Internal Medicine - Emma Holliday Ramahi

2mm ST elevation
- STE immediately
- T wave inversion 6hrs-yrs
- Q waves last forever
new LBBB (wide, flat QRS)
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Terms in this set (409)
2mm ST elevation
- STE immediately
- T wave inversion 6hrs-yrs
- Q waves last forever
new LBBB (wide, flat QRS)
STEMI on ECG?
Anterior: LAD - V1-4
Lateral: Circumflex - I, aVL, V4-6
Inferior: RCA - II, III, aVF
RV: RCA - V4 on R side ECG!
Localized infarcts on ECG?
[Anterior, Lateral, Inferior, RV]
Cath lab
...
Thrombolytics w/in 6hrs
Contra: bleeding, hx hemorrhagic stroke, recent closed head trauma
Emergency reperfusion options? Contraindications?
Sx: HoTN, tachycardia, clear lungs, JVD, and NO pulsus paradoxus.

Txt: vigorous fluid resuscitation, increase preload. DON'T give nitro, will worsen sx
RV infarct Sx? Txt?
ECG
Cardiac enzymes
CP workup?
NSTEMI
Check enzymes q8h x 3 to look for trend
Normal ECG, elevated cardiac enzymes. Dx? Workup?
Myoglobin
Rises 1st, peak 2h, nml by 24h (detect NEW infarct)
CKMB
Rise 4-8, peak 24h , nml by 72h
Troponin I
Rise 3-5h, peak 24-48h, nml by 7-10d
Cardiac enzymes? (3)
Morphine
O2
Nitrates
ASA/clopidogrel
Beta-blocker

Coronary angiography w/in 48h
NSTEMI acute txt? Immediate workup?
PCI w/ stenting
CABG if:
- L main dx
- 3 vessel dx
- 2 vessel dx in DM
- >70% occlusion
- pain despite txt
- post-MI angina

DC on:
Beta-blocker (Metoprolol, Labetalol)
ACEI if CHF or LV dysfxn
Statin
Heparin (while in hospital)
+Nitrates
NSTEMI interventions and discharge Rx?
Exercise ECG
- dc Beta-blockers and CCB before
If + -> Coronary angiography
Unstable angina workup?
Contra: - old LBBB - bilat STE - on Digoxin Exercise ECHO Chemical stress test w/ Dobutamine or Adenosine MUGAContraindications to exercise stress test and alternatives?Multi Gated Acquisition Scan nuclear medicine test shows perfusion areas of heart DC caffeine or Theophyline beforeMUGAArrhythmias (most Vfib)Post-MI complications: Most common cause of death?Papillary muscle rupturePost-MI complications: New systolic murmur 5-7d s/p?Ventricular free wall rupturePost-MI complications: Acute severe hypotension?Ventricular septal rupturePost-MI complications: "step up" in [O2] from RA->RV?Ventricular wall aneurysmPost-MI complications: Persistent STE ~1mo later + systolic MR murmur?AV-dissociation Valve not opening properly -> blood bounds back to neck Either V-fib or 3rd degree heart blockPost-MI complications: "Cannon A-waves"?Dressler's syndrome (probably) autoimmune pericarditis Txt: NSAIDs, ASAPost-MI complications: 5-10wks later pleuritic CP, low grade temp? Dx? Txt?Pericarditis diffuse STE on ECG Txt: NSAIDsYoung, healthy pt w/ CP: worse w/ inspiration, better w/ leaning forward, friction rub. Dx? Txt?costochondriasisYoung, healthy pt w/ CP: worse w/ palpationmyocarditisYoung, healthy pt w/ CP: vague w/ hx of viral infxn and murmurPrinzmetal's angina Dx: Ergonovine stimulation test to ID blood vessel spasms Txt: CCB or NitratesYoung, healthy pt w/ CP: occurs at rest, worse at night, few CAD risk factors, hx migraine headaches (~female), w/ transient STE during episodes. Dx test? Txt?Wenkebach/ Mobitz Type I 2nd deg heart blockProgressive, prolongation of the PR interval followed by a dropped beat3rd deg heart blockregular P-P interval and regular R-R interval, Cannon-a waves on physical exam.MAT (multifocal atrial tachycardiavarying PR interval with 3 or more morphologically distinct P waves in the same lead. Old person w/ chronic lung dx in pending respiratory failureVentricular tachycardia Unstable pt: cardiovert Stable pt: Lidocaine, AmiodaroneThree or more consecutive beats w/ QRS <120ms @ a rate of >120bpm Txt?Wolf-Parkinson-White Delta wave representing early ventricular activation via the bundle of Kent Txt: Procainamide Contra: Beta blokers, Digoxin, CCB (Verapamil, Diltiazem), anything that slows AV node conduction will worsen arrhythmiaShort PR interval followed by QRS >120ms with a slurred initial deflection. Txt? Contraindications?Atrial flutter "sawtooth waves" Unstable pt: cardiovert Stable pt: Beta blockers, DigoxinRegular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm. Txt?Torsades de pointe Seen in a pt w/ low Mg and low K. Lithium or TCA ODprolonged QT interval leading to undulating rotation of the QRS complex around the EKG baselineSupraventricular tachycardia Txt: carotid sinus massage, ice to the face, AdenosineRegular rhythm w/ a rate btwn 150-220bpm. Sudden onset of palpitations/ dizziness. Txt?Hyperkalemiapeaked T-waves, wide QRS, short QT and long PR. Renal failure patient/ crush injury/ burn victim.Cardiac tamponade "electrical alternans"Alternate beat variation in direction, amplitude and duration of the QRS in a pt w/ pulsus paradoxus, HoTN, distant heart sounds, JVDAtrial fibrillation Dilation of RA predisposes Txt: rate control w/ Beta blockers or DigoxinUndulating baseline, no p-waves, irregular R-R interval in a hyperthyroid pt (too much Synthroid), old pt w/ SOB/ dizziness/ palpitations w/ CHF or valve dx. Txt?Aortic Stenosis Cause: degeneration Txt: replace valveSEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardusHOCM younger ptSEM *louder w/ valsalva,* softer w/ squatting or handgrip.Mitral Valve ProlapseLate systolic murmur w/ *click* louder w/ valsalva and handgrip, softer w/ squattingMitral Regurgitation*Holosystolic* murmur radiates to axilla w/ LAEVSDHolosystolic murmur w/ late diastolic rumble in kiddosPDAContinuous machine like murmurASDWide fixed and split S2Mitral StenosisRumbling diastolic murmur with an opening snap, LA enlargement and A-fibAortic RegurgitationBlowing diastolic murmur with widened pulse pressure.nitrates, lasix and morphineTxt for acute pulmonary edema?myocarditis (Coxsackie B)young person w/ CHF?primary pulomnary HTN R heart cath --> PCWP normal (elevated in CHF)young pt w/ no cardiomegaly on CXREF<55% ischemic, dilated Reversible: EtOH w/ abstinenceSystolic CHFnormal EF Reversible cause: Hemachromatosis w/ phlebotomyDiastolic CHF*ACE-I* improve survival - prevent remodeling by aldo. *B-blocker* (metoprolol and carveldilol) improve survival- prevent remodeling by epi/norepi *Spironolactone* - improves survival in NYHA class III and IV *Furosemide* - improves sxs (SOB, crackles, edema) *Digoxin* - decreases sxs and hospitalizations. NOT survivalCHF TxtPneumoniaOpacification, consolidation, air bronchogramsCOPDhyperlucent lung fields with flattened diaphragmsCHFheart > 50% AP diameter, cephalization, Kerly B lines & interstitial edemaPulmonary abscess (anaerobes, Staph)Cavity containing an air- fluid levelTuberculosisUpper lobe cavitation, consolidation +/- hilar adenopathyMediastinal mass (LAD, CA) LA enlargement from mitral stenosisThickened peritracheal stripe and splayed carina bifurcationSystemic causes: CHF, nephrotic sx, cirrhosisTransudative Pleural EffusionLocal causes: parapneumonic, CAExudative Pleural Effusion+ gram or Cx pH < 7.2 glucose < 60 Txt: drain w/ test tubeComplicated Pleural EffusionRA TB malignant or pulmonary fibrosisTransudative Pleural Effusion buzzwords: low pleural glucose? high WBC? bloody?Transudative if: LDH < 200 LDH eff/serum < 0.6 Protein eff/serum < 0.5 (if any one violated --> exudative)Light's Criteria?Pleural Effusion Txt: thoracentesis>1cm fluid on lateral decubitus CXR. Txt?after surgery long car ride hyper coagulable state (cancer, nephrotic)Risks for PE?Sxs: pleuritic CP, hemoptysis, SOB, Decr pO2, tachycardia. Random signs: R heart strain on EKG, sinus tachy, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2. Westermark Sign on CXR - focus of oligemia (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)Signs of PEGive Heparin 1st! V/Q scan Spiral CT pulmonary angiography (gold standard)Suspect PE, workup?Heparin/Warfarin overlap Thrombolytics if severe (NOT if s/p surgery or hemorrhagic stroke) Surgical thrombectomy if life threatening IVC filter if contraindications to chronic coagulationTxt for PE?Acute Respiratory Distress Syndrome impaired gas exchange, inflammatory mediator release, hypoxemiabilateral fluffy infiltratesSepsis gastric aspiration trauma low perfusion pancreatitisCauses of ARDS?1) PaO2/FiO2 < 200 (<300 means acute lung injury) 2) Bilateral alveolar infiltrates on CXR 3) PCWP is <18 (r/o cardio cause of pulmonary edema)Dx criteria for ARDS?mechanical ventilation w/ PEEPTxt for ARDS?low FVC, low FEV1 -> *low FEV1/FVC* high TLC high RV DLCO reduced in emphysema 2/2 alveolar destruction-> more space Ex: COPD, emphysema, asthma (FEV1 improves >12% w/ bronchodilator),Obstructive lung dx PFTs?low FVC, low FEV1 -> *normal FEV1/FVC* low TLC low RV DLCO reduced in ILD 2/2 fibrous thickening distance Ex: interstitial lung dx (sarcoid, silicosis, asbestosis), structural (obesity, MG/ALS, phrenic nerve paralysis, scoliosis)Restrictive lung dx PFTs?Productive cough >3mo for >2 consecutive yrsCOPD dx criteria?1st line = ipratropium, tiotropium 2nd Beta agonists 3rd Theophylline Goal SpO2: 94-95% bc pts are chronic CO2 retainers so hypoxia is the only drive for respirationCOPD txt? Goal SpO2?PaO2 <55 (If cor pulmonale, <59) SpO2<88%Indications to start O2 (in COPD)?Change in sputum, increasing SOBCOPD exacerbation criteria?O2 to 90% albuterol/ipratropium nebs PO or IV corticosteroids Abx: FQ or macrolideCOPD exacerbation txt?FEV1Best prognostic factor for COPD?1) Quitting smoking (can decr rate of FEV1 decline 2) Continuous O2 therapy >18hrs/dayInterventions shown to improve COPD mortality? (2)Pneumococcus w/ a 5yr booster annual influenza vaccineVaccinations for COPD pt?Hypertrophic Osteoarthropathy Next best step... get a CXR Most likely cause is underlying lung malignancyNew clubbing in a COPD pt?Mild intermittent asthma Step 1: SABA (Albuterol)Asthma: sx 2x/wk, normal PFts. Txt?Mild persistent asthma Step 2: SABA + ICSAsthma: sx 4x/wk, PM cough 2x/mo, normal PFTs. Txt?Moderate persistent asthma Step 3: low dose ICS + LABA (Salmeterol)Asthma: daily sx, PM cough 2x/wk, FEV1 60-80%. Txt?Severe persistent asthma Step 4-6: med-high dose ICS + LABA (+ PO steroids)Asthma: daily sx, PM cough 4x/wk, FEV1 <60%. Txt?inhaled albuterol + PO/IV steroids monitor Peak flow rates and blood gas (low PCO2) Normalizing PCO2 --> impending respiratory failure --> INTUBATEAsthma exacerbation Mgmt? Sign of impending respiratory failure?*Silicosis* Get yearly TB test! More predisposed. Give INH for 9mo if >10mm1cm nodues in *upper lobes* w/ *eggshell calcifications*. Mgmt?*Asbestosis* Most common cancer is broncogenic carcinoma, but incr risk for mesotheliomaReticulonodular process in *lower lobes* w/ *pleural plaques*. Associations?*Hypersensitivity Pneumonitis* = "farmer's lung"Patchy *lower lobe* infiltrates, thermophilic actinomyces.*Sarcoidosis* Also hypercalcemia 2/2 increased macrophages making vitamin D Dx: biopsy - non-caseating granuloma Txt: steroidsHilar LAD, ↑ACE *erythema nodosum*. Dx? Txt?Ophthalmology -> uveitis conjunctivitis in 25%Important referral for pt w/ sarcoidosis?Pt <4oyo size <3cm well circumscribed popcorn calcification = hamartoma (most common) concentric calcification = old granuloma Mgmt: CHR or CT q2mo to monitor for growthCharacteristics of benign pulmonary nodules? Mgmt?smoker older pt size >3cm eccentric, spiculated calcification Mgmt: open lung bx, remove noduleCharacteristics of malignant pulmonary nodules?lung CAA patient presents with weight loss, cough, dyspnea, hemoptysis, repeated PNA or lung collapse*Adenocarcinoma* Occurs in scars of old PNAMost common lung CA in *non*smokers?AdenoCA (peripheral) --> liver, bone, brain, adrenalsLung CA mets?*Squamous cell carcinoma* paraneoplastic syndrome 2/2 PTHrP secretion -> low PO4, high CaPt w/ nephrolithiasis, constipation, malaise, low PTH, *central* lung mass?exudative high hyaluronidaseCharacteristics of AdenoCA pleural effusion?Superior Sulcus Syndrome from *small cell lung carcinoma* (central CA)Pulmonary patient with shoulder pain, ptosis, constricted pupil (mitosis), and facial edema?Lambert Eaton Syndrome from *small cell lung carcinoma*. Abs to pre-synaptic Ca channelsPatient with ptosis better after 1 minute of upward gaze?SIADH from *small cell lung carcinoma*. Produces euvolemic hyponatremia. Txt: Fluid restriction +/- 3% saline in <112Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Txt?*Large Cell Carcinoma* Peripheral CA more likely to cause cavitation highly metastaticCXR showing *peripheral* cavitation and CT showing distant mets?NSCLC easier to resect SCLC more sensitive to chem/radsWhich lung cancer has a better prognosis, NSCLC or SCLC?Crohn's disease mimics appendicitis Fe deficiencyIBD involving the terminal ileum?Ulcerative Colitis Rarely ileal backwash but never higherContinuous IBD involving the rectum?Pyoderma gangrenosum Assoc w/ Crohn's dx Txt: address Crohn's, no I&D or AbxUlcerative Colitis PSC increases risk of cholangioCAIBD w/ increased for Primary Sclerosing Cholangitis (PSC)?fistulae - Crohn's, give Metronidazole granulomas on bx - Crohn's transmural inflam - Crohn's high risk CRC - UC pANCA - UCIBD with: fistulae? granulomas on bx? transmural inflam? high risk CRC? pANCA?Crohn's DiseaseSmokers have a higher risk of which IBD?Txt: ASA, sulfasalzine to maintain remission. Corticosteroids to induce remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dxIBD Txt?Alcoholic HepatitisAST>ALT (2x) + high GGT?Viral HepatitisALT>AST & in the 1000s?Ischemic Hepatitis ("shock liver")AST and ALT in the 1000s after surgery or hemorrhage?Obstructive (stone/cancer) Dubin's Johnsons, RotorElevated direct bili?Hemolysis Gilbert's, Crigler NajjarElevetated indirect bili?Bile duct obstruction, if IBD -> PSCElevated alk phos and GGT?Paget's disease Sx: incr hat size, hearing loss, HA Txt: BisphosphonatesElevated alk phos, normal GGT, normal Ca? Txt?Primary Biliary Cirrhosis Txt: bile resins More common w/ UCAntimitochondrial Ab? Txt?*Autoimmune Hepatitis* Txt: steroidsANA + antismooth muscle Ab? Txt?*Barium swallow* - best 1st test *Endoscopy* - next best test, can be dx and allow for bx of suspicious masses or tx in dilation of peptic strictures or injecting botox for achalasia. *Manometry* - achalasia. *24 pH monitoring* - GERD If HIV+ (CD <100) or otherwise immunocompromised, remember Candida, CMV and HSV esophagitisDysphagia workup?Achalasia Txt: CCB, nitrates, botox, or heller myotomy Assoc w/ Chagas dx and esophageal cancer.Dysphagia to liquids & solids?Diffuse esphogeal spasm Txt: CCB or nitratesDysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regure?GERD Most sensitive test is 24-hr pH monitoring. Do endoscopy if "danger signs" present. Txt: behav mod 1st, then antacids, H2 block, PPI.Epigastric pain worse after eating or when laying down cough, wheeze, hoarse? Workup? Txt?*Boerhaave's Sx - Esophageal Rupture* Next best test - CXR, gastrograffin esophagram. NO edoscopy Txt: surgical repair if full thicknessIf hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase. Workup? Txt?Gastric Varices Txt: *Endoscopic sclerotherapy or banding*. Don't prophylactically band asymptomatic varices. Give *Beta blockers* If in hypovolemic shock? do ABCs, NG lavage, medical tx w/ Octreotide or Somatostatin. Balloon tamponade only if you need to stablize for transportIf gross hematemesis unprovoked in a cirrhotic w/ pHTN? Txt? Acute Mgmt?Esophageal Carcinoma Squamous cell CA in smoker/drinkers in the middle 1/3. AdenoCA in ppl with long standing GERD in the distal 1/3. Workup: barium swallow -> endoscopy w/ bx -> staging CTIf progressive dysphagia and weight loss? Workup?#1 cause is *non-ulcerative dyspepsia*. Dx of exclusion. Txt: H2 blocker and antacid. • If GERD sx, tx empirically w/ PPI for 4 wks then re-evaluate. • If biliary colic sxs predominate ->RUQ sono • If hx of stones or drinking, check amylase and lipase, CT scan best imaging for pancreatitis.Mid-epigastric pain>50 y/o hx of smoking and drinking recent unprovoked weight loss odynophagia Fe-def anemia melenaDanger sxs warranting endoscopic work up in pt w/ mid-epigastric pain?Gastric Ulcers - *Double-contrast barium swallow* shows punched out lesion w/regular margins. - *EGD w/ bx* - H. pylori, malign, benign. - Txt: Sucralfate, H2-block, PPI. Surgery if ulcer remains s/p 12wks txt.Mid-epigastric pain worse w/ eating and hx of NSAID and/or steroid use? Workup? Txt?Duodenal Ulcers - 95% assoc w/ H. pylori. Dx: blood, stool or breath test but EGD w/ bx (CLO test) can also r/o CA. - Txt: Healthy pts <45yo can try H2 block or PPI - H. pylori txt: PPI, Clarithromycin + Amoxicillin for 2wksMid-epigastric pain better w/ eating? Workup? Txt?Zollinger-Ellison Syndrome - Best test is *secretin stim test* (finding high gastrin) - Txt: resection if localized, long term PPI if metastatic. - Look for pituitary and parathyroid problems (MEN1)Suspect this if Mid-epigastric pain/ulcers don't improve w/ eradication of H.pylori, large, multiple or atypically located ulcers? Workup? Txt?Acute Cholecystitis US -> thickened wall HIDA-> shows non-visualization of GB. Txt: cholecystectomy. If too unstable, can place a percutaneous cholecystostomyRUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's. Normal labs. Workup shows? Txt?Choledocolithiasis - Same sxs as acute cholecytitis - US will show stones. - Txt: cholecystectomy or ERCP to remove stoneRUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy's. Labs: obstructive jaundice, high bili, alk phos Txt?Ascending Cholangitis Txt: fluids, broad spec Abx, ERCP and stone removalRUQ pain, fever, jaundice (+hypotension and AMS)? Txt?Rare Primary sclerosing cholangitis (Ulcerative colitis) Liver flukes Thorothrast exposure Txt: surgeryRisk factors for cholangiocarcinoma?Acute Pancreatitis - most 2/2 Gallstones & ETOH - Amylase >1000 means stone - Dx: CT scan imaging - Txt: NG, NPO, IVF, Observe - Prognosis: worse if old, WBC>16K, Glc>200, LDH>350, AST>250... drop in Hct, decr calcium, acidosis, hypox - Complications: pseudocyst (no cells!), hemorrhage, abscess, ARDsMid-epigastric pain radiating to the back, N/V, Turner's sign, Cullen's sign. Labs: incr amylase & lipase Txt? Complications?Chronic Pancreatitis Can cause splenic vein thrombosisChronic mid epigastric pain, DM, malabsorption (steatorrhea)? Complication?*Pancreatic adenoCA* *Usually don't have sxs until advanced, only if in head of pancreas - Dx: EUS and FNA biopsy - Tx: Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.Courvoisier's sign = large, nontender GB, itching and jaundice Trousseau's sign = migratory thrombophlebitis. Dx? Txt?Hemachromatosis Sx: hepatitis, DM, golden skinHigh Fe, low ferritin, low Fe binding capacity?Wilson's Disease Sx: hepatitis, psychiatric sxs (basal ganglia), corneal depositsLow ceruloplasmin, high urinary Cu?NS if HoTN, tachycardia Fecal WBC - tests for invasion stool Cx Most commonly - viral, Rotavirus in daycare, Norwalk, cruise ships Picnic - B. cereus, Staph, sx after 1-6hrs Hx Abx use - stool for C. diff antigenDiarrhea workup? Most commonly? Picnic? Hx Abx use?EHEC Shigella Vibrio parahaemolyticus, Salmonella Entamoeba histolyticaBloody diarrhea?Sprue Chronic pancreatitis Whipple's dx CF if young personFoul smelling, bulky diarrhea in malnourished pt?consider carcinoid syndrome (metastatic) *Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) -> Dementia, Dermatitis, Diarrhea.Diarrhea + flushing, tachycardia/ hypotensionStrep Pneumo H. Influenza N. meningitidis Empiric txt: Ceftriaxone and VancomycinMost common meningitis bugs? Empiric txt?Lysteria Txt: AmpicillinCommon extra meningitis bug in old and young pts? Txt?Staph aureus Txt: VancomycinCommon extra meningitis bug in pts w/ brain surgery?RIPE + steroidsTB meningitis txt?IV CeftriaxoneLyme meningitis txt?Empiric Abx (+steroids if you think bacterial) Exam for high ICP LP, Gram stain1st steps in meningitis management?High protein low glucose >1000 WBC (diagnostic)LP bacterial meningitis?Ppx w/ RifampinAdvice for roommate of the kid in the dorms who has bacterial meningitis and petechial rash?Strep pneumoniae Txt: Macrolides, Fluoroquinolones, 3rd gen cephalosporineMost common pneumonia bug? Empiric txt?Atypicals: Mycoplasma assoc w/ cold agglutinins Txt: Macrolides, Fluoroquinolones, DoxycyclineMost common pneumonia bug in young healthy people? Txt?HCAP: Pseudomonas Kelbsiella E. coli MRSA Txt: Pip/Tazo, Impipenem + VancomycinMost common pneumonia bugs in pt's hospitalized w/in 3mo or in the hospital for >5-7d? Txt?H influenzae Txt: 3rd gen CephalosporinMost likely pneumonia bug in old smokers w/ COPD? Txt?Klebsiella Txt: 3rd gen CephalosporinMost likely pneumonia bug in alcoholic w/ currant jelly sputum? Txt?Legionella, aka "PNA+" Dx: urine antigen Txt: Macrolides, Fluoroquinolones, DoxycyclineMost likely pneumonia bug in old man w/ HA, confusion, diarrhea, and abdominal pain? Txt?MRSA Txt: VancomycinMost likely pneumonia bug in a pt who just had the flu? Txt?Q fever (Coxiella burnetti - tick feces, cow placenta -> aerosolized) Txt: DoxycylineMost likely pneumonia bug in farmer who just delivered a baby cow and now has vomiting and diarrhea? Txt?Franciella tularensis Txt: Streptomycin, GentamicinMost likely pneumonia bug in a pt who just skinned a rabbit? Txt?PPD >15mm, >10mm if prison, healthcare, nursing home, DM, ETOH, chronically ill, >5mm for AIDS, immune suppressed If + PPD --> do CXR.TB screening test? Next step if +?+ CXR --> acid fast stain of sputum (if negative x3 clear) - CXR --> need negative acid fast stain of sputum x3Next step after +PPD and +CXR?RIPE x6mo (12mo for meningitis, 9mo if pregnant) *R*ifampin *I*NH *P*yrazinamide *E*thambutolTxt for tuberculosis?children <4yo Ppx: INH x9mo (+vit B6)Who should get chemoprophylaxis after a known TB exposure? What is the ppx?*R*ifampin - orange/red fluids, +CPY450 *I*NH - periph neuropathy, sideroblastic anemia, hepatitis w/ mild LFT bump *P*yrazinamide - benign hyperuricemia *E*thambutol - optic neuritis, other color vision abnormalRIPE side effects?Staph aureusMost common bug for acute endocarditis?Viridens group strep Mitral valveMost common bug for subacute endocarditis of native valve? Which valve?Staph aureus Tricuspid valve R side murmurs worse w/ inspirationMost common bug for endocarditis in IVDU? Murmur features?blood Cx TTE then TEE Major and Minor criteriaDx of endocarditis?CHF is #1 cause of death septic emboli to lungs or brainComplications of endocarditis?Strep viridens txt: PCN x4-6wk Staph txt: Nafcillin + Gentamicin or VancomycinEndocarditis abx?Prosthetic valve Hx of endocarditis Uncorrected congenital lesionWho gets ppx for endocarditis?colonoscopy assoc w/ CRCStrep bovis bacteremia mgmt?*Acute retroviral syndrome* (looks like mono) 2-3 wks s/p HIV exposure but 3wks before seroconversion, ELISA negFever, fatigue, LAD, HA, pharyngitis, n/v/d +/- aseptic meningitisHIVA young patient with new/bilateral Bell's Palsy?that means they have sex with lots of strangers and are at risk for HIVPatient "travels a lot for work"?HIVA young patient with unexplained thrombocytopenia and fatigue?HIVA young patient with unexplained weight loss >10%?HIVA young patient with thrush, Zoster, or Kaposi sarcoma?CD4 < 350 or viral load >55,000 (except preggos get tx >1,000 copies)When to start HAART?ZidovudineHIV Rx SE: GI, leukopenia, macrocytic anemiaDidanosineHIV Rx SE: Pancreatitis, peripheral neuropathyIndinavirHIV Rx SE: Nephrolithiasis and hyperbilirubinemiaEfavirenz (nNRI)HIV Rx SE: Sleepy, confused, psychoAbacavir DC drug and never use again!HIV Rx SE: hypersensitivity rash, F, N/V, muscle aches, SOB in 1st 6wksAZT, lamivudine and nelfinavir for 4wksPost-exposure ppx (HIV)?PCP Dx: Bronchoscopy w/ BAL to visualize bugHIV+ patient with DOE, dry cough, fever, chest pain, elevated LDH? CXR: "bilat diffuse symmetric interstitial infiltrates" How to Dx?1st line: Trim-Sulfa 2nd line: Trim-Dapsone or Primaquine-Clindamycin or Pentamidine + Steroids when PaO2<70, A-a gradient >35Txt for PCP?CD4<200 (can dc if >200 x6mo) 1st: Trim-Sulfa 2nd: Dapsone 3rd: Atovaquone 4th: aerosolized Pentamidine (~> pancreatitis)When to give ppx for PCP?CMV MAC CryptosporidiumHIV pt (CD4<50) w/ diarrhea? (3)Sx: bloody diarrhea Dx: colonoscopy w/ bx -> intranuclear inclusions Txt: Gancyclovir (~> neutropenia), Foscarnet (~> renal tox)CMV in HIV pt? Dx? Txt?MAC Dx: bx negative, exclude alternative causes Txt: Clarithromycin and Ethambutol +/- RifampinHIV pt (CD4<50) w/ diarrhea, wasting, fevers, night sweats? Dx? Txt?CD4<50 Ppx: Azithromycin weeklyMAC ppx in HIV pt?transmitted via dog poo, swimming pool Sx: watery diarrhea w/ mucus Dx: oocysts in stool are acid fastCryptosporidium in HIV pt? Dx?Toxoplasmosis Txt: empiric *pyramethamine sulfadiazine* (+ folic acid) x6wks. If no improvement in 1wk, consider biopsy for CNS lymphoma.HIV pt w/ multiple ring enhancing lesions on CT? Txt?CNS lymphoma Assoc w/ EBV infxn of B- cells Txt: HAART.HIV pt w/ one ring enhancing lesion on CT? Txt?HSV encephalitis (predisposed for *temporal lobe*) Txt: Acyclovir ASAP!HIV pt w/ seizure + *deja vu aura* and 500 RBCs in CSF?Strep pneumo Also worry about Cryptococcus Dx: +India ink Txt: ampho IV x2wks then fluconazole maintenanceMost common meningitis in HIV pt? Workup?sounds like MS *PML* - JC polyomavirus demyelinates at grey-white jxn. Dx: Brain bxHIV pt w/ hemisensory loss, visual impairment, Babinski? Dx?AIDS-Dementia complex Check serum, CSF and MRI to r/o treatable causesHIV pt w/ memory problems or gait disturbance? Workup?Medical Emergency! NEVER do a DRE - may induce bacteremia across gut wall [single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500]Neutropenic fever cautions?[single temp > 101.3 or sustained temp >100.4 x1hr. ANC < 500] Mucositis 2/2 chemo causes bacteremia (usually from gut) Bugs: Pseudomonas or MRSA (if port present)Etiology of neutropenic fever? Most common bugs?Blood cx Start *3rd or 4th gen cephalosporin* (ceftazidime or cefipime) + *vanc* if line infxn suspected or if septic shock + *amphoB* if no improvement and no source found in 5 days.Neutropenic fever workup and mgmt?Lyme Txt: Doxycycline (Amoxicillin for <8yo) Heart or CNS dx needs IV ceftriaxoneTarget rash, fever, CNVII palsy, meningitis, AV heart block? Txt?Rocky Mtn Spotted Fever - Rickettsia "Rickettsia at wRists" Txt: Doxycycline even if <8yoRash @ wrists & ankles (palms & soles), fever and HA? Txt?Ehrlichiosis Dx: morulae intracellular inclusions Txt: DoxycyclineTick bite, *no rash*, myalgia, fever, HA, ↓plts and WBC, ↑ALT? Dx? Txt?Nocardia (aerobic) Txt: trim-sulfaImmune suppressed, cavitary lung dx (purulent sputum) + weight loss, fever. Gram + aerobic branching partially acid fast? Txt?Actinomyces (anaerobic) Txt: high dose PCN x6-12wksNeck or face infection w/ draining yellow material (+sulfur granules). Gram+ anaerobic branching? Txt?Check osmolarity Check volume status Txt: - Correct w/ NS if hypoV - 3% saline only if seizures or [Na] < 120 - fluid restrict + diuretics Don't correct faster than 12-24mEq/day or else *Central Pontine Myelinolysis*Hyponatremia workup? TxT?CHF nephrotic cirrhoticHypervolemic hypoNa causes?diuretics or vomiting + free waterHypovolemic hypoNa causes?SIADH (check CXR if smoker) Addison's (adrenal insufficiency) HypothyroidismEuvolemic hypoNa causes?Replace water w/ D5W or other hypotonic fluid Don't correct faster than 12-24mEq/day or else *cerebral edema*Hypernatremia txt?HypoCatetany perioral tingling Chvostek (CNVII reflex) Troussaeu (BP cuff-> spasms) prolonged QT intervalHyperCa■ kidney STONES ■ psychic MOANS ■ abdominal GROANS ■ achy BONES Shortened QT intervalhypoK Txt: K+ (make sure pt can pee) max 40mEq/hrparalysis, ileus, ST depression, U waves? Txt?hyperK Txt: Ca-gluconate, then insulin + glc, Kayexalate, Albuterol and Sodium bicarb, Last resort = dialysispeaked T waves, prolonged PR and QRS, sine wavesTxt?Metabolic alkalosis Check urine Cl if [Cl]>20 +HTN - hyperaldo (Conns), if normoTN think Barter's or Gittlemans if [Cl]<20 - think vomiting, NG suction, antacids, diureticsHCO3 high pCO2 high Next test? Ddx?Respiratory alkalosis hyperventilation from anxiety, high ICP, fever, pain, ASApCO2 low HCO3 low Ddx?Metabolic acidosis Check Anion gap (Na-Cl-HCO3) Gap -> MUDDLES non-gap -> diarrhea, diuretic, RTA (I, II, IV)HCO3 low pCO2 low Next test? Ddx?Respiratory acidosis hypoventilation from opiates, brainstem injury, ventilation problemspCO2 high HCO3 high Ddx?Distal tubule, can't excrete H+ Cause: Lithium/AmphoB, analgesics, SLE, Sjogrens, SCA, hepatitis Dx: Urine pH>5.4, *hypoK*, stones Txt: replete K, PO bicarbType I RTA Causes? Dx/presentation? Txt?Proximal tubule, can't reabsorb HCO3 Cause: Fanconi sx, myeloma, amyloidosis, vitD deficiency, autoimmune dx Dx: *hypoK*, osteomalacia Txt: replete K, mild diuretic, NO bicarbType II RTA Causes? Dx/presentation? Txt?hyperRenin, hypoAldo Cause: DM (>50%), Addison's dx (adrenal insufficiency), SCA, aldo deficiency Dx: *hyperK*, hyperCl, high urine [Na] even w/ salt restriction Txt: *Fludrocortisone*Type IV RTA Causes? Dx/presentation? Txt?hereditary or acquired proximal tubule dysfxn defective transport of glucose, AA, Na, K, PO4, uric acid, bicarb -> Type II RTA, replete K, mild diureticFanconi's anemia>25% or 0.5 rise Cr over baseline Workup: BUN/Cr -> prerenal if >20/1 Urine Na and Cr -> prerenal if FENA<1% If pt on diuretic measure FENurea -> prerenal if <35%ARF? Workup?fluids and treat underlying issue (reason for low renal perfusion)Prerenal ARF Txt?*AEIOU* *A* - acidosis *E* - electrolyte imbalance (esp K>6.5) *I* - Intoxication (esp antifreeze, Li) *O* - overloaded V -> CHF sx or pulmonary edema *U* - uremia -> pericarditis, AMS NOT for high Cr or oliguria alone!Indications for emergent dialysis?Intrinsic: *ATN* Txt: fluids, avoid nephrotox, dialysis if indicatedMuddy brown casts in a pt w/ ampho, aminoglycosides, statins, cisplatin or prolonged ischemia? Txt?Intrinsic: *AIN* Txt: Stop offending agent. Add steroids if no improvement.Protein, blood and Eos in the urine + fever and rash who took Trim-sulfa 1-2wks ago? Txt?Intrinsic: *Rhabdomyolysis* 1st test is check [K+] or EKG. Txt: bicarb to alkalinize urine to prevent precipitationArmy recruit or crush victim w/ CPK of 50K, +blood on dip but no RBCs? Txt?Intrinsic: *Ethylene glycol intox* Txt: dialysis or NaHCO3 if pH<7.2Enveloped shaped crystals on UA? Txt?Intrinsic: *Contrast nephropathy* Prevent by hydrating before or giving bicarb or NACBump in creatinine 48-72hrs s/p cardiac cath or CT scan?#1 cause of death *CVD* -> goal LDL<100 *HTN* (2/2 ↑aldo), fluid retention -> *CHF* *Normochromic normocytic anemia* -> loss of EPO *↑K, ↑PO4, ↓Ca* (leads to 2ndary hyperPTH) ↑PO4 leads to precip of Ca into tissues -> *renal osteodystrophy and calciphylaxis* (skin necrosis) *Uremia* -> confusion, pericarditis, itchiness, increased bleeding 2/2 platelet dysfxnComplications of CKD?Uremia bleeding 2/2 platelet dysfxnconfusion, pericarditis, itchiness, increased bleedingBladder/Kidney cancer until proven otherwisepainless hematuria?bladder CA or hemorrhagic cystitis (cyclophosphamide)"termina hematuria" + tiny clots?Glomerular sourceDysmorphic RBCs or RBC casts?Proteinuria (but <2g/24hrs) hematuria edema azotemiaDefinition of nephritic syndrome?Berger's Dz (IgA nephropathy)Hematuria *1-2 days* after runny nose, sore throat & cough?Post-strep GN Sx: smoky/cola urine Dx: best 1st test is ASO titer EM: Subepithelial IgG humpsHematuria *1-2 weeks* after sore throat or skin infxn?Goodpasture's Syndrome Abs to collagen IVHematuria + Hemoptysis?Alport Syndrome XLR mutation in collagen IVHematuria + Deafness?Henoch-Schonlein Purpura IgA. Supportive tx +/- steroidsHematuria in Kiddo s/p viral URI w/ Renal failure + abd pain, arthralgia and purpura? Txt?HUS E.Coli O157H7 or Shigella. Don't tx w/ ABX (releases more toxin)Hematuria in Kiddo s/p hamburger and diarrhea w/ renal failure, MAHA and petechiae?TTP Txt: plasmapheresis. DON'T give platelets. vs. DIC PT and PTT are normal in HUS/TTP.Hematuria in Cardiac patient s/p ticlopidine w/ renal failure, MAHA, ↓plts, fever and AMS? Txt?Wegener's Granuolmatosis Dx: Most accurate test is bx Txt: steroids or cyclophosphamide.c-ANCA, kidney, lung and sinus involvement? Txt?Churg Strauss Dx: Best test is lung bx Txt: Cyclophosphamidep-ANCA, renal failure, asthma and eosinophilia? Txt?Polyarteritis Nodosa Affects small/med arteries of every organ except the lung! Txt: cyclophosphamidep-ANCA, NO lung involvment, Hep B? Txt?CT for kidney stonesBest test for pt w/ flank pain radiating to groin + hematuria?Calcium oxalate stones Txt: HCTZMost common type of kidney stones? Txt?Cysteine stones Can't resorb certain AAKid w/ family hx of stones?Struvite stones = Mg/Al/PO4 Proteus Staph Pseudomonas KlebsiellaKidney stones in pt w/ chronic indwelling foley and alkaline pee?Uric Acid stone Txt: alkalinize urine + hydrationKidney stones in pt w/ leukemia being treated w/ chemo? Txt?Pure oxylate stone Ca not reabsorbed by gut (pooped out)Kidney stones in pt s/p bowel resection for volvulus?<5mm - will pass spontaneously, hydrate >2cm - open or endoscopic surgical removal 5mm-2cm - extracorporal shock wave lithotripsyTxt for kidney stones of different sizes?Repeat UA test in 2 weeks, then quantify w/ 24hr urineBest 1st test for pt w/ proteinuria?>3.5g protein/24h hypoalbuminemia edema hyperlipidemia (fatty/waxy casts)Definition of nephrotic syndrome?Minimal Change Disease Fusion of foot processes Txt: steroidsMost common nephrotic sx in kids? Txt?Membranous Nephropathy thick capillary walls w/ subepi spokesMost common nephrotic sx in adults?FSGS Mesangial IgM deposits Limited response to steroidsNephrotic syndrome associated w/ heroin use and HIV?Membranoproliferative GN tram track BM w/ subbed depositsNephrotic sx assoc w/ chronic hepatitis and low complement?suspect rental vein thrombosis 2/2 peeing out ATIII, protein C and S Do CT or US ASAPIf nephrotic pt suddenly develops flank pain?Orthostatic Bence Jones in multiple myeloma UTI pregnancy fever CHFRandom causes of proteinuria?Iron deficiency anemia hypochromic microcytic anemiaMicrocytic anemia MCV = 70, ↓Fe, ↑TIBC, ↓retic, ↑RDW, ↓ferritinAnemia of chronic diseaseMicrocytic anemia MCV = 70, ↓Fe, *↓TIBC*, ↓retic, nl ferritin.Thalassemia RDW - little variation, suggests genetic causeMicrocytic anemia MCV = *60*, ↓RDWSideroblastic anemia May be caused by INHMicrocytic anemia MCV = 70, ↑Fe, ↑ferritin, ↓TIBCFolate deficiencyMacrocytic anemia MVC = 100, ↓retics, ↑homocysteine, nl methylmelonic acid.B12 deficiencyMacrocytic anemia MVC = 100, ↓retics, ↑homocysteine, ↑methylmelonic acidAcanthocytosis (spur cell) -> Liver dxMacrocytic anemia MVC = 100Aplastic Crisis Sickle Crisis from hypoxia, dehydration or acidosisNormal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin in Sickle cell kid w/ sudden drop in Hct?Cold Agglutinins Destruction occurs in the liver. IgM mediatedNormal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Cyanosis of fingers, ears, nose + recent Mycoplasma infx?Warm Agglutinins Destruction in spleen. IgG. Drug rxn or malignancy Txt: steroids 1st, then splenectomy.Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ sudden onset after PCN, ceph, sulfas, rifampin or Cancer?Hereditary spherocytosis (AD loss of spectrin) Txt: splenectomy.Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Splenomegaly, +FH, bilirubin gallstones, ↑MCHC?Paroxysmal Nocturnal Hemoglobinuria Defect in PIG-A. Lysis by complement. Incr risk for aplastic anemiaNormal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Dark urine in AM, Budd-Chiari syndrome?G6PDH def Heinz bodies, Bite cells. Avoid oxidant stress.Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ sudden onset after primiquine, sulfas, fava beans?ITP Txt: prednisone 1st. Then splenectomy. IVIG if <10K. RituximabA patient walks in with thrombocytopenia: 30 y/o F recurrent epistaxis, heavy menses & petechiae. ↓plts only? Txt?VWD Txt: DDAVP for bleeding or pre-op. Replace factor VIII (contains vWF) if bleeding continues.A patient walks in with thrombocytopenia: 20 y/o F recurrent epistaxis, heavy menses, petechiae, normal plts, *↑ bleeding time and PTT*? Txt?Hemophilia Txt: DDAVP if mild, otherwise replace factorsA patient walks in with thrombocytopenia: 20yo M w/ recurrent bruising, hematuria, and hemarthrosis, ↑ PTT that corrects w/ mixing studies? Txt?VitK def ↓ II, VII, IX and X. Same for warfarin toxicity. Txt: *FFP* acutely + vitK shotA patient walks in with thrombocytopenia: 50y/o M "meat-a-tarian" just finished 2wks of clinda has hemarthroses & oozing at venipuncture sites? Txt?Liver Disease. GI bleeding is most common 1st depleted: VII, so PT increases 1st not depleted: VIII and vWF b/c they are made by endothelial cells.A patient walks in with thrombocytopenia: 50y/o M "beer-a-tarian" w/ severe cirrhosis? 1st factor depleted? 2 factors not depleted?Schistocytes! DIC Causes: Sepsis, rhabdo, adenocarcinoma, heatstroke, pancreatitis, snake bites, OB stuff, Tx of M3 AML (Auer rods) Txt: FFP, platelet transfusion, correct underlying d/oA patient walks in w/ thrombocytopenia and this smear... If PT and PTT are ↑, fibrinogen ↓, D-dimer and fibrin split products ↑? Causes? Txt?TTP/HUS Causes: O157:H7, Ticlopidene Txt: plasmapheresis, NOT plateletsA patient walks in w/ thrombocytopenia and this smear... If PT and PTT are normal? Causes? Txt?HIT IgG to heparin bound to PF4 Txt: stop heparin, reverse warfarin w/ vitK, start Lepirudin7 days post-op, a patient develops an arterial clot. Her platelets are found to be 50% less than pre-op? Txt?Cancer Nephrotic sx - pee out ATIII protein C and S preferentially, at risk for RVTWhat to look for in someone w/ unprovoked thrombus?Lupus anticoagulantWhat to look for in someone w/ unprovoked thrombus? ↑PTT, multiple SABs, false+ VDRL?Protein C/S deficiencyWhat to look for in someone w/ unprovoked thrombus? Skin necrosis after warfarin is started?Factor V Leiden V is resistant to CWhat to look for in someone w/ unprovoked thrombus? Most common inheritable pro-coag state?ATIII DeficiencyWhat to look for in someone w/ unprovoked thrombus? Still clots on heparin?OCPs/HRTWhat to look for in someone w/ unprovoked thrombus? Female smoker >35yo?OAKnee pain, DIP involvement no swelling or warmth, worse @ the end of the day, crepetence.RAPIP and wrists bilaterally, worse in the AM, low grade fever.Psoriatic Arthritis.DIP joint involvement, rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers.SLESymmetric, bilateral arthritis, malar rash, oral ulcers, proteinuria, thrombocytopenia. Arthritis is not erosive or have lasting sequellae.Septic arthritisA patient comes in w/ acute swollen painful joint... tap: WBCs >50KGonococcal Cx may be negative. Look also for tenosynovitis and arm pustules. Txt: *Ceftriaxone*Septic arthritis in 30yo who "travels a lot for work"? Txt?Staph aureus Txt: *Nafcillin or Vancomycin*Septic arthritis in 70yo nun? Txt?Inflammatory If no crystals, think RA, ank spon, SLE, Reiter'sA patient comes in w/ acute swollen painful joint... tap: WBCs 5-50KGout - Monosodium Urate Acute TX? *Indomethacin + colchicine* (steroids if kidneys suck). Chronic TX? *Probenecid* if undersecreter. *Allopurinol* if overproduc.Inflammatory arthritis w/ needle shaped, negatively birefringent crystals? Txt?Pseudogout Txt: Calcium pyrophosphateInflammatory arthritis w/ rhomboid shaped, positively birefringent crystals? Txt?OA hypertrophic osteoarthropathy traumaA patient comes in w/ acute swollen painful joint... tap: WBCs 200-5KNormalA patient comes in w/ acute swollen painful joint... tap: WBCs <200ANA - peripheral/rim staining.Ab If negative, rules out SLE?Anti-dsDNA or Anti-SmithAb Most sensitive for SLE?Anti-histoneAb Drug induced lupus? (hydralazine).Anti-Ro (SSA) or Anti-La (SSB)Ab Sjogren's Syndrome?Anti-centromereAb CREST syndrome?Anti-Scl-70, Anti-topoisomeraseAb Systemic Sclerosis?Anti-RNPAb Mixed connective tissue disease?RF (against Fc of IgG) Anti-CCP (cyclic citrullinated peptide)2 Ab tests for RA?Leser Trelat signSign of systemic diseaseDermatomyositisSign of systemic diseaseseborrheic dermatitisSign of systemic diseaseerythema multiformeSign of systemic diseaseacanthosis nigricansSign of systemic diseaseDermatitis herpetiformisSign of systemic diseasePorphyria Cutanea TardaSign of systemic diseaseErythema nodosumSign of systemic diseaseNecrolytic migratory erythemaSign of systemic diseaseBullous pemphigoidSign of systemic diseasePemphigus vulgarisSign of systemic diseaseBehcet's syndromeSign of systemic diseaseAcrodermatitis enteropathica (Zn deficiency)Dermatitis of PellagraTinea capitisActinic keratosis precursor lesion for squamous cell CA Txt: 5FU or excisionKaposi sarcomaBacillary angiomatosisShave or punch bx then surgical removal (Mohs)Txt basal cell carcinomatreat precursor lesions (actinic keratosis or keratoacanthoma) Txt: Excisional bx at edge of lesion, then wide local excision. Can use rads for tough locations.Txt squamous cell carcinomaSuperficial spreading (best prog, most common) Nodular (poor prog) Need full thickness biopsy b/c depth is #1 prog Tx w/ excision - 1cm margin if <1mm thick, - 2cm margin if 1-4mm thick - 3cm margin if >4mm High dose IFN or IL2 may helpMgmt for melanomaProlactinoma Sx: amenorrhea/hypoT Txt: Bromocriptine or Cabergoline even if large (>10mm)Most common pituitary adenoma? Sx? Txt?#1 FSH and LH #2 GR #3 TSH #4 ACTHOrder of hormones lost in hypopituitarism?DI lack of ADH (or nonfunctional)Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine?Nephrogenic DI Txt: HCTZ/amiloridePolyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p ddAVP? Txt?Central DIPolyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p water deprivation, ↑ w/ DDAVP?I123 RAIU scan. If ↑ = Graves If ↓ = factitious or thyroiditis 1st Txt: propanolol + PTU/MTZ I123 ablation surgery (pregnant, children)See low TSH, high free T3/T4. Next best step? Txt?PTU + Iodine (Lugol's sol'n) + propranololThyroid storm txt?1st: check TSH if low -> RAIU if normal -> FNAWorkup for thyroid nodule?"hot nodule" -> excision or radioactive I131 "cold nodule" -> surgically excise and check pathologyRAIU workup (s/p low TSH)?PapillaryMost common type of thyroid nodule, spreads via lymph, psammoma bodies?Follicular must surgically excise whole thyroidthyroid nodule that spreads via blood?Medullary Assoc w/ MEN2 (look of pho, hyperCa)Thyroid nodule associated w/ calcifications and amyloidosis?AnaplasticThyroid nodule w/ 80% in 1st yr?Thyroid lymphomaHashimoto's predisposes you to this type of thyroid nodule?Suspect Cushing's 1mg ON dexa suppression test or 24hr urine cortisol if abnormal, dx Cushing's 8mg ON dexa suppression testOsteoporosis, central fat, DM, hirsutism? Best screening test?adrenal neoplasm vs ectopic ACTH plasma ACTH Chest CT if smoker abdominal CT/DHEASOsteoporosis, central fat, DM, hirsutism? No adrenal suppression after 8mg ON dexa? Nest test?Suspect Adrenal Insufficiency Cosyntropin stimulation test (60min after 250mcg)Weakness, hypotension, weight loss, hyperpigmentation, ↑K, ↓Na, ↓pH? Best screening test?Autoimmune (Addison's disease) Txt: NaCl resuscitation, Long term replacement of dexamethasone and fludrocortisoneMost common cause of adrenal insufficiency? Txt?hypoparathyroidismPerioral numbness, Chvortek, Trousseau s/p Thyroidectomy, ↓[Ca], ↑[PO4], ↓[PTH]?hyperparathyroidism Dx w/ FNA of suspicious nodules. Can use Sestamibi scan. Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.Kidney stones, constipation/abd pain or psychiatric sxs, ↑[Ca], ↓[PO4], ↑vitD, ↑[PTH]? Dx? Txt?*MEN1* - pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor. *MEN2a* - parathryoid hyperplasia, medullary thyroid cancer, pheochromocytoma *MEN2b* - medullary thyroid cancer, pheochromocytoma, MarfanoidMEN?FBGL > 126 x 2 2hr OGTT > 200 random glc > 200 + sxs (polyuria, polydipsia, blurred vision)Dx of DM?DKA Dx: ketones in blood and urine, AGMA, hyperK Txt: high volume NS + insulin bolus and drip, add K once peeing, add glucose<200Nausea, vomiting, abdominal pain, Kussmaul respirations, coma w/ BGL=400? Dx? Txt?HHS Txt: high volume fluid and electrolytes, may require insulinPolyuria, polydipsia, profound dehydration, confusion and coma w/ BGL = 1000? Txt?CVDMost common cause of death in DM pts?Heart: LDL<100, BP<130/80 Kidney: microalbuminemia (30-300 in 24hrs), start ACEI Eye: annual screening for proliferative retinopathy -> vitreous humor/neovasc Nerves: podiatric exam qyr. Tx gastroparesis w/ metoclopramide or Eythromycin, may get ED, 3rd, 4th, 6th CN palsyImportant screening for DM pts?80% ischemic 20% hemorrhagicMost common cause of stroke?noncontrast CT to r/o hemorrhage diffusion-weighted MRI best for ischemic, CT can be negative for 1st 48hrsBest 1st test for stroke? Most accurate test?TPA w/in 3-4.5hrs ASA >4.5hrs Heparin only for those in Afib, basilar clotStroke txt w/in 3-4.5hr? later?stroke w/in 3mo surgery w/in 2wks LP w/in 1wkContraindications to tPA?Add dipyridamole or switch to clopidogrel. Don't use ticlopidine! (why?)If pt has stroke while on ASA?Nimodipine to reduce ischemic stroke from vc (most common cause of M&M)If pt has SAH?W/in days or rupture or when <10mmWhen to clip an aneurysm?When occlusion >70% and is symptomatic. (>60% if <60y/o)When to do endarterectomy?R MCA strokeWhere's the lesion? L hemiplegia/hemisensory loss, L homonomous hemianopsia w/ eyes deviated twoards the R + apraxia.R ACA strokeWheres the lesion? L hemiplegia/hemisensory loss in the leg>arm. Confusion, behavioral disturbance.R Webber'sWhere's the lesion? L hemiplegia + R ptosis & eye deviated to the right and downR Benedikt'sWhere's the lesion? Falling to the L + R ptosis & eye deviated to the right and down.R Wallenburg (PICA)Where's the lesion? L hemisensory loss + Horners + R facial sensory loss.Major R cerebellar arteriesWhere's the lesion? Vertigo, vomiting, nystagmus and clumsiness with the right arm.Paramedial branches of the basilar arteryWheres the lesion? Total paralysis except for vertical eye movements.Lorazepam + LD of phenytoin. Then phenobarbitol. Then anesthesiaStatus Epilepticus Txt?simple if no LOC and complex if LOC (may have lip smacking) Both can generalize. Txt: 1st line = carbamazepine or phenytoin. Then valproate or lamotriginePartial seizures begin focally. (Arm twitch, de-ja-vu, burning rubber smell)? Txt?1st line = valproic acid, then lamotrigine, carbamezepine, phenytoinGeneralized seizures txt?ethosuximideAbsence sz txt?Absence Seizure. Tx w/ ethosuxamideEEG buzzword: 3 Hz spike-and- wave Txt?Creutzfeldt Jakob. Dementia + myoclonusEEG buzzword: Triphasic burstsDelirium. Contrast w/ psychosis that has no EEG changesEEG buzzword: Diffuse background slowingInfantile spasms. Tx w/ ACTH. Most are associated w/ mental retardation.EEG buzzword: Hypsarrhythmia Txt?Subarachnoid hemorrhage. Noncon CT 1st!Acute HA: "Worse headache of my life"Meningitis. Abx then CT then LPAcute HA: + Fever and Nuchal rigidityconsider space occupying lesion (brain tumor) most important prognostic feature is grade (degree of anaplasia)Acute HA: deep pain that wakes pt up at night, worse w/ coughing or bending forwardTemporal arteritis Check ESR, then give steroids, then to temporal artery dx Can lead to blindnessAcute HA: unilateral pounding, w/ changes in vision and jaw claudicationPseudotumor cerebri also assoc w/ OCPs Normal CT, elevated P on LP Txt: wt loss, Acetazolamide, then shunt or optic nerve sheet fenestrationFat lady on minocycline or who takes isotreintoin w/ abducens nerve palsy/diplopiaGuillain-Barre CSF shows albumino-cytologic dissociation Campylobacter, HHV, CMV, EBV Txt: IVIG or plasmapheresis, monitor VC for intubation reqDiarrhea 3wks ago, now areflexia and ascending paralysis? Most likely bug? Txt?Myasthenia Gravest 1st test: ACh-Ab Most accurate test: EMG, decrease in muscle fiber contraction Acute txt: IVIG or plasmapheresis, monitor VC for intubation req Chronic txt: Pyridostigmine, GCs/Azathioprine, thymectomy (<60yo) Rx to avoid: Aminoglycosides, beta blockersNasal voice, ptosis, dysphagia, respiratory acidosis? Dx? Txt?Multiple sclerosis neurodeficits separated by time and space Dx: MRI, increased T2 at periventricular white matter Acute txt: steroids (3d IV then 4wk PO), plasma exchange is 2nd line Chronic txt: IFN-beta1a, beta1b, Glatiramer reduces exacerbationsurinary retention, Babinski on R, episode of double vision 6mo ago? Dx? Txt?Acute Leukemia on BiopsyA patient presents w/ fatigue, petechiae, infection bone pain and HSM... If >20% blasts?ALL. Most common cancer in kidsA patient presents w/ fatigue, petechiae, infection bone pain and HSM... CALLA or TdT?AML. More common in adults. RF = rads exposure, Down's, myeloprolif. M3 has Auer Rods and causes DIC upon tx.A patient presents w/ fatigue, petechiae, infection bone pain and HSM... Auer rods, MPO, esterase?Hairy Cell Leukemia. See enlarged spleen but no adenopathy. Hairy Cells have numerous cytoplasmic projections on smear. Tx w/ cladribine 5-7day single courseA patient presents w/ fatigue, petechiae, infection bone pain and HSM... Tartate resistant acid phosphatase, ↓monos & CD11 and CD22+?Danorub, vincris, pred. Add intrathecal MTX for CNS recurrence. BM transplant after 1st remission.Tx of ALL?Danorub + araC If *M3 -> give all trans retinoic acidTx of AML?CML- 9:22 transloc --> tyrosine kinase Tx w/ imantinib (Gleevec), inhibits tyrosine kinase. 2nd line is bone marrow transplant. Cx = blast crisis.A patient presents w/ fatigue, night sweats, fever, splenomegaly and elevated WBCs w/ low LAP and basophilia?CLLAsymptomatic elevation in WBCs found on routine exam - 80% lymphs.If Lymphadenopathy - Stage 0 or 1 need no tx- 12 yrs till death If Splenomegaly - Stage 2 tx w/ fludrabine If Anemia, If Thrombocytopenia - Stage 3 or 4 tx w/ steroidsStaging CLL: If LAD? If splenomegaly> If anemia? If thrombocytopenia?Think LymphomaEnlarged, painless, rubbery lymph nodes"B-symptoms" = poor prognosis along w/ >40, ↑ESR and LDH, large mediastinal LNDDrenching night sweats, fevers & 10% weight lossHodgkin's LymphomaOrderly, centripetal spread + Reed Sternberg cells?Lymphocyte predominantHodgkins lymphoma w/ best prognosis?Non-hodgkin's LymphomaLymphoma most likely to involve extra nodal sites?I = 1 node group II = 2 groups, same side of diaphragm III = both sides of diaphragm, extension into organ IV = BM or liverLymphoma staging?Stage I/II get rads Stage III/IV get ABVD ChemoLymphoma txt?Multiple myeloma 1st test: serum protein electrophoresis - IgG monoclonal spike Confirmatory test: BM bx showing >10% plasma cells Txt: if young, BM transplant. If old, melphalan + prednisone. Hydration and Lasix, then Bisphosphonates for hyperCaBone pain, "punched out lesions" on x-ray, hyper Ca? Best 1st test? Txt?Waldenstrom MacroglobulinemiaDizziness, HA, hearing/vision problems and monoclonal IgM M-spike?MGUSNo sxs, immunoglobulin spike found on routine exam?Polycythemia Vera 1st test: EPO, make sure it isn't secondary (PSG, carboxyHbg) Txt: scheduled phlebotomy, Hydroxyurea can prevent thrombosesOlder pt w/ generalized pruritis and flushing after hot bath. Hct of 60%? Best 1st test? Txt?