clin med last two lectures Flashcards
Endocrine pancreas (DIABETES)
Islet of langerhan
insulin and glucagon
Exocrine pancreas
Acinar cells- amylase, lipase, protease
Pancreatic juice- electrolytes, bicarb, enzymes, neutralize acid
Acute pancreatitis
Alc induced >Males
Gallstone induced >Females
Pathophys of Pancreatitis
High TRYPSIN levels, pancreas destroys itself
Subtypes of pancreatitis
Necrosis or nah
Two most common causes of Pancreatitis
Gallstones
Alcohol (chronic use)
Abdominal pain with pancreatitis
Acute, post meal
Epigastric –> radiating into back
Constant, steady, boring
Better w leaning forward
PE of Pancreatitis
Tachy, hypo, fever
Sometimes jaundice, pallor, sweating
Epigastric pain
Guarding
Dec bowel sounds
Scleral icterus, be thinking of
Choledocholithiasis or Edema of pancreatic head
Parotid swelling can be sign of
Mumps
Severe necrotizing pancreatitis
Cullen sign- bruising around belly button
Grey turner- bruising to flanks
Panniculitis- red tiny nodules
Labs of Pancreatitis
Elevated:
Bilirubin, Triglycerides, Pancreatic enzymes, LIPASE (more spec to pancreas)
CRP >150= severe pancreatitis
Genetic testing panc
Strong fam hx of pancreatitis
<35 YO onset
If Clinical presentation and Labs are suggestive of Pancreatitis, do we want a CT?
NOT RECOMMENDED
most cases are uncomplicated
IV contrast may worsen panc
Suspect pancreatitis, what imaging do I order?
US –> EUS –> MRCP
Do not do ERCP unless
EUS or MRCP are abnormal
Diagnostic criteria for Pancreatitis,
Requires TWO of the following
Clinical (acute, persistent, severe, boring, epigastric pain radiating to back)
Elevated Lipase or Amylase
Imaging
Get a CT if >72 hours of onset sx AND
Persistent or recurrent abd pain
Inc in panc enzymes after initial decrease
New or worse organ dysfx
Sepsis (fever and increased WBC)
Tx for Pancreatitis
Admit SUPPORTIVE Meds (pain, abx, n/v) Aggressive hydration Monitor for worsening
Complications of pancreatitis
Local (fluid, cyst, necrosis)
Systemic inflammatory response syndrome (SIRS)
Organ failure
Pancreatic pseudocyst
Localized collection of fluid (enzymes, blood, and pancreatic tissue)
Palpable mass mid epigastric
may spont resolve or get bigger
Complicated if: rupture, hemorrhage, infection
Tx of Pancreatic pesudocyst
Surgery vs drainage if symptomatic or infected
Most cases of Pancreatitis are
Mild acute
Better in 3-5 days
- no organ failure
- no local or systemic complications
SIRS
Present on admission
Persists >48 hours
Death related to pancretitis
First 2 weeks: SIRS/organ failure
After 2 weeks: Sepsis
Some causes of pancreatitis you can treat to prevent another case
Remove gallstone
Stop drinking
Lower triglycerides w diet / meds
Discontinue offending med
Chronic pancreatitis
Progressive inflammatory changes
Long term structural damage of pancreas
Is Mortality lower with chronic or acute pancreatitis?
Chronic
Sx of Chronic pancreatitis
STEATORRHEA
DM
weight loss
Brittle DM
alpha and beta cells of pancreas affected d/t chronic pancreatitis
hard to control
typically insulin DEPENDENT
Classic TRIAD of Chronic Pancreatitis
DM
Steatorrhea
Calcifications
Most labs with CHRONIC Pancreatitis are more mild, maybe even normal… so we test
Fecal fat
72 hr: Gold standard
Test of choice for Steatorrhea
Fecal Elastase
Calcifications on X Ray
Calcifications, ductal dilation, and pseudocyst on CT
Chronic Pancreatitis
ERCP (diagnostic and therapeutic) of Chronic Pancreatitis shows what?
“chain of lakes” gold standard
Tx of Chronic Pancreatitis
Behavior Pain relief Lithotripsy Endoscopic dilation or stenting Decompression/drainage
Acute, severe, epigastric pain radiating to back
better w leaning forward
Pancreatitis
Diagnosis of Pancreatitis (at least 2)
Clinical
Labs (lipase/amylase)
Imaging
Triad: DM, steatorrhea, calcifications
“chain of lakes” on ERCP
Chronic Pancreatitis
“chain of lakes”
alternating stenosis and dilation of pancreatic duct on ERCP
Pancreatic CA
Males>females
Etiology:
Abn glucose metabolism
Insulin resistance
Obese
Chronic pancreatitis
Is Pancreatic CA usually exocrine or endocrine?
Exocrine
Most common type of Pancreatic CA
Ductal adenocarcinoma
Head of pancreas
Only cure for pancreatic CA
Resection
BUT unfortunately most already have locally advanced or METs when it is found
Presentation of Pancreatic CA
Epigastric pain
Jaundice
Weight loss
maybe also: dark urine, steatorrhea
PE shows this:
Hepatomegaly Abd pain RUQ/epigastric mass "Courvoiser sign" Ascites Jaundice/icterus
be thinking
Pancreatic CA
Courvoisier sign
Nontender palpable gallbladder
Initial imaging if pt has JAUNDICE
Abdominal US
Initial imaging if pt has Epigastric pain and weight loss (but no jaundice)
Triple phase thin slice enhanced helical CT of Abd
Resection of Pancreatic CA
Whipple procedure
Prognosis for Pancreatic CA
Very poor
5 yr survival <5%
Prognosis with Un-resectable pancreatic CA
8-12 mo with local invasion
3-6 mo if METs
Lymphogranuloma Venereum (LGV)
all among MSM w HIV infection
HIV populations most affected
Men
20-29
Hispanic and African American
CD4 count is what
T helper cells that enhance the immune response and tell B cells to MAKE ANTIBODIES
HIV stages
Primary infection “Acute HIV” (sx)
Clinical latency
Symptomatic HIV
AIDS
Acute HIV/ primary infection
2-6 wks after exposure
Mono like/ Flu like
Lasts about 2 wks, resolves spontaneously
Viral load EXTREMELY high
During acute HIV, the routine HIV Ab test will be
negative! antibodies are not made yet
Common manifestations of Acute HIV
- Rash
- Mouth ulcers
+ others
Labs with Acute HIV
Elevated LFT
LOW blood counts (white, red, platelet)
Clinical latency to HIV
Immune system starts to resolve to infection
Patient seroconverts within 3 MONTHS of infection- now they are producing antibodies
Clinical latency
last avg 10 years
HIV remains active in lymphnodes
Pt has no sx (or lymphadenopathy)
Symptomatic infection HIV
Lymph nodes “burnt out”
Virus may mutate
Body fails to keep up replacement of CD4 count
HIV RNA viral load increase
HIV (and AIDS) sx
Oral hairy leukoplakia
Kaposi Sarcoma
Thrush
Others: fever, night sweat, arthralgia, weight loss, prolonged diarrhea
AIDS is defined as CD4 <200 OR
HIV + 1 of the 27”AIDs defining conditions”
PCP Toxoplasmosis CMV Thrush of esoph/tracheus/bronchi Kaposi sarcoma etc
PCP
Pneumocystis Jirocevi PNA
when CD4 <200
BACTRIM
Toxoplasmosis
when CD4 <100
SULFA and PYRIM
ToxoPlaSmosis
tx starts with P and S
Pyrimethamine
Sulfa
Sx: HA, focal neuro def, AMS
Dx: lesions on Brain CT or MRI
1st line tx: Sulfa and Pyrimethamine
MAC
when CD4 <50
Bacteria in soil and dust
Sx: Night sweat, weight loss, abd pain, diarrhea, ANEMIA
Dx: AFB
Tx: Macrolide + Ethambutol
CMV (herpes gets in eye)
when CD4 <50
Most common RETINAL infection in AIDS pts
Dx: white fluffy exudates on fundoscopic exam
Tx: IV Gangcyclovir
AIDs related Kaposi sarcoma
Most frequent in homosexual male
Classic Kaposi’s
Elderly eastern european and Mediterannean males
Screen everyone for HIV at least one
Everyone 13-64YO Anyone being tx for TB Each STD presentation Annual for risk pts Pregnant women
DIAGNOSTIC testing for
Opportunistic infection
TB
Sx consistent with HIV (weight loss, night sweat, diarrhea >1wk, PNA)
Sx consistent w Acute HIV
Test of choice for HIV
Combo HIV antibody AND Antigen test
HIV Antibody test
only will show positive AFTER pt Seroconverts
4-12 wks after infection
PEP post exposure proph for HIV
Must start w/in 72 hours
3 drug regimen for 28 days
PrEP for people at risk
partner to HIV positive, ror MSM
Daily med
main option is Truvada
Normal CD4 count
600-1200 cells per cubic/mm
All HIV+ pts should be screened for TB AND
given TB prophylaxis if latent TB is present
If HIV+ pt CD4 falls below 250
give Diflucan prophylactically for Cocci
If HIV+ pt CD4 falls below 200
give Bactrim prophylactically for PCP
If HIV+ pt CD4 falls below 100
give Bactrim prophylactically for Toxoplasosiss
Syphillis
Trepenoma Pallidum
Direct contact w infected lesion
Clinical presentation of Primary syphillis
Painless chancre lasting 4-6 wks (then resolves)
Secondary syphillis has many manifestations
+ systemic like malaise and lymphadonopathy
Rash (common) on PALMS AND SOLES
Warts- Condyloma lata- highly infectious
Mucous patches- highly infectious
How long does Secondary Syphillis last?
2-6 wks then enter Latent period
Latent syphillis
No sx
Syphillis is NO LONGER transmitable
may persist for YEARZz
Tertiary (late) syphillis
Most do not get to this point
only 15% of those untreated
10-30 yrs after infected
Tertiary syphillis
can damage heart, blood vessles, brain, and nervous sx
Clinical sx of Tertiary syphillis
NEURO and EYE
Paralysis, coordination troubles, dementia, vision change, blindness
Dx of Syphillis
Start w RPR or VDRL (non specific)
Confirm w Treponemal antibody test: FTA-ABS
If you suspect Neuro or Ocular involvement from Syphillis, what do you need to do?
Lumbar Puncture
perform VDRL on spinal fluid to confirm
Syphillis tx
BENZATHINE Pen G ( a shot)
Retest syphillis after tx at
6, 12, 24 mo
Check RPR titer
Congenital syphillis
stillbirth
neonatal death
infant disorder- deaf, neuro imp, bone disoder
If pregant pt is PCN allergic, consider
desensitization with oral PCN
Monitor serology closely to confirm successful tx
LGV
Lympho Venereum
Treat with DOXY
Caused by CHLAMYDIA
Rare, but present in MSM
Unilateral inguinal BUBO (swollen lymphnode)
Anal d/c and rectal bleeding
Tx: DOXY
Chancroid
H. ducreyi
Painfu, tender ulcer
FOUL SMELLING d/c
Tx: Azithro, Ceftriaxone, or Cipro
