Internal Medicine 2

Causes of aortic stenosis

bicuspid aortic valve, senile/age-related sclerosis (calcification), rheumatic heart disease

cullen sign

bruising around umbilicus (pancreatitis or ectopic pregnancy)- hemoperitoneum

Grey Turner's sign

bruising in flank area (lower back area)- retroperitoneal bleed

confounding variable

a factor other than the independent variable that might produce an effect in an experiment Stratification can remove confounder. Ex. alcohol users as associated with bladder cancer. Alcohol + smokers do not give bladder cancer, alcohol and non smokers do not give bladder cancer.

Cerebral lobe hemorrhage

contralateral hemiparesis (frontal lobe) contralateral hemisensory loss (parietal lobe) homonymous hemianopsia (occipital lobe) eyes deviate away from hemiparesis seizure

Thalamus hemorrhage

contralateral hemiparesis and hemisensory loss nonreactive miotic pupils upgaze palsy eye deviate [T]oward hemiparesis

osteomalacia causes

disease marked by softening of the bone caused by calcium and vitamin D deficiency Malabsorption Intestinal bypass surgery Celiac sprue Chronic liver disease Chronic Kidney disease Increased Alk phos, increased PTH Decreased Ca & phosphorus & 25 OH-D Decreased urinary calcium Xrays w/ thin cortex, b/l pseudofractures

Anticholinergic effects

dry mouth/skin constipation blurred vision/mydriasis urinary retention hyperthermia vasodilation delerium/hallucinations TRT: PHYSOSTIGMINE

Prolactinoma labs

elevated prolactin normal TSH, T3/4, normal renal function w/ creatinine. Suppression of GnRH --> decrease FSH/LH oligo/amenorrhea, infertility, galactorrhea, HA, visual defects, gynecomastia

prevent cardiorespiratory arrest and neuro disability in smoke inhalation victims....

empirically trt for cyanide toxicity w/ antidote such as hydroxocobalamin or sodium thiosulfate or with nitrates to induce methemoglobinemia.

Hypotonic hyponatremia due to SIADH

euvolemic. urine Na+ conc. elevated. serum uric acid low, serum K+ normal. acid-base normal.

Effect modification

extraneous variable (modifier) changes the direction or strength of an association between a risk factor and a disease. Stratification can make the effects of modifier more apparent. Ex. family hx of breast cancer modifies association of OCP use and breast cancer. (different strength of family hx +OCP and breast cancer than no family hx +OCP and breast cancer)

adhesive capsulitis

frozen shoulder Deceased passive and active ROM Stiffness +/- pain

dermatitis herpetiformis treatment

gluten free diet and DAPSONE

Dacrocystitis

inflammation of the lacrimal sac. painful, redness, sudeen. staph aureus or beta hemolytic strep.

ulcerative colitis gross and microscopic

mucosal and submucosal only. friable mucosa w/ superficial or deep ulcerations. loss of haustra --> lead pipe appearance on imaging. Continuous and ALWAYS rectal involvement. crypt abscesses and ulcers. NO granulomas. Th2 mediated. Leukocytosis, iron deficiency anemia, reactive thrombocytosis, elevated inflammatory markers (ESR).

Pyelonephritis treatment

outpatient: fluoroquinolone- ciprofloxacin, levofloxacin inpatient: IV antibiotics- fluoroquinolone, aminoglycoside +/- ampicillin need culture before trt.

Criteria for extubation

pH > 7.25 normal ABG Adequate oxygenation on minimal support (fraction of inspired air FiO2 <40% and positive end-expiratory pressure [PEEP] <5cm H20 Intact inspiratory effort and sufficient mental alertness to protect the airway

RA is sensitive & specific for

sensitive: RF specific: Anti-CCP

Postictal lactic acidosis

transient anion gap metabolic acidosis that resolves without trt in 90 min following resolution of seizure activity. commonly after tonic clonic seizure.

rotator cuff tear

traumatic rip of one or more of the muscles or tendons within the rotator cuff of the shoulder. Similar to rotator cuff tendinopathy, weakness with external rotation. Age >40 yrs.

WBC casts

tubulointerstitial inflammation, acute pyelonephritis, transplant rejection

restless leg syndrome

uncomfortable sensations in legs causing movement and loss of sleep secondary causes: iron def. uremia, DM, MS, parkinsons, pregnancy, drugs trt: supplement iron, leg massage, heating pads, exercise, FIRST LINE DRUG: dopamine agonists- pramipexole. ALTERNATE: alpha-2-delta calcium channel ligands (gabapentin)

angiodysplasia is associated with..

von Willebrand's disease calcific aortic stenosis advanced renal disease

Multifocal Atrial Tachycardia etiologies

- exacerbation of pulmonary disease (COPD) - electrolyte disturbance (hypokalemia) - catecholamine surge (sepsis) Rapid, irregular pulse, ECG w/ >3 p-wave forms and atrial rate >100/min Correct underlying source, AV nodal block (verapamil) if persistant.

Pulmonary hypertension causes

-Primary Pulmonary HTN - Left sided heart disease -Sustained hypoxemia (COPD, ILD) -Chronic thromboembolic diseases pulmonary vasculitis or occlusion (PE) *can lead to cor pulmonale - Other causes: sarcoidosis

treatment for hypertriglyceridemia

150-500 mg/dL: lifestyle modifications such as wt loss, moderate alcohol intake, increase exercise and statin therapy. >1000 mg/dL: initial goal is pancreatitis prevention; fibrates + fish oil + abstinence from alcohol . Once at 500 mg/dL go to lifestyle modifications and statin.

AST/ALT ratio

<1.0: INFLAMMATORY: viral hepatitis 1-2: NECROTIC: fulminant necrotic hepatitis, decompensated cirrhosis >2.0: alcoholic hepatitis, hepatocellular carcinoma

Subclavian steal syndrome

Occlusion due to severe atherosclerosis of left subclavian artery. Leads to decreased pressure in distal subclavian artery and reversal "steal" of blood flow in the ipsilateral vertebral artery. Sx → LE ischemia (pain, fatigue, paresthesia), vertebrobasilar ischemia (dizziness, ataxia, vertigo, nausea, confusion, supraclavicular systolic bruit, can have 4th heart sound due to LVH from HTN, lower brachial systolic BP in affected arm >15mmHg Dx: doppler US, magnetic resonance angiography

TB test induration positive size

(+) IF: >5 mm in HIV pts, TB exposed pts, nodular or fibrotic changes consistent with TB on xray, organ transplant, immunosuppressed. >10mm: in recent immigrants, IV drug users, high risk living setting, DM, leukemia, ESRD, children <4 yrs. >15 mm: in healthy pts.

Asthma exacerbation treatment

- first oxygen -then (short acting beta2 agonist) albuterol and ipratropium - then IV or oral corticosteroids Elevated or even normal partial pressure of CO2 suggests failure of medical therapy and impending respiratory collapse. These patients require endotracheal intubation and mechanical ventilation. (consider also if you see absent wheezing, decreased breath sounds, decreased mental status, and marked hypoxia with cyanosis)

Uncomplicated Cystitis Treatment

--Nitrofurantoin 5 days (avoid in pyelonephritis or creatinine clearance <60) --Trimethoprim-sulfamethoxazole 3 days --Fosfomycin single dose Fluoroquinolones only if above cannot be used.

Muddy casts

ATN

SVT treatment

Adenosine

Postive pressure ventilation complications

Alveolar damage, pneumothorax, hypotension.

Biceps tendinopathy/rupture

Anterior shoulder pain Pain with lifting, carrying, overhead reaching Weakness less common

Polymyositis/Dermatomyositis specific for:

Anti-Jo-1

Diffuse scleroderma specific for:

Anti-Scl-70

Mixed connective tissue disease

Anti-U1 RNP (ribonucleoprotein), ANA, Rh, anti cyclic citrullinated peptide, elevated CK, anemia/cytopenias Features of: SLE, systemic sclerosis, polymyositis. Raynaud phenomenon, hand/finger swelling, arthritis/synovitis, inflammatory myopathy.

Limited scleroderma specific for:

Anti-centromere

SLE specific for:

Anti-dsDNA/anti-Sm

Drug-induced lupus specific for:

Anti-histone

Chrohn disease gross and histologic

Any GI portion, usually terminal ileum & colon. skip lesions, rectal sparring. transmural --> fistulas. cobblestone mucosa, creeping fat, bowel wall thickening leading to string sign on barium swallow. linear ulcers, fissures. Noncaseating granulomas and lymphoid aggregates. Th1 mediated.

Pancoast tumor symptoms

Arm pain and muscular atrophy due to brachial plexus involvement C8-T2 Horner syndrome (ptosis, anhydrosis, miosis) from involvement of sympathetic chain and inferior cervical ganglion. Shoulder pain from chest wall invasion. Supraclavicular lymph node enlargement Wt loss Hoarseness- recurrent larygneal nerve. SVC syndrome Squamous cell lung cx and lung adenocarcinoma are the most common tumors.

Hereditary Hemorrhagic Telangiectasia

Autosomal dominant disorder resulting in thin-walled blood vessels, especially in the mouth and GI tract- Arteriovenous malformations with life threatening complications (GI bleeds, hemoptysis)

Hypokalemia causes

B.A.D. L.O.A.D. B-arters/Conns syndrome(hyperaldosteronism), beta adrenergic agents (albuterol) A-lkalosis D-iuretics L-axative abuse O-ther causes: insulin overdose, hematopoiesis A-cute glucose load D-iarrhea may be as a result of increased K entry into cells, potassium wasting or GI fluid loss.

Methanol vs. ethylene glycol poisoning

Both AG acidosis + inc serum osm gap. Both substitutes for alcohol. Methanol damages eyes, but ethylene glycol damages the kidneys

CKD and PTH

CKD has decreased GFR. This leads to decreased 1,25-dihydroxyvitamin D and decreased Ca+2 absorption. This also leads to phosphate retention leads to high serum phosphorus. These both result in increased PTH. SECONDARY HYPERPARATHYROIDISM

CREST stands for

Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasia [[w/ limited systemic sclerosis]]

Serum-ascites albumin gradient (SAAG)

Calculation used to distinguish if a peritoneal effusion is a transudate or an exudate. > 1.1 g/dL: Portal hypertensive (cardiac stress, cirrhosis, budd-chiari syndrome)- consistent with increased hydrostatic pressure within hepatic capillary beds. < 1.1 g/dL: NOT portal hypertension (TB, peritoneal carcinomatosis, pancreatic ascites, nephrotic syndrome)

Extraarticular manifestations of RA

Cardiac - pericarditis, myocarditis, rh nodules on valves, CAD (3x increased risk) Renal - drug related, amyloid late Lung - pleural effusion (low ph, glu); diffuse fibrosis, intrapulmonary nodules Vasculitis - like polyarteritis nodosa (nail fold infarcts), necrosis/ ulceration over malleoli Nerves - mononeuritis multiplex, carpal tunnel, cervical myelopathy Eyes - episcleritis, scleritis, sicca Skin - rheum nodules in 25% (indicate more severe dz), Raynaud, Sjogren syndrome. Blood - anemia of CD; neutropenia Bone loss- osteoporosis/penia 2x risk RH (+), cyclic citrullinated peptide antibodies, inflammatory (TNF, IL-1)

conditions associated with afib

Cardiac: HTN, CAD, rheumatic, valvular disease, CHF, HOCM, congenital disease of the heart, post-cardiac surgery Pulmonary: OSA, PE, COPD, acute hypoxia (pneumonia) Other: Hyperthyroidism, Obesity, DM, Alcohol abuse, Amphetamines, Theophylline, Cocaine

Complicated cystitis treatment

Fluoroquinolones 5-14 days, extended spectrum antibiotics (ampicillin/gentamicin) for more severe Complicated= DM, preg. renal failure, urinary tract obstruction, indwelling catheter /stent, immunosuppression, hospital acquired. Culture before trt.

CCB adverse effects

Constipation (most common) HA Peripheral edema- 25% after 6 months due to preferential dilation of precapillary vessels (amlodipine and nifedipine are worse in this than non-dihydropyridine CCBs like diltiazem and verapamil). CCB+acei can lower the CCB effects of peripheral edema. Bradycardia Heart failure Heart block Hypotension QT prolongation

basal ganglia hemorrhage

Contralateral hemiparesis and hemisensory loss Homonymous hemianopsia Gaze palsy

Pons hemorrhage

Deep coma and total paralysis within minutes [P]inpoint reactive pupils

Crohn disease presentation and complications

Diarrhea (may or may not be bloody), fistulas (enterovesical which can cause recurrent UTI and pneumaturia), phlegmon/abscess, strictures (causing obstruction), perianal disease. Pyoderma gangrenosum, erythema nodosum, arthiritis. Kidney stones (calcium oxalate), gallstones,

RBC casts

Glomerulonephritis

Peutz-Jeghers syndrome

Hamartomatous (benign) polyps throughout GI tract and mucocutaneous hyperpigmentation (freckle-like spots) on lips, oral mucosa, and genital skin; autosomal dominant disorder

Risk factors for cellulitis

Immune suppression: DM, HIV, chronic glucocorticoid therapy. Breaches in skin barrier: dry skin, chronic inflammation like eczema, radiation, chronic wounds like pressure ulcers or venous ulcers, dermatophyte infection. Chronic edema: postsurgical lymphedema, chronic venous insufficiency, CHF, CKD. Obesity [[[NOTE: cellulitis is typically gram (+) skin flora like group B strep or staph aureus]]

Statin guidelines

High intensity statin= <75 yrs old + (ACS, stable angina, CABG, Stroke, TIA, PAD), OR LDL >190 OR >7.5% ASCVD w/ DM [[high=atorvastatin, rosuvastatin]] Moderate= >75 yrs old + (ACS, stable angina, CABG, Stroke, TIA, PAD) OR <7.5% ASCVD w/DM [[Moderate= atorvastatin 10-20mg, rosuvastatin 5-10mg, simvastatin, pravastatin, lovastatin]]

Nephrotic syndrome complications

Hypercoagulation- urinary loss of antithrombin 3, altered levels of protein c and s, increased platelet aggregation, hyperfibrinogenemia due to increased hepatic synthesis, impaired fibrinolysis. Renal vein thrombosis is the most common manifestation of coagulopathy, but arterial thrombosis and PE can also occur. Also protein malnutrition, iron resistant microcytic hypochromic anemia due to transferrin loss, vit D def due to increased urinary excretion of cholecalciferol-binding protein, decreased thyroxin levels due to loss of thyroxine-binding globulin and increased susceptibility to infection.

Clinical signs of pulmonary HTN

Left parasternal lift, Right ventricular heave Loud P2, right sided S3 Pansystolic murmur of tricuspid regurg JVD Ascites Peripheral edema Hepatomegaly

Euthyroid sick syndrome

Low T3 Normal T4 Normal TSH After an acute illness. DO NOT treat, repeated TSH later after patient gets better

Metabolic alkalosis causes

Low urine chloride: severe vomiting, excessive GI suctioning, prior diuretics High urine chloride: current diuretic use, Bartter & Gitelman syndromes, excess mineralcorticoid activity- primary hyperaldosteronism, cushing disease, extopic ACTH production excessive NaHCO3

Cerebellum hemorrhage

NO hemiparesis focal weakness ataxia, nystagmus occipital headache, neck stiffness

Fatty casts

Nephrotic syndrome

HIV diarrhea

Non-bloody w/ low grade fever: cryptosporidum (spores in villi) CD4 <180 Non-bloody w/ high fever: mycobacterium avium complex CD4 <50 Bloody, painful, n/v: CMV CD4 <50

pH of pleural fluid

Normal: 7.6 Transudate 7.5 Exudate 7.3

community acquired pneumonia treatment for outpatient, inpatient (ICU) and inpatient (non-ICU)

Outpatient: Macrolide or doxycycline (healthy) fluoroquinoloine or beta-lactam+ macrolide (comorbities) Inpatient (non-ICU): fluoroquinolonie IV or beta-lactam + macrolide (IV) Inpatient (ICU): beta-lactam +macrolide beta-lactam + fluoroquinolone

Rotator cuff impingement or tendinopathy

Pain with abduction, external rotation Subacromial tenderness Normal range of motion with positive impingement tests (Neer, Hawkins)

Calcific Uremic Arteriolopathy (Calciphylaxis)

Pathophysiology: arteriolar and soft tissue calcification, local tissue ischemia and necrosis Risk factors: ESRD, hyperCa, hyperPO3, hyperPTH, obesity, DM, oral anticoagulants. Clinical manifestation: painful nodules and ulcers, soft tissue calcification on imaging, skin bx: arterial calcification/occlusion, subintimal fibrosis.

management of cirrhosis

Periodic surveillance of liver function tests (INR, albumin and bilirubin) Then you know whether you are COMPENSATED or DECOMPENSATED: Compensated: US for HCC +/- AFP q 6months, EDG varicies surveillance Decompensated: Variceal hemorrhage (start BB or endoscopic variceal ligation, repeat EDG qyear), Ascites (dietary Na+ restriction, diuretics, paracentesis, abstinence from EtOH), Hepatic encephalopathy (check infection, GI bleed- lactulose therapy)

aortic stenosis presentation

Progressive dyspnea on exertion, exertional syncope. Delayed (slow rising) and diminished (weak) carotid pulse- pulsus parvus and tardus Presence of single and soft second heart sounds (S2) Mid to late peaking systolic murmur with maximal intensity at 2nd right intercostal space radiating to carotids

hepatorenal syndrome

Progressive renal failure associated with hepatic failure characterized by a sudden decrease in urinary output, elevated BUN +CR, decreased urine sodium excretion, and increased urine osmolarity. It occurs as cirrhosis progresses and patients develop splanchnic arterial dilation and an overall decrease in vascular resistance. This activates RAAS and results in renal vasoconstriction w/ decreased perfusion and GFR. TRT: address precipitating factors (hypovolemia, anemia, infection) Splanchnic vasoconstriction (midodrine, octreotide, norepinephrine) Liver transplant

Headache warning signs

Progressively frequent or severe over a 3-month period. Sudden onset like a "thunderclap" or "the worst headache of my life". Presence on awakening. New onset after age 40 years. Aggravated or relieved by change in position. Precipitated by Valsalva maneuver. Associated symptoms of fever, night sweats, or weight loss. Presence of cancer, HIV infection, or pregnancy. Recent head trauma. Associated papilledema, neck stiffness, or focal neurologic deficits. Change in freq., intensity, characteristics. Seizures, change in consciousness.

Chondrocalcinosis

Pseudogout- acute monoarticular arthirits due to pyrophosphate dihydrate crystal deposition disease. Secondary causes to elevated calcium are hyperparathyroidism, hypothyroidism, hemochromatosis.

Cholesterol crystals in atherosclerotic emboli

Risk factors: hypercholesterolemia, HTN, DMT2, cardiac cath or vascular procedure. Clinical features: livedo reticularis, ulcers, gangrene, blue toe syndrome, kidney injury, stroke or amaurosis fugax, hollenhorst plaques in ocula, intestinal ischemia, pancreatitis. Labs: elevated creatinine, eosinophilia, hypocomplementemia. Skin or renal bx with biconvex, needle shaped clefts within vessels and perivascular inflammation with eosinophilia.

SJS vs TEN

SJS <10% TEN >30% 4-28 days after exposure. Causes: allopurinol, sulfonamides, carbamazepine, lamotrigine, phenytoin, NSAIDs, sulfasalazine, mycoplasma pneumoniae, vaccination, graft-vs-host disease.

ANA is sensitive for....

SLE, drug induced lupus, diffuse and limited sclerosis, polymyositis/dermatomyositis

Lactate high

Sepsis or cell death in the body

HTN Work up and Treatment

Standard Work-up: CMP- chemistry panel Lipid panel (risk for CAD) UA (hematuria, urine protein/creatinine ratio) EKG (evaluate for CAD or LVH) Further work up should be done if sx: Renal parenchymal disease- elevated creatinine, abnormal UA w/ proteinuria, RBC casts. Renovascular disease- severe HTN >55 yrs old, recurrent flash pulmonary edema, resistant HF. abd. bruit. Primary aldosteronism- hypokalemia, hypernatremia Pheochromocytoma- paroxysmal elevated BP w/ tachycardia. HA, diaphoresis Cushing syndrome- central obesity, facial plethora, proximal muscle weakness, abd. striae, ecchymosis, amenorrhea/ED Hypothyroidism- fatigue, dry skin, cold intolerance, constipation, wt gain, bradycardia Hyperparathyroidism- hypercalcemis, kidney stones, neuropsychiatric presentations (confusion, depression, psychosis) Coarctation of the aorta- differential HTN w/ brachial-femoral pulse delay

ulcerative colitis clinical presentation & complications

Sx: bloody diarrhea, fecal incontinence wt loss, fever Complications: toxic megacolon, primary sclerosing cholangitis (p-ANCA), colorectal cancer, erythema nodosum, pyoderma gangrenosum, spondyloarthritis 2 peaks: 15-40 yrs, 50-80 yrs.

Polysaccharide vaccine

This PCV vaccine is given to the older population over 5 years of age, and is recommended for anyone over 65 years old USES T-CELL INDEPENDENT B-CELL RESPONSE -Moderate levels of intermediate-affinity antibodies

Glenohumeral osteoarthritis

Uncommon Usually caused by trauma Gradual onset of anterior or deep shoulder pain decreased active and passive abduction and external rotation

complicated vs uncomplicated parapneumonic effusion

Uncomplicated: sterile exudate, pleural analysis: pH>7.2, Glucose >60, WBC <50,000- use only abx. Complicated: bacterial invasion of pleural space. pH <7.2, Glucose <60,000, WBC >50,000,- use abx +drainage.

Reactive Arthiritis

Urethritis, conjunctivitis, Asymmetric oligoarthritis Type of seronegative spondyloarthropathy. Often involves knee, sacroiliac spine, achilles pain (enthesitis) mucocutaneous lesions, mouth ulcers Trt: NSAIDS first line!

diabetic nephropathy testing

Urine microalbumin/creatinine ratio Microalbuminuria- typically urine albumin excreted is 30-300 mg/24 hr. Initial diabetic nephropathy has glomerular hyperfiltration and increase in creatinine clearance. Creatinine clearance then declines with progression of diabetic nephropathy. Low creatinine when renal damage is advanced.

cullen sign and grey turner sign

acute pancreatitis

Broad waxy casts

chronic renal failure

Amyloid angiopathy

deposition of B-amyloid protein in vascular walls in the brain making them weak and more likely to bleed- cause intraparenchymal lobar hemorrhage stroke in elderly.

septic arthritis tx

gram positive -vancomycin -nafcillin -clindamycin gram negative -ceftriazone negative microscopy- vancomycin [+ ceftriazone if immunocompromise] ESR and CRP will be elevated.

vomiting acid-base disturbance

hypokalemic, hypochloremic metabolic alkalosis. phase I: generation phase: body depletes of total body acid (loss of fluid, Na+, Cl-). normally acidic gastric secretions stimulate pancreas and liver to excrete bicarb into duodenum. Loss of gastric acid means there is a build up of alkali. phase II: maintenance: although excess alkali are filtered in glomerulus, they are reabsorbed as a result of activated RAAS. Fluid depletion triggers RAAS in attempt to conserve Na and H2O. Aldosterone functions to retain water at the expense of K+ and acid secretion in urine- contraction alkalosis. giving saline and potassium- removes RAAS activation, restoring kidney's ability to excrete excess bicarb and you need to treat the hypokalemia

ruptured placenta increases what risks?

increases risk for DIC, due to TF being released by decidual bleeding, and hypovolemic shock. Potential fetal complications include hypoxia and preterm delivery.

gastric paresis trt

metoclopramide-prokinetic and antiemetic properties

Peak airway pressure

peak airway pressure = resistive pressure + PEEP + elastic pressure Maximum pressure measured as the tidal volume is being delivered resistive pressure = flow x resistance plateau pressure: pressure measured during inspiratory hold when pulmonary airflow and resistive pressure are both 0. It is the sum of elastic pressure and PEEP plateau pressure = elastic pressure + PEEP elastic pressure is increased in pulmonary fibrosis by causing stiffer lungs and higher elastic pressure. pathology: when increased peak pressure associated with unchanged plateau pressure this suggests increased airway resistance such as bronchospasm, mucus plus, endotrachael tube obstruction. Elevation in both peak and plateau indicates decreased pulmonary compliance: pneumothorax, pulmonary edema, pneumonia, atelectasis, right mainstem intubation.

conjugate vaccines

polysaccharides linked to proteins - Converts polysaccharides into T-dependent antigens - High affinity antibodies with memory cell formation

sarcoidosis

pulmonary: hilar lympahdenopathy, interstitial infiltrates. cutaneous: papules, nodeuls, plaques, erythema nodosum ophthalmologic: anterior and posterior uveitis, keratoconjunctivitis sicca neurologic: facial nerve palsy, central diabetes insipidus, hypogonadotropic hypogonadism cardio: AV block, dilated or restrictive cardiomyopathy GI: hepatosplenomegaly, asx LFT abnormalities Other: hypercalcemia, peripheral lymphadenopathy, parotid gland swelling, polyarthritis, constitutional sx like fever and malaise

Angiodysplasia

submucosal dilation of venules in cecum and arteriovenous malformations; most common in right colon, cause of hematochezia. increased in >60 yrs. can be missed on colonoscopy.