- rest angina with duraton over 20 min, new onset angina, or increasing angina
- UA and NSTEMI MI are part of the continuum of acute coronary syndrome in which plaque rupture and coronary thrombosis compromise blood flow
- NSTEMI and Unstable angina are treated with medical managment (antiplatelet therapy, nitro, b-blockers, and morphine) and considered for revascularization!
HOCM Diagnositc criterias
Septum: ventricular wall thickness ration over 1.3
- asymmetric setpal wall thickening in Echo!
Which antiarrhythmica shows these advere effects: Confusion, Slurred Speach, Tremor and personality changes
Adverse effects b-blockers
associated with depression, sexual adverse effects, sleep disurbance
Adverse effects SSRI:
sexual disfuncion and anxiety, GI symptoms
adverse Effects ACEIs:
hyperkalemia, renal failure, dry cough*
Cardiac Tamponade history / signs:
- Chest pain, fatique, psypnea
- Becks triad: hypotension, distant heart sounds, distended neck veins
- usually due to trauma; but can as well be due to myocardial rupture, pericaritis, tumor, hypothyreosis, cancer, aortic dissection.
First step management HOCM
CCB second line
Effect of therapeutic Mg?
Decreases ca influx and reduces early afterpolarizations, therapuetic in torsade de pointes
Empiric management of pulsless electrical activity
Atropin, ephedrin, bicarbonate!
Bicarbonate because it can be due to severe acidosis..
Common adverse effect of alpha1blockage?
Triad od AbdomAA rupture?
Abdominal pain, pulsatile abd mass, hypotension.
Murmur in mitral valve prolaps?
Late systolic apical murmur preceeded by a click
Indication for sodium bicarbonate?
Qrs widening over 100msec, ventricular arrhythmias, and hypotension
-increase in pH plus increase in extracellular sodium!
hypertension, bradycardia, irregular respirations
- is suggestive of increased intracranial pressure*
- erythematous, round, and clears centrally with a peripheral scale
- in pytiriasis rosea
- may be confused with erythema mirgans
- may come with prodrome, headache, malaise or sore throat
- mostly asymptomatic
- herald patch, trunk and proximal extremities
- palms and soles
type IV, eczematous rash with pruritic papules, and crusting
- typicall "slapped cheek" rash
- edematous, erythematous, plaques
- Parvovirus B19
- Staphylococci, epidermal infection
- typically face and neck or extremities
- rash with vesicular, honey-colored crusting
- can be intensely pruritic
- hyperpigmentated, thickened plaques
- axillae, back of the neck, or hands
- associated with diabetes or insulin resistance
5 p's: purlpe, polygonal, pruritic, planar papules and Wickham's striae= grey white lines or dots seen on the surface
- may be associated with hep C infection or drug exposure (including B-blockers, penicillamine, ACEIs..)
- usually self-limited
- systemic steroids or UV therapy
classic: pretibial erythematous tender nodules in young woman
- inflammation of subcutaneous fat
- associated with strep pharyngitis, hypersensitivity reaction to drugs, IBD, sacroidosis, tuberculosis
-associated with morbus crohn
Acyclovir therapy in herpes
effective if initiated within 72h of infection!
actinic ceratosis / seborrhoic keratosis DD:
- AK has a erythematous base, and is brighter than SK
- risk of development of Scamous cell carcinoma from AK
- but risk is rather small
Typical postmenopausal women, itching anogenital region, white, wrinkleled labia
- treat with topical steroids
white lesions, pruritic with sorrounding erythematous mucosa, may be edematous.
-GnRH synthesis disorder
- amenorrhoe and pubertas tarda
- associated with anosmie and hyposmie, color blindness
Endocrine adverse effect of amiodaron
- due to inhibiting producion of T3
Sings of hypocalciemia
Chvostek sing: twiching of facial nerve due to palpation
Troussaus sign: induced carpal spasm
Effect of hypomagnesiemia
Can make hypocalciemia by decreasing producion of PTH and decrease sensitivity to the hormone
Symptomatic treatment of hyperprolaktinemia
Dopamin to suppress Prolactin
Diabetes in children history
Poliuria, polydipsia, no weight gain and increased food intake
HLA association in DM 1
De quervain thyrioditis
- subacute granulomatous thyrioditis!
- inflammation causes destrucion of follikels with effect of hyperthyreosis as long as in storeage
pancreatic tumors, hyperparathyroidism, pituary adenoma (Prolactinoma), can be associated with Zoellinger Ellison (ulcers due to gastrinoma)
medullary thyroid cancer, pheochromocytoma, hyperparathyroidism
medullary thyroid cancer, pheochromosytoma, mucusal neuromas
which oral antidiabetic can make lethargy, seizure like episodes?
Sulfonyureas due to severe hypoglykemia
Effect of Metformin?
inhibits hepatic gluconeogenesis, increases peripheral sensitivity to insulin
Effect of alpha- Glucosidase inhibitors?
decrease intestinal absorption of carbohydrates
reactive hyperglycemia following hypoglycemia
- can be due to high insulin intake at night, with hyperglykemia in ther morning
Compare regular insuline / Neutral protamine Hagegendorn NPH Insuline
NPH Insulin has longer peak action and longer overall duration (8h/ 20h) than regular insulin
Condition due to exogenous high cortisol intake
- Cushing syndrome, low ACTH, low free urinary cortisol
Sodium - (Chloride plus bicarbonate) = 8-12
In patients with a normal anion gap the drop in HCO3− is compensated for almost completely by an increase in Cl− to maintain electroneutrality*
Examples for high anion gap acidosis
Ketoacidosis, Lactatacidosis, Renal failure (causes high anion gap acidosis by decreased acid excretion and decreased HCO3− reabsorption. Accumulation of sulfates, phosphates, urate, and hippurate accounts for the high anion gap)
Exapmles for normal anion gap acidosis
= called hyperchloremic acidosis
Diarrhea, renal tubular acidosis (due to loss of HCO3-), Addisons disease (mineralocorticoid deficiency)
Example for low anion gap
Hypoalbuminemia: as Albunin vaues as a Aniona (is neg charged), and loss of it leads to retention of other Anions such as Chloride or HCO3-, can also lead to Alkalosis*
thioamide drug used to treat hyperthyroidism (including Graves' disease) by decreasing the amount of thyroid hormone produced by the thyroid gland. Its notable side effects include a risk of agranulocytosis.
On 3 June 2009, the FDA published an alert "notifying healthcare professionals of the risk of serious liver injury, including liver failure and death, with the use of propylthiouracil." As a result, propylthiouracil is no longer recommended in non-pregnant adults and in children as the front line antithyroid medication
Treatment Dequervain, subacute thyroiditis
NSAR like Ibuprofen
Lab findings in polycystic ovarian syndrome:
low FSH, high LH, high Estrogen
Metformin, advantage, adverse effects`?
- Does not lead to weight gain :-), can make weigh loss
- can make lactate acidosis :-(*****, especially in patient with liver, renal failure, heart disease,
- gastrointestinal upset :-(
First line treatment hyperprolactinemia, Prolactinoma?
Bromocriptine (a dopamine agonist) , can decrease prolactin secretion and size of tumor**
Effect of Rosaglitazone
is a thiazolidinedione and acts by increasing tissue insulin sensitivity
DM type 2 Dg:
finding on two seperate occasions of a fasting blood glucose level of 126 or higher (can be different)
First step managment in palpated nodule
TSH in serum
Managmant in nodule with low TSH?
radionucleide scan to determine wheter the nodule is hot or cold
Managment in nodule with normal TSH?
always fine needle aspiration*
- if neg, make radionucleide scan
Secondary Hyperparathyroidism Cause, findings?
- caused by chronic renal disease
- diminished ability to excrete phosphate leads to hyperphosphatemia.
- excess phosphate binds to calcium causing hypocalcemia
- Parathyroids reacts with hyperplasia
- Lab shows: low calcium, high phosphate, elevated creatinine, high PTH
Secondary hypoadrenalism: History / DEF
- due to corticosteroid intake
- may become unable to mount an appropriate response to ACTH
- S: renal failure, hypotension, hyponatriemia
Secondary hypoadrenalism: Treatment:
restart steroids and gradually tapering off
a-Glucosidase inhibitors adverse effect common:
-reduce the amount of carbohydrates absorbed from the intestine
-GI upset and flatulence
Managment of Papillary Thyroid-Ca in a Pregnant woman:
- until the second trimester hemithyroidektomy
- in the third trimester wait and monitor*
IGF-1 / GH First Step:
always IGF-1 first because GH is secreted in a pulsatile manner and is difficult to measure.
Signs of hypocalcemia:
weakness, dry skin, patchy alopecia, circumoral numbness, paresthesias, Chvosteck sign, Troussaud sing, cataracts, myocardial dysfunction, osteomalazia and seizures
-reabsorbed in the loop of Henle
- lack of magnesium inhibits PTH and causes Hypocalciemia and Hypoparathyroidism
- magnesium closes potassium channels (K), thats why you cant keep the potassium if you havent enough magnesium
- Release of calcium from the sarcoplasmic reticulum is inhibited by magnesium. Low levels of magnesium stimulate the release of calcium and thereby an intracellular level of calcium
Treatment of ketoacidosis:
- give insulin
- give Potassium (K) (because Insulin thrives K from extra to intracellular)
- monitor magnesium (because mg is needed to keep the potassium or use it )*
First-first Step managment in Peochromocytoma:
Give Prazosin= alpha adrenergic blocker to control hypertension**
- later you can give Beta-blocker... whatever...
Di George Syndrome:
deletion of chromosome 22q11
- abnormal facies, cleft palate,
- congenital heart defects (e.g fallots)
- parathyroid hypoplasia with hypocalcemia
- tetany, frequent infections with fungus or p. jirovecii
- measure serum Ca2+!!
- increased levels of urine 5-HIAA are a byproduct of serotonin metabolism
- often affects the righ heart valves (right heart failure), murmur
- Flushing of the skin, Diarrhea, Hypotension!
-tumors of the neural crest often occur in young children
- associated with hirschsprungs disease and Neurofibromatosis
- associated with elevated levels of urinary catecholamine levels = vanillylmandelic acid!
Nicain B3 Deficiency
pellagra: B3 think 3D
- dermatitis, diarrhea, dementia
Budd-Chiari syndrome: Def and Therapy
- secondary hepatic vein thrombosis typically associated with hypercoagulabe states such as PCV or Malignancy
- causing portal hypertension
- spyder- web collaterals in US
- RUQ pain, hepatomegaly and ascites
- Therapy is thrombolysis followed by anticoagulation, and TIPS (shunt)
medial treatmend for portal hypertension?
Med treatment for hepatic encephalopathy?
- copper acumulation in multiple organs (brain and liver)
- Basal ganglina dysfuction and hemolytic anemia
- liver cirrhosis with portal hypertension (needs upper endoscopy to look for varices)
Gastritis type B:
- antral-dominant (antrum)
- chronic gastritis
- use uf NSAR
- Infection with H. pylorii
Gastritis type A:
- affects the fundus
- autoimmune type
- associated with Vit B12 Deficiency (intrinsic factor), pernizious anemia (Megaloblastic anemia)
H. Pylorii Gastritis Therapy?
- Metronidazole and Clarithromycin
H. Pylorii Gastritis Diagnosis:
- positive H. pylorii antibody test
- breath urea test
- gastric biopsy and culture
- atrophic calcificated pancreas
- exocrine insufficiency lead to malabsorption and fatty stools and diarrhea, fould smelling
- needs enzyme replacement
radioative Vit B12 is given to measure the GI ability to absorb it
- in Megaloblastic anemia such as pernizious anemia
Carcinoid tumors: rule of thrid
1/3 metastazize, 1/3 accompagnied by second malignancy, 1/3 present with multiple carcinoid tumors
- often in the appendix
- often in the right heart
Plummer Vinsion syndrome:
Iron deficiency anemia and dysphagia due to upper esophageal webs,
oesophageal tear due to heavy vomiting**
- cause of upper GI bleeding
- endoscopic diagnosis
- birds beak appearance in barium swollow
- dysphagia of fluid and solid
- non functioning oseophagus sphinkter
gastric MALT Lymphoma:
95% of gastric MALT lypmhoma are associated with H. pylorii infection
- majority of cases achieve remission with simple antibiotic eradication :-O
dilated proximal bowel,
- delayed mekonium and abdominal distensio
- pass mecoium after rectal stimulation
necrotyzing enterocolitis. very common in neborn
- make bowel rest, stop feeding, nasogastric tube
Acute mesenteric ischemia:
- common in elderly with atherosclerothic disease
- abdominal angina symptoms: few hours, postprandial
- bloody diarrhea
- bowel may become gangrenous with fluid and protein leaking trough the damaged mukosa causing shock and metabolic acidosis.
Schönlein-Hennoch Classic tetrad / signs:
- pruritic rash, arthralgias (aches and pain), abdominal pain, and glomerular renal involvement
- common in children
- asscociated with intussception (and other GI compl)
- invagination of the intestine:
- nausea vomiting rectal bleeding
- dance sign
- associated with Schonlein-Hennooch
Hemochromatosis: signs: History
Dg of H. should be suspected when a patient presents with
- diabetes, hepatomegaly, skin pigmentation, arthritis and hypogonadism
Which Colon polyps carry the highest risk of malignancy?
Villious Adenoma (large, broad based polyp)
Colon-CA Surgery / Indication for abdominoperineal resection?
- if the lesion is under 10cm from the anal verge, its not possible to preserve the anal sphinkter
- resection of the rectum and anus with placement of permanent colostomy
Gram-negatice rods on gram stain
Oesophagusspasms / Nutcracker O. / DD:
- both are characterized by odynophagia and dysphagia of solids and liquids
- Globus feeling
- Oesophagusspams: Nitro can releave symptoms, manometry shows uncoordinated contractions (can be treated with moytomy)
- Nutcracker O. makes continous, cordinated contractions on manometry (can not be treated with myotomy), Nitro?
Crohns Disease complications:
small bowel obstruction is most common indication of surgery in Crohns
- neuronal deficit to relaxate oesophagus sphinkter
- Dysphagia of solid and liquids
- birds peak on barium swallow
- Treatement: pneumatic dilatation work in 80-90%, botox, anticholinergic agents, CCB
Hemochromatosis: compl / Diagnosis:
- coagulopathy, hepatocellular carcinoma, liver cirrhosis
- Dg: is confirmed by Perls Prussian blue stain of liver biopsy
-presents as acute epigastric pain, radiating to the back
- often in alkis
- nausea, emesis, fever
- Dg: amylase,lipase, CT
- Treatment: food restriction, fluid resuscitation
-nearly pathognomonic for cystic fibrosis
- or less commonly volvulus
- resulting in pancreatic insufficiency, which causes mekonium to become maculaginous and viscid, sticking to the walls.
rare complication of cholelithiasis and occurs when a gallstone enters the bowel through a biliary-enteric fistula and creates an obstruction
- DG: Rx, CT
Partia small bowel obstruction Treatment:
- nasogastric tube suction
- intravenous hydration, correction of electrolytes
- nothing to mouth
Complete small bowel obstruction: Signs / Treatment:
- present with vomiting, crampy abdominal pain with of without passage of feces or flatus since 12-24h
Surgery is appropriate for:
- complete small bowel obstruction
- small bowel obstruction with vascular compromise such as necrotic bowel
- or symptoms lasting at least 3 days without resolution!
Treatment of acute Mesenteric Ischemia:
- i.v. fluids, Heparin, Antibiotics
- no Warfarin start!!
- Exploratory laparatomy, with resection of nonviable bowel!
2 year old Child, mucous, bloody diarrhea, normal emesis, abdomina pain ?
Intussusception mostly idiopathic, most common abdominal emergency in children under 2 years
- cause mucosal bleeding with mucus (currant-jelly stools)
- episodes typically last 15-20 min
Children under 2y bowel obstruction most common , second most common:
- 1. pylorusstenosis
- 2. intussusception
Routine colonoscopy repeat time?
- normal each 10 y
- if multiple large lesion removed return in 3 y
Watery, non bloody diarrhea with cramping in patients who reveive antibiotics think: ?
Pseudomembranous colitis and Clostridium difficile:
- especially with cephalosporins, ampicillin / amoxicillin and clindamycin!!
- kill normal bac flora
- C. difficile has 2 toxins: 1 Enterotoxin A and a Cytotoxin B!
- Treat with cease of antibiotic therpy or start Metronidazol or Vancomycin!
vertebral, anorectal, cardiovascular, tracheal, esophageal, renal and limp abnormalities
- often occur with TEF (tracheoosesophageal fistula) and EA (esophageal atresia)
Hepatic Encaphalopathy Therapy:
- disturbed intellectual function, consciousness and neuromuscular function
- Reduce protein consumption, give lactulose and metronidazole (spontan bak periton???)
4 F's of Cholelithiasis:
Fat, Fourty, Female, Fertile
-common in Asians
- short duration of watery diarrhea, flatulence after eating icecream or mikl
- resolve after eg 1d
hairy cell leukemia
rare malignancy of B-lymphocytes
- male predominance
- presents with pancytopenia!! (hallmark)
- fatique bruising infections
- spleen shows hairy cell lymphocytes with cytoplasmatic projections
Why does Warfarin cause a hypercoagulable state the first 3 days of administration?
- 9, 10, 7, 2, C, S are Vit K dependent factors
- due to a lower half-lives of C, S than the coagulation factors
- heparine induced thrombocytopenia
- commonly occurs 4-10 day after initiation of unfractioned heparin
- HIT is associated with thrombosis!!! due to platelet activation rather than bleeding
- because platelet count is over 20'000 bleeding is rarely seen
- presence of platelet antibodies which cause limb- and life-threatening thrombosis, in artheries too.
- first intervention is immediate cessation of heparin! and initiation of a direct thrombin inhibitor. (Lepirudin)
Posttransplant lymphoproliferative disorder PTLD
- any patient who is chronically immunosuppressed is at risk to develop a lymphoproliferative malignancy!!!
- cardiac transplant (4.6% risk), liver (3.0%), kidney (1.0%)
- PTLDs generally occur in extranodal locations and may respond completely to reduction in immunosuppression
- most PTLDs are related to EBV infection so Therapy with Acyclovir has shown to be able to resolute malignancy too
Brown / redish urine with gastrointestinal distress and neurological symptoms (seizures) following ingestion of alcohol or/ and barbiturate?
Acute intermittend porphyria:
- severe autosomal dominant form of porphyria with results as a partial deficiency of porphobilinogen deaminsase activity
- attacks can be triggered by stress, alcohol, premenstrual period, and consumption of drug who are CY P 450 iducers, like barbiturate
Cutaneous T-lymphocyte lymphoma CTCL
- mycosis fungoides,
- makes Paultries abcess due to epidermal cluster of atypical lymphocytes
- men, mid thirty
- progress from: patch phase, plaque phase, cutaneous tumor, leonine facies
- Sezary syndrome is mucosis fungoides with systemic illness, erythroderma and presece of atypical T-lymphocytes in blood!
Treatment of seminoma:
- Stage I and IIA orchidectomy and irration of the retroperitoneum
- Stage IIB and III orchidectomy and radiation therapy
Courvoisiers sign :
palpable nontender gallbladder, result of common bile duct obstruction and compression by pancreatic adenocarcinoma at the head of the pancreas!
Hemophilia A and B, Factors involved, PT, aPTT?
- Hemophilia A: factor 8!!
- Hemophilia B factor 9!!
- Hemophilia C factor 11
- prolonged aPTT
- PT, bleeding time, platelet count normal!
- because are they are intrinsic cascade (8,9,10,11,12,5,2)
Infections post bone marrow transplant Day 7 ?
- fungal infections such as Candida and Aspergillus
whats the dillio mann
Infections post bone marrow transplant Day 20-30 (1-3 weeks)?
- susceptible to aerobic bacteria found in the gut or the skin
- Staph aureus (up to 3 weeks)
- gram neg bacteriemia such as Escherischia coli, Pseudomonas, Klebsiella
- Herpes simplex virus risk highest at 2 weeks following transplant (severe mucositis)
Euvoleme hyponatriemia with Lung cancer, wich type of lung cancer?
- a paraneoplastic syndrome in this kind of tumor with syndrome of innapropriate ADH secretion (SIADH)
- diagnosis is set with: hyponatremia, urines osmolarity over 50-100, and urine sodium over 20
Which type of lung cancer can make hypercacliemia?
Squamous cell carcinoma, due to paraneoplastic syndrome and PTHrP
Renal failure and Bence Jones Proteins?