Medicine Part 2 Flashcards
Most common causes of ESRD
Diabetes
HTN
How is ESRD defined?
Not by BUN or Cr
Loss of kidney function leading to clinical and lab findings of uremia
Calciphylaxis
Hyperphosphatemia –> calcium adn PO4 precipitate –> vascular calcifications –> skin lesions/necrosis!
Absolute indications for dialysis
AEIOU
Acidosis
Electrolytes - HYPERkalemia
Intoxications - methanol, eth glycol, lithium, aspirin
Overload - hypervolemia that can’t be solved
Uremia - based on clinical presentation, like pericarditis
Microscopic hematuria usually
glomerular in origin
Gross painless hematuria usually
Bladder or kidney cancer
Hematuria
> 3 erythrocytes / HPF on UA
Order to evaluate proteinuria
Urine dipstick - specific for albumin
UA
Dipstick + blood
UA no RBC
What is it?
Hemoglobinuria
Myoglobinuria
Proteinuria
> 150 mg protein/days
Glomerular d/o vs tubular d/o
In glomerular but not in tubular:
- need biopsy usually
- steroids and immunosuppressive meds for tx
In tubular but not in glomerular:
- acute presentation,
- caused by toxins
- does not cause nephrotic syndrome
Acute Interstitial Nephritis
- features
- seen on labs
- causes
Polyruia and sterile pyruria (maybe some WBC casts) are early manifestations
acute interstitial renal inflammation + pyuria + eosinophils (hypersensitivity) + azotemia
happens after drugs METHICILLIN #1 NSADs captopril penicillins sulfonamides rifampin TMP cephalosporins
AIN treatment
Remove offending agent
Steroids if still getting worse
Acute tubular necrosis
- causes
- stages
Toxic (#1 aminoglycosides) or Ischemic (more serious, prerenal azotemia usually (shock, sepsis) or crush injury w/ myoglobinuria) → granular casts (muddy brown)
o This is medullary necrosis and ATN is limited to outer medullar segments b/c renal medulla is susceptible to ischemic injury b/c low medullary blood flow → glomeruli look normal
o Stages: (1) inciting event → (2) Maintenance (oliguric, risk of hyperkalemia & met acidosis) → (3) Recovery (polyuric, risk of hypoK)
Nephrotic syndrome
- features
o Hyperlipidemia b/c increased hepatic lipoprotein synth – but only LDL; HDL will decrease!
o Hypoagammaglobinemia = increased risk infection
o Hypoalbuminemia = edema
o Hypercoagulable = loss antithrombin 3
Minimal change disease
-only lose albumin, not all globulins
Diffuse cortical necrosis
usually due to hypOperfusion of kidney (vasospasm, DIC, abruption placentae, septic shock), medulla spared
Renal papillary necrosis
- what is it
- causes
- dx
necrosis of renal papillae (supplied by vasa recta) = hematuria, proteinuria
o “POSTCARDS” = Pyelonephritis, Obstruction, Sickle Cell, TB, Cirrhosis, Analgesic abuse (phenacetin, acetaminophen, aspirin), Renal transplant rejection, Diabetes (#1), Systemic vasculitis
o DACS = Diabetes Mellitus (#1), Acute pyelonephritis, Chronic phenacetin use (acetaminophen), Sickle Cell
Dx w/ ecretory urogram - note change in papilla or medulla
Acute renal failure
↓ renal function → ↓GFR → INCREASE BUN and Creatinine (azotemia)
will also have met acidosis!
Chronic renal failure
Hyper K (#1 COD b/c arrhythmia) Metabolic ACIDosis (increase H+, ↓ bicarb) Uremia Anemia renal osteodystrophy dyslipidemia Na/H2O retention growth retardation in children;
FREE Ca will be decreased b/c increase in PO4 will bind up the free Ca in blood
Renal tubular acidosis
D/o of renal tubules –> nonanion gap HYPER Cl metabolic acidosis
Glomerular function OK
decrease in acid excreted in urine
Type 1 RTA
- what is it?
Distal
Can’t secrete H+ at distal tubule –> new bicarb cannot be made
Urine pH does not go below 6
Type 1 RTA
- effects of it
Decrease ECF
Hypo K, HYPER Cl, met acidosis
Renal stones
Type 1 RTA
- causes
MM
Nephorcalcinosis
Amphotericin B
Lupus, Sjorgen’s
Medullary sponge kidney
Analgesics
Type 2 RTA
- waht is it?
Proximal
Can’t reabsorb HCO3 at PCT –> more bicarb excreted in urine
Type 2 RTA
- effects
Hypo K, HYPER Cl, met acid
NO KIDNEY STONES
Type 2 RTA
- causes
Fanconi's syndrome Wilson's Lead toxicity Amyloid MM
Type 4 RTA
Hypoaldo or resistant to aldo
Decreased Na absorbtion + decreased H and K secretion in DCT
HYPERkalemia (not hypo) + acidic urine + met acidosis
Hartnup syndrome
AR
defective aa transporter
Tryptophan can’t be reabsorbed –> NAD deficiency
Dermatitis, diarrhea, ataxia, psych disturbances (all like pellagra)
Supplement w/ NAD if symptomatic
Fanconi’s syndrome
PCT dysfunction
can’t transport
- glucose
- aa
- Na
- K
- PO4
- uric acid
- bicabr
Results in
- rickets
- osteomalacia, osteoporosis
- polyuria,
- dehydration
- type 2 RTA
- hypercalciuria
- hypo K
Dx ADPKD
Ultrasound
Can use CT and MRI
Extrarenal involvement of ARPKD
Liver - protal HTN, cholangitis
Pulm insufficiency - pulm hypoplasia + enlarged kidneys - mostly because not enough amniotic fluid
Potter syndrome
Medullary sponge kidney
Cystic dilation of CD
can be assoc w/ hyper PTH and parathyroid adenoma
Benign; some stones and more UTI sometimes
Dx medullary sponge kidney
Intravenous pyelogram - inject contrast to see on xray
Renal artery stenosis
- causes
Atherosclerosis (31)
Fibromuscular dysplasia
- usually in young fems
- bilateral in 50% ppl
Dx renal artery stenosis
Renal arteriogram
- DO NOT USE FOR RENAL FAILURE. Contrast can be nephrtoxic
MRA - ok for renal failure
Renal vein thrombosis
- when is it seen?
RCC invasion
Nephrotic syndrome
Preggers/OCP
Dx renal vein thrombosis
renal venography
IVP
Where does sickling of sickle cell most commonly occur in kidney?
Renal papille
Can get papillary necrosis, renal fail, lots of UTIs
ACEI can help
Causes of hyperoxaluria
Steatorrhea
Small bowel disease
Crohns
Pyridoxine deficiency
Initial test to dx urinary tract obstruction
Renal ultrasound
Gold standard to dx urinary tract obstruction
Intravenous urogram (IVP)
NOT for preggers, allergies to contrast
PSA
DRE
Transrectal ultrasonography (TRUS)
- what do you do with these results when screening for prostate cancer?
PSA > 10 —> Do TRUS w/ biopsy
DRE abnormal —> Do TRUS w/ biopsy
PSA < 4 + DRE (-) —–> annual f/u
4.1 < PSA < 10 + DRE (-) —–> biopsy
DRE of prostate cancer
Prostate hard, nodular, irregular
PSA of cancer vs PSA normal
PSA cancer usually bound by plasma proteins
PSA normal usual free in plasma
Risks for RCC
Cigarettes Phenacetin analgesics ADPKD Chronic dialysis Mercury Cadmium HTN
Dx RCC
Renal US only detects mass
Abdominal CT (w/ and w/o contrast) - for dx and staging
Tx RCC
Radical nephrectomy
Take out:
kidney
adrenal
Gerota’s fascia
Transitional cell caricinoma
Can be anywhere along kidneys –> ureter
Mostly in bladder
Frequently recurs
TCC risk factors
Pee SAC
Phenacetin
Smoking (#1)
Aniline dyes
Cyclophosphamide
Dx TCC
Cystoscopy + biopsy (definitive)
Staging of TCC
CXR
CT scan
Testicular cancers
- Germ cell tumors
Most common
Seminomas
- radiosensitive, slow growing
Embryonal
- very malignant, mets early
Choriocarcionma
- most aggressive, mets always
Teratoma
- usually no mets
Yolk sac
- rare, usually in kids
Testicular vs. scrotal cancers
Testicular cancers usually always malignant
Scrotal cancers usually benign
Testicular cancers
- Non germ cell tumors
Usually benign, less common
Leydig cells
- benign, tx w/ surgery
- secrete estrogens and androgens –> precocious puberty
Sertoli cells
- usually benign
Testicular cancer risk factors
Cryptochidism (risk still there w/ correction)
Kleingelter’s
Testicular ca tumor markers
B HCG
- increased in choriocarcinoma
AFP
- increased in embryonal tumors
US to try and localize tumor
DDx of testicular mass
Cancer
Varicocele
Torsion
Spermatocele
Hydrocele
Epididymitis
Lymphoma
Tx testicular cancer
Inguinal (not scrotal) excision of testicle
CT scan to stage
BHCG and AFP measurements
Penile cancer assoc
HSV
HPV 18
Testicular torsion
Surgical emergency
After 6 hrs, may have infarction and no longer save testicle
Epididymitis
Infection of epididymis
Usually E coli
Gonorrhea, Chlamydia in sex active
Fever
Less acute onset vs. torsion
Total body water
60-40-20
60% body wt = water
40% = ICF
20% = ECF
- 15% = interstitial
5% = plasma
What is impt to track to assess volume status?
Urine output
Normal kids = > 1 mL/kg/hr
Normal adults = 0.5-1 mL/kg/hr
Anascara
extreme generalized edema
Fluid replacement therapy options
NS
- increase intravascular volume if dehydrated
- not great for CHF
D51/2NS = 5% dextrose, 1/2 NS
- standard maintenance fluid
- dextrose to inhibit muscle breakdown
D5W
- dilute powdered meds
- only some stays intravascular b/c diffuses into TBW compartment; not great to replenish intravascular
Lactated ringer’s solution
- good to replacing intravascular volume
- NOT a maintenance fluid
- common trauma resuscitation
- DO NOT USE if hyperkalemia is concern b/c has K
Calculation of maintenance fluids
100.50.20 rule
For 70 kg man:
10 kg x 100
10kg x 50
50 kg x 20
Total: 2500
2500/24 = 104 mL/hr
Changes in Na concentration = ?
Changes in Na content =
Concentration –> reflection of water homeostaiss
Content –> reflection of Na homeostasis
Hyper/hyponatremia
vs
Hypo/hypervolemia
Hyper/hyponatremia caused by too little/too much WATER
Hyper/hypovolemia caused by too much/too little Na
Hypo Na symptoms
Usually neuro sx
Headache, delirium, irritability
Muscle twitching, weakness
Hyperactive deep tendon reflexes
Seizures, coma
N/V, watery diarrhea
HTN b/c increased ICP
Oliguria
Tx hyponatremia
- hypotonic hyponatremia
Mild (120-130)
- withhold free water
Moderate (110-120)
- loop diuretics + saline
Severe (< 110)
- hypertonic saline increasing serum Na by 1-2 mEq/L/hr
Risks of correcting hypoNa too fast
Central pontine demyelination
Risks of correcting hyper Na too fast
cerebral edema
Hyper Na symptoms
Neuro sx usually
AMS
restlessness
Weakness
Focal neuro deficits
What should be given to differentiate nephrogenic from central DI if DI suspected?
DesmopressiN
Hypoalbuminemia, Ca is low. But ionized Ca is normal.
How do you est ionized Ca
Total Ca - (serum albumin * 0.8)
What alters Ca binding to albumin?
pH changes
Increase pH –> increase binding of Ca
- decrease ionized Ca
- total Ca ok
Causes of decreased Ca
Hypo PTH Acute pancreatitis Renal insufficiency Hyper PO4 Pseuhypoparathyroidism Hypo Mg Vit D deficiency Malabsorb Blood transfusion w/ citrated blood Osteoblastic mets Hypoalbuminemia DiGeorge
Features of decreased Ca
Rickets, osteomalacia Tetany - Chovstek's, Trousseau's sign Seizures Basal ganglia calcifications Arrhythmias
PROLONGED QT`
Causes of increased Ca
Hyper PTH
Renal failure (usually hypo Ca but can be hyper w/ high enough PTH)
Acromegaly
Addison’s
Metastatic ca
MM
PTH paraneoplastic
Vit D intox
Milk alkali syndrome
Thiazides,, lithium
Sarcoidosis
Familial hypocalciuric hypercalcemia
Features of increased Ca
Stones Bones Groans Psych overtones ---> All increased PTH signs
POlydipsia, polyuria
HTN
Wt loss
SHORT QT
1st step in management of hyper Ca
Increase urinary excretion via IV fluids
Diuretics (furosemide) to stop Ca reabsorb
What can you use to quickly tell why someone is hypokalemic?
Presence or absence of HTN
HTN - aldo increased - causes K wasting
No HTN - GI or renal loss of K
Hypo K EKG
Flattened T wave/ T wave inversion
U wave
Does dig cause hyper or hypo K?
What predisposes to dig toxicity
Causes HYPER K
Hypokalemia predisposes - allows Dig to bind more to Na/K pump
Features of hypo K
Arrhythmias Muscle weakness, paralysis, cramps Paralytic ileus Polyuria adn polydipsia N/V
How best to replete K?
KCl
10 mEq KCl increases K by 0.1 mEq/L
Add lidocaine so KCl doesn’t burn as much
How fast can you infuse K?
10 meq/hr in periph IV line
20 meq/hr in central line
When do you correct hypo Mg first?
In both hypo K and Ca
How does hyper K affect kidneys to worsen acidosis?
Inhibits renal ammonia synthesis and reabsorb
Net acid excretion is impaired!
Metabolic acidosis
Further makes K move out of cells
Hyper K EKG
Peaked T waves
Prolonged PR interval
Widen QRS
–> eventually get QRS merge w/ T wave producing sine pattern
–>
Vfib
Tx Hyper K
IV calcium
- decreases membrane excitability
- be careful giving this to pts on dig b/c can worsen toxicity
Shift K into cell
- glucose + insulin (fastest)
- sodium bicarb (for emergencies)
Remove K from body
- Kayexalate (exchange resin)
- hemodialysis
- diuretics
Where is most of Mg in body?
Bones
Where is most of K in body?
Intracellular
Where is most of Na in body?
Extracellular
Causes hypo Mg
Malabsorb
Fasting
Fistulas
TPN
Alcoholism
SIADH Diuretics Bartter;s syndrome Gentamicin, amphotericin B, cisplatin, PPIs Renal transplant
DKA, burns, lactation
Hypo Mg features
Muscle twitching Weakness Tremors Hyperreflexes Seizures AMS
Hypo K and Ca
Hypo Mg EKG
Prolonged QT
T wave flattening
Torsades
Causes of hyper Mg
Renal failure
Burns, trauma, ECF volume deficit
Mg-laxatives, antacids
Adrenal insufficiency
Adnreal insufficiency
Rhabdomyolysis
Hyper Mg features
Nausea Facial paresthesias Deep tendon reflex LOSS Respiratory depression Coma
Hyper Mg EKG
Like hyper K
Increased PR
Widened QRS
Elecated T
Tx hyper Mg
No Mg
IV calcium gluconate
Saline + furosemide
Dialysis
Intubation if respiratory depression
Where is most of PO4 in body?
Bones
Causes of decreased PO4
DKA
Alcohol abuse
Hypo PO4 clinical features
Encephalopathy
COnfusion
Seizures
Paresthesias
Weakness
Myalgias
Rickets
Hemolysis
RBC dysfunction
Cardiomyopathy b/c low ATP
Rhabdomyolysis
Hyper PO4 causes
Renal insufficiency Bisphosphoates Hypo PTH Vit D intoxication Tumor calcinosis Rhabdo cell lysis acidosis
Hyper PO4 features
Metastatic calcification + soft tissue calcifications
Neuro changes from decreased Ca
Tx hyper PO4
PO4 binding antacids (Al OH or carbonate)
Hemodialysis
Which bicarb value is more reliable?
- serum vs. ABG?
Serum (venous) CO2
Salicylate OD acid base status
Respiratory Alkalosis
Metabolic acidosis
Causes of renal loss of bicarb
Proximal tubular acidosis
- MM
- cystinosis
- Wilsons
Distal tubular acidosis
- can’t make HCO3
- SLE, sjogren’s, amphotericin B
Acetazolamide
Causes of GI loss of bicarb
Diarrhea
Pancreatic fistulas
Small bowel fistulas
Ureterosigmoidostomy
Danger to tx acidosis w/ bicarb
Bicarb takes 24 hrs to get to brain
Hyperventilation is continuing though
PaCO2 low while HCO3 increases - dangerous
What can be used to clinically detect endogenous depression?
Dexamethasone suppression test
50% of pts w/ depression, DST will be abnormal
Hallmark of prolonged seizures
Cortical laminar necrosis
Can lead to persistent neuro deficits and recurrent seizures
Status epilepticus
Any 1 seizure > 5 mins
Cluster of seizures w/ pt not recovering normal mental stauts in between
Initial TB infection - what does it look like on CXR?
Peripheral pulmonary focus
- Gohn focus remains as calcified granuloma
Mediastinal or hilar lymphadenopathy on CXR
Hyposthenuria
Found in pts w/ sicklle cell + trait
Thought to result from RBC sickling in vasa rectae of inner medulla which impairs countercurrent exchange and free water reabsorb
Proximal muscle weakness
Spares muscles of mastication and facial expression
Dysphagia possible
What is this?
Polymyositis/Dermatomyositis
Muscle biopsy to dx
Large blunt hyphae
Thick walled budding spores
What is this?
Malassezia furfur
Causes tinea versicolor
Hypopogmented macules that do not tan
Do not appear scaly
Scale on scraping
What is this? How to tx?
Tinea versicolor
Topical selenium sulfide ltion
Ketoconazole shampoo
What do you expect in any pt w/ hx of cancer or fever who p/w back pain and neuro sx, particularly loss of bowel or bladder function?
How do you confirm dx?
What should you do 1st?
Compression of thecal sac
MRI to confirm
Glucocoritoicds (dexamethasone) to start asap so decrease risk of permanent neuro damage
Low leukocyte alk phos + leukocytosis
CML
Most impt modifiable factors for decreasing HTN
Wt control > physical activity > Na restrict > moderation of EtOH consumption
Waldenstroms macroglobulinemia
Plasma cell neoplasm
IgM spike –> hyperviscosity
Hepatosplenomegaly, lymphadenopathy Anemia --> tiredness Increased bleeding Night sweats headaches Dizziness Visual problems (retinal v engorgement) Pain and numbess in extremities --> demyelinating sensorimotor neuropathy
MM vs. Waldernstroms
MM has
IgA or IgG
Doesn’t have hyperviscosity
Big danger of pancreatic necrosis
Locally released pancreatic enzymes can increase vascular permeability w/in and around pancreas
Large volume of plasma into retroperitoneum
Hypotension mainly due to increase in vascular permeatbility!!!
Valvular consequence of aortic dissection
Best way to dx AD
Aortic regurg
Transesophageal echo (more than MRI b/c MRI is long)
Contraindicaitons to liver transplant
Irreversible cardio-pulm dz causing prohibitive risk
incurable or recent malignancy outside of liver
Active EtOH or IVDU
During acute asthma, what is one indicator of severe attack
Normal PaCO2
Should be decreased b/c hyperventilate
Normal to increased = CO2 retention b/c severe obstruct and/or respiratory muscle fatigue
How do you improve ARDS oxygenation
Increase PEEP w/ low tidal volumes on ventilator setting
How does a person get infected w/ cystercosis
If eat larvae in undercooked pork, will get intestinal infection
If eat eggs from human feces, cystercercosis happens
- larvae will invade intestinal wall adn can go to muscle, brain, subQ tissue, eye
NOT GOTTEN BY EATING INFECTED PORK AS THE ONLY WAY - POOP OF HUMAN!
When is AS symptomatic?
Valve area < 1 cm2
Systemic effects of sarcoidosis
ACE increase
Increase vitamin D
Antiphospholipid syndrome features
Arterial and venous thromoboses
Thrombocytopenia
Prolonged PTT
Avoid preggers loss w/ LMWH
Signs of glucocorticoid deficiency
Weakness
Fatigue
Loss of appetite
Eosinophilia
Presentations of P vera
HTN Increased peptic ulceration Gouty arthritis Plethoric face Splenomegaly Hypercellular bone marrow
Earliest renal abnormality in pts w/ DM
Glomerular hyperfiltration
ACEi reduce intraglomerular HTN –> decrease glomerular damage
This can eventually cause thickening of glomerular BM –> nodular sclerosis
Pneumonia + GI sx + elevated LFTs
What is this? How do you tx?
Legionella pneumoniae
Quinolone or macrolide ot tx
What is infection w/ Moraxella catarrhalis commonly assoc w/
COPD
PFTs in IPF
Decreased TLC
normal FEV1/FVC
Diffusing capacity decreased
Increased Aa gradient
Diagnostic criteria for ARDS
Acute onset
PaO2/FiO2 < 200
Bilateral infiltrates on CXR
Swann Ganz P < 18 mm Hg
What should FiO2 be if person is adequately venetillated to prevent O2 toxicity to lungs?
below 60%
Increase PEEP as needed to maintain adequate O2 after FiO2 lowered
Bilateral trigeminal neuralgia
Transient muscle weakness
What is this most likely?
MS!
MS is one of few conditions presenting w/ bilatearl trigminal neuraligia
Systemic issue w/ L sided endocarditis
Can send septic emboli to regions rich in blood supply (brain, kidney, livre, spleen)
R sided endocarditis more likely to cause septic pulm emboli
Lab values for portal HTN causing splenomegaly
Anemia
Thrombocytopenia
Expansile adn eccentric lytic area (soap bubble) in epiphysis
Pain, swelling, decreased ROM
Most get pathologic fractures
Giant cell tumor
How do you diagnose a pheochromocytoma?
CT scan
MRI better for extra adrenal catecholamine secretion
Mibg scan if cr shows nothing
Any wide complex tachyarrhythmia is what until proven otherwise?
Ventricular tachycardia
In an MI, what is your long term prognosis most influenced by?
What do you do to achieve this?
How quickly?
Duration of time that lapses before coronary blood flow restored
Use Percutaneous transluminal coronary angioplasty and fibrinolysis
- PCTA better
- should be done w/in 90 mins
Fibrinolytics should be done w/in 30 mints
Erythematous rash and maculopapular
Starts on face –> trunk and extremities
Lymphadenopathy (occipital and posterior cervical)
Arthritis in adult women
Maybe some conjunctivitis
What is this?
Rubella
Measles does not have arthritis
What are cholesterol emboli usually preceded by?
Angiography
Plaque is disrupted by catheter or guidewire
Blue toe syndrome Livedo reticularis (reddish-cyanotic reticular discoloration of skin) Acute renal failure Ab pain Sometime pancreatitis Eosinophils in blood DECREASED COMPLEMENT LEVELS
Cholesterol emboli
Infarction of
- medial vermis of cerebellum
- lateral cerebellum
Medial
- severe vertigo
- nystagmus
Lateral
- dizziness
- ataxia
- weakness
- tendedncy to sway towards side of lesion
Dizziness
Hearing loss
Tinnitus
Meniere’s disease
Pathophys of benign positional vertigo
Ca crystals in inner ear shift position
Nystagmus
Nausea
Vomitting
4 cardinal symptoms of rest less syndrome
Uncomfortable sensation/urge to move legs
Discomfort worse at night/sleep
Discomfort worse at rest
Discomfort helped by mvmt of affected limbs
Pathophys of RLS
Abnormalities of dopaminergic transmission in CNS
What vaccines should pts w/ chronic liver disease get?
Tdap (every 10) Influenza Pneumococcal vaccine (every 5) Hep A Hep B
Major causes of vit K deficiency
Inadequate diet intake
Intestinal malabsorb
Loss of storage sites due to hepatocellular disease
How long does vit K storage last?
30 day
acutely sick - 7-10 days
Hemolytic uremic syndrome
Often follows diarrhea
Thrombocytopenia
MAHA
Fever
Renal failure (rather than neuro sx of TTP)
Shiga-toxin binds to the globotriaosylceramide (Gb3) receptor on the surface of the glomerular endothelium
This action includes a cascade of signaling events leading to apoptosis and binding of leukocytes to endothelial cells.
The Shiga-toxin-activated endothelial cells then become thrombogenic (clot-producing)
Additionally, the binding action of Shiga-toxin inactivates a metalloproteinase called ADAMTS13
What should all pts w/ significant bladder outlet obstruction get?
Foley catheter
Prolonged obstruction > 2 weeks can results in permanent kidney damage
How do you best view an acoustic neuroma?
MRI w/ contrast
DO NOT miss this as reason for hyperkalemia in an asymptomatic pt
Pseudohyperkalemia
- venipuncture can hemolyze RBC –> cause K to be released
When do you tx hyperkalemia?
How do you do it?
If cardiac toxicity (EKG shows), muscular paralysis, K > 6,5
+ Ca gluconate to stabilize myocardial membrane
- push K into cells w/ insulin and/or B-agonists
- can also use Na Bicarb to shift into cells
Nonhealing ulcer
Scaling plaque w/ central ulceration
Biopsy shows polygonal cells w/ atypical nuclei at all levels of epi w/ zones of keritnization
What is this?
Squamous cell carcinoma of skin
Sunlight is risk factor
Personality changes Compulsive behaviors Impaired memory Visuospatial functions intact \+ family hx in some
What is this?
Frontotemporal dementia (Pick’s disease)
Fluctuating cognitive impairment
Bizarre, visual hallucinations
Some parkinsonism but poor response to D agonist therapy
What is this?
Lewy body dementia
Eczematous lesion on breast
Biopsy = large cells that appear to be surrounded by clear halos
What is this?
Paget’s disease of breast
Usually represents underlying adenocarcinoma
Halo cells b/c cancer cells become retracted from adjacent keratinocytes
Corneal sensation is via which nerve?
CN 5 - Trigeminal
3 most common causes of chronic cough (> 8 weeks)
Post nasal drip
Asthma
GERD
Steps to tx ascites
Na and water restriction
Spironolactone
Loop diuretic (not more than 1 L/day of diuresis)
Frequent abdominal paracentesis (2-4L/day if renal function ok)
When are vascular shunts for liver cirrhosis indicated?
Symptomatic varices
Side to side porto caval shunt to help ascites but worsens encephalopathy
Peritoneo jugular shunt tx ascites
Indications for hemodialysis
Refractory hyper K
Volume overload/pulm edema NOT responding to diuretics
Refractory met acidosis (pH < 7.2)
Uremic pericarditis
Uremic encephalopathy or neuropathy
Coagulopathy due to renal failure
Best to tx frostbite
Rapid re-warming w/ warm water (40-44)
Result in less tissue damage than slow rewarming
Osgood Schlatter disease
Overuse injury caused by repetitive strain
Young kids w/ rapid growth spurt
Avulsion of apophysis of tibial tubercle
1 COD in dialysis pts
Cardiovascular disease
GERD hx
- progressive dysphagia to solids w/o anorexia or wt loss
Benign strictures
GERD hx
- progressive dysphagia to solids w/ anorexia or wt loss
- GERD for > 20 years
Adenocarcionma of esophagus
Charcot’s joint
Neurogenic arthropathy
Usually in diabetic neuropathy
Complication of neuropathy and repeated joint trauma
Affects wt bearing joints –> functional limitation, deformity, degenerative joint disease
Persistent ST segment elevation after recent MI and deep Q waves in same leads
Ventricular aneurysm
Causes of pulsus paradoxus
Cardiac tampanode
ASthma
COPD
–> in pulm conditions b/c extra negative pressure gets more blood into lungs, further decreasing LV preload
What prevents development of pulsus paradoxus even in presence of pericardial effusion and cardiac tamponade?
Signficiant arotic regurg – causes large increase in LVEDP preventing septum shift
Pts w/ hyper PTH increased risk of developing what arthropathy?
Pseudogout - CPPD deposition
Dx lactose intolerance
Lactose hydrogen breath test
Increase H level after eat lactose –> indicates bacterial carb metabolism (as lactose no absorbed by gut so bacteria get to it)
Waddling gait
Muscular dystrophy
- weakness of gluteal muscles
Spastic gait
Lesions of UMN
Slow, stiff, effortful movements
Wide based high stepping gait
Loss of proprioception
Dorsal roots or posterior column damage
Pathology of angioedema
C1 inhibitor deficiency, dysfunction or destruction
Leads to increased C2b and bradykinin = edema producing factors
C4 levels are depressed
erythema nodosum - what is it?
Infection of fat cells
It is a panniculitis
When are you at risk for hypocalcemia due to citrate chelation
If transfuse > 1 unit/5 min
Live failure b/c liver processes citrate
Definition of HTN
- in gen pop
- in diabetics and renal disease
Gen pop > 140/90
Diabetes and renal disease > 130/80
Emergency eval of headache
Noncontrast CT to rule of ICH
Small bleeds may not show up - LP can be done if high suspicion and no bleed shown
Which headache is most responsive to ppx?
Cluster headaches
– use verapamil
Pt w/ migraines but do not respond to drugs for tx migraines. What are they?
Rebound analgesic headaches
Try and wean from analgesics!
Do you need antibiotics for bronchitis?
NO! Usually viral
Causes of laryngitis
Usually viral
Moraxella catarrhalis, H influenzae
Sore throat Ddx
Viral infection
Tonsilitis
Strep throat
Mononucleosis
When should a pt w/ GERD be screened for Barrett’s
Symptomatic for at least 5 yrs
What Pulm finding are you at risk for w/ GERD?
REcurrent aspirationi pneumonia
you can find lipid laden macrophages in cytology
Need ppx for dental procedures for these groups
- Prosthetic cardiac valves
- History of prior infective endocarditis
- Unrepaired cyanotic congenital heart disease
- Completely repaired congenital heart disease for 6 months following repair
- Repaired congenital heart disease with residual defects or abnormalities
- Cardiac transplantation recipients with cardiac valvulopathy
How to tx small focal breast cancer
Lumpectomy w/ sentinel lymph node biopsy
Irradiation
1st degree family hx colorectal cancer - what’s the screening procedure?
Age 40
OR
10 yrs younger than 1st diagnosis
1st degree heart block
First-degree atrioventricular block is diagnosed when the PR interval is greater than 0.20 sec
EKG of WPW
PR interval (<0.11 sec), prolonged QRS duration, and slurred onset of the QRS (delta wave) complex.
Chronic alcoholism pts have risk of what electrolyte abnormality if they get admitted?
Hypo phosphate
Can be normal on admissions and decrease over first 12 to 24 hrs. Possibly because of IV glucose admin
Manifestation of rapid decrease in phosphate
Confusion
Rhabdomyolysis
Hemolytic anemia
Muscle weakness
Tx gallstone pancreatitis
ERCP with sphincterotomy and stone extraction
Orthostatic prteinuria
Increase in urinary protein excretion only in uprivht psiion
Most common in yong adults or children
Urine aniongap formula
Normal value
= (U sodium + U potassium) - U chloride
How do you tell if metabolic acidosis is of renal or extrarenal origin just by labs?
Extrarenal causes of metabolic acidosis are associated with an appropriate increase in net acid excretion primarily reflected by high levels of urine ammonium excretion, whereas kidney causes of this condition are associated with low net acid excretion and decreased urine ammonium levels.
Can get Urine ammoium w/ urine anion gap
Metabolic acidosis of extrarenal origin is suggested by a large, negative UAG caused by significantly increased urine ammonium excretion. Conversely, metabolic acidosis of kidney origin is suggested by a positive UAG related to minimal urine ammonium excretion.
If pt w/ polymyagia rheumatica has a prednisone taper 2x but keeps getting flares, what should be done?
Add steroid sparing agent and incease prednisone
Example ismethoteate.
When do you need a TTE for a murmur?
3/6 or greater systolic murmur
Diastolic murmur
Continuous murmur
New murmur if last PE was healthy
PR interval length
120 to 200ms
No more than 1 large box
QRS length
80 to 120ms
3 small boxes
QT interval
< 1/2 of R-R interval
How to tell the earliest if someone has rheumatoid arthritis?
A radiograph showing marginal joint erosions would most likely support a diagnosis of rheumatoid arthritis (RA).
Erosions of cartilage and bone are cardinal features of RA. Erosions and joint-space narrowing may develop as early as 2 to 3 mos
Where do you find rheumatoid factor?
RA
Hep C
Histo of Acute promyelocytic anemia
predominant cell is a large immature granulocyte with multiple granules overlying the cytoplasm and nucleus.
AML diagnosis
The diagnosis of AML is confirmed by a bone marrow aspirate showing hypercellular marrow containing greater than 20% to 30% myeloblasts.
Once the diagnosis of acute leukemia is established, the classification is based on the morphology of the immature cells.
The presence of Auer rods confirms the myeloid nature of the leukemia.
ALL features
lymphocytosis, neutropenia, anemia, thrombocytopenia, lymphadenopathy, and hepatosplenomegaly at presentation.
An increased number of lymphoblasts found on bone marrow examination are suspicious for the diagnosis.
When to screen for asymptomatic bacteruria
pregnant women
before urologic surgery
Pt w/ TB - suggestive pleural effusion. How do you best evaluate next?
Pleural biopsy
Is a duodenal ulcer cancerous?
No
Most common causes of gastric ulcers
NSAIDs
H pylori
Diabetic retinopathy classifications
nonproliferative (with hard exudates, microaneurysms, and minor hemorrhages), which is not associated with visual decline
proliferative (with “cotton-wool spots” and neovascularization), which is associated with loss of vision.
The presence of hypotension, hyponatremia, and a decreased urine sodium excretion accompanied by a bland urine sediment raises suspicion for…..
Prerenal azotemia
Tumor lysis syndrome may manifest as what electrolyte abnormalities?
hyperkalemia
hyperphosphatemia
hyperuricemia.
Meniscal tear vs. ligament injuries (ACL)
Swelling faster in ligament injuries
Click/knock of joint w/ loose cartilage
Pain on walking
What could have happened? what tests do you do to figure this out?
Meniscal tear
Pain along the joint line is 76% sensitive for a meniscal tear
an audible pop or snap on the McMurray test is 97% specific for a meniscal tear.
McMurray test
Maximally flexing the hip and knee and applying abduction (valgus) force to the knee while externally rotating the foot and passively extending the knee
Suspect common bile duct stone for sx of pancreatitis and jaundice. But none seen on US. What do you think it is?
Abdominal ultrasonography has a sensitivity of only 50% to 75% for choledocholithiasis, and a common duct stone should be suspected in the correct clinical situation even when ultrasonography does not show a stone
Suspected osteomyelitis - you cultured the ulcer ontop of the wound and it shows X bacteria. What do you do next?
Cx from sinus tract or ulcer base don’t reflect bacterial etiology of underlying osteo
DO A BONE BIOPSY! Then do antibiotic therapy
The one exception is Staphylococcus aureus, which, if found in superficial cultures, correlates well with findings on deep cultures
Cardiac events in pts w/ long QT syndrome
Cardiac events in patients with LQTS include syncope and cardiac arrest due to torsade de pointes ventricular tachycardia.
Risk factors Long QT
female sex hypokalemia hypomagnesemia structural heart disease previous QT-interval prolongation history of drug-induced arrhythmia
Familial syncope…causes?
Long QT syndrome
When do you consider HIT?
HIT/T should be considered in any patient with an otherwise unexplained decrease in the platelet count and/or a new thrombotic event 5 to 10 days after initiation of heparin therapy.
Gold std diagnose HIT
14C-serotonin release assay (SRA)
Abnormal uterine bleeding - what types
infrequent menses, excessive flow, prolonged duration of menses, intermenstrual bleeding, and postmenopausal bleeding.
Asthma exacerbation - signs of respiratory failure
Slightly elevated or even normal Paco2 levels often indicate impending respiratory failure rather than recovery,
pulse oximetry less than 95%, respiration rate greater than 30/min, and heart rate greater than 120/min
Dx ankylosing spoindyliis
MRI of sacroiliac joints
If pt w/ CRF is without fluid overload, hyperkalemia, metabolic acidosis, or uremic symptoms, what do you do for them?
Keep them on meds
Hemodialysis or Kidney replacement therapy can be delayed
. Transplantation in patients who have not yet been treated with hemodialysis is associated with better patient and allograft outcomes.
Whaty is the most appropriate option patient with continued anginal symptoms despite optimal medical therapy.
Coronary angiograph
Coronary revascularization is beneficial in patients with chronic stable angina and the following conditions
angina pectoris refractory to medical therapy; a large area of ischemic myocardium and high-risk criteria on stress testing; high-risk coronary anatomy, including left main coronary artery stenosis or three-vessel disease; and significant coronary artery disease with reduced left ventricular systolic function
Risk factors for legionnaires disease include
smoking, diabetes mellitus, hematologic malignancy, other types of cancer, chronic kidney disease, and HIV infection.
Test for legionella?
Leginoella urinary antigen test
The patient is having a moderate to severe exacerbation of chronic obstructive pulmonary disease (COPD)…what do you do?
should be placed on noninvasive positive-pressure ventilation (NPPV).
A landmark study found that NPPV reduced the need for intubation, the length of hospital stay, and the mortality rate in such patients.
Contraindications to NPPV include
impending respiratory arrest, cardiovascular instability, altered mental status, high aspiration risk, production of copious secretions, and extreme obesity, as well as surgery, trauma, or deformity of the face or upper airway.
What do you suspect in patients with explosive onset, widespread psoriasis and the occurrence of dactylitis; marked distal interphalangeal (DIP) joint involvement; asymmetric joint involvement; symptoms of enthesitis; or joint ankylosis.
HIV-related psoriatic arthritis
Diarrhea + N/V
Cause?
VIral gastroenteritis
Food poisoning
Diarrhea + fever + blood in stool
Shigella
Campylobacter
Salmonella
E. coli
Diarrhea + no fever + no blood
VIruses (rotavirus)
Entertoxic E coli
Food poisoning (Staph aureus, C. perfringens)
Fecal leukocytes in
C diff Camylobacter Salmonella Shigella EIEcoli
Endocrine causes of conspitation
hypo TH
Hyper Ca
Hypo K
Uremia
Dehydration
1 way decrease SBP
Reduce BMI
Severe diarrhea electolyte disturbancce
Metabolic acidosis
Hypo K
Vomiting electrolyte disturbance
Metabolic alkalosis
Hypo K
Positive straight leg test means…
Nerve root compression
If low back pain in the absence of progressive neuro deficits, osteoporosis, steoird use, constitutional sx, hx of malignancy, recent trauma, IV drug use, is refractory to conservative tx for at least how many months, what should you do next?
3 months
MRI
Osteochondritis dissecans
Area of necrotic bone and degenerative changes in overlying cartalage
Bone and cartilage can separate and become loose –> pain, catching and popping
Plica syndrome
Dx of exclusion
Usually in atheletes w/ overuse injuries
Most common ankle ligament injured
Anterior talofibular ligament
Trochanteric bursitis
Common cause of lateral hip pain
Very painful on palpation
Tx w/ NSAIDs
Tests for carpal tunnel syndrome
Tinel’s sign
- tap over median N @ wrist –> paresthesias
Phalen’s test
- palmar flexion of wrist for 1 min –> paresthesias
Definitive dx of carpal tunnel
Electomyography and nerve conduction velocity study
Cartilage vs. bone –> which one has nerve endings?
Bone!
That’s why in arthritis, wear down cartilage and don’t notice but will notice once bone starts rubbing against each other!
Where is pain of osteoarthritis of hip?
In groin
Can radiate to anterior thigh
Where do you hold the cane for L knee pain?
R hand
Is there a correlation b/n x ray osteoarthritis and severeity of disease?
No
Type 1 vs type 2 osteoporosis
Type 1 - more trabecular bone loss
Type 2 - = trabecular and cortical bone loss
Calcitonin effects
No help w/ hip
Helps w/ spine (lumbar)
Which osteoporotic fracture has highest morbidity and mortality?
Hip
SENSORINEURAL HEARING LOSS PATHOPHYS
DEGENERATION OF SENSORY CELLS AND NERVE FIBERS AT BASE OF COCHLEA
Screening for ab aortic aneurysm
w/ US at age 65 in all men w/ smoking hx - only 1 test needed, no repeat if normal
Osteoporosis screening
DEXA scan starting at 65
RBBB
Wide QRS
rSr in chest leads
Wide S in lead I
LBBB
Wide QRS
No Q in I, V5, V6
Notched R in I, V5, V6
Q waves pathologic if
> 0.04 s wide
> 25% height of QRS
T wave inversions in
MI Pericarditis Cardiomyopathy INtracranial bleed Acidosis LBB LVH
Peaked T waves in
early MI
Hyper K
Hyper Mg
To do ASAP after putting in central venous line
CXR to check for pneumothorax
Causes of rales
fluid in lungs
atelectasis
pneumonia, CHF, ILD
Causes of wheezes
Asthma
Causes of rhonchi
Chronic bronchitis
Snoring quality, low pitch, due to lots of mucus
Type 1 error
Null hypothesis rejected even though it is true
FALSE +
Type 2 error
Null hypothesis not rejected even though it is false
False -
Effects of increase mineralocorticoid secretion
Increased tubular reabsorb of Na and HCO3
Loss of Cl in urine
Metabolic alkalosis and expansion of ECF
PaCO2 mainly determined by
Respiratory rate
Tidal volume
How much does 1 unit of packed RBC increase Hb level?
Hb increase by 1
Hct increased by 3
Hb x 3 = Hct
FFP
All clotting factors
NO RBCs, WBCs, platelets
Cryoprecipitate
Factor 8
Fibriongen
For hemophili A, DIC, vWD
Dx beta thalassemia
Hemoglobin electrophoresis
- increase HbF and HbA2
Periph blood smear
- microcytic
- hypochromic
- target cells maybe
Tx thalassemias
frequent PRBC transfusions
Clinical features of b-thalassemia
Anemia
Hepatosplenomegaly
Expansion of marrow space
Crew cut skull
Sideroblastic anemia
- what is it?
- causes?
- tx?
Abnormality in RBC iron metabolism
Hereditary or acquired
Chloamphenicol
INH
Alcohol
Lead
Collagen vascular disease
Myelodysplasia
Tx w/ removing offending agent, B6
Consequence of aplastic anemia
Transform into leukemia
Increased infections
Causes of B12 deficiency
Pernicious anemia
Gastrectomy
Vegans
Alcoholism
Crohn’s disease
Diphyllobothrium latum
SIBO
Causes of folate deficiency
Tea and toast diet
Alcoholism
Long term antibiotic use
Increased Demand
Preggers
Hemolysis
MTX, phenytoin
Hemodialysis
Signs of intravascular hemolytic anemia
Dark urine color (hemoglobinuria)
Schistocytes
Low haptoglobin
Increased LDH
Signs of extravascular hemolytic anemia
Spherocytes or helmet cells
Increased LDH
Increased unconjugated bilirubin –> jaundice
What does sickle cell survival correlate with?
Frequency of vaso occlusive crises
More = shorter lifespan
Aplastic crisis in sickle cell
- precipitants
- tx
Caused by virus (eg parvo B19)
Tx blood transfusion
Splenic sequestration crisis
Sudden pooling of blood into spleen –> splenomegaly + hypovolemic shock
Happens in sickle cell adn beta thal
More common in kids b/c they ahve intact spleens
Consequences of sickle cells
Painful bone crises Dactylitis Acute chest syndrome (repeated episodes of pulmonary infarctions) Splenic infarctions Avascular necrosis of joints (hip, shoulder) Priapism Renal papillary necrosis w/ hematuria Chronic leg culcers b/c vaso occlusion Ab crises Infections w/ H influenzae, strep pneumo Salmonella osteo
Manage painful crises
Hydration
Morphine for pain
Keep pt warm
Supplemental O2 if hypoxic
When do you do blood transfusion for sickle cell?
Acute chest syndrome
Stroke
Unresponsive priapism
Cardiac decomp
Paroxysmal noctual hemoglobinuria
Deficiency of anchor proteins linking complement-inactivating proteins to blood cell membranes
Intravascular hemolysis
Pancytopenia
Dx PNH
Ham’s test
- pt cell incubated in acidified serum –> triggers alternative complement –> lysis of PNH cells
Sugar water test
- mix pt’s serum in sucrose –> hemolysis if PNH
Flow cytometry to detect CD55 or 59
Tx PNH
Glucocorticoids (prednisone)
- most don’t respond
Platelet disorders
ITP TTP HIT Bernard Soulier Glanzmann's
Idiopathic thromocytopenic purpura
- what is it
- clinical features
- dx
- tx
IgG antibodies on platelets –> removed by spleen
Minimal bleeding
NO splenomegaly
Dx
- plt count < 20,000
- low periph platelets
- increased megakaryocytes
Tx
- steroids
- IV immunoglobulin
- splenomgaly
- plt transfusions
- romiplastim, eltrombopag
Thrombotic thrombocytopenic purpura
- what is it
- clinical features
- tx
Plt consumption disorder
Plt count decreased
PT, PTT normal
TTP = HUS + fever + AMS
Features
- hemolytic anemia
- thrombocytopenia
- renal failure
- fever
- neuro signs
Tx
- plasmapheresis
- steroids, splenectomy
- NO plt transfusions
Bernard Soulier
AR
Deficiency in GpIb
Plts large, plt count low
Glanzman’s thrombathenia
AR
Deficiency in GpIIb-IIIa
Plt count NORMAL
Thrombin time
Measure of fibrinogen concentration
Bleeding time
Reflects plt function
Of clotting factors, which has shortest 1/2 life? How does this affect PT or PTT
Factor 7
PT increases 1st with clotting factor deficiency
Inherited hypercoagulable states
AT 3 deficiency (AD)
Antiphospholipid antibody syndrome (acquired)
Protein C deficiency (AD)
Proetin S deficiency
Factor 5 leiden (protein C can’t activate factor 5)
Prothrombin gene mutation
Hyperhomocysteinemia
How long are you hypercoagulable for preggers?
All of preggers
2 months postpartum
Highest incidence of cancers in men
Prostate > lung > colon
Higher mortality cancers in men
Lung > prostate > colon
Highest incidence of cancers in women
Breast > lung > colon
Highest death cancers in women
Lung > breast > colon
Oncologic emergies needing immediate tx
Hyper Ca
- fluids, diuretics, bisphosphanates
Spinal cord compression
- steroids, MRI
Pericardial tamponade
- pericardiocentesis
Tumor lysis syndrome
- IV fluids
- tx electrolyte abnormalities
DCIS vs LCIS - which is palpable?
DCIS
1st step for breast mass in woman > 30
Biopsy
When do you need chemo after removing breast lump?
Don’t need it for small lesions (< 1cm) w/o lymph node involvement
Indicates poor prognosis staging in CLL
Thrombocyotpenia
Dx MM
> 10% abnormal plasma cells in bone marrow + 1 of the following:
M protein in serum
M protein in urine
Lytic bone lesions
Waldenstrom’s macroglobulinemia
Malignant prolif of plasmocytoid lymphocytes
IgM
No bone lesions
NO cure
Dx Hodgkin’s lymphoma
Biopsy of lymph node shows Reed Sternberg cells
Clinical features of Hodgkin’s lymphoma
Painless lymphadenopathy
Constitutional symptoms (poorer prognosis)
Spread continuity from 1 lymph node to adjacent lymph node
Pruritus
Cough
Myelodysplastic syndrome
Acquired clonal blood d/o
Ineffective hematopoiesis
Apoptosis of myloid precursors
Results in pancytopenia despite normal or hypercelllular bone marrow
Abnormalities of myelodysplastic syndromes
Low retic count
Howell Jolly bodies
Basophilic stippling
Ringed sideroblasts
Tx myelodysplastic syndrome
RBC and plt transfusions
EPO
GCSF
Vit B6, 12 folate for cell turnover
Essential thrombocythemia
Plt > 600,000
Dx of exclusion
Splenomegaly
Pseudohyper K
Elevated bleeding time
Increased megakaryocytes in bone marrow
Normal pulse in setting of high fever is suggestive of…
atypical CAP
Approach to CAP
Lower vs. upper?
- nasal discharge, sore throat –> usually upper
If lower, is it PNA vs. bronchitis?
- CXR to tell
If CXR not suggestive of PNA, what do you do
DO NOT tx w/ antibiotics
False negative CXR for PNA in…
Neutropenia
Dehydration
PCP
Early disease
PNA hints
- alcoholics
- immigrants
- nursing home
- HIV +
- transplant recipients
Alcoholics - Klebs
Immigrants - TB
Nursing home - Pseudomonas
HIV - PCP, M TB
Transplant - Legionella
If suspect PNA is the following, how do you test?
TB
PCP
Legionella
TB - acid fast
PCP - silver stain
Legionella - urinary antigen
When do you admit for PNA?
If pt is hypoxic or hypotensive
Parts of lungs most affected by aspiration lung abscess
Posterior segments of upper lobes
Superior segments of lower lobes
Right lung more affected
CXR of lung abscess
Thick walled cavitation w/ air fluid levels
Who is contagious w/ TB
Active TB
Primary TB NOT contagious
Radiologic findings in primary TB
Ghon’s complex
- calcified primary focus w/ assoc lymph node
Ranke’s complex
- Ghon complex –> fibrosis and calcification
Primary Tb
usually asymptomatic
May have pleural effusion
Secondary (active) TB
Constitutional sx
Dry cough –> purulent sputum
Apical rales
Definitive dx of TB
Sputum culture
PCR
PPD
DO NOT use to dx active TB - only for latent TB
If pt is symptomatic or has abnormal CXR, order sputum acid-fast test, not PPD
Positive PPD:
No risk factors: >= 15
High risK> 10 mm
HIV, acitve TB close contacts : 5 mm
If person had BCG vaccine and positive PPD, what do you do?
INH for 9 months no matter what!
When do you stop TB tx as a result of adverse effects?
If liver transaminases rise to 3-5x upper limit of normal
Kerning’s sign
Can’t fully extend knees when supine
Irritate meninges
Brudzinski’s sign
Flex legs adn thighs that is brough on by passive flexion of neck
Irritate meninges
Dx meningitis
LP
Do a CT scan 1st
Get blood cx before start abx
Best way to Dx viral encephalitis
CSF PCR
Best way to Dx encephalitis
MRI of brain
Transmission
- Hep A
- Hep B
- Hep C
- Hep D
- Hep E
A, E - fecal oral
B - sex, parenteral
C - parenteral
D - w/ hep B
If transaminases are really elevated, what do you think of?
Viral hepatitis
Shock liver
Drug induced hepatitis
Symmetric descending flaccid paralysis
Botulism
Dx botulism
ID toxin in serum, stool, or gastric contents
How does a UTI happen?
Colonization of vaginal area by pathogens from fecal flora
E. coli Staph saprophyticus Enterococcus Klebs Proteus
You suspect HUS in someone. What do you do next? How do you tx?
Peripheral blood smear to diagnose
Tx is supportive
Do not use abx
May need dialysis if ARF, PRBC for anemia
Only do platelet transfusion if bad. Otherwise can make worse
Do we recommened screening for early stage lung cancer even if pt smokes?
NO
How to dx acute parvovirusB19 infection?
IgM Abs
Transient aplastic crisis in pts w/ chronic hemolytic anemia - what do you think happened?
Parvo B19 infection
Pink pearly nodules w/ telangiectasias + flecksof melanin pigment
What is this?
How to tx?
Basal cell carcinoma
Superficial lesions tx w/ curettage, imiquimod, cryotherapy, or excision
How do ou improve survival in severe sepsis?
Agggressive fluid rescussitation
If lactic acid resolves in 6 hrs, good for survival
5-6L fluids/6hrs.
Causes of prostatitis
Usually gm -
E coli Klebs Proteus Pseudomonas Enterobacter Serratia
Which is worse - acute vs chronic prostattis?
- how do you tell what it is?
Acute
Acute - prostate tender - fever - pt looks ill DO NOT MASSAGE THE PROSTATE as can cuse bacteremia WBC in UA, U cx always + for bacteria
Chronic
- prostate may not be tender
- pt doesn’t look ill
- WBC in UA, U Cx may or may not be +
Most common STD? Most cmmon bacterial STD?
STD - HPV
Bacterial STD - chlamydia
Leading cause of infertility in women
Chlamydia b/c of tubal scarring
Complication of gonorrhea and chlamydia
Infertility
Fitz-hugh curtis syndrome
When do you do csection for hIV + mom?
Viral load > 1000 copies
Best indicator of status of immune system ad risk for opportunistic infections and disease progressio
CD4 count
> 500, immune system normal
Best indicator of adequacy and response to antiretrovirals?
Viral load (HIV-1 RNA levels)
Leading cause of death in pts w/ AIDS
PCP
When at increased risk for CMV or MAC w/ HIV?
CD4 < 50
Dx cryptococcal meningitis
CSF ID
tain w/ india ink
When do you see esophageal candidiasis in HIV?
CD 4 < 100
How long to seroconvert to HIV +
3-7 weeks
When does ELISA become + for HIV?
1-12 weeks after infection
If negative, usually doesn’t have HIV
When do you say someon has AIDS?
CD4 < 200
PCP signs
Dyspnea, dry cough, fever
CD4 < 200
CXR = bilateral interstitial infiltrates
Increased LDL
Hypoxia
Bronch to dx fully
When do start px for MAC in HIV?
CD4 < 100
Where does HSV stay latent?
dorsal root ganglia
Reactivaton of HSV assoc w/
stress
fever
infection
sun exposure
How to tx herpetic whitlow?
Acyclovir
DO NOT incise and drain
Dx herpes
Tzanck smear - quickest - shwes multinucleated giant cells
Cultur of HSV is gold standard (2-3 days)
ELISA
Most common presentations of syphillis
Chancre
Inguinal lymphadenopathy
Maculopapular rash of 2ndary syphilis
Dx syphilis
NOntreponemal test - RPR, VDRL
- very sensitive
- if +, confirm w/ specific treponemal test
- can be + w/ SLE
Treponemal test - FTA-abs, MHA-tp
- more specific
- not for screening, just to confirm
Lymphogranuloma venereum
STD by C. trachomatis
Painless ucer at site of inoculation –> tender inguinal lymphadenopathy few wks later –> constitutional sx
How to dx cellulitis?
Clinical!
It is inflammation of skin adn subQ tissue
When is cellulitis med emergency?
Orbital involvement
Likely cause of cellulitis if caused by break in skin
Group A srep
Likely cause of cellulitis if caused by wounds, abscesses
Staph aureus
Likely cause of cellulitis if caused by immersion in water
Pseudomonas
Aeromonas
Vibrio vulnificus
Likely cause of cellulitis if caused by acute insusitis
H. influenzae
Erysipelas
- what is it
- tx
Celluitis confined to dermis and lymphatics
Usually caused by group A strep
Tx IM penicllin or erythromycin
Necrotizing fascitis
- what is it
- common causes
- clinical features
Infectio of deep soft tissues rapidly tracking along fascial planes
Strep pyogenes
Clostridium perfringens
Fever and pain out of proportion to appearance of skin
Tissue necrosis
Crepitus
Lymphadenitis
Inflammation of lymph node usually due to local skin or soft tissue bcterial infection
Tender lymph nodes, red streaking of skin from wund or area of cellulitis
Dx of tetanus
Clinical
Tx tetanus
Neutralize unbound toxin w/ passive immunization
Give 1 dose IM tetanus immune globulin
+ active immunizaton w/ Tdap
When do you give tetanus immunoglobulin?
If suspect pt is not immunzed for tetanus and has a bad woud. Don’t need it in minor wounds for these ppl
When do you give tetanus/diptheria toxoid
If suspect pt is not immunized for tetanus and has clean, minor wound or worse
Common osteo bugs in catheter septicemia
Staph aureus
Common osteo bugs in prosthetic joint
Coag-negative staph
Common osteo bugs in diabetic foot ulcer
polymicrobial
Common osteo bugs in nosocomial
pseudomonas
Common osteo bugs in IV drug use, neutropenia
Fungal
Pseudomonas
Common osteo bugs in sickle cell
Salmonella
Common osteo bugs in vertebrae
M. TB
Pott’s disease
How do you use ESR for osteo?
Monitor response to therapy
Best way to dx osteo
Needle aspiration of infected bone
MRI
Most common joint affected in septic arthritis
Knee
What do you do for septic arthritis?
Joint aspiration + analyze synovial fluid
Tx immediately if suspect - do not delay starting abx
Most impt tests to confirm clinical suspicion of Lyme disease
ELISA
Western blott to confirm
Pathophys of RMSF
Rickettsia rickettsii multiply in vascular endothelium adn spred to diff layers of vasculature
Damage endothelium –> increased vascular perm –> activate complement, microhemorrhages, microinfarcts
Dx is clinical
Fever patterns of P falciparum P ovale P vivax P malariae
P falciparum –> constant
P ovale, vivax –> every 48 hr spike
P malariae –> every 72 hrs spike
How do you screen for HCC? How can you dx w/o Bx?
Ultrasound
Patients with a compatible ultrasound imaging study and a subsequent serum α-fetoprotein level greater than 500 ng/mL (500 µg/L) can be diagnosed with hepatocellular carcinoma without a biopsy.
Corrected [HCO3]
= measured [HCO3] + (measured anion gap – 12)
Dx diffuse parenchymal lung disease
High-resolution CT (HRCT) is more sensitive than chest x-ray for DPLD and reveals ground-glass and reticular linear opacities, subpleural cysts, and honeycombing in patients with advanced disease.
Mycobacterium avium intracellulare
causes fevers, diarrhea, malabsorption and anorexia, and can disseminate to the bone marrow
Always consider in HIV pts w/ diarrhea
Bronchial breath sounds - meaning
when bronchial breath sounds are heard in a location other than the trachea, it is suggestive of pulmonary consolidation
V/Q mismatch examples
pneumonia, pulmonary edema, and COPD/asthma
Pulmonary shunt
- what is it
- examples
extreme form of V/Q mismatch where there is no ventilation.
This is clinically recognized when a patient who is hypoxic fails to respond to oxygen.
right-to-left intracardiac shunt
acute respiratory distress syndrome (ARDS)
PTT and BT affected. What does this person have?
von Willebrand disease is one of the few hemostatic disorders characterized by both a platelet and coagulation defect due to a reduction or defect in von Willebrand factor (vWF), which supports platelet adhesion and also serves as a carrier protein for factor VIII.
The diagnosis is confirmed by measuring the vWF antigen level and activity.
The three classic findings in chronic pancreatitis are
abdominal pain that is usually mid-epigastric,
postprandial diarrhea,
diabetes mellitus secondary to pancreatic endocrine insufficiency.
Dx w/ CT
The presence of pancreatic calcifications on radiographs confirms the diagnosis.
A patient with a breast mass requires
triple assessment:
palpation,
mammography
ultrasonography (if BI-RADS 1-3, skip to biopsy if 4,5)
—> distinguishes cystic from solid mass
biopsy (FNA) or aspiration
5 major cardiovascular risk factors
cigarette smoking,
hypertension,
older age (men ≥45 years; women ≥55 years),
low HDL-cholesterol level (<65 years).
Goal LDL in pts w/ 0-1 cardio risk factors
below 160 mg/dL (4.1 mmol/L).
Allergic bronchopulmonary aspergillosis
typ 1 HS rxn
Asthma
Eosinophilia
Pulmonary aspergilloma
Inhale spores into lung
Chronic cough, hemoptysis
Can resolve spontaneously; may need lung lobectomy
invasive aspergillosis
hyphae invade lung vasculature –> thrombosis and infarction
Immunocomp at risk
Diffuse bilateral pulm infiltrates
Dx aspergillosis
Fungus ball on CXR
Sputum has aspergillosis
Blood cx not helpful
What is characteristic of tissue biopsy of cryptococcus?
Lack of inflammatory response
What should you be suspicious of for persistent fever in ICU?
Fungal infection
Antimicrobial resistance
Needing surgery (abscess)
Drug fever
Top causes fever of unknown oritin
Infection - TB, endocarditis, HIV
Neoplasms - lymphoma, leukemia
How many organs must be involved to be TSS?
3
Renal GI Heme MS CNS
Before starting oral retinoids, what do you ABSOLUTELY need to do for fems?
Get 2 negative pregnancy tests
Use 2 forms of BC for 1 month before starting med through 1 month after stopping med
How do you tell between SCC and keratoacanthoma
Keratoacantoma grows SUPER FAST
Hypersensitivity of allergic contact dermatitis
Type 4
Eg poison ivy
Is pityriasis rosea contagious?
NO
Multiple round/oval patches appear than generalized rash w/ multiple oval shaped lesions. What is this?
Pityriasis rosea
Usually not on face
Common infectious cause of erythema multiforme
HSV
Acyclovir can help prevent HSV assoc EM
What should you always rule out when child presents w/ molluscum contagiosum?
Child abuse
It is highly contagious, may have sex abse
Marjolin’s ulcer
SCC arising from chronic wound such as previous burn scar
Usually very aggressive
Who has better prognosis for malignant melanoma - men or women?
Women
Most impt indicator of melanoma prognosis
Depth of invasion
Angioedema vs. urticaria
Angioedema is deeper in skin (deep skin/subQ)
Angioedema is more tender and burning vs. pruritic b/c fewer mast cells/sensory N endings in deeper tissues
Hypersensitivity rxns 1-4
1 - IgE
2 - IgG (Goodpastures, pemphigus vulgaris)
3 - Antigen-Ab complex (SLE, serum sickness)
4 - T cell mediated (poison ivy, TB)
How long dos it take for a drug allergy to appear?
1 month
Usually not less than 1 week
Diagnose cobalamin deficiency in a patient with a low-normal vitamin B12 level with…
methylmalonic acid and homocysteine measurements.
Levels of methylmalonic acid and homocysteine become elevated in patients with vitamin B12 deficiency before serum vitamin B12 levels decrease below the normal range
How do you get hypo Ca in acute pancreatitis?
Acute pancreatitis can generate free fatty acids that chelate insoluble Ca salts –> hypo Ca
This is saponification
All pts w/ acute monoarthritis should be suspected to have….
Septic arthritis
Arthrocentesis to dx
usually manifests as acute monoarthritis and is characterized by pain on passive range of motion in the absence of known trauma.
MRI of joints is useful when?
detecting avascular necrosis
soft-tissue masses
collections of fluid not visualized by other imaging modalities
peripheral blood smear showing few, but large, platelets supports the presence of
a young population of platelets, consistent with increased turnover.
ITP!
For parapneumonic effusion, what situations/characteristics are abx not enough? How else do you tx?
the presence of loculated pleural fluid,
pleural fluid with a pH less than 7.20,
pleural fluid with a glucose < 60 mg/dL
lactate dehydrogenase > 1000 U/L,
positive pleural fluid Gram stain or culture,
presence of gross pus in the pleural space
Chest tube or catheter drainage to tx too
Drug induced lung toxicity
hypersensitivity-type reaction, with presenting symptoms of fatigue, low-grade fever, cough.
Peripheral blood eosinophilia may be present.
AMIODARONE is a common cause
Acute eosinophilic pneumophilia is MUCH FASTER progressing than this so can r/o if disease has been around for awhile
How does handgrip help HOCM murmur?
increasing afterload and decreasing the relative pressure gradient across the left ventricular outflow tract.
Aortic stenosis vs. HOCM - differences
HOCM is associated with rapid upstrokes of the carotid arteries,
aortic stenosis, is associated with a carotid artery pulsation that has a slow up-rise and is diminished in volume.
murmur of aortic stenosis decreases with the Valsalva maneuver.
decreased anion gap in the presence of anemia, proteinuria, hypercalcemia, and renal failure suggests
Multiple myeloma
How does low anion gap happen in MM?
Most unmeasured anions consist of albumin. Therefore, the presence of either a low albumin level or an unmeasured cationic light chain, which occurs in multiple myeloma, results in a low anion gap.
Milk alkali
characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali
Often w/ excess milk and antacids for dyspepsia
Glomerular vs. nonglomerular hematuria
RBC casts in glomerular
Normal RBC in nonglomerular
Evaluate persistent hematuria with
cystoscopy
The best way to screen for hearing loss is the
whispered voice test.
dyspnea at rest or on exertion, platypnea, and hypoxemia in the setting of chronic liver disease.
hepatopulmonary syndrome
The hypoxemia results from pulmonary vascular dilatation with intrapulmonary shunt and ventilation-perfusion mismatch, which may worsen when the individual is in an upright position.
CXR is nl
Cells of sickle cell
Sickle cell
Target RBC
Criteria for Type 2 DM
fasting plasma glucose level of at least 126 mg/dL
a random plasma glucose level of at least 200 mg/dL
and symptoms of hyperglycemia (for example, polyuria, polydipsia, or blurred vision),
or a 2-hour oral glucose tolerance test (OGTT) result of at least 200 mg/dL
Impaired fasting glucose is diagnosed when
the fasting plasma glucose level is in the range of 100 to 125 mg/dL
impaired glucose tolerance
plasma glucose level at the 2-hour mark of an OGTT is 140 to 199 mg/dL
Imaging results of ischemic colitis
What is a definitive diagnosis?
Thickened bowel wall on CT
The finding of patchy segmental ulcerations on colonoscopy in a patient with a compatible history establishes the diagnosis.
Management of hyperglycemic hyperosmolar syndrome mainly involves
identifying the underlying precipitating illness and restoring a markedly contracted plasma volume.
Insulin reduces glucose levels but should be administered only after expansion of the intravascular space has begun.
Potassium should not be administered until urine output is verified, because these patients are prone to acute kidney injury.
Incidental asymptomatic adrenal mass - what do you do next?
Plasma-free metanephrine levels (for pheo)
overnight dexamethasone suppression test (Cushing’s)
Adrenal incidentalomas unlikely to secrete aldo and screen if have HTN or hypo K
Acute chest syndrome in patients with sickle cell anemia should be managed by
exchange transfusion.
Red blood cell exchange transfusions are performed to increase the hemoglobin A level to at least 50% and thereby decrease the percentage of abnormal sickle cells and prevent hemoglobin S polymerization and sickling.
Will see pulm infiltrate on CXR for acute chest syndrome
Dark blue or black berry like lesions that are symmetric, elevated, and one color
Nodular melanoma
Usually in older
Tend to expand vertically rather than horiz
Goal LDL of pts with previous stroke or TIA
Less than 100
Who should get HPV vaccine?
All girls between 9 and 26 regardless of sex activity
Genital herpes lesions
Vesicles that ulcerated and are painful.
Can have crusted roof
Chancroid lesions
Deep ragged ulcers
Purulent
May have tender lymph nodes
Prosthetic joint infection
Pain is main sx
Usually no fever or leukocytosis
Arthrocentesis is gold std to dx
Zinc excess can cause…
Copper deficiency
Copper def can look like b12 def and have demyelination
Patients with new-onset heart failure and angina should be evaluated with
cardiac catheterization and angiography if they are possible candidates for revascularization.
Patients with new-onset heart failure and angina should be evaluated with
cardiac catheterization and angiography if they are possible candidates for revascularization.
Sequelae of infective endocartitis
Fever Roth's spots (white spots on retina) Osler nodes (tender nodes on fingers or toes) Murmur Janeway lesions (painless erythematous lesions on palm) Anemia Nailbed Hemorrhage Emboli
HUS commonly manifests as
acute kidney injury (AKI) accompanied by thrombocytopenia and microangiopathic hemolytic anemia (schistocytes on peripheral blood smear).
When is prostate cancer screening beneficial?
Under 75 years old
how to reduce the risk of ventilator-associated pneumonia (VAP).
Semi-erect position
Oral placement of endotracheal tubes better than nasal placement
Osteoporosis screening guidelines
Guidelines recommend that screening for osteoporosis begin at age 65 years for women. Women aged 60 to 64 years should be screened if they are at higher than average risk for osteoporosis.
The most predictive risk factor for osteoporosis is weight below 70 kg (154 lb), as with this patient.
Pneumococcal vaccine is indicated for
persons age 65 years and older or for those younger than 65 years who live in long-term care facilities, or who have chronic illnesses, or who are Alaskan natives or American Indians.
Which acute hepatitis rarely causes symptoms?
C
cosyntropin stimulation test
is used to determine the adrenal reserve by measuring the response to a standard dose of synthetic adrenocorticotropic hormone.
The test does not detect Cushing syndrome but, rather, adrenal insufficiency
the most common causes of cirrhosis in the United States
Alcohol and chronic hepatitis C infection are
drinks to cause alcoholic cirrhosis
6 alcoholic drinks per day for men
3 alcoholic drinks per day for women for 10 years
Bowen disease
SCC in situ
Gradually enlarging
Well demarcated
erythematous scaly plaques
can look like psoriasis, BCC, eczema
Cryptogenic organizing pneumonia
Alveolar filling opacities on CXR
The tempo of the disease process is the key to differentiating COP from other interstitial lung diseases.
COP is often acute or subacute, with symptom onset occurring within 2 months of presentation in the majority of patients.
The presentation is so suggestive of an acute or subacute lower respiratory tract infection that patients have almost always been treated with and failed to respond to one or more courses of antibiotics before diagnosis.
How does a mixing study help w/ diagnosing disorders in coagulation?
The results of the mixing study will normalize in a patient with a factor deficiency but will remain abnormal if an inhibitor is present.
classic ekg finding for pe
s1q3t3
For what women is there no proven benefit to routine Pap testing to detect cancer.
In asymptomatic women who have had a complete vaginal hysterectomy for benign disease
Still need it if did a complete vaginal hysterectomy but for a malignant disease reason
Also need to screen if have cervix in still
1st step for tx hyper K
intravenous calcium gluconate
THEN:
Sodium bicarbonate and β-antagonists such as albuterol and glucose (with or without insulin) would facilitate intracellular potassium shift.
How do you tell DIC from HUS and TTP?
Neither TTP nor HUS is associated with elevations of the prothrombin or partial thromboplastin time or the D-dimer or depression of the fibrinogen level.
Do you tx salmonella diarrhea w/ abx?
No, only some cases (severly ill, young, immunocompromised)
May prolong disease duration!
When do you do tests for lymphadenopathy?
patients with systemic symptoms,
progressively enlarging lymph nodes,
or persistently enlarged nodes for more than 2 weeks
If lymph node < 2 cm, don’t need to do tests!
How do you 1st manage prostate cancer screening?
physicians discuss potential, but uncertain, benefits and possible harms (complications of future diagnostic testing and therapies, including incontinence; erectile dysfunction; and bowel dysfunction) before ordering PSA testing
Osteoporosis is diagnosed by
the presence of fragility fractures (fracture secondary to minor trauma, such as falling from a standing position),
or by a bone mineral density (BMD) T-score less than −2.5 in patients who have not experienced a fragility fracture.
AST vs ALT - which is more specific to liver tissue?
ALT
Cholestatic injury (cholestasis),
which consists of a lack of or an abnormality in the flow of bile,
is indicated primarily by an elevation of serum alkaline phosphatase and relatively minimal elevations of AST and ALT.
only calcium channel blockers with demonstrated neutral effects on mortality in patients with heart failure.
Amlodipine and felodipine
First-generation calcium channel blockers (such as nifedipine) have been shown to increase the risk of heart failure decompensation and hospitalization.
Pt with severe, rapidly progressive pneumonia, especially during influenza season…waht do you suspect? What should you give to tx?
Methicillin-resistant Staphylococcus aureus (MRSA) should be suspected
cefotaxime, levofloxacin, and vancomycin.
Peptic ulcer in gastric antrum - what do you do?
Biopsies of all gastric ulcers should be performed, because even small, benign-appearing gastric ulcers may harbor malignancy
Treatment for peptic ulcer disease is guided by the biopsy and presence of H. pylori infection.
How do you screen for bleeding d/o prior to surgery?
Clinical hx!
In the absence of a personal or family history of abnormal bleeding, liver disease, significant alcohol use, malabsorption, or anticoagulation therapy, the likelihood of a bleeding disorder is low, and no further preoperative testing is required.
Patients with any of these risk factors should be screened further by obtaining a prothrombin time (PT/INR), an activated partial thromboplastin time, and a platelet count.
The treatment for an acute STEMI is
either revascularization or thrombolytic therapy.
Thrombolytic agents are an alternative to primary PCI in suitable candidates with STEMI. How long before you give it?
Thrombolytics should be administered within 12 hours after the onset of chest pain; the earlier the administration, the better the outcome.
Progestin withdrawal challenge for secondary amenorrhea
If get menstural flow,
indicates relatively normal estrogen
no anatomical blockage
Then this person has chronic anovulation
Patients with an elevated or rising serum PSA level noted during routine screening should…
undergo prostate biopsy, even if they are asymptomatic.
Any rise greater than 0.75 ng/mL/year (0.75 µg/L/year) is considered abnormal and should be evaluated
Patients with new-onset urinary incontinence should first be evaluated for
transient, reversible causes, for which the mnemonic DIAPERS may be useful:
Drugs,
Infection,
Atrophic vaginitis,
Psychological (depression, delirium, dementia),
Endocrine (hyperglycemia, hypercalcemia),
Restricted mobility,
Stool impaction.
anserine bursitis,
the diagnosis rests on the finding of focal tenderness on the upper, inner tibia, about 5 cm distal to the medial articular line of the knee
one of the leading causes of death in patients with polymyositis and dermatomyositis
ILD with progressive pulmonary fibrosis and secondary pulmonary arterial hypertension
When do you have an inferolateral MI
Left dominant circulation if your PDA comes off LCX.
Will see st elevation in I avL V VI and II III aVF
What do you use for UTI in person with long QT?
Not fluoroquinolone, tmp smx, or nitrofurantoin.
Use amoxicillin
If you have high suspicion that a person has lung cancer, what do you do next?
Sample lymph node to determine stage
Pt has neisseria meningitis meningitis. Best next step for infection control management?
Face mask because droplet precautions
Acute abdomen pain. What do you do first ?
Supine and upright ab radiographs to look for air fluid levels (bowel obstruct) or free peritoneal air (perforated viscus)
GI bleed of unknown origin, what can help you ID the source?
Upper endoscopy
1/3-2/3 soured of bleeds of obscure etiology are found in reach of upper endo
When can you not use adenosine nuclear perfusion stress test?
Pts with asthma , bronchospastic dz
When do you do ppx for cirrhotic pts for SBP? Med?
When hospitalized for gi bleed like varicies
Give IV ceftriaxone
CRC screening methods
Annual home high-sensitivity FOBT, sampling two to three consecutive specimens, is a method recommended by the U.S. Preventive Services Task Force (USPSTF) for screening if the patient is willing to undergo colonoscopy if results are positive.
colonoscopy every 10 years
flexible sigmoidoscopy every 5 years combined with annual high-sensitivity FOBT every 3 years.
SLE vs rosacea or seborrheic dermatitis
SLE - The nasolabial folds are relatively protected from the sun, and the absence of the rash in this area helps to distinguish it from other common rashes of the face, including rosacea and seborrheic dermatitis.
In patients with trifascicular block, permanent pacer implantation is recommended for
intermittent third-degree atrioventricular block, type II second-degree atrioventricular block, and alternating bundle branch block.
A pacer is not indicated for asymptomatic trifascicular block.
The “get up and go” test
Persons are timed in their ability to rise from a chair, walk 10 feet, turn, and then return to the chair.
Most adults can complete this task in 10 seconds,
most frail elderly persons, in 11 to 20 seconds.
Those requiring more than 20 seconds should undergo a fall evaluation.
The most effective treatment for hepatorenal syndrome is
liver transplantation.
secondary amenorrhea - 1st lab tests to do
Laboratory evaluation is first directed toward ovarian failure, hyperprolactinemia, and thyroid disease.
FSH (>20 = ovarian failure)
prolactin, thyroid-stimulating hormone, and free thyroxine (T4) levels are generally measured.
Septic arthritis usually has leukocyte counts
greater than 50,000/µL (50 × 109/L) and a predominance of polymorphonuclear cells.
Venous stasis vs cellulitis
Bilateral involvement, absence of fever or leukocytosis, hyperpigmentation due to hemosiderin deposition, and minimal pain help distinguish venous stasis dermatitis from cellulitis.
What is the peak expiratory flow rate for
- mild
- mod
- severe
- life threatening
Athsma attack? When do you admit?
Mild > 70% –> home
Mod 40-69% –> ER
Severe < 40% –> inpt
Life threatening < 25% –> inpt
acute cholangitis vs acute cholecystitis
Patients with acute cholecystitis may have right upper quadrant pain and gallstones, but the bilirubin level is usually not greater than 2 mg/dL (34.2 µmol/L), and aminotransferase levels are normal.
The four-point Centor criteria
\fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough
often used as a prediction rule in patients with suspected GABHS infection.
Patients with two Centor criteria have an intermediate probability for GABHS infection, and rapid streptococcal antigen testing (sensitivity of 88% and specificity of 94%) is a reasonable strategy for these patients.
Patients with 0 or 1 criterion have a low (<3%) probability of GABHS, and neither testing nor antibiotic treatment is recommended.
Antibiotics are not indicated for this patient before rapid streptococcal antigen testing is done to determine whether they are needed. If treatment is indicated, the antibiotic of choice is penicillin. Macrolide antibiotics and first- and second-generation cephalosporins are alternative choices for penicillin-allergic patients.
Best test to evaluate infrequent syncope
implantable loop recorder
The initial treatment in acute cocaine intoxicatino should include
sedation with lorazepam, administered intravenously or intramuscularly.
Intravenous fluids should be administered to establish adequate urine output for possible rhabdomyolysis, and an electrocardiogram should be obtained to assess for myocardial ischemia.
When to start tx for gout?
Uric acid–lowering therapy typically is not initiated until a patient experiences two documented acute attacks.
What tx help to prevent disease flares in gout associated with changes in uric acid levels and may need to be continued until therapeutic serum uric acid levels have been achieved.
Prophylactic colchicine, low-dose corticosteroids (10 mg/d or less), or nonsteroidal anti-inflammatory drugs (NSAIDs) initiated at least 1 week before beginning or adjusting the dose of uric acid–lowering therapy
Polymyositis and dermatomyositis vs inclusion body myositis
IBM didn’t respond to steroids
Anti Jo1 in all
What do you use to treat scleroderma renal crisis?
Acei
Which thyroid cancers should use radioablation on?
Follicular
Papillary
The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is
left ventricular ejection fraction less than 35%
Hemachromatosis susceptible to these organisms
VYL
Vibrio vulnificus
Yersinia
Listeria
The primary eligibility criterion for implantable cardioverter-defibrillator implantation for primary prevention of sudden cardiac death in the setting of heart failure is
left ventricular ejection fraction less than 35%
Hemachromatosis susceptible to these organisms
VYL
Vibrio vulnificus
Yersinia
Listeria
What kind of tachy is WPW?
Atrioventricular reentrant tachy
Zoster vaccine is indicated in
all patients age 60 years and older without contraindications, regardless of history of prior varicella infection.
The vaccine is more efficacious in preventing herpes zoster among adults 60 to 69 years of age than among those 70 years or older. On the other hand, the vaccine prevents postherpetic neuralgia to a greater extent among adults aged 70 years or more.
A reported history of possible herpes zoster is not a contraindication to vaccination.
Septic shock
A subset of severe sepsis, defined as sepsis-induced hypotension despite adequate fluid resuscitation plus the presence of perfusion abnormalities. Patients receiving inotropic or vasopressor agents may no longer be hypotensive by the time they develop hypoperfusion abnormalities or organ dysfunction; however, they would still be considered to have septic shock
Severe sepsis
Sepsis associated with organ dysfunction, hypoperfusion, or hypotension.
Most patients with vertebral osteomyelitis have
back or neck pain that gradually worsens over weeks or months;
fever is present in only 50% of patients
leukocytosis is typically absent,
the erythrocyte sedimentation rate is often greater that 100 mm/h.
Always get blood cx and MRI imaging first.
Blood cultures are positive in 75% of patients with vertebral osteomyelitis
Then can start abx if infected and know organism
Sinoatrial node dysfunction .
comprises a collection of pathologic findings that result in bradycardia.
These include sinus arrest, sinus exit block, and sinus bradycardia.
Approximately 50% of patients with sinoatrial node dysfunction also have associated supraventricular tachycardia, most often atrial fibrillation or atrial flutter
Most patients with vertebral osteomyelitis have
back or neck pain that gradually worsens over weeks or months;
fever is present in only 50% of patients
leukocytosis is typically absent,
the erythrocyte sedimentation rate is often greater that 100 mm/h.
Always get blood cx and MRI imaging first.
Then can start abx if infected and know organism
Coronary calcium testing may be considered in
asymptomatic persons with a 10% to 20% Framingham 10-year risk category (intermediate risk) and in young persons with a strong family history of premature cardiovascular disease.
Pheochromocytoma classic sx
classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients
Coarctation of teh aorta can ave murmurs in theback - how?
The systolic and diastolic murmurs noted over the back are related to collateral vessels, which also cause the sign of rib notching, seen on this patient’s chest radiograph on the inferior surface of the posterior upper thoracic ribs bilaterally.
Pheochromocytoma classic sx
classic triad of sudden severe headaches, diaphoresis, and palpitations carries a high degree of specificity (94%) and sensitivity (91%) for pheochromocytoma in hypertensive patients
In considering surgical treatment for patients with back pain from radiculopathy or spinal stenosis, guidelines recommend referring patients after
a minimum of 3 months to 2 years of failed nonsurgical interventions.
Failure is defined as progressive neurologic deficits and severe pain that is not responsive to conservative treatment
GERD diagnosis
Endoscopy if GERD sx + alarm sx (dysphagia)
Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD
Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.
Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.
The diagnosis of diabetic ketoacidosis is based on
a blood glucose level greater than 250 mg/dL (13.9 mmol/L),
anion gap metabolic acidosis (arterial pH <7.30),
a serum carbon dioxide level less than 15 meq/L (15 mmol/L),
positive serum or urine ketone concentrations.
GERD diagnosis
Endoscopy if GERD sx + alarm sx (dysphagia)
Response to empiric treatment with a proton pump inhibitor such as omeprazole would be sufficiently sensitive and specific to diagnose GERD
Testing for H. pylori is not indicated for patients with GERD, because the presence or absence of H. pylori does not correlate with the presence or absence of GERD or guide therapy.
Ambulatory esophageal pH monitoring is the gold standard for diagnosing GERD and is typically used in patients in whom the diagnosis is uncertain or who are unresponsive to empiric therapy.
Diagnose spinal cord compression due to bone metastases with
MRI scan.
Radionuclide bone scanning is very sensitive for detecting bone metastases and has the advantage of visualizing the entire skeleton, but it has a high false-positive rate and provides no information about thecal sac compression.
the primary cause of morbidity in patients with systemic sclerosis;
Pulmonary disease
PAH is among the most common manifestations of lung involvement in these patients
Pulmonary function studies in patients with PAH usually reveal an isolated decreased DLCO in the setting of normal airflow and lung volumes
Cervicitis
is the presence of a mucopurulent cervical discharge or endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is commonly caused by either gonorrhea or chlamydial infection,
the primary cause of morbidity in patients with systemic sclerosis;
Pulmonary disease
PAH is among the most common manifestations of lung involvement in these patients
Routinely screen sexually active women under the age of 25 years for
chlamydia, gonorrhea, and HIV
Treat acute sinusitis with
symptomatic measures
Most cases of acute sinusitis are caused by a virus
NO abx unless:
symptoms lasting longer than 7 days,
facial pain,
purulent nasal discharge.
The data as a whole suggest that if antibiotics are to be used, amoxicillin or doxycycline are adequate first-line agents.
Routinely screen sexually active women under the age of 25 years for
chlamydia, gonorrhea, and HIV
Which is worse, ingesting alkali or acidic solutions on your esophagus?
Alkali
- causes liquefactive necrosis TRANSMURALLY
acidic is only on the surface
Smoking cessation is associated with
a decreased rate of decline in lung function.
Improved lung function
What do you measure on ppd?
The induration—not the erythema—resulting within 48 to 72 hours is then measured.
stage 2 hypertension
systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg
recommend initiating treatment with two medications in patients with stage 2 hypertension or those whose blood pressure is greater than 20 mm Hg systolic or 10 mm Hg diastolic above target. Low-dose hydrochlorothiazide and an angiotensin-converting enzyme (ACE) inhibitor
What do you measure on ppd?
The induration—not the erythema—resulting within 48 to 72 hours is then measured.
Ischemic colitis
older than 60 years and usually present with left lower quadrant pain, urgent defecation, and red or maroon rectal bleeding that does not require transfusion
Colonoscopic findings are generally segmental and include hemorrhagic nodules, linear and circumferential ulceration, and gangrene
vs mesenteric ischemia - in SI!
- Severe abdominal pain is almost invariably present, but early physical examination findings are minimal, illustrating the classic teaching of “pain out of proportion to examination.”
Acute small bowel (mesenteric) ischemia
should be suspected in patients who have risk factors for embolism or thrombosis and who present with sudden-onset, severe abdominal pain that, in the early stage, is out of proportion to the physical examination findings
Ischemic colitis is
due to a temporary interruption in mesenteric blood flow and typically occurs in older individuals with significant cardiac and peripheral vascular disease; patients present with abdominal pain.
Fitz Hugh Curtis syndrome
RUQ pain and pelvic adenexal tenderness
Gonococcal perihepatitis
To confirm that an elevated ALP is of liver origin,
measure other bile duct enzymes (γ-glutamyl transpeptidase, 5’-nucleotidase)
ALP indicates
cholestatic disease
