Case Files Im Cases 16-26

Front 1

types of colitis

Back 1

ISCHEMIC (usu > 50yo), INFECTIOUS (c.dif, e.coli, salmonella, shigella, campylobacter), RADIATION, IBD (15-25yo, sometimes 60-70yo [crohn's])

Front 2

sx in UC vs Crohns

Back 2

UC: bloody diarrhea; Crohn: chronic abd pain, diarrhea, weight loss

Front 3

tx of UC

Back 3

5-ASA (oral/rectal), steroids (to induce remission), immune modulators (severe refractory dz; 6-MP, AZA, MTX, TNF-antibody [infliximab])

Front 4

which IBD a/w cancer

Back 4

UC

Front 5

radiologic findings in UC vs Crohns

Back 5

Crohns: string sign on barium swallow; UC: lead pipe colon (loss of haustral folds)

Front 6

arthritis in IBD

Back 6

a/w crohn (polyarticular, asymmetric); also see ankylosing spondylitis with Crohn

Front 7

total colectomy in IBD

Back 7

with UC complications (eg carcinoma, toxic megacolon, perforation, uncontrollable bleeding)

Front 8

what is toxic megacolon?

Back 8

colon > 6cm, systemic toxic sx (fever, leukocytosis, tachycardia, hypotension, altered mental status)

Front 9

tx of toxic megacolon

Back 9

NPO, IV fluids, IV antibiotics (prophylactically in case of perf), surgery

Front 10

what area most often affected in Crohn dz?

Back 10

terminal ileum

Front 11

temporal relationship between GFR and Cr levels

Back 11

Cr lags GFR (bc it is both filtered and secreted) ==> by the time Cr rises, GFR has already fallen significantly

Front 12

what is anuria?

Back 12

<50ml/day urine output (acute obstruction, cortical nephrosis, vascular catastrophies like aortic dissection)

Front 13

what is oliguria?

Back 13

<400ml/day urine output (poor prognostic factor in ARF)

Front 14

sx of uremia

Back 14

CONFUSION, PERICARDITIS, SEIZURES, COMA, fatigue, weakness, nausea, itchiness

Front 15

what meds can cause prerenal failure

Back 15

NSAIDS (--| PG --> afferent dilation); ACEi (--| ACE --> ATII --> efferent constriction)

Front 16

main use of FE_Na

Back 16

used to distinguish oliguric PRERENAL failure from oliguric ATN (FeNa <1% in prerenal bc trying to reabsorb everything; FeNa > 2% in ATN b/c reabsorption damaged)

Front 17

effects of diuretics on FeNa

Back 17

diuretics may caused elevated FeNa even with prerenal dz

Front 18

indications for dialysis

Back 18

AEIOU: ACIDOSIS (pH < 7.2), ELECTROLYTES (K>6.5 + EKG changes), INGESTIONS, OVERLOAD (CHF, pulm edema, refractory to tx), UREMIA (pericarditis, seizure, confusion)

Front 19

two main causes of renal failure in hospitalized patients

Back 19

prerenal azotemia and ATN (distinguished by FeNa); also: drug tox

Front 20

main causes of postrenal failure

Back 20

men: prostatic hypertrophy; both: bilateral uretral obstruction by abdominal/pelvic MALIGNANCY

Front 21

tx of hyperkalemia

Back 21

C BIG K (calcium gluconate, beta-agonist/bicarb, insulin, glucose, Kayexalate)

Front 22

characteristics of pericardial friction rub (timing, where heard, what heard)

Back 22

come and go over hours; best heard at left sternal border; can have up to 3 components (presystole/atrial contraction, systolic, diastolic) -- usu 2 or 3 components

Front 23

classic ECG findings in acute pericarditis

Back 23

diffuse ST elevation and PR depression; unlike MI, no QRS changes

Front 24

why would it be bad to confuse MI for pericarditis?

Back 24

MI often treated with thrombolytics -- in pericarditis, this could cause pericardial hemorrhage --> tamponade

Front 25

tx of pericarditis

Back 25

if VIRAL/IDIOPATHIC, tx symptoms: ASA/NSAID to relieve chest pain; sx usu resolve in 2-3wks; ALL OTHER CAUSES, tx underlying pathology, eg dialysis for uremia

Front 26

what kind of hematologic disorders found in SLE?

Back 26

hemolytic anemia, leukopenia, lymphopenia

Front 27

major complication of SLE

Back 27

renal involvement --> HTN, chronic renal failure, nephrotic syndrome, ESRD

Front 28

MCC death in SLE

Back 28

INFECTION related to immunosuppression used to tx SLE; VASCULAR dz, eg MI

Front 29

what can make urine pigmented/red/dark?

Back 29

RBCs, myoglobin (muscle breakdown product), hemoglobin (from RBC lysis)

Front 30

sources of RBCs in urine, how to distinguish?

Back 30

intrarenal vs extrarenal; presence of RBC casts or dysmorphic/fragmented RBCs suggests glomerular source (glomerulonephritis)

Front 31

definition of nephrotic syndrome

Back 31

protein > 3.5g/24hr

Front 32

common signs of glomerulonephritis (4)

Back 32

1) hematuria; 2) edema; 3) hypertension; 4) proteinuria [<3.5g/d]

Front 33

what dzs can cause gross hematuria following URI?

Back 33

IgA nephropathy or post-strep GN

Front 34

tx of glomerulonephritis

Back 34

supportive only -- hemodyalysis for renal failure, antihypertensives and diuretics for edema, +/- immunosuppressive drugs; tx underlying dz if possible

Front 35

definition of nephrotic syndrome

Back 35

urine protein > 3.5g/d; serum hypoalbuminemia (<3g/dL); edema

Front 36

cellular elements on u/a in nephrotic syndrome

Back 36

few, if any -- waxy casts, oval fat bodies if hyperlipidemia

Front 37

common tests for new nephrotic syndrome

Back 37

1) serum glucose / HbA1c for diabetic nephropathy; 2) ANA for SLE; 3) SPEP/UPEP for multiple myeloma, amyloidosis; 4) viral seroligies for HIV, viral hepatitis

Front 38

use of diuretics in nephrotic syndrome

Back 38

advised, but must be given in much higher doses b/c both thiazides and loop diuretics are highly protein-bound ==> dec delivery to kidney in nephrotic syndrome; ACEi and ARBs used in diabetics

Front 39

diet modification for pts with nephrotic syndrome

Back 39

salt restriction, protein restriction (protein in diet --> filtered protein --> renal damage)

Front 40

heme consequences of nephrotic syndrome

Back 40

protein wasting --> decreased antithrombin III, protein C, protein S ==> hypercoagulable; give anticoagulation if evidence of thrombus formation

Front 41

protein losses in nephrotic syndrome and their consequences

Back 41

hypogammaglobulinemia --> INFECTION; hypotransferrinemia --> iron deficiency anemia;

Front 42

ACEi and nephrotic syndrome

Back 42

ACEi slow progression of renal dz even when pt is normotensive

Front 43

goal HbA1c in diabetic nephropathy

Back 43

6.5-7.0

Front 44

alternative to measuring microalbuminemia over a day

Back 44

rnadom urine albumin/creatinine ratio -- 30-300 is in range for early diabetic nephropathy

Front 45

2 mcc monoarticular arthritis

Back 45

1) INFECTION (s.aureus/gonococcus); 2) CRYSTALLINE (gout/pseudogout); 3) SYSTEMIC (usu polyarticular, but can start as mono)

Front 46

acute tx for monoarticular arthritis

Back 46

joint aspiration, empiric antibiotic tx even before cultures/crystal anaylsis are available (need to prevent septic arthritis --> joint destruction)

Front 47

how does timeline help differentiate between causes of monoarticular arthritis?

Back 47

crystalline is usually episodic

Front 48

incidence of gout vs pseudogout

Back 48

gout is much more common

Front 49

location of gout vs gonococcal vs staph arthritis

Back 49

GOUT: podagra, ankle, midfoot, knee (toe --> knee); GONOCOCCAL: migratory arthalgias and tenosynovitis --> wrists, hands, pustular skin lesions; STAPH: large weight-bearing joints (knee, hip)

Front 50

PE in true arthritis vs bursitis

Back 50

TRUE ARTHRITIS: painful limitation of ROM in active AND passive motion; BURSITIS: no limitation of passive motion

Front 51

what does normal joint fluid look like?

Back 51

acellular, colorless, <200 WBC/mm3, <25% PMNs, glucose ~= blood

Front 52

what are psuedogout crystals made of?

Back 52

calcium pyrophosphate dehydrate

Front 53

gout vs pseudogout crystals

Back 53

GOUT: needle shaped, negatively birefringent, yellow under polarizing light; PSEUDOGOUT: rhomboid shaped, positively birefringent, blue under polarized light

Front 54

how to dx gonococcal arthritis?

Back 54

joint fluid cx often NEGATIVE (gonococcal arthritis is mediated by IC deposition, not direct infection); look at cultures of blood, skin lesions, urethra, cervix, etc. instead

Front 55

XRT findings in pseudogout

Back 55

chondrocalcinosis or linear calcium deposition in joint cartilage

Front 56

tx of septic arthritis

Back 56

DRAINAGE plus GONOCOCCAL: IV ceftriaxone; STAPH: nafcillin, vanc;

Front 57

tx for asymptomatic hyperuricemia

Back 57

NONE -- usu does not progress to gout, and lowering of urate levels doesn’t decrease incidence.

Front 58

what is the std tx of acute gout? When to use alternative tx?

Back 58

NSAIDS, colchicine; both are contraindicated in renal insufficiency ==> use STEROIDS

Front 59

dietary modification for gout

Back 59

avoid organ-rich foods (eg liver), avoid alcohol

Front 60

tx for pseudogout

Back 60

same as gout -- NSAIDs, colchicine, steroids

Front 61

where is the rash of disseminated gonococcal infection found?

Back 61

extensor surfaces of distal extremities

Front 62

how to use timing to differentiate causes of polyarticular disease?

Back 62

acute (<6wks): consider VIRAL (HBV, HCV, rubella, parvovirus B19), or EARLY rheumatic;

Front 63

causes of symmetric polyarthritis

Back 63

RHEUMATOID ARTHRITIS, but also SLE, psoriatic arthritis, rhematic fever

Front 64

characteristic finding of psoriatic arthritis

Back 64

"sausage digits" due to tendon inflammation; also, skin and nail changes typical of psoriasis; [sausage digits can also be seen in reiter syndrome]

Front 65

hand findings in RA

Back 65

MCP and PIP arthritis (DIP sparing, unlike OA -- heberdon's nodes); radial deviation of wrist, ulnar deviation of MCP

Front 66

radiologic findings in RA

Back 66

joint space narrowing, subchondral polysclerosis, marginal osteophyte formation, cyst formation

Front 67

extraarticular manifestations of RA

Back 67

vasculitic lesions, ocular manifestations (Sjogren's), interstitial lung dz, cardiac, neurologic, ANEMIA of chronic disease

Front 68

what is felty syndrome?

Back 68

RA, splenomegaly, leukopenia, lymphadenopathy, thrombocytopenia

Front 69

tx for RA

Back 69

steroids for palliative tx, DMARDs (disease-modifying anti-rheumatic drugs); more recently, TNF-antagonists (etanercept, infliximab)

Front 70

types of DMARDs

Back 70

MTX, hydroxychloroquine, sulfasalazine, penicillamine, azathioprine, cyclophosphamide, cyclosporine

Front 71

what % of RA patients have RF in the serum?

Back 71

85%

Front 72

stages of lyme disease

Back 72

1) EARLY LOCALIZED (1mo, erythema migrans [expanding lesion +/- central clearing] usu around belt/axilla; 2) EARLY DISSEMINATED (days-months after bite, migratory msk pain w/o arthritis, cardiac [conduction, myositis, pericarditis, cardiomyopathy], neuroloic [CN palsies, meningitis] 3) LATE DISEASE

Front 73

tx of lyme disease

Back 73

doxycycline, amoxicillin, cefuroxime, erythromycin for 1 MONTH; IV if severe sx such as 3rd degree heart block or neuro manifestations

Front 74

what is sciatica?

Back 74

pain in distribution of lumbar / sacral nerves roots (usu L5/S1) +/- motor or sensory deficits

Front 75

what is spondylolisthesis?

Back 75

anterior displacement of vertebral body --> spinal stenosis, often from DJD in elderly

Front 76

what is spondylolysis?

Back 76

defect in pars interarticularis -- congenital or 2/2 stress fracture

Front 77

what serious etiologies of back pain must be ruled out?

Back 77

malignancy, infection, spinal cord compression, cauda equina syndrome

Front 78

how to differentiate muscular back pain from spinal process by PE?

Back 78

spinal process --> palpable point tenderness over spinous process; MSK process --> paraspinal tenderness

Front 79

when to prescribe bed rest in lower back pain

Back 79

only with severe pain / neurologic deficits -- otherwise, activity helpful

Front 80

tx of low back pain

Back 80

scheduled NSAIDs, nonaspirin analgesics, muscle relaxants; most cases of disk herniation resolve spontaneously within 4-6 wks w/o surgery

Front 81

"Red Flags" of low back pain

Back 81

1) New onset pain >50yo or <20yo; 2) Fever; 3) unintentional weight loss; 4) pain worsened in supine position; 5) bowel/bladder incontinence; 6) History of cancer; 7) Immunosuppression; 8) Saddle anesthesia; 9) Major motor weakness

Front 82

classic lab findings in multiple myeloma

Back 82

elevated calcium, mild renal failure

Front 83

when to perform imaging in low back pain?

Back 83

only if surgery being considered (persistent > 6wks), or ?neoplastic/inflam cause

Front 84

what does ferritin indicate?

Back 84

iron stores; NOTE: also an acute phase reactant

Front 85

normal iron intake

Back 85

15mg/day, only 1-2mg/day absorbed

Front 86

iron losses with menstruation

Back 86

30mg/month

Front 87

mcc causes of iron deficiency

Back 87

men: GI bleed; women: also consider menstruation, pregnancy (increased blood volume +

Front 88

first lab finding in iron deficiency

Back 88

decreased ferritin levels (before Hb, serum Fe drop)

Front 89

symptoms of severe iron deficiency

Back 89

pica, plummer-vinson syndrome (glossitis, cheilosis, koilonychia, esophageal webs)

Front 90

how do you distinguish causes of microcytic anemia?

Back 90

RDW -- increased in Fe deficiency (cells of varying sizes), normal in thallassemia (all small)

Front 91

labs in ACD vs Fe deficiency

Back 91

both have decreased serum Fe, but ACD has inc ferritin and dec TIBC, while Fe defic has dec Ferritin and inc TIBC

Front 92

Fe studies in sideroblastic anemia

Back 92

problem with RBC synthesis, but not Fe deficiency ==> inc serum Fe, inc ferritin, inc transferrin saturation

Front 93

sensitivity of fecal occult blood testing for GI cancer

Back 93

50%

Front 94

MCC left-sided abd pain in older pt

Back 94

diverticulitis (also consider CRC)

Front 95

ddx of LLQ abd pain

Back 95

diverticulitis, CRC (+/- perf), ischemic colitis (usu a/w bleeding)

Front 96

prevalence of diverticulosis in elderly

Back 96

50-80% in >80yo

Front 97

complications of diverticulosis (3)

Back 97

acute diverticulitis (most common), hemorrhage, obstruction

Front 98

tx of diverticular hemorrhage

Back 98

self-limiting ==> tx w increased fiber in diet

Front 99

looks like "left sided appendicitis"

Back 99

diverticulitis

Front 100

stages of diverticulitis

Back 100

4: 1) small confined pericolic abscess; 2) distant abscess; 3) generalized peritonitis from abscess rupture; 4) fecal peritonitis from bowel perf

Front 101

fecaluria

Back 101

from colovesical fistula, virtually pathognomonic for diverticulitis

Front 102

what imaging to dx diverticulitis?

Back 102

CT -- look for pericolic fat stranding, thickening of bowel wall (>4mm), peridiverticular abscess

Front 103

tx for diverticulitis

Back 103

SURGERY if indicated (generalized peritonitis | uncontrolled sepsis | perf | clinical deterioration); ANTIBIOTICS (braod-spectrum eg TMP-SMX | cipro/metro | clinda/gent); INPATIENT: IV hydration, electroylytes, bowel rest

Front 104

gender prevalence of colovesical fistulas

Back 104

more common in MALES (in females, uterus is in the way)

Front 105

clinical presentation of diverticulitis

Back 105

LLQ pain, fever, leukocytosis, constipation, signs of peritoneal inflammation