Internal Med EOR

*Sjogren's syndrome*

Autoimmune Dz that attacks exocrine glands (*drys you up*) ---attacks salivary, lacrimal, *parotid*, thyroid glands Sx: - Drys your head up! -----Xerostomia (dry mouth) ----- Keratoconjunctivitis sicca (dry eyes) - Incr. incidence of non-Hodgkins Lymphoma Dx: - *ANA* - *AntiSS-A (Ro) and AntiSS-B (La)* - + RF - *+ Schirmer test* Tx: - *Pilocarpine* (cholinergic drug- cause your to lose fluid) - *Cevimeline* (stimulates muscarinic cholinergic receptors)

*Reactive Arthritis [Reiter's syndrome]*

*"Can't see, can't pee, can't climb a tree"* (most helpful saying ever!) Etiology: - Autoimmune response to an infection in the body - MC in 20-40 yo Males - Chlamydia (MC), Gonorrhea, Salmonella, Shigella Sx: - *Arthritis (asymmetric) + conjunctivitis + urethritis/cervicitis* - sausage toes/fingers - *keratodera blennorrhagicum* (hyperkeratotic palms/soles) Dx: - *+HLA-B27!!!* - neg. bacterial culture of synovial fluid Tx: - NSAIDs - methotrexate if bad

*A Fib*

*Be able to identify on ECG* - no p-wave -narrow QRS - Irregularly irregular - rate 80-140 -causes thrombi/ embolis Causes: - ischemia - Cardio dz - cadriomyopathies - electrolytes - endocrine (thyroid) - drug/EtOH Tx: -UNstable= synchronized cardioversion - Stable= ---BB (MC= metoprolol- caution with reactive airway dz) ---CCB (diltiazem or verapamil) ---Digoxin (use for rate control in Hypotension or CHF) ---If risk score >2, then anticoagulant (aspirin for low risk, *Warfarin*/ NOAC for high risk) Uses Non-Vitamin K antagonist oral anticoags (NOAC) for most things now, but use Warfarin (INR goal = 2-3) for pts with kidney probs, HIV meds, anti-epileptic meds (CP450-inducers like carbamazepine and phenytoin) or cost issues - use heparin bridge til therapeutic levels of warfarin.

*Gastroenteritis causes* (know bolded ones for sure)

*Vomiting AND diarrhea* "GI Bug" often viral or bacterial *NON-INVASIVE(small bowel/ large volume stool):* Staph aureus: - dairy/egg/ mayonnaise - self limting vomiting, cramps, diarrhea Bacillus Cereus: - Fried rice - self limiting Vomiting 1-6 hrs later *Vibrio cholerae!!!!* - contaminated water - "rice water stools", rapid dehydration - fluids and tetracyclines if severe/life threatening E.Coli - Travelers diarrhea - very watery diarrhea - fluroquinolone if severe *INVASIVE- CAUSES HIGH FEVER AND CAN"T HAVE ANTI_MOTILITY DRUGS!!* (in large bowel + fever, + blood) *Campylobacter enteritis* - MC cause of enteritis in US (seagull shape) - can be post gillain-barre syndrome - undercooked poultry - RLQ pain, watery then bloody stool - Erythomycin if severe *Shigella* - highly virulent - explosive water/mucoid/bloody diarrhea - PUNCTATE UlCERS on sigmoidoscpoy - Trimethoprim-sulfa. if severe *Salmonella* - in poultry and pets - self limiting mucus + bloody diarrhea - pea soup stool + rose spots= typhoid fever Enterohemorrhagic E coli - beef, Unpasterized milk/apple cider/ day-care - watery diarrhea +/- low grade fever - can cause HUS in kids Yersinia Enterocolitica - mimics appy and can cause mesenteric adenitis

Who gets a statin

- Any form of clinical atherosclerotic cardiovascular disease (ASCVD) - Primary LDL-C levels of 190 mg per dL or greater. - DM, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL. - NO DM, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%

*Thyroid cancer*

- Most pts are Euthyroid - High ? of CA if nodule in pt<20 or cold nodule - Post surgery, want the TSH to stay low at 0.1-2 *4 Types:* Papillary: - *MC type* -MC in young females w/*RADIATION EXPOSURE* - Least aggressive/ High cure rate - Mets common LOCALLY - *Tx= Total/subtotal thyroidectomy + thyroglobulin monitoring for 6 months* Follicular: - incr. w/ *iodine deficiency* - MC in 40-60 yo - more aggressive than papillary but slow growing - DISTANT Mets common(lung, liver, brain, bone) - excellent prognosis - *Tx= Total/subtotal thyroidectomy + thyroglobulin monitoring for 6 months* Medullary: - Associated with *MEN 2* (NOT RADIATION) - more aggressive - comes from parafollicular cells - *secretes calcitonin* - local Mets early, distant in late - Poorer prognosis - Tx= Total Thyroidectomy + monitor calcitonin level Anaplastic: - May occur many yrs post radiation - *MC in MALES >65 yo* - *Most aggressive* w/ rapid growth - may invade trachea - POOR PROGNOSIS - Tx= most can't be resected, radiation, chemo, *Palliative tracheostomy*

Antiphospholipid syndrome ---- (can't remember if this was on there or not)

- associated with systemic lupus erythematosus - hypercoagulable state ---------- *recurrent venous or arterial thrombosis* at an early age ---------- spontaneous abortions Dx: - *lupus anticoagulant* - *anticardiolipin* - *anti-beta 2 glycoprotein I antibodies*. - Prolonged dilute Russell viper venom time (DRVVT) - *prolonged PTT* Tx: - IV heparin, then: - low dose aspirin - warfarin

TB tests

- will turn positive 2-4 weeks after infxn Positive if: - > 5mm = HIV+, Immunosuppresed, Close contact TB, CXR has calcified granuloma - >10 mm= High-risk populations (prision/ health-care, immigrants where TB prevelant, DM) - >15 mm= no know TB risk factor False Negatives from: - Anergy (HIV/Sacroid) - wrong test placement - less 2-4 weeks - CA False Positives: - cross reaction with Mycobacterium - w/in 10 yrs of BCG vaccination

*Pneumoconiosis*

fibrotic lung disease caused by the *inhalation of MINERAL/SAND dusts* -CXR= ------eggshell appearance ------nodular opacities/ pleural plaques

*Colorectal cancer*

3rd MC CA death in US Etiology: - Adenocarcinoma - MC Mets= *Liver*, lungs, lymph RF: - *Familial adenomatous polyposis* - Lynch syndrome - Peutz- Jehgers (autosomal dominant- polyps + hyperpigmenation of lips, oral mucosa and hands) - *Age >50* - UC/Crohns - low fiber/ high red-meat diet - smoking/ EtOH Sx: - Large Bowel Obstruction (MC cause in adults) ----- right side= bleed, diarrhea ----- left side = bowel obstruction, present later - change in bowel movements Dx: - *Colonoscopy with Biopsy- TOC* - Barium enema (apply core lesion) - incr. CEA levels (used in treatment monitoring) - iron def. anemia Tx: - localized= surgical resection - Stage 3/4= chemo (5FU) *Screenings:* - Average risk= annual FOB at 50/ Colonoscopy q10 yrs (Flex sig q5 yrs) from 50-75 - 1st degree relative >60 = annual FOB at 40/ colonoscopy q 10 yrs - 1st degree relative <60 = annual FOB at 40/ 10 yrs before age Dx/ Colonoscopy q 5 yrs. Lynch= start colonoscopy at 20-25 yrs q1-2 yrs FAP= start screening at 10-12 yrs with flex sig.

*Heart Murmurs*

AS= Systolic Ejection Murmur at RUSB to carotids (+ narrow pulse pressure) ------NO EXERCISE!! Need replaced and BB/CCB/nitrates AR= blowing Diastolic murmur at RUSB/LUSB (+ wide pulse pressure/ anything pulses) ----- AKA= Austin Flint murmur -----Tx= BP control PS= harsh mid-Systolic murmur at LUSB -----Tx: balloon valvuloplasty if severe PR= early Diastolic murmur (aka Graham Steell) -----Tx: not ever needed TS= mid- Diastolic Murmur at LLSB ------Tx: diuretics TR= holo-Systolic high-pitched murmur at LLSB/LMSB ------Tx: diuretics MS= early mid-DIASTOLIC rumble at apex/ opening snap -----Tx= surgery if really severe/ very symptomatic MR= Holo-Systolic Murmur at apex to axilla ------Tx: BP control/ Surgery if HF ALL Valve MURMURS ARE LOUDER WITH SQUATTING/HAND GRIP (quieter with valsalva) BEST WAY TO DX IS TEE (not tte)

Trigeminal Neuralgia Tx

Carbamezapine

Pheochromocytoma

Catecholamine-secreting adrenal tumor ---- secretes Norepi and epi when triggered ---- 90% benign ---- associated with MEN 2 Sx: - *HTN!* - like crazy high BP - *Palpitation, HA and Excessive sweating* - chest/abd pain, fatigue, weight loss Dx: - *incr. 24 hr urinary catecholamines* ----- incr. metanephrine and vanillylmandelic acid - MRI/ CT to visualize tumor Tx: - Complete adrenalectomy ----Pre surgery= -------PHEnocybenzamine or PHEntolamine FIRST! -------then add BB -STOP metocloprimide if currently taking it

*Hypo-calcemia*

Etiology: - *Hypo-parathyroidism= MC* - Chronic renal Dz - *Vitamin D def* - Hypo- magnesesmia -PPIs Sx: - Muscle cramps - finger/circumoral paresthesias - *Chvostek's (facial tap) and Trousseaus (carpal spasm)* - incr. deep tendon reflexes - Diarrhea/ abd pain -*prolonged QT* Dx: - decr. ioniazed calcium Tx: - mild= PO calcium and vitamin D - Severe/sxs= IV calcium gluconate -CORRECTED WITH ALBUMIN!!

*Idiopathic Pulmonary fibrosis*

Chronic progressive interstitial scarring Etiology: - Unknown - MC in Smoking Men 40-50 yo - survival <10 yrs at time of diagnosis Sx: - dyspnea - cough - inspiratory crackles - *clubbing of finger* Dx: - CXR/CT ----- diffuse reticular opacities (*honeycombing!!!*) ----- *ground glass opacities!!!!!* - PFTs -----Restrictive (*decr. TLC/ RV and normal or increased FEV1/FVC*) Tx: - no effective Tx! - Lung transplant is only cure - maybe O2 or steroids for exacerbations

*systemic lupus erythematosus* ------ know this one super well cause it was all over the place

Chronic systemic connective tissue Dz Etiology: - MC in 20-40 yo AA/Hispanic/Native Am. Female - genetics, sun exposure, estrogen - Drug induced= *Procainamide, hydralazine, INH, Quinidine* + anti-histone Abs Sx: - *Joint pain + fever + malar "butterfly" rash* -----spares nasolabial folds (Dermatomyocytis doesn't) - Discoid lupus= annular red patches on face/scalp- no scarring - *Glomerulonephritis* - *retinitis* - oral ulcers - alopecia - Women More likely to have *miscarriage* or baby born with HR in 20-30 (attacks baby's electrical system in heart) Dx: - *+ Anti- Nuclear Ab: ANA= best INITAL test* - *+ Anti- double stranded DNA & Anti-Smith Ab= 100% specific* (not sensitive) - Antiphospholipid AB Syndrome (APLS) = incr. risk of thrombosis - + anticardiolipin Ab= false + VDRL/RPR - Lupus anticoagulant = incr. risk of thrombosis Tx: - Sun protection - *Hydroxychloroquine for lesions* (ok in preg.) - NSAIDs or Acetaminophen for arthritis - +/- steroids

*Pneumonia*

Community Accquired (CAP) = outside, w/in 48 hrs of hospital setting (Strep pneumo, Mycoplasma) Hospital Accquired (HAP)= after 48 hr of hospital setting (MRSA/ PSeudomonas) Sx: - sudden fever - productive cough - pleuritic chest pain - *Rigors* - tachy- cadia/-pnea - dullness to percussion - *INCR. tactile fremitus* - Egophony - rales - Atypical= asx/ malasie, Sore throat, HA, N/V Dx: - CXR ----consolidation ---- Abcess= S. aureus ----upper lobe buldging fissure/cavitations= klebsiella - sputum culture ---- rusty= strep pneumo ---- currant jelly= klebsiella *Tx:* - CAP OUT-pt= Azitro (Macrolide) or Doxy. - CAP IN-pt=Beta-lactam (end in -penem) + Azithro or Flouro. - ICU pt= B=L + Azithro or B-L + fluro - HAP= B-L + Fluro (Pseudomonas coverage) - MRSA = add vanco - Legionella = Levo or Azithro - Aspiration = Clinda or Metronidazole or Augmentin Vaccines:(don't think vaccines for this were on IM test) *PCV13:* - healthy kids= 2,4,6, 12 months - adults > 65 or chronic Dz get 1 dose if did not receive as a kid. *PPSV23:* - Age >65= 1 dose - 2-64 yo w/ Chronic Dz= 1 dose and 1 dose >5yrs later. - Kids>2 with Chronic dz= must wait 8 weeks after finishing PVC13 vaccine series

*Systemic Sclerosis (Scleroderma)*

Connective Tissue Disorder= Thickened skin, lung, Heart, kidney and Gi tract Types: Limited Cutaneous systemic sclerosis: - MC type - better prognosis - Dx: --*+ Anti-Certromere Ab* -Sx: -- *CREST syndrome* -------*C*alcinosis cutis -------*R*aynaud's -------*E*sphageal motility disorder -------*S*clerodactyly (shiny/thick skin + claw hand) -------*T*elangietasia Diffuse Cutaneous systemic sclerosis: - often has multi-organ involvement - worse prognosis -Dx: -- *+ Anti-SCL-70 Ab* - Sx: --skin thickening of *trunk and proximal extremities* Tx: - *Acute= DMARDs and Steroids* -------hydroxychloroquine -------leflunomide -------methotrexate -------sulfasalazine -------minocycline - Raynauds= *CCB* or prostacyclin

*Stomach Cancer*

Etiology: - Adenocarcinoma (MC) - MC in males >40 yo RF: - *H. pylori* - high nitrates diet (salted/cured/smoked/pickled) - pernicious anemia - chronic gastritis Sx; - Dyspepsia - early satiety - weight loss - N/V/blood loss (iron def. anemia) Mets: - Virchows node (supraclavicular LN) - Sister Mary Joseph node (umbilical LN) - ovaries - rectum Dx: - upper endoscopy with biopsy ---- ulcerative- all layers ---- polypoid- into lumen ----Linitis plastica- diffuse thickening of wall(worst) Tx: -gastrectomy - radiation/chemo - POOR prognosis

Esophagitis

Etiology: - *GERD = MC* - infectious if immunocompromised (*Candida, HSV, CMV*) - radiation, meds, toxic injection, eosinohilia RF: - Preg - smoke - obese -allergies - EtOH, chocolate, spicy foods - meds (NSAIDs, BB, CCB, *bisphosphonates*) Sx: - odynophagia (painful swallowing) - dysphagia (difficulty swallowing) - restrosternal chest pain *Candida= linear yellow/white plaques* *HSV= small deep ulcers* *CMV= large superficial shallow ulcers* Eospinophilic = multiple corrugated rings Pill-induced = well-defined ulcers of varying depth Dx: - upper endoscopy Tx: Treat cause - GERD= PPI/ H2 blockers - Candida = PO fluconazole - HSV = Acyclovir - CMV =Ganicilovir - Eosinophilc= remove food allergy+inhaled steriod - Pill-incuded= take meds with 4oz H2O and don't lay down for 30-60 mins after taking meds.

Cholangitis

Etiology: - Biliary tract infxn due to Obstruction --- *gallstones*, CA - *E coli*, Klebsiella, enterobacter, anaerobes or enterococcus Sx: - Charcots triad (*fever/chills, RUQ pain, jaundice*) - Reynolds Pentad (Charcots triad + *shock + altered mental status*) Dx: - Labs: ----Leukocytosis ----cholestasis ----incr. alk phos + incr. GGT and bilirubin - US/ CT - *Cholangiography via ERCP= gold standard*(also therapeutic) Tx: - ABX ---*Ampicillin/sulbactam* ---perpercillin/tazobactam ---Ceftiraxone + metronidazole --- Fluroquinolone + metronidazole --- Ampicillin + Gentamicin - *common bile duct decompression vie ERCP*

Gastritis

Etiology: - H. pylori = MC - NSAIDs/Asprin - Acute stress - EtOH, bile salts, trauna, corrosives, etc. Sx: - asx MC - epigastric pain - N/V, anorexia, small upper GI bleed Dx: - ednoscopy = gold standard - h. pylori testing (urea breath test, stool antigen) Tx: - H.pylor + = Clarithromycin + Amoxicillin + PPI ----- metronidazole if PCN allergy - H. pylor - = acid suppression (PPI or H2 blocker) +/- sucralfate

hyper-parathyroidism

Etiology: - Primary (MC)= ------Parathyroid adenoma (MC) ----- parathyroid hyperplasia - Secondary= ------ Hypocalcemia/Vit D def. ------ Chronic Kidney Failure (MC) Sx: - "stones, bones, abd groans, and psychic moans" - decr. deep tendon reflexes Dx: -*Hyper-calcemia+ incr. PTH+ decr. phoshate* - osteopenia on bone scan Tx: - Parathyroidectomy (if primary) - Vit D + Calcium supplements - treat cause if secondary

Cholecystitis

Etiology: - gallstone obstruction - *E.coli (MC)*, Lebsiella, Enterococci, B. fragilis, Clostridium Sx: - RUQ pain that is *continuous* - N/V - worse with fatty foods/ large meals - fever - + Murphys sign - + Boas sign ( referred pain to r shoulder area) ------ caused by phrenic nerve irritation Dx: - *US is the initial test of choice* - CT - labs: incr. WBCs/ bilirubin, alk phos, LFTs - *Hida Scan is gold standard* (+ mean nonvisulaization of the gallbladder) Tx: - NPO, IV fluids, ABX (ceftriaxone + metronidazole) - Cholecystectomy (w/in 72 hrs) - pain control

Anal Fissure

Etiology: - low-fiber diet - constipation - anal trauma - *MC at midline* Sx: - severe painful rectal pain w/ bowel movements - pt avoiding having a bowel movement - constipation - Bright red blood per rectum Tx: - Supportive! (warm sitz baths, fiber, ater, stool softner) - 2nd line= Nitroglycerin (cause HA and dizzy) or Nifedipine ointment to vasodilate

Diverticular Dz

Etiology: - outpouching of mucosa into vasa recta of colon wall - *Sigmoid = MC area* - usually >40 yo Diverticulosis= pouching due to low fiber/ constipation/ obesity --- Usually asx ---MC cause of lower GI bleeding Diverticulitis= inflammed diverticula --- due to obstruction/ infx/ *fecaliths* --- *Fever/ LLQ pain MC*/ N/V / diarrhea or constipation/ flatulence/ bloating Dx: - *CT w/ contrast* - incr. WBCs and + Guaiac Tx: -losis= high fiber diet/ fiber supplements - litis= clear liquid diet/ Cipro or Bactrim + metronidazole

*Hemorrhoids*

Etiology: - superior hemorrhoid vein= proximal to dental line - inferior hemorrhoid veins= distal to dental line RF: - straining, constipation, preg, obesity, prolongeg sitting, cirrhosis Sx: External: - *perianal pain* with defecation - +/- skin tags Internal: - intermittent rectal bright red bleeding MC - rectal pain suggests complication Classification of internal: 1) does not prolapse 2) prolapses w/ straining but spontaneousl reduce 3)prolapse w/ straining and manual reduction 4) irreducible and my stangulate Dx: - digital rectal exam - FOBT -proctosigmoidoscopy/colonoscopy r/o other dz Tx: -conservative (1st): fiber, stiz baths, topical steriods - Procedures (2nd or strangulated-stage 4): ---- band ligation ---- sclerotherapy ---- infrared coagulation -Hemorrhoidectomy (all stage 4s and failed txs)

*Pancreatitis*

Etiology: pancreatic enzymes autodigest pancreas - GALLSTONES(1) and EtOH(2) are MC Causes -----EtOH MC in men - meds (thiazides, AIDS meds, estrogen, valproic acid) - Scorpion bite - *Mumps in KIDS* Sx: - Epigastric pain (constant, boring, *radiating to back*) ---worse with eating/standing, *better with leaning forward*/fetal position - N/V/ fever/ decr. bowel sounds/ tachycardia - *Necrotizing = cullen's (periumbilical) and Grey Turner (flank) ecchymosis* - Steatorrhea - Glucose intolerance - *difficulty absorbing Fat-soluable vitamins* Dx: - Labs: ---- *LIPASE*(71-14 days) or amylase (3-5 days) ---- *x3 incr in ALT= Gallstones* ---- hypocalcemia / incr. triglycerides -*Abd CT IS TEST OF CHOICE!!!!!!!!!!!* w/ contrast for acute - *MR cholangiopancreatography- best test for CHRONIC* - US/ Xray (sentinel loop (dilated ileus) and Colon cutoff sign (colon colapse near pancreas)) -Follow *Fasting Glucose levels in Chronic* due to incr. risk of DM Tx: - SUPPORTIVE!! ---NPO, IV fluids, analgesia (Merperidine!) ---may take 3-7 days -ABX ONLY IF NECROTIZING (imipenem) RANDOS CRITERA FOR PROGNOSIS: - *score > 3 = likely pancreatitis* - At Admission: (GALAW) 1) Glusoce >200 2) Age >55 3) LDH >350 4) AST > 250 5) WBC >16,000 -Within 48 hrs 1) Calcium <8 2) Hematocrit fall >10% 3) Oxygen <60 4) BUN >5 5) Base deficit >4 6 ) Sequestration of fluid >6

*Hyper-thyroidism*

Etiology: - *Graves (MC)* - toxic multinodular goiter (TMG) - TSH secreting pituitary adenoma - taking too much T4/T3 - thyrotoxicosis Sx: (think everything is HYPER-active) - Increased BMR - HEAT intolerance - weight loss - skin= warm, moist, fine hair, alopecia - goiter - HYPER-activity - diarrhea - tachycardia/palpitations - high-output HF - scanty periods - hyper- glycemia Dx: - Decr. TSH + incr. T4= Graves, TMG, Toxic adenoma -Incr. TSH+Incr. T4=TSH secreting PA Tx: - Radioactive Iodine - Methimazole or PTU (preg.) - BB for thyrotoxicosis - Surgery for tumors or if all else fails

*Hypo-thyroidism*

Etiology: - *Iodine def*. (MC world-wide) - *Hashimoto's* (MC in US) - de Quervain's throiditis (*PAINFUL & SUBACUTE*-post-viral) - Postpartum - pituitary Hypothyroidism - Cretinism - Riedel's thyroiditis (*hard woody nodule*) Sx: (think everything is slowing down) - Decr. BMR - COLD intolerance - weight gain - *loss of outer 1/3 eyebrow* - dry/thick skin - goiter - non-pitting edema - hypoactivity - Brady cardia/ decr. CO - menorrhagia - hypoglycemia Dx: - Incr. TSH + Decr. T4 - + thyroid Ab= --------Hashimotos --------Silent thyroiditis --------Postpartum - *Antimircosomial and Thyroid Peroxidase Ab= Hashimotos* - Incr. ESR= de quervain's thyroiditis Tx: - Levothyroxine - aspirin for thyroiditis conditions

*Celiac Dz*

Etiology: - autoimmune response against a-gliadin - loss of villi - MC in Irish/Finnish women Sx: - *diarrhea* - abd pain/bloating - *steatorrhea* - malabsorbtion - *Dermatitis Herpetiformis* (papulovesicular rash on extensor surfaces/ neck and trunk ) Dx: - + Endomysial IgA AB and Transglutaminase Ab - *Small bowel Biopsy= definitive!!* Tx: - gluten free diet (no wheat, rye or barley) ------- oats, rice and corn are ok - steroid if really bad flair

*Endocarditis*

Etiology: - *MC valves= Mitral* (then A>T>P) EXCEPT for *IVdrug userers = Tricuspid is MC * - MC organism is *S. Aureus* (*MRSA* for IV drug users and Prosthetic valves= *Staph epidermis* and *enterococci for >50yo M with GI/GU procedures) - *SUBACUTE= infection of ABNORMAL VALVES with LESS VIRULENT ORGANISMS (STREP VIRDANS)* Sx: (*know all of these!!!!!*) - *Fever* - *ECG conditions* - Janeway lesions (erythematous macules on palms and soles) - Roth Spots (petechiae) - Osler's nodes (tender nodules on fingers) - Splinter hemorrhages Dx: - Blood cultures - ECG - Echo (TEE>TTE) -Labs (leukocytosis, anemia, Incr. ESR and rf) *DUKE CRITERIA* (2 major or 1 major and 3 minor): - Major: ---Sustained Bacteremia ---Endocardial Involvement (+echo or new valvular regurg). - Minor: ---Predisposing condition ---Fever ---Vascular and embolic phenonena --- Immunologic phenomena Tx: - *Acute= Nafcillin + Gentamicin for 4-6 weeks*(Vanco + gent if thinking MRSA) - Subacute= Pen or Ampicillin + gentamicin (vanco if IVDA) - Prosthetic valve= Vanco + gentamicin *+ rifampin* - fungal = amphotericin B Prophylaxis: - *Amox.* (clinda if allergy) 2g 30-*60 mins prior* to a procedure - Prosthetic heart valves - heart repairs - prior hx of endocarditis - congenital heart disease - *Dental or respiratory procedures*

Hyper-natremia

Etiology: - *Net water loss= MC* (dehydration) Sx: - CNS dysfunction ------confusion, coma, muscle weakness, seizure -SHRINKAGE of Brain Cells ------ water moves out of cells cause more in blood. Dx: - SERUM Na+ >145 Tx: - Hypotonic fluids (oral if possible) - *Correct <0.5/hr for avoid CEREBRAL EDEMA*

Hyper-calcemia

Etiology: - *primary hyper-parathyroidism* - CA - Thiazides and Lithium Sx: - most asx - *kidney stones* - polyuria - *painful bones/ fractures* - ileus - *Constipation*(groans) - decr. Deep tendon reflexs - depression/psychosis (*psychic moans*) - *short QT* Dx: - ionized Calcium Tx: - furosemide= first line - calcitonin - bisphosphonates if severe (IV pamidronate) --------denosumab is bisphosphonates fail -CORRELATED WITH ALBUMIN

*diabetes insipidus*

Etiology: - ADH deficiency (Central) - MC, idiopathic - insensitivity to ADH (Nephrogenic)- Lithium, hyper-calcemia, hypo-kalemia, ATN Sx: - Sxs with decreased oral free water intake - Polyuria (up to 20 L/day) - Polydipsia - Nocturia - Hyper-natremia - dehydration - hypotension Dx: - Fluid Deprivation test= establishes DI diagnosis ----- continued production of dilute urine (Uosm < 200 and specific gravity < 1.005) Desmopressin stimulation test= determines cause ----- reduced urine output= central ----- continued dilute urine= nephrogenic Tx: - Hypotonic fluid if dehydration sxs. - Central= *DDAVP* or Carbamazepine - Nephrogenic= Na+/protein restriction and Hydroclorothiazide and Indomethacin _use Amiloride if caused by lithium use.

Restrictive Cardiomyopathy (RCM)

Etiology: - Amyloidosis (MC), Sarcoidosis, hemochromatosis (aka all the *"-osis-es"*) - *Diastolic dysfunction* ---------due to rigidity- not hypertrophy Symptoms: -RHF sxs(peripheral edema, JVD, hepatic congestion) - *Kussmaul's sign*- incr. JVP >20 with inspiration Dx: - Echo ----- normal ventricle thickness, dilated atria, diastolic dysfunction. Tx: - treat underlying cause

*peripheral arterial disease*

Etiology: - Atherosclerosis of lower extremities Sx: - *INTERMITTENT CLAUDICATION* brought on by exercise (MC = femoral artery and popliteal artery) - Leriche's syndrome= claudication, impotence, decr. femoral pulses - resting leg pain -*acute arterial embolism (6Ps-Paresthesias, pain, pallor, pulselessness, paralysis, poikilothermia)* -gangrene (wet=ulcers, dry=mummification of digit) - *bruits and decr. cap refill* - atrophic skin - pale on elevation and dusky red with dependency Dx: - *Ankle-Brachial Index (+ if < 90)* - Arteriography= GOLD STANDARD - US - Hand held doppler Tx: - *CILOSTAZOL, asprin or clopidogrel* (antiplatelet) - Exercise - ACEI - Revascularization with angioplasty, fem-pop bypass, endarterectomy - Supportive (foot care, exercise, decr. risk factors) - Heparin or thrombolytics if acute - amputation if gangrene

Hypertrophic Cardiomyopathy (HCM)

Etiology: - Autosomal Dominant inheritance - *Athlete who collapses OR kids physical with a murmur that gets quieter while squatting* - *Diastolic Dysfunction* - Subaortic outflow obstruction --------Hypertrophied septum/ systolic anterior motion of the mitral valve. Symptoms: -*Dyspnea= MC initial complaint* - Angina - Arrhythmias - Sudden cardiac death due to VFib. - *Harsh systolic ejection murmur @ LLSB* ------*Louder with Valsalva and quitter with squatting/handgrip* ------no carotid radiation of murmur - S4 Dx: - Echo (wall thickness- esp. septal) Tx: - AVOID DEHYDRATION & EXTREME EXERCISE - *BB* or CCB - surgical Myomectomy -*ICD to prevent VF* - EtOH ablation - AVOID DIURETICS, NITRATES and DIGOXIN!!!!!

*Acromegaly*

Etiology: - Groth hormone-secreting pituitary adenoma - Called gigantism in kids Sx: - being huge - *DM/ glucose intolerance* - enlargment of hand/feet/skull/JAW - *coarse facial features* - *thickened doughy skin* - deepened voice *Dx:* - incr. insulin-like growth factor screening test -*confirmatory= oral glucose suppression test* (GH levels will stay increased) Tx: - *Transsphenoidal surgery + Bromocriptine* ----- possible S/E of surgery= SAIDH or DI - *Octreotide*- inhib. growth hormone secretion --------S/E= diarrhea and cholecystitis

*PUD*

Etiology: - H.pylori (MC) - NSAIDs (2nd MC) - Zollinger-Ellison Syndrome(gastrin producing tumor) - EtOH, smoking, stress, males, old, steroid, CA Sx: - *Dyspepsia (gastric PAIN)* -------- worse at night, can be acid dyspepsia (worse w/o eating) or food provoked dyspepsia (pain after meals) - *GI Bleed (MC cause of upper GI bleed)* Types: (Know the difference between the two) Duodenal: - caused by acid, pepsin or *H. pylori* damaging - MC type (MC in duodenal bulb) - ages 30-55 - Almost always benign - *Better while eating, worse 2-5 hrs later* Gastric: - caused by decr. mucus, bicarb, *NSAIDS decreasing protective factors* - MC in antrum of stomach - ages 55-70 - can be malignant - *Worse while eating, not as bad 2-5 hrs later* Dx: - *Endoscopy= gold standard*- w/ biopsy if CA possible - Upper GI series (must do endscopy if GU seen) - *H. pylori testing* (endoscopy, +urea breath test, + H. pylori stool antigen, + serologic antibodies) Tx: - H. pylori eradication ------ triple therapy (Clarithro + Amox + PPI) -------------metronidazole + tetracycline if no PCN. ------ Quad therapy (PPI+ Bismuth subsalicylate+ Tetra. + Metro) - If no H. pylori: ----- PPI or H2 blocker ----- Misoprostol ----- Antacids, Bismuth, sucralfate - Parietal cell vagotomy if refractory - Bilroth 2 causes dumping syndrome

*Hypo- parathyroidism*

Etiology: - damage/removal during neck/thyroid *surgery* - *autoimmune* destruction of parathyroid gland Sx: - carpopedal spasms - Trousseau's and Chvostek's - INCR deep tendon reflexes Dx: - hypo-calcemia + decr. PTH + incr. phosphate Tx: - Calcium supplements (IV if severe) - Vit D

*Sarcoidosis*

Etiology: - Idiopathic(exaggerated t cell response/ granulomas) - Afro-Americans, North-eastern females - 20-40 yo Sx: - 50% asx - *dry cough/ dyspnea*- MC - Lymphadenopathy - *Erythema NODOSUM* - *Lupud pernia is pathonomonic* (raised-red coloring of nose/cheek/chin) - parotid gland enlargement - anterior uveitis/ blurred vision - arthralgia/fever/weight loss/palsies/DI Dx: - Tissue Biopsy= noncaseating granulomas - *CXR= bilateral hilar lympadenopathy* - PFT= restrictive (in advanced) and decr. DLco - Galliu scam= panda sign (parotid gland) - Incr. CD4:CD8 -*INCREASE ACE* Tx: - *Observe= most have remission in 2 yrs* - Oral Steriods if sx worsen(or methotrexate) - Hydroxychloroquinine for skin lesions (ok in preg) - NSAIDs - Interstitial lung Dz and Lupus Perinio = poorer prognosis

Hypo- natremia

Etiology: - Impaired kidney free water excretion (incr. ADH) - incr. water intake Sx: - CNS dysfunction ------fatigue, HA, N/V, cramps, AMS, decr. DTR, seizure, coma -*Cerebral edema* ------ water moves into cells cause there is more in cells than blood. Dx: - SERUM Na+ <135 Tx: - Hypotonic: ------isovolemic= water restriction ------Hyper-volemic=water AND sodium restriction ------Hypo-volemic= NS - Hypertonic ------NS until hemo-stable then 1/5 NS - Sever Hyper-volvemic ------Hypertonic saline + furosemide - Correct <0.5/hr to prevent SHRINKING/DEMYELINATION

*Rheumatic fever*

Etiology: - MC in 5-15 yrs. - *MC = GABHS* Sx/ Dx: *JONES criteria* - joints (polyarthritis) - Oh my CARDITIS - Nodules - Erythema MARGINATUM - Sydenham's chorea - fever Tx: - Aspirin - Penicillin G (or erythromycin if PCN allergy) Secondary Prevention: - IM PenG every 3-4 wks until 40 yo

*Cluster HA*

Etiology: - MC in YOUNGE/MIDDLE AGE *MALES* Sx: - severe unilateral periorbital/ temporal pain - sharp/lancinating pain - Last <2 hrs - *occur several times daily x 6-8 wks* - *ipsilateral Horner's syndrome* (ptosis/ miosis/ anhydrosis) - *NASAL CONGESTION/ CONJUNCTIVITIS/ LACRIMATION* Triggers: - worse at night - EtOH - stress - certain foods Tx: - *100% O2= 1st line* - SQ Sumatriptan or Ergotamines - *Prophylaxis= Verapamil* or steroid, Valproic acid, lithium

*Esophageal Varicies*

Etiology: - MC= portal vein HTN RF: - *Cirrhosis of liver* (MC in adults) Sx: - upper GI bleed - possible hypovolemia if hemorrhaging Dx: - upper endoscopy -------- + "red whale" markings -------- cherry red spots Tx: 1) - *Endoscopic ligation= Tx of choice* - *Octreotide= DOC* (acute bleeding) ------watch for vasoconstriction in other areas like heart or bowel 2) Balloon tamponade 3) Surgical Decompression via Trans Jugular Intrahepatic Portosystemic Shunt (TIPS) Prevention of Rebleeds (NOT ACUTE BLEEDS): - *nonselective BB (*propanolol or nadolol)* - Isosorbide (long-acting nitrate) Abx prophlylaxis= Fluro. or Ceftriaxone

*Myocarditis*

Etiology: - MC= viral infections (*Coxsackie B*) - Lupus, Rheumatic fever, uremia, Clozapine Sx: - Viral prodrome - Heart failure (systolic) - megacolon - +/- concurrent pericarditis Dx: - CXR, ECG - + Ck-MB and Troponin - Echo- ventricular dysfunction - *Endomyocardial Biopsy- gold standard* Tx: - Supportive tx for systolic heart failure (Diuretics, ACEI, BB, inotropes if severe- Dopamine)

*TB*

Etiology: - Mycobacterium tuberculosis leading to granulomas - inhalation of airborne droplets Sx: Primary TB: - CONTAGIOUS - night sweats - fever/chills - fatigue - anorexia/ weight loss - rales/rhonchi near apices - Pott's Dz (in vertebrae) - Scrofula (lymphnode involvement) - risk of HIV infxn Chronic/ latnent TB: - CASEATING granuloma formation - NOT CONTAGIOUS Secondary TB - Waning immune defenses - Caitary lesions in Apex/upper - CONTAGIOUS Dx: - *Acid-Fast smear/ culture x 3 days* - CXR ---- can be used as screening in known TB ---- Primary= middle/lower consolidation ---- Miliary= millet-seed ---- Reactivation= apical fibrocavitary Dz ---- Latent= *galulomas/ Ghon complex/ Rankes complex* - Interferon Gamma Release Assay/ TB Gold assay Tx: - Initial= ---- "R.I.P.E"= Rifampin, Isoniazid (INH), Pyrazinamide, Ethambutol -----*Side Effect (Know these)* -----------Isoniazid= Peripheral neuropathy (B6) ----------- Pyrazinamide= gout and liver Dz/ photosensitive rash ----------- Ethambutol= Optic neuritis ----------- Rifampin= Thrombocytopenia & orange secretions. --use for 6 months! --no longer contagious after 2 wks treatment - INH= prophylaxis in kids <4 yo - Latent= -----1) INH + Pyridoxine(B6) for 9 months/ 12 if HIV+ -----2) Rifampin + Pyrazinamide for 4 months

*Cholelithiasis*

Etiology: - NO inflammation present - *Cholesterol* (MC, mixed or pure) - Black stones (hemolysis or EtOH) - Brown stones (Asains or infection) RF: - Fat, Fair, Female, Forty, Fertile Sx: -Biliary colic(episodic, abrupt, RUQ, last 30min-hrs) - Nausea - Brought on by *fatty foods* Dx: - US= TOC Tx: - Observation - possible *ursodeoxycholic acid* to dissolve stones - *ELECTIVE* cholecystectomy in sx pts.

(Bronchial) *Carcinoid Tumor*

Etiology: - Rare - *neuroendocrine* (enterochromaffin cell) CA -----Secrete Serotonin, ACTH, ADH, MSH - slow growth/ low mets (MC= GI tract) Sx: - Asx in 25-40% - SAIDH, Cushing's, obstruction - *Carcinoid Syndrome* (diarrhea, flushing, tachy, bronchoconstriction, hemo-instability, acidosis) Dx: - Bronchoscopy (pink/purple well-visualized central tumor) - CT - Octreotide scintography Tx: - Surgical excision - Octreotide to help with sxs.

*congestive heart failure*

Etiology: - acute worsening of baseline symptoms and pulmonary congestion -Start to see CXR findings and sympathetic activation RF; -*DM* - MI - FHx - HTN Sx (worsening of HF symptoms) -Left sided: (*think of fluid backing up into lungs*) ---*Dyspnea* --- Pulmonary edema --- Pleural effusion --- cough w/ frothy sputum production --- HTN --- Cheyne-Strokes breathing (fast-deep breathing with periods of apnea) ---*S3*(systolic) or s4 (diastolic) murmurs --- coo/pale skin - Right sided: (*think fluid backing up into body*) ---Peripheral edema ---JVD ---GI/hepatic congestion (esophageal varicies, etc). LEFT SIDED CAN LEAD TO RIGHT SIDED BUT RARELY THE OTHER WAY AROUND Dx: - EF< 35% ususally (normally like the EF>50%) seen on ECHOCARDIOGRAM -Reduced EF=Systolic HF, Non-reduced=Diastolic HF - BNP - CXR ---Kerley B lines ---Butterfly (batwing) pattern ---pulmonary edema ---Cardiomegaly --- perihilar edema ---cephalization of vessels Tx: - Lasix (furosemide) - Morphine (reduces preload) - Nitrates . (reduce pre and after- load) - Oxygen (PRN) - position (upright to decr. venous return) If diastolic failure (S4 gallop) - BB - ACE - CCB - Diuretics (Usually lasix + Potassium or Spironolactone) ----want to control HR/BP/ relieve ischemia

*Irritable Bowel Syndrome*

Etiology: - idiopathic ----- Abnormal motility ----- Visceral Hypersensitivity ----- Psychosocial interactions - MC in women in teens-20s (PA student has abd and bowel habit changes when she is stressed) Sx: - *abd pain associated with altered bowel habits* - *pain relief with defecation* Dx: - ROME IV CRITERIA ---recurrent abd pain *at least 1 day/wk for 3 mon. + 2 of the following 3*: -------1) related to defecation -------2) associated with change in stool frequency -------3) associated with change in stool form (appearance) Tx: - Lifestyle change ------stop smoking, low fat diet, no sorbitol/fructose, sleep, exercise - Dicyclomine or Loperamide for diarrhea - Laxatives for Constipation (i.e. lubiprostone) - Amitriptyline or Serotonin receptor agonist for pain

Bell palsy

Etiology: - idiopathy unilateral CN7 palsy ----- possibly from inflammation or compression RF: - DM - Preg - Post URI - Dental nerve block Sx: - Ipsilateral hyperacusis (ear pain) - unilateral facial paralysis - *UNABLE TO LIFT AFFECTED EYEBROW!!!!!!!!!!!!!!* - taste disturbance in *anterior 2/3 tongue* - weakness/paralysis only affect face - incomplete palsies= better prognosis Dx: - Dx of exclusion Tx: - no tx required - Prednisone w/in 72 hrs of sx onset - Artificial tears/ eye patch for sleep - +/- Acyclovir Prognosis: - function usually returns win 2 weeks - taste restoration usually proceeds motor.

*Adrenal Insufficiency (Addison's Disease)*

Etiology: - lack of cortisol and aldosterone coming from adrenals - Primary= -------Autoimmune (MC in US) ------- Infxn (MC worldwide, TB, HIV, fungal, CMV) -------Meds (Ketoconazole, rifampin, barbiturate) - Secondary (MC type) ------- *exogenous steroid use withdrawl!!!!* ------- hypopituitarism Sx: - Primary ------Hyperpigmentation (incr. ACTH) ------Orthostatic hypotension (decr. aldosterone) ------Hypo-natremia ------Hypo-glycemia ------Hyper-kalemia ------Metabolic acidosis (non-anion) ------Decr. Sex hormones (decr. in libido, axillary and pubic hair) -Secondary: ------ *Hypo-glycemia* ------ muscle weakness/aches, fatigue, weight loss/anorexia ------ abd pain ------ HA ------ SALT CRAVING ------ Hypotension Dx: - *High dose ACTH (cosyntropin) stimulation test* ---- no incr. in cortisol levels =adrenal insufficiency - CRH stimulation test (stimulation of pituitary- tells you the cause) ---- Incr. ACTH but low cortisol= Primary ---- low ACTH AND low cortisol = secondary Tx: - Primary= Hormone replacement + steroids - Secondary = steroids Steroids= *Hydrocortisone 1st*, then prednisone, dexa, *Fludrocrtisone for primary only* - will need to incr. steroid dose during illness/stress/surgery to mimic body's natural response.

Phlebitis

Etiology: - seen with IV caths, trauma, preg, varicose veins, factor V Leiden(MC) -usually benign/self-limited but can become septic ----Trousseau's sign of malignancy(ex. pancreatic CA) Sx: - Local phlebitis (tenderness, pain, induration, erythema +/- palpable cord +/- fever if septic) Dx: - Venous deuplex US (noncompressible vein) - Factor V leiden work up Tx: - Supportive!!! (elevation, warm compress, NSAIDS, support stockings) - Heparin/warfarin is near saphenofemoral junction - Penicillin+ aminoglycoside if septic

*Peripheral venous disease*

Etiology: - superficial venous system (greater/lesser saphenous veins) - Deep venous system (femoral, iliac, popliteal, posterior tibial, and superficial femoral) - Perforating veins Thrombophlebitis - inflammation caused but a blood clot Sx: - Veichows triad (*intimal damage, stasis, hypercoaguability*) -factor v Leiden mutation -protein C or S deficiency - antithrombin 3 deficiencies, - oral contraception - CA

Aortic Dissection

Etiology: - tear in the intima of aorta - 65% ascending and ascending = high mortality RF: - *HTN!!!* - age 50-60 - male - trauma, FHx, turner syndrome, collagen disorders, cocaine Sx: - sudden severe tearing chest pain ---- radiates to : Type A= anterior chest, arch= neck/jaw, Type B= interscapular - *decreased peripheral pulses* or >20 differance between R and L arm - N/V, diaphoresis - Type A(deBaey 1/2)= new-onset aortic regurg., MI, cardiac tamponade, Hypotension -Type B (deBakey 3) = HTN, back pain, spine ischemia Dx: - *CT with contrast* - *MRI ANGIO= GOLD STANDARD* -TEE if hemodynamically unstable -CXR may show widening of mediastinum Tx: - *1st = fluid recessitation* - Surgery in Acute proximal (type A) and acute distal w/ complications (type B) - Type B w/out complications: ---Esmolol or Labetalol (SBP target 120 and HR<60 in 60 mins) ---sodium nitroprusside PRN

Pulmonary HTN

Etiology: -1) Idiopathic MC cause (MC in middle-aged women) -2) L Heart Dz -3) hypoxemic or chronic lung Dz -4) chronic thromboembolic Dz Sx: - *Dyspnea* - weakness/ fatigue/syncope if severe - *Accentuated S2* - *signs of RHF* (JVD, Peripheral edema, Ascites) - systolic ejection click Dx: - ECG= cor pulmonale, RVH, right axis deviation - *RIGHT SIDED HEART CATH* is definitive ------ mean pulm pressure > 25 - CBC= polycythemia w/ incr. hematocrit Tx: - *Idiopathic= CCB*, epoprosteol, Iloprost, "-afil"s" - Otherwise treat underlying cause.

*Hepatitis*

Fluminant hepatitis= acute hepatic failure Etiology: - rapid liver failure + hepatic encephalopathy +/- coagulopathy -------*Because the liver is no longer filtering AMMONIA or making COAGULATION FACTOR* - *Acetaminophen over use/dose = MC* - *drug reaction* (Isoniazid, pyrazinamide, rifampin, antiepileptics, abx) - *viral hepatitis* - *Reye syndrome* - Budd-Chiari syndrome Sx: ENCEPHALOPATHY - Vomiting - coma/ seizures - *Asterixis/ hypperreflexia* - increase intracrainial pressure - *Coagulopathy* - hepatomegaly - Jaundince (not in Reyes) Dx: - *incr Ammonia levels* - *incr PT/ INR >1.5)* - LFTs - hypoglycemia Tx: Encephalopathy: - Lactulose (lactic acid neutralizes ammonia) - Rifaximin/ Neomycin (kill normal bacteria making ammonia) - *Protein restriction* LIVER TRANSPLANT IS THE ONLY DEFINITIVE TX

*Gout/ Pseudogout* (easy question)

Gout= -----------------------------Psuedo= adult males--------------------females/elderly monosodium urate------------Ca2+ pyrophosphate neg. birefringent needles-----weak pos. rhomboids MC= 1st MTP joint(1 joint) ----knees, wrist, MCPs (>1) Mouse bite(punched out) ----Chondrocalcinosis Tx: -Acute: NSAIDS 1st-----------------intraarticular steroids 1st Cholchicine----------------Cholchicine steriods--------------------NSAIDs -Chronic: Uric acid lowering---------NSAIDs ---allopurinol ---febuxostat ---probenecid Cholchicine-------------- +/- Cholchicine NEVER USE CHRONIC MEDS IN ACUTE ATTACKS BECUASE IT MAY PRECIPITATE AN ATTACK!!!!!

Statins

High intensity statin: - Atorvastatin 40-80mg -Rosuvastatin 10-20 mg Moderate intensity statin: - Simvastitin -Prevastatin -Fluvastatin - lovastatin - Pitastatin - low dose Atorvastatin (10-20 mg) - low dose rosuvastatin (5-10 mg) Ezetimibe is used with statins to prevent cardiovascular Dz MC S/E= - myalgias/myopathys - GI upset

*Polymyositis/Dermatomyositis*

Idiopathic muscle inflam. of limbs/neck/pharynx Sx: PM: - *Progressive symmetrical PROXIMAL muscle weakness* - usually painless DrM: - *Heliotrope (blue-purple eyelids)* - *Gottron's papules* (scaly knuckles) - malar rash *including* nasolabial folds (lupus spares the folds) - photosensitive poikiloderma in V-sign -alopecia Dx: - *incr. aldolase* and CK - abnormal EMG - * + Anti-Jo 1 Ab* (myositis specific Ab) - * + Anti- SRP Ab* (exclusive for Polymyositis) - *+ Anti-Mi-2 Ab* (exculssive for dermatomyositis) - muscle biopsy (endomysial= PM, peri-fasciular./-vasicular= DrM) Tx: - High-dose Corticosteroids*= 1st line - methotrexate - Azathioprine - IVIG

Ketamine

Intubation Medication used in Asthma - bronchodilator

*Chronic Bronchitis*

Inflammation of the trachea/ bronchi after URI Etiology: - *Adenovirus (MC)*, parainfluenza, influnza, RSV, S. pnuemoniae, H. influ, Sx: - *Cough* that lasts is hallmark. - may present similar to pneumonia - Chronic may leads to COPD ----- signs of cor pulmonale, peripheral edema, cyanosis, Respiratory acidosis, V/Q mismatch, *"Blue Bloaters"* Dx: - *CLINICAL* Tx: - Chronic= treat like COPD - Acute= symptomatic tx ------fluids, rest, +/-bronchodilators, +/-antitussives

*Bronchiectasis*

Irreversible bronchial dilation by transmural inflam./infxns Etiology: - *MC= Cystic Fibrosis* - recurrent lung infxns (*H. influ in non-CF, Pseudomonas in CF pts.*) - obstruction from FBA, tumors, mucous Sx: - Daily chronic productive cough - thick mucopurulent/ *foul-smelling sputum* - *Hemoptysis* ------MC cause of massive hemoptysis world wide - crackles in bases, dyspnea, rhonchi, clubbing Dx: - *High res. CT* ------ airway dilation/lack of tapering/ wall thickening/ *tram-track appearance* - PFT = *OBSTRUCTIVE* pattern Tx: - Ampicillin, *Amoxicillin*, Trimeth-Sulf. - Fluoroquinalones if CF. - Clarithro + Ethambutol if MAC - Corticosteroids + itraconazole if aspergillus

*Cirrhosis*

Irreversible liver fibrosis with nodular regeneration Etiology: - *EtOH = MC in US* - nonalcoholic fatty liver dz(obese, DM, high chol.) - hemochromatosis - drugs - autoimmune Sx: - *Ascites* (decr. oncotic pressure) - *gynecomastia* - spider angioma/ caput medusa/ palmar erythema - muscle wasting/ Dupuytren's contracture - bleeding (decr. coags) - *confusion & lethargy* - *asterixis* (flapping tremor) - fetor hepaticus - *esophageal Varices* (due to portal HTN) Dx: - *incr. ammonia levels* - *US* - liver biopsy Tx: Encephalopathy - *Lactulose or Rifaximin* to reduce ammonia --- 2nd line= neomycin (causes diarrhea) Ascites - *Na+ restriction* - diuretics (spironolactone, furosemide) - paracentesis Pruritus: - *Cholestyramine* *LIVER TRANSPLANT IS DEFINATIVE* - (screen for HCC via US and AFP first)

*occupational lung disease*

Know what jobs get what diseases -----especially silicosis ;)

COPD

MC >55 y.o. Etiology: - inflammation -> alveolar wall destruction -> no recoil -> incr. compliance -> air obstruction RF: - Smoking - a-1 antitrypsin deficiency if <40y.o Grades: - 1/mild= FEV1 >80% - 2/ mod.= FEV1 > 50% - 3/ severe= FEV1 > 30 % - 4/ very severe= FEV1<30 % Types: Emphysema: - enlargement of terminal airspace/ air trapping - Sx= -----*Dyspnea(MC)* ----- hyper-resonance/decr. breath sounds -----Barrel chest ----- *pursed lip breathing* ----- mild hypoxia ----- *resp. alkalosis!!* ----- *pink puffers* Chronic Bronchitis: - *productive cough >3 months x 2 consecutive yrs. -Sx= ----- *Productive cough (MC)* ----- Rales/ rhonchi/ wheezing ----- Cor pulmonale sxs ----- *resp. acidosis!!* ----- *severe hypoxia/ V/Q-mismatch* ----- hypercapnia ----- *blue bloaters* *Dx:* - *PFT/ Spirometry* -----FEV1 <1=high mortality ----- C.B= decr FEV1/FVC ----- Emph. = incr. FVC - CXR/CT -----C.B.= incr. AP diameter ----- Emph= flat diaphragm/ incr. AP diameter/ decr. vascular markings Tx: - *Stop smoking* 1) *Bronchodilators*-(grade 1 & 2/ mild & moderate) - anticholinergic + B-2 agonist ----- (anticholinergics 1st) -*tropium*s ----- (B-2 agonist) Albuterol/ Terbutaline/ Salmeterol ------ *Theophylline*- *Chronic* (not used in acute) 2) *Cotricossteriods* (grade 3/severe) 3) Oxygen (grade 4/ very severe) ----- only proven therapy to decr. mortality ----- use if Cor pulmonale or O2< 88% or PaO2<55 Need Pneumonia and Flu Vaccines

*Dilated Cardiomyopathy*

MC cardiomyopathy Etiology: - *Systolic Dysfunction* - Idiopathic (MC), *EtOH*, *cocaine*, pregnancy, doxorubacin, viral myocarditis, Symptoms: - *Systolic HF* (both R and L) - possible viral myocarditis (*angina, + cardiac enzymes, viral prodrome*) - Pulmonary congestion - peripheral edema, incr. JVP, hepatic congestion Dx: - Echo ------*L* Ventricle dilation, decr. EF, LV hypokinesis - Xray (but not very good) ----- cardiomegaly Tx: - *HF treatment* (ACEI, BB, Diuretics, sodium restriction, maybe digoxin) - ICD if EF<35%

*bronchogenic carcinoma (lung cancer)*

MC cause of CA deaths in both men and women Etiology: - 50-60 year-olds - MC cause= smoking (asbestosis is 2nd MC) - *METs to Brain, Bone, Liver, Lymph, Adrenals* Types: - Non-Small Cell -----*Adenocarcinoma= MC, typically peripheral,* Bronchioloalveolar -----*Squamous cell= Central*, *cavitary lesions*, Hyper-Calcemia & Pancoast syndrome -----Large Cell= *AGGRESSIVE* - Small Cell ---- Mets early, central, aggressive, NO SURGERY for tx. Sx: - *Cough/ Hemoptysis/ weight loss/ Trousseau's* - SVC syndrome (dilated neck veins/facial plethora) - Hyper-Calcemia- Squamous cell - SIADH/ Hypo-Natremia - Cushing's, Lambert-Eaton (weakness improves with use) - Pancoast Syndrome (shoulder pain/Horners/ atrophy in arms) *Dx:* - CXR/CT - Sputum cytology/ Bronchoscopy - central - Transthoracic needle biopsy- peripheral Tx: - Non-small cell= surgery - Small cell= chemo +/- radiation *Screening* (American Cancer Society): - Average risk patients - not recommended - High-risk patients: -------55 - 74 years of age, in good health -------30 pack-year smoking history (packs of cigarettes smoked per day x number of years the person has smoked) ------Patient is currently smoking or quit w/in 15y -Test of choice is an annual low-dose helical CT scan

*Graves*

MC cause of hyperthyroidism Sx: - Thyroid bruits - Opthalmopathy (lid lag + exophthalmos) - Pre-tibial myxedema - plus normal Hyperthyroid sxs Dx: - Decr. TSH + Incr T4 - + Thyroid-stimulating Immunoglobulins - Diffuse uptake on RAIU Tx: - Radioactive iodine= MC - *BB= First line in acute* -Methimazole or PropylThioUracil/PTU (ok in preg) - Thyroidectomy if all else fails

Pericarditis

MC causes= idiopathic and viral (*coxackie* and echovirus) infxn Sx: - *Pleuritic chest pain* - *Postural pain- better when leaning forward* - *pericardial friction rub* Dx: ECG - *Diffuse concave ST elevations* in precordial leads (V1-V6) -PR depression in same leads as ST elevation - VR = ST depression and PR elevation - NO RECIPROCAL CHANGES Echo to look for complications like effusion or tamponade Tx: - *NSAIDs* or aspirin - *Colchicine is 2nd line* - corticosteriods if sx > 48 hrs and refractory to other meds.

*Hepatic Cancer*

MC secondary to Metastasis (lung, breast) Primary liver CA= Hepatocellular Carcinoma RF: - Chronic Hepatitis (B,C &D) - Cirrhosis/ EtOH-ism - aflatoxin B1 exposure Sx: - Malaise - Weight loss - Jaundice - Abd pain - Hepatosplenomegaly - Rapid onset Ascites (possibly bloody) Dx: - US - *incr. alpha-Fetoprotein * - *NO NEEDLE BIOPSY* (can cause seeding) Tx: - surgical resection (if 1 lobe and no cirrhosis) *Surveillance = US q 6 months*

Solitary Pulmonary Nodule

Nodule= well-circumscribed lesion <3 cm Etiology: - Granulomatous infxns (*TB*, histoplasmosis, etc.) - Tumors - Inflammation (RA, Sarcoidosis, Wegener's) - Mediastinal Tumors (THYMOMA MC mediastinal tumor) Benign: - round/smooth - slow - Calcifications - Cavitary Malignant: - Irregular/speculated - Rapid growth (may double in 4 months) - Cavitary with thickened walls Dx: -CXR to observe w/ CT initially if very likely benign - Needle aspiration/biopsy if moderate prob. its benign - Resection w/ biopsy if likely malignant.

*polymylagia rheumatica*

PAIN/ STIFFNESS in SHOULDER/HIP/ NECK Etiology: - idiopathic inflammation - closely related to Giant Cell arteritis - pt present of "morning stiffness and difficulty combing her hair" Sx: - *SYNOVITIS, BURSITIS and TENOSUNOVITIS* ------common in mornings >30 mins ------ in pelvic, neck and shoulder girdle Dx: - Clinical - incr. ESR, anemia, +/- incr. platelets Tx: - *Low-dose Corticosteroid* - NSAIDs - Methotrexate ---------S/E= Liver toxicity and Folate def.

*MI*

RF: -*ATHEROSCLEROSIS* -DM -FHx Sx: - Anginal pain (retrosternal pressure>30mins) ---Radiates to shoulder, neck, arm, stomach, or jaw ---not relieved with Nitro ---Levine's sign (fist to chest) - Angina Pain *at rest* - anxitey/ tachy/ palpitations/ N/V / dizzy/ diaphoresis - *S4 or (chest pain + bradycardia) = inferior MI* Dx: - ECG: ----STEMI= ST elevations *>1mm in 2 contiguous leads* OR *new L BBB* ---Q wave > .03sec/.1 deep or 25% of R wave= previous STEMI * CARDIAC MARKERS!!* - Ck appears in 4-6 hrs and lasts f04 4 days - *Troponin I&T in 4-8 hrs and lasts 10 days * Tx: see "MI tx" section for Tx

*Esophageal Cancer*

Squamous Cell: - MC world wide - *MC in UPPER 1/3 of esophagus* - Peaks at 50-70 yo - *Smoke*/ EtOH - *Afrian-Americans* Adenocarcinoma: - MC in US - *MC in LOWER 1/3 of esophagus* - younger, obese, Caucasians - *GERD* and *Barrett's esophagus* Sx: - *Dysphagia to solid foods* (later liquids) - Odynophagia - weight loss, chest pain - Virchows node - Hyper-calcemia in squamous cell Dx: - upper endoscopy with biopsy Tx: - esophageal resection - radiation - chemo (5FU) depending on stage

*MI tx*

Reperfusion Therapy within 12 hrs of sx onset* ---either PCI/CABG or thrombolytics PCI - best within 3hrs of sx onset (especially 90 mins) - do PCI prior to thrombolytics CABG: - +3 vessels - L main coronary artery - decr. left ventricular EF Thrombolytics: - *Alteplase*/ reteplase/tenecteplase ---dissolve clot by activating plasminogen --- higher rebleed risk - Streptokinase --- activates plasminogen ---less effective that TPA but better if high risk of brain bleed *Additional Therapy:* First things to start prior to reperfusion therapy: - Morphine - Oxygen (only give PRN if O2 sats are low) - Nitro - Aspirin (lowers mortality 20%) Going home on: - Aspirin +/- heparin ---(glycoprotein 2/3 inhibitors are alternative to both of these) - BB (unless contraindicated) - ACE inhib. (slows progression to CHF) - Nitro PRN - Statin

Coronary Vascular Dz

Risk Factors: - SMOKING - DM - FHx - Hyperlipidemia - previous Dz or Trauma - HTN - Men Etiology: - MC cause= Atherosclerosis - artery vasospasm, stenosis, Pulm HTN, HTN. Causes of Atherosclerosis: - *Fatty streak formation* - lipid deposition in WBCs - Then Plaque forms(LDL is oxidized) - Then you get Fibrous plaques/ caps (causes narrowing of the lumen +/- calcification > 70% reduced lumen is usually when you get Sxs.

arrhythmias

See Dr. Lee notes

*Pneumonia Pathogens*

Strep Pneumo= MC CAP -Gram + cocci H. Influ= 2nd MC CAP, COPD, Bronchiectasis, CF - Gram - rods *Mycoplasma*=MC ATYPICAL/WALKING Pneumonia and college/ millitary - Lack cell wall - can cause bullous myringitis (ear pain) *Chlam. Pneumo*= Sinusitis + URI + hoarsness - intracellular Parasite Legionella= Contaminated water/aquatic places - sx= losing fluid everywhere Staph Aureus= after viral illness (i.e. FLU) - gram + cocci *Klebsiella*= EtOHics, chronic illness - have CAVITARY lesions - gram - rods Anaerobes= Aspiration Pneumonia, MC in R lower lobe Pseudomonas= Immunocompromized (HIV, CF, Bronchiectasis) - gram - rod *Viral* - *RSV* = MC in infants/ small kids - Parainflucenza= inflants/small kids - *CMV*= transplant pts/ AIDS - *Varicella Zoster*= adults Fungal: - *Pneumocystis Jirovecii* (aka PCP or pneumocystitis) = Compromised host ---- associated with O2 desaturation w/ ambulation -----Tx = TMP-SMX - *Histoplasmosis= Mississippi/ Ohio* river valley - *Coccidioides= soil of southwest USA*( including CA) Pneumonitis= Aspiration pneumonia from GASTRIC FLUIDS!!

Cushing's disease -------- don't remember if this one was there or not

Syndrome= sx related to cortisol excess Disease= sx caused specifically by incr. pituitary ACTH secretion Etiology: - *Exogenous = iatrogenic (steroid use, MC type)* - Endogenous= Cushing's, ectopic ACTH tumor (small cell lung CA), or Adrenal adenoma Sx: - Central Obesity - moon face - buffalo hump - supraclavicular fat pads - wasting of extremities/ muscle weakness - purple striae - hyper-pigmentation - *hypo-kalemia* - acanthosis nigricans - hirsutism/ oily skin/ acne/ incr. libido Dx: - low-dose Dexamethasone suppression test ----- no suppression= Cushing's Syndrome - 24 hr urinary free cortisol levels ----- incr. cortisol levels = Cushing's Syndrome - Salivary Cortisol levels To determine cause now: - High-dose dexamethasone suppression test ----- Suppression= Cushing's DISEASE ----- no suppression= adrenal or ectopic tumor - ACTCH levels ----- Decreased= adrenal tumor or exogenous steroids ----- normal/Increased= Cushing's Dz or Ectopic tumor Tx: - Cushing's Dz= transspendoidal surgery - Adrenal or Ectopic tumor= remove tumor or Ketoconazole - Exogenous steroids= GRADUAL taper off steroids.

GERD

Transient relaxation/ incompetency of the LES Sx: - *Heartburn (pyrosis)* ------- regurgitation, dysphagia, night cough, worse when supine, - horseness, pneumonia, asthma, chest pain Dx: - 1) clinical - 2) PPI trial - 3) Endoscopy - 4) Esophageal Manometry (decr. LES pressure) - 5)24 hr ambulatory pH monitoring=gold standard Tx: - 1) lifestyle modifications ----------elevate head of bed, avoid laying after eating, avoid caffeine/spicy/citrus, stop smoking and drinking, weight loss - 2) PRN H2 blockers/ endoscopy - 3) Scheduled PPI - Nissen Fundoplication if refractory. Complications: - esophagitis - stricture - Adenocarcinoma - Barrett's esophagus --------squamous epithelium replaced by metaplastic columnar cells

Hiatal Hernia ----(might have been on there, but I can't remember)

Type 1: - *sliding hernia" (GE junction and stomach slide into mediastinum) - *MC type* - Tx = same as GERD Type 2: - "rolling hernia" (only fundus of stomach protrudes through diaphragm) - May lead to strangulation - Tx= surgical repair

*pituitary adenoma* (read more on this than what is in the quizlet)

Types: - *Prolactinomas (MC)* ----- Dopamine inhibits prolactin release ----- sx: Amenorrhea, Galactorrhea - *Somatotropinoma* ----- Sereates growth-hormone ----- Sx: acromegaly/gigantism, DM& glucose intolerance - *Adrenocorticotropinomas* ----- secrete ACTH ----- Sx: Cushing's Dz, hyperpigmentation (melanocyte stimulating hormone) - *TSH-secreting Adenomas* ----- Sx: thyrotoxicosis, Hyperthyroid sxs, Sits on optic nerve in the brain Tx: - Transsphenoidal surgery (except prolactinomas!) - Meds 1st line for prolactinomas - add Bromocriptine & Octreotide for acromegaly - Cabergoline or Bromocrpitine for prolactinomas

*Esophageal Strictures*

Types: Esophageal Web: - membranes in *mid-upper* esophagus - congenital or acquired - MC in white women 30-60 yo - Sx= Plummer-Vinson syndrome (dysphagia + esophageal webs + iron def. anemia) Schatzki ring: - " pt that has hard time eating steak" = common pt - *lower* espohageal constrictions/webs - at squamocolumnar junction -*MC associated with hiatal hernias* Dx: - Barium esophagram *Tx:* - *endoscopic dilation if no reflux* - Antireflux surgery if reflux present

*Inflammatory Bowel Dz*

Ulcerative colitis *Crohn's* what it looks like: -Only colon +rectum . vs *Any segment of GI tract* - Always in rectum vs *MC= terminal iliuem* - Mucosa/submucosa only vs *Transmural* ----------------ON COLONOSCOPY--------------- - uniform inflammation vs *skip leasions* - Pseudopolyps vs *cobblestones* -------------------ON BARIUM----------------------- - Stovepip sign(no haustra) vs *String sign* -------------------ON LABS-------------------------- + P-ANCA vs *+ ASCA* Sx: LLQ colickypain MC vs *RLQ pain MC* - Tenesmus and urgency vs. *Weight loss* -Bloddy diarrhea= hallmark vs *no bloddy diarrhea* Sx of *Both:* -Arthritis -Seroneg. spondyloarhtopathy -uvitis -fever/fatigue/ malasie -Erythema nodosum -Pyoderma gangrenosum Complications: primary sclerosis *perianal dz* cholangitis Granulomas Colon CA Fe and B12 deficiency *Toxic megacolon* *Smoking Makes it Better!* Dx in ACUTE: flex sigmoidoscpy Upper GI series (NO barium/colonoscopy in acute) *Tx for BOTH*: - Aminosaliculates (*sulfasalazine, mesalamine*) - Oral Mesalamine best for maitenance - *Corticosteriods for Acute flares only!* - Immune modifying agenst (mercaptopurine, Azathioprine and methrotrexate) ---------parenteral nutrition is an alternative - Anti-TNF -----Adalimu*mab*, inflixi*mab*, certolizu*mab* (inhib cytokines) ----- Natalizu*mab* (inhib integrins)

*Angina Tx*

Unstable: - PTCA (1-2 vessel disease no involving l main coronary artery and normal-ish function) - *CABG (L main coronary artery, symptomatic/critical, 3+ vessels, EF<40%)* Stable: - Nitroglycerin ( incr. cardio blood supply, decr. demand) ---Contra= SBP<90, RV infarction, Sildenafil and PDE-5 inhib - BB (incr. cardio blood supply, decr. demand - CCB (especially with prinzmetal angina) - Aspirin (decr. thromboxane A2)

*Polyarteritis nodosa*

Vasculitis/ necrotitis of MEDIUM/SMALL arteries Etiology: - Associated with *Hep B* (muscular arteries) - incr. micro-aneurysms - MC in men 45yo Sx: - *renal HTN* (incr. renin and renal failure) - *SPARES LUNGS* - arthritis - neuropathy - *mononeuritis multiplex* - livedo reticularis, purpura, nodule or Raynaud's Dx: - incr. ESR - ANCA NEGATIVE - *renal or mesenteric ANGIOGRAPHY* --------- micro-aneurysms w/ abrupt cut-off of small arteries Tx: - Corticosteroids -+/- plasmapheresis is HBV+

Hyperlipemia screening/ treatments

When to screen: - Male >35 with no risk - Male > 20 with incr. risk of CAD - Women > 45 with incr. risk of CAD - possibly women 20-45 with incr risk of CAD

*Fibromyalgia*

Widespread chronic muscular pain Etiology: - Idiopathy (maybe increase in pain perception) - MC in middle aged women or with another autoimmune disorder Sx: - diffuse pain - *Extreme fatigue* - stiff/tender joints - *Sleep disturbances* - hazziness *Dx:* - Diffuse pain in 11 of 18 trigger points > 3mons - muscle biopsy (Moth-eaten appearance) *Tx:* - exercise (swimming is preferred) - TCAs (*Amitriptyline*) - Duloxetine - SSRIs - Neurontin - *Pregabalin* (only FDA approved)

*Paget's disease (osteitis deformans)*

abnormal bone remodeling - incr. osteoclast resorption = larger/weaker bones - lytic phase= osteoclasts - sclerotic phase= osteoblasts Etiology: - MC in >40yo or Western/European descent - 40% autosomal dominant Sx: - Asx= MC - high Alk phos - *Bone pain (MC)* - *incr. fractures* - *deafness* Dx: - *incr. alk phos.* - Xray= ------ *"blade of grass/flame shaped" lucency*= lytic phase ------ Coarsened trabeculae= sclerotic phase ------ skull= cotton wool appearance - Osteoclasts= absorb bone - Osteoblasts= make bone *Tx:* - Bisphosphonates= DOC ----- Alendronate, Risendronate, Pamidronate, Zoledronic acid ------ S/E= atypical femur Fx, jaw osteonecrosis, esophagitis - Calcitonin

Hypoventilation syndrome

consequence of severe obesity and untreated OSA, chronic hypercapnia/hypoxic resp. failure, secondary erythrocytosis, low serum Cl, hypertension, cor pulmonale

Aortic aneurysm

diameter of aorta >3cm - MC infrarenally RF: - *Atherosclerosis* - age > 60yo -*smoking* - caucasian males -connective tissuse disorders, hyperlipidemia, HTN Sx: - expanding rate = 0.25-0.5 cm per yer (larger expland more rapidly) - *>5cm is a high rupture risk* - MOST= ASX! - acute leak/rupture= back pain and hypotension/syncope and pulsatile abd mass. Dx: - Abd US best inital for AAA and best to monitor size - CT best for TAA and further evaluation of AAA - Angiography = gold standard Tx: - *>5.5 or explaning >0.5cn in 6 months= Immediate surgery* - >4.5= refer to vascular surgeon - 4-4.5 = monitor by US q6months - 3-4 = monitor by US qyearly

Mallory-Weiss Tear

ongitudinal mucosal laceration @ gastroeshophageal junction or cardia Etiology: - *persistant retching/vomiting* ----EtOH binge ----Bulemia Sx: -*hematemesis* - hydrophobia -abd pain - syncope - Can lead to Boerhaave Syndrome(full thickness tear) Dx: - upper endoscopy = test of choice ------ see superficial longitudinal mucosal erosions Tx: - supportive - acid suppression - epi/ sclerosing agents/ band ligation/ clipping/ balloon if severe bleeding Can lead to Boerhaave Syndrome(full thickness tear) - retrosternal chest pain - pneumomediastinum - contrast espohagram to dx - surgery if large/ severe

Anal Fistula

open tract between 2 areas RF: - deeper abcesses Sx: - anal dishcarge - pain Tx: - I&D followed by W.A.S.H ---Warm water cleans ---Analgesics ---Sitz baths ---High fiber diet

Cor Pulmonale

right ventricular hypertrophy and *heart failure*(R-SIDED and diastolic) due to pulmonary hypertension