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Bunuan Study Guide_edit

Terms in this set (120)

Secondary causes of atrial fibrillation
"PIRATES"
Pulmonary HTN, PE
Ischemic heart disease
Rheumatic heart disease
Anemia, Atrial myxoma
Thyroid toxicosis
EtOH, Electrolyte imbalances
Stresses, Sepsis, Shock
Rate control for atrial fibrillation
Beta blockers
Non-DHP CCB's (diltiezam, verapamil)
Digoxin with underlying CHF
Steps necessary prior to cardioversion of atrial fibrillation
Less than 48 hours in duration
TEE to check for thrombus
4 weeks anticoagulation therapy
Best rhythm control for atrial fibrillation
Amiodarone
Amiodarone toxicity
Pulmonary fibrosis
Thyroid toxicity
Liver toxicity
Bradycardia
Argyria (Blue man syndrome)
CHADS2/CHA2DS2-VASc score
CHF
HTN
Age > 75 (or 75=2, 65=1)
DM
Stroke/TIA prior = 2

Vascular disease
Female sex
**CHADS2 score > 2 --> anti-coagulate
Secondary causes of HTN
Renal artery stenosis
OCP's
Pheochromocytoma
Hyperaldosteronism
Cushing's syndrome
Hyperthyroid
Cocaine/Meth
Obstructive sleep apnea
Hyperparathyroidism
Fibromuscular dysplasia
Coarctation of the aorta
Causes of macrocytic anemia
B12 deficiency
Folate deficiency
Alcohol
Hypothyroidism
Chemotherapy
Reticulocytosis
Causes of microcytic anemia
Iron deficiency
alpha-thalassemia
beta-thalassemia
Anemia of chronic disease (10%)
Lead poisoning
Sideroblastic anemia
Hypercoagulable states
20210A Prothrombin gene mutation
Protein C deficiency
Protein S deficiency
Factor V Leiden
Antithrombin III deficiency
Pregnancy
OCP/Estrogen therapy
SLE
Antiphospholipid antibody syndrome
Smoking
Malignancy
Sickle cell disease, meyloproliferative disorders
Heparin induced thrombocytopenia
Hyperhomocystenemia
Pulseless Electrical Activity causes
5 H's and 5 T's
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/hyperkalemia
Hypothermia
Tension Pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis (pulmonary)
Thrombosis (coronary)
**Treat with CPR and epinephrine
Virchow's Triad
Stasis
Hypercoagulability
Endothelial damage
**Increased risk for VTE
Differential diagnosis for chest pain
Angina/MI
Cardiac tamponade
Aortic dissection
Pericarditis
Pulmonary embolism
Chostochondritis
Rib fracture
Cocaine
GERD/gastritis
Cholecystitis
Pancreatitis
Malory-Weiss
Pneumonia
Herpes Zoster/Post-herpetic neuralgia
Panic attack
Risk factors for atherosclerosis
Diabetes
Hyperlipidemia
HTN
Gender/Age
Smoking
Rheumatoid arthritis
HIV
S/S of cardiac chest pain
Substernal chest pain radiating to the arm/jaw
Levine' sign (fist over sternum)
Diaphoresis
SOB
N/V
**EKG is first step
Indications for CABG
3+ vessel disease
Left main coronary artery disease
Populations that present with atypical cardiac pain
Female
Diabetes
Elderly
S/S of endocarditis
Fever
New murmur
Janeway lesions (palms/soles)
Roth spots (retinal hemorrhages)
Osler nodes (hands/feet)
Splinter hemorrhages
**Need transesophageal echo to Dx
Organisms associated with endocarditis
Viridans strep
Staph aureus
Staph epidermitis
HACEK
-Haemophilus ducreyi
-Actinbacter
-Cardiobacter
-Eikenella
-Kingella
Chlamydophila psittaci
Coxiella brunetii
Baronella
Causes of thrombocytopenia
Decreased production: aplastic anemia, Fanconi anemia, congenital rubella/parvovirus, leukemia, myelofibrosis, myelodysplastic syndrome, ethanol, gold/chemotherapy, chloramphenicol, benzene, radiation

Increased destruction: ITP, SLE, Heparin induced thrombocytopenia, HIV, DIC, TTP/HUS, HELLP, linezolid

Sequestration: Cirrosis --> Portal HTN --> splenomegaly
S/S of TTP/HUS
Fever
Anemia
Thrombocytopenia
Renal failure
Neurologic abnormality
*E. coli 0157H7
Diagnosis of TTP/HUS
ADAMSTS13
Peripheral smear --> schistocytes
Treatment of TTP/HUS
Corticosteroids
Plasmapharesis
Splenectomy
Causes of DIC
Gram negative sepsis
Amniotic fluid emboli
Retained POC
Abruptio placentae
Burns, surgery, Fx
Malignancy
Shock
Rattlesnake venom
Labs in DIC
Increased: PT, PTT, bleeding time
High D-Dimer, increased fibrin split products
Decreased fibrinogen, platelets
Treatment of DIC
FFP, platelets, cryoprecipetate
Low dose heparin (controversial)
O2, IV fluids
Maintain BP and renal perfusion
Elevated troponins with no MI
CKD
PE
CHF
Myocarditis
Leak from wall stress (a-fib)
Stenting options for STEMI
Drug-alluding stent: better outcomes life-long, need 12 mo anti-platelet therapy

Bare metal stent: 3 mo anti-platelet therapy, better for non compliance/co-morbid conditions with potential up coming surgery
Initial management for MI
Morphine
Oxygen
Nitroglycerine
Aspirin (at least 162 mg)
**Talk to cardiologist before starting more aggressive anti-platelet therapy
Causes of CHF
MI/Ischemic heart disease
HTN
Valvular disease
Uncontrolled a-fib
Rheumatic fever
Pulmonary HTN
Anemia
Hyperthyroidism
Pregnancy
Beriberi (thiamine deficiency)
Paget disease of the bone
SLE
Sarcoidosis
Amyloidosis
Wilson disease
Hemochromatosis
Coxsacki/myocarditis
HIV
Chaga's disease
Doxorubicin
EtOH
Meth, cocaine
Hypertrophic cardiomyopathy
S/S of CHF
Paroxysmal nocturnal dyspnea
Orthopnea
Pulmonary edema
Crackles/rales
Displaced PMI
LE edema
Hepatomegaly
JVD
Cardiac cachexia
Medication therapy for CHF
ACE inhibitors/ARB + Beta blockers +/- spironolactone
Diuretics for volume control (carful with aortic stenosis)
Digoxin if a-fib
Vasodilators: dobutamine, milrinone
Medications for symptomatic African American patients with CHF
Isosorbide dinitrate
Hydralazine
Device therapy for CHF
Biventricular pacing to reduce risk of dyssynchronous ventricular contraction
ICD's decrease risk of sudden death
Dx of CHF
CXR: Cardiomegaly, cephalization (bat-wing appearance), pleural effusion, kerley B lines

EKG: :LVH, prior MI, widened QRS, lead I p-waves for atrial size

Echo: LV function, valves, pulmonary pressure, ejection fraction (50% is normal)

Labs: BNP, troponins, CRP
Risk factors for HCAP
Hospitalization > 2d in past 90 days
Nursing home/extended care facility residence
Long term infusions/Abx
Hemodialysis in previous 90 days
Home wound care
Family member with MDR
Immunosuppressive therapy
Non-ambulatory/tube feedings
Gastric acid suppressive agents
Risk factors for MRSA pneumonia
Cavitary infiltrate w/ necrosis
Rapid pleural effusion
Gross hemoptysis
Concurrent influenza
Neutropenia
Erythematous rash
Skin pustules
Young, previously healthy
Severe PNA in summer
Pneumonia organisms
Strep pneumo
Haemophilus influenzae
M. catarrhalis
Pseudomonas
Staph aureus
Pneumocystis pneumonia
Hypoxia in HIV patients
Bilateral ground glass appearance on CXR
Elevated LDH
Occurs at CD4 ≤ 200
Treat w/ TMP-SMX x3 weeks
TB treatment
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
**4 drugs x2 mo --> INH + Rif x4 mo.
**Prophylaxis = INH x9 mo.
S/S of COPD
Cough w/ sputum
Exertional dyspnea
Fatigue
Prolonged expiration
Wheezing/crackles
Cyanosis
Tachypnea
Accessory muscle use/Tripod position
Bitemporal wasting
Signs of cor pulmonale
Hoover's sign (paradoxical rib motion)
Clubbing = look for other cause than COPD
COPD Treatment
Beta-2 agonists (albuterol, salmeterol)
Inhaled corticosteroids (iprtropium, tiotropium)
Inhaled glucocorticoids
Theophylline (rarely used)
Oxygen therapy (need Sa02 ≤ 88% for home therapy)
Management of COPD exacerbation
B2 agonist w/ anticholinergic (nebulizer tx)
IV methylprednisolone/oral prednisone
Antibiotics (azithromycin, fluoroquinolone)
BiPAP/CPAP to keep Sa02 > 90%
S/S of pulmonary ebolism
SOB
Tachypnea
Pleuritic chest pain
Syncope
Mildly elevated troponins (RV microinfarct)
Hemoptsis
Atrial fibrillation
Elevated D-dimer
EKG findings in pulmonary embolism
Most common: Sinus tachycardia

Most unique: S1Q3T3
S-wave lead I
Q-wave lead III
Inverted T-wave lead III
CXR findings in pulmonary embolism
Westermark sign = focal oligemia
Hamptom's hump = peripheral wedge density above diaphragm
Palla's sign = enlarged right descending pulmonary artery
Normal/near normal common
Risk factors for upper extremity DVT
Central line (IJ)
Peripheral line (PICC)
Paget-Schrotter's syndrome
Diagnostic test for pulmonary embolsim
Spiral CT or CT angiography of the chest
Pulmonary embolism work-up
ABG (not diagnostic, respiratory alkalosis common)
CXR
Venous doppler to check for DVT
V/Q scan
Spiral CT/CTA
D-dimer
Treatment for PE/DVT
Supplemental O2
Acute anticoagulation: UFH/LMWH
Oral warfarin/direct thrombin inhibitory for for long term (INR: 2.0-3.0)
Thrombolytic therapy (tPA) if indicated
IVC filter if cannot anti-coagulate
Well's criteria for PE
DVT = 3.0
Alternate Dx less likely = 3.0
HR > 100 = 1.5
Immobilization (>3d in 4wks) = 1.5
Previous DVT/PE = 1.5
Hemoptysis = 1.0
Malignancy = 1.0
**> 4.0 = PE likely
Venous Doppler for DVT
Loss of "wink sign"
Homan sign = pain w/ dorsiflexion
Thrombus
Causes of acute pancreatitis
I GET SMASHED
Idiopathic
Gallstones
EtOH
Trauma
Steroids
Mumps (coxsacki)
Autoimmune (AIP, sjogren's syndrome)
Scorpion venom
Hypertriglyceridemia
ERCP
Drugs
*Pancreatic divisum
Drugs that can cause acute pancreatits
Metformin
Glipizides
HIV drugs/Protease inhibitors
Fibrates
Statins
Dapsone
Furosemide
Isoniazid
Azathioprine
6-MP
Sulfonamides
Tetracyclines
Valproic acid
Estrogens
S/S of acute pancreatitis
Epigastric pain that radiates to the back
Pain worse when supine and after meals
N/V, anorexia
Grey Turner sign = Flank ecchymoses
Cullen's sign = periumbilical ecchymoses
Fox's sign = inguinal ecchymoses
Fever
Tachycardia
Leukocytosis
Hypoactive bowel sounds
Diagnosis of acute pancreatitis
Amylase/lipase (lipase more specific)
LFT's (AST/ALT, cholestasis)
LDH
Leukocytosis
KUB series (r/o other causes)
Abdominal USN (gallstones)
CT abdomen (most accurate)
ERCP (biliary obstruction)
Complications of acute pancreatitis
Pancreatic necrosis +/- infection of necrosis
Pseudocyst
Abscess
Hermorrhagic pancreatitis
ARDS
Pancreatic ascites
Pleural effusion
Ascending cholangitis
Purtscher Retinopathy = blindness
Ranson's criteria
GA LAW
Glucose > 200
Age > 55
LHD > 350
AST > 250
WBC > 16,000

C HOBBS
Ca2+ < 8
Hct drop > 10%
O2 sat < 60
BUN increase > 8
Base deficit > 4
Fluid sequestration > 6L
**Predicts mortality
Causes of chronic pancreatitis
EtOH
Smoking
Hereditary pancreatitis
Tropical pancreatitis
Idiopathic
Autoimmune pancreatits
S/S chronic pancreatitis
Abdominal pain
N/V
Wt loss, anorexia
Malabsorption/malnutrition
Diarrhea/steatorrhea
Diabetes (very sensitive to insulin due to alpha cell/glucagon destruction)
Diagnosis of chronic pancreatitis
CT/X-ray for calcifications
ERCP = gold standard
Treatment of chronic pancreatitis
Analgesics
Bowel rest
Pancreatic enzyme + H2 blocker
Insulin, frequent/small meals, etc.
Glucocorticoid toxicity
Immunosuppression
Hyperglycemia
Hypertriglyceridemia
Cushing's syndrome (moon facies, buffalo hump, abdominal striae)
Osteoporosis
AVN of the femoral head
Anxiety
Leukocyotisis (demarginization of neutrophils)
Increased BUN (muscle breakdown)
Adrenal insufficiency
Cataracts
Etiologies for elevated BUN
Total parenteral nutrition
Dehydration
GI bleed
Steroid abuse
Causes of pericardial effusion
Uremia
Lupus
TB
Drugs that increase creatinine
Bactrim (TMP-SMX)
Cimetidine
Differential diagnosis for upper GI bleed
Peptic ulcer disease-NSAIDs, H. pylori
Esophageal varices
Mallory-Weiss
Boerhaave syndrome (transmural rupture)
Dieulafoy's lesion (vascular malformation)/AVM
Adenocarcinoma/Barrett esophagus
Fistula (ie aorto-enteric)
Esophagitis
Causes of esophagitis
Bisphosphonates
Iron tablets
Candida
CMV
Herpes
Differential diagnosis for lower GI bleed
Diverticulitis
Angiodysplasia/AVM
IBD-Ulcerative colitis, Chron's disease
Colonic polyps
Colorectal cancer
Ischemic colitis
Salmonella, shigella, EHEC, campylobacter
Causes of cirrhosis
EtOH, drugs
Chronic hepatitis B, C
Autoimmune hepatitis
NAFLD
Cystic fibrosis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Alpha-1 AT deficiency
Wilson disease
Hemochromatosis
Cardiac cirrhosis
Hepatocellular carcinoma
Metastases
Schistosomiasis
S/S of cirrhosis
Jaundice
Ascites
Spider angioma
Pruritis
Palmar erythema
Gynecomastia
Testicular atrophy
Deputren's contracture
Parotid gland enlargement
Mousy odor
Edema
Hypersplenism/thrombocytopenia
Esophageal varices
Encephalopathy, asterixis
Causes of fulminant hepatits
Shock liver
Acute hepatitis B
Acetaminophen overdose (give N-acetylecystine)
Treatment of esophageal varices
Somatostatin/octreotide for splanchnic vasodilation
PPi drip
Monitor H/H, IV saline
Intervention-band ligation
Beta-blockers for secondary prevention
Hepatitis C
Strain 1 most common
Strain 2, 3 most treatable
EtOH can increase viral replication
R/o HIV before treatment
Treat with Pegylated interferon and ribavirin
Depression = severe side effect of PEGIFN
2x yearly USN for HCC
Pain in hepatomegaly
Stretching of Glisson's capsule
Causes of ascites
Cirrhosis
Peritonitis
CHF
TB
Malignancy/ovarian
Pancreatitis
Nephrotic syndrome
Complications of cirrhosis
Portal HTN (varices, splenomegaly, ascites/SPB)
Hepatorenal syndrome
Hepatic encephalopathy
Coagulopathy
Bone disease/osteoporosis
Hematologic abnormalities
Treatment of ascites
Furosemide + Spironolactone
IV albumin + large volume paracentesis
Na restriction, TIPS, liver TPX
SAAG
Serum-Ascites Albumin Gradient
>1.1 = cirrhosis ascites
<1.1 = infection, malignancy
Spontaneous bacterial peritonitis
E. coli from gut to ascites via lymphatics
Dx: >250 PMNs in paracentesis
Tx w/ cefotaxime
Treatment of alcoholic cirrhosis to extend life
Glucocorticoids
Pentoxifylline
S/S of Parkinson disease
Pill rolling tremor/resting tremor
Cogwheel rigidity
Shuffling gait
Mask-like facies
Bradykinesia
Micrographia
Depression
Dementia
Causes of dementia
Alzheimer disease
Vascular dementia (multi-infarct, biswanger)
Lewy body dementia
Advanced Parkinson disease
Frontotemporal dementia (Pick disease)
Huntington disease
Prion disease-Creutzfeldt-Jakob
HIV
Dementia pugilistica
Progressive multifocal encephalopathy
Korsakoff syndrome
Pallegra (Dementia, Dermatitis, Diarrhea, Death)
Neurosyphilis
B12 deficiency
Hypothyroidism
Depression/pseudodementia
Normal pressure hydrocephalus
Types of strokes
Hemorrhagic
Ischemic
Embolic
**Permissive HTN to 220/120
Drugs that can cause acute renal failure
NSAIDs

ACE inhibitors

Anesthetics
-Enflurane
-Methoxyflurane
Anti-microbials
-Acyclovir
-Aminoglycosides
-Amphotericin B
-Bacitracin
-Cephalosporins
-Foscarnet
-Pentamidine
-Polymyxins
-Sulfonamides
-Tetracyclines
-Vancomycin

Anti-ulcer
-Cimetidine
-Milk alkali

Chemotherapy
-5-azacitidine
-Carboplatin
-Cisplatin
-Cyclosporin A
-Tacrolimus
-Penicillamine
-Ifosfamide
-Methotrexate
-Mitomycin
-Nitrosuria
-Plicamycin
-Recombinant IL-2

Protease Inhibitor
-Indinavir
-Ritonavir

Recreational drugs
-Amphetamines
-Heroin
FENa
Fraction excretion of sodium
(U)Na x (S)Cr/(U)Cr x (S)Na
<1% = prerenal failure
>2-3% = Intrinsic renal failure
Causes of pre-renal failure
Dehydration-vomiting, diarrhea, poor oral intake
CHF
Hypotension-sepsis, hemorrhage
Hepatorenal syndrome
Renal artery stenosis
Causes of intrinsic renal failure
Acute tubular necrosis-long standing ischemia, toxins
Lupus nephritis
Post-strep glomerulonephritis
Wegener's granulomatosis (cANCA)
Goodpasture syndrome
HIV(HIVAN)
IgA nephropathy
TTP/HUS
Renal artery occlusion
Tumor lysis syndrome
Allergic interstitial nephritis
Time course for renal vascular complications
2d = IgA nephropathy
1 week = post-strep GN
1 month = HSP
Causes of post-renal failure
Enlarged prostate
Nephrolithiasis
Pelvic neoplasm
Retroperitoneal fibrosis (radiation)
Bilateral ureteral obstruction
Obstruction of solitary kidney
**USN to look for hydronephrosis
Causes of rhabdomyolysis
Myositis
Statins
Crush injury
Colchicine
Meth use
Excessive exercise
Management of rhabdomyolysis
Myoglobinuria (detected in UA as hemoglobin)
IV fluids
Bicarb drip for anuria/oliguria
Causes of post-op fever
Wind: Pneumonia, atalectasis
Wound: Infection
Water: UTI
Walking: DVT
Wonder drugs
Indications for acute dialysis
"AEIOU"
Acidosis resistance to other treatment
Electrolyte imbalance (K+, Ca2+) resistant to other treatment
Intoxication (lithium, ethylene glycol, salicylates)
Overload, volume
Uremia
Causes of chronic kidney disease
Diabetes
HTN
HIV
SLE
Solitary kidney
Hepatits B, C
Adult polycystic kidney disease
FSGS
Sarcoidosis
Multiple myeloma
Causes of anemia in CKD
Decreased EPO
Iron deficiency/impaired utilization
Hyperparathyroidism --> BM fibrosis
Decreased RBC survival in uremic state
B12/folate deficiency
Cardiac complications of CKD
HTN
CHF
Uremic pericarditis
Vascular calcification
Neurologic complications of CKD
Encephalopathy, asterixis
Fatigue
Hyperreflexia
Parasthesias
Peripheral neuropathy
Restless leg syndrome
Uremic seizures
Bony complications of CKD
Phosphate retention --> Increased PTH and Increased bone turnover --> osteitis fibrosis cystica (secondary hyperparathyroidism)

Decreased vitamin D activation --> decreased Ca2+/increased PTH
Dermatologic complications of CKD
Pruritis
Calcifilaxis
Uremic frost
Nephrogenic fibrosing dermopathy
Causes of AG metabolic acidosis
"MUD PILES"
Methanol
Uremia
DKA
Paraldehyde
Isoniazid/Iron tablets
Lactic acidosis
Ethylene glycol
Salicylates, Sepsis
Toluene
Causes of Non-AG metabolic acidosis
"DDDD H"
Diarrhea
Drains (peritoneal)
Diamox (acetazolamide)
Distal RTA
Hyperchloridemia
Causes of hypokalemia
Vomiting
Diarrhea
Diuretics (furosemide, HCTZ, mannitol)
IV insulin
Recovery phase of ATN
Hypomagnesemia
Hyperaldosteronism
Cushing's syndrome
Barter's syndrome
Liddle's syndrome
Black licorice
Hypokalemic periodic paralysis
Malnutrition
S/S of hypercalcemia
"Stones, bones, groans, psychiatric overtones"
Nephrolithiasis
Bone pain, osteitis fibrosis cystica
N/V/C/D
Depression, fatigue, anorexia, sleep disturbance, anxiety, lethargy
EKG findings of hyperkalemia
Peaked T waves
Widened QRS
Widened PR interval
Loss of P waves
Treatment of hyperkalemia
Insulin + glucose
Sodium bicarbonate
Na polysterene
Calcium gluconate
Furosemide
Albuterol (4x nebulizer tx, need 10g)
Kayexalate (acidify the gut to pull K+ in)
Hemodialysis
Causes of hypercalcemia
Hyperparathyroidism
Vitamin D toxicity
Milk alkali syndrome
Granulomatous diseases
Malignancy (PTHrp)
Thiazides
Lithium
Sarcoidosis
Treatment of hypercalcemia
Bisphosphonates
Calcitonin
IV fluids + furosemide
SIRS criteria
Tachycardia (HR>90)
Tachypnea (RR > 20, PCO2 < 35)
WBC >16,000, <4,000, or 10% bands
Temp >100.4 or less than 96.8
**Need 2/4
Sepsis
SIRS + infection
Severe sepsis
Sepsis + Hypotension, end organ failure, lactate > 4 mmol
Septic shock
Sepsis that requires use of vasopressors (NE) after adequate fluid resuscitation
S/S of hyponatremia
Headache
N/V
Seizure
Coma
Increased intracranial pressure
Lethargy
Visual changes
Hypovolemic hyponatremia
Thiazide overuse
Primary adrenal insufficiency
Cerebral salt wasting
GI losses: Vomiting, diarrhea
Euvolemic hyponatremia
SIADH
Primary polydypsia
Hypothyroidism
Non-osmotic ADH release (stress, surgery)
Mineralocorticoid deficiency
Hyerpvolemic hyponatremia
CHF
Renal failure
Cirrhosis
Causes of SIADH
CNS: Tumor, ischemic/hemorrhagic stroke, trauma, psychosis, infection

Tumor: Small cell, CNS, duodenal, pancreatic, olfactory neuroblastoma

Pulmonary: TB, COPD, pneumothorax, ILD, ventilator dependent respiratory failure

Drugs: SSRI, haldol, tegretol, bromocriptine, oxytocin, NSAIDs, ecstasy, reglan

Other: N/V, pain, emotional stress, surgery, HIV
Outpatient treatment of CAP
Levoquin
Azythromycin to cover atypicals
Augmentin
Doxycycline for COPD
Inpatient treatment of CAP
Levoquin + 3rd gen cephalosporin + azithromycin/doxycycline to cover atypicals
Treatment of HCAP
Almost always inpatient
Vancomycin to cover MRSA
Pseudomonas: cefepime, zosyn, tobramycin, imipenem/cilastin
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