IMC 2.0 Flashcards
Define Cardiomyopathy
? is the MC type of cardiomyopathy
What causes this MC type to develop
Heart muscle dz
Dilated; Systolic dysfunction
Injury/damage (CAD/MI/ETOH) to myocardium leading to weakened ventricular contractions
? is the primary indication for cardiac transplant
This condition is also the MC cause of ?
Idiopathic dilated cardiomyopathy
Heart failure
What is the hallmark of Dilated Cardiomyopathy
What are the possible etiologies of this Dz
What infections can cause this
Dilation and impaired contraction of one/both ventricles
PG CEVICHE:
Post-partum Genetics
Chemo ETOH Viral Ischemic Cocaine Heavy-metal Endocrine
Chagas HIV Lyme
What is seen on PE for Dilated Cardiomyopathy
What is the main Dx modality
What would be seen on CXR
Left sided HF:
Dyspnea Fatigue S3 gallop
Cardiomegaly
Echo: ventricular dilation and dysfunction (EF 40% or
How is Dilated Cardiomyopathy Tx
What medication is used if increased contractility is needed
What mnemonic can be used to Tx
Loop + ACEI + BB
Digitalis
AABCD:
Anti-coagulation ACEI BBs CCBs Diuretic/Digoxin
What is the MC form of HOCM
How is this conditions passed along
What would be seen on PE since most of these are ASx
Septal hypertrophy- narrows LV outflow tract
Autosomal dominant defect of sarcomeric proteins
Bifid carotid pulse
S4 gallop
Dyspnea w/ exertion
What type of murmur does HOCM present with
What causes murmur to be louder/quieter
These characteristics are exact opposite of ? murmur
High pitched cresc-decresc at LLSB
Inc: Valsalva/Stand
Dec: Squat, Grip, Leg raise
AS:
Dec w/ valsalva
Inc w/ squat
Dec w/ stand
How is HOCM differentiated from Athletic Heart
How does HOCM appear on EKGs
What is the Dx test of choice
Athletes won’t have diastolic dysfunction
Septal depolarization: dagger-like septal q-waves w/ LVH
TTEcho
How is HOCM Tx
What drugs need to be avoided
What drug is c/i
Metoprolol and/or Verapamil to dec contractility/HR
Nitrates
Decreasing preload: diuretics, ACEIs, ARBs
Digoxin
When is implantable de-fib considered for HOCM Tx
What definitive tx options are available
+ syncope
sudden arrest
LV >30mm thick
Surgical (septal myectomy- considered best) or,
Alcohol ablation of hypertrophy
Metoprolol
Verapamil
Digoxin
Class 2, decreases HR, increases PR
B1 selective
Class 4; greater action on heart than peripheral vessels
Dose reduction needed in hepatic dzs
Derived from Foxglove; inhibits NaKATP in cardiac membrane to dec intracellular K levels to increase contraction w/out increasing O2 demands
Overcome/inhibited by sympathetic nervous system
HypoK= inc effect of medication
Antidote: Digoxin Immune Fab (Digibind)
Define Constrictive Cardiomyopathy
What is the MC etiology of this world wide
What other etiologies can cause this
RHF w/ Hx of infiltrative process
Tropical Endomyocardial Fibrosis
Amyloidosis-MC
Sarcoidosis
Rad/Chemo
What will be seen on PE of Restrictive Cardiomyopathy
What abnormals will be seen
How is this Dx
What is the next step if Dx is doubtful?
P-HTN w/ normal EF, size and wall thickness
Large atria
Early diastolic filling
Echo: dilated atria, hypertrophy, ‘starry night/speckle pattern’
MRI- abnormal textures
What could be seen on EKG of Restrictive Cardiomyopathy
This can mimic ? other Dx, so what test is used to differentiate
What is used for Txs
Non-specifics w/ low voltage waves
Constrictive pericarditis- cardiac MRI
Diuretics if edema/pulmonary congestion present
Rate/Rhythm: BB/Verapamil
Define an ASDn and the MC type
What type of murmur does this defect produce and
What condition can chronic defects develop into
Non-cyanotic defect w/ diastolic L-R shunt causing volume over load to RA/RV d/t failure of foramen ovale to close;
Osteum Secundum
Wide-fixed split S2: lub, dub-dub
at Pulmonic area
Eisenmenger’s: chronic L-R shunting causing cyanosis/clubbing that dec as shunt progresses
ASDs are the second most common defects behind ? defect
Most Pts w/ small ASDs can be ASx until ? age, but then develop ?
What abnormal clot event can ASDs allow to happen
VSD
<30: ASx
>30: dyspnea, angina
>50: Afib, RVF
Paradoxical embolization
How are ASDs definitively Dx
What can be seen on EKG
What would be seen on CXR
Echo
R axis deviation
RVH
RBBB w/ rSR pattern in V1
Cardiomegaly w/ dilated RA/RV
How are ASDs Tx
<3mm- spontaneous closure, usually by 3y/o
ASx and small: observe w/ serial Echos
Med/Large w/ evidence of RV volume overload on echo- closed between 2-6y/o
Coarctations of the aorta present w/ Sxs of ? and PE findings of ?
Half of Pts w/ have ? defect which puts the at increased risk to develop ?
What will be seen on EKG/CXR
L sided HF;
Bounding Arm BP > Leg BP
Bicuspid aorta:
Berry aneurysm
EKG: LVH
CXR: notched ribs, figure-3 sign of aorta
How is a Dx of Coarctated Aorta made
How are these Tx
How are these Tx if found in neonates
Echo
Ages 2-4y/o: balloon angioplasty w/ stent placement/surgical repair
Prostaglandin E-1- keeps ductus arteriosus open
When is emergent surgical repair of an aortic coarctation warranted
What happens if these are left untreated
Circulatory shock
Cardiomegaly
Severe HTN/CHF
Death by 50y/o d/t:
Aortic rupture/dissection
CVA
What are the 3 types of aortic coarctations by location
Preductal: narrowing proximal to ductus arteriosus; life threatening, Turners/Intracranial aneurysm
Ductal: narrowing at insertion of ductus arteriosus, appears when ductus closes
Post-Ductal: narrowing distal to ductus arteriosus; MC in adults
Define a PDA
What ‘saying’ is used to remember this type of defect’s murmur
How do Pts present
Blood flows aorta to L Pulm Artery causing transient systolic murmur d/t
Patent for your machine- machinery like murmur at 1st ICS LSB
Poor feeding
FTT
Tachy/Tachy
What are the two “classic findings” of a PDA
What would be seen on EKG
What is best for Dx
Wide pulse pressure w/ low DBP
Harsh, continuous machinery murmur at 2nd ICS (pulmonic)
Normal/LVH
Echo
How are PDAs Tx
Normally, a ductus arteriosus closes to form ? structure
? is the MC pathological murmur of childhood
Indomethacin, possibly w/ fluid restriction
Surgical/Catheter correction
Ligamentum arteriosum
VSD- hole in interventricular setum (large= L-R shunt)
How do VSDs present on exam
If left un-Tx, what can these defects lead to?
What will be seen on EKG/CXR and what is best for Dx
Loud, harsh holosystolic murmur at LLSB w/ systolic thrill
Eisenmengers
EKG: norm/LVH
CXR: inc pulm vasculature
Dx w/ Echo
How are VSDs Tx
When is Tx changed for infants?
Watchful expectation: as VSDs become smaller, murmur shortens
CHF and Retarded growth= Digoxin and Diuretics
Tx failure= surgery within first 6mon of life
What are the 4 parts of Tetrology of Fallot
Why is this defect a cyanotic one
What ‘spells’ will be seen here
PROVe:
PS RVH Overriding VSD
PS causes R -L shunt through VSD
Tet- hypercyanotic during crying/feeding
Unique fact of Tetrology of Fallot
What kind of murmur occurs
How is this condition Dx
Only cyanotic congenital herat Dz on PANCE blue-print
Harsh systolic ejection at LSB
Echo
What is the CXR finding for Tetrology
What would be seen on EKG and why are serial EKGs needed annually
How are these Pts Tx
Boot shaped heart
Enlarged RA/RV;
QRS width d/t risk for sudden death/HF
Surgery w/in first year of life
Define NSTEMI
How will Pts present
What drugs are used for Txs
Myocardial necrosis w/out ST elevation/q-waves d/t incomplete blockage causing sub-endocardial infarct
SOB
Pain radiation to jaw/shoulder
BB ASA/Clop Statin Heparin Ng ACEI PCI reperfustion
What are the 3 biomarkers used during N/STEMI workups and timing to appear/peak/return to baseline
Troponin: most sens/spec
2-4hrs, 12-24hrs, 7-10days
CK/CKMB:
4-6hrs, 12-24hrs, 48-72hrs
Myoglobin-
1-4hrs, 12hrs, 24hrs
Define STEMI
What Tx is done first
How quickly must PCI be done
Myocardial necrosis w/ ST elevations d/t fully blocked artery involving full wall thickness
ASA/Clopidogrel
PCI <90min
Thrombolysis <3hrs no PCI ability
What are the absolute c/i’s for thrombolytic therapy for NSTEMIs
What is NOT an absolute c/i
ICH Hx Cerebral vascular lesion Dx Malignant intracranial neoplasm Ischemic stoke <3mon Suspected ADissection
Active menses
Define Angina Pectoris
What is done for work up
What test provides definitive Dx
Chest pain/discomfort inc w/ exertion/emotion, is predictable, lasts <15min, and relieved w/ rest/nitro
Stress Test: reversible wall motion abnormality/ST depression <1mm
Coronary angiography
How is Angina Pectoris Tx
What surgical Txs are avail?
Pts w/ ? Hx have poorer prognosis
Sublingual Nitro (or IV) BB
Angioplasty and Bypass
LVEF <50%
Left main artery
Define Unstable Angina
What process causes this pain
How is this type Tx
Chest pain that inc w/ exertion/emotion and is now increasing/present at rest
Unchanged O2 demand
Decreased supply
Ntg/Morphine ASA/Clopidogrel LMWH x 2days BB ACEI Statin
Why is Clopidogrel used in Unstable Angina
Pts that respond to medical therapy have ? next step
What is the next step if they don’t respond to medical therapy
Decreases incidence of MIs
Stress test
Revascularization
All Pts w/ Unstable Angina/NSTEMI w/ high LDL get ? Rx’d
Define Prinzmetal Angina
What are possible triggers
ACEI and Statin (HMG-CoA reductase inhibitor)
Smooth muscle in coronary artery spasms causing ST elevations w/out clot present
Hyperventilation Acetylcholine Ergonovine Histamine Serotonin NO deficiency
What is the first and second RF for Prinzmetal Angina
What do Pts describe pain as and what may be seen on EKG
How is Prinzmetal Tx
1- smokine
2- cocaine
Cyclical in early morning hrs
Inverted U-waves
ST/T abnormalities
Initially: Nitrates
After Dx: Amlodpine and long acting nitrates
HF is a syndrome of ?
LV failure causes ? S/Sxs
RV failure causes ? S/Sxs
Ventricular dysfunction
SOB, Fatigue
Peripheral edema
Abdominal fluid accumulation
Systolic L HF will present w/ ?
How is this form of HF Tx
How is an acute exacerbation Tx
S3
Thin, dilated LV w/ EF <40%
Displaced down/left apical impulse
Loop and ACEI and BB
D/c BB
O2 ACEI Nitro
IV Diuretic x2 normal dose
Diastolic L HF will present w/ ?
This Dx will increase in severity in Pts older than ? and w/ ? predisposing Dx
What will be seen on Echo
How is this form Tx and what is avoided
S4
LVH w/ dec relaxation
Apical heave/lift
> 55y/o w/ HTN
Normal EF
ACEI and BB or CCB
No diuretics in chronic Pts
Never use digoxin
Right HF can be d/t ?
What PE findings will be absent
How is this Dx
P-HTN
Rales JVD Edema
Gold standard: Echo and Doppler
Define High Output HF
What can cause this type of HF
What will be the first S/Sx of Dx
Increased metabolic demand surpasses heart output
Hyperthyroid
Severe anemia
Beriberi
Thiamine deficient
Tachycardia progressing into systolic failure
A normal EF if between ?
Pts are at risk for increased mortality if EF is below ?
What are these high risk Pts next step
55-60
<35
Cardio defib placed
BNP levels >100 indicate ? issue present in a Pt
What are the 4 NYHA classifications
What Tx step needs to be started ASAP in HF Pts
CHF
1: no limitations
2: slight limitation
3: marked limitation
4: unable to carry out activities w/out discomfort and have Sxs at rest
ACEI- decreases comorbidity and mortality
What are 3 specific beta-1 drugs used in HF to reduce mortality from HF
Only heart valve to have two leaflets, all other have 3
Diastolic murmurs almost always indicate ?
Bisprolol
Metoprolol succinate
Carvedilol
Mitral
Heart Dz
What are the two basic types of diastolic heart murmurs
? category of murmurs is the MC kind
Early decrescendo: regurg through incompetent semilunar valve
Rumbling: stenosis of AV valve
Mid-systolic- AS, PS
What are the 4 diastolic murmurs
AR: high pitch, blowing murmur
Pt sits, leans fwd
Diaphragm at Erb’s
MS: low decrescendo rumble w/ opening snap at apex
Pt supine w/ bell at mitral
PR: high pitch decrescendo, inc w/ inspiration
Pt leans fwd, diaphragm at pulmonic
TS: mid-diastolic rumble w/ opening snap
Pt supine, bell at tricuspid
What are the four mid-systolic murmurs
AS: ejection cresc-decrescen
Pt sits, diaphragm at aortic
PS: harsh mid-systolic crescen-decrescen w/ wide-split S2 radiating to L shoulder/neck
Pt supine, bell at tricuspid
HOCM: mid-systolic murmur w/ S4 and apical lift
Pt supine, diaphragm at mitral
MVP: mid-systole click at apex
Pt supine, diaphragm at mitral
What are the pan/holosystolic murmurs
MR: blowing murmur at apex w/ split S2
Pt supine, diaphragm at mitral
TR: high pitched murmur
Pt supine, diaphragm at tricuspid
VSD: harsh murmur w/ wide radiation and fixed, split S2
Pt supine, diaphragm at tricuspid
Define A-Fib
What are two possible etiologies
Irregular, Irregular w/ narrow QRS complexes but w/out defined P-waves
Age
ETOH abuse
Define A-Flutter
What are 4 possible etiologies
Regular, sawtooth pattern EKG w/ atrial rate between 250-350 and narrow QRS complexes
COPD
CHF
ASD
CADz
How is A-fib Tx
How are unstable Pts w/ rapid ventricular rates Tx
Rate control <110 w/:
Diltiazem Metoprolol Verapamil
Rhythym control depends on duration:
Afib <48hrs= amiodarone, TEE, cardioversion
Afib >48hrs= anticoag x 21days, then cardioversion
Synchronized cardioversion
How is anticoagulation for A-fib/Flutter determined
CHA2DS2-VASc:
0 pts= 81-325mg ASA/day
1pt: either 81-325mg/day or anticoag
2pts or more= anticoagulation
CHF/LVEF <40-1 HTN-1 Age +/>75- 2 DM-1 Stroke/TIA/Throm-embolism- 2 Vasc Dz- 1 Age 65-74-1 Female- 1
What DOACs can be used for anticoagulation when Tx Afib/Flutter
When is Warfarin indicated
What is the INR target if Warfarin is used
Dabigatran
Edoxaban
Apixaban
Rivaroxaban
Rx- phenytoin/antivirals Unacceptable cost increase Mechanical valves Mitral stenosis EGFR <30
2-3 (2.5)
Define PSVT
What are 3 etiologies
SVT w/ abrupt on and offset d/t short-circuit arrhythmia w/out other structural heart Dzs
AVNRT- tachydysrhythmia starting above BoHis
WPW- abnormal accessory electrical conduction pathway in Bundle of Kent between atria and ventricles
AVNRT: small pathway in/near AV node allows impulse to travel in circles causing fast, regular beating
? is the MC sustained dysrhythmia in adults
A-flutter is seen in Pts w/ ? 4 Dx/comorbidities
What are the 3 EKG characteristics for WPW
A-fib
COPD
ETOH abuse
MV Dz
Thyrotoxicosis
D-wave
Wide QRS >120msec
Short PR <120msec
Define Orthodromic tachycardia
Define Antidromic tachycardia
How is PSVT Dx
Accessory path to AV to accessory path (tall, deep QRS)
AV node to accessory to AV node (D-wave, tall QRS)
Holter Monitor to catch episodes
How is PSVT Tx vis non-Rx maneuvers
What meds are used if Sxs are present or if only PSVT is present
What is definitive Tx
What needs to be avoided in WPW
Vagal
Carotid massage
Valsalva
+Sxs= adenosine
Regular- BB/CCBs
Wide QRS= procainamide
Radio frequency ablation
No adenosine
No CCBs
Define the 3 types of premature beats
These may have an increased frequency d/t ?
What are two variants
Atrial- abnormal shape P-wave
Ventrical- early, wide QRS w/out p-wave
Junctional- narrow QRS (0.10msec) no/inverted p-wave
Stimulants (caffeine)
Trigeminy- every 3rd beat
Every other- bigeminy
Premature Atrial Beats are common in ? population
Pts w/ heart Dz, PACs can precedde ? issues
PVCs can be ASx or be felt where?
COPD Pts
PSVT
A-fib/flutter
Throat
How are premature beats Dx
How are they Tx depending on the type
Define V-Tach
EKG or Holter monitor
PAC: reassure
PVC: BB, consider ablation
PJC: only Tx if >10/min w/ lidocaine/antiarrhythmic
EKG w/ 3 or more consecutive premature ventricular beats (QRS complex loses sharp peak, becomes wide/bizarre)
V-Tach is a common complication from ? two issues
Unstable Pts w/ monomorphic VT should be immediately Tx w/ ?
How is unstable polymorphic V-Tach Tx
Stable Pts w/ V-Tach and adequate end organ perfusion are Tx w/ ?
MI
Dilated myopathy
Synchronized direct current cardioversion starting at 100J
Immediate D-fib
In order:
Amiodarone Lidocaine Procainamide
Define V-Fib
How is this Tx
Uncoordinated quivering of ventricles w/out useful contractions
CPR Defib w/ non-synchronized cardioversion (120, 150, 180) Intubate Amiodarone x 2 q2-4min 1mg Epi q 3-5min
Define Sick Sinus Syndrome
What are the 4 types of this condition
How are these Dx
How are these Tx
Dysfunction of Sinus Node’s automaticity and impulse generation
Brady: resting HR <60
Pause < 3 sec
Arrest > 3 sec
Tachy-Brady Syndrome- alternating tachy/brady
EKG/Holter monitor
Most PTs w/ Sxs= Pacemaker
BB/CCB/Digoxin in Pts w/ tach risk for block/arrest, also prepared for pacing
Define AV Block
What are the 2 MC causes
What are the 3 types
Interruption of impulse transmission from atria to ventricles
Idiopathic fibrosis/sclerosis of conduction system
Ischemic heart dz
1st: PR >0.2sec (5 small square)
2nd:
Type 1: longer longer drop, Wenckebach
Type 2: some dropped, some get through, Mobitz 2
3: Ps and Qs dont agree, not you’ve got a 3rd degree
How is a 1st AV Block Tx
How are 2nd* Blocks Tx
How are 3* blocks Tx
ASx: none
Unstable: pacing
Type 1: Tx only if Sx bradycardia and other causes have been excluded
Type 2: pacer, these almost always progress to 3* block
R/o ischemic cause
Pacer
Define Cardiogenic Shock
What are the 3 MC causes
How is this Dx
How is this Tx
Impaired cardiac contractility and pump failure d/t dec cardiac output
HF
Acute MI
Tamponade
Inc pulm cap wedge pressure >15mm
Fluids
Pressors: dobutamine, NorEpid,
Ultimately balloon pump
Define O-HOTN
What is the MC cause of this in diabetics
What is the next test ordered for these Pts
How is this Tx
Dec SBP >20mm
Dec DBP >10mm
Both 2-5min after standing
Autonomic dysfunction; lack of HR increase by >10bpm
Tilt table;
if HR increases >15bpm, d/t low volume
Dec venous pooling
Inc Na/fluid intake
Define Essential/Primary HTN
What are the ACC/AHA Classifications
What are the target goals for Tx
Resting SBP 130 or higher
Resting DBP 80 or higher
On two separate visits
Norm: <1120/80 and <80
Elevate: 120-129 and <80
Stage 1: 130-139 or 80-89
Stage 2: 140 or > or 90 or >
+ comorbidiites: <130/80
<60y/o/DM/CKDz: <140/90
60 or >: <150/90
How is normal BP Tx
How is elevated BP Tx
How is Stage 1 Tx
How is Stage 2 Tx
Yearly eval w/ healthy lifestyle
Healthy lifestyle and reassess 3-6mon
ASCVD calculator:
<10% risk: healthy life style and reassess 3-6mon
>10% risk/CVD/DM/CKDz: lifestyle mod and 1 medication w/ reassess in 1mon;
Goal met- reassess 3-6mon
Goal not met- different med or titrate w/ montly f/u until goal met
Healthy lifestyle and 2 meds
Goal met at 1mon f/u: reassess 3-6mon
Not met at f/u: different med/titrate up
Continue monthly f/u until goal met
How is Primary HTN in nonblacks, even w/ DM, Tx
How are Black Pts w/ HTN Tx
ACEI/ARB
CCB- Amlodipine or,
Thzd like- chlorthalidone/indapamide
Thzd type and CCB
When are the following classes of meds c/i d/t previous Dx:
CCB
ACE/ARB
BB
Angina pectoris
Diabetics w/ proteinuria
Pregnancy
Asthma
Side effect of using the following classes for HTN Tx:
ACEI
Spironolactone
BBs
CCBs
Hydralazine
Cough Angioedema HyperK
HyperK
Impotence
Leg edema
Lupus-like syndrome
pericarditis
Define Secondary HTN
When does this Dx need to be considered
What is the MC cause and what is a common combo cause
SBP 130 or >
DBP 80 or > or,
Both w/ correctable cause
Pt refractory to antihypertensive meds or severe
Primary aldosteronism
OCP + ETOH
What labs are ordered for newly Dx Secondary HTN
Define Infective Endocarditis
What does the infective process cause
UA
Spot urine albumin/cr ratio
EKG
Infection of endocardium w/ Strep/Staph/Fungi
Fever* Murmurs Vegetations
Define Acute Bacterial Endocarditis
Define Subacute Bacterial Endocarditis
Endocarditis in IVDA is usually d/t ?
Prosthetic valves are usually infected w/ ?
Infection of normal valves w/ Staph A
Infection of abnormal valves w/ Strep Viridians
Staph A
Staph Epidermis
How is endocarditis caused by fungus differentiated
When are these types of infections commonly seen
How are they Tx
Usually from contaminated lines, causes large, slow growing vegetations
Post-valve replacement, <2mon post-op
Amphotericin B
What types of microbes can grow on native heart valves and cause endocarditis
? is the MC cause of endocarditis
How does this type present
HACEK: Haemophilus Aggregatibacter Cardiobacterium Eikenelia Kingellia
Strep Viridians
Late complication of valve replacement w/ small vegetations and emobli
What are the peripheral stigmata of Infective Endocarditis seen on exam
How is this Dx
What is the gold standard for Dx
Splinter hemorrhages Olser nodes- painful Roth spots- retinal hemorrhage Janeway lesion- septic emboli Petechia, palate/conjunctiva Splenomegaly Hematuria
3 blood cultures, 1hr apart
TEE echo
What criteria is used for Dx Infective Endocarditis
Modified Duke:
Definite:
2 Major or
1 Major, 3 minor or
5 minor
Possible:
1 major and 1 minor or,
3 minor
Fill in, finish
How are native valves, no IVDA w/ endocarditis Tx
How are prosthetic valves w/ endocarditis Tx
How are IVDA w/ endocarditis Tx
If any endocarditis Pt is PCN allergic, ? is used for substitution
IV Nafcillin, Ampicillin, Gentamicin
IV Vanc Gentamicin Rifampin
IV Nafcillin
Vanc
What is used for endocarditis prophylaxis
Define Acute Pericarditis
What is the form of pericarditis seen 3-5d after MI
2g Amoxicillin 30-60min prior to procedures
MC Coxsackie infection causing inflamed sac
Dresslers Syndrome
How is acute pericarditis Dx
What PE finding may be present
This PE finding is common in Pts w/ ?
EKG
Echo: Complications/effusion/tamponade
Kussmaul- inc of CVP during inspiration instead of normal decrease
Constrictive pericarditis
How is acute pericarditis Tx
Define Cardiac Tamponade
What are the 3 Ds of this
What triad
NSAID/ASA x 7-14d
CCS if Sxs >48hrs
Fluid between sac and heart causing constriction
Distant sounds
Distended jugular vein
Dec arterial pressure
Becks:
HOTN
Muffled sounds
JVD
What is a classic finding in cardiac tamponads?
What is seen on EKGs
What is seen on CXRs
Pulsus Paradoxus- SBP drop of 10mm w/ inspiration
Narrow pulse pressures
Electrical alternans w/ low voltage QRS
Water bottle heart
What is the Gold standard for Dx cardiac tamponades
How are these Tx
What causes Rheumatic Fever
Echo
IV fluids- increase preload, prevent RV collapse
Centesis- therapeutic
Balloon pericardiotomy, window- if compensation
Hx of GAS infections
How do Pts w/ Rheumatic Fever present
What mnemonic is used for PE
How is this Tx
Red skin lesions on trunk
Non-tender lumps on joints
JONES: Joints Oh no, carditis Nodules Erythema marginatum Sydenhams chorea
NSAIDs, ABX
How do Pts w/ aortic dissection present
What would be seen on CXR
What is the gold standard test for Dx
How are these Tx
Sudden, tearing chest pain that radiates between scapula and w/ diminished pulses
Wide mediastinum
MRI angiography
Ascending: surgery
Descending: BB, observe
Indications to repair AAA
When is annual monitoring used
When is q6mon monitoring used
What class medicaiton is used for these PTs
> 5.5cm or,
Expands >0.6cm/year
> 3cm
> 4cm
BB
Define Varicose Veins
What makes these symptomatic
How are these Tx
Dilated superficial veins
Pain w/ exertion
Compression Elevation Wound care Sclerotherapy Surgery
Define Chronic Venous Insufficiency
What is a common skin finding in these PTs
What is a common but severe finding
How are these Tx
Impaired venous return causing edema/discomfort
Stasis dermatitis
Non-healing ulcer at medial malleolus
Compression
Wound care
Surgery
Define Esophagitis
What are the two categories and causes of each
Inflammation that can damage tissue
Non-infectious: Reflux Medication (BisPhos/NSAID) Eosinophilic- barium swallow= multiple corrugated rings Radiation Corrosive
Infectious, hallmark= odynophagia
Fungal: linear white plaques
HSV: punched out lesions
CMV: solitary ulcer/erosion
How is Fungal Esophagitis Tx
How is HSV Esophagitis Tx
How is CMV Esophagitis Tx
How is Corrosive Esophagitis Tx
How is Eosinophilic Esophagitis Tx
PO Fluconazole
Acyclovir
Ganciclovir
Steroids
Steroids via inhaler
How is Esophagitis Dx
How is Bisphosphonate induced esophagitis prevented
Edondoscopy
Biopsy
Double contrast esophogram
Culture
Take w/ 4oz water
Avoid laying down x 30-60min
Define Achalasia
What is this a MC of
How is it Dx
How is it Tx
LES fails to relax and d/t loss of Auerbach plexus
MC motility d/o w/ dysphagia to liquid and solid
Barium swallow- bird beak
Botulinum injection- temporary
How will esophageal strictures present
Define Esophageal Web
Define Schatzki Ring
What is a major contributor to ring development
Solid food dysphagia w/ Hx of GERD
Thin membrane in esophagus
Mucosal ring at B-ring junction; associated w/ hiatal hernia
GERD
Define Plummer Vinson
What is another term for esophageal strictures
How are these Dx and Tx
Esophageal webs and Dysphagia and Fe Deficient Anemia
Steakhouse syndrome- gradually progressive dysphagia to solids that occur when meal is wolfed down
Endoscopy/Dilation
Define Esophageal Spasms
How is it Dx
How is a Dx confirmed
How is it Tx
Non-peristaltic contraction causing stabbing chest pain after ingesting hot/cold liquids and foods
Barium swallow- corkscrew
Manometry
Nitrate, CCB
How does esophageal cancer present
What is the MC type in the world
What is the MC type in the US and d/t ? complications
Difficulty swallowing solids to liquids w/ adenopathy
SCC
Adenocarcinoma in distal esophagus- d/t GERD/Barrett’s
How is esophageal cancer Dx and staged
What treatment options are available
How often should Pts w/ Barretts have endoscopic screening
Dx: endoscopy w/ biopsy
Stage w/ CT
Resection
Radiation
Chemo w/ 5-FU
q3-5yrs
SCC of the esophagus is associated w/ ? Hxs
What part of the esophagus is affected
Define GERD
Smoking
ETOH use
Upper 2/3
Incompetent LES allows reflux of contents into esophagus
What are the risks of long standing GERD
What drugs can cause this issue to develop
What is the gold standard study for Dx
Metaplasia
Esohpagitis
Barretts/Cancer
Stricture
Antihistamines TCAs Progesterone Anticholinergics Nitrates CCBs
pH probe
What is a common c/c of GERD that is easily/commonly overlooked
Typical Sxs of GERD can be Tx w/ trial of ?
What is done if Pt fails to improve, is long standing, or has complications?
Chronic cough
PPI
Endoscopy w/ cytologic washings and biopsy
What is the only test to consistently detect Barretts Esophagus
What are the red flags that put PTs at high risk for GI malignancy
How is GERD Tx
Endoscopic biopsy
GERD Sxs and: Dysphagia Recurrent vomitting Weight loss Hematemesis Anemia Melena >50y/o
Weight loss HOB elevated 6" H2 antagonist PPI Tx 8wks after Sxs resolve
Define Gastritis
What are the common Sxs that indicate this Dx
What are the two categories of gasgritis
Inflammation of stomach lining
Dyspepsia
Abdominal pain
Acute: rapidly developing lesions in gasgric antrum
Chronic:
Type A: slowly developing lesions in fundus from anti-parietal Abs; associated w/ pernicious anemia; risk for adenocarcinoma
Type B: slowly developing lesions in gastric antrum; often ASx; inc risk to develop PUD
What is the gold standard test for Dx gastritis
What 3 tests can be used to detect presence of H Pylori
What is the risk of using PPIs during Tx
Endoscopy w/ four biopsies
Fecal Ag
Serology Ag
Urea breath test
Dec Ca absorption (hip Fx)
Dec B12/Mg
Inc respiratory infection (pneumonia)
C Diff
What meds are used for the Tx of gastritis
What happens if Pts Sxs return after Tx
What are the two types of ulcers seen in PUDz
H2RA: Famotidine, Cimetidine
Omeprazole
D/c PPI when ASx x 8wks
Sxs return <3mon- d/c PPI for upper endoscopy
Gastric- pain worse w/ meals
Duodenal- pain better w/ meals and change in stool color
What is the MC cause of gastric ulcers
These ulcers are usually anatomically located where?
Rarely, these can develop into ?
H Pylori
Anterior duodenum- if develop on posterior, inc risk for bleeding from gastroduodenal artery or causes pancreatitis
Zollinger Ellison Syndrome- gastrinoma, tumor of pancreas causing stomach to make too much gastrin; Dx when gastrin >200pg
Tx: PPI and resection
Where are gastric ulcers MC found anatomically
PUD is the MC cause of ? that presents as ?
What is the most accurate method for Dx
Lesser curvature of antrum
Non-hemorrhagic GI bleeds that present w/ melena
Upper endoscopy
How is a ruptured gastric ulcer Dx
How is H Pylori Tx
What is the next step if biopsy is negative for Pylori
Serum amylase
Free air under diaphragm on upright CXR
4wks of:
Clarithromycin
Amoxicillin (metronidazole)
PPI (omeprazole)
Breath test
Stool Ag test
MC causes of acute pancreatitis
What two PE findings indicate Dx
GET SMASHED: Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting HyperCa/lipid ERCP Drugs
Cullens- umbilical bruising
Grey-Turner- flank bruising
What is Ranson’s Criteria used for during acute pancreatitis
Predicts severity, 3 or more means severe:
At admission: Glucose >200 Age >50 Leukocyte >16K AST >250
At 48hrs: BiCarb <20 BUN inc by 1.8 or > Arterial PO2 <60 Ca <8 Hct dec by 10% Fluid sequestriation >6L
How is Chronic Pancreatitis different than Acute
What is the classic triad?
What may be seen on PE imaging
Same clinical features + fat malabsorption and statorrhea
Pancreatic calcification
Statorrhea
DM
Pancreatic pseudocyst
How is pancreatitis Dx
What is seen on x-ray
What would be heard w/ auscultation on exam
What are the best initial tests for Dx Chronic Pancreatitis
Amylase, only if 3x higher
Abdominal CT- TOC
Sentinal loops
Dec bowel sounds
CT pancreatic protocol
MRI w/ MRCP
How is acute pancreatitis Tx
What is needed if biliary sepsis is suspected
Why can mild pancreatitis progress to severe <48hrs
What is the only definitive Tx for chronic pancreatitis
NPO, IV fluids
Analgesics
Bowel rest
ERCP
Inadequate fluid replacement
Address:
Alcohol/low fat diet
What is the MC form of pancreatic cancer
What ‘sign’ is seen on PE
What node can be present
Ductal adenocarcinoma at head of pancreas
Courvoisier's Sign: Jaundice Abdominal pain Palpable gallbladder Light stool, dark urine
Virchows- lymph node in left supraclavicular fossa; take lymph from abdominal cavity
AKA- seat of the devil
How are pancreatic neoplasms Dx
Where are they more likely to be found in ascending order
What tumor marker is used to track progression/therapy
How are pancreatic neoplasms Tx
Abdominal CT
Head>body
Define Celiac Dz
This is a ? d/o
What are 4 common c/c
Inflammation of the small bowel d/t ingestion of gluten (wheat, rye, barley) leading to malabsorption
Autoimmune
Diarrhea
Flatulence
Weight loss
Steatorrhea
How is Celiac Dz Dx
How is a Dx confirmed
This confirmation is only done after ?
- IgA anti-endomysial Abs- specificity nearly 100%, sensitivity lower than TG-IgA
- IgA Antitissue transglutaminase Ab- will be +98% of Pts
Mucosal biopsy of proximal/bulb and distal duodenum
IF Pt tested pos for IgA endomysial Ab
How is Celiac Dz Tx
Supplementation may be needed if Pt becomes ? deficient
Define Lactose Intolerance
Gluten free diet
Fe B12 Folic acid Ca Vit D
Insufficient lactase enzyme- hydrolysis of lactose to glucose/galactose
How is a Dx of Lactose Intolerance made by presumption
How is a definitive Dx made
What other lab results can indicate this Dx
Mils Sxs after >2 servings/day or >1 serving not associated w/ meal and,
Resolves in 5-7 days w/ avoidance and,
Reoccurs w/ rechallenge
Lactose breath Hydrogen test-
Pt drinks lactose liquid
Breath into machine q30min
+= >H than usual (>20ppm)
Acidic feces- normally alkaline, acidic indicated lactose intolerance or E Colie/Rotavirus contagion
How is Lactose Intolerance Tx
Facts of Crohns: involvement, visual finding, diarrhea type, fistulas, esophageal finding, histology, smoking impact and serology result
Avoid dairy
Lactose free food
Lactase supplements
Anywhere in GI rectum spared; Skip lesions Non-bloody w/ abdominal pain \+fistula Endoscopy= aphthoid, deep (cobblestone) Transmural, noncaseating granuloma Smoking worsens ASCA
Facts of Ulcerative Colitis: involvement, visual finding, diarrhea type, fistulas, esophageal finding, histology, smoking impact and serology result
Only involves colon including rectum Continuous pattern of involvement Bloody Rare abdominal pain No fistula/perianal dz Erythematous, friable tissue Tubular/lead pipe radiograph finding Mucosa only crypt abscess Smoking protects p-ANCA
How does UC present
Where does the inflammation affect the colon
What is the MC site
Bloody pus diarrhea w/ pain, fever, urgency
Inflammation only in colon, not transmural
Rectum
What is the bimodal distribution of UC
How is it Dx
What Ab tests are run
15-25y/o and 55-65y/o
Barium enema w/ lead pipe appearance
Biopsy w/ continuous inflammation w/ lost haustral markings and lumen narrowing
Antineutrophil cytoplasmic Abs (p-ANCA)
How does Crohns Present
What is the MC site
What is this conditions distribution
Abdominal pain, non-bloody diarrhes and PO aphthous ulcers
Terminal ilium
Mouth to anus w/ transmural cobblestoning and skip lesions
What complications can arise from Crohns
What complications can arise from UC
What antibody test is run for Crohns
Strictures- string sing w/ barium study
Toxic mega colon
Colorectal cancer
Anti-Saccharomyces cerevisiae Abs (ASCA)
How is UC/Crohns Dx w/ colonoscopy
What is the risk in UC if haustral markings are lost
Why are LFTs needed
What annual/2yr monitoring should these PTs have
US: continuous inflammation
Crohns- focal ulcerations that alternate w/ normal mucosa
Toxic megacolon
Inc ALT/y-glutamyl transpeptidase suggest primary sclerosing cholangitis
Vit D, B12
How are Crohns/UC Tx
What is the MOA of these meds
If colon involved-
Sulfasalazine
Mesalamine (UC>Crohns)
No 5-ASA response= Metronidazole
No response to Metro/acute exacerbations=
Budesonide/Predisone
No response to any-
Azathioprine/6-Mercaptopurine
5-ASA block prostaglandin release to reduce inflammation
What meds are added to UC/Crohns Tx if terminal ileal dz is present preventing bile acid absorbtion
What meds need to be avoided
How can UC be Tx w/ surgery
What surgical option is avail for Crohns Pts
Bile acid sequestrants
Anti-diarrheals- induce ileus
Total colectomy
Segmental resection
What criteria is used to Sx-base Dx IBS
What is the criteria for Mixed IBS
What red flags need to be r/o
Rome:
Abdominal pain for 3d/mon in past 3mon w/ 2 or more:
Improved w/ defecation
Onset associated w/ change of defecation frequency
Change in stool consistency
More than 1/4 are diarrhea
More than 1/4 are constipated
Rectal bleeding
Weight loss
Fever
+ red flag= imaging/colonoscopy
Why are lab results useless in IBS Dx
How is this Tx
How does Acute Mesenteric Ischemia present
CBC/Chemistries are normal in IBS
Anticholinergics: Hyoscyamine
Sudden onset severe abdominal PooP to exam w/ Hx of PVDz/Smoking/DM
Board review questions will have Pts w/ Acute Mesenteric Ischemia present w/ ? issues
What x-ray sign is seen
What is the MC site of obstruction to cause this
Afib/MI/CHF
Thumb-printing
Superior mesenteric artery
What can cause younger Pts to have Acute Mesenteric Ischemia
What is the gold standard for Dx
How is this Tx
OCPs/Illicit drugs
Mesenteric angiography
Revascularization
Define Polyps
Once Dx, what meds can help prevent formation of new polyps
What MC does this cause in Peds
Clumps of cells on lining of colon/rectum
ASA
Cox-2 inhibitors
Painless rectal bleeding
Where are adenomatous polyps commonly found in the colon
What type of polyp has a 30-70% risk of malignant transformation
Define Familial Adenomatous Polyposis
Distal colon/rectum
Villous adenomas
Hundred/thousands of colorectal polyps by 15y/o and cancer by 40y/o
What is the recommended screening for 1st degree relatives of Pts w Familial Adenomatous Polyposis
What screening is recommended for family members
How are Polyps Tx
Genetic screening after 10y/o
Annual sigmoidoscopy starting 12y/o
Snare/Electrosurgical forceps during total colonoscopy
Unsuccessful colonoscopy removal= laparotomy
Colon Ca is the 3rd leading cause of cancer death behind ?
When is colon cancer screenings recommended for average risk Pts w/ stool tests
1st: lung; 2nd: skin
Start 50, end 75y/o
Guaiac fecal occult test 1/yr
Fecal immunochemical test 1/year
FIT-DNA test q1/3yrs
When is flexible sigmoidoscopy recommended for colon cancer screenings
When is colonoscopy recommended for colon cancer screenings
When is CT colonoscopy recommended
Once q5yrs or,
Once q10yrs w/ FIT every year
q10yrs
q5yrs
When are colon cancer screening started if single first degree relative is Dx
How is colon cancer Tx
What is monitored during Tx
<60 at Dx: start colonoscopy at 40 or 10yrs younger than age of Dx; if negative- q5yrs
5-FU mainstay of chemo
Surgical resection
CEA
Define Diverticulosis
How does this present
Define Diverticulitis
How does this present
Large outpouching of mucosa in colon
Painless rectal bleeding
Infammed diverticula d/t obstructing matter
LLQ pain
Fever
Inc WBC/CRP
What are the 3 clinical indicators used to Dx Diverticulitis
How is this Dx
What needs to be avoided during work up
Absent vomiting
CRP >5mg
LLQ tenderness only
CT- fat stranding and bowel wall thickening
Colonoscopy- risk of perf
How is mild diverticulitis Tx
How is Constipation defined by Rome 3 criteria
Low residue diet
Broad ABX
NG tube if +ileus
Any two x 3mon w/ Sxs onset >6mon prior: Sensation of obstruction <3 bm/wk Straining Lumpy/hard stool Incomplete sensation Digital maneuvers needed
How is constipation Tx w/ fiber
What are the bulk forming laxatives used
What is the next step if Pts don’t respond to bulkers
Constipation lasting longer than ? needs to have further investigatory studies
20-25gm/day
Psyllium seed
Methylcellulose
Calcium polycarbophil
Wheat Dextrin
Osmotics, start w/:
Polyethylene glycol
> 2wks and refractory to Txs
Diarrhea after picnic w/ egg salad is d/t ?
Diarrhea from shellfish is d/t?
Diarrhea from poultry/pork is d/t?
Diarrhea from poorly canned food is d/t?
Diarrhea from daycare outbreak is d/t?
Diarrhea from cruise ships is d/t?
Diarrhea from fresh water consumption is d/t?
Staph A
Vibrio cholera
Salmonella
C perfringens
Rotavirus
Norovirus
Giardia
How does acute/chronic hepatitis present
How is Hep A passed
How is it Dx and what result shows prior infection
How is it Tx
How is it vaccinated
Tea urine, pale stool
Pruritus
Vague abdominal pain
Fecal-oral transmitted
Serum IgM anti-HAV
IgG Ab to HAV distinguishes acute from prior infection;
+IgG= prior infection, acquired immunity
Tx: supportive
Vaccine x 2, first at 1y/o
How is Hep B passed
How is it Dx
How is it prevented
What is the risk of this Dx
Sex/Sanguineous
HBeAg- highly infectious
HBsAg- ongoing infection
anti-HBc- have/had infection
Anti-HBs- immune
Vaccine x 3: birth, 1mon, 6-18mon
Hepatocellular carcinoma
How is Hep C passed
How is this screened for
How is this Dx
What is the risk of the Dx
How is this Tx
ASx transmision through IVDA , sex, sanguineous
Anti-HCV Abs
HCV RNA quantitation
Cirrhosis/hepatocellular carcinoma
Antiretrovirals against RNA synthesis
How is Hep D passed
What is the risk of the Dx
How is this Dx
How is this Tx
Only w/ co-infection of Hep B
Hepatocellular carcinoma
Anti-HDV- active infection
Tx/prevent infection
How is Hep E passed
How is this Tx
What lab result suggests alcoholic hepatitis
Pregnant mother to baby
Support/vaccinate
AST:ALT ration >2:1
3 RFs for Fatty Liver Dz
How is this Dx
How is this Tx
Obese Hyperlipid Insulin resistance
ALT>AST
US: steatohepatitis (inc echogenicity and coarse texture)
Biopsy: large fat droplets
Lifestyle mod/DM control
Define Cirrhosis
What is the MC cause
What will be seen on lab results
Chronic liver dz w/ fibrosis, disrupted liver architecture and widespread nodules
Alcoholic liver Dz
AST > ALT
What Syndrome are liver cirrhosis PTs at risk for
What is the MC complication of cirrhosis
When is paracentesis warranted for Tx
Budd Chiari: abdominal pain
Ascities
Hepatomegaly
Ascites- abdominal fluid collection from portal-HTN and hypoalbumin
SOB
Early satiety
Tense ascites
How does hepatic encephalopathy present on PE
How is cirrhosis Tx
Define Cholelithiasis
Asterixis- flapping tremor when Pt flexes hands
Avoid alcohol
Salt restriction
Transplant
Gallstones w/out inflammation
90% of cholelithiasis is ? saying
What are the other 10%
What is the cardinal Sx
What referred sign can be seen
Fat Female Forty Fertile w/ cholesterol stones
Pigmented- brown/black
Biliary colic from obstructed cystic duct
Boas- right subscapular pain of biliary colic
What is the Dx modality of choice for cholelithiasis
What lab result will be elevated during obstructions
What clotting factors does the liver make
Abdominal US 8hrs after fasting
ALK-P
1 2 5 7 9 10 12 13
Define Cholecystitis
What PE finding helps w/ Dx
Chronic Cholecystitis can develop into ?
Inflammed gallbladder d/t cholelithiasis and an obstructed biliary duct
Murphys- pain in RUQ w/ palpation and inspiration
Porcelain GB, premalignant condition
How is cholecystitis Dx
Define Cholangitis
What presenting triad can be seen
What pentad can this develop into
US- 1st line
Gold standard: HIDA scan if equivocal US/suspected acalculous cholecystitis
Infected obstruction d/t stones w/ E Coli
Charcot’s Triad:
F/C
RUQ pain
Jaundice
Reynolds- HOTN, AMS
How is Cholangitis Dx
What tumor marker indicates liver neoplasms
When does hematuria become ‘clinically significant’?
Initial: RUQ US
Optimal: ERCP for Dx and Tx
+ Charcots- go direct to ERCP
Alpha-fetoprotein and abnormal images
> 3 RBCs/high power field on two different occasions
How does Nephrolithiasis/Urolithiasis present
What are the 4 types of stones
Colicky flank pain w/ +CVA tenderness
Calcium oxalate- MC, avoid grapefruit juice
Struvite- chronic UTIs, w/ Klebsiella/Proteus origins
Uric acid- acidic urine; excess meat/ETOH and gout
Cystine- rare genetic, young male w/ stones
What is the gold standard for Dx Nephrolithiasis/Urolithiasis
What would be seen on UA
What labs need to be ordered
Spiral CT w/out contrast
Microscopic hematuria
BUN, Cr levels to eval renal function
How is Nephrolithiasis/Urolithiasis Tx
What are 3 indications Pts need admission
IV morphine/ketorolac
Hydration
ABX if UTI present
Flomax- alpha blocker if stone >5mm but <10mm
Pain uncontrolled w/ PO meds
Anuria
Renal colic, UTI and fever
What size Nephrolithiasis/Urolithiasis stones are expected to pass naturally
What sizes are not expected to pass and what is done
When is Urology consult needed
5-10mm, may require elective lithotripsy
> 10mm- ureteral stend or percutaneous nephrostomy (gold standard)
Stone doesn’t pass in 3days
Extracorporeal shock wave lithotripsy Tx for Nephrolithiasis/Urolithiasis is best for ? sizes
What is the next step and indicated for ? size
> 5mm <2cm
Percutaneous nephrolithotomy- >2cm
Define a UTI
What is the MC and 2nd MC cause
How do these present
Infection in any part- kidney, bladder or urethra
1st- E Coli
2nd- Enterococcus/Saprophyticus
Dysuria w/out urethral d/c
No F/C/flank pain
Define Honeymoon Cystitis
What is the MC cause of recurrent cystitis in men
How are UTIs Dx
Uncomplicated UTI in women preceded by sex
Chronic bacterial prostatitis
Urine dipstick- nitrie, leukocyte esterase UA: pyuria Culture- gold standard; >100K CFU for women >1K CFu for men/cath Pts
What is an uncomplicated UTI
Female w/out comorbidities
Fosfomycin- single dose, expensive
Allergic to TMP and resistance to E coli: Nitrofuantoin/Flqn
TMP/SMX for resistant E Coli strains
Phenazopyridine- urethral analgesic
How is a lower UTI in pregnancy Tx
How are post-coidal UTIs Tx
How are complicated UTIs Tx
Nitrofurantoin
Cephalexin
TMP-SMX
Cephalexin
Fluoroquinolone
TMP-SMC
Cephalosporin
Avoid- Nitrofurantoin
How is pediatric cystitis Tx
How
Cephalosporin- first line
Keflex
Cefixime/Cefdinir/Cefibutene if inc likelihood of renal involvement
Define Pyelonephritis
How doe Pyelonephritis present
What is the MC microbe to cause this
How is this Dx and what is pathognemonic
Ascending UTI that reaches renal pelvis (staph A- hematogenous)
Fever
CVA tenderness
N/V
E coli
UA: WBC casts (nomonic for pyelo and interstitial nephritis)
What is the next step if complicated pyelonephritis is seen
How is this Tx outpatient
How is this Tx inpatient
How is this Tx in pregnancy
Renal US
Cipro
Levo
Cephalexin
Ceftriaxone
Admit
Ceftriaxone
Define Nephrotic Syndrome
What would be seen on a 24hr UA collection
What lab results would be abnormal
Peripheral/Periorbital edema
Ascites/effusion
HTN
> 3.5g/day
Hypoalbuminemia
Hyperlipidemia
How is nephritic syndrome different from nephrotic syndrome?
What are the two classifications of nephrotic syndrome
Peripheral/Periorbital edema HTN Oliguria Hematuria Proteinuria 1-3gm/day
Primary- Dx w/ kidney biopsy
Secondary- DM, HIV, Hep B/C, Lupus, Antiphospholipid syndrome
Why is proteinuria seen in nephrotic syndromes?
What type of cells make up the basement membrane
What Pt presentation makes nephrotic syndrome a possible Dx
Capillary endothelial cells change and unable to filter serum protein by sizes
Podocytes
Young child w/ unexplained edema/ascites:
Edema + 3.5gm of protein on 24hr collection
Fatty casts w/ maltese cross
Oval fat bodies
Hypoalbumin
Hyperlipid
What are the MC causes of primary nephrotic syndrome in adults
What is the MC cause in Peds
What form affects IVDA
Membranous nephropathy- malignancy/Hep B
Minimal Change Dz: assume Dx if syndrome improves after CCS Txs
Focal Segment Glomerulosclerosis- obese Pt w/ HIV and IVDA, probably black w/ SCDz
What are the MC causes of secondary nephrotic syndrome
How is nephrotic syndrome Dx
How is this Tx
Lupus
DM
Pre-eclampsia
Proteinuria >3.5g/day
Casts- lipiduria
Hypoalbumin <3.5g
Hyperlipid: LDL >130, Tgly >150
Statin
Angiotensis inhibition
Na restricion
Diuretic
How is Minimal Change Dz Tx
What is used for Tx if Pt is a frequent relapser
How is Membranous Nephorpathy Tx
ACEI- for mild condition
Prednisone
ImmSupp w/:
Chlorambucil
Cyclo-sporine/phosphamide
High risk progressing to ESRD: Glucocorticoids and, Cyclophosphamide Low risk: ACEI Persistent- lipid lowering Rx
How is Focal Segmental Glomerulosclerosis Tx
How are steroid resistant cases Tx
Prednisone- 1st line
ACEI- dec proteinuria
Cyclosporine addition
What defines HyperK
What is seen on EKG
What is seen on PE
How is it Tx
Serum K >5
Peaked T wave, prolonged QRS
Muscle fatigue
Sodium bicarb
Glucose
Caclidum gluconate
What define HypoK
What is seen on EKG
What is seen on PE
How is it Tx
Serum K <3.5
Flat/inverted T-wave, Uwave
Muscle cramps, constipation
No dextrose fluids
Replete K/Mg
HypoCa is defined as ?
What is the MC cause and other possibles
What is seen on EKG
What is seen on PE
How is it Tx
Serum Ca <8.4
Ionized Ca <4.4
MC: hypoparathyroid
Other: thryoid surgery, renal dz
QT prolongation
Trousseaus
Chvosteks
IV calcium gluconate
IF suspecting imbalance of phosphorous or Ca, always order ? lab
HyperCa in elderly is Dx as ? until disproven
PTH
Ca
HyperCa is defined as ?
What is the MC cause and other causes
Saying for remembering PE findings
What is seen on EKG
How is it Tx
Serum Ca >10.5
Ionized Ca >5.6
MC: hyperparathyroid
Other: mets, MM, TB, sarcoidosis
Stone Bones Groans Moans
Short QT
IV NS and Furosemide
HypoNa is defined as ?
What causes this
What is seen on PE
Serum Na <135
ETOH
Hypervolemia- CHF, nephrotic syndrome, RF, cirrhosis
Euvolemic- SIADH, steroids, hypothyroid
Hypovolemic- Na loss
Seizures
Altered gait
Mimics HypoK if <105
Why does HypoNa need to be Tx slowly
How is it Tx
How fast should a deficiency be corrected
Osmotic demyelination syndrome
ASx: water restriction
Moderate: IV NS, Loops
Sev: 50mL 3% NS
10mEq or less over 24hrs
What defines HyperNa
How does it present
How is it Tx
What happens if Tx is too fast
Serum Na >145
Poor tugor
Dry skin
Flat veing
IV D5W
Cerebral edema
Pontine herniation
What Na lab result indicates Diabetes Insipidus
What are the two possible locations of the issue
What consistent lab result indicates DI
Low urine Na
High serum Na
Polyuria
Neurogenic/central- deficient ADH from posterior pituitary
Nephrogenic- kidneys don’t respond to vasopressin or d/t lithium/renal dz
Urine osmolality <250 despite hyperNa
What is the 3 step approach to Acid-Base D/o
What causes respiratory acidosis
What causes respiratory alkalosis
1st: ph (7.35-7.45)
2nd: PCO2 (35-45)
3rd: HCO3 (20-26)
Lungs fail to excrete CO2
Excessive CO2 loss
What is the next step if metabolic acidosis is encountered
What causes a high anion gap
What causes a low anion gap
Anion Gap- Na - (Cl+BiCarb)= 10-16
Excess H+ ions >16; MUDPILES:
Methanol Uremia DKA Paraldehyde Infection LAcidosis Ethylene glycol Salicylates
<16Loss of BiCarb- diarrhea
What causes metabolic alkalosis
Saying to remember average normal valued for acid-base numbers
Loss of H+L vomit, bulemia, OD of antacids
Additional bicard- hyperalimentation therapy
24/7 40/40
BiCarb/pH CO2/acid
