4 star topics Flashcards
Most common causes of acute pericarditis
Viral infections - HIV Bacterial - TB especially Neoplasms - mets or primary Trauma (CPR, cardiac surgery) Complications of MI (Dressler's Sn 2-4 weeks post MI) Rheumatologic disease (SLE, RA) Renal failure - uremic pericarditis Radiation Drugs
Clinical findings suggestive of acute pericarditis
Pleuritic CP - worse with coughing or inspiration; worse when supine; better when sitting up and leaning forward
PE: pericardial friction rub
Testing:
ECG - diffuse ST elevation, PR depression
ECHO: pericardial effusion - usually transudative; exudative - neoplasm, TB; absent does not r/o
CXR: usually nl, may show enlarged cardiac silhouette - canteen heart
Treatment of acute pericarditis
NSAIDs - ibuprofen, indomethacin
Colchicine
If no response in 1-2 weeks, look for other cause - neoplasm, bacterial, SLE, recent MI
Causes of cardiac tamponade
pericarditis
hemorrhage - chest trauma, aortic dissection
Physical exam findings suggest cardiac tamponade
Beck’s triad: hypotension, JVD, muffled heart sounds
Pulsus paradoxus - decreased capacity of LV
-SBP decreases >10 mmHg with inspiration
Diagnostic tests in cardiac tamponade
ECHO - pericardial effusion/fluid, collapse of ventricles
ECG: low voltage, electrical alternans
Main causes of acute pancreatitis
PANCREATITIS
hyperParathyroidism Alcohol Neoplasm Cholelithiasis Rx - NRTIs (didanosine, zalcitabine, stavudine), Ritonavir, Sulfanamides Ercp Abdominal surgery hyperTriglyceridemia Infection - mumps Trauma Idiopathic Scorpion sting - not in US
Presentation and Diagnostic testing for acute pancreatitis
Rapid onset of severe epigastric abd pain
- may radiate to back
- Worse with eating -> sitophobia
N/V
Intravascular depletion -> tachycardia, hypotension/shock, multi organ failure
Cullen/Grey turner sign
Dx:
Elevated lipase (and amylase) - not indicative of severity
Ranson critieria for severity/prognosis
Best radiology study: CT scan - enlarged, inflamed, may show pseudocyst
Abd XR: dilated loop of bowel near pancreas “sentinel loop”; elevation of diaphragm, pleural effusion
Ranson criteria
Severity of pancreatitis - one point for each
On admission: GA LAW Glucose >200 AST >250 LDH >350 Age >55 WBC > 16,000
During first 48 hours: CALvin and HOBBeS Serum calcium less than 8 Hematocrit decrease >10% paO2 less than 60 Base deficit >4 BUN increase >5 Sequestration of fluids >6L (bad sign)
0-2 points = 0-3% mortality
3-5 points = 11-15% mortality
6-11 points = >40% mortality
Management of acute pancreatitis
IVF NPO NG suction - ppx for N Correct electrolyte abnormalities Opioids for pain control - use meperidine (morphine can cause sphincter of Oddi spasms)
If not tolerating referring -> Nasojejunal feeding (won’t stimulate pancreas) or TPN
Cholecystectomy if caused by choledocholithiasis
Complications of pancreatitis
Respiratory failure Renal failure Shock Sepsis DIC Hemorrhage
Pancreatic necrosis, abscess, pseudocyst
Chronic pancreatitis
Most common cause of chronic pancreatitis
alcoholism
Symptoms suggestive of chronic pancreatitis
recurrent epigastric pain
N/V
Fat malabsorption/steatorrhea
Best lab test for diagnosing chronic pancreatitis
fecal elastase is low
XR/CT - calcifications, enlarged ducts
MRCP
Management of chronic pancreatitis
Stop etOH use Stop smoking Opioids for analgesia Pancreatic enzymes Vitamin supplements Small, low fat meals
Surgery to decompress dilated duct, resect part of pancreas
Complications of chronic pancreatitis
Pseudocysts - resolve on one, or drain if complications, pain or not resolving
Obstruction of bile ducts/duodenum
Malnutrition
glucose intolerance/DM
pancreatic cancer
Pancreatic pseudocyst vs true cyst
Pseudocyst: fluid contained by inflammatory tissue
Cyst - fluid contained by epithelial tissue
Complications of pancreatic pseudocyst
rupture abscess pseudo aneurysm - erosion into adjacent blood vessel with hemorrhage into pseudocyst -painful as it expands rapidly -dangerous
Test to distinguish pseudocyst from cystic pancreatic neoplasm
Aspirate fluid via CT guided percutaneous aspiration or endoscopic U/S needle aspiration
Pseudocyst fluid high in amylase
Systemic lupus erythematosis (SLE)
MC in women, AA
Onset black women 15-45, all others 40-60
Features: 4 out of 11 over time
- Malar rash
- Discoid rash
- Photosensitivity
- Painless oral ulcers
- Arthritis - inflammatory, non erosive, affects at least 2 joints
- Serositis - pericarditis, pleuritis, pleural effusion
- Renal disorders - glomerulonephritis, proteinuria, renal failure - cause of death
- Neurologic disorders - seizures, psychosis, peripheral neuropathy
- Hematologic disorders - hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
- ANA high (1:160, 1:320)
- Immunologic disorder - anti-dsDNA, anti-Smith, antiphospholipid antibodies
Diagnostic testing:
ANA, anti-dsDNA, anti-Smith, antiphospholipid
Low C3 and C4
Anti-histone Ab - drug induced
Tx:
Avoid sun exposure
Hydroxychloroquine, NSAIDs, glucocorticoids
Complications:
- Hypercoagulability - lupus anticoagulant, anticardiolipin Ab, antiphospholipid Ab
- Immunocompromised
- CV disease
- Renal failure
Drugs associated with drug induced lupus
SHIPP
Sulfonamides Hydralazine Isoniazid Phenytoin Procainamide
Anti-histone Ab
Polymyalgia reumatica (PMR)
Strongly associated with Giant Cell Arteritis
MC: elderly women
Joint pain and stiffness in shoulders, neck, and/or hips
No muscular weakness
significantly elevated ESR and CRP
Anemia common
Negative serologic markers - ANA, RF
MRI or PET show synovial inflammation
Tx:
Low-dose glucocorticoids (15-20 mg/day) for 2-4 weeks, then gradual taper over 1-2 years
Polymyositis and dermatomyositis
Progressive, symmetric weakness of proximal limb muscles - hip flexors, shoulders, deltoids; trouble climbing stairs, raising hands over head
Minimal muscle soreness/tenderness
Skin manifestations in dermatomyositis:
- malar rash
- heliotrope rash on eyelids
- Gottron’s papules on knuckles, elbows, or knees
- Mechanic hands (hyperkeratosis and cracking of hands or feet)
- “Shawl sign” on shoulders
- “V sign” on anterior chest
Dx testing:
Elevated CK, ALT, AST, andaldolase
ANA frequently positive
ANTI-JO1 - antisynthetase Ab
EMG distinguishes muscle pathology from nerve pathology
MUSCLE BX - muscle fiber degeneration and inflammatory cells
Tx:
High dose glucocorticoids for 4-6 weeks, then gradual taper
Methotrexate or azathioprine - may reduce duration of glucocorticoid tx
Complication: risk of malignancy - breast, prostate, colon, lung
Fibromyalgia
Increased sensitivity to pain without specific cause
Risk: women 20-50
Assoc with inflammatory rheumatologist dz (RA, SLE), depression, IBS
Features:
Widespread muscle and joint swelling or inflammation
Multiple tender trigger points
Severe fatigue
Sleep disturbance
Depression or anxiety in at least 30% of patients
Cognitive disturbance - “fog”
Labs and XR normal
Tx: Non pharm: -Reassure -stretching exercises -sleep hygiene -Address psych issues - depression, anxiety, ptsd
Pharm: Acetaminophen and NSAIDS - avoid opiates Pregabalin SNRIs - fluoxetine, milnacipran, venlafaxine Sleep aids as needed
Systemic sclerosis (scleroderma)
Excess collagen deposition in skin and other tissues
Diffuse cutaneous systemic sclerosis
Limited cutaneous systemic sclerosis
Tx:
Supportive care - PPI, CCB, ACE-I
Tx severe skin sclerosis with methotrexate, mycophenolate, or cyclophosphamide
Diffuse cutaneous systemic sclerosis (dcSSc)
Widespread sclerosis involving skin and visceral organs
Progresses rapidly, early involvement of visceral organs
Skin may appear shiny and lack wrinkles - finger contractions and ulcerations
Assoc with anti-DNA topoisomerase 1 Ab - anti-Scl 70 and/or anti-RNA polymerase Ab
Limited cutaneous systemic sclerosis (lcSSc)
Skin involvement limited to hands +/- face and neck
Less visceral involvement; progresses less rapidly
CREST syndrome: Calcinosis cutis: calcifications in deep layers of the skin, often in fingers Raynaud phenomenon Esophageal dysmotility - LES sclerosis Sclerodactyly Telangiectasis - lips, hands, or face
Assoc with anti-centromere Ab
Sjogren syndrome
Exocrine glands
Clinical features:
Xerophthalmia - dryness, conjunctivitis, sensation of sand in eyes
Xerostomia - dysphagia, enlarged parotid glands, dental caries
Arthritis
Nasal dryness
Vaginal dryness
Dx:
Anti-SSA aka Anti-Ro Ab
Anti-SSB aka Anti-La Ab
Tx:
Dry eyes: artificial tears, cyclosporin eye drops
Dry mouth: muscarinic agonists - pilocarpine, cevimeline
Arthritis: hydroxychloroquine or methotrexate
Osteoarthritis aka DJD
Joint degeneration with erosion of articular cartilage
Risk: aging, obesity, joint injury
Features:
Noninflammatory arthritis of hips, knees, ankles, hands/feet, spine
Pain worse with use, better with rest
No systemic sxs
Assymmetric arthritis with boney enlargement of DIP joints (Heberden’s) and PIP (Bouchard’s)
Dx:
XR: osteophytes and joint space narrowing
ESR normal, no Ab
Tx: Prevent overuse, provide rest periods Wt loss Acetaminophen, NSAIDs, or celecoxib Glucocorticoid joint injections Hyaluronic acid joint injection Joint replacement for severe disease
Rheumatoid arthritis (RA)
Type III hypersensitivity reaction -> immune complexes deposited in tissues -> joint inflammation and pannus formation (synovial hypertrophy, granulation tissue on articular cartilage)
Risk: Women, HLA-DR4
Features:
Chronic inflammatory arthritis - hands, wrists, large joints
Morning stiffness
Pain and stiffness worse with rest, improves with use - gel phenomenon
Systemic sxs: subcutaneous nodules, pleuritis, pericardiits, scleritis
Swelling of MCPs and PIPs - Boutonniere and swan neck deformities
Ulnar deviation of fingers (away from thumb)
Dx:
elevated ESR and CRP
Positive RF - anti IgG Ab
Positive anti-citrullinated protein antibodies (ACPA)
Treatment of RA
DMARDs, with adjuncts of steroids or NSAIDs
Drugs in MSK treatment notecards
Psoriatic arthritis
Patterns of arthritis:
Assymetrical, inflammatory arthritis involving DIP joints
Symmetrical arthritis like RA
Severe, mutilating arthritis (arthritis mutilans)
Spondyloarthritis
Dactylitis - sausage fingers Anterior uveitis (inflammation of iris and ciliary bodies) or conjunctivitis
Dx:
HLA-B27
Seronegative (negative RF, ANA)
XR: fingers “pencil-in-cup” deformities
Tx:
NSAIDs or celecoxib
Methotrexate, leflunomide, or TNF alpha inhibitors
Ankylosing spondylitis
White Men 20-30s
LBP worse with inactivity, improves with exercise
Reduced spine mobility - abnormal Schober test
Possible hip and shoulder pain
Anterior uveitis - eye pain, blurred vision, photophobia
CV Dz - aortic regurg, conduction disturbances
Dx:
HLA-B27
Negative RF, ANA
XR pelvis - sacroilitis and SI joint fusion
XR L-spine - vertebral fusion “bamboo spine”
Tx:
PT and exercise
NSAIDs or celecoxib continuously
TNF alpha inhibitors
Paget disease of bone
Focal areas of excessive bone remodeling (overcast overactivity -> osteoblast overactivity)
-axial skeleton, long bones of legs
Presentation: asx or bone pain arthritis bone deformity - bowed tibias, kyphosis Increased risk of fx hearing loss increased skull circumference - hat doesn't fit
Dx:
Elevated alk phos - marker of osteoblast activity
XR: osteolytic lesions and hyper dense sclerotic lesions
Radionuclide bone scan: “hot spots”
Tx: bisphosphonates or calcitonin injections
Risk: osteosarcoma
Anterior shoulder dislocation
MC
Arm position: external rotation and slight abduction
Bankart lesion - Tears anterior labrum and capsule of shoulder
Axillary artery and nerve at risk
Classic scenario: Blow to abducted, externally rotated, extended arm - block a basketball shot
Physical exam: Prominent acromion (if thin pt), loss of shoulder roundness
Posterior shoulder dislocation
Arm position: internal rotation and adduction
Unable to externally rotate
XR: “light bulb” on AP view
Neurovascular compromise unusual
Classic scenario: blow to anterior shoulder, seizure, electrocution
Exam: posterior prominence and anterior shoulder is flat
