IM Flashcards
Creat of normal kidney, CRF, and ESRD
- 8
- 0
- 0 (need dialysis)
Urinalysis of prerenal AKI
Una<10
FEna<1% or FEurea <35%
BUN:Cr >20
Signs of AKI
Elevated creat or decreased urine output
Causes of prerenal AKI
Anything in front of the heart: CHF, MI, diarrhea, dehydration, aggressive diuresis, cirrhosis, gastritis, FMD/RAS
Causes post-renal AKI
Anything behind the kidney: cancer/stones in the ureter, bladder, urethra
BPH, foley, neurogenic bladder
Dx post-renal AKI
CT: stones, US: hydronephrosis
Most common causes of post-renal AKI
BPH, neurogenic bladder, kinked catheter
Most common place of bladder obstruction
Ureter
Muddy casts indicate
ATN
WBC casts or eosinophils indicate
AIN
RBC casts indicate
GN
Next step if RCB casts are seen in UA
R/O nephrotic syndrome:
- proteinuria >3.5g/day
- increased cholesterol
- edema
Phases of ATN
Prodrome: elevated creat, normal urine output
Oliguric: elevated creat, urine output drops
Polyuric: increased urine output
Avoid contrast ATN in existing renal damage
Tons of IVF, n-acetyl-cysteine, stop ACEI/ARBs
Indications for dialysis
Acidosis Electrolytes Ingestion (SLIME) Overload Uremia
Definition of CKD
> 3 decreased GFR (creat ~2)
GFR in renal failure/ESRD
<15
DM drug contraindicated in CKD?
Meformin
Secondary complications of CKD
Anemia (decreased EPO)
HyperPTH (increased phosphate and decreased Ca)
Volume overload
Acidosis
How to correct moderate vs severe hyper and hypo natreamia?
Moderate (both): IV NS
Severe hyper: IV D5W/ hypo: IV hypertonic (3%)
Max Na correction per hour and day?
0.25 mmol/hr
4-6/day
Equation to measure serum osmoles
Serum osmoses = (2*Na) + (glucose/18) + (bun/2.8)
Causes of hypertonic hyponatremia
Elevated glucose, BUN or sugar alcohols
How to correct Na for elevated glucose
For every 100mg glucose above 100, add 1.6 to Na
Causes of euvolemic hyponatremia
RTA
Addisons
Thyroid
SIADH
Treatment for hypercalcemia
IVF (can add furoside after fluids)
Calcitonin if severe, bisphosphonates for chronic
Sx of hypercalcemia
Boans, stones, groans, moans
When would you see elevated PTH-rp
Squamous cell of lung
Sx of hypocalcemia
Perioral tingling, Trousseau and Chvostek
Treatment for hypocalcemia
IV Ca if severe
Next step of Asx hypocalcemia
Check albumin
Order of EKG changes with elevated K?
Peaked T wave, prolonged PR, wide QRS, sine wave
Normal K
- 5-5.5
4. 0-5.5 in hospital/cardiac patients
Sx of hyperkalemia
Areflexia, flaccid paralysis, paresthesias (decreased motor and sensation) and EKG changes
Treat hyperkalemia
- IV Ca gluconate
- Insulin/glucose or bicarb
- Kayexalate (aka sodium polystyrene sulfonate)
Radiolucent kidney stones
Uric acid and cysteine
Radioopaque kidney stones
Calcium and struvite
Diagnostic test for kidney stones
U/A first then non-con CT
Treatment of kidney stones
<5mm: IVF and pain
<7mm: CCB (amlodipine) or terazosin
<1.5cm: lithotripsy or ureteroscopy
>1.5cm: exlap or perc anterograde nephrolithotomy
Classic triad of RCC
flank pain, hematuria, flank mas
Factors that increase risk of RCC
Smoking, ESRD, VHL
How does RCC spread?
Hematogenously
Common complications of RCC
Renal vein thrombosis, anemia/polycythemia
Normal serum pH?
7.4
Normal ABG CO2?
40
Causes of respiratory acidosis
Hypoventilation: Opiates, COPD/asthma/OSA, decreased muscle strength (GB)
Next step after determining metabolic acidosis?
Anion gap
Normal value and equation for serum anion gap?
12
Na-Cl-Bicarb
>12 = anion gap acidosis
Causes of +anion gap acidosis?
Methanol Uremia DKA Propylene glycol Iron and INH Lactic acidosis Ethylene glycol Salicylates
Next step of -anion gap acidosis?
Urine anion gap; Na+K-Cl
What causes +urine anion gap acidosis?
RTA
What causes -urine anion gap acidosis?
Diarrhea
Causes of respiratory alkalosis?
Hyperventiliation: Pain, anxiety, hypoxemia
Next step after determining metabolic alkalosis and its normal value?
Urine Cl; 10
Metabolic alkalosis with urine Cl <10
Volume responsive aka contraction alkalosis
Diuretics, dehydration, emesis, NG
Metabolic alkalosis with urine Cl >10
Not volume responsive; look for HTN
+ Hyperaldosterone (renal arter stenosis or Conn’s)
- Genetic (Barter, Gitelman)
What is the Diamond Classification and what are the components?
IDs risk of CAD based on sx
Substernal chest pain, worse with exertion, better with NTG
Typical is 3/3, atypical is 2/3
When should nitrates be avoided in treatment of angina?
Right sided infarct (II, III, aVF)
Why do we give B-blockers for angina?
Reduce myocardial work, prevent ventricular arrhythmias
When do you do a CABG?
Left main stem or 3 vessel disease
Causes of systolic heart failure?
“cant push blood forward”
Leaky valves, dilated cardiomyopathy, dead muscle, “floppy” muscle (EtOH, HTN, drugs)
Causes of diastolic heart failure?
“cant relax/fill”
Hypertrophy or infiltration (tamponade, effusion)
Most common cause of heart failure?
Hypertension: increases systemic vascular resistance, hypertrophies and then fails
Classic triad of CHF
Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea
Sx of left sided heart failure
Orthopnea, crackles, rales, exertional dyspnea, S3 (overly compliant), PND
Sx of right sided heart failure
Hepatosplenomegaly, JVD, peripheral edema, exertional dyspnea, increased JVP
What is BNP used for?
To determine if the patient is volume overloaded or not
How do you diagnose CHF?
BNP
2D echo: systolic failure (EF<55%) or diastolic (nml EF)
Nucelar study
Treating CHF class I-III
Reduce preload and afterload
Reduce preload: reduce fluid by restricting salt (<2g/day) and PO fluids (<2L); add furosemide/nitrates at class II
Reduce afterload: ACE-I or ARBs; add spironolactone or hydralazine at class III
Beta-blocker
Treating CHF class IV
Same drugs as I-III
Add ionotropes: dobutamine and prepare for transplant
When is an AICD considered in CHF?
EF <35%
When do you need to work up a murmur?
Diastolic, symptomatic or > grade 3
Murmur of mitral stenosis?
Diastolic opening snap followed by decrescendo murmur
What indicates the severity of mitral stenosis?
Earlier snap = worse stenosis
How do you treat mitral stenosis?
Preload reduction
Balloon valvotomy/replacement
Sequelae of mitral stenosis
CHF sx, Afib (atrial stretch)
What causes mitral stenosis?
Rheumatic fever
What causes aortic stenosis?
Calcification
Murmur of aortic stenosis
Crescendo-decrescendo at the aorta
Sx of aortic stenosis
Angina, especially with exertion
Syncope
Sequela of aortic stenosis
CHF (bad prognosis, 1-3 years)
Treatment of aortic stenosis
Decrease preload Replace valve (also will require CABG dt loss of ostia)
Murmur of mitral regurg
Holosystolic radiating to axilla
High-pitched, blowing
Sequelae of mitral regurg
Afib (atrial stretch), Pulmonary congestions/CHF, cardiogenic shock (decreased forward flow)
Causes of acute mitral regurg
Ruptured papillary muscle or chordae, endocarditis, trauma
Causes of chronic mitral regurg
2/2 ischemia or MVP
Sx of mitral regurg
Exertional dyspnea, fatigue, CHF
Murmur of aortic insufficiency
Decrescendo murmur heard best aortic valve
Cause of aortic insufficiency
Floppy valve 2/2 ischemia or infection
Presentation of aortic insufficiency
Dilated heart failure (chronic) cardiogenic shock (acute)
Murmur of MVP
Mid-systolic click followed by a late systolic rumble
Cause of MVP
Usually congenital
Also seen in pregnant women
Treat MVP
Expand intravascular volume
Murmurs that improve with leg raise (and worsen with valsalva)
HCOM and MVP
*all the rest are the opposite
Result of leg raise vs valsalva
Leg raise: increases venous return
Valsalva: decreases venous return
Types of cardiomyopathy
Dilated, Hypertrophic, Restrictive
Mechanism in dilated cardiomyopathy
Decreased contractility -> systolic heart failure
Cause of dilated cardiomyopathy
Ischemia, valve disease, infections, metabolic, EtOH, etc
Cause hypertrophic cardiomyopathy
AD mutation in sarcomeres
Asymmetric hypertrophy of septal wall
What causes improvement in murmur/sx of HCM?
Increased preload (increased volume moves the hypertrophied tissue out of the way)
Population of hypertrophic cardiomyopathy
Sudden death of young athelete
Treatment of HCM?
Hydration and B-blockers (or CCB) (increase in ventricular filling)
Mechanism of restrictive cardiomyopathy
Heart cant relax -> diastolic failure
Causes of restrictive cardiomyopathy
Sarcoid, amyloid, hemochromatosis, Cancer, fibrosis
Treatment of restrictive cardiomyopathy
Diuresis and HR control
Eventual transplant
Cause of concentric cardiomyopathy and sequelae
HTN
Diastolic CHF
Sx of pericarditis
Pleuritic and positional CP (better with leaning forward)
Friction rub
EKG of pericarditis
Diffuse ST elevation and PR segment depression (pathognomonic)
Treatment of pericarditis
NSAIDS and colchicine
Sx of chronic pericardial effusion
Looks like CHF: exertional dyspnea, orthopnea, PND
Sx of acute pericardial effusion/tamponade
Becks triad: JVD, hypotension, distant heart sounds
Pulsus paradoxus
Treatment of tamponade
Pericardiocentesis
Pericardial knock indicates what?
Constrictive pericarditis (fibrosis)
Neuro cause of syncope
Vertebrobasilar insufficiency
What is second line to statins?
Fibrates
What makes an arrhythmia unstable?
CP, SOB, AMS, systolic bp <90
First line treatment for unstable arrhythmias
electricity
Fast + unstable rhythm vs slow + unstable rhythm treatment
Shock
Pace
Treatment for fast + narrow + stable arrhythmia
Adenosine
Treatment for fast + wide + stable arrhythmia
Amiodarone
Treatment for acute afib
Rate control first (BB or CCB)
When do you shock in cardiac arrest?
Only vtach or vfib
Age related sick syndrome
Dry eyes and mouth
Higher risk in women, w/ DM or thyroid disorders
Exocrine atrophy
Labs in Pagets
Ca, Serum phosphorus normal
Alkaline phosphatase and urine hydroxyproline high
Treatment for Pagets
Bisphosphonates
Factors associated with increased prevalance
PPV (up) and NPV (down) in a higher prevalence population
Pain with walking that is relieved by bending forward
Osteoarthritis/spinal stenosis
Main difference between SJS and TEN
<10% BSA: SJS (also has basal cell degeneration on bx)
>30% BSA: TEN (full thickness epidermal necrosis)
Most common type of kidney stone
calcium oxalate
Cause of pronator drift
UMN/pyramidal or corticospinal tract dysfunction
Sx of basal ganglia dysfunction
Extrapyramidal sx: resting tremor, rigidity, bradykinesia, choreiform movements
Sx of cerebellar dysfunction
Ataxia, intention tremor, impaired rapid alternating movements
Sx of Huntington’s
Chorea, delayed saccades, depression, decreased executive function, motor impersistance
Sx of SAH (besides HA)
Meningeal irritation (n/v, photophobia)
Pure motor hemiparesis
Lacunar infarct in the internal capsule
Will see microatheroma and lipohyalinosis of small vessels
Elevated homocysteine levels is related to
Decreases folate, B6 and B12
EKG of pericarditis
Diffuse ST elevations with depression in aVR
Common abnormalities associated with MG?
Thymic: thymoma or thymic hyperplasia
Cause of achalasia and sx?
Degeneration of neurons in the myenteric plexus
Gradual dysphagia to solids and liquids
Mechanism of PAH in SS?
Hyperplasia of the intimal smooth muscle layer
Cross sectional study set up
Compare two groups; see if they have risk factors and then see if they have the dz
Histone ab
Drug induced lupus
ds-DNA ab
Lupus + renal
Smooth muscle ab
autoimmune hep
mitochondrial ab
PBC
Centromere ab
CREST
RO/LA ab
Sjorgrens
CCP or RF ab
Rheumatoid arthritis
Jo ab
Polymositis
Topoisomerase ab
Systemic scleroderma
Classic RA presentation
Symmetric arthritis of 3+ joints that spares the DIPs
CREST
Collagen replaces smooth muscle; skin tightness in hands/face
Spares heart and kidneys; effects skin and GI
anti-centromere
Systemic sclerosis
Diffuse disease with cardiac and renal involvement
Anti-scl (topoisomerase 1)
Treatment for scleroderma
Treat sx: CCB, penicillamine, steroids, ACE-I
Difficulty rising from chair but intact grip strength
Polymyositis/dermatomyositis/inclusion body myositis
Gottron’s papules
Scaly area over major joints -> myositis
Will be seen with photosensitivity, heliotrope rash and proximal muscles weakness
Presentation of ankylosing spondylitis
Back pain, morning stiffness, improved with exercise/use; can have achilles tendon inflammation
Associated with IBD but independent of course
Presentation of reactive arthritis
Asymmetric b/l arthritis of low back and hands
Presentation of psoriatic
Symmetric PIP and DIP, pitting of nails
Enteropathic arthritis
Symmetric, b/l, non-deforming, peripheral and migratory
Hx of diarrhea
Increase risk for which bugs with immunosuppression following transplant?
CMV and Pneumocystis
Dx for proximal muscle weakness
myositis vs Eaton Lambert
What is the ice pack test for?
MG
XR findings of OA
Joint space narrowing, osteophytes and subchondrol sclerosis/cysts
Cancers associated with Lynch syndrome
Colorectal, endometrial, ovarian
Feltys syndrome
RA + neutropenia + splenomegaly
Part of the spine affected in RA?
Cervical only
Complications of PBC
Nutrient deficiencies, hepatocellular carcinoma, metabolic bone disease
CT of diffuse axonal injury
Minute punctate hemorrhages with blurring go gray-white interface
Often seen in sudden deceleration
Hemoptysis + hematuria
Goodpasture
Asthma + hematuria
Churg Strauss
Hemineglect indicates a lesion where?
Non-dominant (usually right) parietal lobe
Presentation of dacrocystitis
Infection of lacrimal sac
Sudden onset pain and redness over medial canthal region; can have purulent discharge
Presentation of episcleritis
Inflammation of the episcleral tissue between the conjunctiva and sclera
Hordeolum
Abscess over upper or lower eyelid
First line for symptomatic PVCs
BB or CCB (increase dose if already on)
Pemphigus vulgaris
Autoimmune against desmoglein; ab on epithelial cells throughout lesion
Between epithelial cells; blister is thin (+ Nikolsky)
Life threatening, involves mucosa, 30-50s
Bullous pemphigoid
Autoimmune against hemidesmosomes (basement membrane); intact epithelium detached from BM; ab at dermal-epidermal junction
Rigid blister; not life threatening/no mucosal involvement/70-80s
Dermatitis herpetiformis
IgA against translutaminase
Ab-antigen complex deposition
Multiple, small, vesicular eruptions; pruritic
Seen on butt, legs, extensor surfaces
Porphyria Cutanea Tarda
Bullae on sun-exposed areas
Dx with coral red urine under Wood’s lamp
Seborrheic dermatitis
Fungal infection in areas of hair
Pityriasis Rosea
Herald patch: flat, oval, salmon-colored scaling lesion -> multiple similar appearing lesions with trailing scale
Spares palms and soles if self-limiting
Can be initial presentation of syphillis; will have hands and feet
Lichen planus
Intensely pruritic pink or purple flat topped papule with a reticulated network of white lines
Can be caused by lichenoid drug eruption
Atopic dermatitis
- Dry, red, itchy rash
- Associated with 3As: asthma, allergies, atopy
What type of HS is contact dermatitis?
IV
Statsis dermatitis
Chronic LE edema
Edema, erythema, brown discoloration with scaling
Might look like cellulitis but will be b/l
Urticaria
Type I HS
Crosslinking of IgE on mast cells -> histamine
-Annular, blanching red papule
Drug reaction
Pink, morbilliform rash 7-14 days after exposure
Widespread, symmetric, pruritic
Erythema-Multiforme
Cutaenous drug reaction
Target shaped lesion on palms and soles
Self-limited
Differentiate SSSS and TEN
SSSS doesnt have mucosal involvement
Nevi
Bening hyperplasia of melanocytes
Wise excesional bx
Seborrheic keratosis
Large, brown, greasy, crusted mole; stuck on
Actinic keratosis
Premalignant -> SCC
Erythematous with sandpaper-like yellow to brown scale
Cryosurgery; 5-FU for diffuse lesions
SCC
Invasive malignancy of keratinocytes that can met
Fleshy, erythematous, crusted or ulcerated
Keratoacanthoma
Looks like SCCC but will regress spontaneously
Erysipelas
S. pyognes
Dark red, well demarcated, indurated lesions that outline the lymphatics “climb up the extremity”
Medial knee pain/pain at top of tibia
pes anserinus
Treatment: strengthen quads
Anterior knee pain
patellofemoral syndrome
Muscle weakness following an asthma exacerbation
Possible hypokalemia; SE of B2 agonist
Thrombotic thrombocytopenia purpura
Thrombocytopenia, microangiopathic hemolytic anemia, renal insufficiency, neuro changes, fever
Treat with plasma exchange
Most common cause of constrictive pericarditis in developing countries
TB
Required to dx malignant HTN
papilledema/retinal hemorrhages
Mixed connective tissue disease
Scleroderma, RA, myositis, SLE mix
Anti-U1
Widened pulse pressure
aortic regurg
Sx of acute angle-closure glaucoma
Severe eye pain, halos, injection, poorly responsive to light, tearing, headache
Treat: acetazolamide, BB, steroid
Gonococcal vs non-gonococcal septic arthritis
Gonococcal tends to be multi joint
Metabolic alkalosis + low urine Cl
Vomiting or previous diuretic use
Serum changes in diarrhea vs vomiting
Vomiting leads to alkalosis; diarrhea leads to acidosis
Nerve that gives corneal sensation
Trigeminal
Best measurement of response to treatment in DKA?
Serum anion gap (monitor resolution of ketonemia)
Hyponatremia, hypotension and hyperkalemia
Adrenal insufficiency
Treatment for prostatitis
Acute: TMP/SMX or quinolone
Chronic: quinolone
Rhabdo
RBC in UA -> ATN/Rhabdo
Most common cause of nosocomial blood stream infections
Central venous catheter (regardless of what the culture shows)
Treat acute pericarditis
NSAIDs and colchicine
Type I cryoglobulinemia
Assoc w/lymphoproliferative or hematologic diseases
Asymptomatic, hyerviscosity, livedo reticularis
Type II/III cyroglobulinemia
Assoc w/ HCV, HIV, SLE
Arthralgias, glomerulonephritis, HTN, palpable purpura
Low C4
