Integrative Cases III Flashcards
What are some other medical conditions that individuals experiencing hypoactive delirium (decreased alertness) are at higher risk for?
- Peptic ulcer disease
- Pulmonary emboli
- Aspiration pneumonia
___ is useful in differentiating delirium and dementia on exam without knowing the full history.
Inattention is useful in differentiating delirium and dementia on exam without knowing the full history.
Patients with dementia do not become inattentive until the dementia is severe, while patients with delirium will often become acutely inattentive.
c-ANCA vs p-ANCA
c-ANCA is often against PR3
p-ANCA is often against MPO
Both may present with small vessel vasculitis resulting in glomerulitis.
ANCA-associated gomerulonephritis will be ___ on immunofluorescence
ANCA-associated gomerulonephritis will be pauci-immune on immunofluorescence
UTI in the presence of highly alkaline pH (~8 or above) suggests ___ infection.
UTI in the presence of highly alkaline pH (~8) suggests Proteus mirabilis infection.
These produce bases which elevate urine pH.
Most cases of uncomplicated cystitis in young women are treated with ___.
Most cases of uncomplicated cystitis in young women are treated with empiric nitrofurantoin.
Can a woman’s UTI be transmitted sexually to a male partner?
No.
Are kidney stones always painful?
Actually not always. Most often, yes, but not necessarily. It should always be on the differential for painless, protein-poor hematuria.
Fat embolism syndrome
- Occurs following trauma to large bones or orthopedic procedures
- Onset of 24-72 hours, usually self-limited and resolves quickly, but may last for months or be refractory
- Involves vacsulature of the extremities, lungs, and brain, often presenting as the trinity of dyspnea, cyanosis, and mental status change
- Some evidence that microemboli may cause delirium post-operatively in orthopedic patients
Patient presents with evidence of subacute renal failure. Extremities show petechiae. They are febrile. What is the most likely diagnosis?
TTP or HUS
Don’t forget that these exist and cause acute renal failure!
Hyperemia of small bowel on CT
Suggests local engorgement of blood vessels reuslting from inflammation
Proctitis
Inflammation of the rectum
May be seen in both Crohn’s and UC
Bile acid diarrhea
Bile acid diarrhea can occur when there has been disruption of the reabsorption of bile acids– in this case, partial removal of the ileum
Bile salts can induce secretion and mucus production and increase colonic motility, resulting in diarrhea (not just steatorrhea!)
Treatment is bile acid sequestration w/ oral sequestrants
Immodium
Aka Loperamide
mu opioid agonist, slows intestinal motility
Why doesn’t UC tend to present with malnutrition?
The colon isn’t involved in nutrient absorption! (at least not much)
How to target specific areas of UC involvement
Complications of having a J pouch
Increased frequency of bowel movements, “pouchitis,” fistulizing, infertility, and development of Crohn’s.
Tenesmus
A continual or recurrent inclination to evacuate the bowels, caused by disorder of the rectum or other illness.
Someone presents with apparent IBD and has mouth ulcerations. What is the diagnosis?
Not enough information!
Yes, Crohn’s can present with mouth ulcers primary to the Crohn’s pathology. BUT, UC can also present with secondary mouth ulcers due to physiologic stress. You would need a biopsy to differentiate these.
FMT for refractory C. diff
90% effective for refractory cases!
____ is the human microbiome segment that tends to include most of the pathogenic species.
Proteobacteria is the human microbiome segment that tends to include most of the pathogenic species.
Expected respiratory compensation for metabolic acidosis and alkalosis
Acidosis: pCO2 expected = 1.5 x [HCO32-] + 8 +/- 2
Alkalosis: pCO2 expected = 0.7 x [HCO32-] + 21 +/- 1.5
Serum creatinine and eGFR are least accurate when. . .
. . . GFR is closest to normal.
Both are most accurate when GFR is low, which is honestly when we really need it to be accurate
ACE inhibitors and GFR
Ace inhibitors will lead to a mild reduction in GFR with greater test-retest GFR variance
Tm in type II RTA
The most severe RTA
Type I. It is extremely rare, but by far the worst RTA.
Since effectively no H+ is secreted from the collecting duct, K+ losses are also profound.
Results in VERY low blood pH and VERY low potassium
The most common RTA
Type IV
Although, the acidosis is usually mild. The hyperkalemia is more significant.
FGF-19
Occulomotor movements
Pedal ulcers seen in diabetes occur most frequently at ___ and are most often attributed to be due to ___.
Pedal ulcers seen in diabetes occur most frequently at the metatarsal heads and are most often attributed to be due to damage to the vasa nervorum.
37-year-old M presents with renal failure. No FHx of renal disease or history of prior renal disease. Patient reports regular injection of heroin. Kidnies are visualized by ultrasound and appear moderately enlarged, but have no cysts. A renal biopsy is taken and shown below, stained with Congo red. What is the likely diagnosis?
AA Amyloidosis
Arterioles show involvement by a material which is strongly congophilic on Congo red staining. Congo red is a dye used to stain amyloid. Amyloid will also appear as pale eosinophilic and amorphous on H and E, and will be apple‑green birefringent on polarized light microscopy. Glomerular amyloid appears as amorphous material in the mesangium and capillary loops.
In cases of AA amyloidosis associated with injection-drug use, heroin is the most commonly implicated drug. A specific type of heroin, “black tar,” may be more likely to cause AA amyloidosis than other types. Renal involvement is universal in patients with AA amyloidosis.
Fungi with septate vs aseptate fungi in clinical medicine
Patient presents with elevated kappa and lambda light chains in blood. Kappa light chain is 150.9 mg/L while lambda light chain is 71.5 mg/L. What is the likely cause?
Increased blood levels of kappa and lambda light chains are typically found in patients with reduced kidney function, with a greater elevation of kappa than of lambda light chains and with an increase in the kappa:lambda ratio.
A normal kappa:lambda ratio ranges from 0.26-1.65. Slight increase in this ratio with substantial serum rise indicates kidney pathology, while dramatic increase with a heavily dominant light chain indicates hematologic malignancy.
Lung cancer patient is treated with PD-L1 blockade. Three weeks later, she presents with slightly elevated troponin at 0.19 ng/mL. EKG is negative for ischemic changes, but echo shows slight dyskinesis of the left lateral and septal walls. Imaging does not support spread of the cancer to the heart or pericarditis. What is the likely etiology?
Autoimmune myocarditis associated with the use of PD-L1 blockade
If you suspect a patient has hemoltyic-uremic syndrome, but Shiga-1 and Shiga-2 tests come back negative, you should. . .
. . . do a genetic test for pathologic variants of complement in order to diagnose atypical HUS.
What is going on in this H and E?
The arrows point to fragmented red blood cells within the glomerulus. This is characteristic of microangiopathic hemolytic anemia, and may be seen in any of the three: DIC, TTP, or HUS.
Why is nephrotic syndrome sometimes associated with thrombosis?
Because antithrombin is also lost in the heavy proteinuria, making endogenous heparin a less effective anticoagulant
Forms of tularemia
Tularemia lifecycle
Rickettsialpox vs Rocky Mountain Spotted Fever
Rickettsialpox lesions
Rocky Mountain Spotted Fever lesions
Xanthelasma
Sharply-demarcated periocular deposites of cholesterol underneath the skin. Seen in advanced hyperlipidemia.
Cardinal signs of various types of shock
Platypnea
Breathing is easier while lying down than standing up.
The opposite of orthopnea.
Diagnostic criteria for diabetes
AA vs AL amyloid
Complications of various diarrheas
Salt-losing nephropathies
Treating RPGN
- Induction:
- Corticosteroids
- Plasma exchange
- Cyclophosphamide
- Rituximab
- Maintenance:
- Corticosteroids
- Methotrexate
- Leflunomide
- Azathioprine
- Autoantibody-mediated disease (namely anti-GBM/Goodpasture’s) may be treated w/ Rituximab
MPA vs GPA vs eGPA
AGN vs RPGN
Acute Glomerulonephritis: Syndrome of AKI and sudden onset edema and/or worsening hypertension. Urinalysis includes active sediment, significant proteinuria, hematuria, and possibly red cell casts.
Rapidly Progressing Glomerulonephritis: Syndrome of proteinuria and hematuria, sometimes with red cell casts, that progresses to renal failure in days to weeks. Pathologic hallmark is celluloproliferative crescenting.
Why does botox help patients with Hirschrung’s disease relax the internal anal sphincter?
It blocks the acetylcholine from the extrinsic nerves – that is, the sympathetic and parasympathetics that are overgrown in Hirschprung’s since they were never able to find their synaptic enteric neuron partners.
Why does bile acid in the colon cause diarrhea?
It induces secretion. So, these diarrheas will present as an electrolyte-transport related diarrhea.
Delta ratio
Urinary anion gap
