firecracker feb 12 Flashcards
erythema multiforme infectious causes
HSV
Mycoplasma pneumoniae
what is erythema multiforme
acute cutaneous hypersensitivity condition
immune mediated
target like lesions
erythema multiforme most common among
males
20-40
erythema multiforme other findings besides target lesions
malaise, mylagias
macules
plaques, vesicles
erythema multiforme lesions
red center
pale inner ring
red outer ring
meds linked to erythema multiforme
penicillins
erythema multiforme diagnosis
skin biopsy
increased lymphocytes
necrotic keratinocytes
erythema multiforme treatment
stop offending agent
corticosteroid
analgesics
how does membranous nephropathy present
edema
dyspnea
risk factors for autoimmune hepatitis
caucasian/northern europe
female
acute hep a and b infections
DR3,4
membranous nephropathy treatment
corticosteroids, cytotoxic agents, statins, ACEI
lab findings in membranous nephropathy
hyperlipidemia
hypoalbuminemia
proteinuria
What is the role of anticoagulation in the management of membranous nephropathy?
increase in coagulopathies
severe proteinura >5g/day
autoimmune hepatitis serological
Anti smooth muscle
anti live rkidney microsomal
autoimmune hepatitis treatment
prednisone
azathioprine
membranous nephropathy - immunoflourescnce
granular deposits of IgG and C3
What is found on electron microscopy in patients with membranous nephropathy?
sub-epithelial immune complex deposits
secondary membranous nephropathy
hep b, c
autoimmune - lupus
drugs - gold, penicillaine
malignancies
autoimmune hepatitis
circulating antibodies
hepatocellular inflamm
fibrosis
follicular carcinoma %
15%
what is the first and second step in working up someone with a thyroid nodule?
- ultrasound (FNA)
- radionucleotide scan if suspicious
- biopsy
What percentage of thyroid CA’s are from a medullary carcinoma?
5%
medullary carcinoma - cells
parafollicular/C cells
produce calcitonin
How does follicular thyroid CA commonly spread?
hematogenous spread –> present with mets
thyroid CA treatment
surgical removal
radioactive iodine ablation
lobectomy if less than 1cm
total thyroidectomy if greater than 1 cm
What medication is started post-operatively for patients who have undergone surgery for thyroid cancer?
levothyroxine
What is the most common sub-type of thyroid CA?
papillary
What is a common history in patients who develop papillary thyroid CA? How does it spread?
exposure to ionizing radiation
spreads thru lymphatics
prolactinoma signs & symptoms
F: galactorrhea, amenorrhea
M: loss of libido, erectile dysfxn, gyecomastia
prolactinoma =
hyperfunctioning adenoma of anterior pituitary
hormones secreted from anterior pituitary
My FLAT PiG
MSH, FSH, LH, ACTH, TSH, Prolactin, GH
prolactinoma treatment
bromocriptine or cabergoline —> dopamine agonists
dopamine inhibits prolactin release
other causes of hyperprolactinemia
pregnancy
drugs
hypothyroid/hypothalamic damage
causes of central DI
idiopathic
trauma
tumors
anorexia
diabetes insipidus
can’t retain water
water normally retained by reabsorbing it from urine
DI symptoms
polyuria, polydipsia, new onset nocturia
First Step Of workup for DI
urinarlysis
dilute urine, urine osm less than serum osm (290)
urine specific grav less than 1.06
causes of nephrogenic DI
hereidtary renal diseases
lithitum toxicity
hypokalemia
hypercalcemia
second step of DI workup
water deprivation test
no change in urine osm after water deprivation
DDAVP test
increased urine osm in central
no change in nephrogenic (renal resistance to ADH)
central DI treatment
desmopressin
nephrogenic DI treatment
underlying disorder
symptoms with hctz, indomethacin, amiloride
secondary adrenal insufficiency most commonly caused by
glucocorticoids
What infective infiltrative disorders may affect the adrenal glands?
TB
Histo
HIV
secondary adrenal insufficiency
failure of HPAxis
decreased ACTH
What pituitary neoplasms commonly suppress ACTH production?
pituitary adenoma
What are some causes of adrenal insufficiency?
- autoimmune destruction
- Tb, Hiv
- infarction of adrenal gland
- Waterhouse-Friderichsen
- DIC
what is low in adrenal insuffieiency
low morning cortisol, less than 5
What is a common cause of adrenal insufficiency in patients in a hypercoagulable state or in sepsis?
hemorrhagic adrenal infarction
What hormones are secreted by the adrenal cortex?
aldosterone
cortisol
androgen
What is “stress dosing” of steroids and when is it indicated in adrenal insufficiency?
increased doses given in cases of stress like infection or surgery
What may precipitate adrenal crisis?
stress - surgery, sepsis
look for hypotension, hyponatremia, hyperkalemia
What replacement therapy is needed in patients with primary adrenal failure in addition to prednisone?
aldosterone with fludrocortisone
What is the cosyntropin test and what would be considered an abnormal result?
differentiate 1 vs 2 ACTH def
ACTH analog
cortisol > 20 normal result
lower indicates non response, primary adrenal failure
What is a common life-threatening complication of adrenal insufficiency?
shock (adrenal crisis)
treatment for adrenal crisis
IV glucose and corticosteroids
What test is used to confirm acromegaly if IGF-1 are found to be elevated?
ORAL glucose tolerance test
What are two important metabolic complications of acromegaly?
DM
HLD
What can be used to treat persistent elevations in insulin growth factor 1 after transphenoidal resection of the growth hormone secreting pituitary adenoma?
radiation therapy
What constitutes an abnormal oral glucose tolerance test in patients with acromegaly?
GH remains greater than 2 within two hours after ingestion of 75g glucose
Patients who have been diagnosed with acromegaly based on elevated IGF-1 levels and positive glucose tolerance test require what further testing?
MRI of brain
What is the cause of obstructive sleep apnea in acromegaly?
GH causing macroglossia
acromegaly rx
somatostatin and dopamine analogues such as ocretotide and bromocriptine
CNS symptoms of acromegaly
bitemporal hemianopsia
headaches
body parts affected by acromegaly
hands, skull, jaw
cause of primary hyperPTH
single benign adenoma
hyperplasia of parathyroid glands
triad of primary hyper PTH
hypercalcemia
elevated PTH
elevated 24 hr urinary calcium
secondary hyperPTH
parathyroid glands chronically stimulated by hypocalcemia to release PTH
how does primary hyperPTH present
hypercalcemia
bones, stones, moans, groans, polyuria
causes of secondary hyperPTH
CKD
Malabsorption
Rickets
PseudohyperPTH
indications for surgical intervention in primary hyperPTH
elevated cr
hypercalcemia
kidney stones
osteoporosis
secondary hyperPTH labs
low calcium, high phosphorus
high PTH
cortisol production
hypothalamus produces CRH
pituitary produces ACTH
ZF of adrenal gland produces cortisol
what test to determine ACTH-independent vs ACTH-dependent cushing’s
plasma ACTH
what causes glucose intolerance in Cushing’s?
cortisol-stimulated gluconeogenesis
obesity-induced peripehral insulin resistance
How does a low-dose dexamethasone suppression test help diagnose Cushing’s syndrome?
normal morning cortisol following dexa should be s
Complications of cushing’s
diabetes
CVD
opportunistic infections
imaging in cushings
look for source
infections in Cushing’s syndrome
Nocardia
PCP
fungal
skin in Cushing’s
thinning
bruising
striae
hyperpigmentation
acne in Cushings?
imablance in adnrogens, estogren, GnRH
osteoporosis in Cushings?
reduced calcium absorption in intestines and kidneys
lab abnormalities in Cushings
hypokalemia
hypercalciuria
metabolic alkalosis
Cushings work up
24 urinary free cortisol test (3x)
low dose dexamethasone suppresion test
Cardiogenic Shock
decrease CO
increase SVR
increase PCWP
Hypovolemic Shock
decrease CO
increase SVR
decrease PCWP
Neurogenic Shock
decrease CO
decrease SVR
decrease PCWP
Septic Shock
increase CO
decrease SVR
decrease PCWP
Pharmacologic Agents in Cardiogenic Shock
Dopamine - vasopressor
Dobutamine - inotrope
Shock =
circulatory collapse
inadequate blood delivery resulting in hypoperfusion of tissues
How is anaphylactic shock managed?
airway maintenace
epinephrine
diphenhydramine
IV fluids
cardiogenic shock defined as
hypotension below 80-90 or 30mmhg below baseline
urine output less than 20 ml/hr
causes of cardiogenic shock
acute mi arrhythmias tension PTX cardiac tamponade massive PE
neurogenic shock =
SNS failure causing widespread peripheral vasodilation and bradycardia
anaphylactic shock =
type I hypersenisitivty rxn
etiology of neurogenic shock
CNS or spinal cord injury
cardiogenic shock =
heart fails to generate sufficient CO to perfuse tissues
causes of hypovolemic shock
hemorrhage
excess fluid loss
cause of anaphylactic shock
massive degranulation of mast cells and basophils in response to allergic rxn
management of neurogenic shock
IV fluids, vasoconstrictors to treat vasodilation
atropine for braycardia
management of hypovolemic shock
IV fluids or transfusions
surgery
dressing if due to burns
hemodynamic effects of cardiogenic shock
decrease in SV
increase in EDP and ESV
cardiogenic shock - PE findings
JVD, pulm edma
AMS
cool, clammy skin
weak thready pulse
management of shock related to MI
revascularization
use of aspirin and heparin
clinical features of neurogenic shock
warm, well perfused skin
low-normal urine output
symptoms of ARDS - focus on breath sounds
wheezing
rales
rhonchi
ARDS
acute lung inury
complement activation –> lung damage
refractory hypoxemia
PaO2/FiO2 ratio for ARDS
<200
ARDS lab findings
resp alkalosis
decrease o2
decrease co2
causes of ARDS, A
aspiration
acute pancreatitis
air or amniotic embolism
causes of ARDS, R
radiation
causes of ARDS, D
drug over dose
DIC
drowning
causes of ARDS, s
shock
sepsis
smoke inhalation
CXR for ARDS
bilateral pulmonary edema with infiltrates
BCC risk factors
p53, HPV
BCC
most common
sun exposed areas
BCC lesion
pearly, waxy apperance
telangiectases throughout lesion
BCC diagnosis
skin biopsy
BCC treatment
electrodessication and curettage surgical excision cryotherapy topical meds radiation therapy
BCC - meds
5FU
imiquimod
tazarotene
BCC -radiation
extensive dz
can’t undergo surgery
SCC risk factors
HPV
actinic keratosis
SCC lesion
scaly, ulercated skin lesion
shallow ulceration with healed up borders
gold standard for diagnosing melanoma
excisional skin biopsy with a 1-2mmof normal appearing skin
melanoma complications
scarring, keloid formation, metastasis, death
cause of dehydration in HHNK
increased blood glucose –> increased insulin demand –> increased plasma osm –> osmotic diuresis –> dehydration
HHNK lab values
elevated glucose, 600+
elevated plasma osmolality, +350
no ketones
potassium levels in HHNK
normal despite low total-body stores
what prevents ketoacidosis in HHNK
some circulating insulin which prevents lipolysis
HHNK ABG
normal ph, normal bicarb
HHNK presentation
polydipsia, polyuria, AMS, dehydration
Cr in HHNK
prerenal azotemia
HHNK treatment
NS
Insulin
glucose
potassium
when glucose reaches 250-300 in HHNK
given 5% dextrose
Hemophilia A
Factor 8 def
Hemopihilia A&B inheritance patterns
x linked recessive
hemophilia lab values
prolonged PTT
hemophilia symtpoms
hemarthroses (bleeding into joints)
intramuscular hematomas
Hemophilia B
def of Factors 9
Hemophilia A treatment
Factor 8 during acute bleeding episodes
minor dz, DDAVP
Hemophilia B treatment
factor 9 concentrates
not DDAVP
coccidiomycosis treatment
self resolving
coccidiomycosis skin findings
genearlized macular erthematus eruption of eryhthema nodosum
coccidiomycosis symptoms
fevers/chills/night sweats
chest pain
coccidiomycosis symptom constellation
erythema nodusum, fever, chest pain, arthrlagias
extrapulmonary sites of TB
meningitis
potts - bones of spine
Tb treatment
RIPE for 2 months
4 months of isoniazid & rifampin
asymptomatic TB treatment
isoniazid for 9 months
Tb test - 5mm induration
HIV positive
close contact
CXR changes
immunosuppression
gastritis triggers (3)
alcohol
nsaid
h pylori
gastritis - best diagnostic study
upper endoscopy with mucosal biopsy
gastritis - determining extent of erosions
double contrast barium study
gastritis - lab tests
CBC
stool guiac
stool antigen and urea breath test
CKD most common causes
HTN
DMT2
Glomerulonephritis
stage III CKD
30-59
5 absolute indications for emergent dialysis in CKD
acidosis electrolyte abnormalities ingestion of toxins overload of fluid uremia
stage V CKD
less than 15
CKD sodium and water retention
HTN, accelerated atherosclerosis
peripheral edema
CHF
Renal Osteodystrophy in CKD
hyperphosphatemia stimulates PTH
decreased alpha1vit D causes increased PTH
low calcium
osteitis fibrosis cystica
treatment of CKD anemia
EPO stimulating agents (can increase BP & thrombotic risk)
Stage IV CKD
15-29
CKD anemia
decreased EPO
normochromic, normocytic anemia
CKD labs
elevated Bun, CR increase K, phosphate decreased Na, Ca anemia metabolic acidosis
volume managemnt in CKD
loop diuretics
CKD anion-gapped metabolic acidosis
decreased excretion of H ions in ammonium
decreased renal excretion of organic anions
hyperkalemia in CKD
inability to excrete potassium
platelet dysfunction in CKD
uremia-induced
increased bleeding risk
CKD increased infection risk
uremia-induced neutrophil dysfunction
CKD metabolic acidosis treatment
sodium bicarb
CKD stage 1
90+
CKD dietary modifications
low phosphate diet, phosphate binders
vit d analogues
low potassium diet
protein restriction
CKD stage II
60-89
treatment of AIN
- supportive
- corticosteroids
AIN presentation
ARF w/
fever, rash, N/V, malaise
AIN lab values
increase in Cr
eosinophilia
AIN caused by what toxins?
cadmium lead copper mercury mushrooms
AIN caused by what drugs?
Pencillin, NSAID, Allopurinol, Diuretics, Cephalosporins, PPI, Sulfonamide/Sulfasalazine, Rifampin
AIN caused by systemic diseases?
Strept, Legionella
Sarcoidosis, Amyloidosis,
SLE
Myoglobinuria, high uric acid levels
AIN urinalysis
granual and epithelial casts
AIN kidney biopsy
inflamm cells in interstitium
tubular cell necrosis
AIN complications
ATN
ARF, CRF
RPN
septic arthritis PE findings
warm, red, tender joint
skin lesions
septic arthritis cause in young male
N. gonorrhea
septic arthritis- most common pathogen
s. aureus
septic arthritis in immunocompromised
fungal, candida
treatment for S. aureus septic arthritis
nafcillin/oxacillin/dicloxacillin
treatment for N. gonorrhoeae septic arthritis
ceftriaxone + axithro/doxy
surrigical irrigation and drainage usually not necessary
septic arthritis in sickle cell pts and IV drug users
Salmonella
Pseudomonas
gram negative septic arthritis treatment
aminoglycoside
MRI in septic arthritis
confirm joint effusion
joint aspirate in septic arthritis
wbc 50000+
high neutrophil count
low glucose
septic arthritis treatment
surgical irrigation and drainage
septic arthritis - what to monitor for treatment efficacy
CRP
septic arthritis lab findings
WBC 10K+
ESR 30+
CRP 5+
septic arthritis symptoms
pain in joint
fever
pain with passive ROM
Malaria affects which RBCs
vivax/ovale: reticulocytes
malariae: mature RBC
falciparum: reticulocytes & RBC
malaria vector
Anopheles mosquito
malaria symptoms
chills, myalgia, HA
NVD
splenomegaly
hypnozoites associated with
vivax/ovale
fever & malaria
falciparum constant
ovale and vivax - q48hr
marlariae - q72h
most severe form of malaria with cerebral, renal & pulm symptoms
falciparum
primaquine as treatment and prophylaxis for malaria in
Mexico and Argentina
treatment of malaria in chloroquine resistant areas
quinine sulfate + tetracycline
atovaquone-proguanil
artemether-lumefantrine
med for Pvivax and Povale malaria
primaquine phosphate, two weeks
malaria prophylaxis
chloroquine
mefloquine
malaria diagnosed with
perpheral blood smear with giemsa-staining
primary syphilis
painless chancre (ulcerated penile lesion)
4 causes of false positives with VDRL
viruses (mono, hepatitis)
drugs
rheumatic fever
lupus and leprosy
tertiary syphilis
gumma formation
aortitis
neurosyphilis
congenital syphilis initial symptoms
rhinitis
lesions on palms/soles
HSM, jaundice
hemolytic anemia, thrombocytopenia
neurologic symptoms of tertiary syphilis
tabes dorsalis
argyll-roberston pupils
broad based ataxia
stroke
condyloma lata
smooth, flat, lessions in most areas
screening test and confirmatory test for syphilis
VDRL or RPR
FTA-ABS
negative VDRL with positive FTA
sucessfully treated syphilis
treatment for primary syphilis
benzanthine penicillin IM
doxy or tetracycline for 2 weeks
treatment of secondary and tertiary syphilis
benzathine pencilline g IM for 3 wks
doxy for 28 d
three general causes of acquired long QT syndrome
drugs
electrolyte imbalance
MI
long qt =
delayed in repolarization of myocardium
What effect does every drug that causes prolongation of the QT interval have?
block cardiac Ikr current mediated postassium channels
diagnosis of Qt prolong on ECG?
qt/sqrt(RR)
less than 440
electrolyte imbalances that can cause long qt
hypokalemia
hypomagnesium
hypocalcemia
drugs that cause long qt
quinidine, amiodarone haloperiodal, methadone cisapride erythromycen aresenic trioxide
prolonged QT life threatening complication
torsades de pointes
long qt treatments
stop drug, correct electrolytes, IV mag sulfate
lactase absorbed …
brush border of enterocytes
borborygmi
rumbling noises made by gas and fluid in intestines
tests for lactose intolerance
lactose absorption test (minimal increase in serum glucose)
lactose breath hydrogen test
lactose intolerance stool
bulky, frothy, watery
lactase deficiecny pathophysiology
lactase production decreases over time
injury to small intestine
etiologies of DIC
1) sepsis
2) trauma
3) malignancy
4) ob complications
5) severe intravascular hemolysis (malaria, AHTR)
pathogenesis of DIC
1) exposure of excess tissue factor
2) coagulation
3) thrombosis & fibrinolysis
4) hemorrhage
chronic DIC clinical manifestations
asymptomatic
predilection for thrombosis
factors that determine whether DIC will be acute or chronic
- etiology
- rate
DIC lab findings
1) thrombocytopenia
2) shistocytes
3) decreased fibrinogen, elevated PTT, PT
4) elevated
FDP, D-dimer
lab findings in chronic DIC
elevated FDPs, D-dimer, schistocytes
no coagulopathies
DIC supporative care
transfuse platelets if less than 50K
increased INR/decrease in fibrinogen: FFP or cryoprecipate
purpura fulminans
rate but fatal complication of DIC
extensive tissue thrombosis and skin necrosis
treat with proctein c
what predisposes to myxedema coma?
longstanding uncontrolled hypothyroidism (usually primary)
supportive measures in myxedema coma?
intubation with mechanical ventilation
passive rewarming
non-dilute fluids with electrolytes and glucose
myxedema coma =
severe hypothyroidism
with
decreased MS, hypothermia, hyponatremia
What makes airway management challenging in a patient with myxedema coma?
nonpitting edema - enlarged tongue, edematous pharynx
4 complications of myxedema coma
cardiac abnormalities
lipid abnormalities
anemia
depression
myxedema coma labs
TSH, free T4, cortisol
myexedma coma clinical presentation
decreased MS
hypothermia
hyponatremia
hypercapnia
myxedema cardiac abnormalities
low cardiac output, hypotension, CHF
reverse with correction of thyroid hormones
drug given during myxedema coma
IV levothyroxine (T4)
hereditary elliptocytosis genetic mutations
eryhtrocye membrane proteins: alpha spectrin, beta spectrin
hereditary elliptocytosis more prevalent in africa…
protection against malaria
primary cause of symptoms in hereditary elliptocytosis
hemolytic anemia/chronic hemolysis
treatment of hereditary elliptocytosis with severe symptoms
splenectomy
blood transfusion
most severe type of hereditary elliptocytosis
hereditary pyropoikilocytosis
best initial treatment for hereditary elliptocytosis
no treatment
folic acid
6 states that worsen hemolytic anemia in hereditary elliptocytosis?
neonates (high 2,3BPG) renal allograft rejection TTP/HUS infection pregnancy b12 def
roles of vWF in hemostasis
adheres to platelets and subendothelial components
binds favtor VIII
vWD diagnostic tests
plasma vwf antigen
plasma vwf activity (ristocetin cofactor assay)
factor VIII activity
wVD clincial scenarios
difficult to control epistaxis
excessive bleeding following invasive procedures
menorrhagia
excessive peripartum bleeding
vWD pts before surgery should be given
vWF concentrate
presenting symptoms of FSGS
edema
foamy urine
HTN
dyspnea
FSGS risk factors
IV drug use
HIV
FSGS biopsy
sclerotic changes in glomeruli
FSGS treatment
steroids, cytotoxic agents, ACEI, statins
FSGS lab findings
HLD, hematuria, high levels of proteinuria, hypoalbuminemia
wegner’s biopsy
granulomatous inflamm of blood vessels
MPGN etiologies
Hep B,C
Lupus
bacterial endocarditis
autoimmune, idiopathic
MPGN lab findings
hematuria
hypocomplementemia
osmotic diuresis leading to hypernatremia
mannitol
glucosuria
renal cell CA triad
hematuria
palpable flank masses
flank pain
renal cell CA paraneoplastic syndromes
PTHrp, EPO, ACTH, Renin
causes of hypervolemic hypernatremia
cushings
exogenous steroids
primary hyperaldosteronism
hypercalcemia ekg findings
av block, shortened qt
renal sodium loss – hypovolemic hypernatremia
diuretics
osmotic diuresis
renal failure
extra renal sodium loss – hypovolemic hypernatremia
diarrhea, diaphoresis, respiratory
good pastures triad
anti GBM antibodies
rapidly progressive GN
pulmonary hemorrhage
MPGN treatment
steroids with aspirin or dipyridamole
polyarteritis nodosa risk factors
hep B, C, older age, male
polyarteritis nodosa - alternative to tissue biopsy
mesenteric or renal arteriography emonstrating multiple aneurysms and irregular constrictions
polyarteritis nodosa =
vasculitis of medium sized muscular arteries
segmental transmural inflamm leads to fibrinoid necrosis
polyarteritisi nodosa, rule out
ANCA
polyarteritis nodosa presentation
systemic symptoms
multisystem organ damage
polyarteritis nodosa - organ most commonly involved
kidney
PAN transmural inflamm leads to
aneurysm of arterial wall
PAN labs
increase WBC, ESR
decreased hgb, hct
proteinuria, hematuria
polyarteritis nodosa - body parts affected
kidneys, heart, gi tract
muscle, nerves, joints
PAN treatment
steroids
cyclophosphamide
PAN skin manifestations
erythema nodosum like
palpable purpura similar to HSP
PAN gi symptoms
ischemic abd pain (after meals, leads to wt loss)
PAN CNS symptoms
named nerve s- both motor and sensory deficits
PAN diagnosis
biopsy of tissue
HSP pathophysiology
small vessel vascuilitis characterized by IgA
HSP joint manifestations
transient non-migratory arthralgia
HSP renal
iga immune complex deposition
HSP treatment
mainly self limiting/supportive
otherwise, prednisone and acei and diuretics
HSP GI symptoms
colicky abd pain
increased risk of intussusception
HSP urinalysis
blood and protein in ruine
rBC casts
HSP tetrad
palpable purpura
polyarticular arthritis
abd pain
renal failure
