IM All together
Pulmonary Hypertension WHO Group 1 Tx
1st line: CCB (Verapamil) Other: PDE-5, Prostacyclin, Bosentan)
Abnormal extensor response (decerebrate posturing) GCS
2
Eyes open to pain GCS
2
Incomprehensible sounds GCS
2
When should you get the PCV13 for pneumonia
2, 4, 6 months, 1-1.5 years old
NCEP recommends screening all adults at ___________ regardless of risk factors
20 years of age
AIDS is defined by the CDC as a CD4 count below
200
How many joules to cardiovert a fib vs atrial flutter
200 joules - fib 50 joules - flutter
For acute exacerbations of chronic bronchitis, in which bacterial causes are more likely, empiric first-line treatment is what?
2nd gen Cephalosporin
which generation are the "respiratory" cephalosporins?
2nd generation
Abnormal flexion (decorticate posturing) GCS
3
Eyes open to verbal command GCS
3
Inappropriate words and jumbled phrases GCS
3
USPSTF recommends screening for patients with NO evidence of CVD and NO other risk factors should begin at _____________
35 years of age
Confused, yet coherent speech GCS
4
Spontaneous eye opening GCS
4
Withdraws from a noxious stimulus GCS
4
anti-flu drugs are only useful if taken within how long?
48 hours
Hospital acquired pneumonia
48 hours AFTER Pseudomonas Klebsiella S. aureus
What is the proper time to read the PPD test?
48-72 hours
Alert and oriented verbal GCS
5
Localizes to a noxious stimulus GCS
5
- Elective lithotripsy or uteroscopy - increased fluids and analgesics what size kidney stone?
5-10 mm stone
Prediabetes A1C
5.7-6.4
Obeys commands motor GCS
6
Health care workers who sustain an possible HIV injury must be counseled. Testing should be done on the health care worker and the patient; retesting is recommended when?
6 weeks 3 months 6 months
door to balloon time in STEMI
90 minutes
Normal GFR
90-120
Normal LDL levels
< 100
Treatment goal of finger stick blood glucose monitoring
< 130 fasting < 180 postprandial
ACC/AHA Target blood pressure
< 130/80
Normal cholesterol levels
< 200
High HDL levels
< 40
What makes an a fib patient hemodynamically stable
< 48 hours since onset of a fib > 48 hours with clearance from echo
- likely to pass spontaneously - drink a lot of water - strain urine to catch stone for analysis - maybe alpha blocker or CCB what size kidney stone?
< 5 mm stone
Treatment goal A1C
< 7
Normal BP
<120/80
- inpatient tx if unable to maintain adequate oral intake - ureteral stent or percutaneous nephrostomy (gold standard) - Urgent tx: extracorporeal shock wave lithotripsy (ESWL) - Uteroscopy what size kidney stone?
> 10 mm stone
Diabetes fasting glucose
> 126 (2 separate times)
High LDL levels
> 160
- Percutaneous nephrolithotomy what size kidney stone?
> 2 cm stone
Diabetes oral glucose tolerance test
> 200
Diabetes random glucose test
> 200 + diabetes symptoms
High total cholesterol levels
> 239
Diabetes A1C
> 6.5
Normal HDL Levels
> 60
BLASTS + AUER RODS in ADULT PATIENT Population: - Adults (80%) - majority of patients > 50 y/o Anemia Thrombocytopenia Neutropenia Splenomegaly Gingival hyperplasia Leukostasis (WBC > 100,000)
Acute Myeloid Leukemia (AML)
Causes: MC cholelithiasis or alcohol abuse Hyperlipidemia Trauma Drugs Hypercalcemia Penetrating PUD Antiretroviral medication
Acute Pancreatitis
Clinical Features: Epigastric pain radiating to back Pain lessens when patient leans forward or lies in fetal position Nausea/vomiting Fever Leukocytosis Grey Turner Sign Cullen sign Poor prognosis - severe hypovolemia - adults respiratory distress syndrome - tachycardia < 130 bpm
Acute Pancreatitis
Diagnosis Elevated serum amylase Elevated serum lipase (more sensitive, only with elevations 3x normal) Elevated WBC Elevated liver enzymes US may be helpful to look for gallstones Plain films may reveal a sentinel loop
Acute Pancreatitis
MC type of NSCLC (35-40%) Metastatic to distant organs Arises from mucous glands Appears in periphery of lungs Most likely in non-smokers
Adenocarcinoma NSCLC
MC type of esophageal cancer in US
Adenocarcinomas Lower 1/3 esophagus Risk: GERD
If IGF-1 is elevated fivefold, it is highly suggestive for what?
Adenoma
MCC: abrupt withdrawal of steroids
Adrenal Crisis
Cushings disease What Pituitary Adenoma?
Adrenocorticotopinomas
First line therapy for chronic angina
Beta blockers
Inpatient standard pneumonia tx
Beta lactam + Macrolide or Fluroquinolone monotherapy
How often are screening recommended for those at high risk—patients with achalasia, tylosis, history of radiation or caustic injury.
Biannually
Clinical features: Painless hematuria is the most common presenting symptom. Bladder irritability Pain Voiding symptoms Infection
Bladder Cancer
Diagnostic studies: CBC Blood chemistry Cystoscopy with biopsy, which has an accuracy rate of nearly 100%, is the definitive diagnostic procedure
Bladder Cancer
General characteristics: Causal factors: - exposure to tobacco - occupational carcinogens - schistosomiasis - exposure to cyclophosphamide - chronic infections 3x MC in men
Bladder Cancer
Genetic disorder Causes syncope. v fib, and sudden death often during sleep MC in Asian men
Brugada syndrome
Aortic bifurcation common iliac PAD
Buttock/hip claudication
Best hypertension medication for black people and elderly
CCB (Amlodipine, Verapamil) Thiazide like diuretic
"CREST" syndrome, which is associated with limited scleroderma.
Calcinosis cutis Raynaud phenomenon Esophageal dysfunction Sclerodactyly Telangiectasias
MOA: inhibit osteoclasts Take with water 1-2h before meals Contraindications: - nephrotoxic - thrombocytopenia - atypical femure fx - jaw osteonecoris
Calcitonin & Bisphosphonates (Aldendronate, Risedronate)
MC Kidney stone 75%-85% Radiopaque Tx: hydrochlorothiazide to decrease urine excretion of mineral
Calcium Stones
Can be life-threatening. The mortality rate is higher than 40%. Occurs in very ill patients with indwelling instrumentation Any suspect catheters should be removed IV amphotericin B is recommended. If disseminated disease develops - positive blood cultures; retinal lesions; or infection of dermis, brain, meninges, or myocardium - flucytosine should be added - alternatively, fluconazole can be tried What kind of candidiasis?
Candidal fungemia
General characteristics: MC form = C. albicans - part of the normal flora of human hosts and is an opportunistic pathogen Risk factors - neutropenia - recent surgery - chronic illness (especially diabetes mellitus) - broad-spectrum antibiotic therapy - IV catheterization (especially total parenteral nutrition) - chemotherapy or corticosteroids - injection drug use - cellular immunodeficiency, as in HIV disease.
Candidiasis
Immunocompetent children and adults aged 1 month to 50 years with bacterial meningitis tx
Cefotaxime or Ceftriaxone PLUS Vancomycin
AKA celiac sprue
Celiac Disease
Clinical presentation: Iron, B12 or folate deficiency Osteoporosis, bone pain Detmatitis herpetiforms (10%) Diarrhea Steatorrhea Flatulence Weight loss Weakness, Abdominal distension Infants and children may present with failure to thrive.
Celiac Disease
Diagnostic studies: IgA TTG (best!) most sensitive IgG DGB (gluten sensitivity) IgA Endomysal after (+) blood test: - Confirm with EGD with duodenal mucosal biopsy
Celiac Disease
General characteristics: MC in Europe and the United States Response to GLUTEN Presents in childhood, early adulthood Triggers autoimmune response that damages proximal S.I. mucosa --> Loss of villi --> Malabsorption
Celiac Disease
Treatment: Gluten-free diet Patients should be referred to a nutritionist A lactose-free diet may also be needed initially until the intestinal inflammation resolves. Prednisone may be required in refractory cases.
Celiac Disease
When does screening for prostate cancer start?
Age 50 High risk (AA, FHx, BRCA) Age 40-45
Adults older than 50 years of age and those of any age with alcoholism or debilitating illness with bacterial meningitis tx
Ampicillin + cefotaxime OR Ceftriaxone + vancomycin
Foul smell/bad taste bacterial pneumonia
Anaerobic
Clinical Features: Severe tearing pain on defecation, often accompanied by hematochezia Bright red blood is often noted on the stool or tissue paper
Anal Fissure
Linear lesions in the rectal wall most commonly found on the posterior midline
Anal Fissure
Treatment: Bulking agents and increased fluids to avoid straining Sitz baths will relieve acute pain Topical nitroglycerin ointment or topical styptic, such as silver nitrate (1% to 2%) or gentian violet solution (1%), may help with healing
Anal Fissure
Clinical features Produce anal discharge and pain when the tract becomes occluded Tract should not be explored on examination because this may open new tracts.
Anal Fistula
General characteristics: Chronic complication of abscess. Open tract between two epithelium-lined areas
Anal Fistula
Treatment: Abscess - surgical drainage - followed by warm-water cleansing, analgesics, stool softeners, and high-fiber diet (WASH regimen). Fistulae must be treated surgically.
Anal Fistula
IgE mediated severe systemic hypersensitivity reaction What kind of shock?
Anaphylactic Shock
Pruritis, hives Angioedema Respiratory distress Treatment: - Epinephrine 0.3mg IM repeat q5-10min prn - Epinephrine 1mg IV if cardiovascular collapse What kind of shock?
Anaphylactic Shock
(1%) Seen in the elderly Most aggressive Causes dysphagia or vocal cord paralysis NO good iodine uptake Local resection and radiation What type of Thyroid cancer?
Anaplastic type
Diagnostic studies: bone marrow biopsy Treatment: - stop causative agent - RBC transfusion - bone marrow transplant - immunosuppressive agents
Aplastic Anemia
MC chronic arrhythmia Risk increases with age Leads to a significant decrease in cardiac output MC of embolic CVAs
Atrial Fibrillation
Arrhythmia that usually occurs in those with COPD, HF, ASD, or CAD Right atrium stretch
Atrial Flutter
Benign arrhythmia with no treatment
Atrial premature beats
Unstable bradycardia tx
Atropine OR Epi or Dopamine Maybe pacing
Clinical Features: Low grade fever Relatively mild pulmonary symptoms that are self limited Occurs in young, healthy adults Maybe: nonproductive cough, myalgia, fatigue
Atypical Community Acquired Pneumonia
Diagnosis: Organism not detected on culture or stain WBC are normal or slightly elevated CXR: segmental unilateral lower lung infiltrates or diffuse infiltrates
Atypical Community Acquired Pneumonia
Treatment: Tight control of hyperglycemia is vital Pharmacology (deep, constant, aching pain) - Amitriptyline - Duloxetine - Gabapentin - Pregabalin
Diabetic peripheral neuropathy
If sodium is > 200 then what needs to be done?
Dialysis
Patient must have: 2 major, 1 major + 3 minor, or 5 minor for diagnosis to be made Major Criteria - Two positive blood cultures of a typical causative microorganism - Echocardiographic evidence of endocardial involvement - New valvular regurgitation murmur Minor Criteria - Fever higher than 100.4°F (38°C) - Vascular phenomena (e.g., embolic disease or pulmonary infarction) - Immunologic phenomena (e.g., glomerulonephritis, Osler nodes, Roth spots) - Positive blood culture not meeting major criteria
Duke Criteria for Infective Endocarditis
Cause: ORAL (dental, candy, brush) -others: IVDU, EGD, TURP, cath, •Localization of the infection is determined by turbulent blood flow •MC bug: S. aureus •MC on Left side, TV MC in IVDU
Endocarditis
Commonly occurs after head trauma or brain surgery Primary = genetic or autoimmune Secondary = damage to hypothalamus/stalk May lack "osmostat" Responds to desmopressin What kind of diabetes insipidus?
Central (Neurogenic) DI
Characterized by ischemia or hemorrhage in the CNS resulting in infarction. MC in increased age, AA, Native, Latin, Men Contralateral paralysis
Cerebral Vascular Accident
Clinical features Begin abruptly or upon awakening Symptoms correlate with the area of the brain that is supplied by the affected vessel, especially with ischemic events - Carotid/opthalmic - MCA, ACA, PCA (cerebral arteries) - Basilar - Lacunar Hemiparesis or hemisensory deficit Contralateral paralysis
Cerebral Vascular Accident
Diagnostic studies Labs: CBC, ESR, platelet, PT/PTT, Lipids, BUN/Cr, Electrolytes, glucose Noncontrast CT scan - gold standard during acute phase - differentiates ischemic from hemorrhagic Additional imaging - diffusion-weighted MRI - neurovascular imaging with CTA - MRA - carotid ultrasonography - echocardiography - electrocardiography (ECG) LP reserved for pts with hemorrhage
Cerebral Vascular Accident
Treatment: Acute treatment is aimed at reversing the ischemia and salvaging tissue in the core and surrounding penumbra. Thrombolytic therapy - acute ischemic = tPA Labetalol - If BP > 185/110 and thrombolytic therapy is indicated, BP must be controlled to <185/110 - If thrombolytic therapy not indicated, no need to treat w/ Labetalol Antiplatelet therapy w/ Aspirin - initiated early for acute ischemic - Do not give until 24 hours after tPA, if tPA is given
Cerebral Vascular Accident
Clinical features: Sudden onset of an unusually severe, generalized headache, which patients may describe as "the worst headache I've had in my life." - accompanied by nausea and vomiting, seizure activity, or an altered state of consciousness. BP rises precipitously Develop a fever of up to 102°F (38.9°C) Nuchal rigidity or other signs of meningeal irritation
Cerebral aneurysm/subarachnoid hemorrhage (SAH)
General characteristics: Large group of obligate intracellular parasites - C. psittaci (psittacosis) - C. pneumoniae (respiratory infections) - C. trachomatis (trachoma, inclusion conjunctivitis, pneumonia, and genital infections).
Chlamydia
Treatment: Azithromycin, doxycycline, and erythromycin are effective Erythromycin is the drug of choice in pregnant women All partners should be treated.
Chlamydia
Longer prodrome Sore throat, hoarseness What kind of pneumonia?
Chlamydia pneumoniae
Clinical presentation: Presentation varies from mild to fulminant Charcot triad is present in 50-70% of cases. Reynolds pentad may indicate sepsis. If present, the disease can become rapidly fatal.
Cholangitis
Diagnostic studies: RUQ ultrasonography - biliary dilation or stones - good initial test Leukocytosis with left shift High alk phos, GGT, bilirubin Mildly increased transaminase levels US/CT (FIRST!) ERCP-diagnostic test of choice
Cholangitis
Treatment: Initially: - Antibiotics (fluoroquinolone, cephalosporin, ampicillin, gentamicin with metronidazole) - Fluid and electrolyte replacement - Analgesia ERCP and stent placement can be done when the patient is stable. Percutaneous transhepatic biliary drainage or surgical biliary drainage may be required. Cholecystectomy should be performed after the acute syndrome is resolved when choledocholithiasis is present.
Cholangitis
gallstone lodged and obstruction in CBD --> infection - Bacterial infection or hepatic injury
Cholangitis
Clinical presentation: Colicky epigastric or right upper quadrant (RUQ) pain becomes steady and increases in intensity. Often occurs after a high-fat meal. Nausea, vomiting, and low-grade fever are common. (+) Murphy's sign (increased discomfort and the patient catching his or her breath with GB palpation on inspiration) (+) Boas sign (referred pain to R shoulder)
Cholecystitis
Diagnostic studies: ↑ Alk-P ↑ conjugated bilirubin Leukocytosis Ultrasound - gallstones 95% - thick gallbladder - sludge HIDA scan can be used for confirmation of the diagnosis. - no visualization of gallbladder Endoscopic retrograde cholangiopancreatography (ERCP) can identify cause, location, and extent of biliary obstruction
Cholecystitis
Treatment: Cholecystectomy (first 24-48 hours) Ceftriaxone +/- Flagyl IV Morphine or Demerol for pain
Cholecystitis
caused by obstruction of the bile duct, generally by a stone, leading to chronic inflammation MC due to stone lodged in cystic duct
Cholecystitis
gallstones in common bile duct (CBD) Symptomatic - passes are "uncomplicated" - typically symptomatic Normal Labs
Choledocolithiasis
Asymptomatic Biliary colic RUQ pain (hallmark) - follow fatty meals - may radiate to back and right shoulder blade! *don't typically see N/V, fever, chills with biliary colic
Cholelithiasis
By age 75 years, 35% of women and 20% of men have gallstones. Only 30% of people with gallstones develop symptomatic disease. Gallstone form from: - Ratio of cholesterol too high - Ratio of bilirubin too high - Gallbladder not emptying bile Types: Cholesterol gallstones (MC!)
Cholelithiasis
Diagnosis: Pain after eating and at night Boas sign—referred right subscapular pain RUQ ultrasound - high sensitivity and specificity if >2 mm CT scan and MRI
Cholelithiasis
Definitions: Progression of ongoing loss of kidney function (GFR). GFR less than 60 mL/min/1.73 m2 or presence of kidney damage (proteinuria, glomerulonephritis, or structural damage from PCKD) for ≥3 months. 5 stages
Chronic kidney disease (CKD)
Diagnostic studies: Measurement of GFR is the gold standard - Cockcroft-Gault formula Proteinuria Albuminuria early in the disease. BUN and creatinine are elevated. Hemoglobin and hematocrit, serum electrolytes, and urinalysis are abnormal. Cystatin C is elevated when the GFR is less than 88
Chronic kidney disease (CKD)
Treatment: ACEi/ARB Erythropoietin, iron supplements, and antiplatelet therapy should be considered to maintain hemoglobin Need for dialysis or kidney transplantation coordinated w/ nephrology Pneumococcal vaccination is recommended.
Chronic kidney disease (CKD)
spasm of facial muscle after tapping facial nerve in front of ear associated with hypocalcemia
Chvostek sign
mainstay of treatment in PAD (helpful for intermittent claudication)
Cilostazol
Hypovolemic Shock Cardiogenic Shock Obstructive Shock
Circulatory Shock
Left sided colorectal lesions
Circumferential, causing change in bowel habits and obstructive symptoms
Diagnostic studies Laboratory values are often minimally abnormal until late in the disease. Anemia Mild elevations of AST and alkaline phosphatase Increased γ-globulin Decreased albumin Abnormal coagulation studies. Ultrasonography, CT, or MRI can confirm the size and number of nodules and is helpful in guiding biopsy.
Cirrhosis
Irreversible fibrosis and nodular regeneration throughout the liver MC cause = alcohol Other causes - Hepatitis B - Hepatitis C - Congenital disorders
Cirrhosis
Treatment Abstinence from alcohol is key Treatment of viral causes Salt restriction and bed rest may be sufficient treatment for ascites, although spironolactone, 100 mg daily, may be added as a diuretic. Liver transplant is indicated in selected patients. Spontaneous bacterial peritonitis is treated with antibiotics.
Cirrhosis
Mycobacterium avium complex HIV Prophylaxis
Clarithromycin, rifabutin
what is the lincosamide abx?
Clindamycin
Hypertensive urgency tx
Clonidine
Clinical features:: Unilateral pain Ipsilateral lacrimation Conjunctival injection Nasal congestion Miosis Ptosis. Patients pace incessantly around the room because the pain is severe and not relieved by rest
Cluster headache
Extremely severe, unilateral, periorbital headaches Short in duration May occur several times a day over a period of weeks to months. Typical patient: middle-aged male, often without a family history of headache or migraine.
Cluster headache
Treatment: 1st line: - Administration of 100% oxygen and/or - injection of subcutaneous sumatriptan Prophylactic therapy of choice - Verapamil. Preventive therapy with a short course of oral corticosteroids may be given for periods that are less than a few months.
Cluster headache
AKA Black Lung
Coal workers' pneumoconiosis
Occupation: - Coal mining Diagnosis: - CXR: nodular opacities at upper lung fields, hyperinflation Complications: - Progressive massive fibrosis
Coal workers' pneumoconiosis
what is the MOA of nitroimidazole abx?
DNA damage
Treatment: 1. Fluid 1L/hr NS or LR 2. Monitor glucose/hr for first 24 hours 3. IV regular insulin (goal glucose 150-200) 4. Potassium if < 5.2 5. Bicarb if pH <7.0
Diabetic Ketoacidosis
Clinical features: Lower > upper extremities Numbness Pain Dysesthesias (burning) Paresthesias or anesthesia Reduced deep tendon reflexes or impaired vibratory sensation At risk for chronic wounds and amputation, especially in those who also smoke cigarettes.
Diabetic peripheral neuropathy
Diagnostic studies: Serial nerve conduction studies can be completed to document the presence, severity, and course
Diabetic peripheral neuropathy
General considerations: MC neuropathy in the western hemisphere Present as mixed polyneuropathy (motor, sensory, and autonomic) Generally related to the duration and severity of hyperglycemia Result of vascular insufficiency or nerve infarction.
Diabetic peripheral neuropathy
Diagnostic studies: The diagnosis is usually established clinically. Vesicular fluid may be cultured (definitive) or stained (Tzanck smear, immunofluorescent staining) revealing multinucleated giant cells. Antibodies can be identified in the serum by PCR techniques.
Herpes Simplex Infection
5 F's of acute cholecystitis
Female, Fat, Forty, Fertile, Fair
Acute Interstitial Nephritis triad
Fever Rash Arthralgia
Hypertriglyceridemia (isolated) tx
Fibrates Niacin
Central pain disorder whose cause and pathogenesis are poorly understood. May occur spontaneously May occur with: - RA - SLE - Sjögren syndrome - hypothyroidism - sleep apnea in men.
Fibromyalgia
Clinical features: Nonarticular musculoskeletal aches Fatigue Sleep disturbance Multiple tender "trigger" points on examination Characterized by pain above and below the waist that is bilateral and axial for a duration of at least 3 months
Fibromyalgia
Diagnostic studies: Recognized by the typical pattern of pain and other symptoms as well as by exclusion of contributory or underlying diseases such as: - hypothyroidism - hepatitis C - vitamin D deficiency. There are no routine laboratory markers Often a diagnosis of exclusion. Abnormality of the T-cell subsets has been described. Pain in 11/18 "trigger points" 3 MONTHS
Fibromyalgia
Treatment: SSRIs SNRIs TCAs (Amitryptilline) NSAIDs are not effect Pregabalin or gabapentin can be effective in reducing pain and improving sleep. Aerobic exercise improves conditioning Cognitive-behavioral therapy Mindfulness training are often helpful
Fibromyalgia
Esophagitis treatment for candida cause
Fluconazole Ketoconazole
Obese patients Heroin use HIV+ black males. Primary, when no underlying cause is found Secondary, when an underlying cause is identified Familial forms Secondary to nephron loss and hyperfiltration, such as with chronic pyelonephritis and reflux, morbid obesity, diabetes mellitus
Focal segmental glomerulosclerosis (FSGS):
(consciousness impaired) Formerly called complex partial seizures Aura followed by impaired consciousness Automatisms (ie. Lip-smacking) Present with a postictal state (confusion and loss of memory) which differentiate them from absence seizures
Focal seizures with cognitive impairment
EEG reveals interictal spikes or spikes associated with slow waves in the temporal or frontotemporal areas
Focal seizures with cognitive impairment
(consciousness maintained) Formerly called simple partial seizures No alteration in consciousness. Abnormal movements or sensations Isolated activity of limb Transient altered sensory perception May spread to include the entire side of the body "Jacksonian march"
Focal seizures with retained awareness
MC cause poor dietary intake (alcoholics, anorexia, low fruit/veg intake) Other causes - defective absorption - pregnancy - chronic hemolytic anemias - alcohol abuse - Phenytoin, trimethoprim-sulfamethoxazole, sulfasalazine - malabsorption
Folate Deficiency
Normal Methylmalonic acid ↑ Homocysteine Sore tongue (glossitis) Macro-ovalocytes Hypersegmented polymorphonuclear cells Howell-Jolly bodies What macrocytic anemia?
Folate Deficiency
Treatment Oral replacement (1 mg/day) with folic acid is first-line treatment. Avoid alcohol and folic acid metabolism antagonists (e.g., trimethoprim, seizure medications).
Folate Deficiency
Clinical features: Progressive chorea and dementia Usually fatal within 15 to 20 years. Earliest mental changes often are behavioral, with irritability, moodiness, and antisocial behavior that generally progress to an obvious dementia. The earliest physical signs may be a mere restlessness or fidgetiness, but, eventually, severe choreiform movements and dystonic posturing occur.
Huntington Disease
Diagnostic studies: CT demonstrates cerebral atrophy as well as atrophy of the caudate nucleus.
Huntington Disease
General characteristics Inherited, autosomal dominant disorder Gene responsible is on the short arm of chromosome 4. Symptoms of the disease usually do not develop until after 30 years of age. Often by this time, those who are affected have already had children who may eventually be similarly affected.
Huntington Disease
Treatment No cure, and progression of the disease cannot be halted. Symptomatic treatment - Phenothiazines to control dyskinesia - Haloperidol or Clozapine to control any behavioral disturbances. Children of patients should receive genetic counseling. Genetic testing is very sensitive and specific and can make a definitive diagnosis even in the presymptomatic state.
Huntington Disease
Malignant hypertension tx
Hydralazine
Clinical features: Soft, nontender fullness of the hemiscrotum that transilluminates Mass may wax and wane in size An indirect hernia may be concurrently present.
Hydrocele
Hydrocele
Hydrocele
Mass of the fluid-filled congenital remnants of the tunica vaginalis Usually resulting from a patent processus vaginalis.
Hydrocele
Diagnosis: - Increased BUN/Cr - Electrolyte imbalance - IV urogram, US, CT, MRI Treatment: - Remove obstruction/drain urine - Nephrostomy tube: upper tract - Catheter: lower tract
Hydronephrosis
Water inside kidney causes distention/dilation of pelvis and calyces by obstruction of free flow of urine from kidney
Hydronephrosis
Clinical features: Most patients are asymptomatic until serum calcium > 12 mg/dL Anorexia Nausea Constipation Polyuria Polydipsia Dehydration Change in level of consciousness (lethargy, stupor, and coma). Signs of intravascular volume depletion (e.g., orthostatic hypotension and tachycardia)
Hypercalcemia
Diagnostic studies: Serum calcium is high after corrected for albumin levels. Chest radiography may reveal an underlying pulmonary mass. Perform urinalysis for hematuria, an early sign of RCC. A 24-hour urine collection - elevated urine calcium suggests malignant neoplastic or paraneoplastic process or hyperparathyroidism. - decreased urine calcium suggests primary hyperparathyroidism
Hypercalcemia
General characteristics: Significant elevation in serum calcium after adjustment for albumin level MC in hospitalized patients with malignancy Other causes include: - vitamin D intoxication - hyperparathyroidism - sarcoidosis
Hypercalcemia
Treatment: Isotonic saline (normal saline or Ringer's, lactate) should be used for volume repletion. Loop diuretics (Furosemide) should be used if the patient is hypervolemic after volume repletion. - NO HYDROCHLOROTHIAZIDE Bisphosphonates alone or in combination with calcitonin or zoledronic acid if severe
Hypercalcemia
Spirinolactone can cause what?
Hyperkalemia
Clinical Features: Asymptomatic Xanthomas Premature arcus senilis
Hyperlipidemia
Pharmacological Tx: Statins (SE: myalgia, GI) Niacin Bile acid sequestreants (cholestyramine) Fibric acid derivatives (Gemfibrozil, clofibrate)
Hyperlipidemia
Clinical features: Neurologic manifestations result from alterations in the brain water content - Brain cell shrinkage may be substantial and can cause damage to the supporting vasculature. Dry mouth and mucous membranes Lack of tears Decreased salivation Flushed skin Tachycardia Hypotension Oliguria and anuria Hyperreflexia
Hypernatremia
Diagnostic studies: Plasma sodium > 145 mEq/L Urine sodium - decreased if because of extrarenal losses - elevated if because of renal losses or sodium excess (DI) Hyperosmolar coma may be indicated by: - elevated serum glucose - decreased UO - increased urine osmolality
Hypernatremia
General characteristics: Serum sodium > 145 mEq/L Either too much salt or not enough water. Causes include: - deficit of thirst - hypotonic fluid loss - urinary loss - gastrointestinal (GI) loss - burns - diuretic therapy - osmotic diuresis (hyperglycemia, mannitol administration) - sodium excess - diabetes insipidus (DI)
Hypernatremia
Treatment: Treated on an inpatient basis. ID cause and treat accordingly. Free water may be administered: - orally, which is the preferred route - IV or subQ - 5% dextrose solution in water or saline.
Hypernatremia
Clinical features: Mild hypercalcemia is likely to be asymptomatic stones, bones, groans, psychic moans, and fatigue overtones - Renal loss of calcium and phosphate - Enhanced release of calcium from bones - Increased GI absorption and abdominal cramps - Irritability, psychosis, and depression
Hyperparathyroidism
Diagnostic studies: Primary - Serum calcium > 10.5 mg/dL - Phosphate < 2.5 mg/dL - PTH > 55 pg/mL Malignancy - elevated calcium - low PTH Parathyroid Cancer - extreme elevations of both calcium and PTH
Hyperparathyroidism
General characteristics: Primary - MCC = Benign parathyroid adenomas -Other: parathyroid hyperplasia, carcinoma Secondary - chronic kidney disease d/t hyperphosphatemia - hypocalcemia - vit D deficiency
Hyperparathyroidism
(16%) Often metastasizes to lung, bone, brain, and liver Increased iodine uptake What type of Thyroid cancer?
Follicular type
green sputum bacterial pneumonia
H. flu Pseudomonas
MCC of Bronchiectasis
H. flu, Pseudomonas (cystic fibrosis)
In patients with chronic lung disease what are some additional causes to bronchitis
H. influenzae S. pneumoniae M. catarrhalis
Clinical characteristics: Malaise Weight loss Abdominal swelling Weakness Jaundice Upper abdominal pain Hepatomegaly, splenomegaly Hepatic bruit Ascites Clinical manifestations typically occur late in disease.
Hepatic Cancer
Diagnostic studies: α-Fetoprotein may be elevated - also elevated in chronic hepatitis C and cirrhosis. Imaging with sonography, CT, MRI, or hepatic angiography can show the lesion.
Hepatic Cancer
Acute - fatigue - malaise - nausea, vomiting - anorexi - fever - right upper quadrant pain Transmission: Fecal-oral Serum IgM anti-HAV Vaccine: killed (inactivated) - given in two doses, recommended for travelers.
Hepatitis A
Acute and Chronic Transmission: Sexual or sanguineous Risk of hepatocellular carcinoma The vaccine is given to all infants (birth, 1-2 mo, 6-18 mo) Antivirals: *1st LINE; Tenofovir, Adefovir
Hepatitis B
Chronic Asymptomatic Transmission: IV drug use is the most common. Also sexual or sanguineous Screen with testing for anti-HCV antibodies Diagnosis with RNA quantitation Risk of cirrhosis and hepatocellular carcinoma Treatment: Interferon alpha 2-B AND Ribavirin
Hepatitis C
Only occurs when coinfected with Hepatitis B Risk of hepatocellular carcinoma
Hepatitis D
Pregnant woman, 3rd world countries Waterborne This + mother = high infant mortality Treatment: - Self-limited - Oral Ribavirin x3 months - Recombinant vaccines
Hepatitis E
Occurs in patients with very low WBC counts (pts with leukemia) With aggressive chemotherapy, the WBC count begins to rise, and the patient develops fever, right upper quadrant pain and tenderness, and nausea. An increase in alkaline phosphatase and multiple low-density defects in the liver, spleen, and kidneys develop Diagnosis is confirmed with biopsy. Treatment is amphotericin B; once the patient responds, he or she can be switched to fluconazole. What kind of candidiasis?
Hepatosplenic candidiasis
What hereditary disorder has a high risk of colon cancer
Hereditary nonpolyposis colorectal cancer (HNPCC or Lynch syndrome)
Clinical findings: Recurrence of lesions is heralded by burning or stinging Neuralgia may also occur, but constitutional symptoms are unlikely Lesions = begin as erythematous papules - rapidly develop into tiny, thin-walled, grouped vesicles, which continue to erupt over 1 to 2 weeks. Maximum shedding is during the first 24 hours of each outbreak The number of episodes tends to decrease with time
Herpes Simplex Infection
Complications: Pyoderma Eczema herpeticum Herpetic whitlow (grouped vesicles on the fingers; common in health care workers) Herpes gladiatorum (disseminated cutaneous infections; common in wrestlers) Keratoconjunctivitis (dendritic corneal ulcers; may cause blindness) Infants exposed to herpes in utero or during delivery - High rate of visceral and CNS infection - Mortality and sequelae rates are high. - Cesarean section is recommended for women with active infection.
Herpes Simplex Infection
Slowly enlarging thyroid gland progressing over year Asymptomatic unless impinging or causing a thoracic inlet obstruction. Multiple painless nodules are palpable Labs may show a euthyroid, hyperthyroid, or hypothyroid state. May be endemic in iodine deficient areas
Nontoxic goiter
Require: - intact parasympathetic and somatic nerve supply - unobstructed arterial inflow - adequate venous constriction - hormonal stimulation - psychological desire Disorders of any of these systems may result in impotence
Normal Erections
MCV 80-100 Caused by: - organ failure (kidney, endocrine, or liver) - impaired marrow function - acute blood loss - chronic systemic disease elevating hepcidin in response to inflammation Parvovirus B19, chemo, toxins, aplastic anemia, pure red cell aplasia
Normocytic anemias
Diarrhea on a cruise ship Watery diarrhea Tx: Hydration
Norovirus
Tenofovir (Viread) What Antiretroviral Medications?
Nucleotide reverse transcriptase inhibitors
use for variceal bleeding
Octreotide
Drop in blood pressure on position change causing decreased blood flow to the brain, adverse effect of multiple medications Systolic blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease of 10 mm Hg, or a pulse increase of 30 beats per minute
Orthostatic hypotension
what 2 drugs are used for influenza A and B prophylaxis and treatment?
Oseltamivir and Zanamavir
Painful, violaceous, raised lesions of the fingers, toes, or feet Associated with endocarditis
Osler Nodes
Treatment: Asymptomatic primary - keep active - avoid immobilization - drink adequate fluids Symptomatic - Parathyroidectomy - Hypocalcemia and transient hyperthyroidism may occur postoperatively. Secondary - Vit D, Ca+ supplementation
Hyperparathyroidism
General characteristics: Acquired causes - MC = following parathyroidectomy or thyroidectomy - autoimmune disease - heavy metal toxicity (e.g., Wilson disease, hemochromatosis) - thyroiditis - hypomagnesemia (chronic alcoholism). DiGeorge syndrome
Hypoparathyroidism
What hyperthyroidism med should be taken during the first trimester of pregnancy?
PTU (SE: fulminant hepatic necrosis)
Early wide "bizarre" QRS, no p wave seen
PVC
Early wide bizarre QRS, no p wave seen What premature beat?
PVC
AKA Osteitis Deformans
Paget Disease of the Bone
Inferior wall
II, III, AFV
Preexposure rabies vaccination of persons at high risk (veterinarians, animal handlers, missionaries to under developed countries, and travelers)
IM Human diploid cell vaccine (HDCV) (Days 0, 7, and either 21 or 28)
HA that are typically worse w/ awakening or lying down May awaken person at night New onset HA age >40 Fever, Night sweats Immunocompromised/ malignancy hx DX: MRI
Intracranial Tumor
Clinical Features: New or changing cough Hemoptysis Pain Anorexia Weight loss Asthenia (abnormal weakness/fatigue) Patients may also exhibit lymphadenopathy, hepatomegaly, and clubbing of the fingers. Paraneoplastic syndromes occur in 10% to 20% of patients - Cushing, SIADH, neuropathy, thrombophlebitis, anemia, etc
Lung Cancer
Diagnosis: CXR and CT scans Cytology of sputum Bronchoscopy
Lung Cancer
Leading cause of cancer deaths in men and women
Lung Cancer
Clinical findings: Starts with shaking chills (the cold stage) Followed by fever (the hot stage) Finally, diaphoresis (the sweating stage). Patients are fatigued between attacks. Release of tissue necrosis factors and cytokine There may be liver and spleen enlargement if symptoms continue for more than 4 days. Infection with P. falciparum can be much more severe
Malaria
MC location of gout
MTP of big toe (podagra)
Metabolic Acidosis anion gap mnemonic
MUDPILERS
For acute exacerbations of chronic bronchitis, in which bacterial causes are more likely, empiric second-line treatment is what?
Macrolide or TMP-SMX (Bactrim)
What valve is most often affected in rheumatic fever?
Mitral valve, followed by aortic valve
Symptoms daily Nighttime symptoms >1x/week FEV1 >60% FEV1/FVC reduced 5% Some limitation with daily activities What asthma classification?
Moderate Persistent
Nevirapine (Viramune) Delavirdine (Rescriptor) Efavirenz (Sustiva) Etravirine Rilpivirine (Edurant) What Antiretroviral Medications?
NNRTIs
Peptic Ulcer Disease quadruple therapy
PPI Bismuth (pepto) Tetracycline Flagyl
Zidovudine (AZT; Retrovir) Didanosine (ddI; Videx) Zalcitabine (ddC; Hivid) Stavudine (d4; Zerit) Lamivudine (3TC; Epivir) Emtricitabine (Emtriva) Abacavir (Ziagen What Antiretroviral Medications?
NRTIs
Hyponatremia
Na <135
Hypernatremia
Na >145
Clinical features: Diffuse or isolated, painless, persistent lymphadenopathy Bone marrow involvement is frequent. Common extralymphatic sites are the GI tract, skin, bone, and bone marrow. Burkitt = is likely to present with abdominal fullness.
Non-Hodgkin's Lymphoma
Diagnostic studies: Persistent, unexplained, enlarged nodes should be excised for histologic study. Staging is accomplished by: - chest radiography - CT of the abdomen and pelvis - bone marrow biopsy - possibly lumbar puncture.
Non-Hodgkin's Lymphoma
General characteristics: 90% of cases are derived from B lymphocytes. = higher with HIV and other immunodeficiencies 20 and 40 years of age. Divided into clinically indolent and aggressive groups. - Indolent = tend to convert to aggressive disease - Aggressive = 1/3 are curable with chemotherapy.
Non-Hodgkin's Lymphoma
Treatment: Indolent with one or two involved nodes - radiation alone. Intermediate- or high-grade - chemotherapy - immunotherapy - autologous stem cell transplantation
Non-Hodgkin's Lymphoma
Management: Surgery remains the treatment of choice if patient can tolerate the procedure and complete resection is possible Cure is unlikely without resection Adjuvant or neoadjuvant chemotherapy may be considered to improve survival
Non-Small Cell Lung Cancer
Squamous cell carcinoma Adenocarcinoma Large Cell carcinoma
Non-Small Cell Lung Cancer
Which is more common small cell or non small cell lung cancer?
Non-Small Cell Lung Cancer
Clinical Features: Fever and a new-onset heart murmur Fever, cough, dyspnea 90% pts will have a stable murmur Palatal, conjunctival, or sublingual petechiae Splinter hemorrhages Osler nodes Janeway lesions Roth spots Pallor and splenomegaly
Endocarditis
Diagnostic Studies: Three sets of blood cultures 1 hour apart Echo (TEE) to find valve Duke Criteria
Endocarditis
Inflammation of the lining or valves of the heart caused by the presence of bacteria in the bloodstream Typically introduced via dental or medical procedures in the mouth, intestinal tract or urinary tract
Endocarditis
Occurs through direct inoculation at surgery, in injection drug users, or in late-stage HIV disease 50% of cases involve nonalbicans Candida spp. Resistant to treatment. Organisms cause large vegetations. Splenomegaly, petechiae, murmur, and large vessel embolization are common. Treatment is amphotericin B Infected valves must be surgically replaced Once the patient has recovered, will typically receive lifelong fluconazole. What kind of candidiasis?
Endocarditis
Enter mucosal epithelium of the intestines Invade and replicate within macrophages in Peyer patches, mesenteric lymph nodes, and the spleen; bacteremia accompanies infection. Prodrome of malaise, headache, cough, and sore throat. Abdominal pain, distention, and constipation and/or diarrhea ("pea soup") develop as the fever increases. Patient appears toxic and then generally improves over the next 7 to 10 days. The organism can be isolated from the blood during the first week of the illness; later, the blood cultures will likely be negative. Stool culture is not reliable. Treatment: Resistance to ampicillin, chloramphenicol, and TMP-SMX is increasing. What kind of Salmonellosis?
Enteric fever (typhoid fever)
Enfu virtide (Fuzeon) Maraviroc (Selzentry What Antiretroviral Medications?
Entry inhibitors
Clinical features: Heaviness and dull, aching discomfort in the affected hemiscrotum Radiates up the ipsilateral flank. Epididymis is markedly swollen and exquisitely tender to touch Eventually becoming a warm, erythematous, enlarged scrotal mass. As the disease progresses, it may become difficult to distinguish the testes from the epididymis. Phren sign + Urinalysis reveals pyuria and bacteriuria. Cultures show positive results for suspected organisms.
Epididymitis
Infection of the epididymis acquired by retrograde spread of organisms through the vas deferens. < 35 years of age Chlamydia and gonococci are the most common organisms > 35 years of age, E. coli is the most common organism. History of the patient may reveal heavy lifting, trauma, or sexual activity.
Epididymitis
Treatment: < 35 years of age (Chlamydia or Gonorrhea) - IM Ceftriaxone + Doxycycline or - Azithromycin - test for cure should be done 1 week after conclusion of therapy. < 35 years of age - Ciprofloxacin - Supportive care may include bed rest, scrotal elevation, and analgesics.
Epididymitis
CT of brain: - convex (lens) bleed - does NOT cross suture lines Treatment: - high ICP: Mannitol
Epidural Hematoma
Middle meningeal artery MCC: temporal FX Signs: - LOC, HA, N/V, focal sx - CN III palsy - LUCID INTERVAL --> coma
Epidural Hematoma
Pheochromocytoma Triad
Episodic Palpitation Headache Diaphoresis (+ HTN = highly suggestive)
Clinical findings Fever Sore throat Exudative pharyngitis Tonsillitis/gingivitis Soft palate petechiae Posterior cervical nodes lymphadenopathy Splenomegaly is present in 50% of cases. Maculopapular rash may develop if pt given Amoxicillin MC complication = Secondary bacterial pharyngitis Other = splenic rupture
Epstein-Barr Virus
Diagnostic studies: Heterophile antibodies are positive within 4 weeks False-positive syphilis test (VDRL or RPR) in some infected patients. Early granulocytopenia Later lymphocytic leukocytosis Lymphocytes appear as larger cells that stain darker and are vacuolated.
Epstein-Barr Virus
General characteristics: HHV 4 Transmitted via saliva. Characteristic disease = mononucleosis (the "kissing disease" Associated with: - Burkitt lymphoma - nasopharyngeal carcinoma - pediatric leiomyomas - collagen vascular diseases
Epstein-Barr Virus
Treatment: Treatment is symptomatic, with nonaspirin antipyretics and anti-inflammatories Patients with splenomegaly should avoid contact sports. Prognosis is good. Although full recovery may take months, 95% recover without specific treatment.
Epstein-Barr Virus
Clinical features: The medical history must be adequately evaluated. - β-blockers/SSRI may be the cause Physical examination should look for penile deformities - , Peyronie disease [fibrous plaque causing penile curvature] - testicular atrophy - hypertension - peripheral neuropathy
Erectile Dysfunction
Diagnostic studies" CBC Urinalysis Thyroid function tests Serum testosterone Prolactin FSH/LH Direct injection of vasoactive substances into the penis induces erections in men with intact vascular systems - Patients who do not achieve erections with injections may undergo studies to evaluate the arterial and venous vasculature - such as ultrasonography of the cavernous arteries, pelvic arteriography, and cavernosonography.
Erectile Dysfunction
General characteristics: Consistent inability to maintain an erect penis with sufficient rigidity to allow sexual intercourse Most cases have a primary organic rather than a psychogenic cause. Nearly all cases have a secondary psychogenic component.
Erectile Dysfunction
Treatment: PDE-5 inhibitor therapy is considered the mainstay of treatment - Sildenafil - Vardenafil - Tadalafil If PDE-5 ineffective - vacuum constriction devices - injected or inserted vasoactive substances - penile prostheses Patients with disorders of the arterial system are candidates for arterial reconstruction. True psychogenic - behaviorally oriented sex therapy Hypogonadism - testosterone replacement therapy Weight loss for BMI > 30 kg/m2
Erectile Dysfunction
Clinical features: The main clinical feature is progressive dysphagia for solid food associated with marked weight loss Solid food dysphagia then fluids Odynophagia Tracheo-esophageal fistula --> cough, PNA Chest or back pain (mediastinal estension)
Esophageal Cancer
Diagnostic studies Biphasic barium esophagram is the best initial test to visualize the lesion Endoscopy with brushings for diagnosis Endoscopic sonography and CT for staging.
Esophageal Cancer
Screening colonoscopy when
Every 10 years starting at 50
How often can you give sublingual nitroglycerin?
Every 5 minutes up to 3 times
Screening flexible sigmoidoscopy when (in lieu of colonoscopy)
Every 5 years starting at age 50
Signs/Symptoms Colitis present for at least 1wk prior to onset Severe bloody diarrhea Distention Malaise PE: FAT BAT •Fever, altered mental status, Toxic, BP low, abdominal pain, tachycardia
Toxic Megacolon
Total/segmental non-obstructive colonic dilatation (>6cm) + toxicity Complication of IBD, radiation, ischemia
Toxic Megacolon
Treatment: Complete bowel rest & NG tube DC all antimotility agents (opiates, anticholinergics) Prophylaxis PPI & DVT IV steroids & surgical consult Flagyl + Amp/Gent or Ceftriaxone
Toxic Megacolon
General Characteristics: T. gondii Fecal oral, cat feces - primary (good immune): asymptomatic or mono-like - primary (bad): necrotizing lesion, encephalopathy - congenital: retardation, hearing loss, chorioretinitis "The toxic cat spiraled out of control with the sulfa pyramid due to necrotizing brain lesion. This caused her retina to swell & the marines/guards were called in." Dx: PCR, IgG/IgM Tx: - pregnancy=Spiramycin - immunocompromised: Pyrimethamine & Sulfa
Toxolasmosis
rapid destruction/breakdown of vasopressin What kind of diabetes insipidus?
Transient DI of Pregnancy and Puerperium
Clinical features: Carotid circulation - contralateral hand-arm weakness with sensory loss - Ipsilateral visual symptoms or aphasia - Amaurosis fugax - Carotid bruit may be present, but with a high-grade stenosis (95% or greater) Vertebrobasilar circulation - diplopia - ataxia - vertigo - dysarthria - cranial nerve palsies - lower extremity weakness - dimness or blurring of vision - perioral numbness - drop attacks
Transient Ischemic Attacks
Vertigo without position changes No hearing loss or tinnitus (inflammation of the vestibular portion of CN VIII) Like labyrinthitis, it is often associated with a viral illness
Vestibular neuronitis
Diarrhea from shellfish Profuse watery diarrhea Tx: Hydration
Vibrio cholerae
CSF Analysis: Clear color Normal pressure Normal to mildly elevated WBC count, lymphocytes or monocytes Normal protein Normal glucose
Viral (Aseptic) Meningitis
Clinical features: Acute confusional state, especially in children and young adults. Symptoms may have persisted for several days Number of systemic manifestations, suggesting a particular causal agent (e.g., rash, pharyngitis, adenopathy, pleuritis, carditis, jaundice, organomegaly, diarrhea)
Viral (Aseptic) Meningitis
MC cause - enteroviruses (coxsackievirus A or B, echoviruses) - HSV 2 - arthropod-borne viruses May also reflect an inflammatory process in the parameningeal area (i.e., sinusitis, otitis, abscess). Encephalitis frequently associated with childhood exanthems, arthropod-borne agents, and herpes simplex virus type 1.
Viral (Aseptic) Meningitis
Treatment: With the exception of infection with herpes simplex virus, the course is generally benign and self-limited, and no specific therapy is required Acyclovir for herpes virus Acetaminophen for headache Anticonvulsants for seizures Support breathing if necessary
Viral (Aseptic) Meningitis
- HBeAg - highly infectious - HBsAg - ongoing infection - Anti-HBc - had/have infection - IgM - acute - IgG - not acute - Anti-HBs - immune
Viral Hepatitis
Clinical features Pruritis Pale stool Tea-colored urine Vague abdominal discomfort Fatigue Malaise Anorexia Nausea
Viral Hepatitis
Diagnosis: ALT and AST elevations are seen in all types, indicating hepatocellular damage. Bilirubin of greater than 3.0 mg/dL will be associated with scleral icterus, if not frank jaundice US and MRI of the liver
Viral Hepatitis
Acute Bronchitis is caused by what >90% of the time
Viruses (rhinovirus, coronavirus, RSV)
MC cause = pernicious anemia because of a lack of intrinsic factor Other causes - strict vegan diet - gastric surgery - blind loop syndrome - pancreatic insufficiency - metformin use - Crohn disease. Irreversible neurologic damage can be caused by uncorrected deficiency. Absorption occurs in the terminal ileum and storage is in the liver.
Vitamin B12 Deficiency
Treatment: Lifelong supplemental vitamin B12 given IM for pernicious anemia. Daily oral cobalamin may be effective, especially after an adequate parenteral loading. Strict vegans; patients with gastric bypass, gastrectomy, or resection of the ileum; and those with blind loop syndrome require vitamin B12 supplementation Neurologic signs and symptoms are reversible if treated within 6 months.
Vitamin B12 Deficiency
↑ Methylmalonic acid ↑ Homocysteine Hypersegmented neutrophils Poikilocytosis Stocking glove paresthesia Loss of position, fine touch, and vibratory sensation Balance problems and ataxia Dementia What macrocytic anemia?
Vitamin B12 Deficiency
Macrocytic Anemias
Vitamin B12 Deficiency Folate Deficiency
Complications: - intestinal ischemia - gangrene X-ray: - U-shaped, distended segment of colon seen as an ahaustral collection of gas. GI series & CT: "birds beak"
Volvulus
Elevated _____________ are also a risk factor for atherosclerosis; severe elevations can cause pancreatitis
Triglycerides
Most sensitive cardiac biomarkers in MI
Troponin
carpal tunnel spasm after BP cuff applied for 3 minutes associated with hypocalcemia
Trousseau sign
Clinical Features: Fever Night sweats Weight loss Cough (non productive or productive) Hemoptysis. Ghon complex
Tuberculosis
Diagnostic Studies: CXR: - In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the upper lungs with or without mediastinal or hilar lymphadenopathy Definitive - Diagnose TB with sputum for AFB smears and cultures
Tuberculosis
Torsion bowel --> bowel obstruction MC in elderly Sigmoid (MC!) 80% Infants: bilious vomiting Adults: distention, abdominal pain, N/V Fever, tachycardia
Volvulus
Treatment: Endoscopic decompression IV Fluids
Volvulus
Autosomal dominant, congenital bleeding disorder MC congenital coagulopathy Six major types - characterized by deficient or defective vWF - Type I accounts for 75% to 80% of cases.
Von Willebrand Disease
Clinical features: Bleeding occurs in nasal, sinus, vaginal, and GI mucous membrane Spontaneous hemarthrosis and soft-tissue bleeds are less common than in hemophilia A. Common cause of menorrhagia. Bleeding is exacerbated by aspirin or NSAIDs Bleeding decreases with use of estrogen or pregnancy.
Von Willebrand Disease
Lab findings Pt normal Increased PTT Abnormal PFA (platelet function analysis) Normal platelet count
Von Willebrand Disease
Treatment Type 1 - Desmopressin acetate (DDAVP nasal spray) for bleeding prevention prior to procedures Factor VIII concentrates are preferred if factor replacement is necessary.
Von Willebrand Disease
General characteristics: Gastrin-secreting tumor (gastrinoma) causes hypergastrinemia, which results in refractory PUD. About one-third of gastrinomas are part of a syndrome known as multiple endocrine neoplasia type I (MEN1), an autosomal dominant condition.
Zollinger-Ellison syndrome (ZES)
Treatment: Active: -4 drugs x two months Rifampin (RIF) Isoniazid (INH) Pyrazinamide (PZA) Ethambutol (EMB) Then 2 drugs x 4 months Isoniazid (INH) Rifampin (RIF) Latent - INH for 9 months OR Rifampin for 4 months
Tuberculosis
Posterior wall
V1-3
Treatment: Use of PPIs controls gastrin secretion. Surgical resection of the gastrinoma should be attempted when possible.
Zollinger-Ellison syndrome (ZES)
which antibiotic causes Red Man Syndrome?
Vancomycin (Van the Red Man)
Initial therapy for patients with suspected infective endocarditis
Vancomycin with Ceftriaxone Prosthetic valve: add Rifampin
Occurs in 75% of females at least once during their lifetime Risk factors: - age extremes - pregnancy - uncontrolled diabetes mellitus - corticosteroids - HIV disease. Symptoms: - pruritus - burning - dyspareunia - white, cottage cheese or curd-like discharge - white plaques on vaginal walls. Treatment is with topical azoles or oral fluconazole. What kind of candidiasis?
Vulvovaginal disease
Name some anticoagulants
Warfarin Heparin Xa inhibitors Dabigatran
Atopic Triad
Wheeze Eczema Seasonal rhinitis
Clinical features: "Kissing" ulcers (each side of luminal wall touching each other) Abdominal pain may be accompanied by a secretory diarrhea that improves with H2 blockers (ranitidine, cimetidine) or PPIs (omeprazole, lansoprazole) Occult or frank bleeding, causing anemia, may be present.
Zollinger-Ellison syndrome (ZES)
Diagnostic studies: Fasting gastrin level > 150 A secretin test is needed to confirm - Patients are given secretin 2 U/kg IV. - In these patients, the gastrin levels will increase by more than 200 pg/mL
Zollinger-Ellison syndrome (ZES)
what are the anti-herpetic antivirals?
acyclovir, valacyclovir, famciclovir
Abnormal bone remodeling and disorganized osteoid formation Increased osteoclast bone resorption --> Abnormal trabecular formation --> Large, weak, less compact bones with more vasculature and prone to fracture MC in western Europeans
Paget Disease of the Bone
Clinical Features: MC asymptomatic-incidental finding Bone pain (MC symptoms) Soft bones --> bowed tibia, kyphosis Deafness
Paget Disease of the Bone
Labs: - HIGH alk phos - Normal Ca & Ph X-ray: - "blade of grass/ flame" lucency Skull: cotton wool
Paget Disease of the Bone
Treatment: Asymptomatic: none Symptomatic: - Calcitonin & Bisphosphonates (Aldendronate, Risedronate)
Paget Disease of the Bone
The 6 P's caused by acute arterial embolism
Pain Pulseless Pallor Paresthesia Poikilothermia Paralysis
Tumor of the lung apex Causes Horner syndrome and shoulder pain Affects brachial plexus and cervical sympathetic nerve
Pancoast tumor
The classic triad for chronic pancreatitis
Pancreatic calcification Steatorrhea Diabetes Mellitus
Side effect of uncontrolled hypertriglyceridemia
Pancreatitis
Most common (76%) Single thyroid nodule Least aggressive Spreads by local extension Caused by genetic mutation or translocation. What type of Thyroid cancer?
Papillary type
Pneumonia MC in children <2 year
Parainfluenza virus
2nd MC neurodegenerative disease MC between 45 and 65 years of age. Characterized by degeneration of cells in the substantia nigra, causing a deficiency of the neurotransmitter dopamine and an imbalance of dopamine and acetylcholine. Patients generally complain of: - problems related to their slowed movements - difficulty arising from a seated position - difficulty ascending and descending stairs - trouble with getting dressed - difficulty with handwriting (micrographia).
Parkinson's Disease
General characteristics: Caused by a fungus found in the lungs of humans and many animals. Premature or debilitated infants in underdeveloped areas Sporadic cases are found in patients with abnormal cellular immunity MC opportunistic infection in HIV disease.
Pneumocystis jiroveci pneumonia
What vaccinations do COPD patients need to receive?
Pneumococcal Influenza yearly
Clinical features: In simple cases these are usually asymptomatic. In complicated cases - dyspnea - inspiratory crackles - clubbing of the fingers - cyanosis
Pneumoconiosis
General characteristics: Chronic fibrotic lung diseases Caused by the inhalation of coal dust or various inert, inorganic, or silicate dusts. Types: - coal workers' pneumoconiosis, - silicosis - berylliosis - asbestosis
Pneumoconiosis
Treatment: First line: Serial phlebotomy Myelosuppressive therapy with hydroxyurea may be indicated Low-dose aspirin reduces the risk of thrombosis.
Polycythemia Vera
Clinical features: Pain and stiffness of proximal joints (neck, shoulder, pelvis) is the predominant feature, being most severe after rest and in the morning Resolves with movement Musculoskeletal symptoms are usually bilateral, proximal, and symmetrical. Giant cell (temporal) arteritis must be ruled out.
Polymyalgia Rheumatica
Diagnostic studies: ESR is markedly elevated (>50 mm/hr) Temporal arteritis is confirmed by biopsy (minimum length 2.5 cm).
Polymyalgia Rheumatica
General characteristics: Pain and stiffness in the neck, shoulder, and pelvic girdles and is accompanied by constitutional symptoms (e.g., fever, fatigue, weight loss, depression) MC in women > 50 y.o. Cause is unknown (idiopathic) Associated with giant cell (temporal) arteritis
Polymyalgia Rheumatica
Treatment: Patients respond quickly to low-dose corticosteroid therapy - May be required for up to 2 years and slowly tapered. - Higher doses are required if giant cell arteritis is present DMARDS Calcium 1200 mg, Vitamin D 800 mg Treatment should not be delayed while awaiting biopsy.
Polymyalgia Rheumatica
Clinical features: Insidious, painless, proximal muscle weakness Dysphagia Skin rash (malar or heliotrope rash around the eyes) Polyarthralgias Muscle atrophy.
Polymyositis
Diagnostic studies: Elevated muscle enzymes - creatine phosphokinase (CPK) - aldolase (+) Anti-Jo 1 and Anti-Mi (+) Anti-SRP; Anti-155/140 Muscle biopsy should be performed and will show myopathic inflammatory changes.
Polymyositis
General characteristics: Inflammatory disease of striated muscle MC in women Affects the: - proximal limbs - neck - pharynx - skin Cause is unknown, but there is a strong association with an occult malignancy.
Polymyositis
Treatment: High-dose steroids Methotrexate Azathioprine Xerostoma = Pilocarpine Used until symptoms resolve.
Polymyositis
Dizziness/vertigo Gait abnormality/ataxia Nausea and vomiting Visual loss, hemianopia Headache, confusion, impaired consciousness Dysarthria, dysphagia Drop attacks Anterior or posterior circulation stroke?
Posterior Circulation Stroke
Vertebral artery Basilar artery Supplies the: - brain stem - cerebellum - thalamus - portions of the temporal and occipital lobes Anterior or posterior circulation stroke?
Posterior Circulation Stroke
Management: Primarily supportive No effective treatment is available Supportive therapy: - oxygen - vaccinations (pneumococcal, influenza vaccine) - rehabilitation Corticosteroids may relieve the chronic alveolitis in silicosis.
Pneumoconiosis
Slower onset, immunosuppression Increased lactate dehydrogenase More hypoxemic than appears on chest radiography Interstitial infiltrates MC in HIV with CD4 <200 What kind of pneumonia?
Pneumocystis jiroveci
Clinical findings: Fever Shortness of breath Nonproductive cough Less commonly, may present with spontaneous pneumothorax Recurrent pneumothorax is often related to previous pentamidine use. Physical exam findings are disproportionate to imaging result - show diffuse interstitial infiltrates that may be heterogeneous, miliary, or patchy
Pneumocystis jiroveci pneumonia
Diagnostic studies Blood gas - hypoxia - hypocapnia - reduced carbon dioxide diffusion LDH typically is increased WBC count is usually low. The organism can be demonstrated with specific stains of induced sputum or via bronchoalveolar lavage.
Pneumocystis jiroveci pneumonia
Group A strep - 10-14 days after infection - diagnosed with ASO titers and low serum complement Treatment is supportive + antibiotics
Postinfectious
Causes: Tubular obstruction Obstructive uropathy (urolithiasis, BPH, bladder outlet obstruction) What type of AKI?
Postrenal AKI
Urine sodium, FENa, osmolality, and BUN-to-Cr ratio vary based on timeframe of obstruction Urinalysis normal What type of AKI?
Postrenal AKI
What is the name give to vertebral osteomyelitis associated with Mycobacterium tuberculosis bacteria
Pott's disease
ACE contraindicated in what?
Pregnancy (cough, angioedema, hyperkalemia)
Causes: Hypovolemia Hypotension Ineffective circulating volume (HF, cirrhosis, nephrotic syndrome, early sepsis) Aortic aneurysm Renal artery stenosis or embolic disease What type of AKI?
Prerenal AKI
Urine sodium < 20 mEq/L FENa < 1% Urine osmolality > 500 mOsm/kg Elevated BUN:Cr ratio (20:1) Urine specific gravity > 1.02 Urinalysis normal What type of AKI?
Prerenal AKI
problem with the adrenal gland The most common cause is autoimmune destruction and adrenal metastases Worldwide - TB, secondary infections
Primary adrenal insufficiency (Addison's disease)
↓ cortisol ↓ aldosterone ↑ plasma renin activity ↑ ACTH No increase in cortisol level after the ACTH stimulation test
Primary adrenal insufficiency (Addison's disease)
General characteristics: Present when the pulmonary arterial pressure rises to a level inappropriate for a given cardiac output Once present, it is self-perpetuating. Primary (idiopathic) - rare and has a fatal outcome.
Pulmonary Hypertension
Pulmonary Hypertension WHO Group 1
Pulmonary arterial hypertension Muscle hypertrophy & endothelial dysfunction
what 2 drug interactions should you be careful of with flouroquinolones?
QTc prolongers and multivalent cation drugs (decreased absorption)
Causes: Acute tubular necrosis Nephrotoxins (NSAIDs, aminoglycosides, radiologic contrast) Interstitial diseases (acute interstitial nephritis, SLE, infection) Glomerulonephritis Vascular diseases (polyarteritis nodosa, vasculitis) What type of AKI?
Renal (Intrinsic) AKI
Pneumonia MC in children <1 year
Respiratory syncytial virus
- most noticeable at rest - may be only very slight with voluntary effort It is characterized as a "pill-rolling" tremor. - usually does not affect the head What diagnostic feature of Parkinson's?
Resting tremor
Four diagnostic features of Parkinson's disease
Resting tremor Bradykinesia Rigidity Unstable posture
Causes: Results from fibrosis or infiltration of the ventricular wall because of collagen-defect disease Amyloidosis Post-radiation Post-open heart Diabetes Endomyocardial fibrosis
Restrictive Cardiomyopathy
Echo: Small or normal left ventricular size Normal or mildly reduced left ventricular function
Restrictive Cardiomyopathy
Signs/Symptoms: Dyspnea, fatigue Right-sided heart failure > left-sided Elevated JVP Kussmaul sign Echo: - ST-T changes - Conduction abnormalities - Low voltage
Restrictive Cardiomyopathy
Treatment: Diuretics
Restrictive Cardiomyopathy
found on passive range of motion testing; cogwheel rigidity What diagnostic feature of Parkinson's?
Rigidity
TIMI and GRACE score
Risk Stratisfication for MI
Combo of calcium, ammonium, magnesium 10%-15% of kidney stones Radiopaque Formation increased by UTIs with urease-producing bacteria Common in patients with abnormal urinary tract anatomy and urinary diversions Common in patients who require frequent catheterization
Struvite Stones
Defined as hypotonic hyponatremia Urine osmolality of greater than 100 mOsm/kg Absence of extracellular fluid volume deficit Urine sodium is usually greater than 40 mEq/L. what kind of hyponatremia?
SIADH
Brady-tachy: Arrhythmia in which bradycardia alternates with tachycardia Sinus arrest: prolonged absence of sinus node activity (absent P waves) > 3 seconds
Sick Sinus Syndrome
Secretes GH --> acromegaly What Pituitary Adenoma?
Somatotropinoma
Nocturnal hypoglycemia followed by rebound hyperglycemia due to a surge in growth hormone Treatment: - decreased nighttime NPH dose or give bedtime snack
Somogyi effect
Primary: no lung disease - rupture of subpleural apical bleb - tall, thin males 10-40yo Secondary: underlying lung dx
Spontaneous Pneumothorax
25-35% of NSCLC Bronchial in origin Centrally located mass More likely to present with hemoptysis Diagnosed with sputum cytology
Squamous NSCLC
MC type of esophageal cancer worldwide
Squamous cell carcinomas Upper 1/3 esophagus Risk: smoking, alcohol
What does von willebrand factor do?
Stabilizes factor 8, low levels can cause psuedohemophilia A
Exacerbated by physical activity Relieved by rest <30 minutes Responsive to sublingual nitroglycerin What kind of angina?
Stable Angina
GFR >90 mL/min/1.73 m2 BSA Persistent albuminuria Generally asymptomatic No increase in BUN or creatinine Acid-base maintenance is adaptive through an increase in remaining nephron function What stage CKD?
Stage 1 CKD
Indolent infection of abnormal valves with less virulent organisms (S. viridans)
Subacute bacterial endocarditis
Thyrotoxicosis --> period of hypothyroidism --> resumption of euthyroid within 12 months ESR is markedly elevated Antithyroid antibody titers are low. Treatment of choice is aspirin
Subacute painful Thyroiditis
de Quervain's, granulomatous, or giant cell MCC of a painful thyroid gland MC young/middle aged women It is believed to be the result of a preceding viral illness The thyroid gland is often tender. Fever, fatigue, dysphagia, and otalgia may be present and may persist for months.
Subacute painful Thyroiditis
Berry arterial aneurysm MCC: rupture, AV Malformation Symptoms: - "thunderclap" sudden HA - meningeal symptoms, no focal neuro
Subarachnoid Hemorrhage
CT of brain LP: CT (-) --> xanthrochromia, high CSF Supportive tx: bed rest, stool soft Lower BP: Nicardipine, Nimodipine, Labetalol
Subarachnoid Hemorrhage
CT of brain: - concave (cresecent) - DOES cross suture lines Evacuate with massive 5mm + midline shift
Subdural Hematoma
Cortical bridging veins MC in elderly MCC: blunt trauma Symptoms: varies, may have focal neuro sx
Subdural Hematoma
Glyburide Glipzide Glimeperide
Sulfonylureas
What diabetic meds can cause hypoglycemia?
Sulfonylureas Meglitinides
The only therapy that may alter the course of COPD in patients with resting hypoxemia (PaO2 < 55 mm Hg or SaO2 < 88%)
Supplemental Oxygen
Diagnosed when seizures fail to cease spontaneously or recur so frequently that full consciousness is not restored between successive episodes. The length of time seizure activity must persist to diagnose is generally more than 5 minutes. Benzodiazepines (lorazepam) are the preferred initial treatment after which typically phenytoin is given
Status Epilepticus
Single rigor Rust-colored sputum Right lower lung What kind of pneumonia?
Streptococcus pneumoniae
Most cases of native valve infective endocarditis (IE) are caused by what?
Streptococcus viridans Staphylococcus aureus Enterococci
Age ≥65 ≥3 CAD risk factors (Hypertension, hypercholesterolemia, diabetes, family history of CAD, or current smoker) Known CAD (stenosis ≥50%) ASA use in past 7 days Severe angina (≥2 episodes in 24 hrs) EKG ST changes ≥0.5mm Positive cardiac marker All one point 0-2 points low risk 5-7 points high risk
TIMI Score
Gastroenteritis tx Illness is self-limited, and treatment is symptomatic. Specific treatment with _________________ required for severely ill or malnourished patients with, sickle cell disease, or patients who develop bacteremia.
TMP-SMX or Ampicillin or Ciprofloxacin
Treatment of choice in Pneumocystis jiroveci Prophylaxis recommended in all HIV patients with CD4 < 200
TMP/SMX (bactrim)
Signs/Symptoms: HYPERMETABOLIC Nausea/vomiting/diarrhea Tremors, psychosis (AMS) Lid lag High fever Palpitations, tachycardia Liver failure Insulin resistance Increased free T3 & T4 Decreased TSH
Thyroid Storm
Treatment: 1. Propranolol 2. PTU 3. Iodine 4. Glucocorticoids Definitive: radioactive iodine surgery
Thyroid Storm
General characteristics: MC in women Poorer prognosis in men Most remain microscopic and indolent.
Thyroid cancer
Management: Ultrasonography is routinely performed RAIU to assess risk of malignancy and help plan the surgical approach PET scanning for detecting thyroid cancer metastases with limited iodine uptake Surgical resection is indicated and RAI ablation may be useful for residual disease. Patients require T4 replacement for life.
Thyroid cancer
Painless neck swelling and a palpable, single firm nodule is the most common presentation.
Thyroid cancer
Risk factors: Childhood irradiation to head and neck confers a 25-fold increased - may emerge 10 to 40 years postexposure Other risks include: - family history - Gardner syndrome - MEN type II syndrome
Thyroid cancer
The clinical syndrome caused by excess circulating thyroid hormone (T4 or T3). F>M 20-40 y.o.
Thyrotoxicosis
Dementia triad
memory impairment visuospatial problems language impairment
what are the major ADRs of metronidazole?
metallic taste at high doses, disulfiram-like reactions, fetotoxic in first trimester (cat B after that)
What is the treatment for bacterial vaginosis?
metronidazole
what is a good abx for anaerobic infections below the diaphragm?
metronidazole
what is the nitroimidazole abx?
metronidazole
what is the treatment for giardiasis?
metronidazole
what is the treatment for mild C. Diff infections?
metronidazole
what is the treatment for mild c. diff?
metronidazole
what is the treatment for trichomoniasis?
metronidazole
which antibiotic is known for causing a disulfuram-like reaction?
metronidazole (drinking a beer on the metro (subway))
what 2 drugs are considered the gold standard anti-aerobic abx?
metronidazole or augmentin
what is a topical anti-fungal commonly used to treat vaginal candida infections?
miconazole (monistat)
chronic gi bleed has what type of anemia
microcytic
which antibiotic can cause transient (not permanent) vestibular dysfunction (SNHL)?
minocycline
Heard at apex
mitral regurgitation
Holo/pansystolic blowing murmur
mitral regurgitation
Radiates to left axilla
mitral regurgitation
Has an opening snap
mitral stenosis
Heard best with bell in LLR position at apex
mitral stenosis
can be holo/pansystolic or crescendo
mitral stenosis
low pitch mid diastolic rumbling
mitral stenosis
seen in rheumatic fever
mitral stenosis
heard at apex and can turn into mitral regurgitation
mitral valve prolapse
late systolic murmur with mid systolic click
mitral valve prolapse
what are the anti-staph penicillins?
nafcillin (IV) and dicloxacillin (PO)Naf rhymes with staph. He had a staph infxn on his DICk
what is the gold standard IV anti-MSSA abx?
nafcillin (naf rhymes with staph)
acute GI bleed has what type of anemia
normocytic
when would you use clindamycin for strep throat or a skin/soft tissue infection?
serious PCN allergy
HBsAg
ongoing infection
terbinafine is typically used to treat what?
onychomycosis and cutaneous dermatophyte infections
rapid change from lying to sitting or sitting to standing SBP drop >20 or SBP <90 or pulse increase >30bpm What cause of syncope?
orthostatic
what are the major ADRs of aminoglycosides?
ototoxicity and nephrotoxicity
Most gastrinomas are found in the ________________, but they may be found anywhere or may metastasize
pancreas or duodenum
Patients with ___________ impotence have normal nocturnal erections of adequate frequency and rigidity.
psychogenic
usually congenital sounds like aortic stenosis
pulmonic stenosis
which class of abx can cause acute tubular necrosis (ATN)?
aminoglycosides (esp. gentamicin)
which class of abx is known for causing permanent SNHL?
aminoglycosides (esp. gentamicin)
which abx would you use for endocarditis prophylaxis prior to a dental procedure?
amoxicillin
which abx would you use to treat Lyme Disease in a child under 8 y/o?
amoxicillin
if you treated a sinus infection or otitis media with amoxicillin and the patient did not get better, which abx would you use next?
amoxicillin/clavulanate (augmentin)
which abx would you use as prophylaxis or to treat an animal or human bite?
amoxicillin/clavulanate (augmentin)
which antifungal is used for deep fungal infections (Cryptococcus, blastomycosis, etc)?
amphotericin B
which antimicrobial is the most nephrotoxic?
amphotericin B
which abx is associated with a diffuse, maculopapular, nonurticarial rash when given to someone with EBV?
ampicillin
Blowing murmur
aortic regurgitation
Early diastolic murmur
aortic regurgitation
Radiates to LSB/apex and leaning forward
aortic regurgitation
heard at pulmonic valve
aortic regurgitation
Better heard if leaning forward and aortic valve
aortic stenosis
Crescendo decrescendo systolic ejection murmur
aortic stenosis
Radiates to carotids
aortic stenosis
low CO due to stenosis What cause of syncope?
aortic stenosis
Peripheral Vascular Disease is most commonly the result of ______________ and is a significant independent risk factor for cardiovascular and cerebrovascular morbidity and mortalit
atherosclerosis
Irregularly irregular rhythm with disorganized and irregular atrial activations and an absence of P waves
atrial fibrillation
There are four pea-sized parathyroid glands on the posterior aspect of the thyroid gland. These glands secrete parathyroid hormone (PTH) and cause serum __________ levels to rise.
calcium
Class 4 Congestive Heart Failure
can't carry on physical activity; anginal syndrome at rest
Overly rapid correction of hyponatremia can cause what?
central pontine myelinolysis
what is the silver standard (2nd line) oral anti-MSSA drug?
cephalexin (Keflex)
if someone gets a rash from penicillin, you wouldn't give them a penicillin, but you could potentially give what class?
cephalosporin
if someone has an anaphylactic reaction to PCN, you wouldn't give a PCN or what other class?
cephalosporin
which class of abx are very similar to penicillins with regard to mechanism of action and allergic reactions?
cephalosporin
which drug can turn bodily fluids orange/red?
rifampin
which abx causes Red Lobster Syndrome?
rifampin (Rifampin the Red lobster)
what is the gold standard oral anti-MSSA drug?
dicloxacillin
which oral antibiotic would you use for a skin abscess in which s. aureus is the suspected organism?
dicloxacillin
which drug can cause red-green color blindness? and what is the actual cause of the blindness?
ethambutol; optic neuritis
Is the urine osmolality <100 mOsm/kg? If yes, think
excessive water intake (primary polydipsia).
Is the ECFV decreased and the urine sodium decreased (<10 mEq/L)? If yes, think
extrarenal sodium loss
The family should undergo yearly sigmoidoscopy beginning at 12 years of age Inherited mutation (APC gene) Diagnosis confirmed with genetic testing Prophylactic colectomy recommended!
familial adenomatous polyposis
metronidazole is pregnancy category B, except when?
first trimester...fetotoxic
RCC triad
flank pain hematuria abdominal mass
which class of abx are associated with tendon ruptures, esp Achilles tendon?
flouroquinolones
which antifungal medication is used to treat vaginal or esophageal candidiasis?
fluconazole
which antifungal medication would you give an adult with oral candidiasis?
fluconazole
Anti-HBc
had/have infeciton
Cushing SYNDROME Management
hydrocortisone
In severe symptomatic hyponatremia with sodium of less than 120 mEq/L what tx?
hypertonic (3%) saline may be used very cautiously
Is the plasma osmolality >295 mOsm/kg? If yes, think
hypertonic hyponatremia (hyperglycemia)
Is the plasma osmolality <280 mOsm/kg? If yes, think
hypotonic hyponatremia and measure the urine osmolality.
Anti-HBs
immune
Is the urine osmolality >100 mOsm/kg? If yes, think
impaired renal diluting ability and assess the ECFV (extracellular fluid volume)
what can be done to limit the risk of Red Man Syndrome when giving vancomycin?
infuse over 60 minutes
what is the MOA of the flouroquinolones?
inhibit bacterial DNA topoisomerases
what is the MOA of cephalosporins?
inhibit cell wall synthesis
what is the MOA of PCN?
inhibits cell wall synthesis
what is the MOA of trimethoprim & sulfamethoxazole?
inhibits folate synthesis
what is the MOA of tetracyclines?
inhibits the 30S bacterial ribosome
what is the MOA of the aminoglycoside abx class?
inhibits the 30S bacterial ribosome
What is the MOA of macrolide abx?
inhibits the 50S bacterial ribosome
what is the MOA of lincosamide abx?
inhibits the 50S bacterial ribosome
Severe thrombocytopenia (spontaneous bleeding can occur)
less than 50,000 platelets
what are the respiratory flouroquinolones?
levofloxacin and moxifloxacin
which mostly affects the: - skin of the face, neck, and distal elbows and knees - late in the disease causes isolated pulmonary hypertension what kind of Systemic Sclerosis (Scleroderma)?
limited
what are the 3 best oral abx for MRSA infections?
linezolid (Zyvox), Doxy, TMP-SMX
Common site of metastasis for other primary cancers, especially lung and breast cancers.
liver
Class 2 Congestive Heart Failure
slight limitation physical activity; comfortable at rest
Hypertensive emergency tx
sodium nitroprusside, beta blocker, CCB
Encephalomyelitis occurs where?
spinal cord/nerve
Stenosis of subclavian artery proximal to the vertebral artery --> Sx with left arm exertion --> Angina, finger ulceration What cause of syncope?
subclavian steal
Femoral artery PAD
thigh/upper calf claudication MC
what is the main use for respiratory flouroquinolones?
upper and lower URIs
what is the bronze standard (3rd line) IV anti-MSSA abx?
vancomycin
what is the gold standard IV MRSA drug?
vancomycin
what is the treatment of mod-severe c. diff?
vancomycin
hereditary RCC
von Hippel-Lindau disease Hereditary papillary renal carcinoma.
be careful of Bactrim/septra in people taking what medication?
warfarin (get an INR)
As generations of abx increase what happens to coverage?
you lose gram pos coverage and gain gram neg coverage
Patients may have mild symptoms or none - thalassemia trait [two normal α-chains] - carriers [three normal α-chains] Patients are often diagnosed after a nonresponse to treatment for a suspected iron deficiency or a normal ferritin level with a microcytic anemia. Patients with one α-globin chain (instead of the normal four) have Hgb H disease which is variably symptomatic When all four chains are deleted, stillbirth occurs from hydrops fetalis.
α-Thalassemia
Screening is recommended for __________ in patients with possible COPD who are young, or have a positive family history of COPD at a young age, or have emphysema
α1-antitrypsin deficiency
AKA Cooley anemia
β-Thalassemia major
Popliteal artery PAD
Lower calf claudication
Aur Rods and > 20% blasts seen in bone marrow
Acute Myeloid Leukemia (AML)
MC type of prostate cancer
Adenocarcinoma
Outpatient healhty adult pneumonia tx
Amoxicillin or Doxycycline or Macrolide
Neonates up to 1 month with bacterial meningitis tx
Ampicillin Cefotaxime Gentamicin
Charcot triad
RUQ tenderness Jaundice Fever
what is the parenteral/injectable 3rd gen cephalosporin?
ceftriaxone
which cephalosporin is used for meningitis?
ceftriaxone
what are the 2nd generation "respiratory" cephalosporins?
cefuroxime
No eye opening GCS
1
No motor response GCS
1
No sounds GCS
1
Should hypovolemia or hypernatremia be treated first?
1. Hypovolemia (NS or LR) 2. Hypernatremia
Stable patients: Paroxysmal ventricular tachycardia tx
1. Valsalva maneuvers 2. Adenosine (rapid IV push) 3. CCB or BB
Preferred pharmacology for acute V tach
1. amniodarone 2. lidocaine 3. procainamide
Hemodynamically stable a fib treatment
1. Treat with heparin 2. Cardiovert
Mild thrombocytopenia
100,000 to 150,000 platelets
Prediabetes fasting glucose
100-125
Prehypertension
120-129/<80
Stage 1 Hypertension
130-139/80-89
Stage 2 Hypertension
140-159/90-99
Prediabetes oral glucose tolerance test
140-199
Acute Hepatitis Fecal oral transmission Self limited
A E
Shingles prevention
A single dose Zostavax Indicated in patients aged 60 years or older
Also known as drop attacks Looks like syncope, sudden loss of muscle tone
Atonic Seizures
Non-black pts initial tx
ACE/ARB CCB Thiazide like diuretic
Systolic HF tx
ACEi Beta blocker Loop diuretic
Diastolic HF tx
ACEi Beta blocker or CCB
Auer Rods and > 20% blasts seen in bone marrow
Acute Myeloid Leukemia (AML)
Newer biologic DMARDs
Abatacept Rituximab Infliximab Adalimumab
Formerly known as petit mal Brief impairment of consciousness with an abrupt beginning and ending. At times involuntary movements may occur, but they are uncommon and the patient has no recollection and witnesses commonly miss them
Absence Seizures
What suggests secondary polycythemia?
Absence of splenomegaly
Indications for dialysis
Acidosis Electrolyte imbalances Ingestion Overload (volume) Uremia
Form of polycystic kidney disease Long-term renal disease MC in African American men
Acquired cystic kidney disease (ACKD)
Clinical Features: Doughy, moist handshake Macroglossia Carpal tunnel syndrome Deep, coarse voice Obstructive sleep apnea Goiter HTN and cardiomegaly Weight gain and insulin resistance Arthralgias and arthritis Colon polyps Hyperhidrosis Bitemporal hemianopsia
Acromegaly
Enlargement and elongation of the hands, feet, and jaw as well as internal organ involvement in adults. Onset is in the 30s so it does not affect long bones. Increased risk of diabetes mellitus (DM) (30%), HTN, and CAD. At diagnosis, 10% have overt heart failure with dilated left ventricle and reduced ejection fraction.
Acromegaly
If IGF-1 levels are normal for age this rules out
Acromegaly
IgM
Acute
"Addisonian Crisis" Sudden worsening of adrenal insufficiency due to "stressful" event Triggers: - surgery - trauma - volume loss - hypothermia - MI, -fever - sepsis - hypoglycemia - steroid withdrawal
Acute Adrenal Insufficiency
Signs/Sympetoms: Hypovolemic Shock (MC!) Hypotension Hypovolemia Abdominal pain, N/V Fever Weakness, lethargy, confusion BMP -hyponatermia -hyperkalemia -hypoglycemia
Acute Adrenal Insufficiency
Treatment: IVF: normal saline (D5NS if hypoglycemia) IV HIGH dose Hydrocortisone Reversal of electrolytes Fludricortisone
Acute Adrenal Insufficiency
Diagnosis: Increased IOP 60-80 (normal 10-20): firm to palpation Fundoscope: cupping of optic nerve
Acute Angle Closure Glaucoma
Obstruction of aqueous humor outflow due to the lens or peripheral iris blocking the trabecular network History: - dark room (movie) - reading - dilating, anticholinergics - coke
Acute Angle Closure Glaucoma
Signs/Symtpoms: Sudden eye pain & HA Colored halos around light Peripheral "tunnel" vision loss Nausea/Vomiting Fixed mid-position pupil, hazy cornea, injection
Acute Angle Closure Glaucoma
Treatment: Supine position 1. Acetazolamide (lower pressure & aqueous humor production) 2. Timilol (reduce pressure without affectiving visual acuity) 3. Pilocarpine or Carbachol (cholinergic --> pupil constriction)
Acute Angle Closure Glaucoma
Clinical Features: Cough (with or without sputum) Dyspnea Fever Sore throat Headache Myalgias Expiratory rhonchi or wheezes. Note: Sputum color is not predictive of bacterial involvement. Signs of pneumonia such as tachypnea and tachycardia should be absent.
Acute Bronchitis
Diagnosis: Generally, no laboratory evaluation is required unless there is a strong need to differentiate from pneumonia. The CXR will be negative
Acute Bronchitis
Management: Hydration Expectorants analgesics Antitussives (dextromethorphan, guaifenesin, and bromhexine; do not use if less than 2) Antibiotics are indicated for: - elderly patients - those with underlying cardiopulmonary diseases and a cough for more than 7 to 10 days - any patient who is immunocompromised
Acute Bronchitis
Unstable angina STEMI NSTEMI
Acute Coronary Syndromes
Fever Rash Arthralgia Eosinophilia WBC casts ￬GFR ￪BUN/Cr *BUN: CR ratio <20:1 Renal biopsy: inflam cells w/n renal interstitium Abdominal Pelvic US: enlarged kidneys
Acute Interstitial Nephritis
Interstitial inflammatory response with cell-mediated immune rxns Causes: •Medication (70%) •Infections (staph, strep, CMV...), Immunologic (SLE, Sjogrens...)
Acute Interstitial Nephritis
Treatment: Remove cause, supportive care IV or oral corticosteroids if persists Urgent dialysis ~1/3 pts
Acute Interstitial Nephritis
DX: CT angiogram Labs: CBC, lactate Treatment - NPO, rest, fluids - emergent SURGERY - Pain control, anti-emetics
Acute Mesenteric Ischemia
Decrease of blood supply to bowel MCC: emboli, thrombus Signs/Symptoms - Crampy, abdominal pain - Bloody diarrhea - HALLMARK: pain out of proportion
Acute Mesenteric Ischemia
Treatment Oral intake must be stopped to prevent continued secretion of pancreatic juices Fluid volume must be restored and maintained. Parenteral hyperalimentation should be started early to prevent nutritional depletion. Pain is managed with an opioid The patient must be monitored closely for complications, including: - pancreatic pseudocyst - renal failure - pleural effusion - hypocalcemia - pancreatic abscess
Acute Pancreatitis
Diagnosis: CXR: - bilateral pulmonary infiltrates - AIR BRONCHOGRAMS - spares costophrenic angles ABG: - PaO2/FIO2 <200 - NOT responsive to 100% O2 (refractory hypoxemia) Swanz-Ganz cath: pressure <18 *differentiates from pulm edema
Acute Respiratory Distress
MC form non-cardiogenic pulmonary edema Acute hypoxemic respiratory failure following systemic or pulm insult WITHOUT evidence of HF Inflammatory alveolar damage --> Increased permeability of alveolar-capillary barrier --> Pulmonary edema --> Low O2 Causes: MCC-sepsis
Acute Respiratory Distress
Signs/Symtpoms: Rapid onset of profound DYSPNEA within 12-48h after event SOB, tachypnea Intercostal retractions Crackles Hypoxemia (no response to O2) Multiple organ failure: kidney, liver, CV, CNS HALLMARK: diffuse alveolar damage
Acute Respiratory Distress
Treatment: Non-invasive or mechanical ventilation PEEP ((+) end-expiratory pressure) - prevents alveolar collapse - give at lowest effective levels - does not improve mortality - risks: barotrauma, pneumothorax, auto-peep Treat underlying disease
Acute Respiratory Distress
Infection of normal valves with a virulent organism (S. aureus)
Acute bacterial endocarditis
Typically occurs in individuals from 6 months to 5 years of age Lesions heal in about 2 weeks, although shedding may continue. HSV-1 Abrupt onset, fever, anorexia, listlessness, and gingivitis. Mucosa is red, swollen, and friable. Vesicles appear on the oral mucosa, tongue, and lips Vesicles may rupture and coalesce to form ulcers and plaques Regional lymphadenopathy is common.
Acute herpetic gingivostomatitis
Common in adults manifesting initial HSV-1 disease Fever, malaise, headache, and sore throat. Vesicles are formed on the posterior pharynx and tonsils Vesicles rupture and form shallow ulcers A grayish exudate may be present over the posterior mucosa.
Acute herpetic pharyngotonsillitis
General characteristics: Syndrome of rapidly deteriorating glomerular filtration rate (GFR) with the accumulation of nitrogenous wastes (urea, creatinine) referred to as azotemia Serum creatinine acutely increases by more than 0.5 mg/dL or more than 50% over baseline level Process develops in less than 7 days.
Acute kidney injury (AKI)
Treatment: Pre-renal - Achievement of normal hemodynamics (IV fluids, blood products, and improving cardiac output) Intrarenal - adjustment and avoidance of medications - nephrotoxic agents Postrenal - Relief of urinary tract obstruction (ureteral stents, urethral catheter Short-term dialysis should be implemented when serum creatinine exceeds 5 to 10 mg/dL
Acute kidney injury (AKI)
CHILD Lymphadenopathy Bone pain Bleeding Fever Bone marrow > 20% blasts in bone marrow Population: - Children - most common childhood malignancy peak age 3-7 Highly responsive to chemotherapy (remission > 90%)
Acute lymphocytic leukemia (ALL)
Diagnosis: Terminal deoxynucleotidyl transferase
Acute lymphocytic leukemia (ALL)
Most common in children (3-7 years old)
Acute lymphocytic leukemia (ALL)
Esophagitis treatment for HSV cause
Acyclovir
Inpatient with prior p. aeruginosa isolated pneumonia tx
Add Pipercillin tazobactam, Cefepime, Cetazideme
Inpatient with prior MRSA isolated pneumonia tx
Add vancomycin or Linezolid
Tuberculosis is the most common cause of this endocrine disorder in the developing world.
Addison's disease
MC cause of delirium
Alcohol abuse
Liver enzymes: AST:ALT ratio > 2:1
Alcoholic Hepatitis
Treat HTN and BPH
Alpha blockers
MC used thrombolytic therapy for STEMI
Alteplase, Reteplase, Tenecteplase
Reynolds pentad
Altered mental status Hypotension RUQ tenderness Jaundice Fever
Strongest predisposing factor to asthma
Atopy
Clinical features: Progressive memory loss Disorientation Language difficulties Inability to perform complex motor activities Intellectual decline should be present in two or more areas of cognition and documented by a mental status examination or a similar scale of cognitive ability. Physical exam: Abnormal clock drawing test
Alzheimer's Disease
Pathology of intracellular neurofibrillary tangles and extracellular neuritic plaques. RF: old age, genetics, FH Characterized by steadily progressive memory loss and other cognitive deficits Typically begin during the sixth or seventh decade of life.
Alzheimer's Disease
Treatment: Acetylcholinesterase inhibitors - Tacrine - Donepezil - Galantamine - Rivastigmine - May improve memory function and delay disease progression. Memantine - moderate to severe cases Vigilant family supervision is required. Day care centers and respite care are adjuncts to family supervision.
Alzheimer's Disease
what 2 drugs are used only for influenza A prophylaxis and treatment?
Amantadine and Rimantadine
Clinical findings Colitis - mild to moderate (few semiformed stools without blood) - severe dysentery (higher number of liquid stools streaked with blood or bits of necrotic tissue) Distention Hyperperistalsis Generalized abdominal tenderness Localized ulcerative lesions of the colon and localized granulomatous lesions of the colon result in pain, intestinal obstruction, and hemorrhage.
Amebiasis
Diagnostic studies: Stool specimens - cysts or trophozoites Sigmoidoscopy, colonoscopy, or rectal biopsy - ulcers - collection of exudates should be examined for trophozoites. Serology - detect antibodies up to 10 years after the infection and, therefore, cannot be used to differentiate the past from the present infection. Ultrasonography, CT, MRI, or radioisotope scanning reveals the size and location of hepatic abscesses.
Amebiasis
General characteristics: Cysts of Entamoeba histolytica are viable in the soil and water for weeks to months Transmission via food or water, fly droppings, or human-to-human contact. Ingestion of cysts--> Pass through to the intestines where they hatch --> Trophozoites invade the mucosa and induce necrosis Ulcers - flask shaped - occur anywhere in the large bowel or terminal ileum - usually are limited to the muscularis, but if they penetrate the serosa, they may cause perforation, abscess, or peritonitis.
Amebiasis
Treatment: Asymptomatic infection - luminal amebicide (diloxanide furoate, iodoquinol, or paromomycin). Mild to moderate infections - tinidazole or metronidazole plus a luminal amebicide Hepatic abscess - tinidazole or metronidazole plus a luminal amebicide - followed by chloroquine - if there is no response within 3 days of initial treatment, the abscess should be drained Follow-up with at least three stool examinations at 2- to 3-day intervals starting 2 to 4 weeks after the end of treatment.
Amebiasis
Antibiotic prophylaxis to prevent endocarditis is recommended before invasive dental work or surgical procedures in patients with infective endocarditis What antibiotic?
Amoxicillin Allergy: Clindamycin, Cephalexin, Azithromycin
Microcytic/Normocytic Anemia ↓ Iron ↓ TIBC 10-20% Saturation ↑ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH Elevated CRP/ESR
Anemia of Chronic Disease
Paroxysmal chest "squeezing" or pressure, often accompanied by a sensation of smothering and a fear of impending death
Angina
Treatment: Aspirin/Clopidegrel for all patients Nitroglycerin for acute Beta blocker for chronic CCB if Beta blocker contraindicated (COPD/asthma) ACEi for CHF Ranolazine for exercise Extreme: Revascularization via angioblasty or graft
Angina
CCB's contraindicated in what?
Angina pectoris (edema)
Anterior choroidal artery Anterior cerebral artery Middle cerebral artery Supplies the: - cortex - subcortical white matter - basal ganglia - internal capsule Anterior or posterior circulation stroke?
Anterior Circulation Stroke
Unilateral arm/leg weakness Speech difficulties Unilateral arm/leg paresthesias or anesthesias Visual changes Anterior or posterior circulation stroke?
Anterior Circulation Stroke
Stone in the upper ureter. Where does pain radiate to?
Anterior abdomen
Pulmonary Hypertension WHO Group 4 tx
Anticoagulant
Hashimoto's labs
Antithyroid peroxidase Antithyroglobulin antibodies
The only anemia where all three cell lines are decreased (pancytopenia) - ↓ WBC - ↓ RBC - ↓ Platelets - will have normal MCV and ↓ Retic Loss of blood cell precursors Causes: chemicals, drugs, radiation (ACE-I, sulfonamides, phenytoin, chemo, radiation)
Aplastic Anemia
Diagnosis: Rovsing: RLQ Psoas: SLR Obturator: twist CT scan = study of choice - no contrast Tx: appendectomy, preop antibiotic of Piperacillin-tazobactam
Appendicitis
Rectocecal: - abd and flank pain Pelvic: - tender abd and rectal pain
Appendicitis
Signs/Symptoms: Dull periumbilical or epigastric pain --> RLQ Nausea/vomiting Anorexia Symptoms increase over 24h McBurneys point pain
Appendicitis
Occupation: - insulation - demolition - construction Diagnosis: - Bx: asbestos bodies - CXR: linear opacities at bases and pleural plaques - LOWER LOBES (linear opacities, pleural plaques) Complication: - Increased risk of lung cancer and mesothelioma, especially if a smoker
Asbestosis
Smoking cessation is especially important for patients with _______, because smoking interferes with short asbestos fiber clearance from the lung.
Asbestosis
Clinical Features: Dyspnea Wheezing Cough (worse at night) Chest tightness Fatigue Prolonged expiration Hyperresonance to percussion Decreased breath sounds Tachycardia, tachypnea Accessory muscles
Asthma
Diagnosis: Spirometry shows decreased FEV1/FVC ratio + > 12% increase in FEV1 after bronchodilator therapy ABG show hypoxemia and hypercapnia in severe cases Methacholine challenge test (bronchial provocation test) - If spirometry nondiagnostic - FEV1 decrease of more than 20%
Asthma
Obstruction of airflow Bronchial hyperreactivity Inflammation of the airway Disease of chronic inflammation leading to airway narrowing and increased mucus production
Asthma
Pharmacological Treatment 1. SABA prn 2. Low dose ICS 3. Low dose ICS + LABA or medium dose ICS 4. Medium dose ICS + LABA 5. High dose ICS + LABA and omalizumab for allergies pts 6. High dose ICS + LABA + oral corticosteroids and consider omalizumab for allergy pts
Asthma
Samter's Triad
Asthma Nasal polyps Aspirin/NSAID allergy
Beta blockers contraindicated in what?
Asthma (impotence)
MC form of polycystic kidney disease Almost always bilateral Symptoms develop in 4-5th decade of life
Autosomal dominant polycystic kidney disease (ADPKD)
Less common form of polycystic kidney disease Begins in utero Can lead to fetal and neonatal death Renal and hepatic failure = cause of death
Autosomal recessive polycystic kidney disease (ARPKD)
Chronic Hepatitis Transmitted parenterally or by mucous membrane contact
B C D
Characterized by: - prolonged or recurrent fevers - bacteremia and local infection in bone, joints, pleura, pericardium, lungs, or other site MC in immunosuppressed persons. Blood cultures confirm the diagnosis. Treatment - fluoroquinolone - carbapenems or azithromycin are used in resistant cases - Abscesses should be drained. What kind of Salmonellosis?
Bacteremia
CSF Analysis: Turbid to grossly purulent color Elevated pressure Elevated WBC, increased neutrophils Elevated protein Decreased glucose
Bacterial Meningitis
Clinical features: Altered mental status Fever Headache Vomiting Stiff neck Petechial rash is characteristic of N. meningitidis. Symptoms are acute, with patients presenting within hours or 1 to 2 days of infection. Soft-tissue abscess Otitis Kernig and Brudzinski signs
Bacterial Meningitis
Symptoms are based on three processes: - inflammation - increased intracranial pressure - tissue necrosis Primary causes today: - Streptococcus pneumoniae - Neisseria meningitidis - Group B streptococci. MC in neonates: Group B strep
Bacterial Meningitis
Treatment Antibiotic treatment is begun immediately if the CSF is not clear and colorless. Antibiotics should not be delayed if the LP cannot be accomplished or if imaging is necessary. Blood cultures x2 Repeat LP and CSF analysis are crucial to assess response to treatment - CSF should be sterile after 24 hours. - decrease in pleocytosis and the proportion of neutrophils should be seen within 3 days.
Bacterial Meningitis
Treatment of choice of PCP pneumonia
Bactrim
associated with adenocarcinomas in the distal third of the esophagus, whereas squamous cell lesions tend to occur in the proximal two-thirds
Barrett's Esophagitis
Occupation: - High-technology fields: aerospace, nuclear power, ceramics, foundries, tool and die manufacturing Diagnosis: - CXR: diffuse infiltrates and hilar adenopathy Complications: - Requires chronic steroids
Berylliosis
Clinical features: Facial muscle weakness Paralysis involves the forehead and lower face Cannot close the eye, raise the brow, or smile on the affected side Pain about the ipsilateral ear often precedes the facial weakness or is noted concurrently with the weakness. Clinical evaluation reveals no abnormality beyond the motor function of CN VII. The weakness peaks in about 21 days or less, and recovery (partial or complete) occurs within 6 months.
Bell Palsy
MC cause = HSV activation. Other causes - herpes zoster - trauma - neoplasia - toxins End result is damage to the myelin layer of the facial nerve.
Bell Palsy
Treatment: Lubricating eye drops to prevent corneal drying Course of oral prednisone - if begun soon after the onset of symptoms, has been shown to increase the percentage of patients who completely recover and should be considered in those at risk of a poor prognosis. Surgery should be considered in severe or recalcitrant cases.
Bell Palsy
Unilateral facial muscle weakness and drooping is the primary complaint with onset occurring over hours and without apparent cause.
Bell Palsy
Clinical features: Symptoms of obstruction and irritation. Obstructive symptoms - decreased force of urinary stream - hesitancy and straining - postvoid dribbling - sensation of incomplete emptying Irritative symptoms - frequency - nocturia - urgency DRE reveals an enlarged prostate.
Benign Prostatic Hyperplasia
Diagnostic studies: Prostate-specific antigen (PSA) is typically slightly elevated. Other tests are done to evaluate for: - renal damage - infection - prostate or bladder cancer
Benign Prostatic Hyperplasia
Proliferation of the fibrostromal tissue of the prostate can lead to compression of the prostatic urethra, creating an obstruction of the urinary outlet leading to LUTS. Disease of older men. Can start as early as 45 mean age 65
Benign Prostatic Hyperplasia
Treatment: α-adrenergic antagonists (prazosin, etc.) 5α-reductase inhibitors (finasteride, dutasteride) Phosphodiesterase-5 inhibitors (tadalafil, vardenafil) Procedures to relieve obstruction - balloon dilation - microwave irradiation - stent placements Surgical treatment is transurethral resection of prostate or transurethral incision of prostate.
Benign Prostatic Hyperplasia
cavernous hemangioma hepatocellular adenoma infantile hemangioendothelioma
Benign liver neoplasms
Rheumatic fever prophylaxis
Benzathine penicillin every 4 weeks
Treatment Superficial lesions - endoscopic resection and fulguration - followed by cystoscopy every 3 months Recurrent or multiple lesions - intravesical instillation of thiotepa, mitomycin-C, or bacillus Calmette-Guérin (BCG) Reccurent cancer, diffuse TCC in situ, tumors invaded into muscle - Radical cystectomy
Bladder Cancer
Clinical findings: Initially: - visual changes, including diplopia and loss of accommodation - 12 to 36 hours after ingestion - Infants display irritability and opisthotonus. Additional manifestations: - ptosis - impaired extraocular muscle movements - fixed, dilated pupils - cranial nerve palsies, dysphonia Mental status changes or sensory deficits do not occur. Respiratory paralysis ensues and, unless mechanical assistance is provided, death results.
Botulism
Diagnostic studies: The toxin can be identified using specific antiserum after mouse inoculation with the patient's serum
Botulism
General characteristics: Anaerobic, spore-forming bacillus found in the soil May inadvertently be packed in food (home-canned, smoked, or commercial), where toxin is produced and stored until ingested. Toxin inhibits the release of acetylcholine at the neuromuscular junction. Infant and wound forms result from exposure to the bacteria or spores and elaboration of the toxin in vivo. - do not feed infants honey
Botulism
Treatment: Antitoxin is available through the CDC The CDC will also assist with obtaining assays of serum, stool, or suspect food. Respiratory failure necessitates intubation and mechanical ventilation. - If dysphagia persists, IV nutritional support and hyperalimentation are required.
Botulism
- the slow, shuffling gait - reduced arm swing - slowed rapid alternating movements - infrequent blinking - micrographia and masklike facies What diagnostic feature of Parkinson's?
Bradykinesia
Clinical features: Chronic purulent sputum (often foul smelling) Hemoptysis Chronic cough Recurrent pneumonia. Localized chest crackles Clubbing of the fingers
Bronchiectasis
Diagnostic studies: High-res chest CT is imaging of choice - dilated, tortuous airways. CXR - crowded bronchial markings - basal cystic spaces are characteristics - tram-track lung markings - honeycombing - atelectasis Bronchoscopy is warranted to evaluate hemoptysis, remove secretions, and rule out obstructing lesions.
Bronchiectasis
General characteristics: Abnormal, permanent dilation of the bronchi and destruction of bronchial walls Causes: - congenital (cystic fibrosis) - acquired from recurrent infections (TB, fungal infection, lung abscess) - obstruction (tumor) Results from bronchial injury subsequent to severe infection and/or inflammation Half of all cases occur in patients with cystic fibrosis.
Bronchiectasis
Management: Productive cough - antibiotic - bronchodilators - chest physiotherapy Antibiotics - amoxicillin - amoxicillin-clavulanate - trimethoprim-sulfamethoxazole - ciprofloxacin Bronchodilators are helpful for maintenance and for treating acute exacerbations.
Bronchiectasis
defined as inflammation of the airways (trachea, bronchi, bronchioles) characterized by cough
Bronchitis
MCC cancer deaths
Bronchogenic Carcinoma
Diarrhea in patient post antibiotics
C Diff
Diarrhea in poorly canned home foods Cramping, watery diarrhea Tx: Supportive
C perfringens
Peptic Ulcer Disease triple therapy
CAP: Clarithromycin, Amoxicillin, PPI
Helpful biomarker, especially for reinfarction
CKMB
Metabolic Alkalosis mnemonic
CLEVER-PD
Diaper dermatitis - does not indicate immune deficiency in newborns - diaper area is red, with defined margins - pustules, vesicles, papules, or scales may be seen, and satellite lesions Children and adults (particularly adults with diabetes) dermatitis - in dark, moist areas, such as axillae or under the breasts or large panniculus - especially if the immune system is stressed - lesions have distinct borders - satellite lesions are common. Treatment is with topical antifungal creams What kind of candidiasis?
Candidiasis - Cutaneous disease
AKA Carcinoid adenomas or bronchial gland tumors
Carcinoid Tumor of the Lung
Bronchoscopy reveals a pink or purple central lesion that is well vascularized. The lesion can be pedunculated or sessile. CT and octreotide scintigraphy localize the disease. Treatment: - Surgical excision carries a good prognosis. - The lesions are resistant to radiation therapy and chemotherapy. - Octreotide can be used to treat symptoms.
Carcinoid Tumor of the Lung
Well-differentiated neuroendocrine tumors Rare, low grade malignant neoplasms Commonly found in GI tract Hemoptysis, cough, wheezing, recurrent pneumonia Carcinoid syndrome (flushing, diarrhea, wheezing, hypotension) is rare, occurring in 10% of patients.
Carcinoid Tumor of the Lung
Cool, mottled skin Pliguria Altered mental status LVH, pulmonary edema Frothy sputum Decreased BP and CO Increased wedge pressure Treatment - Isotonic fluids (AVOID a LARGE amount!) - Revascularization if ischemic: PCI - Ionotropic support: decreased contractility & CO - Norepinephrine, dobutamine, dopamine if persistent What kind of shock?
Cardiogenic Shock
Insufficient CO to meet metabolic needs Causes: - Acute MI (MC!) - Cardiotoxic drug effects - Infection - Mechanical - Valve What kind of shock?
Cardiogenic Shock
Sustained or recurrent patients: Paroxysmal ventricular tachycardia tx
Catheter ablative surgery
Right sided colorectal lesions
Cause chronic blood loss and iron deficiency anemia
Diagnostic studies: Initially = Noncontrast Head CT LP with evaluation of CSF - elevated opening pressures - grossly bloody fluid in all four tubes - Xanthochromia may also be present if the blood has been in the CSF over 2 hours Cerebral angiography to evaluate the entire vasculature when convenient because as many as 20% of individuals will have multiple anuerysms
Cerebral aneurysm/subarachnoid hemorrhage (SAH)
General characteristics: Risk factors include: - smoking - hypertension - hypercholesterolemia - heavy alcohol use Associated with: - polycystic kidney disease - coarctation of the aorta
Cerebral aneurysm/subarachnoid hemorrhage (SAH)
Treatment: Supportive medical treatment - prevention of elevated arterial or intracranial pressures that might lead to re-rupture of the affected vessel - strict bed rest - mild sedation - administration of stool softeners to prevent strainin Management of hypertension is important, but care must be taken to prevent hypotension and inadequate cerebral perfusion Surgical management: - clipping or wrapping of aneurysms - removal or embolization of an AV Malformations by intra-arterial catheter.
Cerebral aneurysm/subarachnoid hemorrhage (SAH)
Stable arrhythmias as treated with medicine Unstable arrhythmias are treated with electricity What are some signs of unstable arrhythmia
Chest pain Hypotension Altered mental status Dyspnea
Periods of difficult breathing (dyspnea) followed by periods of no respirations (apnea) Associated with hyponatremia
Cheyne Stokes breathing
A distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apnea
Cheyne-stokes breathing
Clinical findings: Lymphogranuloma venereum starts with a vesicular or ulcerative lesion The infection spreads to the lymph nodes, causing inguinal buboes Urethritis and cervicitis - In males, MCC of nongonococcal urethritis. Discharge is less painful than with gonococcal urethritis and usually is watery. - Females are typically asymptomatic or may develop cervicitis, salpingitis, or PID Infection with this species is a leading cause of infertility.
Chlamydia
Diagnostic studies: The diagnosis is typically established clinically and is presumptive Gram stain is negative NAAT
Chlamydia
MC cause of Bacterial Meningitis
Community: s. pneumo Healthcare: s. aureus < 1 month: GBS
Treatment Generally, only the complications should be treated because most people with gallstones will never develop the disease. Symptomatic (Biliary Colic): - Laparoscopic cholecystectomy Complications include: - cholecystitis - pancreatitis - acute cholangitis.
Cholelithiasis
Clinical findings: A sudden onset of severe, frequent, "rice water" diarrhea (gray, turbid, and without odor, blood, or pus) Dehydration Hypotension Electrolyte imbalance Diagnosis is clinical. Stool cultures will be positive
Cholera
General characteristics: Produces a toxin that activates adenylyl cyclase in intestinal epithelial cells of the small intestine. Results in hypersecretion of water and chloride ion and massive diarrhea. Death results from hypovolemia. Epidemics occur in times of war, overcrowding, natural disasters, and famine, and where sanitation is inadequate. Infection results from ingestion of contaminated food or water.
Cholera
Treatment: Replacement of fluids and electrolytes is essential. - Moderate cases: Oral rehydration with water containing salt and sugar - Severe cases require IV hydration. Antibiotics should be reserved for the severely ill or those with serious comorbidities - Tetracycline - Ampicillin - Chloramphenicol - Trimethoprim-sulfamethoxazole (TMP-SMX) The key to prevention is clean water and food sources as well as proper waste disposal
Cholera
"Blue bloaters"
Chronic Bronchitis
Disease characterized by a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause.
Chronic Bronchitis
Increased interstitial markings at bases Diaphragms not flattened
Chronic Bronchitis
Mild dyspnea Chronic productive cough Noisy lungs: rhonchi and wheeze Peripheral edema Overweight and cyanotic Pursed lip breathing Grunting expirations
Chronic Bronchitis
Porcelain gallbladder =
Chronic Cholecystitis
Diagnostic studies: SMUDGE CELLS on peripheral smear Mature lymphocytes (isolated lymphocytosis with leukocytosis > 20,000) Treatment - observation - lymphocytes are > 100,000 - symptomatic, treat with chemotherapy
Chronic Lymphocytic Leukemia (CLL)
Middle age patient Often asymptomatic (seen on blood tests) Fatigue Lymphadenopathy Splenomegaly Population: - Adults - most common form of leukemia in adults - peak age 50 y/o
Chronic Lymphocytic Leukemia (CLL)
SMUDGE CELLS on peripheral smear, mature lymphocytes
Chronic Lymphocytic Leukemia (CLL)
Diagnostic studies: Philadelphia chromosome (translocation of chromosome 9 and 22) - BCR ABL gene - "Philadelphia CreaM cheese", splenomegaly Tx: tyrosine kinase inhibitors (imatinib, nilotinib) and allogeneic bone marrow transplantation
Chronic Myeloid Leukemia (CML)
Philadelphia chromosome (translocation of chromosome 9 and 22
Chronic Myeloid Leukemia (CML)
Strikingly Increased WBC count > 100,000 Hyperuricemia Population: - Adults - patient usually > 50 y/o 70% asymptomatic until the patient has a blastic crisis
Chronic Myeloid Leukemia (CML)
Clinical and pathophysiologic syndrome that includes emphysema and chronic bronchitis Irreversible airflow obstruction - Loss of elastic recoil of alveoli - Increased airway resistance Risks = SMOKING (>15 pack years)
Chronic Obstructive Pulmonary Disorder
Diagnosis: CXR Pulmonary function testing showing decreased FEV1/FVC ratio CBC showing polycythemia due to hypoxia
Chronic Obstructive Pulmonary Disorder
Management: Smoking cessation is the most important intervention Anticholinergic inhalers (ipratropium or tiotropium) are superior to β-adrenergic agonists in achieving bronchodilation Short-acting bronchodilators should be prescribed for acute exacerbations of dyspnea Supplemental O2 for hypoxemia
Chronic Obstructive Pulmonary Disorder
Almost 90% of cases caused by alcohol abuse Other causes: - cholelithiasis - PUD - hyperparathyroidism - hyperlipidemia Some cases can resolve if alcohol consumption is decreased.
Chronic Pancreatitis
Clinical features: Same as those of acute pancreatitis, with the addition of: - fat malabsorption and steatorrhea late in the disease - Fecal fat will be elevated if malabsorption is present
Chronic Pancreatitis
Diagnosis: The amylase level may be elevated early but will decrease with each episode and cease to be a useful marker. Abdominal plain-film radiography reveals calcification in 20% to 30% of patients. Gallstones may also be seen.
Chronic Pancreatitis
Treatment Same as for acute pancreatitis A low-fat diet should be recommended at discharge. Surgical removal of part of the pancreas can control pain The only definitive treatment is to address the underlying cause, which most commonly is alcohol.
Chronic Pancreatitis
Can be either benign or malignant. Removal can reduce the risk of colon cancer. Inherited polyposis syndromes (familial adenomatous polyposis, Peutz-Jeghers syndrome) convey genetic predisposition to multiple colonic polyps with a near 100% risk of developing colonic cancer
Colonic Polyps
Clinical features Generally asymptomatic Constipation, flatulence, and rectal bleeding may occur. If bleeding may cause iron deficiency anemia.
Colonic Polyps
Diagnostic studies Heme-positive stool is common. Barium enema, flexible sigmoidoscopy, and colonoscopy can detect polyps. Histologic evaluation is needed to determine dysplasia. - hyperplastic = the lowest risk of dysplasia - tubular polyps = increased risk - villous polyps = highest risk of malignancy.
Colonic Polyps
Treatment: Depends on the size and histology Larger and dysplastic - removed and frequent follow-up arranged. Single distal hyperplastic - requires the same follow-up as someone without polyps - every 10 years Multiple hyperplastic polyps, hyperplastic polyps at sites rather than distal, or tubular polyps - 5-year follow-up. Villous polyps - follow-up colonoscopy at 3 years
Colonic Polyps
Clinical features Slow growing, and symptoms often appear late in the disease Abdominal pain Change in bowel habits Painless rectal bleeding Intestinal obstruction Fatigue and weakness may occur if chronic blood loss has led to anemia.
Colorectal Cancer
Diagnostic studies Occult blood in the stool - can be an early marker - used for screening adults older than 40 years of age. Colonoscopy is recommended in those older than 50 years of age or 10 years before the earliest diagnosis of colon cancer in a first-degree relative Carcinoembryonic antigen (CEA) may be used to monitor progress after dx Chest radiography and CT are used to detect metastases.
Colorectal Cancer
Patients older than 50 years of age with new-onset constipation should be evaluated for what?
Colorectal Cancer
Treatment Surgical resection accompanied by chemotherapy in patients with stage III (Dukes C or higher) or higher (and sometimes in stage II [Dukes B]) lesions. Radiation may be used for rectal tumors.
Colorectal Cancer
Adult with comorbidities pneumonia tx
Combination of Augmentin or Cephalosporin and Doxycycline or Macrolide Fluoroquinolone monotherapy
Clinical Features: 1-10 day history Cough Purulent sputum SOB Tachycardia Pleuritic chest pain Fever/chills Crackles Dullness to percussion if effusion Bronchial breath sounds over area of consolidation
Community Acquired Pneumonia
Diagnosis: Sputum stain or culture (MC pathogen is strep pneumoniae) CXR: - lobar or segmental infiltrated - air bronchograms - pleural effusion Elevated WBC Elevated procalcitonin indicated bacterial
Community Acquired Pneumonia
AKA reflex sympathetic dystrophy
Complex Regional Pain Syndrome
Clinical features: Most occur following a soft-tissue injury Hallmark feature = is severe burning or throbbing pain with associated allodynia in the affected region/extremity Cyanosis Abnormal sensitivity to cold and warm exposure Abnormal skin temperature Atrophy may also be present
Complex Regional Pain Syndrome
Diagnostic studies: Primarily Clinical Regional nerve block - complete relief of pain is consistent with this Bone scintigraphy Plain x-rays MRI
Complex Regional Pain Syndrome
General characteristics: Usually begins after: - an operation - an injury (such as fracture) - following a vascular event such as stoke/MI Characterized by: - regional pain in the affected limb that is greater than expected - restricted mobility - edema - color changes of the skin - spotty bone thinning Cause is unknown, thought to be d/t abnormal sensitivity to inflammatory mediators of pain
Complex Regional Pain Syndrome
Treatment: Early mobilization following an injury Pain relief: - Amitriptyline - Nortriptyline - Gabapentin - NSAIDs in select patients. If other treatments fail: - Bisphosphonates - Regional nerve blocks - Dorsal column stimulation
Complex Regional Pain Syndrome
Mild traumatic brain injury Headache Vision changes Vomiting LOC Confusion Dizziness Amnesia CT: study of choice --> normal Tx: rest, no contact sports, no lights
Concussion
Leads to abnormalities in the: - skin or mucous membranes - nasal discharge (snuffles) - hepatosplenomegaly - anemia - osteochondritis If infants are not treated, they may develop: - interstitial keratitis - Hutchinson teeth - saddle nose - deafness - CNS abnormalities. What stage of syphilis?
Congenital Syphilis
results from a group of disorders characterized by alterations in serum calcium related to resistance to PTH.
Congenital pseudohypoparathyroidism
Diagnosis: Echo determines ejection fraction X-ray - cardiomegaly - pulmonary effusions - interstitial edema (Kerley B Lines) - Venous dilation - Alveolar fluid Increased BNP (> 500) Thyroid in elderly Iron for hemochromatosis
Congestive Heart Failure
MC cause: CAD HTN M DM LV remodeling ⇒ dilation, thinning, mitral valve incompetence, RV remodeling
Congestive Heart Failure
Signs/Symptoms: Exertional/nocturnal dyspnea Chronic nonproductive cough Fatigue Nocturia Cheyne-stokes breathing Edema Rales S4 (diastolic HF, preserved EF) S3 (systolic; reduced EF) JVD >8cm, cyanosis, hepatomegaly, jaundice
Congestive Heart Failure
Treatment: Aerobic exercise Low sodium diet Tobacco/alcohol cessation ACEi + BB Loop diuretics
Congestive Heart Failure
signs of shock
Cool Pale Low cap refill
Risks: - pulm disease --> COPD -interstitial lung disease - pulm HTN Symptoms = JVD, ascites, edema DX: echo, R cath Treatment: diuretics & oxygen, anticoag
Cor pulmonale
condition that causes the right side of the heart to fail. Long-term high blood pressure in the arteries of the lung and right ventricle of the heart can lead to this
Cor pulmonale
Definitive diagnostic procedure for angina, but used selectively because of cost and invasiveness
Coronary angiography
AKA Ischemic Heart Disease
Coronary vascular disease
Characterized by insufficient oxygen supply to cardiac muscle Most commonly caused by atherosclerotic narrowing Less often caused by constriction of coronary arteries (vasospastic prinzmetal angina)
Coronary vascular disease
Clinical Features: Angina pectoris Levine sign Risk factors - smoking, diabetes, dyslipidemia, HTN, family hx, men > 55, women > 65
Coronary vascular disease
Diagnosis: High-sensitivity high CRP Lipids Triglycerides Carotid U/S
Coronary vascular disease
Mechanism of Action: Foam cells are macrophages that gobble up lipids in the wall; it then dies off and stays there and becomes a foam cell; when it dies it releases cytokines that attract more macrophages to the area ⇒ plaque clot Fibrous plaque forms over lipid core: - Complete clot - ST-elevation MI - Incomplete clot - unstable angina/NSTEMI - Vulnerable plaque is easy to rupture; thick plaque is stable - Adhesion, activation, aggregation, propagation of clot, platelet adherence
Coronary vascular disease
Treatment: Preventative lifestyle modification Primary prevention = platelet inhibitors (Aspirin, clopidogrel) = cornerstone Sublingual NTG Long acting nitrate Beta blockers or CCBs ACEi Ranolazine before exercise
Coronary vascular disease
Gradual onset Mouth to anus distribution Rectum frequently spared Predominantly right sided Skip lesions Cobblestoning Transmural depth Diarrhea and pain Barium study: string sign + ASCA Complications - fistulas - toxic megacolon - colon cancer
Crohn's Disease
Treatment: Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin First line: Mesalamine Maintenance: 5-ASA (Asacol, Pentasa) Surgery is not curative. Adjacent portion of the bowel is affected post-op
Crohn's Disease
Clinical findings: Pulmonary disease may develop in patients with COPD, chronic steroid use, or posttransplant. Fever, cough, and dyspnea occur Chest radiography reveals nodules or pneumonitis. CNS disease causes headache and meningeal signs - occurs with a CD4 count of less than 50 cells/μL
Cryptococcus
Diagnostic studies: CSF - variable pleocytosis (predominantly lymphocytes) - increased opening pressure - increased protein - decreased glucose. Budding, encapsulated fungus may be isolated on a culture. Antigen can be detected in CSF and serum. India ink stain or serology with latex agglutination assay
Cryptococcus
General characteristics: C. neoformans Encapsulated, budding yeast Found in soil contaminated with dried pigeon dung. Transmitted through inhalation
Cryptococcus
Treatment: In patients with HIV disease - oral fluconazole is continued for 10 weeks - severe = amphotericin B can be administered for the first 2 weeks, followed by oral fluconazole. - Lifelong fluconazole therapy is recommended. In non-HIV immunocompromised patients - the mortality rate is much higher - treatment is amphotericin B.
Cryptococcus
Low dose 1 mgdexamethasone suppression test at 11 pm → Failure of steroid to decrease cortisol levels is diagnostic --> Proceed next to high dose dexamethasone suppression test
Cushing's Disease
Signs/Symptoms: Increased ACTH secretion from anterior pituitary Prolonged exposure to excess cortisol Buffalo hump Moon facies Pigmented striae Obesity Skin atrophy Hypertension Weight gain Hypokalemia
Cushing's Disease
24-hour urinary free cortisol is the most reliable index of cortisol secretion = elevated urinary cortisol Low 1 mg dose dexamethasone suppression test → Give a steroid (dexamethasone) --> Failure of steroid to decrease cortisol levels is diagnostic (cortisol >5) --> High dose dexamethasone suppression test --> No suppression = this
Cushing's Syndrome
Impairment of cystine transport <1% of kidney stones Radiolucent Occur only in autosomal recessive cystiuria tx: alkali to increase urine citrate
Cystine Stones
Clinical features: Frequency, urgency, dysuria Suprapubic discomfort. Gross hematuria may occur Symptoms in women often appear following sexual intercourse or use of a diaphragm with spermicide. Examination is often unremarkable, especially in elderly patients.
Cystitis
Diagnostic studies: Urinalysis - pyuria - bacteriuria - hematuria Urine dipstick: nitrite, leukocyte esterase Urine culture - positive (>103 CFUs/mL) for the offending organism. Imaging is warranted only if pyelonephritis, recurrent infections, or anatomic abnormalities are suspected.
Cystitis
Infection of the normal bladder MC cause - E coli 80% - enterococci Route of infection typically is ascending from the urethra. MC in women.
Cystitis
Treatment Uncomplicated in women - TMP/SMX - Nitrofurantoin Fluids should be encouraged Hot sitz bath Preventive measures - proper hygiene - urine acidification - voiding after intercourse.
Cystitis
Clinical findings: Perinatal infection - infant may be asymptomatic until later in life - jaundice, hepatosplenomegaly, periventricular CNS calcifications, mental retardation, motor disability, and purpura. Acute acquired - transmitted through sexual contact, breast milk, blood transfusion, or respiratory droplets - fever, malaise, myalgias, arthralgias, splenomegaly, abnormal liver enzymes, leukopenia, and atypical lymphocyte Neurologic manifestations include polyradiculopathy, transverse myelitis, and encephalitis. Infection is theorized to play a role in the pathogenesis of inflammatory bowel disease, atherosclerosis, and breast cancer.
Cytomegalovirus
Diagnostic studies: Tissue biopsy looks for intracytoplasmic inclusions ("owls' eyes"). Patients may exhibit lymphocytosis or leukopenia. Culturing is very difficult; antigens can be detected in blood, urine, or CSF via PCR.
Cytomegalovirus
General characteristics: HHV 5 Most infections are asymptomatic. Illness occurs in the immunocompromised, especially patients with HIV disease or posttransplant.
Cytomegalovirus
Treatment: Ganciclovir, valganciclovir, foscarnet, and cidofovir - Initial IV loading therapy is followed by maintenance therapy. - Sustained-release ganciclovir implants for suppression of retinal infections Prevention - limiting blood transfusions - filtering to remove leukocytes - restricting the organ donor pool to seronegative donors
Cytomegalovirus
Sitagliptin (Januvia) Saxagliptin
DPP-4 Inhibitors
therapy that should be considered for all SS and S β0 thalassemia patients as young as 1 year old to increase Hgb F production, prevent complications, and increase lifespan.
Daily lifelong oral hydroxyurea
Normal glucose until 2-8 am when it rises. Results from decreased insulin sensitivity and a nightly surge of counter-regulatory hormones during nighttime fasting Treatment: - bedtime injection of NPH to blunt morning hyperglycemia - avoiding carbohydrate snack late at night
Dawn Phenomenon
ACEi/ARB contraindicated in what?
Diabetes with proteinuria
ACUTE onset & fluctuating over 24 hours Characterized by: - alteration of consciousness - waxing and waning of symptoms - psychomotor retardation or agitation - decreased attention span. Medical emergency and should be evaluated promptly. MC with surgical admissions, especially orthopedic and urologic procedures.
Delirium
Diagnosis: Mental status examination (MMSE) Labs (chemistry, B12/folate) LP in a febrile, delirious patient (cerebral edema)
Delirium
Encourage family visitation Remove or avoid restraints when possible Mobilize the patient Assist with feeding Reduce noise Provide familiar surroundings, including assistive devices such as eyeglasses and hearing aids.
Delirium
Reversible causes: Surgery in patients with heart disease or diabetes Alcohol Abuse Thyroid storm UTI Pneumonia TBI Meds (benzos, anticholinergics, opioids)
Delirium
Treatment: Usually reversible if treat underlying cause Recommend lorazepam or preferably haloperidol in small doses, if medication is necessary to permit thorough evaluation.
Delirium
Symptoms: - Fruity breath - nausea, vomiting - dehydration - tachypnea (Kussmaul breathing) Labs - elevated glucose > 250 - low bicarb - low pH - ketonuria - ↓ Insulin, ↑Glucagon
Diabetic Ketoacidosis
Progressive impairment of intellectual functioning Compromise in at least two of the following spheres of mental activity: - language - memory - visuospatial skills - executive function - emotional behavior - personality
Dementia
Types: MC Alzheimer's Vascular Parkinson's Hungtington's Frontotemporal
Dementia
is a congenital cause of hypocalcemia arising from parathyroid hypoplasia, thymic hypoplasia, and outflow tract defects of the heart.
DiGeorge syndrome
Clinical features: Intense thirst with fluid intake of 2 to 20 L/day Craving for ice water Large-volume polyuria Hypernatremia Dehydration. Unremitting enuresis may be present in partial disease. *aggravated by STEROIDS
Diabetes Insipidus
Diagnostic studies: 24hr urine for volume and creatinine >2L/24hr Serum osmolality is high Uric acid may be high Urine osmolality is low BUN may be low A supervised vasopressin challenge test may distinguish central from nephrogenic MRI of the pituitary, hypothalamus, and the skull may reveal mass lesions.
Diabetes Insipidus
General characteristics: Caused by a deficiency of or resistance to vasopressin (ADH) Serum osmolality is 285 to 295 mOsm/kg. Normal urine specific gravity is between 1.010 and 1.030 - in this may be closer to 1.00.
Diabetes Insipidus
Treatment: Desmopressin acetate - central - associated with pregnancy Mild cases may require no treatment except adequate hydration. Respond partially to hydrochlorothiazide with potassium or amiloride supplementation - Central - Nephrogenic Indomethacin - Nephrogenic
Diabetes Insipidus
Clinical Features: Polyuria Polydipsia Polyphagia Fatigue Weight loss (low water) Dawn Phenomenon Somogyi effect
Diabetes Mellitus Type 1
Low Insulin and C peptide levels GAD65 IA-2 antibodies
Diabetes Mellitus Type 1
No insulin due to destruction of beta cells (Islet cells) Autoimmune- HLA-DR3/4/O antibodies. Islet cell antibodies MC in Children Risk of DKA
Diabetes Mellitus Type 1
Treatment: Insulin Check glucose 3x daily at home Increase fiber in diet GFR and urine albumin/year
Diabetes Mellitus Type 1
High fasting insulin and C peptide
Diabetes Mellitus Type 2
Treatment: Metformin Sulfonylureas Thiazolidinedione Alpha-glucosidase inhibitors Meglitinides GLP-1 Agonist DDP 4 inhibitors SGLT2 inhibitors Insulin if A1c > 9
Diabetes Mellitus Type 2
Causes: Associated with reduced strength of ventricular contraction, resulting in dilation of the left ventricle Idiopathic Alcohol related Major catecholamine discharge Myocarditis Endocrinopathies, genetic diseases
Dilated Cardiomyopathy
Echo: Left ventricular dilation and dysfunction
Dilated Cardiomyopathy
MC type of cardiomyopathy
Dilated Cardiomyopathy
Signs/Symptoms: MC in black men Left or biventricular heart failure Cardiomegaly S3, elevated JVP ECG: - S-ST changes - Conduction abnormalities - Ventricular ectopy
Dilated Cardiomyopathy
Treatment: Abstinence from alcohol is essential. Underlying disease should be treated. CHF requires supportive treatment. b-blocker + ACE + Loop diuretic ie. AABCD (anticoagulation, ACE-I, b - blocker, CCB, and diuretic)
Dilated Cardiomyopathy
Clinical findings: Nasal infection = nasal discharge. Laryngeal infection = upper airway and bronchial obstruction. Pharyngeal infection - MC form - Gray membrane covers the tonsils and pharynx - Complain of mild sore throat, fever, and malaise. Myocarditis and neuropathy involving the cranial nerves may develop; untreated cases exhibit toxemia and prostration. Diagnosis is clinical; a culture confirms it.
Diphtheria
General characteristics: Corynebacterium diphtheriae Transmitted via respiratory secretions. Has a propensity for mucous membranes, especially the respiratory tract. Produces an exotoxin that causes myocarditis and neuropathy.
Diphtheria
Treatment: Horse serum antitoxin must be administered in all cases. It is obtained from the CDC. Airway obstruction may necessitate the removal of the membrane via laryngoscopy. Penicillin or erythromycin is effective. Contacts should be treated with erythromycin. Patients should be isolated until three negative pharyngeal cultures are documented.
Diphtheria
Any age Cause: sepsis, burns, trauma Abnormal PT/PTT Bleeding and clotting disorder Treatment: - fresh frozen plasma - Cryoprecipitate - Platelets
Disseminated Intravascular Coagulation (DIC)
Septic Shock Neurogenic Shock Anaphylactic Shock
Distributive Shock
Generally presents as sudden-onset, large-volume hematochezia Resolves spontaneously, although continuous or recurrent bleeding is indication for surgery.
Diverticular Bleeding
Diagnostic studies: Plain-film radiography should be done to rule out free air. CT is warranted if patients do not respond to therapy. Barium enema should be avoided during an acute episode because it may lead to perforation and peritonitis.
Diverticular Disease
General characteristics: Diverticulosis Diverticulitis MC > 60 Can be prevented with a high-fiber diet and avoidance of obstructing or constipating foods.
Diverticular Disease
Clinical Features: Sudden-onset abdominal pain, usually in the LLQ or suprapubic region With or without fever Symptoms may range from mild disease to severe infection with peritonitis. Altered bowel movements as well as nausea and vomiting are common.
Diverticulitis
Inflammation of the diverticula caused by obstructing matter Occult blood in the stool and mild to moderate leukocytosis MC in sigmoid colon
Diverticulitis
large outpouchings of the mucosa in the colon
Diverticulosis
what is the DOC for tick-borne diseases in children over 8 y/o?
Doxycycline
"Post MI Syndrome" Pericarditis Fever Leukocytosis Pericardial or pleural effusion 1-2 weeks after MI
Dressler Syndrome
Amiodarone has a 100-day half-life May cause a serum increase of T4 by 20%-40% during the first month of therapy but causes cellular resistance to T4. A resultant hypothyroid picture ensues with elevated TSH and symptoms typical of hypothyroidism.
Drug induced Thryoiditis
Causes: Procainamide Hydralazine Isoniazid Methyldopa Quinidine Chlorpromazine. f the offending agent is stopped, the symptoms typically resolve. These patients have positive antihistone antibodies.
Drug-induced lupus
Traveler's diarrhea from food Cramping, water diarrhea Tx: Hydration, bismuth/loperamide
E-coli
Diagnostic studies for angina
ECG Stress test Echo Coronary angiography
When are Implantable cardioverter-defibrillators (ICDs) are indicated in heart failure
EF <35%
____________ may be indicated if greater than 70% stenosis of the common or internal carotid artery is present in CVA
Endarterectomy
"Pink puffers"
Emphysema
CXR Findings: Decreased lung markings at apices Flattened diaphragms Hyperinflation Small, thin-appearing heart Parenchymal bullae and blebs
Emphysema
Clinical Findings: Exertional dyspnea Cough is rare Quiet lungs No peripheral edema Thin; recent weight loss Barrel chest Hyperventilation Pursed-lip breathing
Emphysema
Condition in which the air spaces are enlarged as a consequence of destruction of alveolar septa Irreversible enlargement of air spaces distal to terminal bronchioles --> Destruction of air spaces; loss of elastic recoil in acinus --> Air trapping
Emphysema
Pneumonia MC in postsplenectomy
Encapsulated organisms Streptococcus pneumoniae Haemophilus pneumoniae
Clinical Features: Involves the brain directly Altered consciousness Seizures Personality changes Other focal neurologic signs Involvement of HPA - temp dysregulation - DI - SIADH
Encephalitis
Inflammation of brain parenchyma Causes: - MC = herpes (HSV, VZV, EBV) - Enterovirus, MMR, rabies, HHV6, History: - Travel/Exposure history -camping/hiking, animal bite - Sexual history (HSV 1 or 2) - Ill contacts - Vaccine history
Encephalitis
Treatment: Supportive, control sx Seizure: IV Lorazepam HSV/VZV/EBV: Acyclovir IV 21 days - first dose within 30 minutes - all cultures before antiviral! Clinical Course: - CSF analysis for PCR repeated at completion of antiviral - continue therapy until (-)
Encephalitis
Work-Up: LP with CSF analysis - CSF PCR amplification MRI HSV etiology-90%, EEG-75% Labs: - CBC, CMP, PT/PTT - Blood cultures (no sepsis) - Culture any herpetic lesion for Tzanck smear
Encephalitis
General characteristics: Local spread to the mediastinum is common because the esophagus has no serosa. Risk factors: - cigarette smoking - chronic alcohol use. - exposure to other caustic agents - spicy foods - mucosal abnormalities - poor oral hygiene - human papillomavirus (HPV)
Esophageal Cancer
Treatment: Generally surgical Radiotherapy and adjunctive chemotherapy have been used in various combinations with or without surgery.
Esophageal Cancer
Dilated veins in the distal esophagus or proximal stomach Caused by elevated pressure in the portal venous system, typically from cirrhosis
Esophageal Strictures
Presentation: Often asymptomatic until hematemesis Etiology: - Portal hypertension (from cirrhosis) - Budd-Chiari syndrome (from occlusion of hepatic veins)
Esophageal Strictures
Screening: Indicated when cirrhosis or portal hypertension is diagnosed When high-risk - prophylaxis should be started - further screening is not necessary Every 2 to 3 years for patients without varices Every 1 to 2 years for patients with small varices
Esophageal Strictures
Treatment: Therapeutic endoscopy - endoscopic banding and IV octreotide Prevent with nonselective beta-blockers
Esophageal Strictures
Clinical Features Painless upper GI bleed that can be bright red frank bleeding or coffee ground in appearance. Large bleeds may cause hypovolemic shock.
Esophageal Varices
Diagnosis: Established clinically when a patient with signs of cirrhosis presents with hematemesis. Endoscopy will localize the bleeding. Generally asymptomatic until they bleed, at which point they are frequently life threatening.
Esophageal Varices
General characteristics: Dilations of the veins of the esophagus, generally at the distal end. Underlying cause in adults is portal hypertension MC cause - cirrhosis either from alcohol abuse or from chronic viral hepatitis Budd-Chiari syndrome may cause thrombosis of the portal vein, leading to this
Esophageal Varices
Treatment: Prevention of bleeding - β-blocker - discontinuation of hepatotoxic agents, especially alcohol - Endoscopic band ligation may be used if medical therapy is insufficient. Endoscopic band ligation is the preferred therapy for acute bleed. Endoscopic pharmacologic vasoconstriction (e.g., octreotide) in conjunction is highly effective
Esophageal Varices
Clinical features Odynophagia (painful swallowing) or dysphagia (difficulty swallowing) in an immunocompromised patient. Physical examination may reveal signs of underlying immune deficiency such as: - fever - lymphadenopathy - rashes
Esophagitis
Diagnostic studies Endoscopy - CMV or HIV reveals large, deep ulcers - HSV is characterized by multiple shallow ulcers - Candidal infection shows white plaques. Cytology or culture from endoscopic brushings is needed for definitive diagnosis. Evaluate for underlying immunodeficiency.
Esophagitis
rare, except in immunocompromised persons. Common Causes - Fungal: Candida sp. should be considered, especially if oral thrush is present. - Viral: CMV and HSV Uncommon Causes - HIV - Mycobacterium tuberculosis - Epstein-Barr virus (EBV), - Mycobacterium avium intracellulare
Esophagitis
Cause is unknown Autosomal dominant inheritance Higher prevalence with increased age Enhanced by emotional stress Small quantities of alcohol commonly provide dramatic, temporary relief from the tremor. Although the tremor may interfere with manual skills, it causes only minimal disability.
Essential Tremor
Clinical features: Rhythmic, 6- to 8-Hz, to-and-fro movement Usually of the upper extremities but sometimes of the head (titubation). The tremor may initially be in only one extremity. Speech may also be affected if the laryngeal muscles are involved.
Essential Tremor
Treatment: Low doses of a β-blocker, usually propranolol - Used with caution in asthmatics and those with bradycardia. Primidone if propranolol fails. Primidone and propranolol in refractory patients
Essential Tremor
Most useful and cost effective diagnostic study for angina
Exercise stress testing
Exogenous administration of what can cause reactivation of tuberculosis and candidiasis?
Exogenous corticosteroids
Hemorrhoids that are visible perianally
External Hemorrhoids
Stone in the ureteropelvic junction. Where does pain radiate to?
Frequency Urgency Lower pelvic pain
Clinical features: Frontal lobe symptoms: - behavioral symptoms (euphoria, apathy, and disinhibition) - compulsive disorders Significant speech impairment. Several primitive reflexes (frontal release signs) are often elicited, including the palmomental, palmar grasp, and rooting reflexes.
Frontotemporal dementia
Laboratory studies: MRI - frontal lobe and/or anterior temporal lobe atrophy - in early cases may appear normal. PET scans classically - frontal and/or anterior temporal hypometabolism - differentiates from Alzheimer associated with biparietal hypometabolism.
Frontotemporal dementia
Secondary to degeneration of the frontal lobe of the brain and may include the temporal lobe Between age 40 and 70 ctiologies include: - Pick disease - dementia associated with ALS
Frontotemporal dementia
Treatment: Cholinesterase inhibitors are not effective Supportive care is essential as there is no curative treatment. Behavioral symptoms may require treatment SSRIs for depression.
Frontotemporal dementia
Clinical features: Patients with episodic hemolysis are usually healthy and have no splenomegaly. Female carriers are rarely affected.
G6PD Deficiency
Laboratory findings: During hemolytic episodes - reticulocytes increase - serum indirect bilirubin increase. Peripheral smear reveals - bite cells - Heinz bodies (denatured hemoglobin).
G6PD Deficiency
Treatment: In most cases, hemolytic episodes are self-limited as red cells are replaced as soon as the offending agent is stopped Oxidative drugs and fava beans should be avoided.
G6PD Deficiency
X-linked recessive disorder MC - American black males (10% to 15%) - some Mediterranean populations Episodic hemolysis causes: - Oxidative drugs (e.g., aspirin, dapsone, primaquine, quinidine, sulfonamides, nitrofurantoin) - fava bean ingestion - infection cause episodic hemolysis Severe deficiency may cause chronic hemolysis.
G6PD Deficiency
Diagnostic studies: Random IGF-1 levels A 75-g loading dose 1-hour oral glucose tolerance test (OGTT) will show failure of GH to decrease to less than 2 μg/L MRI is the imaging modality of choice - a negative scan virtually rules out a GH pituitary adenoma. Skull radiography - enlarged sella and thickened skull - hands or feet may reveal tufting of the terminal phalanges
GH excess
Etiology: MCC = benign pituitary adenoma - > 1 cm in diameter - stimulates GH release - GH stimulates release of insulin-like growth factor 1 (IGF-1) from the liver Somatotroph-producing tumors account for 10% to 15% of pituitary tumors Mixed cell tumors, pituitary adenomas are often associated with PRL secretion (40%).
GH excess
Presentation: Gigantism Acromegaly
GH excess
Treatment: Somatostatin analogs (octreotide/lanreotide) are inhibitory and may decrease tumor size Transsphenoidal microsurgery most successful in patients with: - preoperative blood GH < 50 ng/mL - pituitary tumors no larger than 2 cm in diameter - best measure of surgical success is normalization of GH and IGF-1 levels Pegvisomant blocks hepatic IGF-1 production, providing normalization of IGF-I in about 90% of patients Regardless of treatment modality, IGF-1 should be measured every 3 to 4 months, then every 6 months once well controlled.
GH excess
PRL levels can also be measured because ___________________ often co-secrete PRL
GH-secreting tumors
Exanitide Dulaglutide Semaglutide (Ozempic) Liraglutide
GLP-1 Agonists
Clinical features: Dyspepsia weight loss associated with anemia and occult GI bleeding in a patient older than 40 years of age are the typical presenting complaints Progressive dysphagia Postprandial vomiting Signs of metastatic spread include Virchow node and Sister Mary Joseph nodule
Gastric adenocarcinoma
Diagnostic studies: Iron deficiency anemia is the MC lab finding Liver enzymes may be elevated Endoscopy with cytology should be done on any patient older than 40 years of age with dyspepsia who is unresponsive to therapy After the diagnosis has been established, abdominal CT is used to determine the extent of disease.
Gastric adenocarcinoma
General characteristics: Among the most common types of cancer worldwide but is less common in the United States MC in men younger than 40 With early diagnosis there is an 80% cure rate Muscularis propria is involved, the cure rate is 50% Lymphatic spread, the cure rate is 10%. Strong association with H. pylori and smoking
Gastric adenocarcinoma
Treatment: Curative or palliative resection of the tumor. Chemotherapy or radiation may provide some palliative benefit or may be used preoperatively for some tumors.
Gastric adenocarcinoma
Causes: Erosive: - NSAIDs - alcohol - stress from CNS injury, burns, sepsis, or surgery Non-erosive: - H. pylori - systemic - autoimmune disorders (e.g., pernicious anemia)
Gastritis
Clinical features - Generally reflect the underlying syndrome rather than the gastric injury itself. - Dyspepsia and abdominal pain are common indicators Treatment - Remove the causative factor (e.g., NSAIDs, alcohol). - Treat the underlying cause.
Gastritis
Diagnostic studies Endoscopy with biopsy reveals the location and extent as well as the presence of H. pylori. A urea breath test can be used to detect H. pylori Specific tests for underlying conditions (e.g., vitamin B12 level, CBC for pernicious anemia) should be assessed as indicated by history.
Gastritis
Inflammation of the stomach Protective factors include: - mucus - bicarbonate - mucosal blood flow - prostaglandins - alkaline state - hydrophobic layer, - epithelial renewal. Any imbalance in protective factors can lead to inflammation.
Gastritis
MC form of Salmonella infection. Incubation period is 8 to 48 hours after ingestion of contaminated food or drink. Fever Nausea and vomiting Crampy abdominal pain Bloody diarrhea Last 3 to 5 days. Diagnosis is made through stool culture. Illness is self-limited, and treatment is symptomatic. What kind of Salmonellosis?
Gastroenteritis
Most common form of Salmonella infection. 8 to 48 hours after ingestion of contaminated food or drink. Fever, nausea and vomiting, crampy abdominal pain, and bloody diarrhea last 3 to 5 days. Diagnosis is made through stool culture.
Gastroenteritis
Clinical features: MC Heartburn - worse after meals and when lying down - relieved with antacids Hoarseness Halitosis Sore throat More severe disease, generally caused by a severe impairment of lower esophageal sphincter tone, occurs spontaneously when supine, whereas less severe disease is associated with a pattern of heartburn following meals but not associated with nighttime symptoms
Gastroesophageal Reflux Disease
Diagnostic studies Most often, a clinical diagnosis More severe symptoms warrant endoscopy to confirm the diagnosis and to assess for epithelial damage. Be sure to consider the possibility that symptoms are caused by myocardial ischemia (ECG) Severe or refractory cases - Barium swallow - Esophageal manometry - Ambulatory 24-hour pH monitoring Consider CBC to evaluate for anemia if there is suspicion of esophageal bleed.
Gastroesophageal Reflux Disease
Result of recurrent reflux of gastric contents into the distal esophagus because abnormality of the lower esophageal sphincter. Can lead to Barrett esophagitis Medications may cause or worsen: - including antibiotics (tetracycline) - bisphosphonates - iron - NSAIDs Other predisposing factors include: - obesity - pregnancy - diabetes - hiatal hernia
Gastroesophageal Reflux Disease
Clinical features: Hematuria is present Urine is often tea or cola colored. Oliguria or anuria is present. Edema of the face and eyes is present in the morning Edema of the feet and ankles occurs in the afternoon and evening. Hypertension is also a common
Glomerulonephritis
Treatment Lifestyle modifications - Smoking cessation - No eating before bedtime - Avoid large meals - Avoidance of alcohol, caffeine, etc - Raise the head of the bed Pharmacotherapy - Antacids if mild - Histamine (H2) blockers (cimetidine, ranitidine, famotidine, nizatidine) - PPI (-prazole) is first line in moderate to severe disease or in patients who are unresponsive to H2 blockers or have evidence of erosive gastritis. .Surgical and endoscopic techniques are available for refractory cases
Gastroesophageal Reflux Disease
Occur when there is widespread seizure activity in the left and right hemispheres of the brain. Start midbrain or brainstem and spreads to both cortices Types - Absence seizures - Tonic-clonic seizures - Atonic seizures - Clonic seizures - Tonic seizures - Myoclonic seizures
Generalized Seizures
Treatment: No cure, tx to prolong life and alleviate sx Management of pain Control of HTN (ACE/ARB) High fluid intake Low protein diet Dialysis or transplantation should be considered when renal insufficiency becomes life threatening
Genetic Studies
_______________ for PKD 1 and PKD 2 can detect the presence of the mutation before symptoms develop. Early detection may allow affected individuals to forestall loss of kidney function through diet and BP control.
Genetic Studies
Hilar lymphadenopathy in addition to a peripheral granulomatous lesion due to Mycobacterium tuberculosis infection in the mid to lower lung segments is referred to as a
Ghon complex
Clinical features: Unilateral temporal headache Scalp tenderness Jaw claudication Throat pain Diplopia Elevated inflammatory markers. Symptoms of polymyalgia rheumatica (pain and stiffness mainly of shoulder and pelvic girdle) are present in 50% of patients. The temporal artery examination is usually normal but may be nodular, enlarged, tender, or pulseless.
Giant Cell Arteritis
Diagnostic studies: High ESR and CRP High alk phos Normochromic normocytic anemia Thrombocytosis Temporal artery biopsy should be performed promptly for definitive diagnosis Temporal artery ultrasonography may show: - thickening (halo sign) - stenosis - occlusion
Giant Cell Arteritis
General characteristics: Systemic inflammatory condition of medium and large vessels. MC in > 50 y.o. w/ polymyalgia rheumatica Varicella-zoster antigen is found in nearly 75% of temporal arteries If not treated aggressively, it can cause blindness. Large-vessel problems (e.g., thoracic aortic aneurysm) occur in 15% of patients within 7 years.
Giant Cell Arteritis
Treatment: High-dose prednisone (1 to 2 months before tapering) and low-dose aspirin Treatment should be initiated immediately and not delayed for biopsy results
Giant Cell Arteritis
- scalp tenderness - jaw claudication - headache - temporal artery tenderness - may lead to vision loss
Giant cell (temporal) arteritis
Occurs in children prior to closure of the epiphyses and causes excess growth of long bones. It is extremely rare compared to acromegaly. What kind of GH excess?
Gigantism
Eye opening - 4 pts Verbal - 5 pts Motor - 6 pts
Glasgow Coma Scale
Damage of the renal glomeruli by deposition of inflammatory proteins in the glomerular membranes as the result of an immunologic response. The severity of disease is dictated by the degree of glomerular injury. 60% of cases are in children 2 to 12 years of age. Prognosis is excellent in children and worse in adults, especially in those with preexisting renal disease.
Glomerulonephritis
Diagnostic studies: Urinalysis Serum complement (C3) levels are often decreased. Renal biopsy may be done to determine exact diagnosis or severity of disease if diagnosis remains in doubt.
Glomerulonephritis
Treatment: Steroids and immunosuppressive drugs may be used to control the inflammatory response, which is responsible for the damage Dietary management: Salt and fluid intake should be decreased. Dialysis should be performed if symptomatic azotemia is present. Medical therapy - ACEi if chronic
Glomerulonephritis
Two types: Nephritic - IgA Nephropathy (Berger disease) - Postinfectious - Membranoproliferative - Rapidly progressive Nephrotic - membranous - minimal change disease - focal segmental glomerulosclerosis (FSGS) - Secondary: lupus, diabetes, preeclampsia
Glomerulonephritis
Clinical findings: Men - burning on urination - a serous or milky discharge - 1 to 3 days later, the urethral pain is more pronounced - discharge becomes yellow, creamy, profuse Women - often asymptomatic - dysuria, frequency and urgency - purulent urethral discharge - vaginitis and cervicitis are common Conjunctivitis is caused by direct inoculation - copious purulent discharge - usually unilateral - global rupture is a risk if the patient is not treated adequately
Gonorrhea
Diagnostic studies: Gram stain of urethral discharge typically shows Gram-negative intracellular diplococci. Smears are less often positive in women Cultures are essential in all cases
Gonorrhea
General characteristics: Gram-negative intracellular diplococcus that is transmitted during sexual activity. The highest incidence is found in 15- to 29-year-olds.
Gonorrhea
Treatment: Treatment of choice is IM ceftriaxone or oral cefixime Doxycycline or azithromycin should be administered simultaneously regardless of coinfection with Chlamydia. All partners should be treated. Infection is reportable in most states
Gonorrhea
- (+) anti-GBM antibodies - dx linear IgG deposits - treat with high dose steroids, plasmapheresis + cyclophosphamide What type of Rapidly progressive glomerulonephritis?
Goodpasture's syndrome
Treatment: Elevation and rest Weight loss Dietary modifications: - decreased ingestion of purines (meats, beers, cheese) - decreased alcohol intake - increased protein Pharm - NSAIDS are drug of choice (Indomethacin) - Colchicine (SE: GI) - If cannot take above: Corticosteroid injection - Allopurinol = prophylaxis, not during acute attack
Gout
Young, >30 years old M>F Asymmetric Great toe, lower extremity joints Painful, red, swollen, tophi Synovial fluid crystals: - sodium urate - needle like crystals - negatively birefringent
Gout
- (+) C-ANCA What type of Rapidly progressive glomerulonephritis?
Granulomatosis with polyangiitis (Wegener's)
CSF Analysis: Variable Color Normal pressure Mildly elevated WBC count, lymphocytes Elevated protein Decreased glucose
Granulomatous Meningitis
Clinical features: Presentation is less acute; patients typically have symptoms for weeks to months. Subtle mental status changes are common.
Granulomatous Meningitis
Diagnostic studies: CSF analysis and culture is key, but results may take weeks depending on etiology. CT or MRI: - marked enhancement of the meninges - occasionally hydrocephalus. Serologic studies may help to confirm suspected etiologies. Treatment depends on cause.
Granulomatous Meningitis
Pathogens: - Mycobacterium tuberculosis - fungi (Cryptococcus, Coccidioides sp., Histoplasma) - spirochetes (Treponema pallidum, Borrelia burgdorferi). MC in immunocompromised individuals. Noninfectious cause = sarcoidosis
Granulomatous Meningitis
MC cause of hyperthyroidism Autoimmune disease affecting TSH receptors Some antibodies act like TSH to cause secretion of thyroid hormone Diffuse symmetric, enlargement and goiter may be seen Associated with HLA markers Exophthalmos
Grave's disease
AKA acute idiopathic polyneuropathy
Guillain-Barre Syndrome
Clinical featuresL Symmetrical extremity weakness that begins in lower extremities and ascends Proximal > distal muscles Deep tendon reflexes decreased or absent Sensory abnormalities are common but generally less marked than the motor symptoms. Can be life threatening if the muscles of respiration or swallowing are involved
Guillain-Barre Syndrome
Diagnostic studies: Electrophysiologic studies may reveal: - marked slowing of nerve conduction velocities, both motor and sensory - denervation or axonal loss CSF evaluation: - elevated protein - cell counts are normal
Guillain-Barre Syndrome
General considerations: Following minor infections, immunizations, or surgical procedures Progressive ascending flaccid paralysis Relationship with a preceding infection of the lungs or GI tract. MC precipitant = Campylobacter jejuni
Guillain-Barre Syndrome
Treatment: Hospitalized with close monitoring of respiratory status Plasmapheresis ASAP - reduces the time required for recovery IV immunoglobulin (IVIG) - preferred to plasmapheresis in adults with CV instability and in children PT, OT, Speech therapy Recovery is slow, but approximately more than half of patients make a full recovery within 1 year
Guillain-Barre Syndrome
Metabolic Acidosis non-anion gap mnemonic
HARDUPS
Elevated ____ are thought to be protective for CAD
HDL
Hemolysis Elevated Liver enzymes Low Platelets Population: Pregnant females Cause: Eclampsia Treatment: Delivery, MgSO4
HELLP Syndrome
In what population is a PPD ≥ 5 mm considered a positive test?
HIV Recent Tb exposure immunosuppressants
murmur increases with valsalva What cause of syncope?
HOCM
More than 85% of the U.S. population has evidence of infection Transmission is via infected saliva. Primary infection can be asymptomatic or produce severe disease. Recurrent, self-limited attacks are common Trigeminal Nerve What type of HSV?
HSV type 1
About 25% of the U.S. population is infected Transmission via sexual contact or from the mother's genital tract during delivery. This virus typically causes genital lesions (vulva, vagina, cervix, glans, prepuce, and penile shaft). Asymptomatic shedding and painful eruptions can be frequent Sacral root ganglion What type of HSV?
HSV type 2
Pneumonia MC in COPD
Haemophilus pneumoniae
MC Thyroid disease in the US females MC cause of sporadic goiter in children Thyroid is diffusely enlarged with firm, small nodules. Often progresses to hypothyroidism with detectable thyrotropin receptor-blocking antibodies and antithyroid peroxidase.
Hashimoto thyroiditis (aka chronic lymphocytic thyroiditis)
MC cause of hypothyroidism
Hashimoto thyroiditis (aka chronic lymphocytic thyroiditis)
PDE-5 side effects
Headache Flsuhing Visual disturbances Priapism
Secondary to hypertension Account for about 15% of strokes Caused by the rupture of a blood vessel Can be intracerebral or subarachnoid Less predictable Presentation is variable because of complications of blood dispersion, cerebral edema, and increased intracranial pressure
Hemorrhagic Stroke
Bleed proximal to ligament Coffee-ground: mild, frank blood: severe
Hematemesis
maroon/bright red --> LGI bleed
Hemathochezia
Clinical features: Jaundice from elevated indirect bilirubin Bilirubin gallstones Bone marrow expansion visible on x-rays Sickle cell disease can cause delayed puberty. Hepatosplenomegaly may be the cause of RBC lysis. Petechiae and purpura may indicate thrombocytopenia caused by TTP; DIC; HUS; and HELLP syndrome
Hemolytic Anemia
Decreased RBC survival and increased cell lysis. Mnemonic HIT - Hereditary, Immune attack, and Trauma to the RBCs. Hereditary - intrinsic (problem within the RBC) - hereditary spherocytosis - G6PD deficiency - sickle cell syndromes. External to the erythrocyte - immune attack - trauma to RBCs caused by TTP, HUS, DIC, burns
Hemolytic Anemia
Diagnostic studies: Elevated corrected reticulocyte count Falling hemoglobin Elevated indirect bilirubin Elevated LDH Direct Coombs or direct antiglobulin test (DAT) - antibodies on the RBCs Indirect Coombs - antibodies in the pts serum
Hemolytic Anemia
Children Cause: E coli Normal PT/PTT Fever Bleeding and clotting disorder Renal failure Treatment - support - emergent plasma exchange - no platelets
Hemolytic Uremic Syndrome (HUS)
Clinical features: Severely affected patients - repeated spontaneous hemorrhagic episodes with hemarthroses - epistaxis - intracranial bleeding - hematemesis - melena - microscopic hematuria - bleeding into the soft tissue and gingiva. Less severely affected patients - experience excessive bleeding following trauma or surgery PTT is prolonged. Reduced factor 8
Hemophilia A
General characteristics: Hereditary disease characterized by excessively prolonged coagulation time - X-linked recessive Most severe bleeding disorder
Hemophilia A
Treatment: First line: Infusion of recombinant factor VIII Mild-Moderate - Desmopressin (DDAVP) may elevate factor VIII Avoid aspirin Pain management - celecoxib - acetaminophen - opioids
Hemophilia A
Factor IX deficiency AKA Christmas diseas Heterogeneous group of disorders X-linked recessive disorder affecting males
Hemophilia B
- conservative and supportive measures - Antiedema (manitol/steroids) - endovascular repair and surgical clipping Treatment for what kind of CVA?
Hemorrhagic
HIT assay (PF4 heparin antibody ELISA test) is positive PTT Abnormal Causes clotting Tx: Stop heparin and use another anticoagulant
Heparin Induced Thrombocytopenia
General characteristics: Humans are the only reservoi Transmission via close contact and inoculation of virus into the mucosal surface or through cracks in the ski Remains latent within the dorsal root ganglia - Type 1 = trigeminal nerve - Type 2 = sacral root ganglia Reactivation may be precipitated by fever, stress, menses, trauma, ultraviolet light, weight gain or loss, immunosuppression
Herpes Simplex Infection
Treatment: Local wound care and supportive therapy are recommended. Treatment is with antivirals (e.g., acyclovir, valacyclovir). Keratitis is treated with trifluridine. Patients with frequent outbreaks may benefit from suppressive therapy - Foscarnet is beneficial in immunocompromised patients with resistant infections.
Herpes Simplex Infection
DX: barium upper GI series, upper endoscopy Tx: - Type 1 = same as GERD - Type 2 = surgery
Hiatal Hernia
Protrusion of the upper portion of the stomach into the chest cavity due to diaphragm tear It can cause symptoms of GERD
Hiatal Hernia
Type I: sliding hernia (MC) Type II: rolling hernia --> fundus protrudes
Hiatal Hernia
Clinical findings: Most infections are asymptomatic or mild and unrecognized. Acute - occurs in epidemics when the soil is disturbed - patients are prostrate and febrile, with few pulmonary complaints. Progressive disseminated - may be fatal within 6 weeks - fever, dyspnea, cough, weight loss, and prostration - ulcers may develop in the mouth, pharynx, liver, spleen, adrenals Chronic progressive pulmonary - occurs in older patients, especially those with COPS - manifests as chronic progressive pulmonary changes with calcified nodes and pericarditis. Disseminated disease - occurs in immunocompromised patients - represents reactivation rather than a new acute infection. - CD4 count of less than 100 cells/μL - fever and multi-organ failure; fulminant disease, septic shoc - Chest radiography shows miliary infiltrates.
Histoplasmosis
Diagnostic studiesL Anemia of chronic disease Increased alkaline phosphatase Increased lactate dehydrogenase (LDH) Increased ferritin A urine antigen assay can confirm the presence of disseminated disease Bronchoalveolar lavage may be helpful in patients with chronic pulmonary disease.
Histoplasmosis
General characteristics: H. capsulatum Dimorphic fungus found in soil infested with bird or bat droppings. Endemic to many areas and is transmitted by inhalation.
Histoplasmosis
Treatment: Itraconazole orally for weeks to months is recommended. Amphotericin B is recommended for patients who cannot tolerate or fail itraconazole therapy or in patients with meningitis or severe disease. Lifelong suppressive therapy with itraconazole is recommended for the immunocompromised.
Histoplasmosis
Clinical features: Painless cervical, supraclavicular, and mediastinal lymphadenopathy. Pain in the affected node after ingestion of alcohol may occur. Nodes on both sides of the diaphragm indicate stage III or above. A designation indicates a lack of constitutional symptoms. One-third of patients present with constitutional (stage B) symptoms (fever, night sweats, weight loss, pruritus, and fatigue), which are associated with a poorer prognosis.
Hodgkin's Lymphoma
Diagnostic studies: Lymph node biopsy Reed-Sternberg cells confirm the diagnosis Basic staging includes: - CT of neck, chest, abdomen, and pelvis - biopsy of the bone marrow
Hodgkin's Lymphoma
Group of cancers characterized by: - enlargement of lymphoid tissue, spleen, and liver - presence of Reed-Sternberg cells in lymph node biopsy tissue Epstein-Barr virus also appears to be an important factor MC in 15 and 45 years, peaking in the 20s, and again after 50 years of age Rare in children younger than 5 years of age.
Hodgkin's Lymphoma
Treatment: Combination chemotherapy cures most patients, even those with advanced-stage disease Low risk Stage IA and IIA - Radiation therapy Most other patients receive ABVD chemotherpay - Adriamycin - Bleomycin - Vinblastine - Dacarbazine
Hodgkin's Lymphoma
What is atrial fibrillation called when it is caused by excessive alcohol use or withdrawal
Holiday Heart
Clinical findings: The site of penetration is pruritic. Erythematous dermatitis with maculopapular or vesicular eruption follows (cutaneous larvae migrans) Scratching can cause secondary bacterial infections. Pulmonary stage may cause cough, wheeze, blood-tinged sputum, and low-grade fever.
Hookworms
Diagnostic studies: Eggs can be demonstrated in feces. Stool is positive for occult blood Hypochromic microcytic anemia and eosinophilia may be found
Hookworms
General characteristics: Endemic to the moist tropics and subtropics Humans are the only host. Eggs are passed in the stool and hatch in moist soil. Larvae penetrate the skin --> Migrate in the bloodstream to the pulmonary capillaries, where they destroy alveoli --> Carried by cilia to the mouth --> Larvae attach to the small bowel mucosa and suck blood --> Once mature, they release eggs to continue the cycle
Hookworms
Treatment: Mebendazole (twice/day for 3 days) or either pyrantel or albendazole Pyrantel cannot be used in children less than 5 years of age None of the treatments are recommended in pregnancy. Supportive treatment includes a high-protein diet, vitamins, and ferrous sulfate.
Hookworms
What does angina show on the ECG?
Horizontal or downsloping ST depression Nonspecific T wave changes
Unilateral facial anhidrosis, ptosis, miosis
Horner Syndrome
Pneumonia that occurs >48 hours after admission into the hospital MC in ICU patients on mechanical ventilation Pseudomonas aeruginosa = most likely pathogen in ICUs Other common organisms = staph aureus
Hospital-acquired (nosocomial) pneumonia
Clinical features: The acute syndrome is not identified ofte Can be progressive and insidious, or can be rapidly fatal Time from infection to symptomatic disease averages 10 year Systemic manifestations include fever, night sweats, and weight loss - wasting syndrome is a result of increased metabolic rate and decreased protein synthesis - disproportionate loss of muscle mass.
Human Immunodeficiency Virus
Diagnostic studies: Screening - detects antibodies - develop antibodies within 6 weeks of exposure 1. Rapid HIV antibody tests; results are available within 20 minutes 2. If positive, the rapid test should be followed with an ELISA tests 3. Confirmatory Western blot analysis to confirm infection further (false + ELISA can occur after influenza vaccine/connective tissue disease) CD4 count - decreases as the illness progresses, without treatmen - should be measured at the same time of day and by the same laboratory. - CD4 > 350 can have levels measured every 6 months - CD4 < 350 measured every 3 months or with any change in the patient status. Viral load is a measure of actively replicating virus, which correlates with disease progression.
Human Immunodeficiency Virus
General characteristics: Highest prevalence Afric Infects all the cells containing the T4 antigen, primarily the CD4 helper inducer lymphocytes - result is a disordered function of the immune system. - virus attaches to the T4 antigen, replicates, and causes cell fusion or cell death. - macrophages serve as a reservoir of virus and promote its dissemination to other organs. Transmitted through bodily fluids
Human Immunodeficiency Virus
Treatment: Postexposure prophylaxis (PEP) - offered to individuals with a high probability of exposure - should be started within 72 hours of exposure. Antiretroviral therapy - decision to begin therapy should be made by the patient. - combination therapy with drugs from different classes should be continued for at least 4 weeks Pregnant women - counseled on the risk to the fetus. - antiretroviral therapy to the mother during pregnancy, labor, and delivery and to the newborn - can be transmitted through breast milk.
Human Immunodeficiency Virus
Treatment: Stage 1 10 yr risk < 10% - healthy lifestyle management and reassess in 3-6 months Stage 1 10 yr risk > 10% - 1 med + lifestyle + reassess in 1 month - If goal met after 1 month - reassess in 3-6 months - If goal not met after 1 month, consider different med or titrate - Continue monthly follow-up until goal achieved Stage 2 - lifestyle + 2 BP meds
Hypertension
most significant and treatable risk factor for stroke
Hypertension
BP must be reduced within 1 hour to prevent progression of end-organ damage or death Strikingly elevated, >180/>120
Hypertensive Emergency
BP must be reduced within hours BP persistently >180 systolic or >120 diastolic
Hypertensive Urgency
Causes: - Graves - Toxic multinodular goiter - Hashimoto thyroiditis - Pituitary tumor - Pregnancy - Exogenous thyroid hormone - Excessive dietary iodine intake - Radiographic contrast - Amniodarone use
Hyperthyroidism
Symptoms: hair loss clammy skin soft nails exophthalmos tachycardia weight loss diarrhea heat intolerance muscle weakness, cramps sleep difficulties hyperreflexia fine tremor anxiety, nervousness oligomenorrhea or amenorrhea
Hyperthyroidism
Treatment: Propanolol to conotrol symptoms Methimazole Propylthiuracil Radioactive Iodine ablation Thyroidectomy
Hyperthyroidism
Causes: Hereditary syndromes Chronic hypertension Demonstrates massive hypertrophy (particularly of the septum) Small left ventricle Systolic anterior mitral motion Diastolic dysfunction.
Hypertrophic Cardiomyopathy
Echo: Left ventricular hypertrophy Asymmetric septal hypertrophy Small left ventricular size Normal or supranormal function
Hypertrophic Cardiomyopathy
Signs/Symptoms: Dyspnea, chest pain, syncope Sustained PMI S4 Variable systolic murmur Bisferiens carotid pulse ECG: - Left ventricular hypertrophy - Exaggerated septal Q waves
Hypertrophic Cardiomyopathy
Treatment: Beta blockers or CCB Septal myetomy/alcohol septal ablation Avoid volume depletion
Hypertrophic Cardiomyopathy
Respiratory Alkalosis mnemonic
Hyperventilation-CHAMPS
Clinical features: Dry skin Brittle nails Pruritus Muscle cramping Shortness of breath Numbness and tingling in the extremities Severe cardiovascular manifestations include syncope and angina. Classic neurologic findings: - Trousseau sign - Chvostek sign
Hypocalcemia
Diagnostic studies: Corrected serum calcium < 8.5 mEq/L Ionized calcium should also be measured Magnesium, phosphate, albumin, liver function tests, and other electrolytes should be obtained. BUN and creatinine should be measured to assess renal function.
Hypocalcemia
General characteristics: More common than hypercalcemia MC in critically ill patients. - chronic disease (most common cause is CKD) - hypoparathyroidism Although it typically presents in a mild, asymptomatic form, severe hypocalcemia can result in complete cardiovascular collapse.
Hypocalcemia
Treatment: Treat any emergent cardiovascular states. Replacement (IV calcium gluconate or calcium chloride). Mild - can be treated on an outpatient basis - oral calcium and vitamin D supplements.
Hypocalcemia
Diagnostic studies: Serum sodium < 135 mEq/L Plasma osmolality decreased, except in cases of fluid redistribution because of hyperglycemia or proteinemia.
Hyponatremia
General characteristics: Plasma sodium < 135 mEq/L MC electrolyte disorder seen in the general hospital population secondary to the use of hypotonic fluid administration. Type is determined by the serum osmolality and volume status. - Hyponatremia with hypervolemia - Hyponatremia with euvolemia - SIADH - Hyponatremia with hypovolemia
Hyponatremia
Treatment: Treat hypovolemia on an inpatient basis, especially if symptomatic or if serum sodium is less than 125 mEq/L Treat the underlying cause - usually requires fluid restriction - in hypovolemic hyponatremia where isotonic saline is the treatment.
Hyponatremia
Hypothyroidism Glucocorticoid excess Syndrome of inappropriate secretion of antidiuretic hormone (SIADH). what kind of hyponatremia?
Hyponatremia with euvolemia
Heart failure Nephrotic syndrome Renal failure Hepatic cirrhosis what kind of hyponatremia?
Hyponatremia with hypervolemia
Occurs with renal or nonrenal sodium loss what kind of hyponatremia?
Hyponatremia with hypovolemia
Clinical features: Hypocalcemia may cause: - tetany - carpopedal spasms - muscle or abdominal cramps - paresthesias - hyperreflexia - teeth, nail, and hair defects. Findings in patients with chronic disease: - lethargy - anxiety - parkinsonism - mental retardation - personality changes - blurred vision caused by cataracts
Hypoparathyroidism
Diagnostic studies: Decreased PTH Decreased adjusted serum calcium Increased phosphate levels Serum magnesium may be low ECG changes - prolonged QT intervals - T-wave abnormalities Radiography - chronic increased bone mineral density, especially in the lumbar spine and skull.
Hypoparathyroidism
Treatment: Maintenance therapy - oral calcium (1 to 2 g/day) - vitamin D preparations to keep serum calcium at 8 to 8.6 mg/dL - Calcitriol (activated vitamin D) or Ergocalciferol PTH - linked to osteosarcoma - reserved for those who do not respond to vitamin D and calcium treatment Phenothiazines and furosemide should be avoided because of the risk of further calcium los
Hypoparathyroidism
signs of significant bleeding
Hypotension Tachycardia Low pulse pressure Tachypena
inability to produce and secrete vasopressin (levels will be low) What kind of diabetes insipidus?
Hypothalamic DI
Etiology: Hashimoto's (chronic lymphocytic/autoimmune) Previous thyroidectomy/iodine ablation Congenital
Hypothyroidism
Labs: TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4) Hashimoto's: Antithyroid peroxidase, antithyroglobulin antibodies
Hypothyroidism
Treatment: Levothyroxine - replacement T4; T4 is converted to T3 - taken on an empty stomach Follow up with serial TSH monitoring every 4-6 weeks
Hypothyroidism
Does the ECFV(extracellular fluid volume) appear normal? If yes, think
Hypothyroidism, SIADH, K+ depletion, Thiazides
Diagnosis: Polysomnography (sleep study) Alternative: home sleep apnea testing (HSAT)
Hypoventilation Syndrome
Risks: obesity, structural, fhx, alc, hypothyroid 1. pharyngeal wall collapse repetitively 2. failure of upper airway dilator muscle 3. sleep-related obstruction and breath cessation
Hypoventilation Syndrome
Signs/Symptoms: Snoring Interrupted sleep Daytime sleepiness Fatigue Wake up with breath holding, gasping, choking Causes: HTN, CAD, DM, mood
Hypoventilation Syndrome
Treatment: Lifestyle: - weight loss - exercise - nonsupine sleep - avoid alcohol and sedatives Mild/moderate: CPAP Severe: CPAP, surgery
Hypoventilation Syndrome
Respiratory Acidosis mnemonic
Hypoventilation-CHAMPP
Loss of blood or fluid volume Causes: - hemorrhagic - GI - pancreatitis - DKI - burn What kind of shock?
Hypovolemic Shock
Pale, cool extremities Slow cap refill Low skin turgor Increased HR Decreased BP and CO CBC: increased hgb and hct; decreased in late shock Vasoconstriction Low wedge pressure Tx: - Volume resuscitation: NS or LR - Blood: PRBCs What kind of shock?
Hypovolemic Shock
Lateral wall
I, AVL, V5-V6
Esophagitis treatment for CMV cause
IV Gangiclovir 2nd line: Foscarnet
Emergency treatment for tetany includes airway maintenance and slow administration of what?
IV calcium gluconate
Torsades de Pointes tx
IV magnesium
Clinical features: Insidious dry cough Exertional dyspnea Constitutional symptoms (fatigue, malaise, etc.). Clubbing of the fingers Inspiratory crackles
Idiopathic Pulmonary Fibrosis
Diagnostic studies: CXR - progressive fibrosis over several years CT - diffuse, patchy fibrosis - pleural-based honeycombing - ground glass opacities - traction bronchiectasis PFT may show a restrictive pattern (low TLC, RV, DLco)
Idiopathic Pulmonary Fibrosis
General characteristics: MC diagnosis in patients with interstitial lung disease Risk factors: - cigarette smoking - exposure to metal and wood dust MC in men aged 50 to 75 years Histopathologic patterns - usual interstitial pneumonia - respiratory bronchiolitis-associated interstitial lung disease - acute interstitial pneumonitis
Idiopathic Pulmonary Fibrosis
Management: Remains controversial, because none has been shown to improve survival or quality of life compared to no treatment Early referral for lung transplant
Idiopathic Pulmonary Fibrosis
AKA Idiopathic Pulmonary Fibrosis
Idiopathic fibrosing interstitial pneumonia
Acute - self-limited - autoimmune (IgG) disorder - MC in children - preceding viral URI - Tx: resolves spontaneously Chronic - any age - MC in women - coexists with HIV, Hep C, Autoimmune diseases
Idiopathic thrombocytopenic purpura (ITP)
MC cause of acute glomerulonephritis worldwide Young males within days (24-48 hours) after URI or GI infection Caused by IgA immune complexes which are the first line of defense in respiratory and GI secretions so infections cause an overproduction which then damages the kidneys Diagnosed by (+) IgA deposits in mesangium and with immunostaining
IgA Nephropathy (Berger disease)
Pulseless V tach tx
Immediate defib and CPR
What happens to the pain of a duodenal ulcer with food?
Improves
Avoid PDE-5's when?
In pts taking nitrates (combo can drop BP)
Clinical features Abdominal pain may occur anywhere - Worsened by food intake - relieved with defecation. - postprandial urgency is common. Physical examination is generally normal but may include a tender, palpable sigmoid colon and hyperresonance on percussion over the abdomen. Dyspepsia (indigestion) is common. Urinary frequency and urgency are common in women
Inflammatory Bowel Disease
Crohn's Disease or Ulcerative Colitis
Inflammatory Bowel Disease
Functional disorder without a known pathology Thought to be a combination of altered motility, hypersensitivity to intestinal distention, and psychological distress. Remains an intermittent, lifelong problem MC in women Exacerbations may be associated with menses or stress.
Inflammatory Bowel Disease
Viral pneumonia MC causes
Influenz
Clinical findings: Abrupt onset Fever/chills Malaise Muscle aches Substernal chest pain Headache Nasal stuffines Nonproductive cough
Influenza
Diagnostic studies: Leukopenia and proteinuria may be present. Virus can be isolated from the throat or nasal mucosa. Rapid antigen tests are proving to be helpful. Results are most accurate during the first few days of illness. Viral cultures take 2 to 5 days to return
Influenza
General characteristics: Caused by an orthomyxovirus Epidemics during the fall or winter. Three strains exist (A, B, and C) and are typed based on the surface antigens hemagglutinin (H) and neuraminidase (N) MC type = A Public health authorities follow changes in strains to predict new virus and steer vaccine development
Influenza
Prevention: Trivalent virus vaccine. Vaccine should be administered to all the patients yearly in October Vaccine contraindications - hypersensitivity to eggs or other components of the vaccine - during acute febrile illness - cases of thrombocytopenia. Tenderness, redness, and induration at the injection site may occur A nasal spray (FluMist) was in use but is no longer recommended
Influenza
Treatment: All patients require supportive care with rest, analgesics, and cough suppressants as needed. Neuraminidase inhibitors - Zanamivir inhalation or oral Oseltamivir - administered within 48 hours of the onset of symptom - Effective against both influenza A and influenza B - Contraindicated in patients less than 12 years of age Prognosis in uncomplicated cases is very good; patients generally recover in 1 to 7 days. Pneumonia is the cause of most fatalities. Amantadine and rimantadine are no longer recommended as single therapy agents because of resistance.
Influenza
Intraparenchymal MCC: HTN, AVM, trauma Symptoms: HA, N/V
Intracerebral Hemorrhage
Raltegravir (Isentress) Dolutegravir (Tivicay) Elvitegravir combo What Antiretroviral Medications?
Integrase inhibitors
Disease-modifying agents for MS
Interferon-β Glatiramer acetate Matalizumab Dimethyl fumarate Teriflunomide
Symptoms </=2 days/week Nighttime symptoms </=2/month FEV1 >80% FEV1/FVC normal No interference with daily activities What asthma classification?
Intermittent
CT: intraparenchymal bleed DO NOT PERFORM LP (herniation) Supportive treatment: +/- Mannitol Gradual BP reduction
Intracerebral Hemorrhage
Stone in the lower ureter. Where does pain radiate to?
Ipsilateral groin Testicle in men Labia in women
Microcytic Anemia ↓ Iron ↑ TIBC < 16% Saturation ↓ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH
Iron Deficiency Anemia
Treatment: Ferrous sulfate 325 mg 3/day Best absorbed on an empty stomach Supplemental Vit C for absorption Common SE: Constipation
Iron Deficiency Anemia
Clinical features Abdominal pain may occur anywhere - Worsened by food intake - relieved with defecation. - postprandial urgency is common. Physical examination is generally normal but may include a tender, palpable sigmoid colon and hyperresonance on percussion over the abdomen. Dyspepsia (indigestion) is common. Urinary frequency and urgency are common in women
Irritable Bowel Syndrome
Diagnosis of exclusion Diagnosis is based on the Rome IV criteria Laboratory findings are generally normal. Colonoscopy, barium enema, ultrasonography, or CT should be performed to rule out other pathology Endoscopic studies are indicated in patients with persistent symptoms, weight loss or anorexia, bleeding, or history of other GI pathology.
Irritable Bowel Syndrome
Functional disorder without a known pathology Thought to be a combination of altered motility, hypersensitivity to intestinal distention, and psychological distress. Remains an intermittent, lifelong problem MC in women Exacerbations may be associated with menses or stress.
Irritable Bowel Syndrome
Treatment Reassurance Avoidance of any known triggers is important. High-fiber diet Bulking agents, such as psyllium hydrophilic mucilloid Diarrhea: Dicyclomine or Loperamide Constipation: laxatives
Irritable Bowel Syndrome
MCC: hypotension or atherosclerosis Symptoms: - LLQ pain - Bloody diarrhea Dx: Colonoscopy Tx: Restore perfusion and observe for perforation
Ischemia Colitis
Characterized by insufficient oxygen to cardiac muscle Leads to Angina MC Cause: Atherosclerotic narrowing Less Common Cause: Constriction of coronary arteries Rare cause: Congenital anomalies, emboli, arteritis, and dissection
Ischemic Heart Disease
MC type of stroke (85%) Caused by a blockage 2/3 are thrombotic - often preceded by TIA 1/3 embolic - arise from the heart, aortic arch, or large cerebral arteries - occur abruptly and without warning
Ischemic Strokes
what is the DOC for latent TB? how long do pts take it?
Isoniazid; 9 months
Painless macules of the fingers, toes, or feet Associated with endocarditis
Janeway lesions
Major Criteria - carditis - erythema marginatum - subcutaneous nodules - Sydenham chorea - arthritis Minor Criteria - fever - polyarthralgia - rapid ESR - Elevated CRP - History of rheumatic fever
Jones Criteria
Pneumonia most common in alcohol abuse
Klebsiella pneumoniae
Red currant jelly sputum Chronic illness, including alcohol abuse Upper lung What kind of pneumonia?
Klebsiella pneumoniae
Elevated _____ increase risk of CAD
LDL
Acute onset, vertigo, hearing loss, and tinnitus of several days to a week. Often preceded by a viral respiratory illness Continuous vertigo. There is an absence of neurologic deficits
Labyrinthitis
Occur in areas supplied by small perforating vessels Result from: - atherosclerosis - hypertension - diabetes Silent, pure motor or sensory stroke "Dysarthria-Clumsy hand syndrome" Ataxic hemiparesis
Lacunar Infarcts
Least common NSCLC Heterogeneous group of undifferentiated types that do not fit elsewhere Cytology typically shows large cells Doubling time is rapid, and metastasis is early Central or peripheral masses
Large Cell NSCLC
Sideroblastic anemia is what until proven otherwise?
Lead toxicity (other cause: alcohol)
Virchow node
Left supraclavicular lymphadenopathy
Chronic cardiac or respiratory disease Hyponatremia Diarrhea, other systemic symptoms What kind of pneumonia?
Legionella pneumoniae
Pneumonia MC in air conditioning/aerosolized water
Legionella pneumoniae
refers to a buildup of plaque in the iliac arteries → claudication, impotence, decreased femoral pulses
Leriche syndrome
Clenched fist over the sternum and clenched when describing chest pain May be seen in patients with ischemia
Levine Sign
which is a clenched fist over the sternum and clenched teeth when describing chest pain, may be seen in patients with ischemia
Levine Sign
First line tx for hyperlipidemia
Lifestyle changes
defining location seperating UGI from LGI bleed
Ligament of Treitz
Basal insulin Glargine (Lantus) duration: 24 hours Detemir duration: 12-24 hours
Long Acting Analog insulin
Pulmonary Hypertension WHO Group 2
Lungs --> L heart disease Pulmonary venous hypertension (heart)
Clinical findings: Stage 1: early localized infection (7 to 10 days after bite) Stage 2: early disseminated infection (days to weeks later) Stage 3: late persistent infection (months to years later)
Lyme Disease
Diagnostic studies: Antibodies can be detected by enzyme immunoassay (EIA) or immunofluorescent assay (IFA) A Western blot assay is used as a follow up confirmatory test if EIA or IFA is positive
Lyme Disease
General characteristics Borrelia burgdorferi Transmitted to humans by Ixodides, a small tick Tick must feed for more than 24-36 hours to transmit the spirochete MC vector-borne disease in the United States. Up to 75% do not recall having been bitten by a tick.
Lyme Disease
Treatment: Doxycycline is the drug of choice Alternatives include amoxicillin, cefuroxime, ceftriaxone, or cefotaxime Prevention - proper clothing - tick repellent - thorough search for ticks after outdoor exposure are essential Prophylactic therapy (with doxycycline in a single 200 mg oral dose) is indicated if patient meets all CDC criteria: - 1) endemic area - 2) tick adhered > 36 hours - 3) therapy begins within 72 hours of tick bite - 4) no contraindication to doxycycline.
Lyme Disease
All patients with ACS should have what
MONA (morphine, oxygen, nitroglycerin, aspirin) Beta blocker ACEi
Diagnostic studies: Blood films are stained with Giemsa or Wright stain - examined at 8-hour intervals for 3 days during and between attacks - percentage of infected red blood cells ranges from 5-20% During attacks, leukocytosis or leukopenia may develop. Severe infections cause: - hepatic changes - hemolytic jaundice Antibodies ap - peak 8 to 10 days later, which is too late for diagnostic benefit - persist for 10 years, making the distinction between old and new infection difficult
Malaria
General characteristics: Types: - Plasmodium vivax - Plasmodium malariae - Plasmodium ovale - Plasmodium falciparu Transmission is through the bite of the Anopheles mosquito. - mosquito ingests the parasite - sporozoites mature and get transferred to humans via saliva - sporozoites invade hepatocytes and mature as tissue schizonts - schizonts escape the liver and invade red blood cells, where they multiply and cause rupture of the cell within 48 hours. The cycle of invasion, multiplication, and red blood cell rupture continues.
Malaria
TreatmentL Prevention is the key to the control of malaria - prevention of mosquito bites - chemoprophylaxis is recommended for patients traveling to areas of endemicity Chloroquine - drug of choice for both prophylaxis and treatment - well tolerated and is safe in pregnancy. Alternative drugs - Atovaquone - Proguanil (Malarone) - Mefloquine - Hydroxychloroquine
Malaria
most common cause of hypercalcemia in hospitalized patients
Malignancy
Defined as elevated BP associated with papilledema and either encephalopathy or nephropathy If untreated, progressive renal failure occurs
Malignant Hypertension
Clinical Features: Hematemesis with or without melena H/o retching, vomiting, straining 50% cases Upper endoscopy after resuscitation
Mallory-Weiss Tear
Diagnostic Studies: Upper endoscopy: Superficial longitudinal mucosal erosions
Mallory-Weiss Tear
Treatment: Supportive: - fluids - transfusions Severe: - epinephrine - sclerosing agent - band ligation - clipping
Mallory-Weiss Tear
UGI bleeding due to longitudinal mucosal laceration at the cardia or gastroesophageal junction Due to increase in intragastric pressure --> vomiting after ETOH
Mallory-Weiss Tear
(4%) 1/3 sporadic 1/3 familial 1/3 associated with multiple endocrine neoplasia (MEN) syndrome. Local mets NO good iodine uptake Cause symptoms from their possible secretion of calcitonin, prostaglandins, serotonin, adrenocorticotropic hormone (ACTH), and other peptides. What type of Thyroid cancer?
Medullary type
Repaglinide Nateglinide
Meglitinides
Due to SLE, viral hepatitis
Membranoproliferative glomerulonephritis
MC in non-diabetic adults associated with malignancies. Caused by immune complex formation in the glomerulus - basement membrane becomes damaged
Membranous nephropathy
Increased endolymphatic fluid in the inner ear Episodic vertigo, tinnitus, nausea, and hearing loss Not associated with URI
Meniere disease
Meningoencephalitis occurs where?
Meninges
Smoking and asbestos are synergistically linked to lung cancer, especially ___________.
Mesothelioma
Methanol Uremia DKA Propylene glycol Isoniazid, infection Lactic acidosis Ethylene glycol Rhabdo.renal failure Salicylates (ASA)
Metabolic Acidosis anion gap
Hyperalimentation Acetazolamide Renal tubular acidosis Diarrhea Ureto-pelvic shunt Post-hypopcapnis Spironolactone
Metabolic Acidosis non-anion gap
Contraction Licorice Endo (Cushings) Vomiting (loss of H+ from GI tract) Excess Alkali Refeeding Alkalosis Post-hypercapnia Diuretics
Metabolic Alkalosis
Contributor to coronary artery disease Includes three or more of the following: - abdominal obesity - triglycerides greater than 150 mg/dL - high-density lipoprotein (HDL) less than 40 mg/dL for men and less than 50 mg/dL for women - fasting glucose greater than 110 mg/dL - HTN.
Metabolic Syndrome
Diabetic Ketoacidosis is what?
Metabolic acidosis
What hyperthyroidism medicine should be taken after the first trimester of pregnancy?
Methimazole
Other DMARDs
Methotrexate Corticosteroids Sulfasalazine Antimalarials Leflunomide.
Giardia lamblia diarrhea tx
Metronidazole
C Diff tx
Metronidazole Vancomycin Fidaxomicin
MC Pituitary Adenoma
Microadenoma
- (+) P-ANCA What type of Rapidly progressive glomerulonephritis?
Microscopic polyangiitis
Where is stable angina pain usually felt?
Midsternal, but may radiate Pain classically radiates to the left Women: right shoulder and back pain
Clinical features: Migraine with aura: - visual changes, field cuts, or flashing lights - the aura usually lasts several minutes but less than 1 hour. - can also be associated with transient neurologic deficits and hemisensory loss. Migraine without aura - more common - accompanied by nausea, vomiting, photophobia, and phonophobia - headache typically lasts 4 to 72 hours. Patients often retreat to quiet, dark rooms and prefer to lie quietly
Migraine headache
Dysfunction of the trigeminovascular system, resulting in the perivascular release of substance P and subsequent neurogenic inflammation. MC type is WITHOUT an aura
Migraine headache
Moderate or severe in intensity Unilateral Throbbing or pulsating discomfort Triggers, include chocolate, red wine, hard cheeses, monosodium glutamate, hormonal changes, exertion, dehydration, fatigue, changes in sleep pattern, and stress. RF: FH, Women (menstrual cycle pattern)
Migraine headache
Treatment: Mild to moderate: - Aspirin, acetaminophen, or NSAIDs. - Consider a triptan if simple analgesics are not effective. Moderate to severe migraine headache - Triptans are the first option - Triptan plus NSAID is also effective Severe headaches with associated nausea - subcutaneous triptan plus antiemetic (i.e., prochlorperazine). Medical prophylaxis: - β-blockers - tricyclic antidepressant - calcium channel blockers - valproic acid - topiramate
Migraine headache
Symptoms >2 days/week, not daily Nighttime symptoms 3-4x/month FEV1 >80% FEV1/FVC normal Minor limitation with daily activities What asthma classification?
Mild Persistent
What is the name give to Tb spread outside the lungs?
Miliary Tb
MC cause in kids. Child with idiopathic nephrotic syndrome improves after treatment with corticosteroids. The cause and pathogenesis is unclear and it is currently considered idiopathic.
Minimal change disease
If you have had a fib for greater than 48 hours what must you do before cardioverting
Must be on anticoagulants + rate control (BB/CCB) for 3-4 weeks before cardioversion
Any form of clinical atherosclerotic cardiovascular disease (ASCVD) Primary LDL-C levels of 190+ DM 40-75 y.o. + LDL of 70-189 No DM + 40-75 y.o. + 10-year ASCVD risk ≥ 7.5%
Most Likely to Benefit from Statin Therapy
Thrush - causes white plaques that can be scraped off, revealing reddened mucosa - denture wearers, infection may manifest as a painful red palate. Esophagitis - odynophagia and pain on swallowing - symptoms resemble gastroesophageal reflux. Treatment is with oral fluconazole, itraconazole, or amphotericin B if recurrent or recalcitrant. What kind of candidiasis?
Mucosal disease of the mouth and esophagus
Clinical features: Sensory complaints in the limbs Extremity weakness Vision loss Numbness or tingling Vision changes Lhermitte sign (feeling of shock that runs down the spine and into the extremities with neck flexion) Bowel and bladder problems become more prominent as the disease progresses
Multiple Sclerosis
Diagnostic studies: The diagnosis must be questioned if signs and symptoms are not related to multiple areas of the CNS over time. Cannot be based exclusively on labs MRI for visualizing lesions in the CNS. CSF - sterile inflammation - mild lymphocytosis - slight protein elevation - elevated immunoglobulin G index - oligoclonal bands in CSF NOT serum - increased myelin basic protein
Multiple Sclerosis
General characteristics: Immunologic disorder - CNS immunoglobulin production - alteration of T lymphocytes Characterized by inflammation associated with multiple foci of demyelination in the CNS Relapsing-remitting pattern of episodes or a primary progressive course Associated with HLA-DR2 MC in Women b/n 18-45 y.o.
Multiple Sclerosis
Treatment: High-dose IV corticosteroids for exacerbations Plasma exchange if do not respond to steroids Disease-modifying agents - decrease the number of relapses - decrease brain lesion buildup - important for long term therapy. Symptomatic - Baclofen and diazepam for spasticity - Anticholinergics (oxybutynin) for bladder
Multiple Sclerosis
Clinical features: Patients are prone to recurrent infections, particularly with encapsulated organisms, because of neutropenia and failure of antibody production. MC presenting complaints include: - anemia - bone pain (particularly in the low back or ribs), -infection - hyperviscosity syndrome.
Multiple myeloma
Diagnostic studies: Anemic, with normal cell morphology Rouleaux formation (RBCs stacking like coins) Monoclonal spike on serum protein electrophoresis Positive Bence Jones protein in the urine Radiograph - lytic lesions are present on radiography - generalized osteoporosis Hypercalcemia late finding Increased serum protein
Multiple myeloma
General characteristics: Malignancy of plasma cells Producing an abundance of monoclonal paraprotein (M protein) Replacement of bone marrow leads to: - pancytopenia - osteolysis with bone pain - osteoporosis - hypercalcemia -pathologic fractures Plasmacytomas may cause spinal cord compression.
Multiple myeloma
Treatment: Referral for specialist care with combination chemotherapy and transplant options Bisphosphonates are important adjunctive therapy.
Multiple myeloma
Clinical features: Presenting problems: - ptosis - diplopia - difficulty in chewing or swallowing - limb weakness Weakness and fatigability of affected muscles, which improve after a short rest. Sensation is normal No reflex changes. Diagnosis confirmed if there is improvement by administering a short-acting anticholinesterase (edrophonium)
Myasthenia Gravis
Diagnostic studies: Chest CT or MRI should be obtained to rule out a coexisting thymoma Electrophysiologic studies: - decrementing muscle response - Repetitive nerve stimulation and single-fiber EMG are the two studies frequently used Serum assay for elevated levels of circulating acetylcholine receptor antibodies - positive in 80% to 90% of patients - If negative, antibodies to muscle-specific tyrosine kinase (MuSK)
Myasthenia Gravis
General characteristics: Disorder of antibodies directed against the acetylcholine receptor on the muscle surface. Involves muscle weakness and fatigability, which improve with rest. MC in young women, older men
Myasthenia Gravis
Treatment: Mainstay of therapy is administration of a cholinesterase inhibitor (pyridostigmine) Thymectomy often leads to improvement of symptoms and may lead to remission of symptoms. Refractory: - Corticosteroids - immunosuppressive agents - IVIG - plasmapheresis
Myasthenia Gravis
Low-grade fever Cough Bullous myringitis Cold agglutinins What kind of pneumonia?
Mycoplasma pneumoniae
Pneumonia MC in young adults, college setting
Mycoplasma pneumoniae Chlamydia pneumoniae
Acute = must be treated with reperfusion therapy Cause: - prolonged myocardial ischemia, usually caused by thrombus formation - 1/5 will die to v fib
Myocardial Infarction
Clinical Features: Nontraumatic chest pain Crushing retrosternal pain or pressure Heaviness or tightness Increasingly severe pain > 30 mins at rest MC early mornings Elevation of cardiac biomarkers
Myocardial Infarction
Clinical Presentation: 1. Viral prodrome: fever, myalgia, malaise, HF symptoms 2. Heart Failure: dyspnea, exercise intolerance, syncope, tachypnea, tachycardia, impaired systolic function, megacolon 3. Pericarditis: fever, CP, friction rub, effusion
Myocarditis
Diagnostic Studies: CXR: cardiomegaly EKG: dysrhythmias Labs: cardia enzymes, ESR TTE Echo: ventricular dysfunction Endomyocardial biopsy-GOLD STANDARD!
Myocarditis
Inflammation of heart muscle due to myocellular damage MCC: Viral infection Etiologies: - Infectious: Enterovirus (MC),
Myocarditis
Treatment: supportive symptomatic therapy beta blockers IVIG
Myocarditis
Muscle jerking, but not the tonic phase, occurs in the morning
Myoclonic Seizures
Life threatening Obtundation (reduced alertness) CO2 retention Coma Treatment: - thyroxine IV bolus
Myxedema Crisis
Should generally not be performed if the tumor is resectable for fear of seeding in hepatic cancer
Need biopsy
Moderate proteinuria 1-3.5 g/day Classic presentation: - edema - HTN - hematuria - RBC Casts/dysmorphic RBCs - proteinuria 1-3.5 g/day - azotemia (elevated BUN/Cr)
Nephritic Syndrome
Associated with chronic renal failure, lithium toxicity, hypercalcemia, and hypokalemia Kidney unable to respond to vasopressin (levels are high) May be inherited Abnormal receptors in the kidneys No response to desmopressin What kind of diabetes insipidus?
Nephrogenic DI
AKA Renal Calculi
Nephrolithiasis
Clinical features: Generally asymptomatic until inflammation or complete or partial ureteral obstruction develops Unilateral back pain Renal colic that waxes and wanes. Hematuria, dysuria, frequency Fever, chills, n/v Costovertebral angle tenderness Location can determine direction of pain and its radiation.
Nephrolithiasis
Diagnostic studies: Leukocytosis UA - hematuria - leukocytes - crystals Helical (spiral) CT w/o contrast is imaging of choice - if child or pregnant use U/S Intravenous pyelogram (IVP) - rarely indicated - if considered, remember to confirm that the patient has normal renal function before the procedure.
Nephrolithiasis
Occur throughout the urinary tract and are common causes of pain, infection, and obstruction. Caused by increased saturation (supersaturation) of urine with stone-forming salts (calcium, oxalate, and other solutes) or a possible lack of inhibitors (citrate) in the urine to prevent crystal formation. Typically formed in the proximal tract and pass distally.
Nephrolithiasis
Treatment: All stones should undergo chemical analysis as the type of stone may dictate additional treatment. Analgesics should be administered, including morphine, meperidine, or ketorolac. Depending on stone makeup antibiotics if signs of infection are present
Nephrolithiasis
Types: Calcium Uric Acid Cystine Struvite
Nephrolithiasis
Severe proteinuria > 3.5 g/day Massive edema Fatty casts with "maltese cross" sign Hypoalbuminemia Hyperlipidemia Lipiduria Oval fat bodies
Nephrotic Syndrome
Acute spinal cord injury blocks sympathetic system increased vagal tone What kind of shock?
Neurogenic Shock
Bradycardia Hypotension Warm, dry skin WIDE pulse presure Clinical diagnosis Treatment - fluid and vasopressors (alpha-activity to increase sympathetic tone) What kind of shock?
Neurogenic Shock
What on a ECG besides ST elevation indicates a STEMI
New LBBB
First line tx for hypertensive urgency/emergency if pregnancy
Nicardipine + Labetalol
Ventricular premature beats and unsustained V tach tx
No tx, if pt symptomatic BB or CCB
Treatment of viral pneumonia
O2 Fluids Rest Antipyretics
What three components comprise asthma
Obstruction of airflow Bronchial hyperreactivity Inflammation of the airway
CXR EKG Increased wedge pressure CBC, CMP, lactate, coagulation studies, cultures, ABG Treatment - PE: heparin, TPA - Tamponade: pericardiocentesis - Pneumothorax: needle decompression - Aortic dissection: surgery What kind of shock?
Obstructive Shock
Physical obstruction of blood flow of heart or great vessels Causes: - Pulmonary embolism - Pericardial tamponade - Tension pneumothorax - Aortic dissection - S/S of underlying disease What kind of shock?
Obstructive Shock
Pulmonary Hypertension WHO Group 3 Tx
Oxygen
abnormally shaped P wave What premature beat?
PAC
Pneumonia when over 65
PCV15 followed by PPSV23 one year later OR PCV20
Mnemonic for SJS and TEN
PECSLAPP + mycoplasma penicillin ethosuximide carbamazepine sulfa medications lamotrigine allopurinol phenytoin phenobarbital
Narrow QRS complex, no p wave or inverted p wave What premature beat?
PJC
Treatment: There is no cure and the disease will progress. 1st Line: dopamine agonist or with levodopa. Failure of a patient to initially respond favorably to levodopa should cause question of the diagnosis Younger patients - Dopamine agonist (bromocriptine, pramipexole, ropinirole) - Amantadine for tremor Selegiline COM (tolcapone and entacapone) - adjuncts to levodopa/carbidopa therapy - permit a lowering of the total levodopa/carbidopa dose.
Parkinson's Disease
narrow, complex tachycardia, no discernible P waves
Paroxysmal supraventricular tachycardia
MC paroxysmal tachycardia Occurs in patients without structural problems Patient presents with "racing heart"
Paroxysmal ventricular tachycardia
Rule of 10s: - 10% bilateral - 10% extra-adrenal - 10% malignant Catecholamine secreting adrenal tumor --> NE and E
Pheochromocytoma
Any ulcer of the upper digestive system (e.g., gastric ulcer, duodenal ulcer) Causes - Any discreet break in mucosa caused by injury, NSAIDs, stress, alcohol, or other irritants will lead to an ulcer. - H. pylori is the most common cause of PUD Associated with gastric malignancy
Peptic Ulcer Disease
Clinical features Abdominal pain or discomfort is the primary clinical feature. - Burning or gnawing pain that often radiates to the back. Dyspepsia (belching, bloating, distention, heartburn) or nausea is also reported. Complications include bleeding, perforation, and penetration. - Bleeding typically manifests as melena.
Peptic Ulcer Disease
Diagnostic studies Endoscopy is best for detecting small or healing ulcers Various tests may be used to detect H. pylori. - Serum antibody tests are highly sensitive - Stool antigen testing - Urea breath test
Peptic Ulcer Disease
Treatment Irritating factors (smoking, NSAIDs, alcohol) should be avoided. Combination therapy for H. pylori regimen should be taken for 2 to 4 weeks. Options include the following: Prophylactic treatment with misoprostol or a PPI should be considered in patients with a history of ulcer who require daily NSAID use
Peptic Ulcer Disease
most common cause of GI bleeds
Peptic Ulcer Disease
Diagnosis: EKG will demonstrate diffuse, ST-segment elevations in the precordial leads Echo may show pericardial effusion/tamponade
Pericarditis
MC viral infection in men <50 Causes: - SLE, uremia, coxsackievirus, TB, RA, neoplasm, drug, radiation, scleroderma, MI, open-heart surgery, radiotherapy
Pericarditis
MOA: inflammation of pericardial sac; often ⇒ pericardial effusion
Pericarditis
Signs/Symptoms: Sharp, pleuritic substernal radiating chest pain Relieved by sitting upright and leaning forward Cardiac friction rub is characteristic Elevated WBCs indicate infection
Pericarditis
Treatment: Treat underlying disease! NSAIDs 7-14 days Steroids if sx > 48 hrs Abx to treat bacterial endocarditis Pericardiocentesis; head at 45 degrees Dressler's syndrome: pericarditis 2-5 days after acute MI
Pericarditis
Diagnosis: Doppler ultrasonography Ankle-brachial index ≤ 0.9 Angiography
Peripheral Arterial Disease (PAD)
Management: Risk factor modification: discontinue tobacco, control diabetes, hypertension, hyperlipidemia β-Blocker ACE inhibitor Statins Antiplatelet therapy (cilostazol, aspirin, clopidogrel) Revascularization: Angioplasty → Fem-pop bypass → Endarterectomy
Peripheral Arterial Disease (PAD)
Signs/Symptoms: Intermittent claudication, foot or lower leg pain with exercise that is relieved by rest Weak or absent distal pulses Arterial bruits Loss of hair, shiny atrophic skin, pallor with dependent rubor
Peripheral Arterial Disease (PAD)
atherosclerotic disease of the lower extremities (and vessels outside the heart and brain)
Peripheral Arterial Disease (PAD)
Decreased tactile response when walking causes the patient to be unaware when feet touch the ground, leading to imbalance and falls Decreased sensation in lower extremities, particularly the feet
Peripheral neuropathy
Majority of prostate cancers originate where?
Peripheral zone (outer portion of the prostate palpable on rectal examination)
Recurrent Torsades de Pointes treatment
Permanent pacemaker
Graves Disease Labs
Peroxidaase antibodies Thyroglobulin antibodies
Clinical findings: 1. Catarrhal stage: - sneezing, coryza, loss of appetite, and malaise - hacking cough most prominent at night - often misdiagnosed as an upper respiratory viral illness - most infectious stage. 2. Paroxysmal stage: - Spasms of rapid coughing fits followed by deep, high-pitched inspiration (the whoop) - Infants are at risk for apnea. 3. Convalescent stage: - decrease in frequency and severity of paroxysms - begins usually 4 weeks after cough began and may last for an additional several weeks Adults are often misdiagnosed; any cough persisting for more than 2 weeks with no other cause should be questioned.
Pertussis
Diagnostic studies Diagnosis is made by a culture using a special media. PCR assays may be available through some health departments. WBC count is usually mildly elevated Lymphocytosis is characteristic.
Pertussis
General characteristics: Species = Bordetella; Gram-negative pleomorphic bacillus Humans are the sole reservoir. Infection is highest in premature infants and in those with cardiac, pulmonary, or neuromuscular disorders. Older children and adults tend to have milder disease.
Pertussis
Treatment: A macrolide (azithromycin, clarithromycin) An alternative therapy is TMP-SMX. A supportive therapy is essential. Close contacts should also be treated with a macrolide.
Pertussis
Drugs to be avoided in hypoparathyroidism due to risk of further calcium loss
Phenothiazines Furosemide
Clinical Featuers: Triad: - episodic palpitations - HA - diaphoresis *triad + HTN is HIGHLY suggestive Anxiety Pallor Syncope Tachycardia Paroxysms <1hr Emotions/physical stressors
Pheochromocytoma
Management: resection of tumor Awaiting Surgery: - Maintain BP < 160/90 - Alpha-Adrenergic Blockers: Cardura, Minipress, Hytrin Diet-high salt and water intake
Pheochromocytoma
Plasma Free Metanephrines - sit 15min - elevated --> assess urine 24h Urine Metanephrine and Creatinine - (+) if >2.2mcg/mg of creatinine Imaging: CT/MRI with contrast
Pheochromocytoma
relief of pain with scrotal elevation
Phren sign
What is the hallmark of iron deficiency anemia?
Pica
Clinical findings: Perianal pruritus (crawling sensation that is worse at night) Insomnia Weight loss Enuresis Irritability Examination at night may reveal worms in the anus or in the stool Scratching causes excoriations and secondary skin infections (i.e., impetigo). Migration can cause vulvovaginitis, diverticulitis, appendicitis, cystitis, and granulomatous reactions.
Pinworms (enterobiasis)
Diagnostic studies: Eggs can be captured on a piece of cellophane tape over the perianal skin Three tries over three consecutive nights yield 90% success rate.
Pinworms (enterobiasis)
General characteristics: Humans are the only host for MC in children Infection is easily passed through hands, food, drink, and fomites The eggs are swallowed and hatch in the duodenum Larvae pass to the cecum and mature in 3 to 4 weeks Gravid females pass through the anus to lay eggs on the perianal skin
Pinworms (enterobiasis)
Treatment: All members of the household should be treated concurrently. Albendazole, mebendazole, or pyrantel is administered in a single dose and then repeated 2 to 4 weeks later. Hand washing after defecation and before meals must be stressed Bed sheets should be washed thoroughly.
Pinworms (enterobiasis)
Diagnostics: MRI = study of choice - sellar lesions - pituitary tumors Labs: - Prolactin, FSH, LH - GH, IGF-1 - ACTH - TSH
Pituitary Adenoma
Treatment: Transphenodial surgery - active and compressive tumors Prolactinomas: - MEDICATION - Dopamine Agonists: Cabergoline, Bromocriptine Acromegaly: - surgery - Bromocriptine
Pituitary Adenoma
Types: Microadenoma Functional: secretes hormones Nonfunctional Compressive: local symptoms
Pituitary Adenoma
What should be avoided in thrombocytopenia?
Platelet antagonist (aspirin, NSAIDs)
Treatment: Empiric treatment is recommended for immunocompromised patients presenting with cough or dyspnea. - drug of choice is TMP-SMX. - patients often get worse at the start of the treatment Dapsone is an alternative treatment a - good choice for patients who are sensitive to sulfa Nebulized pentamidine can be used either IV or IM for prevention
Pneumocystis jiroveci pneumonia
Denotes inflammation in the alveoli or interstitium of the lung caused by microorganisms that infect the lower respiratory tract. Leading cause of morbidity and mortality worldwide.
Pneumonia
Tension Pneumothorax: - Needle decompression - large-bore needle (14-16 guage) at 2nd ICS at midclavicular line-leave in until thoracostomy tube places - Oxygen 2-4L nasal cannula Small Primary (<15-20%): observe x6hr Large: chest tube (thoacostomy) & admit
Pneumothorax
Clinical features: Fever Anorexia/weight loss Abdominal pain Peripheral neuropathy Arthralgias Arthritis Skin lesions, including palpable purpura and livedo reticularis Hypertension, edema, oliguria, and uremia may be present in patients with renal involvement.
Polyarteritis Nodosa
Diagnostic studies: Requires confirmation by vessel biopsy or angiography Elevated ESR and CRP Proteinuria Positive hepatitis B surface antigen (HBsAg). Presence of antineutrophil cytoplasmic antibody (ANCA) is usually not found.
Polyarteritis Nodosa
General characteristics: Small and medium artery inflammation involving the skin, kidney, peripheral nerves, muscle, and gut occurs Necrotizing, no glomerulonephritis MC in men aged 40-60 Cause is unknown Associated with hepatitis B
Polyarteritis Nodosa
Treatment: Initial management is with high doses of corticosteroids. Cytotoxic drugs and immunotherapy may also be used (cyclophosphamide) Concomitant treatment of hepatitis B may be required. Hypertension should be treated if present.
Polyarteritis Nodosa
Clinical features: MC back and flank pain Headaches (greater risk of intracranial aneurysms) Early sign = Nocturia One or both kidneys may be palpable and feel nodular or tender Cysts may also be present on the liver, pancreas, and other locations.
Polycystic Kidney Disease
Diagnostic studies: Anemia Urinalysis shows: - proteinuria - hematuria - pyuria - bacteriuria Diagnostic method of choice = U/S - shows fluid-filled cysts. Excretory infusion urography reveals multiple lucencies. Angiography shows bending of small vessels around cysts. Computed tomography (CT) shows large renal size and multiple thin-walled cysts.
Polycystic Kidney Disease
General characteristics: Growth of numerous cysts in the kidneys - made of epithelial cells from the renal tubules and collecting system. - cysts replace mass of the kidneys, reducing function and leading to kidney failure Types: - autosomal dominant - autosomal recessive - acquired
Polycystic Kidney Disease
Clinical features: Epistaxis may be the presenting complaint. Generalized pruritus after bathing is characteristic. Incidence of PUD is high MC complication = thrombosis Headache Dizziness Fullness in head and face Weakness/fatigue Tinnitus Blurred vision Burning pain Redness of the extremities Splenomegaly Plethora Engorged retinal veins Systolic HTN
Polycythemia Vera
Diagnostic studies Hematocrit levels - Males > 54% - Females > 51% Primary - thrombocytosis (platelets high) - leukocytosis - peripheral smear shows neutrophilic leukocytosis, increased basophils and eosinophils, and increased number of large platelets Red cell morphology is usually normal EPO levels are generally low. Hyperuricemia can also develop
Polycythemia Vera
JAK2 mutation is diagnostic for the primary (genetic) cause. May convert to CML
Polycythemia Vera
Slowly progressive bone marrow disorder Characterized by increased numbers of RBCs and increased total blood volume. - hyperviscosity - decreased cerebral blood flow - hypercoagulability Secondary causes - chronic hypoxia - cigarette smoking - living at high altitudes - renal tumors MC cause of death = thrombosis
Polycythemia Vera
most common cause of hypercalcemia in ambulatory patients
Primary Hyperparathyroidism
disorder of thirst mechanism (ADH levels low) What kind of diabetes insipidus?
Primary Polydispsia
Chancre, which is a painless ulcer with a clean base and firm, indurated margins Develops at the site of inoculation, MC in the genital area Associated with regional lymphadenopathy (rubbery, discrete, nontender) What stage of syphilis?
Primary Syphilis
Diagnosis: High dose cosyntropin (synthetic ACTH) stimulation test Blood or urine cortisol is measured after an IM injection of cosyntropin (synthetic ACTH) - The normal response is a rise in blood and urine cortisol levels after synthetic ACTH is given - This results in little or no increase in cortisol levels (< 20 mcg/dL) after ACTH is given
Primary adrenal insufficiency (Addison's disease)
Lab Findings: ↓ sodium ↓ 8 AM cortisol ↑ ACTH (primary) ↑ potassium (primary) low DHEA
Primary adrenal insufficiency (Addison's disease)
Treatment: Hydrocortisone/prednisone PO daily Crisis: Hypotension, altered mental status - Emergent IV saline - Glucose - Steroids
Primary adrenal insufficiency (Addison's disease)
Typically autoimmune. May be due to TB in endemic areas Destruction of the adrenal cortex resulting in loss of cortisol production Nonspecific symptoms: - hyperpigmentation - hypotension - fatigue - myalgias - GI complaints - weight loss
Primary adrenal insufficiency (Addison's disease)
Invariably HSV-2 Initial episode may be asymptomatic or severe Preexisting antibodies to HSV-1 may have an ameliorating effect Fever, headache, malaise, and myalgias are common Vesicles develop on the external genitalia, labia, vaginal mucosa, glans, penis, prepuce, shaft, or perianal area Vesicles rupture and form tender ulcers, which crust over Mucosa may be red and edematous. Females tend to have severer disease and higher rates of complications - Cervix is involved in more than 70% of female patients, manifesting as ulcerative or necrotic mucosa.
Primary genital herpes
Caused by vasospasm at rest, with preservation of exercise capacity Cocaine Coronary artery vasospasms causing transient ST-segment elevations, not associated with clot What kind of angina?
Prinzmetal (Variant) Angina
Stable tachycardia tx
Procainamide, amiodarone, or sotalol
Lactation Suppressing pregnancy Low FSH Oligomenorrhea Amenorrhea Galactorrhea Decreased libido Hypogonadism What Pituitary Adenoma?
Prolactinomas
How do you diagnose both viral and bacterial meningitis?
Prompt LP and CSF analysis
Clinical features: Many cases are not clinically apparent. Prostate may be enlarged, nodular, and asymmetric. Urinary obstruction Irritative voiding In advanced disease, patients may present with; - bone pain from metastases - possible spinal cord impingement if the vertebral bodies are involved.
Prostate Cancer
Diagnostic studies: Elevated PSA Pathologic examination of tissue removed for treatment of obstructive prostatic hyperplasia reveals that 10% have malignancy Transrectal ultrasonography - hypoechoic lesions Biopsy confirms the diagnosis
Prostate Cancer
General characteristics: Slow-growing, malignant neoplasm of the adenomatous cells - can lead to urinary obstruction and metastatic disease 75% originate in peripheral zone 20% originate in transitional zone 6% originate in central zone Rarely seen in men younger than 40
Prostate Cancer
Treatment: Stages A and B disease (tumor confined to the prostate) - radical retropubic prostatectomy - brachytherapy - external beam radiation therapy. Stage C disease (tumor with local invasion) - similar to stages A and B disease but with reduced effectiveness Stage D disease (distant metastases) - hormonal manipulation using orchiectomy, antiandrogens, LH-releasing hormone agonists, or estrogens. - Chemotherapy has limited usefulness
Prostate Cancer
Caused by ascending infection into the prostatic ducts. Chronic nonbacterial = MC - cause unknown - diagnosis of exclusion - often associated with chronic pelvic pain syndrome Complication - prostatic abscess (uncommon)
Prostatitis
Clinical features: Acute infection - sudden onset of high fever - chills - low back and perineal pain - avoid vigorous prostate exam Chronic infection - variable symptoms, ranging from asymptomatic to acute symptomatology All forms - Frequency, urgency, dysuria - Some obstruction - swollen and tender prostate
Prostatitis
Diagnostic studies: Urinalysis - Pyuria - Hematuria and bacteriuria may also be found. Prostatic fluid - leukocytosis Culture typically - acute = positive for e.coli - chronic = positive for same organism or enterococcus - nonbacterial = negative
Prostatitis
Treatment: Uncomplicated cases - Ciprofloxacin - Levofloxacin - Trimethoprim-sulfamethoxazole - Culture urine 1 week after conclusion of therapy. - If fever is not resolved after 36 hours, suspect a prostatic abscess and consult a urologist for management. Chronic - Fluoroquinolone > TMP/SMX Chronic, recurrent, or resistant - transurethral resection of the prostate (TURP) for ultimate resolution.
Prostatitis
Saquinavir (Fortovase, Invirase) Tipranavir/ritonavir (Aptivus/Norvir) Darunavir/ritonavir (Prezista/Norvir) Ritonavir (Norvir) Indinavir (Crixivan) Nelfinavir (Viracept) Amprenavir (Invirase) Lopinavir/ritonavir (Kaletra) Fosamprenavir (Lexiva) Atazanavir (Reyataz) What Antiretroviral Medications?
Protease inhibitors
Clinical characteristics: Patients typically complain of memory problems, but with thorough testing memory, language, attention span, and concentration appear intact. In true dementia, the patient will often give wrong answers, have poor attention and concentration, and appear indifferent or unconcerned.
Pseudodementia
MC type of headache. Aabnormal, increased neuronal sensitivity. Associated history of significant stress or minor trauma to the head or neck.
Pseudodementia
Patients with psychiatric illness who appear to be demented. It is often seen as part of a major depressive episode
Pseudodementia
AKA Calcium pyrophosphate deposition disease (CPPD)
Pseudogout
Old, >60 y.o. M=F Asymmetric Large joints, knee, LE Painful, red, swollen, no tophi Synovial Fluid Crystals - Rhomboid shaped crystals - positively birefringent
Pseudogout
Ventilator bacterial pneumonia
Pseudomonas Acinetobacter
Pneumonia MC in Cystic Fibrosis
Pseudomonas sp.
Pulmonary Hypertension WHO Group 4
Pulm HTN secondary to thromboembolism --> occludes pulm arteries
1. Oxygen, IV Fluids if needed 2. Anticoagulation - Anti-thrombin III: Heparin (renal), LMWH - Factor Xa inhibitor - Direct thrombin inhibitor - Vitamin K inhibitor: Warfarin TPA: *hemodynamic compromise - begin UFH or LMWH after infusion Thromboembolectomy: - pts with life-threatening PE and CI to TPA
Pulmonary Embolism
Diagnosis: EKG: sinus tachycardia, S1Q3T3 CXR: Hamptoms Hump or westmark VQ Scan: poor perfusion, good vent Spiral CT: BEST Pulmonary angiography: GOLD Wells Score >6: high, 2-6: mod - +3: DVT, alt dx not likely - +1.5: HR >100, VTE hx, immobilization for 4 weeks - +1: malignancy, hemoptysis
Pulmonary Embolism
Symptoms: Dyspnea (sudden onset) Pleuritic chest pain Hemoptysis (pulm infarction) Cough, wheeze DVT symptoms (Homans sign: dorsiflexion causing pain) Tachypnea, tachycardia Hypoxemia; rales Hypotension and syncope JVD & S3 and S4 sounds
Pulmonary Embolism
Thrombus of the pulmonary artery or its branches Types: thrombus MC! Risks (Virchows Triad): - venous stasis - injury (to vessel wall) - hypercoagulability: medications
Pulmonary Embolism
Clinical features: Narrow splitting and accentuation of S2 Systolic ejection click Dyspnea Angina-like retrosternal chest pain Weakness Fatigue Edema Ascites Cyanosis Effort syncope.
Pulmonary Hypertension
Diagnostic studies: CXR - enlarged pulmonary arteries. ECG - right ventricular hypertrophy - atrial hypertrophy - right ventricular strain Echo - estimating pulmonary arterial pressure - right heart catheterization offers more precise hemodynamic monitoring (GOLD standard)
Pulmonary Hypertension
Use caution during treatment because rapid correction of hypernatremia can cause what?
Pulmonary or cerebral edema, especially in patients with diabetes mellitus.
Clinical features: Fever Flank pain Shaking chills Frequency, urgency, dysuria Costovertebral angle tenderness is pronounces Young children may have fever and abdominal discomfort.
Pyelonephritis
Diagnostic studies: CBC - leukocytosis - left shift Urinalysis - pyuria - bacteriuria - varying degrees of hematuria - WBC casts may be seen. Urine culture - should be obtained before beginning antibiotics - heavy growth of the offending agent. Complicated: - renal ultrasonography may show hydronephrosis secondary to obstruction.
Pyelonephritis
Infectious inflammatory process involving the kidney parenchyma and renal pelvis. Bacteremia common in diabetics and elderly women. MC cause: - E coli 85% - proteus - Klebsiella - Enterobacter - Pseudomonas Ascends from the lower urinary tract
Pyelonephritis
Treatment: Outpatient - TMP/SMX - Fluroquinolone (-floxacin) Inpatient - severe infections - complicating factors (old age, comorbidity, obstruction) - IV fluoroquinolones - Cephalosporins - Penicillins - Gentamycin Failure to respond = ultrasound
Pyelonephritis
Toxoplasmosis HIV prophylaxis
Pyrimethamine
what is a major consideration when prescribing a macrolide?
QTc prolongation
Sjogren Syndrome antibodies
RF ANA Anti-Ro Anti-La
Risk of renal dysfunction Injury to kidney Failure of kidney function Loss of kidney function (persistent AKD) End-stage kidney disease (ESKD)
RIFLE Classification of Acute Kidney Failure
Clinical findings: History of an animal bite may not be apparent Pain and paresthesias at the site Skin is sensitive to changes in temperature and wind. Muscle spasms and extreme excitability. Thick, tenacious saliva is produced. Hydrophobia is defined as painful spasms caused by drinking water. Less commonly, patients may exhibit an ascending paralysis.
Rabies
Diagnostic studies: Suspected animals should be euthanized so that their brains can be tested for the virus using fluorescent antibody markers. CSF may show reverse transcriptase by PCR MRI may reveal nonenhancing, ill-defined changes in the brain stem, hypothalamus, or subcortical matter.
Rabies
General characteristics: Rhabdovirus Transmitted via infected saliva from an animal bite or an open wound. Vectors include dogs, bats, skunks, foxes, raccoons, and coyotes; rodents and lagomorphs (rabbits) do not transmit. .Incubation period between the bite and the onset of symptoms is from 10 days to years (typically 3 to 7 weeks) - A correlation exists between the period of incubation and the distance of the wound from the brain.
Rabies
Treatment: No specific treatment is available Mechanical ventilation and oxygen therapy should be started. Vaccine immunoglobulin is given along with: - monoclonal antibodies - ribavirin - interferon-α - ketamin Almost universally fatal within 7 days, MC from respiratory failure Prevention is the key. - Control of bat populations is helpful in preventing the spread. - All household pets should be immunized - After an animal bite, local care with cleansing, debridement, and flushing is recommended. Wounds should not be sutured.
Rabies
Postexposure immunization for rabies
Rabies immunoglobin (in wound and IM at a distant site) IM Human diploid cell vaccine (HDCV) (Days 0, 3, 7, 14, 28)
Postexposure immunization for rabies if the pt has receive active immunization in the past
Rabies immunoglobin not given IM Human diploid cell vaccine (HDCV) (Days 0. 3) Rabies antibody titers should be checked every 2 years; Boosters if become seronegative.
Shows increased uptake in Graves disease and toxic multinodular goiter Uptake is more diffuse and symmetric in Graves disease Should never be done in pregnant women or in those with laboratory-confirmed disease
Radioactive Iodine Uptake
Leukocyte count >16,000 Blood glucose level >200 Lactate dehydrogenase >350 (normal, <50) AST >250 (normal, <120) Arterial PO2 <60 mm Hg Base deficit >4 mEq/L Calcium Falling BUN Rising Risk of mortality rises with each additional factor
Ranson Criteria for Poor Prognosis for Pancreatitis
Lispro, Aspart, Glulisine Duration: 4-5 hours Take 15-20 minutes before a meal
Rapid Acting Analog Insulin
Crescent formation on biopsy due to fibrin and plasma protein deposition Goodpasture's syndrome Vasculitis Microscopic polyangiitis Granulomatosis with polyangiitis (Wegener's)
Rapidly progressive glomerulonephritis
vasospasm of the digital arteries causing a characteristic white-blue-red pattern is seen in more than 75% of patients with scleroderma
Raynaud phenomenon
AKA Reiter Sydrome
Reactive Arthritis
Clinical features: Asymmetric arthritis that involves large joints usually below the waist (i.e., knee and ankle) Mucocutaneous lesions (balanitis, stomatitis) Urethritis Conjunctivitis
Reactive Arthritis
Diagnostic studies: 50-80% of patients are HLA-B27 positive. Synovial fluid culture is usually negative. Evidence of permanent and progressive joint disease may be present on radiography.
Reactive Arthritis
Seronegative arthritis Often a sequelae to: - sexually transmitted infections (chlamydial urethritis or Ureaplasma) - gastroenteritis (Shigella, Salmonella, Yersinia, or Campylobacter). Leading cause of nontraumatic monoarthritis.
Reactive Arthritis
Treatment: Physical therapy and NSAIDs are the mainstay of treatment. Antibiotics given at the time of infection will reduce the chance of developing the disorder but do not alleviate the symptoms
Reactive Arthritis
Major complication of thyroidectomy
Recurrent laryngeal nerve damage (hoarseness)
Take 15-20 minutes before meals Duration 5-8 hours, up to 12 hours Regular
Regular Insulin (short acting)
Increased urine sodium > 40 mEq/L FENa > 1%-2% Urine osmolality of 300-500 mOsm/kg Decreased BUN:Cr ratio (<15:1) Urine specific gravity of 1.01-1.02 Urinalysis + for: granular casts, WBCs and casts, RBCs and casts, proteinuria, and tubular epithelial cells What type of AKI?
Renal (Intrinsic) AKI
Atherosclerotic occlusive disease 5% of pts with HTN have this MC > 45yo w/ atherosclerotic disease Suspect if unexplained HTN in woman < 45 year old
Renal Artery Stenosis
Don't use ACE if BILATERAL Medical management Angioplasty +/- stent Surgical bypass - more risks, no greater efficacy
Renal Artery Stenosis
HTN (refractory new onset) Pulmonary edema with poor HTN Audible abdominal bruit Elevated BUN/Cr if ischemia Doppler US *BEST - asymmetric kidney (unilat) - small hyperchoic kidney (bilat) Renal angiography *GOLD
Renal Artery Stenosis
Clinical features: Called "internists' tumor" because it is commonly discovered as an incidental finding on abdominal imaging. Gross or microscopic hematuria, followed by pain or an abdominal mass
Renal Cell Carcinoma
Diagnostic studies: Patients presenting with hematuria should undergo ultrasonography to rule out a stone CT scanning with and without contrast is the primary technique for diagnosing Other confirming studies can include MRI with contrast and arteriography.
Renal Cell Carcinoma
General characteristics: Hypernephroma or renal adenocarcinoma MC in Native American/Alaskan men Linked to cigarette smoking Associated with paraneoplastic syndromes, including: - erythrocytosis - hypercalcemia - hypertension, - hepatic dysfunction in the absence of hepatic metastases.
Renal Cell Carcinoma
MC type of renal malignancy
Renal Cell Carcinoma
Treatment: Localized disease (Stage T1-T3a) - Radical nephrectomy - radiation therapy has not been shown to prolong survival for early stage lesions Disseminated disease the brain, bone, or lungs - Radiation therapy - Radical nephrectomy has little role in advanced disease Hormonal therapy and chemotherapy have shown little effect.
Renal Cell Carcinoma
Is the ECFV decreased and the urine sodium increased (>20 mEq/L)? If yes, think
Renal solute loss (diuretics, osmotic diuresis, Addison disease)
Hypoventilation CNS depression (acute/chronic resp failure) Hemo/pneumothorax Airway obstruction Myopathy Pneumonia Pulmonary Edema
Respiratory Acidosis
Hyperventilation CNS disease Hypoxia Anxiety Mechanical Ventilators Progesterone Salicylates
Respiratory Alkalosis
A fatty liver with encephalopathy Rapidly progressive 30% fatality rate Rarely occurs in patients more than 18 years of age May develop 2 to 3 weeks after the onset of influenza A or varicella infection, especially if aspirin is ingested. Treatment is supportive.
Reye syndrome
AKA Carditis Migratory joint pains, especially in the knees, ankles, and elbows Chest pain/discomfort. Jones criteria 2 major or 1 major and 1 minor. ↑ antistreptolysin O (ASO) titers
Rheumatic Fever
Treatment: Strict bed rest IM penicillin for documented strep infection; if allergic erythromycin Salicylates reduce fever and relieve joint problems Corticosteroids relieve joint symptoms Prevention: - early treatment of streptococcal pharyngitis - prevention of recurrence is essential to prevent heart damage
Rheumatic Fever
Systemic immune response occurring usually 2 to 3 weeks following a β-hemolytic streptococcal pharyngitis MC in recent immigrants MC Ages 5-15
Rheumatic fever
30-50 y.o. F>M Symmetric Joints: Hands, wrists, ankles Ulnar deviations Swan neck and Boutonniere deformities Sub Q nodules Stiffness lasting >1 hour plus systemic symptoms
Rheumatoid Arthritis
Chronic inflammatory disease with synovitis affecting multiple joints as well as other systemic extra-articular manifestations The juvenile form occurs in patients younger than 16 years of age. A cascade of events leads to joint destruction. Hyperplastic synovial tissue (pannus) may erode cartilage, subchondral bone, articular capsule, tendons, and ligaments.
Rheumatoid Arthritis
Clinical Features Joint pain and deformity Muscle weakness Myositis Myopathy Osteopenia/osteoporosis The DIP joints are usually spared. Extra-articular manifestations: skin, lungs, kidneys, eyes, liver, blood system, and heart
Rheumatoid Arthritis
Diagnostic studies Labs - Elevated ESR and CRP = Rheumatoid factor (RF) positive in 80% of patients. - Anti-CCP antibodies positive in 95% (more specific) Radiography - Soft-tissue swelling - juxta-articular demineralization
Rheumatoid Arthritis
Treatment: Consultation with a rheumatologist is recommended for initiation of treatment and development of a long-term plan. PT/OT NSAIDs + DMARDs Methotrexate is frequently the initial DMARD. Methotrexate + biologic DMARD is a common choice.
Rheumatoid Arthritis
Bacterial meningitis prophylaxis if: - Exposure H. flu, S. pneumo, N.mening - GBS (+) 35-37 weeks gestation - Neurosurgery
Rifampin
what are the drugs used to treat active TB?
Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE)
MCC of left sided heart failure
Right sided heart failure
Clinical findings: Fever/chills Headache Nausea/vomiting Myalgias Insomnia The face is typically flushed and the conjunctiva injected Faint macules to maculopapules to petechiae develop first on the wrists and ankles, and then spread to the extremities and trunk
Rocky Mountain Spotted Fever
Diagnostic studies: Leukocytosis, thrombocytopenia Hyponatremia Proteinuria Hematuria Transient rise in aminotransferases or bilirubin is possible. CSF analysis reveals pleocytosis and hypoglycorrhachia. A rise in antibody titers appears during the second week of illness.
Rocky Mountain Spotted Fever
General characteristics: Rickettsia rickettsii Transmitted by the wood tick Transmission is highest during the late spring and summer. MC occurs in the eastern United States.
Rocky Mountain Spotted Fever
Treatment: Mild, untreated cases wane during the second week. Prompt tx with doxycycline or chloramphenicol hastens recovery. Death is caused by pneumonitis or respiratory or cardiac failure. Prevention is the key. - protective clothing - tick repellant - prompt tick removal
Rocky Mountain Spotted Fever
Crampy, abdominal pain 1x/wk x3mo AND 2/3: -relieved with defecation! -Change in stool frequency -change in stool form
Rome IV Criteria
Diarrhea breakout in a day care center Watery diarrhea Tx: Hydration
Rotavirus
Exudative lesions in the retina Associated with endocarditis
Roth Spots
accounts for approximately 75% of nontraumatic cases of SAH and has a mortality rate of 50%.
Ruptured saccular (berry) aneurysm
Systolic HF (reduced EF) What heart sound?
S3
Diastolic HF (preserved EF) What heart sound?
S4
Canagliflozin
SGLT2 Inhibitor
Positive exercise stress test in angina
ST depression of 1+ mm
1. Aspirin and Clopidogrel at once 2. Immediate (within 90 mins) coronary angiography and primary PCI are superior to thrombolysis 3. Thrombolytic therapy within 3 hours
STEMI
SPHERE of Lung Cancer Complications
SVC syndrome Pancoast Tumor Horner Syndrome Endocrine Recurrent laryngeal nerve Effusions
Diarrhea from poultry or pork
Salmonella
Clinical features: Three patterns are recognized. - Enteric fever (typhoid fever) - Gastroenteritis - Bacteremia
Salmonellosis
General characteristics: There are more than 2,000 serotypes of salmonellae, all of which are members of the species Salmonella enterica Transmitted by ingestion of contaminated food or water.
Salmonellosis
Clinical features: Dry cough x 2-4 weeks Dyspnea of insidious onset Chest discomfort. Malaise Fever Extrapulmonary findings - erythema nodosum - lupus pernio - anterior uveitis - enlargement of parotid glands, lymph nodes, liver, or spleen
Sarcoidosis
Diagnostic studies: Serum blood tests - leukopenia - eosinophilia - elevated ESR - hypercalcemia/hypercalciuria Elevated ACE levels Radiographic - demonstrate symmetric bilateral hilar - right paratracheal adenopathy - bilateral diffuse reticular infiltrates Transbronchial orfine-needle node biopsy - confirms the diagnosis - shows noncaseating granulomas
Sarcoidosis
General characteristics: Multiorgan disease of idiopathic cause. Characterized by noncaseating granulomatous inflammation in affected organs (e.g., lungs, lymph nodes, eyes, skin, liver, spleen, salivary glands, heart, nervous system) 90% of patients have lung involvement MC Black women and N European whites
Sarcoidosis
Management: There is no cure 90% of cases are responsive to corticosteroids and can be controlled with modest maintenance doses. Immunosuppressant cytotoxic drugs for patients refractory to corticosteroids
Sarcoidosis
Lesions may involve skin, mucous membrane, eye, bone, kidneys, CNS, or liver There may be relapsing lesions during early latency What stage of syphilis?
Secondary Syphilis
insufficient pituitary ACTH production Cause: Pituitary macroadenoma or a central nervous system tumor Can be identified on an MRI Removed through transsphenoidal resection
Secondary adrenal insufficiency
↓ cortisol ↓ ACTH Increase in cortisol after ACTH administration, but no aldosterone deficiency No increase in ACTH after a CRH injection
Secondary adrenal insufficiency
Transient disturbances of cerebral function caused by abnormal paroxysmal neuronal discharges in the brain Diagnosed with EEG
Seizures
Treatment: Generalized convulsive and focal - Lamotrigine - Carbamazepine - Phenytoin - Valproic acid - Phenobarbital - Topiramate. Generalized nonconvulsive: - Ethosuximide - Valproic acid
Seizures
Bacteria systemic inflammatory response peripheral vasodilation increased capillary perm. What kind of shock?
Septic Shock
Hypotension WIDE pulse pressure INCREASED CO*** WARM extremities SIRS Criteria: 2/4 Treatment: - ABX (Vanc or Ceftriaxone + Zosyn) - IV fluids - Vasopressors if no response to fluids What kind of shock?
Septic Shock
Symptoms throughout day Nighttime symptoms nightly FEV1 <60% FEV1/FVC reduced >5% Extreme limitation with daily activities What asthma classification?
Severe Persistent
Fecal oral diarrhea Purulent, bloody, cramping diarrhea Supportive tx
Shigella
Clinical findings: Diarrhea (loose mixed with blood and mucus) Lower abdominal cramps Tenesmus (feeling you need to poop) Accompanied by fever, chills, anorexia, headache, and malaise. HLA-B27 individuals may mount a reactive arthritis because of temporary disaccharidase deficiency.
Shigellosis
Diagnostic studies: Stool is positive for leukocytes and red blood cells Stool culture yields species Sigmoidoscopy reveals inflamed engorged mucosa, punctate lesions, or ulcers.
Shigellosis
General characteristics: Most common species: - S. sonnei - S. flexneri - S. dysenteriae
Shigellosis
Treatment: Replacement of fluid volume is essential. Antibiotics of choice = Ciprofloxicin (if unable use Fluoroquinolone) Empiric treatment with a fluoroquinolone is recommended in: - severely ill - elderly - malnourished - HIV+ - food handlers - health care/day care workers
Shigellosis
Clinical features: 6 months after birth when protective Hgb F levels fall to adult levels Mild to severe complications - vascular occlusions - painful crises - strokes - chest syndrome - bone infarctions - avascular necrosis (AVN) - splenic sequestration - delayed growth/puberty Patients should avoid high altitudes and deep-sea diving. Life expectancy for type SS is 40 to 50 years of age
Sickle Cell Anemia
Diagnostic studies: Electrophoresis demonstrates the level of different hemoglobins in the red cell - Hgb S is 50% or greater Peripheral smear may reveal: - sickled cells (5% to 50%) - target cells - nucleated RBCs - Howell-Jolly bodies Reticulocyte count, indirect bilirubin, and LDH are elevated when hemolyzing. White blood cell (WBC) count is elevated
Sickle Cell Anemia
Family of autosomal recessive inherited hemoglobinopathies (SS, SC, SD, SO Arab, S β+ thalassemia, and S β0 thalassemia) RBCs containing primarily Hgb S sickle under hypoxia, dehydration, acidosis, and extreme temperature conditions MC in African Americans
Sickle Cell Anemia
Treatment: Symptomatic treatment of pain episodes includes administration of analgesics, hypotonic fluids, and rest. May require transfusion or exchange transfusion. Low-dose daily penicillin from birth until 6 years of age Pneumococcal vaccine (booster every 10 years) Transcranial Doppler screening for stroke Pulmonary function testing (PFT) for restrictive disease screening Chronic folate supplementation
Sickle Cell Anemia
Microcytic Anemia Dimorphic stippling of RBCs ↑/Normal Iron Normal TIBC 50-100% Saturation ↑ Ferritin Normal Hemoglobin Normal Indirect bilirubin LDH
Sideroblastic Anemia
Treatment: Chelation therapy for lead toxicity Removal of toxin Pyridoxine (Vitamin B6)
Sideroblastic Anemia
More common in women, diabetic, elderly Present with minor pain often associated with GI tract
Silent MI
Occupation: - mining - sand blasting - quarry work - stone work Diagnosis: - CXR: nodular opacities at upper lung fields, egg shell calcifications Complication: - increased risk of tuberculosis - progressive massive fibrosis
Silicosis
Normal, minimal variations in the SA Node's pacing rate in association with the phases of respiration. Heart rate frequently increases with inspiration, decreases with expiration
Sinus arrhythmia
Clinical features: Mucous membranes are most affected Dry mouth (xerostomia) Dry eyes (xerophthalmia or keratoconjunctivitis sicca) Parotid glands may also be enlarged.
Sjogren Syndrome
Diagnostic studies: Schirmer test - evaluates tear secretions by the lacrimal glands - wetting of less than 5 mm of filter paper placed in the lower eyelid for 5 minutes is positive for decreased secretions Biopsy of the lower lip mucosa confirms lymphocytic infiltrate and gland fibrosis.
Sjogren Syndrome
General characteristics: Autoimmune disorder that destroys the salivary and lacrimal glands (exocrine glands) May also be a secondary complication to a preexisting connective tissue disorder such as RA, SLE, polymyositis, or scleroderma. MC in middle aged women
Sjogren Syndrome
Treatment: Mainly symptomatic, with the goal of keeping mucosal surfaces moist - artificial tears and saliva - increased oral fluid intake - ocular and vaginal lubricants Pilocarpine or cevimeline improves symptoms by stimulating the exocrine glands Cyclosporine may improve ocular symptoms.
Sjogren Syndrome
13-15% of lung cancer More likely to spread early Not amenable to surgery Originates in the central bronchi Metastasizes to the lymph nodes Prone to early metastasis and is aggresive
Small Cell Lung Cancer
Management: Combination chemotherapy is the treatment of choice and results in improved median survival Patients rarely live for more than 5 years after the diagnosis is established.
Small Cell Lung Cancer
Number one risk factor for lung cancer
Smoking
What is the most contributory factor to COPD?
Smoking
Benign: - <30 years old - Round, oval - Sharply circumscribed margins - Up to 3 cm - Surrounded by normal tissue - May be calcified Malignant: - Older ages - Round, oval, uneven - Indistinct margins - Usually >2 cm - Rapidly progressive
Solitary Pulmonary Nodule
Management: Benign - Low risk: CT every 3 months for a year - Intermediate risk: hospitalize, biopsy, high-resolution CT or PET scan Malignant - If high probability: resect
Solitary Pulmonary Nodule
Nodule: <3cm Mass: >3cm Risks: Thymomas (MC)
Solitary Pulmonary Nodule
General characteristics: MC in young women Must be > 1 cm in diameter to be palpated Most are asymptomatic Thyroid adenoma is the MC type Usually benign Adenoma = encapsulated Multinodular = not encapsulated Bleeding into the nodule may cause pain and enlargement.
Solitary thyroid nodule
Types Follicular adenoma (MC) Papillary adenomas (rare) Hurtle cell (eosinophilic staining and has a malignant potential)
Solitary thyroid nodule
Workup: Fine needle aspiration - Malignant --> Surgical excision - Hypercellular --> RAIU --> cold nodule gets excised, hot nodule gets observed - Benign --> T4 treatment, reaspirate in 1-2 years Multiple nodules with a dominant nodule or history of radiation therapy --> surgical excision
Solitary thyroid nodule
Erythema migrans, a flat or slightly raised red lesion that expands over several days, typically with central clearing ("bull's eye") - MC sites are the groin, thigh, or axilla - typically resolves in 3 to 4 weeks without treatment Flu-like illness occurs in 50% of patients. What stage of Lyme Disease?
Stage 1: early localized infection
GFR 60-89 mL/min/1.73 m2 BSA Generally asymptomatic No increase in BUN or creatinine Acid-base maintenance is adaptive through an increase in remaining nephron function What stage CKD?
Stage 2 CKD
Manifestations typically involve the skin, CNS, and MSK Headache Stiff neck Fatigue/malaise Cardiac (pericarditis, arrhythmias, and heart block) or neurologic (aseptic meningitis, Bell palsy, and encephalitis) manifestations occur in up to 20% of the cases. What stage of Lyme Disease?
Stage 2: early disseminated infection
GFR 30-59 mL/min/1.73 m2 BSA May remain asymptomatic Serum BUN and creatinine increase Other hormones (PTH), erythropoietin, cacitriol become abnormal What stage CKD?
Stage 3 CKD
Musculoskeletal disease includes joint pain without objective findings - frank arthritis (typically large joints) - chronic synovitis. CNS and PNS manifestations - subacute encephalopathy (memory loss and mood changes) - axonal polyneuropathy (paresthesias and encephalopathy) - leukoencephalitis (cognitive change, paraparesis, ataxia, and bladder dysfunction). Acrodermatitis chronicum atrophicans - bluish-red discoloration of distal extremities with atrophy - seen in Europe but not in the US What stage of Lyme Disease?
Stage 3: late persistent infection
GFR 15-29 mL/min/1.73 m2 BSA Anemia, acidosis, hyperkalemia, hypocalcemia, hyperphosphatemia What stage CKD?
Stage 4 CKD
GFR < 15 mL/min/1.73 m2 BSA Candidate for renal replacement therapy What stage CKD?
Stage 5 CKD
Hemorrhoids confined to the anal canal and may bleed with defecation Management: - high fiber diet - increased fluids - bulk laxatives
Stage I Internal Hemorrhoids
Hemorrhoids that protrude from the anal opening but reduce spontaneously. Bleeding and mucoid discharge may occur. Management: - high fiber diet - increased fluids - bulk laxatives
Stage II Internal Hemorrhoids
Hemorrhoids that require manual reduction after bowel movements. Patients may develop pain and discomfort Management: - May benefit from suppositories with anesthetic and astringent properties
Stage III Internal Hemorrhoids
Hemorrhoids that chronically protruding and risk strangulation Management: - injection - rubber band ligation - sclerotherapy
Stage IV Internal Hemorrhoids
Diarrhea after a picnic and egg salad Rapid onset Cramping Tx: Supportive
Staph aureus
IV Drug User endocarditis
Staph aureus + Tricuspid valve
Endocarditis with intravenous drug users
Staphylococcus aureus
Endocarditis with prosthetic valve
Staphylococcus epidermidis
Rare, nonviral condition caused by Gram-positive bacteria (MC Staphylococcus aureus) Findings include: - tender thyroid gland - fever - pharyngitis - overlying erythem Fine-needle aspiration (FNA) with Gram stain and culture is required Treatment includes medications for the underlying cause
Suppurative Thyroiditis
Unstable patients: Paroxysmal ventricular tachycardia tx
Synchronized cardioversion
Unstable tachycardia tx
Synchronized cardioversion
V tach with severe hypotension or loss of consciousness tx
Synchronized cardioversion
Diagnostic Studies Electrocardiography Ambulatory monitoring (Holter) Echocardiography Tilt-table test Electrophysiologic studies CT/MRI
Syncope
Sudden, transient loss of consciousness not resulting from trauma. Cardiac: carotid sinus, aortic stenosis, HOCM Neurologic: basilary artery, subclavian steal syndrome Other: orthostatic, vasovagal
Syncope
Clinical findings: Three types - primary - secondary - tertiary Early infectious (primary and secondary) and late (tertiary) syphilis are separated by a symptom-free latent phase, during which the infectious stage may recur.
Syphilis
Diagnostic studies: Serologic testing is the recommended method for diagnosis Dark-field microscopy, but the technique is difficult Immunofluorescent staining techniques are somewhat more reliable The organism cannot be cultured Nontreponemal antigen tests detect nonspecific antibodies to lipoidal antigens. - VDRL and RPR tests become positive 4 to 6 weeks after infection Specific testing for tertiary syphilis includes lumbar puncture, joint fluid analysis, and biopsy as indicated.
Syphilis
General characteristics: Treponema pallidum Spirochete that can affect almost any organ or tissue Transmission occurs most frequently during sexual contact Congenital - transmitted via the placenta from the mother to the fetus - can result in severe birth defects
Syphilis
Treatment: Benzathine penicillin G, 2.4 million units IM in a single dose - late latent and tertiary syphilis require three weekly injections Neurosyphilis - aqueous penicillin every 4 hours for 10 to 14 days Jarisch-Herxheimer reaction (fever, toxic state) - to prevent this, antipyretics should be administered during the first 24 hours of treatment All cases should be reported to the appropriate public health agency for contact tracing
Syphilis
Autoimmune disorder characterized by: - inflammation - positive ANA - involvement of multiple organs MC in women of childbearing age. MC in African American women
Systemic Lupus Erythematosus
Clinical Features: Criteria (must meet >/= 4) - Malar rash - Discoid rash - Photosensitivity - Oral ulcers - Arthritis - Serositis (heart, lungs, or peritoneal) - Renal disease - ANA - Hematologic disorders (hemolytic anemia, leukopenia, leukocytosis, thrombocytopenia) - Immunologic disorders (LE cell, anti-DNA, anti-Sm, false-positive serologic test for syphilis) - Neurologic disorders (seizures or psychosis in absence of any other cause)
Systemic Lupus Erythematosus
Diagnostic studies Routine laboratory studies should include CBC, BUN/Cr, ESR, UA, C3/C4 ANA is present (99%), but low titers have a low predictive value. Markers for progression of disease: - Antibodies to Smith antigen - Double-stranded DN - Depressed levels of serum complement (C3/C4)
Systemic Lupus Erythematosus
Treatment: NSAIDs for MSK complaints Antimalarials (hydroxychloroquine or quinacrine) for MSK complaints and cutaneous manifestations Corticosteroids - Topical or intralesional for cutaneous manifestations. - Oral corticosteroid for disease flares Methotrexate at low doses for arthritis, rashes, serositis, and constitutional symptoms.
Systemic Lupus Erythematosus
Clinical features: Two types: - diffuse (35%) - limited (65%) Swelling in the fingers and hands and may spread to involve the trunk and the face. Raynaud phenomenon Skin changes Polyarthralgias Esophageal dysfunction
Systemic Sclerosis (Scleroderma)
Diagnostic studies: ANA is present in 90% with diffuse Anticentromere antibody Anti-SCL-70 antibody Patients should be monitored for development of hypertension, heralding kidney involvement.
Systemic Sclerosis (Scleroderma)
General characteristics: Unknown cause Characterized by deposition of collagen in the skin and, less commonly, in the kidney, heart, lungs, and stomach. MC in women aged 30-50
Systemic Sclerosis (Scleroderma)
Treatment: There is no cure Treatment is aimed at organ-specific disease processes - PPI for reflux disease - ACE inhibitors for renal disease - avoidance of triggers - CCB for Raynaud - immunosuppressive drugs for pulmonary hypertension
Systemic Sclerosis (Scleroderma)
Secondary Hyperthyroidism labs
TSH high T3/T4 high
Primary hypothyroidism labs
TSH high T3/T4 low
Primary Hyperthyroidism labs
TSH low T3/T4 high
Secondary hypothyroidism labs
TSH normal T3/T4 low
Occurs after a major catecholamine discharge Results in hypocontractility of the left ventricular apex. Clinical presentation can be indistinguishable from acute MI
Takotsubo Cardiomyopathy (Stress-Induced Cardiomyopathy)
Treatment: Supportive care Inotropes should generally be avoided. Most patients return to baseline within 2 months.
Takotsubo Cardiomyopathy (Stress-Induced Cardiomyopathy)
SIRS Criteria
Temp >100.4 (38) Pulse: >90bpm RR: >20 or PaCO2 <32 WBC: >12,000 or <4,000
Clinical features: Band-like mild to moderate pain around the head or generalized head pain Steady or aching (nonpulsatile) Not associated with focal neurologic symptoms Bilateral No photophobia, phonophobia, n/v Pain may be episodic or chronic. Stress and anxiety are typical precipitants. PE is normal
Tension Headache
Treatment: 1st line: - Aspirin - Acetaminophen - NSAIDs NO TRIPTANS Ketorolac intramuscularly can be used in the outpatient or hospital setting for more severe HAs.
Tension Headache
MC type of headache. Abnormal, increased neuronal sensitivity. Associated history of significant stress or minor trauma to the head or neck.
Tension Headaches
(EMERGENT) - air entering pleural sac - MCC: cardiopulm, (+) pressure - resp. compromise & CV collapse - tracheal deviation, displaced PMI
Tension Pneumothorax
Hummatous lesions involving skin, bones, eyes, and viscera Cardiovascular disease Nervous system Neurosyphilis can result in: - asymptomatic disease - meningovascular syphilis (chronic meningitis) - generalized paresis - tabes dorsalis (chronic progressive degeneration of parenchyma). Tabes dorsalis manifests with: - impaired proprioception - loss of vibratory sense - Argyll Robertson pupil (reacts to light but does not accommodate) What stage of syphilis?
Tertiary Syphilis
Insufficient CRH production MC cause: - sudden withdrawal of glucocorticoid therapy - after the cure of Cushing disease
Tertiary adrenal insufficiency
↓ cortisol ↓ ACTH Increase in cortisol after ACTH administration, but no aldosterone deficiency ACTH levels increase after CRH injection
Tertiary adrenal insufficiency
Clinical features: Sudden onset of severe unilateral pain and scrotal swelling Testis is painful to palpation Testicle and scrotum are edematous No relief with elevation of the testicle (negative Prehn sign).
Testicular Torsion
Diagnostic studies: Clinical diagnosis. If the diagnosis is equivocal, do not wait for laboratory studies. Doppler ultrasonography - decreased blood flow to the affected spermatic cord and testis. Radioisotope scan - decreased uptake in the affected testes.
Testicular Torsion
Testis is abnormally twisted on its spermatic cord Compromising arterial supply and venous drainage of the testis, leading to testicular ischemia. MC in prepubertal and postpubertal young males (12 to 18 years of age) Especially with a history of cryptorchidism (late descent of the testes).
Testicular Torsion
Treatment: Mild analgesics may be administered once the diagnosis is made This is a surgical emergency. Manual detorsion - may be attempted by experienced clinicians - whether this is successful or not, surgery will be required. Definitive treatment = Surgical detorsion with orchiopexy Emergent surgical intervention on the affected testis must be followed by elective surgery (orchiopexy) on the contralateral testis, which is also at risk
Testicular Torsion
Clinical findings: Initial pain and tingling at the site of inoculation Followed by spasticity of the muscles nearby Jaw and neck stiffness Dysphagia Irritability are Hyperreflexia Muscle spasms, especially in the jaw (trismus) and face.
Tetanus
General characteristics: Spores are ubiquitous in soil. Spores germinate in wounds where the bacteria produce a neurotoxin (tetanospasmin), which interferes with neurotransmission at the spinal synapses of inhibitory neurons. The result is uncontrolled spasm and exaggerated reflexes. Puncture wounds are most susceptible. The elderly, migrant workers, newborns, and injection drug users are at a particular risk.
Tetanus
Prevention: Active immunization is recommended starting in childhood. - three to four initial doses - followed by boosters every 10 years. An additional booster is recommended if a major injury occurs, and if it has been more than 5 years since the last booster.
Tetanus
Treatment: Tetanus immune globulin should be given intramuscularly (IM). A full course of tetanus toxoid should be administered once the patient recovers. Bed rest, sedation, and mechanical ventilation often are necessary to control spasms. Penicillin is given to all the patients to eradicate toxin-producing organisms.
Tetanus
Microcytic Anemia Target cells ↑/Normal Iron ↑/Normal TIBC 30-100% Saturation ↑/Normal Ferritin Abnormal Hemoglobin electrophoresis ↑ Indirect bilirubin
Thalassemia
Microcytic anemias (TICS)
Thalassemias Iron deficiency Chronic Sideroblastic
Diagnosis: XRAY (best!): - Transverse or R colon is dilated, 6-15cm supine
Toxic Megacolon
Drugs to avoid in hyperparathyroidism
Thiazides Lithium carbona Vitamin A/D Ca+ containing antacids
Pioglitazone Rosiglitazone
Thiazolidinediones
Causes - impaired marrow production (e.g., vitamin B12 or folate deficiency; congenital; or marrow damage from drugs, leukemia, infections) - increased destruction (e.g., immune-mediated HIT, ITP, HIV, SLE, or nonimmune in DIC, TTP, and HELLP) - hepatosplenic sequestration.
Thrombocytopenia
Clinical features Below 50,000/μL - petechiae, purpura - bleeding (nose, gums, GI tract, menorrhagia) - Caused by TTP, HELLP, HIT, HUS, and DIC
Thrombocytopenia
What to do if PCI not available for STEMI?
Thrombolytic therapy w/in 3 hours
Adults Cause: ADAMTS 13 and big vWF Normal PT/PTT Fever Bleeding and clotting disorder CNS failure Treatment - emergent plasma exchange - no platelets
Thrombotic thrombocytopenic purpura (TTP)
__________ abnormalities are very common in patients with myasthenia gravis.
Thymus
TSH secreting What Pituitary Adenoma?
Thyrocotixosis
Extreme hyperthyroidism High fever Tachycardia Tremor Delirium N/v Mortality is high Treatment: - PTU given orally - Propanolol - IV Sodium IOdide
Thyroid Storm
Potentially fatal complication of untreated thyrotoxicosis Triggers: surgery, trauma, infection, illness, pregnancy
Thyroid Storm
AKA convulsive seizures (formerly known as grand mal) Bilaterally symmetric and without focal onset Begins with a sudden loss of consciousness—a fall to the ground Tonic phase: very stiff and rigid 10-60 seconds. Clonic phase: generalized convulsions and limb jerking Postictal phase: a confused state
Tonic-Clonic Seizures
Polymorphic Vtach Occurs in patients: - with hypokalemia/hypomagnesium - following drugs that prolong QT (antiarrhythmics)
Torsades de Pointes
Polymorphic ventricular tachycardia that appears to be twisting around a baseline
Torsades de pointes
Acetaminophen toxicity: Treatment with N-Acetylcysteine within 8-10 hrs
Toxic Hepatitis
Diagnostic studies: Patients at greater risk of stroke and may need hospitalization - older - elevated BP - weakness/speech impairment - diabetes If outpatient workup is chosen, the evaluation should be completed within 2 days. Head CT or MRI to exclude a small cerebral hemorrhage. Definitive: Conventional angiography (invasive; associated with risk of stroke)
Transient Ischemic Attacks
MC in older patients and those at risk for vascular disease. 1/3 will have a stroke in 5 yeares Sudden onset of focal neurologic deficits is secondary to disturbance of cerebral circulation. - Relate directly to either the carotid or the vertebral vascular distribution. Only last for a few minutes Typically completely resolve within 1 hour. By definition, symptoms resolve completely and result in no infarction of tissue.
Transient Ischemic Attacks
Treatment: Prophylactic antiplatelet therapy is initiated if not cardiogenic. - aspirin, clopidogrel, or ticlopidine Cardiogenic - anticoagulation with IV heparin for those who are admitted to the hospital and with warfarin for long-term therapy Carotid endarterectomy - anterior circulation - moderate to high-grade carotid stenosis
Transient Ischemic Attacks
penetrating or blunt, iatrogranic ((+) pressure)
Traumatic Pneumothorax
Pulmonary Hypertension WHO Group 2 Tx
Treat underlying symptoms
Caused by: - autoimmune disorders (pernicious anemia) - other non infectious factors Involves the BODY of the stomach Type A or Type B gastritis?
Type A Gastritis
Caused by: - H pylori or other infectious cause Located in the ANTRUM AND BODY of the stomach Type A or Type B gastritis?
Type B Gastritis
Low Risk - Aspirin and Clopidogrel antiplatelet therapy - Anticoagulation with Enoxaparin High risk - Cardiac catheterization - Antiplatelet and anticoagulation therapy - Coronary angiography (if positive PCI: angioplasty and stent)
UA/NSTEMI
what are the 2nd generation cephalosporins typically used for?
URTIs and soft tissue infections
what are the oral 3rd gen cephalosporins used for?
URTIs and soft tissue infections (similar indications as 2nd gen)
Another name for cystitis
UTI
Sudden or gradual onset Isolated to the colon starts at the rectum and moves proximally Mucosal depth Bloody, pus filled diarrhea Tenesmus (feeling you need to poop) Barium enema: Lead pipe appearance (loss of haustral markings) Complications - toxic megacolon - colon cancer
Ulcerative Colitis
Treatment: Colectomy is curative Pharmacology 1. Aminosalicyclates (Sulfasalazine, Mesalamine) 2. Steroids *acute flares only 3. Immunomodulators 4. Anti-TNF
Ulcerative Colitis
Sister Mary Joseph nodule
Umbilical nodule
Closely related to NSTEMI Common manifestation of CV disease 3 common presentations: - angina at rest - new onset of angina symptoms, increasing pattern of pain in previously stable patients Less responsive to nitroglycerin Lasts longer Occurs at rest or with less exertion What kind of angina?
Unstable Angina
- difficulty in standing from a seated position - unsteadiness on turning - difficulty in stopping - a tendency to fall What diagnostic feature of Parkinson's?
Unstable posture
In which lung segment does Mycobacterium tuberculosis reactivate?
Upper
Places stones are most likely to lodge
Ureteropelvic junction (kidney stones) Ureterovesicular junction (bladder stones) Ureter at the level of the iliac vessels.
Reactive Arthritis tetrad
Urethritis Conjunctivitis Oligoarthritis Mucosal ulcer
5%-10% of kidney stones Radiolucent Form in individuals with persistently acidic urine with or without hyperuricemia More common in men Tx: allopurinol to decrease acid
Uric Acid Stones
Clinical findings" Primary infection (chickenpox) - generalized pruritic eruption that follows a centripetal pattern. - begin as erythematous macules and papules, form superficial vesicles ("dewdrop on rose petal"), and later crust over - at any given time, several morphologies can be identified. Reactivation (shingles) - painful eruption, usually following a dermatomal pattern - thoracic and lumbar areas are the most common sites - trigeminal eruptions that include the tip of the nose (Hutchinson sign) risk corneal involvement. Clinical dx Supportive tx
Varicella Zoster
General characteristics: HHV-3 Primary infection (chickenpox) - most cases occur in late winter or spring. - patients are most contagious 1 day before the rash appears - a single attack confers lifelong immunity. - benign illness in childhood - life-threatening in adults or immunocompromised patients. Reactivation (shingles) - reactivation of varicella virus that has been dormant in ganglionic satellite cells. - outbreak may be precipitated by illness, stress, or advancing age.
Varicella Zoster
Clinical features: Chronic, nontender mass Does not transilluminate Usually on the left side. Bag of worms," - increases in size with Valsalva - decreases in size with elevation of the scrotum or supine position
Varicocele
General characteristics: Formation of a venous varicosity within the spermatic vein (pampiniform plexus). MC in left spermatic vein - vein is longer than the right and joins the left renal vein at right angles.
Varicocele
Treatment: Surgical repair (left spermatic vein ligation) can be performed if it is painful or if it appears to be a cause of infertility.
Varicocele
AKA multi-infarct dementia Includes lacunar and multiple cortical infarctions. M>F Associated with HTN, with or without a history of TIA or stroke.
Vascular dementia
Symptoms typically occur in a stepwise fashion and are related to the area of the CNS affected. Cortical symptoms: - speech difficulty - trouble performing routine tasks - sensory interpretation difficulty - confusion, amnesia - executive dysfunction. Subcortical symptoms: - gait problems - urinary difficulties - motor deficits - personality changes. Focal neurologic findings on PE: unilateral weakness, Babinski sign, or unilateral hyperreflexia. Social behaviors may be well maintained
Vascular dementia
Treatment: Control of hypertension and metabolic disorders Standard medical regimens can be used to treat insomnia, agitation, or depression. Caregivers should identify and reduce home hazards and arrange, as necessary, community services or preparation of an advance directive.
Vascular dementia
- lack of immune deposits - (+) ANCA antibodies What type of Rapidly progressive glomerulonephritis?
Vasculitis
decrease in arterial pressure and HR mediated by parsympathetic tone What cause of syncope?
Vasovagal
MC cause of syncope
Vasovagal (neurocardiogenic)
No effective pumping action exists with this arrhythmia Without intervention patient will die
Ventricular Fibrillation
3+ consecutive premature beats Can be sustained or unsustained (both are electrolyte abnormalities Associated with acute MI and dilated cardiomyopathy
Ventricular Tachycardia
Erratic rhythm with no discernable waves (P, QRS, or T waves)
Ventricular fibrillation
Three or more consecutive VPBs, displaying a broad QRS complex tachyarrhythmia
Ventricular tachycardia
Rate control CCBs
Verapamil Diltiazem
CCBs
Verapamil Diltiazem dipine
Tpa must be given within what time frame?
Within 4.5 hours
What happens to the pain of a gastric ulcer with food?
Worsens
what is the main use of ciprofloxacin?
abdominopelvic infections
what are the major SE of flouroquinolones?
arthropathy and tendonopathy
Regular, sawtooth pattern and narrow QRS complex
atrial flutter
what antibiotic would you use to treat chlamydia (non-gonoccocal urethritis/cervicitis)?
azithromycin
what are the macrolide abx?
azithromycin, clarithromycin, erythromycin
vertigo, visual dysfunction, perioral numbness, ataxia What cause of syncope?
basilar artery
What is valsalva?
bearing down coughing holding breath
A ruptured cerebral arterial aneurysm or, less commonly, an arteriovenous malformation (AVM) causes
bleeding into CSF in the subarachnoid space
the anti-influenza medication Zanamavir is associated with what side effect?
bronchospasm
slow SA and AV node due to pressure on carotids (turtleneck) What cause of syncope?
carotid sinus
what are the most common 1st generation cephalosporins?
cefazolin (IV) and cephalexin (PO)
which antibiotic would you use for perioperative prophylaxis?
cefazolin (ancef)
what is the silver standard (2nd line) IV anti-MSSA abx?
cefazolin (ancef); which is a 1st gen cephalosporin and is used in perioperative prophylaxis
what are the oral 3rd generation cephalosporins?
cefpodoxime (vantin) and cefdinir (omnicef)
what is the 5th generation cephalosporin?
ceftaroline
what is the only cephalosporin with MRSA coverage?
ceftaroline
what are the 4th generation cephalosporins?
ceftazidime and cefepime
what is the DOC for gonorrhea?
ceftriaxone
what is the non-respiratory flouroquinolone?
ciprofloxacin
what are the 2 most common anti-pseudomonal abx?
ciprofloxacin and levofloxacin
what is the silver standard (2nd line) anti-aerobic abx?
clindamycin
which abx is most commonly associated with C. Diff?
clindamycin
which affects the: - skin as well as the heart, lungs, GI tract, and kidneys what kind of Systemic Sclerosis (Scleroderma)?
diffuse
Is the ECFV increased and the urine sodium decreased? If yes, think
edematous disorders (CHF, cirrhosis, nephrotic syndrome)
Kussmaul breathing
gasping, labored breathing, also called air hunger
what are the aminoglycoside abx?
gentamicin and tobramycin
Pulmonary Hypertension WHO Group 5
heme, systemic & metabolic (sickle cell, sarcoidosis)
Cirrhotic patients must be screened every 6 months for _______________ regardless of successful treatment of the underlying cause.
hepatocellular carcinoma
AKA aneurysmal leak Produces a less severe but atypical headache Focal neurologic signs resulting from pressure on the brain or cranial nerves. Corresponding sentinel headache usually occur 1 to 3 weeks prior to the severe SAH
herald bleed
In what population is a PPD ≥ 10 mm considered a positive test?
high risk populations (e.g., medical employees) IVDU
HBeAg
highly infectious
Is the plasma osmolality between 280 and 295 mOsm/kg? If yes, think
isotonic hyponatremia (paraproteinemia, hypertriglyceridemia)
flouroquinolones are contraindicated in what population?
kids under 18
Class 3 Congestive Heart Failure
marked physical limitation; comfortable at rest
Class 1 Congestive Heart Failure
no limitation of physical activity
IgG
not acute
which antifungal medication would you give a child with oral candidiasis (thrush)?
nystatin S&S (swish and swallow)
In what population is a PPD ≥ 15 mm considered a positive test?
patients with no known risk factors
How will the purified protein derivative test result if a patient has had previous immunization or exposure to tuberculosis?
positive
Is the ECFV increased and the urine sodium increased? If yes, think
renal failure
what are the 2 main organisms treated with PCN in primary care?
s. pyogenes (group A strep) and t. pallidum (syphilis)
Pulmonary Hypertension WHO Group 3
secondary to lung disease
which class of abx causes Yellow Babies by displacing bilirubin?
sulfonamides (Bactrim/Septra)
What should patients on INH take daily and why?
supplemental vitamin B6 (Pyridoxine) daily to prevent neuropathy
Cushing DISEASE Management
surgical removal of pituitary tumor Hyperandrogenism: Flutamide Hypercortisolism: Metrypone HTN: K+ sparing diuretics, CCB
what is the generic name for Lamisil?
terbinafine
when prescribing oral terbinafine, what labs would you order and when?
terbinafine is hepatotoxic. order baseline LFTs and then periodically while taking the med
which class of abx causes teeth discoloration and is contraindicated in children <8yo?
tetracylines
MC type of bladder cancer
transitional cell carcinoma
seen in IV drug users blowing murmur
tricuspid regurgitation
patients with sulfa allergies should not get what abx?
trimethoprim/sulfamethoxazole
what is the treatment of PCP pneumonia?
trimethoprim/sulfamethoxazole
which abx can cause hemolytic anemia in G6PD deficient patients?
trimethoprim/sulfamethoxazole
Community acquired pneumonia bacterial causes
within 48 hours of hospital Strep pneumo Mycoplasma pneumo
Symptoms begin by 4 to 6 months of age - when the switch from fetal hemoglobin (Hgb F) to adult hemoglobin (Hgb A) occurs Manifestations: - severe anemia - growth retardation - abnormal facial structure - pathologic fractures, osteopenia - bone deformities - hepatosplenomegaly and jaundice Tx: iron chelation and allogeneic stem cell transplantation
β-Thalassemia major
Metabolic Alkalosis labs
↑ pH ↑ CO2 ↑ HCO3-
Respiratory Alkalosis labs
↑ pH ↓ CO2 ↓ HCO3-
Respiratory Acidosis labs
↓ pH ↑ CO2 ↑ HCO3-
Metabolic Acidosis labs
↓ pH ↓ CO2 ↓ HCO3-
Mean pulmonary arterial pressure _____________ is diagnostic of pulmonary hypertension
≥ 25 mm Hg
