IM Uworld Flashcards
Gout
Risk factors
Protective Factors
Presentation
RF- alcohol use, high protein, high fructose, underlying medical conditions (HTN, obesity, CKD, transplant), medications ASA, diuretics
Protective- coffee, vitamin C, dairy
Acute, monoaricular arthritis 12-24 hours reaching peak in early morning
TTP Pathophys Syms Labs Dx Treatmetn
Decrease in ADAMTS so ucnleaved vWF and platelets trapped then causes shearing of RBC and end organ damage. Can be acquired or hereditary.
Syms- FATRN- hemolytic anemia with decreased haptoglobin, increase in LDH with schistocytes. Thrombocytopenia (increase BT with normal PT/PTT)
Management- plasma exchange
Dx- peripheral blood smear
Fibromyaglia vs. polymylagia vs giant cell
All can have diffused pain.
Fibro- ALL LABS ARE NORMAL. Can have point tenderness over traps, lateral epicondyle, costochondral junction. treat with patient education, regular aerobic, good sleep.
GCA and poly wil have high ESR. Treat with high (GCA) and low dose steroids.
Interstital cystitis (painful bladder)
- associated with anxiety and fibromyalgia
CP- painful anterior vaginal wall. Bladder pain with filling, frequency
Dx- normal UA, bladder pain with no cause > 6 weeks
Tx- amytriptyline, analgesics
Megaloblastic anemia
On peripheral smear?
What’s elevated?
B12 or folate is low
Have large RBCs and hypersegmented neutrophils
remember folate and B12 are involved in the conversion of homocysteine to methionine. If they are low, then we have elevated homocysteine
Tx of uncomplicated kidney stones
Hydration, analgesics, and alpha blockers to decreease ureteral muscles and decrease intraureteral pressures.
Abestosis
CP
Dx evaluation
CP- work mention, progressive dyspnea, bibasilar end-inspiratory fine crackles and clubbing.
PLEURAL PLAQUES ARE PATHOGNOMONIC
INTERSTITAL FIBROSIS on imaging.
Good pasture disease
What two organ systems? Symptoms?
Pulm and Renal
SOB, cough, hemoptysis caused by pulm hemorrhage. systemic symptoms like fever, weight loss, arthralgia.
Cause antibodies to the alpha-3 chain of IV collagen.
Renal biopsy demonstrate linear IgG
What is light’s critreat
Critrea for pleural effusion
Transudate- Protein P/S ratio .5, LDH >.6 and due to increase capillary permeability, infection, malignancy, PE
US vs CT for suspected nephroliathiasis
Remember that ureteral colic can causes a vagal reaction of colonic ileus. Needle shaped crystals on UA are suggestive of uric stones which are radiolucent (black on xray) and have to be evaluated on CT.
PTHrP released in what cancers
Symptoms of hypercalciumia
Ovarian and breast
Renal
Squamous of the lung (particularlly rapid onset and severe hypercalcemia)
Polyuria, neuropsych symtoms, neuromuscular excitability, decreased Gastro motilyt
Signs of diabetic retinopathy
Tx
microaneurysm (early sign), dot and blot hemorrhage, hard exudate, macular edema
Usually asym at first even if they have early signs
Tx- argon laser photocoagulation
Acute respiratory Distress
Causes
Pathophys
Dx
Clinical syndrome characterized by acute onset
respiratory failure, bilateral lung opacities,
Pao2/Fio2, NO SIGNS OF HEART FAILURE
Causes- SPARTAS: Sepsis, Pancreatitis, Pneumonia,
Aspiration, uRemia, Trauma, Amniotic
fluid embolism, Shock. Endothelial
damage alveolar capillary permeability
protein-rich leakage into alveoli diffuse
alveolar damage and noncardiogenic
pulmonary edema (normal PCWP) A .
Results in formation of intra-alveolar hyaline
membranes B . Initial damage due to release
of neutrophilic substances toxic to alveolar
wall, activation of coagulation cascade, and
oxygen-derived free radicals.
Management: mechanical ventilation with low
tidal volumes, address underlying cause.
Acid/base imbalance post seizures
pathophys
post ictal anion gap metabolic acidosis.
tonic-clonic seizures serum lactic acis rise due to skeletal muscle hypoxia amd impaired hepatic lactic acid uptake.
usually the postictal
Management of alcholic cirrhosis
Compensated- 6 month US to check for HCC and AFP, EGD for varices check
Uncompensated- varciceal hemo- repeat EGD every year, nonselective beta blocker
Ascites- low sodium, paracentesis
Hepatic encephalopathy- lactulose
Indications for urgent dialysis (
AEIOU
Acidosis ph<7.1
Electrolyte abnormality (symptomatic hyperkalemia K>6.5)
Ingestion
Overload
Uremia symtomatic encephalopathy, pericarditis, bleeding.
Tidal volume in ventilator
6ml/kg
Causes of hypercalcemia algorithim
Concfirm hypercalcemia/correct for albumin
- Measure PTH
A. PTH high- hyperparathyroidism, familial hypocalciuric hypercalcemia
B. Suppressed PTH- measure PTHrP, 1-25, 25
Consider malignancy, vitamin D toxicity, granulomatous disease, thyrotoxicosis, immbolization (~4 weeks causing increase osteoclastic activity)
Chronic Cough evaluation
> 8 weeks
1. Think of common things- asthma (steroids), post nasal, GerD (PPI) and treat empirically.
- No relief- get chest x-ray
- Consider chest CT if suspect parenchymal lung disease or malignancy or if infectious suspecting get sputum
- If resp work up negative consider cardiac origin and get echo or direct laryngoscopy
Most common cause of isolated elevated alk phos….. describe disease findings
Pagets!!
Can be asymtomatic, or can have bone pain and deformity (hearing loss, big skulls, giant cell tumor, osteosarcoma)
x-ray with mixed lytic/sclerotic lesions, cortical thickening.
Calcium and phosphate usually normal. Often found incidentally on blood work. Pagets is 2/2 to increase in osteoclastic activity, dx with radionuclide bone scan with focal increase in uptake, and treat with biphosphates.
Common causes of vertigo
Meniere disease, BPPV, vestibular neuritis, migraine, brainstem/cerebellar stroke
Meniere disease
Recurrent episodes of 20 mins, sensorineural hearing loss, tinnitus and/or feeling fullness caused by elevated endolymphatic pressure.
Presentation of different causes of vertigo and underlying causes
Meinere- endolymphatic pressure (episodic)
BPPV (brief episodes triggered by head movement)
Vestibular neuritis (ACUtE SINGLE EPISODE often after viral episodes)
Migraine (vertigo associated with HA)
Brainstem (sudden-onset, persistent vertigo with other neurologic symtoms)
PAC workup and ekg findings
Preamture activation of the atria because activation orginating from somewhere other than the SA node
- Tell patietns to stop smoking/drinking/caffeine because these are preciptiating factors.
- If no clear risk factors, consider transthoraic echo to evaluate for cardiac/valve abnormality
Lab findings in hyperosmolar hyperglycemic state
Bicarb >18, Glucose >600, normal anion gap, negative for ketones, serum osmolality >320
More likely to have neurological syms than DKA because of elevated serum osmolaity and hyperglycemia
Gastrinoma
CP
Workup
Diagnosis
AKA Sollinger Ellison syndrome-
recurrent PUD not responding to PPIs. Pt usually 20-50 and has diarhea, weight loss, frank GI bleeding
- Do endoscopy (multiple stomach ulcers/thickneded gastric folds)
- Check gastrin level >1000 is diagnotic then check gastric pH <4 then they have gastrinoma
Vaccines for HIV positive patients
-Flu- inactivated Hep B- unless documented immunity PCV 13 and PCV 23 Varicella if CD4>200 Can also give MMR if >200 but usually have it from childhood
Findings of aortic stenosis
Increased apical impulse, narrow pulse pressure, cor-decro systolic murmur
Difference between conjugate and polysacc vaccine
Polysacc- relatively t cell independent. remember polysacc. can’t be present to T cells alone
Conjugate/poly- the conjugate presetned to T cell and their are high affinity antibodies with memory cell formation
Indications fro CT pelvic abd abdomen in uncomplicated pyelo
- No improvement in 48-72 hours
- Gross hematuria
- Suspecting urinary obstruction phrolithiasis
- hx of of complicate pyelo often in immunosuppressed, stones, DM these patients usually require
How to diagnosis HEp C
- Serology- positive AB
2. Confirm with virus RNA on molecular test
Indications for cystoscopy
- gross hematuria with no evidence of infection or glomerular disease
- microscopic hematuria wtihno evidence of glomerular or infection AND increased risk of malignancy
- recurrent UTIs
- concern of obsturction, stricutre
- Irritative symptoms but no UTI
- abnormal b
Spinal cord compression cuases
Signs early and late
Management!!!!
SPinal injury, malignancy, infection
Gadually worsening pain that’s worse at night, early signs are symmeteric weakness and hypoactive/absent reflexes
Late- b/l babinski, decreased rectal tone
Management- EMERGENCY MRI, IV steroids, rad-onc on consult
Types of acne and treatment
- Comeedonal- close/open comedones on forehead, chin. cAn progress to inflammatory. Treat with topical retinoids, szlicyclic, azeliac, or glycolic acid
- Inflammatory- papules inflammed <5mm and pustules. Treat mild with topical retinoids, benzoyl peroxide, moderate add topical antibiotics, severe, add oral AB
- Nodular (cystic) Large >5mm nodules. Treatment same as inflammatory but unresponseive severe oral isotretinoin
4 disease processes to consider when a patient is hypokalemic, alklosis, and normotensive
- Bulemia
- Diuretic abuse
- Barrter- AR defect in ascending loop. Presents like loop diuretic abuse. Hypokalemia, alkosis )volume constriction, and H/K exchange, hypocalemia - loops lose calcemi)
- Gitelman’s - dlike lifelong thiazides.
PAPS pes anserinus pain syndrome
Not true inflammation of the bursua. The area were there conjoined tendons of the gracilis, sartorius, semitendinosus. Can be caused by abnormal gair, overuse or truama. well definted tenderess over the medial tibila plateua.
Causes of recurrent Pneumonia
Work up
Recurrent pneumonia in the same location should raise suspicion for localized airway obstruction and impaired bacterial clearnace. Think of external bronchical compression from lymphadenopathy, expanding neoplasm or internal due to foreign body, bronchiectasis, brochical stenosis
Especially if smoker think malignancy
GET CT OF CHEST first. then consider bronch so we know where we’re possibly looking.
critrea for Long term oxygen in COPD
Rest PaO2<55, pulse ox <88
PaO2<59 or Ossat <89 with cor pulmonale, evidenc eof right heart failure and HEMATOCRIT >55%
Primary vs secondary adrenal insufficiecny
Primary- usually AI and cortisol and Aldosterone are both low and ACTH is high. Hypperkalemia, hyponatremia, hypotension, hyperpigmentation
secondary usually to chronic steroid use so the HPA axis is suppressed. Cortisol is low and ACTH is low, but aldo is high because it can be activated in the RAAS system
acid base determination
- Check ph acidosis or alkolosis
2. serum bicarb- if low then primary is metabolic acidosis with lungs trying to compensate
Thymona
CP
Location
ANTERIOR mediastinum
Usually young female or male and !20% of patients with MGravis have thymoma.
If large enough it can cause horners, facial and upper extremity edema.
Location and examples of neurogenic tumors
POSTERIOR mediastinum. Meningocele, enteric cyst, lymphomas, diaphragmatic hernia, esophgeal tumors, aortic anuerysms.
AFib location of ectopi
Absent P waves replaced by chaotic fib waves and irregular r-r and qrs intervals. Most frequant location of ectopic is pulmonary veins.
Retinal vein occulsion CP Findings of exam Dx Tx
Acute, unilateral, PAINLESS loss of vision
Exam- blood and thinder, optic disk swelling retinal hemorrhage, dilated veins, cotton woold spots.
Bronchiectasis
CP
pathology
CP- nonsmoking patient with chronic cough with daily large amounts of mucoprulent sputum, dyspnea, sinus congestion, fatigue, weight loss and hemopytsis with crackles at the base on PE.
recurrent infections beacuse imprired clearance
Presents like chronic bronchitis but in bronchiectasis usually bacterial and improve with AB.
Chest x-ray shows linear atelectasis, dilatated and thickened airways and irregular peripheral opacities.
INdications for Lipid lowering therapy
- Clinically atherosclerotic disease- <75 high intensity, >75 moderate intensity
- Estimated 10 year ASCVD >7.5- moderate to high
- Diabetic between 40-75. qo year >7.5 then high, 10 year<7.5 then moderate
- LDL >190- high intensity
Antihypertensive that can causes cyanide poisioning
Nitroprusside paraenteral vasodilator with quick onset. Pt will have quick improvement followed by mental status changes, lactic acidosis, seizures, coma.
Tx of syphyis in penicillin allergies
- stage one/early syphiliis can be treated with oral doxy
If doxy CIndicated or if tx failure or if CNS involement, then desensitize.
Cases of specalized RBC treatmetn
- Irridiated
- Leukoreduced
- Washed
- Irridiated- Bone marrow transplant, acuired or congential cellular immunodeficiency
- Leukoreduced- previous nonhemolytic febrile reaction, chornically transfused, CMV seronegative at risk patients, potential transplant patients
- Washed- IgA, contiuned allerigic reaction with red cell transfusion
Factorial design tstudy
studiies with multiple interventions with 2 different variable endpoints
Ludwig angina
Progressive cellulits of the submandibular space that usually arise from dental infections and are polymicrboial and CP- fevers chills malaise and local compressive signs. Get CT to rule out abcess and treat with IV AB. (Amp-sul, clinda)
Ventricular anuersym post MI
Timeline
EKG findings
5days-3months
usually EKG findings resolve but in ventricular anurseyms ST elevations and deep Q waves remain.
Can lead to left ventricular heart failure
Diagnosis on echo
Findings of Aortic stenosis
Clinically
Murmur
Progressive fatigue, exertional lightheadness, delayed carotid pulses
Right sternal border murmur, soft and SINGLE s2, mid to late peaking of systolic murmur
Remember aortic sound makes up most of S2 and that pulmonic is generally slightly after. But with the delay they are now together
Side effects of EPO
Worsenening HTN
Headaches
Flu like symptoms
Red cell aplasia
AERD ASA exacebated resp disease
Clinically diagnosis with 3 things
- asthma
- Chronic rhinosinusitis
- Bronchospasm and nasal congestion follow ASA/NSAID
diagnostic tree in Cushing
- Late night salivary cortisol or low dose dexa or 24 hour urine free cortisol
- When high cortisol (2 of the 3 positive) determined, measure ACTH levels.
Cryoglobulinemia
types CP and their associated diseases.
caused by mixed immune complex deposition in small and medium vessels leading to endothelial and end organ damage.
Presents wtih fatigue, nonblanching, palaable purpura, arthralgia, renal disease, peripheral neuropathies
De quervain tenosynovitis
inflammation of the abductor pollicis longus and extensor pollicus brevis as they pass through a fibrous sheath at the radial styloid process.
Positive finklestein test- hand tugged under fingers and flex wrist down (towards ulnar) and it ellicts pain. Classically effects new moms that hold babies with finger abducted and extended.
Angiodysplasia
CP
Etiology
Patients at higher risk (3x)
painless GI usually dark marron (vs diverticulosis bright red) bleeding 2/2 to dilated submucosal veins/AV malformations. More common in ppl with renal disease/von Willebrand possible b/c of increased bleeding risk
More common in Aortic stenosis patients
Tx with cautery
Diagnostic criteria of acute liver injury (3)
- Severe acute liver injury ALT and AST often >1000
- Signs of hepatic encephalopathy (confusion, asterixis)
- Synethtic liver dysfunction like INR >1.5
Indications for lower back imaging
x-ray vs. MRI vs. Bone scan
- X-ray- Suspected malignancy (also consider inflammatory markers) , OA/compression fracture, ankylosing spondylitis
- MRI- sensory/motor deficits, Cuada equina syndrome, suspected epidural abcess
- Bone scan- when they have indication for MRI, ut can’t
Nonalcoholic fatty liver disease
Hepatic steatosis on imaging
exclusion of other causes of fatty liver and of excessive alcholic abuse
Clinical features- mostly nothing and they have metabolic syndrome, +/- steatohepatitis (AST/ALT ratio <1) , hyperecholic on US
Tx- diet and exercise and consider bariatric sx if BMI > 35
Peritonsillar abcess CP
Muffled voice, unilateral lymphs enlarged, and uvala deviated. (vs epiglottitis that has no deviation and bilateral) Presentation usually starts with fever, chills, sore throat (tonsillitis) then progresses to abcess formation.
Tx- needle drainage and then IV AB
Complications- infection in the parapharyngeal space which may spread to the carotid sheath.
FiO2 in intubation
Usually high immediately after intubation ~.6 60%, but can cause oxygen tox and form proinflammatory oxygen free radicals and predispose to atelectatsis.
FAP- familial adenmatous polypois
fam hx, patient with osteomas and colonic polpys
Screening guideliens0 increased screening intervals starting at 10-12 years old with annual colonoscopies once colorectal adenomas are detected.
proctocolectomy preformed when then have colorectal cancer or adenomas with high grade dysplasia.
Blood gasses in CHF exacerbation
Hypopoxia, hypercapnia and resp alkalosis
PFT in Ankolosying
restrictive
Reduced vital capacity and reduced total lung capacity.
Normal FEV/FVC (or slightly elevated)
Normal or increased functional residual and residual due to fixation of rib in an inspiratory position
disseminated gonococcal infection
Triad of polyarthralia, tenosynovits, and painless vesiculopustules skin.
Vesiculopustular- tend to number two to ten and may be dismissed as furuncles or pimples.
mechanism of HIT
Heparin induces conformational change in platelet surface protein. In HIT, HIT antibodies form in resposne to the platelet surface protein and bind to platelets causing aggregation, thrombocytopenia, and prothrombotic state.
Classically, patients will have skin necrosis at injection site of heparin
Esophageal Perforation
Etiology
CP
Dx
Management
Etiology- Spontaneous- Boerhave
INstrumentation, Esophagitis, Esophageal Ulcer
CP- chest and adominal pain and systemic signs, subcutaneous emphysema in the neck, Hamman sign (crunching on chest ausculation)
Dx- CXR or CT- wide mediastinum, pneumomedistinum, pneumothorax
Water soluble constartr esophagogram- leak at perf site
Management- AB and supportive plus surgery for significatn leak and SIR
Obestiy Hypoventiliation
Diagnostic Critrea
Dx test
Tx
Obese BMI >30, Daytime hypercapnia PaCO2 >45, no other causes of hypoventiliation
Workup- ABG, chest x-ray with no pulm disease, TSH, polysomnography, restrictive PFTs
Tx- Nocturnal Positive pressure ventilation, weight loss, avoidance of sedatives, resp stimulants as last resort.
Acute epididymitis
Syms
Dx
Tx
Age <35- sexually transmitted
>35 bladder outlet obsturction
unilateral testicular pain, epididymal edema, dysuria
Dx- UA, NAAT
Tx- levo- Coliform bacteria, Cef/doxy- STI
Chronic prostatis/Chronic pelvic pain sydnrome
Symptoms- pain in pelvis, perineum, genitalia, Irritative voiding, pain with ejaculation
Dx- no mild prostate tenderness
Management- alpha blockers, AB (cipro) if hx of UTI, 5 alph
Patellofemoral pain syndrome
CP
Etiology
Tx
CP- poorly localized, anterior knee pain espeically in young athlethes/women worst with activity and walking up/down stairs
test0 patellofemoral compressin test- reproduction of pain when the patella is compressed into the trochlear grove.
Etiology- overuse or malalignment
Tx- reduce intensity of exercise, activity modication, NSAIDS. Stretch and strethening the quads.
Osgood Schaltter Disease
Typical Pt
CP
Preadolescent/adolescent atheletes
Pain icnrease with sports, relieved at rest. Tenderness and swelling at TIBIAL TUBERCLE
Central retinal VEIN occulsion
Painless, sudden (or subacute) vision loss that can progress to venous thrombosis which is PAINFUL. Fundoscopy shows dlated and tortous veins leading to scatter and diffuse hemorrhage (blood and thunder), disk swelling, and cotton wool spots.
Zenkers Diveritculum
CP
Pt population
Dx test
CP- foul smelling breathin secondary to pooling of material in diveritculum. Increase risk of aspiration pneumonia, Usually occurs at the posterior lower cerviccal esophagus near the cricipharyngeus muscle.
Pt pop- elderly man
Dx with contrast esophagram.
Bug and layer of skin infected in
Cellulitis
Erysipelas
Erythema nodosum
Nec fas
Cellulits- DEEP dermis and subcutaneous fat
Prulent- staph aureus/MRSA
Non prulent- strep group a/MSSA
Erysipelas- superficial (eri superficial country) dermis/lymphatics/sharply demarcated/rapid with fever/ Strep pygones
erythema nodosum- Subcutaneous inflammation 2/2 infectious strep pharyngiits, AI, IBD
Nec Fas- Fascia and subcutaneous fat marked by severe pain
Frost bite
CP
Management
Superfiical pallor and anesthesia, blistering and eschar formation, deep tissue necrosis and mummification
Tx- RAPID REWARMING in 37-39 water bath, alagesics and wound car, thrombolysis in severe, limb threathening cases.
Manifestations of cholesterol emboli and in what cases
Skin manifestations- livedo reticularis mottled, discolored skin, blue toe syndrome, AKI, Pancreatitis, mesenteric ischemia, CNS- stroke, amaurosis fugax, ocular involvement (hollenhorst plaques)
Cholesterol emboli can occur after vascular procedure (cardiac cath) and occlude blood vessels in pts with a bunch of comorbidites
Lab findings- increase creatinine, eosinophilia, hypocomplement, UA benign with eosinophilia, Skin and renal biopsy with biconvex, needle shaped clefts within occluded vessels and perivascular inflammation with eosinophils.
Head vs tail pancreatic cancer
Head- 60-70%- jaundice, common bile duct obstruction, elevated alk phos, and bili. DX WITH ULTRASOUND.
Tail- no obstructive jaundice. USE ABDOMINAL CT. US doesn’t see the tail well due to overlying bowel
Abdominal US if jaundice, CT is no jaundice
Marfan findings by organ system
Skeletal- arachnodactyl, decrease upper to lower body ratio, increase arm to height ratio, pectus deformity, scoliosis, kyphosis
Ocular- ectopia lens
CV- aortic dissection, regurg, dilation, MITRAL PROLAPSE
Pulm- Spontaneous Pnemothorax
Skin- Recurrent or incisional gernia, skin strriae
AD defect in matrix protein fibrillin
Causes and tx of Calcium ocalate stones
Most common stone, caused by vitamin C abuse, malabsorption, hypocitraate, antifreeze
Tx- Give them some TLC. Thiazides, Low sodium diet, Citrates
Also inrcease fluids and normal calciium, urine alkalinization (potassium citrate/bicarb)
Features of different transplant rejections.
Hyperacute, acute, Chronic, Graft vs host
Hyperacute- preexisting AB that react to donor. Wide scale thrombosis–> ischemia/necrosis. Immediate removal
Acute- weeks to months 2/2 humoral rxn like hyperacute but AB develop after transplant or CD8 cells activated against donor.
Presents with vasculitis of graft with dense interstitial lymphocytic infiltrate. Give immunosuppressants.
Chronic- months to years CD4 t cells responds to donors APC presenting donor peptides. Presents with proliferation of vascular smooth muscle, parechymal atrophy, intersisital fibrosis. Organ specific damage- bronchiolitis obliternas, accelerated atherosclerosis, chronic graft nephropathy, vanishing bile ducts.
Graft vs host- grafted immunocompetent T cells proliferate and reject hos as foreign causing severe organ dysfunction. Mculopapuplar rash, jaundice, usually in bone marrow and liver transplant
Severe pancreatitis
CP
RFactors
Complications
Fever, tachy, hypotension, CUlLLEN sign- periumbilical bluish coloration indicating hemoperitoneum, Grey Sign- reddish blue on flank representing retropitoneal bleed.
RF for severe AP- age >75, obesity, alcoholism, CRP >150, Rising BUN and creatinine in the first 48 hours, GET CT OR ERCP FOR extrapancreatic inflammation or necrosis
Complications- pseudocyst, peripancreatic fluid collection, nsc pancreatitis, ARDS, Acute renal failure, GI bleeding
Boerhaave Syndrome
Etiology
CP
Lab/imaging
Tx
Esophageal TRANMURAL TEAR 2/2 forceful retching, esophageal air/leak
CP- vomitting, retching, fever, septic shock, subcutaneous emphysema may be seen
Lab/imaging- CT or contrast esophagraph with gastrografin
Chest xray- widened pneumomediastium/pleural effusion EXUDATIVE, low PH with VERY HIGH AMLASE
Presentation and causes of nerve damage in DM
Microvascular damage, demyelination, oxidatie stress, deposition of glycosylateion end products.
Small fibers injury causes POSITIVE SIGNS pain, paresthsia, allodynia
LARGE fiber= NEGATIVE signs like numbness, loss of proprioception, dimished ankle
Parapneumonic effusions
Uncomplicated vs complicated
Uncomplicated- sterile exudate, Ph >7.2, glucose>60, WBC >50,000
Complicated- bacterial invasion of pleural space
ph<7.2 (anerobic use of glucose by bacteria and neutrophils) , low glucose (high metabolic demand), high protein
Poor oxygenation on ventilator (PO2 <60) change what? x2
- PEEP (preevnts and reopens collapsed allveolars) or FiO2 (start high and then wean below 60 b/c high FiO2 can lead to pulm ocygen toxicity iwth formation of proinflammatory oxygen free radicals)
Features of carcinoid syndrome
CP
Dx
Tx
Skin-flushing, telangiectasis, cyanosis, GI- diarhea, cramping Pulm- bronchospasm, Miscellaneous: NIACIN deficiency(diarhea, dementia, dermatitis)
Dx- Elevated 25 hour urinary excreation of 5-HIAA, CT/MRI with localized tumor, Echo (for heart)
Tx- octreotide for symptoms AND PRIOR TO SX.
Niacin deficit- tumors secrete histamine, serotonin and VIP. Serotonin is made by trypotophan which is also used to make niacin, So too much serotonin is not enough tryptophan
Greatest/most effective ways to change of BP
- weight loss to BMI <25
- DASH diet (high in fruits ane vegetables and low in total fats)
- Exercise
- Dietary sodium
- Alcohol intake
Presentation of ACL injury
vs. Meniscal tear
ACL- popping, with rapid onset of pain, significant swelling (effusion/hemarthrosis)
, joint instability. Anterior laxity on exam. MRI. RIce and sx.
Menisical tear- can be rapid changing in direction. Subacute and chronic locking or popping.
MCL don’t have hemoarthrosis either
Herpes Simplex Keratitis presentation and findings on exam
1 cause of corneal blindness in the USA
PAIN, photophobia, blurred vision, possiblehx of episodes before and recurrence percipitated by outdoor activities.
Exam- CORNEAL VESCILES and dendritric ulcers.
Dx on epithlial scarpings with multi nucleated giant cells and treat with oral/topical retrovirals.
Supra-valvular aortic stenosis
Congenital left ventricular outflow obstruction due to discrete or diffuse narrowing of the ascending aorta.
Similiar to AS, but systolic murmur heard best in the first right intercostal space and patient has unequal carotid pulses with differntial blood pressures in upper extremity.
Can lead to left ventricular hypertriphy and carotid artery stenosis is often as associated anomaly so when they exercise they have icnrease myocardial oxygen demand.
