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105 Cards in this Set

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  • Back
types of colitis
ISCHEMIC (usu > 50yo), INFECTIOUS (c.dif, e.coli, salmonella, shigella, campylobacter), RADIATION, IBD (15-25yo, sometimes 60-70yo [crohn's])
sx in UC vs Crohns
UC: bloody diarrhea; Crohn: chronic abd pain, diarrhea, weight loss
tx of UC
5-ASA (oral/rectal), steroids (to induce remission), immune modulators (severe refractory dz; 6-MP, AZA, MTX, TNF-antibody [infliximab])
which IBD a/w cancer
radiologic findings in UC vs Crohns
Crohns: string sign on barium swallow; UC: lead pipe colon (loss of haustral folds)
arthritis in IBD
a/w crohn (polyarticular, asymmetric); also see ankylosing spondylitis with Crohn
total colectomy in IBD
with UC complications (eg carcinoma, toxic megacolon, perforation, uncontrollable bleeding)
what is toxic megacolon?
colon > 6cm, systemic toxic sx (fever, leukocytosis, tachycardia, hypotension, altered mental status)
tx of toxic megacolon
NPO, IV fluids, IV antibiotics (prophylactically in case of perf), surgery
what area most often affected in Crohn dz?
terminal ileum
temporal relationship between GFR and Cr levels
Cr lags GFR (bc it is both filtered and secreted) ==> by the time Cr rises, GFR has already fallen significantly
what is anuria?
<50ml/day urine output (acute obstruction, cortical nephrosis, vascular catastrophies like aortic dissection)
what is oliguria?
<400ml/day urine output (poor prognostic factor in ARF)
sx of uremia
CONFUSION, PERICARDITIS, SEIZURES, COMA, fatigue, weakness, nausea, itchiness
what meds can cause prerenal failure
NSAIDS (--| PG --> afferent dilation); ACEi (--| ACE --> ATII --> efferent constriction)
main use of FE_Na
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)
effects of diuretics on FeNa
diuretics may caused elevated FeNa even with prerenal dz
indications for dialysis
AEIOU: ACIDOSIS (pH < 7.2), ELECTROLYTES (K>6.5 + EKG changes), INGESTIONS, OVERLOAD (CHF, pulm edema, refractory to tx), UREMIA (pericarditis, seizure, confusion)
two main causes of renal failure in hospitalized patients
prerenal azotemia and ATN (distinguished by FeNa); also: drug tox
main causes of postrenal failure
men: prostatic hypertrophy; both: bilateral uretral obstruction by abdominal/pelvic MALIGNANCY
tx of hyperkalemia
C BIG K (calcium gluconate, beta-agonist/bicarb, insulin, glucose, Kayexalate)
characteristics of pericardial friction rub (timing, where heard, what heard)
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
classic ECG findings in acute pericarditis
diffuse ST elevation and PR depression; unlike MI, no QRS changes
why would it be bad to confuse MI for pericarditis?
MI often treated with thrombolytics -- in pericarditis, this could cause pericardial hemorrhage --> tamponade
tx of pericarditis
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
what kind of hematologic disorders found in SLE?
hemolytic anemia, leukopenia, lymphopenia
major complication of SLE
renal involvement --> HTN, chronic renal failure, nephrotic syndrome, ESRD
MCC death in SLE
INFECTION related to immunosuppression used to tx SLE; VASCULAR dz, eg MI
what can make urine pigmented/red/dark?
RBCs, myoglobin (muscle breakdown product), hemoglobin (from RBC lysis)
sources of RBCs in urine, how to distinguish?
intrarenal vs extrarenal; presence of RBC casts or dysmorphic/fragmented RBCs suggests glomerular source (glomerulonephritis)
definition of nephrotic syndrome
protein > 3.5g/24hr
common signs of glomerulonephritis (4)
1) hematuria; 2) edema; 3) hypertension; 4) proteinuria [<3.5g/d]
what dzs can cause gross hematuria following URI?
IgA nephropathy or post-strep GN
tx of glomerulonephritis
supportive only -- hemodyalysis for renal failure, antihypertensives and diuretics for edema, +/- immunosuppressive drugs; tx underlying dz if possible
definition of nephrotic syndrome
urine protein > 3.5g/d; serum hypoalbuminemia (<3g/dL); edema
cellular elements on u/a in nephrotic syndrome
few, if any -- waxy casts, oval fat bodies if hyperlipidemia
common tests for new nephrotic syndrome
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
use of diuretics in nephrotic syndrome
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
diet modification for pts with nephrotic syndrome
salt restriction, protein restriction (protein in diet --> filtered protein --> renal damage)
heme consequences of nephrotic syndrome
protein wasting --> decreased antithrombin III, protein C, protein S ==> hypercoagulable; give anticoagulation if evidence of thrombus formation
protein losses in nephrotic syndrome and their consequences
hypogammaglobulinemia --> INFECTION; hypotransferrinemia --> iron deficiency anemia;
ACEi and nephrotic syndrome
ACEi slow progression of renal dz even when pt is normotensive
goal HbA1c in diabetic nephropathy
alternative to measuring microalbuminemia over a day
rnadom urine albumin/creatinine ratio -- 30-300 is in range for early diabetic nephropathy
2 mcc monoarticular arthritis
1) INFECTION (s.aureus/gonococcus); 2) CRYSTALLINE (gout/pseudogout); 3) SYSTEMIC (usu polyarticular, but can start as mono)
acute tx for monoarticular arthritis
joint aspiration, empiric antibiotic tx even before cultures/crystal anaylsis are available (need to prevent septic arthritis --> joint destruction)
how does timeline help differentiate between causes of monoarticular arthritis?
crystalline is usually episodic
incidence of gout vs pseudogout
gout is much more common
location of gout vs gonococcal vs staph arthritis
GOUT: podagra, ankle, midfoot, knee (toe --> knee); GONOCOCCAL: migratory arthalgias and tenosynovitis --> wrists, hands, pustular skin lesions; STAPH: large weight-bearing joints (knee, hip)
PE in true arthritis vs bursitis
TRUE ARTHRITIS: painful limitation of ROM in active AND passive motion; BURSITIS: no limitation of passive motion
what does normal joint fluid look like?
acellular, colorless, <200 WBC/mm3, <25% PMNs, glucose ~= blood
what are psuedogout crystals made of?
calcium pyrophosphate dehydrate
gout vs pseudogout crystals
GOUT: needle shaped, negatively birefringent, yellow under polarizing light; PSEUDOGOUT: rhomboid shaped, positively birefringent, blue under polarized light
how to dx gonococcal arthritis?
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
XRT findings in pseudogout
chondrocalcinosis or linear calcium deposition in joint cartilage
tx of septic arthritis
DRAINAGE plus GONOCOCCAL: IV ceftriaxone; STAPH: nafcillin, vanc;
tx for asymptomatic hyperuricemia
NONE -- usu does not progress to gout, and lowering of urate levels doesn’t decrease incidence.
what is the std tx of acute gout? When to use alternative tx?
NSAIDS, colchicine; both are contraindicated in renal insufficiency ==> use STEROIDS
dietary modification for gout
avoid organ-rich foods (eg liver), avoid alcohol
tx for pseudogout
same as gout -- NSAIDs, colchicine, steroids
where is the rash of disseminated gonococcal infection found?
extensor surfaces of distal extremities
how to use timing to differentiate causes of polyarticular disease?
acute (<6wks): consider VIRAL (HBV, HCV, rubella, parvovirus B19), or EARLY rheumatic;
causes of symmetric polyarthritis
RHEUMATOID ARTHRITIS, but also SLE, psoriatic arthritis, rhematic fever
characteristic finding of psoriatic arthritis
"sausage digits" due to tendon inflammation; also, skin and nail changes typical of psoriasis; [sausage digits can also be seen in reiter syndrome]
hand findings in RA
MCP and PIP arthritis (DIP sparing, unlike OA -- heberdon's nodes); radial deviation of wrist, ulnar deviation of MCP
radiologic findings in RA
joint space narrowing, subchondral polysclerosis, marginal osteophyte formation, cyst formation
extraarticular manifestations of RA
vasculitic lesions, ocular manifestations (Sjogren's), interstitial lung dz, cardiac, neurologic, ANEMIA of chronic disease
what is felty syndrome?
RA, splenomegaly, leukopenia, lymphadenopathy, thrombocytopenia
tx for RA
steroids for palliative tx, DMARDs (disease-modifying anti-rheumatic drugs); more recently, TNF-antagonists (etanercept, infliximab)
types of DMARDs
MTX, hydroxychloroquine, sulfasalazine, penicillamine, azathioprine, cyclophosphamide, cyclosporine
what % of RA patients have RF in the serum?
stages of lyme disease
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
tx of lyme disease
doxycycline, amoxicillin, cefuroxime, erythromycin for 1 MONTH; IV if severe sx such as 3rd degree heart block or neuro manifestations
what is sciatica?
pain in distribution of lumbar / sacral nerves roots (usu L5/S1) +/- motor or sensory deficits
what is spondylolisthesis?
anterior displacement of vertebral body --> spinal stenosis, often from DJD in elderly
what is spondylolysis?
defect in pars interarticularis -- congenital or 2/2 stress fracture
what serious etiologies of back pain must be ruled out?
malignancy, infection, spinal cord compression, cauda equina syndrome
how to differentiate muscular back pain from spinal process by PE?
spinal process --> palpable point tenderness over spinous process; MSK process --> paraspinal tenderness
when to prescribe bed rest in lower back pain
only with severe pain / neurologic deficits -- otherwise, activity helpful
tx of low back pain
scheduled NSAIDs, nonaspirin analgesics, muscle relaxants; most cases of disk herniation resolve spontaneously within 4-6 wks w/o surgery
"Red Flags" of low back pain
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
classic lab findings in multiple myeloma
elevated calcium, mild renal failure
when to perform imaging in low back pain?
only if surgery being considered (persistent > 6wks), or ?neoplastic/inflam cause
what does ferritin indicate?
iron stores; NOTE: also an acute phase reactant
normal iron intake
15mg/day, only 1-2mg/day absorbed
iron losses with menstruation
mcc causes of iron deficiency
men: GI bleed; women: also consider menstruation, pregnancy (increased blood volume +
first lab finding in iron deficiency
decreased ferritin levels (before Hb, serum Fe drop)
symptoms of severe iron deficiency
pica, plummer-vinson syndrome (glossitis, cheilosis, koilonychia, esophageal webs)
how do you distinguish causes of microcytic anemia?
RDW -- increased in Fe deficiency (cells of varying sizes), normal in thallassemia (all small)
labs in ACD vs Fe deficiency
both have decreased serum Fe, but ACD has inc ferritin and dec TIBC, while Fe defic has dec Ferritin and inc TIBC
Fe studies in sideroblastic anemia
problem with RBC synthesis, but not Fe deficiency ==> inc serum Fe, inc ferritin, inc transferrin saturation
sensitivity of fecal occult blood testing for GI cancer
MCC left-sided abd pain in older pt
diverticulitis (also consider CRC)
ddx of LLQ abd pain
diverticulitis, CRC (+/- perf), ischemic colitis (usu a/w bleeding)
prevalence of diverticulosis in elderly
50-80% in >80yo
complications of diverticulosis (3)
acute diverticulitis (most common), hemorrhage, obstruction
tx of diverticular hemorrhage
self-limiting ==> tx w increased fiber in diet
looks like "left sided appendicitis"
stages of diverticulitis
4: 1) small confined pericolic abscess; 2) distant abscess; 3) generalized peritonitis from abscess rupture; 4) fecal peritonitis from bowel perf
from colovesical fistula, virtually pathognomonic for diverticulitis
what imaging to dx diverticulitis?
CT -- look for pericolic fat stranding, thickening of bowel wall (>4mm), peridiverticular abscess
tx for diverticulitis
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
gender prevalence of colovesical fistulas
more common in MALES (in females, uterus is in the way)
clinical presentation of diverticulitis
LLQ pain, fever, leukocytosis, constipation, signs of peritoneal inflammation