Internal med Flashcards
Thin basement membrane disease
- familial disorder
- presents in adulthood as microscopic hematuria without proteinuria
- thinned BM
Alport’s syndrome
- familial disorder which usually presents in childhood as recurrent gross hematuria and proteinuria
- sensorineural deafness usually occurs!
- EM findings include alternating areas of thinned and thickened capillary loops w/ splitting of the GBM
Recurrent episodes of hematuria, sensorineural deafness, and a family hx of renal failure
Alport’s syndrome
Hydroxyurea
-decreases the frequency and severity of pain crises in pts w/ sickle cell anemia by increasing hemoglobin F levels
tx of choice for pts w/ autoimmune hemolytic anemia?
prednisone
Erythropoietin
-tx of choice for anemia of chronic disease, chronic kidney disease, and transient bone marrow failure after chemo or bone marrow transplant
splenectomy
- tx of choice for moderate, symptomatic, hereditary spherocytosis.
- also a tx option in autoimmune hemolytic anemia and for those w/ massive splenomegaly associated w/ B-thalassemia major or hemoglobin H disease
B-thalassemia minor (trait)
- usually asymptomatic w/ mild anemia, disproportionately high RBC count, low MCV, and hemoglobin >10 g/dL.
- commonly confused w/ iron deficiency anemia, however, iron deficiency has low RBC count and rarely becomes microcytic until the hemoglobin is <10g/dL.
- no specific therapy is required for B-thalassemia minor
P. jiroveci
- opportunistic pathogen, and an important cause of pneumonia in immunocompromised hosts
- bilateral diffuse interstitial infiltrates beginning in the perihilar region is characteristic finding on chest x-ray
- tachypnea, tachycardia, cyanosis w/ minimal chest findings
Aspergillosis
- seen in immunocompromised pts.
- chest x-ray shows solid mass surrounded by a radiolucent crescent (crescent sign, Monod’s sign)
True or False: candida is an extremely rare organism to cause pneumonia in any patient.
True
Ménière’s disease
- typically presents w/ a combination of vertigo, ear fullness, tinnitus, and hearing loss
- first line therapy consists of environmental and dietary modifications, including maintenance of a low-salt diet
- other triggers include alcohol, caffeine, and nicotine
- medical therapy w/ diuretics, antihistamines, or anticholinergics may be tried
Diabetic ketoacidosis
- type 1 diabetics
- younger age
- less pronounced altered mentation compared to HHS
- more rapid onset of hyperglycemic symptoms
- hyperventilation and abdominal pain common
- glucose 250-500 mg/dL
- bicarb <320 mOsm/kg
Hyperosmolar hyperglycemic state
- type 2 DM
- older age
- more pronounced altered mentation (compared to diabetic ketoacidosis)
- gradual onset of hyperglycemic symptoms
- hyperventilation and abdominal pain less common
- glucose >600
- bicarb >18
- normal anion gap
- negative or small serum ketones
- serum osmolality >320
an increase in extracellular pH (alkalemia) promotes the binding of calcium to albumin and lowers serum ionized calcium concentration
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hyperglycemia and glucosuria-induced osmotic diuresis cause free water loss that exceeds sodium loss
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Despite normal or elevated serum potassium levels, pts w/ hyperosmolar hyperglycemic state (HHS) or diabetic ketoacidosis have a total body potassium deficit due to excessive urinary loss caused by glucosuria-induced osmotic diuresis. Aggressive insulin therapy for HHS can lower serum potassium levels further and cause severe hypokalemia!
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Neuroleptic Malignant Syndrome (NMS)
- typically presents w/ fever, muscle rigidity, autonomic instability and mental status change. Serum CK is often elevated.
- Dantrolene, a muscle relaxant, is the most common drug used to reverse the condition, followed by bromocriptine (a dopamine agonist) and amantadine (an antiviral drug w/ dopaminergic properties)
Premature Ventricular Complexes (PVCs)
- common in pts post-MI and can be recognized by their widened QRS (>120msec), bizarre morphology, and compensatory pause.
- even though they may indicate a worse prognosis, tx is not indicated unless the patient is symptomatic (beta-blockers are first line therapy for symptomatic pts)
Amiodarone
-second line therapy for symptomatic PVCs
Digoxin
-can be used to treat atrial arrhythmias like atrial flutter and atrial fibrillation. It has no role in the treatment of ventricular arrhythmias!
Brain death
- clinical diagnosis
- characteristic findings are absent cortical and brain stem functions
- the spinal cord may still be functioning; therefore, deep tendon reflexes may be present
- an isoelectric EEG can be used as a confirmatory test, but is not absolutely necessary
- note that the heart rate fails to accelerate after atropine injection because vagal control of the heart is lost, and the heart rate becomes invariant
Timolol
eye drops used to treat glaucoma
Mannitol
- osomotic diuretic used to reduce intracranial pressure associated w/ cerebral edema
- its an IV infusion and requires careful monitoring of renal function and electrolytes
- used in inpatient setting for severely elevated intracranial pressure (obtunded pts)
what is the first line medical tx for idiopathic intracranial hypertension?
- Acetazolamide (inhibits choroid plexus carbonic anhydrase, thereby decreasing CSF production and intracranial hypertension) w/ or w/o furosemide
- optic nerve sheath decompression or lumboperitoneal shunting is recommended for pts refractory to medical therapy
- corticosteroids and serial lumbar punctures are not recommended as long-term primary tx, however, they may be used as bridging therapies for pts awaiting definitive surgical tx
Lumbago
- “Lumbosacral strain”
- usually related to physical strain and has less dramatic onset
- usually paravertebral muscle tenderness rather than spinal tenderness is the feature
common complication of advanced osteoporosis
- compression fracture of vertebrae
- usually manifests as acute back pain w/o an obvious preceding trauma in a predisposed patient. Neuro exam will be normal
- NOTE: absent ankle reflex can be seen in elderly pts as part of the normal aging process
Note that serum creatinine does not usually become elevated in obstructive uropathy unless both ureters are obstructed
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Renal vein thrombosis
-usually occurs in pts w/ a predisposing condition such as hypercoagulabilit
Serum creatinine usually does not become elevated in obstructive uropathy unless both ureters are obstructed.
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Hepatorenal syndrome
- can occur in pts w/ severe liver disease; they develop systemic hypoperfusion and subsequent renal failure
- the diagnosis is suggested by an elevated creatinine and a very low urine sodium level, typically less than 10 mEq/L
how do pts w/ cerebellar hemorrhage present?
- ataxia, vomiting, occipital headache, gaze palsy, and facial weakness
- there is no hemiparesis
Lichen planus
-inflammatory condition characterized by pruritic, violaceous, flat-topped papules w/ fine white streaks on the surface called Wickham’s striae
Dermatitis herpetiformis
- pruritis, papules, and vesicles mainly over the elbows, knees, buttocks, posterior neck, and scalp.
- associated w/ HLA B8, DR3, and DQw2, and is see in pts w/ gluten-sensitive enteropathy
Miliaria
- heat rash
- superficial aggregated small vesicles, papules, or pustules over the trunk, which are associated w/ burning and itching
- commonly seen in people living in hot and moist climates
Molluscum contagiousum
- single or multiple rounded, dome-shaped papules w/ central umbilication
- causative agent is poxvirus
- usually self- limited and resolves spontaneously in immunocompetent individuals
- genital lesions should be treated to prevent sexual transmission
- best form of tx is curettage or application of liquid nitrogen
what happens to the murmur intensity in a person w/ hypertrophic cardiomyopathy who stands up from a supine position?
-decreased venous return causes increased intensity of ejection systolic murmur
Paradoxical splitting of second heart sound
- normal splitting is best heard during INSPIRATION. In paradoxical splitting, A2 follows P2 w/ maximal splitting noted during EXPIRATION and being less pronounced during inspiration.
- seen in pts w/ fixed left ventricular outflow tract obstruction (ie. aortic valve or subaortic stenosis, Left BBB, right ventricle paced rhythm)
Dressler’s syndrome
- present WEEKS after an MI w/ chest pain that is improved by leaning forward
- diffuse ST elevation w/ the exception of reciprocal depression in aVR due to pericarditis
- NSAIDs are the tx of choice
- anticoagulation should be avoided to prevent development of a hemorrhagic pericardial effusion
Essential tremor
- bilateral action tremor of the hands, usually w/o leg involvement
- possible isolated head tremor w/o dystonia
- usually no other neurologic signs
- relieved w/ alcohol in many cases
Parkinson’s disease tremor
- resting tremor (4-6Hz) that decreases w/ voluntary movement
- usually involves legs and hands
- facial involvement less common
Cerebellar tremor
- usually associated w/ ataxia, dysmetria, or gait disorder
- tremor increases steadily as the hand reaches its target
Physiologic tremor
- low amplitude not visible under normal conditions
- acute onset w/ increased sympathetic activity (drugs, hyperthyroidism, anxiety, caffeine)
- usually worse w/ movement and can involve the face and extremities
Parkinson’s disease triad
- resting tremor
- rigidity
- postural instability
- bradykinesia
Resting tremor
- often the presenting symptom of Parkinson’s disease
- usually a “pill-rolling” tremor that starts in one hand and can progress to involve other extremities, jaw, face, tongue, and lips.
Cerebellar dysfunction
-can cause postural, action, or intention (worsens as the hand moves closer to its target) tremors. The tremors have a lower frequency. Although severe cerebellar dysfunction can cause resting tremor, pts usually develop other signs (nystagmus, ataxia, dysmetria)
the most common tremor
- essential tremor
- familial in 50% of cases and affects 5% of the population
- typically present as action/postural tremors in upper extremities that worsen at the end of goal-directed activities
- usually affect bilateral upper extremities but can also involve the head, chin, voice, and trunk
Pneumocystis pneumonia
- more common in HIV pts w/ CD4 < 200
- typically present w/ subacute respiratory symptoms w/ diffuse infiltrates on chest x-ray and an increased alveolar-arterial gradient
Isoniazid causes idiosyncratic liver injury w/ histological features similar to those seen in pts w/ viral hepatitis.
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acute asthma exacerbation
-an elevated or even normal arterial partial pressure of carbon dioxide suggests decreased respiratory drive (likely due to respiratory muscle fatigue) and impending respiratory failure. In these pts, tx involves endotracheal intubation and mechanical ventilation, inhaled short-acting beta-2-agonist, inhaled ipratropium, and systemic corticosteroids.
Squamous cell carcinoma
- second most common form of non-melanoma skin cancer (after basal cell)
- single most important risk factor is exposure to sunlight
Ehrlichiosis
-should be suspected in a patient from an endemic region w/ a history of tick bite, febrile illness w/ systemic symptoms, leukopenia and/or thrombocytopenia, and elevated aminotransferases. Rash is uncommon, and the drug of choice is DOXYCYCLINE
drug of choice to treat Lyme disease
Ceftriaxone
Peritonsillar abscess
- a muffled voice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis
- a peritonsillar abscess is a potential complication of tonsillitis and requires both IV antibiotic therapy and urgent drainage of the abscess
- deviated of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis
Primary hypothyroidism
-characterized by low circulating levels of thyroid hormones w/ TSH levels of more than 10 IU/L
Secondary and tertiary hypothyroidism
-characterized by low circulating thyroid hormone levels w/ low or inappropriately normal TSH levels
Subclinical hypothyroidism
- mildly elevated serum TSH levels and normal circulating thyroid hormone levels
- pts do not have clinical features of overt hypothyroidism
Pts w/ generalized resistance to thyroid hormones
- have high serum T4 and T3 levels w/ normal to mildly elevated TSH levels
- pts typically have features of hypothyroidism despite having elevated free thyroid hormones
Pts w/ upper GI bleeding who have a depressed level of consciousness and ongoing hematemesis should be intubated to protect the airway as a part of initial stabilization and resuscitation. Prompt endoscopic tx w/ band ligation or sclerotherapy should then be performed to stop the bleeding.
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most common form of skin cancer in the US?
basal cell carcinoma (75%)
Mohs surgery
- special type of surgery wherein microscopic shaving is done, such that 1-2 mm of clear margins are excised.
- this technique currently has the highest cure rate for basal cell cancer, but is indicated only in pts w/ high-risk features, as well as those w/ lesions in functionally critical areas (perioral
primary pulmonary hypertension
- can be seen in middle-aged pts, and it presents w/ exertional breathlessness
- lungs will be clear to ausculatation
- chest x-ray would show enlargement of the pulmonary arteries w/ rapid tapering of the distal vessels (pruning) and enlargement of the right ventricle
Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the tx of choice for symptomatic gallstone disease.
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3 most common causes of aortic stenosis
- senile calcific aortic stenosis
- bicuspid aortic valve
- rheumatic heart disease
Myxomatous valve degeneration
-typical pathologic entity that causes mitral valve prolapse
Bicuspid aortic valve
-the cause of aortic stenosis in the majority of pts under 70 years old
Clostridium perfringens
- spore forming organism
- spores germinate in foods such as meats, poultry, or gravy
- ingestion results in watery diarrhea due to production of toxin in the gut
- symptom onset is later than w/ preformed toxins (8-14 hrs after ingestion)
Bacillus cereus
- causes nausea and vomiting after eating rice
- symptom onset is within one to six hours
vitamin D deficiency
-causes osteomalacia and hypocalcemic tetany in adults
vitamin E deficiency
-can cause RBC fragility, hyporeflexia, muscle weakness, and blindness
A tea and toast diet is associated w/ folic acid deficiency. Folic acid is heat sensitive. Folic acid deficiency causes macrocytic anemia.
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Neoplastic epidural spinal cord compression
- presents w/ worsening focal back pain, bilateral lower-extremity weakness, sensory loss, and gait ataxia
- bowel/bladder disturbances are late findings
- in the acute phase of spinal cord injury, pts can develop spinal shock w/ absence of reflexes and flaccid paraplegia as a result
Tx of actively bleeding esophageal varices
- hemodynamic support, pharmacologic tx (octreotide), endoscopic therapy, and prophylactic antibiotics.
- coagulopathy, anemia, and thrombocytopenia are common complications and may also require correction
Winter’s formula
- used to calculate the expected decrease in pCO2 during metabolic acidosis
- pCO2= 1.5(HCO3) + 8
- if the pCO2 is not within 2 of this number, then there is another acid-base process occurring at the same time
Type II Renal tubular acidosis
- defective tubular bicarb reabsorption.
- oftentimes inherited, and may be a component of Fanconi syndrome
- can also occur w/ use of drugs like carbonic anhydrase inhibitors
Type 1 Renal tubular acidosis
- low tubular ammonium production is a component
- primary defect is failure to excrete sufficient H+ in the urine
- w/o sufficient hydrogen ions in the tubular fluid, ammonium cannot be produced
Renal tubular epithelial cells exchange chloride for bicarb. Thus, when the urine chloride is increased, bicarb resorption into the plasma is increased and urinary excretion of H+ is increased.
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Tachypnea causes further lowering of the pCO2 because CO2 is more readily diffusable than O2.
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Erythema nodosum
- presents as painful nodules on the anterior legs that can progress to appear as bruises w/ eventual scarring
- can be associated w/ infections (strep, TB) or sarcoidosis or can be idiopathic
Lambert-Eaton syndrome
- NMJ disorder that presents most commonly w/ muscle weakness and dry mouth
- most often associated w/ small cell lung cancer or lymphoproliferative disorders (Hodgkin lymphoma)
Polyarteritis nodosa
- more commonly associated w/ hepatitis B
- necrotizing vasculitis in small and medium vessels likely due to the deposition of circulating antigen-antibody immune complexes in blood vessel walls
Chronic hepatitis C
- can be asymptomatic or present w/ fatigue and nonspecific symptoms (arthralgias, myalgias, etc)
- Pts usually have waxing and waning elevations in transaminase levels
- extrahepatic sequelae can include essential mixed cryoglobulinemia, porphyria cutanea tarda, and membranoproliferative glomerulonephritis
3 main categories of diabetic retinopathy
- background or simple (microaneurysms, hemorrhages, exudates, retinal edema)
- pre-proliferative (cotton wool spots)
- proliferative or malignant (neovascularization)
- visual impairment occurs w/ the development of macular edema.
- Argon laser photocoagulation is performed for the prevention of complications
Lumbar spinal stenosis
- most commonly caused by degenerative joint disease
- “neuropathic claudication” is often used to describe lumbar stenosis
- refers to exacerbation of leg symptoms w/ walking (similar to PVD)
- Unlike PVD, the symptoms are positional and remain while standing still. Pain is relieved by flexion of the spine. Diagnosis is made based on clinical hx and classic findings on spinal MRI
ACE inhibitors, ARBs, beta-blockers, and spironolactone all confer a survival benefit in CHF. While digoxin and furosemide (loop diuretics) can reduce CHF symptoms and hospitalizations, they do not improve survival.
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murmur of hypertrophic cardiomyopathy
-systolic murmur decreases w/ squatting and increases w/ straining
Patients w/ cardiac tamponade
- usually have clinical features of Beck’s triad: hypotension, distended neck veins, and muffled heart sounds
- these symptoms are due to an exaggerated shift of the interventricular septum toward the left ventricular cavity, which reduces left ventricular preload, stroke volume, and cardiac output
Enterococci, especially Enterococcus faecalis, are a common cause of endocarditis associated w/ nosocomial urinary tract infections
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Monoclonal gammopathy of uncertain significance (MGUS)
- can be differentiated from multiple myeloma by an absence of renal insufficiency, hypercalcemia, anemia, and lytic bone lesions.
- although MGUS is asymptomatic, there is a 1% per year risk of progression to multiple myeloma
Suppurative hidradenitis
- chronic follicular occlusive disease most commonly affecting the intertriginous skin, including the axillary, groin and inframammary regions
- it appears as painful inflammatory nodules and draining sinus tracts that can last weeks or longer
Allergic contact dermatitis
- inflammatory skin condition caused by allergens such as poison sumac, cosmetics, and nickel
- it presents days to weeks after exposure w/ an intensely pruritic erythematous rash w/ vesicles at the site of exposure
- secondary infection as a result of excessive scratching is possible, and is suggested by pus filled vesicles
Active hepatitis B infections typically presents w/ positive HB surface antigen, positive Be antigen, and absent surface antibody. Health care workers exposed to blood from HB patients (ocular, mucous membrane, or skin) should receive post-exposure prophylaxis. Unvaccinated individuals should receive both the HB vaccine and HB immune globulin as soon as possible.
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Interventricular free wall rupture and papillary muscle rupture
-typically occur 3-7 days after MI and present w/ new onset systolic murmur
Ventricular free wall rupture
- typically occurs 3-7 days after anterior wall MI
- presents w/ rapid deterioration secondary to pericardial tamponade
- pulseless electrical activity is common
Pulmonary infarction secondary to pulmonary embolism
- can cause chest pain, but it should not cause diffuse ST elevations on ECG
- while the pain of PE is pleuritic, it should not improve w/ leaning forward
Ventricular aneurysms
- complication of anterior wall MI that can occur days to months after the initial infarction
- presents w/ akinesis of the involved portion of the left ventricular wall, ventricular arrhythmias, and systemic embolization
Acute pericarditis
- typically occurs in the first several days after MI
- characterized by sharp, pleuritic pain that is worse in the supine position and improved by sitting up and leaning forward
- diffuse ST elevations, especially w/ PR depressions, are typical ECG findings
Brain death
- refers to a total loss of brain function and is a legally acceptable definition of death
- criteria include: absent cranial nerve reflexes, fixed and dilated pupils, no spontaneous breaths, and agreement of two physicians
bowel ischemia
- the diagnosis depends on a high index of clinical suspicion in pts w/ known risk factors for thromboembolic disease (atrial fibrillation, peripheral vascular disease)
- typical features include acute abdominal pain out of proportion to exam findings, and associated metabolic acidosis (increased serum lactate levels)
- Mesenteric angiography is the gold standard for diagnosis
Recent studies have suggested that a brain that has seized for > 5 minutes (status epilepticus) is at increased risk of developing permanent injury due to EXCITATORY CYTOTOXICITY. Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures.
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Aldosterone secretion from the zona glomerulosa is ACTH-independent. As a result, secondary (central) adrenal insufficiency does not cause hyperkalemia or salt wasting
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Secondary (central) adrenal insufficiency
- most commonly due to pituitary masses (adenoma)
- in contrast to primary adrenal insufficiency, secondary adrenal insufficiency does not cause salt wasting, hyperkalemia, or hyperpigmentation
Eaton-Lambert syndrome
-associated w/ SMALL CELL carcinoma of the lung, and results from autoantibodies directed against VOLTAGE-GATED CALCIUM CHANNELS in the PRESYNAPTIC motor nerve terminal
Multiple sclerosis (MS)
- Multicentric CNS inflammation and demyelination are indicative
- rare in people younger than 15 and older than 60
- sensory loss, spasticity, cerebellar symptoms, optic neuritis, depression, etc.
ALS
- upper and lower motor neuron degeneration
- initially presents w/ bulbar symptoms, followed by upper and lower limb weakness
Polymyositis
- immune-mediated muscle inflammation
- presents as proximal weakness characterized by difficulty ascending and descending stairs, combing hair, kneeling down, etc
- CPK level is typically high and it is not associated w/ absent reflexes
Myasthenia gravis
- autoantibodies against postsynaptic receptors
- reduction of postsynaptic ACh receptors leads to muscle weakness
- the muscle weakness is provoked by repetitive or sustained use of the muscles involved
- deep tendon reflexes are usually preserved, and may be somewhat brisk in clinically weak muscles
Anserine bursitis
- presents w/ sharply localized pain over the anteromedial part of the tibial plateau just below the joint line of the knee
- Valgus stress test fails to reproduce the pain, thereby ruling out damage to the medial collateral ligament, and radiographs are classically normal
- Tx is w/ rest, ice and maneuvers to reduce pressure on the bursa. Corticosteroid injections into the bursa are also helpful.
Prepatellar bursitis
- presents w/ pain and swelling directly over the patella
- exam shows cystic swelling over the patella w/ variable signs of inflammation
- the most common cause is trauma
Medial collateral ligament injury
- presents w/ pain along the medial joint line and is aggravated by walking
- caused by valgus stress applied on the lateral aspect of the knee when it is partially flexed
- the knee pain is aggravated by valgus stress testing
Medial compartment osteoarthritis
- presents w/ pain along the medial joint line typically in pts older than 40
- morning stiffness of less than 30 minutes, crepitus and bony tenderness on examination
- x-ray of the knee shows narrowing of the joint space and osteophyte formation
- anserine bursitis may accompany medial compartment osteoarthritis due to the chronic gait abnormality caused by the arthritic pain
Patellofemoral syndrome
- common overuse pain syndrome of the knee
- pts present w/ peripatellar pain worsened by activity or prolonged sitting (due to sustained flexion) and may also complain of crepitus w/ motion of the patella
Decubitus ulcers
- elderly and critically ill pts w/ immobility, poor nutrition, and sensory impairment are at risk of developing decubitus ulcers
- ulcers form as a result of uninterrupted pressure on the tissue overlying bony prominences
- the elbows, coccyx, hips and heels are sites at especially high risk
- patient repositioning every two hours and pressure reducing devices (air/foam mattresses) are important methods of prevention
Hyponatremia
- can be classified according to the patient’s volume status (hypovolemic, euvolemic, hypervolemic)
- hypovolemia increases the activity of the RAAS and sympathetic nervous systems, and stimulates ADH release from the pituitary
- The elevated ADH increases renal water reabsorption to cause hyponatremia until correction of the hypovolemia
- Tx w/ normal saline usually
Peripheral neuropathies
-typically present w/ motor abnormalities such as distal muscle weakness, sensory abnormalities, and decreased deep tendon reflexes on physical exam
Proximal muscle weakness w/ or w/o muscle atrophy can occur in 60-80% of pts w/ untreated hyperthyroidism and correlates to the duration of the hyperthyroid state. Hip flexors and quadriceps are predominantly affected, and the weakness can gradually progress to involve the proximal muscles of the upper extremities.
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Collagenous colitis
- uncommon disorder producing chronic watery diarrhea
- the colon is frequently involved, but colonoscopy shows normal mucosa
- biopsy shows mucosal subepithelial collagen deposition
IBS
- chronic disorder characterized by distressing GI symptoms such as diarrhea, constipation, pain, and bloating
- biopsy results are normal in irritable bowel syndrome, and features of malabsorption should prompt a search for an alternate explanation
Celiac disease
- should be suspected in any patient w/ malabsorption and iron deficiency anemia
- IgA anti-endomysial and anti-tissue transglutaminase antibodies are highly predictive of celiac disease but may be absent if there is concurrent selective IgA deficiency (which is common in Celiac pts)
Celiac disease
- autoimmune reaction to gluten which affects the small bowel
- symptoms include diarrhea, weight loss and fatigue
- it may also lead to malabsorption of vitamin D, K, B12, calcium, folic acid, and zinc
Vitamin A deficiency
- may be caused by nutritional deficiency or malabsorption
- symptoms include blindness, dry skin, and impaired immunity
Selenium deficiency
- like zinc deficiency, may result from chronic TPN
- may also result from malabsorption or malnutrition (food sources include nuts, meat, and fish)
- the most important feature of deficiency is cardiomyopathy!
SLE
- multisystem autoimmune disease which may present w/ malar and discoid rashes, oral ulcers, and alopecia
- fever, weight loss, arthritis, as well as renal, neurologic, and hematologic symptoms are also common
Zinc deficiency
- may result from chronic total parenteral nutrition or malabsorption
- symptoms include alopecia, skin lesions, abnormal taste, and impaired wound healing
leading cause of blindness in industrialized countries
macular degeneration
Lens opacification
-cause of visual loss from cataracts
enlarged blind spot
-may be seen w/ papilledema
increased intraocular pressure
-cause of glaucoma, which does NOT typically present w/ distortion of straight lines
Macular degeneration
- the most common cause of blindness in industrialized nations
- activities that require fine visual acuity are usually the first affected, and pts w/ this condition may report that straight grid lines appear curved
Idiopathic intracranial hypertension
- presents w/ headache, vision changes (blurry or double vision), papilledema, and/or cranial nerve palsies (usually CN VI)
- CSF exam shows increased opening pressure (>250) and normal studies
- IIH is most common in young obese women
- growth hormone, tetracyclines, and excessive vitamin A and its derivaties (ie isotretinoin, all-trans-retinoic acid) can cause IIH
- Withdrawal of these meds leads to symptom resolution. Weight loss and acetazolamide for idiopathic cases.
Multiple sclerosis
- usually presents w/ >2 distinctive episodes of CNS dysfunction w/ at least some resolution
- classic features include optic neuritis, Lhermitte’s sign, Uhthoff’s phenomenon (worsening symptoms w/ increased body temperature), motor and sensory deficits, and bowel or bladder dysfunction
Normal pressure hydrocephalus
- the result of impaired absorption of CSF
- Pts present w/ the triad of impaired gait, cognitive difficulties, and urinary incontinence
- CT scan shows enlarged ventricles
- typically seen in elderly pts
Viral encephalitis
- may present w/ fever, headaches, neurologic deficits, and altered mental status
- CSF exam shows a moderate WBC count (lymphocyte predominant) and elevated protein
Large artery atherosclerosis and cardiac emboli are typically characterized by more prominent clinical manifestations because larger vessels are involved, although this is not always true
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Berry aneurysms
-can cause compression symptoms (most typically oculomotor abnormalities) before rupture, and is devastating on rupture secondary to subarachnoid hemorrhage
Always suspect lacunar stroke if a patient presents w/ a limited neuro deficit. The typical lacunar stroke scenarios are pure motor stroke, pure sensory stroke (thalamus), ataxic-hemiparesis, and dysarthria-clumsy hand syndrome. The principle cause of lacunar stroke is hypertension.
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Hepatic hydrothorax
- cause of transudative pleural effusions in pts w/ cirrhosis who have no underlying cardiac or pulmonary disease to account for development of such an effusion
- usually results in a right-sided pleural effusion
- initial tx is usually w/ salt restriction and diuretics
- TIPS placement is considered in pts w/ refractory hepatic hydrothorax
what is the most frequent precipitant of Guillain-Barre Syndrome (GBS)?
Campylobacter jejuni
-(Herpes virus, Mycoplasma, and Hemophilus influenzae have also been associated)
Ascending aortic dissection
- arises from an intimal tear that allows a false lumen to be created between the media and adventitia of the aorta
- Pts present w/ severe chest pain that radiates to the back and neck
- hypertension is a major risk factor
- the chest x-ray may reveal a widened mediastinum
Pulmonary emboli
- cause dyspnea, tachycardia, pleuritic chest pain, and tachycardia
- while there are suggestive chest x-ray findings, the chest x-ray is normal in most cases
- the most common ECG finding is a sinus tachycardia
Chest x-ray findings in Pulmonary emboli
- usually normal chest x-ray
- may see dilatation of the pulmonary artery proximal to the clot and collapse of the vessels distal to the clot (Westermark’s sign)
- Pleural infiltrates corresponding to areas of pulmonary infarction (Hampton’s hump)
The nephrotic syndrome
- can result in alterations in lipid metabolism
- this dyslipidemia puts affected pts at increased risk for accelerated atherosclerosis
- this atherosclerotic tendency, along w/ intrinsic hypercoagulability, places pts w/ nephrotic syndrome at risk for complications such as stroke and MI
Distinction between case control and retrospective cohort studies
-the order in which outcomes are risk factors are assessed: case control studies determine the outcome and then look for associated risk factors; retrospective cohort studies ascertain risk factor exposure and then determine the outcome
retrospective cohort study
- similar to a prospective cohort study except that risk factor exposure and the outcome of interest both occur in the past and are assessed through review of records.
- unlike a case control study, risk factor exposure is determined before the outcome is known, thus allowing calculation of the relative risk
Premature atrial complexes (PAC’s)
- tobacco and alcohol are reversible risk factors
- Beta-blockers are often helpful in pts who are symptomatic
Screening for bladder cancer
-is NOT recemmended, even in pts who are at risk of developing the disease (due to its low incidence and poor PPV of the current screening tests)
Contrast-induced nephropathy
- presents as a transient spike in creatinine within 24 hrs of contrast administration, w/ a return to normal renal function within 5-7 days
- pts w/ diabetes and elevated baseline Cr are at especially high risk
- Adequate IV hydration w/ isotonic bicarb or normal saline and administration of acetylcysteine help to minimize the risk of contrast-induced nephropathy
Gout has NEGATIVELY birefringent crystals!
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Gout is a common manifestation of myeloproliferative disorder-induced increases in uric acid production, because there is increased catabolism and turnover of purines. Note that Polycythemia vera commonly causes splenomegaly and characteristic pruritis w/ hot baths due to histamine release from an increased number of circulating basophils.
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CKD can cause gouty attacks by decreasing the amount of uric acid excreted in the urine.
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Hemochromatosis
- autosomal recessive iron overload syndrome most often due to mutation of the HFE gene.
- the symptoms are related to iron accumulation in various organs: hepatic dysfunction progressing to cirrhosis, diabetes, hypogonadism, skin pigmentation, and arthritis
Lesch-Nyhan syndrome
- caused by genetic deficiency of the enzyme hypoxanthine-guanine phosphoribosyl transferase (HPRT)
- characterized by overproduction of uric acid, behavioral problems (especially self-injurious actions), and neurologic disability, and is generally diagnosed in childhood
Hyperparathyroidism
- increases bone resorption and can thus elevate serum calcium concentrations
- a high serum calcium concentration can cause chondrocalcinosis and calcium pyrophosphate dihydrate deposition disease (pseudogout). The crystals in pseudogout are POSITIVELY birefringent.
Gout is a common manifestation of myeloproliferative disorder-induced increases in uric acid production
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Vaccinations for pts w/ chronic liver disease?
- hepatitis A and B
- influenza
- invasice pneumococcal disease
- like all adults, they should get a Td booster at least every 10 years w/ the Tdap once in place of the Td
Guillain-Barré syndrome
- most commonly presents w/ ascending flaccid paralysis
- involvement of respiratory and bulbar muscles puts pts at high risk for respiratory failure
- serial measurements of forced vital capacity are the best means of monitoring respiratory function
In a normal (bell-shaped) distribution:
- 68% within 1 SD from mean
- 95% within 2 SD from mean
- 99.7% within 3 SD from mean
Pancreatic cancer
- can be due to hereditary (first degree relative w/ pancreatic cancer, hereditary pancreatitis) or environmental (cigarette smoking, obesity) risk factors.
- cigarette smoking is the most consistent reversible risk factor for pancreatic cancer
Noninvasive evaluation w/ compression ultrasonography is recommended as an initial test in pts w/ moderate or high probability of DVT. In pts w/ low probability, a D-dimer assay can further assess risk. An US can be performed on pts w/ a positive D-dimer; pts w/ a negative D-dimer require no further testing.
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The most important steps in the management of lactic acidosis from septic shock is what?
-IV normal saline w/ or w/o vasopressor therapy to maintain the intravascular pressure and antibiotics to correct the underlying infection
ARDS
- associated w/ hypoxemia (PaO2/FiO2 <300 mmHg) and bilateral alveolar infiltrates
- Objective assessment (echo) is needed to definitively exclude hydrostatic pulmonary edema in pts w/o ARDS risk factors
Cholesterol embolization
- can cause acute renal failure, skin changes in the lower extremities including bluish discoloration or livedo reticularis, GI symptoms, elevated eosinophils in the blood or urine, and decreased complement levels
- while it may occur spontaneously, a hx of recent angiography in a patient w/ abdominal aortic atherosclerosis is often the main clue to the diagnosis
Echinococcus granulosus
- the majority of human infections are asymptomatic
- HYDATID CYSTS can be found in almost any part of the body but liver (most commonly) is involved in 2/3 of pts and the lungs are involved in 25% of pts. It is most commonly seen in areas where sheep are raised.
4 causes of microcytic anemia
- iron deficiency
- anemia of chronic disease
- thalassemias and other hemoglobinopathies
- lead poisoning, sideroblastic anemia
indicator of iron reserves in the body
-serum ferritin
Carpal tunnel syndrome
- occurs in approx 30% of pts w/ HYPOTHYROIDISM
- deposition of mucopolysaccharide protein complexes within the perineurium and endoneurium of the median nerve is thought to be primary responsible for its pathogenesis
The current vaccination schedule for HIV-infected individuals
- includes all routine vaccinations for adults, as well as serial pneumococcal boosters
- men who have sex w/ men should also receive hepatitis A immunization
- pts w/ CD4 cell counts <200 should not receive live vaccines
causes of hypomagnesemia
-poor nutrition, diuretic use, malabsorption, and alcohol abuse
Cushing’s syndrome
- caused by corticosteroid excess
- hypokalemia and hypernatremia are the electrolyte abnormalities most commonly observed because most corticosteroids have some mineralocorticoid activity and will bind to aldosterone receptors in the kidney, causing renal potassium wasting
Electrical cardioversion is indicated for sustained monomorphic ventricular tachycardia pts who are hemodynamically unstable, pulseless, or severely symptomatic. Hemodynamically stable pts can first be given antiarrhythmics (ie. IV amiodarone) as these may lead to sinus rhythm and avoidance of the need for cardioversion
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Acute angle-closure glaucoma
- usually seen in older pts
- may present w/ a red, painful eye and blurred vision
- corneal opacification can be present, but ulceration is not typical
- the pupil is fixed and mid-dilated
- extraocular symptoms such as headache and nausea are common
the murmur in hypertrophic cardiomyopathy
- crescendo-decrescendo
- increases w/ the Valsalva maneuver
AV fistula
- causes high-output cardiac failure by shunting the blood from the arterial to venous side, thereby increasing cardiac preload
- the patient develops heart failure despite maintaining a normal or high cardiac output because the circulation is unable to meet the oxygen demand of the peripheral tissues
Choriocarcinoma
- metastatic form of gestational trophoblastic disease
- may occur after molar pregnancy or normal gestation, and the lungs are the most frequent site of metastatic spread
- suspect choriocarcinoma in any postpartum woman w/ pulmonary symptoms and multiple nodules on chest x-ray
- an elevated beta hCG helps to confirm the diagnosis
Trypanosoma cruzii
- cause of Chagas’ disease
- endemic in South America and may cause megacolon, megaesophagus, and cardiac disease
- causes both systolic and diastolic heart failure
- may also cause arrhythmias and mitral/tricuspid regurgitation
Constrictive pericarditis
- caused by pericardial scarring and thickening that result in diastolic heart dysfunction
- pts present w/ signs of decreased cardiac output and venous overload
- common etiologies in the U.S. include viruses, cardiac surgery, chest radiation, and idiopathic causes.
- Tuberculosis is the most common cause in developing countries and endemic areas such as Africa, India, and China
Severe pain in a patient w/ a mild urinary obstruction, such as BPH, may cause urinary retention due to inability to Valsalva
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Studies have shown that the risk for sepsis is present up to 30 yrs and probably longer after splenectomy. Current recommendations?
-State that pts should receive anti-pneumococcal, Haemophilus, and meningococcal vaccines several weeks before the operation, and daily oral penicillin prophylaxis for 3-5 yrs following splenectomy.
Thrombocytopenia and hypercoagulation within days of initiating anticoagulant therapy are most likely caused by what?
-unfractionated heparin; Heparin-induced thrombocytopenia is often associated w/ abnormal intravascular thrombosis.
Postoperative cholestasis
-can develop after a prolonged surgery characterized by hypotension, extensive blood loss into tissues, and massive blood replacement
Nonsense and frameshift mutations are typically more severe than missense mutations. Silent (same sense) mutations do not affect the structure of the protein
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Neurofibromatosis type 2
- subcutaneous neurofibromas, hyperpigmented cafe-au-lait spots, deafness due to acoustic neuromas (typically BILATERAL), and a family hx of the disease
- autosomal dominant mutation in tumor suppressor gene on chromosome 22
- Wishart is the severe form
- Gardner is the milder form
Blastomycosis
- fungal infection endemic to the central U.S.
- usually causes a mild pulmonary illness, but disseminated infection may occur even in immunocompetent individuals
- cutaneous blastomycosis manifests as well-circumscribed verrucous nodules and plaques that progress to microabscesses
Actinomyces and Nocardia
- Gram positive rods (and Nocardia is also weakly acid-fast)
- Nocardia often presents as a subacute pneumonia that mimics tuberculosis infection. The majority of pts are immunocompromised.
- Actinomyces causes abscesses primarily at the head and neck w/ characteristic granular yellow pus (“sulfur granules”). It can also cause indolent pulmonary disease.
Blood cultures from separate venipuncture sites should be obtained over a specified period in all pts w/ suspected infective endocarditis prior to initiating antibiotic therapy.
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Viral infection may present w/ symmetric arthritis. Viral arthritis is distinguished from rheumatoid arthritis and other causes of symmetric arthritis by its acute onset, lack of elevated inflammatory markers, and resolution within 2 months.
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Arthritis must be present for at least 6 weeks in order to diagnose rheumatoid arthritis.
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Psoriatic arthritis
- often affects the distal interphalangeal joints
- Dactylitis (sausage digit), nail findings, and psoriasis of the skin are characteristic
Acute rheumatic fever
- occurs in the setting of recent strep infection
- polyarthritis, carditis, chorea, erythema marginatum and subcutaneous nodules are characteristic
- the arthritis of rheumatic fever is migratory in nature and usually first affects the joints of lower extremities
IV adenosine
-causes temporary AV block, which is useful in identifying and in some cases terminating supraventricular tachycardias
Amiodarone
- antiarrhythmic used in many cases of supraventricular and ventricular tachyarrhythmias
- not used in cases of bradycardia because it slows the SA and AV nodes
Symptomatic sinus bradycardia
- should be treated w/ IV atropine, followed by transcutaneous pacing
- medications that slow the heart rate should be replaced w/ alternative therapeutic regimens
- if the bradycardia does not resolve, a permanent pacemaker may be necessary
Torsades de pointes
- polymorphic ventricular tachycardia which occurs in the setting of a prolonged QT interval and is seen in pts w/ familial long QT syndrome, malnourished pts predisposed to hypomagnesemia (such as alcoholics), and in pts taking certain drugs (tricyclic antidepressants), certain antiarrhythmics (amiodarone, sotalol), and anti-infective agents (moxifloxacin, fluconazole)
- Tx includes cessation of any offending agents, and initiation of magnesium sulfate!
Sotalol
-class III antiarrhythmic which inhibits inward potassium ion channels, thereby prolonging the QT interval
Calcium gluconate
-cardio-protective in cases of hyperkalemia (peaked T waves, followed by lengthening of the PR and QRS intervals)
Amiodarone
- class III antiarrhythmic used for both ventricular and atrial tachycardia
- causes QT prolongation
