IMC 4.0 Flashcards
? is the MC type of cardiomyopathy
What is the MC non-ischemic cause
What part of the heart if affected
Dilated
ETOH abuse
MCC- ischemic dz
All 4 chambers
Dilated Cardiomyopathy is characterized by ?
What heart sound is present
What Sxs can this present w/
Dec contraction strength- systolic dysfunction
S3- ventricular gallop
Fatigue
Edema
Exertion dyspnea
Displaced apical pulse (megaly)
? is the most definitive method to Dx Dilated Cardiomyopathy
What findings are Dx
What will be seen on EKG
Echo
Dilated ventricles
EF <50%, often <30%
Non-specific ST/T changes
What will be seen on CXR of Dilated Cardiomyopathy
How is this Tx
What med is added if increased contractility is needed
Balloon heart- megaly and pulmonary congestion
Loop+ACEI+BB
Transplant/LVAD
Digitalis
What medication is used in Dilated Cardiomyopathy to reduce remodeling
What medication is used to decrease the effects of excess catecholamines
Chronic use of ? street drug can lead to this
Angiotensin Converting Enzyme Inhibitors- ACEI
BBs
Cocaine
Define HOCM
What type of murmur does this have
What makes murmur louder/softer
Ventricular hypertrophy w/ diastolic dysfunction
Medium, mid-systolic cresc-decresc w/ S4
Dec- squat, grip, raise (increased preload)
Inc- valsalva, stand (dec preload)
How is HOCM genetically linked
This condition presents mimicking ?
What type of murmur is present
Autosomal dominant affect on sarcomeres
AS- angina, syncope, HF
S4 gallop w/ apical lift
What type of JVD wave is present in HOCM
How is this Dx
What is seen on EKG
Prominent A-wave
Echo- LVH, thick septum
MRI
LVH
Non-specific ST/T changes
How is HOCM Tx
What Rxs need to be avoided
What medication is c/i?
Diltiazem/Verapamil/Metoprolol
Exercise cessation
+syncope/arrest= ICD
Decrease preload: Diuretics ACEI Nitrates ARBs
Digoxin- increases contraction/obstruction
How does HOCM cause death
Define Restrictive Cardiomyopathy
What Hx is in the Pts report
Post-exertional ventricular arrhythmia
Noncompliant ventricles (MC- LV) that resist diastolic filling
Myocardial infiltration w/ abnormal tissue-
Amyloidosis- MC
What type of HF and sound is associated w/ Restrictive Cardiomyopathy
Half of these etiologies are ?
How is this Dx
Diastolic HF w/ S4
Idiopathic
Echo- normal EF, dilated atria, hypertrophy
Cath- high atrial pressure
What is seen on EKG of Restrictive Cardiomyopathy
If a Dx is in doubt after an Echo, what is the next step?
What would be seen on CXR
Non-specific ST/T changes
Low voltage complexes
MRI- abnormal textures
Pulmonary vascular congestion
Normal heart size
How is Restrictive Cardiomyopathy Tx
Why must Rxs be used cautiously
What populations are at higher risk for developing this condition
+edema/pulmonary congestion= diuretic
Definitive- transplant
Avoid lowering preload
Northern European men
Define ASD
What does this defect cause to occur
How common are these defects
Atrial wall defect causing L to R diastolic shunt
Volume overload of RA/RV
2nd MC behind VSD
Small ASDs can remain ASx as long as 30y/o but then ? occurs
This defect is often associated w/ ? d/t the stretching
This allows for ? event to occur
> 30: dyspnea, angina
50: Afib, RVF
Arrhythmia- RBBB
Paradoxical embolization- DVT causes stroke/brain abscess if septic
What happens to the S2 in an ASD
What kind of S1/S2 is present
How is this Dx
Shunting of blood equalizes blood volume entering ventricles- eliminates normally wide, split S2
Loud S1
Wide fixed split- lub dub-dub
Echo w/ bubble contrast
What is seen on EKG of ASDs
What is seen on CXR
How is this Tx
RAD
RVH
RBBB w/ rSR in V1
Megaly w/ dilated RA/RV
Small/central <3mm: observe
+Evidence of RV volume overload- surgical closure at 2-6y/o
Define PDA
How do Pts present
What type of murmur is produced
Systolic murmur d/t persistent ductus arteriosus (aorta to L-PA) causes L-R shunt
FTT
Poor feeding
Tachy/Tachy
Continuous machinery at 2nd LICS (patent your machine)
What are two common PE findings of PDA
What is seen on EKG
What is seen on CXR
Machinery murmur
Wide pulse pressure (arm>leg)
LVH, normal
LVH
Prominent LA, PA, aorta
How are PDAs Tx
Since these may be identified at birth, especially if premature, what is the next step
? congenital infection can cause a PDA
Indomethacin- decreases Prostaglandin E1/E2
Fluid restriction
Surgery/Catheter
Re-eval in 24hrs
Congenital Rubella
Define a VSD
? is this murmur the MC of
What type of murmur is created
Hole in septum causing L-R shunt between ventricles
MC congenital defect
MC pathological murmur of childhood
Harsh, loud holosystolic w/ systolic thrill
How is a VSD identified on PE
How is the Dx confirmed
How is this Tx
Pt supine
Diaphragm at tricuspid
Echo
Watchful expectation
Infant w/ CHF + growth retardation- digoxin + diuretic
Medical failure- surgery <6mon old
Peds w/ VSD need ? prophylaxis prior to procedures
What is being prevented
What is the MC outcome and the most UNCOMMON outcome
PCN/Amox
Allergy- Erythromycin
Bacterial endocarditis
MC: spontaneous closure
MUC- CHF secondary to VSD
Define Coarctation of Aorta
What is the usual PE finding
Half of these Pts will have ? defect putting them at risk for ? sequelae
Narrowing of aorta, MC below origin of left subclavian artery
Arm BP > Leg BP
Bicuspid aorta;
Berry aneurysm
What does Coarctation look like on EKG?
What does it look like on CXR
How is it definitively Dx
LVH
Rib scalloping/notching
Figure 3 sign
TTEcho or CT/MRA
How is Coarctation of Aorta Tx
How is Tx different if seen in neonates
Why would emergent surgical repair be needed
Balloon angioplasty w/ stent between 2-4y/o
Prostaglandin E1- keeps ductus arteriosus open
Shock
Megaly
Severe HTN/CHF
What happens if Coarcations are left untreated
Infantile Coarctation is associated w/ ? two defects
Unique fact of Tetrology of Fallot
Death by 50y/o d/t:
Rupture/dissection
CVA
PDA
Turner Syndrome- order karyotype analysis
Only cyanotic congenital heart dz on blueprint
What are the 4 features of Tetrology of Fallot
What makes this a Pentology
What is the resulting shunt created?
PS RVH Overriding VSD
ASD
PS- R to L through VSD
How is Tetrology of Fallot Dx
What is seen on CXR
What serial monitoring do Pts need
Echo
Boot shaped heart
EKG for QRS widening
How is Tetrology of Fallot Tx
What happens if these are left untreated
What are complications that arise after surgical correction
Surgery
Sudden cardiac death/HF <20y/o
HF
Outflow obstruction
PR
Arrhythmias
What hereditary T-cell disorder is associated w/ Tetrology of Fallot
What PE finding measures the severity of this condition
Infants/Peds will have ? common PE finding
DiGeorge Syndrome
PS
Cyanosis
Tet Spell= hypercyanotic
Define Primary HTN
What are the ranges for Normal, Elevated, Stage 1 and Stage 2
According to USPSTF, Pts need HTN screening starting at ? age and how often
SBP 130 or > or,
DBP 80 or >
On two readings, on two separate visits
N: <120 and <80
E: 120-29 and <80
1: 130-39 or 80-89
2: 140 or >, or 90 or >
Start at 3y/o, annual at 18y/o:
Normal- qYear
+RFs/SBP 120-29- q6mon
When measuring BP, Pts reasts x ?min
The cuff needs to cover ? much of arm
How big of width does bladder need
Rest >5min and >30min since tobacco/caffeine ingestion
80% of arm
40% of arm
BP discrepancy of ? in both arms needs further eval
When is anti-hypertensive therapy initiation indicated
What is the target BP for PTs w/ or w/out comorbidities
> 15mmHg
All Stage 2
Stage 1 w/ ASCVDz, DM2, CKDz or 10yr risk of 10% or more
140/90 w/out comorbidiites
<130/80
<60 w/ CAD/CKD/DM: <140/90
60/>: <150/90
When Tx HTN, how much salt intake is recommended
How much exercise is recommended
If medication is needed, ? is used per ethnicity
<2.3g/day (1tsp)
Mod intensity: 30min/day x 5d/wk
Vigorous intensity: 30min/day x 3d/wk
Non-black/DM:
ACEI/ARB
CCB
Thzd (chlorthalidone, indapamide)
What HTN Txs are recommended for Stage 2 HTN
When are ACEI/ARB, BB, or CCBs c/i for Tx
How long are therapies recommended
Two BP meds from different classes w/ lifestyle mod
ACEI/ARB- DM w/ proteinuria
BB- asthma
CCB- angina pectoris
F/u 1mon
Goal not met- increase dose or add 2nd med
What is done for HTN if BP is uncontrolled despite 2 anti-HTN meds
What is done if one med causes to much leg edema
What is done if the diuretic is not tolerated
ACEI/ARB and
Amlodipine and
Thzd-like
Substitude Amlodipine w/ Verapamil/Diltiazem
Use mineralcorticoid receptor agonist (Spironolactone)
S/e of ACEI
S/e of Spironolactone
S/e of BB
S/e of CCB
S/e of hydralazine
S/e of thiazides
Cough Angioedema HyperK (c/i- pregnant)
HyperK
Impotence (c/i asthma)
Leg edema
Lupus-syndrome (and Procainamide)
Pericarditis
HypoK
What are the 5 modifications used for Tx HTN and how much of a decrease is expected
? is the initial medical therapy for DM when starting HTN Tx
What EKG changes would be seen after long standing HTN
Weight loss: 5-20mm DASH diet: 8-14mm Na dec: 2-8mm PT: 4-9mm Dec ETOH: 2-4mm
ACEI- beneficial for neuropathy
LVH
What are two non-modifiable RFs for HTN
? anti-hypertensive agent has alpha and beta blocking activity
Pt w/ BP of 135/85, what is the next step and Tx
Age
FamHx CADz
Carvedilol
10yr HDz/stroke risk:
<10%- start lifestyle
>10%, CVDz, DM, CKD- start meds
Define Secondary HTN
When is this Dx suspected
What is the MC cause
130/80 or higher w/ identifiable cause
Severe BP
Refractory to HTN med
Primary aldosteronism- high Na, low K
What is the MC cause of curable HTN
? sweet diet finding can increase BP readings
When Tx HTN, lifestyle modification can be tried for how long before meds are used
Excessive ETOH and OCP combo usage
Licorice
6mon
When Tx HTN, a initial BP higher than ? indicates starting Tx w/ two med
Define Cardiogenic Shock
What is the MC cause
> 160mg
Pump fails, insufficient CO to maintain perfusion
Acute MI
What PE findings suggest cardiogenic shock
What vitals suggest this Dx
How is this Dx
Pulm congestion
AMS
Tachycardia
HOTN
JVD
UOP <20
SBP <90
Pulmonary capillary wedge pressure >15mm
How is Cardiogenic Shock Tx
How does this Dx present post-MI
What type of MI are at highest risk for this sequel
Fluids/Pressers: Dobutamine, NorEpi
Balloon pump
<72hrs post-MI as free wall rupture
Q-wave transmural
Lateral wall
Define O-HOTN
What criteria is used for Dx
What may be the cause in DM/older aged PTs
Excessive fall of BP when upright
Drop of >20 SBP
Drop of >10DBP
Both 2-5min after supine to standing
Autonomic dysfunction- HR inc <10bpm= tilt table
> 100bpm or inc by >30bpm= hypovolemia
How/why does post-postprandial O-HOTN occur
What is the DDx if during Bp checks Sxs present but no HOTN is present
How is O-HOTN Tx
Insulin response to high carb meal
Blood pools in GI tract
Alcohol worsens HOTN
POTS Dz
Inc Na/fluids
Fludrocortisone
Midodrine
? class of drug has the most common adverse effect of OHOTN
Define NSTEMI
What would be seen on EKG
MAOIs- inhibit enzymes that break down neurotransmitters
Myocardial necrosis w/out ST elevation/Q-waves d/t incomplete block (subendocardial infarct)
ST depression
T-wave inversion
What are the 3 cardiac biomarkers used during N/STEMI work ups
How are NSTEMIs Tx
Myoglobin:
1-4hrs; 12hrs; 24hrs
Troponin: most sensitive
2-4hrs; 12-24hrs; 7-10days
CK/CK0MG:
4-6hrs; 12-24hrs; 48-72hrs
MONA BNAH:
BB ASA Reperfusion-PCI Clopidogrel Heparin ACEI NTG Statin
Define STEMI
Since these are Tx similarly to NSTEMIs, what is done first
Myocardial necrosis w/ ST elevation/Q-waves d/t complete block (full wall thickness)
ASA and Clopidogrel
Reperfusion <12hrs of Sx onset
Gold Standard: PCI <90min
Thromolytic therapy <180min w/ TPA/Streptokinase
Where on EKG would abnormal be seen:
Anterior wall
Inferior wall
Lateral wall
Posterior wall
Anteroseptal
A: 1, aVL, V2-6; LAD
I: 2, 3, aVF RCA- SA/AV nodes
L: 1, aVL, V5-6 w/ reciprocal in 3, aVF; LCX
P: ST depression V1-3; RCA/LCX
AS: V1-V3; LAD/Septal
What are the 6 absolute c/is for fibrinolytic therapy for STEMI Tx
Suspected ADissection
Active bleeding/diathesis
Malignant intracranial neoplasm
Ischemic stroke <3mon
CV lesion
HTN, Intercranial
How long after Sxs do NSTEMI/Unstable Angina need angiography
Why is ASA used in N/STEMIs and TIAs
What is the MC type of MI and what is the ‘widow maker’
24-48hrs later
Decreases mortality
MC: Inferior (2, 3, aVF d/t RCA)
WM: LAD
What meds w/ Pts be d/c home w/ after NSTEMI
What med is held until d/c and why is it started then
When would BBs be with held from PTs
BB ACEI Ntg ASA Statin
ACEI- dec LVH/remodeling to increase EF
2nd/3rd* heart blocks
Why do Pts w/ inferior wall MIs have N/V/weakness and bradycardia
Define Stable Angina
Time frame for this Dx and possible presentation sign
Inc vagal tone
SA involvement
Pain/discomfort increased w/ exertion/emotion, predictable and relieved w/ rest/Nitro
<15min;
Levine sign
How is Stable Angina worked up
How is the Dx definitive and what wold be seen
How is this Tx
Stress test- reversible wall abnormalities/ST depression >1mm
Coronary angiography;
>70% stenosis
Nitro- sublingual/IV
BB
Angioplasty/Bypass
Stable Angina Pts have decreased prognosis if ?
What is the most sensitive clinical findings for Dx this condition
What is the most useful and cost-effective non-invasive test
LVEF <50%
Left main involved
Horizontal/down sloping ST depressions on EKG
Stress test: ST depression >1mm is pos
Pts w/ ? Hx have the highest risk for/are at the same risk for CADz compared to those w/ atherosclerosis
What is the most widely used test to Dx ischemic heart dz in Pts w/ classic angina Sxs
What is the TxOC for HF and what class increases these benefits
DM
Nuclear stress test
ACEI- dec morbidity and mortality B1 selective BBs: Bisprolol Metoprolol succinate Carvedilol
What causes BNP to be released and abnormally low
How is dyspnea early on in HF quantified
HF is a syndrome of ?
Released d/t inc ventricular pressures
Low- obesity
Amount of activity that precipitates Sxs
Ventricular dysfunction
Systolic LHF
S3 w/ dilated, thin LV from CADz/MI
LVEF <40%
Tx: Loop ACEI BB
Worse: O2 ACEI Nitro w/ IV diuretic at x2 PO dose, no BB until d/c
Diastolic LHF
S4 d/t hypertophied LV
Inc >55y/o w/ HTN
Normal EF
Tx: ACEI and BB/CCB; don’t use diuretics/digoxin
Exacerbation Tx- NOAL
RV HF
D/t P-HTN
No rales, JVD or edema
Dx w/ cardiac cath
High Output HF
Increased metabolic demand exceed CO
Hyperthyroid
Severe anemia
Beriberi/thiamine deficient
First- tachy, then systolic failure
How is HF Dx
What is the most important part of determining prognosis
BNP levels over ? amount means CHF is likely
Echo
EF:
Norm- 55-60; <35 increased mortality
> 100
What are the 4 NYHA HF classifications
1: no activity limitations
2: slight activity limitations; ordinary activity causes Sxs but comfortable at rest
3: marked limitation of activity; less than ordinary activity causes Sxs but comfortable at rest
4: unable to carry out activity, also have Sxs at rest
An S3 heart sound on inspiration most likely indicates ? type of HF
An S3 heart sound on expiration most likely indicates ? type of HF
? type of HF is associated w/ paroxysmal nocturnal dyspnea
Right sided
Left sided
Left sided
? antiarrhythmic is used to Tx Afib/flutter in Pts w/ HF
? drug affects RAAS, helps limit remodeling and adds to the effects of ACEIs
? is the most effective diuretic in Tx of HF
Digoxin
Spironolactone
Furosemide
? class medication is recommended in all stages of chronic HF
? 4 med classes are important in Tx HF because they all decrease mortality
How do they accomplish this benefit?
BBs
ACEI/ARB
BB
Spironolactone
Inc sympathetic stimulation and aldosterone production- regulates Na/water in body
Only valve w/ two leaflets
Classic AS presentation
Who gets fed during AS causing Sx
MV
Syncope
Angina
Dyspnea
1- coronary artery
2- carotids
3- L subclavian (arm pain)
Pt w/ angina is given Nitro and passes out, ? is underlying issue
What type of S2 will be heard
What additional heart sound may be heard
AS
Split S2
S4
? is the MC acquired heart valve stenosis
Where can this murmur radiate to
How is this best heard and what maneuvers will make this louder/softer
AS d/t calcification
Neck, apex
Leaning fwd w/ expiration;
Inc w/ squat
Dec w/ grip, straining
AS w/ ? suggests a congenital origin
What will be seen on PE if LVH is present
What type of abnormal microscopy result can be seen
Ejection sound
Apical impulse
Helmet cells (schistocytes)- fragmented RBCs from passing through calcified stenotic AV
What makes AS louder
What makes AS quiet
What is the MC cause of AS in younger PTs
Sit, lean fwd w/ exhale (valsalva)
Squat
Hand grip
Stand
Early onset calcification of congenital bicuspid valve
What is the MC cause of AR
What can Pts present w/ as c/c
What PE finding suggests AS has caused structural changes
Weak valve tissue from aging, floppy flaps
Aware of heart when laying down
Down, displaced apex
What term describes the pulses of the Pt w/ AR
What two findings suggest a large regurg flow is present
? congenital syndrome is associated w/ AR
Water hammer- increased pulse pressure
Mid-systolic
Austin flint
Marfans- MVP and AR
What is the best initial test for Pts w/ suspected AR
What does AR do to pulse pressures
What is the mainstay of Tx of AR
TTE
Widens
Dec after load until surgical correction
What is the difference in severity of mild/severe AR
What is the MC cause of MS
What is heard on exam
Severe AR- shorter murmur
Rheumatic heart dz
Apical opening snap (lateral decubitus)
+PHTN- palpable RV impulse
Loud S1
LAH- Tx w/ ACEI
MR is the MC ? murmur
What type of murmur is produced
What are 4 etiologies of MR
2nd MC (after AS) MCC- MVP
Holosystolic at apex w/ dec S1, split S2 radiating to axilla, and apical S3
CADz HTN Infection Rheumatic heart dz MVP
What are two odd c/c Pts w/ MR may present w/
How is MR different from TR
Female w/ MVP have increased issues w/ ?
SOB worse w/ laying/activity
Inc nocturnal urination
Not louder w/ inspiration
Inc pulses- palpitations w/ exercise
What maneuvers change the features of MVP
What may be seen on EKG
How are these Pts Tx
Squat- delays
Standing- moves closer to S1
ST depression
PVCs
Early inferior repolarization
QTc prolongation
+palpitations: BB
Avoid smoke/caffeine
Surgical repair- especially w/ impaired LV systolic function
Where is TS heard
What makes murmur louder
What is the MC cause of this defect
Diastolic rumble at LLSB
Inspiration
Rheumatic valve heart dz
How is TS Tx
How does TR present
What is the MC cause
Percutaneous balloon valvotomy
Holosystolic at LLSB that radiates to sternum and inc w/ inspiration
RVF/dilation initiated from PHTN/LVF
How does TR change the JVD wave
How does PS present
What is the MC cause
Inc w/ large ‘V’ waves
Systolic murmur at pulmonic area that inc w/ inspiration
Congenital malformation in kids
What will be heard on PE of PS
What type of murmur is heard in PR
What causes PR
Widely split S2 w/ dec P2 w/ R sided S4
Diastolic decrescendo at pulmonic area that inc w/ inspiration
PV annular dilation/damage/congenital malformation
What is this murmur of PR AKA
Since PR can be indistinguishable from AR, how is it differentiated
How is this murmur Tx
Graham-Steel murmur
PR inc w/ inspiration, AR does not
Valve replacement
? is the MC cardiac arrhythmia and what is it’s biggest RF
The prevalence of this MC increases d/t ?
Why does this conduction irregularity develop
Afib d/t HTN- irregular, irregular w/out P-waves and narrow QRS
Age
SA node generation is overwhelmed/disorganized MC by pulmonary veins
What is the most important lab ordered for Afib work up
What two neurological issues can cause Afib
What is the best imaging for Dx
TSH to measure thyroxin (inc cellular metabolic rate); Graves present w/ Afib
Suabarachnoid hemorrhage
CVA
TTE- initial (valves, chamber/wall dimension)
TEE- most accurate (thrombus)
Where/what is the most common site of an embolus to develop during Afib
How is Afib Tx and w/ ? goal
How is rate control achieved w/ Rxs
LA appendage
1- Unstable: Cversion
2- >48hrs: anticoagulate x 21days
3- Afib + RVR= chemical conversion
<110bpm:
IV Diltiazem/SAME-olol
Low dose digoxin, slower/inadequate rate control
What is a s/e of using Sotalol for rate control of Afib
What is the drug of choice for Tx Afib in WPW
What med is best for rhythm control if there is/no CAD/CHF
Torsades
Procainamide- security detail to AV node
Flecainide: -CAD/CHF
Dronedarone: +CAD, -CHF
Amiodarone: +CHF
Why are CCBs used for rate control of Afib
DHP vs non-DHP CCBs
If using Amiodarone/Dronedarone for rhythm control, ? drug can’t also be used
Road block between SA/AV node (5 land to 2 lane)
Pine tree- outdoor
(CCBs w/ -pine, outpatient)
Non-pine (non-DHP)- no out-PT; Verapamil; Diltiazem
Dabigatran- DOAC for Afib d/t non-valvular d/o
When/why would Digoxin be used in the Tx of Afib
What alternatives to Warfarin are available and indication for use
How does AFlutter appear on EKG
HF and dec LV function;
Inc intracellular Ca
Dabigatran- DOAC for Afib d/t non-valvular d/o
Rivaro/Api-xaban: no antidote and no blood testing
Irr/Regular w/ sawtooth P-waves
How is AFlutter Tx
How is rate control in Aflutter different than Afib
If conversion is needed for Aflutter, how much energy is needed
Diltiazem
Flecainide
Dronedarone>Amiodarone
Rate control more difficult
50-100J
How is the need for anticoagulation for Afib/Flutter determined
What DOACs can be used
When/why would Warfarin be used and w/ ? goal
CHA2DS2-VASc:
0- none/ASA 81-325mg
1- ASA 81-325 or anticoag
2 or >- anticoagulate
Dabigatran
Edoxaban
Apixaban
Rivaroxaban
INR goal: 2.5: Prosthetic valves EGFR <30 Rx: Phenytoin, antiretrovirals MS
What does the CHA2DS2-VASc stand for
? DOAC has a reversal agent if needed
Eliquis dosage needs to be lowered if used w/ ? ABX
CHF/LVEF 40% or less HTN Age 75 or >: 2pts DM Stroke/TIA/Emboli: 2pts Vascular dz Age 65-74 Female
Dabigatran
Clarithromycin
Define Paroxysmal AFib
When is this Dx changed to Persistent/Permanent Afib
Define Multifocal Atrial Tachycardia
Intermittent attacks that self resolve <7days
Persist:>7d
Permanent: >12mon
MC in COPD Pts w/ irregular, irregular rhythm and varying P-wave morphology
Nearly 90% of Afib PTs will present w/ ?
AFlutter may develop as a sequelae to ?
Aflutter Pts are more likely to present w/ ? c/c
ASx
Open heart surgery
Fatigue
Exercise intolerance
What is the main difference between Afib/Flutter Txs
? is the most rapid method to lower INR in PTs on Warfarin
Define PSVT
Aflutter cured w/ RFA
FPPlasma
SVT w/ abrupt start and stop in Pts w/out other structural heart Dz
What are the two types of PSVT
How are these Dx
How are these Tx
AVNRT: tachyarrhythmia developing above Bundle of His
WPW: abnormal pathway between atria and ventricles in Bundle of Kent
Holter monitor to capture episodes
Stable: Vagal, Carotid massage, Valsalva
Sxs: Adenosine
Regular: BB/CCBs
Definitive: RFA
What meds are avoided in Tx of WPW
What is the Tx oc choice for long term management
Why is Adenosine used for PSVT Tx w/ fear
Adenosine, CCBs
RFA
Transient asystole d/t T1/2 of 6sec
What are the 3 types of premature beats
What abnormal beat presentation can these have
PVC: wide/bizarre QRS w/out P-wave
PAC: abnormal P-wave, common in COPD Pts
PJC: narrow QRS w/ no/inverted P-wave
Trigeminy
Bigeminy
Pts w/ heart Dz and frequent PACs will soon develop ? issues
What are two etiologies of PVC
If Pt has palpitations, they describe them as ?
PSVT Afib/flutter
Hypoxemia
E+ imbalance
In throat
How are premature contractions Dx
How are these Tx
How is V-Tach Tx
EKG, Holter
PAC: reassure
PVC: BB, ablation
PJC: only Tx if >10/min or multifocal w/ lidocaine/antiarrhythmic
Stable: Amiodarone, Lidocaine, Procainamide
Unstable monomorphic: synchronized cardioversion starting at 100J
Unstable polymorphic: Dfib
How is VTach defined
This is a common complication d/t ?
? antiarrhythmic used for long term can cause hyper/hypo-thyoidism
3 or more consecutive premature ventricular beats
Acute MI
Dilated cardiomyopathy
Amiodarone- similar structure to thyroxine w/ iodine
What are the different classes of antiarrhythmic drugs?
S/e of using Procainamide
How is VFib Tx
1a: Na blocker
1b: fast Na blocker
1c: potent Na blocker
2: BB
3: K blocker
4: Ca blocker
Drug induced lupus eruption
CPR
Defib- non-synch conversion 120 150 180
Epi
Amiodarone 6mg, 12mg
Define VFib
This MC develops d/t ? myocardial abnormal
This rhythm can be caused by abusing ? two drug
Uncoordinated quivering of ventricle w/out useful contractions
MI- ischemia increases excitability of myocardium, predisposes heat to Vfib
Meth, Cocaine
? technique can providers use to Tx VFib if no defibrillator is present
Define 1* Heart Block and the Tx if needed
Define the two types of 2* Heart Blocks and their Txs
Precordial thump
PR >.20 (5 small squares): problem between SA/AV nodes; Tx w/ BBs
Mobitz Type 1: Wenckebach-
Long, long, drop; no Tx unless unstable- pacing
Mobitz Type 2:
Dropped QRS, Pwave w/out QRS; Tx w/ pacemaker
Define 3* Heart Block
What class of drug is c/i in all heart blocks
Only two blocks have constant R-Rs
Constant P-P, R-R interval
Erratic PR; Tx w/ pacer after r/o ischemic dz
CCBs
1st, 3rd degree
? is the MC cause of AV blocks
? is the only complete AV block
Why do Pts w/ Mobitz Type 2 need pacers
Idiopathic fibrosis/sclerosis
Ischemic heart dz
3rd degree
Always pathologic, almost always progress to 3rd degree blocks
? type of Dz infection can cause a 3* heart block
? is the MC cause of 3* blocks
Define Sick Sinus Syndrome
Lyme Dz
Myocardial ischemia
Dysfunction of sinus nodes automaticity and impulse generation
Define 4 abnormals seen in Sick Sinus Syndrome
What is the MC cause of the underlying sinus node dysfunction
Most PTs w/ SSS will need ? Tx
Sinus brady: <60bpm
Pause: <3 seconds
Arrest: >3 seconds
Tachy-Brady: alternates; Tx w/ pacemaker
Idiopathic SA fibrosis
Pacemaker
Use BB/CCB/Digoxin if prepared to transcutaneous pace
Define Acute and Subacute Endocarditis
MC cause in native valves infection is ? group
MC cause in IVDA
MC cause in prosthetic valves
Acute: Staph infects normal valves
Sub: Strep V infects abnormal valves
HACEK
Staph A w/ small vegetations
Staph epidermis
How does endocarditis of a fungal origin present
What is the time frame for presentation
What type of fungus will be cultured and how is it Tx
Contaminated line cause slowly grown, large vegetations
<2mon post-valve replacement
Candidia; Tx w/ Amphotericin B
? microbe is the MC cause of infective endocarditis
How does this microbe origin present
What are the peripheral findings of endocarditis
Strep viridians
Late complication of valve replacement w/ small vegetation/emboli
Splinter hemorrhages Roth spots Janeway- sign septic emboli Osler node- painful Spelnomegaly Hematuria
How is endocarditis Dx
How is this condition Tx depending on valve type
TEE- gold standard
+Blood cultures, 3 sets, 1hr apart
Native w/out IVDA: Nafcillin Ampicillin Gentamicin
Prosthetic: Vanc Gentamicin Rifampin
IVDA: Nafcillin
PCN allergy- Vanc
What are Pts prophylactically Tx w/ post-endocarditis
Four RFs for developing infective endocarditis
Pts presenting w/ ? two Sxs signal suspected Dx
2g Amoxicillin
PCN allergy-Clinda
Prosthetic valve
Rheumatic heart dz
IVDA
Congenital defect
Fever- MC Sx
New murmur- TR/MR
Stroke
What are 3 possible adverse outcomes from infective endocarditis
Non-IVDA endocarditis MC affects ? valve
IVDA MC affects ?
Glomerulonephritis
Septic emboli
Splinter hemorrhages
Mitral
Tricuspid
5 criteria for Pts to need endocarditis prophylaxis
Pericarditis is MC from ? microbe and often leads to ? sequelae complication
? syndrome of pericarditis is seen 3-5d post-MI
Prosthetic valve
Prosthetic material repair
Hx endocarditis
Congential heart dz
Coxsackie;
Pericardial effusion
Dresslers
How is pericarditis Dx
What PE finding may be seen
How is it Tx
EKG w/ diffuse, ST elevation in 1/2, V5/6
Kussmaul sign- increased CVP w/ inspiration; common in constrictive pericarditis
NSAID/ASA x 7-14d
Sxs >48hrs- CCS
What are 3 autoimmune etiologies of pericarditis
What 2 inflammatory Dzs can cause this
What 2 medications can cause this
SLE RA Scleroderma
Sarcoidosis
Amyloidosis
Hydralazine
Procainamide
How do Pericardial Effusions present
What would be seen on EKGs
What would be seen on Echo
Same as pericarditis w/ fluid accumulation around heart
Low voltage QRS
Alternans
Tachy
Swinging heart
Water bottle sign
What are the “3-Ds” of a cardiac tamponade
What Triad is this AKA
What are two possible complications of an effusion
Muffled sounds
Elevated JVD w/ rapid x-descent, attenuated y-descent
HOTN
Beck’s Triad
Tamponade
Constrictive pericarditis
? is a classic finding on PE of cardiac tamponade
What would be seen in PTs VS
What is the gold standard of Dx
Pulsus paradoxus- SBP dec x 10mmHg w/ inspiration
Narrow pulse pressure
Echo
How is pericardial effusion different from tamponade
How is the tamponade Tx
? is the MC cause of non-traumatic tamponade
Effusion doesn’t cause RV collapse
Urgent- centesis
IV fluids to inc preload
Met malignancy
How do tamponades lead to death
? is one of the most consistent tamponade findings
What would make this consistent finding absent
IVC pressure decreases preload
Pulsus paradoxus
Hypovolume
Low press tamponade
LV
How do AAAs present
How do A-Dissections present
When is screening indicated
Back pain
Pulsatile mass
HOTN
Tearing pain radiating to back w/ different arm pulses
Male >65 w/ +smoking history
? is the difference between dissection and AAA in structural involvement
What is the initial and gold standard Dx test of choice for AAA
What is the CXR finding for aortic dissections and how are they Tx
AAA involves all 3 layers
Dissection- one layer, intima
US- initial
Angiography- gold standard
Widened mediastinum;
Ascending- surgery
Descending- BBs
What is the Dx test of choice for aortic dissections
How are AAAs managed depending on size
MRI angiography
<3cm- no more tests 3-4.4cm: annual 4.5-5cm: q6mom, refer 5-5.4cm: q3mon >5.5 or >0.5cm expansion in 6mon- immediate repair even if ASx
Define Venous Insufficiency
What is a common PE finding
If ulcer present, they are commonly located ?
Impaired venous return causing skin change, edema, pain
Stasis Dermatitis
Medial malleolus
How is Chronic Venous Insufficiency Dx
How are they Tx
Define Varicose Veins
US, D-dimer
Elevation, compression
Ulcers- wound care, compression
Dilatd superficial veins in lower extremities w/out obvious cause
If symptomatic, what do varicose veins present w/
How are these Tx
Define Acute Bronchitis
Pain w/ exertion
Full/pressure
Hyperesthesia
Compression Elevation Wound care Sclerotherapy Surgery
Cough lasting >5days
? Sx is unusual for bronchitis and it’s presence should shift Dx to ?
95% of bronchitis is d/t ? etiology
If caused by bacteria, ? microbes can cause this
Fever;
Pneumonia
Viral
M Catarrhalis- MC bacterial cause of acute bronchitits
H influenzae
Strep pneumoniae
How is acute bronchitis Dx
How are these cases Tx
Acute exacerbations of chronic bronchitis d/t bacteria are Tx w/ ?
CXR
Tx Sxs, >95% are viral:
Cough: Dextromethorphan, Guaifenesin
Wheeze/Pulm Dz: albuterol
1st: 2-Gen Cephalosporin
2nd: 2-Gen Macrolide or TMP/SMX
When are ABX indicated for the Tx of Acute Bronchitis
How does Acute Sinusitis present
What is the MC cause
Elderly
+CardioPulm Dz and cough x 7-10days
ImmComp
Sinus pain w/ drainage
Sxs worsen 5-7d or do not improve >10days
Strep pneumo
What is First, Second, and Third Line Tx for Acute Sinusitis
What is the gold standard and other form of imaging method if needed
? microbe is the MC cause of chronic sinusitis
1st: Augmentin
2nd: Doxy
3rd: Levaquin
CT- gold standard
X-ray w/ waters view
Staph A
Time frame for acute sinusitis
When is this converted to chronic sinusitis
Time frame for sub-acute sinusitis
<4wks w/ sudden onset
> 12 consecutive wks
4-12wks
What are the indications to use ABX for Tx of Sinusitis
What ABX are options for first line Tx
Why would second line ABX be needed and what can be used
Sxs >10d w/out improving
Fever >102
+purulent d/c
Improvement w/ rapid worsening of Sxs
Augmentin*
Amoxicillin
PCN allergy- Doxy, Cefixime or Cefpodoxime w/ or w/out Clindamycin
No improvement in 7d; Augmentin 2g BID Levofloxacin Moxifloxacin PCN allergy- Doxy, Levoflox, Moxiflox
How is Chronic Sinusitis Tx
How is sinusitis in Peds Tx
Why do Sinusitis Pts lose sense of smell
3wk Tx course of:
Augmentin
PCN allergy- Clinda
Augmentin
PCN allergy: Cefpodoxime, Cefdinir
Olfactory epithelium destroyed by viral infection/chronic sinusitis
? is the MC microbe to cause acute bacterial sinusitis in adults?
? is the MC type of bacterial pneumonia that is MC seen in Pts >40y/o
This MC type if common in Pts w/ ? MedHx
Staph A
Strep pneumonia- rust colored sputum
Splenectomy
How does Staph A pneumonia present
How is it Tx if MRSA is suspected
Pseudomonas causes pneumonia in ? populations
Salmon colored sputum after influenza
Vanc
ICU ventilator CF w/ Vit A deficiency Bronchiectasis Malignancy COPD
When/where is mycoplasma pneumonia more commonly seen
What two findings indicate this Dx
MC microbe to cause pneumonia in drinkers w/ aspiration
Pts <40y/o in dorms
Cold agglutinins
Bullous myringitis
Erythema Multiforme
Klebsiella
Strep Pneumo, H influenza induced pneumonia usually present w/ ? S/Sxs
Atypicals like Mycoplasma, Chlamydia and viruses present w/ ? S/Sxs
What two Pt populations are most frequently admitted for CAP
Productive cough
Fever, high
Tachy/Tachy
Non-productive cough w/ fever
Elderly
COPD
How do the 3 typical microbes (Hflu, Morax, Strep Pneumo) that cause pneumonia appear on CXR
How do the 3 atypicals (Legion Mycoplasma C-pneumonia) appear on CXR
Lobar pneumonia and sicker Pt
Interstitial infiltrates, Pt not as sick
? is the MC nosocomial infection
? is the 2nd MC
? is the MC type of pneumonia in older adults and is more common in winter month
UTI d/t foley
Pneumonia w/ Strep Pneumo
Pneumococcal pneumonia d/t Strep Pneumo
What vaccine is used to help reduce CAP
What Pts should get this vaccine
? is the biggest lymph node of the body
PCV-13, 1 year later;
PPV-23
Annual influenza
Age >65y/o Smokers Sickle cell dz DM Indian/Inuit Chronic liver Dz
Spleen- largest Ab maker in body
How is CAP Tx outpatient w/ no ABX use x 90days
How is CAP Tx outpatient if +ABX use x 90days or +comorbidities
How is CAP tx in areas w/ macrolide resistance
Macrolide (Azith/Clarith) or,
Doxy
M/L/G-floxacin or,
Macrolide (A/C-mycin) and Augmentin (Beta-lactam)
M/L/G-floxacin or,
Macrolide (A/C-mycin) and Augmentin (Beta-lactam)
How is CAP Tx in ICU
How is this Tx regiment changed it Pt has COPD
? is the MC atypical pneumonia and MC pneumonia in younger adults w/ ? outbreak trend
M/L/G-floxacin or Azith and
Cefotax/Ceftriax or Ampicillin (antipseudomona w/ beta lactam coverage)
Levofloxacin (Levaquin) becomes 1st
Mycoplasma in adults <40y/o w/ summer/fall outbreaks
How does Mycoplasma Walking Pneumonia present on CXR
How is it Tx
How does Legionella induced pneumonia present
Patchy infiltrates more extensive than exam
1- Azith/Clarith-romycin
2- Doxy/Augmentin
3- Levofloxacin (Levaquin)
HypoNa Diarrhea Fever
What is the CURB-65 scale used for
How is anaerobic pneumonia Tx
Pneumonia ICU admission: Confused Urea >20 RR 30/> BP: <90/60 65 or older Each one= 1pt 0-1: low risk 2pts: mod risk, consider admit 3-5: high risk, ICU admit
Augmentin
Amox/PCN and Metronidazole
? PE finding is a constant finding in Legionnaires pneumonia
What are the two distinct clinical presentations of this Dz
What does it look like on CXR
Bradycardia
1st- Pontiac fever; viral-like syndrome
2nd- pneumonia
Mid/lower lobe w/ patchy infiltrate
Inc LDH= pleural effusion
How is Legionairres Pneumonia Dx
How is this form of pneumonia Tx
Define Pneumocystic Carinii Pneumonia
IFA and ELISA
Sputum DFA
Legionella urine Ag
1- Azithromycin
2- Levofloxacin (Levaquin)
3- Doxy
Pneumocystis jiroveci- unicellular fungi in ImmComp Pts (AIDS CD4 <200)
How does Pneumocystis jiroveci present
How does it appear on CXR
How is this type Dx
F/C
Dyspnea, low PO2
Dry cough x wks
Bilateral, perihilar infiltrates w/ inflamed alveolar cells
Bronchial lavage/biopsy
How is the degree of lung injury in Pneumocystis Jiroveci measured
How is this Tx
What s/e may be seen d/t this medication
LDH level
TMP/SMX (+ Dapsone)
Allergy- Pentamidine
Pancreatitis
Renal failure
Prolong QT
Chlamydia pneumonia is associated w/ ? Hx but lacks ? presenting Sx
What 3 forms are pathogenic to humans
How is it passed along
Birds;
Afebrile
Pneumoniae
Psittaci
Trachomatis
Inhalation of dried feces
How is Chlamydia Psittaci Tx
? are the 3 MC causes of viral pneumonia
1- Doxy
2- Azithromycin
Influenza
Adenovirus
Parainfluenza
How is Viral Pneumonia in Peds Dx
How is an RSV etiology tested for
How will they present
PCR testing for Adenovirus
Nasal wash
Tachypneic w/ wheeze
How is RSV pneumonia Tx
What will these Pts be at risk for later in life
Pts w/ pneumonia and Tx w/ Macrolides but bounce back now need to be Tx w/?
1- Ribavirin
2- Palivizumab
Reactive airway dzs
Levofloxacin (Levaquin)
Peds w/ CAP are Tx w/ ?
How is CAP Tx outpatient w/ no comorbidities, recent ABX use and low resistance rate
What is the s/e of using Macrolide or Fluoroquinolone class ABXs
1st- Amoxicillin, <5y/o
2nd- Azithromycin, >5y/o
1- Azith/Erythromycin
2- Clarithromycin/Doxy
Prolonged QT interval
MC cause of viral pneumonia in adults
MC cause of viral pneumonia in kids
MC cause of fungal pneumonia in western states
Influenza
RSV
Valley Fever d/t Coccidioides
MC cause of fungal pneumonia from caves/zoos in Ohio/MS river valley
? fungal spore is found in soil and can lead to meningitis
MC fungal pneumonia etiology in COPD/TB
Histoplasma capsulatum
Cryptococcus
Pulmonary aspergillosis
? is a major RF for CAP
? microbe is a tag along but exacerbator of H Influenza pneumonia
Histoplasma Capsulatum looks like ? on CXR
Recent hospitalization
M Catarrhalis
Sarcoidosis
What are 3 positive PE findings seen in pneumonia
Poor dental hygiene can cause pneumonia from ? type of microbes
? beta-lactam ABX is used in the Tx of CAP
Tactile fremitus
Egophony: spoken ‘ee’ heard as ‘ay’
Dull percussion
Anaerobes
Ceftriaxone
How is Klebsiella Pneumonia Tx
Pneumovax can be given to Pts w/ increased risk of pneumococcal dz starting at ? age
? is the TxOC for Peds w/ Chlamydial Pneumonia
3rd Gen: Cefotaxime
23mon
Erythromycin/Sulfisoxazole
What is seen on CXR of hypersensitivity pneumonitis
How is Coccidioides Pneumonia Dx
How Coccidioides and Aspergillosis Tx ?
Diffuse nodular densities
EIA for IgG/IgM
C/A: Flu/Itra-conazole
How is Crypto/Histoplasma capsulatum pneumonia Tx
When/what is used in AIDS Pts for daily prophylaxis against Jiroveci
Amphotericin B and Flucytosine
TMP/SMX;
Hx of PJP infection
CD4 <200
How is Viral Pneumonia differentiated from Mycoplasma Pneumonia
How is Viral Pneumonia Dx
If Sxs <48hrs, what is used for Tx depending on strain of influenza
Adeno- fast onset w/ GI Sxs x7days
Myco- slow, insidious
Rapid Influenza Ag
RSV nasal swab
Neg agglutinin titer
A/B: Zan/Oselt-amivir
A only: Ama/Riman-tadine
? is the MC cause of lower respiratory tract infections in kids worldwide
This is the leading cause of ? two Dxs in infants
? is the MC pathogen of Bronchiolitis
RSV, almost all will have it by 3y/o
Bronchiolitis
Pneumonia
RSV
How is RSV Dx
What is seen on PE
What does this look like on CXR
How is it Tx
Nasal RSV Ag test
Fever
Wheezing cough
Rhinorrhea
Flaring nares
Diffuse infiltrates
Steroids
When does Pt w/ RSV need to be admitted
When is prophylaxis indicated
What is used for prophylaxis
Feeding difficulty
O2 desat
Retractions
Tachypnea
28wk, 6 day or < and <12mon at start of RSV season <12mon w/ CH/LDz, Congenital airway abnormality ImmComp <24mon w/ CF
Palivizumab
What organism causes TB
How is it transmitted
What are the classic findings on PE
Mycobacterium tuberculosis
Respiratory droplet
Fever
Anorexia
Weight Loss
Night sweat
When are TB PPDs read as positive
Induration= raised area
>5mm: \+CXR ImmComp/HIV Pred equivalent of 15mg/day >1mon Close contacts
>10mm: IVDA High prevelance immigrant High risk living Bypass surgery Medical employees
> 15mm:
No RFs
How is TB Dx
What would be seen on CXR
What would be seen on biopsy results
Sputum smear/culture for Acid Fast Bacilli and staining
Upper cavitary lesion
Apical Ghon complex
Caseating granuloma
What is the name of TB spread out of the lungs
What are two types
Miliary
Potts- TB to spine
Scrofula- TB to cervical nodes
How is TB Tx
How long is Tx done per med type
+PPD= CXR
Neg CXR= Isoniazid x 9mon w/ B6 (Pyridoxine) to prevent neuropathy or sideblastic anemia
Active TB= RIPE w/ baselines prior to Tx: Rifampin Isonizid Pyrazinamide Ethambutol
RIPE x 2mon
IR x 4mon
What are the s/e of RIPE Tx drugs
When is a Pt w/ active TB considered for therapy cessation
What is used for prophylaxis for PTs living w/ +TB
Rif: orange fluids
INH: neuropathy
Pyra: gout
Emb: optic neuritis, red/green blindness
Neg AFB x 2 in a row
Isoniazid x 12mon
What part of RIPE Tx needs to be adjusted if CrCl is <30mL/min
What PT education is given w/ RIPE Tx
Which meds can cause hepatotoxicity
E/P to 3x/wk
Take meds on empty stomach
RIP
RIPE Tx can interact w/ ? other Tx method
CXR finding of a Ghon complex indicated ? Dx
What part of the lung is MC involved w/ these complexes
Raltegravir for HIV, double dose for HIV Tx
Primary TB
Lower lobes
How is L-TB Tx
Administration of ? drug can reactivate a latent infection
Mycobacterium MC affects ? part of lung
INH x 9mon or,
Rifampin x 4mon or,
RIF and PZA x 2mon w/ infected contact
Exogenous CCS
Upper lobes
TB is the MC cause of ? endocrine d/o in the world
PPDs need to be read w/in ? time frame
Why do Pts w/ Rheumatoid Arthritis need TB tests prior to Tx
Addisons Dz
48-72hrs
Etanercept: anti-cytokine agent, can reactivate dormant TB
+HIV Pt w/ positive PPD is Tx how
Define Asthma
What PE finding indicates emergency
INH and RFN
Chronic, reversible, inflammatory airway dz
Lack of wheezing
How is Asthma Dx
Define FEV
Define FVC
Peak expiratory flow rate (Dec FEV1:FVC ratio)
Forced Expiratory Volume- measures how much air exhaled w/ forced breath
Total amount exhaled during FEV test
What are the 4 asthma classifications and Ts
Intermittent:
Sx <2x/wk
or 2/< wake up/wk
Tx: SABA PRN
Mild: Sx >2/wk or 3-4 wake up/mon SABA >2d/wk Minor limitations Tx: Low ICS daily
Moderate: Daily Sxs >1 waking >wk Daily SABA use Some activity limits Tx 3: Low ICS+LABA daily Tx 4: Med ICS+ LABA daily
Severe: Daily Sxs Wake 7x/wk Multiple SABA daily Extremely limited activity Tx 5: High ICS+LABA daily Tx 6: High ICS+LABA+PO CCS
How is an asthma exacerbation Tx
When Tx Asthma, considered SQ allergen immunotherapy for ? Steps
Consider consult at ? step
PO CCS
Iprtropium bromide
Nebulized SABA
O2
2-4
Step 3
How is exercise induced asthma prophylactically Tx
What is the ICS used for Asthma Txs
? PE finding suggests improvement of an asthma attack after Tx
Albuterol- B2 agonist
Nedocromil
Beclomethasone
Cromolyn
Inc FEV1
What is the MOA of Salmeterol for Asthma Tx
COPD is umbrella term for what two Dxs
What causes the risk for infection and loss of lung recoil to occur
Relaxation of bronchial smooth muscles
Chronic bronchitis
Emphysema
Dec ciliary/WBC function
Frayed elastin fibers
How is COPD Dx
What is the criteria for chronic bronchitis Dx
What are common findings seen in these Pts
PFT: FEV1/FVC 50%
Productive cough >3mon x 2yrs
Inc Hgb/Hct (polycythemia)
P-HTN
How is COPD Tx
What is the single most important medication fro Tx
What vaccines are highly recommended
Mild: SABA (FEV1>80)
Mod: LABA (Tiotropium) + ICS (Fluticasone, Salmeterol)
Low O2- too much removed respiratory drive
PaO2 <55mmHg/ PaCO2>55mmHg
SpO2 <88% or 89% w/ CorPulmonale
Flu
Pneumoccocal
? is the inhaler of choice for COPD Pts
Define Emphysema
Why are Blue Bloaters blue and why are Pink Puffers pink
Ipratropium bromide- anticholinergic blocks constrictive effect of Ach on airway muscles
Enlarged air spaces d/t destruction of alveolar septae
Blue: Chronic hypoxia
Pink: CO2 retention
? CXR finding is pathognemonic for Emphysema
Pts <40y/o w/ COPD need ? test
Hallmark of blue bloater
Parenchymal Bullae (subpleural blebs)
Alpha-1 antitrypsin
Productive cough
3 parts of PFT that are decreased in COPD
2 parts that are increased
? drugs is used in COPD Tx for preventing nocturnal bronchospasms
Max vent volume
Tidal volume
Vital capacity
Total lung capacity
Residual volume
Theophylline- xanthing drug prevents spasms and prolongs dilation
What microbes cause infections in COPD PTs
What ABX are used during COPD exacerbation
? are the indications to use these ABX
H influenza
Strep Pneumo
Moraxella
Strep Viridians
1- macrolide
2- Cefuroxime Cefpodoxime, Fefdinir
3- Doxy
Inc quantity and purulence
COPD Pts >65y/o are predisposed to infections by ?
How are these Pts Tx w/ ABX
Blue Bloater is common in ? smoking Hx
Pseudomonas
1- Cipro/Levofloxacin
2- Augmentin
3- Doxy
> 40pk/year
Difference in CXR between Blue Bloater and Pink Puffer
? is the most effective Tx for COPD
What will ABGs of chronic bronchitis show
Blue: diaphragm not flat
Cessation
Resp acidosis
COPD Gold Categories
A: breathless if hurrying on level ground; less Sxs, 0-1 exacerbation past 12mon w/ no admission
Tx: SABA/SAMA
B: walks slower than others; more Sxs, 0-1 exacerbation past 12mon w/ no admission
Tx: LABA/LAMA w/ SABA
C: breathless if hurrying on level ground; less Sxs
2/> exacerbation/year w/ 1 or more admission
Tx: LAMA, SABA
D: walks slower than others; more Sxs; 2/> exacerbation/year w/ 1 or more admission
Tx: LAMA+LABA+SABA
Define Centriacinar Emphysema
This form of emphysema is associated w/ ?
What part of the lung is affected
Morphological pattern of destruction to bronchioles and central acini
Smoking
Upper lobe
COPD Pts w/ ? other Dx have increased risk for mortality
Why do emphysema PTs breathe through pursed lips
COPD exacerbation are managed w/ ? 3 meds
Bronchiectasis
Inc pressure in airway prevents collapse
Systemic steroids
ABX
Antivirals
SABAs for COPD Tx
SAMAs for COPD Tx
LABAs for COPD Tx
LAMAs for COPD Tx
Levabuterol
Albuterol
Pirbuterol
Ipratropium Bromide
Salmeterol
Olodaterol
Formoterol
Arformoterol
Aclidinum bromide
Tiotropiium Bromide
Umeclidinium
Glycopyronium bromide
Interstitial lung Dzs
Which one is MC of the interstitial dzs
This is MC caused by four etiologies
-Pulmonary alveolar proteinosis
-Eosinophilic Pulm -Syndrome
Interstitial pneumonia
-Diffuse interstitial pneumonia
Sarcoidosis
Interstitial pneumonia
Medication
Environment
Occupation
Infection
What is the MC type of interstitial pneumonia
What histological pattern is seen
What is no pattern is seen by the lab
Pulmonary fibrosis
Usual Interstitial Pneumonia
IPF
3 criteria used to Dx Pts >65y/o w/ IPF/UIP
What are the three methods to Dx this condition
How are these Pts Tx as long as they don’t have IPF
Inspiratory crackles
Restrictive PFT
CXR findgins
Pleural honey combing
BAL- esp P Jirovecii
Lung biopsy- standard
Transbronchial biopsy
Pred: 1-2mg/kg/day x 2mon
How are PTs w/ IPF Tx
What is the only definitive Tx fo IPF
How is sarcoidosis Dx and Tx
Nintedanib and
Pirfenidone
Transplant
Biopsy w/ non-caseating granulomas
Tx: Pred 1mg/kg/day
How is Sarcoidosis Tx if refractory to steroid Tx
What is a good/poor prognosis for these PTs
Methotrexate
Azathioprine
Infliximab
Good: only hilar adenopathy
Bad: lung parenchyma involvement
Define Pulmonary Alveolar Proteinosis
MC presenting c/c
CXR findings
How is this Tx
Phospholipid accumulation in alveolar spaces
Dyspnea
Bilateral alveolar infiltrates
Whole lung lavage
GM-CSF: granulocyte macrophage colony stimulating factor
What can cause Eosinophilic Pulm Syndromes
What syndrome can be seen here
One third of cases are idiopathic d/t ?
How is this Tx
Helminth infection
Filariae infecition
Loffler: helminthe larva infiltrate into pulmonary passage
Chronic: female w/ asthma
Acute: febrile illness w/ cough/dyspnea
Pred
What are the 7 types of Occupational Pulmonary Dzs
Pneumoconioses
Hypersenstivity Pneumonitis
Obstructive airway d/o
Toxic lung injury
Cancer
Pleural Dz
Other
Define Pneumoconioses
What are the 3 types of Penumoconiose Dzs
How are all Tx
Fibrotic lung dz from inhaled inorganic dusts
Coal Worker:
Silicosis
Asbestosis
Supportive
How does Coal Worker Pneumoconiosis appear on CXR
? RF does not play into this conditions severity
Complicated Coal Workers is AKA ?
Coal Workers + Rheumatoid Arthritis causes ?
Diffuse opacities in upper lobes
Smoking
Progressive Massive Fibrosis- contraction of upper lobes, similar to Complicated Silicosis
Caplan Syndrome
How does Silicosis appear on CXR
These PTs are at increased risk for ? future Dx
Asbestosis Pts usually don’t seek Tx until ? long after exposure
Egg shell calcification throughout lungs
Pulmonary TB
> 15yrs
How is Asbestosis best Dx
? tissue finding suggests significant exposure
What finding characterizes Hypersensitivity Pneumonitis
CT- detects parenchymal fibrosis
Ferruginous body
Interstitial infiltrates of lymphocytes and plasma cells w/ noncaseating granulomas
What causes Farmers Lung
What causes Humidifier Lung
What causes Bird Fancier Lung
Moldy Hay
Contaminated humidifier/heating systems
Bird serum/excretions
What causes Bagassosis
What causes Sequoisis
What causes Maple Bark Stripper Dz
Moldy sugar cane
Modly redwood dust
Rotting maple tree bark
What causes Mushroom Picker Dx
What causes Suberosis
What causes Detergent Workers Dz
Moldy compost
Moldy cork dust
Enzyme additives
What are the 3 Occupational Obstructive Airway Dzs
Occupational Asthma- Dx w/ bronchial provocation
Industrial Bronchitis- exposured coal dust, hemp, cotton, flax
Byssinosis- textile worker; Sxs worse on first day back to work; leads to Chronic Bronchitis
Example of Toxic Lung Injury
What is a later complication experienced and how can this be prevented
? flavoring can cause a Toxic Lung Injury
Silo Filler- inhaled Nitrogen Dioxide
Bronchiolitis obliterans;
Early CCS Tx
Diacetyl- butter flavored popcorn
What three toxic inhalations lead to the development of bronchogenic carcinomas
? inhalation causes small-cell carcinomas
Pleural Dzs can develop d/t exposure to ? two inhalants
Cigarette, Asbestos, Radon gas
Chloromethyl methyl ether
Asbestos
Talc
Define Berylliosis
Systemic Sxs manifest mimicking ?
Size requirements for pulmonary nodule or mass
Pulmonary d/o from mining materal for fluorescent lamps
Sarcoidosis
<3cm- nodule
>3cm- mass
Pulmonary nodules are AKA ?
What are the steps for work up
Coin lesions
1- Incidental CXR
2- CT
3- Suspicious (ill-defined border, lobular, spiculated)- biopsy
4- non-suspicious (calcified, smooth edges) <1cm: f/u 3mon, 6mon and yearly x 2yrs
Coin lesion that has not grown in ? time is considered benign
What CXR finding is suspicious
What diameter is suggestive of benign/malignant
2yrs or more
Volume doubling from 21-40 days
<1.5cm: benign
>5.3cm: Ca
Exception: Abscess, Wegener, Hydatid cyst
PTs <35y/o, nonsmoking w/ incidental lung nodule finding needs ? next step if no prior CXRs are avail
Non-small cell lung Ca has ? four sub-types
? is the MC type seen in non-smoking females
CT scan of chest
Adeno- MC lung Ca
Squamous- MC in smoker
Large- Dx of exclusion, rapid grower
Carcinoid
Bronchogenic Adenocarcinoma-
MC presentation of adenocarcinoma
What CXR finding indicates Squamous Cell Ca
What CXR finding suggest adenocarcinoma
Pleural effusion w/ inc LDH
Central mass w/ hemoptysis
Peripheral mass
What CXR finding suggests large/carcinoid
What is Small Cell Lung Ca so deadly
What lab findings signal Small Cell Lung Ca
Throughout lung
Almost always in smoker
Mets early/at Dx
Rarely surgical
ADH= SIADH: HypoNa, HyperCa ACTH= Cushing Synd.
What syndrome can Small Cell Lung Ca cause
How are lung Cas Dx
Pancoast tumor of lung are most likely ? type
Lambert Eaton Myasthenic Syndrome- muscle weakness d/t ACTH/ADH
Bronchoscopy w/ biopsy (central) or,
Fine needle transthoracic
Squamous
Adenocarcinoma
Pt presents w/ facial/arm swelling means a Pancoast Tumor is causing ?
Pancoast Syndrome is ? trifecta
How is Non-Small Cell Ca Tx
Superior Vena Cava Syndrome
Shoulder pain
Horners
Bone destruction (PTH from squamous Ca)
Stage 1-2: surgery
Stage 3: chemo then surgery
Stage 4: palliative
How is Small Cell Ca Tx
Small Cell Ca is AKA ?
How is Carcinoid Syndromes Dx
Non-surgical= Chemo
Oat Cell Carcinoma
CT scan w/ Octreoscan
UA- inc 5-HIAA
CXR- pedunculated sessile growth in central bronchi
Squamous Cell and Small Cell both start ?
? type of lung Ca starts in the pleura
Centrally (SCs start central; all others start peripheral)
Mesothelioma (asbestosis), not a bronchogenic carcinoma
Define Carcinoid Syndrome
Why is there a hormonal excess
Where are the tumors located
Specific to carcinoids- serotonin increases bronchoconstriction (asthma), peristalsis (diarrhea) and facial flushing*
Tryptophan converted into serotonin instead of niacin/proteins
Colon
Appendix- Peds pts
Bronchials
Small intestine
What lab result indicates Pt has Carcinoid Syndrome
What other lab result is elevated and decreased
? nutritional dz may be c/c presentation
5-HIAA- serotonin elevated in urine
Inc: chromogranin A, protein of carcinoid Ca
Dec: tryptophan
Pellagra- niacin deficiency
What heart valve lesions may be present during Carcinoid Syndromes
How are these Tx
What is the MC site for these tumors to mets to
TIPS:
Tricuspid insufficiency
Pulmonic Stenosis
Surgical excision (resistant to Chemo/Rad)
Octerotide- somatostatin analogue to decrease serotonin secretion
Niacin (Vit B3)
Liver to lungs
What is the mnemonic for Carcinoid Syndrome and why is this
Normal pulmonary BP is ? so P-HTN is then defined as ?
What is the MC of P-HTN
FDR:
Flushing: inc histamine/bradykinin
Diarrhea: pellagra
R-sided valves: collagen thickens d/t inc serotonin
15/5;
>25mmHg at rest
MS
How is P-HTN Dx
What would be seen on EKG
How is this Tx depending on the etiology
Right heart cath- gold standard
T-wave inversion V1-V4,
2, 3, aVF
2* LVF: Diuretic Anticoagulant Digoxin
Cardiogenic- (pulm artery HTN) Prostanoids, Phosphodiesterase inhibitor, Endothelin antagonist
What structural changes does P-HTN cause
? respiratory drug is used for P-HTN Tx
O2 saturation of 90% correlates to ? PO2 value
Smooth muscle hypertrophy
Initmal fibrosis in Pulm Arteries
Bosentan- endothelin antagonist to decrease vascular resistance
60mmHg
DVT presents w/ ? PE finding
Females older than 35y/o should have ? birth control d/t inc risk
How are these Dx
Homan- extend leg, push foot to head, +pain
Progestin only
D-Dimer
Venography w/ Duplex US- gold standard
How are DVTs Tx
If Pt has recurrent DVTs, how is Tx changed
Where are DVTs more commonly developed
LMWH
Fondaparinux
Lifetime anticoagulation
Left iliac- compressed by aortic bifurcation
How do PEs present
How are these Dx
How are they Tx
SOB w/ tachycardia*- MC Sx of PE
Spiral CT VQ scan (pregnant)
Heparin w/ Xa inhib (Riva/Apixa/Edoxaban) then Dabigatran (DOAC)
Renal insuff- Warfarin (INR 2-3)
Heme-unstable: thrombolytic
? part of the lung is more commonly affected by PEs
If PE is a fat emboli from long bone Fx, how does the Pt present
How is the probability of a PE calculated
Lower lobes
Hypoxemia
Neuro abnormals
Petechial rash
Wells Score:
>4- PE likely, image
=4- unlikely, D-dimer
What do ABGs during PEs show
What would be seen on EKG
What CXR terms may be seen
Respiratory alkalosis
S1Q3T3
Westermark
Hampton hump
Where does the obstruction in OSA tend to occur
What are the RFs for OSA
How can this present
Ooropharynx
Alcohol Hypothyroidism Sedatives Obesity FamHx Anatomical obstruction
Personality change Dec intellect Dec libido Monring HAs Polycythemia
How is OSA Dx and differentiated from CSA
What is an alternative test for Pts w/ high suspicion but no medical comorbidity
How is this Tx by severity
Polysomnography w/:
>5 apneas w/ comorbidity
15/> regardless of comorbidity
Home sleep apnea test
Mild-Mod:
PO appliance
Pos pressure therapy
Sev: CPAP
Uvulopalatopharyngoplasty
Tracheostomy- life threatening OSA
During OSA work ups, Cheyne Stokes respiration are commonly seen in PTs w/ ? Dx
How is the severity of sleep-disordered breathing measured
What are the 3 categories of severity
CHF
Apneic + hypopneic episodes/hr
Normal AHI <5
Mild: 5-15
Mod: 15-30
Sev: >30
When is OSA Tx indicated
? class medication is c/i in these Pts
What are the different types of pneumothorax
Sx w/ AHI >5
All AHI >15
Benzos
Spot- ruptured bleb
Secondary Spot- cough/lung dz
Traumatic
Tension- leads to shock
What will be seen on PE of Pneumothorax
How are these Tx
How do Pts w/ Sarcoidosis present
Dec sounds
Dec tactile fremitus
<20% diameter self resolve
Needle aspiration
Chest tube
CXR q24hrs
Spiking fever
Erythema Nodosum
How is Sarcoidosis Dx
What lab result will be elevated
What would be seen on a PFT
How is it Tx
Tissue biopsy- noncaseating granulomas
HyperCa
ACE higher 4x normal
Restrictive pattern
PO Pred and ACEI
Define Sarcoidosis
What is the hallmark CXR finding
What are 3 DDxs for this hallmark finding
Systemic granulomatous dz w/ noncaseating granulomas
Mediastinal adenopathy
Young female: sarcoidosis
Ohio kid/zookeeper w/ fever- Histo
Old ceramic worker- beryllosis
What is used for assessing Sarcoidosis progression and Tx guides
How is this Tx
What is the leading cause of death for this population
Serial PFTs
CCS
ACEI for HTN
Methotrexate
Pulmonary fibrosis
What are the 4 organs MC involved in sarcoidosis in sequence
What are the 4 stages of this Dz
Lung
Nodes
Skin
Eye
1- bilat adenopathy
2- bilat adenopathy and reticular opacities
3- reticular opacities
4- opacities w/ volume loss and fibrosis
Define Transudate
What is the MC cause
What are other possible causes
“Transient” thin water fluid from pulmonary circulation back pressure/dec osmotic pressure
CHF
Cirrhosis w/ ascites
Hypoalbumin- nephrotic syndrome
Define Exudate
What is the MC cause
What are other possible causes
Thicker fluid from tissue infection, damage, inflammation allowing blood protein/water to escape
Pneumonia
Ca PE TB Pancreatitis
What criteria is used for pleural effusions as an exudate
Lights Criteria: one of three= (Inc Protein, Inc LDH) 1- pleural protein:serum protein >0.5 2- pleural LDH:serum LDH >0.6 3- pleural LDH >2/3 upper limit of lab's normal serum LDH
Isolated L-sided pleural effusion is most likely a ?
Isolated R-sided pleural effusion is most likely as ?
How are these Tx
Exudate
Transudate
Thoracentesis
Chronic/recurrent: pleurodesis or indwelling cath
Define Empyema
Usually these are Tx how
Define Decortication
infected pleural effusion
Chest tube
Thoracotomy and removal of infected fibrous rings from around lung
Define ARDS
What is the MC cause
Usually ? other organs will fail too
How is this Tx
Respiratory failure d/t Inflammation of lungs and fluid accumulation in alveoli decrease O2 sats
1-Sepsis (2- trauma, 3- aspiration/near-drown)
Kidney Liver
Intubate for mechanical PEEP, PaO2 >60/SaO2 >90
What physiological process causes ARDS
This process allows for ? to develop
How is this Dx
Inc alveolar-capillary membrane permeability
Non-cardiogenic pulmonary edema (protein rich)
CXR w/ air bronchograms and bilateral fluffy infiltrates
Define Delirium
This is common in hospitalized PTs d/t ?
What is the 4 criteria needed for Dx
Acute onset of temporary AMS
Drugs
Infection
Dehydration
Dec consciousness
Cognitive change
Rapid onset
Evidence physical condition
Testing to Dx Delirium includes ?
How is this Tx
? are the MC type of hallucinations experienced by these Pts
CT/MRI
Tx cause
Supportive care
Sedation
Visual
? antipsychotic is used for delirium Tx
What is the MC cause of delirium
What is the saying for anticholinergic ODs
Haloperidol
ETOH abuse
Hot as Hades Mad as a hatter Dry as a bone Red as a beet Blind as a bat
How do Cluster HAs present
What will Pt look like
How are these Tx
Unilateral eye pain w/ lacrimation and nasal congestion x 15-180min
Same time, every day attack causing pacing/rubbing head
O2 12-15L via non-rebreather
Sumatriptan
What is used of Cluster HA prophylaxis
How do Migraine HAs present
How is this Tx in order
Lithium
Divalproex
Verapamil
Topiramate
Unilateral throb/pulsating HA w/ photo/phono-phobia and N/V
NSAID 5-HT1 agonist (Triptan- constrict dilated vessels) Atenolol Ergotamine Reglan + Benadryl
When are migraine Tx c/i
How are these Dx
When is neuroimaging indicated
Cardiac dz
Cerebrovasc dz
PVDz
PIN:
Photophobia
Impairment, job/life
Nausea
New onset >50y/o
Changed pattern
Atypical/unremitting
Prolonged/bizarre aura
When is migraine prophylaxis indicated
What is used for prophylaxis
4/> HA/mon
8/> HA days/mon
1st line:
Divalproex
Topiramate
PMT-olol
2nd:
Amytriptyline
Venlafaxine
A/N-olol
3rd:
Botox
CHRP monoclonal Abs
? is the MC form of aura w/ migraines
Define Migraine Equivalent
When are these Dx as Chronic Migraines
Ophthalmic
Migraine aura w/out HA
> 15d/mon x 3mon
How do Tension HAs present
How are they Tx
What are two categories of these HAs
Bilateral front/occipital HA in ‘band-like’ pattern
1st: NSAID
2nd: ASA/caffeine
Ergotamine
Episodic: <15d/mon
Chronic: 15/>d/mon
What is used for Tension HA prophylaxis
Medication overuse HAs must be avoided by limiting abortive agent use to ?
How does an esophageal stricture tend to present
TCA: amytriptyline
CBTherapy
No more than 2d/wk
Dysphagia to solids w/ gradual progression
MCC of esophogeal strictures is d/t ?
Define Esophageal Web
Define Schatzki Ring
Benign peptic strictures from GERD
Thin mucosal membrane growing across lumen
Eosphageal ring at B-junction, MC from hiatal hernia
Define Plummer-Vinson Syndrome
Define Steakhouse Syndrome
How are esophageal strictures Dx
Dysphagia
Iron deficient anemia
Cheilosis
Esophageal webs
Progressive dysphagia to solids, worse after heavy meal that was wolfed down
Initial- barium swallow
Dx- Upper Endoscopy
How are esophageal strictures Tx
? esophageal stricture is PROXIMAL/MID and not distal
What are the 3 types of hernias
Endoscopy w/ dilation
H2 antagonist
PPI
Infectious esophagitis
Diaphragmatic
Ventral
Umbilical- refer >2y/o
How are hernias Dx
Define Direct Hernia
Define Indirect Hernia
US/Clinical
Intestine goes through external ring at Hesselbach Triangle, rarely into scrotum; felt on side of finger
MC; intestine goes through inguinal ring into canal; felt on tip of finger; congenital/<1y/o Pt
(“i” indirect through “i” of inguinal)
? type of hernia have high incidence of strangulation
What are the 5 types of non-infectious esophagitis
What is the hallmark Sx of infectious esophigitis
Femoral d/t femoral ring rigidity
Medication Eosinophilic Radiation Corrosive Reflux
Odynophagia- pain w/ swallowing liquid or solid
How does Fungal Esophagitis present
How does HSV Esophagitis present
How does CMV esophagitis present
How does Eosinophilic Esophagitis present
Linear white/yellow plaques; Tx Fluconazole
Mulitiple punched out lesions on EGD; Tx Acyclovir
Solitary ulcer/erosion on EGD; Tx Ganciclovir
MedHx of asthma and multiple corrugated rings on swallow; Tx inhaled steroid
How is Esophagitis Dx
How is Corrosive Esophagitis Tx
How is Bisphosphonate induced esophagitis Tx
Endoscopy w/ biopsy and culture
CCS
Take w/ 4oz of water, avoid laying down x60min
? is the MCC of esophagitis
Esophagitis induced from chemo/rad is expected after ? much radiation
What are these PTs at risk for developing
GERD
5000cGy
Strictures
What are the two main types of esophageal Ca
How are these Cas Tx
How do these usually present
SCC, MC world- d/t smoking and ETOH
Adeno, MC in US- d/t Barrett’s esophagus
Resection-no mets
Rad/Chemo w/ 5-FU
Dysphagia to solids progressing to liquids w/ adenopathy
Adenocardinoma of the esophagus is usually found in ? area and d/t ? progression
How are esophageal Ca Dx and staged
Barretts Esophagitis need endoscopic screenings ? often
Distal esophagus: GERD to Barretts
Dx: upper endoscopy
Stage: CT
q3-5yrs
How is GERD Dx
What is an upper GI study used for
? presenting GERD c/c is often overlooked
pH probe: Gold Standard
Endoscoyp w/ cytologic washing
Anatomy, not reflux
Chronic cough
How is GERD Tx
What are 5 meds that can cause LES relaxation
What is an uncommon Sx seen in GERD
H2 antagonist BID
Persistent Sxs- switch to PPI (most effective)
Once Sxs stop, continue x 8wks
CCBx Diazepam Theophylline Meperidine Morphine
Odynophagia
Two common presenting Sxs of gastritis
What are the two types of gastritis
Dyspepsia
Abdominal pain
Acute: rapid developed lesion in gastric antrum
Chronic:
Type A- slow lesions in fundus d/t Ab w/ risk for adenocarcinoma
Type B- ASx slow lesions in antrum from NSAID/Pylori w/ PUD risk
How is gastritis Dx
How is this Tx
What are four s/e of medical therapy
Endoscopy w/ four biopsies
H2RA: Famotidine, Cimetidine, Omeprazole- D/c when ASx x 8wks
PPI causes: Hypochloride Dec Ca (hip Fxs) Dec serum B12 Dec Mg
Gastritits Tx can make Pts at increased risk for ?
What two infections can cause gastritis
? is the MCC
Pneumonia
C Diff
HSV
CMV
H Pylori
Microscopic shape of H Pylori
What are the two types of ulcers seen in PUDz
How can the location be hinted at on PE
Gram-neg spiral bacillus
Duodenal
Gastric
Food decreases pain of duodenal ulcer
What type of PUD ulcer is more common
Both types of ulcers are MC caused by ?
What anatomic plane are these usually found on
Duodenal > Gastric
H Pylori
Anterior duodenum
Rarely, duodenal ulcers can be caused by ? syndrome
PUD is the MC cause of ?
How does this MC usually present
Zollinger-Ellison: gastrinoma tumor of pancreas causing excess gastrin to be produced; Dx w/ serum gastrin >200pg
Non-hemorrhagic GI bleeds
Melena
How is PUDz Dx
How is PUD Tx w/ Triple Therapy
What is the next step if H Pylori was suspected
Upper endoscopy w/ biopsy
PPI \+H Pylori= Omeprazole Amoxicillin Metronidazole/Clarithromycin Quad therapy: add Bismuth
Eradication confirmation in 4wks
How are NSAID induced PUD Tx
How is Zollinger Ellison Tx
When is PPI Tx used w/ caution
D/c NSAID
PPI x 8wks minimum
PPI
Tumor resection
Hepatic impairment
4 RFs for gastric Ca
How are these Dx
How are they Tx
FamHx
Ulcers
H Pylori
Pernicous anemia
Guiac
CBC- micro/hypo
EGD w/ biopsy
Gastrectomy
What are the MC Sxs of gastric Ca
? is the most important RF
What are two metastatic signs
Early: pain, indigestion
MC: Weight loss
H Pylori
Virchow node- L-supraclavicular
Mary Joseph- umbilical
What EGD finding indicates a gastric Ca Dx
What does the mnemonic WEAPON stand for
Linitis Plastic- thickening of stomach wall
Weight loss Emesis Anorexia Pain Obstruction Nausea
Virchows node is associated w/ L-supraclavicular, what is associated w/ the R side
What causes Celiac Dz
What does this Dz cause to occur
Hodgkin’s lymphoma: right nodule drains mediastinum, a common origin site
Autosomal recessive inheritance of an immunologic response to gluten
Injury to proximal intestine mucosa
? is a dermatological manifestation of Celiac Dz
How is this Dx
How is a Dx confirmed after a positive Dx test
Derm. herpetiformis- European male w/ painful, pruritic bilateral extensor lesions
Dx: punch biopsy
Tx: Dapsone, diet
IgA endomysial Ab- inc spec, lower sense
IgA transglutaminase AB- + in most Pts on gluten free diet
Endoscopic intestinal biopsy
Why are Pts sensitive to gluten in Celiac Dz
What causes lactose intolerance
How is this Dx
Sensitivity to gliadins- alcohol-water soluble fraction of gluten
No lactase enzyme: digests lactose into glucose/galactose
Hydrogen breath test >20ppm <90min
Stool acidity- E Coli/Rotavirus
What is the difference in appearance of Crohns and UC
What is the difference in areas involved
Crohns- transmural cobblestone, skip lesions
UC- limited to sub/mucosa crypt abscess
Crohns- spares rectum, +abdominal pain
? radiographic findings are pathognemonic fo Crohns and UC
? one is protected by smoking
? Ab test is used for UC
Crohns: Terminal ileum string sign
UC: lead pipe d/t loss of haustra
UC
p-ANCA
What upper GI Sx can indicate Crohns
What is the MC site
What Ab test is used
Aphthous ulcer
Terminal ileum
ASCA
How is UC and Crohns Tx w/ 5-ASAs
What Rx is used if there is no response
What is the next step if there is still no response
Sulfasalazine w/ supplemental folate
Mesalamine
Metronidazole
Azathioprine
6-Mercaptopurine
Which IBDz can be cured w/ surgery
What medical therapy needs to be avoided in these PTs
What are 3 extraintestinal manifestations of IBDz
UC
Anti-diarrheals- induces ileus
Uveitis
Erythema nodosum
Arthritis
How is IBS standardized by Sx-based criteria
What are labs not needed for Dx
What med is used for Tx as an anti-spasmodic
Rome criteria: Pain 3d/mon x 3mon w/ two of: Improved w/ BM Changed frequency Changed consistency
Routine studies are normal in IBS
Hyoscycamine- anticholinergic
IBS is a ? d/o
? infection leads to increased prevalence of IBS
? is the MC vessel blocked leading to intestinal ischemia
Functional, not organic
Giardia lamblia
Superior mesenteric artery
Mesenteric ischemia presents as pain after ? and relieved by ?
What will be seen on x-ray
How is this Dx
How is it Tx
<30min after eating;
Relief w/ laying/squat
Thumb-printing of small bowel
Mesenteric angiography- gold standard
Colonoscopy
Revascularization
What meds can help prevent future poly growth after polypectomy
Colonic polys are the MC cause of ? in Peds
Where are adenomatous polyps commonly found
ASA
Cox-2 inhibitors
Painless rectal bleeding
Distal colon/rectum
Polyps located ? are more likely to be malignant
What type of polyp has a 30-70% chance of malignant transformation
How are these Dx
Proximal colon
Villous adenoma
Colonoscopy for Dx and therapeutic q/ f/u q3-5yrs
Define Familial Adenomatous Polyposis
What screening is needed for first degree relatives
When is a sigmoidoscope recommended
> 100 polyps by 15y/o and Ca by 40y/o
Genetic screen at 10y/o
12y/o
What two RFs trigger the start to colon Ca screenings
What types of screening are recommended for Pts that have no Sxs/RFs
Under routine circumstances, when should Pts start and stop getting screening colonoscopies
Adenomatous polyp or 1st* relative w/ Dx- start at 40y/o or 10yrs younger than age of Dx
> 50:
Colon- q10yrs
Flex sig, contrast enema, tumor cells- q5yrs
45y/o - 75y/o
Colon Ca is the ? leading cause of death
How is colon Ca Dx
How are these Tx
3rd
Lung, skin, colon
Colonoscopy w/ biopsy
Enema= apple core lesion
Resection
Chemo w/ 5-FU
What lab result is monitored in colon Ca Pts during Tx
Where is Diverticulitis MC found
How is this Dx
CEA- carcinoembryonic antigen
Descending colon
Western society- sigmoid
CT w/out contrast- fat stranding w/ wall thickening
NO colonoscopy
Diverticulitis is the MC cause of ?
How is diverticulitis Tx
What 3 PE findings is suggestive of positive Diverticuosis Dx
Painless, massive lower GI bleeds
Cipro or,
Augmentin + Metronidazole
No vomit
Inc CRP >5mg
LLQ pain
? is NOT a complication of Diverticulosis
? two microbes cause the inflammatory process of diverticulitis
? criteria is used to define constipation
Colon Ca
E Coli
Bacteroides fragilis
Rome 3
Pts >50y/o w/ constipation need ? r/o
How much fiber is recommended during Tx
Ca
20-25g/day
What are the bulking laxatives
What are the osmotic laxatives
What are the softener suppositories
Psyllium seed
Methycellulose
Ca polycarbophil
Wheat dextrin
Polyethylene glycol
Glycerin
Bisacodyl
Constipation lasting longer than ? long needs further work up
? anti-HTN med class doesn’t cause constipation
? is the MC organic cause of constipation in Peds
> 14days
BBs
Hirschprung dz
Define Hep A
Where does this cause outbreaks
How is it Dx
RNA virus transmitted via fecal-oral
Military
Enclosed environment
Daycare
Early: anti-HAV IgM
Late: anti-HAV IgG, remains elevated for life
How is Hep A Tx
When are vaccines given
Define Hep B
IgG globulin no more than 14d after exposure
<24mon, just as effective as immune globulin injections
DNA virus ‘Dane” particle via blood, IVDA, intercourse
When can pregnant females get Hep B vaccine
? is the first sign of infection
What is the 2nd sign
What is the 3rd sign
27-36wks
HBsAg- subway, serological hallmark of HBV infection
HBeAg- egg= replication and infectious
HBcAg- intracellular Ag in liver cell
? lab result means Dx of acute Hep B
? lab result means decreased viral replication
? lab result appears after clearance of the HBsAg or indicates vaccination
anti-HBc (Ab IgM)
anti-HBe (Ab IgM)
anti-HBs (Ab IgM)
anti-HBs
How does Chronic Hep B develop
? test is used to differentiate from passive and active Hep B immunity
What lab result will indicate health care worker is Hep B immunized
HBsAg is always positive, ‘e’ can occasionally develop >6mon after infection
Core Abs
IVDA: +cAbs
Healthcare: -cAbs
anti-HBs (we never exposed to the core)
How is Hep B Tx
Define Hep C
Incubation period and these Pts are at risk for ?
Hep B DNA vaccine
Single strand RNA in post-transfusion/transplant/IVDA Pts
2wks-6mon;
Hepatocellular Ca
How is Hep C Dx
How is Hep C Tx
Define Hep D
How is D transmitted
anti-HCV Abs in serum
Interferon, controls chronic Hep C
RNA virus requiring HBsAg for infection
Clotting factors
Drug users
? infection causes 50% of fulminate hepatitis infections
This infection puts Pts at increased risk for ?
Hep D
Inc severity of Hep B attacks
Chronic hepatitis
Cirrhosis
Define Hep E
How is this transmitted
Pt wants to be tested to see if they have Hep A, ? lab is ordered
Similar to Hep A d/t trasmission and prevalence in young adults
Fecal-oral
Anti-HAV IgM
What Hep B lab result would a PA-C and IVDA have in common
What lab test says Pt is actively infectious
What lab result would be positive in chronic Hep B Pt
Anti-HBs
HBeAg
HBsAg
Hep D needs / part of Hep B to exist
What is the first evidence of infection w/ Hep B
What is the lab result needed for Dx of Hep B
What lab result indicated Hep B virus replication and infection
HBsAg
Anti-HBs
Anti-HBc
HBeAg
What Hx does Hep A present w/
What are two PE findings
How long are they contagious
Travel to Asia
Hepatomegaly and jaundice
1wk of jaundice
How are Hep A Pts Dx
What Pt education goes w/ Dx
What do family members get for Tx
IgM anti-HAV
Immune for life
IV-IGg
How does Hep B present to clinic
What lab result means Pt is immune
? lab result means Pt is positive for infection
Flu-like w/ jaundice
anti-HBs
HBsAg
? lab result mean acute Hep B
? lab result means chronic Hep B
Hep E outbreaks is associated w/ ?
How is it Dx
Anti-HBc IgM
Anti-HBc IgG
Waterborne outbreaks
IgM anti-HEV
When are Hep C screenings recommended
What anti-virals are used for tx
How is Chronic Hep E Tx
18-79y/o
Sofosbu-vir
Velpatas
Daclatas
Glecapre
Ribavirin
Define Cirrhosis
What PE findings may present late in the Dz process
What skin changes can be seen
Hepatic fibrosis d/t regenerative nodules surrounded by fibrotic tissue preventing regeneration
Terrys nail- white bed
Ascites
Gynecomastia
Palmar erythema
Caput medusae
Spider angioma
How is Cirrhosis Dx
Once Dx, all PTs need ? f/u imaging
What abnormal lab results will be seen
Gold Standard: biopsy
EGD
AST > ALT Anemia Dec platelets Inc unconjugated bili Inc PTT
What scoring system is used for Cirrhosis Mortality
What meds are sued for prophylaxis against variceal hemorrhage
What is used if encephalopathy is present and what is avoided
Child-Pugh:
Class A: 5-6pts
Class B: 7-9pts
Class C: 10-15pts
Non-selective BBs:
Nadolol
Propranolol
Lactulose+Neomycin; Sedatives
What is used in cirrhosis if pruritis is present
Cirrhosis Pts w/ sudden onset fever and abdominal pain need ? Dx r/o
Why can cirrhosis Pts present w/ foul breath
Cholestyramine
Bacterial peritonitis
Fetor Hepaticus- musty breath d/t sulfur in blood passing into lungs
What are 3 features of decompensated liver cirrhosis
Define Palm Tree Sign
? tumor marker is used for liver Ca
Jaundice
Encephalopathy
Ascites
Caput Medusae: enlarged superficial epigastric veins in umbilicus
alpha-Fetoprotein
Hepatocellular carcinoma occurs in the setting of ? two Dxs
How are these worked up if <1cm
Inc alpha-fetoprotein in ? two populations should raise concern
Chronic liver dz
Cirrhosis
MRI
Neg= US q3mon
Cirrhosis
Hep B
How are liver Cas Tx
What Tx option is not attempted d/t ineffectiveness
What are the 5 F’s of Cholelithiasis
Transplant if tumor is <5cm or,
3/< tumors, all 3/
Define Cholelithiasis
What is the best test to Dx Cholelithiasis
What is the cardinal Sxs
Stones in gallbladder w/out inflammation
RUQ US, best after NPO x 8hrs to fill/distend gallbladder
Biliary colic d/t temporary obstruction
Define Boas Sign
What are the 3 potential complications that can arise from this condition
Right subscapular pain d/t biliary colic
Cholecystitis- cystic duct obstruction
Choledocholithiasis- gallstones in biliary tree
Cholangitis- biliary tract infection d/t obstructed stones
How is Choledocholithiasis Tx
How is Cholangitis Dx
What lab result will be elevated if bile flow is obstructed, specific to the biliary tree, and what Dx is then likely
What lab result is used to confirm this lab elevation
ERCP stone extraction
ERCP
Alkaline phosphatase (ALK-P)- cholestasis
GGT
The liver’s ability to synthesize clotting factors is reflected by ? lab result
What clotting factors does it make
How is Cholelithiasis Tx
Prothrombin time
1 2 5 8 9 10 12 13
Cholecystectomy
? ABX is a major cause of biliary sludge
This ABX can cause ? type of stones to be formed
Define Cholecystitis
Ceftriaxone- binds Ca in bile w/in gallbladder
Frank stones
Inflamed gallbladder d/t obstruction of biliary duct
What is the most specific test to Dx cholecystitis
What PE finding helps w/ Dx
How is this Dx
HIDA Scan
Murphy’s Sign
RUQ US then,
HIDA
How is cholecystitis Tx
Define Cholangitis
What is the MC microbe involved
Lap Cholecystectomy
Infected obstruction in bile duct
E Coli
Define Charcots Triad
Define Reynold’s Pentad
How is Cholangitis Dx
RUQ pain
Jaundice
Fever
HOTN
Confusion
RUQ US then,
ERCP for Dx and Tx
? is the top 3 MCC of acute cholangitis
What are the 3 products secreted by the pancreas
What is the MCC of acute and chronic pancreatitis
Choledocholithiasis
ERCP
Tumor
Amylase
Insulin
Glucagon
Acute: gallstone
Chronic- ETOH
How is pancreatitis Dx
How is this Tx
? RF increases the risk for pancreatic Ca
Abdominal CT
Analgesia
Bowel rest
IV fluids
Smoking
What tumor marker is used to track pancreatic Ca
How does pancreatitis present
What is the mnemonic for causes of pancreatitis
CA 19-9
Steatorrhea
Pain radiating to back, better w/ leaning fwd
GET SMASHED: Gallstone Ethanol Trauma Steroid Mumps Autoimmune Scorpion HyperCa HyperLipid ERCP Drugs
What criteria is used to predict the severity of pancreatitis
What are the indications at admission
What are the indications at 48hrs
Ranson’s criteria
Glucose >200 Age >55y/o Leukocyte >16K LDH >350 AST >250
Arterial PAO2 <60 BiCarb <20 Ca <8 BUN inc x 1.8 Hct dec x 10% Sequestered >6L
What is the triad of chronic pancreatitis
What extra finding may be seen on imaging
? lab result is sens and spec for Dx
Pancreatic calcification
Steatorrhea
DM
Pseudocyst- Pt will have palpable mass and jaundice
Lipase > 3x normal
How is Pancreatitis Dx
What would be seen on x-ray
How is Chronic Pancreatitis Dx
Abdominal CT w/ contrast
Sentinal loops
CT
MRI w/ MRCP
How is pancreatitis Tx
What is the best part of Tx
When are hemorrhoids more prevalent
NPO
IV analgesia, fluid bowel rest
Fluids
Pregnancy
Post-child birth
How are hemorrhoids Tx
What are the 3 types
Stool softener
CCS sitz bath
Internal- rubber band ligation
External: distal to dentate
Internal: prox to dentate
Mixed; prox and distal
What are the 4 degrees of hemorrhoids
Pts w/ anal fistulas need ? other Dx considered
What is an uncommon PE finding in anorectal abscesses
1: no prolapse
2: prolapse, spot reduction
3: prolapse, need manual reduction
4: irreducible, risk for strangulation
Crohns
Fevers- more likely in deep abscesses
Define Anorectal Fistula
When/why is imaging needed for abscesses
How is anal fistula Dx
Tract between two areas d/t deep anorectal abscess
CT if recurrent
Anoscopy
How are anorectal abscess/fistulas Tx
Vit B3 deficiency is AKA ?
What would be seen on PE
InD
Softener w/ inc fiber
Fistula- surgery
Niacin- Pellagra; 4 D’s: dermatitis diarrhea dementia death
Bright red tongue
What populations are at risk for Vit B3/niacin deficiency
What Rx can cause Niacin/Vit B3 deficiency
What is VitB1 deficiency
ETOH
Mal-absorption syndrome
INH therapy
BerBeri- burning feet syndrome
What is the MCC of VitB1 deficiency
What issue can present in these populations
What is VitB2 deficiency and what does it present w/
Alcoholics
Wernickes encephalopathy- abnormal eye movement, abnormal stance/gait, AMS
Riboflavin- cheilosis, angular stomatitis, magenta tongue
What is VitB6 deficiency
What does this deficiency present w/
How is this Tx
Pyidoxine-
Seb Derm-like eruption
Atrophic glossitis w/ ulcers
Conjunctivitis
Neuorpathy
INH OD Tx
What is the first sign of Vit A deficiency
Who does this present in
How does Vit C deficiency present
Night blindness
CF
Mal-absorption
Spruce/pancreatic d/o
Scuvy- easily bleeds/bruises, hair/tooth loss, joint pain/swelling
Prolonged Vit D deficiency leads to
What other chronic Dz can lead to this deficiency
Where is Vit K synthesized and what does it control
Rickets
End stage renal dz- can’t activate Vit D to absorb Ca in intestine
Liver; any Dz impacting liver- dec K
PT and PTT
What population is at inc risk for Vit K deficiency
Define Phenylketonuria
This is the MC ? and w/out Tx ? develops
Exclusively breast fed infants
Genetic d/o preventing normal use of protein
Inborn error or protein metabolism;
Brain development
First vaccine given to infant
Second shot given is ?
What is the 3rd test
Hep B
Vit K
PKU
Define Kwashiorkor Deficiency
Define Marasmus
Folate deficiency can cause ?
Inadequate intake of protein leading to edema
Inadequate intake of ALL energy forms
Neural tube defect
Vit B12 deficiency can lead to ?
? is the MC type of kidney stone and what prevention can dec incidence
If the stone is infected, most likely a ? stone infected by ?
Cobalamin- degeneration of spinal cord
Calcium oxylate- grapefruit juice
Struvite- Proteus Klebsiella Pseudomonas Staph
Kidney stones larger than ? will probably need surgical help
What is the MC location for these to get lodged
Best method to Dx is ?
> 5mm- need lithotripsy
UVJ
Abdominal/pelvic CT w/out contrast
How are kidney stones Tx
What are the 4 types of kidney stone and what are they associated w/
All of these are radiopaque except for ? type
1st: toradol
2nd morphine
3rd: opiate
4: Tamsulosin/CCB
Ca Oxalate- MC
Struvite- chronic UTI w/ Klebsiella/Proteus
Uric Acid- acidic urine d/t meat/alcohol/gout
Cystine- genetic
Cystine- lucent
When do kidney stones need to be admitted
What Tx method is best for stones >5mm but <2cm
What Tx method is best if the above method fails and is best for stones >2cm
Uncontrolled pain
Anuria
Renal colic and UTI/fever
Lithotripsy
Percutaneous nephrolithotomy
? is the primary intervention of choice for struvite kidney stones
? is the MC and 2nd MC microbe to cause cystitis
How is this Tx w/ 1st, 2nd line meds and during pregnancy
Percutaneous nephrolithotomy
1st- E Coli
2nd- Enterococcus/Saprophytics (sexually active female)
1st: TMP/SMX
2nd: Cipro
Pregnant- Nitrofurantoin/Cephalexin
Pain- Phenazopyridine
Complicated- Cipro
Define Cystitis
How can this present in Peds
? is the MC cause of recurrent cystitis in men
Infection of bladder causing dysuria w/out d/c
New onset incontinence in previously toilet trained Pt
Chronic bacterial prostatits
How is cystitis Dx
What lab results indicated Dx
When/why would imaging be needed
Urine culture- gold standard
Urine dipstick w/ + nitrites, luekocyte esterase
> 100K CFU women
1K CFU men/cath Pts
Pyelo
Recurrent
Anatomic abnormals
When would ASx cystitis in geriatric need Tx
How are postcoidal UTIs Tx
How is Pediatric Cystitis Tx depending on renal involvement
DM
+ structure abnormals
TMPSMX
Cephalexin
Low risk- Keflex
High risk- 3rd gen (Cefix, Cefdinir, Ceftibuten)
When working up female cystitis, squamous cells are seen on UA. What is the next step
Define Pyelonephritis
How does this present
Repeat UA w/ clean catch, squamous epithelial cells indicate vaginal flora
Ascending UTI that reaches renal pelvis
CVA tenderness w/ F/C/N/V
What is the MC microbe that causes Pyelonephritis
What lab result is pathognomonic for dx
How is this Tx outpatient, admitted and pregnant
E Coli
WBC casts
Cipro/Levo/Cephalexin
IV Ceftriax
Preg: IV Ceftriax
Define Nephrotic Syndrome
Pts w/ this syndrome are at increased risk for ?
What is the MCC in adults and Peds
Protieinuria >3.5g/24hrs
Hypoalbuminemia
Hypercholesterol
Normal renal function
DVT- hypercoagulable
Adult: DM
Peds: post-viral infection
How is nephritic syndrome different from nephrotic syndrome
What are the two classifications of nephrotic syndrome
Why is there proteinuria in nephrotic syndrome
What two lab results suggest a Dx of Nephrotic Syndrome
Neph: Hematuria
1-3g/day proteinuria
HTN
Oliguria
Primary: kidney biopsy
Secondary: systemic dz
Podocytes damaged by IgG Abs
Fatty cast w/ maltese cross
Oval fat bodies
What are the MC primary cause of Nephrotic Syndrome
Membranous Nephropathy- MC in non-DM w/ malignancy/infection w/ Hep B
Minimal Change- MCC in kids; assume Dx w/ idiopathic nephrotic syndrome improved w/ CCS
Focal Segmental Glomerulosclerosis: occurs in obese, heroine, AfAm w/ HIV
What are the MC secondary causes of Nephrotic Syndrome
How is Nephrotic Syndrome Dx
How is this Tx
Lupus
DM
Pre-eclampsia
Amyloidosis
24hr urine w/ >3.5g of protein
Statin Angiotensiin inhibition Na restriction Diuretic Steroids/Cyclosporine
MC first Sx of nephrotic syndrome in Peds is seen as ?
What does HyperK look like on EKG
How is it Tx
Facial swelling
Peak T
Prolonged QRS
Muscle fatigue
Bicarb Insulin Gluconate
What does HypoK look like on EKG
How is this Tx
What needs to be avoided
Flat/inverted T wave
U-wave
Replete K and Mg
Avoid Dextrose fluids
What can cause HyperVolemic, HypoNa
What can cause Euvolemic HypoNa
What can cause HypoVolemic NypoNa
CHF
Nephrotic syndrome
RF
Cirrhosis
SIADS
Steroids
Hypothyroid
Na loss
How is ASx HypoNa Tx
How is Moderate HypoNa Tx
How is severe HypoNa Tx
Correcting serum Na should be done how fast in order to prevent ?
Water restriction
IV NS, Loop diuretic
50mL bolus w/ 3% NS
= 10mEq.L over 24hrs;
Osmotic demyelination syndrome
What lab result indicates underlying
How is this Tx
What adverse outcomes can occur from Tx
What lab results indicates HyperNa d/t Diabetes Insipidus
BUN/Cr >20:1 d/t decreased flow to kidneys, more urea remains in blood
D5W
Cerebral edema
Pontine herniation
Urine osmolality <250 w/ HyperNa
MCC of HypoCa
What EKG/PE findings can be seen
How is HypoCa Tx
Hypoparathyroidism
QT prolongation
Traousseaus
Chvosteks
Calcium gluconate
Calcium chloride
MCCC of HyperCa
What ‘saying’ goes with this condition
What does EKG look like
How is this Tx
Hyperparathyroid
Stone Bones Groans Moans
Shortened QT interval
NS w/ Furosemide
What is the 3 step approach to Acid-Base d/os
DDx for metabolic acidosis
How is anion gap calculated
pH: 7.35-7.45
PCO2: 35-45
HCO3: 20-26
MUDPILES: Methanol Uremia DKA Paraldehyde Infection Lactive acidosis Ethylene glycol Salicylates
Na - (Cl+HCO3)= 10-16
DDx for low anion gap <16
Define Orchitis
Since this is usually d/t a virus, bacterial orchitis is MC d/t?
Loss of BiCarb d/t:
Pancreatic/biliary drainage
Renal tubular acidosis
Diarrhea
Unilateral testicular inflammation d/t mumps
Concurrent epididymitis
How is Orchitis Dx
How is this Tx
When/why would ABX be used
UA w/ culture
Pyuria
Bacteruria
NSAIDs
Scrotal support
ABX
Ice/Rest
<35/sexually active post-puberty male:
Ceftriax and Doxy or,
Azith and Doxy (PCN allergy)
> 35w/out STI suspected:
Levofloxacin or TMP/SMX
Where is the epididymis located and what does it do
In Pts <35y/o this is usually d/t ? and Tx w/
In Pts >35y/o this is usually d/t ? and Tx w/?
Posterior testis;
Connect efferent duct w/ vas deferens
Chlamydia/Gonorrhea;
Ceftriax and Doxy
E-Coli/Pseudomonas; Cipro
What PE sign is seen in epididymitis
MCC for ED
How is this Tx and when is this drug class c/i
Prehns: elevation brings relief
Psychogenic
Sildenafil- empty stomach 1hr prior, lasts 8hrs
Tadalafil- 2hrs prios, lasts 36hrs
Verdenafil- take w/ non-fatty food, lasts 8hrs
CAD/CVA
What is the biggest RF for ED
What are 3 common causes of priapisms
How are these Tx
Atherosclerosis
Trazadone
Cocaine
Sickle Cell Dz
Stair climbing
Sudafed
If Pt experiences erection during sleep, cause of ED is most likely d/t?
What causes the Sxs of BPH
This is Tx w/ any drug w/ ? class
Psychogenic
Residual volume d/t increased cell numbers increasing urinary resistance
-sin: a- blockers
Prazosin Terazosin Tamulosin
-ride:
Finasteride- 5a reductase, inhibits T converted to DHT; dec size of prostate
What 3 classes of drugs need to be avoided when Tx BPH
How is BPH Dx
What lab marker for Ca is usually elevated and needs to be checked
Anticholinergics
Sympathomimetics
Opioids
DRE- uniform, large, firm and rubbery prostate
PSA:
<4 normal
>4 w/ BPH- prostatitis/Ca
How is BPH Tx if refractory to meds
? is the MC non-cutaneous Ca among males
When does screening begin for this MC
TURP- transurethral resection of prostate
Prostate
PSA test at 50
+1st* relative/AfAM at 40
What type of Ca is prostate Ca
What is the MC site this Ca will mets to
What RF leads to an increased risk while ? may be protective
Adenocarcinoma
Bone
High fat diet increases risk;
Soy decreases risk
When is a transrectal biopsy for prostate Ca indicated
What presenting c/c indicates prostate Ca has metastesized
What will be felt on PE
PSA >10
Abnormal transrectal US
Back pain
Hard, nodular and asymmetric
PSA >4 next step
PSA >10 next step
How is prostate Ca Tx but w/ ? adverse outcome
US w/ needle biopsy
Bone scan r/o mets
Protatectomy- ED
How is prostate Ca w/ mets Tx
What monitoring is needed
? is the MC type of bladder Ca in the USA
Androgen deprivation therapy- Leuprolide
PSA <0.1
Urothelial carcinoma- AKA transitional cell carcinoma
SCC bladder Ca is associated w/ ? infection
How does bladder Ca present
How is it Dx
How is it Tx
Schistosoma haematobium
Painless hematuria w/ +smoking Hx
Cystoscopy w/ biopsy- gold standard
Chemo, surgery, cystoscopy q3mon
What are the 5 types of incontinence
Urge: detrusor overactivity; MC elderly, nursing home
Dx: urodynamic study
Stress: weak floor after delivery; r/o infection w/ UA
Overflow: impaired detrusor contractility; high postvoid volume/nocturnal wetting, common in DM/neuro d/os
Functional: can’t reach toilet in time d/t physical/mental blockades
Mixed: stress and urge- MC
How is urinary incontinence Dx
UA- r/o UTI (only mandatory study for Peds w/ enuresis)
Postvoid residual:
overflow= high PVR
stress/urge- low/norm PVR
Urodynamic-
stress- normal contraction
urge- inc contraction during filling
US w/ cystoscope- anatomic abnormals
How is Urge incontinence Tx
How is stress Tx
How is Overflow Tx
Bladder training
Anticholinergics (oxybutynin)
TCA (Imipramine)
Kegels
Estrogen
Pessary
Sling, mid-urethral
Intermittent self-cath
Cholinergic- Bethanechol, inc contractions
A-blocker- Tera/Doxazosin- dec sphincter resistance
How is functional incontinence tx
How is Mixed incontinence Tx
? is the most definitive Tx for primary enuresis
Scheduled voidings
Lifestyle mod w/ pelvic floor exercises
Desmopressin
How does prostatitis present
How is this Tx
Hesitency w/ dec flow
Saddle tenderness
<35: C/G
>35: Ecoli, pseudomonas;
Doxy/Ofloxacin/Ceftriax
>35: EColi/Pseudo; Cipro/TMPSMX
How does acute bacterial prostatits present on DRE
? is the MC form of prostatitis
How are acute and chronic cases Tx
Boggy, warm and tender- do not massage (sepsis)
Chronic bacterial w/ enlarged, nontender prostate
Acute:
<35: Ceftriax and Doxy
>35: Flqln/TMP-SMX
Chronic- Flqnln or TMP-SMX
? is the MC type of renal malignancy
? does this originate
This is more common in ? population
Renal Cell Ca
Proximal renal tubular epithelium
AfAm
How does Renal Cell Ca present
What labs would be abnormal
What are the 1st and 2nd MC types
Weight loss
Hematuria
Palpable mass
Normo/Normo anemia (EPO flare)
HTN w/ hyperCa
Clear cell carcinoma
Transitional cell
What is the biggest RF for Renal Cell Ca
How is this Dx
How is it Tx
Smoking
Abdominal CT or US
Surgery w/ nephrectomy
? is the MC type of testicular Ca and the two types
When does this tend to appear
What is seen on PE
Germ cell:
Seminoma
Non-seminomatous
20-34y/o w/ cryptorchidism/orchitis
Painless, swollen and hard testi
What are the 3 most important tumor markers for Dx testicular Ca
? lab result isolates Dx to NSGCT testicular tumor
What lab result is sen in both Seminomas and NSGCT
bHCG
AFP
LDH
AFP
HCG
What does LDH indicate for testicular Ca
How is testicular Ca Tx
? tumor marker is used to monitor for relapse
High burden- seminoma, recurrence of NSGCT
Orchiectomy
Seminomatous- radiation
NSGCT- radioresistant
AFP
How does Acute RF look on lab results
What can cause this
What is the first and second MC cause of Chronic RF
Inc Cr/BUN
Dec GFR
ACEI w/ bilat stenosis Hypovolemia Infection Nephritic syndrome Tubular necrosis
1st: DM
2nd: HTN
What type of UA results is seen in Chronic RF
What are the 3 mechanisms of Acute RF
Broad Waxy Casts
Prerenal: perfusion
Renal: glomerular, tubular, interstistial
Postrenal: obstruction
Prerenal SpecGrav, BUN, Osmolality and FENA
Renal SpecGrav, BUN, Osmolality and FENA
> 1.030
20
500
<1
<10.10
<10
<300
>1
What types of casts are seen on UA during acute tubular necrosis
What other lab result is seen d/t this damage
What 3 lab results make this Dx likely
Muddy borwn
Unable to concentrate urine- high FENa
FENa >2%
Muddy casts
High osmolality
What lab results suggest Interstitial Nephritis
What results are seen in Glomerulonephritis
Why does CKDz develop Vit D deficiency and Hyperphosphate
WBC casts Eosinophils
Oliguria
Hematuria
RBC casts
Vit D cant be made into Calcitriol
Dec excretion
How is CKDz defined
? is the MC cause
What are the 5 stages
eGFR <60ml x 3mon or any 3: Albuminuria >30mg Proteinuria >0.2 Hematuria Structural abnormals
HTN
1: GFR 90mL or > w/ albuminuria or hreditary dz
2: 60-89
3: 30-59
4: 15-29
5: <15
How is CKDz Dx
? is the marker for kidney damage
What meds are used to slow Dx progression
Cockcroft Gault formula for GFR
Proteinuria
ACEI/ARB w/ pneumococcal vaccine
How does RA present
What joints does it primarily affect
What syndromes can these Pts develop
Warm, swollen and symmetrically stiff joints x 1hr every morning
MCP
PIP
Wrist
Felty- RA, Splenomegaly, and Neutropenia
Caplan- pneumoconiosis and RA
What type of effusion is seen in RA PTs
? rheum lab results will be positive in most PTs and which one is more specific
What type of anemia could be seen
Exudative
RF, C1M;
Anti-CCP more spec for RA
Normo/Normo
? monotherapy is the best initial Tx medication for early RA w/ poor prognosis
? is used 2nd line for Tx
What is the s/e of using this 2nd line Tx
Methotrexate
Hydroxychloroquine
Eye toxicity
What drugs are used 1st through 4th line for Tx of RA
What is the pathophysiologic reason for RA Dz
What two PE findings suggest OA Dx
Methotrexate
Hydroxychloroquine
Sulfasalzine (HMS- triple therapy)
Infliximab
Synovial inflammation
PIP Bouchard
DIP Heberden
What is the first medication elderly PTs w/ OA are Tx w/
What three x-ray findings aid w/ Dx
OA in the knee commonly causs ?
Tylenol
Narrowing
Oseophyte
Sclerosis
Baker’s cyst
How does SLE present
? syndrome do these Pts have that put them at risk for DVTs
How is this Tx
? monoclonal Ab can be used to inhibit B-cell factors
Fatigue
Hand/wrist joint pain
Malar rash
What are 4 medications that can cause lupus
Define Discoid Lupus
What two tests are 100% specific for SLE Dx
Procainamide
Isoniazid
Quinidine
Hydralazine
Annular, erythematous patches on face/scalp that heal w/ scars
Antidouble strand DNA (dsDNA) and,
Anti-Smit Ab (anti-SM)
Why do women w/ SLE have increased risk for miscarriages
What lab results will be decreased during flares
What two lab positives put neonates at higher risk for neonate lupus
B2 glycoprotein 1 Ab
Complement- C3, C4, CH50
Anti-Ro, Anti-La
? lab result positive is highly sensitive for drug induced lupus
How is SLE Dx confirmed
Antihistone Ab
4 or more RASHNIA4 Renal d/o Arthralgia Serositis Heme d/o Neuro d/o Imm derangement ANA 4 rashes: malar, discoid, photosensitive mucosal
How is SLE Tx
? is the MC constitutional Sx associated w/ SLE
? is the most specific Ab for SLE and ? has the most sensitivity for screening
Sun protection
Hydroxychloroquine*
NSAIDs/Tyelenol
Fatigue
Anti-Smith;
ANA
How is Systemic Sclerosis characterized on PE
What syndrome do these PTs develop
? is the MC GI Sx
Thickened skin from accumulation of collagen
CREST- Calcinosis Raynauds Esophageal dysfunt Sclerdactyly Telangiectasis
GERD
How is Scleroderma Dx
How is it Tx during renal crisis or Raynauds crisis
Anti-centromere A- limited crest but better prognosis
Antiscl70- diffuse/multiple organs involved
Anti-tropoisomerase Ab
ACEI- Captopril
CCB/Prostacyclin
How is Scleroderma induced P-HTN Tx
? three GI infection can stimulate Retiers
How is Ankylosing Tx
Ambrisentan and Tadalafil
Shigella
Salmonella
Campylobacter
PT w/: Indomethacin Methotrexate/Sulfasalazine Pred- flares Etanercept/Infliximab
Define Ankylosing
How does this present
What 4 systemic issues can this present w/
Seronegative spondyloarthropathy affecting SI joint and spine
Morning back pain that dec w/ activity
Psoriasis
IBDz
Anterior uveitis
Aortic regurg
? is the gold standard to Dx Ankylosing
How is Reiters Tx
What would be seen on a synovial aspiration result
X-ray
Indometh/Diclofenac
Doxy for Chlamydia
Sulfasal/Methotrex
Etanercept/Infliximab
Aseptic w/ negative bacterial culture
? is the MC form of inflammatory arthritis
This MC is a d/o of ?
? is the underlying physiologic issue
Gout
Purine metabolism
Hyperuricemia
? medication can induce gout
How is this Dx
How is this Tx
How does Tx change if cause is pseudogout
Thiazides
Needle shaped monosodium urate crystals w/ negative biregringence (pos fringence/rhomboid- pseudo)
1st: Indomethicin/Naproxen/Ibuprofen
2nd: Colchicine
Steroids
? is usually the first sign of gout attack
What x-ray findings signal pseudogout
When is gout prophylaxis indicated
Podagra- MTP of great toe
Chondrocalcinosis- linear radiodensities
2 or more flares/year:
Allopurinol- dec uric acid production
Probenecid- inc urine excretion
How is Firbomyalgia Tx
? is the preferred method of exercise PT
? is the Sjogrens Dx test and ? lab result is Dx
TCA
Pregabalin- only FDA approved Tx
Swimming
Schirmers tear test: <5mm of lacrimation in 5min
Anti-RO and antiLA (Anti-SSA, Anti-SSB)
? part of the body does Sjogrens affect
How is this Tx
Define Giant Cell Arteritis
Exocrine glands- salivary/lacrimal w/ parotid enlargement
Tears
Pilocarpine- cholinergic
Cevimeline- muscarinic stimulation
Autoimmune viral infection causes monocyte activation/cytokine production leading to tissue destruction
The vasculitis of GCA affects ? structures
This is MC in ? population w/ ? Dx
How is this Dx
Extracranial branch of carotid: Posterior ciliary Occipital Ophthalmic Temporal
Female >50 w/ Polyalgia Rheumatica
ESR >100
Biopsy
Define Polymyalgic Rheumatica
? other Dx is closely related w/ this population
How is this Tx
Idiopathic inflammation of synovitis, bursitis, tenosynovitis causing proximal joint stiffness
GCA
Methotrexate, CCS
Define Polyarteritis Nodosa
One quarter of Pts will have ? underlying Dx
How is this Dx
Systemic vasculitis of arteries in men 40-50y/o
Hep B/C
Biopsy- necrotizing arteritis
? lab result is seen in Polyarteritis Nodosa
How is this Tx and ? is done if refractory
How is this Tx if underlying Hep B is present
ANCA negative
Steroids; Cyclophosphamide
Plasmapheresis
Cephalosporin Generation endings
1st: Fa/Pha
2nd: everything else
3rd: one/ten/me
4th: Pi
5th: Rol
Define Hyperthyroidism
What is the preferred method for Tx hyperthyroidism during pregnancy
How can Pts present
PTU
Excess production of thyroxine hormone
Weight loss
Anxiety
Tachycardia/PVCs
? is the MCCC of hyperthyroidism
What lab result will be seen and what will be seen if condition is causes by the MCC
How is it Tx
Graves dz- antithyrotropin Ab (TSHR-Ab) against TSH receptor
Low TSH, inc F-T4/T3
Graves Dz: low TSH, inc T3
Methimazole
Propylthiouracil
Thyroid storm occur in ? two populations
How does this lead to death
How is Graves Abs tested for
Graves Dz
Toxic Multinodular goiter
Cardiogenic shock
CV collapse
TSI, TBII
How are the cardiac Sxs of Graves Dz Tx
Define Hypothyroidism
What is the MCC and what would be seen on lab results
Atenolol
Thyroid gland doesn’t produce enough thyroid hormone
Hashimotos-
Inc TSH, low FT4
What does Primary Hypothyroidism look like on lab results
What does Secondary Hypothyroidism look like
? lab result is not sensitive for the Dx of hypothyroidism
Inc TSH, low FT4
Low TSH, low FT4
T3
How is a Dx of Hashimoto’s confirmed
Anemia is often present, ? type
? other CMP lab result will be high in primary hypothyroidism
Anti-TPO Abs
Normo/Normo
Cholesterol
How is Hypothyroidism Tx
? is a severe form of hypothyroidism seen nondiagnosed/under Tx cases
? presentation should suggest a Dx of Hashimotos Thyroiditis
L-Thyroxine/Synthroid
Myxedema Coma
Goiter w/ tenderness
+MedHx recent viral illness
What lab result would be elevated during Hashimotos Thyroiditis
? type of thyroid activity is seen in postpartum thyroiditis
Define Quevains Thyroiditis
Anti-TPO Abs
Hyper x 5-7mon
MCC of thyroid pain after infection; starts hyper, progresses to hypo
What are two drugs that can cause drug induced thyroiditis
? causes Bacterial Thyroiditis
? lab result should indicate Pt w/ heat, pain, swelling has a bacterial form
Lithium
Amiodarone
Staph, Strep
Inc WBC
4 etiologies of a painful thyroiditis
3 etiologies of a nonpainful thyroiditis
DeQuervains/Granulomatous
Infectious
Radiation
Trauma
Postpartum
Drug induced
Hashimotos
How is Hashimotos’ Thyroiditis Tx
How is Subacute/Postpartum Thyroiditis Tx
How is Drug induced Thyroiditis Tx
How is Bacterial Thyroiditis Tx
Chronic hypo- T4 substitution
BBs and ASA
D/c offender
Surgical drainage of abscess and specific ABX
? is the MC RF for thyroid carcinoma
? is the MC form
? is the MC beign nodule
Radiation exposure
Papillary
Adenoma
? PE findings suggest thyroid Ca
What Lab/US results also suggest a Dx
How is thyroid Ca Dx
Firm/hard
Fixed w/ swallowing
Swollen lymph nodes
Microcalcification
Irregular margin
Size >1cm
Solid
US w/ biopsy if >1cm
How is a thyroid nodule determined to be benign or malignant
What is the next step if uptake shows Ca
How is this Tx
Cold- no iodine uptake, Ca
Hot, takes up iodine, non-Ca
Fine needle aspiration
Removal of thyroid
Anaplastic Ca- Tx w/ chemo/rad
Define Hyperparathyroidism
When do PTs become symptomatic
What causes primary and secondary hyperparathyroidism
Aver active, secretes PTH, leads to hypercalcemia
Ca >12
Primary: parathyroid adenoma
Secondary: CKDz
What is the saying for hyperparathyroidism
How is this condition Tx
Define Hypoparathyroidism
Bones Stones Groans Psychic moans
Ectomy
Furosemide/Calcitonin
Bisphosphonates
Dec PTH causing low Ca levels
What do Pts w/ hypoparathyroidism present w/
What triad is used for Dx
What is seen on EKG
Chvosteks’s sign
Trousseaus sign
Dec Ca
Inc DTRs
Dec PTH
Inc Phosphate
Prolonged QTc
How is hypoparathyroidism Tx short term
How is this Tx if tetany is present
How is this Tx long term
Vit D, Ca
IV Ca gluconate
Recombinant human PTH
Define Paget’s Dz
What form of bone Ca is most associated w/ this condition
? parts of the body are most affected
Bone remodeling d/o causing weaker bone
Osterosearcoma
Femur
Lumber
Pelvis*
Skull*
How can Pts w/ Paget’s Dz present
How is this Dx
How is it Tx
Arthritis
Bone pain
Excessive warmth
Deafness
Inc Alk Phos
Lytic lesions/thickened cortices on x-ray
Bisphosphonates
Calcitonin
Total cholesterol is desired to be below ?
LDL is desired to be below ?
HLD is desired to be below? ?
<200
<100
<40: low
>60: high
What are the LDL goals if <1RF, 2RFs, DM/CADz, 10yr risk of >20%
<160- normal population, 1RF
<130 for 2RFs
<100- DM, CADz
<70- 10yrs risk of 20%, recent MI, CAD w/ DM/current smoking
How is hypercholesterol Tx
What is a s/e of Tx, especially over ? dose
When are lipid screening began depending on organization recommending
1st: lifestyle
2nd: statin
Rhabdo, >80mg- check serum creatine kinase
USAPSTF: 35y/o
NCEP: 20y/o
How is hypertriglycerides Tx
What bile sequestrant is used for DM w/ hypertriglyceride
1st: Fibrates (gemfibrozil)
2nd: Niacin, Omega-3, Bile sequestrant (Resin)
Colesevelam hydrochloride
Pts w/ LDL of 190/> are Tx w/ ?
How is DM between 40-75y/o Tx
High intensity statin:
Atorva: 40-80
Rosuva: 20mg
ASCVD 7.5/>: high intensity ASCVD <7.5: moderate intensity Atorva- 10mg Rosuva- 10mg Simva- 20-40mg Prava- 40-80mg Lova- 40mg Flu XL- 80mg Flu- 40mg BID Pita- 2-4mg
How are non-DM w/ LDL >190 Tx
What are the two types of hypertriglycerides
ASCVD 7.5/>: moderate intensity
ASCVD <7.5: lifestyle
Combines- 2b; total, LDL and Tgd all elevated
Familial hyper- 4; normal LDL, elevated Tgd
Hypertriglycerides >500 put PTs at risk for ?
Levels over 2000 put Pts at risk for ?
? type of hypertriglyceride causes palmar xanthomas
Pancreatitis
Xanthomas
Lipemia retinalis
Chlomicronemia- N/V/pain/pancreatitis
Type 3
How often are fasting lipid panels needed
What is the next step if triglycerides are found to be >150mg
What is the next step if levels are found to be >1000
Start at 20y/o,
No comorbiditeis- repeat q5yrs
+ comorbidities- repeat q12mon
Fast x 12-16hr and recheck
Beta-quantification and electrophoresis
? 3 meds are used to lower triglyceride levels
What causes Type 1 DM to emerge
Statins
Fibrates
Niacin
Fish oil
B-cells fail to respond and are destroyed
Define Dawn Phenomenon
Define Somogyi effect
Dec insulin sensitivity and surge of regulator hormones during fasting; Tx inc night time insulin
Nocturnal hypoglycemia w/ rebound hyperglycemia d/t GH surge; Tx w/ dec nighttime insulin
How is DM Dx
How is this Tx
? vaccines do these Pts need
Random >200 w/ Sxs
Fasting 126 or >
A1c 6.5% or >
A1c goal <7
Basal (Glargine)
Rapid (Humalog)
Flu
Tdap
PCV12
Pneumococcal
Bolus-rapid insulin
Bolus short acting insulin
Basal-immediate
Basal-long acting
Post-prandial control:
Lispro Aspart Glulisine
Fasting control:
Regular: Humulin-R, Novolin-R
NPH: Humulin-N, Novolin-N
Glargine Detemir
MOA and S/e of Metformin
Dec liver glucose production, peripheral glucose utilization, and intestinal absorption
Lactic acidosis
MOA and s/e of Sulfonylureas
Stimulate pancreatic B-cells to release insulin
Hypoglycemia
Weight gain
MOA and s/e of thiazolidinediones
Inc insulin sensitivity at peripheral receptor sites
Fluid retention/edema
MOA and s/e of a-glucosidase inhibitor
Delays glucose absorption in intestine
Inc LFT/hepatitis
MOA and s/e of Meglitinides
Stimulate b-cell insulin release
Hypglycemia
MOA and s/e of GLP-1 agonists
Mimicks incretin to cause insulin secretion, decreases glucagon and delays gastric emptying
Hypoglycemia
Gastroparesis
MOA and s/e of DDP-4 inhibitors
Inhibits degradation of GLP-1
Pancreatitis
RF
MOA and s/e of SGLT2 inhibitors
Dec renal glucose threshold to increase urinary eexcretion
UTIs
Normal fasting glucose is ?
Criteria for DM Dx
Criteria for Pre-DM Dx
70-100
A1c 6.5/>
Fasting 126/>
2hr 200/>
Random 200/> w/ Sxs
A1c 5.7-6.4
Fasting 100-125
2hr w/ 75g- 140-199
How often is A1c checked for controlled and uncontrolled DM
MCC of gynecomastia in infant/boys
MCC of gynecomastia in men
Control: q6mon
Uncontrol: q2mon
Physiologic gynecomastia
Drugs (spironolactone)
Idiopathic
Persistent pubertal
gynecomastia
How is Osteoporosis Dx
What scores mean porotic/penic
How are these Tx and w/ ? Pt education
DEXA on all females 65/>
Porotic:
T-score -2.5 or <
Penia:
T-score -1 - 2.4
PO Bisphosphonates (Alendronate, Risedronate) Take w/ water, remain upright x 30min to avoid jaw necrosis
How often are f/u DEXA scans needed depending on T-scores
How is this Tx if PT can’t tolerate PO Bisphosphonates
What medication is sued for Tx in PTx w/ very high risk of Fx (-3.5/>)
-1 - -1.5: q5yrs
-1.5 - -2: q3-5yrs
>-2; q1-2yrs
IV Zoledronic Acid
Teriparatide- recombinant PTH
How to remember Addisons Dz
What E+ findings are seen on lab results
ADrenal Down
ADD hormone for Tx
HyperK
HypoNa
Primary adrenocortical insufficiency is AKA and d/t?
What lab results will be seen
Define secondary adrenocortical insufficiency and lab results seen
Addisons Dz- adrenal destruction causing dec cortisol/aldosterone
Inc ACTH
Dec cortisol
Dec aldosterone
Pituitary failure;
Dec ACTH
Dec cortisol
Normal aldosterone
? are the two etiologies of secondary adrenocortical insufficiency
How is this Dx
Exogenous steroids- MCC
Hypopituitarism
8AM ACTH w/ ACTH stimulation test
Inc ATCH and low cortisol= primary Dx
Low ACTH, low cortisol= secondary Dx
? two stimulation tests are used toDx adrenal insufficiency
ACTH Cosyntropin:
IM ACTH given
Normal: cortisol levels rise
Insufficiency: little/no increase
CRH stimulation- differs the cuase of the insufficiency
Primary- high ACTH, low cortisol
Secondary- low ACTH, low cortisol
How is Addison’s Tx
How is Secondary Insufficiency Tx
What lab results suggest Cushings Syndrome
Cortisol replacement
Hydrocortisone
Fludrocortison
Inc cortisol
Inc BP
Dec K+
Cushings Dz is MCC by ?
? body types is seen here
How is Cushings Syndrome Dx
Pituitary adenoma
Buffalo hump
Moon facies
Pigmented striae
Low dose Dexamethasone suppression and,
24hr urine cortisol (gold standard)
How is the cause of Cushing Syndrome differentiated
High dose dexamethasonze suppression test-
Suppressed cortisol- pituitary ACTH secreting tumor
ACTH level:
dec ACTH= adrenal tumor
Norm/Inc ACTH: ectopic ACTH tumor
How is Cushings Dz Tx
What med is used for Pts ineligible for the primary Tx
Adrenal neoplastic Dz is AKA ?
Transsphenoidal surgery
Ketoconazole
Pheochromocytoma
Define Pheochromocytoma
This Dx is associated in ? other d/os
What are the 5Ps of episodic Sxs
Catecholamine (Epi, NorEpi) secreting adrenal tumor
NF-1
MEN2A/2B
Von Hippel Lindau Dz
Pressure, Inc BP Pain, HA Persipiration Palpation, tachy Pallor
How is a Pheo Dx
How is this Tx
What must be doe prior to Tx
24hr catecholamine w/ metabolites (metanephrine and vanilymandelic acid)
Complete adrenalectomy
Non-sel A-block: phenoxybenzamine/phentolamine
Then, BBs
Gigantism and Acromegaly are both caused by ?
What are these rarely caused by
What is the difference between Gigantism and Acromegaly
Pituitary adenomas secreting excess GH
Non-pituitary tumor secreting GHRH
G: GH hypersecretion begins in childhood, before epiphyses closure
A: hypersecretion in adulthood
How is Acromegaly/Gigantism Dx
What lab result is used to track therapy response
How are both cases Tx
IGF-, 2-10x normal
IGF-1
Surgery/radiation
Non-surgical= Octreotide/Lanreotide to suppress HG
Define Diabetes Insipidus
What are the two types
Deficient/resistant ADH resulting in massive polyuria
Central- no ADH production
Nephrogenic- partial, complete insensitivity to ADH
How is Diabetes Insipidus Dx
How is the etiology of the Dx determined
Water Deprivation test- pos- diluted urine production despite water restriction
Desmopressin stimulation test:
Central= dec urine output
Nephrogenic= continued production of diluted urine
How is Diabetes Insipidus Tx depending on the etiology
Define Glomerulonephritis
What is the MCC
Central: Desmopressin
Nephro: Na/Protein restriction w/ Hydrochlorothiazide or indomethacine
Sudden onset of hematuria, proteinuria and RBC casts d/ glomeruli inflammation
Post-infection GABHS/Strep species
World: Beurgers Dz
How is Post-Infectious Glomerulonephritis Dx
? is the MCC of this worldwide
How does the worldwide MC present
ASO titer and,
Low C3/C4
IgA Nephropathy- Bergers Dz
Hematuria
URI
Flank pain
How is IgA Nephropathy/Berer’s Dx
Define Alports Syndrome
How is this Dx
IgA deposits in mesangium on staining
Isolated, persistent hematuria in kids w/ RF, HL and anterior lenticonus on Opto exam
C3/C4 levels
What causes Membranoproliferative Glomerulonephritis
How is this Dx
What lab result suggests a Dx of Rapidly Progressive Glomerulonephritis
SLE/Viral hepatitis induced damage to glomerulus
Low C3,C4 levels
Crescent formation on biopsy d/t fibrin/plasma protein deposition
How is Goodpastures Syndrome Dx
How is it Tx
What is seen on vasculitis induced glomerulonephritis
+anti-GM Abs
Linear IgG deposits
Steroids
Plasmapheresis w/ cyclophosphamide
ANCA Abs
How is glomerulonephritis Dx
What lab is needed if Pt has recent strep infection
What is the gold standard for Dx
Hematuria (>3RBCs/field)
RBC casts
Proteinuria
Antistreptolysin-o titer
Renal biopsy
What lab result is often decreased in glomerulonephritis
How is this Tx
What are the cysts in Polycystic KDz made of
C3
ACE/ARB is protective
Post-strep- use Nifedipine
Steroids/Na/Fluid restriction
Epithelial cells from renal tubules
? is one of the MC human genetic d/os
What ER c/c can these Pts have
What Cardiac issues can they have
Autosomal dominant PCKDz
Brain aneurysm induced worst HA ever
MVP, LVH
How is PCKDz Dx
Genetic studies for ? can be done prior to Sx onset
How is this condition Tx
US
PDK1/PKD2
ACEI/ARB
Transplant
? is the MC form of anemia
What type of anemia is seen
What are the two MCCs
Fe deficient
Micro/Hypo
Dyfunctional uterine bleeding GI bleed (men)
How is Fe Deficient Anemia Tx
What is the first, second and last sing of this condition developing
What lab result suggest lead poisoning and how is it Tx
Ferrous sulfate
1st: low ferritin
2nd: rising TIBC
3rd: micro/hypo
Pt w/ neuro Sxs-
Basophilic stippling, Sideroblastic anemia
Thalassemia;
Tx EDTA
What is seen on a peripheral smear of Fe Defficient anemia
How long does Tx take
How often do these Pts need f/u
Poikilocytes- pencil/cigar shaped
6wks corrects anemia
6mon replaces Fe stores
q3mon x 12mon
When Tx Fe Deficient anemia, taking meds w/ ? can increase absorption
? lab result suggests Tx is working
? are the MCC of Anemia of Chornic Dz
Vit C
Inc reticulocyte counts
Chronic RF
CT d/o
How is Anemia d/t Renal Failure Dx
How is this Tx
What does B12 Deficiency anemia look like
+RF and dec EPO levels
Recombinant EPO- Procrit, Epogen when Hgb <10
Fe supplements
Hypersegmented neutrophils
Neuropathy- loss of vibratory/proprioception
Inc Methylmalonic acid
B12 Anemia leading to pernicious anemia is d/t ?
How is B12 Anemia Dx
What other lab results are elevated
Dec intrinsic factor
Macrocytosis and,
Hypersegmented neutrophils
MMA
Homocysteine
What is seen in Folate Deficient Anemia
Of the two macro anemias (B12/Folate) hos does Folate appear differently
What is the risk if mother has tthis during pregnancy
Dec folate
Inc MCV- macro
Folate- no Neuro Sxs
Inc risk neural tube defects
How is Folate Deficient Anemia Dx
How is this Tx
What causes hemolytic anemia
Magaloblastic
Folate <3
Normal MMA
400-1000ug/day of Folate
Premature RBC breakdown
What are the two etiologies of the premature RBC breakdown of Hemolytic Anemia
Intracorpuscular:
RBC membrane defects (spherocytosis)
Extracorpuscular:
Autoimmune (+Coombs, Tx Pred)
G6PD
Chemo s/e
How does Hemolytic Anemia present
What test will be positive if cause is autoimmune
What four results indicated the other causes
Splenomegaly
Inc indirect bili
Inc LDH
Direct Coombs (Abs to RBCs, Indirect- Abs in serum)
Spherocytosis- fragility test
G6PD- Heinz body
Sickle- inc retic count w/ pain
Thalassemia: very low MCV w/ normal TIBC/Ferritin
? lab result pentad is the hallmark of hemolytic anemia
How are these Tx
Define Aplastic Anemia
Corrected Retic >2
Falling Hgb
Inc indirect bili
Inc LDH
Autoimmune: steroids
Spherocytosis: splenectomy
Normo/Normo from loss of blood cell precursors causing anemia w/out reticulocytes
Unique fact about Aplastic Anemia
When is this Dx suspected
What is the most accurate test
Only one where all 3 lines are dec: WBC RBC Platelet
WBC <1500
Platelet <50K
Marrow biopsy- hypocellular marrow w/ fatty infiltrates
How is Aplastic Anemia Tx
How is Tx changed in PTs ?50y/o
What med is used to decrease risk of infections
RBC transfusion w/ leuko-reduced, platelet transfusion
Anti-thymocyte globulin + cyclosporine/Pred
Figrastim- G-CSF
How is Sickle Cell inherited
? lab result is used to track crisis progress
What does the punnet square look like
Homozygous of HgbS
Retic count
HbSS- Dz
HbSA- trait
Two parents w/ trait= 1/4 chance of kid w/ HbSS
How is Sickle Cell Dx
? bodies are seen in lab results
? med is used to decrease frequency of crisis
HgbSS on electrophoresis
Howell Jolly- nuclear remains not phagocytosed
Hydroxyurea
Define Thalassemia
Thalassemia and Fe Deficient are both micro/hypo, how is Thalassemia different
What other lab finding helps w/ Dx
Autosomal recessive blood d/o w/ abnormal Hgb formation
Higher RBC count
More micro/hypo than Fe deficient
Nucleated erythroblasts
Stopped on B-Thalassemia
b
