IM 4 Flashcards
2 major treatment issues to address in all patients with new-onset AF?
- Rate or rhythm control strategy
- Risk stratification for prevention of systemic embolization
Current evidence suggests that there is no significant difference in morbidity and mortality rates, including embolic risk between the rate and rhythm control strategy
Systemic thromboembolism is a major cause of long-term morbidity in patients with AF - how is this managed?
Warfarin (or newer oral anticoagulants) significantly reduce this risk in patients at moderate to high risk of thromboembolic events; CHA2DS2VASc score for risk stratification
Scoring of CHA2DS2-VASc?
Congestive heart failure HTN A2 = Age 75+ DM S2 = Stroke/TIA/Thromboembolism Vascular disease (prior MI, PAD, or aortic plaque) A = Age 65-74 Sc = female
Risk/Rx - CHA2DS2Vasc?
0 = low risk, no antithrombotics 1 = intermediate risk, none or aspirin or oral anticoagulants 2+ = high risk, oral anticoagulants
The high incidence of UTIs in women is primarily due to?
The shorter length of the female urethra
Presentation of acute epididymitis?
Unilateral testicular pain
Epididymal edema
Dysuria, frequency (with coliform infection)
The causative organism of acute epididymitis can be predicted based on the age of the patient - discuss.
> 35 - bacteriuria related to bladder outlet obstruction (eg, BPH) -> ascending coliform bacteria such as E. coli
<35 - STI with C. trachomatis or N. gonorrhea
Dx acute epididymitis?
UA/cultures
NAAT for chlamydia and gonorrhea
Rx acute epididymitis?
If STI - ceftriaxone/doxycycline
If coliform - levofloxacin
Classic presentation of Hyperosmolar Hyperglycemic State?
Gradual hyperglycemic symptoms (polyuria, polydipsia, etc.), AMS in an older patient with DM2
Lab findings in HHS?
Glucose >1000 mg/dL Normal pH and bicarbonate Normal AG Negative or small serum ketones Serum osmolality >320 mOsm/kg
Initial management of HHS?
Aggressive hydration with normal saline
IV insulin
Careful monitoring and supplementation of potassium
Why are arterial pH and AG typically normal in HHS (as opposed to DKA)?
Unlike DKA, HHS is caused by a relative rather than absolute insulin deficiency, and accumulation of ketoacids will be minimal.
Why is fluid replacement the most important initial step in management HHS?
Severe hyperglycemia induces an osmotic diuresis, which can lead to a deficit of 8-10 L in total body water; aggressive rehydration improves tissue perfusion and responsiveness to insulin therapy
Presentation - infectious epiglottitis?
Rapidly progressive and life-threatening Fever, sore throat, drooling, muffled voice Airway obstruction (stridor, dyspnea) Pooled oropharynx secretions Laryngotracheal tenderness
Commonly presents in adults with DM, obesity, and preceding URI
In adults, most cases of infectious epiglottitis are caused by what bacteria?
S. pneumoniae, H. influenzae
Whereas children classically have abrupt onset of drooling, dysphagia, and distress in the setting of infectious epiglottitis, adults present…?
…more subtly, with sore throat, fever, and laryngotracheal tenderness to palpation. With worsening of the swelling, difficulty swallowing, pooled oral secretions, and respiratory compromise can develop
Dx epiglottitis?
Direct visualization or soft-tissue lateral neck radiograph (enlarged epiglottis, loss of the vallecular air space, and or distended hypopharynx)
Radiographs may also help exclude other conditions
[If significant respiratory compromise, establish airway prior to considering neck radiograph]
Most common type of leukemia in the US?
Chronic lymphocytic leukemia
Clinical presentation of CLL?
Classic hallmark: dramatic lymphocytosis
Lymphadenopathy (cervical, supraclavicular, axillary), HSM, mild thrombocytopenia and anemia, often asymptomatic, though may present with extreme fatigue, B symptoms, infection, or weigh loss
Almost always seen in the elderly (median age - 70)
Peripheral smear findings of CLL?
Mature lymphocytes with the presence of smudge cells (pathognomonic)
Dx CLL?
Severe lymphocytosis and smudge cells
Flow cytometry
Lymph node and bone marrow biopsy not generally needed
Prognosis of CLL?
Median survival 10 years
Worse prognosis with multiple chain lymphadenopathy, HSM, anemia/thrombocytopenia