Firecracker/Step Up Cirrhosis, Dyspnea Flashcards
Cirrhosis pathology
diffuse, irreversible
firbosis, necrosis, nodules
Cirrhosis - most common causes
Hep C > Alcohol > NAFLD > Hep B
Cirrhosis - less common causes
Autoimmune, PBC, PSC, Wilson’s Disease, Hematochromatosis, alpha 1 antitrypsin def, drugs
Findings in Cirrhosis
Jaundice, Ascites, Hepatic Encephalopathy, Asterixis
Palmary erythema, spider angiomatas, gynecomastia
caput medua
Compensated cirrhosis
fatigue, wt loss, weakness
Decompensated cirrhosis
ascites, edema
confusion, pruritis
hematemesis, melena
liver biopsy for cirrhosis
presence of fibrosis
regenerating hepatic nodules
decreased number of septa
ultrasound in cirrhosis
assess countour of liver
impedeance of blood flow
amount of ascites
Severe Complications of cirrhosis
SBP, varices
hepatorenal/hepatopulmonary syndrome
portal vein thrombosis, cardiomyopathy, hepatic encephalopathy
Treatments for Cirrhosis
beta blockers
lactulose
TIPS
hepatic congestion can occur secondary to
right sided heart failure
constrictive pericarditis
treatment of varices
IV antibiotics
IV octreotide for 3-5 d
beta blockers
endoscopic treatment
albumin in cirrhosis
hypoalbuminemia = reduced oncotic pressure
SAAG > 1.1
portal HTN likely
fetor hepaticus
musty odor of breath
associated with hepatic encephalopathy
SBP most common causes
e coli
klebsiella
s. pneumonia
how to treat coagulopathy in cirrhosis
FFP (not vit k)
ascites usually found in
portal htn/increased hydrostatic pressure
hypoalbuminemia
malignacies - ovarian
infections - tb
clinical presentation of ascites
abdominal swelling and wt gain
SOB
physical exam for ascites
bulging flanks
fluid waves
shifting dullness
evaluation of ascitic fluid
apperance
albumin, total protein
cell count, cell culture
causes of portal htn with SAAG > 1.1
Budd-Chiari
CHF
constrictive pericarditis
SAAG < 1.1
nephrotic syndrome
cancer
complications of ascites
SBP
hepatic hydrothorax
treatment of ascites
sodium restriction
diurectics - furosemide, spironolactone
beta blocker
alcoholic progression of liver disease
fatty steatosis –>
alcoholic hepatitis –>
liver cirrhosis/fibrosis
alcoholic liver disease liver biopsy shows
Mallory bodies
steatosis
fibrosis
Mallory bodies
eosinophilic hyaline inclusion bodies
steatosis
fatty deposion
LFTs in alcoholic liver disease
AST:ALT 2:1
lab tests for alcoholic liver disease
bilirubin, alk phos, GGT
PT/INR
MCV
alcoholic liver dz complications
cirrhotic complications
liver failure
HCC
death
Disulfiram/Antabuse
inhibits acetaldehyde dehydrogenase
flushing, vomiting, nausea
drug induced liver injury
tylenol, statins, Atbs(amox-clauv, isoniazid), amiodarone, antifungals, valproic acid
pre-renal azotemia
decreased renal blood flow
decrease in glomerular hydrostatic pressure –> –>
decrease in amount of nitrogenous waste products filtered
Causes of pre renal azotemia
hypovolemia, hypotension
decreased CO
RAS/fibromuscular dysplasia
meds: ACEIs, NSAIDs
pre renal azotemia that leads to renal damage
has progressed to intrinsic renal dz
Intrinsic Renal Disease
damage to renal parenchyma
depends on location: glomerular dz, tubular-interstitial dz, vascular dz
Type I RPGN
Good pasture syndrome
Type II RPGN
poststreptococcal glumerolonephritis
lupus nephritis
iga nepropathy
Type III RPGN
wegner granulomatosis
tubular-interstitial dz
ATN or AIN
ATN
ischemic (more common)or nephrotoxic insult
epithelial casts, muddy-brown renal tubular casts
Vascular diseases
intrarenal vascular occlusion
intrarenal vasculitis
intrarenal vasculitis
wegener granulomatosis
intrarenal vascular occlusion
renal artery/vein thrombosis
thrombotic microangiopathies: HUS, TTP
Post renal azotemia
obstruction or urine outflow
causes of post renal azotemia
obstruction of urethra by BPH neprholithiasis neoplastic obstruction retroperitoneal fibrosis bilateral staghorn stones
retroperitoneal fibrosis
bilateral obstruction of ureters
bilateral staghorn stones
bilateral obstruction of kidneys
ARF symptoms
fatigue, anorexia, nausea, AMS
oliguria, hematuria, flank pain
weight gain + edema!!!
pre renal azotemia labs
minimal-> no proteinuria
hyaline casts
osm > 500
FeNa<1
intrinsic: tubular dz labs
mild-mod proteinuria
pigmented granular casts
1 FeNa
AIN labs
mild-mod proteinuria, leukocytes
white cells and casts, eosinophils, RBCs
1 FeNA
acute glomerulonephritis labs
mod to severe proteinuria
RBCs and RBC casts
>500 osm
<1 FeNa
postrenal azotemia labs
minimal/no proteinuria
crystals, rbcs, white cell
1 FeNa
imaging for ARF
ultrasound
ct
renal arteriography
renal biopsy
AKI complications
uremia volume expanison --> pulm edema hyperkalemia hyponatremia hypernatremia metabolic acidosis hypocalecemia hyperphosphatemia anemia infections
AKI treatment
prevention
correct underlying fluid and electrolyte imbalances
dialysis
pre-renal AKI treatment
maintenace of euvolemia, underlying disorder treatment
swan-ganz catheter
intra-renal AKI treatment
supportive
possible immunosupp meds
postrenal AKi treatment
bladder catherization or surgical removemnt
prognosis of AKI
decreases with increasing age and severity
mortality in AKI
infection
cardiorespiratory complications
dyspnea - broad causes
cardiac, pulmn, cirrhosis, kidney, hematological (anemia)
dyspnea - cardiac
ACS, CHF, pericarditis
dyspnea - pulm
bronchitis, pneumonia, COPD, pulmonary embolism, pulmonary fibrois, pulmonary htn
HAP organisms
GNR
S auerus
ventilator associated
Aspiration pneumonia
right lower lobes
GN, anaerobes
HAP - acquire up to…
90 days after d/c (stay 2 nights)
30 days after nursing home/rehab
risk factors for aspiration
seizures
oropharyngeal muscle fatigue
cns depression
alcoholics - common organism for pneumonia
Klebsiella
pneumonia diagnosis
PA and lateral CXR
sputum gram culture
methanamine silver stain
PCP
severe complications of pneumonia
acute respiratory failure
pleural effusion
empyema
sepsis
CAP treatment
azithromycin for 5 days
Pneumonia treatment - inpatient, non ICU
respiratory fluroquinolone (moxi/gemi/levofloxacin)
or
B lactam + macrolide
Pneumonia treatment - inpatient, ICU
blactum + azithromycin OR resp fluroquinolone
or
azetronam + fluroquinolone (peniclllin allergic)
pneumonia - pseudomonas
pipercillin-tazobactam, cefepime or imipenem
+
cipro or levofloxacin or aminoglycoside+erythromycin
CA MRSA pneumonia
add vanc or linezolid
CURB-65
predicts 30 day mortality
confusion, BUN >19, RR >30, bp: systolic <60
65 or older
SIRS diagnosis
2 or more of HR>90 Temp 100.4 WBC 12000 RR > 20 or PaCo2<32
Sepsis diagnosis
2 or more SIRS criteria
plus positive blood cultures or source of active infection
sepsis can progress to
septic shock
DIC
multiple organ dysunfction
death
risk factors for sepsis
bacteremia advanced age diabetes cancer immunosuppresion
severe sepsis
meet criteria for sepsis and evidence of organ dysfunction, hypotension, or hypoperferusion
Septic shock
sepsis and hypotension refractory to fluid resuscitation
septic shock caused by
peripehral vasodilation leading to severe drop in systemic vascular resistance
skin of individual in septic shock
flushed, warm
other lab values in patients with sepsis
elevated lactic acid
increased bun/cr
elevated liver enzymes
septic shock - lab values to differentiate from other types of shock
CO normal or elevated
MVO2 increased
SVR decreased
PCWP normal or decreased
symptoms of sepsis/septic shock
fever, hypothermia, tachycardia, tachypnea, AMS, oliguria, abd pain
Cause of sepsis
1) Gram Positive –> S. aureua
2) GN: E coli
3) fungal: Candida
if you acquire sepsis in hospital, coverage must include
MRSA, pseudomonas, e coli
treatment of sepsis
broad spectrum antibiotics
IV fluids
pressors
first line vasopressor in sepsis
norephinephrine/levophed
most common cause of cryptogenic organizing pneumonia
idiopathic
viral infections
drugs
CTD
saddle embolusm
occludes bifurcation of R and left main pulmonary arteries
most common cause of PE
DVTs
PE symtpoms
sudden onset of dyspnea, pleuritic chest pain, tachypnea, tachycardia
PE later findings
resp alkalosis with hypoxia and hypocarbia
loud P2
right heart failure
PE imaging
CT angiogram
V/Q scan
not used
gradient in PE
increased A-a gradient
areas of unused ventilation
low Pco2
PE CXR
normal
may show Hamptom’s hump or westermark’s sign
hamptom’s hump
wedge shaped infarct
westermark’s sign
oligemia in affected zone
PE EKG classic finding
S1 s wave in 1
Q3 q wave in 3
T3 inverted t wave in III
but has to be large enough to cause cor pulmonale and new RBBB
PE most common EKG finding
nonspecifict St and t wave changes
PE treatment
thrombolytics
6 months of warfari (with heparin bridge)
PE treatment if anticoagulation can’t be used
IVC filter