random Flashcards
Heberden and Bouchard nodes
- can be cause by severe osteoarthritis
- hard, bony nodules over the distal (Heberden) and proximal (Bouchard) interphalangeal joints, respectively
rheumatoid nodules
- firm, flesh-colored and NONTENDER
- typically occur over pressure points such as the elbow and extensor surface of the proximal ulna
- almost all these pts will have positive rheumatoid factor levels
“sausage digit”
-severe PSORIATIC arthritis typically first affects the distal interphalangeal joints and clinically manifests as a “sausage digit”, where the digit takes on a swollen fusiform shape w/ significant hyperemia
Chronic tophaceous gout
- urate crystals can be deposited in the skin resulting in the formation of tumors (tophi) w/ a chalky white appearance
- be on the lookout for the great toe being affected (podagra) w/ monosodium urate crystals
- Uric acid crystals form in the renal tubules and collecting system resulting in NEPHROLITHIASIS
- Ddx includes rheumatoid nodules and calcinosis cutis when suspected tophi are seen
- Note that diuretics in general have a hyperuricemic effect resulting from hypovolemia-associated enhancement of uric acid reabsorption in the proximal tubule
myocardial contusion
- tachycardia, new bundle branch blocks or arrhythmia
- sternal fracture is commonly associated injury
myocardial rupture
- cardiac tamponade (muffled heart sounds, hypotension, distended neck veins)
- diagnosis is made rapidly w/ US
esophageal rupture
- rare following blunt trauma
- Iatrogenic (ie w/ endoscopy) and esophagitis-related etiologies are more common
- may have pneumomediastinum and PLEURAL EFFUSIONS
Diaphragmatic rupture
- abdominal pain, pain referred to the shoulder, shortness of breath, and/or vomiting
- CXR may show abdominal viscera above the diaphragm, and/or loss of the diaphragmatic contour
Hemothorax
- may result from injuries to the aorta, myocardium, hilar blood vessels or lung parenchyma
- symptoms depend on degree of blood loss and can range from SOB to shock
Pts sustaining rapid deceleration injuries to the chest require radiographic evaluation for aortic injury w/ x-ray, CT scan and possibly TEE as well
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Persistent pneumothorax and significant air leak following chest tube placement in a patient who has sustained blunt chest trauma suggests what?
- Tracheobronchial rupture
- other findings include pneumomediastinum and subcutaneous emphysema
rash associated w/ secondary syphilis
- generalized maculopapular lesions involving the trunk and extremities w/ associated lymphadenopathy
- rash typically does NOT spare the palms and soles
Disseminated gonococcal infection
- causes high fever, chills, tenosynovitis, polyarthralgia, and pustular lesions on the trunk and extremities
- should be considered when risk factors for gonococcal infection are present
- routine blood and pustule cultures can be negative due to the fastidious nature of Neisseria gonorrhoeae
- may also have migratory asymmetric polyarthralgia without purulent arthritis (wrists, ankles, fingers, and knees)
- recurrent DGI: check terminal complement activity
- treat for chlamydia empirically w/ azithromycin or doxycycline
- treat gonorrhea w/ IV ceftriaxone
Osteoarthritis
- non-inflammatory arthritis presenting with pain that is worse w/ activity and improved w/ rest
- x-ray findings include joint space narrowing and osteophytes, and subchondral sclerosis/cysts.
- synovial fluid analysis will reveal fewer than 2000 WBC/ml, no organisms, and no crystals
- most commonly affects hands and weight-bearing joints
- increasing age is leading risk factor
- typically have mild morning stiffness (
Punched out erosions w/ a rim of cortical bone
- characteristic x-ray findings in gouty arthritis
- acute joint pain and synovial fluid shows WBC count 2000-50,000/mL and NEEDLE-SHAPED, NEGATIVELY birefringent crystals (yellow when parallel)
periarticular osteopenia and joint margin erosions
- classic for rheumatoid arthritis (RA)
- inflammatory arthritis presenting w/ morning stiffness ( >30 minutes) and systemic symptoms of fever, malaise, and weight loss
- WBC count of synovial fluid is 2,000-50,000/mL
- wrists, MCP and PIP joints are commonly involved
- the joints will be warm to the touch
normal joint space w/ soft tissue swelling
- infectious arthritis
- cell count of > 50,000/mL is typical on synovial fluid and gram stain is often positive
calcification of cartilaginous structures
- CHONDROCALCINOSIS
- typical of pseudogout, or calcium pyrophosphate dihydrate (CPPD) deposition
- acute swelling, stiffness, and pain of the knee after surgery or medical illness
- synovial fluid = 2,000 - 50,000mL w/ RHOMBOID, POSITIVELY birefringent crystals (blue when parallel)
Ankylosing spondylitis
- pts can develop restrictive lung disease due to diminished chest wall and spinal mobility
- PFTs show a mildly restrictive pattern w/ reduced vital capacity and total lung capacity but normal FEV1/FVC
- low back pain (age of onset
obstructive lung disease patten on PFTs
-FEV1:
Restrictive lung disease (including obesity) pattern on PFTs
- FEV1: 70%
- FVC:
Rotator cuff tear
- may result from trauma (eg falling on an outstretched arm) or as the end result of chronic impingement and tendonitis
- similar to pts w/ rotator cuff tendinitis, pts often complain of pain upon reaching and lifting the arm over head. However, weakness of the shoulder is more common in rotator cuff tears, and symptoms do not improve w/ lidocaine injection
Adhesive capsulitis
- aka “frozen shoulder”
- idiopathic condition characterized by pain and contracture
- inability to lift the arm above the head due to fibrosis of the shoulder capsule
Cervical radiculopathy
- typically presents w/ pain of the neck and arm
- paresthesias of the arm are present in 80% of pts
- weakness may affect the shoulder, elbow, or wrist
- movement at the neck exacerbates symptoms
thoracic outlet syndrome
- combination of numbness, weakness and swelling due to compression of the subclavian vessels and lower trunk of the brachial plexus
- a weakened radial pulse and reproduction of symptoms w/ specific arm movements supports the diagnosis
Rotator cuff tendonitis
- usually caused by impingement and is most common in middle-aged and older pts who perform repetitive arm movements above the head
- presents w/ pain when lifting the arm
- may be differentiated from rotator cuff tear and frozen shoulder by injection of the joint w/ lidocaine
- in the case of isolated rotator cuff tendonitis, any pain and limitation of motion is resolved by the injection
who may be rheumatoid factor positive?
-pts w/ rheumatoid arthritis, SLE, Sjogren syndrome, dermatomyositis, HCV infection and others
Antimitochondrial antibodies is associated w/ what?
Primary biliary cirrhosis
Anti-neutrophil cytoplasmic antibodies
-granulomatosis w/ polyangiitis (Wegener’s)
Anti-smooth muscle antibodies
-autoimmune hepatitis
anti-topoisomerase-1 antibodies
systemic sclerosis
Systemic sclerosis
- form of scleroderma w/ widespread organ involvement
- GERD, right heart failure, and hypertension result from involvement of the esophagus, pulmonary arteries and kidneys, respectively.
- antinuclear autoantibodies and anti-topoisomerase-1 antibodies would most likely be present
Pseudogout
- cannot be reliably distinguished from gout and septic arthritis based on history and physical alone
- diagnosed by the presence of RHOMBOID, POSITIVELY birefringent crystals on synovial fluid analysis, and radiographic evidence of CHONDROCALCINOSIS
- acute form of calcium pyrophosphate dihydrate (CPPD) crystal disease
- frequently precipitated by trauma, surgery, or medical illness
- knee is most commonly affected joint
gout
- monosodium urate crystals
- needle-shaped and NEGATIVELY birefringent on synovial fluid analysis
most common crystal found in renal calculi?
calcium oxalate
type of renal calculi found in pts w/ UTI caused by urease-producing organisms (Klebsiella, Proteus)?
Struvite (magnesium ammonium phosphate)
Initial disease-modifying antirheumatic drug of choice in pts w/ rheumatoid arthritis? side effects?
- Methotrexate
- side effects: GI symptoms, oral ulcers or stomatitis, rash, alopecia, hepatotoxicity, pulmonary toxicity, and bone marrow suppression
- FOLIC ACID supplementation has been shown to reduce the incidence of adverse effects of MTX therapy w/o loss of efficacy
Anti-cytokine agents used for treatment of rheumatoid arthritis?
- TNF-a inhibitors (etanercept, infliximab, adalimumab), IL-1 receptor antagonists (anakinra, canakinumab), and IL-6 receptor antagonists (tocilizumab)
- these agents are generally reserved for use in pts resistant to intitial DMARD therapy
- TNF-a inhibitors can cause neutropenia, infections (reactivation of latent TB, opportunists), exacerbations of heart failure, demyelinating illness, and increased risk of malignancy
Side effects of chronic glucocorticoid use?
-weight gain, HTN, peptic ulcer disease, glucose intolerance, myopathy, osteoporosis, increased risk of infections
Felty syndrome
-clinical disorder seen in pts w/ severe, long-standing (>10 yrs) RA that is characterized by neutropenia and splenomegaly.
Pts w/ RA have an approx. 2-fold increase risk of lymphoma, which may present w/ low-grade fever, fatigue, and a palpable spleen
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Polymyalgia rheumatica (PMR)
- age > 50
- subacute to chronic (>1 month) pain in the shoulder and hip girdles
- morning STIFFNESS lasting > 1 hour
- constitutional symptoms
- elevated ESR (> 40)
- no other apparent explanation of symptoms
- Tx: low-dose prednisone (if uncomplicated), which should result in rapid relief of symptoms
Fibromyalgia
- most commonly presents in young to middle-aged women w/ widespread pain, fatigue, and cognitive/mood disturbances
- pts have point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter
- regular aerobic exercise and good sleep hygiene are recommended
NSAIDS are occasionally useful in polymyalgia rheumatica for mild breakthrough discomfort or minor relapse of symptoms while tapering glucocorticoids. However, they are much less effective than glucocorticoids for initial management and are not recommended.
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what are you concerned about in a chronically wounded, scarred or inflamed skin over time? what is the eponym?
- Squamous cell carcinoma
- malignancy should be suspected in all non-healing wounds
- SCC arising within burn wounds is known as a MARJOLIN ULCER
- SCC has also been described arising in the skin overlying a focus of osteomyelitis, radiotherapy scars and venous ulcers; these types tend to be more aggressive
- a biopsy should be obtained in all chronic wounds failing to heal in order to rule out malignancy
When a wound fails to heal after a prolonged period, biopsies should be obtained to ensure the ulcer has not degenerated into a squamous cell carcinoma. When SCC arises within a burn wound, these ulcers are known as what?
Marjolin ulcers
Melanoma
-typically occurs in pts w/ a nevus that has increased in size, changed color, become palpable or become symptomatic (painful, pruritic, or bleeding)
Basal cell carcinoma
- classically presents on chronically sun-exposed skin
- lesions are usually pearly telangiectatic papules w/ a central “rodent” ulceration
Dysplastic nevi
- melonocytic nevi exhibiting characteristics not seen in standard nevomelanocytic nevi
- size greater than 6 mm, irregular borders, irregular pigmentation
- varying degrees of architectural disorders and cytologic atypia
precursor lesion to squamous cell carcinoma?
Actinic keratosis (common on chronically sun-exposed skin)
Polymyositis
- idiopathic inflammatory muscle disease
- slowly progressive PAINLESS, PROXIMAL WEAKNESS of the LOWER EXTREMITIES characterized by difficulty ascending and descending stairs or rising from a seated position; proximal arm weakness usually follows, leading to difficulty combing hair or working w/ the hands overhead
- pts may develop dysphagia due to involvement of the striated muscles of the upper pharynx
- there are NO skin findings in PM, distinguishing it from dermatomyositis
- a MUSCLE BIOPSY is the best diagnostic test and typically shows a mononuclear infiltrate surrounding necrotic and regenerating muscle fibers
Myasthenia gravis
- muscle weakness and fatigability
- cranial nerve and proximal limb weakness that worsens w/ repeated activity and resolves w/ rest
- symptoms resolve rapidly w/ administration of edrophonium (anticholinesterase test)
Electroencephalography (EEG)
-used primarily in the evaluation of pts w/ seizure or sleep disorders
Lumbar puncture
-useful to evaluate weakness in cases of suspected Guillain-Barre syndrome (ascending weakness w/ paresthesias and autonomic disturbances) or multiple sclerosis (episodic optic neuritis or transverse myelitis)
Hyperkalemia is a possible complication of ACE inhibitor (eg lisinopril) therapy and may present w/ flaccid paralysis. However, uncommon in pts w/o underlying renal insufficiency or additional meds that cause hyperkalemia
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Giant cell arteritis
- a temporal artery biopsy is necessary to make the diagnosis
- usually presents w/ headache, jaw claudication, and systemic symptoms
- commonly associated w/ polymyalgia rheumatica, which causes diffuse PAIN in the shoulders and hips but NOT WEAKNESS
Tension pneumothorax
- emergency situation and needs immediate needle thoracostomy based on clinical diagnosis (no imaging needed!)
- placement of subclavian central venous catheters accounts for approx. 1/4 of iatrogenic pneumothorax
- clinically characterized by rapid onset severe SOB, tachycardia, tachypnea, hypotension, and distention of the neck veins due to SVC compression
- tx: immediate needle thoracostomy to decompress pleural cavity, followed by an emergency tube thoracostomy w/ underwater seal
Cardiac tamponade
- hypotension, tachycardia, elevated systemic venous pressure and pulsus paradoxus
- pericardiocentesis is indicated
Mild traumatic brain injury (TBI) management
- pts w/ mild TBI w/ repeated vomiting, headache, or LOC should undergo head CT scan without contrast or observation for 4-6 hours
- if head CT scan is normal or the observation period is uneventful, pt can be discharged home w/ a reliable guardian; detailed return precautions should also be provided
- Mild TBI: GCS 13-15, LOC
serious TBI
- GCS 5 min, neuro deficit, signs of basilar skull fracture
- require neuroimaging w/ non-contrast head CT, close inpatient monitoring w/ neuro checks q2 hrs, and a neurosurgery consult
Minor head trauma
- GCS of 15, normal mental status, no abnormal neuro or funduscopic findings, and no evidence of skull fracture
- do NOT require neuroimaging or hospitalization
why order non-contrast head CT in trauma?
because contrast looks like an acute bleed, thus distinguishing them more difficult
Sjogren syndrome
- diagnosed when subjective or objective evidence of dry eyes and mouth exists in the presence of either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and / or SSB (La).
- autoimmune condition that most commonly affects women in their fifth and sixth decade
- keratoconjunctivitis sicca (xerophthalmia, dry eyes) and xerostomia (dry mouth); increased incidence of dental caries; difficulty swallowing
Antimitochondrial antibodies
-associated w/ Primary Biliary Cirrhosis (PBC), an autoimmune disease characterized by progressive jaundice, varices, and other signs of cirrhosis
Barium swallow test
-used to assess disease of esophageal motility such as achalasia or presence of esophageal diverticulum
test to diagnose Barrett esophagus
- esophageal endoscopy w/ biopsy
- Barrett’s: metaplasia of squamous epithelium to columnar epithelium and is a precursor of esophageal adenocarcinoma
what is the most common cause of lower extremity edema?
- Venous insufficiency (valvular incompetence)
- classically worsens throughout the day and resolves overnight when the patient is recumbent
how does edema caused by lymphatic obstruction present?
- uncommon cause of edema
- may result from malignant obstruction of lymph nodes, lymph node resection, trauma, and filariasis
- classically affects the DORSA OF THE FEET and causes MARKED THICKENING and RIGIDITY of the skin
signs of arterial occlusion in extremity?
pain, pallor, paresthesias, pulselessness, and coolness to the touch
Rotator cuff tears
- result from chronic rotator cuff tendonitis and shoulder trauma
- shoulder pain and weakness when lifting the arm above the head (or mid arc abduction, external rotation) is suggestive of rotator cuff pathology
- a lidocaine injection ameliorates the pain and weakness of rotator cuff TENDONITIS, while it does not improve symptoms of rotator cuff TEAR
- MRI is excellent at visualizing soft tissue structures and is the study of choice for diagnosing rotator cuff tears
what can shoulder x-ray diagnose?
-fractures, dislocations, and calcific tendonitis
Multiple myeloma presentation
- pain in the spine, ribs, or back
- may be accompanied by hypercalcemia and anemia
Fat embolism
- presents w/ dyspnea, confusion and petechiae in the upper part of the body and occurs after multiple fractures of long bones
- severe respiratory distress, petechial rash, subconjunctival hemorrhage, tachycardia, tachypnea, and fever
- diagnosis can be confirmed by FAT DROPLETS IN URINE or presence of intra-arterial fat globules on fundoscopy; may occur 12 to 72 hrs after the injury
- serial x-rays shows increasing diffuse bilateral pulmonary infiltrates within 24-48 hrs of onset of clinical findings
- tx: prompt respiratory support (use of heparin, steroids, LMW dextran is controversial)
air embolism
- can occur in a trauma patient who is on a respirator, or with subclavian vein access
- can result in sudden collapse and cardiac arrest
amniotic fluid embolism
-occurs immediately after the rupture of membranes
Thromboembolism
-can cause pulmonary embolism in bed-ridden patient
what does morning stiffness indicate?
INFLAMMATORY arthritides
Psoriatic arthritis
- occurs in 5-30% of pts w/ psoriasis
- classic presentation involves the DIP joints
- morning stiffness, deformity, dactylitis (sausage digit), and nail involvement are common
- current tx options for psoriatic arthritis include NSAIDs, methotrexate, and anti-TNF alpha agents
tophi
cutaneous deposits of monosodium urate crystals in chronic gout
-commonly occur over joints and the helix of the ear, and may ulcerate
Gottron’s papules
- violaceous plaques, slightly scaly
- can present with dermatomyositis
- usually over the MCP joints, which at times can look similar to psoriasis
Enteropathic arthritis
- occurs in 10-20% of pts w/ Chron disease and UC
- most often affects the lower extremities and sacroiliac joints and tends to wax and wane w/ the symptoms of bowel disease
- these pts have prominent GI symptoms and other extraintestinal manifestations of inflammatory bowel disease
Neuropathic arthropathy (Charcot joint)
- most commonly affects the lower limbs
- most cases occur w/ diabetes, but syphilis and alcoholism are other causes
- peripheral neuropathy is believed to result in decreased proprioception, which leads to frequent trauma and eventual destruction of the joint
Rheumatoid arthritis often presents w/ morning stiffness (indicating inflammatory etiology). The MCP and PIP joints are prominently involved, whereas the DIP joints classically are not. Dactylitis and nail involvement are also not expected in RA
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joint and skin involvement in sarcoidosis?
- polyarthritis affecting the ankles and knees
- causes protean cutaneous manifestations, the most common of which is ERYTHEMA NODOSUM
- also often have cough, chest pain, and dyspnea
Bowel ischemia (colonic ischemia)
- may complicate up to 7% of procedures on the aortoiliac vessels and most commonly affects the distal left colon
- pts report dull pain over the ischemic bowel as well as hematochezia
- colonoscopy shows a discrete segment of cyanotic and ulcerated bowel
Acute diverticulitis typically does not present with rectal bleeding, while diverticulosis does
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radiation proctitis
- diarrhea, rectal bleeding, tenesmus and incontinence
- later, strictures and fistulae may form
C. diff colitis (pseudomembranous colitis)
- abdominal pain, fever, and watery diarrhea
- diagnose by detecting toxin in the stool w/ ELISA
IBD can be differentiated from colonic ischemia both by the acute onset of the latter as well as differences in appearance on colonoscopy. Namely, ischemia typically spares the rectum and involves only a segment of the colon while IBD does not.
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Glasgow coma scale (GCS)
- all trauma pts should be triaged using the GCS, which can predict the severity and prognosis of coma, during the primary survey.
- the GCS assesses the patient’s ability to open his/her eyes, motor response, and verbal response
All pts w/ smoke inhalation should be suspected to have what?
- acute carbon monoxide poisoning
- tx w/ 100% oxygen via a nonrebreather facemask
- early symptoms of carbon monoxide poisoning are typically neurological and include agitation, confusion, and somnolence
- diagnosis confirmed clinically and documenting an elevated carboxyhemoglobin level (> 3% in nonsmokers and > 15% in smokers)
- pulse ox is unreliable!
a bolus of 50% dextrose and IV thiamine is indicated in any unconscious patient as an emergency measure to assess for hypoglycemia.
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Volkmann’s ischemic contracture
-the final sequel of compartment syndrome in which the dead muscle has been replaced w/ fibrous tissue
Reflex sympathetic dystrophy
- vague painful condition seen as a sequel of infection on trauma which may be minor
- characterized by pain, hyperesthesia and tenderness, which are out of proportion to the physical findings
- Sudeck’s atrophy is a radiographic term for spotty rarefaction seen in pts w/ RSD
manifestations of SLE
- constitutional: fever, fatigue and weight loss
- symmetric, migratory arthritis
- butterfly rash and photosensitivity
- serositis: pleurisy, pericarditis, and peritonitis
- thromboembolic events (due to vasculitis and antiphospholipid antibodies)
- cognitive dysfunction and seizures
- hemolytic anemia, thrombocytopenia, and leukopenia
- HYPOCOMPLEMENTEMIA (c3 and c4)
- ANA (sensitive) and ANTI-dsDNA and ANTI-SM (specific)
- renal involvement: proteinuria and elevated creatinine
Systemic Lupus Erythematosus (SLE)
- autoimmune disease that is most commonly diagnosed in young women
- more than 90% of patients w/ SLE have joint involvement, most often affecting the hands
- Joint pain may be severe but SLE induced arthritis is usually NON-DEFORMING (unlike RA)
Tx of joint symptoms in SLE
- most pts will respond to conservative treatment w/ NSAIDs
- low dose glucocorticoids or antimalarials (eg hydroxychloroquine) can be added for more severe joint symptoms
“pencil-in-cup” deformities
-distal phalangeal resorption is characteristic of the ARTHRITIS MUTILANS variant of psoriatic arthritis
Cartilage degradation is the underlying pathologic mechanism of osteoarthritis (OA). Pts w/ OA may develop muscle atrophy from limitations of joint movement.
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Subluxation of the cervical vertebrae and tendon damage in the hands may occur in RA
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SLE
- autoimmune disease most commonly diagnosed in young women
- 90% of pts have joint involvement, most often affecting the hands
- joint pain may be severe but SLE induced arthritis is usually NON-DEFORMING (ie no bone resorption or subluxation or permanent deformity)
Inflammatory breast cancer
- uncommon
- presents w/ an erythematous and brawny edematous cutaneous plaque overlying a mass on the breast commonly with axillary lymphadenopathy
- 25% of pts w/ this condition will have metastatic disease at time of presentation
Nipple discharge in a NON-lactating women should ALWAYS raise suspicion for breast cancer, especially if spontaneous, unilateral, localized to a single duct, occurs in a patient over 40 years old, is bloody, or is associated with a mass! Biopsy with histology must be done
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mastitis
- typically in younger lactating women
- tx w/ an antibiotic that covers Staph and Strep, and encourage continued breast feeding or breast pumping of the affected breast
cellulitis of breast that fails to respond to empiric antibiotic therapy
- biopsy for culture
- acid-fast organisms and fungi may rarely cause mastitis and breast abscess
Rheumatic fever
- preventable complication of streptococcal group A pharyngitis
- usually precedes the onset of rheumatic fever by 2-4 weeks
- diagnosed clinically using Jones criteria (2 major, or 1 major and 2 minor)
- Criteria includes, major: Carditis, migratory polyarthritis, sydenham chorea, subcutaneous nodules, and erythema marginatum; minor: fever, arthralgias, elevated ESR/CRP, prolonged PR interval
- supportive lab findings: positive strep antigen test or elevated ASO titer
- prevented w/ treatment w/ penicillin of strep pharyngitis
ALL
-malignancy of WBC’s that causes lymphocytosis or lymphopenia along w/ anemia or thrombocytopenia
Juvenile idiopathic arthritis
- diagnosed when arthritis is present > 6 weeks
- systemic symptoms including rash, can be seen in children with JIA, but the arthritis is usually NOT migratory
Henoch-Schonlein purpura
-small vessel vasculitis that can cause a transient, migratory arthritis and rash that is purpuric (arthritis typically involves lower joints)
Acute rheumatic fever
- peak incidence age 5-15; twice as common in girls
- Major: Joints (migratory arthritis), Carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham chorea
- Minor: fever, arthralgias, elevated ESR/CRP, Prolonged PR interval
- late sequelae: mitral regurgitation/stenosis
- prevention: penicillin for GROUP A STREP (strep pyogenes) pharyngitis
- diagnosis based on evidence of preceding group A strep infection along w/ 2 major criteria, or 1 major plus 2 minor criteria
SLE
- autoimmune disease that affects multiple organ systems
- arthritis and elevated CRP/ESR can be seen, but the rash is usually present across the cheeks (malar rash).
- Multiple organ system involvement (eg, hematologic, neurologic, renal) is needed for the diagnosis
diagnostic criteria for SLE?
SOAP BRAIN MD
-Serositis (pleuritis/pericarditis)
-Oral ulcers
-Antinuclear antibody (ANA)- very SENSITIVE
-Photosensitivity (skin rash to sunlight)
-Blood (hemolytic anemia, leukopenia, thrombocytopenia)
-Renal (proteinuria and cell casts)
-Arthritis (symmetric, involving 2+ small or large peripheral joints)
-Immunologic (anti-dsDNA)
-Neurological (seizures, psychosis)
Note that anti-smith antibodies are the most SPECIFIC for SLE!
-Need 4 out of 11 to diagnose SLE
Acute appendicitis
- CLINICAL diagnosis
- classic presentation of migratory RLQ pain, nausea, vomiting, fever, leukocytosis, McBurney point tenderness, and Rovsing sign should have IMMEDIATE appendectomy to prevent appendiceal rupture.
- imaging studies such as CT and US are useful for pts with NONCLASSIC symptoms, equivocal findings on initial assessment, or delayed presentation
Role of antibiotics in appendicitis?
- Abx should be given PREoperatively to all pts and should be continued POSToperatively for those w/ appendiceal rupture
- pts w/ appendicitis who have had symptoms > 5 days usually have a PHLEGMON with an abscess that has walled off; they can be managed conservatively w/ IV abx, bowel rest, and delayed appendectomy weeks later
Presentation of cardiac tamponade
hypotension, tachycardia, distant heart sounds, neck vein distension, ELECTRICAL ALTERNANS (varying amplitude of the QRS complexes from beat to beat) on ECG
Blunt abdominal trauma
- often causes splenic injury which can present w/ delayed onset hypotension, LUQ pain, and left shoulder pain (Kehr sign)
- pts should have an abdominal CT scan w/ IV contrast for diagnosis
- those w/ persistent hemodynamic instability require urgent laparotomy
Patellofemoral syndrome
- very common cause of anterior knee pain
- symptoms are chronic and associated w/ activities such as CLIMBING STAIRS w/ extension at the knee
- women are affected much more often than men
- diagnosis is based on history and physical exam; tx involves stretching and strengthening the thigh muscles in addition to avoiding activities that worsen the pain
- risk factors include overuse, malalignment, and trauma
- diagnostic test includes the PATELLAR GRIND TEST (patellofemoral compression test) and reproduction of pain w/ squatting
- subacute to chronic pain, increased w/ squatting, running, prolonged sitting, using stairs
patellar tendonitis
- primarily athletes (“jumper’s knee”)
- episodic pain and tenderness at inferior patella
Osgood-Schlatter disease
- preadolescent/adolescent athletes; recent growth spurt
- increased pain w/ sports, relieved by rest; tenderness and swelling at tibial tubercle
Penile fracture
- surgical EMERGENCY that requires emergent urethral imaging (retrograde urethrogram) and surgical repair
- the most common cause is a crush injury of the erect penis, most commonly during intercourse where the female is on top of the male
- often accompanied by snapping sensation or sound, followed by severe pain and swelling; due to tearing of the tunica albuginea, which invests the corpus cavernosum
Circumsision
- treatment of choice for phimosis, paraphimosis, and Zoon’s balanitis
- also associated w/ lower risk of squamous cell carcinoma of the penis
Acute mediastinitis
- can occur following cardiac surgery that is usually due to intra-op wound contamination and presents w/ fever, chest pain, leukocytosis, and mediastinal widening on chest x-ray
- its a serious condition that requires drainage, surgical debridement, and prolonged antibiotic therapy
- typically presents within 14 days post-op
- clinical diagnosis and confirmed during surgery when pus is seen in mediastinum
- high mortality rate even with appropriate treatment
Atrial fibrillation commonly (up to 15-40%) occurs within a few days after CABG and is usually self-limited, w/ resolution in 24 hours after CABG.
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treatment for pericarditis
NSAIDS
Postpericardiotomy syndrome
- fever, leukocytosis, tachycardia, and chest pain
- usually autoimmune and occurs a few weeks following a procedure with a pericardium incision
- NSAIDS or steroids treat the inflammation, and pericardial puncture is indicated if tamponade occurs
what to do with amputated part in traumatic amputations?
- amputate parts should be wrapped in saline-moistened sterile gauze, sealed in a plastic bag, placed on a bed of ice and brought to the ED with the patient
- younger pts w/ sharp amputations w/ no crush injury or avulsion are the best candidates for amputation reimplantation
Baker cysts
- develop as a result of excessive fluid production by an inflamed synovium, as occurs in cases of RA, osteoarthritis, and cartilage tears
- the excess fluid accumulates in the popliteal bursa which expands, creating a tender mass in the popliteal fossa
- baker cysts occasionally burst and release their contents into the calf, resulting in an appearance similar to a DVT
MCL tears
- MCL is most commonly injured ligament of the knee
- surgery is rarely necessary for MCL tears; bracing and early ambulation is the preferred treatment
- MRI is the investigation of choice for defining soft tissue injuries of the knee
If a patient develops a whistling noise during respiration following rhinoplasty, what should you suspect?
- Nasal septal perforation likely resulting from a septal hematoma
- up to 25% of rhinoplasties need to be revised
- common complications include patient dissatisfaction, nasal obstructions and epistaxis; those that involve the nasal septum are less common but more serious
- additional conditions that can cause septal perforation are self-inflicted trauma (nose picking), syphilis, TB, intranasal cocaine use, sarcoidosis, and granulomatosis w/ polyantiitis (Wegener’s)
nasal polyps
- usually seen in pts w/ asthma and allergic disorders but may also occur in pts w/ other inflammatory conditions of the nasal mucosa
- they may cause chronic nasal obstruction and should be surgically removed in symptomatic pts
foreign bodies in nose
- common in children
- pts will have nasal obstruction and may have a foul odor, halitosis, and nasal bleeding
- following surgery, a retained foreign body such as nasal packing most classically would cause toxic shock syndrome
allergic rhinitis
- presents w/ rhinorrhea, nasal pruritis, cough and occasionally dyspnea
- on exam, the nasal mucosa is edematous and pale, and polyps may be present
nasal furunculosis
- results from staphylococcal folliculitis following nose picking or nasal hair plucking
- potentially life threatening as it can spread to the cavernous sinus
- pts may complain of pain, tenderness, and erythema in the nasal vestibule
management of a suspected urethral injury?
- Retrograde urethrogram should be first step!
- foley catheterization in the presence of a urethral injury will predispose the patient to abscess formation and worsening of the urethral damage
- classic signs of posterior urethral injury include blood at the urethral meatus, inability to void and a high-riding prostate on digital rectal exam. Perineal or scrotal hematomas are also frequently seen and such an injury is most classically associated w/ pelvic fracture
how are urethral injuries managed?
- Retrograde urethrogram is almost always the first step
- immediate surgical repair is occasionally done in cases of ANTERIOR urethral injury
- most cases of urethral injury are treated w/ urinary diversion via a suprapubic catheter while the primary injury and associated hematomas are allowed to heal. After healing is complete, residual damage, such as urethral stricture, is assessed and repaired
Retrograde cystogram with post void films
- used for diagnosis of BLADDER INJURY
- may occur following major trauma, especially pelvic fracture
- pts typically complain of gross hematuria
Ileus can occur as a result of a vagal reaction caused by ureteral colic from kidney stones. Needle-shaped crystals on urinalysis indicate uric acid stones! Uric acid stones are radiolucent, and must be evaluated by abdominal CT, US, or IV pyelography. Ileus will resolve when the ureterolithiasis is treated. Stones
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Colonoscopy is NOT indicated for right-sided pathology and should NOT be performed in ACUTE pathology of the bowel wall due to the risk of perforation.
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Enteroclysis
-used to diagnose small bowel tumors and other pathology, which can cause intestinal obstruction
What should ALWAYS be obtained following placement of central venous catheter?
Chest x-ray to confirm proper placement of the catheter tip and absence of complications before administering drugs or other agents through the catheter
- complications: arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, vascular perforation, myocardial perforation leading to tamponade
- catheter tip should be located proximal to either the cardiac silhouette or the angle between the trachea and the right mainstem bronchus; ideally in the superior vena cava
Esophageal rupture (Boerhaave syndrome)
- most commonly occurs following instrumentation of the esophagus
- less commonly, it may occur in pts w/ protracted vomiting who have been resisting the urge to vomit; rupture in these cases typically occurs into the mediastinum resulting in pneumomediastinum; rupture typically occurs a few centimeters above the gastroesophageal junction
- retrosternal chest pain and crepitus in the suprasternal notch are common following rupture of esophagus within the mediastinum
True or false: acute pancreatitis can cause a left sided pleural effusion?
True
perforated duodenal ulcer
-epigastric pain and air would be visualized under the diaphragm on upright abdominal x-ray, but pneumomediastinum is NOT associated w/ duodenal perforation
Mallory-Weiss tear
- an INCOMPLETE mucosal tear at the gastroesophageal junction usually resulting from protracted vomiting
- the common presentation is self-limited hematemesis
- pneumomediastinum does NOT occur in such tears because the rupture is incomplete
Serum sickness-like reaction
- most commonly caused by antibiotics (B-lactams and sulfa drugs)
- symptoms arise 1-2 weeks after exposure and include fever, urticarial rash, arthralgia, and lymphadenopathy. the abnormalities should resolve within 48 hours w/ withdrawal of the offending agent. some cases may need steroid treatment
- type III hypersensitivity reaction
- lab findings: nonspecific hypocomplementemia and elevated ESR/CRP, which are consistent with any type III hypersensitivity reaction
acute rheumatic fever
- can follow untreated strep pharyngitis and may present w/ frank arthritis, erythema marginatum, and fever
- ARF after appropriate antibiotic therapy is extremely rare and highly unlikely
Anaphylaxis
- presents acutely w/ skin changes plus hypotension, respiratory distress, or GI symptoms
- type 1 hypersensitivity reaction
Henoch-Schonlein purpura
- systemic IgA-mediated vasculitis occurring after an upper respiratory infection
- presents w/ fever, arthralgia, and a palpable purpuric rash of the lower extremities
Mononucleosis
- presents as fever, cervical lymphadenopathy, pharyngitis, and malaise
- those treated w/ an aminopenicillin can develop a MORBILLIFORM (measles-like) rash on the trunk; however, the rash typically spares the extremities and arthralgia does not occur
Scarlet fever
-presents w/ fever, and scarlatiniform “sandpaper” rash following strep pharyngitis
Stevens-Johnson syndrome
- severe mucocutaneous reaction most commonly triggered by medications (eg sulfa drugs, anticonvulsants).
- affected pts develop acute high fever, vesicular or bullous lesions, and painful hemorrhagic oral erosions
Palpable breast abnormalities
- pts 30 are evaluated w/ mammogram and US
- palpable breast masses should generally have an imaging evaluation even if the findings are relatively benign on physical exam
- imaging evaluation is helpful both in characterizing the lesion as benign or malignant, and for guiding biopsy if needed
physical exam findings of a rubbery, firm, freely mobile mass are suggestive of a fibroadenoma or other benign mass. findings of a hard, irregular, and fixed mass are typically palpated in patients w/ breast malignancies.
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Anterior spinal cord syndrome
- can be due to spinal cord infarction as a potential complication of thoracic aortic aneurysm surgery
- typically presents w/ spinal shock (abrupt onset of bilateral flaccid paralysis and loss of pain/temp sensation below the level of spinal injury)
- upper motor neuron signs (spasticity and hyperreflexia) subsequently develop over days to weeks
- vibration and proprioception are usually preserved
- the anterior spinal artery (ASA) supplies the anterior 2/3 of the spinal cord, including motor tracts (eg anterior corticospinal tract) and sensory tracts involved in pain/temp sensation (eg spinothalamic tract); the ASA is particularly dependent on blood supply for the radicular arteries that originate from the thoracic aorta, such as the artery of Adamkiewicz
lumbar plexopathy
-peripheral neuropathy characterized by asymmetrical focal weakness, numbness, and paresthesias due to involvement of multiple adjacent nerve roots
Medial meniscus tears
- typically injured during forceful torsion of the knee with the foot planted
- pts complain of a popping sound and severe pain at the time of injury; McMurray’s sign is commonly positive on physical exam
- a bucket handle tear of the medial meniscus leads to locking of the knee joint during terminal extension
ACL tear
- hx of forceful hyperextension injury to knee or a noncontact torsional injury of the knee during deceleration
- effusion is seen rapidly following injury due to the ACL being well-perfused
- Lachman’s test, anterior drawer test and pivot shift test are used for clinical diagnosis
PCL tear
- classically seen in the “dashboard injury”, which refers to forceful posterior-directed force on the tibia with the knee flexed at 90 degrees
- the posterior drawer, reverse pivot shift and posterior sag tests will help w/ clinical diagnosis
Main mechanism responsible for pain relief in pts w/ anginal pain treated w/ nitroglycerin?
- dilation of veins (capacitance vessels) and decrease in ventricular preload
- it is unclear whether nitro significantly increases coronary blood flow in pts w/ obstructive coronary heart disease
Positive predictive value
- proportion of subjects with a positive test who actually have the disease out of all subjects who test positive for the disease
- PPV = TP/TP+FP
Negative predictive value
- proportion of subjects with a negative test, and who actually do NOT have the disease out of the total number of people who test negative for the disease
- NPV = TN/TN+FN
Sensitivity and specificity are useful for assessing the VALIDITY of a test. Predictive values are not true indices of the validity of a test, but are still important because pts present with positive or negative test results, and their true disease state is frequently unknown.
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Hyperparathyroidism predisposes to what?
- Pseudogout
- pseudogout tends to present as an acute onset, painful monoarthritis affecting the knee; rhomboid shaped, positively birefringent crystals are diagnostic of pseudogout
- hyperparathyroidism causes elevated calcium levels and low phosphorus concentrations. Subsequently hypercalcemia can cause constipation, fatigue, excessive urination, abdominal pain, urinary stones, mental status changes, and osteoporosis
Gout
- needle shaped crystals w/ NEGATIVE birefringence
- presents as acute onset, painful monoarthropathy
Struvite crystals
-have the shape of coffin lids and are seen in nephrolithiasis caused by chronic UTI with urease-producing organisms
otitis externa vs malignant (necrotizing) otitis externa
- topical antibiotics and corticosteroids are appropriate for otitis externa, but not for malignant otitis externa, which requires IV abx and possible debridement if no response to abx
- the severity of pain, presence of granulation tissue, and elevated ESR are all clues that distinguish OE from MOE
antibiotics effective against Pseudomonas aeruginosa
- Anti-pseudomonal penicillins: Ticarcillin, Piperacillin
- Cephalosporins: Ceftazidime (3rd gen), Cefepime (4th gen)
- Aminoglycosides: Amikacin, Gentamicin, Tobramycin
- Fluoroquinolones: Ciprofloxacin, Levofloxacin
- Monobactams: Aztreonam
- Carbapenems: Imipenem, Meropenem
Malignant (necrotizing) otitis externa
- severe infection of the external auditory canal and skull base usually caused by Pseudomonas aeruginosa
- its seen most frequently in elderly pts w/ diabetes or immunosuppression
- presents as severe, unrelenting ear pain (especially prominent at night), purulent drainage w/ a sense of fullness, and conductive hearing loss on the affected side. Otoscopy shows granulation tissue and an edematous external auditory canal
- as the infection spreads beyond the external auditory canal, osteomyelitis of the skull base or TMJ can develop and present w/ pain exacerbated by chewing
- EMPIRIC TREATMENT WITH IV CIPROFLOXACIN
Hazard ratios
- proportions that indicate the chance of an event occurring in the treatment group compared to the chance of the event occurring in the control goup
- when reviewing a drug advertisement, it is important to critically read all presented info
- hazard ratios 1 signifies that an event is more likely to occur in the treatment group. A ratio close to 1 implies little difference between the two groups. In addition, if the 95% confidence interval contains the null value of 1, this indicates that there is no significant difference between the two groups.
Successful randomization in a clinical trial
- allows a study to eliminate bias in treatment assignments
- an ideal randomization process minimizes selection bias, results in near-equal treatment and control group sizes, and achieves a low probability of confounding variables
The null hypothesis
- is always the statement of NO RELATIONSHIP between the exposure and the outcome
- to state the null hypothesis correctly, you should recognize the study design first
what is the key pathogenic factor in the development of type 2 DM and associated abnormalities (hypertension, dyslipidemia)?
-Insulin resistance typical for pts w/ central-type obesity!
Metabolic syndrome
- hypertension, impaired fasting glucose, and dyslipidemia
- pts are also characteristically overweight w/ predominantly central (abdominal) fat distribution
- Insulin resistance plays a central role in the pathogenesis of the metabolic syndrome
- Diagnosis of the metabolic syndrome is based on at least 3 of the 5 following criteria:
1. abdominal obesity (men: waist circuference > 40 in; women: waist circumference > 35 in)
2. fasting glucose > 100 - 110 mg/dL
3. BP > 130/80
4. Triglycerides > 150 mg/dL
5. HDL (men:
Insulin resistance is associated w/ several other systemic effects such as?
-dyslipidemia, endothelial dysfunction, procoagulable state, increased sympathetic activity, increased markers of inflammation, decreased uric acid excretion, increased sodium absorption, disordered breathing and increased testosterone production from the ovaries
In clinical trials, randomization is said to be successful when a similarity of baseline characteristics of the patients in the treatment and placebo groups is seen
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Tx of uncomplicated cystitis
- Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance 20%)
- Fosfomycin single dose
- Fluoroquinolones only if above options cannot be used
- Urine culture needed only if initial treatment fails
Tx of complicated cystitis
- Fluoroquinolones for 5-14 days (do NOT use in pregnancy; consider nitorfurantoin, amoxicillin, and cephalexin instead), extended spectrum abx (ampicillin/gentamicin) for more severe cases
- obtain sample for urine culture prior to initiating therapy and adjust abx as needed
- associated w/ diabetes, pregnancy, renal failure, urinary tract obstruction, indwelling catheter, urinary procedure (eg cystoscopy), immunosuppression and hospital-aquired
Tx of pyelonephritis
- Outpatient: fluoroquinolones (eg ciprofloxacin, levofloxacin)
- Inpatient: IV abx (fluoroquinolone, aminoglycoside +/- ampicillin)
- obtain sample for urine culture prior to initiating therapy and adjust abx as needed
Uncomplicated cystitis
- commonly occurs in otherwise healthy pts and has a low risk of tx failure
- UA confirms diagnosis
- Pts can be tx without a urine culture, which may be done later in those who fail initial therapy
- oral TMP/SMX, nitrofurantoin, and fosfomycin are effective first-line tx options
- presents w/ dysuria, urinary frequency, and suprapubic tenderness
Recommended vaccines for chronic liver disease
- Tdap/Td: Tdap once as substitute for Td booster, then Td every 10 years
- Influenza: annually
- Pneumococcal vaccines: PPSV23 once, then revaccination w/ sequential PCV13 and PPSV23 at age 65
- Hepatitis A: 2 doses 6 months apart with initial negative serologies
- Hepatitis B: 3 doses at 0 months, 1 month and at least 4 months w/ initial negative serologies
Pneumococcal vaccines
- the 13-valent pneumococcal conjugate vaccine (PCV13) is recommended initially for all adults age > 65 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) after at least 6-12 months
- for adults age
Following splenectomy, pts are at increased risk for sepsis due to encapsulated organisms including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae. Vaccinations against each of these organisms should be administered either > 14 days before scheduled splenectomy or > 14 days after splenectomy.
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most common cause of sepsis in post-splenectomy pts?
-Strep pneumoniae
Strep pneumo vaccination in asplenic pts
- following splenectomy, the 13-valent pneumococcal conjugate vaccine (PCV13) should be given first, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 8 weeks later. Pts need revaccination w/ PPSV23 fiver years later and again at age 65
- all pts should receive vaccines either >14 days before scheduled splenectomy or > 14 days after splenectomy
hepatorenal syndrome
- seen in pts w/ severe liver cirrhosis secondary to systemic and renal hypoperfusion
- pts have acute renal failure (creatinine > 1.5 mg/dL) w/ a very low urine sodium level, typically
Pathophysiology of hepatorenal syndrome
- pts w/ severe liver cirrhosis have increased nitric oxide generation in the splanchnic circulation secondary to portal hypertension. This is thought to cause systemic vasodilation, which reduces peripheral vascular resistance and BP, causing renal hypoperfusion. Reduced renal perfusion would then activate compensatory pathways (the renin-angiotensin-aldosterone system, sympathetic nervous system, and antidiuretic hormone) that increase water and sodium retention and worsen volume overload. Any factor that may further reduce glomerular capillary pressure (such as hypotension from GI bleeding) causes an acute decline in glomerular filtration and can precipitate hepatorenal syndrome.
- lab results are similar to those of prerenal azotemia: elevated serum creatinine (> 1.5 mg/dL) and a very low urine sodium level, typically
common glomerular disease associated with Hepatitis C infection?
Membranoproliferative glomerulonephritis
Interstitial nephritis
-usually presents w/ eosinophils or leukocytes in the urine
Remember that acute kidney injury is NOT seen in obstructive uropathy unless BOTH URETERS ARE OBSTRUCTED!!!!
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Renal vein thrombosis
- usually occurs in pts w/ a predisposing condition, such as hypercoagulability, trauma, nephrotic syndrome, or severe dehydration
- acute renal vein thrombosis presents w/ abdominal pain and hematuria
Nonalcoholic fatty liver disease (NAFLD)
- resembles alcohol-induced liver injury on histology but occurs in pts w/ minimal or no alcohol hx
- most likely mechanism is insulin resistance leading to increased peripheral lipolysis, triglyceride synthesis, and hepatic uptake of fatty acids
- definition: hepatic steatosis on imaging or biopsy; exclusion of significant alcohol use; exclusion of other causes of fatty liver
- features: mostly asymptomatic; metabolic syndrome; +/- steatohepatitis (AST/ALT ratio 35
- macrovesicular fat deposition and peripheral displacement of the nucleus
Approximately 10-20% of pts on isoniazid will develop mild aminotransferase elevation within the first few weeks of treatment. This hepatic injury is typically self-limited and resolve without intervention. Liver enzymes should be
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Diabetic nephropathy
- begins w/ HYPERfiltration (increased GFR) and microalbuminuria (incipient nephropathy); if not treated adequately, microalbuminuria may progress to macroproteinuria, defined as urine protein excretion > 300 mg/24 hrs; this increase in urinary protein is accompanied by a progressive decline in GFR
- the most beneficial therapy to reduce progression of diabetic nephropathy is STRICT BLOOD PRESSURE CONTROL; pts w/ diabetic nephropathy should be treated toward a target BP of 130/80 mmHg
- ACE inhibitors or ARBs are first-line tx for pts w/ diabetes mellitus, but must be initiated carefully as they may induce an acute decline in GFR and hyperkalemia
daily protein recommendations for pts w/ diabetic nephropathy and azotemia?
-0.8g/kg/day protein
Intensive glycemic control (HbA1c
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Pts w/ mild primary hyperaldosteronism may not have spontaneous hypokalemia, but they are prone to developing diuretic-induced hypokalemia. Other findings include metabolic alkalosis and mild hypernatremia (143-147 mEq/L). The best screening test is early-morning plasma aldosterone concentration (PAC) to plasma renin activity (PAC) ratio. A PAC/PRA ratio > 20 w/ plasma aldosterone > 15 ng/dL suggests primary hyperaldosteronism.
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Secondary hyperaldosteronism
- causes: diuretic use, cirrhosis or CHF, renovascular HTN (renal artery stenosis or fibromuscular dysplasia), renin-secreting tumor, malignant HTN, coarctation of aorta
- Increased plasma renin activity and plasma aldosterone concentration, but with a PAC/PRA ratio
Dexamethasone suppression test
- can diagnose Cushing’s syndrome
- central obesity, purple striae, proximal muscle wasting, glucose intolerance, and HTN
what is the preferred initial screening test for primary hyperaldosteronism?
- the ratio of plasma aldosterone concentration to plasma renin activity via early morning sampling; a PAC/PRA ratio > 20 with plasma aldosterone > 15 ng/dL suggests primary hyperaldosteronism
- adrenal suppression testing is then used to confirm diagnosis, and positive tests requires adrenal imaging by CT. Adrenal vein sampling is the most SENSITIVE test for differentiating adrenal adenoma and bilateral adrenal hyperplasia in pts w/o discrete unilateral adrenal mass on imaging, can then be done to differentiate between hyperplasia and adenoma. Surgery for adenoma, medical therapy for hyperplasia.
pheochromocytoma
- plasma free metanephrines would be elevated
- HTN and the classic triad of episodic headache, sweating, and palpitations w/ tachycardia
management of pts w/ hyperkalemia and significant EKG changes (QRS prolongation and peaked T waves)?
-therapy includes emergent administration of IV calcium gluconate to stabilize the cardiac membrane, then lowering serum potassium by driving potassium intracellularly with insulin and glucose, sodium bicarb, or beta-2 agonists such as albuterol; the final step would be to excrete excess potassium by elimination from the body.
example of an alpha 1 agonist
-phenylephrine
beta 1 agonists have chronotropic and inotropic effects
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alpha 1 antagonists
-cause peripheral vasodilation, and are used in the tx of HTN and BPH
beta 1 blockers
-commonly used in tx of HTN, heart failure, and atrial fibrillation
most health care providers believe that insulin resistance is the first event in the development of type 2 DM; however, type 2 DM does NOT develop without a beta cell secretory defect. Increased insulin secretion from the beta cells is required to cope with increased insulin resistance. If beta cells are able to compensate for the increased insulin resistance, subjects generally remain normoglycemic at the expense of very high insulin levels; however, if beta cells are unable to compensate fully, glucose intolerance and type 2 DM results.
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Tempromandibular joint (TMJ) dysfunction
- can result in referred pain to the ear that is worsened with chewing
- pts typically report a hx of nocturnal teeth grinding
- pain is worsened w/ chewing; some hear audible clicks or crepitus w/ jaw movement, but not always
- initial tx consists of conservate measure such as nighttime bite guard, but surgical intervention is sometimes necessary
Ramsay Hunt syndrome
- form of herpes zoster infection that causes Bell’s palsy
- vesicles are typically seen on the outer ear
Glossopharyngeal neuralgia
-pts experience intermittent, severe, stabbing pain in areas innervated by CN IX and X, which includes the ear.
Otitis media
-can result in ear pain, but it will usually cause erythema and/or limited mobility of the TM
Otitis externa
-usually results in ear discharge and pain w/ pulling on the pinna
Cerumen impaction
-usually causes conductive hearing loss as opposed to pain
Diabetic ketoacidosis (DKA)
- presents w/ metabolic acidosis, polyuria, dehydration, decreased level of consciousness, and diffuse abdominal pain, and is often precipitated by acute infection
- DKA is characterized by an osmotic diuresis that reduces total body potassium stores even though serum potassium level may be elevated
- occurs in type 1 DM
- infection can precipitate DKA in type 1 DM due to systemic release of insulin couterregulatory horomes such as catecholamines and cortisol; the resultant excess of glucagon causes hyperglycemia, ketonemia, and an osmotic diuresis; this diuresis is accompanied by a net renal loss of potassium w/ depletion of total body potassium stores; despite reduction in TOTAL body potassium, the SERUM potassium concentration may be elevated due to acidemia and decreased insulin activity, causing redistribuation of potassium to ECF compartment
- mild leukocytosis may also be seen
- reduction in effective circulating blood volume, which activates the RAAS and accelerates renal potassium losses
- increase in circulating free fatty acids due to underlying relative excess of glucagon to insulin and consequent increase in lipolysis
- hyperglycemia in DKA contributes not only to osmotic diuresis and hypovolemia but also to serum HYPERosmolality, which will most likely promote pituitary vasopressin release
- hepatic gluconeogenesis would be increased due to both the increased ratio of circulating glucagon to insulin and the increased circulating levels of catecholamines and cortisol
- hyperglycemia and hyperketonemia in DKA cause an osmotic diuresis and increased urinary excretion of glucose, ketones, sodium, potassium, Mg, and phosphate
Calcium oxalate crystals (rectangular, envelope-shaped crystals) are seen in what?
- pts w/ ETHYLENE GLYCOL (anti-freeze) poisoning
- Ethylene glycol, methanol and ethanol intoxication causes metabolic acidosis w/ both an anion gap and an osmolar gap
normal pH
7.35 - 7.45
normal anion gap
6-12
normal osmolar gap
must always calculate anion gap when you have a metabolic acidosis! When the anion gap is markedly elevated and frank uremia is NOT present, the osmolar gap should be calculated to assess for ethanol, methanol, or ethylene glycol intoxication!
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how do you calculate serum osmolality?
serum osmolality = [2Na + Glu/18 + BUN/2.8]
how do you calculate the osmolar gap?
osmolar gap = observed osmolarity - calculated osmolarity
normal is
sequelae following ethylene glycol ingestion
-ARDS, heart failure, renal failure
Aspirin (salicylate) toxicity
-causes a MIXED anion gap metabolic acidosis and respiratory alkalosis with NO osmolar gap
Methyl alcohol poisoning
-can cause visual changes (“snowfield vision”) and acute pancreatitis
Uremia (renal failure) causes an anion gap metabolic acidosis due to failure to excrete acids as NH4+
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McCune-Albright syndrome
- rare condition characterized by the 3 P’s: Precocious puberty, Pigmentation (cafe au lait spots), and Polyostotic fibrous dysplasia
- responsible for 5% of cases of female precocious puberty and may be associated with other endocrine disorders
- sporadic and has been attributed to defect in the G-protein cAMP-kinase function in affected tissue
Peutz-Jeghers syndrome
- GI tract polyposis and mucocutaneous pigmentation
- may also involve the development of an estrogen-secreting tumor, leading to precocious puberty
Sturge-Weber disease
-sporadic phakomatosis characterized by mental retardation, seizures, visual impairment and a characteristic port-wine stain over the territory of the trigeminal nerve
Edema, stasis dermatitis, and venous ulcerations result from lower extremity venous insufficiency due to valve incompetence. Such disease classically occurs on the medial leg superior to the medial malleolus. Increased pressure in postcapillary venules causes extravastion of RBCs, leading to hemosiderin deposition in skin causing the characterstic color changes. Venous congestion causes microvascular disease and ultimately ulcerations. Xerosis (dry skin) is the most common early finding; lipodermatosclerosis and ulcerations characterize late disease.
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arterial thrombosis
- classically presents w/ a pt complaining of severe pain in a single extremity
- onset of pain is less acute than that seen in arterial occlusion due to EMBOLUS
- the extremity typically exhibits coolness to touch, pallor, pulselessness, and paralysis on exam
Raynaud disease
- arterial spasm in response to cold or emotional stress causing discoloration and discomfort of the distal digits
- may ultimately result in distal digital gangrene if severe
Neurosyphilis
may cause tabes dorsalis, a lesion of the posterior spinal cord characterized by loss of proprioceptive sensation from the legs, ataxia, and paresthesias
Syringomyelia
-classically presents w/ central cord syndrome; weakness of upper extremities and loss of pain and temp sensation in a “cape-like” distribution over the neck, shoulders, upper arms and hands
Cystic fibrosis
- clinical features: chronic sinopulmonary disease (eg bronchiectasis), GI and nutritional abnormalities (eg pancreatic insufficiency, meconium ileus, failure to thrive), salt loss syndromes (eg acute salt depletion, chronic metabolic alkalosis), male urogenital abnormalities (eg obstructive azoospermia)
- diagnosis: one or more clinical features OR hx of cystic fibrosis in a sibling OR positive newborn screening test PLUS increased sweat chloride concentration > 60 mmol/L on 2 or more occasions OR identification of 2 CF mutations OR abnormal nasal epithelial ion transport (potential difference)
- recurrent respiratory infections, steatorrhea, and failure to thrive are hallmark features. Sweat chloride testing by QUANTITATIVE PILOCARPINE IONTOPHORESIS is the gold standard for diagnosis. Pilocarpine is a cholinergic drug that is applied to the patient’s extremity to induce sweating. A chloride level of > 60 mmol/L on 2 separate occasions confirms the diagnosis. Abnormal or intermediate results should be followed by DNA analysis. Nasal potential difference measurement can be performed if sweat testing and DNA analysis are equivocal.
Pts w/ X-linked agammaglobulinemia suffer from recurrent sinopulmonary infections and failure to thrive. However, only boys are affected by the Bruton tyrosine kinase gene mutation!
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what is the screening test for primary ciliary dyskinesia?
-Exhaled nasal nitric oxide test
Severe combined immunodeficiency syndrome (SCID)
- X-linked or autosomal recessive disorder characterized by recurrent respiratory infections and chronic diarrhea
- affected pts have an absolute lymphocyte count
The diagnosis of celiac disease is confirmed by the appearance of duodenal villous atrophy on small bowel biopsy
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Congenital toxoplasmosis
- classic triad: chorioretinitis, hydrocephalus, and intracranial calcifications
- maternal infection is acquired by exposure to feces from infected cats, or ingestion of infected raw meat or unpasteurized goat’s milk
- risk of transmission during pregnancy increases as pregnancy progresses, but severity of disease decreases
- other complications include: hydrocephalus, microcephaly, hepatosplenomegaly, microphthalmia, microcephaly, diffuse lymphadenopathy, jaundice, diffuse petechiae
- lab results show hyperbilirubinemia and thrombocytopenia
Congenital syphilis
-intermittent fever, osteitis and osteochondritis, mucocutaneous lesions, lymphadenopathy, hepatomegaly, and persistent rhinitis
Congenital rubella syndrome
- microcephaly, microphthalmia, and meningoencephalitis; sensorineural deafness, cardiac anomalies (eg persistent ductus arteriosus, atrial septal defects), congenital glaucoma and cataract
- classic triad: deafness, cataracts, and cardiac defects
Herpes simplex infection in birth
-encephalitis, chorioretinitis, and disseminated disease
Developmental milestones of a 1 year old
- fine motor: two-finger pincer grasp, turns several pages of a book at a time
- gross motor: walks w/o assistance, waves bye, climbs up on furniture
- language: says 2-3 words, says “mama” and “dada”
- social: imitates actions, plays reciprocal games (peek-a-boo), indicates wants
developmental milestones of a 2 year old
- fine motor: builds tower of 6 cubes, turns individual pages of a book
- gross motor: walks up and down stairs, jumps, throws a ball overhead
- language: 200 word vocabulary, uses 2-word phrases, 2-quarters (50%) of speech intelligible
- social: follows 2-step commands, remove clothes
developmental milestones of a 3 year old
- fine motor: copies a circle, uses utensils to feed self, stacks 9 blocks
- gross motor: climbs stairs w/ alternative feet, rides a TRIcycle, kicks a ball
- language: uses 3 word sentences, states first name, 3-quarters (75%) of speech intelligible
- social: washes/dries hands, helps w/ simple household tasks, group play
developmental milestones of a 4 year old
- fine motor: copies a cross, draws a person, begins to use scissors, holds crayon w/ tripod grasp
- gross motor: hops on one foot w/o losing balance, jumps over objects
- language: counts to 10, tells stories, uses plurals and prepositions
- social: cooperative play, has imaginary friends, imitates adult roles
Cerebral palsy
- group of syndromes characterized by nonprogressive motor dysfunction; 3 primary subtypes- spastic, dyskinetic, and ataxic
- the etiology is often multifactorial, with PREMATURITY as the leading risk factor
- affected pts have uncoordinated and limited voluntary movements
- risk factors: prematurity, IUG restriction, IU infection, antepartum hemorrhage, placental pathology, multiple gestation, maternal alcohol consumption, maternal tobacco use
- managment: physical, occupational and speech therapies; Baclofen and botulinum toxin for spasticity
- comorbidities: intellectual disability, epilepsy, strabismus, scoliosis
what is the primary medications tx for preeclampsia?
Magnesium sulfate
what is the treatment of choice for pregnant pts w/ syphilis? what if they have an allergy to that drug?
- Penicillin is treatment of choice
- if patient is allergic to penicillin, the allergy should be confirmed w/ skin testing and the patient should then undergo desensitization using incremental doses of oral penicillin V so that she can safely take the medication
adverse effects of Tetracycline during pregnancy?
-harmful effect on teeth and bones of the fetus
why can’t fluoroquinolones be used during pregnancy?
-musculoskeletal system risks to fetus
what is the most common cause (80%) of postpartum hemorrhage within 24 hours of delivery?
- UTERINE ATONY
- its important to make a quick diagnosis by checking the firmness and location of the uterus fundus; if bleeding persists despite treatment, other causes should be ruled out
- a soft, “boggy”, poorly contracted uterus is characteristic
- risk factors: uterine overdistention (eg multiple gestation, polyhydramnios, macrosomia) and uterine fatigue (prolonged labor)
most common cause of excess postpartum blood loss? Treatment?
- Uterine atony
- Initial tx includes bimanual uterine massage (resolves hemorrhage in most cases), fluid resuscitation (SBP > 90), uterotonic agents (eg oxytocin, methylergonovine, carboprost), and blood transfusion as needed
when is hysterectomy indicated in postpartum bleeding?
-abnormally adherent placenta (eg placenta accreta), or when all other attempts to control bleeding are unsuccessful or a rupture uterus cannot be repaired
when is curettage indicated in postpartum hemorrhage?
-when suspected retained placental tissue; this can be determined by an echogenic mass on US, absence of the normal endometrial stripe on US, or a nonintact placenta on exam
Uterine artery embolization or ligation of the uterine or internal iliac arteries can be used for a patient w/ stable vital signs and persistent bleeding if the rate of loss is not excessive. It can also be used as an alternate to hysterectomy in a stable patient who wishes to preserve fertility.
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Postictal lactic acidosis
- commonly occurs following a tonic-clonic seizure
- its a transient anion gap metabolic acidosis that resolves without treatment within 60 to 90 minutes following resolution of seizure activity
Dopamine is a positive inotrope and a vasoconstrictor used in pts w/ hypotension who do not respond to less aggressive measures such as IV fluids
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Squamous cell carcinoma
- 2nd most common form of non-melanoma skin cancer (after basal cell carcinoma)
- the single most important risk factor for the development of squamous cell carcinoma is exposure to sunlight
- polygonal cells with atypical nuclei at all levels of the epidermis with zones of keratinization
- SCC is more aggressive than basal cell carcinoma because it metastasizes frequently
what imaging study would you use to evaluate increasing head circumference and signs of increased intracranial pressure in children?
CT scan of the brain
- note that you could also perform a sedate MRI if stable and asymptomatic to spare child from radiation exposure
- US is most useful in infants under 6 months of age
- Tx of hydrocephalus consists of a shunt that is placed from the ventricle to the peritoneum, pleura, or right atrium
when caring for an unemancipated minor, informed consent from one parent or guardian is considered legally sufficient to justify proceeding with therapy. Physicians should also provide care in urgent situations without waiting for parental consent.
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Parents cannot deny their children life-saving treatment unless the benefits are minimal or would not alter the prognosis.
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Circumstances in which minors do not require consent
- medical: emergency care, STIs, substance abuse, prenatal care
- emancipated minor: homeless, parent, married, military, financially independent, high school graduate
agents used to shift potassium intracellulary
- insulin and glucose
- sodium bicarb
- beta 2 agonists
Medical tx for patients with rheumatoid arthritis?
- ALL pts should receive DMARDs as early as possible in the disease course
- Methotrexate is the initial DMARD of choice in most pts w/ active RA
- NSAIDS and glucocorticoids should be used for initial temporary symptomatic relief while awaiting response to DMARD therapy; they do NOT alter disease progression however
- nonbiologics: methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine
- biologics: etanercept, infliximab, adalimumab, tocilizumab, rituximab
- pts should be tested for hep B and C and TB before starting therapy!
- if pts do not respond after 6 months, they may require biologic DMARDs such as TNF-a inhibitors (etanercept, infliximab) as step-up therapy
Eczema herpeticum
- form of primary herpes simplex virus infection associated w/ atopic dermatitis
- numerous vesicles over the area of atopic dermatitis are typical
- the infection can be life-threatening in infants; thus, prompt tx with acyclovir should be initiated
Varicella
-vesicular eruption that is not localized, but tends to spread over the head and to the trunk
Impetigo contagiosa
-manifests as thick-crusted facial lesions that are frequently honey-colored
The 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for all adults age > 65 followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23) 6-12 months later. Sequential PCV13 and PPSV23 are also recommended for adults age
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Histoplasma
- usually causes an asymptomatic or minor respiratory illness in healthy pts, but immunocompromised pts can develop severe pulmonary or disseminated disease
- the most rapid and sensitive test to diagnose disseminated histoplasmosis in immunocompromised pts is urine or serum assay for Histoplasma antigen
- disseminated disease typically presents w/ systemic symptoms and involves the reticuloendothelial system, resutling in cytopenias, lymphadenopathy, and hepatosplenomegaly.
treatment for histoplasmosis?
- mild to moderate: no treatment or oral itraconazole
- severe: amphotericin B (switche to oral itraconazole once initial response is documented
Flucytosine
-anti-fungal effective against Cryptococcus and Candida
Metronidazole
-effective against amebiasis and other anaerobic bacterial infections
what is the preferred antifungal tx for histoplasmosis?
Itraconazole
Diagnostic criteria for ADHD
- 6 or more inattentive and/or 6 or more hyperactive/impulsive symptoms for 6 or more months
- several symptoms present before age 12
- symptoms occur in at least 2 settings
- functional impairment (social, academic)
- subtypes: predominantly inattentive, predominantly hyperactive/impulsive, combined type
By age 12 months, a child’s weight and height should…?
- weight should triple; height should increase by 50%
- developmental milestones include walking independently, using a 2-finger pincer grasp, saying a few words other than “mama” and “dada”, and imitating the actions of others.
UTI antibiotics in pregnancy
- recommended: nitrofurantoin, amoxicillin, amoxicillin-clavulanate, cephalexin
- contraindicated: tetracylines (interfere with fetal bone and tooth development), fluoroquinolones (bone deformities and arthropathy), TMP-SMX (contraindicated in first trimester as it interferes w/ folic acid metabolism, should be avoided during third trimester as it increases the risk of kernicterus in the newborn)
- pregnant women w/ asymptomatic bacteriuria should be treated w/ antibiotics to decrease the risk of pyelonephritis, preterm birth, low birth weight, and perinatal mortality.
Cardiac output/index, SVR, and LVEDV in CHF?
-CHF due to left ventricular systolic dysfunction is characterized by decreased cardiac output/index, increased systemic vascular resistance (SVR), and an increase in left ventricular end-diastolic volume (LVEDV)
cardiac index/output, SVR, and LVEDV after acute or recent myocardial infarction?
-Cardiac index is reduced due to myocardial dysfunction, while SVR is increased to maintain vital organ perfusion; LVEDV remains relatively normal in the early phase before LV remodeling and/or dilatation occurs over the following several weeks
Cardiac index/output, SVR, and LVEDV in high-output CHF (severe anemia, thyrotoxicosis, aortic regurgitation)
-increased LVEDV, decreased SVR, normal/increased CI
Placental abruption
- laboring pts w/ placental abruption at term may be allowed to deliver vaginally if the woman and fetus are stable
- Cesarean delivery is indicated if the mother is hypotensive w/ severe bleeding or if the condition of the fetus deteriorates
- presents as vaginal bleeding and hyperactive and tender uterus
- bleeding between the decidua and placenta interface causes placental detachment, which can compromise the fetus
- US should be performed to rule out placenta previa (contraindication to vaginal delivery), but it detects only 25% of cases of abruption
- laboring patients > 34 WEEKS GESTATION CAN PROCEED TOWARD VAGINAL DELIVERY
Placental abruption overview
- risk factors: maternal HTN or preeclampsia/eclampsia, abdominal trauma, prior placental abruption, cocaine and tobacco use
- presenation: sudden-onset vaginal bleeding, abdominal or back pain, high-frequency and low-intensity contractions, hypertonic tender uterus
- diagnosis: clinical presentation, US (not required for diagnosis) to rule out placenta previa
- Tx: unstable maternal VS or nonreassuring fetal heart tracing at any gestational age means emergent C-section; stable maternal VS, reassuring fetal heart tracing, no placenta previa and >34 wks gestation means a trial of vaginal delivery
full term
> 37 weeks
Kleihauer-Betke test
- used to measure the amount of fetal hemoglobin transferred into the maternal bloodstream
- it should be performed on an Rh-negative woman w/ an Rh-positive fetus to determine the dose of Rh immune globulin to prevent Rh sensitization
management of suspected bacterial meningitis in adult
- empiric abx must NOT be delayed while awaiting results of CT scan or performing LP to diagnose bacterial meningitis
- VANCOMYCIN plus AMPICILLIN plus CEFEPIME is the drug regimen of choice for immunocompromised pts w/ suspected bacterial meningitis
- Corticosteroids must be started at the same time as abx and should be discontinued if cultures show an organism other than Strep pneumoniae
evaluation of bacterial meningitis
- head CT, blood cultures, LP
- indications for head CT: immunocompromised, previous CNS disease, new onset seizure, papilledema, altered mental status, focal neuro deficits
bacterial meningitis in 2-50 year olds
- most commonly N. meningitidis, S. pneumoniae
- give Vancomycin plus a 3rd generation cephalosporin
bacterial meningitis in age > 50
- S. pneumoniae, N. meningitidis, Listeria
- Vancomycin plus ampicillin plus a 3rd gen cephalosporin
bacterial meningitis in neurosurgery/shunt patient
- gram negative rods, S. aureus, and coagulase-negative Staph
- Vancomycin plus cefepime
Bacterial meningitis in immunocompromised state
- Pneumococcus, N. meningitidis, Listeria, gram negative rods
- Vancomycin plus ampicillin plus cefepime
Bacterial meningitis in penetrating trauma to skull
- S. aureus, coagulase-negative Staph, and gram negative rods
- Vancomycin plus cefepime
what leads on ECG do you look at for axis deviation evaluation?
lead 1
lead aVF
-if up in 1 and up in aVF, then its a normal axis
-axis deviation can be a sign of ventricular hypertrophy or bundle branch block
how to evaluate ECG?
-rate, rhythm, axis, intervals, ischemia, and hypertrophy
normal intervals on ECG?
- PR interval: 120-200 msec; in AV block PR interval > 200 msec or there will be no QRS after a P wave
- QRS interval: 120msec; LBBB has deep S wave and no R wave in V1, and a wide/tall R waves in 1, V5, V6; RBBB has RSR’ (“rabbit ears”) complex w/ wide R wave in V1 and wide S wave in V5, V6.
- QT interval: 440 msec, and predispose to ventricular tachyarrhythmias
what leads do you look at on ECG for bundle branch blocks?
V1 and V5/V6
-WiLLiaM MaRRoW
signs of ischemia/infarction on ECG?
- T wave inversion –> ST segment changes (elevation or depression) – Q waves (> 40 msec or more than 1/3 the QRS amplitude; note that Q waves signify either an acute or prior ischemic event and do NOT give info on when the event occurred
- poor R wave progression; on normal ECG, R waves increase in size from V1 through V5
signs of hypertrophy on ECG?
- Right atrial hypertrophy: tall P wave in lead II (>2.5 mm)
- Left atrial hypertrophy: wide P wave in lead II (>120 msec); notched P waves are frequently seen (cameL has Left atrial enlargement)
- LVH: S wave amplitude in V1 + R wave amplitude in V5/V6 = > 35 mm; alternatively, amplitude of R in aVL + S in V3 is > 28 mm in men or > 20 mm in women
- RVH: Right axis deviation and an R wave in V1 > 7 mm
what conditions is Kussmaul sign seen?
- Cardiac tamponade and constrictive pericarditis
- Increase in JVP w/ inspiration is Kussmaul sign
harsh systolic ejection murmur that radiates to the carotids?
aortic stenosis
holosystolic murmur that radiates to the axilla
mitral regurgitation
a midsystolic click or late systolic murmur with a preceding click
mitral valve prolapse
Diastolic murmurs are ALWAYS ABNORMAL!
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an early decrescendo murmur
-aortic regurgitation
a mid to late, low-pitched murmur
-mitral stenosis
S3 gallop
- sign of fluid overload
- often normal in younger pts and in high-output states (eg pregnancy)
S4 gallop
- sign of decreased compliance (ie HTN, diastolic dysfunction)
- usually pathologic but can be normal in younger pts and athletes
things that can cause peripheral edema
-right heart failure, biventricular failure, nephrotic syndrome, hepatic disease, lymphedema, hypoalbuminemia, and drugs
pulsus paradoxus
- decreased SBP w/ inspiration
- possible sign of Pericardial tamponade; also seen in obstructive lung disease, tension pneumothorax, and foreign body in airway
increased peripheral pulses
-compensated aortic regurgitation (bounding pulses), coaractation (greater in arms than legs), PDA
pulsus alternans
- alternating weak and strong pulses
- cardiac tamponade, impaired left ventricular systolic function; poor prognosis
pulsus parvus et tardus
- weak and delayed pulse
- aortic stenosis!
management options for atrial fibrillation
ABCD
- anticoagulate
- B blockers for rate control!!
- cardiovert/calcium channel blockers
- Digoxin (in refractory cases)
opening snap followed by a mid diastolic murmur
mitral stenosis
machine-like murmur
PDA
CHA2DS2-VASc score
- used to estimate stroke risk in pt w/ atrial fibrillation; anticoagulate if score is > 2
- CHF (1 point)
- HTN (1 point)
- Age > 75 (2 points)
- Diabetes (1 point)
- Stroke or TIA hx (2 points)
- Vascular disease (1 point)
- Age 65-74 (1 point)
- Sex category (female; 1 point)
first degree AV block
- can occur in normal individuals; associated w/ increased vagal tone and w/ B-blocker or CCB use
- asymptomatic
- PR interval > 200 msec
- no treatment necessary
Second degree AV block (Mobitz type 1/Wenckebach)
- drug effects (digoxin, B-blockers, CCBs) or increased vagal tone; right coronary ischemia or infarction
- usually asymptomatic
- progressive PR lengthening until a dropped beat occurs; the PR interval then resets
- Tx: stop offending drug; Atropine as indicated
Second degree AV block (Mobitz type II)
- results from fibrotic disease of the conduction system or from acute, subacute, or prior MI
- occasonally syncope; frequent progression to third-degree AV block!!!!
- unexpected dropped beat(s) without a change in PR interval
- Tx is PACEMAKER PLACEMENT
Third degree AV block (complete)
- no electrical communication between the atria and ventricles
- syncope, dizziness, acute heart failure, hypotension, cannon A waves
- no relationship between P waves and QRS complexes
- Tx is PACEMAKER PLACEMENT
Sick sinus syndrome/ tachycardia-bradycardia syndrome
- a heterogeneous disorder that leads to intermittent supraventricular tachyarrhythmias and bradyarrhythmias
- secondary to tachycardia or bradycardia; may include syncope, palpitations, dyspnea, chest pain, TIA, and stroke
- this is the MOST COMMON INDICATION FOR PACEMAKER PLACEMENT
drug used to treat Wolff-Parkinson-White syndrome?
Procainamide
Atrial fibrillation
- acute AF: PIRATES: Pulmonary disease, Ischemia, Rheumatic heart disease, Anemia/Atrial myxoma, Thyrotoxicosis, Ethanol, Sepsis.
- chronic AF: HTN, CHF
- often asymptomatic but may present w/ SOB, chest pain, or palpitations; physical exam shows an IRREGULARLY IRREGULAR pulse
- no discernable P waves w/ variable and irregular QRS response
- for chronic AF, initial therapy: RATE CONTROL WITH B-BLOCKERS, CCB, or Digoxin; Anticoagulate w/ warfarin for pts w/ CHADS-VASc > 2; for unstable AF, or new-onset AF ( 2 days or unclear duration, must get TEE to rule out atrial clot!!!!
atrial flutter
- circular movement of electrical activity around the atrium at a rate of approx. 300 times per minute
- usually asymptomatic but can present w/ palpitations, syncope, and lightheadedness
- regular rhythm; “SAWTOOTH” APPEARANCE OF P WAVES; atrial rate is usually between 240-320 bpm and ventricular rate is about 150 bpm.
- Tx: anticoagulation, rate control, and cardioversion as in atrial fibrillation
multifocal atrial tachycardia
- multiple atrial pacemakers or reentrant pathways; COPD, hypoxemia
- may be asymptomatic; at least 3 DIFFERENT P WAVE MORPHOLOGIES
- three or more unique P waves, rate > 100 bpm
- treat the underlying disorder; verapamil or B-blockers for rate control and suppression of atrial pacemakers (not very effective)
AVNRT
- a reentry circuit in the AV node depolarizes the atrium and ventricle nearly simultaneously
- occurs at AV junction
- rate 150-250 bpm; P WAVE IS OFTEN BURIED in QRS or shortly after
- Tx: cardiovert if hemodynamically unstable; carotid massage, valsalva, or adenosine can stop the arrhythmia
AVRT
- occurs at AV junction
- an ectopic connection between the atrium and ventricle that causes a reentry circuit; seen in WPW
- a retrograde P wave is often seen after a normal QRS; PREEXCITATION DELTA WAVE IS CHARACTERISTICALLY SEEN IN WPW
- cardiovert, valgal maneuvers, adenosine
Paroxysmal atrial tachycardia
- rapid ectopic pacemaker in the atrium (not sinus node)
- rate > 100 bpm; P wve w/ an unusual axis BEFORE each normal QRS
- Tx: adenosine can be used to unmask underlying atrial activity by slowing down the rate
PVCs
- ectopic beats arise from ventricular foci; associated w/ hypoxia, electrolyte abnormalities, and hyperthyroidism
- early, wide QRS not preceded by a P wave; PVCs are usually followed by a compensatory pause
- Treat the underlying cause; if symptomatic, give B-blockers
Wolff-Parkinson-White syndrome
- abnormal fast accessory pathway from atria to ventricle
- characteristic DELTA WAVE w/ widened QRS complex and shortened PR interval
- tx is observation for asymptomatic pts
Ventricular tachycardia
- can be associated w/ CAD, MI, and structural heart disease
- can progress to VF and death
- 3 or more consecutive PVCs; wide QRS complexes in a regular rapid rhythm; may see AV dissociation
- cardioversion if unstable; antiarrhythmics (amiodarone, lidocaine, procainamide)
Ventricular fibrillation
- totally erratic wide-complex tracing
- immediate electrical defibrillation and ACLS protocol!
Torsades de pointes
- associated w/ long QT syndrome, proarrhythmic response to meds, hypokalemia, congenital deafness, and alcoholism
- polymorphous QRS; VT w/ rates between 150 - 250 bpm
- give MAGNESIUM initially and cardiovert if unstable; correct underlying disorder
use of diuretic and digoxin in CHF?
-used for symptomatic relief only and confer NO mortality benefit
most common presenting symptoms of systolic dysfunction?
-exertional dyspnea
lab abnormality in CHF?
- brain natriuretic peptide (BNP) > 500 pg/mL
- decreased EF
Acute treatment of CHF?
- Loop diuretics (most commonly; Lasix)for aggressive diuresis
- Morphine
- Nitrates
- Oxygen
- Position (upright)
- LMNOP
- AVOID B-BLOCKERS IN DECOMPENSATED CHF, but resume once euvolemic
chronic treatment of CHF?
- lifestlye: limit dietary sodium and fluid intake
- meds: b-blockers and ACEIs/ARBs (help prevent remodeling of the heart and decrease mortality; avoid CCBs!). Diuretics prevent volume overload. Low-dose spironolactone has been shown to decrease mortality w/ advanced heart failure. Daily aspirin and a statin if underlying cause was prior MI
- advanced tx: implantable cardiac defibrillator if EF
Loop diuretics Lose calcium; thiazides take it in
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Diastolic dysfunction/ nonsystolic dysfunction
- decreased ventricular compliance w/ normal systolic function
- ventricle either has IMPAIRED ACTIVE RELAXATION or IMPAIRED PASSIVE FILLING
- LVEDP is increased, cardiac output remain normal, and EF IS NORMAL OR INCREASED
Loop diuretics
- Furosemide (Lasix), ethacrynic acid, bumetanide, torsemide
- side effects: ototoxicity, HYPOKALEMIA, HYPOCALCEMIA, dehydration, gout
Thiazide diuretics
- HYDROCHLOROTHIAZIDE, chlorothiazide, chlorthalidone
- side effects: hypokalemic metabolic alkalosis, hyponatremia, and hyperGLUC (hyperGlycemia, hyperLipidemia, hyperUricemia, hyperCalcemia)
potassium sparing diuretics
- SPIRONOLACTONE, triamterene, amiloride
- side effects: hyperkalemia, gynecomastia, sexual dysfunction
Carbonic anhydrase inhibitors as diuretics
- Acetazolamide
- side effects: hyperchloremic metabolic acidosis, neuropathy, NH3 toxicity, sulfa allergy
Osmotic agents as diuretics
- Mannitol
- side effects: pulmonary edema, dehydration; contraindicated in anuria and CHF
dilated cardiomyopathy
- left ventricular dilation and decreased EF must be present
- most cases are idiopathic; most common secondary causes are ischemia and long-standing HTN; also coxsackievirus, Chagas disease are rare
- ECHO is diagnostic
- an S3 gallop signifies rapid ventricular filling in the setting of fluid overload and is associated with dilated cardiomyopathy
Differentiate between dilated, hypertrophic, and restrictive cardiomyopathies
- Dilated: impaired contractility, increase LVEDV, increased LVESV, decreased EF, and usually decreased wall thickness
- Hypertrophic: impaired relaxation, decreased LVEDV, decreased LVESV, increased or normal EF, markedly increased wall thickness
- Restrictive: impaired elasticity, increased LVEDV, increased LVESV, decreased or normal EF, usually increased wall thickness
most common cause of sudden death in young athletes?
hypertrophic obstructive cardiomyopathy
- inherited as an autosomal dominant trait
- key finding is a systolic ejection crescendo-decrescendo murmur that increases with decreased preload
- Echo is diagnostic and shows an asymmetrically thickened septum and dynamic obstruction of blood flow
- Tx: B-blockers are initial therapy; CCB are second-line; avoid intense athletic competition and training
Restrictive cardiomyopathy
- decreased elasticity of myocardium leading to impaired diastolic filling w/o significant systolic dysfunction; caused by INFILTRATIVE DISEASE (amyloidosis, sarcoidosis, hemochromatosis) or by scarring and fibrosis
- right sided heart failure symptoms often predominate
- echo is diagnostic, w/ rapid early filling and a near-normal EF
- ECG frequently shows LBBB; low voltages are seen in amyloidosis
- Tx: generally palliative only; cautious use of diuretics for fluid overload and vasodilators to decrease filling pressure
Prinzmetal (variant) angina
-mimics angina pectoris but is caused by vasospasm of coronary vessels; classically affects young women at rest in the early morning and is associated w/ ST segment elevation in the absence of cardiac enzyme elevation
angina pectoris
- substernal chest pain secondary to myocardial ischemia
- classic triad: substernal chest pain, precipitated by stress, relieved by rest
- pain can radiate to neck or arm or associated with SOB, N/V, diaphoresis, or lightheadedness; pain is usually dull and pressure-like
- ECG is best initial test for any type of chest pain (ECG stress test is contraindicated for pts w/ abnormal baseline ECGs)
Differential diagnosis of chest pain
- cardiac origin
- GERD (hx of hoarseness and worse after meals; relief w/ PPIs)
- MSK/costochondritis (pain is tender to palpation and movement)
- Pneumonia/pleuritis (worsening w/ breathing (pleuritic))
- Anxiety (hx of panic disorder or anxiety attacks)
Tx for chronic stable angina
- aspirin, b-blockers, and nitroglycerin
- risk factor reduction (smoking, cholesterol, HTN)
unstable angina vs NSTEMI
- unstable angina: new onset, accelerating, or occurring at rest; signals impending infarction based on plaque instability
- NSTEMI: myocardial necrosis marked by elevations in troponin I and CKMB
- Unstable angina is NOT associated w/ elevated cardiac enzymes; NSTEMI is diagnosed by serial cardiac enzymes (elevated) and ECG
- Tx: aspirin, oxygen, IV nitro, IV morphine, B-blockers
- admit to hospital and monitor until acute MI has been ruled out by serial cardiac enzymes
- Pts w/ refractory chest pain, a TIMI score of > 3, a troponin elevation, or ST changes > 1 mm should be given IV heparin and scheduled for angiography and possible PCI or CABG
TIMI risk score for unstable angina/NSTEMI
- age > 65 (1 point)
- 3 or more CAD risk factors (premature family hx, DM, smoking, HTN, increased cholesterol) (1 point)
- known CAD (stenosis > 50 %) (1 point)
- ASA use in past 7 days (1 point)
- severe angina (2 or more episodes within 24 hours) (1 point)
- ST deviation > 0.5 mm (1 point)
- cardiac marker (1 point)
- scale from 0-7; pts at higher risk 3 or more points benefit from enoxaparin, glycoprotein IIb/IIIa inhibitors, and early angiography
best predictor of survival in STEMI?
LV ejection fraction
Treatment of MI
- MOAN
- Morphine
- Oxygen
- ASA
- Nitro
Remember that women, diabetics, the elderly, and post-transplant heart pts may have atypical or clinically silent MIs
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most sensitive and specific cardiac enzyme
- Troponin I
- stays elevated longer than CK-MB
ST-segment abnormalities on ECG with Inferior, Anterior, Lateral, and Posterior MIs
- Inferior MI: involving RCA/PDA, ST elevation in leads II, III, and aVF; obtain a right-sided ECG to look for ST elevation in right ventricle!
- Anterior MI: involving LAD and diagonal branches; ST elevation in leads V1-V4
- Lateral MI: involving LCA; ST elevation in leads I, aVL, and V5-V6
- Posterior MI: ST depression in V1-V2 (anterior leads); obtain posterior ECG leads V7-V9
initial tx of STEMI
- ASA, b-blockers (unless in heart failure or cardiogenic shock; instead give ACEIs if not hypotensive), clopidogrel, morphine, nitrates, and oxygen
- in inferior wall MI, avoid nitrates due to risk of severe hypotension
Emergent angiography and PCI vs thrombolysis
-If PCI cannot be performed within 90 minutes, AND there are no contraindications to thrombolysis (eg a hx of hemorrhagic stroke, or recent ischemic stroke, severe heart failure, or cardiogenic shock), AND the pt presents within 3 hrs of chest pain onset, thrombolysis w/ tPA, reteplase, or streptokinase should be performed instead of PCI
common post-MI complications
- first day: heart failure
- 2-4 days: arrhythmia, pericarditis
- 5-10 days: left ventricular wall rupture (acute pericardial tamponade causing electrical alternans, pulseless electrical activity), papillary muscle rupture (severe mitral regurgitation)
- weeks to months: ventricular aneurysm (CHF, arrhythmia, persistent ST segment elevation, mitral regurgitation, thrombus formation)
- Dressler syndrome: an autoimmune process occurring 2-10 wks post-MI, presents w/ fever, pericarditis, pleural effusion, leukocytosis, and elevated ESR
dyslipidemia
- total cholesterol > 200 mg/dL
- LDL > 130 mg/dL
- Triglycerides > 150 mg/dL
- HDL 35 years of age or > 20 w/ CAD risk factors, then every 5 yrs.
- Tx: hx of CAD, CVA, or PAD –> high intensity statin; LDL between 70-189 WITHOUT diabetes (>7.5% 10 yr risk–> high intensity statin; between 5-7.5% 10 yr risk–> moderate intensity statin; no statin); LDL between 70-189 WITH diabetes (>7.5% 10 yr risk–> high intensity statin; moderate intensity statin); for pts w/ LDL > 190–> high intensity statin
- high intensity therapy is a goal reduction of > 50% LDL; moderate intensity is reduction of 30-50% LDL
- first intervention should be a 12 week trial of diet and exercise
Statins
- decrease LDL
- decrease triglycerides
Fibrates (gemfibrozil)
- decrease triglycerides
- increase HDL
cholesterol absorption inhibitors (ezetimibe)
-decrease LDL
Niacin
- increase HDL
- decrease LDL
- causes skin flushing which can be prevented with aspirin ingestion
bile acid resins (cholestyramine)
- decrease LDL
- can decrease absorption of other drugs in GI tract
HTN definition
- SBP > 140, and/or DBP > 90 on 3 measurements separated in time in pts 60, SBP > 150 and/or DBP > 90 (if no hx of CKD, DM)
- pts > 18 yrs w/ CKD or DM, SBP > 140 and/or DBP > 90
- you will initiate treatment above any of these variables for these populations
Treatment of HTN
ABCD
- ACEIs/ARBs
- B-blockers
- CCBs
- Diuretics (typically thiazides)
treatment of HTN in pregnancy
-b-blockers (typically labetalol), hydralazine
tx of HTN in CKD
ACEIs, ARBs
Hypertensive urgency
-elevated BP with MILD TO MODERATE SYMPTOMS (headache, chest pain) WITHOUT end-organ damage
Hypertensive Emergency
- elevated BP w/ signs or symptoms of impending end-organ damage such as acute kidney injury, intracranial hemorrhage, papilledema, or ECG changes suggestive of ischemia or pulmonary edema
- tx w/ IV meds (labetalol, nitroprusside, nicardipine) w/ goal of lowering MAP by no more than 25% over the fist 2 hours to prevent cerebral hypoperfusion or coronary insufficiency
Tx of pheochromocytoma
- Diagnose w/ urinary metanephrines and catecholamine levels or plasma metanephrine
- surgical removal of tumor after treatment with BOTH A-BLOCKERS AND B-BLOCKERS
Conn syndrome (hyperaldosteronism)
- most often secondary to an aldosterone-producing adrenal adenoma
- causes the triad of HTN, unexplained hypokalemia, and metabolic alkalosis
- metabolic workup w/ plasma aldosterone and renin levels; increase aldosterone and decreased renin levels suggest primary hyperaldosteronism; surgical removal of tumor
Cushing syndrome
- due to ACTH producing pituitary tumor, an ectopic ACTH secreting tumor, or cortisol secretion by an adrenal adenoma or carcinoma; also due to exogenous steroid exposure
- tx is surgical removal of tumor; removal of exogenous steroids
Causes of pericarditis
CARDIAC RIND
- Collagen vascular disease
- Aortic dissection
- Radiation
- Drugs
- Infections
- Acute renal failure
- Cardiac (MI)
- Rheumatic fever
- Injury
- Neoplasma
- Dressler syndrome
- viral infection, TB, SLE, uremia, drugs, radiation, neoplasms, post-MI or Dressler’s
classic presentation of pericarditis
- pleuritic chest pain, dyspnea, cough, fever
- chest pain tends to WORSEN IN THE SUPINE POSITION, and with inspiration; classic patient is SEEN SITTING UP AND BENDING FORWARD
- may hear pericardial friction rub on exam, elevated JVP, pulsus paradoxus (a decrease in SBP > 10mmHg on inspiration) if tamponade present
- ECG will show DIFFUSE ST-SEGMENT ELEVATION AND PR-SEGMENT DEPRESSIONS, followed by T wave inversions
B-blockers
- decrease cardiac contractility and renin release
- side effects: bronchospasm (in severe active asthma), bradycardia, CHF exacerbation, impotence, fatigue, depression
ACEIs
- block aldosterone formation, reducing peripheral resistance and salt/water retention
- side effects: cough, angioedema, rahes, leukopenia, hyperkalemia
ARBs
- sartan
- block aldosterone EFFECTS, reducing peripheral resistance and salt/water retention
- side effects: rashes, leukopenia, and hyperkalemia but NO COUGH
Caclium channel blockers
- Dihydropyridines (nifedipine, felodipine, amlodipine), and Nondihydropyridines (diltiazem, verapamil)
- decrease smooth muscle tone and cause vasodilation; may also decrease cardiac output
- Dihydropyridines: headache, flushing, peripheral edema
- Nondihydropyridines: decreased contractility
Vasodilators
- Hydralazine: headache, lupus-like syndrome
- Minoxidil: orthostasis, hirsutism
- decrease peripheral resistance by dilating arteries/arterioles
a1-adrenergic blockers
- prazosin, terazosin, phenoxybenzamine
- cause vasodilation by blocking actions of norepinephrine on vascular smooth muscle
- side effects: orthostatic hypotension
centrally acting adrenergic agonists
- methyldopa, clonidine
- inhibit the sympathetic nervous system via central a2 adrenergic receptors
- side effects: somnolence, orthostatic hypotension, impotence, rebound HTN
exam of a patient w/ acute tamponade
- Beck triad (hypotension, distant heart sounds, JVD), a narrow pulse pressure, pulsus paradoxus, and Kussmaul sign (increased JVD on inspiration)
- CXR will show enlarged, globular, water-bottle shaped heart
- ECG could show ELECTRICAL ALTERNANS, which is diagnostic
S1Q3T3 on ECG?
Pulmonary embolism
size of AAA determines treatment
> 5 cm–> surgical repair
monitoring
Screening for AAA?
-screen all men 65-75 years of age w/ a hx of smoking once by US
classic exam finding for aortic stenosis?
Pulsus parvus et tardus (weak, delayed carotid upstroke)
-also, systolic murmur radiating to the carotids
exam findings with aortic regurgitation
- blowing diastolic murmur at left sternal border, mid-diastolic rumble (Austin Flint murmur), and midsystolic apical murmur
- WIDENED PULSE PRESSURE causes de Musset sign (head bob w/ heartbeat), Corrigan sign (water-hammer pulse), and Duroziez sign (femoral bruit)
Dissections involving the ASCENDING aorta are surgical emergencies! Those involving the DESCENDING aorta can often be managed w/ BP and heart rate control
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Virchow triad
- hemostasis
- trauma (endothelial damage)
- hypercoagulability
Treatment for DVT?
anticoagulate w/ IV unfractionated heparin or subcutaneous LMWH followed by PO warfarin for a total of 3-6 months
Diagnosis of PAD
-get and ABI; if
Orthostatic hypotension
-drop in SBP > 20 mmHg when moving from lying down to standing and is typically preceded by a lightheaded or presyncopal sensation
All pts w/ hypotension/shock after a MVA should be presumed to have hypovolemic shock from hemorrhage. An elevated pulmonary capillary wedge pressure at baseline should raise the suspicion of myocardial dysfunction due to cardiac contusion and prompt an urgent echocardiogram.
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High-energy, blunt, rapid deceleration trauma to the chest commonly causes aortic injury. In most cases of aortic rupture, death is the immediate result. In pts w/ a contained rupture, the diagnosis must be made quickly. Widened mediastinum and left-sided hemothorax are classic chest x-ray abnormalities pointing to this diagnosis.
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esophageal rupture
- causes pneumomediastinum and pleural effusion
- diagnosis confirmed w/ water-soluble contrast esophagography
bronchial rupture
-pneumothorax that does not resolve w/ chest tube placement, pneumomediastinum and subcutaneous emphysema
Wolff-Parkinson-White syndrome
- pts w/ WPW who develop atrial fibrillation w/ a rapid ventricular rate should be treated w/ cardioversion if hemodynamically unstable, or antiarrhythmics such as PROCAINAMIDE or ibutilide if stable. AV nodal blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they can cause increased conduction through the accessory pathway!!
- accessory pathway conducts depolarization directly from atria to ventricles w/o traversing the AV node
Acute type A aortic dissection
- type A involves the ascending aorta and is a SURGICAL EMERGENCY; all other locations are type B
- type A can extend into the pericardial space, causing hemopericardium and rapidly progressing to cardiac tamponade and cardiogenic shock
- bedside TEE is typically performed in the ED for rapid diagnosis and early treatment!!
aortic dissection
- risk factors: HTN (most common), Marfan syndrome, cocaine use
- features: severe, sharp, tearing chest or back pain; > 20 mmHg variation in SBP between arms
- complications (involved structure): Stroke (carotids), acute aortic regurgitation (aortic valves), Horner’s syndrome (superior cervical sympathetic ganglion), acute MI (coronary artery), pericardial effusion/tamponade (pericardial cavity), hemothorax (pleural cavity), lower extremity weakness (spinal or common iliac arteries), abdominal pain (mesenteric artery)
all pts who have had a MI should receive secondary prevention. Which meds have been shown to have a mortality benefit when given as secondary prevention?
- aspirin (75-325 mg/day)
- beta-blockers
- ACE inhibitors
- lipid lowering statin drugs
-in addition, CLOPIDOGREL should be given to all pts w/ unstable angina/NSTEMI, as well as pts who are post percutaneous coronary intervention (PCI)
Clopidogrel
- should be given to all pts w/ unstable angina/NSTEMI, as well as those having had a PCI
- belongs to drug class called Thienopyridines, and has an anti-platelet effect by antagonizing ADP
- for pts who need to be on aspirin but cannot tolerate it, clopidogrel is an appropriate alternative because it is as effective
- for pts who are post UA/NSTEMI, clopidogrel + aspirin has been shown to be more effective in terms of mortality than aspirin alone. Clopidogrel should be taken for 12 months, aspirin indefinitely.
- clopidogrel + aspirin is more effective than aspirin alone for the first 30 days following PCI as it helps prevent subacute stent thrombosis
- basically, clopidogrel should be prescribed for at least 12 months following UA/NSTEMI, 30 days for bare metal stents, and up to 1 year for drug eluting stents following PCI
Amiodarone
- class III antiarrhythmic agent, well known for causing pulmonary fibrosis
- thyroid dysfunction (hypo and hyper), hepatotoxicity, corneal deposits and skin discoloration (blue-gray) are other potential side effects
- excellent drug for BOTH atrial and ventricular arrhythmias
Procainamide
- used to treat atrial AND ventricular arrhythmias
- side effects: nausea, drug-induced lupus, agranulocytosis, and QT prolongation
Lidocaine
- class IB anti-arrhythmic agent use to treat VENTRICULAR arrhythmias
- high doses can cause confusion, seizures and respiratory depression
Quinidine
- class IA anti-arrhythmic used to treat ATRIAL arrhythmias
- side effects: diarrhea, tinnitus, QT prolongation, torsades de pointes, hemolytic anemia and thrombocytopenia
Digoxin
- inotrope used to treat ATRIAL arrhythmias
- can cause nausea, anorexia, AV block, and ventricular and supraventricular arrhythmias
Chagas disease
- chronic disease that can cause megaesophagus, megacolon, and/or cardiac dysfunction
- the PROTOZOAN Trypanosoma cruzi, endemic to Latin America, is responsible
Don’t give beta blockers to cocaine-using individuals, as this allows unopposed alpha agonist activity that can worsen vasospasm. Instead use calcium channel blockers and alpha blockers like phentolamine to help reduce vasospasm.
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Right ventricular myocardial infarction (RVMI)
- presents w/ hypotension, elevated JVP, and clear lung fields in the setting of acute inferior MI
- pts require increased RV preload to maintain cardiac output and may need IV fluid support
- Nitrates, diuretics, and opioids can reduce RV preload and should be avoided!
Situational syncope
- should be considered in differential of syncopal episodes
- the typical scenario would be a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits
pulmonary capillary wedge pressure (PCWP)
- estimation of left ventricular end diastolic pressure
- elevated in pts w/ left ventricular systolic and/or diastolic dysfunction
- elevation typically causes signs of pulmonary edema
Cor pulmonale
- impaired function of the right ventricle due to PULMONARY HYPERTENSION that usually occurs due to chronic lung disease
- signs of right ventricular failure: elevated JVP, right ventricular 3rd heart sound, tricuspid regurgitation murmur, hepatomegaly w/ pulsatile liver, lower-extremity edema, ascites, and/or pleural effusions
- echo will shows signs of increased right heart pressures, and right heart catheterization will show pulmonary systolic pressure > 25 mmHg
calcium channel blockers
- dihydropyridine: amlodipine, nimodipine, nifedipine
- non-dihydropyridine: diltiazem, verapamil
- mechanism: block voltage dependent L-type calcium channels of cardiac and smooth muscle, thereby reduce muscle contractility;
- Verapamil is most effective in cardiac muscle (Verapamil = Ventricle)
- DHPs (except nimodipine) are used for HTN, angina, Raynaud’s
- Non-DHPs are used for HTN, angina, ATRIAL FIBRILLATION/FLUTTER
- Nimodipine: subarachnoid hemorrhage (prevents cerebral vasospasm)
- side effects: cardiac depression, AV block, peripheral edema, flushing, dizziness, hyperprolactinemia, and constipation
Digoxin
- cardiac glycoside
- mechanism: direct inhibition of Na/K ATPase leads to indirect inhibition of Na/Ca exchanger/antiport. Increased Ca conduction leads to positive inotropy. Stimulates vagus nerve which decreases HR.
- used to increase contractility in CHF, and to slow conduction at AV node and SA node in ATRIAL fibrillation
- can cause change in color vision, hyperkalema, AV block
- antidote is to slowly normalize potassium, cardiac pacer, anti-digoxin Fab fragments, Mg
Antiarrhythmics
- Na channel blockers (class 1)
- B-blockers (class 2)
- potassium channel blockers (class 3)
- Calcium channel blockers (class 4)
“Some Blokes Possess Cardio”
Class 1 anti-arrhythmics (sodium channel blockers)
- slow or block conduction (esp in depolarized cells); decrease slope of phase 0 depolarization and increase threshold for firing in abnormal pacemaker cells; they are state dependent (selectively depress tissue that’s frequently depolarized; hyperkalemia causes increased toxicity for all class 1 drugs
- Class 1A: Quinidine, Procainamide, Disopyramide (“the Queen Proclaims Diso’s Pyramid”); increase AP duration, increase refractory period, increase QT interval; used for BOTH ATRIAL AND VENTRICULAR ARRHYTHMIAS, esp re-entrant and ectopic SVT and VT BOTH ATRIA AND VENTRICLES
- Class 1B: Lidocaine, Mexiletine; decrease AP duration; preferentially affect ischemic or depolarized Purkinje and ventricular tissue; used for ACUTE VENTRICULAR ARRHYTHMIAS (esp post-MI), digitalis induced arrhythmias (1B is Best post-MI) VENTRICLES
- Class 1C: Flecainide, Propafenone (“Can I have Fries, Please”); significantly prolongs refractory period in AV NODE; minimal effect on AP duration; used for SVTs, INCLUDING ATRIAL FIBRILLATION; contraindicated post-MI!!!!! ATRIA
Class 2 anti-arrhythmics (B-blockers)
- Metoprolol, propranolol, esmolol, atenolol, timolol, carvedilol
- decrease SA and AV nodal activity by decreasing cAMP, decreasing Ca currents; suppress abnormal pacemakers by decreasing slope of phase 4
- used for SVT, slowing VENTRICULAR rate during a. fib and a. flutter
- treat overdose with glucagon
Class 3 anti-arrhythmics (Potassium channel blockers)
- Amiodarone, Ibutilide, Dofetilide, Sotalol (“AIDS”)
- increase AP duration, increase effective refractory period, increase QT interval (all the same as class 1 anti-arrhythmics)
- used for ATRIAL FIBRILLATION, ATRIAL FLUTTER, VENTRICULAR TACHYCARDIA (amiodarone, sotalol)
- know that amiodarone can cause PULMONARY FIBROSIS, hepatotoxicity, hypo/hyperthyroidism, corneal deposits, skin deposits, etc.; must check PFTs, LFTs, and TFTs when using amiodarone; it also has class I,II,III, and IV effects and alters the LIPID MEMBRANE
Class 4 anti-arrhythmics (calcium channel blockers)
- Verapamil, diltiazem
- decrease conduction velocity, increase effective refractory period, increase PR interval
- used for prevent NODAL ARRHYTHMIAS (eg SVT), rate control in ATRIAL FIBRILLATION
- can cause flushing, constipation, edema, AV block, CHF
Adenosine
- increase potassium out of cells leads to hyperpolarizing the cell and decrease Ca conductance
- drug of choice in DIAGNOSING/ABOLISHING SUPRAVENTRICULAR TACHYCARDIA; very short acting (~15 sec)
- may cause flushing, hypotension, chest pain; effects blocked by theophylline and caffeine
Mg
-effective in torsades de pointes and DIGOXIN toxicity
Anti-arrhythmics used for VENTRICULAR arrhythmias?
Class 1a, 1b (sodium blockers), and class 3 (potassium blockers)
anti-arrhythmics for atrial arrhythmias?
-class 1a, 1c (sodium blockers), class 2, class 3
Adenosine
-inhibits L-type calcium channels, decreasing conduction velocity in the AV node; this can lead to a transient AN nodal block and is used in the tx of AV node-dependent reentrant tachycardia
Complete heart block
- type 3 AV block
- temporal dissociation of P waves and QRS complexes (AV dissociation)
- pts w/ symptomatic 3rd degree AV block should be managed w/ temporary pacemaker insertion while undergoing further evaluation to identify and correct reversible causes
- a permanent pacemaker is indicated if no reversible causes of heart block are found.
Antibiotic therapy in pts w/ infective endocarditis
- should be tailored to the specific organism as soon as they are identified (start empiric IV vancomycin first)
- most viridans group strep are highly susceptible to penicillin and should be treated w/ IV aqueous penicillin G or IV ceftriaxone for 4 weeks
Dihydropyridine Ca-channel blockers most common side effect
-peripheral edema
what is the most frequent cause of isolated aortic stenosis in elderly patients?
age-dependent idiopathic sclerocalcific changes
-these changes are common and usually have minimal hemodynamic significance, but sometimes may be severe
ECG in pts w/ Wolff-Parkinson-White syndrome
-shortened PR interval, delta waves, and widening of the QRS complex
Mitral regurgitation
- holosystolic murmur heard best at the apex w/ radiation to the axilla
- exertional dyspnea, fatigue, atrial fibrillation, and signs of heart failure
Pts w/ persistent tachyarrhythmia (narrow or wide complex) causing hemodynamic instability should be managed w/ IMMEDIATE SYNCHRONIZED DC CARDIOVERSION. Pts who have minimal symptoms and remain hemodynamically stable during an episode of regular, narrow-complex SVT can be managed initially w/ a trial of vagal maneuvers and/or IV adenosine.
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murmur of atrial septal defect?
-fixed, split S2 in addition to systolic ejection murmur at the left upper sternal border
Coarctation of aorta
- associated w/ Turner syndrome
- diminished or absent lower extremity pulses and upper extremity HTN
PDA
- continuous machine-like murmur
- strongly associated w/ congenital rubella syndrome
Tetralogy of Fallot
-cyanosis, a single second heart sound, and a harsh crescendo-decrescendo murmur caused by right ventricular outflow tract obstruction
Truncus arteriosus
-strongly associated w/ DiGeorge syndrome
Half of pts w/ Down syndrome have congenital cardiac defects. What are the most common ones?
- failure of endocardial cushion fusion results in AV septal defects
- Complete AV septal defects causes heart failure in early infancy (~6 wks) and require surgical repair
- Complete AV septal defects > Ventricular septal defect > Atrial septal defect
Diastolic and continuous murmurs as well as loud systolic murmurs revealed on cardiac auscultation should always be investigated using TTE. Midsystolic soft murmurs (grade I-II/VI) in an asymptomatic young patient are usually benign and need no further work-up
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Constrictive pericarditis
-important cause of right heart failure and is characterized by progressive peripheral edema, ascites, elevated JVP, pericardial knock (middiastolic sound), and pericardial calcifications on chest x-ray
Cardiac amyloidosis
- echo will show increased ventricular wall thickness w/ a normal or nondilated left ventricular cavity
- pts w/ amyloidosis may also have heavy proteinuria, periorbital purpura, and hepatomegaly
Mitral stenosis
- classically presents during pregnancy
- its most often due to rheumatic fever and occurs much more often in countries w/ limited access to abx
Pericardial effusion
- can occur within days or months after cardiac surgery and is referred to as postpericardiotomy syndrome
- life-threatening fluid accumulation is characterized by distant heart sounds, hypotension, and distended jugular veins (Beck’s triad) and requires drainage
Bacterial endocarditis
-fever, new murmur, petechiae, splinter hemorrhages, Osler nodes, Janeway lesions, Roth spots
high dose niacin
- used to treat lipid abnormalities, but frequently produces cutaneous flushing and pruritis
- prostaglandin-induced peripheral vasodilatation and can be reduced by low-dose aspirin
Paroxysmal supraventricular tachycardia (PSVT)
- sudden onset, regular, and narrow-complex tachycardia
- Adenosine and vagal maneuvers can terminate PSVT by transiently slowing SA and AV node conduction
In atrial fibrillation (AF) w/ rapid ventricular response (RVR), rate control should be attempted initially w/ beta blockers or calcium channel blockers. Immediate synchronized electrical cardioversion is indicated in hemodynamically unstable pts w/ rapid AF.
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Pts presenting the the ED w/ chest pain and suspected acute coronary syndrome should be administered aspirin as soon as possible! Early antiplatelet therapy w/ aspirin reduces the rate of MI and overall mortality in pts w/ ACS
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PVCs
- common in pts post-MI and can be recognized by their widened QRS (> 120msec), bizarre morphology, and compensatory pause
- even though they may indicate a worse prognosis, tx is NOT indicated unless the patient is symptomatic (then give beta blockers)
Digoxin can be used to treat atrial arrhythmias like atrial flutter and atrial fibrillation, but it HAS NO ROLE IN THE TREATMENT OF VENTRICULAR ARRHYTHMIAS!!!
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4 anomalies in tetralogy of fallot?
- VSD
- RVH
- pulmonary stenosis
- overriding aorta
Tetralogy of Fallot
- presents w/ varying degrees of cyanosis depending on the severity of right ventricular outflow tract obstruction
- “Tet” spells result from sudden spasm of the right ventricular outflow tract during exertion
- the murmur is typically a harsh crescendo-decrescendo systolic murmur over the left upper sternal border, reflecting turbulence at the stenotic pulmonary artery
Infective endocarditis
- can present w/ several nonspecific symptoms and physical exam findings due to immunologic and/or vascular phenomena
- early recognition is important to avoid a missed or late diagnosis in such pts
- definitive diagnosis is based on Duke Criteria and requires a more comprehensive evaluation
Adult Still’s disease
- inflammatory disorder characterized by recurrent high fevers (>39C), rash, and arthritis
- the rash is often maculopapular and nonpruritic, affecting the trunk and extremities during febrile episodes
Variant angina (Prinzmetal’s angina)
- vasospastic disorder that typically occurs in young female smokers
- chest pain usually occurs in the middle of the night, and episodes are associated w/ transient ST elevations on ECG
- treatment is with CCB or nitrates
up to 70% of pts w/ mitral stenosis will develop atrial fibrillation because of the significant LEFT atrial dilatation.
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aortic dissection
- causes chest pain that is classically described as sudden, tearing, and radiating to the back
- HTN is the most common predisposing factor
Marfan’s syndrome
- mutation of the FIBRILLIN gene, which results in “weakened” connective tissue
- pts are at increased risk for aortic dissection
Ehlers-Danlos syndrome
-connective tissue disease involving collagen that can predispose to aortic dissection
the fourth heart sound (S4)
-low frequency sound heard at the end of diastole just before S1 that is commonly associated w/ LVH from prolonged HTN
Dilated cardiomyopathy
- can be seen following viral myocarditis, particularly after a Coxsackievirus B infection
- diagnosis made by Echo, which typically shows dilated ventricles and diffuse hypokinesia resulting in systolic dysfunction (low ejection fraction)
- tx is largely supportive, involving mainly the management of CHF symptoms
Asymmetric septal hypertrophy
- hypertrophic cardiomyopathy
- young pts; athletes; sudden cardiac death
concentric hypertrophy
- follows chronic pressure overload, such as w/ valvular aortic stenosis or untreated HTN
- only develops in CHRONIC conditions
eccentric hypertrophy
- follows chronic volume overload, as seen in valvular regurgitation
- develops slowly over time in response to ventricular volume overload
Mitral stenosis
-mid-diastolic murmur and an opening snap, ECG can show left atrial hypertrophy (camel hump, wide P wave in lead II)
Exertional heat stroke
- defined as a body temp > 40C (104F) WITH CNS dysfunction or end-organ damage
- most commonly induced by strenuous exercise during hot and humid weather
- dehydration, hypotension, and tachycardia are common
- systemic effects such as seizures, ARDS, DIC, and hepatic/renal failure may also occur
- Tx consists of rapid cooling by ice-water immersion and supportive managment
Nonexertional (classic) heat stroke
- occurs in absence of strenuous activity and typically affects elderly pts w/ significant underlying comorbidities that limit their ability to escape or cope w/ excessive heat
- management involves EVAPORATIVE COOLING, rather than ice-water immersion which is used in exertional heat stroke; this is due to increased mortality with that method in this population
Serotonin syndrome vs malignant hyperthermia
- serotonin syndrome: typically seen in pts taking SSRI
- malignant hyperthermia: usually triggered by certain anesthetic agents
- both conditions cause MUSCULAR RIGIDITY, serotonin syndrome has significant HTN
sustained monomorphic ventricular tachycardia (SMVT)
- electrical cardioversion is indicated for SMVT pts who are hemodynamically unstable, pulseless, or severely symptomatic
- hemodynamically stable pts can first be given anti-arrhythmics (IV amiodarone) as these may lead to sinus rhythm and avoidance of the need for cardioversion
Carotid sinus massage
-useful vagal maneuver to terminate paroxysmal supraventricular tachycardia (PSVT), a regular, narrow-complex tachycardia
Digoxin
- used for rate control in SUPRAVENTRICULAR ARRHYTHMIAS (a. flutter, fibrillation, atrial tachycardia), esp in pts w/ hypotension and/or heart failure who are unable to tolerate beta blockers or calcium channel blockers!!!!
- can potentially worsen ventricular arrhythmias!
Beta blocker overdose
- presents w/ bradycardia, hypotension, wheezing, hypoglycemia, delirium, seizures, and cardiogenic shock
- IV fluids and atropine are the first-line treatment options
- IV glucagon should be administered in pts w/ profound or refractory hypotension
aminophylline
-methylxanthine which acts by blocking phosphodiesterase, thereby increasing levels of cAMP; causes bronchodilation and has positve inotropic/chronotropic effects
Digoxin-specific antibody (Fab)
-antidote to digoxin toxicity, which usually presents w/ fatigue, anorexia, nausea, blurred vision, disturbed COLOR PERCEPTION, and cardiac arrhythmias
Dobutamine
-inotropic agent that can cause significant vasodilation and worsen hypotension
Digitalis toxicity
- causes increased ectopy and increased vagal tone
- atrial tachycardia w/ AV block occurs from the combination of these two digitalis effects, and is relatively specific for digitalis toxicity
Digitalis can be used to increase vagal tone and is sometimes used to treat atrial fibrillation if beta-blockers or calcium channel blockers have NOT been completely effective
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Multifocal atrial tachycardia is associated with what?
Pulmonary disease
Warfarin or target-specific oral anticoagulants (eg rivaroxaban, apixaban, dabigatran) should be used to reduce the risk of systemic thromboembolism in pts w/ atrial fibrillation and moderate to high risk of thromboembolic events (CHA2DS2-VASc score 2 or greater). Pts w/ lone AF (score 0) are at low risk of systemic embolization and anticoagulant therapy is not indicated.
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murmur of aortic regurgitation
- best heard along the left sternal border at the 3rd and 4th interspaces
- may be heard in some pts only by applying firm pressure w/ the diaphragm of the stethoscope while the patient is sitting up, leaning forward, and holding breath in full expiration
- congenital bicuspid aortic valve is the most common cause of AR in young adults in developed countries
- Rheumatic heart disease is the most common cause in developing countries
Innocent cardiac murmurs
- result from normal blood flow from a structurally normal heart
- the intensity is typically grade 1 or 2 and DECREASES with maneuvers that decrease venous blood return, such as standing.
- benign murmurs are also early or mid-systolic in timing
- management consists of observation and reassurance
which meds to hold prior to cardiac stress test?
- Beta blockers, calcium channel blockers, and nitrates are anti-anginal agents and should be withheld for at least 48 hrs prior to cardiac stress testing
- however, these meds should be continued in pts w/ known CAD undergoing stress testing to assess the efficacy of antianginal therapy
Mobitz type 1 second degree AV block
- progressive prolongation of PR interval leading to a non-conduction P wave and a dropped QRS complex
- the PR interval prolongation is best appreciated by measuring the PR intervals just before and after the dropped QRS complex
- constant PP interval, decreasing RR interval
PACs
- indicate depolarization of the atria originating in a focus outside the SA node
- they are seen on ECG as a P wave w/ abnormal morphology, often occurring earlier in the cardiac cycle than a normal P wave
Impaired SA node automaticity
- leads to sick sinus syndrome, which is often due to degeneration and/or fibrosis of the SA node and surrounding atrial myocardium
- pts may present w/ fatigue, lightheadedness, palpitations, presyncope, or syncope
- ECG often shows bradycardia, sinus pauses/arrest, SA exit block, or alternating bradycardia and atrial tachyarrhythmias (tachy-brady syndrome)
Wolff-Parkinson-White syndrome
- ventricular preexcitation that is due to an accessory conduction pathway that directly connects the atria and ventricle, bypassing the AV node
- the ECG shows a characteristic pattern of short PR interval (
Gastroesophageal reflux in infants
- extremely common due to their shorter esophagus, incomplete closure of the lower esophageal sphincter, and greater time spent in the supine position
- parents should be reassured about adequate weight gain and advised to hold the infant upright after feeds
Indicators of a severe asthma attack
-include normal to increased PCO2 values, speech difficulties, diaphoresis, altered sensorium, cyanosis, and “silent” lungs
Immobilization of an individual w/ high bone turnover results in increased osteoclastic activation that can lead to hypercalcemia. Bisphosphonate therapy and hydration in immobilized pts is helpful in reducing hypercalcemia and preventing osteopenia
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approx. 40% of circulating serum calcium is bound to proteins, mostly albumin. Changes in the albumin level will affect the total serum calcium without affecting the ionized fraction.
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causes of hypercalcemia in malignancy
-local osteolytic metastasis, secretion of parathyroid hormone-related protein (PTHrP), and increased formation of 1,25-dihydroxyvitamin D
Malaria
- should be suspected in any ill pts, esp. those w/ a hx of febrile paroxysms, who have traveled to an endemic-tropical region
- thick and thin blood smears should be ordered for parasite detection and quantification
- nonimmune children are at highest risk of death, but the sickle cell trait confers some protection from severe complications
- Plasmodium falciparum, P. vivax, P. ovale, or P. malariae transmitted by bite of infected Anopheles mosquito
- antimalarial drugs: atovaquone-proguanil, doxycycline, mefloquine, chloroquine, hydroxychloroquine
Monosymptomatic (isolated) enuresis
- urinary incontinence in children age >5
- urinalysis, urologic imaging for children w/ significant daytime sx and hx of recurrent UTI
- avoid sugary/caffeinated beverages, void regularly during the day and immediately before bed, drink ample fluids in the morning and early afternoon; minimize fluid intake before bed, reward system
- ENURESIS ALARM: 1st line intervention when behavior modifications fail; best long-term outcome
- meds: DESMOPRESSION (1st line), TCAs (2nd line)
anterior MI on ECG
- blocked vessel is LAD
- some or all of leads V1-V6 involved
inferior MI on ECG
- RCA or L circumflex artery
- ST elevation in leads II, III, and aVF
posterior MI on ECG
- L circumflex or RCA
- ST depression in leads V1-V3
- ST elevation in leads I and aVL (LCX)
- ST depression in leads I and aVL (RCA)
Lateral MI on ECG
- L circumflex, or diagonal artery
- ST elevation in leads I, aVL, V5 and V6
- ST depression in leads II, III, and aVF
Right ventricle MI (occurs in 1/2 of inferior MI) on ECG
- RCA
- ST elevation in leads V4-V6R
The right coronary artery supplies blood to the AV node through the AV nodal artery in 90% of pts; and RCA occlusion can cause AV block. Inferior MI is most commonly associated w/ sinus bradycardai due to increased vagal tone in the first 24 hrs after infarction and decreased RCA blood supply to the SA node
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Right coronary artery occulsion
- can cause acute inferior and posterior wall MIs
- inferior wall MI presents w/ ST segment elevations in the inferior leads (II, III, and aVF)
- ST segment depression in leads V1 and V2 in this setting usually suggests a posterior wall MI
- Inferior MI is also associated w/ hypotension, bradycardia, and AV block
Acute pericarditis on ECG
-diffuse PR segment depression and diffuse ST segment elevation across multiple limb and precordial leads
Left anterior descending coronary artery occlusion
- LAD usually supplies the anterior walls of the left ventricle as well as the anterior 2/3rds of the septum
- occlusion of this vessel can cause ST segment elevation in all precordial leads, but most commonly in V1-V4
- second degree AV block can be seen
Left circumflex coronary artery
- supplies the posterolateral wall of the left ventricle
- occlusion can cause ST segment elevation in leads I, II, III, and aVL
Occlusion of the left main coronary artery
- usually a catastrophic event and presents as sudden cardiac death in the majority of pts
- occlusion of both LCX and LAD causes ST segment elevations in anterior and lateral leads (I aVL, V1-V6)
In pts w/ sickle cell disease, acute severe anemia w/ low or absent reticulocytes
- APLASTIC CRISIS
- this is an acute drop in Hgb and is known complication of sickle cell disease
- alternative things that can cause an acute drop in Hgb: hyperhemolytic crisis, splenic sequestration, or an aplastic crisis
- aplastic crisis is a transient arrest of erythropoiesis that results in a severe drop in Hgb and virtual absence of reticulocytes on peripheral smear (reticulocytes
hyperhemolytic crisis
- rare complication of sickle cell disease that is characterized by a sudden, severe anemia accompanied by an APPROPRIATE RETICULOCYTOSIS (in contrast to aplastic crisis)
- etiology unknown
Splenic sequestration
- occurs in sickle cell pts who have not yet developed auto-splenectomy
- caused by vasoocclusion and pooling of red cells within the spleen, which may lead to severe hypotensive shock
- characterized by a dramatic drop in Hgb concentration that is accompanied by persistent reticulocytosis
- physical exam shows a rapidly enlarging spleen
- mortality rate of 10-15% and 50% chance of recurrence, so splenectomy is usually recommended after the first episode
Acute chest syndrome
- characterized by the presence of fever, chest pain, and an infiltrate on chest x-ray
- multifactorial and related to pulmonary infarction and infection
vasoocclusive crisis
- acute onset of pain and caused by vasoocclusion secondary to the sickling of RBCs
- these crises may be precipitated by changes in weather, dehydration, or infection
Oliguria, azotemia and an elevated BUN/creatinine ratio of >20:1 in the post-op state
- pre-renal failure from hypovolemia most likely, though urinary catheter obstruction should first be ruled out
- the next step in diagnosis/management of acute renal failure manifesting as oliguria or anuria is an IV fluid challenge
pre-renal vs intrinsic renal disease
-elevated BUN/Cr ratio > 10:1 and FENa 1 is intrinsic renal
finding of atypical squamous cells of undetermined significance on cytology
- women age 21-24 yrs: repeat cytology in 1 year
- women age >25 yrs: HPV DNA test; those who test positive for HPV require colposcopy; pts w/ a negative HPV test can be followed w/ repeat Pap smear and HPV test in 3 yrs
routine cervical cancer screening guidelines
- cytology every 3 yrs or a combo of cytology and HPV DNA test every 5 yrs in women age >30 yrs
- for women age 21-29 yrs, cytology every 3 yrs is recommended
Central retinal artery occlusion syndrome
- ophthalmologic emergency!
- treated w/ an ocular massage and high-flow oxygen!
- painless loss of monocular vision
- risk factors: carotid artery disease, endocarditis, cardiac valvular disease, long bone fx, hypercoagulable states, vasculitis, atrial myxoma
- amaurosis fugax
management of acute angle closure glaucoma
- topical pilocarpine and beta-blockers
- sudden, painful loss of vision w/ red eye
oropharyngeal dysphagia
-difficulty w/ initiating swallowing associated w/ coughing, choking, or nasal regurgitation
esophageal dysphagia
- can initiate swallowing but have difficulty passing the food down the esophagus
- dysphagia which is initially w/ solids but eventually liquids favors a mechanical obstruction
- progressive dysphagia suggests esophageal stricture or cancer
- nonprogressive dysphagia favors esophageal rings
- upper GI endoscopy is initially recommended except in pts w/ hx of prior radiation, caustic injury, complex stricture, or surgery for esophageal/laryngeal cancer; these pts have increased risk of perforation w/ endoscopy and can benefit from having a barium swallow first; pts w/ negative endoscopy should then have barium swallow for further evaluation
- pts w/ dysphagia to liquids and solids at onset favor a motility disorder; intermittent dysphagia suggest a primary esophageal motility disorder; progressive dysphagia indicates secondary causes such as achalasia or systemic sclerosis (scleroderma); barium swallow is recommended initially for these pts as its more effective than endoscopy in evaluating motlity disorders; pts who have a barium swallow suggesting a motility disorder then undergo esophageal motility studies (manometry) to confirm the diagnosis
24 hr pH monitoring
-might be helpful to confirm diagnosis of gatroesophageal reflux
Bee stings are a common cause of anaphylaxis. Anaphylaxis requires emergency administration of IM epinephrine to prevent and treat respiratory distress and circulatory collapse.
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what is the treatment of all nondisplaces scaphoid fractures (fractures w/
- wrist immobilization for 6-10 wks
- if x-rays are negative but suspicion is high, immobilize wrist and re-image in 7-10 days or proceed immediately w/ CT scan
Orthotopic liver transplantation remains the only effective mode of treatment of fulminant hepatic failure and should be considered in any patient presenting w/ this condition, regardless of etiology. Contraindications include: irreversible cardiopulmonary disease, incurable or recent (
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Diagnostic peritoneal lavage
-done on hemodynamically UNSTABLE pts w/ BLUNT abdominal trauma and INCONCLUSIVE FAST exam
any penetrating wound below the 4th intercostal space (ie level of the nipples) is considered to involve the abdomen and requires an exploratory laparotomy in unstable pts
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CURB-65
- Pneumonia hospitalization criteria, 2-3 = consider inpatient tx; > 4 = admission
- Confusion
- Uremia (BUN > 19)
- Respiratory rate ( > 30 breaths/min)
- Blood pressure (SBP 65 yrs
common causes of pneumonia by age
- neonates: GBS, E. coli, Listeria
- children: Viruses, S. pneumo, Mycoplasma, Chlamydia pneumoniae, S. aureus
- adults (18-40): Mycoplasma, S. pneumo, Viruses, C. pneumoniae
- adults (40-65): S. pneumo, H. influenza, Mycoplasma, Viruses, Anaerobes
- elderly: S. pneumo, H. influenza, Viruses, S. aureus, gram - rods, anaerobes
atypical pneumonia
-MCL (mycoplasma, chlamydophila, legionella)
nosocomial pneumonia
-GNRs, Staph, anaerobes, Pseudomonas (intubated pts)
Immunocompromised pneumonia
-Staph, gram + rods, fungi, viruses, Pneumocystis jirovecii (w/ HIV), mycobacteria
Alcoholics/IV drug users pneumonia
-S. pneumo, Klebsiella, Staph
Cystic fibrosis pneumonia
-staph, Pseudomonas, Burkholderia, mycobacteria
COPD pneumonia
-H. influenza, Moraxella catarrhalis, S. pneumo
Postviral pneumonia
-Staph, S. pneumo, H. influenza
recurrent pneumonia
-obstruction, bronchogenic carcinoma, lymphoma, Wegener granulomatosis, immunodeficiency, unusual organisms (Nocardia, Coxiella burnetii, Aspergillus, Pseudomonas)
Tx for suspected community acquired pneumonia
macrolide or doxycycline
Tx for pneumonia in > 65 or w/ comorbidities
Fluoroquinolone or B-lactam + macrolide
tx of pneumonia requiring ICU care
antipneumococcal B-lactam + either azithromycin or fluoroquinolone
Tx of hospital acquired pneumonia
- extended spectrum cephalosporin or carbapenem w/ antipseudomonal activity
- add an aminoglycoside or a fluoroquinolone for coverage of resistant organisms (Pseudomonas) until lab sensitivities are back
common side effects of TB meds
- Rifampin turns body fluids red/orange
- Ethambutol can cause optic neuritis
- INH causes peripheral neuropathy and hepatitis
how to diagnose active and latent TB?
- active: sputum culture or gram stain for acid-fast bacilli; chest x-ray
- latent: PPD and chest x-ray
Tx of TB
active disease: directly observe tx w/ 4 drug regimen (INH, pyrazinamide, rifampin, ethambutol) x 2 months followed by INH and rifampin for 4 months; must give vitamin B6 w/ INH!
latent disease: + PPD w/o symptoms needs INH x 9 months or INH x 6 months or rifampin x 4 months
PPD readings as positive
> 5 mm: HIV or risk factors, close TB contacts, CXR evidence of TB
10 mm: indigent/homeless, residents of developing nations, IV drug use, chronic illness, prisoners, healthcare workers
15 mm: everyone else, including those w/ no known risk factors
-note that a negative test w/ negative controls implies anergy from immunosuppression, old age, or malnutritions and does NOT rule out TB
Lemierre syndrome
-thrombophlebitis of the jugular vein due to Fusobacterium, an oral anaerobe
Modified Centor criteria
- used to determine tx plan for acute pharyngitis
- Fever 1 point
- tonsillar exudate 1 point
- tender anterior cervical lymphadenopathy 1 point
- lack of cough 1 point
- 3-14 yrs of age 1 point
- 15-45 yrs of age 0 point
- > 45 yrs of age -1 point
- if 4-5 points, treat empirically; if 2-3 points, perform rapid antigen test. if + test, treat w/ abx. if - test, perform throat culture; if 0-1 point, no testing or abx required, symptomatic tx only
tx of acute bacterial sinusitis
-amoxicillin/clavulanate for 10 days or clarithromycin, azithromycin, TMP-SMP, a fluoroquinolone, or a second-generation cephalosporin for 10 days
meningitis in newborn
- GBS
- E. coli/GNRs
- Listeria
meningitis in children
- S. pneumo
- N. meningitidis
- H. influenza serotype b
- Enteroviruses
meningitis in adults
- N. meningitidis (#1 in teens)
- S. pneumo
- Enteroviruses
- HSV
meningitis in elderly
- S. pneumo
- GNRs
- Listeria
- N. meningitidis
meningococcal meningitis
- petechial or purpuric rash
- waterhouse-friderichsen syndrome (adrenal insufficiency due to bleeding into the adrenal gland) is characterized by profound hypotension and has high mortality
how to differentiate Guillain-Barre from MS on LP?
GB has high protein levels in CSF; MS has high gamma globulin in CSF
Tx of bacterial meningitis
Give abx as soon as possible!
- close contacts w/ meningococcal meningitis should receive Rifampin, Ciprofloxacin, or ceftriaxone
- Dexamethasone decreases complications in S. pneumo meningitis only!
- if immunocompromised, elderly, or neonate, add ampicillin for Listeria
- 60 yrs/alcoholism/chronic illness: Ampicillin + vancomycin + cefotaxime or ceftriaxone
The presence of RBCs in CSF without a hx of trauma is highly suggestive of what?
- HSV encephalitis
- subarachnoid hemorrhage
most common causes of encephalitis
-HSV and arboviruses
Giemsa stain
trypanosomes
Tx for common encephalitis conditions
- HSV encephalitis: IV acyclovir
- CMV encephalitis: IV ganciclovir +/- foscarnet
- Doxycycline for Ricketsia such as Rocky Mountain spotted fever or ehrlichiosis
- Lyme encephalitis: Ceftriaxone
classic triad in brain abscess
headache, fever, and a focal neurologic deficit
Treatment of brain abscess
-broad spectrum IV antibiotics and surgical drainage; lesions
AIDS defining illnesses
- Esophageal candidiasis
- CMV retinitis
- Kaposi sarcoma (HHV-8)
- CNS lymphoma, toxoplasmosis, PML
- P. jirovecii pneumonia or recurrent bacterial pneumonia
- HIV encephalopathy
- Disseminated mycobacterial or fungal infection
- invasive cervical cancer
If a pregnant HIV + patient is not on ART at the time of delivery, she should be treated w/ Zidovudine (AZT) intrapartum. Infants should receive AZT for 6 wks after birth
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initial tx regimen for HIV?
-combo of 2 nucleoside/nucleotide reverse transcriptase inhibitors (RTIs), plus either one non-nucleoside RTI or one protease inhibitor or one integrase inhibitor
common side effects of HIV meds
- Protease inhibitors: hyperglycemia, hyperlipidemia, lipodystrophy
- Nucleoside RTIs: bone marrow suppression, neuropathy
- Indinavir: crystal induced nephropathy, nephrolithiasis
- Didanosine: pancreatitis
- Abacavir: hypersensitivity rxn
- Nevirapine: liver failure
- Efavirenz: vivid dreams, hallucinations
what are the only live vaccines that should be given to HIV pts (if CD4 > 200)?
MMR and varicella
Prophylaxis for HIV related opportunistic infections
P. jirovecii: CD4 5mm or high risk; INH x 9mo (+pyridoxine) or rifampin x 4 mo
Candida: fluconazole or fluconazole or nystatin mouth wash
HSV: daily suppressive acyclovir, famciclovir, or valacyclovir
S. pneumo: Pneumovax every 5 yrs if CD4 > 200
Influenza: annual vaccine
Aspergillus appearance
- 45 degree angle branching septate hyphae (think of the capital letter “A” and how it’s angle is 45 degrees)
- rare fruiting bodies
cryptococcus appearance
- yeasts w/ wide capsular halo
- narrow-based buds
Mucor appearance
-irregular broad nonseptate hyphae, wide-angle branching
the CSF antigen test for cryptococcal meningitis is highly sensitive and specific. Can also use india ink stain
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how to differentiate thrush from hairy leukoplakia?
thrush can be easily rubbed off, hairy leukoplakia cannot
tx of cryptococcal meningitis
-IV amphotericin B + flucytosine x 2 wks; then fluconazole x 8 wks
diagnosis of histoplasmosis
CXR: diffuse nodular densities, focal infiltrate, cavity, or hilar lymphadenopathy
Urine and serum polysaccharide antigen test is most sensitive.
Tx of histoplasmosis
- mild: supportive or itraconazole
- moderate: itraconazole for > 1 year
- severe: liposomal amphotericin B followed by itraconazole for 1 yr or greater
appearance of histoplasmosis
-histiocyte macrophage containing numerous yeast cells
Nocardia
- partially acid-fast, gram +, branching rod found in soil that is a common cause of lung and CNS infection in immunocompromised
- TMP-SMX is treatment
Hypercalcemia of malignancy
- most commonly (80%) due to parathyroid hormone-related peptide (PTHrP) production
- other mechanisms include excess vitamin D production, bone metastasis w/ local cytokine release to induce bone resorption, and ectopic PTH production
- breast cancer most commonly causes hyper calcemia by producing PTHrP, either systemically or locally by bone metastases
cytokines produce in osteoclastic bone resorption in malignancies (multiple myeloma, lymphomas, leukemia)?
- IL-6
- IL-3
- RANK-L
- TNF-a
- macrophage inflammatory factor 1-a
Ectopic PTH production is an extremely rare cause of hypercalcemia of malignancy. PTH-independent hypercalcemia usually has serum PTH levels 40 pg/mL. PTH levels of 20-40 pg/mL are considered indeterminant. When both calcium and PTH levels are elevated in malignancy pts, its imperative to rule out coexistent primary hyperparathyroidism before diagnosing ectopic PTH production by the tumor.
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Peripheral artery aneurysm
- manifests as a pulsatile mass that can compress adjacent structures (nerves, veins) and can result in thrombosis and ischemia
- popliteal and femoral artery aneurysms are the most common peripheral artery aneurysms
- they are frequently associated w/ AAA
Inguinal hernias are located above the inguinal ligament; an indirect hernia may descend into the scrotum
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when choosing between meds for depression, consider tx guidelines as well as the safety and side effect profiles. Also, consider a med that may be effective for more than one condition. Buproprion is an example of a med w/ 2 uses, as it is an antidepressant and a smoking cessation aid
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uses for amitriptyline other than depression?
diabetic neuropathy and prevention of migraine headaches
mirtazapine
effective antidepressant; however, weight gain is fairly common
Phenelzine
MAOI
Cushing’s syndrome
- if due to ectopic ACTH production, it causes rapid onset of HTN, metabolic alkalosis, hyperglycemia, hypokalemia, and proximal muscle weakness
- in contrast to Cushing’s DISEASE (ACTH-producing pituitary adenoma), administration of high-dose dexamethasone does NOT suppress plasma cortisol levels in most pts w/ ectopic ACTH syndrome
- ACTH independent: usually due to exogenous steroids, adrenal adenoma, or primary pigmented nodular adrenocortical hyperplasia; get an adrenal CT to exlude adrenal adenoma
- ACTH dependent: most commonly due to Cushing’s disease (ACTH-producing pituitary adenoma), ectopic ACTH production, or ectopic CRD production; due a high-dose dexamethasone suppression test; failure to suppress serum cortisol levels by 50% makes ectopic ACTH most likely
first step in management of a suspected urethral injury
-retrograde urethrogram (helps determine urethral injury and location for repair)
Sporotrichosis
- gardener’s disease
- the initial lesion, a reddish nodule that later ulcerates, appears at the site of the thorn prick or other skin injury
- from the site of inoculation, the fungus spreads along the lymphatics forming subcutaenous nodules and ulcers
Metoclopramide
- prokinetic agent used to treat nausea, vomiting, and gastroparesis
- pts taking this med should be monitored closely for the development of drug-induced extrapyramidal symptoms (dystonic rxn most commonly; tx involves stopping the drug and giving benztropine or diphenhydramine)
4 questions to ask when evaluating case of arthritis?
- Is it an inflammatory process?
- Is it monarticular or polyarticular?
- Is it symmetric or asymmetric?
- What is the duration of symptoms?
Viral arthritis
- can preset w/ symmetric small joint inflammatory arthritis
- distinguished from other causes of symmetric inflammatory arthritis by the fact that it tends to resolve within two months
- positive inflammatory markers such as ANA and rheumatoid factor may occur
- tx involves NSAIDs for resolution of symptoms
- antiviral therapy is unnecessary as the symptoms are self-limited
- causative agents include: parvovirus, hepatitis, HIV, mumps, and rubella among many others
seronegative spondyloarthropathies
- include ankylosing spondylitis, reactive arthritis, and psoriatic arthritis
- asymmetric arthritis and inflammatory back pain w/ a negative rheumatoid factor
