Internal Medicine

SNRT (sinus node recovery time)
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Compliance EquationC = ∆V / ∆PGraves DiseaseB cell disease. T3 predominant: better remission. Over time T cells can attack thyroid and cause hypothyroidHyperthyroidism and B adrenergic receptorsWill hypercouple B1 but not B2 (lungs) and can worsen asthma due to increased BMR and asthma medication breakdownCauses of HTNVolume (diuretics), Pressor (Angiotensin, Adrenergic), Compliance (CCB). Plasma Renin Activity vs Aldosterone to determine cause.DysbiosisChange in gut flora in stomach of obese patient.Cellulitis FeaturesRedness, swelling, skin streaking (seen post insect bite or pruritic dermatophysis)Pericarditis EKGDiffuse ST segment elevation-upward curves (smile) PR depression. Treat with NSAID and ColchicineCardiac Tamponade TreatmentIVF to open the ventricles and pericardiocentesisTemperature vs Heart rate change1° F causes an increase in HR by about 10 BPMDASH DietHigh in fruits, vegetables, legumes, low fat products. Low in snacks, sweets, meats, saturated fatsPreHTN, Stage I, Stage IIPreHTN: >120 / >80 Stage I: >130 / <90 Stage II: >140 / >90Insulin Sliding ScaleStart at 0.5 x weight in kg = daily insulin Split dose in 1/2 = night 1/2 dose divide by 3 meals 1500/ total insulin required = how much BS will drop per unit of insulin extra given If patient NPO and hyperglycemic then give # of units between base and sugar number.1 unit of Blood changes HgB by how muchIncrease hematocrit by 3, hemoglobin by 1. Transfuse normal patient at 7.1 hemoglobin Transfuse CAD patient at 8 hemoglobinLudwig AnginaRapidly progressive cellulitis of submandibular space. Usually from dental infectionLower Back Pain Treatment"Belt-like" Maintain moderate activity, NSAIDs, exercise therapy, muscle relaxants, TCAAntivirals effect on ShinglesValacyclovir shortens symptoms and decreases postherpetic neuralgiaGVHD (Graft Versus Host Disease) Signs- Macopapular rash (resemble SJS) - Profuse watery diarrhea - Jaundice/ abnormal LFTs - Liver inflammation *Donor T cells attack HLA antigens* Can occur within 100 days of transplantAnalgesic nephropathy microscopyPapillary necrosis and tubulointerstitial nephritisHow to test for AcromegalyTest IGF-1 instead of GH because GH fluctuatesDOC for decreasing thromboembolic riskApixaban (aspirin is less effective)Bacillary AngiomatosisBright red, friable, firm, exophytic lesions.Kaposi SarcomaOn trunk, face, extremities. Papules that become plaques or nodules. Color is light brown to pink to dark violet. *HHV8*Parasitic causes of Traveler's DiarrheaCryptosporidium parvum, Cyclospora, GiardiaFactorial Design Study2 or more experimental interventions, each with 2+ variables that are studied independently.Euthyroid Sick SyndromePatient with acute illness. Fall in total and free T3 levels with normal levels of T4 and TSH.Adult Still DiseaseInflammatory disorder. Recurrent high fevers, arthritis/ arthralgias, salmon colored macopapular rash.Vasovagal Syncope: Cause and Treatment1. Cough, defecation, micturation: stimulation of visceral organs. 2. Carotid hypersensitivity 3. Emotional (seeing blood) Treat with B blocker: blocks vagal dischargeNeurogenic SyncopeProblem with posterior circulation (low blood to back of brain). Sudden and no prodrome. Focal neurologic deficit. Use Carotid USG or CT angiogram to diagnoseHigh Intensity Statin Low Moderate Intensity StatinHigh: Atorvastatin 40, 80mg or Rouvastatin 20, 40 mg (always start with high intensity unless over 75 or other contraindication) Moderate: Atorvastatin 10, 20 mg or Rouvastatin 5, 10 mg (Statin intolerance, age over 75, liver and renal disease)Who Gets Statins1. Vascular disease 2. LDL >190 3. LDL 70-189, 40-75 yoa, diabetic 4. LDL 70-189, 40-75 yoa, high calculated 10 yr riskTreatment for SVT, A-Fib, Torsades, V-TachSVT: Adenosine, shock A-Fib: Rate = Rhythm, shock Torsades: Magnesium, shock V-Tach: Amiodarone, shockWhen to use PACE and Atropine for BradyarrhythmiasPACE: any bradyarrhythmia Atropine: Sinus bradyarrhythmia, Mobitz Type I, Mobitz Type II can push to 3rd degree blockNo Pulse Code: VT/VF or PEA AsystoleVT/VF: repeat 2 min CPR, check pulse/ rhythm/ shock if indicated. Alternate between epinephrine and amiodarone PEA Asystole: repeat 2 min CPR, check pulse/ rhythm/ shock if indicated. Alternate between epinephrine and absentWhat Causes Elevated D DimerDVT, Sepsis, Heart Failure, Aortic Dissection. Multiply age x 10 to get estimated normal D dimer levels (may be what is considered elevated).Septic ShockEnd Organ Damage with Hypotension after adequate fluid resuscitation (30mL/kg in 3 hours) or Lactate over 4 (2 to be safe) with fluid resucitationPneumococcal Vaccine RecommendationsPrevnar13 at 65 yoa and Pneumovax23 one year later. Need 5 years between Pneumovax23 injections. PPSV23 alone: chronic heart/ lung/ liver disease, DM, smokers, alcoholics PCV13 + PPSV23: CSF leaks, cochlear implants, sickle cell, asplenia, HIV, malignancy, CKDECG Evolution post MINormal -> hyperacute T waves (high and tall) -> ST elevation -> Q waves and T wave inversion -> ST elevation improves -> Q waves persist and T waves normalizeSerous Otitis MediaMC middle ear pathology in AIDS. Auditory tube dynfunction from HIV lymphadenopathy or obstructing lymphomas. Conductive hearing loss, dull tympanic membrane.Atheroembolism (Cholesterol Embolism)Caused by recent cardiac catheterization. Plaque is disrupted -> cholesterol crystals in BV cause partial or complete occlusion of arterioles -> blue toe syndrome, livedo reticularis, gangrene, ulcers.Severity of Asthma Categories and TreatmentI: Day sx <2x/ week, night sx <2/mo, FEV1 80% (SABA). Intermittent II: Day sx <1/day, night sx <1/mo, FEV1 80% (SABA + ICS). Mild III: Day sx >1/day, night sx >1/week, FEV1 60-80% (SABA, ICS, LABA). Moderate IV: Day sx >1/day, frequent night sx, FEV1 <60% (SABA, higher ICS, LABA). Severe V: Refractory (still symptomatic) -> oral steroidsAsthma Exacerbation TreatmentOxygen, Nebulizer (ipratropium + albuterol), steroids (oral or IV), measure peak expiatory flow rate (normal -> go home, worse -> ICU, need more time -> floor admission).Asthma Exacerbation w/o Improvement TreatmentRacemic Epinephrine, SubQ Epinephrine, MagnesiumNeurogenic ShockHypotension. TBI or spinal cord injury, interruption of ANS, low vascular resistance, altered vagal tone.Brain Metastasis Imaging and SymptomsMRI of brain with contrast shows well-circumscribed lesions with vasogenic edema at the gray-white matter junction. Headaches, focal deficits, cognitive changes, seizures.Chronic Alcoholism and HypokalemiaHypomagnesemia results from chronic alcoholism due to poor nutritional intake --> leads to refractory hypokalemia (cannot be fixed with potassium) Intracellular Mg inhibits K secretion by ROMK channels in kidney --> low Mg allows for increased K loss in urinePulmonary Nodule: What to do nextLook at old films: If no change in 2 years = stable and left alone If new = unstable. Low risk = serial CTs, high risk = biopsy if thinking lung cancerBronchogenic CarcinomaBibasilar reticulonodular infiltrates, honeycombing, and bilateral pleural thickening and plaques. (Mesothelioma is MC unilateral pleural abnormality with large pleural effusion).Hyperoxaluria CausesChron's disease or any SI fat malabsorption disorder cause increased oxalate absorption (Ca bound to fat instead and oxalate is free to absorb)Theophylline ToxicityCNS stimulation (HA, insomnia, seizures), GI disturbances (N/V), cardiac toxicity (arrhythmia). Metabolized by Cyt p450 system in liver. Treatment: Activated charcoal Bowel irrigation Benzodiazepines for seizures Phenytoin or Phenobarbital for refractory seizures Beta blockers for ventricular arrhythmiasRate vs Rhythm ControlRate: AV block to prevent extra ventricular beats, Beta blockers, CCBs Rhythm: Cardioversion, soltalol, amiodarone, propafenoneCHA2DS2-VASc scoreStroke risk and need for anticoagulation CHF HTN Age >75 DM Stroke/TIA/Thromboembolism Vascular Disease Age 65-74 SexWolf Parkinson White Syndrome TreatmentProcainamide or amiodarone to slow conduction and convert to sinus if hemodynamically stable. DC Cardioversion in hemodynamically unstable.Causes of TransudateNephrosis, gastrosis, cirrhosis, CHF, protein malnutrition. Increased hydrostatic or decreased oncotic pressureCauses of ExudateMalignancy, pneumonia, TBDiagnosing Pleural EffusionLateral Decubitus CXR -> if loculated -> thoracostomy -> then thoracotomyLight's CriteriaDetermines exudative effusion LDH of pleural effusion (>2/3), LDH fluid: LDH serum (>0.6) , Total protein fluid: TP serum (>0.5)PE AnticoagulationHeparin and Warfarin (Bridge): 5 days or until INR is 2-3. OR NOAC (apixaban). OR IVC filter: DVT where next PE will kill person and anticoagulation is contraindicated. OR tPA: massive PE, and hypotension.ECG Heart Rate and QRS ReadingHR: 300, 150, 100, 75, 60, 50, 43, 37 (1 box - 8 boxes) 1 box = 40ms. Normal QRS = 3 or less boxes (120ms). Wide QRS = beat starts in ventricles + slow depolarization. Rate = 300/ # of big boxes Rate for Irregular Rhythm: # of R waves in 6 seconds multiplied by 10Type I vs Type II MIType I: STEMI, NSTEMI. Plaque rupture, need revascularization with PCI, artery occlusion. Type II: Non ruptured plaque, more demand required (sepsis, exercise), demand ischemia, NO PCIIschemic Stroke Imaging4 hours for MRI. 48 hours for CTWinters FormulaMetabolic Acidosis with compensation. PaCO2 = 1.5[HCO3] + 8 +/-2 **Last 2 digits of pH should be estimated PaCO2 with non-mixed metabolic acidosis and good respiratory compensation**Metabolic Alkalosis Compensation Formula1 mEq increase in HCO3 -> 0.5-0.7 increase in PaCO2 PaCO2 = 0.9[HCO3] + 16Respiratory Acidosis CompensationPaCO2 increase by 10 mmHg -> HCO3 increase by 1 mEq (acute) OR 3 mEq (chronic)Respiratory Alkalosis CompensationDrop in PaCO2 by 10 mmHg -> HCO3 drop by 2mEq (acute) OR 4 mEq (chronic)Anion GapNormal = 12. Na - Cl - HCO3BUN: Cr RatioNormal: 10-20 : 1 Pre-renal: high BUN : normal Cr (>20:1). Low GFR -> RAAS -> high ADH -> high urea reabsorption Renal: low BUN : normal Cr (<10:1). Low GFR, kidney cannot reabsorb -> urea lost in urine Post renal: high BUN : high Cr (10-20:1). Block of urine, ratio starts normal + becomes low after prolonged obstructionFibromyalgiaYoung women, chronic widespread pain, fatigue, impaired concentration, tenderness at trigger points (midtrapezius, costochondral junction). Over 3 months of symptoms with widespread pain index or symptom severity score. Normal labs.PolymyositisProxmial muscle weakness (difficulty with stairs), mild/absent pain. High muscle enzymes (CK, Aldolase, AST), Autoantibodies (ANA, anti-Jo 1), endomysial infiltrate and patchy necrosis on BIOPSY.Polymyalgia RheumaticaOver 50, stiffness (and pain) in shoulders/ hip girdle/ neck, associated with temporal arteritis. Elevated ESR + CRP, rapid improvement with glucocorticoids.Therapy Types: 1. Adjuvant 2. Consolidation 3. Induction 4. Maintenance 5. Neoadjuvant 6. Salvage1. Treatment with standard therapy, at same time 2. After induction therapy with multidrug regimens to reduce tumor burden 3. Initial dose of tx to rapidly reduce tumor size 4. After induction and consolidation therapy 5. Given before standard therapy for a certain disease. 6. Given after standard tx failsHypercalcemia TreatmentShort term: normal saline hydration + calcitonin (avoid loop diuretics) Long term: Bisphosphonates (zolendronic acid)Malignant Hypertension Eye EffectsSevere HTN with retinal hemorrhages, exudates, or papilledemaHypertensive EncephalopathySevere HTN with cerebral edema, non-localizing neurologic sx and signsHIV EsophagitisMC is Candida albicans. Viral esophagitis is more likely with severe odynophagia, no dysphagia, and no thrush.GERD and AsthmaWorsens asthma from microaspirations -> more vagal tone + bronchial reactivity. Sore throat, morning hoarseness, worsening cough only at night, albuterol use after meals.Common Variable ImmunodeficiencyRecurrent respiratory (PNA, sinusistis, otitis) and GI (salmonella, campylobacter) infections. Autoimmune disease (RA, thyroid disease). Chronic lung ulcers (bronciectasis). GI disorders (IBD, chronic diarrhea). Very low IgG, low IgA/IgM. Tx with immunoglobulin replacement therapy.SialadenosisNontender, enlarged submandibular glands. Seen in advanced liver disease (alcoholic/ nonalcoholic cirrhosis), altered dietary patterns or malnutrition (DM, bulimia).Vaccines in Chronic Liver DiseaseHAV, HBV, Influenza, Tdap, PPSV23Myasthenic CrisisPrecipitated by infections, surgery, pregnancy, tapering immunosuppressive drugs, medications (fluoroquinolones, beta blockers, macrolides, aminoglycosides). Increased generalized + oropharyngeal weakness, respiratory insufficiency + dyspneaCOPD TreatmentSABA -> LAMA -> LABA -> ICS -> PDE4 Inhibitors -> oral steroidsWhen to Give O2 in COPDSpO2 under 88% or PaO2 under 55. *Keep between 88-92% because they need hypoxic drive to stimulate respiration*COPD Exacerbation TreatmentAntibiotics (Doxycycline, Azithromycin), Bronchodilators (albuterol, ipratropium), Steroids (Prednisone, methylprednisolone)ARDS TreatmentLow TV and High RR to maintain CO2. PEEP to maintain O2.Job Asscoiation 1. Silicosis 2. Berylliosis 3. Black Lung 4. Hypersensitivity Pneumonitis1. sand blasting and rock queries, more likely to get TB 2. aeronautics, electronics 3. caplans syndrome (arthritis and lung fibrosis) 4. Bird franciers, antigen mediated, 4-48 hours to start, 24-48 hours stopsUrsodeoxycholic AcidTreatment for cholelithiasis who does not get surgery and for PBCCharcot's triadRUQ pain, jaundice, and fever/chills in the setting of ascending cholangitisReynold's PentadRUQ pain, fever/chills, jaundice, AMS (altered mental status), hypotension (Cholangitis)Antibiotics for Cholecystitis, Choledocholithiasis, CholangitisCirpofloxacin + Metronidazole Ampicillin + Gentamicin + Metronidazole Pipericillin + Tazobactam (expensive + should be last choice)Esophagitis CausesPill induced Infections (Candida, HSV, CMV, HIV) Eosinophils Caustic Everything Else (GERD) *PIECE - always need to take a biopsy to diagnose*Eosinophilic Esophagitis TreatmentPPI if not already on one. Oral Aerosolized Steroids if already failed PPI.Shatzki's RingRing at GE junction, steakhouse dysphagia (Large pieces of food will get stuck). Treat by lysing the ringNeuroleptic Malignant Syndrome CausesDA receptor blockade. Rxn to 1st generation antipsychotics, antiemetics (metoclopramide), antiparkinson medication withdrawal.Neuroleptic Malignant Syndrome SymptomsMental status change Muscle rigidity Hyperthermia Autonomic instability (tachycardia, tachypnea, dysrhythmias, diaphoresis). High CK (muscle rigidity) Leukocytosis Moderate LDH Low iron Myoglobinuric acute renal failureSerotonin Syndrome SymptomsTachycardia HTN Hyperthermia Agitation Slow continuous horizontal eye movements Dilated pupils Tremor Akathisia Hyperreflexia Myoclonus Babinski sign Flushed skinIsoelectric AxisI = 90° II = -30° III = +30° aVL = +60° aVF = 0° When R = SLBBB EKGT waves + QRS go in opposite directions (in same means ischemia). QRS over 120 ms.Gonorrhea treatmentCeftriaxone initially and then Doxycycline if it progresses to PIDST Bowing on ECGLVH usually in anterior or anterior lateral leadsR wave progression- In the precordial leads, you should start mostly negative (V1) and progress to mostly positive (V6) **The normal R wave transition occurs between V3 and V4** If you have early R wave progression, it can be caused by: - Posterior MI - RVH - RBBB - WPW If you have late R wave progression, it can be caused by: - Anterior MI - LVH - LAFB (left anterior fascicular block) - LBBB - Lung diseaseEndocarditis TreatmentProphylaxis: amoxicillin (ampicillin, cephalosporins, clindamycin) Streptococcus: Penicillin G Staph aureus: nafcillin with gentamicin MRSA or coagulase (-): Vancomycin HACEK: CeftriaxoneSigns of Acute Arterial OcclusionPain, Pallor, Pulselessness, Parasthesias, Poikilothermia, Paralysis Likely due to thromboembolic occlusion from left atrial fibrillation. Need to be started on aticoagulation while further tests are done --> heparinMedications Associated with HypomagnesemiaAminoglycosides, Amphotericin B, Cisplatin, Cyclosporin, Pentamidine, PPICorrected Calcium FormulaCorrected Calcium = Calcium + {0.8 x (4.0 - [albumin])}Delta GapDifference between anion gap and HCO3 gap. DG = ∆AG - ∆HCO3 or (AG calculated - 10) - (24 - HCO3 measured)Transtubular Potassium Gradient EquationTTKG = (urine K/ serum K) / (urine osmolality/ serum osmolality) TTKG <2 suggests non renal source of hypokalemia TTKG >4 suggests hypokalemia is from inappropriate renal secretion of K+Medication that Exacerbate Cardiac symptoms of HypomagnesemiaDigoxin will worsen atrial and ventricular arrhythmiasBloody TAP vs Subarachnoid HemorrhageXanthochromia means SAH. If you have 4 tubes of CSF and tube 1 has 3+ blood and tube 4 has 1+ blood then most likely bloody tap. If tubes 1 and 4 all have 3+ blood then most likely SAHRespiratory rate of 24 with 100% O2Most likely acid base disorder causing increased respiration but normal saturationLactic Acidosis Type A vs BA: Sepsis or septic shock, abnormal O2 B: Large tumor, Metformin, usually normal O2Mohs micrographic surgeryUsed on face. Sequential removal of thin skin layers with microscopic inspection to confirm that the margins have been cleared of malignancyMost Common Causes of Digital ClubbingLung malignancies, cystic fibrosis, right to left cardiac shuntsS1Q2T3 on EKGSignifies PE. S wave in lead I, Q wave in lead II, and inverted T wave in lead IIIWestermark sign and Hampton Hump and Palla sign of PEWestermark: nonspecific prominence of central pulmonary artery with decreased pulmonary vascularity. Hampton: peripheral wedge shaped density above the diaphragm. Palla: enlargement of the right descending pulmonary arteryEsophageal perforationBoerhaave syndrome, Esophagitis, esophageal ulcer. Chest and abdominal pain, fever subcutaneous emphysema in the neck, Hamman sign (chrunching sound on auscultation/ suprasternal crepitus). Pneumomediastinum or unilateral pleural effusion (MC Left). Pleural fluid has low pH and high amylase (exudative) and may have food particlesPeripheral Arterial DiseassCauses: Atherosclerosis, Thromboangitis obliterans (Buerger's Disease) PE Findings - Low or absent pulses below stenosis - Bruits over stenotic lesions - Poor wound healing from low perfusion - Cool extremity, prolonged venous filling - Shiny, atrophied skin with nail changes - Foot pallor with leg elevation (Buerger's test)Area of Atrophy: 1. Alzheimer's Disease 2. Pick's Disease1. Frontal and parietal lobes 2. Frontal and temporal lobesTransfusion Reactions TimelineAnaphylaxis - seconds to minutes Acute Hemolytic - minutes to 1 hour Febrile Nonhemolytic/ TRALI - 1 to 6 hours Delayed hemolytic - 2 to 10 daysWhen to give irradiated RBCsBM transplant recipients Acquired or congenital immunodeficiency Blood components from 1st for 2nd degree relativesWhen to give leukoreduced RBCsChronically transfused patients CMV seronegative at risk (AIDS/ transplant) Potential transplant recipients Previous febrile nonhemolytic transfusion reactionWhen to give washed RBCsIgA deficiency Complement dependent autoimmune hemolytic anemia Continued allergic reaction (hives) with RBC transfusion despite antihistamine treatmentAlpha 1 Blockers and Ureteral StonesAlpha 1 receptors on distal ureter, base of detrussor, bladder neck, and urethra. Block receptor causes relaxation of muscle and allows stone to pass (also prevents reflex ureteral spasm and pain)Hypothyroid MyopathyMyalgias, proximal muscle weakness, elevated CK, fatigue, delayed DTRs ( myalgias and delayed DTRs are absent in polymyositis)Cluster Headache Treatment100% O2, subcutaneous sumatriptanRestless Leg Syndrome TreatmentDopamine agonists like pramipexole is first line. Gabapentin and enacarbil (calcium channel ligands) are second line.Steppage GaitCharacteristic of injury to the common peroneal nerve (L5 radiculopathy) due to inability to dossifelx at the ankle (tibialis anterior is messed up). Distal sensory loss and weakness. Motor neuropathyIchthyosis Vulgaris"Lizard skin". Chronic inherited skin disorder characterized by diffuse dermal scaling. Mutation in filaggrin gene. Skin is dry and rough with horny plates resembling fish or reptile scales.Subacute Thyroiditis (de Quervian thyroiditis)Postviral inflammatory process, prominent fever + hyperthyroid symptoms, painful/tender goiter, elevated ESR + CRP, low radioiodine uptakeNormal CXR, Immunocompetent, Nonsmoker with cough DDxUpper Airway Cough Syndrome Asthma GERDExpected increase in serum K+ if 10mEq KCl is givenFor every 10mEq KCl serum K+ will increase by 0.1mEq/LTreatment of ITP*Antibodies to Gp IIb/IIIa* Platelets >30,000 + no bleeding: observation Platelets <30,000 or bleeding: Corticosteroids and/or IVIG, splenectomy (second line) or rituximab if contraindicated Severe life threatening bleeding: platelet infusionHow fast should the water deficit in hypernatremia be correctedShould not exceed 12mEq/L in a 24 hour periodWhich diseases can cause hypercalcemia secondary to hypervitaminosis DChronic granulomatous inflammation (TB, sarcoidosis), Hodgkin lymphomaComponents of initial workup for hyperkalemiaThorough h&p Urine K+ excretion Plasma renin activity, serum aldosterone, serum cortisol (evaluate RAAS) EKGTreatment of Primary Biliary CholangitisFirst Line: Antihistamines, Cholestyramine, Colestipol Second Line: Corticosteroids, colchicine, steroids Ursodeoxycholic AdicCauses of Peptic Ulcer DiseaseH. pylori, NSAIDs, malignancy, curling ulcers, cushing ulcers, gastrinomasWhich lung cancers have cavitationSquamous cell carcinoma is most likely to have cavitations. Small cell carcinoma is least likelyTreatment for GastroparesisMetoclopramide (PO) for stable disease Erythromycin (IV) for acute attackCyclic Vomiting SyndromeHabitual THC, N/V cycles for weeks. Tx by stopping THC and using Metoclopramide and Erythromycin to help.How to tell difference between invasive and enterotoxic diarrheaInvasive has blood and fecal leukocytes (lactoferrin), fever, leukocytosis. Enterotoxic has none of those.Stool Osmolar GapSOG = Measured Osm (290) - Calculated Osm (2 x Na + K) Under 30 = secretory (normal Osm is close to calculated) Over 100 = osmotic (other stuff if GIT other than electrolytes)Systemic Sclerosis effect on LungsHyperplasia of pulmonary arterial intima causing pulmonary HTN. Lung parenchyma unaffected -> normal FEV1/FVC ratioDefibrillation Vs CardiovertDefibrillation: V Fib or pulseless ventricular tachycardia (amiodarone after this + CPR fail) Cardioversion: Atrial fibrillation or Ventricular tachycardia with a pulse. Persistent narrow or wide QRS complex tachycardia causing hemodynamic instability.Lacunar Stroke of Posterolateral ThalamusAtherothrombotic occlusion of branches of posterior cerebral artery. Sensory loss of contralateral side of body (posteromedial nuclei is face). Transient hemiparesis, athetosis, ballistic movements.Thalamic Pain Syndrome (Dejerine-Roussy Syndrome)Several weeks to months following stroke in thalamus. Paroxysmal burning pain over affected area exacerbated by light touch (allodynia).TCA OverdoseHyperthermia, dilated pupils, intestinal ileus, seizures, QRS prolongation (risk of ventricular arrhythmia), hypotension. TX with sodium bicarbonateHepatorenal SyndromeRF: Advanced cirrhosis, portal HTN, edema Precipitating factors: low renal perfusion, GI bleed, vomit, sepsis, too much duiretic, low GFR (NSAIDs) Dx: Renal hypoperfusion, FeNa <1%, no tubular injury, no urine RBC/ granular casts/ protein, no improvement in renal function with fluids TX: Treat hypovolemia/ anemia/ infection, use splachnic vasoconstrictors (octreotide, NE, midodrine), liver transplantVagal ManeuversCarotid massage Cold water immersion or diving reflex Valsalva maneuver Eyeball pressure *increase PNS tone in heart and cause temporary slowing of conduction in the AV node and increase in AV node refractory period -> can terminate AVNRT (atrioventricular nodal reentrant tachycardia)Physical Counterpressure Maneuversleg crossing with tensing muscles, handgrip and tensing arm muscles with chenched fists, lying supine with leg raising. Done during prodrome before syncope -> improve venous return + CO, may abort syncopal episodeMinerals Absorbed in DuodenumFolate (macrocytic anemia) Iron (microcytic anemia) Calcium (osteoporosis)D xylose Absorption TestAbsorbed: Pancreatic enzyme problem not intestinal wall Not Absorbed: Intestinal luminal border problem (Endoscopy and biopsy)Diverticulitis TreatmentKUB: look for perforation/ obstruction CT: look for mild (liquid diet, oral Cipro/metronidazole or Gentamicin/ampicillin/metronidazole), severe (NPO, IV abx), or abscess (NPO, IV abx, drain)Treatment for Colon CancerSurgical resection, stage with a pan-CT, and FOLFOX/FOLFIRI chemo (VEGF inhibitor - Bevacizumab)Colon Cancer Screening- Colonoscopy every 10 years starting at age 50 (now 45) - Sigmoidoscopy at 50 every 5 years + fecal occult blood test every 3 years - FOBT every yearPeutz-Jeghers syndromeFreckles on the lips and cancers of the small bowel. Benign polyps in the colonCauses of CirrhosisViral HBV (sex) and HCV(IVDU) -chronic inflammation Wilson's - increased copper Hemochromatosis - iron overload A1AT - COPD + cirrhosus PSC - puritis, painless jaundice, men, extrahepatic PBC - intrahepatic, pruritis, painless jaundice, women EtOH NASH/NAFLD Something else *VW Happens*Treatment of GI Bleed1. Stabilize: 2 large bore IVs (18g+), IVF, IV PPI, type and cross, call GI *Cirrhotic - octreotide + ceftriaxone* 2. EndoscopyCancer caused by Sjorgens syndromeMarginal zone lymphoma is most common. Tumors arise in LN, mucosa associated lymphoid tissue, and exocrine glands. Unilateral glandular swelling (parotid), nodular gland, cutaneous vasculitis or palpable purpura, hypocomplementemia, systemic features (fever, weight loss, fatigue).Treatment of Upper GI BleedABCs, fluid replacement, IV PPI, +/- abxBrugada Criteria for VT1. No RS complex in any precordial leads 2. An R-to-S interval >100ms in any precordial leads 3. Arterioventricular dissociation (p waves are regular but not related to the rate of QRS complexes) 4. Leads V1, V2, and V6 fulfilling classic criteria for VT *If no criteria met, the rhythm is likely a wide-complex SVT*Increased Risk of HIT syndrome-Thrombocytopenia (drop in platelets >50% with nadir in platelets >20,000/uL -Timing (drop in platelets 5-10 days following exposure to heparin or w/I 24h if patient has had prior exposure within past 3 months) -Thrombosis (new)1 Unit PRBCs should increase Hemoglobin and Hematocrit by how muchHgB: increase of 1 unit Hct: increase of 3 unitsLeukemia CutisPlum colored purpura, cutaneous manifestation of leukemiaSickle Cell Children Vaccines + ABX prophylaxisS. pneumonia H. influenza N. menigitidis HBV Seasonal influenza Penicillin or erythromycin (if penicillin allergy) within 3 months of lifeAspiration PneumonitisLung parenchyma inflammation hours after aspiration of gastric acid with direct tissue injury. Can have no sx, nonproductive cough, low O2, respiratory distress. CXR infiltrates that will resolve on their ownPancreatitis ComplicationsEarly (1-3d): ARDS, Saponicifaction, Pleural Effusion, Ascites Mid (1-3wks): SIRS/Infection Late (3-7wks): Abscess, Pseudocyst OR Early: -GRASS- Glucose elevated Renal failure ARDS Sepsis Shock Late: -NAP- Necrosis Abscess PseudocystBest test for Pancreatitis outcomeBUN - unknown whyIBD (Crohn's + UC) TreatmentMild: 5-ASA (better for UC) Moderate: Prednisone, Immune modulators - 6MP, Azathioprine, Methotrexate (both) Severe: TNF inhibitor (infliximab) - Crohn's. Surgical resection - UC curative Flare: R/O infection (C diff), Prednisone + abx (cirpofloxacin/ ampicillin-gentamycin + metronidazole) Perianal disease: Drainage *Erythema nodosum - tender nodules on legs*Causes of Vertigo1. Meniere disease: sensorineural, tinnitus + ear fullness, recurrent, endolymphatic hydrops (Hearing loss, tinnitus, vertigo) 2. BPPV: Head movement cause sx, Dix-Hallpike cause nystagmus 3. Vestibular neuritis: 1 episode, post viral infection, head thrust test (same as labrynthitis but without hearing loss) 4. Migraine: visual aura 5. Brainstem/Cerebellar stroke: persistent vertigo, sudden onsetIntracranial HTN SymptomsHA worse at night, N/V, decreased consciousness/ cognitive function, vision changes, unsteady gait, seizures. Leaning forward, Valsalva, cough increase pressure + SX.Acute Interstitial NephritisCause: Penicillins, TMP-SMX, cephalosporins, NSAIDs SX: Macopapular rash, fever, new drug exposure, +/- arthralgias Labs: AKI, pyuria, hematuria, WBC casts, eosinophilia, urinary eosinophils, biopsy - inflammatory infiltrate + edema TX: DSC offending drug, +/- systemic corticosteroidsDrugs Associated with PhotosensitivityTetracyclines Chlorpromazine/ Prochlorperaazine Furosemide/ HCTZ Amiodarone Promethazine PiroxicamPhlegmonSolid mass of inflamed pancreas. Complication of pancreatitis. Often with patchy necrosis. Can become secondarily infected causing a pancreatic abscessHyper/Hyponatremia and Free WaterHypoNa: less stuff in blood, free water into cells and cell swelling HyperNa: More stuff in water, free water moves into blood and cells shrink (2 x Na) + glucose/18 + BUN/2.8 = Serum Osm (~280)Hyper/Hyponatremia SymptomsMild: Asx Moderate: N/V, confusion, headache Severe: Coma, seizuresHypernatremia TreatmentMild: free water by mouth Moderate: IVF with normal saline Severe: D5WHyponatremia TreatmentMild: dz specific Moderate: IVF with normal saline Severe: 3% NaClHypertonic HyponatremiaGlucose or BUN elevated and Na is correcting for the serum Osm by decreasing. For every 100 increase in BS over the 1st 100 increase serum Na by 1.6 (common in DM)Hypotonic Hyponatremia TreatmentVolume Up: diuresis Volume Down: IVF with normal saline - fluid resuscitation Euvolemia: RTA (U/A, urine electrolytes), Addison's (cortisol), Thyroid disease (TSH), SIADH (DX of exclusion) - TX with volume restriction, gentle diuresis, demeclocyclineAnticoagulation in HITAgratroban in normal hepatic and renal function and renal dysfunction Fondaparinux in hepatic dysfunction Agratroban or Bivalirudin at reduced doses in hepatic and renal dysfunctionTesting for HIT SyndromeAnti-PF4 antibodies Serotonin-release assay is gold standardCauses of HypermagnesemiaDKA Tumor lysis syndrome Excessive tissue breakdown (sepsis, burns, trauma) Adrenal insufficiency RhabdomyolysisHyperbilirubinemia DDXMainly Unconjugated: Hemolysis, drugs/portosystemic shunt, Gilbert syndrome Mainly Conjugated: Predominanty high AST + ALT - Viral hepatitis, autoimmune hepatitis, toxin/drug-related hepatitis, hemachromatosis, ischemic hepatitis, alcoholic hepatitis. Normal AST, ALT, Alkaline Phosphate: Dubin-Johnson syndrome, Rotor syndrome Predominantly elevated alkaline phosphatase: Cholestasis or pregnancy, malignancy (pancreas, ampullary), cholangiocarcinoma, primary biliary cirrhosis, primary sclerosing cholangitis, choledocholithiasis -> abdominal imaging (usg/ CT), Antimitochondrial antibodyHow does Sodium Bicarbonate work in TCA overdoseTCAs inhibit Na channels in the His-purkinjie system and myocardium. Increases duration of repolarization, and prolongs absolute refractory periods. Result is hypotension, QRS prolongation, and ventricular arrhythmias (VT, VF). Sodium Bicarbonate: increases serum pH and extracellular sodium. Increased pH decreases drug activity for Na channels. Elevated extracellular Na increases electrochemical gradient across cardiac cells and ability of TCAs to bind to fast Na channelsMixing Study to Diagnose Hemophilia vs antiphospholipid antibodyHemophilia: positive mixing study, clotting after mixing (adding clotting factors) Antiphospholipid Antibody: negative mixing study, no correction because it is a clotting inhibitorDiabetic Nephropathy ProgressionHyperfiltration: glomerular hypertrophy, increased GFR Incipient DN: Mesangial expansion, GBM thickening, anterior hyalinosis. Moderately increased albuminemia. HTN Overt DN: Mesangial nodules (Kimmelsteil-Wilson lesion), tubulointerstitial fibrosis. Overt proteinuria. Nephrotic syndrome. Decreased GFRAnterior Uveitis vs Acute Angle GlaucomaUveitis: painful, red eye with photophobia, tearing, diminished visual acuity Glaucoma: red, painful eye with diminished visual acuity, more common in elderly, headache, nausea, vomitingWhat conditions cause secondary ITPHIV Hepatitis C SLE Acute or Subacute Viral InfectionsHow does Sodium Polystyrene increase K+ excretionKayexalate is a cation exchange resin that works by increasing K+ excretion through the GI tract4 features of Nephrotic SyndromeProteinuria Edema Hyperlipidemia HypoalbuminemiaSecondary causes of GlomerulonephritisLupus nephritis Postinfectious glomerulonephritis (poststreptococcal GN) HCV + HBV related GN (cryo-GN) Vasculitis-related GN (Wegners, Churg-Strauss, polyarteritis nodosa, microscopic polyangitis, Henoch-Shonlein purpura) Infective endocarditis GN(+) Glomerular Immune Complexes and granular IF staining and Low C3/C4: GlomerulonephritisSLE (+ ANA, anti-smith, anti-DNA) Postinfectious (+ ASO) Infectious endocarditis (+ Blood cultures) Cryoglobulinemia (+ cryoglobulin/ HCV, HBV) Membranoproliferative GN(+) Glomerular Immune complexes and Granular IF staining and normal C3/C4: GlomerulonephritisPrimary GN: no IgA immunostain Systemic Vasculitis - IgA Nephropathy or Henoch-Shonlein purpura: (+) IgA immunostain(+) Circulating anti-GBM and linear IF staining: GlomerulonephritisAnti-GBM GN: no lung involved Goodpasture GN: lung involved(+) p-ANCA and Paucy-immune IF staining: GlomerulonephritisMicroscopic polyangitis or Polyarteritis Nodosa: No granulomas Churg-Strauss: (+) Granulomas, Asthma, Eosinophils(+) c-ANCA and Paucy-immune IF staining: GlomerulonephritisWegner's GNWhich Antimicrobials work just as good PO as IV?Quinolones Azithromycin Doxycycline Clindamyin Metronidazole TMP-SMX Fluconazole LinezolidShy-Drager syndrome SymptomsMultisystem atrophy - spontaneous myelin degeneration, glial inclusions Akinetic rigid parkinsonism, ANS failure (urogenital dysfxn, Cerebellar ataxia, pyramidal signs - UMN lesion, impotence, abnormal lacrimation + salivation, postural hypotension), cognitive dysfunction Dysphagia, hemibalism, chorea, dystonia, stridor, OSA, central sleep apnea, ataxic breathingUse of Memantine in AlzheimersNoncompetitive antagonist of NMDA glutamate receptors AD has high receptor activity -> prevents Mg from re-entering and blocking channel pore causing chronically open state and excessive Ca2+ influxBrugada SyndromeAD mutation in cardiac Na channel SCN genes - reduce Na inflow and duration of normal AP Sudden cardiac arrest from VT or V fib, syncope from tachyarrhythmia, palpitations from AF, nocturnal agonal respirations Type 1 ECG: elevated ST descends with upward convexity to an inverted T wave Type 2 ECG: ST segment has saddle back, elevated ST descends towards baseline and then rises again to an upright or biphasic T waveAV Junctional TypeAVNRT: Reentrant circuit using dual pathways within the AV node (AV node Reentrant tachyardia) AVRT: Reentry through AVN + accessory pathway. Pre-excitation (WPW) or concealed accessory pathway. Can be orthosdromic or antidromic.UA Osmolarity Calculation from UA Specific GravityLast 2 digits of urine specific gravity x 30 1.010 -> 10 x 30 = 300mOsm/kg -> urine osmNephrotic Syndrome ComplicationsRenal protein wasting Low Antithrombin III, protein C + S --> hypercoaguable Hypogammaglobulinemia --> increased infection risk (pneumococcal infection) Hypotransferrinemia --> iron deficiency anemia Low Vitamin D binding protein --> Vitamin D deficiencyAlbumin to Calcium ratioAlbumin normal = 4 Calcium normal = 10 ∆ Albumin of 1 causes ∆ Ca by 0.8Hypocalcemia SymptomsTetany Perioral tingling Trousseau's sign Chvostek's sign Check albumin levels to see if it corrected itself (added 0.8 to value)Types of Hyperparathyroidism1° autonomous adenoma 2° early renal failure, appropriate response to low Ca 3° autonomous from long term kidney failure, multiple adenoma (cinacalcet prevents this) High PTH, High Ca, Low PhosCancer Causing HypercalcemiaCancer mets invade bone -> High Ca and P (PTH is low) PTH-rp is also released from cancer (Squamous cell carcinoma of lungs) -> High Ca, low P (PTH-rp binds PTH receptor), low PTHHypervitaminosis D: Causes and blood levelsGranulomas (sarcoid, TB) High Ca, High P, Low PTH Check 1,25-Vitamin D blood levelFamilial Hypercalcemic HypocaliuriaInactivating mutation of the calcium sensing receptor gene -> less sensitive ASx high Ca (11-12) Low urine Calcium High PTH Kidney also increases Mg reabsorption and can be high Phosphorous is normal Look for family historyPseudohypoparathyroidismPTH insensitivity in end organs High PTH, Low Calcium, High PhosphorousTreatment of Hyperkalemia MnemonicC BIG K Calcium gluconate Beta agonists/ bicarbonate Insulin Glucose Kayexalate *Calcium for cardiac stabilization, Insulin/ glucose or Beta agonists or Sodium bicarbonate for rapid acting tx*Acute BronchitisNormally after viral respiratory illness, cough for 5 days to 3 weeks, no systemic findings, wheezing or rhonchi and chest wall tenderness. Symptomatic treatment (NSAIDs and Bronchodilators), no antibioticsTumor Lysis SyndromeAfter cytotoxic chemotherapy High phosphorous, potassium, uric acid (cell lysis). Low calcium (binds phosphate and precipitates) AKI (uric acid + calcium phosphorous). Cardiac arrhythmias (high K) Give IV fluids and allopurinol/ rasburicaseDrug Induced Lupus CausesProcainamide Hydralazine Isoniazid Diltiazem Check anti-histone levelMost common cause of MRMVP - myxomatous degeneration of the mitral valve leaflets and chordaeWhen to Treat Based on PPD Induration>/= 5mm: HIV +, contact with TB +, nodular/fibrotic changes on CXR (prior TB), organ transplant/ immunosuppressed >/= 10mm: <5 yr immigration from TB endemic area, IVDU, resident/employee of prison/ nursing home/ hospital/ homeless shelter, work in mycobacterium lab, high risk for TB reactivation (DM, leukemia, ESRD, chronic malabsorption syndrome), kid under 4 or exposed to adult in high risk category >/= 15mm: Healthy individualsStrep viridians groupCan cause infective endocarditis from gingival manipulation and respiratory tract incision or biopsy. Streptococcus sanguinis, mitis, oralis, mutants, sobrinus, milleriDOC for SLEHydroxychloroquin Helps improve joint symptoms and prevents disease flares. Used as monotherapy if mild symptoms, add steroids for more severe cases Steroids - flare IV cyclophosphamide - lupus nephritis (acute) PO mycophenolate mofetil - lupus nephritis (chronic)Treatment of HyperkalemiaRecheck K (may be hemolysis) ECG: peaked T waves, wide QRS = unstable (no ECG ∆ is stable) Unstable = Emergent: 1. Stabilize cardiac myocytes with Calcium 2. Temporize by shifting K into cells with Insulin and D50 and NaHCO3 and Beta Agonists 3. Decrease K through urine with Loop Diuretics and through stool with Kayexalate. Dialysis if absolutely needed. Stable = UrgentTreatment of HypokalemiaGI loss: vomit and diarrhea Renal loss: high Aldosterone + diuretics Recheck K ECG: flat T waves Replete K: 1. oral better than IV 2. Peripheral IV <10mEq/hr (burns) 3. Central IV <20mEq/hr (hyperK on heart) 10mEq of K will change serum K by 0.1 Magnesium can cause refractory hypokalemia!Diagnosing Kidney StoneUrinalysis Non Contrast CT of Abdomen is the best - look for stone or hydronephrosis (can't do in pregnancy) Ultrasound KUB XR - good for tracking stoneTreatment of Kidney Stones<5mm give IVF and pain meds <7mm medical expulsive therapy (CCB, alpha blocker to dilate ureter) In between: lithotripsy (proximal) or urethroscopy (distal) >3cm Surgery Septic: Nephropathy (proximal) or stent (distal)Types of Kidney StonesCaOxalate - radio opaque (TX with thiazides, low red meat and increase citrate) Struvite - radio opaque (TX with ABX + surgery if too large) Uric Acid - radio lucent (TX allopurinol + rasburicase) Cystine - radio lucentMetabolic Alkalosis DiagnosisUrine Chloride Under 10: Diuretics, dehydration, emesis/ NG suction (contraction alkalosis) Above 10: look for HTN 1. HTN: Hyperaldosteronism (renal artery stenosis and primary hyperaldosteronism) 2. No HTN: Barters + Gittlemans diseaseMUDPILES for Metabolic AcidosisANION GAP: Methanol Uremia DKA Propylene glycol Isoniazid or Iron Lactate Ethylene glycol Salicylates NON ANION GAP: Urine anion gap = Na + K - Cl 1. Gap: RTA 2. No gap: DiarrheaAdd Back Method to Check Bicarbonate in Anion Gap AcidosisCalculate Anion Gap How much more H+ is needed from 12 (normal anion gap) to get to calculated anion gap Add number of H+ needed to Bicarbonate 1. If this number above normal Bicarbonate (24) --> Anion gap acidosis with metabolic alkalosis 2. If this number is below normal Bicarbonate (24) --> Anion gap acidosis with a non-gap metabolic acidosisPrognosis Factors in Breast Cancer1. TNM staging 2. ER+ and PR+ (good prognosis) 3. Her2/neu overexpression (worse prognosis) 4. Histological grade of tumorPostconcussive SyndromeFollowing mild TBI Headache, confusion, amnesia, difficulty concentrating or multitasking, vertigo, mood alterations, sleep disturbances, anxietyPes Anserinus Pain SyndromeAnserine bursitis - caused by abnormal gait, overuse, trauma. Conjoined tendon of gracilis, sartorius, and semitendinosus. Localized pain over anteromedial tibia, not aggravated by valgus stress test. Pain when lying on side and other knee is pressing on injured bursa.External HordeolumStye. Acute inflammatory disorder of the eyelash follicle or tear gland and presents as an erythematous, tender nodule at the lid margin. MC infection with Staph aureus but can be sterile.Reticulocyte IndexOver 2% = RBC destruction and bone marrow trying to compensate Less 2% = RBC production anemia and bone marrow can't compensateMacrocytic Non-Megaloblastic Anemia CausesCirrhosis Alcohol Drugs (5-FU, Cytarabine, Zidovudine) Metabolic (Lesch Nyhan, Hereditary Orotic Aciduria)Sideroblastic Anemia CausesReversible: Drugs, Alcohol, Lead poisoning Irreversible: B6 deficiency, Myelodysplastic syndrome Ringed sideroblasts on bone marrow biopsyG6PD MedicationsDapsone TMP-SMX NitrofurantoinAutoimmune Hemolytic Anemia+ Coombs test IgM: Mycoplasma, Mono TX with avoiding cold + Coombs test IgG: Autoimmune, Cancer TX with steroids, rituximab, splenectomy **Will see spherocytes on blood smear**Diagnosing and Treating Paroxysmal Nocturnal HemoglobinuriaDx: Flow cytometry shows CD55/59 (-) TX: Eculizumab in severe casesAcalculous cholecystitisRF: Severe trauma or recent surgery, prolonged fasting/ TPN, Sepsis/ ICU, burns Sx: Jaundice, leukocytosis, high LFTs, RUQ pain, fever Dx: abd US, HIDA/ CT if needed Tx: Enteric ABX, cholecystostomy for drainage, cholecystectomy when stableMixed CryoglobulinemiaHTN is MC presentation - Palpable purpura - Proteinuria - Hematuria - Glomerulonephritis - Peripheral neuropathies - Arlthralgias - Hepatosplenomegaly - Elevated liver enzymes - Hypocomplementemia Can have CNS and pulmonary involvement *Usually have underlying HCV infection or SLE. Rheumatoid factor will be elevated*BUN + BUN/Cr in GI BleedElevated because of increased urea production from intestinal breakdown of hemoglobin AND increased urea reabsorption by the proximal tubule due to hypovolemiaTreatment of Comedonal, Inflammatory, and Nodular/Cystic AcneComedonal: Topical retinoids, salicylic, azelaic, glycolytic acid Inflammatory: Topical retinoids, benzoyl peroxide (mild), topical erythromycin/ clindamyin (moderate), oral abx (severe) Cystic: Topical retinoids, benzoyl peroxide, topical abx (moderate), oral abx (severe), oral isotretinoin (unresponsive severe)Antibiotics for Asymptomatic Bacteriuria and Cystitis in PregnancyNitrofurantoin Cephalexin Amoxicillin-clavulanic acid FosfomycinBradycardia TreatmentAssess airway and monitor oxygen IV access in place Atropine 0.5mg IV push repeat 3 to 5 minutes Transcutaneous pacing ASAPSkin Findings in SarcoidosisErythema nodosum (tender nodules on the shin) Lupus perino (violaceous rash on nose and cheeks)Causes of Muscle Failure in Achalasia + ComplicationDysfunction of nitric oxide synthase producing neurons Denervation of esophageal muscle *Increased risk for squamous cell carcinoma*Bundle Branch BlockWide QRS with bunny ears in V1 (big R wave) = RBBB Wide QRS in lead I and big S wave in V1 (below baseline) = LBBBNeurogenic Claudication (Pseudoclaudication)Posture dependent pain Lumbar extension worsens pain (walk downhill) Lumbar flexion relieves pain (bent forward when walking) Lower extremity numbness + tingling Lower extremity weakness + back pain Normal pulses and examination MRI of spine to diagnoseFixed Upper Airway Obstruction: Pulmonary Flow Volume LoopObstruction limits airflow during inspiration and expiration Flattening of top and bottom of volume curve. Can be due to laryngeal edemaSerum-ascites albumin gradient (SAAG)Serum albumin - Ascites albumin SAAG over 1.1 means ascites is from portal HTN: Cirrhosis, Heart failure, Hepatic metastasis, Thrombosis (Budd-Chiari syndrome, portal vein thrombosis) Under 1.1 means cause other than portal HTNPancreatitis TreatmentSupportive care - Pain control - IVF - Bowel rest Usually self limiting and improve in 4-7 days. **Nothing by mouth except essential medications (antiplatelet if have stent)**Panhypoputuitarism LevelsLow cortisol + ACTH Low FSH, LH, Testosterone Low TSH + Free T4 **Normal Aldosterone - regulated by RAAS**Infections After Liver Transplant Over Time< 1 month: Bacterial from operative complications (hepatic abscess, biliary leak, wound infection) or hospitalization (intravascular catheter, external drain) 1-6 months: Opportunistic (CMV, Aspergillus, TB) when high dose immunosuppressive meds > 6 months: Maintenance immunosuppressants, typical community acquired infections at higher rate than general populationJuvenile DermatomyositisSymmetric proximal muscle (perimysial [polymyositis is endomysial] weakness Heliotrope rash (reddish purple) - on cheeks, nasal bridge, eyelids Gottron papules - flat-topped erythematous hyperkeratotic papules on MCP + PIP, DIP Elevated muscle enzymes Myopathic electromyography Inflammation + necrosis on biopsy MRI of muscle will show edema -> inflammation of muscle (don't need bx or EMG if (+) MRI and elevated enzymes) **Mediated by CD4+ and B cells (Polymyositis = CD8+)** Tx: glucocorticoids, azathioprine, methotrexateDrugs that cause Torsades de PointesABCDEs AntiArrhythmics (class IA - quinidine + class III) AntiBiotics (macrolides) Anti"C"ychotics (haloperidol) AntiDepressants (TCAs) AntiEmetics (ondansetron) Methadone, cisapride, arsenic toxinChronic PancreatitisCause: alcohol use, CF, ductal obstruction, autoimmune SX: epigastric pain with intermittent pain free intervals, malabsorption, DM Labs: amylase/ lipase can be normal. CT/ MRCP shows calcifications, dilated ducts, large pancreas TX: pain management, alcohol + smoke stop, small frequent meals, pancreatic enzyme supplementDrug Induced AcneGlucocorticoids, androgens, immunomodulators (Azathioprine, EGFR inhibitors), anticonvulsants (phenytoin), antipsychotics, antiTB (isoniazid) Monomorphic papules/ pustules, no comedones/ cysts/ nodulesRai and Binet Staging for CLLRai Stage 0: Lymohocytosis I/II: Lymphadenopathy and organomegaly III/IV: Anemia and thrombocytopenia Binet Stage A: Fewer than 3 LN sites B: 3+ LN sites involved C: Anemia and thrombocytopenia *Later stage = worse prognosis and less remission chance*Tropheryma whippleiIn sewage and waste water Weight loss, arthralgias, diarrhea w/ or w/o blood, abdominal pain, oculomasticory myorhythmia *Brain, arthralgias, diarrhea, lymphadenopathy* Complications: Endocarditis, malabsorption, dementia, skin hyperpigmentation, arthritis, steatorrhea, nystagmus *PAS (+) macrophages on histology* TX: - Doxycycline - TMP-SMXOculomasticatory MyorhythmiaWhipple's disease Eye movement disturbances with rapid repetitive movement of facial musclesPolysaccharide Vaccine vs Conjugate Vaccine ImmunityPolysaccharide: T cell independent B cell response, less effective in young and old Conjugate: T cell dependent B cell response, improved immunogenicity from formation of higher affinity antibodies and memory cellsLab Tests to Order in Atrial FibrilationRenal function Electrolytes TSH CBC PT/INRHow to treat SarcoidosisGlucocorticoids Refractory Methotrexate Infliximab Lung transplantParaneoplastic Syndromes in Large Cell CarcinomaGynecomastia GalactorrheaVital signs and Labs seen in Toxic MegacolonFever >38°C HR over 120 BPM Neutrophilic leukocytosis >10,500 Anemia HypotensionFelty SyndromeRA, splenomegaly, neutropenia, Lymphadenopathy, thrombocytopenia SANTA: Splenomegaly, Anemia, Neutropenia, Thrombocytopenia, Arthritis (RA) Seen in severe nodule forming RA Positive anti-RF and anti-CCP Markedly elevated ESRAge Related Sicca SyndromeAge related dry eye syndrome Lacrimal and salivary gland exocrine output declines with age, associated with atrophy, fibrosis, and ductal dilation of the glandsHPV Vaccination RecommendationsMale and females 11-12, can be as early as 9. For patients who did not get it as a kid can do up to 26 in women and up to 21 in men Not for adultsNonallergic RhinitisNasal congestion, rhinorrhea, sneezing, postnasal drainage Later onset (>20), no obvious allergic trigger Perennial symptoms (can worsen with seasonal changes), erythematous nasal mucosa TX: Mild - intranasal antihistamine or glucocorticoids Moderate/ Severe - combination therapySubacute Granulomatosis Thyroiditisde Quervian's Fever, myalgias, jaw pain, and tender thyroid 1st hyperthyroid and then hypothyroid Elevated ESR, painful thyroid and decreased radioiodine uptake Self limited and resolves without interventionRiedel ThyroiditisChronic inflammatory disease Slow fibrous replacement of thyroid causing hypothyroid Thyroid is enlarged but nontenderCreutzfeldt-Jakob EEGSharp, triphasic, synchronous discharges Rapidly progressive dementia and myoclonusCarcinoid Syndrome FeaturesSkin flushing, telangiectasias, cyanosis, diarrhea + cramping, valvular lesions (R > L), bronchospasm Octreotide + surgery for liver metastasisLemierre SyndromeHigh fever, rigors, respiratory symptoms, unilateral neck swelling/ pain Affects healthy adolescents and young adults Fusobacterium necrophorum causes tonsillopharyngitis followed by bacteremia leading to septic thrombophlebitis of internal jugular vein and septic emboli to lungs Look for thrombophlebitis with neck US, high resolution CT, MRIARDS vs Cardiogenic Pulmonary Edema Swan-Ganz CatheterARDS: less than 18 mmHg Cardiogenic Pulmonary Edema: over 18 mmHg PCWPWhat is CalciphylaxisTissue ischemia from calcification of smaller BVs Elevated phosphate causes Ca-phosphate precipitationScleroderma Renal CrisisSystemic Sclerosis can cause interstitial and perivascular fibrosis of the kidneys Sudden onset HTN Papilledema Azotemia Microangiopathic hemolytic anemia Hematuria Proteinuria *ACE inhibitors can delay, prevent, and reverse uremia in this patients*Side Effects DMARDsMethotrexate - Hepatotoxicity, stomatitis, cytopenias Leflunomide - Hepatotoxicity, cytopenias Hydroxychloroquine - Retinopathy Sulfasalazine - Hepatotoxicity, stomatitis, hemolytic anemia TNF Inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab) - Infection, demyelination, CHF, malignancyEmpiric ABX for Purulent or Non-purulent CellulitisClindamycin Amoxicillin plus TMP-SMX Amoxicillin plus TetracyclineABX for Erysipelas w/o Systemic ManifestationsOral penicillin and amoxicillinAge in ALL, CLL, AML, CMLALL: 7 and CLL: 87 (extremes of age) CML: 47 and AML: 67 (you can get AML from CML blast crisis so CML has to be younger)What to do with no tender LNExcisional biopsy Then stage: CXR CT chest/ abdomen/ pelvis BM biopsyHodgkin's vs Non-Hodgkin's LymphomaH: Pel Epstein fevers (cyclical), EtOH LN pain, B symptoms NH: Burkitts lymphoma (starry sky), extranodal disease, no B symptomsChemo Man ToxicitiesC = Cisplatin - Ototoxicity and nephrotoxicity V = Vincristine and Vinblastine - peripheral neuropathy B = Bleomycin - pulmonary fibrosis D = Danarubicin and Doxarubacin - cardiomyopathy MF = Methotrexate and 5-FU - BM suppression P = Cyclophosphamide - hemorrhagic cystitis N = Nitrosureas (lomustine, carmustine) - cross BBB + neurotoxicMultiple Myeloma Diagnosis + TXSpep (serum electrophoresis) = M spike Upep (Urine electrophoresis) = Bence Jones proteins Skeletal study (series of X rays) = lytic lesions/ osteopenia BM biopsy showing >10% plasma cells CRAB (hyperCalcemia, Renal failure, Anemia, Bone pain) TX: >70 no donor - chemo <70 with donor - HSCT Melphagan chemo and steroids based TXMonoclonal Gammopathy of Undetermined Significance DxSpep (serum electrophoresis) = M spike Upep (urine electrophoresis) = NO Bence Jones Skeletal survey (series of X rays) = NO lytic lesions BM biopsy <10% plasma cells TX: watch and wait until it becomes MMWaldenstrom's MacroglobulinemiaSpep (serum electrophoresis) = M spike Upep (urine electrophoresis) = NO Bence Jones Skeletal survey (series of X rays) = NO lytic lesions BM biopsy >10% lymphoplasmacytic lymphocytes Hyperviscosity syndrome and constitutional symptoms TX: Rituximab and plasmaphoresis Hyperviscosity, neuropathy, bleeding, hepatosplenomegaly, lymphadenopathy. IgM spike, rouleaux on peripheral smear. >10% clonal B cellsAmaurosis FugaxTransient monocular blindness from retinal ischemia, MC from emboli originating from carotid artery "Gray shade being pulled down over eye"Hepatic HydrothoraxTransudative pleural effusion through small defects in diaphragm, MC on R side From cirrhosis and portal HTN Dyspnea, cough, pleuritic chest pain, hypoxemiaProphylaxis for Esophageal Varices HemorrhageEndoscopic variceal ligation Nonselective Beta blockers - reduce portal venous pressure by blocking vasodilation in mesenteric arterioles which caused unopposed alpha vasoconstriction and reduced portal blood flowTreatment of TTP, DIC, HIT, ITPTTP: Exchange transfusion (NEVER platelets) DIC: Supportive, fix underlying disease, give blood/ platelets/ fibrinogen depending on what they need HIT: Stop heparin, start argatroban (need anticoagulation), bridge to warfarin ITP: steroids, IVIG (hide platelets from body antibodies), splenectomy (culprit of disease), Rituximab (rescue therapy)Thrombophilia CausesFactor V Leiden (MC but not very potent) - can't be blocked by protein C Prothrombin 20210A (common but not very potent) - Antithrombin can't break down Protein C or S deficiency (rare but severe) - blocks V Antithrombin deficiency (rare and severe) - blocks IIa *Anticoagulation after 2nd clot* Antiphospholipid Antibody Syndrome - Lupus Anticoagulant (causes clots in the body, cause bleeding in vitro) *Anticoagulation after 1st clot* Trauma and surgery (10x increased thrombosis risk) Cancer (20x thrombosis risk)Antiphospholipid Antibody SyndromeLupus Anticoagulant Clots in vivo, bleed in vitro Dx with Russel Viper Venom Assay Treat with warfarin (2-3 INR and 4-5 if failure) OR LMW heparin if pregnantLambert Eaton Syndrome SymptomsSymmetric proximal muscle weakness (standing from chair, combing hair) Autonomic dysfunction (dry mouth, erectile dysfunction) Cranial nerve involvement (ptosis) Diminished/ absent DTRs 50% associated with cancer (Small Cell Lung Carcinoma)Sympathetic OphthalmiaSpared eye injury Immune mediated inflammation of sympathetic eye after penetrating injury to the other eye. Anterior Uveitis, panuveotis, papillary edema, blindness. Uncovering of hidden antigens that are normally protected from immunologic recognition by natural barriers. *cell mediated reaction and autoantibodies*Adhesive CapsulitisFrozen shoulder Decreased passive and active ROM. More stiffness than pain. Glenohumeral joint loses its normal distensibility due to chronic inflammation, fibrosis, and contracture of the joint capsuleAmyloidosisAsymptomatic proteinuria or Nephrotic Syndrome Hepatomegaly and macroglossia (visible organ enlargement) Cardiomyopathy (usually restrictive) Peripheral/ autonomic neuropathy Waxy skin thickening and easy bruising Bleeding diathesisPainless ThyroiditisVariant of autoimmune thyroiditis, mild brief hyperthyroid phase, small nontender goiter, spontaneous recovery Positive TPO antibody and low radioiodine uptakePseudotumor CerebriIdiopathic intracranial HTN Increased intracranial pressure in an alert patient No focal neurological symptoms except CN VI palsy Normal CSF exam except for increased pressure Tx with acetazolamide - inhibits choroid plexus carbonic anhydrase which decreases CSF production *Blindness is MC complication*Antibiotic Ladder for G(+) and G (-)Lowest Penicillin - works for G (+) and (-) Medium G (+): Methecillin/ Nafcilin G (-): Amoxicillin/ Ampicillin (with sulbactam/ clavulanic acid to cover G(+) too) High (resistant) G (+) MRSA: Vancomycin G (-) Pseudomonas: Pipericillin (with Tazobactam to cover G (+) too) Highest (very resistant) G (+): Linezolid G (-): Carbapenems **Cephalosporins 1st and 2nd generation for G (+), 3rd generation for G (+) and G (-), 4th generation for G (-) Pseudomonas** **Fluoroquinolones 1st generation (Cirpofloxacin) works for G(-), 2nd generation (Levofloxacin) is soft tissue infections + URI mostly G(-), and 3rd generation (moxifloxacin) covers G(-) and G(+) for pneumonias**Anaerobic AntibioticsMetronidazole - Abdomen and Groin Clindamycin - anywhere else in the bodyEmpiric Coverage for CAP, HCAP, Meningitis, UTI, CellulitisCAP: Moxifloxacin (IV or PO) or Azithromycin or Ceftriaxone (IV in hospital) and Azithromycin (PO can go home) - S pneumonia, M catarralis, H flu, Klebsiella, S aureus, Legionella HCAP: Vancomycin and Pipericillin / Tazobactam (MRSA and Pseudomonas) Meningitis: Ceftriaxone, Vancomycin, +/- steroids, +/- Ampicillin (immunocompromised) UTI: Amoxicillin (pregnant) or Nitrofurantoin (woman) or TMP-SMX (no renal failure) or Fosfomycin (sulfa allergy) or Ceftriaxone (IV and sepsis and pyelonephritis) or Cirpofloxacin (PO ambulatory with pyelonephritis) Cellulitis: Vancomycin (MRSA) or Clindamycin or TMP-SMX or 1st or 2nd cephalosporin if not MRSAPrEP and PEP for HIV and PregnancyPrEP (pre exposure): Emtricitabine + Tenofovir (NRTIs) PEP (post exposure): Emtricitabine + Tenofovir +/- Raltegravir (integrase inhibitor) Pregnancy: 2 + 1 and also ZidovudineOpportunistic Infections and HIV>500 - normal infections >350 - normal infection more often <200 - PCP (TMP-SMX or Dapsone or Atovaquone) +/- steroids if hypoxic <100 - Toxoplasmosis (TMP-SMX or Pyrimethamine and Leucovorin) <50 - MAC (Azithromycin)TB Screening and TreatmentPPD If (+): Exposed - get CXR If (-): Not exposed - Annual screen, 2 tier test (do it twice) CXR If (+): Activated TB - RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) If (-): Latent - need Isoniazid + Vit B6 for 9 months **BCG vaccine treat extrapulmonary TB in neonate in 3rd world country - treat PPD as normal (but do gamma interferon)** **if had (+) PPD in the past then start screen with CXR from now on**RIPE TB Side EffectsRifampin: Red tears and urine Isoniazid: Peripheral neuropathy (B6) Pyrazinamide: Hyperuricemia and Gout Ethambutol: Red green color blindnessOrgans Effected in SepsisHeart: hypotension Brain: altered mental status Kidney: BUN/Cr elevation Liver: high LFTs Lungs: ARDSGoals of Sepsis TherapyCVP 10-12 (*Fluid: 2-3L and ABX*) Urine output >/= 0.5cc/kg/hr MAP >65 mmHg (Vasopressors) Central venous oxygen saturation over 70% **Remove source/ plastic (catheters, central lines)**FAILS Mnemonic for Unsafe Lumbar PunctureFocal neurological deficit Altered mental status Immunocompromised (neonate, elderly, monoclonal ab, HIV therapy, chemotherapy) Lesion Seizures **If unsafe - give antibiotics look for space occupying lesion on CT scan then do LP if (-)** **If mass lesion and HIV (+) or AIDS and Toxoplasmosis Ab (+) - treat with TMP-SMX and re-scan in 6 weeks** **If mass lesion without HIV/ Toxo Ab - perform brain biopsy - cancer needs chemo/ radiation and if abscess need drainage and ABX**Empiric Treatment for Bacterial and Nonbacterial MeningitisBacterial: Ceftriaxone, Vancomycin, Steroids, (if immunocompromised then Ampicillin too) Cryptococcus - Amphotericin B Rocky Mountain Spotted Fever + Lyme - Ceftriaxone TB - RIPECellulitis TreatmentNontoxic/ Nonseptic Strep: 1st generation cephalosporins (PO) Staph: TMP-SMX, clindamycin (PO) Toxic/ Septic Strep: Piperacillin/ Tazobactam, Ampicillin/ Clavulanic acid (IV) Staph: Vancomycin, Linezolid, Clindamycin (IV) Diabetic with ulcer and cellulitis Vancomycin and Piperacillin/ Tazobactam **Osteomyelitis will be refractive - 6 weeks of pip/tazo and vanc**Gas Gangrene and Necrotizing Fascitis TreatmentGG: X Ray to see gas, Debridement, Penicillin and Clindamycin NF: X Ray to see gas, Debridement, Vancomycin + Piperacillin/ Tazobactam. FOR EXAM 3rd generation cephalosporins, clindamycin, ampicillinAbscess in Lung and Bronchitis TreatmentAbscess: Does not need drainage Tx:3rd generation cephalosporin and Clindamycin Bronchitis: Macrolide or Doxycycline or Fluoroquinolone (moxifloxacin)When to get Urine CulturePregnant Recent procedure Unknown organism > 10 ^5 colonies on UAAcid Base Shifts in Calcium HomeostasisIncrease in pH causes albumin to dissociate from hydrogen and then albumin binds calcium. Decreased free ionized calcium can cause hypocalcemia symptoms (total calcium is unchanged) *H+ leaves albumin in acidotic state*Papillary Muscle Rupture vs Interventricular Septum RuptureWithin 3-5 days post MI Papillary: Severe pulmonary Edema, new holosystolic murmur Septum: Chest pain, new holosystolic murmur, biventricular failure, shockEpidural Spinal Cord CompressionLower extremity motor weakness and ataxia Hyperreflexia Bladder and bowel dysfunction Saddle Anesthesia MC locations are thoracic and lumbar spine TX with IV glucocorticoids - decrease vasogenic edema (from obstructed epidural venous plexus), alleviates pain, and can restore neurological function XR + MRI --> drain, hematoma, I&D, ABX for abscess, surgery for fx, radiation for cancerLaxative Abuse vs Carcinoid vs VIPoma vs Adrenal Insufficiency vs GiardiaLaxative: melanosis coli (dark pigmentation), metabolic alkalosis, hypokalemia (impairs Cl reabsorption - decreases Cl-HCO3 exchange + metabolic alkalosis), frequent voluminous watery diarrhea, nocturnal diarrhea + cramps Carcinoid: Diarrhea, flushing, venous telangiectasia, bronchospasm, cardiac valve abnormalities VIPoma: Diarrhea during fasting and dehydration, tea colored stool, hypokalemia, hypochlorhydria, NO melanosis coli Adrenal: Hypotension, chronic diarrhea, Hyponatremia, hyperkalemia, metabolic acidosis Giardia: Persistent diarrhea, travel/ immunocompromised, NO melanosis coliBehcet DiseaseYoung adults, Turkish, Middle Eastern, Asian SX: Recurrent painful oral aphthous ulcers, genital ulcers, Uveitis, erythema nodosum, acneiform lesions, thrombosis DX: Pathergy - exaggerated skin ulceration with minor trauma (needlestick) Biopsy - nonspecific Vasculitis of different-sized vesselsAntiplatelet/ Antithrombin Therapy for Ischemic StrokePresentation within 3-4.5 hours of symptom onset - IV alteplase Stroke with no prior antiplatelet therapy - aspirin Stroke on aspirin therapy - Aspirin + dipyridamole OR clopidogrel Stroke with A fib - Long term anticoagulation (warfarin, dabigatran, rivaroxaban) Stroke with large anterior circulation artery occlusion w/I 24 hrs of symptom onset - Mechanical thrombectomy (regardless if received alteplase) then aspirin Intracranial large-artery atherosclerosis - Aspirin + clopidogrel for 90 days, then aspirinCancer-Related Anorexia/ Cachexia Syndrome TreatmentHypercoaguable state associated with weight loss, anorexia, excessive reduction in skeletal muscle. Progesterone analogues (megestrol acetate) or corticosteroids is effective at increasing appetite, causing weight gain, and improving well-being. Progesterone analogues are preferred over corticosteroids in patients with longer life expectancies due to less side effects.Porphyria Cutanea TardaSx: Blisters, bullae, scarring, hypopigmentation/ hyperpigmentation on sun exposed skin (back of hands + forearms), scarring and clacification similar to scleroderma Associated with HCV, HIV, excessive alcohol consumption, estrogen use, smoking DX: mildly elevated liver enzymes and iron overload, elevated plasma or urine porphyrin levelsTreatment for BPPV, Meniere disease, Acoustic neuromaBPPV: anticholinergics (meclizine, diphenhydramine) or benzodiazepines Meniere: Antihistamines and anticholinergics during attacks, diuretics to reduce endolymphatic fluid Neuroma: surgeryErythema Multiforme Minor vs MajorMinor: after HSV or other infection, urticarial or bullous skin lesions. Target lesion is pathognomonic Major: SJS/ TEN, 2+ mucosal surfaces. MC induced by drugs (sulfonamides, NSAIDs). Petechiae, vesicles, bullae, desquamation of skinCauses of Arteriovenous FistulaCongenital: PDA, Angiomas, Pulmonary AVF, CNS AVF Acquired: Trauma, Iatrogenic (femoral catheterization), Atherosclerosis (aortocaval fistula), Cancer Signs: wide pulse pressure, strong arterial peripheral pulse, systolic flow murmur, tachycardia, flushed extremities. LVH + left displaced PMIFever and Neutropenia (ANC <1000) Treatment AlgorithmSuspected G(+) [catheter, skin/soft tissue infection, mucositis]: IV vancomycin + antipseudomonal tx G(-) [no obvious source]: Antipseudomonal monotherapy (cefepime, Cirpofloxacin, imipenem) or dual therapy (beta lactam + aminoglycoside) --> fever persists for 3 days ADD vancomycin Fever persists for 5-7days in either case: Add antifungal tx (Fluconazole or Amphotericin B)Centor CriteriaCough (1) Exudates (1) Nodes (1) Temp over 38°C (1) OR age under 14 (+1 pt) over 14 (-1 pt) 1 or less: do nothing (viral) 2-3: rapid strep, follow up with culture if you really think they have strep 4+: tx with ABX TX: Amoxicillin Clavulanic acidEpistaxis TreatmentAnterior bleed - cauterize Posterior bleed - packing (need prophylaxis antibiotics)Choanal AtresiaNo pathway from nose to throat (atresia or stenosis). Turn blue with feeds and pink with coughing. Snoring Look for atresia by trying to pass catheter or look for stenosis with fiber optic scope. Treat with surgeryInfective Endocarditis TreatmentNative valve: Vancomycin Prosthetic under 60 days: Vancomycin + Gentamicin + Cefipime Prosthetic between 60-365 days: Vancomycin + Gentamicin Prosthetic over 365 days old: Vancomycin + Gentamicin + Ceftriaxone Subacute IE: Gentamicin + Ceftriaxone **Amoxicillin is prophylactic treatment**Chronic HypopituitarismDeposition disease or tumor Will sacrifice FSH/LH and GH to make sure TSH and ACTH levels don't fall too much SX: low libido, amenorrhea, fatigue DX: Insulin stimulation test or Vasopressin stimulation test (give insulin and see blood glucose drop, epinephrine/ cortisol increase and GH not change TX: replace hormones and treat underlying diseaseCentral Cord SyndromeHyperextension injuries in elderly patients with preexisting degenerative changes in the cervical spine. Damage to the central portion of the anterior spine. Weakness more pronounced in the upper extremities May have loss of pain and temperature sensation in the arms from damage to the spinothalamic tractSyphilis Treatment1°: single dose of intramuscular penicillin G 2.4mU 2° Early: single dose of IM penicillin G 2.4mU 2° Late: IM penicillin G 2.4mU at 1 week intervals for 3 doses 3°: IV penicillin for 10-14 daysWhat 2 medical conditions put patients at greater risk for transfusion-related hypocalcemiaHepatic or renal failure since the liver and kidney normally metabolize citrate (which is used to inhibit coagulation in blood products and chelates free calcium)Drugs that bind calciumCitrate Foscarnet FluoroquinolonesHow do phosphorous levels determine etiology of hypocalcemiaHypocalcemia with low serum phosphorus suggests vitamin D deficiency Hypocalcemia with high serum phosphorous suggests renal failure or intravascular chelation of calciumHow do hypo and hypermagnesemia affect serum calciumCause refractory hypocalcemia by inducing PTH resistance and/or decreasing PTH secretion Need to give magnesium and calcium Magnesium is needed to cause PTH release, too high ot too low will cause resistance or decreased releaseClinical manifestations of AmyloidosisRenal - heavy proteinuria with nephrotic syndrome, peripheral edema Cardiac - restrictive cardiomyopathy, conduction defects, low voltage CNS - peripheral &/or autonomic neuropathy, stroke GI - hepatomegaly, dysmotility, malabsorption, GI bleeding due to vascular fragility Pulmonary - pulmonary nodules, tracheobronchial infiltration, pleural effusion Musculoskeletal - enlarged tongue, shoulder pad enlargement Skin - thickening of skin, subcutaneous nodules/plaques, ecchymoses, periorbital edema Heme - anemia, thrombocytopeniaNissen FundoplicationWrapping the gastric fundus around the esophagus to increase sphincter pressure. Surgical procedure used for refractory GERDPathophysiology of Mobitz Type I and Mobitz Type II heart blockMobitz I: Intranodal or HIS bundle conduction defect that results from medication (beta blockers, digoxin, CCB's), increased vagal tone, or right coronary artery mediated ischemia. Mobitz II: Intranodal conduction abnormality in either the bundle of His or Purkinjie fibersAssociations with AngiodysplasiaPainless GI bleeding Distal submucosal veins and arteriovenous malformations, increased incidence after age 60. MC in right colon More common in people with ESRD and von Willebrand disease More common in patients with aortic stenosis, possibly from acquired vs factor deficiency Diagnosed with endoscopic evaluationMEN SyndromesMEN 1: Pituitary adenoma, Parathyroid hyperplasia, Pancreatic tumors MEN 2A: Parathyroid hyperplasia, Pheochromocytoma, Medullary thyroid carcinoma MEN 2B: Pheochromocytoma, Mucosal neuromas, Marfanoid body habitus, Medullary thyroid carcinomaFirst Line antiepileptic for Generalized epilepsy, Atonic/ Myoclonic seizure, Focal epilepsy, Absence seizureGenerlized:Valproate, lamotrigine, levitriacetam (keppra) Atonic/ Myoclonic: Valproate Focal: Lamotrigine Absence: Ethosuximide (hyperventilation can trigger absence seizure)Esophageal Varices Pharmacology TreatmentHigh dose beta blockers Isosorbide mononitrate to prevent acute variceal bleedingTreatment for SIADH and Central and Nephrogenic DISIADH: Demeclocycline Central DI: DDAVP (desmopressin) Nephrogenic DI: Gentle diuresis (HCTZ +/- amiloride)Radioactive Iodine Uptake Scan ResultsGraves - normal thyroid with universal growth and activity (receptors are upregulated everywhere) Thyroiditis - transient hyperthyroid, cold RAIU scan Multinodular Goiter and Toxic adenoma - Spots of RAIU with no activity in rest of thyroid Factitious Disorder and Struma Ovarii - no RAIU because T4 is coming from somewhere elsePapillary, Follicular, Medullary, Anaplastic Thyroid CancerPapillary - MC, Orphan Annie eyes, resection Follicular - FNA shows thyroid tissue, spreads hematogenously, RAI ablation (will attack all mets) Medullary - C-cells and calcitonin, MEN2A and 2B, RET oncogene, associated with pheochromocytoma Anaplastic - rapidly fatal, local spread, in elderlyHow to Diagnose Cushings1st: Low Dexamethasone Suppression test - doesn't suppress cortisol - Cushing's Syndrome 2nd: Get ACTH - Normal = adrenal tumor, High = ACTH dependent 3rd: High Dexamethasome Suppression test - Suppresses = Cushing's disease (pituitary) - need to resect. If NO suppression - ectopic from tumor - need to find it (lungs) *Also need late night salivary cortisol or 24 hour urine cortisol with low dexamethasone to say Cushing's syndrome*How to Diagnose Addison's Disease1st: AM cortisol - if low, think Addison's 2nd: Corticosyntropin stimulation test (ACTH) - if cortisol increases then pituitary deficiency. If NO change - adrenal gland problem 3rd: CT/MRI to check Pituitary/ Adrenal Gland *If Pituitary tx with Cortisol, If Adrenal tx with Cortisol and Fludricortisone (Aldosterone)*How to Diagnose Conn's Syndrome1st - Aldosterone:Renin ratio - if not elevated then Congenital Adrenal Hyperplasia or Licorice ingestion. If high renin and aldosterone (<10) then Fibromuscular Dysplasia (STENT) or Atherosclerosis (NO STENT) If high aldosterone and low renin (>30) then Conn's 2nd do Salt Suppression test - no suppression of aldosterone with salt load 3rd to MRI - look for tumor 4th do adrenal vein sampling to see which side is hyperfunctioning and then resect tumorType I diabetes AutoantibodiesGlutamic Acid Decarboxylase (GAD) Insulin Autoantibody/ Protein Tyrosine Phosphatase (IA-2)Diabetic Oral Medications + Side EffectsSulfonylureas: Glipizide, Glyburide. Hypoglycemia + weight gain Meglitinides: Repaglinide, Nateglinide. Hypoglycemia + weight gain Biguanides: Metformin. GI upset, diarrhea, lactic acidosis TZDs: Pioglitazone, Rosiglitazone. Weight gain, worsen CHF Alpha Glucosidase Inhibitor: Acarbose. Diarrhea GLP-1/ incretin analog: Exenatide. Increase insulin secretion with food. Diarrhea, pancreatitis, weight loss DPP-IV inhibitor: Sitagliptin. Stop GLP-1 breakdown. Weight neutral, pancreatitis SGLT-2 Inhibitor: Canaglifozin. Stop glucose/ Na kidney reabsorption. Euglycemia DKARaynaud's Phenomenon TreatmentCalcium channel blockers for persistent symptoms Aspirin for patients at risk of digital ulceration *Primary RS in young female and symmetric. Secondary RS in older men and asymmetric*Trichinella spiralis SymptomsIntestinal stage: Asx or abdominal pain, nausea, vomiting + diarrhea Muscle stage: myositis, subungual splinter hemorrhages, periorbital edema, eosinophilia (with elevated CK and leukocytosis) *Ingestion of under-cooked meat* *Periorbital edema, myositis, and eosinophillia*Senile PurpuraSkin fragility, ecchymosis, normal labs (coagulation + blood counts). AKA actinic purpura, non-inflammatory disorder seen in elderly or middle-aged with extensive sun exposure. Loss of elastic fibers in perivascular connective tissue - minor abrasion rupture superficial BV's + cause exravasation of blood.Morton NeuromaNumbness or pain between the 3rd and 4th toes Clicking sensation when palpating space between 3rd & 4th toes while squeezing metatarsal joints Mechanically induced neuropathic degeneration of the interdigital nervesErysipelasS. pyogenes Superfical dermis and lymphatics, raised sharply demarcated edges, rapid spread and onset, fever in early course External ear involvementHow much insulin to start patient atOutpatient DM II: 0.1 U/kg with long acting and titrate up until morning fasting sugar is normal Hospital: 0.5 U/kg or 0.3 U/kg if Cr >1.5, age >65, bG <180 = Total Daily Insulin, then divide in 1/2 for qHS and 1/2 for qACBack pain from MetastasisHx of malignancy, age >50, worse at night, unintentional weight loss, cauda equina syndrome (weakness, urine retention/ incontinence, saddle anesthesia)Causes of 1st Time StrokeVascular (stroke) Infection (meningitis, encephalitis) Trauma (TBI, brain bleed) Autoimmune (cerebritis - lupus) Metabolic (Ca, Na, hypoxemia) Ingestion/ withdrawal (benzo, alcohol) Neoplasm Sych (psych)Parkinson Treatment OptionsCOMT inhibitors: Tolcapone (cross BBB but fulminant hepatitis), Entacapone MAO-B inhibitors: Selegiline (metab to amphetamine/ methamphetamine), Rasagiline Levodopa/Carbidopa - sinemet (carbidopa cannot cross BBB) DA Agonists: Non-Ergot Alkaloid = Ropinerole, Pramipexole, Rotigotine (transdermal patch), Ergot Alkaloid = Bromocriptine (less used b/c of side effects) *young (<70) and functional = DA Agonists, old (>70) and nonfunctional = Sinemet, then COMT/ MAO-B inhibitors to help when Sinemet effect wears off*Renal Vein Thrombosis and Nephrotic SyndromeLoss of antithrombin III in urine increases risk of venous and arterial thrombosis Acute presentation of abdominal pain, fever, hematuria MC seen in membranous glomerulopathyValley FeverCoccidioidomycosis, endemic mold of desert Southwest CAP (fever, CP, cough, nonproductive cough, lobar infiltrate), arthralgias, erythema nodosum/ erythema Multiforme Symptoms last weeks or monthsPulmonary ContusionUnder 24 hrs after blunt thoracic trauma Tachypnea, tachycardia, hypoxia Rales or decreased breath sounds. CT/CXR with patchy alveolar infiltrate not restricted by anatomical borders Treat with pain control, pulmonary hygeine (nebulizer, chest PT), O2 and ventilationGlucocorticoid Induced MyopathyProgressive proximal muscle weakness and atrophy without pain or tenderness, lower extremity muscles are more involved. Difficulty getting up from chair, climbing stairs, brushing hair Normal ESR and CKHidradenitis SuppurativaOccurs in intertriginous areas. Chronic inflammatory occlusion of folliculopilosebaceous units (prevents keratinocytes from properly shedding from the follicular epithelium) Solitary painful inflammatory nodules that last for days to months, chronic + relapsing. Complications: sinus tracts, comedones, scarring which leads to sense rope-like bands in skin with strictures + lymphedemaTelogen EffluviumAcute, diffuse, noninflammatory hair loss. Scalp + hair fibers appear normal. Hair shafts easily pull out. Triggered by severe illness, fever, surgery, pregnancy, childbirth, emotional distress, endocrine + nutritional disorders. Hair follicles go into widespread rest/shedding phase. SELF LIMITEDAchalasia TreatmentsEsophagomyotomy Botulinum toxin injections into LES Nitrates CCBsWhat is Renal Tubular AcidosisDecrease in urinary excretion of H+ -> non-anion gap hyperchloric metabolic acidosis with alkaline urine Volume depletion from urine loss Polyuria Dehydration Anorexia Vomiting Constipation Hypotonia Children -> failure to thriveType 1 RTADistal RTA Hyperchloremic metabolic acidosis with high urine pH from an inability to secrete H+ by the distal tubules and collecting ducts --> cannot generate HCO3 Nephrocalcinosis -> increased Ca + PO4- excretion into an alkaline urine Risk of osteomalacia *Usually lifelong disease*Type 2 RTAProximal RTA Lack of reabsorption of HCO3 --> HCO3 is replaced in serum by Cl- --> hyperchloremic non-anion gap metabolic acidosis. *Hypokalemia from increased Na+ delivery to distal tubule* From: Fanconi's syndrome, Cystinosis, Wilson's disease, Lead poisoning, Multiple myeloma, Nephrotic syndrome, Amyloidosis *Resolves with disease treatment*Type 4 RTAMineralocorticoid Deficiency RTA Aldosterone deficiency OR resistance --> hyperkalemia and low urine pH Associated with interstitial renal disease and diabetic nephropathy *Tx with fludricortisone*Causes of reactive arthritisShigella, Salmonella, Yersinia, Campylobacter, Chlamydia, MycoplasmaNecrotizing PneumoniaCommuntiy acquired MRSA that attacks young patients with influenza Rapidly progressive + fatal High fever, productive cough with hemoptysis, leukopenia, multilobular cavitary infiltrates Tx with vancomycin or linezolidCaustic Ingestion Sx, Tx, ComplicationsSx: hoarseness, stridor, dysphagia, odynophagia, epigastric pain, bleeding Tx: ABCs, decontamination (remove clothes), CXR, endoscopy Complications: upper airway compromise, perforation, strictures, stenosis (2-3 weeks), ulcers, cancerPerivalvular Abscess in the HeartPatient's with endocarditis and conduction abnormalities on ECG Abscess extends into adjacent cardiac conduction pathways --> leads to syncope MC seen with aortic valve involvementAnalgesic Rebound HeadacheWithdrawal from analgesic HA medication Take meds over 10 times per month and then stopBack: Herniation, Osteophyte, Compression Fracture, Spinal Stenosis TreatmentHerniation: neurosurgery is better than conservative therapy at 6 months but equal at 1 year Osteophyte: surgery Compression Fracture: surgery and follow up on osteoporosis (MC cause) Spinal Stenosis: LaminectomyReversible Causes of DementiaTSH/ T4 (hypothyroidism), Vitamin B12, LFTs (cirrhosis), depression, RPR (syphilis), BMP (BUN/Cr)DDX for DizzinessIf they have LOC, black out, pass out --> Syncope/ Pre-Syncope If spinning and unsteady --> Vertigo (NO LOC)Central vs Peripheral VertigoPeripheral: Tinnitus + hearing loss. NO FND, neighborhood signs, brain stem lesions Central: Neighborhood signs (Horner's with lateral medullary infacrt), brainstem lesions, cerebellar signs, FNDs. *Posterior Fossa Insults*Posterior Fossa LesionsMS, CVA, Tumor, Abscess, Migraines, SeizuresAcute Chest SyndromeSickle cell crisis within lungs may be associated with infection or pulmonary infarction. New pulmonary infiltrate, chest pain, fever, tachypnea, wheezing, cough TX with oxygen, analgesics, antibioticsHerpes Simplex Keratitis vs Herpes Zoster OphthalmicusHSK: frequent cause of corneal blindness, MC in adults. pain, photophobia, blurred vision, tearing, redness. Corneal vesicles + dendritic ulcers. TX with antiviral (topical/ oral) HZO: MC in elderly. Fever. malaise, burning, itching in periorbital region. Vesicular rash along 1st branch of CN VAlternate Treatment for SyphilisIf severe allergy to penicillin G can use Doxycycline *Ceftriaxone is alternate if tertiary syphilis*Arsenic PoisoningBinds sulfhydryl groups + disrupts cellular respiration and gluconeogenesis In pesticides/ insecticides, contaminated water (Wells), pressure treated wood Acute: Garlic breath, vomiting, watery diarrhea, QTc prolongation Chronic: Hypo/hyperpigmentation, hyperkeratosis, stocking-glove neuropathy Treat with Dimercaperol, succimerTreatment of Severe Cancer PainShort acting opioids (morphine, hydromorphone) Calculate total daily dose and convert to long acting formulation (fentanyl patch, oxycodone) PLUS short acting opioids for breakthrough painDiabetic Autonomic Neuropathy of the GI TractDelayed gastric emptying, gastroparesis (anorexia, N/V, early satiety, postprandial fullness) TX with increased fiber + small frequent meals. Metoclopramide (prokinetic and antiemetic). Erythromycin (used IV for acute exacerbations) Cisapride (not used in USA - arrhythmia risk)Causes of Pulsus ParadoxusCardiac tamponade Asthma Obstructive sleep apnea Pericarditis Croup Drop in systolic BP over 10 mmHg with inspirationWhen to do endoscopy for GERDAlarm symptoms: dysphagia, odynophagia, weight loss, anemia, GI bleeding, recurrent vomiting Male over 50 with chronic (5+ yrs) symptoms and CA risk factors (tobacco)Side effects of CyclosporineNephrotoxiticy (hyperkalemia, hypophosphatemia, hypomagnesemia) HTN Neurotoxicity (HA, visual disturbances, seizure, mild tremor, akinetic mutism) Glucose intolerance Infection Malignancy (Squamous Cell Carcinoma of skin + lymphoproliferative disease) Gingival hyperplasia + hirsutism (NOT SEEN IN TACROLIMUS) GI manifestationsClinical Manifestations of Chromium, Copper, Iron, Selenium, and Zinc DeficiencyChromium: impaired glucose control in DM Copper: brittle hair, skin depigmentation, ataxia, peripheral neuropathy, sideroblastic anemia, osteoporosis Iron: microcytic anemia Selenium: thyroid dysfunction, cardiomyopathy, immune dysfunction Zinc: alopecia, pustular skin rash (perioral + extremities), hypogonadism, impaired wound healing, impaired taste, immune dysfunctionP2y12 Receptor BlockersClopidogrel, prasugrel, ticagrelor Reduction in recurrent MI and cardiovascular death compared to aspirin alone in patients with NSTEMI Recommended for at least 12 months in all patients following drug-eluting stent placementMultiple Sclerosis TreatmentInterferon Glatiraner FingolanodeLupus SymptomsMalar rash Discoid rash Serositis (pleuritic chest pain) Oral ulcers Arthritis Photosensitivity Blood (anemia, thrombocytopenia) Renal failure (nephritis) ANA Immunologic (Anti-dsDNA, Anti-sm) NeurologicSjogren's Syndrome TriadDry eyes Dry mouth Parotid swellingFindings in Idiopathic Inflammatory Myopathy (Myositis)Heliotrope rash Grotton's pappules Shall sign (photosensitivity) Proximal muscle weakness *Anti-Mi and Anti-Jo* Treat with steroidsMost Common Nephropathy in HIVFocal segment glomerulonephritisArsenic Poisoning Sx and TxBinds to sulfhydryl groups + disrupts cellular respiration and gluconeogenesis In pesticides/ insecticides, contaminated water (Wells), pressure treated wood Acute: Garlic breath, vomiting, watery diarrhea, QTc prolongation Chronic: Hypo/hyperpigmentation, hyperkeratosis, stocking-glove neuropathy Treat with dimercaperol and succimerCerebral Amyloid AngiopathyMC cause of spontaneous lobar hemorrhage in adults over 60. Beta Amyloid deposition in the walls of small to medium size cerebral arteries -> vessel wall weakening + predisposition to rupture Same proteins as in Alzheimer'sCharcots JointConditions: Vitamin B12 deficiency, Diabetes, Peripheral nerve damage, spinal cord injury, syringomyelia, tabes dorsalis SX: deformed joints, lacking/decreased sensation with loss of neurological input, arthritis/ arthropathy, mild pain, factures, degenerative joint disease + loose bodies on joint imaging TX underlying condition, use mechanical devices (assist weight bearing, decrease further trauma) *patients don't feel when they hurt the foot because of nerve damage*Pseudogout & Gout TreatmentPseudogout: Cochicine, NSAIDs, Steroids Gout: Low Elimination: Probenecid High Production: IVF + Allopurinol/ Febuxostat (Tumor Lysis Syndrome - Rasburicase) Flare: Colchicine, NSAIDs, Steroids3 Infections Seen in Cushing's SyndromeNocardia Pneumocystis Pneumonia Cutaneous fungal infections6 Causes of Viral MeningitisHSV Varicella zoster Enterovirus (echovirus) Lymphocytic choriomeningitis virus HIV MumpsWhat is Mixed Connective Tissue DiseaseCombination of SLE Polymyositis Dermatomyositis Scleroderma Rheumatoid arthritis3 Malignancies that Metastasize to the Adrenal GlandsLung cancer Breast cancer Melanoma2 Genetic Conditions and 3 Non-Genetic Conditions that Predispose to OsteosarcomaGenetic: p53 genetic mutations Familial retinoblastoma (Rb gene mutations) Non-Genetic: Paget's disease of the bone Radiation exposure Bone infarctsWhat 3 lab findings are abnormal in osteosarcomaElevated alkaline phosphatase, ESR, and LDHHSV RetinitisMC cause of corneal blindness in US. Can be seen in HIV Rapid progressing b/l necrotizing retinitis, keratitis, conjunctivitis with eye pain, rapid vision loss Fundoscopy - widespread pale peripheral lesions with central necrosis of retinaLyme Disease TreatmentDoxycycline is first line Amoxicillin or Cefuroxime in pregnant patient or under 8 years oldSpondyloarthropathies TreatmentPAIR (Psoriatic, Ankylosing spondylitis, IBD related, Reactive) NSAIDs (1st line) Local steroids DMARDs (doesn't help axial skeleton) TNF alpha inhibitors *Reactive + active infection - Doxycycline/ azithromycin and Ceftriaxone* *IBD related - Treat IBD and arthritis improves WITHOUT NSAIDs*Seborrheic Dermatitis vs Pityrasis RoseaSD: Rash on face where there is hair only. Scales and flaking. Autoimmune after Maelezzi sp Tx with selenium shampoo PR: Self limiting, unknown pathology Herald patch (salmon colored and well demarcated) that will start to have trailing scale Spares palms and soles (unlike syphilis)Lichen PlanusUnknown pathology, raised purple papule with lacey network of white lines (looks like scale) Tx with topical steroids and then UV light if fails (opposite of psoriasis where UV light is first) *can be from medication change - loops, thiazides, ACE inhibitors*Alopecia Areata vs Tinea Capitis vs Traction Alopecia vs Androgen AlopeciaAA: Autoimmune destruction of hair follicle. Well circumscribed patch of hair loss Exclamation point - hair is normal distal to scalp and thin/ depigmented proximal to scalp Treat with steroids TC: Well circumscribed patch with all hairs the same length KOH prep to see fungus Treat with oral griseofulvin TA: Pulling hair too tight (braid and ponytail) Androgen: Circular patch starting at crown Treat with minoxidil and finasterideProcess of hair loss in ChemotherapyHair cell cycle: 1. Anagen - growth 2. Captogen -regression 3. Telogen - resting 4. Exogen - shedding Chemotherapy 1. Anagen Effluivain - growth to shedding phase 2. Telogen Effluvian - growth to resting phase *Both lead to hairloss*Atopic Dermatitis vs Contact Dermatitis vs Stasis Dermatitis vs Hand DermatitisAD: Allergy, Asthma, Atopy Kids - Rash along diaper line, crusty vesicles Adults - symmetric lichenification from scratch-itch cycle on AC fossa, popliteal fossa, extensors Treat by avoiding trigger, emulsions, short term topical steroids CD: Type IV HS Treat by avoiding trigger and topical steroids SD: Peripheral edema (CKD, CHF, Cirrhosis) Erythema, skin darkens, woody changes in lower extremities Tx with compression stockings or diuretics and elevating the legs *Associated with maleolar/ stasis ulcers* HD: Too much hand washing (healthcare or food industry) Treat with protective gloves and avoiding harsh soapsTreatment for TineaTinea pedis, Tinea cruris, Tinea corporis = treat with topical antifungals Onchomycosis = oral antifungal terbinafine Tinea Capitis = oral antifungal griseofulvinHenoch-Schonlein Purpura Pathophysiology and GI SxSmall vessel vasculitis characterized by IgA, C3, and fibrinogen deposition in blood vessels. GI: colicky abdominal pain and increased risk of intussusceptionWhat 3 tumors metastasize to bone causing Lytic LesionsLung Thyroid RenalCauses of PTH Dependent and PTH Independent HypercalcemiaDependent: Primary Hyperparathyroidism Familial Hypocalciuric Hypercalcemia Lithium Independent: Malignancy Vitamin D toxicity Granulomatous disease Drug Induced (Thiazides) Milk-Alkali Syndrome Thyrotoxicosis Vitamin A toxicity ImmobilizationConditions Associated with Chronic Hepatitis CMixed cryoglobulinemia syndrome Mebranoproliferative glomerulonephritis PCT Lichen planusCutoff for Modified Wells Score and Treatment4 or less check D dimer Over 4 check CT pulmonary angiogramSmall Cell Carcinoma of the Lungs Paraneoplastic SyndromesEctopic ACTH SIADH Ectopic growth hormone secretion Peripheral neuropathy Subacute Cerebellar degeneration Lambert Eaton Limbic encephalitis Dermatomyositis ( also in ovarian Cancer)Adenocarcinoma of the Lungs Paraneoplastic SyndromesHypertrophic osteoarthropathy (specific form of clubbing) DIC Thrombophlebitis Microangiopathic hemolytic anemia Dermatomyositis (also seen in ovarian Cancer)Diseases Associated with DystoniaWilson's disease Parkinson's Disease Huntington's disease Encephalitis Neuroleptic use (associated with tardive dyskinesia)Diffuse vs Limited Systemic SclerosisLimited: Sclerosis of distal extremities, face, and neck Diffuse: Sclerosis of proximal limbs and trunk. Increased fibrosis of heart, lungs, and kidneyPolyarteritis Nodosa- Associated with HBV + HIV - Necrotizing vasculitis of small and medium sized vessels - Lungs usually spared - Livedo reticularis from vasculitisTranylcypromineMAOI Can cause HTN crisis from eating aged cheese or wine that can cause a buildup of tyramineBenztropine and TrihexyphenidylParkinson's Disease treatment - loss of DA neurons causes dysregulation in the release of ACh in the striatum which causes exacerbation of certain motor symptoms ACh antagonist Adverse Effects Dry Mouth Constipation Blurry Vision TachycardiaTetrabenazineInhibits VMAT-2 which facilitates loading of DA and other monoamines into synaptic vesicles Depletes presynaptic DA and decreases DA release Treats chorea from Huntington's disease and tardive dyskinesiaSelegineMAOI that decreases breakdown of DA in the brain Potentiates effects of levodopa in Parkinson's disease but NO anticholinergic side effects Side Effects: Insomnia Orthrostatic hypotension Sexual dysfunction Weight gain MyoclonusRiluzoleTreats ALS and improves survival Reduces glutamate induced cytotoxicity by blocking NMDA receptors, inhibits glutamate release, and inhibits Na channels Side Effects: Nausea and muscle weaknessToxicities of Cilostazole and DypyramidoleAbdominal pain Facial flushing Headache Hypotension Nausea *Inhibits phosphodiesterase III*Single Strongest Risk Factor for Peripheral Vascular DiseaseCigarette SmokingTheophylineBronchodilation (smooth muscle relaxation) and suppression of airways in response to stimuli Side Effects: Cardiac flutter/ tachycardia HA Hyperactivity Insomnia Restlessness Seizures Status epileptics GERD/ GI ulcer/ N/V Difficulty with micturition/ diuresis TremorHow Fast to Lower Elevated BP (HTN emergency/ urgency)25% in the first day 10-12% in the first few hoursWhy is Pravastatin different from other statinsNo CYP450 metabolismTreatment difference for Right Sided MINo nitrites because you do not want to decrease preload to get blood to left side of heartStool Osmolar Gap Equation and Interpretation290 - 2 (stool Na + stool K) Gap under 50: Pure secretory diarrhea Gap over 125: Pure osmotic diarrhea Gap between 50 and 125: Mixed diarrhea or mild carbohydrate malabsorptionUncomplicated Vs Complicated Parapneumonic Effusions Vs EmpyemaUncomplicated: Sterile exudate, pH over 7.2, Glucose over 60, WBC under 50,000, NEGATIVE gram stain + culture, treat with abx Complicated: Bacterial invasion of pleural space, pH under 7.2, Glucose under 60, WBC over 50,000, NEGATIVE gram stain + culture, treat with abx and drainage Empyema: Pus and bacteria in the pleural fluidTamoxifen vs RaloxifenTamoxifen is for premenopausal and postmenopausal women. Stimulates ER in bone and endometrium -> can cause uterine cancer but prevent osteoporosis Raloxifen is for postmenopausal women only. Stimulates ER in bone only -> prevents osteoporosis, no endometrial cancer riskWhat infection can Daptomycin NOT be used forPneumonia because the surfactant will inactivate itTactile Fremitus MnemonicIncreased in pneumonia and consolidation - chickens can walk on the ground (solid) Decreased in pneumothroax and pleual effusion - chickens cannot swim or fly (liquid and air)LegionellaHyponatremia, hypophosphatemia, Gram negative rodsSplenic Abscess TriadFever, leukocytosis, LUQ pain Also splenomegalyChronic Arsenic PoisoningHyperpigmentation, hyperkeratosis, stocking glove neuropathyNeurologic Deficits in Pseudotumor CerebriPapilledema, CN VI palsey, visual field deficitsWhy is Clopidogrel used more often than TiclopidineTiclopidine causes neutropeniaWhat can cause asterisksHepatic encephalopathy Uremic encephalopathy HypercapniaWhen surgical intervention is needed for AAARapidly increasing diameter, large diameter, symptomatic, ruptureHow to Treat Staphylococcal Toxic Shock SyndromeVancomycin ClindamycinCauses of Toxic Shock SyndromeTampon use Severe burns Severe wounds Insect bites Secondary to TEN2 Treatments for Essential Tremor when Pharmacology FailsDeep Brain Stimulation ThalamotomyCauses of Transcellular Shift Causing HypophosphatemiaRespiratory alkalosis and high levels of insulinTriad of Boerhaave SyndromeForceful vomiting Retrosternal chest pain Subcutaneous emphysema Early Sighn: Fever, hypotension Abdominal rigidity TachypneaWho needs prophylaxis antibiotics prior to invasive proceduresCongenital cyanotic lesions Prior valve repair using prosthetic material Prior history of endocarditis History of heart transplantMass effects of lung cancerSuperior vena cava syndrome Horner's syndrome Pancoast tumorGastric BezoarHair ball causing small bowel obstruction Mentally retarded patient with patch of hair loss and vomiting after mealsRhabdomyolysis and Urine(+) blood in urine with no RBCs and person found on floor Myoglobin in urine can cause acute tubular necrosisAcute CHF ManagementLMNOP Lasix (furosemide) Morphine Nitrates Oxygen Position (upright)EKG Exercise Stress Test vs Exercise EchoEKG: unstable angina Echo: old LBBB or baseline ST elevation or on DigoxinAlcoholic Cerebellar Degeneration- Progressive gait dysfunction - Truncal ataxia - Nystagmus - Intention tremor or dysmetria - Impaired disdiadochokinesia - Muscle hypotonia causing pendular knee reflexThyroglobulin and Thyroid CancerThyroglobulin is made by thyroid gland and thyroid cancer - which gets converted into T3 and T4 If thyroglobulin is detected after thyroid removed from cancer - CANCER HAS RETURNEDDigital Clubbing and PathologyLung malignancies Cystic fibrosis Right-to-left cardiac shunts *Emphysema and COPD cannot cause clubbing*When to Start DMARDs in RAAs soon as possible as they delay disease progression *NSAIDs and COX inhibitors are for sx relief only*What Causes Elevated LFT's in NAFLDInsulin resistance leading to increased peripheral lipolysis, triglyceride synthesis, and hepatic uptake of fatty acidsSmall vs Large Nerve Fiber InjurySmall: positive symptoms (pain, parasthesias, allodynia) Large: negative symptoms (numbness, loss of proprioception and vibration sense, diminished ankle reflexes)Causes of Diarrhea in Patients with AIDSCryptosporidium Microsporidium/ Isosporidium MAC CMVWhat Happens to Brain in Prolonged SeizuresCortical laminar necrosis *when seizures last over 5 minutes*1. Dacryocystitis 2. Episcleritis 3. Chalazion1. Infection of the lacriaml sac 2. Inflammation of the episcleral tissue between the conjunctiva and the sclera 3. Lid discomfort, granulomatosis inflammation of the melboiman glandBlepharospasmForceful eyelid contractions of the eyelid - form of dystonia Caused by Parkinson's disease, antipsychotics, or idiopathic (MC) Treat botulinum toxin if severe1. Cerebellar Gait Disorder 2. Gait Apraxia (Frontal Gait) 3. Parkinsonism 4. Steppage 5. Vestibular1. Ataxic - staggering, wide based. Disdiadokinesia, dysmetria, nystagmus, Romberg sign 2. Magnetic (freezing) - start and turn hesitation. Dementia, incontinence, frontal lobe signs 3. Short steps, shuffling. Bradykinesia, resting tremor, postural instability, decreased arm swing 4. Footdrop, excessive hip and knee flexion while walking, slapping quality, falls. Distal sensory loss and weakness 5. Unsteady, falling to one side. Normal sensation, reflexes and motor strength, nausea, vertigoAplastic Crisis VS Splenic Sequestration CrisisAplastic: - Low Reticulocytes - Transient arrest of erythropoiesis - Secondary to infection (parvovirus B19) Splenic: - Increased Reticulocytes - Splenic vaso-occlusion - rapidly enlarging spleen - Occurs in children prior to autosplenectomyCommon FIbular NeuropathyCompressive injury *Transient* - Unilateral foot drop - Numbness/ tingling over the dorsal foot and lateral shin - Impaired ankle dorsiflexion (walking on heels) and great toe extension - Preserved plantar flexion (walking on toes) and reflexesCalcaneal Apophysitis (Sever Disease)RF: - Running/ jumping sports - Growth spurts - Athletic cleat use or footwear without heel padding SX: - Heel pain (50% bilateral) - Pain with calcaneal palpation or compression - Decreased gastrocnemius/ soleus flexibility TX: - NSAIDs - Ice - Activity limitationCervical MyelopathyWho: - Age over 55 - Degenerative cervical spine/ discs - canal stenosis - cord compression SX: - Gait dysfunction - usually 1st to onset - Extremity weakness/ numbness - LMN signs (arms) - muscle atrophy, hyporreflexia - UMN signs (legs) - Babinski, hyperreflexia - Proprioception/ vibration/ pain sensation decrease TX: - Nonsurgical - immobilization - Surgical - decompression1. Glomerular Hematuria 2. Nonglomerular hematuria1. GLOMERULAR - Microscopic > Gross - Glomerulonephritis (poststreptococcal, IgA nephropathy) - Basement membrane disorder (Alport syndrome) - Nonspecific or no symptoms - Nephritic syndrome - UA: blood and protein, RBC casts, dysmorphic RBCs 2. NONGLOMERULAR - Gross > Microscopic - Nephrolithiasis - Cancer (renal, prostate) - Polycystic kidney disease - Infection (cystitis) - Papillary necrosis - Dysuria - Urinary obstruction - UA: blood but no protein, normal appearing RBCsVon Hippel-Lindau Disease- Cerebellar and retinal hemangioblastomas - Pheochromocytoma - Renal Cell Carcinoma (clear cell type) - usually start as multiple renal cysts +Germline mutation*MC Cause of Sepsis in Sickle Cell PatientsStrep PneumoniaeEffect of Intensive Glycemic Control in T2DMMacrovascular complications (acute MI, stroke) - No change Microvascular complications (nephropathy, retinopathy) - Will show improvementMI Location Based on Coronary Vessel InvolvementGlucagonoma Features- Weight loss - Necrolytic Migratory Erythema (large indurated plaques with central clearing) - DM/ hyperglycemia - GI symptoms (diarrhea, anorexia, abdominal pain)Vulvar Lichen SclerosusSeen in prepubertal girls, perimenopausal or postmenopausal women - Thin white wrinkled skin over the labia minora/ majora - Atrophic changes that extend over the perinium and anus - Excoriations, fissures, erosions from severe pruritis - Dysuria, dyspareunia, painful defecation *Punch biopsy on adults to r/o malignancy* Tx with topical corticosteroidsAsymptomatic Proteinuria in ChildCheck 1st morning Urine - Elevated protein:Cr - evaluate for glomerular or parenchymal disease - Normal protein:Cr - Check UA: if positive (orthostatic) and if negative (transient)Side Effects of: 1. Cyclosporin 2. Tacrolimus 3. Azathioprine 4. Mycophenolate1. Nephrotoxicity, HTN, GUM HYPERTROPHY, HIRSUTISM, tremor 2. Same as cyclosporin WITHOUT gum hypertrophy and hirsutism 3. Diarrhea, leukopenia, hepatotoxicity 4. Bone Marrow suppressionCavernous Sinus ThrombosisHeadache Binocular palsies (CN III, IV, V, VI) Periorbital edema Hypoesthesia or Hyperesthesia in V1/V2 distribution Papilledema Intracrainal HTN - leading to vomitingCMV Symptoms seen in Transplant PtPulmonary: dyspnea on exertion, dry cough GI: abdominal pain, hematochezia, diarrhea Pancytopenia Mild Hepatitis Interstitial infiltrates on CXR *Pneumonitis, Gastroenteritis, Hepatitis* TX with valacyclovirManifestations of SarcoidosisSide Effect of AmiodaronePulmonary toxicity - chronic interstitial pneumonitisCauses of Recurrent Pregnancy LossAntithyroid peroxidase in high levels can increase the chance of miscarriage in both hypothyroid and euthyroid womenMultifocal Atrial TachycardiaCause: - Exacerbation of pulmonary disease (COPD) - Electrolyte disturbance (hypokalemia) - Catecholamine surge (sepsis) SX: - Asymptomatic - Rapid, irregular pulse - ECG: >3 P wave forms and atrial rate >100/ min TX: - Correct underlying disturbance - AV nodal blockade (Verapamil) if persistentPaget's Disease of the BoneSX: - Many are Asx - HA - Hearing loss - Spinal stenosis - Radiculopathy - Long bone bowing, fracture, arthritis of adjacent joints - Giant cell tumor - Osteosarcoma Pathogenesis: - Osteoclast dysfunction and increased bone turnover Labs: - Elevated alkaline phosphatase - Elevated urine hydroxyproline and PINP (bone turnover markers) - Ca and Phos are usually normal Imaging: - XR: osteolytic or mixed lytic/ sclerotic lesions - Bone scan: focal increased uptake TX: - Bisphosphonates1. Prerenal Azotemia 2. Acute Glomerulonephritis 3. Acute Tubular Necrosis 4. Postrenal Azotemia 5. Normal Kidney Function