Internal Medicine EOR Exam Cards Flashcards
3 Anginas
Stable angina - Predictable, relieved by rest and/or nitroglycerine
Unstable angina - Previously stable and predictable symptoms of angina that are more frequent, increasing or present at rest
Prinzmetal variant angina - Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot
3 premature cardiac beats
PVC: Early wide bizarre QRS, no p wave seen
PAC: abnormally shaped P wave
PJC: Narrow QRS complex, no p wave or inverted p wave
Paroxysmal supraventrivular tachycardia
Narrow complex tachycardia without discerbale P waves
A fib/flutter
Fib - Irregularly irregular with absence of clear P waves
Flutter - Sawtooth pattern
2 Sick sinus syndromes
Brady-Tachy - Bradycardia alternates with tachycardia
Sinus arrest - no P wave for 3+ seconds
Sinus arrhythmia when does the pulse increase and decrease?
HR increases with inspiration and decreases with expiration
Ventricular tachycardia
3+ ventricular complexes in a row - WIDE complex tachy
Presentation and management of dilated cardiomyopathy
Caused by ischemia
S3 gallop, rales, JVD
No alcohol, ACEI Diuretic
Presentation and management of hypertrophic cardiomyopathy
Young athlete with fam hx of sudden death
Sustained PMI, bifid pulse, S4 gallop; high pitched mid-systolic murmur at LLSB increased with Valsalva and standing (less blood in the chamber); decreased with squatting
Tx: refrain from physical activity; BB or CCB; surgical or alcohol ablation of hypertrophied septum and defibrillator insertion
Presentation of restrictive cardiomyopathy
Hx of: Amyloidosis, sarcoidosis, hemochromatosis, scleroderma, fibrosis, cancer
PE: pulmonary HTN; normal EF, normal heart size, large atria, normal LV wall, early diastolic filling
Tx: non-specific; diuretics, ACE-I, CCB
Presentation of heart failure
Exertional dyspnea
Non-productive cough
Nocturnal dyspnea
Orthopnea
Cheyenne stoke breathing
JVD 8+ cm
EF categories for heart failure (3)
HFrEF: EF ≤ 40% or “HF with reduced ejection fraction” (previously called “systolic HF”)
HFpEF: EF ≥ 50% or “HF with preserved ejection fraction” (previously called “diastolic HF”)
HFmEF: EF 41% to 49% or “HF with mildly reduced ejection fraction”
4 NYHA classes for heart failure
Class 1: no limitation of physical activity
Class 2: slight limitation in physical activity; comfortable at rest
Class 3: marked physical limitation; comfortable at rest
Class 4: can’t carry on physical activity; anginal syndrome at rest
Diagnostic results for CHF including what you will see on a CXR
BNP, CXR with Kerley B lines
Echo is of course the best test
Pharm management for HFrEF - 3
ACEI (or entresto)
BB
Aldosterone antagonist (Spironolactone)
Pharm management for HFpEF
ACEI
BB or CCB
No diuretics
Three beta blockers for heart failure
Metoprolol
Carvedolol
Bisoprolol
6 first line, evidence based medications for HFrEF
Entresto
ACEI/ARB
BB
Aldosterone antagonist
SGLT2 (flozin)
Diuretic as needed
4 second line agents for CHF
Hydralazine + isosorbide dinitrate
Ivabradine - reduces hospitalization not mortality
Digoxin - Last line
Vericugat - Last line - recent hosp. with IV diuretics
Risk factors and diagnosis for CAD
RF: smoking, diabetes, dyslipidemia (↑ LDL, ↓ HDL), hypertension, family hx, men > 55, women > 65
Dx: high-sensitivity high CRP, lipids, triglycerides, carotid U/S
Management and prevention of CAD
Smoking cessation and lifestyle modification
ASA = cornerstone for primary prevention
Secondary prevention = aspirin, β-blockers, ACE-I/ARB, statins; nitro if symptomatic
MOA of atherosclerosis
Foam cells are created when macrophages eat lipids in vessel walls. They release cytokines to attract more macrophages
Fibrous plaque forms over lipid core
Adhesion, activation, aggregation, propagation of clot, platelet adherence
Acute, Subacute, IVDU, and Prosthtic Valve causes of bacterial endocarditis
Acute bacterial endocarditis: Infection of normal valves with a virulent organism (S. aureus)
Subacute bacterial endocarditis: Indolent infection of abnormal valves with less virulent organisms (S. viridans)
Endocarditis with intravenous drug users - Staphylococcus aureus
Endocarditis with prosthetic valve - Staphylococcus epidermidis
Definitive and possible Duke’s criteria for endocarditis (# of major/minor criteria, not what they are)
Definite: 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria
Possible: 1 major and 1 minor criterion, or 3 minor criteria
3 Major Duke’s criteria for endocarditis
Blood cultures: S. aureus, S. viridans, S. bovis or other typical species x 2, 12 hours apart
Drug users: Staphylococcus. Non-drug users: Streptococcus
Echocardiogram: vegetations are seen (tricuspid-IV drug users, mitral-non drug users)
New regurgitant murmur
4 Minor Duke’s criteria for endocarditis
Risk factor,
Fever 100.5, V
ascular phenomena (splinter hemorrhages, Janeway lesions: painless, palms and soles),
Immunologic phenomena (Osler node: raised painful tender; Roth spots: exudative lesions on the retina)
Janeway lesions
Painless lesions of endocarditis
Palms and soles
Osler nodes
Painful lesions of endocarditis
Fingers and toes
Management of endocarditis
Basic
Prosthtic valve
Dental ppx
IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside
Prosthetic valve: Add rifampin
High-Risk patients prophylaxis for procedures: Amoxicillin - 2 g 30-60 minutes before the procedure
Murmur of aortic stenosis
Harsh systolic ejection crescendo-decrescendo at the right upper sternal border with radiation to neck and apex
Presentation of aortic stenosis
Dyspnea, angina, syncope with exertion; squatting increases intensity; split S2
Increased BNP, helmet cells (schistocytes); cardiomegaly
Murmur of aortic regurg
Soft high pitched, blowing, crescendo-decrescendo along left sternal border; loud leaning forward/squatting
Presentation of aortic regurg
Leaflets of aorta don’t close during diastole → blood regurgitates from the aorta into left ventricle → volume overload left ventricle
S3 or S4 with severe; water-hammer pulse (arterial pulse large and bounding)
Murmur of mitral stenosis
Diastolic low-pitched decrescendo rumbling with an opening snap heart best at the apex with pt. lying lateral decubitus position
Presentation of mitral stenosis
Leaflets of the mitral valve thicken, stiffen from rheumatic fever → valve doesn’t open well in diastolic; cause = rheumatic heart
Left atrial hypertrophy, may also have mitral regurge
murmur of mitral regurg
Blowing holosystolic murmur at the apex with split S2 radiating to the left axilla
Presentation of mitral regurg
Mitral valve doesn’t close fully in systole → blood regurge from LV to LA → murmur
Caused by: CAD, HTN, MVP, rheumatic, heart valve infection; apical S3 = volume overload on the ventricle
Presentation of MVP
Midsystolic ejection click heard best at the apex
Abnormal systolic ballooning in part of the mitral valve into the left atrium
Murmur of tricuspid stenosis
Mid-diastolic rumbling murmur at LLSB with opening snap
Presentation of tricuspid stenosis
RARE! Leaflets of tricuspid valve = stiff/immobile → impaired RV filling from decreased tricuspid valve orifice = increased RA pressure → right and left heart failure
Murmur of tricuspid regurg
High-pitched holosystolic murmur at LLSB radiates to the sternum and increases with inspiration
Presentation of tricuspid regurg
Tricuspid fails to close fully in systole, blood regurgitates from RV → RA = murmur
Murmur of pulmonary stenosis
Harsh, loud, medium pitched systolic murmur heard best at 2nd/3rd left intercostal space that may increase with inspiration
Presentation of pulmonic stenosis
Stenosis of pulmonic valve impairs flow across the valve; increases afterload on the ventricle
widely split S2; early pulmonic ejection sound; RVH
Murmur of pulmonic regurg
High pitched early diastolic decrescendo murmur at LUSB that increases with inspiration
Presentation of pulm regurg
Blood leaks abnormally backward from pulmonary artery though pulmonic valve → RV (RHF)
USPSTF and NCEP cholesterol screening guidelines
USPSTF - 35
NCEP - 20
Four statin benefit groups
Patients with any form of clinical atherosclerotic cardiovascular disease (ASCVD)
Patients with primary LDL-C levels of 190 mg per dL or greater
Patients WITH diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
Patients WITHOUT diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
Optimal LDL, Total CHolesterol, and HDL levels
LDL <100
Total <200
HDL >60
2 high intensity statins
Atorvastatin 40-80
Rosuvastatin 20
Expected cholesterol reduction with high intensity statin
50+% reduction
Expected cholesterol reduction with moderate intensity statin
30-50% reduction
Expected cholesterol reduction with low intensity statin
Under 30% reduction
5 low intensity statins
Simvastatin 10
Pravastatin 10
Lovastatin 20
Fluvastatin 20
Pitavistatin 1 (not a typo)
Levels considered high for lipids
LDL over 189
Total over 239
HDL under 40
Normal, Elevated, Stage 1 and Stage 2 HTN
Normal - <120/80
Elevated - 120-129/<80
Stage 1 - 130-139/80-89
Stage 2 - 140+/90+
Peds normal, elevated, stage 1 and stage 2 HTN
Normal BP: Both systolic BP (SBP) and diastolic BP (DBP) <90th percentile
Elevated BP: SBP and/or DBP ≥90th percentile but <95th percentile, or 120/80 mmHg to <95th percentile (whichever is lower)
Stage 1 hypertension: SBP and/or DBP ≥95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower)
Stage 2 hypertension: SBP and/or DBP ≥95th percentile + 12 mmHg, or ≥ 140/90 mmHg (whichever is lower)
Management for normal and elevated BP
Normal: evaluate yearly and encourage healthy lifestyle changes
Elevated: Recommend healthy lifestyle changes and reassess in 3-6 months
Management for Stage 1 HTN
If ASCVD risk >10%, 1 medication with 1 month follow up
Management for stage 2 HTN
2 medications of different classes and lifestyle with 1 month f/u
If not reduced consider differentials
FIrst line HTN meds for non black and diabetic patients
ACE inhibitor or ARB
Long-acting calcium channel blockers (most often a dihydropyridine such as amlodipine)
or a thiazide-like diuretic (chlorthalidone or indapamide)
Recommended HTN meds for black patients
CCB or thiazide diuretics
CI’s for CCBs
Angina pectoris
May cause leg edema
CIs for ACE/ARB
Diabetes with proteinuria
ACE only - cough, hyperkalemia, pregnancy, and angioedema
SE of spironolactone
hyperkalemia
CI of BB
Asthma
May cause impotence
SE of hydralazine
Lupus like synrome
Pericarditis
Definition and management of hypertensive urgency
BP 180/120+ Without end organ damage
Immediate reduction not needed - start on 2 drug regimen with outpatient follow up
8 Indications of end organ damage (meaning hypertensive emergency)
Retinal hemorrhages
Papilledema,
Encephalopathy,
Acute and subacute kidney injury,
Intracranial hemorrhage,
Aortic dissection,
Pulmonary edema,
Unstable angina or MI
General management of hypertensive emergency
Reduce BP in first hour by 10-20% and then and additional 5-15% over the next 23 hours
Targets are Under 180/120 in first hour
and under 160/110 in the next 24 hours
Drug of choice for hypertensive urgency
Clonidine - immediate reduction NOT required, may start on 2 medication regimen
Drug of choice for hypertensive emergency
Sodium nitroprusside
Indication to reduce BP to 140 in the first hour
severe preeclampsia, eclampsia, or pheochromocytoma crisis
Indication to reduce BP to 120 in first hour
Aortic DIssection
Drug of choice for hypertensive retinopathy
Clevidipine or Sodium Nitroprusside
Diagnosis and mangement of unstable angina
Admit for continuous cardiac monitoring
Stress test if symptoms resolve
MONA
Antiplatelet, BB, LMWH
Presentation and management of prinzmetal angina
Smoking is #1 risk factor, cocaine abuse also risk factor
May see U waves
No reduction in exercise capacity
Transient ST elevation
Management for prinzmetal angina
Stress test or heart cath (no clot found)
IV nitrates
Propranolol = Contrindicated
CCB and long acting nitrates to treat
Presentation of an NSTEMI
Elevated troponins WITHOUT ST elevation or Q waves
Subendocardial infarct without complete blockage
Troponin as a cardiac biomarker
Most sensitive and specific, appears at 2-4 hours, peaks at 12-24 hours, and lasts for 7-10 days
CK-MB as a cardiac biomarker
Appears at 4-6 hours, peaks at 12-24 hours, and returns to normal within 48-72 hours
Myoglobin as a cardiac biomarker
Less commonly used appears at 1-4 hours. The peak is 12 hours and returns to baseline levels within 24 hours
Management for NSTEMI
Beta Blockers + NTG + aspirin and clopidogrel + heparin + ACEI + statins + reperfusion
NO thrombolysis
Less time sensitive than a STEMI
How a STEMI is different from an NSTEMI
Full thickness infarct with ST elevation/q waves along with biomarker elevation
EKG finding for anterior MI
Q waves and ST elevation in leads I, AVL, and V2 to V6
EKG finding for inferior MI
Q waves and ST elevation in leads II, III, and AVF
EKG finding for lateral MI
ST elevation in the lateral leads (I, aVL, V5-6). Reciprocal ST depression in the inferior leads (III and aVF)
EKG findings for posterior MI
ST depressions in V1 to V3
Time windows for STEMI PCI and Thrombolytics
Give ASA and Plavix immediately
PCI - 90 minutes
THrombolytics - 30 minutesif PCI not available
6 Absolute contraindications to thrombolytic use for an MI
Prior intracranial hemorrhage (ICH)
Known structural cerebral vascular lesion.
Known malignant intracranial neoplasm.
Ischemic stroke within 3 months.
Suspected aortic dissection.
Active bleeding or bleeding diathesis (excluding menses)
Presentation of myocarditis
MCC - viral infection (can be from bacterial, parasitic, cardiotoxin, systemic disorders, radiation, hypersensitivity)
Fatigue, fever, chest discomfort, dyspnea, palpitations, tachycardia disproportionate to fever or discomfort
Diagnosis of myocarditis
Biopsy is gold standard
Echo with hypokinesis
Treatment supportive with antidysrhythmic
Presentation, diagnosis and management of pericarditis
Lupus, uremia, cocksackie virus
Pain relieved by sitting forwards with a friction rub
Diffuse ST elevation of EKG, effusion or tamponade on echo
NSAIDs, steroids and abx if needed
Dressler’s syndrome
Pericarditis abt. 5 days after an MI
Leriche syndrome
Plaque in the iliac arteries
Impotence, claudication, and diminished femoral pulses
Femoral artery PAD
MC
Claudication in the thigh and upper calf
Popliteal PAD
Pain in the lower calf
6 P’s of acute arterial embolization
Pain,
Pulselessness,
Pallor,
Paresthesias,
Poikilothermia (inability to regulate temperature),
Paralysis
Diagnosis of PAD
Arteriography is gold standard but only done if revascularization is planned
ABI < 0.9 is diagnostic (1-1.2 is normal)
Management of PAD
Smoking cessation!!
Control T2DM, HLD
Cilostazol (pledal), Aspirin, Plavix
May revascularize
Presentation, diagnosis and management for varicose veins
Aching and fatigue with dilated tortuous veins
Greater saphenous is MC
Duplex US to diagnose
Weight loss, compression,exercise, ablation to treat
Presentation, diagnosis and management of phlebitis
Dull pain and erythema if superficial
Swelling and heat with redness if deep
Homan’s sign, induration
Venous duplex US for dx, d-dimer
Rest, elevation NSAID, anticoagulation if deep
Presentation, diagnosis and management of chronic venous insufficiency
Progressive itching, edema, dull pain andulcerations
Stasis dermatitis, thin atrophic skin
Clinical dx, duplex US may be used
Compression, elevation, skin grafting for tx
Etiology of rheumatic fever
Not infection, inflammatory reaction from Strep A pharyngitis
5 Major JONES criteria for rheumatic fever
Carditis
Chorea
Erythema marginatum
Polyarthritis
Subcutaneous nodules
4 minor JONES criteria for rheumatic fever
Arthralgia
Elevated ESR or C-reactive protein
Fever
Prolonged PR interval (on ECG)
Management of rheumatic fever
Aspirin/NSAID/Steroid for acute
PCN-G
Five years (or until 21) for no carditis
10 years with carditis without residual heart damage
Indefinite for carditis and residual heart damage
MC valve affected in rheumatic heart disease
Mitrea>Aortic>Tricuspid
Hypersensitivity type of rheumatic heart disease
Immune mediated - type II
Presentation of rheumatic heart disease
10-20 years after acute rheumatic fever
Mitral regurg in early stage, stenosis later on
Diagnosis of rheumatic heart disease
Echo
Anti-strptolysin titers (ASO)
Aschoff bodies on histology - granulomas with giant cells
Rheumatic fever prophylaxis for PCN allergy
Sulfadiazine
Murmur of ventricular septal defect
Harsh holosystolic murmur heard at LSB with wide radiation and fixed, split S2
Presentation and management for an aortic aneurysm
Flank pain, hypotension, pulsatile abdominal mass; screen if male >65 and hx of smoking
Tx: immediate surgical repair if >5.5cm or expands >0.5cm per year; monitor annual if >3cm, q6mo >4cm; beta-blocker
Presentation and management of aortic dissection
Sudden onset tearing chest pain between scapula; diminished pulses; widened mediastinum; unequal blood pressures on the arm
Tx: ascending aorta = surgical emergency; descending: beta-blocker
Presentation, Diagnosis, and Management of arterial embolism/thrombus
6 Ps
Angiography is gold standard
IV heparin if not limb threatening
Surgery potentially
Presentation of giant cell arteritis
Jaw claudication and HA, thickened temporal artery scalp pain elicited by touching scalp/hairbrush; acute vision disturbances; associated with polymyalgia rheumatica
Amaurosis fugax (temporary monocular blindness) secondary to anterior ischemic optic neuritis
Diagnosis and management of giant cell arteritis
Dx: ESR >100, temporal artery biopsy
Tx: high dose prednisone URGENTLY – don’t wait for biopsy results
Diagnosis and management of venous insufficiency
Trendelenburg test, US
Sclerotherapy, vein stripping, compression
Virchow’s triad
Stasis
Injury
Hypercoaguability
4 hypercoagulable states
OCP
Cancer
Surgery
Factor 5 disease
Anticoagulation for venous coagulation
Heparin to coumadin bridge
Presentation, diagnosis and management of acute bronchitis
COugh for over 5 days with sputum production that lasts fr 2-3 weeks
May have SOB, fever, chest discomfort
Usually viral and clinical dx - CXR to rule out pneumonia
NSAIDs, Cough suppressants, albuterol
Presentation of asthma
Attacks of breathlessness and wheezing
Hx of allergies or eczema
Dx for asthma
Decreased FEV1/FVC (under 75-80%) with over 12% increase with bronchodilator therapy
Intermittent asthma
Less than 2 times per week with less than 2 night symptoms per month
SABA PRN - Albuterol
Mild persistent asthma
More than 2 times per week or 3-4 nigt symptoms per month
Low dose ICS
Moderate persistent asthma
Daily symptoms or more than 1 nightly episode per week
Low/medium dose ICS and LABA - ie. budesonide
Severe persistent asthma
SYmptoms several times a day and nightly
High dose ICS and LABA and steroids maybe
Acute asthma tx
Oxygen, Nebulizer, Ipratropium bromide, Oral steroids
Presentation, diagnosis and management of bronchiectasis
Dilation and damage of airways due to inadequate airway clearance
Daily cough with foul sputum, frequent infections
Tram track markings on CXR; CT is gold standard
Oxygen, Aggressive abx, physiotherapy and lung transplant for tx
Presentation of carcinoid tumor
Tumors secrete serotonin, histamine, bradykinin
MC appendix to liver to lungs metastasis
May have flushing, diarrhea, wheezing
Diagnosis of carcinoid tumor
Octreoscan
Urinalysis with 5-HIAA
Pellagra (Niacin/B3 deficiency)
CXR with pedunculated sessile growth in central bronchi
Management of carcinoid tumor
Surgical excision and octreotide. Do not respond to chemo/radiation
Presentation of emphysema
Loss of elastin in the lungs causes permanent alveolar enlargement.
DOE, with pursed lip breathing
Pink Puffer
Barrell chest appearance w/ cachexia
Resp. Acidosis
Increased TLC with decreased FEV1
Presentation of chronic bronchitis
Chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years
Rales, rhonchi, respiratory acidosis
Blue bloaters
FEV1/FVC<0.7
COPD Diagnosis
Spirometry = Gold standard
Decreased FEV1 = Obstruction
Hyperinflation on CXR
Arrhythmia associated with COPD
Multifocal atrial tachycardia
Mild COPD threshold and management
FEV1 > 80%
Bronchodilators prn short-acting /decrease risk factors
Moderate COPD threshold and management
FEV1 50-80%
Add long acting bronchodilator
Severe COPD threshold and management
FEV1 30-50%
Add Pulm rehab and ICS
Very severe COPD threshold and management
FEV<30%
Add Oxygen
Bronchodilators SABA, SAMA, LABA, LABA
SABA - Albuterol, Terbutyline
SAMA - Ipratropium bromide (preferred over albuterol in COPD)
LABA - Salmeterol
LAMA - Tiotropium
Theophylline
Last line for COPD due to narrow therapeutic index
6 Etiologies of Cor Pulmonale
COPD (most common),
Pulmonary embolism,
Vasculitis,
Asthma,
ILD,
Acute respiratory distress syndrome
Presentation of Cor Pulmonale
Lower extremity edema, neck vein distention, hepatomegaly, parasternal lift, tricuspid/pulmonic insufficiency, loud S2
Diagnosis and management of Cor Pulmonale
Increased pressure in the right ventricle and pulmonary arteries
Right heart catheterization is the gold standard
Treat underlying lung disease, no diuretics
5 Etiologies of hypoventilation syndrome
Central respiratory drive depression (drugs -narcotics, benzodiazepines, neurologic disorders - multiple sclerosis, etc.),
Neuromuscular disorders (ALS, myasthenia gravis, etc.),
Chest wall abnormalities,
Obesity hypoventilation, and
COPD
Presentation and diagnosis and treatment of hypoventilation syndrome
Sluggish and sleepy during the day
PFTs, sleep studies, CXR, arterial blood gas, serum bicarb
Lifestyle, CPAP, etc.
Presentation of idiopathic pulmonary fibrosis
Scarring over time making it harder to take a deep breath
Often some exposure, though cause is often unknown, amiodarone also potential cause
Inspiratory crackles
Diagnosis of idiopathic pulmonary fibrosis
CXR with fibrosis
CT scan with honeycombing and diffuse patchy fibrosis
Restrictive lung disease of PFT (decreased lung volume, normal/increased FEV1/FVC ratio)
Management of idiopathic pulmonary fibrosis
Antifibrotic drugs (pirfenidone or nintedanib), oxygen therapy, and eventually lung transplant
Most patients deteriorate and the median survival is about 3 years from diagnosis
4 pneumoconeoses with source and imaging findings
Coal workers - from coal (nodular opacities in upper lung fields)
Silicosis - from mining, sandblasting, and quarries (eggshell calcifications)
Asbestosis - Insulation, demolition, shipbuilding (mesothelioma)
Berrylosis - High tech field, nuclear power, ceramics, aerospace, electrical plants, foundries; requires chronic steroids (hilar adenopathy)
Management of pneumoconeosis
Steroids to relieve chronic alveolitis
Smoking cessation = synergistically linked to lung cancer
Causes of viral pneumonia in kids and adults with dx and tx
Kids - RSV - comes on FAST
Adults - Flu
Nasal swabs for dx, flu with Tamiflu (A and B) if sx began <48 hrs; symptomatic tx = beta 2 agonists, fluids, rest
Presentation, dx, and management of bacterial pneumonia
fever, dyspnea, tachycardia, tachypnea, cough, +/- sputum
Dx: patchy, segmental, lobar, multilobar consolidation; blood cultures x2, sputum gram stain
Tx: outpatient = doxy, macrolides; inpatient = ceftriaxone + azithromycin/respiratory FQs
Coccidiodmycosis
Non-remitting cough/bronchitis non-responsive to conventional tx
Fungal inhalation in western states; test with EIA for IgM and IgG
Tx: fluconazole / itraconazole
Pulmonary aspergillosis
Usually those with healthy immune systems
Tx: fluconazole / itraconazole
Cryptococcus
Found in soil; can disseminate and à meningitis
Lumbar puncture for meningitis
Tx: amphotericin B
Histoplasmosis
Pulmonary lesions that are apical and resemble cavitary TB; worsening cough and dyspnea, progression to disabling respiratory dysfunction; no dissemination
Bird or bat droppings (caves, zoo, bird); Mississippi Ohio river valley
Signs: mediastinal or hilar LAD (looks like sarcoid)
Tx: amphotericin B
CD4 threshold for pneumocystis jirovecci
Under 200
Diagnosis and management for pneumocystis jirovechi pneumonia
CXR: diffuse interstitial or bilateral perihilar infiltrates
Dx: bronchoalveolar lavage PCR, labs, HIV test; low O2 sat despite supplemental oxygen
Tx: Bactrim and steroids; pentamidine for allergy
Prophylaxis for high risk pt with CD4 <200 = daily Bactrim
CURB-65 scoring
Confusion,
Urea >7,
RR >30,
Systolic BP < 90 mmHg or Diastolic BP ≤ 60 mmHg,
Age >65
CURB-65 interpretation
0-1 = low risk, consider home tx
2 = probable admission vs close outpatient management
3-5 admission, manage as severe
Pulmonary hypertension definition
Pulmonary SBP >20mmHg
MCC and other causes of pulmonary hypertension
MCC = Mitral stenosis
Cor Pulmonale
Presentation of pulmonary hypertension
DOE, fatigue, chest pain
Loud P2
JVD, Ascites, Hepatojugular reflex
Diagnosis of pulmonary hypertension
R heart cath is gold standard
CXR with enlarged pulmonary arteries
T wave inversion in right and anterior EKG leads
Management of pulmonary hypertension
Caution with diuretics, with digoxin and anticoagulants if MI associated
Vasodilators
Small cell lung cancer
Epidemiology
Management
Location
Management
Paraneoplastic syndrome assoc.
Small Cell (15% of cases) - 99% smokers,
Does not respond to surgery and metastases at presentation
Location: (central mass), very aggressive
Treatment: Combination chemotherapy needed
Paraneoplastic syndromes: Cushing’s, SIADH
Lung Adenocarcinoma
Epidemiology
Associations
Location
Paraneoplastic syndrome assoc.
Most common (peripheral mass), 35-40% of cases of lung cancer
Most common
Associated with smoking and asbestos exposure
Location: Periphery
Paraneoplastic syndrome: Thrombophlebitis
Squamous Cell Lung Cancer
Epidemiology
Potential Symptom
Paraneoplastic syndrome assoc
Hemoptysis, 25-35% of lung cancer cases
Location: central
May cause hemoptysis
Paraneoplastic syndrome: hypercalcemia
Elevated PTHrp
Large Cell Lung Cancer
Epidemiology
Management
Location
Parneoplastic syndrome assoc.
Large cell - fast doubling rates - responds to surgery rare (only 5%)
Location: Periphery 60%
Paraneoplastic syndrome: Gynecomastia
Management of NSCLC
Stage 1-2 surgery
Stage 3 Chemo then surgery
Stage 4 palliative
Management of lung carcinoid
Treated with surgery
Management of SCLC
Chemotherapy - NO Surgery
Presentation of sarcoidosis
Cough and fever with bilateral hilar adenopathy
Elevated ACE and Calcium levels
Pulm manifestations most common
Second derm manifestations: erythema nodosum (tender red nodules, usually on the lower legs), or lupus pernio (chronic, violaceous, raised lesions on the face)
Diagnostics of sarcoidosis
Hypercalcemia with ACE levels 4x normal
Non-caseating granulomas on lung biopsy
Hilar lymphadenopathy on CXR
Management of sarcoidosis
Steroids help 90%
Methotrexate, serial PFTs to monitor, ACE-I for periodic HTN
Pulm fibrosis is leading cause of death
Common demographic of sarcoidosis
African American
Size cutoff for pulmonary nodule vs. mass
3 cm
Pulmonary nodule workup
Get CT if found on CXR, biopsy if suspiscious
Suspicious pulmonary nodule criteria and management
Ill defined, lobular or spiculated nodules on CT
Biopsy
Non suspicious pulmonary nodule criteria and management
Well defined with smooth calcifications (central, popcorn, or concentric)
Under 1.5 cm
If < 1 cm monitor at 3 mo, 6 mo, then yearly for 2 yr
Pulmonary nodule growth for beign v malignant
Benign - no growth in 2 years
Malignant - double in 21-40 days
Diameter of pulmonary lesion strongly suspected of cancer
> 5.3 pulmonary lesion
Hepatitis A presentation, diagnosis and managment
Fatigue, malaise, N/V, RUQ pain
Trip abroad with dark colored urine
Icterus and liver tenderness
IgM anti HAV
Supportive care
Hepatitis B Serologies
HBeAg
HBsAg
Anti-HBc
Anti-HBc IgG
Anti HBc IgM
Anti-HBs
HBeAg – highly infectious
HBsAg – ongoing infection
Anti-HBc – had/have infection
IgM – acute
IgG – not acute
Anti-HBs – immune
Chronic hepatitis B serology
HBsAg — Positive
IgG anti-HBc — Negative
Anti-HBs — Negative
Acute hepatitis B serology
HBsAg — Positive
IgM anti-HBc — Positive
Anti-HBs — Negative
Resolved hepatitis B serology
HBsAg — Negative
Total anti-HBc — Positive
Anti-HBs — Positive
Vaccinated HBV serology
Anti-HBs positive only
Presentation, diagnosis and management of hepatitis C
IV drug and alcohol use, may be sexual
HCV antibodies
Tx: antiretrovirals target complex of enzymes needed for HCV RNA synthesis
Hepatitis with risk of hepatocellular cancer
Hepatitis B
Hepatitis D
Occurs only with hepatitis B with risk of hepatocellular carcinoma
Hepatitis E
Pregnant women in thrid-world countries with hepatitis symptoms
Supportive tx
Alcoholic hepatitis
AST:ALT ratio of > 2:1
Acetominophen toxicity management
N-acetyl-cysteine within 8-10 hours
Presentation and management of fatty liver disease
ALT>AST
US with increased echogenicity and echotexture
Large fat droplets on biopsy
Weight loss for tx
Presentation of acute pancreatitis
Upper abdominal pain radiating to the back with nausea and vomiting
Cullen and Gray-Turner signs
Diagnosis of chronic and acute pancreatitis
Abdominal CT for ruling out necrosis
ERCP for chronic pacreatitis
Clinical with amylase and lipase
GET SMASHHED causes of pancreatitis
Gallstones,
Ethanol,
Trauma,
Steroids,
Mumps,
Autoimmune disease, Scorpion sting, Hypercalcemia,
Hyperlipidemia,
ERCP, and
Drugs
Ranson’s criteria at admission - 5
Age > 55
Leukocyte: >16,000
Glucose: >200
LDH: >350
AST: >250
Ranson’s criteria at 48 hours - 6
Arterial PO2: <60
HCO3: <20
Calcium: <8.0
BUN: Increase by 1.8+
Hematocrit: decrease by >10%
Fluid sequestration >6L
Pancreatic pseudocyst
A circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue
Complication of pancreatitis
Management of pancreatitis
Fluids, analgesics, bowel rest
Triad of chronic pancreatitis
Pancreatic calcification (plain abdominal x-ray),
Steatorrhea (high fecal fat), and
Diabetes mellitus
Presentation and management of anal fissure
Rectal pain and bleeding shortly after defecation with BRB
Superficial paper-cut laceration with sentinel pile of thickened mucosa
Dx via visualization or anoscopy
Management of anal fissure
Sitz bath, fiber, water, and stool softeners
Heals in 6 weeks
Botox if failing conservative tx
Presentation, diagnosis and management of rectal abcess/fistula
Communication between the rectum and perianal skin
Generally located within 3 cm of the anal margin
Fistulae will produce anal discharge and pain when the tract becomes occluded
DX: Anoscopy
TX: Fistulas must be treated surgically
Presentation of anorectal cancer
Rectal bleeding and tenesmus
MCC is adenocarcinoma
Diagnosis and management of anorectal cancer
Colonoscopy for any rectal bleeding
Treated with wide local surgical excision, radiation with chemotherapy for large tumors with metastases
Presentation and imaging sign for colon cancer
Painless rectal bleeding and change in bowel habits
Apple core lesion on barium enema
Adenoma is MC
Frequencies for colorectal cancer screening modalities
45-75 years of age
FIT/FOBT - Yearly
FIT-DNA - every 1-3 years
Sigmoidoscopy - every 5 years
Colonoscopy - every 10 years
CT colonography - every 5 years
Tumor marker for colon cancer
CEA
Characteristics of benign v. malignant colon lesions
More likely to be malignant: sessile, > 1 cm, villous
Less likely to be malignant: Pedunculated, < 1 cm, tubular
Management of colon cancer
Resect tumors and adjuvant chemotherapy
Presentation of esophageal neoplasm
Progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis
MCC - squamous cell
Screen Barret’s patients every 3-5 years (adeno)
Smoking/Alcohol, upper 2/3 (squamous)
Presentation of Gastric Cancer
Abdominal pain and unexplained weight loss are the most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool
2 nodes of gastric cancer
Virchow’s node - supraclavicular
Sister Mary Joseph - umbillical
Diagnosis of gastric cancer
Upper endoscopy with biopsy; linitis plastica – diffuse thickening of stomach wall d/t cancer infiltration (worst type)
Management of gastric cancer
Gastrectomy, XRT, chemo; poor prognosis
Presentation of celiac disease
Diarrhea, steatorrhe, flatulence with eating gluten, weight loss and abd distension
Dermatitis herpetiformis
5 Associated diseases of celiac disease
T1DM,
Autoimmune hepatitis,
Autoimmune thyroid DZ,
Down, turner, Williams syndrome,
Increased incidence of small bowel lymphoma
Diagnosis and management of celiac disease
IgA anti-endomysial (EMA) and anti-tissue transglutaminase (anti-TTG) antibodies
Small bowel biopsy (duodenum) is the gold standard
Treatment: Lifelong gluten-free diet
4 causative organisms of cholangitis
E. coli, Enterococcus, Klebsiella, Enterobacter
Triad and Pentad of cholangitis
Charcot’s triad: RUQ tenderness, jaundice, fever
Reynold’s pentad: Charcot’s triad + altered mental status and hypotension
Initial and best imaging for cholangitis
US - Initial
ERCP - Best
Management of cholangitis
Aggressive care and emergent removal of stones, Cipro + metronidazole
Antibiotics, fluids, and analgesia.
ERCP to remove stones, insert a stent, repair the sphincter
Cholecystectomy (performed post-acute)
4 diseases associated with primary sclerosing cholangitis
IBD, cholangiocarcinoma, pancreatic cancer, colorectal cancer
Presentation of cholecystitis
Fourty, Female, Fat, Fertile, Fair
RUQ pain after a high fat meal
Low grade fever, leukocytosis, jaundice
Diagnosis of cholecystitis
US initial with 3+mm gallbladder wall thickening and percicolic fluid
+ Murphy’s sign
HIDA gold standard
CT for perf/abscess
Labs of cholecystitis
Elevated alkaline phosphatase
Conj Billirubin
GGT
Management of choledocholithiasis
ERCP with stone removal
Porcelain gallbladder
Sign of chrinic cholecystitis
Presentation, dx and tx for cholelithiasis
Nilliary colic from mild to severe
Boas sign - referred paim to R scapula
Managment for cholelithiasis
None if asymptomatic
Cholecystectomy if symptomatic
Budd-Chiari Triad
Abdominal pain, ascites, and hepatomegaly
Presentation and management of ascites
Abdominal distension and fluid wave
Measure serum albumin concentration
Lasix, Aldactone, Paracentesis
Presentation of esophageal varices rupture
Dilated submucosal veins, retching or dyspepsia, hypovolemia, hypotension, and tachycardia
Hepato renal syndrome
Progressive renal failure in ESLD, secondary to renal hypoperfusion from vasoconstriction - azotemia (elevated BUN), oliguria (low urine output, and hypotension
Presentation of hepatic encephalopathy
Asterixis (flapping tremor), dysarthria, delerium, coma
General presentation of cirrhosis
Ascites, pulmonary edema/effusion, esophageal varices, Terry’s nails (white nail beds)
Skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation
Management of cirrhosis
Avoid alcohol
Lab monitoring every 3-4 months
Endoscopy for varices
US every 6-12 months for hepatocellular carcinoma
Presentation of Crohn Disease
MC in caucasians 15-35
Weight loss, diarrhea, aphthous ulcers, anemia, fatigue
MC site of crohn disease
Terminal ileum
Diagnosis of crohn disease
String sign on barium enema, Cobblestoning and skip lesions from mouth to anus
Anti-saccharomyces cerevisiae antibodies (ASCA)
and pANCA
Lifestyle management of crohns
Crohn’s: supplement with vitamin B12, folic acid, vitamin D
Smoking cessation
Surgery not curative in Crohn’s; curative in UC
Medication management of crohns
Aminosaliciylates (mesalamine, sulfasalazine) mesalamine best for maintainance -> Corticosteroids -> Immune modulators - 6-mercaptopurine, azathioprine, and methotrexate or 6-mercaptopurine (anti-TNF drug)
Presentation of diverticulitis
Left sided Appendicitis
MC in sigmoid colon
Fever/chills/Nausea/vomiting/left-sided abdominal pain
Diagnosis of diverticulitis
CT with oral, rectal and IV contrast
Bowel thickening and fat stranding on CT
Management of diverticulitis
Conservative management (pain control + liquid diet x 2-3 days), sometimes antibiotics, and sometimes percutaneous or endoscopic ultrasound-guided drainage or surgical resection
Recurrent attacks or the presence of perforation, fistula, or abscess require surgical removal of the involved portion of the colon
Increase bulk the diet with high-fiber foods and bulk additives such as Metamucil
Presentation of esophageal stricture
Progressive dysphagia to solids
Webs in the mid-upper esophagus
Rings at the esophageal-gastric junction
MCC is GERD
Plummer vinsons syndrome
esophageal webs + dysphagia + iron deficiency anemia
Diagnosis and management of esophageal stricture
Endoscopy (rule out malignancy)
Barium swallow - tortuous esophagus
Dilation to treat
Management of esophageal varices
Banding and Beta Blocker, IV octreotide for bleeding
Screening for esophageal varices
When high-risk varices are diagnosed, prophylaxis should be started, and further screening is not necessary
Otherwise, screening should be repeated every 2 to 3 years for patients without varices and every 1 to 2 years for patients with small varices
2 Medications that can cause esophagitis
NSAIDs or Bisphosphonates
Management of esophageal candidiasis
Fluconazole 100 mg PO Daily
HSV v CMV esophagitis and managment
HSV - Punch lesions use acyclovir
CMV - Large solitary ulcers use gancyclovir
Management of corrosive esophagitis
Steroid
Diagnosis and Management of eosinophilic esophagitis
Biopsy and barium swallow with corrugated rings
Allergen elimination
Steroid topical of inhaled
Prevention of bisphosphonate indiced esophagitis
Take with water avoid reclining for 30-45 minutes
4 radiosensitizing drugs causing esophagitis
doxorubicin, bleomycin, cyclophosphamide, cisplatin
General presentation of gastritis
Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis
DIagnosis, Location and management of H. Pylori gastritis
LOcated in the antrum and body of the stomach
Breath or fecal antigen test
CAP (Clarithromycin, Amoxicillin, PPI0 4-8 weeks
OR quad therapy (PPI, Pepto, 2 ABX
Dividing line for upper/lower GI bleeds
Ligament of trietz
Autoimmune Gastritis presentation, dx and tx
Hypersensitivity leading to pernicious anemia
Schilling test showing decreased intrinsic factor
Vitamin B12
Presentation of E. coli travelers diarrhea
Occurs in the first 2 weeks and lasts 4 days without treatment
3+ unformed stools with one of: fever, nausea, vomiting, abdominal cramps, tenesmus, bloody stools
Empiric treatment for travellers diarrhea
Ciprofloxacin and Loperamide (if over 2)
Abx for campylobacter or shigella
FQ
Abx for travelers diarrhea in pregnant, FQ resistant, or under 2
Z-max
Prophylaxis for travelers diarrhea
FQ - 90% effective
Bismuth - 50% effective
Etiology of viral gastoenteritis
Daycare - Rotavirus
Cruise ship - Norovirus
Presentation of viral gastoenteritis
Lasts 48-72 hours but symptoms may linger up to one week
Myalgias, malaise, possible low-grade fever
Headache, watery diarrhea, abdominal pain, nausea, and vomiting
Supportive tx
Presentation of salmonella enteric fever
Raw poultry, pork, or egg consumption
Flu like with GI symptoms
Pea soup diarrhea
Rose spots on trunk
Presentation of salmonella gastroenteritis
1/10,000 egg yolks
Inflammatory diarrhea 24-48 hours after consumption
Management for salmonella infection and when to treat vs. support
Rocephin or sometimes Azithromycin or FQ
Only treat in immune compromised
Presentation of shigellosis
Primarily affects children
Abdominal pain and inflammatory diarrhea with mucous and tenesmus
Large amounts of fecal leukocytes
Management for shigellosis
Bactrim may us FQ
Do not use antidiarrheals
EHEC/ETEC
Undercooked ground beef
12-60 hour onset
May have bloody or non-bloody stool
No fecal laukocytes
Abx if severe
HUS - Hemolysis with thrombocytopenia
Presentation of cholera
Life threatening rice water diarrhea
Seafood consumption
24-48 hour incubation
Abx for cholera - 5 options
Doxycycline, azithromycin, furazolidone, bactrim, or ciprofloxacin
Presentation, Dx of giardiasis
Drinking from outdoor streams
Bulky foul stool
Stool for cysts and trophozooites
Tx for giardiasis
Tinidazole - first line
Flagyl also an option
Pinworm
Enterobius vermicularis
Itching with scotch tape test
Mebendazole
Tapeworm
Taenia saginata
GI symptoms and weight loss
Eating undercooked beef
B12 defficiency
Eggs in stool
Praziquantel to tx
Hookworm
Water contact, cough from lungs to GI tract
Eosinophilia and anemia, serpiginous rash
Stool for worms
Tx mebendazole or pyrantel
Roundworm
Pancreatic duct, common bile duct, and bowel obstruction
MC intestinal worm
Stool for eggs or worms
Albendazole, mebendazole, or pyrantel pamoate
Amebiasis
Entamoeba histolytica cysts and trophozoites
Metronidazole for the acute phase, followed by Paromomycin to eliminate any remaining cysts
Causes liver cysts
Schistosomiasis
Contaminated water
Rash, abdominal pain, bloody stools
Eggs in urine/Feces
PRaziquantel to treat
Presentation of GERD
Retrosternal pain/burning shortly after eating worse with carbonation, greasy foods, spicy foods, and lying down
Diagnosis of GERD
Endoscopy with biopsy—the test of choice but not necessary for typical uncomplicated cases
Indicated if refractory to treatment
Upper GI series (barium contrast study)—this is only helpful in identifying complications of GERD (strictures/ulcerations)
PH Probe is the gold standard for diagnosis (but usually unnecessary)
7 GERD “red flag” symptoms
dysphagia, recurrent vomiting, weight loss, hematemesis, anemia, melena, or age > 50
Management of GERD
H2 blocker, PPI, Dietary modifications - fatty foods, coffee, alcohol, orange juice, chocolate; avoid large meals before bedtime
Defining line between external and internal hemorrhoids
Dentate line
Thrombosed and unthrombosed hemorrhoids w/ tx
Bleed if not thrombosed
Significant pain and pruritus but no bleeding
Treat with excision
May use sitz bath, hydration, fiber and topical anesthetic for nonthrombosed or mild
Presentation and management of internal hemorrhoids
Bright red blood per rectum, pruritus and rectal discomfort
Fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids
Rubber band ligation If protrudes with defecation, enlargement, or intermittent bleeding
Closed hemorrhoidectomy if permanently prolapsed
3 Etiologies of hepatic carcinoma
Cirrhosis,
Hepatitis B-D,
Aflatoxin from Aspergillus
Marker, imaging, management and prognosis for liver cancer
Alpha-fetoprotein
Abnormal imaging
Resection and transplant with poor prognosis
Hiatal hernia presentation and management
Symptoms of GERD that are worse with lying down
Substernal regurgitation and dysphagia
Chest palpitations and shortness of breath
Diagnosis of hiatal hernia
Barium or endoscopy
Ultrasound
Management for sliding vs. rolling hiatal hernia
Sliding - treat like GERD
Rolling (type II) - Surgery/Fundiplication to avoid complications
Presenation of IBS
Abdominal pain and altered bowel function with no organic cause able to be found
Rome Criteria for IBS
Recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria:
Related to defecation
Associated with a change in stool frequency
Associated with a change in stool form (appearance)
Dx of IBS
CBC, FOBT, O&P, SIgmoidoscopy/Endoscopy, Barium Swallow
Management of IBS
Management includes dietary modifications (e.g., low FODMAP diet), fiber supplementation, and pharmacotherapy (e.g., antispasmodics, laxatives for IBS-C, antidiarrheals for IBS-D)
Psychological therapies (e.g., cognitive-behavioral therapy) and probiotics may also be beneficial
Presentation, diagnosis and management for a mallory-weiss tear
History of alcohol intake followed by vomiting with blood
Upper endoscopy showing superficial longitudinal mucosal erosions
Supportive tx - inject epinephrine if needed.
Hiatal hernia presentation and management
Symptoms of GERD that are worse with lying down
Barium or endoscopy
PPI with surgery needed 15% of cases
Rolling vs. Sliding (rolling is worse)
Duodenal ulcer
Often better after eating with lass pain than a stomach ulcer
More likely to be H pylori
Stomach ulcer
Gnawing burning pain that is worse with meals
Often caused by H pylori
Diagnostics for stomach ulcers
Upper endoscopy with biopsy if malignant appearing
Management for PUD
PPI 4-8 weeks
CAP tx for H pylori
d/c NSAIDs
Tests for H pylori
Breath or Stool test
Bismuth and concomitant therapies for H pylori
Bismuth quadruple therapy:
Bismuth subsalicylate,
Metronidazole,
Tetracycline, and a
PPI given for 14 days
Concomitant therapy consists of a Clarithromycin,
Amoxicillin, a
Nitroimidazole (tinidazole or metronidazole), and a
PPI administered together for 10-14 days
Presentation of Ulcerative Colitis
Most common in the rectum
Shallow - mucosa only
Hematochezia and pus-filled diarrhea, fever, tenesmus, anorexia, weight loss
Diagnosis of UC
Barium enema: Lead pipe appearance (loss of haustral markings) -> may lead to toxic megacolon
P-ANCA on serology
Colonoscopy: continuous lesions in the mucosa/submucosa of rectum and colon
Tx of UC
Medications: Prednisone and mesalamine
Colectomy is curative
Complication of UC
Toxic Megacolon
Screening in UC
Screen for anemia, liver disease
Check B12 and D vitamins every 1-2 years
Presentation of fibromyalgia
Widespread muscular pain, fatigue, muscle tenderness, headaches, poor sleep, and memory problems
Pain is worse in the morning, fatigue and sleep disturbances
Worsened with stress
MC in 20-50 year-old women
Assoc with hypothyroidism, RA, or sleep apnea
Diagnosis of fibromyalgia
Widespread pain index must be greater than seven, and the symptom severity scale must be greater than five for at least three months
Biopsy, “moth-eaten” appearance type I muscle fibers, injury to the muscle
Management for fibromyalgia
Stress reduction, sleep , exercise
Duloxetine (Cymbalta)
Milnacipran (Savella),
Pregabalin (Lyrica)
Presentation of true gout
Men over 30 (more common in women poste menopause)
Assymmetric tophi - great toe
Pain, swelling redness, tenderness
Podagra
Sudden gout attack
Labs/Diagnostics of gout
Rod shaped negatively birefringent crystals
Serume uric acid over 8
Punched out lesions on XR
Lifestyle modifications for gout
Elevation, rest, decrease purines (meats, beer, seafood, alcohol), weight loss, increase protein, limit alcohol
Management of gout attack
Indomethacin is best
Colcicine (bad GI s/e) or steroids if not tolerated
Meds to avoid in gout
Thiazide diuretics
Aspirin
No allopurinol while acute
2 drugs for long term gout management
Allopurinol
Colchicine
Presentation of pseudogout
Over 60, Large joint involvement without LE tophi
Rhomboid, birefringent, calcium pyrophosphate crystals
Linear calcifications of XR
Management of pseudogout
NSAIDs, colchicine, intra-articular steroid injections
Colchicine = prophylaxis, NSAIDs = acute attacks
Epidemiology of polyarteritis nodosa (PAN)
MC in men 40-50
Inflammation of small and medium blood vessels
Assoc with HBV and HCV
Presentation of PAN
Arterial andyeurism and thrombosis
Hypertension, aneurysm, thrombosis, necrosis - following damage
Renal failure, fevers, myalgias, amaurosis fujax, neuropathy, livedo reticularis, ulcers, gangrene
Diagnosis of PAN
Tissue biopsy or angiogram
Biopsy shows becrotizing arteritis
Angiogram shows aneurisms
Elevated ESR without elevated ANCA in most cases
Management of PAN
Steroids (prednisone) +/- cyclophosphamide if refractory
Plasmapheresis in patients with Hepatitis B virus
Presentation of polymyalgia rheumatica (PMR)
PAINFUL synovitis, bursitis, and tenosynovitis - aching STIFFNESS of PROXIMAL JOINTS (shoulder, hip, neck) in patients > 50 years old
Joint pain and stiffness as opposed to muscle pain and weakness (polymyositis)
May have temporal arteritis
Diagnosis of PMR
Marked elevation in ESR
Temporal artery biopsy for temporal arteritis
Management of PMR
Low dose steroid for up to 2 years, methotrexate may be used
Presentation of polymyositis
PAINLESS muscle weakness without skin rash
Proximal muscle weakness
Fatigue
Diagnosis of polymyositis
Muscle biopsy - endomysial involvement
↑ Muscle enzymes: ↑ aldolase, creatine kinase; ↑ ESR, (+) muscle biopsy, abnormal EMG
“Mechanic’s hands” hyperkeratotic cracked hands with a dirty appearance
Serology of polymyositis (3)
+) ANTI-JO 1 Ab: Myositis-specific Antibody-associated with interstitial lung fibrosis
(+) Anti-SRP Ab: signal recognition particle Ab
(+) Anti-Mi-2 Ab: specific for dermatomyositis
Management of polymyositis
corticosteroids and sometimes other immunosuppressants (methotrexate/azathioprine)
Presentation of reactive arthritis (Reiter Syndrome)
Autoimmune response to separate infection (often gonorrhea/chlamydia)
Assymmetric
Conjunctivitis, Uveitis, Urethritis, Arhtritis (can’t see, can’t pee, can’t climb a tree)
Diagnosis of reactive arthritis
Hx of infection w/ positive HLA-B27 ab
Management of reactive arthritis
NSAID and abx to treat initial infection
Presentation of rheumatoid arthritis
Morning stiffness > 30 mins with improvement during the day
Small joints with MCP as the MC
4 presentations of systemic rheumatoid arthritis
Boutonniere deformity: flexion at PIP, hyperextension of DIP
Swan neck deformity: flexion at DIP with joint hyperextension at PIP
Ulnar deviation at MCP joint
Rheumatoid nodules
2 serologies for rheumatoid arhtritis
(+) Rheumatoid Factor (sensitive but not specific); Increased CRP and ESR
(+) Anti-citrullinated peptide antibodies (most specific for RA)
Drug management for rheumatoid arthritis
Methotrexate - first line
Hydroxychloroquine (add to MTX)
Sulfasalazine (add to MTX and HCQ)
Leflunomide - May be a monotherapy - good for unclear diagnosis
NSAIDs, low dose steroids for pain
May also use biologics
Presentation of Sjogren Syndrome
Attacks exocrine glands causing dryness - dry mouth, dry eyes, parotid enlargement
Joint pain
Diagnosis of Sjogren Syndrome
(+) Rheumatoid Factor (RF)
(+) Schirmer Test (<5mm lacrimation in 5 min)
Management of Sjogren Syndrome
Artificial tears
Pilocarpine: a cholinergic drug that increased lacrimation and salivation (side effects include diaphoresis, flushing, sweating, bradycardia, diarrhea, N/V, incontinence and blurred vision)
Cevimeline: stimulates muscarinic cholinergic receptors
Classic triad of lupus
Joint pain, Fever, Malar Rash
8 Other signs of lupus
Discoid rash (chronic, can scar)
Photosensitivity (other rashes from sun exposure)
Mucosal involvement (ulcers, mouth, and nose)
Serositis (pleuritis, pericarditis)
Joint arthritis (2 or more)
Renal disorders (abnormal urine protein, diffuse glomerulonephritis)
Neurologic disorders (seizures, psychosis)
Hematologic disorders (anemia, thrombocytopenia, leukopenia)
Serology of lupus
(+) Anti-nuclear Ab (ANA): ANA best initial test (not specific)
(+) Anti-double-stranded DNA and Anti-Smith Ab: 100% specific for SLE (not sensitive)
Management of lupus
Manage with sun protection, hydroxychloroquine (for skin lesions), NSAIDs, or acetaminophen for arthritis
Pulse dose steroids; cytotoxic drugs (methotrexate, cyclophosphamide)
Presentation of Scleroderma (Systemic sclerosis)
Systemic connective tissue disorder causing thickened skin
Tight, shiny, thickened skin due to fibrous collagen buildup
Reynauds phenomenon
CREST syndrome
Part of scleroderma:
Calcinosis cutis,
Raynaud’s phenomenon,
Esophageal motility disorder,
Sclerodactyly (claw hand),
Telangiectasia
Serology of Scleroderma
(+) ANTI-CENTROMERE AB: associated with limited crest disease and better prognosis
(+) ANTI-SCL-70 AB: associated with diffuse disease and multiple organ involvement (+) ANA
Management of scleroderma
Acute management with DMARDs and steroids
Treat Raynaud’s with vasodilators (CCBs and prostacyclin)
Presentation of acromegaly/gigantism
Sweating, visual defects. macroglossia, and bony enlargement - gigantism presents with excess height since growth plates are not closed
Diagnosis and management of acromegaly/gigantism
Labs and imaging
GH test 2 hour after glucose load
Increased IGF-1
MRI/CT shows a pituitary tumor
Treatment: Pituitary tumor removal
Etiology of Addisons disease
MCC - Autoimmune
Can also be brought on by TB
Presentation of addisons disease
Hyperpigmentation, hypotension, fatigue, myalgias, GI complaints, weight loss
Due to reduction in cortisol
Diagnosis of addisons disease
↓ sodium, ↓ 8 AM cortisol, ↑ ACTH (primary), ↑ potassium (primary), low DHEA
High dose cosyntropin (synthetic ACTH) stimulation test
Blood or urine cortisol is measured after an IM injection of cosyntropin (synthetic ACTH)
The normal response is a rise in blood and urine cortisol levels after synthetic ACTH is given
Primary adrenal insufficiency results in little or no increase in cortisol levels (< 20 mcg/dL) after ACTH is given
Management of addisons disease and addisonian crisis
Hydrocortisone/prednisone PO daily
Crisis: Hypotension, altered mental status
Treatment: Emergent IV saline, glucose, steroids
Cushing syndrome v disease
Syndrome - nonspecific source
Disease - pituitary adenoma
Presentation of cushing disease
obesity (buffalo hump, moon facies, supraclavicular pads), HTN, thirst, polyuria, hypokalemia
Proximal muscle weakness, pigmented striae; backache, headache, oligomenorrhea/amenorrhea / ED; emotional lability/psychosis
Due to excess cortisol
Diagnosis of cushing disease
24 hr urine free cortisol, late-night serum cortisol, and/or low-dose dexamethasone suppression test
High ACTH = pituitary adenoma likely
Low ACTH = Non-pituitary etiology likely
Dexamethsone suppression test
Give a steroid (dexamethasone) ⇒ failure of steroid to decrease cortisol levels is diagnostic ⇒ proceed next to high dose dexamethasone suppression test ⇒ no suppression = Cushing’s syndrome
Suppression < 5 ugs/dL excludes Cushing with some certainty
Managment of cushing disease
transsphenoidal selective resection of pituitary tumor cures 75-90%
Irradiation provides remission in 50-60%
95% 5-year survival
Causes of central diabetes insipidus
Idiopathic, autoimmune destruction of posterior pituitary from head trauma, brain tumor, infection, or sarcoidosis
Causes of nephrogenic diabetes insipidus
Drugs (Lithium, Amphoterrible), hypercalcemia and hypokalemia affect the kidney’s ability to concentrate urine, acute tubular necrosis
Diagnosis of diabetes insipidus
Serum osmolality is high while urine osmolality is low
No response to fluid restriction (not psychogenic)
No response to desmopressin (nephrogenic as opposed to central)
Management of central and nephrogenic diabetes insipidus
Central = desmopressin/DDAVP
Nephrogenic = sodium and protein restriction, HCTZ, indomethacin
Markers of T1DM
HLA-DR3/4/O antibodies. Islet cell antibodies
Insulin, GAD65, and IA-2 antibodies
Fasting and postprandial glucose levels that makr diabetes
126 fasting
200 postprandial
A1c for diabetes
6.5+
A1c for prediabetes
5.6-6.4
Criteria for metabolic syndrome
3+ of five criteria
Fasting TG over 150
HDL under 40
BP over 130/85
Fasting Glucose over 100
Waist circumference over 40(M) 35(F)
If they are on meds for any of these conditions that counts
Insulin effect on sdium, blood vessels and lipolysis
Retains sodium, dilates blood vessels, leads to FFAs in blood stream
In insulin resistance it still retains sodium but DOES NOT dilate blood vessels
3 poly’s of a general diabetes presentation
Polyuria
Polydipsia
Polyphagia
Dual peak of T1DM incidence
4-7 or 10-14
4 potential exam findings for T2DM
Poorly healing footh ulcer, Balanoposthitis, Rash in intertriginous fold, Acanthosis nigricans
Fasting BS
Postrprandial BS
A1c
Desired for patients who are diabetic for glycemic control to be acheived
A1c - Under 7%
Fasting BS - 80-130
Postprandial BS - Under 180
2 best antihypertensives for DM
ACE or ARB ~Pril or ~Sartan
5 bolus insulins
Lispro
Aspart
Glulisine
Technosphere (IN)
Human REGULAR
5 Basal insulins
Human NPH
Detemir
Glargine (U300 is ultra long)
Tresiba (ultra long)
Dawn phenomenon
Hyperglycemia that occurs in the morning due to the body naturally countering the effects of insulin
Somogyi effect
Hyperglycemia that occurs because of excessive nocturnal insulin - high BS is a rebound reaction
2 ways to differentiate between Dawn and Somogyi
Check BS at 3 am Low=Somyogi, Med/High=Dawn
Decrease bedtime insulin improves with somyogi, gets worse with Dawn
Metformin
Biguanide - FIRST LINE
Inhibits hepatic gluconeogenesis
Decreases glucose absorption
Slightly improves insulin sensitivity
Pro/Con of metformin
Cheap, weight loss, good lipid profile
GI side effects, metallic taste, B12 deficiency, can cause lactic acidosis
TZDs
Rosiglitazone and Pioglitazone
Unlock muscle and fat cells and improve insulin sensitivity
CI in: CHF, liver disease, fluid retention, weight gain, bladder cancer (pioglitazone), a potential increase in MI (rosiglitazone)
3 Sulfonylureas and 2 Meglitinides
Glimepiride
Glipizide
Glyburide
Lower A1c by 1-2%
Repaglinide
Nateglinide
Lower A1C by .5-1%
MOA of SUlfonylureas
Stimulates pancreatic beta-cell insulin release (insulin secretagogue)
May cause hypoglycemia
Alpha glucosidase inhibitors
Block breakdown of starches in the intestine and delay carb absorption
Acarbose and Miglitol
Reduce A1c by .5-.8
TID with GI side effects
SGLT2 inhibitors
Halt renal glucose absorption in the PCT
(sugar flows in the toilet instead)
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin
DPP-4 inhibitors
Extend effects of Incretin by inhibiting its degradation
END in Liptin
Management of DKA
TREAT WITH FLUIDS! Patients with DKA are always dehydrated and need large-volume IV fluid resuscitation, usually isotonic fluids such as normal saline. If the corrected serum sodium level is high, this can be reduced to half-normal saline. Insulin should always be administered by an IV pump to guard against accidental overdose.
Indication to add insulin for T2DM
A1c > 9
EKG and lab findings for hypercalcemia
Shortened QT interval
↑ PTH, ↑ Calcium, ↓ phosphorus
Stones, bones, groans, moans
Management of hypercalcemia
IV normal saline and furosemide
Etiology, presentation and management of hypernatremia
Diarrhea, burns, diuretics, hyperglycemia, diabetes insipidus, a deficit of thirst
Poor skin turgor, dry mucous membranes, flat neck veins, hypotension, increased BUN/CR ratio > 20:1
Slow correction with with D5W to avoid cerebral edema and herniation
