NEJM Flashcards
Paget disease
When alk phos is elevated but GGT is not, this is likely of bone origin, like Paget disease, a disorder of bone repair and resorption. Patients should undergo bone scintigraphy to assess the extent of disease.
calcium containing kidney stones (MC-ly calcium oxalate) treatment
- increase po IVF
- Low sodium diet because urine Na increases the urine calcium levels
- long acting thiazide (chlorthalidone) to decrease hypercalciuria
Primary hyperparathyroidism dx
- increased PTH in s/o hypercalcemia and a normal 25-hydroxyvitamin D level.
- Hypercalcemia may be intermittently present on labs and may be long-standing
- An increased urine calcium level helps to confirm dx but is not required
Indications for surgery in 1 hyperparathyroidism
pts are at risk for kidney stones and fracture at the distal third of the radius (primarily is cortical bone) caused by low bone mineral density
-surgery serum calcium more that 1mg/dl above the upper limit of normal range (I.E >11.5)
-creatinine clearance below 60
-age less than 50
or an osteoporosis diagnosis on the basis of either bone mineral density or presence of a fragility fracture
Light’s 3 criteria for an exudative pleural effusion
- ratio of pleural fluid protein level to serum protein level >0.5
- Ration of pleural fluid LDH level to serum LDH level >0.6
- Pleural fluid LDH level >2/3 times the upper limit of normal for serum LDH
pt should meet 1 or more above criteria
Differential for exudative effusion is extensive:
pneumonia, PE, malignancy, viral disease, coronary artery bypass surgery, TB
CVID - common variable immunodeficiency
20% of pts with CVID autoimmune disease: autoimmune cytopenias, vitiligio, pernicious anemia
Other diseases associated with CVID RA, primary biliary cholangitis, thyroiditis, Sjogren, SLE, IBD
Left main coronary artery obstruction
ST elevation that is more prominent in lead aVR than in lead V1 indicates obstruction of the left main coronary artery; this high-risk scenario requires triage to a center that can perform urgent intervention
Antimitochondrial antibody
is associated with primary biliary cholangitis (previously referred to as primary biliary cirrhosis)
Anti smooth muscle antibodies
are used to evaluate autimmune hepatitis.
X-linked hypophosphatemia
symptomatic x-linked hypophosphatemia is treated with the administration of phsophate and burosomab, a monoclonal antibody to fibroblast growth factor 23
Hantavirus cardiopulmonary syndrome
Sin Nombre virus is transmitted from the rodent Peromyscus maniculatus to humans via airborne transmission. Pts may rapidly progress into ARDS and shock. No treatment except ICU care. Hemoconcentration, thrombocytopenia, and left shift leukocytosis without toxic granulation is indicative of infection with hantavirus
Felty syndrome
~ 1% of pts with RA develop Felty syndrome, with its classic triad of RA< splenomegaly and neutropenia
Infertility testing
the MC-ly used test to assess ovarian reserve is a day-3 FSH level, which is expected to be below 10mlU/mL in women with reproductive potential; levels of 10-20 are associated with both poor ovarian stimulation and failure to conceive. The anti-mullerian hormone level is a similar biochemical measure of ovarian reserve and can be measured at any stage of the menstrual cycle.
DM 2 treatment in CKD
For pts who can not take metformin or it is insufficient, current guidelines recommend either a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist. However, SGLT-2 inhibitors are only appropriate in pts with milder stages of CKD. When GFR is <25 to45 then better choice is GLP-1 receptor antagonist
