardiac valves,), or alcoholic cirrhosis 3. biliary tract infection

cholelithiasis 1. clinical pres 2. complications 3. dx

1. biliary colic, from temporary obstruction of the gallbladder with gallstones RUQ pain, radiates to the right subscapular region (BOAS SIGN) 2. cholecystitis, choledocholithiasis, gallstone ileus, malignancy 3. RUQ ultrasound (>2mm), CT/MRI

what fraction of patients with biliary colic develop cholecystitis in 2 years

...

what causes pain in biliary colic vs cholecystitis

30% (10% of patients with gallstones develop cholecystitis)

biliary colic = contraction of gallbladder against obstructed cystic duct acute cholecystitis = pain from inflammation of the gallbladder wall

...

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acute cholecystitis 1. patho 2. clinical pres 3. dx/tx

1. obstruction of cystic duct --> inflammation of gallbladder wall 2. RUQ/epigastric pain, radiates to right scapula/shoulder, N/V, anorexia, MURPHY'S SIGN, fever, leukocytosis 3. RUQ ultrasound - thickened gallbladder wall, pericholecystic fluid, distended gallbladder, stones CT scan - higher sens for complications - perforation, abscess, pancreatitis HIDA scan - positive if gallbladder NOT visualized tx = admission, hydration, IVF, NPO, IV ABX, analgesics Cholecystectomy within 24-48 hours

signs of biliary tract obstruction

elevated ALP, GGT, jaundice, pruritus, clay colored stools, dark urine

acalculous cholecystitis 1. patho 2. tx

1. dehydration, ischemia, burns, trauma --> non-obstructive cholecystitis 2. emergent cholecystectomy

complications of cholecystitis

gangrenous cholecystitis, perforation, emphysematous cholecystitis, cholecystoenteric fistula with gallstone ileus, gallbladder empyema

choledocholithiasis 1. patho 2. dx/tx

1. gallstone in CBD 2. elevated D-bili, ALP, RUQ ultrasound (only 50% sensitive) ERCP is gold standard - and therapeutic PTC tx = ERCP with sphincterotomy/extraction/stent, lapcholecoholithotomy

complications of choledocholithiasis

cholangitis, obstructive jaundice, acute panc, biliary colic, biliary cirrhosis

cholangitis 1. patho 2. clinical pres 3. dx/tx

1. ERCP/PTC/choledochal cyst/obstruction --> biliary stasis/bacterial overgrowth 2. CHARCOT-TRIAD: RUQ pain, jaundice, fever REYNOLDS PENTAD - charcot + septic shock, altered mental status 3. RUQ ultrasound, hyperbilirubinemia, leukocytosis, elevated LFTs PTC (when duct dilated)/ERCP - NOT DURING ACUTE PHASE tx = IVF, ABX, monitoring UOP/BP, after afebrile 48 hours --> ERCP/PRC

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complication of cholangitis

hepatic abscess- high fatality

primary sclerosing cholangitis 1. patho 2. clinical associations 3. dx/tx

1. idiopathic thickening of bile ducts/narrowing of lumen --> cirrhosis, portal hypertension, liver failure 2. ULCERATIVE COLITIS ***, crohn's 3. ERCP/PTC - shows multiple bead like strictures of intra/extrahepatic ducts tx = liver transplant***, ERCP stent placement for strictures cholestyramine - for pruritus

primary biliary cirrhosis 1. patho 2. clinical pres 3. dx/tx

1 autoimmune process --> progressive cholestatic livers disease with destruction of the intrahepatic bile ducts (ductopenia on biopsy) 2. fatigue, pruritus, jaundice, RUQ discomfort, xanthoma/xanthelasmata* 3. positive antimitochondrial antibodies*** elevated ALP, elevated cholesterol/HDL non caseating granulomas inc. immunoglobulin M liver biopsy (showing DUCTOPENIA), abd. US/CT scan tx = cholestyramine (pruritus), calcium, bisphosphonates, vitamin D, ursodeoxycholic acid (slows disease)

cholangiocarcinoma 1. patho 2. risk factors

1.adenocarcinoma of intra/extrahepatic bile ducts --> prox 1/3 = klatskin tumor, distal extrahepatic, intrahepatic 2. PSC, UC, choledochal cysts, clonorchis sinensis (hong kong)

causes of secondary biliary cirrhosis

mechanical obstruction, sclerosing cholangitis, cystic fibrosis, biliary atresia

choledochal cysts 1. patho 2. clinical pres 3. dx/tx 4. complications

1.cystic dilations of the hepatic ducts 2. epigastric pain, jaundice, fever, RUQ mass 3. ultrasound, ERCP tx = surgery 4. cholangiocarcinoma, hepatic abscess, recurrent panc/cholangitis, rupture, biliary obstruction, cirrhosis, portal HTN

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biliary dyskinesia 1 patho 2. dx/tx

1. motor dysfunction of the sphincter of Oddi (CCK relaxes) leads to recurrent biliary colic without evidence of stones 2. HIDA + IV CCK and determine gallbladder ejection fraction

acute appendicitis 1. patho 2. clinical pres 3. DX

1. lumen of appendix obstructed by: lymphoid hyperplasia (60%), fecalith (30%), foreign body --> bacterial growth, inflammation --> compromised blood supply --> necrosis, perforation, peritonitis 2. epigastric pain that moves toward umbilicus/RLQ with signs of peritonitis, anorexia**, n/v, rebound, ROVSING'S SIGN, PSOAS SIGN, OBTURATOR SIGN 3. CLINICAL DX, leukocytosis, CT scan (98-100% sensitive), ultrasound tx = appendectomy

carcinoid syndrome 1. patho 2. clincal pres

1. neuroendocrine cells --> serotonin (10% of carcinoid tumors) - located in appendix***, small bowel (highest chance of mets), rectum, bronchus 2. cutaneous flushing, diarrhea, sweating, wheezing, abdominal pain,

appendicitis complications

perforation of appendix 20% - will present as high fever, tachycardia, leukocytosis, peritoneal signs

acute pancreatitis 1. patho 2. what viruses associated with acute panc 3. what drugs associated with acute panc

1. alcohol/gallstones/POST ERCP/ viral /drugs/post-op/scorpion bites/cancer/hypertriglyceridemia/ hypercalcemia/uremia--> inflammation of pancreas from prematurely activated pancreatic digestive enzymes 2. mumps, cox B 3. sulfonamides, thiazide, furosemide, estrogen, HIV meds

acute pancreatitis 1. clinical pres 2. dx

1. epigastric pain radiating to the back, worse when supine/after meals, low grade fever, tachycardia, epigastric tenderness, dec. bowel sounds, leukocytosis, GREY TURNER'S SIGN, CULLEN'S SIGN, FOX'S SIGN 2. serum lipase, amylase, LFTs, , hyperglycemia, hypoxemia, leukocytosis glucose, calcium, hematocrit, BUN, ABG, LDH, AST, WBC CT abdomen - most sensitive/specific ERCP - identify gallstones abdominal XR -may show calcifications abdominal ultrasound - may detect calc/pseudocysts

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ranson's criteria 1. admission 2. 48 hours 3. mortality %

acute pancreatitis 1. complications 2. tx

1. GA-LAW: glucose >200, Age >55, LDH >350, AST>250, WBC >16000 2. C HOBBS: calcium 10%, PaO28mg/dL, Base deficit >4 mg/dl, fluid sequestration >6L 3. 7 criteria - 100% 1. ARDS*** pancreatic abscess pancreatic necrosis (sterile or infected) pancreatic pseudocyst - 2-3 week to develop no epithelial lining, (>5cm drain) hemorrhagic pancreatitis - cullen, grey turner, fox, CT with IV contrast ascending cholangitis (gallstones) 2. NPO, IVF, pain control, NG tube, early enteral nutrition via nasojejunal tube AFTER RECOVERY FROM GALLSTONE PANCREATITIS ALL PATIENTS SHOULD BE SCHEDULED FOR CHOLECYSTECTOMY

chronic pancreatitis 1. patho 2. clinical pres 3. dx/tx

1. chronic alcoholism --> fibrotic replacement of the pancreas and dilation of the pancreatic duct 2. severe abdominal pain, n/v, aggravated by drinking alcohol/eating, malabsorption, diabetes mellitus (triad) 3. CT scan shows calcifications ERCP**- will show ductal dilation/strictures abdominal xray - shows calcifications specific but not sensitive serum amylase and lipase are normal stool elastase is decreased

chronic pancreatitis 1. tx

1. narcotics, NPO, pancreatic enzymes and H2 blockers (dec. CCK release), insulin,

complications of chronic pancreatitis

narcotic addiction, DM (langerhans loss), pseudocysts, pancreatic duct dilation, CBD obstruction (2/2 fibrosis), B12 malabsorption

pancreatic cancer 1. risk factors 2. clinical pres 3. dx 4. tx

1. cigarette smoking (NOT ALCOHOL), chronic pancreatitis*, diabetes, obesity benzidine/beta naphthylamine exposure 2. dull abdominal pain, obstructive jaundice (head), weight loss, depression, fatigue, migratory thrombophlebitis, courvoisier's sign 3. ERCP**, CT scan***, CA 19-9, CEA 4. whipple procedure (10% survival at 5 years), ERCP with stent placement if unresectable

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676.

GI bleeding 1. upper GI bleeding causes 2. lower GI bleeding causes

1. prox to ligament of treitz - PUD, duodenal ulcer, gastritis, reflux esophagitis, varices, mallory weiss, hemobilia, dieulafoy, aortoenteric fistula 2. diverticulosis, angiodysplasia, IBD (UC/crohn's), colorectal cancer/polyps, ischemic colitis, hemorrhoids, anal fissure

GI bleeding 1. hematemesis 2. coffee ground emesis 3. melena 4. hematochezia - occult blood in the stool

1. moderate-severe ONGOING upper GI bleeding 2. lower rate of upper GI bleeding 3. upper GI black, tarry, foul smelling stools (hemoglobin broken down by bacteria indicates blood has been in GI tract for several hours 4. bright red blood per rectum typically left colon or rectum

causes of dark stools

melena, bismuth, iron, spinic, charcoal, licorice

GI bleeding 1. diagnostic test for hematemesis, hematochezia, melena, occult blood 2. dx 3. tx

1. hematemesis/melena - upper GI endoscopy hematochezia/occult blood colonoscopy 2. BP, pulse rate, CBC with diff, BUN/Cr, PT/PTT/INR stool guaiac, hemoglobin/hematocrit, upper endoscopy, NG tube (bile but no blood = not upper GI), colonoscopy, radionucleotide scan (tagged RBCs), arteriography (must be during active bleeding, therapeutic = embolization/vasopressin) 3. ABCs- Oxygen, 2 large bore IVs, draw blood hgb/hct/pt/ptt/platelet, monitor hgb q4-8 type and cross EGD with coagulation colonoscopy

normal hematocrit in young adult vs. elderly

young adult >7-8 elderly >10

indications for surgery in patient with GI bleed

hemodynamically unstable and not responding to IV fluids, severe initial bleed or recurrence after endoscopic treatment continued bleeding >24 hours visible vessel at base of ulcer 5 units of blood within 4-6 hours

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esophageal cancer 1. risk factors for SCC 2. risk factors for adeno - 5-15% 5 year prognosis 3. clinical pres 4. dx/tx

1. AA, alcohol, tobacco, nitrosamines, hot foods/beverages 2. GERD, barrett's 3. dysphagia (solids--> solids/liquids), weight loss, anorexia, odynophagia, hematemesis, hoarseness, aspiration, 4. barium swallow upper endoscopy with biopsy/brush cytology*** metastatic work up - CT cx/abd, CXR, bone scan tx = palliation, surgery (0,1,2a), adjuvant chemo/radiation

achalasia 1. patho 2. causes 3. clinical pres

1. LES fails to relax when swallowing and abnormal peristalsis of esophagus 2. idiopathic, adenocarcinoma, chagas 3. dysphagia to both solids/liquids, patients eat slowly, and drink a lot of water with food, food gets stuck in esophagus, regurgitation/aspiration, CX pain, weight loss

achalasia 1. dx/tx

1. barium swallow*** - BIRD BEAK upper GI endoscopy rules out esophagitis/esophageal cancer manometry***- failure of LES relaxation biopsy - absent myenteric plexus tx = sublingual nitroglycerine, CCBs, botulinum toxin, mechanical dilation, heller myotomy

what cancer are patients with achalasia at increased risk for

squamous cell cancer of the esophagus

diffuse esophageal spasm 1. patho 2. clinical pres 3. dx/tx

1. non-peristaltic contractions preventing advancement of food bolus, LES function is normal 2. non-cardiac chest pain that mimics angina 3. esophageal manometry- simultaneous, multiphasic repetitive contractions after swallow with normal sphincter Barium swallow - corkscrew esophagus tx = nitrates, CCBs, TCAs

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esophageal hiatal hernias 1. sliding (type 1) 2. paraesophageal (type 2) 3. dx/tx 4. type 3

1. gastroesophageal junction/stomach herniate into thorax associated with GERD 2. stomach herniates into the thorax, but NOT GE junction- risk for strangulation and should be repaired 3. barium upper GI series, upper endoscopy tx = type 1 = antacids, small meals, nissen's fundoplication type 2 = elective surgery 4. combination of type 1 and 2

mallory weiss syndrome 1. patho 2. clinical pres 3. dx/tx

1. mucosal tear at the GE junction, after repeated vomiting 2. hematemesis 3. upper endoscopy tx = stops on its own, or angiographic embolization, acid suppression

plummer vinson syndrome 1. patho 2. complications 3. dx/tx

1. iron deficiency --> upper esophageal webs, koilonychia, atrophic oral mucosa, iron deficiency anemia 2. progress to SCC of the oral cavity 3. esophageal dilation, correct nutritional deficiency

schatzki's ring 1. patho 2. clinical pres 3. tx

1. ingestion of acid (mucosal necrosis), alkali (liquefactive full thickness necrosis), detergents -> lower esophageal ring and sliding hiatal hernia 2. dysphagia 3. esophagectomy for full thickness necrosis

zenker's diverticula + tx

failure of cricopharyngeal muscle to relax during swallowing increases pressure and causes outpouching of mucosa (false diverticula)--> dysphagia, regurgitation, halitosis, chronic cough tx = cricopharyngeal myotomy, diverticulectomy

traction diverticulum

mid esophagus, near tracheal bifurcation from mediastinal inflammation and adenopathy (ex. tuberculosis)

epiphrenic diverticulum

lower 1/3 of esophagus, associated with esophageal dysmotility/achalasia

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boerhaave's syndrome 1. patho 2. clinical pres 3. dx/tx

1. blunt trauma, medical tubes, vomiting, alcohol binges, bulimia --> TRANSMURAL tear in esophagus 2. severe chest pain, tachycardia, hypotension, tachypnea, dyspnea, fever, HAMMANS SIGN (mediastinal crunch from heart hitting air filled tissues), PTX 3. gastrografin swallow CXR - air in mediastinum tx = IV, NPO, abx, H2 blockers surgery if patient is unstable

peptic ulcer disease 1. causes 2. clinical pres 3. dx/tx

1. h.pylori, NSAIDs, gastric acid hypersecretion (ZES), smoking, alcohol/coffee 2. aching, gnawing pain, nocturnal symptoms and variable effects of food, upper GI bleeding, n/v, early satiety, weight loss 3. endoscopy (also therapeutic) H.pylori detected on biopsy urea breath test h.pylori serology (false negative with PPI, bismuth, antibiotics, upper GI bleeding) serum gastrin tx - acid suppression (PPI or H2), triple/quadruple therapy cytoprotection - sucralfate, misoprostol (reduces ulcers with NSAID therapy)

duodenal ulcers 1. malignant potential 2. location 3. age 4. associated blood type 5. clinical pres

1. low 2. 1-2 cm distal to pylorus (posterior wall) 3. 40 4. A 5. smokers, eating does not relieve pain

lifestyle modifications for PUD

stop smoking, stop NSAIDs, decrease eating before bed

complications of PUD (3) + dx/tx

*perforation -CXR free air under diaphragm tx = emergency surgery - vagotomy

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*Gastric outlet obstructionbarium swallow, upper endoscopy, saline load test (750 injected, after 30 min aspirate >400ml = + test) tx = NG suction, volume replacement, surgery

...

*GI bleeding - stool guaiac, upper GI tx= resuscitation, diagnose site of bleeding, surgery for acute bleeding

...

acute gastritis 1. patho 2. clinical pres

1. inflammation of the gastric mucosa 2/2 NSAIDs, H.pylori, cigarette smoking, caffeine, shock, sepsis, burns 2. epigastric pain 3. PPI, stop NSAIDs, test for H.pylori

gastric cancer 1. morphologies 2. risk factors 3. clinical pres

1. ulcerative, polyploid (solid mass), superficial spreading, linitis plastica 2. atrophic gastritis, gastric polyps, h.pylori (3-6x the risk), pernicious anemia, low vitamin C, high salt diet, menetrier's disease, preserved foods (salt, nitrates), blood type A 3. abdominal pain, weight loss, dec. appetite, anorexia, melena, guaiac positive stools

1. krukenberg tumor 2. blumers shelf 3. sister mary joseph node 4. virchows node 5. irish's node

1. stomach cancer met to the ovary 2. stomach cancer met to the rectum (pelvic cul de sac) 3. met to periumbilical lymph nodes 4. met to supraclavicular fossa nodes 5. met to left axillary adenopathy

chronic gastritis 1. patho 2. dxt/tx

1. H.pylori, autoimmune (anti-parietal cell/anti-intrinsic factor antibodies), 2. upper endoscopy with biopsy

autoimmune gastritis

serum anti-parietal cell and antiintrinsic factor antibiotics --> pernicious anemia

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gastric cancer 1. dx/tx

1. upper endoscopy with multiple biopsies barium upper GI series abdominal CT for staging/mets FOBT tx = surgical resection with wide margins >5cm

small bowel obstruction SBO 1. three ways to differentiate small bowel obstruction 2. patho/clinical pres

1. partial vs complete obstruction, closed vs open loop (closed has vascular compromise/necrosis/peritonitis), proximal vs distal SBO (distal has more dilated proximal loops) 2. adhesions (MCC), incarcerated hernias, malig, intussus, crohn's, SMA syndrome --> 3. obstruction --> dehydration, inc. intestinal secretions proximal to the obstruction, distention/vomiting (hypokalemic, hypochloremic met.alk), obstipation, abdominal distention, nausea/vomiting, strangulation --> shock, peritonitis, free air, lactic acidosis

SBO 1. dx/tx

1. plain abdominal films- show dilated loops of small bowel/air fluid levels proximal to the point of obstruction, minimal gas in colon. Barium enema - identifies site of obstruction, follow up for inconclusive XR upper GI series serum lactate - to detect strangulation/necrosis tx = non-operative if incomplete and no fever, peritoneal signs, leukocytosis, IVF w/ K+, NG tube, abx, surgery for complete obstruction (ex. lysis of adhesion/bowel resection)

difference in clinical pres between proximal vs distal SBO

proximal - frequent vomiting, severe pain, minimal abdominal distension distal - less frequent vomiting, significant abdominal distention

large bowel obstruction 1. causes

1. volvulus, adhesions, hernias, colon cancer (MCC) - fluid/electrolyte imbalances not as severe as SBO

paralytic ileus 1. patho 2. causes 3. dx

1. absent peristalsis, without mechanical obstruction 2. narcotics, post-operative, spinal cord, shock, hypokalemia, peritonitis 3. abdominal plain films show uniform gas distribution in small bowel,colon, and rectum failure to pass contrast past a fixed point tx = IVF, NPO, electrolytes (hypokalemeia), NG suction,

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celiac sprue 1 patho 2. dx/tx

1. hypersensitivity to gluten --> loss of microvilli--> weight loss, abdominal distension, bloating, diarrhea 2. anti-endomysial, anti-transglutaminase small bowel biopsy shows flattening of villi tx = avoid wheat, barley, rye

crohns disease 1. patho 2. clinical pres 3. extraintestinal manifestations

1. chronic flaring/remitting TRANSMURAL inflammatory disease that can affect any part of the GI tract, usually includes terminal ileum, skip lesions, FISTULAS, STRICTURES, NON CASEATING GRANULOMAS*, mesenteric fat wrapping 2. diarrhea, malabsorption/weight loss, abdominal pain, n/v, fever, malaise 3. uveitis, arthritis, ank spondy (CUC), pyoderma gangrenosum (C20% mortality/coma 2. fever, tachycardia, agitation, psychosis, confusion,n/v, diarrhea 3. IVF, cooling blankets, glucose, PTU q2hour + iodine, beta blockers for heart rate, dexamethasone (blocks T4-T3 conversion)

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hypothyroidism 1. causes 2. clinical pres

1. hashimoto's (autoimmune), iatrogenic- radioiodine, thyroidectomy, mediations, secondary/tertiary hypothyroidism (low T4/T3 and low TSH) 2. fatigue, weakness, heavy menstrual periods*, weight gain, cold intolerance, dull expression, muscle weakness/rhabdomyolysis, arthralgias, depression, dry skin, coarse hair, hoarseness, non-pitting edema (myxedema), dec. DTRs, bradycardia, goiter

associated conditions with hashimotos thyroiditis

lupus, pernicious anemia, thyroid carcinoma, thyroid lymphoma

myxedema coma + tx

hypothermia, respiratory depression, dec. consciousness from chronic hypothyroidism exacerbated by stress, elevated PCO2, hyponatremia (trauma, infection, cold, narcotics) tx = IV levothyroxine (500 mcg bolus, then daily), hydrocortisone for impaired adrenal reserves

hypothyroidism 1. dx 2. tx

1. high TSH, low TSH (2' hypoparathyroidism), low free T4, antimicrosomal/antithyroglobulin antibodies (hashimotos), anti thyroid peroxidase elevated LDL, dec. HDL normocytic anemia 2. levothyroxine, TSH monitoring

subacute thyroiditis (granuomatous) 1. patho 2. clinical pres 3. dx/tx

subacute lymphocytic thyroiditis 1 .patho 2. clinical pres 3. dx

1. post viral HLA-B35 associated --> leakage of thyroid hormone from thyroid gland --> hyperthyroid-->euthyroid->hypothyroid 2. painful tender thyroid gland, history of viral illness, and symptoms of hyper/hypothyroid 3 radioiodine uptake is low TSH is low from elevated T4/T3 high ESR tx = NSAIDs/aspirin, corticosteroids, recovery of thyroid function after 1 year 1. transient thyrotoxicosis, followed by hypothyroidism 2. similar to subacute thyroiditis, but without pain 3. low iodine uptake (vs graves), low TSH anti-TPO antibodies

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chronic lymphocytic thyroiditis 1. patho 2. clinical pres 3. dx/tx

1. hashimoto's/lymphocytic 2. goiter, slow decline in thyroid function 3. antiperoxidase, antithyroglobulin antibodies irregular distribution of I-131 not required for diagnosis tx = thyroid hormone replacement

thyroid associated ophthalmopathy

autoimmune destruction of periorbital connective tissue - lid retraction, proptosis (lymphocytes invade EOM and stimulate GAG deposition), lagophthalmos, - may be hypo/hyperthyroid or euthyroid

fibrous thyroiditis 1. patho 2. tx

1. fibrous tissue replaces thyroid 2. surgical removal

thyroid nodules 1. what fraction are cancerous 2. features of malignant nodule 3. diagnosis

1. 4-10% 2. nodule is fixed, no movement with swallowing solitary, history of neck radiation, history of rapid development, vocal cord paralysis, cervical adenopathy 3. Ultrasound guided FNA (reliable for all cancers except follicular) thyroid scan (radioactive iodine) - cold or hot thyroid ultrasound - diff between solid and cystic

risk factors for thyroid cancer

head/neck radiation gardner's syndrome/cowden's syndrome (papillary cancer) MEN type 2 - medullary thyroid cancer

papillary thyroid cancer (most common) 1. risk factor 2. pattern of mets 3. dx

1. radiation to the head/neck 2. cervical lymph nodes, with rare distant mets, iodine uptake positive 3. orphan annie eye nuclei, psammoma bodies on biopsy

follicular carcinoma 1. pattern of mets 2. risk factor 3. dx 4. hurthle cell carcinoma

1. hematogenous spread*** to brain/lung/bone/liver, 20% of pts have distant mets 2. iodine deficiency 3. tissue sample because need to see extension past fibrous capsule 4. abundant cytoplasm, tightly packed mitochondria, oval nuclei with prominent nucleoli - radioiodine resistant

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medullary carcinoma of the thyroid 1. risk factors + patho 2. dx

1. 1/3 sporadic, 1/3 familial, 1/3 MENII (also screen for pheo)-- arises from parafollicular C cells --> excess calcitonin production 2. sheets of cells in an amyloid stroma (APPLE GREEN BIREFRINGENCE

anaplastic carcinoma 1. risk factors + patho

longstanding follicular/papillary thyroid carcinoma - death within a few months- metastasis is by direct extension

thyroid cancer treatment 1. papillary 2. follicular carcinoma 3. medullary carcinoma 4. anaplastic

1. lobectomy with isthmusectomy, total thyroidectomy if >3cm or bilateral, TSH suppression, radioiodine therapy 2. total thyroidectomy with post op iodine ablation 3. total thyroidectomy, radioiodine, modified neck dissection 4. chemotherapy and radiation , palliative surgery

1. what fraction of cold nodules are malignant

1. 20% - thus a cold nodule on thyroid scan does not tell very much about the mass, however a warm nodule greatly reduces risk of malignancy

pituitary adenomas 1. what hormonal abnormalities 2. other nonhormonal clinical clues 3. dx/tx

1. inc. prolactin/GH/ACTH/TSH, or hypopituitarism from compression of the causes hypopituitarism 2. headache, bitemporal hemianopsia (compression of the optic chiasm) 3. MRI, pituitary hormone levels tx = transsphenoidal resection, radiation/medical therpy

hyperprolactinemia 1. causes 2. clinical pres in men 3. clinical pres in females

1. prolactinoma (MCC), antipsychotics, H2 blockers, metoclopramide (DA antagonist), verapamil, estrogen, pregnancy, renal failure, hypothalamic lesions, hypothyroidism, idiopathic 2. hypogonadism, dec. libido, infertility, impotence, galactorrhea, gynecomastia, parasellar signs 3. menstrual irregularities, amenorrhea (prolactin inhibits GnRH release and thus LH/FSH), vaginal dryness,

hyperprolactinemia 1. dx 2. tx

1. elevated serum prolactin, pregnancy test (r/o), TSH level (r/o hypothyroid), CT or MRI 2. bromocriptine, cabergoline (dopamine agonists) for 2 years surgery

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acromegaly 1. patho 2. clinical pres

1. GH secreting adenoma --> excess GH AFTER*** epiphyseal closure (before closure = gigantism)--> broadening of the skeleton 2. coarse facial features, abnormally large hand/feet, organomegaly, CAD, arthralgia, HCM, macrognathia, glucose intolerance, hyperhidrosis headache, bitemporal hemianopsia, cavernous sinus compression, HTN, sleep apnea

acromegaly 1. dx 2. tx

1. IGF 1 (somatomedin C levels) oral glucose suppression test (oral glucose does not suppress GH) random GH level 2. transsphenoidal resection of pituitary adenoma radiation if post op elevation in IGF-1 octreotide/somatostatin suppresses GH

craniopharyngioma 1. patho 2. clinical presentation

1. suprasellar tumor from remnants of rathke's pouch- usually adenoma 2. parasellar effects - headache, bitemporal hemianopsia, papilledema, changed in mentation, hyperprolactinemia, diabetes insipidus, panhypopituitarism 3. MRI surgical excision with or without radiation

causes of hypopituitarism

pituitary tumor, radiation, sheehan's syndrome, sarcoidosis, hemochromatosis, head trauma, cavernous sinus thrombosis

top ddx of polyuria/polydipsia

diabetes mellitus, diuretics, DI, primary polydipsia

cause of central DI cause of nephrogenic DI

central - dec. release of ADH from posterior pituitary* - idiopathic, trauma/surgery, tumors (#1 = breast), sarcoid, TB, syphilis, handschuller-christian, eosinophilic granuloma, encephalitis nephrogenic - lithium use, hypercalcemia, hypokalemia pyelonephritis, demeclocycline, mutations in ADH receptor or aquaporin 2 gene

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diabetes insipidus 1. clinical pres 2. dx 3. tx

1. 5-15 liters of urine/day, polydipsia, minimal hypernatremia (patients drink water) 2. low urine SG, low osmolarity plasma osmolality normal to slightly elevated (280-310) withhold fluids measure hourly, when stable brain swelling--> lethargy, somnolence, weakness, seizures, coma, death chronic hyponatremia - asymptomatic or n/v, anorexia, neuro symptoms less common NO EDEMA*********

SIADH 1. dx 2. tx

1. hyponatremia, serum hypoosmolality inappropriately elevated urine osmolality low serum uric acid (hemodilution) low BUN/Cr (diluted) normal thyroid/adrenal plasma/urine ADH level 2. underlying issue water restriction, normal saline lithium or demeclocycline (ADH blocker) if symptomatic - restrict water intake, give isotonic saline, hypertonic saline in severe cases **DO NOT CORRECT FASTER THAN 0.5mEq/L/hour

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hypoparathyroidism 1. causes 2. dx/tx

1. head and neck surgery, THYROIDECTOMY, parathyroidectomy, 2. arrhythmias, PROLONGED QT, rickets, osteomalacia, neuromuscular irritability numbness/tingling circumoral, fingers, toes tetany, hyperactive DTR, CHVOSTEK SIGN (tap CNVII causes muscle twitch), TROUSSEAU'S SIGN (carpal spasm w/ 3min of BP cuff) 3. low calcium, high phosphate, low PTH, low urine cAMP tx = IV calcium gluconate, D3 supplementation, ( target calcium is 8-8.5)

primary hyperparathyroidism 1. patho 2. clinical pres 3. dx 4. radiographic dx

1. adenoma*, hyperplasia, carcinoma ( parathyroids making too much PTH 2. nephrolithiasis, bone aches/pains, osteitis fibrosa cystica (brown tumors), muscle pains, pancreatitis, PUD, gout, constipation, depression, fatigue, anorexia, sleep disturbances, anxiety, lethargy, nephrolithiasis 3. serum calcium/albumin, PTH, hypophosphatemia, hypercalciuria, elevated urine cAMP, Cl:phos ratio >33:1*** 4. subperiosteal bone resorption at radial aspect of 2nd/3rd phalanges

primary hyperparathyroidism 1. tx

1. hyperplasia - remove all 4 glands, small amount of tissue implanted in forearm surgical removal of adenoma (age 400 mg in 24 hours)

pseudohypoparathyroidism

end organ PTH resistance elevated PTH, low urinary cAMP, hypocalcemia, hyperphosphatemia

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secondary hyperparathyroidism 1. patho

cushing syndrome 1. causes 2. clinical pres

1. chronic renal failure, vitamin D deficiency, renal hypercalciuria --> elevated PTH and low or low normal serum calcium tx - renal failure - give calcitriol, oral calcium supplements, phosphate restriction, sinacelet furosemide (NOT THIAZIDE) inc. fluid intake 1. iatrogenic (MCC), cushing's disease (pituitary), adrenal adenomas/carcinomas ectopic ACTH (2/3 of SCC of lung, bronchial carcinoma, thymoma) 2. central obesity, hirsutism, moon facies, buffalo hump, striae, lanugo, acne, easy bruising, diabetes, hypogonadism, masculinization in females (cushing disease), depression, mania, infections (impaired immunity)

effects of cortisol

impaired collagen production, enhanced protein catabolism anti-insulin effects/glucose intolerance impaired immunity enhanced catecholamine effects

Cushing syndrome 1. dx

1. overnight low dose dexamethasone suppression test: if serum cortisol 50% suppression = Cushing disease (pituitary), 4x normal ACTH level - low = adrenal tumor, high = pituitary source, ectopic ACTH CRH stimulation test- no response= ectopic ACTH tumor, positive response = pituitary Cushing's

response to low dex/high dex/CRH : 1. healthy 2. Cushing disease 3. adrenal tumor 4. ectopic ACTH

1. suppress/suppress/mild increase 2. no suppress/suppress/LARGE INCREASE 3. no suppress/suppress/NO CHANGE 4. no suppress/no suppress/NO CHANGE

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Cushing syndrome tx

iatrogenic - taper glucocorticoid pituitary Cushing- transphenoidal surgery adrenal Cushing's - adrenalectomy

pheochromocytoma 1. patho 2. clinical pres 3. lab findings during a paroxysm

1. chromaffin cells or sympathetic ganglia--> tumors that produce catecholamines 90% are adrenal 2. HTN, persistently high with paroxysms of severe HTN, pounding headache, sweating, tachycardia, palpitations, anxiety, impending doom, hypertension assc. with surgery 3. hyperglycemia, hyperlipidemia, hypokalemia

pheochromocytoma 1. dx 2. tx

1. urine screen: metanephrine, VMA, HVA, normetanephrine (also check creatinine to see if good sample) plasma metanephrines urine/serum epi/norepi - if elevated indicates that the tumor is adrenal or organ of zuckerkandl) CT/MRI for tumor localization 2. FIRST - phenoxybenzamine (dec. BP) SECOND - beta blocker (dec. tachycardia) surgical tumor resection and ligation of the venous supply

pheochromocytoma rule of 10s

10% are... familial, bilateral (MEN II), multiple, pediatric, extra adrenal (organ of zuckerkandl)

primary hyperaldosteronism 1. patho 2. clinical pres

1. conns syndrome/adrenal hyperplasia/adrenal carcinoma excessive aldosterone production independent of RAAS --> inc. Na/K pump activity in cortical collecting ducts--> sodium retention/HTN/hypokalemia/met.alk* 2. HTN, headache, fatigue, weakness, polydipsia, nocturnal polyuria, no peripheral edema

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primary hyperaldosteronism 1. dx 2. tx

1. aldo:renin ratio*** - shows inc. aldo, dec. renin >30:1 oral sodium loading - 3 days of high salt diet - high aldo + high urine sodium = + dx saline infusion test - will not inc. aldosterone, normal patient will be 6cm

adrenal insuficiency 1. primary causes 2. secondary causes 3. tertiary adrenal insufficiency

1. addisons (MCC), tuberculosis (MCC), cytomegalovirus, fungal/parasite (cryptococcus, pneumocystis, toxoplasmosis), iatrogenic, lung/breast mets 2. long term steroid therapy + stress of surgery/trauma/serious injury --> symptoms of adrenal insufficiency 3. hypothalamic disease

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adrenal insufficinecy 1. clinical pres 2. dx 3. tx

1. anorexia, n/v, abdominal pain, lethargy, confusion, psychosis hypoglycemia (cortisol deficiency) hyperpigmentation (1' deficiency from inc. ACTH/MSH breakdown product) stress in tolerance low aldosterone (ONLY*** in 1' adrenal insuff NOT secondary) --> sodium loss, hyponatremia, hyperkalemia, hypovolemia, hypotension, shock, syncope, renal failure 2. low plasma cortisol, high/low plasma ACTH (1' vs 2'), Cosyntropin test - infusion of ACTH measure plasma cortisol: primary = no inc. in cortisol, secondary = first test no response, second test 4-5 days later WILL get a response MRI of brain for 2' and 3' disease 3. 1' = daily glucocorticoid and daily mineralocorticoid 2' = daily glucocorticoid

congenital adrenal hyperplasia 1. patho 2. clinical pres (male vs female) 3. salt wasting form clinical pres1

1. AUTOSOMAL RECESSIVE 21 HYDROXYLASE (90%) DEFICIENCY/11 HYDROXYLASE DEFICIENCY--> dec cortisol/aldosterone production and inc. ACTH secretion + shunting of intermediates toward DHEA and testosterone 2. female - ambiguous genetalia but normal ovaries/uterus male - no genital abnormalities 3. emesis, dehydration, hypotension, shock in first 2-4 weeks of life total lack of aldo activity --> hyponatremia/hyperkalemia, hypoglycemia

congenital adrenal hyperplasia 1. dx

1. 17 hydroxyprogesterone elevated 2. cortisol and mineralocorticoid surgery - early correction of female genital abnormalities

diabetes mellitus 1. patho type 1 2. patho type 2

1. autoimmune destruction of beta cells in response to environmental/genetic factors (HLA DR/DQ) 2. obesity, age, genetic (>type 1) --> inc. fatty acids causes muscle insulin resistance --> beta cells desensitized to glucose, dec. insulin secretion

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1. dawn phenomenon 2. somogyi effect 3. how to diagnose/treat for the above

1. inc. nocturnal GH secretion inc. morning hyperglycemia 2. episodic hypoglycemia at night counterregulation system leads to morning hyperglycemia (2/2 adrenergic response to hypoglycemia) 3. measure 3am blood glucose Low = somogyi - dec. evening insulin to avoid nocturnal hypoglycemia High = dawn - inc. evening insulin

diabetes mellitus dx

two* fasting blood glucose >126 single glucose level >200 with symptoms inc. glucose level on oral glucose tolerance hemoglobin A1c >6.5

diabetes mellitus 1. screening

1. all adults over age 45 every 3 years, test anyone with symptoms

impaired glucose tolerance dx

fasting blood glucose 110-126 2 hour postprandial 140-200 hemoglobin A1c 5.7 -6.4

diabetes mellitus sx

polyuria (osmotic retention) polydipsia (to maintain plasma volume) fatigue (inc blood glucose) weight loss (loss of anabolic insulin effects) blurred vision (swelling of lens from osmosis) fungal infections (candida albicans) numbness/tingling (neuropathy, mono=microscopic vasculitis, poly = multifactorial)

diabetes maintenance 1. patient monitoring

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focus on: feet, vascular disease (CAD/PVD), neurologic disease, eye disease, renal disease, infectious disease

1. daily blood glucose levels 2. HbA1c every 3 months keeping below 7.0 screen for microalbuminuria 1x/year BUN/Cr 1x/year eye screening yearly by ophthalmologist feet check at every visit yearly LDL (treat if >100) target BP 30 years old pneumococcal vaccine

five stages of type 1 diabetes

stage 1 - genetic susceptibility stage 2 - autoimmune beta cell destruction stage 3 - continuded beta cell destruction and dec. insulin release, glucose normal stage 4 - insulin dependent C-peptide is present stage 5 - no C - peptide present

side effects 1. sulfonylureas 2. metformin 3. acarbose 4. TZD (rosiglitazone, pioglitizone) - pramlintide, repaglinide, nateglinide

1. hypoglycemia, weight gain 2. GI upset, n/v, abdominal pain, lactic acidosis, metallic taste 3. GI upset (diarrhea, cramping flatulence) 4. hepatotoxicity monitor LFTs

mechanism 1. sulfonylureas 2. metformin 3. acarbose 4. TZD (rosiglitazone, pioglitizone)

1. stimulates pancreas to make more insulin 2. enhances insulin sensitivity, dec. gluconeogenesis in the liver 3. reduces glucose absorption from the GI tract 4. reduces fat/muscle insulin resistance

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advantages 1. sulfonylureas 2. metformin 3. acarbose 4. TZD (rosiglitazone, pioglitazone)

1. cheap 2. mild weight loss 3. low risk, non-toxic

2/3 rule calculation for insulin dosing - in addition to a regimen, the patient should use a sliding scale of intermediate insulin insulin, monitor 4 times/day - before meals and at bedtime

kg * 0.5 units/kg = units/day 2/3 morning (all 70/30) or 2/3 NPH, 1/3 regular 1/3 evening (all 70/30) or 2/3 NPH, 1/3 regular

how to decide insulin vs. oral hypoglycemic

severe hyperglycemia and type 1 patients >240 use insulin oral hypoglycemia for type 2 with moderate hyperglycemia 110240

onset/duration 1. human insulin lispro 2. regular insulin 3. NPH insulin/lente insulin 4. ultralente insulin 5. 70/30 mixture 6. glargine (lantus)

modifying insulin dosage for 1. illness, or unclear home insulin dose 2. illness 3. before surgery

1. why is diabetic goal BP 130/80 and LDL progression to proteinuria, progressive sclerosis and ESRD *ONCE GET PROTEINURIA DAMAGE IS IRREVERSIBLE AND GLYCEMIC CONTROL DOES NOT PREVENT PROGRESSION ANYMORE***

ACE inhibitors or ARB

...

diabetic retinopathy 1. frequency 2. background 3. proliferative 4. other ocular problems

1. 75% after 20 years of retinopathy 2. hemorrhages, exudates, microaneurysms, venous dilation, macular edema, asymptomatic if no retinal edema 3. NEOVASCULARIZATION and scarring, vitreous hemorrhage, retinal detachment 4. cataracts, retinopathy, glaucoma #1 cause of blindness in the US

diabetic neuropathy 1. peripheral neuropathy clinical pres 2. peripheral neuropathy treatment 3. CN abnormalties

1. stocking glove numbness and paresthesias ulcer formation, charcot joints, hypersensitivity to light touch, burning pain at night 2. gabapentin, TCA, pregabalin 3. CNIII palsy - eye pain, diplopia, ptosis, inability to adduct the eye, pupils are spared also CN VI and CNIV

diabetic neuropathy 1. mononeuropathies 2. autonomic neuropathy

1. median nerve, ulnar nerve, common peroneal diabetic lumbosacral plexopathysevere deep pain in thigh, atrophy/weakness in thigh/hip muscles truncal neuropathy in distribution of intercostal nerves 2. impotence in men (MCC), neurogenic bladder (retention/incontinence), gastroparesis (n/v early satiety) alternating constipation/diarrhea, postural hypotension

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does diabetic control help micro or macrovascular disease

microvascular by 50%, no clear improvement in macrovascular

diabetic foot 1. patho

1. arterial ischemia and neuropathy --> ulcers/infections, repetitive injuries, masks symptoms of rest pain, falsely elevated BP readings

diabetic infections 1. which infections

1. cellulitis, candidiasis, pneumonia, polymicrobial foot ulcers, osteomyelitis

treatment of diabetic complications 1. macrovascular disease 2. nephropathy 3. retinopathy 4. neuropathy 5. diabetic foot

1. risk reduction, aspirin, glycemic control 2. ACE inhibitors (slows microalbuminuria-->proteinuria, slows GFR decline) 3. ophthalmology/photocoagulation 4. NSAIDs, TCA, gabapentin, metoclopromide, 5. foot care, podiatry visits

DKA 1. patho 2. causes 3. clinical pres

1. more common in type 1 - insulin deficiency and glucagon excess --> severe hyperglycemia and accelerated ketogenesis,osmotic diuresis, volume depletion, metabolic acidosis 2. stress or illness, trauma, surgery, sepsis, GI bleeding, inadequate insulin 3. n/v, KUSSMAUL RESPIRATIONS (rapid/deep), abdominal pain, acetone breath odor, orthostasis, tachycardia, polyuria, polydipsia, polyphagia, weakness, drowsiness, or coma

DKA 1. dx

1. hyperglycemia >450, or 900, hyperosmolarity 320 mOsm/L serum pH>7.3, serum HCO3- >15, elevated BUN (pre-renal azotemia)

hyperosmolar hyperglycemic nonketotic 1. tx

1. ***Fluid replacement - 1L NS in first hour, 2nd liter in second hour, then switch to 1/2NS low dose insulin to lower blood glucose (5-10 unit bolus then infusion at 2-4 units/hour) switch to D5 1/2NS when blood glucose is 250

physiologic response to low blood glucose

@ 80 insulin decreases lower than 80 glucagon increases epinephrine/cortisol are next hormone @ 50s symptoms of hypoglycemia occur

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hypoglycemia 1. why is brain so sensitive to hypoglycemia' 2. causes

1. brain cannot use FFA as an energy source, symptoms correlate with blood glucose levels 2. overdosing insulin (see low C-peptide), anti-insulin antibodies, factitious hypoglycemia, insulinoma, ethanol ingestion (inc. NADH, dec. gluconeogenesis), postoperative hypoglycemia (ex. dumping syndrome), adrenal insufficiency, liver failure, glycogen storage diseases

hypogycemia 1. clinical pres 2. dx 3. tx

1. blood glucose of 40-50, inc epi --> sweating, tremors, inc. BP/pulse, anxiety, palpitations neuroglycopenic sx - irritability, behavioral changes, weakness, drowsiness, HA, convulsions, coma, death 2. blood glucose 100 mg/dL if patient is alcoholic, give THIAMINE BEFORE***GLUCOSE to avoid wernickes endcephalopathy

hypoglycemic unawareness 1. patho

1. diabetic neuropathy and blunted autonomic response leads to loss of neurogenic symptoms and do not recognize hypoglycemia

insulinoma 1. patho

1. insulin tumor from beta pancreas cells, associated with MEN1, usually benign 2. sympathetic activation - diaphoresis, tremors, high BP, anxiety neuroglycopenic symptoms - headache, visual disturbances, confusion, seizures, coma 3. WHIPPLE'S TRIAD - fasting hypoglycemia symptoms, blood glucose 20% insulin level) and sulfonylurea abuse shows normal proinsulin level (15 mEq/hour (normal dehydration, hypokalemia), achlorhydria (VIP inhibits gastric acid), hyperglycemia, hypercalcemia 2. CT/MRI, octreod

what is the #1 cause of neurologic disability, and the 3rd leading cause of death

stroke aka cerebrovascular accident

classes of ischemic stroke

TIA, reversible ischemic neurologic deficit (>24 hours, blockage of blood flow does not last long enough to cause permanent infarction 2.max 24 hours, usually less than 30 mins, but indistinguishable from a stroke at time of presentation 3. 30% 5 year stroke risk 4. age, HTN, smoking, afib, HLD, hypercoagulability, vasoconstrictive drugs (cocaine/amphetamines), polycythemia vera, sickle cell

ischemic stroke 1. sources of emboli 2. thrombotic stroke locations 3. lacunar stroke

1. heart - embolization of mural thrombus, or afib internal carotid, aorta, paradoxical (via vein to ASD) 2. atherosclerotic lesions in the carotid @ bifurcation or MCA 3. HTN/DM causes narrowing of arterial lumen by thickening of the vessel wall in the basal ganglia, thalamus, internal capsule, brainstem

source of embolic stroke evaluation

1. echocardiogram carotid doppler ECG/Holter monitor

symptoms of TIA 1. carotid system TIA 2. vertebrobasilar TIA 3.

1. temporary loss of speech, paralysis, paresthesias of contralateral extremity, amaurosis fugax (curtain like loss of sight 2. dizziness, double vision, vertigo, ipsilateral facial numbness, contralateral limb weakness, dysarthria, hoarseness, dysphagia, projectile vomiting, headaches

subclavian steal syndrome

stenosis of subclavian artery PROXIMAL to vertebral artery - left arm exercise causes vertebral artery flow reversal --> vertebrobasilar insufficiency/upper extremity claudication tx= surgical bypass

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thrombotic stroke 1. clinical pres 2. MCA clinical pres 3. lacunar stroke clinical pres 4. anterior cerebral artery

1. patient often awakens from sleep with neurologic deficits 2. contralateral hemiparesis, hemisensory loss aphasia (left), apraxia, contralateral hemineglect (right parietal), confusion (non-dominant hemisphere 3. small lacunar vessels --> isolated findings, limited deficits pos limb internal capsule = pure motor lacunar stroke VPL thalamus = pure sensory lacunar stroke ataxic hemiparesis (pos limb IC), clumsy hand syndrome (pons), dysarthria (pons) 4. contralateral lower extremity/face

causes of carotid bruit

murmur referred from the heart turbulent flow in the internal carotids

stroke 1. dx / workup 2. complications

1. CT scan without contrast differentiates ischemic from hemorrhagic - ischemic = dark, hemorrhage = bright MRI - more sensitive - takes longer in emergency setting ECG - to detect MI or atrial fibrillation carotid duplex - detect stenosis MRA - evaluate carotids, vertebrobasilar MCA/ACA/PCA, circle of willis 2. cerebral edema/mass effect 1-2 days after stroke - lower ICP with hyperventilation/mannitol hemorrhage into infarction seizures

stroke 1. treatment

1. supportive - airway, oxygen, IV fluids tPA within 3 hours aspirin if patient presents after 3 hours clopidogrel if patient cannot take aspirin, if cant take clopidogrel take ticlopidine bed 30 degrees to prevent aspiration BP control ife >220/120, or MAP >130, acute MI, aortic dissection, heart failure, hypertensive encephalopathy, patient is undergoing thrombolysis

contraindications to tPA

> 3 hours after stroke onset uncontrolled HTN, bleeding, anticoagulation, no aspirin for 24 hours after tPA (all inc. risk for hemorrhagic conversion)

stroke 1. prevention

control risk factors, aspirin, carotid endarterectomy for symptomatic and >70% stenosis

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840.

intracerebral hemorrhage 1. causes/patho 2. clinical pres 3. dx 4. tx

1. sudden inc. in BP (50-60%), amyloid angiopathy, anticoagulation/thrombolytic, brain tumors, AVM --> rupture of deep vessels in basal ganglia, pons, cerebellum, other 2. focal deficits that worsen over 30-90 minutes , altered LOC, stupor, coma, headache, inc. ICP 3. CT of head **( shows bright white signal) coagulation panel, platelet count 4. ICU, ABCs, gradual BP reduction (nitroprusside) if >160/>105 mannitol/diuretics reduce ICP surgical evacuation of CEREBELLAR hematomas only

1. complications of hemorrhagic stroke 2. brain complications associated with cocaine use

inc. ICP, seizures, rebleeding, vasospasm, hydrocephalus, SIADH 2. ICH, ischemic stroke, SAH

pupillary findings in intracerebral hemorrhage

pinpoint - pons poorly reactive pupils - thalamus dilated pupils - putamen

subarachnoid hemorrhage 1. causes/patho 2. anatomic locations 3. clinical pres

1. saccular aneurysms at bifurcations of arteries of circle of willis, trauma, AVM --> bleeding into subarachnoid space 2. junction of ACA with anterior communicating, junction of PCA with internal carotid, MCA bifurcation 3. sudden "worst headache of my life", transient LOC, vomiting, meningeal irritation, nuchal rigidity, photophobia, retinal hemorrrhages

subarachnoid hemorrhage 1. dx/tx

1. non-contrast CT scan lumbar puncture if CT scan is inconclusive-see blood in SAF, and xanthochromia from RBC lysis tx = neurosurgery, reduce risk of rebleeding, stool softeners, analgesia, HTN, lower BP gradually (to account for possible decreased CPP), CCB for vasospasm

SAH complications

rerupture, vasospasm, communicating hydrocephalus, seizures, SIADH

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parkinsons disease 1. pathophys 2. clinical pres 3. pathologic finding

1. loss of dopamine containing neurons in substantia nigra/locus ceruleus, shifts dopamine/acetylcholine balance in the basal ganglia toward acetylcholine 2. pill rolling tremor at rest that goes away when performing routine takes, bradykinesia, cogwheel rigidity*, expressionless facies/dec. blinking, dysarthria, dysphagia, micrographia, impaired cognition, orthostasis, constipation, personality changes, depression, significant disability within 510 years 3. lewy bodies (hyaline inclusion bodies)

shy drager syndrome 1. patho/clincal pres 2. tx

parkinsonian symptoms + autonomic insufficiency (orthostasis, constipation, inc. sweating, oily skin, incontinence) * risk of laryngeal stridor/bulbar dysfunction 2. volume expansion - fludrocortisone, salt supplementation, alpha agonists, compression devices

parkinson syndrome 1. treatment

1. no cure carbidopa-levodopa (Sinemet) relieves symptoms - shows "on-off" phenomenon bromocriptine, pramipexole (dopamine agonists) selegiline - MAOI ~ L-dopa adjunctive agent amantadine - for early or mild disease anticholinergic drugs - trihexyphenidyl benztropine *best for tremor/rigidity dominant disease amitriptyline - both anticholinergic and antidepressant DBS for patients that don't respond medications or develop disease before age 40

what drugs cause parkinsonian side effects

metoclopramide (gastrokinetic), typical antipsychotics, reserpine (antipsychoticantihypertensive)

huntington's chorea 1. patho 2. clinical pres

1. AUTOSOMAL DOMINANT chromosome 4 CAG trinucleotide repeat disorder that shows genetic anticipation, degeneration of the GABAergic neurons of the caudate nucleus 2. onset between age 30-50, chorea of face/head/tongue, irritability, personality change, antisocial behavior OCD, impaired mentation, incontinence dementia before age 50

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huntingtons chorea 1. dx/tx

1. MRI - caudate/putamen atrophy, bilateral enlarged ventricles PET scan - dec. glucose metabolism DNA testing, genetic counseling for family members tx= symptomatic, dopamine antagonists help with psychosis/chorea, anxiolytics/antidepressants

physiologic tremor 1. causes

1. fear, anxiety, fatigue, hypoglycemia, hyperthyroidism, pheochromocytoma, alcohol withdrawal, valproate, lithium, caffeine, theophylline

essential tremor 1. patho 2. clinical pres 3. tx

1. autosomal dominant inheritance, 2, exacerbated by intentional activities, DECREASED BY ALCOHOL USE, no parkinsonism symptoms present 3. propranolol, primidone (anticonvulsant, can precipitate acute intermittent porphyria attackabdominal pain, confusion, headache, hallucinations - check UA)

different tremors clinical pres/associated symptoms 1. parkinsonian 2. cerebellar 3. essential tremor

1. tremor at REST, pill rolling, associated with rigidity, bradykinesia, shuffling gait, improved by action 2. intention tremor, coarse, associated with ataxia, nystagmus, dysarthria, improved by rest 3. associated with postures - ex. outstretched hands, fine tremor, associated with head tremor or vocal tremulousness, improved by alcohol

ataxia 1. causes (acquired/inherited)

1. alcohol, B12/thiamine deficiency, cerebellar infarction, neoplasm, demyelinating disease (MS/HIV), tabes dorsalis inherited = friedreich's ataxia, ataxia telangiectasia

friedreich's ataxia 1. patho/clinical pres

1. Autosomal recessive chromosome 9 defect --> degeneration of dorsal columns, corticospinal tract, spinocerebellar tracts, cerebellum Clinical pres= ataxia , nystagmus, impaired vibratory sense, proprioception, kyphoscoliosis

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ataxia telangiectasia 1. patho/clinical pres

1. autosomal recessive - Frederich's ataxia + telangiectasia + increased risk of cancer (ESPECIALLY NONHODGKIN S LYMPHOMA, ALL, STOMACH CANCER,), IgA deficiency

tourettes syndrome 1. patho 2. clinical pres 3. tx

1. AUTOSOMAL DOMINANT associated with OCD 2. multiple motor tics - blinking, grimacing, head jerking, shoulder shrugging phonic tics (>1 kind)- grunting, sniffing, clearing throat, coprolalia 3. clonidine, pimozide, haloperidol

dementia 1. diagnostic criteria 2. vascular dementia 3. binswanger's disease

1. progressive loss of intellectual function, with PRESERVATION OF CONSCIOUSNESS, associated with inc. age 2. stepwise deterioration in intellectual function from cerebral infarction 3. diffuse subcortical white matter degeneration in patients with atherosclerosis/HTN

primary causes of dementia

alzheimer's disease, vascular dementia, binswanger's disease, brain tumors, chronic subdural hematomas, NPH, lewy body dementia, picks disease, MS, parkinsons, huntington, wilsons

infectious causes of dementia

HIV infection (AIDS dementia), neurosyphilis, cryptococcus, CJD, progressive multifocal leukoencephalopathy

metabolic causes of dementia

thyroid disease, B12 deficiency, thiamine deficiency (--> korsakoff dementia), niacin deficiency

what toxins cause dementia

chronic alcoholism, aniline dyes, lead, mercury

pseudodementia

severe depression that can cause a decline in cognition but is responsive to antidepressants patients are overly concerened about their memory loss

1. dementia lab workup 2. dementia pharmacologic treatment

1. CBC with diff, chemistry panel, TSH, B12, folate, VDRL, HIV screening, CT or MRI of head 2. vitamin E, tacrine, donepezil

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alzheimers disease 1. risk factors 2. pathology findings 3. dx/tx

alzheimers disease 1. clinical pres

1. age : 10-15% of people over age 65, 1530% over age 80 family history, downs syndrome, chromosome 21, 14, 19 abnormalities, loss of CHOLINERGIC neurons* 2. senile plaques- dilated, tortuous neuritic plaques around beta amyloid core, neurofibrillary tangles - in cytoplasm of neurons 3. clinical diagnosis, CT or MRI shows diffuse cortical atrophy with ventriculomegaly tx = cholinesterase inhibitors - donepezil, rivastigmine, galantamine memantine - NMDA antagonist ginkgo, lecithin vitamin E 2000IU/day HRT associated with lower risk of alzheimers disease 1. early - forgetfulness, impaired ability to learn, poor performance, change in judgement intermediate - progressive memory impairment, visuospatial disturbances later stages- help needed for daily living, difficulty remembering names of relatives advanced- complete debilitation, loss of bowel/bladder control, death 2/2 infection

lewy body dementia 1. clinical pres 2. tx

1. visual hallucinations predominant initially, disorganized speech, extrapyramidal symptoms, fluctuating mental status, faster progression 2. selegiline, neuroleptic agents (for hallucinations/psychosis)

altered mental status 1. what part of the brain is responsible for arousal 2. what part of the brain is responsible for cognition

1. RAC in brainstem 2. cerebral cortex

causes of delirium

P.DIMMWIT postoperative, dehydration/malnutrition, infection, medications, metals, withdrawal stages, inflammation/fever, trauma/burns

what drugs can cause delirium

TCAs, corticosteroids, anticholinergics, hallucinogens, cocaine

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delirium 1. clinical pres 2. dx/tx

1. rapid deterioration of mental status, FLUCTUATING LEVEL OF CONSCIOUSNESS, disorientation, frequently abnormal vital signs, may include hallucinations 2. MMSE, chemistry panel, B12, thiamine tx = underlying cause, haloperidol for agitation, supportive

ddx for coma/stupor

SMASHED structural brain pathology - stroke, subdural/epidural, tumor, abscess, herniation meningitis, mental illness alcohol, acidosis seizures, substrate deficiency (thiamine) hypercapnia, hyperglycemia, hyperthermia, hyponatremia hypoglycemia, hypoxia endocrine - addisonian crisis, thyrotoxicosis, hypothyroidism, encephalitis (uremia) drugs - opiates, barbiturates, benzos, dangerous compounds - monoxide, cyanide, methanol

coma 1. criteria 2. causes 3. diagnosis

1. decreased LOC, patient unresponsive to any stimuli 2. bilateral structural brain lesions, or brainstem, or cerebellum, or RAC damage, global brain dysfunction - metabolic or systemic disorders psychiatric - conversion, malingering 3. ABC, assume trauma, stabilize cervical spine, assess LOC (via GCS) asymmetric movement = most likely mass lesion pupillary light reflex - indicates midbrain intact, morphine, anoxic encephalopathy, bilateral fixed/dilated (severe anoxia), unilateral fixed /dilated uncla herniation, pinpoint pupils - ICH, narcotics independent breathing - intact brainstem toxicologic analysis CT or MRI of brain LP if suspect meningitis or SAH

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coma 1. treatment 2 brain death 3. persistent vegetative state

multiple sclerosis 1. patho 2. clinical pres

multiple sclerosis 1. dx

multiple sclerosis 1. clinical course

1. correct cause: airway, supp. o2, naloxone, dextrose, thiamine before glucose, BP, electrolytes, lower ICP if herniation 2. irreversible absence of brain/brainstem function, no brainstem reflexes (pupils, calorics, gag, cornea, dolls eyes) no drug intox or metabolic condition core body temp >32 C clinical evidence or CT/MRI shows causative explanation for brain death repeat examinations, or EEG shows isoelectric activity 3. comatose, but eyes are open, appear awake, may have random limb/head movements, spontaneous respirations 1. selective CNS white matter demyelination of the brain and spinal cord, classically at the angles of the ventricles, pyramidal, cerebellar pathways, MLF, optic nerve, posterior columns 2. transient sensory deficits, paresthesias/dec. sensation of upper/lower limbs, fatigue*, weakness/spasticity, leg stiffness, optic neuritis, central scotoma, dec. pupillary reaction, INTERNUCLEAR OPHTHALMOPLEGIA (adduction deficit), bilateral trigeminal neuralgia cerebellar involvement- ataxia, intention tremor, dysarthria, incontinence, impotence, constipation memory loss, personality change, emotional lability, anxiety, depression neuropathic pain/hypersesthesas 1. clinically definite - two episodes, evidence of white matter lesions clinical or imaging laboratory supported - two episodes of symptoms, at least one white matter MRI lesion, abnormal CSF probable MS- two episodes of symptoms, and either one white matter lesion, or oligoclonal bands evoked potentials - remyelinated neurons conduct slowly clinically silent - stable or benign disease relapsing and remitting primary progressive - onset typically later 1/3 of patients develop debilitating disease

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multiple sclerosis 1. tx

1. high dose IV methylprednisone for acute attack plasma exchange therapy for steroid refractory acute attacks DMT- interferon B1a, B1b, glatiramer acetate reduce relapse rates by 35% (SE is flu like symptoms) cyclophosphamide for rapidly progressing disease baclofen or dantrolene for spasticity carbamazepine or gabapentin for neuropathic pain

locked in syndrome 1. clinical pres 2. patho

1. patients completely paralyzed except for respiration, blinking, and vertical eye movement, patients are fully aware of their surroundings and can feel pain 2. hemorrhage or infarction of the ventral pons

guillain barre syndrome 1. patho 2. clinical pres

1. mycoplasma, campylobacter jejuni, CMV, hepatitis, HIV, hodgkins disease, lupus, HIV seroconversion --> inflammatory demyelinating polyneuropathy of peripheral nerves 2. abrupt onset of ascending symmetric weakness/paralysis of all four extremities, PRESERVED SENSORY* respiratory, facial, bulbar muscles, spares sphincter control/mentation autonomic features - arrhythmias, tachycardia

guillain barre 1. dx/tx

1. **CSF shows elevated protein**, normal cell count, dec. NCV on EMG tx= pulmonary monitoring/mechanical ventilation, IVIG, plasmapheresis, DO NOT GIVE STEROIDS IN GUILLAIN BARRE SYNDROME recovery usually occurs in 1-3 weeks, but if persists >6 weeks probably will have relapsing course

myasthenia gravis 1. patho 2. clinical pres 3. myasthenic crisis + tx

1. autoimmune disorder against nicotinic AchR, results in muscle fatigue especially rapidly stimulated muscles 2. skeletal muscle weakness exacerbated by use, involves cranial nerves first symptoms often diplopia, ptosis, blurred vision, dysarthria, dysphagia 3. infection or stressor --> diaphragm/intercostal fatigue results in respiratory failure ET tube + withdrawl anticholinesterases + plasmapheresis

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myasthenia gravis 1. dx

duchenne's muscular dystrophy 1. patho 2. clinical pres 3. dx/tx

1.anti- Ach-R test EMG shows decremental response CT scan of thorax to rule out thymoma (10% of patients 75% histologically abnormal) edrophonium tensilon test tx = pyridostigmine, thymectomy - can cause complete remission 3rd line agents: corticosteroids, azathioprine, cyclosporine IVIG for exacerbations serial FVCs calcium pyrophosphate 2. tx + monitoring crystals in joints, inc. with age, 2. knees***/wrists, can be mono or polyarticular, fever, leukocytosis 3. joint aspirate weakly positively birefringent rod shaped and rhomboid crystals (CPP crystals) XR CHONDROCALCINOSIS** tx= underlying cause, NSAIDs/colchicine, intra articular steroid injections*

1. CK, LDH, aldolase, AST/ALT elevated ANA, anti-Jo-1 (anti synthetase), anti SRP, anti-Mi2, fever EMG- myopathic potentials/fibrillations muscle biopsy - shows inflammation/necrosis 2. corticosteroids then slowly taper, MTX, cyclophosphamide, chlorambucil, Pt for refractory disease MONITOR: with muscle strength and CK levels

what precipitates a gout attack

dec. temp, dehydration, stress, 964. inclusion body myositis inc. alcohol intake, starvation 1. clinical pres 2. dx/tx gram stain and culture

1. common in elderly (M>F), proximal AND distal muscle weakness, loss of DTRs 2. elevation in CK, absence of autoantibodies, tx = treatment refractory

what should always be done on a joint aspirate in a patient with a painful joint complications f gout

nephrolithiasis, tophaceous gout, degenerative arthritis

what NSAIDs should not be used in gout

aspirin can aggravate, acetaminophen has no antiinflammatory properties 965. polymyalgia rheumatica 1. patho 1. polymyositis, dermatomyositis, childhood 2. clinical pres 3. tx onset dermatomyositis,

idiopathic inflammatory myopathy (polymyositis/dermatomyositis) 1. diseases 2. childhood onset dermatomyositis key clinical

inflammatory myopathy (polymyositis/dermatomyositis) 1. common clinical pres 2. dermatomyositis unique features

collagen vascular disease myositis, myositis of malignancy, inclusion body myositis 2. subcutaneous calcifications 1. symmetrical proximal*** muscle weakness of neck flexors, shoulder girdle, pelvic girdle, dysphagia (30%), arthralgias, CHF/conduction defects/ILD both rarely , 2. heliotrope rash around eyes, bridge of nose, cheeks gottron's papules - papular erythematous knuckle lesions V-sign - rash over face, neck, ant. chest shawl sign - shoulders, upper back, elbows, knees periungual erythema/telangiectasias subcutaneous calcifications vasculitis of GI tract, kidneys, lungs, eyes

1. autoimmune (HLADR4) 2. hip/shoulder muscle pain after a period of inactivity, pain with movement, but strength is normal. constitutional symptoms - malaise, fever, depression, weight loss, fatigue joint swelling of knees, wrists, hands signs/symptoms of temporal arteritis 3. elevated ESR correlates with disease activity tx = corticosteroids

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fibromyalgia 1. clinical pres 2. dx 3. tx

ankylosing spondylitis 1. patho 2. clinical pres 3. dx/tx

1. multiple tender TRIGGER POINTS, symmetrical, stiffness, constant aching pain, aggravated by weather, stress, sleep deprivation, cold temperature, worse in the morning *sleep is disrupted, anxiety/depression is common 2. widespread pain >3 months, 11/18 trigger point sites, r/o myofascial syndromes, rheumatoid arthritis, ank spondy, CFS, lyme, hypothyroid, polymyositis 3. tx = SSRI, TCAs, CBT, psych eval 1. HLA B27 Male>females, ascending fusion of the spine, 2. MORNING STIFFNESS, lower back pain bilateral sacroiliitis, lower back pain, limited lumbar spine motion, neck pain is late, loss of lordosis, enthesitis (inflamm@ site of tendon attachments), fatigue, low grade fever, weight loss, vertebral fractures with minimal trauma extra articular: anterior uveitis, iridocyclitis 3. MRI/CT/plain film - sacroiliitis, sclerotic sacro-iliac junction, eventually bamboo spine from column fusion inc. ESR 4. indomethacin, anti-TNF (etanercept, infliximab) PT, surgery, strict immobilization with back injury

causes of monoarticular joint pain 2. causes of polyarticular joint pain

1. osteoarthritis, gout, pseudogout, trauma, septic arthritis, hemarthrosis 2. RA, SLE, viral arthritis, rheumatic fever, lymes, gonococcal arthritis, drug induced arthritis

reactive arthritis 1. patho 2. clinical pres 3. dx

1. preceding infection:: salmonella, shigella, campylobacter chlamydia, yersinia --> asymmetric inflammatory oligoarthritis 2. TRIAD, arthritis, urethritis, conjunctivitis/anterior uveitis, fatigue, malaise, weight loss, fever, joint pain 3. synovial fluid analysis 4. NSAIDs***, no response sulfasalazine, azathioprine

ankylosing spondylitis 1. complications

1. restrictive lung disease, cauda equina syndrome, spine fracture with spinal cord injury, osteoporosis ,spondylodiscitis, aortitis

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psoriatic arthritis 1. clinical pres

1. 10% of patients,usually preceded by skin disease, tends to affect smaller joints, asymmetric, polyarticular, NAIL INVOLVEMENT***

temporal arteritis 1. patho 2. clinical pres 3.comorbid conditions 4. dx/tx

1. inflammatory arteritis of temporal, aorta, or carotids 2. fatigue, malaise, weight loss, fever, headaches*, visual impairment**, jaw claudication, tenderness over temporal artery, absent temporal pulse 3. polymyalgia rheumatica** (40%), aortic aneurysm*, aortic dissection** (follow with serial cxr) 4. ESR elevated, temporal artery biopsy (90%) tx = high dose prednisone early before bx results. if bx positive, treat for 4 weeks, then taper for 2-3 YEAR*, FOLLOW ESR to determine efficacy

takayasu's arteritis 1. patho 2. clinical pres 3. tx 4. complications

1. vasculitis of the aortic arch and major branches 2. fever, night sweats, arthralgias, fatigue, absent carotid, pain radial, or ulnar pulses, discrepancy in 4 limb BP 3. tx - steroids, treat HTN, surgery or angioplasty for stenosed vessels 4. limb ischemia, aortic aneurysms, aortic regurgitation, stroke

vasculitis by vessel size 1. large vessel 2. medium vessel

1. takayasu's, temporal 2. PAN, kawasaki's disease, wegener's granulomatosis, churg-strauss microscopic polyangiitis 3. henoch schonlein purpura, hypersensitivity virus, behcets syndrome

churg strauss 1. patho 2. clinical pres 3. dx/tx

1.P-ANCA -multi organ vasculitis including respiratory, cardiac, GI, skin, renal, neuro 2. fever, fatigue, weight loss, respiratory - asthma, dyspnea skin lesions - subQ nodules, palpable purpura 3. biopsy of lung/skin, p-ANCA tx = steroids

Medicine 2_1 Study online at quizlet.com/_14lxem 1.

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wegeners granulomatosis 1. patho 2. clinical pres 3. dx/tx

polyarteritis nodosa (PAN) 1. patho 2. clinical pres 3. dx/tx

behcets syndrome 1. patho 2. clinical pres 3. dx/tx

1. vasculitis of the kidneys and UPPER AND LOWER GI tract 2. upper respiratory symptoms, purulent bloody nasal discharge, oral ulcers, cough, hemoptysis, dyspnea, glomerulonephritis, conjunctivitis, scleritis, arthralgias, myalgias, tracheal stenosis, constitutional symptoms 3. CXR, ESR, anemia, c-ANCA positive, thrombocytopenia *lung biopsy tx = poor prognosis, ***cyclophosphamide/corticosteroids renal transplant 1. HEP B*, HIV, drug reactions -> medium vessel vasculitis of nervous system/GI tract/kidney --> PMN invasion and fibrinoid necrosis + intimal proliferation -> renal artery/AAA/nerve damage, NO PULMONARY INVOLVEMENT 2. fever, weakness, weight loss, myalgias, arthralgias, abdominal pain, PERIPHERAL NERVES, HTN, mononeuritic multiplex, livedo reticularis. diffuse glomerulonephritis 3. biopsy of tissue (NO GRANULOMAS), mesenteric angiography (look for aneurysms)** ESR, p-ANCA (myeloperoxidase) FOBT tx = corticosteroids, cyclophosphamide 1. autoimmune leukocytoclastic venulitis 2. recurrent oral and genital ulcers, arthritis (knees/ankles), eye involvement (uveitis, optic neuritis, iritis, conjunctivitis), CNS involvement (meningoencephalitis, HTN) fever, weight loss, aortic disease 3. PATHERGY TEST elevated ESR/CRP, tissue biopsy, steroids

buergers disease 1. patho 2. clinical pres 3. tx

1. cigarettes --> small vessel vasculitis of arms/legs --> gangrene 2. ischemia, cyanotic, distal extremities, ulceration of digits 3. tx smoking cessation

hypersensitivity vasculitis 1. patho 2. clinical pres 3. dx/tx

1. penicillin/sulfa drugs/infection--> small vessel vasculitis 2. palpable purpura, macules, vesicles, 3. tissue biopsy tx = withdraw offending agent, steroids

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acute kidney injury 1. definition 2. clinical pres 3. what decreases the probability of recovery from AKI 4. what is the MCC death in AKI

1. rapid decline in renal function, with increased serum creatinine (>50% relative inc., or absolute increase of 0.5-1.0mg/dl) - may be oliguric, anuric, nonoliguric 2. dec. urine output, weight gain, edema, due to positive water/sodium balance, azotemia (inc. BUN/Cr) 3. increasing age and presence of comorbid conditions 4. infection, and cardiorespiratory complications

RIFLE criteria of AKI 1. risk 2. injury 3. failure 4. loss 5. ESRD

1. 1.5x increase in serum creatinine or GFR decrease by 25% or urine output 3 months

three possible locations of AKI

prerenal, intrinsic, post-renal

what causes azotemia

catabolic drugs (ie. steroids), GI/soft tissue bleeding, dietary protein intake

pre-renal failure 1. patho 2. causes 3. what drugs should be avoided in patients with prerenal failure

1. reversible dec. in arterial blood volume or renal perfusion --> dec. GFR --> inc. BUN/Cr/uremic toxins 2. hypovolemia, dehydration, excess diuretics, diarrhea, burns, hemorrhage, CHF, renal artery obstruction,cirrhosis 3. NSAIDS, ACE inhibitors, cyclosporin

monitoring patient with AKI

daily weights, intake, output, BP, serum electrolytes, Hb, Hct, monitor WBC for infection

urine osmolarity/urine Na/FeNa/urine sediment 1. pre-renal 2. ATN

1. >500, 40, >1%, full brownish pigment/granular epithelial casts

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pre-renal failure 1. clinical pres 2. dx

1. dry mucus membranes, hypotension, tachycardia, dec. skin turgor, oliguria/anuria 2. oliguria (20:1 urine osmolarity >500 dec. urine Na+ 2-3%, urine osmolality ATN/AKI if >20000 2. elevated CK, hyperkalemia, hypocalcemia, hyperuricemia 3. IVF, mannitol (osmotic diuresis), bicarbonate (pushes K+ into cells)

ATN 1 . two types of ATN 2. nephrotoxic agents

1. ischemic (shock, hemorrhage, sepsis, DIC, heart failure) and nephrotoxic 2. aminoglycosides, vancomycin radiocontrast NSAIDS + CHF myoglobinuria, chemotherapeutic drugs- kappa, gamma, light chains

ATN 1. phases

oliguric - 10-14 days (500ml/day from fluid/salt overload from oliguric phase recovery phase

tests for postrenal failure

palpation of bladder ultrasound of kidney/bladder- residual volume, hydronephrosis, obstruction catheter insertion - voids large urine volume

post renal AKI 1. patho

1. urethral obstruction (BPH), kidney obstruction, nephrolithiasis, neoplasms (bladder, cervix, prostate), retroperitoneal fibrosis

AKI 1. Blood labs to order 2. UA findings 3. how to rule out post-renal failure

1. elevated BUN/Cr, electrolytes, K+, Ca2+. PO4-, albumin, CBC 2. 3+ or 4+ protein suggest intrinsic renal failure from glomerular injury 3. bladder catheterization, renal ultrasound

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UA : urine sediment/protein/blood 1. pre-renal failure 2. ATN 3. acute glomerulonephritis 4. acute interstitial nephritis 5. post renal

1. few hyaline casts/negative/negative 2. muddy brown casts, renal tubular cells/trace/negative 3. dysmorphic RBCs, RBCs with casts, WBCs with casts, fatty casts/4+ protein/3+ blood* 4. RBCs, WBCs, eosinophils/1+ protein/2+ blood 5. +/RBC+WBC/negative/negative

AKI 4. urine chemistry 5. FENa 6. imaging

1. urine Na, urine Cr, 2. must get urine electrolytes/plasma electrolytes-> FENa = (UNa/PNa)/(UCr/PCr) ~~ 1% = ATN 3. renal ultrasound - to evaluate obstruction, hydronephrosis-- CT scan of abdomen/pelvis

AKI 1. volume complications + tx 2. metabolic complciations 3. fatal complications

1. ECF volume expansion causing pulmonary edema - tx = furosemide 2. hyperkalemia from dec. excretion and shifts from intracellular metabolic acidosis due to dec. excretion of hydrogen ions hypocalcemia - loss of ability to form vitamin D hyponatremia if drinking plain water hyperphosphatemia hyperuricemia 3. hyperkalemic cardiac arrest, pulmonary edema

what is the pathogenesis of AKI related infection/sepsis

uremic end products inhibit immune functions and increased susceptibility to infection

1. what drugs should be avoided in AKI 2. treatment of fluid overload 3. pre-renal AKI treatment

1. NSAIDs, nephrotoxic agents (aminoglycosides, radiocontrast) 2. diuresis, daily weight measurement, always consider cardiac function 3. treat underlying disorder, NS to restore euvolemia/BP, dont give to patinets who have ascites/edema, stop ACE inhibitors/NSAIDS

1. intrinsic AKI tx 2. post renal AKI tx

1. stop agent, trial of furosemide for oliguria 2. bladder catheter, uro consult

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CKD 1. definition 2. MCC 3. how to measure CKD

1. dec. GFR 60

chronic renal insufficiency

patients renal function is compromised but not failed - serum Cr usually 1.5-3.0

CKD 1. hematologic effects 2. endocrine/metabolic effects 3. sexual effects -also pruritus

1. normochromic normocytic anemia (dec. EPO) bleeding 2/2 interference with platelet function 2. hyperphosphatemia--> dec. D3--> hypocalcemia --> secondary hyperparathyroidism--> renal osteodystrophy/bone fractures + calciphylaxis 3. HPG disturbance dec. testosterone, amenorrhea, infertility, hyperprolactinemia

CKD 1. dx 2. radiologic dx`

1. urinalysis, Cr clearance/GFR, CBC shows anemia/thrombocytopenia, hyperkalemia, hypocalcemia, hypomagnesemia, hyperphosphatemia, meta. acid 2. renal ultrasound shows small kidneys suggesting chronic renal disease

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CKD 1. tx

1. low protein - 0.7-0.8 g/kg body weight/day low salt diet if HTN/CHF present restrict potassium, phosphate, Mg ACE inhibitors - reduce risk of ESRD progression, but WATCH FOR HYPERKALEMIA, strict blood control with ACE +/diuretics, glycemic control, smoking cessation

CKD 1. how to correct the hyperphosphatemia 2. hypo to correct hypo D3 and acidosis 3. """ anemia 4. """" pulmonary edema 5. """" pruritis

calcium citrate (oral phosphate binder) 2. oral bicarb and oral D3 3. EPO 4. dialysis 5. capsaicin, cholestyramine, UV light

1. indicates for emergent hemodialysis

AEIOU Acidosis - intractable metabolic acidosis electrolytes - hyperkalemia (refractor to other treatments) I - intoxications: methanol, ethylene glycol, lithium, aspirin, magnesium containing laxatives O - hypervolemia U - severe based on clinical presentation, uremic pericarditis, uremic encephalopathy

vascular access in dialysis

seldinger central catheter tunneled catheter - used up to 6 months AV fistula - for permanent access

1. disadvantages of hemodialysis 2. disadvantages of peritoneal dialysis

1. hypotension from rapid removal of intravascular volume, hypoosmolality from solute removal 2. hyperglycemia, hypertriglyceridemia, peritonitis

1. complications of dialysis

1. hypotension --> MI, fatigue hyposmolality --> nausea, vomiting first use syndrome - cx pain, back pain, anaphylaxis after using new dialysis machine sepsis beta 2 microglobulin amyloidosis peritonitis, hernias, hyperglycemia

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proteinuria 1. definition 2. glomerular proteinuria 3. tubular proteinuria 4. overflow proteinuria

1. >150mg protein/24 hours 2. due to glomerulonephritis/glomerular damage--> severe protein loss 3. small proteins filtered through glomerulus are normally reabsorbed - but with tubular damage they spill into urine-- 2/2 sickle cell, urinary track obstruction, interstitial nephritis 4. small protein production overwhelms tubules (ex. bence jones)

nephrotic syndrome 1. key features 2. causes

urine protein>3.5g/24 hours, hypoalbuminemia, edema (2/2 hypoalbuminemia) exacerbated by inc. aldosterone, hyperlipidemia/lipiduria - inc. hepatic LDL/VLDL synthesis hypercoagulable - loss of anticoagulants in urine 2. diabetes (MCC)*** membranous, membranoproliferative, minimal change (MCC in children), diabetes, SLE, RA, polyarteritis nodosa, henoch schonlein purpura, wegeners, amyloidosis, cryoglobulinemia,

nephrotic syndrome 3. what drugs cause nephrotic syndrome- also infections, MM, malignant HTN, and transplant rejection 4. dx***** ~ do this diagnostic sequence for hematuria as well, basically any renal failure that there is not a clear etiology

1. captopril, heroin, heavy metals, NSAIDs, penicillamine 4. urine dipstick - >30mg/dl (>1+), 4+ >500 mg/dl urinalysis - will show RBC casts, WBC casts, fatty casts *urine micro-albumin - more sensitive than dipstick Cr, BUN/Cr, CBC (anemia 2/2 renal failure), renal ultrasound, IVP (pyelonephritis), ANA, anti-GBM, hepatitis serology, anti-streptococcal antibody, complement levels, cryoglobulin, serum/urine electrophoresis renal biopsy

urinalysis 1. pH 2. specific gravity 3. protein - also glucose, blood, ketones, nitrite, leukocyte esterase 4. Microscope

1. avg 6.0, range 4.5-8 2. 1.002 - 1.035-- will normally vary with volume status 3. 1+ = 50-150mg/day, 2+ = 0.51.5g/day, 3+ = 2-5g/day, 4+ = >5g/day 4. look for casts , cells, bacteria, WBCs, RBCs, crystals

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nephrotic syndrome 1. tx

1. treat underlying disease (diabetes, MM, SLE, MCD) ACE inhibitors/ARBs - dec. urinary albumin limit dietary protein, treat hypercholesterolemia vaccinate against pneumococcal/influenza

Hematuria 1. definition 2. microscopic vs. gross hematuria 3. painless hematuria - check CBC for IDA

1. hematuria, >3 erythrocytes/HPF on urinalysis 2. glomerular vs nonglomerular (ie. post-renal such as trauma, stones, malignancy) 3. bladder or kidney cancer until proven otherwise

common causes for hematuria

cystitis, urethritis, prostatits

hematuria 1. causes 2. systemic causes 3. medication causes

1. kidney stones, infection (URI, urethritis, pyelo), bladder or kidney cancer, glomerular disease, IgA nephropathy, trauma, strenuous exercise (ex. marathon), cysts PCKD 2. SLE, rheumatic fever, HSP, wegener's, HUS, goodpasture's, PAN) 3. NSAIDs, cyclophosphamide, analgesics

hematuria 1. dx

1. urine dipstick, urinalysis RBCs/casts ~ GN pyuria --> send for culture if + for blood, but no RBCs on microscopy~ most likely hemoglobinuria, or myoglobinuria cytology to detect cancer 24 hour urine Cr/protein blood tests - coags, CBC, BUN/Cr IVP, CT scan, ultrasound renal biopsy

glomerular disorders 1. patho 2. clinical pres

1. impairment of selective filtration results in excretion of blood cells/larger proteins, and dec. GFR 2. isolated proteinuria, isolated hematuria, nephrotic syndrome

nephritic syndrome 1. patho 2. lab findings 3. clinical findings

1. Post strep + others -->glomerular INFLAMMATION 2. hematuria, AKI, azotemia, oliguria, proteinuria (not nephrotic range ie. 3.5g/24hr, hypoalbuminemia, hyperlipidemia 4. edema, hypercoagulability, inc. infections

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minimal change disease 1. patho 2. diagnosis 3. tx

1. hodgkin's disease*/nonhodgkin's/idiopathic/post infectious/rifampin --> systemic T cell dysfunction--> nephrotic syndrome 2. no histologic findings of light microscopy, foot processes fusion on electron microscopy, OVAL FAT BODIES ON URINE ELECTRON MICROSCOPY 3. 4-8 weeks of steroid therapy, usually full recovery

FSGS 1. demographics/clinical pres 2. dx 3. tx

1. blacks, AIDS patients*--> hematuria, HTN--> renal insufficiency within 5 years 2. focal segmental glomerulosclerosis on light microscopy 3. cytotoxic agents, steroids, immunosuppressive agents, ACE/ARBs

IgA nephropathy 1. patho 2. dx 3. tx

1. gross hematuria 5 days after upper respiratory infection or exercise --> 2. IgA and C3 on electron microscopy of kidney biopsy , SERUM COMPLEMENT LEVELS ARE NORMAL 3. steroids

membranous glomerulonephritis 1. patho 2. clinical pres 2. dx

1. hep C/B, syphilis, malaria, gold (tx for RA) captopril, penicillamine, neoplasm, lupus -> glomerular thickening 2. active urinary sediment, hypertension, worsening renal function, proteinuria, hypoalbuminemia 3. subepithelial deposits on renal biopsy, decreased C3

hereditary nephropathy (alports syndrome) 1. patho 2. clinical pres -no treatment

1. X LINKED OR AUTO DOM mutation in basement membrane protein 2. hematuria, pyuria, hearing loss, progressive renal failure

membranoproliferative glomerulonephritis 1. patho 2. dx

1. hep C/V, syphilis, lupus, cryoglobulinemia 2. tram tracking on renal biopsy with glomerular basement that stains for C3 and not immunoglobulins DEPRESSED C3***

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poststreptococcal GN 1. patho 2. clinical pres 3. dx 4. tx

1. post group B hemolytic strep or impetigo -> 10-14 days 2. hematuria, edema, HTN, low complement***, proteinuria 3. ASO titer*, anti-DNAse B titer, low C3 biopsy shows sub epithelial deposits 4. antihypertensives, loop diuretics, steroids for severe

goodpasture's syndrome 1. patho 2. clinical pres 3. dx 4. tx

1. IgG anti-GM antibody --> proliferative GN, pulmonary hemorrhage 2. rapidly progressive renal failure, hemoptysis, cough, dyspnea 3. renal biopsy shows linear* immunofluorescence 4. plasmapheresis removes circulating antiIgG antibodies

HIV nephropathy 1. clinical pres 2. dx 3. tx

1. proteinuria, edema, hematuria 2. histopath resembles FSGS 3. prednisone, ACE inhibitors, HAART

AIN 1. patho 2. clinical pres 3. dx/tx

1. allergy to meds - penicillin, cephalo, sulfa, diuretics, anticoagulants, phenytoin infection - legionella, streptococcus CVD - sarcoidosis, SLE, Sjogren's 2. rash, fever, eosinophilia, pyuria, hematuria 3. inc. BUN/Cr, urine eosinophils, proteinuria, hematuria 4. remove offending agent, steroids

renal papillary necrosis 1. patho 2. tx

1. analgesics, diabetes, sickle, UTO/UTI, alcoholism, transplant rejection 2. stop offending agent

type 1 RTA 1. patho/clinical pres 2. causes 3. dx 4. tx

1. inability to secrete H+ at distal tubule--> pH of urine is >6, dec. ECF volume, hypokalemia, renal stones/nephrocalcinosis (inc. Ca2+/phos excretion), rickets/osteomalacia 2. congeintal , MM, nephrocaclinosis, ampho B, lupus/sjogrens, analgesic nephropathy 3. hypokalemic, hypochloremic, non-AG met acid 4. sodium bicarbonate, phosphate salts (inc. excretion of titratable acid)

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type 2 RTA 1. patho 2. causes 3. tx

1. inability to reabsorb HCO3- in the proximal tubule* leading to inc. bicarb, K+, Na+ in the urine, NO, BASIC URINE, aminoaciduria, glycosuria, phosphaturia NEPHROCALCINOSIS/NEPHROLITHIASIS 2. fanconi's, cystinosis, wilsons, lead, MM, nephrotic syndrome, amyloidosis 3. no bicarb, sodium restriction inc. sodium/bicarb reabsorbtion

type 4 RTA 1. patho/causes

1. interstitial renal disease, diabetic nephropathy, hypoaldosteronism or resistance to aldosterone -> dec. Na absorption, dec. H+/K+ secretion--> HYPERKALEMIA*, and acidic urine

hartnups syndrome 1. patho 2. clinical pres 3. tx

1. AUTO RECESSIVE defect in amino acid transporter --> dec. tryptophan absorption and nicotinamide deficiency 2. pellagra (niacin def seen in corn based diets) - dermatitis, diarrhea, ataxia, psychiatric 3. give nicotinamide

analgesic nephropathy patho

nsaids, phenacetin, aspirin etc --> hematuria - renal papillary necrosis***, or interstitial nephritis

fanconi's syndrome 1. patho 2. clinical pres 3. dx/tx

1. proximal tubule dysfunction --> defective transport of glucose, amino acids, phosphate, uric acid, bicarb, sodium, potassium 2. impaired growth, glucosuria, phosphaturia, rickets, osteomalacia, proteinuria, 3. phosphate, potassium ,alkali, salt supplementation, hydration

ADPKD 1. patho 2. clinical pres 3. complications 4. dx/tx

1. AUTODOM, AUTOREC--> renal failure from recurrent pyelo/nephrolithiasis 2. hematuria, abdominal pain, HTN, palpable kidneys, 3. intracerebral berry aneurysms, renal failure, kidney stones, MVP/AR, cysts in liver/spleen/pancreas/brain, diverticula, hernias 4. US/CT/MRI tx = not curable, treat infections/control HTN

ARPKD 1. patho 2. clinical pres 3. dx /tx

1. aka "infantile" cysts of the renal collecting ducts, and hepatic fibrosis 2. portal HTN, cholangitis, pulmonary hypoplasia, potter syndrome 3. ultrasound during pregnancy, ultrasound

potter syndrome

oligohydramnios --> hypoplasia of the lungs, club feet, abnormal facies

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renal artery stenosis 1. patho 2. clinical pres 3. dx/tx

1. atherosclerosis/fibromuscular dysplasia -->RAS causes dec. blood flow to JGA --> RAAS --> HTN 2. HTN refractory to medical therapy, may be malignant, abdominal bruit, dec. renal function 3. renal arteriogram, BUT NO CONTRAST IN PTS WITH RENAL FAILURE. MRA duplex doppler ultrasound tx = revascularization, by PCI with stent ACE inhibitors, CCBs.

renal vein thrombosis 1. patho 2. clinical pres 3. dx/tx

1. nephrotic syndrome***, RCC, trauma, preg/OCP, retroperitoneal fibrosis, aortic aneurysm, lymphadenopathy 2. renal failure, flank pain, HTN hematuria, proteinuria 3. renal venography, IVP tx = anticoagulation

atheroembolic disease of renal arteries 1. patho 2. risk factors 3. clinical pres

1. showers of cholesterol crystals from plaques in arteries 2. warfarin 3. LIVEDO RETICULARIS, , hollenhorst plaques in the retina, digital cyanosis, elevated creatinine, elevated ESR,

hypertensive nephrosclerosis 1. patho 2. clinical pres

1. systemic HTN --> thickening of glomerular afferent arterioles --> proteinuria, / ESRD 2. proteinuria, rising Cr, dec. in renal function,

sickle cell nephropathy 1. patho

1. sickling of RBCs in microvasculature leads to infarction mostly in renal papillae --> nephrotic syndrome, 5% ESRD,

renovascular hypertension clinical pres

malignant HTN, sudden onset HTN, HTN suddenly worsened HTN that does not respond to standard medical therapy

nephrolithiasis 1. predisposing conditions

1. low fluid intake, gout, crohns, hyperparathyroid, type 1 RTA, UTIs (esp proteus), low calcium, high oxalate diet

calcium stones 1. patho 2. microscopic findings/radio findings

1.. calcium oxalate, or calcium phosphate, inc GI absorption, dec. renal reabsorption, inc. bone reabsorbtion of calcium, primary hyperparathyroidism, sarcoidsosi, malingnacy 2. bipyramidal or ovals, radiodense on abdominal radiograph

causes of hyperoxaluria

steatorrhea causes calcium loss small bowel disease, crohns, pyridoxine deficinecy

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uric acid stones 1. patho 2. microscopic findings/radio findings

1. persistently acidic* urine ( alkalinization of urine--> ammonia combined with mg/phos-->struvite calculi

1. what size stones can pass spontaneously 2. clinical pres of urinary stone 3. dx/tx

1. 3 days - consider urology consult

indications for admission for renal calculi

pain not controlled with oral meds anuria renal colic stone > 1cm

renal calculi prevention

2L/day of water limit animal protein intake if patient has hyperuricosuria thiazide diuretics - dec. urine calcium, allopurinol

UTO 1. lower urinary tract causes 2. upper urinary tract causes 3. clinical pres

1. BPH, prostate cancer, urethral stricture, neurogenic bladder, trauma (pelvic fracture/bladder cancer) 2. kidney stones, blood clots, sloughed papilla, tumors, strictures, ureteropelvic dysfunction, pregnancy, tumors, AAA, retroperitoneal fibrosis, endometriosis, crohns 3. renal colic/pain, oliguria, recurrent UTI, hematuria, renal failure

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UTO 1. dx 2. tx

1. renal ultrasound urinalysis KUB - shows stones IV contrast urogram cystoscopy CT scan 2. catheter, urethrotomy, prostatectomy, nephrostomy tube, ureteral stent,

prostate cancer 1. risk factors 2.clinical pres

1. age, AA, high fat diet, family history, pesticide/herbicide exposure 2. presents late- obstruction of the urethra occurs, difficulty voiding, dysuria, inc. urinary frequency, after mets- back pain, pelvic pain,weight loss

prostate cancer 1. dx

1. DRE- 70% have spread if palpable - abnormal DRE --> TRUS PSA screening/PSA velocity/ PSA density

what causes an elevated PSA

prostate cancer, prostatitis prostatic massage needle biopsy, cystoscopy, BPH, prostatitis, advanced age

what diagnostic studies 1. PSA >10 2. abnormal DRE 3. PSA 10 ng/dl (50%) PSA velocity >0.75/year

prostate cancer 1. treatment

1. contained disease - radical prostatectomy for locally invasive - radiation and androgen deprivation metastatic - orchiectomy, antiandrogens (flutamide), LHRH agonists (leuprolide), GnRH antagonists (degarelix) estramustine (estrogen+nitrogen mustard)

RCC 1. patho 2. sites of mets 3. risk factors

1. sporadic, or VHL 2. lung, liver, brain, bone 3. cigarettes, phenacetin PCKD, chronic dialysis (multicystic kidney disease), heavy metals (mercury/cadmium), hypertension

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RCC 1. clinical pres 2. paraneoplastic syndromes 3. dx 4. tx

1. HEMATURIA, abdominal/flank pain*, flank mass, weight loss, fever, paraneoplastic syndromes 2. polycythemia (EPO), PTHrp, renin, cortisol, gonadotropins, fever of unknown origin 3. CT with contrast, abdominal ultrasound 4. surgery***, interferon alpha/2, sunitinib (tyrosine kinase inhibitor)

bladder cancer 1. patho 2. risk factors 3. clinical pres

1. typically transitional cell cancers 10% squamous and adeno (transitional cell cancer can occur in the bladder, renal pelvis, or ureter) spreads by local invasion 2. cigarettes, aniline/azo dyes, long term cyclophosphamide treatment, schistosomiasis 3. painless hematuria, irritable bladder irritation, dysuria frequency

bladder cancer 1. dx 2. tx

1. urinalysis/urine culture, urine cytology, IVP, cystoscopy 2. stage 0 - mucosal limited - intravesical chemo stage A - lamina propria - transurethral bladder resection Stage B - muscle invasion - radical cystectomy, node dissection ,removal of prostate, uterus, ovaries, anterior vaginal wall, urinary diversion stage C - to pervesicular fat stage D - cystectomy, systemic chemotherapy

testicular cancer 1. germ cell 2. non-germ cell 3. risk factors

1. germ cell = seminomas (radiosensitive), non-seminomas (embryonal [necrosis/malig], chorio [mets quickly, yolk sac, teratoma) 2. leydig cell tumors - secrete androgens/estrogens, precocious puberty/gynecomastia sertoli cells -usually benign 3. cryptorchidism, klinefelter's syndrome 4. dx - testicular exam/ultrasound, b-HCG (chorio/non-sem), AFP (embryonal), CT chest

penile cancer 1. risk factors 2. ddx for testicular mass

1. uncircumcised, HSV, HPV 2. varicocele, spermatocele, hydrocele, lymphoma

testicular torsion 1. patho

1. twisting of spermatic cord causes ischemia/infarction 2. acute severe testicular pain, swollen/tender scrotum, elevated testicles, 3. testicular ultrasound, surgical emergency - detorsion and orchiopexy

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epididymitis 1. patho 2. clinical pres

1. e.coli in children/elderly, in young men - gonorrhea/chlamydia 2. swollen tender testicle, fever, chills, scrotal pain/mass 3. r/o torsion (ultrasound), and abx

fluids 1. TBW 2. ICF 3. ECF 4. plasma, interstitial fluid

1. 60% of body weight men, 50% women 2. 2/3 of TBW = 40% of body mass 3. 1/3 TBW = 20% of body mass 4. plasma = 1/3 ECF, 1/12 TBW interstitial fluid = 2/3 ECF

fluids 1. normal/minimum urine output 2. insensible loss 3. what is the best way to assess volume status - lower extremity edema may not be volume overload, TBW may be high, but patient may be intravascularly

1. 800-1500 ml/day, minimum = 500-600ml/day 2. 600-900 ml/day 3. urine output 0.5-1.0ml/kg/hour

causes of oliguria

cardiac failure (low blood flow to kidney) ATN/AIN/kidney damage post renal obstruction

1. what fraction of intravascular volume is in venous vs arterial system 2. what patients third space fluids

1. 85% venous, 15% arterial 2. liver failure, nephrotic syndrome (hypoosmolar), left sided CHF (pulmonary edema), right sided CHF (anasarca)

fluid replacement uses 1. normal saline 2. D51/2NS + 20 mEq kcl/L 3. D5w 4. lactated ringers

1. blood loss or dehydrated, urgent resuscitation 2. standard maintenance - glucose spares muscle breakdown 3. dilute powdered medicines, hypernatremia, only 1/12 remains intravascular 4. intravascular volume, NOT maintenance, trauma resuscitation, DO NOT USE IF PATIENT IS HYPERKALEMIC OR ESRD

causes of hypovoluemia

vomiting, diarrhea, NG suction, fistula, ascites, effusions, bowel obstruction, burns, polyuria (ex. DKA), sepsis, retroperitoneal inflammation, trauma, insensible losses (skin 75%, respiratory tract 25%)

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1. clinical presentation hypovolaemia 2. urine panel findings

altered MS, sleepiness, apathy, coma orthostasis, dec. pulse pressure, dec. CVP and PCWP poor skin turgor, hypothermia, pale extremities, dry tongue, oliguria, ileus, weakness, ARF (pre-renal azotemia) 2. FENa 20, low urine sodium, elevated hematocrit (3% inc for every liter of deficit)

1. how does CBC change with dehydration 2. how to correct a volume deficit

1. 3% inc. in hematocrit with each 1L of dehydration 2. bolus LR or NS, monitor HR/BP/UOP/weight, maintain UOP at 0.5-1ml/kg/hr, replace blood with crystalloid 3:1 ratio Then maintenance D51/2NS with 20mEq KCl/L

hypervolemia 1. causes 2. clinical features 3. tx

1. iatrogenic, CHF, nephrotic syndrome, cirrhosis, ESRD 2. weight gain, peripheral edema, ascites, pulmonary edema/rales, JVD, elevated CVP/PCWP, peripheral edema 3. fluid restriction, diuresis, UOP monitor/daily weights, swan ganz catheter placement

Na+ concentration is reflection of water homeostasis Na+ content is reflection of sodium homeostasis 1. sodium homeostasis 2. water homeostasis 3. NATREMIA VS VOLEMIA

1. inc. sodium increases ECF, which inc. GFR, dec. in sodium intake causes dec. GFR and reduced sodium excretion 2. osmoreceptors in hypothalamus stimulated by plasma hypertonicity(>295 mOsm/kg), inc. ADH production -->V2 receptors in collecting ducts, 3. natremia- too much or too little water volemia - too much or too little sodium

hyponatremia 1. definition 2. symptomatic hyponatremia level 3. symptoms of hyponatremia

1. plasma Na < 135mmol/L 2. occurs at Na HA, delirium, twitching, weakness, hyperactive DTR, seizures, coma, n/v ileus, watery diarrhea CV HTN from inc. ICP inc salivation/lacrimation oliguria --> anuria *****

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hypotonic hyponatremia 1. hypovolemic hypotonic hyponatremia 2. euvolemic hypotonic hyponatremia 3. hypervolemic hypotonic hyponatremia

1. osmolality inc. in plasma solids lower plasma sodium concentration but the amount of sodium is normal

hypertonic hyponatremia

osmotic substances cause water shift out of cells - hyperglycemia, mannitol, sorbitol, glycerol, maltose

adjusting Na for glucose

for every 100 of glucose, serum sodium level decreases by 3

diagnosis of specific type of hyponatremia

BMP, plasma osmolality, assess volume status (hypo, eu, hyper) urine osmolality

hyponatremia 1. treatment

1. 120-130 hold water 110-120 - loop diuretics + saline 145 2. diuretics, osmotic diuresis (glycosuria), renal failure, diarrhea, diaphoresis, respiratory losses 3. diabetes inspiidus, respiraotry losses 4. iatrogenic ~ TPN, NaHCO3-, glucocorticoids, saltwater drowning, hyperaldosteronism

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hypernatremia 1. clinical pres 2. dx 3. tx

1. neurologic symptoms - restlessness, focal neuro deficits, confusion, seizures, coma tissues, mucous membranes dry, salivation decreases 2. urine volume low, urine osmolality >800mOsm/kg 3. hypovolemic - give NS to restore hemodynamics isovolemic - DDAVP for DI, oral fluids, D5W IV hypervolemic - diuretics, D5W, dialyze if ESRD

water deficit calculation

water deficit = TBW (1-[actual Na/desiredNa)

calcium 1. normal range 2. corrected calcium 3. effect of pH

1. 8.5-10.5 2. corrected = total - [albumin*0.8] 3. high pH calcium binds albumin thus total Ca is normal, but ionized is low

PTH 1. actions

1. inc bone resorption, inc Ca2+ reabsorption at the kidney, dec. PO4reabsorption, inc. gut activation of D3 ==== inc plasma Ca2+, dec. plasma PO4-

calcitonin 1. actions

1. dec bone resorption, dec kidney Ca2+ reabsorption,inc kidney PO4reabsorption, dec gut absorption of Ca2+ ===== dec plasma Ca2+ and dec. plasma PO4-

vitamin D 1. actions

inc. bone resorption, inc Ca2+ reabsorption, dec. PO4- reabsorption, inc. gut Ca2 reabsorption, inc. gut PO4reabsorption

hypocalcemia 1. causes

1. hypoparathyroidism (iatrogenic MCC), acute pancreatitis (deposition), renal insufficiency (dec. D3 ESRD), hyperphosphatemia (ESRD), pseudohypoparathyroidism (resist to PTH), hypomagnesemia (dec. PTH secretion), D3 deficiency, malabsorption (short bowel), transfusion (citrate binds Ca), osteoblastic mets, hypoalbuminemia, digeorge (no thymic shadow)

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hypocalcemia 1. clinical pres 2. cardiac manifestations 3. lab workup 4. tx

1. rickets, osteomalacia, neuromuscular irritability- numbness, tingling, tetany, chvostek's sign, trousseau's sign, grand mal seizures, basal ganglia calcifications 2. LONG QT*** 3. BUN, Cr, magnesium, albumin, ionized calcium, amylase, lipase 4. IV calcium gluconate, oral calcium supplements, vitamin D, thiazide diuretics (dec. urinary calcium), magnesium

hypercalcemia 1. causes 2. what drugs cause hypercalcemia - sarcoidosis -familial hypocalciuric hypercalcemia (low urine Ca2+

1. hyperparathyroidism(inc. Ca, dec PO4), pagets disease of bone, acromegaly, addisons, metastatic cancer(prostate=osteoblastic, kidney=osteolytic), MM (lysis of bone tumor, release of OAF), PTHrp (lung cancer) 2. milk-alkali syndrome, vitamin D intoxication, thiazide, lithium (inc. PTH)

hypercalcemia 1. clinical pres 2. cardiac findings ECG 3. dx

stones -nephrolithiasis, nephrocalcinosis bones - bone aches/pains, osteitis fibrosa cystica grunts and groans -muscle pain/weakness, pancreatitis, PUD, gout, constipation psychiatric overtones- depression, fatigue, anorexia, sleep disturbances, anxiety, lethargy - other- polyuria/polydipsia, hypertension, weight loss, 2. SHORT QT*** 3. same workup as hypocalcemia, + radioimmunoassay of PTH (PTH vs PTHrp)

hypercalcemia 1. tx

1. IV fluids diuretics - furosemide BISPHOSPHONATES (pamidronate) calcitonin glucocorticoids hemodialysis phosphate- risk of metastatic calcification

potassium 1. where is it located in the body 2. hypokalemia causes 3. hyperkalemia causes 4. potassium secretion`

1. intracellular 2. alkalosis, insulin, albuterol 3. acidosis, renal failure 4. kidneys, GI tract

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hypokalemia 1. causes 2. bartter syndrome

vomiting, NG suction (hypokalemic met alk), diarrhea, laxatives, enemas, diuretics, renal tubular disease, parenchymal disease, glucocorticoids, mg deficiency, insulin administration, insufficient dietary intake 2. autosomal recessive defect in salt reabsorption in thick ascending limb hypokalemia, met. alk, inc.urine chloride (>20)~ key to distinguish from contraction alkalosis

what acid base disturbance with diarrhea

hypokalemic non-anion gap metabolic acidosis

in a patient who is hypokalemia 1. what does it mean if they are hypertensive 2. what does it mean if they are normotensive 3. what drugs cause hypokalmeia

1. could be excess aldosterone 2. probably renal or GI loss 3. bactrim, ampho B, B2 agonists,

hypokalemia ECG findings

T wave flattening, T wave inversions U waves prolongation of the QU interval (also seen with quinidine)

what electrolyte to monitor in patients on digoxin

monitor K+, hypokalemia predisposes to digoxin toxicity monitor Ca, hypercalcemia predisposes to digoxin toxicity

hypokalemia 1. clinical pres 2. tx

1. arrhythmias (prolongs conduction), weakness, fatigue, paralysis, cramping, ileus, polyuria, polydipsia, N/V 2. identify cause, adjust drugs, oral KCL, 10 mEq KCL inc. K+ by 0.1mEq/L, monitor K+ and EKG max 10 mEq/hr in peripheral IV line max 20 mEq/hr in central line add 1% lidocaine to dec. pain

hyperkalemia 1. causes

1. renal failure, addison's, K+ sparing diuretics (spirono), hyporeninemic hypoaldosteronism, ACE inhibitors***, transfusion, acidosis, rhabdo, hemolysis, burns, insulin deficiency (dec. NAK ATPase activity), bactrim

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pseudohyperkalemia

prolonged tourniquet use with or without repeated fist clenching--> acidosis/K+ loss from cells`` also hemolysis during venipuncture

hyperkalemia 1. clinical pres 2. ECG 3. tx

1. muscle weakness, dec. DTR, respiratory failure, n/v, intestinal colic, diarrhea 2. K+ > 6.0 tall peaked T waves, QRS widening, PR prolongation,loss of P waves, sine wave pattern, vfib 3. IV calcium gluconate*** stabilizes resin myocardial membrane Glucose and insulin sodium bicarbonate - inc. pH (emergency only) kayexalate - GI potassium exchange resin hemodialysis diuretics - furosemide

hypomagnesemia 1. causes 2. renal causes 3. clinical pres 4. relationship between mg and k 5. ECG changes - tx = oral or parenteral Mg

1. malabsorption, prolonged fasting, fistulas, TPN w/o mg, alcoholism 2. SIADH, diuretics, bartter's, gentamicin, ampho B, cisplatin, renal transplant 3. COEXISTING HYPOCALCEMIA, neuromuscular/CNS hyperexcitability, muscle twitching, weakness, tremors, hyperreflexia, seizures, altered mental status 4. when Mg or K decreases, the other ion decreases 5. prolonged QT, T wave flattening, torsade de pointes

hypermagnesemia 1. causes 2. clinical pres 3. ECG changes 4. tx

1. renal failure***, early burns, severe acidosis, trauma/surgical stress, adrenal insufficiency, rhabdomyolysis 2. nausea, facial paralysis, loss of DTRs (first), somnolence, death from respiratory failure/cardiac arrest 3. hyperkalemia type changes- inc PR interval, widened QRS, elevated T waves 4. calcium gluconate for cardioprotection, saline/furosemide, dialysis, intubation

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hypophosphatemia 1. causes 2.clinical pres

hyperphosphatemia 1. causes 2. clinical pres 3. tx

1. alcohol abuse (dec. intestinal abs), vitamin D deficiency, malabsorption, excessive use of antacids, hyperalimentation or starvation hyperglycemia, osteomalacia, ATN, RTA, hypokalemia, hypomagnesemia 2. encephalopathy, confusion, seizures, paresthesias, muscle weakness, myalgias/rhabdo, bone pain, rickets/osteomalacia hemolysis, RBC dysfunction, WBC dysfunction, platelet dysfunction cardiomyopathy/myocardial depression 1. renal insufficiency, bisphosphonates, hypoparathyroidism, D3 intoxication, calcinosis, PO4 enemas, D3 overdose, 2. metastatic calcification, soft tissue calcifications, serum * calcium > 70 = likelihood for precipitates to form hypocalcemia --> neuromuscular irritability/tetany 3. phosphate binding antacids w/ aluminum hydroxide or carbonate, hemodialysis

metabolic acidosis 1. criteria 2. anion gap 3. AG metabolic acidosis causes

1. dec. pH, dec. bicarbonate conc 2. AG = Na+ - (Cl + HCO3-) - reflects unmeasured ions, proteins, phosphates, organic acids, sulfates 3. ketoacidosis - diabetic, starvation, alcohol abuse lactic acidosis renal failure- dec. NH4+ excretion, retention of organic ions, sulfate, phosphate

effect of acidosis on the body

right shift oxygen hemoglobin curve depresses CNS, dec. pulmonary blood flow, arrhythmias, myocardial function impairment, hyperkalemia

effects of alkalosis on the body

dec. cerebral blood flow left shifts oxygen hemoglobin dissociation curve, arrhythmias, tetany, seizures

how to tell if met.acid is a mixed disorder

delta AG < delta HCO3- ~~ AG acid + high AG acid delta AG > delta HCO3- ~~ met alk + high AG acid

salicylate toxicity acid/base disturbance

primary resp. alk, primary met.acid `

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1. non-AG met acid causes

1. diarrhea (HCO3- loss), pancreatic fistulas, small bowel fistulas, ureterosigmoidoscopy proximal RTA (MM, cystinosis, wilsons), distal RTA (SLE, sjogrens, ampho B), acetazolamide (CA inhibitor)

1. metabolic acidosis clinical pres 2. dx

1. hyperventilation - kussmaul respirations when pH dec. response to catecholamines***-->lactic acidosis, --> dec. CO --> hypotension-->worsening acidosis 2. history, AG, expected PaCO2=1.5(HCO3-)+8+/-2 if more than expected there is also resp.acid b/c of inadequate compensation ***inadequate compensation is a sign of impending resp. failure ***PaCO2 less than expected, patient has met acid + resp. alk

metabolic acidosis 1. tx

1. sodium bicarbonate(but takes 24 hours to get to brain) H+ = 24[PaCO2/HCO3-] ~ so while patient gets bicarb, PaCO2 is still very low --> severe intracranial alkalosis mechanical respiration for respiratory fatigue

metabolic alkalosis 1. definition 2. first step in evaluation 3. causes: saline sensitive 4. causes: saline resistant 5. how high should respiratory compensation be

1. inc. blood pH, inc. HCO32. is the patient volume expanded or contracted 3. loss of gastric H+, ECF volume contraction saline sensitive- urine Cl < 10mEq/L, ECF contraction, hypokalemia: vomiting,, NG, diuretics, villous adenoma (high chloride diarrhea) 4. urine Cl>20mEq/L, ECF expansion, primary hyperaldosteronism, cushings, K+ deficiency, Bartter's syndrome, diuretic abuse 5. PaCO2 to 50-55, if higher there is probably resp acid as well

metabolic alkalosis 1. dx 2. tx

1. inc. HCO3-, inc. pH, hypokalemia, PaCO2 is elevated, urine chloride (high or low) 2. NS + potassium if saline sensitive, if saline resistant can address underlying cause or spironolactone Ammonium chloride for severe (risk of tox in patients with liver failure)

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respiratory acidosis 1. definition 2. compensation 3. causes 4. clinical pres

1. blood >40mmHg, reduced blood pH 2. acute - 1mmol/L for every 10mmHg PaCO2 pH inc. by 0.08 chronic - 4mmol/L for every 10mmHg PaCO2 3. COPD, airway obstruction, myasthenia, brainstem injury, narcotic overdose, respiratory fatigue 4. somnolence, confusion, myoclonus with asterixis, HA, confusion, papilledema

respiratory acidosis 1. treatment

1. patency of airway, supplemental oxygen (if PaO260, no improvement with supplemental oxygen, obtunded, deteriorating mental status)

respiratory alkalosis 1. definition 2. compensation 3. causes

1. inc. blood pH, dec. PaCO2 2. acute: HCO3- dec by 2 mmHg for every 10 mmHg dec in PaCO2, blood pH inc by 0.08 chronic: HCO3- dec by 5 mEq/L for every 10 mmHg dec in PaCO2 and blood pH dec. by 0.02 3. alveolar hyperventilation - anxiety, PE, pneumonia, asthma, sepsis, hypoxia, mechanical ventilation, pregnancy (inc. progesterone), cirrhosis, salicylates,

respiratory alkalosis 1. clinical pres 2. tx

1. dec. cerebral blood flow (vasoconstriction), lightheadedness, dizziness, anxiety, paresthesias, perioral numbness, tetany, arrhythmias 2. correct underlying cause, inhaled CO2, or breathing into paper bag

anemia 1. compensatory mechanisms 2. when to transfuse 3. clinical pres

1. inc. CO (HR*SV), inc. extraction ratio, right shift of hemoglobin curve (via inc. 2,3 DPG), expansion of plasma volume 2. Hb concentration2% impliese excessive RBC destruction) hb*3 = hct, iron, B12, folate, EPO (ESRD) 2

pseudoanemia

decrease in hemoglobin/hct 2/2 dilution acute volume infusion or overload

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after patient is found to have anemia what is next lab test

retic, B12, folate

cryoprecipitatecomponents+what is it used to treat

VIII, XIII, fibrinogen, vWFused for hemophilia A, DIC, vWD

how much change in CBC with 1 unit of PRBCs and 1 unit of platelets

1 unit or PRBCs- inc. Hb 1, inc Hct 3 1 unit of platelets - inc platelet count by 10,000

blood products for massive blood loss

1:1:1 - platelets:FFP:PRBCs

hemolytic transfusion reactions: intravascular hemolysis 1. patho 2. symptoms/complications 3. tx

1. ABO mismatched blood --> anti-# IgM--> complement activation, C9 punches holes in RBCs 2. fever, chills, n/v, flank pain, chest pain, dyspnea, hypovolemic shock, hypotension, tachycardia, DIC, renal failure, hemoglobinuria (ATN) 3. stop transfusion, fluid replacement, epinephrine, dopamine/norepi for pressure control

hemolytic transfusion reactions: extravascular hemolysis 1. patho 2. clinical pres + tx

1. minor antigen reaction occurs 3-4 weeks after transfusion, previous exposure creates memory-B cells that will produce Ig against antigen and lead to splenic/liver/bone marrow sequestration 2. late onset -- fever, jaundice, anemia tx none

anemia 1. interpretation of reticulocytes 2. microcytic anemia ddx

1. >2 excessive RBC destruction or blood loss with bone marrow response accumulated porphyrins/iron in mitochondria

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anemia 1. macrocytic ddx 2. normocytic ddx

1. B12/folate deficiency, liver disease (up to 115) due to altered lipoprotein synthesis), stimulated erythropoiesis (polychromatophilic RETICS), myelodysplasia 2. aplastic anemia, bone marrow fibrosis, tumor, AOCD, renal failure (inflamm/malig)

evaluation of suspected hemolytic anemia

first retic >2, then check haptoglobin, LDH, bilirubin

microcytic anemia 1. causes 2. clinical pres 3. dx 4. tx

1. chronic blood loss, menstrual bleeding, GI blood loss, infants/toddlers drinking human milk (low iron), rapid growth in adolescents, pregnancy 2. pallor, fatigue, generalized weakness, DOE, orthostasis 3. dec. ferritin, inc. TIBC, inc. transferrin, inc RDW, microcytic hypochromic RBCs on smear, stool guaiac 4. ferrous sulfate - SE = constipation, nausea, dyspepsia iron dextran- IV or IM

beta thalassemia (cooley's anemia) 1. patho beta thal 2. demographics 3. clinical pres + tx

1. deficient beta chain, excess alpha chains aggregate and damage membranes 2. mediterranean, middle eastern, and indian ancestry 3. severe hypochromic microcytic anemia, hepatosplenomegaly***, marrow expansion, FTT, skull xray shows "crew cut" 4. HbF/HbA2 elevated - peripheral smear shows microcytic hypochromic RBCs with target cells tx = frequent PRBCs

alpha thalassemia 1. patho 2.

1. alpha chain decrease, beta tetramers

what is the consequence of frequent transfusions in beta thal patients

iron overload and hemochromatosis tx -= desferoxamine

what type of microcytic anemia is inc. RDW characteristic of

IDA

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thalassemia minor 1. patho 2. clinical pres

1. heterozygous beta-chain thalassemia 2. asymptomatic, mild microcytic hypochromic anemia 3. dx = hemoglobin electrophoresis

what is next diagnostic test in patient who has IDA, but does not respond to iron

hemoglobin electrophoresis- to rule out alpha/beta thalassemia

alpha thalassemia 1. one mutation/deletion clinical pres 2. alpha thalassemia trait clinical pres 3. HbH disease 4. 4 alpha loci mutations

1. mutation/deletion of only one alpha locus- asymptomatic, normal hemoglobin/hematocrit 2. two alpha loci mutations- mild hypochromic anemia 3. hemolytic anemia, splenomegaly, microcytic hypochromic anemia, HbH on gel electrophoresis tx = PRBC transfusions 4. hydrops fetalis fatal at birth

sideroblastic anemia 1. patho 2. dx 3. tx

1. hereditary acquired - chloramphenicol, INH, alcohol, lead*, collagen vascular disease, myelodysplasia 2. inc. serum ferritin**, inc. serum iron*, BASOPHILIC STIPPLING, normal TIBC, TIBC saturation normal/elevated ringed sideroblasts on marrow biopsy 3. remove offending agent, B6 supplementation

anemia of chronic disease 1. patho 2. dx 3. tx

1.chronic infection, TB, lung abscess, cancer, RA, SLE, trauma-->IL6/ cytokines + HEPCIDIN*** are suppressive effect on EPO (dec. retics) and dec. iron absorption from the gut 2. low serum iron, low TIBC, low serum transferrin, INCREASED SERUM FERRITIN, normochromic, normocytic 3. no treatment, do not give iron

aplastic anemia 1. patho 2.clinical pres

1.radiation, chloramphenicol, sulfonamides, gold, carbamazepine, parvo B19, hep C, hep B, EBV, HZV, HIV, benzene, insecticides--> bone marrow failure-->pancytopenia 2. fatigue, dyspnea, petechiae, easy bruising, inc. infections (neutropenia), 3. normocytic, normochromic anemia, bone marrow shows hypocellular marrow, absence of progenitors tx = bone marrow transplant, PRBC/platelt transfusion,

pernicious anemia

autoimmune destruction of parietal cells and intrinsic factor leads to impaired absorption of B12 in terminal ileum

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B12 deficiency 1. function of b12 2. dietary sources/storage 3. causes of deficiency

1. homocysteine to methionine, methyl malonyl CoA to succinyl CoA 2. meat, fish- about 3 years supply in the liver 3. pernicious, gastrectomy, poor diet content (vegan), alcoholism, crohns disease, ileal disease, diphyllobothrium latum, blind loop (bacterial overgrowth

b12 deficiency 1. clinical pres

1. anemia, stomatitis, glossitis, neuropathy (B12*** vs folate), demyelination (pos. columns, corticospinal tracts, spinocerebellar tracts), ataxia, upper motor neuron signs, urinary/fecal incontinence, dementia

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1. peripheral smear shows megaloblastic anemia - hypersegmented PMNs, serum B12 3 crises/year - median age of death - 35 years 4. 2/2 parvo b19, - blood transfusion and patient recovers in 10-14 days

sickle cell anemia 1. clinical pres 2. painful bone crisis 3. hand foot syndrome 4. acute chest syndrome

1. jaundice, pallor, gallstone disease (pigmented), high output heart failure aplastic crisis (parvo) 2. painful bone crisis - tibia, humerus, self limiting in 2 -4 days 3. painful swelling of dorsa of hands and feet from avascular necrosis of metacarpal and metatarsal bones 4. repeated episodes of pulmonary infarctions- cx pain, respiratory distress, pulmonary infiltrates, hypoxia

sickle cell anemia 1. splenic disease 2. avascular necrosis 3. priapism + treatment 4. CVAs

1. multiple splenic infarctions cause functional asplenia by age 4 years (nonpalpable) 2. most commonly in the hip and shoulder 3. vasoocclusion --> erection, lasting between 30 mins and 3 hours tx = hydralazine, or nifedipine, or antiandrogen 4. cerebral thrombosis especially occurs in children

sickle cell anemia 1. renal complications 2. extremity complications 3. abdominal complications 4. infectious complications

1. renal papillary necrosis with hematuria, 2. chronic leg ulcers 3. abdominal crisis - mimics acute abdomen 4. functional asplenia leads to increased risk for - h.flu, s.pneumo, neisseria meningitidis (encapsulated bacteria)

1. sickle cell anemia diagnosis 2. sickle cell pain crisis tx 3. sickle cell tx

1. anemia, sickle peripheral smear, howell jolly bodies hemoglobin electrophoresis 2. hydration, IV fluids, morphine, keep patient warm, supplemental O2 3. avoid high altitudes (low O2 tension), maintain fluid intake, vaccination against h.flu, s.pneumo, n.mening, hydroxyurea (inc. HbF), blood transfusion , bone marrow transplant

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hereditary spherocytosis 1. patho 2. clinical pres 3. dx 4. tx

1. AUTOSOMAL DOMINANT - mutation in spectrin--> splenic trapping and destruction (extravascular) 2. hemolytic anemia, jaundice, splenomegaly, gallstones*, hemolytic crisis (2/2 parvo b19) 3. osmotic fragility to hypotonic saline, elevated retic, elevated MCHC >36%, spherocytes on smear, direct coombs negative 4. splenectomy folate supplementation (prevents aplastic crisis)

causes of spherocytosis

hereditary spherocytosis, G6PD, ABO incompatibility, hyperthermia, AIHA

G6PD deficiency 1. patho + triggers 2. clinical pres 3. peripheral smear findings

1. x linked disorder infection- G6PD cannot generated NADPH to reduce glutathione OXIDIZING DRUGS- sulfonamides, nitrofurantoin, primaquine, dimercaprol, fava beans, infection 2. episodic hemolytic anemia, dark urine, jaundice on exam, peripheral smear shows BITE CELLS, HEINZ BODIES (Hb precipitates), PRUSSIAN BLUE STAIN POSITIVE tx = avoid triggers, maintain hydration, RBC transfusion 3. bite cell from removal of heinz bodies by splenic macrophages

AIHA 1. patho 2. warm AIHA 3. cold AIHA

1. autoantibodies against RBC membrane antigens (IgG anti-Rh) leads to destruction of RBCs 2. leukemias, lymphomas, CLL, collagen disease, alpha methyl dopa -->IgG--> extravascular hemolysis --> splenomegaly 3. mycoplasma, infectious mononucleosis -> IgM* binds to RBC membrane--> intravascular hemolysis

AIHA 1. clinical pres 2. dx 3. tx

1. fatigue, pallor, jaundice, 2. microspherocytes, elevated reticulocytes direct coombs test positive - IgG- warm AIHA RBCs covered with complement alone - it is cold AIHA 3. often self limiting warm - glucocorticoids, splenectomy, azathioprine/cyclophosphamide, RBC, folate supplementation cold - avoid cold exposure, RBC transfusions, chemotherapeutic,

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paroxysmal nocturnal hemoglobinuria 1. patho 2. clinical pres 3. complications 4. tx

1. deficiency in proteins that link complement inactivating proteins to blood cell membranes-->complement mediated intravascular lysis, hypercoagulable state, bone marrow aplasia 2. chronic paroxysmal intravascular hemolysis, inc. LDH, normochromic normocytic anemia, pancytopenia, venous thrombosis, abdominal, back pain, muscle pain 3. aplastic anemia, myelodysplasia, myelofibrosis, acute leukemia 4. glucocorticoids, BMT

1. HIT type 1 + tx 2. HIT type 2 + tx

1. heparin causes platelet aggregation, IgG antibody mediated platelet activation/endothelial activation and intravascular thrombin generation--> vascular thrombosis*** 3-12 days after starting heparin-heparin should be DC

1. causes of bone marrow failure 2. causes of bone marrow invasion 3. causes of bone marrow injury

1. aplastic anemia, congenital aplastic anemia (fanconi's), congenital intrauterine rubella 2. tumors, leukemia, fibrosis 3. gold, ethanol, cancer chemotherapy, benzene, chloramphenicol, radiation, infection

paroxysmal nocturnal hemoglobinuria 1. diagnosis

Ham's test*** - patients cells placed in acidified serum, triggering alternate complement pathway causes lysis of PNH cells sugar water test- patients blood + glucose - causes hemolysis flow cytometry shows low CD55, and CD59

platelet disorders 1. causes of thrombocytopenia 2. causes of thrombocytosis 3. qualitative platelet disorders 4. hereditary platelet disorders

1. decreased production, increased destruction, sequestration 2. reactive - IDA, splenectomy, rebound, inflammatory disease, autonomous - myeloproliferative, polycythemia vera, essential thrombocytosis, CML 3. ASA, NSAIDs, antibiotics, high dose PCN, uremia (effects vwF XIII), liver disease (TPO), marrow disorders (leukemia etc), multiple myeloma, ITP, cardiopulmonary bypass (causes partial degranulation) 4. vWD, bernard soulier, glanzmanns

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1. what causes increased platelet destruction 2. dilutional thrombocytopenia 3. thrombocytopenia in pregnancy

1. ITP, infection, drug induced, HIT type 2, HIV associated thrombocytopenia DIC, TTP, HIT type 1 2. post hemorrhage, post transfusion 3. incidental finding, or preeclampsia/ecclampsia, or HELLP syndrome

thrombocytopenia 1. clinical pres

1. cutaneous petechiae bleeding, purpura, ecchymosis with minor trauma, mucosal bleeding, epistaxis, menorrhagia, hemoptysis, GI/GU bleeding

immune thrombocytopenic purpura 1. patho 2. clinical pres 3. dx

1. acute post viral, or adult chronic--> autoimmune antibody against hosts platelets which are then removed by splenic macrophages 2. petechiae/ecchymoses on the skin, minimal bleeding symptoms, mucous membrane bleeding, NO SPLENOMEGALY*** 3. platelets hyaline microthrombi occlude small vessels causing mechanical damage to RBCs 2. hemolytic anemia (MAHA), thrombocytopenia, ARF, fever, fluctuating neurologic signs 3. tx = plasmapheresis****, corticosteroids, splenectomy, NO PLATELET TRANSFUSION

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heparin induced thrombocytopenia 1. patho 2. dx/tx 3. complications

1. unfractionated heparin (15%), rarely LMWH--> drop in platelets a few days after administration--> platelet aggregation/activation+procoagulant release leads to venous thrombosis/DVT/PE**** 2. antiplatelet factor IV or serotonin assay tx= STOP HEPARIN, give direct thrombin inhibitor to bridge to warfarin (lepirudin, argatroban, rivaroxaban) 3. heparin induced thrombocytopenia and thrombosis (HITT)- 25% mortality rate

bernard soulier 1. patho 2. dx

1. AR- Gp1bIX defect leads to platlet adhesion to subendothelium dysfunction 2. abnormally large platelets, mildly low platelet count

glanzmann's thrombasthenia

1. AR - GpIIb-IIIa deficiency 2. prolonged bleeding time, platelet count normal

von willebrand's disease 1. patho 2. sub regions of factor VIII 3. type 1/2/3 4. clinical pres

1. defect in factor VIII or vWF 2. coagulant portion, and antigenic portion (= vWF) 3. type 1 = dec. vWF, type 2 = qualitative abnormalities of vWF, type 3 = absent vWF 4. cutaneous/mucosal bleeding, epistaxis, easy bruising, excessive bleeding with minor trauma, menorrhagia, GI bleeds

von willebrand's disease 1. dx 2. tx

1. prolonged bleeding time, dec. vWF, dec. factor VIII, reduced ristocetin induced platelet aggregation 2. DDAVP induces endothelial release of vWF(type 1/2) factor VIII concentrates, - after trauma/during surgery cryo - has risk of viral transmission avoid NSAIDs/aspirin

hemophilia A 1. patho 2. clinical pres 3. dx

1. XLR - deficiency in factor VIII 2. hemarthrosis, knees most commonly , progressive joint destruction (2/2 recurrent hemarthrosis), intracranial bleeding, retroperitoneal/intramuscular hematomas 3. prolonged PTT, low VIII, normal vWF tx = analgesia (NOT ASPIRIN/NSAIDS), VIII concentrate for acute bleeding/dental work, DDAVP for mild disease

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treatment of hemophilia B

IX concentrates, DDAVP doesnt do anything

disseminated intravascular coagulation 1. patho 2. clinical pres

1. infection (gram neg sepsis)/OB/fluid emboli/retained fetus/abruptio placentae, trauma, malignancy (lung/pancreas)--> abnormal activation of coagulation leading to microthrombi formation and consumption of platelets, fibrin, coagulation factors --> activation of fibrinolytic system 2. superficial hemorrhage, ecchymosis, petechiae, purpura, OOZING FROM PROCEDURE SITES, thrombosis

disseminated intravascular coagulation 1. dx 2. tx

1. PT, PTT, bleeding time, TT - ALL INCREASED, fibrin split products increased, d-dimers increased, dec. fibrinogen, dec. platelet count peripheral smear - shows schistocytes 2. underlying cause, FFP, platelet transfusions cryo, low dose heparin, O2, IV fluids

what does thrombin time measure

measures fibrinogen concentration

liver disease vs vitamin K deficiency coagulopathy

liver disease- PT and PTT elevated, TT, fibrinogen, platelets normal vitamin K - PT prolonged, PTT, TT, platelet count, fibrinogen levels normal

complications of DIC

intracranial bleeding --> death thromboembolism - stroke, PE, ischemic colitis, ARF, arterial occlusion

vitamin K deficiency 1. patho 2. dx

1. no leafy greens, broad spectrum abx/NPO, TPN, small bowel disease, inflammatory bowel disease, obstructive jaundice, warfarin 2. PT prolonged first then PTT vitamin K, or FFP

coagulopathy of liver disease 1. patho 2. poor prognostic indicator

1. cholestasis/hypersplenism only vWF not made by the liver 2. prolonged PT

antithrombin 3 deficiency 1. patho

1. autosomal dominant antithrombin 3 deficiency --> hypercoagulable state due to uninhibited thrombin

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antiphospholipid syndrome 1. patho - lupus anticoagulant, anticardiolipin, beta 2 microglobulin etc.

1. acquired hypercoagulable state (LUPUS) -- > recurrent arterial/venous thrombosis

protein C deficiency 1. patho

1. auto dom- deficiency of factor V/VIII inhibitor --> unregulated prothrombin activation and inc. thrombotic events

factor V leiden 1. patho

1. protein C resistance --> protein C can no longer inactivate factor V--> unregulated prothrombin activation

secondary hypercoagulable states

malignancy (panc, GI, lung, ovaries) antiphospholipid antibody syndrome pregnancy immobilization, OCPs, postoperative (esp. ortho), nephrotic syndrome, HIT, DIC, PNH

what drug is not effective in patients with antithrombin III deficiency

HEPARIN

heparin 1. mechanism 2. indications

mechanism - potentiates action of antithrombin to inhibit II and X, prolongs PTT 2. DVT, PE, ACS, unstable angina/MI, LMWH, a.fib

IV heparin dosing/monitoring/reversal

1. 70-80u/kg bolus, and then 15-18u/kg/hr infusion 2. monitor with PTTtherapeutic = 60-90s, or anti-factor Xa levels 3. protamin sulfate reverses heparin

heparin side effects heparin contraindications

bleeding, HIT, osteoporosis, transient alopecia, rebound hypercoagulability contraindications - previous HIT, active bleeding, hemophilia, thrombocytopenia, HTN, brain, eye, spine surgery

LMWH

inhibits factor Xa, but less IIa and platelet aggregation

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warfarin 1. monitoring 2. administration 3. side effects 4. reversal

1. prolongs PT and INR 2. start patient on heparin, once PTT is therapeutic, switch the patient to warfarin, and once INR is therapeutic, stop heparin 3. hemorrhage, skin necrosis (2/2 rapid dec. in protein C), TERATOGENIC, should not to give to patients with fall risk 4. 5 day half life-- vitamin K infusion, or FFP

clopidogrel 1. patho 2. important drug interaction

1. ADP antagonist, inc. bleeding time 2. ACS, NSTEMI, >1 year after stent placement

most common/mortality cancers in men vs women

men - prostate, lung, colon / lung, prostate, colon women - breast, lung, colon / lung, breast, colon

oncologic emergencies that require treatment

hypercalcemia - IV fluids, diuretics, bisphosphonates spinal cord compression - steroids, MRI pericardial tamponade pericardiocentesis tumor lysis syndrome - IV fluids + electrolyte correction

features of benign breast masses

age 5g/dL, bence jones proteinuria, 2. NO BONE LESIONS, fatigue, weight loss, anemia, abnormal bleeding, hyperviscosity syndrome 3. chemotherapy and plasmapheresis

hodgkins lymphoma 1. patho 2. clinical pres

1. bimodal age distribution - nodular sclerosing (reed sternberg), mixed cellularity, lymphocyte predominant, lymphocyte depletion (worst) 2.constitutional symptoms painless lymphadenopathy, supraclavicular, axillary, mediastinal nodes

hodgkins disease 3. dx 4. tx

3. lymph node biopsy inflammatory cell infiltrate shows B-cells, reed sternberg cell, bone marrow biopsy, leukocytosis, eosinophilia 4. radiotherapy for stages I/II/IIIA stage IIIB, IV require chemotherapy

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non-hodgkins lymphoma 1. risk factors 2. clinical pres

1. immunosuppression, EBV, HTLV 1, helicobacter pylori gastritis, autoimmune disease (hashimoto's, sjogrens, MALT) 2. lymphadenopathy (painless, firm, mobile), palpable cervical, supraclavicular, axillary nodes, B symptoms, HSM, recurrent infections, anemia symptoms, SVC obstruction, respiratory involvement, bone pain, skin lesions

epidemiological associations with NHL

burkitts lymphoma, HIV associated lymphomas, adult T-cell lymphoma in japan and caribbean

non-hodgkins disease 1. dx 2. markers of tumor load 3. tx

1. lymph node biopsy - any node >1cm for >4 weeks CXR - may show hilar/mediastinal adenopathy CT- chest, abdomen, pelvis ALP - elevated if bone involved 2. LDH, B2 microglobulin 3. observation, chemotherapy (CHOP), radiation therapy, very high dose chemotherapy with BMT (last resort)

indolent or low grade lymphomas 1. types 2. clinical pres 3. progression 4. tx

1. small lymphocytic, follicular 2. elderly patients, painless peripheral lymphadenopathy, 3. painless peripheral lymphadenopathy-> diffuse large cell with t(14;18) 4. eventually widespread liver, spleen, bone marrow involvement- radiotherapy for local disease only

intermediate grade lymphoma 1. types 2. clinical pres 3. tx

1. diffuse large B cell lymphoma, 2. locally invasive presenting as large extranodal mass 3. 85% cure with CHOP

high grade lymphomas 1. types 2. tx

1. lymphoblastic lymphoma (T cell -->T cell ALL), burkitt's t(8;14) (small cell noncleaved) lymphoma- jaw mass in african, abdominal organ mass in americans 2. combination chemotherapy 50-60% curative

mycosis fungoides 1. patho/clinical pres 2. dx 3. tx

1. T cell lymphoma of skin - eczematous skin lesions/exfoliative dermatitis, erythematous stage, plaque stage, tumors stage- disseminates to lymph nodes 2. cribriform lymphocytes 3. no cure, symptomatic radiation and topical chemotherapy

sezary syndrome

skin/blood stream involvement

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HIV associated lymphomas

burkitts or diffuse, large cell lymphoma very poor prognosis

CHOP therapy

cyclophosphamide, hydroxydaunomycin (doxorubicin), oncovin (vincristine), prednisone

AML 1. risk factors 2. promyelocytic clinical pres/tx

1. radiation, myeloproliferative syndromes, downs syndrome, chemo (alkylating agents) 2. t(15;17), pancytopenia/DIC, all trans retinoic acid

ALL 1. patho 2. age 3. poor prognostic indicators

1. early lymphocytic malignancy 2. 15, CNS involvement, B cell phenotype, inc. LDH, rapid leukemia proliferation

ALL/AML 1. clinical pres 2. key classic locations for extranodal ALL/AML

1. anemia, associated symptoms, bacterial infections, mucosal bleeding, splenomegaly, hepatomegaly, lymphadenopathy, bone/joint pain, focal neuro dysfunction (CNS invasion), 2. ALL- testicles, anterior mediastinal mass* AML - skin nodules

tumor lysis syndrome

chemotherapy in acute leukemia and high grade NHL--> hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia MEDICAL EMERGENCY

1. ALL response to treatment

1. full remission in 75% of children 30-40% of adults

CLL 1. age 2. patho 3. dx 4. tx

1. >50 2. monoclonal mature lymphocytes that are not functional 3. WBC 50k-200k, anemia (AUTOIMMUNE HEMOLYTIC), thrombocytopenia, neutropenia SMUDGE CELLS - fragile leukemic cells flow cytometry bone marrow biopsy - infiltrating leukocytes 4. symptomatic chemotherapy

myeloid cell line

erythrocytes, granulocytes, platelets

CML 1. patho 2. clinical pres

1. t(9;22) BCR-Abl chronic indolent course then BLAST CRISIS --> blast/promyelocytic production 2. constitutional symptoms, fevers, nigth sweats, infections ,bruising, anemia, splenomegaly/hepatomegaly, lymphadenopathy

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CML 1. dx 2. tx

1. marked leukocytosis 50-200k with left shift to granulocytes BASOPHILIA low blasts/promyelocytes LOW LEUKOCYTE ALKALINE PHOSPHATASE ACTIVITY, thrombocytosis, bone marrow biopsy 2. imatinib - targets BCR-Abl chemoradiation --> BMT

polycythemia vera 1. patho 2. clinical pres

1. malignant hematopoietic cell proliferation --> inc. RBC mass (9-14 years survival), myelocytes and platelets*** 2. 2/2 hyperviscosity, HA, dizziness, weakness, pruritus (in the bath 2/2 histamine from inc. basophils), gout attack dyspnea, thrombotic - DVT, CBA, MI, portal vein thrombosis bleeding - GI or GU, ecchymosis, epistaxis, splenomegaly, hepatomegaly HTN

polycythemia vera 1. dx 2. tx

1. rule out secondary polycythemia elevated RBC, hemoglobin/hematocrit (>50), thrombocytosis, leukocytosis LOW EPO, elevated B12 hyperuricemia bone marrow biopsy 2. phlebotomy lowers hematocrit

myelodysplastic syndromes 1. patho 2. dx 3. tx 4. progression?

1. idiopathic/radiation-> ineffective hematopoiesis, apoptosis of myeloid precursors, pancytopenia, hypercellular marrow 2. marrow biopsy shows dysplastic cells with ringed sideroblasts, blasts normal MCV low reticulocyte count Howell jolly bodies, basophilic stippling, 3. EPO, G CSF, B6, B12, folate supplementation 4. can become AML with very poor prognosis

essential thrombocythemia 1. dx 2. tx 3. clinical pres

1. platelets >600k with no cause (ie. non-reactive), peripheral smear shows irregular platelets, bone marrow shows inc. megakaryocytes, 2. antiplatelets - anagrelide, low dose aspirin, hydroxyurea 3. erythromelalgia - burning/pain in extremities from microvascular occlusion , thrombosis, CVA

reactive thrombocytosis

infection, inflammation, bleeding, IDA etc.

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pneumonia 1. most common community bacterial pathogen 2. most common nosocomial 3. indications for pneumococcal vaccine

1. s.pneumo 2. gram negative rods (E.coli/pseudomonas), s.aureus 3. age >65, heart disease, SCD, pulmonary disease, diabetes, cirrhosis, cigarette smokers***

community acquired pneumonia 1. patho 2. clinical pres 3. dx

1. s.pneumo, h.flu, moraxella, klebsiella, s.aureus 2/2 aspiration of nasopharyngeal flora 2. acute onset fever, shaking chills, cough with thick purulent sputum, dyspnea, pleuritic chest pain (with effusions), tachycardia, tachypnea, late crackles, friction rub, 3. CXR - shows consolidation/infiltrates (only way to differentiate between pneumonia and acute bronchitis) O2 sat, BUN/Cr, BMP, pre-treatment blood cultures, gram stain/culture of sputum

atypical pneumonia 1. clinical pres 2. patho 3. dx

1. sore throat/headache --> nonproductive cough and dyspnea, fevers, pulse temperature dissociation(normal pulse/high fever), wheezing, rhonchi, crackles 2. mycoplasma, chlamydia pneumoniae, chlamydia, coxiella burnetii, legionella, adenovirus, paraflu, RSV 3. CXR - reticulonodular infiltrates,

what is a good sputum cultures

>25PMNs LEFT LUNG posterior segments of upper lobes, and superior segments of lower lobes

lung abscess 1. patho 2. micro

1.aspiration of oropharyngeal contents/hematogenous spread/direct contact/food --> 2cm or larger suppurative cavitary lesions 2.prevotella, peptostrepto, fuso, bacteroides, s.aureus, s.pneumo, aerobic gram negative bacilli

lung abscess 1. risk factors 2. clinical pres

lung abscess 1. tx

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1. alcoholism, drug addiction, CVA, seizure disorders, general anesthesia, NG or ET tube 2. fever, chills, foul smelling breath, shortness of breath, weight loss 3. CXR - thick walled cavitation with air fluid levels CT scan cultures with bronchoscopy 1. gram pos - ampicillin, or amoxicillin/clavulanic or ampicillin/sulbactam or vancomycin anaerobes - clindamycin or metronidazole gram neg- fluoroquinolone or ceftazidime

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tuberculosis 1. patho 2. secondary TB 3. risk factors for TB

1. droplet transmission --> multiplication in the lymphatics/blood --> granulomas -> immune insult --> reactivation 2. weakening of host immunity - HIV, malig, immunosuppressants --> apical posterior segment cavitary lesions, miliary TB 3. HIV, recent immigrants, prisoners, health care, close contact, alcoholics, diabetics, glucocorticoid use, hematologic malig, IVDU

tuberculosis 1. primary TB clinical pres 2. secondary TB "" 3. radiographic findings

1. asymptomatic, or pleural effusion, may turn into progressive TB 2. constitutional symptoms, dry cough --> purulent sputum, hemoptysis (advanced) apical rales 3. upper lobe infiltrates with cavitations, pleural effusions ghon complex - calcified primary focus with associated lymph node rankes complex - ghon complex undergoes fibrosis/calcification

tuberculosis 1. extrapulmonary sites

1. pleura, GU tract, spine, intestines, meninges,

tuberculosis 1. dx

1. sputum culture (three morning sputum samples), PCR PPD test - detects latent TB Elevated adenosine deaminase levels in pleural fluid

PPD positive + PPD, what is next step in management

>15mm - no risk factors >10mm- high risk populations/recent immigrants, homeless, prisoners, healthcare workers, nursing home >5mm- HIV, steroid, recent contact with TB+, organ transplant patients

next step = get CXR

...

tuberculosis 1. treatment for latent TB 2. treatment for active TB

1. pos. PPD - negative CXR - INH + pyridoxine (to prevent neuropathy) OR pyrazinamide + rifampin or rifabutin for 2 months 2. 2 months of 4 drugs (isoniazid, rifampin, pyrazinamide, ethambutol or streptomycin) then 4 months of 2 drugs (isoniazid and rifampin)

TB treatment 1. toxicity

1. monitor liver transaminases and discontinue if they rise to 3-5x the upper limit of normal

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1. flu epidemic vs pandemic

1. epidemic from minor genetic reassortments pandemic is from major genetic recombination

influenza (orthomyxovirus) 1. clinical pres

1. rapid onset fever, chills, malaise, headache, nonproductive cough, sore throat, +/- nausea 2. supportive, zanamivir/oseltamivir

meningitis 1. patho 2. bacterial pathogens neonates + tx 3. "" children+ tx 4. adults + tx 5. elderly >50+ tx 6. immuo/hospitalized+tx

1. hematogenous CNS seeding, retrograde nerve transport, contiguous spread (via sinus/OM/surg/trauma) 2. GBS, e.coli, listeria monocytogenes- cefotax + amp + vanc + aminoglycoside 3. n.meningitidis, s.pneumo, h.flu - cefotaxime or ceftriaxone + vanc 4. s.pneumo, n.meningitidis, h.flu - cefotaxime or ceftriaxone + vanc 5. s.pneumo, n.mening, l.monocyto- ceftriaxone or cefotax + vanc + amp 6. l.monocyto, gram negative bacilli, s.pneumo ceftazidime + vancomycin

chronic meningitis causes

mycobacterium, fungi, lyme disease, parasites

meningitis 1. complications

1. seizures, coma, brain abscess, deafness, brain damage, hydrocephalus

aseptic meningitis 1. patho 2. treatment

1. non-bacterial pathogens HSV, enterovirus, echovirus 2. treat as bacterial until certain of diagnosis

meningitis 1. clinical pres

1. triad - fever, nuchal rigidity, change in mental status headaches, n/v, malaise, photophobia papilledema, seizures *inc. ICP cranial nerve palsies kernig's sign - cannot fully extend knees when patient supine and hips at 90' brudzinski's sign - flexion of legs/thighs caused by passive passive flexion of the neck

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meningitis 1. dx 2. tx

1. CT scan BEFORE CSF EVALUATION CSF examination - cloudy, inc. opening pressure examine for cell count, protein/glucose, gram stain, culture (+AFB), crypto antigen/india ink

CSF findings: WBC count/diff/glu/protein 1. normal 2. bacterial meningitis

1. 500 jaundice, dark urine (direct bili), RUQ pain, n/v, fever/malaise, hepatomegaly 2. same as regular + hepatic encephalopathy (asterixis/palmar erythema), hepatorenal syndrome, bleeding diathesis 3. hepatitis serologies hep C- viral PCR

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what is only hepatitis B marker that can be detected during the period

IgM anti-HBc HBsAg is earliest* detectable marker but disappears during window period (1-2 weeks) TEST FOR BOTH IN SCREENING

hepatitis B serologies 1. HBsAg 2. HBeAg 3. anti-HBsAg 4. anti-HBcAg 5. diagnosis of hep C

1. early detection 1-2 weeks, indicates chronic hepatitis if persistent 2. reflects active viral replication, detectable soon after HBsAg 3. after vaccination or clearance of HBsAg indicates immunity 4. only marker present during window period, indicates INFECTION (does not distinguish acute vs chronic) 5. anti-HCV - may not be detectable for months HCV PCR viral load - detectable 1-2 weeks after infection

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botulism 1. patho 2. clinical pres 3. dx 4. tx

1. preformed toxins from c. botulinum - spores inactivated by 100C for 10 minutes wound contamination 2. SYMMETRIC DESCENDING FLACCID PARALYSIS - starts with dry mouth, diplopia, dysarthria diarrhea, n/v 3. stool toxin, serum or gastric bioassays 4. watch RESP STATUS***, gastric lavage, antitoxin, penicillin for wounds

ddx in foodborne "botulism"

guillain barre, eaton lambert syndrome, myasthenia gravis, diphtheria, tick paralysis

UTI 1. patho 2. risk factors

1. ascending infection from the urethra- e coli, s.sapro, enterococcus, klebsiella, proteus, pseudomonas, enterobacter, yeast 2. female, sex, pregnancy, catheters, DM, spinal cord injury, immunocomp, incomplete voiding, neurogenic bladder, BPH uncircumcised males, anal intercourse

non-infectious causes of cystitis

cytotoxic agents - cyclophosphamide pelvic radiation dysfunctional voiding interstitial cystitis

UTI 1. dx

2. dipstick analysis- positive urine leukocyte esterase, positive nitrites (enterobacteriaceae), urinalysis- clean catch (no squamous cells) or straight cath-- >1 bacteria/HPF, >10 leukocytes/ul, hematuria, proteinuria urine gram stain - >10^5 organisms urine culture* - only if >65yo, diabetes, recurrent UTI, >7 days symptosm

UTI 1. clinical pres 2. what diagnostic tests for suspected structural abnormalities

1. dysuria, frequency, urgency, suprapubic tenderness, gross hematuria 2. IVP, cystoscopy, excretory urography

complicated UTI 1. definition 2. what risk factors

1. any UTI past the bladder (pyelo, prostatitis, urosepsis) 2. men, diabetes, renal failure, pregnancy, history of pyelo, resistant organisms, immunocomp (HIV/transplant)

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UTI 1. uncomplicated cystitis treatment 2. UTI in pregnant patient tx 3. UTI in men tx 4. treated UTI that relapses 5. > 2 UTI's/year

1. bactrim 3 days, nitrofurantoin 5-7 days (for pregnant***), fosfomycin 1 dose fluoroquinolones - 3 days cipro phenazopyridine - urinary analgesic 2. ampicillin, amoxicillin or oral cephalosporins 7-10 days (NO CIPRO CAUSES FETAL ARTHROPATHY) 3. same as women but 7 days 4. treat for 2 more weeks + urine culture 5. chemoprophylaxis- single dose bactrim after intercourse, or low dose bactrim for 6 months

pyelonephritis 1. patho 2. organisms 3. complications

1. vesicoureteral reflux + risks for complicated UTI --> ascending infection to kidney 2. Ecoli, proteus, klebsiella, enterobacter, pseudomonas, enterococcus, s.aurues 3. sepsis in up to 25%, emphysematous pyelonephritis (in diabetics), chronic pyelo/scarring

pyelonephritis 1. clinical pres 2. dx 3. tx

1. fever, chills, flank pain, cystitis symptoms, n/v, diarrhea 2. urinalysis - pyuria, bacteriuria, leukocyte casts urine cultures, blood cultures, CBC (leukocytosis/left shift) renal ultrasound, CT, IVP, retrograde urethrogram 3. single dose of ceftriaxone or gentamicin before bactrim or fluoroquinolone 10-14 days ampicillin for gram positive cocci (s.sapro) very ill - hospitalize + parenteral - amp + gent or cipro use IV abx until patient afebrile, then 14-21 day PO abx course urosepsis - IV abx 2-3 wks

prostatitis 1. acute bacterial prostatitis patho 2. chronic bacterial prostatitis patho 3. clinical pres

1. ascending infection from the urethra and reflux of infected urine, s/p catheterization - e coli, klebsiella, proteus, enterobacter, serratia 2. more common, often diagnosed incidentally 3.acute- fever, chills, toxic appearance, dysuria, frequency, urgency, lower back pain chronic - asymptomatic, afebrile, recurrent UTIs, irritative voiding and obstructive symptoms DRE

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prostatitis 1. dx acute vs chronic 2. tx acute vs chronic - tends to recur

1. acute - urinalysis shows sheets of WBCs in acute, urine cultures positive chronic - DRE boggy tender prostate, WBCs in expressed prostatic secretions 2. acute - hospitalize and IVabx, mild outpatient bactrim or fluoro or doxy 4-6 weeks chronic - fluoroquinolone long course

genital warts patho

HPV - mos common STD

chlamydia 1. patho 2. clinical pres 3. dx 4. tx 5. complications

1. intracellular pathogen STD, coinfection with gonorrhea common 2. asymptomatic (80% women), dysuria, purulent discharge, scrotal pain/swelling, post-coital bleeding 3. enzyme assay, PCR 4. azithro 1x, doxy 7 days 5. epididymitis/proctitis in men women - PID, salpingitis, tubo ovarian abscess, ectopic preg, fitz hugh curtis syndrome

gonorrhea 1. patho 2. clinical pres 3. complications

1. gram negative diplococcus 2. often asymptomatic in women , males have purulent discharge, erythema/edema of urethral meatus, urinary frequency, also pharynx, conjunctiva, and rectum infection 3. PID, epididymitis, prostatitis, tuboovarian abscess, salpingitis, fitz hugh curtis syndrome, disseminated disease

what cancer associated with chlamydia

cervical cancer

gonorrhea 1. disseminated disease clinical pres 2. dx 3. tx 4. tx for disseminated

1. fevers, arthralgias***, tenosynovitis, migratory polyarthritis/septic arthritis, endocarditis, rash on distal extremities (discrete purpuric or pustular lesions with central necrosis/hemorrhage) 2. gram stain of urethral discharge, culture, syphillis and HIV, blood cultures 3 cetriaxone one dose + azithro one dose or doxy (for coexisting chlamydia) 4. hospitalize and IV or IM ceftriaxone for 7 days

HIV 1. when is cesarean delivery indicated 2. phases of HIV 3. cause of death

1. when HIV viral load is >1000 2. primary infection, asymptomatic, symptomatic, and full blown AIDS 2. opportunistic infections, wasting, cancer

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HIV/AIDS 1. primary infection 2. asymptomatic infection 3. symptomatic HIV (preAIDS) 4. AIDS

1. mononucleosis syndrome that lasts 2-4 weeks - fever, sweat, malaise, lethargy, headaches, arthralgias 2. CD4 >500- 4-7 years, seropositive, but no clinical evidence 3. 1-3 years, persistent generalized lymphadenopathy, localized fungal infections, recalcitrant vaginal/trichomonas infections oral hairy leukoplakia, seborrheic dermatitis, psoriasis, molluscum, warts, constitutional symptoms 4. CD4 proctocolitis, stricture, elephantitis of genitals , 3. serologic compliment fixation, immunofluorescence 4. doxy 21 days

pediculosis pubis (capitis,corpora) 1. patho 2. clinical pres` 3. dx 4. tx

1. phthirus pubis STD, fomites 2. regional pruritus 3. examination of hair shows nits or lice 4. 1% permethrin shampoo for pt and sexual partner, combs, cloths and bed linens washed or thrown away

cellulitis 1. patho 2. most common pathogens 3. clinical pres 4. dx/tx

1. breaks in skin, catheters, incisons, bites, venous stasis, lymphedema, diabetic ulcers--> inflammation of skin/subcutaneous tissue 2. strep A, or s.aureus 3. erythema, warmth, pain, swelling, +/-fever 4. clinical, blood cultures if fever present tx = oxacillin, IV nafcillin (highest risk AIN), cephalosporin IV until signs improve then PO abx 2 weeks

cellulitis pathogens 1. local trauma/skin breaks 2. wounds/abscesses 3. water immersion 4. acute sinusitis

1. strep pyogenes 2. s.aureus 3. pseudomonas, aeromonas, vibrio vulnificus 4. haemophilus influenzae

erysipelas 1. patho 2. clinical pres 3. risk factors 4. complications 5. tx

1. Group A strep infection confined to dermis and lymphatics 2. fiery red painful lesions of the lower extremities and face 3. lymphatic obstruction, local trauma, abscess, fungal infections, DM, alcoholism 4. sepsis, local spread, nec. fascitis 5. IM or oral penicillin or erythromycin

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necrotizing fasciitis 1. patho 2. risk factors 3. clinical pres 4. tx

1. s.pyogenes or c. perfringens deep soft tissue infection that spreads rapidly along fascial planes 2. surgery, DM, trauma, IVDU 3. fever, pain out of proportion, crepitus, discoloration, cutaneous anesthesia --> sepsis/TSS, multiorgan failure 4. prompt surgical exploration + antibiotics

differentiating DVT from cellulitis

erythema, warmth, tenderenss in both DVT typically in posterior calf homans sign not sensitive VENOUS DOPPLER MUST BE USED TO DISTINGUISH THE TWO CONDITIONS

necrotizing fasciitis 1. tx

1. broad spectrum ABX, rapid surgical exploration and excision of devitalized tissue

lymphadenitis 1. patho 2. clinical pres

1. inflammation of a lymph node from strep or staph infection 2. fever, tender lymphadenopathy, red streaking, thrombosis, sepsis 3. penicillin G, anti-staph penicillins, cephalosporins, warm compresses

tetanus 1. patho 2. clinical pres 3. dx/tx

1. deep punctures/bites/necrotic wounds--> c. tetani gram negative anaerobic bacillus produces exotoxin in contaminated wounds --> blocks inhibitory transmitters at NMJ 2. hypertonicity, trismus (lockjaw), generalized muscle contractions, risus sardonicus (grin), opisthotonos (arch back), sympathetic hyperactivity 3. clinical dx + wound cultures tx= ICU, respiratory support, diazepam for tetany, single dose tetanus immune globulin

when to give tetanus immunization for wound management

Td for clean wounds and Td+TIG for dirty wounds IF : 10 years since last booster

osteomyelitis 1. patho 2. risk factors 3. clinical pres

1. hematogenous, direct spread (ulcers, trauma, PVD) of s.aureus and coagulase negative staph --> infection of long bones (tibia, humerus, femur), foot/ankle, and vertebral bodies 2. open fractures, DM, IVDU, sepsis 3. pain over area of affected bone, systemic symptoms, draining sinus (chronic)

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osteomyelitis organisms 1. catheter septicemia 2. prosthetic joint 3. diabetic foot ulcer 4. nosocomial infections 5. IVDU 5. sickle cell

1. s.aureus 2. coagulase negative staph 3. polymicrobial 4. pseudomonas 5. fungal species, pseudomonas 6. salmonella

osteomyelitis 1. dx 2. tx

1. +/-WBC count, ESR/CRP, needle aspiration + culture plain radiograph - only + after >10 days radionuclide bone scans - + after 2-3 days MRI is most effective imaging study 2. oxacillin, first gen cephalosporin, aminoglycoside and beta lactam if gram negative surgical debridement*

potts disease

TB osteomyelitis of the vertebral column

acute infectious arthritis 1. patho 2. pathogens

1. hematogenous/contiguous /traumatic/iatrogenic --> microorganisms invade the joint space --> cytokine release and and destruction of the joint 2. s.aureus, n.gonorrhoeae in young sexually active adults salmonella - sickle cell disease or immunodeficiency

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acute infectious arthritis 1. clinical pres

1. warm, swollen, painful, limited active/passive range of motion, palpable effusion, constitutional symptoms common

gonococcal arthritis 1. clinical pres 2. tx

1. MONO/OLIGO arthritis that progresses in a migratory additive pattern tenosynovitis of hands/feet 2. antibiotics to cover gonorrhea and chlamydia

acute infectious arthritis 1. dx 2. tx

1. joint tpa WBC>50k 80% PMNs, gram stain of fluid, culture, crystal analysis, PCR of synovial fluid blood cultures- positive in 50% of cases leukocytosis, inc. ESR/CRP CT or MRI 2. immediate empiric antibiotics, daily aspiration of joint (only shoulder/knee)

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acute bacterial arthritis treatments 1. s.aureus 2. immunocomp or risk for gram negative 3. high risk for gonococcal

1. oxacillin or 1st gen cephalo x4 weeks add vancomycin if MRSA 2. 3rd gen cephalo or aminoglycoside 3-4 weeks, use aminoglycoside + extended spectrum penicillin for pseudomonas 3. IV 3rd gen cephalosporin then oral agent for 3-10 days once clinical improvement

lyme disease 1. patho 2. stage 1 clinical pres 3. stage 2 clinical pres 4. stage 3 clinical pres

1. ixodidae tick carries borrelia burgdorferi 2. erythema migrans (enlarging bulls eye rash) 3. intermittent flu like symptoms, headache, stiff neck, fevers, meningitis, encephalitis, cranial nervitis (BL bells palsy), cardiac (AV block, pericarditis) 4. arthritis, chronic CNS disease encephalitis, transverse myelitis acrodermatitis chronica atrophicans

lymes disease serology

IgM 3-6 weeks IgG remains elevated if patient has disseminated disease IgG may remain elevated even though adequate abx treatment VDRL may be positive

lymes disease 1. diagnosis 2. tx

1. history, serologic studies - ELISA, western blot 2. 10 days antibiotic therapy spread beyond skin 20-30 days antibiotic therapy doxycycline, amox or cefuroxime (preg), erythromycin (preg) 30-60 days for facial nerve palsy, arthritis, or cardiac disease

rocky mountain spotted fever 1. patho 2. clinical pres 3. dx/tx

1. tick bites feeds on mammals - rickettsia rickettsii then multiplies in vascular endothelium 2. sudden onset fever, chills, malaise, n/v, myalgias, photophobia papular rash that starts peripherally@wrists/ankles (5 days after fever) and spreads centrally (INCLUDES PALMS/SOLES) 3. clinical, immunoassay tx = doxycycline for 7 days, use IV if patient vomiting CNS/pregnant - give chloramphenicol

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malaria 1. patho 2. clinical pres 3. dx 4. tx

1. falciparum (most dangerous), ovale, vivax, malariae- via mosquito vector 2. fever, chills, myalgias, headache, n/v, diarrhea falciparum - constant fever ovale/vivax - 48 hour spikes malariae - 72 hour spikes 3. peripheral smear, giemsa stain 4. tx chloroquine, quinine + tetracycline, atovaquone proguanil, mefloquine IV quinidine + doxy for falciparum 2 week primaquine for vivax/ovale relapse mefloquine for traveler prophylaxis

rabies 1. patho 2. clinical pres 3. dx/tx

1. bite or scratch or corneal transplant --> 3 month incubation 2. prodrome including headache, sore throat, encephalitis then hydrophobia, combativeness, hypersalivation, ascending paralysis 3. virus or viral antigen in tissues, serum antibody titers, negri bodies in tissues, PCR detects viral RNA tx = clean wound, capture animal, human rabies immunoglobulin in wound and gluteal region 3 antirabies vaccines over a 28 day period

other zoonosis page 400, review this

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candidiasis 1. risk factors 2. clinical pres

1. antibiotics, immunosuppression,DM, immunocompromised 2. yeast infection - thick white cottage cheese like vaginal discharge- painless, pruritic oral thrush - thick white plaques (suggests HIV) cutaneous - erythematous eroded patches with satellite lesions GI tract - esophagitis (odynophagia),

candidiasis 1. dx 2. tx

1. KOH preparation demonstrates yeast, blood or tissue culture 2. remove catheters, clotrimazole troches 5 times/day nystatin 3-5x/day miconazole or clotrimazole cream for vaginal candidiasis ampho B, voriconazole, caspofungin for systemic candidiasis

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aspergillus 1. patho 2. allergic bronchopulmonary aspergillosis 3. pulmonary aspergilloma 4. invasive aspergillosis 5. tx

1. spores inhaled into lung 2. type 1 hypersensitivity reaction presents as asthma and eosinophilia 3. history of sarcoid, histo, TB, bronchiectasis--> chronic cough, hemoptysis 4. hyphae invade lung vasculature and cause thrombosis/infarction-> fever, cough, respiratory distress, diffuse bilateral pulmonary infiltrates 5. ABPA- corticosteroids massive hemoptysis - lobectomy invasive aspergillosis- ampho B, voriconazole, caspofungin

cryptococcus 1. patho 2. clinical pres 3. dx

1. budding yeast with thick polysaccharide capsule - assoc. with pigeon droppings 2. meningitis/meningoencephalitisheadache, fever, irritibaliity, dizziness, confusion, also pulmonary infection 3. LP if suspect meningitis, latex agglutination, india ink smear shows yeast tx= ampho B with flucytosine for 2 weeks then PO fluconazole

page 403 for blastomyces, histo, cocci, sporo pg 404 for parasites

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fever of unknown origin 1. definition

1. fever 38.3 (101) on several occasions for at least 3 weeks no diagnosis despite 1 week of inpatient or 3 outpatient visits 2. TB, occult abscess, endocarditis, sinusitis, HIV, mono, malaria or parasite , occult neoplasms (hodgkins, leukemia, solid tumors), collagen vascular disease, sarcoid, crohns , drug fevers (penicillin, sulfonamides, quinidine, barbiturates), PE, hemolytic anemia

1. fever of unknown origin diagnostic workup 2. tx

1. CBC, UA, pan culture, complement assay, PPD, LFTs, ESR, ANA, RA, TSH, CXR, tagged WBC, MRI, node biopsy 2. antibiotics empirically

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toxic shock syndrome 1. patho 2. clinical pres 3. lab findings

1. menstruating women with tampon use, surgical wounds, insect bites 2. flu like symptoms, diffuse macular erythematous rash,hyperemic mucous membranes, strawberry tongue, warm skin, n/v, thrombocytopenia, cardiopulmonary disease, confusion, disorientation, rash that desquamates on PALMS AND SOLES 3. increased PTT, elevated BUN/Cr, hyponatremia, hypocalcemia, hyperbilirubinemia, elevated ALT

fever vs hyperthermia

fever - there is elevation of hypothalamic set point - treat when >105, preg, hyperthermia - no alteration of hypothalamic set point - tx = external cooling or dantrolene for malignant hyperthermia

toxic shock syndrome 1. tx

1. hemodynamic stabilization- aggressive fluid, pressors if needed remove source anti-staph therapy - nafcillin, oxacillin, or vanc, clindamycin

catheter related sepsis 1. causes/clinical pres

1. s.aureus, s. epidermidis - THERE MAY BE NO SIGNS OF INFECTION AT THE CATHETER SITE

neutropenic fever 1. causes 2. dx 3. tx

1. bone marrow failure, bone marrow invasion, from hematologic malig, hypersplenism, SLE, AIDS, drug reactions, chemotherapy 2. CXR, pan culture, CBC, CMP, 3. isolation (positive pressure), broad spectrum abx (with antipseudomonal covg), antifungal agents, GCSF

neutropenia definition

neutrophil most dangerous forms of erythema multiforme 2. mucocutaneous lesion >@ sites, lesions appear targetoid, fever, tachycardia, hypotension, 2. admit to ICU/burn unit

lichen planus 1. clinical pres

1. pruritic, polygonal, purple, flat topped papules - of unknown cause - commonly on wrists, shings, oral mucosa, and genitals

bullous pemphigoid 1. patho 2. clinical pres 2. tx

1. triggers - UV light, NSAIDs, antibiotics NO acantholysis, IgG anti basement membrane (anti BP230, anti-BP180) and C3 deposits at the dermal epidermal junction 2. TENSE blistering lesions at extensor areas, POSITIVE NIKOLSKY'S SIGN subepithelial blisters of abdomen, groin, extremities, LESS easily ruptured than pemphigus vulgaris 2. systemic or topical glucocorticoids, azathioprine for severe

pemphigus vulgaris 1. patho 2. clinical pres 3. tx

1. autoimmune blistering due to IgG desmoglein INTRACELLULAR in the lower epidermis 2. FLACCID blistering lesions on oral mucus membranes that become erosive rupturing blisters, NIKOLSKY POSITIVE tx = glucocorticoids, azathioprine, methotrexate

genital warts 1. treatment

1. liquid nitrogen freezing, salicylic acid*, 5FU, surgical excision or laser therapy, podophyllin for genital warts

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molluscum contagiosum tx

curretage, podophyllin, cantharidin, cryosurgery

herpes zoster treatment

local injection of triamcinolone in lidocaine, antiviral agents, corticosteroids, live vaccine

dermatophytes 1. organisms 2. dx

1. superficial fungi - trichophyton, microsporum, epidermophyton 2. KOH stain to see fungus

scabies 1. patho 2. clincial pres 3. tx

1. sarcoptes scabiei var hominis 2. severe pruritis worse at night, burrows, dark dot is female mite, excoriations, eczematous plaques 3. permethrin 5% cream left on overnight lindane - y benzene hexachloride - 2nd line treatment - risk of seizures topical corticosteroids/oral antihistamines to control pruritis

dermatophyte infections 1. tinea corporis dx/tx 2. tinea capitis dx/tx 3. tinea unguium dx/tx 4. tinea pedis dx/tx 5. tinea cruris dx/tx

1. direct microscopy with KOH prep topical antifungals ketoconazole/miconazole 2. woods lamp - if lights up its microsporum, if not its trichophyton - tx = ORAL** griseofulvin 3. nail scrapings - ORAL griseofulvin 4. direct microscopy - topical antifungals, 5. """""

actinic keratosis 1. patho 2. dx/tx

1. small rough scaly lesions 2/2 sun exposure 2. erythematous papules with a central scale, hyperkeratotic, cutaneous horns 2. biopsy to exclude SCC bx shows acanthosis (thickening of epidermis), parakeratosis (nuclei in corneum), dyskeratosis, hyperkeratosis (thickening of stratum corneum)

basal cell carcinoma 1. patho 2. dx 3. tx

1. basal cells of the epidermis 2. pearly smooth papule with rolled edges and surface telangiectasias (3Ps pearly, pink papule) 3. surgical resection

squamous cell carcinoma of skin 1. patho 2. clinical pres 3. dx/tx

1. skin sun exposure, actinic keratosis, skin damage 2. crustin ulcerated nodule or erosion 3. biopsy shows invasive cords of squamous cells with keratin pearls complete excision

marjolin's ulcer

SCC arising from a chronic wound such as a previous burn scar

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melanoma 1. most important prognostic factor 2. features of melanoma

1. depth of invasion 2. asymmetry, border irregularity, color vairation, diameter >6mm, elevation -

stages of decubitus ulcers

1. skin intact, non- blanching erythema 2. partial thickness skin loss 3. full thickness skin loss into subQ tissue 4. full thickness extending into muscle/bones/joints/tendons etc

psoriasis 1. patho 2. clinical pres 3. tx

1. abnormal proliferation of skin cells, improves in summer, worst during winter, exacerbated by trauma 2. koebner's phenomenon well demarcated erythematous plaques/papules with thick silver scaling auspitz sign - removal of scale -->pinpoint bleeding extensor surfaces pitting of nails/onycholysis arthritis - pencil in cup deformity of the DIP 3. topical corticosteroids, calcipotriene/calcitriol, tars, tazarotene (vitamin A derivative), anthralin,immune modulating therapy (MTX, cyclosporine), TNF blockers phototherapy, acitretin, UV light

seborrheic keratosis 1. patho 2. clinical pres 3. tx

1. autosomal dominant - harmless growths 2. dark elevated plaques appear suck on the skin 3.cryotherapy or curettage

vitiligo 1. patho 2. clinical associations 3. tx

1. autoimmune depigmentation condition of the skin 2. DM, autoimmune hypothyroidism, pernicious anemia, addison's disease, alopecia areata, hypopituitarism 3. glucocorticoids, phototherapy

urticaria 1. patho

1. inflammatory mediators released by mast cells in response to foods, drugs, latex, dander, pollen, dust, plants 2. edematous wheals and hives that disappear and reappear elsewhere, intense pruritis

hereditary angioedema

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autosomal dominant C1 esterase inhibitor deficiency 433.

hypersensitivity types

1. IgE -anaphylaxis/asthma 2. IgG or IgM cytotoxic - good pastures.pemphigus 3. antigen antibody complexes - SLE, arthrus reaction, serums sickness 4. T cell mediates - allergic contact dermatitis , tuberculosis, transplant rejection

anaphylaxis 1. patho 2. clinical pres 3. tx

1 type 1 IgE reaction 2.pruritus, erythema, urticaria, angioedema dyspnea, respiratory distress, asphyxia hypotension, shock, arrhythmias abdominal pain, n/v, severe diarrhea 3. ABCs, epinephrine immediately IV if severe, subQ if less severe, antihistamines, corticosteroids IV fluids, oxygen

amoebic liver abscess 1. patho 2. clinical pres 3. dx/tx

1. travel to endemic area --> entamoeba histolytica --> hepatic abscesses 2. RUQ pain, 3. indirect hemagglutination assay, ultrasound will show abscess with well defined margins, blood cultures tx = metronidazole, no aspiration necessary

ecoli 0157:H7 1. sources 2. clinical presentation

1. contaminated ground beef, raw milk, fecal oral 2. mild diarrhea, hemorrhagic colitis, acute renal failure, HUS

parvo b19 1. clinical pres in children 2 clinical pres in adults

1. erythema infectiosum - fever like illness with a slapped cheek rash 2. viral arthritis *** - pain lasts about 30 minutes, no symptoms, no systemic symptoms diffuse lace like rash, polyarthropathy, aplastic crisis (in G6PD or sickle cell patients), spontaneous abortion, hydrops fetalis

target O2 saturation in COPD patients

88-92%, overly aggressive O2 will increase PaCO2

meperidine side effects

metabolized to normeperidine inc. risk of CNS toxicity, sedation, seizures, resp. depression

septic arthritis 1. patho

1. hematogenous spread by staph aureus, or beta hemolytic strep is most common. gonorrhea in sexually active young adults

p-anca

anti - myeloperoxidase

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microscopic polyangiitis 1. patho 2. clinical pres 3. dx

1. pauci immune necrotizing small vessel vasculitis--> 2. glomerulonephritis, pulmonary hemorrhage, fever 3. P-ANCA positive

cryoglobulinemia 1. patho 2. clinical pres 3. dx

1. small vessel vasculitis, assc. with hep C--> renal involvement, alveolar hemorrhage, arcuate artery aneurysms 2. palpable purpura*** (think of adult HSP), arthritis, glomerulonephritis, livedo reticularis, abdominal pain, 3. low complement

tarsal tunnel syndrome clinical pres

posterior tibial nerve entrapment between medial malleolus and flexor retinaculum--- pain in the ankle/heel and numbness of sole of foo at night

hypertrophic osteoarthropathy clinical associations

intrathoracic malignancy, suppurative lung disease, congenital heart disease

exudative pleural effusion fluid lab findings

...

complicated vs uncomplicated

total pleural protein:serum protein>0.5 LDH pleural fluid:LDH serum >0.6 LDH pleural fluid >2/3 upper limit of normal

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complicated pH1.1

c.difficile best diagnostic test

c.diff stool toxin assay, or colonoscopy showing pseudomembranes

disease associated with microvesicular fat (micronodular sclerosis

autoimmune hepatitis chronic viral hepatitis

1. how to dec. GI Side effects with chronic NSAID use

1. cotreat with misoprostol 2. inc. cardiovascular events, also same degree of renal dysfuntion

bleeding prophylaxis for cirrhotic patients with varicies

propranolol (non-specific beta blockers) octreotide

intermittent mesenteric ischemia 1. patho 2. post-prandial abdomina pain/weight loss

1. atherosclerotic obstruction of visceral arteries

lab findings in rhabdomyolysis ARF

hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, elevated creatinine high RBCs on urine dipstick but few RBCs on urine microscopy

acute uric acid nephropathy

chemotherapy tumor lysis associated renal damage

osmolar gap 1. calculation

1. 2Na+BUN/28+glu/18 2. patients have toxic ingestion of methanol, ethylene glycol, paint thinners

ethylene glycol key lab findings

hypocalcemia, high anion gap, high osmolar gap*

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hyponatremia 1. with inc. ECF fluid overload 2. normal volume status 3. low volume (ie low blood pressure/high pulse) 4. when see hyponatremia then evaluate volume status THEN WHAT

1. heart failure, cirrhosis, nephrotic syndrome, renal insufficiency 2. SIADH 3. plasma osmolality hypoosmolar = low plasma osmolality high plasma osmolality = hyperglycemia normal plasma osmolality hypoproteinemia, hyperglycemia

1. analgesic nephropathy 2. protease inhibitor effect on GU

1. high level analgesic use causes renal colic/papillary necrosis 2. can cause obstructive renal stones

refeeding syndrome

hypophosphatemia, hypokalemia due to intracellular shifts after feed starving person or alcoholic

alcoholic with hypocalcemia

2/2 hypomagnesemia decreases end organ PTH response

hyporeninemic hypoaldosteronism 1. patho

1., old patients, CHF - beta blockers, ACE inhibitors, spironolactone --> life threatening hyperkalemia

cause of postoperative hyponatremia

nausea, pain, and anesthetic agents causes potent release of ADH by neurohypophysis

testicular cancer 1. patho

1. solid mass from the testis metastasizes to the retroperitoneal/para aortic nodes (stage 2)

key clinical feature distinguishing sickle SS from sickle SC disease

splenomegaly seen in sickle SC

myeloproligerative disorders

polycythemia vera, essential thrombocytosis, CML, myelofibrosis

gaisbock syndrome

erythrocytosis with normal red blood cell mass from decreased plasma volume.

breast cancer 1. adjuvant for pre/post menopausal women

1. post menopausal = hormonal tamoxifen (ER antagonist) or anastrozole** (aromatase inhibitor) premenopausal - oophorectomy, tamoxifen

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transfusion related acute lung injury 1. patho 2. clinical pres

1. antibodies in donor blood that bind to HLA on recipients WBCs > WBC agglutination and trapping in the lungs 2. appears like volume overload on CXR

ABO or Rh mismatch reaction

leads to recipient Ig binding to donor RBCs and then complement fixation and intravascular hemolysis

delayed hemolytic transfusion reaction

antibodies to minor antigents antigenic memory cells response within several days to a week and make antibodies against transfused cells

hypercoagulable states

prothrombin G202 factor V leiden, OCPs pregnancy Protein C, S and ATII deficiencies lupus cancer

antithyroid medications (PTU, methimazole) complications

leukopenia rare agranulocytosis

1. where in the brain do hypertensive hemorrhages occur 2. where in the brain does cerebral amyloid angiopathy hemorrhage occur

1. in the central structures of the brain (thalamus, basal ganglia, cerebellum) 2. lobar hemorrhages in the elderly

restless leg syndrome 1. tx

1. dopamine enhancing drugs pramipexole, ropinirole

what imaging modality is best for spinal cord and posterior fossa

MRI

carotid sinus hypersensitivity 1. patho 2. clinical pres

1. baroreceptors of carotid sinus are activated sending impulses through glossopharyngeal nerve to medulla 2. syncope from turning head or wearing collared shirt or shaving 3. ECG carotid massage, or duplex doppler if bruit is heard

what can cause coma

severe metabolic disturbanceshypoglycemia, hyponatremia, intoxication brainstem dysfunction - RAC or pons bilateral hemispheric insults

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parkinsons disease 1. treatment 2. SE of parkinsons treatment

1. levodopa- dopamine precursor carbidopa - dopa decarboxylase inhibitor direct dopamine agonistsropinirole/pramipexole anticholinergics - benztropine mesylate dec. degree of tremor 2. limb/facial dyskinesias

paraneoplastic cerebellar degenerations 1. associated cancers 2. patho 3. other paraneoplastic neuronal syndromes

1. small cell lung, breast, female genital, lymphomas 2. anti- Hu/Ri/Yo/Tr - neuronal antigens 3. encephalopathy with sensory neuropathy, opsoclonus myoclonus syndrome, lambert-eaton myasthenic syndrome

hypertension management in the context of acute cerebral ischemia/stroke

DO NOT AGGRESSIVELY TREAT 2x weekly headache medication use-->

complex partial seizures

1. psychomotor seizures - complex auras, abnormal motor behaviors, impaired consciousness

vascular dementia

1. stepwise neurological defects resulting from bilateral cerebral infarcts, hemiparesis, extensor plantar responses, pseudobulbar palsy

treatment for a patient who had a TIA

immediate anti-platelet therapy carotid doppler

diffuse itchiness associated with what condition

polycythemia vera, lymphoma, thyroid disorders

CYP450 inducers

BullShit CRAP GPS induces my rage! Barbiturates St. John's wort Carbamazepine Rifampin Alcohol (chronic) Phenytoin Griseofulvin Phenobarbital Sulfonylureas

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CYP450 inhibitors

VICK'S FACE All Over GQ stops ladies in their tracks. Valproate Isoniazid Cimetidine Ketoconazole Sulfonamides Fluconazole Alcohol (acute) Chloramphenicol Erythromycin (macrolides) Amiodarone Omeprazole Grapefruit juice Quinidine

1. joint complications of diuretics 2. what type of beta blocker should be used in COPD/asthma 3. what antihypertensives are contraindicated in pregnancy 4. alpha blockers long term risk

1. hyperuricemia and gout attacks 2. non-cardioselective - should choose metoprolol or esmolol 3. ACEs/ARBs 4. inc. risk of congestive heart failure (orthostatic hypotension in the short term)

cardiac risk index

ischemic heart disease, CHF, cerebrovascular disease, insulin therapy, pre-op Cr>2.0

common variable immunodeficiency 1. patho 2. clinical pres

1. T cell abnormalities and hypogammaglobulinemia 2. 2nd decade of life onset of recurrent diarrhea (GIARDIA LAMBLIA) and respiratory infections

nasal turbinates in allergic vs infectious rhinitis

allergic - pale and boggy infectious - red and inflamed

how to deal with administering contrast to a patient with contrast allergy

premedicate with antihistamines and corticosteroids-- don't need to avoid altogether

IgA deficiency 1. clinical pres

1. severe blood product allergic reactions, inc. incidence of sinopulmonary infections `` inc. risk for giardia lamblia ***

ataxia telangiectasia 1. patho

1. ATM gene mutation abnormal DNA repair 2. lymphomas, cerebellar ataxia, immunodeficiency, ocular/facial telangiectasias

postprandial hypotension

just what it sounds like

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what increases the risk of cholesterol embolization

hypertension, smoking, elevated CRP

pulmonary hyptension physical examination findings

loud S2, prominent a waves, right ventricular heave, ejection click, right ventricular fourth heart sound

pacemaker indicatiosn

persistent bradycardia, new LBBB, new mobitz type 2, symptomatic wenckebach type 2

why are ace inhibitors contraindicated in pregnancy

cause renal dysgenesis and oligohydramnios

contrast medium side effects

contrast induced nephropathy (see risk factors), n/v, anaphylaxis, hives, itching, angioedema

what is electrocardiography useful to detect

latent ischemic heart disease

treatment of atrial flutter

diltiazem/verapamil, beta blockers, digoxin

what cardiac defects increase risk for infectious endocarditis

VSD*** mitral prolapse, mitral stenosis, asymmetric septal hypertrophy, Low risk = ASD

what clincal scenario is nitroglycerine used for a heart failure patient

normal BP, with moderate pulmonary congestion --- when BP is low, must give inotropic agents

AV dissociation

independent beating of atria/ventricles fixed P-P, fixed R-R, variable P-R

causes of coronary artery aneurysm

atherosclerosis, trauma, angioplasty, atherectomy, vasculitis, mycotic emboli, kawasaki syndrome, arterial dissection

what is the cause of ST elevation >2 weeks after an infarct + CXR finding

ventricular aneurysm look for calcified bulge on CXR

clinical presentation of familial hyperchoesterolemia

AUTOSOMAL DOMINANT tendon xanthomas, xanthelasma, arcus senilis

hypertension effect on the eyes

cotton wool spots, hemorrhage, papilledema fibrinoid necrosis

left ventricular hypertrophy EKG findings

high voltage QRS in V5/B6, deep S in V1/V2, prolonged QRS in precordial leads

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1. pulsus tardus et parvus 2. pulsus paradoxus 3. hyperkinetic (bounding) pulse 4. bisferiens pulse

1. pulse is weak and late - aortic stenosis 2. >10mmHg drop in BP with inspiration - cardiac tamponade, pericarditis, OSA, COPD, tension PTX, severe asthma 3. high pulse pressure or low peripheral resistance - fever, anemia, AV fistula, aortic regurgitation 4. double peak per cycle - aortic regurgitation, HCM

1. dicrotic pulse 2. pulsus alternans 3. pulsus bigeminus

1. systolic percussion wave and prominent dicrotic wave in diastole dilated cardiomyopathy, low CO, high SVT - sepsis 2. alternating strong/weak beats aortic and mitral valve stenosis, pericarditis 3. two heartbeats close together followed by longer pause, large QRS followed by a smaller one - HCM, digitalis tox,

JVP findings 1. large a waves 2. kussmaul's sign 3. slow y descent 4. prominent v wave 5. prominent x descent 6. prominent y descent

1. inc. filling resistance - TS, pulmonary hypertension, complete heart block (right atrium contracts against tricuspid closed by right ventricular systole 2. inc. in JVP during inspiration from right heart failure or constrictive pericarditis 3. obstruction of right ventricular filling - atrial myxoma or tricuspid stenosis 4. accentuated atrial filling - tricuspid regurgitation, 5. cardiac tamponade, restrictive cardiomyopathies 6. constrictive pericarditis

JVD waveform 1. a wave 2. x descent 3. v wave 4. y descent

1. atrial systole 2. atrial relaxation during ventricular systole 3. rising atrial pressure from increased atrial filling, 4. tricuspid opens

1. which murmurs are increased by handgrip/pressure cuff 2. which murmurs are increased by valsalva/standing - most murmurs decrease with valsalva/standing

1. mitral regurgitation, VSD, aortic regurgitation 2. HOCM, MVP

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how to differentiate constrictive pericarditis vs cardiac tamponade on physical exam

constrictive pericarditis has kussmaul's sign

1. best antihypertensive for those with CAD 2. best antihypertensive for patients with left ventricular dysfunction or multiple cardiovascular risk factors 3. what type of antihypertensive is contraindicated in patients with bilateral renal artery stenosis

1. beta blockers 2. ACE 3. ACE

carcinoid syndrome effect on the heart

fibrous plaques on the endothelium on the right side of the heart--> tricuspid regurgitation, distorted cardiac valves, pulmonic stenosis

treatment for bullous stage of contact dermatitis

wet dressings several times/day with burow's solution or boric acid, baths oral corticosteroids for severe cases

clinical associations with acanthosis nigricans

visceral carcinomas - GI and GU, especially stomach diabetes, obesity, acromegaly cushings syndrome

urticaria/pruritic erythematous lesions progressing to nikolsky's negative bullous lesions

bullous pemphigoid - IgG anti basement membrane without acantholysis

keratoacanthoma

grows on exposed hairy skin grows rapidly then involutes more common on white skinned males telangiectasias with a central keratotic plug

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atopic dermatitis 1. clinical pres 2. management

1. erythematous excoriated papules/plaques that weep and become secondarily impetiginized 2. change in environment topical steroids adequate humidity

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zinc deficiency clinical presentation

abnormal taste*, impaired wound healing, dermatitis around the mouth with acral involvement, then to hands, scalp, trunk, feet, alopecia, seen in chronic malabsorption states bypass surg, IBD, alcoholism

what type of melanoma is invasive early

nodular melanoma

sezary syndrome

T cell lymphoma - HTLV1- malignancy of helper T cells

cutaneous reactions of TMP SMX

urticarial eruption within days morbilliform reaction within weeks especially in AIDS patients

tetracycline dermatologic changes

photosensitivity, mottling of teeth in children

what drugs cause erythema nodosum

OCPs, sulfonamides, penicillins - panniculitis tender subcutaneous erythematous nodules classically on the anterior portion of the legs

chloroquine dermatologic side effect

polymorphous light eruption exacerbation of porphyria cutanea tarda black pigmentation of the face, mucous membranes

dermatologic side effects of antineoplastics

stomatitis, alopecia dystrophic nail changes (bleomycin, hydroxyurea, 5FU) cellulitis, ulceration, urticaria

erythroderma 1. causes 2. clinical pres

1. drugs - sulfa, penicillins, gold, allopurinol, captopril, phenytoin, carbamazepine

2. diffuse rash, fever, eosinophilia, interstitial nephritis

...

what drugs cause pemphigus vulgaris

captopril penicillamine

treatment for pain in patients with acute intermittent porphyria

oral phenothiazines, narcotics, NSAIDs DO NOT USE: barbiturates, sulfonamides, alcohol, carbamazepine, valproate, estrogen/progestin

what lipid disturbance is seen in patients with insulin resistance

hypertriglyceridemia

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in adrenocortical insufficiency what occurs with water balance

low aldosterone decreases circulating volume (via inc. natriuresis) leading to inc. ADH production and hyponatremia

hyperparathyroidism 1. effect on bones

1.

what is role of FSH in men

stimulates sertoli cells and then spermatogenesis

androgen insensitivity 1. patho

1. X linked androgen receptor defect leads to XY and female genetalia

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treatment for erythropoietic protoporphyria

beta carotene

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vitamin A toxicity clinical pres

...

what vitamins classically deficient in alcoholics

magnesium, folate

1. causes of hypomagnesemia 2. clincal pres of hypomagnesemia

1. alcoholism, milk diet in infants, chronic diuretic use, acute pancreatitis, 2. anorexia, n/v, tremor, altered mental status

cystinuria 1. patho 2. clinical pres

1. autosomal dominant defect in proximal tubule reabsorption of cystine, ornithine, arginine, lysine 2. ureterolithiasis with radiopaque stones

mcardles disease 1. patho 2. clinical pres

1. glycogen storage disease- defect in glycogen phosphorylase 2. cramps/muscle pains, inc. CK, inc. Lactate with exercise

gauchers disease 1. patho 2. clinical pres

1. autosomal recessive deficiency in glucocerebroside --> accumulation of glucosylceramide in lysosomes 2. hepatosplenomegaly, neurologic/mental retardation, bone lesions (erlenmeyer flask femur), severe bone disease, lipid laden macrophages (gaucher cells)

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tay sachs disease 1. patho 2. clinical pres

1. hexosaminidase A deficiency --> accumulation of GM2 ganglioside in lysosomes 2. mental retardation, seizures, blindness, cherry red macula

type 3 hyperlipoproteinemia

homozygous Apo-E defect --> raised yellow plaques on palms/fingers,2/2 abnormal accumulation of chylomicrons and VLDL

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type 1 hypolipoproteinemia

deficiency of lipoprotein lipase presents as eruptive xanthomas, acute pancreatitis

familial combnined hyperlipidemia

autosomal

what is the most important factor in diet induced cholesterol elevation

...

"""" in diet induced triglyceride elevation

total amount of fat and saturated fat consumed

total amount of calories

...

causes of secondary dyslipidemias

DM, hypothyroidism, renal disease, alcoholism, anorexia Drugs - estrogen, glucocorticoids

osteomalacia

vitamin D deficiency leads to bowing of long bones, and wide osteoid borders on bone surfaces

vitamin D resistant rickets 1 patho 2. clinical pres 3. dx

1. X linked recessive end organ insensitivity to vitamin D --> renal phosphate wasting 2. alopecia and vitamin D deficiency - ie. osteomalacia/rickets despite vitamin D supplementation 3. normal serum calcium, normal alk phos, normal levels of vitamin D, symptoms of rickets

hormone replacement therapy 1. advantages

1. dec. vaginal atrophy, incr. bone mineralization 2. inc. risk of venous thromboembolism inc risk of breast cancer

when should a patient with an eating disorder be hospitalized

weight vasomotor palpitations, tachycardia, lightheadedness, diaphoresis, dizziness, confusion, syncope

what patients is a low salt diet recommended for

hypertension, CHF, CKD

whipples disease 1. patho 2. dx

1. infection with gram positive bacilli - tropheryma whippelii --> GI, arthritis, CNS, eye 2. small intestine biopsy shows PAS positive macrophages with non-acid fast gram positive bacilli

what vitamin deficiency associated with celiac disease

iron deficiency

what tumors are most common in the distal ileum

lipomas and carcinoid tumors

what kind of cancer is more common in celiac disease, regional enteritis, congenital immune disorders, organ transplant, AIDS

primary small bowel lymphoma

lab characteristics of cirrhotic ascitic fluid

SG pedal edema from protein malnutrition 3. mucosal biopsy to rule out cancer/lymphoma tx =high protein diet, anticholinergic drugs, H2 blockers

why does the sclera stain first with bilirubin

high elastin content

1. rotors syndrome 2. dubin johnson

1. defect of hepatic storage of conjugated bilirubin resulting leaking into plasma 2. conjugated hyperbilirubinemia, diagnosis is elevated urinary coproporphyrin I(>80% of total) grossly black liver dense granular pigments of epinephrine metabolite*** (not seen in rotor)

what noncardiac condition presents like angina and is relieved by sublingual nitro

diffuse esophageal spasm

how to diagnose osmotic diarrhea

stool osmotic gap

secretory diarrhea clinical pres

large volume, painless, watery

hepatic complications of anabolic steroids

cholestasis/jaundice without inflammation peliosis hepatis (blood in the liver)

hemoglobin C disease 1. patho 2. clinical findings

1. lysine substitution for glutamic acid 2. targetoid RBCs, splenomegaly, less symptomatic than HbS, intracellular HbC CRYSTALS

what is is the cause of febrile transfusion reaction

patients antibodies react to donor leukocytes in PRBCs usually after about 7 transfusions patients are sensitized--- must filter/wash the RBCs to remove the WBCs

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bone marrow finding in hemolytic anemia

increased erythroid to myeloid ratio

causes of anemia in preganncy

folate deficiency (megaloblastic) dilutional anemia disproportionate increase in plasma volume IDA

what kind of bone abnormalities seen with sickle cell anemia

bone infarction- can look like osteomyelitis AVN of femoral head

fish oils effect on coagulation

prolong bleeding time- by reducing platelet arachidonic acid, and competing with COX

when does post radiation cancer occur

increased frequency of cancer at the same age that you would expect the cancer to occur leukemia has the lowest latency at 5-7 years post exposure

what is the most important prognostic factor in colon cancer

DEPTH OF TUMOR PENETRATION (DUKES STAGE)

also young age, male gender, and rectal location are poor prognostic factors

...

what decreases risk of breast cancer in women

late menarche, early menopause, early first pregnancy

what is the most important prognostic factor in bone tumors

more distal tumors have better prognosis ex - pelvic girdle is worse than femur, and femur is worse than tibia.

Adult T cell leukemia/lymphoma 1. patho 2 . tx

1. HTLV 1 or other retrovirus ---> fulminant leukemia with skin involvement 2. not responsive to treatment, but helps to control symptoms

most common clinical pres of hodgkins lymphoma

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enlarge cervical or supraclavicular lymph nodes

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chemotherapy side effects 1. cyclophosphamide 2. doxorubicin 3. bleomycin 4. MTX 5. cisplatin

1. hemorrhagic cystitis - tx = mesna + hydration 2. cardiomyopathy/CHF 3. lung injury, skin reactions 4. liver toxicity, myelosuppression, GI mucositis 5. renal, ototoxicity, myelosuppression, peripheral neuropathy

paraneoplastic syndromes associated cancers 1. eaton lambert 2. SIADH 3. cushings syndrome 4. non-metastatic hypercalcemia (PTHrP)

1. small cell lung 2. small cell lung 3. small cell lung 4. squamous cell lung (

what type of cancers occur among chinese americans at a higher than normal rate

nasopharyngeal carcinoma, liver cancer

poor prognostic factors for patients with non hodgkin's lymphomas

>60 years of age, high serum LDH, poor performance status, ann arbor 3 or 4

what increases risk for cholangiocarcinoma

clonorchis, ulcerative colitis

1. how to treat brain metastases pain associated with inc. ICP 2. limitation of carbamazepine for use in neuropathic cancer pain

1. steroids 2. leukopenia, thrombocytopenia

posterior circulation TIA 1. clinical pres 2. what structures does the basilar artery supply

1. tinnitus, vertigo, diplopia, ataxia, hemiparesis, bilateral visual impairment (homonymous hemianopsia) 2. pons, midbrain, cerebellum

acoustic neuroma clinical presentation

-- develop from schwann cells deafness, headache, ataxia, tinnitus, diplopia

subdural hematoma

venous origin 2/2 head injuryesp. in elderly clinical pres - fluctuating LOC, altered mental status, seizures, papilledema

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wernicke korsakoff 1. patho 2. clinical pres 3. tx

1. infarction of mamillary bodies 2. confusion, ataxia, nystagmus, ophthalmoplegia (6th nerve) korsakoff = irreversible amnesia, confabulation, apathy 3. THIAMINE BEFORE GLUCOSE

benign paroxysmal positional vertigo 1. patho 2. clinical pres

1. calcium debris (loose otoconia) in semicircular canals 2. sudden onset of brief vertigo episodes, dix hallpike maneuver positive

what to start treatment with for a withdrawing chronic alcoholic

diazepam, thiamine, magnesium

what is a key feature of peripheral vertigo vs central vertigo

tinnitus and deafness is found in peripheral vertigo peripheral vertigo tends to relapse and remit whereas central is more constant

hypokalemic periodic paralysis 1. patho 2. clinical pres 3. tx

1. familial/thyrotoxicosis --> hypokalemia after large carbohydrate meals/stress 2. recurrent attacks of weakness, loss of DTR, paralysis 3. potassium supplementation, low carbohydrate, acetazolamide, imipramine

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638.

arteriovenous malformation clincial pres

symptoms start between ages 1030, headaches similar to migraines, seizures, or rupture

hypertensive encephalopathy 1. locations of hemorrhage

1. cerebellum, pons, thalamus

cerebellar hemorrhage 1. clincal pres

1. headache, vomiting, gait ataxia, dizziness, vertigo, eyes deviate away from hemorrhage possible ipsilateral 6th nerve palsy

pontine hemorrhage key clinical findings

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impaired oculocephalic reflexes, small reactive pupils, coma, quadriplegia

PML pathogen

JC virus (papovavirus) in the immunosuppressed

which vaccines are associated with ADEM

smallpox or rabies

which vitamin deficiency can cause demyelination

B12

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cavernous sinus thrombosis 1. patho 2. clinical pres

1. 2/2 trauma, neoplastic, or infectious 2. papilledema, hemorrhages of orbital veins, headache, diplopia, sensory loss of face (3,4,6,V1/V2)

1. oculomotor palsy clinical presentation 2. argyll robertson pupil 3. tonic pupil (holmes-adie syndrome)

1. ipsilateral no response to light, no consensual light response 2. small irregular pupils, impaired light response, accomodation intact 3. parasympathetic lesion @ or distal to ciliary ganglion - large unilateral pupil, no light response (shy drager, amyloid, diabetes, healthy)

1. horners syndrome pupil

1. constricted on affected side, intact light reaction, no reaction to darkness

seizure treatments 1. status epilepticus 2. partial seizures 3. tonic clonic seizures 4. myoclonic seizures 5. absence seizures

1. lorazepam or diazepam 2. phenytoin, carbamazepine, 3. phenytoin, carbamazepine, valproic acid 4. valproate 5. ethosuximide, valproate

phenytoin side effects

gum hyperplasia, hirsutism, SJS/TEN

long term seizure prophylaxis

phenytoin, carbamazepine

1. hyperuricemia renal effect 2. sickle cell anemia renal effect

1. urate crystals in the medulla or pyramids with mononuclear or giant cell 2. ischemic injury leads to functional tubule defect and concentrating defect, papillary necrosis, FSGS

what drugs should be avoided in patients with renal impairment

NSAIDs and ACE

post-strep glomerulonephritis 1. microscopic findings

diffuse mesangial proliferation, IgG and C3 granular subepithelial deposits

what is key urine finding indicating glomerulonephritis

red cells/red cell casts indicate that the glomerulus is bleeding - granular casts, protein will also be present but this is not specific

glucocorticoid drug acid base disturbance

metabolic alkalosis because glucocorticoids have some mineralocorticoid activity

hepatic cirrhosis acid base disturbance

respiratory alkalosis - 2/2 elevated progestins stimulate respiratory drive

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henoch schonlein 1. patho 2. kidney injury type

1. URI, drugs, foods, insect bites-> immune complex vasculitis of the skin, GI tract and kidneys 2. diffuse proliferative glomerulonephritis

polycystic kidney disease clinical pres

renal/hepatic cysts, intracranial aneurysms, colonic diverticula

why do osteophytes cuase pain in osteoarthritis

stretching of periosteal nerve endings

what cardiac complication of ankylosing spondylitits

aortic insufficiency (4%)

side effect of phenylbutazone (an NSAID used to treat joint pains)

aplastic anemia

what to think in a patient with new onset clubbing of the distal extremities

secondary hypertrophic osteoarthropathy - next step should be a chest x ray

blood count findings in SLE

leukopenia (2/3 of patients) or pancytopenia

what is the best predictor of likelihood for extraarticular manifestations of RA

high IgG anti Fc Ig (RA factor) titers

668.

most common extraarticular manifestation of ankylosing spondylitis

anterior uveitis - pain, photophobia, inc. lacramation

669.

rheumatoid arthritis radiographic findings early vs late

early = NORMAL late = bony erosions and loss of cartilage, periarticular osteopenia, joint margin erosions (narrowing of joint space)

ehlers danlos 1. clinical pres

1. skin hyperextensibility /fragility/ bruisability, habitual dislocation of joints

relapsing polychondritis 1. clincial pres 2. associated underlying conditions

1. auricular/nasal chondritis that relapses and remits 2. SLE, RA, sjogren's, vasculitis

rheumatoid arthritis cellular/molecular mechanism

CD4+ T cells inc. IL2

661.

662.

663.

664.

665.

666.

667.

670.

671.

672.

673.

marfans syndrome 1. heart lesions 2. body features

1. cystic medial degen of aorta leads to aortic dilatation and mitral insufficiency 2. chest deformities (pectus), long limbs, high arched palate, high pedal arches, pes-planus

what heart lesion most common in HLA B27+ patients

aortic stenosis (1-6%)

where do rheumatoid nodules typically occur

olecranon bursa, proximal ulna, achilles tendon, occiput

caplans syndrome

diffuse nodular fibrosis that occurs when rheumatoid nodule occur in the lungs of patients with pneumoconiosis

most common eye manifestation in RA

sjogrens

anti-RNP associated diseases

polymyositis, scleroderma, lupus, mixed connective tissue disease

what serologic marker correlates with disease activity in lupus

anti-dsDNA

what kind of crystal arthropathy characteristic of END STAGE renal failure

hydroxyapatite (small nonbirefringent crystals)

CPPD prophylaxis

colchicine

clinical presentaion that favors pseudogout over gout

old age, pre-existing joint disease, knee involvement

measels 1. clinical pres 2. complications 3. treatment

1.cough/fever/coryza--> koplik spots, fever, rash that starts at the head and DESCENDS CONFLUENTLY (compare to rubella) 2. otitis media (most common), bronchitis, lymphadenitis pneumonia, encephalitis (sclerosing panencephalitis that leads to death by 1 year) 3. aerosolized ribavirin for pneumonia

mumps clinical pres mumps treatments

bilateral parotitis, oophoritis, orchitis, meningitis, hyperamylasemia (from parotid inflammation) fever tx = symptomatic,

treamtent for diarrhea

oral hydration loperamide or bismuth fluoroquinolones or TMP SMX

674.

HIV 1. detection

1. EIA - 99.5% sensitive, NOT SPECIFIC AT ALL LOTS OF FALSE POSITIVES Western blot - more specific `

675.

treatment of tetanus

penicillin or metronidazole, respiratory support

676.

heterophil negative mono

CMV

physical manifestations of congenital syphilis

hutchinsons teeth, saddle nose, saber shins

prophylactic antibiotic choice for travelers diarrhea

ciprofloxacin inf symptoms develop

treatment for legionella

macrolides - azithromycin fluoroquinolones levofloxacin or moxifloxacin

hospital acquired pneumonia organisms

s. aureus, gram negatives, or s.pneumo

empiric treatment for neutropenic fever

broad gram negative/gram positive coverage for a bacteria

- dont need to treat for fungal/viral unless there is an indication

...

EBV associated malignancies

anaplastic nasopharyngeal carcinoma (US) burkitts lymphoma (Africa) HIV associated CNS lymphomas

native valve endocarditis caues

strep viridans > s.aureus > enterococcus

multiple myeloma infectious risk

defect in humoral immunity - susceptibility to encapsulated organisms s.pneumoniae and klebsiella

what kind of infections are associated with cell mediated immunity defects

candida/fungal and viral infections -

congenital toxoplasmosis

chorioretinitis, strabismus, epilepsy, hydrocephalus

what antibiotics potentiate phenytoin

sulfonamides by displacing phenytoin from albumin

what antibiotic potentiates the effects of oral hypoglycemics

sulfonamides

best diagnostic test for T cell defect

candida infection positive reaction means intact T cell response

677.

678.

679.

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681.

682.

683.

684.

685.

686.

687.

688.

689.

690.

691.

692.

693.

694.

695.

696.

697.

698.

699.

aspirin allergy mechanism

pseudoallergic reaction due to the enhanced leukotriene synthesis

HLA associations 1. ank spondy 2. juvenile arthritis, rheumatoid arthritis 3. type 1 DM 4. reiters syndrome

1. B27 2. DR4 3. DR3 4. B27

ant/middle/posterior mediastinal masses

posterior mediastinal masses include neurogenic tumors, meningocele,meningomyelocele, gastroenteric cysts, and esophageal diverticula. anterior mediastinal masses include thymomas, lymphomas,teratomas, and thyroid masses. Middle mediastinal masses include vascular lesions,lymph nodes, and pleuropericardial and bronchogenic cysts.

what lung disease associated with ankylosing spondylitis

bilateral upper lobe fibrosis/fibrocavitary disease

hypoxemia while recieving 100% oxygen

right to left shunt (atelectasis, vascular abnormalities, ARDS, congenital cardiac malformations) ~~ compare to VQ mismatch which is easier to correct with oxygen therapy

lab findings for sarcoidosis

elevated ACE, ESR, hyperglobulinemia, hypercalcemia (elevated D3) falsely positive ANA and RF

causes of pulmonary eosinophilia

Allergic bronchopulmonary aspergillosis (in asthmatics), parasitic reactions, and drugs loeffler's syndrome - benign idiopathic pulm. eosinophilia churg-strauss

side effects associated with quinidine

drug/platelet complex thrombocytopenia* , hepatitis, bone marrow suppression, lupus syndrome, GI side effects,

LSD clincial pres

sympathomimetic effects - pupillary dilitation, piloerection, hypothermia, tachycardia, dizziness, weakness, drowsiness, nausea, paresthesias

700.

701.

702.

703.

704.

705.

706.

707.

708.

709.

710.

711.

712.

713.

folate deficiency causes

chronic alcoholism, small bowel disease, inadequate intake, MTX, diagnostic tests includes serum folate or RBC folate (will detect rapid changes in intake)

perchlorate and thiocynaate

anti hyperthyroid drugs, both inhibit iodide transport, work by preventing thyroid gland from concentrating iodide

which fluroquinolones need renal adjustment

all of them except moxifloxacin (liver met), or pefloxacin

ampicillin vs penicillin

acid resistant, better PO absorption, very high bio availability PO

ADH effects

inc. water permeability of the distal collecting duct, bradycardia, inc. RR, suppression of fever

what patients should get treated with clopidogrel

unstable angina, STEMI, NSTEMI, post PCI

what is the treatment for SVT

vagal maneuvers - carotid massage, immersion in cold water, valsalva adenosine, beta blockers, CCBs

neurocardiogenic syncope (situational syncope)

vasovagal syncope - occurs in response to pain, body actions (urination), coughing fits nausea, diaphoresis, tachycardia, pallor preceding syncope

what viral infection associated with dilated cardiomyopathy

coxsackie b adeno, cmv, echo, hep c,

isolatd systolic hypertension + TX OF CHOICE

cuased by dec. elasticity of arterial wall which causes inc. systolic BP

treatment of choice is HCTZ

...

most common cause of constrictive pericarditis in developing countries

tuberculosis

what is the only murmur that will increase with decreased preload

HCM ie. during valsalva, or standing

which murmurs inc/dec. with inc. afterload

ie. handgrip or squat dec - AS, HCM inc - MS

714.

715.

716.

717.

718.

719.

720.

721.

722.

723.

724.

725.

726.

statin side effects

elevated liver enzymes myopathy - HMG CoA reductase inhibitors dec. mevalonate which is also used to synth CoQ10

how to differentiate restrictive cardiomyopathy from HCM on echo

HCM has septal thickening restrictive has symmetric ventricular thickening

theophylline toxicity

headache, insomnia, GI disturbance, arrhythmias ciprofloxacin and erythromycin both inhibit P450 and inc. theophylline levels

flow loop for upper airway obstruction ex. laryngeal edema

flow limitation in both inspiratory and expiratory limbs

flow loops 1.obstructive disease processes 2. restrictive lung disease 3. upper airway obstruction

1. scooped out appearance 2. small volume restrictive pattern 3. blunted inspiratory/expiratory flow loops

aspergilloma 1. CXR

1. radiolucent mass that changes position

what is the most likely location of formation of a PE clot

iliofemoral veins ~ calf veins less likely to make it to the heart

auscultatory findings in emphysema

prolonged expiratory phase, end expiratory wheezing

treatment for inpatient vs outpatient community acquired pneumonia (not ICU, not intubated)

inpatient - levofloxacin outpatient azithromycin, or doxycycline

right heart cath findings of PE

elevated pulmonary artery pressure (normal is 25/15), elevated right atrial pressures hypotension and shock

most fatal complication of bronchiectasis

life threatening hemoptysis

hypertrophic osteoarthropathy clinical pres

digital clubbing, **sudden onset** arthropathy of the wrist and hands - first diagnostic test is a chest x ray

what is the cause of bronchial obstruction causing recurrent pneumonia

bronchiectasis, bronchial stenosis, foreign body

727.

728.

729.

730.

731.

732.

733.

734.

735.

736.

737.

738.

what is the functional consequence of diaphragmatic flattening in COPD

increased work of breathing

ddx of unilateral leg swelling/pain

muscle strain, bakers cyst, DVT, cellulitis

diagnostic steps for DVT

low pretest probability - Ddimer - if negative don't anticoag, if positive, compression US and then anticoag if necessary

739.

740.

high pretest probability - do compression ultrasound first

...

auscultatory findings of lobar pneumonia

dullness to percussion bronchial breath sounds with prominent expiratory component E-->A egophony whispered pectoriloquy crackles

interstitial lung disease auscultory findings

resonant to percussion, vesicular breath sounds FINE END INSPIRATORY CRACKLES

distinguishing clinical features of atypical pneumonia

indolent course, higher incidence of extrapulmonary manifestations (HA, sore throat, erythema multiforme or other rash)

chronic bronchitis- 1. definition, 2. patho

1. productive cough 3 months per year for 2 years, prominent bronchovascular markings, normal DLCO, right heart failure, profound O2 desat 2. destruction of airspaces distal to terminal bronchioles, dec. pulmonary vascular markings, dec. DLCO, moderate O2 desat

741.

742.

complications of PEEP

alveolar damage, tension pneumothorax, hypotension

differentiation of asthma and COPD

CXRs are UNRELIABLE airway expansion in COPD is a LATE finding

best way to distinguish is FEV1 before and after bronchodilatory expecting >15% response in the asthmatic

...

causes of choriocarcinoma

post normal gestation, molar pregnancy, abortion

743.

744.

745.

746.

what is common nonpulmonary comorbid condition in asthmatics

GERD - up to 75% of patients

what kind of MI presents with abdominal pain

posterior and inferior MIs ECG should be first diagnostic chest for abdominal pain

factitious diarrhea diagnosis

melanosis coli colonoscopy shows darkening of colon, and lymphoid nodules 2/2 laxative abuse

right sided vs left sided colon caner clinical pres

right sided anemia, left sided obstruction

constipation, back pain and renal impairment in an elderly patient suggests what condition

multiple myeloma constipation is 2/2 hypercalcemia renal impairment is 2/2 BJ proteinuria

celiac disease 1. clinical pres

1. bulky foul smelling floating stool, loss of muscle mass/fat Dermatitis herpetiformis - subclinical gluten enteropathy (sub cutaneous IgA) pallor from IDA (duodenum) bone pain from osteomalacia easy bruising (K deficiency) hyperkeratosis (A deficiency)

most common complication of PUD

hemorrhage

treatment of ascites

sodium and water restriction spironolactone (aldosterone blocker) loop diuretic - with spironolactone frequent paracentesis (24 L/day) if renal function intact

747.

748.

749.

750.

751.

752.

753.

754.

755.

drug induced pancreatitis

furosemide, thiazides IBD drugs - ASA, sulfasalazine immunosuppression azathioprine, L-asparaginase valproic acid AIDS drugs - didanosine, pentamidine antibiotics - metronidazole, tetracycline

what does migratory thrombophlebitis and atypical venous thrombosis suggest clinically and what is the next diagnostic test

chronic DIC and malignancy next diagnostic test should be pan CT scan

chronic pancreatitis best diagnostic test

fecal elastase study*** diagnoses the pancreatic exocrine insufficiency serum lipase and amylase may not be reliable and only mildly elevated

lactose intolerance 1. dx

1. H+ breath test, or lactose tolerance test

gallstones 1. pigment stones 2. treatment for nonsurgical candidates

1. calcium bilirubinate - from hemolysis (black) or chronic biliary tract infection (brown) 2. ursodeoxycholic acid

hepatitis B 1. chronic treatment 2. post exposure prophylaxis

1. interferon, lamivudine (reverse transcriptase inhibitor) 2. HBIG and hepatitis B vaccine

diagnostic test for recurrent pancreatitis with no identifiable cause

ERCP

hepatitis C 1. extrahepatic manifestations

1. cryoglobulinemia (renal/GI), b cell lymphoma, autoimmune (sjogrens/thyroiditis), lichen planus, ITP, porphyria cutanea tarda

non alcoholic fatty liver disease 1. patho 2. biopsy findings 3. top 3 risk factors 4. tx

1. obesity/type 2 dm --> insulin resistance/inc lipolysis and fat accumulation in hepatocytes --> proinflammatory cytokines/oxidative stress --> inflammation, fibrosis, cirrhosis 2. macrovesicular fat deposition in hepatocytes (indistinguishable from alcohol) 3. obesity, diabetes mellitus, hypertriglyceridemia 4. underlying conditions, ursodeoxycholic acid

756.

757.

758.

759.

760.

761.

762.

763.

764.

765.

766.

In someone with a solitary liver mass and no history of chronic liver disease what is the first diagnostic test that should be performed

most likely mets colonoscopy, CT abdomen, AFP

hepatotoxic drugs 1. hepatitis causing drugs 2. cholestatic drugs

1. acetaminophen, tetracycline, isoniazid, chlorpromazine, halothane, antiretroviral therapy, 2. chlorpromazine, nitrofurantoin, erythromycin anabolic steroids, colestipol

why is AST>ALT in alcoholics

they have deficiency of pyridoxal 6 phosphate which is ALT cofactor

alcohol hepatitis histologic findings

ballooning of cytoplasm, PMN infiltration, fibrosis, necrosis, mallory hyaline

alpha 1 antitrypsin deficiency histologic findings of liver/lungs

PAS positive hepatocyte granules*** Panacinar emphysema

emphysematous changes of the lower lobes

...

indications for TIPS

refractory cirrhotic hydrothorax refractory ascites recurrent variceal bleeding patients waiting for liver transplant and needing portocaval shunts

pancreatitis hypotension pathogenesis

inflammatory effects from pancreatic enzyme release inc. vascular permeability

also systemic hypotension occurs from endothelial injury

...

acute hepatic failure vs fulminant hepatic failure

fulminant includes hepatic encephalopathy

acute/fulminant both have liver synthetic failure within 8 weeks of injury onset

...

767.

768.

769.

770.

771.

772.

773.

774.

775.

776.

777.

what lab value will indicate that ascites is from portal hypertension

non-bloody, SAAG>1.1

complications of ERCP

pancreatitis, perforation, biliary enteric fistula, biliary peritonitis, sepsis, hemorrhage, contrast related complications

hemolytic reactions\ 1. diagnosis of ABO mismatch 2. complications of ABO mismatch 3. febrile transfusion reaction

1. coombs test positive, plasma free hemoglobin, pink plasma, plasma hemoglobin >25, hemoglobinuria 2. DIC, ARF, shock 3. reactions to cytokines released by leukocytes in storage

factors that increase the probability of progression of hepatitis C

male sex age of infection >40 longer duration of infection coinfection with HIV immunosuppression liver comorbidities

hepatic adenoma 1. definition 2. associated conditions 3. histological findings

benign epithelial tumors found in right lobe assc. with anabolic steroids, glycogen storage disease, pregnancy, diabetes, OCPs 2. enlarged adenoma cells with glycogen and lipids

focal nodular hyperplasia

non-malignant tumor, hyperplastic response to hyperperfusion biopsy shows sinusoids and kupffer cells

what primary malignancies metastsize to the liver

GI, lung, breast, skin (melanoma)

when should ACE inhibitors not be used for renal protection

proteinuria >300mg in a diabetic (it is irreversible)

creatinine >3-3.5 ~ will worsen the renal failure -

...

initial hematuria terminal hematuria total hematuria

initial = urethral source terminal = bladder or prostatic cause total = bladder or kidney cause

incontinence 1. what medications associated with overflow incontinence

1. anticholinergics, antipsychotics, TCAs, sedative hypnotics

778.

779.

780.

781.

782.

783.

784.

785.

786.

787.

initial tests for patient with suspected BPH

DRE urinalysis, serum creatinine - to rule out infection

what is important rule out for patient with voiding systems and negative prostatic culture

bladder cancer do repeat prostatic cultures and cystoscopy

acyclovir renal side effect

crystalluria with renal tubular obstruction - avoid with good hydration when using IV acyclovir

renal vein thrombosis in nephrotic syndrome 1. patho 2. clinical pres 3. most common nephrotic syndrome associated with RVT

loss of antithrombin 3/S/C leads to hypercoagulable state in the renal vein 2. sudden onset abdominal pain, fever, hematuria 3. membranous glomerulonephritis

fibromuscular dysplasia 1. dx

1. hypertension, string of beads on angiography hum or bruit in the costovertebral angle

progression of diabetic kidney disease

inc. GFR GBM thickening mesangial expansion nodular sclerosis

how to avoid urate nephropathy in patients who will start chemotherapy for lymphoma and leukemia

allopurinol pretreatment

drugs that cause interstitial nephritis

penicillins, PPIs, NSAIDs

sulfonamides, rifampin, phenytoin, allopurinol

...

medullary cystic kidney 1. clinical pres 2. dx/tx 3. acquired cystic kidney disease

1. recurrent UTI and renal stones 2. contrast filled cysts on IVP, tx = same as normal person with renal stones 3. occurs in dialysis patients

788.

789.

790.

791.

792.

793.

794.

795.

796.

cyclosporine 1. toxicity 2. mechanism 3. advantage/disadvantage of tacrolimus

1. nephro, renal vasoconstriction/HTN, hyperkalemia, neurotoxicity/tremor gingival hypertrophy, hirsutism* infection, SCC, anorexia, n/v, diarrhea 2. calcineurin inhibitor (thus no transcription of IL2 via NFKB) 3. no hirsutism or gum hypertrophy - higher incidence of neurotoxicity diarrhea

797.

798.

799.

azathioprine 1. mechanism 2. SE

1. purine analog metabolized to 6-MP 2. diarrhea, leukopenia, hepatotoxic

800.

mycophenolate 1. mechanism 2. SE

1. reversible inosine monophosphate dehydrogenase inhibitor ~ rate limiting purine synthesis step 2. bone marrow suppression

801.

what drugs cause hyperkalemia

ACE inhibitors, NSAIDs, spironolactone, amiloride

serum osmolality 1. high >295

1. hyperglycemia, radiocontrast, mannitol

SIADH lab diagnosis

serum osm Sosm UNa >20 Uosm >100-150

blind loop syndrome acid base disturbace

excess production of Dlactate caues hypochloremic met. acid

chloride sensitive vs resistant met. alk

sensitive - Urine Cl 20 and volume expansion - primary hyperaldosteronism, bartter, gitelman, black licorice **wont respond to NS infusion

...

802.

803.

804.

805.

806.

807.

808.

broad categories of causes of metabolic acidosis

ketoacidosis - alcoholic, diabetic, starvation intoxications - methanol, formalin, salicylate, ethylene glycol, INH, metformin tissue hypoxia renal failure

cause of hypocalcemia in an alcoholic

chronic pancreatitis leads to ADEK insufficiency and thus inability to absorb calcium from the gut

alcoholism electrolyte imbalance

hypomagnesemia, hypokalemia, hypophosphatemia

what kind of acid base disturbance seen in normal pregnancy

progesterone stimulates the DRG of medullary respiratory center --> chronic resp. alkalosis

aspirin toxicity 1. patho 2. clinical pres

1. stimulates respiratory center (resp.Alk) and it is a acid so also met. acid 2. fever, tinnitus, tachypnea

postictal acid base disturbance

transient anion gap metabolic acidosis that resolves without treatment 60-90 minutes after seizure activity

avascular necrosis of the hip 1. causes 2. clinical pres 3. dx

1. corticosteroids, alcoholism, hemoglobinopathies, lupus (antiphospholipid) 2. progressive hip or groin pain without restriction of range of motion 3. MRI

what must be ruled out in any patient with RA, fever and a new inflamed red joint

septic arthritis- these patients are at a higher risk for septic arthritis usually with staph aureus

what is important test before starting therapy for lupus patient with renal impariment

kidney biopsy to determine the degree of impairment

most common cause of isolated elevated ALP in the elderly

PAGETS DISEASE OF BONE

viral arthritis 1. patho 2. dx 3. tx

1. post parvo, hepatitis, HIV, mumps, rubella 2. positive ANA (weak), rheumatoid factor positive 3. NSAIDs, will resolve with time

what fraction of patients with dermatomyositis will develop cancer

10% - breast, lung, ovarian, urogenital

809.

810.

811.

812.

813.

814.

what inflammatory diseases associated with aortic aneurysms

behcets, takayasu, giant cell arteritis, ank spondy, RA, psoriatic arthritis, reiters arthritis

- unrelated - also marfan's, ehlers danols, syphilis

...

what inflammatory diseases associated with renal failure

SLE, wegener's, PAN, churg strauss, behcets

what inflammatory diseases associated with alveolar hemorrhage

goodpasture, wegener's, PAN, churg strauss, behcets, antiphospholipid syndrome

what inflammatory diseases associated with depositional disease and carpal tunnel syndrome

RA, sarcoid, amyloidosis, hypothyroidism (myxedema)

key characteristic of lupus arthritis

it is NON-DEFORMING

key clinical feature of back pain 2/2 metastasis

pain that is worse at NIGHT

lesch nyhan syndrome 1. patho 2. clinical pres

1. hypoxanthine guanine phosphoribosyltransferase deficiency --> elevated uric acid 2. self mutilation, neurologic disabilities in childhood

823.

824.

825.

826.

827. 815.

816.

817.

818.

819.

820.

821.

822.

vertebral compression fractures 1. risk factors 2. clinical pres

1. demineralization/trauma - osteomalacia, osteoporosis, 2. intense focal pain, worse when lying down

what is the cause of kidney damage in lupus

immune complex deposition and activation of complement (-->low C3 in the blood)

which organ is most likely to be damaged when using hydroxychloroquine for lupus

RETINA

degenerative joint disease Xray findings

narrowing of joint spaces, subchondral cysts/sclerosis, heberdens nodes, bouchers nodes, osteophytes

what physical exam findings suggests lumbar disk herniation

straight leg raise

rheumatoid arthritis increases risk of osteopenia/osteoporosis

yes it does indeed

828.

829.

830.

what part of the spine is most likely effected by RA

cervical spine -- MUST EVALUATE FOR SUBAXIAL SUBLUXATION (ATLANTOAXIAL INSTABILITY) PRIOR TO SURGERY

normal pressure hydrocephalus 1. patho 2. clinical pres 3. tx

1. impaired CSF absorbtion leads to ventricular dilatation 2. slow broad based shuffling gait, urinary incontinence, memory loss 3. serial lumbar punctures, VP shunt (if LPs are helpful)

metoclopramide 1. mechanism 2. side effects

1. dopamine ANTAGONIST - used to treat nausea, vomiting, gastroparesis 2. dystonic reactions - tardive, dystonia, parkinsonism, NMS, neck stiffness

features of cerebellar disorders

ipsilateral - nystagmus, hypotonia, dysarthria, incoordination, dysdiadokinesia

best drug for parkinson's patients younger than 70 years and with minimal bradykinesia

benztropine (anticholinergics)

familial dysautonomia (riley day)

ashkenazi jewish ancestry - gross autonomic dysfunction, severe orthostasis

pseudotumor cerebri 1. risk factors 2. clinical pres 3. dx/tx

1. corticosteroids, OCPs, trauma 2. presence of inc. ICP features, no focal signs except 6th nerve palsy, elevated opening pressure, normal CSF micro, only vent. enlargement on imaging, seen in young obese females, headaches and memory impairment, neck pain, n/v, double vision 3. CT/MRI to rule out space occupying lesion, empty sella from downward herniation of arachnocele, increased opening pressure on LP, papilledemasee shrunken ventricles on MRI 4. acetazolamide***, lumbar punctures, lumboperitoneal shunting optic nerve sheath fenestration

anticholinergic symptoms

ie. from benztropine or trihexyphenidyl overdose *red as a beet dry as a bone, hot as a hare mad as a hatter full as a flask - flushing, anhidrosis, hyperthermia, mydriasis, delirium, urinary retention,

831.

832.

833.

834.

835.

836.

837.

838.

839.

840.

side effects of levodopa

nausea and vomiting because of GI effect of dopamine ~ avoid with carbidopa

MAOI + what other drugs precipitate serotonin syndrome

TCAs or SSRIs

propranolol used to specifically treat which conditions

portal hypertension essential tremor hyperthyroidism (symptoms only)

aminoglycoside toxicity

ototoxicity, nephrotoxicity

what electrolyte abnormality associated with intracerebral hemorrhage

SIADH --> hyponatremia

1. medial medullary syndrome 2. lateral medullary syndrome (wallenberg) 2. lateral pontine syndrome

1. occlusion of vertebral or a branch - contralateral hemiparesis/sensory loss, and tongue deviation to the side of the lesion 2. ipsilateral horners, sensory loss on face, palate/pharynx/vocal, ataxia, contralateral body sensory loss 2. contralateral hemiparesis/sensory loss, ipsilateral CNV sensory loss, ipsilateral limb ataxia

mid pontine syndrome

1. ipsilateral limb ataxia, contralateral eye deviation, face/arm/leg paralysis

842.

843.

844.

845.

creutzfeldt jakob disease 1. patho 2. clinical pres

1. prion disease 2. rapidly progressing dementia, myoclonus, periodic high EEG voltage showing sharp triphasic pattern

1. picks disease 2. lewy body disease 3. multi infarct dementia

1. frontotemporal dementiapersonality changes (euphoria/disinhibition), compulsive behaviors, hyperorality, impaired memory 2. fluctuating cognitive impairment, bizarre visual hallucinations***, parkinsonism that is poorly responsive to therapy 3. cognitive/motor dysfunction, stepwise loss of function

carotid artery stenosis 1. when to operate 2. medical therapy

841.

1. >60% regardless of symptoms, 2. aspirin for life

846.

847.

848.

849.

850.

what is the treatment for patient who is suspected intoxication and cannot give good history

thiamine, supplemental O2, naloxone, dextrose

absence seizures EEG finding

3 hz spike and wave tx = ethosuximide or valproic acid

what patients are at a higher risk for subdural hemorrhage

elderly and alcoholics both have brain atrophy

waterhouse friderichsen syndrome

bilateral hemorrhage of adrenal glands 2/2 DIC during neisseria meningitis results in acute adrenal insufficiency

antiarrythmics 1. procainamide + SE 2. synchronized DC cardioversion 3. lidocaine + SE

1. antiarrhythmic used to treat both supraventricular and ventricular arrhythmias SE= drug induced lupus, agranulocytosis, QT prolongation 2. used to treat afib/aflutter 3. ventricular arrhythmias in ACS patients, ****increases risk of asystole SE = confusion, seizures, resp. depression

tetralogy of fallot

MCC cyanotic heart disease,dyspnea, growth retardation, clubbing, polycythemia Tet-spells - patient squats to inc. SVR CXR shows boot shaped heart

stab wounds and arterial catheterization is associated with what site complication

AV fistulas leading to high output heart failure

av fistula clinical pres

widened pulse pressure, strong peripheral arterial pulsations

situational syncope (autonomic dysreg syncope)

LOC immediatly after urination or other activity

how to distinguish septic shock vs hypovolemic/neurogenic shock

septic shock has high MVO2 from hyperdynamic circulation and improper distribution of CO

851.

852.

853.

854.

855.

856.

857.

858.

859.

860.

hypovolemic and neurogenic shock have dec. MVO2 from inc. oxygen extraction

...

how do OCPs cause hypertension

inc. angiotensinogen by the liver in 5% of users

amyloidosis 1. causes 2. clinical pres

1. MM (AL), RA, IVDU other chronic inflammatory conditions 2. restrictive cardiomyopathy, easy bruisability (liver involvement), renal impairment/nephrotic range proteinuria, hepatomegaly, cardiomyopathy, pseudohypertrophy, peripheral neuropathy

in what specific situation is beta blocker contraindicated in MI

pulmonary edema

endocarditis 1. clinical pres 2. complications

1. non-specific symptoms - fever, malaise, 2. mycotic aneurysm, abdominal abscesses*, septic PE, renal abscess, conjunctival hemorrhage, janeway lesions, (erythematous macules) oslers nodes (nodules on fingers/toes),

why is nifedipine contraindicated STEMI

causes vasodilatation and reflex tachycardia

- diltiazem and verapamil dont help either

...

amiodarone side effects

pulmonary (cumulative) fibrosis, elevated LFTs, corneal deposits, blue gray skin discoloration, hypothyroidism*

slows SA/AV node conduction thus can cause bradycardia

...

cocaine mediated cardiac ischemia 1. tx 2. why are pure beta blockers contraindicated

1. benzos*, nitrates, aspirin 2. they lead to unopposed cocaine mediated alpha vasoconstriction' *choose a CCB insted to control vasospasm

861.

862.

863.

864.

865.

866.

867.

868.

869.

what is the cause of inc. orthostatic hypotension with increased age + what other changes to the heart with age

progressively decreasing baroreceptor sensitivity *

worsening diastolic function, dec. resting/maximal CO. dec. # of myocytes

...

how does the kidney adapt to respiratory alkalosis

excreting bicarbonate in the urine

what are poor prognostic indicators during an asthma attack

NORMAL PaCO2 - because it should be low 2/2 hyperventilation

others - speech difficulty, diaphoresis, altered sensorium, cyanosis, silent lungs

...

what decreases mortality in COPD

home oxygen smoking cessation

indication for NIPPV

respiratory distress pH 45, RR>25/min

complete opacification of a SINGLE lung with shifted mediastinum

indicates a collapsed lung, should look for bronchial lesion with bronchoscopy -- causes include mucus plugging, tumor, foreign body

reyes syndrome 1. patho 2. tx

hepatic encephalopathy in children associated with viral infections and salicylates - mitochondrial injury --> extensive fatty vacuolization of the liver without inflammation 2. glucose, FFP, mannitol (for cerebral edema)

870.

871.

872.

873.

874.

875.

876.

877.

878.

879.

880.

881.

legionella pneumonia 1. clinical pres 2. treatment 3. dx

hypoventilation syndrome

1. refractory to beta lactam (also mycoplasma), HYPONATREMIA CONFUSION, ABDOMINAL PAIN, DIARRHEA acute onset fever, malaise, headache, non-productive cough, dyspnea, 2. erythromycin or azithromycin 3. HYPONATREMIA, organism negative smear (only polymorphs) consequence of severe obesity and untreated OSA, chronic hypercapnia/hypoxic resp. failure, secondary erythrocytosis, low serum Cl, hypertension, cor pulmonale

882.

883.

884.

885.

aspirin sensitivity syndrome

pseudo allergic reaction - 2/2 aspirin induced prostaglandin/leukotriene imbalance * tx = leukotriene receptor antagonist

886.

what conditions will increase fecal fat

bacterial overgrowth, pancreatic insufficiency, celiac disease, crohns disease

887.

D-xylose test

simple sugar that does not need to be digested to be absorbed tests for INTACT MUCOSA OF PROXIMAL SMALL BOWEL ONLY ONLY - THUS if pancreatic insufficiency is present D-xylose absorption/excretion will not be effected

888.

acid fast oocysts

cryptosporidium parvum - chronic diarrhea in HIV patients with CD41-2 years failure to respond to PPI

^ALARM SYMPTOMS

...

GI bacterial overgrowth nutrient defiencies

Vitamin D Vitamin A - night blindness B12 - neuropathy

what vitamin deficiency in carcinoid syndrome

niacin - used to synth seratonin/5HIAA metabolites

which type of polyps are most likely to progress to malignancy

villous adenoma, sessile adeoma, size >2.5cm

889.

890.

891.

892.

893.

what GI pathology is often associated with elevated BUN

upper GI bleeding

two situations where you can see elevated BUN without elevated Cr

upper GI bleeding steroids

1. vitamin E deficiency clinical pres 2. Vitamin C """

1. RBC fragility, hyporeflexia, muscle weakness, blindness 2. perifollicular hemorrhage, swollen gums, poor wound healing

most common complication in UC

colon cancer (1% per year)

gallstone risk factors

caucasian race, obesity, female, OCP, DM, hypomotility of gallbladder (preg), ileal disease, clofibrate, octreotide, ceftriaxone

pancreatic pseudocyst treatment

5cm - drain

liver histo findings 1. balloon degeneration with inflamm cells 2. panlobular mononuclear inflammation 3. piecemeal necrosis

1. acute alcoholic hepatitis 2. acute viral hepatitis, bridging necrosis (confluent hepatic necrosis between adjacent lobules) 3. inflammatory cells extend between portal ducts with periportal bridging fibrosis

how to evaluate liver damage in acute vs chronic hepatitis

acute - LFTs chronic - liver biopsy

causes of liver biliary ductopenia

PBC, transplant rejection, hodgkins disease, GVHD, sarcoid, CMV/HIV

entamoeba histolytica 1. patho 2. clinical pres 3. dx/tx

1. contaminated water in endemic region (south america) 2. bloody diarrhea, RUQ pain 3. THIN WALLED CYST IN RIGHT LOBE OF LIVER, sterile aspirate, stool exam shows trophozoites tx = metronidazole -- DO NOT DRAIN (compare to echinococcus)

What should all cirrhotic patients be screened for

esophageal varices HCC - (AFP)

what is the risk associated with porcelain gallbladder

2/2 chronic cholecystitis

894.

895.

896. 897.

risk is cancer of the gallbladder

...

906.

when to give hep A Ig vs hep A vaccine

give immunoglobulin if travel will occur in less than 4 weeks

907.

otherwise give vaccine

...

uric acid stones 1. dx 2. tx

1. radiolucent stones on KUB, acid urine pH