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
