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medicine 2

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major risk factors


for atherosclerotic
heart disease

DM
Hyperlipidemia
hypertension
cigarette smoking
Age >45 M, >55 F
family history of MI at young age
high LDL level

CAD prognostic
factors

LVF EF<50%
left main
two or three vessel diseases

1. clinical
presentation of
stable angina
2. dx:
3. what to do with
patients with
positive stress or
echo

1. gradual onset chest or substernal


pain brought on by inc. myocardial
demand* (exertion/emotion)
relieved with rest or nitroglycerin
NO CHEST WALL TENDERNESS
NO CHANGE WITH POSITION
2. normal PE/ECG
*stress test- (HR to 85% max (220age))
-->subendocardial ischemia (ST
depression on ECG)
*stress echocardiography- shows wall
motion abnormalities- akinesis or
dyskinesis
3. cardiac catheterization

what is the
advantage of stress
echo vs stress ECG

LV size/function
dx. valvular disease
identifies CAD
* if positive -->cardiac cath

what is a positive
stress test

If during a stress test the patient


experiences:
ST depression
chest pain
hypotension
arrhythmias

metabolic syndrome
X

WE = waist expanded (>35in F, 40in


M)
IG = impaired glucose (>110mg/dl)
H = hypertension (BP >130/85)
H = HDL low (<50mg/dl F, <40mg M)
H = hyperurecemia
T = TGs > 150mg/dl
D: DM

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3
INSULIN RESISTANCE 2/2 OBESITY
-->
hypercholesterolemia/low HDL
hypertriglyceridemia - >150
impaired glucose tolerance >110
diabetes
hyperuricemia
HTN

syndrome X

exertional angina with normal


coronary arteriogram
stress test shows evidence of ischemia

indications for
stress ECG

confirm angina DX
evaluate therapy response in CAD pts
identify pts with CAD

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types of stress test

* get the HR up to 85% (220age)


exercise tolerance test
(ST segment depression)
exercise or dobutamine
echocardiogram (wall motion
abnormalities)
exercise or dipyridamole
(dec. uptake of thallium isotope
in ischemic area during
exercise)

how does
dipyridamole/adenosine
work for pharmacologic
stress test

cause generalized coronary


artery dilation
*diseased coronaries are already
maximally dilated so under
dipyridamole/adenosine they
receive relatively less blood

holter monitor
1. use

1. detect silent ischemia,


evaluating arrhythmias, monitor
pacemakers, evaluate
unexplained syncope/dizziness

Cardiac catheterization
1. info gathered
2. coronary
angiography/PCI/CABG
eval
3. indications for
cardiac cath

1. hemodynamics (CVP, PCWP,


SVC, CI), intracardiac pressure,
CO, oxygen saturation
2. performed during cath,
visualizes the coronaries ~~~
can accomplish all of the above
3. positive stress test,
angina with non-diagnostic
non-invasive tests
angina unresponsive to medical
therapy
severely symptomatic
evaluation of valvular disease

coronary angiography
1. info gathered
2. what can be done

1. identifies CAD, delineates


coronary anatomy
2. PCI, angioplasty/stenting,
diagnosis

at what level of coronary


occlusion does angina
occur

>70% occlusion

stress echocardiography
+ follow up with positive
result

echocardiography after exercise


will show akinesis or dyskinesis
~ this is mores sensitive than
ECG to detect ischemia
- follow up with positive result is
CARDIAC CATHETERIZATION

types of stress test

exercise tolerance test


dobutamine echocardiogram
dypyridamole thallium
may also use adenosine

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thallium 201
stress test

use any type of stress test (exercise,


dobutamine, or dypridamole)

give thallium - no
uptake indicates
ischemia

...

secondary
hypertension
1. renal causes
2. endocrine
causes
3. medication
causes
- others include
coarctation,
cocaine, sleep
apnea

1. renal artery stenosis, chronic renal


failure, PKD
2. hyperaldo, thyroid/parathyroid,
cushings syndrome, pheo, acromegaly
3. OCP****, decongestants, estrogen,
steroids, TCA, NSAIDs

HTN effect on
heart

inc SVR --> concentric LVH --> dec


CO/sx of heart failure

what other
conditions
comorbid with
HTN

accelerates atheroscloerosis -->


accelerated CAD and peripheral vascular
disease

what are is the


end organ
damage sites of
HTN

heart - LVH, MI, CHF*, CAD, dissection


Brain - stroke (ischemic/lacunar), TIA
encephalopathy
CKD - nephrosclerosis, arteriosclerosis
dec. GFR
PVD
retinopathy

HTN effect on the


eyes

*early - AV nicking, cotton wool spots=>


hemorrhage and exudates
*papilledema

cutoff for HTN in


general pop vs
diabetics

general - 140/90
diabetics/renal disease - 130/80

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cardiac
complications of
HTN

CAD, CHF, MI, PVD, aortic dissection

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CNS
complications of
HTN

intracerebral hemorrhage, TIA,


ischemic stroke, lacunar stroke (2/2
small vessel hyalinosis +
microatheromas)

renal
complications of
HTN

arteriosclerosis of afferent/efferent
arterioles and glomerulus
(nephrosclerosis)

what labs to
evaluate target
organ damage in
HTN

urinalysis
BMP (K/BUN/Cr)
Fasting glucose
lipid panel
ECG

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when is a drug needed to treat


hypertension

stage 1 or greater- patient


should be treated with
lifestyle + drug

stage 2 - lifestyle modification


and 2 drug como

...

pre-hypertension just treat


with lifestyle modification

...

lifestyle modifications for HTN

no-added salt or lowsodium diet


weight loss
avoid alcohol (pressor
action)
regular aerobic exercise
low sat fat, lots of fresh
produce
stress management

best treatment for African


Americans with hypertensino

thiazide diuretics (b/c


they usually have saltsensative HTN)
BUT* if there is also
diabetes, ACE is best
choice

why are ACE inhibitors


prefered to treat HTN in
diabetic patients

ACE inhibitors have a


protective effect on the
kidneys

drug choices to treat HTN

thiazides
beta blockers
ACE
ARB
CCB
alpha blockeres
vasodilators
(hydralazine/minoxidil)q

what patients is alpha blockers


useful to treat HTN

those who have both


HTN and BPH

treatment of refractory HTN

vasodilators
(hydralazine, minoxidil)
+ beta blockers +
diuretics

what is the goal BP in patients


with HTN

135/85 minimum goal for


patients with diabetes or
renal disease

what is first important test


before starting an
antihypretensive drug on a
woman

pregnancy test
contraindicatedthiazides, ACE, CCBs
Safe - Beta blockers,
hydralazine

which antihypertensives are


associated with decreased risk
of new-onset diabetes

ACE and ARB

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side effects of antihypretensive agents


1. thiazides
2. beta blockers
3. ace inhibitors

1. hypokalemia, hyperuricemia,
hyperglycemia,
hypertriglyceridemia, met.alk,
hypomagnesemia
2. bradycardia, bronchospasm,
insomnia, masked
hypoglycemia
3. dry cough, ARF,
hyperkalemia, rash, altered
taste

cardiovascular risk
factors

smoking, diabetes, DM,


hypercholesterolemia,
HDL<35
age>60, male, HTN, family
history

1. screening for
hyperlipidemia
2. effect of high dietary
sat.fat on lipid panel
3. effect of high calorie
on lipid panel
4. effect of alcohol on
lipid panel

1. every 5 years starting at age


20 with a fasting lipid profile
2. increases LDL and
cholesterol
3. increase TG
4. increase TG and HDL

1. age effect on
cholesterol
2. thiazides effect on
lipid panel
3. beta blockers ""
4. estrogens ""
5. corticosteroids and
HIV proteases ""

1. 2mg/dL per year increase


2. inc. LDL, cholesterol, TG
3. inc TG, dec. HDL
4. inc. TG
5. elevates serum lipids

1.goal levels for


cholesterol, LDL,
triglycerides
2. LDL goal for diabetic
3. LDL goal for diabetic
and CAD
4. HDL goal

1. <200 cholesterol
<130 LDL
<125 triglycerides
2. <100
3. <70
4. >60, every inc. in 10 HDL
lowers CAD by 50%

physical symptoms of
hyperlipidemia

usually asymptomatic....
xanthelasma
xanthoma
pancreatitis

what other labs should


be ordered to rule out
secondary
hyprelipidemia

TSH - hypothyroidism
LFTs - chronic liver dz
BUN/Cr - nephrotic syndrome
glucose level - comorbid
diabetes

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what labs must be


ordered when starting a
patient on statins and
fibrates

LFTs

what effect can dietary


therapy have on LDL

drop LDL by 10%

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statins
1. effect on lipid panel
2. side effects
- only lipid drug that
reduces mortality,
first line**

1. lowers LDL
2. monitor LFTs, may be CPK
elevation

niacin
1. effect on lipid panel
2. what patients
should not use niacin
3.

1. lowers TG, lowers LDL, inc.


HDL
2. diabetic patients- may worsen
glycemic control
3. flushing, check LFT, CPK

cholestyrine/colestipol
1. effect on lipid panel
2. SE

1. lowers LDL and TH


2. bad taste, GI side effects

fibrates
1. effect on lipid panel
2. SE

1. lowers TG, VLDL, inc. HDL


2. mild LFT, gynecomastia,
gallstones, weight gain

how to treat high TG

exercise/diet, nicotinic acid,


fibrates, fish oil +/- statins

tension headache
1. clinical pres
2. tx

1.worsens throught the day,


precipitated by stress/depression,
aching, viselike pain that is band
like around head +/- tender
muscles in posterior neck
2. NSAIDs, acetaminophen, or
migraine medications

emergency headache
evaluation

non-contrast CT, +/- LP because


CT may miss small bleeds

cluster headaches
1. clinical pres
2. tx

1. episodic lasts - 2-3 months with


remission
chronic cluster - last 1-2 years
*excruciating unilateral periorbital
pain "deep, burning, stabbing,"
ipsilateral lacrimation, flushing,
nasal stuffiness, ipsilateral
horners syndrome
2. 100% O2 inhalation (acute) ***
prednisone 40mg for several weeks
to abort the headache
sumatriptan,
prophylaxis: verapamil (best for
cluster), or carbamazepine
alternatives: ergotamine,
methysergide, lithium (for chronic
form), corticosteroids

migraine
1. clinical pres

1. hormone changes, stress,


sleeping disturbance, drugs/foods->
a. prodrome - elation, inc. appetite
or depression/sleepiness
b. severe throbbing unilateral
headache 4-72 hours, throbbing,
dull or achy, photophobia, inc.
sens to smell

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migraine
2. tx
3. prophylaxis

2. NSAIDs or acetaminophen, DHE


(5HT1 ag.)., sumatriptan (selective
5HT1 ag.)
3. TCA, beta blockers***, CCB,
valproate, methysergide, NSAIDS
(menstrual migraines)

1. DHE
contraindications

1. CAD, pregnancy, TIA, PVD, sepsis


2. CAD, pregnancy, uncontrolled HTN,
basilar artery migraine, hemiplegic
migraine, MAOI, SSRI, lithium

rebound analgesic
headaches

occur every 1-2 days, do not respond to


migraine medications

what does
migraine that
does not resolve
with medications
indicate

probably not a migraine

cough
1. acute cough
causes
2. chronic cough
causes
3. dx
4. tx

1. <3 weeks, URI


2. pneumonia, COPD, fibrosis, cancer,
asthma, abscess, TB, pulmonary edema
3. CXR (if pulmonary cause,
hemoptysis, chronic cough)
4. stop smoking,
antihistamine/decongestant, abx
anti-tussives - codeine, DXM, benzoate,
guaifenesin

1. causes of cough
in patients with
normal CXR`

1. smoking, postnasal drip (URI,


rhinitis, sinusitus), GERD, Asthma,
ACE

what features of
URI indicate
bacterial origin

yellow sputum*
fever and cough
NO headache, myalgias, or rhinorrhea

acute bronchitis
1. clinical pres
2. dx
3. tx

1. cough 1-2 wks up to 1 month, cx pain,


SOB, +/- fever
2. clinical dx - no CXR,
3. no abx, cough suppressants,
bronchodilators

rhinosinusitis
1. patho
2. clinical pres
3. tx

1.hand-hand contact --> MCC URI rhinovirus, corona virus, PIV,


coxsackie, RSV, adeno
2. 10-14 days rhinorrhea, sore throat,
malaise, non-productive cough, nasal
congestion, fever in children (adults
indicates bacterial complication)
3. hydration, rest/analgesics (NSAIDs),
DXM/codeine, neo-synephrine spray
<3 days (affrin), antihistamines

what is
distinguishing
features between
rhinosinusitis vs.
influenza

influenza has more pronounced fever,


headache, myaligas

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acute
sinusitis
1. clinical pres

1. >10 days, prolonged nasal stuffiness,


purulent discharge, cough, sinus
pain/pressure worse with bending head
down/percussion, fever,
maxillary - cheek pain
frontal - lower forehead pain
ethmoid - retro-orbital pain/lateral nose

acute
sinusitis
1.
pathogenesis

1. common cold/polyps/deviated
septum/foreign body --> inflammation of
paranasal sinuses, obstruction of sinus
ostia, trapping of secretions--> s.pneumo, h.
flu, moraxella, anerobes

acute
sinusitis
1. dx
2.
complications
3. tx

1. purulent drainage from turbinates,


transillumination, palpation, sinus
radiographs, CT head
2. mucocele, polyps, orbital cellulitis,
osteomyelitis of frontal/maxilla, cavernous
sinus thrombosis, meningitis, brain abscess
3. saline spray,
pseudoephedrine/oxymetazoline,
amoxicillin, amox-clavulanate, TMP/SMX,
levofloxacin, moxifloxacin, cefuroxime
2nd gen antihistamines - loratadine,
fexofenadine
nasal steroids - fluticasone, beclomethasone

chronic
sinusitis
1.
pathogenesis
2. clinical
pres

1. staph aureus, gram negative rods -->


2. nasal congestion, post-nasal discharge,
pain/headache >2-3 months.

laryngitis
1. patho +
clinical pres
2. treatment

1. viral, moraxella, h.flu --> hoarseness +/URI symptoms


2. self limiting

sore throat
1. patho
2. which can
cause
exudative
tonsillitis
3. dx/tx

1. adeno, PIV, rhino, EBV, HSV,


s.pyogenes*, chlamydia, mycoplasma,
gonococcal, EBV, coryne.dip, candida -->
2. EBV, c.dip, s.pyogenes, candida
3. dx - throat culture, rapid strep, monospot
tx - penicillin, erythromycin, viral, EBV
(dont give amox)

treatment for
EBV
pharyngitis

acetaminophen, ibuprofen
NOT amox

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dyspepsia
1. patho +
clinical pres
2. dx
3. when to do
endoscopy for
dyspepsia

1. GERD, PUD, functional dyspepsia, (90%)


gastritis, hepatobiliary, pancreatic,
esophageal spasm, DM gastroparesis, IBS, -> epigastric symptoms , heartburn, bloating,
nighttime awakening,
2. response to empiric therapy, endoscopy,
h.pylori stool antigen/urea breath test
3. weight loss, anemia, dysphagia,
obstruction, upper GI bleeding, nonresponders to empiric therapy,

dyspepsia
1. tx

1. avoid alcohol, caffeine, smoking, raise


head of bed, avoid eating before sleep
H2 blockers, PPI, endoscopy , h.pylori
treatment

peptic
stricture
clinical
presentation

dysphagia and GERD

GERD
1.
pathogenesis
2. clinical
pres

1. inappropriate relaxation of LES, dec.


esophageal motility, gastric outlet
obstruction, hiatal hernia
2. heartburn, dyspepsia (retrosternal burning
after large meals)
regurgittation
waterbrash -reflex salivary hypersecretion
chronic cough
hoarseness, sore throat
early satiety, post-prandial n/v

complications
of GERD

erosive esophagitis, barrett's, peptic


strictures, esophagitis, aspiration
pneumonia (lipid laden macrophages),
dental erosion,

diagnosis of
GERD

24 hour esophageal monitor, Upper GI series


(barium contrast)
endoscopy with biopsy (if refractory)
esophageal manometry

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when to
screen for
barrett's
esophagus

after 5 years of symptomatic GERD

GERD
treatment

behavior -avoid fatty foods, smoking,


alcohol, orange juice, chocolate,
H2 blocker
PPI
promotility agent - metoclopramide
(dopamine antagonist), bethanechol
nissen fundoplication (for stricture,
intractability, hemorrhage, stricture,
barrett's)

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acute diarrhea (2-3wks)


1. patho
2. common viral pathogens
3. common bacterial
infections
4. common parasites
infections
5. pathogens in
elderly/immunosuppressed

1. viral, bacteria, parasites,


food poisoning
abx (c.diff),
malabsorption
Ischemic bowel disease
2. norwalk virus, rotavirus,
calicivirus, astrovirus,
enterovirus
3. watery - ETEC, staph
aureus, c.perfringens
bloody - shigella,
campylobacter, salmonella,
EHEC
4. giardia lamblia,
entamoeba histolytica,
cryptosporidium
5. MAC, cryptosporidium,
cyclospora, CMV

chronic diarrhea
1. patho
2. pathogens that can cause
chronic diarrhea

1. IBS, IBD, medications,


bacterial, colon cancer,
diverticula, celiac, panc.
insuff, short bowel, bacterial
overgrowth, post surgical,
hyperthyroid, addisons,
diabetes, gastrinoma,
VIPoma, laxatives
2. shigella, salmonella,
campylobacter, EIEC

important questions for


patient with diearrhea

blood/melena
other assc. sx
sick contacts/travel
assc. with certain foods
other medical problems
(AIDS etc)
recent med changes

acute diarrhea
1. lab tests for suspicious
cases (chronic, severe
illness/fever, blood, IBD
suspicion, volume
depletion)

1. CBC
(anemia/leukocytosis)
stool sample - #1 fecal
leukocytes/culture
c.diff toxin (treat empirically
if suspicious),
ova/parasites, giardia
ELISA,
stool culture - very low
sensitivity dont order
routinely (only detect
shig/salm/camp)
flexible sigmoidoscopy with
bx

1. which causes of diarrhea


have fecal leukocytes
2. what electrolyte
abnormality with diarrhea

1. campylobacter,
salmonella, shigella, EIEC,
c.diff
2. hypokalemic met alk.

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acute diarrhea
1. when to
hospitalize
2. tx

1. dehydration, PO intolerance, profuse


bloody diarrhea, high fever/toxic
2. stop cause (abx or food), rehydrate,
monitor electrolytes, loperamide
5 day course of ciprofloxacin - if bloody,
severe, + stool culture, traveler diarrhea
c.diff- metronidazole

constipation
1. patho
2. what meds
cause
constipation
3. what
neuromuscular
causes ""

1. diet (fiber), meds, IBS, obstruction,


ileus, hemorrhoids/fissures, hypothyroid,
hypercalcemia, hypokalemia, uremia,
dehydration, neuromuscular disorders,
congenital
2. anticholinergics, antidepressants,
narcotics, iron, CCB, aluminum/calcium
antacids,
3. parkinsons, MS, CNS lesions,
scleroderma, DM

constipation
1. dx
2. complications
of chronic
constipation
3. tx

1. H&P, abdoinal films, TSH, serum


calcium, CBC, electrolytes, r/o
obstruction!, rectal examination
radio-opaque marker transit, anorectal
motility study
2. hemorrhoids, rectal prolapse, anal
fissures, fecal impaction
3. inc. physical activity, inc. fiber/fluid,
enema, surgery

see page 450 for


list of all
diarrhea

.............

irritable bowel
syndrome
1. patho +
clinical pres
2. dx
3. tx

1. depression, anxiety, somatization -->


abnormal resting activity of the bowel >3
months --> diarrhea, constipation,
cramping relieved by defecation,
bloating/distention
2. diagnosis of exclusion use dx
modalities for diarrhea
3. loperamide/diphenoxylate,
colace/psyllium/cisapride, tegaserod
maleate (serotonin agonist)

nausea/vomiting
1. patho
2. bilious,
feculent,
undigested,
projectile

1. viral/food, preg, DKA, addisonian


crisis, uremia,electrolyte, PUD, GERD,
SBO, ileus (hypercalcemia/hypokalemia),
hyperthyroid, pancreatitis, appendicitis,
pyelo, chole,
MI, cisplatin/chemo, digitalis*,
erythromycin/abx,
2. bilious - obstruction distal to vater
feculent - distal intestinal obstruction,
bacterial overgrowth, gastrocolic fistula
undigested - esophageal problem
projectile - inc. ICP, pyloric stenosis

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nausea/vomiting
1. dx
2. tx.

1. CBC, electro, LFT, B-HCG,


abdominal films upright/supine
(r/o obstruction).
2. self limiting, rehydration with
1/2 normal saline,
prochlorperazine, promethazine,
avoid large fatty meals,

hemorrhoids
1. external vs internal
2. causes
3. clinical pres

1. external = inferior hemorrhoidal


plexus
internal = superior rectal plexus
2. constipation, pregnancy, portal
HTN,l obesity, prolonged
sitting/standing
3. bleeding/rectal prolapse, BRB
per rectum,
external - painless unless
thrombosed
internal - painless mass when they
prolapse

hemorrhoids
1. tx

1. sitz bath, stool softeners to


reduce strain, high fiber, high fluid
diet, topical steroids, rubber band
ligation, surgical
hemorrhoidectomy

lower back pain


(acute >4 wk, chronic
>12 wk)
1. risk factors
- 90% of patients with
lumbar
herniation/sciatica
improve with
conservative care

1. smoking, obesity, old age, low


edu, workers comp, dissatisfaction,
psychological factors (depression,
anxiety)

1. what exacerbates
disc herniation pain
2. what exacerbates
spinal stenosis pain

1. coughing/sneezing increase
intraspinal pressure
forward flexion, sitting, driving,
lifting
2. standing, walking, relieved by
bending or sitting (walking on a
shopping cart)

cauda equina
syndrome
1. patho
2. clinical pres
3. treatment

1. severe stenosis of the lumbar


spine 2/2 disc herniation
2. leg pain, bladder dysfunction
(retention/incontinence), saddle
anesthesia
3. immediate MRI, surgical
emergency

1. spondylolisthesis
2. lumbar herniation
clinical pres.
3. lumbar disc
herniation treatment

1. forward slippage of cephalad


vertebrae at L4-L5, L5-S1
2. radicular leg pain/back pain
3. anti-inflammatory, physical
therapy, epidural steroid, early
mobilization,
ONLY MRI AFTER 4-6 WEEKS OF
CONSERVATIVE TREATMENT

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spinal stenosis
1. patho
2. clinical pres
3. dx/tx
**differentiate from
arterial claudication
by checking pulses

1. degenerative changes (facet


osteophytes/ligamentum flavum
hypertrophy) --> narrowing of
spinal canal
2. neurogenic claudication radicular or buttock pain, cramping,
numbness, paresthesias- relieved by
sitting, worse with
walking/standing
3. good distal pulses, straight leg
test negative
epidural steroid injections

musculoligamentous
back strain
1. patho

1. bending/twisting --> back "gives


way" --> radiation to buttock/upper
posterior thigh/knee due to muscle
spasm

imaging in back pain

what is seen on MRI/X Ray does not


necessarily correlate with what the
patient experiences
*psychosocial variables have a
higher correlation

vertebral
compression
fracture
1. patho
2. tx

1. acute back pain from minor stress


in elderly patients or pts on long
term steroids pain @ level of fracture
2. bracing, analgesics,
kyphoplasty/vertebroplasty,

physical exam test


for radiculopathy

straight leg raise positive at 30-60


degrees with the patient supine

spine pain
1. when to get
imaging/MRI

1. no imaging until 4-6 weeks of


symptoms, or prog. neuro deficits,
disability sx, osteoporosis, hx of
malig, constitutional sx, recent
trauma, IVDU
when patient has failed
rest/PT/NSAIDs for >3 mo

acute lower back


pain
1. tx

1. AVOID PROLONGED
INACTIVITY, ATTEMPT WALKING
ROUTINE
NSAIDS, acetaminophen, activity
modification, slow return to
activities
PT if above fails
surgery if >1 year of failed
conservative tx

1. clinical
presentation of
cervical spondylosis
2. MCC acute neck
pain

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115.

116.

1. axial neck pain, cervical


radiculopathy, cervical myelopathy
2. cervical strain
117.

cervical
radiculopathy
1. patho +
clinical pres
2. dx/tx

1. spondylosis, herniation, impingement,


carpal tunnel, cubital tunnel, thoracic
outlet, zoster, pancoast tumor -->
compression of spinal nerve --> arm
pain, numbness, tingling, weakness,
unilateral neck pain
2. dx = MRI of cervical spine
tx = NSAIDs, time, PT, epidural
injections

cervical
myelopathy
1. patho +
clinical pres

1. cervical stenosis --> spinal cord


compression - unsteady gait, loss of
hand dexterity, cane/walker use
2. surgical decompression

evaluation of
gait
unsteadiness in
an elderly
patient

always consider cervical


stenosis/cervical myelopathy and order
an MRI

how to
differentiate
shoulder
impingement
(C5
radiculopathy)
from cervical
stenosis

relief when inject subacromial space


with cortisone

causes of
arthritis

osteoarthritis,
systemic autoimmune disease - RA, SLE,
IBD, psoriatic arthritis
crystal arthropathies
infectious - septic arthritis/lymes disease
trauam
chargot joint
congenital - hip dysplasia, legg-calve
perthe, SCFE
sickle cell, hemophilia (recurrent
hemarthrosis)
wilsons, hemochromotosis

patellofemoral
pain
1. clinical
presentation
2. tx

1. pain worse with stair


climbing/descending,
2. PT focuses on quads/hamstring rehab

meniscal tears
1. dx
2. tx

1. knee effusions, tenderness along


medial/lateral joint lines,
McMurray+
2. arthroscopic meniscectomy or repair

osteochondritis
dissecans
1. patho +
clinical pres
2. tx

1. necrotic area of bone and degeneration


of the overlying cartilage leadign to a free
body in the joint space --> catching,
popping, pain
2. arthroscopy with removal of fragment

118.

119.

120.

121.

122.

123.

124.

125.

126.

causes of
acute
monoarticular
arthritis

septic
disseminated gonorrhea
gout/pseudogout
rheumatic fever
lymes disease
seronegative spondyloarthropathy

bakers cyst
1. patho

1. intra-articular pathology (RA, OA) -->


cyst formation (MCC popliteal fossa -->
rupture that causes pain/swelling
extending into the calf
when they burst they MIMIC thrombophlebitis
(pseudothrombophlebitis), DVT

patellar
tendinitis
1. patho
2. tx

1. jumpers knee- anterior knee pain in the


inferior pole of the patella
tx = activity modifications, quad/hamstring
rehab

plica
syndrome
1. patho

1. repeated injury such as what is seen in


athletes --> feeling of snapping in the knee,
pain along medial ptella
2. PT, anti-inflammatory meds,
arthroscopy only if refractory

diagnosis of
knee pain

radiographs if suggest degernative/truam


MRI for soft tissue/ligmentous damage
knee aspiration

ligaments on
the lateral
aspect of the
ankle
ligaments on
the medial
aspect of the
grade 1,2,3
ankle sprains

ATFL, CFL, PTL


deltoid
Grade 1 - partial ATFL
Grade 2 - full ATFL, partial CFL
Grade 3 - full ATFL, full CFL

dx of ankle
sprains

tenderness over ligmaents


no radiographs if ottawa rules are met
(patietn can walk four steps at time of
injury/evaluation, no bony tenderness over
distal 6cm of the malleolus)

treatment of
ankle sprains

RICE, controlled weight bearing, gradual


inc. to full weight bearing, PT

1.
supraspinatus
tendinitis + tx
2. rotator cuff
tear + dx

1. impingement syndrome of the C5 root impingement of greater tuberosity on


acromion, pt. will complain of pain with
overhead activity
tx = acromioplasty, steorid injections
2. if there is weakness with abduction - dx
= MRI
tx = PT, steroid injections, arthroscopic
surgery

127.

128.

129.

130.

131.

132.

133.

134.

135.

lateral
epicondylitis
1. patho
2. tx

1. inflammation/degeneration of forearm
extensor tendons from excessive
supination/pronation
2. PT, splinting, injections

medial
epicondylitis
1. patho

1. pain @ medial epicondyle from flexor


origin, from overuse of flexor/pronator
muscles

de quervain's
tenosynovitis
1. patho
2. dx
3. tx

1. abductor pollicis longus and extensor


pollicis brevis tendon inflammation --> pain
@ radial styloid, pain radiates to the elbow
or into the thumb
2. finkelstein's test, pain at radial wrist
when pinch gripping
3. thumb spica splint/NSAIDs, local
cortisone injections

olecranon
bursitis
1. patho
2. tx

1. trauma, overuses --> swelling over elbow,


from effusion into olecranon bursa
2. conservative

trochanteric
bursitis
1. patho
2. tx

1. trauma, overuse, weak hip muscles, -->


pain over lateral hip from friction between
gluteus medius and tensor fascia lata
2. NSAIDs, activity modification, local
cortisone injections

ddx for hand


numbness

cervical radiculopathy, peripheral


neuropathy (DM), median nerve in forearm
(carpal tunnel syndrome)

carpal tunnel
syndrome
1. patho
2. dx
3. tx

1. median nerve compression in carpal


tunnel causes numbness/pain in median
nerve distribution --> severe atrophy of
thenar muscles (later)
2. tinels sign - tap median nerve causes
paresthesias
phalen test - wrist flexion 1 min -->
paresthesias
3. wirst splint @ night, NSAIDs, local
corticosteroids, surgical release*

hip
osteoarthritis
clinical pres

groin pain that radiates to the anterior thigh

osteoarthritis
1. patho
2. clinical
pres
3. dx

1. degeneration of cartilage from wear/tear


of the weight bearing joints
2. pain worsens with activity, stiffness in the
morning that gets worse during the day , NO
swelling or warmth, NO TENDERNESS TO
PALPATION
progresses to limited ROM/bony crepitus*
3. plain radiograph - joint space narrowing,
osteophytes, sclerosis of subchondral bony
endplates, subchondral cysts

136.

137.

138.

139.

140.

141.

142.

143.

144.

145.

osteoarthritis
1. tx

1. avoid excess movement, weight loss, PT


(swimming), canes/walkers
acetaminophen*, COX2 inhibitors, intraarticular injections of corticosteroids,
viscoelastic supplementation, total joint
replacement

heberden's
nodes
bouchard's
nodes

bony overgrowth and osteoarthritic changes


at DIP

bouchard's
nodes - """ at
PIP

...

osteoporosis
1. patho
Type 1
Type 2

1. failure to reach peak bone mass @ age 30


Type 1 - post-menopausla women- loss of
trabecular bone - vertebral
compression/colles fractures
Type 2 - loss of trabecular/cortical >70yo,
femoral neck, intertrochanteric prox.
humerus, pelvis fractures

146.

147.

secondary
osteoporosis

2/2 steroids, immobilization, hyperthyroid,


long term heparin, hypogonadism, D3 def.

osteoporosis
1. risk factors
2. tx

1. estrogen depletion, eating disorders,early


menopause, hyperthyroid, hypogonadism,
smoking/alcohol, steroids, heparin
2. <2 bisphosphonates or SERM (raloxifene)
calcium/vitamin D, calcitonin (dec. hip fx),
weight bearing exercise, smoking cessation

osteoporosis
1. dx
2. secondary
osteoporosis
dx

1. DEXA (< - 2.5 compared to 30 year old


person) dual energy x-ray absorptiometry for
all women >65 - use T scores (>50 yo)/Z
scores (pre-meno)
2. Ca, phos, ALP, TSH, D3, PTH, Cr, CBC

osteoporosis
tx

diet, Ca 1200mg/day, 800IU D3/day,


weight bearing exercise 3x/wk,
smoking/alcohol cessation,
bisphosphonates (aldronate/risedronate
inb. osteoclasts), PTH therapy, calcitonin,
estrogen-progestin therapy
`

ARMD
1. patho
2. risk factors
3. tx

1. non-exudative ARMD form drusen under


RPE--> atrophy/degen of central retina
exudative - sudden vision loss from serous
fluid leakage
CENTRAL VISION LOSS****
2. HTN, caucasian, smoking, FH
3. anti-VEGF injections/laser
photocoagulation (wet), OTC vitamins (dry)

MCC of vision
loss in
developed
countries

diabetic retinopathy
ARMD (age > 65)
cataracts
glaucoma

148.

149.

150.

151.

glaucoma
1. patho
2. open angle
3. closed angle glaucoma
4. dx

1. inc. IOP, ON damage,


cupping of ON, loss of
ganglion cells
2. impaired outflow, silent
progression
3. rapid IOP from
obstruction of outflow by
iris- CAN BE CAUSED BY
DILATION DROPS****
4. tonometry,
ophthalmoscopy,
genioscopy, visual field test

1. OA glaucoma clinical
pres
2. CA """

1. painless IOP, peripheral


scotoma
2. red painful eye, sudden
dec. VA, N/V (mimics acute
abdomen), headache,
dilated non-reactive
pupil***, halos around light

1. OA glaucoma tx
2. CA """"""

1. beta blockers,alpha
agonists, CA inhibitors,
prostaglandin analogs,
laser/surgery
2. immediate referral,
pilocarpine drops, IV
acetazolamide, oral glycerin,
laser/surgery

risk factors for cataracts

1. old age, cigarettes,


glucocorticoids, UV, trauma,
diabetes, wilsons, downs
syndrome

red eye
1. MCC
- refer if FFF, recent eye
surgery, corneal
opacification/ulcer/foreign
body, chemical exposure,
2. subconjunctival
hemorrhage
3. keratoconjunctivitis
sicca
4. blepharitis

1. conjunctivitis
2. focal, unilateral rupture of
small conjunctival vessels by
valsalva, trauma, HTN
3. autoimmune, meds,
CNV/VII, foreign body
sensation
4. inflammation of eyelid,
staph aureus

red eye
1. episcleritis
2. scleritis
3. anterior uveits

1. inflammation of episclera,
autoimmune, include dull
ache/discharge, self limited
NSAIDs
2. pain with palpation of the
eyeball
3. iris/ciliary body inflamm,
circumcorneal injection,
blurred vision,
pain/photophobia,
ipsilateral constrictionassc. with sarcoid, ank
spondy, reiters, IBD

152.

153.

154.

155.

156.

157.

158.

159.

HSV keratitis
1. clinical pres
2. tx

1. UNILATERAL similar to viral conj.


irritation, photophobia, DENDRITIC
ULCER
2. acyclovir, topical antivirals

viral conjunctivitis
1. patho + clinical
pres

1. adeno is MCC, hyperemia of both


eyes, palpable pre-auricular node

bacterial
conjunctivitis
1. patho
2. tx
- chlamydial = MCC
blindness
worldwide (tx =
tetra,doxy,erythro)

1. s.pneumo or gram neg -irritation,


hyperemia, tearing, mucopurulent
exudate
2. broad spectrum abx

allergic
conjunctivitis
1. patho
2. tx

1. seasonal--> redness, itching,


tearing, rhinorrhea,
2. cold compress, topical
antihistamines, systemic
antihistamines, NSAIDS

amaurosis fugax
1. patho
2. dx

1. monocular vision loss 2/2


embolization from carotid
2. carotid ultrasound, cardiac workup
(lipids, ECG)

OSA
1. patho
2. dx
3. tx

160.

161.

162.

1. obesity, structural abn. of hard/soft


palate, FH, alcohol/sedatives,
hypothyroid--> intermittent
obstruction of airflow--> daytime
sleepiness, snoring, personality
change, systemic/pulm HTN,
arrhythmias
2. polysomnography - measure
apneas/hypopneas
5-15 = mild
15-30 = moderate
>30= severe
3. <20 apneas/night - weight loss,
sleep hygiene
>30 apneas/night - CPAP,
uvulopalatopharyngoplasty,
tracheostomy

complications of
OSA

inc. pulmonary vascular resistance,


inc. pulm HTN, cor pulmonale,
systemic hypertension

narcolepsy
1. clinical pres
2. tx

1. inherited REM sleep regulation


disorder -- >sleep attacks, excessive
sleepiness, cataplexy, sleep paralysis,
hypnagogic hallucinations
2. methylphenidate, planned napping

163.

164.

165.

Insomnia
1. transient
insomnia
2. secondary
insomnia
3. definition
of insomnia
4. tx

1. psychological stress/time zone crossing


2. depression, anxiety, PTSD, mania,
schizo, OCD, meds/substance abuse,
alcohol, sedatives
3. difficulty initiating/maintaining sleep,
non-restorative sleep >1 month, excessive
worry about not being able to fall asleep
4. underlying cause, sedative hypnotics as
short as possible

treatment for
obesity

1. diet, exercise, lifestyle


orlistat up to 4 years
bariatric surgery

incontinence
(urge, stress,
overflow,
functional)
1. usual
causes in
males
2.. usual
causes in
females
3. risk factors

1 BPH, neurologic disease


2. hormonal changes, or pelvic floor
dysfunction
3. recurrent UTI, immobility, dementia,
spine injury, DM, CHF, multiparity, BPH,
prostate cancer, diuretics, beta blockers,
anticholinergics/adrenergics (inc.
retention), CCBs, alcohol

1. causes of
conductive
hearing loss
2.
sensorineural
hearing loss
3.. treatment
for cerumen
impaction

c1. cerumen, OE, TM perf, OM, otosclerosis,


pagets disease
2. presbycusis (degen of sensory
cells@cocholea, high freq->low freq),
chronic loud noise >85db, infection,
aminoglycosides, aspirin (reversible)
infection, menieres disease, TORCH
infections
3. carbamide peroxide, triethanolamine

menieres
disease
1. clinical
pres
2. patho
2. tx

1. triggers - alcohol, caffeine, nicotine, high


salt foods --> fluctuating unilateral hearing
loss, progressive hearing loss, vertigo,
hearing loss, nystagmus, vomiting
2. distention of endolymphatic compartment
of the middle ear
2. salt restriction***, meclizine

urge
incontinence
1. patho
2. clinical
pres
3. dx
4. tx

1. dementia, stroke, illness, parkinson's -->


detrusor instability/involuntary
contractions
2. sudden urge to urinate, large volume
voids, with low residual
3. urodynamic study,
4. bladder training exercises,
anticholinergics (oxybutynin), TCA
(imipramine)

166.

167.

168.

169.

170.

171.

172.

173.

stress
incontinence
1. patho
2. clinical
pres
3. tx

overflow
incontinence
1. patho
2. clinical
pres

1. multiparity --> pelvic diaphragm


weakness/loss of bladder
support+hypermobility of bladder neck allows
proximal urethra to descend below the
bladder floor
2. involuntary small volume urine loss during
activities that inc. intrabdominal pressure
(cough, laugh, sneeze, exercise) with small
post-void residual
3. urinalysis (r/o infection), kegel exercises,
estrogen replacement, urethropexy,
1. neurogenic bladder (DM, LMN lesions)
anticholinergics, alpha agonists, BPH**
(MCC), strictures, fecal impaction-->
inadequate contraction (dec. detrusor
contractility) causes overdistention -->
leakage after overcoming urethral resistance
2. nocturnal wetting, freq. loss of small
volume urine, large post vol residual
3. self cath, cholinergics (bethanechol),
alpha blockers (terazosin prazosin),

reflex
incontinence
1. patho

1. spinal cord injury, MS, DM, tabes,


herniation, cord compression --> no sense of
urinary urge

incontinence
dx

1. urinalysis*, post void catheterization


(normal is <50ml), urine cultures, BUN/Cr,
blood glucose, cystometry, uroflow, IVP,
voiding cystourethrogram

fatigue
1. causes

1. psych, endocrine (hypothyroid, DM,


addison's, anemia, occult malig (panc), CRF,
mono, HB/CV, mono, CMV, TB,
endocarditis, OSA, CHF, antihypertensives,

fatigue lab
workup

CBC, TSH, fasting glucose, BMP, UA, LFTs,


ESR, HIV, calcium

CFS
1. patho
2. tx

1. fatigue >6 months, triggered by flu like


illness, new or definite onset of unexplained
fatigue, not relieved by exertion, dec. memory,
muscle pain, sore throat, tender nodes,
unrefreshing sleep, joint pain, headaches,
malaise
2. cognitive behavior therapy, exercise,
social, psychological, antidepressants,
NSAIDs

erectile
dysfunction
1. patho
2. dx
3. tx

1. 80% organic 20% psychogenic


- HTN, smoking, hyperlipidemia,
antihypertensives, sickle cell, pelvic surg,
alcohol
2. DRE, neurologic exam, check PVD.
3. treat underlying cause (atherosclerosis),
PDE5 inhibitors, intracavernosal injections,
implants.

174.

175.

176.

177.

178.

179.

180.

181.

182.

183.

184.

alcoholism
1.
complications

1. GI- gastritis, esophagitis, PUD, hepatitis,


pancreatitis, mallory weiss tears,
cardiomyopathy, essential hypertension (>3
drinks/day), wernicke korsakoff, thiamine
B1 def, hypomagnesemia, folate def,
peripheral neuropathy (B1 def), sexual
dysfunction, inc. cancer (oral, esophagus,
lung, liver)

alcoholism
1. treatment

1. AA, disulfiram, naltrexone, acamprosate,


benzos (tx. withdrawal), thiamine, folate,
multivitamins

most
important
causes of
mortality with
smoking

lung cancer, COPD, atherosclerotic


cardiovascular disease, varencline

alcohol
withdrawal
1. symptoms
2. DT

1. tachycardia, sweating, anxiety,


hallucinations
2. delirium within a week after stopping
alcohol, - hallucinations, confusion,
sweating, tachycardia, inc. BP
tx = benzo taper

health risks
assc. with
smoking

CAD, MI, stroke, COPD,


lung/eso/larynx/bladder/cervix/panc
cancers, PUD, osteoporosis, premature skin
aging, PVD, burgers disease, low birth
weight/spon abortion

smoking
cessation aids

varenicline - partial a4b2 - subunit of the


nicotinic acetylcholine receptor
nicotine replacement
Buproprion**- use in combo with
replacement

1. HTN
screening
2. womens
breast
screening

1. all adults >18yo every 2 years


2. monthly self exams >20 years of age,
physician physical every 3 years until age
40, yearly after that
mammogram every 1-2 years for women
>40, yearly >50, stop at age 70

1. cervical
cancer
screening

1. within 3 years of sexual activity or at age


21, if 2 consecutive smears negative, repeat
every 3 years until age 35 then every 5 years
until age 65

1. STD
screening

1. all women at risk screened yearly until


age 26

1. eye
screening
2. ear
screening

1. all diabetics yearly fundus exam,


glaucoma only for high risk pts
2. informally at visits, young adults only if
have risk factors (noise exposure)

1.
osteoporosis
screening
2. AAA

1. DEXA at age 65
2. ultrasound at age 65 with history of
smoking

185.

186.

187.

188.

189.

190.

191.

192.

193.

194.

195.

page 481 for adult vaccine


schedule

.....

HPV vaccine
reccomendation

age 9-26 years of age

contraindications of to
vaccination

hx. of anaphylaxis, mod-sev


illness

how to tell if a CXR film is


good

intervertebral spaces visible


vertebral bodies visible
through cardiac silouette
>9 ribs should be visible on
inspiration
heart larger than normal with
inadequate inspiration
symmetrical spacing of the
clavicles
clavicular heads should be
aligned
vertebral bodies should be
alignsed

positioning for
1. ET tube
2. central line
3. swan ganz
4. NG tube

1. 4-6 cm above carina


2. in SVC above right atrium
3. in the L or R main pulm
arteries
4. proximal to the pylorus,
distal to GE junction

abdominal images
1. standard abdominal
film
2. obstruction series

1. supine, good for gas pattern


2. supine, upright look for free
air, air fluid levels can be seen
on upright

ileus vs mechanical
obstruction on
obstruction series xrays

air in small intestine supports


ileus b/c involves entire GI
tract
scattered dilated loops
supports ileus
stacked dilated loops supports
mechanical obstruction
prominent/multiple air fluid
level supports mechanical
obstruction

ECG
1. detemrine rate
2. determining axis
3. LAD axis
4. RAD axis

1. # of large boxes/300=
1/#BPM
2. I and aVF should be positive
(= normal axis)
3. I positive, aVF negative
4. I negative, aVF positive
I negative, aVF negative extreme LAD

1. first degree heart block


ECG
2. second degree ""

1. PR>0.2
2. progressive PR lengthening
and then dropped QRS

does Hib vaccine prevent


otitis

no , because it is caused by
NTHI

adult hep B vaccination

3 doses, 0,1-2,4-6

196.

197.

198.

199.

200.

201.

202.

203.

204.

205.

risk factor
modification for
CAD

smoking cessation
HTN - <130/80 for diabetics
HLD - statins and diet
DM - strict glycemic control
obestity
exercise
Diet

medical
treatment for
CAD

aspirin - reduces morbidity/MI risk


beta blockers - reduce cardiac work/O2
demand
Nitrates - reduce preload, dec. O2
demand
CCBs- coronary dilators, vasodilators,
reduce afterload

what drugs
decrease
mortality in CHF

beta blockers
ace inhibitor
hydralazine + isosorbide dinitrate
spironolactone (blocks aldosterone)

treatment for
stable angina

aspirin, beta blocker, nitrates, pain


control, supplemental oxygen

side effects of
nitrates

headache
orthostasis
tolerance
syncope

indications for
CABG or
coronary
angioplasty

moderate disease - normal EF/mod.


angina, two vessel disease not well
controlled by medical therapy

severe disease dec. EF, severe


angina, 3 vessel,
left main, LAD

...

acute coronary
syndrome

unstable angina, NSTEMI, STEMI

unstable angina
1. pathogenesis
2. clinical history
of unstable
angina
3. how to
differentiate
between unstable
angina and
NSTEMI
4. managment

1. stenosis has increased via


thrombosis, hemorrhage, or plaque
rupture --> decreased blood supply due
to reduced resting coronary flow***
2. increasing frequency, duration,
intensity of chest pain, new onset severe
angina, angina at rest
3. no elevation of CK and troponin in
unstable angina
4. rule out MI, stabilize, stress test, or
initial cardiac cath (without stress test)

treatment of
unstable angina

IV access, pain control, oxygen,


nitrates, aspirin (MONA)

206.

207.

208.

209.

beta blockers
LMWH (enoxaparin) 2-2.5
INR
clopidogrel - reduces MI in
USA
gpIIb/IIIa inhibitors abciximab, tirofiban
K+ and Mg+ replacement

...

TIMI risk score

risk of death/ischemia in
patients with unstable
angina/NSTEMI
Age>65
>3 CAD risk factors
known CAD >50% stenosis
2 episodes of angina in last
24 hours
aspirin use in last 7 days
elevated cardiac enzymes
ST change >0.5mm
0-1 point = 5%
2 points = 8%
3 points = 13%
4 points = 20%
5 points = 26%
6-7 points = 41%

when to proceed to
cath/revascularization in a
patient with unstable
angina

medical therapy fails to


reduce symptoms
ECG changes indicative of
ischemia,
ventricular arrhythmias
new mitral regurgitation
new septal defect

variant prinzmetals angina


1. patho
2. clinical pres
3. diagnosis
4. tx

1. transient coronary
vasospasm associated with
atherosclerosis, smokers
2. angina pain, ventricular
dysrhythmias, night time
onset*
3. transient ST elevation
during chest pain
coronary angiographyadminister ergonovine
shows coronary vasospasm
4. CCBs***, nitrates,
smoking cessation
avoid aspirin (prostacyclin
inhibitor)
avoid beta blockers

211.

212.

213.

214.

215.

216.

217.

218.
210.

myocardial infarction
1. patho
2. clinical pres

...

219.

patients often have a


history of angina, CAD,
or arrythmias
30% mortality rate

1. interruption of blood flow 2/2


atheromatous plaque rupture and
acute coronary thrombosis
2. intense crushing substernal
chest pain
radiation to neck, jaw, arms,
back, left side
dyspnea, diaphoresis, weakness,
fatigue, n/v, impending doom,
syncope
does not respond to nitroglycerin
+/- epigastric discomfort
sudden cardiac death 2/2 V.fib

what patients have


asymptomatic MIs

post operative
diabetics
patients on beta blockers
women

myocardial infarction
3. diagnosis

3. ECG - ST elevation or
depression, peaked T waves
(earliest), Q waves (late), T wave
inversion
cardiac enzymes - inc. 3-5 hours
post MI, peak 24-48 hours,
measure q8hrs for 24 hours

right ventricular MI
clinical presentation

1. ECG changes, hypotension,


elev. JVP, hepatomegaly, clear
lungs*

12 lead ECG findings of


MI
1. Anterior MI
2. posterior MI
3. lateral MI

1. ST elevation V1-V4
2. large R wave V1-V2
ST depression V1-V2
prominent upright T waves V1V2
3. ST elevation/Q waves I, aVL
4. ST elevation/Q waves II, III,
aVF

what to look for during


cardiac monitoring in
patient with MI

hyper/hypotension
PVCs which predict Vfib or VT
auscultation for lung crackles,
S3/S4, friction rubs
in unstable patient
hemodynamic monitoring with
pulmonary artery catheter

what hemodynamic
information from a
pulmonary artery
catheter

CVP, PCWP, SVR, CI

NSTEMI
1. patho
2. ECG findings

1. subendocardial ischemia
2. non-ST elevation, ST
depression, T wave inversions,
no Q waves

what patients may have


falsely elevated
troponin

patients with renal failure

220.

221.

222.

223.

224.

225.

226.

1. medical treatment
for acute MI
2. surgical treatment
for acute MI

1. IV access
supplemental oxygen - limits
myocardial damage
nitrates - dilate coronaries,
vasodilator, reduces preload
morphine - venodilator, analgesia
Aspirin - antiplatelet
LMWH
beta blockers - reduce MVO2,
reduce post-MI remodeling of
myocardium
ACE inhibitors
atorvastatin - stabilizes plaques,
lowers cholesterol
Stress EKG before leaving hospital
--> angiography --> possible PCI
or CABG
2. early thrombolysis, PCI or
CABG- within 90 minutes of
arrival improves outcome

which drugs reduce


mortality in patient
with MI

aspirin, beta blockers, ace


inhibitors

troponin vs CKMB

troponin - inc. within 3-5 hours


post MI, returns to normal after 5 14 days
CKMB- rises within 4-8 hours,
returns to normal in 48-72 hours

what medical therapy


after a patient
receives a stent

aspirin/clopidogrel for 12 months


for patients with drug eluting
stents

""" for at least 30 days


with bare stents

...

complications of MI
1. pump failure
2. pump failure
treatment

1. MCC in hospital mortality, can


lead to cardiogenic shock
2. ACE/diuretic, if severe
hemodynamic monitoring

complications of MI

pump failure
arrhythmias
asystole
AV block
recurrent infarction
interventricular septum rupture
papillary muscle rupture
ventricular pseudoaneurysm
ventricular aneurysm (persistent
ST elevation)
acute pericarditis
Dresslers syndrome

227.

228.

229.

230.

231.

232.

233.

complications of MI
1. arrhythmias +
(tx)
2. asystole tx

1. PVCs, afib, PSVT, idioventricular


rhythm, sinus tach, sinus brady
(atropine)
VT (tx = cardioversion +
amiodarone),
Vfib (tx = defibrillation, CPR)
2. defibrillation, transcutaneous
pacing

complications of MI
1. AV block
2. tx

1. ischemia to a conduction tract


2. only treat second and third degree
blocks
pacemaker in the setting of anterior
MI
atropine in the setting of inferior MI
pacemaker for sustained conduction
deficits

complications of MI
1. recurrent
infarction dx
2. tx

1.repeat ST elevation, enzymes are


less reliable and may still be elevated
from first infarction (check CKMB
because declines faster than
troponin)
2. repeat thrombolysis or repeat
cath/PCI

MCC death first few


days after MI

ventricular tachycardia or ventricular


fibrillation

1. when is
thrombolytic
therapy (alteplase)
prefered over PCI
2.contraindications
to thrombolytic
therapy

1. present late to the hospital within


first 6 hours
patients in which PCI is
contraindicated
2. recent head trauma or CPR, hx of
stroke, recent surgery, dissecting
aneurysm, bleeding or diathesis

mechanical
complications of MI
1. free wall rupture
+ tx
2. interventricular
septum rupture +
tx
3. papillary muscle
rupture+ tx
4. ventricular
pseudoaneurysm +
tx
5. ventricular
aneurysm

1. peak occurrence 2 weeks after MI, -> hemopericardium/tamponade,


90% fatal
tx = hemodynamic stabilization,
pericardiocentesis, surgery
2. """""
3. mitral regurg
tx = mitral valve replacement, IABP,
sodium nitroprusside (dec. afterload)
4. incomplete free wall rupture
contained by pericardium
dx/tx = bedside echocardiogram,
emergency surgical repair (HIGH
risk of rupture)
5. rarely rupture, seen as persistent
ST elevation
tx = medical management,
sometimes surgery

complications of MI
1. acute pericarditis
2. tx

1. inflammation of the pericardium


post MI. pleuritic type chest pain
2. tx = time and rest, NSAIDs, NO
CORTICOSTEROIDS (inhibits
myocardial healing)

234.

235.

236.

237.

238.

239.

240.

241.

complications
of MI
1. dresslers
syndrome

1. immunological reaction- fever, malaise,


pericarditis, pleuritic type chest pain,
leukocytosis WEEKS TO MONTHS post MI
tx. = aspirin, or ibuprofen, glucocorticoids

chest pain
ddx

heart - angina, MI, pericarditis, dissection


lungs - embolism, pneumothorax, pleuritis,
pneumonia,
GI - GERD, DES, PUD, esophageal rupture
chest wall - costochondritis, muscle strain,
rib fracture, herpes zos, thoracic outlet
psych - panic attack, anxiety, somatization
drug - cocaine

chest pain
workup

ALL CASES - ECG, chest X Ray


CLINICAL SUSPICIONS - cardiac enzymes,
nitroglycerin, work up for PE, treat for
GERD (young, no risk factors), cardiac
workup (older, diabetic, with risk factors)

characteristic
of pleuritic
chest pain

changes with respiration


changes with position

high output
heart failure definition
and causes

inc. CO needed to maintain peripheral O2


requirements
chronic anemia, pregnancy, hyperthyroid,
AV fistulas, wet beriberi, pagets disease of
bone, mitral regurg, aortic insufficiency

CHF
1.
pathogenesis
2. what does
the frank
starling curve
describe

1. end point of many diseases, heart cannot


meet circulatory demands -->
RAAS/sympathetic sys-->
vasoconstriction/fluid retention--> inc.
preload--> inc. LVEDV (but failing heart
does not inc. contractility) --> symptoms of
congestion
2. increasing preload increases stroke
volume in a normal heart, but not in a
failing heart

1. CHF clinical
presentation

1. dyspnea, orthopnea (pillows),


paroxysmal nocturnal dyspnea (waking 1-2
hours after going to sleep with SOB),
nocturnal cough, confusion, memory
impairment, diaphoresis

left sided
heart failure
signs

displaced PMU
S3- rapid filling into non-compliant left
ventricle (@ apex with bell)
S4- atrial systole blood ejected into noncompliant left ventricle
crackles/rales - fluid in small airways
dullness to percussion of lung fields -pleural
effusion
strong P2 component of S2 - from pulm.
HTN

242.

243.

244.

245.

NYHA
classification of
CHF

class 1 - symptoms with vigorous


activities
class 2 - symptoms with moderate
exertion ex. climbing flight of stairs,
carrying packages - slight limitations
class 3 - usual daily activities walking across the room, getting
dressed - marked limitations
class 4 - symptoms at rest incapacitating

right heart failure


signs

peripheral pitting edema


nocturia (venous return with leg
elevation)
JVD
hepatomegaly/hepatojugular reflex
ascites
right ventricular heave

diagnostic tests for


CHF

CXR - pulmonary edema,


cardiomegaly, kerley B lines (dilation
of lymphatics), pleural effusion,
prominent interstitial markings
ECG - chamber enlargement
cardiac enzymes -r/o MI
CBC - anemia
Echocardiogram - estimates EF (< or
> 40%), r/o pericardial effusion,
determine sys/dias dysfunction
BNP
radionuclide ventriculography t99m, detects EF, used when severe
pulmonary disease
cardiac cath- to r/o CAD induced
CHF
stress testing

BNP
1. when is it
released
BNP can help
differentiate
between CHF and
COPD causing
dyspnea

1. released by ventricles in response


to ventricular expansion and
pressure overload`

246.

247.

248.

249.

250.

251.

252.

253.

CHF treatment
1. MILD (I and II)
2. MILD-MODERATE (II
and III)
3. MODERATESEVERE(III and IV)
4. what drug for patients
who cannot tolerate ACE
inhibitors

1.- sodium restriction <4g/day,


exercise, smoking cessation
-diuretics (furosemide, HCTZ) symptom control
- ACE inhibitors/ARBs systemic vasodilator, left vent.
systolic dysfunction,
2. loop diuretic, ace inhibitor,
beta blocker (esp. post MI
CHF)
3. loop diuretic, ace inhibitor
digoxin - EF <40%, severe
CHF, afib
spironolactone - dec.
morb/mort in stage 3/4 CHF
4. hydralazine and isosorbide
dinitrate

spironolactone vs
eplerenone

eplerenone does not cause


gynecomastia

what must be monitored


for patient on
spironolactone

renal function, and potassium


levels

which drugs reduce


mortality for patients
with CHF

beta blockers
spironolactone (stage II and
III)
ACE inhibitors
hydralazine + nitrate

what must be monitored


for a patient on an ACE
inhibitor

BP, potassium, BUN, Cr

digoxin toxicity
symptoms
ECG findings

N/V, ectopic beats,


arrhythmias:
AV block,atrial tach (inc.
ectopy) with 2:1 AV block (inc.
vagal tone)
Afib, visual disturbances,
disorientation
*verapamil increases digoxin
levels
ECG - scooped ST segments,
prolonged PR, shortened QT, T
wave inversion

what drugs are


contraindicated in
patients with CHF

metformin - lactic acidosis


TZDs - fluid retention
NSAIDs - CHF exacerbation
antiarrhythmics with negative
inotropic effects

ICD indications

implanted cardiac defibrillatorprevents sudden cardiac death


in patients
>40 days post MI,
EF <35%
class II or III symptoms despite
medical tx

254.

cardiac resynchronization therapy indications

same as ICD, but for


patients with a QRS
>120 msec

255.

diastolic heart failure dysfunction

beta blockers
diuretics
ACEs/ARBS
DO NOT USE digoxin +
spironolactone

1. acute decompensated heart failure


2. ddx
3. dx

acute dyspnea assc.


with left sided sys/dias
function
2. PE, asthma,
pneumonia (all rapid
respiratory distress)
3. ECG, CXR, BNP,
Echo, coronary
angiogram, serial
weight measurements

treatment acute decompensated heart failure

oxygenation/ventilation
with non-rebreather,
NPPV, intubation
diuretics***
nitrates
inotropes - dobutamine
(faster onset than
digoxin)

premature atrial complexes


1. patho
2. ECG findings
3. tx

...

http://meds.queensu.ca/central/assets/modules/ECG/Slide11.JPG

1. adrenergic excess,
drugs, alcohol, tobacco,
electrolyte, ischemia,
infection--> atria fire on
their own without SA
node
2. early P waves with
different morphology,
normal QRS
3. asymptomatic, beta
blockers if symptomatic

premature ventricular complexes


1. patho
2. ECG findings
3. tx

...

256.

257.

258.

259.

260.

261.

262.

263.

264.

http://meds.queensu.ca/central/assets/modules/ECG/premature_ventricular_complex.html
265. atrial fibrillation
1. heart disease -1.CAD,
structural
MI, HTN,
heartmitral
1. causes
valve disease, pericarditis,
dz, hypoxia,
pericardial
2. patho
trauma
electrolytes,
pulmonary disease
stimulants,
- PE
meds
hyper/hypothyroid
--> beat fires on
sepsis, malig, DM
its own from a
excessive alcoholventricular focus
sick sinus syndrome
2. wide QRS, lost
pheochromocytoma
P wave (hiding in
2. multiple atrial;QRS
focicomplex),
fire continuously
causing rapid irregular
compensatory
ventricular rate -> thromboembolism,
pause*hemodynamic
compromise
couplet - two
successive PVCs
266. atrial fibrillation
1. fatigue, exertional dyspnea,
bigeminy - sinus
1. clinical
palpitation, dizziness, angina, syncope
beat followed by
features
2. irregularly irregular rhythm, no
PVC
2. ECG
identifiable P waves
trigeminy - two
3. tx
3. RATE CONTROLLED - *Beta
sinus beats
blockers or CCB
followed by PVC
*immediate electrical cardioversion if
3. asymptomatic
unstable
no treamtent, beta
*digoxin or amiodarone if LV
blockers if
dysfunction
symptomatic
*anticoag - if >48 hours,
(palpitations,
anticoagulation 3 weeks before and 4
dizziness)
weeks after cardioversion (INR 2-3)
should post MI PVCs be suppressed with antiarrhythmics
TEE - to detect LA
NO
thrombus
NO NO *pharma cardioversion
increases
- ibutilide,
risk of
procainamide, flecainide,
death
sotalol,
amiodarone
management of patient with frequent PVCs
workup for
267. how does afib
under age 60, nostructural
other heart
heart
disease
treatment differ
do not need heparin/warfarin
disease
for patients with
if heart disease is
lone afib
found patient
should have
268. chronic afib
beta blockers/CCBs
electrophysiologic
treatment
warfarin
study and
269. 1. cardioversion
1. shock that is synchronous
possible ICDwith QRS
2. defibrillation
(NOT T-wave) - used
for afib, aflutter,
implantation
to
VT with pulse, SVT
prevent sudden
2. shock that is not
synchronous
cardiac
death with
QRS - Vfib, pulseless VT
causes of diastolic heart dysfunction
infiltrative
270. indications for
Vfib, or VT that is
not controlled by
cardiomyopathies
automatic
medical therapy (amyloid,
implantable
sarcoid),
defibrillator
hypertrophic
271.

atrial flutter
1. causes
2. patho
3. ECG
4. tx

cardiomyopathy,
1. heart failure, rheumatic
heart disease,
CAD, COPD, ASD
2. right atrial macro-reentry focus firse
250-350BPM
3. saw tooth baseline, with QRS every 23 atrial contractions (II, III, aVF)
4. same as for Afib

multifocal atrial
tachycardia
1. causes
2. ECG findings +
dx
3. wadering
atrial pacemaker
4. tx (w and w/o
LV dysfunction)

1. COPD, or other pulmonary disease


2. >3 P wave morphologies
- vagal maneuvers/adenosine show AV
block does not disturb atrial tachycardia
3. same as MAT, rate 60-100 BPM
4. improve oxygenation/ventilation
LV intact: BB, CCB, digoxin,
amiodarone, flecainide, propafenone
LV not intact: digoxin, diltiazem,
amiodarone

paroxysmal
supraventricular
tachycardia
1. AV nodal reentrant
tachycardia +
ECG
2. orthodromic
AV re-entrant
tachycardia +
ECG
3. causes
4. tx

1. PACs --> two paths in the AV node,


reentrant circuit within the AV node
ECG - narrow QRS with no P waves (P
waves inside QRS)
2. PAC or PVC --> retrograde accessory
path between atria/ventricles
ECG - narrow QRS, +/- P waves
3. ischemia, digoxin toxicity (PSAT w/
2:1 block)
4. vagal maneuvers, IV adenosine.
IV verapamil
IV esmolol

274.

vagal maneuvers

valsalva, carotid sinus massage, breath


holding, head submersion in cold water
or ice pack

275.

PSVT prevention

digoxin*
verapamil, beta blockers
radiofrequency catheter ablation

WPW syndrome
1. patho
2. dx
3. tx

1. accessory conduction pathway


through bundle of kent causes premature
ventricular excitement --> orthodromic
reciprocating tachycardia (through AV
node), or supraventricular tachycardia
by avoiding AV node (afib or flutter)
2. narrow complex tachycardia, short
PR, delta wave
3. radio-frequency ablation of re-entrant
loop accessory pathway
procainamide**, quinidine** (IA or
IC)
(AVOID digoxin/verapamil/beta
blockers which act @ AV node)

272.

273.

276.

277.

ventricular
tachycardia
(sustained and
nonsustained)
1. patho
2. causes
3. ECG

1. rapid repetitive firing of >3 PVCs @


100-250BPM
2. CAD post MI*, active ischemia,
cardiomyopathies, congenital defects,
long QT
3. AV dissociation is present, wide
variable shaped QRS (>0.12s)
- no response to vagal manuevers or
adenosine

278.

279.

280.

281.

282.

283.

284.

285.

ventricular
tachycardia
1. sustained
VT tx
2. nonsustained VT
tx

1. stable + sys BP>90: IV amiodarone,


procainamide, or sotalol
unstable or severe sx: synchronous DC
cardioversion, and amiodarone, and ICD
placement
2. electrophysiologic study, possible ICD
placement, amiodarone

Ventricular
fibrillation
1. causes
2. patho
3. clinical
pres
4. ECG
5. tx

1. ischemia, antiarrhythmic drugs (QT


prolonging), Afib (ex. in WPW)
2. multiple ventricular foci firing in the
ventricles, no CO, usually starts with Vtach
3. loss of consciousness, no pulse,
4. no P waves, no QRS, no waves can be
identified
5. defibrillation(200,300,360) and CPR,
epinephrine 1 mg IV every 3-5mins, defib
again after first epi.
IV amiodarone before 1st defib
2nd line: lidocaine, magnesium,
procainamide

pulseless
electrical
activity
1. causes
2. clincial
findings
3. tx

1. 6Hs and 6Ts


H: hypovolemia, hypoxia, hyrogen ions,
hypothermia, hypoglycemia,
hyper/hypokalemia
T: tamponade, tension pneumo, thrombosis
(MI/PE), trauma (hypovolemia),
tablets(drugs), toxins
2. monitor shows electrical activity, but no
pulse present
3. IV access and CPR/ACLS resuscitation
with IV fluids, not cardioversion

sinus
bradycardia
1. causes
2. symptoms
3. tx

1. ischemia, vagal tone, antiarrythmics,


athletes
2. fatigue, exercise intolerance, angina,
syncope
3. atropine

sick sinus
syndrome
1. patho
2. sx

1. sinus node causes persistent sinus


bradycardia
2. dizziness, confusion, syncope, fatigue,
CHF
3. pacemaker

first degree
AV block

due to delay in AV node


prolonged PR, QRS follows each P

second
degree AV
block
1. type 1
(wenckebach)
2. type 2
3. tx for type 1
vs 2

1. progressive PR interval elongation until


there is a lost QRS, block within AV node
2. sudden loss of P wave without preceding
PR interval prolongation, progressed to
complete heart block, block within the hispurkinje system
3. pacemaker required for type 2

third degree
AV block + tx

absence of atrial impulse conduction to the


ventricles, AV dissociation

286.

287.

288.

289.

290.

tx = atropine
acutely,
pacemaker
implantation**
****

...

dilated
cardiomyopathy
1. patho
2. clinical pres
3. dx
4. tx

1. CAD, alcohol (look for macrocytosis),


doxo, adriamycin,
thiamine/selenium/phosphate
deficiency
uremia
viral (cox), chagas, lyme, HIV
hyper/hypothyroid
SLE, scleroderma
pheochromocytomas, cocaine
familial
2. L/R CHF, S3, S3, mitral regurg,
tricuspid regurg, cardiomegaly,
arrhythmias, sudden death
3. ECG, CXR, echocardiogram
4. digoxin, diuretics, vasodilators,
transplant, anticoag.

HCM
(hypertrophic
cardiomyopathy)
1. patho
2. clinical pres
3. dx

1. AUTOSOMAL DOMINANT-->
diastolic dysfunction, worse with
exercise or valsalva + dynamic outflow
obstruction
2. angina, syncope, dyspnea (on
exertion or valsalva), arrythmias,
SUDDEN CARDIAC DEATH
3. loud S3, systolic ejection murmur @
LSB, rapidly increasing two upstroke
carotid pulse (bisferiens pulse)
Echocardiogram - shows left ventricular
hypertrophy esp. of septum
ECG, family history

HCM
1. treatment

1. avoid strenuous exercise


symptomatic: beta blockers*
CCBs, diuretics, myomectomy, mitral
replace, pacemaker

HCM murmur
features

systolic ejection murmur @ LLSB


decreased with squatting/lying down
(dec. outflow obstruction, sustained
hand grip
increased with valsalva and standing
(dec. LV size and inc. outflow
obstruction)

291.

292.

293.

294.

295.

restrictive
cardiomyopathy
1. patho
1a. clinical pres
2. dx
3. tx

1. amyloid, sarcoid,
hemochromatosis, scleroderma,
carcinoid, chemotherapy -->
impaired diastolic ventricular
filling
1a. absent pulses, absent
kussmaul's sign, prominent x
descent
2. echocardiogram - shows
enlarged RA/LA sizes, sparkled
appearance in amyloidosis
ECG - low voltage,bundle branch
blocks, LVH
endomyocardial biopsy

3. hemochromatosis phlebotomy,
deferoxamine
sarcoidosis glucocorticoids
amyloid - none
digoxin for systolic
failure
avoid
diruetics/vasodilators

...

myocaridtis
1. patho
2. clinical pres
3. dx/tx

1. coxsackie, parvo b19, HHV6,


bacteria, GAS, lymes,
mycoplasma, SLE, sulfonamides -> inflammation of myocardium
2. fatigue, fever, cx pain,
pericarditis, CHF, arrhythmia,
death
3. cardiac enzymes, ESR
tx= supportive

acute pericarditis
1. causes (long list...)

1. idiopathic/infectious (cox*,
echo, adeno, ebv, flu, HIB,
hep A/B, TB*, fungal, toxo)
Acute MI (within 24 hrs)
uremia
collagen dz - SLE, scleroderma,
RA, sarcoid
hodgkins lymphoma, breast/lung
cancer
drug lupus: procainamide,
hydralazine
Dresslers syndrome- weeks to
months after MI
post pericardectomy sndrome
amyloid
radiation
trauma

acute pericarditis
1. treatment
2. complications

1. supportive 1-3 weeks


2. pericardial effusion, pericardial
tamponade

296.

297.

298.

299.

300.

301.

acute pericarditis
1. clinical pres

1. preceeding viral illness


severe pleuritic chest pain,
retrosternal, left precordial
KUSSMAULS SIGN, PROMINENT Y
DESCENT
radiates to trapezius ridge/neck
positional - worse when lying
supine***, coughing, swallowing,
deep breathing
better when sitting up and leaning
forward
*Pericardial friction rub (3
components)

best positioning to
hear a pericardial
friction rub

seated upright during expiration

acute pericarditis
1. dx
2. tx

1. fever and leukocytosis


pericardial friction rub
ECG -- diffuse ST elevation, PR
depression
ST segment returns to normal in 1
week
T wave inversion (then reverses later)
echocardiogram often normal (unless
effusion)
2. self limited
treat underlying cause
NSAIDS
Colchicine
glucocorticoids (avoid if possible)

constrictive
pericarditis
1. patho
2. clincal pres
3. dx

1. post viral, uremia, radiation, TB,


connective tissue disorders --> fibrous
scarring and obliteration of
pericardial cavity/LATE* diastolic
filling restriction
2. edema, ascites, pleural effusion,
hepatomegaly DOE, fatigue, exercise
intolerance, cachexia, JVD
kussmaul's sign
3. ECG: low voltage, T wave flattening
Echo: inc. pericardial thickness,
limited diastolic filling
CT/MRI - pericardial thickening
Cath - rapid y descent, dip and plateau
(square route sign)

diagnostic
modality of choice
for pericardial
effusion and
cardiac tamponade

echocardiogram

constrictive
pericarditis
1. tx

1. underlying condition*
diuretics
monitor/treat for coagulopathy

302.

303.

304.

305.

306.

pericardial
effusion
1. pathogenesis
2. clinical pres
3. dx

1. ascites, pleural effusion, CHF,


cirrhosis, nephrotic syndrome OR
acute pericarditis --> leads to
exudation of fluid into pericardial
space
2. muffled heart sounds, soft PMI,
dullness at left lung base, friction rub
(+/-)
3. echo- see effusion (as little as
20mL)
CXR- >250ml enlarged silhouette
"water bottle"
ECG - low voltage, flat T waves,
electrical alternans
CT/MRI
pericardial fluid - glucose, cell
count/diff, cytology, SG, Hct, gram
stain, acid fast, fungal smear,
cultures, LDH

pericardial
effusion
1. tx

1. repeat echo 1-2 weeks,


no pericardiocentesis unless there is
tamponade

cardiac
tamponade
1. patho
2. causes
- note also
interventricular
septum bows into
LV during
inspiration
further reducing
LV filling

1. >200ml of rapid fluid accumulation,


or 2 liters of slow fluid accumulation-> mechanical filling and diastolic
impairment--> chamber pressure
equalization-->dec. LV preload, dec.
SV, dec. CO
2. trauma, malignancy, uremia
central line placement, pacemaker
insertion, pericardiocentesis
pericarditis
POST MI free wall rupture

cardiac
tamponade
1. clinical pres
2. dx

1. elevated JVD*, narrow pulse


pressure,
pulsus paradoxus- >10 mmHg
drop in arterial pressure during
inspiration
muffled heart sounds
tachypnea, tachycardia, hypotension,
cardiogenic shock
3. echocardiogram
CXR - enlarged silhouette
ECG - electrical alternans alternate
variation in direction of ECG waves due to pendular heart swinging
Pulsus paradoxus - >10mmHg decline
in sys. pres with inspiration
cardiac cath - equal chamber
pressures, elevated right atrial
pressure, loss of Y descent

becks triad

cardiac tamponade:
hypotension, muffled heart sounds,
JVD

307.

308.

309.

310.

311.

cardiac
tamponade
1. tx

1. nonhemorrhagic and stable monitor with echo/CXR/ECG, dialysis


(for uremia)
hemorrhagic - emergent surgery*,
pericardiocentesis

mitral stenosis
1. patho
2. clinical pres/PE

1. rheumatic heart dz** --> cross


reactivity between streptococcal
antigen and valve--> scarring,
inc. LA pressure, pulm HTN,
Afib**
2. DOE, orthopnea, PND,
palpitations, CX pain, hemoptysis
(bronchial vein rupture),
thromboembolism
murmur - S2 followed by OS (closer =
mores severe) followed by diastolic
rumble, loud S1 in LLD position with
bell
LATE: JVD, hepatomegaly, ascites,
right vent. heave, loud P2 (pulm HTN)

mitral stenosis
1. dx
2. tx

1. CXR - left atrial enlargement


echo - left atrial enlargement, thick
mitral valve, fish mouth orifice
2. diuretics for pulm
congestion/edema
beta blockers - lower CO/HR
endocarditis prophylaxis
anticoagulation with warfarin
percutaneous balloon valvuloplasty
open commissurotomy/mitral
replacement

aortic stenosis
1. patho
2. clinical pres
25% 3 year survival
w/o treatment @
time of
presentation with
symptoms

1. senile aortic calcification, bicuspid


aortic valve, rheumatic fever --> LV
outflow obs, LVH, mitral regurg
2. angina (3 yr surv), syncope (2 yr
surv), dyspnea/heart failure (1.5 yr
surv.)
* murmur - harsh crescendodecrescendo systolic murmur, @ right
2nd ICS, radiates to carotids, soft S2
parvus et tardus - delayed carotid
upstrokes
sustained PMI, precordial thrill

aortic stenosis
1. dx
2. tx

1. CXR - calcified aortic valve,


dilatation of proximal ascending
aorta, enlarged LV/LA
ECG - LVH, LA abnormalities
Echocardiogram - immobile thickened
aortic valve, dilated aortic root, LVH
2. no sx = no tx
sx = aortic valve replacement

312.

313.

314.

315.

aortic
regurgitation
1.
causes/patho
2. symptoms

1. infective endocarditis, trauma, dissection,


iatrogenic
rheumatic fever, bicuspid, marfans, ehlers,
syphilis. OI, behcets, reiters--> inadequate
closure of aortic valve leaflets--> LV
dilation/hypertrophy--> elevated pulmonary
pressures
2. DOE, PND, angina orthopnea,
palpitations worse with lying down,
cyanosis,

aortic
regurgitation
1. clinical
presentation

1. decrescendo diastolic murmur at 3rd ICS


left sternal border
Widened pulse pressure
corrigan's pulse (water hammer pulse)rapidly increase pulse that collapses
suddenly decreases
austin-flint murmur - low pitched diastolic
rumble from competing retrograde flow,
increases with handgrip
S3, displaced PMI
de Musset's sign (head bobbing), mullers
sign (uvula bobbing, duroziez's sign (pistol
shot sound over femoral arteries)

aortic
regurgitation
1. dx
2. tx

1. CXR - LVH, dilated aorta


ECG- LVH
Echo- LV size/function/reversal of flow in
aorta
cardiac cath - severity of regurg, LV
dysfunction
2. CCBs (nifedipine)***, salt restriction,
diuretics, digoxin, ACE
aortic valve replacement

mitral
regurgitation
1. patho
2. clinical
pres
3. dx
4. tx

acute (high mortality) - endocarditis(staph),


papillary muscle rupture, chordae rupture
chronic MVP, rheumatic fever, marfans,
cardiomyopathy
2. DOE, PND, orthopnea, palpitations,
pulmonary edema, holosystolic murmor @
apex, radiates to back or axilla, afib, S3,
wide S2, palpable P2
3.CXR - cardiomegaly, dilated LV, pulm
edema
Echo - MR, dilated LA/LV, dec. LV function
4. afterload reduction w/ vasodilators
anticoagulation
IABP, mitral valve repair/replacement

316.

317.

318.

319.

320.

321.

tricuspid
regurgitation
1.causes
2. clinical pres

1. RV dilation 2/2 left ventricular failure,


right ventricular infarction, inferior MI,
cor pulmonale, tricuspid endocarditis
rheum arthritis, ebstein's anomaly,
carcinoid, SLE
2. RVF failure signs - ascites,
hepatomegaly, edema, JVD, pulsatile
liver
prominent V waves and rapid Y descent
blowing holosystolic murmur @LLSB
worse with inspiration, reduced with
expiration/valsalva

tricuspid
regurgitation
1. dx
2. tx

1. echocardiogram
2. diuretics for volume overload
treat underlying cause
valve repair, tricuspid ring

mitral valve
prolapse
1. patho
2. sx/clinical
pres

1. myxomatous degeneration of the mitral


leaflet/chordae leads to prolapse
*common in marfans, OI, Ehlers danlos
2. usually asymptomatic
mid systolic click and mid to late systolic
murmur, standing and valsalva increase
murmur (b/c they dec. LV chamber size),
squatting decreases murmur

MVP
1. dx/tx

1. dx = echocardiogram
tx = reassurance, beta blockers
surgery rarely

rheumatic heart
disease
1. patho
2. clinical pres
3. tx

1. GAS immunological reaction with


valves
2.JONES CRITERIAMAJOR: migratory polyarthritis,
erythema marginatum, carditis, chorea,
subQ nodules (over tendons)
MINOR: fever, ESR, polyarthralgias, hx.
rheumatic fever, prolonged PR interval,
evidence of strep infection
3. penicillin, erythromycin for strep
pharyngitis
NSAIDs for rheumatic fever
erythro/amox* for dental/GI/GU
prophylaxis

infective
endocarditis
1. acute
2. subacute
3. native valve
endocarditis
4. IVDU
5. prosthetic
valves
6. pathogenesis
7. recent bladder
instrumentation
8. colon cancer

1. s.aureus on a normal valve


2. on DAMAGED valves s.viridans,
enterococcus on damaged valves
3. s. viridans, s. aureus, s. epidermidis,
HACEK - haemophilus, actinobacillus,
cardiobacterium, eikenella, kingella
4. IVDU = s.aureus***, enterococcus,
strep, candida, pseudomonas
5. s.epidermidis
6. --> cardiac failure, myocardial
abscess, septic emboli,
glomerulonephritis
7. enterococcus
8. s.gallolyticus/bovis

322.

323.

324.

325.

326.

327.

328.

329.

330.

331.

332.

333.

MCC epiglottitis +
CXR finding

haemophilus influenza (often beta


lactamase producing), #2 is strep.
pyogenes
CXR - lateral neck xray shows
THUMBPRINT SIGN

weil felix titer

antibody titer for rickettsial


organisms ie. rocky mountain spotted
fever

neisseria gram
stain

gram negative diplococci

clinical
presentation of
mycoplasma
pneumonia + dx

both upper (sore throat, otitits) and


lower respiratory symptoms (CXR
infiltrates), myringitis hemolytic
anemia, no organisms on gram stain
dx = IgM cold agglutination, positive
complement fixation test

methenamine silver
stain

pneumocystis

dx EBV

heterophile antibodies, and atypical


lymphocytes on peripheral smear

amoebic liver
abscess
1. dx/tx
2. clinical
presentation

1. indirect hemagglutination and


ultrasound
tx = metronidazole
2. RUQ pain, possible history of
diarrhea, history of travel or endemic
region

Coxsackievirus can
produce a
morbilliform
vesiculopustular
rash, often with a
hemorrhagic
component and
with lesions of the
throat, palms, and
soles.

...

stages of lymes
disease

stage 1 - erythema chronicum


migrans (bulls eye rash that
enlarges)
stage 2 - neurologic, cardiac, arthritic
(migratory monoarticular) symptoms
weeks to months after stage 1

what lab test


detects both
syphilis and lymes
disease

VDRL

what toxin causes


toxic shock

TSST 1 superantigen increases TNF,


IL1 release from PMNs

treatment of
influenza outbreak
in a nursing home

oseltamivir and flu vaccines for the


entire population

334.

335.

336.

337.

338.

339.

340.

341.

342.

343.

what is sensitive and


specific for diagnosis of
vertebral osteomyelitis
and what is the cause

MRI of the spine


prior UTI is most common
mechanism for bacteremia and
vertebral seeding

causes of fever of
unknown origin

infections, malignancies,
collagen vascular disease,
granulomatous disease

stills disease (juvenile


RA)
1. clinical presentation
2. diagnostic blood test

classic presentation is the triad


of persistent high spiking fever
(FUO), joint pain and a
distinctive salmon-colored rash

2. elevated serum
ferritin**, RF is often
negative

...

acute hepatitis A
incubation period

1 month****- does not


neccessarily happen immediatly
after exposure

features of chickenpox
rash

papules vesicles and scabs in


variable stages of development

what patients are most


likely to get anaerobic
cellulitis

diabetics

what are the causes of


non-gonococcal
urethritis

ureaplasma urealyticum,
trichomonas vaginalis ,
chlamydia trachomatis

infectious endocarditis
1. clinical presentation
endocarditis
2. complications of
infective endocarditis
3. tx

1. new heart murmur,


unexplained fever
2. cardiac failure, myocardial
abscess, solid organ damage
from emboli,
glomerulonephritis
3. parenteral antibiotics for 4-6
weeks
if cannot isolate culture - vanc +
aminoglycoside until organism
is isolated

dukes criteria

344.

345.

346.

347.

infective endocarditis
diagnostic criteria
Major - sustained bacteremia,
endocardial involvement by
echo, new valvular
regurgitation
Minor - predisposing condition,
fever,
septic or pulm emboli, mycotic
aneurysm, intracranial
hemorrhage, janeway lesions
immune phenomenon glomerulonephritis, osler's
nodes, roth spots, rheumatoid
factor
non major blood culture/echo

348.

349.

350.

351.

352.

endocarditis
prophylaxis
indications +
tx

indications: prior history of infective


endocarditis, prosthetic heart valves,
untreated CYANOTIC congenital heart
disease, s/p <6 mon after
amoxicillin for patients with known
valvular disease - for oral, GI/GU surgery

nonthrombotic
marantic
endocarditis
1. patho
2.
complications

1. metastatic cancer --> sterile deposits of


fibrin/platelets that forms ALONG LINES
OF CLOSURE OF VALVE LEAFLETS
2.embolizations of vegetations to brain or
body

non-bacterial
verrucous
endocarditis
(libman
sacks)
1. patho
2.
complications
+ tx

1. SLE --> warty vegetations on BOTH


SIDES of the valve leaflets
2. embolization
tx = treat SLE and anticoagulate

ASD
1. patho
2. clinical
pres
3. dx physical,
Echo, CXR,
ECG

1. ostium secundum, ostium primum (low in


septum), sinus venosus (high in septum) -->
left to right shunt with RA/RV dilation -->
pulmonary hypertension (late)
2. asymptomatic then develops into exercise
intolerance, DriOE, fatigue @ age 40
3. systolic ejection murmur at LSB, wide
fixed split S2* (inc. blood flow), RVF.
Echocardiogram w/contrast bubble study
CXR - large pulmonary arteries, inc.
pulmonary markings
ECG - RBBB

treatment of
refractory
c.difficile

switch to oral vancomycin***


metronidazole has a failure rate of 25%

treatment for
hospital
MRSA

linezolid, daptomycin, vancomycin TMP


SMX

HIV
treatment
1. raltegravir
2. maraviroc
3. basic
treatment of
HIV

1. integrase inhibitor
2. CCR5 antagonist
3. 2 NRTI + 1 NNRTI, or 2 NRTI + protease
inhibitor

prophylaxis
against
malaria

atovaquone-proguanil, mefloquine, or
primaquine, 2 days before trip starts based
upon CDC sensitivities

catheter
associated
UTI

fungal, e.coli, other gram negatives

353.

354.

355.

356.

357.

358.

359.

360.

361.

362.

363.

cervicofacial
actinomyces

fluctuant lesion and fistula over


the mandible

blastomycosis clinical
presentation

chronic respiratory infection,


verrucous crusted skin lesions,
osteolytic bone lesions

aspergillus related
disease

disseminated in
immunocompromised
allergic bronchopulmonary young woman with asthma
aspergilloma - bronchial plugs
with hyphae

which diseases are


associated with
peeling of the skin

staph toxic shock


kawasaki
scarlet fever
severe drug reaction

which diseases
associated with
peeling of the skin

meningococcus, gonococcemia,
rickettsia, infectious endocarditis,
atypical measles, DIC associated
with sepsis

causes of dysphagia in
HIV patients

candida***(empiric fluconazole),
HSV, cytomegalovirus

risk factors for IV


contrast induced
nephropathy +
avoidance of
complications

1. volume depletion, diabetes,


CHF, CKD, multiple myeloma
2. hydration*** with isosmolar
fluids, and sodium bicarb, nacetylcysteine

treatment for COPD


exacerbation

steroids
- Bipap is better because is
reduces CO2 retention,
- NOT OXYGEN THERAPY because of haldane effect and
hypoxia drives respiration in
COPD patients

causes of delirium

medications (anticholinergics,
antihistamines, TCAs),
postsurgical, infection,
electrolytes, benzos,
fluoroquinolones.

healthcare associated
pneumonia
1. associated settings
2. bacteria
3. tx

1. long term care, recent


hospitalization, chronic dialysis
2. inc. risk for acinetobacter, s.
aureus, pseudomonas
3. carbapenem, fluoroquinolone,
vancomycin

what decreases risk of


ventilator associated
pneumonia

daily interruption of sedation


(sedation holiday),
oropharyngeal intubation,
elevating head of the bed

364.

365.

366.

367.

368.

369.

370.

complications
of ASD
2. when to treat
ASD

1. pulmonary hypertension
eisenmenger disease- irreversible
pulmonary hypertension leads to shung
reversal, heart failure, cyanosis
right heart failure
A.fib
stroke (PARADOXICAL EMBOLI), Afib
2. when pulm:systemic > 2:1 or if
symptoms

VSD
1. patho
2. clinical pres
3.
complications
4. dx/tx

1. right to left shunt leads to pulmonary


hypertension
2. holosystolic harsh murmur @ 4th left
ICS decreases with valsalva/handgrip,
prominent P2
3. CHF, growth failure, lower resp.
infections, eisenmenger's, cyanosis, DOE,
aortic regurgitation
4. ECG - ventricular hypertrophy
CXR - PA
echo - shows septal defect
tx = surgical repair if pulm:sys pressure
2:1, no abx prophylaxis if uncomplicated
VSD

coarctation of
the aorta
1. patho
2. clinical pres
3. dx/tx

1. narrowing of aorta @ left subclavian


origin near lig. arteriosum
2. brachiofemoral delay, underdeveloped
lower body, leg fatigue, claudication,
headache, turner's features
3. ECG - LVH
CXR - rib notching, figure 3 from
indentation of the aorta
tx = surgical decompression, percutaneous
balloon aortoplasty

coarctation of
the aorta
complications

HTN, cerebral aneurysms, infectious


endocarditis,aortic dissection

clinical
associations
with PDA

congenital rubella syndrome, high


altitude, premature birth

PDA
1. clinical
presentation
2. tx

1. asymptomatic, heart failure


continuous machinery murmur, wide pulse
pressure, bounding peripheral pulses,
LOWER EXTREMITY clubbing/cyanosis
2. indomethacin, PGE, do not correct if
severe pulm htn.

TOF
1. patho
2. tet spells
3. dx

1. VSD, right ventricular hypertrophy,


pulmonary stenosis, aortic override.
2. squatting after exertion increases SVR
and increases blood flow from RV to lungs
3. echocardiography
CXR - BOOT SHAPED HEART
EKG shows enlarged RA/RV

371.

372.

373.

374.

375.

hypertensive
emergency
1. definition
2. clinical findings

1. >220/>120 with end organ


damage
* requires immediate treatment
2. altered mental status,
papilledema, hypertensive
encephalopathy, renal failure,
hematuria, unstable angina, MI,
CHF, pulmonary edema,
dissection

hypertensive urgency

>220/>120 without evidence of


end organ damage

posterior reversible
encephalopathy
syndrome
1. patho
2. symptoms
3. dx

1. 2/2 hypertensive emergency autoregulatory failure of cerebral


vessels leads to arteriolar dilation
and extravasation of fluid into the
brain
2. insidious onset headache,
seizures, visual changes
3. posterior cerebral white matter
edema

treatment for
hypertensive
emergency

1. lower the BP (hydralazine,


esmolol, nitroprusside, labetalol,
nitroglycerin) 25% in 1-2 hours
and then reduce gradually (with
less intensive therapy)
2. order CT to r/o intracranial
bleeding
3. negative CT proceed with
lumbar puncture

aortic dissection
1. risk factors
2. type A vs type B
3. clinical pres
*****BE CAREFUL
AND DO NOT GIVE
THROMBOLYTIC IF
PRESENTATION IS
SIMILAR TO
MYOCARDIAL
INFARCTION

1. hypertension, smoking,
cocaine, trauma, marfans, ehler
danlos, bicuspid aortic valve,
coarctation, third trimester
pregnancy
2. type A includes the ascending
aorta
type B distal to the subclavian
artery
3. severe tearing, ripping
sensation anterior chest (type A),
or interscapular (type B),
diaphoresis, pulse asymmetry
between limbs, aortic regurg
murmur (A), neurologic
(obstruction of carotid)

376.

377.

378.

379.

380.

381.

382.

383.

aortic
dissection
1. dx / tx***

1. CXR - widened mediastinum, right sided


pleural effusion
TEE*** (NOT TTE)
CT*/MRI - disadvantage is it takes longer
aortic angiography
tx= ANTIHYPERTENSIVES FIRST***
IV beta blockers, IV nitroprusside
immediately
Type A - surgical emergency
Type B - medical - lower bp, pain control, if
symptoms persist treat surgically

AAA
1. patho
2. clinical
pres
3. ruptured
AAA clinical
pres
4. dx/tx

1. trauma, HTN, vasculitis, smoking,


syphilis, marfans (thoracic) --> dilatation
of aorta between renal arteries and iliac
bifurcation
2. usually ASYMPTOMATIC, throbbing
hypogastric and lower back pain, severe
pain in back or lower abdomen radiating to
groin, buttocks or legs, grey turner sign,
cullen sign
3.abdominal pain, hypotension, palpable
pulsatile mass , syncope, n/v
4. ultrasound = diagnosis of choice***
CT scan = only if hemodynamically stable

AAA
1. tx

1. >5 cm in diameter, surgical resection with


graft placement
ruptured = open repair or endovascular

leriche
syndrome

atheromatous occlusion of distal aorta


above the bifurcation causing
BILATERAL CLAUDICATION
IMPOTENCE
DEC. FEMORAL PULSES

PVD
1. associated
conditions
2. common
sites
3. risk factors

1. coexisting CAD, MI, diabetes, lung


disease
2. superficial femoral (in hunter's canal),
popliteal, aortoiliac
3. smoking**, CAD, HLD, HTN, DM**

PVD
evaluation

ECG, CBC, BUN/Cr, coagulation profile


(factor V, antithrombin III, protein S/C)

PVD
1. intermittent
claudication
2. rest pain
3. clinical
findings

1. leg pain reproduced by same walking


distance relieved by rest
2. pain in distal metatarsals prominent at
NIGHT awakens from sleep relieved by
hanging legs over the bed
3. dec. pulse, atrophy, loss of hair, thick
toenails, decreased skin temp, ischemic
ulcers, infarction, gangrene, pallor of
elevation, rubor of dependency (BUERGER'S
TEST)

brodie
trendelenburg
test

...

384.

385.

386.

387.

388.

389.

PVD
diagnosis
PVD tx

1. normal ABI between 1.0 and 1.3


ABI > 1.3 is due to noncompressible vessels
and is an indication of severe disease
claudication <0.8
rest pain <0.4
pulse volume recordings (small waveform
means poor collateral flow)
arteriography/arterial doppler
2. stop smoking, graduated exercise, foot
care, atherosclerotic risk factor reduction,
aspirin + ticlopidine/clopidogrel, cilostazol
(PDE inhibitor), angioplasty, surgical bypass
grafting, bypass grafting

acute
arterial
occlusion
1. patho
2. clinical
pres
3. dx/tx

1. afib, post-MI, endocarditis, myxoma,


aneurysm --> embolization most commonly
the femoral artery
2. pain, pallor, polar (cold), paralysis,
paresthesias, pulselessness
3. arteriogram*, ECG, echocardiogram \
tx = reestablish perfusion within 6 hours,
immediate, fogarty balloon embolectomy,
thrombolytics

cholesterol
embolization
syndrome
1. patho
2. clinical
presentation
3. dx/tx

1. surgical or radiographic maneuvers,


thrombolytic therapy--> showers of
cholesterol from proximal source
(atherosclerotic plaque) from aorta, iliac, or
femoral arteries
2. small discrete areas of tissue ischemiablack/blue toes, renal insufficiency,
abdominal pain/bleeding
3. dx = Eosinophilia*******
tx = supportive, DO NOT
anticoagulate,control BP, AVOID amputation
or surgical resection

mycotic
aneurysm
cause and
treatment

infection of the wall of the aorta leads to


damage of the aortic wall
tx = IV abx and surgical excision

luetic heart
1. patho

1. syphilitic aortitis leads to retrograde


extensionaortic regurgitation and stenosis of
the aortic branches (coronaries)
tx = IV penicillin and surgical repari

DVT
1. pahto
2 risk
factors
3. clinical
pres

1. virchows triad - endothelial injury,


hypercoagulability, venous stasis
2. prior history, prolonged immobilization,
cardiac disease, CHF, obesity, major surgery
(esp. ortho), pregnancy and estrogen use,
smoking
3. classic findings- unilateral leg
swelling/pain better with elevation/rest
HOMANS sign - calf pain with dorsiflexion,
palpable cord, fever

390.

391.

392.

393.

394.

395.

396.

DVT dx
tx

doppler analysis, doppler ultrasound good for proximal thrombi, not for distal
Venography - best for calf veins
impedance plethysmography
D-dimer testing - high sens
tx = if doppler is positive start
anticoagulation, if non-diagnostic
repeat every 2-3 days for up to 2 weeks
- heparin bolus titrate up to 1.5-2x
aPTT, start warfafarin for 3-6 months,
thrombolytic therapy (massive PE and
unstable)
IVC filter - prevents PE

complications of
DVT

PE
post thrombotic syndrome (chronic
venous insufficiency)
phlegmasia cerulea dolens - severe leg
edema that compromises arterial supply
results in impaired sensory/motor
function

how to prevent
post-op DVT

leg elevation, compression stockings,


early ambulation, pneumatic boots

heparin or
LMWH +
pneumatic
compression =
BEST COMBO

...

chronic venous
insufficiency
1. pathogenesis

1. history of DVT destroys venous


valves--> ambulatory venous
hypertension --> edema and
extravasation of RBCs/proteins into
subQ tissue leads to pigmentation-->
reduced capillary flow and ulceration
with mild trauma

chronic venous
insufficiency
1. clinical
presentation
2. tx

1. swelling worse at end of day,


standing, sitting, elevation provides
relief
brawny, atrophic, shiny, indurated,
cyanotic skin
venous ulcers - MEDIAL MALLEOLUS
2. leg elevation avoid prolonged
standing, elastic stockings, wet to dry
saline dressings, unna venous boot,
skin graft

superficial
thrombophlebitis
1. patho
2. clincal pres

1. upper extremities - IV infusion


lower extremities - varicose veins
2. pain tenderness, erythema along
course of vein, with tender palpable
cord
3. tx = no anticoagulation, aspirin,
severe with pain/cellulitis - rest,
elevation, hot compresses, only use abx
if suppurative

397.

398.

399.

400.

401.

402.

403.

404.

septic phlebitis
tx

remove the offending IV canula and


treat with IV abx x

migratory
superficial
thrombophlebitis

2/2 occult malignancy especially


pancreatic cancer

1. most common
tumor of the
heart
2. atrial myxoma
3. atrial myxoma
clinical pres

1. metastasis from other primary tumors


2. MCC primary heart tumor - usually
from intratrial septum near fossa ovalis
3/ fatigue, fever, syncope, positional
murmur, DIASTOLIC TUMOR PLOP

shock
1. clinical
presentation

1. lactic acidosis, anuria/oliguria,


altered mental status

CO/SVR/PCWP
for
1. cardiogenic
shock
2. hypovolemic
3. neurogenic
4. septic

1. dec,inc, inc
2. dec, inc, dec
3. dec, dec, dec
4. inc, dec, dec

cardiogenic
shock
1. patho
2. clinical pres
3. dx

1. post MI, tamponade, tension


pneumothorax, arrhythmias, massive
PE, cardiomyopathy, valve defects, VSD
--> CO too low to maintain tissue
perfusion
2. BP <90, urine output <20 ml/hr, inc.
JVP, pale cool skin, hypotension,
pulmonary congestion
3. ECG - ST changes,
echo - see MI changes, valve defects etc.
swan ganz cath - PCWP (<18), CO (>4),
CI (>2.2), SVR

cardiogenic
shock
4. tx

4. NO IV FLUIDS IF LEFT
VENTRICULAR PRESSURES ARE
ELEVATED
ABCs,
identify cause, aspirin and heparin,
treat arrhythmias/tamponade
dopamine dobutamine norepinephrine, or phenylephrine
do not use nitroprusside/nitroglycerin
- diuretics
IABP

intra aortic
balloon pumps
effects

decrease afterload, increase CO,


decrease myocardial demand, increases
diastolic pressure (inc. coronary flow)

405.

406.

407.

hypovolemic shock
-page 66 good
classification of shock
chart
1. causes
2. dx/tx
- cool skin
****MONITOR URINE
OUTPUT AND
HEMODYNAMIC
MONITORING ARE
BEST INDICATORS OF
SHOCK STATUS

1. trauma, GI bleed,
retroperitoneal bleed
vomiting, severe diarrhea,
dehydration, burns, third
spacing
2. central venous line or
pulmonary arterial catheterdec. CVP/PCWP/dec. CO/inc.
SVR
tx = ABC, IV hydration (class
II,III,IV) with crystalloid if
non-hemorrhagic

septic shock
1. definition
2. patho
3. clinical pres
4. tx

1. shock induced by sepsis


unresponsive to fluid
resuscitation
2. pneumonia, pyelo,
meningitis, abscess,
cholangitis, cellulitis,
peritonitis --> SIRS--> sepsis -> septic shock --> multi organ
dysfunction syndrome
3. signs of SIRS, signs of
shock, temperature, severe
peripheral vasodilation,
WARM FLUSHED SKIN
4. IV abx, including fungal
coverage, fluid administration,
vasopressors

1. SIRS
2. sepsis
2a. severe sepsis
3. septic shock
4. multiorgan
dysfunction

2 or more of
fever >38 or hypothermia <36
hyperventilation >20 bpm, or
PaCO2<32
Tachycardia >90
Inc. WBC >12000 or <4000 or
>10% bands
2. positive blood cultures (2
different sites) before abx
administration + SIRS
2a. sepsis with organ
dysfunction, hypoperfusion or
hypotension
3. hypotension induced by
sepsis despite adequate volume
resuscitation
4. altered organ function in
acutely ill patient leading to
death

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417.

neurogenic
shock
1. patho
2. clinical pres
3. tx

1. failure of nervous system ot maintain


adequate vascular tone - results from
spinal cord injury, severe head injury,
spinal anesthesia, sympathetic blockade
--> peripheral vasodilation and decreased
SVR
2. warm skin, low UOP,
bradycardia/hypotension
3. IV fluids, cautious use of
vasoconstrictors, trendelenburg position,
control body temp

COPD
1. chronic
bronchitis
diagnostic
criteria
2. pathogenesis

1. chronic cough producing sputum for >3


months for >2 years
2. excess mucus production narrows
airways--> productive cough--> scarring
of airways, enlargement of mucus glands,
smooth muscle hyperplasia

diagnostic test
for sjogrens

schirmers test with anti-Ro antibodies

DMARDs

methotrexate, anti-TNFs, antimalarials,


sulfasalazine

other associated
conditions with
ank-spondy

uveitis, other joint disease, crohns

1. what are the


causes of reiters
syndrome
2. clinical pres
3. clinical
associations

gonorrhea,non-gonococcal urethritis,
GI infections - yersinia, campylobacter,
salmonella, shigella
2. oligoarticular arthritis, conjunctivitis,
urethritis, keratodermia
blennorrhagicum (looks like papular
psoriasis), spondylitis
3. HLA B27,

Scleroderma
systemic
sclerosis,

systemicvasculopathy of small and


medium-sized vessels, excessive collagen
depositionin tissues, and an abnormal
immune system. It is an uncommon
multisystemdisease affecting women
more often than men. There are two
variants of scleroderma

polymyalgia
rheumatic
1. patho +
clinical
association

1. proximal joint stiffness worse in the


morning associated with giant cell
arteritis (50% of patients with GCA have
polymyalgia rheumatica),

radiological
finding of
psoriatic
arthritis

pencil in cup deformity @ DIP

chondromalacia
patellae

common problem in runners - pain is


worse when walking down stairs - lateral
displacement of the patella with knee
extension

418.

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422.

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424.

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426.

427.

dermatomyositis
vs. polymyositis
etiology

dermatomyositis is immune complex


deposition

polymyositis is T
cell mediated

...

emphysema
1. patho

1. alveolar wall destruction to to excess


protease (from PMNs/macrophages), or
lack of anti-protease enlargement of the
air spaces distal to the terminal
bronchioles

causes of COPD

tobacco smoke
alpha 1 antitrypsin
environment (2nd hand smoke)
chronic asthma

how does
tobacco smoke
cause
emphysema

increases number of activated


PMNs/macrophages and also inhibits
alpha 1 antitrypsin

centrilobular
emphysema

destruction limited to respiratory


bronchioles (proximal to acini) usually
in upper lung zones]
*** centrilobular is seen in
SMOKERS**

panlobular
emphysema

destruction involves proximal and distal


acini in the lung bases
**panlobular is seen in patients
with alpha 1 antitrypsin
deficiency**

COPD
1. clinical
presentation
2. PFT findings
that defines
COPD

1. cough, sputum production,


progressively worsening DOE, full
exhalation >6 seconds, end expiratory
wheezes, hyperresonance,
2. dec. FEV1 FEV1/FEV <0.70 (= airway
obstruction), increased TLC, inc FRC,
inc. RV

key history in
COPD patients

history of cardiopulmonary disease,


smoking history
family history
occupation
overall health
history of respiratory infections
pulmonary medications
symptoms- cough, dyspnea, sputum,
wheezing

pink puffer

emphysema
thin (inc. work of breathing)
lean forward
barrel chested
tachypnea with prolonged expiration
through pursed lips
accessory muscles

428.

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432.

433.

434.

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437.

blue bloater

chronic bronchitis
overweight and cyanotic
chronic cough with sputum

Obstructive/restrictive
lung dz
1. FEV
2. FEV1/FVC
3. peak expiratory flow
4. residual volume
5. TLC
6. VC
7. peak expiratory flow

1. low/normal or slightly low


2. low/normal or high
3. low/normal
4. high/low,normal or high
5. high/low
6. low/low
7. <350 L/min

COPD CXR

hyperinflation, flattened
diaphragm, enlarged retrosternal
space, dec. pulmonary vascular
markings

what is the best


screening test for
COPD

peak flow meter ~ if <350L/min


then proceed to PFTs

clinical monitoring of
COPD patients

serial FEV1 measurements


pulse OX
exercise tolerance

functional residual
capacity

ERV + RV

treatment of COPD

1. smoking cessation
beta agonist - salmeterol
ipratropium - longer lasting
combo therapy
inhaled steroids- slow FEV1
decline minimally, use with
bronchodilators
exacerbations - steroids,
antibiotics
theophylline
oxygen therapy
vaccination - strep.pneumo every
5 years
pulmonary physiotherapy
BETA BLOCKERS
CONTRAINDICATED IN ACUTE
COPD AND ASTHMA

what is the risk of long


term hypoxemia

pulmonary hypertension and cor


pulmonale

criteria for long term


oxygen in COPD
patient

PaO2 55mmHg
O2 sat <88%
PaO2 55-59+ polycythemia
Hct>55 or cor pulmonale
hypoxia during exercise or sleep
(nocturnal)
**in the context of optimal
medical therapy

>15 hours a day shows


survival benefit

...

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442.

1. acute COPD
exacerbation
2. tx

1. pulmonary infections --> persistent


increase in dyspnea not relieved with
bronchodilators, inc. sputum/cough,
can lead to acute respiratory failure
2. CXR, bronchodilators, systemic
corticosteroids, azithro or levofloxacin,
supplemental O2, positive pressure vent
(CPAP/BIPAP), mechanical vent

asthma
1. definition
2. extrinsic vs
intrinsic
3. clinical pres

1. TRIAD - airway inflammation,


airway hyper responsiveness and
airway obstruction
2. extrinsic = atopic - IgE produced to
environmental antigens, eczema and
hay fever.... intrinsic has no
environmental triggers
3. WORSE AT NIGHT* intermittent
SOB, wheezing, chest tightness, cough

1. signs of acute
severe asthma
attack (acute
asthma
exacerbation
2. treatment

1. tachypnea, diaphoresis, wheezing,


speaking in incomplete sentences, use
of accessory muscles (**indicates
impending respiratory failure)
2. nebulized albuterol, oxygen, IV
corticosteroids/taper, IV magnesium

what are the


causes of
wheezing (4)

asthma
CHF - 2/2 edema/congestion
COPD - inflamed narrow airways
cardiomyopathies - pericardial diseases
causing edema
Lung cancer- obstruction of the airways

asthma
4. dx

4. Peak flows*** - normal 450650L/min


mild >300, mod 100-300, sev <100
PFTs*** dec. FEV1, dec. FEV1/FVC, at
least 12% of airflow obstruction is
reversible (inc. in FEV1 by 12% with
bronchodilator),
dec. in FEV1 >20% with methacholine
or histamine
CXR- only mild hyperinflation
ABGs - if in respiratory distresshypocarbia (LOW PaCO2), hypoxemia

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classification/treatment
asthma
1. mild intermittent
2. mild persistent
3. moderate persistent

1. sx 2 or less times/week albuterol rescue inhaler


2. >2x/wk but not every day albuterol + low dose inhaled
steroid
3. daily sx, freq exacerbations daily inhaled corticosteroid or
cromoly, nedocromil,
methylxanthine, or
antileukotriene
4. daily high dose inhaled
corticosteroid, long acting beta
2 agonist, or methylxanthine
and systemic steroids

side effects of inhaled


corticosteroids

sore throat, oral candidiasis,


hoarseness

what to order in a
suspected acute asthma
exacerbation

PEF - decreased
ABG - inc A-a gradient
CXR - rule out
pneumonia/pneumothorax

asthma complications

status asthmaticus (no response


to standard meds),
acute respiratory failure
(respiratory muscle fatigue)
pneumothorax, atelectasis,
pneumomediastinum

aspirin sensitive
asthma

seen in patients with asthma


and nasal polyps, asthma is
exacerbated by aspirin

bronchiectasis
1. patho
2. clinical pres
3. dx/tx

1. CF***, infection, humoral


immunodeficiency, airway
obstruction --> permanent
dilation of bronchial wall,
damaged cilia
2. chronic cough with foul
smelling mucopurulent purulent
sputum, dyspnea, hemoptysis,
recurrent pneumonia
3. high res CT, obstructive PFTs,
abnl CXR, bronchoscopy
tx = abx for exacerbations,
hydration, chest physiotherapy,
bronchodilators

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453.

cystic fibrosis
1. patho
2. clinical pres
3. tx

1. AUTOSOMAL RECESSIVE - defect in


chloride proteins causing impaired
chloride/water transport leading to thick
secretions of respiratory tract, exocrine
pancreas, sweat glands, intestines, GU
2. obstructive lung disease, chronic
pulmonary infections (pseudomonas),
pancreatic insufficiency, GI
complications
3. pancreatic enzyme replacement, fat
soluble vitamin supplement (ADEK),
vaccinations (flu, pneumo), abx, inhaled
rhDNase

lung cancer
1. types
2. risks
3. clinical pres
- tends to
present late
4. sites of mets

1. small cell (25%)


squamous, adeno, large cell,
bronchoalveolar (75%)
2. smoking - pack years, adeno has
lowest association with smoking,
asbestos, radon, COPD
3. cough, hemoptysis, obstruction,
wheezing, dyspnea, recurrent
pneumonia, constitutional symptoms
4. brain, bone, adrenals, liver

lung cancer
clinical
syndromes
1. SVC syndrome
2. phrenic nerve
palsy
3. hoarseness
4. horners
syndrome
5. pancoast
tumor

1. facial fullness, facial/arm edema,


dilated veins of anterior chest, JVD
2. destruction of phrenic nerve by tumor
causes hemidiaphragm paralysis
3. due to involvement of recurrent
laryngeal nerve
4. cervical sympathetic chain anhidrosis, ptosis, miosis
5. superior sulcus tumor involves C8-T2
causes radiation down the arm

1. which type of
lung cancer
associated with
airway
involvement
2. what kind of
lung cancer
associated with
pancoast tumor
3. which type of
lung cancer seen
in women, nonsmokers

1. SCC
2. SCC
3. bronchoalveolar

paraneoplastic
syndromes
1. small cell
2. squamous cell
3.
adenocarcinoma

1. SIADH, ectopic ACTH, hypertrophic


pulmonary osteoarthropathy, eaton
lambert - similar to myasthenia gravis
2. PTHrp, hypertrophic osteoarthropathy
3. hypertrophic osteoarthropathy

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457.

458.

lung cancer
1. dx

1. CXR (stable >2 years =


BENIGN) NOT A SCREENING
TEST
CT CHEST WITH CONTRAST
- useful for staging
sputum cytology - only
diagnoses central tumors
fiberoptic bronchoscope w/ bx
- only diagnoses central
tumors
whole body PET scan - detects
lymph node, thoracic, distant
metastasis
thoracic needle biopsy
mediastinoscopy - identifies
advanced disease and rules out
surgery as treatment

lung cancer
1. tx

1. NSCLC - surgery + radiation


adjuvant
SCLC - chemotherapy and
radiation, non-surgical

solitary pulmonary
nodule
1. possible causes
2. features favoring
benign
3. feature favoring
malignant
- page 80- algorithm

1. granuloma, hamartoma,
adenoma, carcinoma
2. age <50, non-smoker,
<1cm, smooth borders, central
calcification, no change in
size
3. age >50 (50%), smoker, size
> 2cm,

1. radiographic features
of SCC lung cancer
2. """"""
adenocarcinoma
3. """""" large cell
4. """""" small cell

1. central location, cavitary


2. peripheral location, plerual,
less associated with smoking
3. peripheral
4. central, extrinsically
compresses bronchi

1. management for a SPN


that is at new, or has
changed within 2 years
2. """ 1cm or larger that
has changed or is new or
films are not available

1. serial CT scan
2. PET scan

459.

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461.

mediastinal mass
1. MCC in older
patients
2. ant. mediastinal
masses
3. middle
mediastinal
masses
4. posterior
mediastinal
masses
5. symptoms of
mediastinal
masses
6. dx

1. mets, usually lung


2. thyroid, teratogenic tumors,
thymoma, lymphoma
3. lung cancer, lymphoma, aneurysms,
bronchogenic cysts, morgagni hernia,
pericardial cysts
4. neurogenic tumors, esophageal
masses, enteric cysts, aneurysms,
bochdalek hernia
5. cough, chest pain, dyspnea,
dysphagia, SVC syndrome, hoarseness
(RLN), horners (sympathetic ganglia),
diaphragm paralysis (phrenic)
6. CT scan

1. transudative vs
exudative pleural
effusions
2. causes of """"

1. transudative - elevated capillary


pressure in visceral or parietal pleura
or dec. plasma oncotic pressure
exudative - increased permeability of
pleural surfaces
2. transudative - CHF, cirrhosis,
nephrotic syndrome, peritoneal
dialysis, hypoalbuminemia, PE,
atelectasis
exudative - bacterial pneumonia, TB,
malig, metastasis, viral infection, PE,
collagen vascular disease

1. what tests
should be
performed on an
exudative pleural
effusion
2. lab findings that
distinguish
exudative vs
transudative
effusion

1. differential cell count, glucose, pH,


amylase, triglycerides, microbiology,
cytology
2. plerual protein:serum protein >0.5
pleural LDH: serum LDH >0.6
LDH > 2/3 upper limit of normal

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467.

pleural
effusion
1. dx
2. tx

1. CXR - blunting of costophrenic angle


(~250ml) lateral decubitus better than PA and
lateral
CT scan is most reliable
thoracentesis (only if >10 mm deep on lateral
decubitus, complication = PTX ) --> SEND
FLUID TO BE TESTED FOR THE 4 C'S chemistry (glucose, pH, LDH, protein),
cytology, cell count, culture (and gram stain)
2. transudative - diuretics, sodium restriction ,
therapeutic thoracentesis if massive /dyspnea
exudative - treat underlying disease
parapneumonic - abx, chest tube, intrapleural
thrombolytics, surgical lysis

special
pleural
effusions
1. elevated
amylase
2. milky
opalescent
3. frankly
purulent
4. bloody
5.
lymphocytic
6. pH <7.2

1. esophageal rupture, pancreatitis,


malignancy
2. chylothorax
3. empyema
4. malignancy
5. TB
6. parapneumonic effusion or empyema

what does
low glucose
in a pleural
effusion
indicate

...

what does
low pH
pleural
effusion
indicate

exudative effusion- rheumatoid arthritis, TB,


esophageal rupture, malignancy, lupus

empyema***
must place
chest tube

...

empyema
1. patho
2. tx

1. complicated bacterial pneumonia, exudative


pleural effusion --> empyema (pus) (ie. a
complicated parapneumonic effusion)
2. thoracentesis, abx, rib resection/open
drainage

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471.

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473.

474.

pneumothorax
1. patho
2.secondary
pneumothorax
3. clinical pres
4. dx/tx

1. traumatic (transthoracic needle


aspiration, thoracentesis, central line), or
spontaneous (subpleural blebs) --> air in
normally airless pleural space
2. complication of COPD, asthma,
interstitial lung disease, neoplasms, CF,
TB
3. ipsilateral chest pain, dyspnea, cough,
dec. breath sounds, hyperresonance, dec.
tactile fremitus, mediastinal shift toward
PTX****
4. CXR - visceral pleural line
tx = small just observe
large or with symptoms - administer
oxygen and place a chest tube

fibromyalgia
1. clinical pres
2. dx

1. diffuse musculoskeletal pain (WITHOUT


weakness), worsens with exercise,fatigue,
non-restorative sleep, absence of joint
swelling
2. 11/18 tender point sites,

tension
pneumothorax
1. patho
2. clinical pres
3. dx/tx

1. mechanical ventilation, CPR, trauma -->


air accumulate in pleural space through
opening that acts as a valve leads to
collapse of ipsilateral lung and medi
2. hypotension, distended neck veins,
tracheal shift away from PTX, dec. breath
sounds on affected side, hyperresonance to
percussion on affected side
3. dx- DO NOT DO CXR IF SUSPECTED ,
decompress via large bore cx tube

malignant
mesothelioma
clinical
association

asbestos exposure

define
interstitial
lung disease

inflammatory process of the alveolar wall


with widespread fibroelastic
proliferation/collagen deposition that can
lead to irreversible lung damage

what drugs are


known to be
toxic to the
lungs

chemotherapeutics, amiodarone,
penicillamine, nitrofurantoin, bleomycin,
phenytoin

end stage
interstitial
lung disease is
referred to as

honeycomb lung

475.

476.

477.

478.

479.

sarcoidosis
1. patho
2. clinical
pres

1. chronic systemic NONCASEATING


GRANULOMAS of unknown etiology (more
common in AA women <40years old
2. constitutional symptoms, dry cough,
erythema nodosum (painful skin lesions on
shins), DOE, erythema nodosum, plaques,
subQ nodules, anterior uveitis, arrhythmias,
conduction defects, sudden death, arthritis, ,
bone lesions, bells palsy, optic nerve
dysfunction, papilledema, hepatomegaly

sarcoidosis
1. dx
2. PFTs
3. tx

1. CXR - bilateral hilar adenopathy (4 stages)


skin anergy
elevated ACE
hypercalcemia*, hypercalciuria
elevated vitamin D (granuloma activates 25 -> 1,25D3)
low PTH
**transbronchial biopsy showed
noncaseating granulomas**
2. dec lung volumes (VC and TLC), dec.
DLCO, dec. FEV1/FVC
3. spontaneously improve in 2 years
systemic corticosteroids,
methotrexate

classic
clinical
presentation
for
sarcoidosis

constitutional symptoms
respiratory complaints
erythema nodosum
blurred vision
bilateral hilar adenopathy

CXR staging
of
sarcoidosis

stage 1 - bilateral hilar adenopathy without


parenchymal infiltrates
stage 2 - hilar adenopathy with parenchymal
infiltrates
stage 3 - diffuse parenchymal infiltrates
without hilar adenopathy
stage 4 - pulmonary fibrosis with
honeycombing and fibrocystic parenchymal
changes

histiocytosis
x
1 patho
2. clinical
pres
3. dx/tx

1. chronic interstitial pneumonia caused by


proliferation of histiocytes 90% are cigarette
smokers
2. dyspnea and nonproductive cough, lytic
bone lesions, spontaneous pneumothorax,
diabetes insipidus
3. CXR shows honeycomb with cystic lesions,
reticulonodular appearance
tx = corticosteroids or lung transplant

480.

481.

482.

483.

484.

485.

486.

487.

488.

wegeners
granulomatosis
1. patho
2. clinical pres
3. dx/tx

1. necrotizing granulomatous
vasculitis affects lungs/upper
airway**, kidneys, and other organs
2. upper and lower respiratory
infections, glomerulonephritis,
pulmonary nodules, skin findings subQ nod, purpura, pyoderma
gangrenosum
3. tissue biopsy positive for CANCA*** ~ anti proteinase 3
tx = glucocorticoids +
cyclophosphamide

churg strauss
syndrome
1. patho
2. clinical pres
3. dx/tx

1. granulomatous vasculitis in asthma


patients,
2. pulmonary infiltrates, rash,
eosinophilia
3. CBC - eosinophilia
p-ANCA (myeloperoxidase positive
tissue biopsy
tx = systemic glucocorticoids

coal workers
pneumoconiosis

inhalation of coal dust with carbon


and silica can progress to fibrosis of
the lungs

substances that
cause
pneumoconiosis

silica, berylium, asbestos, coal dust,


graphite,carbon, aluminum, talc

asbestosis
1. patho
2. complications
3. dx/tx

1. diffuse interstitial lung fibrosis of


the LOWER LOBES
2. bronchogenic carcinoma,
malignant mesothelioma
3. CXR shows pleural plaques and
hazy infiltrates with linear opacities

CXR findings for


asbestosis/silicosis

asbestosis - pleural plaques


silicosis - egg shell calcifications

silicosis
1. patho
2. clinical pres
3. dx

UPPER LOBES nodular, localized


peribronchial fibrosis
2. DOE, cough with sputum
3. CXR, restrictive PFTs

diagnosis of
berylliosis

beryllium lymphocyte proliferation


test

hypersensitivity
pneumonitis
1. patho
2. causes
3. clinical pres
4. dx / tx

1. inhalation of organic dusts,


thermophilic actinomycetes, fungi,
avian proteins--> serum IgG/IgA -->
flu like features
2. farmers lungs (moldy hay), bird
breeders lung (avian droppings), air
conditioner lung, bagassosis,
mushroom worker's lung
3. cough, dyspnea, fever, chills,
myalgia 4-8 hours after exposure
4. IgG antibody to offending antigen
tx = steroids*****, and avoidance-bronchodilators/antihistamines are
INEFFECTIVE

489.

490.

491.

492.

493.

494.

495.

eosinophilic
pneumonia
1. dx
2. tx

1. fever, peripheral eosinophilia, CXR with


peripheral pulmonary infiltrates
2. systemic glucocorticoids

goodpasture's
syndrome
1. patho
2. clinical pres
3. dx/tx

1. IgG anti-GBM and alveolar basement


membrane -->
pneumonitis/glomerulonephritis
2. hemoptysis, dyspnea, hematuria
3. tissue biopsy, IgG anti GBM
tx = plasmapheresis*, cyclophosphamide,
corticosteroids

pulmonary
alveolar
proteinosis
1. patho
2. clinical pres
3. dx/tx

1. accumulation of surfactant and


phospholipids in alveoli
2. dry cough, dyspnea, hypoxia, rales
3. CXR - ground glass, bilateral alveolar
infiltrates resembling a bat
lung biopsy ***
tx= lung lavage, GCSF, dont give steroids

idiopathic
pulmonary
fibrosis
1. patho
2. dx

1. gradual onset dyspnea, non-productive


cough
2. CXR - normal or honeycomb
lung biopsy***
PFTs - restrictive lung pattern (dec. TLC,
FEV1/FVC normal, dec. FEV1, dec. FVC)
tx = supplemental O2, corticosteroids with
and without cyclophosphamide, lung
transplantation

cryptogenic
organizing
pneumonitis
1. patho
2. dx

1. virus/meds/connective tissue disease -> inflammatory lung disease that presents


similar to pneumonia
2. CXR similar to pneumonia, abx
ineffective
tx = corticosteroids

radiation
pneumonitis
1 patho

1. thoracic radiation --> interstitial


pulmonary inflammation--> 2 years later
alveolar thickening, pulmonary fibrosis
2. low grade fever, cough, chest fullness,
dyspnea, pleuritic chest pain, hemoptysis
3. normal CXR
CT scan - diffuse infiltrates, ground glass
densities, patchy consolidation,
pericardial/pleural effusions
tx = corticosteroids

respiratory
failure
1. hypoxia
definition
2. hypoxemic
respiratory
failure
definition
3. causes of
hypoxemic
respiratory
failure

1. PaO2 <60, and PaCO2>50


2. low PaO2 with PaCO2 either low to
normal O2 saturation <90% with FiO2 >
0.6
3. V/Q mismatch, intrapulmonary
shunting
ex. ARDS, pneumonia, pulmonary edema ,

496.

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500.

501.

502.

ventilatory
respiratory
failure
1. definition
2. causes

1. hypercapnia**** and hypoxemia


2. dec. minute ventilation or inc. dead
space leads to CO2
retention/hypoxemia
ex. CNS depression, mechanical
restriction, respiratory fatigue, COPD,
asthma CF, severe bronchitis

how to change a
patient's
ventilation vs
oxygenation

ventilation - PaCO2- inc. RR or tidal


volume (minute ventilation = RR*TV)
oxygenation - PaO2 - inc FiO2 or inc
PEEP

two causes of
respiratory
failure
1. VQ mismatch
2.
intrapulmonary
shunting

1. hypoxia without hypercapnia, seen in


chronic lung disorders, RESPONSIVE
TO OXYGEN
2. no ventilation in perfused areas,
venous blood shunted into arterial
circulation without oxygenation - ex.
atelectasis, pneumonia, pulmonary
edema, NOT RESPONSIVE TO
OXYGEN

what are causes


of inc. CO2
production
leading to
hypercapnic
respiratory
failure

sepsis, DKA, hyperthermia

clinical pres. of
respiratory
failure

dyspnea, cough, inability to speak in


complete sentence, use of accessory
muscles, tachypnea, tachycardia,
cyanosis, impaired mentation

evaluation of
hypoxemic
patient
Pg 96 - evaluation
of hypoxic
patient

get ABG
look at PaCO2 elevated or not
look at A-a gradient
look at response to oxygen
1. if PaCO2 is elevated and A-a is
normal = hypoventilation
2. if PaCO2 is elevated and A-a is
elevated = hypoventilation + another
factor
3. if PaCO2 is normal, and A-a is
normal = low inspired PAO2
4. if PaCO2 is normal, A-a increased,
and response to supp O2 = VQ
mismatch
5. if PaCO2 is normal, A-a increased,
no response to supp O2 = shunt

treatment for
respiratory
failure

treat underlying cause - ex.


bronchodilators, corticosteroids, abx
provide supplemental oxygen at lowest
possible concentration
NPPV for conscious patients with
possible impending respiratory failure

503.

504.

505.

506.

507.

508.

509.

ways to
improve
tissue
oxygenation

inc. FiO2, inc. PEEP, inc. inspiratory time


fraction, inc. CO, inc. hemoglobin, remove
venodilators

NPPV
1. indications
2.
requirements

1. attempt to avoid intubation in patient


with impending respiratory failure
2. patient must be neurologically intact,
awake and cooperative

ARDS
1. patho
2. causes

1. bilateral inflammatory lung processes -->


inc. alveolar capillary permeability-->
massive intrapulmonary shunting
(atelectasis, surfactant dysfunction)/no
improvement with supplemental O2, dec.
pulmonary compliance, inc. dead space,
inc. A-a gradient.
2. sepsis***(pneumonia, urosepsis, wounds
etc), aspiration, severe trauma, pancreatitis,
massive transfusions, near drowning,
intracranial HTN

ARDS
1. clinical pres
2. dx
3. tx

complications
of ARDS

1. dyspnea, tachypnea, tachycardia,


hypoxemia
hypoxemia unresponsive to oxygen
PaO2/FiO2 <200
2. CXR - bilateral* pulmonary infiltrates
PaO2/FiO2<200, PCWP <18
ABG- PaO2 <60, initially PaCO2 low, then
PaCO2 high with inc. work of breathing
Pulmonary catheter - PCWP<18
3. oxygenation, mechanical ventilation with
PEEP, lower intravascular volume to PCWP
of 12-15 mmHg, vasopressors as needed
scarring, honeycombing, barotrauma 2/2
mechanical ventilation,, PTX,
pneumomediastinum, line infections, ileus,
stress ulcer, multiorgan failure, critical
illness myopathy

mechanical
ventilation
1. indications
2. goals

1. significant respiratory distress, impaired


LOC with lack of airway protection,
respiratory muscle fatigue
hypoxemia - PaO2 <70
hypercapnia - PaCO2 >50
2. PaO2 - between 50 and 60
PaCO2 - between 40 and 50
pH between 7.35-7.5

ventilator
settings
1.assisted
controlled
2.
synchronous
intermittent
mandatory
ventilation

1. guarantees a preset minute ventilation-breath delivered when patient initiates, if


patient does not initiate ventilator takes
control, every breath over the determined
rate delivers the same tidal volume
2. patients breathe on their own above set
mandatory rate* (volume is not determined)
without ventilator assistance or set volume,
if no breath initiated, ventilator will
determine breath

510.

511.

512.

513.

514.

515.

516.

ventilator settings
1. CPAP
2. pressure support
ventilation

1. no volume breaths delivered,


useful for weaning
2. pressure is delivered with an
initiated breath , enhances patients
respiratory efforts

ventilator
1. tidal volume
/minute ventilation
2. FiO2 setting
3. I:E ratio
4. PEEP settings

1. 8-10ml/kg at 10-12 breaths per


minute, adjust to achieve patients
baseline PaCO2
2. initially 100%, then titrate to
lowest FiO2 to maintain PaO2 5060 (>90% sat)
If FiO2 0.5 is not adequate, add
PEEP to allow for lowering of FiO2
3. 1:2 is the usual ration
4. 2.5-10 cm H2O, prevents
atelectasis,

extubation criteria

1. intact cough with secretion


suction, adequate respiratory drive
PaO2 >75, PaCO2 <45
O2 sat >90 on PEEP of 5cm H2O
and FiO2 <40-50%
TV > 5ml/kg
RR<30 breaths/min
vital capacity - 10-15ml

drugs used to
diagnose pulmonary
hypertension

nitric oxide, intravenous adenosine,


IV prostacyclin

what is the function


of PEEP and CPAP on
mechanical
ventilation

inc. PaO2 at a constant FiO2

what ventilator
settings associated
with oxygen toxicity

FiO2 >0.6 for 2-3 days

pulmonary
hypertension
1. definition
2. passive type
3. hyperkinetic type
4. obliterative

1. pulmonary arterial pressure


>25mmHg at rest or >30 during
exercise
2. resistance to pulmonary venous
drainage - ex. mitral stenosis, LVF,
myxoma
3. high pulmonary blood flow - ex.
left ot right shunts, ex.
VSD,ASD,PDA
4. obliterative type - resistance from
destruction of small pulmonary
vessels - ex. PPH, collagen disease,
CREST

517.

518.

519.

520.

pulmonary
hypertension
1. obstructive
type
2.
vasoconstrictive
type
3. increased
intrathoracic
pressure
- inc. blood
viscosity
*or classify by
post capillary,

1. resistance to flow through large pulm


arteries
2. hypoxia induced vasoconstriction ex. chronic hypoxemia, COPD,
obstructive sleep apnea
3. inc. pressure to pulm vasculature - ex.
PEEP, COPD

complications of
mechanical
ventilation

anxiety, sedation/discomfort (tx =


benzo, opioid, propofol)
tracheal secretions - tx= suction
nosocomial pneumonia
barotrauma
oxygen toxicity
hypotension
tracheomalacia - switch to
tracheostomy after 2 weeks
laryngeal damage,

pulmonary
hypertension
1. clinical pres
2. dx

PPH
1. patho
2. dx/tx
-exertional
syncope common
- presents late,
very poor
prognosis only 23 year survival

521.

522.

523.

1. DOE, fatigue, CX pain, syncope on


exertion (50%)***, loud P2, JVD,
hepatomegaly, peripheral edema (with
heart failure later)
2. RVH with RAD
Echo- dilated pulmonary artery with
RA/RV hypertrophy
abnormal IV septum movement
cardiac cath - shows elevated
pulmonary artery pressures
1. abnormal pulmonary arteriolar
resistance --> thickening of arteriolar
walls, most common in middle age
women
2. cardiac cath***
CXR - enlarged central pulmonary
arteries, enlarged RV, clear lung fields
PFT - restrictive pattern
ECG - right axis deviation
tx = IV prostacyclins, CCBs (nifedipine
or diltiazem),
nitric oxide/adenosine/CCB trials
anticoag with warfarin

524.

525.

526.

527.

cor
pulmonale
1. patho
2. clinical
pres
3. dx/tx

1. COPD, PE, ILD, asthma, CF, sleep apnea,


PPH --> right ventricular
hypertrophy/failure
2. signs of RV failure, cyanosis, clubbing
3. treat underlying disorder, USE
DIURETICS CAUTIOUSLY THESE
PATIENTS ARE PRELOAD DEPENDENT,
long term O2 therapy, digoxin for LV
failure,

how does PE
cause death

hypoxemic respiratory failure


acute pulmonary hypertension and RV
failure

pulmonary
emboli
sources

DVT
fat embolism
amniotic embolism
air embolism
septic embolism (IVDU)
schistosomiasis

PE
1. patho
2. DVT
sources
3.
complications
4. risk factors

1. thrombus from other region of the body


embolizes to the pulmonary vascular tree -->
dead space, inc PulmVR- acute cor
pulmonale
2. deep veins of the lower extremities and
pelvis
3. recurrent PE, pulmonary HTN (66%)
4. age >60, malig, hx of DVT/PE, hereditary
hypercoagulability, cardiac diseease,
obesity, nephrotic syndrome, pelvic/ortho
surg, major trauma, pregnancy, estrogen
use

two
important PE
studeies

The PIOPED study, the Christopher study

clinical
presentation
of fat
embolism

dyspne, altered mental status, petechiae


over the chest

PE clincal
pres
PE mortality

dyspnea ***, pleuritic chest pain, cough,


hemoptysis, sycope, S3/S4, inc. P2
tachypnea, SOB - due to inc. dead space-->
hypoxemia/hypercarbia
30% mortality, 10% if diagnosed within 1
hour,
if untreated 30% will die from recurrent PE
treatment reduces mortality to 2-8%

528.

529.

530.

531.

532.

533.

534.

535.

PE
1. dx
2. how to rule
out PE
3. what
patients
cannot have
spiral CT

1. ABG - low PaO2, low PaCO2, high pH


elevated A-a gradient*
CT scan - intraluminal filling defects in
central/segmental or lobar pulmonary
arteries
Pulmonary angiogram**** definitive dx
D-dimer 2. negative pulmonary angiogram,
negative D-dimer assay, low prob VQ scan
3. patients with renal failure due to the IV
contrast

PE
1. CXR findings
2. negative CTA but high
clinical
suspicion=
what prob of
PE
3. tx

1. atelectasis, or pleural effusion,


westermark's sign (prom central pulm
artery with local oligemia), hampton's
hump (lung infarction)
2. 5%
3. supplemental O2, anticoag (START
IMMEDIATELY with heparin and
warfarin), continue for 3-6 months
thrombolytics - TPA, streptokinase
IVC filter

complications
associated
with IVC filters

higher risk for DVT


perforation of the IVC wall
IVC obstruction

indications for
IVC filters

contraindication for anticoagulation


complication of current anticoagulation
failure of adequate anti-coagulation
low pulmonary reserve at high risk for PE

wells criteria
for acute PE

symptoms/signs of DVT - 3
alt diagnosis less likely than PE - 3
HR > 100 bpm - 1.5
immobilization >3 days or surgery in
previous 4 weeks - 1.5
previous DVT or PE - 1.5
hemoptysis - 1.0
malignancy - 1.0

if <4 - get Ddimer


if >4 get spiral
CT scan

...

pulmonary
aspiration
1. anatomic
location
2. clinical
presentation
3.
predisposing
factors

1. lower portions of the right upper lobe


upper portions of hte right lower lobe
2. symptoms of pneumonia 2-4 days after
aspiration (in 40% of patients who
aspirate)
3. reduced LOC, alcoholism, extubation,
excessive vomiting, ileus, tracheostomy,
anesthesia/surgery, NMJ diseases,
esophageal disorders (achalasia, GERD,
cancer)

what is the
indication for
an INR 2.5-3.5

recurrent MI, antiphospholipid antibody


syndrome

536.

537.

538.

539.

540.

541.

542.

543.

1. aspiration
pneumonia clinical
pres
2. dx
3. tx

1. initially asymptomatic, then


cough, SOB, fever, tachypnea,
hypoxemia, frothy sputum
2. CXR similar to bacterial
pneumonia, atelectasis,
collapsed areas
3. ABCs, clindamycin, early
bronchoscopy for obstruction,

how to prevent
aspiration pneumonia

keep head of bed elevated, NG


tube

dyspnea
1. key history
2. most common causes

1. acute vs chronic, heart/lung


disease, baseline level of activity,
exertional component, smoking,
sputum
2. CHF exacerbation,
pneumonia, bronchospasm, PE,
anxiety

dyspnea
1. cardiovascular
causes
2. respiratory causes
3. psychiatric causes
4. chest wall causes
5. neuromuscular
causes
6. systemic causes

1. CHF, ischemia,
pericarditis/tamponade,
arrhythmias, valve disease,
congenital
2. COPD, asthma, PE, ARDS,
pneumonia, TB, bronchitis,
pleural effusion, pulmonary
edema, PTX, airway obstruction,
ILD
3. GAD, panic attacks,
hyperventilation
4. kyphoscoliosis, rib fractures,
ank spondy
5. myasthenia , muscular
dystrophy
6. chronic anemia, sepsis, DKA,
GERD, narcotics

dyspnea
1. dx

1. pulse ox - COPD may be


chronically low
ABG - indicated if pulse ox is low
CXR - can show etiology
CBC - anemia, infection
ECG - ventricular
hypertrophy/ischemia
Echo- further eval
VQ scan, bronchoscopy

what are the


complications of
aspiration

lung aspiration/pneumonia

what lab/studies used


to distinguish between
lung/heart disease

CXR, sputum gram stain, PFT,


ABG, ECG, echocardiogram

what will a chronic


COPD patient's blood
gas show at baseline
and during
exacerbation

baseline - normal pH, elevated


HCO3exacerbation - low pH, normal
HCO3-

544.

545.

546.

547.

548.

549.

550.

551.

552.

hemoptysis
1. massive hemoptysis
definition + most
common causes
2. causes
3. dx

1. >600 ml in 24 hoursbronchiectasis ,and bleeding


diathesis
2. bronchitis, TB, bronchiectasis,
pneumonia, idiopathic, good
pastures, PE with infarction,
aspergilloma, mitral stenosis,
hemophilia.
3. CXR - may show fungus ball,
mass, granuloma, opacity
fiberoptic bronchoscopy - if
suspicious for lung carcinoma
CT chest -

indication for home


oxygen

O2 saturation <88%

acidosis expected
changes for
respiratory/metabolic
on ABG

10 mmHg change in PaCO2 expect


0.08 change in pH

what is normal PaO2


what is the risk of
taking an ABG

90 in a 20 year old person


will decrease

radial artery spasm


which can result in
ischemia of the hand

...

what is spirometry
useful to evaluate
what is DLCO useful
to evaluate
what conditions have
high vs low DLCO

obstructive vs restrictive lung


disease
degree of functional impairment

asthma vs COPD,
monitoring of
sarcoidosis and
emphysema

...

High - asthma,
obesity, left to right
shunt, exercise,
pulmonary
hemorrhage
Low - emphysema,
sarcoid, fibrosis,
pulmonary vascular
disease, anemia

...

hemoptysis
evaluation

CXR, fiberoptic bronchoscopy, CT


chest

553.

554.

555.

556.

557.

558.

559.

560.

561.

colorectal
cancer
1. screening
2. staging
3.
recurrence
surveilance
4. methos of
spread of
CRC

1. FOBT (PPV 20%), DRE (10% palpable),


colonoscopy, flexible sigmoidoscopy (2/3
colon cancer) barium enema
2. CT scan of chest, abdomen, pelvis
3. CEA 4. direct extension, portal systme to liver,
lymphatic

colorectal
cancer risk
factors

age >50
adenomatous polyps
IBD - UC 20% at 30 years of age
family history (first degree relatives

CRC
1.
histological
classes
2.
morphology
types

1. tubular, tubulovillous, villous (worst)


2. sessile, pedunculated

FAP

autosomal dominant APC mutation leads to


hundreds of adenomatous polyps in the colon,
and duodenum (90%), as well as stomach,
jejunum, ileum
tx = prophylactic colectomy

gardners
syndrome

colon polyps, osteomas, dental abnormalities,


soft tissue tumors, desmoid tumors, sebaceous
cysts, epidermoid inclusion cysts

turoct's
syndrome

AUTOSOMAL RECESSIVE
colon polyps, cerebellar medulloblastoma,
GBM

peutz
jeghers

hamartomas of entire GI tract - small bowel,


colon, stomach
pigmented spots of the face, lips, oral
mucosae, face, genitalia , palmar surfaces
inc. incidence of stomach, ovary, breast,
cervix, lung cancer
intussusception

familial
juvenile
polyposis
coli

many juvenile polyps, low risk of CRC

HNPCC
1. lynch 1

1. early onset CRC, absence of antecedent


multiple polyposis
2. lynch 1 + early onset of other cancers female (endometrial 43%/ovarian) skin,
stomach, pancreas, brain, breast biliary

562.

563.

564.

565.

566.

567.

568.

569.

570.

CRC
1. clinical
presentation
2. right sided
clinical pres
3. left sided
clinical pres
4. rectal clinical
pres

1. abdominal pain, large bowel


obstruction, weight loss, blood in stool
2. no obstruction (large diameter),
melena, occult blood, IDA, change in
bowel habits, RLQ mass
3. obstruction, hematochezia, change
in caliber of stools (pencil)
4. hematochezia, tenesmus, rectal
mass/feeling of incomplete evacuation

what fraction of
CRC patients are
metastatic at
clinical
presentation

20%

CRC
1. tx
2. follow up

1. surgical resection of tumor and


regional lymphatics, pre-op CEA, post
op chemo/radiation
2. stool guaiac
annual CT scan of pelvis + CXR for 5
years
colonoscopy at 1 year and then every 3
years
CEA every 3-6 months

non-neoplastic
polyps

hyperplastic polyps, juvenile polyps


(remove), inflammatory polyps (UC)

adenomatous
polyps
+ histology, size,
typia, and
morphology

benign lesions with significant


malignant potential (villous
>tubulovillous > tubular), (large >
small), (atypia > no atypia), (sessile
>pedunculated)

Diverticulosis
1. patho
2. clinical pres
3. dx/tx

1. low fiber/constipation --> inner


colon bulges through weakness
2. asymptomatic or incidental finding,
LLQ pain, bloating,
constipation/diarrhea
3. barium enema
tx = high fiber foods, psyllium

diverticulosis
1. complications

1. painless rectal bleeding (5% is


severe), diverticulitis

diverticulitis
1. patho
2. clinical pres
3. complications
4. recurrence rate

1. impacted feces in a diverticulum


leads to erosion/microperforation
2. LLQ pain, leukocytosis, altered
bowel habits, lower GI bleeding RARE
(compare to diverticulosis)
3. abscess, colovesical fistula,
obstruction, colonic
perforation(peritonitis)
4. 30% of medically treated patients at
5 years

what is worse,
rectal cancer, or
colon cancer

rectal has higher recurrence rate, lower


5 year survival

571.

572.

573.

574.

575.

576.

what is the
indication for
radiation in CRC

NOT indicated for colon cancer


radiation IS indicated for rectal cancer

where are most


colonic polyps
found
+ most common
symptoms of
colonic polyps

in the rectosigmoid junction


most common symptom is painless
rectal bleeding

diverticulitis
1. dx
2. tx

1. CT abdomen with oral/IV contrast


Ab XR - rules out ileus or obstruction (air
fluid levels), and perforation (free air)
BARIUM ENEMA/COLONOSCOPY
ARE CONTRAINDICATED
2. IV abx (7-10 days) cipro/flagyl, bowel
rest, NPO, IVF
surgery if persists 3-4 days or
complicated

angiodysplasia
1. patho +
clinical pres
2. dx/tx
3. key clinical
association
(non-GI)

1. tortuous submucosal vein in the colon


--> bleeding, 15% massive bleeding
2. colonoscopy (better than
angiography)
tx= 90% stops bleeding spontaneously,
right hemicolectomy if persistent
bleeding
3. AORTIC STENOSIS

acute mesenteric
ischemia
1. patho (4)
2. mortality

1. arterial embolism (cardiac - afib, MI,


valves),
arterial thrombosis (atherosclerosis,
may be 2/2 dec. CO from MI),
non-occlusive (splanchnic
vasoconstriction in critically ill/elderly),
venous thrombosis
(infection/hypercoagulable, portal HTN,
malig, pancreatitis)
2. 60-70%, 90% if bowel infarction

acute mesenteric
ischemia
1. clinical pres
2. dx/tx

1. abdominal pain disproportionate to


physical findings, anorexia, GI bleeding,
sepsis, shock, peritonitis
2. mesenteric angiography**, SERUM
LACTATE***
plain film abdomen (rule out other
causes
thumbprinting on barium enema
(edematous mucosal folds)
tx = IVF, broad spectrum ABX
papaverine vasodilator into SMA
thrombolytics/embolectomy
heparin (for venous thrombosis)
surgery - for non-viable bowel if
peritonitis symptoms
AVOID VASOPRESSORS - WORSEN
ISCHEMIA

577.

578.

579.

580.

581.

582.

583.

584.

chronic
mesenteric
ischemia
1. patho
2. clinical pres
3. dx/tx

1. atherosclerotic occlusion of main


mesenteric vessels
2. progressive *postprandial abdominal
angina, weight loss
3. mesenteric angiography
tx = surgical revascularization

ogilvie's
syndrome
1. patho
2. causes
3 dx/tx

1. SIGNS/SYMPTOMS/RADIOGRAPH
of large bowel obstruction without
mechanical obstruction
2. recent surgery/trauma, serious
medical illness, meds (narcotics,
psychotropics, anticholinergics)
3. diagnosis of exclusion after
mechanical obstruction ruled out
tx = stop offending agents, IV fluids,
electrolyte, decompression with
enemas/NG suction, surgical
decompression (with
cecostomy/colostomy)

diagnostic test of
choice for
diverticulosis vs
diverticulitis

diverticulosis - barium enema


diverticulitis - CT scan with oral/IV
contrast

comorbid
condition with
AVM

aortic stenosis

comorbid
conditions with
acute mesenteric
ischemia

heart disease - CHF, coronary disease

clinical
presentation of
acute mesenteric
ischemia
1. embolic
2. arterial
thrombosis
3. nonocclusive
ischemia
4. venous
thrombosis

1. sudden onset, more painful


2. more gradual and less severe than
embolic
3. occurs in critically ill patients
4. symptoms for days or weeks

signs of
intestinal
infarction

hypotension, tachypnea, lactic acidosis


*****, altered mental status

when should
colonic
distension be
immediately
decompressed

when the colon diameter exceeds 10cm - RISK FOR RUPTURE AND DEATH

585.

586.

587.

588.

589.

pseudomembranous
colitis (antibiotic
resistant colitis)
1. patho
2. most common abx
associated
3. clinical pres
4. compliations

1. abx treatment kills normal flora


that inhibit growth of c.diff --> c.diff
overgrowth/toxin formation
2. clindamycin, cephalosporins,
ampicillins (but all abx can cause)
3. sx in the first week of abx
treatment (or later) --> profuse
watery diarrhea, crampy abdominal
pain, toxic megacolon (risk of perf)
4. toxic megacolon, colonic
perforation, anasarca

pseudomembranous
colitis
1. dx/tx

1. c.diff stool antigen***


flexible sigmoidoscopy - shows
pseudomembrane
abdominal XR - rule out megacolon
tx = stop offending antibiotic
metronidazole, oral vanc if resistant
recurrence in 2-8 weeks in 35%

colonic volvulus
1. patho
2. locations
3. risk factors
4. clinical pres

1. twisting of intestine loop around


mesenteric attachment site causes
obstruction and vascular
compromise, necrosis, perforation
2. sigmoid 75%, colonic 25%
3. chronic illness, inc. age,
institutionalization, CNS disease,
chronic constipation, laxative
abuse, anti-motility drugs
4. acute colicky abdominal pain,
distension, obstipation, n/v

cecal volvulus
pathogenesis

congenital lack of fixation of the


right colon in younger patients

colonic volvulus
1. dx

1. Ab XR - sigmoid volvulus - omega


loop sign
cecal volvulus - coffee bean sign large air fluid level in RLQ
sigmoidoscopy diagnostic/therapeutic for sigmoid
volvulus
barium enema (don't do if suspect
strangulation) - shows narrowing at
twist = bird beak
tx = sigmoidoscopic decompression
(sigmoid)
emergency surgery (cecal)

590.

591.

592.

593.

cirrhosis
1. patho
2. causes

1. fibrotic replacement of normal liver


architecture -->
decreased hepatic blood flow (portal
hypertension)
impaired biochemical function - albumin,
clotting factors, urea cycle.
2. alcoholic liver (20% of heavy drinkers),
chronic hep B/C, acetaminophen, MTX,
autoimmune, primary biliary cirrhosis,
hemochromatosis, wilson's, right heart
failure, alpha w antitrypsin,

Childs
classification
Childs 1
Childs 2
Childs 3

1: no ascites, no encephalopathy, bilirubin


<2, albumin >3.5, good nutrition
2: controlled ascites, minimal
encephalopathy, bilirubin 2-2.5, albumin 33.5, good nutrition
3: uncontrolled ascites, severe
encephalopathy, bilirubin >3, albumin <3,
poor nutrition

cirrhosis
1. portal
hypertension
bleeding
complications
+ tx
2. variceal
bleeding
clinical pres
3. variceal
bleeding tx
-rectal
hemorrhoids,
caput
medusae

1. bleeding, hematemesis, melena,


hematochezia, esophageal variceal bleeding
tx = TIPS- transjugular intrahepatic
portosystemic shunt
2. hematemesis, melena, hepatic
encephalopathy
3. non-selective beta blockers (prophylaxis),
prophylactic abx , IV octreotide 3-5 days,
emergent upper GI endoscopy
(ligation/sclerotherapy)

ascites
1. patho
2. dx
3. tx

1. cirrhosis/portal hypertension -->


accumulation of peritoneal fluid due to
portal hypertension/hypoalbuminemia
2. abdominal ultrasound (as little as 30ml),
diagnostic paracentesis (cell count,
albumin, gram stain, culture) ascitic fluid
albumin >1.1 suggests portal HTN
3. tx = bed rest, low sodium diet, diuretics,
therapeutic paracentesis, peritoneovenous
shunt or TIPS

594.

595.

596.

597.

hepatic
encephalopathy
1. patho
2. clinical pres
3. tx

1. ammonia + other toxic metabolites


accumulate
TRIGGERED BY alkalosis, hypokalemia,
sedative drugs, infection, hypovolemia.
2. dec. mental function, confusion, poor
concentration, asterixis (with arms
extended, hands dorsiflexed),
rigidity, hyperreflexia
fetor hepaticus - musty breath
3. lactulose - prevents ammonia
absorption (bacterial metabolism of
lactulose forms NH4+ in lumen of gut)
neomycin (oto/nephro toxic) or rifaximin
- kills bowel flora dec. ammonia
production
limit protein to 30-40 g/day
ornithine aspartate
sodium benzoate
BCAA

hepatorenal
syndrome
1. patho
2. clinical pres
3. tx

1. progressive FUNCTIONAL renal failure


in advanced liver disease, 2/2 renal
hypoperfusion from renal vessel
vasoconstriction TRIGGERED BY*
diuretics/infection, large volume tap
without albumin
2. RENAL FAILURE THAT DOES NOT
RESPOND TO VOLUME
RESUSCITATION azotemia, oliguria,
hyponatremia, hypotension, low urine
sodium (<10mEq/L)
3. liver transplant

classic signs of
chronic liver
disease

ascites, varices, gynecomastia,


hyperestrinism (not being cleared from
blood + dec. HBG) - testicular atrophy,
palmar erythema, spider angiomas, hair
lossl
hemorrhoids, caput medusae
hypothyroidism - primary failure of TSH
release

treatment of
bleeding
esophageal
varices

variceal ligation/banding
endoscopic sclerotherapy
IV vasopressin
IV octreotide - causes splanchnic
vasoconstriction, reduces portal pressure
esophageal balloon tamponade
TIPS, shunts, liver transplant

598.

599.

600.

601.

602.

603.

ddx of ascites

cirrhosis, portal HTN,


CHF,
chronic renal disease
massive fluid overload
tuberculous peritonitis
malignancy
hypoalbuminemia
peripheral vasodilation secondary to
endotoxin induced release of NO (--> inc.
renin secretion

laboratory
monitoring for
patient with
cirrhosis

CBC, renal function


electrolytes, LFTs, coagulation studies
EVERY 3-4 MONTHS ^
endoscopy to find varices
CT guided biopsy for suspected HCC

compliations of
liver failure

AC9H
ascites, coagulopathy
hypoalbuminemia, hypoglycemia,
hyperammonemia, portal hypertension,
hyperestrinism, hyperbilirubinemia,
hepatic encephalopathy, hepatorenal
syndrome, HCC.

spontaneous
bacterial
peritonitis
1. patho
2. clinical pres
3. dx/tx

1. infected ascitic fluid (e.coli, klebsiella,


s.pneumo) *ONE ORGANISM (vs
perforation is polymicrobial)
2. abdominal pain, fever, altered mental
status, vomiting, rebound, sepsis
3. paracentesis - PMNs- >250, WBC
>500, positive ascitic cultures, protein
>2.5. SAAG <1.1, SG >1.016
tx = abx cefotaxime or ceftriaxone,
albumin,
repeat paracentesis in 2-3 days, look for
lower PMN/WBCs

1.
hyperestrinism
in liver failure
clinical pres
2.coagulopathy
in liver failure

1. spider angiomas (dilated cutaneous


arterioles), palmar erythema,
gynecomastia, testicular atrophy
2. inc. PT (vitamin K dependent factors)

treatment of
cirrhosis

abstinence from alcohol


interferons for hep B/C
avoid acetaminophen, alcohol
6 months abstinence to be eligible for liver
transplant

604.

605.

606.

607.

608.

609.

wilsons disease
1. patho
2. clinical pres

1. AUTOSOMAL RECESSIVE deficiency of ceruloplasmin -->


inability to excrete copper--> copper
accumulation in liver, kidney, cornea,
brain (basal ganglia) (hepatolenticular
degen)r
2. acute hepatitis, cirrhosis/liver
failure, kayser fleischer rings, EPS
signs, (parkinsonism symptoms resting tremor, rigidity, bradykinesia),
chorea, drooling, incoordination from
copper in basal ganglia

wilsons disease
1. dx/tx

1. dec. serum ceruloplasmin


inc. urine copper
elevated LFTs,
liver bx (shows elevated copper levels)
tx = D- penicillamine (chelator)
Zinc - prevents dietary copper uptake
liver transplantation

hemochromatosis
1. patho
2. organs effected
3. clincal pres
4. complications

1. AUTOSOMAL RECESSIVE (HLAA3) defect in HFE gene -->


inappropriate iron absorption and
accumulation of iron in the intestines
and other organs as
ferritin/hemosiderin --> excess free
oxygen radicals
2. liver, pancreas (DIABETES) , heart,
skin (BRONZE)
3. liver disease, fatigue, arthritis,
diabetes, arrhythmias, abdominal pain
4. cirrhosis, cardiomyopathy (CHF),
DM, arthritis (2nd/3rd MCP,
hyperpigmentation (BRONZE),
hypothyroid, cardiac condution
abnormalities *

secondary
hemochromatosis

2/2 multiple transfusions or in chronic


hemolytic anemia

signs of acute
liver failure

coagulopathy
jaundice
hypoglycemia
hepatic encephalopathy
infection
elevated LFTs

hemochromatosis
1. dx/tx

1. elevated serum iron, ELEVATED


SERUM FERRITIN
elevated transferring saturation
(>50%), dec. TIBC
liver biopsy - determines hepatic iron
genetic testing
tx = repeated phlebotomies,
deferoxamine, liver transplant

610.

611.

612.

613.

614.

615.

616.

617.

hepatocellular
adenoma
1. patho
2. clinical pres
3. dx/tx

1. females, OCP use, anabolic steroid use


2. asymptomatic, but can rupture causing
hemoperitoneum/hemorrhage
3. CT, ultrasound, hepatic arteriography
tx = dc OCP, resect tumors >5cm

cavernous
hemangioma
1. patho
2. clinical pres
3. dx/tx

1. small vascular AVM liver tumors, inc. in


size from pregnancy/OCP
2. asymptomatic, rupture/hemorrhage,
obstructive jaundice, coagulopathy, CHF
from large AV shunt
3. CT scan with IV contrast, NO BIOPSY
WILL HEMORRHAGE
tx = none required unless high risk for
rupture

focal nodular
hyperplasia

benign liver tumor with no malignant


potential, no association with OCPs, no
treatment required

HCC
1.two
pathological
types
2. risk factors
3. clinical pres

1. non-fibrolamellar (hep B/C)


unresectable with short survival
fibrolamellar (not associated with hep
B/C) more often resectable
2. cirrhosis (alcohol, hep B or C 10% of
patients get HCC)*** , aflatoxin, vinyl
chloride, thorotrast, AAT,
hemochromatosis/wilson's,
schistosomiasis, hepatic adenoma (10%),
cigarettes, type 1 glycogen storage disease,
tyrosinemia
3. abdominal pain, weight loss, anorexia,
fatigue, portal HN, ascites, jaundice,
splenomegaly , paraneoplastic syndromes

paraneoplastic
syndromes
associated
with RCC

erythrocytosis, thrombocytosis,
hypercalcemia, carcinoid syndrome,
hypertrophic pulmonary osteodystrophy,
hypoglycemia, high cholesterol

HCC
1. dx
2. tx

1. liver bx
hep B/C serology, LFTs, coagulation
studies
ultrasound, CT cx/ab/pelvis,
elevated AFP (40-70% of patients)
elevated alk phos
2. tx = liver resection, liver transplantation

most common
malignant liver
tumors

HCC and cholangiocarcinoma

nonalcoholic
steatohepatitis
1. patho + risk
factors
2. dx

1. no alcohol use, but have same changes


to liver -risk factors = obesity, hyperlipidemia, DM,
usually asymptomatic/benign
2. routine LFT shows mild elevation of
ALT/AST
macrovascular liver changes on liver
biopsy

618.

619.

620.

621.

622.

623.

624.

gilberts
syndrome
1. patho
2. clinical
pres
3. dx/tx

1. AUTOSOMAL DOMINANT - decreased


uridine diphosphate glucuronyl transferase
activity --> unconjugated
hyperbilirubinemia***
2. asymptomatic jaundice with fasting, fever,
alcohol, infection
3. normal liver bx, no treatment necessary

hemobilia
1.
patho/clincal
pres

1. trauma, papillary thyroid carcinoma,


surgery, tumors, infection -> blood draining
into the duodenum --> melena, hematemesis,
jaundice, RUQ pain
2. arteriogram, upper GI endoscopy (blood
from ampulla of vater)
tx = transfusion, resuscitation

polycystic
liver cysts
1. patho

1. assc. with polycystic kidney disease, rarely


progress to cirrhosis

hydatid liver
cysts
1. patho
2. treatment

1. echinococcus granulosus, or echinococcus


multilocularis --> CALCIFIED CYST****right
lobe of the liver--> rupture into peritoneal
cavity -- > fatal anaphylactic shock
2. surgical resection (don't spill),
mebendazole after surgery

pyogenic
liver abscess
1. patho
2. clinical
pres
3. dx/tx

1. biliary
obstruction/appendicitis/diverticulitis -->
bacterial proliferation - ecoli, klebsiella,
proteus, enterococcus, anaerobes
2. fever, malaise, anorexia, weight loss,
nausea, vomiting, RUQ pain
3. CT scan, elevated LFTs
tx = IV abx, percutaneous drainage

amebic liver
abscess
1. patho
2. clinical
pres
3. dx/tx

1. fecal oral - entamoeba histolytica -->


hepatic portal vein --> liver
2. fever, RUQ pain, n/v, hepatomegaly,
diarrhea
3. IgG assay, LFTs, E. histolytica stool
antigen
Ultrasound, CT scan
tx = IV metronidazole , aspiration if abscess
is large

budd chiari
syndrome
1. patho
2. clinical
pres
3. dx/tx

1. hypercoag, polycythemia, preg,


inflammatory disease, cancer
myeloproliferative --> occlusion of hepatic
venous outflow --> hepatic congestion
2. hepatomegaly, ascites, abdominal pain,
jaundice, variceal bleeding
3. hepatic venography, serum ascites
albumin gradient >1.1g/dl
tx = *balloon angioplasty with stent
placement, portacaval shunts
liver transplant
anticoag, thrombolytics diuretics

625.

626.

627.

628.

629.

630.

three major causes


of jaundice

hemolysis, liver disease, biliary


obstruction

jaundice
1. what level is
clinical observable
2. clinical finding
unique to
conjugated
hyperbilirubinemia
3. sources of
bilirubin
4. clinical findings
unique to
unconjugated
bilirubin

1. total bili >2mg/dl


2. dark urine/pale stools b/c
conjugated bili is loosely bound to
albumin
3. hemoglobin, myoglobin, liver
enzymes (--> unconj bilirubin in the
spleen)
4. tightly bound to albumin, cannot
be excreted in the urine, cross BBB
and causes neurological
damage/deficits

causes of
conjugated
hyperbilirubinemia
1. dec intrahepatic
excretion of
bilirubin
2. extrahepatic
biliary obstruction

1. hepatocellular disease (viral or


alcoholic hepatitis, cirrhosis), Dubin
johnson, rotors syndrome, PBC, PSC
2. gallstones, head of pancreas
carcinoma, cholangiocarcinoma,
periampullary tumors, extrahepatic
biliary atresia

causes of
unconjugated
hyperbilirubinemia
1. excess
production of
bilirubin
2. reduced hepatic
uptake of bilirubin
or impaired
conjugation

1. hemolytic anemia
2. gilberts, crigler najjar,
sulfonamides, penicillin, rifampin,
radiocontrast agents, immature conj.
system (physiologic jaundice of
newborn), hepatitis, cirrhosis

what labs to order


for
1. unconjugated
hyperbilirubinemia
2. conjugated
hyperbilirubinemia

1. CBC, retic, haptoglobin, LDH,


peripheral smear
2. ultrasound or CT, ERCP, MRCP,
liver biopsy

clinical
presentation of
cholestasis

jaundice
gray stools, dark urine (conjugated)
pruritus
serum alk phos
elevated cholesterol
skin xanthomas

631.

632.

633.

634.

635.

636.

637.

638.

Aminotransferases
1. which is more
sensitive/specific for
liver damage
2. what condition
does ALT and AST
not rise at same rate
3. mildly elevated
LFTs
4. moderate elevated
LFTs (100s-1000s)
5. severely elevated
LFTs (>10,000)

1. ALT
2. alcoholic liver disease - AST:ALT
2:1
3. chronic viral hepatitis, acute
alcoholic hepatitis
4. acute viral
5. ischema, shock liver,
acetaminophen toxicity, viral
hepatitis

why are LFTs not


always elevated in
patients with
cirrhosis or
metastatic liver
disease

because the number of functioning


hepatocytes is greatly reduced.

causes of elevated
LFTs in
asymptomatic
patients

Autoimmune hepatitis, hep B/C,


drugs, ethanol, fatty liver,
growths(tumors, hemodynamic
(CHF), iron (hemochormatosis),
copper (wilsons, AAT)

alkaline phosphatase
1. what causes very
high elevation
2. if levels are mildly
elevated what should
be the next step
3. what is possibility
if ALP is elevated but
GGT is normal

1. extra hepatic obstruction of bile


flow,
2. get a GGT which will tell if
elevated ALP is from a hepatic
origin
3. pregnancy, bone disease

where is
AST/ALT/ALP found
in the body

ALT - LIVER ONLY


AST - skeletal muscle, heart,
kidney, brain
ALP - bone, gut, placenta`

at what hemoglobin
level will central
cyanosis be present

> 4 g/dl desaturated


ie. 80% saturation in a COPDer
with hemoglobin 20
or 60% saturation in IDA patient
with hemoglobin of 10

tachybradycardia
syndrome
1. patho
2. tx

1. period tachycardia followed by


sinus node suppression-2. pacemaker (prevents the
tachycardia)
medications for the bradycardia

contraindications to
cardiac stress testing
+ what to do to test
them for CAD

pre-existing ST depression, LVH


** do nuclear testing instead

639.

640.

641.

642.

643.

644.

645.

what conditions have low


albumin

chronic liver disease


nephrotic syndrome
malnutrition
inflammatory states -sepsis,
trauma, burns

what clotting factors not


synthesized by the liver

III, VIII, vWF

cholelithiasis
1. yellow/green stones\
2. black stones
3. brown stones

1. obesity, diabetes, multi


partum, OCP, cirrhosis, CF
2. hemolysis (SCD,
thalassemia, spherocytosis,
cardiac valves,), or alcoholic
cirrhosis
3. biliary tract infection

cholelithiasis
1. clinical pres
2. complications
3. dx

1. biliary colic, from


temporary obstruction of the
gallbladder with gallstones
RUQ pain, radiates to the
right subscapular region
(BOAS SIGN)
2. cholecystitis,
choledocholithiasis, gallstone
ileus, malignancy
3. RUQ ultrasound (>2mm),
CT/MRI

what fraction of patients


with biliary colic develop
cholecystitis in 2 years

...

what causes pain in


biliary colic vs
cholecystitis

30% (10% of patients with


gallstones develop
cholecystitis)

biliary colic = contraction


of gallbladder against
obstructed cystic duct
acute cholecystitis = pain
from inflammation of the
gallbladder wall

...

646.

647.

648.

649.

650.

651.

652.

acute cholecystitis
1. patho
2. clinical pres
3. dx/tx

1. obstruction of cystic duct -->


inflammation of gallbladder wall
2. RUQ/epigastric pain, radiates to
right scapula/shoulder, N/V,
anorexia, MURPHY'S SIGN, fever,
leukocytosis
3. RUQ ultrasound - thickened
gallbladder wall, pericholecystic
fluid, distended gallbladder, stones
CT scan - higher sens for
complications - perforation, abscess,
pancreatitis
HIDA scan - positive if gallbladder
NOT visualized
tx = admission, hydration, IVF, NPO,
IV ABX, analgesics
Cholecystectomy within 24-48 hours

signs of biliary
tract obstruction

elevated ALP, GGT, jaundice,


pruritus, clay colored stools, dark
urine

acalculous
cholecystitis
1. patho
2. tx

1. dehydration, ischemia, burns,


trauma --> non-obstructive
cholecystitis
2. emergent cholecystectomy

complications of
cholecystitis

gangrenous cholecystitis, perforation,


emphysematous cholecystitis,
cholecystoenteric fistula with
gallstone ileus, gallbladder empyema

choledocholithiasis
1. patho
2. dx/tx

1. gallstone in CBD
2. elevated D-bili, ALP,
RUQ ultrasound (only 50% sensitive)
ERCP is gold standard - and
therapeutic
PTC
tx = ERCP with
sphincterotomy/extraction/stent, lapcholecoholithotomy

complications of
choledocholithiasis

cholangitis, obstructive jaundice,


acute panc, biliary colic, biliary
cirrhosis

cholangitis
1. patho
2. clinical pres
3. dx/tx

1. ERCP/PTC/choledochal
cyst/obstruction --> biliary
stasis/bacterial overgrowth
2. CHARCOT-TRIAD: RUQ pain,
jaundice, fever
REYNOLDS PENTAD - charcot +
septic shock, altered mental status
3. RUQ ultrasound,
hyperbilirubinemia, leukocytosis,
elevated LFTs
PTC (when duct dilated)/ERCP - NOT
DURING ACUTE PHASE
tx = IVF, ABX, monitoring UOP/BP,
after afebrile 48 hours --> ERCP/PRC

653.

654.

655.

656.

657.

658.

complication of
cholangitis

hepatic abscess- high fatality

primary sclerosing
cholangitis
1. patho
2. clinical
associations
3. dx/tx

1. idiopathic thickening of bile


ducts/narrowing of lumen -->
cirrhosis, portal hypertension, liver
failure
2. ULCERATIVE COLITIS ***,
crohn's
3. ERCP/PTC - shows multiple bead
like strictures of intra/extrahepatic
ducts
tx = liver transplant***, ERCP stent
placement for strictures
cholestyramine - for pruritus

primary biliary
cirrhosis
1. patho
2. clinical pres
3. dx/tx

1 autoimmune process -->


progressive cholestatic livers disease
with destruction of the intrahepatic
bile ducts (ductopenia on biopsy)
2. fatigue, pruritus, jaundice, RUQ
discomfort,
xanthoma/xanthelasmata*
3. positive antimitochondrial
antibodies***
elevated ALP, elevated
cholesterol/HDL
non caseating granulomas
inc. immunoglobulin M
liver biopsy (showing
DUCTOPENIA), abd. US/CT scan
tx = cholestyramine (pruritus),
calcium, bisphosphonates, vitamin
D,
ursodeoxycholic acid (slows disease)

cholangiocarcinoma
1. patho
2. risk factors

1.adenocarcinoma of
intra/extrahepatic bile ducts -->
prox 1/3 = klatskin tumor, distal
extrahepatic, intrahepatic
2. PSC, UC, choledochal cysts,
clonorchis sinensis (hong kong)

causes of secondary
biliary cirrhosis

mechanical obstruction, sclerosing


cholangitis, cystic fibrosis, biliary
atresia

choledochal cysts
1. patho
2. clinical pres
3. dx/tx
4. complications

1.cystic dilations of the hepatic ducts


2. epigastric pain, jaundice, fever,
RUQ mass
3. ultrasound, ERCP
tx = surgery
4. cholangiocarcinoma, hepatic
abscess, recurrent panc/cholangitis,
rupture, biliary obstruction,
cirrhosis, portal HTN

659.

660.

661.

662.

663.

664.

biliary
dyskinesia
1 patho
2. dx/tx

1. motor dysfunction of the sphincter of


Oddi (CCK relaxes) leads to recurrent biliary
colic without evidence of stones
2. HIDA + IV CCK and determine
gallbladder ejection fraction

acute
appendicitis
1. patho
2. clinical
pres
3. DX

1. lumen of appendix obstructed by:


lymphoid hyperplasia (60%), fecalith
(30%), foreign body --> bacterial growth,
inflammation --> compromised blood
supply --> necrosis, perforation, peritonitis
2. epigastric pain that moves toward
umbilicus/RLQ with signs of peritonitis,
anorexia**, n/v, rebound, ROVSING'S
SIGN, PSOAS SIGN, OBTURATOR SIGN
3. CLINICAL DX, leukocytosis,
CT scan (98-100% sensitive), ultrasound
tx = appendectomy

carcinoid
syndrome
1. patho
2. clincal pres

1. neuroendocrine cells --> serotonin (10%


of carcinoid tumors)
- located in appendix***, small bowel
(highest chance of mets), rectum, bronchus
2. cutaneous flushing, diarrhea, sweating,
wheezing, abdominal pain,

appendicitis
complications

perforation of appendix 20%


- will present as high fever, tachycardia,
leukocytosis, peritoneal signs

acute
pancreatitis
1. patho
2. what
viruses
associated
with acute
panc
3. what drugs
associated
with acute
panc

1. alcohol/gallstones/POST ERCP/ viral


/drugs/post-op/scorpion
bites/cancer/hypertriglyceridemia/
hypercalcemia/uremia--> inflammation of
pancreas from prematurely activated
pancreatic digestive enzymes
2. mumps, cox B
3. sulfonamides, thiazide, furosemide,
estrogen, HIV meds

acute
pancreatitis
1. clinical pres
2. dx

1. epigastric pain radiating to the back,


worse when supine/after meals, low grade
fever, tachycardia, epigastric tenderness,
dec. bowel sounds, leukocytosis, GREY
TURNER'S SIGN, CULLEN'S SIGN, FOX'S
SIGN
2. serum lipase, amylase, LFTs, ,
hyperglycemia, hypoxemia, leukocytosis
glucose, calcium, hematocrit, BUN, ABG,
LDH, AST, WBC
CT abdomen - most sensitive/specific
ERCP - identify gallstones
abdominal XR -may show calcifications
abdominal ultrasound - may detect
calc/pseudocysts

665.

666.

667.

668.

669.

670.

ranson's
criteria
1. admission
2. 48 hours
3. mortality %

acute
pancreatitis
1.
complications
2. tx

1. GA-LAW: glucose >200, Age >55, LDH


>350, AST>250, WBC >16000
2. C HOBBS: calcium <8mg/dl, Hematocrit
>10%, PaO2<60 mmHg, BUN >8mg/dL,
Base deficit >4 mg/dl, fluid sequestration
>6L
3. <3 criteria - 1%
3-4 criteria - 15%
5-6 criteria - 40%
>7 criteria - 100%
1. ARDS***
pancreatic abscess
pancreatic necrosis (sterile or infected)
pancreatic pseudocyst - 2-3 week to develop
no epithelial lining, (>5cm drain)
hemorrhagic pancreatitis - cullen, grey
turner, fox, CT with IV contrast
ascending cholangitis (gallstones)
2. NPO, IVF, pain control, NG tube, early
enteral nutrition via nasojejunal tube
AFTER RECOVERY FROM GALLSTONE
PANCREATITIS ALL PATIENTS SHOULD
BE SCHEDULED FOR
CHOLECYSTECTOMY

chronic
pancreatitis
1. patho
2. clinical
pres
3. dx/tx

1. chronic alcoholism --> fibrotic


replacement of the pancreas and dilation of
the pancreatic duct
2. severe abdominal pain, n/v, aggravated
by drinking alcohol/eating, malabsorption,
diabetes mellitus (triad)
3. CT scan shows calcifications
ERCP**- will show ductal
dilation/strictures
abdominal xray - shows calcifications specific but not sensitive
serum amylase and lipase are normal
stool elastase is decreased

chronic
pancreatitis
1. tx

1. narcotics, NPO, pancreatic enzymes and


H2 blockers (dec. CCK release), insulin,

complications
of chronic
pancreatitis

narcotic addiction, DM (langerhans loss),


pseudocysts, pancreatic duct dilation, CBD
obstruction (2/2 fibrosis), B12
malabsorption

pancreatic
cancer
1. risk factors
2. clinical
pres
3. dx
4. tx

1. cigarette smoking (NOT ALCOHOL),


chronic pancreatitis*, diabetes, obesity
benzidine/beta naphthylamine exposure
2. dull abdominal pain, obstructive jaundice
(head), weight loss, depression, fatigue,
migratory thrombophlebitis, courvoisier's
sign
3. ERCP**, CT scan***, CA 19-9, CEA
4. whipple procedure (10% survival at 5
years), ERCP with stent placement if
unresectable

671.

672.

673.

674.

675.

676.

GI bleeding
1. upper GI
bleeding causes
2. lower GI
bleeding causes

1. prox to ligament of treitz - PUD,


duodenal ulcer, gastritis, reflux
esophagitis, varices, mallory weiss,
hemobilia, dieulafoy, aortoenteric fistula
2. diverticulosis, angiodysplasia, IBD
(UC/crohn's), colorectal cancer/polyps,
ischemic colitis, hemorrhoids, anal
fissure

GI bleeding
1. hematemesis
2. coffee ground
emesis
3. melena
4. hematochezia
- occult blood in
the stool

1. moderate-severe ONGOING upper GI


bleeding
2. lower rate of upper GI bleeding
3. upper GI black, tarry, foul smelling
stools (hemoglobin broken down by
bacteria indicates blood has been in GI
tract for several hours
4. bright red blood per rectum typically
left colon or rectum

causes of dark
stools

melena, bismuth, iron, spinic, charcoal,


licorice

GI bleeding
1. diagnostic test
for
hematemesis,
hematochezia,
melena, occult
blood
2. dx
3. tx

1. hematemesis/melena - upper GI
endoscopy
hematochezia/occult blood colonoscopy
2. BP, pulse rate, CBC with diff, BUN/Cr,
PT/PTT/INR stool guaiac,
hemoglobin/hematocrit, upper
endoscopy, NG tube (bile but no blood =
not upper GI), colonoscopy,
radionucleotide scan (tagged RBCs),
arteriography (must be during active
bleeding, therapeutic =
embolization/vasopressin)
3. ABCs- Oxygen, 2 large bore IVs, draw
blood hgb/hct/pt/ptt/platelet, monitor
hgb q4-8
type and cross
EGD with coagulation
colonoscopy

normal
hematocrit in
young adult vs.
elderly

young adult >7-8


elderly >10

indications for
surgery in
patient with GI
bleed

hemodynamically unstable and not


responding to IV fluids,
severe initial bleed or recurrence after
endoscopic treatment
continued bleeding >24 hours
visible vessel at base of ulcer
5 units of blood within 4-6 hours

677.

678.

679.

680.

681.

esophageal
cancer
1. risk factors
for SCC
2. risk factors
for adeno
- 5-15% 5 year
prognosis
3. clinical pres
4. dx/tx

1. AA, alcohol, tobacco, nitrosamines, hot


foods/beverages
2. GERD, barrett's
3. dysphagia (solids--> solids/liquids),
weight loss, anorexia, odynophagia,
hematemesis, hoarseness, aspiration,
4. barium swallow
upper endoscopy with biopsy/brush
cytology***
metastatic work up - CT cx/abd, CXR,
bone scan
tx = palliation, surgery (0,1,2a), adjuvant
chemo/radiation

achalasia
1. patho
2. causes
3. clinical pres

1. LES fails to relax when swallowing and


abnormal peristalsis of esophagus
2. idiopathic, adenocarcinoma, chagas
3. dysphagia to both solids/liquids,
patients eat slowly, and drink a lot of
water with food, food gets stuck in
esophagus, regurgitation/aspiration, CX
pain, weight loss

achalasia
1. dx/tx

1. barium swallow*** - BIRD BEAK


upper GI endoscopy rules out
esophagitis/esophageal cancer
manometry***- failure of LES relaxation
biopsy - absent myenteric plexus
tx = sublingual nitroglycerine, CCBs,
botulinum toxin, mechanical dilation,
heller myotomy

what cancer
are patients
with achalasia
at increased
risk for

squamous cell cancer of the esophagus

diffuse
esophageal
spasm
1. patho
2. clinical pres
3. dx/tx

1. non-peristaltic contractions preventing


advancement of food bolus, LES function
is normal
2. non-cardiac chest pain that mimics
angina
3. esophageal manometry- simultaneous,
multiphasic repetitive contractions after
swallow with normal sphincter
Barium swallow - corkscrew esophagus
tx = nitrates, CCBs, TCAs

682.

683.

684.

685.

686.

687.

688.

esophageal
hiatal hernias
1. sliding (type
1)
2.
paraesophageal
(type 2)
3. dx/tx
4. type 3

1. gastroesophageal junction/stomach
herniate into thorax associated with
GERD
2. stomach herniates into the thorax, but
NOT GE junction- risk for strangulation
and should be repaired
3. barium upper GI series, upper
endoscopy
tx = type 1 = antacids, small meals,
nissen's fundoplication
type 2 = elective surgery
4. combination of type 1 and 2

mallory weiss
syndrome
1. patho
2. clinical pres
3. dx/tx

1. mucosal tear at the GE junction, after


repeated vomiting
2. hematemesis
3. upper endoscopy
tx = stops on its own, or angiographic
embolization, acid suppression

plummer
vinson
syndrome
1. patho
2.
complications
3. dx/tx

1. iron deficiency --> upper esophageal


webs, koilonychia, atrophic oral mucosa,
iron deficiency anemia
2. progress to SCC of the oral cavity
3. esophageal dilation, correct nutritional
deficiency

schatzki's ring
1. patho
2. clinical pres
3. tx

1. ingestion of acid (mucosal necrosis),


alkali (liquefactive full thickness
necrosis), detergents -> lower esophageal
ring and sliding hiatal hernia
2. dysphagia
3. esophagectomy for full thickness
necrosis

zenker's
diverticula + tx

failure of cricopharyngeal muscle to relax


during swallowing increases pressure and
causes outpouching of mucosa (false
diverticula)--> dysphagia, regurgitation,
halitosis, chronic cough
tx = cricopharyngeal myotomy,
diverticulectomy

traction
diverticulum

mid esophagus, near tracheal bifurcation


from mediastinal inflammation and
adenopathy (ex. tuberculosis)

epiphrenic
diverticulum

lower 1/3 of esophagus, associated with


esophageal dysmotility/achalasia

689.

690.

691.

692.

693.

694.

boerhaave's
syndrome
1. patho
2. clinical
pres
3. dx/tx

1. blunt trauma, medical tubes, vomiting,


alcohol binges, bulimia --> TRANSMURAL
tear in esophagus
2. severe chest pain, tachycardia,
hypotension, tachypnea, dyspnea, fever,
HAMMANS SIGN (mediastinal crunch from
heart hitting air filled tissues), PTX
3. gastrografin swallow
CXR - air in mediastinum
tx = IV, NPO, abx, H2 blockers
surgery if patient is unstable

peptic ulcer
disease
1. causes
2. clinical
pres
3. dx/tx

1. h.pylori, NSAIDs, gastric acid


hypersecretion (ZES), smoking,
alcohol/coffee
2. aching, gnawing pain, nocturnal
symptoms and variable effects of food, upper
GI bleeding, n/v, early satiety, weight loss
3. endoscopy (also therapeutic)
H.pylori detected on biopsy
urea breath test
h.pylori serology (false negative with PPI,
bismuth, antibiotics, upper GI bleeding)
serum gastrin
tx - acid suppression (PPI or H2),
triple/quadruple therapy
cytoprotection - sucralfate, misoprostol
(reduces ulcers with NSAID therapy)

duodenal
ulcers
1. malignant
potential
2. location
3. age
4. associated
blood type
5. clinical
pres

1. low
2. 1-2 cm distal to pylorus (posterior wall)
3. <40
4. O
5. NSAID use, pain that is relieved by food,
nocturnal pain

gastric ulcers
1. malignant
potential
2. location
3. age
4. associated
blood type
5. clinical
pres

1. high - 5-10%
2. type 1 70% on lesser curvature,
type 2 - gastric AND duodenal
type 3 - pre-pyloric
type 4 - near GE junction
3. >40
4. A
5. smokers, eating does not relieve pain

lifestyle
modifications
for PUD

stop smoking, stop NSAIDs, decrease eating


before bed

complications
of PUD (3) +
dx/tx

*perforation -CXR free air under diaphragm


tx = emergency surgery - vagotomy

695.

696.

697.

698.

699.

700.

701.

*Gastric outlet
obstructionbarium swallow,
upper endoscopy,
saline load test
(750
injected, after 30
min aspirate
>400ml = + test)
tx = NG suction,
volume
replacement,
surgery

...

*GI bleeding - stool


guaiac, upper GI
tx= resuscitation,
diagnose site of
bleeding, surgery
for acute bleeding

...

acute gastritis
1. patho
2. clinical pres

1. inflammation of the gastric mucosa


2/2 NSAIDs, H.pylori, cigarette
smoking, caffeine, shock, sepsis,
burns
2. epigastric pain
3. PPI, stop NSAIDs, test for H.pylori

gastric cancer
1. morphologies
2. risk factors
3. clinical pres

1. ulcerative, polyploid (solid mass),


superficial spreading, linitis plastica
2. atrophic gastritis, gastric polyps,
h.pylori (3-6x the risk), pernicious
anemia, low vitamin C, high salt diet,
menetrier's disease, preserved foods
(salt, nitrates), blood type A
3. abdominal pain, weight loss, dec.
appetite, anorexia, melena, guaiac
positive stools

1. krukenberg
tumor
2. blumers shelf
3. sister mary
joseph node
4. virchows node
5. irish's node

1. stomach cancer met to the ovary


2. stomach cancer met to the rectum
(pelvic cul de sac)
3. met to periumbilical lymph nodes
4. met to supraclavicular fossa nodes
5. met to left axillary adenopathy

chronic gastritis
1. patho
2. dxt/tx

1. H.pylori, autoimmune (anti-parietal


cell/anti-intrinsic factor antibodies),
2. upper endoscopy with biopsy

autoimmune
gastritis

serum anti-parietal cell and antiintrinsic factor antibiotics -->


pernicious anemia

702.

703.

704.

705.

706.

707.

gastric cancer
1. dx/tx

1. upper endoscopy with multiple biopsies


barium upper GI series
abdominal CT for staging/mets
FOBT
tx = surgical resection with wide margins
>5cm

small bowel
obstruction
SBO
1. three ways
to
differentiate
small bowel
obstruction
2.
patho/clinical
pres

1. partial vs complete obstruction, closed vs


open loop (closed has vascular
compromise/necrosis/peritonitis), proximal
vs distal SBO (distal has more dilated
proximal loops)
2. adhesions (MCC), incarcerated hernias,
malig, intussus, crohn's, SMA syndrome -->
3. obstruction --> dehydration, inc.
intestinal secretions proximal to the
obstruction, distention/vomiting
(hypokalemic, hypochloremic met.alk),
obstipation, abdominal distention,
nausea/vomiting,
strangulation --> shock, peritonitis, free air,
lactic acidosis

SBO
1. dx/tx

1. plain abdominal films- show dilated


loops of small bowel/air fluid levels
proximal to the point of obstruction,
minimal gas in colon.
Barium enema - identifies site of
obstruction, follow up for inconclusive XR
upper GI series
serum lactate - to detect
strangulation/necrosis
tx = non-operative if incomplete and no
fever, peritoneal signs, leukocytosis, IVF w/
K+, NG tube, abx, surgery for complete
obstruction (ex. lysis of adhesion/bowel
resection)

difference in
clinical pres
between
proximal vs
distal SBO

proximal - frequent vomiting, severe pain,


minimal abdominal distension
distal - less frequent vomiting, significant
abdominal distention

large bowel
obstruction
1. causes

1. volvulus, adhesions, hernias, colon


cancer (MCC)
- fluid/electrolyte imbalances not as severe
as SBO

paralytic
ileus
1. patho
2. causes
3. dx

1. absent peristalsis, without mechanical


obstruction
2. narcotics, post-operative, spinal cord,
shock, hypokalemia, peritonitis
3. abdominal plain films show uniform gas
distribution in small bowel,colon, and
rectum
failure to pass contrast past a fixed point
tx = IVF, NPO, electrolytes (hypokalemeia),
NG suction,

708.

709.

710.

711.

712.

celiac sprue
1 patho
2. dx/tx

1. hypersensitivity to gluten --> loss of


microvilli--> weight loss, abdominal
distension, bloating, diarrhea
2. anti-endomysial, anti-transglutaminase
small bowel biopsy shows flattening of villi
tx = avoid wheat, barley, rye

crohns disease
1. patho
2. clinical pres
3.
extraintestinal
manifestations

1. chronic flaring/remitting
TRANSMURAL inflammatory disease that
can affect any part of the GI tract, usually
includes terminal ileum, skip lesions,
FISTULAS, STRICTURES, NON
CASEATING GRANULOMAS*, mesenteric
fat wrapping
2. diarrhea, malabsorption/weight loss,
abdominal pain, n/v, fever, malaise
3. uveitis, arthritis, ank spondy (C<UC),
erythema nodosum (C>UC), pyoderma
gangrenosum (C<UC), aphthous oral
ulcers, cholelithiasis, nephrolithiasis

epidemiology
of IBD

caucasians, jewish, age of onset 15-35


years

crohns disease
1.
complications
2. dx/tx

1. fistulae (vagina, skin, intestine,


bladder), anorectal fissures, abscesses,
SBO, B12/bile acid malabsorbtion,
cholelethiasis, neprholithiasis (inc. abs of
oxalate), aphthous ulcers, narcotic abuse,
psychosocial issues
2. endoscopy with biopsy- cobblestone
appearance, pseudopolyps
barium enema
tx = sulfasalazine (5 ASA aka
mesalamine)- blocks prostaglandin
release, reduces inflammation
metronidazole
prednisone - for exacerbations
azathioprine, 6MP with steroids for
exacerbations
cholestyramine/colestipol for terminal
ileal disease
surgical - high recurrence rate

ulcerative
colitis
1. patho
2. clinical pres
3. dx/tx

1. relapsing and remitting MUCOSAL


inflammation of the rectum (always) and
colon
2. hematochezia***, abdominal pain,
frequent small bowel movements, fever,
anorexia, weight loss, tenesmus (rectal dry
heaves), extraintestinal findings (see
crohns card)
3. stool cultures/ova/parasites - negative
fecal leukocytes
colonoscopy
PANCA positive
- crypt abscesses

713.

714.

715.

716.

717.

718.

ulcerative
colitis
4. extra
intestinal
manifestations
/ complications

4. IDA, hemorrhage, electrolytes,


strictures, benign/malignant, colon
cancer, ankylosing spondylitis*, primary
sclerosing cholangitis,
cholangiocarcinoma (50% of patient have
UC), toxic megacolon, growth
retardation, narcotic abuse, psychosocial
tx = corticosteroids for exacerbations
sulfasalazine (5ASA after bacterial
metabolism) by suppository
immunosuppressants for resistant
disease- prevents relapses
surgery often curative (compare to
crohns)

graves disease
1. dx

1. diffuse uptake on thyroid scan, antiTSH-R antibodies


low TSH
elevated T4
only order T3 if T4 is normal and TSH is
low
T3 TBG resin study - radioactive T3 binds
to TBG or resin - if resin binds alot of
radio-T3 TBG is probably normal, if resin
does not bind much elevated TBG is
probably causing elevated thyroid
hormones.

graves disease
(80% of
hyperthyroid)
1. patho
2. clinical pres

1. anti TSH-R antibodies triggers excess


hormone release,
2. **exophthalmos (edema of
extraocular muscles/retroorbital
tissue) , *pretibial myxedema
(mucopolysaccharides), **thyroid
bruit nervousness, arrhythmias (sinus
tach, afib, PVCs)
warm moist skin
insomnia, tremor, hyperactivity,
tremulousness, sweating, heat
intolerance, weight loss, diarrhea,
palpitations
hypertension (2/2 inc. expression of SR
calcium dependented ATPase)

plummer's
disease (15% of
hyperthyroid)
1. patho
2. clinical pres
3. dx

1. multinodular toxic goiter - multiple


hyperfunctioning areas
2. see graves disease card
3. patchy uptake on thyroid scan ,
possible bruit over thyroid gland
see graves disease card

toxic thyroid
adenoma

single hyperfunctioning nodule, single


nodule

1. hashimotos
thyroiditis
2. de quervain's
(subacute,
granulomatous)
thyroiditis

1. transient hyperthyroid,
multinodularity,
2. exquisitely tender diffusely enlarged
gland after/during viral illness

719.

720.

721.

722.

723.

724.

postpartum
thyroiditis
iodine induced
hyperthyroidism
iatrogenic
hyperthyroidism

...

causes of
elevated TBG

pregnancy, liver disease, OCP, aspirin

hyperthyroidism
tx

thionamides - methimazole (men/nonchild age women), PTU (for pregnant dec. conversion of T4-T3) - SE =
agranulocytosis (MONITOR
LEUKOCYTES)
iopanoic acid - dec. thyroid hormone
release from thyroid gland
beta blockers - for symptoms (tachy,
sweating, weakness)
sodium ipodate - rapid improvement for
medically refractory hyperthyroidism
I-131 ablation of thyroid follicular cells repeat after 6-12 months if initially
unsuccessful- (can cause temporary
worsening)
subtotal thyroidectomy - SE- recur hyper,
hypothyroidsm

graves disease
treatment

beta blocker - for symptom control, taper


@ 4-8 weeks
methimazole- for 1-2 years, remeasure
anti-TSH, if relapse 1 more year of
methimazole
radioactive iodine ablation

graves treatment
in pregnant
women

endocrinology consult and PTU

thyroid storm
1. patho
2. tx

1. acute exacerbation of thyrotoxicosis in


response to stress (infection*, DKA,
stress, childbirth)-->20%
mortality/coma
2. fever, tachycardia, agitation,
psychosis, confusion,n/v, diarrhea
3. IVF, cooling blankets, glucose, PTU
q2hour + iodine, beta blockers for heart
rate, dexamethasone (blocks T4-T3
conversion)

725.

726.

727.

728.

729.

730.

hypothyroidism
1. causes
2. clinical pres

1. hashimoto's (autoimmune),
iatrogenic- radioiodine, thyroidectomy,
mediations, secondary/tertiary
hypothyroidism (low T4/T3 and low
TSH)
2. fatigue, weakness, heavy menstrual
periods*, weight gain, cold intolerance,
dull expression, muscle
weakness/rhabdomyolysis, arthralgias,
depression, dry skin, coarse hair,
hoarseness, non-pitting edema
(myxedema), dec. DTRs, bradycardia,
goiter

associated
conditions with
hashimotos
thyroiditis

lupus, pernicious anemia, thyroid


carcinoma, thyroid lymphoma

myxedema
coma + tx

hypothermia, respiratory depression, dec.


consciousness from chronic
hypothyroidism exacerbated by stress,
elevated PCO2, hyponatremia (trauma,
infection, cold, narcotics)
tx = IV levothyroxine (500 mcg bolus,
then daily), hydrocortisone for impaired
adrenal reserves

hypothyroidism
1. dx
2. tx

1. high TSH, low TSH (2'


hypoparathyroidism), low free T4, antimicrosomal/antithyroglobulin antibodies
(hashimotos), anti thyroid peroxidase
elevated LDL, dec. HDL
normocytic anemia
2. levothyroxine, TSH monitoring

subacute
thyroiditis
(granuomatous)
1. patho
2. clinical pres
3. dx/tx

subacute
lymphocytic
thyroiditis
1 .patho
2. clinical pres
3. dx

1. post viral HLA-B35 associated -->


leakage of thyroid hormone from thyroid
gland --> hyperthyroid-->euthyroid->hypothyroid
2. painful tender thyroid gland, history of
viral illness, and symptoms of
hyper/hypothyroid
3 radioiodine uptake is low
TSH is low from elevated T4/T3
high ESR
tx = NSAIDs/aspirin, corticosteroids,
recovery of thyroid function after 1 year
1. transient thyrotoxicosis, followed by
hypothyroidism
2. similar to subacute thyroiditis, but
without pain
3. low iodine uptake (vs graves), low TSH
anti-TPO antibodies

731.

732.

733.

734.

735.

736.

737.

chronic
lymphocytic
thyroiditis
1. patho
2. clinical pres
3. dx/tx

1. hashimoto's/lymphocytic
2. goiter, slow decline in thyroid function
3. antiperoxidase, antithyroglobulin
antibodies
irregular distribution of I-131 not
required for diagnosis
tx = thyroid hormone replacement

thyroid
associated
ophthalmopathy

autoimmune destruction of periorbital


connective tissue - lid retraction,
proptosis (lymphocytes invade EOM and
stimulate GAG deposition),
lagophthalmos, - may be
hypo/hyperthyroid or euthyroid

fibrous
thyroiditis
1. patho
2. tx

1. fibrous tissue replaces thyroid


2. surgical removal

thyroid nodules
1. what fraction
are cancerous
2. features of
malignant
nodule
3. diagnosis

1. 4-10%
2. nodule is fixed, no movement with
swallowing
solitary, history of neck radiation, history
of rapid development, vocal cord
paralysis, cervical adenopathy
3. Ultrasound guided FNA (reliable for
all cancers except follicular)
thyroid scan (radioactive iodine) - cold or
hot
thyroid ultrasound - diff between solid
and cystic

risk factors for


thyroid cancer

head/neck radiation
gardner's syndrome/cowden's syndrome
(papillary cancer)
MEN type 2 - medullary thyroid cancer

papillary
thyroid cancer
(most common)
1. risk factor
2. pattern of
mets
3. dx

1. radiation to the head/neck


2. cervical lymph nodes, with rare distant
mets, iodine uptake positive
3. orphan annie eye nuclei, psammoma
bodies on biopsy

follicular
carcinoma
1. pattern of
mets
2. risk factor
3. dx
4. hurthle cell
carcinoma

1. hematogenous spread*** to
brain/lung/bone/liver, 20% of pts have
distant mets
2. iodine deficiency
3. tissue sample because need to see
extension past fibrous capsule
4. abundant cytoplasm, tightly packed
mitochondria, oval nuclei with
prominent nucleoli - radioiodine
resistant

738.

739.

740.

741.

742.

743.

744.

medullary
carcinoma of the
thyroid
1. risk factors +
patho
2. dx

1. 1/3 sporadic, 1/3 familial, 1/3


MENII (also screen for pheo)-- arises
from parafollicular C cells --> excess
calcitonin production
2. sheets of cells in an amyloid
stroma (APPLE GREEN
BIREFRINGENCE

anaplastic
carcinoma
1. risk factors +
patho

longstanding follicular/papillary
thyroid carcinoma - death within a
few months- metastasis is by direct
extension

thyroid cancer
treatment
1. papillary
2. follicular
carcinoma
3. medullary
carcinoma
4. anaplastic

1. lobectomy with isthmusectomy,


total thyroidectomy if >3cm or
bilateral, TSH suppression,
radioiodine therapy
2. total thyroidectomy with post op
iodine ablation
3. total thyroidectomy, radioiodine,
modified neck dissection
4. chemotherapy and radiation ,
palliative surgery

1. what fraction of
cold nodules are
malignant

1. 20%
- thus a cold nodule on thyroid scan
does not tell very much about the
mass, however a warm nodule
greatly reduces risk of malignancy

pituitary adenomas
1. what hormonal
abnormalities
2. other nonhormonal clinical
clues
3. dx/tx

1. inc. prolactin/GH/ACTH/TSH, or
hypopituitarism from compression of
the causes hypopituitarism
2. headache, bitemporal
hemianopsia (compression of the
optic chiasm)
3. MRI, pituitary hormone levels
tx = transsphenoidal resection,
radiation/medical therpy

hyperprolactinemia
1. causes
2. clinical pres in
men
3. clinical pres in
females

1. prolactinoma (MCC),
antipsychotics, H2 blockers,
metoclopramide (DA antagonist),
verapamil, estrogen, pregnancy,
renal failure, hypothalamic lesions,
hypothyroidism, idiopathic
2. hypogonadism, dec. libido,
infertility, impotence, galactorrhea,
gynecomastia, parasellar signs
3. menstrual irregularities,
amenorrhea (prolactin inhibits
GnRH release and thus LH/FSH),
vaginal dryness,

hyperprolactinemia
1. dx
2. tx

1. elevated serum prolactin,


pregnancy test (r/o), TSH level (r/o
hypothyroid),
CT or MRI
2. bromocriptine, cabergoline
(dopamine agonists) for 2 years
surgery

745.

746.

747.

748.

749.

750.

acromegaly
1. patho
2. clinical pres

1. GH secreting adenoma --> excess


GH AFTER*** epiphyseal closure
(before closure = gigantism)-->
broadening of the skeleton
2. coarse facial features, abnormally
large hand/feet, organomegaly,
CAD, arthralgia, HCM,
macrognathia,
glucose intolerance, hyperhidrosis
headache, bitemporal hemianopsia,
cavernous sinus compression, HTN,
sleep apnea

acromegaly
1. dx
2. tx

1. IGF 1 (somatomedin C levels)


oral glucose suppression test (oral
glucose does not suppress GH)
random GH level
2. transsphenoidal resection of
pituitary adenoma
radiation if post op elevation in IGF-1
octreotide/somatostatin suppresses
GH

craniopharyngioma
1. patho
2. clinical
presentation

1. suprasellar tumor from remnants


of rathke's pouch- usually adenoma
2. parasellar effects - headache,
bitemporal hemianopsia,
papilledema, changed in mentation,
hyperprolactinemia, diabetes
insipidus, panhypopituitarism
3. MRI
surgical excision with or without
radiation

causes of
hypopituitarism

pituitary tumor, radiation, sheehan's


syndrome, sarcoidosis,
hemochromatosis, head trauma,
cavernous sinus thrombosis

top ddx of
polyuria/polydipsia

diabetes mellitus, diuretics, DI,


primary polydipsia

cause of central DI
cause of
nephrogenic DI

central - dec. release of ADH from


posterior pituitary* - idiopathic,
trauma/surgery, tumors (#1 =
breast), sarcoid, TB, syphilis, handschuller-christian, eosinophilic
granuloma, encephalitis
nephrogenic - lithium use,
hypercalcemia, hypokalemia
pyelonephritis, demeclocycline,
mutations in ADH receptor or
aquaporin 2 gene

751.

752.

753.

diabetes
insipidus
1. clinical
pres
2. dx
3. tx

1. 5-15 liters of urine/day, polydipsia, minimal


hypernatremia (patients drink water)
2. low urine SG, low osmolarity
plasma osmolality normal to slightly elevated
(280-310)
withhold fluids measure hourly, when stable <30
mOsm/kg increase, inject 2G desmopressin,
measure urine osmolality in 1 hour
nephrogenic - no response with dehydration, no
response with DDAVP
central - no response with dehydration, inc. urine
osmolarity with DDAVP
primary polydipsia - inc. urine osmolality with
dehydration, no further response with DDAVP
3. central DI: DDAVP, chlorpropamide (inc.
ADH secretion)
nephrogenic DI - sodium restriction, THIAZIDE
diuretics

SIADH
1. patho
2. clinical
pres

1. neoplasms (lung, pancreas, prostate, bladder,


lymphoma, leukemia)
stroke, head trauma, infection
pneumonia, TB
positive pressure ventilation
meds - vincristine, NSAIDs, SSRI,
chlorpropamide, oxytocin, morphine,
desmopressin
2. acute hyponatremia --> brain swelling-->
lethargy, somnolence, weakness, seizures, coma,
death
chronic hyponatremia - asymptomatic or n/v,
anorexia, neuro symptoms less common
NO EDEMA*********

SIADH
1. dx
2. tx

1. hyponatremia,
serum hypoosmolality
inappropriately elevated urine osmolality
low serum uric acid (hemodilution)
low BUN/Cr (diluted)
normal thyroid/adrenal
plasma/urine ADH level
2. underlying issue
water restriction, normal saline
lithium or demeclocycline (ADH blocker)
if symptomatic - restrict water intake, give
isotonic saline, hypertonic saline in severe cases
**DO NOT CORRECT FASTER THAN
0.5mEq/L/hour

754.

755.

756.

757.

hypoparathyroidism
1. causes
2. dx/tx

1. head and neck surgery,


THYROIDECTOMY,
parathyroidectomy,
2. arrhythmias,
PROLONGED QT, rickets,
osteomalacia,
neuromuscular irritability
numbness/tingling circumoral, fingers, toes
tetany, hyperactive DTR,
CHVOSTEK SIGN (tap
CNVII causes muscle
twitch), TROUSSEAU'S
SIGN (carpal spasm w/
3min of BP cuff)
3. low calcium, high
phosphate, low PTH, low
urine cAMP
tx = IV calcium gluconate,
D3 supplementation, (
target calcium is 8-8.5)

primary
hyperparathyroidism
1. patho
2. clinical pres
3. dx
4. radiographic dx

1. adenoma*, hyperplasia,
carcinoma (<1%) -->
parathyroids making too
much PTH
2. nephrolithiasis, bone
aches/pains, osteitis
fibrosa cystica (brown
tumors), muscle pains,
pancreatitis, PUD, gout,
constipation, depression,
fatigue, anorexia, sleep
disturbances, anxiety,
lethargy, nephrolithiasis
3. serum calcium/albumin,
PTH, hypophosphatemia,
hypercalciuria, elevated
urine cAMP, Cl:phos ratio
>33:1***
4. subperiosteal bone
resorption at radial aspect
of 2nd/3rd phalanges

primary
hyperparathyroidism
1. tx

1. hyperplasia - remove all


4 glands, small amount of
tissue implanted in forearm
surgical removal of
adenoma (age <50, dec.
bone mass,
nephrolithiasis, marked
elevated serum calcium,
urine calcium >400 mg in
24 hours)

pseudohypoparathyroidism

end organ PTH resistance elevated PTH, low urinary


cAMP, hypocalcemia,
hyperphosphatemia

758.

759.

760.

761.

762.

secondary
hyperparathyroidism
1. patho

cushing syndrome
1. causes
2. clinical pres

1. chronic renal failure, vitamin D


deficiency, renal hypercalciuria -->
elevated PTH and low or low
normal serum calcium
tx - renal failure - give calcitriol,
oral calcium supplements,
phosphate restriction, sinacelet
furosemide (NOT THIAZIDE)
inc. fluid intake
1. iatrogenic (MCC), cushing's
disease (pituitary), adrenal
adenomas/carcinomas ectopic
ACTH (2/3 of SCC of lung,
bronchial carcinoma, thymoma)
2. central obesity, hirsutism, moon
facies, buffalo hump, striae,
lanugo, acne, easy bruising,
diabetes, hypogonadism,
masculinization in females
(cushing disease), depression,
mania, infections (impaired
immunity)

effects of cortisol

impaired collagen production,


enhanced protein catabolism
anti-insulin effects/glucose
intolerance
impaired immunity
enhanced catecholamine effects

Cushing syndrome
1. dx

1. overnight low dose


dexamethasone suppression test: if
serum cortisol <5 this excludes
Cushing's syndrome, >5 is
Cushing's syndrome
high dose dex suppression test >50% suppression = Cushing
disease (pituitary), <50%
suppression = ectopic ACTH
pyelonephritis
24 hour urine cortisol >4x normal
ACTH level - low = adrenal tumor,
high = pituitary source, ectopic
ACTH
CRH stimulation test- no
response= ectopic ACTH tumor,
positive response = pituitary
Cushing's

response to low
dex/high dex/CRH :
1. healthy
2. Cushing disease
3. adrenal tumor
4. ectopic ACTH

1. suppress/suppress/mild increase
2. no suppress/suppress/LARGE
INCREASE
3. no suppress/suppress/NO
CHANGE
4. no suppress/no suppress/NO
CHANGE

763.

764.

765.

766.

767.

Cushing syndrome
tx

iatrogenic - taper glucocorticoid


pituitary Cushing- transphenoidal
surgery
adrenal Cushing's - adrenalectomy

pheochromocytoma
1. patho
2. clinical pres
3. lab findings
during a paroxysm

1. chromaffin cells or sympathetic


ganglia--> tumors that produce
catecholamines 90% are adrenal
2. HTN, persistently high with
paroxysms of severe HTN, pounding
headache, sweating, tachycardia,
palpitations, anxiety, impending
doom, hypertension assc. with surgery
3. hyperglycemia, hyperlipidemia,
hypokalemia

pheochromocytoma
1. dx
2. tx

1. urine screen: metanephrine, VMA,


HVA, normetanephrine (also check
creatinine to see if good sample)
plasma metanephrines
urine/serum epi/norepi - if elevated
indicates that the tumor is adrenal or
organ of zuckerkandl)
CT/MRI for tumor localization
2. FIRST - phenoxybenzamine (dec.
BP) SECOND - beta blocker (dec.
tachycardia)
surgical tumor resection and ligation
of the venous supply

pheochromocytoma
rule of 10s

10% are...
familial, bilateral (MEN II), multiple,
pediatric, extra adrenal (organ of
zuckerkandl)

primary
hyperaldosteronism
1. patho
2. clinical pres

1. conns syndrome/adrenal
hyperplasia/adrenal carcinoma
excessive aldosterone production
independent of RAAS --> inc. Na/K
pump activity in cortical collecting
ducts--> sodium
retention/HTN/hypokalemia/met.alk*
2. HTN, headache, fatigue, weakness,
polydipsia, nocturnal polyuria, no
peripheral edema

768.

769.

770.

771.

primary
hyperaldosteronism
1. dx
2. tx

1. aldo:renin ratio*** - shows inc.


aldo, dec. renin >30:1
oral sodium loading - 3 days of high
salt diet - high aldo + high urine
sodium = + dx
saline infusion test - will not inc.
aldosterone, normal patient will be
<8.5 ng/dL
adrenal venous sampling
renin-aldo stimulation testrecumbency/upright position +
measure serum aldo
BMP - hypokalemia
CT/MRI of adrenals will show
hyperplasia or adenoma
iodocholesterol scanning
2. surgical resection for adenoma
spironolactone for bilateral
hyperplasia

1. MEN type 1
2. MEN IIA
3.MEN IIB

1. MENIN GENE: parathyroid


hyperplasia, pancreatic islet cell
tumors, pituitary tumors
2. RET GENE: MTC, pheo,
hyperparathyroidism
3.RET GENE: mucosal neuromas
(nasopharynx, oropharynx, larynx,
conjunctiva)
MTC, Marfanoid body habitus,
pheochromocytoma

adrenal
incidentaloma

non-functioning adrenal tumor,


most are benign, inc risk with inc.
size, resect any tumor >6cm

adrenal
insuficiency
1. primary causes
2. secondary causes
3. tertiary adrenal
insufficiency

1. addisons (MCC), tuberculosis


(MCC), cytomegalovirus,
fungal/parasite (cryptococcus,
pneumocystis, toxoplasmosis),
iatrogenic, lung/breast mets
2. long term steroid therapy + stress
of surgery/trauma/serious injury -->
symptoms of adrenal insufficiency
3. hypothalamic disease

772.

773.

774.

775.

adrenal
insufficinecy
1. clinical
pres
2. dx
3. tx

1. anorexia, n/v, abdominal pain,


lethargy, confusion, psychosis
hypoglycemia (cortisol deficiency)
hyperpigmentation (1' deficiency from inc.
ACTH/MSH breakdown product)
stress in tolerance
low aldosterone (ONLY*** in 1' adrenal
insuff NOT secondary) --> sodium loss,
hyponatremia, hyperkalemia, hypovolemia,
hypotension, shock, syncope, renal failure
2. low plasma cortisol, high/low plasma
ACTH (1' vs 2'),
Cosyntropin test - infusion of ACTH measure
plasma cortisol: primary = no inc. in cortisol,
secondary = first test no response, second test
4-5 days later WILL get a response
MRI of brain for 2' and 3' disease
3. 1' = daily glucocorticoid and daily
mineralocorticoid
2' = daily glucocorticoid

congenital
adrenal
hyperplasia
1. patho
2. clinical
pres (male
vs female)
3. salt
wasting
form clinical
pres1

1. AUTOSOMAL RECESSIVE 21
HYDROXYLASE (90%) DEFICIENCY/11
HYDROXYLASE DEFICIENCY--> dec
cortisol/aldosterone production and inc.
ACTH secretion + shunting of intermediates
toward DHEA and testosterone
2. female - ambiguous genetalia but normal
ovaries/uterus
male - no genital abnormalities
3. emesis, dehydration, hypotension, shock
in first 2-4 weeks of life total lack of aldo
activity --> hyponatremia/hyperkalemia,
hypoglycemia

congenital
adrenal
hyperplasia
1. dx

1. 17 hydroxyprogesterone elevated
2. cortisol and mineralocorticoid
surgery - early correction of female genital
abnormalities

diabetes
mellitus
1. patho type
1
2. patho type
2

1. autoimmune destruction of beta cells in


response to environmental/genetic factors
(HLA DR/DQ)
2. obesity, age, genetic (>type 1) --> inc. fatty
acids causes muscle insulin resistance -->
beta cells desensitized to glucose, dec. insulin
secretion

776.

777.

778.

779.

780.

781.

1. dawn
phenomenon
2. somogyi
effect
3. how to
diagnose/treat
for the above

1. inc. nocturnal GH secretion inc. morning


hyperglycemia
2. episodic hypoglycemia at night
counterregulation system leads to morning
hyperglycemia (2/2 adrenergic response to
hypoglycemia)
3. measure 3am blood glucose Low = somogyi - dec. evening insulin to
avoid nocturnal hypoglycemia
High = dawn - inc. evening insulin

diabetes
mellitus dx

two* fasting blood glucose >126


single glucose level >200 with symptoms
inc. glucose level on oral glucose tolerance
hemoglobin A1c >6.5

diabetes
mellitus
1. screening

1. all adults over age 45 every 3 years, test


anyone with symptoms

impaired
glucose
tolerance dx

fasting blood glucose 110-126


2 hour postprandial 140-200
hemoglobin A1c 5.7 -6.4

diabetes
mellitus sx

polyuria (osmotic retention)


polydipsia (to maintain plasma volume)
fatigue (inc blood glucose)
weight loss (loss of anabolic insulin
effects)
blurred vision (swelling of lens from
osmosis)
fungal infections (candida albicans)
numbness/tingling (neuropathy,
mono=microscopic vasculitis, poly =
multifactorial)

diabetes
maintenance
1. patient
monitoring

...

782.

783.

784.

785.

focus on: feet, vascular disease


(CAD/PVD), neurologic disease,
eye disease, renal disease,
infectious disease

1. daily blood glucose


levels
2. HbA1c every 3
months keeping below
7.0
screen for
microalbuminuria
1x/year
BUN/Cr 1x/year
eye screening yearly by
ophthalmologist
feet check at every visit
yearly LDL (treat if
>100)
target BP <130/80
(ACE/ARB)
daily aspirin if >30
years old
pneumococcal vaccine

five stages of type 1 diabetes

stage 1 - genetic
susceptibility
stage 2 - autoimmune
beta cell destruction
stage 3 - continuded
beta cell destruction
and dec. insulin
release, glucose
normal
stage 4 - insulin
dependent C-peptide is
present
stage 5 - no C - peptide
present

side effects
1. sulfonylureas
2. metformin
3. acarbose
4. TZD (rosiglitazone,
pioglitizone)
- pramlintide, repaglinide,
nateglinide

1. hypoglycemia,
weight gain
2. GI upset, n/v,
abdominal pain, lactic
acidosis, metallic taste
3. GI upset (diarrhea,
cramping flatulence)
4. hepatotoxicity monitor LFTs

mechanism
1. sulfonylureas
2. metformin
3. acarbose
4. TZD (rosiglitazone,
pioglitizone)

1. stimulates pancreas
to make more insulin
2. enhances insulin
sensitivity, dec.
gluconeogenesis in the
liver
3. reduces glucose
absorption from the GI
tract
4. reduces fat/muscle
insulin resistance

786.

787.

788.

789.

790.

791.

advantages
1. sulfonylureas
2. metformin
3. acarbose
4. TZD (rosiglitazone,
pioglitazone)

1. cheap
2. mild weight loss
3. low risk, non-toxic

2/3 rule calculation for insulin


dosing
- in addition to a regimen, the
patient should use a sliding scale
of intermediate insulin insulin,
monitor 4 times/day - before
meals and at bedtime

kg * 0.5 units/kg =
units/day
2/3 morning (all
70/30) or 2/3 NPH,
1/3 regular
1/3 evening (all
70/30) or 2/3 NPH,
1/3 regular

how to decide insulin vs. oral


hypoglycemic

severe hyperglycemia
and type 1 patients >240 use insulin
oral hypoglycemia for
type 2 with moderate
hyperglycemia 110240

onset/duration
1. human insulin lispro
2. regular insulin
3. NPH insulin/lente insulin
4. ultralente insulin
5. 70/30 mixture
6. glargine (lantus)

modifying insulin dosage for


1. illness, or unclear home insulin
dose
2. illness
3. before surgery

1. why is diabetic goal BP 130/80


and LDL <100
2. macrovascular complications
of DM
3. microvascular complications
of DM

1. 15 min/4hr
2. 30-60 min/4-6hr
(only insulin given
IV)
3. 2-4 hr/10-18 hr
4. 6-10 hr/18-24 hr
5. 30min/10-16 hr
6. 3-4hr/24hr (@
bedtime)
1. total number of SSI
regular insulin on
day 1 divide into 2/3
morning 70/30 and
1/3 evening 70/30
2. normal insulin
dosing - to avoid
DKA
3. 1/3-1/2 of usual
daily insulin
requirement
1. accelerated
atherosclerosis in
diabetics, 2-4x risk of
CAD, MCC death in
diabetics is CAD
2. CAD, PVD (60%),
cerebrovascular
disease
3. diabetic
nephropathy,
diabetic retinopathy,
diabetic neuropathy

792.

793.

794.

795.

796.

797.

diabetic
nephropathy
1. pathology
2. dx
3. tx

1. increased GFR**, glomerular


basement membrane thickening,
hyaline nodular glomerulosclerosis
(kimmelstiel wilson syndrome),
diffuse glomerulosclerosis
2. microalbuminuria 30-300mg/day,
albumin:creatinine ratio 0.02-0.2
3. strict glycemic control

progression of
diabetic
nephropathy
what drugs if
patient has HTN
and
microalbuminuria

microalbuminuria --> progression to


proteinuria, progressive sclerosis and
ESRD
*ONCE GET PROTEINURIA
DAMAGE IS IRREVERSIBLE
AND GLYCEMIC CONTROL
DOES NOT PREVENT
PROGRESSION ANYMORE***

ACE inhibitors or
ARB

...

diabetic
retinopathy
1. frequency
2. background
3. proliferative
4. other ocular
problems

1. 75% after 20 years of retinopathy


2. hemorrhages, exudates,
microaneurysms, venous dilation,
macular edema, asymptomatic if no
retinal edema
3. NEOVASCULARIZATION and
scarring, vitreous hemorrhage, retinal
detachment
4. cataracts, retinopathy, glaucoma
#1 cause of blindness in the US

diabetic
neuropathy
1. peripheral
neuropathy
clinical pres
2. peripheral
neuropathy
treatment
3. CN abnormalties

1. stocking glove numbness and


paresthesias
ulcer formation, charcot joints,
hypersensitivity to light touch,
burning pain at night
2. gabapentin, TCA, pregabalin
3. CNIII palsy - eye pain, diplopia,
ptosis, inability to adduct the eye,
pupils are spared
also CN VI and CNIV

diabetic
neuropathy
1.
mononeuropathies
2. autonomic
neuropathy

1. median nerve, ulnar nerve, common


peroneal
diabetic lumbosacral plexopathysevere deep pain in thigh,
atrophy/weakness in thigh/hip
muscles
truncal neuropathy in distribution of
intercostal nerves
2. impotence in men (MCC),
neurogenic bladder
(retention/incontinence),
gastroparesis (n/v early satiety)
alternating constipation/diarrhea,
postural hypotension

798.

799.

800.

801.

802.

803.

does diabetic
control help
micro or
macrovascular
disease

microvascular by 50%, no clear


improvement in macrovascular

diabetic foot
1. patho

1. arterial ischemia and neuropathy -->


ulcers/infections, repetitive injuries, masks
symptoms of rest pain, falsely elevated BP
readings

diabetic
infections
1. which
infections

1. cellulitis, candidiasis, pneumonia,


polymicrobial foot ulcers, osteomyelitis

treatment of
diabetic
complications
1.
macrovascular
disease
2.
nephropathy
3. retinopathy
4. neuropathy
5. diabetic foot

1. risk reduction, aspirin, glycemic control


2. ACE inhibitors (slows
microalbuminuria-->proteinuria, slows
GFR decline)
3. ophthalmology/photocoagulation
4. NSAIDs, TCA, gabapentin,
metoclopromide,
5. foot care, podiatry visits

DKA
1. patho
2. causes
3. clinical pres

1. more common in type 1 - insulin


deficiency and glucagon excess --> severe
hyperglycemia and accelerated
ketogenesis,osmotic diuresis, volume
depletion, metabolic acidosis
2. stress or illness, trauma, surgery, sepsis,
GI bleeding, inadequate insulin
3. n/v, KUSSMAUL RESPIRATIONS
(rapid/deep), abdominal pain, acetone
breath odor, orthostasis,
tachycardia, polyuria, polydipsia,
polyphagia, weakness, drowsiness, or
coma

DKA
1. dx

1. hyperglycemia >450, or <850 (recent


alcohol consumption can produce
euglycemia
met. acid pH <7.3, HCO3- <15 mEq/L, inc.
anion gap
ketonemia/acidosis
others: hyperosmolarity, hyponatremia
(dilutional- 1.6mEq/L for every 100mg/dl
of glucose), hypokalemia (exacerbated by
treatment with insulin)

804.

805.

806.

807.

808.

809.

810.

DKA
1. tx

1. insulin immediatly - 0.1units/kg of


regular insulin bolus followed by infusion
of 0.1 units/kg/hour **CHECK
POTASSIUM BEFORE STARTING
continue insulin until ion gap closes and
metabolic acidosis is corrected , give SC
insulin after patient begins eating
IVF immediatly, then 5% glucose once
blood glucose reaches 250
check BUN/Cr then prophylactically
replace potassium

DKA ddx

alcoholic ketoacidosis
hyperosmolar hyperglycemic nonketotic
syndrome
hypoglycemia
sepsis
intoxication - MUDPILES

lab orders
when a patient
presents with
suspected DKA

blood glucose, CBC, BMP, BUN/Cr,


urinary analysis, ECG, CXR, blood
cultures
Start IVF, start insulin, start potassium

DKA
complications

cerebral edema if glucose is dropped too


rapidly
hyperchloremic anion gap acidosis from
too rapid saline infusion

hyperosmolar
hyperglycemic
nonketotic
syndrome
1. patho
2. clinical pres
3. dx

1. type 2 diabetics: stress/illness + low


insulin --> hyperglycemia --> severe
hyperglycemia, hyperosmolarity,
dehydration
ketones low b/c small amount of insulin
stops glucagon release
2. thirst, polyuria, dehydration/volume
depletion, hypotension, tachycardia
CNS: seizures (hyperosmolarity), lethargy,
confusion
3. hyperglycemia >900, hyperosmolarity
320 mOsm/L
serum pH>7.3, serum HCO3- >15,
elevated BUN (pre-renal azotemia)

hyperosmolar
hyperglycemic
nonketotic
1. tx

1. ***Fluid replacement - 1L NS in first


hour, 2nd liter in second hour, then
switch to 1/2NS
low dose insulin to lower blood glucose
(5-10 unit bolus then infusion at 2-4
units/hour)
switch to D5 1/2NS when blood glucose is
250

physiologic
response to low
blood glucose

@ 80 insulin decreases
lower than 80 glucagon increases
epinephrine/cortisol are next hormone
@ 50s symptoms of hypoglycemia occur

811.

812.

813.

814.

815.

816.

hypoglycemia
1. why is
brain so
sensitive to
hypoglycemia'
2. causes

1. brain cannot use FFA as an energy


source, symptoms correlate with blood
glucose levels
2. overdosing insulin (see low C-peptide),
anti-insulin antibodies, factitious
hypoglycemia, insulinoma, ethanol
ingestion (inc. NADH, dec.
gluconeogenesis), postoperative
hypoglycemia (ex. dumping syndrome),
adrenal insufficiency, liver failure, glycogen
storage diseases

hypogycemia
1. clinical
pres
2. dx
3. tx

1. blood glucose of 40-50, inc epi -->


sweating, tremors, inc. BP/pulse, anxiety,
palpitations
neuroglycopenic sx - irritability, behavioral
changes, weakness, drowsiness, HA,
convulsions, coma, death
2. blood glucose <50, serum insulin, Cpeptide, sulfonylurea levels, 72 hour fast
diagnoses insulinoma
3. 1/2-2 ampules D50W, then switch to
D10W when glucose is >100 mg/dL
if patient is alcoholic, give THIAMINE
BEFORE***GLUCOSE to avoid wernickes
endcephalopathy

hypoglycemic
unawareness
1. patho

1. diabetic neuropathy and blunted


autonomic response leads to loss of
neurogenic symptoms and do not recognize
hypoglycemia

insulinoma
1. patho

1. insulin tumor from beta pancreas cells,


associated with MEN1, usually benign
2. sympathetic activation - diaphoresis,
tremors, high BP, anxiety
neuroglycopenic symptoms - headache,
visual disturbances, confusion, seizures,
coma
3. WHIPPLE'S TRIAD - fasting
hypoglycemia symptoms, blood glucose <50
during attack, glucose relieves symptoms

how to
distinguish
between
sulfonylurea
abuse and
insulinoma

insulinoma shows elevated proinsulin


(>20% insulin level) and sulfonylurea abuse
shows normal proinsulin level (<20%
insulin level)

BOTH have
inc. insulin,
dec. glucose,
and inc. cpeptide levels

...

817.

818.

819.

820.

821.

822.

823.

zollinger ellison syndrome


1. patho
2. anatomic location
3. clinical pres
4.dx/tx

1. pancreatic islet tumor that


secretes gastrin leading to
gastric acid
hypersecretion/ulcers (assc
with MEN1)
2. gastrinoma triangle cystic duct, 2nd/3rd portion
of duodenum, and pancreatic
neck inferiorly
3. peptic ulcers, diarrhea,
weight loss, abdominal pain
4. secretin injection**
(normally inhibits gastrin
secretion) but in gastrinoma
paradoxical increase in
gastrin
fasting gastrin, basal acid
>15 mEq/hour (normal <10)
tx = PPI, exploration and
resection

glucagonoma
1. patho
2. clinical pres

1. glucagon producing tumor


of the pancreas
2. TRIAD- hyperglycemia,
necrotizing dermatitis,
weight loss

necrotizing migratory
erythema, glossitis,
stomatitis, hyperglycemia,
with low amino acids, high
glucagon
tx = surgical resection

...

somatostatinoma
1. clinical pres

1. TRIAD gallstones, diabetes


, steatorrhea

VIPoma (vernermorrison, WDHA


syndrome)
1. clinical pres
2. dx/tx

1. watery diarrhea(->dehydration, hypokalemia),


achlorhydria (VIP inhibits
gastric acid), hyperglycemia,
hypercalcemia
2. CT/MRI, octreod

what is the #1 cause of


neurologic disability, and
the 3rd leading cause of
death

stroke aka cerebrovascular


accident

classes of ischemic stroke

TIA, reversible ischemic


neurologic deficit (>24 hours,
<2wks),
evolving stroke - stroke that
worsens
complete stroke - maximal
deficit has occured

824.

825.

826.

827.

828.

TIA
1. patho
2. clinical pres
3. future risk
after TIA
4. risk factors

1. embolic, hypotension, carotid stenosis -> blockage of blood flow does not last
long enough to cause permanent
infarction
2.max 24 hours, usually less than 30
mins, but indistinguishable from a stroke
at time of presentation
3. 30% 5 year stroke risk
4. age, HTN, smoking, afib, HLD,
hypercoagulability, vasoconstrictive drugs
(cocaine/amphetamines), polycythemia
vera, sickle cell

ischemic
stroke
1. sources of
emboli
2. thrombotic
stroke
locations
3. lacunar
stroke

1. heart - embolization of mural thrombus,


or afib
internal carotid, aorta, paradoxical (via
vein to ASD)
2. atherosclerotic lesions in the carotid @
bifurcation or MCA
3. HTN/DM causes narrowing of arterial
lumen by thickening of the vessel wall in
the basal ganglia, thalamus, internal
capsule, brainstem

source of
embolic stroke
evaluation

1. echocardiogram
carotid doppler
ECG/Holter monitor

symptoms of
TIA
1. carotid
system TIA
2.
vertebrobasilar
TIA
3.

1. temporary loss of speech, paralysis,


paresthesias of contralateral extremity,
amaurosis fugax (curtain like loss of sight
2. dizziness, double vision, vertigo,
ipsilateral facial numbness, contralateral
limb weakness, dysarthria, hoarseness,
dysphagia, projectile vomiting, headaches

subclavian
steal syndrome

stenosis of subclavian artery PROXIMAL


to vertebral artery - left arm exercise causes
vertebral artery flow reversal -->
vertebrobasilar insufficiency/upper
extremity claudication
tx= surgical bypass

829.

830.

831.

832.

833.

834.

thrombotic stroke
1. clinical pres
2. MCA clinical
pres
3. lacunar stroke
clinical pres
4. anterior
cerebral artery

1. patient often awakens from sleep


with neurologic deficits
2. contralateral hemiparesis,
hemisensory loss
aphasia (left), apraxia, contralateral
hemineglect (right parietal), confusion
(non-dominant hemisphere
3. small lacunar vessels --> isolated
findings, limited deficits
pos limb internal capsule = pure motor
lacunar stroke
VPL thalamus = pure sensory lacunar
stroke
ataxic hemiparesis (pos limb IC),
clumsy hand syndrome (pons),
dysarthria (pons)
4. contralateral lower extremity/face

causes of carotid
bruit

murmur referred from the heart


turbulent flow in the internal carotids

stroke
1. dx / workup
2. complications

1. CT scan without contrast differentiates ischemic from


hemorrhagic - ischemic = dark,
hemorrhage = bright
MRI - more sensitive - takes longer in
emergency setting
ECG - to detect MI or atrial fibrillation
carotid duplex - detect stenosis
MRA - evaluate carotids,
vertebrobasilar MCA/ACA/PCA, circle
of willis
2. cerebral edema/mass effect 1-2 days
after stroke - lower ICP with
hyperventilation/mannitol
hemorrhage into infarction
seizures

stroke
1. treatment

1. supportive - airway, oxygen, IV fluids


tPA within 3 hours
aspirin if patient presents after 3 hours
clopidogrel if patient cannot take
aspirin, if cant take clopidogrel take
ticlopidine
bed 30 degrees to prevent aspiration
BP control ife >220/120, or MAP >130,
acute MI, aortic dissection, heart
failure, hypertensive encephalopathy,
patient is undergoing thrombolysis

contraindications
to tPA

> 3 hours after stroke onset


uncontrolled HTN, bleeding,
anticoagulation, no aspirin for 24
hours after tPA (all inc. risk for
hemorrhagic conversion)

stroke
1. prevention

control risk factors, aspirin, carotid


endarterectomy for symptomatic and
>70% stenosis

835.

836.

837.

838.

839.

840.

intracerebral
hemorrhage
1.
causes/patho
2. clinical
pres
3. dx
4. tx

1. sudden inc. in BP (50-60%), amyloid


angiopathy, anticoagulation/thrombolytic,
brain tumors, AVM --> rupture of deep
vessels in basal ganglia, pons, cerebellum,
other
2. focal deficits that worsen over 30-90
minutes , altered LOC, stupor, coma,
headache, inc. ICP
3. CT of head **( shows bright white signal)
coagulation panel, platelet count
4. ICU, ABCs, gradual BP reduction
(nitroprusside) if >160/>105
mannitol/diuretics reduce ICP
surgical evacuation of CEREBELLAR
hematomas only

1.
complications
of
hemorrhagic
stroke
2. brain
complications
associated
with cocaine
use

inc. ICP, seizures, rebleeding, vasospasm,


hydrocephalus, SIADH
2. ICH, ischemic stroke, SAH

pupillary
findings in
intracerebral
hemorrhage

pinpoint - pons
poorly reactive pupils - thalamus
dilated pupils - putamen

subarachnoid
hemorrhage
1.
causes/patho
2. anatomic
locations
3. clinical
pres

1. saccular aneurysms at bifurcations of


arteries of circle of willis, trauma, AVM -->
bleeding into subarachnoid space
2. junction of ACA with anterior
communicating, junction of PCA with
internal carotid, MCA bifurcation
3. sudden "worst headache of my life",
transient LOC, vomiting, meningeal
irritation, nuchal rigidity, photophobia,
retinal hemorrrhages

subarachnoid
hemorrhage
1. dx/tx

1. non-contrast CT scan
lumbar puncture if CT scan is inconclusive-see blood in SAF, and xanthochromia from
RBC lysis
tx = neurosurgery,
reduce risk of rebleeding, stool softeners,
analgesia, HTN, lower BP gradually (to
account for possible decreased CPP), CCB
for vasospasm

SAH
complications

rerupture, vasospasm, communicating


hydrocephalus, seizures, SIADH

841.

842.

843.

844.

845.

parkinsons
disease
1. pathophys
2. clinical
pres
3. pathologic
finding

1. loss of dopamine containing neurons in


substantia nigra/locus ceruleus, shifts
dopamine/acetylcholine balance in the
basal ganglia toward acetylcholine
2. pill rolling tremor at rest that goes away
when performing routine takes,
bradykinesia, cogwheel rigidity*,
expressionless facies/dec. blinking,
dysarthria, dysphagia, micrographia,
impaired cognition, orthostasis,
constipation, personality changes,
depression, significant disability within 510 years
3. lewy bodies (hyaline inclusion bodies)

shy drager
syndrome
1.
patho/clincal
pres
2. tx

parkinsonian symptoms + autonomic


insufficiency (orthostasis, constipation, inc.
sweating, oily skin, incontinence)
* risk of laryngeal stridor/bulbar dysfunction
2. volume expansion - fludrocortisone, salt
supplementation, alpha agonists,
compression devices

parkinson
syndrome
1. treatment

1. no cure
carbidopa-levodopa (Sinemet) relieves
symptoms - shows "on-off" phenomenon
bromocriptine, pramipexole (dopamine
agonists)
selegiline - MAOI ~ L-dopa adjunctive agent
amantadine - for early or mild disease
anticholinergic drugs - trihexyphenidyl
benztropine *best for tremor/rigidity
dominant disease
amitriptyline - both anticholinergic and
antidepressant
DBS for patients that don't respond
medications or develop disease before age 40

what drugs
cause
parkinsonian
side effects

metoclopramide (gastrokinetic), typical


antipsychotics, reserpine (antipsychoticantihypertensive)

huntington's
chorea
1. patho
2. clinical
pres

1. AUTOSOMAL DOMINANT chromosome


4 CAG trinucleotide repeat disorder that
shows genetic anticipation, degeneration of
the GABAergic neurons of the caudate
nucleus
2. onset between age 30-50, chorea of
face/head/tongue, irritability, personality
change, antisocial behavior OCD, impaired
mentation, incontinence dementia before
age 50

846.

847.

848.

849.

850.

huntingtons chorea
1. dx/tx

1. MRI - caudate/putamen atrophy,


bilateral enlarged ventricles
PET scan - dec. glucose metabolism
DNA testing, genetic counseling for
family members
tx= symptomatic, dopamine
antagonists help with
psychosis/chorea,
anxiolytics/antidepressants

physiologic tremor
1. causes

1. fear, anxiety, fatigue,


hypoglycemia, hyperthyroidism,
pheochromocytoma,
alcohol withdrawal, valproate,
lithium, caffeine, theophylline

essential tremor
1. patho
2. clinical pres
3. tx

1. autosomal dominant inheritance,


2, exacerbated by intentional
activities, DECREASED BY
ALCOHOL USE, no parkinsonism
symptoms present
3. propranolol, primidone
(anticonvulsant, can precipitate
acute intermittent porphyria attackabdominal pain, confusion,
headache, hallucinations - check
UA)

different tremors
clinical
pres/associated
symptoms
1. parkinsonian
2. cerebellar
3. essential tremor

1. tremor at REST, pill rolling,


associated with rigidity,
bradykinesia, shuffling gait,
improved by action
2. intention tremor, coarse,
associated with ataxia, nystagmus,
dysarthria, improved by rest
3. associated with postures - ex.
outstretched hands, fine tremor,
associated with head tremor or
vocal tremulousness, improved by
alcohol

ataxia
1. causes
(acquired/inherited)

1. alcohol, B12/thiamine deficiency,


cerebellar infarction, neoplasm,
demyelinating disease (MS/HIV),
tabes dorsalis
inherited = friedreich's ataxia,
ataxia telangiectasia

friedreich's ataxia
1. patho/clinical pres

1. Autosomal recessive chromosome


9 defect --> degeneration of dorsal
columns, corticospinal tract,
spinocerebellar tracts, cerebellum
Clinical pres= ataxia , nystagmus,
impaired vibratory sense,
proprioception, kyphoscoliosis

852.

853.

854.

855.

856.

857.

858.

859.

860.
851.

ataxia
telangiectasia
1. patho/clinical
pres

1. autosomal recessive - Frederich's


ataxia + telangiectasia + increased risk
of cancer (ESPECIALLY NONHODGKIN S LYMPHOMA, ALL,
STOMACH CANCER,), IgA deficiency

tourettes
syndrome
1. patho
2. clinical pres
3. tx

1. AUTOSOMAL DOMINANT associated with OCD


2. multiple motor tics - blinking,
grimacing, head jerking, shoulder
shrugging
phonic tics (>1 kind)- grunting, sniffing,
clearing throat, coprolalia
3. clonidine, pimozide, haloperidol

dementia
1. diagnostic
criteria
2. vascular
dementia
3. binswanger's
disease

1. progressive loss of intellectual


function, with PRESERVATION OF
CONSCIOUSNESS, associated with inc.
age
2. stepwise deterioration in intellectual
function from cerebral infarction
3. diffuse subcortical white matter
degeneration in patients with
atherosclerosis/HTN

primary causes
of dementia

alzheimer's disease, vascular dementia,


binswanger's disease, brain tumors,
chronic subdural hematomas, NPH, lewy
body dementia, picks disease, MS,
parkinsons, huntington, wilsons

infectious
causes of
dementia

HIV infection (AIDS dementia),


neurosyphilis, cryptococcus, CJD,
progressive multifocal
leukoencephalopathy

metabolic
causes of
dementia

thyroid disease, B12 deficiency, thiamine


deficiency (--> korsakoff dementia),
niacin deficiency

what toxins
cause dementia

chronic alcoholism, aniline dyes, lead,


mercury

pseudodementia

severe depression that can cause a


decline in cognition but is responsive to
antidepressants
patients are overly concerened about
their memory loss

1. dementia lab
workup
2. dementia
pharmacologic
treatment

1. CBC with diff, chemistry panel, TSH,


B12, folate, VDRL, HIV screening, CT or
MRI of head
2. vitamin E, tacrine, donepezil

861.

862.

863.

864.

865.

866.

alzheimers
disease
1. risk factors
2. pathology
findings
3. dx/tx

alzheimers
disease
1. clinical pres

1. age : 10-15% of people over age 65, 1530% over age 80


family history, downs syndrome,
chromosome 21, 14, 19 abnormalities, loss
of CHOLINERGIC neurons*
2. senile plaques- dilated, tortuous neuritic
plaques around beta amyloid core,
neurofibrillary tangles - in cytoplasm of
neurons
3. clinical diagnosis, CT or MRI shows
diffuse cortical atrophy with
ventriculomegaly
tx = cholinesterase inhibitors - donepezil,
rivastigmine, galantamine
memantine - NMDA antagonist
ginkgo, lecithin
vitamin E 2000IU/day
HRT associated with lower risk of
alzheimers disease
1. early - forgetfulness, impaired ability to
learn, poor performance, change in
judgement
intermediate - progressive memory
impairment, visuospatial disturbances
later stages- help needed for daily living,
difficulty remembering names of relatives
advanced- complete debilitation, loss of
bowel/bladder control,
death 2/2 infection

lewy body
dementia
1. clinical pres
2. tx

1. visual hallucinations predominant


initially, disorganized speech,
extrapyramidal symptoms, fluctuating
mental status, faster progression
2. selegiline, neuroleptic agents (for
hallucinations/psychosis)

altered mental
status
1. what part of
the brain is
responsible for
arousal
2. what part of
the brain is
responsible for
cognition

1. RAC in brainstem
2. cerebral cortex

causes of
delirium

P.DIMMWIT
postoperative, dehydration/malnutrition,
infection, medications, metals,
withdrawal stages, inflammation/fever,
trauma/burns

what drugs can


cause delirium

TCAs, corticosteroids, anticholinergics,


hallucinogens, cocaine

867.

868.

869.

delirium
1. clinical
pres
2. dx/tx

1. rapid deterioration of mental status,


FLUCTUATING LEVEL OF
CONSCIOUSNESS, disorientation, frequently
abnormal vital signs, may include
hallucinations
2. MMSE, chemistry panel, B12, thiamine
tx = underlying cause, haloperidol for
agitation, supportive

ddx for
coma/stupor

SMASHED
structural brain pathology - stroke,
subdural/epidural, tumor, abscess,
herniation
meningitis, mental illness
alcohol, acidosis
seizures, substrate deficiency (thiamine)
hypercapnia, hyperglycemia, hyperthermia,
hyponatremia hypoglycemia, hypoxia
endocrine - addisonian crisis, thyrotoxicosis,
hypothyroidism, encephalitis (uremia)
drugs - opiates, barbiturates, benzos,
dangerous compounds - monoxide, cyanide,
methanol

coma
1. criteria
2. causes
3. diagnosis

1. decreased LOC, patient unresponsive to


any stimuli
2. bilateral structural brain lesions, or
brainstem, or cerebellum, or RAC damage,
global brain dysfunction - metabolic or
systemic disorders
psychiatric - conversion, malingering
3. ABC, assume trauma, stabilize cervical
spine, assess LOC (via GCS)
asymmetric movement = most likely mass
lesion
pupillary light reflex - indicates midbrain
intact, morphine, anoxic encephalopathy,
bilateral fixed/dilated (severe anoxia),
unilateral fixed /dilated uncla herniation,
pinpoint pupils - ICH, narcotics
independent breathing - intact brainstem
toxicologic analysis
CT or MRI of brain
LP if suspect meningitis or SAH

870.

871.

872.

873.

coma
1.
treatment
2 brain
death
3.
persistent
vegetative
state

multiple
sclerosis
1. patho
2. clinical
pres

multiple
sclerosis
1. dx

multiple
sclerosis
1. clinical
course

1. correct cause: airway, supp. o2, naloxone,


dextrose, thiamine before glucose, BP,
electrolytes, lower ICP if herniation
2. irreversible absence of brain/brainstem
function, no brainstem reflexes (pupils, calorics,
gag, cornea, dolls eyes)
no drug intox or metabolic condition
core body temp >32 C
clinical evidence or CT/MRI shows causative
explanation for brain death
repeat examinations, or EEG shows isoelectric
activity
3. comatose, but eyes are open, appear awake,
may have random limb/head movements,
spontaneous respirations
1. selective CNS white matter demyelination of
the brain and spinal cord, classically at the
angles of the ventricles, pyramidal, cerebellar
pathways, MLF, optic nerve, posterior columns
2. transient sensory deficits, paresthesias/dec.
sensation of upper/lower limbs, fatigue*,
weakness/spasticity, leg stiffness, optic neuritis,
central scotoma, dec. pupillary reaction,
INTERNUCLEAR OPHTHALMOPLEGIA
(adduction deficit), bilateral trigeminal
neuralgia
cerebellar involvement- ataxia, intention tremor,
dysarthria,
incontinence, impotence, constipation
memory loss, personality change, emotional
lability, anxiety, depression
neuropathic pain/hypersesthesas
1. clinically definite - two episodes, evidence of
white matter lesions clinical or imaging
laboratory supported - two episodes of
symptoms, at least one white matter MRI lesion,
abnormal CSF
probable MS- two episodes of symptoms, and
either one white matter lesion, or oligoclonal
bands
evoked potentials - remyelinated neurons
conduct slowly
clinically silent - stable or benign disease
relapsing and remitting primary progressive - onset typically later
1/3 of patients develop debilitating disease

874.

875.

876.

877.

878.

multiple
sclerosis
1. tx

1. high dose IV methylprednisone for acute


attack
plasma exchange therapy for steroid refractory
acute attacks
DMT- interferon B1a, B1b, glatiramer acetate
reduce relapse rates by 35% (SE is flu like
symptoms)
cyclophosphamide for rapidly progressing
disease
baclofen or dantrolene for spasticity
carbamazepine or gabapentin for neuropathic
pain

locked in
syndrome
1. clinical
pres
2. patho

1. patients completely paralyzed except for


respiration, blinking, and vertical eye
movement, patients are fully aware of their
surroundings and can feel pain
2. hemorrhage or infarction of the ventral pons

guillain
barre
syndrome
1. patho
2. clinical
pres

1. mycoplasma, campylobacter jejuni, CMV,


hepatitis, HIV, hodgkins disease, lupus, HIV
seroconversion --> inflammatory
demyelinating polyneuropathy of peripheral
nerves
2. abrupt onset of ascending symmetric
weakness/paralysis of all four extremities,
PRESERVED SENSORY* respiratory, facial,
bulbar muscles, spares sphincter
control/mentation
autonomic features - arrhythmias, tachycardia

guillain
barre
1. dx/tx

1. **CSF shows elevated protein**, normal


cell count, dec. NCV on EMG
tx= pulmonary monitoring/mechanical
ventilation, IVIG, plasmapheresis,
DO NOT GIVE STEROIDS IN GUILLAIN
BARRE SYNDROME
recovery usually occurs in 1-3 weeks, but if
persists >6 weeks probably will have relapsing
course

myasthenia
gravis
1. patho
2. clinical
pres
3.
myasthenic
crisis + tx

1. autoimmune disorder against nicotinic AchR, results in muscle fatigue especially rapidly
stimulated muscles
2. skeletal muscle weakness exacerbated by
use, involves cranial nerves
first symptoms often diplopia, ptosis, blurred
vision, dysarthria, dysphagia
3. infection or stressor -->
diaphragm/intercostal fatigue results in
respiratory failure
ET tube + withdrawl anticholinesterases +
plasmapheresis

879.

880.

881.

882.

883.

884.

myasthenia gravis
1. dx

duchenne's
muscular
dystrophy
1. patho
2. clinical pres
3. dx/tx

1.anti- Ach-R test


EMG shows decremental response
CT scan of thorax to rule out
thymoma (10% of patients 75%
histologically abnormal)
edrophonium tensilon test
tx = pyridostigmine,
thymectomy - can cause complete
remission
3rd line agents: corticosteroids,
azathioprine, cyclosporine
IVIG for exacerbations
serial FVCs <15 ml/kg = indication for
intubation
1. X LINKED RECESSIVE - mutation
in dystrophin causes muscle fibers to
die and replaced by fibrous scar tissue
2. progressive, symmetric proximal
muscle weakness, especially the pelvic
girdle
Gowers maneuver (proximal lower
extremity weakness),
pseudohypertrophy (fat replaces
muscle), wheelchair confinement,
respiratory failure/death by third
decade.
3. serum CK, muscle biopsy, DNA
testing

Becker's muscular
dystrophy

1. x linked recessive, similar to


duchennes muscular dystrophy but
less severe, some dystrophin present

what drugs
exacerbate
myasthenia gravis

aminoglycosides, tetracyclines
beta blockers
quinidine, procainamide, lidocaine

neurofibromatosis
type 1
1. patho/clinical
pres
2. complications

1. AUTOSOMAL DOMINANT
DISEASE NF1 - cafe au lait spots,
macrocephaly, short stature, learning
disabilities neurofibromas, CNS
tumors (gliomas, meningiomas),
axillary or inguinal freckling, iris
hamartomas (lisch nodules), bony
lesions
2. scoliosis, disfiguring
neurofibromas, scoliosis, optic nerve
gliomas*, renal artery stenosis,

neurofibromatosis
type 2
1. patho/clinical
pres
2. complications

1. AUTOSOMAL DOMINANT bilateral acoustic neuromas*, multiple


meningiomas, cafe au laits,
neurofibromas, cataracts

885.

886.

887.

888.

889.

890.

891.

892.

893.

tuberous
sclerosis
1.
patho/clinal
pres

AUTOSOMAL DOMINANT - cognitive


impairment, epilepsy, facial angiofibromas,
adenoma sebaceum, retinal hamartomas,
renal angiomyolipomas, rhabdomyomas of
the heart, retinal hamartomas
- hard nodules throughout the brain,
seizures, mental retardation

sturge weber
1.
patho/clinical
pres

1. facial vascular nevi capillary


angiomatosis of the pia (ipsilateral to
vascular nevi)
epilepsy, mental retardation

von-hippel
lindau
disease
1.
patho/clinical
pres

1. AUTOSOMAL DOMINANT - cavernous


hemangiomas of the brain stem, renal
angiomas and multiple organ cysts, assc.
with RCC, assc. with pheochromocytoma

syringomyelia
1.
patho/clinical
pres
2. associated
conditions

1. abnormal collection of fluid in the spinal


cord parenchyma--> bilateral loss of
pain/temp sensation in a cape like
distribution with preservation of fine touch,
areflexia, fasciculations, muscular atrophy
2. arnold chiari, post traumatic/infectious,
intramedullary tumors

brown
sequard
syndrome
1. patho

1. cord hemisection - fracuture/stab wound -> contralateral loss of pain/temperature,


ipsilateral loss of position/vibration,
ipsilateral hemiparesis

transverse
myelitis
1.
patho/clinical
pres

1. post-viral --> thoracic spine


demyelination --> weakness, back pain,
sensory deficits, sphincter disturbance
2. MRI with contrast
tx = high dose steroid therapy

horners
syndrom
1.
patho/clinical
pres
2. causes

cervical sympathetic disruption -->


ipsilateral ptosis (levator palpebrae still
intact), miosis, anhidrosis
2. idiopathic, pancoast tumor (superior
sulcus), internal carotid dissection,
brainstem stroke, neck trauma

poliomyelitis
1. patho
2. tx

1. anterior horn destruction and motor


neuron destruction of the spinal cord-->
asymmetric weakness inc. in the legs,
absent DTRs ,flaccid atrophic muscles,
normal sensation
2. no treatment available

dizziness
1. causes
2. dx

1. pre-syncope, vertigo, multisensory stimuli


(profound shock or overwhelming sensory
overload), cerebellar disease, cardiovascular
disease, TIAs, hyperventilation, anxiety,
2. audiogram, CT/MRA, MRI of posterior
fossa

894.

895.

896.

897.

898.

899.

1. central vertigo
2. peripheral
vertigo

peripheral vertigo
1. benign positional
vertigo + tx
2. menieres
disease + tx

1. gradual onset, look for


cardiovascular risk factors,
nystagmus can be bidirectional or
vertical, dysarthria, dysphagia,
diplopia, facial numbness, weakness,
hemiplegia ~ ie. significant neuro
deficits associated
2. cochlear or retrocochlear - abrupt
onset, head position has strong effect,
brainstem deficits absent except
tinnitus
1. vertigo associated with position
change, usually in patients >60 years
of age 2/2 labyrinthine dysfunction
tx = meclizine
2. TRIAD - vertigo, tinnitus, hearing
loss
attacks last for hours to days and
recur
hearing loss becomes permanent
tx = sodium restriction, diuretics

peripheral vertigo
1. acute
labyrinthitis
2. ototoxic drugs
3. acoustic
neuromas

1. viral infection of cochlea and


labyrinth
2. aminoglycosides, furosemide,
aspirin, cyclophosphamide
3. 8th CN, ataxia, gait unsteadiness,
nystagmus, hearing loss, tinnitus

central vertigo
1. casues

MS, vertebrobasilar insufficiency,


migraine associated vertigo

syncope
1. definition
2. cardiac syncope
clinical pres
3. vasovagal
syncope
(neurocardiogenic,
vasodepressor,
simple faints) + dx
+ tx

1. transient loss of
consciousness/postural tone
secondary to decreased cerebral blood
flow + rapid recovery of consciousness
without resuscitation
2. sudden without prodrome - face hits
floor- from arrhythmias, aortic
stenosis, HCM, pulmonary HTN,
prolapsed mitral valve, massive MI
3. MCC syncope - emotional stress,
fear, fatigue, diagnose with the *TILT
TABLE STUDY - patient will have
symptoms when upright or standing,
but not when supine
tx = supine posture, elevate legs, Bblockers, disopyramide

syncope
1. orthostatic
hypotension +
dx/tx
- also consider
vertebrobasilar
TIA, hypoglycemia,
hyperventilation,
hypovolemia,

1. ganglionic blockers, DM***, old


age, bed rest - defect in vasomotor
reflex , common in elderly, diuretics
TILT TABLE TEST POSITIVE
tx= inc. sodium intake, inc. fluid
intake, fludrocortisone

900.

901.

902.

903.

904.

905.

906.

what must be
considered if
patient has syncope
on exertion

HCM, aortic stenosis, + other causes


of cardiac syncope

seizures vs.
syncope

seizures tend to be longer


seizures bladder control is lost,
syncope bladder control is retained

evaluation of
syncope

history - before, during, after


syncopal episode, patient meds,
witnesses
physical exam - BP/pulse in 3
positions, MS, murmurs, carotid
pulses
ECG**, CBC, CMP
holter monitoring, tilt table testing,
CT scan, EEG, echocardiogram,

seizure
1. definition
2. epilepsy
definition
3. causes

1. sudden abnormal discharge from


the brain
2. recurrent idiopathic seizures
3. four Ms, four Is
metabolic/electrolytes hyponatremia, hypo/hyperglycemia,
hypocalcemia, uremia, thyroid storm,
hyperthermia
mass lesions - tumors, hemorrhage
missing drugs - non-compliance with
anticonvulsants, withdrawal from
alcohol/benzo/barbiturates
4 Is = intoxications, infections,
ischemia, inc. ICP

H&P for patient


who just had a
seizure

witness account
baseline, anticonvulsants, recent
dose changes, seizure disorder
examine for head inj, spine fractures,
tongue lacerations, bowel/bladder,
papilledema/signs of inc. ICP
do complete neuro exam

1. pseudoseizures
2. which drugs
(intoxications) can
cause seizures
3. what infections
can cause seizures
4. what ischemic
events can cause
seizures
-inc. ICP (4 Ms and
4 Is)

1. psychiatric in origin, diagnose


with EEG
2. cocaine, lithium, lidocaine,
theophylline, mercury/lead
poisoning, CO poisoning
3. septic shock, bacterial or viral
meningitis, brain abscess
4. strokes, TIAs

treatment for
eclampsic seizure

magnesium infusion

907.

908.

909.

910.

911.

epilepsy
1. partial
seizure
2. simple
partial
seizure
3. complex
partial
seizure
4. gneralized
sizure

1. begins in one part of the brain and


produces symptoms referable to that part of
that part of the brain
2. CONSCIOUSNESS REMAINS INTACTmay progress to a complex partial, may have
unilateral clonic tonic movement
3. CONSCIOUSNESS IMPAIRED, postictal
confusion, automatisms*** last from 1-3
minutes- inc. lip smacking, chewing,
aggression, olfactory/gustatory
hallucinations
4. LOSS OF CONSCIOUSNESS - disruption
of entire brain activity
two types - tonic clonic, absence

epilepsy
1. tonic clonic
2. absence
^ both of the
above are
generalized
seizures

1. aka grand mal bilaterally symmetric and


without focal onset, begins with loss of
consciousness, tonic phase (rigidity/risk of
apnea), clonic phase (jerking), flaccid
phase, regain consciousness
postictal confusion for 10mins - hours
2. school age children- patient stares into
space, looks absent minded, each episode
several seconds , may include, tongue biting,
vomiting, apnea, incontinence, no loss of
postural tone

epilepsy
1. dx

1. first seizure - CBC, electrolytes (*esp. Ca,


Na, glucose, BUN*), blood glucose, LFTs,
BUN/Cr, serum calcium urinalysis
EEG - abnormal EEG is not necessarily a
seizure, and a patient may have a normal
EEG after a seizure
CT of head to identify structural lesions
MRI of brain with and w/o gadolinium LP and cultures if patient is febrile

epilepsy tx

seizure risk
of recurrence
with normal
EEG vs
abnormal
EEG

ABCs- secure airway, roll patient on side to


prevent aspiration
history of non-compliance with anticonvulsants
one drug therapy, inc. dose, then add second
agent if neccessary
If seizures controlled for 2 years, taper very
slowly, and with EEG monitoring
first seizure--> EEG/neuro consult,
anticonvulsant therapy
15% vs 41%

912.

913.

914.

915.

916.

status
epiliepticus

prolonged sustained unconsciousness with


persistent convulsive activity - 20% mortality,
caused by med non-compliance, alcohol
withdrawal, intracranial infection,
neoplasm, metabolic disorder

Amyotrophic
lateral
sclerosis
1. patho
2. clincal
pres

1. anterior horn/corticospinal tract


degeneration --> upper AND lower motor
neuron signs onset between age 50-70
80% mortality at 5 years
2. PROGRESSIVE MUSCLE WEAKNESS first in arms/legs (DISTAL), no pain,
cramping, spasticity, fasciculations*,
impaired speech/swallow-->aspiration,
DOE, orthopnea, respiratory failure
(terminal)
PRESERVATION of bowel/bladder,
sensation, cognition, extraocular, sexual
function
- both upper and lower motor neuron signs

Amyotrophic
lateral
sclerosis
1. dxt/tx

1. EMG*/ NCV - confirms lower motor


neuron disease,
two regions (probable), or three-four regions
(definite) - bulbar (face, larynx, tongue, jaw),
cervical, thoracic, lumbosacral
tx = supportive,
riluzole - glutamate blocker, delay death by 35 months

epilepsy
1. tx

tx = airway, IV diazepam, IV phenytoin, 50


mg dextrose, IV phenobarbital if resistant
Long term tx - only treat patients with
abnormal EEG, MRI, or >1 seizure:
phenytoin*, carbamazepine
2nd line - valproate, phenobarbital,
primidone
absence seizures - ethosuximide, valproic
acid
B-HCG in women before starting drug
(teratogenic)

aphasia
1. definition
2. patho

1. loss or defect of language (speaking,


fluency, reading, writing, comprehension)
2. injury to the left cerebral hemisphere
(dominant in 95% of right handed people),
for left handed people 50% are left dominant- stroke, trauma, brain tumor, alzheimers
disease

917.

918.

919.

920.

921.

922.

923.

aphasia
1. wernicke's
aphasia
2. brocas
aphasia
3. conduction
aphasia
4. global
aphasia

1. receptive, fluent aphasia - patient cannot


comprehend written or spoken language,
speech is grammatically correct but doesn't
make sense, patients cannot understand
their own words
2. expressive, non-fluent aphasia, no
grammatical construction, good
comprehension
3. disturbance in repetition, defect in arcuate
fasciculus
4. disturbance in all areas of language
function - comprehension, speaking,
reading, fluency associated with right
hemiparesis

EMG/NCV
findings
1. lower motor
neuron
disease
2. myasthenia
gravis
3. myopathy

1. EMG fibrillations/fasciculations at rest,


dec. NCV (GB, MG, MS),
2. repetitive stimulation causes fatigue
3. no electrical activity at rest, dec.
amplitude with muscle contractions

bells palsy
1.
causes/patho
2. dx
3. tx

1. idiopathic, HSV, borrelia, GB, tumor -->


swelling of CN VII leading to hemifacial
weakness/paralysis--> full recovery in
weeks to months
2. consider lymes disease, clinical diagnosis
3. usually no treatment required
EMG if persists >10 days, short course of
steroid/acyclovir
patch eye to prevent abrasion
do not use steroids if lyme is suspected

trigeminal
neuralgia (tic
douloureux)
1.
patho/clinical
pres
2. dx/tx

1. idiopathic --> severe lancinating pain, no


motor or sensory paralysis
2. dx - clinical dx, MRI to rule out
cerebellopontine angle tumor
tx= carbamazepine***,
baclofen, phenytoin, surgical
decompression

cerebral
cortex lesions
clinical pres
(localization)

sensory motor deficits of the contralateral


face/trunk/extremities, upper extremities
worse than lower extremities
aphasia if left hemisphere, visual spatial
deficits if right hemisphere

subcortical
lesions
clinical pres
(localization)

internal capsule, cerebral peduncles,


thalamus, pons COMPLETE hemiparesis (compare to
cortical lesion)

cerebellar
lesion clinical
pres
(localization)

incoordination, intention tremor, ataxia

924.

925.

926.

927.

928.

929.

930.

brainstem
clinical pres
(localization)

crossed hemiplegia - ipsilateral face,


contralateral body deficits

spinal cord
clinical pres
(localization)

spinal shock, upper motor neuron signs


UMN signs - spasticity, inc. DTR, clonus,
pos. babinski
decrease in sensation below a sharply
demarcated band

plexopathy
clinical pres
(localization)

trauma is MCC, deficits are in more than


one nerve, , post-surgical hematoma is
MCC of lumbosacral plexopathy
Erb C5-C6, Duchenne C8-T1
Lumbosacral plexus L5-S3

radiculopathy
clinical pres
(localization)

effects a myotome and a dermatome weakness


and dermatomal sensory deficit

peripheral
neuropathy
clinical pres
(localization)

diabetes/trauma/entrapment/vasculitis -> distal nerve injury typically asymmetric,


dec.DTRs, can include numbness,
paresthesias, tingling, muscle atrophy,
fasciculations
diabetes --> nerve infarction
common locations radial/ulnar/median/musculocutaneous,
long thoracic, axillary, femoral

neuromuscular
junction
clinical pres
(localization)

FATIGABILITY, recovery with rest

myopathy
clinical pres
(localization)

1. symmetric weakness of proximal >


distal muscles, patient has normal reflexes
(initially), normal sensation, no
fasciculations

931.

932.

933.

934.

935.

systemic lupus
erythematosus
1. patho
2. subtypes of
lupus
3. clinical pres

1. genetic/environ/hormonal -->
autoantibodies, deposition of immune
complexes, complement activation, tissue
destruction/vasculitis --> damage to
multiple organ systems
2. spontaneous, discoid, drug induced,
ANA negative
3. fatigue, malaise, fever, weight loss
butterfly rash, photosensitivity, discoid
lesions, alopecia, raynauds, joint pain,
arthritis (symmetric inflammatory),
myalgia, pericarditis**, libman sachs
endocarditis, myocarditis
pleuritis*, pleural effusion
hemolytic anemia,
leukopenia,lymphopenia,
thrombocytopenia
proteinuria >0.5g/day, azotemia,
glomerulonephritis, pyuria
impaired immune response
n/v, dyspepsia, dysphagia PUD
seizures, psychosis, depression,
headaches, TIA, CVA
conjunctivitis, raynauds, sjogrens
syndrome

ANA negative
lupus
1. clinical pres
2. dx
3. neonatal
lupus clinical
pres

1. raynauds, arthritis, subacute cutaneous


lupus
2. anti-Ro (SS-A) positive, ANA negative
anti- Ro is risk for neonatal lupus
3. skin lesions, AV block, transposition of
great vessels, valvular and septal defects

systemic lupus
erythematosus
1. dx

4 or more:
mucocutaneous signs - rash, photosens,
oral or nasopharyngeal ulcers, discoid
rash,
arthritis, pericarditis, pleuritis, hemolytic
anemia, leukopenia, thrombocytopenia,
proteinuria,
seizures, psychosis, VDRL positive
positive ANA screening
anti-dsDNA (correlates with disease
activity), anti-Sm, anti-histone esp. in drug
induced lupus,
anti-Ro(SS-a), anti-La(SS-B) assc. with
sjogrens, subacute cutaneous SLE,

neonatal lupus
CBC, bun/Cr,
urinalysis,
serum
electrolytes

...

conditions
with elevated
ANA

SLE, RA, scleroderma, sjogren's, mixed CT


disease, polymyositis, dermatomyositis,
drug induced lupus

936.

937.

938.

939.

940.

941.

1. C-anca
2. P-anca
3. lupus
anticoagulant
4. anti-Ro,
anti-La
5. ESR/CRP

1. wegeners granulomatosis
2. polyarteritis nodosa
3. antiphospholipid
4. sjogrens, subacute cutaneous SLE,
complement deficiency (C2/C4), ANA
negative lupus
5. infection, malig, rheumatologic disease,
tissue necrosis, preg, vasculitis,
pancreatitis

systemic lupus
erythematosus
1. tx

1. avoid sun, NSAIDs, local or systemic


corticosteroids
antimalarials - hydroxychloroquine - req.
annual retinal exam
cyclophosphamide -for glomerulonephritis
monitor renal function/HTN

scleroderma
(systemic
sclerosis)
1. patho
2. clinical pres

1. cytokines stimulate fibroblasts cause inc.


collagen deposition + widespread fibrosis
2. raynauds**, ulceration, gangrene
periungual telangiectasias
mat telangiectasia - 2-7mm on the
face/hands
cutaneous fibrosis/ SCLERODACTYLY
GI- dysphagia, reflux from esophageal
dysmotility
pulm- interstitial fibrosis**** or pulm HTN
(only 10%)
pericardial involvement, pericardial
effusions, CHF, arrhythmias
renewal crisis- rapid malignant
hypertension
pulmonary artery hypertension/right heart
failure

drug induced
lupus
1. patho
2. what drugs
3. dx

1. drug induced lupus like syndrome that


DOES NOT AFFECT the CNS or kidneys
2. hydralazine, procainamide, isoniazid,
chlorpromazine, methyldopa, quinidine
3. anti-histone positive***, ANA positive,
no anti-dsDNA/anti-Sm

scleroderma
1. dx/tx

1. ANA positive, anti-centromere positive


(for CREST), anti-topo 1 (anti- Sc-70)
barium swallow and PFT detects common
complications
tx = no cure,
symptomatic treatments - NSAIDS for pain,
H2 blockers
avoid cold/smoking, CCBs to prevent
raynauds
treat pulm/renal complications

CREST
syndrome

calcinosis of the digits, raynauds,


esophageal dysfunction, sclerodactyly,
telangiectasias (mat like patches over
digits/under nails and on the face)
- more limited than diffuse scleroderma

942.

943.

944.

945.

946.

947.

ddx for raynauds

primary raynaud's, scleroderma, SLE,


mixed CT disease, buerger's vasculitis,
beta blockers, nicotine, bleomycin,
thromboangiitis obliterans

what
distinguishes
CREST from
diffuse
scleroderma

CREST does not involve renal, lung, and


heart early in the disease
anti-centromere positive

antiphospholipid
syndrome
1. patho
2. clincal pres
3. dx/tx

1. hypercoagulable state associated with


SLE or other collagen vascular disease
2. recurrent venous thrombosis,
recurrent fetal abortion,
thrombocytopenia, livedo reticularis
3. lupus anticoagulant anti-cardiolipin
antibody, PTT or PT is prolonged , and
not corrected with adding normal
plasma
tx = long term anticoagulation INR 2.53.5

sjogrens
syndrome
1. patho
2. primary
sjogrens
3. secondary
sjogren's

1. lymphocytic infiltrates destroy


lacrimal and salivary glands - can also
involve lungs, skin, thyroid, vessels,
liver
2. dry eyes, dry mouth but no other
rheumatologic disease
3. dry eyes, dry mouth and connective
tissue disease (RA, systemic sclerosis,
SLE, polymyositis, inc. risk of nonhodgkins lymphoma),. patients have
dry eyes, dry mouth, arthralgias,
fatigue, chronic arthritis, interstitial
nephritis, vasculitis

sjogrens disease
1. dx
2. tx

1. ANA, anti-Ro(SSA), anti-La (SSB),


inc. ESR, normocytic normochromic
anemia, leukopenia, schirmers test
2. pilocarpine, or cevimeline, artificial
tears, good oral hygiene, NSAIDs,
steroids for arthralgias/arthritis

mixed connective
tissue disease
1. patho
2. dx

1. has many features of SLE, RA,


systemic sclerosis, and polymyositis
2. anti-U1-RNP, ANA, anti-RF

948.

949.

rheumatoid
arthritis
1. patho
2. clinical pres
3.
extraarticular
manifestations

1. autoimmune disease of the joint


synovium + extraarticular manifestations
(IgG anti-Fc IgG)
2. inflammatory polyarthritis that spares
the DIPs, morning stiffness*** pain
commonly includes hands (MCP, PIP),
knees, ankles, elbows, hips, shoulders,
ulnar deviation of MCP joint, boutonniere's
deformity of PIP, swan neck contractures,
inc. atlanto occipital instability
3. low grade fever, weight loss,
pericarditis, pericardial effusions,
conduction abnormalities, valvular
incompetence, pleural effusions,
interstitial fibrosis (similar to IPF),
episcleritis, scleritis, sjogrens xerostomia,
rheumatoid nodules over extensor surfaces
and organs

rheumatoid
arthritis
1. skin
2. pulm
3. cardiac
4. ocular
5. nervous
system
6. felty's
syndrome
7. blood
8. vasculitis

1. thin, atrophic easy bruising, ulcerations,


rheumatoid nodules
2. pleural fluid with low glucose/high
protein/high LDH, pulmonary fibrosis,
restrictive PFTs CXR shows honeycomb
3. rheumatic nodules, pericarditis (40%)
4. scleritis, scleromalacia (softening of
sclera), dry eyes
5. mononeuritic multiplex - infarction of
nerve trunk,
6. RA, neutropenia, splenomegaly,
anemia, thrombocytopenia,
lymphadenopathy,
7. AOCD, normocytic, normochromic
anemia
8. microvascular vasculitis, can progress to
mesenteric vasculitis, PAN

950.

951.

952.

rheumatoid arthritis
1. poor prognostic indicators
2. dx
3. tx

Gout
1. causes/patho

synovial fluid appearance/WBCs/PMN/other


1. normal
2. non-inflam arthritis OA/trauma
2a. inflammatory arthritisRA/gout/SLE
3. gout
4. septic arthritis

1. high RF titers, subQ nodules,


953. erosive
arthritisarthritis, autoantibodies to RF onset/location/presence
2. inflammatory arthritis of 3 or more
of inflam/XR/labs/other
joints, symptoms >6 weeks,
1. osteoarthritis
high anti-RF titers (higher titers=
2.poorer
RA
prognosis), anti-ACPA, anti-CCP3. gouty arthritis
inc. ESR/CRP
AICD
XR- loss of juxta articular bone mass
near finger joints, NARROWING of joint
space
3. tx exercise , NSAIDs, low dose
corticosteroids,
DMARDs- MTX - SE= GI upset, oral
ulcers, alopecia, bone marrow
suppression, hepatocellular injury,
954. gout
interstitial pneumonitis
1. clinical pres
supplement MTX with folate
2. chronic tophaceous
sulfasalazine
gout
etanercept, infliximab - anti-TNF, use if
MTX does not control the disease
leflunomide
hydroxychloroquine - eye exam every 6
months from retinopathy
1. OBESITY/ALCOHOL/PURINE
INTAKE, renal
disease/NSAIDs/diuretics/acidosis/lesch
nyhan/ PPRPS
955. gout
overactivation/chemotherapy/hemolysis1. dx/tx
-> hyperuricemia crystallization of
monosodium urate in joints --> IgG
coating/PMN infiltration inflammatory
monoarticular arthritis
1. clear/<200/<25%
2. clear, yellow, red
(trauma)/<2000/<25%/RBCs for trauma
2a. / /2000-5000/<50%
3. cloudy yellow/>5000/50-70%/
positively birefringent pseudogout,
negatively birefringent gout
4.
turbid/purulent/>50,000/>70%/synovial
fluid culture positive for bacteria except
gonococcal (only 25% +)

1. insidious/weight bearing
joints/no inflam/narrowed joint
space, osteophytes, subchondral
sclerosis/subchondral cysts
2. insidious/PIP, MIP, wrists,
ankles, knees, ulnar deviation,
swan neck deformity, boutonniere
deformity/yes inflam/narrowed
joint space, bony EROSIONS/inc.
ESR, RF, anemia/extra-articular
findings
3. sudden/great toe, knees, ankles,
elbows/Yes inflamm/punched out
erosions with rim of cortical
bone/crystals/tophi,nephrolithiasis
1. asymptomatic, 40-60 years old,
initial attack typically one joint,
often first MTP (podagra), pain,
erythema, warmth, desquamation
of overlying skin, 60% have second
attack within one year,
2. >10-20 years, tophiaggregations of urate crystals
surrounded by giant cells 2/2
multiple gout attacks- located: ext.
surface of forearm, elbow, knees,
achilles tendons, pinna of ear
joint aspiration- needle shaped
negatively birefringent urate
crystals
serum uric acid - NOT helpful can
be normal
XR - punched out erosions with
cortical bone
tx= lifestyle modification (low
purine diet), early bed rest ,
NSAIDs* (indomethacin),
colchicine (contraindicated in
renal insufficiency or stones*
/cytopenia)
7-10 day oral prednisone if no
response to NSAID/colchicine, or
intra-articular injection
prophylaxis - >2 attacks
probenecid/sulfinpyrazone (if urine
urate is <800mg/day) or
allopurinol (if >800mg/day) +
colchicine/NSAID for 6 months to
prevent another attack (SE = SJS)

956.

957.

958.

959.

960.

961.

962.

pseudogout
1. patho
2. clinical pres
3. dx/tx

1.
963. inflammatory myopathy
age/hemochromatosis/hyper (polymyositis/dermatomyositis)
PTH/hypothyroid/Bartter's 1. dx
syn--> calcium pyrophosphate 2. tx + monitoring
crystals in joints, inc. with
age,
2. knees***/wrists, can be
mono or polyarticular, fever,
leukocytosis
3. joint aspirate weakly
positively birefringent rod
shaped and rhomboid crystals
(CPP crystals)
XR CHONDROCALCINOSIS**
tx= underlying cause,
NSAIDs/colchicine, intra
articular steroid injections*

1. CK, LDH, aldolase,


AST/ALT elevated
ANA, anti-Jo-1 (anti
synthetase), anti SRP, anti-Mi2, fever
EMG- myopathic
potentials/fibrillations
muscle biopsy - shows
inflammation/necrosis
2. corticosteroids then
slowly taper,
MTX,
cyclophosphamide,
chlorambucil, Pt for
refractory disease
MONITOR: with
muscle strength and
CK levels

what precipitates a gout attack

dec. temp, dehydration, stress,


964. inclusion body myositis
inc. alcohol intake, starvation 1. clinical pres
2. dx/tx
gram stain and culture

1. common in elderly
(M>F), proximal AND
distal muscle
weakness, loss of
DTRs
2. elevation in CK,
absence of
autoantibodies,
tx = treatment
refractory

what should always be done on a


joint aspirate in a patient with a
painful joint
complications f gout

nephrolithiasis, tophaceous
gout, degenerative arthritis

what NSAIDs should not be used


in gout

aspirin can aggravate,


acetaminophen has no antiinflammatory properties 965. polymyalgia rheumatica
1. patho
1. polymyositis,
dermatomyositis, childhood 2. clinical pres
3. tx
onset dermatomyositis,

idiopathic inflammatory
myopathy
(polymyositis/dermatomyositis)
1. diseases
2. childhood onset
dermatomyositis key clinical

inflammatory myopathy
(polymyositis/dermatomyositis)
1. common clinical pres
2. dermatomyositis unique
features

collagen vascular disease


myositis, myositis of
malignancy, inclusion body
myositis
2. subcutaneous calcifications
1. symmetrical proximal***
muscle weakness of neck
flexors, shoulder girdle, pelvic
girdle, dysphagia (30%),
arthralgias, CHF/conduction
defects/ILD both rarely ,
2. heliotrope rash around
eyes, bridge of nose, cheeks
gottron's papules - papular
erythematous knuckle lesions
V-sign - rash over face, neck,
ant. chest
shawl sign - shoulders, upper
back, elbows, knees
periungual
erythema/telangiectasias
subcutaneous calcifications
vasculitis of GI tract, kidneys,
lungs, eyes

1. autoimmune (HLADR4)
2. hip/shoulder muscle
pain after a period of
inactivity, pain with
movement, but
strength is normal.
constitutional
symptoms - malaise,
fever, depression,
weight loss, fatigue
joint swelling of knees,
wrists, hands
signs/symptoms of
temporal arteritis
3. elevated ESR
correlates with disease
activity
tx = corticosteroids

966.

967.

968.

969.

970.

fibromyalgia
1. clinical pres
2. dx
3. tx

ankylosing
spondylitis
1. patho
2. clinical pres
3. dx/tx

1. multiple tender TRIGGER POINTS,


symmetrical, stiffness, constant aching
pain, aggravated by weather, stress, sleep
deprivation, cold temperature, worse in the
morning
*sleep is disrupted, anxiety/depression is
common
2. widespread pain >3 months, 11/18
trigger point sites, r/o myofascial
syndromes, rheumatoid arthritis, ank
spondy, CFS, lyme, hypothyroid,
polymyositis
3. tx = SSRI, TCAs, CBT, psych eval
1. HLA B27 Male>females, ascending
fusion of the spine,
2. MORNING STIFFNESS, lower back pain
bilateral sacroiliitis, lower back pain,
limited lumbar spine motion, neck pain is
late, loss of lordosis, enthesitis (inflamm@
site of tendon attachments), fatigue, low
grade fever, weight loss, vertebral fractures
with minimal trauma
extra articular: anterior uveitis, iridocyclitis
3. MRI/CT/plain film - sacroiliitis,
sclerotic sacro-iliac junction, eventually
bamboo spine from column fusion
inc. ESR
4. indomethacin,
anti-TNF (etanercept, infliximab)
PT, surgery, strict immobilization with
back injury

causes of
monoarticular
joint pain
2. causes of
polyarticular
joint pain

1. osteoarthritis, gout, pseudogout, trauma,


septic arthritis, hemarthrosis
2. RA, SLE, viral arthritis, rheumatic fever,
lymes, gonococcal arthritis, drug induced
arthritis

reactive
arthritis
1. patho
2. clinical pres
3. dx

1. preceding infection:: salmonella,


shigella, campylobacter chlamydia,
yersinia --> asymmetric inflammatory
oligoarthritis
2. TRIAD, arthritis, urethritis,
conjunctivitis/anterior uveitis,
fatigue, malaise, weight loss, fever, joint
pain
3. synovial fluid analysis
4. NSAIDs***, no response sulfasalazine,
azathioprine

ankylosing
spondylitis
1.
complications

1. restrictive lung disease, cauda equina


syndrome, spine fracture with spinal cord
injury, osteoporosis ,spondylodiscitis,
aortitis

971.

972.

973.

974.

975.

psoriatic
arthritis
1. clinical pres

1. 10% of patients,usually preceded by skin


disease, tends to affect smaller joints,
asymmetric, polyarticular, NAIL
INVOLVEMENT***

temporal
arteritis
1. patho
2. clinical
pres
3.comorbid
conditions
4. dx/tx

1. inflammatory arteritis of temporal, aorta,


or carotids
2. fatigue, malaise, weight loss, fever,
headaches*, visual impairment**, jaw
claudication, tenderness over temporal
artery, absent temporal pulse
3. polymyalgia rheumatica** (40%),
aortic aneurysm*, aortic dissection**
(follow with serial cxr)
4. ESR elevated, temporal artery biopsy
(90%)
tx = high dose prednisone early before bx
results. if bx positive, treat for 4 weeks, then
taper for 2-3 YEAR*, FOLLOW ESR to
determine efficacy

takayasu's
arteritis
1. patho
2. clinical
pres
3. tx
4.
complications

1. vasculitis of the aortic arch and major


branches
2. fever, night sweats, arthralgias, fatigue,
absent carotid, pain radial, or ulnar pulses,
discrepancy in 4 limb BP
3. tx - steroids, treat HTN, surgery or
angioplasty for stenosed vessels
4. limb ischemia, aortic aneurysms, aortic
regurgitation, stroke

vasculitis by
vessel size
1. large vessel
2. medium
vessel

1. takayasu's, temporal
2. PAN, kawasaki's disease, wegener's
granulomatosis, churg-strauss microscopic
polyangiitis
3. henoch schonlein purpura,
hypersensitivity virus, behcets syndrome

churg strauss
1. patho
2. clinical
pres
3. dx/tx

1.P-ANCA -multi organ vasculitis including


respiratory, cardiac, GI, skin, renal, neuro
2. fever, fatigue, weight loss,
respiratory - asthma, dyspnea
skin lesions - subQ nodules, palpable
purpura
3. biopsy of lung/skin, p-ANCA
tx = steroids

Medicine 2_1
Study online at quizlet.com/_14lxem
1.

2.

3.

4.

5.

wegeners
granulomatosis
1. patho
2. clinical pres
3. dx/tx

polyarteritis
nodosa (PAN)
1. patho
2. clinical pres
3. dx/tx

behcets
syndrome
1. patho
2. clinical pres
3. dx/tx

1. vasculitis of the kidneys and UPPER


AND LOWER GI tract
2. upper respiratory symptoms, purulent
bloody nasal discharge, oral ulcers, cough,
hemoptysis, dyspnea, glomerulonephritis,
conjunctivitis, scleritis, arthralgias,
myalgias, tracheal stenosis, constitutional
symptoms
3. CXR, ESR, anemia, c-ANCA positive,
thrombocytopenia
*lung biopsy
tx = poor prognosis,
***cyclophosphamide/corticosteroids
renal transplant
1. HEP B*, HIV, drug reactions -> medium
vessel vasculitis of nervous system/GI
tract/kidney --> PMN invasion and
fibrinoid necrosis + intimal proliferation -> renal artery/AAA/nerve damage,
NO PULMONARY INVOLVEMENT
2. fever, weakness, weight loss, myalgias,
arthralgias, abdominal pain,
PERIPHERAL NERVES, HTN,
mononeuritic multiplex, livedo reticularis.
diffuse glomerulonephritis
3. biopsy of tissue (NO GRANULOMAS),
mesenteric angiography (look for
aneurysms)**
ESR, p-ANCA (myeloperoxidase)
FOBT
tx = corticosteroids, cyclophosphamide
1. autoimmune leukocytoclastic venulitis
2. recurrent oral and genital ulcers,
arthritis (knees/ankles), eye involvement
(uveitis, optic neuritis, iritis,
conjunctivitis), CNS involvement
(meningoencephalitis, HTN) fever, weight
loss, aortic disease
3. PATHERGY TEST elevated ESR/CRP, tissue biopsy, steroids

buergers
disease
1. patho
2. clinical pres
3. tx

1. cigarettes --> small vessel vasculitis of


arms/legs --> gangrene
2. ischemia, cyanotic, distal extremities,
ulceration of digits
3. tx smoking cessation

hypersensitivity
vasculitis
1. patho
2. clinical pres
3. dx/tx

1. penicillin/sulfa drugs/infection--> small


vessel vasculitis
2. palpable purpura, macules, vesicles,
3. tissue biopsy
tx = withdraw offending agent, steroids

6.

7.

8.

9.

10.

11.

12.

acute kidney injury


1. definition
2. clinical pres
3. what decreases
the probability of
recovery from AKI
4. what is the MCC
death in AKI

1. rapid decline in renal function, with


increased serum creatinine (>50%
relative inc., or absolute increase of
0.5-1.0mg/dl)
- may be oliguric, anuric, nonoliguric
2. dec. urine output, weight gain,
edema, due to positive water/sodium
balance, azotemia (inc. BUN/Cr)
3. increasing age and presence of
comorbid conditions
4. infection, and cardiorespiratory
complications

RIFLE criteria of
AKI
1. risk
2. injury
3. failure
4. loss
5. ESRD

1. 1.5x increase in serum creatinine or


GFR decrease by 25% or urine output
<0.5 for 6 hours
2. 2x inc. in serum creatinine, or GFR
decrease by 50% or urine output
<0.5ml/kg/hour for 12 hours
3. 3x inc. in serum creatinine or GFR
decrease by 75%
4. complete loss of kidney function
(w/ dialysis) for >4 weeks
5. complete loss of kidney function >3
months

three possible
locations of AKI

prerenal, intrinsic, post-renal

what causes
azotemia

catabolic drugs (ie. steroids), GI/soft


tissue bleeding, dietary protein intake

pre-renal failure
1. patho
2. causes
3. what drugs
should be avoided
in patients with
prerenal failure

1. reversible dec. in arterial blood


volume or renal perfusion --> dec.
GFR --> inc. BUN/Cr/uremic toxins
2. hypovolemia, dehydration, excess
diuretics, diarrhea, burns,
hemorrhage, CHF, renal artery
obstruction,cirrhosis
3. NSAIDS, ACE inhibitors,
cyclosporin

monitoring patient
with AKI

daily weights, intake, output, BP,


serum electrolytes, Hb, Hct, monitor
WBC for infection

urine
osmolarity/urine
Na/FeNa/urine
sediment
1. pre-renal
2. ATN

1. >500, <20, <1%, scant


sediment/hyaline casts
2. >350, >40, >1%, full brownish
pigment/granular epithelial casts

13.

14.

15.

16.

17.

18.

19.

20.

pre-renal
failure
1. clinical pres
2. dx

1. dry mucus membranes, hypotension,


tachycardia, dec. skin turgor,
oliguria/anuria
2. oliguria (<0.5ml/kg/hr), BUN:Cr >20:1
urine osmolarity >500
dec. urine Na+ <20, FENA <1%
urine:plasma Cr >40:1
hyaline urine sediment

intrinsic renal
failure
1. patho
2. clinical pres
3. lab findings

1. ATN, glomerulonephritis, allergic


glomerulonephritis goodpasture's,
wegener's granulomatosis, post-strep
glomerulonephritis, RAS, TTP, HUS
2. usually edema, tea colored urine
3. BUN/Cr ratio <20:1, urine Na >40,
FeNA >2-3%, urine osmolality <350
(impaired resorption), urine:plasma Cr
<20:1

rhabdomyolysis
1. patho
2. lab findings

1. skeletal muscle breakdown from trauma,


crush injury, prolonged immobility,
seizures, snake bites, cocaine,
statins* --> myoglobin --> ATN/AKI if
>20000
2. elevated CK, hyperkalemia,
hypocalcemia, hyperuricemia
3. IVF, mannitol (osmotic diuresis),
bicarbonate (pushes K+ into cells)

ATN
1 . two types of
ATN
2. nephrotoxic
agents

1. ischemic (shock, hemorrhage, sepsis,


DIC, heart failure) and nephrotoxic
2. aminoglycosides, vancomycin
radiocontrast
NSAIDS + CHF
myoglobinuria,
chemotherapeutic drugs- kappa, gamma,
light chains

ATN
1. phases

oliguric - 10-14 days (<400-500ml/day)


diuretic - >500ml/day from fluid/salt
overload from oliguric phase
recovery phase

tests for postrenal failure

palpation of bladder
ultrasound of kidney/bladder- residual
volume, hydronephrosis, obstruction
catheter insertion - voids large urine
volume

post renal AKI


1. patho

1. urethral obstruction (BPH), kidney


obstruction, nephrolithiasis, neoplasms
(bladder, cervix, prostate), retroperitoneal
fibrosis

AKI
1. Blood labs to
order
2. UA findings
3. how to rule
out post-renal
failure

1. elevated BUN/Cr, electrolytes, K+, Ca2+.


PO4-, albumin, CBC
2. 3+ or 4+ protein suggest intrinsic renal
failure from glomerular injury
3. bladder catheterization, renal
ultrasound

21.

22.

23.

24.

25.

26.

UA : urine
sediment/protein/blood
1. pre-renal failure
2. ATN
3. acute
glomerulonephritis
4. acute interstitial
nephritis
5. post renal

1. few hyaline
casts/negative/negative
2. muddy brown casts, renal
tubular cells/trace/negative
3. dysmorphic RBCs, RBCs with
casts, WBCs with casts, fatty
casts/4+ protein/3+ blood*
4. RBCs, WBCs, eosinophils/1+
protein/2+ blood
5. +/RBC+WBC/negative/negative

AKI
4. urine chemistry
5. FENa
6. imaging

1. urine Na, urine Cr,


2. must get urine
electrolytes/plasma electrolytes->
FENa = (UNa/PNa)/(UCr/PCr)
~~ <1% = prerenal failure, >1% =
ATN
3. renal ultrasound - to evaluate
obstruction, hydronephrosis-- CT
scan of abdomen/pelvis

AKI
1. volume complications
+ tx
2. metabolic
complciations
3. fatal complications

1. ECF volume expansion causing


pulmonary edema - tx =
furosemide
2. hyperkalemia from dec.
excretion and shifts from
intracellular
metabolic acidosis due to dec.
excretion of hydrogen ions
hypocalcemia - loss of ability to
form vitamin D
hyponatremia if drinking plain
water
hyperphosphatemia
hyperuricemia
3. hyperkalemic cardiac arrest,
pulmonary edema

what is the
pathogenesis of AKI
related infection/sepsis

uremic end products inhibit


immune functions and increased
susceptibility to infection

1. what drugs should be


avoided in AKI
2. treatment of fluid
overload
3. pre-renal AKI
treatment

1. NSAIDs, nephrotoxic agents


(aminoglycosides, radiocontrast)
2. diuresis, daily weight
measurement, always consider
cardiac function
3. treat underlying disorder, NS
to restore euvolemia/BP, dont
give to patinets who have
ascites/edema, stop ACE
inhibitors/NSAIDS

1. intrinsic AKI tx
2. post renal AKI tx

1. stop agent, trial of furosemide


for oliguria
2. bladder catheter, uro consult

27.

28.

29.

30.

31.

32.

33.

CKD
1. definition
2. MCC
3. how to measure
CKD

1. dec. GFR <60ml/min or kidney


damage
2. diabetes MCC, HTN 2nd MCC,
chronic glomerulonephritis,
interstitial nephritis,
3. Cr clearance, plasma Cr varies
inversely with the GFR

CKD
1. clinical
presentation (CV,
GI, neuro)

1. HTN 2/2 water/salt retention, dec.


GFR stimulates RAAS
CHF from volume overload, HTN,
anemia
n/v, loss of appetite,
lethargy, somnolence,
confusion, peripheral neuropathy,
uremic seizures, weakness, asterixis

radiographic
contract induced
ATN pathogenesis

rapid spasm of the afferent arteriole


prevent with saline hydration

azotemia vs uremia

azotemia = elevated BUN


uremia = signs/symptoms associated
with accumulation of nitrogenous
wastes - usually when BUN >60

chronic renal
insufficiency

patients renal function is


compromised but not failed - serum
Cr usually 1.5-3.0

CKD
1. hematologic
effects
2.
endocrine/metabolic
effects
3. sexual effects
-also pruritus

1. normochromic normocytic anemia


(dec. EPO)
bleeding 2/2 interference with
platelet function
2. hyperphosphatemia--> dec. D3-->
hypocalcemia --> secondary
hyperparathyroidism--> renal
osteodystrophy/bone fractures +
calciphylaxis
3. HPG disturbance dec. testosterone,
amenorrhea, infertility,
hyperprolactinemia

CKD
1. dx
2. radiologic dx`

1. urinalysis, Cr clearance/GFR, CBC


shows anemia/thrombocytopenia,
hyperkalemia, hypocalcemia,
hypomagnesemia,
hyperphosphatemia, meta. acid
2. renal ultrasound shows small
kidneys suggesting chronic renal
disease

34.

35.

36.

37.

38.

39.

CKD
1. tx

1. low protein - 0.7-0.8 g/kg body


weight/day
low salt diet if HTN/CHF present
restrict potassium, phosphate, Mg
ACE inhibitors - reduce risk of ESRD
progression, but WATCH FOR
HYPERKALEMIA,
strict blood control with ACE +/diuretics, glycemic control, smoking
cessation

CKD
1. how to correct the
hyperphosphatemia
2. hypo to correct
hypo D3 and
acidosis
3. """ anemia
4. """" pulmonary
edema
5. """" pruritis

calcium citrate (oral phosphate


binder)
2. oral bicarb and oral D3
3. EPO
4. dialysis
5. capsaicin, cholestyramine, UV
light

1. indicates for
emergent
hemodialysis

AEIOU
Acidosis - intractable metabolic
acidosis
electrolytes - hyperkalemia (refractor
to other treatments)
I - intoxications: methanol, ethylene
glycol, lithium, aspirin, magnesium
containing laxatives
O - hypervolemia
U - severe based on clinical
presentation, uremic pericarditis,
uremic encephalopathy

vascular access in
dialysis

seldinger central catheter


tunneled catheter - used up to 6
months
AV fistula - for permanent access

1. disadvantages of
hemodialysis
2. disadvantages of
peritoneal dialysis

1. hypotension from rapid removal of


intravascular volume, hypoosmolality
from solute removal
2. hyperglycemia,
hypertriglyceridemia, peritonitis

1. complications of
dialysis

1. hypotension --> MI, fatigue


hyposmolality --> nausea, vomiting
first use syndrome - cx pain, back
pain, anaphylaxis after using new
dialysis machine
sepsis
beta 2 microglobulin amyloidosis
peritonitis, hernias, hyperglycemia

40.

41.

42.

43.

proteinuria
1. definition
2. glomerular
proteinuria
3. tubular
proteinuria
4. overflow
proteinuria

1. >150mg protein/24 hours


2. due to
glomerulonephritis/glomerular
damage--> severe protein loss
3. small proteins filtered through
glomerulus are normally reabsorbed - but with tubular damage they spill
into urine-- 2/2 sickle cell, urinary
track obstruction, interstitial
nephritis
4. small protein production
overwhelms tubules (ex. bence jones)

nephrotic syndrome
1. key features
2. causes

urine protein>3.5g/24 hours,


hypoalbuminemia,
edema (2/2 hypoalbuminemia)
exacerbated by inc. aldosterone,
hyperlipidemia/lipiduria - inc.
hepatic LDL/VLDL synthesis
hypercoagulable - loss of
anticoagulants in urine
2. diabetes (MCC)*** membranous,
membranoproliferative, minimal
change (MCC in children), diabetes,
SLE, RA, polyarteritis nodosa,
henoch schonlein purpura, wegeners,
amyloidosis, cryoglobulinemia,

nephrotic syndrome
3. what drugs cause
nephrotic
syndrome- also infections,
MM, malignant
HTN, and
transplant rejection
4. dx***** ~ do this
diagnostic sequence
for hematuria as
well, basically any
renal failure that
there is not a clear
etiology

1. captopril, heroin, heavy metals,


NSAIDs, penicillamine
4. urine dipstick - >30mg/dl (>1+),
4+ >500 mg/dl
urinalysis - will show RBC casts,
WBC casts, fatty casts
*urine micro-albumin - more
sensitive than dipstick
Cr, BUN/Cr, CBC (anemia 2/2 renal
failure), renal ultrasound, IVP
(pyelonephritis), ANA, anti-GBM,
hepatitis serology, anti-streptococcal
antibody, complement levels,
cryoglobulin, serum/urine
electrophoresis renal biopsy

urinalysis
1. pH
2. specific gravity
3. protein
- also glucose, blood,
ketones, nitrite,
leukocyte esterase
4. Microscope

1. avg 6.0, range 4.5-8


2. 1.002 - 1.035-- will normally vary
with volume status
3. 1+ = 50-150mg/day, 2+ = 0.51.5g/day, 3+ = 2-5g/day, 4+ =
>5g/day
4. look for casts , cells, bacteria,
WBCs, RBCs, crystals

44.

45.

46.

47.

48.

49.

50.

51.

nephrotic
syndrome
1. tx

1. treat underlying disease (diabetes, MM, SLE,


MCD)
ACE inhibitors/ARBs - dec. urinary albumin
limit dietary protein,
treat hypercholesterolemia
vaccinate against pneumococcal/influenza

Hematuria
1. definition
2.
microscopic
vs. gross
hematuria
3. painless
hematuria
- check CBC
for IDA

1. hematuria, >3 erythrocytes/HPF on


urinalysis
2. glomerular vs nonglomerular (ie. post-renal
such as trauma, stones, malignancy)
3. bladder or kidney cancer until proven
otherwise

common
causes for
hematuria

cystitis, urethritis, prostatits

hematuria
1. causes
2. systemic
causes
3.
medication
causes

1. kidney stones, infection (URI, urethritis,


pyelo), bladder or kidney cancer, glomerular
disease, IgA nephropathy, trauma, strenuous
exercise (ex. marathon), cysts PCKD
2. SLE, rheumatic fever, HSP, wegener's, HUS,
goodpasture's, PAN)
3. NSAIDs, cyclophosphamide, analgesics

hematuria
1. dx

1. urine dipstick, urinalysis


RBCs/casts ~ GN
pyuria --> send for culture
if + for blood, but no RBCs on microscopy~
most likely hemoglobinuria, or myoglobinuria
cytology to detect cancer
24 hour urine Cr/protein
blood tests - coags, CBC, BUN/Cr
IVP, CT scan, ultrasound
renal biopsy

glomerular
disorders
1. patho
2. clinical
pres

1. impairment of selective filtration results in


excretion of blood cells/larger proteins, and
dec. GFR
2. isolated proteinuria, isolated hematuria,
nephrotic syndrome

nephritic
syndrome
1. patho
2. lab
findings
3. clinical
findings

1. Post strep + others -->glomerular


INFLAMMATION
2. hematuria, AKI, azotemia, oliguria,
proteinuria (not nephrotic range ie.
<3.5g/24hr)
3. HTN, edema

nephrotic
syndrome
1. patho
2. causes
3. lab
findings

1. abnormal glomerular PERMEABILITY


2. MCD, membranous, diabetes, SLE, drugs,
infection, FSGS,MPGN,
3. urine protein>3.5g/24hr, hypoalbuminemia,
hyperlipidemia
4. edema, hypercoagulability, inc. infections

52.

53.

54.

55.

56.

57.

minimal change
disease
1. patho
2. diagnosis
3. tx

1. hodgkin's disease*/nonhodgkin's/idiopathic/post
infectious/rifampin --> systemic T
cell dysfunction--> nephrotic
syndrome
2. no histologic findings of light
microscopy, foot processes fusion
on electron microscopy, OVAL
FAT BODIES ON URINE
ELECTRON MICROSCOPY
3. 4-8 weeks of steroid therapy,
usually full recovery

FSGS
1.
demographics/clinical
pres
2. dx
3. tx

1. blacks, AIDS patients*-->


hematuria, HTN--> renal
insufficiency within 5 years
2. focal segmental
glomerulosclerosis on light
microscopy
3. cytotoxic agents, steroids,
immunosuppressive agents,
ACE/ARBs

IgA nephropathy
1. patho
2. dx
3. tx

1. gross hematuria 5 days after


upper respiratory infection or
exercise -->
2. IgA and C3 on electron
microscopy of kidney biopsy ,
SERUM COMPLEMENT LEVELS
ARE NORMAL
3. steroids

membranous
glomerulonephritis
1. patho
2. clinical pres
2. dx

1. hep C/B, syphilis, malaria, gold


(tx for RA) captopril,
penicillamine, neoplasm, lupus -> glomerular thickening
2. active urinary sediment,
hypertension, worsening renal
function, proteinuria,
hypoalbuminemia
3. subepithelial deposits on renal
biopsy, decreased C3

hereditary
nephropathy (alports
syndrome)
1. patho
2. clinical pres
-no treatment

1. X LINKED OR AUTO DOM


mutation in basement membrane
protein
2. hematuria, pyuria, hearing
loss, progressive renal failure

membranoproliferative
glomerulonephritis
1. patho
2. dx

1. hep C/V, syphilis, lupus,


cryoglobulinemia
2. tram tracking on renal biopsy
with glomerular basement that
stains for C3 and not
immunoglobulins DEPRESSED
C3***

58.

59.

60.

61.

62.

63.

poststreptococcal
GN
1. patho
2. clinical
pres
3. dx
4. tx

1. post group B hemolytic strep or impetigo -> 10-14 days


2. hematuria, edema, HTN, low
complement***, proteinuria
3. ASO titer*, anti-DNAse B titer, low C3
biopsy shows sub epithelial deposits
4. antihypertensives, loop diuretics, steroids
for severe

goodpasture's
syndrome
1. patho
2. clinical
pres
3. dx
4. tx

1. IgG anti-GM antibody --> proliferative GN,


pulmonary hemorrhage
2. rapidly progressive renal failure,
hemoptysis, cough, dyspnea
3. renal biopsy shows linear*
immunofluorescence
4. plasmapheresis removes circulating antiIgG antibodies

HIV
nephropathy
1. clinical
pres
2. dx
3. tx

1. proteinuria, edema, hematuria


2. histopath resembles FSGS
3. prednisone, ACE inhibitors, HAART

AIN
1. patho
2. clinical
pres
3. dx/tx

1. allergy to meds - penicillin, cephalo, sulfa,


diuretics, anticoagulants, phenytoin
infection - legionella, streptococcus
CVD - sarcoidosis, SLE, Sjogren's
2. rash, fever, eosinophilia, pyuria,
hematuria
3. inc. BUN/Cr, urine eosinophils,
proteinuria, hematuria
4. remove offending agent, steroids

renal
papillary
necrosis
1. patho
2. tx

1. analgesics, diabetes, sickle, UTO/UTI,


alcoholism, transplant rejection
2. stop offending agent

type 1 RTA
1.
patho/clinical
pres
2. causes
3. dx
4. tx

1. inability to secrete H+ at distal tubule-->


pH of urine is >6, dec. ECF volume,
hypokalemia, renal stones/nephrocalcinosis
(inc. Ca2+/phos excretion),
rickets/osteomalacia
2. congeintal , MM, nephrocaclinosis,
ampho B, lupus/sjogrens, analgesic
nephropathy
3. hypokalemic, hypochloremic, non-AG met
acid
4. sodium bicarbonate, phosphate salts (inc.
excretion of titratable acid)

64.

65.

66.

67.

68.

69.

70.

71.

type 2 RTA
1. patho
2. causes
3. tx

1. inability to reabsorb HCO3- in the


proximal tubule* leading to inc. bicarb, K+,
Na+ in the urine, NO, BASIC URINE,
aminoaciduria, glycosuria, phosphaturia
NEPHROCALCINOSIS/NEPHROLITHIASIS
2. fanconi's, cystinosis, wilsons, lead, MM,
nephrotic syndrome, amyloidosis
3. no bicarb, sodium restriction inc.
sodium/bicarb reabsorbtion

type 4 RTA
1.
patho/causes

1. interstitial renal disease, diabetic


nephropathy, hypoaldosteronism or
resistance to aldosterone -> dec. Na
absorption, dec. H+/K+ secretion-->
HYPERKALEMIA*, and acidic urine

hartnups
syndrome
1. patho
2. clinical
pres
3. tx

1. AUTO RECESSIVE defect in amino acid


transporter --> dec. tryptophan absorption
and nicotinamide deficiency
2. pellagra (niacin def seen in corn based
diets) - dermatitis, diarrhea, ataxia,
psychiatric
3. give nicotinamide

analgesic
nephropathy
patho

nsaids, phenacetin, aspirin etc --> hematuria


- renal papillary necrosis***, or interstitial
nephritis

fanconi's
syndrome
1. patho
2. clinical
pres
3. dx/tx

1. proximal tubule dysfunction --> defective


transport of glucose, amino acids,
phosphate, uric acid, bicarb, sodium,
potassium
2. impaired growth, glucosuria,
phosphaturia, rickets, osteomalacia,
proteinuria,
3. phosphate, potassium ,alkali, salt
supplementation, hydration

ADPKD
1. patho
2. clinical
pres
3.
complications
4. dx/tx

1. AUTODOM, AUTOREC--> renal failure


from recurrent pyelo/nephrolithiasis
2. hematuria, abdominal pain, HTN,
palpable kidneys,
3. intracerebral berry aneurysms, renal
failure, kidney stones, MVP/AR, cysts in
liver/spleen/pancreas/brain, diverticula,
hernias
4. US/CT/MRI
tx = not curable, treat infections/control
HTN

ARPKD
1. patho
2. clinical
pres
3. dx /tx

1. aka "infantile" cysts of the renal collecting


ducts, and hepatic fibrosis
2. portal HTN, cholangitis, pulmonary
hypoplasia, potter syndrome
3. ultrasound during pregnancy, ultrasound

potter
syndrome

oligohydramnios --> hypoplasia of the lungs,


club feet, abnormal facies

72.

73.

74.

75.

76.

77.

78.

79.

80.

renal artery
stenosis
1. patho
2. clinical pres
3. dx/tx

1. atherosclerosis/fibromuscular dysplasia
-->RAS causes dec. blood flow to JGA -->
RAAS --> HTN
2. HTN refractory to medical therapy, may
be malignant, abdominal bruit, dec. renal
function
3. renal arteriogram, BUT NO CONTRAST
IN PTS WITH RENAL FAILURE.
MRA
duplex doppler ultrasound
tx = revascularization, by PCI with stent
ACE inhibitors, CCBs.

renal vein
thrombosis
1. patho
2. clinical pres
3. dx/tx

1. nephrotic syndrome***, RCC, trauma,


preg/OCP, retroperitoneal fibrosis, aortic
aneurysm, lymphadenopathy
2. renal failure, flank pain, HTN
hematuria, proteinuria
3. renal venography, IVP
tx = anticoagulation

atheroembolic
disease of renal
arteries
1. patho
2. risk factors
3. clinical pres

1. showers of cholesterol crystals from


plaques in arteries
2. warfarin
3. LIVEDO RETICULARIS, , hollenhorst
plaques in the retina, digital cyanosis,
elevated creatinine, elevated ESR,

hypertensive
nephrosclerosis
1. patho
2. clinical pres

1. systemic HTN --> thickening of


glomerular afferent arterioles -->
proteinuria, / ESRD
2. proteinuria, rising Cr, dec. in renal
function,

sickle cell
nephropathy
1. patho

1. sickling of RBCs in microvasculature


leads to infarction mostly in renal papillae
--> nephrotic syndrome, 5% ESRD,

renovascular
hypertension
clinical pres

malignant HTN, sudden onset HTN, HTN


suddenly worsened HTN that does not
respond to standard medical therapy

nephrolithiasis
1. predisposing
conditions

1. low fluid intake, gout, crohns,


hyperparathyroid, type 1 RTA, UTIs (esp
proteus), low calcium, high oxalate diet

calcium stones
1. patho
2. microscopic
findings/radio
findings

1.. calcium oxalate, or calcium phosphate,


inc GI absorption, dec. renal reabsorption,
inc. bone reabsorbtion of calcium, primary
hyperparathyroidism, sarcoidsosi,
malingnacy
2. bipyramidal or ovals, radiodense on
abdominal radiograph

causes of
hyperoxaluria

steatorrhea causes calcium loss


small bowel disease, crohns, pyridoxine
deficinecy

81.

82.

83.

84.

85.

86.

uric acid
stones
1. patho
2. microscopic
findings/radio
findings

1. persistently acidic* urine (<5.5),


hyperuricemia (gout, chemotherapy,
leukemia, lymphoma [via purine release])
2. radiolucent flat square plates
3. requires CT, ultrasound, or IVP for
detection

struvite stones
1. patho

1. UTI 2/2 urease producing bacteria


(proteus, klebsiella, serratia, enterobacter)-> alkalinization of urine--> ammonia
combined with mg/phos-->struvite calculi

1. what size
stones can
pass
spontaneously
2. clinical pres
of urinary
stone
3. dx/tx

1. <0.5cm
2. sudden onset paroxysms of flank pain
that radiates anteriorly to the groin, n/v,
hematuria***, UTI
3. urinalysis - microscopic or gross
hematuria
UA micro- shows crystals possibly
urine pH - alkaline suggests infection stone,
acidic urine suggests calcium oxalate or uric
acid stones,
serum chemistry - BUN, Ca, Cr, oxalate,
citrate levels
KUB- does not show cystine/uric acid
stones
*CT scan without contrast*
IVP
renal ultrasound
tx = analgesia - IV morphine/ketorolac
fluid hydration, ABX for infection
>3 days - consider urology consult

indications
for admission
for renal
calculi

pain not controlled with oral meds


anuria
renal colic
stone > 1cm

renal calculi
prevention

2L/day of water
limit animal protein intake if patient has
hyperuricosuria
thiazide diuretics - dec. urine calcium,
allopurinol

UTO
1. lower
urinary tract
causes
2. upper
urinary tract
causes
3. clinical pres

1. BPH, prostate cancer, urethral stricture,


neurogenic bladder, trauma (pelvic
fracture/bladder cancer)
2. kidney stones, blood clots, sloughed
papilla, tumors, strictures, ureteropelvic
dysfunction, pregnancy, tumors, AAA,
retroperitoneal fibrosis, endometriosis,
crohns
3. renal colic/pain, oliguria, recurrent UTI,
hematuria, renal failure

87.

88.

89.

90.

91.

92.

93.

94.

95.

UTO
1. dx
2. tx

1. renal ultrasound urinalysis


KUB - shows stones
IV contrast urogram
cystoscopy
CT scan
2. catheter, urethrotomy, prostatectomy,
nephrostomy tube, ureteral stent,

prostate
cancer
1. risk factors
2.clinical
pres

1. age, AA, high fat diet, family history,


pesticide/herbicide exposure
2. presents late- obstruction of the urethra
occurs, difficulty voiding, dysuria, inc.
urinary frequency,
after mets- back pain, pelvic pain,weight loss

prostate
cancer
1. dx

1. DRE- 70% have spread if palpable


- abnormal DRE --> TRUS
PSA screening/PSA velocity/ PSA density

what causes
an elevated
PSA

prostate cancer, prostatitis


prostatic massage
needle biopsy, cystoscopy, BPH, prostatitis,
advanced age

what
diagnostic
studies
1. PSA >10
2. abnormal
DRE
3. PSA <4
DRE negative
4. PSA 4.1-10,
DRE negative

1. TRUS with biopsy


2. TRUS with biopsy
3. annual follow up
4. TRUS with biopsy

PSA
adjustmentsage adjusted,
PSA velocity,
PSA density

....

when is TRUS
with biopsy
indicated

PSA >10 ng/dl (50%)


PSA velocity >0.75/year

prostate
cancer
1. treatment

1. contained disease - radical prostatectomy


for
locally invasive - radiation and androgen
deprivation
metastatic - orchiectomy, antiandrogens
(flutamide), LHRH agonists (leuprolide),
GnRH antagonists (degarelix)
estramustine (estrogen+nitrogen mustard)

RCC
1. patho
2. sites of
mets
3. risk factors

1. sporadic, or VHL
2. lung, liver, brain, bone
3. cigarettes, phenacetin PCKD, chronic
dialysis (multicystic kidney disease), heavy
metals (mercury/cadmium), hypertension

96.

97.

98.

99.

100.

101.

RCC
1. clinical pres
2.
paraneoplastic
syndromes
3. dx
4. tx

1. HEMATURIA, abdominal/flank pain*,


flank mass, weight loss, fever,
paraneoplastic syndromes
2. polycythemia (EPO), PTHrp, renin,
cortisol, gonadotropins, fever of unknown
origin
3. CT with contrast, abdominal ultrasound
4. surgery***, interferon alpha/2, sunitinib
(tyrosine kinase inhibitor)

bladder cancer
1. patho
2. risk factors
3. clinical pres

1. typically transitional cell cancers 10%


squamous and adeno (transitional cell
cancer can occur in the bladder, renal
pelvis, or ureter) spreads by local invasion
2. cigarettes, aniline/azo dyes, long term
cyclophosphamide treatment,
schistosomiasis
3. painless hematuria, irritable bladder
irritation, dysuria frequency

bladder cancer
1. dx
2. tx

1. urinalysis/urine culture, urine cytology,


IVP, cystoscopy
2. stage 0 - mucosal limited - intravesical
chemo
stage A - lamina propria - transurethral
bladder resection
Stage B - muscle invasion - radical
cystectomy, node dissection ,removal of
prostate, uterus, ovaries, anterior vaginal
wall, urinary diversion
stage C - to pervesicular fat
stage D - cystectomy, systemic
chemotherapy

testicular
cancer
1. germ cell
2. non-germ
cell
3. risk factors

1. germ cell =
seminomas (radiosensitive),
non-seminomas (embryonal
[necrosis/malig], chorio [mets quickly,
yolk sac, teratoma)
2. leydig cell tumors - secrete
androgens/estrogens, precocious
puberty/gynecomastia
sertoli cells -usually benign
3. cryptorchidism, klinefelter's syndrome
4. dx - testicular exam/ultrasound, b-HCG
(chorio/non-sem), AFP (embryonal), CT
chest

penile cancer
1. risk factors
2. ddx for
testicular
mass

1. uncircumcised, HSV, HPV


2. varicocele, spermatocele, hydrocele,
lymphoma

testicular
torsion
1. patho

1. twisting of spermatic cord causes


ischemia/infarction
2. acute severe testicular pain,
swollen/tender scrotum, elevated testicles,
3. testicular ultrasound, surgical
emergency - detorsion and orchiopexy

102.

103.

104.

105.

106.

107.

108.

epididymitis
1. patho
2. clinical pres

1. e.coli in children/elderly, in young


men - gonorrhea/chlamydia
2. swollen tender testicle, fever,
chills, scrotal pain/mass
3. r/o torsion (ultrasound), and abx

fluids
1. TBW
2. ICF
3. ECF
4. plasma,
interstitial fluid

1. 60% of body weight men, 50%


women
2. 2/3 of TBW = 40% of body mass
3. 1/3 TBW = 20% of body mass
4. plasma = 1/3 ECF, 1/12 TBW
interstitial fluid = 2/3 ECF

fluids
1.
normal/minimum
urine output
2. insensible loss
3. what is the best
way to assess
volume status
- lower extremity
edema may not be
volume overload,
TBW may be high,
but patient may be
intravascularly

1. 800-1500 ml/day,
minimum = 500-600ml/day
2. 600-900 ml/day
3. urine output 0.5-1.0ml/kg/hour

causes of oliguria

cardiac failure (low blood flow to


kidney)
ATN/AIN/kidney damage
post renal obstruction

1. what fraction of
intravascular
volume is in venous
vs arterial system
2. what patients
third space fluids

1. 85% venous, 15% arterial


2. liver failure, nephrotic syndrome
(hypoosmolar), left sided CHF
(pulmonary edema), right sided CHF
(anasarca)

fluid replacement
uses
1. normal saline
2. D51/2NS + 20
mEq kcl/L
3. D5w
4. lactated ringers

1. blood loss or dehydrated, urgent


resuscitation
2. standard maintenance - glucose
spares muscle breakdown
3. dilute powdered medicines,
hypernatremia, only 1/12 remains
intravascular
4. intravascular volume, NOT
maintenance, trauma resuscitation,
DO NOT USE IF PATIENT IS
HYPERKALEMIC OR ESRD

causes of
hypovoluemia

vomiting, diarrhea, NG suction,


fistula, ascites, effusions, bowel
obstruction, burns, polyuria (ex.
DKA), sepsis, retroperitoneal
inflammation, trauma, insensible
losses (skin 75%, respiratory tract
25%)

109.

110.

111.

112.

113.

1. clinical
presentation
hypovolaemia
2. urine panel
findings

altered MS, sleepiness, apathy, coma


orthostasis, dec. pulse pressure, dec. CVP
and PCWP
poor skin turgor, hypothermia, pale
extremities, dry tongue, oliguria, ileus,
weakness, ARF (pre-renal azotemia)
2. FENa <1%, BUN:Cr >20, low urine
sodium, elevated hematocrit (3% inc for
every liter of deficit)

1. how does CBC


change with
dehydration
2. how to
correct a
volume deficit

1. 3% inc. in hematocrit with each 1L of


dehydration
2. bolus LR or NS, monitor
HR/BP/UOP/weight, maintain UOP at
0.5-1ml/kg/hr, replace blood with
crystalloid 3:1 ratio
Then maintenance D51/2NS with 20mEq
KCl/L

hypervolemia
1. causes
2. clinical
features
3. tx

1. iatrogenic, CHF, nephrotic syndrome,


cirrhosis, ESRD
2. weight gain, peripheral edema, ascites,
pulmonary edema/rales, JVD, elevated
CVP/PCWP, peripheral edema
3. fluid restriction, diuresis, UOP
monitor/daily weights, swan ganz
catheter placement

Na+
concentration
is reflection of
water
homeostasis
Na+ content is
reflection of
sodium
homeostasis
1. sodium
homeostasis
2. water
homeostasis
3. NATREMIA
VS VOLEMIA

1. inc. sodium increases ECF, which inc.


GFR, dec. in sodium intake causes dec.
GFR and reduced sodium excretion
2. osmoreceptors in hypothalamus
stimulated by plasma hypertonicity(>295
mOsm/kg), inc. ADH
production -->V2 receptors in collecting
ducts,
3. natremia- too much or too little water
volemia - too much or too little sodium

hyponatremia
1. definition
2. symptomatic
hyponatremia
level
3. symptoms of
hyponatremia

1. plasma Na < 135mmol/L


2. occurs at Na <120mEq/L
3. water shifts and increases ICF volume,
leading to cerebral edema--> HA,
delirium, twitching, weakness,
hyperactive DTR, seizures, coma,
n/v ileus, watery diarrhea
CV HTN from inc. ICP
inc salivation/lacrimation
oliguria --> anuria *****

114.

115.

116.

117.

118.

119.

120.

hypotonic
hyponatremia
1. hypovolemic
hypotonic
hyponatremia
2. euvolemic hypotonic
hyponatremia
3. hypervolemic
hypotonic
hyponatremia

1. osmolality <280 mOsm/kg,


low urine sodium <10mEq/L, due
to extrarenal loss- diarrhea,
vomiting, NG suction,
diaphoresis, third spacing,
burns, pancreatitis.
high urine sodium >20mEq/L due to diuretic excesses, low
aldosterone, ATN
2. no evidence of ECF
expansion/contraction- SIADH,
psychogenic polydipsia, post-op
hyponatremia, hypothyroidism,
oxytocin, D5W, hypotonic
solution, water after intense
exertion, haldol, cyclophos
3. water retaining states - CHF,
nephrotic syndrome, liver disease

isotonic hyponatremia
(pseudohyponatremia)

any condition that causes inc


protein/lipid levels --> inc. in
plasma solids lower plasma
sodium concentration but the
amount of sodium is normal

hypertonic
hyponatremia

osmotic substances cause water


shift out of cells - hyperglycemia,
mannitol, sorbitol, glycerol,
maltose

adjusting Na for
glucose

for every 100 of glucose, serum


sodium level decreases by 3

diagnosis of specific
type of hyponatremia

BMP, plasma osmolality, assess


volume status (hypo, eu, hyper)
urine osmolality

hyponatremia
1. treatment

1. 120-130 hold water


110-120 - loop diuretics + saline
<110 or symptomatic - give
hypertonic saline to inc. serum
sodium by 1-2 mEq/L/hr, DO
NOT INC. SODIUM MORE
THAN 8mmol/L during first 24
hours- OR GET PONTINE
MYELINOLYSIS

hypernatremia
1. definition
2. hypovolemic
hypernatremia cause

1. serum sodium >145


2. diuretics, osmotic diuresis
(glycosuria), renal failure,
diarrhea, diaphoresis, respiratory
losses
3. diabetes inspiidus, respiraotry
losses
4. iatrogenic ~ TPN, NaHCO3-,
glucocorticoids, saltwater
drowning, hyperaldosteronism

121.

122.

123.

124.

125.

126.

127.

hypernatremia
1. clinical pres
2. dx
3. tx

1. neurologic symptoms - restlessness,


focal neuro deficits, confusion, seizures,
coma
tissues, mucous membranes dry, salivation
decreases
2. urine volume low, urine osmolality
>800mOsm/kg
3. hypovolemic - give NS to restore
hemodynamics
isovolemic - DDAVP for DI, oral fluids,
D5W IV
hypervolemic - diuretics, D5W, dialyze if
ESRD

water deficit
calculation

water deficit = TBW (1-[actual


Na/desiredNa)

calcium
1. normal
range
2. corrected
calcium
3. effect of pH

1. 8.5-10.5
2. corrected = total - [albumin*0.8]
3. high pH calcium binds albumin thus
total Ca is normal, but ionized is low

PTH
1. actions

1. inc bone resorption, inc Ca2+


reabsorption at the kidney, dec. PO4reabsorption, inc. gut activation of D3
==== inc plasma Ca2+, dec. plasma PO4-

calcitonin
1. actions

1. dec bone resorption, dec kidney Ca2+


reabsorption,inc kidney PO4reabsorption, dec gut absorption of Ca2+
===== dec plasma Ca2+ and dec. plasma
PO4-

vitamin D
1. actions

inc. bone resorption, inc Ca2+


reabsorption, dec. PO4- reabsorption, inc.
gut Ca2 reabsorption, inc. gut PO4reabsorption

hypocalcemia
1. causes

1. hypoparathyroidism (iatrogenic MCC),


acute pancreatitis (deposition), renal
insufficiency (dec. D3 ESRD),
hyperphosphatemia (ESRD),
pseudohypoparathyroidism (resist to
PTH), hypomagnesemia (dec. PTH
secretion), D3 deficiency, malabsorption
(short bowel), transfusion (citrate binds
Ca), osteoblastic mets, hypoalbuminemia,
digeorge (no thymic shadow)

128.

129.

130.

131.

132.

hypocalcemia
1. clinical pres
2. cardiac
manifestations
3. lab workup
4. tx

1. rickets, osteomalacia,
neuromuscular irritability- numbness,
tingling, tetany, chvostek's sign,
trousseau's sign, grand mal seizures, basal
ganglia calcifications
2. LONG QT***
3. BUN, Cr, magnesium, albumin, ionized
calcium, amylase, lipase
4. IV calcium gluconate, oral calcium
supplements, vitamin D, thiazide diuretics
(dec. urinary calcium), magnesium

hypercalcemia
1. causes
2. what drugs
cause
hypercalcemia
- sarcoidosis
-familial
hypocalciuric
hypercalcemia
(low urine
Ca2+

1. hyperparathyroidism(inc. Ca, dec PO4),


pagets disease of bone, acromegaly,
addisons, metastatic
cancer(prostate=osteoblastic,
kidney=osteolytic), MM (lysis of bone
tumor, release of OAF), PTHrp (lung
cancer)
2. milk-alkali syndrome, vitamin D
intoxication, thiazide, lithium (inc. PTH)

hypercalcemia
1. clinical pres
2. cardiac
findings ECG
3. dx

stones -nephrolithiasis, nephrocalcinosis


bones - bone aches/pains, osteitis fibrosa
cystica
grunts and groans -muscle
pain/weakness, pancreatitis, PUD, gout,
constipation
psychiatric overtones- depression, fatigue,
anorexia, sleep disturbances, anxiety,
lethargy
- other- polyuria/polydipsia, hypertension,
weight loss,
2. SHORT QT***
3. same workup as hypocalcemia, +
radioimmunoassay of PTH (PTH vs
PTHrp)

hypercalcemia
1. tx

1. IV fluids
diuretics - furosemide
BISPHOSPHONATES (pamidronate)
calcitonin
glucocorticoids
hemodialysis
phosphate- risk of metastatic calcification

potassium
1. where is it
located in the
body
2. hypokalemia
causes
3.
hyperkalemia
causes
4. potassium
secretion`

1. intracellular
2. alkalosis, insulin, albuterol
3. acidosis, renal failure
4. kidneys, GI tract

133.

134.

135.

136.

137.

138.

139.

hypokalemia
1. causes
2. bartter
syndrome

vomiting, NG suction (hypokalemic met


alk), diarrhea, laxatives, enemas, diuretics,
renal tubular disease, parenchymal disease,
glucocorticoids, mg deficiency, insulin
administration, insufficient dietary intake
2. autosomal recessive defect in salt
reabsorption in thick ascending limb hypokalemia, met. alk, inc.urine chloride
(>20)~ key to distinguish from contraction
alkalosis

what acid
base
disturbance
with
diarrhea

hypokalemic non-anion gap metabolic


acidosis

in a patient
who is
hypokalemia
1. what does
it mean if
they are
hypertensive
2. what does
it mean if
they are
normotensive
3. what drugs
cause
hypokalmeia

1. could be excess aldosterone


2. probably renal or GI loss
3. bactrim, ampho B, B2 agonists,

hypokalemia
ECG findings

T wave flattening, T wave inversions


U waves
prolongation of the QU interval (also seen
with quinidine)

what
electrolyte to
monitor in
patients on
digoxin

monitor K+, hypokalemia predisposes to


digoxin toxicity
monitor Ca, hypercalcemia predisposes to
digoxin toxicity

hypokalemia
1. clinical
pres
2. tx

1. arrhythmias (prolongs conduction),


weakness, fatigue, paralysis, cramping,
ileus, polyuria, polydipsia, N/V
2. identify cause, adjust drugs, oral KCL, 10
mEq KCL inc. K+ by 0.1mEq/L, monitor K+
and EKG
max 10 mEq/hr in peripheral IV line
max 20 mEq/hr in central line
add 1% lidocaine to dec. pain

hyperkalemia
1. causes

1. renal failure, addison's, K+ sparing


diuretics (spirono), hyporeninemic
hypoaldosteronism, ACE inhibitors***,
transfusion, acidosis, rhabdo, hemolysis,
burns, insulin deficiency (dec. NAK ATPase
activity), bactrim

140.

141.

142.

143.

pseudohyperkalemia

prolonged tourniquet use with or


without repeated fist clenching-->
acidosis/K+ loss from cells``
also hemolysis during venipuncture

hyperkalemia
1. clinical pres
2. ECG
3. tx

1. muscle weakness, dec. DTR,


respiratory failure, n/v, intestinal
colic, diarrhea
2. K+ > 6.0 tall peaked T waves,
QRS widening, PR
prolongation,loss of P waves, sine
wave pattern, vfib
3. IV calcium gluconate*** stabilizes resin myocardial
membrane
Glucose and insulin
sodium bicarbonate - inc. pH
(emergency only)
kayexalate - GI potassium exchange
resin
hemodialysis
diuretics - furosemide

hypomagnesemia
1. causes
2. renal causes
3. clinical pres
4. relationship
between mg and k
5. ECG changes
- tx = oral or
parenteral Mg

1. malabsorption, prolonged
fasting, fistulas, TPN w/o mg,
alcoholism
2. SIADH, diuretics, bartter's,
gentamicin, ampho B, cisplatin,
renal transplant
3. COEXISTING HYPOCALCEMIA,
neuromuscular/CNS
hyperexcitability, muscle twitching,
weakness, tremors, hyperreflexia,
seizures, altered mental status
4. when Mg or K decreases, the
other ion decreases
5. prolonged QT, T wave flattening,
torsade de pointes

hypermagnesemia
1. causes
2. clinical pres
3. ECG changes
4. tx

1. renal failure***, early burns,


severe acidosis, trauma/surgical
stress, adrenal insufficiency,
rhabdomyolysis
2. nausea, facial paralysis, loss of
DTRs (first), somnolence, death
from respiratory failure/cardiac
arrest
3. hyperkalemia type changes- inc
PR interval, widened QRS, elevated
T waves
4. calcium gluconate for
cardioprotection,
saline/furosemide, dialysis,
intubation

144.

145.

146.

147.

148.

149.

150.

hypophosphatemia
1. causes
2.clinical pres

hyperphosphatemia
1. causes
2. clinical pres
3. tx

1. alcohol abuse (dec. intestinal


abs), vitamin D deficiency,
malabsorption, excessive use of
antacids, hyperalimentation or
starvation
hyperglycemia, osteomalacia, ATN,
RTA, hypokalemia,
hypomagnesemia
2. encephalopathy, confusion,
seizures, paresthesias, muscle
weakness, myalgias/rhabdo, bone
pain, rickets/osteomalacia
hemolysis, RBC dysfunction, WBC
dysfunction, platelet dysfunction
cardiomyopathy/myocardial
depression
1. renal insufficiency,
bisphosphonates,
hypoparathyroidism, D3
intoxication, calcinosis, PO4
enemas, D3 overdose,
2. metastatic calcification, soft tissue
calcifications,
serum * calcium > 70 = likelihood for
precipitates to form
hypocalcemia --> neuromuscular
irritability/tetany
3. phosphate binding antacids w/
aluminum hydroxide or carbonate,
hemodialysis

metabolic acidosis
1. criteria
2. anion gap
3. AG metabolic
acidosis causes

1. dec. pH, dec. bicarbonate conc


2. AG = Na+ - (Cl + HCO3-)
- reflects unmeasured ions, proteins,
phosphates, organic acids, sulfates
3. ketoacidosis - diabetic, starvation,
alcohol abuse
lactic acidosis renal failure- dec. NH4+ excretion,
retention of organic ions, sulfate,
phosphate

effect of acidosis on
the body

right shift oxygen hemoglobin curve


depresses CNS, dec. pulmonary
blood flow, arrhythmias, myocardial
function impairment, hyperkalemia

effects of alkalosis
on the body

dec. cerebral blood flow


left shifts oxygen hemoglobin
dissociation curve, arrhythmias,
tetany, seizures

how to tell if
met.acid is a mixed
disorder

delta AG < delta HCO3- ~~ AG acid


+ high AG acid
delta AG > delta HCO3- ~~ met alk +
high AG acid

salicylate toxicity
acid/base
disturbance

primary resp. alk, primary met.acid `

151.

152.

153.

154.

155.

1. non-AG met
acid causes

1. diarrhea (HCO3- loss), pancreatic


fistulas, small bowel fistulas,
ureterosigmoidoscopy
proximal RTA (MM, cystinosis, wilsons),
distal RTA (SLE, sjogrens, ampho B),
acetazolamide (CA inhibitor)

1. metabolic
acidosis
clinical pres
2. dx

1. hyperventilation - kussmaul respirations


when pH <7.2,
acidosis--> dec. response to
catecholamines***-->lactic acidosis, -->
dec. CO --> hypotension-->worsening
acidosis
2. history, AG,
expected PaCO2=1.5(HCO3-)+8+/-2
if more than expected there is also
resp.acid b/c of inadequate compensation
***inadequate compensation is a sign of
impending resp. failure
***PaCO2 less than expected, patient has
met acid + resp. alk

metabolic
acidosis
1. tx

1. sodium bicarbonate(but takes 24 hours


to get to brain)
H+ = 24[PaCO2/HCO3-] ~ so while
patient gets bicarb, PaCO2 is still very low
--> severe intracranial alkalosis
mechanical respiration for respiratory
fatigue

metabolic
alkalosis
1. definition
2. first step in
evaluation
3. causes:
saline
sensitive
4. causes:
saline
resistant
5. how high
should
respiratory
compensation
be

1. inc. blood pH, inc. HCO32. is the patient volume expanded or


contracted
3. loss of gastric H+, ECF volume
contraction
saline sensitive- urine Cl < 10mEq/L, ECF
contraction, hypokalemia: vomiting,, NG,
diuretics, villous adenoma (high chloride
diarrhea)
4. urine Cl>20mEq/L, ECF expansion,
primary hyperaldosteronism, cushings, K+
deficiency, Bartter's syndrome, diuretic
abuse
5. PaCO2 to 50-55, if higher there is
probably resp acid as well

metabolic
alkalosis
1. dx
2. tx

1. inc. HCO3-, inc. pH, hypokalemia,


PaCO2 is elevated, urine chloride (high or
low)
2. NS + potassium if saline sensitive, if
saline resistant can address underlying
cause or spironolactone
Ammonium chloride for severe (risk of tox
in patients with liver failure)

156.

157.

158.

159.

160.

161.

162.

respiratory
acidosis
1. definition
2.
compensation
3. causes
4. clinical pres

1. blood >40mmHg, reduced blood pH


2. acute - 1mmol/L for every 10mmHg
PaCO2
pH inc. by 0.08
chronic - 4mmol/L for every 10mmHg
PaCO2
3. COPD, airway obstruction, myasthenia,
brainstem injury, narcotic overdose,
respiratory fatigue
4. somnolence, confusion, myoclonus with
asterixis, HA, confusion, papilledema

respiratory
acidosis
1. treatment

1. patency of airway, supplemental oxygen


(if PaO2<60***can exacerbate acidosis in
COPD), correct reversible causes, improve
alveolar ventilation, naloxone,
bronchodilators intubation/mech vent (if
PaCO2>60, no improvement with
supplemental oxygen, obtunded,
deteriorating mental status)

respiratory
alkalosis
1. definition
2.
compensation
3. causes

1. inc. blood pH, dec. PaCO2


2. acute: HCO3- dec by 2 mmHg for every
10 mmHg dec in PaCO2, blood pH inc by
0.08
chronic: HCO3- dec by 5 mEq/L for every
10 mmHg dec in PaCO2 and blood pH dec.
by 0.02
3. alveolar hyperventilation - anxiety, PE,
pneumonia, asthma, sepsis, hypoxia,
mechanical ventilation, pregnancy (inc.
progesterone), cirrhosis, salicylates,

respiratory
alkalosis
1. clinical pres
2. tx

1. dec. cerebral blood flow


(vasoconstriction), lightheadedness,
dizziness, anxiety, paresthesias, perioral
numbness, tetany, arrhythmias
2. correct underlying cause, inhaled CO2,
or breathing into paper bag

anemia
1.
compensatory
mechanisms
2. when to
transfuse
3. clinical pres

1. inc. CO (HR*SV), inc. extraction ratio,


right shift of hemoglobin curve (via inc. 2,3
DPG), expansion of plasma volume
2. Hb concentration<7g/dl or inc. oxygen
carrying capacity (CAD or pulmonary
disease)
3. depends on patient, they may be
asymptomatic at Hb 7 or 8: headache,
fatigue, poor conc, diarrhea, nausea,
pallor(conjunctiva), hypotension,
tachycardia, jaundice (if hemolytic, blood
in stool

anemia
1. dx
2. tx

1. reticulocyte index (>2% impliese


excessive RBC destruction)
hb*3 = hct, iron, B12, folate, EPO (ESRD)
2

pseudoanemia

decrease in hemoglobin/hct 2/2 dilution


acute volume infusion or overload

163.

164.

165.

166.

167.

168.

169.

after patient is found to


have anemia what is next
lab test

retic, B12, folate

cryoprecipitatecomponents+what is it
used to treat

VIII, XIII, fibrinogen, vWFused for hemophilia A, DIC,


vWD

how much change in CBC


with 1 unit of PRBCs and
1 unit of platelets

1 unit or PRBCs- inc. Hb 1, inc


Hct 3
1 unit of platelets - inc platelet
count by 10,000

blood products for


massive blood loss

1:1:1 - platelets:FFP:PRBCs

hemolytic transfusion
reactions: intravascular
hemolysis
1. patho
2.
symptoms/complications
3. tx

1. ABO mismatched blood -->


anti-# IgM--> complement
activation, C9 punches holes
in RBCs
2. fever, chills, n/v, flank pain,
chest pain, dyspnea,
hypovolemic shock,
hypotension, tachycardia,
DIC, renal failure,
hemoglobinuria (ATN)
3. stop transfusion, fluid
replacement, epinephrine,
dopamine/norepi for pressure
control

hemolytic transfusion
reactions: extravascular
hemolysis
1. patho
2. clinical pres + tx

1. minor antigen reaction occurs 3-4 weeks after


transfusion, previous exposure
creates memory-B cells that
will produce Ig against antigen
and lead to splenic/liver/bone
marrow sequestration
2. late onset -- fever, jaundice,
anemia
tx none

anemia
1. interpretation of
reticulocytes
2. microcytic anemia ddx

1. >2 excessive RBC


destruction or blood loss with
bone marrow response
<2 inadequate RBC production
(take a look at slide)
2. IDA, thalassemias,
sideroblastic (lead, B6 def,
alcohol)-->accumulated
porphyrins/iron in
mitochondria

170.

171.

172.

173.

174.

175.

176.

anemia
1. macrocytic ddx
2. normocytic
ddx

1. B12/folate deficiency, liver disease


(up to 115) due to altered lipoprotein
synthesis), stimulated erythropoiesis
(polychromatophilic RETICS),
myelodysplasia
2. aplastic anemia, bone marrow
fibrosis, tumor, AOCD, renal failure
(inflamm/malig)

evaluation of
suspected
hemolytic anemia

first retic >2,


then check haptoglobin, LDH, bilirubin

microcytic
anemia
1. causes
2. clinical pres
3. dx
4. tx

1. chronic blood loss, menstrual


bleeding, GI blood loss,
infants/toddlers drinking human milk
(low iron), rapid growth in adolescents,
pregnancy
2. pallor, fatigue, generalized weakness,
DOE, orthostasis
3. dec. ferritin, inc. TIBC, inc.
transferrin, inc RDW, microcytic
hypochromic RBCs on smear, stool
guaiac
4. ferrous sulfate - SE = constipation,
nausea, dyspepsia
iron dextran- IV or IM

beta thalassemia
(cooley's anemia)
1. patho beta thal
2. demographics
3. clinical pres +
tx

1. deficient beta chain, excess alpha


chains aggregate and damage
membranes
2. mediterranean, middle eastern, and
indian ancestry
3. severe hypochromic microcytic
anemia, hepatosplenomegaly***,
marrow expansion, FTT, skull xray
shows "crew cut"
4. HbF/HbA2 elevated - peripheral
smear shows microcytic hypochromic
RBCs with target cells
tx = frequent PRBCs

alpha
thalassemia
1. patho
2.

1. alpha chain decrease, beta tetramers

what is the
consequence of
frequent
transfusions in
beta thal patients

iron overload and hemochromatosis


tx -= desferoxamine

what type of
microcytic
anemia is inc.
RDW
characteristic of

IDA

177.

178.

179.

180.

181.

182.

183.

thalassemia
minor
1. patho
2. clinical pres

1. heterozygous beta-chain thalassemia


2. asymptomatic, mild microcytic
hypochromic anemia
3. dx = hemoglobin electrophoresis

what is next
diagnostic test in
patient who has
IDA, but does not
respond to iron

hemoglobin electrophoresis- to rule out


alpha/beta thalassemia

alpha thalassemia
1. one
mutation/deletion
clinical pres
2. alpha
thalassemia trait
clinical pres
3. HbH disease
4. 4 alpha loci
mutations

1. mutation/deletion of only one alpha


locus- asymptomatic, normal
hemoglobin/hematocrit
2. two alpha loci mutations- mild
hypochromic anemia
3. hemolytic anemia, splenomegaly,
microcytic hypochromic anemia, HbH
on gel electrophoresis
tx = PRBC transfusions
4. hydrops fetalis fatal at birth

sideroblastic
anemia
1. patho
2. dx
3. tx

1. hereditary
acquired - chloramphenicol, INH,
alcohol, lead*, collagen vascular
disease, myelodysplasia
2. inc. serum ferritin**, inc. serum
iron*, BASOPHILIC STIPPLING,
normal TIBC, TIBC saturation
normal/elevated
ringed sideroblasts on marrow biopsy
3. remove offending agent, B6
supplementation

anemia of chronic
disease
1. patho
2. dx
3. tx

1.chronic infection, TB, lung abscess,


cancer, RA, SLE, trauma-->IL6/
cytokines + HEPCIDIN*** are
suppressive effect on EPO (dec. retics)
and dec. iron absorption from the gut
2. low serum iron, low TIBC, low serum
transferrin, INCREASED SERUM
FERRITIN, normochromic, normocytic
3. no treatment, do not give iron

aplastic anemia
1. patho
2.clinical pres

1.radiation, chloramphenicol,
sulfonamides, gold, carbamazepine,
parvo B19, hep C, hep B, EBV, HZV,
HIV, benzene, insecticides--> bone
marrow failure-->pancytopenia
2. fatigue, dyspnea, petechiae, easy
bruising, inc. infections (neutropenia),
3. normocytic, normochromic anemia,
bone marrow shows hypocellular
marrow, absence of progenitors
tx = bone marrow transplant,
PRBC/platelt transfusion,

pernicious
anemia

autoimmune destruction of parietal


cells and intrinsic factor leads to
impaired absorption of B12 in terminal
ileum

184.

185.

186.

187.

188.

189.

190.

191.

B12 deficiency
1. function of
b12
2. dietary
sources/storage
3. causes of
deficiency

1. homocysteine to methionine, methyl


malonyl CoA to succinyl CoA
2. meat, fish- about 3 years supply in the
liver
3. pernicious, gastrectomy, poor diet
content (vegan), alcoholism, crohns
disease, ileal disease, diphyllobothrium
latum, blind loop (bacterial overgrowth

b12 deficiency
1. clinical pres

1. anemia, stomatitis, glossitis,


neuropathy (B12*** vs folate),
demyelination (pos. columns,
corticospinal tracts, spinocerebellar
tracts), ataxia, upper motor neuron signs,
urinary/fecal incontinence, dementia

193.

1. peripheral smear shows megaloblastic


anemia - hypersegmented PMNs, serum
B12 <100 pg/ml, elevated methylmalonic
acid, elevated homocysteine, antiintrinsic factor
2. IM dose of unlabeled B12 to saturate
binding sites, oral dose of radioactive B12,
measure radio B12 in urine and plasma,
repeat oral B12 with intrinsic factor- if it
is pernicious, adding intrinsic factor will
increase serum conc
3. IM cyanocobalamin once/month

194.

b12 deficiency
1. dx
2. schilling test
3. tx

folate
deficiency
1.
sources/storage
2. clinical pres
3. dx/tx

1. raw green vegetables, 3 months worth


of stored folate
2. inadequate diet, alcoholism, long term
oral ABX, pregnancy, hemolysis, MTX,
phenytoin, hemodialysis
3. serum folate, elevated homocysteine
ONLY,
tx= dietary folic acid

causes of
hemolytic
anemia

immune hemolysis, mechanical


hemolysis (prosthetic valves, MAHA),
burns, toxins (snake bites/recluse spider),
sickle cell anemia, HbC, spherocytosis,
PNH
G6PD, pyruvate kinase

intravascular
vs
extravascular

intravascular = inside circulation


extravascular = within reticuloendothelial
system (spleen/bone marrow/liver)

lab studies for


hemolytic
anemia

elevated retic, inc. LDH, dec.


haptoglobin, dec. hb/hct, inc. retic count,
schistocytes (intravascular),
spherocytes/helmet cells (extravascular),
sickled RBCS, heinz bodies (G6PD),
elevated indirect bilirubin , direct coombs
positive, (in AIHA)

smear findings
for hemolytic
anemia

schistocytes, helmet cells

192.

195.

196.

sickle cell
anemia
1. patho
2. what
triggers
sickling
3. correlation
of sickle crisis
and age of
death
4. treatment
of aplastic
crisis

1. AR - substitution of uncharged valine for


negative glutamic acid at 6th position of the
beta chain
2. acidosis, hypoxia, changes in
temperature, dehydration, infection
3. >3 crises/year - median age of death - 35
years
4. 2/2 parvo b19, - blood transfusion and
patient recovers in 10-14 days

sickle cell
anemia
1. clinical pres
2. painful
bone crisis
3. hand foot
syndrome
4. acute chest
syndrome

1. jaundice, pallor, gallstone disease


(pigmented),
high output heart failure
aplastic crisis (parvo)
2. painful bone crisis - tibia, humerus, self
limiting in 2 -4 days
3. painful swelling of dorsa of hands and
feet from avascular necrosis of metacarpal
and metatarsal bones
4. repeated episodes of pulmonary
infarctions- cx pain, respiratory distress,
pulmonary infiltrates, hypoxia

sickle cell
anemia
1. splenic
disease
2. avascular
necrosis
3. priapism +
treatment
4. CVAs

1. multiple splenic infarctions cause


functional asplenia by age 4 years (nonpalpable)
2. most commonly in the hip and shoulder
3. vasoocclusion --> erection, lasting
between 30 mins and 3 hours
tx = hydralazine, or nifedipine, or antiandrogen
4. cerebral thrombosis especially occurs in
children

sickle cell
anemia
1. renal
complications
2. extremity
complications
3. abdominal
complications
4. infectious
complications

1. renal papillary necrosis with hematuria,


2. chronic leg ulcers
3. abdominal crisis - mimics acute abdomen
4. functional asplenia leads to increased
risk for - h.flu, s.pneumo, neisseria
meningitidis (encapsulated bacteria)

1. sickle cell
anemia
diagnosis
2. sickle cell
pain crisis tx
3. sickle cell tx

1. anemia, sickle peripheral smear, howell


jolly bodies hemoglobin electrophoresis
2. hydration, IV fluids, morphine, keep
patient warm, supplemental O2
3. avoid high altitudes (low O2 tension),
maintain fluid intake, vaccination against
h.flu, s.pneumo, n.mening, hydroxyurea
(inc. HbF), blood transfusion , bone
marrow transplant

197.

198.

199.

200.

201.

hereditary
spherocytosis
1. patho
2. clinical
pres
3. dx
4. tx

1. AUTOSOMAL DOMINANT - mutation in


spectrin--> splenic trapping and destruction
(extravascular)
2. hemolytic anemia, jaundice,
splenomegaly, gallstones*, hemolytic crisis
(2/2 parvo b19)
3. osmotic fragility to hypotonic saline,
elevated retic, elevated MCHC >36%,
spherocytes on smear, direct coombs
negative
4. splenectomy
folate supplementation (prevents aplastic
crisis)

causes of
spherocytosis

hereditary spherocytosis, G6PD, ABO


incompatibility, hyperthermia, AIHA

G6PD
deficiency
1. patho +
triggers
2. clinical
pres
3. peripheral
smear
findings

1. x linked disorder
infection- G6PD cannot generated NADPH
to reduce glutathione
OXIDIZING DRUGS- sulfonamides,
nitrofurantoin, primaquine, dimercaprol,
fava beans, infection
2. episodic hemolytic anemia, dark urine,
jaundice on exam,
peripheral smear shows BITE CELLS,
HEINZ BODIES (Hb precipitates),
PRUSSIAN BLUE STAIN POSITIVE
tx = avoid triggers, maintain hydration, RBC
transfusion
3. bite cell from removal of heinz bodies by
splenic macrophages

AIHA
1. patho
2. warm
AIHA
3. cold AIHA

1. autoantibodies against RBC membrane


antigens (IgG anti-Rh) leads to destruction
of RBCs
2. leukemias, lymphomas, CLL, collagen
disease, alpha methyl dopa -->IgG-->
extravascular hemolysis --> splenomegaly
3. mycoplasma, infectious mononucleosis -> IgM* binds to RBC membrane-->
intravascular hemolysis

AIHA
1. clinical
pres
2. dx
3. tx

1. fatigue, pallor, jaundice,


2. microspherocytes, elevated reticulocytes
direct coombs test positive - IgG- warm
AIHA
RBCs covered with complement alone - it
is cold AIHA
3. often self limiting
warm - glucocorticoids, splenectomy,
azathioprine/cyclophosphamide, RBC,
folate supplementation
cold - avoid cold exposure, RBC
transfusions, chemotherapeutic,

202.

203.

204.

205.

206.

paroxysmal
nocturnal
hemoglobinuria
1. patho
2. clinical pres
3. complications
4. tx

1. deficiency in proteins that link


complement inactivating proteins to
blood cell membranes-->complement
mediated intravascular lysis,
hypercoagulable state, bone marrow
aplasia
2. chronic paroxysmal intravascular
hemolysis, inc. LDH, normochromic
normocytic anemia, pancytopenia,
venous thrombosis, abdominal, back
pain, muscle pain
3. aplastic anemia, myelodysplasia,
myelofibrosis, acute leukemia
4. glucocorticoids, BMT

1. HIT type 1 + tx
2. HIT type 2 + tx

1. heparin causes platelet aggregation,


<48 hours after initiating heparin, no
treatment is needed
2. heparin induces PF4 release and
triggers formation of heparin PF4
complexes--> IgG antibody mediated
platelet activation/endothelial
activation and intravascular thrombin
generation--> vascular thrombosis***
3-12 days after starting heparin-heparin should be DC

1. causes of bone
marrow failure
2. causes of bone
marrow invasion
3. causes of bone
marrow injury

1. aplastic anemia, congenital aplastic


anemia (fanconi's), congenital
intrauterine rubella
2. tumors, leukemia, fibrosis
3. gold, ethanol, cancer chemotherapy,
benzene, chloramphenicol, radiation,
infection

paroxysmal
nocturnal
hemoglobinuria
1. diagnosis

Ham's test*** - patients cells placed in


acidified serum, triggering alternate
complement pathway causes lysis of
PNH cells
sugar water test- patients blood +
glucose - causes hemolysis
flow cytometry shows low CD55, and
CD59

platelet disorders
1. causes of
thrombocytopenia
2. causes of
thrombocytosis
3. qualitative
platelet disorders
4. hereditary
platelet disorders

1. decreased production, increased


destruction, sequestration
2. reactive - IDA, splenectomy,
rebound, inflammatory disease,
autonomous - myeloproliferative,
polycythemia vera, essential
thrombocytosis, CML
3. ASA, NSAIDs, antibiotics, high dose
PCN, uremia (effects vwF XIII), liver
disease (TPO), marrow disorders
(leukemia etc), multiple myeloma, ITP,
cardiopulmonary bypass (causes
partial degranulation)
4. vWD, bernard soulier, glanzmanns

207.

208.

209.

210.

211.

1. what causes
increased platelet
destruction
2. dilutional
thrombocytopenia
3.
thrombocytopenia
in pregnancy

1. ITP, infection, drug induced, HIT


type 2, HIV associated
thrombocytopenia
DIC, TTP, HIT type 1
2. post hemorrhage, post transfusion
3. incidental finding, or preeclampsia/ecclampsia, or HELLP
syndrome

thrombocytopenia
1. clinical pres

1. cutaneous petechiae bleeding,


purpura, ecchymosis with minor
trauma, mucosal bleeding, epistaxis,
menorrhagia, hemoptysis, GI/GU
bleeding

immune
thrombocytopenic
purpura
1. patho
2. clinical pres
3. dx

1. acute post viral, or adult chronic-->


autoimmune antibody against hosts
platelets which are then removed by
splenic macrophages
2. petechiae/ecchymoses on the skin,
minimal bleeding symptoms, mucous
membrane bleeding, NO
SPLENOMEGALY***
3. platelets <20,000, remainder of
blood count normal, dec. platelets on
blood smear, inc megakaryocytes on
bone marrow,
anti-platelet IgG.....

immune
thrombocytopenic
purpura
1. tx

corticosteroids, IVIG (saturates RES),


splenectomy, (70-80% effective),
platelet transfusions
romiplostim, eltrombopagthrombopoietin receptor agonists

thrombotic
thrombocytopenic
purpura
1. patho
2. clinical pres
3.dx tx

1. ADAMTS13 defect cannot break


down vWF multimers-->hyaline
microthrombi occlude small vessels
causing mechanical damage to RBCs
2. hemolytic anemia (MAHA),
thrombocytopenia, ARF, fever,
fluctuating neurologic signs
3. tx = plasmapheresis****,
corticosteroids, splenectomy, NO
PLATELET TRANSFUSION

212.

213.

214.

215.

216.

217.

heparin induced
thrombocytopenia
1. patho
2. dx/tx
3. complications

1. unfractionated heparin (15%), rarely


LMWH--> drop in platelets a few days
after administration--> platelet
aggregation/activation+procoagulant
release leads to venous
thrombosis/DVT/PE****
2. antiplatelet factor IV or serotonin
assay
tx= STOP HEPARIN, give direct
thrombin inhibitor to bridge to
warfarin (lepirudin, argatroban,
rivaroxaban)
3. heparin induced thrombocytopenia
and thrombosis (HITT)- 25% mortality
rate

bernard soulier
1. patho
2. dx

1. AR- Gp1bIX defect leads to platlet


adhesion to subendothelium
dysfunction
2. abnormally large platelets, mildly
low platelet count

glanzmann's
thrombasthenia

1. AR - GpIIb-IIIa deficiency
2. prolonged bleeding time, platelet
count normal

von willebrand's
disease
1. patho
2. sub regions of
factor VIII
3. type 1/2/3
4. clinical pres

1. defect in factor VIII or vWF


2. coagulant portion, and antigenic
portion (= vWF)
3. type 1 = dec. vWF, type 2 =
qualitative abnormalities of vWF, type
3 = absent vWF
4. cutaneous/mucosal bleeding,
epistaxis, easy bruising, excessive
bleeding with minor trauma,
menorrhagia, GI bleeds

von willebrand's
disease
1. dx
2. tx

1. prolonged bleeding time, dec. vWF,


dec. factor VIII, reduced ristocetin
induced platelet aggregation
2. DDAVP induces endothelial release
of vWF(type 1/2)
factor VIII concentrates, - after
trauma/during surgery
cryo - has risk of viral transmission
avoid NSAIDs/aspirin

hemophilia A
1. patho
2. clinical pres
3. dx

1. XLR - deficiency in factor VIII


2. hemarthrosis, knees most commonly
, progressive joint destruction (2/2
recurrent hemarthrosis), intracranial
bleeding,
retroperitoneal/intramuscular
hematomas
3. prolonged PTT, low VIII, normal
vWF
tx = analgesia (NOT
ASPIRIN/NSAIDS), VIII concentrate
for acute bleeding/dental work,
DDAVP for mild disease

218.

219.

220.

221.

222.

223.

224.

225.

226.

treatment of
hemophilia B

IX concentrates, DDAVP doesnt do


anything

disseminated
intravascular
coagulation
1. patho
2. clinical
pres

1. infection (gram neg sepsis)/OB/fluid


emboli/retained fetus/abruptio placentae,
trauma, malignancy (lung/pancreas)-->
abnormal activation of coagulation leading
to microthrombi formation and
consumption of platelets, fibrin,
coagulation factors --> activation of
fibrinolytic system
2. superficial hemorrhage, ecchymosis,
petechiae, purpura, OOZING FROM
PROCEDURE SITES, thrombosis

disseminated
intravascular
coagulation
1. dx
2. tx

1. PT, PTT, bleeding time, TT - ALL


INCREASED, fibrin split products
increased, d-dimers increased, dec.
fibrinogen, dec. platelet count
peripheral smear - shows schistocytes
2. underlying cause, FFP, platelet
transfusions cryo, low dose heparin, O2, IV
fluids

what does
thrombin
time measure

measures fibrinogen concentration

liver disease
vs vitamin K
deficiency
coagulopathy

liver disease- PT and PTT elevated,


TT, fibrinogen, platelets normal
vitamin K - PT prolonged,
PTT, TT, platelet count, fibrinogen levels
normal

complications
of DIC

intracranial bleeding --> death


thromboembolism - stroke, PE, ischemic
colitis, ARF, arterial occlusion

vitamin K
deficiency
1. patho
2. dx

1. no leafy greens, broad spectrum


abx/NPO, TPN, small bowel disease,
inflammatory bowel disease, obstructive
jaundice, warfarin
2. PT prolonged first then PTT
vitamin K, or FFP

coagulopathy
of liver
disease
1. patho
2. poor
prognostic
indicator

1. cholestasis/hypersplenism only vWF not


made by the liver
2. prolonged PT

antithrombin
3 deficiency
1. patho

1. autosomal dominant antithrombin 3


deficiency --> hypercoagulable state due to
uninhibited thrombin

227.

228.

229.

230.

231.

232.

233.

234.

235.

antiphospholipid
syndrome
1. patho
- lupus anticoagulant,
anticardiolipin, beta 2
microglobulin etc.

1. acquired hypercoagulable
state (LUPUS) -- >
recurrent arterial/venous
thrombosis

protein C deficiency
1. patho

1. auto dom- deficiency of


factor V/VIII inhibitor -->
unregulated prothrombin
activation and inc.
thrombotic events

factor V leiden
1. patho

1. protein C resistance -->


protein C can no longer
inactivate factor V-->
unregulated prothrombin
activation

secondary hypercoagulable
states

malignancy (panc, GI,


lung, ovaries)
antiphospholipid antibody
syndrome
pregnancy
immobilization, OCPs,
postoperative (esp. ortho),
nephrotic syndrome, HIT,
DIC, PNH

what drug is not effective in


patients with antithrombin
III deficiency

HEPARIN

heparin
1. mechanism
2. indications

mechanism - potentiates
action of antithrombin to
inhibit II and X, prolongs
PTT
2. DVT, PE, ACS, unstable
angina/MI, LMWH, a.fib

IV heparin
dosing/monitoring/reversal

1. 70-80u/kg bolus, and


then 15-18u/kg/hr infusion
2. monitor with PTTtherapeutic = 60-90s, or
anti-factor Xa levels
3. protamin sulfate reverses
heparin

heparin side effects


heparin contraindications

bleeding, HIT,
osteoporosis, transient
alopecia, rebound
hypercoagulability
contraindications - previous
HIT, active bleeding,
hemophilia,
thrombocytopenia, HTN,
brain, eye, spine surgery

LMWH

inhibits factor Xa, but less


IIa and platelet aggregation

236.

237.

238.

239.

240.

warfarin
1. monitoring
2. administration
3. side effects
4. reversal

1. prolongs PT and INR


2. start patient on heparin, once PTT
is therapeutic, switch the patient to
warfarin, and once INR is therapeutic,
stop heparin
3. hemorrhage, skin necrosis
(2/2 rapid dec. in protein C),
TERATOGENIC, should not to give to
patients with fall risk
4. 5 day half life-- vitamin K infusion,
or FFP

clopidogrel
1. patho
2. important drug
interaction

1. ADP antagonist, inc. bleeding time


2. ACS, NSTEMI, >1 year after stent
placement

most
common/mortality
cancers in men vs
women

men - prostate, lung, colon / lung,


prostate, colon
women - breast, lung, colon / lung,
breast, colon

oncologic
emergencies that
require treatment

hypercalcemia - IV fluids, diuretics,


bisphosphonates
spinal cord compression - steroids,
MRI
pericardial tamponade pericardiocentesis
tumor lysis syndrome - IV fluids +
electrolyte correction

features of benign
breast masses

age <35
fibroadenoma - round movable mass,
which changes based on menstrual
cycle
cysts - benign if not bloody

premalignant
breast cancers

ductal CIS- lumpectomy or mastectomy


lobular CIS- removal of lesion does not
reduce risk of spread of the cancer

monoclonal
gammopathy of
undetermined
significance MGUS
1. diagnosis
2. tx
3. progression

1. IgG spike <3g and <10% plasma


cells in bone marrow. BJ proteinuria
<1g/24 hours and no endo organ
damage (lytic lesions, anemia,
hypercalcemia)
2. nothing just observe 3. 20% progress to myeloma in 10-15
years

243.

244.

245.

246.
241.

242.

247.

multiple myeloma
1. patho
2. clinical pres

1. monoclonal plasma cell


proliferation --> anemia, leukopenia,
thrombocytopenia
2. CRAB - hypercalcemia/bone pain2/2 osteolytic lesions, fractures,
vertebral collapse
anemia -- normochromic normocytic
2/2 marrow infiltration
renal failure- myeloma nephrosis
immunoglobulin precipitating in
renal tubules,
BJ protein in urine
recurrent infections - MCC death

multiple myeloma
1. dx
2. tx

1. monoclonal M-protein Ig spike on


serum/urine protein electrophoresis
plain radiographs - lytic lesions
bone marrow biopsy - >10%
abnormal plasma cells RBCs- rouleaux formation
hypercalcemia, elevated ESR
2. hematopoietic cell transplantation
(NOT IF PATIENT HAS RECEIVED
CHEMOTHERAPY), systemic
chemotherapy (alkylating agents),
palliative radiation therapy

waldenstroms
macroglobulinemia
1. path
2. clinical pres
3. tx

1. plasmacytoid lymphocyte
proliferation --> IgM paraprotein
>5g/dL, bence jones proteinuria,
2. NO BONE LESIONS, fatigue,
weight loss, anemia, abnormal
bleeding, hyperviscosity syndrome
3. chemotherapy and plasmapheresis

hodgkins
lymphoma
1. patho
2. clinical pres

1. bimodal age distribution - nodular


sclerosing (reed sternberg), mixed
cellularity, lymphocyte predominant,
lymphocyte depletion (worst)
2.constitutional symptoms painless
lymphadenopathy, supraclavicular,
axillary, mediastinal nodes

hodgkins disease
3. dx
4. tx

3. lymph node biopsy inflammatory


cell infiltrate shows B-cells, reed
sternberg cell, bone marrow biopsy,
leukocytosis, eosinophilia
4. radiotherapy for stages I/II/IIIA
stage IIIB, IV require chemotherapy

248.

249.

250.

251.

252.

253.

254.

255.

non-hodgkins
lymphoma
1. risk factors
2. clinical pres

1. immunosuppression, EBV, HTLV 1,


helicobacter pylori gastritis, autoimmune
disease (hashimoto's, sjogrens, MALT)
2. lymphadenopathy (painless, firm,
mobile), palpable cervical,
supraclavicular, axillary nodes, B
symptoms, HSM, recurrent infections,
anemia symptoms, SVC obstruction,
respiratory involvement, bone pain, skin
lesions

epidemiological
associations
with NHL

burkitts lymphoma, HIV associated


lymphomas, adult T-cell lymphoma in
japan and caribbean

non-hodgkins
disease
1. dx
2. markers of
tumor load
3. tx

1. lymph node biopsy - any node >1cm for


>4 weeks
CXR - may show hilar/mediastinal
adenopathy
CT- chest, abdomen, pelvis
ALP - elevated if bone involved
2. LDH, B2 microglobulin
3. observation, chemotherapy (CHOP),
radiation therapy, very high dose
chemotherapy with BMT (last resort)

indolent or low
grade
lymphomas
1. types
2. clinical pres
3. progression
4. tx

1. small lymphocytic, follicular


2. elderly patients, painless peripheral
lymphadenopathy,
3. painless peripheral lymphadenopathy-> diffuse large cell with t(14;18)
4. eventually widespread liver, spleen,
bone marrow involvement- radiotherapy
for local disease only

intermediate
grade
lymphoma
1. types
2. clinical pres
3. tx

1. diffuse large B cell lymphoma,


2. locally invasive presenting as large
extranodal mass
3. 85% cure with CHOP

high grade
lymphomas
1. types
2. tx

1. lymphoblastic lymphoma (T cell -->T


cell ALL),
burkitt's t(8;14) (small cell noncleaved)
lymphoma- jaw mass in african,
abdominal organ mass in americans
2. combination chemotherapy 50-60%
curative

mycosis
fungoides
1.
patho/clinical
pres
2. dx
3. tx

1. T cell lymphoma of skin - eczematous


skin lesions/exfoliative dermatitis,
erythematous stage, plaque stage, tumors
stage- disseminates to lymph nodes
2. cribriform lymphocytes
3. no cure, symptomatic radiation and
topical chemotherapy

sezary
syndrome

skin/blood stream involvement

256.

257.

258.

259.

260.

261.

262.

263.

264.

265.

HIV
associated
lymphomas

burkitts or diffuse, large cell lymphoma very poor prognosis

CHOP
therapy

cyclophosphamide, hydroxydaunomycin
(doxorubicin), oncovin (vincristine),
prednisone

AML
1. risk factors
2.
promyelocytic
clinical
pres/tx

1. radiation, myeloproliferative syndromes,


downs syndrome, chemo (alkylating agents)
2. t(15;17), pancytopenia/DIC, all trans
retinoic acid

ALL
1. patho
2. age
3. poor
prognostic
indicators

1. early lymphocytic malignancy


2. <15
3. age <2 / >9, WBC >15, CNS involvement,
B cell phenotype, inc. LDH, rapid leukemia
proliferation

ALL/AML
1. clinical
pres
2. key classic
locations for
extranodal
ALL/AML

1. anemia, associated symptoms, bacterial


infections, mucosal bleeding, splenomegaly,
hepatomegaly, lymphadenopathy,
bone/joint pain, focal neuro dysfunction
(CNS invasion),
2. ALL- testicles, anterior mediastinal
mass*
AML - skin nodules

tumor lysis
syndrome

chemotherapy in acute leukemia and high


grade NHL--> hyperkalemia,
hyperphosphatemia, hyperuricemia,
hypocalcemia
MEDICAL EMERGENCY

1. ALL
response to
treatment

1. full remission in 75% of children


30-40% of adults

CLL
1. age
2. patho
3. dx
4. tx

1. >50
2. monoclonal mature lymphocytes that are
not functional
3. WBC 50k-200k, anemia
(AUTOIMMUNE HEMOLYTIC),
thrombocytopenia, neutropenia
SMUDGE CELLS - fragile leukemic cells
flow cytometry
bone marrow biopsy - infiltrating leukocytes
4. symptomatic chemotherapy

myeloid cell
line

erythrocytes, granulocytes, platelets

CML
1. patho
2. clinical
pres

1. t(9;22) BCR-Abl chronic indolent course


then BLAST CRISIS --> blast/promyelocytic
production
2. constitutional symptoms, fevers, nigth
sweats, infections ,bruising, anemia,
splenomegaly/hepatomegaly,
lymphadenopathy

266.

267.

268.

269.

270.

271.

CML
1. dx
2. tx

1. marked leukocytosis 50-200k with


left shift to granulocytes
BASOPHILIA
low blasts/promyelocytes
LOW LEUKOCYTE ALKALINE
PHOSPHATASE ACTIVITY,
thrombocytosis, bone marrow biopsy
2. imatinib - targets BCR-Abl
chemoradiation --> BMT

polycythemia
vera
1. patho
2. clinical pres

1. malignant hematopoietic cell


proliferation --> inc. RBC mass (9-14
years survival), myelocytes and
platelets***
2. 2/2 hyperviscosity, HA, dizziness,
weakness, pruritus (in the bath 2/2
histamine from inc. basophils),
gout attack dyspnea,
thrombotic - DVT, CBA, MI, portal vein
thrombosis
bleeding - GI or GU, ecchymosis,
epistaxis, splenomegaly, hepatomegaly
HTN

polycythemia
vera
1. dx
2. tx

1. rule out secondary polycythemia


elevated RBC, hemoglobin/hematocrit
(>50), thrombocytosis, leukocytosis
LOW EPO, elevated B12
hyperuricemia
bone marrow biopsy
2. phlebotomy lowers hematocrit

myelodysplastic
syndromes
1. patho
2. dx
3. tx
4. progression?

1. idiopathic/radiation-> ineffective
hematopoiesis, apoptosis of myeloid
precursors, pancytopenia, hypercellular
marrow
2. marrow biopsy shows dysplastic cells
with ringed sideroblasts, blasts
normal MCV
low reticulocyte count
Howell jolly bodies, basophilic
stippling,
3. EPO, G CSF, B6, B12, folate
supplementation
4. can become AML with very poor
prognosis

essential
thrombocythemia
1. dx
2. tx
3. clinical pres

1. platelets >600k with no cause (ie.


non-reactive), peripheral smear shows
irregular platelets, bone marrow shows
inc. megakaryocytes,
2. antiplatelets - anagrelide, low dose
aspirin, hydroxyurea
3. erythromelalgia - burning/pain in
extremities from microvascular
occlusion , thrombosis, CVA

reactive
thrombocytosis

infection, inflammation, bleeding, IDA


etc.

272.

273.

274.

275.

276.

277.

pneumonia
1. most common
community
bacterial
pathogen
2. most common
nosocomial
3. indications
for
pneumococcal
vaccine

1. s.pneumo
2. gram negative rods
(E.coli/pseudomonas), s.aureus
3. age >65, heart disease, SCD,
pulmonary disease, diabetes, cirrhosis,
cigarette smokers***

community
acquired
pneumonia
1. patho
2. clinical pres
3. dx

1. s.pneumo, h.flu, moraxella, klebsiella,


s.aureus 2/2 aspiration of
nasopharyngeal flora
2. acute onset fever, shaking chills,
cough with thick purulent sputum,
dyspnea, pleuritic chest pain (with
effusions), tachycardia, tachypnea, late
crackles, friction rub,
3. CXR - shows consolidation/infiltrates
(only way to differentiate between
pneumonia and acute bronchitis)
O2 sat, BUN/Cr, BMP, pre-treatment
blood cultures, gram stain/culture of
sputum

atypical
pneumonia
1. clinical pres
2. patho
3. dx

1. sore throat/headache --> nonproductive cough and dyspnea, fevers,


pulse temperature dissociation(normal
pulse/high fever), wheezing, rhonchi,
crackles
2. mycoplasma, chlamydia pneumoniae,
chlamydia, coxiella burnetii, legionella,
adenovirus, paraflu, RSV
3. CXR - reticulonodular infiltrates,

what is a good
sputum cultures

>25PMNs <10 epithelial cells per high


powered field

pneumonia
organisms
1. in alcoholics
2. in immigrants
3. in nursing
home
4. HIV patients
5. transplant
patients/renal
failure/lung
disease/smokers

1. klebsiella (gram negative encapsulated


rods, currant jelly sputum)
2. TB
3. upper lobes, pseudomonas
4. PJP pneumonia, mycobacterium TB
5. legionella

stains
1. acid fast
2. methenamine
silver stain
3. urine antigen
assay

1. myco TB
2. pneumocystis and other fungi
3. LEGIONELLA

278.

279.

280.

281.

282.

283.

284.

285.

286.

community
acquired
pneumonia
1. tx <60
2. tx >60
3. tx for
hospitalized

1. <60 years of age most likely s.pneumo,


c.pneumo, m.pneumo, or legionella -azithromycin or clarithromycin, or
doxycycline
5 days of treatment or afebrile for 48 hours
2. >60 or patients or comorbidities treated
with abx in past 3 months, use a
fluoroquinolone (levo or moxi), or
second/third gen cephalosporin
5 days of treatment or afebrile for 48 hours
3. fluoroquinolone or 3rd gen cephalo +
macrolide

hospital
acquired
pneumonia
treatment

gram negative rods


cephalosporins w/ pseudomonal coverage ceftazidime/cefepime
carbapenams- imipenem
piperacillin tazobactam

pneumonia
complications

pleural effusions - tx with thoracentesis


pleural empyema
acute respiratory failure

what to test
thoracentesis
fluid for

gram stain, culture, pH, cell count,


determination of glucose, protein, LDH

ventilator
associated
pneumonia
1. dx
2. tx

1. new cxr infiltrate, purulent secretions in


endotracheal tube, rising WBC count,
bronchoalveolar lavage
2. ceftazidime or cefepime or piperacillin
tazobactam, or aminoglycoside or
fluoroquinolone, vancomycin or linezolid

likely
locations of
lung
abscesses

RIGHT LUNG>LEFT LUNG


posterior segments of upper lobes, and
superior segments of lower lobes

lung abscess
1. patho
2. micro

1.aspiration of oropharyngeal
contents/hematogenous spread/direct
contact/food --> 2cm or larger suppurative
cavitary lesions
2.prevotella, peptostrepto, fuso, bacteroides,
s.aureus, s.pneumo, aerobic gram negative
bacilli

lung abscess
1. risk factors
2. clinical
pres

lung abscess
1. tx

287.

288.

289.

1. alcoholism, drug addiction, CVA, seizure


disorders, general anesthesia, NG or ET
tube
2. fever, chills, foul smelling breath,
shortness of breath, weight loss
3. CXR - thick walled cavitation with air
fluid levels
CT scan
cultures with bronchoscopy
1. gram pos - ampicillin, or
amoxicillin/clavulanic or
ampicillin/sulbactam or vancomycin
anaerobes - clindamycin or metronidazole
gram neg- fluoroquinolone or ceftazidime

290.

291.

292.

293.

294.

tuberculosis
1. patho
2. secondary TB
3. risk factors
for TB

1. droplet transmission --> multiplication


in the lymphatics/blood --> granulomas -> immune insult --> reactivation
2. weakening of host immunity - HIV,
malig, immunosuppressants --> apical
posterior segment cavitary lesions,
miliary TB
3. HIV, recent immigrants, prisoners,
health care, close contact, alcoholics,
diabetics, glucocorticoid use, hematologic
malig, IVDU

tuberculosis
1. primary TB
clinical pres
2. secondary TB
""
3. radiographic
findings

1. asymptomatic, or pleural effusion, may


turn into progressive TB
2. constitutional symptoms, dry cough -->
purulent sputum, hemoptysis (advanced)
apical rales
3. upper lobe infiltrates with cavitations,
pleural effusions
ghon complex - calcified primary focus
with associated lymph node
rankes complex - ghon complex
undergoes fibrosis/calcification

tuberculosis
1.
extrapulmonary
sites

1. pleura, GU tract, spine, intestines,


meninges,

tuberculosis
1. dx

1. sputum culture (three morning sputum


samples), PCR
PPD test - detects latent TB
Elevated adenosine deaminase levels in
pleural fluid

PPD positive
+ PPD, what is
next step in
management

>15mm - no risk factors


>10mm- high risk populations/recent
immigrants, homeless, prisoners,
healthcare workers, nursing home
>5mm- HIV, steroid, recent contact with
TB+, organ transplant patients

next step = get


CXR

...

tuberculosis
1. treatment for
latent TB
2. treatment for
active TB

1. pos. PPD - negative CXR - INH +


pyridoxine (to prevent neuropathy)
OR pyrazinamide + rifampin or rifabutin
for 2 months
2. 2 months of 4 drugs (isoniazid,
rifampin, pyrazinamide, ethambutol or
streptomycin)
then 4 months of 2 drugs (isoniazid and
rifampin)

TB treatment
1. toxicity

1. monitor liver transaminases and


discontinue if they rise to 3-5x the upper
limit of normal

295.

296.

297.

298.

299.

300.

301.

1. flu epidemic vs
pandemic

1. epidemic from minor genetic


reassortments
pandemic is from major genetic
recombination

influenza
(orthomyxovirus)
1. clinical pres

1. rapid onset fever, chills,


malaise, headache, nonproductive cough, sore throat,
+/- nausea
2. supportive,
zanamivir/oseltamivir

meningitis
1. patho
2. bacterial pathogens
neonates + tx
3. "" children+ tx
4. adults + tx
5. elderly >50+ tx
6.
immuo/hospitalized+tx

1. hematogenous CNS seeding,


retrograde nerve transport,
contiguous spread (via
sinus/OM/surg/trauma)
2. GBS, e.coli, listeria
monocytogenes- cefotax + amp +
vanc + aminoglycoside
3. n.meningitidis, s.pneumo,
h.flu - cefotaxime or ceftriaxone
+ vanc
4. s.pneumo, n.meningitidis,
h.flu - cefotaxime or ceftriaxone
+ vanc
5. s.pneumo, n.mening,
l.monocyto- ceftriaxone or
cefotax + vanc + amp
6. l.monocyto, gram negative
bacilli, s.pneumo
ceftazidime + vancomycin

chronic meningitis
causes

mycobacterium, fungi, lyme


disease, parasites

meningitis
1. complications

1. seizures, coma, brain abscess,


deafness, brain damage,
hydrocephalus

aseptic meningitis
1. patho
2. treatment

1. non-bacterial pathogens HSV, enterovirus, echovirus


2. treat as bacterial until certain
of diagnosis

meningitis
1. clinical pres

1. triad - fever, nuchal rigidity,


change in mental status
headaches, n/v, malaise,
photophobia
papilledema, seizures *inc. ICP
cranial nerve palsies
kernig's sign - cannot fully
extend knees when patient
supine and hips at 90'
brudzinski's sign - flexion of
legs/thighs caused by passive
passive flexion of the neck

302.

303.

304.

305.

306.

307.

meningitis
1. dx
2. tx

1. CT scan BEFORE CSF


EVALUATION
CSF examination - cloudy, inc.
opening pressure
examine for cell count,
protein/glucose, gram stain,
culture (+AFB), crypto
antigen/india ink

CSF findings: WBC


count/diff/glu/protein
1. normal
2. bacterial meningitis

1. <5/lymphos or mono/5075/<60
2. >1000/PMNs/low/high
3. <1000/lymphos or mono/5075/moderate elevation

encephalitis
1. patho
2. causes
3. risk factors

1. viral origin --> diffuse


inflammation of brain
parenchyma +/- meningitis
2. HSV (MCC), arbovirus (EEE,
WNV), polio (enterovirus),
measles, mumps, EBV toxo,
aspergillosis, metabolic, T cell
lymphoma, rabies
3. AIDS CD4 <200,
underdeveloped country travel,
exposure to vectors, exposure to
wild animals (bats)

encephalitis
1. clinical pres

1. prodrome - headache, malaise,


myalgias
headache, photophobia, nuchal
rigidity, confusion, delirium,
disorientation
hemiparesis, aphasia, CN deficits

altered mental status


ddx

sepsis, UTI, urosepsis,


pneumonia, bacterial meningitis,
subdural empyema
NMS (haloperidol)
delirium tremens
thyroid storm

encephalitis
1. dx
2. tx

1. CXR, urine/blood cultures,


urine tox screen,
LP (after CT) - lymphocytosis >5
with normal glucose (similar to
viral mening)
CSF PCR - diagnosis for many
viral causes
MRI - r/o focal cause (ie.
abscess), inc. T2 signal in
frontotemporal (=HSV)
EEG - unilateral or bilateral
temporal lobe EEG discharges
2. HSV - acyclovir 2-3 weeks
CMV - ganciclovir or foscarnet
anticonvulsants for seizures
cerebral edema - hyperventilation,
osmotic diuresis, steroids

308.

309.

310.

311.

312.

313.

vasculitis associated
with hep B/C

hep B - PAN
hep C - cryoglobulinemia

hep B vs hep C
1. what percent have
clinical hepatitis
after exposure
2. what percent have
chronic hepatitis
after clinical
hepatitis
3. what percent of
chronic hepatitis
develop cirrhosis
4. what fraction
develop HCC

1. 70% vs 75%
2. 10% vs 90%
3. 25% vs 20%
4. 40% vs 25%

mechanism of
transmission
1. hep A/E
2. hep B
3. hep D
4. hep C

1. fecal oral
2. parenterally or sexually
3. coinfection with hep B or
superinfection in chronic hep B
carrier
4. parenteral (most commonly in
IVDU)

hepatitis
1. clinical pres
2. fulminant
hepatitis clinical
features
3. dx

1. transaminases >500 jaundice,


dark urine (direct bili), RUQ pain,
n/v, fever/malaise, hepatomegaly
2. same as regular + hepatic
encephalopathy (asterixis/palmar
erythema), hepatorenal syndrome,
bleeding diathesis
3. hepatitis serologies
hep C- viral PCR

314.

315.

what is only hepatitis


B marker that can be
detected during the
period

IgM anti-HBc
HBsAg is earliest* detectable
marker but disappears during
window period (1-2 weeks)
TEST FOR BOTH IN SCREENING

hepatitis B serologies
1. HBsAg
2. HBeAg
3. anti-HBsAg
4. anti-HBcAg
5. diagnosis of hep C

1. early detection 1-2 weeks,


indicates chronic hepatitis if
persistent
2. reflects active viral replication,
detectable soon after HBsAg
3. after vaccination or clearance of
HBsAg indicates immunity
4. only marker present during
window period, indicates
INFECTION (does not distinguish
acute vs chronic)
5. anti-HCV - may not be detectable
for months
HCV PCR viral load - detectable 1-2
weeks after infection

316.

317.

318.

319.

320.

botulism
1. patho
2. clinical pres
3. dx
4. tx

1. preformed toxins from c. botulinum


- spores inactivated by 100C for 10
minutes
wound contamination
2. SYMMETRIC DESCENDING
FLACCID PARALYSIS - starts with
dry mouth, diplopia, dysarthria
diarrhea, n/v
3. stool toxin, serum or gastric
bioassays
4. watch RESP STATUS***, gastric
lavage, antitoxin, penicillin for
wounds

ddx in foodborne
"botulism"

guillain barre, eaton lambert


syndrome, myasthenia gravis,
diphtheria, tick paralysis

UTI
1. patho
2. risk factors

1. ascending infection from the


urethra- e coli, s.sapro, enterococcus,
klebsiella, proteus, pseudomonas,
enterobacter, yeast
2. female, sex, pregnancy, catheters,
DM, spinal cord injury,
immunocomp, incomplete voiding,
neurogenic bladder, BPH
uncircumcised males, anal
intercourse

non-infectious
causes of cystitis

cytotoxic agents - cyclophosphamide


pelvic radiation
dysfunctional voiding
interstitial cystitis

UTI
1. dx

2. dipstick analysis- positive urine


leukocyte esterase, positive nitrites
(enterobacteriaceae),
urinalysis- clean catch (no squamous
cells) or straight cath-- >1
bacteria/HPF, >10 leukocytes/ul,
hematuria, proteinuria
urine gram stain - >10^5 organisms
urine culture* - only if >65yo,
diabetes, recurrent UTI, >7 days
symptosm

UTI
1. clinical pres
2. what diagnostic
tests for suspected
structural
abnormalities

1. dysuria, frequency, urgency,


suprapubic tenderness, gross
hematuria
2. IVP, cystoscopy, excretory
urography

complicated UTI
1. definition
2. what risk factors

1. any UTI past the bladder (pyelo,


prostatitis, urosepsis)
2. men, diabetes, renal failure,
pregnancy, history of pyelo, resistant
organisms, immunocomp
(HIV/transplant)

321.

322.

323.

324.

UTI
1.
uncomplicated
cystitis
treatment
2. UTI in
pregnant
patient tx
3. UTI in men
tx
4. treated UTI
that relapses
5. > 2
UTI's/year

1. bactrim 3 days, nitrofurantoin 5-7 days


(for pregnant***), fosfomycin 1 dose
fluoroquinolones - 3 days cipro
phenazopyridine - urinary analgesic
2. ampicillin, amoxicillin or oral
cephalosporins 7-10 days (NO CIPRO
CAUSES FETAL ARTHROPATHY)
3. same as women but 7 days
4. treat for 2 more weeks + urine culture
5. chemoprophylaxis- single dose bactrim
after intercourse, or low dose bactrim for 6
months

pyelonephritis
1. patho
2. organisms
3.
complications

1. vesicoureteral reflux + risks for


complicated UTI --> ascending infection to
kidney
2. Ecoli, proteus, klebsiella, enterobacter,
pseudomonas, enterococcus, s.aurues
3. sepsis in up to 25%, emphysematous
pyelonephritis (in diabetics), chronic
pyelo/scarring

pyelonephritis
1. clinical pres
2. dx
3. tx

1. fever, chills, flank pain, cystitis


symptoms, n/v, diarrhea
2. urinalysis - pyuria, bacteriuria, leukocyte
casts
urine cultures, blood cultures, CBC
(leukocytosis/left shift)
renal ultrasound, CT, IVP, retrograde
urethrogram
3. single dose of ceftriaxone or gentamicin
before bactrim or fluoroquinolone 10-14
days
ampicillin for gram positive cocci (s.sapro)
very ill - hospitalize + parenteral - amp +
gent or cipro use IV abx until patient
afebrile, then 14-21 day PO abx course
urosepsis - IV abx 2-3 wks

prostatitis
1. acute
bacterial
prostatitis
patho
2. chronic
bacterial
prostatitis
patho
3. clinical pres

1. ascending infection from the urethra and


reflux of infected urine, s/p catheterization
- e coli, klebsiella, proteus, enterobacter,
serratia
2. more common, often diagnosed
incidentally
3.acute- fever, chills, toxic appearance,
dysuria, frequency, urgency, lower back
pain
chronic - asymptomatic, afebrile, recurrent
UTIs, irritative voiding and obstructive
symptoms
DRE

325.

326.

327.

328.

329.

330.

331.

prostatitis
1. dx acute vs
chronic
2. tx acute vs
chronic
- tends to
recur

1. acute - urinalysis shows sheets of WBCs


in acute, urine cultures positive
chronic - DRE boggy tender prostate, WBCs
in expressed prostatic secretions
2. acute - hospitalize and IVabx, mild
outpatient bactrim or fluoro or doxy 4-6
weeks
chronic - fluoroquinolone long course

genital warts
patho

HPV - mos common STD

chlamydia
1. patho
2. clinical
pres
3. dx
4. tx
5.
complications

1. intracellular pathogen STD, coinfection


with gonorrhea common
2. asymptomatic (80% women), dysuria,
purulent discharge, scrotal pain/swelling,
post-coital bleeding
3. enzyme assay, PCR
4. azithro 1x, doxy 7 days
5. epididymitis/proctitis in men
women - PID, salpingitis, tubo ovarian
abscess, ectopic preg, fitz hugh curtis
syndrome

gonorrhea
1. patho
2. clinical
pres
3.
complications

1. gram negative diplococcus


2. often asymptomatic in women , males
have purulent discharge, erythema/edema
of urethral meatus, urinary frequency, also
pharynx, conjunctiva, and rectum infection
3. PID, epididymitis, prostatitis,
tuboovarian abscess, salpingitis, fitz hugh
curtis syndrome, disseminated disease

what cancer
associated
with
chlamydia

cervical cancer

gonorrhea
1.
disseminated
disease
clinical pres
2. dx
3. tx
4. tx for
disseminated

1. fevers, arthralgias***, tenosynovitis,


migratory polyarthritis/septic arthritis,
endocarditis,
rash on distal extremities (discrete purpuric
or pustular lesions with central
necrosis/hemorrhage)
2. gram stain of urethral discharge, culture,
syphillis and HIV, blood cultures
3 cetriaxone one dose + azithro one dose or
doxy (for coexisting chlamydia)
4. hospitalize and IV or IM ceftriaxone for 7
days

HIV
1. when is
cesarean
delivery
indicated
2. phases of
HIV
3. cause of
death

1. when HIV viral load is >1000


2. primary infection, asymptomatic,
symptomatic, and full blown AIDS
2. opportunistic infections, wasting, cancer

332.

333.

334.

335.

HIV/AIDS
1. primary
infection
2.
asymptomatic
infection
3.
symptomatic
HIV (preAIDS)
4. AIDS

1. mononucleosis syndrome that lasts 2-4


weeks - fever, sweat, malaise, lethargy,
headaches, arthralgias
2. CD4 >500- 4-7 years, seropositive, but no
clinical evidence
3. 1-3 years, persistent generalized
lymphadenopathy, localized fungal
infections, recalcitrant
vaginal/trichomonas infections oral hairy
leukoplakia, seborrheic dermatitis,
psoriasis, molluscum, warts, constitutional
symptoms
4. CD4 <200 and disseminated
opportunistic infections and malignancies

HIV/AIDS
1. best
indicator of
immune
status/risk of
infection
2.
progression
of CD4 decline
3. at what CD4
do
opportunistic
infections
occur

1. CD4
2. 50/year
3. 200-500 - HZV, TB lymphoma,
pneumonias, kaposi's
<200 get more opportunistic infections

HIV/AIDS
1. best
indicator of
effectiveness
of
antiretroviral
therapy
2. when does
medication
regimen
- measure
CD4 and viral
load every 3-4
months

1. viral load
2. when viral load is >50 after 4 months of
treatment, NEVER STOP TREATMENT

AIDS
pulmonary
complications
1. CD4 count
2. PJP clinical
pres and dx
3. other
pulmonary
infections

1. <200
2 .fever, non-productive cough, SOB
w/exertion-->rest, d
x = diffuse interstitial infiltrates,
methenamine silver stain tx = 3 wks bactrim
+steroids
prophylaxis bactrim 1x/day
3. TB (may be PPD neg), CMV/MAC
(CD4<50), crypto, histo, kaposi

336.

337.

338.

339.

340.

341.

AIDS nervous
system
complications
1. AIDS
dementia
2.
toxoplasmosis
clinical pres +
dx

1. 33% of patients, early memory


loss/cognitive deficits, later mental status,
aphasia
2. reactivation of latent disease- symptoms
of a mass (deficits/headache) and
encephalitis (fever, altered MS)- dx =
contrast enhancing lesions in basal
ganglia/subcortical white matter

AIDS nervous
system
complications
1. cryptococcal
meningitis +
tx
2. other CNS
infections

1. stains with india ink, culture positive of


CSF fluid
tx = amphotericin B 10-14 days then 8-10
weeks PO fluconazole, lifelong fluconazole
maintenance
2. bacterial meningitis, histo, CMV, PML,
HSV, neurosyphilis, TB

AIDS GI
complications
1. diarrhea
2. oral lesions
3. esophageal

1. e.coli, shigella, salmonella,


campylobacter, CMV, giardia, crypto,
isospora, MAC
2. candida thrush, HSV/CMV ulcers, oral
hairy leukoplakia (EBV), kaposi
3. candidiasis, dysphagia/odynophagia
most commonly candida, but CMV/HSV
(CD4 <100)

AIDS skin
complications

kapsosi sarcoma - raised


brown/black/purple papulse of face, chest,
genitals, oral cavity
HSV, warts, shingles, syphillis, warts,

AIDS
opportunistic
infections
1. CMV + tx
2. MAC + tx
3. HIV
wasting
syndrome
4.
malignancies

1. disseminated GI, pulmonary, retinitis,


colitis, esophagitis
tx = ganciclovir or foscarnet
2. wasting syndrome, lymphadenopathy,
anemia, diarrhea, weight loss
3. involuntary loss of >10% of body weight
+ chronic diarrhea fever, persistent
weakness
4. kaposi, NHL (rapidly growing), primary
CNS lymphoma

HIV/AIDS
1. dx
2. tx

1. PCR RNA viral load test (also measures


therapy effectiveness)
p24 antigen assay
ELISA- positive 1-12 weeks after infection
(99% sensitive)
western blot confirmation
2. antiretrovirals CD4 <500, and
symptomatic
2NRTI + either NNRTI or protease inhibitor
continue in pregnant patients

342.

343.

344.

pneumocystis
pneumonia
1. CD4
2. clinical pres
3. dx
4. tx

1. <200
2. dyspnea, dry cough, fever
3. CXR (bilateral interstitial
infiltrates), LDL (elevated), ABG (inc.
A-a + hypoxia), bronchoscopy/BAL
***methenamine silver stain
4. tx = bactrim + steroids
prophylaxis with bactrim, atovaquone
or pentamidine

MAC prophylaxis
in AIDS

prophylaxis with azithromycin or


clarithromycin or rifabutin with CD4
<50

toxoplasmosis
prophylaxis +
treatment in AIDS

prophylaxis with bactrim when CD4


<100
tx = sulfadiazine and pyrimethamine

AIDS vaccinations

pneumovax every 3-5 years


influenza yearly
hep B

genital ulcers
1. syphilis
2. primary HSV
3. chancroid
4.
lymphogranuloma
venereum
5. granuloma
inguinale

1. single raised painless clean ulcer,


firm painless bilateral
lymphadenopathy
2. grouped painful vesicles
pustules/ulcers, painful firm bilateral
lymphadenopathy
3. purulent ulcer with shaggy border
(progressive, multiple in women),
fluctuant unilateral painful fistulizing
lymphadenopathy
4. painless papule, vesicle, ulcer,
painful unilateral fluctuant fistulizing
lymphadenopathy
5. nodules coalescing into
granulomatous ulcers, suppurating
pseudobubo lymphadenopathy

HSV
1. patho
2. HSV 1 clinical
pres
3. HSV 2 clinical
pres

1. lives in dorsal root ganglia where it


can reactivate at any time
2. asymptomatic, fever, malaise, oral
lesions, vesicles on patches of
erythematous skin, herpes labialis,
bells palsy
3. longer primary infection up to 3
weeks, recurrent episodes shorter,
constitutional symptoms, genital
vesicles, pustules

348.

349.
345.

346.

350.

351.
347.

352.

HSV
1. what
causes
recurrences
2. herpetic
whitlow
3.
disseminated
HSV
4/ HSV in
pregnant
women
5. neonatal
HSV
6. ocular HSV

1. stress, fever, infection, sun exposure


2. HSV infection from inoculation of finger,
painful vesicular lesion, treat with acyclovir,
do not I&D
3. encephalitis, meningitis, keratitis***,
chorioretinitis, pneumonitis
4. may be disseminated and fatal
5. congenital malformations, IUGR,
chorioamnionitis, neonatal death
6. keratitis, blepharitis, keratoconjunctivitis

HSV
1. dx
2. tx

1. tzanck smear - swab base with wright's


stain (shows multinucleated giant cells)
culture***
ELISA
2. no cure, oral/topical acyclovir 7-10 days,
valacyclovir, famciclovir, acyclovir
prophylaxis, foscarnet in
immunocompromised

syphilis
1. patho
2. primary
3. secondary
4. latent
5. tertiary

1. treponema pallidum spirochetes via sexual


contact
2. chancer painless ulcer with clean base 3-4
wks after exposure, highly infectious,
painless inguinal adenopathy
3. maculopapular rash includes palms/soles,
flu like illness, condyloma lata**
4. positive results, no active symptoms
5. cardiovascular, neurosyphilis (dementia,
personality changes, tabes dorsalis),
gummas,

syphilis
1. dx
2. tx

1. dark field microscopy, RPR, VDRL (70%


specific), FTA-ABS, MHA-TP more specific
2. abx - benzathine penicillin G one dose or
oral doxy, or oral azithromycin, or
tetracycline
latent/tertiary syphilis - penicillin 3 doses
IM once per week

chancroid
1. patho
2. clinical
pres
3. dx

1. gram negative rod h.ducreyi via sexual


contact
2. painful genital ulcers with unilateral
tender adenopathy
3. clinical after syphilis/HSV rule out
4. azithro 1x, ceftriaxone 1x, or oral azithro
erythro cirpro

353.

354.

355.

356.

357.

lymphogranuloma
venereum
1. patho
2. clinical pres
3. dx
4. tx

1. c.trachomatis STD
2. painless ulcer at inoculation, tender
unilateral adenopathy and
constitutional symptoms -->
proctocolitis, stricture, elephantitis of
genitals ,
3. serologic compliment fixation,
immunofluorescence
4. doxy 21 days

pediculosis pubis
(capitis,corpora)
1. patho
2. clinical pres`
3. dx
4. tx

1. phthirus pubis STD, fomites


2. regional pruritus
3. examination of hair shows nits or
lice
4. 1% permethrin shampoo for pt and
sexual partner, combs, cloths and bed
linens washed or thrown away

cellulitis
1. patho
2. most common
pathogens
3. clinical pres
4. dx/tx

1. breaks in skin, catheters, incisons,


bites, venous stasis, lymphedema,
diabetic ulcers--> inflammation of
skin/subcutaneous tissue
2. strep A, or s.aureus
3. erythema, warmth, pain, swelling,
+/-fever
4. clinical, blood cultures if fever
present
tx = oxacillin, IV nafcillin (highest
risk AIN), cephalosporin IV until signs
improve then PO abx 2 weeks

cellulitis
pathogens
1. local
trauma/skin
breaks
2.
wounds/abscesses
3. water
immersion
4. acute sinusitis

1. strep pyogenes
2. s.aureus
3. pseudomonas, aeromonas, vibrio
vulnificus
4. haemophilus influenzae

erysipelas
1. patho
2. clinical pres
3. risk factors
4. complications
5. tx

1. Group A strep infection confined to


dermis and lymphatics
2. fiery red painful lesions of the lower
extremities and face
3. lymphatic obstruction, local trauma,
abscess, fungal infections, DM,
alcoholism
4. sepsis, local spread, nec. fascitis
5. IM or oral penicillin or erythromycin

358.

359.

360.

361.

362.

363.

364.

necrotizing
fasciitis
1. patho
2. risk factors
3. clinical pres
4. tx

1. s.pyogenes or c. perfringens deep soft


tissue infection that spreads rapidly along
fascial planes
2. surgery, DM, trauma, IVDU
3. fever, pain out of proportion, crepitus,
discoloration, cutaneous anesthesia -->
sepsis/TSS, multiorgan failure
4. prompt surgical exploration + antibiotics

differentiating
DVT from
cellulitis

erythema, warmth, tenderenss in both


DVT typically in posterior calf
homans sign not sensitive
VENOUS DOPPLER MUST BE USED TO
DISTINGUISH THE TWO CONDITIONS

necrotizing
fasciitis
1. tx

1. broad spectrum ABX, rapid surgical


exploration and excision of devitalized
tissue

lymphadenitis
1. patho
2. clinical pres

1. inflammation of a lymph node from strep


or staph infection
2. fever, tender lymphadenopathy, red
streaking, thrombosis, sepsis
3. penicillin G, anti-staph penicillins,
cephalosporins, warm compresses

tetanus
1. patho
2. clinical pres
3. dx/tx

1. deep punctures/bites/necrotic wounds-->


c. tetani gram negative anaerobic bacillus
produces exotoxin in contaminated wounds
--> blocks inhibitory transmitters at NMJ
2. hypertonicity, trismus (lockjaw),
generalized muscle contractions, risus
sardonicus (grin), opisthotonos (arch
back), sympathetic hyperactivity
3. clinical dx + wound cultures
tx= ICU, respiratory support, diazepam for
tetany, single dose tetanus immune
globulin

when to give
tetanus
immunization
for wound
management

Td for clean wounds and Td+TIG for dirty


wounds IF : <3 doses, unknown status or
>10 years since last booster

osteomyelitis
1. patho
2. risk factors
3. clinical pres

1. hematogenous, direct spread (ulcers,


trauma, PVD) of s.aureus and coagulase
negative staph --> infection of long bones
(tibia, humerus, femur), foot/ankle, and
vertebral bodies
2. open fractures, DM, IVDU, sepsis
3. pain over area of affected bone, systemic
symptoms, draining sinus (chronic)

365.

366.

367.
368.

369.

370.

371.

osteomyelitis
organisms
1. catheter
septicemia
2. prosthetic
joint
3. diabetic
foot ulcer
4.
nosocomial
infections
5. IVDU
5. sickle cell

1. s.aureus
2. coagulase negative staph
3. polymicrobial
4. pseudomonas
5. fungal species, pseudomonas
6. salmonella

osteomyelitis
1. dx
2. tx

1. +/-WBC count, ESR/CRP,


needle aspiration + culture
plain radiograph - only + after >10 days
radionuclide bone scans - + after 2-3 days
MRI is most effective imaging study
2. oxacillin, first gen cephalosporin,
aminoglycoside and beta lactam if gram
negative
surgical debridement*

potts disease

TB osteomyelitis of the vertebral column

acute
infectious
arthritis
1. patho
2. pathogens

1. hematogenous/contiguous
/traumatic/iatrogenic --> microorganisms
invade the joint space --> cytokine release
and and destruction of the joint
2. s.aureus,
n.gonorrhoeae in young sexually active
adults
salmonella - sickle cell disease or
immunodeficiency

372.

373.

acute
infectious
arthritis
1. clinical
pres

1. warm, swollen, painful, limited


active/passive range of motion, palpable
effusion, constitutional symptoms common

gonococcal
arthritis
1. clinical
pres
2. tx

1. MONO/OLIGO arthritis that progresses in


a migratory additive pattern
tenosynovitis of hands/feet
2. antibiotics to cover gonorrhea and
chlamydia

acute
infectious
arthritis
1. dx
2. tx

1. joint tpa WBC>50k 80% PMNs, gram


stain of fluid, culture, crystal analysis, PCR of
synovial fluid
blood cultures- positive in 50% of cases
leukocytosis, inc. ESR/CRP
CT or MRI
2. immediate empiric antibiotics, daily
aspiration of joint (only shoulder/knee)

374.

375.

376.

acute
bacterial
arthritis
treatments
1. s.aureus
2.
immunocomp
or risk for
gram negative
3. high risk
for
gonococcal

1. oxacillin or 1st gen cephalo x4 weeks


add vancomycin if MRSA
2. 3rd gen cephalo or aminoglycoside 3-4
weeks, use aminoglycoside + extended
spectrum penicillin for pseudomonas
3. IV 3rd gen cephalosporin then oral agent
for 3-10 days once clinical improvement

lyme disease
1. patho
2. stage 1
clinical pres
3. stage 2
clinical pres
4. stage 3
clinical pres

1. ixodidae tick carries borrelia burgdorferi


2. erythema migrans (enlarging bulls eye
rash)
3. intermittent flu like symptoms, headache,
stiff neck, fevers, meningitis, encephalitis,
cranial nervitis (BL bells palsy), cardiac (AV
block, pericarditis)
4. arthritis, chronic CNS disease encephalitis, transverse myelitis
acrodermatitis chronica atrophicans

lymes disease
serology

IgM 3-6 weeks


IgG remains elevated if patient has
disseminated disease
IgG may remain elevated even though
adequate abx treatment
VDRL may be positive

lymes disease
1. diagnosis
2. tx

1. history, serologic studies - ELISA,


western blot
2. 10 days antibiotic therapy
spread beyond skin 20-30 days antibiotic
therapy
doxycycline, amox or cefuroxime (preg),
erythromycin (preg)
30-60 days for facial nerve palsy, arthritis,
or cardiac disease

rocky
mountain
spotted fever
1. patho
2. clinical
pres
3. dx/tx

1. tick bites feeds on mammals - rickettsia


rickettsii then multiplies in vascular
endothelium
2. sudden onset fever, chills, malaise, n/v,
myalgias, photophobia papular rash that
starts peripherally@wrists/ankles (5 days
after fever) and spreads centrally
(INCLUDES PALMS/SOLES)
3. clinical, immunoassay
tx = doxycycline for 7 days, use IV if patient
vomiting
CNS/pregnant - give chloramphenicol

377.

378.

379.

380.

381.

malaria
1. patho
2. clinical pres
3. dx
4. tx

1. falciparum (most dangerous), ovale,


vivax, malariae- via mosquito vector
2. fever, chills, myalgias, headache, n/v,
diarrhea
falciparum - constant fever
ovale/vivax - 48 hour spikes
malariae - 72 hour spikes
3. peripheral smear, giemsa stain
4. tx chloroquine, quinine + tetracycline,
atovaquone proguanil, mefloquine
IV quinidine + doxy for falciparum
2 week primaquine for vivax/ovale relapse
mefloquine for traveler prophylaxis

rabies
1. patho
2. clinical pres
3. dx/tx

1. bite or scratch or corneal transplant -->


3 month incubation 2. prodrome including headache, sore
throat, encephalitis
then hydrophobia, combativeness,
hypersalivation, ascending paralysis
3. virus or viral antigen in tissues, serum
antibody titers, negri bodies in tissues,
PCR detects viral RNA
tx = clean wound, capture animal, human
rabies immunoglobulin in wound and
gluteal region
3 antirabies vaccines over a 28 day period

other zoonosis
page 400,
review this

dfasfasfasldjflasdjkfk

candidiasis
1. risk factors
2. clinical pres

1. antibiotics, immunosuppression,DM,
immunocompromised
2. yeast infection - thick white cottage
cheese like vaginal discharge- painless,
pruritic
oral thrush - thick white plaques (suggests
HIV)
cutaneous - erythematous eroded patches
with satellite lesions
GI tract - esophagitis (odynophagia),

candidiasis
1. dx
2. tx

1. KOH preparation demonstrates yeast,


blood or tissue culture
2. remove catheters,
clotrimazole troches 5 times/day
nystatin 3-5x/day
miconazole or clotrimazole cream for
vaginal candidiasis
ampho B, voriconazole, caspofungin for
systemic candidiasis

382.

383.

384.

385.

386.

aspergillus
1. patho
2. allergic
bronchopulmonary
aspergillosis
3. pulmonary
aspergilloma
4. invasive
aspergillosis
5. tx

1. spores inhaled into lung


2. type 1 hypersensitivity reaction presents as asthma and eosinophilia
3. history of sarcoid, histo, TB,
bronchiectasis--> chronic cough,
hemoptysis
4. hyphae invade lung vasculature
and cause thrombosis/infarction->
fever, cough, respiratory distress,
diffuse bilateral pulmonary infiltrates
5. ABPA- corticosteroids
massive hemoptysis - lobectomy
invasive aspergillosis- ampho B,
voriconazole, caspofungin

cryptococcus
1. patho
2. clinical pres
3. dx

1. budding yeast with thick


polysaccharide capsule - assoc. with
pigeon droppings 2. meningitis/meningoencephalitisheadache, fever, irritibaliity,
dizziness, confusion, also pulmonary
infection
3. LP if suspect meningitis, latex
agglutination, india ink smear shows
yeast
tx= ampho B with flucytosine for 2
weeks then PO fluconazole

page 403 for


blastomyces, histo,
cocci, sporo
pg 404 for
parasites

ergwregtrwaefsdz

fever of unknown
origin
1. definition

1. fever 38.3 (101) on several


occasions for at least 3 weeks no
diagnosis despite 1 week of inpatient
or 3 outpatient visits
2. TB, occult abscess, endocarditis,
sinusitis, HIV, mono, malaria or
parasite , occult neoplasms
(hodgkins, leukemia, solid tumors),
collagen vascular disease, sarcoid,
crohns , drug fevers (penicillin,
sulfonamides, quinidine,
barbiturates), PE, hemolytic anemia

1. fever of unknown
origin diagnostic
workup
2. tx

1. CBC, UA, pan culture, complement


assay, PPD, LFTs, ESR, ANA, RA,
TSH, CXR, tagged WBC, MRI, node
biopsy
2. antibiotics empirically

387.

388.

389.

390.

391.

392.

393.

toxic shock
syndrome
1. patho
2. clinical pres
3. lab findings

1. menstruating women with tampon use,


surgical wounds, insect bites
2. flu like symptoms, diffuse macular
erythematous rash,hyperemic mucous
membranes, strawberry tongue, warm
skin, n/v, thrombocytopenia,
cardiopulmonary disease, confusion,
disorientation, rash that desquamates on
PALMS AND SOLES
3. increased PTT, elevated BUN/Cr,
hyponatremia, hypocalcemia,
hyperbilirubinemia, elevated ALT

fever vs
hyperthermia

fever - there is elevation of hypothalamic


set point - treat when >105, preg,
hyperthermia - no alteration of
hypothalamic set point - tx = external
cooling or dantrolene for malignant
hyperthermia

toxic shock
syndrome
1. tx

1. hemodynamic stabilization- aggressive


fluid, pressors if needed
remove source
anti-staph therapy - nafcillin, oxacillin, or
vanc, clindamycin

catheter
related sepsis
1.
causes/clinical
pres

1. s.aureus, s. epidermidis - THERE MAY


BE NO SIGNS OF INFECTION AT THE
CATHETER SITE

neutropenic
fever
1. causes
2. dx
3. tx

1. bone marrow failure, bone marrow


invasion, from hematologic malig,
hypersplenism, SLE, AIDS, drug reactions,
chemotherapy
2. CXR, pan culture, CBC, CMP,
3. isolation (positive pressure), broad
spectrum abx (with antipseudomonal
covg), antifungal agents, GCSF

neutropenia
definition

neutrophil <1500/mm3
ANC <500 is at risk for severe infection

infectious
mononucleosis
1. causes
2. what should
be tested for in
pregnant
woman
3. clinical pres

1. EBV, CMV, HIV, strep, toxo


2. HIV, CMV, toxo - risk of harming fetus
3. fever up to 104, sore throat, malaise,
myalgias, lymphadenopathy***,
splenomegaly (AIHA, thrombocytopenia),
maculopapular rash, hepatomegaly

394.

395.

396.

397.

398.

399.

400.

infectoius
mononucleosis
1. dx
2. tx

1. monospot test - detects heterophile


antibodies (sheep red cells) will be
undetectable 6 months after infection,
(not present in CMV mono)
EBV - specific antibody testing
peripheral blood smear - lymphocytes
with large atypical lymphocytes
throat culture to rule out group A strep
2. rest, fluids, avoid strenuous activities,
short course of steroids for
airway/thrombocytopenia/hemolytic
anemia

infectious
mononucleosis
1. complications

hepatitis, meningoencephalitis, guillain


barre, bells palsy, splenic rupture,
airway obstruction, AIHA,
thrombocytopenia

rosacea
1. clinical
findings
2. tx

1. erythema telangiectasisa, papules, no


comedones, rhinophyma
2. topical metronidazole, systemic
antibiotics, isoretinoin, avoid
alcoholic/hot beverages

keratoacanthoma

1. epithelial tumors that resemble SCC,


lesions grow very quickly and progress
to a dome with central crater

tinea versicolor
1. patho
2. clinical pres
3. dx /tx

1. superficial infection with malassezia


furfur, hot humid weather excessive
sweating, skin oils
2. hyper/hypopigmented lesions most
commonly of the trunk
3. KOH prep shows spaghetti and
meatballs pattern, woods lamp
tx = oral or topical ketoconazole,
selenium sulfide lotion

common
locations of
seborrheic
dermatitis
tx

dry scales and erythema:


scalp, behind ears, external ear canal,
eyebrows, armpits, under breasts
tx = sunlight exposure, dandruff
shampoo, topical ketoconazole, topical
corticosteroids

contact
dermatitis
1. irritant type
2. allergic type
3. clinical pres
4. dx/tx

1. chemical or physical insult to skin no previous sensitizing event


2. delayed type 4 hypersensitivity
reaction - with or without atopic history
ex. poison ivy, poison oak, iodine,
nickel, rubber
3. acute stage - erythematous
papules/vesicles oozing edema, pruritus
only in areas of contact
4. patch testing, avoid allergen, cold
water, topical corticosteroids, systemic
corticosteroids

401.

402.

403.

404.

405.

406.

407.

408.

pityriasis
rosea
1.
patho/clinical
pres
2. tx

1. HSV7 - herald patch ==> christmas tree


distribution of oval lesions (with fine
collarette of scale) on trunk upper arms and
thighs, not on face
2. antihistamines, spontaneously remits in
6-8 weeks

erythema
nodosum
1. patho
2. dx

1. hypersensitivity vasculitis - red subQ


elevated nodules typically over anterior tibia
(shins)--- caused by strep infections*,
sarcoid, IBD, behcets, fungal infections,
pregnancy, meds (OCP, sulfa, amiodarone,
abx), syphilis, TB
2. CXR (for sarcoid/TB), ASO titer, VDRL,
CBC, ESR, cultures, skin biopsy

erythema
multiforme
1. patho
2. tx

1. erythematous macules that resemble


target lesions, may be pruritic and painful
-- caused by medications (penicillin, sulfa
drugs, phenytoin, allopurinol, barbiturates),
post - HSV
2. acyclovir, antihistamines, analgesics

SJS and TEN


1. patho
2. clinical
pres

1. sulfonamides, NSAIDs, phenytoin,


barbiturates-->most dangerous forms of
erythema multiforme
2. mucocutaneous lesion >@ sites, lesions
appear targetoid, fever, tachycardia,
hypotension,
2. admit to ICU/burn unit

lichen planus
1. clinical
pres

1. pruritic, polygonal, purple, flat topped


papules - of unknown cause - commonly on
wrists, shings, oral mucosa, and genitals

bullous
pemphigoid
1. patho
2. clinical
pres
2. tx

1. triggers - UV light, NSAIDs, antibiotics


NO acantholysis, IgG anti basement
membrane (anti BP230, anti-BP180) and C3
deposits at the dermal epidermal junction
2. TENSE blistering lesions at extensor
areas, POSITIVE NIKOLSKY'S SIGN
subepithelial blisters of abdomen, groin,
extremities, LESS easily ruptured than
pemphigus vulgaris
2. systemic or topical glucocorticoids,
azathioprine for severe

pemphigus
vulgaris
1. patho
2. clinical
pres
3. tx

1. autoimmune blistering due to IgG


desmoglein INTRACELLULAR in the lower
epidermis
2. FLACCID blistering lesions on oral
mucus membranes that become erosive
rupturing blisters, NIKOLSKY POSITIVE
tx = glucocorticoids, azathioprine,
methotrexate

genital warts
1. treatment

1. liquid nitrogen freezing, salicylic acid*,


5FU, surgical excision or laser therapy,
podophyllin for genital warts

409.

410.

411.

412.

413.

414.

415.

416.

417.

molluscum
contagiosum
tx

curretage, podophyllin, cantharidin,


cryosurgery

herpes zoster
treatment

local injection of triamcinolone in


lidocaine, antiviral agents, corticosteroids,
live vaccine

dermatophytes
1. organisms
2. dx

1. superficial fungi - trichophyton,


microsporum, epidermophyton
2. KOH stain to see fungus

scabies
1. patho
2. clincial pres
3. tx

1. sarcoptes scabiei var hominis


2. severe pruritis worse at night, burrows,
dark dot is female mite, excoriations,
eczematous plaques
3. permethrin 5% cream left on overnight
lindane - y benzene hexachloride - 2nd line
treatment - risk of seizures
topical corticosteroids/oral antihistamines to control pruritis

dermatophyte
infections
1. tinea
corporis dx/tx
2. tinea capitis
dx/tx
3. tinea
unguium dx/tx
4. tinea pedis
dx/tx
5. tinea cruris
dx/tx

1. direct microscopy with KOH prep topical antifungals ketoconazole/miconazole


2. woods lamp - if lights up its
microsporum, if not its trichophyton - tx =
ORAL** griseofulvin
3. nail scrapings - ORAL griseofulvin
4. direct microscopy - topical antifungals,
5. """""

actinic
keratosis
1. patho
2. dx/tx

1. small rough scaly lesions 2/2 sun


exposure
2. erythematous papules with a central
scale, hyperkeratotic, cutaneous horns
2. biopsy to exclude SCC
bx shows acanthosis (thickening of
epidermis), parakeratosis (nuclei in
corneum), dyskeratosis, hyperkeratosis
(thickening of stratum corneum)

basal cell
carcinoma
1. patho
2. dx
3. tx

1. basal cells of the epidermis


2. pearly smooth papule with rolled edges
and surface telangiectasias (3Ps pearly,
pink papule)
3. surgical resection

squamous cell
carcinoma of
skin
1. patho
2. clinical pres
3. dx/tx

1. skin sun exposure, actinic keratosis,


skin damage
2. crustin ulcerated nodule or erosion
3. biopsy shows invasive cords of
squamous cells with keratin pearls
complete excision

marjolin's
ulcer

SCC arising from a chronic wound such as


a previous burn scar

418.

419.

420.

421.

422.

423.

424.

melanoma
1. most
important
prognostic
factor
2. features
of
melanoma

1. depth of invasion
2. asymmetry, border irregularity, color
vairation, diameter >6mm, elevation -

stages of
decubitus
ulcers

1. skin intact, non- blanching erythema


2. partial thickness skin loss
3. full thickness skin loss into subQ tissue
4. full thickness extending into
muscle/bones/joints/tendons etc

psoriasis
1. patho
2. clinical
pres
3. tx

1. abnormal proliferation of skin cells,


improves in summer, worst during winter,
exacerbated by trauma
2. koebner's phenomenon
well demarcated erythematous
plaques/papules with thick silver scaling
auspitz sign - removal of scale -->pinpoint
bleeding
extensor surfaces
pitting of nails/onycholysis
arthritis - pencil in cup deformity of the DIP
3. topical corticosteroids,
calcipotriene/calcitriol, tars, tazarotene
(vitamin A derivative), anthralin,immune
modulating therapy (MTX, cyclosporine),
TNF blockers
phototherapy, acitretin, UV light

seborrheic
keratosis
1. patho
2. clinical
pres
3. tx

1. autosomal dominant - harmless growths


2. dark elevated plaques appear suck on the
skin
3.cryotherapy or curettage

vitiligo
1. patho
2. clinical
associations
3. tx

1. autoimmune depigmentation condition of


the skin
2. DM, autoimmune hypothyroidism,
pernicious anemia, addison's disease,
alopecia areata, hypopituitarism
3. glucocorticoids, phototherapy

urticaria
1. patho

1. inflammatory mediators released by mast


cells in response to foods, drugs, latex,
dander, pollen, dust, plants
2. edematous wheals and hives that disappear
and reappear elsewhere, intense pruritis

hereditary
angioedema

425.

426.

427.

428.

429.

430.

431.

432.

autosomal dominant C1 esterase inhibitor


deficiency
433.

hypersensitivity
types

1. IgE -anaphylaxis/asthma
2. IgG or IgM cytotoxic - good
pastures.pemphigus
3. antigen antibody complexes - SLE,
arthrus reaction, serums sickness
4. T cell mediates - allergic contact
dermatitis , tuberculosis, transplant
rejection

anaphylaxis
1. patho
2. clinical pres
3. tx

1 type 1 IgE reaction


2.pruritus, erythema, urticaria,
angioedema
dyspnea, respiratory distress, asphyxia
hypotension, shock, arrhythmias
abdominal pain, n/v, severe diarrhea
3. ABCs, epinephrine immediately IV if
severe, subQ if less severe,
antihistamines, corticosteroids IV fluids,
oxygen

amoebic liver
abscess
1. patho
2. clinical pres
3. dx/tx

1. travel to endemic area --> entamoeba


histolytica --> hepatic abscesses
2. RUQ pain,
3. indirect hemagglutination assay,
ultrasound will show abscess with well
defined margins, blood cultures
tx = metronidazole, no aspiration
necessary

ecoli 0157:H7
1. sources
2. clinical
presentation

1. contaminated ground beef, raw milk,


fecal oral
2. mild diarrhea, hemorrhagic colitis,
acute renal failure, HUS

parvo b19
1. clinical pres
in children
2 clinical pres
in adults

1. erythema infectiosum - fever like illness


with a slapped cheek rash
2. viral arthritis *** - pain lasts about 30
minutes, no symptoms, no systemic
symptoms
diffuse lace like rash, polyarthropathy,
aplastic crisis (in G6PD or sickle cell
patients), spontaneous abortion, hydrops
fetalis

target O2
saturation in
COPD patients

88-92%, overly aggressive O2 will


increase PaCO2

meperidine
side effects

metabolized to normeperidine inc. risk of


CNS toxicity, sedation, seizures, resp.
depression

septic arthritis
1. patho

1. hematogenous spread by staph aureus,


or beta hemolytic strep is most common.
gonorrhea in sexually active young adults

p-anca

anti - myeloperoxidase

434.

435.

436.

437.

438.

439.

440.

441.

442.

microscopic
polyangiitis
1. patho
2. clinical pres
3. dx

1. pauci immune necrotizing small


vessel vasculitis-->
2. glomerulonephritis, pulmonary
hemorrhage, fever
3. P-ANCA positive

cryoglobulinemia
1. patho
2. clinical pres
3. dx

1. small vessel vasculitis, assc. with hep


C--> renal involvement, alveolar
hemorrhage, arcuate artery aneurysms
2. palpable purpura*** (think of adult
HSP), arthritis, glomerulonephritis,
livedo reticularis, abdominal pain,
3. low complement

tarsal tunnel
syndrome
clinical pres

posterior tibial nerve entrapment


between medial malleolus and flexor
retinaculum--- pain in the ankle/heel
and numbness of sole of foo at night

hypertrophic
osteoarthropathy
clinical
associations

intrathoracic malignancy, suppurative


lung disease, congenital heart disease

exudative pleural
effusion fluid lab
findings

...

complicated vs
uncomplicated

total pleural protein:serum protein>0.5


LDH pleural fluid:LDH serum >0.6
LDH pleural fluid >2/3 upper limit of
normal

444.

445.

446.

447.

448.

449.

complicated pH<7.2, glucose


<60, positive
gram
stain/culture

...

pulmonary
embolism
1. sources
2. clinical pres
3. dx
4. tx

1. 80% deep veins of the legs


2. unilateral leg pain/swelling, then
tachypnea*, tachycardia*, pleuritic
chest pain (indicates pulmonary
infarction), hemoptysis, wheezing. JVD
3. D-dimer (90% sens, not specific), CT
pulmonary angiogram (PE protocol)
ABG - hypocapnia*, hypoxia*
respiratory alkalosis, inc. A-a gradient
ECG- sinus tachy, atrial fibrillation,
pseudoinfarction (inferior leads)
new pleural effusion exudative
>transudative
VQ scan, S4, new RBBB*
4. immediate IV heparin or LMWH if
there are no contraindications
thrombolytics only if hemodynamically
compromised

recommended PE
prophylaxis
during hip
replacement

443.

450.

451.

452.

warfarin titrated to INR 2-2.5


or LMWH BID

453.

454.

455.

456.

fenfluramine/phentermine
clinical association

PPH in people who take


these drugs as appetite
suppressants

workup of suspected
carbon monoxide poisonin

venous carboxyhemoglobin
CXR
then start supplemental O2

what drugs will increase


theophylline levels

cimetidine, erythromycin,
ciprofloxacin, allopurinol,
and zafirlukast

what murmurs are


increased by by exercise,
and decreased by amyl
nitrate

VSD, mitral regurgitation

digoxin specific
indications

symptomatic systolic
dysfunction
atrial flutter, atrial
fibrillation

treatment for atrial


fibrillation

warfarin INR to 2-3,


medical/electrical
cardioversion after 3 weeks
of anticoagulation

AAA risk factors

smoking, hypertension

indications for ventricular


fibrillation

v.fib, or hypotensive v.tach

EKG findings right


ventricular hypertrophy

peaked P waves II, III, aVF,


tall R waves V1-V3,deep S in
V6, right axis deviation

acute coronary syndrome


1. tx

1. initial - morphine, oxygen,


nitro, anticoag/aspirin
beta blocker
clopidogrel
admission - trend cardiac
enzymes,

supraventricular
tachycardia SVT treatment

adenosine - 6mg, then 12mg


if necessary
verapamil - 2.5-5mg
If adenosine/verapamil fail
can try procainamide
DC cardioversion
immediately if
HEMODYNAMICALLY
UNSTABE

treatment for idiosyncratic


ventricular rhythm in the
context of acute MI

amiodarone + beta blocker

what kind of murmurs


worse with inspiration

right sided heart murmurs

romano ward syndrome

congenital QT prolongation,
and deafness--- family
history of sudden cardiac
death

457.

458.

459.

460.
461.

462.

463.

464.

treatment of
symptomatic
claudication

graduated exercise regimen,


cilostazol - PDI - decreases platelet
aggregation and causes
vasodilitation improves exercise
tolerance

1 . vitamin D
deficiency lab
findings
2. postmenopausal
osteoporosis
findings

elevated iPTH, normal ionized


calcium, elevated alk phos
2. normal iPTH, normal ionized
calcium, normal alk phos

pagets disease
(osteitis deformans)
1. complications
2. dx
3. treatment

1. bone pain, thickening of


calvarium, hearing loss***, bone
deformity, congestive heart failure
(acoustic meatus/VIII),
hypercalcemia
2. normal calcium, normal
phosphate, elevated alk phos***,
elevated urinary: hydroxyproline,
deoxypyridinoline, n-telopeptide, ctelopeptide
tx:asymptomatic - NO TREATMENT
symptomatic - bisphosphonates
Xray - shows resorption/sclerosis
especially in the skull, femur, axial
skeleton
subcutaneous injections of
calcitonin if cannot tolerate
bisphosphonates

struma ovari

ectopic thryoids

1. effect of HRT on
lipid panel
2. adverse effects of
HRT used for postmenopausal
osteoporosis

1. dec. LDL, inc. HDL, inc. TG


2. inc. risk of breast cacner

cushing disease vs
exogenous
glucocorticoid
difference in clinical
presentation

exogenous glucocorticoid use does


not cause hirsutism.

prolactinoma
clinical pres

galactorrhea (non-preg), irregular


menses, amenorrhea, bitemporal
hemianopsia

empty sella
syndrome
1. patho

1. enlargement of the sella turcica


from CSF pressure compressing the
pituitary gland
2. chronic headaches, or
asymptomatic, rim of pituitary tissue
is fully functional

465.

466.

467.

468.

469.

470.

471.

472.

473.

474.

475.

1. best test for


diabetic
gastroparesis
2. treatment

scintigraphic gastric emptying study


2. glycemic control, small frequent
meals, dopamine antagonists
(metoclopramide), bethanechol,
erythromycin (motilin interaction),
cisapride

1. how to
determine if
ascitic fluid is
from portal
hypertension

serum albumin - ascitic fluid albumin


= >1.1

c.difficile best
diagnostic test

c.diff stool toxin assay, or colonoscopy


showing pseudomembranes

disease associated
with
microvesicular fat
(micronodular
sclerosis

autoimmune hepatitis
chronic viral hepatitis

1. how to dec. GI
Side effects with
chronic NSAID
use

1. cotreat with misoprostol


2. inc. cardiovascular events, also
same degree of renal dysfuntion

bleeding
prophylaxis for
cirrhotic patients
with varicies

propranolol (non-specific beta


blockers)
octreotide

intermittent
mesenteric
ischemia
1. patho
2. post-prandial
abdomina
pain/weight loss

1. atherosclerotic obstruction of
visceral arteries

lab findings in
rhabdomyolysis
ARF

hyperkalemia, hyperuricemia,
hyperphosphatemia, hypocalcemia,
elevated creatinine
high RBCs on urine dipstick
but few RBCs on urine microscopy

acute uric acid


nephropathy

chemotherapy tumor lysis associated


renal damage

osmolar gap
1. calculation

1. 2Na+BUN/28+glu/18
2. patients have toxic ingestion of
methanol, ethylene glycol, paint
thinners

ethylene glycol key


lab findings

hypocalcemia, high anion gap, high


osmolar gap*

476.

477.

478.

479.

480.

481.

482.

483.

484.

485.

486.

hyponatremia
1. with inc. ECF fluid
overload
2. normal volume
status
3. low volume (ie low
blood pressure/high
pulse)
4. when see
hyponatremia then
evaluate volume status
THEN WHAT

1. heart failure, cirrhosis,


nephrotic syndrome, renal
insufficiency
2. SIADH
3. plasma osmolality hypoosmolar = low plasma
osmolality
high plasma osmolality =
hyperglycemia
normal plasma osmolality hypoproteinemia, hyperglycemia

1. analgesic
nephropathy
2. protease inhibitor
effect on GU

1. high level analgesic use causes


renal colic/papillary necrosis
2. can cause obstructive renal
stones

refeeding syndrome

hypophosphatemia, hypokalemia
due to intracellular shifts after
feed starving person or alcoholic

alcoholic with
hypocalcemia

2/2 hypomagnesemia decreases


end organ PTH response

hyporeninemic
hypoaldosteronism
1. patho

1., old patients, CHF - beta


blockers, ACE inhibitors,
spironolactone --> life
threatening hyperkalemia

cause of postoperative
hyponatremia

nausea, pain, and anesthetic


agents causes potent release of
ADH by neurohypophysis

testicular cancer
1. patho

1. solid mass from the testis


metastasizes to the
retroperitoneal/para aortic nodes
(stage 2)

key clinical feature


distinguishing sickle
SS from sickle SC
disease

splenomegaly seen in sickle SC

myeloproligerative
disorders

polycythemia vera, essential


thrombocytosis, CML,
myelofibrosis

gaisbock syndrome

erythrocytosis with normal red


blood cell mass from decreased
plasma volume.

breast cancer
1. adjuvant for
pre/post menopausal
women

1. post menopausal = hormonal tamoxifen (ER antagonist) or


anastrozole** (aromatase
inhibitor)
premenopausal - oophorectomy,
tamoxifen

487.

488.

489.

490.

491.

492.

493.

494.

495.

496.

transfusion related
acute lung injury
1. patho
2. clinical pres

1. antibodies in donor blood that


bind to HLA on recipients WBCs > WBC agglutination and trapping
in the lungs
2. appears like volume overload on
CXR

ABO or Rh mismatch
reaction

leads to recipient Ig binding to


donor RBCs and then complement
fixation and intravascular
hemolysis

delayed hemolytic
transfusion reaction

antibodies to minor antigents


antigenic memory cells response
within several days to a week and
make antibodies against
transfused cells

hypercoagulable
states

prothrombin G202
factor V leiden,
OCPs
pregnancy
Protein C, S and ATII deficiencies
lupus
cancer

antithyroid
medications (PTU,
methimazole)
complications

leukopenia
rare agranulocytosis

1. where in the brain


do hypertensive
hemorrhages occur
2. where in the brain
does cerebral amyloid
angiopathy
hemorrhage occur

1. in the central structures of the


brain (thalamus, basal ganglia,
cerebellum)
2. lobar hemorrhages in the
elderly

restless leg syndrome


1. tx

1. dopamine enhancing drugs pramipexole, ropinirole

what imaging
modality is best for
spinal cord and
posterior fossa

MRI

carotid sinus
hypersensitivity
1. patho
2. clinical pres

1. baroreceptors of carotid sinus


are activated sending impulses
through glossopharyngeal nerve
to medulla
2. syncope from turning head or
wearing collared shirt or shaving
3. ECG carotid massage, or duplex
doppler if bruit is heard

what can cause coma

severe metabolic disturbanceshypoglycemia, hyponatremia,


intoxication
brainstem dysfunction - RAC or
pons
bilateral hemispheric insults

497.

498.

499.

500.

501.

502.

503.

504.

505.

parkinsons disease
1. treatment
2. SE of parkinsons
treatment

1. levodopa- dopamine precursor


carbidopa - dopa decarboxylase
inhibitor
direct dopamine agonistsropinirole/pramipexole
anticholinergics - benztropine
mesylate dec. degree of tremor
2. limb/facial dyskinesias

paraneoplastic
cerebellar
degenerations
1. associated
cancers
2. patho
3. other
paraneoplastic
neuronal syndromes

1. small cell lung, breast, female


genital, lymphomas
2. anti- Hu/Ri/Yo/Tr - neuronal
antigens
3. encephalopathy with sensory
neuropathy, opsoclonus myoclonus
syndrome, lambert-eaton
myasthenic syndrome

hypertension
management in the
context of acute
cerebral
ischemia/stroke

DO NOT AGGRESSIVELY TREAT


<185/110 is acceptable

medication overuse
headache

>2x weekly headache medication


use-->

complex partial
seizures

1. psychomotor seizures - complex


auras, abnormal motor behaviors,
impaired consciousness

vascular dementia

1. stepwise neurological defects


resulting from bilateral cerebral
infarcts, hemiparesis, extensor
plantar responses, pseudobulbar
palsy

treatment for a
patient who had a
TIA

immediate anti-platelet therapy


carotid doppler

diffuse itchiness
associated with
what condition

polycythemia vera, lymphoma,


thyroid disorders

CYP450 inducers

BullShit CRAP GPS induces my rage!


Barbiturates
St. John's wort
Carbamazepine
Rifampin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas

506.

507.

508.

509.

510.

511.

512.

513.

514.

CYP450 inhibitors

VICK'S FACE All Over GQ stops


ladies in their tracks.
Valproate
Isoniazid
Cimetidine
Ketoconazole
Sulfonamides
Fluconazole
Alcohol (acute)
Chloramphenicol
Erythromycin (macrolides)
Amiodarone
Omeprazole
Grapefruit juice
Quinidine

1. joint complications of
diuretics
2. what type of beta
blocker should be used
in COPD/asthma
3. what antihypertensives are
contraindicated in
pregnancy
4. alpha blockers long
term risk

1. hyperuricemia and gout


attacks
2. non-cardioselective - should
choose metoprolol or esmolol
3. ACEs/ARBs
4. inc. risk of congestive heart
failure (orthostatic hypotension
in the short term)

cardiac risk index

ischemic heart disease, CHF,


cerebrovascular disease, insulin
therapy, pre-op Cr>2.0

common variable
immunodeficiency
1. patho
2. clinical pres

1. T cell abnormalities and


hypogammaglobulinemia
2. 2nd decade of life onset of
recurrent diarrhea (GIARDIA
LAMBLIA) and respiratory
infections

nasal turbinates in
allergic vs infectious
rhinitis

allergic - pale and boggy


infectious - red and inflamed

how to deal with


administering contrast
to a patient with
contrast allergy

premedicate with
antihistamines and
corticosteroids-- don't need to
avoid altogether

IgA deficiency
1. clinical pres

1. severe blood product allergic


reactions, inc. incidence of
sinopulmonary infections ``
inc. risk for giardia lamblia ***

ataxia telangiectasia
1. patho

1. ATM gene mutation


abnormal DNA repair
2. lymphomas, cerebellar
ataxia, immunodeficiency,
ocular/facial telangiectasias

postprandial
hypotension

just what it sounds like

515.

516.

517.

518.

519.

520.

521.

522.

523.

524.

525.

526.

527.

528.

529.

what increases the


risk of cholesterol
embolization

hypertension, smoking, elevated


CRP

pulmonary
hyptension physical
examination
findings

loud S2, prominent a waves, right


ventricular heave, ejection click,
right ventricular fourth heart sound

pacemaker
indicatiosn

persistent bradycardia, new LBBB,


new mobitz type 2, symptomatic
wenckebach type 2

why are ace


inhibitors
contraindicated in
pregnancy

cause renal dysgenesis and


oligohydramnios

contrast medium
side effects

contrast induced nephropathy (see


risk factors), n/v, anaphylaxis,
hives, itching, angioedema

what is
electrocardiography
useful to detect

latent ischemic heart disease

treatment of atrial
flutter

diltiazem/verapamil, beta blockers,


digoxin

what cardiac defects


increase risk for
infectious
endocarditis

VSD***
mitral prolapse, mitral stenosis,
asymmetric septal hypertrophy,
Low risk = ASD

what clincal scenario


is nitroglycerine
used for a heart
failure patient

normal BP, with moderate


pulmonary congestion
--- when BP is low, must give
inotropic agents

AV dissociation

independent beating of
atria/ventricles
fixed P-P, fixed R-R, variable P-R

causes of coronary
artery aneurysm

atherosclerosis, trauma,
angioplasty, atherectomy,
vasculitis, mycotic emboli,
kawasaki syndrome, arterial
dissection

what is the cause of


ST elevation >2 weeks
after an infarct
+ CXR finding

ventricular aneurysm
look for calcified bulge on CXR

clinical presentation
of familial
hyperchoesterolemia

AUTOSOMAL DOMINANT
tendon xanthomas, xanthelasma,
arcus senilis

hypertension effect
on the eyes

cotton wool spots, hemorrhage,


papilledema
fibrinoid necrosis

left ventricular
hypertrophy EKG
findings

high voltage QRS in V5/B6, deep S


in V1/V2, prolonged QRS in
precordial leads

530.

531.

532.

533.

534.

1. pulsus tardus et
parvus
2. pulsus
paradoxus
3. hyperkinetic
(bounding) pulse
4. bisferiens pulse

1. pulse is weak and late - aortic


stenosis
2. >10mmHg drop in BP with
inspiration - cardiac tamponade,
pericarditis, OSA, COPD, tension
PTX, severe asthma
3. high pulse pressure or low
peripheral resistance - fever, anemia,
AV fistula, aortic regurgitation
4. double peak per cycle - aortic
regurgitation, HCM

1. dicrotic pulse
2. pulsus alternans
3. pulsus
bigeminus

1. systolic percussion wave and


prominent dicrotic wave in diastole dilated cardiomyopathy, low CO, high
SVT - sepsis
2. alternating strong/weak beats aortic and mitral valve stenosis,
pericarditis
3. two heartbeats close together
followed by longer pause, large QRS
followed by a smaller one - HCM,
digitalis tox,

JVP findings
1. large a waves
2. kussmaul's sign
3. slow y descent
4. prominent v
wave
5. prominent x
descent
6. prominent y
descent

1. inc. filling resistance - TS,


pulmonary hypertension, complete
heart block (right atrium contracts
against tricuspid closed by right
ventricular systole
2. inc. in JVP during inspiration from right heart failure or constrictive
pericarditis
3. obstruction of right ventricular
filling - atrial myxoma or tricuspid
stenosis
4. accentuated atrial filling - tricuspid
regurgitation,
5. cardiac tamponade, restrictive
cardiomyopathies
6. constrictive pericarditis

JVD waveform
1. a wave
2. x descent
3. v wave
4. y descent

1. atrial systole
2. atrial relaxation during ventricular
systole
3. rising atrial pressure from
increased atrial filling,
4. tricuspid opens

1. which murmurs
are increased by
handgrip/pressure
cuff
2. which murmurs
are increased by
valsalva/standing
- most murmurs
decrease with
valsalva/standing

1. mitral regurgitation, VSD, aortic


regurgitation
2. HOCM, MVP

535.

536.

537.

538.

539.

540.

how to differentiate
constrictive pericarditis
vs cardiac tamponade on
physical exam

constrictive pericarditis has


kussmaul's sign

1. best antihypertensive
for those with CAD
2. best antihypertensive
for patients with left
ventricular dysfunction
or multiple
cardiovascular risk
factors
3. what type of antihypertensive is
contraindicated in
patients with bilateral
renal artery stenosis

1. beta blockers
2. ACE
3. ACE

carcinoid syndrome
effect on the heart

fibrous plaques on the


endothelium on the right side
of the heart--> tricuspid
regurgitation, distorted cardiac
valves, pulmonic stenosis

treatment for bullous


stage of contact
dermatitis

wet dressings several


times/day with burow's
solution or boric acid, baths
oral corticosteroids for severe
cases

clinical associations with


acanthosis nigricans

visceral carcinomas - GI and


GU, especially stomach
diabetes, obesity, acromegaly
cushings syndrome

urticaria/pruritic
erythematous lesions
progressing to nikolsky's
negative bullous lesions

bullous pemphigoid - IgG anti


basement membrane without
acantholysis

keratoacanthoma

grows on exposed hairy skin


grows rapidly then involutes
more common on white
skinned males
telangiectasias with a central
keratotic plug

543.

544.

545.

546.

547.

548.

549.

550.

551.

552.
541.

542.

atopic dermatitis
1. clinical pres
2. management

1. erythematous excoriated
papules/plaques that weep and
become secondarily
impetiginized
2. change in environment
topical steroids
adequate humidity

553.

554.

555.

zinc deficiency
clinical
presentation

abnormal taste*, impaired wound


healing, dermatitis around the mouth
with acral involvement, then to hands,
scalp, trunk, feet, alopecia,
seen in chronic malabsorption states bypass surg, IBD, alcoholism

what type of
melanoma is
invasive early

nodular melanoma

sezary syndrome

T cell lymphoma - HTLV1- malignancy


of helper T cells

cutaneous
reactions of TMP
SMX

urticarial eruption within days


morbilliform reaction within weeks
especially in AIDS patients

tetracycline
dermatologic
changes

photosensitivity, mottling of teeth in


children

what drugs cause


erythema
nodosum

OCPs, sulfonamides, penicillins


- panniculitis tender subcutaneous
erythematous nodules classically on
the anterior portion of the legs

chloroquine
dermatologic side
effect

polymorphous light eruption


exacerbation of porphyria cutanea
tarda
black pigmentation of the face, mucous
membranes

dermatologic side
effects of antineoplastics

stomatitis, alopecia
dystrophic nail changes (bleomycin,
hydroxyurea, 5FU)
cellulitis, ulceration, urticaria

erythroderma
1. causes
2. clinical pres

1. drugs - sulfa, penicillins, gold,


allopurinol, captopril, phenytoin,
carbamazepine

2. diffuse rash,
fever,
eosinophilia,
interstitial
nephritis

...

what drugs cause


pemphigus
vulgaris

captopril
penicillamine

treatment for pain


in patients with
acute intermittent
porphyria

oral phenothiazines, narcotics,


NSAIDs
DO NOT USE: barbiturates,
sulfonamides, alcohol, carbamazepine,
valproate, estrogen/progestin

what lipid
disturbance is
seen in patients
with insulin
resistance

hypertriglyceridemia

556.

557.

558.

559.

560.

561.

562.

563.

564.

565.

566.

567.

568.

in adrenocortical
insufficiency what
occurs with water
balance

low aldosterone decreases


circulating volume (via inc.
natriuresis) leading to inc. ADH
production and hyponatremia

hyperparathyroidism
1. effect on bones

1.

what is role of FSH in


men

stimulates sertoli cells and then


spermatogenesis

androgen
insensitivity
1. patho

1. X linked androgen receptor


defect leads to XY and female
genetalia

572.

treatment for
erythropoietic
protoporphyria

beta carotene

573.

vitamin A toxicity
clinical pres

...

what vitamins
classically deficient in
alcoholics

magnesium, folate

1. causes of
hypomagnesemia
2. clincal pres of
hypomagnesemia

1. alcoholism, milk diet in infants,


chronic diuretic use, acute
pancreatitis,
2. anorexia, n/v, tremor, altered
mental status

cystinuria
1. patho
2. clinical pres

1. autosomal dominant defect in


proximal tubule reabsorption of
cystine, ornithine, arginine, lysine
2. ureterolithiasis with radiopaque
stones

mcardles disease
1. patho
2. clinical pres

1. glycogen storage disease- defect


in glycogen phosphorylase
2. cramps/muscle pains, inc. CK,
inc. Lactate with exercise

gauchers disease
1. patho
2. clinical pres

1. autosomal recessive deficiency


in glucocerebroside -->
accumulation of glucosylceramide
in lysosomes
2. hepatosplenomegaly,
neurologic/mental retardation,
bone lesions (erlenmeyer flask
femur), severe bone disease, lipid
laden macrophages (gaucher cells)

569.

570.

571.

574.

tay sachs disease


1. patho
2. clinical pres

1. hexosaminidase A deficiency -->


accumulation of GM2 ganglioside
in lysosomes
2. mental retardation, seizures,
blindness, cherry red macula

type 3
hyperlipoproteinemia

homozygous Apo-E defect -->


raised yellow plaques on
palms/fingers,2/2 abnormal
accumulation of chylomicrons and
VLDL

575.

576.

577.

578.

579.

580.

type 1
hypolipoproteinemia

deficiency of lipoprotein lipase


presents as eruptive xanthomas,
acute pancreatitis

familial combnined
hyperlipidemia

autosomal

what is the most


important factor in diet
induced cholesterol
elevation

...

"""" in diet induced


triglyceride elevation

total amount of fat and saturated


fat consumed

total amount of calories

...

causes of secondary
dyslipidemias

DM, hypothyroidism, renal


disease, alcoholism, anorexia
Drugs - estrogen,
glucocorticoids

osteomalacia

vitamin D deficiency leads to


bowing of long bones, and wide
osteoid borders on bone surfaces

vitamin D resistant
rickets
1 patho
2. clinical pres
3. dx

1. X linked recessive end organ


insensitivity to vitamin D -->
renal phosphate wasting
2. alopecia and vitamin D
deficiency - ie.
osteomalacia/rickets despite
vitamin D supplementation
3. normal serum calcium,
normal alk phos, normal levels
of vitamin D, symptoms of
rickets

hormone replacement
therapy
1. advantages

1. dec. vaginal atrophy, incr.


bone mineralization
2. inc. risk of venous
thromboembolism
inc risk of breast cancer

when should a patient


with an eating disorder
be hospitalized

weight <75% expected


severe electrolyte disturbances

failure of detumescence
associated with what
conditions

sickle cell anemia


CML

1. niacin deficiency
clinical pres
1a. niacin excess
clinical pres
2 .thiamine deficiency
clinical pres

1. pellagra (seen in corn based


diets)- diarrhea, dermatitis,
dementia
1a. flushing, hepatotoxicity
2. beriberi - high output cardiac
failure, peripheral vasodilation,
water retention

581.

582.

583.

584.

585.

586.

587.

588.

1. vitamin A excess clinical


pres
1a. vitamin A deficiency
clinical pres
2. selenium deficiency

1. abdominal pain, n/v,


headache, dizziness,
papilledema
1a. night blindness, vision
loss, dry skin, impaired
immunity
2. cardiomyopathy

1. vitamin C deficiency
clinical pres

1. perifollicular
hyperkeratotic papules,
tendency to hemorrhage

what decreases lower


esophageal sphincter tone

chocolate, ethanol, caffeine,


tobacco

dumping syndrome
1. patho/clincal pres

1. postgastrectomy, DM simple sugars --> vasomotor


palpitations, tachycardia,
lightheadedness,
diaphoresis, dizziness,
confusion, syncope

what patients is a low salt


diet recommended for

hypertension, CHF, CKD

whipples disease
1. patho
2. dx

1. infection with gram


positive bacilli - tropheryma
whippelii --> GI, arthritis,
CNS, eye
2. small intestine biopsy
shows PAS positive
macrophages with non-acid
fast gram positive bacilli

what vitamin deficiency


associated with celiac
disease

iron deficiency

what tumors are most


common in the distal ileum

lipomas and carcinoid


tumors

what kind of cancer is


more common in celiac
disease, regional enteritis,
congenital immune
disorders, organ
transplant, AIDS

primary small bowel


lymphoma

lab characteristics of
cirrhotic ascitic fluid

SG <1.016, protein <25g/L,


low WBCs

afferent loop syndrome


1. patho
2. clinical pres

1. distention and incomplete


drainage of the afferent loop
with bacterial overgrowth
2. nausea/vomiting/bloating
30-40 minutes after eating +
postprandial pain, bloating,
diarrhea, fat and B12
malabsorption

593.

594.

595.

596.

597.

598.

599.
589.

590.

591.

592.

what is the most common


site for colon cancer.

600.

601.

rectosigmoid

602.

603.

1. which hepatitis has


very high chronic
infection if transmitted
vertically

1. hep b

what increases the risk


for NSAID GI ulcerse

steroid use, h.pylori infection,


smoking, alcohol

mentriers disease
1. patho
2. clincal pres
3. dx/tx

1. large gastric mucosal folds -> protein malabsorption


2. abdominal pain, n/v,
anorexia, --> pedal edema from
protein malnutrition
3. mucosal biopsy to rule out
cancer/lymphoma
tx =high protein diet, anticholinergic drugs, H2 blockers

why does the sclera stain


first with bilirubin

high elastin content

1. rotors syndrome
2. dubin johnson

1. defect of hepatic storage of


conjugated bilirubin resulting
leaking into plasma
2. conjugated
hyperbilirubinemia, diagnosis
is elevated urinary
coproporphyrin I(>80% of
total)
grossly black liver
dense granular pigments of
epinephrine metabolite*** (not
seen in rotor)

what noncardiac
condition presents like
angina and is relieved by
sublingual nitro

diffuse esophageal spasm

how to diagnose osmotic


diarrhea

stool osmotic gap

secretory diarrhea
clinical pres

large volume, painless, watery

hepatic complications of
anabolic steroids

cholestasis/jaundice without
inflammation
peliosis hepatis (blood in the
liver)

hemoglobin C disease
1. patho
2. clinical findings

1. lysine substitution for


glutamic acid
2. targetoid RBCs,
splenomegaly, less
symptomatic than HbS,
intracellular HbC CRYSTALS

what is is the cause of


febrile transfusion
reaction

patients antibodies react to


donor leukocytes in PRBCs
usually after about 7
transfusions patients are
sensitized--- must filter/wash
the RBCs to remove the WBCs

604.

605.

606.

607.

608.

609.

610.

611.

612.

613.

614.

bone marrow finding in


hemolytic anemia

increased erythroid to
myeloid ratio

causes of anemia in
preganncy

folate deficiency
(megaloblastic)
dilutional anemia disproportionate increase in
plasma volume
IDA

what kind of bone


abnormalities seen with
sickle cell anemia

bone infarction- can look like


osteomyelitis
AVN of femoral head

fish oils effect on


coagulation

prolong bleeding time- by


reducing platelet arachidonic
acid, and competing with
COX

when does post radiation


cancer occur

increased frequency of cancer


at the same age that you
would expect the cancer to
occur
leukemia has the lowest
latency at 5-7 years post
exposure

what is the most


important prognostic
factor in colon cancer

DEPTH OF TUMOR
PENETRATION (DUKES
STAGE)

also young age, male


gender, and rectal location
are poor prognostic
factors

...

what decreases risk of


breast cancer in women

late menarche, early


menopause, early first
pregnancy

what is the most


important prognostic
factor in bone tumors

more distal tumors have


better prognosis
ex - pelvic girdle is worse
than femur, and femur is
worse than tibia.

Adult T cell
leukemia/lymphoma
1. patho
2 . tx

1. HTLV 1 or other retrovirus


---> fulminant leukemia with
skin involvement
2. not responsive to
treatment, but helps to
control symptoms

most common clinical


pres of hodgkins
lymphoma

615.

616.

617.

618.

619.

620.

enlarge cervical or
supraclavicular lymph nodes

621.

622.

623.

chemotherapy side
effects
1. cyclophosphamide
2. doxorubicin
3. bleomycin
4. MTX
5. cisplatin

1. hemorrhagic cystitis - tx =
mesna + hydration
2. cardiomyopathy/CHF
3. lung injury, skin reactions
4. liver toxicity,
myelosuppression, GI mucositis
5. renal, ototoxicity,
myelosuppression, peripheral
neuropathy

paraneoplastic
syndromes associated
cancers
1. eaton lambert
2. SIADH
3. cushings syndrome
4. non-metastatic
hypercalcemia (PTHrP)

1. small cell lung


2. small cell lung
3. small cell lung
4. squamous cell lung (

what type of cancers


occur among chinese
americans at a higher
than normal rate

nasopharyngeal carcinoma,
liver cancer

poor prognostic factors


for patients with non
hodgkin's lymphomas

>60 years of age, high serum


LDH, poor performance status,
ann arbor 3 or 4

what increases risk for


cholangiocarcinoma

clonorchis, ulcerative colitis

1. how to treat brain


metastases pain
associated with inc. ICP
2. limitation of
carbamazepine for use
in neuropathic cancer
pain

1. steroids
2. leukopenia,
thrombocytopenia

posterior circulation
TIA
1. clinical pres
2. what structures does
the basilar artery supply

1. tinnitus, vertigo, diplopia,


ataxia, hemiparesis, bilateral
visual impairment
(homonymous hemianopsia)
2. pons, midbrain, cerebellum

acoustic neuroma
clinical presentation

-- develop from schwann cells


deafness, headache, ataxia,
tinnitus, diplopia

subdural hematoma

venous origin 2/2 head injuryesp. in elderly


clinical pres - fluctuating LOC,
altered mental status, seizures,
papilledema

624.

625.

626.

627.

628.

629.

630.

631.

632.

633.

634.

635.

wernicke korsakoff
1. patho
2. clinical pres
3. tx

1. infarction of mamillary bodies


2. confusion, ataxia, nystagmus,
ophthalmoplegia (6th nerve)
korsakoff = irreversible amnesia,
confabulation, apathy
3. THIAMINE BEFORE
GLUCOSE

benign paroxysmal
positional vertigo
1. patho
2. clinical pres

1. calcium debris (loose


otoconia) in semicircular canals
2. sudden onset of brief vertigo
episodes, dix hallpike maneuver
positive

what to start treatment


with for a withdrawing
chronic alcoholic

diazepam, thiamine, magnesium

what is a key feature of


peripheral vertigo vs
central vertigo

tinnitus and deafness is found in


peripheral vertigo
peripheral vertigo tends to
relapse and remit whereas
central is more constant

hypokalemic periodic
paralysis
1. patho
2. clinical pres
3. tx

1. familial/thyrotoxicosis -->
hypokalemia after large
carbohydrate meals/stress
2. recurrent attacks of weakness,
loss of DTR, paralysis
3. potassium supplementation,
low carbohydrate,
acetazolamide, imipramine

637.

638.

arteriovenous
malformation clincial
pres

symptoms start between ages 1030, headaches similar to


migraines, seizures, or rupture

hypertensive
encephalopathy
1. locations of
hemorrhage

1. cerebellum, pons, thalamus

cerebellar hemorrhage
1. clincal pres

1. headache, vomiting, gait


ataxia, dizziness, vertigo, eyes
deviate away from hemorrhage
possible ipsilateral 6th nerve
palsy

pontine hemorrhage
key clinical findings

636.

639.

640.

641.

642.

643.

impaired oculocephalic reflexes,


small reactive pupils, coma,
quadriplegia

PML pathogen

JC virus (papovavirus) in the


immunosuppressed

which vaccines are


associated with ADEM

smallpox or rabies

which vitamin
deficiency can cause
demyelination

B12

644.

645.

646.

647.

cavernous sinus
thrombosis
1. patho
2. clinical pres

1. 2/2 trauma, neoplastic, or


infectious
2. papilledema, hemorrhages of
orbital veins, headache, diplopia,
sensory loss of face (3,4,6,V1/V2)

1. oculomotor palsy
clinical
presentation
2. argyll robertson
pupil
3. tonic pupil
(holmes-adie
syndrome)

1. ipsilateral no response to light, no


consensual light response
2. small irregular pupils, impaired
light response, accomodation intact
3. parasympathetic lesion @ or distal
to ciliary ganglion - large unilateral
pupil, no light response (shy drager,
amyloid, diabetes, healthy)

1. horners
syndrome pupil

1. constricted on affected side, intact


light reaction, no reaction to darkness

seizure treatments
1. status
epilepticus
2. partial seizures
3. tonic clonic
seizures
4. myoclonic
seizures
5. absence seizures

1. lorazepam or diazepam
2. phenytoin, carbamazepine,
3. phenytoin, carbamazepine,
valproic acid
4. valproate
5. ethosuximide, valproate

phenytoin side
effects

gum hyperplasia, hirsutism, SJS/TEN

long term seizure


prophylaxis

phenytoin, carbamazepine

1. hyperuricemia
renal effect
2. sickle cell
anemia renal effect

1. urate crystals in the medulla or


pyramids with mononuclear or giant
cell
2. ischemic injury leads to functional
tubule defect and concentrating
defect, papillary necrosis, FSGS

what drugs should


be avoided in
patients with renal
impairment

NSAIDs and ACE

post-strep
glomerulonephritis
1. microscopic
findings

diffuse mesangial proliferation, IgG


and C3 granular subepithelial
deposits

what is key urine


finding indicating
glomerulonephritis

red cells/red cell casts indicate that


the glomerulus is bleeding
- granular casts, protein will also be
present but this is not specific

glucocorticoid
drug acid base
disturbance

metabolic alkalosis because


glucocorticoids have some
mineralocorticoid activity

hepatic cirrhosis
acid base
disturbance

respiratory alkalosis - 2/2 elevated


progestins stimulate respiratory drive

648.

649.

650.

651.

652.

653.

654.

655.

656.

657.

658.

659.

660.

henoch schonlein
1. patho
2. kidney injury type

1. URI, drugs, foods, insect bites-> immune complex vasculitis of


the skin, GI tract and kidneys
2. diffuse proliferative
glomerulonephritis

polycystic kidney
disease clinical pres

renal/hepatic cysts, intracranial


aneurysms, colonic diverticula

why do osteophytes
cuase pain in
osteoarthritis

stretching of periosteal nerve


endings

what cardiac
complication of
ankylosing spondylitits

aortic insufficiency (4%)

side effect of
phenylbutazone (an
NSAID used to treat
joint pains)

aplastic anemia

what to think in a
patient with new onset
clubbing of the distal
extremities

secondary hypertrophic
osteoarthropathy - next step
should be a chest x ray

blood count findings in


SLE

leukopenia (2/3 of patients) or


pancytopenia

what is the best


predictor of likelihood
for extraarticular
manifestations of RA

high IgG anti Fc Ig (RA factor)


titers

668.

most common
extraarticular
manifestation of
ankylosing spondylitis

anterior uveitis - pain,


photophobia, inc. lacramation

669.

rheumatoid arthritis
radiographic findings
early vs late

early = NORMAL
late = bony erosions and loss of
cartilage, periarticular
osteopenia, joint margin erosions
(narrowing of joint space)

ehlers danlos
1. clinical pres

1. skin hyperextensibility
/fragility/ bruisability, habitual
dislocation of joints

relapsing
polychondritis
1. clincial pres
2. associated
underlying conditions

1. auricular/nasal chondritis that


relapses and remits
2. SLE, RA, sjogren's, vasculitis

rheumatoid arthritis
cellular/molecular
mechanism

CD4+ T cells inc. IL2

661.

662.

663.

664.

665.

666.

667.

670.

671.

672.

673.

marfans syndrome
1. heart lesions
2. body features

1. cystic medial degen of aorta leads


to aortic dilatation and mitral
insufficiency
2. chest deformities (pectus), long
limbs, high arched palate, high
pedal arches, pes-planus

what heart lesion


most common in
HLA B27+ patients

aortic stenosis (1-6%)

where do rheumatoid
nodules typically
occur

olecranon bursa, proximal ulna,


achilles tendon, occiput

caplans syndrome

diffuse nodular fibrosis that occurs


when rheumatoid nodule occur in
the lungs of patients with
pneumoconiosis

most common eye


manifestation in RA

sjogrens

anti-RNP associated
diseases

polymyositis, scleroderma, lupus,


mixed connective tissue disease

what serologic
marker correlates
with disease activity
in lupus

anti-dsDNA

what kind of crystal


arthropathy
characteristic of END
STAGE renal failure

hydroxyapatite (small nonbirefringent crystals)

CPPD prophylaxis

colchicine

clinical presentaion
that favors
pseudogout over gout

old age, pre-existing joint disease,


knee involvement

measels
1. clinical pres
2. complications
3. treatment

1.cough/fever/coryza--> koplik
spots, fever, rash that starts at the
head and DESCENDS
CONFLUENTLY (compare to
rubella)
2. otitis media (most common),
bronchitis, lymphadenitis
pneumonia, encephalitis
(sclerosing panencephalitis that
leads to death by 1 year)
3. aerosolized ribavirin for
pneumonia

mumps clinical pres


mumps treatments

bilateral parotitis, oophoritis,


orchitis, meningitis,
hyperamylasemia (from parotid
inflammation) fever
tx = symptomatic,

treamtent for
diarrhea

oral hydration
loperamide or bismuth
fluoroquinolones or TMP SMX

674.

HIV
1. detection

1. EIA - 99.5% sensitive,


NOT SPECIFIC AT ALL
LOTS OF FALSE
POSITIVES
Western blot - more specific
`

675.

treatment of tetanus

penicillin or metronidazole,
respiratory support

676.

heterophil negative mono

CMV

physical manifestations of
congenital syphilis

hutchinsons teeth, saddle


nose, saber shins

prophylactic antibiotic
choice for travelers
diarrhea

ciprofloxacin inf symptoms


develop

treatment for legionella

macrolides - azithromycin
fluoroquinolones levofloxacin or
moxifloxacin

hospital acquired
pneumonia organisms

s. aureus, gram negatives,


or s.pneumo

empiric treatment for


neutropenic fever

broad gram negative/gram


positive coverage for a
bacteria

- dont need to treat for


fungal/viral unless there is
an indication

...

EBV associated
malignancies

anaplastic nasopharyngeal
carcinoma (US)
burkitts lymphoma (Africa)
HIV associated CNS
lymphomas

native valve endocarditis


caues

strep viridans > s.aureus >


enterococcus

multiple myeloma
infectious risk

defect in humoral immunity


- susceptibility to
encapsulated organisms
s.pneumoniae and
klebsiella

what kind of infections are


associated with cell
mediated immunity defects

candida/fungal and viral


infections -

congenital toxoplasmosis

chorioretinitis, strabismus,
epilepsy, hydrocephalus

what antibiotics potentiate


phenytoin

sulfonamides by displacing
phenytoin from albumin

what antibiotic potentiates


the effects of oral
hypoglycemics

sulfonamides

best diagnostic test for T


cell defect

candida infection
positive reaction means
intact T cell response

677.

678.

679.

680.

681.

682.

683.

684.

685.

686.

687.

688.

689.

690.

691.

692.

693.

694.

695.

696.

697.

698.

699.

aspirin allergy
mechanism

pseudoallergic reaction due to the


enhanced leukotriene synthesis

HLA associations
1. ank spondy
2. juvenile arthritis,
rheumatoid arthritis
3. type 1 DM
4. reiters syndrome

1. B27
2. DR4
3. DR3
4. B27

ant/middle/posterior
mediastinal masses

posterior mediastinal masses


include neurogenic tumors,
meningocele,meningomyelocele,
gastroenteric cysts, and esophageal
diverticula.
anterior mediastinal masses
include thymomas,
lymphomas,teratomas, and thyroid
masses.
Middle mediastinal masses include
vascular lesions,lymph nodes, and
pleuropericardial and
bronchogenic
cysts.

what lung disease


associated with
ankylosing
spondylitis

bilateral upper lobe


fibrosis/fibrocavitary disease

hypoxemia while
recieving 100%
oxygen

right to left shunt (atelectasis,


vascular abnormalities, ARDS,
congenital cardiac malformations)
~~ compare to VQ mismatch which
is easier to correct with oxygen
therapy

lab findings for


sarcoidosis

elevated ACE, ESR,


hyperglobulinemia, hypercalcemia
(elevated D3)
falsely positive ANA and RF

causes of pulmonary
eosinophilia

Allergic bronchopulmonary
aspergillosis (in asthmatics),
parasitic reactions, and drugs
loeffler's syndrome - benign
idiopathic pulm. eosinophilia
churg-strauss

side effects
associated with
quinidine

drug/platelet complex
thrombocytopenia* , hepatitis,
bone marrow suppression, lupus
syndrome, GI side effects,

LSD clincial pres

sympathomimetic effects - pupillary


dilitation, piloerection,
hypothermia, tachycardia,
dizziness, weakness, drowsiness,
nausea, paresthesias

700.

701.

702.

703.

704.

705.

706.

707.

708.

709.

710.

711.

712.

713.

folate deficiency
causes

chronic alcoholism, small bowel


disease, inadequate intake, MTX,
diagnostic tests includes serum
folate or RBC folate (will detect
rapid changes in intake)

perchlorate and
thiocynaate

anti hyperthyroid drugs, both


inhibit iodide transport, work by
preventing thyroid gland from
concentrating iodide

which
fluroquinolones need
renal adjustment

all of them except moxifloxacin


(liver met), or pefloxacin

ampicillin vs
penicillin

acid resistant, better PO


absorption, very high bio
availability PO

ADH effects

inc. water permeability of the


distal collecting duct,
bradycardia, inc. RR, suppression
of fever

what patients should


get treated with
clopidogrel

unstable angina, STEMI,


NSTEMI, post PCI

what is the treatment


for SVT

vagal maneuvers - carotid


massage, immersion in cold
water, valsalva
adenosine, beta blockers, CCBs

neurocardiogenic
syncope (situational
syncope)

vasovagal syncope - occurs in


response to pain, body actions
(urination), coughing fits
nausea, diaphoresis, tachycardia,
pallor preceding syncope

what viral infection


associated with
dilated
cardiomyopathy

coxsackie b
adeno, cmv, echo, hep c,

isolatd systolic
hypertension
+ TX OF CHOICE

cuased by dec. elasticity of arterial


wall which causes inc. systolic BP

treatment of choice is
HCTZ

...

most common cause


of constrictive
pericarditis in
developing countries

tuberculosis

what is the only


murmur that will
increase with
decreased preload

HCM
ie. during valsalva, or standing

which murmurs
inc/dec. with inc.
afterload

ie. handgrip or squat


dec - AS, HCM
inc - MS

714.

715.

716.

717.

718.

719.

720.

721.

722.

723.

724.

725.

726.

statin side effects

elevated liver enzymes


myopathy - HMG CoA
reductase inhibitors dec.
mevalonate which is also
used to synth CoQ10

how to differentiate
restrictive cardiomyopathy
from HCM on echo

HCM has septal thickening


restrictive has symmetric
ventricular thickening

theophylline toxicity

headache, insomnia, GI
disturbance, arrhythmias
ciprofloxacin and
erythromycin both inhibit
P450 and inc. theophylline
levels

flow loop for upper airway


obstruction ex. laryngeal
edema

flow limitation in both


inspiratory and expiratory
limbs

flow loops
1.obstructive disease
processes
2. restrictive lung disease
3. upper airway obstruction

1. scooped out appearance


2. small volume restrictive
pattern
3. blunted
inspiratory/expiratory flow
loops

aspergilloma
1. CXR

1. radiolucent mass that


changes position

what is the most likely


location of formation of a PE
clot

iliofemoral veins
~ calf veins less likely to
make it to the heart

auscultatory findings in
emphysema

prolonged expiratory
phase, end expiratory
wheezing

treatment for inpatient vs


outpatient community
acquired pneumonia (not
ICU, not intubated)

inpatient - levofloxacin
outpatient azithromycin, or
doxycycline

right heart cath findings of


PE

elevated pulmonary artery


pressure (normal is 25/15),
elevated right atrial
pressures
hypotension and shock

most fatal complication of


bronchiectasis

life threatening hemoptysis

hypertrophic
osteoarthropathy clinical
pres

digital clubbing,
**sudden onset**
arthropathy of the wrist
and hands
- first diagnostic test is a
chest x ray

what is the cause of


bronchial obstruction
causing recurrent
pneumonia

bronchiectasis, bronchial
stenosis, foreign body

727.

728.

729.

730.

731.

732.

733.

734.

735.

736.

737.

738.

what is the functional


consequence of
diaphragmatic
flattening in COPD

increased work of breathing

ddx of unilateral leg


swelling/pain

muscle strain, bakers cyst,


DVT, cellulitis

diagnostic steps for DVT

low pretest probability - Ddimer - if negative don't


anticoag, if positive,
compression US and then
anticoag if necessary

739.

740.

high pretest probability


- do compression
ultrasound first

...

auscultatory findings of
lobar pneumonia

dullness to percussion
bronchial breath sounds with
prominent expiratory
component
E-->A egophony
whispered pectoriloquy
crackles

interstitial lung disease


auscultory findings

resonant to percussion,
vesicular breath sounds
FINE END INSPIRATORY
CRACKLES

distinguishing clinical
features of atypical
pneumonia

indolent course, higher


incidence of extrapulmonary
manifestations (HA, sore
throat, erythema multiforme or
other rash)

chronic bronchitis- 1.
definition, 2. patho

1. productive cough 3 months


per year for 2 years, prominent
bronchovascular markings,
normal DLCO, right heart
failure, profound O2 desat
2. destruction of airspaces distal
to terminal bronchioles, dec.
pulmonary vascular markings,
dec. DLCO, moderate O2 desat

741.

742.

complications of PEEP

alveolar damage, tension


pneumothorax, hypotension

differentiation of
asthma and COPD

CXRs are UNRELIABLE airway expansion in COPD is a


LATE finding

best way to distinguish


is FEV1 before and after
bronchodilatory
expecting >15%
response in the
asthmatic

...

causes of
choriocarcinoma

post normal gestation, molar


pregnancy, abortion

743.

744.

745.

746.

what is common nonpulmonary comorbid


condition in asthmatics

GERD - up to 75% of
patients

what kind of MI presents with


abdominal pain

posterior and inferior


MIs
ECG should be first
diagnostic chest for
abdominal pain

factitious diarrhea diagnosis

melanosis coli colonoscopy shows


darkening of colon, and
lymphoid nodules
2/2 laxative abuse

right sided vs left sided colon


caner clinical pres

right sided anemia, left


sided obstruction

constipation, back pain and


renal impairment in an
elderly patient suggests what
condition

multiple myeloma
constipation is 2/2
hypercalcemia
renal impairment is 2/2
BJ proteinuria

celiac disease
1. clinical pres

1. bulky foul smelling


floating stool, loss of
muscle mass/fat
Dermatitis herpetiformis
- subclinical gluten
enteropathy (sub
cutaneous IgA)
pallor from IDA
(duodenum)
bone pain from
osteomalacia
easy bruising (K
deficiency)
hyperkeratosis (A
deficiency)

most common complication of


PUD

hemorrhage

treatment of ascites

sodium and water


restriction
spironolactone
(aldosterone blocker)
loop diuretic - with
spironolactone
frequent paracentesis (24 L/day) if renal function
intact

747.

748.

749.

750.

751.

752.

753.

754.

755.

drug induced
pancreatitis

furosemide, thiazides
IBD drugs - ASA, sulfasalazine
immunosuppression azathioprine, L-asparaginase
valproic acid
AIDS drugs - didanosine,
pentamidine
antibiotics - metronidazole,
tetracycline

what does migratory


thrombophlebitis and
atypical venous
thrombosis suggest
clinically and what is
the next diagnostic test

chronic DIC and malignancy next diagnostic test should be


pan CT scan

chronic pancreatitis
best diagnostic test

fecal elastase study*** diagnoses


the pancreatic exocrine
insufficiency
serum lipase and amylase may
not be reliable and only mildly
elevated

lactose intolerance
1. dx

1. H+ breath test, or lactose


tolerance test

gallstones
1. pigment stones
2. treatment for nonsurgical candidates

1. calcium bilirubinate - from


hemolysis (black) or chronic
biliary tract infection (brown)
2. ursodeoxycholic acid

hepatitis B
1. chronic treatment
2. post exposure
prophylaxis

1. interferon, lamivudine (reverse


transcriptase inhibitor)
2. HBIG and hepatitis B vaccine

diagnostic test for


recurrent pancreatitis
with no identifiable
cause

ERCP

hepatitis C
1. extrahepatic
manifestations

1. cryoglobulinemia (renal/GI),
b cell lymphoma, autoimmune
(sjogrens/thyroiditis), lichen
planus, ITP, porphyria cutanea
tarda

non alcoholic fatty liver


disease
1. patho
2. biopsy findings
3. top 3 risk factors
4. tx

1. obesity/type 2 dm --> insulin


resistance/inc lipolysis and fat
accumulation in hepatocytes -->
proinflammatory
cytokines/oxidative stress -->
inflammation, fibrosis, cirrhosis
2. macrovesicular fat deposition
in hepatocytes
(indistinguishable from alcohol)
3. obesity, diabetes mellitus,
hypertriglyceridemia
4. underlying conditions,
ursodeoxycholic acid

756.

757.

758.

759.

760.

761.

762.

763.

764.

765.

766.

In someone with a solitary liver


mass and no history of chronic
liver disease what is the first
diagnostic test that should be
performed

most likely mets


colonoscopy, CT
abdomen, AFP

hepatotoxic drugs
1. hepatitis causing drugs
2. cholestatic drugs

1. acetaminophen,
tetracycline,
isoniazid,
chlorpromazine,
halothane,
antiretroviral therapy,
2. chlorpromazine,
nitrofurantoin,
erythromycin
anabolic steroids,
colestipol

why is AST>ALT in alcoholics

they have deficiency


of pyridoxal 6
phosphate which is
ALT cofactor

alcohol hepatitis histologic


findings

ballooning of
cytoplasm, PMN
infiltration, fibrosis,
necrosis, mallory
hyaline

alpha 1 antitrypsin deficiency


histologic findings of liver/lungs

PAS positive
hepatocyte
granules***
Panacinar
emphysema

emphysematous changes of the


lower lobes

...

indications for TIPS

refractory cirrhotic
hydrothorax
refractory ascites
recurrent variceal
bleeding
patients waiting for
liver transplant and
needing portocaval
shunts

pancreatitis hypotension
pathogenesis

inflammatory effects
from pancreatic
enzyme release inc.
vascular permeability

also systemic hypotension occurs


from endothelial injury

...

acute hepatic failure vs


fulminant hepatic failure

fulminant includes
hepatic
encephalopathy

acute/fulminant both have liver


synthetic failure within 8 weeks
of injury onset

...

767.

768.

769.

770.

771.

772.

773.

774.

775.

776.

777.

what lab value will


indicate that ascites
is from portal
hypertension

non-bloody, SAAG>1.1

complications of
ERCP

pancreatitis, perforation, biliary


enteric fistula, biliary peritonitis,
sepsis, hemorrhage, contrast related
complications

hemolytic reactions\
1. diagnosis of ABO
mismatch
2. complications of
ABO mismatch
3. febrile transfusion
reaction

1. coombs test positive, plasma free


hemoglobin, pink plasma, plasma
hemoglobin >25, hemoglobinuria
2. DIC, ARF, shock
3. reactions to cytokines released by
leukocytes in storage

factors that increase


the probability of
progression of
hepatitis C

male sex
age of infection >40
longer duration of infection
coinfection with HIV
immunosuppression
liver comorbidities

hepatic adenoma
1. definition
2. associated
conditions
3. histological
findings

benign epithelial tumors found in


right lobe
assc. with anabolic steroids,
glycogen storage disease,
pregnancy, diabetes, OCPs
2. enlarged adenoma cells with
glycogen and lipids

focal nodular
hyperplasia

non-malignant tumor, hyperplastic


response to hyperperfusion
biopsy shows sinusoids and kupffer
cells

what primary
malignancies
metastsize to the
liver

GI, lung, breast, skin (melanoma)

when should ACE


inhibitors not be
used for renal
protection

proteinuria >300mg in a diabetic (it


is irreversible)

creatinine >3-3.5 ~
will worsen the renal
failure
-

...

initial hematuria
terminal hematuria
total hematuria

initial = urethral source


terminal = bladder or prostatic
cause
total = bladder or kidney cause

incontinence
1. what medications
associated with
overflow
incontinence

1. anticholinergics, antipsychotics,
TCAs, sedative hypnotics

778.

779.

780.

781.

782.

783.

784.

785.

786.

787.

initial tests for patient with


suspected BPH

DRE
urinalysis, serum
creatinine - to rule out
infection

what is important rule out for


patient with voiding systems
and negative prostatic culture

bladder cancer
do repeat prostatic
cultures and
cystoscopy

acyclovir renal side effect

crystalluria with renal


tubular obstruction
- avoid with good
hydration when using
IV acyclovir

renal vein thrombosis in


nephrotic syndrome
1. patho
2. clinical pres
3. most common nephrotic
syndrome associated with RVT

loss of antithrombin
3/S/C leads to
hypercoagulable state
in the renal vein
2. sudden onset
abdominal pain, fever,
hematuria
3. membranous
glomerulonephritis

fibromuscular dysplasia
1. dx

1. hypertension,
string of beads on
angiography
hum or bruit in the
costovertebral angle

progression of diabetic kidney


disease

inc. GFR
GBM thickening
mesangial expansion
nodular sclerosis

how to avoid urate nephropathy


in patients who will start
chemotherapy for lymphoma
and leukemia

allopurinol pretreatment

drugs that cause interstitial


nephritis

penicillins, PPIs,
NSAIDs

sulfonamides, rifampin,
phenytoin, allopurinol

...

medullary cystic kidney


1. clinical pres
2. dx/tx
3. acquired cystic kidney disease

1. recurrent UTI and


renal stones
2. contrast filled cysts
on IVP,
tx = same as normal
person with renal
stones
3. occurs in dialysis
patients

788.

789.

790.

791.

792.

793.

794.

795.

796.

cyclosporine
1. toxicity
2. mechanism
3. advantage/disadvantage of
tacrolimus

1. nephro, renal
vasoconstriction/HTN,
hyperkalemia,
neurotoxicity/tremor
gingival hypertrophy,
hirsutism*
infection, SCC, anorexia,
n/v, diarrhea
2. calcineurin inhibitor
(thus no transcription of
IL2 via NFKB)
3. no hirsutism or gum
hypertrophy - higher
incidence of neurotoxicity
diarrhea

797.

798.

799.

azathioprine
1. mechanism
2. SE

1. purine analog
metabolized to 6-MP
2. diarrhea, leukopenia,
hepatotoxic

800.

mycophenolate
1. mechanism
2. SE

1. reversible inosine
monophosphate
dehydrogenase inhibitor
~ rate limiting purine
synthesis step
2. bone marrow
suppression

801.

what drugs cause


hyperkalemia

ACE inhibitors, NSAIDs,


spironolactone, amiloride

serum osmolality
1. high >295

1. hyperglycemia,
radiocontrast, mannitol

SIADH lab diagnosis

serum osm <270,


Uosm>Sosm
UNa >20
Uosm >100-150

blind loop syndrome acid


base disturbace

excess production of Dlactate caues


hypochloremic met. acid

chloride sensitive vs resistant


met. alk

sensitive - Urine Cl <20


2/2 volume contraction diuretics/vomiting - urine

resistant - urine Cl>20 and


volume expansion - primary
hyperaldosteronism, bartter,
gitelman, black licorice
**wont respond to NS
infusion

...

802.

803.

804.

805.

806.

807.

808.

broad categories of
causes of metabolic
acidosis

ketoacidosis - alcoholic,
diabetic, starvation
intoxications - methanol,
formalin, salicylate, ethylene
glycol, INH, metformin
tissue hypoxia
renal failure

cause of hypocalcemia in
an alcoholic

chronic pancreatitis leads to


ADEK insufficiency and thus
inability to absorb calcium
from the gut

alcoholism electrolyte
imbalance

hypomagnesemia,
hypokalemia,
hypophosphatemia

what kind of acid base


disturbance seen in
normal pregnancy

progesterone stimulates the


DRG of medullary respiratory
center --> chronic resp.
alkalosis

aspirin toxicity
1. patho
2. clinical pres

1. stimulates respiratory center


(resp.Alk) and it is a acid so
also met. acid
2. fever, tinnitus, tachypnea

postictal acid base


disturbance

transient anion gap metabolic


acidosis that resolves without
treatment 60-90 minutes after
seizure activity

avascular necrosis of the


hip
1. causes
2. clinical pres
3. dx

1. corticosteroids, alcoholism,
hemoglobinopathies, lupus
(antiphospholipid)
2. progressive hip or groin
pain without restriction of
range of motion
3. MRI

what must be ruled out in


any patient with RA, fever
and a new inflamed red
joint

septic arthritis- these patients


are at a higher risk for septic
arthritis usually with staph
aureus

what is important test


before starting therapy
for lupus patient with
renal impariment

kidney biopsy to determine the


degree of impairment

most common cause of


isolated elevated ALP in
the elderly

PAGETS DISEASE OF BONE

viral arthritis
1. patho
2. dx
3. tx

1. post parvo, hepatitis, HIV,


mumps, rubella
2. positive ANA (weak),
rheumatoid factor positive
3. NSAIDs, will resolve with
time

what fraction of patients


with dermatomyositis
will develop cancer

10% - breast, lung, ovarian,


urogenital

809.

810.

811.

812.

813.

814.

what inflammatory
diseases associated with
aortic aneurysms

behcets, takayasu, giant cell


arteritis, ank spondy, RA,
psoriatic arthritis, reiters
arthritis

- unrelated - also marfan's,


ehlers danols, syphilis

...

what inflammatory
diseases associated with
renal failure

SLE, wegener's, PAN, churg


strauss, behcets

what inflammatory
diseases associated with
alveolar hemorrhage

goodpasture, wegener's,
PAN, churg strauss, behcets,
antiphospholipid syndrome

what inflammatory
diseases associated with
depositional disease and
carpal tunnel syndrome

RA, sarcoid, amyloidosis,


hypothyroidism (myxedema)

key characteristic of lupus


arthritis

it is NON-DEFORMING

key clinical feature of back


pain 2/2 metastasis

pain that is worse at NIGHT

lesch nyhan syndrome


1. patho
2. clinical pres

1. hypoxanthine guanine
phosphoribosyltransferase
deficiency --> elevated uric
acid
2. self mutilation, neurologic
disabilities in childhood

823.

824.

825.

826.

827.
815.

816.

817.

818.

819.

820.

821.

822.

vertebral compression
fractures
1. risk factors
2. clinical pres

1. demineralization/trauma
- osteomalacia,
osteoporosis,
2. intense focal pain, worse
when lying down

what is the cause of kidney


damage in lupus

immune complex deposition


and activation of
complement (-->low C3 in
the blood)

which organ is most likely


to be damaged when using
hydroxychloroquine for
lupus

RETINA

degenerative joint disease


Xray findings

narrowing of joint spaces,


subchondral cysts/sclerosis,
heberdens nodes, bouchers
nodes, osteophytes

what physical exam


findings suggests lumbar
disk herniation

straight leg raise

rheumatoid arthritis
increases risk of
osteopenia/osteoporosis

yes it does indeed

828.

829.

830.

what part of the


spine is most likely
effected by RA

cervical spine -- MUST EVALUATE


FOR SUBAXIAL SUBLUXATION
(ATLANTOAXIAL INSTABILITY)
PRIOR TO SURGERY

normal pressure
hydrocephalus
1. patho
2. clinical pres
3. tx

1. impaired CSF absorbtion leads to


ventricular dilatation
2. slow broad based shuffling gait,
urinary incontinence, memory loss
3. serial lumbar punctures, VP shunt
(if LPs are helpful)

metoclopramide
1. mechanism
2. side effects

1. dopamine ANTAGONIST - used to


treat nausea, vomiting, gastroparesis
2. dystonic reactions - tardive,
dystonia, parkinsonism, NMS, neck
stiffness

features of
cerebellar
disorders

ipsilateral - nystagmus, hypotonia,


dysarthria, incoordination,
dysdiadokinesia

best drug for


parkinson's
patients younger
than 70 years and
with minimal
bradykinesia

benztropine (anticholinergics)

familial
dysautonomia
(riley day)

ashkenazi jewish ancestry - gross


autonomic dysfunction, severe
orthostasis

pseudotumor
cerebri
1. risk factors
2. clinical pres
3. dx/tx

1. corticosteroids, OCPs, trauma


2. presence of inc. ICP features, no
focal signs except 6th nerve palsy,
elevated opening pressure, normal
CSF micro, only vent. enlargement on
imaging,
seen in young obese females,
headaches and memory impairment,
neck pain, n/v, double vision
3. CT/MRI to rule out space occupying
lesion, empty sella from downward
herniation of arachnocele, increased
opening pressure on LP, papilledemasee shrunken ventricles on MRI
4. acetazolamide***, lumbar
punctures, lumboperitoneal shunting
optic nerve sheath fenestration

anticholinergic
symptoms

ie. from benztropine or


trihexyphenidyl overdose
*red as a beet
dry as a bone,
hot as a hare
mad as a hatter
full as a flask
- flushing, anhidrosis, hyperthermia,
mydriasis, delirium, urinary retention,

831.

832.

833.

834.

835.

836.

837.

838.

839.

840.

side effects of
levodopa

nausea and vomiting because of GI


effect of dopamine
~ avoid with carbidopa

MAOI + what other


drugs precipitate
serotonin syndrome

TCAs or SSRIs

propranolol used to
specifically treat
which conditions

portal hypertension
essential tremor
hyperthyroidism (symptoms only)

aminoglycoside
toxicity

ototoxicity, nephrotoxicity

what electrolyte
abnormality
associated with
intracerebral
hemorrhage

SIADH --> hyponatremia

1. medial medullary
syndrome
2. lateral medullary
syndrome
(wallenberg)
2. lateral pontine
syndrome

1. occlusion of vertebral or a branch


- contralateral hemiparesis/sensory
loss, and tongue deviation to the side
of the lesion
2. ipsilateral horners, sensory loss
on face, palate/pharynx/vocal,
ataxia, contralateral body sensory
loss
2. contralateral hemiparesis/sensory
loss, ipsilateral CNV sensory loss,
ipsilateral limb ataxia

mid pontine
syndrome

1. ipsilateral limb ataxia,


contralateral eye deviation,
face/arm/leg paralysis

842.

843.

844.

845.

creutzfeldt jakob
disease
1. patho
2. clinical pres

1. prion disease
2. rapidly progressing dementia,
myoclonus, periodic high EEG
voltage showing sharp triphasic
pattern

1. picks disease
2. lewy body disease
3. multi infarct
dementia

1. frontotemporal dementiapersonality changes


(euphoria/disinhibition),
compulsive behaviors, hyperorality,
impaired memory
2. fluctuating cognitive impairment,
bizarre visual hallucinations***,
parkinsonism that is poorly
responsive to therapy
3. cognitive/motor dysfunction,
stepwise loss of function

carotid artery
stenosis
1. when to operate
2. medical therapy

841.

1. >60% regardless of symptoms,


2. aspirin for life

846.

847.

848.

849.

850.

what is the treatment for


patient who is suspected
intoxication and cannot give
good history

thiamine, supplemental
O2, naloxone, dextrose

absence seizures EEG


finding

3 hz spike and wave


tx = ethosuximide or
valproic acid

what patients are at a


higher risk for subdural
hemorrhage

elderly and alcoholics both have brain atrophy

waterhouse friderichsen
syndrome

bilateral hemorrhage of
adrenal glands 2/2 DIC
during neisseria meningitis
results in acute adrenal
insufficiency

antiarrythmics
1. procainamide + SE
2. synchronized DC
cardioversion
3. lidocaine + SE

1. antiarrhythmic used to
treat both supraventricular
and ventricular
arrhythmias
SE= drug induced lupus,
agranulocytosis, QT
prolongation
2. used to treat afib/aflutter
3. ventricular arrhythmias
in ACS patients,
****increases risk of
asystole
SE = confusion, seizures,
resp. depression

tetralogy of fallot

MCC cyanotic heart


disease,dyspnea, growth
retardation, clubbing,
polycythemia
Tet-spells - patient squats
to inc. SVR
CXR shows boot shaped
heart

stab wounds and arterial


catheterization is
associated with what site
complication

AV fistulas leading to high


output heart failure

av fistula clinical pres

widened pulse pressure,


strong peripheral arterial
pulsations

situational syncope
(autonomic dysreg syncope)

LOC immediatly after


urination or other activity

how to distinguish septic


shock vs
hypovolemic/neurogenic
shock

septic shock has high


MVO2 from hyperdynamic
circulation and improper
distribution of CO

851.

852.

853.

854.

855.

856.

857.

858.

859.

860.

hypovolemic and
neurogenic
shock have dec.
MVO2 from inc.
oxygen
extraction

...

how do OCPs
cause
hypertension

inc. angiotensinogen by the liver in 5%


of users

amyloidosis
1. causes
2. clinical pres

1. MM (AL), RA, IVDU other chronic


inflammatory conditions
2. restrictive cardiomyopathy, easy
bruisability (liver involvement), renal
impairment/nephrotic range
proteinuria, hepatomegaly,
cardiomyopathy, pseudohypertrophy,
peripheral neuropathy

in what specific
situation is beta
blocker
contraindicated
in MI

pulmonary edema

endocarditis
1. clinical pres
2. complications

1. non-specific symptoms - fever,


malaise,
2. mycotic aneurysm, abdominal
abscesses*, septic PE, renal abscess,
conjunctival hemorrhage, janeway
lesions, (erythematous macules) oslers
nodes (nodules on fingers/toes),

why is
nifedipine
contraindicated
STEMI

causes vasodilatation and reflex


tachycardia

- diltiazem and
verapamil dont
help either

...

amiodarone side
effects

pulmonary (cumulative) fibrosis,


elevated LFTs, corneal deposits, blue
gray skin discoloration,
hypothyroidism*

slows SA/AV
node conduction
thus can cause
bradycardia

...

cocaine
mediated
cardiac
ischemia
1. tx
2. why are pure
beta blockers
contraindicated

1. benzos*, nitrates, aspirin


2. they lead to unopposed cocaine
mediated alpha vasoconstriction'
*choose a CCB insted to control
vasospasm

861.

862.

863.

864.

865.

866.

867.

868.

869.

what is the cause of


inc. orthostatic
hypotension with
increased age
+ what other changes
to the heart with age

progressively decreasing
baroreceptor sensitivity *

worsening diastolic
function, dec.
resting/maximal CO.
dec. # of myocytes

...

how does the kidney


adapt to respiratory
alkalosis

excreting bicarbonate in the urine

what are poor


prognostic
indicators during an
asthma attack

NORMAL PaCO2 - because it


should be low 2/2 hyperventilation

others - speech
difficulty,
diaphoresis, altered
sensorium, cyanosis,
silent lungs

...

what decreases
mortality in COPD

home oxygen
smoking cessation

indication for NIPPV

respiratory distress
pH <7.35, PaCO2>45, RR>25/min

complete
opacification of a
SINGLE lung with
shifted mediastinum

indicates a collapsed lung, should


look for bronchial lesion with
bronchoscopy -- causes include
mucus plugging, tumor, foreign
body

reyes syndrome
1. patho
2. tx

hepatic encephalopathy in children


associated with viral infections and
salicylates
- mitochondrial injury --> extensive
fatty vacuolization of the liver
without inflammation
2. glucose, FFP, mannitol (for
cerebral edema)

870.

871.

872.

873.

874.

875.

876.

877.

878.

879.

880.

881.

legionella
pneumonia
1. clinical pres
2. treatment
3. dx

hypoventilation
syndrome

1. refractory to beta lactam (also


mycoplasma), HYPONATREMIA
CONFUSION, ABDOMINAL PAIN,
DIARRHEA acute onset fever, malaise,
headache, non-productive cough,
dyspnea,
2. erythromycin or azithromycin
3. HYPONATREMIA, organism negative
smear (only polymorphs)
consequence of severe obesity and
untreated OSA, chronic
hypercapnia/hypoxic resp. failure,
secondary erythrocytosis, low serum Cl,
hypertension, cor pulmonale

882.

883.

884.

885.

aspirin
sensitivity
syndrome

pseudo allergic reaction - 2/2 aspirin


induced prostaglandin/leukotriene
imbalance
* tx = leukotriene receptor antagonist

886.

what
conditions will
increase fecal
fat

bacterial overgrowth, pancreatic


insufficiency, celiac disease, crohns
disease

887.

D-xylose test

simple sugar that does not need to be


digested to be absorbed tests for INTACT
MUCOSA OF PROXIMAL SMALL
BOWEL ONLY ONLY
- THUS if pancreatic insufficiency is
present D-xylose absorption/excretion
will not be effected

888.

acid fast
oocysts

cryptosporidium parvum - chronic


diarrhea in HIV patients with CD4<180

also may be
isospora

...

when to order
EGD for
patients with
GERD

n/v
weight loss, anemia, melena/blood
long duration of symptoms >1-2 years
failure to respond to PPI

^ALARM
SYMPTOMS

...

GI bacterial
overgrowth
nutrient
defiencies

Vitamin D
Vitamin A - night blindness
B12 - neuropathy

what vitamin
deficiency in
carcinoid
syndrome

niacin - used to synth seratonin/5HIAA


metabolites

which type of
polyps are most
likely to
progress to
malignancy

villous adenoma, sessile adeoma, size


>2.5cm

889.

890.

891.

892.

893.

what GI pathology
is often associated
with elevated BUN

upper GI bleeding

two situations
where you can see
elevated BUN
without elevated Cr

upper GI bleeding
steroids

1. vitamin E
deficiency clinical
pres
2. Vitamin C """

1. RBC fragility, hyporeflexia, muscle


weakness, blindness
2. perifollicular hemorrhage, swollen
gums, poor wound healing

most common
complication in UC

colon cancer (1% per year)

gallstone risk
factors

caucasian race, obesity, female, OCP,


DM, hypomotility of gallbladder
(preg), ileal disease, clofibrate,
octreotide, ceftriaxone

pancreatic
pseudocyst
treatment

<5cm observe for 6 weeks if


persistent then drain
*no ABX necessary
>5cm - drain

liver histo findings


1. balloon
degeneration with
inflamm cells
2. panlobular
mononuclear
inflammation
3. piecemeal
necrosis

1. acute alcoholic hepatitis


2. acute viral hepatitis, bridging
necrosis (confluent hepatic necrosis
between adjacent lobules)
3. inflammatory cells extend between
portal ducts with periportal bridging
fibrosis

how to evaluate
liver damage in
acute vs chronic
hepatitis

acute - LFTs
chronic - liver biopsy

causes of liver
biliary ductopenia

PBC, transplant rejection, hodgkins


disease, GVHD, sarcoid, CMV/HIV

entamoeba
histolytica
1. patho
2. clinical pres
3. dx/tx

1. contaminated water in endemic


region (south america)
2. bloody diarrhea, RUQ pain
3. THIN WALLED CYST IN RIGHT
LOBE OF LIVER, sterile aspirate,
stool exam shows trophozoites
tx = metronidazole -- DO NOT
DRAIN (compare to echinococcus)

What should all


cirrhotic patients
be screened for

esophageal varices
HCC - (AFP)

what is the risk


associated with
porcelain
gallbladder

2/2 chronic cholecystitis

894.

895.

896.
897.

risk is cancer of the


gallbladder

...

906.

when to give hep A Ig vs


hep A vaccine

give immunoglobulin if travel will


occur in less than 4 weeks

907.

otherwise give vaccine

...

uric acid stones


1. dx
2. tx

1. radiolucent stones on KUB,


acid urine pH <5,
2. hydration, sodium bicarb or
sodium citrate dissolves the
stones

varicoceles that fail to


empty in the
recumbent position

RCC
diagnose with CTA

what should be first


diagnostic test for
patient with BPH
symptoms and elevated
Creatinine

kidney, ureter, bladder ultrasound

900.

amikacin

aminoglycoside

901.

causes of priapism

sickle cell/leukemia, trauma,


spinal cord/cauda equina,
trazodone/prazosin

erythropoietin side
effects

worsening hypertension (30%),


flu like symptoms

1. hypertensive
nephropathy
histological
progression

1. dec. in blood flow,


Nephrosclerosis - hypertrophy
and intimal medial fibrosis of
afferent and efferent arteries
Glomerulosclerosis - progressive
loss of glomerular capillary
surface area with
glomerular/peritubular fibrosis
2. glomerular
hyperperfusion/renal
hypertrophy and INC. GFR
GBM thickening, glomerular
hypertrophy mesangial
expansion, GFR NORMAL
microalbuminuria and
progressive glomerular
sclerosis/fibrosis (kimmelstiel
wilson)

898.

899.

what kind of urine sediment


seen in chronic kidney
disease

broad casts, waxy casts

urine sediments
1. muddy brown casts
2. RBC casts
3. WBC casts
4. Fatty casts
5. Broad and waxy casts

1. ATN
2.glomerulonephritis
3. interstitial
nephritis/pyelo
4. nephrotic syndrome
5. CRF

why not to do a prostatic


massage and culture of
prostatic secretions for
suspected prostatitis

risk of urosepsis
just get a midstream urine
sample/culture and treat
empirically pending
culture results

best test for osteomyelitis

MRI of spine

causes of restrictive lung


disease

ILD, neuromuscular
disease, alveolar edema,
pleural fibrosis, chest wall
abnormalities

how does alcohol precipitate


gout

ethanol metabolized to
lactate which competes
with urate for renal
excretion

912.

serum sickness like reaction

1-2 weeks after a drug


fever, urticarial rash,
polyarthralgia,
lymphadenopathy

913.

methotrexate side effects

dihydrofolate reductase
inhibitor
macrocytic anemia*
nausea, stomatitis, rash,
hepatotoxicity, ILD,
alopecia, fever

914.

cyclosporine side effects

viral
infections/lymphoma,
nephrotoxicity

915.

azathioprine side effects

pancreatitis, and dose


dependent bone marrow
suppression

what drugs associated with


raynauds phenomenon

beta blockers and


ergotamine

how to diagnose rotator cuff


tendinitis

neer test positive (passive


motion above head)
injection of lidocaine
improves range of
motion/pain relief

adhesive capsulitis

aka frozen shoulder


pain/contracture due to
fibrosis of the shoulder
capsule
lidocaine injection does
not help pain

908.

909.
910.

911.

902.

903.

904.

905.

causes of kidney
transplant rejection +
tx

acute rejection, cyclosporine


toxicity, vascular obstruction,
ATN
tx = IV steroids

1. risk
most common cause of
death in dialysis
patients

cardiovascular disease
hyperphosphatemia, inc. PTH,
inc. homocysteine, accelerated
atherogenesis 2/2
uremia/dialysate oxidative stress,
inc. calcium intake

916.

917.

918.

919.

920.

921.

922.

923.

924.

925.

926.

927.

lateral epicondylitis

2/2 forceful wrist extension


degenerates extensor carpi
radialis brevis tendon (aka tennis
elbow), pain near lateral
epicondyle worse with use,
supination, extension

anserine bursitis
1, clinical pres

1. nighttime pain from knees


hitting each other, pain over the
medial tibial plateau below the
joint line- valgus stress does not
exaggerate pain (compare to MCL
tear)

prepatellar bursitis

pain directly above the patella


wtih cystic swelling

pagets disease of bone


1. patho

1. inc. bone turnover due to


osteoclast dysfunction and
increased bone breakdown with
compensatory deposition

hypervitamin D
causes

granulomatous disease - sarcoid,


TB

tick borne paralysis


1. clinical pres
2. tx

1. rapidly ascending paralyisis


over hours to days (vs GBS), CSF is
normal
2. remove the tick

progressive multifocal
leukoencephalopathy
1. patho

1. JC polyomavirus reactivation in
immunocompromised patients.
causes destruction of white matter
2. hemiparesis, disturbance in
speech, vision, gait

causes of enhancing
lesions in the brain of
immunocompromised
patients

1. anterior vs
posterior circulation
of the brain

toxoplasmosis (strongly
enhancing) - MCC - avoid with
bactrim prophylaxis
primary CNS lymphoma (weakly
enhancing) - check for EBV DNA
in CSF

928.

929.

930.

931.

932.

1. ant= internal carotid supplies


ant/mid cerebral arteries
pos = paired vertebral arteries
supplies basilar and paired
posterior cerebral arteries
933.

934.

935.

936.

2. ACA stroke clinical


pres
3. MCA """"
4. PCA """"
5. lacunar infarcts

2. contralateral motor/sensory
deficits more pronounced in the
lower limbs, urinary
incontinence, primitive reflexes
3. contralateral motor/sensory
deficits more pronounced in the
upper limbs and homonymous
hemianopsia
4. homonymous hemianopsia,
alexia without agraphia,
sensory symptoms, third nerve
palsy with vertical gaze, motor
deficits (cerebral peduncle and
midbrain)
5. pure motor, pure sensory,
dysarthria clumsy hand, ataxic
hemiparesis- most common
location is the putamen (very
close to internal capsule)

glioblastoma multiforme
1. clinical pres

1. n/v, headaches worse with


position changes, coughing,
sneezing
2. butterfly appearance with
central necrosis and
serpiginous contrast
enhancement

stroke
primary/secondary
prevention

aspirin and statin

sumatriptan/ergotamine
contraindications

pregnancy, familial hemiplegic


migraine, uncontrolled
hypertension, CAD***,
prinzmetal, ischemic stroke,
basilar migraine

restless leg syndrome


1. clinical pres
2. risk factors
3. tx

1. uncomfortable sensation to
move legs, worse during sleep,
alleviated by movement
2. iron deficiency, elderly, CKD
3. dopamine agonists*pramipexole, ropinerole,
levodopa

lewy body disease vs


parkinsons disease

both involve alpha synuclein


inclusions

lewy body has early onset


dementia

...

parkinsons has early


onset motor

...

most common sites of


migration of
cardioembolic stroke

lateral striate arteries - supply


the internal capsule, caudate,
putamen, globus pallidus
- high risk of hemorrhagic
conversion

937.

938.

939.

940.

941.

942.

943.

944.

945.

946.

947.

948.

atherothrombotic
strokes

occur at rest, gradual onset,


successive strokes with
increasing frequency

upper thoracic spinal


cord lesion clinical pres

paraplegia, bowel/bladder
incontinence, anesthesia from
the nipples down

what is best
measurement of
respiratory function in
GBS

FVC

atrial fibrillation
treatment
1. lone afib
2. afib + risk factors

1. aspirin alone
2. warfarin

what conditions in ACS


are nitrates
contraindicated

**right ventricular
infarction/inferior wall
MI**DO NOT WANT TO DEC.
PRELOAD TREAT WITH IV
FLUIDS
aortic stenosis, recent
phosphodiesterase use,

950.

951.

952.

what is the next step for


someone with
hypotension does not
respond to fluid
hemodynamics

dobutamine and dopamine to


inc. CO

what patients have a very


high incidence of latex
allergy

spina bifida

five p's of acute arterial


limb ischemia

pain, pulselessness, pallor,


paresthesias, paralysis

how to treat a new


diagnosis of rheumatic
heart disease

antibiotic prophylaxis with


penicillin first, then
anticoagulate

chagas disease
1. patho
2. clinical pres

1. t.cruzi protozoa
2.megacolon, megaesophagus,
dilated cardiomyopathy

antiarrhythmics
1. quinidine + SE
2. digoxin + SE

1. atrial arrhythmias
SE= tinnitus, QT, hemolytic
anemia, thrombocytopenia
2. inotrope and treats atrial
arrhythmias, especially in the
context of systolic dysfunction
SE= nausea, anorexia, AV
block,
ventricular/supraventricular
arrythmias

what electrolytes
abnormalities
associated with loop
diuretics

949.

953.

954.

955.

956.

hypokalemia,
hypomagnesemia, and
potentiate digoxin toxicity

957.

958.

959.

960.

961.

most common cause


of death in patients
with acute MI

complex ventricular arrhythmias from a ventricular reentrant


arrhythmias around the area of
infarction ex. v.fib

treatment of
congenital long QT
syndrome

beta blockers

what electrolyte
abnormality indicates
the severity of heart
failure

serum sodium level


(hyponatremia) - when low it is
associated with overactive
neurohumoral axis- high renin,
aldosterone, vasopressin,
norepinephrine

why are CCBs and


vasodilators not
indicated in aortic
dissection

the cause peripheral


vasodilatation, reflex tachycardia
increasing sheer stress
***beta blockers are treatment of
choice

in what medical
context is FeNA
useless to determine
volume status

if patient is on diuretics

pneumoconiosis PFTs

restrictive pattern with reduced


DLCO

acute massive PE
echo/EKG findings

hemodynamic instability
echo - RV dilatation
ekg - RV strain/ right axis
deviation

this is an indication
for thrombolytics

...

what is suggested by
new clubbing in a
COPD patient

occult malignancy - probably


hypertrophic osteoarthropathy

how does PND differ


in a patient with
chronic bronchitis vs
LV failure

chronic bronchitis - cough occurs


at the same time every night from
mucus buildup
LV failure - occurs whenever the
patient lays down

what is key
distinguishing feature
between asthma and
COPD on PFTs (both
have dec. FEV1:FVC)

asthma shows inc. FEV1 with


bronchodilator

COPD shows no
change in FEV1 with
bronchodilator

...

what is key feature


distinguishing chest
wall vs ILD (both have
normal FEV1:FVC)

ILD will have decreased DLCO


chest wall will have normal DLCO

962.

963.

964.

965.

966.

967.

968.

969.

970.

971.

972.

what cancers have


higher than normal
incidence in asbestos
exposure

bronchogenic carcinoma,
mesothelioma

what is target PaO2


when patient is on
ventilator

>60 ~ adjust with FiO2 before


PEEP

blastomycosis clinical
pres and treatment

recent travel to great lakes,


mississippi river and ohio river
basins
skin, bone and pulmonary
symptoms
itraconazole or amphotericin B

what is best treatment


for a cough caused by
post nasal drip

fluticasone nasal spray and H1


blockers

how to follow low


probability for
malignancy
pulmonary nodules

serial CT scans

CHF exacerbation
blood gas findings

hypoxemia from effusions


hypocapnia and resp. alk from
tachypnea

pickwickian
syndrome (obesity
hypoventilation
syndrome)
1. clinical pres
2. ABG findings

1. extreme obesity, thick neck,


hypersomnolence, distant heart
sounds, low voltage EKG, poor
CXR
2. hypercapnia, hypoxemia,
alveolar hypoventilation during
wakefulness -- due to increasing
of CNS chemoreceptor set-point
for CO2

973.

974.

975.

976.

ABG findings for


different types of
hypoxemia
1. hypoventilation
2. low inspired oxygen
content
3. shunting
4. VQ mismatch

1. PaCO2 elevated, normal A-a


2. normal PaCO2, normal A-a
gradient
3. normal PaCO2 and elevated A-a
gradient that DOES NOT
CORRECT WITH 100% OXYGEN
4. normal PaCO2 and elevated A-a
gradient that DOES CORRECT
WITH 100% OXYGEN

if patient is overly
ventilated on a
mechanical ventilator
what should be
adjusted first

adjust the RR first, not the TV


because decreasing TV can trigger
increased ventilatory rate

what is the effect of


glucocorticoids on the
CBC

see neutrophilia 2/ mobilizing the


marginated neutrophil pool, and
bone marrow release

list the causes of


repeated nocturnal
awakenings

asthma, GERD, CHF, OSA

977.

978.

979.

980.

981.

982.

causes of TIA

blood vessels - atherosclerosis,


inflammation, dissection
embolism disease
vasculitis, dissection,
hypercoagulable states

what pathologic
processes is
responsible for
diabetic
mononueropathies

nerve ischemia

cerebellar
lesions/tumors
clinical pres

ipsilateral ataxia, nystagmus,


intention tremors, loss of
coordination, broad based gait,
dysmetria, dec. rapid alternating
movements, nystagmus

HSV encephalitis
1. patho
2. dx

1. HSV virus causes destruction of the


temporal lobes
2. CSF - lymphocytic pleocytosis,
ERYTHROCYTOSIS, elevated protein
levels, normal glucose
MRI- shows temporal lobe
abnormalities
EEG = slow intermittent high
amplitude waves

TB and fungal
meningitis

markedly elevated proteins


low glucose
lymphocytic pleocytosis

most common
organisms in brain
abscesses

aerobic and anaerobic


streptococci/bacteroides

what is most
important risk
factor for stroke

hypertension
CHADS2 - CHF, hypertension,
age>75, diabetes, previous stroke

stroke clinical pres


1.posterior limb of
IC
2. MCA
3. ACA
4. vertebrobasilar
system

1. motor impairment without cortical


or visual abnormalities
2. contralateral hemiplegia,
hemianopia, aphasia OR hemineglect
3. contralateral weakness of lower
extremity, abulia, akinetic mutism,
emotional disturbances, eyes deviate
toward lesion, sphincter incontinence
4. many different brainstem
syndromes with contralateral
hemiplegia and ipsilateral cranial
nerve involvement

what is the major


cause of mortality
in SAH

vasospasm with symptomatic


ischemia and infarction - usually
occurs about 7 days after SAH

complications of
heat stroke

seizures, ARDS, DIC, hepatic/renal


failure

983.

984.

985.

986.

987.

988.

989.

990.

991.

992.

993.

994.

pathogenesis of end organ


damage in malignant
hypertension

fibrinoid necrosis of small


arterioles

three uses for nacetylcystine

prevents contrast induced


nephropathy
mucolytic (CF)
acetaminophen overdose

niacin flushing
mechanism + how to avoid

non-hypersensitivity
histamine/prostaglandin
release

take with a low dose


aspirin 30 minutes before
taking the niacin

...

which antihypertensive
should be avoided in
asthmatics

beta blockers

why does renal perfusion


decrease in CHF

activation of the RAAS


system causes
afferent/efferent
vasoconstriction and
enhanced sodium
reabsorption to increase total
body volume

what needs to be ruled out


before a diagnosis of
SIADH can be made

hypothyroidism, adrenal
insufficiency

hypertension/hypokalemia
possible casues

primary hyperaldo
renovascular HTN
renin tumor
SAME
CAH
glucocorticoid suppressible
hyperaldosteronism

which hypoglycemics lead


to weight gain

insulin, TZDs, sulfonylureas


metformin causes weight
loss!

metabolic syndrome
(uworld)

abdominal obesity (>40 M,


>35F)
fasting glucose >100-110
BP>130/80
TG>150
HDL (<40M, <50W)

most common causes of


thyrotoxicosis with dec.
radioiodine uptake

***#1 subacute lymphocytic


thyroiditis
also- subacute
granulomatous (dequervain's
pain), levothyroxine
overdose, iodine induced
thyrotoxicosis

causes of primary adrenal


insufficiency

TB, fungal, CMV

995.

996.

997.

998.

999.

1000.

1001.

1002.

1003.

which antihyperthyroid
treatment can actually cause
atrial fibrillation

radioactive iodine because it destroys


follicular cells which
transiently elevates serum
thyroid hormone levels

in a patient which has


rapidly progressing
symptoms of androgen
excess how to differentiate
ovarian vs adrenal source

elevated testosterone ovarian source


DHEAS - adrenal source

effect of hyperthyroidism '


1. bones
2. heart
3. eyes

1. rapid bone loss because


thyroid hormones
stimulate osteoclastic
resorption
2. hyperdynamic
circulation - tachycardia,
systolic hypertension,
inc. pulse pressure, atrial
fibrillation
3. infiltrative
ophthalmopathy with
accumulation of
glycosaminoglycans in
retro orbital muscles

vitamin D toxicity clinical


pres

inc. calcium absorption hypercalcemia


constipation, abdominal
pain, polyuria, polydipsia

most common thyroid


malignancy

papillary carcinoma

trichinella spiralis clinical


pres

initial invasion into


intestinal wall - n/v,
diarrhea, abdominal pain
systemic hypersensitivity
- splinter hemorrhages,
periorbital edema*,
retinal hemorrhage,
chemosis
muscle aches/pains*
from larvae entering
skeletal muscle

most common cause of


osteomyelitis in sickle cell
disease patients

GBS, ecoli

what kind of prophylaxis


appropriate for transplant
recipients

oral TMPSMX - PCP,


toxo, nocardiosis
oral valganciclovir - CMV
vaccinate against
influenza, pneumo, hep B

infectious causes of bloody


diarrhea

EHEC, shigella,
salmonella,
campylobacter

1004.

1005.

1006.

1007.

1008.

1009.

side effect associated


with ceftriaxone

biliary sludging

anti-pseudomonals

cefepime
piperacillin-tazobactam
ciprofloxacin
aztreonam
imipenam/cilastatin
tobramycin
gentamicin
amikacin

coronary artery
disease equivalents

symptomatic carotid disease


PVD
AAA
DM
framingham >20%

infectious screening
after patient is
diagnosed with HIV

hep A/B, PPD, toxo serology,


VDRL

empiric treatment for


pneumonia in CF
patient

piperacillin and tobramycin


(antipseudomonal penicillin and
aminoglycoside/fluoroquinolone)

why should
fluoroquinolones not
be used in children

causes cartilage destruction and


growth retardation

management of
suspected
esophagitis in an HIV
patient

start empiric fluconazole 3-5 days


if no response do esophagoscopy
with biopsy

pulmonary cavitary
lesion in an HIV
patient possible
causes

mycobacterium TB
atypical mycobacterium
Nocardia - gram + weakly acid
fast branching rods- tx = bactrim
gram negative rods
anaerobes

1016.

1017.

1018.

1019.

1020.
1010.

1011.

1012.

1013.

1014.

1015.

human bite/dog bite


antibiotic treatment

amoxicillin clavulanate

treatment of
histoplasmosis in an
HIV patient

amphotericin B followed by
lifelong treatment with
itraconazole

what kind of
pneumonia post
influenza

staphylococcus aureus pneumonia

actinomycosis
dx/treatment

high dose IV penicillin 6-12 weeks


dx = anaerobic gram positive
branching bacteria with yellow
sulfur granules

1021.

1022.

1023.

1024.

1025.

bacillary
angiomatosis

bartonella henselae in
immunosuppressed patients
large pedunculated exophytic
papule with collarette of scale
looks like large cherry angioma
****careful before biopsy because
these lesions hemorrhage
tx = azithromycin**

treatment for
enterobius

albendazole, mebendazole, or
pyrantel pamoate

babesiosis
1. clinical pres
2. dx
3. tx

1. NO RASH - jaundice,
hemoglobinuria, renal failure,
death
2. giemsa thick/thin blood
smears, intravascular hemolysis,
anemia, thrombocytopenia,
atypical leukocytes (maltese
cross)
3. quinine-clindamycin,
atovaquone-azithromycin

treatment for bone


pain/hypercalcemia
due to osseous
metastasis or PTHrp

orchiectomy androgen ablation


acute pain - radiation therapy for
new mets
zoledronic acid - bisphosphonate

lead poisoning
1. clinical pres
2. tx

1. non-specific complaints,
peripheral neuropathy, microcytic
anemia, renal damage/interstitial
nephritis
2. succimer, or EDTA chelators

why should folate not


be replaced alone
without checking B12

replacing folate in the context of


B12 deficiency can cause
peripheral neuropathy

1. acute monocytic
special diagnostic test
2. acute
lymphoblastic
leukemia diagnostic
test

1. alpha naphthyl esterase


positive, peroxidase negative (no
auer rods)
2. PAS positive, TdT positive
(specific for immature T/B)

metastatic brain
tumors
1. location
2. treatment

1. grey white junction


2. surgical resection + whole
brain radiotherapy

what conditions
should leukocyte
alkaline phos be used
to confirm a
diagnosis

leukemoid reaction - high


Polycythemia vera - high
CML - low

hyposthenuria

inability to concentrate urine from


sickling in the vasa recta
impairing countercurrent
exchange and free water
reabsorbtion

1026.

1027.

1028.

1029.

1030.

what drugs cause


folate deficinecy

phenytoin, primidone, phenobarbital,


trimethoprim (inhibits DHFR), MTX

why must
warfarin always be
bridged

temporary increase in risk of DVT,


venous limb gangrene or skin
necrosis
due to loss of protein S/C (HL only 9
hours vs 60 hours for other factors)
leading to temporary hypercoagulable
state

what tumors never


metastasize to the
brain

non-melanoma skin cancer


oropharyngeal cancer
esophageal cancer
prostate cancer

graft vs host
disease
1. patho
2. organs effected

1. donor T cells recognise host


minor/major HLA antigens
2. skin, intestine, liver

mycobacterium
leprae
1. clinical pres

1. hypopigmented patches with areas


of anesthesia

contact dermatitis
1. what kind of
reaction

1. type 4 hypersensitivity
urushiol, nickel, formaldehyde,
certain fragrances, preservatives,
rubber, chemicals
2. calamine lotion, topical
antihistamines, topical
corticosteroids, oral steroids

1037.

1038.

1039.

1040.
1031.

1032.

1033.

1034.

1035.

1036.

prophyria cutanea
tarda
1. patho

1. uroporphyrinogen decarboxylase
deficiency in heme synth path
triggers - ethanol/estrogens
2. painless blisters,, skin fragility,
facial
hypertrichosis/hyperpigmentation
3. elevated urinary porphyrin
tx = phlebotomy,
hydroxychloroquine, interferon alpha

treatment for
seborrheic
dermatitis

moisturizers, topical antifungals,


anti-dandruff shampoos, topical
steroids

ichthyosis

gradual scaling of dry skin


progressing to horny plates over the
extensor surfaces worsens during the
winter

1. cherry
hemangiomas
2. strawberry
hemangioma

1 .appear in 3rd or 4th decade, do not


regress spontaneously
2. grow rapidly and regress by 5-8
years of age

what skin
conditions
associated with
parkinsons
disease

seborrheic dermatitis

1041.

1042.

1043.

1044.

1045.

1046.

1047.

1. chalazion
2. hordeolum
3. stye

1. sterile granulomatous inflammatory


lesion of meibomian glands
2. purulent infection of an eyelid
gland (staph)
3. external hordeolum involving zeis
or molls glands

immune
deficiency
associations
1. C3 deficiency
2. C5-C8
deficiency
3. C1 inhibitor
deficiency
4. phagocytosis
5. C1q deficiency

1. recurrent pyogenic infections


2. neisseria infections
3. hereditary angioedema (unopposed
C2b and bradykinin production).. not
infection...
4. bacterial infections
5. systemic lupus erythematosus

scarlet fever
1. patho
2. clinical pres

1. streptococcus pyogenes infection


2. higher fever, sandpaper rash,
exudative pharyngitis, rash
desquamates

eczema
herpeticum

HSV infection associated with atopic


dermatitis
life threatening
start acyclovir

felon

needle injury (ie. tailors) causes


bacterial infection of distal volar
space --> tense abscess, intermittent
throbbing pain

what patients at
high risk for
herpetic whitlow

those who are in contact with


orotracheal secretions - ex. dentists

rubella
1. clinical pres

1. fever/malaise, suboccipital adenitis


polyarthralgia, maculopapular face
rash that spreads to involve trunk and
extremities

dermatitis
herpetiformis
treatment

dapsone - both therapeutic and


diagnostic

vancomycin side
effects

nephrotoxicity, ototoxicity, red man


syndrome

delirium tremens

48-96 hours after last drink


hypertension, hyperthermia,
agitation, hallucinations (tactile),
death
tx= benzodiazepines

how does bicarb


treat aspirin
overdose vs TCA
overdaose

aspirin - alkalinizes the urine and


enhances excretion
TCA - narrows the QRS complex by
alleviating the cardio-depressant
action on sodium channels

1048.

1049.

1050.

1051.

1052.

1053.

1054.

treatment of
neuroleptic
malignant
syndrome

dantrolene
bromocriptine (dopamine agonist)
amantadine (antiviral with
dopamine agonist properties)

what is the most


reliable indicator of
opioid intoxication

bradypnea
- not miosis becuase there are often
coingestions

iron toxicity clinical


presentation

5 phases
1. GI phase - first 6 hours - nausea,
vomiting, hematemesis, melena,
abdominal plain
latent phase - 24 hours asymptomatic
metabolic acidosis/shock - 72 hours
hepatotoxicity - 96 hours
mucosal scarring and bowel
obstruction weeks to months post
ingestion

TCA overdose
clinical
presentation

anticholinergic - dilated pupils,


flushed dry skin, ileus
EKG- dec. myocardial conduction
velocity and widening of QRS- tx =
bicarb

torsade de pointes
1.risk factors
2. tx

1. malnourished, familial long QT,


hypomagnesemia, TCA,
amiodarone, sotalol,
fluoroquinolones, fluconazole
2. magnesium sulfate

1. methanol
overdose clinical
pres
2. ethylene glycol
clinical pres
3. aspirin overdose
clinical pres
4. lithium ""

1. anion gap metabolic acidosis,


disc hyperemia, n/v, abdominal
pain
2. similar to methanol except it
damages the kidneys
3. anion gap met. acid, tinnitus,
fever, hyperventilation (resp alk.)
4. hyperreflexia, ataxia, seizures

how to differentiate
alcohol from
benzodiazepene
intoxication

benzodiazepine intoxication does


not have nystagmus

poisoning
treatments
1. aspirin/TCA
overdose
2. torsades 2/2
prolonged QT
3. lithium
4. lead poisoning
5. acetaminophen
6. iron
7. ethylene glycol
8. organophosphate
9.
diphenhydramine

1. sodium bicarb
2. mgSO4
3. hemodialysis
4. succimer, calcium EDTA
5. N-acetylcysteine
6. deferoxamine
7. ethanol, fomepizole (ADH
inhibitor), sodium bicarbonate,
hemodialysis
8. atropine, pralidoxime
9. physostigmine

1056.

1057.

1058.

1059.

1060.

1061.

1062.

1063.

1064.

1065.

1066.
1055.

1067.

1068.

1069.

ethylene glycol
poisoning
1. patho

1. ethylene glycol metabolized by


ADH to oxalic acid*** (binds
calcium causing
hypocalcemia/calcium oxalate
crystals) and glycolic acid (damages
renal tubules)

phencyclidine
intoxication
treatment

haloperidol and calm setting, urine


acidification

beta blocker toxicity


clinical pres/
treatment

bradycardia, AV block,
hypotension, diffuse wheezing***
tx = atropine, IV fluids, calcium,
glucagon** (inc. cAMP and inc.
Calcium levels --> improved cardiac
contractility)

digoxin toxicity
clinical pres

blurred vision, disturbed color


perception, fatigue, headache,
abdominal pain

acetaminophen
toxicity
1. treatment

1. activated charcoal within 4 hours


rumack-matthew nomogram measure at 4 hours and decided
whether or not to give Nacetylcysteine

carbon monoxide
poisoning diagnosis

carboxyhemoglobin levels
tx = hyperbaric oxygen

cyanide poisoning
1. patho

1. burning rubber or plastic


2. headaches, n/v abdominal
discomfort, confusion, coma,
BITTER ALMOND BREATH

methemoglobinemia
1. clinical pres

1. cyanosis, blue discoloration of


the skin/mucus membranes

organophosphate
poisoning
1. clinical pres
2. tx

cholinergic excess - bradycardia,


miosis, fasciculations, salivation,
lacrimation, urination, defecation
2. tx = atropine, pralidoxime

when to screen for


ovarian cancer

patients who are at higher than


average risk - screen with CA125
and transvaginal ultrasound

what kind of
immune response
from pneumococcal
vaccine

T cell independent B cell response


because it is a polysaccharide
vaccine

what CD4 count


needed to give a live
vaccine

>200

what drugs are best


for raising HDL

fibrates

CRAO vs CRVO

CRAO - pallor of the disk, cherry red


fovea, boxcar segmentation of blood
in both retinal arteries and veins

1070.

1071.

1072.

1073.

1074.

1075.

1076.

1077.

1078.

1079.

1080.

1081.

CRVO - disk swelling,


venous dilatation,
tortuosity, retinal
hemorrhages, cotton
wool spots

...

CRAO treamtent

ocular massage and high flow


oxygen

trachoma
1. clinical pres

1. follicular conjunctivitis,
pannus neovascularization of the
cornea,
2. oral tetracycline or
erythromycin

1. HSV retinitis
2. CMV retinitis
3. toxo retinitis

sympathetic
ophthalmia

1082.

1083.

1. widespread pale peripheral


lesions and central necrosis of
the retina - rapid vision loss
"acute retinal necrosis"
2. painless, yellowish white fluffy
or granular retinal lesions near
retinal vessels, retinal
hemorrhages
3. necrotizing retinochoroiditis fluffy white lesions surrounded by
retinal edema and vitritis
2/2 damage to an eye via
penetrating injury leads to
immunologic reaction to hidden
antigens- anterior/panuveitis,
papillary edema

1084.

1085.

1086.

1087.

1088.

1089.

retropharyngeal
abscess
1. clinical pres

1. fever, neck pain, trsimus,


limited cervical extension

1090.

diphtheria
1. clinical pres

1. pseudomembranous
pharyngitis, low grade fever,
nasal discharge, cervical
adenopathy

1091.

otitis externa
1. patho
2. treatment

1. pseudomonas>staph infection
of the external ear - causes severe
ear pain/drainage, can progress
to skull base or TMJ, destruction
of VII
2. topical neomycin, or systemic
ciprofloxacin if severe

key distinguishing
features of orbital
cellulitis vs preseptal
cellulitis

orbital cellulitis - has


proptosis/dec. visual acuity

***both may have pain


with eye movement

...

ACE inhibitor side


effects

cough, hyperkalemia,
angioedema

beta blocker side


effets

bradycardia, inc. airway


resistance, fatigue, depression,
sexual dysfunction

most common
middle ear
pathology in HIV
patients

serous otitis media - due to auditory


tube dysfunction from HIV
lymphadenopathy, or obstructing
lymphomas

cholesteatoma
1. patho

1. chronic middle ear disease leads


to formation of a retraction pocket in
the tympanic membrane that fills
with granulation tissue
2.

aspirin
exacerbated
respiratory disease

asthma, nasal polyps, chronic


rhinosinusitis, bronchospasm
following NSAIDS

peritonsillar
abscesses clinical
pres

uvular deviation, hot potato voice,


lymphadenopathy

allergic rhinitis
diagnosis

clinical history, eosinophils on


nasal cytology

cause of ascending
vs descending
aortic aneurysms

ascending - cystic medial


degeneration
descending - atherosclerosis

PTU/methimazole
side effects

agranulocytosis - look for sore


throat
and discontinue medication
immediately

hypercalcemia of
bedrest

2/2 activation of osteoclasts causing


increased bone turnover
tx = bisphosphonates

why must beta


blocker not be given
alone in
pheochromocytoma

beta blocker leads to unopposed


alpha and a sudden rise in blood
pressure

***give alpha
blocker first THEN
beta blocker

...

MEDICINE2 - step up to
medicine/pretest/lange/uworld/MKSAP4
Study online at quizlet.com/_iq4nz
1.

2.

3.

4.

5.

6.

7.

8.

9.

lab value differences


between: diabetes
insipidus, primary
polydipsia, and SIADH

diabetes insipidus - dilute


urine with elevated serum
osmolality
primary polydipsia - both
plasma and urine are dilute,
inc. urine osmolality with
water restriction
SIADH - low serum osmolality
with high urine osmolality

CMV pneumonitis clinical


pres

transplant/immunosuppressed
patients
patchy lung infiltrates
(compare to PJP) and colitis
(2/2 ulcerations)

what types of infections


are those with iron
overload more susceptible
too

listeria, yersinia enterocolitica,


vibrio vulnificus
** because iron increases
bacterial virulence and
decreased

malaria fever cycles


1. 48 hours
2. 72 hours
3. no periodicity
+ anemia, n/v, headache,
malaise, myalgia, anemia,
splenomegaly

1. vivax, ovale
2. malariae
3, falciparum

malignant otitis externa


clincial pres

severe ear pain, otorrhea, pain


with chewing
granulation tissue in ear canal
***MCC=pseudomonas
aeruginosa

cutaneous larva migrans

common in tropical climates


with SAND
pruritic, elevated, serpiginous
lesion
2/2 ancylostoma braziliense

oseltamivir/zanamivir vs
amantadine/rimantadine

10.

11.

12.

13.

14.

oseltamivir/zanamivir
(neuraminidase inhibitors) type A/B
amantadine/rimantadine only type A

cultures grow
s.bovis/gallolyticus in
someone with
endocarditis
what is the next step

colonoscopy to look for GI


malignancy

ehrlichiosis clinical
pres/tx

systemic symptoms,
leukopenia, thrombocytopenia,
elevated LFTs
tx = doxycycline

15.

16.

17.

HIV therapy reactions


1. didanosine
2. abacavir
3. nevirapine
4. indinavir
5. any NRTI
6. any NNRTI

1. pancreatitis
2. hypersensitivity syndrome
3. liver failure
4. crystal induced
nephropathy***
5. lactic acidosis
6. stevens johnson

pneumonia in special cases


1. cystic
fibrosis/bronchiectasis
2. alcoholics, diabetics
3. poor dentition
4. post-influenza

1. pseudomonas,
stenotrophomonas
2. klebsiella
3. anaerobes (oral flora)
4. staph aureus - can
necrotize forming small thin
walled abscesses

which bacteria should be


suspected if urine pH is
high

urease positive organisms proteus, klebsiella,


enterobacter

infectious diarrhea
1. seafood
2. daycare
3. ground beef
4. undercooked pork
5. poultry

1. v.parahaemolyticus
2. shigella
3. EHEC
4. yersinia enterocolitica
5. campylobacter jejuni

most common valve


abnormality in infectious
endocarditis

mitral regurgitation

nocardia
1. patho/risk
factors/clinical pres
2. dx/tx

1. cell mediated immunity


defect --> pneumonia, CNS,
skin
2. crooked branching,
beaded gram positive
partially acid fast
BRANCHING rods
tx = TMP SMX, minocycline

key distinguishing features


between acute HIV and
infectious mononucleosis

primary HIV - more likely to


include rash and diarrhea
mono - more likely to include
tonsillar exudate

treatment of lymes disease


in pregnant women

cant use doxycycline as it is


teratogenic....
USE AMOXICILLIN

18.

treatment for cat bites

need to consider pasteurella


multocida- localized
cellulitis, fever,
lymphadenopathy
tx = amoxicillin clavulanate
NOT ERYTHRO- 50%
resistance

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

drug of choice for


malaria
chemoprophylaxis

mefloquine (esp in chloroquine


resistant areas)

when to use
prednisone in
addition to TMPSMX
for treatment of PJP

when PaO2 <70

disseminated
histoplasmosis
clinical pres

palatal ulcers, hepatosplenomegaly,


pancytopenia , lymphadenopathy

30.

because histoplasmosis targets


histiocytes in the reticuloendothelial
system

31.

bartonella henselae
1. clinical pres
2. dx/tx
infection

1. local cutaneous vesicular,


erythema, papular rash, + regional
tender lymphadenopathy that may
be suppurative
2. dx = warthin-starry stain
5 days of AZITHROMYCIN

32.

how to correct
elevated
homocysteine levels

pyridoxine and folate

senile purpura

ecchymotic lesions that occur on the


dorsum of the hands and forearms
due to perivascular connective tissue
atrophy

hairy cell leukemia


1.
2. dx/tx

2. CD11c positive, tartrate resistant


acid phosphatase positive, fine hair
like cellular projections
tx = cladribine (2
chlorodeoxyadenosine)

pagets disease of the


breast
1. clinical pres
2. dx

1. red, oozing, crusting of the nipple


unresponsive to steroids or
antibiotics
2. invading cells with hyperchromic
nucleus, halos, and prominent
nucleoli

lupus anticoagulant
1. patho

1. IgM or IgG that binds


phospholipids prolonging PTT
2. long PTT, normal PT, vWF/BT
and platelet counts normal
russell viper venom test will be
prolonged

what should be
evaluated before
starting EPO for a
patient with CKD

iron stores - EPO can worsen iron


deficiency anemia

what should be the


next test in a patient
with trousseaus
syndrome

migratory thrombophlebitis
look for occult malignancy
especially pancreatic cancer
CT abdomen

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

ewings sarcoma
1. patho

1.
2. white males first or
second decade, inc.
ESR, onion skinning
periosteal reaction,
and moth eaten soft
tissue
- often affects
metaphysis of femur,
tibia and humerous

which lung cancer has the least


association with smoking

bronchoalveolar
carcinoma,
adenocarcinoma

poor prognostic indicators in


CLL

splenomegaly, anemia,
thrombocytopenia***

what is the risk associated with


tamoxifen (anti-estrogen)
therapy

increased risk for


endometrial cancer,
and increased risk for
uterine sarcoma

steroid abuse side effects

testicular suppression,
gynecomastia,
erythrocytosis,
hepatotoxicity, inc.
LDL

how to reduce risk of abortion in


SLE mother with history of
multiple abortions and labs
consistent with lupus
anticoagulant (VDRL, PTT,
platelets)

aspirin and heparin

treatment for metastatic


prostate cancer

palliative radiation and


leuprolide (LHRH
analogue antiandrogen therapy)

what cancer associated with


pernicious anemia

gastric 2x than general


population

lupus anemia pathogenesis

warm AIHA type 2


hypersensitivity leads
to anemia and a
similar mechanism for
thrombocytopenia

what substance in PRBCs/blood


products can lead to
hypocalcemia

citrate which is used as


an anticoagulant

ulcerative colitis colon cancer


screening

start 8 years after


diagnosis, then repeat
every 1 to 3 years

tear drop RBCs

seen in diseases that


infiltrate bone marrow
ex. myelofibrosis

best drug for cancer associated


anorexia

megestrol acetate

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

most common cause of


visible nasal mass,
frequent nosebleeds
and nasal obstruction
in a child

juvenile angiofibroma - can cause


bony erosion

why is testicular biopsy


of suspicious testicular
mass contraindicated

risk of spilling cancer cells perform radical orchiectomy first

what is target urine


output in
hypercalcemic crisis

>200ml/hr

metastatic cord
compression treatment
algorithm

neurological examination, IV
steroids, MRI/CT myelogram,
radiotherapy or surgery

direct thrombin
inhibitors

argatroban (liver metabolized),


lepirudin (kidney excreted)

treatment for sickle cell


vaso occlusive crisis

hydration, supplemental oxygen,


exchange transfusion

giant cell tumor of bone


1. clinical pres

1. soap bubble appearance, knee


pain, possible mass

clinical pres/treatment
for primary
dysmenorrhea

bilateral lower quadrant pain


during onset of menses
NSAIDs

what is risk associted


with HRT

breast cancer - specifically the


progesterone component

what is the most


important factor in
lump detection on a
breast examination
what pattern should be
used

57.

58.

59.

60.

61.

**use HRT for the shortest


amount of time possible

62.

time--- should be 3 minutes per


breast

63.

start at midaxillary line, up and


down pattern from clavicle to
inframammary line, each point
should be checked with 3 different
pressures

64.

65.
53.

54.

55.

56.

which physical exam


finding indicates
severity of aortic
stensosis

absence of A2 indicates severe


disease

best test for patients


with minimal BRBPR

anoscopy

subclinical
hyperthyroidism vs
thyroiditis diagnosis

radioiodine uptake will be normal


in subclinical hyperthyroidism
and decreased in thyroiditis

how to decrease risk of


prostate cancer

only proven way is with


finasteride - dec risk by 25%

drug induced pancreatitis

furosemide, thiazide
sulphasalazine, 5-ASA
azathioprine, Lasparaginase
valproate
didanosine, pentamidine
metronidazole,
tetracycline

what drugs associated with


cholelithiasis

fibrates, octreotide,
ceftriaxone (use
cefotaxime to avoid
biliary sludging)

which liver function test is


best indication of hepatic
synthetic capacity

PT

why is spironolactone used in


patients with cirrhosis

limited hepatic
inactivation of
aldosterone and
increased aldosterone
secretion is most
responsible for cirrhotic
ascites

cause of post-op jaundice

increased pigment load


(transfusion), decreased
liver functionality
(hypotension), dec.
bilirubin excretion (ATN)

when does a HCV patient need


to be treated

when LFTs are elevated

1. famciclovir
2. valacyclovir
3. ganciclovir
4. valganciclovir
5. acyclovir

1. herpes zoster
2. herpes zoster
3. CMV
4. CMV
5. HSV

dermatomyositis/polymyositis
clinical assc.

cancer - screen every 6 12 years

pneumococcal vaccine
ages/indications

all adults >65 years of age


all adults with CV
disease, pulmonary,
hepatic, renal,
immunosuppression or
metabolic disease with 5
year boosters

treatment for diabetic


neuropathy

amitriptyline,
desipramine,
nortriptyline, gabapentin,
NSAIDs

what patients should not take


zanamavir

asthmatics - because this


drug causes
bronchospasm
should use oseltamivir

what must be checked in every


patient with hyperlipidemia

TSH - to rule out


hypothyroidism

normal split S2 excludes severe


disease

66.

67.

68.

69.

70.

71.

what causes of ascites have a


SAAG <1.1/protein >2.5 vs
>1.1/protein<2.5

<1.1 nephrotic syndrome,


SBP, malignancy,
tuberculosis
>1.1 cirrhosis, right sided
heart failure, budd chiari

causes of ST elevations

STEMI, prinzmetal's
variant angina,
pericarditis

does chest Xray correlate with


clinical improvement after
treatment for CAP

76.

77.

NO IT CAN TAKE WEEKS


FOR THE CXR TO
RETURN TO NORMAL

what to think when alcoholic has


hypocalcemia/hyperphosphatemia

hypomagnesemia which leads to dec.


PTH secretion and
end organ PTH
resistance
mimics hypoparathyroidism

treatment for non-ICU vs ICU


pneumonia

non-ICU - beta
lactam +macrolide
or doxy or
fluoroquinolone
monotherapy
ICU - beta lactam +
macrolide or
fluoroquinolone

most appropriate antiviral agent


for a patient with genital herpes
simplex virus infection without
systemic complications.

Oral valacyclovir

which vaginal infections


associated with high pH

trichomonas and
bacterial vaginosis

indications for thoracostomy tube


in pleural effusion

pH <7, pus

what joint effected by tophaceous


gout

DIP

when to use needle vs tube for


pneumothorax treatment

needle - small,
primary
spontaneous
tube - large,
secondary/complex

1. bacterial vaginosis
2. trichomonas vaginalis

1. increased
malodorous fishy
discharge, vaginal
erythema - clue
cells, tx =
metronidazole or
clindamycin
2. yellow green
pruritic frothy
discharge - not
malodorous

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BY HOW PATIENT DOES
CLINICALLY!!!!
72.

73.

74.

treatment for recurrent


venous thromboembolism in
association with metastatic
cancer

LOW MOLECULAR
WEIGHT HEPARIN
LONG TERM
NOT WARFARIN , NOT
IVC FILTER

79.

what cancer occurs at inc.


freq in pts who recieved
mediastinal irradiation for
hodgkins disease

solid tumors of the chest


wall - breast cancer

80.

why should PCO2 be


measured in status
asthmaticus

cannot be detected by
conventional monitors
and pulse-ox

81.

In mild asthma - PCO2 is


low
in severe asthma/status
asthmaticus - PCO2 is
high - risk of respiratory
arrest
PCO2 is a marker of
severity of asthma attack
75.

78.

relative vs secondary
erythrocytosis

relative - no true increase


in RBC mass just dec.
plasma volume dehydration, diarrhea
secondary - typically EPO
mediated, or smoking,
COPD

82.

83.

with systemic
complications acyclovir

1. vertebral artery stroke clinical


presentation
2. PCA """
3. MCA
4. ACA

1. horners syndrome, dysarthria, dysphagia, dec. pain/temp sensation, dysmetria,


ataxia, vertigo
2. contralateral visual field deficit
3. contralateral face/ arm>leg weakness, sensory loss, aphasia or hemi neglect
4. contralateral leg weakness

85.

creatinine cutoff for metformin

>1.5 should use insulin insted

86.

OCP LFT abnormality

conjugated hyperbilirubinemia

84.