studying Flashcards
severe htn lvls
> 180/120 either and or
Encapsulated bacteria
SHiNE SKiS
- streptococcus pneumonia
- hemophilus pneumonia
- Neisseria meningitidis
- E. Coli
- Salmonella
- Klebsiella
- group b Strep
indinavir
MOA
USE
SE
protease inhibitor
HIV therapy
SE: crystal nephropathy by drug precipitation in urine, 8% of users w/urinary symptoms
HIV-drug life threatening side effects didanosine- abacavir- NRTI- NNRTI- nevirapine-
didanosine (adenosine analog, NRTI)- pancreatitis
abacavir (NRTI)- hypersensitivity syndrome/DRESS
NRTI-lactic acidosis
NNRTI-SJS
nevirapine (NNRTI)- liver failure
Hyperkalemia
EKG manifestations
Cardiac abnormalities
sign’s/symptoms usually >7 in chronic hyperK, may occur with lower lvl in acute.
- peaked T, prolonged PR -> ST elevation, peaked T, loss P wave -> sine wave
- sinus node dysfunction (bradycardia/arrest), AV block, ventricular arrhythmia’s
1st: IV calcium to stabilize cardiac membrane
- insulin helpful for temporary HyperK decrease
long term: diuretics, hemodialysis, cation exchange resins (sodium polystyrene sulfonate - aka kayexelate)
%chronic cough with ACEi’s
20%
abciximab is what?
ebtifibatide is what?
gp2b3a inhibitor, used sometimes for short course with PCI
abciximab: monoclonal antibody (mab)
ebtifibatide: A heptapeptide derived from venom in a rattlesnake
fluphenazine?
typical antipsychotic, used in schizophrenic’s with poor compliance. injection q2-3 weeks. More powerful than haldol.
SE: inhibit shivering/autonomic thermoregulation
Acyclovir SE in kidney
In IV form, causes Crystal induced AKI as it is excreted in urine but has poor solubility. Causes intratubular obstruction. occurs within 24-48hrs.
cyclosporine
MOA
USE
SE
MOA: Inhibit transcription IL-2 and activation of T-lymphocytes by IL-2
USE: immunosuppression: psoriasis, Rheumatoid Arthritis, organ transplant prophylaxis/tx,
SE: nephrotoxicity (most common), HTN, hyperglycemia, , infection, malignancy (scc and lymphoproliferative disorters), GI (anorexia, N/V/D), gingival hypertrophy, hursitism.
Azathioprine
MOA
USE
SE
MOA: purine analog enzymatically converted to 6-mercaptopurine, which is incorporated into replicating DNA and halts replication. Also blocks purine synthesis…
USE: Renal transplant rejection ppx, Rheumatoid Arthritis, crohn’s, and other autoimmune
SE: Major = dose related diarrhea, leukopenia, hepatotoxicity. Rare= neoplasia
Mycophenolate
MOA
USE
SE
MOA: inhibits inosine monophosphate dehydrogenase (IMPDH), a rate limiting enzyme in purine (guanosine) synthesis. Cytostatic for T and B lymphocytes, which require this pathway
USE: organ transplant rejection ppx, use in conjuction with cyclosporine and steroids.
SE: Major = bone marrow suppression
Vitamin A deficiency
Blindness, dry skin, impaired immunity.
Think likely 2/2 Celiac’s disease,
May have assoc problems with with B12, vit D, vit K, vit E, calcium, folate, zinc
*traditionally the beta carotene eyesight vitamin
Zinc deficiency
may occur from TPN
alopecia, impaired taste, bullous/pustular lesions around orifices and or extremities, impaired wound healing
selenium deficiency
may occur from TPN
may cause cardiomyopathy
cannibinoid usefuleness in cachexia/anorexia
Shown benefit in HIV cachexia,
cancer related benefit is small over placebo
progesterone > corticosteroid is better
Donepezil
MOA
USE
Acetylcholinesterase inhibitor
USE: Alzheimer Dementia
pulsus parvus et tardus
slow rising, low amplitude pulse found in aortic stenosis
Hairy cell leukemia
- population
- cell
- characteristic under microscopy
- stain
- Tx
- elderly
- B-cell tumor, often with fibrotic marrow and dry tap, cytopenia/pan, +- leukocytosis
- Stain TRAP (tartrate-resistant acid phosphatase) positive
- Tx; cladribine, a purine analog
Doxycycline
MOA
USE
SE
MOA: tetracycline (30s inhibitor)
USE: CAP, zoonic infections like lyme disease, acne, chlamydia, early syphilis only (though pcn G 1st line)
SE: NOT safe in pregnancy, crosses placenta, accumulates in long bones and teeth. Photosensitivity (as are all tetracyclines)
NOT toxic to kidneys
Azythromycin
MOA: macrolide (50s inhib)
USE: CAP, sinus infections, strep pharyngitis, chlamydia
*safe in pregnancy
Chlamydia tx
azythromycin* 1g x1, or doxycycline 100mg BID x7 days.
Cotreat with ceftriaxone* 250mg x1 for neisseria gonorrhea.
- recommended to use in pregnancy
- doxy is NOT safe
- **N gonorrhea always needs both tx due to cephalosporin resistance increasing, but chlamydia only needs one
Dx: both N/gonnorrhea and chlamydia with nucleic acid amplification test (NAAT)
What proportion of patients have a posterior descending artery derived from the LEFT coronary?
LCA 10%, the rest are RCA (90%)
MAP definition using pressures as well as systemic equations (ie. CO)
MAP= CO x TPR MAP= DPB + 1/3(DBP-SBP)
What artery supplies the SA and AV nodes?
RCA supplies SA and AV nodes
What arteries supply the Interventricular septum?
LAD supplied anterior 2/3 of interventricular septum, the posterior descending artery supplies the posterior 1/3
Homocysteine relation to atherosclerosis
High serum homocysteine increases atherosclerotic risk threefold
Gold Standard for identifying CAD
Coronary angiography, but more invasive so used somewhat judiciously
Stress test HR goal
max HR= 220-age
Goal Stress HR is 85% of max
if considering bblocker overdose, what to give after atropine? Will pacing work?
S/S: Bradycardia, hypotension, AV block Bblocker also with hypoglycemia, wheezing, delirium, seizures
Tx: Secure airway, IVFB, IV atropine -> glucagon, +- IV calcium, vasopressors, insulin&glucose
*** pacing is indicated later in this case (usually try after atropine) because it is less effective in BB/CCB poisoning, particularly because of the decreased inotropy. Otherwise it is typically used as second line to atropine in symptomatic bradycardia not assoc w/overdose.
*CCB, digoxin, cholinergic agents may cause similar symptoms. But they are less likely to cause wheezing (maybe except the cholinergic?)
Glucagon
MOA
USE
MOA: stimulates adenylate cyclase to produce increased cellular cAMP ->promotes hepatic glycogenolysis and gluconeogenesis
+
Elevations in cAMP increase the intracellular pool of calcium available for release during depolarization, augmenting contractility.
USE: BB toxicity, CCB toxicity, hypoglycemia, anaphylaxis (for pt. on BBlocker)
SE: vomiting common, counter ppx with ondansetron
Digoxin
MOA
USE
SE
MOA:
-HF: inhibit Na/K atpase, thereby transiently increaseing intracellular Na -> increased Na:Ca exchange -> more Ca intracellularly = contractility
-Supraventricular arrhythmias: directly suppresses AV node
USE:
- Rate control in Afib (offlabel)
- Heart failure (
- SVT
Digoxin toxicity
fatigue, nausea, anorexia, abdominal discomfort, blurred vision, disturbed color perception, cardiac arrythmias
tx; Digoxin specific antibody (Fab)
bumetanide?
loop diuretic
torsemide?
loop diuretic
HFrEF pharm tx
optimal in all patients +- loop
1) loop + ACE/ARB
2) BBlocker (metoprolol, bisoprolol, carvedilol)
If still refractory
3) if NYHA class II-IV and EF spirinolactone/eplerenone
4) Digoxin if persistent symptoms
* * LVEF .150, NYHA III/IV => CRT
Type A aortic dissection mortality
tx:
1-2%/hr from symptom onset
tx: morphine pain control, systolic BP 100-120, HR labetolol/propranolol
Esmolol
Selective B1, short half life.
Duration 10-30min
Labetolol
alpha1, B1&B2 blocking
Propranolol
B1 &B2,
- NO alpha 1 blocking
- **care in prinzmetals angina and cocaine induced vasospasm/htn
Carvedilol
alpha1, B1&B2 blocking
Hydralazine
MOA: direct vasodilation arterioles (not venules) decreases systemic resistance. unclear mechanism
USE: HTN
Duration: up to 12 hrs
SE:reflex tachy w/increased BP/wall stress
Nitric Oxide MOA
NO diffuses readily across cell walls -> smooth muscle -> activates guanalyl cyclase -> cGMP -> protein kinase G -> activates myosin phosphatases -> inactivate myosin light chain through dephosphorylation
High output cardiac failure
causes
explanations
s/s
Causes:
- congenital or otherwise AVF
- cancer AVF
- Hyperthyroidism: thyroid hormone itself is chrono/inotropic, also activates sympathetic autonomic system
- anemia
- thiamine deficiency (BeriBeri): unknown mechanism vasodilation and augmented venous return requires heart to work harder
- paget disease (bone)
In case of AV fistula, there is high preload, -normal-high cardiac output, but despite this cannot maintain perfusion/oxygen demand to peripheral tissue because of the constant shunting to the venous side.
s/s may have pulmonary/venous congestion => edema, dyspnea, tachycardia, bounding/quick upstroke of arteries, wide pulse pressure, midsystolic murmer from high flow
paget disease of bone (osteitis deformans) What is it? s/s dx tx
Local abnormality in bone metabolism in older population causing accelerated bone remodling
s/s: majority asymptomat, but otherwise -> pain, either from primary lesion(s) or from their overgrowth effect on surrounding tissue. May develop fractures, nerve impingement, tumor
Dx: radiologic
tx: bisphosphanates can reduce pain and resoption
**excessive bone remodling especially in multiple sites increases vascularity and can sometimes led to high output heart failure (rarely) or bleeding at site during surgery.
Hypersensitivity syndrome/DRESS
some drugs that cause
drug reaction with rash, fever, multiorgan failure.
Caused by anti epileptics, allopurinol, abacavir, dapsone, minocycline, vancomycin, SMX…among others
Name 4 P2Y12 inhibitors
P2Y12 is the ADP receptor on platelets
Direct competitive inhibitors
clopidogrel (plavix)
ticlodipine (ticlid)
prasugrel (effient)
Allosteric inhibitor
ticagrelor
IBD peak
Bimodal, most in 20’s-30’s, but a second peak at 60’s.
What intestines does the following supply?
SMA:
IMA:
SMA: entire small intestine except proximal duodenum, also ascending and transverse colon
IMA: sigmoid, descending colon… some rectum, though a lot comes from branches off iliacs there
- acute mesenteric ischemia refers to small intestinal ischemia
- *colonic ischemia refers to well… colonic ischemia
- **occurs from embolus (50%), thrombus 20%, and hypoperfusion (30%)… small % from venous thrombus
Hemophilia
A&B
genetics
s/s
Dx
Tx
x-linked recessive
- hemarthrosis, intramuscular hematomas
- GI bleeding
- GU bleeding (hematuria)
A is missing factor VIII
B is missing factor IX
Dx: Both prolonged PTT and missing respective factor
Tx; factor VIII or IX, desmopressin for A
Von Willebrand Disease genetics s/s Dx Tx
Autosomal dominant (most common bleeding disorder, 1% of population). Decreased/impaired VWF which binds collagen-> Gp1b
s/s
mucosal bleeding (menorrhagia, epistaxis, GI).
easy bruising/skin bleeding
No deep tissue bleeding
Dx: ristocetin cofactor assay (binds vwf to gp1b readily forming platelet clumps), ptt normal to increased (depending on degree of factor VIII loss)
Tx; desmopressin (releases vwf in weibel palade bodies from endothelium)
Drugs that cause bronchospasm in asthmatics
ASA
Beta blockers, even selective may do so in high doses
factor V leiden
autosomal dominant mutation where factor V is resistant to cleavage by activated protein C.
Thus prothrombotic. Most common inherited hypercoagulability in whites
Vitamin B3
- alternate name?
- deficiency caused by?
- deficiency name/s/s
vitamin B3 = niacin
pellagra = diarrhea, dermatitis (sunburnesque), dementia
- abdominal discomfort, glossitis
- occurs in malnutrition (3rd world/bowel diseasE)
cyanocobalamin
B12
deficiency = macrocytic anemia + peripheral neuropathy
Body stores 3-4 years, strict vegans may become deficient, crohns, celiac?, pernicious anemia, + others
-found in eggs, milk, meat, fish, poultry. NOT IN PLANTS
pyridoxine
B6: Deficiency = irritability, depression, stomatitis, glossitis, dermatitis, increased homocysteine, neuropathy/ataxia/paresthesias , may cause cheilosis
**rare deficiency, but isoniazid use can cause as it competes for a cofactor spot to participate in production of synaptic neurotransmitters
Riboflavin
B2: cheilosis (dry cracked skin on angle of mouth), glossitis, pharyngitis, seborrheic dermatitis, ANEMIA
-occurs in malnutrition, anorexia, avoidance of dairy (good source), phenobarbital use
folate
B9: macrocytic anemia in deficiency
found in green vegetables and liver. inactivated in cooking. deficient in 3-4 months
*recommended as daily supplement for all those with SCD due to constant RBC turnover.
vitamin E
deficiency, mostly only caused by fat malabsorption. Vegans/vegetarians ok
RBC fragility/hemolysis
Neuromuscular: hyporeflexia, weakness, ataxia
->through subacute combined degeneration on spinal cord
*used on scars to help heal
nikosloki sign
skin sloughing with gentle lateral pressure
seen in staph scalded skin syndrome
erythema multiforme
immune mediated, target like skin lesions, self limited. Rare ocular involvement. occur over 2-5 days, resolve over 2 weeks. when infectious, occur days after disease began.
Cause: infection =90%, HSV most common, mycoplasma pneumonia causes a lot too
also may be medications (NSAID, sulfa, antiepileptic, antibiotics), autoimmune disorders, malignancy
cerebral salt wasting
Cause: traumatic injury/surgery, SAH,
pathophys: somehow CNS disruption -> altered neural input to kidneys. Also natriuretic ?BNP? released. There is some debate about if CSW is real, or if body is appropriately excreting sodium.
findings: hypovolemia, hyponatremia, high urine Na >20meq
Can you use antidepressants in bipolar disorder
generally no, they cause mood destabilization
Bipolar I has manic and usually depressive episodes
Bipolar II has hypomanic (no manic) and depressive episodes
difference is essentially whether hospitalization or significant impairment occurs
absence seizure
last how long?
treatment?
classic EEG?
avg 10sec, generally
ethosuxide
3hz spike wave
Cluster headache
s/s
tx
ppx
s/s: ipsilateral ptosis/miosis, sudden, intense retroorbital pain, tearing, runny nose, facial swelling/sweating, last (15-180min) 2hrs avg, cluster in 6-8 wk intervals with remissino up to 1yr. NORMAL vision
tx; 100% oxygen and sumatriptan, intranasal lidocaine
ppx; lithium, verapamil (nondihydropyridine), ergotamine
why does high volume transfusion lead to hypocalcemia?
citrate preservative in blood binds calcium
** hypocalcemia rare if normal liver (citrate metabolized), however if poor synthetic function (cirrhotic)–> bad news
carbon monoxide half life in humans
5hrs room air
1-2hrs with 100% oxygen
cardinal parkinsonism signs
tremor (4-6hz), rigidity (lead pipe/cogwheel with passive movement), bradykinesia (slow, low amplitude, difficulty initiating movments), postural instability
Inflammatory Breast Carcinoma
s/s “peau d’orange” = superficial dimpling and fine pitting, itching, axillary lymphadenopathy, +- nipple retraction/flattening, breast mass +-
*NO fever
Dx: US/mammography depending age 30+-> biopsy for definitive dx
uvea
middle portion of eye: anterior part comprised of ciliary body and iris, posterior is the choroid
keratitis+
conjunctivitis
=
keratoconjunctivitis
keratitis is inflammation of cornea
conjunctivitis is inflammation of conjunctiva
huntingtons chorea
genetics onset s/s imaging/path Tx:
autosomal dominant, trinucleotide CAG repeats, chromosome 4
onset 40’s-50’s
s/s movement disorder (chorea), behavioral disturbance, depression common, dementia late
path/imaging: atrophy of caudate/putamin (neostriatum) nucleus, seen as enlargement of lateral ventricles
Tx: tetrabenazine (inhibits synnaptic vesicle uptake of monoamines) -> atypical antipsychotics -> typical antipsychotics
*off-label amantadine used
*increases in dopamine, decreases in GABA and Ach. pathophys has to do with glutamate excess-> NMDA toxicity
Imipramine
tricyclic antidepressant
Tricyclic antidepressant cardiotoxicity
and tx
what other toxicity?
TCA -l fast Na channels in purkinje system -> decreased conduction velocity, increased absolute refractory period, prolongs repolorization. which creates QRS prolongation, hypotension, ventricular arrhythmias
tx: bicarb indicated if QRS >.10, to increase pH to 7.50-7.55 and create more extracellular Na. Increased pH decreases TCA avidity to Na channels, and increased extracellular Na increases electrochemical gradient (and competes for TCA sites)
** CNS (seizures coma), anticholinergic
vast majority of head and neck cancer is?
SCC
weight loss in neonates
up to 7% in first 5 days
regain weight by 10-14days
wet diaper normal
wet diaper = days of life until 1 week. then about 6/day is normal
- the red of uric acid is normal if dehydrated
- do not have to worry about lesch-nyhan (self mutilation) purine metabolism problem if growing normally
- **feed q2hrs x15min/side for first month of life
Nitroprusside MOA USE Onset Duration
MOA: breaks down into NO -> peripheral vasodilation through direct action on arteriolar/venous smooth muscle
USE: acute HTN/crisis, 2nd line uncommon use for aortic dissection
Onset: less than 2min
Duration: 1-10min
idiopathic intracranial hypertension (pseudotumor cerebri)
s/s
cause
Dx
tx
s/s: HA, visual loss/changes, pulsatile tinnitus, diplopia, papilledema, CN VI palsy
risks/causes: overweight women, medications: tetracycline (doxy/mino), isotretinoin, growth hormone, OCP’s
Dx; high opening pressure with otherwise normal LP.
tx: weight loss, stop offending agent, acetazolamide for idiopathic cases
Histoplasma capsulatum
location path s/s Dx Tx
mold=fungi
present in soil, bird, bat droppings
Endemic: mississippi/ohio river basin = mississipi, arkansas, illinois, indiana, ohio, missouri, alabama, texas, oklahoma, iowa, kentucky, tennesse… Histo is for the Hicks
Path: histo HIDES within macrophages (smaller than rbc), caseating or noncaseating granuloma formation (mimics tb which can have either as well).
s/s: pulmonary symptoms, mediastinal/hilar lymph nodes, arthralgias, erythema nodosum
- If immunocompromised -> disseminates: hepatosplenomegally, pancytopenia, lymphadenopathy
- *HIV CD4 less 100 disseminates bad
- amphotericin B for severe 1-2wks, itraconazole for less severe/transition to for 1yr
**If thinking sarcoid then CONSIDER histoplasmosis!
Blastomycosis dermatiditis location path s/s Dx Tx
East of mississippi and Central America within wood/soil
path: same size as rbc, outside macros, blasto buds broadly
s/s pulmonary, skin lesions, osteolytic bone lesions, prostate involvement, granulomas possible
Dx;culture
tx: amphotericin B, most ppl do need tx
coccidiomycosis location path s/s Dx Tx
location: southwest US, california, especailly after earthquakes
path: spherules filled with endospores
s/s: meningitis, pneumonia, bone, skin, may show erythema nodosum
dx:serum, histology of tissue, culture,
tx; none -> ampho B
ca 19-9
pancreatic cancer antigen, used to follow/treat, not diagnose
ca-125
ovarian cancer antigen, not widely used other than after a postmenopausal adnexal mass is found
endometriosis symptoms
dysmenorrhea (especailly at start of menses), dyspareunia, dyschezia, chronic pelvic pain, INFERTILITY, cervical motion tenderness, adnexal mass (can be only finding), uterosacral ligament nodules, posterior cul-de-sac nodules
tx; 1st medical (nsaid/ estrogen OCP)
2nd line surgery
**DO NOT NEED TX IF ASYMPTOMATIC
dx; direct visualization, though may tx without this
Niemann-pick disease
Deficiency?
s/s
histology
Lysosomal storage disease
Deficiency in sphingomyelinase -> accumulates sphingomyelin
s/s: progressive neurodegeneration/loss of motor milestones (2-6mo), HEPATOSPLENOMEGALLY, CHERRY RED SPOT on macula, AREFLEXIA, hypotonia
Histology: foam cell (w/zebra body)
*Children die early, almost universally by age two
- *most lysosomal disease are autosomal recessive except fabry’s and hunters
- *differentiate from tay-sachs by hepatosplenomegally and areflexia
Tay-sachs disease
Deficiency?
s/s
lysosomal storage disease
Defieciency: hexosaminidase A leads to excess gm2 ganglioside
s/s: progressive neurodegeneration/loss of motor milestones, hypotonia, cherry red spot on macula, NO HEPATOSPLENOMEGALLY, HYPERreflexia,
*Life expectancy 2-5yrs, usually die by pneumonia
Histology: lysosomes with onion skin/whorled inclusions
Gaucher disease
Deficiency
s/s
histology
tx
lysosomal storage disease
*most common of them
Deficiency: glucocerebrosidase -> accumulate glucosylceramide
s/s: hepatosplenomegally, aseptic necrosis of femur, bone crises (pain), pancytopenia. NO LOSS OF MILESTONES
Histology: Gaucher cells (crumped tissue paper), PAS + (note that if it’s bacteria that’s whipples disease)
tx: one of the few lysosomal storage disease can be treated with enzyme replacement therapy
Niemann-pick vs tay-sachs
Niemann-pick has hepatosplenomegally and areflexia
Tay-sachs has NO hepatosplenomegally and has HYPERreflexia
do craniopharyngiomas often have calcifications?
yep, whereas a pituitary adenoma would not… and may have pituitary hormone secretion (prolactin w/amenorrha and galactorrhea)
Nephrotic vs Nephritic clinical features
Nephrotic: edema, proteinuria >3.5g/day, hypoalbuminemia, frothy urine, NO blood, hyperlipidemia, fatty casts, hypercoaguability (loss of ATIII), increased risk infection (loss IG)
Nephritic: hematuria, RBC casts, azotemia, oliguria, HTN (2/2 salt retention), proteinuria, periorbital edema (esp postinfectious glomerulonephritis)
Hepatitis B and C are a risk factor for which renal syndrome(s)?
membranous nephropathy, which is a nephrotic syndrome. less common but also membranoproliferative glomerulonephritis (which can be nephritic/nephrotic)
*Membranous nephropathy also caused by SLE, NSAIDS/drugs, tumors, and other infections
renal syndromes in SLE
membranoproliferative glomerulonephritis (MPGN) which is nephrotic/nephritic or Diffuse proliferative glomerulonephritis which is nephritic
may also have membranous nephropathy
Focal segmental glomerulosclerosis (FSGS) is associated with what diseases?
nephritic or nephrotic?
Nephrotic syndrome
-HIV, heroin abuse, massive obesity, Interferon tx, CKD, sickle cell
CNIII
ischemia vs compression
somatic and parasympathetic fibers run in this BUT NOT sympathetic. Sympathetic not affected by compression or ischemia, it comes in seprately.
ischemia: causes somatic injury (leaving only CN VI and IV and giving down and out gaze w/ptosis (levator palpebrae)… but pupil still reactive) BECAUSE blood supply is different for somatic/parasympathetic fibers
compression: affects somatic and parasympathetic fibers –> addition of fixed dilated eye without accommodation.
hypoxemia causes
5
Normal A-a
high elevation: duh
hypoventilation: opioids
high A-a
V/Q mismatch: COPD
diffusion limitation: pulm fibrosis
shunt: pulm edema, congenital, airway obstruction
IgA Nephropathy (Berger’s Disease)
syndrome?
prevalence?
cause?
Nephritic syndrome
prevalence: most common Glomerulonephritis in adults
cause: often presents/flares with URI, pharyngitis, or acute gastroenteritis. Will flare wtihin 5 days of illness
* associated with henoch-schonlein purpura
Renal papillary necrosis
causes
NSAID
NSAID’s, sickle cell, acetamenophen/analgesic, infection (pyelo), diabetes
**acetamenophen is more long term abuse
lumbar stenosis
pain relief with flexion or extension?
spinal flexion
saline responsive vs nonresponsive metabolic alkalosis
check urine chloride. If high, not responsive, if low it is responsive.
most notable opportunistic infections after organ transplant
PCP (pulmonary symptomcs, but not GI/hepatic)
CMV (pneumonitis, Gastroenteritis, hepatitis)
metabolic syndrome
3/5 of the following
1) abdominal obesity, men>40 women >35 inches by sex
2) fasting glucose 100-110
3) BP >130/80
4) triglicerides >150
5) HDL low, men
Takayasu arteritis
Path population s/s Dx Tx
Large artery vasculitis, primarily involving aorta and its branches
population: women less than 40, asian
s/s: constitutional (fever, weight loss), arthralgias, myalgias, arterio-occlusive ( arm claudication, ulcers), pulse deficits, bp inconsistencies (right to left), bruits
dx: elevated ESR/CRP, anemia possible
- CXR: aortic dilation/wide mediastinum,
- CT/MRI: wall thickening/narrowing lumen
Tx: glucocorticoids
Kawasaki Disease
path population s/s Dx Tx
Acute vasculitis illness in children
s/s fever, mucositis, conjunctivitis, rash, cervical lymphadenopathy, acral edema
cardiac: tachycardia, coronary artery dilation, delayed CA aneurism (day 10+)
self limited, resolves 1-2 weeks
Dx: fever 5+ days and 4/5: conjuntival injection, mucositis, acral edema/erythema, rash, cervical adenopathy
Tx: IVIG + ASA, to decrease chance of CA dilation
Giant Cell Arteritis (temporal arteritis)
path population s/s Dx Tx
Large vessel vasculitis
older peoople, 50+y/o, incidence rises with age peak in 70’s. Almost never occurs in younger than 50
s/s scalp tenderness, low grade fever 1/2, headache 2/3, jaw claudication, amaurosis fugax uni/bilateral ->blindness in 25-50%untreated, aortic aneurism, rarely aortic dissection, chronic pain/stiffness shoulders/hips/neck (ie. coexisting polymyalgia rheumatica)
Dx: symptoms as above, elevated ESR/CRP, –> temporal artery biopsy
tx: steroids, high dose then taper for 1 year
Hydroxychloroquine
MOA:
USE:
SE:
MOA: TNF/IL-1 suppressor among other things
USE: SLE, malaria, RA
SE: Retinopathy most common after 5-7 years (ophthamologic testing at baseline and after 5 yrs)
Tx syphilis
dx: RPR/VDRL & antibody test Early 1st line: PCN G 2nd: Tetracycline (like doxy), 3rd: ceftriaxone (poor data, results not great) 4th: azithromycin (poor results)
tertiary/neurosyphilis
PCN G, must desensitize if allergic to pcn.
- *Must desensitize pcn allergic females if pregnant as no other options are good
- *Tx for syphillis if typical chancre even if RPR negative
Are antihistone antibodies seen in idiopathic SLE?
YEs, up to 80% of cases
where are carotid arteries in relation to mouth?
directly posterior and lateral to tonsilar pillars (those folds by the tonsils)
Give dopamine agonist to stop milk production after infant demise?
That would be bromocriptine, but don’t do it, because USFDA said it’s not approved. but yes dopamine -l prolactin production.
so just give NSAID to help poor woman with pain
Pulmonary HTN groups
1) Idiopathic and misc
2) Left heart disease
3) Chronic lung disease (COPD, ILD, chronic hypoxia)
4) thromboembolic occlusion of vasculature
5) multifactorial
Bosentan
MOA
USE
MOA: endothelin receptor antagonist
USE: idiopathic PAH
SE: inhibits spermatogenesis
Sildenafil
MOA
USE
MOA: phosphodieterase-5-inhib
USE: erectile dysfunction, idiopathic PAH,
SE: hypotension, esp with nitrates
Shoulder distocia
When during delivery, after head delivery, anterior shoulder has significant trouple delivering below pubic symphysis.
Where to sympathetic fibers originate on spine?
T1-L2/3
Erb-Duchenne palsy
“waiters tip”: extended elbow (loss of bicep), pronated forearm, flexed wrist/fingers
- brachial plexus injury C5-6 (shoulder distocia)
- grasp reflex intact
- LOSS OF BICEP
klumpke’s palsy
“claw hand”
- wrist extension, supination, mcp extension, pip/dip flexion
- Brachial plexus c8-T1 injury (traumatic birth/pulled out by arm or catching oneself while falling out a tree)
- may have sympathetic injury -> horner’s syndrome
Empiric osteomyelitis treatment children with Sickle Cell disease (microinfarcts in bone => nidus for infection)
In SCD Treat for both Salmonella (2/3 of cases): ceftriaxone Staph aureus (1/4 cases): vancomycin
**IF no SCD, staph aureus is primary bug, salmonella extremely rare.
caudate nucleus atrophy =
lenticulate nucleus atrophy =
diffuse cerebral cortex atrophy =
frontal/temporal atrophy =
caudate = huntingtons lenticulate = wilsons diffuse cerebral cortex = alzheimers frontotemporal = pick's disease PArkinsonism: no good radiographical findings
wilson’s disease (hepatolenticular degeneration)
genetics/pathophys
dysfunctions
Autosomal Recessive: defective cellular copper transport such that copper cannot be excreted in bile duct -> build up copper prominently
liver -> dysfunction & eventual cirrhosis
cornea -> brown/grey-green deposition = kayser-fleischer rings
brain -> psychiatric disturbances, parkinsonism, tremor, dysarthria… various
labs: low serum ceruloplasm, high serum copper,
tx: D-penicillamine (chelator)
second generation antipsychotic greatest agranulocytosis/leukopenia risk
clozapine
corrigan pulse
“water hammer”, from aortic regurge, wide PP,
rapid upstroke and downstroke of pressure
medical abortion regimen
mifepristone (progesteron antagonist) followed 24-48hrs later by misoprostol (prostaglandin E1 -> uterine contraction)
+- antibiotic ppx (doxycycline)
progesterone as contraceptive
- prevents ovulation as plan B by -l LH surge.
- Long term (as OCP) increases cervical mucous (barrier to sperm entry)
*Plan B = levonorgestrel
pleurodesis
medical obliteration of pleural space
tickborne paralysis vs guillane barre
ticks: ascending paralysis hours-days, not necessarily symmetrical, no prodrome, hyporeflexia, no autonomic dysfunction, normal CSF. ticks must feed 4-7 days and then release a neurotoxin (find them and remove them!)
guillane barre: ascending paralysis, symmetric, mostly normal sensation, hyporeflexia, CSF with high protein but few cells (may not show early but 90% prevalence by 1 week) = albuminocytologic dissociation, prodromal illness, autonomic dysfunction (tachycardia, urinary retention, arrhythmias).
Tx: IVIG OR plasmapheresis. they are equivalent in efficacy
multiple causes: CAMPYLOBACTER most common, cmv, ebv, IN general often URI’s or GI illnesses.
primary dermatomyositis; polymyositis
commonalities/presentations
s/s
labs
antibody
-symmetrical/increasing proximal muscle weakness (difficulty getting up from seated/climbing stairs/carrying groceries)
-elevated muscle enzymes: CK, aldolase, LDH, AST
-anti-jo-1
(also anti Mi-2)
-electromyography abnormalities
valgus vs varus
L in valgus = lateral movement of distal part
varus would be medial movement
choanal atresia
congenital nasal malformation where the posterior part of the nasal passages do not canalize completely.
- cyanotic/distressed while feeding
- improve with crying (breathing through mouth)
phenelzine
MOA
USE
SE
MOA: monoamine oxidase inhibitor (MOI), prevents breakdown of monoamines (epi, dopamine, seratonin)
USE: depression
SE: tyramine (wine, cheese, cured meats, aged things) metabolism is inhibited by MOI’s. tyramine is a sympathomimetic that can facilitate release of other monoamines –> HYPERTENSIVE CRISIS
-hypotension as SE -> tx with phentolamine/nitroprusside
heliotrope rash (around eyes) and gottrons papules (over joints)
both nearly pathognomonic for dermatomyositis
they are violacious, scaly
Edwards syndrome
genetics
s/s
Trisomy 18, “Election age is 18” and you watch Edwards scissor hands (with clenched hands/overlapping fingers)
s/s mental retardation, rocker bottom feet, vsd/congenital heart issues, micrognathia (small jaw), CLENCHED HANDS, PROMINENT OCCIPUT, LOW SET EARS. Death usually by 1years old but some live into school age.
*most common trisomy resulting in live birth after trisomy 21
Patau’s syndrome
genetics
s/s
Trisomy 13, puberty at age 13
s/s rocker bottom feet, sever mental retardation, congenital heart disease, cleft liP/Palate, holoPROSENCEPHALY, POLYDACTYLY
death usually by 1 year
Digeorge syndrome
genetics
s/s
CATCH-22
microdeletion chromosome 22q11
Cleft Palate, Abnormal facies, THYMIC APLASIA -> Tcell deficiency, Cardiac defects (truncus arteriosus, tetrology of fallot, transposition, asd/vsd), HypoCALCEMIA (second to parathyroid aplasia)
- normal to impaired cognition. may live to adulthood
- aberrant 3rd/4th branchial puches
congenital infection: rubella neonatal manifestations
PDA (or pulmonary artery hypolasia), cataracts, deafness
commonality with others
+- blueberry muffin rash
hepatosplenomegally
jaundice
congenital infection: toxoplasma gondii manifestations
chorioretinitis, hydrocephalus, intracranial calcifications
commonality
muffin rash
hepatosplenomegally
jaundice
first line tx OCD
1) SSRI
+ CBT
ESR points
increases with age
upper limit normal roughly = age/2 in men
(age+10)/2 in women
CKD, particularly ESRD elevates ESR, as does obesity and anemia
most common cause of hip pain in children
transient synovitis
most common ages 3-10
Etiology: unknown, but commonly post viral/mild trauma
*Rule out: bony lesions/fx/legg-calve-perthes with plain radiographs
Tx: NSAID/rest -> recovery in 4 weeks
contrast to septic arthritis by inflammatory/infectious markers and FEVER
Legg-calve-perthes disease
what is it?
s/s
Syndrome of idiopathic avascular necrosis (osteonecrosis) of hip in children
s/s acute or insidious hip pain/limp usually between ages 3-12
tx: difficult hah!
kleptomania tx
CBT \+- SSRI's lithium naltrexone anticonvulsants
DM1 onset
Bimodal, most in age 4-6 and then at puberty
threatened abortion defenition
any vaginal bleeding prior to 20weeks with a closed cervix/os, and an alive fetus
- inevitable abortion is one with an open cervix, vaginal bleeding, often with visualization of products of conception
- incomplete has products of conception within cervical canal/vagina.
- missed abortion is one in which there is fetal demise cervical os is closed
inevitable, incomplete, and missed abortion can all be managed with similar efficacy with expectant management, medical (misoprostol), or D&C
stillbirth = miscarriage at 20+ weeks
hyposthenuria
Inability of kidneys to concentrate urine.
*such as occurs in sickle cell disease/trait when sickling of cells in vasa rectae of inner medulla injures and subsequently impairs countercurrent exchange and free water absorption.
winters formula
*you idiot
metabolic acidosis: PaCO2= 1.5 (bicarb) + 8 +- 2
Metabolic alk (not winters) PaCO2= .9(bicarb)+16 +-2
argatroban
direct thrombin inhibitor
fondaparinux
direct thrombin inhibitor
HIT
when presents?
concern?
After 5+ days of therapy, usually 5-10
antibodies to neoantigen (from platelet factor 4 interaction with Heparin) attack platelets
->thrombocytopenia 50% or more
-> procoagulable state: skin necrosis, venous > (Greater than) arterial thrombosis
*heparin potentiates ATIII -> inactivates thrombin (& FIX, X, XI, XII)
DLCO in asthma vs bronchitis
*also whats a positive bronchodilator challenge in PFT
DLCO normal/increased in Asthma, normal (bronchitis)/decreased(emphysema) in COPD
+challenge is FEV1 improvement 12% or more, and 200+mL
Asthma will usually have a + bronchodilator test with complete reversability, COPD may respond, but not completely
legionella pneumonia
syndromes:
dx/imaging
tx:
aerosol transmission from environmental water sources, no person to person.
syndromes:
- CAP/HAP
- legionaires: pneumonia, fever, GI (N/V/D), lethargy, HA
- pontiac fever: mild flu-like syndrome
Dx:
- sputum clt AND urine antigen test
- xray: interstitial pneumonia
- hyponatremia
tx: macrolide (azithro) or quinolone (levofloxacin)
venous vs arterial thrombosed extremity
venous: warmth, swelling, tenderness, erythema
arterial: mottled, cold, no swelling, pulseless
brief psychotic disorder
psychosis for one or more days, less than one month
- schizophrenoform is 1-6months
- schizophrenia timeframe must be six months or more
Amiodarone toxicity
Cardiac: sinus Brady, AV block, proarrhythmia-QT prolongation and risk of torsades
Pulmonary: chronic interstitial pneumonitis & pulmonary fibrosis, can occur from as little as 2 days, and up to year after use (half life up to like half a year, lipophillic)
Endocrine: hypo/hyperthyroid
Hepatic: elevated transaminases/hepatitis
ocular: optic neuropathy, corneal microdeposits
Derm: blue-grey skin
neuro: peripheral neuropathy
- 50% on long term amio will develop significant side effects
- *1/5 will discontinue drug due to toxicity
vaccination schedule for preterm infants
vaccinate by chronologic, not gestational age.
Allergic interstitial nephritis
a subset of acute interstitial nephritis
cause?
s/s
labs
tx:
Usually caused by medications 5days to weeks after exposure, less commonly by infection
- NSAIDs
- PCN (nafcillin)
- cephalosporin
- TMP-SMX
- diuretics
s/s maculopapular rash, fever, +- arthrlgias
labs: hematuria, mild proteinuria, WBC casts, eosinophilia, urinary eosinophils
tx: discontinue offending agent, +- steroids
follicular vs papillary carcinoma of thyroid
follicular carcinoma: encapsulated, invades through capsule and into blood vessels (vs the adenoma) -> brain, bone, lung
papillary carcinoma: non-encapsulated, psammoma bodies… good prognosis
P450 inducers/inhibitors
INDUCERS (decrease bleeding risk)
*momma barb steals phen-phen and refuses greasy carbs chronically
-modafinil (stimulant/shift work), barbituates, st.john wart, phenytoin, rifampin (tb), griseofulvin (antifungal), carbamazepine, chronic alcohol use
+ginseng
INHIBITORS (increase bleed risk as increased coumadin lvls)
MAGIC RACKS GQ
-macrolides (not azithro), amiodarone, grapefruit juice, isoniazid, cimetidine (H2blocker for GERD), ritonavir, acute alcohol abuse, cipro, keoconazole, sulfonamides, gemfibrozil (fibrate), quinidine,
+NSAIDS, ACETAMENOPHEN, OMEPRAZOLE, SSRI, Thyroid supplementation, vitamin E
Adenosine MOA
inhibit L type calcium channels, decreasing conduction velocity at AV node -> av block
Nitroglycerine
MOA
USE
SE
onset
duration
MOA: ->NO, peripheral venous greater than artery dilation. primarily reduces myocardial O2 demand by decreasing preload, but also has coronary dilatory effects (which may cause paradoxical decreased perfusion pressure across stenotic lesions bc they are already maximally dilated), modest afterload effects.
USE: angina, ACS, CHF
SL
onset: 1-3min, peak 7min
duration: 25min+
IV
onset: immediate
duration: 3-5min
SE: hypotension !!! no Phosphdiesterase inhibs! (sildanefil, vardenafil, tadalifil)
*preload reduction -> decreased EDV/ESV
chlordiapoxide
MOA
USE
aka. librium
MOA: benzodiazapine
USE: alcohol withdrawal
promethazine
MOA
USE
trade: phenergan
MOA: H1 blocker AND Dopamine blocker (phenothiazine)
USE: antiemetic, motion sickness
clonidine
MOA
USE
MOA: alpha 2 agonist, involved in negative feedback. stimulates inhibitory neurons -> reduces sympathetic outflow, and certain excitatory neurotransmissions
USE: HTN (esp in renal disease), ADHD,
methadone
MOA:
USE:
MOA: opioid (binds these receptors)
USE: opiate replacement therapy
*It is still a full potent opioid
spinothalamic tract/anterolateral tract
pain, temperature, crude touch
dorsal/posterior column (medial lemniscus)
fine touch, vibration, proprioception
Major depression dx
symptoms majority of time for 2+ weeks 5+ of SIGECAPS, must include one of * sadness* interest loss* guilt energy decrease concentration problems appetite change psychomotor retardation/agitation sleep increase/decrease
mirtazapine
MOA
USe
SE
MOA:atypical, alpha 2 antagonist, noradrenergic, serotinergic, H1 blocker
USE: depression
SE: drowsiness, increased appetite/weight gain
sertraline
Zoloft SSRI
citalopram
Celexa SSRI
paroxetine
Paxil SSRI
granuloma inguinale (donovanosis)
what?
dx:
cause: Klebsiella, transmission by sexual contact with open sores
Genital NONPAINFUL, extensive/progressive ulcerative lesions, NO LYMPHADENOPATHY
dx: (wright giemsa) deeply staining gram negative intracytoplasmic cysts (donovan bodies)
* vs syphillis is single well circumscribed ulcer, nonpainful, bilateral lymphadenopathy, corkscrew by darkfield light microscopy
tx: doxy or azithro
Beçet syndrome presentation
thought to be vasculitis
*painful aphthous ulcers, genital ulcers (painful), systemic symptoms
+uveitis, skin lesions (erythema nodosum, acneophorm lesions), thrombosis, pathergy (exagerated skin response to minor trauma like needlestick -> ulcer)
Tularemia
cause
s/s
Tx
Francisella Tularenesis, gram negative aerobic bacterium. Zoonotic spread (handling rabbits, hamsters, or bit by ticks) also by biting flies, mosquitos
s/s fever, chills, HA, malaise, ulcer(s) at site of bite but can also spread/random, lymphadenopathy
dx:serologic antibodies
tx: streptomycin (aminoglycoside) or ciprofloxacin (qunolone), doxycycline if meningitis
renal insufficiency
is basically CKD/ renal failure
voiding cystoureterogram
how work?
indication?
what can it tell you
contrast injected into bladder -> xray during filling/voiding-> see if there is reflux
Indication in children if 2+ febrile UTI’s or a UTI with organism other than E. Coli. 25% children w/first UTI have VUR
tells you if: VUR primarily, but show bladder shape/emptying/posterior urethral valve in males… not as helpful with say… urinary stasis
ecthyma
impetigo that penetrates into the dermis and causes ulceration with scab looking on top
molluscum contagiosum
poxvirus
flesh colored papules, central umbilication, SPARES palms/soles
+- pruritic, nonpainful
tx: none, self-limited
IF infant gets HSV, what then?
may be life threatening -> systemic acyclovir
wernicke’s encephalitis
what?
tx?
- thiamine (B1) deficiency
- eyes (primary horizontal nystagmus/conjugate gaze palsy/oculomotor dysfunction), lies (confabulation/encephalopathy), capsize (ataxia)
- glucose & thiamine
disorder of internuclear ophthalmoplgia, affects what?
medial longitudinal fasciculus (MLF) damage, common in Multiple Sclerosis. This occurs because CNVI directs the lateral rectus on the ipsilateral side, then sends information to CN III nucleus via the MLF to the contralateral medial rectus. When MLF damaged, you won’t get the medial rectus to move.
sheep parasitic transmission
echinococcus (tapeworm) -> invade hematologically through intestines -> liver/pulmonary, and other visceral invasion -> see cysts on imaging (especially common in liver)
neurocysticercosis
from pigs
by taenia solium (tapeworm)
-most carriers of tapeworm do not develop cysticercosis, it is human fecal->oral transmission with the eggs that leads to this. Ingestion of the meat only gives you intestinal tapeworm.
s/s seizures, hydrocephalus, may infect muscle/SQ tissue which is largely asymptomatic, ocular (pain, diplopia)
tx:albendazole
breastfeed after alcohol timeframe
2-3hrs
galactosemia
enzyme deficiency/defect (galactose-1-phosphate-uridyl transferase GALT), infants cannot breastfeed. Usually present in first few days with jaundice, vomiting, hepatomegally, failure to thrive, lethargy, hypotonia, cataracts.
osgood-schlatter disease
apophysitis of the tibial tubercle, typically overuse/adolescent inflammation of patellar tendon/apophysis
apophysis is a secondary ossification center used for tendon insertion
Diamond-Blackfan anemia
(congenital hypoplastic anemia)
genetics
pathology
s/s/labs
genetics: spontaneous/autosomal dominant/recessive
path: defect in erythroid progenator cells which increases apoptosis
s/s webbed neck, shield chest, PALLOR, TRIPHALANGEAL FINGERS, MACROCYTIC ANEMIA (not megaloblastic), LOW RETIC COUNT,
Wiscott-aldrich syndrome
genetics
s/s/labs
X-linked impaired WAS protein gene: impaired cytoskeleton regulation
microthrombocytopenia (may have petechiae/purpura/bleeding), eczema, hypogammaglobulinemia/immunodeficiency
(high IgA and IgE, low normal IgG/IgM) w/recurrent infections
tx:hematopoetic stem cell transplant
Fanconi’s anemia
genetics
s/s/labs
Autosomal recessive
*progressive pancytopenia/macrocytosis
s/s cafe-au-lait spots, microcephaly, microphthalmia (small eyes), short stature, horseshoe kidney, ABSENT thumbs
most common hypertensive cerebral hemorrhages in order
basal ganglia (putamen… which may involve internal capsule), contralateral symptoms, contralat homonymous hemianopsia
cerebellum: ipsilateral ataxia, stiff neck, HA, nystagmus
thalamus: eyes deviate TOWARD lesion, upgaze palsy, nonreactive miotic pupils, contralateral symptoms (internal capsule?)
pons (coma, pinoint reactive pupils)
cerebral cortex: contralateral symptoms, contralateral homonymous hemianopsia (occipital lobe), eyes deviate AWAY
lateral geniculate nucleus
damage will cause contralateral homonymous hemianopsia, it is prior to optic chiasm
- located dorsal thalamus
- as will any damage prior to hitting the optic chiasm (as in optic tract but NOT optic nerve)
bitemporal hemianopsia
damage/compression optic chiasm (as in pituitary tumors or craniopharyngioma)
wernicke’s aphasia
aka receptive aphasia
damage to temporal lobe, usually left
cannot understand spoken/written language, will speak fluently but in “word salad” that doesntt make sense
*if nondominant wernicke’s: sensory dysprosody -> inability to comprehend tone, pitch, rhythm, emotion of speech
broca’s aphasia
aka expressive aphasia
frontal lobe damage, usually left,
can understand, cannot speak well though knows what want to say
reactive arthritis
aka reiters syndrome
- HLA-B27 associated reactive arthropathy
- incited by infection: GU (chlamydia) or GI: shigella (GI/diarrhea/gastroenteritis), salmonella, yersinia, campylobacter, c diff
- “can’t see, can’t pee, can’t climb a tree”
- conjunctivitis, urethritis, arthritis (acute/oligoarthritis)
tx: by cause/symptomatology
cancer arising from chronic wounds/scars/inflammation
called what from burn wound?
SCC
*If from burn = marjolin ulcer
size concern form melanoma
over 6mm
a:asymmetric
b:order irregular
c:olor variation
diameter
evolution
kaposi sarcoma
HHV 8 and HIV, angioproliferative, brown/violacious
hepatojugular reflux definition
constant pressure on upper abdomen elicits over 3cm jvd elevation that is sustained during applied pressure
= right heart failure
how often US for cirrhotic liver?
every 6 months
