PANCE Flashcards
Primary HTN is defined by ? readings
Ranges for Normal, Elevated, Stage 1 and Stage 2 HTN
What are the ACC/AHA HTN targets
What are the JNC-8 HTN targets
SBP ≥130/ ≥DBP 80
N: <120/80 and <80
E: 120-129 and <80
1: 130-39 or 80-89
2: ≥140/≥90
A: <130/80
J: <60y/o/CKDz/DM: <140/90
≥60y/o: <150/90
When does ACC/AHA suggest starting Rx management for HTN
How is OHOTN Tx
What is the earliest stage of an atherosclerotic plaque
All Stage 2
Stage 1 w/: DMT2
ASCVDz/≥10% CKDz
Inc Na/Fluids, Fludrocortisone, Midodrine
Inflammation induced foam cell (lipid laden macrophage) w/ fatty streak
Absolute c/is for fibrinolytic therapy for STEMI Tx
Suspect dissection Active bleed/diathesis Malignant intracranial neoplasm Ischemic stroke <3mon Cerebral vascular lesion Hemorrhage, cranial
? medication is used for chronic angina and safe for the above c/i but w/ ? s/e
? is the only drug class shown to be antianginal and prolong life in Pts w/ CADz
? medication is used during CHF to reduce morbidity and mortality
Ranolazine; QTc prolongation
BBs
ACEI
What are the 3 beta-1 selective used to reduce mortality from HF
Why do ventricles release BNP in response to inc volume
What can cause this to be artificially low
Bisprolol
Metoprolol succinate
Carvedilol
Dec RAAS, Inc Na excretion
Obesity, Constrictive pericardial dz
HF w/ EF of ? is a sign of increased mortality and need for ? next step
What are the 4 NYHA HF Classificaitons
? scoring system is used to estimate risk of major bleeding in Pts on anticoag meds
<35; defib placement
1: ASx, no limitations
2: Sx w/ mod activity
3: Sx w/ mild activity
4: Sx at rest
HAS-BLED:
HTN Abnormal Kid/Liv function Stroke
Bleeding Labile INR Elder >65y/o Drugs/ETOH
0-1: low 2: mod 3-6: high
AR
MS
PR
TS
AS
PS
HOCM
MVP
MR
TR
VSD
Sit, lean fwd; Diaphragm at Erbs
L lat-decubits; Bell at mitral
Sit, lean fwd: Diaphragm at Pulmonic
Supine; Bell at Tricuspid
Sit; Diaphragm at Aortic
Supine; Bell at Tricuspid
Supine; Diaphragm at Mitral
Supine, Diaphragm at Mitral
Supine, Diaphragm at Mitral apex
Supine, Diaphragm at Tricuspid
Supine; Diaphragm at Tricuspid LLSB
MCC of AR
What is a rare seronegative cause
What will be seen on PE in this condition
Aging process makes leaflets weak/floppy
Ankylosing
Wide pulse pressure, Water hammer/Corrigan pulse heard at LSB
What 5 other signs are seen when AR is present
What extra murmur can be present w/ AR
What is the indication after load reduction is needed and what class is preferred
Hill: leg > arm BP Musset- head bob Quinke- nail bed Duroziez- to-and-fro Traubes: pistol sound over femoral/radial pulses
Austin-Flint: diastolic murmur from blood hitting anterior mitral leaflet
SBP >140 w/ ARBs
MCC of MS
What is heard w/ this murmur
MC Sx of MS
Rheumatic fever
Opening snap after S2
Dyspnea
What will be heard on PE of MR
? maneuver intensifies MR murmur
MC murmur associated w/ Marfans
Soft S1, wide split S2 w/ loud P2
Hand grip
MVP
? part of the valve is MC involved in MVP
? unique presentation in females can indicate underlying MVP
How is MVP defined by Echo
Middle cusp of posterior leaflet (both= Barlow Syndr.)
POTS
Billowing leaflet 2mm/> above annular plane
When is medical Tx for MVP indicated and ? is used
In the USA, TS is MC d/t ? etiologies
TS is characterized by ? four PE findings
Palpitations= BBs
Rheumatic fever-MC
Prior regurge
Carcinoid syndrome
Hepatomegaly
Ascites
Right HF
Dependent edema
Tricuspid stenosis will cause ? type of JVP finding
Since this valvulopathy can mimic ?, it’s differentiated by ?
? is the mainstay of Tx, particularly ? one is considerable bowel ischemia is present
Giant a-wave
MS;
Increases w/ inhalation
Loop diuretics;
Tosemide, Bumetanide
How is TS Tx if liver is engorged/ascites is present
? congenital and iatrogenic etiology can cause TR
? JVP wave is altered w/ TR
Aldosterone inhibitors
Ebstein Anomaly: septal, posterior leaflets into the RV
Pacemaker lead injury
X-descent fades w/ inc regurg
Large V-wave w/ rapid descent
MCC of TR
PS is usually d/t ? and found in ? population
What type of PE finding is heard w/ PR
RVF and dilation d/t P-HTN or LVF
Congenital- Peds
Widely split S2 w/ pulmonic ejection sound
Right sided S4
What secondary murmur is also heard w/ PR
? is a common EKG finding in these Pts
What is the MC c/c of PR
Graham Steel- diastolic pulmonary murmur d/t dilated annulus; mis-Dx as AR
RBBB
Dyspnea w/ exertion
Define Ortner’s Syndrome
? leaflet is affected by age and calcification the most
? is the most important lab ordered for Afib work up and ? is the MC site for thrombus to develop
Hoarse voice d/t PR
Posterior
TSH (thyroxine)- inc cellular basal metabolic rate; LA
How is the Anticoagulation need for Tx of Afib/flutter determined
When is Warfarin used and w/ ? INR goal
CHF/LVEF <40% HTN Age >75 DM Stroke/TIA/Embolis Vasc Dz Age 65-74y/o Female
INR 2.5: Prosthetic valve EGFR <30 Rx: phenytoin, antiretroviral Mitral stenosis
Mnemonic for BBBs
What do these look like on EKG
What are the two types of PSVT
WiLLiaM MoRRoW:
V1- W and M in V6= LBBB
V1- M and W in V6- RBBB
LBBB: up bunny ears V4-6
RBBB: up bunny ears V1-3
AVNRT: arrhythmia from above BoHis
WPW: arrhythmia from BoKent
3 EKG characteristics of WPW
What two medications can be used to manage WPW
How are PSVTs definitively Dx
D-wave c/ slow ventricular activation
Narrow tachycardia
Short PR interval
Procainamide, Quinidine
Holter monitor
How are PSVTs Tx
What can not be used for Tx in WPW
What are the 3 types of premature beats
Carotid massage/valsalva
Adenosine for Sxs
BBs/CCBs if regular
Definitive: ablation
Adenosine or CCBs
PAC: abnormal P-wave
PJC: narrow QRS
PVC: wide QRS
Premature Atrial Contractions are common in ? population
Pts w/ heart Dz and frequent PACs may soon develop ?
? type of premature beats are common in healthy adults
COPD
PSVT, Afib/Flutter
PVCs
If PVCs are symptomatic, what is described
What causes PJCs
How are premature beats Dx
Palpitations in throat
Irritable site in AV node fires before SA node
EKG, Holter monitor
How are premature beats Tx
How is wide and regular V-tach Tx
PAC: reassure
PJC: only if >10/min or multifocal= lidocaine/antiarrhythmic
PVC: only if Sxs, BBs/ablation
Stable: amiodarone, procainamide
Unstable: cardiovert
Pulseless: defib
V-tach rhythm is a frequent complication of ? heart conditions
How is Stable V-Tach Tx
How is unstable Pts w/ monomorphic VTach Tx
MI, Dilated myopathy
In sequence:
Amiodarone Lidocaine Procainamide
Synchronized conversion
? valvulopathies can predispose Pts to VFib
SSS may also manifest and present as ?
What are the 4 possible presentations of SSS
AS/PS
Chronotropic Incompetence- inappropriate HR response to exercise/stress
Brady: sinus <60bpm
Pause: <3 seconds
Arrest: >3 seconds
Tachy-Brady syndrome
How is IE in native valves w/out IVDA Tx
How is prosthetic valve IE Tx
How is IVDA IE Tx
Genta Naficillin Ceftriaxone
Vanc Genta Rifampin
Cefepime and Vanc
Who needs Infective Endocarditis prophylaxis
What is used for IE prophylaxis
Heart valves w/ ? d/o are more likely to become infected w/ endocarditis
Prosthetic material
Previous Dx IE
Unrepaired cyanotic heart dz
Transplant w/ regurg
2g Amox/Clinda
Regurgitation
? microbe can cause culture-negative Endocarditis
How can endocarditis be prophylactic Tx while cultures are pending
Rheumatic fever MC affects ? valve and follows ? but is technically not a ?
Bartonella quintana
Vanc and Ceftriax
Mitral;
Strep throat infection;
Inflammatory reaction
How is Rheumatic Fever Tx
When is AB prophylaxis indicated for Peds
Acute pericarditis can often progress into developing ? issue
CCS ASA/NSAID Pen G Benzathine
PCN allergy: Erythromycin
W/out carditis: for 5yrs or until 21y/o
Carditis, no residual damage: 10yrs
Carditis and residual damage: >10yrs
Pericardial effusion
How does a pericardial effusion present
How is it Dx
How is it Tx
Low voltage QRS
Alternans
Distant sounds
EKG: low voltage w/ alternans
Echo: swinging heart
Centesis
Window if recurrent
? triad is seen in Cardiac Effusion w/ Tamponades
? is a classic finding for this condition
? is the gold standard for Dx
Becks: HOTN Inc JVD Muffled
Pulsus paradoxus- inhale dec SBP >20mm
Echo w/ RV collapse during diastole
When does USPSTF recommend screenings for AAA
How are Aortic Aneurysms screened for
? is the gold standard for screening
65-75y/o w/ +smoking Hx
Initial: US
CT- test of choice for thoracic aneurysms/eval of known AAA
Angiography
What medical therapy is used for AAAs until surgical correction
How do Aortic Dissections present to ED
What is the gold standard for Dx
BBs
Tearing chest pain radiating to scapuas and decreased pulses
MRI angiography
How are aortic dissections Tx
What are the 5 Ps of arterial occlusions
What are common causes of the thrombus formation
Ascending: surgery
Descending: LEP-olol, morphine/dilaudid
Pallor Pulselessness Paresthesia Paralysis Poikilothermia
Afib, MS
? is the gold standard for Dx or arterial occlusions
? is done for Tx until surgery is needed
AV malformations are more likely to be located ?, Dx by ? and Tx w/ ?
Angiography
IV heparin
Brain Lungs Spine;
Angiography;
Surgical excision
How does Peripheral Artery Dz present
If ulcers are present how do they appear on PE
How are these Dx
Intermittent claudication and ABI <0.9
Well circumscribed, lateral/distal
Angiography- gold standard
Doppler US
? is the definitive Tx of peripheral artery dz
? medical management is used
What PE finding suggests thrombo/phlebitis
Arterial bypass
Anti-platelet/lipid
Cilostazol
ASA
Clopidogrel
Palpable cord
How are thrombo/phlebitis Dx
How is phlebitis Tx
How is thrombophlebitis Tx
Venous duplex US- noncompressable vein indicates clot
NSAID Elevate Compress
Anticoagulation
How does Venous Insufficiency appear on PE
Where do ulcers appear in this condition
How does a Venous Thrombosis present
Hyperpigmentation
Atrophic skin
Stasis dermatitis
Superior to medial/lateral malleolus
Unilateral, asymmetrical swelling of lower extremity
? is first line imaging for DVTs
How are these Tx
Define Acute Bronchitis
Duplex US
Venography- gold standard
LMWH or, Fondaparinux or, Factor Xa inhibitors
Afebrile cough x 5 days (fever- think pneumonia)
MCC of acute bronchitis
What are other possible etiologies
How is this Tx
Viral
HFlu, M catarrhalis*, Strep pneumo
Support, Dextrmethorphan, Guaifenesin
When are ABX indicated for acute bronchitis
Define Sinusitis
Criteria for Acute, Chronic
ImmSupp/Elderly w/ CardioPulm Dz and cough x 7-10days
Sxs worsening over 5-7d or don’t improve >10d
A: <4wks, quick onset
C: >12wks
Gold standard method to Dx sinusitis
Indications to use ABX
What is used for adults
Sinus CT
Fever >102
Rapid worsening after improvement
Nasal d/c
Sxs >10d
Amox/Augmentin
Doxy/Clinda if allergic
When/Why are second line ABX used for sinusitis
What meds are used now
What meds are used for chronic sinusitis
Sxs don’t improve x 7d
2g BID Augmentin
Moxi/Levo-floxacin
3rd gen Cephalo
Augmentin, Clinda
What is used for Peds w/ sinusitis
When is f/u needed
How do Pts w/ bacterial pneumonia present
Augmentin
72hrs: no improvement, switch meds
Cough Dyspnea Tachy/Tachy Fever
How does Strep Pneumo pneumonia present
How does Staph A pneumonia present
How does Mycoplasma pneumonia present
Rust colored sputum, common in asplenics
Salmom sputum after influenza
Walking pneumo w/ bullous myringitis
How does Histoplasmosis pneumonia present
? is AKA Valley Fever
What are 3 common PE findings for Pts w/ pneumonia
Bat dropping contact mimicking sarcoidosis on CXR
Coccidioides- unremitting cough despite Txs
Tactile fremitus Egophony Dull percussion
How is bacterial pneumonia Tx
When are the admitted
What ABX are used
Doxy, Marcolides
> 50y/o w/ comorbidities
AMS
Dehydrated
Cefrtiax + Azith/Flqn
How is Coccidioides Pneumonia Dx
What Pts does Aspergillus infect and how is it Tx
How are both Tx
EIA for IgM/IgG
TB/COPD Pts w/ healthy immune system
Flu/Itra-conazole
Cryptococcus pneumonia can also cause ?
? form of pneumonia is apical and mimics TB
How are both Tx
Meningitis
Histoplasma from bird/bat droppings in Ohio River valley w/ hilar adenopathy
Amphotericin B
How is P Jirovici Dx
What is a common PE finding
How are they Tx and what is used if allergic to primary med
Bronchoalveolar lavage
Low O2 despite supplemental O2
TMP-SMX; Pentamidine
MCC of pneumonia in adults
MCC of pneumonia in Peds
How is viral pneumonia Dx
Influenza
RSV
Rapid Ag- flu; Nasal swab- RSV
? two meds can be used to Tx influenza A and B
What two can only treat Influenza A
How is RSV pneumonia Tx
Zanamivir, Oseltamivir
Amantadine, Rimantadine
Ribavirin
What are the classic findings of TB on PE
Define Drug Resistant TB
Define Multiple Drug Resistant TB
Fever Anorexia Weight loss Night sweats
Resistant to one: I/R
Resistant to I and R
How is TB Dx
What is seen on CXR
What is seen on biopsy results
Acid fast smears and Mycobacterium cultures
Apical Ghon complexes w/ cavitary lesions
Caseating granulomas
What are the two forms of miliary TB
How is TB Tx
What are the s/e of RIPE therapy
Potts Dz: spine
Scrofula: cervical lymph nodes
+ PPD= CXR
Neg CXR: latent, Tx w/ Isoniazid/B6 x 9mon
Active CXR:
Baseline LFTs- RIPE x 8wks; RI x 16wks
R: orange fluids
I: neuropathy
P: hyperuricemia
E: red-green blindness
What is used for prophylaxis for household members
When are Pts considered fully Tx
Isoniazid x 12mon
Two negative AFB smears and cultures
Why do Pts need to be tested prior to Tx w/ Etanercept for RA
What part of RIPE needs to be adjusted if CrCl is <30
? RIPE adjustment is needed if Pt is also on HIV meds
Activates latent TB
P/E- 3 x/wk
Raltegravir, double dose when w/ Rifampin
What are the 4 indications to test for TB w/ NAAT
? is the traditional test for latent TB
Define Ranke Complex
HIV
Endemic resident
MDR contact
Previously Tx for TB
TST via Mantoux method
Calcified hilar lymph node
How are pregnant Pts w/ TB Tx and w/ ? educational piece
How is asthma Dx
What type of improvement result helps w/ Dx
R/I/E x 4-8wks, R/I x 7months
Breast feeding not c/i
Peak expiratory flow: FEV1/FVC 75-80%
> 10% inc of FEV1
Define Intermittent Asthma
Define Mild
Define Moderate
Define Severe
Sx/SABA ≤2 days/wk
Awake ≤2 x/month
No activity interference
Sxs/SABA ≥3day/wk
Awake 3-4x/mon
Minor limitations
Daily Sxs/SABA w/ ≥1 awakening/wk
Some limitations
Daily Sxs
Nightly awakenings
SABA several x/day
Extreme limitations
Step 1 Asthma Tx
Step 2 Asthma Tx
Step 3 Asthma Tx
Step 4 Asthma Tx
Step 5 Asthma Tx
Step 6 Asthma Tx
1- Intermittent; SABA PRN
2- Mild; Low ICS daily
3- Moderate; Low ICS + LABA daily
4- Moderate; Med ICS + LABA daily
5- Persistent; High ICS + LABA daily
6- Persist; High ICS+LABA+PO CCS daily
What is used for acute Tx of asthma exacerbation
MC inhaled precipitant
Define Samter Syndrome and Atopic Triad
Nebulized SABA
O2
PO CCS
Ipratropium bromide
Cigarette smoke
Samter: Asthma ASA Polyps
Atopic: Asthma Rhinitis Eczema
What defines Chronic Bronchitis
What defines Emphysema
Most smokers will be Dx w/ ? and termed ?
Productive cough x 3mon/year x 2yrs
Structural changes
Chronic bronchitis, blue bloater
What is the single best variable for predicting which Pt will develop COPD
How is Chronic Bronchitis Dx
What is seen on CXR
Hx 40 pack/year smoker
Lung biopsy w/ inc Reid index (gland layer >50% of bronchial wall)
Inc interstitial markings and non-flat diaphragm
What will be seen on PFT in chronic bronchitis
What is the most effective therapy for Tx Pts w/ chronic bronchitis
When is supplemental O2 indicated
FEV/FVC ratio <0.7
Cessation
SaO2 <89% or,
Rest PaO2 <55mmH
How are COPD exacerbation Tx
If ABX are used, ? ones and w/ ? indication
What will probably develop in these Pts d/t chronic hypoxic vasoconstriction
O2 (goal 88-92%)
Nebulized albuteral and Ipratropium
PO Prednisone
Inc dyspnea, sputum/purlence;
Azith/Cefur/Doxy
Cor pulmonale
COPD Gold Categories
A: Less Sx, Low risk;
Breathless w/ hustle on flat ground, 0-1 exacerbation, 0 admission; SABA/SAMA
B: more Sx, low risk;
Breathless w/ walking slower than peers, 0-1 exacerbations, 0 admission; LAMA/LABA
C: less Sx, High risk
Breathless w/ hustle on flat ground, ≥2 exacerbations, ≥1 admissions; LAMA and SABA
D: more Sxs, High risk;
Breathless w/ walking slower than peers, ≥2 exacerbation, ≥1 hospitalizations
LAMA+LABA w/ SABA
What causes structural changes seen in emphysema
What type of breathing habit do these Pts develop
What term is used for these Pts
Destruction of alveolar septae d/t lost elastin
Purse lip, keeps airway from collapsing
Pink puffer- retained CO2
What is different between Blue Bloaters and Pink Puffers on CBC results
? is the MC of all interstitial lung dzs
How is this MC Dx
BB- Inc H/H
PP- normal Hct
Idiopathic pulmonary fibrosis
CXR w/ diffuse, patchy fibrosis and pleural base honeycomb
What type of PFT results are seen in Idiopathic Pulmonary Fibrosis
How is this Tx
Define Pneumoconiosis
Restrictive pattern- dec volume, normal/inc FEV1/FVC
CCS O2 Transplant
Pulmonay fibrosis w/ known cause;
Exposure to mining/dust causing dec lung volume/FVC (restrictive dz)
Asbestosis CXR findings
Coal Workers CXR findings
Sillicosis CXR findings
Linear pattern w/ basilar predominance, opacities and honeycomb
Nodular opacities in upper fields and less prominent hilar adenopathy
Egg shell classifications of hilar nodes
Berylliosis CXR findings
? restrictive lung dz makes Pts at increased risk for TB
? restrictive lung dz needs tobacco cessation more than others
Difuse infiltrates w/ hilar adenopathy
Sillicosis- need serial TST/CXRs
Asbestosis
? tissue finding indicates significant exposure to asbestos
? size lung mass is a nodule or a mass
How are incidental CXR findings of pulmonary nodules managed
Ferruginous body
<3cm- coin lesion, nodule (<30mm)
>3cm- mass
CT w/out contrast-
Ill defined, lobular, spiculated= biopsy
<1cm, calcified, smooth/defined border= f/u 3mon, 6mon, annual x 2yrs
What are the two categories of lung cancer
What are the 4 subtypes of one of these categories
Small cell
Non-Small cell:
Adeno: non-smoker w/ small peripheral lesion; MC bronchogenic Ca
SCC: central, solitary mass in smokers w/ hemoptysis
Large: fast growth that rarely responds to surgery
Carcinoid- lack differentiation
How does Small Cell Lung Ca present
What lab results would be seen
What syndrome can this Ca cause
Aggressive and almost always in smokers;
more likely to spread early
ACTH/ADH: HypoNa/HyperCa
Lamber Eaton- limb weakness
How are lung Ca Dx
Pancoast tumors are more likely to be ? types
What makes up the Pancoast Syndrome
Bronchoscopy w/ biopsy if central or,
Fine Needle Transthoracic aspiration (most useful)
Adeno/SCC
Shoulder pain Horners Bone destruction
How is Non-Small Cell lung Ca Tx
How is Small Cell Ca Tx
? measurement means PHTN
Stage 1-2: surgery
Stage 3: chemo then surgery
Stage 4: palliative
Chemo, no surgery option
> 25mmHg at rest
? is the MCC of PHTN
How is this Dx
How is this Tx depending on the origin
MS
Right sided catheterization
LVF: diuretic, digoxin, anticoagulate
Cardiogenic: prostanoids, PD5 inhibitors, endothlin antagonists
Pulm Artery HTN: endothelin antagonists, prostanoids
Lab result showing s/e of prolonged rescue inhaler B-2 agonist use
Preferred fluid used for aortic dissections
? artery supplies LV and if occluded will cause a loss of ejection fraction?
HypoK
Crystalloids
LAD
Why do Tet Spells lead to cyanosis
What does squatting help w/ Tet Spells
Tetrology of Fallot is associated w/ ? chromosomal abnormalities
22 deletions, DiGeorge Syndrome
Worsened pulmonary outflow obstruction
Increases systemic vascular resistance
What valves are MC affected by Rheumatic Fever in descending order
? is cardiotoxicity d/t BB/CCBs Tx
How is sinus bradycardia Tx if atropine is ineffective
M>A>T
Glucagon
Dopamine, Epi
Most PEs arise from where in the body
What are the 4 specific RFs
What triad would be seen if a fat emboli is the cause
Iliofemoral DVTs
Cancer
OCPs
Pregnancy
Surgery
Hypoxemia
Neuro abnormals
Petechial rash
How are PEs Tx
How long is medical therapy used for
What are the indications for embolectomy
Acute phase: Heparin
Then: ARE-aban and Dabigatran
3mon minimum
Unstable w/ c/i for thrombolytic therapy
What are the 5 RFs for OSA
For a Dx, ? sleep study or lab results are needed
How is mild/mod/sev OSA Tx
Obesity Anatomy FamHx
ETOH/Sedative Hypothyroid
≥5 events/hr w/ Sxs
≥15 events/hr
PCO2 > 45mmHg
Mild/Mod: CPAP, PO piece
Sev: CPAP Uvuloplasty
Tracheostomy
What is the hallmark CXR finding for almost all pulmonary sarcoidosis
What other 3 DDx need to be considered though if this hallmark is seen
How is pulmonary sarcoidosis Dx
How is this Tx
Mediastinal adenopathy
Young female: sarcoidosis
Kid from Ohio/zookeeper: histo
60y/o ceremics: berylliosis
HyperCa; Inc ACE 4x
CCS ACEI Methotrexate w/ serial PFTs
Define ARDS
What 3 events account for 75% of all ARDS cases
What 3 things can be seen on PE
Resp failure d/t fluid in lungs from inc alveolar capillary permeability
Sepsis syndrome- MC
Sev/mulitple trauma
Aspiration/inhalation
Tachypnea Pink sputum Crackle
What would be seen on CXR of ARDS
How is it Dx
How is ARDS Tx
Bronchogram, Bilat infiltrates
Bilateral infiltrates
Non-CHF Sxs
PaO2:FiO2 <300
Sxs developing <7d
Intubate w/ lowest level of PEEP to maintain PaO2 >60mm/SaO2 >90
How is the mortality of septic shock predicted
? is an indirect marker of tissue perfusion used in sepsis Tx
? is the MCC of sepsis and ? is the MC manifestation
qSOFA
Lactate
Pneumonia; Fever
A Dx of sepsis should be considered if Pt presents w/ two of ? three Sxs
What causes gram positive shock
What causes gram negative shock
Worsening mentation
RR ≥22/min
SBP ≤100mmHg
Exotoxins from staph/strep
Endotoxins from EColi Klebsiella Proteus or Pseudomonas
MCC of anaphylaxis
? type of reaction is the usually
What does this reaction cause to happen
Ingested foods
MC a Type 1 IgE mediated reaction
Mast cells/basophils cause HOTN, shock, angioedema from fluid shift from intravascular space
What is usually the first sign of anaphylaxis
Acronym for acute asthma exacerbation Tx
Cutaneous pruritus/urticaria/angioedema
BIOMES:
Bagonist Ipratropium O2 Mg sulfate Epi/Terbutaline Steroids
Mod/High suspicion for DVT needs ? next steps
Duplex US:
Pos= anticoagulate
Neg= repeat US in 5-7d
D-Dimer: Pos: Duplex US Pos US- anticoagulate Neg US- repeat in 5-7d Neg D-dimer: DVT excluded
Kawasakis mnemonic
GCA is associated w/ ? other Dx
Crash and Burn: Conjunctivitis Rash Adenopathy Strawberry tongue Hand/feet swelling Burning fever >5d
Polymyalgia rheumatica
? is the MC primary cardiac tumor
? genetic condition is this MC associated w/
When do ASx AAAs need to be refereed for elective repair
Atrial myxoma in LA
Carney syndrome
≥5.5cm or expands ≥0.6cm/6mon
Janeway lesions are more common w/ ? form of endocarditis
Ebstein’s Anomaly is associated w/ ? arrhythmia
? three defects make up this condition
Subacute
WPW
Small ASD/PFO
Dilated RA, small RV
TV insufficiency
? features are associated w/ an innocent murmur
Define Leriche Syndrome
? heart condition has a pericardial knock
≤2 intensity Minimal radiation Softer w/ sitting Musical/vibratory Short systolic duration
Claudication in thigh/butt d/t atherosclerosis in aortoiliac system
Constrictive pericarditis
MOA for Adenosine
This is the first line drug used to Tx ?
Preferred anticoagulant for pregnancy
Inhibits AV node conduction
PSVT
LMWH
What two anticoagulants can be used during breast feeding
What labs are ordered for Secondary HTN work up
What is the next step in work up after a suspected Dx of infectious endocarditis is suspected
LMWH< Warfarin
CBC/CMP Lipid UA ECH
Blood culture x 3, then empiric ABX
How are hemodynamically unstable Pts w/ WPW Tx
What is the first step in Tx of orthodromic AVRT in stable Pts
What is the definitive Tx for these Pts
Conversion
Vagal then adenosine then BB/CCBs
Ablation
What are the Hs and Ts for PEA
Hypovolemia
Hypoxia
Hypothermia
HyperK
Tension pneumo
Thrombus
Toxicologic
Tamponade
What is the most specific finding on stress test for myocardial ischemia
What drugs need to be avoided in 2* Type 2 and 3 AV blocks
What causes the PDA to close after birth
2mm down sloping ST depressions
Adenosine BBs CCBs Digoxin
Pulm vasculature resistance dec= bradykinin release
PDA defects are associated w/ ? two conditions
When would Pts benefit from Palivizumab administration
What type of murmur exists w/ AS
Downs, Maternal rubella
Cyanotic heart defect
Mod/Sev P-HTN
Congenital HF w/ meds
Paradoxically split S2 w/ narrow pulse pressures
What are the 5 cyanotic congenital heart Dzs
Why do Pts w/ Brugadas have inc risk for sudden death
Define Brugadas and how is this acquired and Tx
Truncus arteriosus Transposition of great vessels Tricuspid atresia Tetrology Total anomalous pulm vascu
Inc risk for Vfib
Pseudo-RBBB w/ ST elevation in V1-2; Autosomal dominant; ICD
How are stable Pts w/ monomorphic V-tach Tx
What are the s/e of the first line med
MCC of V-tach
Procainamide or Amiodarone then Sotalol
Pro: HOTN, prolonged QTc
Structural heart Dz
How are unstable Pts in V-tach Tx
Mnemonic for s/e of loop diuretics
What are the loop diuretics
Synch’d conversion
Ototoxicity HypoK/Mg Dehydrate Allergy to sulfa Alkalosis, metabolic Nephritis Gout
Furosem/Torem/Bumetan-ide
What adverse outcome of MI appears 2-7d after w/ mid-systolic murmur and rapid onset of pulm edema
How does a Klebsiella induced lung abscess appear on CXR
Although Klebsiella and alcohol is common, ? microbe is more common cause of pneumonia
Acute MR w/ sinus tachy
R sided infiltrate in upper love w/ bulging fissure
Strep pneumonia
CXR w/ decreased vascularity d/t suspected PE is called ?
What causes Croup
What is heard on PE and what is seen on CXR
Westermark’s sign
Parainfluenza virus
Inspiratory stridor, Steeple sign
Two MCC of Ventilator Associated Pneumonia
What causes Pertussis
What are the three stages of this condition
Staph A, Pseudomonas
Bordatella
Catarrhal: lacrimation
Paroxysmal: whoop
Convalescent: resolution
How is Whooping Cough Tx
Pancreatitis induced pleural effusion would have ? inc lab result
What does surfactant expression begin during development
Pertussis: Azithromycin or TMP/SMX
Amylase
20wks; gradual increase until 36wks
What is the MC presenting S/Sx and finding of a PE
Define Esophageal Ring
What syndrome can this develop
S: tachypnea
Sx: dyspnea at rest/exertion
F: normal CXR
Schatzki- distal stricture at B-ring junction; almost always w/ hiatal hernias
Steakhouse: progressive dysphagia to solids
Define Esophageal Web
? syndrome can develop w/ esophageal webs
Pts that develop the above syndrome are at increased risk for developing ?
Membrane across mid/upper esophagus MC d/t GERD
Plummer Vinson:
iron deficient anemia Dysphagia Cervical-web Glossitis Cheilosis
SCC
How are esophageal strictures Dx
How are these Tx
When do umbilical hernias need surgical referral
Initial: barium swallow, upper endoscopy
H2 antagonist, Omeprazole, Endoscopy w/ dilation; PPI dec recurrence
Persists >2yrs of life
Define Strangulated hernia
Define Obstructed Hernia
Define Incarcerated
Blood supply has been impaired
Irreducible hernia w/ intact blood supply
Occluded and irreducible, can progress to strangulated
? is the main RF for esophagitis
Endoscopy for esophagitis work up shows multiple, shallow ulcers meaning ? etiology
Two MC meds that cause medication induced esophagitis
ImmComp
HSV
NSAIDs, Bisophosphonates
When is Eosinophilic Esophagitis a considered Dx
What would be seen on barium swallow and how is it definitively dx
Radiation exposure exceeding ? much puts these Pts at risk for ?
Asthma and GERD non-responsive to antacids
Ribbed esophagus w/ multiple corrugated rings; Biopsy
5000 cGy; Stricture
What is the hallmark sign of infectious esophagitis
Since esophagitis primarily occurs in ImmComp Pts, what are the MC microbes
What would be seen on exam if etiology was fungal
Odynophagia- pain w/ swallow
C albicans HSV CMV
Linear yellow/white plaques w/ odynophagia
What would be seen on PE if etiology of esophagitis was viral and how they’re Tx
How is esophagitis Dx
How is esophagitis Tx depending on cause
HSV- shallow punched out lesions; Acyclovir
CMV- large, solitary ulcer; Ganciclovir
Biopsy Culture Endoscopy
Double contract esophogram
Candida: Fluconazole
HSV: acyclovir
CMV: ganciclovir
Corrosive: steroid
Chronic GERD puts Pts at risk for ? Dz
What are Pts at risk for if the above issue develops
What is the gold standard and test of choice for Dx
Barretts; f/u screening q3-5yrs
Adenocarcinoma
Gold: 24hr pH monior w/ manometry confirmation
TxoC: endoscopy w/ cytologic washing
? meds lower LES pressure and worsen GERD Sxs
Pts w/ GERD Sxs and ? RFs are considered high risk and need endoscopy
Progesterone Anticholinergic/histamines Nitrates TCAs CCBs
Hematemesis Age >50 Weight loss Anemia/melena Recurrent vomiting Dysphagia
How is GERD Tx
H2 antagonist class ending
PPI class ending
H2 antagonist, Qd then BID
Sxs persist- switch to PPI
Continue x 8wk after Sx control
- tidine
- prazole
Define Achalasia
What will be seen on swallow studies
What is the best study for Dx
How is achalasia Tx
Motility d/o in distal esophagus d/t loss of auerbach plexus- no peristalsis and weight loss
Bird beak/Rat tail
Manometry
EGD dilation or mytomy
CCBs, Nitro, PPIs prevent stricture return
Define Diffuse Esophageal Spasm
What would be seen on a barium swallow
What is the best method to confirm a Dx of esophageal spasm after a barium swallow and how is this Tx
Non-peristaltic, painful contractions after ingesting hot/cold food
Corkscrew appearance
Manometry; w/ Nitrates/CCB/Botox
How does esophageal cancer present
What is the MC type of esophageal Ca
What part of the esophagus is MC affected and by ? RFs
Dysphagia to solids progressing to liquids w/ adenopathy
World: SCC
USA: Adeno d/t GERD/Barretts
Distal; men who smoke
How is esophageal Ca Dx
How is this Tx
How often are Pt w/ Barretts f/u and screened
Endoscopy w/ biopsy- test of choice; CT for staging
Resection, Radiation, Chemo w/ 5-FU
q3-5hrs
Rosh Pulm- #19
Rosh Cards- #70
GI- Gastritis
What happens if achalasia is left untreated
? infectious Dz can cause Achalsia Sxs
Candidiasis esophagitis not responding to itraconazole needs ? Tx adjustment
Sigmoid esophagus
Chagas
Itraconazole suspension of Voriconazole
Refractory candidiasis esophagitis infections are Tx w/ ?
How is CMV esophagitis Tx but is limited d/t ? s/e
Pts intolerant or unresponsive to the above Tx are then Tx w/ ?
IV Caspofungin
Ganciclovir; neutropenia
IV Foscarnet
How is herpetic esophagitis Tx
Pts that are intolerant/unresponsive to the above Tx are then Tx w/ ?
Normal LES pressure ranges
A/F/V-cyclovir
IV Foscarnet
10-35mmHg
Most GERD reflux is induced by ?
What two autoimmune Dzs can have worse GERD Sxs
? Dx study needs to be avoided during a GERD work up
Gastric distension by vasovagal reflex
Sjogrens, Scleroderma
Barium study
When Tx GERD w/ H2 antagonists (-tidine), Pt education for pill use
? medication is the preferred initial med for Tx of GERD
What two Sxs are common indicators of gastritis
Take prior to eating
PPIs: -prazole
Inflammation of stomach lining- Dyspepsia, Abdominal pain
Acute Gastritis usually develops in ? part of stomach
What are the two types of Chronic Gastritis
Antrum
Type A- in fundus d/t anti-parietal Abs, associated w/ Pernicious Anemia; risk for AdenoCa
Type B- in antrum d/t NSAIDs, Pylori and often ASx; risk to develop PUD
How is Gastritis Dx
What are 3 methods to detect H Pylori if a suspected DDx
How is this Tx
Endoscopy w/ 4 biopsies
Fecal Ag, Serology, Urea breath test
Mild: Famot/Cime-tidine
Sev: Omeprazole taper, d/c when ASx x 8wks
What is the next step for gastritis if Sxs return ≤3mon of d/c acid suppression meds
What are the s/e of PPI use
What RF increases incidence of gastric ulcers and dec healing time
Upper endoscopy
HypoCl/B12/Mg
Dec Ca absorption
Pneumonia
C D-ff
Cigarette smoke
What type of PUD ulcer are MC
The MC is MCC by ?
How do Pts present
Duodenal > Gastric
H pylori
Dec pain w/ food
Duodenal ulcers are MC located ?
If located elsewhere, ? is the increased risk
PUD can rarely be caused by ? syndrome
Anterior duodenum
Posterior= bleeding from gastroduodenal artery/acute pancreatitis
Zollinger Ellison- gastrinoma of pancrease releasing excess gastrin; >200=Dx
Gastric ulcers are MC found located ?
? is the MCC of non-hemorrhagic GI bleed
This MC typically presents as ?
Lesser curvature of antrum
PUD
Melena
What is the most accurate Dx test for PUD
All Pts undergoing this test need ? additional test
What would be seen on labs/rads if an ulcer ruptured
Upper endoscopy
H pylori biopsy
Inc serum amylase, Pneumo-diaphragm
How is PUD Tx
When is Pylori eradication testing performed
How are Pts w/ NSAID induced PUD Tx
All Pts- PPI
H Pylori: Metro/Clarithromycin Amox PPI
≥4 weeks after completing therapy
PPI for minimum of 8wks
Define Functional Dyspepsia
Functional dyspepsia is the MCC of ?
How can this be managed
Dyspepsia w/out etiology on scope/studies
Chronic dyspepsia
Desipramine, Nortriptyline
Buspirone- dec bloat/fullness
What are the 4 RFs for gastric Ca
How does this form present
How is this Dx
FamHx
Anemia, pernicious
Gastric ulcers
H pylori**- most important
Vague fullness/early w/ meal
Anorexia
N/V w/ weight loss
EGD w/ biopsy; Pos guiac
What lab results may be seen in Pts w/ gastric Ca
How is this Tx
What mnemonic is used for gastric Ca suspicion
Microcytic/Hypochromic
Gastrectomy w/ rad/chemo
WEAPON:
Weight loss Emesis Anorexia Pain Obstruction Nausea
What is the MC early Sx of gastric Ca
Overall, what is the MC Sx
What lymph nodes will be involved
Epigastric discomfort/indigestion
Weight loss
L-side virchows node (r-side= HL)
Sister Mary, Joseph- umbilical
What is the MC type of gastric cancer worldwide
What EGD finding suggests gastric Ca presence
Define Celiac Dz
Adeno
Linitis Plastica- diffuse thickening of stomach wall
Immune response to gluten causing injury to proximal end mucosa
What blood test is used to Dx Celiac Dz
How is the Dx confirmed after ? positive test
Celiac Pts may need correction of ? deficiencies
IgA endomysial and transglutaminase Ab
+ endymysial Ab: mucosal biopsy from duodenal bulb
B12 Ca D, Vit Fe Folate
What lab test has a higher spec but lower sense for Celiac testing
What causes lactose intolerance
Pts may need ? supplementation
EMA-IgA
No lactase= dec conversion of lactose in glucose/galactose
Ca
How is a presumptive Dx of lactose intolerance made
How is the Dx confirmed
Fecal pH test can also be performed w/ ? being normal
Mild Sxs w/ lactose ingestion that resolve 5-67d after eliminating from diet
Lactose breath H test
+= 20ppm over baseline
Normally alkaline;
Abnormal- intolerance, Rotavirus/EColi infection
How is lactose intolerance Tx
Crohns involvement
Appearance on colonoscopy
Lactase supplements;
Lactose avoidance
Global GI tract, spares rectum
Skip lesions, cobble stone
? type of diarrhea does Crohns have
Risk for fistula development
Appearance on x-ray
Non-bloody w/ frequent abdominal pain
Yes
Terminal ileum string sign
Crohns histological findings
Effect of smoking on condition
What serology marker is used for this
Transmural, non-caseating granuloma
Worsens Dz
ASCA and Perinuclear antineutrophil cytoplasmic Ab
UC area of involvement
Appearance on colonoscopy
? type of diarrhea do Pts have
Colon, usually w/ rectum
Continuous lesions
Non-painful, bloody
UC risk for fistula development
Appearance on x-rays
Histological findings
No
Erythematous, friable ulcers w/ lead pipe appearance d/t loss of haustral folds
Mucosa only crypts abscess
Effect of smoking w/ UC
? serology marker is used
How is this Dx
Protective
p-ANCA
Barium enema- lead pipe
Flex sigmoid- dec risk for perf
? complications can arise from UC
Pts need ? nutritional screening q1-2yrs
How are UC and Crohns Tx
Toxic megacolon, Ca
Vit D, B12
Sulfasalazine/Mesalamine- block prostaglandin release; UC > Crohns
What is the next step in Tx if Pts w/ UC/Crohns don’t respond to 5-ASA Tx
What med is used during exacerbation
What meds can be used in conjunction w/ the above if no response is achieved
Metronidazole
Systemic CCS
Azathioprine, 6-Mercaptopurine
What bile acid sequestrants are used during UC/Crohns Tx
Which one can be Tx w/ surgery
What do asthma exacerbations get upon d/c
Cholestyramine, Colestipol
UC w/ total colectomy
Beta agonist, CCS
? antihypertensive med can cause prolonged HOTN when used w/ Sildenafil
? P2Y12 inhibitor is c/i in Pts w/ MEdHx of TIA <12mon
What criteria is used for Dx IBS
A-blockers
Prasugrelor
Rome:
Pain x 3d/mon x 3 mon w/ ≥2 of:
Improved w/ BM
Changed freq/consistency
Pts w/ IBS report w/ ? c/c and ? relieving fact
What red flags make the Rome Criteria for Dx invalid
What is the next step if red flags are present
N/V, bloat relieved w/ defecation
Hematochezia Weight loss
Fever
Imaging or colonoscopy; no labs- normal during IBS
How is IBS Tx
Toxic megacolon is a complication of ?
How do Pts present
Hyoscyamine before meals for antispasmotic effect
IBS: UC > Crohns
Shock Abdominal distension Fever Enlarge colon >6cm Peritonitis
Criteria used w/ radiology to Dx Toxic Megacolon
How is this Tx
Three of:
Fever Leukocytosis >10.5K Anemia Tachy >120bpm
One of:
HOTN E+ imbalance AMS Dehydration
Ceftriax+Metro, Decompression, Resection
? is the MC vessel blocked during intestinal ischemia
What would be seen on x-rays
How is it Dx by gold standards and how is it Tx
Superior Mesenteric artery
Thumb printing
Angiography; Revascularization
How does chronic mesenteric ischemia present
What MedHx do Pts usually have
? two meds can help prevent formation of new polyps
Post-prandial pain w/in 60min of eating, resolves <3hrs
PVDz Smoker DM
ASA, Cox-2 inhibitors
Polyp growths are the MCC of ? in Peds
These tend to be more malignant w/ ? association
Define Familial Adenomatous Polyposis
Painless rectal bleeding
More superior in intestine they are
Thousands of polyps by 15y/o, Ca by 40y/o
When do first degree relatives need screening w/ FamHx for Familial Adenomatous Polyposis
? types of polyps are common in the distal colon/rectum
What types of plyps have a higher risk for Ca transformation
Genetic screening after 10y/o
Adenomatous: MC tubular type, least risk
Villous adenomas
When do Pts start routine screening colonoscopies
How can this form of Ca be screened for
How often are scopes performed
45y/o, ending at 75y/o
Guiac q12mon
Fecal q12mon
FIT DNA q 1-3yrs
Flex Sigmoid: q5yrs or,
q10yrs w/ FIT every year
Colonoscopy: q10yrs
CT colonography q5yrs
What is seen on barium study if colon cancer is present
How is this Tx
? is the MCC of lower GI bleeds and how does this MC present
Apple core lesion
Resection w/ 5-FU chemo
Diverticulosis- painless rectal bleeding in Pt w/ LLQ pain
Where are diverticuli MC found
How does diverticulitis w/ macroperforation present
? triad is considered a pos Dx
Descending colon;
Western society- sigmoid
Constipation LLQ pain
Inc WBC/CRP Fever
No vomit, CRP >5mg, LLQ tenderness
How is diverticulosis Dx
What ABX are used for Tx
When is admission indicated
Noncontrast CT: fat stranding w/ thick wall
X-ray r/o free air
Avoid colonoscopy
Cipro or Augmentin w/ Metronidazol
Complicated
Uncomplicated w/ fever >102.5, Septic, ImmSupp, NPO
What are the bulk-forming laxative
What are the osmotic laxatives
What are the suppositories used for constipation Tx
Psyllium Ca polycarbophil Methylcellulose Dextrin
Lactulose Mg Polyethylene glycol Sorbitol
Glycerin Bisacodyl Senna
? Pt presentation w/ constipation needs to have colon Ca r/o
Constipation lasting more than ? and refractory to Tx needs further work up
What causes Traveler’s Diarrhea
> 50y/o w/ new onset constipation
> 2wks
E Coli
Diarrhea after picnic/egg salad
Diarrhea after shellfish
Diarrhea after pork/poultry
Staph A
Vibrio cholerae
Salmonella
Diarrhea after poorly preserved canned foods
? lab result indicates inflammatory diarrhea
How can the frequency of diarrhea be decreased
C perfringens
WBCs in stool
Loperamide Diphenoxylate Codeine Paregoric
Hep A virus type and mode of transmission
Where are epidemics seen
What vectors can also carry this virus
RNA virus transmitted via ATM
Daycare/Barracks
Water, Milk, Shellfish
What labs are seen during Hep A during early/late phase
How is this Tx
When are vaccinations given
Acute: anti-HAV IgM
Later: anti-HAV IgG
Immune globulin IgG <2wks since exposure
12-23mon
Hep B virus type and mode of transmission
What lab result is seen first and is the first sign of infection
What lab result is seen w/ viral replication and indicates infectiousness
Where is the Ag core going to be found
DNA virus w/ Dane particle from sex/blood products
HBsAg
HBeAg
HBcAg- intracellular, liver- Pt now ‘has’ Hep B
What is the first response seen to Hep B infections
How is acute Hep B Dx
What is the second response seen in response to Hep B
What is the last response seen to Hep B infections
HBcAb IgM; x3mon- IgG
HBcAb
HBeAb IgM; x3mon- IgG
HBsAb IgM; x3mon- IgG
What lab result suggests Pt is immune to Hep B
How do you differ active from passive Hep B immunity
How do you Dx Chronic Hep B
anti-HBs IgM/IgG
ABcAg; anti-HBc Ab
HBsAg is always Pos
Hep C virus type and mode of transmission
What is different between Hep C and B
How is Hep C Dx
Single RNA strand in transfusion recipients and IVDA
Hep C more likely to be chronic
Anti-HCV Abs
How is Chronic Hep C managed
Hep D virus type and mode of transmission
Hep D will cause >50% of all ? cases
Interferon
RNA virus transmitted w/ HBsAG
Fulminate hepatitis
Hep E infection resembles ? and is transmitted by ?
MC infectious cause of dilated cardiomyopathy
What are the 3 phases of acute heptatitis
Hep A; via ATM
Enterovirus: Coxsackie B
Prodromal: dec smoking, spiking fever- Hep A
Icteric: jaundice after fever
Fulminant: encephalopathy, coagulopathy
What lab results are seen w/ acute hepatitis
Only ? etiologies of hepatitis can become chronic
Define Fulminant Hepatitis
Inc ALT/AST:
Acute >500, Chronic <500
B, C, D
Acute liver failure in Pts w/ hepatitis
What are 3 etiologies for Fulminant hepatitis
How does this form of hepatitis appear on PE
Tylenol OD- MC in USA
Viral infection
Reye syndrome- kids w/ ASA use after viral infection
Encephalopathy w/ astrix
Coagulopathy- INR ≥1.5
Reye syndrome- uncontrollable N/V w/ hand/foot rash
How is Fulminant Hepatitis managed
What is definitive Tx
What lab result suggest alcoholic liver dz
IV fluid/E+
Mannitol- inc ICP
PPI- stress ulcer prophylaxis
Liver transplant
AST>ALT x 2
AST- normally in mitochondria, ETOH induces injury/release
What are the etiologies for non-alcoholic fatty liver dz
What are the two types
HyperLipid Obese GCCS DM
NAFL: benign, no fibrosis or malignant potential
NA Steatohepatitis- inflammation and fibrosis w/ premalignant potential
How is NAFL Dz Dx
Define Cirrhosis
What is the MCC
Biopsy- fatty deposits w/out alcoholic Hx
Irreversible fibrosis w/ nodular regeneration 2/2 chronic liver dz
Chronic Hep C > alcohol
What may be seen on PE of cirrhosis
How is this Dx and managed definitively
What type of f/u surveillance do these Pts need
Telangiectasis Ascites Gynecomastia Confusion Lethargy Asterixis Medusa Spider angioma
Liver biopsy; Transplant
RUQ US q6mon
How is cirrhosis encephalopathy managed
How is cirrhosis ascites managed
How is cirrhosis pruritus managed
1st: Lactulose/Rifampin
2nd: Neomycin
Na restriction
Spironolactone Furosemide
Cholestyramine
How is cirrhosis staging done
? autoimmune d/o can cause cirrhosis
? lab/rads are ordered at Dx
Child-Pugh: Serum albumin Encephalopathy Ascites Total bili PT INR A: 5-6pts B: 7-9pts C: 10-15pts
Wilson’s Dz- inc copper, dec ceruloplasmin w/ +FamHx
A-fetoprotein- high= MRI
EGD
Pt w/ cirrhosis presenting w/ ? two Sxs suggest spontaneous peritonitis
What marker is used to see if Pts convert to cancer
? vascular issue can develop and present in a triad
Fever, Abd pain
A-fetoprotein
Budd Chiari- hepatic vein thrombosis: Pain Ascites Megaly- lver
? is the MCC of portal HTN in peds
What are the two types
How is this Dx
Budd Chiari
1: hepatic vein thrombisis (MC)
2: hepatic/IVC occlusion
RUQ Us- screening
Venography- test of choice
Define ‘Nutmeg Liver’
How is Budd Chiari Tx
How is autoimmune hepatitis Tx
Congestive hepatopathy, DDx for Budd Chiari Dx
Shunt decompression
Diuretics for ascites
CCS
How is Wilson’s Dz induced cirrhosis Tx
What is used for prophylaxis against variceal hemorrhage/esophageal bleeds
Define Hepatocellular Carcinoma
Penicillamine- chelation therapy
Nadolol, Propranolol
Tumor developing d/t chronic liver dz and cirrhosis
Hepatocellular Carcinomas work up once lesion <1cm is found
What sizes have a good prognosis w/ transplant Tx
Define Cholelithiasis
Contrast MRI;
Neg- f/u US q3mon
No rad findings- biopsy
Single tumor <5cm
≤3 tumors all ≤3cm
Gallstones (cholesterol > pigment) w/out inflammation
What are the RFs for cholelithiasis
? is the cardinal Sx of cholelithiasis
How is this Dx
5 Fs: Fat Fertile Female Flatulent Forty
Biliary colic
RUQ US after 8hrs of fasting
What lab result is elevated when there is obstructed bile flow in cholelithiasis
What lab result is decreased
What clotting factors are made in the liver and how are they assessed
ALK-P, confirmed w/ GGT
Albumin
1 2 5 7 9 10 12 13 w/ PT
How is cholelithiasis Tx
Black gallstones mean ?
Brown gallstones mean ?
Ursodeoxycholic- dissolves stones over 6-9mon;
Cholecystectomy
Hemolysis, ETOH related cirrhosis
Asian, parasite/bacterial infection
Define cholecystitis
What PE finding aids w/ Dx
What ABX are used for cholecystitis prior to ? surgical procedures
Cystic duct obstruction leading to EColi infection/inflammation
Murphy- pain w/ inspiration Boas- pain to R shoulder;
US then HIDA- most specific
Ceftriax and Metronidazole;
Cholecystostomy- percutaneous drainage
? pre-malignant condition can develop from chronic cholecystitis
Define Choledocholithiasis and what this can lead to
What PE finding is more suggestive of choledocholithiasis
and what is the Dx test of choice
Porcelain GB
Gallstone in common bile duct; cholestasis- inc ALP w/ GGT
Jaundice; ERCP
Define Cholangitis
What triad presents w/ ascending cholangitis and what additional Sxs makes this into a pentad
How is this Dx
Biliary tract infection 2/2 obstructed common bile duct and EColi/Klebsiella
Charcot: F/C, RUQ pain and jaundice;
HOTN/shock and AMS
US then cholangiography via E/MRCP
How is pulmonary wedge pressure measured
HyperK EKG changes
S1/S2 sounds
Swan Ganz cath
Peaked T, Dropped P, Wide QRS, Sine wave
S1: MT S2: AP
What is the classic presentation for pancreatic cancer
What is the imaging study of choice for this
What PE sign may be seen
Painless jaundice and pruritus w/ mass compressing bile duct w/ jaundice
Abdominal CT:
Neg: endoscopic US w/ biopsy
Pos: resection w/ biopsy
Courvoisier sign- palpable gallbladder
What is the worst type of pancreatic cancer w/ the lowest prognosis
What is the MC s/e after PUD surgery
What is the MCC of pediatric intestinal obstruction
Ductal adenocarcinoma
Weight loss d/t early satiety
Intussusception- colicky pain, vomit and bloody stool
How is intussusception Dx
MCC of small bowel obstruction
MCC of large bowel obstructions
US or pneumatic enema- Dx and therapeutic
Adhesions
Neoplasms
? is the MC location for primary anal fissures to develop and what would be seen on PE of chronic fissures
How are these Tx in order
What part of the cardiac system has the slowed electrical conduction
Posterior to midline; skin tags
WASH, Topical nifedipine/Nitro, Botox, Lateral internal sphincterotomy
AV node
What causes Primary Anal fissures posterior to midline
What causes Secondary anal fissures lateral to midline
What type of cells make surfactant
Trauma Constipation Vaginal delivery
Crohns Malignancy Communicable/Granulomatous Dzs
Type 2 pneumocytes
What criteria allows for Tetrology Pts to play in sports after surgical correction
What mnemonic is used for DDxs for pancreatitis
R ventricular pressure <50mmHg
GET SMASHED
Gallstone Ethanol Trauma Steroid Mumps Autoimmune Scorpions HyperCa Hyperlipid ERCP Drug
How is chronic pancreatitis’ presentation different from acute
What is the classic triad for chronic pancreatitis
What anatomical variant may be seen w/ chronic cases
Steatorrhea, Fat malabsorbed
Pancreatic calcification Steatorrhea DM
Pancreatic pseudocyst
? lab result is more specific for pancreatitis
What is the Dx test of choice
How is this x if biliary sepsis is present
Serum lipase 3x higher
Initial: CT or MRCP
Dx: CT** or
Xray: sentinel loop w/ dec bowel sounds; colon cut off sign
ERCP
What lab result is highly suspicious for gallstone induced pancreatitis
What lab result will be seen on BMP
Once admitted, how are Pts managed
ALT 3x higher than normal
HypoCa- necrotic fat binds to Ca via soponification
LR w/ Meperidine and Imipenem
What is the most sensitive and specific test for pancreatic function w/ chronic pancreatitis
What tumor marker is used to track PTs after pancreatic cancer Tx
Name of surgical procedure
Fecal elastase
CA 19-9
Pancreaticoduodenectomy- whipple
How is pancreatic cancer managed if Pt is inoperable
MC Sx of anorectal Ca
What is the MC type
ERCP w/ stent
Hemaochezia w/ tenesmus
Adenocarcinoma
What studies are ordered for hemorrhoids
How are hemorrhoids classified
Anoscopy- benign PE
Colon/Sigmoidoscopy- >40y/o w/ RFs for cancer
Degree of prolapse:
1: none below dentate line
2: spot reduction
3: manual reduction
4: irreducible, may strangulate
How are internal hemorrhoids Tx
Hemorrhoidectomy is used for Tx of ? stages
What is the MC microbe and location for anal fistula/abscess
Docusate/Psylliumw/ sitz baths
Lidocaine/witch hazel
Rubber band ligation
+bleeding= sclerotherapy
Stage 4 and medical failures
Staph A; posterior wall
How are anorectal abscess and fistulas Tx
Define anal fissure
InD then WASH:
Warm water cleanse Analgesic Sitz bath High fiber
Painful linear tear/crack along distal canal
How are anal fissures Tx
Define Vit C deficiency
What condition develops d/t the deficiency
First: Sitz bath, inc water/fiber
2nd; Nitro, Nifedipine
3rd: botox to internal sphincter
4th: internal sphincterotomy
Ascorbic acid
Scurvy: tooth loss w/ 3 Hs-
Hyperkeratosis: hyper hair follicles w/ curled hair
Hemorrhage: gun/skin/joint bleeding and dec healing
Heme: anemia w/ glossitis
How is Vit C deficiency Dx
How does Vit D deficiency appear on PE
What would be seen on x-rays
Leukocyte ascorbic levels > serum levels
Bone pain
Prox muscle weakness
Bowing of long bones
Looser lines- pseudo Fxs
How is Vit D deficiency Tx
What is the other name for Vit D and it’s role in the body
Viatmin A deficiency/toxicity
Ergocalciferol
1,25 Dihydroxycalciferol- needed to absorb Ca from intestine
Inc: idiopathic intracranial HTN
Dec: night blindness
What is seen on PE if Vit A deficiency is present
B2 deficiency syndrome name
B1 Deficeincy
Bitot’s spots: white spot in conjunctiva
Riboflavin-
Oral: magenta colored tongue
Ocular: photophobia
Genital: scrotal dermatitis
Thiamine: d/t alcoholism
What are the two forms of B1 Thiamine Deficiency
What form of encephalopathy can form
Why is this such a concern
Dry Beriberi: symmetric peripheral neuropathy
Wet Beriberi: high output HF w/ dilated myopathy
Wernicke: ataxia, confusion, ophthalmoplegia
Neuro emergency commonly seen in alcoholics
? form of dementia can form w/ B1 Thiamine deficiency
What are the etiologies of B3 Deficiency
What condition does this present as
Korsakoff: short term loss w/ confabulation d/t Wernickes
Untreated corn lacking tryptophan
Carcinoid syndrome: inc tryptophan metabolism w/ serotonin production
Hartnup dz: dec tryptophan absorption
Pellagra: Dermatitis (sun exposed) Diarrhea Dementia
How does B6 deficiency present
How is B12 absorbed into the gut
What is the MCC of this deficiency
Peripheral neuropahty and anemia
W/ intrinsic factor in distal ileum
Pernicious anemia- dec IF d/t parietal cell Abs
How does B12 deficiency appear on PE
How is this Dx
Since this presents similarly to folate deficiency, what lab results are used to differ the two
Initial Sx: symmetric paresthesia in legs
Lat/Post spinal cord demyelination: loss of vibratory/proprioception, dec DTRs
CBC w/ peripheral smear: macrocytic w/ hypersegmented neutrophils and macro ovalocytes
Inc LDH, homocysteine, methylmalonic acid
Define RA
How does this present on exam
What two syndromes can be seen w/ this Dz
Chronic autoimmune inflammatory dz w/ persistent symmetric polyarthritis
AM stiffness improving through day, affects DIP and PIP
Felty: RA + splenomegaly + dec WBC
Caplan: coal worker lung and RA
What are the two hand deformities seen w/ rheumatoid arthritis
How is RA Dx
How is RA Tx w/ DMARDs
Boutonniere: PIP flexion, hyperextend DIP
Swan neck: DIP flexion, hyperextend PIP
Rheum factor: sens, not spec
Anti citrullinated peptide Abs: most spec
NSAIDs w/ CCS
Hydroxychloroquine Methotrexate* Sulfasalazine
How is RA Tx w/ Biologics
Lab results seen w/ OA
What DDx can occur w/ OA in the knee
IL-1 antagonist: Anakinra
Anti-TNF: Etanercept Infliximab Adalimumab
Normal ESR/CRP
Bakers Cyst
What are four meds that can induce lupus
Define SLE
What lab result is usually pos in these Pts
Procainamide Isoniazid Quinidine Hydralazine
Autoimmune dz w/ rash (maculopapular butterfly), joint pain, fever
ANA and anti-histone Abs, normal complement
What are the three types of SLE
How is this Dx
What lab result means Pt is at increased risk for thrombosis
Fixed erythematous: rash on cheeks/nose bridge
Discoid: annular, erythematous patches
Systemic: Renal Alopecia CNS Eye CV
Initial: ANA
Anti-double DNA/AntiSmith- 100% spec
Antiphospholipid Ab syndrome
What lab result can indicated females w/ SLE will have frequent miscarriage/livedo reticularis
What complement levels are dec during flares
? lab results suggest increased risk for neonatal lupus erythematosus during pregnancy
B-2 glycoprotein 1 Ab
C3,4 CH50
Anti Ro/La
? lab result has high sensitivity for an etiology for drug induced lupus
How is SLE managed
Define Scleroderma
Antihistone Ab
Hydroxychloroquine
NSAID/Acetaminophen
Sun protection
CT d/o w/ thickened skin (sclerodactyly)
Limited Cutaneous Systemic Sclerosis is AKA ? syndrome
How is the vascular phenomenon Tx
How is Scleroderma Dx
CREST: Carlcinosis Raynauds gErd, Sclerodactyly Telangiectasis
Raynauds- CCB and prostcyclin
Anti-centromere Ab- limited crest, better
Anti-SCL 70 Ab- diffuse Dz w/ multiple organ involvement
How is Scleroderma Tx to prevent progression/if pulm system is involved
What meds are used if P-HTN develops
What is the drug of choice for renal crisis
Methotrexate
Mycophenolate
Cyclophosphamide
Ambrisentan and Tadalafil
Captopril
Define Ankylosing Spondylitis
This Dx is also associated w/ ? other four Dx
How is this condition Dx
Seronegative arthropathy affecting sacroiliac joints
Psoriasis IBDz Anterior uveitis AR
CRP/ESR, HLA-B27
X-ray: gold standard
How is Ankylosing Spondylitis managed
What meds can be used for relieving joint Sxs
What lab result will be Pos in >80% of Reitters Pts
PT w/ NSAIDs
Refractory: a-TNF Etanercept/Infliximab
Sulfasalazine, Methotrexate
HLA-B27
Define Reitters Syndrome
What GI infections can cause this
Other than + HLA-B27, what other lab result aids w/ Dx
Autoimmune response to infection, MC G > C
Salmonella/Shigella
Campylobacter
Yersinia
Aseptic synovial fluid
How is Reitters Tx
Define Gout
How is this Dx if the attack is in great toe
NSAIDs/ABX
No response: methotrexate, a-TNF, CCS
Uric acid accumulation in joints/tissue
Podagra
How does acute gouty arthritis present
How does chronic gout present
Define Pseudogout
Podagra, monoarthropathy
Tophi deposition
Ca pyrophosphate crystal in tissues, MC knee, wrist
What will be seen on x-rays of pseudogout
How is gout Dx
How is pseudogout Dx
Chondrocalcinosis- linear radiodensities
Neg birefringent needles
Rat bite/punched out erosion on x-ray
Inc serum uric acid/ESR/WBCs
Pos birefringent, rhomboid crystals
How is acute gout Tx/managed
What is avoided
When/How is chronic gout considered for managed
1st: Indomethacin, Naprosyn
2nd: colchicine, steroid
ASA- inc serum uric acid
Tophi or ≥2 attacks/year:
Allopurinol: red uric acid production
Probenecid: inc uric acid secretion
NSAID or Colchicine
How is Pseudogout Tx
What is used for prophylaxis
Define Polymyositis
CCS then NSAID
Colchine
Chronic, idiopathic inflammation causing symmetric, proximal weakness/pain
What would be seen on PE in Pts w/ Polymyositis
What parts of the body are MC affected
How is Polymyositis different from Dermatomyositis and Polymyalgia Rheumatica
Early fatigue
Inability to rise from seated
Shoulders, Hips
Derm: skin changes
PR: lack of joint pain
Polymyositis:` inc muscle enzymes/CrK
Define Dermatomyositis
What differentiators may be seen on exam
Autoimmune myopathy w/ symmetric proximal weakness AND cutaneous findings
Gottrons: raised purple, scaling plaques on bone prominences
Shawl/V-sign: pink rash on neck/trunk
Heliotrope rash: purple/red rash around eyes/on lids
What would be seen on muscle biopsy results in Dermatomyositis Pts
What serology result is specific for Dermatomyositis
What marker is specific for interstitial lung fibrosis
Endomysial inflammation
Anti-Mi-2 Ab
Anti-Jo 1 Ab
How is Polymyositis/Dermatomyositis Tx
What two presenting factors are unique for fibromyalgia
How is this Dx
Suppress w/ CCS
Long term management- Methotrexate
Sleep disturbances, Sxs worse w/ stress
Pain w/ 4kgs of force in 11 of 18 sites
How is fibromyalgia managed
What is the only FDA approved med for Tx
What is the preferred method of PT
TCAS
Pregabalin
Swimming
What part of the body is attacked during Sjogrens
How is it Dx
What test can be done in office for Dx
How is Sjogrens Tx
Exocrine glands: Xerostomia, Keratoconjunctivitis sicca
ANA, Anti-SS A/B (anti-RO/La)
Schirmers: pos if <5mm lacrimation in 5min
Pilocarpine- cholinergic for xerostomia Cevimeline
What is the Rule of 50 for GCA
What causes this to occur
What branches of the carotid artery are affected by GCA
Steroids ESR Age >50
Viral infection causing monocyte activation and cytokine production
Post-Ciliary Occipital Ophthalmic Temporal
GCA prevalence is closely linked w/ ? other Dx
What type of vision loss can occur
Polymylagia Rheumatica- inflammatory condition causing synovitis, bursitis and tenosynovitis
Amaurosis fugax- temporal monocular d/t ischemic optic neuritis
What do Pts present w/ as c/c w/ polymyalgia rheumatica
How are Pts w/ this condition managed
Define Polyarteritis Nodosa and w/ co-Dx may exist w/ this
AM stiffness/joint swelling w/ normal strength
CCS, Methotrexate
Vasculitis of med/small arteries; Hep B/C
Two abnormal c/c making Polyarteritis Nodosa a possible dx
What PE finding supports this
How is a Dx confirmed
New foot/wrist drop
Rapidly inc HTN
Tender lumps on thigh/lower legs
Biopsy- necrotizing arteries
Ateriography- arterial aneurysms
What rheum factor is usually negative in Pts w/ Polyarteritis Nodosa
How is this Tx
? is the MCC of hyperthyroidism
ANCA neg
Steroids w/ cyclophosphamide
Hep B: plasmapheresis
Graves dz
What will lab results show in hyperthyroidism
How is this Dx
How is this Tx
Low TSH, high T3 and FT4 (graves- only T3 is elevated)
Anti-thyrotropin Abs via TSI/TBII
Methimazole- mild cases
PTU- pregnancy
Cards Sx: Atenolol
? is the MCC of hypothyroidism
What will be seen on lab results
How is this form of thyroid d/o Dx
Autoimmune Hashimoto
High TSH, low FT4
Anti-thyroid peroxidase (TPO) Abs
Lab results for Primary Hypothyroidism
Lab results for Secondary Hypothyroidism
How is this Tx
Inc TSH, low T4 w/ high cholesterol
Low TSH and low T4 w/ low cholesterol
Thyroxine/Synthroid- synthetic free T4
What presentation shift DDx from Hashimotos thyroiditis to subacute thyroiditis
? is the MCC of thyroid pain
What path does this follow and w/ ? lab result
Neck tenderness/goiter w/ recent viral illness
Subacute thyroiditis (Quervains)
Hyper to hypo-thyroid;
Inc ESR
Two meds that cause thyroiditis
Infectious thyroiditis are usually d/t ? microbes
How is Subacute/Postpartum thyroiditis Tx
Lithium Amiodarone
Staph/Strep
BBs, ASA
? is the MC RF for thyroid Ca
? is the MC type
? is the MC benign thyroid nodule
Radiation
Papillary in females 40-60y/o
Thyroid adenoma
Thyroid nodules must be bigger than ? size to be palpable
What are the RFs for thyroid Ca
How are thyroid Ca Dx
> 1cm diameter
FamHx
Age >65/<20
Radiation
US
>1cm- biopsy
How to tell if thyroid nodules are malignant or not
How is thryoid Ca Tx
What Tx step is different for ? type of Ca
Thyroid uptake:
Ca- cold, no uptake; next step= FNA
Benign- hot (uptake)
Thyroidectomy w/ chemo
External beam radiation- anaplastic Ca
First line Tx for tinea corporis
How does this appear on PE
What other DDx appears similarly
Topical clotrimazole
Red, itching scaly patch w/ scaly edges and central clearing
Granuloma annulare- benign inflammatory condition w/out scaling
? is the MC overlooked DDx when assessing isolated pleural effusions
What is the MCC of isolated effusions
Define Lymphogranuloma venereum
PE
HF
STD from Chlamydia trachomatis in MSM- painless genital ulcers resolving <3days
What PE finding may be seen w/ Lymphogranuloma venereum
How is this Tx
How are scabies Tx in adults/infants or in nursing home populations
Groove sign- adneopathy above and below inguinal ligament
Doxy
Permethrin 5%; PO Ivermectin
Common s/e to IV delivered chemo Txs
What two atypicals have the least amount of weight gain associated w/ use
Define DI and what lab results are seen
`Irritative voiding Sxs
Aripiprazole, Ziprasidone
Dec ADH secretion= Inc serum Na/Osm, dec urine Osm
Medical management for chronic barotrauma/pain w/ flying
How does Primary Immune Thrombocytopenia present
How are Pts managed
Pseudophedrine (decongestants)
Petechiae, gingival bleeding after viral illness
Platelets <10K: IVIG, steroids transfuse
Platelets >20K: observe
How is life threatening HypoMg Tx
Histology results of psoriasis biopsy
S/e of lidocaine toxicity
IV CaCl or Ca gluconate w/ dialysis
hyerpkeratosis, parakeratosis, acanthosis
Bradycardia, heart blocks
Max doses of lidocaine w/ or w/out epi
Pts w/ open skull Fxs need ? ABX prophylaxis
When do hyperCa Sxs begin in pts w/ hyperparathyroidism
3-5mg/kg w/out; 5-7mg/kg w/
Vanc w/ Ceftriax
> 12
