general Flashcards
polymayalgia rheumatica is associated with __________ (causes headache)
giant cell arteritis
creatinine kinase levels in polymyalgia rheumatica?
creatinine kinase will be normal because muscles are spared in polymyalgia rheumatica. mm biopsy will also be normal. the mm pain is referred pain from joints and connective tissue. however, inflammatory markers ESR and CRP will be elevated and pt may have low grade fever
typical pt demographic of polymyalgia rheumatica; aggrevating/relieving factors
usually women >50; worse at morning/night. Improved with activity. Treated with low dose corticosteroid, activity, diet (bonus: often triggered by adenovirus, parvovirus)
hematogenous osteomyelitis is most common in which demographics
children; IV drug users; may also cause vertebral osteomyelitis in adults >50. Most common pathogen is staph aureus.
treatment in adults: IV Vancomyocin PLUS IV antipseudomonal fluroquinolones or antipseudomonal cephalosporins
in kids >3mo IV nafcillin/oxcillin or cefazolin
3 complications of osteomyelitis
sequestrum, abscess, or, in children growth impairment
imaging of choice for osteomyelitis
MRI (not visible on Xray for first two weeks)
exogenous osteomyelitis
usually due to multiple pathogens. Can be due to trauma, contiguous from a wound like a diabetic ulcer (think Staph epidermidis and Streptococci!); contiguous spread from cellulitis, prosthetic device;
blood test findings for rheumatoid arthritis
RF factor (IgM) and anti-CCP antibody you may also see anemia because the liver over produces hepcidin, decreasing iron absorption and causing iron trapping in macrophages)
extra articular complications of rheumatoid arthritis
interstitial lung fibrosis pleural effusion anemia athrosclerosis muscle breakdown rheumatoid nodules general inflammatory signs (weakness, malaise, fatigue, decreased appetite, fever)
Felty syndrome
rheumatoid arthritis + granulocytopenia + splenomegaly
- *can lead to life threatening infections **
tx: methotrexate
articular manifestations of rheumatoid arthritis
morning stiffness; symmetrical inflammation and pain of joints especially starting with smaller joints
rheumatoid hand: ulnar deviation of the fingers, swan neck finger, Boutonniere deformity; **Atlanto-axial sublexation (be sure to get an Xray if someone has neck pain with RA!)
differential for rheumatoid arthritis might include…
OSTEOARTHRITIS (but this will usually be asymmetrical in weight-bearing joints without constitutional symptoms! plus a little bit older crowd)
PSORIATIC ARTHRITIS (look for psoriatic skin lesions and nail changes)
GOUT (usually just one joint, often a big toe, acute attacks, asymmetrical)
PSEUDOGOUT (again asymmetrical and usually just one joint)
labs in piagets disease of the bone
elevated alk phos, normal serum calcium and phosphate
most common lung cancer in non smokers,
adenocarcinoma
CREST syndrome
Calcinosis cutis (little nodules usually over pressure points) Reynaud's phenomenon Esophogeal hypomotility Sclerodactyly Telangectasia
dx: ana , anti centromere
diffuse scleroderma has anti scl 70 (antitopoisomerase I antibody) , anti RNA polymerase III
Tx: methotrexate, PPIs for GERD, organ specific symptom relief
angina pectoris, erythema nodosum, decreased or absent bilateral brachial and radial pulse, syncope
Takayasu arteritis I can’t taka ya pulse
autoimmune granulommatous inflammation of aorta and major branches
high ESR, angiography is gold standard for dx
tx: corticosteroids, may need methotrexate, cyclophosphamide or even surgical bypass
what virus associated vasculitis should you consider in a young person with stroke or MI?
Polyarteritis nodosa
associated with Hep B, Hep C
Clinical features
Nonspecific symptoms: fever, abdominal, muscle, and joint pain
Renal involvement; hypertension, renal impairment
Coronary artery involvement; increased risk of myocardial infarction
Skin involvement; rash, ulcerations, nodules
Usually spares the lungs!!
Blood tests Hepatitis B serology Hepatitis C serology ↑↑ ESR ANCA-negative Angiography: Treatment corticosteroids, cyclophosphamide Antiviral therapy against HBV and HCV
diagnostic test to differentiate between chlamydia and gonorrhea
nuclea acid amplification test
treatment for genital chlamydia
azithromycin or doxycycline
treatment for mastitis
dicloxacillin & continued breast feeding (covers s.aureus)
USPSTF guideline on mammography
biennial screening women 50-74
if women have several risk factors like early menarche, nulliparity and first degree relatives with cancer, screening can begin at 40
USPSTF guineline on abdominal aortic anuerysm screening
one time screening for abdominal aortic aneurysm for men 65-75 who have ever smoked
most common vaginal cancer
squamous cell carcinoma, usually caused by HPV type 16 or 18
colorectal cancer screening
Either colonoscopy every 10 years, an annual fecal occult blood test, or sigmoidoscopy every 5 years is indicated in every adult ≥ 50 years of age.
Pap smear recommendations
A Pap smear should be conducted to screen for cervical cell dysplasia every 3 years starting at 21 years or every 5 years at 30 years, if combined with HPV testing.
syphilis screening
basically everyone should get screened for syphillis, especially pregnant women!!
initial tests: RPR (rapid plasma reagin) or VDRL
confirmatory test: fluorescent treponemal antibody absorption test FTA-ABS
tx for endometriosis
mild/mod pain w/o complications: empirical treatment with nsaids and hormonal contraceptives
severe symptoms: GnRH agonist (buserelin, goserelin) and estrogen-progesteron OCPs
surgical intervention: fist line is laprascopy; 2nd line is hysterectomy +/- salpingo oophorectomy
steps of diagnosis for endometriosis
Physical exam: check for rectovaginal masses and adnexal masses
transvaginal ultrasound: evidence of ovarian cysts (chocolate cysts); uterus usually not enlarged
laproscopy is confirmatory but you can treat empirically if it’s mild/moderate without complications!
morning sickness treatment options in order of preference
- pyridoxine (B6)
- doxylamine
- diphenhydramine of dimenhydrinate
- last resort: methylprednisolone (not in 1st trimester)
PID outpatient treatment
one dose IM ceftriaxone and then oral doxy
Foul-smelling, frothy, yellow-green, vaginal purulent discharge with pH>4.5
Trichomonas, protozoa with multiple flagella on saline wet mount
treat with metronidazole or tinidazole
screening for chlamydia trachomatis and N. gonorrhea
screening for sexually active women 24 and younger and older women at increased risk
nucleic acid amplification testing (NAAT)
treatment for yeast infection
topical nystatin, topical azoles or oral fluconazole
symptoms and treatment for Legionnaire’s disease
watery diarrhea and atypical pneumonia (cough, low grade fever, sob), hyponatremia, patchy lung infiltrates
Levofloxacin
first line for acute bacterial rhinosinusitis
oral amoxicillin-clavulanic acid (penicllin +beta lactamase inhibitor)
superior vena cava syndrome is most commonly caused by _______cancer or ________________ (particularly young patients)
lung cancer (small cell, squamous) or non-hodgkin lymphoma in young pts symptoms include headache that worsens with leaning forward, engorged veins over the anterior chest, and swelling that is limited to the head, neck, and upper extremities.
granulommatous disease like sarcoidosis, tuburculosis, chrons, cat scratch fever, granulomatosis with polyangiitis, etc. are associated with high serum _____
high serum calcium
macrophages produce more 1alpha hydroxylase which activates vitamin d leading to bone resorption
antiarrhythmic associated with pulmonary fibrosis and chronic interstitial pneumonitis!
amiodarone (blocks voltage gate K+ channels used for vtach and vfib, low negative ionotrope)
tx for vasomotor rhinitis
azelastine nasal spray (astelin, astepro)
vasomotor rhinitis = A condition characterized by an increase in blood flow to the nasal mucosa, which results in nasal congestion, rhinorrhea, and postnasal drip. Not attributable to a known allergic process. Triggers include drugs (e.g., NSAIDs), emotional stimuli (e.g., anxiety, excitement), strong odors (e.g., cigarette smoke, perfume), and cold, dry air.
complications of bronchiectesis
damage to broncheal vessels –> hemoptysis (usually self limited), hemorrhage
cor pulmonale
pathophys of bronchiectesis
Bronchiectasis is an irreversible and abnormal dilation in the bronchial tree that is generally caused by cycles of bronchial inflammation in addition to mucous plugging and progressive airway destruction. Although the widespread use of antibiotics has made bronchiectasis rare, conditions such as cystic fibrosis (CF), severe or protracted pneumonia, immunodeficiency, and COPD continue to cause it. The most important clinical finding is a chronic cough with copious mucopurulent sputum. Other symptoms may include dyspnea, rhinosinusitis, and hemoptysis. Physical examination reveals crackles and rhonchi on auscultation, often accompanied by wheezing. High-resolution computer tomography is the best diagnostic test and shows thickened bronchial walls, a signet-ring appearance, and “tram track” lines. Treatment focuses on alleviating symptoms and preventing exacerbations, and includes pulmonary physiotherapy and antibiotics to treat underlying infections. In rare cases, massive hemoptysis may complicate bronchiectasis and necessitate surgery or pulmonary artery embolization.
Light’s Criteria
- Plueral fluid protein: serum protein <= 0.5 transudative; >0.5 exudative -Pleural fluid LDH: serum LDH <= 0.6 transudative; > 0.6 exudative -Pleural fluid LDH <2/3 the upper limit of normal serum LDH, suggests transudative; >2/3 uln suggest exudative. Really high ldh like >1000 suggests malignancy, rheumatoid effusion, empyema
name some thangs that cause transudative pleural effusions
Stuff that ups hydrostatic pressure like CHF or CKD (Na+ retention)
stuff that loses protein content (decreases oncotic pressure) like cirrosis or nephrotic syndrome or protein losing enteropathy
name some thangs that cause exudative pleural effusions
exudative pleural effusions suggest local lung parenchymal damage
malignancy, TB, other infection, Dressler’s, pneumonia, PE, autoimmune disease especially the ones that affect vascular collegen like sarcoidosis, RA, vasculitis, SLE, pancreatitis, trauma, chylothorax, hemothorax, pseudochylothorax
___________ is a trigger for asthma and associated with difficult to treat asthma. think about empiric therapy in pts with risk factors like obesity who’s asthma worsens when lying down or after meals
GERD
PPIs (prazoles)
COPD pathophys
The hallmark pathophysiologic mechanism in COPD is irreversible progressive obstruction of expiratory airflow due to chronic bronchitis and/or emphysema. In emphysema, chronic exposure to cigarette smoke destroys the alveolar walls, enlarging the airspace. These airways eventually collapse and cause obstruction, leading to air trapping and hyperinflation. In chronic bronchitis, cigarette smoke causes the proliferation of mucinous-secreting cells (goblet cells) and impairs ciliary function. These effects lead to excess mucous secretion, mucus plug formation, and airflow obstruction.
tactile fremitus is ___________ in pneumonia
increased
say 99, use ulnar side of hand on their back
also ask patient to whisper “123” it will sound clearer where there is consolidation. THis is called whispered pectoriloquy
tactile fremitus is __________ in pleural effusion
decreased
painless genital ulcers which heal spontaneously within a few days followed by swelling of LNs in a few weeks +/- abscess, pus
Lymphogranuloma venereum
Chlamydia trachomatis serotypes L1, L2, L3
tx: doxycycline
untreated can lead to chronic lymphedema, strictures, infertility
very painful genital ulcers with necrotic base, usually one for men, multiple for women, often with painful inguinal lymphadenopathy
chancroid caused by Haemophilus ducreyi
tx: azithromycin or single dose IM ceftriaxone
granuloma inguinale: cause, symptoms, treatment
large, painless ulcers, beefy red, bleed easily; may get bacterial superinfection and smell bad
caused by Klebsiella granulomatis (Donovan bodies)
tx: azithromycin
_____________ is associated with a positive Prehn sign (relief of pain when lifting the testicle)
epididymitis
prostate cancer most commonly mets to ____
bone
step 1 treatment
SABA PRN (albuterol, levalbuterol, terbutaline)
step 2 treatment for asthma
low dose ICS (fluticasone, budesonide, bethomeclasone, mometasone, etc)
intermittent asthma criteria
intermittent: sx less than or = twice a week, nighttime wakings less than or = twice a month, one or less exacerbations a year, no interference with normal activity
step 3 for asthma
low dose ICS+ LABA Advair (fluticasone +someterol) Symbicort (budesonide + formeterol) Dulera (mometasone +formeterol) consider adjunct tiotropium (antimuscrinic), allergen immunotherapy)
step 4 for asthma
daily symptoms, nightly wakings, extreme interference with daily activity, FEV1<60% predicition, 2 or more exacerbations a year, SABA use several times a day
referral!
Med dose ICS+LABA
Steps 5, 6 for asthma
referral! high dose ICS+LABA, maybe oral corticosteroids, maybe anti
name 2 long acting insulins
glargine (Lantus)
Detemir (Levemir)
name 3 rapid acting insulins
novolog (Aspart)
humalog (Lispro)
Glulisine (Apidra)
if you get hit in the head with a log, it will hurt rapidly
name a short acting insulin
regular, human insulin Humulin R, Novolin R
name an intermediate acting insulin
NPH Humulin N, Novolin N
According to JNC 8 guidelines, In the general population, pharmacologic treatment should be initiated
when blood pressure is
___ mm Hg or higher in adults 60+ years and
____mm Hg or higher in adults younger than 60 years.
and _______mmHg for adults with diabetes or CKD
150/90 for adults >60
140/90 for adults <60
140/90 for adults with htn and diabetes or CKD, regardless of age
consider ACEi or ARB as initial treatment if CKD
in nonblack pts, initial htn treatment should include
thiazide, ARB, ACEI, or calcium channel blocker
in black pts, initial htn treatment should include
thiazide or calcium channel blocker
According to JNC 8 guidelines, if the target blood pressure is not reached within _____ after
initiating therapy, the dosage of the initial medication should be increased, or a second medication should be added.
one month
Do not combine an ACEi with ______
ARB
causes of secondary hypertenstion
RECENT
Renal (renal artery stenosis, glomerulonephritis–remember nephritic syndrome is low level proteinuria, microhematuria, oliguria and htn)
Endocrine (Conn (hyperaldosteronism), Cushing (hypercortisol), hyperthyroidism)
Coarctation of the aorta
Estrogen (oral contraceptives)
Neurologic (raised intracranial pressure, neurostimulants like cocaine, pcp, meth)
Treatment (NSAIDS, corticosteroids)
and also Obstructive sleep apnea
USPSTF recs for pap smears
every 3 years starting at 21; every 3 years after 30 or every 5 years if combined cytology with HPV testing
USPSTF recs for HIV screening
all preggers
all ppl 15-65
USPSTF recs on osteoporeosis screening
screening in women > 65years unless increased risk
does acetaminophen have anti inflammatory properties?
no
does acetaminophen have bleeding effects?
no
acetaminophen has ____ toxicity
liver
there’s a lot of liver pathology like NASH, alcoholic, hep C so it’s good to check CMP before starting acetaminophen for pain (it does have narcotic sparing effects)
2 major risks of NSAIDS
renal toxicity GI bleeding (be careful in elderly, may prescribe ppi)
topical nsaids
lidocaine (otc), diclofenac (can be really expensive)
gabapentin, topiramate, and cymbalta can all be used to tx_____
pain
antibodies in primary biliary cholangitis?
asymptomatic at first –> pruritis, fatigue, sky high cholesterol, jaundice –> cirrhosis, portal hypertension, ascities, gi bleed
anti mitochondrial
name drug used to treat primary biliary cholangitis
ursodeoxycholic acid
maybe liver transplant
ursodeoxycholic acid is used to treat
primary biliary cholangiitis
tx acute gout
cholcocine and nsaids like indomethacine
allopurinal for prevention
celiac tests
IgA tTG (anti tissue transglutaminase antibody) * screen test can be falsely neg IgA levels (lowered) if IgA tTG is negative but you still suspect celiac, do IgG deaminated gliadin peptide (DGP)
recurrent sinusitis/pneumonia/bronchitis + situs inversus + infertility
primary ciliary dyskinesia (Kartagener)
Vague discomfort and swelling in the scrotal region with multiple palpable cords (“bag-of-worms”) that enlarge on standing or with a Valsalva maneuver, usually in teens
varicocele
GET US!
tx: laprascopic varicolectomy
____________ polyps carry the highest risk of malignant transformation of all types of colonic polyps
adenomatous
villous adenomatous is the worse
contraindication for rotavirus vaccine
hx of intussusception
what pneumo vaccine to healthy adult over 65?
PPSV23
what pneumo vaccine to immunocompromised adult?
PCV13 then PPSV23 at least 8 weeks later
guidelines for when to treat osteoporosis
t score
treatment for osteoporosis
- bisphosphonates are first line: alendronate or risendronate. oral daily. 30 min before eating/reclining. GI side effects.
- smoking cessation
- alcohol and caffeine moderation
- daily sunlight
- PT/Exercise with strength and balance training
- fall risk assessment
- vitamin D supplement
amitriptyline side effects
TCA, dry mouth, blurred vision, constipation , risk of overdose
pharma therapy for fibromyalgia
*always give exercise rx (moderate aerobic 20-30 min 2-3x wk)
amitriptyline, duloxetine, milnacipran, gabapentin, pregabalin (lyrica), cyclobenzaprine (muscle relaxant)
tx for postmenopausal vaginal dryness
topical estrogen cream
tx for bacterial vaginosis
metronidazole (don’t need to treat partners bc not sti, it’s from imbalance of vaginal flora, douching is risk factor, caused by gardenella vaginalis)
tx vulvovaginal candidiasis in pregnancy
intravaginal clotramazole
2 major complications of giant celll arteritis
blindness, aortic aneurism
what antibiotic for rheumatic fever
penicillin
Lupus symptoms
- Fever
- Joint problems
- ANA+, anti dsDNA, anti Smith
- oral ulcers, alopecia
- skin stuff : malar rash, discoid lupus, subacute or acute cutaneous lupus,
- proteinuria! nephritis!
- low white blood cells, low platelets, low complement, hemolysis
- antiphospholipid antibodies (hypercoag?) anticardiolipin, lupus anticoagulant, anti beta2gp1
- psych issues! seizure delirium
Sjorgens antibodies
anti Ro/SSA
anti La/SSB
acute treatment of COPD exacerbation
bronchodilators (like albuterol and ipratropium (anticholinergic)),
systemic steroids,
antibiotics,
possibly O2
spirometry findings in COPD
reduced FEV1, reduced FVC,
FEV1:FVC <70
Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______
light COPD: salbutemol or salmeterol
more severe: tiotropium (LAMA) and maybe salmeterol too
Treat COPD pts based on their GOLD category. But my shortcut: if <= 1 exacerbation (no hospital) a year with mild symptoms, give them ______
light COPD: albuterol, ipatropium, salbutemol or salmeterol
more severe: add tiotropium (LAMA) and maybe salmeterol too to prn saba
**for frequent exacerbations, add inhaled steroids like fluticasone
guidelines for O2 therapy for COPD
when sat 88% at rest; use at least 15h a day to decrease mortality
abx for strep pneumo
penicillin (macrolide if they are allergic)
tx for peripheral arterial disease
- superivised graded exercise therapy, smoking cessation
- aspiring, clopidegrel, statin! manage BP and blood sugar
- if still symptomatic, give cilostazol (phosphodiesterase inhibitor)
cilostazol
phosphodiesterase inhibitor, used for PAD if conservative treatment, aspiring, clopedigrel doesnt work
a septic joint on exam:
very limited range of motion
ROM preserved if it’s nearby cellulitis, bursitis, osteomyeolitis
lab findings in RA
RF
anti CCP (anti citrullinated protein antibody)
elevated sed rate and CRP
anemia
thrombocytosis
low albumin (correlates with severity of disease)
acute treatment for gout
nsaids (be careful in elderly, may need to add ppi)
maybe colchicine
maybe glucosteroids
long term treatment/prevention gout
allopurinol (reduces uric acid production)
probenecid (increases uric acid secretion)
sulfasalazine
DMARD for RA
infliximab
anticytokine for RA
etanercerpt
anticyokine for RA
recent stomach bug or UTI followed by migratory arthritis, maybe conjunctivitis or iritis, dysuria
reactive arthritis – this is an autoimmune process!
HLA-B27, usually young men
dx: CRP, ESR, CBC with diff, maybe arthrocentesis,
tx: nsaids (if really severe, glucocorticoids or dmards)
tx for disseminated lyme disease
ceftriaxone
tx for localized lyme disease
doxycycline
name symptoms of stage II of lyme disease
carditis
migratory arthralgia –> lyme arthritis (large joints)
early neuroborreliosis: (usually cranial nerve like facial palsy)
erythema migrans
name symptoms of late lyme disease
months to years later
chronic lyme arthritis, late neuroborreolosis: asepctic/lymphocytic meningitis, progressive encephelomyeolitis
which antihypertensive class increases gout risk?
hydrochlorothiazide
labs at initial prenatal visit
Hep B surface antigen HIV Syphilis GC, CT cervical swab rubella antibody ( negative - stay away from sick ppl; if acutally get rubella at <16 wks, counsel to terminate) Pap smear if patient is due urinanalysis and urine cx CBC blood type and Rh status with antibody screen
don’t forget to screen for DV, substances, vitamins, preterm labor risk, genetic risk, family hx, depression
folic acid supplement: take ______ before conceiving
1 month at least, 400-800ug for low risk. 1mg for DM, 4mg if previous neural tube defect child
congenital rubella
cataracts congenital hearing loss cardiac defect blueberry muffin rash growth restriction hemolytic anemia, thrombocytopenia, hepatosplenomegaly, jaundice later: CNS problems like ID, microcephaly. skeletal abnormalities miscarriage
syphilis in pregnancy
treat with penicilin If less than 1 year, 1 dose IM.
If more than 1 year or unknown, penicillin IM each week x3
gonorrhea in pregnancy
may cause preterm labor, blindness
ceftriaxone
Chlaymydia in pregnancy
may cause neonatal blindness, pneumonia
azithromycin or amoxicillin
if mom is Hbsag pos in pregnancy
check LFTs and hep serology to determin if chronic or active. Baby will need Hep B vaccine and HepB IG right away
nuchal translucency can be given at _____ weeks pregnancy or combined test (NT, hCG, and PAPP-A)
10-13 weeks
if positive that means increased risk not a diagnosis.
you’ll offer karyotype, follow up ultrasounds, chorionic villas sampling or second trimenster screenin
trisomy screen at weeks ______ of pregnancy
15-20
tests reveal risk not dx. may be skewed by inaccurate dating. offer genetic amniocentesis
trisomy screen at weeks ______ of pregnancy
15-20
tests reveal risk not dx. may be skewed by inaccurate dating. offer genetic amniocentesis
triple screen: hCG, unconjugated estriol, alpha fetoprotein
quad screen adds inhibin A
GBS culture in pregnancy at weeks __________
35-37 if positive you get penicillin during labor. helps to prevent early group B strep sepsis pneumonia or meningitis of newborn
name 2 vaccines you can get in pregnancy
tdap, flu
baby gives social smile at __ mo
2 months
focus on face at 1 mo
baby sits well unsupported at — months
6
baby says mama dada byebye at — mo
9 months
baby crawls at —- months
9
baby walks at — months
12
baby babbles at —- months
6
age 3 developmental milestones
rides tricycle, 3/4 of speech understood by strangers, , bridge of 3 cubes, repeats 3 numbers, plays in a group (3 kids)
vision screen rec to rule out amblyopia/stabismus
3-5 yo
strabismus should be referred to a pediatric ophthalmologist
vaccines at birth
Hep B
vaccines at 2 mo
don't hate pediatric RNs for poking plus HepB dTap Hib PCV (PCV13) rotavirus Polio Hep B (same at 4 mo (minus HepB) and 6 mo (incl Hep B))
vaccines at 6 mo
don't hate pediatric RNs for poking plus HepB dTap Hib PCV (PCV13) rotavirus Polio Hep B (same at 4 mo (minus HepB) and 6 mo (incl Hep B))
vaccines at 4 mo
don't hate pediatric RNs for poking dTap Hib PCV (PCV13) rotavirus Polio (same at 2 and 6 mo except you get Hep B at those but NOT at 4 mo)
vaccines at 12-18mo
Dwarf People Holler and Hate Many Vaccines
Dtap PVC Hep A (one at 12 month, second dose 6 mo later) Hib MMR Varicella
vaccines at 4-6 yo
Don't Poke Me, Val Dtap Polio MMR Varicella
a common complication of topical decongestants
rebound congestion
allergic rhinitis exam
look for allergic shiners, nasal crease, septal deviation, boggy nasal mucosa thats pale bluish grey. cobblestoning of persterior pharynx. tonsillar hypertrophy. look for lymphadenopathy. pulm.
tx allergic rhinitis
- allergen avoidance/removal
- antihistamines 2nd gen loratidine, cetirizine, ranitidine
- oral decongestant: pseudoephedrine . rebound congestion
- intranasal corticosteroids like fluticasone
- leukotriene inhibitors like monelukast, zileuton
- oral corticosteroids
- desensitization
Tx for allergic rhinitis
- allergen avoidance/removal
- antihistamines 2nd gen loratidine, cetirizine, ranitidine
- __________________
- intranasal corticosteroids like fluticasone
- leukotriene inhibitors like monelukast, zileuton
- oral corticosteroids
- desensitization
- oral decongestant: pseudoephedrine . rebound congestion
tx for allergic rhinitis
- allergen avoidance/removal
- antihistamines 2nd gen loratidine, cetirizine
- oral decongestant: pseudoephedrine . rebound congestion
- intranasal corticosteroids like fluticasone
- _________________________
- oral corticosteroids
- desensitization
leukotriene inhibitors like montelukast, zileuton. also used in asthma.
tx for anaphylaxis (cutaneous sympommts, dyspnea, visceral edema, hypotension)
aqueous epinephrine 1:1000, in a dose of 0.2-0.5 ml subq or im, can give every 15-20min
IV fluids
intubation
tx for acute uticaria
eliminate trigger, second gen antihistamine like loratadine, ceterizine, fexofenadine, ranitidine
ranitidine+diphenhydramine particularly effective
most common cause of keratoconjunctivitis
adenovirus , usually with URI symptoms, tarsal conjunctival cobblestoning, morning crusting, modest discharge, usually bilateral
give antihistamines, decongestants. compress?
contraindications for bupropion
recent MAOi use, eating disorder, seizure disorder
pharmacological smoking cessation aid
bupropion (risk: suicidal ideation) - start 1-2 wks before quit date, can use patch with it, use up to 6 mo
chantix (varenicline) start 1 wk before quit day, use up to 6 mo,$$
pregnant ppl should try to not use pharm if possible, bupropion and varenicline are category C
fatigue, weakness, dyspnea, palpitations in geriatric pt
always consider anemia! check conjunctival pallor
also CHF, afib, angina
glossitis, decreased vibratory and positional senses, ataxia, confusion, dementia, pearly grey hair at early age, paresthesia, headache palpitation
vit B 12 deficiency
folate deficiency can also cause similar symptoms but neuro exam is normalish? both cause megaloblastic anemia. always test both vit B 12 and folate levels and remember their metabolism is interdependent.
also note that profound iron deficiency can cause glossitis, dysphagia, spoon nails (koilonychias)
hypothyroidism can also cause macrocytic anemia!
anemia workup
CBC with RBC indices
peripheral blood smear
reticulocyte count
lab findings in iron deficiency anemia
microcytic low ferritin low serum iron low transferrin saturation High TIBC
folate deficiency is most common among _____ and B12 is most common among people with ______
alcoholics often folate deficient
B12 deficiency in pernicious anemia, gasterectomy, malabsorption disease, vegans. confirmed by elevated MMA (methylmelonic acid)
give IM B12 daily for 7 days, weekly for 4 weeks, then monthly for rest of life or oral B12
oral folate until correcte
if qrs is upright in leads ______ of ecg, then axis is okay
I, II
how to calc hr on ecg
count the big boxes between 2 qrs complexes and divide by 300
each small box is 0.04s, each large box is .20 seconds
regular hr is 60-100
how to find axis on ecg
find lead where impulses equal above and below line. it’s 90 degrees from that. find the lead with highest R. That tells you the direction (i.e. which 90 degree angle)
normal axis is -30 to +90. negative to -30 is left axis deviation and above +90 is right axis deviation
squared off flattening of st segment on ecg
ischemia
downslope of st segment on ecg plus u wave
hypokalemia
normocytic anemia may occur in renal disease because of….
decreased EPO production by the kidneys
lab findings in anemia of chronic inflammation
the body has a ton of iron stores but can’t use them because inflammation has messed with the reticuloendothelial system! therefore
serum ferritin (iron storage) will be high! (low in iron deficiency)
TIBC low (because plenty of iron around)
serum iron (normal or low)
transferrin saturation - low or normal
normo or microcytic
pernicious anemia
most common cause of B12 deficiency. macrocytic anemia. burning in feet, ataxia, confusion, glossitis, early grey hair. fatigue!!
autoantibodies against intrinsic factor
elevated methylmalonic acid(MMA) confirms B12 deficiency
also Gastric Endoscopy to look for atrophic gastritis
virus, E coli, shigella, salmonella, giardia, cambylobacter and amebiasis are most common causes of…
acute gastroenteritis
1. test stool for fecal leukocytes!
most pts with acute diarrhea have self-limited processes and do not require much workup. But you need to be more cautious when…
bloody diarrhea kids or elderly diarrhea >48 hrs volume depletion fever >100.4 severe abdominal pain immunocompromised pts
travelers diarrhea treatment
- only people with increased risk of complications like those with underlying IBD, renal disease, immune compromise need prophylaxis (ciprofloxacin)
- tx traveler’s diarrhea with ciprofloxacin 500mg bid 1-3 days unless a kid or pregnant!
- 2nd line is azithromycin (safe for kids and preg.)
- rifaximin can be given if nonbloody and NO fever
vomiting and diarrhea 6 hours after eating…
s. aureus
test and tx for C. difficile
C. difficile toxin immunoassay
metronidazole or vancomycin
hormonal replacement therapy for women can increase risk of…
bad cardiovascular outcomes
screen all women over ___ yo for hyperlipidemia
45
when should you get an ankle or foot xray?
bony tenderness of the posterior edge or tip of the medial or lateral malleolus or if the patient is unable to bear weigh immediately or when examined
get foot exray if bony tenderness over the navicular bone or base of 5th metatarsal or pt cant bear weight(Ottawa ankle rules)
start with xray. if thats normal and symptoms persist, you might get MRI to look at ligaments/tendons
management for ankle sprain
PRICE protection rest ice compression elevation & nsaids or acetominophen
provocative test for supraspinatus injury (rotator cuff)
empty can test
provocative test for subscapularis
lift off test
provocative test for infraspinatus and teres minor
external rotation with elbows flexed and arms at sides
provocative test for subacromial impingement of the supraspinatus tendon
hawkins impingement (flapping chicken wing)
how to test for large rotator cuff tear
drop arm test – pt unable to slowly lower arm from raised position
how to test for anterior talofibular ligament tear
anterior draw ankle test
what does it mean to have positive inversion stress test of ankle? (invert ankle with one hand while stabilizing lower leg with the oth3er, excessive translation or palpable clunk of talus on tibia)
calcaneofibular ligament
lachman test
knee in 20deg flexion. stabilize upper leg and pull forward on tibia. excessive translation with no solid end point suggest ACL tear
anterior cruciate ligament tested with Lachman
anterior drawer test of knee tests for…
ACL tear
valgus test of knee
test medial collateral ligament (push inwards above knee, outwards at ankle; remember leg flexed to 30 deg)
varus test of knee
lateral collateral ligament
pull lateral above knee, push medial at ankle or so. leg is flex at 30 deg.
when should you get a knee x ray
- > 55 yo
- patella tenderness
- head of fibula is tender
- can’t flex knee to 90 degrees
- cant bear weight for four steps regardless of limping
start with xray. if thats normal and symptoms persist, you might get MRI to look at ligam2. ents/tendons
actinic keratosis and HPV raise risk for…
squamous cell carcinoma
most aggressive form of melanoma
nodular
superficial spreading is most common form
dark spot under nail, on palm or sole of foot in African American pt or Asian american pt
acral lentiginous melanoma
work up for microscopic hematuria (no proteinuria)
3+ RBCs per HPF on 2/3 urine samples (always confirm dipstick with microscopy). Do workup with 1+ sample if risk factors like smoking, exposure to benzenes or aromatic amines, hx gross hematuria, >40yo, hx urologic probs, hx irritaiting voiding sx, hx UTI, analgesic abuse, hx pelvic irradiation
your concern is to rule out maliginacy including Renal cell carcinoma and transitional cell carcinoma
1. Repeat UA. urinary sediment. Red cell casts and dysmorphic rbcs –> renal glomerular disease. Eosinophils –> interstitial nephritis perhaps from analgesics or other drugs
2. Get urine cx.
3. serum creatinine to test renal function
4. upper UT imagining: CT, or US or intravenous pyelogram
5. lower UT imagining: cystoscopy
name 3 first line tx for uncomplicated UTI
TMP-SMX
nitrofurantoin
fosfomycin
what arrhythmia occurs in hyperthyroid pts?
afib
pathophysiology of graves disease
IgG autoantibodies to TSH receptors
tx:
methimazol (propylthiouracil if pregnant)
beta blockers
definitive tx: radioactive iodine ablation (may have to tx hypothyroidism then)
Graves might go into remission for adolescents after pharma tx
propylthiouracil
anti thryorid drug for pregnant women
can cause agranulocytosis
methimazol
first line antithyroid drug
can cause agranulocytosis
thyroid storm symptoms
fever, confusion, restlessness, psychotic like behavior, tachycardia, HTN, dysrhythmias, signs of high output heart failure like dyspnea, peripheral vasoconstriction
usually graves disease but can also be acute thyroiditis
most common causes of hyperthyroidism
- Graves disease
- autonomous thyroid nodule (hyperfunctioning nodules rarely malignant)
- early thyroiditis
- overuse of thyroxine supplementation
difference in radionucleotide imaging of graves disease vs thyroiditis
thyroiditis is patchy uptake, reduced activity (just releasing everything already in there)
grave: huge uptake, huage activity
diminished relaxation phase of reflexes, low BP, nonpitting edema, hair loss, dry skin, depression, low energy, weight gain, slowed mentation, constipation, cold intolerance
hypothyroidism
most common cause of hypothyroidism
Hashimotos (autoimmune) followed by hypothalamic/pituitary dysfunction
to determine hypothal v pituitary prob: TRH test. Give TRH. If pituitary is healthy and happy it will release TSH in 30 minutes.
treatment for hypothyroidism
levothyroxine
are you more worried about cold or hot thyroid nodules on radionucleotide imaging?
cold : ( Gotta do a fine needle aspiration
carotid sinus syndrome
syncope, carotid sinus bulb stimulated in the neck , sinus pause, super rare, way less common than vasovagal
syncope workup
history, physical, ecg, orthostatic BPs/HR – suprine, sitting, standing at least 1 min between. Get hr!!!
orthostatic hypotension can be neurodegenerative incl diabetic
postural orthostatic tachycardia syndrome –really toned then have to stop working out all of a sudden
a kid with hypertension in arms, rib notching on xray, diminished femoral pulses, short 2/6 midsystolic murmur is heard at the left paravertebral interscapular area
coarctation of aorta
present in turner syndrome
hypertension in kid with increased urine VMA and HVA
neuroblastoma
anti centromere antibodies are marker for
scleroderma
outpt cap tx in adult
azithromycin is reasonable Once you’ve decided that a patient can be managed as an outpatient, you should select a drug regimen that covers the likely causative agents. In this setting, the most
likely bug is S. pneumoniae, with the next most likely bugs being H.influenzae and Moraxella catarrhalis. You also need to consider the “atypical” causes of pneumonia like Mycoplasma,
Chlamydia, and Legionella. (In fact, the CXR shown was taken from a patient with Mycoplasma.) A significant number of S.pneumoniae strains are resistant to beta-lactams, as are many H.flu
strains and almost all Moraxella strains. Atypical pneumonias are also impervious to beta-lactams and cephalosporins, so your antibiotic choices are limited to macrolides, quinolones, and
tetracyclines. Although erythromycin or tetracycline could work, macrolides like clarithromycin or azithromycin (answer D) cover H.flu better and would be the best choice among those listed.
Doxycycline or a “respiratory” fluoroquinolone like levofloxacin or moxifloxacin are reasonable outpatient monotherapies, as well.
most common hereditary bleeding disorder
normal PT, normal or increased PTT, increased bleeding time
von wilebrand deficiency (autosomal dominant)
give desmopressin for mild disease (increases release of von willebrand factor)
these are oozy bruisy pts versus hemophila or clotting factor deficiency pts that have big bleeds like hemoartrosis.
Petechiae suggest Platelet deficiency; Cavity or joint bleeding suggests Clotting factor deficiency
The PT, aPTT, and bleeding
time also localize this patient’s bleeding disorder to her platelets. The PT and aPTT measure the function of the coagulation cascade. (In particular, the PT measures the extrinsic pathway and is
used to monitor warfarin therapy, while the aPTT measures the intrinsic pathway and is used to monitor heparin therapy.) Meanwhile, the bleeding time evaluates platelet function. This patient
has a borderline elevation of her aPTT (caused by mild deficiency of Factor VIII, which is carred on von Willebrand factor) but her primary abnormality is an elevated bleeding time, indicating
platelet dysfunction
microangiopathic hemolytic
anemia, thrombocytopenia, mental status changes or neurological abnormalities, fever, and renal dysfunction
TTP
thrombocytopenic thrombotic purpura
give plasmopheresis!
splenectomy for refractory cases
Factor VIII is treatment for…
Hemophila A
functional ovarian cyst or physiological ovarian cyst
usually asymptomatic but can cause pelvic pain, fullness, constipation. Get ultrasound.
tuboovarian abscess
consider in pt with hx of PID who presents with fever lower abdominal pain leukocytosis
active pulmonary TB looks like lobar pneumonia with ipsilateral hilar lymphadenopathy and atelectasis. How do you treat?
R.I.P.E. rifampin isonizid pyrazinomide ethambutol
causes for short stature include endocrinopathies, growth hormone deficiency, malnutrition or abuse, or malignancy. What are the 2 most common causes?
familial short stature and constitutional delay of growth, and both of these present with a normal growth velocity. The best test to differentiate familial short
stature from constitutional delay is bone age.For familial short stature, bone age should match chronological age, while in
constitutional delay, bone age will lag behind chronological age. Bone age taken by taking xrays of hand and wrist.
A child that has small stature but is overweight for their height may have growth hormone deficiency. Conversely, a child that is
underweight for their height may have malnutrition.
what do you use to tx uti in preggars
bactrim, amoxicillin, augmentin, nitrofurantoin, cephalexin, other cephalosporins. Remember you treat even asymptomatic uti’s if she’s pregnant
parvovirus B19
fifth disease
slapped cheeks
erythema infectiousum
2 conditions associated with strawberry tongue
kawasaki and scarlet fever (GABHS)
name symptoms of kawasaki
strawberry tongue
lymphadenopathy (often unilateral)
desquamanation of skin (look especially at hands and feet)
rash
high fever >5 days
peripheral edema
**remember the complication we’re afraid of is coronary artery anuerysm
treatment of kawasaki disease
serial ECHOs to watch for coronary artery aneurysm
aspirin (yep, in kids!)
IV IgG
corticosteroids
when deciding what gout prophylaxis , get 24 hr urine uric acid measurement. Undersecreters get _______ as prophylaxis and overproducers get_______
Undersecreters get probenecid
overproducers get allopurenol.
causes of erythema multiforme
abx mycoplasma yersinia HSV hepatitis viruses over bacteria and viruses NSAIDs other drugs idiopathic
treat/stop underlying trigger; topical steroid, antihistamine. may need hospitalization if severe mucosal involvement
allergic triad
atopic dermatitis
allergic rhinitis
asthma
treatment for scabies
permethrin
oral ivermectin. Lindane cream can be used, but is second-line in the pediatric population due to its toxicity. The key to successful
eradication is to treat all family members and close contacts at the same time. Fomite transfer is not as much of a concern as it is for head lice, but precautions should be taken including bagging
personal items for 3 days and then washing them
treatment for molluscum contagiosum
outside of genitals, let it ride. will resolve in immunocompetant host
what is the meaning of alpha fetoprotein
you can think of an increased AFP as being caused by any defect in which the fetal body cavity is left open. These
include neural tube defects like anencephaly (answer C) or myelomeningocele and abdominal wall defects like gastroschisis or omphalocele. Obviously, of course, a larger fetus produces more
AFP than a smaller one, so the interpretation of MSAFP results depends on having accurate gestational dates. Therefore, the two most common non-pathological reasons for an elevated
MSAFP are multiple gestations and inaccurate dates. Finding a DECREASED MSAFP is also a sign of diseases – usually chromosomal abnormalities. Both trisomy 18 (answer D) and Down’s
syndrome or trisomy 21 (answer E) are associated with decreased AFP (usually <0.5 MoM). Fragile X syndrome (answer A) is the most common inherited cause of mental retardation after
trisomy 21. It is a trinucleotide repeat disorder, and must be diagnosed with molecular DNA testing. There is no specific pre-natal screening available, although mothers who are thought to be at
risk of being carriers may elect to have themselves cytogenetically tested.
trigeminal neuralgia tx
oxcarbazepine or carbamazepine (antiepileptic drugs)
anti smooth muscle antibodies
autoimmune hepatitis
tx for autoimmune hepatitis
prednisone and azathioprine
first line tx for symptomatic bradycardia
atropine iv
hemolytic anemia, black gallstones, jaundice, splenomegaly in childhood
increased red blood cell distribution width
increased mean corpuscular hemoglobin concentration (MCHC)
spherocytosis
mutation in spherocytosis
defects in spectrin, ankyrin …spherical RBCs get trapped in spleen…splenomegaly
Hemolytic uremic syndrome happens after infection with
shiga toxin enterohemorrhagic e coli O157:H7 (most often)
diarrhea followed by 1. renal probs 2. low platelets 3. hemolytic anemia (jaundice, dyspnea, fatigue)
hemolytic uremic syndrome
tx for functional constipation in kids
osmotic laxatives like polyethylene glycol
blood on urine dipstick but no rbcs on microscopy in setting of crush injury or extreme exercise
rhabdomyelosis, myoglobin cross reacts on urine dipstick
give IV fluids to prevent ATN!
mupiricin is a topical abx used to treat…
impetigo
treatment for alopecia areta
steroids like clobetasol
alopecia areta is autoimmune process
3 most common causes of chronic cough
The most likely culprits in an otherwise healthy person are, in order, postnasal drip, asthma, and GERD. S
treat postnasal drip with antihistamine and decongestant
In the appropriate setting, chronic
cough can be a sign of CHF or intrinsic lung disease. Smokers can have chronic cough related to emphysema, chronic bronchitis, or the irritation of the tobacco smoke itself.
vit K dependent clotting factors
II, VII, IX, X, S , C
in HIV pts when CD4 <200, begin prophylaxis for _____ with ________
pneumocystis carnii pneumonia
trimethoprim-sulfamethoxazole
In HIV pts when CD4 <100, begin prophylaxis for _____ with _______
toxoplasmosis with trimethoprim-sulfamethoxazole
In HIV pts when CD4 <50, begin prophylaxis for _______ with__________
mycobacterium avium complex (MAC) with azithromycin or clarithromycin
PPD is positive in high risk pt (e.g. hiv+) if greater that __ mm
5
PPD is positive in medium risk pt (eg homeless) if grerater than __ mm
10
PPD is positive in low risk pt if greater than— mm
15
treatment for recurrent candiasis in hiv+ pts
fluconazole
infant with rash involving the palms and soles, and the blood-tinged purulent nasal discharge (known as the “snuffles”, Lymphadenopathy and organomegaly
congenital syphilis
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions
baby with deafness and cataracts as well as numerous purpuric skin lesions in mom without prenatal care
congenital rubella - blueberry muffin baby
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions
baby with hydrocephalus, chorioretinitis, and intracranial calcifications
congenital toxoplasmosis
All TORCH infections can cause poor feeding, fever, deafness, mental retardation, hepatosplenomegaly, and thrombocytopenia, and so you should always
consider them when you see an infant with one of those conditions
baby with vesicular lesions on the skin, eyes, or mouth, …can lead to life-threatening disseminated disease or encephalitis
congenital herpes …especially in mom’s with active infections in pregnancy or during vaginal delivery
symptoms of hypercalcemia
“Bones, Stones, Abdominal Groans, and Psychiatric Undertones, bone fractures kidney stones vomiting, constipation weakness, fatigue, altered mental status
causes of hypercalcemia
CHIMPANZEES Calcium oversupplementation Hyperparathyroidism Immobility or iatrogenic (thiazides!) Milk alkali syndrome Paget's disease Acromegaly or Addison's Neoplasms Zollinger Ellison when associated with MEN 1 Excess vitamin D Excess vitamin A Sarcoidosis
charcot’s triad
RUQ pain fever chills jaundice = acute cholangitis
Reynold’s pentad = the above plus shock and altered mental status
Testing positive for only Chlamydia mandates
treatment for only Chlamydia, BUT testing positive for only gonorrhea mandates treatment for BOTH gonorrhea and Chlamydia. Chlamydia is the most common STI, and patients with gonorrhea
(which is much less prevalent than Chlamydia) tend to be co-infected with chlamydia.
if you test postive only for chlamydia you get:
if you test positive only for gC you get:
chlamydia only: azithromycin
GC only: ceftriaxone + azithromycin
tx for syphilis
one time IM benzathine penicillin G
tx for acute dystonic reaction from antipsychotics
oral diphenhydramine
symptoms of neuroleptic malignant syndrome
fever, muscle rigidity and increased CPK, autonomic instability
treat with IV Dantrolene
tx for herpes encephelitis
Acyclovir is used to treat herpes encephalitis, which can present with increased lymphocytes in the CSF. However, the hallmark of herpes encephalitis on CSF analysis is a markedly
elevated RBC
tx for bacterial meningitis in adults
ceftriaxone if you’re not worried about drug resistant strep pneumo
vancomyocin + cefotaxime if you’re worried about drug resistant strep pneumo
hallmark signs of cryptoccocal meningitis
elevated opening pressure on lumbar puncture! this is opportunistic infection seen in HIV or immunocompromised pts. Treatment is Amphotericin B and flucytosine
confirm with latex agglutination or India ink preparation
what do you do for a clot in the superficial femoral vein?
anticoagulation because it’s actually a deep vein
what do you do for a superficial vein clot?
rest, NSAIDs, elevation, and heat
they’re more likely to be palpable
pANCA, pt with ulcerative colitis or chron’s disease, pruritis, maybe portal hypertension leading to hepatosplenomegaly, onion skin fibrosis of bile ducts, beading on ERCP
primary sclerosing cholangitis
liver transplant = tx
vertigo + hearing loss following viral illness
labarynthitis (vestibular neuritis) self limited. oral corticosteroids may help it go away sooner. + antiemetics benzodiazopenes antihistamines
Describe cover-uncover test for strabismus
cover-uncover test is used to test for strabismus. In a normal patient, there should be no movement of the eyes when either one is covered and then uncovered. If the patient’s eyes are
misaligned, however, the non-dominant eye will jump and re-fixate once the dominant eye is uncovered. tx is occlusion of dominant eye
whats the most common mutation in retinoblastoma
mutations in both copies of RB tumor suppressor
severe acne vulgaris treatment
oral isotretinoin
teratogen
raises TGs
hepatoxicity
treatment for mild acne
topical retinoid, topical salicyclic acid, topical benzoyl peroxide
try for 3 months. if it doesnt work, add topical antibiotic like clindamycin
treatment for pseudotumor cerebrei
acetazolamide, may need surgery
remember, the danger of the raised intracranial pressure is risk of blindness
cosyntropin stimulation test checks for…
response of adrenal glands…cosyntropin is synthetic ACTH so it should cause the adrenals to release cortisol if they are acting correctly. This is diagnostic for Addisons (primary adrenal insufficiency) or if they adrenals are hypoprofused (secondary adrenal insufficiency – commonly caused by abruptly stopping steroid meds)
fatigue, weakness, weight loss, diarrhea, nausea, hyperpigmentation on joints, face, neck; low cortisol levels after cosyntropin/ACTH administration
primary adrenal insufficiency (Addisons) : hydrocortisone to replace corticoids and flutracortisone to replace mineralocorticoids
methacholine challenge is for diagnosis of…
asthma
methacholine should decrease FEV1, seldom done because seems awfully mean
wheezing on physical exam means the problem is bronchioles
palivizumab
antibody prophylaxis for RSV
What we call pre-renal “failure” is really a normal physiological mechanism that occurs in response to decreased renal perfusion
pressure. Although the kidneys are failing to do their job of removing wastes from the body, the kidneys themselves haven’t “failed” – if they were getting enough blood, they’d be able to do their
job just fine! Therefore, here’s an easy way to remember that the key feature of pre-renal disease is an elevated BUN/creatinine ratio. Remember that the body’s normal BUN/Cr is 10-15:1. In
ATN, that ratio doesn’t change, because the body retains both BUN and creatinine equally. However, in pre-renal failure, the body retains more BUN than creatinine, leading to an increase in the
BUN/Cr ratio. Therefore, if the kidneys are able to retain more BUN than creatinine, they must be intrinsically working okay – the diagnosis is pre-renal disease, not ATN. If you want a more
detailed explanation, keep reading; otherwise, feel free to skip to the next teaching point! Unlike creatinine, which is freely filtered at the glomerulus and is not reabsorbed or metabolized by the
kidney, about half of the filtered BUN gets passively reabsorbed, mainly at the proximal tubule. Remember that when there is decreased blood flow to the kidney, almost of the reabsorption of
sodium and water occurs at the proximal tubule instead of other “downstream” segments of the nephron. Thus, urea nitrogen gets reabsorbed at the proximal tubule as well, leading to an
increase in BUN that is greater than the increase in creatinine.
Other than pre-renal disease, there are a couple of other conditions that can increase the BUN out of proportion to the
creatinine. One is a GI bleed – reabsorption of RBCs in the gastrointestinal tract will increase the BUN. Corticosteroids and tetracyclines (which inhibit protein anabolism) also can increase the
BUN. 4) You can think about the FeNa in much the same way as the BUN/Cr ratio. If the FeNa is low – less than 1% - then the kidneys are avidly holding on to sodium. If they’re able to do that,
the kidneys themselves must be doing okay, and the problem must be that they’re not getting enough blood. Patients with ATN have an elevated FeNa (>2%) because the kidney becomes like a
leaky sieve and allows sodium to escape. 5) One important limitation of the FeNa is that it is affected by diuretics, which cause increased loss of sodium in the urine. In patients taking diuretics,
the fractional excretion of urea (FeUrea) should be measured instead. 6) Hyaline casts are occasionally seen in normal urine, and so they are commonly mentioned as a distractor on the
USMLE. Other casts are always pathological. The finding of “muddy brown” or granular casts is pathognomonic for ischemic ATN. Cytotoxic effects of iodinated contrast material (answer A) is the
mechanism of contrast nephropathy. Always consider this as a possibility in any patient who receives i.v. contrast – especially patients who are elderly or have diabetes or pre-existing chronic
renal insufficiency. T
complication of IBD where pt presents with decreased bowel sounds or maybe diarrhea/vomiting, severe abdominal pain, signs of sepsis, ab distension
toxic megacolon
seen on ab x ray - loss of haustration, multiple air fluid levels
icu - NPO, correct electrolytes
may need surgery
lots of neutrophils in blood or csf, think bacterial infection
lots of _____, think viral
leukocytes
calculate anion gap
cations - anions
Na+ -Cl- - HCO3-
normal is 6-12
normal anion gap
6-12
diabetic ketoacidosis
primarialy DM1
high anion gap acidosis
hyperglycemia–> hyerperosmolality–>osmotic diuresis–>dehydration,
insulin deficency–> body has to rely on lipolysis –> ketone production–> ketosis and using up bicarb as a buffer __> high anion gap acidosis
Insulin deficiency → hyperosmolality → K+ shift out of cells + lack of insulin to promote K+ uptake → intracellular K+depleted → total body K+ deficit despite normal or even elevated serum K+ There is a total body potassium deficit in DKA. This becomes important during treatment, when insulin replacement leads to rapid potassium uptake by depleted cells and patients may require potassium replacement.
fruity breath, abdominal pain, dehydration,
somnulence
coma
all happens in less than 24 hrous
tx: fluid resuscitation, insulin, bicarb if pH <6.9
hyperosmolar hyperglycemic state
more common in DM2
characterized by symptoms of marked dehydration (and loss of electrolytes) due to the predominating hyperglycemia and osmotic diuresis.
N/V, polyuria, polydipsia, altered mental status, coma, slower onset than DKA
Severe asthma attack. try IV methylprednisolone and nebulized albuterol and supplemental O2. Rising CO2 in the face of sustained tachypnea is a
very ominous sign - it shows that the patient’s airways are so constricted that he is no longer able to get rid of CO2! If a normal patient began breathing at 35-40/minute (like this patient) they
would very soon have a pCO2 in the teens or 20s as they blew off their CO2. This patient also appears to be fatiguing as well - his respiratory rate has dropped from 42 to 35
pulsus paradoxus is a bad sign in an asthma attack – a drop of more than 10 mmHg during inspiration
a lack of wheezing on auscultation during severe asthma attack is actually a bad sign “silent chest”–> not moving enough air to make wheezes
you don’t need imaging for asthma attack
treatment for onchymyccosis
3 months oral terbinafine and itraconazole
remember to do scrapings and KOH examination
what do you do for low grade vesiculouretral reflux in babies
abx prophylaxis for uti, routine screening cx every 3-4 months, they’ll probably outgrow the reflux
how do you know if ascites is exudative or transudative
serum albumin -ascites albumin >1.1 is transudative and caused by portal hypertension: right sided CHF, cirrhosis, budd chiari
serum albumin - ascites albumin <1.1 is exudative and caused by other things like pancreatitis, peritonitis, mets,
idiopathic avascular necrosis of the hip that occurs in children ages 3-12 with a peak incidence is 5-7 years old. It predominantly affects males and
10% of cases are familial. Patients present with a limp and Trendelenburg gait (pelvis tilts downward on unaffected side while trunk sways toward affected side during stance). Pain is mild and
usually referred to anteromedial thigh or the knee, but can lead to disuse causing atrophy of the thigh and buttock. Physical exam reveals limited internal rotation and abduction of the hip. Initial
radiographs are usually normal, but bone scans can show decreased perfusion to the femoral head, and MRI will show marrow changes
Legg-Calve-Perthes disease
Renal tubular acidosis type 1
mild dehydration, hypokalemia –> muscle cramps, paralysis, fatigue, kidney stones, calcifications in kidneys
caused by autoimmune disorders, inherited, meds like amphotericin B, lithium, analgesics
distal convoluted tubes; alpha interculated cells cant secrete protons or they are leaky from lithium and amphotericin B and protons are diffusing from tubule into cell to blood.
Renal tubular acidosis type 2
cant reabsorb bicarb in proximal convoluted tubule
academia, hypokalemia
nausea, vomiting, muscle cramps and paralysis, fatigue, kidney stones, calcifications, urine may still be acidified
-Fanconi syndrome (aminoaciduria, uric aciduria, proteinuria, glucosuria, phosphaturia) (genetic or from tetracyclines)
Renal tubular acidosis type 4
aldosterone resistance or aldosterone deficiency in collecting duct --> hyperkalemia -> arrhythmia ENAC transporter mutation Addisons (no aldosterone) severe hypovolumeia lupus
less ammonium in the urine
Tx for renal tubular acidosis type I
want to correct academia by replenishing bicarb, correct hypokalemia
-give potassium citrate
Tx for renal tubular acidosis type II
give potassium citrate and thiazide diuretics
vit D and calcium in kids
tx for renal tubular acidosis type IV
correct hypoaldosteronism
give fludrocortisone, loop diuretics to increase sodium delivery, increase K+/H+ exchange
underlying deficiency in renal tubular acidosis type IV
Deficiency of or inability to respond to the hormone aldosterone
underlying deficiency in renal tubular acidosis type ii
innability to reabsorb bicarbonate from the urine
underlying deficiency in renal tubular acidosis type 1
Inability to excrete acid in urine
key lab abnormalities seen in alcoholics include
hypoglycemia; macrocytic anemia; elevated AST and ALT, with a 2:1 ratio of AST/ALT; low magnesium; elevated PT; and low albumin. Don’t give iv fluid with glucose to an alcoholic without first giving …… or you’ll maybe precipitate….
thiamine
wernicke’s encephalopathy
vital signs in delirium tremens
htn
tachycardia
low fever
young, asymptomatic patient with cervical lymphadenopathy
) or an incidentally-found widened mediastinum. The presence of symptoms generally indicates a worse prognosis. Typical symptoms include
the “B symptoms” of fever, night sweats, and unexplained weight loss. More rarely, patients complain of pruritus (especially after a hot shower) or severe pain following alcohol ingestion. If any of these
findings are described on the USMLE, it’s almost always a tipoff that the diagnosis is Hodgkin’s. -There are several commonly used staging systems for Hodgkin’s lymphoma, but the only one that you’re
likely to be tested on is the simple Ann Arbor system. Under this classification, stage I disease involves only a single lymph node region, stage II disease involves two or more lymph node regions on the
same side of the diaphragm, stage III disease involves lymph node regions on both sides of the diaphragm, and stage IV describes disseminated disease.
pell epstein fevers (cyclical fever) associated with…
hodgkin lymphoma
symptoms related to pancytopenia (like easy bruising, anemia, or neutropenia). The CBC should show a high WBC, and microscopic examination
should show numerous circulating myeloid blasts. If you suspect this diagnosis, the next step is a bone marrow biopsy.
aml
the most effective tx for allergic rhinitis is
nasal corticosteroids like nasal beclomethasone
community acquired MRSA treatment
trimethaprim-sulfamethoxazole, clindamycin
abortive treatment for cluster headaches
100% oxygen
2 most common causes of pancreatitis in US
gallstones
alcohol abuse
There are a number of less frequent but still important causes
like drugs (especially thiazides and steroids), hyperlipidemia, and instrumentation (like ERCP). 2) The treatment for pancreatitis is supportive care, designed to correct fluid and electrolyte
disturbances. This is a very serious disease, with an overall mortality of around 10%!
the most common cause of isolated bloody nipple discharge in a healthy young
female
intraductal papilloma
If lesion is palpable: Core needle biopsy is confirmatory and rules out malignancy.
Shows papillary cells with fibrovascular core
Otherwise: ductogram
Treatment: surgical excision
Multiple ring enhancing lesions throughout the brain on CT
toxoplasmosis
Cortical atrophy and ventricular enlargement on brain ct in setting of memory loss
alzheimers
classic triad of symptoms in normal pressure hydrocephalus
memory loss
gait disturbance
urinary incontinence
A CT in this patient would likely show ventricular enlargement
(hydrocephalus) WITHOUT cerebral atrophy
(alzheimers pts can have gait disturbance and urinary incontinence but it would be much much later in course of disease)
focal segmental glomerulosclerosis
most common nephrotic syndrome in adults, esp latinx and blacks
unresponsive to steroids
associated with heroin, sickle cell, hiv
some glomeruli, some sclerosis
not immune mediated no immunofluroscence
primary focal segmental glomerulosclerosis
most common nephrotic syndrome in adults, esp latinx and blacks
unresponsive to steroids
associated with heroin, sickle cell, hiv
some glomeruli, some sclerosis
not immune mediated no immunofluroscence
secondary focal segmental glomerulosclerosis
some of the glomeruli die and the remaining glomeruli have compensatory hypertrophy and increased capillary pressure to try to maintain GRF
membranoproliferative glomerulonephritis
subendothelial immune deposits - preformed antigen-antibody complexes. Why? who knows? but we don’t get inflammation but rather mesangial proliferation
tram tracking of basement membrane
immunofluroscent: granular pattern IgG and C3
dense deposit disease
c3 nephritic factor antibody targets C3 convertase (which is increased in activity)
immunoflorescent pattern: linear ribbon of compliment C3 in basement membrane
membranous disease (nephrotic syndrome)
subepithelial deposits
HIV, hep b hep c , syphilis, captopril, lung cancer, colon cancer, or primary/idiopathic
Three Ps of MEN 1
MEN-1 is the “three P’s”: patients tend to have Parathyroid hyperplasia, Pancreatic islet tumors, and Pituitary tumors in
addition to gastrinomas and Zollinger ellison syndome (one or many gastrin-secreting tumors
cause the overproduction of gastric acid, leading to symptoms of mucosal ulceration, diarrhea, malabsorption, and GERD)
MEN-2A
medullary thyroid cancer, phenochromocytomas, and hyperparathyroidism, so the mnemonic here is “2 MPH” (think “two miles per
hour”).
MEN-2B
medullary thyroid carcinoma and pheochromocytoma, but NOT hyperparathyroidism.
diagnosing zollinger ellison syndrom
fasting gastrin (elevated) basal acid secretion (elevated) secretin stimulation test (paradoxical increase of gastrin with admin of secretin in ZE pts) octreotide or somatostatin scan remember association of ZE with MEN 1
Parvovirus B19 can cause ______ in pts with hereditary spherocytosis or sickle cell disease
aplastic anemia
in friedrich ataxia you die of…
cardiomyopathy
trinucleotide repeat
nephrotic syndrome with subepithelial deposits of IgG and complement (spike and dome); thickened capillary loops
membranous (most common nephrotic syndrome among adults)
membranous nephrotic syndrome is associated with…
hep B, solid tumors like lung cancer
is poststreptococcal glomerulonephritis nephrotic or nephritic?
nephritic (hematuria, htn)
lupus tends to cause membranous neprotic syndrome
thckened capillary loops, hypercholesterolemia, edema from salt retention, proteinura
most common nephrotic syndrome among HIV+, african american, obesty, sickle cell patients, heroin use
focal segmental glomerulosclerosis
Nodular glomerulosclerosis with Kimmelstiel-Wilson nodule
diabetic nephropathy
even though diffuse glomerulosclerosis is the most common finding
most common cause of acute kidney injury (not pre renal)
acute tubular necrosis
muddy brown casts & epithelial cell casts
due to ischemia and/or toxins
if you find low testosterone in a man, what test do you do next
LH/FSH if LH/FSH is low or normal, then you know it’s secondary hypogonadism (i.e. a central problem). You’ll want to check prolactin, TIBC (think hemochromatosis), maybe brain MRI. If LH/FSH are high, then it’s primary hypogonadism and something wrong with the testes…like klinefelters for example and you’ll want karyotyping
Patients being treated with amiodarone (Cordarone) should be monitored periodically with serum
levels of
TSH
pathogenesis of TTP
deficiency or autoantibodies against ADAMTS13, usually aquired, like most autoimmune stuff middle age women. Risk factors are pregnancy, systemic illness like HIV, SLE, cancer, infection.
ADAMTS13 doesn’t cleave von Willebrand factor complexes, which then hang around and stick to the endothelia of microvasculature all over the place causing tiny clots –> shearing of RBCs –> ischemia, especially in brain and kidney
Remember pentad of clinical signs: Thrombocytopenia (all the platelets get used up), Neuro signs, Microangiopathic hemolytic anemia (jaundice!), Impaired renal function, Fever
pathogenesis of TTP
deficiency or autoantibodies against ADAMTS13, usually aquired, like most autoimmune stuff middle age women. Risk factors are pregnancy, systemic illness like HIV, SLE, cancer, infection.
ADAMTS13 doesn’t cleave von Willebrand factor complexes, which then hang around and stick to the endothelia of microvasculature all over the place causing tiny clots –> shearing of RBCs –> ischemia, especially in brain and kidney
Remember pentad of clinical signs: Thrombocytopenia (all the platelets get used up), Neuro signs, Microangiopathic hemolytic anemia (jaundice!), Impaired renal function, Fever
urgent tx = plasmopheresis or even splenectomy
external rotation of the shoulder involves
infraspinatus teres minor
which diuretics increase risk of gout
thiazides
loop diuretics
acei can cause ____kalemia
hyperkalemia
thiazides can cause ____kalemia
thiazides can cause hypokalemia
what kind of medication can you give to help a kidney stone pass faster
alpha 1 blocker
tamsulosin
doxazosin
prazosin
what labs predict pancreatitis severity
BUN creatinine hematocrit
hemoglobinapathies like sickle cell falsly lower A1c. instead get…
serum fructosamine
TMP-SMX can cause —- that predisposes to infection
agranulocytosis
look for low leukocytes
ampicillin sulbactum is empiric treatment for lung abscess (think aspiriation)
strep pneumo, gram negative anaerobes
first line allergic conjunctivitis
ketorolac, ketotifen (antihistamin)
2nd line is glucocorticoid like flourometholone
elevated LH:FSH ratio is marker in common syndrome…
PCOS
serious side effect of metformin
lactic acidosis
watch for kidney or heart problmes…more risk of lactic acidosis
first step in nonmassive hemoptysis
CXR
dry cough, uveitis, symmetrical arthritis, no autoantibodies
get CXR…look for hilar lymphadenopathy and chronic sarcoidosis. Biopsy is diagnosis (noncaseating granulomas)
increased calcium levels, ACE levels, restrictive PFT pattern;
if symptomatic…glucocorticoids
antibody in granulomatosis with polyangiitis
c-ANCA
extra articular manifestation of ankylosing spondylitis
cardiac stuff, uveitis, prostitisi, nephropathy, inflammatory bowel disease
no antibodies
HLA B 27
af am woman with nephritis, history of miscarriages, and pleuritis
think SLE!
she will have low complement levels
+anti ds DNA
B symptoms (fever night sweats...) smudge cells on peripheral blood smear lymphocytic leukocytosis with suppression of other blood lines should point to... B-cell antigens CD5, CD19, CD20, and CD23 on flow cytometry
chronic lymphocytic leukemia
most common cause of epididymitis in sexually active men <35
CT, GC
CREST syndrome antibodies
anti centromere
infertility workup for woman
- progesteron level at luteal phase
then… - hysterosalpingography to make sure tubes are patent
then… - FSH, prolactin, estradiol
then…
referral
