2. HB Clinical Medicine Flashcards
CBC
• Most basic test we can order > CBC ○ L: saw horse ○ Basic CBC > \_\_\_\_, Hbg, \_\_\_\_ and platelets ○ Important to understand liver status • Can be drawn by an X • There's an expanded > when getting a differential of the \_\_\_\_ ○ Can include \_\_\_\_ indices
WBC
Hct
WBC
RBC
Platelet count (Plt) • Range: 150,000 - \_\_\_\_ cells/mm3
- High (thrombocytosis)
- ____ reactions, blood d/o, ____, post- splenectomy
- Low (thrombocytopenia)
- ____ (due to portal hypertension)
- associated with ____• Higher than normal > thrombocytosis
• Lower than normal > thrombocytopenic
○ Problematic in that you may alter treatment based on how low
§ <50k > consult physician if patient needs ____ esp in a lot of bleeding
□ <20k may see ____ bleeding in oral cavity
400k
inflam
malignancy
hypersplenism
liver cirrhosis
platelet infusion
spontaneous
Liver Function Assessment
LIVER INJURY TESTS (enzymes)
____, ALT, ____
TESTS OF SYNTHETIC FUNCTION
____, prothrombin time
MARKER OF HEPATIC TRANSPORT CAPABILITY
Serum ____
• Liver injury tests • Tests of synthetic function • Marker of hepatic transport capabilty ○ Cricial lab values that request from physicain in a patient that we know has liver disease in order to make sure they're stable for treatment
AST
ALP
albumin
bilirubin
Aspartate aminotransferase (AST) • \_\_\_\_ [serum glutamic oxaloacetic transaminase] • Released from injured \_\_\_\_ • Range: \_\_\_\_ U/L • AST > ALT in \_\_\_\_ liver disease • \_\_\_\_:1
* Old name = SGOT * Liver disease > has more AST * Can look at AST/ALT values > can tell the etiology of the disease usually
SGOT hepatocytes 8-33 alcohol-realted 2
Alanine aminotransferase (ALT)
- ____ [serum glutamic pyruvic transaminase]
- Released from injured ____
- Range: ____ U/L
- ALT > AST in ____
- ____:1• Can look at just lab test and look at just ALT and AST and figure out the disease type
SGPT hepatocytes 4-36 viral hepatitis 10
Alkaline phosphatase (ALP) • Released from injured hepatocytes (often due to \_\_\_\_ obstruction) • Range: \_\_\_\_ U/L • high = \_\_\_\_, cholestatic liver dz., \_\_\_\_ dz., hyperparathyroidism, \_\_\_\_, osteomalacia • low = \_\_\_\_, hypothyroidism
• Pagets/OM = bone disorders
biliary 20-130 ESLD metastatic pagets scurvy
Albumin
- Protein synthesized in ____ • ____% of total protein
- Range: ____g/dL
- Low = ____ disease, malnutrition, ____
liver 65 3.5-5.0 liver dehydration
activated Prothrombin Time (aPT)
• Screening test to identify acquired or inherited deficiencies in the activities of factors ____, prothrombin and ____
• Monitor oral anticoagulant therapy with ____, which decreases the activity of ____ and prothrombin
• Range = ____s
* Order regularly in a clinic setting * Pt > patients on warfarin (coagulant) > affected by warfarin > assessing their Pt and their INR
V, VII, X fibrinogen warfarin VII, IX, X 10-12.5
aPT
• Prolongation of the aPT occurs when there is:
- ____ disease
- ____ deficiency
- Disseminated ____ coagulation
- ____ Syndrome
- Treatment with certain antibiotics, chemotherapeutics, or antithrombotic drugs
• Elevated PT > coagulation issue
liver
vitamin K
intravascular
nephrotic
INR: International Normalized Ratio
• Mathematical “____” (of the ____ ratio) for differences in the sensitivity of thromboplastin reagents
• Relies upon “____” thromboplastins
• Allows for comparison of results between labs and standardizes
reporting of the activated prothrombin time
• Range=____
• Primary test clinically > INR ○ Activated PT > differences in values that couldn't be standardized based on diff reagents used § Couldn't get a standard number > INR created to correct that • Important to understand INR in context of PT; look at both! ○ If PT is sig elevated > and INR is normal > still not \_\_\_\_ • 1.0 is a normal value for someone who is not anticoagulated
correction aPT reference 0.8-1.2 normal
activated Partial Thromboplastin Time (aPTT)
• Screening test to identify acquired or inherited deficiencies in the activities of Factors ____
• Monitor ____ anticoagulation
• Screening test to assess reduction in the activity of fibrinogen, Factors ____
(____ more sensitive)
• Range = ____s
• Clinically > heparinized (patients are usually hospitalized, or on low MW heparin) ○ Blood thinner is usually warfarin, but some heparin patients in hospital • Range is diff from aPT
IX, VIII and XI heparin V and X PT 25-41
Serum bilirubin
• Breakdown product of ____ that is transported / metabolized by liver
• Total (____ mg/dl)
- Increased in patients with:
- ____
- Cirrhosis
- ____ obstruction
- Hemolysis
- ____• Hyperbilirubinemia > common in ____
○ Liver isn’t processing RBC as quickly
○ Look jaundiced > go under special light to break up the pigment
○ Common finding in newborns to determine how well liver is functioning
hemoglobin 0.3-1.0 hepatitis biliary fasting newborns
Cirrhosis
- A late stage of progressive hepatic ____ characterized by distortion of the hepatic architecture and formation of ____ nodules
- Compensated vs. Decompensated
- Considered ____
- Only therapeutic option may be liver ____• Clinically > is patient is compensated or decompensated
○ Comp: functioning ____
○ Decomp: develop the ____ > the stigmata of liver disease
○ A question asked if patient is aware of medical status
fibrosis regenerative irreversible transplanation actively sequalae
• Irregualr surface and nodules > ____ appearance
Natural history of CLD • CLD > progress > compensated (liver funcitons and maintains homeostasis) > transition marked by things that may present in oral cavity or on the face: ○ \_\_\_\_ hemorrhage ○ Ascites ○ \_\_\_\_ (altered mental) ○ Jaundice § Can see it on the \_\_\_\_ • Then decompensated > higher risk for death
variceal
encephalopathy
gingiva
Decomp shortens survival
• Survival times in cirrhosis ○ 260 patients who had comp cirrhosis ○ Median survival of all w cirrhosis: \_\_\_\_ years; but those w sequalae of decomp > \_\_\_\_ years § Difference in life expectancies
9
1.6
I : Confirming the diagnosis
- ____ examination findings
- ____ testing findings
- ____ showing evidence of portal hypertension (with varices)
- May present ab initio with one of the life threatening complications
- Histologically (____): GOLD STANDARD
- Discovered incidentally at ____ or autopsy
physical radiologic endoscopy biopsy surgery
Physical Examination Findings Jaundice
• Patient is jaundiced
○ ESLD
• Yellowing of ____
Physical Examination Findings Palmar Erythema • Palmar erythema ○ \_\_\_\_ change w ESLD § Redness § Can be decompensated
Physical Examination Findings Spider Angiomas
• Spider angiomas
○ Cirrhosis/ESLD
○ Not always in obvious position, can see on ____
Physical Examination Findings Ascites
• Portal hypertension and fluid retention > ascites
○ Don’t do dentistry > end stage liver dx > should be in the ____
Physical Examination Findings Hepatic Encephalopathy
• Hepatic encephalopathy
○ Altered mental status:
○ I: ____ changes
○ II: ____, flapping tremor and muscle ____
○ III: ____, loud and ____
sclera vascular neck hospita; personality lethargy twitching noise violent
Radiologic diagnosis
* Liver on an axial view * \_\_\_\_ of the liver, no smooth surface > representative of liver cirrhosis
nodularity
Endoscopic Diagnosis
Varices
• Endoscopic diagnosis ○ Looking for varices > rupture and you will see blood in the \_\_\_\_ lumen > difficult to stop the bleeding
esophaegeal
Histologic Diagnosis
Cirrhosis is defined by the presence of ____ septa that diffusely involve the liver and ____ the parenchyma into nodules
• Gold standard = \_\_\_\_
fibrosis
subdivide
histologic dx
II : Determining the etiology
\_\_\_\_
\_\_\_\_
\_\_\_\_
\_\_\_\_ ingestion
• Once pt comes in and they have symptoms of liver dx > what is causing it? ○ Focusing on viral and alcohol related § But genetic and autoimmune is also seen
viral
autoimmune
genetic
toxic
Viral Hep - overview
A Source of virus: \_\_\_\_ Route of xmission: \_\_\_\_ Chfronic infection: \_\_\_\_ Prevention: \_\_\_\_
B Source of virus: \_\_\_\_ Route of xmission: \_\_\_\_ Chfronic infection: \_\_\_\_ Prevention: \_\_\_\_
C Source of virus: \_\_\_\_ Route of xmission: \_\_\_\_ Chfronic infection: \_\_\_\_ Prevention: \_\_\_\_
D Source of virus: \_\_\_\_ Route of xmission: \_\_\_\_ Chfronic infection: \_\_\_\_ Prevention: \_\_\_\_
E Source of virus: \_\_\_\_ Route of xmission: \_\_\_\_ Chfronic infection: \_\_\_\_ Prevention: \_\_\_\_
feces
fecal-oral
no
pre/post-exposure immunization
blood/blood-derived body fluids
percut permucosal
yes
pre/post-exposure immunication
blood/blood-derived body fluids
percut permucosal
yes
blood donor screening; risk behavior mod
blood/blood-derived body fluids
percut permucosal
yes
pre/post-exposure immunization; risk behacvior mod
feces
fecal-oral
no
ensure safe drinking water
Estimates of acute and chronic disease burden for viral hepatitis
• Estimated burden of disease • Chronic inf mostly related to \_\_\_\_ and \_\_\_\_ ○ HBV ○ HCV § Shown to be more than \_\_\_\_!
HBV
HCV
HBV
Hepatitis A Virus
• ____
• Single ____ worldwide
• Acute disease and asymptomatic infection
• No ____ infection
• Protective ____ develop in response to infection
• Confers lifelong ____
* One serotype worldwide > easy to develop vaccine * Endemic outbreaks of HPA > from restaurants, food
rna picornavrius serotype chronic abs immunity
Geograph distribution of HPA
• HPA vaccine is recommended for people who \_\_\_\_ or work in areas where the prevalence is high
travel
HPA transmissino
- viral infection of the liver spread when ____ matter enters the mouth
- may last several weeks and can be debiliatting but most people ____ completely
- preventable w careful ____, keeping toilets and bathrooms clean, avoiding infected water sources
• Symptoms ○ \_\_\_\_ ○ Vomiting ○ (High \_\_\_\_) • Spread by ○ Direct \_\_\_\_ ○ Food/beverages ○ \_\_\_\_ and spoons
fecal
recover
hand washing
nausa
fever
contact
cups
Hepatitis A : Clinical Features
• Jaundice by age group:
<6 yrs 6-14 yrs >14 yrs
<10% 40%-50% 70%-80%
• Rare complications: \_\_\_\_ hepatitis \_\_\_\_ hepatitis \_\_\_\_ hepatitis • Incubation period: Average \_\_\_\_ days Range 15-45 days • Chronic sequelae: \_\_\_\_
• Jaundice is primarily in patients >\_\_\_\_ years of age (younger kids usually do not!) • Rare complications ○ Different types of liver complications • Will take a month for someone to develop HPA infection w symptoms ○ Tough to go back and trace what people were doing ○ Two weeks to month and half
fulminant cholestatic relapsing 25 none 14
Prevention of Hepatitis A • \_\_\_\_ (e.g., hand washing) • \_\_\_\_ (e.g., clean water sources) • Hepatitis A \_\_\_\_ (pre-exposure) • Immune \_\_\_\_ (pre- and post-exposure)
hygiene
sanitation
vaccine
globulin
Hepatitis D (Delta) Virus
• Co-infection with ____
– Severe, acute disease
– low risk of ____ infection
• Super-infection
– usually develop chronic ____ infection
– high risk of severe, ____ liver disease
• Don't see it often • No HBV > cannot get HBD ○ Exam question • Can be infect w HBV, and then HBD can come in > superinfection
HBV
chronic
HDV
chronic
Hepatitis E
• Small, ____-stranded 7.5 kb ____ virus
• Most outbreaks associated with ____-contaminated drinking water
• Minimal ____ transmission
• U.S. cases usually have history of ____ to HEV-endemic areas
• Fecally-contam drinking water > similar to HPA
single RNA fecally person-to-person travel
Hepatitis E - Clinical Features
• Range:
____ days
• Case-fatality rate:
Overall, 1%-3%
____ women 15%-25%
• Illness severity:
Increased with ____
• Chronic sequelae:
____ identified
15-60
pregnant
age
none
