medicine Flashcards
3 initial steps for management of arrythmia
IVF, O2, monitor (telemetry)
systolic <90, chest pain, SOB, altered w/onset of arrythmia
means?
unstable
stable arrythmia: fast + wide rythm
what drug
means ventricular tachycardia: administer amiodarone
stable: fast + narrow rythm
what tx
adenosine (3 doses)
stable; slow rythm; which drug
atropine and prepare to pace
drugs for AFIB/Flutter
if CHF?
B-blocker or Diltiazem/verapamil; if they have CHF you have to avoid these, give Digoxin and Amiodarone
during code, what to give for VT/VF in between cycles
alternate between epinephrine and amiodarone every 2 minutes
2 minutes CPR, pulse check, shock if indicated, 2 minutes CPR – cycle repeats
during code for PEA/Asystole what do adminster?
alternate between EPI and absent each cycle; no SHOCK
first step in mngt focal neurological deficit
non-contrast CT: ischemic vs. hemorrhagic
blood is white on CT
if non-contrast CT shows hemorrhagic stroke what is the next step?
decrease BP and call neurosurgery : coil, clip, craniotomy
give FFP if INR is abnormal
3 tests to determine etiology of stroke:
ECG, ECHO, cartoid U/S
ECG (afib/aflutter, give warfarin or non vit k anticoag, not heparin), ECHO (look for vegetations, give warfarin, NOAC, heparin bridge), carotid U/S (>70% occlusion, intervene surgically)
3 absolute contraindications for tPA
given <3 hrs/4.5 hrs after ischemic stroke (no bleeding)
hx of intracranial bleed, rx of bleeding (often GI bleed), or recent surgery
chronix tx for ischemic stroke
LMWH, aspirin 81 mg + dipyridamole, if aspirin fails switch to clopidogrel, high potency statin, A1c < 8%, control BP w. ACEi + diuretics
HTN control for acute **ischemic stroke management
Permissive HTN (220/120) – to protect penumbra (tissue surrounding ischemic area)
lab findings in stable angina
No troponin-I or ST elevation
Stenosis > 70% + pain alleviated by rest = stable angina
<70% for asymptomatic CAD
first test for STEMI
ST elevation shows earlier than troponin-I increase; 12 lead ECG first**
- positive if new LBB or ST elevation in two anatomically contiguous leads = send to cath lab
Troponins peak between 8-11 hours
NSTEMI vs. unstable angina
both have pain at rest
NSTEMI has elevated troponins, UA does not
Diamond classification for chest pain
- Chest pain is substernal (often crushing and radiating up arm + jaw)
- Worse on exertion
- Improved with nitroglycerin
Associated with pain: dyspnea, diaphoresis, pre-syncope
Pain is Non positional, non-pleuritic, non-tender pain
3/3 typical, 2/3 atypical, 1/3 non angina
MONA BASHC stands for
Morphine (give last), Oxygen, Nitro, ASA (aspirin), Beta-blocker, ACEi, Statin, Heparin, Clopidogrel
morphine and oxygen are contested
Reperfusion injury = extra oxygen creates free radicals, damages myocytes – happens if oxygen is left for too long; solution is to titrate down after 100% saturation if possible
Stress Tests: stress: treadmill or pharmacology (can’t walk); Test via ECG, if + use ECHO, if + use ??
Nuclear
Cath lab – coronary angiogram – release dye
+> 3 vessels or 1 major artery ???
CABG; coronary artery bypass grafting
Cath lab: Only 1 or 2 vessels occluded
stent ; inflate balloon and leave stent
metal stent – increased rx of stenosis ; drug-eluting stent – increasing rx of thrombosis
when to give tPA in setting of STEMI
Only when transport time to percutaneous intervention > 60 min (small rural hospital)
chronic mngt of CAD
Manage with B-Blocker + ACEi, dual antiplatelet therapy: aspirin 81 + clopidogrel 75, high potency statin (atorvastatin, rosuvastatin)
Prerenal causes that involve leakage into third space
3
nephrosis, gastrosis (malnutrition), cirrhosis (loss of albumin)
other prerenal causes: Diarrhea, diuresis, dehydration, hemorrhage
Clot: fibromyalgia (young female) or renal atherosclerotic disease (old man)
3 signs of nephrotic syndrome
= >3.5 g protein/day, increased cholesterol, edema
post renal causes:
Ureters: cancer or stones
Bladder: cancers, stones, neurogenic
Urethra: cancer, stones, BPH, foley
prodrome of ATN (3)
Muddy brown casts + first Cr rises, then oliguric phase (decreased urine); then polyuria phase (increase urine)
Prerenal lab values
Prerenal: BUN:Cr, UNa, FeNa , FeUrea
Prerenal: BUN: Cr > 20, UNa < 20, FeNa < 1%, FeUrea <35%
prerenal AKI tx
Give IVF or diuresis depending on physical exam state (dehydration vs. edema)
mngmt of post-renal AKI
U/S or CT – look for hydroureter/hydronephrosis
Can relieve with foley, nephrostomy, or surgery
CKD Stage 5: GFR < ?
15
= ESRD
CDK Stage 1: GFR > ?
II: ?
III: 30-59
IV: 15-29
Stage 1: GFR >90
II: 60-89
III: 30-59
IV: 15-29
stage IV CKD management
prepare for dialysis needed for upcoming Stage 5 CKD
AV fistula placement
STAGE 5 = need dialysis
Goal HTN, DM for CKD
Goal HTN < 130/<80; use ACEi or ARB
DM: A1c < 7, BG: 80-120 – Orals or Insulin; metformin should not be used, rx of lactic acidosis bad for CKD
Insulin is cleared by kidneys; CKD increases rx of hypoglycemia w/insulin and sulfonylureas
Anemia of Chronic Kidney Disease is a diagnosis of exclusion
how to determine
decreased EPO, Hb < 12, **normocytic anemia
diagnostic: CBC + rule out via iron, folate, VB12 levels
Tx and goal for anemia of chronic kidney disease
Goal Hb > 10
Tx: Fe, EPO, Transfusions if needed
Complications of CKD: tx for secondary hyperparathyroidism (high phophorus, low calcium)
Dx: BMP- Ca, P
phosphate binders: sevelamer
Calcimimetics: cinacalcet
Ca + Vit D
other complications:
Volume overload: loop diuretics (furosemide) +/- thiazide
Met acidosis: tx with Sodium Bicarbonate
For acid-base disorders first check pH, then check ??
CO2
while tell you whether respiratory or metabolic
acidemia
CO2 >40 = ??
respiratory acidosis: hypoventilation (opiate overdose, COPD, asthma, OSA, weak respiratory volume)
acidemia
CO2 < 40
metabolic acidosis
check anion gap (Na – Cl- Bicarb)
Anion gap = Methanol, uremia, DKA, propylene glycol, isopropyl alcohol, ethylene glycol, salicylate (MUDPILES)
Non – anion gap metabolic acidosis = check urine anion gap = Na + K+ - Cl
positive urine anion gap = renal tubular acidosis
Regular anion gap = diarrhea – lose bicarbonate in stool causes acidosis
Non – anion gap metabolic acidosis = check ??
urine anion gap = Na + K+ - Cl
positive urine anion gap = renal tubular acidosis
Regular anion gap = diarrhea – lose bicarbonate in stool causes acidosis
Alkalemia
CO2 < 40
respiratory alkalosis: hyperventilation: pain, anxiety, hypoxemia
Alkalemia
CO2 > 40
metabolic alkalosis
Contraction alkalosis: diuretics, dehydration, and emesis/ng suction
not volume responsive = look for HTN, Barter’s and Gettleman’s, SIADH
next test for metabolic alkalosis
Urine Chloride **
Is the person volume responsive/volume down? increase RAAS, sodium reabsorption draws in chloride = Contraction alkalosis = urine chloride will be low
Volume responsive/down conditions: diuretics, dehydration, and emesis/ng suction
Not volume down/responsive = look for HTN, Barter’s and Gettleman’s, SIADH
primary maneuver for tet spells
knee to chest positioning or squatting
Knee-chest positioning increases arterial oxygenation via increased systemic vascular resistance and thus left-sided heart pressures. This, in turn, decreases right-to-left shunting across the VSD and promotes blood flow into the pulmonary circulation rather than the aorta.
first-line treatment for hemodynamically stable patients with sustained monomorphic VT.
Intravenous procainamide
Papillary muscle rupture occurs ??? days after an MI
whereas Ventricular aneurysms can develop ??? after an MI because of scar tissue formation that leads to thinning and weakening of the ventricular wall symptoms
2–7 days for pap rupture
several weeks to months for ventricular aneurysms
Beta blockers (e.g., metoprolol), calcium channel blockers (e.g., amlodipine), and nitrates can reduce the sensitivity of ??? as a result of their antianginal activity.
cardiac exercise stress testing
??? may manifest in clinical features ranging from asymptomatic arrhythmias to rapidly fatal cardiac rupture. Blunt chest trauma and/or sudden deceleration can lead to decreased contractility and arrhythmias due to injury to cardiac myocytes and pacemaker cells. Decreased contractility directly contributes to cardiogenic shock with decreased cardiac output and hypotension
cardiac contusion
the murmur disappears or becomes softer when patients compress the internal jugular vein, lie in the supine position or flex their heads, as seen here. This feature helps differentiate it from the murmur in a patent ductus arteriosus.
Venous hum is a common benign finding on auscultation in childhood. The murmur is most likely caused by turbulence in the internal jugular vein (e.g., when blood enters the thoracic inlet)
patient presents with signs of acute limb ischemia (6 Ps: pain, paresthesia, pallor, paralysis, pulselessness, and poikilothermia), which can be caused by ??
thromboembolism as a result of atrial fibrillation (Afib)
tx w/ Warfarin
nitrates are contraindicated in patients with ?? infarction and/or hypotension
inferior wall infarction and/or hypotension
early reperfusion is associated with improved clinical outcomes, door-to-PCI time should be < ??
< 90 minutes
When used in combination with amolodpine/calcium channel blockers (CCB), this drug ??? results in reduction of the transcapillary pressure and significantly reduces the risk of developing CCB-related peripheral edema.
ACEi or ARB
Since many tumors produce proteins and cytokines with thrombophilic effects, malignancy should be ruled out as an underlying cause in cases of a first unprovoked DVT in an adult via what tests???
** chest x-ray
a basic malignancy workup includes a CBC, renal function tests, liver function tests, and urinalysis (within normal limits in this patient)
treatment of choice for prosthetic valve IE due to methicillin susceptible staphylocci
Intravenous therapy with nafcillin and rifampin for at least 6 weeks in combination with gentamicin for 2 weeks
evidence of right-sided heart failure (peripheral edema, jugular venous distention, split S2), and pronounced central pulmonary arteries, all of which are strongly suggestive of ??
pulmonary hypertension
what test to use for diagnosis of pulmonary hypertension??
Right-heart catheterization
diagnosis is made when the mean pulmonary artery pressure is ≥ 20 mm Hg at rest and there is no evidence of underlying pulmonary and left heart conditions (e.g., valvular heart disease, systolic dysfunction, diastolic dysfunction). While PAH is often idiopathic, amphetamine and cocaine use have been associated with development of PAH.
contraindications to metformin therapy
renal insufficiency and HF with decreased cardiac output
strongest independent risk factor for the development of an abdominal aortic aneurysm (AAA)
history of smoking
common cause of infective endocarditis following nosocomial UTIs.
Enterococcus faecalis infection
Duke’s criteria for Infective Endocarditis
patient must have: two major criteria, one major and three minor criteria, or five minor criteria.
Major criteria include: (1) two separate blood cultures positive for typical pathogens and (2) evidence of endocardial involvement in echocardiography.
Minor criteria include: (1) underlying heart disease or IV drug abuse, (2) fever, (3) signs of embolism, (4) immunologic findings (e.g., Osler nodes), (5) Roth spots, and (6) positive blood culture for an atypical pathogen
systolic anterior motion of the anterior mitral valve leaflet is associated with?
hypertrophic cardiomyopathy
+ symmetrical septal hypertrophy, and septal wall thickness of >15 mm
3 criteria for defining acute liver injury
elevated aminotransferases (often >1000 U/L)
Signs of hepatic encephalopathy (HE)
Impaired hepatic synthetic function (defined as INR >1.5
Elevated serum alkaline phosphatase levels are indicative of cholestasis. These patients (with or without hyperbilirubinemia) should be evaluated with what test??
right upper-quadrant ultrasound to assess for intrahepatic or extrahepatic causes of biliary obstruction
Osmotic diarrhea occurs due to the presence of a nonabsorbed, osmotically active solute (eg, polyethylene glycol, sorbitol, lactose), which inhibits water resorption and results in a ????? stool osmotic gap.
The diarrhea occurs after ingestion of the causative substance (eg, milk in a patient with lactose intolerance) and does not occur during fasting
high >125
Secretory diarrhea occurs due to toxins (eg, produced by Vibrio cholerae), hormones (eg, produced by VIPomas), congenital disorders of ion transport (eg, cystic fibrosis), or bile acids (in postsurgical patients). It is caused by secretion of electrolytes and water into the intestine, resulting in a ?? stool osmolarity gap.
The diarrhea is typically large in volume and persists while fasting and at night.
low SOG (<50 mOsm/kg)
presence of a well-circumscribed liver lesion with a central scar likely represents an incidental finding of ?????, a benign regenerative liver nodule common in women age 20-50.
focal nodular hyperplasia (FNH)
In a young adult male with a history of hematochezia (UC), the most likely etiology of recurrent acute cholangitis (eg, similar symptoms in the past) is a biliary stricture due to ???
primary sclerosing cholangitis (PSC)
??? toxicity can occur in patients receiving prolonged infusions or higher doses of nitroprusside, and is most common in patients with renal insufficiency. It is characterized by altered mental status, lactic acidosis, seizures, and coma.
Cyanide
patient with a crescendo-decrescendo systolic murmur best heard at the RIGHT sternal border and brisk carotid pulses most likely has ????
hypertrophic cardiomyopathy (HCM) or aortic stenosis
**differentiate by valsalva - only HCM has changes in position
which cardiac drug causes hypothyroidism and liver toxicity?
amiodarone causes hypothyroidism because the large iodine load suppresses synthesis of thyroid hormone (Wolff-Chaikoff effect), and amiodarone also inhibits the conversion of T4 to T3 in peripheral tissues.
crescendo-decrescendo murmur at the right upper sternal border with radiation to the carotid arteries is a classic description of the murmur caused by
aortic stenosis
??? are the preferred treatment for patients with viral (or idiopathic) pericarditis
Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen, indomethacin) in combination with colchicine
isolated systolic hypertension (ISH), generally defined as a systolic blood pressure (BP) ≥140 mm Hg with a diastolic BP <90 mm Hg (specific BP parameters differ among various guidelines) is most common in elderly patients and is likely due to ???
increased stiffness or decreased compliance of the aortic and arterial walls.
Patients with Wolff-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate should be treated with cardioversion or antiarrhythmics such as ??? (2)
procainamide or ibutilide
Atrioventricular nodal blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction through the accessory pathway.
???, a form of restrictive cardiomyopathy, should be suspected in patients who have manifestations of congestive heart failure (eg, progressive dyspnea, lower extremity edema, jugular venous distension, ascites) with echocardiographic findings of concentric left ventricular (LV) hypertrophy and nondilated LV cavity, especially in the absence of a history of hypertension
Other clinical manifestations include: asymptomatic proteinuria (eg, >300 mg/day), as seen in this patient, or nephrotic syndrome (eg, >3.5 g/day); waxy skin; anemia (seen in this patient); easy bruising with ecchymosis; hepatomegaly; gastrointestinal bleeding; early satiety (also seen in this patient); subcutaneous nodules; enlarged tongue; and peripheral or autonomic neuropathy.
Cardiac amyloidosis
??? should be suspected in patients with sore throat, hoarseness, stridor, pooled oral secretions, and drooling. Risk factors include diabetes mellitus, obesity, and preceding upper respiratory infection. The diagnosis can be confirmed (in those with stable respiratory status) using lateral neck radiograph.
epiglotitis
Trastuzumab is used for the treatment of patients with human epidermal growth receptor 2-positive breast carcinoma and is associated with a risk of ???
cardiotoxicity. Cardiac function should be assessed with echocardiography at baseline and at regular intervals in patients treated with trastuzumab
Periorbital purpura is a rare but highly characteristic skin finding of this disease
**also causes nephrotic syndrome
amyloidosis
**waxy skin changes as well
Infections are common in patients who undergo liver transplantation. Likely etiology can be discerned based on the length of time since transplantation. Most infections within the first month are due to ???; infections during months 1-6 are usually caused by opportunistic pathogens (in the setting of high-dose immunosuppression).
bacterial causes
??? can cause hearing loss that may be either temporary or permanent. Ototoxicity is more common in patients taking high doses, those with coexistent renal failure, or those also being treated with other known ototoxic medications (eg, aminoglycosides).
Loop diuretics
The majority of patients are diagnosed in adulthood (age 20-45) due to a combination of variable presentation and diagnostic delay. Diagnosis is made by quantitative measurement of immunoglobulin levels (significantly reduced serum IgG with low levels of IgA and/or IgM) as well as by markedly reduced or absent immune response to vaccination.
common variable immunodeficiency (CVID): a collective diagnosis that includes a number of genetic defects resulting in impaired B cell differentiation and hypogammaglobulinemia.
The preferred initial treatment for uncomplicated benign prostatic hyperplasia includes ???, which can provide rapid relief of symptoms. 5-alpha-reductase inhibitors can be used as an alternative or in addition to alpha blockers but have a much slower onset of action.
alpha-1 blockers like terazosin / tamsulosin
A photosensitive rash, along with multisystemic symptoms (eg, arthralgias, pancytopenia, splenomegaly), raises concern for ???
systemic lupus erythematosus (SLE)
Morphine is first metabolized in the liver, producing active metabolites (ie, retaining mu-opioid agonist activity) such as morphine-6-glucuronide. In patients with impaired ??? function accumulation of these metabolites can lead to altered mental status, sedation, and respiratory depression.
kidney
metabolites are renally eliminated
??? toxicity should be suspected in a patient with possible environmental exposure (eg, pressure-treated wood, pesticides) who has painful sensorimotor polyneuropathy, skin lesions (hypo- and hyperpigmented, hyperkeratotic), pancytopenia, and mild transaminase elevation.
Arsenic
??? overdose presents within 6 hours of ingestion with bradycardia, hypotension, cardiogenic shock, bronchospasm, altered mental status, and seizures. Hypoglycemia is often seen. Treatment consists of airway management, gastric decontamination, intravenous fluids, intravenous atropine, and intravenous glucagon
Beta blocker
??? toxicity is generally marked by nausea/vomiting, anion gap metabolic acidosis, elevated lactate level, hyperthermia, and tachypnea. Diagnosis is made with serum salicylate level.
Salicylate
Paget disease of bone is characterized by disordered osteoclastic bone resorption. Serum alkaline phosphatase and ??? are increased due to increased bone turnover. Serum calcium will usually be normal in the absence of other complicating factors.
urine hydroxyproline levels
**breakdown product of collagen
The classic presentation involves the distal interphalangeal joints. Morning stiffness, deformity, dactylitis (“sausage digit”), and nail involvement are common.
Psoriatic arthritis
occurs in 5%-30% of patients with psoriasis.
Fracture of a bone containing abundant marrow (eg, pelvis) can release fat into the venous circulation, resulting in fat embolism syndrome. Diagnosis is made based on clinical signs (eg, respiratory distress, neurologic dysfunction, petechial rash), and management is ??
supportive (eg, supplemental oxygen).
Hereditary hemochromatosis (HH) arthropathy often resembles osteoarthritis but differs in age at onset (<40); predilection for the second and third metacarpophalangeal joints and wrists; and presence of chondrocalcinosis. Management is primarily symptomatic (eg, acetaminophen, nonsteroidal anti-inflammatory drugs), but therapeutic ??? is necessary to minimize other systemic complications of HH (eg, liver disease)
phlebotomy
Gout initially causes an episodic monoarthritis typically affecting the ??? metatarsophalangeal joints and knees.
first
Examination findings include bony enlargement and tenderness, crepitus with movement, and painful or decreased range of motion.
Osteoarthritis causes chronic joint pain and is most common with advanced age, obesity, and prior joint injury.
Methotrexate effects are mediated largely by inhibition of dihydrofolate reductase, which causes folate depletion and leads to impaired DNA synthesis. Side effects include oral ulcers, macrocytic anemia, and ???
hepatotoxicity.
??? studies should be checked prior to initiation of methotrexate and periodically thereafter.
Serum liver studies due to hepatotoxicity
Bone loss associated with anemia, renal insufficiency, and hypercalcemia suggests ??
multiple myeloma
??? is characterized by chronic inflammatory back pain and stiffness, lumbosacral tenderness, and reduced spinal range of motion. In young patients with characteristic pain, plain x-rays showing sacroiliitis can confirm the diagnosis.
Ankylosing spondylitis (AS)
Rheumatoid arthritis can cause ??? pleural effusions characterized by low glucose, very high lactate dehydrogenase, and (often) low pH and is associated with interstitial lung disease.
exudative
??? is commonly associated with calcium pyrophosphate dihydrate crystal deposition in joints, leading to chondrocalcinosis, pseudogout, and chronic arthropathy. Patients commonly also have diabetes and liver disease.
Hereditary hemochromatosis
Diagnosis is suggested by iron overload on serum iron studies and can be confirmed by genetic tests.
?? is the most common cause of septic arthritis in young, sexually active patients. Diagnosis is confirmed by Gram stain of the synovial fluid, blood cultures, and genital/pharyngeal nucleic acid amplification tests.
Neisseria gonorrhoeae
Identifying ??? on x-ray of a joint with acute arthritis establishes a diagnosis of probable CPPD crystal arthritis.
chondrocalcinosis
he diagnosis of Sjögren syndrome requires evidence of dry mouth and eyes (eg, positive Schirmer test result for decreased lacrimation) with either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against ???
SSA (Ro) and/or SSB (La).
In patients in whom RA is suspected but who have a negative RF test result, ??? testing should be obtained. Seronegative RA often carries a better prognosis; however, many patients with initially seronegative disease will develop positive markers later in their course.
anti-CCP
Cyclic citrullinated peptide antibodies (anti-CCP)
Myeloproliferative disorders are well-known secondary causes of gout. This patient has a combination of clinical features (in addition to gout) that are highly suggestive of ???, including pruritus triggered by hot baths (aquagenic pruritus), splenomegaly, and headaches.
polycythemia vera (PV)
Diseases associated with Erythema nodosum (EN) include streptococcal infection, ????, tuberculosis (TB), endemic fungal disease (eg, histoplasmosis), inflammatory bowel disease (IBD), and Behçet disease.
sarcoidosis
The initial workup for Erythema nodosum (EN) includes basic laboratory tests (complete blood count, liver function, renal function), antistreptolysin-O antibodies, TB skin testing, and ????
a chest x-ray should be obtained to assess for findings consistent with sarcoidosis (eg, bilateral hilar lymphadenopathy, reticular opacities) or with TB (unlikely in the absence of symptoms).
Scleroderma renal crisis is characterized by the acute onset of hypertension and acute kidney injury in patients with systemic sclerosis. The mainstay of therapy is ??? , which reduce renin-angiotensin-aldosterone system hyperactivity, improve renal function, and normalize blood pressure.
ACE inhibitors (typically captopril)
??? is a complication of seropositive rheumatoid arthritis (RA) characterized by neutropenia and splenomegaly. Most patients have high-titer rheumatoid factor and anticitrullinated peptide antibodies (both of which are usually elevated in RA). Risk of recurrent bacterial infection is significantly increased due to neutropenia.
Felty syndrome
uncommon but serious complication of long-standing, erosive rheumatoid arthritis (RA)
??? typically presents with purulent monoarthritis or the following triad:
Polyarthralgia: Migrating asymmetric small and large joint pain
Tenosynovitis: Pain along multiple flexor tendon sheaths and with passive range of motion; most common in the wrists, fingers, ankles, and toes
Dermatitis: Usually 2-10 pustular/vesiculopustular lesions on the distal extremities that may be confused with pimples or furuncl
disseminated gonococcal infection (DGI)
diagnosis of Systemic sclerosis is based primarily on clinical manifestations and serologic markers. Antinuclear antibodies are present in almost all patients but are nonspecific. ??? and anti-RNA polymerase III are less sensitive but more specific and are associated with extensive disease. Anticentromere antibodies may also be seen, primarily in patients with limited disease.
Anti-topoisomerase I (anti-Scl-70)
Synovial effusions are common in older patients with OA; communication of the joint space with the gastrocnemius or semimembranosus bursa allows the synovial fluid to flow posteriorly into the bursa, forming a ???
popliteal (Baker) cyst
Synovial effusions are common in older patients with ???; communication of the joint space with the gastrocnemius or semimembranosus bursa allows the synovial fluid to flow posteriorly into the bursa, forming a popliteal (Baker) cyst
osteoarthritis
patient, an older woman with dry eyes and mouth, has typical features of ??? Exocrine output from lacrimal and salivary glands declines with age, associated with atrophy, fibrosis, and ductal dilation of the glands
age-related sicca syndrome (ARSS), also called age-related dry eye syndrome.
Treatment for Raynaud phenomenon involves mainly ??? and avoiding aggravating factors.
calcium channel blockers (eg, nifedipine, amlodipine)
??? syndrome presents with localized pain and tenderness over the medial tibial condyle. It is often associated with overuse; risk factors include obesity, diabetes mellitus, knee osteoarthritis, and angular deformity of the knee. The diagnosis is based on clinical features, although x-ray can exclude concurrent osteoarthritis. Management includes quadriceps strengthening exercises and nonsteroidal anti-inflammatory drugs
Pes anserinus pain
The pain of hip ??? is typically felt in the groin, buttock, or lateral hip (trochanteric) region and can radiate to the lower thigh or knee. Patients may have mild pain and brief stiffness with prolonged rest, but the worst pain usually occurs with activity and weight bearing. Examination findings often include decreased rotational range of motion, but synovitis (ie, redness, warmth) is absent. Common x-ray findings include loss of joint space, osteophyte formation, and subchondral sclerosis.
osteoarthritis
patient with exertional arm pain (likely claudication), systemic symptoms, and left arm pulse deficits (likely left subclavian stenosis) has typical features of ???, a chronic large-artery vasculitis that predominantly affects Asian women age <40. It primarily involves the aorta and its branches and is characterized by mononuclear infiltrates and granulomatous inflammation of the vascular media, leading to arterial wall thickening with stenosis, occlusion, or aneurysmal dilation
Takayasu arteritis
CT or MR angiography, the preferred diagnostic modality, may reveal thickening of large-artery walls and narrowing of the arterial lumen.
??? is a seronegative spondyloarthropathy resulting from an infection, typically enteric or genitourinary in origin. Findings may include urethritis, conjunctivitis, mucocutaneous lesions, enthesitis, and oligoarthritis. Nonsteroidal anti-inflammatory drugs are first-line therapy
Reactive arthritis
Hydroxychloroquine is used for patients with active systemic lupus erythematosus. However, it can cause ?? toxicity with prolonged use.
retinal
Patients treated with hydroxychloroquine should have a baseline ophthalmologic evaluation and periodic reassessment.
??? is characterized by clinical features of systemic lupus erythematosus, systemic sclerosis, and polymyositis, which appear sequentially. Important manifestations include Raynaud phenomenon, swelling of the fingers and hands, inflammatory arthritis, and myositis. Autoantibodies for U1 ribonucleoprotein have high sensitivity and specificity.
Mixed connective tissue disease
The most important serologic marker for Mixed connective tissue disease is autoantibodies for ??? which has high sensitivity and specificity.
U1 ribonucleoprotein (anti-U1 RNP)
??? is a small-vessel vasculitis that causes palpable purpura, glomerulonephritis, arthralgias, and peripheral neuropathy. Laboratory abnormalities include cryoglobulins, rheumatoid factor, and hypocomplementemia. Chronic hepatitis C infection is the most common cause, and serologies should be checked in all patients
Mixed cryoglobulinemia syndrome
patient has the following characteristic features of ????:
Age >50
Subacute-to-chronic (>1 month) pain in the shoulder and hip girdles
Morning stiffness lasting >1 hour
Constitutional symptoms (eg, malaise, weight loss)
Elevated erythrocyte sedimentation rate >40 mm/h
No other apparent explanation for symptoms
polymyalgia rheumatica (PMR)
In rheumatoid arthritis, the axial skeleton is also usually spared, with the important exception of the ???
cervical spine
RA involvement of the cervical spine can lead to atlantoaxial subluxation, an important and potentially life-threatening complication that can cause spinal cord compression and difficulties with intubation (eg, during anesthesia)
Claw toe and hammer toe deformities reflect an imbalance in strength and flexibility between the flexor and extensor muscle groups. these deformities may suggest underlying ????. Other complications include callusing, ulceration, joint subluxation, and Charcot arthropathy
diabetic neuropathy
Patients with Paget disease or involvement of high-risk skeletal structures (eg, skull, weight-bearing long bones) should be treated to reduce pain and decrease risk for complications. ???, the preferred therapy, suppress bone turnover.
Bisphosphonates
what is the msot definitive diagnostic test for polymyositis???
muscle biopsy is the most definitive diagnostic test and shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers.
**enodmysial inflammation
Involvement of the skull by ???? disease may cause headaches, frontal bossing, cranial nerve impingement, vertigo, or hearing loss.
Paget disease of bone
Hearing loss may occur due to enlargement of the temporal bone and encroachment on the cochlea in which disease of the elderly???
Paget disease of bone
patient with systemic lupus erythematosus (SLE), who is on prednisone, has atraumatic hip pain with normal x-ray findings, most likely due to ???
osteonecrosis (avascular necrosis) of the femoral head.
??? is a common pattern of thyroid function markers often seen in hospitalized patients. A characteristic feature is decreased peripheral conversion of T4 to T3 by 5’-monodeiodinase. Factors that suppress conversion of T4 to T3 include:
Caloric deprivation
Increased glucocorticoid and inflammatory cytokine (eg, tumor necrosis factor, interferon alpha) levels
Elevated free fatty acid levels
Euthyroid sick syndrome (ESS)
Chronic pancreatitis or pancreatic resection can cause loss of insulin-producing beta cells, leading to pancreatogenic diabetes; exogenous insulin is required. Patients are at risk for rapid and severe hypoglycemia due to???
loss of glucagon-secreting alpha cells as well
Hypercalcemia can be categorized as either parathyroid hormone (PTH) dependent (high-normal or increased PTH [eg, hyperparathyroidism]) or independent (low/suppressed PTH). ???? is the most common cause of PTH-independent hypercalcemia and frequently presents with very high (eg, >14 mg/dL), symptomatic (eg, polyuria, constipation, nausea) calcium levels.
Humoral hypercalcemia of malignancy (HHM)
Radioiodine therapy for Graves disease leads to resolution of hyperthyroidism in 6-18 weeks, but the dose needed for treatment gradually leads to ???? in most patients. This therapy can also acutely worsen Graves ophthalmopathy due to increased titers of thyroid-stimulating autoantibodies.
permanent hypothyroidism
Patients with ??? may not have spontaneous hypokalemia, but they are prone to developing diuretic-induced hypokalemia
The best screening test is early-morning plasma aldosterone concentration (PAC) to plasma renin activity (PRA) ratio
mild primary hyperaldosteronism
Serum Na >145 mEq/L with dilute urine excludes primary polydipsia and suggests ???
diabetes insipidus
The decreased ADH action in both types of DI leads to decreased renal water reabsorption and water loss with polyuria. This results in dilute urine and hypernatremia.
in patients with diabetes mellitus, intensive blood glucose control with insulin decreases the risk of ??? complications but has an uncertain effect on macrovascular outcomes (eg, stroke, myocardial infarction) and mortality.
microvascular
(eg, retinopathy, nephropathy)
The two available ATDs in the United States are propylthiouracil (PTU) and methimazole (MMI). ??? is usually not the preferred drug due to a black box warning of severe liver injury and acute liver failure.
propylthiouracil
Graves’ disease can be treated with anti-thyroid drugs, radioactive iodine therapy, or thyroidectomy. The most serious side effect of anti-thyroid drugs is ??? (0.3% of patients) the two available ATDs in the United States are propylthiouracil (PTU) and methimazole (MMI).
agranulocytosis
Approximately 40%-45% of total blood calcium is bound to ??? and other plasma proteins, the remainder is transported in the blood as ionized calcium (40%-55%) or complexed with phosphate and other anions (5%-15%).
albumin
as a result, patients with hypoalbuminemia may have a significant deficit in total blood calcium.
Graves ophthalmopathy is due to the effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. ??? treatment can raise titers of TRAB and worsen the ophthalmopathy. Glucocorticoids and antithyroid drugs can be used to minimize the effects of this tx
Radioactive iodine (RAI)
The patient’s clinical features - episodic flushing and wheezing, diarrhea, and valvular heart disease with tricuspid regurgitation - are consistent with ???syndrome.
carcinoid
Carcinoid tumors are rare neuroendocrine tumors that cause episodic flushing, secretory diarrhea, bronchospasm, and cardiac valvular abnormalities. Carcinoid cells cause increased production of serotonin from tryptophan which causes what def & syndrome?
Tryptophan required for niacin synthesis, resulting in niacin deficiency (ie, pellagra, with dermatitis, diarrhea, and dementia).
This patient has significant hypertension at a relatively young age, which raises suspicion for secondary causes of hypertension. In particular, his hypokalemia associated with a 3-cm adrenal mass is highly suggestive of ??
primary hyperaldosteronism (Conn syndrome)
Primary hyperaldosteronism (Conn syndrome) causes hypertension, hypokalemia, and metabolic ????. The diagnosis is confirmed by low plasma renin activity with an elevated serum aldosterone level.
alkalosis
Aldosterone also stimulates nephrons to secrete hydrogen ions into the urine, resulting in increased reabsorption of bicarbonate, elevated serum bicarbonate levels, and metabolic alkalosis.
The most accurate markers indicating resolution of diabetic ketoacidosis are the ??? and serum beta-hydroxybutyrate levels. .
serum anion gap
The anion gap estimates the unmeasured anion concentration in the blood and returns to normal with the disappearance of ketoacid anions
Hyperosmolar hyperglycemic state in type 2 diabetes mellitus is characterized by severe hyperglycemia and hyperosmolality without significant ketoacidosis. Neurologic symptoms ranging from confusion to coma are due primarily to ????; this patient’s calculated osmolality is approximately 336 mOsm/kg (using the reported sodium level, not that corrected for hyperglycemia). Common precipitating factors include infection, medications (eg, glucocorticoids), interruption of insulin therapy, trauma, and acute illness.
high plasma osmolality, usually >320 mOsm/kg
This patient has gynecomastia and testicular atrophy. His laboratory results show low testosterone levels and inappropriately low/normal gonadotropin (ie, LH, FSH) levels, indicating ???
secondary (central) hypogonadism.
Causes of secondary hypogonadism include:
Mass lesions in the hypothalamus or pituitary (eg, prolactinomas), severe systemic illness: due to gonadotroph cell damage
Hyperprolactinemia, long-term use of glucocorticoids or opiates: due to suppression of gonadotropin-releasing hormone
Hypothyroidism disrupts the hypothalamic-pituitary-ovarian axis. Low circulating thyroxine levels increase the excretion of hypothalamic thyrotropin-releasing hormone, which in turn stimulates anterior pituitary production of both TSH and ????.
prolactin
The resulting hyperprolactinemia suppresses ovulation, leading to abnormal uterine bleeding (eg, oligomenorrhea
??? is characterized by hypercalcemia, acute kidney injury, and metabolic alkalosis. It is caused by excessive intake of calcium and absorbable alkali, usually in the form of calcium carbonate taken for heartburn or osteoporosis.
Milk-alkali syndrome
Medullary thyroid cancer (MTC) is a calcitonin-producing tumor of the thyroid parafollicular C cells. It often occurs as a component of multiple endocrine neoplasia types 2A and 2B, which are also associated with ???.
pheochromocytoma
Patients with MTC should be screened for pheochromocytoma prior to thyroidectomy with a plasma fractionated metanephrine assay.
Untreated hyperthyroid patients are at risk for cardiac tachyarrhythmias, including atrial fibrillation, and ???
rapid bone loss from increased osteoclastic activity in the bone cells.
Acromegaly causes what change in the heart ???; this may eventually lead to left ventricular dilation and global hypokinesis. This cardiomyopathy is often worsened by concurrent hypertension, obstructive sleep apnea, and valvular heart disease. Complications include heart failure and arrhythmias.
concentric myocardial hypertrophy and diastolic dysfunction
Resistance to thyroid hormone is a rare inherited disorder caused by defects in the thyroid hormone receptor. Patients can have elevated T4 levels with a normal or increased TSH, but most have a ????, and this condition is usually apparent in childhood.
a goiter
??? is characterized by fever, neck pain, and a tender goiter following an upper respiratory illness. Patients have a self-limited thyrotoxic phase followed by hypothyroidism and eventual recovery of thyroid function. Treatment is symptomatic with beta blockers and nonsteroidal anti-inflammatory drugs.
Subacute (de Quervain) thyroiditis
Diabetic neuropathy is the most important contributing factor and is found in >80% of patients with ulcers. ??? testing predicts the risk of future ulcers.
Monofilament
??? is an important cause of hypocalcemia, particularly in alcoholics. It causes decreased release of parathyroid hormone (PTH) and PTH resistance.
Hypomagnesemia
Type 1 multiple endocrine neoplasia is characterized by ??? , pituitary tumors (prolactinoma), and gastrointestinal/pancreatic endocrine tumors (eg, gastrinomas). Common complications include symptomatic hypercalcemia and recurrent peptic ulcers.
primary hyperparathyroidism
Oral estrogen use (eg, menopausal hormone therapy) causes an increase in ???, leading to decreased free thyroid hormone levels. Patients with hypothyroidism on levothyroxine therapy are unable to increase endogenous thyroid hormone production to compensate and require an increased levothyroxine dose
thyroxine-binding globulin
Patients with primary adrenal insufficiency have glucocorticoid and mineralocorticoid deficiency. Most patients require replacement of both glucocorticoid (eg, hydrocortisone) and mineralocorticoid (eg, ????) activity.
fludrocortisone
Primary adrenal insufficiency most commonly results from ???
Clinical manifestations result from deficiency of mineralocorticoids, glucocorticoids, and androgens and include fatigue, weight loss, hypotension, and hyperpigmentation of the skin and mucous membranes
an autoimmune response against the bilateral adrenal cortex and often occurs in conjunction with other autoimmune disease (eg, primary hypothyroidism, vitiligo).
Thyroid storm is a life-threatening thyrotoxicosis usually triggered by a specific event (eg, surgery, trauma, infection, ?????, childbirth) in patients with undiagnosed or inadequately treated hyperthyroidism. Patients can develop fever, hemodynamic instability, cardiac arrhythmias, and congestive heart failure.
iodine contrast
Patients with hyperthyroidism and a suppressed TSH should undergo thyroid radioiodine scintigraphy to distinguish painless thyroiditis from Graves disease. With painless thyroiditis, radioiodine uptake is ??? suggesting the release of preformed thyroid hormone. In contrast, Graves disease causes hyperthyroidism due to increased synthesis of thyroid hormone. Radioiodine uptake will be diffusely ???, and extra-thyroidal manifestations (eg, exophthalmos, pretibial myxedema) are often present
decreased
increased in Graves
Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in anorexia nervosa. what is the moa???
Carbohydrate intake stimulates insulin activity, which in turn promotes cellular uptake of phosphorus, potassium, and magnesium, leading to electrolyte deficiency. Cardiac manifestations include arrhythmias and congestive heart failure. Other common complications involve the muscular (eg, weakness, rhabdomyolysis), gastrointestinal (eg, diarrhea, elevated transaminases), and neurologic (eg, tremor, seizure) systems.
This patient’s hypertension, episodic headaches, and unexplained hyperglycemia should raise suspicion for ????. Paroxysmal hypertension occurs in approximately half of patients and may be associated with orthostasis (possibly reflecting low plasma volume). Vision changes, coinciding with episodes of headache and hypertension, can also occur.
pheochromocytoma
Because catecholamines inhibit insulin secretion, hyperglycemia is also common. Therefore, pheochromocytoma should be considered in patients who develop hyperglycemia that is atypical for both type 1 (ie, usually presents with diabetic ketoacidosis) and type 2 (ie, rarely occurs in patients age <35 with normal BMI, as in this patient) diabetes mellitu
pheochromocytoma has what effect on glucose
Because catecholamines inhibit insulin secretion, hyperglycemia is also common. Therefore, pheochromocytoma should be considered in patients who develop hyperglycemia that is atypical for both type 1 (ie, usually presents with diabetic ketoacidosis) and type 2 (ie, rarely occurs in patients age <35 with normal BMI, as in this patient) diabetes mellitus
Symmetric distal sensorimotor polyneuropathy is the most common neuropathy in patients with diabetes; the clinical features depend on the type of nerve fibers involved.
small vs. large fiber injury
Small fiber injury is characterized by the predominance of positive symptoms (eg, pain, paresthesia, allodynia)
Large fiber involvement is characterized by the predominance of negative symptoms (eg, numbness, loss of proprioception and vibration sense, diminished ankle reflexes).
Patients with hypothyroidism should ??? their levothyroxine dose at the time pregnancy is detected, with subsequent dose adjustments based on TSH and total T4 using pregnancy-specific norms.
increase
besity and cardiovascular disease are common comorbidities in patients with type 2 diabetes mellitus. In these patients, which two meds ??? can be added to decrease cardiovascular mortality, induce weight loss, and minimize the risk for hypoglycemia.
glucagon-like peptide-1 receptor agonists (eg, exenatide, liraglutide) and/or certain sodium-glucose cotransporter-2 inhibitors
which antipsychotic medications has a high frequency of prolactin elevation
Risperidone
Infants born to women with Graves’ disease are at risk for thyrotoxicosis due to ????. Affected infants are irritable, tachycardic, and gain weight poorly. Methimazole plus a β blocker are given to symptomatic patients until the condition self-resolves over a few weeks to months.
passage of maternal TSH receptor antibodies across the placenta
??? most commonly occurs as pruritic, purple/pink, polygonal papules and plaques on the skin of the extremities and trunk, but lesions may also appear on the genitalia or oral mucosa.
Lichen planus
The US Preventive Services Task Force recommends screening mammography for women age 50-74 how often???. Screening at age 40-49 and age ≥75 is not routinely recommended but can be considered on an individual basis
biennial (every 2 years)
Tenderness to gentle percussion over the spinous process of the involved vertebra is the most reliable sign for spinal ???. Pain is not relieved with rest. Fever and leukocytosis are unreliable findings. The erythrocyte sedimentation rate is grossly elevated. MRI is the most sensitive diagnostic study. There should be a very high index of suspicion in patients with a history of injection drug use or recent distant site infection (eg, urinary tract infection).
osteomyelitis
First-line treatment options for ankylosing spondylitis include ????, which provide substantial relief of symptoms and may inhibit progression of the disease for long periods.
nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors
The initial treatment of ankylosing spondylitis includes regular exercise and nonsteroidal anti-inflammatory drugs. ??? are used in patients whose conditions do not respond to less aggressive treatment.
tumor necrosis factor inhibitors and IL-17 inhibitors
The most common cause of an asymptomatic elevation of alkaline phosphatase in an elderly patient is ????, which is frequently discovered incidentally on routine blood tests. X-rays will show osteolytic or mixed lytic-sclerotic lesions, and radionuclide bone scan can fully stage the disease.
Paget disease of bone
??? is an inflammatory disorder that occurs in patients age ≥50; it is characterized by aching pain and stiffness in the hip girdle, shoulders, and/or neck that happens in a short amt of time **acutely. The diagnosis is suggested by the presence of elevated acute-phase inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein), and the condition responds rapidly to low-dose glucocorticoid therapy.
Polymyalgia rheumatica
??? most commonly results from an acquired disruption of the lymphatic system that leads to accumulation of lymphatic fluid in the interstitium. Common causes include malignancy and its treatment (eg, radiation, lymph node dissection), chronic inflammation (eg, recurrent cellulitis, connective tissue disease), and severe chronic venous insufficiency. Obesity is often a strong contributing factor.
typically presents with pain, swelling, and heaviness in one or more extremities. Inability to lift the skin on the dorsum of the second toe (positive Stemmer sign) is highly specific
Lymphedema
which lifestyle intervention works best for hypertension?
the DASH (Dietary Approaches to Stop Hypertension) diet, which is a combination diet rich in fruits, vegetables, legumes, low-fat dairy products, and low in saturated and total fat, can produce a reduction in systolic blood pressure of approximately 11 mm Hg, with a corresponding reduction in diastolic pressure.
the primary risk factors for abdominal aortic aneurysm include male gender, smoking history, and age >65. The US Preventive Services Task Force recommends screening for this condition how ?
a one-time abdominal ultrasound in men age 65-75 who ever smoked.
Women with chronic hypertension who are pregnant or considering pregnancy should be managed with a medication safe for use in pregnancy. which medications are first-line and safe??
Beta blockers (labetalol)
Calcium channel blockers (nifedipine)
Hydralazine
Methyldopa
Patients with ??? typically have recurrent episodes of chest discomfort that resolve spontaneously within 15 minutes. The episodes commonly occur during sleep and may be accompanied by diaphoresis, nausea, palpitations, and dyspnea. Patients are typically young (age <50) and lack most risk factors for coronary artery disease (CAD) (eg, hypertension, diabetes); however, smoking is a strong risk factor.
vasospastic angina
Vasospastic angina results from hyperreactivity of intimal smooth muscle, leading to intermittent coronary artery vasospasm. ??? are the preferred pharmacologic treatment.
Calcium channel blockers (eg, diltiazem, amlodipine) cause coronary artery vasodilation
This complication should be suspected in patients presenting with right-sided heart failure following implantable pacemaker or cardioverter-defibrillator placement.
Transvenous lead placement through the tricuspid valve can cause severe tricuspid regurgitation due to direct valve leaflet damage or inadequate leaflet coaptation.
??? usually occurs as a congenital defect and can often remain asymptomatic until adulthood. Cardiac auscultation reveals an ejection click (high pitched sound after S1), followed by a crescendo-decrescendo systolic murmur over the left second intercostal space and widened splitting of S2.
Pulmonic valve stenosis
??? is a cyanotic congenital heart defect with findings include tall P waves (right atrial enlargement) and left axis deviation (left-sided volume overload) on ECG and decreased pulmonary markings on chest x-ray (hypoplasia of right ventricle and pulmonary outflow tract).
Tricuspid valve atresia
Oral contraceptives (OCs) commonly cause a mild elevation in blood pressure and can sometimes lead to overt hypertension. OCs should not be used in patients with hypertension, and those who develop hypertension while taking OCs should ??
discontinue the medication
The risk of hypertension increases with the duration of OC use and is elevated in those who have a family history of hypertension or who developed hypertension during a previous pregnancy
which HTN drug should be avoided in gout patients ?
Thiazide diuretics can raise circulating uric acid levels and should be avoided.
Losartan is an angiotensin II receptor blocker (ARB) that has a mild uricosuric effect and is the preferred first-line antihypertensive drug for patients with gout. Other options include other ARBs, ACE inhibitors, and calcium channel blockers.
For patients with osteoporosis, which antihypertensives are generally preferred??
thiazide diuretics
thiazides increase calcium reabsorption in the distal tubule, reducing renal calcium wasting and slowing the rate of bone loss.
??? is recommended as an initial test for diagnosis and risk stratification in most patients with suspected stable ischemic heart disease
Exercise stress ECG
???? is useful for differentiating between cardiac disease– and liver disease–related causes of ascites, splenomegaly, and lower extremity edema.
Hepatojugular reflux
Positive hepatojugular reflux (ie, sustained >3-cm rise in jugular venous pressure elicited by compression of the upper abdomen) is highly specific for right ventricular failure. Hepatojugular reflux is not expected with liver cirrhosis.
Heart failure with preserved ejection fraction results from ??? in the setting of a normal left ventricular (LV) ejection fraction (ie, >50%). Concentric LV hypertrophy due to chronic hypertension is usually the primary contributor. Patients develop typical heart failure symptoms (eg, dyspnea, orthopnea, lower extremity edema) resulting from elevated LV diastolic filling pressure and reduced cardiac output.
impaired diastolic relaxation (ie, diastolic dysfunction)
Following myocardial infarction (MI), deleterious cardiac remodeling is mostly driven by neurohormonal mechanisms. Which drugs improve survival following MI, likely due to inhibition of neurohormonal-mediated cardiac remodeling.
ACE inhibitors (eg, enalapril, lisinopril), beta blockers (eg, metoprolol), and aldosterone antagonists (eg, spironolactone)
??? is the most common cause of chronic mitral regurg in developed countries. It occurs due to myxomatous degeneration of the mitral valve leaflets and chordae and causes a mid-systolic click followed by a mid-to-late systolic murmur.
Mitral valve prolapse (MVP)
??? is recognized by saw-toothed flutter waves on ECG; the rhythm can be regular or irregular depending on the variability of the ventricular response rate. It carries a similar risk of arterial thromboembolization to atrial fibrillation and should be similarly managed with chronic anticoagulation.
Atrial flutter
Features of ??? include a wide pulse pressure, “water hammer” pulse, and LV enlargement. The left lateral decubitus position brings the enlarged left ventricle closer to the chest wall and causes a pounding sensation and increased awareness of the heartbeat. the wide pulse pressure (systolic minus diastolic blood pressure) causes a characteristic “water hammer” or Corrigan pulse: rapid, abrupt upstroke followed by rapid collapse of the peripheral pulse
aortic regurgitation
What type of murmur should prompt further evaluation with a transthoracic echocardiogram in a healthy patient
Diastolic and continuous murmurs are usually due to an underlying pathologic cause. Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign and do not require further evaluation.
??? is the most common cardiac arrhythmia, with a prevalence that increases dramatically with age; approximately 70% of those affected are age ≥65. Patients often have episodes of paroxysmal (intermittent) arrythmia in the initial stages and progress to persistent or permanent over time.
Atrial enlargement and subsequent atrial remodeling likely play an important role in the development. Hypertension is the most common underlying comorbidity, contributing to left atrial enlargement via concentric left ventricular hypertrophy and transmission of increased pressure to the left atrium.
Atrial fibrillation (AF)
patient’s middiastolic murmur preceded by an early diastolic sound (ie, opening snap) is consistent with ???
mitral stenosis (MS)
?? is a common complication of mitral stenosis, untreated, that occurs due to left atrial dilation
afib
??? are first-line therapy for preventing symptoms and improving exercise tolerance in patients with stable angina. They help prevent angina by decreasing exertional heart rate and myocardial contractility, leading to a reduction in myocardial oxygen demand
Beta blockers
Sublingual nitroglycerin is used as a first-line agent for rapid relief of symptoms in patients with angina pectoris. The antiischemic effect of nitrates is mediated by ??
systemic vasodilation with a decrease in left ventricular end-diastolic volume and wall stress resulting in decreased myocardial oxygen demand
**Decreased stretching of the walls/stress
Postthrombotic syndrome occurs in >50% of patients with a history of acute deep venous thrombosis and is marked by the development of chronic venous insufficiency distal to the site of thrombus. It usually presents with leg pain, edema, fatigue, superficial venous dilation, and/or ulcer. Treatment includes ???
exercise and compression.
??? is usually secondary (functional), resulting from right ventricular cavity enlargement in the setting of chronic right-sided volume or pressure overload. A prominent V wave in jugular venous pulsation is highly specific
Tricuspid regurgitation
patient with early-onset hypertension and bilateral upper abdominal masses likely has ???
autosomal dominant polycystic kidney disease (ADPKD)
patient’s elevated blood pressure and ECG findings consistent with ??? (high-voltage QRS complexes, lateral ST segment depression, lateral T wave inversion) are suggestive of long-standing systemic hypertension.
left ventricular hypertrophy (LVH)
Hypertrophic cardiomyopathy is a common cause of exertional syncope and may also cause fatigue, dyspnea, chest pain, palpitations, and presyncope. Symptomatic patients should be treated with a ??? as the negative chronotropy and inotropy increase left ventricular volume to reduce left ventricular outflow tract obstruction and improve symptoms.
beta blocker (eg, metoprolol)
??? occur when there is premature activation of the atria originating from a site other than the sinoatrial node. ECG will show an early P wave. By themselves represent a benign arrhythmia that can occur both in healthy individuals and in patients with a variety of cardiovascular and systemic diseases.
Atrial premature beats, also called premature atrial complexes (PACs)
??? pericarditis can occur in patients with blood urea nitrogen levels >60 mg/dL. It presents like other etiologies of acute pericarditis except that classic ECG findings (ie, diffuse ST-segment elevation and PR-segment depression) are typically absent. Dialysis is the best treatment.
Uremic
Degeneration of the sinus node and replacement with fibrous tissue is the most common cause of ???? . Elderly patients are typically affected and have bradycardia, leading to fatigue, dyspnea on exertion, lightheadedness, confusion, and syncope or presyncope. ECG demonstrates sinus bradycardia with delayed or dropped P waves.
sick sinus syndrome
??? most commonly affects relatively young adults (eg, age <55), and patients typically present with dilated cardiomyopathy and signs and symptoms of decompensated heart failure. Less commonly, patients will not develop DCM but will present with chest pain that can mimic myocardial infarction. Sudden cardiac death is rare but can occur.
Viral myocarditis
??? heart failure is caused by decreased systemic vascular resistance that leads to an increase in stroke volume, cardiac output, and venous return and is recognized by a wide pulse pressure and prominent point of maximal impulse. Hyperthyroidism is a common cause
High-output
??? is the most likely diagnosis in this patient with sudden severe chest pain radiating to the back, significant hypertension, decrescendo diastolic murmur of aortic regurgitation (due to proximal extension of the dissection into the aortic valvular annulus), and elevated creatinine of 2.1 mg/dL (possibly due to distal extension into the renal arteries).
Acute type A (ascending) aortic dissection
??? has excellent sensitivity and specificity for the diagnosis of aortic dissection and is the preferred diagnostic study in patients with hemodynamic instability or renal insufficiency.
Transesophageal echocardiogram
Pulsus paradoxus is defined as an exaggerated fall in systemic blood pressure >10 mm Hg during inspiration. It is a frequent finding in cardiac tamponade but can also occur in conditions without pericardial effusion such as ???
severe asthma or chronic obstructive pulmonary disease.
??? infarction commonly involves vagal symptoms (eg, nausea) and bradyarrhythmias and often primarily affects the right ventricle. Right ventricular myocardial infarction presents with jugular venous distension, clear lungs, and often profound hypotension caused by impaired delivery of blood to the left ventricle.
Inferior wall myocardial
?? is the most common underlying arrhythmia responsible for sudden cardiac arrest (SCA) in acute MI and is the most common cause of acute MI-related death.
Ventricular fibrillation
Patients with cocaine-associated chest pain should be treated initially with intravenous ????. These improve the symptoms of psychomotor agitation, reduce myocardial oxygen demand, and alleviate cardiovascular symptoms.
benzodiazepines
??? is a narrowing of the descending aorta that leads to a proximal arterial pressure load. Patients typically present with upper extremity hypertension and diminished femoral pulses with brachial-femoral delay. Chest x-ray usually demonstrates inferior notching of the third to eighth ribs due to pressure-induced enlargement of the intercostal arteries.
Coarctation of the aorta
Nonallergic rhinitis usually presents with nasal congestion and rhinorrhea without specific allergic triggers. Patients should be treated with ???
intranasal glucocorticoids; intranasal antihistamines can be added if needed.
Bisphosphonate-related osteonecrosis of the ??? is characterized by chronic swelling, mild pain, and exposed, necrotic bone. It is often triggered by tooth extractions or other invasive dental procedures. The course can be intractable, and treatment is largely supportive with careful oral hygiene and antibacterial rinses
jaw
??? are the most effective single agent for allergic rhinitis, although maximal benefits may require continuous treatment for several days or weeks
Glucocorticoid nasal sprays
This patient has typical features of ??? including nasal congestion, clear rhinorrhea, and pale, edematous nasal mucosa. Patients may also have nasal creases, pharyngeal cobblestoning, conjunctival edema, or thick, green nasal discharge.
allergic rhinitis
Barotrauma to the ear occurs most commonly after flying and can result in injury (eg, ear pain, hearing loss) to the tympanic membrane (TM). Most barotraumatic TM injuries are treated how??
heal spontaneously within a few weeks.
This patient has a painless, white mucosal lesion on the lateral and inferior surface of the tongue that cannot be scraped off with a tongue depressor. This is most consistent with ???, a potentially malignant or premalignant lesion with risk factors similar to those of squamous cell carcinoma.
oral leukoplakia
??? are the greatest risk factors and have a synergistic effect (ie, multiplicative rather than additive) on the risk for developing both oral leukoplakia and oral squamous cell carcinoma
Tobacco use and alcohol use
patient has tinnitus, hearing loss, and a retracted tympanic membrane (TM), findings consistent with ???
eustachian tube dysfunction.
??? causes fixation of the stapes, which results in conductive hearing loss. It often presents in young women and may progress during pregnancy.
Otosclerosis
Tuberculin skin testing can be used to identify patients with latent tuberculosis infection. In the United States, an induration size ? mm is considered negative in healthy patients with a low likelihood of tuberculosis infection.
15
(ie, ≥15 mm is considered positive)
If serum TSH is normal, a thyroid ultrasound is the next step to determine nodule sonographic features and size. Certain sonographic features (eg, microcalcifications, irregular margins, internal vascularity) carry a much higher risk of malignancy than others (eg, cystic or spongiform lesions). Thyroid nodules >1 cm with these high-risk sonographic features should undergo ????
fine-needle aspiration (FNA) biopsy
Presbyopia is a common age-related that leads to difficulty with near vision. Caused by??? A history of a middle-aged individual who has to hold books at an arms length to read is classic.
decrease in lens elasticity
which eye condition?
Herpes simplex keratitis presents acutely with eye pain, redness, photophobia, tearing, and blurred vision. Slit-lamp examination reveals characteristic dendritic ulcers (linear branching).
Oral hairy leukoplakia typically presents as multiple white lesions on the lateral tongue with a distinct corrugated appearance. Because it occurs almost exclusively in patients with significant immunodeficiency, ??? should be performed, especially in patients with signs of systemic illnes
different then oral leukoplakia which is benign and found in smokers/alcohol
HIV testing
??? infection that most commonly manifests as rhino-orbital-cerebral disease in patients with immunocompromise (particularly poorly controlled diabetes mellitus). Symptoms include acute fever, nasal congestion, purulent nasal discharge, headache, and sinus pain. Local, necrotic spread is common. Diagnosis requires sinus endoscopy with tissue sampling.
Mucormycosis ; an invasive fungal
Rhizopus is the most common cause
Hand-foot-and-mouth disease caused by ??? presents with oral vesicles and ulcers in addition to a maculopapular or vesicular exanthem classically involving the palms and soles. Diagnosis is clinical, and treatment is supportive
coxsackievirus
patient has a slowly expanding, annular, pruritic rash with a raised border and central clearing consistent with ???
tinea corporis (TC). the fungi thrive in warm, moist areas (eg, shower surfaces, pools, gym mats) and can be transmitted by skin-to-skin contact, contact with animals (eg, cats), or via fomites.
tinea corporis First-line treatment is a ???
topical antifungal (eg, terbinafine, miconazole).
Small, pruritic, erythematous papules in a linear pattern are suggestive of ??? bites
bedbug
Chronic, low-level ??? exposure can lead to itching and lichenification. Treatment includes topical corticosteroids and allergen avoidance.
allergic contact dermatitis
ex. nickel on a belt
??? is characterized by a recurrent, pruritic, vesicular rash that primarily affects the palms, soles, and sides of the digits. The diagnosis is based on clinical features, and treatment includes high- and super high–potency topical corticosteroids.
Dyshidrotic eczema (acute palmoplantar eczema)
Whereas idiopathic lichen planus occurs most commonly at the wrists and ankles, ??? lichen planus can have a more diffuse presentation. Treatment includes topical glucocorticoids and discontinuation of the suspected medication.
Drug-induced lichen planus (lichenoid drug reaction) is associated with a number of medications, including ACE inhibitors, thiazide diuretics, beta blockers, and hydroxychloroquine.
drug-induced
5 “Ps” of Lichen planus
pruritic, purple/pink, polygonal papules & plaques
Squamous cell carcinoma in situ of the skin (Bowen disease) presents as a slowly enlarging, well-demarcated, scaly, erythematous patch or plaque that is asymptomatic. It most commonly occurs on sun-exposed skin. Due to its invasive and metastatic potential, timely diagnosis with a ??? is recommended.
punch biopsy
??? is characterized by erythematous, scaly plaques. It is classically found on the extensor surfaces of the knees and elbows (large plaque) but can also occur on the scalp, hands, and trunk (eg, gluteal cleft) as small plaques.
Psoriasis
Lichen planus is often associated with ???. Although this disorder resolves spontaneously, topical glucocorticoids can be used to accelerate healing and alleviate pruritus.
hepatitis C
??? is a lifelong, inherited disorder characterized by diffuse dry and rough skin with fish-like scales. These features are most noticeable on the extensor legs and during the winter. There is no associated erythema or other cutaneous lesions (eg, vesicles, papules) to indicate an alternate diagnosis.
Ichthyosis vulgaris
??? in infants is characterized by yellow, greasy scales of the face (eg, eyebrows, retroauricular areas) and scalp, as well as glistening, confluent erythema of intertriginous areas. The diagnosis is clinical, and the rash typically self-resolves.
Seborrheic dermatitis
Ichthyosis vulgaris is a chronic, inherited disorder characterized by rough and dry skin with fish-like scales. Treatment includes topical ??? to help remove the scales. In addition, frequent bathing and application of moisturizers are also recommended.
keratolytics, such as alpha hydroxy acid (eg, lactic acid), urea, and salicylic acid
??? is an idiopathic inflammatory disorder that presents with round, pruritic, scaly plaques, most commonly on the extremities. It is often associated with dry skin. The diagnosis is based primarily on clinical findings. Treatment includes topical glucocorticoids, emollients, and avoidance of harsh soaps.
Nummular eczema
??? is characterized by retained keratin plugs in the hair follicles. It occurs most commonly on the posterior surface of the upper arm and manifests as small, painless papules; a roughened skin texture; and mottled, perifollicular erythema. Exacerbations are common in cold, dry weather. Treatment includes emollients and topical keratolytics (eg, salicylic acid, urea).
Keratosis pilaris
Inflammatory acne (pustules) is treated with topical retinoids and benzoyl peroxide. When this regimen is inadequate, the addition of topical or oral ???is recommended.
antibiotics
. Bullous impetigo presents with enlarging, yellow fluid-filled, flaccid bullae that leave a collarette of scale after rupture. This condition is caused by ???, and treatment is with oral antibiotics.
Staphylococcus aureus
??? is a self-limited exanthem that classically begins with a solitary, large herald patch followed by clusters of smaller oval lesions oriented in a “Christmas tree” pattern. Management is reassurance alone, although symptomatic relief of pruritus (eg, antihistamines, topical corticosteroids) may be indicated.
Pityriasis rosea
Female pattern hair loss (FPHL) usually presents with gradual thinning of the hair at the vertex and midline and is characterized by replacement of terminal hairs by smaller vellus hairs (follicular miniaturization). Hair loss can be seen in women with hyperandrogenic states, but androgen levels in most women with FPHL are normal. The first-line treatment is topical ???
minoxidil
a direct vasodilator that increases blood flow to the scalp.
Recurrent tinea cruris is common and suggests reexposure to an external source or autoinfection from a concurrent dermatophyte infection elsewhere on the body (eg, tinea pedis, tinea corporis, onychomycosis). Patients should have a thorough ???
skin inspection, and any other sites of infection should be treated.
Scabies is an intensely pruritic rash characterized by small erythematous papules and burrows in the axillae, periumbilical area, genitalia, and interdigital web spaces. First-line treatment is ???
topical 5% permethrin or oral ivermectin.
??? presents with erythematous patches and plaques with greasy scales, most commonly on the central face, ears, and scalp. It is more common in patients with HIV and CNS disorders (eg, Parkinson disease).
Seborrheic dermatitis
lSeborrheic dermatitis tx??
Diagnosis is made clinically, and topical antifungals (eg, ketoconazole, selenium sulfide) are effective for treatment.
Erythema nodosum is a delayed hypersensitivity reaction characterized by 2- to 3-cm, tender, erythematous nodules, most often on the shins. Common triggers include infection, inflammatory bowel disease, sarcoidosis, and malignancy. It can also be triggered by ???
medications, such as penicillins, sulfonamides, and oral contraceptives.
Oral ??? presents with white papules and plaques on the oral mucosa; variants may also show erythematous mucosal atrophy or ulceration. It is often associated with hepatitis C. Treatment includes topical high-potency glucocorticoids.
lichen planus (LP)
white papules or plaques connected by white, lacy markings known as Wickham striae
Tinea pedis most commonly presents with a pruritic rash between the toes. The diagnosis is usually made clinically but can be confirmed with a potassium hydroxide preparation of skin scrapings. A variety of topical ??? is effective for treatment, but nystatin is not effective
antifungal agents (eg, miconazole, terbinafine, tolnaftate)
???, the second most common type of melanoma, usually grow vertically and have symmetric borders and a uniform, dark color. Suspicion should be raised when the lesion appears different from other lesions on the patient (“ugly duckling sign”) or the lesion grows continuously, is elevated, or is firm.
Nodular melanomas
The ABCDE criteria can assist in evaluation of superficial spreading melanoma but are less sensitive for other types of melanoma (eg, nodular, atypical).
Alopecia areata is characterized by patchy, nonscarring hair loss. It is an autoimmune disorder and is often associated with other autoimmune conditions. Treatment includes topical or intralesional corticosteroids like ????. A recurring course is common, but most patients have regrowth over time.
triamcinolone
??? is recommended for patients with gross hematuria or with microscopic hematuria and other risk factors for bladder cancer. Risk factors for bladder cancer include cigarette smoking, certain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure.
Cystoscopy
??? is a common disorder of uncertain etiology, characterized by irritative voiding symptoms (eg, frequency, urgency, hesitancy); perineal or genital pain; and pain or blood on ejaculation. Urine culture is sterile. Treatment includes antibiotics, alpha blockers, and 5-alpha-reductase inhibitors.
Chronic prostatitis/chronic pelvic pain syndrome
is a major complication of systemic sclerosis and should be suspected with signs of right-sided heart failure and a vascular pattern on pulmonary function testing (isolated, reduced DLCO despite normal mechanics).
Pulmonary arterial hypertension: vessel wall thickening can lead to luminal narrowing, elevated pulmonary vascular resistance, and eventual right ventricular failure.
SS can cause interstitial lung disease and PAH
both have reduced diffusion, but interstitial has restrictive lung findings
??? is the most common lung cancer in adolescents and young adults. It typically presents with proximal airway obstruction, leading to dyspnea, wheezing, and recurrent pneumonia in the same lobe of the lung.
Bronchial carcinoid
Carcinoid syndrome is much less common than with gastrointestinal carcinoid tumors.
Treatment of an acute asthma exacerbation includes a short-acting bronchodilator to manage immediate bronchoconstriction and a ??? to dampen late-phase inflammation and prevent symptom relapse.
systemic glucocorticoid (eg, prednisone)
Corticosteroids are continued at home (eg, prednisone 40-60 mg daily for 5-7 days) to prevent relapse and decrease the need for hospitalization
Initial treatment of an acute asthma exacerbation focuses on relaxing bronchoconstriction with ??? (3)
short-acting beta agonist (eg, albuterol), a short-acting muscarinic antagonist (eg, ipratropium), and intravenous magnesium
??? presents with dullness to percussion, increased intensity of breath sounds, and increased tactile fremitus.
Lung consolidation (eg, lobar pneumonia)
Comorbid ??? is common in patients with asthma and can worsen asthma symptoms as a result of microaspiration.
gastroesophageal reflux disease (GERD)
In asthma patients with signs and/or symptoms suggestive of comorbid GERD, proton-pump inhibitor therapy has shown benefit in improving asthma symptoms and peak expiratory flow rate.
??? is a common cause of cough that may be productive of purulent, blood-tinged sputum. Upper respiratory viral infection is the typical etiology, and symptoms are usually self-limiting. Symptomatic treatment and close clinical follow-up are the best management strategies.
Cough for >5 days to 3 weeks (± purulent sputum)
Absent systemic findings (eg, fever, chills)
Wheezing or rhonchi, chest wall tenderness
Acute bronchitis
which type of beat?
Monomorphic ventricular tachycardia is a regular wide-complex tachycardia that may demonstrate fusion and capture beats.
which rash
Erythema multiforme is an acute inflammatory disorder characterized by erythematous, round papules that evolve into target lesions, although the appearance can vary. It is associated with certain infections (especially herpes simplex) as well as medications, malignancies, and connective tissue diseases.
Atrial fibrillation is recognized on ECG by an absence of organized P waves and irregularly irregular R-R intervals. It is most commonly caused by ???
ectopic electrical foci within the pulmonary veins.
???? can occur within 5 days or up to 2 weeks following transmural myocardial infarction. Affected patients have sudden-onset chest pain and rapid development of cardiac tamponade that quickly leads to obstructive shock and pulseless electrical activity cardiac arrest.
Left ventricular free wall rupture
what should be limited in hypertrigylceridemia
what is the cutoff for mild triglyceridemia?
limit alcohol; 500
Under normal circumstances, ??? does not cause any significant prolongation of the QRS duration or QT interval; however, in patients with rapid heart rates, the drug has less time to dissociate from sodium channels, leading to a higher number of blocked channels, which results in a progressive decrease in impulse conduction and widening of the QRS complex. This phenomenon is termed use dependence and is seen most frequently with class IC antiarrhythmic agents (less commonly with class IA drugs and rarely with class IB drugs).
flecainide
these chest x-ray findings indicate????
Pulmonary embolism
??? primarily affects immunocompromised patients and typically causes the triad of fever, pleuritic chest pain, and hemoptysis. CT scan often reveals multiple pulmonary nodules with surrounding ground-glass opacities (“halo sign”).
Invasive aspergillosis
Hyperthyroidism from ??? is due to autonomous production of thyroid hormones from the hyperplastic thyroid follicular cells. The radioactive iodine uptake scan reveals uptake only in the hyperactive nodule, with suppression of uptake in the rest of the gland.
toxic adenoma
**typically need goiter and opthal for diagnosing Graves
what is this finding and what does it increase the risk for???
Porcelain gallbladder is usually diagnosed on abdominal imaging showing a calcified rim in the gallbladder wall with a central bile-filled dark area. It is associated with an increased risk for gallbladder adenocarcinoma and usually requires cholecystectomy
this finding in a neonate with no bowel movement passed is ???
jejunal atresia
triple bubble !
Bright red, firm, friable, exophytic nodules in a patient with HIV are most likely bacillary angiomatosis. The classic lesion is shown in the above picture. Bacillary angiomatosis is caused by Bartonella, a Gram-negative bacillus. Oral ??? is the antibiotic of choice
erythromycin
??? typically presents with subacute or chronic fevers, weight loss, fatigue, and pulmonary symptoms. Chest x-ray classically reveals a diffuse reticulonodular pattern. The most common behavioral risk factor for tuberculosis in the United States is substance abuse.
Miliary tuberculosis
millet seed pattern on x -ray
Erysipelas is a superficial skin infection that manifests with the acute onset of systemic symptoms (rapid fever, chills), regional lymphadenitis, and a warm, tender, erythematous rash with raised, sharply demarcated borders. The majority of erysipelas cases are caused by ???
group A Streptococcus
which infx??
Cutaneous larva migrans is a creeping cutaneous eruption due to dog (Ancylostoma caninum) or cat (A braziliense) hookworm larvae. Most infections arise from walking barefoot on contaminated sand or soil. Symptoms include a pruritic, papular lesion at the portal of entry and intensely pruritic, migrating, serpiginous reddish-brown tracks. Ivermectin is typically given to speed resolution and clearance.
Babesiosis is a tick-borne protozoal illness found primarily in the northeastern United States. Transmission occurs via Ixodes scapularis, and coinfection with other microbes (eg, Borrelia burgdorferi, Anaplasma phagocytophilum) is possible. Symptoms are often flu-like (fever, chills, malaise), and laboratory studies usually show anemia with signs of intravascular hemolysis and thrombocytopenia. Diagnosis is made primarily by ???
identifying organisms on peripheral blood smear (“Maltese cross”)
Ecthyma gangrenosum is a rapidly progressive cutaneous disorder seen most commonly in immunocompromised patients with ???? bacteremia/sepsis. Lesions begin as painless red macules, quickly progress to pustules/bullae, and then form “punched-out” gangrenous ulcers. Patients are usually febrile and ill. Blood cultures and empiric, intravenous antibiotics are required.
Pseudomonas aeruginosa
which two genital ulcers are painless??
syphilis and chlaymydia trachomatis (usually turns to painful buboes)
Ankle pain after trauma may be caused by a sprain or fracture. The Ottawa ankle rules are used to help determine which patients require imaging. X-ray of the ankle is indicated for patients with pain in the malleolar region in association with either ????
1) bony tenderness at the posterior margin or tip of the lateral or medial malleolus or 2) inability to bear weight.
what does CT finding for lung abscess shows
+fever, night sweats, weight loss, blood-tinged sputum
chest x-ray and CT scan typically reveal cavitary infiltrates, often with air-fluid levels in the superior lower lobe or posterior upper lobe (sections that are dependent with recumbency).
patient with sickle cell disease has ????, a life-threatening complication that presents with a new pulmonary density plus fever and/or respiratory symptoms (eg, hypoxia, chest pain).
acute chest syndrome
what are the parameters for light’s criteria???
Effusion protein/serum protein ratio greater than 0.5.
Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6.
Effusion LDH level greater than two-thirds the upper limit of the laboratory’s reference range of serum LDH
***only need 1
??? can lead to large-volume atelectasis (lung collapse) due to airway obstruction. Chest x-ray demonstrates opacification of the affected lung area and mediastinal shifting toward the side of atelectasis.
Mucus plugging in mainstem bronchi
Surgery (under anesthesia) and smoking increase the risk of mucus plugging
??with respiratory failure is a common cause of mixed metabolic and respiratory acidosis.
Sepsis
metabolic alkalosis with high urine chloride; how to differentiate??
volume status
in high volume status: hyperaldosteronism - causes increase in Na and Hydrogen ion exchange, loss of acid in urine
Patients with AIDS who have CD4 counts <50/mm3 are at high risk for infectious colitis with opportunistic bacterial, viral, and protozoal pathogens. ??? colitis should be suspected in those with frequent, small-volume, bloody stools and abdominal pain. Diagnosis is confirmed by colonoscopy with biopsy.
Cytomegalovirus
Any patient with HIV who has active CMV disease requires ocular examination to rule out concurrent retinitis.
what type of cyst??
Simple renal cysts are almost always benign and do not require further evaluation. Features concerning for malignant renal mass include a multilocular mass, irregular walls, thickened septa, and contrast enhancement.
