IM 3 Flashcards
CF-12 38yo F present to your office for evaluation of menstrual irregularity. She states that her periods started when she was 12yo and have been regular ever since, coming once every 28-30 days. She had 3 previous uncomplicated pregnancies and deliveries. However, appx 9 mths ago, her cycles seemed to lengthen, for the last 3 mths she has not had a period at all. She stopped breast-feeding 3 years ago, but over the last 3 mths she noticed she could express a small amount of milky fluid from her breast. She had bilateral tubal ligation after her last preg, and she has no other medical or surgical history. Takes no meds, except vitamins. Over the last year or so, she thinks she has gained about 10lb, feels as if she has no energy depsite adequate sleep. Noticed some mild thinning of her hair and slightly more coarse skin texture. She denies headaches or visual changes. Her physical exam, including pelvic and breast are normal. She is not obese or hirsute. You elicit slightly whitish nipple discharge. her pregnancy test is negative. Dx? Etiology?
Hypothyroidism and hyperporlactinemia. Oligomenorrhea and galactorrhea due to hypothyroidism. Thinning hair, weight gain, previous normal menses.
Amenorrhea:
Primary - absence of menarche by 16yrs, regardless of 2ndary characteristics. Secondary- absence of menstration for 3 or more months in women with normal past menses.
Oligomenorrhea:
Menses at infrequent intervals of more than 40 days or less than 9 menses a yr.
Polycystic Ovarian Syndrome:
Syndrome; infertility, hirsutism, obesity and amenorrhea or oligomenorrhea.
Differential for hypothalamic-pit-ovarian axis?
nutrition, excess exercise, stress, infiltrative dz.
PCOS >30% cases.
Empty sella syndrome (CSF herniation into pit fossa), Shehan syndrome, obstructive hemorrhage.
Premature ovarian failure (loss of functional ovarian follicles before 40)
PCOS: history, labs, therapy
Irregular menses since menarche, obesity, hirsutism.
Slightly elevated testosterone, elevated LH/FSH 2:1,
TX-OCP
Hypothyroidsims: history, labs, therapy
Fatigue, cold intolerance.
Elevated TSH
TX-thyroxine replacement
Hyperprolactinemia: history, labs, therapy
Headache, bitemporal hemianopsia, galactorrhea, meds, hypthyroidism.
Elevated prolacin level
TX-underlying
Ovarian failure: history, labs, therapy
Hotflashes, hypoestrogenemia.
Elevated FSH and LH.
TX-Replacment of hormones
Sheehan sydnrome: history, labs, therapy
Postpartum hemorrhage, unable to breast feed.
Low pit hormones (FSH, TSH, ACTH).
TX- replace hormones
Most common cause of hypothyroidism in the US?
Lymphocytic thyroiditis (Hashimotos), followed by surgical or radioactive iodine uptake. Worldwide - Iodine deficiency.
Elderly with dementia, depression. Must rule out? Other symptoms to consider?
hypothyroidism; fatigue weight gain, msl cramping, cold intolerance, hair thinning, menstrual changes or carpel tunnel syndrome.
Myxedema dull facies, swollen eyes, doughy extremities - hydrophilic polysaccharides in dermis, sparse hair and thickened tongue.
Hormone levels in hypothyroidism? What if she’s pregnant?
TSH high, Free T4 or Estimated by T3uptake. Excess TBG (pregnancy or OCPs) : T4 will be high, T3 uptake will be low. UPTAKE HIGH T3 T4 = HYPERTHYROID; UPTAKE LOW T3 T4 = HYPOTHYROID
Euthyroid:
Fatigue is usually only symptom, slightly elevated TSH, normal T3-T4.
In 5 years patient will progress to overt hypothyroidism.
Derangement of cholesterol metabolism, Thyroid replacement can be prescribed to reduce cardiovascular risk.
Levothyroxine tx and expected outcome on this medication:
Long half life 6-7 days, once daily dosing.
Dosing at low levels 25-50ug/d and increase 4-6 weeks to avg ~2ug/kg body wt.
TSH takes 6-8 weeks to readjust to new dosing level.
42yo for her annual physical. On exam, neck fullness. When you palpaite her thyroid, it is enlarged, smooth, rubbery, and nontender. The patient is asymptomatic. You send her for thyroid function testing: Her T4, fT4 and T3 are normal, but TSH slightly elevated. Which of the following is likely diagnosis??
Hashimoto Thyroiditis
Which of the following laboratory tests could be performed to confirm your diagnosis of the patient?
Antithyroid Ab -
Antithyroperoxidase Ab
Antimicrosomal Ab (markers not the cause).
Biopsy will show lymphocytic infiltration and fibrosis of the gland - pathognomonic.
19yo gymnast, menses has ceased for the last 3 mths. Prior she was regular. Denies excess dieting, although she does work out with her team 3 hours daily. Her physical examination is normal except for her body mass index of 20kg/m2. Which labs should be ordered?
b-Hcg
35yo F diagnosed with hypothyroidism 4 weeks ago presents to your office complaining of persistent feeling of fatigue and sluggishness. After confirming your diagnosis with a measurement of TSH, you started her on levothyroxine 50ug daily. She has been reading about her diagnosis on the internet and wants to try desiccated thyroid extract instead of the medicine you gave her. On exam weighs 175, hr 64. Next best test?
Increase her dose of levothyroxine and have her come back in 4 weeks. Medications like Fe containing vitamins should be taken at different times because they may interfere with absorption.
49yo F presents to ER complaining of 4 week history of progressive abdominal swelling and discomfort. She has no other GI symptoms, normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one was complicate by excessive blood loss, requiring blood transfuion. She is happily married for 20yrs, exercises, does not smoke, drinks occasionally. Wild in her youth, does not use drugs now. HIV negative at the time of her last child. Temp is 100.3 P 88bpm BP 94/60. She is thin, her complexion is sallow, sclerae are icteric, chest is clear, RRR no murmur. Abd distended, mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, fluid wave. No peripheral edema. Lab studies are normal except sNa 129 ablumin 2.8, tb 4 prothromin 15 sec, hgb 12 and MCV 102, Plts 78,000 Dx? next step?
Acites caused by portal hypertension as a complication of hepatic cirrhosis. Paracentesis to evaluate ascitic fluid to try determine etiology as well as evaluate for spontaneous bacterial peritonitis.
Ascites:
Abnormal accumulation >25ml of fluid within the peritoneal cavity.
Tx Sodium Restriction, spirinolactone, loops; large volume paracentesis.
Chronic Hepatitis:
Hepatic inflammation and necrosis for at least 6 mths.
Cirrhosis:
Histologic diagnosis reflecting irreversible chronic hepatic injury, which includes extensive fibrosis and formation of regenerate nodules
Portal Hypertension: Clinical? Dx? Tx?
Increased pressure gradient >10mmHg in the portal vein, usually resulting from resistance to portal flow mc cirrhosis.
Present: Splenomegaly, encephalopthy, bleeding varices.
Dx: Doppler US, SAAG: sAlb-aAlb >1.1 portal htn (transudative) <1.1 exudative BAD
Tx: Bblocker to dec portal htn, Sandostatin or Octeotride for splanchnic vasoconstriction.
Spontaneous Bacterial Peritonitis:
Bac infection of ascitic fluid without any intaabdominal source of infection. 10-20% of cirrhotic patients high mortality.
Fever, dec bowel sounds, few abd symptoms.
Dx Paracentesis >250 PMNs or pos culture. Usually 1 organism, if polymicrobial think intestinal perf.
Tx Cefotaxime or ampicilllin /sulbactam
Hepatitis C infection: Risk factors
Most commonly acquired through percutaneous exposure to blood.
Risk factors: IV drug user, Sharing of straws to snort cocaine, hemodialysis, blood transfusion, tattooing, piercing. Sexual transmission rare. Vertical transmission is uncommon, unless high titers or HIV positive.
70-80% develop chronic hep C in the 10 yrs following infection.
20% of those develop cirrhosis among those
1-4% develop hepatocellular ca
Autoimmune hepatitis, test?
ANA, anti LKM (liver kidney microsome)
Hemochromatosis, test?
High transferrin saturation (>50), high ferritin
Wilson Disease, test?
Low Ceruloplasmin
Treatment of choice for Hep C?
HEP CAR:
pegylated alpha antifuron and ribivarin
SE Alpha I -flu like, depression.
SE Ribivarin -hemolysis
15yo adolescent female with elevated liver enzymes and positive ANA?
Autoimmune Hepatitis, positive ANA and hypergamaglobulinemia, may have other signs and symptoms of LUPUS
56yo M with diabetes, tan skin, family history of cirrhosis?
Bronze diabetic with small testes, joint pain and chest pain.
Hematochromatotis, DM, cirrhosis, hypogonadotrophic hypogonadism, arthropathy, and cardiomyopathy.
35yo M with ulcerative colitis
Sclerosing Cholangitis, autoimmune destruction of both the intrahepatic and extrahepatic bile ducts.
Pt presents with jaundice and biliary obstuction;
cholangiography characteristic for beading of the bile ducts.
56 yo F complaint of pruritis and fatigue
Primary Biliary Cirrhosis thought to be autoimmune leading to destruction of small/medium bile ducts.
Pt women 50-60.
Alk Phos 2x-5x normal
32yo M with Kayser Fleischer rings, dysarthria, and spacticity
Wilson’s Dz inherited copper metabolism, cirrhosis with neurological changes.
CF-14 42 yo hispanic F presents ER with 24hr of severe , steady epigastric abdominal pain, radiating to her back, several episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spontaneously within hour or two. This time the pain did not improve. She has no medical history, takes no medication. Married, 3 children, does not drink alcohol or smoke cigarettes. PE: afebrile, tachycardic, P104 BP 115/74 and shallow respirations 22. Moving comfortably in stretcher, skin warm and diaphoretic, scleral icterus. Her abdomen is soft, mildly distended with marked right upper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, no masses or organomegaly. Her stool is neg for occult blood. Labs TB 9.2 AST 78 ALT 92 Amylase 1249 WBC 16500 82% PMN 16% Lymph. Plain abdomen shows nonspecific gas pattern and no pneumoperitoneum. Dx? Etiology? Next step?
Acute Pancreatitis, due to choledocholithiasis. Next step right upper abdominal US.
Ranson Criteria for severity of pancreatitis? Initially?
intial: Glucose>200, Age >55, LDH >350, AST >250, WBC >16000
Ranson Criteria for severity of pancreatitis? Within 48hrs
Worry about anemia, low volume state, hypoCa Hct drop >10, sCa 5, Base Def >4, Art PO2 6L
Most common cause of pancreatits in the US?
Alcohol, next is biliary tract dz usually stone,
hypertriglyceridemia (>1000)
hypercalcemia
Define low grade fever?
<101
Specific to pancreatitis? Amylase or lipase?
Lipase remanes elevated longer
Dx and Tx of Pancreatitis?
CT abdomen, Treatment is mainly supportive (NPO, analgeisa-meperidine, IVF) Patients with severe pancreatitis will sequester fluid in abdomen, give copious IVFs.
Most common cause of death in severe pancreatitis?
Hypovolemic Shock, due to thirdspacing and inc capillary permeability. non cardio (ARDS) -pulmonary edema cardio -myoglobin dysfunction
Pancreatic complications?
Phlegmon, solid mass of inflammed pancrease with patchy necrosis.
Pancreatic abscess.
Pancreatic pseudocyst collection of inflammatory fluid and pancreatic secretions, most will resolve in 6 wks.
