Cardiology Flashcards
Difference between MI and stable angina?
MI persists >30 mins and is NOT relieved by rest.
Findings for acute MI? Cardiac auscultation finding with Acute MI? (2)
Chest pain (heavy, squeezing, crushing pain localized to the retrosternal area or epigastrium sometimes radiating to the arm, lower jaw or neck)S4 - myocardial noncomplianceS3 - severe systolic dysfunction
ECG signs of Acute MI (4 Stages)
- Earliest: hyperacute T-waves (in the ischemic vascular territories) 2. ST elevation 3. Over hours to days: T-wave inversions4. Diminished R-wave amplitudes = Q-waves - significant myocardial necrosis and replacement of scar tissue
When does ST elevation occur?ST depression?
ST elevation - Acute transmural ischemiaST depression - Acute subendocardium ischemia
Definition of STEMI?
ST-segment elevations more than 1 mm (0.1 mV) in 2 or more contiguous leads (i.e. same vascular territories)
Elevations in Leads II, III, aVF
Inferior surface of the heart supplied by RCA
Elevation in V2 to V4
Anterior surface of the heart supplied by the Left Anterior Descending (LAD)
Elevation to Leads I, aVL, V5, V6
Lateral surface of the heart supplied by the LCX (Left circumflex coronary artery)
Rise and fall of:1. Creatine Phosphokinase (CK)(while CK is found in skeletal muscles and other tissues, CK-MB is not found in significant amounts outside of heart muscle)2. Cardiac specific troponin I and troponin T (cTnI, cTnT) - more specific to heart muscle and preferred markers for myocardial injury.
CK: rise within 4-8hrs. return to normal 48-72 hrs.
cTnI, cTnT: rise within 3-5 hours after infarct. cTnI remain elevated for 7-10 days. cTnT remain elevated for 10-14.
Other Dx with chest pain made worse with anticoagulants.
Aortic Dissection - unequal pulses or pressures in the arms, new murmur of aortic insufficiency, widen mediastinum
Acute pericarditis - pericardial friction rub, diffuse ST elevations
What is the management for Acute MI?
Antiplatelet agents: Aspirin, heparin
Beta-blockers - decrease myocardial oxygen demand
Nitrates - increase coronary blood flow
Morphine - pain, tachycardiaO2
Percutaneous Coronary Intervention (preferred for most) or Thrombolytics
What criteria are met for thrombolytic therapy? (5)
- Chest pain consistent with ischemia
- No contraindications to thrombolytics
- Age < 75 y.o.
- ST segment elevations more than 1 mm in at least 2 anatomically contiguous leads
- MI within 2-6 hours or within 12 hours with persistent chest pain + ST elevations
What criteria are met for PCI? (3)
Preferred method
- <1 hour-90 mins to reperfusion and/or
- contraindications to lytic therapy and/or
- hypotensive or in cardiogenic shock
Sinus Bradycardia is often seen with MI to which heart wall?
Inferior. RCA supplies the inferior wall of the left ventricle and the sinoatrial node.
What steps are taken for secondary prevention after a myocardial infarction to prevent recurrent cardiac events and death?
Smoking cessation Anti-platelets: Aspirin and clopidogrel Beta-blockers Ace-inhibitors Statins
Cardiogenic shock
Hypotension with systolic BP < 80mmHg
Reduced cardiac index less than 1.8 L/min/m^2Elevated LV filling pressure (pulmonary wedge pressure >18mmHg)Due to left ventricular pump failureEvaluated via Swan-Ganz catheterization
What mechanical complications can occur within 1 week of a MI? (4)Tx?
1a. Papillary muscle dysfunction - cause mitral regurgitation that is hemodynamically significant
1b. Papillary muscle rupture - acute mitral regurgitation1c. Ventricular septal rupture
2. Rupture of ventricular free wall - filling of the pericardium, cardiac tamponade develops rapidly with sudden pulselessness hypotension. Almost Always fatal.
Use Doppler echocardiography to distinguish.Tx: Intravenous nitroglycerin or nitroprusside (after load reduction) or aortic balloon until definitive surgical repair can be done.
What late complications can occur after an MI?
- Ventricular aneurysms - if ST elevations persists weeks after the event
- Dressler’s syndrome - immune –> pericarditis, pleuritis, and fever
What is mortality in MI caused by? Management?
Ventricular arrhythmia (VT, VF), pump failure –> cardiogenic shock.
Direct current (DC) cardioversion or defibrillation followed by intravenous antiarrhythmics such as amiodarone
If bradycardia –> atropine
Symptomatic bradycardia –> pacemaker
Diastolic dysfunction
Symptoms
Impaired diastolic relaxation and decreased ventricular compliance, but with preserved ejection fraction > 40% to 50%
Dysnea, peripheral edema, ascites
Systolic dysfunction
Symptoms
Low cardiac output by impaired systolic function ( EF < 40%)Fatigue, lethargy, hypotension
Therapy for Congestive Heart Failure
Decrease mortality:
ACE inhibitors - Reduce preload and afterload so reduce right atrial, pulmonary pressures along with systemic vascular resistance and prevent remodeling.
Beta Blockers - prevent and reverse adrenergically mediated intrinsic myocardial dysfunction and remodeling
Aldosterone Antagonist
Salt restriction
Diuretics - decrease preload
Nitrates (vasodilators) - reduce preload, and clear pulmonary congestion
Digoxin - improve cardiac contractility
What devices are useful in heart failure?
If widen QRS > 120 ms, dysynchronous ventricular contraction –> Cardiac resynchronization therapy (CRT), a biventricular pacemaker.
Patients with EF Implantable cardiac defibrillator (ICD)
Most common symptomatic valvular abnormality in adults? Underlying etiology for 70y.o..
Aortic Stenosis
< 30 y.o. - congenital bicuspid valve
30-70 y.o. - congenital stenosis or rheumatic heart disease
>70 y.o. - degenerative calcific stenosis
Premature Ventricular Complexes
Treatment
Wide QRS, bizarre morphology, compensatory pause
Often in those with cardiac pathology and after an MI. Sometimes worsened with antiarrythmics, so don’t give unless symptomatic. First line: B-blockers. Second line: Amiodarone
Size of the boxes
Normal Range for PR, QT, QRS.
Large boxes: 0.2 sec
Small box: 0.4 sec
300, 150, 100, 75, 60, 50, 43
PR <0.12
QT
Uses of digoxin
Atrial flutter, fibrillation
What are symptoms of hypercalcemia?
Polyuria
Constipation
Neurological symptoms
Anorexia
Symptoms of Multiple Myeloma
Constipation, HyperCalcemia Renal failure Anemia Back pain, bone lytic lesions Bence Jones in the urine Infections
Diagnosis of Cardiac Tamponade due to large pericardial effusions.
Recent Upper Respiratory Infection
Enlarged Silhouette of the heart “water bottle”
Dysnea, elevated JVP, clear lung fields
Beck’s Triad: hypotension, Elevated JVP, muffled heart sounds
Viral Myocarditis presentation
Recent upper respiratory tract infection, fatigue, dysnea, elevated JVP,
but also S3 heart sound + bibasilar rales + pulmonary vascular congestion seen on imaging.
Fixed splitting of the second heart sound
Atrial Septal defect. Will also see enlarge right atrium and ventricle + prominent hilar or proximal pulmonary arterial vasculature.
Early symptoms of Alzheimer’s
Visual-spatial deficit (lost in own neighborhood)
Anterograde memory loss (remember past memories)
Cognitive deficiency that progresses
Speech impairment
Late findings of Alzheimer’s
Neuropsychiatric (i.e. hallucination, wandering)
Dyspraxia (Inability to performed learned motor skills)
Lack of insight regarding the deficits
Non-cognitive neurologic deficits (pyramidal, and extrapyramidal motor, myoclonus, seizure)
Urinary incontinence
Diagnosis of Alzheimers
Mini Mental Status Examination, Neuropsychological testing, and the following clinical criteria:
Two+ of cognitive deficits
Progressively worsening memory + other cognitive function
No disturbances of consciousness
Age >60
Absence of other systemic or neurological disorder causing the progressive cognitive deficit.
Ankylosing spondylitis
Male:Female 2>1
Morning pain for 30 mins
Low back pain + spine stiffness >3months duration should be investigated.
AP x-ray of sacroiliac joints are used to confirm the diagnosis: showing fusion and a bamboo spine
Paroxysmal Nocturnal Hemoglobinuria
Classic 3 conditions
Hemolytic anemia
Hepatic vein thrombosis
Diminished hematopoesis (anemia)
Craniopharyngiomas
Benign tumor arising from Rathke’s pouch, more common in children, located above Sella Turcica and consists of multiple cysts.
Hypopituitarianism, Bitemporal blindness, headaches
+ amenorrhea in women, +sexual dysfunction in adults, +retarded growth in children
Diagnosis: MRI or CT. Tx: surgery, radiotherapy
What drugs are used during acute exasperations of multiple sclerosis? To decrease the frequency?
corticosteroids
Interferons, Cyclophosphamide, plasmapheresis, IVIG, glatiramer acetate
Chalazion
Painful swelling that progresses to nodular rubbery lesion as a result of obstruction of meibornian glands.
Need histological examination to rule out basal cell carcinoma.
Hordeolum (stye)
Acute infection of one of the glands of the eyelid (due to staph normally). Frequent hot compresses + antibiotics are used to treat.
Torsades de Pointe
Polymorphic ventricular tachycardia associated with a prolonged QT interval.
Usually in those with familial prolonged QT or malnourished individuals (i.e. alcoholism) that cause hypomagnesemia.
Those taking antibiotics (fluconazole, moxifloxacin)
Antiarrhythmics (amiodarone, sotalol)
Tricyclic antidepressants
Hyperkalemia
Peaked T-waves.
Tx: Calcium gluconate
Chronic lymphocytic leukemia
Older patients
Patients are often asymptomatic, but when they are, it is due to lymphadenopathy.
Smudge cells
Staging: 0 lymphocytosis 1 lymphocytosis + adenopathy 2 Splenomegaly 3. anemia 4. thrombocytopenia
Dietary Recommendations to prevent renal calculi
- Increase fluid intake
- Increase Ca intake
- Reduce dietary protein and oxalate
- Decrease sodium intake
NNT
Number needed to treat = 1/ARR (absolute risk reduction)
Triad of gait disturbance, urinary incontinence, dementia. Lumbar picture shows normal CSF pressure and MRI shows enlarged ventricles
Normal pressure hydrocephalus
Drugs that can cause G6PD oxidative dress?
Nitrofurantoin, sulfa drugs, anti-malarials
Side effect of fluphenazine
hypothermia
Common side effects of amitriptyline
insomnia, weight changes, dizziness
Heat Stroke
Failure of body thermoregulation upon exposure to high environmental temperatures. Very high core body temperature of >105F, dehydration, confusion, coma, dry skin, flushed skin
Vestibular neuronitis
Acute onset of nystagmus and vertigo without other neurological defects
Meniere’s disease
Increased pressure of the endolymph, thereby causing vertigo, hearing loss, tinnitus, hearing problem.
Hypertension patient who develops vertigo, vomiting, and occipital headache. Dx?
Cerebellar hemorrhage
Overdose on B-blockers Symptoms
Bradycardia, AV block, hypotension, diffuse wheezing
Tx: Fluids, atropine. Anecdote: Glucagon which increases cAMP and causes higher levels of intracellular Ca causing increase contratility.
5 common side effects of amiodarone
Pulmonary fibrosis Corneal deposits Hepatotoxicity Skin changes (blue-gray discoloration) Thyroid dysfunction
Most common cause of endocarditis due to dental caries.
Strep. viridans (including mutans, sanguis)
What are the clinical features of fibromyalgia
Young to middle age women
Widespread musculoskeletal pain on both sides above and below the waist.
Fatigue when waking up in the morning and mid afternoon pain
Cognitive difficulties
Nonspecific gastrointestinal symptoms
Lab/diagnosis of Fibromyalgia
No abnormal lab values
Increasing in severity score over a period >3 months
Local tenderness on physical exam
Clinical features of polymyositis
Proximal muscle weakness (inability to climb stairs, get up from a chair, carry heavy groceries)
Less prominent hip/shoulder involvement
Labs/diagnosis of Polymyositis
Elevated muscle enzyme (i.e. creainine kinase, aldolase, lactate dehydrogenase, aspartate aminotransferase)
Possible autoantibodies
Electromyography is abnormal.
Clinical features of Polymyalgia Rheumatica.
Age>50
Aching and morning stiffness > pain in shoulders, hips, neck, torso
Synovitis, bursitis, decreased range of motion
No significant muscle tenderness
Possible systemic symptoms
Labs/Diagnosis of Polymyalgia Rheumatica.
Erythrocyte Sedimentation rate is significantly elevated
Clinical features make the diagnosis
Symptoms improve with corticosteroids
What is Giant Cell Arteritis (temporal arteritis)
Associated with polymyalgia rheumatica, has systemic symptoms, headaches, claudication, visual disturbances, elevated ESR.
What is hypertensive urgency?
BP >= 180/120, however no signs of end-organ damage
What is hypertensive emergency?
BP >= 180/20 with signs of acute, life-threatening, end-organ damage.
Malignant hypertension - retinal hemorrhage, papilledema, or exudates
Hypertensive encephalopathy - cerebral edema and non-localizing neurological symptoms
Management of Right Ventricular infarcts and Right heart failure.
Requires a high preload to maintain their blood pressure and therefore treated with IV fluids. Preload reducing agents such as nitroglycerine and diuretics should be avoided.
Pansystolic murmur heard loudest at the apex with radiation to the axilla.
What about pansystolic murmur that is best heard at the left sternal border
Mitral regurgitation (i.e. due to papillary muscle rupture)
Ventricular septal rupture.
Pulmonary Embolism clinical presentation
Dysnea, Tachypnea, pleuritic chest pain, and hypotension
Aortic Dissection clinical presentation
Tearing chest pain and back pain and unequal pulses, and hypertension.
Clinical presentation of pleural effusion and cardiac tamponade?
Pericardial fluid causes reduction in diastolic filling and preload, resulting in hypotension and syncope (due to decreased cranial blood flow). Examination shows tachycardia, distended neck vein, pulsus, paradoxus, and muffled heart sounds.
Pulsus Paradoxus
Reduction of the SBP by >10mmHg during inspiration
Seen in cardiac tamponade, pericarditis,
Diagnosis/EKG findings or pericardial effusions
Tx?
Electrical alterans (variation in QRS amplitude) due to heart swinging in the pericardial cavity. Sinus tachycardia.
Tx: Pericardiocentesis
What is the leading cause of secondary hypertension?
Renal Artery Stenosis
Periumbillical systolic-diastolic bruits and history of atherosclerosis.
Abdominal aneurysms
Older men with a smoking + atherosclerotic history
Pulsatile abdominal mass or systolic bruits
Aortic Coarctations
Congenital strictures along the aorta that causes hypertension and differences in blood pressure in upper and lower extremities.
Tricuspid endocarditis (IV drug user) presentation?
Holosystolic murmur of tricuspid regurgitation that is accentuated by inspiration
Early diastolic murmur at the left sternal border. Electrocardiogram shows a sinus rhythm with 2:1 second degree atrioventricular block
Aortic valve endocarditis with perivalvular abscess with regurgitation.
Third heart sound
Ventricular gallop sound after S2.
Heart during rapid filling of the ventricle during diastole.
Turbulent blood flow to the ventricles + stretching of the chordate tendinae due to increased volume.
Normal in children, young adults, pregnancy
Abnormal + associated conditions: Age >40, heart failure, restrictive cardiomyopathy, high output states.
(systolic dysfunction)
Fourth Heart sound
Atrial gallop sound (before S1)
Heard immediately after atrial contraction phase as blood is forced into a stiff ventricle.
Normal: Healthy, older adults
Abnormal/associations: Younger adults, children, ventricular hypertrophy, acute MI.
(diastolic dysfunction)
When is wide and fixed splitting in S2 seen?
Atrial Septal Defect
How does pericardial friction rub present?
Pleuritic chest pain that increases with inspiration and coughing. It decreases when patient sits and leans forward.
Recent RBBB is suggestive of what condition.
Pulmonary embolism
What confers a survival benefit for CHF?
ARBs, Ace inhibitors, Spiranolactone, B-blockers.
While loop diuretics and digoxin can reduce hospitalizations, they do not improve mortality.
What are the hemodynamic result of hypovolemic shock?
Loss in intravascular volume leads to
Right atrial pressure (preload) = decreased
Pulmonary wedge pressure (preload) = decreased
Systemic blood pressure = decreased
Stimulation of the sympathetic
Systemic vascular resistance = increased
What are the hemodynamic result of cardiogenic shock?
Cardiac pump failure leads to decrease cardiac output and blood pressure.
Preload (right atrial pressure, PWP) = increased
Sympathetic:
Systemic vascular resistance = increased
Values as a result of vasodilatory or distributive shock
Caused by sepsis, anaphylaxis, systemic inflammatory response, central nervous injury:
Systemic vascular resistance: decreased
Blood pressure: reduced
Preload ( PCWP and Right atrial pressure) = decreased
Compensatory:
Heart Rate and CO = increase
Common causes of hemoptysis?
Chronic bronchitis, pulmonary embolism, bronchiectasis, lung cancer, mitral stenosis, acute pulmonary edema, tuberculosis, lung abscess, coagulopathy, AVM formations, Wegner’s granulomatosis, goodpasture’s syndrome, systemic lupus erythematous, vasculitis
Papillary muscle rupture
Occures 3-5 days. Acute and severe pulmonary edema and holosystolic murmur. Echo shows a severe mitral regurgitation with flail leaflet
Intraventricular septal rupture/defect
Acute and within 3-5 days. LAD: apical septal rupture. RCA: basal septal rupture. Shock and chest pain, at level of the ventricle, biventricular failure. Left to right shunt at the ventricle
Free wall rupture
Between 5 days to 2 weeks. LAD. Shock and chest pain. Jugular venous distention, distant heart sounds. Pericardial effusion with tamponade. Presents with acute pain, profound shock, and rapid progression to pulseless, electrical activity and death.
Clinical presentation of asbestosis
Prolonged exposure to asbestosis (i.e. shipyard, mining, construction, pipe fitters) Symptoms develop >20 years after initial exposure Progressive dysnea (over months), bibasilar end inspiratory fine crackles & clubbing. Increased risk of malignancies like lung cancer and malignant mesothelioma.
Diagnosis of asbestosis?
History or clinical finding of exposure (i.e. pleural plaques,)
Interstitial fibrosis on imaging or histology and/or pulmonary function test with restrictive pattern. Progressive dysnea.
Physical exam can show digital clubbing, end inspiratory crackles
What is restrictive pattern pattern?
FEV1/FVC = normal or elevated > 80%
Force expiratory volume in 1 sec
Force vital capacity
What is an obstructive pattern?
FEV1/FVC < 80%
Treatment for Community acquired pneumonia
Empirical treatment with moxifloxacin or levofloxacin, which covers strep pneumo, moraxella catarralis, and haemophilus influenza for inpatient. For outpatient, either azithromycin and doxycycline can be used.
What is used if worried about aspirational pneumonia?
clindamycin
Intermittent asthma
daytime symptoms < 2days/week
nighttimes awakenings < 2x/week
Baseline FEV1 and FEV1/FVC are normal, no limitations on daily activities
Management: short acting bronchodilator (albuterol)
mild persistent asthma
symptoms > 2days/week but less than daily
Night-time awakenings 3-4x/month
minor limitation of activity and normal PFTs
Management: low dose inhaled corticosteroids + albuterol
moderate persistent asthma
daily symptoms
weekly night awakenings
FEV1 60-80% should be prescribed:
Long-acting inhaled beta 2-agonist inhaler, low dose inhaled corticosteroids + albuterol prn
Severe persistent asthma
symptoms throughout the day, frequent night-time awakening, extremely limited activity, and FEV1 < 60% as predicted
Management: PRN albuterol inhaler, long acting beta 2 agonist, high dose corticosteroids. Oral prednisone can also be used in cases of severe persistent asthma
How does multiple sclerosis present?
Patchy neurological problems (upper right, lower left, and optical neuritis)
Clinical diagnosis: MRI of brain - cerebellar and cerebral plaques in the periventricular regions, corpus callosum, deep white matter, and basal ganglia
CSF shows increase in immunoglobulin and oligoclonal bands are present in 85-95%.
PPD testing is positive when?
In HIV patients >5mm within 48-72 hours of intradermal injection of 5 tuberculin units
Isoniazid is given for chemoprophylaxis for 9 months in PPD positive HIV infected patients. Pyridoxine is given to prevent neuropathy caused by Isoniazid. Periodic liver function should be monitored.
Alternatives include rifampin with pyrazinamide for 2 months or rifampin alone for 4 months.
Immune complex mediated kidney damage
post-streptococcal, lupus
IgE mediated kidney damage
allergic interstitial nephritis including methicillin induced interstitial nephritis
Cytotoxic antibodies kidney damage
Goodpasture’s syndrome
Delayed hypersensitivities to the kidneys
Non specific chronic glomerulonephritis
Non immune mediated kidney damage
toxins, hypertension, diabetes, other factors
Presentation of Scabies
Infestation of Sarcoptes Scabiei
Generalized itching. Lesions are pruritic vesicles and pustules in “runs” over the finger webs, heels of the palms, and wrist creases. Pruritic papules may be seen over the nipples and areola of the female and scrotum/penis of the male. Head and neck are spared.
Scraping from excoriated lesions show mites, ova, and feces.
Tx: permethrin for adult applied over the neck and down. Low potency steroids to treat the dermatitis. Bedding and clothing should be set aside and cleaned for 2 weeks.
How do body lice present?
Body life infect the seams of clothing, and the nits (lice eggs) are often found in the seams not on human hairs. Maculae cerulean (hemosiderin stained purpuric spots are where lice have fed and is diagnostic of lice infestation.
Urticaria
Evanescent wheals or hives with intense itchiness. Most are acute, self limited and can result from immunological or non immunological conditions
Insect bites
Often grouped in one area, can be vesicles and bullae
Bed bugs
Tend to hide in old furniture and hide in the seams and folds of the mattress. Bites are painless, but pruritic and purpuric macules appear. Bites are in groups of 2 or 3 over exposed areas.
Risk factors for an Aortic Aneurysm rupture
Diameter, rate of expansion, and currently smoking
Conditions for operative and endovascular repair of aortic aneurysm
> 5.5 cm diameter, growing by 1cm/year or 0.5/ half year and presence of abdominal pain, or flank pain, or limb ischemia.
Atheroembolism
Most commonly seen as a complication of cardiac catheterization and other procedures. Skin manifestations are the most common manifestation: blue toe syndrome, livedo reticularis (lacy skin discoloration). Hollenhorst plaques (bright yellow refractive plaques in the retinal artery which indicates a proximal source such as the internal carotid artery). Intestinal ischemia, gastrointestinal bleeding, cerebral ischemia, acute kidney injury may also occur
What infections are caused by Group B Strep?
NIPPLES Necrotizing fasciitis Impetigo Pneumonia Pharyngitis Lymphangitis Erysipelas or cellulitis Scarlet Fever/Strep TSS
What is Erysipelas?
Erysipelas is an inflammation of the superficial dermis most commonly caused by Group B Strep. Sharply demarcated, erythematous, edematous, tender, skin with raised borders. Legs are the most frequently involved site.
What can cause cool, dusty finger tips and necrosis of the finger tips
Norepinephrine-induced vasospasm
Symptoms of alcohol withdrawal
Reflex hyperactivity manifesting as anxiety, insomnia, tremors and diaphoresis in the 6-24 hours. After 48 hours, it can cause hallucinations and withdrawal seizures. The most serious alcohol withdrawal symptom is after 48-96 hours and due to delirium tremens, which includes hypertension, agitation, tachycardia, hallucinations, and fever, and mortality up to 5%.
What is the top choice for alcohol withdrawal
Benzodiazepine. Particularly chlordiazepoxide
Side effects of vancomycin
Red man syndrome, ototoxicity, and nephrotoxicity
Opiate withdrawal
Dilated pupils, piloerection, and complaints of dysphoria, myalgia, and abdominal pain.
Hypothesuria
Impairment in the kidney’s ability to concentrate urine. Commonly found in sickle cell disease and sickle cell trait.
Glucagonoma
Mild diabetes usually easily controlled with oral agents and diet, usually not requiring insulin.
Hyperglycemia with necrotic migratory erythema, diarrhea, anemia and weight loss. Erythematous papules on the face, perineum, and extremities.
Glucagon > 500 pg/mL confirms the diagnosis , anemia, CT/MRI of abdomen showing tumor.
Type 2 heparin induced thrombocytopenia
Heparin-platelet-PF4 induce platelet activation –> procoagulant micro particle release, platelet aggregation –> thrombosis
Heparin-platelet-PF4 also induces removal by splenic macrophages –> thrombocytopenia
Hemarthosis
Bleeding into the joints, which is characteristic of hemophilias.
Ankylosing Spondylitis
Associated with HLA-B27, morning stiffness than improves throughout the day, and onset at 20-30’s, and more in males. Anterior uveitis is the most common extra-articular manifestation.
What does synovial fluid analysis show for gouty arthritis?
White blood cell count between 2,000 - 50,000/ml, needle-shaped, negative birefringent, crystals under polarized light and gram -
It can help distinguish between septic arthritis and pseudo gout.
B-thalassemia presentation
Asymptomatic with mild anemia and disproportionately high RBC count, low mean corpuscular volume, and hemoglobin > 10 g/dL. Target cells are on smear. Normal to increased iron and ferritin. Does not respond to iron supplementation. Elevated hemoglobin A2 on electrophoresis.
Iron Deficiency Anemia
Iron deficiency anemia has a low red blood cell coin which rarely becomes microcytic until the hemoglobin is < 10g/dL.
A-thalassemia presentation
Asymptomatic with mild anemia and disproportionately high RBC count (Hematocrit > 30%). Low mean corpuscular volume, and target cells are on the smear. Normal to increased iron and ferritin. Normal hemoglobin on electrophoresis.
Deferoxamine
Iron chelator used in iron overloaded state in transfusion dependent thalassemia major or sickle cell patients.
Hydroxyurea
Decreases the frequency and severity of pain crisis in patients with sickle cell by increasing hemoglobin F levels.
Treatment of choice for Anemia of Chronic Disease?
Erythropoietin. Also used in anemia associated with chronic kidney disease and transient bone marrow failure after chemotherapy or bone marrow transplant.
Treatment of choice for autoimmune hemolytic anemia
Prednisone
Treatment for symptomatic hereditary spherocytosis
Splenectomy
Inflammatory myopathy
Polymyositis and dermatomyositis both show elevated ESR and creatinine kinase, and associated with proximal muscle weakness. It is confirmed with muscle biopsy.
Colchicine
Inhibits microtubules activity and used to treat flares of gouty arthritis.
Amyotrophic Lateral Sclerosis (ALS)
Presents with progressive weakness of the arms, legs and cranial nerves with mixture of upper and lower motor signs. Riluzole is used to slow down the progression.
Fibromyalgia treatment
TCA, particularly amitriptyline. Mostly muscle pain without objective weakness.
Treatment for myasthenia gravis
Pyridostigmine (an anticholinesterase)
Treatment for cold extremities
Rapid rewarming with warm water (40-44C) No attempts should be made initially to debride frostbite tissues
