IM - Facts From Case Files CRC
IM - Facts From Case Files CRC
IM - Facts From Case Files CRC
Low pitched diastolic murmur at the apex with the bell, usually with a diastolic
rumble. Opening snap after S2 as well.
Can lead to atrial fibrillation due to left atrial enlargement. As well as
pulmonary hypertension --> hemoptysis and signs of right heart failure such as
peripheral edema. + AF --> RVR produces pulmonary congestion
Acute
Paroxysmal
Chronic
Hypertension
Coronary atherosclerosis
Other causes:
Structural heart disease (HTN, mitral valve disease)
Ischemic heart disease
Pericarditis or pericardial injury (post surgical)
Pulm disease (esp PE)
Hyperthyroidism
Stress or increased sympathetic tone (acute illness, pheochromocytoma)
Alcohol consumption ("holiday heart syndrome," alcoholic cardiomyopathy)
Sick sinus syndrome (tachy brady syndrome
Also, pharm agents such as propafenon, sotalol, and amiodarone may be tried to maintain sinus rhythm.
INR>9
If significantly increased bleeding is present, vitamin
K and FFP, intravascular volume replacement.
Mitral valve stenosis
Aortic valve too, but usually in combo with mitral valve
Right side of heart is rarely involved.
Delta wave
Widening of the QRS
Shortening of the PR interval
Some may be asymptomatic, others may develop recurrent tachyarrhythmias. Most by PVST....
others by AFib, which may look like a ventricular tachycardia.... but it will have the irregular RR
interval of AF.
You do NOT do the normal AV nodal blocking drugs because the impulse is not traveling through
the AV node... BB, CCB can actually paradoxically increase Ventricular rate and should be
avoided...
DC cardioversion can be treated if unstable
Stable? Procainamide, or Amiodarone, to slow condution and convert rhythm to sinus.
Mitral stenosis
Aortic regurg
Mitral regurg
Aortic stenosis
HTN
Atherosclerotic heart diseaes
Pericardial or pulmonary disease
Hyperthyroidism
AFIB + WPW
Unstable - DC cardioversion
Stable - Procainamide or Amiodarone
Pain is burnign
Occurs when the stomach is empty
Relieved by food or antacids
Dyspepsia
GERD - burning epigastric or mid chest pain usually occurring after meals and worsening with recumbency.
Biliary colic - acute onset of severe pain in RUQ or epigastrium, precipitated by meals, esp fatty foods, lasts 30-60 minutes
with spontaneous resolution
Gastric ulcers - Food may worsen symptoms, some may have no symptoms at all... 5-10% are malignant
Duodenal ulcers - Pain worse after stomach is emptied (but food stimulated acid production persists), typically 2-5 hours
after a meal. Food may relieve pain.
Gastric carcinoma
Gastric mucosa-associated lymphoid tissue
(MALT) lymphoma
Inhibit prostaglandin synthesis, which results in reduced secretion of mucus
and bicarb, and decreased mucosal blood flow.
This is dose dependent, and can occur within days after treatment is initiated.
If ulceration occurs, NSAID should be discontinued if possible. Acid
suppression therapy should be started.
MEN1 - Parathyroid, Pituitary tumors (prolactin or GH), Pancreatic endocrine tumors (ZE, insulinomas,
VIPomas, glucagonomas (rare)). Commonly presents with kidney stones and stomach ulcers
MEN2A - Medullary thyroid carcinoma (secretes calcitonin), Pheo, Parathyroid
MEN2B - Medullary thyroid carcinoa, Pheo, Oral/intestinal ganglioneuromatosis (assoc with marfanoid
habitus).
Clarithromycin
Amoxicillin
Metronidazole
Tetracycline
Hyponatremia, symptoms?
CHF
Cirrhosis
Nephrotic syndrome
Administration of diuretics....
Hypothryoidism
Adrenal insufficiency -- coritsol deficiency
Thyroid hormone and cortisol are both permissive for free water excretion, so their deficiency
causes water retention
But it is most commonly due to SIADH, but this is a diagnosis of exclusion!
Low Na
High K
Acidosis
Adrenal insufficiency
Also have fatigue, weight loss, low BP, and
hyperpigmentation...
Conn syndrome
Fluid restriction.
Sudden onset of ripping or tearing pain in the chest with radiation to the back.
May also radiate to the neck or extremities as dissection extends.
Often maximal at onset (different from ischemic pain which is progressive).
Pain of dissection is also not relieved by nitrates. May also be associated with
early diastolic murmur of aortic insufficiency..
BP in aortic dissection
A - always involves ascending aorta, but can involve other parts 2/3 originate in the ascending aorta a few cm above aortic valve.
B - does not involve ascending aorta but can involve any other part.
Prevent propagation of the dissection by reducing mean arterial pressure and the rate of rise of
arterial pressure
IV vasodilators such as sodium nitroprusside to lower BP to goal <120, along with IV BBs such
as metoprolol to reduce shear forces and try to achieve a heart rate of 60 BPM.
Labetalol --> both a vasodilator and a BB...
AAA pain?
>3cm
<5 cm is low
>6 cm is 10-20%
5.5cm or greater
Dacron graft in the past, but nowadays with endovascular aortic stent graft.
those below that should be screened with US or CT or MRI at 3-12 months
depending on risk of rupture.
HIV with unknown CD4 presents with subacute onset of fever, dry
cough, and gradually worsening dyspnea. No ARV or prophylactic
meds.
Tachypneic and hypoxemic
<250.
<200
Elevated LDH
Lack of sputum production
Definition of AIDS
CD4<200
or
AIDS defining illness in HIV+ patient.
Recurrent pneumonias
TB
Vaginal candidiasis
Herpes zoster
CD4<200
PCP
Toxo
Cryptococcosis
Histoplasmosis
Cryptosporidiosis
Cd4<50
PCP
Disseminated histo
MTB
Mycobacterium kansasii
Cryptococcal lung disease too..
TB
PCP
Coccidiomyocosis
CD4>200: Bilateral apical infiltrates with cavitation.
CD4<200: CXR extremely variable.. can be hypoxemic with little
infiltrate because TB infects both alveoli and hte circulation.
Consider M. kansasii, which can cause pulm disease and radiographic findings
typicaly of MTB
Toxoplasmosis treatment
IV Ganciclovir
Foscarnet
Cidofovir
<50 CD4
Disseminated infection with persistent fevers, weight loss, constitutional symptoms, and GI
symptoms such as abdominal pain, chronic watery diarrhea.
Diagnosed via mycobacterial blood culture
Treatment of MAC
Clarithromycin
Ethambutol
Rifabutin
For weeks.
Side effects
Also, within 1-2 weeks of starting HAART, improvement in the
immune system can actually cause worsening symptoms as a result
of host responses --> Immune Reconstituion Inflammatory
Syndrome or IRIS.
Treatment of Toxoplasmosis
PCP Presentation
Sulfadiazine with
Pyrimethamine
MAC prophyalxis
When CD4<50
Clarithromycin or
Azithromycin
Rest pain
pallor
Pulselessness
16% of americans
May exist w/o clinically recognized coronary or cerebrovascular
disease..
PAD also confers same risk of death as in persons with prior MI or
CVA.
Smoking
DM
HTN, HLD, elevated homocysteine also play significant roles.
Calves
Proximal stenosis may produce pain in buttocks or thighs..
Severe occlusion may produce rest pain, which often occurs at night and may be relieved by sitting
up and dangling the legs, using gravity to assist blood flow to the feet.
Pentoxifylline (xanthine derivative that increases RBC elasticity) may help, but
it may not.
Cilostazol - Phosphodiesterase inhibitor with vasodilatory and antiplatelet
properties. Has been shown to improve maximum walking distance.
ABI<0.4
Severe or disabling claudication
Rest pain
Nonhealing ulcers
These people should be evaluated for revascularization procedures.
Takayasu arteritis
Buerger disease
Inflammatory condition of small and medium-size arteries that may
affect upper and lower extremities and is found almost exclusively
in smokers, especially males younger than 40 yo.
Six Ps:
Pain
Pallor
Pulselessness
Paresthesias
Poikilothermia
Paralysis
First five develop quickly
Paralysis will develop if arterial occlusion is severe and persistent.
Takayasu arteritis
Really an aortitis
Fever
Stenotic lesions of the SCAs, which may cause unequal blood
pressures, diminished pulses, and ischemic pain in the affected
limbs.
Narrowing of arteries
Arteriovenous "nicking"
Flame shaped hemorrhages with cotton wool
exudates
Prehypertension
120-139
80-89
HTN Stage I
140-150
90-99
HTN Stage II
>160
>100
5-20%
<25 yo or >55
Malignant HTN presentation
Refracotry HTN requiring >=3 antihypertensive meds
HTN that has suddenly become uncontrolled
Rising Cr level with use of ACEIs, or other clinical signs of a secondary cause.
Primary aldosteronism
Cushing syndrome
Pheochromocytoma
Hyperthyroidism
Acromegaly (excess GH)
Cardiomyopathy
Nephropathy
Retinopathy
Cerebrovascular disease
Prehypertension interventiosn
Lifestyle modifications
Stage I HTN
Single antihypertensive
Stage II HTN
Generally,
young - BBs and ACEIs
Old - CCBs, thiazides
AAs? Thiazides better than BBs, and ACEIs and ARBs may be less effective
than in white patients.
Postural hypotension
Drowsiness
Dry mouth
Rebound HTN with abrupt withdrawal
BB side effects
Bronchospasm
Hyperlipidemia
Depression
Erectile dysfunction
Hyperkalemia
Gynecomastia
Reflex tachycardia
H/A
Angina
Lupus-like syndrome
Hyperkalemia
Cough
Angioedema
Acute renal failure
Orthostatic hypotension
Amlodipine or Nifedipine
Tachycardia, flushing, GI side efects, hyperkalemia
edema
Diltiazem
Verapamil
Heart block, constipation
ACEIs
ARBs
ACEI
ACEI
Beta blockers
Hyperthyroidism presentation
AD --> FHx
Bilateral flank masses
Flank pain
Elevated BP
Hematuria
Anabolic steroids
Sympathomimetic drugs
TCAs
OCPs
NSAIDs
Illicit drugs --> cocaine
Caffeine
EtOH
Cutaneous flushing
Headache
Diarrhea
Bronchial constriction with wheezing
Often, HTN
Severely elevated BP
confusion
Increased ICP
And/or seizures
Must rule out whole host of other things including drugs, stroke, SAH, meningitis, mass lesions,
etc.
Men2A vs Men2B
Hypertensive encephalopathy
Myocardial ischemia or infarction assoc with markedly elevated BP
Aortic dissection
Stroke
Declining renal funtion with proteinuria
Pulm Edema --> acute left vetnricular failure
Retinopathy
No. Autoregulation failure can occur in normotensive patients at BPs as low as 160/100.
Longstanding HTN --> adaptive mechanisms such as cerebral arterial autoregulation, may not
show clinical manifestations until BP>220/110.
Thus, should focus on symptoms such as hypertensive encephalopathy rather than the numbers.
Episodic anxiety
Tremor
Orthostatic hypotension caused by volume
contraction from pressure-induced natriuresis
0.01-0.1%
Diagnosis of pheo
RET in MEN2
VHL gene in Von-Hippel Lindau
Familial pheo
Neurofibromatosis
Extensive hepatic necrosis such as toxic injury, viral hepatitis, and ischemia (shock liver).
Alcoholic hepatitis has levels <500 almost always, and AST/ALT ratio of 2:1
Sexually
IVDU - blood
Birth chronically infected mothers...
Age of infection:
Birth --> 90% develop chronic infection
Adults - 95% recover completely without sequelae, 5-10% develop
chronic hepatitis, with fewer developing cirrhosis...
Anti-HBc IgM
Anti-HBc IgG
Anti-HBe
Rarely diagnosed
Not HCV antibody
But rather HCV RNA assay
Interferon
Lamivudine (nRTI) at a level lower than when it is
used for HIV.
Pegylated interferon
Ribavirin
Protease inhibitor if genotype I.
10g or more usually, but lower doses may cause injury in patients with preexisting liver disease,
particularly in those who abuse alcohol.
Alcohol augments P450 activity which produces more toxin from acetaminophen, also
phenobarb does the same...
Less glutathione is available in alcoholism, malnutrition, or AIDS...
Anti-HBc IgG
Anti-HBc IgM
PCOS
Hypothyroidism
HyperPRL
Ovarian failure
Sheehan syndrome
Prolactinomas
If PRL>200 ug/L, an MRI is indicated.
Next?
Surgical or radioactive iodine treatment for hyperthyroidism
Common sx of hypothyroidism
Fatigue
Weight gain
Muscle cramping
Cold intolerance
Hair thinning
Menstrual changes
Carpal tunnel syndrome
Emergency hypothyroidism?
Subclinical hypothyroidism?
TSH mildly elevated (4-10) but free T4 is within normal range. Patients may be asymptomatic or report
vague and subtle symptoms of hypothyroidism such as fatigue/. About half will progress to overt
hypothyroidism within 5 years.
They often also have some sort of derangement of cholesterol metabolism. Elevated total and LDL...
Thyroid replacement can be inititated.... esp if postiive antithyroid antibodies are present.
Dosing of levothyroxine
C. Hashimoto thyroiditis
Anti-HBc IgG
High ferritin
High transferrin saturation
Sodium restriction
Sprinolactone
Loop diuretics
Large volume paracentesis
Decreased liver production of steroid hormone binding globulin --> increase in unbound estrogen.
Massive hemorrhage
OR
More subtle bleeding that can trigger bout of
encephalopathy.
Lactulose
Antibiotics such as neomycin (kill bacteria
that make ammonia??)
Peritoneal carcinomatosis
Tuberculous peritonitis
Pancreatic ascites
Bowel obstruction or infarction
Serositis --> lupus
Nephrotic syndrome.
IV ampicillin, gentamicin
Third generation cephalosporin
Hepatorenal syndrome
Hepatopulmonary syndrome
Serum bilirubin
Serum creatinine
INR
Repalces the Child-Pugh system... A to C.
PSC
Autoimmune destruction of both intrahepatic and extrahepatic bile ducts and is often associated
with inflammatory bowel disease, most commonly ulcerative colitis.
Patients present with jaundice or symptoms of biliary obstruction. Cholangiography reveals
characteristic beading of the bile ducts.
Initial
Age>55
WBC>16k
Serum glucose>200
Serum LDH>350
AST>250
Within 48h of admission
Hct drop>10
BUN rise >5mg/dl after IV hydration
Arterial PO2<60mmHg
Serum calcium <8mg/dl
Base deficit >4mEq/L
Estimated fluid sequestration of >6L
Antiretroviral didanosine
Pentamidine
Thiazides
Furosemide
Sulfonamides
Azathioprine
L-asparaginase
Mumps
CMV
Vomiting
Inability to tolerate PO intake
Third spacing due to inflammatory processes, with sequestration of
large volumes of fluid within the peritoneal cavity.
Mainly supportive
--> "Pancreatic rest"
With-holding food or liquids by mouth until symptoms subside, and adequate narcotic analgesia, usually with meperidine
which is a fast acting opioid.
IV FLUIDS!!!
Hypovolemic shock --> multifactorial, third spacing with sequestration of large fluid volumes in
the abdomen as well as increased capillary permeability.
Phlegmon --> solid mass of inflamed pancreas which may become necrotic or
infected... abscesses --> 100% mortality if not drained.
Others develop ARDS or myocardial dysfunction which both result in a pulmonary edema.
Pseudocyst --> can cause pain, large or expanding or become infected, they
usually require drainage. Usually resolve in 6 weeks if smaller than 6 cm.
Biliary colic
Sudden onset, often precipitated by a large or fatty meal, with severe steady pain in the RUQ or
epigastrium, lasting b/w 1-4 hours....
Mild elevatiosn of alkaline phosphatase level, and slight hyperbilirubinemia... but elevations
>3g/dl suggest a common duct stone.
HIDA scan
Nil per os
IV fluids and antibiotics
Early cholecystectomy w/i 48-72 hours
Cholangitis
Intermittent obstruction of bile duct --> reflux of bacteria up biliary tree, followed by purulent
infection behind obstruction.
Sepsis? Urgent decompression of the biliary tree, either surgically or by ERCP, to remove stones
endoscopically after performing a papillotomy which allows stones to pass.
Age>55
WBC>16k
Serum glucose>200
Serum LDH>350
AST>250
Note that this does NOT include amylase or lipase.
Acute cholecystitis.
NOT acute cholangitis
Gallstones
Alcohol consumption
Hypertriglyceridemia
>=3
Shy-Drager syndrome
Micturition
Defecation
Coughing
Orthostatic hypotension
Older men, episodes can be triggered by turnign head to side, wearing a tight collar, or even by
shaving the neck over the area. Pressure over carotid sinus --> excess vagal activity which leads to
bradycardia, fall in CO, can produce --> sinus arrest or even an AV block... Sometimes, but less
commonly, this can cause a fall in arterial pressure without a drop in HR.
Recurrent syncope? Pacemaker.
Hypovolemia
Imapired autonomic responses
Diabetes
Chronic idiopathic orthostatic hypotension
Primary neurologic conditions
First degree --> prolonged PR interval (>200ms), which also has a conduction delay. Prognosis good, no need for pacing.
Second degree -->
--> I. Progresive lengthening of PR interval until skipped beat. No need for pacing unless symptomatic.
--> II. Dropped beats without lengthening. Permanent pacing indicated because usually progresses to type III.
Third degree --> complete heart block. SA node and AV node fire at independent rates. Atrial rhythm is faster than
ventricular escape rhythm. Permanent pacing is indicated
Atropine
Abdominal pain and frequent, sudden urge to defecate resulting in small voluem with blood or
mucus stooling
Symptoms of colitis
XR findings in colitis
Colonic dilatation on XR
Ischemic
Infectious (C diff, E coli, Salmonella, Shigella, Campylobacter) -->
Travel or antibiotics
Radiation colitis
IBD (Crohn disease vs ulcerative colitis)
15-25
also second peak for Crohn disease b/w ages of 6070
IBD presentation
Anal fissures
Nonhealing ulcers
Radiographic findings in CD vs UC
Skin manifestations of CD vs UC
Ocular complications of CD vs UC
Hepatobiliary complications of CD vs UC
CD:
Cholelithiasis fatty liver: common
PSC: rare
UC:
Fatty liver is common
PSC rare, but less rare than in Crohn's.
Presentation of PSC
Azotemia
Prerenal KI
ASA
NSAIDs
ACEIs
Postinfectious
Vasculitis
Immune complex diseases (lupus, MPGN, cryoglobulinemia)
Cholesterol emboli syndrome
HUS/TTP
Cephalosporins
Methicillin
Rifampin
FENa in glomerulonephritis
<1%
Dialysis
Furosemide
Kayexalate (but not really)
U sodium<20mEq/L
Uremic pericarditis
Hyperkalemia
Metabolic acidosis
Severe hyperphosphatemia
Volume overload refractory to medical management
Sudden onset of substernal chest pain, which worsens on inspiration and with recumbency, that
often radiates to the trapezius ridge.
Is often improved by leaning forward and exacerbated by recumbency.
Complciatiosn of pericarditis
4 of 11 criteria:
Malar rash
Discoid rash
Photosensitivity
Oral or vaginal ulcers
Arthritis
Serositis
Renal involvement
Neurologic disorder: seizure or psychosis
Hematologic disorder: anemia or leukopenia, anemia is hemolytic
Positive dsDNA, Smith Ab, Antiphospholipid antibody, antinuclear, ANA must be positive in absence of drugs knownto cause
+ANA
Renal involvement, and this is what caused most of the deaths. But now it is treated with high doses of
powerful immunosuppressants
CNS disorders are also very serious, as are infection (iatrogenic due to immunosuppression), and vascular
disease --> MI.
Pulsus paradoxus
VDRL test
SLE
MPGN
Infective endocarditis
PSGN/PIGN
Cryoglobulin-induced GN
cANCA
Microscopic polyangiitis
Churg-Strauss
AntiGBM GN
Goodpasture's
Kidney trauma
Renal stones and crystals
Glomerulonephritis
Infection (pyelo)
Neoplasia (RCC)
Vascular injury (vasculitis, renal thrombosis)
Trauma (foley!!)
Infections (urethritis, prostatitis, cystitis)
Nephrolithiasis (ureteral stones)
Neoplasia (prostate, bladder)
Edema
Hypoalbum
Hyperlipidemia
Proteinuria >3g/day
Nephritic syndrome
Hematuria
Edema
HTN
Low degree of proteinuria (<1-2 g/day)
Causes of vasculitis-related GN
Wegener
Churg-strauss
PAN
MPA
HSP
PIGN, PSGN
or Infective endocarditis related
glomerulonephritis
Goodpasture vs Wegeners
Microalbumin definition
30-300mg
Protein
Waxy casts
Oval fat bodies --> Maltese crosses under polarized
light, only if hyperlipidemia is present
Edema
U/A proteinuria
5-15 years
2 years
Tight glycemic control 6.5-7 (only during micro stage, not for more advanced).
Strict BP control (130/80 less than), esp in >1g/d
ACEI or ARB --> reduces progression of renal disease independnet of BP
control
Cardiovascualr risk reduction reduces overall mortality: LDL<100,
Pseudogout joints
Migratory arthralgias and tenosynovitis, often involving the hands and wrists
Usually assoc with pustular lesions, before progressing to a purulent monoarthritis or
oligoarthritis.
Knee
Hip
Large joints! shoulder
Differentiate arthritis from inflammatory conditions adjacent tot the joint,
such as cellulitis or bursitis. You can do so through ROM, which should be
limited in painful everywhere during arthritis...
Joint movement hat is nto limtied by passive motion suggests bursitis rather
than arthritis...
>100000 septic
Inflammatory 2000-75000
Noninflammatory - 50-1000
<200 is normal..
Anything over >2000 WBC should be considered inflammatory and thus infected until proven otherwise.
Usually S aureus.... Treamtent would involve antistaph penicillin such as nafcillin or Vanc if
MRSA is suspected....
ASymptomatic hyperuricemia
Acute gouty arthritis --> monoarticular pain, occuring at night
Intercritical gout (period between attacks)
Chronic tophaceous gout,with intercritical periods no longer
symptomatic.
No.
Pseudogout treatment
Distinctive features of RA
RA diagnosis is what
OA
Fibromyalgia
Hypothyroidism
Neuropathic pain
Depression
Chronicitiy
<6 weeks --> acute, major considerations are viral
infection, or earliest manifestations of true rheumatic
disease.
HBV
HCV
Rubella
Parvovirus B19
Symmetric!!!
Other autoimmune rheumatic diseases such as SLE and psoriatic arthritis, are often
asymmetric.... Lupus may be symmetric but is also characterized by other symptoms such as:
malar rash, serositis (pleuritis, psoriatic arthritis), renal diseas with protein or blood, CNS
manifestations, hemolytic anemia leukopenia, lymphopenia,or thrombocytopenia.
Psoriatic arthritis
Reactive arthritis
This is due to inflammation that is not limited to the joints, but also occurs at
the periosteum, along tnedons, and at insertion points along the bone....
Without evidence of skin or nail changes typical of psoriasis (nail pitting, scaly
plaques). Arthritis can precede rash or vice versa...
Reactive arthritis is an asymmetric inflammatory arthritis that follows infection of GI tract or GU tract --> Salmonella,
Shigella, Campylobacter, Yersinia, or Chlamydia....
Reiter syndrome --> triad of arthritis, uveitis, urethritis...
Utilitay of RF titers
Subcutaneous nodules typicallhy found over extensor surfaces --> proximal ulna or other pressure points.
They only occur in 20-30% of patients with RA, but are highly specific for RA.
Ig that react to Fc portion of IgG... They are usually IgMs, which are found in 80-85% of patients
with RA.
Radiologic findings in RA
Erosion of periarticular bone and cartilage destruction with loss of joint space --> may help diagnosis...
Joint space narrowing
Subchondral polysclerosis
Marginal osteophyte formation
Cyst formation
Typical XR findings do not develop unti later in disease process, and diagnosis is usually made already.
Extraarticular manifestations of RA
Heme manifestations of RA
Felty syndrome
ACD
Nonbiologic DMARDs
MTX
Hydroxychloroquine
Sulfasalazine
Minocycline
Leflunomide
MTX ois often used first, rapid onset of action, and higher tolerability and patient compliance.
TNF antagonists
Etanercept
Infliximab
Adalimumab
Reduces disease severity with RA in weeks.
Crazy DMARDS
Hydroxychloroquine
Sulfasalazine
Oral and parenteral gold
Penicillamine
D5 with NS
Methanol
Ethylene glycol
Would present with similar labs, but may be more serious or even fatal
NA - cl - hco3
Na+K - Cl --> this is an estimate of NH4+ excretion
Normal systemic pH
7.35-7.45
10-12
This will be lower if the patients are hypoalbuminemic, or if there are high levels of immunoglobulins as in
MM
Acute illness --> poor tissue perfusion, such as septic shock, heart failure,
severe anemia, or poisoning affecting tissue oxygen delivery or cellular
respiration (CO, cyanide).
Treatment is aimed at correcting the underlying condition... NaHCO3 may be
used in severe acidemia
<7.1
Lactic acidosis
Ketoacidosis (DAS, or diabetic, alcoholic, starvation)
Toxins (ethylene glycol, methanol, salicylates, propylene glycol)
Renal failure (acute and chronic)
Acetoacetate
Beta-hydroxybutyrate
Test onlhy really picks up acetoacetate, but not betahydroxybutyrate (the predoimnant ketone
produced in AKA). This can lead to underestimation of the degree of ketosis.
This leads to a funny thing when the patient is treated., bc as they are the foration of acetoacetate
is favored, so the degree of measured ketosis may appear to paradoxically worsen.
Thiamine 100mg
Metabolized by ADH to glycolate, glyoxylate, and oxalate --> acute renal failure due to glycolate
induced damage to tubules.. tubular obstruction from precipitated oxalate crystals.
Methanol
Ethylene glycol
These things cannot be normally detected, but can be inferred with the above
constellation of lab findings.
>10
Bicarb loss from GI tract or kidneys... you get a rise in chloride concentration that approximates
fall in bicarb concentration (hyperchloremic metabolic acidosis)
Basis of urine NH4, which cannot directly be measured but can be estimated with UAG
NH4 excretion is low in RTA, but high in NAGMA
UAG = Na +K - Cl. When this is negative, there is high NH4+ to balance out excess Cl.... thus an extrarenal cause of
acidosis... GI probably...
If UAG is positive, this indicates that there is impaired NH4+ excretion, and thus distal Type 1 RTA, hypoaldosteronism, or
Type 4 RTA.. Can also happen in advanced chronic kidney disease.
GI bicarb loss (diarrhea, pancreatic, small bowel drainage, ureterosigmoidostomy, jejunal loop, ileal loop)
Renal acidosis (hypokalemia RTA-II, RTA-I; Hyperkalemia Type IV RTA due to mineralocorticoid deficiency
or resistance).
Druginduced
Other causes: Acid loads, expansion acidosis (due to rapid saline administration)
Loss of acid
Excess endogenous production of bicarb (bicarb normally created in the
kidneys, but may fail to be expressed). This happens in Hyperaldosteronism, or
ECF volume contraction and hypokalemia due to variosu causes (vomiting, NG
suction, diretics)..
Sciatica
Spondylolisthesis
Spondylolysis
URIs
Millions of dollars are expended on this
problem each year.
Malignancy
Infection
Dangerous neurologic processes: spinal cord
compression, cauda equina sydnrome.
Pelvic disease
Renal disease
Aortic aneurysm
GI disease
Neoplasia
Infection
Inflammatory arhtritis
Paget disease
All account for 1% of total LBP
Lung
Breast
Prostate
Lymphoma
GI tumors
Malignant Melanoma
MM --> bone pain, renal failure, anemia
AP and Lat
Sedimentation rate
CBC
MRI may be reserved because it is usually not required to make a diagnosis.
Pott disease
<13 men
<12 women
Micro<80
Normo80-100
Macro>100
1%
Hookworm
Causes of Fe malabsorption
CELIAC DISEASE
Gastrectomy
IBD e.g. CD
Infancy/adolescence
Pregnancy
Vegetarian diet
Increased: Fe deficiency
Decreased: uniform sizes.. may suggest chronic
disease such as thalassemia, or even Fe deficiency
with concomitant anemia of chronic disease...
Iron deficiency
Thalassemia
Sideroblastic anemia
Lead poisoning
Sideroblastic anemia
GI: constipation, nausea, abdominal cramping. Taking iron with meals can help with this but
may decrease absorption.
IV iron when?
20%
Diverticulitis, uncomplicated vs
complicated
75% vs 25%
Complicatd diverticulitis
Abscess
Perforation
Stricture
Fistula
The most common is an abscess.
Complications of diverticulitis
CT scan --> sigmoid diverticula, thickening of the bowel wall to more than 4mm, pericolic fat stranding signifying
inflammation, or the finding of a diverticular abscess.
Bowel rest
Antibiotics --> oral quinolone plus metronidazole,
or amoxicillin-clavulanate for 10-14 days.
Majority is colovesical with male predominance (uterus protects bladder in females)..
Others include colovaginal, coloenteric, colouterine, coloureteral..
Colocutaneous is extremely rare...
Abscess
Fistulas
Obstruction
Strictures
Generalized peritonitis
Uncontrolled sepsis
Perforation
Clinical deterioration
Definition of neutropenia
ANC<500cells/mm3
Definition of fever
What is mucositis
S. epiermidis
S. aureus
CoagStaph --> usually you can keep the line in place. S. aureus or
gram negs, or fungemia, you need to remove the catheter.
Antibiotics
Gram staina nd culture of sputum
Admission
These patients need oxygen, IVF, and analgesia
Fever
Tachycardia
Chest pain
Leukocytosis
Pulmonary infiltrates
Hypoxia
Acidosis
Dehydration
Variations in body temperature
Aplastic crisis
Oxygen
Analgesia
Antibiotics
HgbF stimulators
Hydroxyurea
Decitabine
Pneumonia
Vasoocclusion
Pulmonary embolism
Cerebritis
S. pneumoniae
N. meningitidis is a close second
GBS - 10% of cases
Noenates
Patients >50 or with chronic illness such as diabetes or liver
disease.
Pregnant women, elderly, or patients with cellmediated immunity impariemtn such as AIDS
PCN
Cephalosporins
S. aureus
S. epidermidis
75%
Cryptococcus
HSV meningitis
Steroids in meingitis
CT before LP when?
Janeway lesions are painless hemorrhagic macules on palms and soles, septic emboli possibly
Osler nodes - painful, palpable erythematous lesions --> pads of fingers and toes, they represent vasculitic lesions caused by
immune complexes.
Roth spots
Fever in endocarditis?
95%
Enterococci
CAndida endocarditis
Intravascular catheters
IVDU
HACEK organisms
Haemophilus aphrophilus
Actinobacillus
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Stroke +febrile?
S aureus endocarditis
PCN G
MRSA
or
Coagulase-negative staph
Ceftriaxone
Intractable CHF, >1 serious systemic embolic episodes, or large (>10mm) veg with high risk for embolism
Uncontrolled infection, e.g. positive cultures after 7 days of therapy
No effective antimicrobial therapy (fungal)
Most cases of prosthetic valve endocarditis
Local suppurative complications e.g. myocardial abscess
Amoxicillin
Used for previous infective endo, prosthetic herat valves, CHD or
reparired CHD, valve regurg caused by structurally abnormal valve
in cardiac transplant patients.
antibiotics
infection with fungi
HACEK group
Triad of tamponade
Chronic tamponade
May look more like CHF --> cardiomegaly on CXR (although there should be no pulm edema),
dyspena, elevated JVP, hepatomegaly, and peripheral edema... A high index of suspicion is
required..
Constrictive pericarditis
Historically TB
currently, radiation therapy, cardiac surgery, or any cause of acute pericarditis such as viral
infection, uremia, or malignancy.
Pathophys is similar to that of tamponade. Restricted ability of the ventricles to fill during
diastole b/c of thickened noncompliant pericardium.
Kussmaul sign
No PP or Kussmauls
Progressive exertional dyspnea and dependnet edema.
Endomyocardial fibrsis
Causes of DCM
Viral myocarditis
Beriberi (wet)
Doxorubicin deficiency
Syphilis (nontender)
Chancroid (ducreyi)
Herpes
Superficially ifnected skin lesion.
Seconday syphilis
Tertiary syphilis
Chancre vs chancroid
Chancre - Non erythematous with rolled borders, clean base, very firm,
nontender. Can hav LAD
Chancroid - Painful, exudative, ragged borders, necrotic base, bleeds
easily. LAD is suppurative..
Condyloma lata
Neurosyphilis
May cause vasculitis --> ischemia, stroke, and focal neuro deficits.
Personality changes or dementia
Demyelination of the posterior column with wide-based gait, loss of
proprioception (Tabes dorsalis). Or CN involvement --> Argyll
Robertson pupil
RPR
VDRL
These are tests for lipid antigens that occur as part of host reaction to T.
pallidum and are fairly sensitive.... But low titers may be nonspecific, may
result in false positives.
FTA-ABS
MHA-TP
Dark field microscopy can find T. pallidum fro ulcer scrapings...
this is classic but not really used today.
Primary, Seconadry <1 year - one injection of benzathine PCN G (long lasting IM injection)
Late - Latent syphilis of unknown duration (presumed to be >1year) or with cardiovascula ro
gummas... Three weekly IM injections of benzathine PCN g
Tertiary syphilis or neurosyphilis - IV PCN 10-14 days.
Should be densesitized to PCN and treated, because this is the only treatment known to prevent congenital
infection...
30%
1/3 --> can confirm via dark field microscopy or biopsy with special
stains...
Or just empiric treatment with benzathine PCN
CSF testing.
COPD by PFT
FEV1<80% of predicted
FEV1/FVC <0.7 mild, 0.3-0.5 moderate, <0.3 severe
Reduced FEV1/FVC with minimal response to bronchodilators is the hallmark
of COPD.
ABG in COPD
Poliomyelitis
Myasthenia gravis
Scoliosis
Pneumonia
ARDS
Pulmonary edema
Interstitial fibrosis
Tachypnea (>40)
Inability to speak
ACcessory muscle usage with fatigue
Confusion
Restlessnes
Agitation
Lethargy
Rising PaCO2 level
Extreme hypoxemia
Treat with intubation wtih vent support to correct gas exchange.
Pulm hypertension
Seconadry erythrocytosis
Exercise limtiation
Impaired mental functioning
COPD who are stable? Smoking cessation
Supplemental oxygen
Lung volume reduction srugery
Postnasal drip
Astma
GERD
Psychogenic cough is one of exclusion
Opacification
Air fluid levels
Mucosal thickening
Methacholine
Histamine
SARCOIDOSIS
Possible presentation of MM
Hypercalcemia syymptoms
Acute confusion
Fatigue
Lethargy
Hypercalcemia treatment
Granulomatousdisease
FHH
Milk-alkali syndrome
Meds: Lithium, thiazides
Immobilization
Vit D or A toxicity
Adrenal insufficiency
Hyperthyroidism
HyperCA
HypoP
Elevated PTH
Nephrolithiasis
Peptic ulcers
Mental status changes...
Hyperparathyroidism symptoms
Stones - kidneys
moans - abdominal pain
groans - myalgias
psychiatric overtones - mental status changes.
Bone lysis
Excess 1,25 vitamin D (lymphomas)
Parathyroid hormone-related protein (PTHrP)
In all cases, can distinguish from primary hyperpara by suppresssed PTH level.
ECG abnormalities in PE
Factor V Leiden
Prothrombin gene mutations
Fondaparinux
Direct Factor Xa
Clubbing of fingers
Lung cancer
Chronic septic conditions --> bronchiectasis or lung abscess.
Horner syndroem
Ptosis
Loss of pupillary dilation (miosis)
Anhydrosis on ipsilateral side.
Bronchitis
Lung cancer
Prior eras:
TB
Lung abscess
Bronchiectasis
Most patients require CT scan, CXR.
Pulmonary embolism
85%
15% --> majority found in women for reasons that are unknown...
Thoracic radiation exposure, exposure to environmental toxins such as
absestos or radon
Squamous cell carcinoma. Usually a central / hilar lesion with local extension that may present with sx caused by bronchial
obstruction such as atelectasis and pneumonia.
SCC
Adenocarcinoma
Large cell cancer
Adenocarcinoma mets early to CNS, bones, and adrenal glands.
SIADH
Ectopic ACTH
Eaton Lambert
Cushing
Peripheral neuropathy
Extrathoracic
SVC syndrome
Vocal cord or phrenic nerve paralysis
Malignant pleural effusion
Cardiac tamponade
Tumor w/i 2cm of the carina
Mets to the other lung
Mets to supraclavicular lymph nodes or CI mediastinal node
Invovlement of main pulm artery
Size
0.2% for nodules <3mm
0.9% for 4-7 mm
18% for 8-20mm
50% for >20 mm
Greater than 99% of nodules <8 mm are benign
>1cm --> probably need a PET scan.
Increased ICP
Fatal intracranial venous thrombosis
Pathogens in HCAP
CURB-65
MRSA
Pseudomonas
Acinetobacter
MDR Enterobacteriaceae
Confusion
Urea >20
RR>30
BP<90
Age>65
0 - mortality rate of 1.5% 30 days
2 - 9.2% mortality --> admitted to hospital.
Necrotizing infection:
Staph
TB
GN -->> Klebsiella
SCC
>25 PMNs
<10 epithelial cells per LPF
Diagnostic yield should be good.
30-40%
Chemical injury to the lungs caused by aspiration of acidic gastric contents into
the lungs..... Usually sterile, but rather a chemical burn that causes a severe
inflammatory response... --> respriatory distress and a pulmonary infiltrate
4-6 hours appears, and typically resolves within 48 hours...
Aspiration pneumonia
Addison disease --> adrenal failure to detruction or infiltration o fhte adrenal glands. Most
common cause worldwide is tuebrculous adrenalitis... Other causes can include chronic
granulomatous ifnection such as histo or coccidiomycosis), b/l adrenal hemorrhage (sepsis with
DIC), adrenal mets (commonly from lung, breast, or stomach cancers)
X-linked adrenoluekocydstrophy....
AIDS --> CMV or MAC
Weakenss
Nausea
Vomiting
Abdominal pain
Fever
Hypotension
Tachcyardia,
FEVER
Hyponatremia
Hyperkalemia
Metabolic acidosis
Azotemia --> aldo deficiency
Hypoglycemia
Eosinophilia as a consequence of cortisol deficiency
May go into crisis when stressed by infection, trauma, or surgery... May look identical to septic shock, except for the
hypoglycemia and the hypotension that is corrected by steroids and not pressors.
High in morning
Low as day progresses
Morning plasma cortisol <5ug/dl in an acutely ill paitent is defintivie evidence
of adrenal insufficiency....
Random cortisol level>20 --> intact adrenal function.
Diabetes
HTN
Obesity
Osteoporosis
Cataracts
Autoimmune adrenalitis
Gilbert syndrome
When conjugated bilirubin does not exceed 15% of total bilirubin. Almost
always caused by hemolysis or Gilbert syndrome... But in these syndromes
TBili <5mg/dl, and usually no sign of liver disease.
US. Noninvasive and is very sensitive for detecting stones in the gallbladder as
well as intrahepatic or extrahepatic ductal dilatation.
Cholangiocarcinoma
Pancreatic cancer
Ampullary cancer
None really
Courvoisiers
PBC - cirrhosis
Causeunlikelyt to be gallstones
CAD equivalent
LDL<100
BP<130/80
Injection
Nausea
Risk of pancreatitis
A1C<7
Preprandial glucose 70-130
Postprandial <180
BP <130/80
LDL <100
Infection
Pregnancy
Severe physiologic stressors --> MI
DKA triad
Glucagon --> maintains normal glucose levels by stimulating hepatic gluconeogenesis and glycogenolysis.
Cardiovascular collapse
Hyperglyecmia >250
Acidosis
Anion gap
Ketonemia
Serum potassium level is important.
10-12
Lactic acidossis
Ketoacidosis (diabetic, alcoholic, starvation)
Toxins (ethylene glycol, methanol, salicylates)
Renal failure (acute or chronic, failur eto excrete acids)
SCr in DKA
Glucose q1h
Electrolytes q3-5h
Complications of DKA
Cerebral edema
ARDS
Thromboembolism
Fluid overload
Acute gastric dilatation
Rare but serious complications all.
Alcoholic ketoacidosis
NS
Glucose
Thiamine
Insulin is not necessary
Protuberant eyes
Systolic ejection murmur
Skin warm and dry
Resting tremor
Diarrhea in Hyperthyroidi?
Exophthalmos in hyperthyroid?
"Apathetic hyperthyroid"
Tachycardia (>140)
Fever (104-106)
Agitation
Delirium
Restlessness or psychosis
Vomiting and/or diarrhea
Graes --> 80%, usually in women, esp b/w ages of 30-50 yo.
Graves dermopathy
BOTH!
Graves has Thyroid Stimulating Immunoglobulin (TSI). Thyroid
uptake and scan --> reveal diffusely elevated iodine uptake in our
patient.
Rash,allergies
Arthritis
Hepatitis
Agranulocyutosios
Radioactive iodine --> oral solution of 131I that is rapidly concentrated in thyroid tissue -->
radioablation, depending on dose, w/i 6-18 weeks...
CI in pregnant women, and women are advised to hold of pregnancy for 6-12 months after
treatment.
May exacerbate ophthalmopathy which glucocorticoids can help with.
Thyroid hormone
Amiodarone
Iodine load
50mL
>500 ml usually obscures the whole hemidiaphragm.
<=1500 ml
Degree of pleural inflammation, and along with fluid protein, should always be sent in initial
evaluation.
Malignancy
PE w/infarction
TB
LDL calculation
Men<55
Women<65
Hypothyoidism
DM
Also:
Obstructive liver disease
Chronic renal failure/nephrotic syndrome
Med side effects: progestins, anabolic steroids, corticosteroids
Gallstones
Nausea
LFT increase
Monitor for dyspepsia, gallstones, myalgias (thus do not use with statins... can eb confusing).
Ezetimibe
Within 3 hours.
70%
Treatment of anaphylaxis
Epi
Steroids
Histamine blockers (H1 and H2)
Hymenoptera stings
SJS vs TEN
Serum sickness
Allertic raction tha toccurs 7-10 days after primary administration, or 2-4 days after secondary administration of foreng
serum or a drug.
Fever polyarthralgia, urtiaria, LADm and sometimes GN. Type III HSN reaction, caused by formatin of immune complexes
of IgG and the offending antigen
Usually self limiting, antihistamines, ASA, NSAIds
Diphenhydramine
H2 blockers
Corticosteroids
MMSE scores
Early
Intermediate 21-26
Late 10-20
Advanced <10
Polymyalgia rheumatica
Red flag HA
Cluster headache
Fundmanetla change
First severe and/or worst ha
Abrupt onset
Abnormal PE findings (general or neuro)
Neuro symptoms>1 hr
New HA <5y >50yo
New HA in patients with cancer, immunosuppression, pregnancy
HA assoc with alteration in or LOC
HA triggered by exertion, sex, VAlsalva
Male predominance
Precipitated by EtOH
Occurs with rhinorrhea, lacrimation
Up to 20%
Oxygen
SQ sumatriptan
Osteopenia vs osteoporosis
T score vs Z score