Medicine Flashcards
1
Q
Asymptomatic CAD
A
Negative
Less than 50% occlusion
Don’t stent
Demand ischemia if decrease workload of heart and little perfusion reverse
Outpatient
2
Q
Stable angina
A
Pain with exertion
Relieved wiht rest
No bio markers and ST changes
Usually 70% occlusion
Demand ischemia if decrease workload of heart and little perfusion reverse
Outpatient
3
Q
Unstable angina
A
Pain at rest nothing relive pain
No heart damage no biomarkers or st elevations
90% occlusion
Demand ischemia if decrease workload of heart and little perfusion reverse
Require hospital admission
4
Q
NSTEMI
A
Pain at rest
Elevated biomarkers
No st elevation
90% occlusion
Demand ischemia if decrease workload of heart and little perfusion reverse
Hospital admission
5
Q
Stemi
A
Pain at rest, no relied
Increased biomarkers
Increased st elevations
100% occlusion
Supply ischemia
Hospital admission
6
Q
HPI CAD diamond classification
A
- substernal or left sided chest pain
- Worsened wiht exertion
- Relieved by nitroglycerin
If 3/3 typical angina
2/3 atypical angina
0-1 nonanginal
7
Q
Risk factors CAD
A
DM, smoking, HTN, dyslipidemia, obesity
Family history, early MI >45man >55 woman
8
Q
Associated symptoms CAD
A
SOB
Presyncope
N.V
9
Q
Physical chest pain coronary ischemia
A
Non pleuritic
Non positional
Non tender
10
Q
When someone comes in with chest pain
A
- 12 lead EKG if ST elevation go to cath emergently
- No st elevations get troponins (troponins peak first and last if reinfarction cant recheck troponins check ckmb) reinfarction use ckmb but troponins best, if elevated go to cath urgently
- Stress test to see if coronary ischemia at all if positive go to cath electively (stress test: get HR up with exercise or pharmacology(adenosine of dobutamine) if can exercise best choice if DM foot ulcer, amputation, foot hurt, dont want to and evaluate ekg when baseline ekg is normal, if not normal use echo, if previous CA bypass grafting use nuclear ……look at normal(move under no stress and stress), at risk (move at rest and not move when stress**** this is area of positivity. and dead (doesn’t move at stress and no stress)tissue under conditions so under stress
11
Q
Why do cath
A
3+ CABG
1,2 stent
12
Q
ACS
A
MONA BASH C
Morphine, oxygen, nitrates, aspirin, bb, ace-i, statin, heparin, clopidogrel
Aspirin, BB ace-i and statin go home on
Up to u to decide if ntirates and clopidogrel
If CAD and suffering chest pain give nitrates, if get a stent get clopidogrel if drug eluding 1 year if bare metal stent 1 month if nos tent and angioplasty no clopidogrel
Ppl with chest pain get nitrates
Acute-lovenox and clopidogrel if MI heparin and clopidogrel load, if rule out dont need to do that
Morphine and oxygen -symptoms increase mortality
TPA? Not really cause not how PCI…give TPA in rural setting and stent doing cardiologist far away. Need cath with balloon inflated 90 minutes, if push TPA is 60 minutes. If transport time grater than 60 minutes TPA
13
Q
Bb
A
Reduce workload and ventricular arrhythmia
14
Q
HF
A
JVD, hepatosplenomegalt, peripheral edema , dyspnea on exertion, crackles, orthopnea and paroxysmal nocturnia dyspnea, weight gain.
Displaced PMI and S3-heart failure
Diagnose HF-BNP released when RA stretches, echo that show EF, PAP, and diastolic brings up dif between systolic and diastolic dysfunction , left heart cath to see if ischemic or non ischemic?
15
Q
Diastolic systolic
A
<55 % EFsystolic, ischemic
Diastolic big HTN and infiltration disease EF normal or elevated , HR with preserved ejection fraction
16
Q
Treat HF
A
Stepwise
1. BB ace-i/arb
Diuretic loop
Isdn-hydralazine, spironolactone
Inotropes
If EF<35% and not class four get AICD
Everyone: limit fluid to less than 2L per day keep Nacl to less than 2g a day
17
Q
How treat CHF exacerbation.
A
Chest x ray , ekg, BNP, troponins right now
If all neg not HF and consider something else
EKG and trop+ treat monabash and go to cath
If positive BNP and chest x ray and ekg trop normal CHF exacerbation-LMNOP
Lasix, morphine, nitrates, oxygen, position (sitting up )
18
Q
Grade murmur
A
1 normal S1, S2 louder than murmur
2 S1 S2=murmur
3S1S2
19
Q
Mitral stenosis:
A
Mitral valve thickened and stenosis blood backs up into atrium causing atrium dilation and blood backing up into the lungs
Path: rheumatic heart disease,
Pt: younger with CHF symptoms or afib
Diagnosis-auscultation diastolic murmur heard best at cardia apex 5th ICS mid clavicles , diastolic with opening snap, rumbling
Treat-balloon valvuloplasty can do valve replacement but dont start with that
20
Q
Aortic insuffiency
A
Weak and floppy valve allow blood to flow back into left ventricle during diastole
Lead to HF , big dilated floppy heart product of floppy valve
Path: infection or infarction, aortic dissection,
Present: acute-cardiogenic shock, flash pulmonary edema, chest pain
Chronic-CHF, chest pain
Diagnosis-auscultation in diastole, base of heart RSB 2nd intercostal space, rumbling murmur no opening snap
Treat replace valve emergently for acute if chronic it is urgent/elective and CABG so dont lose flow
21
Q
Aortic stenosis
A
Path-atherosclerosis Ca deposition
Pt old man with atherosclerosis present with chest pain, CHF or syncope , bicuspid valve may increase rate that get AS
Diagnosis: systolic murmur base of heart RSB crescendo decrescendo murmur on auscultation
Treat replacement and CABG so dont lose flow
22
Q
Mitral insuffiency
A
Path infection and infarction
Presentation acute-cardiogenic shock, flash pulmonary edema, emergent valvular replacement. Chronic-CHF, afib,
Diagnosis-auscultation heard at apex, systolic murmur, high pitched holosystolic murmur
Treat-replacement
Acute emergent chronic can be delayed before CHF and afib set in
23
Q
Valsava systolic
A
Make better
Bc decrease venous return
Increase venous return make worse
24
Q
Squatting and leg lift
A
Make systolic murmurs worse
25
Hypertrophic cardiomyopathy
Path-sarcomemere mutation
Pt young athlete with sudden death but see alive. When exercise worsen ventricular outflow obstruction and get SOB and syncope with exertion . Identify by someone in family with sudden cardiac death
Diagnosis-systolic murmur
Like aortic stenosis...more blood makes it better though.
Not old man
Leg lift squat make better
Regardless get echo and see septum
Based on age onset and response to physical exam maneuver.
Treat-avoid dehydration. And bb. Slow HR to increase filling time and maintain preload as best as can. Can’t increase HR
26
MVP
Leaflets of valve dont touch well.
Better with more blood in heart
Path: young women . Diagnosis made when hear mitral regurgitate but better with more blood (leg lift squatting) definitely by echo
Treat bb and avoid dehydration
27
Dilated cardiomyopathy
Dilate-thin and floppy.
Path virus, alcohol, ischemia, wet beri beri
Present-CHF: orthopnea, DND, DOE, crackles, edema
Diagnose: echo see dilated chambers
Treat-CHF symtpoms BB ACE-I , diuretics loop
Definitive treat transplant
Sometimes get etiology specific like alcohol or chemo and stop and hope get better.
28
Hypertrophic obstructive cardiomyopathy
Genetics, sarcomeres
Present with murmur that sound like aortic stenosis in young athlete with DOE, syncope, sudden cardiac death. Family history early sudden cardiac death
Diagnosis echo show asymmetric hypertrophy
Treat-
Definitive transplant but first medical manage
Avoid dehydration(dont get HR up maintain intramuscular volume of ventricle) stop sports, BB =CCBto increase diastole
Poor surgical candidate, etoh ablation, myectoy,AICD if increased risk of death
F/u 1st degree relatives screened with echocardiogram
29
Concentric hypertrophy
Path HTN
Pt present with diastolic CHF,
Diagnose-echo=concentric hypertrophy .
Treat diastolic CHF, avoid dehydration, rate control bb=ccb
Maybe transplant
But main goat control HTN !!!!!
30
Restrictive cardiomyopathy
```
Amyloid (ca),sarcoidosis(fibrosis), hemochromatosis
Pt DIA CHF
Amyloid->neuropathy
Sarcoidosis->pulm disease
Hema->cirrhosis, bronze diabetes
```
Diagnose echo=restrictive pattern —go for amyloid, sarcoidosis, hema
Amyloid-fat pad or gingiva biopsy
Sarcoidosis-cardiac MRI and endo cardiobiopsy
Hema->ferritin->genetic
Treat-DIA, CHF
Bb=ccb
Gentle dieresis so dont have symptoms of volume overload be careful wiht how much bc diastolic HF drop preload too much wont be able to fill
Transplant is definitive , but if can treat underlying disease
31
Pericarditis causes
Bacterial fungal, VIRAL, TB
Immune-RA, LSE, dresslers *uremia
Trauma-penetrating trauma, blunt, aortic dissection
Cancer-breast, lung cancer, esophageal cancer, lymphoma
32
Pericarditis
Anti inflammatory treatment
33
Pericardial effusion
Hemodynamics
34
Constrictive pericarditis
An atomic problem
35
Pericarditis
Path viral, uremia
Present-chest pain, chest pain pleuritic and positional
Diagnosis best is MRI, but first and only is ekg diffuse ST segment elevations everywhere and depressed PR segment
Treatment NSAIDS and colchicine*best
NSAIDS alone (dont give in CKD, thrombocytopenia or PUD)
Colchicine alone(dose limited by diarrhea)
Steroids (if have to....refractory to NSAIDs and colchicine bc recurrent s increases for viral )
Or if uremic-hemodialysis
36
Pericardial effusion
Fluid and cause SOB
Pericarditis symptoms
Diagnose echo see fluid
Treat-pericarditis treat
F/u refractory may need to do pericardial window
37
Pericardial tamponade
Present with CHF symptoms fluid pushing on heart RV weak and easily crushed right sided HF see JVD and hypotension and decrease heart sounds —-this is becks triad for tamponade
Clear lungs
Clinical diagnosis-pulses paradox is >10...
Diagnosis-clinical
Treat-pericardiaocentesis dont wait
F/u give IV fluid increase preload push open ventricle to get BP up...in life right if cant get to OR fast enough..not for test
38
Constrictive pericarditis
Path pericarditis
Pt dia CHF pericardial knock
Diagnosis echo
Treat pericardiectomy
39
MAP
COxSCR
40
CO
HRxSV
41
SV
Contractility x preload
42
Vasovagal
Visceral organ stimulation
Carotid bodies-ties too tight
Psychogenic
Situational and reproducible
Diagnosis-tilt table test
Treat beta blockers
43
Orthostatic
Path volume decrease,
AnslDm, Parkinson’s, age
Pt orthostatic
Systolic change 20, diastolic change 10, HR change 15
Treat give fluids
44
3a syncope
Path valve
Pt exertion all syncope
Diagnose echo
Treat lesion dependent
45
Arythmia syncope
Sudden
No prodrome no warning
Diagnosis ecg
24 hour holster
Event recording
Treat arrhythmia specific
46
4 syncope neurogenic
Posterior circulation. Poor flow
Sudden no prodrome
+FND
Diagnose carotid US but best test CT angiogram
Treatment treat vascular disease
47
Cholesterol treat
1. lifestyle
2. Adherence
Statin-1.anyone with vascular dz(MI, CVD, PVD, Carotid stenosis), 2LDL>190, 3. LDL 70-189 get statin if have DM and 40-75, 4. LDL 70-189 40-75 and high calculated risk (HTN, smoking, obesity, age>45 man >55 woman, family history)
48
High intensity statin
Actorvastatin 40-80
Rosuvastatin 20-40
49
Moderate intensity statin
Atorvastatin10-20
Rosuvastatin 5-10
Simvastatin
20,40
Pravastatin
Lovastatin
50
Low intensity statin
Simvastatin5,10
Pravastatin10,20
Lovastatin 20
51
Everyone should be on
High intensity
But ppl go on moderate intensity age>75, statin intolerance, liver and renal disease
52
Before start stain
Lipid panel
A1C
CK
LFT
53
Routine assessment statin
Lipids 1 year
A1c if diabetic
Do not routinely check ck or lft but check when develop symtpoms like muscle soreness weakness, pain check CK UA
If hepatitis symtpoms check LFT
54
Statin induced myositis or hypotension
Stop statin
| Then restart at lower dose
55
If LDL<70 and no disease
No statin
56
Statin
Decrease LDL and TG
Myositis and LFT prob
57
Vibrates
Decreases TG and increases HDL
Myositis and increase LFT
58
Ezetimibe
Decreases LDL
Diarrhea causes
59
Bile acid resins
Decrease LDL
Diarrhea
60
Niacin
Increases HDL decreases LDL
Flushing->ASA
61
Normal BP
<120 <80
Treat follow up every year
62
Elevated BP
<130, <80
Treat lifestyle and follow up 6 monthsmodificaitons
-eating (<2.4 g nacl a day, DASH diet, K supplementation but not in CKD or ends that cause hyperk use citrus fruits alcohol less than 2 for men and 1 for women)
, exercise(30 minutes a day, 2 hours a week)
, weight loss (BMI>25 should lose weight
63
Stage I HTN
<140, <90
Treat lifestyle modification
And if risk over 10% start a med, if under 10 try lifestyle and check up 3 months. When start med come back oil one month
Side note HTN 2 readings 2 weeks apart 2 visits and home bp monitoring
64
Stage 2
>140 >90
Treat Lifestyle, 2 meds
Come back in a month
2 readings 2 weeks 2 visits home monitor
65
Urgency
220 120
IV medications followed up by own orals
66
Emergency
220 120 and end organ damage
And signs troponins chest pain, SOB
Drip and toe to ICU need 25% reduction in MAP 2-6 hours
67
Heart failure and CAD with HTN
BB ACE-I
metoprolol carvedolol and nebivalol for hF and cAD
68
Stroke and HTN
Combination ACE-i and thiazides recommended
69
CKD and HTN
Ace/arb except if stage 4
70
DM
ACE-i....if amicroalbumineria
71
No other disease besides HTN
Any
| Pick one thiazides, ACE or CCB and if all have is HTN risk of too much med not worth benefit
72
Ccb
Peripheral edema
```
Anti angina (CAD wiht chest pain)
Not useful in HF with reduced EF
```
73
ACE ARB
Both increase Cr(20% ok) can increase K, only ace I cause angioedema and dry cough.
Treat do use use arb after ace induced angioedema
74
Thiazides
Distal collecting duct can decrease K and can be used to decrease urinary Ca to treat kidney stones
Sulfa but no cross reactivity
75
Beta blockers
Decrease HR
HF with reduce EF and CAD
76
Aldosterone antagonist spironolactone and epleronone
Can cause hyper K , spironolactone causes gynecomastia
Used for resistant HTN and hyperaldosterone or CHF class 3
77
Hydralazine ISDN (dilators)
Reflex tachycardya
(DIC)
No use with nitrates or PDE-5 inhibitions
CHF class III
Nitrates are antianginal can be used for CKD , CHF
78
A antagonist
BPH dont control BP cause rthostatic hypotension
79
Don’t use meds
Central acting clonidine(causes rebound HTN can be avoided wiht transdermal patch)
CCB dilitazem for afib and rate control problems only afib
80
Tachycardia QRS wide narrow
Narrow afib, SVT
Wide tornadoes, Vtach
81
SVT treat
Adenosine
Shock
No p waves HR>150, regular , narrow complex
82
A fib
Shock unstable
BB CBB stable
No P wave irregularly irregular
HR<150, chaotic background
Sawtooth
83
Torsades
Mg shock
Sine wave
84
V tach
Amiodarone stable
Shock if not
Monomorphic
85
If unstable
Shock
If stable use drug
86
A fib comes in
1. Stability? Unstable SHOCK
2. Stable? Rate control with CCB verapamil dilitazem=BB
.......if present for less than 48 hours it is new and goal is cardio version
Onset >48 hours or unknown it is old. Can’t be cardivoerted right now. 1st do TTE to decide if structural valvular or non valvular
If coal is cardioversion have to anticoagulation for 3 weeks then do TEE and while there do some form of cardioversion pharm or electrical then anticoagulation for a month usually with warfarin
87
A fib stroke
```
CHF
HTN
AGE>75
DM
Stroke (gets 2 points rest get 1)
2
```
If enough high to need anticoagulation
0 aspirin alone
1 aspirin and anticoagulation
2 or more get anticoagulation (warfarin wiht INR2-3 or novel oral anticoagulant dabigatral apixaban) see if wanna have frequent lab draws for INR or convenience to other with limited access to resolve bleed reversible...usually choose warfarin in valvular disease must choose warfarin in non valve can do novel or warfarin...in valvular must bridge with LMWH
88
Slow bradycardia QRS wide narrow
Wide tertiary IV
Narrow. Sinus Brady, primary secondary I and II
89
Slow rhythm
Pace
Atropine for narrow, but not type II and NOT wide
90
1st degree
Prolonged PR interval no dropped beats
91
SecondaryI
PR prolonging with droop
92
Secondary II
PR prolonged random drops
93
Third degree block
Wide p waves and QRS not associated but
94
ACLS +pulse
Is there an arythmia -sinus tach, NSM
Symptomatic? No-IVF O2 and monitor. Yes-stable? Yes , unstable (systolic<90, CD, SOB, AMS )
Unstable-electrocitiy, fast-shock, slow=pace
Stable-drugs fast wide (vtach)-amiodarone, fast narrow-adenosine, slow atropine prepare to pace
95
A fib , flutter
Controlled with bb or ccb (verapamil or dilitazem)
If CHF have to avoid bb and cbb give amiodarone
96
No pulse
2 min CPR then pulse rhythm check and shock, 2 min cpr check shock 2 min ....shock....until decide to stop.
Alternating epi and amiodarone......
Can shock VT/VF
Can’t shock PEA asystole
Epi , absent, epi absent , epi absent.
CPR is right answer on test only time shock is Vtach/Vfib
97
Asthma
Path-bronchoconstriction and inflammation
Obstructive, ige
Present-wheeze, sob, cough
Atopy, allergies
Decreased lung sounds, hyperresonance
Diagnose-pft fev1/fvc down
Methacoline test
Treat-saba, Laba, ics, leukotriene antag
Cromolyn or nedocromyl for athletic asthma
98
I-IV asthma
Know
99
What do if meds aren’t working
Watch use inhaler see how they are using
Use.a spacer
Medication adherence
100
Asthma exacerbation
Oxygen pulse ox over 90
Ipratropium and albuterol
Steroids
Assess peer
101
Effusion
See on chest x ray
Thoracentesis-if see malignant cells have cancer
-if positive it is stage 4
102
If suspect lung cancer from chest x ray
CT scan
- stage with PET-CT or biopsy?
- get PFT bc probably will do surgery
- then can treat with chemo radiation or surgery
* stage and PFT before treatment
Biopsy:
- EBUS=bronch for large proximal lesions
- CT guided percutaneous biopsy for outside
- video assisted thorascopic surgery for inside lung
- can diagnose with resection
103
If no mass on CXR can u have cancer
Ya
104
Primary prevention lung cancer
Stop smoke self and 2nd hand
105
Screen lung cancer
Low dose CT scan every year between 55 and 80 with 30 pack year history and quit <15 year ago
106
Nodules on low dose CT. Is it cancer
Look at size: <8mm no cancer >2cm cancer
Surface: smooth not cancer. Speculated surface cancer
Smoking: no smoking not cancer history of smoking cancer
Self (age): <45 not cancer >70 cancer
Calcified not cancer
107
What do if find pulmonary nodule
Look at old films
-no change for 2 year stable dont do anything for
-New or change is unstable.
If low risk do serial CT, if high risk do biopsy
108
Small cell
From smoking
Centrally trachea bronchus
ACTH Cushing or SIADH
Treat chemo and radiation-VERY SENSITIVE...not surgery
109
Squamous cell
Smoking
Centrally located trachea bronchus
Parathyroid hormone related peptide hypercalcemia
Stage chemo radiation resection
110
Adenocarcinoma
Non smokers
Exposed to asbestosis
Peripheral
No paraneoplastic
Surgery chemo rad based on stage
111
Carcinoid
Serotonin related
Anywhere
Serotonin syndrome-begins in lung so no metabolism. LEFT SIDE FIBROSIS flushing wheezing diarrhea
Get5HIAA in urine
112
Pleural effusion trans update exudate
Transudate caused by fluid falling out of capillary space hydrostatic pressure or loss of oncotic pressure nephrosis, gastrosis, cirrhosis.
Exudate-stuff in space malignancy, pneumonia, TB
Diagnosis: CXR blunting of costophrenic angle see horizontal meniscus as well not sure if hemothorax, chylothorax, of pleural effusion ....get thoracentesis
113
Someone comes in with pleural effusion or see on CXR
1. Get imaging (****** cheapest is lateral decubitus x ray, US, CT scan) to I find out if can thoracentesis or have to surgery
- if <1cm too small and watch and wait
- septations lobes it is loculated start with thoracostomy(chest tube) can use TPA in there. If this fails need to do thoracotomy
- has CHF dont do anything just diuresis
- no CHF or diuresis fails then do thoracentesis and dont have exclusion criteria.
114
Transudate vs exudate
Lights criteria
LDH
LDH fluid/LDH serum
Total protein fluid/total protein serum
```
LDH >2/3 upper limit normal
>.6
>.5
Any one of these it is an exudate
All of them to be negative to be a transudate
```
115
Tube 1-4 of thoracentesis
1-cell count with diff
Looking for pneumonia , TB (PMNS)or malignanyc(white cell with lymphocytes) hemothorax or cancer (rbc)
2-cytology malignant stage 4
3-glucose, pH, total protein, LDH, Adenosine demaniase(TB0)**, triglycerides*chylothorax)
4-gram stain and culture looking for bacteria fungi and TB
116
DVT
Vircows triad-venous stasis, hypercoagulability(factor 5, bcp, HRT), endothelial injury(smoking or placing lines)
Presentation- unilateral Fluid from leg cant get out distal to clot see edema
Diagnosi US
Treat-anticoagulation
117
PE
Wedge infarct
Necrosis:hemoptysis
Ischemia: chest pain
Pulm HTN: heart strain
100% ventilation 0% perfusion=V/Q mismatch -> hypoxemia
Prostaglandin mediators causes vasodilation and fluid to lead out and larger diffusion barrier for oxygen. Oxygen is diffusion limited
So oxygen falls
CO2 is perfusion limited to this doesn’t effect.
PE=oxygen levels fall so increase CO and have tachycardia and tachypnea which drops CO2 and pH will rise
Decreased CO2, decreased O2, increase pH on ABG
118
Chest X ray PE
Normal unless wedge infarct
119
Ekg PE
Normal maybe s1q3t3 -sign of Right heart strain
| Sinus tach
120
What do if have signs of PE
```
Wells criteria
<2 not a PE get d dimer
D dimer low no PE
>4 CT
>6 ula
```
So if probability high we will diagnose PE with spiral CT, CT angiogram is best test*************** but if do contrast must have normal kidneys bc if Cr elevated cant get it.
If cant get contrast can use V/Q scan can be done with abnormal kidney but require there be a normal chest x ray
121
Treat PE
Anticoagulation
-heparin Warfarin bridge
Or
-novel oral anticoagulants(dabigatran, apixiban dont need bridge)
IVC filter NOOOOO one indication is placed for DVT where next PE will kill and contraindication to anticoagulation-GI bleed and DVT put in but once bleeding risk gone go on anticoagulation.
Tpa-use in massive PE with hypotension unless heparin warfin bridge or NOAC.
122
Obstructive lung disease
Asthma kids, COPD adult(genetics and smoking)
COMPD=emphysema and bronchitis
123
Emphysema
```
Increased CO2 retention
No change in O2 or cyanosis
Increased AP diameter
Prolonged exhalation
Pursed lips
```
124
Bronchitis
Inflammation airways, decreased oxygen=hypoxemia and cyanosis
R CHF
Edema
Blue color cyanosis and edema* blue bloater
125
Diagnosis COPD
PFT=decreased FEV1/FVC decreased FEV1 and no reversibility
126
Treat COPD
SABA then add LAMA then add LABA(include corticosteroids before adding LABA or die if asthma but fine copd) then add ICS add PDE-4 then add steroids
127
Treat copd
Corticosteroids
Oxygen if <88 (goal 88-92) paO2<55
Prevention-flu pna vaccnie, smoking cessation
Dilators- saba, laba, lama, orals
Rehab
Smoking cessation and oxygen prolong life
128
Signs copd exacerbation
Wheezing, cough, sputum
Get CXR, ABG, and ECG
129
Treat copd exacerbation
Antibiotics-doxycycline(teeth), azithromycin (QT so ekg before)
Bronchodilators-albuterol, ipratropium
SteroidsPO prednisone IU methylprednisone
Home-
ICU-IV steroids, NEB, bipap, ETT
Ward-PO, NEB
Home-PO, MOI
130
Ards
Present-sick as shit, hypoxemic-septic shock, acute lung injury, near drowning
P/A<200
Diagnosis-chest x ray pulmonary edema
*note may compare CHF to ARDS with PCWP (elevated in CHF and decreased in ARDS) and LV function(BNP, echo)(fluid back up in pulmonary veins causes fluid to leak out decreased in CHF and elevated in ARDS)
Treat ARDS-intubation TV low and RR high. Oxygen use PEEP to increase oxygen. And treat the underlying disease
131
DPLD interstitial lung disease
Path variable
Present-chronic insidious, hypoxemia, dry cough, dry crackles, restrictive pattern
Diagnosis-chest x ray=reticular NODULAR may start
Best for diagnosis ig is high resolution CT with ground glass opacities
PFT see restrictive FEV1/FVC
BEST test-video biopsy ..diagnosis made on pathology
Treat-steroids and prognosis poor anti inflammatory meds may be benefit like DMARDS and biologics but not well studies. Steroids
132
Idiopathic
Acute<6 weeks have acute interstitial pneumonitis
Chronic >6 months idiopathic pulmonary fibrosis
133
Drug induced DPLD
Bleomycin, amiodarone , radiation
134
Rheumatologist disease DPLD
SLE, RA, systemic sclerosis can cause pulmonary fibrosis
135
Exposures
Asbestos
HP
Pneumocon-silicosis, berylosis, coal.
136
Sarcoidosis
Path AI, female black
Patient-asymptomatic hilar LA, hypoxemia insidious, heart block, Bell’s palsy, erythema nodosum
Diagnosis-chest x ray bl hilar lymphadenopathy central and bl
High resolution CT see ground glass
PFT =restrictive pattern then biopsy see non caseating granulomas
Treatment with steroids
Need cardiac MRI to identify f/u in cardiac
137
Asbestosis
Path: in lung and hangs around increases cancer risk from shipyards and construction. Need 30 years of more of exposure.
Pleural plaques on x ray or diagnose mesothelioma chances are has asbestosis
Diagnosis: imaging
Biopsy see asbestosis barbell bodies
Treat-stop smoking
138
Silicosis
Sandblasting and rock quaries
Upper lung nodules looks like TB rule it out with TB test
139
Berylliosis
Aeronautics industry
| Electronics
140
Coal miners lung
Coal miner
Arthralgias and pulmonary fibrosis-caplan syndrome
Hypersensitivity pneumonitis-bird fanciers antigen mediated person who goes to work during work week then goes on vacation and goes away takes 24-48 hours to set in but 24-48 hours to go away
Regional or temporal DPLD go to work get sick come back and then they’re not.
141
Pemphigus vulgarisms
Desmosomes desmoglein
Nikolsky+
Oral mucosa
30-50
Diagnosis-biopsy show thin walled blister with cells all over the place
IF throughout slide
Treat-steroids high dose transition to mm or rituxinab
142
Pemphigoid
Hemidesmosomes
60-80
Thick wall no nikolsky sign
No oral mucosa
Diagnosis-biopsy intact epithelium IF-basement membrane light up
Treatment0steroids systemic if widespread or topical if local
143
Celiac spruce /dermatitis herpetiformis
IGA deposition in dermis
Vesicular extensor surface on butt
Look for celiac symptoms
Diagnosis-biopsy show neutrophils abscess...get antitransglutaminase and anti endomyoseal
Egd-biopsy small bowel
Treat by removing gluten
144
Porphyria cutaneous targa
Uroporphyrinogen
Blisters on sub exposed areas
Hairy people and easy blistering Dorsum of hand
Diagnosis wood lamp turns coral red
Treatment stay out of sun
F/u hep c, hemochromatosis , recent start bcp
145
Seborrheic dermatitis
Autoimmune maelezzi sp
Present rash and scales flakes
Hair=rash
No hair-no rash
Redness flying eye brows and scalp
Diagnosis clinical
Treat selenium shampoo
F/u cradle cap
146
Psoriasis
Autoimmune =t helper cells
Present erythematous patch silver scale bleeds when picked
On extensor surfaces and gluteal fold
Nail pitting with holes in it
Oncholysis separation of nail from nail bed
Diagnosis clinal
Treatment *UV light and topical steroids
F/u biopsy lesion to rule out lymphoma if thrown together
Joint symptoms consider seronegative arthropies
147
Pityriasis rose a
Path unknown
Self limiting Harold patch salmon covered
Trailing scale
Scaling never reach the end
Spares the palms and soles
If involve palm and soles-syphilis
Diagnosis clinical
Treat-self limiting
148
Lichen planus
Purple papules raised on top of it Lacey network of white lines
Diagnosis-clinical
Treatment -topical steroids
Can use adjunt UV light(mainly for psoriasis)
Keep eye out for medication change may be med induced
-ace i thiazide loop diuretics
149
Atopic dermatitis
Allergies
Asthma
Atopy
Present kids-antecubitous fossa and diaper line vesicles and crusts look like impetigo
Adults-symmetric ilchenification in ac fossa, popliteal fossa and on extensors
Diagnosis-clinical
Treatment avoid a trigger, emulsions,
Steroids
150
Contact dermatitis
Type 4 hypersensitivity
Present poison ivy hiking or shape of an object like hand had close on
Clinical diagnosis
Treat avoid trigger
Topical diphenhydramine to stop itching
151
Stasis dermatitis
```
Peripheral edema stretches skin
Present with edema
Erythematous eventually it darkens
Wood changes look like tree bark hard
Always lower extremity
```
Diagnosis clinical do not biopsy
Bc poor venous circulation
Treatment get fluid out of legs with diuretics or compression stalkings or elevating the legs
F/u may mistake for cellulitis if see lower extremity swollen and red may think cellulitis but if bl it is stasis
Associated with maleolar ulcers
152
Hand dermatitis
Too much hand washing
Health care workers or food industry
Diagnosis clinical
Treat protective gloves instead of hand washing and avoid harsh soaps
153
Urticaria
Type I
IgE cross links mast cells
Release histamine
Capillaries dilate get leaky and leak out proteinacious fluid and see whealpresnt annular red papule does blanch when push on it
Bee sting can do it with out cross link
Histamine
Diagnosis-is there anaphylaxis? Look for hypotension in response to allergic reaction in this case IM epinephrine if no treat normally
Treat steroids and antihistamines H one and two blockers unless anaphylaxis
154
Drug reaction
Presnt: pink morbilloform rash symmetric and often widespread 7-14 days after starting a medication
Diagnosis clinically
Treat-remove the offending agent
Can use antihistamines and steroids
F/u fixed drug eruption: same rash in same place every time give medication-its ok not a contraindication
155
Erythema multiform
Path immune complex mediated
Present targetoid lesion knees palms face fingers
Lyme disease and syphillis and hsv or drug reaction if see targetoid
Diagnose clinical
Treat topical agents like steroid
F/u syphilis chronic HSV? First thing on broad spectrum of SJS and TEn
156
SJS/TEN
Present skin sloughing off
Positive nikolsky sign and looking poorly
SJS-basal layer, dusky, can mirror EM
Less than 10%
TEN-full thickness , sloughing, sheets of skin fall off , greater than 30%
Diagnosis-biopsy
Treat-stop all meds move to burn unit and pray
F/u oral and optho involvement can go blind
157
Drugs that cause reactions
Sulfa
Penicillin >cephalosporins
Antiretrovirals
Anticonvulsants
158
Scalded skin syndrome
Staph infection attacks desmosomes
Patient infant
With. Febrile illness sloughing of skin starts in skin folds
Diagnosis clinical
Treatment nafcillin
159
Mole
Benign lesion from melanocytes
```
Present:hair in mole benign
Asymmetry
Borders
Color
Diameter >5 mm
Evolving
```
Diagnosis clinical
Treat cosmetic
160
Seborrheic keratosis
Benign keratinocytes
Present large greasy stuck on look
Diagnosis long time-Clinical
New changing then must biopsy
Treat cosmetic
161
Actinic keratosis
Premalignant lesion of keratinocytes
Present-erythematous lesion with sand paper like scale yellow to brown and sand paper scale
Diagnosis biopsy
Treat cryoablation, 5-FU
162
Squamous cell carcinoma
Malignant keratinocytes
Flesh colored ulceration
Sun exposure
Diagnose biopsy
Treat resection
Unlike basal can metastasize
Lower lip 90% of the time
163
Keratocanthoma
SCC resolves in 6 weeks biopsy
164
Kaposi sarcoma
HHV8
Immunosupprssed aids, purple lesion very vascular
Diagnosis clinical
Treat retroviral HAART and lesions go away
If dont local or systemic chemo
165
Tinea versicolor
Fungus malezzia
Scaly macules with varying color
Areas that don’t tan
Diagnosis KOH prep spaghetti and meatballs dont need to do biopsy.
Treat selenium shampoo or ketokonazole
166
Vitiligo
Autoimmune destruction of melanocytes
Sharp demarcation patches completely white
Complete depigmentation
Diagnosis woods lamp test
Biopsy see no melanocytes
Treat high potency topical steroids for local
Extensive disease UV light
167
Albinism
Autosomal recessive
Tyrosinase activity is low
Completely depigmented
Patient white
Hair is fair
Eyes are fair
Skin is fair
Diagnosis clinical
Treat prevention keep out of sun
F/u piealbinism
Melanocytes migration or white forelock know that is piealbinism
PKU white kid mental retardation funny smell give special diet
168
Ash leaf
Congenital hypopigmentation patches ash leaf
Shagreen patches
Tuberous sclerosis
Diagnosis woods lamp hypopigmented
CT scan see tubers of brain
Treatment mental retardation seizures and likely die young
169
Male androgen allopecia
Path: 5-DHT hair follicles miniaturize become friable and fall
Circular patch grows out from crown
Diagnosis clinical
Treatment minoxidil and finasteride
170
Alopecia areata
Autoimmune destruction of hair follicle patch well circumscribed but can be anywhere patch
Exclamation point
Diagnosis clinical
Treat steroids
171
Tinea capitis
Fungal infection
Well circumscribed patch of hair loss all hairs equal in length
Diagnosis -trichophyton KOH prep to see the fungus
Treat-start with oral griseofulvin
172
Traction alopecia
Pulls hair too tight
Look for woman brain / pony tail
Diagnosis clinical
Treatment preventable nut irreversible
173
Trichetillomania
OCD PTSD
Woman pulling on hair compulsionto relieve stress
Hairs are different lengths if shave all hair follicles will grow different lengths
Diagnosis clinical
Treatment more OCD treatment med and counseling
174
Chemotherapy
Anagen growth phase of hair
Catogen regression of hair
Telegenic resting phase
Exogen shedding phase
In chemo anagen turns it to exogen shedding phase Or anagen to telogen too small and rushing exiting growth cycle too soon
175
Impetigo
Strep
Kids
Honey crusted lesion on face
Diagnosis clinical
Treat amoxicillin
-clinda if refractory of allergic
No risk rheumatic fever, can cause glomerulonephritis
176
Erisypelas
Strep
Adults dark red well defined indurated
Diagnosis clinical
Treat amoxicillin
177
Acne
1. Topical retinoids for comedones
2. Add benzoyl peroxide if inflamed/pustules
3. doxycycline for severe
4. Isotretinoin for refractory disease first get urine pregnancy test
178
Tinea
Fungal infection
Foot-tinea pedis/athletes foot.
Tinea-pruis-groin
Pedis and pruis treated with topical antifungals
Coropris-boys central clearing treated with topical antifungals
Oncychomycosis and tinea capitis use oral terminating for onychomycosis and griseofulcin for tinea capitis
Confirm oral antifungals with KOH prep if need oral
179
Esophagitis
```
Path: biopsy piece
Pill
Infectious
Eosinohpilic
Caustic
E-gerd
```
Preset-odynophagia, dysphasia
Diagnosis-endoscopy with biopsy
Treat-disease specific , some sort of anti acid -PPI* or H2 blocker
180
Pill induced esophagitis
| Motility
Pill stuck
NSAIDS, antibiotics (tetracyclines), bisphosphate, HIV meds HAART
Present-esophagitis
Diagnosis-endoscopy with biopsy
Treatment-egd remove pill
Remove offending agent and give time to heal and give PPI
F/u avoiding and drinking full glass of water with each pill
181
Infectious esophagitis
| Motility
Candida-oral thrush fluconazole(esophagitis) nystatin for just oral
HSV-see oral lesions treat wiht valcyclovir or acyclovir
CMV-biopsy valgancyclovir or agalcyclovir
HIV-opportunistic infection
Present: esophagitis
Diagnose:endoscopy and biopsy
Treatment :some antibiotics corresponding to each organism
182
Eosinophilia esophagitis
Path: allergic reaction to food causes eosinophilia in esophagus
Present: asthma, allergies, atopy
Diagnosis:: EGD and biopsy>15 eo per hpf.
Treat give PPI trial bc gerd can cause 1st step is treat gerd
If rial fails use oral areosolized steroid
183
Caustic
Path: kid (accident) adult(suicide)
Strong acid or base
Present: larynx-hoarse voice stridor(if stridor intubate)
Esophagus-drooling
Diagnosis-endoscopy with biopsy to determine the severity
Treat low severity-liquid diet and observe
High severity-strictures and necrotic black esophagus keep npo for 72 hours and repeat EGD to see if ready to have for
If catch early on do NG tube lovage flush after suck it out flush water flush it out (if burn on skin flush it)
F/u never neutralize the pH will cause thermophilic reaction and burn. And never induce emesis bc give a second pass of esophagus and larynx a second pass
184
Dysphagia
Motility-foods and liquids not progressive , functional
Diagnose barium
Manometry
Best EGD with biopsy
Mechanical-progressive foods->liquids, obstruction
Diagnose barium
No manometry
Best EGD with biopsy
185
Scleroderma
| Motility
Collagen deposition LES cant contract
```
Presnt Crest (anticentromere)or SS (anti scl70 or anti topoisomerase)
Relentless GERD bc no LES
```
Diagnosis -barium then with manometry and endoscopy with biopsy.
Treat PPI
F/u serology fir SS
186
Diffuse esophageal spasm
| Motility
Contractions of esophagus
Present MI pain from muscle contracting hard.
Diagnosis r/o acs (troponins ekg stress test if factors)
Barium manometry and endoscopy with biopsy
See corkscrew esophagus
Treat CCB->nitrates as neeed
187
Schatzki ring
Ring at GE Junction
Present steak house dysphagia
Diagnosis barium lumen narrowed at GE junction
EGD biopsy
Treatment-lyse
188
Weber
Plummer Vinson
Woman dysphagia, iron defiency, anemia, webs, esophageal cancer
Diagnosis barium swallow see webs
No need EGD with biopsy
Treat-give iron, and do EGD wiht biopsy (screening tool for cancer)
Don’t do esophagectomy to stop cancer, still have risk of cancer have to screen with EGD and treat esophageal cancer when it comes
189
Zenkers diverticulum
Diverticulum
Present old men with halitosis, regurgitation of UNDIGESTED food
Diagnosis-barium then EGD with biopsy
Treat surgery
190
Stricture
Path: GERD
Bottom third of esophagus
Present GERD, dysphagia, weight loss
Diagnosis: barium =symmetric circumferential loss of lumen
Treat-PPI, dilation to open esophagus
191
Cancer
Adeno: GERD bottom third
SCC-smoking alcohol top third
Present: GERD, dysphagia, weight loss
Diagnosis: barium=asymmetric
Treat-chemo/radiation and surgery depending on the stage
192
GERD
Path: acid LES weakness esophagitis
Present: typical:burning chest pain worse when laying down and by spicy foods improved by sitting up and antacids
Atypical:hoarseness, coughing, stridor, nocturnal asthma
Diagnosis:PPI trial and life still for 6 weeks . EGD and biopsy, 24 hour pH monitor best to tell acid coming up
If alarm symptoms skip PPI and jump to endoscopy.
Treat-GERD-PPI
Metaplasia-increase PPI dose high dose
Dysplasia-local ablative therapies-cryo, ablation, rfa
Adenocarcinoma-stage and resect
F/u surveillance EGD
193
Barrets
It’s metaplasia
194
Pt comes in with signs and symptoms of GERD
PPI and lifestyle for 6 weeks-if work keep on low dose PPI
Fail to improve or alarm symptoms(n/v, anemia, weight loss)-EGD with biopsy-
GERD-PPI
Metaplasia(barrets)-high dose PPI
Dysplasia-local ablation and PPI
————for both keep doing endoscopy surgery for change. Metaplasia gerd every 3 years, metaplasia dysplasia every year
Adeno-staging and resection advanced gets chemo and radiation
195
Nissen fundoplication
Surgery for gerd? Can’t tolerate PPI
196
5 etiologies of PUD
H pylori-single ulcer
NSAIDS-shallow and multiple
Malignancy -big heaped up margins and necrotic centers
Curling-burn patients
Cushing -increased ICP, ppl on steroids and ventilators...use gut prophylaxis feed as early as possible or PPI
Gastrinomas -refractory ulcer multiple with diarrhea
Present:GI bleeding, perforation, gastric outlet obstruction, for 20% asymptomatic
80% gnawing epigastric pain worse when eat-gastric if better duodenal
Diagnosis-biopsy and EGD
R/o malignancy, h pylori and give look at ulcer
Treat stop smoking and stop drinking stop NSAIDS , PPI
197
Signs symptoms PUD pt come in
EGD and history suggest NSAIDS-stop them and PPI bid for 9 days
EGD biopsy suggest cancer stage and treat
EGD biopsy h pylori-triple therapy . PPI, clarithromycin, amox
EGD biopsy-just ulcer-treat wiht PPI
198
H pylori
Maltoma one percent
Dyspepsia 15%
Diagnosis-serology- test and treat have to previously not been treated and currently have symptoms, if have positive serology just treat but no longer useful if been treated
Urea breath -good for initial diagnosis has to be off PPI and most of time use serology or endoscopy
Stool ag-eradication, after treated make sure its gone
Egd and biopsy-BEST
Treat-triple therapy clarithromycin, amoxicillin, and PPI
199
Selling ear Ellison
Gastrinoma, decreased gastric pH
Present with big virulent and refractory ulcers sometimes with diarrhea
Diagnosis: gastric <250 is normal
>1600 dont need to additional test its gastrinoma
250-1600—do secretin stimulation test
So to somatostatin receptor sintography-wherever these receptors
Treat-resection
F/u-watch for malignancy
200
Gastroparesis
Path; stomach fails to empty idiopathic usually or diabetic
Present-chronic n/v, abdominal pain especially with eating, if diabetic peripheral neuropathy
Diagnosis-egd to r/o other diseases
Do an emptying study have eat radoitracer take pic at 0,2,4 hours
>60% 2 hr
>10% at 4 hours
But to do this study must be off opiates, anticholinergic, and have good blood glucose control
Treat-avoid opiates, anticholinergic, and control blood sugars
Pro kinetic agents-metoclopramide oral, erythromycin IV, low fiber small volume meals
201
Cyclic vomiting syndrome
Path THC
Present habitual marijuana n/v and cycle vomiting
Diagnosis clinical
-egd to r/o and emptying study
Treat-stop THC
In acute flare metoclopramide erythromycin
Both can be oral or IV
202
Gastric adenoma
East Asia nitrites
Present-early satiety, weight loss, weight loss
Diagnosis egd and biopsy see signet
Pet ct pan ct to stage
Treat resectiona nd chemo dim prognosis
203
Acute diarrhea <2 weeks
Enterotoxic-watery diarrhea, without fever, without leukocytosis , no fecal leukocytes.
-c diff, enterotoxic E. coli, vibrio c, staph aureus, bacillus c, giardia
Invasive-bloody, fever, leukocytosis, fecal WBC, lactoferrin proves invasive
-salmonella, shigella, enterohemorrhagic E. coli o157H7, campylobacter, a. Histolytica
204
Etec
Central America, travelers diarrhea
205
Vibrio c
Third world countries no boiling water
206
S aureus
Protein food, toxin picnic with egg salad potatoe slaw
207
B cereus
Reheated rice
208
Giardia
Fresh water camping
209
Salmonella
Chickens raw eggs, uncooked poultry
210
Shigella EHEC
HUS
Coli-uncooked meat
211
Campylobacter
Most common bloody diarrhea,
212
A histolytica
HIV/AIDS or severe immunodefiency
213
Acute diarrhea most common cause
Usually viral-just rehydrate and wait
PO>IV
Can use loperamide
214
Red flags that acute diarrhea need help
High fever >104, severe abdominal pain , immunocompromised, recent antibiotic use, hospitalized, bloody, electrolyte derangement, greater than 3 days,
215
C diff + first thing do
Treat metronidazole oral, vancomycin oral, both, fidaxomycin PO, fecal transplant
216
If c diff negative
Stool WBC and stool rbc
+ rbc and wbc, it is invasive and want to get a stool culture and a colonoscopy.
Stool culture+ and colonoscopy negative=infection give antibiotics
Stool culture - colonoscopy + medical disease—chronic
- wbc - rbc it is enterotoxic
OTP + parasite antibiotics
OTP - just viral and treat symptomatically and rehydrate
217
C diff
Path-overgrowth of c diff from antibiotics patient presents with watery diarrhea with smell
Diagnose-get c diff NAAT**
Colonoscopy pseudo membrane-DONT DO IT
Treat-oral metronidazole=oral vancomycin but pick metro bccheaper
2nd give same
3rd time fidaxomycin
Refractory-fecal transplant
Vancomycin is right answer if also hav fever, leukocytosis megacolon, and renal failure (BUN Crup) severe c diff give oral vancomycin and metronidazole IV
218
HUS/TTP
Path-EHEC o157H7
Present bloody diarrhea after eating uncooked meat
Renal failure
Anemia
Diagnosis-blood smear confirm micro angioplasty is see schistocytes
Get shiva like toxin assay
Treat-supportive
Plasma exchange
219
Secretorys
Normal osmolality gap, normal fecal WBC< no fearless RBC, no mucous, no change NPO, POSITIVE NOCTURNAL SYMPTOMS< no fecal fat
220
Osmotic diarrhea/malabsorption
Elevated osmolality gap
No wbc, no red, no mucous
Positive change with NPO
No nocturnal symptoms
Fecal fat + if malabsorption not if just osmotic
221
Inflammatory chronic diarrhea
Rbc, wbc, mucous->straight to colonoscopy
222
Stool osmolality gap
Measured osm-calculated OMM
290- 2x(na+K)=<50=secretory
>100=osmotic
223
Chronic diarrhea greater than 4 weeks
```
Laxative abuse
Medications
Lactose intolerance
C diff
Celiac spruce
```
Get fecal wbc, rbc, fearlessly fat, NPO to separate into secretory or inflammatory or osmotic
224
Secretory
Normal tests
Hormone (VIP level) secreting tumors, get hormones, EGD with biopsy, also get c diff
225
Inflammatory
Colonoscopy with egd
226
Osmotic
H and P egd with biopsy D2 specific
227
VIPoma
Path tumor secretes VIP tells intestines to go
Chronic diarrhea
Diagnsosi_VIP level and resection is treatment
228
Ze
Gastrinoma
Present virulent PUD and diarrhea
Diagnosis-gastrin level if less 250 r/o over 1600 have, in between secretin stim test if positive use somatostatin receptor sintography
Treat resection
229
Carcinoid gut
Serotonin
R sided heart fibrosis
(If in lung left sided fibrosis)
Flushing , diarrhea
Diagnosis: made with 5HIAA urine test
CT scan to stage
Treatment is with resection
230
A defiency
Night blind
231
D defiency
Osteoporosis
232
E defiency
Nystagmus
233
K defiency
Bleeding
234
Folate defiency
Anemia
235
Iron defiency
Anemia
236
Calcium defiency
Osteoporosis
237
Can’t absorb or break down fat
Steatorrhea is it intestine or bile pancreas
238
Someone comes in with signs and symptoms of malabsorption
1. 100 gram fat diet collect stool 72 hours-><14 g per day in stool no malabsorption
>14 g a day of fat in stool know have confirmed malabsorption
-next step is intestinal luminal border in tact or a problem with enzymes
-d-xylose absorption test if absorbed intestinal border ok and problem with pancreas (give pancreatic enzymes like in chronic pancreatitis and CF)
-d xylose not absorbed intestinal luminal border-so do edg with biopsy
239
Celiac sprue
Gluten allergy autoimmune IGA mediated
Diarrhea bloating, weight loss,
Dermatitis herpetiformis-all patients with it have celiac dz
Diagnosis-antibodies TTG do not get gliadin, can get endomyoseal. But get TTG! TTG!
EGD wiht biopsy show blunting of the villi loss of surface area
F/u iron defiency and osteoporosis
Treat-avoid gluten takes 3-4 months of avoidance to work
240
Lactose intolerance
Path algae, Asians
Presnt carbohydrate malabsorption bloating foul smelling flatulence
Diagnosis-avoid dairy within day get better
Treat-lactase enzymes
241
Tropical sprue
Infection present with celiac sprue
Diagnosisendoscopy with biopsy
Caribbean farmer though
Not going to get better with gluten avoidance
Treat antibiotics
242
Whipples disease
Path: infection with t whipped I
Present malabsorption +brain+joint+lymph nodes
Diagnosis made egd with biopsy -PAN+ LM
Organisms on EM
Treatment TMP SMP
Doxycycline
243
Diverticulosis
Constipation >50 yrs
Diets poor fiber and veggies
Rich in red meat , western diet makes u get diverticula
Asymptomatic
Diagnosis-colonoscopy when screening colon cancer , CT scan done for something else,
Treat no just prevent progressing so put on high fiber diet and rich in fruit and veggies prophylaxis
244
Symptomatic diverticulosis diverticula spasm
Postprandial left lower quadrant abdominal pain relieved with bowel movement
Older than 50
Diagnosis-clinical of IBD
Treatment high fiber diet
245
Bleeding diverticula
Pt painless hematochexia brigh red blood per rectum
Treat like a GI bleed
2 large bore IV, saline LR, type and cross, call GI.
Once rule out stuff get colonoscopy or arteriogram
Treat embolize
246
Feaclith in diverticula and get perforation
L sided appendicitis
Constant left lower quad ab pain
Fever and leukocytosis
Tender LLQ
Diagnosi upright KUB to rule out free air
Diagnosis diverticulitis with CT IV contrast
Treat mild, severe, abscess, perf, and refractory,
Mild:liquid diet and trey oral antibiotics
Severe: NPO and IV antibiotics
Abscess: NPO IV antibiotics need drain
Perforation: straight to ex lap with IV antibiotics
Refractory-talk about cutting out the colon. Treat acute as if new but once done with treatment do a hemicolectomy .
247
What antibiotics for diverticulitis
```
Cipro and metro
Or
Gentamicin/ampicillin and metro
Or
Pip/tazo NO dont on test
```
248
LLQ abdominal pain
KUB-free air=perforation get x lap and IV antibiotics
- loops of small bowel and air fluid levels-obstruction-surgery ex lap
- see nothing-CT scan with IV contrast will show mild, severe, and abscess
Mild-liquids oral anti
Severe-NPO IV antibiotics
Abscess-NPO IV antibiotics, drain
KUB just need for free air or obstruction, CT can show all three but KUB cheaper so choose first
249
Premalignant lesion polyp
>50 years old, alcohol, smoking, fat, processed red meat, inflammatory disorder like UC Crohns or PSC, genetics
Present: 1. Asymtpomatic screen
-good pedunculated have stalk. Sessile dont know where began and where it ended .
Tubular histology smal good
Villous and large bad
2. Iron defiency anemia in any man or postmenopausal woman. Get colonoscopy
3. Change in caliber stool , alternating bowel habits, or obstruction.
Diagnosis-colonoscopy with biopsy begin age 50 every ten years till 75
Treat resection if progress stage wiht pan CT and chemo (FOLFOX /FOLFURY—vegf inhibitors bevacizumab)
250
Screening
Colonoscopy 50 every ten years till 75 and weigh risk and benefits after
Sigmoidoscopy at 50 every 5 years must be done in conjunction with FOBT every three years
FOBT every year
All three are fine .
251
Results of colonoscopy
No polyps-come back ten risk
Low risk—5-20 year come back
-1-2 polyps all less than 1 cm
Tubular or low grade dysplasia
High risk—1-3 years
More than three or larger than 1 cm or Villous or high grade dysplasia
Mega— need come back this year
-more than ten polyps or sessile polyp
252
FAP
```
Defect in APC gene
Thousands of polyps teens
young
Cancer 30
death40
```
Treat prophylactic colectomy
Start screening at 10 years old
253
Lynch hnpcc
HNPCC/lych-defect in DNA mismatch repair
-Colorectal cancer , endometrial and ovarian
CEO and Meryl lynch
Diagnosis-3 members of family any CEO members in 2 generations and 1 younger than should have happened
254
Turcot
Brain tumors and colorectal cancer
255
Gardner
Jaw tumor and colorectal cancer
256
Peutz jeghers
Mouth freckles on lips
No colon cancer
Has cancer of small bowel even though polyps
Have to do endoscopy to see small bowel cancer
Not colon cancer but polyps
257
VW happens
| Approach to cirrhosis
```
Viral hepatitis b, c
Wilson disease
Hemochromatosis
Alpha 1 antitrypsin defiency
PSC
PBC
Ethanol
NAFLD
Something else
```
258
Viral hep
Chronic inflammation
Have to have it for a long time
IV drug users hep c
Hep b sex
Blood transfusions both
Diagnose antibodies
Treat-hep c cure with direct antiagonists
259
Wilsons diseases
Copper deposition
Present deposition in basal ganglia-chorea
Liver-cirrhosis
Eye-kayser flesher ring
Diagnosis slit lamp , ceruplasmin serum or urinary copper, biopsy show increase copper is best test
Treat-transplant reverse, penicillimine treats copper overload
260
Hemochromatosis
Iron absorption problem
Overload and deposition
Present bronze diabetes, hyperpigmenteed skin ,diabetes, cirrhosis iron in skin, pancreas, liver, diastolic CHF
Diagnosis-get ferritin >1000 suggestive
Transferrin saturation >50% is better
Best test is biopsy show increased iron
Treat phlebotomy, defaroxamine
261
A1 antitrypsin defiency
Young ppl with cirrhosis
Diagnosis biopsy PAS positive macrophages
Treat transplant
262
PSC
| S is for sons of bitches
Primary sclerosis cholangitis
Extrahepatic
Men with pruritus, jaundice painless, 30-50 years old, UC, IBD
Diagnosis-1 MRCP see beeds on a string have diagnosis no biopsy required dont need ERCP with camera down throat biopsy show onion skin fibrosis
Treat-transplant , uirsodeoxycholacid as waiting transplant
263
PBC
Intrahepatic ducts no association with UC or IBD
Chicks, b is for bitches
Pruritus, jaundice, 30-50
Imaging normal.
AMA can help
But only way to diagnose is biopsy
Treatment transplant
264
Alcohol cirrhosis
Alcohol alcohol
Stop etoh
Transplant curative but have to stop drinking
265
NAFLD.NASH
Transplant to treat
266
Hepatic encephalopathy
NH4
Present confused, asterixis
Diagnosis clinical dont get NH3 level
Treat lactulose , rifaximin and zinc
267
Gynecomatia , palmar erythema, spider angiomata
Bc cirrosis liver not metabolizing estrogen
268
Bilirubin
Jaundice
269
Bile salts
Pruritus
270
Portal HTN from cirrhosis
Thrombocytopenia
Ascites
Varrices
271
Varrices
Porto shunt
Portal HTN
Esophagus
Present on asymptomatic screen
Or
Deadly GI bleed
Diagnosis endoscopy
Treatment if bleeding band them, long term those bands fall off reduce portal pressure by giving them bb nadolol or propranolol
Give ceftriaxone and ocreotide
If bleed stop bb and do something else band them also need ceftriaxone, and ocreotide
TIPS-portal vein to hepatic or vena cava decompress portal system likely to induce hepatic encephalopathy though .....do dont do it lightly
272
Ascites
Path-fluid in the belly
Portal HTN related -
=SAAG>1.1 cirhrhosis and right sided heart failure
or not portal HTN related
-SAAD<1.1 infections, TB and cancer
Diagnosis paracentesis=biopsy see serum, albumin-fluid albumin =SAAG
Presnt-bulging flanks, shifting dullness, fluid wave
Treat cirrhosis-furosemide and spironolactone, fluid restriction 3 g Nacl 2 L water, maybe paracentesis
273
Portal HTN relatedspontaneous bacterial peritonitis complication cirrhosis
Spontaneous translocation of organisms in fluid, strep and or gram negative rods
Patient can be asymtpomatic
Fever and abdominal pain, any change in a cirrhosis patient
Diagnosis-paracentesis look for polys>250 neutrophils
Treat IV ceftriaxone or another 3rd generation cephalosporin
Total protein<1 need prophylaxis wiht fluoroquinolone
Treat white count and dont wait for culture, if culture is negative still treat it
274
HCC
Path chronic inflammation from cirrhosis or hep b
Asymptomatic screen
Diagnosis screen RUQ US looking for mass and AFP
Triple phase CT
Treatment -if small get resected, transplant, radio frequency ablation, tace
275
Upper vs lower gi bleed
Lig of treitz
Hematemesisuper or hematochezia if big bleed may be darker digested
Melena upper GI bleed but can be lower
Hematochezia lower usually
276
Symptoms GI bleed
Stabilize! With 2 large bores, IVF, IV PPI, type and cross, caII GI, ocreotide, ceftriazone
EGD+ UGIB
EGD- LGIB
——-let it stop if slow bleed before colonoscopy
——-if fast bleed do arteriogram and embolize
=====ongoing but not brisk can do tagged RBC scan
If all negative can go bill cam endoscopy
277
Varrices
From oral HTN
Cirrhosis
Diagnosis EGD
Treat 1st ocreotide then balloon
Best way is egd banding
Transplant is curative may have to bridge with TIPS
Porophylaxis propranolol
278
PUD
H pylori NSAIDs cancer
Pt dyspepsia
Diagnosis egd with biopsy
Treat PPI
279
Dieulafoy
Normal an atomic variant artery close to mucosal surface and small erosions get into it
Brisk painless bleed
Diagnose egd
Treat resect
280
Diverticula hemorrhage
>50 painless bleed
Diagnose colonoscopy
Treat hemicolectomy
281
Ischemic colitis
Watershed areas
Hypotensive and painful bright red blood per rectum
Diagnosis colonoscopy
Treat supportive
282
Avm
Aortic stenosis
283
Ulcerative colitis
20-30
Continuous on egd stay within colon
Superficial, crypt abscess
Present with bloody diarrhea
Increased risk colon cancer need screening colonoscopy start at year 8 and done annually
Extra intestinal manifestations-PSC, p-ANCA
Treat colectomy is curative
284
Crohn’s disease
Bi modal 20-30, 50-75 bimodal
Skip lesions entire GI tract
EGD biopsy trans mural
Non caseating granulomas
Watery diarrhea
Nutritional defiency and weight loss
Feel worse over time insidious onset
No association with CRC no screening
Extraintestinal manifestation-fistula
Defiency B12 and fats, duodenum is effected can get iron def and orthopenia
Surgery for fistula and abscess drain
285
Mild IBD
5-asa compound, mesalamine better for UC
286
Moderate IBD
Immune modulators good for both
6MP, AZa, methotrexate
Prednisone-can use but try to keep patients off
287
Severe OBD
Crohn-infliximab
UC-surgical resection
288
Flares IBD
r/o infection in particular c diff
Steroids and antibiotics (gram negative and anaerobes cipro and metro)
289
Hep a
Fecal oral route
Acute
RNA
Vaccine
IgM current, igG means immune
Elevated LFT in hepatitis in1000s
290
Hep b
Sex and blood
Acute or chronic
Can cause cancer
DNA
There is a vaccine
LFT 1000s if survive cleared and ok, if immunocompromised no symptoms but infected chronically
Serology
291
Hep c
Blood
Chronic
Can lead to cancer
No vaccine
Rna
292
Hep D
Must have b first in chronic carrier state
DNA no vaccine
Can cause cancer
293
Hep E
Third world pregnant patient has hepatitis
294
Hep c
Ab+ and RNA + you are infected chronic carrier
Ab- and rna+ acute state
Ab + rna - has been treated or cleared it
Treat -not ribaviron and interferon makes u fee like crap for a year.....old ways
Standard therapy now we use protease inhibitors the direct acting antagonist borceprovir sounding things
295
Hep b serology
S=surface
E-infectivity
C-core
```
Hsag=infection
Hbeag=infectious
IgMhbs=early infection
Igghbsag=immune clearing or vaccine
Igghbc=exposure immunity cant get from vaccine
```
Core from being exposed, s is vaccine or exposed
296
Hep b facts
HCC even without cirrhosis
| Reduce risk by treating with antivirals
297
Prerenal
Pump: MI, CHF
Leaky: nephrosis, gastrosis, cirrhosis
Hole:D/D/D/1-1
Clog: fmd, ras
298
Postrenal
Ureters: ca and stones
Bladder: ca, stones, neurogenic bladder
Urethra: cancer stones, BPH , kinked foley
299
Intrarenal
Glomerulonephritis
-rbc casts in urine. Please rule out nephrotic syndrome >3,5 G protein/day, increased cholesterol, edema
Acute interstitial nephritis
- WBC casts, wbc, eosinophils
- infection, TMP SMP, penicillin, cephalosporins
Acute tubular nephrosis
-muddy brown casts
-ischemia
-exposure to toxins : IV contrast and myoglobin from rhabdo
-prodrome Cr rise, ten oliguric phase no urine output need to dialysis, then polyurethaning phase where urinary output explodes
-
300
Increased Cr come in
```
Rule out prerenal
BUN:Cr >20
Una<10
FeNa<1%
Feurea <35%
*if volume down give IVF
If volume up do diuresis
```
Then rule out postrenal
US or CT scan looking for hydroureter, hydronephrosis
*relieve obstruction with foley, nephrostomy (ureter), surgery
Then intrarenal
-history and PE then look at UA
D*disease specific treatment
301
Acute hemodialysis
```
Acidosis
Electrolytes (k, Ca)
Intoxication
Overload
Uremia
```
302
Stages CKD
I GFR>90, prevent progression
II GFR 60-89 prevent progression
III GFR30-59 complication manage
Stage IV GFR 15-29 prepare for dialysis with fistula and manage complications
Stage V CGR <15 hemodialysis
303
Hemodialysis vs peritoneal dialysis
HD 3 times a week for 4H
Peritoneal every night 6-84 hours need cath
Doesn’t matter which one pick
Need when CKD stage five
304
How prevent progression of CKD
HTN, DM, proteinuria
HTN-goal is <130/<80
ACe-I or ARB
DM AC<7
BG80-120
Orals other than metformin or insulin
305
Anemia CKD
Decreased EPO
Present asymptomatic and screen Hgb<12 investigate
Diagnosis of exclusion
R/o other causes of normocitic anemia and check for iron folate
Treat-iron supplementation , give EPO maybe transfusion as needed
Goal is HgB>10
EPO is not a diagnostic test
306
Secondary hyperparathyroidosm
Mineral bone disease
Increased phosphorus
Low ca stimulate PTH which goes to bone and resorts
Present asymptomatic, ca xP>55 35? Calcyphylaxis
Diagnose BMP Ca P
Treat phos binder-saclarer
Calcimimetic-cincalcet
Replace Ca and vitamin D
F/u if dont do this get osteopenia/mineral bone disease
307
Volume overload
Loop diuretics and thiazide
Furosemide
Metolazone
308
Met acidosis
Give sodium bicarbonate
309
Mild hyponatremia
Disease specific
310
Mild hypernatremia
Asymptomatic
| Give them water
311
Moderate hyponatremia
IV fluids normal saline
Bv confusion, HA
312
Moderate hyperna
N/v confusion
| IV saline
313
Severe hypona
Hypertonic saline 3% NaCl
314
Severe hyperna
D5w
Seizures, coma
315
Someone comes in with decreased Na
Serum osm
2xNa+glucose/18+BUN/2.8
Normal is 280
Isotonic-pseudohyponatremia (fats and proteins)
Hypertonic hypona-for 100 blood glucose above 100 correct Na by 1.6
If BG 500 so correct by 4x1.6=6.5 na give
If na 130->actual is 136.5
Hypotonic-hypona-history and PE. To decide are volume up down or euvolemic
If vol up correct Na by giving diuresis
If vol down Correct na by give IV fluids
If euvolemic-RATS
Renal tubular acidosis -UA
Addison disease-cortisol
Thyroid disease=THS
SIADH-diagnosis of exclusion -volume restriction, gentle diuresis, demecocycline
Vaptan is always a distractor dont pick it
316
Osmotic demyelination syndrome
If correct Na too quickly demyelination syndrome leaves spastic quadriplegic only correct .25 per hour and only need .6 per day unless severe give hypertonic saline until stop seizing but in general want to do it slowly dont need big change to get out of symptomatic range
317
1,25 VD from ganuloma
TB or sarcoid
Can increase ca?
318
Most calcium is bound to albumin
Normal albumin is 4 normal ca is 10
For every change in albumin of 1 the ca changes in opposite direction by .8.
If albumin is 3 ca will say 9.2, add .8 so its 10.
319
Hypoca
Tetany, perioral tingling, trousseaus sign chvosteks sing
1. Correct albumin 2. Still low check ionized calcium need IV calcium gluconate the of IV calcium carbonate? if low
320
Hypercalcemia
Kidney stones
Psychic moans
Abdominal groans
Painful bones
1. Recheck Ca-if normal stop, if elevated treat if symptomatic and diagnose is asymptomatic
Treat hypercalcemia that is symptomatic IV fluids************ but in addition can
Immediate phase-calcitonin
Long term phase-bisphosphonates
In between
321
Normal k
3.5-5.5
| Used in lethal injection derrangements are deadly
322
Hyperkalemia
Low also, ace i , arb, aldosterone antagonist
Iatrogenic in correction of hypokalemia
Ingestion and CKD
ESRD
Artifact hemolysis
High K, get recheck if high on recheck get
EKG is what u want to get -peaked T wide QRS
Unstable hyperK if ekg changes emergent
If ekg no changes stable hyperK can fix at leisure urgently
323
Emergent hyperK
Stabilize, temporize, decrease total body K
Stabilize-with CaCl IV lasts few minutes and stabilizes the cardiac myocytes
Temporize-shift K into cells takes K out of serum so heart cant use it with insulin and D50
Decrease TBK-loop diuretics urine and xayexalate for stool lasts days
Dialysis-chronic, acute
324
Urgent hyperK stable
Just reduce total body potassium
325
HypoK
Renal-hyperaldo, diuretics, thiazide, loops
Gi-vomiting and diarrhea
1. Recheck, if real check ekg , regardless of ekg you will replete with oral>IV, if PIV cant go faster than 10 mEq/hr, if central lance cant go more than 10mEq/he
10mEq of K I will change it by .1
326
Kidney stone presentation
Colicky flank pain radiating to groin and hematuria
Get UA
-no microscopic hematuria not a stone and look for something else
- +microscopic hematuria stone
- best non contrast CT, can use US KUB but non contrast CT gold standard
- in pregnancy though Us is best
- KUB can be used to track disease
<5 mm IVF and pain meds
>3 cm surgery
In between lithotripsy
<5 mm IVF pain meds
<7 mm mET-CCB, a blockers
In between-proximal lithotripsy, distal uretoscopy
Surgery-proximal lap>open
Distal=PAN
Septic-nephrotomy (proximal) or stent(distal)
Wanna strain urine to know type of stone bc can modify risk factors ...while modifying come back in 6 weeks for a repeat screen
+ continue to strain
- you can stop
327
Calcium oxalate
Opaque
Increase Ca,increase oxalate
Thiazide, decreased oxalate, increased citrate
328
Struvite MAP
Opaque
Proteus with urea splitting activity
Antibiotics
Huge
Surgery to remove all of the stone burden
329
Uridyl acid
Radiolucent
Gout or tumor lysis
Give allopurinol
Can use rasburicase
330
Cysteine stones
Radiolucent
Genetic disorder
331
Simple cyst kidney
Asymptomatic screen
Small
No lobulations and no deputations
Diagnosis nothing
Treat nothing
332
Complex cyst
Flank mass large
Infection->pyelonephritis
Flank pain
Can rupture and bleed
Bleed->hematuria
UA
CT scan or USbiopsy
Treat disease specific
Resect
333
RCC
Flank pain flank mass and hematuria
Low Hgb
Epo(increase hgb)
Hematogenous spread might find DVT or piece of tumor in vein or IVC
CT scan or US if cant not biopsy it
Treat-resection without biopsy partial or radical nephrectomy will act as the biopsy
334
ADPKD
Asymtpomatic-HTN-ESRD
Cyst-flank mass
Infection-pyelo
Bleed-hematuria
Can have cysts in pancreas and liver—-abscess, pancreatitis, hepatitis
Berry aneurysms subarachnoid hemorrhage
Diagnosis Ct scan or US and biopsy
Treat-supportive->transplant
Fu should screen MRI or CTA or angiogram to look for berry aneurysm
335
ARPCKD
Newborns
Oligohydramnios
Anuric complete renal failure day 1
Palpable flank masses b/l
Diagnosis-US and then biopsy(radially oriented cysts)
Treat supportive transplant could be curative but most likely to die.
336
Respiratory acidosis
CO2>40
Hypoventilation, opiate, asthma, COPD, muscular strength , OSA
337
Metabolic acidosis
CO2<40
Anion gap Na-CL-CO2
>12 anion gap acidosis
<12 non gap
```
MUDPILES anion gap
Methanol
Uremia
DKA
Propylene glycol
Isopropylalcohol
Lactic acidosis
Ethylene glycol
Salicylate
```
Non gap
UAG-urina na+k-cl memorize this
Positive renal tubular acidosis
Negative diarrhea
338
Respiratory alkalosis
CO2<40
Hyperventilation
Pain, anxiety, hypoxemia, high RR
339
Metabolic alkalosis
CO2>40
Urine chloride 1.
Or give volume and watch resolve.
Volume responsive?
Volume down, RAAS is kicked up aldosterone grab na and bring back, and na bring chloride with it
Urine chloride <10
Diuretics, dehydration, emesis / NG suction
Not volume responsive?
Urine cl>10
Look for HTN neg-barters, gittlemans
HTN pos-hyperaldosteronis RAS primary hyperald.
340
Acid base disturbance steps
1.pH
2.CO2
3. Other
3a anion gap
3b acute or chronic
3c bicarbonate appropriate
Expected bicarbonate = bicarbonate given
341
Resp acidosis
Change 10 CO2
Change pH-.08(a), .04(c)
Change bicarbonate by 1(acute) 3 chronic
342
Resp alkalosis
Change 10CO2
Change pH .08(a) .04*c)
Bicarbonate chance 2(a) 4(c)
343
Acidosis
```
1pH down
2. CO2 down
3 others
3a. Anion gap (na-cL-bicarb)
(Albumin x3 is a normal anion gap)
3b pCO2 appropriate (winters 1.5(bicarbonate)+8+/-2)
Given>expected too many respiratory acids so have respiratory acidosis
If given
```
344
Add back method is bicarbonate
Calculated bicarbonate >normal whihc is 24 too may metabolic alkalosis
If less than normal <24 to of ew and metabolic acidosis
345
Alkalosis metabolic
Ph up
CO2 high
Stop here aldosterone is up. Won’t need to do anything else this is it
3a. Just whack to make sure not elevated
On its own or part of another disturbance part or an anion gab meta acidosis with met alkalosis
346
Acute joint pain
Red, hot swollen, tender, loss of function
Trauma, infection, crystalas, reactive(gonorrhea)
347
Chronic indolent joint pain
Inflammatory
-no=osteoarthritis
-yes =inflammatory joint look at number
1 jointmore toxic or flare of multijoint disease
>1 lupus, RA (both seopositive), sero-, other connective tissue disorders
348
What do with acute single joint
Arthrocentesis
-appearance, WBC, PMN, gram +stain, crystals, disease
Will be one of four
Normal (serous, <200 WBC, 25%PMN, neg, neg)
OA -x ray and history (serous, <2000 WBC, 25% PMN, neg neg)
Inflammatory- cloudy , >2000 <50000 WBC, 50% PMN, may have crystals, neg stain and culture
Septic-pus, opaque, white, >50,000, vulture +, crystals -
Staph + right away, gonorrhea may not show up right away if think gonorrhea grab NAAT or chocolate agar if negative gram stain, but usually staph
349
ANA
Lupus
350
Rheumatoid factor
RA
351
Anti ccp
RA
352
Ds-DNA
Lupus, lupus nephritis
353
Anti his tone antibodies
Drug induced lupus
354
Anti centromere
Scleroderma crest
355
Topoisomerase scl70
Scleroderma systemic
356
Smooth muscle
Autoimmune hepatitis
357
Ro and La
Sjorgens
358
Jo
PM-DM
359
And mitochondrial
PBC
360
Lupus
```
Autoimmune and complex formation
Women>men
Black>white
Malar rash
Discoid rash
Serositis
Oral ulcers
Arthritis for large joints (hips knees shoulders elbows)
Photoensitivity (burn earily)
Blood (anemia and thrombocytopenia)
Renal failure
Ana +
Immunologic
Neuro (psychosis)
```
LSE-SLE
Nephritis
1st trimester loss anti phospholipid
361
Diagnosis lupus
1.ANA
Ds-dna(lupus)
Anti smith
Antihistone(drug induced lupus
UA with micro
ESR CRP*
C3 and C4 will be low
Treat-everyone gets hydroxychloriquine
Steroids during flare or first diagnosis
IV cyclophosphamide or oral mycophenolate/mofatil can both be used for lupus nephritis
362
Drug induced lupus
Anti histone antibody
Present medication taking with rash a pain
No visceral involvement
Diagnosis-anti histone antibody
Treat remove agent
*hydralazine, procanamide, methyldopa
363
Lupus nephritis
Ds DNA antibodies
Present catch asymptomatic screen urinalysis or urine micro show proteinuria
Or HTN massive proteinuria and maybe hematuria
Diagnosis-biopsy
Treatment IV cyclophosphamide
Transition to oral mycophenolate
364
Rheumatoid arthritis
Women
>45 pannus formation erode away joints
Morning stiffness >60 minutes, small joints in hands and feet, >3 joints involved, symmetric, MUST SPARE DIP), if last knuckle is involved its not RA, nodules, biopsy see cholesterol , blood test CCP>RF, x ray see erosions or pannus formation, periarticular osteopenia
Treat NSAIDS (ibuprofen, maloxican). For symptoms, DMARDS (methotrexate!!!! This is answer leflunomide hydroxychloroquinne(lupus), sulfasalasine) attempt to combine DMARS before biologics in this order. If pregnant start with hydroxychloroquine) leading up to biologics(infliximab, rituximab, etarnecept for severe not everyone needs before must make sure vaccinated before and test for T and ask if been for fungus endemic areas) for severe disease...steroids in flares on
365
Morning stiffness spine +C1, C2
That’s RA get x ray person need preoperative x ray of neck
366
Felty syndrome
Neuropenia, RA AND SPLENOMEGALY
367
SCLERODERMA
Collagen depo
PresentL limited cutaneous systemic sclerosis=crest
Calcinosis, raynauds, esophageal dysmotility, sclerodactyly,telangiectasia, iron defiency anemia
Anti centromere, can cause pulmonary artery HTN PAH in normal looking lungs
Or
Diffuse cutaneous systemic sclerosis=scleroderma
Limited cutaneous+visceral involvement lung(interstitial lung disease), heart(constrictive pericarditis), kidney (scleroderma renal crisis)
Anti SCL 70/topoisomerase
Can lead to pulmonary artery HTN lung changes before PAH
368
Nephrotoxic systemic sclerosis
If galdolimnium
Sclerodactyyl loss skin folds
Look for MRI and CKD
Otherwise choose scleroderma
369
Sjorgens
Lymphoplasmocytic infiltration of exocrine glands.
Biopsy parotid and see
Present dry eyes (caratoconjunctivitis sicca, ) dry mouth(xerostoma), parotid swelling
Diagnosis ANA RF first
Then Ro, La
Then Schinner test can they make own tears
Treat artificial tears and artificial saliva
F/u another loop for lupus and RA
370
Myositis
IBM-T cell
PM-T cell
DM-complex depo
Presnt: proximal muscle weakness hard to get up from chair, painless, subacute, can be associated wiht malignancy, do age appropriate cancer screening
Skin manifestations and proximal muscle weakness. Heliotrope rash eye, grottons papules-scal symmetrical on large joints.
Shawl sign photosensitive rash.
Diagnosis-CK elevated, EMG , biopsy is best test*, antibodies anti mi anti jo
Treatment steroids
371
Monoarticuloarthropathy with crystals
Get arthro
+crystals==, bugs-, <50000....good or pseudo gout
Pseudo gout-+ bifringement crystals, rhomboid, calcium pyrophosphate
Treat flare with colchicine(causes diarrhea) NSAIDS (first unless CKD) and or steroids (last)
Gout-neg bifringement crystals are needle shaped mono sodium urate
Underexcreter-not in urine probenacid
Increased production(tumor lysis)-give IVF allopurinol or rasburicase to treat
Flare-colchicine, NSAIDS, steroids
If keeps happening get a uric acid **** coming into play after lifestyle changes and repeat acute flare. Only get uric acid when committed person to ongoing chronic therapy >6 is diagnostic . Goal is <6with lifestyle modifications, but more than 2 in a year allopurinol and prophylax with colchicine , NSAIDs and steroids low dose, ideally colchicine**** gout prophylaxis colchicine, allopurinol to decrease uric acid go for allopurinol
372
Monoarticuloarthropathy >50000 with bugs no crystals
Infection-nongonorrhea probably staph
-direct inoculation, hematogenous spread in IV drug users and people on hemodialysis
Diagnosis-gram stain gram _ cocci in clusters.
Treat nafcillin unless MRSA than vanco, and hardwear comes out
Gonorrhea-only hematogenous history of HIV or syphilis, cervicistis , urethritis, sex worker not using condoms,
Diagnosis-gram stain negative , so get NAAT
Treat cefrtiaxone7-14 days IV, and doxyxyxline or azithromycin
373
Seronegative arthritis
Psoriatic
Ankylosis
IBD related
Reactive
Hlab27 but dont look for it
Most are seronegative
Diagnosis-x ray bony erosion and joint destruction CT is getter only use when looking for occult fractures
MRI is best test but expensive
Men more than women
Treat NSAIDS, local glucocorticoid injections, DMARDS , TNF-a inhibitors
374
Ankylosing spondylitis
Man>woman
Sacroilitis
Low back pain gets better with use (morning stiffness)
Diagnosis-x ray lateral lumbar bamboo spine
Treatment-NSAIDS, local steroids, DMARDS dont work for axial skeleton dont use them
If fail go to anti-TNF-alpha
375
Psoriatic
Woman>men
Psoriasis+arthritis
*pic nail pitting
Diagnosis-clinical
Treatment-ankylosing spondylitis NSAIDS, local steroids, DMARDS , anti TNF a if no work
Psoriasis can be treated with UV light and steroid creams
376
Reactive arthritis
Urethritis+arthritis
+conjunctivitis-reiter
Diagnosis-tap->negative, swab find infection
Treat if positive for infection -doxy or azithro and ceftriaxone
NSAIDS and time
377
IBD related
Women >men
Crohns, UC
Arthritis
Diagnosis clinical
Treat-no NSAIDS, treat IBD and arthritis improve
378
Giant cell arteritis
Large vessels, ext carotid, opthal, temporal
>50
Present-jaw claudication, vision changes RAC, temporal tenderness
Diagnosis biopsy see granulomas
Treat-skip diagnostic and give steroids.
379
Takayasu
```
Large vessels
Aortic artery and branches(subclavian and femoral)
Pulselessness
<40
Woman
Diagnosis-angiogram
```
Treat-steroids
380
Kawasaki
IVIG and aspirin give them
381
PAN
Hep B
Gut, renal, shin
Mesenteric ischemia, renal failure, purpura
Sub Q pain nodules
Mononeuritis multiplex-motor and sensory deficit that comes and goes
Diagnosis-angiogram
Treat-steroids and cyclophosphamide
382
Wegners
Granulomatosis with poly angst is
Small vessel disease
ANCA
Hemoptysis, hematuria, nose
Diagnosis c-ANCA, biopsy best (lung usually)
Treatment-steroids and cyclophosphamide
383
Microscopic polyangitis
Wegners with Panca
384
Eosinophilia granulomatosis
Wegners with pANCA and eosinophilia
385
Cryoglobuleminia
Hep c
Purpura palpable+hep c
Diagnosis-check for cryoglobulins
May see decreased compliment
Treatment-severe-plasmaphoresis
Underlying disease treat hep c
Steroids and cyclophosphamide
386
HSP
Present palpable purpura
And gi symptoms pain or a bleed
Diagnosis-biopsy showing leukocytosclatic vascular is and IgA in immunoflorescence
Treat steroids
