COMAT Internal Medicine

CHF exacerbation Treatment

"LMNOP" Lasix (furosemide) --> dec. load on heart Morphine (dec. stress) NO (dec. Preload) Oxygen (starving heart) Position (

Septic Arthritis

* Bacterial arthritis can result from a bite or other trauma, from direct inoculation of bacteria during joint surgery. In most cases, bacterial arthritis arises from hematogenous spread to the joint. S. aureus (including MRSA) is the most common bacterium infecting adult joints.* -In sexually active young adults the most common causative organism is N. gonorrhea. -In other patient populations S. aureus is most common. -It is characterized by sudden onset of joint pain with physical examination demonstrating a warm, erythematous, tender joint with limited range of motion. -A CBC will show an elevated white blood cell count and ESR and CRP will also be elevated. If septic arthritis is suspected a joint aspiration should be done which will show leukocytes >50,000/mm³. -Treatment for gonococcal septic arthritis is ceftriaxone and doxycycline to treat for possible Chlamydia. - For septic arthritis caused by S. aureus the treatment involves percutaneous or possibly surgical drainage and intravenous antibiotics. -Septic arthritis occurs often in joints with preexisting disease including osteoarthritis, diabetes, rheumatoid arthritis, and prosthetic joints, especially those older than 80 with a history of diabetes. -Bacteremia is much more likely to seed in these affected joints than in a normal joint.

Necrotizing Fasciitis

* Necrotizing fasciitis is a deep infection along a fascial plane that causes severe pain followed by rapidly progressive erythema, swelling and subcutaneous tissue necrosis. Diabetes is a major risk factor. Early surgical intervention is the key to management to prevent local and systemic spread of the infection. Treatment includes surgical debridement and broad-spectrum antibiotic therapy.* -Necrotizing fasciitis is a rapidly progressive infection that travels along the fascial plane and invades local vasculature, leading to ischemia and necrosis of overlying subcutaneous tissue. -It can be separated into three separate types based on the causative bacteria: polymicrobial (Type I, usually includes S. aureus, E.coli, and Clostridium perfringens), S. pyogenes (Type II), and clostridial myonecrosis (Type III, gas gangrene). -The infection usually begins at a site of trauma. and in diabetics -Necrotizing fasciitis presents initially with sudden onset of intense pain at the trauma site that is usually out of proportion of clinical findings and then gradually progresses to anesthesia. -Swelling and erythema then develop and quickly spread over hours to days. -As the infection extends into the deep fascia it causes thrombosis in the blood vessels of the dermal papillae. This causes the skin to become friable and take on a bluish, maroon discoloration.

Squamous Cell Carcinoma lung

* Squamous cell carcinoma classically is found in patients with a unilateral hilar mass with hypercalcemia and a smoking history.* -Large left hilar mass on chest x-ray, which is most likely squamous cell carcinoma given his extensive smoking history. -He describes a clinical history of cough and hemoptysis consistent with lung cancer. -His past social history of 40 pack-year smoking puts him at high risk for lung cancer. -Hypercalcemia, which is seen on this patient's laboratory work-up, is very common with squamous cell carcinoma of the lungs. -His hypercalcemia may be a result of bone metastasis or from the release of Parathyroid Hormone related peptide (PTHrP) from the squamous cell carcinoma. -The PTHrP acts similar to PTH and causes an increase in calcium reabsorption in the distal tubules and promotes bone resorption by activating osteoclasts indirectly. -Lung pathology can result in rib somatic dysfunction adjacent to the pathological lung segment. Additionally, you may see TART changes from T2-6 as a result of viscerosomatic reflexes from the underlying lung pathology.

AV Fistulas

* The ideal AV fistula location is in the most distal vessels in the non-dominant upper extremity.* -AV fistulas are typically constructed with an end-to-side vein-to-artery anastomosis between an artery and vein. -In creation of dialysis access fistulas, using the most distal vessels of the upper extremity is recommended. -Creation of more proximal fistulas prevent potential future placement of distal AV fistulas. *radial artery and cephalic vein*

Electrical Cardioversion

*-Electrical cardioversion for atrial fibrillation with RVR is either used for hemodynamically unstable patients or for new-onset atrial fibrillation of <48 hours. * -Given the prior history of palpitations, this patient could have long-standing undiagnosed atrial fibrillation putting him at risk for thromboembolic event. -Also, this patient is hemodynamically stable with BP of 100/60 mm Hg even though the HR is 175 beats/min which makes cardioversion an incorrect answer choice.

Factor V leiden

*-Factor V Leiden is the most common hereditary hypercoaguable disorder that occurs in about 5% of the population. * -Patients with Factor V Leiden have protein C resistance which increases the risk for thrombotic disease. -Approximately 30% of patients with Factor V Leiden will have a thrombotic event by the age of 60. -Protein C is a vitamin K-dependent protein produced in the liver. Protein C deficiency is inherited in an autosomal dominant fashion at a frequency ranging from 1/200 to 1/500 in the general population.

Hypocalcemia; lab findings

*A common lab finding seen in patients with hypocalcemia is hypomagnesemia. This is because significantly low magnesium levels inhibit secretion and function of PTH, resulting in decreased calcium absorption and reabsorption. * -Hypocalcemia is defined as a serum calcium < 8.5 mg/dL. Causes include hypoparathyroidism, malnutrition, hypomagnesemia, acute pancreatitis, vitamin D deficiency, and pseudohypoparathyroidism. -Alcoholism is the most common cause of hypomagnesemia. -The most classical sign of severe hypomagnesemia (less than 1.0 mEq/L or 1.2 mg/dL) is hypocalcemia. -Although the exact mechanism is unknown, it is hypothesized that magnesium interferes with PTH secretion and bone activity, resulting in decreased calcium absorption and reabsorption. -Therefore, the serum magnesium level should always be checked in a patient with hypocalcemia of unknown etiology to determine its potential contribution to the hypocalcemia. *-Patients will not respond to calcium replacement therapy without proper magnesium replacement.*

Screening for AAA

*An abdominal ultrasound for abdominal aortic aneurysm screening is indicated in all men of 65-75 years of age who have ever smoked.* -Abdominal ultrasound has a sensitivity and specificity of 95-100 % for abdominal aortic aneurysm. -The United States Preventive Services Task Force (USPSTF) recommends a one time screening abdominal ultrasound for all men aged 65 - 75 years of age who have ever smoked in their lives. -A normal diameter of aorta is usually 2.0 cm, abdominal aortic aneurysm is classified as diameter greater than 3.0 cm. -Serial ultrasounds are further recommended based on the initial diameter of the abdominal aorta. -Therefore, abdominal ultrasound is the most important preventive screening tool for this patient with a history of smoking.

Corrosive substance injestion

*Any treatment that may induce vomiting or retching is contraindicated when a patient ingests a corrosive substance. Treatment consists of supportive care, intravenous fluids, NPO, proton pump inhibitor infusion, and endoscopy if stable and no signs of rupture of the esophagus and/or stomach.*

Tumor marker for Pancreatic Cancer

*CA 19-9 is the most frequently checked tumor marker for pancreatic cancer. A level above 1000 is diagnostic of pancreatic cancer and has a high risk of being unresectable metastatic disease.* -In patients with pancreatic cancer who have CA 19-9 detectable in their serum, the level has been shown to correlate with tumor burden. -For example, higher CA 19-9 levels typically correlate with higher tumor stage, and more than 95% of patients with unresectable disease have levels higher than 1000 U/mL. -Of patients who undergo curative resection, those whose CA 19-9 levels returned to normal survived longer than those whose levels fell but never normalized. -Serial measurement of CA 19-9 is used to monitor response to therapy.

CCB side effects

*Calcium channel blockers both dihydropyridines and non-dihydropyridines cause peripheral edema, facial flushing, headaches, GI upset, and constipation. They are not associated with abnormal laboratory values. * PERIPHERAL EDEMA IS MOST COMMON -Nifedipine is a dihydropyridine calcium channel blocker. -The most common adverse effect associated with nifedipine is peripheral edema; followed by headache, nausea, heartburn and transient hypotension. -Mechanism of action of nifedipine is by blocking L-type calcium channels (slow channels) in the heart and vascular smooth muscle causing vasodilation. -However, the effects of nifedipine are more specific for vascular smooth muscle relaxation vs. myocardium relaxation, therefor, peripheral edema is common due to systemic vasodilation. -Alternatively, non-dihydropyridines (verapamil or diltiazem) are more specific for the myocardium affecting contractility. -Many anti-hypertensive medications are associated with electrolyte abnormalities, however, nifedipine is not associated with abnormal laboratory values. -Given the patient's physical exam finding of peripheral edema in the setting of *normal lab values*, nifedipine is the most likely pharmacologic agent causing this patient's symptoms.

Central Diabetes Insipidous

*Central DI will cause excessive urine output, a decreased urine osmolality, and can be treated with desmopressin* -The patient has developed central diabetes insipidus (DI) as a result of his traumatic brain injury. -In central DI, antidiuretic hormone (ADH) synthesis is disrupted due to injury of the hypothalamus or pituitary. -Therefore, decreased release of ADH results in an inability to concentrate urine and subsequent polyuria with decreased urine osmolarity. -Common etiologies including neurosurgery or brain trauma, infiltrative diseases and tumor. -Treatment of central DI consist of ADH replacement in the form of desmopressin which can be given as subcutaneous, oral or nasal form. -Other therapeutic modalities include low salt diet and a thiazide diuretic as well.

Coma

*Coma is a complete failure of the arousal system with a positive auditory brain responses but no response in eye opening, verbal response or motor response to stimuli.* -Reflexes and postural responses are intact. -Auditory brain responses test the brain stem and can be normal or abnormal in coma patients. -An abnormal auditory brain response with a GSC of 3 has an increased risk of death compared to patients with a normal response.

Essential tremor

*Essential tremors are benign familial tremors that are usually worse with activity and better with rest. * -Essential tremor is also known as benign familial tremor which is most often confused with Parkinson's disease. -Essential tremor usually presents as bilateral hand tremor (frequency 4 to 6 Hz) that exacerbates with actions example lifting an object, writing, eating etc. -In contrast, Parkinson's disease is usually worse at rest and better with activity. -Essential tremor can progress to involve the neck which results in head oscillations as well, an unlikely finding in Parkinson's disease. -Beta blockers, anticonvulsants and small amounts of alcohol have been used in the treatment of essential tremor. -Essential tremors also have a familial basis with an autosomal dominant mode of inheritance, as suggested in the question stem by the patient's uncle having a history of a tremor as well.

Pt with Renal Failure on TPN

*Excessive protein administration in TPN can worsen renal failure.* -Excessive protein administration in TPN should be avoided to prevent worsening azotemia. -During the breakdown of protein, nitrogen is formed. -Nitrogen is unable to be cleared from the body by a damaged kidney. -Patients with renal failure should have an adjusted range of protein in the solution of 1.2-1.3 g/kg/day. -Protein requirements are also decreased in patients with hepatic encephalopathy (ammonia) while increased in patients with burn injury and high stress level. -In patients with CKD, dietary protein restriction has been shown to decrease the rate of progression of CKD by hemodynamically mediated reductions in intraglomerular pressure. -The remainder of the calories provided should be from carbohydrates (dextrose) and lipids. -Trace elements and fat soluble vitamins are important to consider as some of these can be dialyzed out during hemodialysis and should be replaced to prevent deficiencies.

Gout

*Gout presents with sudden onset of pain and swelling of a single joint. Joint aspiration shows needle-shaped crystals that are negatively birefringent. Excessive alcohol use is a risk factor for gout. * -Gout is typically a monoarthritis that presents with sudden onset of pain and swelling. -It is caused by deposition of sodium urate crystals in the joint. -Risk factors include male gender, diuretic use, excessive alcohol use, renal disease, and urate underexcretion. -Alcohol, especially beer, is high in purines which break down into uric acid. -The most common joint involved is the first metatarsophalangeal joint but other joints can be affected including ankle, knee, and foot. -Joint aspiration will show white blood cells less than 50,000/mm³ and crystals. -In gout, crystals of monosodium urate (MSU) appear as needle-shaped intracellular and extracellular crystals. -When examined with a polarizing filter and red compensator filter, they are yellow when aligned parallel to the slow axis of the red compensator but turn blue when aligned across the direction of polarization (i.e., they exhibit negative birefringence). -Negatively birefringent urate crystals are seen on polarizing examination in 85% of specimens.

Atrial Fibrillation

*Hemodynamically stable atrial fibrillation present for >48 hours is treated with rate control medications.* -This patient's presentation of palpitations with EKG findings of irregular rhythm with no clear p waves is consistent with atrial fibrillation. -More specifically, atrial fibrillation with rapid ventricular response as evidenced by her irregularly irregular rhythm, absence of p waves, and ventricular rate of approximately 175/min on ECG. -The patient has had atrial fibrillation for > 48 hours, given her several month history of palpitations. -In the absence of neurologic symptoms (pre-syncope, syncope, altered mental status) or hemodynamic compromise (BP of 100/60 mm Hg), atrial fibrillation present for >48 hours should be treated with rate control and three to four weeks of anti-coagulation prior to electrical cardioversion due to the high risk of thromboembolism. -Rate control can be achieved with a calcium channel blocker (diltiazem) or beta blocker (metoprolol).

Hypophosphatemia in alcoholics post hydration

*Hypophosphatemia can present with neuromuscular instability including seizures and coma in alcoholics post hydration and feeding.* -Patients other than those with anorexia nervosa are at risk for the refeeding syndrome. These include malnourished elderly patients, some surgical patients, those on chemotherapy, and homeless or alcoholic patients who have not eaten for many days. -This patient's presentation with bilateral temporal wasting and history of daily consumption of alcohol is suggestive of malnutrition and alcoholism, which likely contributed to refeeding syndrome. -Phosphate, calcium, potassium, magnesium and thiamine are some of the nutrients often found to be depleted in chronic alcoholics. -Although phosphate depletion is common in these patients, the absolute fall in the serum phosphate below 1 mg/dL may not happen until 24 hours after hospitalization due to transcellular shift from iatrogenic interventions. -Most alcoholics are initially treated with a "banana bag" which usually contains dextrose and thiamine. - The dextrose in the solutions directly stimulates insulin release resulting in increased uptake of phosphate by cells. -Additionally, alcohol ketoacidosis presents with metabolic acidosis with compensatory respiratory alkalosis causing further intracellular shift of phosphate as well. -Therefore, hypophosphatemia is the most common clinical finding observed in alcohol withdrawal patients in the hospital.

Electrolyte derangement in Refeeding syndrome

*Hypophosphatemia is the hallmark electrolyte disturbance in refeeding syndrome.* - It leads to a variety of disturbances, ranging from cardiomyopathy and arrhythmias to rhabdomyolysis, renal failure, encephalopathy, respiratory failure, and even cardiac arrest and/or death. -During the early phases of starvation, the body switches from carbohydrate to fat and protein metabolism as the main source of energy, and the basal metabolic rate can decrease by as much as 20-25%. -As more prolonged and chronic starvation sets in, the body switches from ketone metabolism and begins using fatty acids for energy. -This is done in an attempt to avoid further protein and muscle breakdown. -This leads to an increase in blood levels of ketone bodies, which then become the main source of energy for the brain. -The liver also decreases its rate of gluconeogenesis, which preserves muscle protein as well. -During refeeding, glycemia leads to an increase in insulin production and decrease in glucagon production. -Insulin leads to glycogen, fat, and protein synthesis which requires the use of several minerals, including phosphate and magnesium, as well as cofactors like thiamine. -The end result is a shift of several minerals and water into the intracellular space, including phosphate, magnesium, and potassium. -These are already functionally depleted, and these shifts combined with an increased basal metabolic rate lead to refeeding syndrome.

Pre renal Azotemia

*In a patient with acute kidney injury, FENa less than 1% and BUN/Creatinine ratio greater than 20:1 is consistent with pre-renal azotemia. *

COPD exacerbation

*In an acute respiratory acidosis that is caused by a COPD exacerbation, correct the ventilation issue first. This allows the other common symptoms (tachycardia, dyspnea, hypoxia) seen to resolve. * -Decreased respiratory rate, physical exam, and the ABG which confirms a CO2 retention issue. This causes an acute respiratory acidosis. -COPD patients have difficulty breathing air out. This mechanism causes a retention of CO2. -The issue that needs to be corrected first is to help the patient relieve that obstruction; otherwise respiratory failure develops. -This is done by steroids, inhaled nebulizers (albuterol and ipratropium), and if needed non-invasive positive pressure ventilation (BIPAP) or invasive ventilation (intubate the patient and place on a ventilator). -The steroids decrease inflammation, the nebulizers help open the airways (albuterol) and decrease mucous production (ipratropium), and the BIPAP or invasive ventilation assists the patient in ventilation to allow the CO2 to be exhaled. -By correcting the respiratory acidosis the other issues will resolve (hypoxia and tachycardia). -It is advised that for patients with a moderate to severe exacerbation be started on antibiotics. -The antibiotic that should be chosen should be based on the local patterns of antibiotic susceptibilities.

Labrynthitis

*Labyrinthitis presents with sudden vertigo lasting hours to days and accompanied by hearing loss and tinnitus.* -Labyrinthitis refers to inflammation of the labyrinth of the inner ear. Though the cause is not clear, it is most often seen after a viral upper respiratory tract infection. -The inflammation may cause sudden vertigo with temporary hearing loss or tinnitus. -Attacks usually last several hours to days. -Both labyrinthitis and BPPV may test positive for Dix-Hallpike maneuver.

Cervical Cancer risk

*Multiple sexual partners is one of highest risk factors for HPV infection and cervical cancer.* -Cervical cancer is caused by human papilloma virus (HPV). The most common mode of transmission for HPV is via sexual intercourse. -However, HPV has many different strains, out of which only 6 are associated with a high risk of cervical cancer, while others just cause warts. -HPV subtypes responsible for squamous cell carcinoma include HPV 16, 18, 45, 33, and 58 versus adenocarcinoma with HPV 16, 18, 45, 33 and 31. -Presenting symptoms include abnormal vaginal bleeding and/or discharge. -Per the most recent cervical cancer guidelines, screening is recommended for women of age 21 to 65-year-old via a pap smear cytology and/or HPV testing. -All the answer choices listed above are high risk factors for HPV infection; however, having multiple sexual partners is the greatest risk factor for contracting HPV. -The risk increases relative to the number of partners, for example two-fold with two partners and greater than six fold with more than three partners. The risk is even higher if those sexual partners have also had multiple sexual partners themselves as well due to rapid transmission of the HPV virus via sexual intercourse.

Adverse effects of Niacin

*Niacin adverse effects include glucose intolerance, pruritus, and an elevation in uric acid levels.* -Patient presents with acute gouty attack as evidenced by the erythematus, warm, tender right great toe. -Niacin was added to his statin therapy at his last appointment. -Niacin is a component of two co-enzymes necessary for lipid metabolism, tissue respiration, glycogenolysis, and inhibition of very low-density lipoprotein (VLDL) synthesis. -It is associated with glucose intolerance, pruritis from a transient histamine release, and elevation in uric acid levels. -It is not a first-line therapy for hyperlipidemia, however it is often added to statin therapy if statins alone are not controlling the hypercholesterolemia. -Niacin is also known to help raise HDL even more than statins, exercise, and tobacco cessation.

Pemphigus vulgaris

*Pemphigus vulgaris is an intraepidermal autoimmune blistering disease with a positive Nikolsky's sign.* -Nikolsky's sign which refers to sloughing and separation of the epidermis upon gentle pressure to the lesions. -Four diseases that are associated with a positive Nikolsky's sign include pemphigus vulgaris, toxic epidermal necrolysis, Stevens-Johnson syndrome and Staphylococcal scalded skin syndrome. -Pemphigus vulgaris is the most common subtype of pemphigus disease. Three other subtypes include pemphigus violaceus, IgA pemphigus, and paraneoplastic pemphigus. -Pemphigus vulgaris is an intraepidermal autoimmune disease with IgG autoantibodies directed against desmoglein resulting in acantholytic epidermal cells. Due to loss of adhesion between epidermal cells, the skin layer comes off easily upon only gentle touch, giving a positive Nikolsky's sign in this patient. -Mucosal membranes are almost always involved in addition to the scalp, trunk, neck, axilla, groin and face. It usually affects younger population compared to bullous pemphigoid which commonly affects elderly. -Clinical symptoms include pain, pruritus and secondary skin infections, which if left untreated can be fatal. -Blisters often leave behind hyperpigmented scars after healing, as present in the patient as well. -Glucocorticoids are the first line treatment for pemphigus vulgaris.

Pernicious Anemia

*Pernicious anemia is an autoimmune disease affecting the ability of the parietal cells to secrete intrinsic factor to bind to vitamin B12. Vitamin B12 deficiency leads to peripheral neuropathy and the findings of megaloblastic cells with hypersegmented neutrophils on peripheral blood smear.* -Pernicious anemia is a chronic illness caused by impaired absorption of vitamin B12 because of a lack of intrinsic factor (IF) in gastric secretions. -Pernicious anemia is caused by the failure of gastric parietal cells to produce IF. IF acts to bind to vitamin B12, and is necessary for the absorption of vitamin B12. -A deficiency in cobalamin, also known as vitamin B12, can lead to a megaloblastic anemia. - These megaloblasts are a product of impaired DNA formation by the red blood cells. -Vitamin B12 deficiency results in subacute combined degeneration of the dorsal and lateral spinal columns due to a defect in myelin formation. -Peripheral neuropathy can result, which is symmetrical in nature and affects the legs more than the arms. - It manifests with paresthesias, ataxia, and loss of vibration and position sense. -A complete blood count will show an elevated red blood cell mean corpuscular volume > 100 fL.

Pseudogout

*Pseudogout most commonly affects the knee and is caused by deposition of calcium pyrophosphate dehydrate crystals. These crystals are rhomboid shape and positively birefringent.* -Pseudogout is a form of arthritis caused by deposition of calcium pyrophosphate dehydrate crystals. -The most common joint affected is the knee. It is usually associated with increasing age but can also be a familial condition or associated with excessive blood calcium levels. -Microscopic analysis in pseudogout shows calcium pyrophosphate (CPP) crystals, which appear shorter than MSU crystals and are often rhomboidal. -Under a polarizing filter, CPP crystals change color depending upon their alignment relative to the direction of the red compensator. -They are positively birefringent, appearing blue when aligned parallel with the slow axis of the compensator and yellow when perpendicular. -Treatment is NSAIDs or colchicine.

Selenium Deficiency A 13-year-old male recently emigrated from China after being diagnosed with congestive cardiomyopathy.

*Selenium deficiency can present as heart failure and cardiomyopathy in children* -Selenium deficiency is seen in some parts of China, New Zealand and Finland. -Keshan disease presents as congestive cardiomyopathy with an enlarged heart in children and young female living in these endemic areas with low soil concentration of selenium. -Some selenium rich foods include fish, shellfish and eggs. -Selenium is an antioxidant that is part of the enzyme glutathione peroxidase, which is found in red and white blood cells. -As such, selenium acts to prevent oxidative damage to both these cell lines. -Selenium deficiency can occur in patients with severely compromised intestinal function and those receiving total parenteral nutrition. -A deficiency of selenium can lead to the development of heart related problems, most commonly a dilated cardiomyopathy.

"Brain dead"

*Spinal reflexes may be present in a patient with brain death.* -Brain death may be diagnosed in the absence of brainstem function. -The patient must be free of any pharmacologic and medical conditions that could otherwise explain their decreased brain function. -Patients cannot be hypotensive, hypothermic, or have decreased oxygen saturation. -*Findings consistent with brain death include: non-reactive pupils, lack of corneal reflex, lack of oculocephalic (doll's eyes) reflex, loss of respiratory drive even with elevated partial pressure of carbon dioxide*. -However, movements originating from the spinal cord or peripheral nerves may persist. -For example facial nerve twitching or fasciculations of trunk and extremities. -Therefore, spinal reflexes may persist despite brain death making it the correct answer choice.

A 25-year-old male is admitted with a 20% total body surface area burn to his legs and chest after an explosion. Upon arrival to the emergency department he is obtunded with poor vital signs. Rapid sequence intubation is successfully performed for airway protection. Soon after the patient later suffers a cardiac arrest.

*Succinylcholine can cause hyperkalemia in patients with spinal cord injuries, large burns, renal failure, or prolonged immobility.* -Depolarizing neuromuscular blockers mimic acetylcholine (ACh) by binding ACh receptors of the motor end plate and causing depolarization of the muscle, which is seen clinically as muscle fasciculations. -Succinylcholine, the only depolarizing neuromuscular blocker available for use, is degraded by plasma pseudocholinesterase. -In patients with a deficiency of pseudocholinesterase, prolonged effects can occur. -Side effects of succinylcholine include muscle pain, rhabdomyolysis, ocular hypertension, malignant hyperthermia, and hyperkalemia. -Patients with spinal cord injuries, large burns, upper and lower motor neuron disease, renal failure, or prolonged immobility are at particular risk for hyperkalemia and resultant cardiac dysrhythmias.

A fib in Post CABG patients

*The electrocardiogram is remarkable for varying R-R intervals and a wavy baseline.* -Post-CABG patient with palpitations and irregular R-R interval is consistent with atrial fibrillation. -Atrial fibrillation refers to fibrillation of the atria resulting in multiple foci in the atria firing continuously resulting in no clear p waves. -The atrial rate is over 400 beats per minute but most impulses are blocked at the AV node resulting in an irregular rhythm with irregular R-R interval. -Atrial fibrillation can present as paroxysmal, recurrent or permanent. -Symptoms consist of palpitations, syncope, angina, dyspnea or even asymptomatic. -Physical examination consists of irregular palpable pulse.

Splenectomy pt with failure to follow up now with current respiratory distress

*Those with a splenectomy are vulnerable to encapsulated organisms: Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenza.* -Some of the host spleen mechanisms to fight these organisms include antibody production, activation of the alternative complement pathway, and phagocytosis of unopsonized particulate matter. -Therefore, after a splenectomy, these patients are at risk for Overwhelming Post-splenectomy Infection (OPSI). -These patients are vulnerable mostly to encapsulated organisms, which include Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenza. -The most common of these organisms is S. pneumoniae, causing up to 90% of overall cases. -It is recommended to receive vaccines for these organisms including pneumococcal vaccine, meningococcal vaccine, and Haemophilus influenzae vaccines two weeks prior to an elective splenectomy, or two weeks post-op an emergent splenectomy.

Uremic Coagulopathy

*Uremic patients have poor platelet function which causes increased bleeding.* -Impaired platelet function is a major determinant of uremic bleeding. -Uremia predisposes toward bleeding due to platelet dysfunction with an inability to aggregate and adhere to the endothelium. -Laboratory values will have a normal coagulation profile, normal platelets, but an abnormal bleeding time. -Uremic patients that are bleeding can be treated with desmopressin which increases plasma levels of von Willebrand factor, factor VIII, and t-PA contributing to a shortened activated partial thromboplastin time (aPTT) and bleeding time.

Ventricular Tachycardia post MI

*Ventricular tachycardia is a common manifestation of myocardial infarction.* -Any patient with a history of heart disease with symptomatic tachycardia and wide QRS complexes should be presumed to have ventricular tachycardia unless proven otherwise. -Ventricular tachycardia is form of wide complex tachycardia characterized by three or more premature ventricular complexes in a row. -The ventricular rate can be between 100 and 250 beats per minute. -The electrocardiogram of ventricular fibrillation reflects AV dissociation which is evident by a regular rate between p waves with no relationship to QRS complexes. -Wide, bizarre QRS complexes that are monomorphic or polymorphic are pathognomonic for ventricular tachycardia. -Although most common causes is coronary artery disease, other etiologies include cardiomyopathies, congenital defects, prolonged QT syndrome and drug toxicity. -Patients can be asymptomatic or complain of palpitations, dyspnea, angina or near-syncope. -Cannon A waves in the neck may be appreciated on physical examination. -If patients are asymptomatic and stable, then they can be treated with lidocaine or amiodarone. -Patients that are hemodynamically unstable are subjected to immediate synchronous cardioversion with CPR.

Warfarin Skin Necrosis

*Warfarin induced skin necrosis is more frequently seen in individuals diagnosed with protein C deficiency.* -Warfarin therapy is one of the most commonly used regimens for anticoagulation due to its ability to be monitored and readily reversed. -It interferes with the gamma carboxylation of the vitamin K dependent clotting factors such as II, VII, IX, X, protein C, and protein S. -Other than bleeding, one of the known major complications of warfarin therapy is full thickness skin necrosis and sloughing over fatty areas, such as the buttocks, the breast, and the thigh. -This phenomenon is known to occur more frequently in individuals diagnosed with protein C deficiency. -This can usually be avoided by using a heparin or low molecular weight heparin (LMWH) "bridge" until the warfarin level is therapeutic.

Acute Hepatitis B Management and treatment

*With acute hepatitis B infection start antiviral therapy with tenofovir disoproxil fumarate.* -Liver biopsy is rarely indicated in acute viral hepatitis. Serologic tests would be indicated during the acute phase which are listed in the lab section in the question. A liver biopsy would be indicated if the diagnosis is uncertain or when the clinical evidence points towards a diagnosis of chronic hepatitis. -Peginterferon is used to treat chronic hepatitis C in conjunction with ribavirin. This is done after an intense therapy course done with antiviral therapy with interferon alfa for an average of 3 months. -These patients need to be first placed on oral therapy such as tenofovir disoproxil fumarate which is a reverse transcriptase inhibitor. -It may be used as retroviral therapy for HIV patients as well. -Tenofovir inhibits replication of hepatitis B virus by inhibiting hepatitis b virus polymerase.

Ventricular Fibrillation

*wandering baseline and irregular complexes with a faint pulse.* -Ventricular fibrillation is characterized by irregular, random waveform with no discernible p waves or QRS complexes. -Fibrillation refers to multiple foci in the ventricles that fire rapidly resulting in no clear P or QRS complex resulting in no cardiac output; therefore, requiring immediate defibrillation and CPR. -Most episodes are precipitated by an ischemic event or use of anti-arrhythmic drugs. -Often initial rhythms include atrial fibrillation with RVR or ventricular tachycardia which transforms into ventricular fibrillation. -This patient's EKG with a wandering baselines and irregular QRS complexes is consistent with ventricular fibrillation and CPR should be started immediately.

benign heart murmurs

- < 3/6 intensity -asymptomatic -systolic

Angina and coronary perfusion

- Chest pain/discomfort present upon exertion with activities like walking and running which is relieved with rest is defined as stable angina. ]- -Although, unstable angina can also present as chest discomfort/pain, it is present at rest. -Coronary artery disease is a manifestation of reduced coronary artery perfusion and a supply-demand mismatch. -A low supply state refers to a decreased blood flow to the coronary arteries secondary to calcification of the coronary arteries, vasospasm, anemia or shock. -A high demand state refers to high oxygen demand states like those seen during exercise and left ventricular hypertrophy. -In this scenario, the patient has a murmur of aortic stenosis (systolic ejection murmur with radiation to the neck) which creates a high demand state resulting in reduced coronary artery perfusion. -As well as a low supply state secondary to coronary artery disease based on patient's risk factors including male with age greater than 55 years, obesity, history of dyslipidemia and hypertension.

Diabetes Diagnosis

- Fasting plasma glucose ≥ 126 mg/dL - Random plasma glucose ≥ 200mg/dL - Hemoglobin A1C ≥ 6.5% - 2-hour plasma glucose ≥ 200mg/dL after 75g oral glucose

ACEi side effect

- Lisinopril is an ACE inhibitor. -*The most common side effects are dry cough, hyperkalemia, acute renal failure in renal artery stenosis, and angioedema. * -Patient's lab does not show any hyperkalemia, making lisinopril an unlikely answer. -It is also not associated with peripheral edema.

classic triad of symptoms with aortic stenosis

- chest pain - exertional dyspnea - syncope

Diagnosis for lung cancer screening

-55-80 y/o - >30 pack year history - quit < 15 yrs ago Screen with low dose lung CT

Osteoporosis and DEXA

-A DEXA scan is a dual-energy x-ray absorptiometry which is the standard for evaluating bone mineral density. -It is recommended at age 65 and every 2 years after. -A 65-year-old white female with no other risk factors has a 9.3% 10-year risk for an osteoporotic fracture according to the U.S. FRAX tool. -A DEXA exam is an x-ray usually of the wrist, femoral neck, or vertebrae that assigns a score, called a T-score, that compares the patient's bone mineral density to that of a control group who are at their peak bone mineral density. -A normal T-score is defined as within 1 standard deviation (SD) of the mean bone mineral density for a healthy young adult. -A T-score of -1 to -2.5 SD indicates osteopenia and a T-score of less than -2.5 SD indicates osteoporosis. -Osteoporosis results from either decreased bone formation or increased bone resorption. -Peak bone mass occurs at age 20-25. -Risk factors include smoking, alcohol use, sedentary lifestyle, decreased estrogen, steroid use, hyperparathyroidism, and inadequate calcium during young adulthood. -It is usually asymptomatic until fractures occur. -Exercise, and adequate vitamin D and calcium are important in preventing osteoporosis. -Once diagnosed the treatment includes bisphosphonates which decrease osteoclast activity. Normal: T-score > -1 SD Osteopenia: T-score < -1 and > -2.5 Osteoporosis: T-score < -2.5

EKG: U wave

-A U wave is a small wave on the EKG that, if present, commonly follows the T wave. -It represents repolarization of the papillary muscles or Purkinje fibers. -A prominent U wave is most commonly associated with hypokalemia. -Other less common causes include hypercalcemia, thyrotoxicosis, intracranial hemorrhage, and digitalis use.

Pyridoxine deficiency

-A deficiency in pyridoxine, also known as vitamin B6, results in stomatitis, glossitis, cheilosis, irritability, confusion, and depression. (vs Riboflavin) -Physical examination would reveal inflammation and fissuring of the lips, cheilosis occurring at the corners of the mouth, atrophy of the mucosa of the tongue, and seborrheic dermatitis. -Pyridoxine is a cofactor in pyridoxal phosphate mediated enzymatic reactions. Pyridoxal phosphate is necessary for the synthesis of heme, as it serves as a coenzyme for the enzyme ALA synthase. -Thus, vitamin B6 deficiency can result in a microcytic, hypochromic sideroblastic anemia with the presence of basophilic stippling seen on a peripheral blood smear. -Pyridoxine deficiency may result from pregnancy or therapy with certain medications, such as the anti-tuberculosis drug isoniazid.

Riboflavin Deficiency

-A deficiency of riboflavin, vitamin B2, is characterized by cheilosis, angular stomatitis, and glossitis. -This can be seen on physical examination as cracked and red lips, inflammation of the lining of mouth and tongue, mouth ulcers, cracks at the corners of the mouth, and a sore throat. -A deficiency of riboflavin may also cause dry and scaling skin, fluid accumulation in the mucous membranes of the mouth, and an iron-deficiency anemia. -The eyes may also become sensitive to bright light. -Additionally, patients may develop seborrheic dermatitis of the face or genitalia. -Riboflavin deficiency may be noted in patients with anorexia nervosa or with malabsorptive syndromes such as celiac sprue.

Lumbar herniated discs

-A lumbar herniated disc results in a sharp lancinating pain that radiates posteriorly down the leg in a dermatomal distribution. -It is unilateral in nature, as opposed to the bilateral involvement of lumbar spinal stenosis. -Most disk herniations occur at the L4-L5 or L5-S1 levels. -An intervertebral disc herniation will affect the lower nerve root in the involved segments. -Thus, a herniation at the L4-5 level will cause impingement upon the L5 nerve root. -These nerve roots are assessed by checking for the absence of the patellar reflex (L4), great toe dorsiflexion (L5), or the Achilles reflex (S1). -Pain will be reproduced on physical examination with unilateral straight leg raise.

Acute abdomen with +FOBT, why CT abdomen vs colonoscopy?

-A positive fecal occult blood test makes colonoscopy a tempting option. -A possible differential for positive fecal occult blood includes mesenteric ischemia (atrial fibrillation with possible embolic phenomenon) vs diverticulitis/diverticulosis (fever, leukocytosis, lower quadrant pain) vs perforated peptic ulcer disease. -However, colonoscopy would not help in urgent management of this patient with an acute abdomen and could be performed at a later time interval.

Schistocytes

-A schistocyte is a fragmented red blood cell that forms various helmet shapes on a peripheral blood smear. -Schistocytes are seen in microangiopathic hemolytic anemia. -Some of these causes include thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and a prosthetic heart valve. -Schistocytes are formed when red blood cells are forced through a vessel that is blocked with fibrin strands, and subsequently becomes sliced into fragments. -These damaged cells become devoid of central pallor, and continue to circulate. -Autoimmune hemolytic anemia is caused by IgG antibodies that react with proteins on the red blood cell surface. -Diagnosis of autoimmune hemolytic anemia is with a positive direct antiglobulin test (Coomb's test). -Glucocorticoids are the first line therapy for autoimmune hemolytic anemia.

Sarcoidosis Vs TB

-Acid fast bacilli on histopathology is seen in infection by Mycobacterium Tuberculosis. -TB granulomas have a characteristic caseation "cheese-like" necrosis within the granuloma that consist of epithelioid macrophages, langhans giant cells, and lymphocytes. -Therefore, these granulomas are called "caseating granulomas" which is not consistent with findings in sarcoidosis. -Also, although TB can also present with dry cough, this patient's presentation of bilateral hilar lymphadenopathy with erythema nodosum is more consistent with sarcoidosis.

Acute abdomen diagnostic steps

-Acute abdomen generally refers to sudden onset of abdominal pain with rapid clinical deterioration. -It is often a clinical diagnosis based on presence of guarding, rebound tenderness and "pain out of proportion" to physical exam, such as this patient. -Other objective signs include the presence of fever, leukocytosis, tachycardia and tachypnea which indicates sepsis from possible intra-abdominal pathology. -In this patient, a differential diagnosis includes appendicitis (right lower quadrant pain with radiation to back), cholecystitis (fat, female, fertile, forty years of age with right upper quadrant pain), peritonitis (fever, leukocytosis, signs of infection) and mesenteric ischemia (atrial fibrillation with positive fecal occult). -Only one of the answer choices listed above could help narrow down the differential diagnosis and give the correct diagnosis in a timely fashion, that is CT abdomen. -A complete CT abdomen is a quick efficient way to look at the gall bladder, appendix, mesentery and the colonic mucosa all together; therefore, making it the most appropriate next step in management.

Calcium Deficiency: A 67 year-old male with a two-day history of paresthesias and witnessed seizures.

-Acute calcium deficiency can present with various manifestations of neuromuscular dysfunction including peri-oral numbness, paresthesias, muscle spasms, muscle cramps and seizures.

Acute Hepatitis

-Acute hepatitis B infection noted by the positive HBsAg and Anti-HBC IgM that is highly infective based on the positive HBeAg. -Notice the detail of the inmate, this would help indicate high risk behavior for hepatitis B, sexual intercourse with multiple partners and intravenous drug abuse. -The patient has rapid progression of symptoms with elevated liver enzymes in the thousands. This is concerning for fulminant hepatic failure. -Clinical signs and symptoms are altered mental status and scleral icterus. -The patient was displaying signs of serum sickness that started with nausea and vomiting that progressed to altered mental status. -Laboratory data of elevated bilirubin levels and elevated INR are showing signs of liver failure. -The patient needs to be admitted to the ICU for fulminant liver failure and started on tenofovir disoproxil fumarate for the acute hepatitis B to lower the viral count. -If the patient does not show signs of improvement the patient would require a liver transplant.

Acute Lymphoblastic leukemia

-Acute lymphoblastic leukemia has a peak incidence between ages 2 and 5. -Symptoms reflect bone marrow infiltration (blasts replacing bone marrow): anemia (pallor, fatigue), thrombocytopenia (petechiae) and neutropenia (fever). -Upon initial evaluation, obtain a complete blood cell (CBC) count. -A hematologist or hematopathologist must evaluate the peripheral smear for the presence and morphology of lymphoblasts (see below). -An elevated leukocyte count of more than 10 × 109/L (>10 × 103/µL) occurs in one half of patients with acute lymphoblastic leukemia (ALL). -*Neutropenia, anemia, and thrombocytopenia are often observed secondary to inhibition of normal hematopoiesis by leukemic infiltration.* - It is important to recognize that 20% of patients with ALL initially present with pancytopenia and no evidence of peripheral blasts.

Managent for symptomatic hypocalcemia

-Acute symptomatic hypocalcemia should be treated with IV 10% calcium gluconate to achieve a serum concentration of 7 to 9 mg/dL. -However, if the hypocalcemia is severe, calcium chloride is given instead. -Calcium gluconate requires a higher dosage than calcium chloride. -Approximately three times more IV calcium gluconate is required to achieve the same effects as the equivalent dose of calcium chloride. -IV calcium chloride is only appropriate if the hypocalcemia is acute and has occurred over a relatively short time frame. -If the hypocalcemia has been chronic, then this regimen can be fatal, because there is a degree of acclimatization that occurs. -The neuromuscular excitability, cardiac electrical instability, and associated symptoms are then not cured or relieved by prompt administration of corrective doses of calcium, but rather exacerbated. -Such rapid administration of calcium would result in effective over correction - symptoms of hypercalcemia would follow. -Associated deficits in magnesium, potassium, and pH must also be corrected. Hypocalcemia will be refractory to treatment if coexisting hypomagnesemia is not corrected first. -Chronic hypoparathyroidism requires vitamin D, oral calcium supplements, and often aluminum hydroxide gels to bind dietary phosphate in the intestine.

Addison's Disease

-Addison's disease results from destruction of the adrenal glands. In the United States, it is most commonly caused by an autoimmune process and patients with other autoimmune diseases are at increased risk for developing primary adrenal insufficiency. (i.e. Diabetes type I) -Approximately 25% of patients with Addison's disease may initially present with adrenal crisis due to an impaired adrenocortical hormone response to severe physiological stress (e.g., trauma, infection, gastrointestinal upset, surgery). -Clinical manifestations of adrenal crisis include nausea, vomiting, abdominal pain, cardiovascular collapse, and/or hypovolemic shock.

Type I DM in Adrenal Crisis

-Addison's disease results from progressive destruction of the adrenal cortices leading to decreased synthesis of cortisol and mineralocorticoids. -The most common cause in the United States is idiopathic/ autoimmune, however, tuberculosis is the most common cause worldwide. -Other causes of primary adrenal insufficiency include CMV, Cryptococcus, toxoplasmosis, bilateral adrenalectomy, and adrenal metastatic disease. -This patient's medical history is suggestive for polyglandular autoimmune syndrome type II. -This term is used to describe an inherited disorder that leads to multiple autoimmune diseases, specifically Hashimoto thyroiditis, type 1 diabetes mellitus, and Addison's disease. -The onset of each disease can vary but commonly manifests in early adulthood and is more common in females. -Clinical symptoms of Addison's disease usually are not present until >90% of the adrenal glands have been destroyed. -Symptoms include insidious onset of weakness, fatigue, anorexia, and hyperpigmentation. -This patient was experiencing mild symptoms of adrenal insufficiency (e.g., fatigue, weakness) over several months. Then, this recent viral gastroenteritis caused an acute increase in cortisol and aldosterone demand. -Recent studies have found that gastrointestinal upset and fever are the two most common precipitating factors of crisis. Other triggers include trauma, surgery, infection/ sepsis, and severe emotional stress. -Adrenal crisis usually presents with intractable nausea, vomiting, and abdominal pain. -The abdominal pain can be so severe that it can be mistaken for an acute abdomen. -Fever may be severe or absent. Patients quickly become intravascularly volume depleted, which progresses to cardiovascular collapse and hypovolemic shock.

German Measles Rubella

-Also known as German Measles, this rash is caused by the rubella virus and affects children, adolescents and adults with little to no prodrome. -Patients can develop a low-grade fever 37.2- 37.8°C (99-100°F) with swollen and tender lymph nodes. T -he rash following the fever is a raised, red, pinpoint rash that starts on the face and spreads downward. -The rash can itch and last up to 3 days.

Alteplase (tPA)

-Alteplase or tissue plasminogen activator (tPA) and other thrombolytics, such as reteplase and tenecteplase, initiates local fibrinolysis by binding to fibrin in a thrombus (clot) and converts entrapped plasminogen to plasmin. -Plasmin then degrades fibrin, helping to break up the clot. -Endothelial cells also secrete tPA that converts fibrin-bound plasminogen to plasmin, initiating clot lysis -Alteplase is indicated for use in acute myocardial infarction, acute ischemic stroke, pulmonary embolism, and central venous access devices. -The acute viscerosomatic reflex for a myocardial infarction may include T1-T5 on the left. There is also a lesser known sympathetic reflex that correlates to C3-C5.

Immediate treatment of hyperkalemia

-Although all answers may be appropriate for the treatment of hyperkalemia, this particular situation requires immediate attention due to EKG changes. -Cardiac complications such as ventricular fibrillation and cardiac arrest may occur with untreated hyperkalemia. -Given the patient's peaked T-waves on EKG, the administration of calcium gluconate is the appropriate first step. -Calcium stabilizes membrane potentials and prevent further cardiac sequelae. -However, the effect of calcium is only transient, and further steps are required to correct the patient's hyperkalemia. -Other treatments of hyperkalemia not provided in the answer choices include administration of IV sodium bicarbonate (also only a temporary effect), peritoneal dialysis, or hemodialysis.

Why not do a plain x ray for acute pancreatitis?

-An upright abdominal radiograph is helpful in patients with an acute abdomen to rule out free air under the diaphragm from perforation. -Although, chronic calcified pancreas can be visualized on x-ray, it is not the initial step in management in case of acute pancreatitis.

Screening with PSA

-As per the most recent USPSTF guidelines, a routine prostate specific antigen is no longer recommended as a screening tool for prostate cancer. -Instead, physicians are encouraged to discuss with patients the risk and benefit of screening for prostate cancer based on symptoms and family history. -However, PSA is recommended as a screening tool in patients with a strong family history of prostate cancer or BRCA 1 mutations as well as in patient's with symptoms.

Renal osteopathic findings

-As with any renal pathology, you may see TART changes from T6-9 representative of viscerosomatic reflex from the underlying kidney pathology. -Additionally you may see Chapman points associated with the kidney pathology, the anterior point displayed above one inch lateral and superior to the umbilicus.

A fibrillation

-Atrial fibrillation refers to fibrillation of the atria resulting in multiple foci in the atria firing continuously resulting in no clear p waves. -The atrial rate is over 400 beats per minute but most impulses are blocked at the AV node resulting in an irregular rhythm with rapid ventricular rate. -Atrial fibrillation can present as paroxysmal, recurrent or permanent. Symptoms consist of palpitations, syncope, angina, dyspnea or even asymptomatic. -Physical examination consists of irregular palpable pulse. -Uncontrolled atrial fibrillation due to tachycardia can result in congestive heart failure. -Additional main complication includes increased risk of thromboembolism due to left atrial dilation. -Treatment consist of rate control, rhythm control and anti-coagulation (based on CHADS2 Score) depending on patient's hemodynamic stability and other co-morbidities. -An electrocardiogram reveals signs of a supraventricular tachyarrhythmia with an atrial rate of 425/min.

A flutter Vs A fib

-Atrial flutter is a supraventricular rhythm secondary to irritable automaticity focus in the atria resulting in organized depolarization. -Typical atrial rate can be 300 beats per minute resulting in more p waves than q waves. -The electrocardiogram is remarkable for a saw tooth baseline due to every two or three flutter waves for every QRS complex. -Best way to differentiate from atrial fibrillation is clear presence of p waves in a regular rhythm. -The main causes of atrial flutter are rheumatic heart disease, chronic obstructive pulmonary disease, pericarditis and atrial septal defect. - -Treatment is based on hemodynamic stability of the patient.

Bacillus Anthrasis

-Bacillus anthracis is a gram positive, spore-forming rod, present in soil. -Anthrax can present as inhalational, gastrointestinal or cutaneous. -Cutaneous anthrax is the most common form of infection of B. anthracis. It is usually seen in farmers as Bacillus anthracis can be present in soil flora in addition to humans working with animal products like drums and textile mills that use animal skin or hair. -Cutaneous lesions usually present in exposed areas like face, neck, hand and arm with previous cuts and open wounds. -They often begin as small pruritic and painless papules which rapidly evolve into a vesicle or a bulla. -These vesicles further progress into necrotic ulcers with a depressed black eschar, a characteristic finding of B. anthracis infection. -Although, lymphadenopathy and lymphangitis are often present similar to cat scratch disease, the lesions appear different on exam making cutaneous anthrax the most likely diagnosis. -A question stem with "black eschar" is a classic presentation of B. Anthracis cutaneous lesion.

Basophilic Stippling

-Basophilic stippling refers to the presence of blue granules of various sizes dispersed throughout the cytoplasm of the red blood cell. -These blue granules represent ribosomal precipitates. -The pathophysiology is due to failure to completely form heme molecules. T -his leads to deposits of iron in the mitochondria of the developing erythroblasts. -It is most often seen in the thalassemias, alcohol abuse, iron overload, and lead poisoning. -First line treatment for sideroblastic anemias is a trial of pyridoxine.

Behcet's disease

-Behcet's disease is an immune-mediated, small-vessel systemic vasculitis that commonly presents with recurrent oral aphthous ulcers, genital ulcers, and uveitis. -Patients may have multisystem involvement affecting the gastrointestinal tract, lungs, musculoskeletal system, and neurological system. -It is seen in young adults, with a mean age of onset between 25-30 years old. -It is an inflammatory vasculitis that mainly involves the venous system. -Diagnostic criteria includes recurrent pathos ulcers (defined as at least 3 episodes within a 12-month period) plus two of the following: Recurrent genital ulcers, commonly involving the scrotum in men and labia in women and sparing the glans penis and urethra. -Ulcers commonly heal within 1-2 weeks with scarring. -Eye lesions, including anterior or posterior uveitis, hypopyon, retinal vasculitis, cystoid macular degeneration. -Skin lesions, including folliculitis, erythema nodosum, and/or acne-like exanthem. -Positive pathergy test, a diagnostic test that involves irritating the skin with a sterile needle. A positive result is marked by the formation of a erythematous papule 2 mm in diameter or larger that within 48 hours -Treatment depends on individual symptoms; however, it usually includes immunosuppressive therapy with glucocorticosteroids and azathioprine. -Serious complications include blindness, permanent neurological deficits, aneurysms, and thrombotic events.

Tx. for thyroid storm

-Beta blocker (propanolol) -PTU -Steroids -Stable Iodine

Biotin deficiency

-Biotin is an important cofactor for enzymes involved in carboxylation reactions, an example of which is the synthesis and oxidation of fatty acids. -A deficiency of biotin can lead to depression, hallucinations, muscle pain, brittle hair, alopecia, dermatitis, and an erythematous perioral macular rash. -Biotin is present in dietary food, and is also produced by intestinal bacteria. -Deficiencies of biotin occur in people who consume massive amounts of raw eggs. -This is because egg white contains a protein, avidin, which combines very tightly with biotin and prevents its absorption.

Brucellosis

-Brucellosis is a type of zoonotic infection transmitted via infected animals (sheep, cattle, pigs) or unpasteurized dairy products. -Acute illness typically presents initially with systemic signs like fever, myalgias, arthralgias, abdominal pain and malaise. -Cutaneous lesions can be papulonodular, ulcerative, erythema-nodosum like eruptions or abscesses, but typically do not present with a painful black base lesion making it a less likely diagnosis.

Bullous pemphigoid

-Bullous pemphigoid is a subepidermal autoimmune disease with autoantibodies directed against the basement membrane of the epidermis (between dermis-epidermis), as compared to the epidermal cell junctions (epidermis-epidermis) in pemphigus vulgaris. -Therefore, nikolsky sign is negative as the blisters are deeper and epidermis does not separate easily on touch. -Symptoms are similar to pemphigus vulgaris including pruritus, urticaria and blister formation. However, blisters form most commonly over the trunk, groin, and the flexor surfaces and less often in the oral mucosa. -Uncomplicated blisters often heal without any scarring whereas in pemphigus vulgaris blisters often heal with hyperpigmented spots. -Bullous pemphigoid also generally affects the elderly as compared to the younger age group in pemphigus vulgaris. However, both diseases are treated with glucocorticoids.

ARDS diagnosis

-CXR: whiteout -capillary wedge pressure via (swan-ganz cath) showing normal -normal LV function

Reiter's Syndrome

-Campylobacter jejuni is associated with gastroenteritis. -Reiter's syndrome is a rare complication of C. jejuni gastroenteritis and presents with a reactive polyarthritis several weeks after the initial enteric infection. -Patients commonly report asymmetric oligoarthritis affecting mainly the knees, ankles and feet. -This patient presented with a monoarticular arthritis and no history of gastroenteritis.

Niacin deficiency in carcinoid syndrome

-Carcinoid syndrome, which classically presents with abdominal pain, flushing, and diarrhea and is confirmed with an elevated urinary level of 5-HIAA. -Carcinoid tumors are slow-growing tumors that arise from the appendix, small intestine, or rectum. -Carcinoid syndrome only occurs if the tumor metastasizes, which occurs in 2% of cases with tumors > 2cm in size. -In addition to flushing and diarrhea, carcinoid syndrome can also present with facial telangiectasias, hepatomegaly, and tricuspid and pulmonary valve stenosis. -Carcinoid tumors synthesize, store and release different polypeptides, amines, and prostaglandins; the most common secretory product is serotonin. -*The serotonin by-product is the result of tryptophan's, an amino acid, conversion by the tumor. -Tryptophan is enzymatically synthesized from vitamin B3 (niacin), which can lead to niacin deficiencies in patient's with carcinoid tumors.* -Niacin deficiency will usually manifest as pellagra, which consists of dermatitis, dementia, and diarrhea. -The next step in management of this patient with an elevated 5-HIAA, a serotonergic precursor, level is localization of the tumor with a computed tomography (CT) scan of the abdomen or somatostatin receptor scintigraphy (SRS). -Treatment includes surgery for isolated tumors or octreotide for tumors that have metastasized, as is likely in this patient presenting with carcinoid syndrome.

Carpel Tunnel Syndrome

-Carpal tunnel syndrome is most commonly due to an inflamed synovium. -Risk factors include obesity, pregnancy, hypothyroidism, rheumatoid arthritis, diabetes mellitus, repetitive motion activities, and advanced age. -The median nerve produces sensation to the radial 3 ½ fingers, and patients will initially complain of paresthesias or numbness in this distribution. - Other symptoms include clumsiness and pain that awakens the patient at night. -It is worsened with repetitive use. - In advanced disease, patients may present with thenar atrophy as the median nerve innervated the flexor muscles of the thumb. -Physical examination will reveal positive Phalen and Tinel's tests. -In the Phalen test, the patient flexes their wrists together and holds it there for one minute. - It is positive if the symptoms are reproduced. -Tinel's test involved tapping on the median nerve. -Treatment is with night splints, activity modification, NSAIDs, and steroid injections.

Cellulitis

-Cellulitis is a local infection of the connective and subcutaneous tissue that also presents with pain, erythema, and swelling. It is also commonly associated with fever and chills. -Common pathogens include S. pyogenes and S. aureus. -Early stages of necrotizing fasciitis may be mistaken for a cellulitis. Therefore, necrotizing fasciitis must be ruled out in all patients with suspected cellulitis. - Cellulitis is not associated with skin coloration and necrosis, as seen in this patient. -Also, this patient's CT scan showed involvement of the deep fascial layers, which are not involved in cellulitis.

What is a chancroid?

-Chancroid is a bacterial sexually transmitted infection caused by Haemophilus ducreyi characterized by painful genital ulcerations. -Chancroid lesions are usually large (10-20 mm) with irregular, deep margins and bloody or purulent secretions. -They are commonly located on the penile shaft, glans penis, and/or urethral meatus, sparing the scrotum. -Patients commonly have significant painful inguinal lymphadenopathy, often with abscess formation. -Chancroid infections do not involve the eyes or skin.

Chlorthalidone Side effects

-Chlorthalidone is a thiazide diuretic. -The most common side effects associated with chlorthalidone are GI symptoms such as dyspepsia or poor appetite, hypokalemia and photosensitivity. -The patient's renal panel is within normal limits and does not show hypokalemia. It also not associated with peripheral edema.

Why not go straight to Lap Chole after findings of choledocolithiasis on US?

-Cholecystectomy has limitations with obstructed CBD and pancreatic duct. We also are not provided any information that indicates the patient has sepsis or an otherwise infected gallbladder, and the ultrasound does not reveal definitive gallstones. -This patient's risk of pancreatic and/or hepatitis needs to be addressed first, followed by gallbladder removal.

Cholestyramine

-Cholestyramine inhibits enterohepatic re-uptake of intestinal bile salts thus increasing fecal loss of bile salt-bound LDL and reducing serum cholesterol. -Adverse effects include flatus and abdominal cramping. It also has significant drug-drug interactions due to its ability to block absorption.

Churg Strauss

-Churg-Strauss syndrome can often also present as a pulmonary-renal syndrome with similar non-specific signs of systemic illness like fever, myalgias and arthralgias. -However, some of the important distinguishing features include the presence of asthma and eosinophilia, which are absent in this patient. -Also, Churg-Strauss and Microscopic polyangiitis are both p-ANCA positive instead of c-ANCA for wegners

H2 blocker or PPI for H pylori therapy?

-Cimetidine is an H2 blocker and is shown to be inferior to PPI therapy. -If an H2 blocker is chosen it should be ranitidine 150 mg twice daily. -Most common side effects are headache, dizziness, and somnolence.

Lab values in Adrenal Crisis

-Classic laboratory values suggestive of adrenal crisis/ primary adrenal insufficiency include hyponatremia (due to decreased aldosterone), hyperkalemia (due to decreased aldosterone), hypoglycemia (due to decreased cortisol), and decreased cortisol (AM cortisol < 3 mcg/dL is diagnostic of adrenal insufficiency). -ACTH would be high in Addison's disease due to lack of negative feedback from cortisol. -The diagnosis of Addison's disease is made with an ACTH stimulation test. -The administration of exogenous ACTH will fail to cause the expected increase in cortisol levels. -Of note, this patient's increased BUN and creatinine indicated acute renal failure secondary to decreased kidney perfusion as a result of hypovolemic shock.

Compartment Syndrome

-Compartment syndrome is a serious condition caused by pressure buildup within the fascial planes of an extremity, which can lead to rapid vascular and neurological damage. -The precipitating event is commonly a major injury to the extremity such as a fracture, crush injury, or constricting bandage on swelling tissue. -Patients will present with pain out of proportion of clinical findings, paresthesias, and muscle tightness. Skin changes are not commonly present.

CRPS

-Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy, presents with autonomic dysfunction and usually only affects one extremity. -Symptoms may include dyshidrosis, color or temperature changes, and marked hyperesthesia. -Patients do not experience paralysis.

Copper Deficiency

-Copper deficiency results in Menkes kinky hair syndrome. -This presents as fine fragile silvery hair, depigmentation of the skin, muscle weakness, neurological abnormalities, and hepatosplenomegaly. -A deficiency in copper results in osteoporosis due to defective collagen. -It is also associated with skin depigmentation due to dysfunctional melanin synthesis from the copper dependent enzyme tyrosinase. -A copper deficiency also results in a microcytic, hypochromic anemia and neutropenia.

Cryptococcis

-Cryptococcosis should be considered in any patient that presents with signs and symptoms suggestive for chronic meningitis, especially patients with underlying immunosuppression. -Cryptococcus neoformans infection can affect almost any tissue type, but most commonly presents with central nervous system and/or pulmonary involvement. -Skin lesions associated with disseminated cryptococcosis are highly variable and may include papules, plaques, purpura, tumor-like lesions and/or rashes. -Patients with underlying HIV infection should always be treated aggressively with induction therapy (amphotericin B + flucytosine + fluconazole) and lifelong maintenance therapy (fluconazole).

Cutaneous Leishmaniasis vs Anthrax

-Cutaneous leishmaniasis presents as a painless papule that develops into a nodule over time. -The nodule further develops into a raised and indurated ulcer with a necrotic base. -Lymphatic gland with palpable lymph glands is commonly seen as well, often before the appearance of the ulcerated nodule. -However, again there is no black eschar present unlike anthrax. -Also, typically it is multiple nodules as it is initiated by a sandfly bite which carries this protozoa of Leishmania spp. -Endemic regions include parts of Africa, Afghanistan, and Iraq.

CMV colitis

-Cytomegalovirus (CMV) colitis is suspected in any immunocompromised patient who presents with bloody diarrhea. -Additional findings of pancytopenia further support CMV infection over other acute bacterial infections. -Diagnosis is confirmed by endoscopy showing punctuate and superficial erosions to deep ulcerations in the colon. -Biopsy of these ulcers reveals characteristic cytomegalic cells which are large cells containing eosinophilic intranuclear intracytoplasmic inclusions, as present in this patient. -Therefore, prompt treatment should be initiated to avoid complications of toxic megacolon and necrotizing colitis. -IV ganciclovir or foscarnet are typical first line agents and are typically continued for 3-6 weeks for treatment of CMV colitis.

Delerium tremens

-Delirium tremens is characterized by hypertension and agitation instead of hypotension and confusion. -Other associated symptoms include hallucinations, fever, diaphoresis which are also not present in this patient. -Also, delirium tremens are typically observed 48-96 hours after the last drink; however, this patient has only been admitted for less than 24 hours making it an incorrect answer choice.

Diagnosis of Cryptococcal meningitis

-Diagnosis of cryptococcal infection can be made by visualizing C. neoformans in the CSF using India ink stain or testing for cryptococcal antigen in blood or CSF. -Radiographic imaging of the brain should be performed prior to lumbar puncture to rule out the possibility of increased intracranial pressure (ICP) or other space-occupying lesions.

Drinking Drain O

-Drain-o is a corrosive agent that contains sodium hydroxide (lye). It is used to unclog many household plumbing drains and causes significant mucosal damage if ingested. -After ingestion the patient should be hospitalized, kept NPO because ingesting further substances may cause more harm, and have serial chest and abdominal radiographic images performed to evaluate for perforation. -If the patient is hypotensive, intravenous fluids should be started first followed by vasopressors if unresponsive to fluids. -If there is a decrease in hemoglobin, blood products should be considered. -Gastric acid suppression with intravenous proton pump inhibitors is often used to prevent stress ulcers of the stomach. -Endoscopy ideally should be performed within 24 hours to assess the severity of damage caused by the chemical erosion. -It is indicated unless the patient is unstable (respiratory distress, hypotensive and/or actively bleeding), or esophageal perforation. -If a perforation is noted on radiographic images a surgical consult is indicated.

Dumping syndrome

-Dumping syndrome can occur in up to 50% of postgastric bypass patients when high levels of simple carbohydrates are ingested. -Early dumping syndrome has a rapid onset (15 minutes) due to the hyperosmolality of food as it rapidly empties into the small intestine. -It presents with colicky abdominal pain, diarrhea, nausea, and tachycardia. -Late dumping syndrome is a result of hyperglycemia and the subsequent insulin response leading to hypoglycemia 2-3 hours after a meal. -Patients present with dizziness, fatigue, diaphoresis and weakness. -Usually dumping is self-limiting and lasts several weeks.

Epoprostenol

-Epoprostenol is also known as prostacyclin and PGI2. -It is a strong vasodilator of all vascular beds. In addition, it is a potent endogenous inhibitor of platelet aggregation. -It is used in pulmonary arterial hypertension.

Erysipelas

-Erysipelas is a streptococcal infection (S. pyogenes) of the upper dermis and superficial lymphatics most commonly seen in young children and the elderly. -It presents with abrupt onset facial swelling and well-defined, indurated lesions that expand along the nasolabial folds and extend to involve the entire face and upper extremities. -The red lesions then progress to flaccid bullae during the second and third day. -Finally, desquamation of the involved skin occurs 5-10 days later.

MALT Lymphoma

-Evidence has demonstrated that the development of MALT lymphomas (MALTomas) is from clonal expansion of B cells that is present in chronic gastritis from Helicobacter pylori infections. -The process is from the accumulation of CD4+ lymphocytes and mature B cells in the gastric lamina propria in H pylori-induced gastritis. -The antigens produced from H. pylori activate T and B cell proliferation, and lymphoid follicle formation. - If this is persistent if can become a monoclonal lymphoma. -Patients with MALT lymphomas can achieve remission in 80-90% of the cases when the infection of H. pylori is eradicated.

Exanthemous Rash from PCN

-Exanthemous rash are the most common cutaneous adverse drug reaction (75-80%). -The rash is a maculopapular eruption that starts distally and spreads centrally 5-14 days after starting the medication. -Delay in rash presentation is a result of cell-mediated type IV hypersensitivity reaction. -Common medication drug reactions include penicillins, cephalosporins, sulfonamide, anticonvulsants and allopurinol. -Rash resolves within 1-2 days of drug discontinuation. PEx: flat, contiguous mobilliform rash with areas of well circumscribed elevation measuring less than 1 cm in size with blanching erythema.

Fifth's disease

-Fifth Disease (erythema infectiosum) is caused by human parvovirus B19 and affects preschool to young school-aged children. -This rash presents as a raised red rash that first appears on the child's cheeks ("slapped cheek"). -A lace-like rash starts on the torso and arms after 1-4 days then spread to the rest of the body. -Flu-like symptoms may be present 7 days prior to appearance of the rash.

Cellulitis 2

-For cellulitis due to dry cracked skin the suspected pathogens are Streptococci and/or Staphylococci. -Nafcillin covers both and is considered a first line therapy. -Other first line therapies for beta hemolytic streptococci and MSSA cellulitis infections are cefazolin (IV), oxacillin (IV), clindamycin (IV and PO), dicloxacillin (PO), and cephalexin (PO). -This is a nonpurulent cellulitis, as noted by the physical exam due to the absence of purulent drainage, exudate, and/or no signs of abscess (if those signs were present on physical exam this would be a purulent cellulitis). -Due to the rapid progression of the disease over a one week period this warrants inpatient hospitalization with intravenous antibiotics. -Cultures are rarely obtained and often nonspecific. -Nafcillin would be the best choice in this case as it covers both of the suspected pathogens and would be the least in creating antibiotic resistance.

Loop Diuretic side effect

-Furosemide is a loop diuretic. -*Most common electrolyte abnormalities associated with furosemide are hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, and hypocalcemia (hypercalciuria). * -The patient's laboratory result does not show any of the electrolyte abnormalities associated with a loop diuretic. -Furosemide is commonly used to treat edema secondary to congestive heart failure, it does not cause peripheral edema. -It is important to note that loop diuretics are not effective for edema secondary to calcium channel blockers.

Gemfibrozil

-Gemfibrozil inhibits peripheral lipolysis, decreases hepatic uptake of free fatty acids leading to inhibition of VLDL secretion, and may increase HDL Cholesterol by an unknown mechanism. -It leads to a greater triglyceride lowering potential than statins, however has not been shown to be associated with a mortality benefit equal to that of statin therapy. -There is an increased risk of myositis when used in combination with statins.

Glycoprotein IIb/IIIa inhibitors

-Glycoprotein IIb/IIIa inhibitors are a class of anti-platelet agents that include abciximab, aptifibatide, and tirofiban. -They are a reversible antagonist of fibrinogen binding to the glycoprotein (GP) IIb/IIIa receptor, the major platelet surface receptor involved in platelet aggregation.

Goodpasture's syndrome Vs Wegner's

-Goodpasture's syndrome is also known an anti-Glomerular basement membrane disease. -It is an important differential diagnosis for Wegener's granulomatosis secondary to ANCA positivity and pulmonary-renal syndrome upon initial presentation. -These patients often present with rapidly progressive glomerulonephritis with elevated creatinine, hematuria, red blood cell casts and even renal failure. -Pulmonary hemorrhage with hemoptysis is present in almost half the patients. -However, this disease does not involve any granulomas and therefore does not lead to saddle nose deformity as seen in this case, making goodpasture's syndrome a less likely diagnosis.

Guillainn Barre

-Guillain-Barré syndrome (GBS) is also a post-infectious polyneuropathy that causes demyelination and neurological deficit. -It is most commonly associated with upper respiratory infections or gastroenteritis (usually caused by Campylobacter species). -GBS is usually a purely motor deficit and does not cause altered sensation. -Also, it is a progressive process that ascends to involve a large portion of the spinal cord, including cranial nerves and nerves that innervate the diaphragm. -Transverse myelitis involves a specific segment of the spinal cord and symptoms are only present below the level of the lesion.

H. Pylori PUD treatment

-H. pylori in vitro is susceptible to monotherapy; however, in clinical practice this is not the case due to recurrence of infections and ulcers. -This leads to colonization and increases the risk for lymphoma. -The most successful treatments studied are triple and quadruple therapy. -The resistance has been thought to be secondary to patient compliance. Therefore, instructing the patient on how to take the medications is crucial for proper healing and eradication. -The standard first line therapy is to give a proton pump inhibitor like omeprazole along with clarithromycin and amoxicillin twice daily. -This allows proper healing of the ulcer due to increasing the pH (more alkaline) and appropriately treating the bacterial infection. -14 day therapy is now preferred. It was once treated with 7 day therapy, but it has fallen out of favor due to recurrence of symptoms and ulcer recurrence. -Quadruple therapy is less preferred and is currently used if there is recurrence. -It consists of omeprazole 20 mg twice daily, bismuth subsalicylate 2 tabs four times daily, tetracycline 500 mg four times daily, and metronidazole 500 mg three times daily. -It is quite noticeable why the triple therapy is preferred due to the less frequent times in dosing which aids in compliance. *For first line therapy it is triple therapy, which includes a PPI (omeprazole), clarithromycin, and amoxicillin. This can be remembered as O-CLAM.*

Candida Esophagitis

-HIV is transmitted via semen and blood. Once it enters circulation, it targets and destroys host CD4+ T lymphocytes, weakening cellular immunity of the host over years to decades. -High-risk individuals include homosexuals, bisexual men, IV drug users, and unborn or newborn infants of HIV positive women. -The initial infection may be asymptomatic or present with vague flu-like symptoms (e.g., malaise, fever, headache, rash) and commonly goes undiagnosed. -Patients will then remain asymptomatic for several years as their CD4+ T cell population is steadily destroyed (average rate of CD4+ T cell decline is ~50/µL per year). -Clinical disease usually does not become apparent until the CD4+ T cell count falls below 200/ µL, placing the patient at risk for opportunistic infections and neoplasms. -The three most commonly seen are pneumocystis pneumonia (40%), cachexia in the form of HIV wasting syndrome (20%) and esophageal candidiasis. -HIV wasting syndrome is defined as involuntary weight loss of > 10% with either chronic diarrhea (2 or more stools/day for > 1 month) or fever and fatigue lasting > 30 days. -Patients commonly have significant muscle wasting with myofiber degeneration and myositis. -There is no definitive treatment for wasting syndrome, however; androgenic steroids, growth hormone, and total parenteral nutrition have been used with variable success.

HSV 2 infection

-HSV-2 infection can also cause painful, ulcerative lesions on the oral mucosa and genitals. -Lesions are usually preceded by prodromal symptoms of tingling, burning and pruritus. -Herpes simplex virus can also infect the eye, causing unilateral follicular conjunctivitis or acute herpetic keratoconjunctivitis with dendritic corneal ulcers. -This is the leading bacterial cause of blindness in the United States. -Tzanck smear of fluid from the lesion will show multinucleated giant cells in herpes simplex virus infection.

HUS vs HSP

-Henoch-Schonlein purpura is a vasculitis caused by IgA and C3 deposition in the small vessels. -It primarily affects children and is classically characterized by palpable purpura, abdominal pain, joint involvement and renal involvement. -Approximately 50% of cases are preceded by an upper respiratory tract infection.

Hepatitis panel

-Hepatitis B immunization will result in positive Anti-HBs antibodies but will not have antibodies to HBc or HBe, both of which will be positive with a previous or active infection of hepatitis B. -Chronic hepatitis B infection will also have positive HBsAg.

Necrotizing Fasciitis 2

-High clinical suspicion is key to diagnosing necrotizing fasciitis. Important signs to be aware of include tissue necrosis, putrid discharge, bullae, severe pain, gas production, rapid burrowing through fascial planes, and lack of classical tissue inflammatory signs. -The infection can be definitively diagnosed by tissue biopsy and culture (performed on deep tissue removed during debridement). -Doppler ultrasound and/or CT can be used to determine the extent of tissue involvement and the presence or absence of gas. -Gas is commonly present in Type I and Type III necrotizing fasciitis, however, gas usually is not present when the cause is S. pyogenes or MRSA.

Histoplasma

-Histoplasma capsulatum is a dimorphic fungus endemic to regions along the Mississippi river and is most commonly found in caves where there are significant bird or bat feces. -Disseminated histoplasmosis can occur in HIV/AIDS patients with CD4+ cell counts < 200/mm3 and usually presents with fever, weight loss, hepatosplenomegaly, lymphadenopathy, non-productive cough, palatal ulcers and pancytopenia. -Symptom onset is acute or subacute with average time of presentation within 14 days of exposure.

If you see Low calcium level in an alcoholic and the pt has seizures due to hypophosphatemia

-Hypocalcemia can also present with neuromuscular irritability ranging from mild paresthesias to carpopedal spasm to seizures. -Although this patient has a low serum calcium level of 7.7 mg/dL, it should be corrected for the serum albumin level. -In a chronic alcoholic with malnutrition, a low albumin level is to be expected. -For every 1g decrease in albumin, serum calcium can be increased by 0.8 since albumin binds free calcium making the corrected serum calcium level to be normal at 8.7 mg/dL. The seizures were not due to calcium.

Hypocalcemia

-Hypocalcemia is defined as a serum calcium level below 8.5 mEq/L or a decrease in the ionized calcium level below 4.2 mg/dL. -The causes of hypocalcemia include pancreatitis, massive soft tissue infections such as necrotizing fasciitis, renal failure, pancreatic and small bowel fistulas, hypoparathyroidism, toxic shock syndrome, abnormalities in magnesium levels, and tumor lysis syndrome. -In general, neuromuscular and cardiac symptoms do not occur until the ionized fraction falls below 2.5 mg/dL. -Clinical findings may include paresthesias of the face and extremities, muscle cramps, carpopedal spasm, stridor, tetany, and seizures. -Patients may exhibit a positive Chvostek's sign (spasm resulting from tapping over the facial nerve) and Trousseau's sign (spasm resulting from pressure applied to the nerves and vessels of the upper extremity with a blood pressure cuff). -Hypocalcemia may lead to decreased cardiac contractility and heart failure. -ECG changes of hypocalcemia include prolonged QT interval, T-wave inversion, heart block, and ventricular fibrillation. *Symptoms of severe hypocalcemia may include paresthesias, muscle cramps, Chvostek sign, Trousseau's sign, decreased cardiac contractility, prolonged QT interval, T-wave inversion, heart block, and ventricular fibrillation.*

What other electrolyte do you treat in Hypocalcemia

-Hypocalcemia will be refractory to treatment if coexisting hypomagnesemia is not corrected first. -Magnesium depletion can cause hypocalcemia by producing PTH resistance, which occurs when serum magnesium concentrations fall below 0.8 mEq/L (1 mg/dL or 0.4 mmol/L) or by decreasing PTH secretion, which occurs in patients with more severe hypomagnesemia -Associated deficits in magnesium, potassium, and pH must be corrected in addition to correcting the calcium levels.

Effects of Hypophosphatemia

-Hypophosphatemia can result in myopathy due to phosphate depletion causing significant rhabdomyolysis. -Additional rare clinical findings include respiratory failure and severe central nervous system dysfunction including delirium, generalized seizures and coma as present in an alcoholic.

Zinc deficiency A 18-year-old male with dysgeusia, anosmia, and growth retardation.

-In Middle Eastern countries, chronic zinc deficiency can result in stunted growth in children with hypopigmented hair. -A mild deficiency is associated with decrease taste sensation (hypogeusia), night blindness, and decreased spermatogenesis. -Severe deficiency may present with diarrhea, alopecia, pustular dermatitis, and decreased immunity with frequent infections. -Some foods rich in zinc include oysters, beef, crabs and cereal. A deficiency in zinc is associated with growth retardation, hypogonadism, infertility, dysgeusia, diarrhea, poor wound healing, and impaired cellular immunity. -Zinc absorption may be impaired in pancreatic disease, malnutrition, malabsorption syndromes, and those receiving chronic total parenteral nutrition. -Acrodermatitis enteropathica is an autosomal recessive disease in which zinc absorption is impaired.

When to order a CT w/ contrast in acute pancreatitis?

-In patients with worsening pancreatitis despite conservative treatment and/or severe pancreatitis at initial presentation, a CT abdomen can be helpful in predicting the extent of tissue necrosis and presence of a pseudocyst. -Although most patients undergo a CT abdomen to find radiologic evidence of pancreatitis, it is not in fact indicated as an initial step. Fluid management first!

Addision's Diagnosis and treatment

-Initiation of glucocorticoid replacement should never be delayed waiting for the results of an ACTH test. Once the patient is stabilized, a thorough investigation should be done to determine the precipitating factor or factors for the crisis. -The steroid dosage can be tapered to a maintenance dose once the patient shows clinical improvement. -Future crises can potentially be avoided by close out-patient follow-up and instructing the patient to increase their steroid dose during periods of physiological stress (e.g., surgery, trauma, infections).

IV Ca Chloride vs IV Ca gluconate

-Intravenous calcium chloride is not the preferred or standard therapy because it can cause tissue necrosis or fatal arrhythmia when infused. -It is generally reserved when a more rapid correction is indicated or when calcium gluconate is unavailable. - If the hypocalcemia has been chronic, then this regimen can be fatal because there is a degree of acclimatization that occurs.

Restrictive Cardiomyopathy causes tx?

-Junk gets in the way preventing heart from properly relaxing and filling -sarcoidosis -amyloidosis -hemochromatosis -cancer -fibrosis Tx: diuresis and HR control

patellar reflex great toe dorsiflexion Achilles reflex

-L4 -L5 -S1

Tx for Labrynthitis?

-Labyrinthitis usually self-resolves within a few days to weeks. -Medical treatment with antihistamines (meclizine) and antiemetics (prochlorperazine) may be prescribed to reduce symptoms of nausea and dizziness.

Sarcoidosis vs Leukoclastic vasculitis

-Leukocytoclastic vasculitis refers to inflammation of the small blood vessels without any immune deposits. -It is typically associated with microscopic polyangitis, polyarteritis nodosa, cryoglobulinemia and hepatitic C infection.

Lumbar Spinal stenosis

-Lumbar spinal stenosis occurs in elderly patients and is due to narrowing of the spinal canal or intervertebral foramen which compresses the spinal cord or nerve roots. -It usually affects adults older than 50-years of age. -It most commonly is degenerative in nature, and referred to as "spondylosis." -This can be due to hypertrophy of the ligamentum flavum or facet joints, along with vertebral body osteophytes, or thickening of the posterior longitudinal ligament. -It manifests with neurogenic claudication, bilateral lower extremity radicular pain, sensory loss, or weakness affecting the legs. -Extension of the lumbar spine results in narrowing of the spinal canal, and thus pain is worsened with standing and walking upright. -Flexion of the spinal canal opens up the spinal canal. Thus, patients will get relief of symptoms when sitting or leaning forward while walking. -Patients will describe a relief of pain when pushing shopping cart at grocery store as they are leaning forward during this activity. -Long-standing compression may result in upper motor neuron (UMN) signs and symptoms. -Here the patient has hyperreflexia of the patellar (L2-L4 roots) reflexes bilaterally with normal Achilles (S1 root) reflexes. -This information localizes the lesion(s) to the lumbar spine and, with the help of the history, confirms the likely diagnosis of spinal stenosis. -Recall that deep tendon reflexes are scored from 0-5 as follows: 0 for absent, 1 for hypoactive, 2 for normal, 3 for brisk, 4 for brisk with unsustained clonus, and 5 for sustained clonus.

Management of Adrenal Crisis

-Management goals in the treatment of adrenal crisis include adequate replacement of fluids, electrolytes and circulating glucocorticoids. -Mainstay treatment includes IV hydrocortisone and aggressive fluid replacement with 5% or 10% dextrose in normal saline. -Adrenal crises can be avoided by appropriately increasing the patient's steroid dose during times of physiological stress. -Standard fluid replacement therapy should be with hypertonic solution (e.g., normal saline) to rapidly restore intravascular volume. It should be given as an intravenous infusion with 5% or 10% dextrose to help correct hypoglycemia. -Hydrocortisone is commonly used for glucocorticoid replacement and can be given as an initial 100 mg bolus followed by a continuous infusion. Large doses of hydrocortisone not only restore circulating glucocorticoid levels, but also supply adequate mineralocorticoid effects. -Conservative treatment of hyperkalemia includes administration of calcium gluconate (if severe hyperkalemia or EKG changes are present) glucose, insulin, bicarbonate (to increase intracellular shift of potassium) and kayexalate (to increase body excretion of potassium). -Patients who cannot tolerate or who are refractory to conservative management may require hemodialysis for rapid potassium removal. -Hyponatremia usually corrects after administration of saline solution and hydrocortisone.

Pulmonary Embolism management

-Management include administration of supplemental oxygen and acute anticoagulation therapy with either unfractionated or low-molecular-weight heparin. -Oral warfarin therapy should be started on the same day. Heparin therapy can be discontinued after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started. -This is done to prevent a paradoxical hypercoagulable state that may occur as a result of the relatively long half-life of factor II, along with the short half-lives of protein C and protein S.

Transverse myelitis management

-Management of transverse myelitis involves reducing spinal cord inflammation and alleviating associated symptoms. -Patients are usually treated with intravenous corticosteroids. -Severe cases may require plasma exchange.

Meniere's Disease Vs Labrynthitis

-Meniere's disease includes a triad of vertigo, tinnitus and hearing loss. -Attacks last hours to days and can recur for several months. -t is not associated with a recent upper respiratory infection.

Microscopic Polyangitis Vs. Wegner's

-Microscopic polyangiitis is also a small-medium size vessel vasculitis with very similar initial presentation of hemoptysis (secondary to alveolar hemorrhage instead of granulomas) and hematuria (secondary to rapidly progressive glomerulonephritis). -Microscopic polyangitis can also be triggered by infections like streptococci or drugs like penicillin. -Thus, both diseases have nearly indistinguishable clinical presentation; however, presence of p-ANCA positive antibodies instead of c-ANCA in microscopic polyangiitis

Albumin and Calcium

-Most calcium ions are inactive and bound to albumin. -The physiologically active form (free ionized calcium) are unbound ions that are hormonally regulated. -Total calcium concentration is a measure of free, ionized calcium plus bound, non-active calcium in serum. -Total calcium levels will fluctuate with albumin concentration. -For each 1 g/dL reduction in albumin levels there is a 0.8 mg/dL decrease in total calcium concentration. *-Therefore, hypoalbuminemia (not hyperalbuminemia) will result in low total calcium. * -However, ionized calcium levels will remain the same and thus will not cause clinical hypocalcemia. -Active/ free ionized calcium values can be estimated using this formula: total calcium - (serum albumin x 0.8).

Multi organ dysfunction syndrome

-Multiple organ dysfunction syndrome (MODS) refers to progressive organ dysfunction in an acutely ill patient to the point that "homeostasis cannot be maintained without intervention." -It is on the far end of the sepsis/shock severity scale. -The definition has loose terms, but typically an abnormal platelet count, serum bilirubin, creatinine, low blood pressure, and a poor Glasgow coma score are objective metrics used to define MODS.

MAC vs CMV colitis

-Mycobacterium avium complex (MAC) infection in HIV patients results in non-specific findings of fever, night sweats, abdominal pain, diarrhea, and weight loss. -Lab abnormalities are typically significant for anemia with elevated LDH and alkaline phosphatase and typical CD4 cell counts <100 cells/microL. -However, it is not typically associated with necrotizing colitis resulting in perforation as present in this patient with CMV colitits

NO role in platelets aggregation?

-NO is an inhibitor of platelet aggregation that is produced by endothelial cells and platelets. -NO is increased in uremic patients, and NO synthesis inhibitors have been shown to normalize bleeding time in research studies. NO PLATELETS AGGREGATE

Necrotizing Fasciitis treatment

-Necrotizing fasciitis is a surgical emergency that requires prompt surgical exploration and debridement of necrotic tissue. -Antimicrobial therapy should be started empirically and include coverage for gram-positive, gram-negative, and anaerobic organisms. - A common regimen used includes penicillin G, third-generation cephalosporin, and clindamycin.

Orthostatic Hypotension "intolerance"

-Orthostatic hypotension may be iatrogenic (drug induced), volume depletion (dehydration and blood loss), post prandial (after meals), primary autonomic (Lewy body diseases such as Parkinson's), and secondary autonomic (diabetes, amyloidosis, and Sjogren's). -Patients may present with symptoms of lightheadedness or dizziness, weakness, difficulty concentrating, blurred vision, tremulousness, pallor, clammy feelings, and nausea. -The history is classic with changes in laying down or sitting position to a standing position and have these symptoms and then pass out - likely orthostatic intolerance. -The criteria for diagnosing orthostatic hypotension with vital signs includes one or both of the following (within 2-5 min of quiet standing after 5 min of supine rest): Systolic: 20 mmHg Diastolic: 10 mmHg -Although the patient does not fit this criteria, it is pointed out that the patient is on an alpha-blocker for the hypertension and benign prostatic hypertrophy (BPH). -Prazosin is known to cause first dose syncope due to orthostatic hypotension. This is due to the fact that the body's natural response to changing positions from sitting or laying to a standing position is to increase peripheral vascular resistance. -This natural physiologic response is now inhibited by the medication which causes a decrease in cerebral blood flow and subsequently syncope due to orthostatic hypotension.

Tx: Regimen for H. Pylori Infection

-PPI -Amoxacillin -Macrolide

Pasteurella

-Pasteurellosis is most commonly caused by Pasteurella multocida, a small gram negative coccobacilli. -Pasteurellosis usually results from cat and dog bites or scratches or licking. -A typical lesion is painful with associated erythema and lymphangitis that can rapidly progress within 24 hours. -Complicated infections if untreated can lead to cellulitis and necrotizing fasciitis. -However, the local lesion although painful like tularemia does not involve a black base lesion making it a less likely diagnosis.

Diabetes

-Patients presenting with these symptoms (polyuria and polydipsia) should be screened for diabetes mellitus. -Screening for diabetes should begin at age 45-years-old every 3 years. - However, screening should begin earlier at age 30-years-old if they have a 1st degree relative with diabetes mellitus, cardiovascular disease, sedentary lifestyle, non-Caucasian race, acanthosis nigricans and is overweight (BMI ≥ 25kg/m2) or obese, history of impaired glucose tolerance, hypertension, hyperlipidemia, history of gestational diabetes, history of a delivery of a baby > 4kg (9 lbs), polycystic ovaries, and/or psychiatric disease (schizophrenia). -Testing for diabetes mellitus consists of performing one of the following tests and repeating the same test a second time to confirm the diagnosis

DKA and potassium

-Patients with DKA or HHS have low potassium secondary to urinary losses due to the osmotic diuresis of glucose and to the need to maintain electroneutrality as ketoacid anions are excreted. -Despite these potassium losses, the serum potassium concentration is usually normal or, in one-third of patients, elevated on admission. It is important to note that insulin lowers the potassium concentration and may cause severe hypokalemia. -A patient's death from cardiac arrest could have been prevented by replacement of potassium. -Treatment of diabetic ketoacidosis (DKA) results in significant plasma potassium losses. -Insulin causes a shift of potassium into the intracellular space, and correction of acidosis causes renal loss of potassium, both via a potassium-hydrogen exchange. -Thus, treatment of DKA requires replacement of potassium even in the face of initial normal or high potassium levels to prevent hypokalemia induced cardiac arrhythmias and arrest.

Hypoglycemia in Addison's Disease?

-Patients with adrenal insufficiency can have hypoglycemia because decreased cortisol leads to decreased gluconeogenesis. -Therefore, the development of Addison's disease in patients with pre-existing diabetes can lead to decreased insulin requirements due to this alteration in glucose regulation.

Pericarditis

-Pericarditis can have many various causes. The most common is a viral infection although the exact etiology is typically unknown: -Coxsackievirus, echovirus, adenovirus, EBV, CMV, influenza, varicella, rubella, HIV, hepatitis B, mumps, parvovirus B19. -Radiation, cancer, trauma, and autoimmune disorders are also common causes. -The key to this case is the diffuse ST segment elevation. -If this was a ST segment elevation myocardial infarction (STEMI) the EKG would have 2-3 consecutive leads of ST segment elevation, but not diffuse ST segment elevation. -The patient presentation of pericarditis is very similar to acute coronary syndrome. -Surprisingly this patient does not have a pericardial friction rub. -The treatment for acute pericarditis is with non-steroidal anti-inflammatory drugs. -The patient may be treated with aspirin 2-4 g/day, ibuprofen 400-600 mg TID, or indomethacin 25-50 mg TID. -Colchicine may also be given or even glucocorticoids if treatment has been refractory.

Peripheral Artery Disease

-Peripheral arterial disease is a limb threatening condition owing to the decrease in available oxygen-rich blood perfusion distal to the occluded site. -Ankle-brachial index (ABI) is a useful, and highly sensitive, tool in the clinic setting used as a screen for disease and a measure of degree of disease. -A low ABI, especially exercise ABI, should be further investigated with Doppler electrocardiography and considered for intervention. -Risk factors for peripheral vascular disease including age >65, male gender, smoking history, and diabetes. -The presenting symptoms in this case provide clues of arterial disease and claudication including onset of pain with a consistent walking distance, atrophic toenails, and change in hair growth. -The location of the claudication is suggested by the arteries which provide tissue perfusion to the left leg, gluteal muscles, and the penis which is the cluster found with *aortoiliac disease also known as Leriche's syndrome. * -Of the listed options, the low ABI is a clue that the there is a decreased blood pressure in the lower extremity compared to the upper extremity. -ABI, or ankle brachial index, is a ratio of blood pressures comparing the systolic blood pressure taken from the calf divided by the ipsilateral arm systolic blood pressure. -A ratio ABI greater than 1.0 is considered normal, while a ABI less than 1.0 represents the presence of arterial disease with less than 0.7 representing severe disease.

Phosgene

-Phosgene- is a chemical weapon used during WWI and in dye manufacturing in the 19th century. -Cobalt II Chloride converts into phosgene when exposed to UV light, creating a free radical which results in laryngospasm with inspiratory stridor and partial airway obstruction and irritation of the eyes, nose and throat.

Phosphate stones

-Phosphate stones typically present as calcium phosphate stones often in combination with calcium oxalate stones as well. -They are typically associated with low urine volume, high urinary pH, high urine phosphate and calcium excretion.

Physiologic tremor

-Physiologic tremor is a very low amplitude and high frequency (10 to 12 Hz) tremor that is usually invisible under normal daily circumstances but exaggerated in certain circumstances. -It can be exaggerated by many drugs including anti-depressants, amphetamines, nicotine and many more. -Other examples include increase sympathetic activity with anxiety, agitation and alcohol or opioid withdrawal. -Although this patient's tremors get better with alcohol, it does not mean that they necessarily get worse with alcohol withdrawal

CMV colitis complications in HIV patient

-Pneumoperitoneum refers to air under the diaphragm secondary to intestinal perforation. -Given this patient's history of HIV and non-compliance with HAART, the differential diagnosis of spontaneous peritonitis must include a host of opportunistic infections. -These infections may be caused by cytomegalovirus (CMV), Mycobacterium avium-intracellulare, microsporidium, and Cryptosporidium among others. -Complicated or untreated CMV colitis can result in mucosal perforation -CMV colitis diagnosis is confirmed by endoscopy showing punctuate and superficial erosions to deep ulcerations in the colon. -Biopsy of these ulcers reveals characteristic cytomegalic cells which are large cells containing eosinophilic intranuclear intracytoplasmic inclusions. -Therefore, prompt treatment should be initiated to avoid complications of toxic megacolon, necrotizing colitis and submucosal vasculitis resulting in perforation as present in this patient. -IV ganciclovir or foscarnet are typical first line agents and are typically continued for 3-6 weeks for treatment of CMV colitis. -This can cause thrombosis of the vessels, ischemia, ulceration, gangrene, and perforation of the involved bowel.

Poliomyelitis

-Poliomyelitis is an infectious myelitis caused by poliovirus. -Infection with poliovirus is very rare today due to vaccination; however, it used to be a common cause of aseptic meningitis in developing nations. -Most patients would recover without sequelae, but a small percentage would develop a more severe illness characterized by myalgia, loss of reflexes, and flaccid paralysis of proximal limb muscles.

Polycythemia Vera

-Polycythemia vera is usually unrecognized and found incidentally. -Common complaints may be itching after being in hot water and hyperviscosity symptoms (headaches, visual disturbances, vertigo, and TIAs). -Patients may have elevated blood pressure secondary to red cell mass elevation. -If the hemoglobin is less than 20 other diagnoses have to be considered (hypoxia from high altitude, smoking, pulmonary disease and tumors). -However, with the hemoglobin at 20 with leukocytosis and thrombocytosis the diagnosis is apparent. -Further testing includes an assay for JAK2 V617F. -Treatment consists of phlebotomy to a goal hemoglobin of ≤14 g/dL and hematocrit ≤45% in males. -In females the goals are ≤12 g/dL hemoglobin and a hematocrit of ≤42%. *This is due to the increased amount of red blood cells in the circulation. Laboratory studies will have elevated levels of hemoglobin, hematocrit, leukocyte count, and platelet count.*

Popcorn calcifications

-Popcorn like calcifications are typically benign and are the result of pulmonary hamartomas. -A hamartoma is a benign, focal malformation that resembles a neoplasm in the tissue of its origin. -This is not a malignant tumor, and it grows at the same rate as the surrounding tissues. -It is composed of tissue elements normally found at that site, but which are growing in a disorganized mass. -They occur in many different parts of the body and are most often asymptomatic and undetected unless seen on an image taken for another reason.

Potassium in heart failure

-Potassium levels should be monitored closely in patients on any potassium sparing medications like ACE inhibitors and spironolactone. -Also, low salt substituents for heart failure patients often contain potassium chloride, which should be used in moderation due to risk of hyperkalemia in patients on potassium sparing medications. -However, low sodium intake is more important in prevention of heart failure exacerbation than potassium.

Primary Myelofibrosis

-Primary myelofibrosis has common symptoms of night sweats, fatigue, and weight loss. -A blood smear would show teardrop cells. -Usually has a mild anemia with normal to high leukocyte and platelet counts. - The bone marrow is extremely hard to aspirate due to the fibrosis. -Radiographic images display osteosclerosis.

Pulmonary Embolism

-Pulmonary embolism occurs when a thrombus originating from the venous circulation (commonly from pelvis or lower extremities) or right side of the heart embolizes to the pulmonary vessels via the right ventricle and pulmonary artery. -The embolus blocks distal blood flow leading to increased pulmonary vascular resistance, pulmonary hypertension, and possible right ventricle failure. -PE usually presents with abrupt onset of tachypnea, pleuritic chest pain, and dyspnea. -Physical examination may reveal a loud pulmonary component to S2 and a prominent jugular A wave due to right heart failure.

Pyomyositis

-Pyomyositis is characterized by a pus-filled abscess that forms within the skeletal muscle. -It is most commonly seen in children aged 2-5 who live in tropical regions. -It is caused by S. aureus. -The infection most commonly affects large muscle groups such as the quadriceps or gluteal muscles and usually remains localized. -However, if left untreated, patients may present in shock due to exotoxins (e.g., toxic shock toxin 1) or enterotoxins produced by the organism.

B1 Deficiency; Thiamine A 54-year-old presents with sensory and motor impairments, mostly of the distal extremities.

-Recognize that in developed countries the most common cause of chronic thiamine deficiency is alcoholism. -Patients can present with horizontal nystagmus (abnormal eye movements), ophthalmoplegia, cerebellar ataxia (lack of co-ordination while walking) and mental impairment (dementia) along with confabulation psychosis termed Wernicke-Korsakoff syndrome. -Thiamine deficiency also causes beriberi. -Dry beriberi presents as symmetrical peripheral neuropathy with both motor and sensory impairment. -Wet beriberi presents with (in addition to neuropathy) signs consistent with CHF including cardiomegaly, lower extremity swelling, and tachycardia.

Tx: for Heart Failure

-Reduce Fluid (Preload) (low Fluids <2 L/day, and low sodium <2g/day) and Diuretics if > Class II -Add Disosorbide Dinitrate if > Class III -Reduce Afterload (ACEi's) -Add Spironolactone or Hydralazine if > class III

Refeeding Syndrome in an alcoholic

-Refeeding syndrome is characterized by hypophosphatemia, hypokalemia, hypomagnesemia, vitamin and mineral deficiencies due to electrolyte and fluid shift following carbohydrate consumption in malnourished patients. -Hypophosphatemia and its related complications are the hallmark of this disease. -This patient's presentation with bilateral temporal wasting and history of daily consumption of alcohol is suggestive of malnutrition. -Phosphate, calcium, potassium, magnesium and thiamine are some of the nutrients often found to be depleted in chronic alcoholics. Although phosphate depletion is common in these patients, the absolute fall in the serum phosphate below 1 mg/dl may not happen until 24 hours after hospitalization due to transcellular shift from iatrogenic interventions. -Therefore, hypophosphatemia is the most common clinical finding observed in alcohol withdrawal patients in the hospital within a few hours of administration of dextrose solutions or a heavy meal. -This patients presentation of generalized seizures is consistent with refeeding syndrome secondary to hypophosphatemia.

Refeeding Syndrome

-Refeeding syndrome is defined as a potentially fatal shift in electrolytes and fluids that occurs in malnourished patients receiving enteral or parenteral nutrition. - Patients at high risk for refeeding syndrome include those who are chronically malnourished and those at high risk for malnutrition, such as in the case of cancer, prolonged starvation, chronic alcoholism, elderly, and postoperative patients. -Refeeding syndrome is precipitated by rapid refeeding. -The hallmark electrolyte disturbance of refeeding syndrome is hypophosphatemia, which leads to widespread dysfunction of cellular processes. -This can be characterized by cardiac instability leading to arrhythmias, congestive heart failure, acute respiratory failure, and even death. -Other electrolytes are also deranged, including sodium and potassium, as well as thiamine, protein, glucose, and fat metabolism. *Refeeding syndrome is a severe and potentially fatal syndrome seen in patients who are severely malnourished and in whom rapid refeeding is initiated. The hallmark metabolic disturbance is hypophosphatemia.*

Rheumatoid Arthritis Vs Wegner's

-Rheumatoid arthritis is a chronic, systemic, inflammatory autoimmune disease that usually presents with symmetrical arthralgias and joint stiffness lasting longer than 1 hour. -an initially present with similar non-specific symptoms like fever, weakness, myalgias and arthralgias, -In rare cases, rheumatoid can present with vasculitis and pulmonary symptoms as well. -Diagnosis of rheumatoid arthritis is based on positive rheumatoid factor (more sensitive, less specific) and/or Anti-CCP antibody (very specific and sensitive). -However, in this case even though rheumatoid factor is mildly positive, anti-CCP antibody is negative which makes rheumatoid arthritis a less likely diagnosis.

Ricin Poisoning

-Ricin is a natural poison derived by caster beans. It is classified as a category B agent of bioterrorism due to its ability to be easily disseminated and cause significant morbidity. -Patients may initially present with gastrointestinal or pulmonary symptoms depending on route of administration. -Without treatment, ricin poisoning leads to shock, multi-organ failure and death within days. -There is no known antidote available for ricin, however, prompt diagnosis and early supportive care usually results in full recovery. -Symptoms of ricin ingestion usually present within 6 hours and may include perioral/oral burning, abdominal pain, vomiting or hematemesis, and bloody diarrhea. -Inhalational ricin poisoning may cause respiratory distress, fever, cough and pulmonary edema.

Ricin

-Ricin toxin is a highly toxic lectin produced from the seeds of the castor oil plant. -Exposure is inhaled, injected or ingested. -Ricin causes severe nausea, diarrhea, seizure, tachycardia and hypotension followed by cardiovascular shock and death within 3-5 days of exposure.

Working up RUQ pain for Gallbladder disease

-Right upper quadrant (RUQ) postprandial pain with radiation to the right shoulder blade is classic for gallbladder disease. -However, to rule in disease, RUQ ultrasound can be useful to help identify gallbladder pathology and rule out liver disease such as hepatitis. -Findings on the ultrasound help dictate the correct next course of actions. -In this case, the ultrasound is significant for a CBD dilation of 8mm which is dilated beyond normal range (normal mean CBD diameter is 4.1mm) suggesting the presence or recent passing of a gallstone. Presence of fluid, pericholecystic fluid, along with gallbladder wall thickening is suggestive of in inflamed gallbladder as seen in cholecystitis. -Normal procedure would be surgical removal of the diseased gallbladder. However, given the CBD dilation which suggests the possibility of a recently passed stone that may still be in the CBD or in the pancreatic duct leading to a high risk of pancreatitis. -Removing the gallbladder alone without attention to the stone would lead to high morbidity. -Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic procedure that allows the physician to visually identify the sphincter of oddi and remove contents found in the distal pancreatic duct. -Once any obstruction is removed, the surgeon would proceed with surgery.

Pulmonary Embolism 2

-Risk factors for PE include age > 60, malignancy, prior deep vein thrombosis or PE, hereditary hyper coagulable states (factor V leiden, protein C or S deficiency, antithrombin III deficiency), prolonged immobilization or long distance travel, cardiac disease (especially CHF), obesity, nephrotic syndrome, major surgery (especially pelvic or orthopedic), major trauma, pregnancy, and estrogen use. -This patient had three risk factors, including age > 60, breast cancer, and CHF, placing her at risk for PE development. - Clinical manifestations of pulmonary embolism vary and are nonspecific. Signs and symptoms include dyspnea, pleuritic chest pain, cough, hemoptysis, tachycardia, and rales. -Although the majority of emboli originate from lower extremity deep vein thromboses, only approximately one-third of patients with PE will have signs and symptoms of DVT. -The Modified Wells Criteria is commonly used to determine whether imaging for PE in appropriate. It consists of a list of factors assigned points. -If a patient has a Modified Wells score > 4 then PE is clinically likely and Spiral CT should be performed immediately. -If their score is < 4, then PE is unlikely and a d-dimer lab study can be used to rule out PE. -Electrocardiogram is nonspecific in patients with PE and the most common finding is sinus tachycardia. However, electrocardiogram is still important in the work-up of PE to rule out cardiac causes of chest pain and shortness of breath (this patient's demonstrates sinus tachycardia with no ST segment changes).

Rubral tremor

-Rubral tremor is result of a midbrain or cerebellar injury which produces a mixture of posture, intention and resting tremor with a low-frequency of 3 to 5 Hz only. -In this question, we have a clear case of tremor that is worse with activity and better with rest, with no history of head trauma, which makes this a less likely diagnosis.

SIADH

-SIADH presents with hyponatremia, hypoosmolality, and high urine sodium concentration. -However, it is characterized by reduced urine output due to excess absorption of water by excess ADH secretion. -Etiologies including brain trauma, drugs, tumor and paraneoplastic syndrome. -It can present as polyuria only if patients also drink a lot of water .

Salmonella species in SS patients (OSTEOMYELITIS VS SEPTIC ARTHRITIS)

-Salmonella infection is much less common in sickle cell patients with septic arthritis compared to osteomyelitis where Salmonella infections (most commonly S. typhimurium) make up more than half of cases. -Salmonella species cause over half of cases of osteomyelitis in sickle cell patients. They are also a less common but potential cause of septic arthritis in this population. Common isolates include S. typhimurium and S. paratyphi. S. enteritidis is not associated with septic arthritis or osteomyelitis in sickle cell disease. However, it has been associated with reactive arthritis (Reiter's syndrome) following gastroenteritis, most commonly in persons with HLA-B27 histocompatibility antigen.

Sarcoidosis

-Sarcoidosis can also cause hypercalcemia but the lesion is usually bilateral with hilar adenopathy. Patients can have other manifestations such as erythema nodosum on the shins. -Hemoptysis is not characteristic. Granulomatous disease increases the concentration of calcitriol (1,25-dihydroxyvitamin D) instead of PTHrP.

Sarcoidosis 2

-Sarcoidosis is a disease in which abnormal collections of chronic inflammatory cells (granulomas) form as nodules in multiple organs. -These granulomas are focal, chronic inflammatory reaction with accumulation of multinucleated giant cells, epithelial cells , lymphocytes and macrophages that gradually resolve. -These non-caseating granulomas most often appear in the lungs or the lymph nodes, but virtually any organ can be affected. -The most common presenting symptoms of sarcoidosis are dyspnea and dry cough. -Bilateral hilar adenopathy is commonly associated with sarcoidosis and the diagnosis can be confirmed with a biopsy via bronchoscopy or open lung biopsy. -Sarcoidosis is associated with other clinical entities such as erythema nodosum and uveitis as well. -Acute sarcoid arthritis can present as Lofgren's syndrome characterized by the triad of hilar lymphadenopathy, erythema nodosum and arthralgias. -First line treatment for sarcoidosis is usually corticosteroids.

Sarin poisoning

-Sarin is a potent inhibitor of acetylcholinesterase which results in toxic accumulation of acetylcholine at the post synaptic cleft, causing miosis, rhinorrhea, bronchospasm, diaphoresis, nausea, vomiting and urinary incontinence. -If not quickly treated the patient will rapidly deteriorate resulting in apnea, coma, convulsions or death. At non-lethal doses, permanent neurological damage may result if untreated. THINK DUMBELLS

Scarlet Fever Rash

-Scarlet fever is cause by streptococcal bacterial infection. -Patients may develop a red rash that looks like a sunburn with a rough texture like sandpaper, most often starting on the chest and stomach then spreading to the rest of the body. -The rash may last between 2-7 days and is associated with red, swollen lips with a strawberry-like tongue. -Skin may peel on hands and feet after the rash fades. -If left untreated, patients can develop rheumatic fever.

Vitamin C deficency (Scurvy)

-Scurvy is a clinical syndrome seen with ascorbic acid deficiency which results in impaired collagen synthesis with disordered connective tissue. -Symptoms occur as early as three months after deficient intake. - Collagen synthesis requires vitamin C as a cofactor to facilitate cross-linking of the alpha peptides. Failure of this step in collagen synthesis results in the symptoms seen in scurvy. -In scurvy, the lack of hydroxylation of proline and lysine causes a looser triple helix formation. -This includes impaired wound healing, defective tooth formation, ecchymoses, bleeding gums, petechiae, coiled hairs, hyperkeratosis, arthralgias, and impaired wound healing. -Radiographic findings in scurvy include periosteal elevation and epiphyseal separation. The epiphyses and periosteum also become easily detachable because of hemorrhaging that occurs below the periosteum. -Vitamin C deficiency results in cortical thinning and decreased trabeculae of bone. This produces a decrease in radiopacity on plain film radiographs, resulting in an appearance that is similar to ground glass. -Generalized systemic symptoms are weakness, malaise, joint swelling, arthralgias, edema, depression, neuropathy, and vasomotor instability.

Knee pain in SS disease with fever

-Sickle cell disease predisposes patients to infections of the joint and bone. Pathogens associated with septic arthritis in sickle cell include S. aureus, Streptococcus, E. coli, and Salmonella. The latter is not seen as frequently in septic arthritis as it is in osteomyelitis. -Sickle cell disease is associated with several musculoskeletal disorders due to repetitive tissue and bone infarction causing necrosis. -Areas of infarction are at increased risk for infection, including septic arthritis and osteomyelitis. -Septic arthritis presents in sickle cell patients similarly to how it presents in the general population with swelling, erythema, pain and decreased range of motion. -It usually involves large joints, most commonly the knee and less commonly the hip, shoulder, or elbow. -Plain radiograph will show soft tissue swelling and joint space narrowing without periosteal involvement (if present, indicates osteomyelitis). -The most common pathogen associated with septic arthritis is Staphylococcus aureus in all populations, including sickle cell patients. -Other microorganisms that can cause septic arthritis in sickle cell disease include Streptococcus, Escherichia coli, and Salmonella.

Heart Failure Exacerbation

-Some of the common symptoms of heart failure include dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral edema and non-specific abdominal symptoms like nausea and vomiting. -Common physical findings in heart failure exacerbation include peripheral edema, pulmonary crackles, elevated jugular venous pressure, hepatojugular reflex, displaced apical impulse, and S3 gallop.

Spherocytes

-Spherocytes are seen in the condition hereditary spherocytosis, and is the result of a mutation in spectrin. -Spectrin is a protein in the red blood cell inner membrane. -Spectrin-deficient red blood cells have decreased membrane mechanical stability. -This causes loss of surface area without loss of volume. -This leads to the spherocytic shape of affected red cells. -First step in treatment is via a splenectomy, which eliminates the associated hemolysis and anemia seen with this disease.

Staphylococcal scalded skin syndrome (SSSS)

-Staphylococcal scalded skin syndrome (SSSS) is a blistering disease caused by exotoxins released by Staphylococcus aureus resulting in detachment of the epidermal layer. -Therefore, a positive nikolsky sign is an important clinical finding. -SSSS can present anywhere from a few small blisters after a local impetigo infection to a complete exfoliation of the skin, depending on the severity of the infection. -Patients can present much sicker with constitutional symptoms including fever, lethargy, and poor feeding. -Treatment includes targeting the underlying infection with antibiotics along with aggressive hydration and supportive care. However, it is typically found in newborn and children making it a less likely diagnosis.

MCC of Infective endocarditis 2/2 IVDU

-Staphylococcus aureus is the most common cause of infective endocarditis secondary to intravenous drug use. -This is due to the skin flora being over the area of uncleaned skin and is complicated by talc that is injected with the drug causing damage to the tricuspid valve. -Staphylococcus aureus is followed by Streptococci and Enterococci, then less common are fungi and gram negative bacilli in intravenous drug users. -Certain areas have reported higher incidents of other organisms (Detroit, MI, and Chicago, IL Pseudomonas aeruginosa and Serratia in San Francisco, CA). -However, overall the most common is Staphylococcus aureus in intravenous drug users.

Causes of infective endocarditis

-Staphylococcus epidermidis is more commonly found with prosthetic heart valves and not with intravenous drug use. This patient does not have a history of valve replacement. -Step bovis: This is associated with colon cancer. The new nomenclature for this organism is Streptococcus gallolyticus. -Viridans strep: This is the second most common cause of infective endocarditis and is associated with subacute endocarditis. -HACEK: These organisms are associated with culture-negative endocarditis. However, recent studies have shown that cultures may be obtained when incubated for at least five days. HACEK organisms include: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella.

Statins

-Statin therapy is the first-line therapy for hypercholesterolemia. -They work by inhibiting HMG-CoA reductase which catalyses the rate-limiting step in cholesterol biosynthesis. -Their main side effects include an elevation in liver transaminases and myositis

Stevens-Johnson syndrome (SJS)

-Stevens-Johnson syndrome (SJS) is another skin blistering disease with associated epidermal necrosis. -It is also associated with a positive nikolsky sign like pemphigus vulgaris and TEN. -Stevens-Johnson syndrome and TEN are distinguished based on the body surface area involvement, typically 10-30% in SJS and greater than 30% in TEN. -However, onset is typically acute with a clear inciting event like new drug or infection, making SJS a less likely diagnosis.

Struvite Stones

-Struvite stones are composed of magnesium ammonium phosphate and calcium carbonate apatite. -These struvite stones can be seen secondary to infections by urea-splitting organisms such as Proteus and Klebsiella. -Occasionally, staghorn shape struvite stones can be seen as well which fill the kidney pelvis.

Sulfer Mustard

-Sulfur mustard is a highly reactive intermediate compound that alkylates the guanine nucleotide in DNA stands which leads to programmed cell death. -It is lipophilic and strongly mutagenic and carcinogenic due to alkylating properties. -Exposure to mustard gas rarely causes immediate symptoms. -Within 24 hours of exposure, victims experience skin irritation followed by fluid filled blisters in the areas of contact or first and second degree burns. -Eye exposure results in miosis and conjunctivitis which can result in temporary blindness. -If inhaled in very high concentrations, damage to the mucous membranes causing bleeding, blistering and pulmonary edema.

Young woman had a syncopal episode at home without any preceding symptoms, EKG NSR, no orthostatic vitals, no signs of dehydration... Work up next?

-Syncope can be caused by many different etiologies. -Due to the patients history and physical it would be pertinent to rule out arrhythmias as a cause. -Electrocardiograms only capture a snap shot of the patient's cardiac rhythm status. -For a patient that has syncopal events it is important to rule out arrhythmias as a cause. -This is better evaluated with a 24 hour Holter monitor. If the patient continues to have syncopal events a 30 day Holter monitor may be performed. -There are a variable of arrhythmias that may cause syncope. -Bradyarrhythmias that cause syncope are attributable to sinus node disease (sinus arrest or sinoatrial block) or atrioventricular block (Mobitz type II, complete AV block). -The patients may experience a tachyarrhythmia-bradyarrhythmia syndrome with sinus node disease. -Typically after the tachyarrhythmia with the sudden decrease in heart rate is the cause of the syncope. -Syncope due to bradycardia or asystole is referred to as Stokes-Adams attack. -Ventricular tacchyarrhythmias such as ventricular tacchycardia with a rate above 200/minute are more likely to cause syncope. -Long QT syndrome is a hereditary disorder known to cause ventricular arrhythmias that cause syncope and even sudden death. -Patients with dilated ventricles are more prone to ventricular arrhythmias.

Allen Test

-The Allen test is used to test the patency of the radial and ulnar arteries of the arm. -The patient elevates the hand and proceeds to make a fist for 30 seconds while pressure is applied over both the radial and ulnar arteries in order to blanch the hand. -The patient is then asked to open the hand and pressure over the ulnar artery is released. -The number of seconds it takes for the hand to return to normal color is recorded. -The same procedure is repeated and pressure is released over the radial artery. -For the ulnar artery, if normal color does not return within 7 seconds than the Allen test is considered positive and the ulnar artery supply to the hand is not sufficient. -It is commonly performed prior to coronary artery bypass grafting because the radial artery is commonly used as a graft. -If the Allen test takes longer than 5 seconds for the radial artery, then it is not considered patent, and is thus insufficient to be used for bypass grating.

What is CHADS2VASc

-The CHADS2VASc score is used for prevention of cardioembolic stroke. -Cardioembolism is approximately 20% of all ischemic strokes. The CHADS2VASc score is utilized to determine the treatment plan with patients that have atrial fibrillation. The score breakdown regarding treatment us as follows: 0 aspirin or no antithrombotic 1 aspirin or anticoagulation (warfarin) 2+ These patients are typically put on heparin and bridged with warfarin to an INR of 2-3

Cozen Test

-The Cozen test is a test for lateral epicondylitis, also known as tennis elbow. -Lateral epicondylitis is an overuse syndrome of the extensor tendons. -The extensor tendons insert onto the lateral epicondyle of the elbow. -Tennis players often suffer lateral epicondylitis as a result of pressure grip strain, or due to backhand shots performed with a leading elbow. -Lateral epicondylitis is caused by microtearing of the extensor carpi radialis brevis tendon. -Physical exam reveals local tenderness over the origin of the extensor tendons on the lateral epicondyle. -The Cozen test is positive if resisted wrist extension triggers pain over the lateral epicondyle over the humerus due to stress placed upon the extensor carpi radialis brevis tendon. -Treatment is with activity modification, ice, NSAID's, and a counter-force brace.

Glascow Coma Scale

-The Glasgow Coma Scale (GCS) is a neurological scale that provides an objective assessment of assessing and recording a patient's level of consciousness using eye opening, verbal and motor responses. -Patients who have no response to stimuli in eye opening, verbal or motor response have a GSC score of 3, compared to a patient with spontaneous eye opening, oriented verbal responses and follows motor commands has a GCS score of 15.

Aortic Dissection

-The acute chest pain, history of smoking (at risk for aneurysm), chest pain radiating to the back, and widened mediastinum is highly suggestive of aortic dissection. -The right sided pleural effusion is most likely secondary to hemothorax from acute aortic dissection as well. -His history of heavy tobacco use and hypertension put him at increased risk for aortic dissection. -The next best step in diagnosis would be to get an emergent CT chest to establish early diagnosis and proceed with medical or surgical management depending on the type of dissection. -Type A dissections involving the aortic arch are taken for emergent surgery whereas -Type B dissections are managed medically with beta blocker therapy.

Pulmonary Embolism ECG and Dx

-The classic ECG findings associated with PE are tachycardia, right-axis deviation, and a S1Q3T3 pattern. -These findings are transient and nonspecific. However, their presence suggests massive PE blocking the central pulmonary arterial circulation leading to cor pulmonale. -Pulmonary angiography is the "gold standard" for diagnosing PE. Due to its invasive nature, it is reserved for patients who are hemodynamically unstable or those with a high clinical pretest probability of PE but equivocal noninvasive test findings. Pulmonary angio = CT with contrast = CTA -Ventilation/perfusion (V/Q) scan uses scintigraphy and isotopes to evaluate the circulation of air and blood within a patient's lungs. It has been replaced by helical CT as the initial diagnostic modality in evaluation of PE. However, it is still commonly used for patients with contraindications to helical CT, specifically the pregnant population.

Hemolytic Uremia Syndrome

-The classic presentation of hemolytic uremic syndrome (HUS) consists of the triad of anemia, thrombocytopenia, and acute renal failure -Hemolytic uremic syndrome produces a micorangiopathic hemolytic anemia with a hemoglobin level that is typically less than 8 g/dl. -The hallmark of hemolytic uremic syndrome in the peripheral smear is the presence of schistocytes. -These consist of fragmented, deformed, irregular, or helmet-shaped RBC's and reflect the partial destruction of RBC's that occurs as they traverse vessels partially occluded by platelet and hyaline microthrombi. -The peripheral smear may also contain giant platelets. This is due to the reduced platelet survival time resulting from the peripheral consumption/destruction. -Additionally, other laboratory tests such as the elevated LDH and indirect bilirubin are also characteristic of HUS *-However, a key distinguishing factor from TTP is the presence of bloody diarrhea often precipitated by E. coli O157:H7 or Shigella.* Additionally, the sympathetic viscerosomatic reflex for the kidneys is T9-L1 ipsilaterally. In this case, both kidneys are effected, thus, the tissue texture changes are bilateral.

Pre renal Azotemia in Lupus flare

-The clinical scenario of a patient with diarrhea strongly hints towards possible volume depletion. Additional objective clinical data like dry mucous membranes should further confirm the suspicion for dehydration as well. -Laboratory data with an elevated creatinine and blood urea nitrogen is consistent with acute kidney injury. AKI secondary to dehydration can result in both pre-renal azotemia and acute tubular necrosis (ATN). 1. Fractional excretion of sodium (FENa) = 100 X (Serum creatinine/Urine creatinine)/(Serum sodium / urine sodium) FENa = 100 X (1.8/22)/(148/14) = 0.76 % , which is consistent with pre-renal azotemia. FENa is less than 1% in pre-renal azotemia and greater than 2% in ATN and AIN (acute interstitial nephritis). *high FENa means the kidney is broken cause it cant resabsorb sodium* 2. Ratio of blood urea nitrogen/serum creatinine BUN/Cr = 23.3, which is consistent with pre-renal disease BUN/Cr is greater than 20:1 in pre-renal disease and either normal or 10 to 15 : 1 in ATN and AIN. 3. Urine sodium Urine sodium is usually less than 20 mmol/L in pre-renal azotemia whereas greater than 40 mmol/L in acute tubular necrosis and post-renal obstruction.

EKG finding in HypoCalcemia

-The hallmark ECG finding associated with hypocalcemia is prolongation of the QT interval due to lengthening of the ST segment. -The length of the ST segment is directly proportional to the degree of hypocalcemia or inversely proportional to the serum calcium level. -Prolongation of the QT interval can result in deadly ventricular dysrhythmias. -Hypocalcemia also causes decreased myocardial contractility, which can lead to hypotension and heart failure in severe cases.

HUS

-The hemolytic-uremic syndrome (HUS) presents with microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury, often followed by a prodromal viral illness. -Classically the condition has been associated Escherichia coli 0157:H7 gastroenteritis. -This particular strain of E. coli produces Shiga toxin, which causes colitis, allowing systemic absorption of Shiga toxin and other toxins from the gastrointestinal (GI) tract. -These toxins promote inflammation and microthrombosis in the glomerular capillaries, leading to a local intravascular coagulopathy. -Renal insufficiency, microangiopathic hemolytic anemia and destructive thrombocytopenia all result largely from these toxin-induced glomerular abnormalities and explain this patient's clinical presentation. -HUS is one of the main causes of acute kidney injury in children less than three years of age. *The hemolytic-uremic syndrome (HUS) presents with microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury, often followed by a prodromal viral illness. Classically the condition has been associated Escherichia coli 0157:H7 gastroenteritis. *

Why not treat hypoxia first berfore hypercapnia in COPD exacerbation?

-The hypoxia is concerning and needs to be treated. -However, this patient needs to have their ventilation issue resolved otherwise the patient will continue to retain more CO2. -Supplemental oxygen should be applied to keep arterial oxygen saturation >90%. -Hypoxemic respiratory drive plays a very small role in COPD patients. -Studies have shown that supplemental oxygen does not reduce minute ventilation in both acute and chronic hypercapnia.

Iron Deficiency Anemia

-The major cause of iron deficiency anemia is blood loss, either overt or occult. -Overt blood loss can be due to traumatic hemorrhage, hematemesis, melena, hemoptysis, menorrhagia, or gross hematuria. -Occult blood loss can be due to microscopic bleeding in the stool caused by a gastrointestinal tract tumor. -The usual presenting symptoms in adults with iron deficiency are weakness, headache, irritability, fatigue, and exercise intolerance. -Laboratory findings will show a microcytic, hypochromic anemia with low serum iron and ferritin levels. -The transferrin or total iron binding capacity levels will be elevated. -Treatment is with oral iron tablets.

Refeeding syndrome - what to supplement with?

-The malnourished patient may be thiamine deficient at baseline. -With refeeding, intracellular uptake of electrolytes leads to increased utilization of thiamine, and Wernicke's encephalopathy may occur, with signs that include encephalopathy, oculomotor dysfunction, and gait ataxia. -Central pontine myelinosis has also been reported as a complication of the refeeding syndrome in anorexia nervosa.

Waterhouse Friederichsen

-The most likely diagnosis is Waterhouse-Friderichsen syndrome, which is characterized by massive hemorrhage of the adrenal glands and septic shock from Neisseria meningitidis bacteremia. -The petechial rash is a classic clue for this bug. -This syndrome, in addition to adrenal hemorrhage, can lead to disseminated intravascular coagulation (DIC) with widespread thrombosis. Elevated creatinine suggests renal failure which is possible but not as probable as DIC in patients with Waterhouse friderichsen syndrome. Adrenal failure is associated with a non-anion gap metabolic acidosis due to lack of aldosterone.

Infectious mononucleosis OMM contraindication

-The patient has signs of an enlarged spleen as noted on physical exam. The spleen is at risk for splenic rupture with contact sports and is in a more friable stage. -Due to this friability it is contraindicated to apply force as the consequence could be traumatic. -The splenic pump is indicated for right-sided congestive heart failure, splenic congestion, infections (except infectious mononucleosis), and parenchymal disease of the spleen. -Contraindicated in the setting of spinal or rib fractures, friable spleen (splenomegaly, especially due to infection), traumatic disruption of the spleen, and lymphatic system malignancy. -This technique is employed by having the patient take very deep breaths and during exhalation the physician's hands apply a force over the spleen and under the rib cage with a low velocity moderate amplitude springing motion. -Additionally, you note restriction in the diaphragm as a result of local inflammation from the expanding spleen. -Take caution if addressing the diaphragm however and only employ indirect techniques that avoid pressure on the spleen.

Hypertrophic Cardiomyopathy

-The patient in this vignette is a young, male athlete who experienced syncope during vigorous exercise with a systolic murmur on examination which is suggestive of hypertrophic cardiomyopathy (HCM). -HCM refers to asymmetric hypertrophy of the left ventricular wall causing left ventricular outflow obstruction. -Symptoms vary from chest pain, dyspnea, syncope to sudden cardiac death depending on the extent of dynamic outflow obstruction. -Loss of consciousness in these patients is thought to be related to sudden left ventricular outflow obstruction and rapid drop in cerebral perfusion pressure. -The degree of LV outflow obstruction in these patients is worsened by factors that reduce left ventricular end diastolic volume (preload), including tachycardia and dehydration in the setting of vigorous exercising in this vignette. -Other maneuvers that decrease preload like valsalva and standing cause an increase in the intensity of the murmur. -Maneuvers that augment venous return and increase preload, such as leg elevation or squatting, decrease the murmur. -The history of sudden death in a male relative is also suggestive of this diagnosis. -Sudden cardiac death in patients with HCM is typically the result of ventricular arrhythmias. -Diagnosis is made by echocardiography which reveals left ventricular hypertrophy with or without left ventricular dynamic outflow obstruction. -Treatment options include beta blockers, defibrillator and septal myotomy. As with any other cardiac pathology you may have osteopathic findings that help confirm diagnosis and can be important for management of the patient. In this case you are provided with the anterior Chapman point (left 2nd ICS) for the heart. You may also see TART changes from T1-4 as a result of viscerosomatic reflexes from the underlying cardiac pathology.

Severe Sepsis and shock management

-The vitals are a clue to giving us the answer of how severe the infection is along with the patient's clinical exam. -The patient is having difficulty following commands which leads us to the understanding that there is decreased oxygen delivery to the organs as revealed by the hypotension. -This is caused by the sepsis, which causes a buildup of lactic acid due to anaerobic respiration secondary to decreased oxygen delivery as a consequence of the hypotension. -The body is trying to overcome this by the response of tachycardia. -The diagnosis is made by the systemic inflammatory response syndrome (SIRS) criteria with a known microbial etiology and hypotension (systolic blood pressure < 90 mmHg) which leads to the diagnosis of severe sepsis. -The diagnosis of septic shock can be made if the patient does not respond to fluid resuscitation. -The treatment would be intravenous antibiotics prior to cultures, intravenous fluids, and if no response to fluid resuscitation for at least 1 hour despite adequate fluid resuscitation vasopressors would need to be started. -The first line vasopressor is norepinephrine.

Antihypertensive medications and osteoporosis

-Thiazide diuretics, such as hydrochlorithiazide, inhibit sodium and chloride resorption in the distal convoluted tubule, which leads to the osmotic force driving their diuretic effect. -However, they stimulate distal tubular resorption of calcium. The decrease in net calcium urinary excretion has beneficial effect on bone mineral density and other conditions, such as recurrent nephrolithiasis or other issues of hypercalciuria. -Thiazide diuretics are generally well tolerated and commonly used as first-line therapy in newly diagnosed hypertension. -Osteoporosis can be a serious medical threat to the well-being of patients and attention should be paid to associated risk factors. -Age-appropriate screening with DEXA scanning and FRAX calculation is recommended. -Loop diuretics, such as furosemide, can lead to hypocalcemia by inhibiting calcium reabsorption in the loop of Henle. -Alpha blockers, CCB, and ACEi have no effect on bone mineral density

Do you need to cover for MRSA for cellulitis? Only experiences dry cracked skin.

-This patient does not have risk factors for a MRSA infection. Studies have shown that with MSSA infections, patients do better with a penicillinase-resistant medication like dicloxacillin verses vancomycin. -The mechanism of action is inhibition of bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor. -Risk factors for MRSA consist of recent hospitalization, long hospital stay, resident of a long-term care facility, hemodialysis, recent antibiotic therapy, HIV, men who have sex with men, sharing sports equipment, diabetes, IV drug use, incarceration, military service, sharing needles, razors or other sharp objects.

Patient with syncope when seated without preceding symptoms and neg orthostatic vitals and EKG with NSR. Why not do a tilt table test?

-This patient has normal vital signs with normal orthostatic vitals. There is no signs of dehydration, no mention of medication use, and no history of autonomic disorders that may cause autonomic neuropathy such as diabetes or amyloidosis. -Also, a big key point was the fact that the patient was sitting down during the event and did not change positions. -That detail eliminates orthostatic hypotension as a cause. -Orthostatic hypotension (intolerance) can be diagnosed with a drop in systolic blood pressure of 20 mmHg or a drop in diastolic blood pressure of 10 mmHg, although there are a large number of false positive results. * For a patient that has a normal physical exam with a syncopal event. It is important to rule out arrhythmias as a cause. A 24 hour Holter monitor should be performed.*

Hypocalcemia in Acute Pancreatitis

-This patient is presenting with acute pancreatitis likely secondary to alcohol abuse. -This is evidenced by her abdominal examination findings and elevated lipase and amylase. -The other laboratory finding that is most likely present in this patient is hypocalcemia. -The cause of hypocalcemia in the setting of acute pancreatitis is multifactorial. -Damage to the pancreas leads to the excess free fatty acid production due to increased activity of pancreatic lipase. -Free fatty acids then bind insoluble calcium salts in the pancreas, forming calcium deposits that are distributed in the retroperitoneum. -Other contributing factors include concomitant hypoalbuminemia and impaired parathyroid hormone secretion (due to glucagon-stimulated calcitonin release). -Clinical manifestations of hypocalcemia are primarily caused by neuromuscular irritability and include parathesias, numbness, spontaneous tonic muscular contractions (tetany), and hyperreflexia. -Classic physical exam findings include contraction of the facial muscles in response to palpation or tapping of the 7th cranial nerve (Chvostek's sign) and carpal spasm in response to BP cuff inflation (Trousseau' sign). -Hypocalcemia can cause QT prolongation, which can lead to deadly arrhythmias. -Management of acute, symptomatic hypocalcemia includes IV calcium gluconate and treatment of the underlying cause. -Serum magnesium levels should be checked and, if low, corrected to allow for appropriate calcium repletion (magnesium is needed for adequate PTH secretion).

Wernicke- Korsakoff with thiamine deficiency

-This patient is presenting with confusion, ataxia, and a history of alcohol abuse, which is seen in Wernicke-Korsakoff syndrome. - It results from a deficiency in thiamine (vitamin B1). -Wernicke's encephalopathy results in necrosis of the mammillary bodies in the periventricular region of the brain. -Symptoms include progressive dementia, confusion, ataxia, and paralysis of the extraocular muscles. -This causes ophthalmoplegia of the bilateral lateral rectus muscles, which results in a sixth nerve palsy. -Korsakoff psychosis is a thought disorder that results in retrograde memory failure and confabulation. -The most common causes of thiamine deficiency include poor diet and chronic alcoholism.

DKA electrolyte abnormality

-This patient is presenting with diabetic ketoacidosis (DKA). -The most common electrolyte abnormality is hyperosmolar hyponatremia. -This hyponatremia is not due to primary sodium loss but is due to the plasma dilutional effect of hyperglycemia. -Therefore, the treatment of his hyponatremia should not be directed to the specific correction of sodium levels, but should be directed towards the correction of his hyperglycemia.

EKG: Osborne waves

-Those with hypothermia (< 93ºF) may display J wave or Osborne wave in leads V2-V5 due to distortion of the early phase of membrane repolarization. -This is also seen in the setting of hypercalcemia, subarachnoid hemorrhage, ventricular fibrillation, and cardiopulmonary arrest from over-sedation.

TTP

-Thrombotic Thrombocytopenic Purpura (TTP) also presents with fever, anemia, and acute renal failure, however TTP characteristically elicits focal neurological deficits which are not present in this case. -Both TTP and HUS can present with elevated LDH, indirect bilirubin, and schistocytes on peripheral smear (consistent with MAHA). -The distinguishing factor the prodromal bloody diarrhea and lack of neurological deficits, both of which are consistent with HUS, not TTP. -TTP can be remembered using the mnemonic FATRN, F-Fever, A-microangiopathic hemolytic Anemia, T-Thrombocytopenia, R-Renal failure, and N-Neurological manifestations. -The ADAMTS-13 assay detects the presence of an enzyme used to cleave VWD factor. In TTP, ADAMTS-13 is deficient leading to increased levels of VWD factor precipitating thrombotic microangiopathy. Thus, ADAMTS-13 is specific for TTP, not HUS.

Oral candidiasis and esophagitis in an HIV pt

-Thrush (oral candidiasis) presents with white, cheesy exudates on an erythematous base that can be scrapped off (unlike hairy leukoplakia). -The presence of odynophagia and retrosternal/ substernal chest pain is highly suggestive of concomitant esophagitis and warrants further evaluation with upper endoscopy. -Treatment is usually with nystatin swish and swallow. -Prognosis is good and candidal infection usually resolves in 1-2 weeks without complications. This patient requires a thorough HIV work-up, investigation for other AIDS-defining illnesses, and should be started on highly active antiretroviral therapy (HAART) as soon as possible.

Dix-Hallpike maneuver

-To perform the Dix-Hallpike maneuver, the patient initially sits upright. -The examiner turns the patient's head 30-45 degrees to the side tested. -Then, as the examiner supports the patient's head, the patient quickly lies supine (within 2 sec), allowing the neck to hyperextend and hang off the edge of the examining table 20-30 degrees past horizontal. -After a 2-20 second period, the onset of torsional upbeat or horizontal nystagmus denotes a positive test for benign paroxysmal positional vertigo. -Nystagmus changes direction when the patient sits upright again. -The Dix-Hallpike maneuver has a positive predictive value of 83% and a negative predictive value of 52% for the diagnosis of BPPV.

Transverse Myelitis

-Transverse myelitis is caused by spinal cord inflammation within a specific region of the spinal cord triggered by a recent bacterial or viral infection. -It is characterized by pain, sensory alteration, and motor dysfunction below the level of the lesion. -Treatment includes intravenous corticosteroids to reduce inflammation followed by aggressive physical therapy to improve neurological dysfunction. -Transverse myelitis is an inflammatory process that involves both sides of a spinal cord segment and causes damage to the myelin sheath, leading to altered nerve conduction. -The exact cause is unknown but it is thought to be caused by an autoimmune reaction triggered by a recent viral or bacterial infection. -Infections it has been associated with include syphilis, measles, Lyme disease, varicella zoster, herpes simplex, cytomegalovirus, Epstein-Barr, influenza, echovirus, human immunodeficiency virus (HIV), hepatitis A, and rubella. -Transverse myelitis usually presents during recovery from the infection. -Symptom onset may be acute (within hours to days) or subacute (within days to weeks). -Classic clinical findings include localized low back pain, sudden paresthesias in the legs, sensory loss, paraparesis (weakness or partial paralysis) and urinary bladder and bowel dysfunction. -Approximately 80% of patients experience allodynia, characterized by increased sensitivity to light touch. -Diagnostic work-up usually includes spine and brain MRI, lumbar puncture and laboratory studies to rule out other etiologies including multiple sclerosis, spinal cord compression (due to tumor, disc herniation, stenosis, abscesses), and infectious myelitis. -Spinal MRI often can detect the inflammatory lesion, which is usually localized to one or more vertebral segments.

Treatment for Gout

-Treatment of an acute gout attack is aimed at pain and inflammation control with NSAIDs, usually indomethacin. -To prevent future attacks patients can limit foods high in purines and limit alcohol intake. -They can also take medications such as allopurinol and probenecid for prevention.

Brown Sequard

-True Brown-Sequard syndrome may occur after injury to one half of the spinal cord. -This lateral hemisection syndrome results in injury to corticospinal tract, spinothalamic tract and the dorsal column unilaterally. -Symptoms include ipsilateral weakness (corticospinal tract), ipsilateral loss of vibration and proprioception (dorsal column tract) along with contralateral loss of pain and temperature sensation (spinothalamic tract). -Posterior column and spinothalamic loss occur on opposite sides of the body in this syndrome secondary to spinothalamic decussation near the level of the lesion (one or two levels below the injury). -This injury may occur due to penetrating trauma (knife or bullet), disc herniation, vasculitis, infarction and demyelination.

Francisella tularensis

-Tularemia is zoonosis caused by Francisella tularensis. -It usually persists in animal carriers and contaminated environments especially in Arkansas, South Dakota, Oklahoma and Missouri. -Ulceroglandular tularemia consists of more than 75% of cases of tularemia. -It typically presents as a tender and pruritic papule that initially develops into an ulcer with an erythematous base that over weeks changes to a black base with yellow exudate. -Regional lymph nodes are often very painful and enlarged as well. Pt was a farmer working in rural pennsylvania, not likely tularemia fiven geography *A painful ulcerated nodule with a black eschar and a history of exposure to rabbits, mice, and beavers is suggestive of ulceroglandular tularemia.*

Vitamin B3 deficiency: Niacin A 45-year-old male from Africa with a hyperpigmented scaling rash on the sun exposed area of his neck.

-Underdeveloped countries with mainly corn and carbohydrate based diet deficient in niacin (vitamin B3) can develop a "casal's necklace" rash: a hyperpigmented erythematous scaly rash just around the neck in the sun exposed areas. -Recall the three D's associated with niacin deficiency (pellagra) include diarrhea, dermatitis and dementia.

Indication for hemodialysis

-Urgent hemodialysis must be initiated in patients with severe hyperkalemia (serum potassium concentration > 6.5 mEq/L or refractory to medical therapy) with renal failure. -This patient with fatigue along with severe hyperkalemia in setting of elevated BUN/Creatinine corresponding to a GFR less than 15 ml/min/1.73 m2 is in acute renal failure.

Uric acid stones

-Uric acid stones are typically seen in patients with low urine volume or hyperuricosuria. -Hyperuricosuria is seen in patients with high protein diet, gout, diabetes mellitus, chronic diarrhea and tumor lysis syndrome. -Treatment includes increased fluid intake and alkalinization of the urine as well.

Vasovagal event

-Vasovagal syncope (common faint) presents with provoked intense emotion, pain, anxiety, sight of blood, and unpleasant odors. -The vasovagal response is due to a trigger with an improper reaction of the autonomic nervous system with relation to heart rate and blood pressure. -The patient has a decrease in heart rate and the blood pressure drops, which causes decreased cerebral blood flow that causes syncope

Wegner's Granulomatosis

-Wegener's granulomatosis, now known as granulomatosis with polyangiitis, is a small-medium vessel necrotizing granulomatous vasculitis. -Granulomatous infiltration of the septum results in the classic saddle nose deformity seen on physical examination. -Initial symptoms maybe non-specific including low-grade fever, weakness, malaise, myalgias and arthralgias indicating a more systemic illness. -However, the two most common initial presentations include hemoptysis and hematuria. -Hemoptysis is secondary to granulomas and nodular densities often seen on chest x-ray. -Hematuria is linked to acute glomerulonephritis with active red blood cell casts on urinalysis -Initial laboratory work up can reveal non-specific findings suggestive of an inflammatory process like mild anemia (secondary to anemia of chronic disease from vasculitis), mild leukocytosis and thrombocytosis due to stress reaction, and an elevated ESR due to underlying inflammatory process. -Wegener's granulomatosis can also have a weakly positive rheumatoid factor but negative anti-CCP antibody which is more specific for rheumatoid arthritis. -A positive C-ANCA helps distinguish Wegener's granulomatosis from other vasculitis disorders like Churg-Strauss syndrome and microscopic polyangiitis which are both P-ANCA positive.

Hemoconcentration from dehydration (when you see elevated H and H on labs)

-While hemoconcentration due to dehydration may cause elevated hemoglobin and hematocrit levels, there is no evidence in the question stem to suggest dehydration. -Also, it would be very unlikely to cause a hemoglobin level that high due to dehydration. -This would also be noted on the basic metabolic panel with elevated sodium and chloride. -A pre-renal ratio may be seen with a BUN/creatinine ratio greater than 20:1 with dehydration.

Lead poisoning; management and treatment

-Whole blood lead levels (BLL) should be obtained in all patients with suspected lead poisoning. -*Then, a plain x-ray of the abdomen should be performed in all children to detect lead-containing objects. * -Retained lead objects in the GI tract are considered a medical emergency and require referral for possible removal. -Further management depends on the patient's BLL level. -Environmental investigation and follow-up testing is required for children with BLLs of 10 µg/dL or higher. -Chelation therapy with either oral succimer (DMSA) or IV ethylenediaminetetraacetic acid (EDTA) is warranted in patients with BLLs greater than 45 µg/dL. -Radiographs of long bones in children with chronic exposure to moderate lead levels may show characteristic lead lines (radiodensity in the distal metaphyseal plate that indicates growth arrest). This finding is associated with BLLs > 40 µg/dL over an extended period of time. Lead lines are rarely found in most cases of lead poisoning. Therefore, the *CDC does not recommend obtaining long bone radiographs.*

Essential Thrombocytosis

-With essential thrombocytosis there would not be an elevated hemoglobin or hematocrit. -the remaining CBC besides the platelets are usually within normal ranges. -A hyperkalemia may be present due to laboratory artifact. -This is due to the large number of platelets releasing potassium during blood clotting; therefore, the potassium is falsely elevated.

Lactase Deficiency Tx:

-asians -dairy -no lactate dehydrogenase tx: no dairy

physiologic effects of PE

-dec. perfusion of gas exchange -increase pulmonary vascular resistance this leads to Right Heart Strain cuz it has to pump harder against resistance (S1Q3T3) on EKG

lung cancer triad of classic symptoms what to do next?

-fever -weight looss -hemoptysis Next: chest X-ray

H. Pylori Tx?

-macrolide -PPI -amoxacillin

H. Pylori Quadruple therapy

-metro -tetracycline -Bismuth -H2 blocker

2 most common blood transfusion reaction

-non-hemolytic febrile transfusion reaction d/t cytokines that are in the stored blood\ Tx: central acting COX-1 inhibitor (acetaminophen) tylenol + stop infusion -urticarial transfusion reaction Tx: diphenhydramine and (maybe 1:1000 Epi)+ stop infusion

adenocarcinoma of lung

-non-smokers -asbestos exposure -periphery causing pleura to pucker

COPD exacerbation, what to do?

-oxygen -Nebulize therapy (Ipratropium > albuterol) -steroids if no improvement -Abx if purulent sputum

causes of diverticulosis

-red meat - >50 y/o - low fiber

charcot's Triad

-rigt upper quadrant pain -jaundice -fever

charcot's Triad

-rigt upper quadrant pain -jaundice -fever add: -hypotension -altered mental status to make reynoldn's Pentad

COPD prevention

-smoking cessation -flu caccine -pheumococcal vaccine ( 1 before 65 and 1 after)

when to use IVC filter

-there's a DVT -next PE will kill them -contraindication to anticoagulation

virchow's triad

-venous stasis -hypercoaulable state -endothelial damage

chads2vasc scores

0-1 generally receive aspirin 1-2 receive aspirin or warfarin >2 receive warfarin or other chronic anticoagulation

MI chronic therapy

1) -High Potency Statin (<100 LDL) for Lipids - HbA1C < 7% for blood sugar -Beta Blockers + ACEi (<140/90) for HTN 2)Reduce Thrombosis Risk -ASA (cox inhibitor) OR Clopidogrel (ADP inhibitor) if pt. has stents 3) Stent or CABG 4) Thrombolytics (tPA or Heparin) only if in first 12 hrs and nothing else available

who gets a statin?

1) anyone w/ vascular disease 2) anyone w/ LDL >190 3) Diabetes + age (40-75) w/ LDL 70-189 4) Risk Factor + LDL 70-189

osteoporosis tx:

1) quit smoking 2) calcium and Vit. D 3) alendronate (bisphosphonate) OR SERM (estrogen)

Diagnosis of angina

1-substernal chest pain 2-worse w/ exertion 3-better w/ NO 1/3 = non-anginal 2/3 = atypical angina 3/3 = typical angina

Stage 1 HTN Tx:

140/90 Thiazide >ACEi > CCB

normal PLT's

150-400 x10^9

Stage 2 HTN Tx:

160/100 2 or more meds (comorbid conditions specific) CAD: BB + ACEi CHF: same CVA, DM, CKD: ACEi

HTN urgency Tx:

180/110 PO Hydralazine

status epilepticus first line and 2nd line

1st: benzodiazepam 2nd: phenytoin

SIRS criteria

2 or more of.... < 96.8 or >100.4

adrenal insufficiency salt wasting genital ambiguity in females 17-hydroxylase increased in labs

21 alpha hydroxylase deficiency

Diagnosis of arrhythmia's

24 hr. Holter Monitor

First Diagnostic Step in CHF

2D Echo tells us systolic or diastolic failure

Duke criteria for infective endocarditis? A 35-year-old female presents with unexplained fever, night sweats, and chills. History reveals (1) intravenous drug use. Vital signs reveal a fever (2). Physical exam reveals systolic murmur best auscultated at the left sternal border of the fifth intercostal space. A plain film chest radiograph is obtained revealing diffuse bilateral nodular densities in varying stages of cavitation (3). A transesophageal echocardiography reveals an oscillating intracardiac mass on the tricuspid valve with notable regurgitant jets. (4)

3 minor criteria, 1 major Murmur is not a criteria

K+ lab values

3.5-5.5

normal WBC's

4,500- 11,000

GCS: response to painful stimuli she opens her eyes. She is demonstrating decorticate posturing. She is only making incomprehensible sounds.

7

normal blood pH

7.35-7.45

normal Calcium blood value in mg/dL

8.5-10

acute diarrhea vs chronic diarrhea

<2 weeks >4 weeks is chronic

what's score indicates dementia on mini mental exam?

<22/30

acute low back pain diagnosis? Tx?

<4 months continued daily activities

if Warfarin is supratherapeutic (INR >3) what to do?

<5 : hold a dose 5-9 : Hold dose + Vit. K >9 : hold dose, Vit. K, lower dose any bleeding: FFP + Vit. K

kidney stone size based tx?

<5mm pass spontaneously (IVF + analgesia) BEER <7mm expulsive therapy (CCB/amlodipine or Alpha Blocker/Terazosin) <1.5cm lithotripsy or ureteroscopy >1.5cm surgery

bradycardia

<60 bpm

Risk assessment of pulmonary nodule

<8mm ------Size------ >2cm smooth/calc.---Surface---- spiculated none -----Smoking---- >30 pack yr Hx <40 ------Self (age)---- >70

Supraventricular Tachycardia (SVT) Tx

> 150 bpm Adenosine

anion gap is considered elevated if greater than what?

>12

Hyperkalemia management

A good mnemonic used in first aid is "C-BIG-K-DI" ( If you see a big K, the patient could die!). -Calcium Gluconate -Bicarbonate or Beta-2 agonists (nebulized albuterol): transient intracellular potassium shift -IV insulin + Dextrose (glucose): insulin shifts potassium intracellularly while glucose prevents hypoglycemia from insulin -Kayexalate: binds potassium in the gut and excreted via feces -Dialysis or Diuretics (furosemide): eliminates potassium from the body

Kidney Stones; Oxalate

A plain film of the abdomen can identify calcium-containing (calcium oxalate), struvite (staghorn), and cystine stones. Kidney stones and Crohns Disease s/p ileum resection -Bile acids are normally absorbed by specific receptors in the distal ileum. -Bile salt malabsorption occurs when more than 50 to 60 cm of terminal ileum is diseased or resected. -Unabsorbed bile salts enter the colon resulting in a secretory or "bile salt" diarrhea. *-Steatorrhea may cause the binding of calcium ions by fatty acids, which makes calcium unavailable in the enteric lumen for binding to oxalates. * *-With fat malabsorption, calcium in the bowel lumen is bound by fatty acids instead of precipitating with oxalate, which is left free for excessive absorption in the colon. * -The absorbed oxalate is excreted in the urine, where it may precipitate to form oxalate urinary stones. -Hyperoxaluria may also be caused by bacterial overgrowth syndromes, chronic disease of the pancreas and biliary tract, jejunoileal bypass in the treatment of obesity, or ileal resection. -Therefore, patient's with Crohn's disease with involvement of the ileum can present with calcium oxalate stones.

CKD patients always get what to treat HTN?

ACEi b/c it's renoprotective

Other Tumor Markers

Alpha-fetoprotein (AFP) is typically elevated with gonadal germ cell tumors or hepatocellular carcinomas. CA-125 is a tumor marker for various malignancies including ovarian, endometrial, breast, and some lymphomas. Carcinoembryonic antigen, or CEA, levels are elevated in adenocarcinomas of the colon, pancreas, lung, breast, and ovary. Lactate dehydrogenase (LDH) is sometimes elevated in various malignancies as cancerous cellular growth is escalated to a point that metabolism takes place anaerobically. LDH may also be elevated in dysgerminomas, lymphoma, and Ewing's sarcoma.

neurofibrillary tangles plaques insidious onset memory goes first diffuse cortical atrophy linked w/ Down's Donepezil for Tx

Alzheimer's Disease

Amoxicillin vs Nafcillin

Amoxicillin would cover Streptococci, but not Staphylococci. The mechanism of action is inhibition of cell wall synthesis by binding to penicillin binding proteins.

just like RA, but involves the lower back in stead of cervical vertebrae

Ankylosing Spondylitis

result in contralateral lower extremity weakness and sensory deficit which is quite profound. In addition, you will see contralateral upper extremity weakness and sensory deficit that is not as significant. Patients will also exhibit personality changes and possible psychiatric disturbances, as well as a return of primitive reflexes (grasp, snout, root, and suckling) due to the involvement of the frontal lobe.

Anterior Cerebral Artery lesion

Head bobbing waterhammer pulse blowing sound Marfan's syndrome

Aortic insufficiency (regurge)

most likely etiology of stroke in a patient with focal deficits and irregular pulse -irregular R-R interval

Atrial Fibrillation

narrow complex tachycardia at 150 beats/minute with the atrial rate of 300 beats/min

Atrial Flutter

Secondary AV Block (Motitz I) "weinkeback" Tx

Atropine

BPPV vs Labrynthitis?

BPPV is vertigo experienced only in specific positions or position changes. Onset is abrupt and lasts several seconds. It is not associated with hearing loss. Both have positive DH Tx: : The Epley maneuver is performed on patients with vertigo secondary to benign paroxysmal positional vertigo. Not in labrynthitis

Bacteremia

Bacteremia is the presence of bacteria in the blood as evidence of positive blood cultures. The diagnosis of bacteremia does not have positive SIRS criteria. This patient does have positive blood cultures and SIRS criteria with hypotension leading to the diagnosis of severe sepsis.

vertigo experienced only in specific positions or position changes. Onset is abrupt and lasts several seconds. It is not associated with hearing loss

Benign Paroxysmal Positional Vertigo (BPPV)

Tx: of A. Fib

Beta blockers + warfarin

PE tx

Bridge Heparin to Coumadin

Chads Vasc Scoring

C congestive heart failure 1 point H hypertension 1 point An age greater than 75-years-old 2 point D diabetes mellitus 1 point S stroke or TIA 2 points (hence CHADS2) V vascular disease 1 point An age 65-74 1 point Sc (sex category) 1 point if female

extreme diarrhea and sickness after administering Abx.

C. Diff Colitis. Abx. kill bacteria, and they release tons of toxins --> colitis + diarrhea

Whipple Disease Tx:

CNS, Joints Tx: Bactrim

Best test for PE

CT angiogram

pathogenesis of carcinoid tumors leading to pellagra

Carcinoid tumors use tryptophan to make Seratonin. Tryptophan is enzymatically synthesized from vitamin B3 (niacin), which can lead to niacin deficiencies in patient's with carcinoid tumors. Niacin deficiency will usually manifest as pellagra, which consists of dermatitis, dementia, and diarrhea.

DiGeorge Syndrome

Cardiac Aortic Tetany (hypoparathyroid) hypocalcemia hypoCalcemia Hemolysis - 22 (c'some) absent 3rd and 4th pharyngeal pouches

Hyponaturemia in SIADH

Causes of hyponatremia can be classified into isotonic, hypotonic, and hypertonic based on the serum osmolality. -Hypotonic hyponatremia can then further be divided into hypovolemic, isovolemic, or hypervolemic based on the patient's clinical volume status. -Syndrome of inappropriate ADH is the most common cause of isovolemic hypotonic hyponatremia. -It should be considered in any patient who presents with chronic hyponatremia without edema, decreased arterial volume or renal insufficiency.

hypothyroidism after cranial radiation (or any other surgery, etc, that can affect anterior pituitary)

Central Hypothyroidism Labs: Low TSH and low T4

complication of the refeeding syndrome in anorexia nervosa.

Central Pontine Myelinolysis

what part of spine does RA affect only?

Cervical spine

How does HTN cause heart failure?

Chronic HTN causes systemic vascular resistance --> Heart works harder (bigger and beefier)--> muscle eventually fails and becomes floppy. This is a contraction problem (Systolic Failure)

Pt. with pencil thin stool alternating bowel habits Iron deficiecy anemia

Colon Cancer Dx: apple core lesion on barium enema

NYHA class of Chronic Heart Failure Class II

Comfortable @ Rest and Walking sxs w/ strenuous activities

NYHA class of Chronic Heart Failure Class III

Comfy @ Rest ONLY sxs w/ walking

Exanthema subitum

Commonly known as Roseloa infantum or Sixth Disease, this rash is caused by human herpesvirus type 6 (HHV-6) and affects children ages 6-36 months. -Patients first develop a fever, usually greater than 39.5°C (103.1°F), with a rash developing as the fever is resolving. -The rash is rosy pink, blanchable and develops first on the neck and chest before spreading to the rest of the body.

Contraindications in Esophageal chemical burns

Contraindications in the setting of esophageal chemical burns include the following: -Nasogastric tube insertion: may induce retching and vomiting. This may worsen the injury and subsequently cause a perforation of the damaged tissue of the esophagus and/or stomach. -Emetics: vomiting causes re-exposure to the esophagus and the oropharynx to the corrosive agent, causing a further decline of the injury. -Neutralizing agents: weakly acidic or basic substances should not be administered because damage due to the corrosive ingestion is generally immediate. Also, the neutralization releases heat; therefore, a consequence of thermal injury may occur causing more tissue damage. *Endoscopy is indicated and should be performed as soon as possible. This should be done within 24 hours in order to fully assess the injury of the esophagus due to the corrosive agent.*

Pancreatic insufficiency Tx:

Cystic fibrosis or gallstones that block pancreatic NZ's ADEK therapy

Cysteine Stones

Cystine stones are hexagon shaped and a rare cause of nephrolithiasis. -Typically seen in patients with autosomal recessive disorder with cystinuria.

what to always get if they have sxs of PE

D-dimer but this shows ANY inflammation, not just in PE. (low specificity, but high sensitivity)

waterhouse-friedrichson syndrome can lead to what?

DIC

what joint does RA never affect?

DIP "Distal Inter-Phalangies"

psoriasis + arthritis joints involved? diagnosis? tx?

DIP + PIP joints psoriatic arthritis NSAID --> methotrexate

Metabolic Acidosis in DKA

DKA results in a high anion gap metabolic acidosis because the increase in ketoacids decreases serum bicarbonate. The body compensates by hyperventilating causing a respiratory alkalosis.

anti-glutamic acid decarboxylse (GAD-65)

DM type 1

RA tx

DMARD's methotrexate (1st) Leflunomide (2nd) hydroxychloroquine (prego) sulfasalazine (additive)

Heart Failure Class IV Tx

Dire situation things to do while waiting for Transplant Dobutamine (inotrope) to relax heart Ventricular Assist Device

Diagnosis of Autoimmune hemolytic anemia

Direct Coombs Test

lumbar pain with lughtning shooting pain down leg. weak L4 (plantar flexion) or L5 (Dorsiflexion)

Disc Herniation

DIC

Disseminated intravascular coagulation (DIC) can also present with diffuse bleeding, schistocytes and hemolysis, making it difficult to differentiate from TTP/HUS. -However, DIC is associated with an increase in both PT and PTT and bleeding usually occurs at venipuncture sites.

Third Degree Block Tx:

Dissociation btw QRS + P waves pace

Left sided appendicitis of elderly stool gets stuck in the diverticula and causes inflammation, infection, or perforation Dx?

Diverticulitis Dx: X-ray KUB (kidneys, ureters, bladder) ensures no free air. CT: determines extent of disease Tx: IV Abx (Ampicillin-gentamycin + Metronidazole)

Doxorubicin

Doxorubicin chemotherapy is associated with an increased risk of developing cardiac side effects, including congestive heart failure (CHF) and dilated cardiomyopathy.

DRESS syndrome

Drug Reaction w/ Eosinophilia & Systemic Symptoms

A Flutter 2/2 rheumatic heart disease

Electrocardiogram is significant for narrow complexes at 150/min in a regular rhythm with F waves in leads II, III, and aVF. -Atrial flutter is a supraventricular rhythm secondary to irritable automaticity focus in the atria resulting in organized depolarization. -Typical atrial rate can be 300 beats per minute resulting in more p waves than q waves. -The electrocardiogram is remarkable for a saw tooth baseline due to every two or three flutter waves for every QRS complex. Therefore, in this patient with a ventricular rate of 150 beats/m, the atrial rate was probably 300 beats/min with a 2:1 atrial flutter. -Best way to differentiate from atrial fibrillation is clear presence of p waves in a regular rhythm. -The main causes of atrial flutter are rheumatic heart disease (mitral valve involvement), chronic obstructive pulmonary disease, pericarditis and atrial septal defect. -Treatment is based on hemodynamic stability of the patient. F waves correspond to the sawtooth pattern of atrial flutter and are best appreciated in leads II, III, and aVF.

esophogeal prlblems and endoscopy shows eosinophilia on Bx. diagnosis? Tx?

Eosinophilic Esophagitis Tx? PPI or swallowed aerosolized Steroids

BPPV Tx

Epley Maneuver

Tremor worse with activities (4-6 Hz)

Essential Tremor

used to distinguish btw restrictive vs obstructive pulmonary disease

FEV1:FVC ratio

Acute pancreatitis initial step

FLUID MANAGEMENT *Early and aggressive fluid administration is the most important initial step in the management of acute pancreatitis. * -This patient has a Chapman's point for the pancreas in the right seventh intercostal space. -The two most common causes of pancreatitis in America include alcoholism and gall stones. -A male patient with a history of alcoholism and recent binge drinking episode with epigastric pain radiating to the back is very suggestive of acute pancreatitis. -Several studies have suggested that intra-acinar activation of proteolytic enzymes like trypsinogen into trypsin results in autodigestive injury to the pancreatic and peripancreatic organs. -This starts the cascade of release of different enzymes and cytokines which results in vascular damage, interstitial hemorrhage and cell necrosis. -Hence, amylase and lipase levels two to three times upper limit of normal are consistent with pancreatitis. -Aggressive early hydration is a key step in the management of acute pancreatitis to prevent organ hypoperfusion secondary to third spacing of fluid from vascular damage. -During the first 24-48 hours, patients are given nothing by mouth so that, theoretically, less pancreatic enzymes are stimulated.

most common hereditary hypercoaguable disorder that occurs in about 5% of the population

Factor V Leiden

2nd line to treat cholesterol

Fibrates "gemfibrizole"

extra- colon cancer Tx:

Folfox (5-Fu + Leucovorin + Oxaliplatin) + Bevacizumab (VEGF inhibitor)

Ranson's Criteria

GA LAW Glu >200 Age >55 LDH > 350 AST > 250 WBC >16K Patients with severe disease are at risk for acute respiratory distress syndrome (ARDS), acute renal failure, cardiac depression, hemorrhage, and hypotensive shock.

GERD progression and Tx?

GERD: PPI Metaplasia (barett's esophagus) : inc. PPI Dysplasia: ablation and PPI AdenoCA: stage and resection

when to consider hemodialysis of CKD?

GFR < 15%

Treatment for Post Kidney transplant CMV colitis

Ganciclovir -Interferon and ribavirin combination therapy eradicates recurrent hepatitis C infection in some patients after transplant. However, this patient's symptoms of abdominal pain with bloody diarrhea are not consistent with hepatitis C infection, making this an incorrect answer choice.

MALToma is caused by?

H. Pylori

#1 risk factor for stroke

HTN

popcorn calcification on CT of chest

Hamartoma

diagnosis of sickle cell

Hemoglobin electrophoresis

what disease has an ALT > AST

Hep. C

what's the first thing to fix in a COPD patient with acute exacerbation?

Hypercapneic (CO2) levels to correct respiratory acidosis.

hypercalcemia treatment (>10.5)

IV fluid then Frosemide (calcium wasting) then Calcitonin (calcium-tone-down) fast and quick then Bisphosphonates (keep calcium in bones) long term

initial management of acute pancreatitis?

IV fluids

constant mucosal infections

IgA def. anaphylactic reaction during blood transfusion due to IgA in the blood being given

Iron Fist Bro

Iron: Duodenum Fe : Jejunum B12: Ileum

Beck's Triad:

JVD, distant heart sounds, hypotension will also see: pulsus paradoxus (<10mmHg), clear lungs. Cardiac Tamponade

udden vertigo lasting hours to days and accompanied by hearing loss and tinnitus. -Often seen after URI

Labrynthitis

Orthopnea, crackles, rales dyspnea on exertion, S3 paroxysmal nocturnal dyspnea (wake up gasping for breath in middle of night)

Left Ventricular Heart Failure

Parkansonian Symptoms WITH Dementia Giveaway: Visual Hallucinations

Lewy Body Dementia

heart condition of lupus

Libman Sack's endocarditis

Ventricular Tachycardia Tx

Look for Tombstones Amiodorone

Risk complication of H. Pylori

MALToma

MI therapy

MONA BASH morphine Oxygen Nitrates ASA Beta-blocker ACEi Statin Heparin

Prevention of HF exacerabtion

MONITOR SODIUM -Medication regimen typically focuses on regression or reverse modeling of the left ventricle with beta blocker, diuretics and ACE inhibitor or Angiotension receptor blocker therapy. -Lifestyle changes include exercise, weight loss and a low sodium diet. -Reduced sodium intake is a key step for prevention in non-pharmacologic management of heart failure. -Water always follows sodium; therefore, monitoring sodium intake is key in monitoring plasma volume in patients. -Increased sodium intake results in increased fluid retention which further decreases the cardiac output. -Sodium restriction is necessary to prevent expansion of the extracellular fluid volume and to prevent peripheral edema to decrease the myocardial wall stress and improve renal flow. -Therefore, sodium intake should be reduced to less than 2 g/day to prevent heart failure exacerbation.

what imaging should be obtained for cluster headaches?

MRI

Duke major criteria

Major Criteria 1. Positive blood culture: typical microorganisms from two separate blood cultures (Viridans streptococci, Streptococcus gallolyticus (new nomenclature for Streptococcus bovis), HACEK group, Staphylococcus aureus). 2. Evidence of endocardial involvement: positive intracardiac mass on valve or on supporting structures of the valve or valve area, abscess, or new partial dehiscence of prosthetic valve, or new valvular regurgitation.

triad of vertigo, tinnitus and hearing loss

Meniere's disease

Metoprolol Side effects

Metoprolol is a beta blocker and is considered second line therapy in lone hypertension. -While it is not associated with significant laboratory abnormalities, it is also not associated with peripheral edema. *Common adverse effects of a beta blocker includes: bradycardia, hypotension, dizziness, decreased libido.*

Tx. for flare ups of Irritable bowel disease (chrons or UC)

Mild: 5-ASA Moderate: oral sterods (prednisone) Severe: Infliximab or cyclosporine (UC)

Duke minor criteria

Minor criteria 1. Predisposition to infective endocarditis: predisposing heart condition or a history of injection drug use. 2. Fever ≥ 38.0ºC (100.4ºF). 3. Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions. 4. Immunologic phenomena: glomerulonephritis, Osler's nodes, Roth's spots, rheumatoid factor. 5. Microbiologic evidence: a positive blood culture, but not meeting major criterion as noted previously or serologic evidence of active infection with organism consistent with infective endocarditis.

cirrhosis of fat people

NASH non-autoimmune

what to do with beta blockers during a CHF exacerbation

NOTHING

tx. for acute pericarditis

NSAID's

pericarditis

NSAID's + colchicine

Criteria to know

NYHA functional classification for CHF TIMI risk score for unstable angina and NSTEMI Duke criteria for infectious endocarditis Duke's staging for colorectal cancer Child's classification to assess severity of liver disease Jones criteria for acute rheumatic fever Light's criteria for exudative pleural effusion Well's Criteria PE Ranson's CHADSVASc

Wet: urinary incontinence Wobbly: ataxia Weird: dementia Tx?

Normal Pressure Hydrocephalus VP shunt

pseudotumor cerebri is associated with what medications?

OCP's oral contraceptives

Obstructive Uropathy

Obstructive uropathy can also present with elevation of creatinine with a fairly normal urinalysis depending on the etiology of obstruction. - Obstruction can be present due to stone, foreign object, benign growth or tumor. -Imaging is typically needed to figure out the exact cause of obstruction. -However, typically FENa is > 1% and BUN/Cr is normal-high but less than 20:1, making this a less likely diagnosis.

what type of diarrhea w/ Bile Acid Resins and Ezetimibe that block resorption of fatty stuff to help cholesterol?

Osmotic Diarrhea

Osteopathic findings in Cryptococcous infection

Osteopathic findings associated with this presentation include TART changes from T1-4 due to the pathology occurring in the head and neck region as a result of viscerosomatic reflexive changes. -You may also see TART changes T2-6 from lung viscerosomatic reflexes. -Additionally, cranial somatic dysfunction can occur and is variable in its presentation. In the above case you have a hyperdynamic CRI as a result of the increased intracranial pressure.

Structural Blocks to cause syncope

PE, aortic stenosis, Hypertrophic Cardiomyopathy, LA Myxoma

tx. for curling's, cushing's, or H. Pulori

PPI's

patient w/ painless jaundice and palpable gallbladder Diagnosis? Diagnostic modality?

Pancreatitis Abdominal CT

tremor worse w/ rest but better with activities like writing diagnosis?

Parkinson's Disease

Diffuse ST segment elevations + PR segment Depressions

Pericarditis

Lead poisoning

Physical examination reveals pale conjunctiva, 1+ diminished patellar reflexes bilaterally, and 3/5 weakness of forearm extensor muscles bilaterally. -Lead poisoning is the most common environmental illness in children in the United States. Most exposure in children is due to lead-contaminated household dust from leaded paints. -Most adult cases of lead poisoning are due to occupational exposure (employees in storage battery manufacturing and lead and zinc ore mining industries). -Symptoms are usually subtle and may include increased irritability, headaches, hyperactivity or lethargy, intermittent abdominal pain, vomiting, and/or peripheral neuropathy. -Physical examination may show signs of iron deficiency anemia (common in children with lead poisoning), and neurological deficits (diminished deep tendon reflexes, weak extensor muscles).

Personality goes first memory remains intact frontal cortical atrophy

Pick's Disease

-esophogeal webs -esophageal Rings -Iron Deficiency -squamous cell CA

Plummer-Vinson Syndrome plumbers use Iron tools to tighten rings around esophogeal pipes in the cobwebs -squamous cell CA -Upper esophagus

what is PEEP

Positive End Expiratory Pressure raises interstitial pressure, forcing fluid back into capillaries

brain arterial lesion that results in vertiqo, nystagmus, and Horner's syndrome with ipsilateral face and contralateral body sensory deficits.

Posterior inferior cerebellar arterial lesion "wallenburg's syndrome"

Diastolic Failure

Preserved Ejection Fraction

autoimmune in females intrahepatic ducts young women w/ cirrhosis AMA screen

Primary Biliary Cirrhosis

mitochondrial antibody

Primary Biliary Cirrhosis PBC is powerhouse tv station

Cirrhosis + Inflammatory bowel disease extrahepatic ducts assoc. w/ UC onion skin fibrosis MRCP --> beads on a string autoimmune disease in males

Primary Sclerosing Cholangitis tx: ursodeoxycholic acid or cholestyramine

Primary AV Block Tx

Prolonged PR interval Atropine

Tx: for Niacin Flushing

Prophylactic ASA

protein c

Protein C is in charge of inhibiting the clotting cascade.

boutonniere deformity

RA

prolonged morning stiffness, but gets better with use

RA

Felty's Syndrome

RA + Neutropenia + Splenomegaly

Urinanalysis interpretation in lupus flare

Recent flare up of lupus, glomerulonephritis and interstitial nephritis are important differential diagnosis; however, given no significant proteinuria, hematuria and casts in the urinalysis they are less likely options. Urinalysis: pH 5.0 Color amber Specific gravity 1.018 Protein trace Nitrite negative Bilirubin negative RBC 4 WBC 2 Casts hyaline -ATN patients usually have epithelial casts or "muddy brown" granular casts; whereas hyaline casts are a very non-specific finding for concentrated urine. -AIN typically presents with white cell, white cell casts and eosinophils in the urinalysis.

frist thing to do if abnormal K+ labs.....

Repeat the lab. if still abnormla get an EKG-12 Lead

Citrillinated antibody and + RF

Rheumatoid ARthritis

Hepatosplenomegaly JVD Peripheral Edema Dyspnea on Exertion and inc. Jugular Venous Pressure

Right Ventricular Heart Failure

pneumonia in a patient recovering from the flu. most likely pathogen

S. Aureus

SIRS review

SIRS requires 2 of 4 of the following: temperature >38°C or < 36°C, respiratory rate >24/min heart rate > 90/min leukocyte count > 12x103/mcL or < 4x103/mcL or >10% bands. Sepsis is SIRS with a proven or suspected microbial etiology. Severe sepsis is Sepsis in a patient with signs of organ dysfunction (hypotension systolic blood pressure < 90 mmHg or mean arterial pressure < 70 mmHg that responds to fluids). Septic shock is severe sepsis unresponsive to fluid resuscitation for at least 1 hour despite adequate fluid resuscitation, therefore requires vasopressors.

antiphospholipid antibody

SLE (lupus)

EKG for MI

ST elevation or new onset LBBB

first step in giant cell arteritis

STEROIDS first, due to high risk of blindness

Urine Osmolality

Serum osm >290 = hypernatremia urine osm >700 mosm = extrarenal loss <700 = renal water loss

Diagnosing Diabetes

The following screening tests are used to diagnose diabetes mellitus: -Fasting plasma glucose ≥ 126 mg/dL, -random plasma glucose ≥ 200 mg/dL with symptoms (polyuria and polydipsia), -hemoglobin A1C ≥ 6.5%, -2-hour plasma glucose ≥ 200 mg/dL after 75 gram oral glucose tolerance test. -These same test should be repeated to confirm the diagnosis unless signs of metabolic decompensation (diabetic ketoacidosis or hyperosmolar hyperglycemic state). -The best test for overt type II diabetes mellitus is fasting plasma glucose, as hemoglobin A1C can have approximately a 20% false negative in the screening setting.

ZE syndrome

The key here is significantly elevated gastrin level off of PPI therapy with recurrent peptic ulcers and diarrhea. This is the clue to think about Zollinger-Ellison syndrome.

Acute abdominal series

The phrase "acute abdominal series" is interchangeable with an "obstruction series" or "complete abdominal series" and typically includes, but is not limited to (depending upon the institution) plain film radiographs with a supine view, prone/lateral rectum view, upright or left lateral decubitus view, and upright chest view. *An acute abdominal series is a set of plain film radiograph views of the abdomen to rule out obstruction. Obstruction and peritonitis are the two most common etiologies of acute abdomen. Although an obstruction series is a very useful test in diagnosing partial vs. complete bowel obstruction, it does not help us rule out other possible etiologies of acute abdomen like Mesenteric ischemia or cholecystitis*

Etiology for HUS

There are two forms of hemolytic uremic syndrome: 1) Diarrhea-associated or shiga toxin-associated HUS (D+ HUS) 2) non-Shiga toxin-associated HUS (D- HUS). D- HUS is noninfectious, has a genetic component and is most commonly precipitated by drugs or pregnancy. It does not present with diarrhea. -D+ HUS, seen in this patient with bloody diarrhea, most commonly affects young children and immunocompromised patients. -It is caused by infection with shiga toxin-producing E. coli O157:H7 or Shigella. -Shiga toxin acts by inactivating host cell ribosomes and increasing cytokine release leading to cellular destruction, specifically within the intestines and glomeruli. -It also alters endothelial cell-adhesion properties resulting in microvascular thrombosis. -Diagnosis can be confirmed with stool culture, which will reveal E. coli O157:H7 or Shigella bacteria.

Hypothyroidism

This patient has clinical signs hypothyroidism. The key clues are the weight gain, constipation, and non-pitting ankle edema. -Other symptoms to look for may be alopecia (hair loss), periorbital edema, decreased heart rate, and delayed reflexes. -Women with hypothyroidism may have either oligo- or amenorrhea or hypermenorrhea-menorrhagia. -Evaluation begins with TSH and T4 levels and we would expect them to be elevated and depressed, respectively. -Treatment is with thyroid replacement. The patient should also be evaluated for causes of her hypothyroidism: medications, autoimmune, etc.

CHADSVasc Scoring and Afib

Those with a score of 0-1 generally receive aspirin; 1-2 receive aspirin or warfarin; and >2 receive warfarin or other chronic anticoagulation. -Anti-coagulation is determined based on CHADS2 score for a patient. -This patient's CHADS 2 score is 2 (age, diabetes) which is consistent with initiating warfarin in this patient. -However, there is no indication to start warfarin in atrial fibrillation with acute rapid ventricular response. -At this point it is more important to have rate control in the acute setting. RATE FIRST, THEN ANTICOAGULATION

what's the main pathologic heart sound of IV drug users?

Tricuspid Regurgitation cuz drugs hit that valve first.

other causes of secondary HTN

Triple HHHARP COmpany Hypercalcemia Hyperthyroid Hyperaldosteronism Aortic Coarctation Renovascular disease Pheochromocytoma Cushings Obstructive Sleep Apnea

non-invasive test to confirm diagnosis of H. Pylori

UREA BREATH TEST

Cholelithiasis Dx

US painful jaundice cuz blocking common bile duct

Ascending Cholangitis

US --> ERCP

Choledocholithiasis Dx + Tx

US --> MRCP Tx: ERCP

Cholecystitis

US--> HIDA scan to see if gallbladder can be filled or not

inflammatory and hamartomatous polyps in colon associated w/?

Ulcerative Colitis

tumor that usually starts in small intestine and metastasizes to liver, spares left side of the heart for this reason cuz liver neutralizes seratoninn that releases from it. leads to what nutrient deficiency?

Urinary 5-HIAA confirms presence of Seratonin synthesis of so much seratonin causes shortage of tryptophan, building block for vitamin B3 (niacin) Niacin deficiency----> pellagra

What is urokinase?

Urokinase is a plasminogen activator that is normally present in the urine. It is the major activator of fibrinolysis in the extravascular compartment, in contrast to TPA which is largely responsible for initiating intravascular fibrinolysis.

common manifestation of myocardial infarction

V. Tachy

risk factors for stroke stepwise decline in function with each episode of stroke abruptly worse with each step MRI show's infarcts in brain

Vascular Dementia

Coma / Brain death / Vegetative state

Vegetative state is a complete absence of behavioral self or environmental awareness. Patient has a preserved capacity for spontaneous or stimulus induced arousal, such as the sleep-wake cycle. Patient postured or withdrawals to noxious stimuli.

lesion will result most classically in vertigo, vertical nystagmus, dysarthria, dystonia, ataxia, and sensory changes in the face. Patients may also experience a "drop attack", during which they suddenly lose postural tone and fall without loss of consciousness. The patient will also likely exhibit labile blood pressure readings on physical examination.

Vertebrobasilar Artery Lesion

Vascular Ischemia--> syncope lasting 8-15 minutes that may be accompanied by facial numbness, paresthesias and visual changes. -Patients usually have a history of atherosclerosis and cardiovascular risk factors.

Vertebrobasilar insufficiency

Vestibular Neuritis vs Labrynthitis?

Vestibular neuritis has a similar presentation to labyrinthitis but is generally distinguished with preserved auditory function.

PE clinical diagnosis

Virchow's Triad SOB, tachycardia, clear CXR CT scan positive D-Dimer V/Q scan -Homan's Sign useless-->check one leg larger than the other

vitamin def. that can cause dementia

Vit. B12 deficiency

decreased PLT aggregation in presence of ristoceitin

Von Willebrand's Disease

c-ANCA

Wegener's granulomatosis

Sickle Cell Anemia / Mononucleosis vs ALL

While the presenting symptoms of sickle cell anemia are similar to those of ALL, sickle cell disease affects red blood cells and is not associated with petechiae, which in this case represents the thrombocytopenia present in ALL. Mononucleosis causes fatigue, but it is typically found in teenagers and is also not associated with petechiae.

Anion Gap formula

[Na+] − ([Cl-] + [HCO3−])

first line diagnosis of acute abdomen

abdominal CT

first thing to do if suspected bowel perf?

abdominal X-ray

first line diagnosis of bowel perforation?

abdominal x-ray

achalasia pathophysiology tx:

absent myeneteric plexus Tx: Myotomy

lewy body dementia tx?

acetylcholinesterase inhibitors -donepezil -rivastigmine -galantamine

are angiograms necessary to diagnose PE?

acutely NO, CT is good enough

Sessile Villous Adenoma Polyp

adenocarcinoma of colon --> colon cancer

HTN emergency

alarm sxs: IV labetalol

what protein binds calcium in blood and regulates the total amount of it?

albumin

ST segment length is inversely proportional to what?

amount of Calcium more calcium = shorter interval less calcium = longer inteval

first line tx. for acute bacterial sinusitis

amoxacillin-clavulanate or just amoxacillin

what type headache comes from coffee or drug w/drawal?

analgesic Rebound

first line tx. for prostate cancer

androgen deprivation with GnRH agonists (leuprolide, goserelin) or GnRH antagonists (degarellx)

Chronic inflammatory arthritis 'Bamboo Spine" HLA-B27 Uveitis Aortic regurgitation calcified achilles tendon

ankylosing spondylitis NSAID--->methotrexate--->etanercept

Tx: of Arrhythmia

antiarrhythmics or AICD (automated implanted cardioverter defibrillator)

who get shingles (zoster) vaccine?

anyone over 60 y/o, even if they've had chicken pox or shingles before

Pleural plaques mesothelioma Broncheoalveolar lavage--> barbell shaped bodies

asbestosis

charcot's triad is for what?

ascending cholangitis

red, hot, swollen joing what to do?

athrocentesis synovial fluid --> normal pus >50,000 --> septic <50,000 --> inflammatory joint

scleroderma

autoimmune deposition of collagen CREST syndrome relaxes lower esophogeal sphincter

smooth muscle antibody

autoimmune hepatitis

Zenker's Diverticulum

bad breath old guy

why is serum Na+ high in pre-renal Acute Kidney Injury?

because kidneys want to conserve salt to inc. BP because there is hypoperfusion of Kidneys

cancer therapy to treat germ cell tumors

bleomycin

pt. with sinus or dental problems, that gets headache and neurological deficits

brain abscess

no response to pain and no cranial nerve reflexes, including pupillary response, oculocephalic reflex, corneal reflex, no response to the caloric reflex test, and lack of spontaneous respiration. Electroencephalography (EEG) including auditory brain responses of the brainstem are negative

brain dead

Defect in B cell synthesis for making Ig's doesn't present until after 6 mo. after birth in breast fed babies

bruton's agammaglobulinemia

anti-hemidesmosome antibody

bullous pemphigoid

peri-oral numbness, paresthesias, muscle spasms, muscle cramps and seizures

calcium deficiency

Heart Failure on CXR

cardiomegaly or pulmonary edema

tropical sprue Tx:

caribbean farmers no improve w/ gluten w/drawal tx: Abx + B12

spontaneous bacterial peritonitis tx:

cefotaxime (3rd gen cephalosporin)

Tx's for neisseria menigititis

cefotaxime or ceftriaxone

anti IgA tissue transglutaminase

celiac disease

central retinal artery occlusion looks like what on optic exam?

cherry-red spot on fovea

p-ANCA

churge-strauss

pylonephritis tx

cipro

otitis externa tx:

cipro + steroid drops

dilated, non reactive pupil seen in what?

closed angle glaucoma

unilateral eye pain abrupt onset emergency cloudy cornea halos around lights

closed-angle glaucoma

Caplan Syndrome is linked with

coal miners lung

complete failure of the arousal system with a positive auditory brain responses but no response in eye opening, verbal response or motor response to stimul

coma

depressed cerebral function (EEG) no response to internal or external stimuli treatment

coma cocktail (Thiamine, D50, Oxygen, Naloxone) patients can fully recover from this

def. in Ig A, M, G,

common variable immunodeficiency

right ventricular failure as a result of pulmonary HTN

cor pulmonale

warning symptoms of saddle anesthesia, incontinence, sexual dysfunction diagnosos? Imaging? Tx?

cord compression Tx: first give steroids image w/ x-ray----> MRI if necessary tx: hematoma--> drian abscess --> I+D cancer--> radiate fracture of vertebra--> surgery

tx for low PLT's <30,000

corticosteroids or Ig's

Prions sporadic mutations or Mad Cow's Disease young kids with dementia rapid decline myoclonus

crutzfield-Jakob Disease

palpable purpura + Hep. C

cryoglobulinemia

stomach ulcers that are from burn patients

curling's ulcers

ulcers from inc. intracranial pressures or ventilated patients

cushing's ulcers

lupus nephritis tx

cyclophosphamide (IV) or mycophenolate Mofetil (PO) "same thing"

hemochromatosis tx increased levels of what?

de*F*eroxamine phlebotomy (lets out Iron in blood) icreased Ferritin he-man holding a ferrit up high above his head

gillian barre tx?

depends on mobility immobile you can use IV Ig's, mobile you can use plasma exchange NOT beneficial to use both

risk factors for coronary artery disease

diabetes smoking HTN Dyslipidemia Age >55 women or >45 men

focal deficits after passing out

didn't pass out it was a stroke get MRI or CT of head

post ictal state after "passing out"

didn't pass out it wsa a seizure get EEG to confirm

used to distinguish btw asthma and COPD

diffusion capacity of Carbon Monoxide (dec. in COPD, cuz alveolar damage)

LLQ pain relieved by bowel movement post-prandial pain

diverticular spasm tx: spasmolytic and Inc. Fiber

out pouching of colon

diverticulosis

The examiner turns the patient's head 30-45 degrees to the side tested. Then, as the examiner supports the patient's head, the patient quickly lies supine (within 2 sec), allowing the neck to hyperextend and hang off the edge of the examining table 20-30 degrees past horizontal. After a 2-20 second period, the onset of torsional upbeat or horizontal nystagmus denotes a positive test

dix-hallpike manuever

tx. for parkinson's if under 70/ healthy?

dopamine agonists -pramipexole -ropinorole

patient gets small rash after taking a drug, no other symptoms

drug reaction

ulcers that feel worse hours after food

duodenal ulcers

Systolic Failure

ejection fraction <55%

widespread metastatic disease usually has what lab finding

elevated lactate dehydrogenase

Tx. for closed angle glaucoma

emergency referral to opthamologist

most common cause of secondary HTN

end stage renal disease or chronic kidney disease

definitive diagnosis of Peptic Ulcer Disease (PUD)

endoscopy ( to see ulcers/malignancy) + biopsy (to see for H. Pylori)

caustic esophagitis mild tx: severe tx:

endoscopy to assess severity... mild: move from liquid to solid diet in 1-2 days severe: NPO for 72 hrs and monitor for perforations. NEVER induce vomiting cuz it can cause more damage on the way up

circumferential scar caused by caustic material of GERD

esophogeal strictures

first line tx for lupus

everyone: hydroxychloroquine + NSAID's flares: steroids life-threatening: cyclophosphamide or mycophenolate Mofetil (oral version of cyclo)

ekg findings on K+ hyperkalemia

everything gets bigger. Peaked T's prolonged PR interval widened QRS

CSF fluid in viral disease

everything normal except lymphocytes present

what does a nuclear study do?

exact EF and if any areas of ischemia (stress test)

dequervian thyroiditis

exquisitely tender thyroid nodule causing moderate hyperthyroidism followed by euthyroidism, followed by hypothyroidism for 2-8 weeks. then return to normal

orbital cellulitis common risk factor

facial infection like sinusitis

Schatzki Ring

fibrous ring in LES that only catches very large diameter foods "steakhouse dysphagia"

delirium in elderly in hospital

first get rid of environmental irritants -tell them where they are frequently -no physical restraints -sleep aids

hyperkalemia tx?

first give Calcium Gluconate (protect heart) then IV insulin + glucose or Bicarb (dec. K+ and replace sugar) then furosemide or kayexalate

Diagnosis of paroxysmal nocturnal hemolytic anemia

flow cytometry

Pericardial Effusion

fluid gets around heart Diagnosis: echo Tx: pericardial window (make hole in pericardium to drain fluid into chest

gastric adenocarcinoma

food with nitrates -deli meats -hot dogs -japanese diets

dementia associated with personality changes diagnosis? tx?

frontotemporal dementia occupational therapy

H. pylori can cause what bad condition?

gastric AdenoCA

ulcers that feel worse with food

gastric ulcers

zollinger-ellison syndrome pathogenesis tx

gastrin secreting gastrinoma somatostatin receptor scintigrapy confirm with secretin stimulation test.....if increases gastrin, positive for zollinger-ellison

celiac sprue tx:

gluten allergy autoimmune fatty stool anti-trasglutaminase antibodies atrophic villi dermatitis herpetiformis tx: stop eating gluten

anti-TSH Receptor

grave's disease

antimicrosomal/ antithyroglobulin antibody

hashimoto's thyroiditis

pain radiating down leg but not past knee

herniated disc

diabetic ketoacidosis blood gas findings

high osmolar metabolic acidosis

tx. for sickle cell

hydroxyurea converts sickle Hb to Fetal Hb

prolonged PR interval

hyperkalemia

widening of QRS complex

hyperkalemia

electrolyte abnormality in burn victims

hyperkalemia ---> cardiac arrest

sudden death in athletes

hypertrophic cardiomyopathy

prolonged QT interval

hypocalcemia

U wave on EKG

hypokalemia

J-wave or Osbourne Wave

hypothermia

uremic pericarditis Tx?

immediate hemodialysis

tx: for diverticulosis

increase fiber in diet dec. red meat

elevated 5-HIAA means what?

increased serotonin in blood--> carcinoid syndrome

histone antibodies

induced lupus

duke criteria

infective endocarditis risk factors

ARDS tx:

intubation oxygen PEEP

cause of diffuse, nontoxic goiter himalayas no nodules

iodine deficiency TSH stimulates thyroid, but no iodine to manufacture thyroid hormone --> hypertrophy of tissue

pneumonia in an alcoholic or patient w/ seizures. most likely pathogen

klebsiella (due to aspiration)

which 2 diseases are positive for dix-hallpike manuever?

labyrinthitis and BPPV

anti presynaptic calcium receptor in muscles

lambert eaton myesthenia due to paraneoplastic syndrome from Small cell CA

TB latent therapy TB active therapy

latent: isoniazid for 9 months active: RIPE therapy

Acute Respiratory Distress Syndrome (ARDS)

leaky capillaries in lungs, and not cardiogenic, so capillary wedge pressure is normal

tx. for parkinson's if >70/ severe symptoms?

levodopa + carbidopa

CREST syndrome

limited scleroderma Calcinosis Raynaud's Esophageal Dysmotility Sclerodactyly Telangiectasia

anti centromere antibody

limited scleroderma (CREST)

colon cancer will metastasize to......

liver or lung

found a pulmonary nodule, now what?

look at old films -no change in 2 yrs --> stable (stop there) -new changes --> unstable (serial CT or Bx)

sodium in blood is low, but osmoles are elevated diagnosis?

low salt, but lots of other shit (BUN, glucose) in the blood so..... hypertonic hyponatremia

ds-DNA antibody

lupus

community acquired pnemonia tx?

macrolide or doxycycline

elderly patient with central vision loss but periphery is OK

macular degeneration Drusen---> macular deposits

what two electrolytes interact directly with each other?

magnesium and calcium hypomagnesemia = hypocalcemia

Labyrinthitis Tx

meclizine (antihistamine) antiemetics (metaclopromide)

triad of vertigo, unilateral hearing loss, and unilateral tinnitus,

meniere's Disease

acute exacerbation of multiple sclerosis tx?

methylprednisolone 2ndary: plasma exchange therapy

autosomal dominant polycystic kidney disease is at incraesed risk for what cerebral malformation?

middle cerebral artery hemorrhage (aneurysms)

Tx: for Migraine mild: Severe:

mild: NSAID's severe: triptan's or Ergot's PPx: propanolol

holosystolic murmur radiating to axilla rheumatic fever

mitral regurge

opening snap rheumatic fever

mitral stenosis

opening snap decrescendo murmur in diastole

mitral stenosis

mid systolic click

mitral valve prolapse to win MVP team has to "click"

anti-U1 Ribonucleoprotein

mixed connective tissue disease

hyperplastic polyp

most common B9 polyp

oligoclonal immunoglobulin G bands

multiple sclerosis

anti Ach receptor

myesthenia gravis

what if pt. has GERD but can't take PPI's

nissen fundoplication

cystitis tx

nitrofurantoin

tx. for open angle glaucoma

no emergency asymptomatic tx: prostaglandin's or topical B-blockers

NYHA class of Chronic Heart Failure Class I

no symptoms at all w/ exercise

most common type of hodgkin lymphoma

nodular sclerosing hodgkin lymphoma

confirmed diagnosis of kidney stone

non-contrast CT US if Prego

Which two groups don't get ACEi/ARB's to treat HTN?

old people or african americans

when to use tPA?

only when there's a massive embolism and there isn't anything else available

cupping of optic disc seen in what?

open angle glaucoma

otitis media tx:

oral amoxacillin x10 days1

preceptal cellulitis vs orbital cellulitis

orbital involves behind eye and makes it stick out and bad oculomotor movements preceptal just involved eyelid

diagnosis of hereditary spherocytosis

osmotic fragility test

swan neck deformity

osteoarthritis

nephrolithiasis main cause

oxaloacitate buildup

Tx: for Cluster Headaches prophylaxis?

oxygen PPx: verapamil (CCB)

what time of acid-base disorder in PE

oxygen can't get it, but rapid breathing still blows off CO2, so..... Respiratory Alkalosis

preseptal cellulitis of eye

painful eyelid and red eyes

anti-desmoglein antibody

pemphigus vulgaris

constrictive pericarditis

pericardium becomes fibrosed and rigid d/t inflamamtion heart pumps and "knocks" on pericardium from the inside Tx: pericardiectomy

p-ANCA

perinuclear nutrophil antibodies

eyes open, response to pain, breath on own but flat EEG, no brain activity

persistent vegetative state (vegetable)

helps numb bladder for pain during UTI

phenazopyridine

ground-glass opacities insidious hypoxia heavy metal exposure

pheumoconiosis

chemical weapon used during WWI and in dye manufacturing in the 19th century. Cobalt II Chloride converts into ................... when exposed to UV light, creating a free radical which results in laryngospasm

phosgene

Hypersensitivity Pneumonitis causes

pigeon feathers, organic dust, actinomyces (Birds)

tx. for Hemolytic Uremic Syndrome from E. Coli 0157:H7

plasma exchange to fix plateletes

vasculitis assoc. w/ Hep. B

polyarteritis Nodosa

associated with giant cell arteritis

polymyalgia rheumatica -multiple joint stiffness

anti-Jo antibody

polymyositis/dermatomyositis

first step in acute respiratory distress

positive pressure ventilation to get O2 sat to 90-95%

when administering insulin, what other electrolyte is important to administer in the blood

potassium because insulin causes K+ to enter cells, causing a hypokalemia.

hyaline casts and low BP is what?

pre-renal azotemia

Ranson Criteria

predicts mortality of acute pancreatitis

wells criteria

probability of PE moderate is score of 2-6 >4 = CT <4 = no CT

hypocalcemia finding on EKG

prolonged QT inverval

orbital cellulitis

proptosis, dec. vision opthalmoplegia

Factor V Leiden Pathogenesis

protein C resistance which increases the risk for thrombotic disease.

what nutrient worsens azotemia

protein in diet

calculated osmoles are elevated, but measured osmoles are normal diagnosis?

pseudohyponatremia (isotonic)

idiopathic intracranial pressure AKA what? Tx:

pseudotumor cerebri Tx: acetazolamide (diuretic acts on PCT)

sub-theraputic levels of INR (lower 2-3) so how to fix it?

put back on heparin until reach theraputic INR (2-3), and then hold that level for at least 5 days. Then can bridge back to warfarin

testicular cancer tx

radical inguinal orchioectomy of spermatic cord and testicle

Secondary AV Block (Mobitz II)

randomly drops QRS

esophageal spasm tx:

relieved with NO manometry shows diffuse spasms throughout esophagus "corkscrew esophagus" Tx: NO + CCB's

secondary hyperparathyroidism

renal failure--> low Vit. D --> low Ca2+ synth--> parathyroid secretes PTH

if suspect gillian barre syndrome, what else do you need to check immediately

respirations with PFT's to ensure they wont' stop breathing!

idioventricular rhythm

rhythm w/out atrial activity

natural poison derived by caster beans

ricin

initial aggressive therapy for pancreatitis

saline bolus (early hydration)

bioterrorist agent causing increased Acetylcholine---> miosis, rhinorrhea, bronchospasm, diaphoresis, nausea, vomiting and urinary incontinence

sarin

pain radiating past knee

sciatica

China, New Zealand and Finland. Keshan disease presents as congestive cardiomyopathy with an enlarged heart in children and young female living in these endemic areas with low soil concentration

selenium deficiency tx: seafood + eggs

aortic valve area measuring 0.7cm2

severe aortic stenosis replace valve

rock dust sand blasting upper lobe nodules inc. risk for gettiing TB

silicosis

primary hyperparathyroidism

single gland just decides to make too much PTH Ca inc P (phosphate) dec.

most common EKG finding of PE? most classic finding on EKG of PE?

sinus tachycardia S1, Q3, T3 (inverted)

diff. btw SJS and toxic epidermal necrolysis

sjs: <10 % body Toxic Epidermal Necrolysis: >30 % body

pain into buttocks bilaterally. better with leaning forward

spinal stenosis

claudication but is positional unique type of siatica leg and butt pain

spinal stenosis get MRI and fix w/ surgery

how do steroids affect stomach ulcers?

steroids block production of PG's --> no protection of endothelial lining of stomach ---> stomach ulcer exacerbation

gastroparesis associated with? Tx?

stomach is paralyzed and food can't go forward (idiopathic) associated with diabetes control blood sugar Tx: prokinetic agents (metaclopromide or IV erythromycin) also can limit fiber gastric emptying study confirm's dx

test to confirm eradication of H. Pylori

stool antigen test

acute abdomen

sudden onset of abdominal pain with rapid clinical deterioration. It is often a clinical diagnosis based on presence of guarding, rebound tenderness and "pain out of proportion" to physical exam, such as this patient -hemoccult blood -leukocytosis

Ulcerative Colitis

superficial bloody diarrhea crypt abscesses colon surical removal to treat p-ANCA screen q8 yrs from diagnosis Tx: 5-ASA, Azathioprine, TNF-inhibitors, 6-mercaptopurine

tx for tuberous sclerosis brain tumor

surgical excision

Tx for achalasia (narrowing of esophagus)

surgical myotomy

NYHA class of Chronic Heart Failure Class IV

sxs @ rest Bed Bound

anti-topoisomerase antibody (Scl-70)

systemic scleroderma

orthostatic Hypotension

systolic dec. by 20 mmHg diastolic dec. by 10 mmHg when moving from laying to standing tx: rehydrate + pressors

Granulomatous Thickening of Aortic Arch Pulseless Disease Young Asian Females tx?

takayasu arteritis tx: prednisone

aortic arch and proximal great vessels constrict due to granulomatous thickening diagnostic tech?

takayatsu's arteritis -MRI

caloric reflex test (COWS) is negative requires ventilator to breathe no sleep/wake cycles

tests for brain dead COWS: Cold Opposite, Warm Same. Cold water = FAST phase of nystagmus to the side Opposite from the cold water filled ear Warm water = FAST phase of nystagmus to the Same side as the warm water filled ear In other words: Contralateral when cold is applied and ipsilateral when warm is applied

splenic vein thrombosis w/out portal HTN

there's something there blocking the splenic vein, only thing there's the Pancreas. It's enlarged b/c it's infected. Pancreatitis

hose with refeeding syndrome are likely --------- deficient

thiamine deficient and, if not replaced, may result in Wernicke-Korsakoff syndrome

diagnosis of malaria

thick/thin films or ELISA

What causes Diastolic Heart Failure?

things that prevent heart from properly filling -Hypertrophic or Restrictive Cardiomyopathy

effusion on chest x-ray, with cancer sxs next step if positive?

thoracocentesis to look for malignant cells if positive: ----> CT scan next -then PFT's to assess ability for surgery -then: Chemo, radiation, surgery

chronic treatment for thromboembolic pulmonary HTN

thrombectomy

Pericardial Tamponade

too much fluid around heart

Chron's Disease

transmural inflamation mouth-->anus watery diarrhea fistulas B12 deficiency (if in terminal ileum) Surgical Resection is NOT curative, so don't do it

inflammatory process that involves both sides of a spinal cord segment and causes damage to the myelin sheath, leading to altered nerve conduction. and allodynia (sensitivity/pain to touch)

transverse myelitis

types of cancer in the esophagus based on height

upper 1/3 = squamous cell CA (hot foods/liquids) lower 1/3 = adenoCA (barett's)

reactivation TB occurs where?

upper lung lobes

tx for gallstones on patient that can't have surgery (cholecystectomy)

ursodeoxycholic acid

vasovagal syncope diagnostic test?

vagus nerve stimulation--> Bradycardia + hypotension --> no blood to brain -valsalva, coughing, pooping, micturition, turn head to shave, carotid massage -psychotropic--> vagus nerve stimulation Diagnosis: tilt table test

complete absence of behavioral self or environmental awareness.

vegetative state

wandering baseline and irregular complexes with a faint pulse

ventricular fibrillation

Neurologic cause for passing put due to lack of posterior circulation in brain Diagnosis?

vertebrobasilar insufficiency -CT angiogram to see vertebrobasilar arteries

phenytoin side effect

vertical nystagmus

like labrynthitis but with preserved auditory function

vestibular neuritis

most common cause of acute diarrhea in US

viral pathogens

when does normal anion-gap occur?

where high amount of sodium and bicarbonate are lost such as in a patient with high ileostomy output or lots of vomiting/diarrhea

narrow QRS complex

wide >.12 msec --> ventricular rhythm narrow <.12 msec --> atrial rhythm

during diabetic ketoacidosis, you have hyperkalemia or normal K+, but after you give insulin and glucose, you have to again give potassium because you may lower K+ too much and cause death!

yeah, all the facts are on the first side

tx. for SIADH

you are reabsorbing too much water so..... fluid restriciton

decrease taste sensation (hypogeusia), night blindness, and decreased spermatogenesis -decreased immunity

zinc deficiency

stomach ulcers from gastrinomas

zollinger-ellison syndrome