SBL clin- hubbard, things i just have to memorize Flashcards
which physical exam test of muscle weakness is indicative of true fatgue
breakaway wkness
if you only could do one test for fatigue, what would it be
reticulocyte count
anemia with foot/wrist drop, ddx?
lead poisening
amyloidosis
systemic autoimmune ds
vincristin therapy
how do B12/folate deficiency and MTX trx cause anemia
decreased RBC production, via xDNA
major causes of mechanical RBC loss–> anemia
march hemoglobinuria/ sports anemia
cardiac anemia
what chemical x cation pumps in the RBC to decrease survival and production
lead
most common cause of hemolytic anemia world wide
associated with what GU finding
malaria
dark urine = “blackwater fever’
transmission, clinical findings with Bartonellosis
sand flea
adhere to RBC membrane
iniial stage= hemolysis –>Oroya Fevere
transmission, clinical findings with
Babesiosis
abx trx=
intraerythrocyte protozoa, from rodents and Lyme Ds tick
Maltese Cross on Giemsa Stain of RBC,
abx trx= atovaquone+ (azithromycin or clindamycin) + quinone for 7-10 days
treatment for autoimmune hemolysis
mainstay= steroids, high dose prednisone
refractory cases= cyclophosphamide + azathioprine
polycythemia vera
etiology sx PE associated with what syndrome trx
95% have JAK2/V617F mutation and nEPO
sx= facial rubor, hyperviscosity signs, HALL= pruritis w hot shower
PE= 70% have splenomegaly, w spent phase
associated: Budd Chiari Syndrome
TRIAD: abd pain + ascities + hepatomegaly
trx: phlebotomy (blood letting)
clin presentation of fibromyalgia
chronic diffuse M pain, multiple tenderpoints on palpation
spontaneous hemarthrosis is hallmark for…
factor 8 and 9 deficiency
clinical presentation of osler weber rendu syndrome
how is it unique
hereditary hemorrhagic telangiectasia
x endoglin= only ENDOTHELIAL cause of hemostatic complication
telangiectasia, hx of bleeding, AV malformation, aneurysm-al dilations throughout body
80% have epistaxis
telangiectasias appear at puberty, then lifeline
what medications can cause hemorrhagic ds (inc bleeding)
ASA
ADP P2YR-R inhib have higher risk than ASA (clopidogrel, prasugrel, ticagrelor)
Vit E
anti-platelet drugs -abx= cephalosporins, pencillin H2 blockers (can replace with PPI) IV heparin digoxin
what herbs are associated with increased bleeding
(antiplt) gingko biloba garlic bilberry ginger dong qui fever few ginseng tumeric meadowsweet willow fish oil concetrated omega 3 fatty acid supplement
anti(coag)
motherwort, chamomile, horse chestnut, red clover, fenugreek
presentation and underlying causes of DIB
present:
the initial thrombosis stage is clinicall MASKED: present with bleeding
=post med/surg/obstetric complication
trx by correcting underlying ds= sepsis, bowel obstruction,
differentiate between the clin presentation of TTP vs HUS
causes of TTP
labs and trx
TTP= purpura, microangiopathic hemolytic anemia, neuro sx, fever
HUS= all those + renal failure
causes= inherited or acquired xADAMTS13 (xvWF cleaving protease)
labs=smear shows schistocytes (fragments), helmet cells= Warburg Effect
trx= plasmapharesis is 100% lifesaving (from a no trx 100% mortality)
underlying causes of
xplt adhesion
xplt aggregation
xplt secretion
xplt adhesion
=vWD, Bernard Soulier (x gpIb)
xplt aggregation
=glanzmann (gp IIb/IIIa)
xplt secretion
=ASA-like condition (dec COX)
=granulocyte storage poolantithrombin III deficiency
clin presentation
trx
what other ds presents this way and how do you treat
clin= recurrent LE thrombophlebitis + DVT + chronic leg ulcers
50% have DVT by 30 yo, inc risk in preg (mom will become less active throughout)
trx= prophylactic anticoags for like
ONLY REPLACE ATIII IFF:
known deficiency AND have DVT AND refractory to heparin
~~~ protein C/S defiency, prophylactic warfarin (need to start an anticoag first and then monotherapy once INR normalizes)
what 2 ds combined are the most common diseases associated with hereditary thrombophlebitis
factor V leiden
(stronger risk of TE ds in homozygrous, trx w DVT prophylaxis)
prothrombin 20210 (aka G-->A ds) inc affinity and dec regulation of prothrombin
causes, clin presentation, labs, and trx for antiphospholipid Ab syndome
acquired from things like SLE, HIV, RA
sx: thromboembolic miscarriage, thrombocytopenia, cerebral ischemia, recurrent stroke
false (+) syphillis
prolonged PTT THAT FAILES TO CORRECT in mixed test, corrects with addition of antiphospholipid
trx: subQ heparin, hydroxychloroquine
what routine pre-op test is used to test liver function/ vit K levels
PT
what do PT, and PTT test or
PT= F1 (fibrinogen), 2 (prothrombic), 5, 7, 10
PTT= F 11, 9, 8, 5, 2 (prothrombin), 1 (fibrinogen), prekalikrein, HMW kallikrein, F12
when do you do…
mixing studies
specific factor assays
MS= to evaluate a long aPTT
SFA: in response to severe bleeding, to guide therapy
thrombin time and DRVVT measure what (what levels will prolong the time)
presence of what drugs can effect this test
measure (fibronogen–>fibrin)
prolonged time w fibrinogen <80-100 mg/dL
heparin= prolonged TT, NORM DRVVT
dabigatran (DVT trx med) = markedly inc TT
test can show effectiveness of LMW heparin,
direct measure levels of –
unfractioned heparin
direct Xa inhib= rivaroxaban, apixaban, edoxaban
what is the use of quantitativ D-dimer assay
do 4 wks after stopping anticoag
stratify risk of recurrent thrombosis
protein C+S levels
inc
or dec
inc= acute thrombosis
dec= warfarin levels
clinical signs of DVT
what testing do you do
homan’s sign= calf pain on dorsiflexion
moses sign: pain w compression of calf
against tibia but not w squeeze
lownberg sign: BP cuff on mid calf and pain elicited
lister’s sign: pain w percussion of anteromedial tibia
=pt w low clin likelihood– do D dimer
gold standard = venography
BUT rarely do it because a duplex US has such good sensitivity and specificity
the four T’s of the anterior mediastinum
thymoma
teratoma
thyroid mass
“terrible” T cell lymphoma
thymoma vs terrible T cell lymphoma
thymoma= M, >40 yo with anterior superior mass
associated with myasthenia gravis
t cell lymphoma = children
4 Ts of heparin induced thrombocytopenia
how to grade
high probability= 6-8 points
intermediate probability= 4-5 points
low probability <3 points
thrombocytopenia
2 pts= >20k, falls >50%
1 pt= 10-19k, fall 30 30-50%
0 pt= plt < 10k, fall <30%
timing of plt count fall
2 pts= clear onset days 5-14, plt fall <1 day
1 pt= consistent w day 4-15 dall, but not clear or onset after day 14 or fall < 1 day prior
0 pt= plt fall <4 days without recent exposure
thrombosis or other sequelae
2 pt= new thrombosis, skin necrosis at injection site, anaphylactic rxn after IV bolus
1 pt= progressive or recurrent thrombosis, erythematous skin lesion, suspected thrombosis not confirmed
0 pt= non
oTher causes of thrombocytopenia:
2= none apparent
1pt= possible
0 pt= definite
clinical presentation of infectious mono
teen w viral illness (fever, quick onset, body aches) and a palpable spleen
immediate vs long term therapy in DVT
when do you put in an IVC filter
immediate anticoag = IV unfractioned heparin, LMWH for outpatient
long term: warfarin (started w heparin) or newers (dabigatran, rivaroxaban, apixaban, edoxaban) =rapid onset, no need bridge but contra in CKD
IVC filter= only if contra to anticoag= short term decr in risk of PE but has a long term increase risk of recurrent DVT
pulmonary embolism
virchow’s triad- causes
CXR findings
mortality is associated with what
Virchow’s triad= endothelial damage, venous stasis, hypercoag
hypercoag ~
—malignancy in 20% of DVT pts = lung>pancreas>colon, rectum, renal, prostate
—-drugs: tamoxifen, bevacizumab, thalidomide
—ds= polycythemia vera, APS
cxr= atelectasis
Westermark Sign= focial oligemia (no vasc can be seen distal to the PE)
Hampton Hump= peripheral, wedge-shaped density above diaphragm
mortality associated with hemodynaic changes after an acute rise in pulmonary A resistance
Wells Criterion scoring for DVT and PE
plus some criterion that aren’t immediately obvious
DVT: >/= 3 -- 75% risk of DVT 0 = 3% risk (+1) - calf swelling > 3cm, tender along deep V, UNILAT pitting edema, active CA, (-2)= alt dx more likely
PE:
>/= 6 - 70% risk
<2 = 2-3% risk
(+3)= clin evidence of DVT, other dx LESS likely
(+1.5)= HR>100, (immobility > 3 days, surgery within 4 weeks, previous DVT)
(+1)= hemoptysis, malignancy
contrast venography vs doppler vs V/Q scan vs CT angio vs D-dimer
pros and cons
contrast venography
- -show anatomy and flow phys
- pain, contrast, invasive
doppler
- —flow phys, cheap, easy, no radation
- inc false +/-, tech dependent
V/Q scan
- —-inc sensitivity, cheap
- dec specificity, miss small defects
CT angio
- —- GOLD STANDARD for sens and spec
- contrast, may miss small clots
D-dimer
- —– (-) test makes test unlikely
- + test NOT diagnostic
anticoag trx of acute DVT and PE
at what point in trx do you reassess who should keep getting trx
- trx if the event was
- unprovoked
- unprovoked and recurrent
- associated w underlying thrombophilia
- associated w CA
- due to transient risk
3 months
-unprovoked
indefinite if bleed risk allows= ASA
-unprovoked and recurrent
indefinite
-associated w underlying thrombophilia
indefinite (if APS, as long as (+) serology, may stop if serology is consistently neg)
-associated w CA
continue as long as CA lives, trx w enoxoparin (LMW heparin)
-due to transient risk
stop at 3 months
post op anticoag trx of
who gets..
LMWH fondaparinaux DOACs: rivaroxibin and apixaban DOAC: dabigatran warfarin
LMWH =most med+critical ts, w/in 4 wks of abd/pelvic CA surgery many ortho (bid, 10 day min) post-joint replacement- = 1 month bariatric pts= bid
fondaparinaux
=many ortho- 10 day min
-post-joint replacement- = 1 month
DOACs: rivaroxibin and apixaban
ortho s/p THA 35 days , TKA 12 days
DOAC: dabigatran
s/p THR IFF CrCl > 30 mL,
CONTRA in renal ds (excreted..)
warfarin
- some ortho, get goal of INR 2.5 with bridge
- high risk s/p THR, TKR, hip fix
drugs that cause lymphadenopathy
allopurinol atenolol captopril cabamezapine cephalosporines etrosuximide gold hydralizine imatinib lamotragine penicilline phenytoin primidine pyrimethamine quinidine sulfanomaide sulindac
PE findings of lymphadenopathy that have diagnositc value
systemic ds + lymphadenopath + splenomegaly –> think lymphoma, CLL, acute leukemia
size
consistency
fixation
tender
anterior cervical lymphadenopathy is associated with what ds/infection
EBV, CMV, toxo
lymphoma, CLL, H+N CA
posterior cervical lymphadenopathy is associated with what ds/infection
EBV and TB
lymphoma, CLL, H+N CA
supraclavicular lymphadenopathy is associated with what ds/infection
1/3-1/2 pts have a malignancy, espt if > 40 yo
R side: retroperitoneal, mediastinal, lung, esophagus
L side: intra-abd CA (virchows node, thoracic duct)
axilary lymphadenopathy is associated with what ds/infection
cat scratch ds, UE melanoma, breast met, silicone breast implant
epitrochlear lymphadenopathy is associated with what ds/infection
ALWAYS PATHALOGIC IF PALPABLE
hand/forearm inection, tularemia, strep, cat scratch ds
SECONDARY SYPHILLIS
sarcoid
inguinal lymphadenopathy is associated with what ds/infection
LE infection (tuleremia) STDs= venerum, primary syphillis, genital herpes/chancroid
lymphoma, melanoma, other skin CA of LE, GU, anus rectum CA
occipital lymphadenopathy is associated with what ds/infection
scalp infection
preauricular adenopathy
conjuntival infections, cat scratch
how does a thoracic adenopathy present
on CXR,
sx= cough/wheeze, dysphagia, swollen UE/neck
mediastinal LAD is associated with different conditions in dif populations
young
endemic areas
old ppl
young – mono, sarcoidosis
endemic areas — histo (looks like lymphoma)
old ppl -primary lung CA, TB, fungi, sarcoidosis
given lymphadenopathy with an abn CXR and (-) PPD, what other entities do you consider
HIV, EBV/CMV, toxo, brucella (from unpasteurized milk, soft cheese)
autoimmune CT ds
findings that are diagnostic of hypersplenism
splenomegaly
cytopenia
normal or hyperplastic BM
response to splenectomy
what triad of sx is seen in myelofibrosis
leukoerythroblastic anemia
poikilocytosis
splenomegaly
