general internal medicine Flashcards
What is Kusmauls sign?
What commonly causes Kusmauls sign?
An increase of JVP on inspiration.
This represents a heart that is unable to accomidate the increased venous return that accompanies inspiratory decrease in intrathoracic pressure
Kusumauls sign causes–> constrictive pericarditis (classic cause)
Common cause–> right sided heart failure
other causes of kusmauls sign–> myocardial restrictive disease (tricuspid stenosis, amyloidosis, superior vena cava syndrome)
-
What is cor pulmonale?
altered structure/ function of the right ventricle that results from pulmonary hypertension caused by
1) diseases of the lung (COPD, pulmonary
2) vasculature (idiopathic pulmonary hypertension)
3) upper airways (OSA)
4) chest wall (kyphoscoliosis)
Cor pulmonale DOES NOT INCLUDE right heart failure due to left heart failure ( which is the most common cause of heart failure)
What is central venous pressure and how do you measure it?
Central venous pressure (cm H2O)= right atrial pressure is an indirect estimate of the pulmonary wedge pressure = pressure in pulmonary arterials
–> which is an indirect measure of the pressure in the left ventricle
CVP= JVP +5
JVP >/= 3 suggests and elevated CVP
–> the 5 cm in that equation is the distance from the angle of louie to the middle of the right atrium where venous pressure is 0 by convention
You can measure CVP by locating the JVP and adding 5cm from the angle of louie
What is the JVP waveform?
What do each of the waves mean?
What do differences in each wave mean?
a wave= right atrial contraction
–> occurs right before the first heart sound
x= atrial relaxation
c= bulging of tricuspid valve into right atrium during ventricular isovolumetric contraction
x1= atrial relaxation after ventricular isovolumetric contraction ( most significant decrease)
v= distention of the right atrium with filling
y= emptying of right atrium after opening of the tricuspid valve
Table 11-1 Abnormalities of the Venous Waveforms
Waveform Cardiac Condition
Absent a wave Atrial fibrillation, sinus tachycardia
Flutter waves Atrial flutter
Prominent a waves First-degree atrioventricular block
Large a waves Tricuspid stenosis, right atrial myxoma, pulmonary hypertension, pulmonic stenosis
Cannon a waves Atrioventricular dissociation, ventricular tachycardia
Absent x descent Tricuspid regurgitation
Prominent x descent Conditions causing enlarged a waves
Large cv waves Tricuspid regurgitation, constrictive pericarditis
Slow y descent Tricuspid stenosis, right atrial myxoma
Rapid y descent Constrictive pericarditis, severe right heart failure, tricuspid regurgitation, atrial septal defect
Absent y descent Cardiac tamponade
What is the definition of pulmonary hypertension?
Increased (> 25 mmHg or higher) blood pressure in the pulmonary arteries
normal pulmonary blood pressure at rest is between 5 and 20mmHg
ddx
Pulmonary Hypertension is often missed because the similarity in the presentation to right sided heart failure, coronary artery disesae, liver disease and Budd-chiari syndrome
the first test for pulmonary hypertension is an echocardiogram–> commonly will show left heart disease
symptoms of pulmonary hypertension are caused by inadequate increase in cardiac output durring exercise
-> dyspnea, lethargy, fatigue
Additional symptoms of pulmonary hypertension emerge as PH progresses and right ventricular hypertrophy and cor-pulmonale develop
What is the difference between bronchiolitis and bronchiectasis?
bronchiolitis–> nonspecific inflamation that affects small airways (< 2mm in diameter)
- >the cause of bronchiolitis is often poorly defined
1) infection with RSV, adenovirus, mycoplasma pneumonia,
2) inhalation injury-> irritants
3) obstructive ventilatory defect without significant response to bronchodilators
bronchiectasis- inflamed and easily colapsable airways, obstruction to airflow
bronchiectasis can affect multiple parts of the lung, and is not restricted to the small airways
bronchiectasis can share clinical features with COPD
What is peri-bronchial cuffing?
Peri-bronchial cuffing (“ donut sign”)- hazyness around large bronchiole seen end on
-represents bronchial wall thickening or fluid around bronchi
causes-pulmonary oedema, small airway inflamatory disease (bronchiolitis, asthma)
What is an air-bronchogram?
air filled bronchi (dark) being made visible by the opacification of surrounding alveoli
-almost always caused by pathological airspace/alveolar process
caused by
- pulmonary consolodation
- pulmonary oedema
- non-obstructive atelectasis
- severe interstitial lung disease
- neoplasms
- pulmonary infarction
- normal expiration
What are Kerley lines?
Kerley lines are seen when the interlobular septa in the interstitium become prominent
Usually occur when pulmonary wedge pressure reaches 20-25mmHg
Can occur most commonly with pulmonary oedema, neoplams (lymphangitic spread), pneumonia, interstitial pulmonary fibrosis, pneumoconiosis, sarcoidosis
kerley A lines- oblique lines < 1mm thick go towards hilum. Represent thickening of the interlobular septa.
- cross normal vasculature
- extend radially from hilum to upper lobes
kerley B lines- oblique lines <1mm thick on periphery of lungs. Represent thickening subpleural interlobular septa.
-usually seen at the lung bases
-
What is stridor?
Stridor is a high pitched wheezing or vibrating sound caused by turbulent airflow in the upper airways.
can occur in expiration, inspiration or both
MOST COMMONLY OCCURS IN INSPIRATION
What is an IADL and what is an ADL?
ADL= activities of daily living = activities needed to get up in the morning, get from place to place using their body, and go to bed in the evening
- bathing
- toileting
- brushing teeth
- dressing eating
- walking
IADL= instrumental activities of daily living= tasks that people do once they are up that support an independant lifestyle
- cooking
- shopping
- managing finances
- using telephone
- driving
- managing medication
What is FEV1/ FVC?
FEV1= forced expiratory volume in 1 second
FVC= Forced vital capacit
FEV1/FVC = proportion of a persons vital capacity that they are able to expire in 1 second
Normal FEV1/FVC ~ 80%
FEV1/FVC is also called the Tiffeneau- Pinelli index
On a pulmonary function test how can you differentiate a restrictive from a obstructive pattern? What is normal?
PFT’s are a graph of flow rate vs lung volume
Normal- high flow rate (around 6 L/sec), around, 6 liters of lung volume
Restrictive- small lung volume, lower flow rate
Obstructive- VERY LARGE lung volume, but at the lower lung volumes the FLOW RATE DROPS OFF.–> CO2- retainer
What is a phelgmon?
Spreading diffuse inflammatory process with formation of suppurative/purulent exudate or pus.
diverticulitis is an example of a phlegmon
What are the different volumes on a PFT?
What are the symptoms and causes of left heart failure vs right heart failure?
left heart failure->symptoms–> left sided S3, rales, wheezes, tachypnea
causes–>previous MI, aortic stenosis, left sided endocarditis
right heart failure–>symptoms–>right sided S3, increased JVP, ascites, hepatomegally, peripheral edema
causes–> left heart failure, pulmonary hypertension, right ventricular MI, mitral stenosis, right sided endocarditis
What is the classification system of HF?
NYHA (New York Heart Association)
I- no symptoms with ordinary physical activity
II-mild symptoms with normal activity ( walking > 2 blocks or 1 flight of stairs)
III-symptoms with minimal exertion (< 2 blocks..)
IV- symptoms at rest
What causes an elevated BNP?
Heart failure, pulmonary embolism, pulmonary hypertension, LVH, ACS, renal failure, overload, sepsis
- wait 2 minutes before doing lying vitals
- Wait 1 minute after standing to do standing vitals
What is p-pulmonale? And what are the causes?
p-pulmonale are peaked p-waves with amplitude
> 2.5mm in inferior leads (II, III, AVF)
>1.5 mm in V1 and V2
primary cause of p-pulmonale is pulmonary hypertension
What are the WHO classification of Pulmonary Hypertension?
1) Pulmonary arterial hypertension- idiopathic, CHD, HIV
2) Left sided heaft failure
3) Hypoxia- OSA, COPD, ILD
4) CTEPH
5) Misc- myeloproliferative
How can you classify hematological malignancies?
1)Myeloid
a)Leukemia
- ALL
- CLL
b)Lymphoma
- Hodgkin
- non-Hodgkin
c)Plasmal Cell dyscrasias
- Multiple Myeloma
- MGUS
- Waldenstrom’s Macroglobinemia
2)Lymphoid
a)leukemia
AML
b)myeloproliferative disorders
polycythemia vera
Essential thrombocythemia
CML
Idiopathic myelofibrosis
Myelodysplastic syndromes
What are auer rods pathognomonic for?
AML
What is the definition of leukemia?
20% or greater blasts in bone marrow at the presentation
leukemia is classified into
1) Myeloid
2) lymphoid
What is the difference between a myleoproliferative and a myleodysplastic disorder?
Myeloproliferative–> cell accumulation–> PRV, CML, ET, MF
Myelodysplastic->abnormal bone marrow cell growth
Both disorders have risk of conversion to acute myeloid leukemia
WHAT IS DRESS SYNDROME?
Dress is Drug Reaction with Eosinophillia and Systemic Symptoms
It is caused by starting a drug
most commonly
1) antiepileptics
2) sulfonamides (5- ASA, vancomycin, daptomycin)
There is a latency period between starting the drug and seeing symptoms
DRESS is associated with reactivation of herpes virus
When to suspect DRESS — The diagnosis of DRESS is suspected in a patient receiving a drug treatment who presents with the following signs and symptoms:
●Skin eruption (morbilliform or diffuse, confluent, and infiltrated) (picture 1A)
●Fever (38 to 40°C [100.4 to 104°F])
●Facial edema
●Enlarged lymph nodes
Treatment of DRESS is
1) stop the drug
2) steroids
3) Treat the organ
What is PRES syndrome?
Posterior reversible encephalopic syndrome – also called– Reversible posterior leukoencephalopic syndrome
Caused by loss of autoregulation in the brain, associated with hypertension
the clinical syndrome of reversible posterior leukoencephalopathy syndrome
What are the commenal flora of the skin?
(CONS)Coagulase negative staph (epidermidis, saprophyticus)
Corynebacteria
propionbacteria acnes
What are the normal bacteria of the mouth?
Strep Viridans
HCEK
Neisseria
Anaerobes (Peptostreptococcus, veillonella, fusobacterium, actinomyces, prevotella)
What are simple criteria for hospitalization of pneumonia patients?
CURB 65
Confusion
Urea> 7
Respiratory rate > 30
Blood pressure –> systolic < 90. diastolic < 60
65 ( Age)
0-1 –> outpatient
2- inpatient
3-5- ICU
What is the approach to abnormal rhythm?
bradyarrhythmia (
- sinus bradycarida
- sick sinus syndrome
- SA block
- AV block
- junctionl escape
- ventricular escape
tachyarrhythmia (>100)
1) constant RR interval
2) irregular RR
What is the normal range for calcium, what is the difference between a serum and ionized calcium, and what are the determinants of each?
Serum calcium normal range is 2.2-2.6 mmol/L
-serum calcium is divided into 3 parts
a)albumin bound 40%
-0.2mmol drop for every 10 drop in albumin
Corrected calcium= serum Ca + (0.2 (40-albumin (g/L)))
b)ionized 45% (free in serum) the fact that this is the largest proportion makes it a good serogate of total calcium
c) bound to inorganic anions 15%
Ionized calcium normal range is 1.15-1.35 mmol/L
- ionized calicum is the most important because it is the free calcium
- ionized calcium is affected by
a) basic pH (acute and chronic respiratory alkalosis)
b) PTH decreases binding of Ca to albumin= increases ionized fraction
c) hyperphosphatemia –>increased phosphate binds Ca and decreases ionized Ca
What are the history, physical exam findings, and ECG findings of pericarditis.
What is the treatment of pericarditis?
Pericarditis can present with chest pain that radiates
Physical exam findings include a
a) high JVP with positive abdomiojugular reflex
b) pulsus paradoxis
ECG findings include
a)widespread STE and PR depression that progress through four phases
Stage 1 – widespread STE and PR depression with reciprocal changes in aVR (occurs during the first two weeks)
Stage 2 – normalization of ST changes; generalized T wave flattening (1 to 3 weeks)
Stage 3– Flattened T waves become inverted (3 to several weeks)
Stage 4 – ECG returns to normal (several weeks onwards)
Tx of idiopathic pericarditis
ASA 650 qid
Admit to hospital if
1) tamponade
2) immunocompromised
3) fever and leukocytosis
4) failure to respond to NSAID therapy
Treatment of pericarditis
What are the causes of aortic stenosis by age?
< 30= congenital bicuspid valve
30-70= rheumatic heart disease
congenital stenosis
>70= calcification
What is fibromuscular dysplasia?
FMD is a non-inflammatory, non-atherosclerotic disorder that leads to arterial stenosis, occlusion, aneuyrsm and dissection
- it can affect one or more body system
- there is often no acute phase reaction like in vasculitis
- It is often associated with hypertension
Clinical manifestations are broad and include
- ischemia related to stenosis
- spontaneous dissection
- rupture of aneurysms
- embolization of intravascular thrombi
Differential diagnosis for fibromusclar dysplasia
- atherosclerosis (usually presents with risk factors)
- vasculitis (usually has acute phase reactants)
What are the risk factors for peripheral artery disease?
Smoking
Hypertension
Dyslipidemia
Elevated homocysteine
What are the stages of hypertension?
Pre hypertension= 120-139/ 80-89
Stage 1 hypertension= 140-159/ 90-99
Stage 2 hypertension= 160/100
What is hypertensive encepalopathy, and what are the common symptoms?
Hypertensive encephalopathy is a form of end organ damage found in extreme hypertension.
Hypertensive encephalopathy is a diagnosis of exclusion
The symptoms of hypertensive encephalopathy are
- severely elevated blood pressures
- confusion
- increased ICP
- +/- seizures
What are neoplasm clusters in MEN I, MEN IIA and MEN IIB?
MEN 1 = “The 3 P’s”
- parathyroid gland
- anterior pituitary
- entero-pancreatic endocrine cells
MEN 2a
- parathyroid gland
- medulary thyroid cancer
- pheochromocytoma
MEN 2b
- mucosal neuromas
- medulary thyroid cancer
- pheochromocytoma
Pheochromocytomas- best tests……
Pheochromocytoma is a neuroendocrine tumor of the medulla of the adrenal glands
-Commonly found in MEN II and VHL
Pheochromocytomas are best diagnosed using 24 hour urine collection for metanephrines, and unconjugated or free catecholamines
Radiographic testing with 123- I metaiodobenzylguandine or octreotide scan is indicated
90% of pheochromocytoma’s are the in adrenal glands
Definitive treatment of choice for pheochromocytoma’s is surgical resection
The medical treatment of a pheochromocytoma is alpha and beta blockade- first establish alpha and then beta.
58 year old woman presents with aphasia and right arm weakness, and a BP of 162/98. What do you do for her blood pressure?
Observe
-in general hypertension should not be acutely decreased in an individual suspected of having a stroke because of the concern for cerbral hypoperfusion and worsening brain ishcemia
What is the serum ascites albumin gradient and when is it useful?
SAAG= Serum albumin- ascites fluid albumin
SAAG tells you the likely underlying etiology of an ascites collection
if > 1.1 g/dl= portal hypertension
- etiologies
a) cirrhosis
b) bud chiari
c) CHF
d) constrictive pericarditis
if< 1.1 g/dl= nonportal hypertension
etiologies
a) peritoneal carcinomatosis
b) tuberculosis peritonitis
c) bowel obstruction or infarction
d) serositis
e) nephrotic syndrome
What are Ransons’s criteria for determining the severity of pancreatitis?
On Admission
Age > 55 years
WBC > 16,000
Serum glucose > 10 mmol/L on admission
AST> 250
LDH> 350
48 Hours Into Admission
Hct drop> 10% from admission
BUN increase > 1.79 mmol/L from admission
Ca < 2 mmol/L within first 48 hours
Arterial pO2 < 60 mmHg within 48 hours
Base deficit (24- HCO3) > 4 within 48 hours
Fluid needs > 6L within 48 hours
Scoring
-each criteria = 1 point
1 to 3= mild pancreatitis
>4 = increased mortality rate 15-100%
What are the criteria for toxic megacolon?
colon with diameter > 6cm on imaging
usually acompanied by fever, leukocytosis, tachycardia, and evidence of serious toxicity such as hypotension or altered mental state
What are the findings in SLE?
Serositis- pleuritis or pericarditis
Oral ulcers-
ANA
Photosensitivity
Blood- hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
Renal- nephritic/ nephrotic or mixed picture
Arthritis-symmetric, non-erosive
Immune
Neurlogic- seizures or psychosis
Malar rash
Discoid rash
What are the casues of gout and pseudogout respectively?
Gout is caused by uric acid crystals (needle shaped and negatively birefringent)
Pseudogout is caused by calcium pyrophosphate dihydrate crystals (blue, rhomboid, positively birefringent)
What are the criteria for the diagnosis of rheumatoid arthritis?
What is Felty’s syndromes?
The combination of
- ra
- splenomegally
- leukopenia
- lymphadenopathy
- thrombocytopenia
What is the differential diagnosis for a rash and fever?
”
What is the difference in labs between b12 and folate deficiency?
b12 deficiency is defined by macrocyclic anemia with methylmalonic acid and homocysteine being high.
Folate just has high homocysteine
What is the definition of neutropenia?
-absolute neutrophil count <500 cells/mm cubed
Or
-ANC <1000 with w predicted decrease to less than 500 cells/mm(cubed)
What are the modified duke criteria for endocarditis?
Major:
- sustained bacteremia by an organism known to cause endocarditis ( or 1 bacterial culture with + serology for Coxiella)
- endocardial involvment documented by either a positive echo or new valvular regurgitation
minor
- predisposing condition
- fever
- vascular phenomenon –> septic arterial or pulmonary emoli, mycotic aneurysms, ICH, janeway lesions, splinter hemorrhages
- immune phenomenon–> + RF, GN, Oslers nodes, roth spots
+ BCx not meeting major criteria
Definitive= 2 major, 1 major + 3 minor or 5 minor
Possible= 1 major+ 1 minor, or 3 minor
What are the indications for surgical management of endocarditis?
- uncontrollable infection (positive cultures after 7 days, no appropriate antimicrobial therapy, )
- local suppurative complications
- most cases of prosthetic valve endocarditis
- intractible congestive heart failure caused by valvular dysfunction
What is a diagnostic test required after recovery from strep bovis endocarditis?
A colonoscopy because a signifiicant number of patients with strep bovis endocarditis have colon cancer or a premalignant polyp which seed the valve
What is the difference between latent, primary and reactivation tuberculosis?
latent- asymptomatic infection
primary- development of critical illness immediately after infection with M tuberculosis
reactivation tuberculosis- illness that occurs after latent TB becomes activated
What segments of the lungs do the different forms of TB affect?
primary pulmonary TB usually affects the middle and lower lung zones
reactivation TB usually affects apical and posterior segments of upper lobes
What is the definition of massive hemoptysis? What is the differential diagnosis for hemoptysis?
More than 100-600ml of blood loss that is coughed up within a 24 hour period
What is the difference between SVC syndrome, horner syndrome, and what is their linking feature?
SVC syndrome–> compression of SVC causing swelling of upper extremeties and formation of new collateral veins
Horner syndrome–> combination of symptoms of miosis (pupils don’t dilate ), ipsilateral anhydrosis, and ptosis (eyelid drop)
Both Horners syndrome and SVC sydnrome are warning signs of cancer development
What are the common types of lung cancers?
Non Small Cell (75%)
- 3 major subgroups
a) squamous cell
b) adenocarcinoma
c) large cell
Small cell (25%)
- more aggressive
- neuroendocrine in origin
What is the staging system for lung cancer?
Stage I- < 3 cm with no nodal or metastatic involvement
Stage II-< 3cm with nodal involvement but no metastatic involvement
****stage IIb- nodes or invasion of chest wall but no distant metastasis
Stage III > 3 cm and invading chest wall ( a vs b is what it is invading)
Stage IV- distant metastasis
How do you assess for the solitary pulminary nodule?
Solitary pulmonary nodule is < 30mm
> 30mm is mass
The risk of malignancy increases with increasing size of the nodule
- Nodules
- Nodules 5 to 9 mm: 2 to 6 percent
- Nodules 8 to 20 mm: 18 percent
- Nodules >20 mm: >50 percent
What are the most common causes of community aquired pneumon
Common Bacterial -S.Pneumo, Moraxella Catarrhalis, Haemophilus Influenza
Viral- influenza, adenovirus
What is the mneumonic for determination if a patient needs to be admitted to the ICU for pneumonia or not?
SMART COP
S- systolic blood pressure <90
M- multilobular infiltrates on CXR
A- albumin < 35 g/L
R- RR> 30
T- Tachycardia ( HR> 125)
C- Confusion
O- O2 sat < 90%
P- pH < 7.35
What are the common causes of cavitation on CXR?
Staph Aureus
Tuberculosis
gram negative organism–> klebsiella
What are the Ottawa ankle rules?
An akle radiographic series is only required if there is any pain in malleolar zone and any of these findings
bone tenderness at posterior tip of (1)lateral or (2) medial malleolus and 6 cm superior
3)innability to weight bear immediately afterwards or in the emergency department
A foot radiographic series is required only if for midfoot pain and any of these findings
1) pain at base of 5th metatarsal
2) pain at navicular
3) innability to weight bear immediately afterwards or in the emergency departmen
What are the ottawa knee rules?
knee X-ray is required only for acute injury patterns with one or more of the following:
- age 55 yrs or older
- tenderness at head of fibula
- isolated tenderness of patella
- inabilty to flex to 90 degrees
- inability to weight bear immediately and in the emergency room ( 4 steps)
What are the Canadial Head CT rule?
CT head is only required for minor head injury patients with any one of the these findings:
High risk
- GCS < 15 at 2 hours after injury
- suspected open or depressed skull fracture
- Any sign of basal skull fracture ( hemotympanum, racoon eyes, CSF otorrhea/ rhinorrhea, Battles sign)
>2 episodes of vomiting
Age > 65
Medium Risk
Amnesia before impact >/= 30 minutes
Dangerous mechanism (pedestrian vs vehicle, ejection from motor vehicle, fall from > 1 meter or 5 stairs
RULE DOES NOT APPLY TO
- non trauma
- GCS < 13
Age < 16
- Coumadin or bleeding disorder
- Obvious open skull fracture
What are the risk factors for the development of diabetes?
BMI > 25
Signs of insulin resistance including (hypetension, low HDL, High TG)
First degree relatives with diabetes
History of gestational diabetes
Being a member of a high risk ethnic group (African American, Hispanics, American indian, Asian americans, Pacific islanders)
What are the indications for thoracentesis?
Uneven or unilateral pleural effusions
Evidence of infection (such as productive cough, fever, pleurisy)
Normal cardial silhouette (no heart failure)
Alarming sign (weight loss, hemoptysis, hypoxia)
Need to evaluate lung parenhyma
What are the characteristics of a pleural effusions that suggest a chest tube will need to be placed for drainage?
Empyema
Positive gram stain of fluid
Prescence of loculations
pH < 7.10
Glucose < 40 g/dl
LDH > 1000 U/L
If chest tube is placed, it is done until drainage rate has decreased to 50 ml/d
It must be followed up with imaging
What are the diagnostic criteria for Giant Cell Arteritis? What is the treatment?
need 3 of the 5
1) Age at onset > 50
2) new headache
3) Temporal artery abnormality (redness or decreased pulsatility not due to athersclerosis)
4) elevated ESR
5) Abnormal temporal artery biopsy ( mononuclear or granulomatous cell infiltration)
What are the diagnostic criteria for a hypertensive crisis, and what are the important physical findings?
Hypertensive crisis is generally defined as blood pressure > 180/120
It is important to identify the following features if they are present
1) focal neurological signs and symptoms due to an ischemic or hemmorrhagic stroke
2) flame hemorrhages, exudates ( cotton wool spots), or papilledema when direct fundoscopy is performed
3) nausea and vomiting ( sign of raised ICP)
4) signs of aortic disection–> BP both arms looking for > 20mm Hg difference, pain radiating to the back
5) Dyspnea and crackles secondary to pulmonary edema
6) Signs of eclampsia in pregnant patients
Important testing includes
1) ECG
2) Chest x-ray
3) urinalysis
4) serum electrolytes and creatinine
5) cardiac enzymes
6) CT or MR head
7) CT/ MT/ echo of heart ( optional)
What is pulsus alternans, and what is it a sign of?
Pulsus alternans is a physical finding of alternating strong and weak pulses that is almost always indicative of left ventricular systolic impairment and carries a poor prognosis
What are Lights Criteria?
Exudates: increased permeability of pleural capillaries or lymphatic dysfunction–> infections (parapneumonic effusion, empyema), malignancy, imflammatory, intra-abdominal (sub-phrenic abscess, ……… ( basically, if it is not transudative, then it is exudative)
Transudates: increased hydrostatic pressure, decreased colloid osmotic pressure–> LVHF, cirrhosis ( low oncotic pressure), nephrotic syndrome, pulmonary embolism, peritoneal dialysis, hypothyroidism, CF, urinothorax
If any of the criteria are met, then the pleural effusion is an exudate
Protein- pleural/ serum = Exudate > 0.5
LDH- pleural/serum= > 0.6
Pleural LDH= > 2/3 upper limit of normal
What defines a complicated pleural effusion?
pH < 7.2
LDH > 1/2 serum
glucose< 2.2
positive gram stain
COMPLICATED EFFUSIONS MUST BE DRAINED AND GIVEN ANTIBIOTICS AND TREATED AS EMPYEMA
What is the appropriate investigation for an incedentaloma ( an incedental mass on the adrenals? What is the appropriate management?
Management:
-always resect functioning tumors
- non-functioning tumors > 4cm resect
- non-functioning tumors < 4cm, reimage in 6-12 months, and resect if enlarging by > 1cm
size > 6cm is the best indicator of primary adrenal carcinoma
What are the absolute contraindications to a progesterone or copper releaseing IUD?
Absolute contraindications for both copper and progesterone
known or suspected pregnancy
undiagnosed genital tract bleeding
acute or chronic PID
lifetsyle risk for STI’s
Absolute contraindications for copper IUD’s
known allergy to copper
wilsons disease
relative contraindications to copper and progesterone
valvular heart disease
presence of prosthetics
past history of PID or ectopic pregnancy
abnormalities of uterine cavity, intracavity fibroids
cervical stenosis
immunosuppressed individuals
relative contraindications to copper IUD
severe dysmenorrhea or menorrhagia
What are the absolute and relative contraindications to anticoagulant therapy?
Absolute
active bleeding
severe bleeding diathesis or platelet count < 20
intracranial bleeding
neurosurgery or occular surgery within 10 days
Relative Contraindications
mild-moderate bleeding diathesis or thrombocytopenia
brain metastasis
recent major trauma
major abdominal surgery within the last 2 days
GI or GU bleeding within 14 days
endocarditis
severe hypertension
recent stroke
