Medicine Flashcards
Leriches syndrome
Atheromatous occlusion of distal aorta just above bifurcation
Causes:
bilateral claudication, (low back, hip, buttock, thigh)
impotence,
and absent or diminished femoral pulses.
atrophy of lower extremities
Normal ankle to brachial index
Ratio of systolic at ankle to arm
.9 to 1.3 is normal
Pts with increased ABI usually due to calcified vessels and false readings.
Claudication because of peripheral vascular disease has lower ABI
Gold standard diagnosing peripheral vascular disease
Arteriography
Gold standard diagnosing acute arterial occlusion
Arteriogram
Homans sign
Calf pain on ankle dorsiflexion
Sign of DVT
Most accurate test to dx DVT
Venography
But invasive and not used a lot
Initial test for DVT
Doppler analysis and duplex US
Phlegmasia cerulea dolens
Extreme cases of DVT
Severe leg edema compromises arterial supply
Signs and symptoms common to all forms of shock
Hypotension
Oliguria
Tachy
Altered mental status
Address what for all pts in shock
ABC
Airway
Breathing
Circulation
Number one cause of bronchiectasis
Cystic fibrosis
Pleural effusion with elevated pleural fluid amylase
Esophageal rupture
Pancreatitis
Malignancy
Pleural effusion with elevated blood
Malignancy
Causes of liver failure
Hepatitis a-e
Drugs - acetaminophen, alcohol, phenytoin, valproate, carbamazepine, ecstasy, cocaine, rifampin, INH, HAART
Ischemia
Autoimmune
Wilson’s, hemochromatosis, fatty liver in preg, HELLP sx
Pleural effusion with elevated mostly lymphocytes + adenosine deaminase marker
TB
Can you see cardiomegaly on AP CXR?
No
Heart is further from film so always looks bigger. Do PA to see
Difference on CXR between alveolar and interstitial pneumonia
Alveolar is fluffy and lumped together
Interstitial is linear streaking
What are the mediastinal masses and where are they?
Anterior mediastinum
Thyroid cancer
Teratoma
Lymphoma
Thymoma
Eggshell calcification a on CXR
Silicosis
Pleural plaques
Asbestosis
Pneumoconiosis with increase risk of TB
Silicosis
What looks like berylliosis and how do you tell the two apart?
Sarcoidosis
Good social history
Causative agent of hypersensitivity pneumonitis in: Farmers lung Air conditioners lung Bagassosis Mushroom workers lung
Sorcerers of thermophillic actinomycetes
CXR with ground glass appearance with bilateral alveolar infiltrates that resemble a bat shape
Pulmonary alveolar proteinosis
Accumulation of surfactant like protein and phospholipids in alveoli
DO NOT give steroids because patients at risk for infection
What is best imaging to detect radiation pneumonitis and what is treatment
CT scan
Corticosteroids
Effects of severe hypoxia
Irreversible organ damage (CNS, cardio)
Effects of severe hypercapnia
Dyspnea
Vasodilation of cerebral vessels causing increased ICP, papilledema, headache, impaired consciousness, coma
CPP =
MAP-ICP
What do you need to determine mechanism of hypoxemia?
PaCO2 level
Aa gradient
Response to supplemental O2
Normal aa gradient by hypoxia
Hypoventilation
Low inspired PO2
What is ventilation monitored by
PaCO2
Vs oxygenation monitored by PaO2
PaCO2 and Aa gradient increased
VQ mismatch or shunting
VQ mismatch improves with O2
Shunt (collapsed lung, ARDS) does not improve with more O2
EF in CAD
> 50% is normal
Less than 50 has increase in mortality
Stress ECG diagnostic value in CAD
75% sensitive if pts can exercise to 85% of max HR for age
220-age = max HR
Is perfusion imaging useful for LBBB?
No
What tx increases mortality for CAD?
What is first line for CAD?
CCB increases HR so increases mortality
Use nitrates or beta blockers
Diagnostic tool for prinzmetals angina
Coronary angiography + ergonovine shows vaso spasm
Ergonovine is alpha Adernergic, dopaminergic, serotonergic, uterine and smooth muscle agonist
Chronology of acute appendicitis pain
Periumbilical to right lower quadrant
Visceral then somatic pain
When do you need screening for ovarian cancer. And what kind of screening is done?
When increased risk secondary to hereditary factors like BRCA
Don’t do screening for pts of average risk
Screening is ab US or CA125
How do you manage exercise induced asthma?
Short acting beta Adernergic agonists 20mins before exercise
Treating trigeminal neuralgia
Carbamazepine
Tx for TTP HUS
Idiopathic, usually has Ab against ADAMTS13 which cleaves vWF so platelets will aggregate more
Plasmaporesis to get rid of antibody
DO NOT give platelets
Orthostatic hypotension
Decrease systolic by more than 20 when stand
Diastolic decreases by more than 10
Ramsay hunt
From of herpes zoster infection
Causes Bell’s palsy
Vesicles seen on outer ear
Pseudo tumor cerebri symptoms, diagnosis, treatment
Headache, blurry vision or loss,papilledema, pulsatile tinnitus, abductees nerve palsy, nausea, vomiting
CT scan then LP if doesn’t show a bleed
Acetazolamide to tx
Chest CT showing wedge shaped infarction is most likely what?
PE
Parvovirus in adults
CNN get anti-b19 antibody
Arthritis affecting MCP, PIP, wrists, ankle joints
Acute onset of symptoms, lack of redness and swelling (vs slow in RA)
What looks like an ST elevation but is not?
Left bundle branch block
If a pt has a suspected PE but kidney failure too, what do you use to detect PE?
VQ scan, NOT CT
Light’s criteria
Lights criteria says a pleural effusion is likely to be exudative if one of the following exists
Pleural fluid protein to serum protein > 0.5
Pleural fluid LDH to serum LDH > 0.6
Pleural fluid LDH > 0.6 or 2/3 times the normal upper limit for serum.
Most common cause of thyroid nodules
Benign colloid nodules
Then follicular adenoma
What electrolyte abnormality do you worry about after surgery needing lots of transfusions?
Hypocalcemia
Hyperactive deep tendon reflexes
What mimics hypocalcemia?
Hypo magnesia that is severe becaus less PTH secreted
Diagnosis of diffuse esophageal spasm
Esophageal motility studies (manometric readings)
Beta 2 agonists can cause what side effect and why
Hypokalemia because drive potassium into cell
Muscle weakness arrhythmias, EKG changes
Porcelain gallbladder
Calcium deposits in gallbladder wall with bluish color and brittle consistency
Rim like calcification in area of gallbladder with central bile filled dark area on CT
At increased risk for gallbladder cancer
Most sensitive test to dx disseminated histoplasmosis
Antigen detection in serum or urine
First line DMARD for Rheumatoid arthritis
Methotrexate
Muddy brown cast
Acute tubular necrosis
RBC casts
Glomerulonephritis
WBC casts
Interstitial nephritis and pyelonephritis
Fatty casts
Nephrotic syndrome
Broad and waxy casts
Chronic renal failure
Gold standard for osteomyelitis diagnosis
Bone biopsy
What did the AFFIRM study show?
Management of afib with rhythm control offers no survival strategy over rate control
There are potential advantages such as lower risk of adverse drug effects with rate control strategy.
Better to rate control
Never give to Wolff Parkinson white patient
Beta blockers
Calcium channel blockers
Causes of afib
PIRATES
Pulm disease (COPD, PE)
Ischemia (ACS)
Rheumatic heart disease (mitral stenosis)
Anemia (high output failure, tachycardia), atrial myxoma
Thyrotoxicosis
Ethanol / endocarditis
Sepsis / sick sinus syndrome
How do you know you are hemodynamiclly unstable (eg for using cardioversion in afib)
Hypotension
Angina
Heart failure
What is the RE-LY trial?
Dabigatran vs warfarin
Dabigatran superior to warfarin to inhibit ischemic stroke and decreases risk of intracranial bleed.
However, dabigatran has increased risk of GI bleed
Diffuse bilateral pulmonary infiltrates in CXR
Hypoxemia refractory to oxygen therapy
ARDS
PaO2 / FiO2 ratio < 200
Necrotic migratory erythema
High blood glucose
Gucagonnoma
Checking if endotracheal tube is in correct place
CXR
Tip of ET should be 3-5cm above carina
Bilateral breath sounds
Minute ventilation =
RR x Tidal volume
What’s the usual I:E ratio?
1:2
Cor pulmonale
Usually secondary to pulmonary disease and not LHF
Usually secondary to COPD
Polycythemia may be present if COPD is cause
Prospective investigation of pulmonary embolism diagnosis (PIOPED)
Guides tx if V/Q performed
Christopher study
Guides tx if spiral CT performed
- What is mortality of PE in first 60 mins if diagnosed?
- How many die of recurrent PE if left untreated?
- Anticoag tx deceased mortality to….
- 10%
- 30%
- 2-8%
Gold standard to diagnose PE
Pulmonary angiography
Is invasive
VQ scan only finds a ventilation but not perfusion in 50% of cases
Goals for aPTT, PT
1.5-2.5times normal aPTT
2-3 PT
2.5-3.5 PT for mech valve
How does Na bicarbonate help in wide QRS (like TCA OD)?
Narrows the qrs because it increases extra cellular Na for action potential.
TCAs act on Na channels and inhibit them
SAAG value saying it is peritonitis
> 1.1
Guillain barre csf findings
How do you assess lung function in GBS?
High protein
Normal cell count
(Albumino-cytologic dissociation)
Vital capacity serial measurements
GBS can lead to respiratory muscle weakness –> respiratory failure
Primary HIV infectious can look a lot like mono. How do you tell the difference?
Mono has LESS rash (unless you used an antibiotic) and diarrhea
EBV has more tonsilar exudates
Most common type of diabetic neuropathy
Symmetric distal sensorimotor polyneuropathy
Mono neuropathy most often due to
Vascular
When do you stop INH?
If patient gets symptoms that look like viral hepatitis so damage to liver
Cand get asymptomatic mild increases in AST and ALT. this is okay and continue drug. This is subclinical hepatic injury and self limited
Dyspnea, tachypneic, normal lung evaluation, right axis deviation
Pulmonary embolism
A pt has PCP. What do you give them? What is an alternative?
TMP SMX + steroids.
Steroids decreases mortality in severe PCP. This is switch PaO2< 70 or Aa > 35
Pentamidine works less well but used for severe cases that intolerant to TMP SMX
Pt has abrupt mental status changes and hallucinations. CSF has mildly deceased glucose and increase in lymphocytes and negative gram stain. What is the gold standard of testing? Start should you do?
CSF PCR. This is most likely viral encephalitis by HSV
You should give acyclovir STAT
What is DDx for high serum Ca and normal PTH? How do you tell the difference between DDx?
Primary hyperPTH
Hypocalciuric hypercalcemia
24 hr urinalysis calcium excretion and creatinine clearance
FHH has decreased urinary calcium excretion edges life increased serum calcium. Primary hyperPTH has increased 24 hr Ca excretion.
Selenium deficiency
Cardiomyopathy
Zinc deficiency
Alopeia
Weird taste in mouth
Bulbous pustule lesions surrounding body offices and/or extremities
Impaired wound healing
What do you use CT with contrast for?
Structural abnormalities
Mass lesions
Not ok for blood because blood already shows up as white and can’t see it with contrast.
MRI is best for no emergency situations where you want to ID vascular malformations, epilepsy foci, etc
How do you diagnose myasthenia gravis?
Eectromyogram
Ach captor antibody test both confirm
Then do CT of chest to look for thymoma
Autosomal dominant
Diffuse telangectasias
Recurrent epistaxis
Widespread AVM
Osler weber rendu syndrome (hereditary telangectasias)
Usually in mucous membranes, skin, GI tract
If in lungs, can do right to left shunt and cause chronic hypoxemia and reactive polycythemia.
First step in managing case of pleural effusion. What is the exception?
What do you do if you suspect malignacy but cytology is negative?
Thoracentesis
See if exudative or transudative.
EXCEPT in cases of pts with clear cut evidence of CHF where you use diuretics and Echo
If cytology is negative, an then negative - you keep going 3 times until you totally rule out malignancy
Type of anemia associated with tea and toast diet
Folate
Leukocytes that h ave undergone partial breakdown during prep of stained smear or tissue section, because of their greater fragility.
Smudge cells of CLL
Most sensitive and specific test for colorectal cancer
Colonoscopy
Do this after have + FOBT
IS fecal occult blood testing sensitive or specific for CRC?
NO
Predictive vlue is only about 20%
Does UC or Crohns have greater risk for CRC?
UC
Familial adenomatous polyposis
AD disease
Colon always involved
90% have duodenum too
100% risk CRC by 30
Prophylactic colectomy
Gardner;s syndrome
Polyps + osteomas + detal abnormalities + benign soft tissue tumors
Turcot’s sydnrome
AR
polyps + cerebellar medulloblastoma or glioblastoma multiforme
Hamartomas through GI tract, pigmented spots around lips, oral mucosa, face, genitalia, and palmar surfaces, inussusception risk
Peutz Jeghers
Hamartomas have low malignant potential
HNPCC
Lynch 1 - early onset CRC
Lynch 2 - Lynch 1 + increased number and eary occurence of other cancers (female GU, skin, stomach, pancreas)
Most common presenting sx of CRC
Ab pain
Most common cause of large bowel obstruct in adults
CRC
Common R sided CRC symptoms
Melena
obstruction is more rare b/c larger luminal diameter
Change in bowel habits uncommon
Triad of R sided CRC
Anemia
Weakness
RLQ mass
Common L sided CRC symptoms
Hematochezia
obstructino more comon b/c smaller luminal diameter
CHANGE in bowel habits - yes! Pencil stools
Most common sx of rectal cancer
Hematochezia
Rectal cancer has higher recurrent rate and lower 5 year survival rate than colon cancer
ACTH stimulation test
Cosyntropin test = During the test, a small amount of synthetic ACTH is injected, and the amount of cortisol, and sometimes aldosterone, the adrenals produce in response is measured
If pts are hypotensive due to adrenal sufficiency, can:
+ hydrocrotisol 100 mL TID
+ normal saline
if the above two don’t work, add fludrocortisone
SIRS criteria
SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a subset of cytokine storm, in which there is abnormal regulation of various cytokines
Temp < 96.8 or > 100.4
HR > 90/min
RR > 20/min or PaCO2 < 32 mmHg
WBC 12x10^9/L (>12,000/mm³), or 10% bands
CHADS2 score
C = CHF H = HTN A = age >=75 D = Diabetes S = previous TIA or stroke or thromboembolism
What is heparin induced thrombocytopenia?
In HIT, the immune system forms antibodies against heparin when it is bound to a protein called platelet factor 4 (PF4). These antibodies are usually of the IgG class and their development usually takes about five days
4T score for HIT
Thrombocytopenia
+2 if > 50% fall in platelet count
Timing
+2 if fall is betwen 5-10 days after commencement of treatment
Thrombosis
+2 in new thrombosis, skin necrosis, or systemic reaction
alTernative cause possible (liver function, chemo)
+2 if no other cause possible
1 cause of systolic CHF
MI
1 cause of diastolic CHF
HTN
CHF treatment to decrease mortality
Beta blocker (carvedilol, bisproplol, metoprolol)
ACE –| / ARBs
- Candesartan is the only one for diastolic heart failure
Spironolactone (stage 3 or 4 CHF)
Hydralazine + nitrate
- If african american good for it
- use this also if can’t use ACE –| or ARBs
AICD (EF < 35%)
Biventricular AICD
Wide QRS and EF < 35% can use this
wide QRS because ventricle desynhrony
CHF treatment for symptoms, not decreasing mortality
Digoxin
Diuretics
Millrinone
- For end stage heart failure
What’s a bad prognostic factor in heart failure?
Hyponatremia
t give more Na!)
Cardiorenal syndrome
1) Can have primary heart failure or renal failure that cause failure of the other organ.
- if this is due to heart failure and decreased perfusion of kidney, look diuretics do not help the worsening kidney fuction
2) Can also have kidney congestion when you have too much volume to kidney and the kidney will get more blood
- this gets better wafter diuretics
Takotsubo cardiomyopathy
- ST elevation
- troponins
- when look at with cath, there are no coronary blockages
- This is really due to increase in catecholamines
- can lead to cardiogenic shock and vfb
LE edema differential
- cirrhosis
- CHF
- DVT
- venous insufficiency (ACE wraps up to thigh, compression stockings)
- cardiac cirrhosis (bad RHF can cause liver cirrhosis)
- Nephrotic syndrome
VRE colonization
VRE, check for colonization via rectal swab
MRSA colonization
MRSA, check for colonization via nares swab
Third spacing
Third-spacing refers to a situation in which fluid shifts out of the blood into a body cavity or tissue where it is no longer available as circulating fluid.
Pathogenesis for normal pressure hydrocephalous
increase in ICP causing ventricular enlargement
Due to:
- diminished CSF absorption at arachnoid villi
- obstructive hydrocephalus
What meds do you hold before cardiac stress testing for:
48 hrs:
48 hrs before vasodilator stress test:
12 hrs before vasodilator stress test:
Continue taking:
48 hrs
- beta blockers
- CCB
- nitrates
48 hrs before
- Dipyridamole
12 hrs before:
- Caffeine
Continue:
- ACE —|
- ARBs
- digoxin
- Statins
- Diuretics
What can cause a false + on stress test
Diuretics
- diuretic-induced hypoK can cause ST segment depression and false +
Photopsia + floaters + curtain coming down over eyes
Retinal detachment
Blurred vision + blunt trauma
Choroidal rupture
Reveals: central scotoma, retinal edema, hemorrhagic detachment of macula
Infectious mononucleosis
EBV
TRIAD: High fever + lymphadenopathy + pharyngitis
Also: fatigue + maculopapular rash + posterior cervical lymphadenopathy + splenomegaly
not as much anterior cervical lymphadenopathy
Leukocytosis + atypical lymphocytes
Heterophile antibodies are negative early in illness
Autimmune hemolytic anemia (IgM cold agglutinin)
Thrombocytopenia
Focal vertebral pain + no neuro sx
Compression fracture (vertebral body demineralization)
Happens in osteomalacia, osteoporosis
Back pain with movement + feel best in morning + perispinal pain
Ligamentous sprains
Low back pain + worse as day goes on + relieved with rest
Lumbar disk degeneration
hallmark of lumbar osteoarthritis
Pain and progressive limitation of back motion + young men + worse pain in AM
Apophyseal joint arthritis of ankylosing spondylitis
testicular fibrosis + azospermia + gynecomastia + increased LH and FSH
Kleinfelter’s
small testes + normal testosterone + low LH
exogenous steroid use
Liver mets characteristics
Colon #1 site mets is to liver
Lung and breast also love to go here
RUQ pain
MILDLY elevated liver enzymes
Firm hepatomegaly
Confirm w/ CT
Hypercalcemia secondary to malignancy - how does this happen?
Osteolytic mets
PTrH secretion
increased Vit D formation
Increased IL6 levels
Most common COD of pts w/ acromegaly
Cardiovascular
Can get Coronary artery disease, cardiomyopathy, arrhythmias, LVH, diastolic dysfunction
Reversible causes of asystole/pulseless electrical activity
5H’s and 5 T’s
Hypovolemia Hypoxia H+ (acidosis) Hypo/hyperkalemia Hypothermia
Tension pneumo Tamponade (cardiac) Toxins (narcotics, benzos) Thrombosis (pulm, coronary) Trauma
Tx for pulseless electrical activity w/o palpable pulses
CPR
Epi
When do you use early defibrilation?
V fib
Pulseless V tach
When do you use synchronized electrical conversion?
Symptomatic / sustained V tach
hemodynamically unstable afib
Back pain initial diagnostic test
Plain film Xray
Acid fast staining organisms
Nocardia (partly)
TB
Tx for nocardia
TMP-SMX (can be used as prophylaxis too)
Minocycline (2nd line)
Tx for paget’s disease
Bisphosphonates
Attributable risk percent
(RR - 1) / RR
Inpatient tx of community acquired pneumonia
Outpatient tx of community acquired pneumonia
Inpatient: NEW fluoroquinolones (levofloxacin, moxifloxacin)
Ceftriaxone + azithromycin
Outpatient: azithromycin, doxycycline
Outpt w/ comorbidities - fluoroquinolones
What is absolutely contraindicated to give first to pt w/ pheochromocytoma
Beta blocker - will get reflex HTN
Block alpha first, then beta
Best initial eval for gallstones
Abdominal ultrasound
ERCP after if US doesn’t reveal anything but there is a high suspicion
Risk factors for gallstones
Native american diabetes obesity rapid wt loss oral contraceptive use
Fat, female, forty, fertile
Best to dx biliary obstruction
ERCP
Best to confirm suspected cholecystitis
HIDA scan
usual cause of renal artery stenosis in young adults? older?
YOUNG: fibromuscular dysplasia
OLD: atherosclerosis
Contraindications of ACE —|
Hyperkalemia
bilateral renal A stenosis
Tx of choice for fibromuscular dysplasia
Percutaneous angioplasty + stent placement
Classic heart sound in MI
S4
Ischemic damage of heart –> diastolic dysfunction –> stiff LV –> atrial gallops (S4)
Behcet syndrome
Recurrent oral ulcers + 2 of the following:
- recurrent genital ulcers
- eye lesions (anterior uveitis, etc)
- skin lesions (erythema nodosum, etc)
- pathergy test
#1 cause of hypercalcemia in ambulatory pts #1 cause of hyperCa in hospitalized pts
Ambulatory: primary hyperPTH
Hospitalized: malignancy
Milk alkali syndrome
Risk of this w/ taking in too much Ca or using old absorbable alkali for tx peptic ulcer disease
TRIAD: hyperCa, metabolic alkalosis, renal insufficiency
Pathogenic factors involved in developing hepatic encephalopathy
What is hepatic encephalopathy characterized by?
- Accumulate NH3 in blood
- Produce false neurotransmitters
- Zinc deficiency
- Increased sensitivity of CNS to inhibitor neurotransmitters (eg GABA)
reversal of sleep cycle
asterixis
progressive coma
characteristic delta waves on EEG
Malignant potential of polyps
Size (larger –> malignant)
Histo type (villous –> malignant)
Atypia of cells
Shape (sessile = flat –> malignant)
Complications of
- diverticulosis
- diverticulitis
Diverticulosis
- painless rectal bleeding
- diverticulitis
Diverticulitis
- bowel obstruction
- abscess
- fistula
- free colonic perforation
Dx
- Diverticulosis
- Divertiulitis
OSIS - Barium enema
ITIS - CT w/ contrast (NOT scope or enema)
Angiodysplasia of colon
- What is it?
- What are its associations?
Dilated, ectatic thin-walled vessels
Lined by endothelium
Prone to recurrent and chronic PAINLESS bleeding
Assoc w/ aortic stenosis, ESRD
- aortic stenosis –> turbulent blood flow through valve –> disrupt vWB multimers –> increased risk of bleeding –> angiodysplasia
- Uremic platelet dysfunction from ESRD –> increase bleeding risk –> angiodysplasia
Acute mesenteric ischemia types
1) Embolic
- usually from heart emboli
- sx SUDDEN + painful
2) Arterial thrombosis
- usually happens w/ CAD
- sx gradual + less severe than embolic
3) Nonocclusive
- due to low CO
- usually in critically ill pts
4) Venous thrombosis
- sx present for many days + gradual worsening
Acute Intestinal infarction signs
HypoTN Tachypnea Lactic acidosis Fever Altered mental status
Can lead to shock
CHECK LACTATE LEVELS IF SUSPECT MESENTERIC ISCHEMIA!!!!
Mesenteric ischemia has > 50% mortality rate!?!?!
Dx acute mesenteric ischemia
Mesenteric angiography
Chronic mesenteric ischemia
usually due to atherosclerosis
abdominal angina, usually postprandial
Wt loss b/c of fear of eating
Ogilvie’s syndrome
signs, sx, radiograph shows large bowel obstruction but there is no mechanical obstruct
Causes: recent surgery, trauma, malignancy, anticholinergics, etc
Decomrpress!
Most frequent cause of pseudomembranous colitis
Clindamycin
Ampicillin
Cephalosporins
Dx pseudomembranous colitis
C diff toxins is stool is diagnostic (need 24 hrs)
Dx sigmoid volvulus
sigmoidoscopy
sigmoid colon #1 site for volvulus
Dx cecal volvulus
Barium enema???
Which volvulus needs surgery?
When do you NOT give barium enema in volvulus
–> cecal volvulus
–> don’t give BE if suspect stranulation
Most common causes of cirhosis
EtOH liver disease
Chronic viral infection (esp Hep C)
Others:
- drugs - acetaminophen, methotrexiate
- PBC
- autoimmune hepatitis
- R heart failure congestion, constrictive pericarditis
- a1-antitrypsin deficiency
- NASH
What do you useto classify severity of liver disease?
Child’s Classification
A is mild, C is severe
Factors
- Ascites
- Bilirubin (higher is worse)
- Encephalopathy
- Ntritioalstatus
- Albumin (lowe is worse)
Gold standard to Dx liver cirrohsis
Liver biopsy
Classic sgns of chronic liver disease
Ascites Varices Gynecomastia, testicular atrophy Pamar erythema, spider angiomas Hemorrhoids Caput medusae
Tx for esophageal/gastric varices
1) Hemodynamic stabilization
- give fluids to maintain BP
2) Variceal ligation/banding
- endoscopy when stabilized
or
2) Enoscopic sclerothrapy
- inject sclerosingitem into varices
- more risk of rebleed than ligation
3) IV octreotide + prophylactic antibiotics
- cause splanchnic vasocontrit and lower portal P
or
3) IV vasopressin
- not as good as octreotide –> lots of complicatons
Long term tx for esophageal/gastric varices
Beta blockers to prevent releed
Ascites from liver cirrhosis - what causes it?
- too much fluid b/c of portal HTN so increased hydrostatic P
- hypoalbuminemia (reduced oncotic P)
ONLY get ascites w/ portal HTN
Serum ascites albumin gradient (SAAG)
> 1.1 = portal HTN ver likely
<1.1 = portal HTN less likely
Tx ascites
Bed rest
Low Na diet
Diuretics (furosemide, spironolactone)
Monitoring pts w/ cirrhosis
- LABS: CBC, renal fnt tests, electrolytes, LFTs
- Endoscopy to see if esophageal varices
- CT guided biopsy to see if HCC
Tx hepatic encephalopathy
1) Lactulose
- Gut bacteria met of lactulose causes acifification of colonic contents, causing NH3 —> NH4 (not absorbable –> ammonia trap)
2) Neomycin
- kills gut bacteria so dec ammonia production
3) Diet limiting protein
Features of hepatic encephalopathy
- dec mental function, confusion, stupor, coma
- asterixis
- rigidity, hyperreflexia
- fetor hepaticus = musty odor of breath
Complications of Liver failure
AC, 9H
Ascites*
Coagulopathy
Hypalbuminemia portal HTN* Hyper NH3 Hepatic encephalopathy* Hepatorenal sx HYPOglycemia (b/c liver stores glycogen) HYPERbilirubinemia/jaundice HyperESTROGEN HCC
- = most serious complications
Causes of spontaneous bacteral peritonitis.
SIgns?
E. coli
Klebsiella
Strep pneumo
SIGNS:
- fever
- change in mental stauts
- ab pain
- rebound tenderness
- all happens in pt w/ known ascites
Spider angiomas - what are they?
Dilated cutaneous arterioles w/ central red spot
How long abstain from EtOH before get liver transplant (eligibility)?
6 months
Wilson’s disease
Liver can’t excrete copper b/c deficiency of ceruloplasmin
Ceruloplasmin is Cu-binding and needed for excetion
Do Kayser fleischer rings interfere w/ vision?
No
Tx Wilson’s disease
- D- penacillamine
- Zinc (prevents Cu uptake from diet)
- Liver transplant
Dx hemochromatosis
ALT and AST
Iron studies
Liver biopsy –> needed for Dx
Complicatons of Hemochromatosis
1) Cirrhosis
- increase risk of HCC
2) Cardiomyopathy
- CHF, arrhythmias
3) DM
- iron deposits in pancreas
4) Arthritis
- usually in 2nd and 3rd MCP, hips, knees
5) Hypogonadism
6) Hypothyroidism
7) Bronze like skin
“CHAD CHuB”
Complications of hepatocellular adenoma
Usually asymptomatic
Rupture –> hemoperitoneum and hemorrhage is major risk
Resect tumors > 5cm that don’t regress after stopping OCP
1 benign liver tumor
Cavernous hemangioma
Malignant
- HCC
Cholangiocarcionmas
Dx cavernous hemangioma
US
CT w/ contrast
NOT biopsy b/c risk rupture and hemorrhage
Hepatic tumors assoic w/ OCP
Hepatocellular adenoma
NOT focal nodular hyperplasia - but this is in women usually
Types of HCC
1) Nonfbrolamellar
- more common
- assoc w/ Hepb B and C
- usually not resectable, short time
2) Fibrolamella
- no Hep assoc
- often resectable, longer survival time
HCC risk factors
Cirrhosis Aflatoxin Vinyl chloride Thorotrast AAT deficiency Hemochromatosis, Wilson's Schistosomiasis Hepatic adenoma Cigs Glycogen storage disease type 1 (Von Gierke's)
Paraneoplastic sx of HCC
Erythrocytosis Thrombocytosis HYPER Ca Carcionid Hypertrophic pulmonary osteodrystrophy HYPO glycemia High cholesterol
HCC tumor marker
AFP
Heyde’s syndrome
Syndrome of aortic valve stenosis associated with gastrointestinal bleeding from colonic angiodysplasia.
Hemobilia
Blood drains into duodenum via common bile duct
Bleed starts anywhere in Hepatobilliary system.
Diagnose with arteriogram
GIST marker
c-kit
Causes of hemobilia
Clinical features
Trauma, tumors, infection
Papillary thyroid carcinoma
Surgery like cholecystectomy
GI bleed so melons or hematemesis, jaundice, RUQ pain
Budd chiari
Block hepatic vein outflow getting hepatic congestion and micro vascular ischemia
Hepatomegaly, RUQ pain, jaundice
Dx via hepatic venography, SAAG
Tx usually needs surgery because thrombocytes may not work. Liver transplant if cirrhosis
3 major causes of jaundice
Hemolysis
Liver disease
Biliary obstruction
Bilirubin metabolism
Hbg to bilirubin in spleen
Unconjugated bilirubin in plasma bound to albumin and not water soluble so NOT excreted in urine
Conjugated in liver
Excreted into intestine and made into urobilinogen and urobili by gut bacteria
Dark urine and pale stools means what?
Conjugated bilirubinemia
Conjugated is soluble so it is the only one to get into the urine.
Where are ALTs and ASTs
ALT - liver
ALT is more specific for liver damage
AST - in many tissues like brain, kidney, heart, skeletal muscle
Alcoholic hepatitis usually has higher increase in AST (a scotch and tonic)
If AST and alt are mildly elevated….
Moderate….
Severe…
Mild = Think chronic viral hepatitis or acute alcoholic hepatitis
Moderate = acute viral hepatitis
Severe = extensive hepatic necrosis due to ischemia, shock, Tylenol, severe viral hepatitis
LFT pearls
Increase in ALP and GGT, small ALT and AST increase = cholestatitic disease
Normal or increase in ALP, very big increase in ALT and AST = hepatocellular necrosis or inflammation
ABCDEFGHI of AST or ALT increase
Autoimmune hepatitis Hepatitis B Hepatitis C Drugs or toxins Ethanol Fatty liver Growths (tumors) Hemodynamic disorders (CHF) Iron (hemochromatosis), copper (Wilson's), or aat deficiency
Cholesterol stone associations
Obesity, diabetes, hyperlipemia
Multiple preggers, OCP
Crohns, illegal resection
Old age
Native American
Cirrhosis
Cystic fibrosis
Pigment stone associations
Black
- hemolysis, alcoholic cirrhosis
Brown
- biliary tract infection
Boas sig
Cholelithiasis
Referred right Subcapsular pain of biliary colic
Pain from
Acute cholecystitis
Biliary colic
Is secondary to what?
Acute cholecystitis
- gallbladder wall inflammation
- several days
Biliary colic
- contraction of gallbladder against obstructed duct
- only a few hrs
High sensitivity and specificity test for cholelithiasis
RUQ ultrasound
Best for dx acute cholecystitis. What do you see?
RUq ultrasound
Thickened gallbladder wall
Pericholecystic fluid
Distended gallbladder
Presence of stones
CT good for ID complications of acute cholecystitis
HIDA if US inconclusive. Sensitivity and specificity are about the same.
Choledocholithiasis
Stones an originate in common bile duct and in gallbladder. Most come from gallbladder
Use ERCP (vs US for cholelithiasis) to dx
Can be asymptomatic for years but if there are symptoms, it is much more threatening than when you get symptoms from cholelithiasis.
Charcots triad
Reynolds Pentad
Sign of cholangitis
RUQ pain
Jaundice
Fever
Only in 50-70% cases
Charcots triad + septic shock + altered mental status
To do for pts with cholangitis
Blood culture
IV fluids
IV antibiotics after blood cultures obtained
Decompress CBD when patient stable
Primary biliary cirrhosis
Features
Clinical presentation
Dx
Tx
Intrahepatic duct destruction leading to portal inflammation and cirrhosis
Vanishing ducts!
Antimitochondrial antibodies
Usually in middle aged women
Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia
Test for AMAs, liver biopsy to confirm disease
Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease
Cholestyramine for pruitus relief
Where are most of cholangiocarcinoma tumors?
Proximal third of CBD
Bad prognosis.
Associated with clonorchis sinensis infection in Asia, choledochol cysts
Primary biliary cirrhosis
Features
Clinical presentation
Dx
Tx
Intrahepatic duct destruction leading to portal inflammation and cirrhosis
Vanishing ducts!
Antimitochondrial antibodies
Increased IgM
Increased ALP, cholesterol
Usually in middle aged women
Can get xanthomas or xanthelasmata, osteoporosis , hepatosplenomegaly, jaundice, statorrhea, portal HTN, osteopenia
Test for AMAs, liver biopsy to confirm disease
Tx with liver transplant. Ursdeoxycholic acid can slow progression of disease
Cholestyramine for pruitus relief
Carcinoid tumors originate from
Neuroendocrine cells usually in appendix
Secrete serotonin
Drugs to increase RBC count. How do you tell which one a person took?
Steroids
– will have gynecomastia, HTN
EPO
–will NOT have gynecomastria, but will have HTN
What alcohol poisonings can you do hemodialysis for?
Methanol
Ethylene glycol
[Na] in normal saline
154
Tx nephrogenic diabetes insipidus
amiloride
HCTZ
Amiloride causes excretion of lithium if that is the cause
Amount of fluid restriction to correct hypoNa
800-1000cc
Coccidiodomycosis clinical features
SW US
Central and S America
Fever Fatigue Dry cough Weight loss Pleuritic chest pain Erythema multiforme Erythema nodosum arthralgias
Histoplasmosis clinical features
SE, mid atlantic, and central US
Acute pneumonia
- cough
- fever
- malaise
Blastomycosis clinical features
South-centrl and north-central US
Lungs Skin Bones Joints Prostate
What is the Well’s score most useful for?
people with low probabiliyt of PE
Hemochromatosis iron panel
Increased
- Fe
- Ferritin
- Transferrin saturation
Decreased TIBC
Cephalization on CXR
= redistribution of blood into the upper lobe vessels.
If hydrostatic P > 10 mHg, fluid begins to leak into interstitum of lung –> excess fluid compresses the lower lobe vessels, perhaps as a result of gravity.
As a result, upper lobe vessels are recruited to distribute a greater volume of blood. In order to carry a greater volume of blood, the upper lobe vessels increase in size
Cause of pancreatiis
EtOH Gallstones post-ERCP Viral(mumps, coxsackie) Drugs (Sulfas, thiazides, furosemide, estrogens, HAART) Pancreas divism HYPER TGs Uremia
Ranson’s Criteria
To assess prognosis of acute pancreatitis
Admission Criteria (GA LAW) Glucose > 200 mg/dL Age > 55yo LDH > 350 AST > 250 WBC >16,000
Initial 48 hrs (C HOBBS) Ca < 8 mg/dL Hct decrease > 10% PaO2 < 60 mm Hg BUN increas > 8 mg/dL Base deficit > 4mg/dL Sequestration of fluid > 6L
5-6 criteria has 40% mortality
How does hypo Ca of pancreatitis happen?
Fat saponification
Fat necrosis binds calcium
How do you dx acute pancreatitis
clniical presentation
lab studies are supportive
- Serum amylase and lipase are most sensitive and specific tests for dx acute pancreatitis
CT is confirmatory (most accurate)
Acute pancreatitis ab radiograph findings
Sentiel loop - air filled bowel in LUQ - sign of localized ileus
Colon cut off sign - air filled segent of tarnsverse colon cutoff at region of pancreatic inflammation
Pancreatic pseudocyst
encapsulated fluid collection appearing 2-3 weeks after acute attack
Has no epithelial lining
Can rupture, get infection, hemorrhage
Dx w/ CT and drain if > 5cm
Can be present at sites distant from pancreas
Tx for acute pancreatitis
Most only need supportive pain control, bowel rest, IV fluids, electrolyte corrections
Most don’t need more therapy
ERCP if it is severe biliary pancreatitis – can remove stone. NOT for EtOH pancreatitis
Pain control in acute pancreatitis
Fentanyl and meperidine
Not morphine b/c itcauses increase in sphincter of Oddi pressure
When give antibiotics for acute pancreatitis
If > 30% of pancreas is necrosed
imipenem
1 cause of chronic pancreatitis
Chronic alcoholism
Methanol can also cause!
Classic signs of chronic pancreatitis
steatorrhea
diabetes
pancreatic calcification on CT scan is diagnostic
usually have constant pain radiating to back
ERCP is gold standard to dx
NO elevation of amylase or lipase
NOT pancreatic cancer if this has been ongoing for > 1 year
What vitamin deficency can you get with chronic pancreatitis?
Vit B12
Classic chronic pancreatitis picture on ERCP
Chain of lakes
areas of strictre and duct dilatation throughout pancreatic duct
Tx chronic pancratitis
INsulin
Pancreatic enzymes ( —| CCK release to decrease secretions from bad pancreas)
H2 blockers (prevents gastric acid made so it doesn’t degrade pancreatic enzyme supplements)
Pancreatic cancer - risk factors
1 - SMOKING
Male sex Black race Obesity FH of pancreatic cancer chronic pancreatitis CHRONIC diabetes benzidine, b-naphthylamine
NOT ALCOHOL
Painles or painful jaundice in pancreatic cancer?
PAINFUL jaundice
Courvoisier’s sign
palpable gallbladder
indicates cancer of head of pancreas
Dx pancreatic cancer
CT preferred for diagnosis and assessment of spread
ERCP most sensitive but invasive
Pancreatic cancer tumor marker
CA 199
CEA (less sensitive and specific)
Aortoenteric fistula
Hx of aortic graft surgery who has small bleed of the duodenum
Quickly turns massive and fatal hemorrhage
Dieulafoy’s vascular malformation
Submucosal dilated arterial lesions causing massive GI bleed
Upper GI bleed
Melena
black, tarry liquid foul-smelling stool
due to degradation of Hb by bacteria in colon - further bleed is from rectum, more likely melena happens - usually upper GI bleed
Hematochezia
Usually a lower GI bleed
Can be upper GI if it is massive and bleeding is so fast it does not stay in GI tract for long
BUN/Cr in GI bleed
BUN/Cr usually increased w/ upper GI bleed, esp if pt has no renal insufficiency
When do you use arteriogrpahy for GI bleed?
For pts w/ lower GI bleeding
Perform during active bleeding
GI bleed indicatons for surger
- hemodynamicallnstable pts not responding to IV fluid, transfusion, endoscopy intervenions, coagulopathy correctins
- severe inital bleed or recurrence of bleed after endoscope
- continued bleed > 24 hrs
- visible vessel at base of ulcer
- ongoing transfusion requirement
Staging esophageal cancer
1 - invades lamina propria or submucosa. nodes -
2a - invades muscularis propria or adventitia; nodes -
—> surgery up to here
–> palliative below
2b - invades up to muscularis propria; nodes +
3 - invades adventita or tumor invades adjacent structions
4- distant mets
Achalasia causes
US: #1 - idiopathic #2 - adenocarcinoma of proximal stomach
World: #1 - Chagas
Esophageal squamous cll cancer causes
EtOH Tobacco Nitrosamines, hot food ingestions HPV Achalasia Plummer Vinson sx
Types of esophageal hiatal hernias
Type 1 - Sliding
Type 2 - Paraesophageal
Type 3 - Sliding + Paraesophageal; tx like it is paraesophageal (surgical)
Where is Mallory weiss tear?
at Gastroesophageal junction
tear is only mucosal
Plummer vinson syndrome
Upper esophageal web –> dysphagia
Iron deficiency anemia
Koilonychia (spoon nails)
Atrophic oral mucosa
Schatzki’s ring usualy accompaniedby
sliding hiatal hernia
Platypnea
Dyspnea relived by laying down, exacerbated by sitting up
Platypnea is due to either hepatopulmonary syndrome or an anatomical cardiovascular defect increasing positional right-to-left shunting (bloodflow from the right to the left part of the circulatory system).
Sitophobia
food fear
Screening for lung cancer
National Lung Screening Trial
- > 30 pack year smoking history
- low dose chest CT yearly for those who are still smoking or smoked in the past 15 years
- shows to have decreased motality but no long term data
Transudative pleural effusion causes
Due to increased hydrostatic or decreased oncotic P
CHF Cirrhosis PE Nephrotic syndrome Peritoneal dialysis Hypoalbuminemia Atelectasis
Exudative pleural effusion causes
Caused by increased capillary permeability
Bacterial pneumonia, TB Malignancy, mets Sarcoidosis Rheumatoid arthritis Viral infection PE
Paraneoplastic syndrome of Small cell lung cancer
SIADH
ACTH
Lambert Eaton
Hypertrophic osteoarthropathy - It is characterized by new bone formation on the outside of the diaphyses of long bones of the limbs, without destruction of cortical bone
Chylothorax pleural effusion - what is in the fluid?
Common causes of it
Triglycerides >110mg/dL
Cancer
Trauma
TB Chronic mediastinal infections Sarcoidosis Lypmhangioleiomyomatosis Radiation fibrosis
Absolute neutrophil count
(% neutrophils + % bands) * WBC / 100
Chemtherapy transfusion reaction - what do you do?
Shortness of breath, rash are red flags
Give
- all things to inhibit all histamines (benadryl, pepcid)
- epinephrine
- steroids
Evaluate
Call oncologist
Traction diverticula
true
At midpoit of esophagus near tracheal bifurcation
Due to traction from contiguous mediastina inflamation and adenopathy (pulmonary TB)
–> TB causes hilar node scarring causing retraction of esophaus
Epiphreic diverticula
- lower 1/3 of esophagus
- usually assoc w/ spastic esophageal dysmotility or achalasia
Associated blood type of duodenal ulcer? Gastric ulcer?
Duodenal - O
Gastric - A
Risk factors of duodenal ulcer? Gastric ulcer?
Duodenal - NSAIDs
Gastric - Smoking
1 nephrotic syndrome associated w/ Hodgkin’s lymphoma
Minimal change disease
1 nephropathy associated w/ carcionma
Membranous glomerulonephritis
Conn’s syndrome lab values
HTN
Mild hyper Na
HYPO K
Metabolic alkalosis (decreased bicarb)
Reason for oxalate stones in Crohn’s, small bowel resection
Happens in IBD, small bowel resection, other malabsorption syndromes
Increased intestinal fat binds dietary calcium –> can’t bind oxalate in gut –> oxalate gets reabsorbed adn precipitates in kidney
Define the following therapies:
- Salvage
- Adjuvant
- Consolidation
- Induction
- Maintenance
- Neoadjuvant
Salvage = form of tx for disease when standard tx fails
Adjuvant = therapy given in addition to standard tx
Consolidation = given after induction therapy to really wipe out tumor cells
Induction = initial tx to kill tumor cells to send pt into remission
Maintenance = given after induction and consolidation to ensure remission
Neoadjuvant = tx given before standard tx
Reddish nodule –> ulcerates –> spreads forming subQ nodules and ulcers
No adenopathy or systemic signs
What is the offending agent?
Sporothrix schenckii
Reddish nodule –> ulcerates –> spreads forming subQ nodules and ulcers
No adenopathy or systemic signs
What is the offending agent?
Sporothrix schenckii
Elderly + dementia + severe depression + very concerned about memory loss
Tx?
Pseudodementia
SSRIs
HTN Hx + unilateral weakness + no changes on CT
Lacunar infarct
microatheroma and lipohyalinosis
Most commonly in internal capsule
HTN Hx + unilateral weakness + no changes on CT
Lacunar infarct
microatheroma and lipohyalinosis
Most commonly in internal capsule
Severe symptomatic hyper Ca
- What happens?
- How do you tx?
Hypercalcemia –> induces salt wasting –> significant volume depletion
Volume depletion causes more reabsoption of solutes, hence more reabsorb of Ca
Tx w/ normal saline (200 mL/hr) + calcitonin + bisphosphanates to reduce serum Ca levels and restore back volume
Sudden loss of vision
Onset of floaters
Fundus is difficult to visualize
1 cause of vitreous hemorrhage is diabetic retinopathy
Vitreous hemorrhage
Sudden painless, unilateral loss of vision
HTN hx perhaps
Disk swelling, venous dilation, cotton wool spots, retinal hemorrhages
Central retinal vein occlusion
Pellagra
- what is it
- causes of it
- symptoms
It is niacin deficiency
Corn based diet
Alcoholics
Carcinoid sx patients
Hartnup’s disease
Diarrhea + Dermatitis + Dementia
- skin rash in sun exposed areas (can look malar rash!)
REMEMBER PELLAGRA when you see malar rash + diarrhea. SLE doesn’t have diarrhea
Fever in neutropenic patient
> 100.9 F
> 100.4 F for more than 1 hr
Febrile neutropenia
Happens when neutrophil count is low
Neutropenia = absolute neutrophil count < 1500/microL
What should tx of febrile neutropenia cover?
Monotherapy?
Combo therapy
Pseudomonas
Monotherapy: ceftazadine, imipenem, cefepime, meropenem
Combo: aminoglycoside + anti-pseudomonal beta lactam
1, #2 muscles involved for myasthenia gravis
1 - extraocular muscles
2 - muscles of jaw (bulbar muscles)
CPK usually normal in myasthenia gravis
Myasthenia gravis vs. primary muscle problem - what lab value is helpful to distinguish?
CPK normal in MG
Myasthenia gravis vs. ALS
normal reflexes in MG
Toxoplasmosis
- Tx
- Prophylaxis
Tx = Sulfadiazine + pyrimethamine
Prophylaxis = TMP-SMX
Rapid plasma reagin test
Screens for syphillis
anti-thyroperoxidase antibodies + enlarged rubbery goiter
- What am I at risk for?
Hashimoto’s
Lymphoma of thyroid (60x)
Dx via core biopsy as FNA may miss diagnosis
Normocytic anemia +
Hyper Ca +
Renal failure +
Elevated total serum protein w/ normal albumin
Multiple Myeloma
Mnemonic: CRAB
- Calcium
- Renal impairment
- Anemia
- Bones (pain, lytic lesions)
HyperCa because of bone lysis from plasmocyte-released humoral factors and expanding plasma cell mass
Hyper Ca can present as CONSTPATION!
Can you see MM lesions on bone scan?
No
There is no associated new bone formation
Use skeletal survey (xray)
Thrombocytopenia +
Hemolytic anemia (increase in indirect Bili, decrease Hg, increase retic count) +
Altered mental status +
Renal failure
TTP-HUS
Peripheral blood smear to tell if there are schistocytes
Colloid solutions used to..
in burns or conditions w/ hypoproteinemia
Classic signs of dehydration
Dry mucosa
Marginally high Hct, electrolytes
BUN/Cr > 20
Tx w/ intravenous crystalline solution (normal saline)
How does respiratory alkalosis happen in preggers?
Progesterone stimulates medulla respiratory centers
This leads to tachypnea –> resp alkalosis
Digital Rectal Exam signs for
- BPH
- Prostate cancer
BPH - smooth, firm enlargement of prostate
PC - palpable nodule at periph of prostate
If get ROS and PE suggestive symptoms of BPH, what is the first thing to do?
Ab ultrasound to look for hydronephrosis
- put in catheter if needed
What test do you use to evaluate spinal stenosis?
MRI
Alterations in consciousness + disorganized speech + visual hallucinations + Extrapyramidal symptoms
Lewy Body Dementia
Pickwickian syndrome (obesity hypoventillation syndrome)
Obesity impedes expansion of chest and ab wall during breathing
Underventillation of lungs and chronically elevated PaCO2, decreased PaO2
Abnormal ABG
Causes of blood diarrhea - bacterial
CSS YE
Campylobacter Shigella Salmonella Yersinia E. coli
HIV pt + bloody diarrhea + normal stool exam
Highly suspicious for CMV
Electrolyte risk with immobilization (eg paralysis)
Hypercalcemia
- possibly due to increased osteoclastic bone resorption
- tx w/ hydration + bisphosphonates
Rhabdomyolysis electolyte imbalance
HYPO Ca
Ca preceipitates w/ PO4 b/c it is released from damaged muscles
Prinzmetal’s angina
- Risk factors
- Tx
Smoking is risk factor
Tx
- CCB
- nitrates
Prior sensitization is needed for phototoxic or photoallergic drug?
Photoallergic
Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines
Prior sensitization is needed for phototoxic or photoallergic drug?
Photoallergic
Phototoxic does not need prior sensitization for drug eruption - an example is tetracyclines
Strk + no hemorrhage on CT w/o contrast + within 4.5 hrs after onset, what is best med to give to improve neuro outcomes?
tPA
NOT STREPTOKINASE
Endotracheal intubation common common complication
Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side
Endotracheal intubation common common complication
Right mainstem bronchus intubation causng asymmetric chest expansion during inspiration and markedly decreased or absent reath sounds on the L side
Manifestatons of Sarcoidosis
Pulm - Bilateral hilar adenopathy
Eye - uveitis
Heme - Lymphadenopathy, Hepatomegaly, splenomegaly
MS - polyarthriis
CNS/Endo - Central DI, Hypercalcemia (makes a1-hydroxylase), increased ACE
Lofgren’s syndrome - erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
Lofgren’s sydnrome
erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
Lofgren’s sydnrome
erythema nodosum + hilar adenopathy + migratory olyarthralgias + fever
NF-2 genetics
Autosomal dominant
Severe disease casued by frameshift or NONSENSE mutations
Less severe are missense
Bradycardia +
AV block +
HypoTN +
Diffuse wheezing
Beta blocker toxicity
Tx w/ glucagon
Wheezing indicative of bb toxicity
Can also get cold and clammy due to cardiogenic shock from bradycardia and hypoTN
Most common origin of ectopic foci for afib
Pulmonary vein
1 cause of atrial flutter
reentrant circuit rotating around tricuspid annulus
Analgesic abuse nephropathy
Tubulointerstitial disease
Characterized by focal glomerulosclerosis
Hyperglycemic nonketotic state is not symptomatic until what glucose level
600 mg/dL of glucose in blood
get altered mental state
Cardiac cath complications
Arthroembolism (cholesterol) –> dislodges anywhere
Common sequelae of embolism:
- Blue toes
- Increase Cr
Optic neuritis sx
- Pain with eye mvmt
- Change in color perception
- Afferent pupilary defect and field loss
- papilledema
- more in fems, multiple sclerosis
Tx Bacillary angiomatosis
Oral Erythromycin
How long does heart transplant last?
~10 years
Nerves severed so be careful of atypical MI
- palps, diaphoresis, but no chest pain
When do you admit a pyelonephrtis patient?
Usually if they can’t meds PO b/c vomitting too much
Emphesematous cholecystitis
- what is it?
- how does it happen?
- clinical manifestaitons
Acute choecystitis arising b/c of infection w/ gas forming bacteria (Clostridium, Escherichia, Staph, Strep, Pseudomonas, Klebs)
- Due to vascular compromise (stenosing of cystic A), immunosuppression (DM2), gallstones
- Crepitus in ab wall adjacent to gallbladder is occasionally detectable - NO peritoneal signs though
Dx w/ ab radiograph
only a small increase in bilirubin or AST/ALTs
underlying path of lateral epicondylitis
Degeneration of extensor carpi radialis brevis tendon near the lateral epicondyle
What restrictive lung disease doesn’t respond to steoids?
Idiopathic Pulmonary FIbrosis
1 finding in interstitial lung disease on PFTs
Decreased diffusion capacity to CO
What kind of age distribution for diagnosis does Crohns have?
Bimodal
How much blood do you ave to lose to become tachycardic? Orthostatic?
Tachy - 15%
Ortho -30%
1 cause of septic arthritis
Staph aureus
Beck’s triad
Cardiac tampanode
- hypotension
- distended neck veins
- muffled heart sounds
- pulsus paradoxus
Young black male + painless hematuria. What do you expect? How does it happen?
Sickle cell trait
Episodes of painless hematuria are classic
Papillary ischemia is possible cause
Tx of stroke in sickle cell patient
Exchange transfusion
- decreases % of sickle cells in blood and another stroke of happening
Continue hydroxyurea
EKG finding of supraventricular tachycardia
Narrow QRS complex
Renal artery stenosis occurs most commonly w/ which nephrotic syndrome?
Membranous glomerulonephritis
Sudden onset
- ab pain
- fever
- hematuria
Most specific arrhythmia for digoxin toxicity
Atrial tachycardia w/ AV block
Digoxin increases vagal tone thus decreasing conduction through AV node
Digoxin also increases ectopy in the atria and venticles
Rare for atachy + AV block together so pretty specific for dig toxicity
Secondary AA amyloidosis
Results from deposition of acute phase reactants (serum amyloid A) in setting of chronic inflammatory disease (psoriasis IBD, rheumatoid arthritis)
Nephrotic syndrome common, hepatomegaly
Elevated BUN + no increase in Cr
OR
Increased BUN/Cr
Pts receiving steroid treatments
Prerenal renal fail
GI bleed
Most common feature of hemophillia
Hemarthroses
Acute monocytic leukemia features
Bleeding gums
Leukocytosis + lots of blast forms
Staining - + alpha-naphthyl esterase
peroxidase (-) b/c lack auer rods
How do you tell the difference between peripheral vascular disease (arterial stenosis) and venous insufficiency?
Artery - shiny, hairless skin
Vein - skin discoloration (purple/pink), hair is ok, edema
Normal skin at birth –> dry skin w/ horny plates over extensor surfaces of limbs
Ichthyosis vulgaris
Blood transfusions received before 1992 1986 1980s Should be screened for...?
1992 - Hep C
1986 - Hep B
1980s - HIV
Essential tremor
Stable at rest
Usually noticeable when pt attempts to do something requiring fine movement
Tx w/ beta blocker - propanolol
anticonvulsants - primidone
topiramate
benzos - clonazepam
Parkinson’s tremor
Worse at rest (4-6 Hz)
Better when try to do something
Asymmetric, assoc w/ rigidity
Dx acute MI
Dx reoccurence of MI
Acute - Troponin T (takes longer to return to normal)
Reoccurence - CK-MB
What do you give for all that have high risk of developing aplastic crisis
Folic acid
If someone says they got something in their eye
High velocity…
- don’t see anything with penlight
- use fluorescein exam (slit lamp, etc)
- never use MRI because it will risk dislodging the item
- use CT or Ultrasound
Dyspnea + fever + cough (nonproductive)
Tachypnea + cyanosis + minimal chest findings
Bilateral diffuse interstitial infiltrates beginning in perihilar region
P. jirovecei
Most common places for perihilar involvement of P. jiroveci
lymph nodes
spleen
liver
bone marrow
HIV pt with CD4 count < 50 / mm3 should receive what prophylaxis against what?
Mycobacterium avium complex
–>Azithromycin
CMV (but also if serum CMV IgG is +)
–> Ganciclovir
Metabolic syndrome diagnosis
3/5 present:
- Ab obesity (> 40 inc men, > 35 inc women)
- Fasting glucose > 100 -110 mg.dL
- BP > 130/80 mm Hg
- Triglycerides > 150 mg/dL
- HDL (Men < 40 mg/dL; women < 50 mg/dL)
Bloody diarrhea bacterial causes
Campylobacter Shigella Salmonella Yersinia E coli
E coli doesn’t have a fever sometimes (vs the other) and has more ab pain than the others - that’s how you tell the difference
Pts w/ cirrhosis - what do you do for them first?
Endoscopy ASAP - esophageal varicies are a big bleed risk. Use beta blockers to prophylactically decrease risk of bleeding.
SLE + anti-ds DNA antibodies
First step in tx?
Kidney biopsy
- informs different nephritis treatments
- is baseline to compare other biopsies to monitor disease progression
Equation for anion gap
AG = Na - (HCO3 + Cl)
What is cor pulmonale most commonly caused by?
COPD
Less frequent:
- Pneumoconiosis
- Pulmonary fibrosis
- Kyphosis
- Primary pulmonary HTN
- repeated episodes of PE
Cause of S3
Reasons for S3
Tx for symptoms for abnormal S3
Tx for long term for abnormal S3
Inflow from L atrium strikes blood already in LV causing an extra sound
Normal in younger athletes and preggers
Abnormal - usuall sign of left ventricular failure
Tx symptoms - diuretics
Tx long term - beta blockers
Atypical lymphocytes Ddx
VACTER RM
Viral hepatitis Acute HIV infection CMV Toxoplasmosis EBV (mono) Rubella
Roseola
Mumps
What diabetes medication do you hold on hospital admission? Why?
Metformin
Metformin gets processed by liver and excreted by kidney. If kidney excretion is bad, will build up metformin and get lactic acidosis.
If pt needs CT w/ contrast, can possibly get renal damage and will decrease ability to excrete metformin.
When do you stop colonoscopy screenings?
85 yo
Best test to evaluate pt w/ epigastric pain
Upper GI endoscopy Can diagnose: - PUD - gastritis - esophagits - rule out cancers of esophagus and stomach - H. pylori infection w/ biopsy
Mets of gastric carcinoma
Krukenberg - mets to ovary
Blumer’s shelf - mets to rectum (can feel on rectal)
Sister mary joseph’s node - mets to periumbilical lymph node
Virchow’s node - mets to supraclavircular ofssa nodes
Irish’s node - mets to left axillary adenopathy
Risk factors for gastric carcionma
atrophic gastritis gastric polyps H. pylori Pernicious anemia Nitrates diet Blood type A
Most common malignancy in asbestosis patients
Bronchogenic carcionma
Causes of renal transplant dysfunction in early post-op period
Tx?
Ureteral obstruct acute rejection cyclosporine toxicity vascular obstruct ATN
IV steroids best tx
Effects of an AV fistula
Decreases systemic vascular R
Increases cardiac preload
INcrease cardiac output
Widens pulse pressure Strong arterial pulsation (brisk carotid upstroke) Systolic flow murmur Tachy Flushed extremities
LV hypertrophy
PMI displaced to left
How can you have heart failure in AV fistula pts?
Heart still pumps lots of CO but circulation is unable to meet O2 demand of peripheral tissues
High output cardiac failure causes
Thyrotoxicosis AV fistula Paget disease Anemia Thiamine deficiency
Congenital AV fistula causes
PDA
Angiomas
Pulmonary AVF
CNS AVF
Acquired AV fistula causes
Trauma
Femoral cath
Aortocaval fistula (eg atherosclerosis)
Cancer
Tx Meniere’s disease
Decreasing triggers that increase endolymphatic retention
Avoid:
- EtOH
- Caffeine
- Nicotine
- Foods high in salt
Do you need to bridge heparin and warfarin in pts w/ afib? DVT?
A fib - NO!
- Your protein C and S levels are normal so if start warfarin without bridging, will have a slight depletion of C and S but not enough to cause necrosis
- heparin use if want to cardiovert someone
DVT - yes!
- Body is actively depleting protein C and S to try and break up clots
- if add warfarin without heparin, you’re going to decrease C and S even more and will definitely have necrosis
Hypertension in pts w/ thyrotoxicosis
Predominantly SYSTOLIC HTN, w/ increase in pulse pressure
Caused by hyperdynamic circulation due to hyperTH. Possibly due to increased expression of myocardial SR Ca-dependent ATP
Managing Nephrolithiasis
Imaging
- helical CT highest sensitivity and specificity
Pain
- Narcotics and NSAIDs if have normal renal function
- NSAIDS better because narcotics can worsen N/V
Size of stone
- < 5 mm = pass spontaneously, drink lots of fluids
Urology consult
- if anuria, urosepsis, acute renal fail
Multiple sclerosis CSF findings
Oligoclonal bands (mostly IgG)
Most important contributor to CHF edema
Increased renal sodium retention
Results from RAAS due to renal hypoperfusion secondary to decreased CO
Pathophysiology of non-EtOH fatty liver disease
Insulin resistance –> fat accumulation in hepatocytes by increasing rate of lipolysis and elevating circulating insulin levels –> intrahepatic fatty acid oxidation –> increase in oxidative stress –> local increase in proinflammatory cytokines TNF-a –> liver inflammation, fibrosis, cirrhosis
Immediate goal of managing pt w/ confusion if hx is limited
Tx potentially reversible causes of confusion
Thiamine –> Wernicke’s encephalopathy
Dextrose –> hypoglycemia
Supplemental O2 –> hypoxia
Naloxone –> Opiate OD
Major cause of morbidity and mortality in SAH pts
Vasospasm of arteries at base of brain
Signs of ischemia happen about 7 days after SAH
Use CCB to prevent!
Warm agglutinin disease
- what is it
- causes
- tx
IgG
Extravascular hemolysis –> splenomegaly
May have spherocytes
Causes
- lymphoma, leukemia (CLL)
- SLE
- a-methyldopa
tx w/
- steroids
- rituximab
- splenectomy
- immunosuppressive drugs
Cold agglutinin antibody disease
- what is it
- causes
- tx
IgM
Intravascular (activates complement –> hemolysis)
Causes:
- Mycoplasma pneumoniae
- EBV
tx w/
- supportive care
- RBC transfusions
- NOT steroids
Common causes of priapism
Sickle cell
Leukemia
Perineal or genital trauma (laceration of cavernous artery)
Neurogenic lesions (spinal cord, cauda equina compression)
Meds - trazodone, prazosin (#1)
What spinal process are diabetics prone to develop?
- How do you dx?
Epidural abscesses
Do an MRI to eval cord compression
Spontaneous bacterial peritonitis
- Ascitic fluid Dx
- When do paracentesis?
- Most commonly cultured organisms
- Empiric therapy?
Dx: + ascitic culture, PMN > 250 / mm3
When: Before antibiotics
Org: E coli, Klebsiella
Empiric tx: 3rd gen cephalosporin
Acute aortic dissection presentation
HTN (not HYPO)
Tearing chest pain
Unequal pulses
Early diastolic murmur - dissection causes aortic regurg
Presentation of influenza
When does tx need to start?
Leukopenia
Acute onset fever, chills, cough, malaise, myalgias, coryza
Antiviral therapy (ostltamivir) must be started w/in 48 hrs to significantly decrease duration and severity
SLE hemotologic abnormalities
Anemia (warm agglutinin hemolysis)
Thrombocytopenia (like ITP in Ab formed against platelets)
Neutropenia (Ab-destruction of WBC)
Medial medullary syndrome
Occlusion of vertebral artery/branch
Contralateral paralysis of arm and leg
Contralateral loss of tactile, vibratory adn position sense
DEviation of tongue to injured side
Wallenberg syndrome
Lateral medulla injury
Ipsilateral Horner
Contralateral loss of pain and temperature sensation on body
Loss of pain and temp of face
weakness of palate, pharynx, vocal cords
cerebellar ataxia
Acute pericarditis EKG
Diffuse ST elevations
PR depressions
Breath sounds over consolidated lung retions
LOUDER + more prominent expiratory component if airways are patent
- egophony also present
- crackles
- decreased if airways are blocked
Acalculous cholecysititis commonly seen in pts…
- Extensive burns
- Severe trauma
- Prolonged TPN
- Prolonged fasting
- Mechanical ventillation
Zenker’s diverticulum
- Where?
- Why?
- Dx?
- Tx?
Happens right above UES by herniating POSTERIORLY between fibers of crcopharyngeal muscle
Motor dysfunction and incoordination responsible for problem
Can sometimes see the outpouching in the neck!
Dx - contrast esophogram to clearly show diverticulum
Surgical tx = excision and cricopharyngeal myotomy
When do you do a carotid endarterectomy?
"Symptomatic" carotid stenosis of 70-99% Asymotompatic stenosis of 60-99% Low surgery risk Good 5 year predicted survival Accessible lesin
<50% - just aspirin
When do a carotid angioplasty w/ stenting?
High surgical risk
Poor 5 year survival
NOT for asymptomatic pts
DVT anticoagulation contraindications
How do you tx?
Recent surgery
Hemorrhagic stroke
Bleeding diathesis
Actve bleeding
IVC filter
Cluster headache features
Intense unilateral retroorbital pain, usually waking pt up from sleep
Starts suddenly, peaks rapidly, lasts 2 hrs
More in men
Redness of ipsilateral eye, Horner’s, runny nose, tearing
Causes of macrocytic anemia
Folate deficiency
B12 deficiency
Orotic aciduria
Myelodysplastic syndrome
Acute myeloid leukemias
Drugs
Liver disease
EtOH abuse
HYPO thyroid
Pernicious anemia
1 cause of B12 deficiency
Usuall have other autoimmune d/o (thyroid, vitiligo)
Shiny tongue (atrophic glositis) Ataxia (shuffling, broad based) DCMLS deficit
How long do you have to be on a pure vegan diet to replete your B12 stores?
Folate stores?
B12 - 4-5 years
Folate - 4-5 months
Extraintestinal manifestations of UC
Sclerosing cholangitis
Uveitis
Erythema Nodosum
Spondyloarthropathy
Toxic megacolon
Colon cancer
1 valvular abnormality in infective endocarditis (not IV drug use related)
Mitral regurgitation
Urinalysis: Gluc - negative Ketones - trace LE - negative Blood - Large RBC - 0-1 WBC - 5-10
What do you suspect?
Rhabdomyolysis –> myoglobinuria
ALWAYS suspect this if test results have large amt of blood on UA but absence of RBCs on microscopy
Altered mental status causes
Decreased glucose
Decreased Na
HYPO thyroid
Increased Ca
Uremia
NH3
Increased CO2
Can you gain wt with cancer?
YES!
Hyper ACTH of small cell –> Cushings –> fat redistribution
Ectopic ACTH causes
Lung cancer
Carcinoid
Pancreatic cancer
Neuoendocrine tumors
Important electrolyte disturbance w/ SAH
Hyponatremia –> Cerebral salt wasting syndrome
1) Inappropriate secretion of vasopressin –> water retention
2) Increased secretion of ANP/BNP –> cerebral salt wasting
3) SIADH also commonly seen
What lab values are best representations of acid base status?
pH
PaCO2
Pronator drift
Sensitive an specific for UMN lesion
UE supinators naturallyw eaker than pronators - exaggerated in pts w/ UMN lesion
Extend arms wti palms up, affected arm will tend to pronate ad drift down
Most common site of hypertensive hemorrhage (intracerebral)
- features on PE
Putamen (35%) - BASAL GANGLIA!
Internal capsule lying adjacent almost always involved–> hemiparesis
Cerebellum (16%), thalamus, and pons also common
Motor deficits opposite site of lesion
Gaze deviation TOWARDS side of lesion
What’s the best way to improve LV function in pt with tachysystolic afib?
Control rhythm or rate
Uremic coagulopathy
Abnormal hemostasis seen in pts w/ CRF
Abnormal bleeding and bruising are characteristic
Guanidinosuccinic acid is #1 uremic toxin implicated in pathogenesis of platelet dysfunction seen in CRF
PTT and PT and TT usually normal
Bleeding time usually prolonged
Platelet count normal, platelet dysfunction present
Extrarenal complicatins of ADPKD
Hepatic cysts (#1)
Berry aneurysm
MV prolpse
Aortic regurg
Colonic diverticula
Ab wall and inguinal hernia
Extrahepatic sequelae of chronic hep C
Chronc arthralgia (false + RF or ANA) Cryoglobulinemia Porphyria cutanea tarda Membranoproliferative glomerulonephritis B cell lymphomas Plasmacytomas Sjogren's, thyroiditis Lichen Planus Idipathic thrombocytopenic purpura (ITP)
FeUrea
< 35% = pre-renal azotemia
> 35% = intrinsic renal failure
FeNa
< 1%
- prerenal
- the physiologic response to a decrease in renal perfusion is an increase in sodium reabsorption to control hyponatremia, often caused by volume depletion or decrease in effective circulating volume (e.g. low output heart failure).
> 2-3%
- ATN or kidney damage
- either excess sodium is lost due to tubular damage, or the damaged glomeruli result in hypervolemia resulting in the normal response of sodium wasting.
Risks for contrast induced nephropathy
FeNa < 1
Diabetes
Decreased GFR
Black currant jelly stools
Intusuception
How do you decide how and where to tx a patient with pneumonia?
CURB-6 C = Confusion U = Urea (BUN > 20) R = RR > 30 B = systolic BP = 65
0-1 = outpt, 2 = admission
Facticious thyrotoxicosis - labs
Hyperthyroidism signs (no goiter or exophthalmos though)
LOW TSH
HIGH T3 and T4
Dx w/ 24 hr radioiodine uptake test –> diffusely decreased iodine uptake by thryoid
Biopsy = follicular atrophy
Reasons for pain postcholecystectomy
1) Sphincter of oddi dysfunciton
- abnormal ALP
- dilatation of biliary tree
- high pressure of sphincter on manometry
2) common bile duct stone
- abrnomal ALP
- dilatation of biliary tree
3) functional pain
- normalLFTs
- no dilatation of biliary tree
- diagnosis of exclusion
When do a cholecystectomy?
Indicated for all pts w/ symptomatic gallstones (eg pancreatitis) who are medically stable enough for surgery
Mass in anterior mediastinum
Thymoma
Retrosternal thyroid
Teratoma
Lymphoma
Dx w/ CT scan
Mass in middle mediastinum
Bronchogenic cysts Tracheal tumors Lymph node enlargement Aortic aneurysms of arch Pericardial cysts
Mass in posterior mediastinum
Neurogenic tumors - meningocele lymphoma diaphragmatic hernias esophageal tumors aortic aneurysms
Dx w/ MRI
How do you decrease risk of contrast-induced nephropathy?
Use non-ionic contrast agents
Tricuspid valve endocarditis + pleuritic pain + cavitating lung nodules on xray
Staph aureus
septic embolism to lungs from staph IV use
Dilated cardiomyopathy causes
Alcohol Adenovirus Beri beri Coxackie Chagas Cocaine Doxorubicin/Danorubicin Enterovirus
Hemochromatosis
HHV 6
Parvovirus B19
Peripartum cardiomyopathy
Tx after diagnose solid testicular mass suggestive of cancer (via US)
Radial orchiectomy
- remove testis and associated cord
Diabetes insipidus features
Polyuria
Polydipsia
DILUTE urine w/ increased serum osmolality
Pts prefer cold water
Primary polydipsia features
Excessive water drinking
Both plasma and urine are diluted
SIADH features
Hyponatremia Low serum osmolality Inappropriate high urine osmolality Hypouricemia and low BUN Normal or reduced Cr b/c of dilution Euvolemia
Osmotic diuresis features
Happens w/ hyperglycemia, glucosuria, mannitol admin
Urine and serum osmolality elevated
Urine > serum
Pap smear screening guidelines
Start at 21 no matter if sex active
21-30:
- screen every 2 years
> 30 w/ 3 consecutive (-) paps, screen every 3 years
If have CIN II/III, screen w/ pap smear every 6 months until 3 negatives obtained
- then resume standard (annual) screening
What should all chronic hep C people get?
Vaccinations to Hep A and B if not already immune
Heat stroke
- characteristics
- consequences
Body temp > 105
Dehydration common –> hot, dry skin and hypotension, tachycardia, tachypnea, hemoconcentration
Seizures
ARDS (scattered rales on exam)
DIC (low platelets, increased PT/PTT) - eg epistaxis
Hepatic/renal failure
Electrical alternans
Pathognomonic for pericardial effusion
Due to swining motion of heart in pericardial cavity causing beat to beat variation in QRS axia adn amplitude
EA + sinus tachy very specific for pericardial effusion
Mixed cryoglobulinemia
Palpable purpura
Proteinuria
Hematuria (RBC casts)
Arthralgias
Hepatospelnomegaly
Low complement
HCV infection usually
Colon cancer screening
Start age 50 or 10 years before 1st diagnosis in family member
Do every 10 years for average risk
Mammogram screenings
age 50 - 75
- every 2 years
> 75
- NONE!
Common complication of CABG
Afib
Rate of afib increases w/ CABG + aortic valve replacement
Pickwickian syndrome (Obesity Hypoventilation syndrome)
Severe obesity + alveolar HYPOventilation during wakefullness + thick neck
Low voltage QRS on EKG
Polycythemia secondary to hypoventilation
Smoking cessation cardiovascular benefits
LITTLE effect on BP reduction
Significantly reduce risk of cardiovascular disease
Risk factors for osteosarcoma
Radiation
Chemo
Paget’s
Osteitis fibrosis cystica
Due to HYPER PTH
Osteoclastic resorption –> replace bone w/ fibrous tissue (brown tumors)
Wernicke’s encephalopathy
Triad
Altered mental status
Ataxia
Nystagmus, conjugate faze palsy
DOES NOT cause asterixis
Chalazion
Painful swelling –> nodular rubbery lesion
Is a chronic granulomatous condition happening when meibomian gland becomes obstructed - chronically can be due to sebaceous carcinoma
Need to do biopsy-histo to see what it is so make sure it’s not basal cell carcinoma
Hordeolum
Stye
Acute infection of gland of eyelid
Use antistaph meds
Indicators for severity in pancreatitis
Hgb
Cr
Clubbing
Chronic hypoxia
NOT in COPD though
If COPD has clubbing, there is another hypoxic event happening on top of the COPD
UA vs. NSTEMI vs. STEMI features on EKG and Labs
UA - (-) trop, nonspecific EKG
NSTEMI - (+) trop, ST depressions, T wave inversions
STEMI - (+) trop, Q waves
Electrolyte abnormalities of chronic alcoholism
Hypomagnessemia
Hypokalemia
Hypophosphatemia
Hypomagnesia
- consequences
- importance of Mg
- how to correct
- causes of it
Can cause refractory hypokalemia
Mg is important cofactor for K uptake and maintenance of intracellular K levels
NEED TO GIVE Mg first for hypoK
Get hypo Mg also with
- diuretics
- poor nutritoin
- malabsorb
- alcohol
Hypophosphatemia effects
Weakness
Rhabdomyolysis
Paresthesias
Respiratory failure
Hypoalbuminemia effects
Decreased oncotic pressure –> edema
Hypocalcemia (b/c Ca bound by albumin)
INTRAVASCULAR hemolytic anemia
- panel of lab results
Increased
- indirect bilirubin
- urinary urobilinogen
- hemoglobinemia
- hemoglobinuria
- LDH
Decreased
- Haptoglobin (binds up the free Hg)
Tumors almost NEVER mets to brain
Non-melanomatous skin cancer
Oropharyngeal cancer
Esophageal carcinoma
Prostate cancer
Do you screen for bladder cancer?
Never
Even w/ smoking history or family history
Common cause of lactic acidosis in pts w/ atherosclerotic disease and afib
Bowel ischemia
Lactic acidosis b/c lactate is end product of anaerobic metabolism in ischemic tissue
Common infectious cause of adrenal insufficiency
TB
Histoplasmosis
Coccidiodomycosis
Cryptococcosis
Sarcoidosis
What should all pts complaining of asthma like sx be questioned about as well?
Reflux!
GERD in 75% of asthma pts
Dystonia
sustained muscle contraction resulting in twisting, repetitive mvmts or abnormal postures
Torticolis is a focal dystonia
Akathisia
Sensation of restlessness causing pt to move frequently
Athetosis
Slow writing mvmts affecting hands and feet
Characteristic of Huntingtons and goes wtih chorea
Myoclonus
involuntary jerking of muscle or muscle group
Sore throat Odynophagia Drooling Progressive airway obstruction Stridor Fever
Epiglottitis!
Common pathogens:
- Hib
- Strep pyogenes
BNP diagnosing CHF
> 100 pg/mL diagnoses CHF w/ high sensitivity
Common causes of thyrotoxicosis
You get increased TH but decreased radioactive iodine uptake
- Subacute lymphocytic thyroiditis (painless) - postpartum relation usually
- Subacute granulomatous thyroiditis (De Quervain’s)
- Levothyroxine OD
- Iodine-induced thyrotoxicosis
- Struma ovarii (teratoma in ovary producing thyroid hormones)
When do you think pancreatic pseudocyst?
A few weeks (~4) post acute or chronic pancreatitis
Dx via US
Resolves spontaneously; only drain if persists for more than 6 weeks, infected, or > 5cm
Best way to dx disc herniation/abscess
MRI of spine
Bacterial overgrowth in small bowel has what manifestations?
Assoc w/ hx of ab surgery
Tetany (b/c vit D deficiency so dec Ca) Night blindness (vit A def) Neuropathy (vit B12 def) Dermatitis Arthritis Hepatic injury
Subclavian atherosclerosis prefers which artery?
Left artery subclavian
Myasthenia crisis
Life-threatening
Weakness of resp and pharyngeal muscles
Usually caused by intercurrent infection
Can be caused by anticholinesterase overdose
Need to do:
- endotracheal intubation
- w/d anticholinesterases for several days
Osteomyelitis - most common cause
Staph aureus
Osteomyelitis - sexually active
N. gonorrhae
Septic arthritis more common
Osteomyelitis - Diabetics and IV drug users, stepping on a nail
Pseudomonas aeruginosa
Serratia
For IV drug users, spine is usual place for osteomyelitis
Will have tenderness to gentle percussion over spinous processes of involved vertebrae
Osteomyelitis - Sickle cell
Salmonella
Osteomyelitis - prosthetic replacement
Staph aureus
Staph epi
Osteomyelitis - vertebral disease
M. tuberculosis (pott’s)
Osteomyelitis - cat and dog bites or scratches
Pasteurella multocida
Flank pain
Poor urine outflow w/ intermittent episodes of high volume urination
UA - occasional RBCs, WBCs, NO CASTS
Obstructive uropathy due to renal calculi
Anterior blood supply to brain
Internal carotid –> branches –> ACA, MCA
Posterior blood supply to brain
Paired vertebral arteries –> basilar artery –> paired PCA
ACA stroke
Contralateral motor and/or sensory deficits more in the lower limb Urinary incontinence Gait apraxia Primitive reflexes Abulia (lack of will/initiative) Paratonic rigidity
MCA stroke
Contralateral motor and/or sensory deficits more in the upper limb
Homonymous hemianopia
IF dominant lobe (left) –> aphasia
IF nondominant lobe (right) –> neglect and/or anosognosia
PCA stroke
Homonymous hemianopia
Alexia w/o agraphia (dominant hemi)
Visual hallucinations (Calcarine cortex)
Sensory sx (thalamus)
3rd nerve palsy w/ paresis of vertical eye mvmt
Motor deficits *cerebral peduncle, midbrain)
Internal carotid stroke
MCA stroke + amaurosis fugax
Lacunar infarcts
Pure motor hemiparesis
Pure sensory stroke
Dysarthria-clumsy hand
Ataxic hemiparesis
Difference in PFTs b/n Ankylosing spondylitis and restrictive lung diseases
Both have decreased
- FEV1
- FVC
- FEV1 / FVC
AS has increased FRC b/c fixation of chest wall in inspiratory position
Restrictive lung disease has decreased FRC
Lupus anticoagulant features
PTT normal or increased
vWF, bleeding time, platelet count normal
D-dimer normal or high
Pain with neck extension Trismus (inability to open mouth normally) Fever Sore throat Dysphagia Odynophagia
Retropharyngeal abscess
Do CT of neck
Best initial test for squamous cell carcionma of mucosa of head and neck
Panendoscopy
- esophagoscopy
- bronchoscopy
- laryngoscopy
to detect primary tumor
Signs of cerebellar dysfunction
Ataxia Broad based gait Dysmetria Intention tremor Difficulty with rapid alternating movements Nystagmus Muscle hypotonia
Causes of atypical pneumonia
M. pneumo C. pneumoniae Legionella Coxiella Influenza
Erysipelas
Specific type of cellulitis
Inflammation of superficial dermis –> prominent swelling
- sharply demarcated, erythematous, edematous, tender
Usually caused by S. pyogenes
Cellulitis after a puncture wound- what org do you suspect?
Pseudomonas
MPGN type 2 - pathophysiology
Unique among glomerulopathies
Caused by IgG antibodies (C3 nephritic factor) against C3 convertase of alternative complement path
- antibodies reacting w/ C3 convertase –> persistent complement activation –> kidney damage
Common causes of UTIs in ppl w/ catheters
- which ones produce alkaline urine?
Alkaline:
- Proteus
Candida
Pseudomonas
Klebs
Pleural fluid glucose:
< 30 mg/dL
30-50 mg/dL
< 30 mg/dL
- empyema or rheumatic effusion
- decreased glucose b/c high met activity of WBC in fluid
30-50 mg/dL
- malignancy
- lupus
- esophageal rupture
- TB
Pica causes
Iron deficiency (blood loss) Psych disease
Vit D toxicity
Constipation
Ab pain
Polyuria
Polydipsia
Pneumococcal (PPSV) vaccine indications
Given once all adults >=65
Give to all adults < 65 w/ chronic diseases:
- Cardio
- pulm
- hepatic
- renal
- metabolic (eg diabetes)
- immunosuppression
Need booster 5 years later if vaccinated before age 65
HIV pts whose CD4 > 200 need pneumovax
Granulomatosis w/ polyangitis
- Features
- Tx
Triad
- systemic vasculitis (subQ nodules, palpable purpura, pyoderma grangenosum)
- upper and lower airway inflammation (saddle nose deformity, epistaxis, otitis, sinusitus)
- glomerulonephritis (RBC casts, proteinuria, sterile pyruia)
+c-ANCA (vs proteinase-3)
Tx w/ cyclophosphamide
Proximal weakness of lambert eaton vs. polymyositis
Both have proximal weakness
CPK high in polymyositis
CPK normal in LE
Polymyositis - anti Jo1 and ANA
Lambert eaton - anti voltage gated Ca channels
Cocaine use
- Clinical features
- Complications
Features
- tachy, HTN, dilated pupils
- chest pain b/c coronary vasoconstrict
- psychomotor agitation, seizures
Complications:
- MI
- Dissection
- Intracranial hemorrhage
Temporal arteritis pt - tx w/ steroids - now comes in with myopathy - what does pt have?
If no tx w/ steroids for TA and came in with morning stiffness and pain in shoulders, hip girdle and neck, what does pt have?
Myopathy - steroid-induced myopathy
- ESR normal
Pain/stiffness - polymyalgia rheumatica
- in 50% of TA
- ESR elevated
Choriocarcinoma loves to spread to
Lungs
RCC triad
Hematuria
Abdominal Mass
Flank Pain
Also can have left sided scrotal varicocele
Abnormal labs in Paget’s
Increased ALP
Urinary n telopeptide
Dermatomyositis
- Findings
- Autoantibody
- Associations
Findings
- proximal extensor muscle inflammatory myopathy
- periorbital edema = hemiotrope sign
- violaceous poikloderma on chest and lateral neck = shawl sign
- poikloderma on knuckles, elbows, knees = Gottron’s sign
- Gottron’s papules = lichenoid papules over joints = pathognomonic
- more in females
Autoanitbody
- anti-Mi-2 (against helicase)
Associations
- Malignancies (ovarian, breast, lung, urogenetal female)
Inflammatory diseases assoc w/ aoritc aneurysms
Behcet Takayasu arteritis GCA Ankylosing spondylitis RA Psoriatic arthritis Relapsing polychondritis Reactive arthritis
Inflammatory disease assoc w/ carpal tunnel
RA
Sarcoidosis
Amyloidosis
Criteria for starting long term O2 therapy in COPD
PaO2 < 55 mmHg
OR
SaO2 < 88% on room air
Pt w/ cor pulmonale
OR
Hct > 55%
If become hypoxic during exercise or sleep
Grave’s disease
- specific signs
Exophthalmos
Pretibial myxedema
Thyroid bruit
HYPERthyroidism features
Nervousness, insomnia, irritability
Hand tremor, hyperactivity, tremulousness
Excessive sweating, heat intolerance
Weight loss, increased appetite
Diarrhea, frequent defecation
Palps
Muscle weakness
Graves Proptosis pathophys
Autoimmune attack on extraocular muscles
Lymphocytes infiltrate EOM and orbita fat –> edema, proliferaion of local interstitial fibroblasts, and deposition of glycosaminoglycans –> fibrosis and increased edema w/ EOM enlargement
Thyroid storm
Med emergency
usually precipitating factor like infection, DKA or stress
high mortality rate
Fever Tachy Agitation or psychosis Confusion N/V, diarrhea
Tx
- supportive (IV fluids, cooling blankets, glucose)
- antithyroid agents
- b-blockers
Myxedema coma
Depressed state of consciousness + HYPOthermia + respiratory depression
Can develop after years of severe untreated hypoTh
Med emergency
Tx
- supportive to maintain BP and respiration
- IV thyroxine and hydrocortisone
HYPOthyroidism features
Fatigue, weakness, lethargy
Menorrhagia, wt gain
Cold intolerance
Constipation
Slow mentation, inability to concentrate
Muscle weakness
Depression
Diminished hearing
Dry skin, coarse hair, hoarseness, nonpitting edema, Bradycartia
Goiter
Hashimoto’s thyroiditis
Rubbery, nontender goiter
Antimicrosomal antibodies
Can also have increased LDL, decreased HDL, normocytic anemia
Papillary carcinoma of thyroid
- Features
- Tx
MOST COMMON
Least aggressive
RIsk factor: hx radiation to head/neck
Spreads via lymphatics in neck - distant mets are rare
Tx
- lobectomy w/ isthmusectomy
- total thyroidectomy if tumor > 3 cm, bilateral, advanced, or distant mets
- TSH suppression theapy, radioiodine therapy
Follicular carcinoma of the thyroid
- Features
- Tx
Loves to absorb I Prognosis worse than follicular spread HEMATOGENOUS Distant mets common Tumor extension past capsule distinguishes it from benign adenoma
Tx
- Total thyroidectomy
- Postop I ablation
Medullary carcinoma of the thyroid
- Features
- Tx
1/3 assoc w/ MEN II
Arises from parafollicular C cells - makes calcitonin
Stains w/ congo red
More malignant than follicular cancer!
Tx
- Total thyroidectomy
Anaplastic carcinoma of the thyroid
- Features
- Tx
Mostly in elderly
Highly malignant
CAn arise from longstanding follicular or papillary thryoid carcinoma
Death usually in months
Tx
- chemo and radiation
- palliative surgery for airway
Hurthle cell tumor
Variant of follicular cancer but more aggressive
Spread by lypmhatics
Tx - total thyroidectomy
Felty syndrome
Form of RA w/ splenomegaly and granulocytoenia
Usually happens if A present fore more than 10 years
Lab values w/ glucocorticid use
Decrese:
- Eosinophil
- Lymphopenic
Increase bone marrow release and mobilize marginated neutrophil pool (neutrophilia)
What makes a Q wave pathologial?
If it is greater than 1/3 of the R wave
Albumin charge change
- Example w/ Ca
Increase pH of blood
- more negative charge on albumin
- increase affinity to Ca
- increase albumin-bound ca
- decreases levels of ionized calcium
Hypocalcemia signs
Crampy pain Paresthesias Perioral tingling Tetany Carpopedal spasm Seizures Prolongation of QT interval on EKG
Hypo K + alkalosis + normotension
- what do you suspect?
Surreptitious vomitting (urine Cl low) Diuretic abuse (Cl urine high) Bartter syndrome (Urine Cl high) Gitelman syndrome (Urine Cl high)
Presbycusis
Sensorineural hearing loss w/ age
symmetrical high freq hearing impairment
Otosclerosis
Chronic conductive hearing loss w/ bony overgrowth of stapes
Usually starts as low freq hearing loss
Pancoast tumor
Shoulder pan radiating into armin ulnar distribution
Caused by tumor ivasion of 8th cervical - 1st thoracic nerves
What can an apical pulmonary tumor cause in terms of symptoms?
Horner’s - sympathetic trunk compression
Pancoast - brachial plexus compression
Hoarse voice - R recurrent laryngeal N compression
SVC syndrome - compress SVC ad decrease blood return from head
Normal distribution of statistical values
Mean = median = ode
Positive skew (tail on right) distribution
Mean > median > mode
Negative skew (tail on left) distribution
Mean < median < mode
Rapidly developing hirsutism
- Best test to dx
- how to interpret the results?
Suggestive of androgen-sereting neoplasm of adrenal or ovary
Serum testosterone and DHEAS (sulfated form of DHEA)
Increased testosterone, normal DHEAS = ovarian source
Increased DHEAS, normal testosterone = adrenal source
DHEA is secreted from both ovaries and adrenals
DHEAS is made only in adrenals
Hairy cell leukemia
- What is it?
- Markers?
Type of B lymphocytic derived chronic leukemia
Tartrate-resistant acid phosphatase stain
CD11c marker
Hypo K+ effects
- physio effects
- EKG
Weakness Fatigue Muscle cramps Flaccid paralysis Hyporeflexia Tetany Rhabdomyolysis Arrhythmias (afib, torsades)
Broad flat T waves, U waves, ST depression
Cystinuria
Impaired amino acid transport of dibasic amino acids (csteine, lysine, argiine, ornithine)
Cysteine is poorly soluble in water –> get renal stones
+ urinary cyanide nitroprusid test
Cysteine kidney stones
Usually due to cystinuria
Hard and radioopague stones
UA shows hexagonal crystals
+ urinary cyanide nitroprusside test
Pt presentation:
- lower ab pain, bloody diarrhea, tenesmus over several weeks
- acute fever, leukocytosis, hypoTN, tachy
What are you worried about?
Probably has undiagnosed IBD
Now has toxic megacolon
Can be lethal
Dx toxic megacolon
Radiographic evidence of colonic distension +
3 of the below:
- Fever > 38C
- HR > 120
- Neutrophilic leukocytosis > 10,500
- Anemia
Plus at least one of the below:
- vol depletion
- altered sensorium
- electrolyte disturbance
- hypoTN
Dx w. abdominal Xray to confirm dilated colon > 6cm
SIADH tx
Hypertonic (3% saline) SLOWLY
Rate of correction not more than 0.5-1 mEq/L/hr
Normal pressure hydrocephalous
Abnormal gait
Incontinence
Dementia (memory loss w/o focal neurologic changes)
Toxoplasmosis CNS
Mass lesions
Usually multiple
In basal ganglia and at cortical grey[white matter interface
Ring-enhancing
Common causes of brain abscesses
Anaerobic Strep
Bacteroides
On CT:
- isolated, round smooth bordered ring enhancing intracranial lesion on contrast CT
- immunocomp pt
- known extracranial bacterial infection
this is a brain abscess
Chlamydia trachomatis screening
Screen all sexually active women age 24 and younger
Screen other asymptomatic women at increased risk for STIs
Sources for PE clots
LE DVT most common
- proximal deep veins (iliac, femoral, popliteal) = > 90%
- calf vein is less than proximal
Cavernous sinus thrombosis
- symptoms
- how do you tell the difference w/ orbital cellulitus?
CST happens b/c facial/ophthalmic venous sys is valveless
Headache Binocular palsies Periorbital edema Hypoesthesia or hyperesthesia in V1/V2 distribution CAN BECOME BILATERAL
Dx w/ magnetic resonance venography
Orbital cellulitus DOES NOT have headache, bilateral cranial nerve findings, or bilateral periorobital edema
VIPoma
Diarrhea Hypo K --> leg cramps Decreased H+ in stomach Dehydration Ab pain Wt loss Facial flushing Redness
Tx - ocretotide to help w/ diarrhea
Glucagonoma
Necrotizing dermatitis
Wt loss
Anemia
Persistent hyperglycemia
Role of spleen in immune system
Blood borne antigens enter spleen via splenic A –> phagocytosed by dendritic cells in WHITE PULP
Dendritic cells present antigens on MHC 2 –> TH cells –> activated TH cells go to marginal zone of spleen –> contact B cells in primary follicles
B cell activation –> secondary follicles –> germinal centers w/ lots of plasma cells form –> make antibodies –> bind antigen –> facilitate phagocytosis by opsoniziation
Leukocyte adhesion defect
Chemotaxis impaired
Autosomal recessive
Defect in integrin B2
Osteonecrosis = aseptic necrosis = avascular necrosis = ischemic necrosis = osteochondritis dessicans
Vasculature of bone disrupted –> bone and bone marrow infaction
Bone can’t remodel –> trabecular thinning –> collapse of affected bone
Use MRI to dx (most sensitive)
Precipitating factors:
- steroid use
- chronic EtOH
- hemoglobinopathies
- trauma
- antiphospholipid syndrome
Liver main functions
Synthetic
- make clotting factor, cholesterol, proteins
Metabolic
- met drugs and steroids
- detoxify
Excretory
- bile excretion
Isolated systolic HTN
Caused by decreased elasticity of arterial wall
- increase in SBP but not DBP
- get widened pulse pressure
Always treated b/c assoc w/ increased risk for CV events
Tx: thiazide, ACE-I or CCB
What abnormal labs are indications for thyroid function tests?
Hyperlipidemia (increased LDL)
Unexplained hypo Na
Elevated serum muscle enzymes
Anemia (normocytic, normochromic)
How do you tell between NPH and atrophy of brain?
Sulci - enlarged in atrophy, not enlarged in NPH
Both have increased ventricle size
Clinical symptoms different though
MMSE < what is suggestive of dementia
24
Pt w/ PID - what else should you test them for?
HIV
Syphilis
Hep B
Pap smear
Hep C if IVDU
Liver main functions
Synthetic
- make clotting factor, cholesterol, proteins
Metabolic
- met drugs and steroids
- detoxify
Excretory
- bile excretion
Tx calcium stones
Hydrocholorthiazide (NOT FUROSEMIDE)
Hydration
Typical renal colic but no stone on flat film of abdomen and pelvis
- what do you consider?
- radiolucent stone (uric acid)
- calcium stones < 1-3 mm in diameter
- Non stone causes (obstruction via blood clot, tumor)
Tx uric acid stones
Hydration
Alkalnize urine
- oral KHCO3 or potassium citrate
Low purine diet w/w/o allopurinol
Secretin stimulation test
Done if suspected Z-E but gastrin values not diagnostic
Secretin stimulates release of gastrin from GASTRINOMA cells
Normally, secretin —-| g cell and gastrin release
Indications for parathyroidectomy in hyperparathyroidism
Symptomatic
OR
Asymptomatic + 1 of features below:
- serum calcium `> 1 mg/dL above upper limit of normal
- < 50 yo
- Bone mineral density < 1-2.5 at any site
- reduced renal function
Small bowel obstruction:
Proximal vs. distal obstruction
Proximal - frequent vomiting, severe pain, minimal ab distention
Distal - less frequent vomitting, LOTS Of ab distention
Tx hypo PTH
Calcium gluconate in severe cases
Oral Ca
Vit D supplementation
What is diagnostic of hyper PTH?
Chloride/phosphorus ratio of > 33
Cl high secondary to renal bicarb wasting
Causes of Cushing’s syndrome
- Iatrogenic (prednisone)
- ACTH secreting adenoma of pituitary –> bilateral adrenal HYPERPLASIA
- Adrenal adenoma
- Ectopic ACTH from tumor
ACTH secreting adenoma of pituitary–> changes in adrenals?
Bilateral adrenal hyperplasia
Helpful signs for increased cortisol in a pt
Impaired collagen production
- easy bruising
- striae
Myopathy
Virilization
Anti-insulin effects (glucose intolerance)
Protein catabolism
- periph muscle wasting
Impaired immunity
Enhance catecholamine activity
- HTN
Whcih cushings syndromes do you see masculinization?
ACTH secreting adenoma
Ectopic ACTH
Pheochromocytoma
- features
- labs
Features
- HTN
- headache
- sweating
- tachy, palps
- anxiety
Labs
- HYPER glycemia, lipidemia
- HYPO K
Rule of 10s for pheochromocytomas
FaCEBk Me
10% are... Familial Children Extraadrenal Bilateral Malignant
Are plasma or serum emtanephrines better for pheo dx?
Plasma
What does it mean if epi levels are high in suspected pheochromocytoma?
Tumor is in adrenal or near adrenal (organ of zuckerandl at aortic bifurcation)
Nonadreanal tumors can’t methylate norepi –> epi
MEN I
Parathyroid hyperplasia
Pancreatic islet cell tumor - ZE, insulinoma
Pituitary tumors
MEN IIa
Medullary thyroid carcionma
Pheochromocytoma
Parathyroid
MEN IIb
Mucosal neuromas + Marfanoid habitus
Medullary thryoid carcinoma
Pheochromocytoma
Causes of primary hyper ALDO
- Conn syndrome = adrenal adenoma making aldo
- Adrenal hyperplasia
- Adrenal carcinoma
Dx primary hyper ALDO
screen w/ early AM plasma aldosterone to plasma renin activity ratio
— > 30 –> hyperaldo
Saline infusion test
- should dec aldo but won’t in primary aldo
Oral sodium loading
- high NaCl diet for 3 days
- High urine aldo + high urine Na = primary aldo
Why is it impt to differentiate adrenal adenoma from hyperplasa?
How do you tell the difference?
HTN assoc w/ hyerplasia NOT benefited by bilateral adrenalectomy
HTN assoc w/ adenoma is usually cured by removal of adenoma
Adrenal venous sampling for aldo levels
- high aldo on one side indicates adenoma
- high level on both sides = bilateral hyperplasia
1 cause of Addison’s disease worldwide?
Addison - TB
Insufficiency - exogenous glucocorticoids, abrupt stop in usage
Clinical findings of adrenal insufficiency
Wt loss Weakness Pigmentation Anorexia Nausea Postural HYPO TN Ab pain Hypo glycemia
What appears in primary but not secondary adrenal insufficiency?
Hyperpigmentation
Hyperkalemia
Alcoholic liver cirrhosis
- Labs
Labs
- AST > ALT by 2x BUT usually less than 500 IU/L. If more, some other hepatic injury happened
- modest hepatic transaminitis
- modest inc GGT
Why does AST increase more than ALT in alcoholic hepatitis?
Hepatic deficiency of pyridoxal-6-P, a cofactor for ALT enzymatic activity
Pleural fluid studies in pleural effusion
- what studies tell you when you need a chest tube?
pH
- low pH usually means empyema
- need thoracostomy w/ low pH
Glucose
- need thoracostomy w/ low glucose
- low in RA, TB, empyema, malignancy, esophageal rupture
Protein
Gm stain
Cell count
Cytology
Empyema
collection of pus within a naturally existing anatomical cavity, such as the lung pleura
Usually in context of pneumonia
+ empyema if:
- has pus
- has + gm stain
- has pH < 7.2 but serum pH is normal
Blood in urine
- at beginning of stream
- at end of stream
- throughout stream
Beg:
- injury in urethra (urethriti, for ex)
End:
- disease in prostate or bladder
All throughout:
- Ureter or kidney disease
Polyarthralgia
Tenosynovitis
Painless vesiclopustural skin lesions
Dissemnated gonococcal infection
What side of the heart is most restrictive cardiomyopathy on?
Right
When is it best to use bronchoalveolar lavage?
Eval suspected malignancy and opportunistic infection (eg PCP)
Bilateral sacroilitis
LImited spine mobilit > 3 mo duration
20-30 yo
Ankylosing spondylitis
Modified acid-fast stin showing oocysts in stool suggestive of…
Cryptosporidium parvum
Isosporal belli (not as common in US)
Presence of spores in stool
Severe malabsorption and persistent diarrhea in HIV pts
Microsporidia
Enterocytozoon bieneusi
Encephalitozoon intestinalis
Symptoms of intracranial hypertension (> 20 mm Hg)
Headaches worse in AM N/V early in day Vision changes Papilledema Cranial nerve deficits Somnolence Confusion Unsteadiness Cushing's reflex (hypertension and bradycardia)
New onset RBBB can suggest….
PE
Dietary recommendation for pts w/ renal calculi
- Decreased dietary protein and oxalate
- Decreased sodium intake
- Increased fluid intake
- Increased dietary calcium
Vit C will increase oxalate stone formation – don’t take too much! Esp if have renal failure
Herpetic whitlow
Common viral infection of hand
Caused by HSV1 or 2
Self limiing
Health care workers coming in direct contact w/ infected orotracheal secretions are at high risk of developing whitlow
Most important cause of torsades de pointes
Hypo Mg
Prolonged QRS suggests…
Prolonged QT suggests…
QRS:bradyarrhythmia (eg BBB)
QT: tachyarrhythmia
Older pt with new diagnosed achalasia + wt loss - what do you do next for the pt?
Endoscopy
Achalasia could be secondary to systemic diseases (Chagas, amyloidosis, sarcoid) or due to mass at GE junction
Use endo to rule out mass!
Dawn phenomenon vs. Somogyi effect
Both cause morning hyperglycemia
Dawn - due to inc in nocturnal secretion of GH
Somogyi - rebound response to nocturnal hypoglycemia –> morning hyperglycemia
Diagnosis of diabetes
1 of the following:
- 2 fasting glucose > 125 mg/dL
- 1 gluc level = 200 mg/dL w/ symptomes
- Inc gluc level on oral gluc tolerance testing
- HbA1c > 6.5%
Optimal tx for DM type 2 pts
Glycemic control
BP < 130/85
LDL < 100, HDL > 40
Smoking cessation
Daily aspirin (if not contraindicated)
1 COD in diabetic patients
Coronary artery disease
Autonomic neuropathy of DM
Impotence in men
Neurogenic bladder - retention, incontinence
Gastroparesis - chronic N/V, early satiety
Constipation and diarrhea
Postural hypoTN
Defense against HYPOglycemia
Insulin decreases
Glucagon increases
Epinephrine increases next
Cortisol also helps
Glucose < 50 –> symptoms
Main organ at risk w/ hypoglycemia
Brain
Brain can’t use free fatty acids as energy source
Hypoglycemic unawareness
Diabetics w/ severe neuropathy –> autonomic response (epi) to decreased glucose is not activated
- these reactions are supposed to be sweating, tremors, increased BP and pulse, anxiety, palps
Can lead to neuroglycopenic symptoms
- headache, visual distrubances, confusion , seizures, coma
Therefore, if hypoglycemic, can go into seizure or coma
Whipple’s triad
Used to dx Insulinoma
Hypoglycemic sx broung on by fasting
Blood glucose < 50 during symptomatic attack
Glucose admin brings relief of sx
Where are most gastrinomas?
Gastrinoma triangle
- cystic duct (superior)
- junction of 2nd and 3rd duodenum portions (inferior)
- neck of pancreas (medially)
Dx Zollinger Ellison syndrome
Secretin injection test
- usually prevents gastrin secretion
- ZES, gastrin will increase a lot after secretin
Glucagonoma manifestations
Necrotizing migratory erythema (below waist) Glossitis Stomatitis BM Hyperglycemia
Somatostatinoma features
Malignant, poor prognosis
Gallstones
Diabetes
Steatorrhea
VIPoma features
Watery diarrhea –> dehydration, hypo K, acidosis
Achlorhydria (VIP —| gastric secretion)
Hyperglycemia
Hypercalcemia
Bartonella henselae
- features
- treatment
Localized cutaneous and lymph node d/o near site of inoculum
Vesicular, erythematous and papular phases - can be pustular or nodular
Dx w/ clinical or + B henselae antibody test or tissue w/ + Warthin-Starry stain
Tx azithromycin
Toxic epidermal necrolysis
- features
- vs. Stevens Johnson?
- drug causing
Erythematous mobilliform eruption —-> exfoliation of skin (+ Nikolsky’s sign)
> 30% of body skin involved
10% involved only in SJS
Oral mucosa has blisters
Common drug causes: sulfa barbs phenytoin NSAIDs
Best imaging for vertebral osteo
MRI
can also see if there is abscess or cord compression
Most common site of ulnar nerve entrapment
Elbow, medial to epicondylar groove
Gene mutation for hemochromatosis
AR disease
C282Y on chromosome 6
Complications of GCA
Aortic aneurysms (do serial CXR) Blindness
Causes of membranous glomerulonephritis
Hep B, C Syphilis Gold Penicillamine SLE Rheumatoid
What bacteria can cause food poisoning in short time?
How do you tell the difference between what bacteria it is?
Bacteria w/ PREFORMED toxins
- Staph aureus
- B. cereus
Tell by what food the person ate
Staph:
- poultry and eggs
- meats
- mayos
- pastries
- milk and daily
B. cereus:
- starchy foods (rice)
Generalized myxedema of hypothyroidism
- where can it go?
Deposition of mucopolysaccharides (matrix substances, mucin)
- perineurium of median nerve and tendons passing through carpal tunnel
- skin
- heart
- nerves
Carpal tunnel due to deposition of substances. What do you see this in?
Hypothyroidism
Dialysis (beta-2-microglobulin)
Accumulation of fluid in carpal tunnel can cause carpal tunnel syndrome. When does this happen?
Preggers
3rd trimester
Carpal tunnel syndrome due to:
- tenosynovial inflammation
- synovial tendon hyperplasia
When do each happen?
Tenosynovial - RA
Hyperplasia - acromegaly
Essential measures in managemetn of DKA
Restore intravascular volume
- NS
Correct hyperglycemia
- Regular insulin IV
Correct electrolyte abnormalities
- K correction crucial
Tx precipitating factors
- use antibiotics for infections
Baker cyst
Assoc w/ RA
Tender mass in popliteal fossa
Happen b/c excessive fluid production by inflamed synovium
Can burst and look like a thrombophlebitis (DVT)
Heart burn, wt loss, chest pain unrelated to eating, dysphagia, regurg of food
What is this?
Esophageal cancer, most likely
Use barium swallow, EGD and biopsy, and PET scan to evaluate
Common etiologies of constrictive pericarditis
Idiopathic
Viral
Cardiac surgery and radiation therapy
TB pericarditis
Clinical presentation of constrictive pericarditis
Fatigue and dypsnea on exertion
Periph edema and ascites
Increased JVP
Pericardial knock
Diagnostic findings of contrictive pericarditis
Increased pericardial thickening and calcification
Prominent x and y descents on JVP
How do you first evaluate pts w/ probably prostatic hyperplasia?
Hx
Rectal exam
Urinalysis
Serum Cr measurement —-> if increased, US of kidneys or CT of abdomen for reason for obstruction, hydronephrosis or underlying renal disease
1 middle ear pathology in pts w/ acquired immunodeficiency
serous otitis media
conductive hearing loss
dull tympanic membrane that is hypomobile
How best do you alter course of diabetic NEPHROpathy once azotemia occurs?
Intensive BP control
< 130/80
ACE inhibitors preferred tx
You would want to control glucose once proteinuria/albuminuria happens
Suddenet onse vertigo, vomiting, occipital headache in HTN pt
Cerebellar hemorrhage (strong suspicion)
Can also see: 6th nerve paralysis conjugate deviation Blepharospasm Coma
If a young pt presents w/ stroke, look for…
Order…
Vasculitis
Hypercoag state
Thrombophilia
Order Protein C, Protein S, antiphospholipid antibodies Factor 5 leiden mutation ANA ESR Rheumatoid factor VDRL/RPR Lyme TEE
PUpillary findings in intracerebral hemorrhage and corresponding level of involvement
Pinpoint pupils = pons
Poorly reactive pupils = thalamus
Dilated pupils = putamen
Top causes for COPD exacerbation
Smoking
Environmental pollutants/exacerbators
Pneumonia
- S. pneumo
- H. influenza
- M. catarrhalis
How do you dx renal artery stenosis?
Captopril renal scan
Parkinson’s disease
- pathophys
- how this is logical for treatment
Dopaminergic path of basal ganglia is compromised
Cholinergic system operate unoppossed
Lewy bodies (hyalin inclusion bodies) are key neuronal finding in brains
Tx will enhance dopamine’s influence or inhibit Ach influence
When do you not do a LP on a suspected SAH?
If slit lamp exam reveals papilledema
May cause herniation - repeat CT scan before LP
Parkinson’s clinical features
Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks
Bradykinesia
Cogwheel rigidity
Shuffling gait
Expressionless facies
Dementia in advanced disease
Personality changes early on - withdrawn, apathetic, dependent, depression
Complicated GERD
- Manifestations
- Diagosis
Manifestations
- dyphagia
- odynophagia
- wt loss
- bleeding
- Fe deficiency anemia
- typical sx: heartburn, regurg, bitter/sour taste
Diagnosis
- Endoscopy (esophagoscopy)
- —also do endo if complicated GERD or antacids/meds don’t control the codition
Contraction alkalosis
Intracellular volume contraction
Increased aldo functions to restore intravascular volume but also causes increased H+ and K+ loss –> alkalosis!
Thyroid myopathy
- predminant PROXIMAL symptoms
- can have a tremor (action)
- can happen in hyper or hypo thyroid
Central vs 7th nerve palsy of face
Central - forehead wrinkling is ok b/c LMN is bilaterally innervated by both UMN; one is knocked out, the other still works
7th nerve - LMN knocked out, doesn’t matter that it is bilateral, the signal will not go through. So forehead and lower face both out.
Irreversible causes of dementia
Alzheimer's Parkinson's Huntington;s Multi infarct dementia Dementia w/ lewy bodies, Pick's disease Unresectable brain mass HIV dementia Korsakoff's PML CJD
Broca’s aphasia
Comprehension ok, can’t speak or write
Posterior part of dominant frontal lobe infarct
WBC count in synovium of
- crystal induced arthritis
- septic arthritis
Crystal: 10-50,000
Septic: 50-150,000
1 cause of prosthetic joint septic arthritis
1 -Staph aureus
2 - Strep
Salmonella can cause in elderlyand immunocompromised
1 cause of septic arthritis in young sex active ppl
Neisseria gonorrhea
Syringomyelia
- Characteristics
- Pathophys
- Acquired causes
Areflexic wakness in upper extremities
Loss of pain and temp w/ preserved position and vibration in cape ditribution
Presence of cord cavity that communicates w/ central canal of spinal cord
Usually in lower cervical or upper thoracic region
Acquired causes:
- trauma
- inflammaory spinal cord d/o
- spinal cord tumors
Monoclonal gammopathy of undetermined significance
- NO anemia, hyper Ca, lytic lesions, and renal insufficiency
- serum monoclonal protein < 3 g / dL
- < 10% plasma cells in bone marrow
Dx w/ metastatic skeletal bone x rays to exclude MM
1% risk of progression to MM
Multiple Myeloma
- Presence of anemia, hyper Ca, lytic lesions, and renal insufficency
- Serum monoclonal protein > 3 g/dL
- > 10% plasma cells in the bone marrow
- Elevated beta-2 microglobulin
Dx amyloidosis
Serum Immunoelectrophoresis (SIEP)
Biopsy ab fat pad, rectum, organ involved
Diagnostic test to dx MS
MRI
- sensitive in ID demyelinating lesions in CNS
- # lesions on MRI NOT necessarily proportional to disease severity or speed of progression
Gm - bacteria causing pneumonia
E coli klebs Pseudomonas Enterobacter Proteus Serratia Acinetobacter
Rare in healthy individuals
What space in the neck carries the highest risk of spreading an infection to the mediastinum?
Retropharyngeal space
- between alar and prevetebral fascia
Complication of infection in paapharngeal space
Involvement of the carotid sheath –> erosion of carotid artery and jugular thrombohlebitis
What does it mean when it says toe webs are fissured and macerated?
Tinea pedis!
Complication of infection in paapharngeal space
Involvement of the carotid sheath –> erosion of carotid artery and jugular thrombohlebitis
What does it mean when it says toe webs are fissuredand macerated?
Tinea pedis!
Top causes for COPD exacerbation
Smoking
Environmental pollutants/exacerbators
Gold std for dx SAH
Xanthochromia
- results from RBC lysis and implies blood has been in CSF for hours and not due to traumatic tab
Parkinson’s disease
- pathophys
- how this is logical for treatment
Dopaminergic path of basal ganglia is compromised
Cholinergic system operate unoppossed
Tx will enhance dopamine’s influence or inhibit Ach influence
When do you not do a LP on a suspected SAH?
If slit lamp exam reveals papilledema
May cause herniation - repeat CT scan before LP
Parkinson’s clinical features
Pill rolling tremor @ rest - worse w/ emotional stress - gone w/ doing tasks
Bradykinesia
Cogwheel rigidity
Shuffling gait
Expressionless facies
Dementia in advanced disease
Personality changes early on - withdrawn, apathetic, dependent, depression
Progressive supranuclear palsy
Degenerative condition of
- brainstem
- basal ganglia
- cerebellum
Like parkinson’s:
- bradykinesia
- limb rigidity
- cognitive decline
NOT like parkinson’s
- no tremor
- ophthalmoplegia
Huntington’s
- pathyophys
Autosomal dominant, chromosome 4 trinucleotide repeat
Loss of GABA producing neurons in striatum
Huntington’s
- clinical features
- diagnosis w/….
Chorea
Altered behavior - irritable, personality changes, psychosis, OCD
Dx w/ MRI - atroph of head of caudate
- DNA testing confirms diagnosis
Seizure causes
4M’s, 4I’s
Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia
Mass lesions - brain mets, tumors
Missing drugs
- noncompliance w/ antiseizures
- w/d from EtOH, benzos, barbs
Misc
- Eclampsia
- HTN encephalopathy
Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO
Infections - septic shock, meningitis, brain abscess
Ischemia - stroke, TIA
Increased ICP - trauma
Alzheimer’s pathophys
Decreased Ach synth –> impaired cortical cholinergic function
Diffuse cortical atrophy on CT or MRI
Features of Cushings
Central obesity Hirsutisum Moon facies Buffalo hump Purple striae on abdomen Lanugo hair Acne Easy bruising
HTN Diabetes Hypogonadism Masculinization in fems Proximal muscle wasting and weakness Osteoporosis Aseptic necrosis of femoral head
Depression
Mania
Decreased immunity
What is arousal dependent on? Cognition?
Arousal - Intact brainstem
- reticular activating system in brainstem
Cognition - cerebral cortex
Causes of delirium
SMASHED (Coma) + P DIMM WIT
Postop state
Dehydration and malnutrition
Infection
Meds - TCAs, steroids, anticholinergics, hallucinogens, cocaine
Metals
W/D states
Inflammation, fever
Trauma, burns
DDx of coma or stupor
SMASHED
Structural brain pathology (stroke, bleed, tumor)
Meningitis, mental illness
Alcohol, acidosis
Seizures, substrate deficiency (thiamine)
Endocrine (Addisonian crisis, thyrotoxicosis, hypoTH), encephalitis, extreme disturbances in Ca, Mg, PO4
Drugs (opiates, barbs, benzos, sedatives), dangerous compounds (CO, CN, MeOH)
Unilateral fixed dilated pupil
Herniation w/ CN III compression
This is anisocoria
Spinal lesion - how can you tell it is in the spinal cord?
Decrease in sensation below a sharp band in the abdomen/trunk
Pinprick felt above level but not below it
Pathognomonic for spinal cord disease
Level of lesion = sensory level
Intranuclear ophthalmoplegia
Strongly assoc w/ MS
Lesion in MLF –>
= ipsilateral medial rectus palsy on attempted lateral gaze (can’t adduct)
= horizontal nystagmus of abducting eye (contralateral to size of lesion)
Diagnostic test to dx MS
MRI
- sensitive in ID demyelinating lesions in CNS
- # lesions on MRI NOT necessarily proportional to disease severity or speed of progression
Guillain Barre
- characteristics
- treatment
Inflammatory demyelinating polyneuropathy - ascending paralysis/weakness
Usually follows infection: C. jejuni, Herpes, Mycoplasma, H. influenzae, HIV
Tx:
- NOT steroids b/c can be harmful
- monitor pulmonary function
- IV IgG if pt has significant weakness
- plasmaphoresis
Principles of using Ultrasound
Images muscle, soft tissue, bone surfaces very well - can delineate interfaces b/n solid and fluid filled spaces
- shos structures of organs
Has trouble penetrating bone
- has difficulty if there is gas b/n transducer and organ of interest (eg seeing pancreas under the bowel is hard)
Clinical features of neonatal lupus
Skin lesions
Cardiac abnormalities (AV block, transposition of great vessels)
Valvular and septal defects
Increased risk for neonatal SLE if have anti-Ro (SSA) antibodies
Duchenne’s Muscular Dystrophy
- pathophys
- lab values
X linked recessive - mutation on gene coding for dystrophin protein –> muscle cells die then
No inflammation
Labs:
- Serum CPK HIGH
Tuberous sclerosis
AD
Cognitive impairment
Epilepsy
Facial angiofibromas, adenoma sebaceum
Retinal hamartomas
Renal angiomyolipomas
Rhabdoomyomas of heart
Sruge Weber
Acquired disease Presence of capillary angiomatoses of pia mater Facial vascular nevi (port wine stain) Epilepsy and mental retardation - tx epilepsy mainly
+ Ro (SS-A) and La (SS-B)
Sjogren's Subacute cutaneous Neonatal lupus Complement deficiency ANA negative lupus
Horner’s syndrome
Ipsilateral -
ptosis
miosis
anhidrosis
Causes:
- pancoast
- internal carotid dissection
- brainstem stroke
- cervical spine injury
Poliomyelitis
- Anterior horn cells and motor neurons of spinal cord and brainstem involved
- LMN involvement
Asymmetrical muscle weakness
Normal sensation
Peripheral vs central vertigo
Periph
- hearing loss and tinnitus only occur here
Central
- focal neuro problems only occur here
Seronegative spondyloarthropathies HLA
HLA B27
Difference between lupus and drug-induced lupus
NO Renal or CNS involvement in drug induced lupus
- also no butterfly rash, alopecia, and ulcers
Pathophys of scleroderm
Cytokines stimulate fibroblasts –> abnormal amt of collagen deposition
It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)
Most important thing to do in syncope workup
Differentiate b/n cardiac and noncardiac causes
Always get an EKG
Seizure causes
4M’s, 4I’s
Metabolic / electolyte disturbances - hypo Na, water intox, hypo glycemia, hyperglycemia, HYPO Ca, uremia, thyroid storm, hyperthermia
Mass lesions - brain mets, tumors
Missing drugs
- noncompliance w/ antiseizures
- w/d from EtOH, benzos, barbs
Misc
- Eclampsia
- HTN encephalopathy
Intoxications - cocaine, lithium, lidocaine, theophylline, Mercury, lead, CO
Infections - septic shock, meningitis, brain abscess
Ischemia - stroke, TIA
Increased ICP - trauma
When do you tx a person who has 1st seizure
DO NOT Tx
Tx w/ antieplipetics if
EEG abnormal
brain MRI abnormal
Patient is in status epilepticus
Amyotrophic lateral sclerosis - features
D/o of anterior horn cells and corticospinal tracts
UMN and LMN signs
Progressive muscle weakness noticed 1st in legs or arms Fasiculations Impaired speech and swallowing Respiratory muscle weakness Wt loss, fatigue
OK throughout: bladder, bowel sensation cognition EOM sex functions
Features of Cushings
Central obesity Hirsutisum Moon facies Buffalo hump Purple striae on abdomen Lanugo hair Acne Easy bruising
HTN Diabetes Hypogonadism Masculinization in fems Proximal muscle wasting and weakness Osteoporosis Aseptic necrosis of femoral head
Depression
Mania
Decreased immunity
Sjogren’s classic triad
Can’t see, can’t spit, can’t climb a tree
Xerophthalmia
Xerostomia
Arthritis
Broca’s aphasia
Expressive, nonfluent aphasia
Speech is slow and needs effort
Good comprehension of language
COnduction aphasia
Can’t repeat
Pathology involves connections b/n Wernicke’s and Broca’s areas
Global aphasia
Disturbance in all areas of language function
Often assoc w/ R hemiparesis (damage of L hemisphere)
Spinal lesion - how can you tell it is in the spinal cord?
Decrease in sensation below a sharp band in the abdomen/trunk
Pinprick felt above level but not below it
Pathognomonic for spinal cord disease
Level of lesion = sensory level
Principle of imaging of MRI
Good for tissues w/ many H nuclei and little density contrast
Good to detect differences between 2 similar but not identical tissues
Brain
Muscle
Connective tissue
Most tumors
Principles of imaging of CT scans
CT of the head
- detects infarction, tumors, calcifications, hemorrhage, bone trauma
- dark structure = infarction and edema
- bright structure = calcifications and blood
Causes of
- dematomyositis
- polymyositis
- inclusion body myositis
derm - humoral immune response
poly - cell mediated process
inclusion body - cell mediated process
Fibromyalgia
Multiple trigger points (tender to palpation)
11/18 to diagnose
Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression
Clinical features of neonatal lupus
Skin lesions
Cardiac abnormalities (AV block, transposition of great vessels)
Valvular and septal defects
Positive ANA conditions
SLE RA Scleroderm Sjogren's syndrome Mixed connective tissue disease Polymyositis and dermatomyositis Drug-induced lupus
Risks for skin cancer
Recent changed mole - 10x
Family hx melanoma - 8x
Sun sensitivity - 2x
Previous sunburns - 2x
Graft vs host disease
Common after bone marrow transplatntation
T cell mediated immune response by donor
Targets
- skin
- intestine
- liver
+ Ro (SS-A) and La (SS-B)
Sjogren’s
Subacute cutaneous
Neonatal lupus
SLE HLA
HLA DR2, 3
Sjogren’s HLA
HLA DR3
RA HLA
HLA DR4
Facticious diarrhea (laxative abuse)
Watery
Increase in freq and vol of stool
10-20 bowel mvmts / day
Characteristic biopsy finding:
- dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli)
- can return to normal after laxative
Difference between lupus and drug-induced lupus
NO Renal or CNS involvement in drug induced lupus
- also no butterfly rash, alopecia, and ulcers
Pathophys of scleroderm
Cytokines stimulate fibroblasts –> abnormal amt of collagen deposition
It is quantity of collagen that causes the problems assoc w/ this disease (composition of collagen is normal)
Ways to Dx sjogren’s
ANA, Anti-Ro, Anti-La
Schirmer test - filter paper to measure lacrimal gland output
Salivary gland biopsy (lip or parotid)
If someone has dysphagia to solids only, what test do you do to eval?
Barium esophagram w/ tablet
Liquid barium may not see obstruction
Rheumatoid arthritis clinical features
Inflammatory polyarthritis
- NO DIP joints
- PIP, MCP, wrists, knees, ankles, elbows
- ulnar deviation of MCP
- Boutonniere deformities of PIP joints
- Swan neck deformities of MCP
Morning stiffness
Constitutional symptoms
Cervical spine involvement - life threatening
Pericarditis, conduction abnormalities, valvular incompetence
Pleural effusions (low glucose)
Episcleritis, scleritis
Poor prognostic indicators in RA
High RF titers
SubQ nodules
Erosive arthritis
Autoantibodies to RF
Antibodies in RA
Radiologic findings
rheumatoid factor
Anti citrullinated protein antibody
Erosions + periarticular osteoporosis
Sjogren’s classic triad
Can’t see, can’t spit, can’t climb a tree
Xerophthalmia
Xerostomia
Arthritis
Pathogenesis of gout
Increased prod of uric acid
- HGPRT deficiency
- PRPP synthetase overactivity
- chemo, hemolysis, heme malignancies
Decreased excretion of uric acid
- renal disease
- NSAIDs, diuretics
- Acidosis
Pathophys of gout
ECF saturated with uric acid –>
uric acid crystals collect in synovial fluid –>
IgGs coat monosodium urate crystals – >
phagocytosed by PMNs –>
release inflammatory mediators and protelytic enzymes from PMNs –>
Inflammation
Tophi
Happens w/ uncontrolled gout for > 10 years
Aggregations of urate crystals surrounded by giant cells in an inflammatory reaction
Common locations:
- forearms
- elbows
- knees
- achilles tendons
- pinna of external ear
Diagnosis of gout
Joint aspiration + synovial fluid analysis
- needle shaped and negatively birefringent urate crystals
Radiographs
- punched out erosions w/ overhanging rim of cortical bone
Pseudogout vs. gout
Different crystals
Pseudogout usually in larger joints (knee)
Pseudogout classically monoarticular
Pseudogout Dx
Joint aspirate
- weakly + biregringent rhomboid crystals (calcium pyrophosphate)
Radiograph
- chondrocalcinosis (cartilage calcification)
Causes of
- dematomyositis
- polymyositis
- inclusion body myositis
derm - humoral immune response
poly - cell mediated process
inclusion body - cell mediated process
Fibromyalgia
Multiple trigger points (tender to palpation)
11/18 to diagnose
Stiffness, body aches, fatigue, sleep disrupted, anxiety, depression
Test to confirm prostatitis
Mid-stream urine sample
Give antibiotics
Prostate is tender and boggy
Treatment for acute mechanical back pain
Without significant neuro deficit
- mobilization + NSAIDs (not bedrest)
W/ lots of neuro deficit
- early surgical decompression
Risks for skin cancer
Recent changed mole - 10x
Family hx melanoma - 8x
Sun sensitivity - 2x
Previous sunburns - 2x
Graft vs host disease
Common after bone marrow transplatntation
T cell mediated immune response by donor
Targets
- skin
- intestine
- liver
Methanol vs ethylene glycol poisoning
Methanol damages vision
Ethylene glycol damages kidneys
- oxalic acid binds ca –> hypoCa and Ca-oxylate crystal deposits
- Glycolic acid injures the renal tubules
Pancreatic cancer clinical features
- tumor in body/tail
- tumor in head
Body/tail - pain adn wt loss
Head - stetorrhea, wt loss, jaundice
Most sensitive screen for diabetic nephropathy
Random urine for microalbumin/creatinine ratio
24 hr collection best but inconvenient
Dx rotator cuff tear
MRI
Facticious diarrhea (laxative abuse)
Watery
Increase in freq and vol of stool
10-20 bowel mvmts / day
Characteristic biopsy finding:
- dark brown discoloration of colon w/ lymph follicles shining through as pale patches (melanosis coli)
- can return to normal after laxative
Dx acute aortic dissection
TEE
CT w/ contrast
Rotator cuff tear vs .tendonitis
Happens usually w/ fall out on outstretched hand
Shoulder pain and weakness
Tendonitis is helped by lidocaine injection - tear is not
Which pleura has nerve endings that give you pleuritic pain?
Parietal pleura
If someone has dysphagia to solids only, what test do you do to eval?
Barium esophagram w/ tablet
Liquid barium may not see obstruction
Fulminant liver failure
no previous liver disease +
Jaundice +
hepatic encephalopathy
When monitoring DKA, and response to treatment, what is most reliable index to monitor response to tx?
Serum anion gap
pH
Fall in serum and urinary ketones lags behind changes in arterial pH or anion gap
1 macrocytic d/o in sickle cell disease
Folate deficiency
Causes of toxic megacolon
ulcerative colitis
CMV colitis in HIV pts
Korsakoff’s syndrome
Irreversible amnesia
Confabulation
Apathy
Indicators for surgery in pts w/ aortic stnosis
SAD -
Syncope
Angina
Dyspnea (from CHF)
Pts w/ severe AS going for CABG
Asymptomatic pts w/ severe AS + poor LV sys function, LV hypertrophy ? 15 mm, valve area < 0.6 cm2 or abnormal response to exercise
When should DM screening start?
age 45 w/ no risk factors
earlier if have risk factors
Managing dysphagia/odynophagia in HIV pts
1 cause of ulcerative esophagitis = CMV
#1 cause of this is candida - 1-2 wk course empiric oral fluconazole
If doesn’t work…endoscopy to investigate other etiologies
CMV esophatitis
Evidence of large, shallow superficial ulcerations
Focal substernal burning pain w/ odynophagia
Presence of intranuclear and intracytoplasmic inclusions
Tx = ganciclovir
HSV esophagitis
Multiple, small, well circumscribed w/ small and deep appearance of ulcers
Cells show ballooning degeneration + eosinophilic intranuclear inclusions
Tx = acyclovir
Cancer assoc w/ pernicious anemia
Gastric intestinal-type cancer
Gastric carcinoid tumors
Pathophys of senile purpura
These are ecchymotic lesions in areas susceptible to trauma in elderly
Happens b/c perivascular CT atrophies as ppl age
No tx needed
Lupus anticoagulant
IgM or IgG that PROLONGS activated PTT
- binds phospholipids used in assay
- it is NOT an anticoagulant though and increases risk of thrombosis and spontaneous abortion
How do you change the urine pH to prevent gouty attacks?
Urine alkalinization
Spinal stenosis
Pain is posture-dependent
Flexion of spine = widening of canal
Extension - narrowing of canal
Pain exacerbated by standing still, walking
Pain improved by sitting, lying down
Normal arterial pulses
Straight leg test negative
Dx w/ MRI
Tx laminectomy
Herniated disc
Low back pain sciatica presentation
- radiates to thighs adn below knee
Pain worsens w/ sitting
+ straight leg test
PFTs of COPD
Decreased
- VC
- FEV1 / FVC
Increased
- functional residual capacity
- total lung capacity
Nephrotic syndrome - etiology of hypercoagulation
Loss of antithrombin 3 in urine altered levels of protein C and S Increased platelet aggregation Hyperfibrinogenemia b/c increased hepatic synth Impaired fibrinolysis
RENAL VEIN thrombosis most common manifestation of coagulopathy
Complications of nephrotic sydnrome
Protein malnutrition
Fe-resistant microcytic hypochromic anemia b/c lose transferrin
Vit D deficiency b/c lose cholechalciferol-binding protein
Decreased thyroixin levels b/c loss of TBG
Increased susceptibility to infection
Solitary nodule that is….on CXR:
- popcorn calcification
- bulls eye
Popcorn - hamartoma
Bulls eye - granuloma
How can TIA produce syncope?
This is rare
Needs to affect posterior circulation and brain stem in order for syncope to occur
Pt receives transfusion - then in 1 hr, gets fever, chills, flank pain, hemoglobinuria. What happeend?
Acute hemolytic transusion reaction
ABO mismatching from clinical error or blood mistyping
hemoglobinuria present!!
Can get DIC, acute renal fail, shock
Tx - supportive
Pt receives transfusion - fevers, chills, malaise. What happened?
Reaction to cytokines in transfused blood products
OR
Antibodies in pt’s plasma reacting w/ donor’s leukocytes
Febrile nonhemolytic reaction
Prevent using leukoreduced blood prods (wash RBCs)
Pt receives tranfusion - within seconds - minutes, gets anaphylactic reaction. What happened?
IgA deficiency
CMV vs. EBV mononucleosis
Both
- atypical lymphocytes (large, basophilic w/ vacuolated appearance)
CMV only:
- no pharyngitis
- no cervical lymphadenopathy
- negative monospot test
Bartter syndrome
Polyuria, polydipsia, growth and mental retardation
- usually presents early but can present late
Defective Na and Cl reabsorb in TAL
Causes hypovolemia –> activates RAAS
Increased urine Cl level
Gitelman syndrome
Defect in DCT in reabsorb Na and Cl
Causes hypovolemia –> activates RAAS
Increased urine Cl level
1 complication of PUD
Hemorrhage - upper GI bleed
Shifts K+ out of cell (causing hyperkalemia)
DO Insulin LAB
Digitalis HyperOsmolarity Insulin deficiency Lysis of cells Acidosis B-adrenergic antagonist
Shifts K+ into cell (causing hypokalemia)
Hypoosmolarity
Insulin (increases Na/K ATPase)
Alkalosis
B-adrenergic agonist
INsulin shifts K INto cells
Renal Cell carcionma (RCC) paraneoplastic conditions
Anemia / erythrocytosis Thrombocytosis Fever Hyper Ca Cachexia
Dx RCC
CT scan of abdomen
Progressive multifocal leukoencephalopathy
- cause
- pathophys
- symptoms
- dx
JC virus (polyomavirus)
Loves cortical white matter
Onset of symptoms gradual
- hemiparesis, distrubances in speech, vision, gait
MRI confirms diagnosis
- multiple demyelinating, nonenhancing lesions w/ no mass effects
No tx available
Most common mass lesion in HIV pts
2 = primary CNS lymphoma
Cerebral toxo
Both are ring enhancing lesions
Toxo loves basal ganglia
Lymphoma loves periventricular
Dizziness vs vertigo
Dizziness - imbalance and unsteadiness
Vertigo - illusion of head mvmt, head spinning
- actute vertigo usually due to dysfunction of labyrinth
Leukomoid reaction
- what is it?
- whcat can it look like?
- how do you tell the difference?
Marked increase in leukocytes due to severe infection or inflammation
Key is increased leukocyte ALP (LAP)
It can look like CML
- LAP is decreased in CML though
Nontender gallbladder + biliary obstruction evident on US + direct bilirubin elevation + disproportionate elevation of ALP
What is this? How do I eval it?
Pancreatic cancer
CT of the abdomen
Basal cell carcinoma
1 malignant tumor of eyelid (lower margin)
Slow growing papule w/ pearly, rolled borders and overlying telangiectasia
Tx w/ surgical excision using microscopically-controlled margins (Mohs technique)
Squamous cell carcinoma
Less common than basal
Faster growing
Often arises from precursor (eg actinic keratosis)
Usually has overlying hyperkeratosis
Keratoacanthoma
Rapidly growing volcano-like nodule w/ central keratotic plug
Usually self limited but treated like SCC
Secondary bacterial pneumonia most commonly due to
Strep pneumo
Staph aureus
H. influenzae
Which is the pathogen to cause post-viral URI necrotizing pulmonary bronchopneumonia w/ multiple nodular infiltrates –> can cavitate to small abscesses?
Staph aureus
blood streaked sputum
Legionnaire’s disease
Can cause intersitial infiltrates on CXR
How do you see amyloidosis deposits in nephrotic syndrome?
Deposits are revealed under polarized light
Apple green birefringence under polarized light after staining w/ congo red
Psammoma bodies?
PSMM
Papillary carcinoma of the thyroid
Serous cystadenoma of the ovary
Meningioma
Mesothelioma
Which thyroid carcionma has hematogenous spread?
Follicular thyroid cancer
Carcinomas spread via….
Lymphatics
Sarcomas spread via….
Hematogenous
Carcinomas that love to spread hematogenously
RCC HCC Follicular thyroid carcinoma Choriocarcionma Prostate adenocarcionma
Hypertrophic osteoarthropathy
Digital clubbing accompanied by sudden-onset arthropathy, commonly affecting wrist and hands
Can be attributed to pulm etiologies like: lung cancer TB Bronchiectasis Emphysema
HNPCC Amsterdam Criteria I
At least 3 relatives w/ colorectal cancer (1 is 1t degree relative of the other 1)
Involvement of >=2 generations
At least one case diagnosed before 50 yo
Family adenomatous polyposis excluded
Which lynch syndrome is associated w/ high risk of extracolonic tumors? What is the most common extracolonic tumor?
Lynch syndrome II
Endometrial carcinoma
1st line tx of anal fissure
Local anesthetic + stool softner + dietary modification (high fiber diet and fluids)
Pt w/ prostate cancer who underwent orchiectomy has bone pain - mets! What do you d to manage bone pain?
Radiation therapy
Caudia equina syndrome
Surgical emergency
Absent rectal tone
Urinary incontinence
Motor and sensory loss in extremities
S/E of PEEP in person w/ ARDS
Alveolar damage
Tension pneumo
Hypotension
This happens if pressures are too high! Can rupture fragile lung parenchyma –> air leakage into pleural space
Risk factors: HTN Smoking Elevated cholesterol Alcohol DM
Which has highest risk for
- CVA?
- CAD
CVA –> HTN (4x risk)
CAD —> hypercholesterolemia
Immune thrombocytopenic purpura
DECREASE platelet count
INCREASE bleeding time
Decrease platelet survival b/c anti GpIIb/IIIa antibodies
Increased megakaryocytes on labs
Thrombotic thrombocytopenic purpura
DECREASE platelet count
INCREASE bleeding time
Decrease platelet survival
Deficiency of ADAMTS 13 —> decrease degradation of vWF multimers –> increase platelet aggregation and thrombosis
Labs: Schistocytes, increased LDH
Sx
- neuro symptoms
- renal symptoms (more in HUS)
- fever
- thrombocytopenia
- microangiopathic hemolytic anemia
What MI is most commonly assoc w/ sinus bradycardia?
Why?
Inferior MI
Increased vagal tone in 1st 24 hrs after infarction
Decreased RCA blood supply to SA node
How does afib happen in grave’s? How do tx?
Increased sensitivity of beta-adrenoreceptors to sympathetic stimuli
Beta blocker (propanolol) to tx
If kidneys want to icnrease bicarb retention (perhaps to fight alkalosis), what will reabsorb less?
Chloride
Common fungal meningitis is AIDS pts
Cryptococcus
Situational syncope
Middle age man
Lose consciousness after urination
Lose consciousness during coughing fits
Grover disease
Acantholytic dermatosis
Pruiritus
Erythematous to brown keratotic papules over the anterior chest, upper back, and lower rib cage
Etiology unknown
Most common electolyte abnormality in adrenal insufficiency?
How does it happen?
Hyponatremia
Volume contraction b/c mineralocorticoid deficiency Increased vaspressin (ADH) b/c lack of cortisol suppression
Features of primary hyperaldo
HYPER TN
HYPO K
Metabolic alkalosis
Decreased renin
Elevated aldo
Diastolic decrescendo murmur @ L 3rd intercostal space that increases with handgril
Aortic regurgitation
Corrected Ca value
- when do you use it?
- how does it get calculated?
Corrected Ca = 0.8 (normal albumin - measured albumin) + measured Ca
Impetigo #1 cause
Staph aureus + Strep pyogenes
Bullous impetigo has bullae and usually Staph aureus
Nonbullous impetigo more common
Hyperkalemia causes
Tumor lysis syndrome
Renal insufficiency
ACE inhibitor
What is quickest way to decrease serum K concentration?
Insulin/glucose administration
1 cause of primary adrenal insufficiency
TB
Autoimmune in developed countires
Vision abnormality assoc w/ NF 1
Optic glioma
Risk factors assoc w/ ab aorta aneurysm expansion and rupture
Large diameter
Rate of expansion
Current cigarette smoking
Indications for surgery on AAA
aneurysm > 5.5 cm
Rapid rate of aneurysm expansion (> 0.5 cm in 5 mo or > 1 cm / yr)
Presence of sx (ab, back, flank pain; limb ischemia)
PaCO2 needed to compensate for pt’s metabolic acidosis
PaCO2 = 1.5 (HCO3-) + 8
If CO2 lower, cannot be due to physio compensation alone - mixed acid base present
Why is there malabsorption in ZE syndrome?
Inactivation of pancreatic enzymes b increased stomach acid
Goal oxyhemoglobin saturation in COPD pts?
90-94%
Glucagonoma sx
Hyperglycemia
Necrotizing dermatitis (erythematous plaques on skin)
Wt loss
Often mets to liver, is malignant
DOES NOT respond to chemo - need surgery
How to tell the difference between cardiac or liver related LE edema?
Hepato jugular reflex
- positive in ppl w/ heart disease
Pt presentation:
- drank unknown bottle of lye
- retrosternal/epigastric pain, hypersalivation, and odynophagia/dysphagia
What do you worry about?
What should you give?
How do you manage?
Worry a/b liquefactive necrosis of esophageal wall –> perforation and mediastinitis
Give IV hydration and get serial ab and chest XRAYS
Endoscopy to see extent of esophageal damage –> determines if need more tx
If perforation, Gastrografin study performed
DO NOT neutralize alkali w/ acid as can exacerbate injury by releasing heat
When do you do a urine culture for a suspected cystitis?
When complicated.
- infections in women who are preggers, young, old, diabetic, immunocompromised, abnormal anatomy
No need for uncomplicated.
Serum ascites albumin gradienet (SAAG)
Serum albumin - ascites albumin
> = 1.1 g/dl = transudative = portal HTN
Persistent muscle pain
Gets worse w/ exercise
Joints not swollen
Palpation over affected muscles–> tenderness
ESR WNL
What does she have?
Fibromyalgia
Radiograph and labs have no abnormalties
Infection that begins to drain fluid (yellow)
Gm + branching bacteria
What is it?
What do you tx with?
Actinomyces israelii
- sulfur granules draining
Tx w/ high dose IV penicillin for 6-12 wks
Scrofula
Draining infection caused by TB
Conditions needing hyperbaric O2 tx
The bends (deep sea diving)
CO poisoing
Slow healing ulcers
Causes of primary hypo parathyroidism
Post surgical
- during thyroidectomy
Congenital absence of parathyroid glands
- Digeorge
Autoimmune
- In APECED syndrome = mucocutaneous candidiasis in polyglandular autoimmune endocrinopathy type 1
Defective CaSR on parathyroid glands
- pseudohypoparathyroidism
Common causes of steppage gait/foot drop
Most commonly due to peripheral neuropathy
Trauma to common peroneal nerve or spinal roots contributing to peroneal nerve (L4 - S2)
Charcot Marie Tooth (congenital)
Postoperative cholestasis
- How does it happen?
- How does the jaundice happen?
- lab abnormalities
Benign condition happening after major surgery w/ hypoTN, lots of blood loss into tissues, massive blood replacement
Jaundice happens b/c
1) Increased pigment load (b/c of transfusion)
2) decreased liver functioning (b/c hypoTN)
3) Decreased renal bilirubin excretion (b/c tubular necrosis)
ALP very high
AST, ALT usually normal/slightly elevated
In spinal cord injury, you need to cath a pt. What can you do to decrease UTI?
Intermitten cath rather than indwelling cath
Indwelling can form biofilm along catheter wall
Type 2 diabetes w/ increasingly blurred vision over 1 week - what is happening?
Nonketotic hyperosmolar syndrome
Acute hyperglycemia –> cause myopic increase in lens thickness and intraocular hypoTN secondary to hyperosmolarity –> blurred vision!
De Quervain’s tenosynovitis
Classically affects new moms holding infants w/ thumb abducted + extended
Inflamm of abductor pollicis longus adn extensor pollicis bevis as pass through fibrous sheath at radial STYLOID process
Tenderness on direct palpation
+ Finkelstein test
A pt has suspected bacterial pneumonia. What do you do 1st? After that?
CXR
Antibiotics ASAP w/o waiting for sputum Gm stain or cx
Best way to eval liver damage in
- acute hepatitis
- chronic hepatitis
Acute - LFT, viral serology
Chronic - liver biopsy
Types of neuropathies in diabetes mellitus
Symmetrical:
peripheral neuropathy
mononeuropathy
- cranial (CN 3 most often - ischemic neuropathy, usually only motor, not PSNS b/c have diff blood supplies)
- somatic
autonomic neuropathy
Paroxysmal supraventricular tachycardia
- What is it?
- How to alleviatae?
1 paroacetxysmal tachy in ppl w/o structural heart disease
Usually due to re-entry into AV node
To dec conduction through AV node:
- valsalva
- carotid sinus massage
- immersion in cold water
- –> these all are vagal manuevers
Liver cysts w/ daughter eggs
- What is this due to
- What occupation do you worry about this?
Echinococcus granulosus
Sheep farmers!
Loves to go to lungs too
Simple renal cyst
- what should it NOT look like
- what is it?
Benign, only observation needed.
Make sure mass does not have:
- multilocular mass
- thickened irregular walls
- thickened septae within mass
- contrast enhancement
What is Wilson’s disease assoc w/?
Fanconi syndrome
Hemolytic anemia
neuropathy
How do you dx Wilson’s?
Liver biopsy –> hepatic cover level > 250 mg /gm dry wt
Low serum ceruloplasmin w/ high urinary Cu excretion
Trousseau’s syndrome
migratory thrombophlebitis
usually due to adenocarcinoma
- most in pancreas
- lung
- prostate
- stomach
- acute leukemia
- colon cancer
Thrombophlebitis of atypical sites like arms and chest is impt clue to underlying carcinoma
Smudge cells
CLL
Paravertebral tenderness = ?
Spinal tenderness = ?
Para - lumbosacral strain
Spinal - compression fracture, etc
Acute, afebrile, blood tinged sputum. Young pt. no smoking hx
PE revealed b/l wheezes
No findings on CXR
What is the dx?
What is the cause?
Acute bronchitis
Usually viral in etiology
How to histoplasma cause cytopenias, lymphadenopathy, adn hepatospenomegaly?
B/c it targets histiocytes and reticuloendothelial system
Dx herpes encephalitis
PCR of HSV DNA in spinal fluid is gold standard
PPD testing
Inducation > 5 mm is + in…
HIV
Recent TB contact
Signs of Tb on CXR
Organ transplants, pts on immunosuppression
PPD testing
Induration > 10 mm is + in…
Recent immigration from TB endemic area IVDU Residents/employees of high risk settings (prisons, homeless shelters) Diabetes CKD Heme malignancies Fibrotic lung disease Kids < 4 yo, teens exposed to high risk adults
PPD testing
Inducation > 15 mm is + in…
Healthy ppl w/ no TB infection risk factors
Pts w/ hemochromatosis and cirrhosis are at increased risk of infection with…
Listeria monocytogenes
Yersinia enterocolitica
Vibrio vulnificus
Possibly b/c impaired phagocytosis due to iron overload in reticuloendothelial cells
Romberg test
Proprioception test
Ataxia, (+) romberg = ataxia is sensory in nature
- DCMLS damaged
Ataxia, (-) romberg = cerebllar dysfunction
Romberg is NOT a test of cerebellar function
Pronator drift
+ pronator = spasticity
Can happen w/ UMN lesion
If pronates, person have pronator drift on that side - tehrefore CONTRALATERAL pyramidal tract lesion
A lesion in the cerebellum = upward drift
If history and physical suggestive of ankylosing spondylitis, how do you confirm the dx?
Plain film X ray demonstrating fused sacroiliac joints and/or bamboo spine
How do you explain sx of P vera?
- dizziness/headache
- pruritus
- PUD
Dizziness/headache - hyperviscosity
Pruirtus - increased histamine (mast cell degranulation) and prostaglandins (stimuli from RBC0
PUD - increased histmine, activates more acid prod by stomach
TImeline to tx acute acetaminophen OD
If eaten within 4 hrs, can give activated charcoal
Obtain acetaminophen level @ 4 hrs (1st timepoint where hepatotoxicity evident)
Then decide to give N acetylcysteine based on result - ok if given wtihin 8 hrs of ingestion
How does syphillis rash spread?
Secondary syphilis
Start on trunk –> palms and soles
1 cause of glomerulonephritis in adults
IgA nephropathy
serum complement levels normal
LOW in post-strep
If you have chronic UTI w/ Klebs, what kidney stone are you more prone to?
Struvite stones
How does aspirin cause an anion gap metabolic acidosis?
1) Uncouples ox phos –> increase rate of O2 consumption in periph tissues –> hyperpyrexia
2) Inhibits enzymes for carb and lipid metabolism –> accumulate pyruvate, lactic, and acetoacetic acid
3) Impair renal fx –> accumulate organic acids like sulfuric and phosphoric acid
Fever, tinnitus, and tachypnea - what do you suspect?
Aspirin intoxication
How does preggers or oral contraceptive increase gallstone formation?
Estrogen –> increase cholesterol secretion
Progesterone –> reduce bile acid secretion, slows gallbladder emptying (stasis)
1 site of mets
1 - Lymph nodes
2 - Liver
–> GI, lung, breast, melanoma loves to go here
Aspirin exacerbated respiratory disease
All 3 features:
ASthma
Chronic rhinosinusitis w/ nasal polyps
Bronchospasm/nasal congestion after Aspirin/NSAID use
Can also have anosmia b/c nose messed up
What shown to prolong survival in pts w/ COPD and hypoxemia?
Long term supplemental O2 therapy
What serum omsmolality does neuro manifestations happen?
> 310
U osm = 2 (Na) + glucose / 18 + BUN / 2.8
Bone marrow transplant pt ~45 days s/p transplant who has lung adn intestinal pathology. What microbe is this?
CMV
- pneumonitis
- lower GI ulcers –> ab pain and diarrhea
Suspected melanoma - what do you do to tx?
Excisional biopsy
After confirm dx of melanoma, excise w/ wide margins
Melanoma - what are the work ups for diff size lesions?
Depth < 1 mm
- excise w/ 1 cm tumor free margin
Depth > 1 mm
- sentinel lymph node study
Cerebellar tumor
Ipsilateral ataxia
Fall toward side of lesion
Nystagmus
intention tremor
ipsilateral muscular hypotonia
Festinating, shuffling gait
Parkinson’s
Broad based gait
Feet lifter higher than usual and make slapping sound w/ floor
Tabes dorsalis
During walking, keep affected arm adducted adn affected leg extended
Will swing leg in semicircle
Hemiparetic patient from stroke
Waddling gait
Muscular dystrophy
- b/c weakness of glut muscles
Metabolic abnormalities of tumor lysis syndrome
Hyper PO4
Hyper K
Hyper uricemia
–> high PO4 and K b/c both intracelluar and released w/ lysis
Hypo Ca
–> decreased b/c freed PO4 binds Ca taking down the [ ]
Age distribution of craniopharyngioma
Biomodal
kids
- stunted growth
age 55-65 yo
- sex dysfunction
Presenting symptoms of craniopharyngiomas
Suprasellar tumors
Hypopituitarism
Headaches
Bitemporal blindness
Mediastinal widening
Often in aortic dissection
Folate vs. B12 deficiency - how do tell the difference?
Both have increase homocysteine
ONLY Cobalmin has elevated methylmalonic acid (folate does not convert methylmalonyl coa –> succinyl Coa)
Type A lactic acidosis
Lactic acidosis from poor O2 delivery to tissues
CO poisoning
Shock
HIV needle stick
- what do you do?
- how do you test?
Test for HIV ASAP
- repeat after 6wks, 3 mos, 6 mos
Ppx of 2-3 drugs
- 2 NRTIs + Protease inhibitor
Difference between drug induced liver injury and isoniazid induced liver injury
Both have liver injury like viral hepatitis
BUT INH doesn’t have rash, arthralgias, fever, leukocytosis, eosinophilia
Vanishing duct (ductopenia) in liver causes
Primary biliary cirrhosis Failing liver transplant Hodgkin's GVHD Sarcoid CMV HIV Medication tox
Characteristic LP finding of SAH
Xanthrochromia
Happens b/c RBC go into CSF and have time to be lysed and digested into bilirubin, thus making a yellow color
If blood in LP b/c damaged BV while doing it, would be red rather than yellow b/c not enough time to digest
Only ilicit drug to cause vertical nystagmus
Phencyclidine
Use benzos to tx severe psychomotor agitation
Seborrheic dermatitis
Assoc w/ parkinsonism or HIV
Fine, loose, waxy scales w/ underlying erythema on scalp, central face, presternal region, interscapular areas, umbilicus, body folds
Type 4 RTA
Can happen in diabetic nephropathy
Aldo deficiency or renal tubular insensitivity to aldo
Retain K
Waste Bicarb
Nonanion gap metabolic acidosis
How do you tell b/n cardiac and noncardiac pulmonary edema
PCWP
> 18 –> impaired LV function
< 18 –> noncardiac etiology (eg ARDS)
Correcting hypernatremia
Usually water deficit in relation to sodium –> hypotonic fluid loss and decreased access to free water
Isotonic 0.9% saline
Once normal volume, switch to 0.45% saline
Don’t correct more than 1 mEq/L/h or cerebral edema
What’s a quick and easy way to tell b/n COPD and asthma?
Bronchodilator response test
- measure FEV1 before and after bronchodilator
- significant FEV1 improvement –> reversible etiology –> asthma
HIV ppx for CD4 count less than:
50
100
50
- Azithromycin, clarithromycin or Rifabutin for ppx against mycobacterium avium complex
100
- Itraconazole for histoplasmosis (if live in endemic area)
What do you do for solitary brain met w/ stable extracranial disease? Multiple mets?
Single - surgical resection, brain radiation
Multiple - palliative whole brain radiation
How big is a pituitary microadenoma?
< 10 mm in diameter
Rabies post exposure prophylaxis
- If dog NOT captured, assume rabid
++++give post-exposure ppx - If dog captured and NO features of rabies, keep to observe for 10 days.
+++++see signs in dog, give post-exposure ppx immediately - Post exposure ppx for bites on head and neck
Recommendation for screening for AAA
65-75 yo M w/ PMH smoking benefit most from screening
Should do 1x abdominal US in pts
What’s the logic behind the timeline for A1c showing you glucose values?
tells you glucose levels over past 100-120 days
This correlates w/ RBC survival time
Person comes in w/ stroke…first thing you do?
CT noncontrast of the head
Winter’s formula for PaCO2 compensation of metabolic acidosis
PaCO2 = 1.5 (HCO3-) + 8
Chronic epigastric pain suddenly worsens and becomes diffuse
Pneumoperitoneum
What is it?
Gastric ulcer perforation
If a pt has an UGIB w/ depressed level of consciousness, + hematemesis, what do you do?
Intubation!
Stabilize first with ABCs
Then endocscopy w/ band ligation or sclerotherapy to stop bleeding
What kind of effusion is CHF?
Transudative
pH = 7.35 for transudative
What is the pH for pleural effusion in
- empyema
- normal
- inflammation
- transudative
empyema - 7.2
normal - 7.64
inflammation - 7.3
transudative - 7.35
Always include in workup of acute delirium in elderly?
UA
Serum electolytes
When do you start colonoscopy screening for UC?
Once disease present for at least 8 years regardless of age of pt
Do exam every 1-2 years
Need prophylactic colectomy if evidence of dysplasia
Dejerine Roussy syndrome
Thalamic stroke
Usually of VPL nucleus
Contralateral hemianesthesia w/ transient hemiparesis, athetosis or ballistic mvmt
Thalamic pain phenomenon
W/ diabetic peripheral neuropathy, how do you get the paresthesias pain? How about the numbness?
Small fiber neuropathy –> pain, allodynia, paresthesias; sensory OK
Pure large fiber –> more numbness, ankle reflex lost
Psoriatic arthritis
- signs adn symptom
DIP usually involved
Morning stiffness
Deformity of involved joints
Dactylitis
Onycholysis (Separation of nail bed)
Eggshell calcification of liver cyst
Hydatid cyst!
Echinoccoccus granulosus
Well’s criteria (Modified)
3 pts
PE as likely or more likely than alternate dx
clin s/s of DVT
1.5 pts
HR > 100 bpm
prior DVT or PE
Immobilization (>3d) or surgery w/in 4 wk
1 pt
Hemoptysis
malignancy
6 = High prob for PE
Previous hx of rheumatic fever
Dental cleaning procedure
Then get infective endocarditis
What order do you do your tx?
What if it is a person who was IVDU who get IE?
Blood cx 1st
Then empiric antiboiotics
Then Transesophageal echo to see valvular vegetations
Transthoracic Echo if tricuspid endocarditis - IVDU
Dukes major criteria
For IE diagnosis
+ Blood Cx
Evidence of endocardial involvement on echo
Dyspepsia
1 or more of sx:
- epigastric pain
- postprandial fullness
- early satiety
w/ ab burning, nausea, bloating
NOT HEARTBURN b/c that is GERD
- usual etiology is GERD, meds, etc
Pt > 55 yo w/ dyspepsia
- what are the alarm sx?
- what do you do for this pt?
- what do you do for pt w/ alarm sx?
Alarm sx: unexplained wt loss vomiting dysphagia GI blood loss odynophagia FH GI cancer
No alarm sx - test for H pylori or empiric H pylori tx (PPI)
Alarm sx - upper endo
Alcohol w/d timeline
6-24 hrs
- reflex hyperactivity in brain –> anxiety, insomnia, tremors, diaphoresis
48 hrs
- hallucinations
- w/d seizures
48-96 hrs
DTs
HTN, agitation, tachy, hallucinations, fever
What’s the best marker for opioid intoxication w/ suggestive clinical feature?
Bradypnea
NOT miosis - sometimes don’t have miosis
Hepatorenal syndrome
Complication of ES liver disease
Decreased GFR in absence of shock, proteinuria, or clear cause of renal dysfunction
- als no response to 1.5 NS bolus
Type 1 - rapidly progressive, pts die w/in 10 wks w/o tx
Type 2- slower; survive 3-6 mos
Usually die of infection and hemorrhage
Need to get liver transplant to survive
Pruritic elevated serpiginous lesions on skin - what caused this? how did you get it?
Ancylostoma braziliense
- hookworm!
Sandy beaches, sandboxes
Can you get mild elevations in transaminases, bilirubin, and amylase in cholecystitis?
Yes!
Even w/o obvious common bile duct or pancreatic disease
- sludge or pus into CBD causes these elevations
BUT ALP is not increased unless cholangitis or choledocholithiasis
Tx acute cholecystitis
NPO
IV antibiotics
analgesics
Laparoscopic cholecystectomy soon after hospitalization
Sx hypercalcemia
Confusion Lethargy Fatigue ANorexia Polyuria Constipation
What type of pericarditis does not present w/ classic EKG diffuse ST segment elevations?
Uremic pericarditis
Inflammatory cells don’t penetrate myocardium
Tx uremic pericarditis w/ dialysis
What’s a normal decreased reflex finding in elderly?
Decreased achilles tendon
What sx are typical for asbestosis? Uncommon?
Typical - progressive dyspnea
Uncommon - cough, sputum prod, wheezing
Large exophytic papule w/ collarette scale
- what is this?
- how do you dx?
- what do you have to be careful of?
- Tx?
Bartonella henselae!
Tissue bx + microscope ID of org
Biopsy can cause hemorrhage - be careful!
Abx to regress lesion
Pt works in daycare
- acute onset of polyarticular (MCP, PIP, wrist) and symmetric arthritis
- resolves in 2 months
What is it?
Parvovirus
How long do you have arthritis before diagnosed as RA?
at least 6 wks
pANCA positivity
Anti-MPO
Microscopic polyangitis
Churgg strauss
Ulcerative colitis
Factorial design study
Randomization to diff interventions w/ additional study of 2 or more variables
Diarrhea in HIV pt - what do you do 1st?
ID causal organism
Then do antibiotic
Tx pts w/ diabetic gastroparesis
Diabetes control + dietary mod
Small frequent meals
Metoclopramide - improve gastric emptying
Erythromycin
Cisapride (not used in US)
Anorexia N/V Early satiety Postprandial fullness bad glucose control
What is this?
DIabetic gastroparesis
Macrocytic anemia
- causes
- what does it look like?
Vit B12 deficiency Folic acid deficiency Hypothyroidism Liver disease Antimetabolites
Macroovalocyte RBCs, hypersegmented neutrophils, anisocytosis, poiklocytosis, basophilic stipling
Retic count decreased
Bone marrow hypercellular
P vera can be associated with what? And why?
Gout! 40% w/ pvera have gou
Myeloprolif d/o are common causes of uric acid overproduction
- increased catabolism and turnover of purines
Delayed sleep phase syndrome
Circadian rhythm d/o
Can’t fall asleep at normal bedtimes (10 or midnight)
Advanced sleep phase disorder
Circadian rhythm disorder
Can’t stay awake in evening (usuallya fter 7 pm) so social functioning difficult
pts complain of early AM insomnia
What is a sensitive marker of dehydration?
BUN/Cr ratio
What do you risk giving bicarb in tx lactic acidosis or ketoacidosis?
Bicarb may paradoxically depress cardiac performance and worsen acidosis by enhancing lactate production
What do you suspect w/:
- decreased haptoglobin
- increased LDH
- decreased Hg
- venous thrombosis
Paroxysmal nocturnal hemoglobinuria
- abnormal anchor protein GP1 which usually binds CD55 adn CD58 which stop complement from destroying RBC
- intravascular hemolytic anemia
- PNH have tendency towards venous thrombosis, particularly hepatic veins
- mild thrombocytopenia too
Use flow cytometry tests to dx - find if cells have CD 55 and 59 on surface
When do you do a DEXA scan for women for osteopororsis?
65 yo - one time
Osteopenia = T score -1.5 to - 2.5 Osteoporosis = T score less than - 2.5
Monoarticular or asymmetric arthropathies
Seronegative spondyloarthropathies
Septic arthritis
Crystalline arthritis
Symmetrical polyarthritis
Viral arthritis (mumps, rubella, parvovirus)
Rheumatoid arthritis
SLE
–> tell the difference b/c viral will resolve but RA and SLE do not resolve in less than 4 weeks
Live vaccines are NOT recommended in HIV pts. But which is the only one that is?
MMR
- measles is life threatening in HIV pts
- usually ok for counts > 200 (CD4)
Causes of aortic aneurysm
- ascending
- descending
CXR findings
ascending
- cystic medial necrosis or CT d/p
descending
- atherosclerosis
CXR
- widended mediastinal silhouette
- increased aortic knob
- tracheal deviation
Tx acute cholangitis
CBD blockage –> infection up the bile duct w/ increased ALP
Supportive
Broad spectrum antibiotics
No response,
Biliary drainage w/ ERCP
Types of polyps in colon
Hyperplastic - nonneoplastic, no further work up needed
Hamartomatous - juvenile, peutz jeghers - usually not malignant
Adenoma - most common, can be premalignant
Probability of adenoma progressing into cancer
Sessile vs/ stalked (pedunculated)
- sessile more cancerous
Tubular, tubulovillous, villous
- villous more malignant
Size
- bigger size, more liekly malignant (>2.5cm)
Intraepidermal blisters + erosions w/ multinucleated giant cells w/ molded stell gray nuclei
HSV
VZV
vessicles
Extensor weakness
Chronic interstitial nephritis
Anemia w/ low-normal MCV
What is happening?
Lead poisoning
How can you tell if someone syncopized vs. seized?
Confused following episode = seizure
Tx pt w/ radioactive iodine - what hyperthyroid d/o is most likely to become hypothyroid after?
Grave’s
The whole thyroid gland is hyperfunctional so will have diffuse take up - complete thyroid ablation
Bronchiectasis vs. chronic bronchitis
Bronchiectasis
- chronic, recurrent cough
- mucoPURULENT expectoration
- occasional hemoptysis
- episodes respond to antibiotics
Chronic bronchitis
- NONPURULENT expectoration
Dx bronchiectasis 1st?
High rest CT scan of chest
Which kidney is easier to palpate if it is enlarged?
Right kidney
Lies lower than L kidney
Rapidly progressive dementia
Myoclonus
Sharp, triphasic synchronous discharges on EEG
CJD
Most common cause of death in pts w/ acute MI
Reentrant ventricular arrhythmia (vfib)
Conjugated or unconjugated hyperbilirubinemia
Conj -
direct bilirubin > 50% of total bili
Unconj -
indirect > 90% of total bilirubin
Recent travel in water area
High grade fever
GI sx
Neuro sx
Rales + CXR = focal lobar consolidatin
What is it?
How to dx?
How to tx?
Legionella pneumophilia
Sputum stain = lots of neutrophils, no organisms b/c intracellular
Cx on charcoal agar
Urinary antigen testing
Tx
- azithromycin (macrolides)
- levofloxacin (newer fluoroquinolones)
Low back pain Difficulty starting urination LE sensory and motor loss Sciatica Loss of sensation in medial thigh Poor rectal tone, perineal anesthesia
Cauda equina syndrome
Spinal nerve roots issue - LMN issue
Parasellar signs due to pituitary adenoma more commonly seen in…? Why?
Men
Early sx in men (eg impotence) are often attributed to psych causes and med eval is delayed –> larger tumor growth
Dx acromegaly
Oral glucose suppression test
- glucose doesn’t suppress GH (normally does)
IGF1 is increased - GH not useful b/c wide physio fluctuation of GH levels
Calcification of suprasellar region on brain imaging
Diagnostic of craniopharyngioma
Which hormones in pituitary lost first usually?
LH, FSH, GH
then…
TSH, ACTH
DDx polyuria + polydypsia
DIabetes mellitus
Diuretic
DI
Primary polydipsia
Diabetes insipidus causes
- Central
- Nephrogenic
Central
- trauma
- tumors
- sarcoidosis
- TB
- syphilis
- encephalitis
Nephrogenic
- Lithium
- Hyper Ca
- Pyelo
- Demeclocycline
- mutations in ADH receptor
Hypoosmotic hyponatremia types
HypoVOL HypoNa = volume contracted
HyperVOL Hypo Na = volume expanded w/ edema
SIADH = volume expanded w/o edema
Why don’t you see edema in SIADH?
Natriuresis still happens despite hypoNa
Vol expansion –> increase ANP –> increase Na urine excretion
Vol expansion –> dec PCT Na abrosption
Vol expansion —| Renin-angiotensin-aldo system
Manifestations of Hyper PTH / increased Ca
Stones
- Nephrolithiasis
Bones
- Osteitis fibrosa cystica
- bone aches adn pains
Groans
- Muscle pain and wekaness
- Pancreatitis
- PUD
- Gout
- Constipation
Psych
- depression, fatigue, anorexia, sleep issues
Other - polydipsia, polyuria - HTN - short QT 0 wt loss
Characteristics of rheumatic heart disease
JONES
Joints Pancarditis SubQ nodules Erythema Nodosum Syndenhams chorea
2 major criteria or 1 major and 2 minor criteria to dx
Minor:
fever
Increased ESR
Proplonged PR
Dx endocarditis
TEE
TTE for R heart valve endocarditis
Dukes criteria (2 major, 1 major + 3 minor, 5 minor)
Major:
sustained bacteremia
Endocardium involved on echo
Minor: predisposing condition fever janeway lesions, pulmonary emboli Glomeruli nephiritis Oslers nodes ROths spots \+ blood cx
When is feNa most useful
If oliguria present
3 vessel opathies in diabetes
Nephropathy Neuropathy - autonomic - peripheral - retinopathy
What should you order for most pts with aki?
Renal ultrasound
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest
Pulm edema
What is microalbuminuria measured by
Microalbumin: Cr ratio
What should you order for most pts with aki?
Renal ultrasound
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest
Pulm edema
What lab value can you find on lupus antiphospholipid?
increase PTT
Cryprecipitate
Factor 8
Fibrinogen
vWF
Factor 12
What should you order for most pts with aki?
Renal ultrasound
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest
Pulm edema
What should you order for most pts with aki?
Renal ultrasound
Most common mortal complications of early phase AKI
Hyperkalemic cardiac arrest
Pulm edema
