Glomerular hematuria a/f URI. Dx?
1. IgA nephropathy (<5 days), nL serum complement
2. post-strep GN (10-21 days), decr. serum complement
Development of renal abnormalities in DM?
1. glomerular hyperfiltration
2. thickening of GBM
3. mesangial thickening
4. nodular sclerosis
Increased DTRs, muscle cramps, (rarely) convulsions in post-op pt who rec'd multiple transfusions...?
hypo-Ca 2/2 citrate binding
Severe hypo-Mg can mimic hypo-Ca, but how?
decreases PTH secretion & peripheral responsiveness to PTH
In blunt trauma to the bladder, where will the rupture occur?
bladder dome, at developmental hiatus, where urachus originated. (can cause chemical peritonitis)
Elderly pt wih
- bone pain
- renal failure
multiple myeloma until proven otherwise
Young black male with painless hematuria. Cause? etiology?
sickle cell trait.
papillary ischemia. Papillary necrosis can occur, with massive hematuria. (Usually mild, resolves spontaneously.)
Causes of drug-induced interstitial nephritis.
- penicillins, cephalosporins
Acute Tx of symptomatic hyper-Ca
(if not caused by malignancy)
1 - IV fluids (incr. renal excretion of Ca by decr. Ca reabsorption in proximal tubule)
2 - loop (block Ca reabsorption in loop)
3 - identify cause and treat!
In non-gap metabolic acidosis, how to narrow down DDx?
urine anion gap; to differentiate between intestinal and renal HCO3 losses.
Hypercoagulability in nephrotic syndrome is a result of...?
- urinary losses of antithrombin III
- altered levels of proteins C & S
- increased platelet aggregation
- hyperfibrinogenemia 2/2 increased hepatic synthesis
- impaired fibrinolysis
How to treat recurrent hypercalcuric renal stones?
increase fluid intake
Characteristics of simple renal cysts (i.e. no further w/u)
- thin walls
- no solid components
- no contrast enhancement
Diabetic pt with non-gap metabolic acidosis, persistent hyper-K, and renal insufficiency. Diagnosis, doctor?
type IV RTA!
- caused by aldosterone deficiency or renal tubular insensitivity to aldosterone
- worsened by ACE-I's, ARB's
Acyclovir adverse effect.
crystalline nephropathy (prevent with adequate hydration)
- usually transient
- Tx with hydration as well as adjusting dose (slow rate of IV infusion)
Cause of abnormal hemostasis in CRF? Tx?
Tx: DDAVP (increases release of factor VIII:vWF multimers from endothelial storage sites)
--transfused platelets would quickly become inactive
+ "dense deposits" in GBM
membranoproliferative GN, type 2.
Dense deposits stain for C3 (not IgGs!)
Cause of Membranoproliferative glomerulonephritis type 2?
IgG against C3 convertase, leading to persistent activation of the alternative complement pathway ==> kidney damage
Renal colic with negative KUB. Causes?
1. radiolucent stone
2. Ca stone 1-3 cm diameter
3. non-stone obstruction (i.e. bloot clot, tumor)
what pCO2 should be to compensate for metabolic acidosis.
paCO2 = 1.5 ( HCO3-) + 8
Claudication with normal ABIs?
[popliteal] arterial entrapment syndrome
- ABI's are falsely negative at rest; exercise ABI's abnl.
- on exam: nL pulses that decrease with plantar/dorsiflexion
Causes of digitalis toxicity?
Digitalis is renally cleared.
toxicity incited by viral illness vs. excess diuretics
Etiology of pitting edema
- increased intravascular hydrostatic pressure
- decreased plasma oncotic pressure
- increased capillary permeability
Complications of anterior, posterior MI?
anterolateral ==> free wall rupture
posteroseptal ==> papillary muscle dysfunction
High output heart failure occurs when...
increased ventricular function can't meet body's metabolic demands.
Causes of high output heart failure?
- beriberi (thiamine def)
- A/V fistulas
Electrolyte abnormalities in primary hyper-aldo
- metabolic alkalosis
Myocardial contusion. EKG findings? Complications?
(can cause cardiogenic shock)
new LBBB or dysrythmia
- myocardial rupture
- septal rupture
- valvular insufficiency
Evolution of EKG in STEMI
T ==> ST ==> Q ==> T ==> ST ==> T
(peaked T ==> ST elevation ==> Q waves ==> T inversion ==> ST normalizes ==> T normalizes)
Physical exam findings in constrictive pericarditis
- sharp "x" and "y" descents
- pericardial knock (early heart sound a/f S2)
What happens if you give DHP-CCB's in STEMI?
they can worsen cardiac ischemia. cause peripheral vasodilation ==> reflex tachycardia.
What is DC cardioversion?
delivery of shock in synchrony with QRS complex--timed NOT to hit T wave (which could cause v.fib)
When treating "acute" afib, present for > 48 hrs (or an unknown time), what precautions should you take?
anticoagulate for 3 weeks before cardioversion and 4 weeks after. (or get echo to demonstrate no clot)
In HHNKS, why are there no ketones?
there is enough insulin to suppress lipolysis, but not enough to lower plasma glucose.
Why treat elderly pts with methimazole/PTU before radioactive hormone?
need to deplete thyroid hormone stores, otherwise hormone released from dying cells ==> thyrotoxicosis
Tx for diabetic gastroparesis
1. Dopamine antagonists b/f meals (metoclopramide, domperidone)
2. Bethanechol (pro-cholinergic)
Fever + sore throat in a patient taking PTU/methimazole = ? Tx?
agranulocytosis. Stop drug and check WBC.
Hypokalemic periodic paralysis
- episodic paralysis 2/2 abrupt decrease in serum K
- cause: familiar or due to thyrotoxicosis
- attacks precipitated by meals, stress
- Pathophys: K influx into cell due to release of epinephrine & insulin
Increased extracellular pH alters electrolyte levels how?
increases affinity of albumin for Ca, effectively decreasing ionied (active) calcium
when nocturnal hypoglycemia leads to morning hyperglycemia due to release of epi, NE, glucagon
Hyper-Ca can result from prolonged immobilization. Tx?
Bisphosphonates decrease hyper-Ca and prevent osteopenia
Hormones produced by seminomas?
serum tumor markers typically nL. But in those with syncytiotrophoblastic giant cells, beta-hCG may be increased.
APECED stands for?
autoimmune polyglandular endocrinopathy, candidiasis, & ectodermal dysplasia
- a cause of primary hypo-PTH
When does tertiary hyper-PTH happen?
when secondary hyper-PTH leads to autonomous PTH secretion ==> hyper-Ca. (e.g. pt with CRF & 2o hyper-PTH receives kidney transplant, but still has hyper-Ca after)
Electrolyte changes in Bartter and Gitelman?
hypochloremic metabolic alkalosis
nL to low BP
elevated urinary chloride (similar to diuretic abuse)
(in chronic vomiting, urinary Cl is low)
Milk alkali syndrome?
- excessive ingestion of Ca leads to hyper-Ca, metastatic calcification, and renal failure
Vertical gaze paralysis
+ pupillary disturbances
+ eyelid retraction
pinealoma (Parinaud's syndrome)
- blocks hypothalamic inhibition pathway (leading to endocrine Sx)
- affects rostral midbrain at level of superior colliculus and CN III
Sx of pure riboflavin (B2) deficiency
- sore throat
- hyperemic & edematous oropharynx
- cheilitis, stomatitis, glossitis
- normocytic, normochromic anemia
- seborrheic dermatitis
Causes of pellagra?
(niacin, B3 def)
- long term isoniazid use
- carcinoid syndrome
- Hartnup's dx
- impaired absorption of neutral AA's, including TRP
==> can normally be converted to niacin
Sx of dry beriberi
symmetrical peripheral neuropathy with sensory & motor impairment of distal extremities
Smoking cessation > ___ weeks preop decreases risk of postop pulmonary complications.
>8 weeks. Smoking cessation closer to surgery increases risk of postop pulm complications!
Can see mild LFT elevation in PNA 2/2 ___.
Legionella. Also GI, neuro Sx. Think cruise ships & hotels!
PE findings in consolidation
increased fremitus, bronchial breath sounds (i.e. full expiratory phase)
Wegener's is defined clinically by what three criteria?
1. systemic vasculitis
2. upper & lower airway granulomatous inflammation
Wegener's. Upper respiratory Sx / complications?
- purulent rhinorrhea
- saddle nose deformity (destruction of nasal cartilage)
Wegener's. Cutaneous involvement?
- painful subQ nodules
- palpable purpura
- pyoderma gangrenosum
For a solitary, coin-shaped pulmonary nodule surrounded by nL parenchyma, what does calcification signify?
calcification favors benign.
"Popcorn" = hamartoma
"Bull's eye" = granuloma
Why should patients with DVT wear compression stockings?
to decrease risk of post-phlebitic syndrome, possible for up to 2 years.
In trauma, what is usually the primary reason for respiratory distress?
pulmonary contusion (which is often seen in trauma severe enough to cause flail chest)
In pt with irregular bleeding (>8 weeks postpartum), enlarged uterus, and pelvic pain, think...?
gestational trophoblastic disease
Gestational trophoblastic disease can occur after...
- normal gestation (25%)
- molar pregnancy (50%)
- abortion (25%)
Name the two types of malignant gestational trophoblastic disease.
1. Gestational trophoblastic neoplasia (locally invasive)
2. Choriocarcinoma (highly metastatic--prefers the lungs)
- great lakes, Mississippi River & Ohio River basins
- highest infection rate in Wisconsin
Pulmonary Sx look like TB or histo
- "characteristic" ulcerated skin lesions
- lytic Bone lesios
Histoplasma capsulatum epidemiology
- Mississippi / Ohio River basins, Central America.
- bird or bat guano (most people infected by adulthood, <25% develop symptoms)
Symptomatic lung infection with histoplasma
- self limitin, fevers/chills, cough
- CXR: patchy lobar or multinodular lobar infiltrate
on CXR: Enlarged pulmonary arteries with "pruning" (rapid tapering of distal vessels) indicates...?
Pt with hypovolemic shock is intubated, mechanically ventilated, and crumps. What happened?
Positive pressure mechanical ventilation increases intrathoracic pressure, decreasing venous return to heart, decreasing preload. In patient with hypovolemic shock, this can rapidly cause circulatory collapse if volume not replaced b/f ventilation!
Type of reaction in aspirin sensitivity syndrome?
pseudoallergic reaction. i.e. an exaggerated release of vasoactive and inflammatory mediators.
Pathophys behind aspirin sensitivity syndrome?
- B/c aspirin inhibits cyclooxygenase 1,2, arachidonic acid is diverted through 5-lipoxygenase pathway.
- Therefore, leukotrienes accumulate, causing bronchoconstriction, nasal polyps
Possible cellular mechanisms for theophylline toxicity?
- PDE inhibition
- adenosine antagonism
- stimulation of epinephrine
Fat embolism Sx
respiratory distress, Mental status changes, petechiae
- Sx have latent period of 12-72 hrs after initial injury
Nonseminomatous germ cell tumors produce what hormones?
hCG & AFP. Occur in young men.
Can occur in anterior mediastinum as a primary site
exudate if any true:
- pleural protein : serum protein > 0.5
- pleural LDH : serum LDH > 0.6
- pleural LDH > 2/3 serum normal [45-90]