Medi

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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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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614.

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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623.

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

637.

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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643.

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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647.

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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660.

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

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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

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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

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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

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720.

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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

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728.

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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.

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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.

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762.

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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

...

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768.

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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.

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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

...

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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