IM 3 Flashcards
Definition and Clinical Presentation of Retinal Detachment
Separations of the layers of the retina, in patients 40-70s, caused by myopia or trauma, through which fluid seeps in and separates the retinal layers.
Photopsia (flashes of light), floaters (spots in the visual field), and curtain coming over the eyes
Tx: laser therapy and cryotherapy are done to create permanent adhesions between the neurosensory retina and the retinal pigment epithelium and choroid
Choroidal rupture
Blunt ocular trauma resulting in central scotoma, retinal edema, hemorrhagic detachment of the macula sub retinal hemorrhage, crescent shaped streak concentric to the optic nerve.
Central retinal artery occlusion (CRAO)
Sudden painless loss of vision in one eye, pallor of the optic disc, cherry red fovea, and boxcar segmentation of blood in the retinal veins.
Proliferative diabetic retinopathy
Initial stages is asymptomatic but later with decrease visual acuity. Neovascularization is the hallmark of proliferative diabetes retinopathy
Exudative macular degeneration
Acute or insidious progressive blurring of central vision bilaterally. Abnormal vessels in the retinal space.
Porphyria Cutanea Tarda
Deficiency of Uroporhyrinogen decarboxylase, part of the Heme synthesis pathway. Results in painless blisters and fragility on the dorsal surface of the hand, facial hypertrichosis, and hyperpigmentation. Can be triggered by ingestion of certain substances (estrogen, ethanol). Elevated urinary prophyrin levels confirms the diagnosis. Phlebotomy and hydroxychloroquine and alpha interferon may provide some relief.
Dermatitis Herpetiform
Pruritic papules and vesicles that are mainly on the elbows and knees, buttocks, posterior neck, and scalp. The condition arises in the context of gluten-sensitive enteropathy, which may be subclinical
Crigler’s Najjar syndrome Type 1
Autosomal recessive disorder of bilirubin metabolism characterized by severe jaundice, and neurological impairment from kernicterus. In infants, indirect bilirubin + 20-25, but can go to 50. If intravenous phenobarbital is administered, the serum bilirubin remains unchanged. Phototherapy and plasmapheresis typically helpful for short term, but liver transplant is the only cure.
Crigler’s Najjar syndrome type 2
Milder autosomal recessive disorder of bilirubin metabolism characterized by lower serum bilirubin levels (<20) and survival into adulthood with no neurological impairment from kernicterus. Liver enzymes and histology are normal. Intravenous phenobarbital can reduce the serum bilirubin levels. Treatment is often unnecessary though periodic administration of phenobarbital or clofibrate can reduce serum bilirubin levels.
Gilbert’s Syndrome
Familial syndrome of bilirubin glucuronidation, where the levels of UDP glucuronyl transferase is reduced. Approximately 9% are homozygous, while another 30% are heterozygous and asymptomatic. Manifestations include icterus 2/2 mild predominately unconjugated hyperbilirubinemia - normal levels are <3. Those who are symptomatic have nonspecific complaints such as abdominal pain, increasing fatigue or malaise. Certain events such as hemolysis, fasting, or costuming a fat free diet, physical exertion, stress, fatigue can trigger for hyperbilirubinemia in these patients.
Dx for Man with syncope when micturating or coughing?
Situational syncope 2/2 autonomic dysregulation by straining and rapid bladder emptying.
How does weight loss affect the systolic blood pressure?
5-20 per 10kg weight loss
How does the dash diet affect systolic blood pressure?
Reduction in 8-14 lbs
In atrial fibrillation with Rapid Ventricular response, how do you manage?
In atrial fibrillation with Rapid Ventricular response, rate control should be attempted initially with a beta blocker or calcium blocker (diltiazem). Immediate synchronized is indicated in hemodynamically unstable patients with rapid atrial fibrillation.
What is Beck’s Triad?
Hypotension, muffled heart sounds, and Jugular venous distention (and pulses paradoxus) –> Tamponade. It can be a complication of aortac dissection
HACEK organisms
Haemophilus aphrophilus, Aggregatibacter actinomycetemcomitans, Carciobacterium hominis, Eikenella Carrodens, Kingella kingae
Risk factors for OSA?
Obesity, Hypothyroidism, tonsillar hypertrophy.
Typical symptoms: daytime sleepiness, headache in the morning, snoring, poor judgement, impotence
Narcolepsy
Poorly regulated rapid eye movement, patients may also suffer from hypnagogic and hypnopompic hallucinations
Pickwickian Syndrome
Obesity hypoventilation syndrome impeding the expansion of the chest and abdomen during breathing causing under ventilation of lungs at all hours.
Murphy’s sign
Worsening of RUQ pain with inspiration, indication of cholecystitis
When does cholecystitis normally arise
It is secondary to stone formation and most commonly arises when gallstone impacts the cystic duct
Cluster headache
recurrent episodes of unilateral, periorbital headache accompanied by ipsilateral rhinorrhea, lacrimation, red eye, and Horner syndrome. Episodes typically affect men between 20-50, occur at night and less than 2 hours.
Enthesitis
When the site where the ligaments/tendon attach to bone becomes inflamed. Typical site include the heel, tibial tuberosity, and iliac crest. Common finding in Ankylosing Spondylitis and other HLA-B27 associated
What drugs/supplement increases the effect of warfarin?
Acetominophen, NSAIDs, antibiotic/antifungal, amiodarone, cranberry juice, ginkgo, vitamin E, omeprazole, thyroid hormone SSRI
What drugs/supplement decrease the effect of warfarin?
Leafy green, Rifampin, Carbamazepine, Oral contraception, Ginseng, St. John’s wort, Green vegetables
What is the pH of empyema?
<7.2. This indicates the need to remove by thoracostomy
Metoclopramide
Dopamine receptor antagonist used to treat nausea, gastroparesis, vomitting. Should be monitored for drug induced extrapyramidal signs (tar dive dyskinesia, dystonic reaction, parkinsonism)
What is mixed cryoglobulinemia?
Palpable purpura, proteinuria, hematuria. Other suggestive clinical manifestations include non-specific symptoms, arthralgias, hepatosplenomegaly, hypocomplementemia, majority of patients have an underlying HCV
Henoch Scholein Purpura
Presents in childhood with palpable purpura on the buttocks, arthralgias, proteinuria, and hematuria with RBC casts on urinalysis. Serum complement levels are normal.
Tumor lysis Syndrome
Tumors with high cell turnover which are commonly poorly differentiated lymphomas (i.e. Burkitt’s lymphoma) and leukemias. Results in hyperphosphotemia, hypocalcemia, hyperkalemia, and hyperuricemia. Allopurinol has greatly reduced the rate of acute urate nephropathy.
Most common type of blood transfusion reaction
Febrile Non-hemolytic: fevers, chills, within 1-6 hours of transfusion, caused by cytokine accumulation during blood storage.
Other types of blood transfusion reactions: Acute hemolytic
Acute hemolytic: flank pain, hemoglobinuria, renal failure & DIC, within one hour of transfusion, positive direct Coomb’s test, pink plasma, Caused by ABO incompatibility
Blood transfusion reaction: Delay Hypersensitivity
2-10 days after, mild fever, hemolytic anemia, positive direct Coomb’s test, positive new antibody screen, caused by anamnestic antibody response
Anaphylactic: Rapid onset of shock; angioedema/urticaria & respiratory distress, within seconds to minutes of transfusion, caused by recipients anti-IgA antibodies
Urticaria/allergic: urticaria, flushing, angioedema, & pruritis, , within 2-3 hours of transfusion; caused by recipient IgE antibodies and mast-cell activation
Primary Raynaud’ Phenomenon
No underlying cause
Usually woman < 30
Possible prevalence in multiple family members
Symmetric attacks, no tissue injury, digital pitting, negative nailfold capillary examination, negative antinuclear antibodies, erythrocyte sedimentation rate
Tx: no further evaluation, avoidance of aggravating factors
Avoidance of aggravating factors
Calcium channel blockers for persistent symptoms
Secondary Raynaud’s Phenomenon
Connective Tissue Diseases, Occlusive vascular conditions (i.e. Buerger’s disease), sympathomimetic drugs (i.e. ephedrine, epinephrine), vibrating tools, hyper viscosity syndromes (cryoglobinemia)
Usually men>40, asymmetric attacks, presence of another attack, painful episodes of tissue injury, abnormal nailfold capillary examination. Abnormal studies for vascular or autoimmune disorder
Tx: eval/tx underlying etiology, Ca blocker for symptoms, aspirin if at risk for digital ulceration, chemical/surgical sympathectomy for severe ischemia
Those with suspected secondary Raynaud’s Phenomenon should have which tests?
Urinalysis
ANA and RF
Complete Blood count/metabolic panel
Erythrocyte sedimentation and complement levels
Guillain-Barre Syndrome
Ascending polyradiculoneuropathy that often preceded by an upper respiratory tract infection or diarrhea (i.e. Campylobacter Jejeuni). Presents as bilateral leg weakness that ascends to the arms, respiratory muscles, and face to generalized flaccid paralysis. Distal parasthesia is common. Reflexes are diminished or absent. Reflexes are diminished/absent. Autonomic disturbances are common and include tachycardia, bradycardia, hypertension, orthostatic hypotension, and urinary retention.
Tx: IVIG, plasmapheresis
CSF composition of Guillain Barre
Protein - increased (due to increase permeability of BBB) (normal is <40)
WBC - normal (0-5)
RBC - normal
Glucose - normal (40-70)
Albuminocytologic dissociation
CSF composition of Bacterial, fungal, tubercular meningitis
Protein - increased
WBC - increased
RBC - normal
Glucose - decreased
CSF composition of viral meningitis
Protein - normal to slightly elevated
WBC - increased
RBC -normal
glucose - normal
What type of toxicity is seen in smoke inhalation
CO poisoning, CO binds to hemoglobin with an affinity of 260x O2, it will displace the O2 and decrease the Hg binding sites available for O2. CO will cause a LEFT shift to the oxyhemoglobin curve. This disallow unloading of the oxygen to the tissues. This results in an increased anaerobic metabolism by the tissue leading to increase lactic acid production and development of an anion gap metabolic acidosis
What induces a seizure?
Emotions, sleep loss, alcohol withdrawal, flashing lights
Clinical clues: auras (olfactory, hallucinations), can occur with sleeping or sitting position, head movements, tongue bitting, rapid, strong movements
What induces a syncope?
Upright position, emotion, heat, crowded places
Clinical clues: signs of pre syncope (i.e. lightheadedness), unlikely to occur with sleeping, or sitting, rarely several clonic jerks can occur with prolonged cerebral hypo perfusion, pallor and diaphoresis, weak slow pulses
Pseudotumor cerebri
young obese female with headaches that suggest brain tumor but has normal neuroimaging and normal CSF pressures.
tx: weight reduction and acetozolamide if weight loss fails. Shunting or optic nerve sheath fenestration can prevent blindness
