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378 Cards in this Set
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why do you give sodium bicarb with TCA OD? |
increase pH and extraccelular sodium , decrease drug avidity to inhibit sodium channels in His-Purkinje (TCAs cause QRS prolongation) |
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ischemic EKG features |
deep T wave inversion in anterior leads |
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blue toes with intact pulses |
atherosclerotic plaque causing "blue toe syndrome" |
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why do you get thrombocytosis |
fe def anemiai and inflammation |
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treatment of rheumatoid arthritis |
NSAIDS corticosteroids, DMARDS- methotrexate, sulfasalzine, hydroxychloroquine, penicillamine TNF antagonists- etanercept, infliximab, adalimumab help within weeks immunosuppressives (asathioprine, leflunomide, hypsporine, cyclophosphamide (but more toxic |
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when do you see polyderma gangrenosum |
chrons (and RA) |
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what does sed rate tell you |
inflammatory process |
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what happens if you get parvo b19 while prego |
hydrops fetalis - miscarriage |
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people with young kids, polyarthritis think to test for |
parvo |
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DS-DNA is also associated with lupus and ? |
nephritis - goes up with active disease |
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what is RNP (ribonucleopeptide) associated with |
MCTD- mixed CT disease- hight incident of pulmonary HTN, ILD( interstitial lung disease), and myositis |
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what protein is associated with congenital heart block, sjogrens, subacute cutaneous lupus, neonatal lupus? |
SSA/B (Ro/La) |
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what kind of lupus doesn't grow hair back? |
discoid lupus- regular SLE lupus grows back. discoid lupus is super disfiguring |
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what is rheumatoid factor |
measure of immune complexes- (normally Fab-Fab, this is Fc-FaB.) its wrong but still an immune complex increased in RA, SLE, sjogren, dermatomyositis, HCV |
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why do we order haptoglobin (acute phase protein) |
look for hemolysis |
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what are associated with pseudogout |
hypomag hyper and hypoPTH, hemochromatosis (HFE protein- increased iron absorption- 1. DM (fibrous of pancreas) 2. micro nodular sclerosis 3. bronze skin 4. arrhythmias/HF 5. arthritis- PSEUDOGOUT 6. hypogonadism- infertility tx: phlebotomy or deferoxamine) can be from red cell infusion. when those red cells die they release all that iron |
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rheumatoid arthritis emial: kareich53@gmail.com |
kareich53@gmail.com |
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who do you manage with cardioversion |
people with persistent tachy causing hemodynamic instability with narrow OR wide QRS. (if stable- vagal maneuvers)- if all else fails- adenosine |
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dipyrimadine and adenosine have what effect on the heart? |
vasodilators dipyrimadine CCB adenosine adenosine slows conduction through AV node |
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pulsus parvus and tardes |
aortic stenosis |
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early diastolic murmur and hyper dynamic pulse (bounding/water pounding) |
aortic regurg |
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decreased tolerance to glucose is a well known side effect of what kind of diuretic? |
thiazides |
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thiazide side effects |
hypokalemia/natermia, hyPER calcemia, retain URIC ACID, INCREASED LDL and trigs |
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digitalis causes what arrhythmia |
atrial tacky with AV block (digitalis increases ectopy in atria and ventricles) |
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how is atrial tacky different than a flutter? |
a tachy is a little slower ( 150-250) and P waves are different (the closer to AV node the more it looks normal though) |
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SE of amiodarone (K channel blocker) |
hypo/hyperthyroid, blue/gray skin, optic and peripheral neuropathies, elevated transaminases, hepatitis, bradyarrythmias, torsades, CHRONIC interstitial pneumonitis = CHECK PFT, LFT, TFT |
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who do you give amiodarone |
ventricular arrythmias and patients with rhythm control issues with a fib and underlying left ventricular systolic dysfxn adenosine for vtach/SVT adenosine slows it down, amiodarone fixes beats |
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when can't you feel PMI? |
cardiac tamponade |
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what murmur does valsalva maneuver ACCENTUATE? as does standing from a supine position- decrease venous return |
hypertrophic cardiomyopathy - hand grip lessens |
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what murmur does hand grip accentuate? |
mitral regurg |
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what murmur is best heard is L lateral decubitus with bell? while coughing |
mitral stenosis |
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what murmur is best heart with patient leaning forward exhaling? |
aortic regurg |
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wide QRS suggests ectopic signal from ___ the AV node |
below av node- wide QRS. above AV node, narrow QRS |
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hypotensive, no pulmonary edema, clear lung fields, elevated JVD (in contrast to pulmonary edema with hypotension) |
Right ventricular infarct. LV infarct will have pulmonary edema |
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how do you fix RV impairment |
increase PREload- give volume with saline or colloid solution -- aka NOT DIURETICS or NITRATE |
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acute heart failure and shock + new onset holosystolic murmur acute, within 5 days post MI new onset holosystolic murmur is this and papillary muscle rupture (flash pulmonary edema/ probably was RCA) |
Ventricular septum Rupture(within 5 days) L>R shunt, "step up" oxygen bewten r atrium and ventricle *vs FREE WALL RUPTURE (5days - 2 weeks) shock/chest pain JVD distant heart sounds (pericardial effusion) |
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how do you treat cardiogenic shock |
after load reduction- IV nitro and dopamine |
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what are late complications weeks after acute MI |
ventricular anerusm (persisting STelevation) and dressler syndrome (immune pericarditis, pleuritis and fever) st elevation: whole wall infarcted st depression: only some of the wall infarcted |
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how do you treat dressler syndrome |
NSAIDS, maybe prednisone |
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what does high output cardiac failure (AVF) look like? |
widened pulse pressure, strong peripheral pulsation, brisk carotid upstroke, increased cardiac preload, increased CO, tacky, flushed extremities, LVH to meet increased oxygen requirements of peripheral tissues |
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causes of a fib? |
HTN and atherosclerosis- most common (I SMART CHAP) |
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what does I SMART CHAP stand for |
causes of a fib- inflammation, surgery, meds (theophylline, caffeine, digitalis) atherosclerosis, rheumatic HD (chronic is mitral stenosis, acute is mitral regard), thyrotoxicosis, Congenital HD (ASD, abstain), HTN, alcohol, pulmonary dz (embolus) |
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how do you fix INR below 6 w/o bleeding? |
hold warfarin |
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how do you fix INR above 6 without bleeding? |
vitamin K |
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how do you fix WPW (delta wave/widening QRS via supraventicular ectopic focus) in patients with AF? --(i thought the S2-O2 snap shortening was this but was thinking of Rheumatic HD's mitral stenosis) |
unsable- DC cardioversion. stable- procainamide or ibutilide rate controll via bblockers, diltiazem/verapamil/digoxin will cause paradoxical increase in tacky |
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how do you treat afib |
stable- RATE control first: nodal blocking agents: digoxin, bblock, diltiazem/verapamil to control VENTRICULAR RATE. unstable- DC cardioversion |
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what increases HR in WPW |
nodal blocking agents- dilt/veram, bblocker, digoxin |
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what are "alarm symptoms" associated with dyspepsia? |
bleeding, recurrent vomiting, dysphagia, anemia, weight loss |
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what is triple therapy for h pylor |
amox, clari, PPI (omeprazole) |
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how do NSAIDs cause ulcers? |
inhibit GD PG synthesis= PG is a vasodilator so less blood flow to mucosa so less mucus and less bicarb |
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what do you suspect if the patient with ulcers doesn't take NSAIDS and they're H pylori negative? |
ZE- gastric secreting tumor usually in pancreas - test for this by measuring gastrin levels |
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most common electrolyte imbalance in hospital? |
hyponatremia |
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what are causes of water gain/hyponatremia? |
polydipsia, ADH release (via pain, (esp post op) drugs, nausea, SIADH), glucocorticoid deficiency (cortisol acts as a diuretic) , hypothyroid, chronic renal insufficiency (can't get rid of the water) |
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what are primary sodium gains, followed way water gain, causing hyponatremia? |
heart failure, cirrhosis, nephrotic syndrome- therefore loss of aldosterone |
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what are causes of pseudo hyponatremia? |
hyprlipid/protein/glycemia, post transurethral resection of prostate/bladder tumor |
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why does resection of prostat/bladder tumor cause hyponatremia? |
mannitol containing bladder irrigation fluid used - fix glucose level to fix hyponatremia |
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lack of what 2 hormones cause water retention/ are permissive for free water excretion? |
thyroid hormone and cortisol. lack of cortisol and thyroid hormone causes max concentrated urine with water retention and hyponatremia |
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can't retain sodium, (no aldosterone), hyponatremic |
addison disease (adrenal insufficiency) |
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what can mimic SIADH? (increased sodium retention/ further increased water retention- hypervolemic hypernatremia) |
cortisol deficiency (SIADH is euvolemic tho) |
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euvolemic hyponatremia |
SIADH |
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causes of SIADH/vasopressin |
pain, CNS disease, post op, paraneoplastic (SSC) cyclophosphamide, carbamazepine |
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SIADH is diagnosis of exclusion, so how do you confirm it? |
hypoosmolar, euvolemic, concentrated urine (OSMOLALITY above 150-200, SODIUM above 20), normal adrenal and normal thyroid |
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what are other clues to show SIADH |
low BUN and low uric acid levels |
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how do you treat SIADH |
water restriction or rapid partial correction with hypertonic 3% saline (can be given with lasix to prevent fluid overload- end up peeing out half normal saline so net is gain of sodium) |
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what is physiologic cause increase in vasopressin/ADH |
post op pain, |
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hyponatremia with hyperkalemia/acidosis is suspicious of? |
adrenal insufficiency-no aldosterone (adison's disease) |
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transtubular potassium gradient is what in Liddle syndrome? (consituaionally active sodium channels in epithelial cells on the collecting tubule) |
greater than 10 |
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stages of HTN |
pre- 140/90 1- 150/99 2- 160/100 |
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what do you start to think if you have uncontrolled HTN that doesn't respond to meds |
hyper aldo
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flash pulmonary edema, HTN, |
b/l renal artery stenosis papillary muscle rupture post MI before day 5 (macrophages cleaning) |
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what thiazide do you use with loops to increase urine outpout |
metolazone (jumpstarts loop diuretic) |
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why do you use ACE/ARB with 2 grams of proteinuria? |
to slow down protein loss - but its contraindicated in renal failure because it can cause hypokalemia |
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normal albumin:creatinine ratio |
35 |
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what can NSAIDS cause in terms of renal |
secondary HTN, because PG dilate the afferent arteriole, restricting renal profusion. NSAIDS stop PG production-- eventually ATN because no |
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what does liddle syndrome look like? |
HTN, hypokalemia, met alkalosis |
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25% rise in creatinine is EXPECTED when you add what drug? (or else up the dose) (except in advanced CKD) |
ACE |
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how do you rule out renal artery stenosis? |
CT with ganollidium contrast (does not lead to ATN but DOES lead to nephrogenis systemic fibrosis) |
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what kind of contrast leads to ATN? |
ionized contrast- if you do get contrast nephropathy- pre medicate with N acetylcysteine or IV sodium bicarb |
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what does gadolinium dye lead to |
nephrogenic systemic fibrosis. DO NOT GIVE TO advanced CKD people used to determine if someone has b/l renal artery stenosis- flash pulm edema |
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what drugs effectiveness go up with CKD? |
loops effectiveness increase with CKD |
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what cardiac change do you see with HTN from hyperthyroid? |
widened pulse pressure- high output failure (narrow pulse pressure with aortic regurg) |
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what 2 groups of patients do you NOT USE a BBLOCKER on |
CHF (already have reduced EF) and asthma (can cause bronchoocnstriction) |
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what antibiotic can cause hyperkalemia by blockin epithelial sodium channels in the collecting tubule |
trimethoprim (antibiotic) |
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what bug causes pneumonia basically only in hospitalized or people with recurrent influ or post influenza? |
s aureus |
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what tests should be ran on every patient with BPH be tested for initially? |
urinalysis (for hematuria) and serum creatinine (only goes up when theres BL obstruction- do US to rule out any other cause besides BPH) |
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how is COPD treatment different than the treatment for asthma |
asthma prevention is corticosteroids and COPD is long acting anticholinergic inhaler (do spirometry before and after albuterol to differentiate the 2) asthma is steroids COPD is anticholinergic |
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what is POSTERIOR uveitis and arterial and venous vasculitis? (also ulcers) |
behcets- VENOUS vasculitis |
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what does teriparatide (PTH analogue- so its paradoxical) treat? |
osteoporosis |
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what else can you use to treat osteoporosis? what do they cause |
alendronate (bisphos)- can also be used for pagets. cause jaw necrosis and proximal femur fracture |
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what drugs cause osteoporosis? t score -2.5 |
antisz, PPI, gluccocorticoids (*), SSRI PPI- hypomag and hypokal |
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what diabetes meds will help you lose weight? how? |
SGLT2 inhibitor (canaglifozin, empaglifozin) because you're peeing out a ton of sugar by acting as a diuretic- peeing out 300 calls of sugar a day. GLP1 agonist- exanitide |
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most common causes of oligomenorrhea? |
hypothyroid and PCOS |
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how do you diagnose PCOS? |
need 2: increased testosterone, LH:FSH >2 and irregular menses or pelvic US treat: weight loss and OC. clomiphene if trying to get prego |
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what is the best test for histo? (cough in immuncompetent- systemic resp (reticuloendothelial like cytopenias/megalies) in AIDS |
histo antigen (not antibody) in urine (faster) or serum hidden halos ohio |
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how do you treat histo? |
itraconizol(anti fungal) - (if severe ampho B followed by itraconizol fora year) |
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what are associated features of brocas (dominant frontal) and wernikes |
brocas- right (contralateral) hemiparesis. wernikes- right superior visual defect |
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which vaccines are live attenuated? (CD8+ T-cell response= INTRACELLULAR pathogens) |
zoster (higher titter to induce cell mediated response) and varicella, and MMR, intranasal influenza |
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who gets screened for a triple A |
MEN over 65 who have ever smoked |
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3 most common organisms for CAP |
s pneumo, moral cat, h influx (Same as OM- treat w amox) if pneumonia- treat with azithro |
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pneumonia with preceding GI symptoms |
legionella (chlamydia psittaci w bird exposure) CMV if immune compromised (form ulcers) |
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pneumonia with diffuse interstitial infiltrate NEVER with pleural effusions |
PCP- NO EFFUSIONs, BUT for can have pneumo's |
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pneumonia with cavitation suggests? what tests are unnecessary in these patients? |
necrotizing pneumonia- S. aureus, TB, or GN (klebsiella) don't need serial CXRs because it takes weeks to resolve |
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when would you do serial CXRs in patients with nectortizing (s. a, TB, pleb)? cavitation |
if they have pleural effusion, a necrotizing infection, not showing improvement |
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how do you treat uncomplicated OP pneumonia? |
macrolides (azithro) or quinolines (levofloxacin) |
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how do you treat hospitalized ICU patients with CAP? |
IV (or beta lactam:cephalo, carbepenem) plus macrolide or beta lactam (cephalo, carbepenem)+ fluoroquinolone (levofloxacin and ceftriaxone) beta lactam (cephalosporin or penem) + macrolide OR fluoroquinolone NON ICU inpatient: fluoroquinelone OR betalactam (cephalo, carbepenem) + macrolide |
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what do you cover for when you're suspecting aspiration pneumonia? |
the usuals- S pneumo and h influx, Gram negatives and oral anaerobes |
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sepsis/DIC (causing hemorrhage of this organ- fried water ), histo, coccidio (granulomatous disses), XLinked adrenoleukodystrophy are causes of?--- and people with AIDS with MAC or CMV may develop?? |
primary adrenal insufficiency- no cortisol OR aldosterone being made (addison's disease is the most common cause though) CHRONIC adrenal insufficiency: autoimune destruction, TB, metastatic carcinoma (LUNG- small cell- LOVES ADRENAL.) |
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when can the patient with adrenal insufficiency be able to maintain moral levels of aldosterone so they're only deficient in cortisol? |
secondary adrenal insufficiency- somethings wrong with the pituitary its not making ACTH (usually exogenous corticosteroid use) |
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what is ab pain, n/v, fever, hypotension, tacky, and weakness? |
addisonian crisis/ acute adrenal insufficiency (adrenal insufficiency) |
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cortisol deficiency labs show ? |
hypoglycemia and eosinophilia |
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low aldosterone labs? |
hyponatremia, hyperkalemia, met acidosis, azotemia |
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how can you tell adrenal insufficiency from shock? |
adrenal insuff has hypoglycemia (vs hyper glycemia in shock) and hypotension that don't respond to pressers but DOES respond to steroids. (because theres no aldosterone either because that comes from the adrenal gland as well). when theres only ACTH missing, renin is fine so theres no hypotension or hyperkalemia or hyponatremia. |
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what is gold standard for testing HPA axis? |
insulin glucose tolerance test |
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gluccocorticoid drug |
hydrocortisone - cortisol, dexamethason |
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mineralocorticoid (aldosterone) drug |
fludrocortisone- aldosterone |
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long term complications of gluccocorticoid excess |
DM, HTN, obestiy, osteoporosis, cararact |
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when do you admit patient with upper resp symptoms? |
curb 65 (confusion, uremia (BUN>20), resp rate >30 , hypotension <90 , older than 65) |
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what is SIRS? sepsis? shock. |
sepsis is sirs with a source. S rr >20, HR >90, WBC 4-12k, temp 38-36. septic shock is when you need pressers. |
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on UA what does monomorphic RBC mean? polymorphic? |
monomorphic is source of RBC is bladder, dysmorphic means RBC is from glomerulus |
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what is PR3 anca another name for? |
C-anca- wegners |
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CR4 is a measure of |
MPO/P anca : microscopic polyangitis- lung and kidney involvment (NECROTIZING vasculitis like weighers but without C anca or sinus involvement and no granulomas like weighers) |
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proximal muscle weaknes, rash on shoulders and back, scales/erythemetous on dorsum of fingers or upper eyelids on hands is the presentation of what |
dermatomyositis presentation (gottron's papules an heloptrope eruption)- due to immune mediated muscle injury |
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what is sarcoid and what are common findings? how do you treat it? |
common findings in sarcoidosis are cough and erythema nodosum, hilar adenopathy, hypercalcemia, elevated ACE levels, non caveating granulomas. don't treat unless symptomatic- with corticosteroids |
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what joints do osteoarthritis affect? whats shown on X-ray |
DIPs- X-ray shows osteophytes, narrowed joint spaces, sunchondral bone cysts. NON INFLAMATORY= NO SYSTEMIC SYMPTOMS in OA |
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what is seen with psoriatic arthritis? |
DIP, dactylitis (sausage digit), nail pitting and psoriatic plaques |
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stiffness and pain of shoulders and pelvic girdle. fever and weight loss are signs of what? what is this associated with? |
polymyalgia rheumatica- systemic signs with shoulder and pelvic pain. associated with temporal giant cell arteritis polymyositis: symmetrical proximal muscle weakness 2/2 pain. DTR are normal, elevated CK and normal ESR. can be seen with raynauds, ILD- but CHECK THYROID FIRST |
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what joints do RA (and SLE ) present with? how do X-rays differ? |
RA and SLE are MCP and PIP. Xray with RA shows joint space erosions, juxtra artiular demineralization (OA has subchondral bone cysts and osteophytes) RA has soft tissue swelling. |
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how can you tell RA from SLE? |
both have hemotologic abnormalities and fatigue, but RA won't have oral ulcers or renal disease like SLE might |
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what chelates calcium, making oxaloacetate more available for absorption, leading to calcium oxalate (most common) stones? |
SI disease or resection or chronic diarrhea leads to fatty acid and bile salt malabsorbtion, leading to increased calciumchellating and increased oxalic acid absorption and calcium oxalate stones) calcium gets chelated out and only oxalate gets resorbed |
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when do you get calciumPHOSPHATE stones? |
primary hyperparathyroidism and RTA (renal tubular acidosis)- form in acidic urine phosphorus trashing hormone- phosphorus sitting in tubes. needs acid to form so thats why RTA |
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when do you get uric acid stones? |
increased cell turnover (hyperuricemia/hyperuricosuria) and dehydration radioLUCent |
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what needs to be positive to make cysteine (hard, radio opaque, hexagonal) stones? made of dibasic amino acids (cysteine, lysine, arginie, ornithine) |
family history- its from and inborn error or metabolism. defective transport of dibasic amino acids by the brush borders of renal tubular an intestinal epithelial cells. positive cyanide nitroprusside test |
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what are hollenorst bodies and what are they a sign on? |
cholesterol particles, can be seen in the eye. look for these with armatosis fugal (painless vison loss) can be sign of impending stroke via embolization |
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when do you see left atrial thrombi? |
left atrial thrombi in patients with mitral stenosis (can't get through so sitting there) |
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when do you see left ventricular thrombi? |
in patients with MI (akinesis) |
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whats the preferred treatment of hepatic encephalopathy? (via cirrhosis- high serum amonia) what if they don't improve within 48 hours? |
1. fluids/ supportive care- fix electrolytes/nutrition W/O restricting protein if you can, 2. treat cause 3. lower serum ammonia give non absorbable disaccharides- 4. add rifaximin (antibiotic) to reduce ammonia producing bacteria in colon if it doesn't work lactulose, lacitol. acidifies the colon and stimulates conversion of ammonia (soluble) no non absorbable ammonium (ammonia trap). |
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what is epislceritis strongly associated with? |
RA and inflammatory bowel disease. |
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most common extra articular manifestation of ankylosing spondylosis? |
anterior uveitis |
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what 3 rheumatology diseases are associated with oral ulcers |
SLE, chrons, Behcets |
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what is hereditary telangiectasia? (osier weber rendu syndrome) |
diffuse telangectasias (blanch), diffuse AVM in (mucus membranes, skin, GI tract), recurrent epistaxis. AVMs can be in lungs- hemoptysis or in the heart- chronic hypoxemia. (clubbing) |
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all patients with idiopathic thrombocytopenia puerpera should be screened for ? |
HIV and hep C. if still nothing- BM biopsy |
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what acute phase reactant is decreased in iron deficiency anemia but increased in ACD? |
ferritin |
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normal RDW with microcytic anemia ? |
chronic disease, thalassemia, |
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what blood value in increased with chronic inflammatory disease, malignancy, or liver injury? |
serum ferritin (low in FDE, but can be high if associated with chronic disease- RA, hodgkin, hepatitis( |
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what usually leads to microcytic anemia with uniform RDW and excess ferritin |
anemia of chronic disease |
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AMS, fever, focal neurologic deficits without nuchal rigidity or signs of meningitis |
arbovirus encephalitis- east//western equine, st lois, west nile also cryptococcus is chronic cough with no signs until way later when they vomit. still doesn't look like meningitis |
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what meningitis has similar findings to meningococal meningitis but without acute onset of purpura/skin lesions? |
pneumococcal meningitis |
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firm, hyper pigmented nodule on LE most often. dimples when pinched or "buttonhole" sign |
dermatofibroma |
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ultra short acting blocker used for rapid rate control in a flutter or a fib? |
esmolol |
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most common cause of lower GI bleeding in elderly? |
diverticulosis (bleedings from right colon) from low fiber diet |
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how can you tell familial hypocalciruic hypercalcemia (abnormal calcium sensing receptors on the parathyroid cells and renal tubules) from hyperparathyroidism? |
FHH has low urinary calcium levels because there are defective calcium sensing receptors on the renal tubules, causing excess resorbtion. urine calcium/creatinine clearance ration is <.01 in FHH and over .02 in primary hyperpara. FHH has mild/no symptoms and doesn't need to be treated |
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what test compares proportions of a categorize outcome? (high or normal with something present or absent) what compares two means? the means of three or more variables? |
chi square compares proportions. T (general population) and Z(same population without disease) compare 2 means. ANOVA compares means of 3+ variables |
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mosquito borne illness, causes polyarthralgias, lymphopenia, rash, fever, and thrombocytopenia from caribean? |
chikungunya fever |
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3 hallmarks for normal pressure hydrocephalus |
gait disturbance, urinary incontinence, dementia |
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indications for aortic valce replacement are? |
symptomatic, syncope, gettting CABG, LV hypertropy >55 mm |
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dot hemorrhages and hard exudates |
diabetic retinopathy |
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what is a BAD prognostic sign in patients with acute renal failure? |
oliguria |
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anuria differential? |
acute obsuction, cortical necrosis, vascular catastrophes (dissection) |
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cephalosporins, PCNs, sulfonamides, methicillin, rifampin, pyelonephritis, HIV can cause what kind of intrinsic acute renal failure? |
tubulointerstitial nephritis (isosthenuric urine, mild proteinuria, leukocytes, white cell casts, urinary eosinophils) |
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vasculitis, cholestrol emboli syndrome, HUS/TTP, post infection, immune complex diseases ( MPGN, infection, SLE, cryoglobulinemia) cause what kind of intrinsic acute renal failure |
glomerulonephritis |
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what are causes of ATN? |
nephrotoxic (aminoglycosides, radio contrast, chemo) and ishemic (hypotension, vascular catastrophe) |
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what are cause of pre renal acute renal failure? |
hypotension, diuretics, burns/sepsis/sirs, nephrotic syndrome (edema, no protein in blood), cirrhosis with portal hypertension, ACE inhibitors, NSAID, CHF, tamponade |
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what kind of renal failure can't concentrate urine, so urine osmolaliy is equal to serum osmolality. specific gravity is 1.01 |
post renal failure |
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obstruction with leukocytes in urine means? |
prostatic hypertrophy.(b/l obstruction) normal microscopic findings on UA (no WBC) with obstruction is compression from a tumor. (unilateral obstruction) creatinine also only rises with b/l obstruction |
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isosthenuric urine (osmolality same as serum) proteinuria, muddy brown granular casts |
ischemic and nephrotoxic ATN acute tubular necrosis |
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moderate/severe proteinuria, RBC casts |
glomerulonephritis |
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isosthenuric urine, mild proteinuria, leukocytes, white cell casts, urinary eosinophils |
tubulointerstitial nephritis (interstitial nephritis and pyelo) |
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what measurement differentiates between oliguric pre renal failure from oliguric ATN? |
Fena. Fena less that 1% pre renal failure (urine sodium will also be low) because its being absorbed Fena more than 2% is ATN (because tubules aren't resorbing sodiumcorrectly) |
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what do you give to ARF people with hyperkalemia immediately? |
calcium to stabilize the myocyte membrane. it won't lower potassium though (short QRS) give magnesium to people with torsades (long QRS) |
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what drug exchanges potassium for sodium in the colon, give to hyperkalemics if they don't make urine (so you can't give them loops) |
sodium polystyrene sulfonate (kayexalate)- may cause bowel necrosis |
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most common cause of aortic regurg in developing countries? in developed countries? |
developing- rheumatic HD most common cause of aortic regurg. Bicuspid aortic valve is the most common cause of aortic regurg in developed countries in acute rheumatic fever, its mitral regurg. CHRONIC rheumatic disease= mitral stenosis then aortic stenosis aortic stenosis from wear and tear won't have mitral involvement and not together on the corners (pathos) leads to MAHA |
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what is required for the diagnosis of acute glomerulonephritis? |
RBC cast (inflammatory cast) or dysmorphic RBC (going through damaged glomeruli) |
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what are people with nephrotic syndrome predisposed to? |
abnormal lipid metabolism, hypercoagulablity (renal VEIN thrombosis-)= MI THEY NEED STATINS. they also lose a lot of vitamin D in urine=hypocalcemia=increased PTH |
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what cancer is SIADH associated with? |
small cell carcinoma of lung |
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what paraneoplastic syndrome is squamous cell cancer? |
PTHr - hypercalcemia and cavitary lung leasions |
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what paraneoplastic syndrome is is associated with adenocarcinoma? |
hypertrophic osetoarthropathy- digital clubbing accompanied by sudden onset arthropathy (wrist and hands) due to underlying lung disease |
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whats the difference between heat exhaustion and heat stroke |
exhaustion- body temp below 104. stroke above 1/4 and AMS. due to loss of thermoregulation. inefficient salt and water replacement leads to heat exhaustion |
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what cancers cause elevated calcium levels by stimulating osteoclast activity throughout direct bone marrow invasion? produce excess 1,25 vitamin d? secrete PTHrP? |
MM, leukemia, breast cancer directly invade bone marrow lymphomas (and 10% of sarcoidosis) produce excess 1,25 vitamin D _sarcoidosis produces vitamin D in the macrophages of the granulomas kidney and lung (squamous cell) cancer secrete PTHrP |
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whats standard triple therapy for uncomplicated diverticulitis? complicated? |
amp, aminoglycoside, metronidazole +amp sulbactam or ticar clav penems for complicatd diverticulits |
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most common cause of meningitis |
strep pneumo (WATCH PCN RESISTANCE W STREP PNEUMO MENINGITIS) , neis mening, GBS/agalctia in neonates or eldery or immuno compromised |
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what causes meningitis with CSF rhinorrhea via trauma or posturgical changes like ventriculoperitoneal shuts |
s aureus and epidermidis |
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what causes edema, vasculitis, coagulation of vessels, leading to severe neurologic complications like seizures, increased IC pressure, and stroke? |
brisk host inflammatory response to meningitis in subarachnoid space |
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what is meningitis in the fall and summer, with severe headache and gastroenteritis? and WBC with lymphocyte predominance |
enterovirus- cell culture or PCR |
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what meningitis has high CSF RBC count? and WBC lymphocyte predominance? |
HSV- PCR fluid to diagnose |
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HIV meningitis causes |
cryptococcus, TB meningitis, RMSF |
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what kind of WBC predominance do you see in bacterial meningitis? |
neutrophilic-- gram stain fluid |
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what test can you use for testing meningitis with S pneumo and H influ if they've been pretreated with antibiotics (most sensitive) |
latex agglutination est |
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what do you see on MRI (even though you usually do CT first to r/o mass or bleeding) w TB meningitis? |
enhancement of basal region on MRI, temorpal lobes with HSV |
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treatment for meningitis caused by strep pneumo and neis meningitis? listeria? |
ceftriaxone and vanc for strep pneumo and neis meningitis. if listeriosis is suspected start ampicillin |
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what do you give to contacts of people with suspected meningococemia or meningococcal meningitis? |
rifampin BID for 2 days |
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what is TB meningitis look like? how do you confirm it? |
nerve palsies, low glucose and high protein levels with low WBC count. CONFIRM TB MENINGITIS WITH AFB CULTURE. PCR is diagnostic but its not sensitive |
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anorexia, weight loss, night sweats, petechia, splenomegaly, glomerulonephritis, tender nodules on finger or toe pads (osier nodes), painless hemorrhagic macules o the palms and soles, (janeway), hemorrhagic retinal lesions with white centers (roth spots), splinter hemorrhages |
subacute endocarditis (viridans) vs acute- high fever, regurg, embolic phenomena (s aureus) |
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whats the most important step in diagnosis endocarditis? |
2 serial blood cultures over a 2-3 hour (24 hours if subacute) period BEFORE starting antibiotics (unless hemodynamically unstable). |
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what do fungal infections, fastidious organisms like abiotrophia, bartonella, coxiella burnetti, legionella, chlamydia, and HACEK organisms cause? |
culture negative endocarditis- (usually a result of antibiotic treatment, fastidious organisms, fungal infection other than candida) |
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what are HACEK organisms? |
haemophilus, aphrophilus/paraphrophilus, actinobacillus, actinomycetemcomitans, cardiobacterium hominis, eikenella, kingella king. (all cause culture negative endocarditis- treat w ceftriaxone) |
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stroke syndrome in febrile patient, always think? |
endocarditis |
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complications of endocarditis? |
CHF (worst) via infection induced valve damage. abscess, conduction disturbances, splenic or renal infarct/abscess MI, stroke. vaso vasorum infection--> mycotic aneuryms in cerebral circulation/valsalva sinus/aorta-->hemorrhage |
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treatment for strep endocarditis? s auras? hacek? |
penicillin G for strep viridans s aureus endocarditis-vanc empirically to cover MRSA. nafcillin +gent HACEK organisms- ceftriaxoe |
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whats surgical indications for endocarditis? |
if fungal, huge embolism risk or embolic episode, positive cultures after a week of therapy, valve endocarditis, abscess |
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whats prophylaxis for people in dental surgery? with no history of endocarditis or prosthetic valve |
amoxicillin, if allergic, ampcillin or cephalosporins |
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what treats low fibrinogen states? (bleeding disorders) |
cryoprecipitate- treat hemophilias, VWF dz, DIC cyproheptadine reverses serotonin syndrome |
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treatment for nocardia? (systemic systems, lung nodules, brain abscess) often confused with TB(presentation) actinomyces is also a acid fast filamentous/ branching rod. but it is ANAEROBIC where nocardia is aerobic. suffer granules and tx is PCN. |
tmp-smx (with brain involvement add penem) |
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smudge cells |
CLL- CHRONIC lymphocytic leukemia |
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what do you use for severe COPD exacerbations and for patients unable to take oral meds? |
IV glucocoricoids (methylpredisolone) (inhaled corticosteroids are for long term management of asthma- get thrus/oral candidiasis) |
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both seminomatous and nonseminomatous germ cell tumors produce B-HCG, how do you tell the difference? |
only NONseminonomatous germ cell tumors produce AFP. MUST BE CONFIRMED WITH Bx- bur first you do testicular US to exclude PRIMARY mediastinal and metastatic germ cell tumors, because most ANTERIOR MEDIASTINAL tumors are primary rather than metastatic. |
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what is clubbing associated with? (both primary and secondary associations) |
1. hypertrophic osteoarthropathy (painful joint enlargement, periostosis of long bones, and synovial effusions) most common cause of 2/2 is lung malignancy, CF, and L-R shunts so- clubbing in someone with COPD- LOOK FOR MALIGNANCIES |
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what is cor pulmonale? what causes it? |
right sided HF 2/2 pulmonary HTN (NOT congenital problems or left sided failure) , caused by COPD, ILD (fibrosis), obstructive sleep apnea, pulmonary vascular disease, or chest wall disorders (kyphoscoliosis) |
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what are some side effects of B2 agonists ( albuterol) |
hypokalemia= muscle weakness, arrythmias, tremor, HA, palpiatiosn- STAHL increase glucose, and insulin |
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what should be suspected in patients presenting with catastrophic worsening of respiratory symptoms |
alveolar blebs that rupture air into pleural space- =secondary pneumothorax PCP |
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what is LMW heparin? |
enoxaparin- CAN give to CKD |
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what is an anticoagulant that acts as an injection factor Xa inhibitor? ORAL factor Xa inhibitor? |
fondapainux- injection Xa inhibitor. Rivaroxaban (oral) both require RENAL clearnace- can't give to kidney failure people |
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what anticoagulant can you give to renal failure patients?
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unfractioned heparin- Lenox |
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what is an immediate ORAL AC ? |
rivaroxaban- injection Xa factor inhibitor- oral |
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who generally presents with persistent productive cough and treated with many courses of antibiotics? how do you confirm? |
bronchiectasis people - CT to confirm (over dilated bronchioles) |
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common cause of PRIMARY pulmonary HTN? |
inactivation of BMPR2 gene, leads to vascular smooth muscle proliferation/thickening of blood vessel wall- plexiform lesions increased volume, and PE (secondary causes of pulmonary HTN is hypoxemia (vasoconstriction of areas with low O2) , |
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w main organmisms in lobar (bacterial) pneumonia? bronchopneumonia (bacterial) |
s pneumo and klebsiella (aspirated)- abscess is complication because it has thick mucoid capsule/jelly sputum hepatization is lobar pneumonia |
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what are the main organisms in bronchopneumonia and what are their complications? |
s. aureus (absbess/empyema), h influ (COPD exacerbation), pseudomonas (in CF patients), M cat (COPD exas), legionella (superimposed on COPD) |
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most common cause of atypical pneumonia? second? in infants? |
myco pneumo- causes autoimmune hemolytic anemia and erythema multiforme CANNOT SEE ON GRAM STAIN doesn't have cell wall chlamydia pneumo second most common cause RSV in infants CMV if immunocompromised influenza in elderly and compromised-- 2ndary pneumonia from staph aureus 2dary bac pneumonia |
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farmer/vet, no rash, high fever, dry cough, interstitial pneumonia |
coxiella burnetti-(rickettsiasl organism on spores) q fever. atypical pneumonia because of the high fever |
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3 bugs and location of aspiration pneumonia? |
R lower lobe abscess 1. bacterioides, fuss bacterium, peptococcus |
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elevated ESR (because of inflammation), flu like symptoms, and joint and muscle aches |
polymyalgia rheumatica- associated with temporal giant cell arteritis (granulomatous) --> GIVE CORTICOSTEROIDS TO PREVENT BLINDNES , same thing but in people under 50 (granulation at AORTIC as opposed to carotid artery branch points is takayatsu "pulseless disease"- elevated ESR and treat with corticosteroids) |
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what is a NECROTIZING vasculitis that can cause increased HBsAg? affects any organ besides lung- causing HTN, neurological disturbances, abdominal pain w melena (mesenteric artery) and skin lesions, in young people |
polyarteritis nodosa "string of pears" which is FIBRINOID necrosis = NODOSa) pears is aneurysm |
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what do you see in sinus, lung and kidney involvement in weighers? |
sinusitis/nasopharyngeal ulceration, hemoptysis w b/l nodular lung infilrates, RPGN (wegners is a necrotizing vasculitis) granulomas |
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whats differences between weighers and microscopic polyangitis |
wegners- c ancca and sinus and granulomas. microscopic poly- no granulmonas, treat both with corticosteroids and cyclophsophamide |
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how do you tell the difference between the 2 p anca diseases? |
microscopic polyangitis- no granulomas churg straus- granulomas (b/c its necrotizing granulomatous vasculitis like weighers) , peripheral eosinophilia, and asthma |
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palpable (b/c theres inflammation) purpura on butt and legs, Gi bleeding, hematuria (IGA nephropathy in mesangium), usually after URI |
henoch shen purpura -IgA immune complex deposition - SELF LIMIITED DONT TREAT |
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what nephrOTIC syndrome is associated with blacks and mexicans, obesity, HIV and heroin use? |
FSGN |
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what nephrotic syndrome wis assc with breast/lung adenocarcinoma, NSADs, hep B, and SLE |
membranous nehproapthy |
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what nephrotic syndrome is assc w hep BC and lipdystophy? |
MPGN |
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what nephrotic syndrome is associated with NSAIDS and lymphoma? |
Minimal change disease |
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what does a nephrotic syndrome 2/2 amyloidosis look like |
hx of RA (leading cause of AA amyloidosis in the US) , enlarged kidneys and hepatomegaly- amyloid deposits seen in glomerular basement membrane, blood vessels, and interstitum. |
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most common COD in dialysis patients? |
cardiovascular dz |
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what can cause crystal induced AKI (drugs precipitate in tubules) |
acyclovir, sulfomamides, methotrexate, ethylene glycol, protease inhibitors |
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normal anion gap metabolic acidosis |
diarrhea, fistulas, CA inhibitors, renal tubular acidosis, uretral diversion, iatrogenic anion gap: methanol, uremia, DKA, polyethylene glycol, infection, iron, isoniazid, lactic acidosis, ethylene glycol, asa salicylates |
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conservative mngmt of uncomplicated uretral stones |
hydration, pain, alpha blockers (decreased sympathetic tone =relaxes muscular tone used for continence and decreases uretral spasm and decreases intrauretral pressure that usually prevents incontinence |
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crescendo decrescendo systolic murmur along the left sternal border without carotid ration |
hypertrophic obsctructive cardiomyopathy (interventricular septal hypertropy)- decreasing preload makes it worse (valsalva, standing. squat gin/leg raise increases preload- makes murmur better. squatting and leg raise make MVP quieter also |
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what is warfarin (blocks epoxide reductase in liver) induced necrosis? |
pain followed by bullae formation and skin necrosis on breast, butt, thighs, abdomen . weeks after you start warfarin (higher risk in protein C or S deficiency) |
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what is shiny tongue (atrophic glossitis), shuffling broad-based gait (ataxia), and neurologic abnormalities with loss of position and vibration sense? if severe enough can lead to thrombocytopenia and or leukopenia? |
pernicious anemia- b12 deficiency.--> unable to make DNA W NEURO (flat doesn't have neuro association) (often has anti-intrinic factor antibody association) thiamine deficiency is motor and sensory loss |
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isoniazid toxicity? |
peripheral nephropathy and hepatotoxicity |
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what is babesiosis? |
lxodes tick bite in NE US . enters RBC and cause hemolysis - hemolytic anemia, jaundice, hemoglobinuria, renal failure, death. really bad in people over 40, a splenic, immune compromised |
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what do you do if afebrile people with a weakly enhancing lesion in brain thats not responding to antibiotics? |
irradiate the brain- its a primary CNS lymphoma |
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how can you distinguish the difference in slurred speech, unsteady gait, and drowsiness bweetween benzo OD and opiod? with alcohol and phenytoin OD? |
opoid has resp depression and pupillary constriction. benzo doesnt have constriction or resp depression. alcohol and phenytoin will have these things PLUS nystagmus |
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why can a patient in respiratory alkalosis present with symptoms of hypocalcemia? |
alkalosis causes a shift in ionized calcium (active form) to bind to albumin- therefore causing a psedohypocalcemia without a decrease in total calcium |
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larger airway narrowing , low pitched continuous |
ronchi- bronchitis, copd or shthma. changes with coughing |
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discontinuous sound heard on inhalation- air opening wet or dry |
wet- pneumonia or CHF rales/crackles. dry crackles is like fibrosis or disease process |
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PML (progressive multifocal leukoencephalopathy) vs toxo vs primary CNS lymphoma |
PML- multiple demyelinating, nonenhancing lesions with no mass effects- no treatment, dead in 6 months toxo: ring enhangin lesion , multiple, basal ganglia. Primary CNS lymphoma: mass lesion, solitary, weakly enhancing, periventricular. EBC DNA in CSF |
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large, pedunculated exophytic papule with a collarette of scale, resemble large pyogenic granuloma or cherry angioma with constitutional symptoms. |
bacillary angiomatosis- bartonella henslae |
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gilberts vs crig naj 1 and crig nag 2 |
glibert: treatment unnecessary. unconjigated bilirubinemia (<3) 2/2 defect in UDP glucuronyl transferae gene (heterozygous asymptomatic) need trigger to set off CJ1: kernicterus (bilirubin encephalopathy) phototherapy/ plasmaphoresis helpful short term- need transplant. indirect bill 20-50 CJ2: indirect bili below 20. liver enzymes are all normal (in gilbert, CJ1 and CJ2 are normal) serum bill improves with IV phenobarbital or clofibrate , in CJ1 serum bill doe not improve dubin johnson: dark liver, conjugated hyperblirubinemia |
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whats open angle glaucoma |
asymptomatic early, then gradual loss offer a period of years, leading to tunnel vision, high pressure (cupping) . *macular degeneration affects central vision- veritcal lines are wavy (grid test)* enlarged blind spot- papilledema |
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what is shy-drager syndrome/multiple system atrophy characterized by? |
parkinsonism, autonomic dysfunction, widespread neuro signs (cerebellar, pyramidal, or lower motor neuron) - always consider when person w parkinsonism experiences orthostatic hypotension, impotence, incontinence etc riley-day/ familial dysautoomia is gross dysfunction of ANS w severe orthostatic hypotension |
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what reverses bblocker OD? (bradycardia, AV block, hypoTN, diffuse wheezing, cold/clammy extremeties, hypoglycemia) |
1. isootnic bolus, IV atropine, doesnt get better-->IV glucagon (to increase intracellular levels of cAMP - also treats calcium channel blocker OD) |
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pyuria with negative urine culture suggests? |
chlamydia or neis got urethritis sterile pyuria-- think TB |
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most common organisms for pylonephritis (WBC casts) |
e coli, e facaelis, klebsielly |
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how do you cure calcium nephrolithiasis stone? (idiopathic hypercalciurizide) |
HCTZ- calcium sparium diuretic |
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why do ESRD people get hypocalcemia? |
can't excrete phosphorus, decreased (hydroxylated) 1/25 Vit D, = increased PTH, burns out bone. - leads to osteosis fibrosis cystica, osteomalacia, and osteoporosis (Tscore -2.5) |
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disorders that cause thrombosis |
high homocysteine (CBS deficiency, B12/folate deficiency, and b6 CBS cofactor) , factor 5 leiden *ost common inherited kind of hypercoaguable state, AT3 deficiency (turned on by heparin like molecule in endothelium), prothrombin 202013, promotes prothrombin activity. high estrogen |
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what happens when you give heparin to AT3 deficiency? |
PTT will not rise. at HIGH doses, kind of helps then start coumaidn. |
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what is DIC? PT/PTT increased, fibrinogen decreased, microangiopathic hemolytic anemia (RBC shear over micro thrombi) , elevated D dimer (BEST SCREENING TEST because ENTIRE coag cascade is activated) |
pathologic coagulation (from obstrectic complications b/c amniotic fluid has tissue thromboplastin) , sepsis activation of IL1/TNF, adenomyocarcinoma mucin activated it, APL (granules coalesce forming aur rods- if they get into circulation they activate coag cascade), rattlesnake bite) activation, clot everywhere, use up platelets and factors (Decreased FIBRINOGEN) FIBRINOGEN does NOT= SPLIT PRODUCTS resulting in bleeding |
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how do you treat DIC? |
blood products, cryoglobulin |
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what is fibrinolysis? how can you tell the diff in DIC |
identical to DIC but NORMAL platelet count NO increase in D-dimer, but there IS increase fibrinogen split products. over activation of plasminogen to plasmin = more fibrin splitting, and serum fibrinogen (get rid of forming new clots), blocks platelet aggregation. knocks out factors. plasmin is INACTIVATED by alpha2 antiplasmin made in liver ex:: radical prostatectomy--> release urokinase which activates plasmin--> bleeds CIRRHOSIS-> not enough alpha2 antiplasmin being produced = overactivity of plasmin. |
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how can you tell DIC from fibrinolysis? DIC- something pissed off coag cascade and it goes cray. |
DIC platelet count is low and elevated Ddimer. -use up all the fibrinogen, so there will be increased D-dimer. treat with blood products/cryoglobulin- used up all factors fibrinolysis is NORMAL platelet count with NO ELEVATION IN D DIMER because there is nothing to split. treat w amino caproic acid (blocks activation of plasmin) |
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what blocks activation of plasminogen? |
aminocaproic acid inactivates plasminogen. alpha2 antiplasmin made in liver inactivates plasmin. use with too much fibrinolysis (no elevation in d dimer, normal platelet count) as opposed to activation of coag cascade (DIC) |
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what is key marker for lymphoBLAST? myelobast? |
tdt- lympphoblast. myeloblast is MPO (blasts are acute leukemia) TDT and MPO= ACUTE LEUKEMIA |
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what is PNH? |
hemolytic anemia, cytopenia, hypercoaguable state (intraabdominal or cerebral venous thrombosis). no CD55 or CD59 on RBC surface is diagnosis |
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what is progressive hip or groin pain without retraction of motion range and normal radiographs? what can cause it? |
avascular necrosis of the femoral head. chronic corticosteroid therapy can cause it, alcoholism, and hemoglobinopathy. MRI to diagnose peg cave perthe in kids |
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what drugs cause peripheral edema and how can you help prevent this? |
amlodipine and nifedipine (peripheral arteriolar dilators= nicreasd hydrostatic pressure) . give with ACE inhibitor to reduce this effect because they cause post cap VENO dilation |
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antibiotic of choice for dog and human bites |
amox clav |
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what help with cancer patient weight gain? |
progesterone analogues - megesrol acetate and medroxyprogesterone |
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itching (first sign, night time), fatigue, elevated alk phos. hepatosplenomegaly, xanthomatous lesions in eyelids, jaunice, steatorrhea, portal HTN,osteopenia women between 35-60. elevated all phis, cholesterol, serum IgM. associated with sjogrens, raynauds, scleroderma, autoimmune thyroid disease, hypothyroid, celiac. |
PBC- antimitochondrial antibody autoimmune destruction of intrahepatic bile ducts and cholestasis. treat with Ursodeoxycholic acid to slow progression and help symptoms. ursodiol treat hyperbilirubinemia PBC and sclerosing cholangitis cholestasis of pregnancy is from estrogen reducing uptake of bile acid by hepatocytes so there is increased serum bile acids in the serum . |
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"beading of bile ducts", intra and extra hepatic bile duts. associated with IBD. present with jaundice |
sclerosing cholangitis |
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extraarticlar manifestations in RA |
vasculitic lesions with ischemic ulcer, keratoconjunctivitis sicca (sjogrens), ILD, myelopathy due to cervical spine immobility (atlantooccipital subluxation with cervical dislocation and spinal cord compression), entrapment neuropathy (carpel tunnel), ACD |
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what is felty syndrome? |
severe nodular forming RA, splenomegaly, leucopenia, lymphadenopathy, throbocytopenia |
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H2 blocker not helping abdominal pain/ulcers? |
ZE- excess acid causes inactivation of pancreatic enzymes |
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progressive, cognitive decline/dementia, fluctuating cognition, visual halucinations, spontaneous parkinsonism features AFTER dementia (assoc w park), REM sleep disorder (vivid dreams), neuroleptic sensitivity, SPECT or PET scan shows low DA transporter uptake in basal ganglia, repeated falls/sycope, autonomic dysfunction, depression, hallucinations |
lewey body dementia (alzheimers is progressively worsening memory/cognition, consciousness is fine!, memory loss BEFORE visuospatial deficits (getting lost), language difficulties),difficulty w learned motor tasks (dyspraxia), non cognitive neuro deficits later. (extrapyramidal motor, myoclonus) |
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howdy you treat VIPoma? (pancreatic cholera- watery diarrhea from VIP binding to intestinal epithelial cells increasing fluid and electrolyte secretion into the lumen-> tea colored, odorless diarrhea, muscle weakness/cramps 2/2 hypokalemia and hypo/achlorhydria 2/2 decreased gastric acid secretion, facial flushing, lethargy, n/v, ab pain, weight loss- most in pancreatic tail) |
IV volume repletion, OCTREOTIDE to decrease diarrhea, hepatic resection of liver mets |
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aminoglycosides |
mycins/amikacin. treat serious gram negatives. cause ARF (PCNs cause AIN). but AZITHROmycin is a macrolide (gram positives, CA Uris) |
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what is weird feeling/pain in face (first), loss of pain and temp in ipsilateral face with hornets syndrome, and contralateral trunk/limbs, dysphagia/aspiration, hoarseness, hiccups, nystagmus (horizontal and vertical), ipsilateral limb ataxia/vertigo and fall to that side, diplopia? |
wallenberg syndrome- lateral medullary sydrom from occlude intracranial vertebral artery |
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|
what cause hyper reflexia? |
seratonin syndrome, MS, s ubacute combined degeneration (B12 cobalmin deficiency from diet, chrons, pernicious anemai) , multi infarct demential, transverse myelitis, CJD, hypocalcemia cerebral palsy |
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what 2 diseases are reflexes normal? |
alzheimers and MG |
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when is there hyporeflexia? |
depression, toluene toxicity, colchicine myopathy, eaton lambert (gets better with movement, small cell lung cancer), west nile virus, hyperkalemia |
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when are reflexes delayed? |
hypothyroidism, syringomyelia |
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when are there nO reflexes? |
GB, |
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contralateral hemiparesis in someone with hypertension (most important risk factor) sudden focal nero deficits that get worse. start in normal activity and precipitated by strenuous activity. |
hypertensive hemmorage ( all in putamen- causing contralateral hemiparesis) and also involve thalamus, pons, cerebellum(more frequently hypertensive hemorrhage than lacunar stroke), and cortex. these are the same things in lacunar stroke but those are not as intense or sudden? |
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complete paraplegia followed by deep coma with pinpoint pupils that ARE reactive to light? decerebrate rigidity |
pontine hemorrhaage |
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contralateral hemiparesis and hemisensory loss, Homonymous HEMIanopsiea, GAZE palsy? |
basal ganglia hemorrhage vs thalamus hemorrhage (contra hemi and sensory loss, NONREACTIVE PUPILS, UPGAZE PALSY, eyes deviate TOWARDS hemiparesis) |
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|
sinusitis bugs and treatment |
s pneumo and H influ- amox clav, doxy or respiratory quinelone (levofloxacin, moxifloxacin) chronis is polymicrobial |
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how do you treat hepatorenal syndrome? (no tubular injury, no improvement in renal function with fluids) |
adress precipitating factors, give splanchnic vasoconstrictors midodrine, octreotide, norepinephrine |
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|
what should always be considered in patients with unexplained elevation of serum CK concentration |
hypothyroidism |
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|
what are extra hepatic manifestations of hep C? |
MPGN, essential mixed cryoglobulinemia, lichen planus, leukocytoclastic vasculitis, porphyria cutanea tarda (fragile skin, photosensitivity, and vesicles and erosions on dorsum of hands) low serum compliment |
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|
muscle weakness and dry mouth (lambert eaton) is often associated with what? |
small cell lung cancer and lymphoproliferative disorders (hodgkins) |
|
|
whats pellagra? |
niacin deficiency: 4 D's- dermatitis, diarrhea, dementia, death. photosensitive pigmented dermatitis in sun exposed areas, diarrhea, dementia, red tongue, diarrhea, vomiting. in alcoholics, anorexics, carcinoid syndrome (increased metabolism of tryptophan into serotonin= niacin deficiency) "casals necklace" sunburnt areas |
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|
B1- thiamine - wernike korsakof/beri beri |
progressive dementia, confusion, ataxia, paralysis of extraocular muscles (CN6 palsy)/ nystagmus beriberi: symetrical peripheral neuopathy w both motor and sensory impairment. wet: with CHF- cardiomegaly, lower extremity swelling, tacky |
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|
B2/riboflavin deficiency: |
cheliosis / angular stomatitis and glossitis. ulcers, sore throat. leads to Fe deficiency anemmia. eyes sensitive to bright light, seborrheic dermatitis on face/genitals.. anorexia or celiac sprue Cheliosis and Corneal vascularization |
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|
b6/pyridoxine deficiency (alas cofactor to make protoporphyrin- sideroblastic anemia) |
stomatitis, glossitis, cheliosis, irritability, confusion, depression, tongue mucosa atrophy, sebborheic dermatitis, POLYNEUROPATHY. coenzyme for ALA synthase= microcytic, hypochromic sideroblastic anemia w basophilic stippling. in pregnancy of isoniazid or alcoholism basophilic stippling: in sideroblastic anemia lead poising vitamin B6 deficiency (isoniazid) thalassemia |
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|
prolonged QT/ ST interval |
hypocalcemia |
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stunned kids with hypo pigmented hair. decreased taste (hypogeusia), night blindness, decreased spermatogenesis, if severe- diarrhea, alopecia, pustular dermatitis, decreased immunity |
zinc defiicency. eat oysters beef crabs and cereal. selenium deficiency is congestive cardiomypathy w enlarged heart from people that come from low selenium soil. eat fish, shellfish, eggs |
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what stones form in acidic urine? alkaline? |
calcium oxalate form in acidic urine(alkaline to prevent) . calcium phosphate form in alkaline urine (acidify to prevent). thiazides prevent calcium stones (resorb calcium) |
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why do alcoholics get banana bags? |
it has dextrose and thiamine. dextrose directly stimulates insulin release= increased uptake of phosphate (phosphate depletion doesn't happen until 24 hours after hospitalization 2/2 transcellular shift from iatrogenic interventions) and because alcohol ketoacidosis presents with metabolic acidosis with compensatory respiratory alkalosis, causing more intracellular gift of phosphate. therenore, hypophosphatemia is the most common clinical finding seen in alcohol withdrawal path ions after administration of dextrose or heavy metal solutions. (hypophos=seizures) referring syndrome = seizures after raid administration of carbs in alcoholics |
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how do you tell the difference between TTP/HUS/ and DIC? |
HUS- microangiopathic hemolytic anemia, thrombocytopenia, acute renal failure. schistiocytes, increased LDH, giant platelets, with BLOODY DIARRHEA (ehec or shigella) there is NO increase in Pt/PTT. TTP doesn't have diarrhea- has fever. FATRN - fever, anemia, thrombocytopenia, renal, neuro neuro defects DIC- increase in PT/PTT and all of those things ITP: acute: usually kids after infection. IGG/spleen eats PLATELETS chronic- usually asymptomatic. if pregnant, IgG can cross placenta so baby has transient thrombocytopenia increased megakaryocytes nothing is wrong with the platelets, so PTT/PT is fine. treat w ivig or splenectomy (get rid of source and problem) |
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what is elevated JVP, hepatomegaly, peripheral edema with clear lung fields in setting of COPD exacerbation indicate? |
indicates primary pulmonary HTN and therefore cor pulmonale have begin to develop. give furosemide to reduce RV filling volumes, therefore reduce peripheral edema. becasureful not to reduce CO too much with the loop--> may lead to PRErenal failure (met acidosis from retained uremia , but fully compensated by resp alkalosis. so there is decreased bicarb but no change in pH) |
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what is paroxysmal SVT? treat it? |
most common paroxysmal tacky (160-220) in people WIHTOUT structural HD. sudden onset regular NARROW COMPLEX tacky Reentry into AV node- treatment is decreasing AV node conductivity (valsalva, cold water, carotid massage INCREASE VAGAL TONE, thus DECREASE AV NODE CONDUCTIVITY) can use adenosine |
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whats the difference between PPSV23 and PCV13 vaccine? (pneumococal polysaccharide) |
PPSV23: 23 polysaccharides, which can't be presented to T cells (because they need to be on a protein), so they are T cell INDEPENDANT B cell response, less effective in young and old- give to less than 65 with no comorbidities- but DO give to chronic disease and asthma people PCV13: 13 polysaccharides on diphtheria toxin protein. this INDUCES a T CELL DEPENDANT B CELL RESPONSE= better immunogenicity 2/2 formation of higher affinity antibodies and memory cells GIVE TO INFANTS AND YOUNG CHILDERN BOTH: people over 65 and immuncompromised |
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what vaccine promotes secretion of IgA antibodies in GI tract? |
oral polio |
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what are lymphocytes that nonspecifically recognize stressed/abnormal (cancer and viral) cells |
NK |
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when should type 2 HIT be suspected (autoimmune d/o 2/2 antibodies against heparin platelet factor 4 complexes? |
platelet count falls over 50% from baseline 5-14 days after starting heparin new onset unexplained thrombocytopenia arterial or venous thrombosis in people recently treated with heparin stop ALL FORMS of heparin- give agatroban, bivalirudin, or fondaparinux- NOT warfarin |
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when do you see ductopenia? |
PBC, failing liver transplant/GVH hodgkins CMV/HIV medication toxicity |
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liver histology: centrilobular/diffuse necrosis |
acetominophen toxicity |
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liver histology: hepatocyte swelling and necrosis, mallory boddies, NEUTROPHILIC infiltration |
alcoholic hepatitis |
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liver histo: periductal portal tract fibrosis SEGMENTAL stenosis of extra AND intrahepatic bile ducts |
primary sclerosing cholangitis |
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what happens to if patient is on TPN for a long time? |
cholestasis (sluge stones)- may progress to fibrosis |
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how do you treat DVT? |
if hemodynamically unstable or illiofemoral clot with limb swelling- thrombolytic therapy if stable and the clot is below the knee, do rivaroxban (quicker acting than warfarin) IVC when theres a clot and you can't do anticoagulation |
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recurrent focal neuroloic dysfunction, non predictable attack. symptoms last a few weeks with variable recovery B/L trigeminal neuralgia transient left arm weakness urinary incontinence nystagmus intention tremor |
MS
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neurofibromatosis type 2 (subq neurofibromas, hyperpigmented cafe au lait, deafness via acoustic neuromas) has 2 variants. what are they |
wishart- frameshift or non sense mutations= early termination. more severe mutations in general gardner: milder: missense or splice site - changed protein structure or post translational process |
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coccidio vs blasto vs histo |
coccidio: southwest, immunecompotent, DRY COUGH, fever, weight loss, pleuritic chest pain, erythema multiform/nodosum, arthralgia cutaneous, california, histo: southEAST, acute pneumonia blasto: central US: immune INCOMPROMISED. skin, lungs, bone, joint, prostate. primary pulmonary infection is asymptomatic or flulike aspergillosos: immunocompromsed, halso sign or lesions with air crescent |
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what is systemic sclerosis? systemic CREST |
anti-topoisomerase 1 autoantibodies thick skin in hands and feet edema that transitions to dermal sclerosis (no hair follicles and sweat glands) flexion contractures raynauds HTN cz kidney involvment- GIVE ACE pulmonary arterial HTN- right heart failure esophogeal/gastric motility: GERD |
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anti smooth muscle antibodies |
autoimmune hepatitis |
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how do you treat meniere's disease? (distention of endolymphatic compartment of inner ear) |
avoid things that increase endolymphatic retention (alcohol, caffeine, nicotine, salt) SAlt retention is initial therapy. if lifestyle modification doesnt work, try diuretics, antihistamines, anticholinergics |
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how do you prevent prostaglandin induced peripheral vasodilation (flushing, itching) after taking niacin? |
give low dose asa |
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who has increased frequency seborrheic dermatitis? (fine, loose, yellow, greasy looking scales) IN nasolabial folds (SLE spares nasolabial folds) |
Parkinson and HIV |
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what do you suspect when a patient presents with hypokalemia alkalosis normotension |
1. serreptitous vomiting 2. diuretic abuse 3. bartter syndrome 4. gitelman's syndrome (barter and gitlemans urince chloride is high) |
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how do you treat cluster headaches (watery eyes, nose, starts behind eye...) ? |
100% oxygen for ACUTE. prophylaxis is CCB Verampamil, prednisone, ergotimine (ergos constrict blood vessels in brain), methysergide (also an ergot) lithium for chronic cluster headaches |
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PSGN vs IgA nephropathy |
PSGN- 2 weeks after strep IgA nephropathy- 5 days- assoc w HSP |
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what causes viral or idiopathic myocarditis and what can it lead to? |
Coxsackie B, parvo, adeno, entero, Human herpes 6. myocarditis can lead to dilated cardiomyopathy, leading to CHF |
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when do you see concentric vs eccentric hypertrophy in the heart? |
concentric- chronic PRESSURE overload (HTN, aortic stenosis, (S4) eccentric- chronic VOLUME overload (regard) (S3) |
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what is PRIMARY pulmonary HTN? |
narrowing of pulmonary vessels- LE edema, dyspnea, elevated JVP, NO CRACKLES |
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ecthyma gangrenosum vs pyoderma gangrenosum |
ecthyma- HEMORRHAGIC pustules with surrounding erythema that evolve into necrotic ulcers. neutropenics with pseudomonis pyoderma- neutrophilic ulcerative skin disease. starts as inflammatory pustule, vesicle, whatever and expands. usually in people with underying systemic disease (IBD, arthropathies, hematologic) give corticosteoids |
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how do you diagnose aortic dissection? |
TEE |
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holosystolic murmur that increases with inspiration? |
tricuspid regurg- with bacterial endocardtitis (Increased with Inspiration= rIght sided murmur) (increase on expiration= left sided murmer) |
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when do you see paradoxical splitting (P2 before A2 worse with EXPIRATION) |
when inhaling, normal splitting is P first with INSPIRATION because when there's inspiration theres increased pulm pressure so it slaps P shut first. When this happens in EXPIRATION, something delayed the aortic valve allowing to P to still be first to shut. left ventricular outflow tract obstruction (aortic valve or sub aortic stenosis, LBBB, |
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what od you give to POSTmenopausal women with breast cancer? |
anastrazole (aromatase inhibitor) can cause ARTHRALGIAS, osteoporosis |
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what is the wells criteria |
3 points for clinical suspicion AND PE most likely diagnosis 1 points for HR >100, previous PE, immobilization for over 5 days 1 point for hemoptysis or cancer |
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what is the most common histologic lesion in diabetic nephropathy? |
diffuse glomerulosclerosis (nodular is kimel wilson)s |
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what treats diabetic nephropathy ? |
metoclopramide- DA receptor ANTagonist used to treat nausea and gastroparesis. SE: agitation and loose stools, EPS (dystonic reactions) |
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what helps tell the difference between glomerular disease and interstitial nephritis? |
urinary sedimentation. red cell casts and dysmorphic cells = glomerular (eosinophils in urine= interstitial) |
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heart defect with congenital rubella |
ASD |
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what 2 congenital heart things cause eisenmenget syndrome? (increased blood flow to right circuit) |
PDA (because its after the arteries to the upper extremeties only LE hypoxia) and VSD |
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what is transposition associated with? |
diabetic mothers. KEEP PDA OPEN with PGE |
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what is ADULT coarctation associated with? (upper extremity higher pulses infantile coarctation associated with PDA |
bicuspid valve |
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people with hashimotos often develop? (hypothyroid with enlarging thyroid) |
B cell lymphoma |
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hyper thyroid treat vs thyroid STORM treatment |
hyperthyroid- storm- PTU (inhibits peripheral t4-t3 and central making, BB, steroids) |
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cretinism (infantile hypothyroid) usually thyroid peroxidase deficiency called myxedema in older people deep voice and big tongue from myxedema |
retard umbilical hernia short enlarged tongue coarse facial features |
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FNA can't distinguish between what thyroid cancers |
follicular carcinoma (invaded capsule) and follicular adenoma |
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carcinoma (endothelial mediated) usually go to lymph nodes. sarcoma (mesothelium) go to blood carcinomas that love the blood are? |
1. choriocarcinoma 2. renal cell carcinoma--> renal vein 3. hepatocellular carcinoma--> hepatic vein 4. follicular carcinoma |
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TB likes to go to where |
bone- pots kidney- sterile pyuria brainstem |
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difference in onset of embolic and thrombotic strokes |
embolic very rapid onset. thrombotic is more when they wake up from sleep they notice |
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difference in presentation of PCA and ANA strokes |
PCA- focal or progressive headaches with oculomotor nerve palsy cn3 =PCA ANEURYSM. RUPTURE is ocular nerve palsy ACA- OCCLUSION leads to LE weakness/paralysis maybe cortical sensory loss b/l babinski RUPTURE- leg mono or paraparesis w/w/o akinetic mutism/bulism |
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what is protein gap? |
total- albumin should be 3-4 |
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what does hyperkalemia (over 7) look like on EKG |
hyperkalemia can mimic GB (ascending paralysis and weakness) short QT interval, spiked T waves they all lengthen pventuallyinto sine waves. also "coved ST elevation" treat: loop/thiazide IV ca and or insulin/glucose na bicarb, dialysis |
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how does hypercalcemia (over 10.5) cause constipation |
calcium depolarizes sodium channels - farther from threshold cause constipation 2/2 decreased muscle tone short QRS interval |
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hypomag (less than 1.5) on EKG |
PROLONGED QT (short QT is HYPERKalemia) and nonspecific T wave changes (u wave) usually s/s from hypocalcemia or hypokalemia peripheral nerve issues usually from GI loss- either diarrhea or vom. |
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what does tamoxifen treat? |
mcune albright and ER breast cancer |
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treat CAH? |
prednisone. replace cortisol and decrease CRH and ACTH release |
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what prevents all cause mortality in atherosclerotic plaque people (unstable angina) |
statins ace inhibitors help with cardiac remodeling and DM |
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eisenmenger's syndrome vs ebstain anomaly |
ebstein anomaly is tricuspid is down and hypertrophies right atrium (lithium) lithium also has tricuspid atresia eisenmengers is reversal of left to right shunt RV hypertrophy pulmonary HTN |
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torsades is polymorphic (multiple ventricual foci that make twisting QRS complexes) polymorphic v tach. whats WPW |
WPW is delta waves, AV junction disorder circles around through bundle of kent treat with carotid massage, valsalva adenosine cardiovert procainimide and ioadadf |
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osbourne wave/ prominent J wave-- prominent positive deflection between the QRS complex and T wave (like a M) |
hypothermia |
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carcinoid tumor |
in the lung, polyp like mass in the bronchus chroografefin positive carcinoid syndrome (bronchospasm, flushing, diarrhea- from stress and alcohol) when it metastacisez to the liver from the small bowel. needs to get into systemic circuit carcinoid heart disease is when it gets to the heart and makes right sided fibrosis (mitral regard and pulmonary valve stenosis) NO LEFT SIDED because lung has monoamine oxidase (like liver) |
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what mets go to lung? |
breast and GI |
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pan coast tumor |
in apex of the lung hits phrenic nerve and recurrent laryngeal sympathetic chain horners syndrome can cause SVC syndrome |
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tertiary syphyllis causes dissection how |
end arteritis in vasovasorum "tree bark appearance" |
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what does epoxide reductase do? |
activates vitamin K in the liver (warfarin blocks this) factors 2, 7, 9, 10, C,S |
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why do you get increased PT with liver failure? |
no epoxy reductase in liver to activate vitamin K clog factors not made big transfusion- dilute out the factors |
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what does homocysteinuria look like |
thrombosis retarded lens dislocation (down) long slender fingers looks like marfans but marinas has upward lens dislocation no CBS, homocysteine can't become cystathione |
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where do we absorb iron? folate? |
duodenim (need acid to absorb) transportin decides if we aborb it or not transferrin (TIBC) ferritin=store ferritin/tibc opposite folate abs in jejunum B12 in ileum |
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when do you see RDW increase? what is reticulocyte count |
fe def anemia, hereditary spherocytosis reticulocyte count bigger than 3%,= BM is fine! (extravascular and intravascular hemolysis) |
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whats associated with vitiligo? autoimmune destruction of melanocytes |
pernicious anemia autoimmune thyroid disease T1DM primary adrenal insufficiency hypo pit alopecia acreata |
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what do you do for PEA? |
epinephrine anything without a pulse |
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what do you do for SVT (wide complex tacky) |
valsalva adenosine |
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defib is when its fibrillation. |
cardiovert when unstable |
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salmetrol- |
long acting b2 agonist |
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fixed, DILATED pupil |
uncal herniation- medial temporal lobe through tentorium cerebella. may cause psi PCA infarct subflacine herniation= midline shift tonsillar herniation: cerebellar tonsils through foramen magnum- cardiorespiratory dysfunction only with subcortical or brainstem lesions central herniation: thalamus and hypothalamus through tentorium cerebella |
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mitosis (small) but normal light response |
pontine lesions cause miosis but a normal light response (argyle robinson is small and no light response but has accommodation) pinpoint pupils in hemorrhage |
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ipsilateral pupillary dilation, loss of light reflex, and ptosis due to compression of cranial nerve III. |
uncal herniation (supratentorial mass effect- contralateral sensory and motor issues) |
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Dilated pupil which may react better to near than to light. 2/2 disease affecting the ciliary ganglion. Is hyper-sensitive to any weak Pilocarpine (eg. 0.1%) with constriction of the pupil, in contrast to the pharmacologically dilated pupil (eg. by atropine) which will not constrict. associated loss of tendon reflexes, particularly the ankle jerks, but almost never any associated systemic disease. likely to become bilateral and the initially dilated pupil will gradually reduce but poor reaction to light will continue |
aide's pupil argyle robinson are small and only react to near not light |
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-paradoxical dilatation of pupils in swinging flash-light test,seen in retinal detachment, optic neuritis etc |
marcus gun pupil |
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what bug causes flu like symptoms with photophobia and jaundice |
lepto (gram negative question mark spirochete) |
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arsenic poisoning (dehydration, cramps, puke, poop) treatment |
arsenic: dimercaprol (IM) and succimer (oral) chelating agents for LEAD: dimercaprol, EDTA, succimer, penicillamine chelating agent for IRON: deferroxamine chelating agent for copper: penicillamine, treantine |
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meckles diverticulum |
vitaline duct (true diverticulum) totally open- pass meconium hardness by umbilicus |
