Casefiles Im Cases 5-15

Front 1

causes and tx of hypervolemic hyponatermia

Back 1

CHF, cirrhosis, nephrotic syndrome; tx with diuretics

Front 2

what is pseudohyponatremia?

Back 2

measurement artifact caused by elevated serum proteims or lipids; rare nowadays

Front 3

hormonal etiologies of hyponatermia

Back 3

TH and cortisol facilitate free water excretion ==> deficit --> retention of free water --> hyponatermia

Front 4

lab clues of SIADH

Back 4

low BUN, low uric acid levels

Front 5

tx of SIADH

Back 5

water restriction, +/- hypertonic saline if neurologic sx

Front 6

tx of hyponatermia

Back 6

HYPOVOL: 0.9% (normal) saline; EUVOL: H2O restric; if neurologic sx, give 3% (hypertonic) saline +/- diuretic (furosemide) to avoid volume overload

Front 7

what neuro syndrome if replenish Na too fast in hyponatermia?

Back 7

osmotic cerebral demyelination / central pontine myelinolysis ==> quadriplegia, pseudobulbar palsy, "locked-in" syndrome, coma, death

Front 8

what is a dissecting aneurysm?

Back 8

aneurysm CAUSED by dissection

Front 9

factors predisposing to aortic dissection (6)

Back 9

Connective tissue diseases (Marfan's, ED); HTN; Pregnancy; Valvular problems (AS, congenital bicuspid Ao valve); Atherosclerosis; Coarctation of the aorta

Front 10

timing of pain in MI vs aortic dissection

Back 10

MI: builds up over minutes; AD: maximal at onset

Front 11

2 types of Aortic dissection

Back 11

Type A: involves ascending aorta (+/- descending), dangerous, requires urgent surgery; Type B: descending aorta only (no ascending involvement), managed medically

Front 12

symptoms of AAA

Back 12

often asymptomatic, detected as midline pulsatile mass on PE

Front 13

major predictive factor for AAA rupture and recommended management

Back 13

size of aneurysm (>5.5cm recommended elective surgery, <5.5 recommended serial imaging)

Front 14

CXR finding with aortic dissection

Back 14

widened mediastinum

Front 15

causes of lung dz in AIDS pt

Back 15

PCP, TB, atypical mycobacteria, cryptococcus, histoplasmosis (disseminated), + usual causes of comm-acquired PNAs (S.Pneumo, mycoplasma, viruses)

Front 16

lab findings characteristic of PCP

Back 16

elevated LDH

Front 17

what CD4 count does presence of thrush suggest?

Back 17

<250

Front 18

how can ABG used to prognosticate PCP / guide therapy?

Back 18

PO2 < 70mmHg or A-a gradient > 35mmHg = BAD ==> corticosteroids followed by bactrim (TMP-SMX)

Front 19

what bugs at CD4 < 500?

Back 19

infections that "normal" people can get: zoster, TB, vaginal candidiasis, recurrent PNA

Front 20

what bugs at CD4 < 200?

Back 20

infections that "normal" people DON'T get: PCP, toxo, fungal (cryptococcosis, histoplasmosis, cryptosporidiosis)

Front 21

what bugs at CD4 < 50?

Back 21

disseminated histoplasmosis, MAC, CMV retintis/esophagitis, CNS lymphoma

Front 22

CXR findings in lung dz with AIDS pts

Back 22

TB presentation highly variable with CD4 < 200; DIFFUSE interstitial infiltrates: PCP, histo; PATCHY infiltrates: cryptococcus; CAVITARY lesions: PCP, coccidiomycosis

Front 23

most common cerebral mass lesion in AIDS pts

Back 23

toxoplasmosis

Front 24

toxo vs cns lymphoma

Back 24

CNS lymphoma: single mass, no improvement with empiric tx (sulfadiazine + pyrimethamine), 90% cases CSF positive for EBV DNA

Front 25

tx for MAC

Back 25

clarithromycin, ethambutol, rifabutin

Front 26

drugs in HAART

Back 26

3: 1) nnRTI/protease inhibitor, 2+3) nRI

Front 27

prophylaxis in AIDS

Back 27

CD4 < 200: BACTRIM (pcp, toxo); CD4 < 50: CLARITHYROMYCIN / AZITHROMYCIN (mac)

Front 28

most common sx a/w periph vascular dz

Back 28

intermittent claudication: pain, ache, fatigue, discomfort in legs a/w exercise, relieved with rest

Front 29

use of ankle-brachial index (ABI) in PAD (periph arterial dz)

Back 29

ABI: nl: >1.0; claudication: 0.41-0.90; critical leg ischemia: <0.4

Front 30

meds used to tx PAD

Back 30

treat RISK FACTORS (SMOKING, htn, hchol); ANTIPLATELET agents (aspirin, clopidogrel); PENTOXIFYLLINE (inc RBC elasticity --> dec bld viscosity); CILOSTAZOL (PDEi ==> vasodilat, antiplatelet)

Front 31

tx of critical leg ischemia

Back 31

?revascularization (eval via angioplasty / imaging), tx w/ balloon, stent, locally-delivered thrombolytic

Front 32

most important intervention for PAD

Back 32

smoking cessation

Front 33

hypertension workup

Back 33

LABS: gluc, Cr, Ca, fasting lipids (LDL, HDL, TG), U/A, ECG

Front 34

Stages of HTN

Back 34

Pre-HTN: <140/90; Stage I HTN: 140-160/90-100; Stage II HTN: >160/100

Front 35

prevalence of primary vs secondary htn

Back 35

1': 92-95%

Front 36

what clinical features raise suspicion of 2' HTN?

Back 36

age of onset (<25 or >55); presenting with malignant HTN; requiring >=3 HTN meds; suddenly uncontrolled; rising Cr with ACEi

Front 37

hormonal causes of HTN

Back 37

Cushings, Hyperthyroidism, Hyper aldo

Front 38

tx of HTN by stage

Back 38

Pre-HTN: lifestyle mod; Stage I: one med; Stage II: >= 2 meds

Front 39

target BP in HTN

Back 39

135/85, unless DM/Renal dz --> 130/80

Front 40

Which drugs are first line for HTN?

Back 40

Thiazides (dec mortality in ALL pts) and beta-blockers; ACEi in diabetes or heart failure

Front 41

lab findings in hyperaldo

Back 41

hypokalemia

Front 42

obstructive sleep apnea and HTN

Back 42

hypoxia/hypercarbia --> systemic vasoconstriction --> systolic and pulmonary hypertension

Front 43

signs of hyperthyroidism --> 2' HTN

Back 43

hyperthyroid signs (nervousness, tremor, weight loss, heat intol, etc.) + WIDENED PULSE PRESSURE (increased systolic BP, decreased diastolic BP)

Front 44

hypertensive emergencies and clonidine

Back 44

clonidine = alpha2 agonist --> increased symp sensitivity; clonidine withdrawal can cause reflex sympathetic surge --> HTN

Front 45

how do blood vessels react to hypertension?

Back 45

vasodilation (mediated by NO)

Front 46

in what range does cerebral autoregulation work?

Back 46

maintains constant cerebral perfusion with MAP 60-120 (range shifts in hypertensive patients ==> focus on SYMPTOMS not NUMBERS)

Front 47

what happens if MAP exceeds the limit of cerebral autoregulation?

Back 47

endothelial dysfunction --> vasogenic edema --> microhemorrhages --> encephalopathy

Front 48

BP goal in hypertensive emergency

Back 48

25% decrease or diastolic of 100-110 over minutes-hours

Front 49

agents used to tx hypertensive crisis

Back 49

either vasodilator (eg nitroprusside + beta blocker (to prevent reflex tachy) or combined alpha/beta anatagonist (eg labetalol)

Front 50

treatment for pheo

Back 50

surgical resection after reversal of excess catecholamine effect (alpha blockers like phenoxybenzamine, sometimes FOLLOWED by beta blocker)

Front 51

why not use beta blocker alone (or first) in pheo?

Back 51

can cause unopposed alpha stimulation --> vasoconstriction --> worsened HTN

Front 52

in what cases would you not treat hypertensive crisis?

Back 52

possible stroke -- decreasing cerebral perfusion will exacerbate ischemia

Front 53

transaminase levels in alcoholic hep vs hepatic necrosis

Back 53

alcoholic hep: levels elevated but < 500; hepatic necrosis: levels > 1000 (toxic injury, viral help, ischemia)

Front 54

clinical findings in acute hep

Back 54

prodrome of nonspecific constitutional symptoms; jaundice, hepatomegaly, dark urine (bilirubinuria)

Front 55

most common cause of acute viral hep in US

Back 55

Hepatitis A

Front 56

Hep B outcome

Back 56

depends on age; 90% of infected newborns --> chronic hep B --> ?HCC; 95% adults with new infection --> complete recovery w/o sequelae

Front 57

tx of viral hep

Back 57

acute viral hep usually self limited --> supportive tx; fulminant hepatic failure --> requires liver xplant

Front 58

findings in fulminant hepatic failure

Back 58

massive necrosis, encephalopathy, worsening coagulopathy, increasing PTT, ascites, peripheral edema, hypoglycemia, hyperammonemia, lactic acidosis

Front 59

how to use HBeAg to establish infection as chronic?

Back 59

if HBeAg elevated after 6 wks of illness --> chronic, high infectivity (in acute, would develop Anti-HBe)

Front 60

Hepatitis vaccines

Back 60

only for A and B, both > 90% efficacious

Front 61

what to do with HepB needle stick?

Back 61

give hepatitis B immune globulin (HBIg); also given to newborn of infected mother

Front 62

tx for hep b

Back 62

alpha-INTERFERON (for hep B and C); LAMIVUDINE for chronic hep B

Front 63

how much acetaminophen needed to cause hepatocellular injury?

Back 63

10g

Front 64

what drugs exacerbate acetaminophen injury, and how?

Back 64

INDUCTION of P450: ethanol, phenobarbital; or DEPLETION of glutathione: malnutrition, alcoholism, AIDS

Front 65

how to evaluate whether or not acetominophen toxicity has occurred?

Back 65

evaluate serum acetaminophen levels relative to time since ingestion (using nomogram)

Front 66

tx for acetaminophen tox

Back 66

gastric decontamination with charcoal + administration of N-acetylcysteine

Front 67

uses of oral lamivudine

Back 67

tx for chronic hep B + antiretroviral prophylaxis for HIV positive patients

Front 68

three most common causes of acute hep w/ transaminase > 1000

Back 68

viral infection, toxic exposure, and ischemic injury

Front 69

what labs first show acute hepatic injury?

Back 69

elevated PT evident before decreased albumin (because PT has shorter half life)

Front 70

main clinical findings in polycystic ovarian syndrome (PCOS)

Back 70

infertility, virilization, hirsutism, obesity, amenorrhea/oligomenorrhea

Front 71

hypothyroidism can cause what other pituitary abnormality?

Back 71

hyperprolactinemia

Front 72

primary vs secondary ameonorrhea

Back 72

PRIMARY: absence of menarche by age of 16 (usually genetic/congenital); SECONDARY: absence of menstruation for >= 3mo in woman with normal past menses

Front 73

oligomenorrhea

Back 73

infrequent menses (intervals > 40d) or < 9 menses/yr

Front 74

main causes of amenorrhea

Back 74

1) Pregnancy; 2) problems of genital outflow; 3) hypothal-pit-ovarian axis (eg PCOS, hypothyroidism)

Front 75

types of hypothal-pit-ovarian axis disorders resulting in amenorrhea

Back 75

45% hypothalamus (nutrition, excess exercise, stress, infiltrative diseases); 30% PCOS; 18% pituitary (neoplasms, empty sella syndrome, sheehan syndrome)

Front 76

causes of hypothyroidism

Back 76

95% primary thyroid failure (hashimoto's -- most common in US; surgical/radioactive; graves); IODINE deficiency (worldwide)

Front 77

what causes and characterizes myxedema?

Back 77

often caused by severe hypothyroidism; accumulation of hydrophilic polysaccharides in dermis --> dull facies, swollen eyes, doughy extremities, enlarged heart, ileus, delayed relaxation of DTR

Front 78

what causes excess thyroid binding globulin (TBG)?

Back 78

pregnancy, oral contraceptives

Front 79

how does T3RU relate to TBG?

Back 79

inverse relationship -- as TBG increases, more of the radioactive T3 is bound --> dec T3RU

Front 80

what T4 and T3RU levels suggest hyperthroidism? Hypothyroidism?

Back 80

hyperthyroidism: elevation of both T4 and T3RU; hypothyroidism: decrease of both T4 and T3RU;

Front 81

what effect does thyroid hormone have on lipids?

Back 81

dec thyroid --> elevated total chol and LDL

Front 82

levothyroxine vs dessicated thyroid extract to tx hypothyroidism

Back 82

levothyroxine (T4) preferred because less bolus effect -- thyroid extract can be varying ratios of T3:T4, unpredictable effects, tachyarrhythmia risk

Front 83

what antibody looked for in hashimoto's?

Back 83

antimicrosomal antibody (aka antithyroperoxidase antibody)

Front 84

causes of ascites

Back 84

CIRRHOSIS (--> portal htn); OTHERS: malignancy, etc. (differentiated by paracentesis)

Front 85

MCC chronic hep

Back 85

viral (B, C), EtOH, drugs/toxins, AIH; less common: metabolic (hemochromatosis, Wilson's, alpha1-antitrypsin deficiency)

Front 86

tx for hep C

Back 86

alpha-interferon + ribavirin

Front 87

tx of portal htn

Back 87

non-selective betablockers (eg propanalol) to lower portal pressure; octreotide if variceal bleed (constricts splanchnic circ)

Front 88

tx of ascites

Back 88

sodium restriction, spironolactone/furosemide, therapeutic paracentesis

Front 89

causes of ascites with SAAG > 1.1

Back 89

PORTAL HYPERTENSION (cirrhosis, portal vein thrombosis, budd-chiari, CHF, constrictive pericarditis)

Front 90

causes of ascites with SAAG < 1.1

Back 90

peritoneal carcinomatosis, tuberculous peritonitis, pancreatic ascites, bowel obstruction / infarction, serositis (eg lupus), nephrotic syndrome

Front 91

spontaneous bacterial peritonitis (SBP) vs secondary peritonitis (eg 2/2 to intestinal perforation)

Back 91

SBP usu 1 org in fluid; 2/2 peritonitis usu polymicrobial

Front 92

PBC epi and clinical presentation

Back 92

epi: mid-aged women; clin: pruritis, fatigue, 2-5x alkphos

Front 93

most common causes of acute pancreatitis in the US (3)

Back 93

1) EtOH, 2) biliary tract dz (incl gallstones), 3) hypertryglyceridemia (>1000)

Front 94

causes of acute pancreatitis

Back 94

GET SMASHeD (Gallstones, EtOH, Trauma, Steroids, Mumps/CMV, Autoimmune, Scorpion sting, Hypercalcemia/Hyperlipid/HyperTG, Drugs (sulfas, furosemide, thiazides etc)

Front 95

most common cause of "idiopathic" pancreatitis (no gallstones on ultrasound, no predisposing factors)

Back 95

BILIARY TRACT DISEASE (biliary sludge [microlithiasis] or sphincter of Oddi dysfunction)

Front 96

describe the pain in pancreatitis

Back 96

severe upper abdominal pain radiating to back, relieved by sitting up/bending forward, exacerbated by food, often accompanied by n/v, low grade fever, volume depletion

Front 97

two labs for pancreatitis and the difference

Back 97

AMYLASE and LIPASE; amylase elevated within hours, stays for 3-4d (longer in urine), not specific to liver; lipase elevated longer, more specific to pancreas

Front 98

tx of pancreatitis

Back 98

mostly supportive, keep pt NPO, IVF; narcotics like meperidine given for pain (no biliary colic)

Front 99

why is pancreatitis patient hypovolemic? (3)

Back 99

1) Inflammation --> third spacing; 2) pulm edema (2/2 ARDS or myocardial dysfunction); 3) dec PO intake, vomiting

Front 100

what is a phlegmon?

Back 100

a solid mass of inflamed pancreas with patchy areas of necrosis, can become abscess (suspect if fever/leukocytosis)

Front 101

characteristics of acute cholecystitis on ultrasound

Back 101

gallbladder wall thickening, pericholecystic fluid

Front 102

amylase levels and severity of pancreatitis

Back 102

unrelated

Front 103

when to suspect complication of pancreatitis?

Back 103

abd pain, mass, persistent hyperamylasemia in pt w/ prior pancreatitis ==> PHLEGMON / NECROSIS / ABSCESS / PSEUDOCYST

Front 104

temporary management of AV node block

Back 104

atropine or isoproterenol (sympathomimetic)

Front 105

neurogenic causes of syncope

Back 105

disturbance of autonomic function --> orthostatic hypotension (eg DM, parkinsonism); also, seizures

Front 106

main causes of syncope

Back 106

excess vagal activity (vasovagal); orthostatic hypotension (volume depletion, neurogenic, drug induced); cardiogenic (arrhythmias, outflow obstruction, PE, severe pHTN)

Front 107

MCC syncope

Back 107

vasovagal (usu preceeded by prodrome of nausea, yawning, diaphoresis -- think of someone fainting at sight of blood)

Front 108

causes of 2nd degree heart block

Back 108

Mobitz I (wenckebach): results from inferior MI; Mobitz II: block within bundle of His

Front 109

what is carotid sinus hypersensitivity

Back 109

vagally mediated cause of syncope in older men, often occurs when head turned to side, when wearing tight collar, or shaving neck over area