Inpatient Medicine Flashcards
HIT- 4T’s
thrombocytopenia
timing:
thrombosis (skin)
no other cause
Charcot’s Triad
RUQ pain, jaundice, fever
acute cholangitis
Reynold’s Pentad
ruq, jaundice, fever
hypotension + confusion
50% mortality
DIC physiology=
abnormal activation of coagulation sequence
microthrombi throughout microcirculation
bleeding+thrombosis occuring
DIC consumption of
platelets
fibrin
coag factors
DIC labs
increased BT, PT, PTT decreased platelets increased fibrin, D-dimer decreased fibrinogen \+schistocytes
HIT type 1
onset 1-4 days
nadir 100,000
not Ab mediated and w/o thromboembolic
observe
HIT type II
Onset 5-10 days
nadir 20,000
antibody mediated, thromboembolic events and hemmorhagic
Acute Pulmonary Edema- BP Control
nitroglycerin or nitroprusside for afterload and preload reduction
Paget Disease
- elevated alk phos
- bone pain
- treat with bisphosphonates
Maturity Onset Diabetes of the Young (MODY)
AD
age 10-45
Lean body type, family history
normal C peptide, do NOT require treatment with insulin
Octreotide- mechanism of action in esophageal varices/HTN
vacoconstricting dilated splanchic blood vessels
TIPS
shunting blood from portal to hepatic vein
Lactulose - Mechanism of Action
actulose is metabolized by bowel flora and make the lumen more acidic, traps NH4+ in colon and decreases ammomnia in the blood
also may decrease ammont of urease producing bacteria
Hep B: Vaccinated
anti-HBs NOT anti-HBc
Hep B: Exposure and Immune
anti-HBs
anti-HBc
Hepatitis B Surface Antigen / HBsAg
infection: recurrent or chronic
Hepatitis B Surface Antibody / HBsAb
immunity: vaccination or infection
Hepatitis B Core Antibody / antiHBc
IgM- Acute Infection
IgG- Chronic Infection
Hepatitis B e-antigen / HBeAg
infectivity
Hepatitis B e-antibody/ HBeAb or antiHBe
low infectivity, window period between HBsAg and anti-HBs
Primary TB
walled off in granulomas
Secondary TB
reactivated
AKI- Official Definition
1.5xCr
GFR decreased by 25%
UOP less than 0.5 ml/kg/hr x 6 hr
Location of RTAs
type 1 - distal
type 2 - proximal
type 4 - distal
Causes of RTAs
type 1 - decreased secretion of H+
type 2 - decreased reabsorption of Bicarb
type 4 - aldosterone def/resistance
BiPAP- how to exhale CO2
increase IPAP
increase rate
Lasix/Spirolactone Ratio
2:5
20 Lasix, 50 spirolactone
IDA Labs Summary
Elevated TIBC, transferrin
Decreased transferrin saturation
Decreased ferritin
Primary Hyperparathyroidism Differential
- Malignancy
- Familial Hypocalciuria Hypercalcemia
- Drugs (lithium, thiazides)
Primary Hyperparathyroidism
- Elevated Ca
- Elevated or Normal (inappropriate) PTH
- Decreased Phos
- Increased Vitamin D
Loop diuretic mechanism
thick ascending limb of Henle
Bind Na/2Cl/K receptor, block NaCl reasborption
Direct Thrombin Inhibitors
argatroban
bivalirudin
Factor Xa inhibitor
fondaparinux
Chronic pancreatitis- classic triad
pancreatic calcifications
steatorrhea
DM
Revised Cardiac Risk Index
H/o ischemic heart disease, CHF, CVA
Pre-op factors: Cr>2, insulin use,
ADH - mechanism/function
increase water reabsorption by kidney’s collecting ducts
SIADH diagnosis
hyponatremia
inappropriate concentrated urine >100
plasma osm < 270
SIADH treatment
H20 restriction
NS or salt tabs+loop
Lithium or Demeclocyline
ST changes
has to be in 2 continguous leads
greater than 1mm for limb leads
greater than 2mm for chest leads
SIRS
Hr 90
RR 20
T 101, 96
WBC 12, 4
Light’s Criteria
exudative if one of the following
ratio of pleural to serum protein 0.5
ratio of pleural LDH to serum LDH 0.6
PLeural LDH 0.6 or 2/3 ULN
amaurosis fugax
ischemic event involving retinal artery
often carotid bruit on neck
Heberden’s Nodules
DIP
Bouchard’s Nodules
PIP
Uncomplicated UTI Adults Outpatient Medications
Bactrim, Macrobid, Fosfomycin
Iron Absorbed In
duodenum
When to Start ESA in CKD
when hemoglobin is less than 10
target 10-11.5
Warm Autoimmune Hemolytic Anemia
IgG
SLE, CLL (lymphoproliferative disorder)
Cold Autoimmune Hemolytic Anemia
IgM
EBV, Mycoplasma
Target Cells
Thalassemia
anti-NMDA receptor encephalitis
classically a young woman with teratoma + psychosis
Chvostek Sign
tapping facial nerve elicits contraction of facial muscles in HYPOcalcemia
Bronchiectasis Physiology =
permanent abnormal DILATION and DESTRUCTION of bronchial walls
ACS IV Septum Rupture
w/in 10 d
new onset systolic murmur
Centrilobular Emphysema
- smoking
- upper lung zones
Panlobular Emphysema
- alpha-1 antitrypsin
- lung bases
Hoarseness in Adults, remember
recurrent laryngeal nerve palsy 2/2 mass
Categories for Thrombocytopenia Differential
- Decreased Production
- Increased Destruction
- Increased Consumption
- Sequestration
Thrombocytopenia- Decreased Production
bone marrow dysfunction - myelofibrosis, aplastic anemias, granulomatosis disease etc
Nutrient Deficiencies- b12 or folate
Thrombocytopenia- Increased Destruction
Splenomegaly/Sequestration
ITP, HIT
MAHA- HUS, TTP
Thrombocytopenia- Increased Consumption
DIC
Bleeding
Herpes Zoster- what should you test for
HIV!! (looking for reason for being immunocompromised)
Postherpatic Neuralgia
Pain >1 month after infection
Ramsey Hunt Syndrome
vesicular rash in external ear
associated with ipsilateral peripheral facial palsy and altered taste
Zoster treatment
if w/in 72 hours of presentation
How to Recheck a platelet count
drawn in citrate or heparin (not EDTA)
TTP testing
ADAMTS13 level less than 10%
Treatment of acute ITP
symptomatic or platelets less than 30,000
HIT diagnosis
screening test: platelet factor 4 (sensitive but not specific)
confirmatory test: serotonin release assay or heparin-induced platelet aggregation assay
Polyarthritis
more than 5 joints
Oligoarthritis
2-4 joints involved
Viral causes of acute polyarthritis
parvovirus
rubella
HIV, Hepatitis B
enthesis
structure on the site of ligament or tendon inserting into bone
suggestive of spondyloarthritis
RA and morning stiffness
usually >60 minutes
ESR =
- fall of erythrocytes through through anticoagulated plasma
- erythrocytes are negative charged
- fibrinogen and APR neutralize the charges and cause slower rate (higher ESR)
Anti-U1-RNP
MCTD
Anticentromere
Crest Syndrome
Anti–Scl-70 (antitopoisomerase-1)
Systemic Scleroderma
Anti–Jo-1
Polymyositis
Antihistone
drug induced lupus
Cryoglobulins
Vasculitis; hepatitis C; myeloma; SLE; RA
Secondary Sjogren Syndrome
response to another rhem disease, most commonly RA and SLE
Sjogren patients at risk for…
non-Hodgkin lymphoma
due to chronic lymphocyte activation
Reasons for CT prior to LP in Adults
Immunocompromised state History of CNS disease Seizure within 1 week of presentation Papilledema Abnormal level of consciousness Focal neurologic deficits
Felty Syndrome
Form of RA w/
splenomegaly
chronic neutropenia
Nephrotic Syndrome (4)
Proteinuira
HLD
Edema
Hypoalbuminemia
Nephritis Syndrome (4)
Hematuria
Mild Proteinuria
HTN
Azotemia/AKI
Central DI
Central: low ADH from posterior pituitary
Nephrogenic DI
Nephrogenic: ADH secretion normal but tubules cannot respond
DI Diagnosis
- urine low SG and low osmolality
- water deprivation test
- Urine osm will ot increase with DI
- W/ desmopressin, urine osm will will NOT correct with nephrogenic version
TCA overdose therapy
sodium bicarbonate
Dermatomyositis
gottron’s papules, heliotropic rash
association with any malignancy
anti-jo
High Reticulocyte Count
hemolysis or blood loss
Transudative Pathophysiology
elevated capillary pressure
or decreased plasma oncotic pressure
Monitoring frequent transfusions
hypocalcemia from citrate binding
hyperkalemia or hypokalemia
metabolic alkalosis (from citrate metabolism).
SLE mainstay of treatment
hydroxychlorquine
Causes of lymphocytosis in pleural effusions
- Malignancy
- TB, histo, blasto, etc
- RA
- Chylous effusion
Diuretic Conversion
1 bumex
20 toresmide
40 furosemide
Plasma Osmolality
275-295
Osmolal Gap
Difference between calculated and measured should be less than 10
Greater than this suggests LWM alcohol
Diuresis with Kidney Injury
Urea Diuresis (kind of osmotic diuresis)
Methacholine Challenge Test
FEV1 reduction by 20%
high NPV, but many things can make this positive
DLCO
gas transfer than alveolar/capillary unit
proportional to surface area of functional lung
Bronchodilator Response
12% increase in FEV1 or FVC or both
at least 200 ml
Things that cause false decrease in pulse saturations
- CO
- methemoglobinemia
- topical anesthetics
- methylene blue
Medications that Reduce Frequency of COPD Exacerbations
Azithromycin
Roflumilast
Muddy brown casts
ATN
RBC casts
glomerular disease
WBC casts
pyelo or AIN
Pancolitis DDx
IBD
Infectious - E coli
Ischemia - hypotension or drugs
Asthmatic triad
wheezing, nasal polyps, ASA sensitivity
Single use of LABA in asthma?
increased risk of asthma related death
When should you get alpha anti-trypsin
less than age 45 with a strong family history and/or w/o strong risk factors
How to diagnosis bronchiectasis when looking at CT
airway larger than accompanying vessel
MDS can transform to….
AML
Chronic Myeloid Leukemia and associated genetics
BCR-ABL fusion gene/Philadelphia chromosome
treat w/ tyrosine kinase inhibitors
Polycythemia Vera
elevated Hgb
fatigue, HA, erythromyelgia, pruritic, HTN, thrombosis
JAK2 mutation
Polycythemia Vera Treatment
ASA for thrombosis, sometimes hydroxyurea
Phlebotomy
Most common secondary cause of polycythemia vera
testosterone
Essential Thrombocytopenia
50% have JAK2 mutation
can have headaches, dysthesias of hands/feet, visual disturbances, TIAs
Essential Thrombocytopenia Treatment
hydroxyurea
Hyperkalemia- always consider…
pseudohyperkalemia
K is intracellular so will rise with Cell Death (first pumping, elevated WBC, platelets)
Hyperkalemia in patients who make urine!
R/o obstruction, hyperglycemia
Loop diuretics + Normal Saline
Fludrocortisone
How to think about ILD
- smoking related
- steroid responsive
- CT related
- exposure related
Obesity Hypoventilation Syndrome triad
- obesity
- sleep disordered breathing
- day time hypercapnia
autoPEEP
intrathoracic pressure remains positive at end of exhalation
can decrease venous return
C diff treatment (adults, kids)
adults PO vanc or fidaxomicin
kids PO vanc or flagyl
DKA definition based on numbers
glucose >250
pH <7.3
+ketones
When to discontinue beta blockers in cirrhotics
Systolics <90
AKI
Na 120
High Risk Lung Nodules
6mm
spiculated
upper lobes
Subtype of lung nodule with highest risk of malignancy
subsolid
qSOFA
quick sequential organ failure assessment
RR>22
SBP <100
altered mental status
Treatment of Invasive Candidiasis
capsofungin, micafungin
poor penetration in CNS and eye though- use azole or amph B
Treatment of histoplasmosis
itraconazole
disseminated/severe disease- amph B
Treatment duration for CLABSI
7-14 days (non S aureus)
S aureus - 4 weeks
HAP
Pneumonia 48 hours after hospitalizations
VAP
Pneumonia 48 hours after mechanical ventilation
Treatment for ESBL organisms
meropenem!
Physiology of Type II RTA (Proximal)
damage to proximal tubule (where bicarbonate is reabsorbed)
Lower TM of bicarb and will pee out Bicarbonate
aka loss of bicarb/HCO3-
Causes of Type II RTA
Fanconi syndromes
drugs - acetazolamide, topiramate
Multiple Myeolma
Physiology of Type I RTA (Distal)
failure to excrete Hydrogen
Causes of Type I RTA
autoimmune (SLE, RA, sjogens)
Amph B
obstructive uropathy, sickle cell anemia
Physiology of Type IV RTA
hyperkalemia interferes with ammonia, hence you can’t store H+ in ammonium
Causes of Type IV RTA
chronic hyperkalemia AKA diabetes, ACE/ARB
obstructive uropathy, sickle cell anemia
Antisynthetase Syndrome
ILD
Raynauld
Mechanics hands
Anti jo
Cameron Lesions
Seen with hiatal hernias
Predictor of DM membranous nephropathy
DM for at least 8 years
Treatment of calcium oxalate stones
Potassium citrate
First Line CAP in Adults
doxy or azithromycin
First Line CAP In adults w/ recent antibiotic use or medical issues
Fluroquinolone
Beta lactam + macrolide
Autoimmune adrenalitis testing
21 hydroxylase antibodies
