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Master the Boards

Terms in this set (1900)

Trigeminal Neuralgia Tx
Carbamezapine
Glucose goal for diabetic pregnant.
1. fasting
2. 1 hr postprandial
3. 2 hrs postprandial
Fasting<95 mg/dL

1 hr < 140 mg/dL

2 hrs < 120 mg/dL
When is a head CT the best initial test? (ex, vs LP)
Head CT is necessary prior to an LP only if there is the possibility that a space occupying lesion may cause herniation.
When any of these are present:
Confusion
Seizures
Focal neurological deficits
What pathogen with very high protein CSF levels
TB
Treatment choice in meningitis is based on (glucose, protein,cell count)
Cell count
Protein and glucose levels are too nonspecific to allow for a treatment decision
What Antibiotic drug group is Listeria resistant to
Cephalosporins
Prophylaxis options to close contacts of N. meningitis pts
Rifampin
Ciprofloxacin
Ceftriaxone
Most common neurological deficit of untreated bacterial meningitis ?
Eight cranial nerve deficit or deafness
What is the most accurate test for herpes encephalitis?
PCR is more accurate than brain biopsy
Best initial therapy if herpes encephalitis is suspected
Acyclovir
Acyclovir resistant herpes encephalitis treatment option
Foscarnet (but more renal toxic than Acyclovir)
Most sensitive physical finding for Otitis media
Immobility of TM
A fully mobile TM essentially R/O OM
Woman with suspected sinusitis. What test is the most accurate test?
Sinus biopsy or aspirate -> gives you precise info on pathogen
CT-> imaging is NEVER the right answer for infectious disease when asked for most accurate test
First line treatment for Otitis media and sinusitis
Amoxicillin +/- clavul. acid
Doxycycline
TMP/SMX
plus decongestant to promote sinus drainage
Best initial therapy in pharyngitis
Penicillin or Amoxicillin
How to treat a patient with step pharyngitis allergic to penicillins
if pt just had rash reaction: give Cephalexin
if pt had an anaphylactic reaction: give Clindamycin or a Macrolide
Pt with suspected infectious diarrhea.
1. What is the best initial test?
2. What is the most accurate test?
1. Blood and/or fecal Leukocyte count (if answer choice is fecal Lactoferrin=better answer choice, more sensitive+specific than fecal leukocytes
2. stool culture
Pt suspected to have Scombroid. Tx?
antihistamine Tx
Giardia treatment
Metronidazole, or tinidazole
Cryptosporidiosis treatment
treat underlying AIDS
Nitazoxanide
B. cereues, Staph A. food poisoning treatment
fluid support as needed
What is a rare complication of acute hepatitis?
aplastic anemia
Pt with hepatitis. Which value has poor prognosis?
PT (because it shows advanced disease)
What level correlates best with Hep C treatment success/failure and Hep C disease activity?
Hep C-PCR RNA level
Which serum marker is the best indicator that a pregnant woman will transmit infection to her child?
e-antigen
T or F. You can have normal Liver Function tests with chronic Hepatitis
True
Therefore transaminases are not good indicators of the activity of chronic hepatitis
Ribavirin SE
anemia
Cystitis vs Urethritis. Both can present with urinary frequency + dysuria+ burning. What physical finding diff. them?
Urethral discharge.
Cystitis does NOT give urethral discharge.
Urethritis
1. Best initial test ?
2. Most accurate test?
1. urethral swab for Gram stain
2. urethral culture, DNA probe or nuclei acid amplification test for N. gon. or Chlamydia trach.
Treatment of Urethritis
Ceftriaxon/or Cefixime
AND Azithromycin/or Doxycycline
Woman with Cervicitis. Treatment
same as Urethritis
Ceftriaxon/or Cefixime
AND Azithromycin/or Doxycycline
First step in woman with cervical motion tenderness and lower abdominal pain
R/O pregnancy
Most accurate test for PID?
laparoscopy (although it is only rarely needed)
Diagnostic test for PID?
Cervical swab culture, DNA probe, or nucleic acid amplification (to confirm etiology; these tests clarify whether to treat the partner, too)
PID treatment inpatient
Cefoxitin or Cefotetan AND Doxycycline
PID treatment outpatient
Ceftriaxone AND Doxycycline (+/- Metronidazole)
PID treatment in penicillin allergic pt
1. Inpatient
2. Outpatient
1. Inpatient: Clindamycin, Gentamicin, AND Doxycycline
2. Outpatient: Levofloxacin AND Metronidazole
Genital Herpes.
1. Best initial test?
2. Most accurate test?
1. Tzanck prep
2. Viral culture
Condylomata Acuminata is a fancy word for
Genital warts (Human Papilloma virus)
Syphilis treatment
Single dose IM Penicillin benzathine
if allergic, Doxcycline
Chancroid treatment
Azithromycin (single dose)
Lymphogranuloma venerum treatment
Doxycycline
Herpes Simplex (genital) treatment
Acyclovir, valacyclovir, famciclovir
Forscarnet for acyclovir resistant Herpes
Name some conditions that can cause false positive VDRL/RPR results
Infection
older age
anti-phospholipid syndrome
IVDrug use and AIDS
malaria
endocarditis
primary and secondary syphillis treatment
IM Penicillin
if allergic: oral doxycycline
tertiary syphillis treatment
Must give penicillin, so if allergic, the answer is "desensitization"
Treatment for neurosyphilis and/or pregnant woman with syphillis and penicillin allergy
Desensitize to Penicillin
Must give Penicillin
Condylomata acuminate is diagnosed by
visual appearance alone
wrong answers are: biopsy, gram stain, culture, serology, smear
How to get rid of genital warts?
cryotherapy with liquid Nitrogen
Surgery for larger ones
laser
or "melting" them with Podophyllin (or trichloroacetic acid)
Imiquimod. Use?
locally applied immunostimulant that leads to the sloughing off of the lesion (HPV wart=condylomata acuminata)
Pediculosis Treatment
Pediculosis=Crabs
Treat with Permethrin
Scabies treatment.
What treatment if disease is widespread?
Permethrin (from neck down)
Ivermectin for widespread disease
Cystitis treatment
Nitrofurantoin (or fosfomycin)
TMP/SMX if resistance is low
Cefixime
What antibiotic group is considered safe in pregnancy?
All beta-lactams are considered safe in pregnancy
Treatment duration and drug of choice for uncomplicated cystitis?
complicated?
Nitrofurantoin for 3 days (uncomplicated)
and
7 days for complicated cystitis
Pyelonephritis treatment
1. Outpatient
2. Inpatient
1. Fluroquinolone (Cipro or Levofloxacin), or Ceftriaxone
2. Aminoglycoside (ex Gentamycin) AND Ampicillin
Chronic prostatitis treatment
long term therapy with TMP/SMX for 6-8 weeks
Pt was diagnosed with pyelonephritis and received adequate treatment. However, after 5-7 days still has fever. What is the next step?
Do US or CT scan to determine if there is an anatomic abnormality causing the infection
Fever and new murmur (or change in murmur), think...
Endocarditis
Best initial test for Endocarditis
Blood culture
Transthoracic and transesophageal Echo
(not ECG)
Best initial therapy in Endocarditis
Vancomycin and Gentamycin
Endocarditis due to Viridan strep. Treatment choice and duration?
Ceftriaxone x 4 weeks
Endocarditis caused by Staph A.. Treatment ?
Oxacillin, nafcillin or cefazolin
Endocarditis due to fungal infection. Treatment?
Amphotericin B and valve replacement
Staph epidermidis or resistant Staph Endocarditis. Treatment?
Vancomycin
Enterococci Endocarditis. Treatment?
Ampicillin and Gentamicin
Endocarditis treated but resistant. What other Abx can be added?
Add an Aminoglycoside and extend duration
What drug do you add to prosthetic valve endocarditis caused by Staphylococcus?
Rifampin
When is surgery the answer to how to treat endocarditis?
if CHF or ruptured valve or chordae tendineae rupture
Also: abscess, fungal infection, AV block, prosthetic valve, recurrent emboli
Common pathogens in culture negative Endocarditis
Coxiella and Bartonella
and
HACEK organisms
(Haemophilius aphrophilus and parainfluenza, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
HACEK endocarditis drug of choice
Ceftriaxone
Most commonly affected joint in Lyme disease?
Knee joint
Cardiac and neurologic manifestations of Lyme disease. Treatment?
IV Ceftriaxone
When is anti-retroviral therapy started (3)
when CD4+ count <500 in an asymptomatic pt
viral load is very high
opportunistic infections occur
Best initial test for HIV in adult?
What is the confirmatory test?
ELISA followed by WESTERN BLOT
How is HIV diagnosed in an infant?
PCR-RNA level or viral culture
because maternal HIV Abs may be present for up to 6 mths after delivery
What should be performed prior to starting Anti-retroviral therapy?
Viral resistance testing (Genotyping)
it should also be done when pt fails to respond to treatment
Best initial drug regimen for HIV
Atripla: ("EFA the EMT at TEN")
EFAvirenz
EMTriatabine
TENofovir
Second line agents for HIV that fail to first line choices
Entry inhibitors: Enfurvirtide ("Entry"), Maraviroc ("rock")

InteGRAse inhibitors: RalteGRAvir
Adverse effects of Zidovudine
Anemia
Abacavir adverse effects
Hypersensitivity, Steven-Johnson reaction
(hypersensitivity is predicted by HLA B5701)
Protease Inhibitor adverse effects
hyperLIPIDemia, hyperGLYCEMia ("protein, lipids, glucose")
What anti-retroviral first line agent to avoid in pregnancy?
Avoid Efavirenz in pregnancy.
What anti-retroviral drug group is safe in pregnancy?
Protease inhibitors
What anti-retroviral should baby receive during delivery to an HIV (+) mom?
Zidovudine (intrapartum)
If HIV mother was NOT on anti-retrovirals prior to pregnancy, what is the management post delivery?
stop anti-retrovirals immediately
When is a C-section indicated in an HIV (+) pregnant woman?
1. if CD 4+ count <350
2. if load is very high > 1000
When does most transmission from HIV mom to fetus occur?
during delivery
(so no fetal scalp electrodes, no fetal scalp blood sample, etc)
Achalasia. What is the most accurate test?
Manometry (although Barium swallow is often done first)
there are 2 types of esophageal spasms:
Diffuse esophageal spasm vs. Nutcracker spasm.
How do you differentiate them ?
Tx ?
can only be distinguished by the "most accurate test":
Manometry

Tx: Ca2+ ch blockers
Nitrates
(similar to Prinzmetal angina)
name 3 pills that can cause Esophagitis
Doxycyline
Alendronate
KCl
AIDS pt has problems swallowing. next best step in management?
empiric therapy with oral Flucanazole
(90% of esophageal infections in AIDS pts are caused by Candida)
-remember: Nystatin swish and swallow is for oral candidiasis
* if treatment does not improve symptoms, then do Endo
Plummer Vinson syndrome can rarely transform into what type of malignancy?
Squamous Cell Carcinoma
"Steakhouse syndrome", think of
think of food bolus obstruction often associated with Schatzki ring
best diagnostic test for Zenker's diverticulum?
what are some things that you should NOT do in those pts?
Barium

Pts with Zenker's: do NOT insert NGT or endoscope, due to risk of perforating the diverticulum
Most accurate test for Scleroderma?
What will it show?
Manometry
* it will show decreased lower esophageal sphincter pressure from and inability to close the LES
M/c cause of epigastric pain in the US esp in a younger person?
non-ulcer dyspepsia (can have normal PE)
Best diagnostic test to find out the cause of epigastric pain
Endoscopy is the only way to truly understand the etiology of epigastric pain

(remember, in the esophagus, Barium might be a good study to start, but for stomach issues, go to Endo)
Pt presents with sore throat, metallic taste, burning epigastric pain radiation up his chest. What is the most appropriate next step in management?
start the pt on a PPI
(if the picture is this clear for GERD then diagnostic testing is not necessary)
*if the clinical picture is not clear: 24 hour pH monitoring
What is "pyrosis"?
heartburn
What are some treatment options for GERD pts unresponsive to medical therapy ?
-Nissen fundoplication
-using a scope and placing a suture around the LES (Endocinch)
-local heat or radiation to scar the LES
Barret's, what changes do you see
columnar METAplasia
How do you manage Barrett's esophagus (just metaplasia)?
How about if it has progressed to low grade dysplasia, how do you manage?
PPIs and rescope every 2-3 yrs

low grade dysplasia: PPIs and rescope every 6-12 mths
(vs high grade dysplasia: Ablation with endoscopy)
atrophic gastritis is associated with what deficiency?
Vitamin B12 def. (remember: IF)
Gastritis treatment
PPIs
Stress ulcer prophylaxis (for 4 conditions)
mechanical ventilation
burns (curling ulcer)
head trauma (cushing ulcer)
COAGULOPATHY
When would you transfuse Platelets in a GI bleed?
When the platel count falls < 50,000 WITH ACTIVE BLEEDING

* you would NOT transfuse platelets without bleeding until the platelet count would < 10,000-20,000)
When would you transfuse packed RBCs in a GI bleed?
in older pts or those who suffer from CAD: if Hct <30
in all others: Hct < 20-25
Propanolol does not do anything for acute variceal bleeds. It PREVENTS bleeds in future
...
C.diff infection treated with Metro. that lead to resolution. 2 weeks later gets it again. Nxt step
recurrent episodes of Cdiff associated diarrhea are best treated with another course of oral Metro
*the answer "oral vancomycin" is the best answer when the patient does NOT respond to Metro, the pts symptoms improved on Metro, so retreat with Metro
Dermatitis, Dementia, Diarrhea. What is it called and what Vitamin def?
Pellagra
Vitamin B3 deficiency (3 D's) = Niacin
Fat malabsorption frequently presents with
weight loss
Whipple's disease treatment
Ceftriaxone followed by TMP/SMX
Chronic pancreatitis and Gluten sensitive enteropathy present very similar with malabsorption. What is a major fact that distinguishes them?
Iron deficiency

Iron does NOT need pancreatic enzymes (like vitamin B12 needs for example)
therefore, only gluten disease which affects the bowel wall, can lead to Iron deficiency due to decreased absorption
Which test to order FIRST when Celiac disease is suspected?
Anti-tissue transglutaminase (first test)

then:
Antiendomysial Ab
IgA antigliadin Ab
What is the most accurate diagnostic test for chronic pancreatitis?
Secretin stimulation test

in a normal pancreas: injection of Secretin will release a large amount of HCO3-
Treatment for Tropical Sprue
TMP/SMX
Tetracycline
Treatment of Carcinoid syndrome?
(just pharmacologically)
Octreotide

it is a synthetic version of Somatostatin
a chloride channel activator that increases bowel movement frequency?
Lubiprostone
anti motility agent for diarrhea
Loperamide
Antispasmodic agents to treat Irritable Bowel syndrome
Hyoscyamine
Dicylomine
What skin manifestation is an indicator of disease activity in Crohn's disease?
Erythema nodosum
When do you start screening pts with Crohn for colon cancer? and how often?
after 8-10 yrs of colonic involvement, with colonoscopy every 1-2 yrs
Acute vs chronic management of UC and Crohn's
Acute: give Steroids : Prednisone or Budesonide ("butt")

Chronic maintenance of remission : 5-ASA derivatives (mesalamine)
a steroid specific for Inflammatory Bowel Disease?
Budesonide ("Butt")
Name the 2 drugs that are used to wean pts with Inflammatory Bowel Disease off Steroids
( for ex, those pts that have severe recurrence every time they stop the steroids) *HY
Azathioprine and 6-Mercaptopurine
Perianal Crohn's disease is treated with what type of Abx?
Cipro + Metro
(covers E.coli and anaerobes of bowel flora)
Fistulaes of Crohn's disease are treated with
TNF agents, such Infliximab

(surgery is only indicated for obstruction)
best initial test in pt with LLQ pain, fever and leukocytosis
CT abdomen
you are thinking Diverticulitis
DO NOT DO ENDO OR BARIUM, infected bowel wall is weak, risk of perforation
Treatment for Diverticulitis
Cipro + Metro
(to cover E.coli and anaerobes of bowel flora)

also: NPO
Screening for positive family history of colon cancer. When to start
start 10 yrs earlier or at 40, whichever is younger
When to start screening pts with HNPCC
(Hereditary nonpolyposis colon cancer syndrome)
*HNPCC= 3 family members, 2 generation and one person got it premature (<50)
start at age 25 with colonoscopy and then every 1-2 yrs thereafter
Thousands of polyps on colonoscopy.
Diagnosis?
what gene mutation?
Screening should begin at? and how often?
FAP
Familial Adenomatous polyposis
APC gene
start screening at 12 yrs EVERY year
One polyp was found on colonoscopy. When is the nxt colonoscopy recommended?
every 3-5 years
Pt with past history of colon cancer, how often should he be screened?
colonoscopy at 1 year after resection
then at 3 years
and after that EVERY 5 yrs
Do polyposis syndrome, such Peutz Jeghers and Gardner and Turcot etc require increased frequency of colon cancer screening?
NO
What is the difference between the pain with acute pancreatitis and acute cholecystitis?
acute pancreatitis: pain stabs straight though to back

acute cholecystitis: pain wraps around to back
Which lab finding is associated with the worst prognosis for pancreatitis?
hypocalcemia

*severe pancreatic damage leads to fat malabsorption
*Ca2+ saponifies with the fat and can't be absorbed
What diuretic (s) are associated with a SE of pancreatitis?
HYDROCHLOROTHIAZIDE

also: Furosemide
Pancreatitis:
best initial test?
most specific test?
best initial test: amylase and lipase

most specific test: CT abdomen

(disease severity strongly correlates with the degree of necrosis seen on CT)
>30% necrosis = extensive necrosis -->GET NEEDLE biopsy
Sentinel loop of bowel on Xray, think
Pancreatitis

sentinel loop= air filled piece of small bowel in LUQ)
Abdominal CT is always performed with oral and IV contrast to better define the outline of abdominal structures
...
More than >30% of necrosis seen on CT or MRI in a pt with pancreatitis. How do you go from here?
*Start adding Abx: Imipenem or Meropenem
(decrease risk of infection)
*do a needle biopsy
severe necrosis (=>30% necrosis is indication for needle biopsy)
*resect and surgical debribement of necrotic tissue to prevent ARDS and mortality
all clotting factors except ______ are made in the liver
factor 8
it is produced in endothelial cells of blood vessels
Platypnea
SOB in supine position
(it is relieved with lying down)
* seen with hepatopulmonary syndrome
Pt with long standing liver cirrhosis complaining of SOB especially in the supine position
hepatopulmonary syndrome
Thrombocytopenia in a chronic cirrhosis pt is due to
splenic sequestration of platelets
serum ascites albumin gradient of >1.1 g/dL , think
ascites are due to portal HTN
(low albumin content in the ascites fluid)
definition of Spontaneous Bacterial Peritonitis

m/c organism to cause it?
infection WITHOUT a perforation of the bowel

*E.coli is the m/c organism
*Anaerobes are rarely the cause, think of it, there is no perforation
*Strep pneumo can cause SBP for unknown reasons
Treatment of Spontaneous Bacterial Peritonitis *HY

what lab value do we use to initiate treatment? *HY
Cefotaxime or Ceftriaxone

*start Tx based on NEUTROPHIL COUNT, not culture
(although fluid culture is the most accurate, the results are not available when we need them)

>250 NO = start treatment

*when the Albmin Ascites level is low, prophylactic -floxacin or TMP/SMX to prevent SBP
Ceftriaxone coverage
Antimicrobial Spectrum:
Staphylococcus aureus (methicillin susceptible), Coagulase negative Staphylococci, Streptococcus pneumoniae (penicillin susceptible), Streptococcus spp., Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitides, Neisseria gonorrhoeae, Enterobacteriaceae, E. coli
clindamycin coverage
Antimicrobial Spectrum:
Streptococcus spp., Staphylococcus spp., H. influenzae, M. catarrhalis, Bacteroides spp., (Clostridia spp.of variable susceptibility) Prevotella spp., Fusobacterium spp., Veillonella spp., Chlamydia trachomatis
TMP/SMX coverage
Antimicrobial Spectrum:
*Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus pneumoniae,
Staphylococcus aureus, Staphylococcus epidermidis, Listeria monocytogenes, Nocardia asteroids, Mycobacterium fortuitum, Escherichia coli, Shigella dysenteriae, Salmonella typhi, Salmonella enteritidis, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus mirabilis, Stenotrophomonas maltophilia, Haemophilus influenzae, Pasteurella multocida, Bordetella pertussis, Brucella melitensis, Neisseria gonorrhoeae, Neisseria meningitides
Binge drinking gives a sudden rise in
GGTP
Liver/bile duct disease vs bone disease. What do they have in common on lab and what distinguishes them?
Both have elevated ALP (Alkaline Phosphatase)
but only liver/bile duct disease will have elevated GGTP
most accurate blood test for PBC?
Tx of PBC?
anti mitochondrial Abs
Tx: Ursodeoxycholic acid ("you're so deoxy")
Which condition in the liver/biliary system is the exclusion to "liver biopsy is the most accurate test"
PSC
Primary sclerosing cholangitis
most accurate test: ERCP
it will show beading of bile ducts
Treatment of Primary sclerosing cholangitis
same as PBC: Ursodeoxycholic acid and cholestyramine
*HY: Primary Sclerosing cholangitis does NOT improve even if the IBD resolves or is surgically removed with colectomy. The pt may still progress to needing a liver transplant
...
Pt with hemochromatosis is susceptible to what bugs that looove Iron?
Yersinia
Listeria
Vibrio
chronic Hep B vs chronic Hep C treatment
(how many drugs for each?)
Hep B -> 1 drug

Hep C -> 2 drugs

(letter B comes first, so just 1 drug)
What type of anemia is associated with Wilson's disease?
Coombs negative hemolytic anemia (it is non immune related anemia)
Decreased Ceruloplasmin is the most accurate test in Wilson's disease. T or F?
False.
All plasma proteins can be decreased in those with liver dysfunction and cirrhosis

*the most accurate test in Wilson's:looking at an abnormally increased amount of Copper excretion into the urine after giving penicillamine
What is the reason behind using Zinc in pt with Wilson's disease?
Zinc interferes with intestinal copper absorption
anti-smooth muscle Abs. Associated with? Treatment
Autoimmune hepatitis
Tx: Prednisone and or Azathioprine
elevated LDH in an AIDS pt with SOB
PCP

* LDH is very useful as a negative predictor, meaning that a LDH level <220 IU/L are very UNLIKELY to have PCP

(but may also be elevated in AIDS pt with Histo or Lymphoma)
pt with AIDS and oral trush, tells you that CD 4 count is below
250
AIDS pt with PCP. When should you give Prednisone along with Abx?
pts with arterial PO2 <70 mmHg or A-a gradient less than 35 mmHg have significant disease and have an IMPROVED prognosis if PREDNISONE is given in conjunction with antimicrobial therapy
m/c CNS mass lesion in AIDS pt

what is another consideration, how to distinguish?
cerebral toxoplasmosis
(multitple enhancing ring lesions, typically in the basal ganglia)

the major alternative diagnosis for it is CNS lymphoma. Consider this, if pt does NOT improve after 2 weeks of anti toxoplasmosis treatment, also usually just one lesion

Next step: examine pts CSF for EBV DNA (because 90% of pts with CNS lymphoma are positive for EBV infection)
treatment of cryptococcal meningitis in AIDS pt
Amphothericin B + Flucytosine
(followed by lifelong prophylaxis with oral flucanazole)
adrenal insufficiency in a pt with AIDS and retinits+ esophagitis.
What bug?
CMV

can cause adrenal necrotizing adrenalitis, which occasionally destroys sufficient adrenal tissue to produce clinical adrenal insufficiency
Pt started HAART treatment and gets worse. What is this syndrome called?
IRIS
Immune Reconstitution inflammatory syndrome

-1-2 weeks of starting HAART, improvement in the immune system can actually cause worsening symptoms as a result of host responses
(therefore, if a pt is really sick, wait for sickness to resolve before starting HAART)
HAART indications
1. acute HIV infection
2. symptomatic (no matter what CD 4 count)
3. pregnant
4. ASYMPTOMATIC but CD 4 count<500
Fact: most common causes of bacterial pneumonia in AIDS pts are the same as those in immunocompetent pts, that is, CAP organisms such as Strep pneumo
Fact: don't start HAART in an acutely ill pt due to IRIS
...
Hypsarrytmia (dancing eyes) and opsoclonus (dancing eyes) in a child, think
diagnosed by?
Neuroblastoma
diagnosed : VMA and metanephrines in urine
Omphalocele is highly associated with what syndrome?
Edward's syndrome (trisomy 18)
Rest pain=warning sign of possible critical limb vascular insufficiency
...
What are the 2 most important risk factors for Peripheral Arterial Disease?
1. smoking
2. DM

others: HTN, dyslipidemia, elevated homocystein
intermittent claudication
most common symptom associated with PAD
*it is characterized by pain with walking and relieve by rest (person leaning over shopping cart)
normal ABI
>1

if .4-.9 claudication
<.4 critical leg ischemia
Pt with history of PAD presents with acute arterial occlusion (the 6 Ps). What is the initial management
anti coagulate with Heparin to prevent propagation of the thrombus
-place the affected limb below the horizontal and apply no pressure on that leg
Cardiomyopathy (such as LVH seen on ECG) is an "end organ damage" secondary to HTN
...
Pt with preHTN but also a comorbity, still needs to be put on medication even though his BP is 120-139/80-89
...
BP goal for HTN treatment
no comorbities
with comorbitities
no com.: 135/85 mmHg
with com.: 130/80 mmHg
BP med of choice in person with heart failure and HTN
ACE inhibitor
BP med of choice in person with Coronary Artery Disease and HTN
beta blocker
BP med of choice in male with HTN and BPH
alpha blocker
how does renal artery stenosis lead to low K+ levels?
decreased renal perfusion leads to decreased GFR. Leads to increase in Renin--> increase in Aldosterone (secondary hyperaldosteronism), which excretes K+
severely elevated BP, confusion, increased ICP and/or seizures.
Diagnosis?
Hypertensive encephalopathy
What is the goal BP in someone with a hypertensive crisis?
160/100-110 mmHg
(it may be very harmful to lower BP too low because it may lead to brain, kidney hypo perfusion)
Hypertensive emergency vs Hypertensive urgency management
Hypertensive ER: inpatient (ICU) with Sodium Nitroprusside
Hypertensive urgency: can be treated outpatient if pt is reliable
Which is the most dangerous panel (of a lipid panel) in terms of risk for CAD?
elevated LDL
(a low HDL is also associated with poor long term prognosis, but is not as dangerous as an elevated LDL)
Worst vs most common risk factor for CAD
worst risk factor: DM
Most common risk factor: HTN
what is the presumed mechanism of Tako Tsubo cardiomyopathy? Treatment?
Massive Catecholamine release (from an overwhelming event for ex)
Tx (just like ischemic heart disease): beta blocker + ACEi
*remember revascularization is of no use because Coronary arteries are normal)
Correcting which of the risk factors for CAD will result in the most immediate benefit for the pt?
1. DM
2. HTN
3.Tobacco
4. Weight loss
smoking cessation results in the greatest IMMEDIATE improvement
(within a year after stopping the CAD risk decreases by 50%)
when the chest pain is described as changing with respiration, changing with bodily position, or touching the chest wall, then do NOT answer "ischemia" or "CAD" as cause for the chest pain
...
most feared complication of pericarditis
cardiac tamponade
*it is very important to differentiate pericarditis from MI, because if you use thrombolytics in pericarditis thinking it is an MI, you can cause life threatening pericardial hemorrhage
you suspect costochondritis, what is the most accurate test?
Physical exam ;)
3 medications for pts with CHRONIC chest pain that have been shown to lower mortality
Aspirin
Beta blockers
Nitroglycerin
Nitroglycerin for acute vs chronic chest pain, route of adminisitration
acute:
Nitro paste, sublingual, IV

chronic: oral, patch
what medication has been indicated for pts unable to take Aspirin or Clopidogrel for anti platelet ?
what are 2 common side effects to look out for
Ticlodipine

*it can cause Neutropenia and TTP
good drug choice for pt with regurgitant valvular disease
ACE i or ARB
What drugs have been shown to lower mortality in systolic dysfunction pts?
ACE i / ARB
Hydralazine -->clear mortality benefit in pts with syst dys

*use Hydralazine in association with Nitrates. Hydralazine dilates arteries to decrease after load, and Nitrates dilate Coronary arteries... this way by dilating arteries, blood will not be stolen from coronary arteries
which lipid lowering agent has clear mortality benefit in CAD?
statins
<100 for CAD pts
<70 for CAD + DM pt
Statins also have a benefit beyond lowering LDL. What is it?
Statins have an antioxidant effect on the endothelial lining of the coronary arteries
What 2 lipid lowering agents have to be used carefully together? why?
careful combining Fibrates with Statins due to increased risk of myositis
Which lipid lowering agent not to give to gout person
niacin --> elevation of Uric acid levels
Why should you not use the -pine Ca2+ channel blockers in CAD?
it may actually increase the mortality due to reflex tachycardia, which will in turn increase myocardial oxygen consumption

the CCBs Verapamil and diltiazem, which do NOT increase heart rate, are only used if:
*pt has asthma
*prinzmetal variant angina
*cocaine induced chest pain
cocaine induced chest pain, what drug is contraindicated?
beta blockers (use Verapamil/diltiazem)
CABG
Coronary Artery Bypass Grafting
*the only ones who have benefit of this procedure are those with chronic/stable disease or those with severe disease such as 3 vessel occlusion of at least 70% stenosis, LAD occlusion, 2 vessel disease in diabetics, etc
what is the best definite therapy for acute coronary syndrome, particularly those with ST elevations?
PCI. Percutaneous Coronary Intervention.
Acute coronary syndrome is associated with what heart sound?
S4
Pt with DVT has stroke, what test to order to show underlying etiology?
TEE to show patent foramen ovale
PVCs should not be treated, even when associated with an acute infarction. Treatment of PVCs only worsens outcome
...
MI pt has been given Aspirin, which next step has the greatest mortality benefit?
Angioplasty=associated with the greatest mortality benefit of all the steps (ex Morphine, Nitrate, etc O2 etc)
remember: beta blockers are associated with a decreased mortality but they are not critically dependent on time (Angioplasty is). As long as the pt receives Metropolol at SOME POINT during the hospital stay (same is true for statins and ACE inhibitor)
What can result in a false positive Troponin test?
Renal insufficiency, troponin is excreted through kidney
Door to balloon time (PCI =Angioplasty)
90 minutes (99 Luftballons, fliegen....)
Which step has decreased the risk of restenosis?
drug eluting stents (they secrete immunosuppressants, not anti coagulants. Like Sirolimus and Paclitaxel)
Also: during procedure Heparin is used. But no warfarin is indicated for any of this. WARFARIN HAS NO PLACE IN THE MANAGEMENT OF CAD.
Contraindications for tPA use
Sever HTN (>180/110)
non hemorrhagic stroke within last 6 mths
recent surgery (last 2 weeks)
major bleeding of bowel or brain
Door to tPA time
30 minutes
What drug can you not use in CAD--> due to Cocaine induced chest pain or Prinzmetal?
beta blockers (leads to more spasm) so use Ca 2+ ch blockers
remember: there is no time urgency for beta blocker, ACE inhibitor and statin, as long as they are given before discharge
...
Pt comes in with chest pain. ECG shows ST depression in V2-V4. Aspirin has been given. What is the appropriate next step?
Heparin
*we want to give Heparin ASAP to prevent clot from growing and occluding the entire vessel

remember: if the pt comes in with a NON stemi, then thrombolytic therapy will not work
tPA (thrombolytics) are only beneficial with ST elev MI

Heparin is best for NON stem elev MI

GP IIb/IIIa are best for NON stem elev MI and those undergoing stenting or PCI (Angioplasty)
...
When would you do an urgent Angioplasty in an NON stemi patient?
if all medications have been given and the pt is not improving and actually getting worse:
developing CHF
S3 gallop develops
worse ECG
rising troponins
What are common complications of MI? and why?
1. Sinus bradycardia --> very common, due to decreased vascular supply to SA node

2. Third degree AV block
*how to distinguish bradycardia from sinus brady vs AV block... AV block has CANNON A waves (atrial systole against a closed tricuspid valve, remember in 3rd degree AV block there is no coherence between atria and Ventricles)

3. RV infarct
*look for a new inferior wall MI and CTA lungs (remember, if blood can't get into heart, can't get into lungs)

4. Tamponade/free wall rupture-->but CTA lungs
5. VTach/VFib -->but CTA lungs
6. Valve or septal rupture--> WET LUNGS (pulm congestion) ***step up of O2 sat from RA to RV
what are cannon A waves
remember the "a" wave is the atrial wave, if tricuspid is closed, such as in complete AV block, you get a higher "a" wave

*these cannon a waves are seen with RV infarction (but you will see tachycardia) and 3 rd degree AV block (bradycardia)

*also: these waves help you distinguish sinus bradycardia from bradycardia associated with AV block
What is the most accurate test to show underlying cause on a pt with a new onset of murmur and pulmonary congestion in a post MI pt with a step up in oxygen saturation between RA and RV?
get an Echo to proof septal rupture
What is the use of an "intraaortic balloon pump"?
to bridge a pt until a permeant fix can be made to a valve (replacement)
Which post infarction medication is best for an anterior wall infarct and why?
ACE inhibitors are best for anterior wall infarctions because of the high likelihood of developing systolic dysfunction
Do NOT give prophylactic anti arryhthmics to post MI pts to "prevent" a deadly arrhythmia... Prophylactic antiarrhythmics increase mortality !!!!! Do NOT be fooled by the question describing that pt has "frequent PVCs and ectopy"
...
ED post MI is most commonly due to
anxiety
(however, from all the post MI meds, beta blockers are notorious to cause it too)
what is the most important of all the tests of CHF and why?
Echocardiography

all the others: ECG, Xray, troponins, BNP, PE, H/P can NOT distinguish systolic vs diastolic dysfunction
Best initial test for CHF evaluation?
Most accurate test for CHF?
Transthoracic echo (transesophageal is better for valves)

most accurate: MUGA (Multiple-gated acquisition scan)
or nuclear ventriculography
pt comes to ED with SOB but no time to get an Echo, what is a quick way to rule out CHF?
get a BNP level. A normal BNP excludes CHF as the cause for SOB
What is the m/c death from CHF?
arrythmias/sudden death

*ischemia provokes ventricular arrhythmias leading to sudden death
* beta blockers are anti arrhythmic and anti ischemic, so they PREVENT sudden death... DO NOT GIVE BETA BLOCKERS IN THE ACUTE TREATMENT
Sprinolacetone only has beneficial effect for what stages of CHF?
stage 3+4
Pt with stage 3 CHF develops gynecomastia? What to do?
This pt most likely is taking Sprinolacetone. Switch pt to Eplerone
DIGOXIN HAS NEVER BEEN PROVEN TO LOWER MORTALITY IN CHF !!!!!!!!!!!!!!!!! it only controls the symptoms (same with diuretics, they decrease symptoms but no do NOT lower mortality)
...
only do dialysis if the hyperkalemia is due to kidney failure...
...
*HY*
What drugs lower mortality in systolic dysfunction?

KNOW THIS
ACEinh/ARBs
Beta blockers
Spironolacetone (stage 3+4)
Hydralazine + Nitrates
implantable defibrillator
What drug that is used in systolic dysfunction should NEVER be used in diastolic dysfunction?
Digoxin
*Digoxin has NO benefit and should NOT be used in diastolic dysfunction
*also: Spironolacetone has no benefit in Diastolic dysfunction
What drugs are clearly beneficial in Diastolic dysfunction?
Beta blockers have clear BENEFIT
Diuretics have Benefit at controlling symptoms of fluid overload
Don't give what type of drug class to HOCM pts and why?
Don't give diuretics to HOCM pts because it decreases
"chamber size" thus can't "open" outflow obstruction
all cardiomyopathies are treated with
diuretics
what murmurs do NOT increase with expiration?
HOCM (expiration=more blood in LV=opens up obstruction)
MVP
Doxorubicin leads to what type of cardiomyopathy
Dilated (DD: Dilated Digoxin)
HY*
Dilated cardiomyopathy

1. What tx for lowering mortality
vs
2. symptom treatment
1. ACE inh., ARBs, beta blockers (metoprolol, carvedilol) and spironolacetone ALL LOWER MORTALITY

2. Diuretics and Digoxin--> treat the symptoms
Hyperthrophic cardiomyopathy is NOT HOCM
from HTN genetic

In terms of treatment, differences?
HCM and HOCM both benefit from Betal blockers (best initial therapy in both)

HOWEVER:
Do NOT give diuretics to HOCM (remember, they decrease left chamber size making HOCM worse)

Diuretic may help HCM
HOCM recommendations
reduce strenous exercise, because anything that increases HR worsens symptoms
What medications NOT to give in HOCM?
anything that decreases Left chamber size:
-ACE inhibitors/ARBs
-Digoxin
-Hydralazine
-Valsalva
-standing suddenly
What is classic for Mitral valve in someone with HOCM?
Systolic anterior motion (SAM) of the mitral valve, this contributes to the obstruction
Best initial pharmac. therapy for HOCM? what is contraindicated?
beta blocker

contraindicated in HOCM: Diuretics (remember they decrease the left chamber size)
What would you see on ECG in someone with HOCM?
Q waves in inferior and lateral leads (they are not a previous MI)
LVH is common
1/4 of pts can have a normal ECG
What should be used in any HOCM pt with syncope?
implantable defibrillator

if that and all other medical therapy fails: ablation of septum
What 2 drugs are not indicated in Hypertrophic cardiomyopathy (but you use them for dilated cardiomyopathy)?
Spironolacetone and Digoxin

(remember you can treat both, dilated and hypertrophic, with beta blockers, diuretics, and ACE inh/ARBs)
Most accurate test for restrictive cardiomyopathy?
endomyocardial biopsy
More blood increases all murmurs except
HOCM and MVP
Why does standing suddenly decreases preload/VR?
when you squat, the muscles squeeze veins shut, so when you stand up quickly, all these veins open up and "store" blood so less gets returned that second (so decreased VR / preload)

that is the same effect diuretics have
Diuretics vs ACE inh. /ARBs on murmurs
Diuretics: decrease VR/preload (just like Valsalva + standing up from squat)

ACE inh./ARBs : decrease after load
Handgrip does what to after load?
increases it
*when you squeeze hand, muscles clamp of UE arteries, thus preventing blood to leave heart (so a handgrip decreases LV emptying)
Regurgitation lesions are best treated with
ACE inhibitors, ARBs and nifedipine (as a vasodilator)
they decrease the after load, so that there will be less regurgitation
diuretics, tachycardia and dehydration make the chamber smaller, thus worsen HOCM and MVP
...
most specific finding on ECG in pericarditis?
PR segment depression

(ST elevation is seen in all leads, too, but not most specific)
What drug decreases recurrence of pericarditis?
Colchicine
What is pulsus paradoxus and what condition is it associated with?
pulsus paradoxus is a decrease of more than 10 mmHG in BP on inspiration (normally increases with inspiration)
-classic finding in Cardiac tamponade
"globular heart" on Xray
Cardiac tamponade (enlarged cardiac shadow expanding in both directions)
Constrictive pericarditis. Remember, the myocardium moves normally... the pericardium is fibroses
*what is a first line treatment approach for constrictive pericarditis?
Diuretics to decompress the filling of the heart and relieve edema and organomegaly (from back up)
PAD.
1. best initial test
2. most accurate test
3. single most effective medication
best initial test: ABI (<0.9 = PAD)

most accurate test: Angiogram (but don't do it UNLESS you will fix it !!!)

single most effective medication for PAD: cilostazol

cilostazol:
indication: intermittent claudication
MOA: inhibits Phosphodiesterase 3 reducing platelet aggregation, suppresses CAMP degradation, producing vasodilation
Cilostazol
Indication and MOA
indication: intermittent claudication
MOA: inhibits Phosphodiesterase 3 reducing platelet aggregation, suppresses CAMP degradation, producing vasodilation
pain between the scapula and difference in BP between left and right arm, think________. What is the best initial test?
Aortic dissection

best initial test: chest xray (widened mediastinum)
Aortic dissection management (pharm)
1. Beta blocker
then
2. Nitroprusside
(3. surgical correction if > 5 cm diameter)

remember, first you want to rate control so you don't get reflex tachycardia with a dilating agent
most accurate test for Aortic dissection?
Angiogram

but CT with contrast is mostly done
underlying cause in peripartum cardiomyopathy
antibodies made against the myocardium
*usually develops post partum so ACE in/ARBs are safe
*following pregnancies puts mother at high risk for developing massive antibody production against myocardium
What are the 2 worst cardiac diseases in pregnancy?
1. peripartum cardiomyopathy
2. Eisenmenger syndrome

(Mitral stenosis will worsen during pregnancy, remember all that increased plasma volume, but it is not worse than the 2 above)
you suspect Kallman syndrome. What is associated in about 50% of pts with Kallman?
Renal agenesis
low TRH, low TSH and low T3/T4.
Where is the lesion?
What electrolyte can be seen with this hypothyroidism?
lesion is in pituitary

Hyponatremia is a common secondary finding in hypothyroidism. Thyroid hormone is needed to excrete water, so in low T3--> retention of water-->hyponatremia
Bodybuilders take what supplement in hope to raise GH?
L-Arginine
effect of elevated TRH on prolactin
increases prolactin release
Insulin release does what to GH levels? If GH levels do not appropriately react to Insulin release, where is the defect?
Normally, Insulin release leads to increase in GH
If GH does NOT increase with Insulin--> pituitary insufficiency
Metyrapone
Metyrapone inhibits 11 beta hydroxylase (in adrenals). A normal response should be an increase in ACTH, since blocking this enzyme will lead to decreased Cortisol production. In pituitary insufficiency however, ACTH will not rise
Replace what hormone before Thyroxine administration? And what are you trying to prevent?
Cortisone

This may precipitate Addisonian crisis through two mechanisms. First, hypothyroidism reduces cortisol clearance. The addition of thyroid hormone replacement increases cortisol clearance, thus decreasing circulating cortisol availability. Second, hypothyroidism reduces the metabolic rate thereby reducing the need for cortisol. The increased metabolic rate accompanying thyroxine replacement increases the cortisol requirements that cannot be provided by the failing adrenals. Patients may die from ensuing Addisonian crisis.
low thyroid hormone has what effect on cholesterol?
thyroid hormone is needed to clear cholesterol from blood. hypothyroidism--> hypercholesteremia
What 2 electrolyte abnormalities inhibit ADH's effect on the kidney?
*HY
Hypercalcemia and hypokalmia

these imbalances down regulate Aquaporin 2 channels

remember: ADH increases the expression of Aquaporin 2 channels
what conditions can lead to Acromegaly?
*pituitary adenoma (most common; associated with MEN)
*ectopic GH
*GHRH production from a lymphoma or bronchial carcinoid tumor
check what other hormone in a pt with increased GH production?
What symptoms besides those of acromegaly would you see then?
Prolactin
Prolactin levels are tested because of cosecretion with GH

in men with increased prolactin: erectile dysfunction
Acromegaly.
Best initial test?
Most accurate test?
Best initial test : IGF-1 level

most accurate: Glucose suppression test
(normally glucose administration should decrease GH)
GH=anti insulin
only do the MRI once you have diagnosed acromegaly ON LABS
Pegvisomant
indication?
MOA?
Pegvisomant is a GH receptor antagonist, it inhibits IGF release from the liver
* it is used in Acromegaly
Treatment options for Acromegaly, besides transphenoidal resection
Cabergoline: Dopamine will inhibit GH release

Octreotide or Lanreotide: Somatostatin inhibits GH release
Which diuretic can raise prolactin levels?
Verapamil--> the only one to raise prolactin levels
Before you get an MRI in ANY endo disorder, you must diagnose it on labs first.
So in someone with high Prolactin levels, what tests to order?
*Pregnancy test (pregnancy elevates pro-lactation)

ALWAYS EXCLUDE PREGNANCY IN ANY WOMAN WITH ELEVATED PROLACTIN

*Thyroid function test (elevated TRH stimulates prolactin release)
*BUN/creatinine (KIDNEY DISEASE ELEVATES PROLACTIN)
*LFTS (cirrhosis elevates prolactin)
Hypothyroidism does what to menstrual flow
menstrual flow.
Hypothyroidism INCREASES menstrual flow
High TSH (double the normal) + normal T4, management?
treatment with thyroxine
Myxedema is associated with which thyroid pathology
hypothyroidism
Grave's disease, what type of auto antibodies
TSH receptor antibodies (they stimulate)
tender thyroid in pt with high T4
Diagnosis?
Treatment?
Subacute thyroiditis

Tx: Aspirin`
from all the hyperthyroidism diagnoses, which one is the only one that has increased radioactive iodine uptake?
Grave's disease has increased iodine uptake

*all the others have decreased uptake
Grave's pt with opthalmoplegia (proptosis, exophal.). Best initial therapy?
Steroids
Use of propanolol in hyperthyroidism (besides protecting heart)
Propanolol blocks target organ effect and inhibits peripheral conversion of T4-->T3
Which Thiourea drug is preferred?
methimazole
Treatment goal of hyperthyroidism ?
TSH in lower 1/2 of reference range and euthyroid
How long does it take for TSH to adjust to new dosing level?
6-8 weeks
Pt was found to have a thyroid nodule. T4 is elevated and TSH is low, next best step?
get an US of thyroid
*remember, malignancy is NOT hyper functioning
What thyroid nodules MUST be biopsied?
*thyroid nodules > 1 cm must be biopsied with a FNA if there is NORMAL thyroid function (normal T4/TSH)
*nodules in those with euthyroid should be biopsied
how can hyperthyroidism lead to hypercalcemia?
hyperthyroidisim--> fever--> IL 1 = osteoclast activator
and that can lead to increased burn turnover
how can hypercalcemia lead to DI?
increased Ca2+ levels lead to down regulation of Aquaporin 2 channels (just like Lithium)
How to treat hypercalcemia secondary to a granulomatous disease process? (like Sarcoid)
Prednisone controls hypercalcemia when it is from sarcoidosis or any other granulomatous disease
Pt had hypercalcemia. Was treated with IV fluids and a dronate. Still high Ca2+, next best step?
Calcitonin (works fast)
Hypercalcemia can lead to PUD. How ?
increased Ca2+ stimulates Gastrin release
You need Magnesium for PTH release. If you have low Magnesium-->low PTH-->hypocalcemia (you pee out Ca2+)
...
corrected Ca+ formula
for every 1 point below normal Albumin, Ca2+ increases by 0.8
how does renal failure lead to hypocalcemia
remember, Vitamin D activation has 2 steps. First in the liver, second in the kidneys (1-alpha-hydroxylase)
*also kidneys can not excrete phosphate, so it binds calcium
low calcium=hyperexcitable and twitchy (Chvostek etc)

High calcium= lethargic and slow (think constipation)
...
best initial test for hypercortisolism?
24 hour urine cortisol (remember the ACTH test is the best initial test to determine the CAUSE)
(if that is not in answer choice, then pick 1 mg overnight dexamethasone)

*the 24 hour test it more specific than the 1 mg test, the 1 mg suppression test has more FALSE POSITIVES
EX: Depression, Obesity, Alcoholism
if ACTH is elevated, and a high dose dexamethasone test can suppress it, where is the lesion?
pituitary (adenoma)

*all others (ectopic and adrenal source are non suppressible)
you suspect a pituitary adenoma secreting elevated ACTH levels but the MRI came back negative. Best next step?
sample the petrosal venous sinus
*high ACTH on petrosal sample
(if the ACTH came from an ectopic location, ACTH would be low in the petrosal sinus-->appropriate feedback)
(because some pituitary lesions are too small to be seen on MRI)
Effects of hypercortisolism on:
glucose
lipids
K+
pH
Leukocytes
Cortisol is ANTI insulin --> hyperglycemia
Hyperlipidemia

Cortisol as Aldosterone like effect:
*Hypokalemia
*Metabolic alkalosis (due to increased H+ excr.)
Leukocytosis (due to demargination of WBCs, 1/2 of all WBCs are "stuck" to blood vessel wall waiting to be released, cortisol clips the anchor)
What cancer loves to metastasize to the Adrenals?
Lung cancer
What is common finding on CBC in hypoadrenalism ? *HY
Eosinophilia
most specific test for adrenal funtion
Cosynotropin test (a synthetic ACTH)
*in a normal person the Cortisol should rise after administration
you suspect primary hyperaldosteronism, what is the best initial test?
What is the most accurate test to confirm the diagnosis?
best initial test: Aldosterone to Renin Ratio
(because an increased Renin level excludes primary hyperaldosteromism; it should be low)

most accurate test to confirm: sample the venous blood that drains the adrenal gland, it will show a high Aldosterone level

remember in Endocrinology, confirm on lab before scan, too many incidental lesions in population
best initial test for Pheochromocytoma
confirm this test with ______
free metanephrines in PLASMA
then
confirm it with 24 hour URINE collection for metanephrines

(blood before urine)
What test to order if pheochromocytoma is NOT in adrenal medulla?
get a MIBG scan
Exercising muscle does NOT need Insulin to transport glucose into cell (even in diabetics), so promote exercise
...
Metformin MOA
decreases hepatic glucose production (stop making it!!) , so it blocks gluconeogenesis
it decreases intestinal glucose absorption
increases insulin sensitivity
What oral hypoglycemic is relatively contraindicated in CHF?
the TZDs (Glitazones)
What would be a good oral hypoglycemic choice for a type 2 diabetic with poor renal function
alpha glucosida inhibitors
(also good for dumping syndrome)
Which oral hypoglycemic agent can cause pancreatitis?
Exenatide (an Incretin)
DKA. What determines DC from ICU, and DC from IV Insulin drip?
closure of anion gap (if that answer is not given, pick "Bicarbonate level")
*remember, if Bicarbonate is low=DANGEROUS
*when gap is increased continue IV Insulin even if glucose goes low-->replace glucose)
Proliferative retionopathy as a chronic complication of DM. What is treatment?
laser photocoagulation
(when neovascularization and vitreous hemorrhage are present, it is called PROLIFERATIVE retinopathy)
at what BP do you add an ACE or ARB to a diabetic?
if >130/80 (even though JNC 8 is 140/90)
what is microalbuminuria (numbers)?
30-300 mg per 24 hours
What is the main stimulant for gastric motility?
stretch of the bowel wall
(diabetics loose that "sense" of stretch-->gastroparesis)
Diabetic nephropathy: 3 drugs used to treat the pain
Pregabalin
Gabapentin
TCAs
best initial test in acute Asthma exacerbation (2 tests)

what is the most accurate diagnostic test?
best initial test:
PEF - Pulmonary Expiratory Flow
ABG- Arterial Blood Gas
*(you still get a chest X-ray but more to RO other etiologies; for example exclude pneumonia as a cause for exacerbation or pneumothorax, etc)

most accurate diagnostic test: PFTs
Zafirlukast is toxic to what organ?
Zafirlukast is associated with what syndrome?
*HY
Zafirlukast is HEPATOTOXIC and has been associated with CHURG STRAUSS SYNDROME
Omalizumab
anti IgE
Anticholinergics in Asthma vs COPD treatment
(Ipratropium and Tiotropium)
Anticholinergics dilate bronchi and decrease secretions
*role in Asthma not clear but they are HIGHLY AFFECTIVE IN COPD
Adverse effects of Systemic Corticosteroids
*HY
Osteoporosis
Cataracts
Adrenal suppresion (which can lead to crisis if stopped abruptly)
Hyperlipidemia
Hyperglycemia (anti insulin effect)
acne
hirsutism
thinning of skin, hair and easy bruising
Respiratory rate is a good indication of the severity of an Acute Asthma exacerbation, also, decreased PEF and ABG with an increased A-a gradient

Pulse oximetry: will not show hypoxia until the pt is nearly in respiratory failure
accessory muscles: subjective
O2 saturation: can be maintained above 90% by hyperventilating
...
Pt is having a severe acute asthma exacerbation unresponsive to Albuterol and Oxygen. What to give while waiting for Corticosteroids to start working?

*HY
Magnesium
*Mg helps relieve bronchospasm
*only used in severe cases that are unresponsive
*if all fails, intubate and take pt to ICU
What ECG finding is associated with COPD?
MAT
Multifocal Atrial Tachycardia
(different looking p waves)
*important: avoid beta blockers in these COPD pts

also: RA and RV hypertrophy
COPD etiology
smoking destroys elastin fibers that are needed for exhalation. Destruction of these fibers leads to loss of Elastic Recoil (inward force)
COPD best initial test vs most accurate test
best initial test: Chest xray
*increased AP diameter
*flattened diaphragm
*hyperinflation

most accurate test: PFTs
COPD management

1. What improves mortality?

2. What improves symptoms (only)?
Smoking cessation and O2 therapy are the ONLY treatments that LOWER MORTALITY

improve symptoms but not mortality:
*SABAs
*Steroids
*Anticholinergics: tiotropium, ipratropium
*LABAs
*pulm rehab
Asthma vs COPD treatment (basic points)
Asthma not controlled on SABA--> ICS

COPD not controlled on SABA--> Anticholinergic (-tropium) --> ICS
Acute exacerbation of chronic bronchitis. What 3 bugs to cover and what Abx groups?
Strep pneumo
Hib
Moraxella catarrhalis

Abx:
1 st line agents:
Macrolides
Cephalosporins
Amox/Clav
Quinolones

2nd line:
Doxycycline
TMP/SMX
What lung disease is associated with high Ig E levels
Allergic bronchopulmonary Aspergillosis
Bronchiectasis. Best initial test? most accurate test?
best initial test: chest xray (shows dilated, thickened bronchi, "tram track" appearance
most accurate test: High resolution CT scan (*HY), will show widening of the bronchi

specific would be a sputum culture (specific organism)
Asthma pt with recurrent episodes of brown flecked sputum and transient infiltrates on chest X-ray. Most likely diagnosis?
Allergic Bronchopulmonary Aspergillosis
*=hypersensitivity of the lungs to fungal antigens
*OCCURS ALMOST EXCLUSIVELY IN ASTHMATICS AND PTS WITH HISTORY OF ATOPIC DISORDERS
Asthma pts are at increased risk to develop what lung disease?
Allergic Bronchopulmonary Aspergillosis
How do you treat Allergic Bronchopulmonary Aspergillosis?
ORAL steroids (inhaled steroids can not deliver drugs into system to be effective)
*HY: INHALED CORTICOSTEROIDS ARE NOT EFFECTIVE in allergic bronchopulmonary aspergillosis
*use Itraconazole for recurrent episodes
Cystic fibrosis
Gene mutation?
inheritance pattern?
what clogs up the ducts?
DLCO up or down?
CFTR = Cystic Fibrosis Transmembrane Conductance Regulator

beta cells (Islet cells) are spared. Only in very late disease will pts develop Diabetes

autosomal recessive

DLCO decreased

NEUTROPHILS DUMP TONS OF DNA INTO AIRWAY SECRETIONS --> that is why we use recombinant human deoxyribonuclease to break DNA down

remember: both men and women can become infertile
Men: azoospermia, vas deferens missing
Women: thick cervical mucus

also: nthg particular seen on chest X-ray, you may see hyperinflation, also long standing disease can lead to respiratory ACIdosis (can't get air out because of thick mucus)
What is the most accurate test for CF?
Sweat Chloride test (NOT genetic testing)
*Cl- levels >60 meq/L on REPEATED testing is diagnosic

How do you make them "sweat"?
Pilocarpine increases ACh levels-->increased sweating
CF Treatment
1. Antibiotics are routine
*inhaled amino glycosides are limited to CF

2. Inhaled recombinant human deoxyribonuclease
(rhDNase)
*remember that NO in CF dump all the DNA into airway secretions, so this drug breaks down the massive amounts of DNA

3. inhaled bronchodilators (ex Albuterol)

4. Vaccines (pneumococcal and influenza)
CAP in COPD pt, what bug most likely?
Haemophilius influenza
"COPD --> COPS Haeve Influence
CAP in diabetic, bug?
Klebsiella (same for alcoholic, "klebt" an flasche)
CAP in pt with poor dentition, sz disorder or aspiration risk, bug?
anaerobes
How do you distinguish Bronchitis from a pneumonia?
pneumonia:
dyspnea, high fever and abnormal chest X-ray (either lung consolidation or infiltrates)
Lung and GI symptoms, think of what bug?
Klebsiella pneumonia ("jelly sputum")
Mycoplasma pneumoniae pneumonia. What are PE findings?
Dry cough
young healthy patients
rarely severe
BULLOUS MYRINGITIS (inflammatory condition of the eardrum--> painful fluid filled vesicles on the tympanic membrane)

MYringitis--?MYcoplasma
Best initial test for all respiratory infections
chest xray
Bugs that cause a "dry" or "non productive cough" with pneumonia.... (5)
Mycoplasma
Viruses
Coxiella
PCP
Chlamydia
*these bugs like the interstitial place and therefore produce less sputum

** these 5 bugs also cause BILATERAL interstitial infiltrates on chest xray
new large pleural effusions secondary to pneumonia should be tapped
...
specific diagnostic test for Pneumonia bugs:

1. Mycoplasma pneumonia
2. Chlamydia pneumophilia
3. Chlamydia psittaci
4. Coxiella burnetti
5. PCP
1. PCR, cold agglutinins (Ig M), serology

2/3/4: all the C's --> Rising serologic titers

5. PCP : Bronchoalveolar lavage (invasive, you need to place a bronchoscope)
PCP is an exception because non invasive testing rarely reveals a diagnosis, so do a lavage
Pts with CSF leak and pst with cochlear implants should receive what vaccine?
Pneumococcal vaccine
Pt got a pneuomococcal vaccine at age 58. Recommendations?
get a 2nd dose at 63 (5 years after first dose)

if given at 65, person only needs 1 dose
meniscus sign
pleural effusion with meniscus sign
Definition of Hospital acquired pneumonia ?

What is the main difference in treatment between CAP and HAP?

What are some treatment choices (what bugs have to be covered?)
>48 hours after admissions
or
after hospitalization stay in the last 90 days

main Tx difference:
MACROLIDES ARE NOT ACCEPTABLE AS TX

You must center the focus on treatment of HAP on gram negative bacilli, such as:
*Pseudomonas
*E.coli
Tx choices:
Antipseudomonal Cephalosporins (Cefepime, Ceftazidime)
Antipseudomonal penicillin: piperacillin/tazobactam
Carbapenems
Ventilator associated Pneumonia. The diagnosis of a specific etiologic agent is extremely difficult to obtain. What is the most accurate diagnostic test?
Open lung biopsy
(most accurate but most dangerous)
Ventilator associated Pneumonia treatment
combine 3 drugs

1. Antipseudomonal beta lactam
Ex: Cephalosporin, Penicillin+betalactam inhibitor, or a Carbapenem

PLUS

2. Second Antipseudomonal agent
Ex: Aminoglycoside or Fluroquinolone

PLUS

3. MRSA agent
Vancomycin or Linezolid
What are the beta lactam antibiotics?
PCNs, Cephalosporins, Monobactams, Carbapenems
Imipenem has what dangerous SE?
seizures
esp with kidney failure pts, because it is excreted by kidneys
Aspiration pneumonia when lying flat, which lobe is affected
upper lobe
Lung abscess is rare and only occurs in what pt population?
Pts that have large aspiration contents
-poor dentition
-loss of gag reflex
-sz
-endotracheal intubation

*WEIGHT LOSS IS COMMON
Best treatment for lung abscess (drugs)
Clindamycin (cleaning mice in the lungs)
Penicillin
best initial, most accurate and most specific test for lung abscess
xray is best initial (air fluid level, thick wall of cavity)
CT more accurate
lung biopsy is most specific

*sputum culture is the WRONG ANSWER for any of these
Most accurate test for PCP
bronchoalveolar levage

however, if the problem says that the sputum stain was positive for PCP, then no further testing is necessary
*negative sputum stain means: do a bronchoalveolar lavage
normal LDH in an HIV pt with cough, what can you RO?
PCP
* a normal LDH = no PCP
What are the indications for adding Steroids to PCP treatment?
*HY
-add steroids if PCP is severe

severe= a pO2 of <70
or
A-a gradient >35
Pt with PCP unable to tolerate TMP/SMX, what can you switch them to?
What are the most common SE of TMP/SMX?
pentamide (ex for G6PD deficiency pts)
or
Clindaymycin and primaquine

2 m/c SE:
Rash (it is a sulfa drug)
bone marrow suppression
also:neutropenia
Do NOT begin antiretroviral treatment in an opportunistic infection. T or F
True
Do NOT start it, can make things worse
if there is a rash or neutropenia from TMP/SMX for PCP, what other drugs could you use for PROPHYLAXIS?
Atovaquone
or
Dapsone (--> do NOT use in G6PD)
minor fissure (pic)
single most accurate test for TB
pleural biopsy
Standard of care for TB is 6 months. when do you extend it to 9 months?
-osteomyelitis
-Miliary TB
-Meningitis
-Pregnancy, or any time Pyraxinamide is not used

**do not use Pyraxinamide in Pregnancy
All TB drugs are toxic to what organ?
SE of Pyrazinamide?
SE of Ethambutol?
All TB drugs are HEPATOtoxic, but do NOT stop Tx unless the transaminases are 3-5 times the UPPER limit of normal

Pyrazinamide: Hyperurecemia

Ethambutol: optic neuritis/color vision (E-->Eye)
** must adjust dose in renal failure, decrease dose in renal failure
What TB drug(s) are contraindicated in pregnancy?
Pyrazinamide ( P-->P regnancy)
Streptomycin (stripping mice not appropriate for fetus)

**remember: if you can't use Pyrazinamide, then Tx for TB increases to 9 mths (vs 6)
When do you use Steroids in TB?
Glucocorticoids decrease the risk of constrictive pericarditis !!!

use steroids in TB pts with PERICARDIAL involvement
on a TB test only the induration counts as mm, NOT erythema
...
symptomatic pt with TB signs. Best test
PPD is not useful
*get a sputum acid fast stain + chest xrays
Two stage TB testing
1st test was negative
2nd test was positive
Is the pt infected?
Yes !!!
the first test was a false negative

remember for 2 stage testing, if the first test is positive, no further testing necessary.
Only do a 2 stage testing if the first test is negative
What would be a good test for TB pt with BCG vaccine?
IGRA
Interferon Gamma Release Assay
(no cross reaction with BCG)
If the problem describes a malignant lesion in the lung, "resection" is the answer. Not FNA, needle biopsy, PET scan etc. A negative test in those will most likely be a false negative. So resect it
...
sputum cytology is positive, most appropriate next step?
resection
(remember, sputum cytology is NOT the same as sputum culture)
use bronchoscopy for central lesions and TRANSTHORACIC BIOPSY for peripheral lesions.
What is the m/c adverse effect of transthoracic biopsy?
pneumothorax
PET scan
Positron Emission Tomography

Agent: FDG 18 (Flouro Deoxy Glucose), basically tagged sugar.
Remember that malignancy has increased uptake of glucose
Drugs that can lead to pulmonary fibrosis
Busulfan
Bleomycin
Amiodarone
NITROFURANTOIN
CYCLOPHOSPHAMIDE
methylergide (used for headaches, serotonin antagonist)

remember that Fibrosis is IRREVERSIBLE
Bagassosi
"bag of sugar"
exposure to moldy sugar cane
"honeycombing" on CT in person with SOB think
interstitial fibrosis (the septa between airspace and blood space thicken)
From all the pneumoconiosis, which one responds most likely to Steroids and why?
Berylliosis because it has granulomas
Granulomas are a sign of inflammation thus respond to steroids
general healthy young AA female with SOB and hilar LAD. What is the best initial test? and what is the most accurate test?
Treatment?
best initial test: chest xray
most accurate test: lymph node biopsy (non-caseating granulomas)
Tx: Prednisone
(do not treat asymptomatic hilar adenopathy)
Pulmonary embolism findings on chest xray. What is the most common?
Pulmonary embolism findings on ECG. What is the m/c?
usually normal in PE
But IF abnormal, then it is most likely ATELECTASIS

ECG: sinus tachycardia. The m/c abnormality is non specific ST-T wave changes (NOT S1,Q3, T3)
Hypoxia and respiratory alkalosis with normal chest X-ray. Most likely diagnosis?
PE
Best initial tests for PE
Chest xray
ABG
ECG

most accurate test: Angiography (but has .5 % mortality rate) --> remember this: when testing for PE, angiography is RARELY done due to mortality risk
but we do a spiral CT (CT angio)
When would you do a V/Q scan first thing?
suspecting PE and pt is pregnant
(remember a normal scan RO a PE)
When and why do you order a D-dimer?
D-dimer is the answer when the pretest probability of PE is low and you need a simple test to EXCLUDE A PE

*a negative D-dimer = no clot
you do Doppler on Lower extremity and find a clot in someone with SOB, what is the next test?
no further testing needed !!!
*you do NOT need a spiral CT or V/Q scan to confirm a PE if there is a clot in the legs because it DOES NOT CHANGE THE THERAPY
Pt with RV dysfunction on ECG has a PE. Treatment?
do not give anticoagulants, but be more aggressive because the next clot could kill the pt
*put an IVC filter into pt
Best initial pharm therpay in PE?
Heparin (start warfarin at same time)
1. When are thrombolytics indicated in PE?

2. When are direct acting thrombin inhibitors indicated in PE?
1. hemodynamically unstable pt (ex hypotension, tachycardia)
Acute RV dysfunction

2. in a pt with Hx of Heparin induced Thrombocytopenia
What will you hear on lung auscultation in a pt with pulmonary HTN?
wide splitting of S2 with a loud P2 or tricuspid and pulmonary valve insufficiency
Best initial vs most accurate test for Pulmonary HTN
best initial test: CXR and CT --> "pruning" of distal vessels (dilation of proximal vessels and narrowing of distal vessels)

most accurate test: Right heart or Swan-Ganz catheter
Pulmonary HTN treatment options
*correct the underlying cause
*idiopathic cases are treated with:
-Prostacyclin analogs (PA vasodilators) : EpoPROstenol, trePROstinil, iloPROst, beraPROst
-Endothelin (potent vasoconstrictor) antagonist: Bosentan
-Phosphodiesterase inhibitor: sildenafil
*O2 slows progression
*only lung transplant is curative
sleep apnea + increased sodium bicarbonate. Diagnosis
obesity hypoventilation syndrome (pickwickian)
definition of ARDS (numbers)
pO2/FiO2 <300

(if <200=moderately severe, if < 100= severe)

-pO2 is pts number
-FiO2 at room air is 21% --> 0.21
if pt is on 50% O2, then --> 0.50
(but remember>50% of FiO2 is toxic to the lungs)
Treatment for ARDS
no tx is proven
*give low Tidal volume ventilation (6 mL/kg
*steroids are not clearly beneficial
*maintain the plateau pressure of < 30 cm of water
m/c cause of joint disease
Degenerative Joint Disease (DJD) = OA
What differentiates OA from RA ?
in OA : lab tests are normal, no inflammation, weight bearing joints, short time of stiffness( <15 mins), effusion is rare, distal joints more than proximal joints in hands
best initial drug in OA
acetominophen
THE PRESENCE OF CRYSTALS IN A JOINT ASPIRATE DOES NOT RULE OUT INFECTION. ALWAYS KEEP SEPTIC JOINT IN MIND
-remember first gout attack and septic joint can present very similar... remember Gout pts can have fever too !!!
...
which skin condition increases risk for developing a gout attack?
Psoriasis--> due to increased cell turn over
Tophi
when do they occur and where
if you see thopi--> think long standing gout, you do NOT see tophi in first attack !!!
Tophi can occur anywhere
What level matters when trying to answer "what is the most likely cause" in a joint aspirate ?
white cell count
"rat bites" on X-ray, think
CHRONIC gout = bone erosions
Acute gout attack treatment in pt with renal insufficiency
STEROIDS
*Triamcinolone

**ONLY USE STEROIDS IN GOUT IF YOU HAVE RULED OUT SEPTIC JOINT

**pts that can not take NSAIDs or steroids--> Colchicine
What is the goal Uric acid level in a gout pt between attacks?
< 6.0 mg/dL (6 letters--> PATRIK)
What gout drug is contraindicated during acute attack?
Allopurinol
*do NOT START it during attack, but if pt is already on it for prophylaxis then you can continue it safely during attack
Colchicine SE
diarrhea
bone marrow suppression (neutropenia)
What is a safe anti hypertension medication that can be used in gout pt
**HY
Losartan (ARB) --> it lowers Uric acid and HTN
Allopurinol and Febuxostat in renal insufficient pts
Allopurinol: it is safe but needs renal dosing adjustments
Febuxostat: safe in renal insufficiency and needs NO DOSE adjustment (xanthine oxidase inhibitor)
Which lipid lowering agent should be avoided in gout?
Niacin

also: Aspiring and thiazides should not be given to gout pts
Allopurinol SE regarding skin conditions
Steven Johnsons syndrome
TEN
What are the 2 most common risk factors for Pseudogout (medical conditions)
**HY
Hemochromatosis
Hyperparathyroidism

(pseudogout is also associated with hypothyroidism, Wilson's disease and DM)
Which drug is effective at preventing another gout and/or pseudo gout attack?
Colchicine
WBC count in septic joint
> 50,000 NO predominance
Point tenderness at the spine with percussion of the VB is HIGHLY SUGGESTIVE of
cord compression
**HYPERreflexia is found below the level of compression
m/c bug in epidural abscess
Empiric treatment?
Staph aureus
(remember an abscess in spinal cord will just present like a mass lesion or cord compassion, however, there will be fever and elevated ESR)

empiric Abx:
anti staphylococcal: Vancomycin, Linezolid

if sensitive staph aureus, switch to beta lactams such as nafcillin, oxacillin or cefazolin (they actually work better)
ADD Gentamycin for synergy
a negative Straight leg raise test rules out ____ with a very high sensitivity
disc herniation,
if straight leg test is negative (no pain shooting down the leg below the knee caps), then there is NO disc herniation
What motor/sensory deficits with the following root level lesion?

1. L4
2. L5
3. S1
L4:
motor deficit: Dorsiflexion of foot
sensory deficit: Inner calf

L5:
motor deficit: Dorsiflexion of toe
sensory deficit: F irst (Five) web space (toe, so also loss of dorsiflexion of toe); inner forefoot

S1:
motor deficit: Eversion of foot
sensory deficit: outer foot (S for S ide)
remember that you want to give contrast intrathecally when imaging spine to outline (around the spinal cord) the spinal cord
what is the most likely diagnosis. Back pain in a 35 year old that is worse with rest and improves with activity ?
Ankylosing spondylitis
What is the most likely diagnosis. Pt with history of breast cancer comes to office with low back pain and hyperreflexia. Best initial step?
cord compression (metastasis)
**initiate corticosteroids STAT
Think of epidural abscess like endocarditis. Treat with Vancomycin until you get sensitivity back. Then adjust.
...
Recommendation for disk herniation pts, treatment etc
NSAIDs and continuation with ordinary activities (NO BED REST)

**Steroid injection into the EPIdural space achieves RAPID AND DRAMATIC BENEFIT
Which drug can be used in BPH and/or male pattern baldness? What receptor does it work on?
Finasteride = 5 alpha reductase inhibitor (Fi...-->Five)
Pt with prostate cancer, before giving Leuprolide you must give what drug first and why?
Leuprolide (in lieu of GnRH) will give a transient testosterone boost, so you must give a peripheral testosterone blocker first (Flutamide)
What differentiates PAD and spinal stenosis? both can have unsteady gait, leg weakness, pain with walking downhill etc
PAD: diminished pulses
spinal stenosis: normal pulses
best initial therapy for Fibromyalgia (pharm wise)

What should not be given?
Amitriptyline

other Treatments:
Milnacipran --> inhibitor of Serotonin reuptake and NE
this drug is specifically approved for FM
Pregabalin

* DO NOT GIVE STEROIDS TO FM pts*
Which drug has been specifically approved for Fibromyalgia ? MOA?
Milnacipran
MOA: blocks reuptake of serotonin and NE
Carpel tunnel syndrome
What is affected first, motor or sensory?
What is best initial therapy?
sensory before motor affected

best initial therapy is NIGHT SPINT
hyperplasia of the palmar fascia, what is it?
-associated with?
Dupuytren Contracture
-associated with Alcoholism and Cirrhosis

**Collagenase injection helps early Dupuytren contra cure
-Triamcinolone or lidocaine injection helps
Pt with anterior knee pain. Pain is particularly bad when walking up or down the stairs. Symptoms are worse just hatter starting to walk after having been seated for a prolonged period of time. Pain improves after walking. Crepitus on PE. X-rays are normal. Diagnosis?
Patellofemoral syndrome
Tarsal tunnel syndrome vs plantar fasciitis pain
taral tunnel pain: gets worse with use
plantar fasciits: PAIN IMPROVES WITH USE
Baker cysts are associated with what disease? When they rupture they can mimic what?
Baker cysts are associated with RA
*may rupture and mimic a DVT
** the presence of soft tissue swelling and tenderness with limited active ROM but NORMAL passive ROM suggests the problem is extra-articular soft tissue inflammation, such as bursitis or tendonitis
...
RA
Splenomegaly
Neutropenia
What syndrome?
Felty syndrome
RA
Pneumoconiosis
Lung nodules
What syndrome?
Caplan syndrome
m/c common cause of death in RA is
CAD
NSAIDs and steroids do NOT stop the progression of RA. Any pt with signs of erosive damage needs to be on
(at least MTX)
DMARDs

erosive means:
*joint space narrowing
*physical deformity of joints
*Xray abnormalities
you want to start a pt on DMARD. What is the best initial DMARD? SE?
Methotrexate
SE:
*hepatotoxic
*bone marrow suppression
*Pulmonary toxicity
What is the first line DMARD for pts not responding or intolerant to the usual #1 DMARD Methotrexate?
TNF inhibitors
*Infliximab
*Adalimumab
*etanercept

-they are also often used in combination with MTX
**you must get PPD before starting these
Which drug can be used in mild RA in which to avoid MTX?
Hydroxychloroquine

**toxic to retina, get eye exam before hand
Best initial therapy for RA?
NSAIDs
(remember in OA, you really don't have inflammation, so Acetomenophin is the first line)
Pt treated with Gold salts for RA. SE?
nephrotic syndrome
*HIGH YIELD*
young person presents with high spiking fevers of 104.1 F and a salmon colored rash on abdomen and chest + mild joint pain, what is the most likely diagnosis
Juvenile RA
-think of kids <16 years of age with "flu like symptoms", limping, poor appetite

other features:
Splenomegaly**
Pericardial effusion**
Mild joint symptoms

on labs:
markedly elevated Ferritin (it is an acute inflammatory maker)
ANA is normal
Anemia
leukocytosis
hypoalbuminemia
m/c kidney disease in SLE pts

**HY
Membranous glomerulonephritis

**you MUST get biopsy to determine severity of lupus nephritis
*RBC casts and hematuria
What are the most specific tests for SLE?
Anti dsDNA -->will rise in acute flare
Anti Smith --> will NOT rise in acute flare
(there are ONLY found in SLE)
**HY
What would you see on blood work in a pt with an acute lupus flare?
low complement and rising anti dsDNA Abs

although anti Smith Abs are very specific for SLE, they do NOT rise in an acute flare

(KNOW THIS)
Treatment of acute Lupus flare
high dose boluses of steroids

(Hydroxychloroquine for mild disease flares limited to skin and joints)
lupus drug that PREVENTS PROGRESSION of the disease
Belimumab
m/c cause of death in young vs old Lupus pts
young pts: Infection

old pts: accelerated atherosclerosis --> MI
Antiphosphospholipid syndrome
What is it?
What are the 2 main Abs produced?
Anti - phospholipid = Antibodies (IgM and IgG) against phospholipds

2 main types:
*Lupus anticoagulant Abs--> leads to elevation in aPTT
*Anticardiolipin Abs--> Abortions, also gives false (+) syphilis test because it binds cardiolipin
thrombosis in arteries + veins + elevated aPTT , think
Anti-phospholipid syndrome
woman comes to office due to recurrent Aboritons and thrombosis. What is the best initial test?
think Anti-phospholipid syndrome

best initial test: Mixing study
(mix pts blood with normal plasma, if aPTT improves, then pt has a clotting factor deficiency)
*if aPTT remains elevated--> APL syndrome
what is the most specific test for anti phospholipid syndrome?
Russell viper venom test
(this test is prolonged in presence of APL Antibodies and Russell viper venom test does not correct when mixed with normal plasma)
On routine lab you find anti phospholipid antibodies in an asymptomatic young woman, best next step?
observation
DO NOT TREAT AN ASYMPTOMATIC ALP
Treatment to prevent recurrence of abortion in a pt with APL syndrome
Heparin + Aspirin
When should you think APL syndrome as a cause for abortion?
2 First trimester events
or
1 Second trimester event (because that is very unusual at that time in pregnancy to have an abortion)
What 3 beta blockers reduce mortality in CHF

*HY*
Carvedilol
Bisoprolol
extended release metropolol
treatment for acute exacerbation of CHF
NO LIP
Nitrates
O2
Loops
Inotorope (dobutamine)
Postitioning (legs down to make blood pool into legs)
Russell's sign
Bullemia nervosa
Waddell's sign
malingering (low back pain)
most specific test for Scleroderma and what do they bind
SCL - 70 (anti topoisomerase)
Pt with Scleroderma. How to treat her pulmonary fibrosis?
**HY
Cyclophosphamide
(improves dyspnea and PFTs)
What slows the underlying disease process in Scleroderma?
MTX
(Penicillamine is NOT effective)
Dermatomyositis is associated with ?

**HY
CANCER
*ovary
*lung
*GI
*lymphoma
Poly and Dermatomyositis.
Best initial test?
Most accurate test?
Best initial test :
CPK (creatine phosphokinase)
Aldolase

Most accurate test: muscle biopsy
Anti-Jo antibodies in Dermato/polymyositis are associated with what manifestation of that disease?
these Abs are associated with LUNG FIBROSIS
What helps with skin lesions of Dermatomyositis
steroids
Hydroxychloroquine
Sjoergen's syndrome is associated with what GI condition?
Primary biliary cirrhosis
Keratoconjunctivits sicca
ocular abnormalities in Sjoergen's syndrome
What is the most dangerous complication of Sjoergen's ?
lymphoma
Best initial test for Sjoergen's ?
Most accurate test?
Best initial test: Schirmer test (measure amount of tears produced)

Best initial test on blood: SS-A, SS-B (SS=Sjoergen Syndrome), also called "Ro" and "La"

most accurate: lip or parotid gland biopsy
(this will reveal lymphoid infiltration in the salivary glands)
Treatment options for Sjoergen's
water the mouth
fluoride
artificial tears to prevent corneal ulcers

Drugs:
*Pilocarpine + cevimeline --> incrase Acetylcholine (= main stimulant of saliva), Cevimeline increases rates of saliva production

*there is no cure but you must screen for lymphoma
Polyarteritis nodosa
1. affects what vessel size
2. classically spares what organ **HY
3. associated with ? **HY
1. PAN affects small to medium sized vessels

2. PAN classically SPARES THE LUNGS **HY

3. Hep B and Hep C are associated with PAN **HY
most common neurological deficit in polyarteritis nodosa?
any large peripheral nerve can be affected but peroneal neuropathy leading to

FOOT DROP is the most common
stroke in a young person, think
drugs
POLYARTERITIS NODOSA
"beading" of renal artery on Angiogram. Think
Polyarteritis nodosa
mononeuritis multiplex
Classic neurologic manifestation of PAN
*multiple peripheral neuropathies (large nerve involvement, ex hand and foot drop)
elevated ESR, normal aldolase and CPK in a pt with muscle pain and stiffness
Diagnosis?
Tx?
polymyalgia rheumatica

Tx: rapid and enormous response to STEROIDS even at low doses
what is the only thumb movement NOT controlled by the median nerve? which nerve does that?
thumb aDDuction (ulnar nerve)
Wegener's G --> upper respiratory findings, name them

What is the best initial test?

WHICH biopsy location is the most accurate?
SINUSITIS
OTITIS MEDIA
mastoiditis
oral and gingival involvement
also: eye lesions (although not consider Upper respiratory)

best initial test: C-ANCA

LUNG biopsy is most accurate
(lung>renal>sinus)
C-ANCA, antibodies against what?
P-ANCA, antibodies against what?
C-ANCA = anti-proteinase-3 antibodies (C=3rd letter)

P-ANCA= anti-myeloPeroxidase antibodies
(P->P eroxidase)
Asthma + Eosinophila, think
Churg Strauss Syndrome
**HY
"leukocytoclastic vasculitis" in a child with abdominal pain, fever and a rash on buttocks
Henoch Schoenlein purpura

remember: serum IgA levels are the wrong answer. They are NOT reliable when testing for HSP
Cryoglobulins and cold agglutinins are both_____
IgM antibodies

But don't confuse the 2

IgM--> Mycoplasma pneumonia, EBV, lymphoma
Cryoglobulin--> Hep C
SLE. What complement is decreased?
C3 (SLE=3 letters)
Hep C , what complement is decreased?
C4 (Hep C=4 letters)
Cryoglobulinemia
serum proteins (globulins) form a gel when exposed to cold
labs will show POSITIVE RHEUMATOID FACTOR
sterile skin pustules after needle irritation in a pt with Multiple Sclerosis like CNS findings
Behcet syndrome

**CNS lesions can mimic MS **
negative RF, enthesopathy, uveitis and HLA B27,
what is the most likely diagnosis (spectrum)?
What pharmacological treatment is NOT helpful
Seronegative Spondyloathropathies

*Corticosteroids are NOT a good treatment for seronegative spondyloathropathies*
back pain made worse with rest and improved with activity
Most likely diagnosis?
Cardiac findings (2) *HY*
Ankylosing spondylitis

Cardiac associations:
1. AV block
2. Aortic insufficiency

A nkylosing --> A V block, A ortic insufficiency (A's)
best initial test in ankylosing spondylitis.
X-ray what body part?
most accurate test?
best initial test: X-ray of the SI joint

most accurate test: MRI
**MRI detects abnormalities years before the X-ray becomes abnormal

**HLA B27 is NOT a confirmatory test... 8% of the population are (+)
What is the underlying cause of the appearance of "sausage fingers" in psoriasis?
enthesopathy (inflammation where tendons and ligaments attach to the bone)
first line treatment in psoriatric arthritis.
What if no response to that (2nd line)?
3 rd line?
1. NSAIDs are first line treatment
if no response to NSAIDs, or severe disease, use
2. METHOTREXATE
3. anti TNF agents if MTX and NSAIDs fail
Keratoderma blennorhagicum
* it is a skin condition that is UNIQUE to what medical condition?
reactive arthritis
(it looks like pustular psoriasis)
First line treatment for Reactive arthritis.
if no response, what is 2nd line?
1. NSAIDs
2. sulfasalazine
Review of Seronegative Spondyloarthorpathies treatments:

1. Ankylosing spondylitis
* what is 1st and 2nd line treatment

2. Psoriatic arthritis
(1., 2., and 3 rd line)

3. Reactive arthritis
1st and 2nd line treatment
1. Ankylosing spondylitis
1. NSAIDs + exercise program
2. (if no response) anti TNF drugs (Etanercept, Adalimumab, infliximab)

2. Psoriatic arthritis
1. NSAIDs
2. (if no response or IF SEVERE), Methotrexate
3. (if no response to MTX), anti TNF drugs

3. Reactive arthritis
1. NSAIDs
2. (if no response) Sulfasalazine

**so try all first on NSAIDs
best initial therapy in osteoporosis
Vitamin D + calcium
Treatment of Osteoporosis is classified into 2 categories:

1. Meds that help stimulate bone formation
(name them)

and

2. Meds that reduce bone resorption
(name them)
1. Meds that help stimulate bone formation:
-vitamin D and Calcium (best initial treatment)
-Bisphosponates (start when T-score is < -2.5)

2. Meds that reduce bone resorption:
-Estrogen replacement
-Raloxifene (**also reduces risk of breast cancer and decreases LDL)
-Teriparatide (analog of PTH that stimulates new bone formation; can cause osteosarcoma in rats and hypercalcemia)
-Calcitonin (nasal spray), DECREASES THE RISK OF VERTEBRAL FRACTURES (but should be a last line agent)
pt with Tscore of -2.7 with a Hx of breast cancer. What would be a good drug?
Raloxifene
Why are joints prone to septic infection?
synovial lining has NO basement membrane
(both, bacteria and antibiotics find their way in it easily)

**risk of infection is directly proportional to the degree of joint damage
**OA joint damage is less severe than RA joint damage, so RA pts have great risk
**however, greatest risk would be a prosthetic joint
**septic arthritis is relatively rare in an undamaged joint
Best initial therapy for septic arthritis
Vancomycin and Ceftriaxone

**if sensitive staph aureus, SWITCH TO oxacillin or cefazolin (same as infective endocarditis, vancomycin has worse outcome if bug is sensitive)
Aztreonam, only effective against
gram (-) bugs
Pt with prosthetic knee. On X-ray: lucency around implant and joint is loose... think
septic arthritis
m/c organism for RECENTLY placed artificial joint
*HY*
Staph. epidermidis
What differentiates Gonoccocal arthritis from septic arthritis?
Gonococcal:
*polyarticular involvement (often migratory, too)
*Tenosynovitis
*rash (typically located on extensor surfaces of lower extremities)
In women, gonococcal arthritis is more common when?
during menses
m/c cause of infectious arthritis in <40 yrs of age
Gonococcal arthritis

** remember this: Gonococcus is very difficult to detect, and the problem may say "negative culture of joint aspirate"
** diagnosis is of then made by finding gonococcal infection in a more typical site, such as the urethra, cervix or pharynx

**Bottom line: culture everywhere when you see polyarticular joint involvement, rash and tenosynovitis
Infectious arthritis should be drained. What are indications for OPEN surgical drainage?
1. when joint fluid is LOCULATED
2. when any of the following joints is involved:
-Hips
-Shoulders
-SI joints
best empiric therapy for disseminated gonorrhea
Cef-triaxone
Cef-otaxime
Cef-tizoxime

(the "Cef's")
Osteomyelitis.
Kids get it how?
Adults get it how?

*HY*
Osteomyelitis in kids: hematogenous spread

Osteomyelitis in adults: contiguous spread (most often from vascular insufficiency and/or DM)

A-->C
K-->H
(alphabetic order)
Pt with suspected osteomyelitis. Pt had X-ray. Pt has pacemaker, most appropriate next step in management?
bone scan
How do you follow the response to Tx in Osteomyelitits?
ESR
diagnostic test of choice for osteomyelitis vs most accurate test
MRI
**biopsy is most accurate
"culturing the drainage is NEVER the right answer"
diabetic pt with ulcer on foot presents with warmth, redness and swelling in the area. "purulent sinus track" in the lesion, think
osteomyelitis
What is the only indication to treat Osteomyelitis with Ciprofloxacin?
CONFIRMED gram negative organism
Treatment addition to osteomyelitis caused by a gram negative bug
ciprofloxacin
(Fluroquinolone)
Tx for hypertrophic cardiomyopathy (drug)

**HY
Beta blocker
Hypertrophic cardiomyopathy presents like pts with______

Dilated cardiomyopathy presents like pts with______
Hypertrophic cardiomyopathy pts present like pts that have Aortic stenosis
(SAD symptoms)
**you differentiate them with valsalva maneuver:
*valsalva makes Hypertrophic CM worse but improves AS murmur

Dilated cardiomyopathy pts present like pts that have CHF
**treatment is the same, diuretics, ACEinh, beta blockers
ECG finding for acute rheumatic fever
PR elevation
HTN and hypokalemia, think
Renal artery stenosis
(kidneys "perceive" low volume--> incr Aldosterone...)
most effective strategy to lower BP?
weight loss
m/c cause of secondary HTN
renal disease
*HY*
Hypertensive Emergency.
What is the BP goal?
How do you go about lowering?
the goal is to get the DIASTOLIC BP below 100 mmHg

*do NOT exceed lowering BP of >25% in the first 2 hours *start IV anti hypertensives but also start oral anti hypertensives, because pt will be admitted and will have to come off IV drugs, so while the orals "kick in" we wean them off the IVs
Microcytic anemias generally have low RI, which type of microcytic anemia, however, has a HIGH, reticulocyte count?
only alpha thalessemia with 3 genes deleted has an elevated recticulocyte count

*most causes of low Reticulocyte count=production problems
TIP : routine blood smear in microcytic anemias is not helpful as they will all by hypo chromic and microcytic and all of them potentially give target cells
...
Sideroblastic anemia can present as what two types of anemia
microcytic and macrocytic
TIP: all macrocytic anemias give a low reticulocyte count.
...
Antimetabolite meds, such as 6 Mercaptourine and Azathioprine, can lead to what type of anemia?
macrocytic
TIP: Blood loss and hemoylysis will raise the reticulocyte count. Also, MCV will raise because reticulocytes are slightly LARGER than RBCs
...
TIP: a HCT of 25-30 is considered very low in the elderly and those with Heart disease. Transfuse PRBCs
...
each unit of Packed RBCs should raise the Hct by how much?
3 points

**remember: in Packed RBCs, plasma has been removed so the Hct is 70-80%
TIP: Cryoprecipitate is NEVER used first thing for anyting
...
What is in Cryoprecipitate?
Fibrinogen
clotting factors
**high levels of: Factor 8 and vWF

**it has high amount of clotting factors in less amount of plasma volume (so in a fluid overloaded pt this may be better, but NEVER first)
what type of transfusion in low aPTT, or PT?

when is that type of transfusion not used ? what diseases?
fresh frozen plasma

FFP is NOT a choice for Hemophilia A, B or vWF
How do you replace "blood" after plasmapharesis?
FFP
m/c cause of sideroblastic anemia?
Alcohol = a bone marrow suppressant

other causes of sideroblastic anemia:
-Lead poisoning
-Isoniazid
-Vitamin B 6 deficiency (just think of Isoniazid, it causes Vit B 6 deficiency)
All microcytic anemias can show Target cells, but which one is most likely to show them?
Thalessemias (Target-->Thalessemia)
Most specific marker for Iron deficiency anemia?
Ferritin = stored Iron
**What type of anemia do you see in CKD?
normocytic anemia

*the only anemia that responds good to EPO replacement
Iron deficiency anemia vs anemia of chronic disease, what are Ferritin, TIBC and iron
both: low Iron (circulating in blood)

Iron d.A.: low Iron, low Ferritin, high TIBC
A of chronic d.: low Iron, HIGH ferritin, low TIBC (binding sites are occupied)
Which microctytic anemia type is the ONLY ONE that has elevated Iron levels?
Sideroblastic anemia
Iron deficiency anemia.
Most accurate test?
bone marrow biopsy (look for stainable Iron, which is decreased)
-this is rarely done, but it is the most accurate test
Classic finding in Iron deficiency anemia, regarding the platelet count?
elevated platelet count
my reasoning: increased EPO
Most accurate test for Sideroblast anemia
prussian blue
Pancreatic insufficiency can lead to what type of anemia?
Macrocytic anemia
*Pancreas produces enzymes that split Vit B12 from carrier
**Celiac disease can lead to what type(s) of anemia?
Microcytic: decreased Iron absorption
Macrocytic: Vit B12 and Folate def

remember: Duo Jej Ileum (Folate Iron B12)
Do you see hyper segmented NO in Alcoholic with anemia?
NO
only B12, folate and antimetabolites will cause hypersegemented NOs
Which macrocytic anemia gives neuro symptoms
Vit B 12 def
Vit B12 vs Folate. Homocysteine and MMA levels
only B12 (2) elevates BOTH

Vit B12: elevated MMA and Homocysteine
Folate: elevated Homocysteine
Vit B 12 and Folate def have both elevated levels of
Homocysteine
Lab abnormalities seen for Vit B 12 def and Folate
increased LDH
increased indirect bilirubin
decreased haptoglobin (scavenger)
**both of these are markers of hemolysis, remember, macrocytes are destroyed as they leave the marrow so that is why LDH and indirect bilirubin are elevated

low reticulocyte count
You suspect Vitamin B 12 def. but levels are normal. Next best test to confirm diagnosis?
MMA levels
How to confirm pernicious anemia?
anti-IF and anti-parietal cell Abs
What is a complication of Vit B 12 or Folate replacement in macrocytic anemic pts?

*HY*
HYPOkalemia

**when replacing B12 and Folate, particularly if there is pancytopenia, cells in the marrow are produced so rapidly that the marrow packages up all the K+, lowering the serum level. Observe and replace.
Hemolytic anemia facts
If there is an acute drop in Hemoglobin accompanied by increased retic , the etiology is mostly blood loss or hemolysis. At that time, get an LDH and haptoglobin, a normal LDH in that setting will rule out hemolysis. Then , increased retic can be attributed to acute blood loss and search for source of blood loss.
If increased reticulocyte count is accompanied by increased ldh , increased indirect bilirubin and low haptoglobin, it indicates hemolysis . Hemolysis can be intravascular or extravascular. Intravascular hemolysis can be further distinguished by getting a urine hemosiderin which will be positive in intravascular hemolysis but not in extravascular. Examples of intravascular hemolysis are G6PD deficiency, infective endocarditis, TTP, HUS , sickle cell, infections like malaria and babesiosis etc. Extravascular hemolysis can occur in spherocytosis, thalassemia, autoimmune hemolysis. A direct coombs test will be positive in autoimmune hemolysis.
Sickle cell disease affects what type of chain, what mutation
beta chain

Val-6-Glu
(valine replaces glutamine at postion 6 on beta chain)
Reticulocyte count in sickle cell disease
always high , they don't have a bone marrow problem
(the only time it would be low would be Parvo B19 infection/crisis)
Sickle cell pt with RUQ pain, think
billirubin gallstone
Sickle cell pts should be on what type of prophylaxis besides vaccinations
penicillin
Folic acid
Sickle cell disease.
Best initial test? most accurate?
best initial test is a peripheral blood smear
most accurate test is Hgb electrophoresis (remember, nthg wrong with bone marrow, so no biopsy)
Ehrlichosis infection. What do you see inside NO?
Morulae
*cytoplasmic inclusion body
Howell Jolly bodies. When do you see them?
aspenics
*remnants of nuclear material
Pt with sickle cell disease presents with chest pain etc. You suspect acute chest syndrome. Management?
O2
hydration
analgesia
**if fever or Leukocytosis is present: YOU MUST START EMPIRIC ANTIBIOTICS
**Ceftriaxone, levofloxacin or moxifloxacin

(pts without a spleen can have overwhelming infections)
Pt with sickle cell disease presents with severe chest pain, lung consolidation and fever. management
O2
hydration
analgesia
MUST GIVE empiric Abx: Ceftriaxone, levofloxacin or moxifloxacin
pneumococcal vaccine
What 2 drugs can be used to PREVENT a sickle cell crisis in a sickle cell pt? MOA?
Hydroxyurea and Decitabine
**both increase Hemoglobin F
Decitabine has less SE
Sickle cell pt in pain crisis, When do you consider exchange transfusion?
acute chest syndrome
priapism
stoke
visual disturbance form retinal infarction

** all the "delicate" organs
Pt with sickle cell disease is in hospital to recover from acute chest syndrome. All of a sudden Hct drops to 22%. Best initial test? and why?
Reticulocyte count
*remember, sickle cell pts normally have a high reticulocyte count because their marrow responds normally (it is functional)
**if there is a Parvo B 19 crisis--> drop in the RI
Aplastic crisis
Best initial test vs most accurate test?
Best initial therapy for parvo aplastic anemia
best initial test: reticulocyte count
most accurate: PCR for Parvo DNA
(IgM level is not as accurate)

best initial treatment: IV immunoglobulin
What is the only manifestation of sickle cell train pts?
isothenuria
**inability to concentrate urine
-hematuria may sometimes occur
elevated MCHC and low MCV. Negative Coombs test.
What condition?

**HY
Hereditary Spherocytosis
-defect in the cytoskeleton
-loss of the normal flexibility characteristic of the biconcave disc that allows the red cells to bend in the spleen
-the negative Coombs test just tells you that there is no autoimmune destruction that leads to this hemolysis
You suspect hereditary spherocytosis. What is the most accurate test ?
management?
osmotic fragility test
** when cells are placed in a slightly hypotonic solution, the increased swelling leads to hemolysis
**solution: hypotonic so the inside of RBC is hyertonic. Water follows solute, goes inside RBC and busts it

**give pts Folic Acid replacement to support RBC production; splenectomy stops hemolysis (destroys these abnormal looking RBCs) but you will still see spherocytes (they just don't get destroyed)
Autoimmune hemolysis
PICMONIC
fire=warm
autoimmune hemolysis=warm hemolysis (IgG)
...
Name 4 causes of warm (autoimmune) hemolytic anemia
SLE --> autoimmune warm hemolysis is one of the diagnostic features of SLE
lymphoma
CLL (fire with grandpa)
Drugs: Rifampin, Penicillin, methyldopa, phenytoin
most accurate test for autoimmune hemolysis?
where are the cells destroyed?
intra or extravascular hemolysis
Coombs test
-this test detects IgG antibody on the surface of RBCs
-Autoantibodies remove small amounts of red cell membranes and lead to a smaller membrane, forcing the cell to become round

**EXTRAVASCULAR HEMOLYSIS

**the cells are being destroyed in the SPLEEN or LIVER, therefore you DO NOT SEE FRAGMENTED cells in autoimmune hemolysis, it does NOT occur in blood vessels
*HY*
Alternate treatment, in general (applies to many things), to diminish the need for Steroids
MACC

Mycophenolate mofetil
Azathioprine
Cyclosporine
Cyclophosphamide
Treatment algorithm for autoimmune hemolytic anemia
What is the best initial therapy?**
When everything fails, what drug can you use? **
*Best initial therapy are Glucocorticoids (prednisone)*
-recurrent episodes: splencectomy
-severe hemolysis not responding to steroids: IVIG

*Rituximab --> when splenectomy does not control the hemolysis*
Name 3 things that can lead to Cold Agglutin disease
**HY

What is the most accurate test?
EBV
Mycoplasma pneumonia
Waldenstroem Macroglobulinemia

*IgM Abs against RBCs
most accurate test: Cold agglutinin titer

(vs autoimmune hemolytic--> Coombs test is most accurate)
but in cold aggl
What is the idea behind giving immunosuppressants to autoantibody conditions
they stop the production of Antibodies
Cold agglutinin treatment
stay warm
adminster Rituximab (and sometimes plasmapharesis)

*HY: steroids and splenectomy DO NOT WORK *
so do NOT pick Prednisone !!!
*HY*
FACT:
Cryoglobulins are often mixed up with cold agglutinins. Although BOTH ARE ASSOCIATED WITH IgM and even though BOTH DO NOT RESPOND TO STEROIDS, cryoglobulins are associated with:
Hep C
Joint pain
Glomerulonephritis

*HY*
...
what are the 3 beta blockers that reduce mortality in CHF
carvedilol
bisoprolol
extended release metropolol
what electrolyte disturbance is a contraindication to starting an ACE inhibitor?
hyerkalemia
Mnemonic for anti hypertensive meds for pregnant women
Hypertensive Mothers Love Nifedipine

Hydralazine
Methyldopa
Labetalol
Nifedipine (and other -dipines)
Septic shock vs Anaphylactic shock. How does treatment differ and why?
Septic shock:
besides IV Fluids
**Norepinephrine-->pressor of choice, because it causes vasoconstriction WITHOUT increased CO

Anaphylactic shock:
besides IV Fluids (if hypotensive)
**Epinephrine--> pressor of choice, because it causes vasoconstriction WITH increased CO
what do ALL shock types have in common?
decreased MAP (mean arterial pressure)
Cilostazol, indication and contraindication?
Cilostazol: used in Peripheral Vascular disease
-increases blood flow to LE

**contraindicated in heart failure pts due to increased mortality
what are the 2 preferred vessels for placing a Schwan Ganz catheter
right internal jugular vein
or
left subclavian
Kawasaki treatment
IVIG
high dose Aspirin, continue high dose until 48 hours after fever resolves, then continue low dose aspirin until inflammatory markers (ESR, Platelets) return to normal
*steroids are of NO USE, do not give them**
necrotizing immune complex inflammation of visceral/renal vessels, this describes what disease

*HY*
Polyarteritis nodosa
m/c vasculitis
termporal arteritis
Centor criteria
used for determine management of pharyngitis

assign 1 point for each:
(FAAT)
Fever
Anterior Cervical Adenopathy
Absence of cough
Tonsillar exudates

0-1 points: do nothing, no throat culture, no Abx
2-3 points: throat culture, if (+)--> treat
4-5: treat empirically
normal A-a gradient
5-15 mmHg
why do we treat pharyngitis?
to prevent acute rheumatic fever
(remember, Abx decrease the risk for acute rheumatic fever but Abx can NOT decrease risk for PSGN)
Glucose 6 phosphate dehydrogenase deficiency
inability to generate what?
inheritance pattern?
what "things" are they susceptible to ?
X linked rec disorder (so think MALES)

**look for an AA men with sudden onset anemia
m/c oxidant stress is infection

others:
Dapsone
quinidine
primaquine
sulfa drugs
nitrofurantoin
fava beans
best initial test for G6PDH def?
most accurate test?
best initial test is : Heinz bodies (methylene blue stain) and bite cells

most accurate test: getting a G6PDH level ONE TO TWO MONTHS AFTER THE EPISOSE
*HY*
-levels are NORMAL right after hemolytic event
HUS and TTP are different versions of the same basic disease caused by deficiency of metalloproteinase ADAMS13
*HUS is associated with E.coli O157H7
*TTP is associated with ticlopidine, clopidrogel, cyclosporine, AIDS, and SLE. Also neuro symptoms with TTP
*both have normal PT, aPTT, negative coombs test
*do NOT give platelets to any of the two
*severe cases can be treated with plasmapharesis
...
Paroxysmal nocturnal Hemoglobinuria
1. what are they deficient in ? specifically CD?
2. what do you see on labs?
PNH is a STEM CELL DEFECT
*it can lead to aplastic anemia, MYELODYSPLASIA, or ACUTE LEUKEMIA
1. deficiency in CD 55 and CD 59
*during sleep-->acidosis--> complement attacks RBCs because they have a deficient DAF (Decay accelerating factor)

2. dark urine fist thing in the morning
iron deficiency anemia
pancytopenia
m/c death of pts with PNH?
most accurate test for PNH?
thrombosis
*large vessel thrombosis, ex: mesenteric and hepatic veins are the most common sites for thrombosis
*HY*
most accurate test for PNH: decreased levels of CD 55+59
best initial therapy for PNH
prednsione (best initial therapy for hemolysis)

-the only cure is allogenic bone marrow transplant
Eculizumab
MOA? use?
complement inhibitor (inactivates C5)
*can be used in PNH which is ultimately a complement over activation problem
Aplastic anemia treatment in
<50 years of age
>50 years of age
in young people: allogeneic bone marrow transplantation (matched donor)
in ppl >50 yrs of age:
ATG (Anti Thymic Globulin)
Cyclosporine --> inhibits T cell function (brings bone marrow back to life because T cells are attacking it)
(or Tacrolimus)
increased Hct despite normal erythropoetin levels, think

increased Hct with increased erythropoetin level, think
Polycythemia vera (low erythropoeitin), you must rule out hypoxia as a cause for it... so if O2 levels are normal then think PV, if O2 levels are low-->hypoxia

renal cell cancer (high erythropoeitin)
Polycythemia vera mutation
what is the most accurate test?
JAK 2
most accurate test: JAK2 mutation
Why do PV pts have pruritus after a shower?
the JAK 2 mutation increases all cell lines, thus increase in basophils
-increased number of basophils that load off their histamine
Thrombosis prevention in Polycythemia vera pts
*phlebotomy and aspirin
*Hydroxyurea helps lower the cell count
TIP: Vitamin B 12 levels are ELEVATED in Polycythemia vera ************
and Iron levels are low because it is all used up to make RBCs (so PV has low MCV)
...
**HY**
Erythromelalgia
what is it? how to treat it?

***
Erythromelalgia=painful red hands in Essential thrombocytosis.
Treat with ASPIRIN
best initial therapy in essential thrombocytopenia
hydroxyurea
tear drop shaped cells , think

Treatment for that condition (drugs)
Myelofibrosis

Thalidomide and lenalidomide: those are TNF inhibitors that increase bone marrow production
fatigue
infection
bleeding
think?
Pancytopenia

fatigue= decreased RBCs
bleeding= decreased platelets
infection=decreased WBCs
Essential thrombocytosis
best initial therapy
Hydroxyurea
Erythromelalgia
what is it?
how to treat it?
painful red hands in ET
Treat with Aspirin
Myelofibrosis treatment options
thalidomide
lenalidomide
MOA: TNF inhibitors that increase bone marrow production

**remember: tear dropped cells, (bone marrow crying)
What mutation is found in 50% of pts with Essential thrombocytosis
JAK2 mutation
Pt with history of myelodysplastic syndrome now has blasts, think
acute leukemia
acute leukemia, type M3, is associated with?
DIC
M3 acute leukemia, what translocation
t 15;17
you suspect acute leukemia,
best initial test
most accurate test
blood smear showing blasts

most accurate: flow cytometry (that will distinguish the different types of acute leukemia)
eosinophilic inclusions in AML
Auer rods
**HY
Myeloperoxidase is characteristic of what?
AML
acute myelocytic leukemia
How are AML and ALL treated initially ? (leukemias)
chemotherapy to remove blasts from the peripheral blood smear
Rasburicase
prevents tumor lysis related rise in uric acid
What should you add to chemotherapy in ALL?
intrathecal chemo
(helps to prevent relapse in CNS); remember most chemo drugs can NOT cross BBB (picmonic)
What should you add to chemo in pts with AML M3 type
all transretionoic acid
CML vs Leukemoid reaction. What distinguishes them?
CML : Low LAP (leukocyte alkaline phosphatase)
leukemoid rxn: high LAP
what is the m/c presentation of CML?
high WBC on routine exam
splenomegaly
high basophils-->pruritus (esp after hot showers)
fatigue, night sweats, abd fullness, LUQ pain
Which myeloproliferate disorder has the highest risk to transform into acute leukemia (blast crisis)?
CML
(if untreated, 20% will develop it)
pt comes in with very high WBC count, cells are predominantly NO and 4% blasts. Pt has blurry vision, priapism, and confusion.
Diagnosis? Next best step?
acute leukostasis reaction

Leukapheresis

*diagnosis is not so important as to treat
*you have to get rid off these cells no matter what the etiology/diagnosis, so do it right away
Pelger Huet cells.
What do they look like and what condition do you find them?
bilobed nucleus of Pelger Huet cells
** these cells are found in myelodysplastic syndrome
what chromosomal abnormality in myelodysplastic syndrome
5q deletion

pts with this deletion have a better prognosis
Myelodysplastic syndrome. The severity of the disease is based on what?

**HY
severity is based on the percentage of blasts
**HY Tip: most patients with myelodysplastic syndrome never develop acute myelogenous leukemia because complications of infection and bleeding lead to death before leukemia occurs
...
Lab findings for Myelodysplastic syndrome
*anemia with increased MCV (macrocytic anemia)
*hypercellular marrow (even though they have pancytopenia)
*prussian blue stain shows ringed sideroblasts
Treatment options for myelodysplastic syndrome
-transfusion
-erythropoeitin
** Lenalidomide: for those with 5 q deletion, can decrease transfusion dependence
**Azacitidine: decreases transfusion dependence (but it does not increase survivial)
Lenalidomide and Azacitidine can be used for what?
Myelodysplastic syndrome
* 50% of pts with CLL are HYPOgammaglobulinemic*
...
4 stages of CLL
stage 0 (elevated WBC count)
stage 1 (lymphadenopathy)
-- no treatment for stage 0 and 1 ---

stage 2 (hepatosplenomegaly)
stage 3 (anemia)
stage 4 (thrombocytopenia)
Tx: Fludarabine (and Rituximab)
* HY *
What type of porphylaxis for pts with CLL
PCP prophylaxis in pts with CLL
Fludarabine
a chemo drug used in CLL
CLL refractory to Fludarabine and Rituximab. What next drug?
Cyclophosphamide
CLL
what cell line is affected?
CLL is a clonal proliferation of normal, mature "appearing" that function abnormally
**m/c symptom is fatigue, otherwise most pts present asymptomatic
Richter transformation
CLL to B cell lymphoma
best inital and most accurate test for Hairy cell leukemia
what cell line is affected?
Hairy cell leukemia affects B cells

best inital test: smear
most accurate test: immunotyping by flow cytometry
Hairy cell leukemia treatment *HY*
Cladribine or Pentostatin *HY*
Pt with painless lymphadenopathy with fever, weight loss and drenching night sweats. You suspect NHL, what is the best intial test ?
best inital therapy is a wide excision biopsy
(NOT a FNA)
-lymph node aspirate by FNA is not enough because the individual lymphocytes appear normal
staging for NHL
stage 1: 1 lymph node group
stage 2: 2 or more lymph node groups on the SAME SIDE of diaphragm
stage 3: both sides of diaphragm
stage 4 disseminated

80-90% of pts present in stage 3 or 4
NHL treatment
local disease: local radiation and small chemo doses

advanced disease (stage 3+4): R-CHOP
Rituximab (CD 20 Ab)
Cyclophosphamide
H=adriamycin (doxorubicin or Hydroxydaunorubicin)
O=vincristine (oncovin)
Prednisone
What test is most useful in determining dosing of chemotherapy in Hodgkins lymphoma?
MUGA or nuclear ventriculogram= most accurate test for assessing LV function

**part of Hod Lym treamtent includes Doxorubicin
Hodgkin's lymphoma treatment
ABVD + Radiation (remember that radiation alone is NEVER right for lymphoma)

Adriamycin (doxorubicin)
Bleomycin
Vinblastine
Dacarbazine
Non Hodkins lymphoma. What types have the worst prognosis?
Burkitt's
immunoblastic type
Hodgkin's lymphoma
which type has best vs worst prognosis
best prognosis: lymphocyte predominant
worst prognosis: lymphocyte depleted
Risks of radiation therapy
radiation increases the risk of solid tumors such as BREAST, LUNG or THRYOID CANCER
*screening for BREAST CANCER is recommended 8 years after radiation therapy*
*radiation also increases the chance of PREMATURE CORONARY ARTERY DISEASE*
Multiple myeloma in simpe terms
MM is an abnormal proliferation of plasma cells (plasma cell normally make Ig)
**these abnormal plasma cells make USELESS immunoglobulins (IgG or IgA) that do NOT fight infection but instead just "clog" up the kidney
MM
-hyperuricemia: due to increased plasma cell turnover
-Anemia: form bone marrow infiltration full of plasma cells
-hypercalcemia: from OAF (osteoclast activating factor)
**renal failure: accumulation of "useless" immunoglobulins (bence jones proteins); also hypercalcemia and hyeruricemia also damage the kidney
(m/c cause of death is kidney failure +/- infection)
...
m/c cause of death in MM
renal failure (Bence Jones proteins, hyperurecemia and hypercalcemia are also toxic to kidneys)
and infection
M spike on serum protein electrophoresis
Multiple Myeloma
M spike = Ig G or Ig A
**remember this will lead to elevated total protein but NORMAL Albumin

M spike DOES NOT mean IgM
What can cause a decreased anion gap acidosis.

*HY*
Mulitple Myeloma
Ig G is ca(+)ionic (positive)
Increased cationic substance will increase Chloride and Bicarb (both are anionic). This decreases the anion gap.
what % for plasma cells to be called MM
>10% + CRABS criteria
++HY++
Bence Jones proteins can NOT be detected by ____. They can only be seen on ______
Bence Jones are NOT detected on dipstick (UA)
**remember the dipstick just reads the albumin, and that is normal in MM
**can only be measured on urine immunoelectrophoresis
does M spike mean these pts def have MM?
NO
99% of pts with M spike have Waldenstroem
best initial therapy in MM
dexamethasone + lenalidomide, bortezomib (or both)
(most effective therapy: autologous bone marrow transplant)
Ig G or Ig A spikes can be common in the elderly, so don't jump on MM. You need at least 10% plasma cells. MGUS pts usually have IgG or IgA spikes but not enough spike.
Treatment for MGUS?
none
follow pts, 1% transform into MM per year
overproduction of IgM from malignant B cells
Waldenstroem Macroglobulinemia
engorged blood vessels on eye exam
mucosal bleeding
IgM spike on plasmapharesis

Diagnosis?
Best initial therapy? *HY*
Long term treatment (not bolded)
Waldenstroem Macroglobulinemia
**overproduction of IgM from malignant B cells leading to hyperviscosity
**no bone lesions with this

*Plasmapharesis is the best intial therpay to remove the IgM and decrease viscosity *

Long term treatment: Rituximab and cyclophosphamide (+prednisone), use bortezomib or lenalidomide as in MM
Platelet deficiency bleeding vs Clotting factor deficiency bleeding
Platelet def: superficial bleeding
epistaxis, gingivial, petechia, vaginal, purpura

Clotting factor def: DEEP bleeding (think of hemophiliacs
bleeding into joints and muscles)
in bleeding disorder, what is considered a major bleed
GI or CNS
elevated megakaryocytes and normal spleen in pt with bleeding gums
ITP

NORMAL speen size
diagnosis of exclusion
Megakaryocytes are inceased
antiplatelet Abs present
Treatment of ITP
no bleed or count > 30,000: no Tx
mild bleed, count <30,000: Glucocorticoids
severe bleed (GI/CNS), count <10,000: IVIG, Anti Rho

recurrent episodes: splenectomy
if that is not effective: Rompiplostim and Eltromobag
(those are synthetic thrombopoietin for ITP)
Romiplostim and Eltrombopag, use?
these are Thrombopoietin synthetics used in ITP
vWD inheritance pattern
AD
vWD is worsened by the use of what
Aspirin
Aspiring makes vWD markedly worse
best initial therapy for vWD
DDAVP (desmopressin)--> releases subendothelial stores of vWF
if there is no response, use factor 8 replacement or vWF concentrate
Hemophilia
1. inheritance pattern
2. does a mixing study correct aPTT?
3. most accurate test?
1. X-linked recessive (so look for a male child)
2. mixing study does correct aPTT (because you supply them with the deficient factor)
3. most accurate test would be a specific assay for factor 8 or 9
Hemophilia treatment, mild vs severe
mild hemophilia: treat with DDAVP
severe hemophilia: replacement of specific factor
which factor deficiency does not have increased bleeding
factor XI deficiency and factor XII deficiency

factor 11 def:
only bleed with trauma or surgery
prolonged aPTT
*use FFP to stop bleeding
elevated aPTT but no bleeding
factor 12 deficiency
no treatment needed
which thrombophilia to test for with first clot
APL syndrome
** this is one condition in which lifelong anticoagulation may be needed
which type of clot is more common in HIT
venous clots are more common in HIT
Diagnostic test to confirm HIT
ELISA for platelet factor 4 (PF4)
(or serotonin relay assay)
HIT management
immediately stop heparin (you can NOT switch to LMWH)
**switch to direct thrombin inhibitor:
-lepirudin
-argatroban
-bivalirudin
**start Warfarin AFTER intitiation of direct thrombin inhibitor

**do NOT give platelets to HIT
there are 2 antiphospholipid syndromes. What are they and which one causes multiple spontanous abortions
Lupus anticoagulant
and
anticardiolipin antibody --> multiple spont. abortions
best initial test for antiphospholipid syndrome
mixing study
aPTT will remain elevated
dysphagia vs odynophagia
D-ysphagia : D ifficulty swallowing
O-dynophagia: Oouch--painful swallowing

both can lead to weight loss
Pt with dysphagia, when should you perform endo?
when pt also shows anemia, weight loss and/or blood in stool, those are alarming symptoms
most accurate test for Achalasia
manometry, which will show a failure of the lower esophageal sphincter to relax
(CXR may show widening of esophagrus, with barium you can see "bird's beak", but not very sensitive or specific)
treatment options for Achalasia
it is not curable (you can't replace absent nerves)
1. pneumatic dilation
2. Botulinum inj.
3. myotomy
young pt no alchohol no tobacco with progressive dysphagia to both solids and liquids, most likely
achalasia
What drug to give head trauma pt or pt with history of metastatic brain cancer before intubation?
Lidocaine (to blunt ICP)
When to stop warfarin before surgery ?
3-4 days
Tip: Steroids are used to treat Croup but not Bronchiolitis
...
do you give steroids in Bronchiolitis?
no
difficulty breathing in a newborn despite medical therapy
vascular ring
Achalasia vs Esophageal cancer, they present very similar, how to differentiate
< 50 years and dysphagia to solids AND liquids (at the same time), think Achalasia

>50 years and PROGRESSIVE (most important word, or "from solids to liquids dysphagia") should make you highly suspicious of cancer

**also remember:
Achalasia: no association with alcohol or tobacco
Esophageal cancer: associated with tobacco and alcohol use
Esophageal cancer treatment
Surgical resection is ALWAYS the thing to try,
chemo and radiation may be used in addition
-stent placement in lesions that are non resectable,to keep esophagus open
AIDS pt with CD 4 count of 43 has pain with swallowing that has become progressively worse over the last several weeks. What is the most appropriate next step?
oral flucanazole
** 90% of esophageal infections in AIDS pts are due to Candida, therefore, treat empiriraclly
**only if pt does NOT respond to treatment, THEN do ENDOSCOPY

(remember nystatin is used for ORAL trush)
Plummer vinson syndrome can rarely transform into____
squamous cell carcinoma
"steakhouse syndrome" think
Schatzki's ring
you suspect Zenker's diverticulum. What is contraindicated?
NG tube placement
Endo
Pt has scleroderma. What would you see on esophageal manometry?
decreased lower esophageal sphincter pressure from an inability to close the LES
-they can present with reflux, so treat with PPIs
Boerhaave vs Mallory weiss tear
Mallory Weiss: non penetrating tear of ONLY THE MUCOSA
Booerhaven: complete penetration of the esophagus
m/c cause of epigastric pain in the US (esp <50)
non ulcer dyspepsia
TIP: Barium studies are good for a start in esophageal problems, but not such good help in stomach
...
diagnostic test for GERD
24 hour pH monitoring
(NOT endo--> Endo is only the answer if the pt has anemia, heme (+) stools, weight loss and more than 5-10 yrs of Barrett esophagus
GERD treatment in cases that are non responsive to all medical therapies
*Nissen fundoplication: wrapping stomach around lower esophagus
*place a suture around the LES (Endocinch)
*local heat or radiation of LES: causing scarring
what kind of histological change in Barrett's
columnar METAPLASIA (with intestinal features)
Esphageal findings:

Barrets alone (metaplasia)--> PPIs and rescope every 2-3
years
Low grade dysplasia: PPIs and rescope every 6-12 mths

High grade dysplasia: Ablation with endoscopy: photodynamic therapy, radiofrequency ablation, endoscopic mucosal resection
...
atrophic gastritis is associated with____
vitamin b 12 deficiency
H.pylori tests, the most accurate?
what are other tests that can be done and their pros and cons
most accurate: Endo

Serology: cheap, excludes infection if negative but the test
test lacks specificity because it can not easily
tell the difference between current vs prev infect

Urea breath test: expensive, (+) only in active infection

Stool antigen: (+) only in active disease

* stool antigen and breath test can be used to FU on treatment efficacy*
Tobacco and alcohol do NOT CAUSE PUD, but they delay healing
...
remember, you can NOT definetly diagnose or differentiate duodenal vs gastric ulcer without an endo
...
Triple therapy was ineffective in H.pylori. next step?
possible antibiotic resistance, so change to Metro and tetracycline AND add bismuth
non ulcer dyspepsia management
>45-55 yrs of age--> Endo
<45 : PPIs trail, if non resolving --> Endo
Why are gastrinomas associated with diarrhea?
acid inactivates lipase
most accurate test for ZES?
Secretin test
(persisitent high gastrin levels despite secretin injection)
ZES diagnosis is confirmed, what is the next best step?
CT and MRI of the abdomen to exclude metastatic disease (they have poor sensitivity but they ARE DONE FIRST)

then

if these tests are normal: Somatostatin receptor scintigraphy (nuclear octreodtide scan) combined with endoscopic US to exclude metastatic disease.
**Gastrinoma is associated with a massive increase in the number of somatostatin recetors in the abdomen
Why do we perfom a somatostatin receptor scintigraphy in ZES?
because Gastrinoma is associated with a massive increase in the number of somatostatin recetors in the abdomen
ZES management
surgically removal (if possible) and PPIs
most accurate test for diabetic gastroparesis
nuclear gastric emptying study (although rarely done because when the diagnosis seems clear, there is NO NEED to do diagnostic testing unless there is failure of therapy)
What is the most important stimulant to gastric motility ?
STRETCH
**diabetics loose the "Sense of Stretch" in diabetic gastroparesis
m/c cause of upper GI bleed vs lower GI bleed
upper GI: PUD
lower GI: diverticulosis
Orthostatic hypotension
increase in pulse by more than 10 points
drop in BP by more than 20 points
Tip: for acute GI bleeding, especially when the bleeding is severe, it is far more important to replace fluids and check the Hct, Plt count and coagulation tests (PT) or INR than it is to do an endoscopy
**80% of GI bleeds will stop sponateously if the fluid resuscitation is adequate
...
At what Plt count do you transfuse platelets in an active symptomatic GI bleed?
<50,000

**you would not transfuse platelets to prevent a spontaneous bleed UNLESS the count were much lower (<10,00-20,000)
At what Hct do you start PRBC replacement in GI bleed? (old vs young, etc)
What is the indication for FFP in active GI bleed?
Packed RBCs:
if Hct <30 % in those who are older or who have CAD
if Hct <20-25% in young

FFP:
if PT or INR is elevated and active bleeding is occuring
Esophageal/Gastric varcices management (acute bleed vs prophylaxis)
acute:
Octreotide : decreases portal pressure
Banding
TIPS
ANTIBIOTICS TO PREVENT SBP

**Propanolol-->Prophylaxis, does nothing for acute bleed
if you have a pt with GI issues and weight loss, don't jump to cancer. Fat malabsorption disorders (Celiac, Whipple, tropical sprue, chronic pancreatitis, etc) can lead to FAT MALABSORPTION--> calorie deficit (remember 1 g of fat has most amount of calories)
...
For Vitamin B 12 to be absorbed, two intact things are needed.
1. pancreatic enzymes to cleave B 12 from carrier protein (needs functional pancreas)
2. intact bowel wall
(celiac, tropical sprue, etc interfere with that)
Whipple disease treatment
Abx: Ceftriaxone followed by TMP/SMX
Chronic pancreatitis vs Celiac disease... They present very similiar, how can you distinguish the two based on labs
Iron deficiency with Celiac disease
** Iron does not need pancreatic enzymes to be cleaved off any carrier, so chronic pancreatitis pts will NOT be deficient in this
**however, Celiac pts can present with Iron deficiency because they do not have an intact bowel wall
you suspect Celiac disease. First test to order.

What is the most accurate test?
Anti-tissue transglutaminase

then others:
antiendomysial Ab
IgA antigliadin Ab

most accurate test: small bowel biopsy
**biopsy is essential in celiac disease to exclude lymphoma
most accurate test for chronic pancreatitis?
Secretin stimulation test
** a healthy pancreas will release a large amount of BICARBONATE rich fluids after IV injection of secretin
Which test has the greatest sensitivity for calcifications in chronic pancreatitis?
CT abdomen
Tropical sprue treatment
TMP/SMX + tetracycline
D-xylose testing. What would you expect in pancreatic disease
a normal test
**abnormal would mean that there is a problem with the bowel wall (it is already a broken down sugar so should be readily absorbed into blood, but if bowel wall is damaged, positive test)
flushing, wheezing, new murmur and intermittent diarrhea
Diagnosis?
best initial diagnostic test?
Treatment?
Carcionoid

best initial diagnostic test: 5 HIAA URINE test

Treatment: octreotide
IBS vs IBD
Irritable bowel syndrome --> no weight loss
Inflammatory bowel disease--> weight loss, anemia
...
Irritable bowel syndrome treatment
-increase fiber in diet
**antispasmodics:
-Hyoscyamine
-Dicyclomine

-TCA
-Loperamide = anti diarrhea
-Lubiprostone = for constipation ("loops you up to go"), it is a chloride channel activator
2 common hepatic associations with UC
1. primary sclerosing cholangitis
2. FATTY LIVER (common)
What skin manifestation is an indicator of disease severity in UC and Crohn's ?
*HY*
erythema nodosum
When should colon cancer screening start in pts with IBD and how often thereafter
8-10 years after colonic involvement,
EVERY 1-2 years **
ANCA and ASCA results in IBD
ANCA (anti neutrophilic cytoplasmic Ab): (+) in UC only

ASCA (Antisaccharomyces cerevesiae Ab): (+) in Crohn's
pt with history of undercooked pork, periorbital edema and muscle aches. Diagnosis and treatment?
Trichinella
Tx: -Bendazole
Taenia solium treatment.
cyst in muscle vs brain
cysts in gut--> use Praziquantel
Brain (neurocystersicosis)--> -Bendazole (Brain) and Corticosteroids (CNS)
m/c food borne disease? tx?
Salmonella
no treatment
*may use a Fluroquinolone in immunocompromised pt
bacterial dysentery, think what bug
what tx?
shigella
Tx: Fluroquinolone, TMP/SMX
(the only bacterial gastroenteritis we treat with abx)
amebic dysentery, think what protoza
Entamoeaba histolytica
what is the only bacterial gastroenteritis we tend to treat with antibiotics
shigella
Fluroquinolones
TMP/SMX
What Histamine receptor gets blocked by anti histamine meds used in GERD?
H2
Cemitidine SE
**HY
Gynecomastia
impotence
feared complication of UC
toxic megacolon
what diameter to be called toxic megacolon?
>6 cm
best long term management of Crohn's and UC (pharm)
sulfasalazine and other 5 ASA drugs
mesalamine
severe cases of Crohn's (and UC) refractory to steroids. What drug options?
anti-TNF (Infliximab)
MTX (hepatotoxic)
**6 - Mercaptourine + Azathiprine to wean pts off steroids
best 2 drugs to use in Crohn's to wean pts off steroids in severe cases?
Azathioprine
6 Mercaptourine
specific steroid used for IBD
Budesonide
(think "butt")
treatment of perianal Crohn's disease
ciprofloxacin and Metro
Fistulae treatment in Crohn's
Infliximab

(only consider surgery if anti TNF treatment has failed)
**CD pts form fistulae due to TRANSMURAL mucosal involvement
Diverticulitis. Best initial test
CT abdomen
Treatment for acute diverticulitis
(you want to cover E.coli and anaerobes)

*Metronidazole and Ciprofloxacin* HY

others:
Amox/clav
Ticac/clav
piperac/tazobactam
ertapenem
pts with Peutz Jeghers syndrome are at increased risk for what type of cancers?
breast cancer
gonadal and pancreatic cancer
colon cancer + osteoma
Gardner syndrome
Polyposis syndromes and colon cancer screening. Recommendations?
none of the polyposis syndromes require increased screening frequency for colon cancer
number 1 cause for acute pancreatitis
alcohol
What diuretic can cause acute pancreatitis?

*HY*
HTZ
what is idiopathic pancreatitis?
no Gallstones seen and no predisposing risk factors. Biliary tract disease is the most likely cause
(ex biliary sludge or sphincter of Oddi dysfunction)
Tip: Pain of pancreatitis goes STRAIGHT through the back like a spear stabbed into the abdomen vs pain from cholecystitis, which goes around the side to shoulder/back
...
worst prognostic factor in pancreatitis?
low calcium

**because when the pancreas has been damaged a lot, it does not produce lipase anymore, so calcium binds with fats in the bowel, leading to calcium malabsorption
*HY*
Acute Pancreatitis
best initial test
most accurate test
best initial test: Amylase + Lipase
most accurate test: CT
Pancreatitis disease severity strongly correlates with what ?
Necrosis seen on CT
>30% necrosis=extensive necrosis and YOU MUST DO A NEEDLE BIOPSY
elevated Amylase levels months after acute pancreatitis
Pseudocyst
What are some pancreatitis complications?
1. Pseudocyst = elevated amylase months after acute pancreatitis
2. Phlegmon= a solid mass of inflamed pancreas, often with patchy areas of necrosis (if it becomes infected it can become an abscess)
3. Abscess= 2-3 weeks after onset, fever + leukocytosis+Hx of pancreatitis, leading cause of early death, if not drained --> 100% MORTALITY
leading cause of early death in pancreatitis
abscess formation that is NOT drained
but MOST COMMON CAUSE OF DEATH: HYPOVOLEMIC SHOCK
best test for abdominal stuff
CT
always done with IV AND oral contrast to better outline structures
m/c cause of death in acute pancreatitis
hypovolemic shock

**third space sequestration in the abdomen
(that is why high volume fluid resucitation is so important)
Pancreatic Pseudocyst
collection of inflammatory fluid, no epithelial lining so weak wall
** usually resolve spontaneously <6 weeks if <6 cm
plain abdominal xray shows sentinel loop of bowel, think
Pancreatitis
What test is diagnostic in pancreatitis and which one is therapeutic?
MRCP is diagnostic
ERCP is for therapy
Management of infected, necrotic pancreatitis
surgical debridement to prevent ARDS and death
*HY*
if there is >30% pancreatic necrosis on CT or MRI, what do you do
pancreatitis with >30% necrosis:
**you MUST ADD ANTIBIOTICS to decrease mortality by decreasing the development of infected, necrotic pancreatitis
* add: Imipenem or meropenem HY*
all clotting factors are made in the liver EXCEPT
factor 8
Pt with caput medusa and spider angiomatas presents with SOB worse in the upright position. What is on your differential?
Hepatopulmonary syndrome

"SOB WORSE WITH UPRIGHT POSITION"
*PLATYPNEA or ORTHODEOXIA*
-a syndrome of SOB + hypoxemia caused by vasodilation of the lung vasculature of pts with liver disease
**decreased hepatic clearance of vasodilators
-the vascular dilations cause OVERperfusion relative to ventilation leading to V/Q mismatch + hypoxemia

*there is no treatment
pt with long standing declining liver cirrhosis develops rapidly declining renal function. Diagnosis?
Hepatorenal syndrome

Tx: somatostatin (octreotide), midodrine
Definition of ascites.
Treatment
abnormal fluid collection > 25 mL

Tx: Na+ restriction + diuretics (spironolacetone, Furosemide)
ascites with very low albumin in fluid, think
CHF
SAAG >1.1
serum albumin: decreased albumin in fluid makes the number bigger, increased SAAG
Spontaneous vs secondary peritonitis
spontaneous peritonitis:
** infection WITHOUT PERFORATION. We actually don't know how the bacteria got there.
*usually monobacterial
E.coli is the m/c organism. Anaerobes rarely cause it. PNEUMOCOCCUS causes spontaneous peritonitis

secondary peritonitis:
**secondary to PERFORATION of bowel
Spontaneous peritonitis.
Best initial test? most accurate test?
*HY*
Best initial test: Cell count with >250 Neutrophils

(is the basis upon which we start therapy)

*gram stain is almost always negative
*Fluid culture is most accurate but never available at the time when you have to make a treatment decision
Spontaneous peritonitis treatment
**HY*
Cefotaxime or Ceftriaxone
(E.coli is m/c)

in some with recurrent ascites, you can give prophylactic Abx: Norfloxacin or TMP/SMX
pt with ascites develops fever and rebound tenderness, think
spontaneous peritonitis
orthodeoxia
SOB with sitting upright
most accurate test for sclerosing cholangitis?
*HY*
ERCP
how to differentiate between bone disease vs bile duct/liver disease
GGTP
both diseases have elevated ALP (Alkaline Phosphatase)
but only liver/bile duct path will also have elevated GGTP

**binge drinking gives a sudden raise in GGTP
elevated GGTP and elevated ALP
liver/bile duct path
primary biliary cirrhosis, most accurate blood test vs most accurate test
most accurate test: liver biopsy
most accurate serum test: anti- mitochondrial Abs
normal bilirubin + elevated ALP
vs
elevated bilirubin + elevated ALP
Primary biliary cirrhosis
vs
Primary sclerosing cholangitis
Iron gets absorbed in what part of small intestine
Duodenum
what 3 bugs are common in pts with hemochromatosis
yersinia
Listeria
Vibrio vulnificus
best initial vs most accurate test for Hemochromatosis
best initial : iron studies
most accurate: biopsy (unless pt gets an MRI + gene testing done, that can be used as confirmatory test)
C282y gene mutation think
Hemochromatosis
pt is anemic but also has hemochromatosis, treatment?
iron chelation
(also used in pt that can not be mannaged with phlebotomy)
Pt is diagnosed with Hep B. Screen pt for what with what test?
screen for HCC with AFP
most accurate way to detect viral replication activity in Hep B and C?
Hep B/C DNA/RNA level by PCR
Hep B vs Hep C treatment
Hep B --> 1 drug

Hep C --> combo
IFN + Ribavirin + telaprevir or boceprevir
do you treat acute hep B infection ? how about acute Hep C infection?
you ONLY treat acute Hep C infection
IFN Side effects beside flu symptoms
thrombocytopenia, leukopenia, depression (so screen ppl for depression before starting these)
Adefovir SE
Renal dyfunction
(used in Hep B treatment)
What type of anemia do you see in Wilson's disease?
*HY*
Coombs negative hemolytic anemia
Wilson's disease
What is it?
typical neuro symptoms that are different from other liver pathologies?
best initial test vs most accurate
Wilson's=copper deposition
low ceruoplasmin
best initial test: slit lamp eye exam

*most accurate test: looking at an abnormally increased amount of coper excretion into the urine after giving penicillamine **
*low ceruloplasmin is NOT the most accurate test*
What can be used to treat Wilson's disease besides penicillamine (esp helpful in pregnant pts)?
ZINC
*zinc interferes with copper absorption
very high levels of AST and ALT , think
autoimmune hepatitis
what auto antibodies in autoimmune hepatitis?
anti smooth muscle Abs
KLM Abs (Kidney-Liver microsomal Abs)
left MCA stroke, what visual field defect (specific name)
right homonymous hemianopsia
(left stroke and you loose the right visual field)
since the eyes "can't see the right, they deviate to the left" LOOKING TOWARDS THE LESION
Personality change/confusion
urinary incontinence
legs>arms affected
what vessel?
ACA
Posterior cerebral artery stroke findings
*HY*
Ipsilateral sensory loss of the face, 9th and 10th CNs
contralateral SENSORY LOSS of limbs
Limb ataxia
contralateral hemianopia with macular sparing
Stroke pt, most accurate test
MRI
(but CT is the best initial test)
best initial therapy for ischemic stroke (early vs late presentation)
best initial therapy for hemorrhagic stroke?
ischemic stroke:
<3 hours: thrombolytics (if no contraindications)
> 3 hours: Aspirin
**HY: if pt is already on Asprin, either ADD dipyridamole or SWITCH to Clopidrogel

hemorrhagic stroke:
nothing you can do
*surgical drainage only helps if in POSTERIOR FOSSA *
Pt has ischemic stroke and is already on Aspirin, next best step

*HY*
either ADD dipyridamole
or
SWITCH to Clopidrogel
pt with carotid stenosis, what is LDL goal
<100 mg/dL
Pseudotumor cerebri associations
Vitamin A toxicity
obese
VENOUS SINUS THROMBOSIS
OCPs
"pseudotumor" because it symptoms mimick a brain tumor (n/v/visual disturbance)
Pseudotumor cerebri affects what CN? and what would be the deficit?
CN 6 (abducens)
"LR6SO4AO3"
lateral gaze is affected (diplopia)
LR6SO4AO3 :)
...
increased ICP but normal CSF
Pseudotumor cerebri
treatment option for Pseudotumor cerebri (besides shunt)
weight loss
acetazolamide
m/c cause of chronic diarrhea in adults?
lactose intolerance
Treatment for Whipple's disease
TMP/SMX or Ceftriaxone x 12 months
m/c cause of large bowel obstruction
neoplasm
m/c cause for SBO in virgin abdomen
hernia

*m/c causes:
1. adhesion
2. hernia
3. cancer
m/c benign small bowel tumor? malignant?
**HY
m/c benign: Leiomyoma
m/c malignant: adenocarcinoma
IBS. how long do symptoms have to present?
>12 weeks
on CT scan : bowel wall thickening and pneumastosis coli, think
ischemic colitis
(pneumastosis coli=air in bowel wall)
thumbprint sign on abdominal xray, think
ischemic colitis
Tip: evaluate pt for glaucoma if presenting with headache and red eye
...
Cluster headache prophylaxis
**HY
Verapamil
besides 100% O2 for cluster headache patient (and ergotamines and triptans), what 2 other drugs can be used specifically for Cluster HA abortion (do not work in migraines)?
Prednison
Lithium
best preventive therapy for migraines
propanolol
Trigeminal neuralgia treatment
Carbamezapine
(or Oxcarbazepine)
Zoster (shingles) vaccine is indicated at what age?
60
besides oral meds for post herpetic neuralgia, what topical cream may be helpful?
topical capsaicin
Diagnostic test for seizures:
remember, rule out underlying condtitions first, get CBC, glucose, UA etc... EEG is never the first thing to do, it is done when all other things came back normal (labs, CT, MRI, etc)
...
What is the definition of "epilepsy"
seizures of unknown cause
(if there is a clear cause, it is NOT epilepsy)
phenytoin vs fosphenytoin
same efficacy but fosphenytoin has less SE
Status epilepticus algorithm
remember that when you use succinylcholine to intubate (NMJ block), it does NOT stop the seizures it just paralyzes the pt. It just stops the external manifestations of a sz
tonic clonic sz, what is tonic vs clonic movement
Tonic=Tense (muscular rigidity)
clonic=jerking movements
It is not necessary to begin antiepileptic drugs for a single seizure. What are the exceptions? When would you treat first seizure
Status epilepticus
Fam Hx of seizure disorder
abnormal EGG or lesion on CT
What is the standard of care of taking a pt off anti epileptic drug for seizures?
2 years seizure free time
what is the best way to tell if there is the possibility of seizure recurrence?
sleep deprivation EEG
sudden onset of extreme HA, photophobia, stiff neck and fever with possible loss of consciousness

*HY*
SAH
fever--> due to blood irritating meninges
How to differentiate meningitis from SAH? both can present with stiff neck, fever, photophobia, HA, etc
in SAH, however, you have SUDDEN ONSET and LOSS OF CONSCIOUSNESS
most accurate test for SAH?
LP
*normal WBC to RBC ration in CSF*
*HY*
this helps you differentiate Infection (meningitis from SAH)

normal ratio:
for every 1 WBC-->500-1000 RBCs

in meningitis: way too many WBCs
in SAH: elevated WBCs but within normal range
cerebral T waves
Intracerebral hemorrhage
on ECG you may see inverted T waves indicating myocardial ischmia
Which drug prevents subsequent ischemic stroke in a pt with SAH?
Nimodipine
(blood leaking on cerebral vessels, irritates them and they spasm-->ischemia)
Tip: Emobilzation is superior to surgical clipping in terms of survival and complications in SAH. If these answer choices are not given, pick "interventional neuroradiology consultation"
...
What drug is given to pt with SAH to prevent a seizure?
Phenytoin
Pt with SAH and hydrocephalus, management?
shunt (only if hydrocephalus is present)
how can you get a brain abscess?
*can spread CONTIGUOUS from sinuses, mastoid air cells and otitis media
*anything that causes BACTEREMIA can allow infected material to end up in the brain and cause an abscess
Brain cancer and abscess can present very similar. Both can give fever (yes cancer can give fever) and they are indistinguishable based on an imaging study alone ("ring" enhancing lesion). What is required to differentiate?
biopsy
treatment duration for brain abscess
very long
6-8 weeks of IV then 2-3 months oral
Empiric treatment for Brain abscess
Penicillin
Metro
Ceftriaxone (or cefepime)

*biopsy to get sensitivity is very important, you want to avoid prolonged empiric therapy*
cafe au lait spots, think
NF
Eight cranial nerve tumors are associated with what neurocutaneous disease?
Neurofibromatoma
(picmonic: Schwanomma and Fabios)
seizures + port wine stain + mental retardation
vs
seizures + adenoma sebacoum + mental retardation
seizures + port wine stain+ mental retard. = Sturge Weber syndrome

seizures+adenoma seb. + mental retard.= Tuberus sclerosus
Adenoma sebaceum
**HY
reddened facial nodules
(tuberus sclerosus)
Shagreen patches
**HY
leathery plaques on the trunk
(tuberus sclerosus)
Ash leaf patches
hypopigmented patches
(tuberus sclerosus)
m/c cause of parkinsonism
idiopathic
the only drug class that can retard parkinsonism progression
MAO inhibitors
*rasagiline
*selegiline
What drugs are used for mild Parkinsonism?

*HY*
Anticholinergics
Amantadine
What drugs are used for severe Parkinsonism?

*HY*
dOpamine agonists (pramipexole, ropinirole)
levOdOpa/carOdOpa
cOmt inhibitors (tolcapone, entacapone)
mOa inhibitors (selegiline, rasagiline)
What drug can be used to extend the duration of Levodopa/Carbidopa?

*HY*
COMT inhibitors:
Tolcapone
Entacapone

**ONLY use COMT inhibitors WITH carbidopa/levodopa
"on/ off phenomena" in Parkinsonism treatment is associated with what drug, and what other drug can you give to help with that?

*HY*
Carbidiopa/levodopa, although the most effective treatment for severe Parkinsonism, can cause "on/off phenomena.
**Give a COMT inhibitor to help with symptoms (Tolcapone, Entacapone)
*they work by blocking the metabolism of Dopamine
MOA of carbidopa/levodopa
*HY*
inhibits peripheral dopamine decarboxylation
crosses BBB and serves as a dopamine precursor
When a pt with severe parkinsonism comes into ED with severe psychosis, you can NOT stop parkinsonism drugs (the pt will become locked in with severe bradykinesia). Add an antipsychotic with the least EPS SE. Ex: start clozapine
...
Shy Drager syndrome
**HY
parkinsonism with autonomic dysfunction and orthostatic hypotension
Spasticity treatment
Baclofen
Dantrolene
Tizanadine (central acting alpha blocker)
Restless leg syndrome treatment
Dopamine agonist: Pramipexole

*think about it: movement relieves pain, Dopamine agonist helps
Pt complains of creeping sensation in legs at night and partner complains of being kicked at night. Diagnosis?
Restless leg syndrome
(give a Dopamine agonist)
dyskinesia, definition
dys-kinesia
movement dis-order
what genetic disease involves caudate nucleus.
What disease symptoms?
Tx?
Huntington's disease:
movement disorder (dykinesia): choreaform
DEMENTIA
BEHAVIOR CHANGES (irritability, moodiness, antisocial behavior, psychotic)

Tx:
treat dyskinesia with Tetrabenazine
treat psychosis: Haloperidol, Quetiapine
Tetrabenazine is used for
Huntington's disease
chromose 4 (=tetra)
Tourette is associated with
treatment for tourettes
ADHD
treatment: neuroleptics
What function remains intact in MS?
sexual function
INO think of
MS
right affected eye can NOT look to the left
(but eyes can converge and right eye can look to right)
best initial test for MS? most accurate?
best initial test: MRI
most accurate test: MRI
Pt with suspected MS has a (-) MRI, next best step
LP to lool for oligoclonal bands
(these bands are not specific for MS)
*HY*
What are the 2 best drugs for prevention of relapse for MS?
Glatiramer and beta-IFN

(know this)
*HY*
A pt with MS develops worsening neurological deficits with the use of a chronic suppressive medication for MS. The MRI show new, multiple white matter hypodense lesions.
What drug?
What is the lesion?

***HY**
NATALIZUMAB

Natalizumab=inhibitor of alpha 4 integrin

** Natalizumab has been associated with the development of PML (progressive multifocal leukoencephalopathy)
**JC virus reactivation **
ALS
what drug can be used to prevent progression of the disease? MOA?
Riluzole
MOA: reduces glutamate buildup in the neuron
most accurate test for ALS and what does it show?
electromyography
it shows loss of neural innervation n multiple muscle groups
"legs look like inverted champagne bottles", think
Charcot Marie Tooth disease
**it is a GENETIC DISORDER with loss of motor and sensory innervation
Peripheral neuropathy. Best initial treatment choices?
Pregabalin or Gabapentin (the GABA words)
TCAs
(and most seizure meds: phenytoin, carbamezapine, lamotrigine)
Pain/numbness in ankle and sole of foot that worsens with walking
Tarsel Tunnel syndrome
(Tibial nerve)
too tight cast on lower extremity with compression of peroneal nerve. what deficits?
weak foot with decreased dorsiflexion and eversion (remember these movements are coupled)
What can cause Bell's palsy besides Lyme?
Sarcoidosis
herpes zoster
tumors
why can pt wrinkle forehead with stroke?
because forehead is innervated by both cerebral sides
what nerve innervates the first 2/3 of tongue, last 1/3?
anterior 2/3: CN 7
posterior 1/3: CN 9
Bell's palsy, if asked what is most accurate test
electromyography and nerve conduction studies (even though never done)
Bell's palsy, best initial treatment?
Prednisone
ascending weakness + loss of reflexes
GBS
most specific diagnostic test for GBS?
nerve conduction study/ electromyography
*it will show: latencies with conduction slowing/decrease in the propagation of electrical impulses
in GBS, autoantibodies attack what?
myelin sheath of peripheral nerves (CNS is NOT involved)
Treatment of GBS
IVIG
or
plasmapharesis

**NEVER BOTH TOGETHER
**DO NOT GIVE STEROIDS
GBS:
peak inspiratory pressure is affected (decreased FVC)
peak expiratory function is NOT greatly impaired in GBS, so problem may say "normal peak flow"; peak flow is an expiratory measure (best used in COPD etc)
...
Myasthenia gravis pts have NORMAL PUPILLARY RESPONSE
...
Best initial test for Myasthenia gravis
Ach receptor antibodies
**for pts without these antibodies, get anti-MUSK Abs (MUSK=Muscle Specific Kinase)
Most accurate test for Myasthenia gravis
EMG
Myasthenia gravis pt, what imaging to do
"chest something" to look for thymoma or thymic hyperplasia
CT WITH contrast is best (remember, you are looking for a mass, not a bleed)
Best initial treatment for Myasthenia gravis
Neostigmine or phyridostigmine
(the longest acting versions of edrophonium)

*if these meds do not control disease:
<60 yrs: thymectomy
>60: give prednisone
Myasthenia gravis pt on meds with no relief, next best step?
<60 yrs: thymectomy
>60: give prednisone
pt presents in acute myasthenic crisis, management?

*HY*
treat with IVIG
or
plasmapharesis

*HY*
ADHD definition
symptoms usually appear <7 yrs
must be present >6 months
symptoms must be present in 2 areas: home AND school
ADHD treatment (1st and 2nd line)
1. Methylphenidate, Dextroamphetamine
2. Atomexitine (NE reuptake inhibitor)

**atomoxetine is usually chosen over the first line agents given the SE of first lines
depression + neuropathic pain, best treatment option
Duloxetine
mania vs hypomania
mania:
> 1 week of symptoms
-distress
-hospitalization required

hypomania:
< 1 week of symptoms
-no hospitalization required
Bipolar disorder (pic)
Tip: Lithium is the correct answer for most bipolar questions
...
acute mania treatment
lithium (#1)
valproic acid
atypical antipsychotics (because they have faster onset than antipsychotics)
Pt with bipolar disorder was recently started on Lithium. In ED now aggressive. Next best management?
give pt antipsychotic (an atypical one preferrably because it has faster onset)

Olanzepine
cyclothymia definition
*hypomanic episodes + mild depression for > 2 years *

Tx: Lithium, valproic acid or carbamezapine, and psychotherapy
atypical depression tx
SSRIs and MAOs (remember are good for atypical depression)
pick SSRI if both are given
Seasonal affective disorder treatment
phototherapy ** and bupropion
postpartum depression
within 1-3 months after birth (but not < 2 weeks, because that is postpartum blues)
*they may have negative feeling towards the baby but that does not mean they want to harm the baby*
treat with antidepressants
Old pts wife died 3 months ago. He is sad, lost appetite, feels hopelessness and feels like he should have died with his wife. Tx?
this is Major Depressive disorder
Tx: antidepressants
MAO safe foods
white wine
processed cheese

unsafe: red wine, aged cheese, CHOCOLATE
SNRI side effects
*****HYPERTENSION *****
blurry vision
weight gain
sexual side effects
GI disturbances
Mirtazapine
use
SE
MOA
use : Depression

SE: weight gain + sedation

MOA: blocks alpha 2 and Serotonin receptors
(other antidepressant class)
Lithium SE
*nephrotoxic
*teratogenic (Ebstein anomaly=tricuspid valve affected)
*leukocytosis
diabetes insipidus
tremors
weight gain
GI disturbance
Valproic acid
alopecia (remember dr fab saying hair falls out)
teratogenic
*hepatotoxic
**MUST monitor levels
toxicity causes hyponatremia, coma or death
pt with hx of bipolar disorder and hyponatremia, which med is she taking
Valproic acid
Lamotrigine SE
Steven Johnson syndrome
most effective treatment for depression
ECT
it is considered the best treatment for depression
SSRI management
stop SSRI
give Cyproheptadine (serotonin antagonist)
What is schizophrenia
Schizophrenia is a thought disorder that impairs judgement, behavior and the ability to interpret reality
the 5 types of schizophrenia
1. Paranoid: most common, characterized by DELUSIONS and HALLUCINATIONS, late onset

2. Catatonic: characterized by psychomotor disturbance, MUTISM

3. Disorganized: worst prognosis, earliest onset, disinhibited behavior with little contact to reality, disheveled, bizzare emotional responses

4. Residual: lack of (+) symptoms but presence of (-) symptoms (think of Arthur from FL)

5. Undifferentiated: does not fit any other category
acute schizophrenia managment
IM atypical antipsychotic
(Olanzapine, ziprazidone)
if non compliance is an issue in a schizophrenia pt, what would be good drug choice
Risperidone (long acting anti psychotic)
what drug to use when pt does not respond to a typical or atypical antipsychotic?
Clozapine
(never a first line treatment)
schizophrenia treatment option (an atypical antipsychotic) with least likely SE of gaining weight
Aripiprazole and Ziprasidone
(the A and Z)
delusional disorder
what is it?
first line treatment
non bizarre delusions for > 1 month
no impairement in level of functioning (they have a job, obey the law, go to work, pay bills)

*atypical antipsychotics are first line
1st line treatment for panic attack vs panic disorder Tx
panic attack: Benzo
panic disorder: SSRI
OCD can coexist with what other "psych" disorder
Tourette's
treatment of choice for OCD
SSRIs (+ behavioral therapy)
first line treatment for PTSD (be specific, which SSRI)
Sertraline (picmonic -->soldier)
Paroxetine

PtSd "Paroxetine and Sertraline

also : psychotherapy to help with coping
what drug to give to treat nightmares in PTSD
prazosin
LUQ pain and referred left shoulder pain.
What is this sign called and what disease?
Kehr's sign
Splenic rupture
(blood irritates phrenic nerve)
General Anxiety disorder, first line treatment
SSRIs
SNRIs

However, therapy ALONE is NOT considered fist line agent
Which anti anxiety med is used frequently in ED because it can be injected IM?
Lorazepam
Which benzos are frequently used in Alcohol withdrawal?
Chlordiazepoxide
Oxazepam
Lorazepam
*those last 2 because they are excreted by kidney, remember alcoholics have bad livers
Which benzo can be used in axiety disorder if addiction is a concern? this one has a longer half life?
clonazepam
*HY*
Flumazenil is a Benzo antagonist given ONLY when acute OD and you are certain that there is NO chronic use of Benzos. It can cause seizures and life threatening reactions in those pts.
...
physical symptoms with no medical explanation. There is usually some psychological component.
Diagnosis?
Treatment of choice?
Somatoform disorder (s) --> there are many, but for all of them :
*Psychotherapy is the treatment of choice*
Which type of somatoform disorder shows the "la belle indifference" ?
Conversion disorder
la belle indifference: the pt is unconcerned about his or her impairement
pain disorder
the presence of pain is the main complaint
-it is a somatoform disorder (psych)
there must be psychological factors associated with the pain
woman with 4 pain, 2 GI, 1 sexual and 1 pseudoneuro problem. Diagnosis and first line of treatment?
Somatization disorder (-somany)
Treatment of choice: Psychotherapy, pt should have one PCP and not be sent to specialists
FActitious disorders can not be diagnosed without first confirming that a legitimate medical illness is not present
...
lack of cooperation from pt=characteristic of malingering. Confront the pt with the outcome
...
which 2 personality disorders may display positive psychotic symptoms?
Borderline
and
Schizotypal type
What is the m/c death in anorexic pts?
arrythmia
**pts with anorexia on ECG: HYPOkalemia
What pharm can be used in anorexic pts to promote weight gain?
SSRIs
excessive daytime sleepiness and abnormalities in REM sleep.
Diagnosis?
Treatment?
Nacrolepsy
Tx:
forced daytime naps
Modafinil: to maintain alertness
methylphenidate and dextroamphetamine AT BEDTIME to induce symptoms of nacrolepsy then
Name 4 common symptoms/features of nacrolepsy
1. Sleep attacks: episodes of irresistable sleepiness and feeling REFRESHED upon awakening

2. Cataplexy --> PATHOGNOMIC FOR NACROLEPSY, sudden loss of muscle tone (by emotions, loud noise,etc)

3. Hallucinations (hypnoGOgic-going to bed, hypnopompic-waking up)

4. Sleep paralysis: pt awake but unable to move, typically occurs upon awakening
Sexual identity vs Gender identity
Sexual identity: based on pts secondary sex characteristics (penis=man; what sex you have)
Gender identity: based on person's SENSE of maleness or femaleness, established by the age of 3
**gender identity disorder: pt has distress with the assigned sex
treat sexual dysfunctions with
psychotherapy
sexual paraphillia where suffering of victim is exciting
sadism (vs machoism: they like to be humilitaed themselves)
What antibiotic is contraindicated in neonates with hyperbilirubinemia? and why?
Ceftriaxone
it displaces Bilirubin from Albumin, increasing the risk for kernicterus or encephalopathy
Very large amounts of protein can only be excreted with what type of renal condition?
Glomerular disease

*HY severe proteinuria = glomerular damage *HY
**HY
a UA measures only the amount of protein excreted at a particular moment in the day. Transient proteinuria is common in ppln.

**STANDING and PHYSICAL ACTIVITY increase urinary protein excretion
--> orthostatic proteinuria
...
normal protein in urine per 24 hrs
<300 mg (MILLIgram)

+1 dipstick = 1 g protein/24 hrs
+2 dipstick = 2 g protein/ 24 hrs
....
What are the 2 methods used to assess the total amount of protein in a day are:
1. a single Protein:Creatinine ratio
2. 24 hour urine collection (rarely done because hard to collect)

Pr:Cr ratio is superior in accuracy because of the difficulty of collecting urine for 24 hrs

a Pr:Cre ratio of 2.5 means that there are 2.5 grams of protein per 24 hrs
numbers for microalbuminuria
30-300 mg/ 24 hours

**remember, UA can not detect this, that is why you do this test on diabetics EVERY year
persistent WBC on UA with negative culture, think
TB
Eosinophils in urine, think
allergic or acute interstitial nephritis
Wright and Hansel stain detects what?

*HY*
Eosionophils in the urine (think allergic interstitial nephritis)
Do you see Eosinophils in NSAID induced renal disease
no
what is considered a normal RBC count on UA?
< 5 RBCs / hpf
pt with hematuria and on miscroscope you see dysmorphic cells, think
glomerulonephritis
**HY
What is the most accurate test for the bladder?
Cystoscopy
Red cell cast in urine
Glomerulonephritis
White cell cast in urine
pyelonephritis
Hyaline casts in urine
normal
dehydration concentrates the urine and the normal Tamm-Horsfall proteins precipitates or concentrates into a cast
waxy casts in urine
CKD
Granular "muddy brown casts" in urine
ATN
(the casts are collections of dead tubular cells)
the key to prerenal azotemia is to assess "what the kidneys get to see"
Ex nephrotic syndrome and CHF
in both nephrotic syndrome and CHF, pts display peripheral edema. They may seem "fluid overload" but you have to think about what the kidneys get to see. In nephrotic syndrome, hypoalbuminemia causes fluid to leak out of vessels so the kidneys get less blood, thus perceives this state as HYPOVOLEMIC. Pt will therefore retain further salt which makes things worse. (why we give ACEinh/ARBs in nephrotic syndrome.
same with CHF. Decreased EF leads to less blood getting to the kidneys. Pt retains salt to increase pressure. Why we give diuretics to CHF pts
m/c cause of intrinsic renal disease
ATN
pre, intrinsic and post renal failure problems. Best inital test? best initial imaging test?
BUN:Cr is best initial test
US
BUN:CR ration in post renal azotemia
20:1 (think of BUN being "pushed back into blood")
ischemia (hypoperfusion) , toxins, drugs (NSAIDs, aminoglycoside, cyclophosphamide, etc) and bence jone proteins BURN THE TUBULAR CELLS OF THE KIDNEY--> ATN
** remember you need alive and functioning tubular cells to absorb water and sodium
** so in ATN, the body inappropriately looses water and sodium and the urine becomes isothenuric
...
isothenuria, when do you see it?
ATN
-urine osm should normally be > 500 but it becomes inappropriately low --> like blood osm (~300 mOsm/L)
-that is what we call isothenuria

**isothenuria is also seen in Sickle cell TRAIT, these pts will continue to produce inappropriately dilute, high volume urine despite dehydration
fact: healthy person on normal diet reabsorbs > 99% of the Na+ that is filtered
*that is why fractional excretion of Na+ is <1%
...
will tubular damage give you proteinuria?
no
proteinuria is seen when glomerulus is damaged
*HY*
it is very important to know the common causes of ATN, because there is no specific test to run that will tell you**

as for drugs:

contrast --> ATN next day

tumor lysis syndrome-->ATN in 2 days

vancomycin, amphotericin, gentamicin --> ATN in 5-10 days

*HY*
...
*HY*
What is proven to mostly benefit at preventing contrast induced nephrotoxicity?
saline hydration
* contrast induced renal failure has some very unique finding on lab* they are?
contrast causes the afferent arteriole to spasm, so the kidney perceives this as hypoperfusion and thus on lab you will see values of prerenal azotemia, even though the contrast itself causes Acute tubular necrosis (burns the tubular cells)

** so if the problem mentions a pt having received contrast and now has BUN:CR of >20 , then think ATN due to contrast
What 3 things should be given to chemo pt before therapy?
Hydration
Allopurinol
Rasburicase (converts Uric acid to allantoin)
Rasburicase is used for what?
prevent tumor lysis syndrome in chemo pt
(given with hydration, allopurinol)
A pt who is suicidal ingests an unknown substance and develops renal failure 3 days later. Her Calcium level is also low and the UA shows an abnormality. What did she take?
Ethylene glycol (windshield wiper fluid) is associated with acute kidney injury based on oxalic acid and oxalate precipitating within the kidney tubules causing ATN.
Oxalate crystals appear as envelope shaped crystals on UA
Person with history of Heroin use, now has glomerular disease. What type does he have?
Focal segmental GN
Acute tubular necrosis is directly proportional to increasing age of pt. The body loses 1% of renal function for every year past the age of 40
...
What electrolyte imbalance increases toxicity of Aminoglycosides and Cisplatin?

*HY*
low Mg
*HY*
Urine dipstick can NOT tell the difference between :
Hemoglobin
Myoglobin
RBCs
...
You suspect rhabomyolysis, what is the most specific test for rhabo?
UA
CPK levels in serum are markedly elevated but it is the findings on UA that tell you myoglobin is spilling into the urine
rhabdomyolysis vs hemolysis

hemolysis: RBCs have no nucleus, so no risk of hyperuricemia
...
What electrolyte will be low in muscle break down?


*HY*
Calcium
Muscle breakdown leads to hypocalcemia because Ca2+ binds damaged muscle cells

**don't treat the hypocalcemia if asymtomatic, because in recovery Ca2+ will return to normal

*HY*
Rhabdo treatment
hydration
Mannitol
Bicarbonate (which drives Potassium back into cell)

**remember: myoglobin is a toxin to tubular cells, so if we hydrate and diurese the pt we increase urine flow rate to minimize toxin exposure time on tubular cells
Tip:
all of these are ineffective at REVERSING ATN:
-Diuretics
-Mannitol
-Steroids

remember, we give diuretics to increase Urine output but that does not change or reverse ATN

**there is no therapy proven to benefit ATN, treat the underlying cause
...
Pt with long standing alcohol hx + ascites + caput medusa now has prerenal azotemia. Diagnosis?
Hepatorenal syndrome
(normal kidneys)
Hepatorenal syndrome is due to splanchnic and systemic vasodilation that occurs in cirrhosis and portal HTN
(increased CO and decreased vascular resistance)
*vasoconstrictor systems are activated due to the dilation and that causes vasoconstriction at afferent kidney arteriole--> prerenal azotemia

*the key is that FeNa will be low and very low urine sodium (because the kidneys are working fine)
Hepatorenal syndrome tx
Midodrine
Octreotide
Albumin (less clear)
Methanol toxicity vs ethylene glycol toxicity
Methanol toxicity does not hurt kidney, but hurts the eye
** methanol causes inflammation of the retina and has NO renal toxicity
Pt with livedo reticularis after cath procedure.
What will you see on UA ?

*HY*
Eosinophiluria

*HY*
livedo reticularis after cath procedure.
diagnosis?
most accurate test? *HY*
treatment?
Atheroembolic disease (dislodged cholesterol emboli)

*HY most accurate test: biopsy one of the purplish skin lesions * (it will show cholesterol crystals)

-there is no specific therapy. Observation and reassurance
fever, rash and eosionophiluria, think
AIN
what happens in AIN?
Antibodies and Eosinophils attack the cells lining the tubules as a reaction to drugs, infection and autoimmune disorders
*HY*
UA can not pick up Eosionophils in urine. What stain is the most accurate?
Hansel or Wright Stain
healthy pts do NOT get papillary necrosis. Kidneys have to be "banged up/damaged" for papillary necrosis to occur.
For ex, a healthy person taking NSAIDs should not get Papillary necrosis. However, a pt with DM, or SICKLE CELL DISEASE can get it!!!
...
Papillary necrosis can be very hard to distinguish from pyelonephritis. Look for the SUDDEN ONSET OF FLANK PAIN IN A PT WITH DM, SICKLE CELL DISEASE etc.
What is the best initial and most accurate test for papillary necrosis?
best initial test: UA (will show RBCs, WBCs, and necrotic tissue)

***HY
most accurate test : CT (shows abnormal internal structures of the kidney from loss of papillae
** HY
Pt is treated for depression and develops hemolytic microcytic anemia... which drug class can do that?
SSRIs
Paroxetine and Fluoxetine especially
**can increase abnormal bleeding risk
what is the tetrad of naprolexy
cataplexy
sleep paralysis
sleep onset REM attacks
hypnagogic hallucinations
Long Term Care Ombudsman, what is it?
elders in institutional settings in all states are protected by this
*when you suspect abuse or neglect in elderly inst. , report to them
papillary necrosis
Papillary necrosis occurs in pts with sickle cell diz or trait, DM, analgesic nephropathy or severe obstructive pyelonephritis. Acute colicky flank pain, gross hematuria and the passage of tissue fragments in urine are characteristic. Ischemic tubular necrosis presents with oliguria in hospitalized severely ill patients.

most accurate test is the CT scan
difference between pyelonephritis and papillary necrosis
pyelonephritis
takes time, few days of onset of pain
(+) urine culture **
on CT: diffusely swollen kidney
treatment: Ampicillin/gentamycin or fluroquinolones

Papillary necrosis
ACUTE ONSET, SUDDEN flank pain (cells slough off right then and there)
(-) urine culture **
on CT: "bumpy" contour of interior where papillae were lost
*HY facts about Tubular diseases of the kidney*

tubular diseases never cause nephrotic syndrome or proteinuria
tubular diseases are NOT treated with steroids and NOT treated with immunosuppressants **
biopsy is NOT needed to establish diagnosis
TUBULAR DISEASES ARE CAUSED BY TOXINS (such as contrast, drugs, toxins)
**treat tubular diseases by correcting hypoperfusion and removing the toxin

(flip card)
*HY* facts about Glomerular disease

Glomerular disease is usually CHRONIC
generally NOT caused by toxins or hypoperfusion
ALL of them can cause nephrotic syndrome
biopsy is the most accurate test
often treated with STEROIDS AND ADDTL IMMUNOSUPPRESSANTS
Goodpasture syndrome. Why do you want to get a CBC on them?
anemia from chronic hemoptysis
Goodpasture syndrome
best initial test
most accurate test
treatment
best initial test: Antiglomerular BM Abs
most accurate: biopsy
treatment: plasmapharesis (to wash out Abs) and steroids.
(cyclophosphamide can be helpful)
m/c cause of acute Glomerulonephritis in the US?
IgA nephropathy
hematuria 1-2 days after an URI, think
IgA nephropathy (synpahringitic)

vs PSGN --> "post" 1-2 weeks after
*HY*
what levels correspond to disease severity in IgA nephropathy?
proteinuria levels

more proteinuria=worse progression
cola colored urine, hematuria and periorbital edema and HTN, think
PSGN
initial confirmatory test for PSGN?
ASO titers (anti streptin lysin O)
anti-DNAse Abs
What are complement levels in serum in PSGN

*HY*
low
*HY*
all pts with PAN should be tested for?
Hep B
Stroke or MI in a young person, think
PAN
best initial test for PAN
*HY*
Angiography of the renal, mesenteric, or hepatic artery showing aneurysmal dilation in association with new onset HTN.

most accurate test: biopsy of a symptomatic site such as skin, nerves or muscle

*there is no blood test to confirm PAN*
ANCA not present in most cases **
PAN treatment
cyclophosphamide and prednisone
Why do you have to biopsy lupus nephritis?
not to diagnose, but to guide therapy

membranous nephropathy is treated with Glucocorticoids combined with either cyclophosphamide or mycophenolate
membranous nephropathy treatment
Glucocorticoids combined with either cyclophosphamide or mycophenolate
if there is no primary disease, how do you treat Amyloidosis?

*HY*
melphalan and prednisone
DM gives small or large kidneys on CT?
large
What hematologic malignancy is associated with Amyloidosis?

*HY*
Multiple Myeloma
(Amyloid is an abnormal protein produced in MM)
Nephrotic syndrome leads to what 2 deficiencies (vitamins, minerals etc)?

*HY*
Iron deficiency anemia (decreased transferrin), hypotransferrinemia

Vitamin D deficiency: loss of Vitamin D binding protein
how does edema in CHF differ from edem in nephrotic syndrome
CHF: edema in dependent areas (legs)

nephrotic syndrome: edema everywhere (even periorbital)
what will you seen on UA in nephrotic syndrome?
*HY*
lipid deposits
(Maltese crosses)
What nephropathy is associated with (solid organ) cancer?

*HY*
membranous nephropathy
you suspect nephrotic syndrome. best inital test?
UA (however, since renal function varies with the time of day as well as posture, the UA is NOT SUFFICIENTLY ACCURATE

**the urine Albumine/Creatinine ratio gives a measure of the average produced over 24 hours
- a ratio of 2:1 means that 2 g of Albumin are excrted in 24 hours

**this ratio is EQUAL IN ACCUACY as a 24 hour urine collection and is so much easier to obtain
Nephrotic syndrome management
**HY
best initial therpy : Glucocorticoids
-if no response after a few weeks, add cyclophosphamide
-for edema: salt restriction + diuretics
-for hyperlipidemia: statins
-for proteinuria: ACE inh./ARBS
which psych med can lead to SIADH?

**HY
SSRIs
which clotting factor has the shortest half life?
factor 7 (S even--> S hortest)
What would you find on a child's ABG that has pyloric stenosis
hypochloremic, hypokalemic metabolic alkalosis

(so they vomit H+ out, so H+ goes into blood since it low there, in exchange K+ goes into cell leaving blood causing hypokalemia)
chronic loop diuretic therapy can lead to what electrolyte imbalance on ABG?
hyponatremic hypochloremic metabolic alkalosis
(also: hypomagnesemia, hypocalcemia, hypokalemia)
(+) lumbosacral spring test means
restricted motion
remember that PSGN can be caused by strep skin infections or pharyngitis,
but rheumatic fever generally only comes after strep pharyngitis.
...
pneumonia tx 2 month old vs 2 year old
2 month old: Macrolide

2 year old: amoxicillin or ampicillin, or a 3rd Gen cephalosporin
Cavernous sinus thrombosis. What CNs are at risk
CN III, IV, V1, V2, VI)

spares mandible (V3)
what shock is the only type that caused high Pulmonary capillary wedge pressure AND JVD ?
think about it... back up from both sides
cardiogenic shock
What type of schock is the only one in which there is low CO even thought there is SVR dilation (low resistance)
neurogenic schock
Make a note that in other types of shock, a low systemic vascular resistance will cause an increase in cardiac output. Neurogenic shock is the exception.
ESRD is not defined by a particular BUN or Creatinine. It is defined as the loss of renal function leading to a collection of symptoms and laboratory abnormalities also known as uremia
*any form of tubular or glomerular disease can lead to ESRD, but DM and HTN are the 2 m/c
...
5 markers of uremia
metabolic acidosis
fluid overload
encephalopathy
hyperkalemia
pericarditis

*these events usually occur at the same time when Creatinine clearance drops below the level at which acids, fluid, and Potassium can be excreted
*each of these is an indication for dialysis
What is the m/c death in dialysis pts with ESRD? explain?
Cardiac disease (not infection)
*ESRD-->accelerated atherosclerosis and HTN because the lymphocytes normally keep arteries free of lipid accumulation. White cells don't work normally in a uremic environment.
where do oral phosphate binders work?
gut
What condition has to be present to diagnose TTP?
intravascular hemolysis (schistocytes)
what is the m/c death from Polycystic kidney disease?
renal failure from recurrent episodes of pyelonephritis and nephrolithiasis causing progressive scarring and loss of renal function
**PCKD pts have weak connective tissue throughout:
ovarian cysts
liver cysts (m/c)
Mitral valve prolapse
diverticulosis
...
pt with high volum NOCTURIA, think
diabetes insipidus
what 2 electrolyte abnormalities can lead to DI?
hypokalemia
hypercalcemia
*they make ADH ineffective at the tubule
what does "polyuria" mean ? specifically?
high urine volume
(NOT peeing often)
polyuria + hypernatremia when deprieving pt of water, think
DI
normal reaction to dehydration/water deprivation
decreased urine volume
increased urine osmolality (concentrated urine)
decreased urine sodium
(+) water deprivation test, what does a (+) mean and when do you use test?
urine volume stays hight despite witholding water

-we use this test to diagnose DI, but both central and nephrogenic DI will have a (+) water deprivation test
nephrogenic DI treatment
*HY*
remember: ADH does not work, so no need to give vasopressin

*correct POTASSIUM AND CALCIUM (remember, hypokalemia and hypercalcemia make ADH ineffective)
*stop lithium/demeocycline
*give HTZ or NSAIDs
*fluids ?!
need to undress. which OD
PCP
PCP OD . what to give them?
Benzo
Which TCA is known to cause orthostatic hypotension?
Imipramine
most sensitive sign of opioid toxicity?
respiratory depression
woman overdosed on TCAs and has wide complex tachy. next step?
sodium bicarb
(not defib)
TCA MOA
NE and serotonin reuptake inhibition
what drugs cause miosis
what drugs cause mydriasis
miosis: PCP + opoids

mydriasis: amphetamine intoxication, cocaine intoxication, LSD intoxication and opiate WITHdrawal
SIADH. most accurate test?
high ADH level
SIADH
urine sodium
uric acid level
BUN

-is each low or high in SIADH?
urine sodium = high (body wants to rid water)

uric acid level = low

BUN = low
Tolvaptan and Conivaptan are used for what?
MOA?
severe, symptomatic SIADH
MOA: ADH blockers

**they are only used in urgent HOSPITAL SETTING
how to treat chronic SIADH in a pt with metastatic cancer?
Demeocycline (blocks the action of ADH)
sodium correction per day
12-24 mEq per day
or 0.5-1 mEg per hour
Tip: look for history of bipolar disorder to suggest psychogenic polydipsia (manic drinking water)
...
hypothyroidism can lead to what type of fluid-electrolyte imbalance
hyponatremia in euvolemic state
*you need thyroid hormone to excrete water*
if hypothyroidism--> water retention
name the 4 most common causes of hyponatremia with Euvolemia (normal volume status)
" pseudo psycho hypo syndrome "
pseudohyponatremia (hyperglycermia)
psychogenic polydipsia
hypothyroidism
SIADH
Besides burns, fever, diahrrea, diuretics. What are 2 important causes of hyponatremia with hypovolemia?
Pneumonia (loss through hyperventilation)
sweating
beta blockers have what effect on K+ levels
increase K+ in blood
*remember the Na+/K+ pump normally transports K+ inside and Na+ to the outside, if beta blockers block that ATPase, then K+ stays outside-->hyperkalemia

**that is why a beta agonist (inhaled albuterol) can be used to treat hyperkalemia, it will promote K+ to enter cell
Heparin has what effect on K+ levels?
heparin increases Potassium levels
tip:
Na+ = CNS symptoms (bother hyper and hyponatremia)

Hyperkalemia does NOT cause seizures
Hyperkalemia = muscular (paralysis, ileus) and cardiac symptoms
...
Calcium is only used in Hyperkalemia if the ECG is abnormal
...
Bartter syndrome
genetic disease causing salt loss in loop of Henle
**can lead to hypokalemia
what effect does volume depletion have on K+ level (reason through)
volume depl.-->decr GFR-->incr.Renin-->incr.Aldost--> increased K+ excretion-->hypokalemia
**remember, Mg2+ is the"gate keeper" for K+, so if magnesium is low, K+ will leave
...
what types of RTA lead to hypokalemia, which ones to hyperkalemia
hyper --> type 4
hypo-->type 1 and 2
hypokalemia -->can be so severe as to lead to rhabdo --> which in turn leads to hyerkalemia (busted muscle cells spill K+ into blood)
...
What is the most characteristic ECG finding for Hypokalemia
U waves
Hypokalemia treatment
maximum rate of ORAL replacement --> there is no maximum, the gut can only absorb as much as the kidneys secrete (intrinsic safety mechanism)
However: IV K+ --> think of movie with injection, if you correct too fast you can cause fatal arrythmia
*so IV K+ replacement must be very slow
Depression with fatigue and difficulty concentrating, best medication ?

**
Bupropion
Depression + ADHD, best drug
Bupropion
you give a depressed pt a SSRI and they start seeing a monkey, think
Bipolar I

**antidepressants given to a patient with bipolar disorder who is not taking mood stabilizers can induce a manic episode
**Panic disorder is associated with what other conditions
Depression **
Mitral valve prolapse
occasionally associated with agoraphobia (fear of public places)
Benzo MOA
increase GABA inhibition of neuronal firing
(Benzos-->increased frequency, Phenobarbs--> increased duration)
neuroleptic vs atypical antipsychotic drugs MOA
typical neuroleptics : block D2

atypical antipsychotics: block dopamine and Serotonin receptors
first line drug for maintenance therapy for psychotic disorders
atypical antipsychotics
(Clozapine is most effective but very last in line to use due to agranulocytosis)
high fever, muscle rigidity, decreased consciousness, increased BP and increased heart rate, think___ and what is treatment?
neuroleptic malignant syndrome
STOP DRUG AND ADMINISTER DANTROLENE
Schizophrenia pts are at high risk for
substance abuse (20-70% of pts)
suicide
pts with bulemia nervosa. Screen them for what?

**
Depression
**HY
hypophosphatemia, cardiovascular collapse, rhabdo, confusion and seizures, think
refeeding syndrome
**HY
do NOT use Benzos or anti-cholinergics in the treatment of delirium or dementia related agitation because they can WORSEN SYMPTOMS
...
normal anion gap
The difference between the ca+ions and the anions is predominantly from what?
6-12 normal anion gap

difference between cations and anions is predomiantly from negative charge from Albumin
2 most important causes of normal anion gap acidosis
RTA
diarrhea

*the anion gap is normal in both of these because the Chloride level rises
*hence both are called: hyperchloremic metablic acidosis

(on the other hand, things that decrease the Chloride level will increase the Anion gap (MUD PIILES)
Distal RTA
type I
*Sjoergen, SLE
*increased stone calcium oxalate formation
distal RTA-->nephrocalcinosis HY*; calcification of the kidney parenchyma

MOA: the distal tubule is responsible for generating NEW bicarb under the influence of Aldosterone
*drugs that damage the distal tubule, Ampho B, and autoimmune diseases--> new new bicarb generation
*if there is new bicarb generation, then acid H+ can NOT be excreted and thus leads to acidosis
*failure of H+ secretion into tubule
*K+ is lost in the urine -->HYPOkalemia
HY thus the urine pH will be high >5.5
*most accurate test: infuse Ammonium chloride into blood of pt, it is an acid, a normal person will be able to excrete the acid and lower urine pH, but distal RTA defect will still not be able to clear acid

Tx: Bicarbonate (the proximal tubule will reabsorb it and correct the acidosis)
Proximal RTA type 2
*decreased ability of the proximal tubule to reabsorb the filtered Bicarb... thus you pee out the base
*things that can damage the proximal tubule:
-Multiple Myeloma (HY)
-Amyloidosis (HY)
-Fanconi sydrome (HY)
-Acetazolamide (that is their MOA, decrease bicarb reabsorption)
-heavy metals
*urine pH is variable
*most accurate test: give pt Bicarb and measure urine pH. Because the pt can NOT reabsorb it, the pH will rise
*K+ is lost in the urine

*HY** :
(difficult to treat with bicarb replacement, still will not be take up)

HOWEVER: Thiazide diuretics cause volume depletion--> which will enhance bicarb reabsorption
type 4 RTA is associated with
**HY*
Diabetes
type 2 RTA is associated with what diesease
-Multiple Myeloma (HY)
-Amyloidosis (HY)
-Fanconi sydrome (HY)
-Acetazolamide (that is their MOA, decrease bicarb reabsorption)
-heavy metals
type 1 RTA is associated with what diseases
autoimmune
Sjoergen
SLE

drugs:
Ampho B
type 4 RTA
type 4=hyporeninemia=hypoaldosteronism

* most often in DIABETES (HY)
*decreased amount of aldosterone in distal tubule leads to decreased Na+ reabsorption and decreased K+ excretion
*thus pts urine will have "salty" urine
*sodium depletion is a test to find out, pts will still pee out salt despite low salt intake
*hyperkalemia
Tx: Fludrocortisone (the steroid with highest mineralcorticoid or "aldosterone" like effect)
Diagnostic test and treatment for
RTA type 1
RTA type 2
RTA type 4
type 1 (distal): Bicarbonate
test: give AlCl (acid), pH will remain high (alkalotic)
type 2 (proximal): Thiazide
test: adminsiter Bicarb
type 4: Fludricortisone
test: salt restriction, pee will still be salty
how to distinguish RTA from diarrhea
Urine anion gap ( = Na - Cl)
(+) UAG=RTA (because you have little Cl in urine)

(-) UAG= diarrhea (think of it, if it is negative, it means it has nothing to do with urine, it is from GI loss, because the ability to excrete acid through the kidney is still intact. The kidney tries to compensate the metabolic acidosis form diarrhea by increasing acid secretion. The more acid secreted, the more choloride in urine --> leads to negative UAG)
What is the most useful lab value in assessing a pt's volume status in metabolic alkalosis ?

*HY*
Urine Cl-

*this level is used to classify pts as either volume depleted (low urine Cl-) or volume repleted (high urine Cl-)

*if low urine Cl- : correct with saline
Milk alkali syndrome

**in what pt groups?
Condition induced by excessive antacids + Calcium-containing Dairy Products/Ca2+ supplements

pt groups: person with chronic peptic ulcer disease (ingesting too much bicarbonate) or person with osteoperosis taking too much calcium *HY*

*hypercalcemia, renal insufficiency, and metabolic alkalosis *
hypercalcemia, renal insufficiency, and metabolic alkalosis, think
Milk aklali syndrome
what is the difference between minute ventilation and RR?
minute ventilation: tells you about the "summary" of all the air inhaled one minute
Minute ventilation= RR x TV

RR: breaths per minute

**minute ventilation is more precise than RR (because someone could have a high RR but only take tiny breaths (small TV)
** no change in Minute ventilation when RR increases but TV decreases
sobbing, crying, lead to what acid-base disorder?
respiratory alkalosis
what is an important step in a pt coming with a kidney stone that have excruciating pain in terms of pharm
give them pain relief so they don't develop respiratory alkalosis
Cysteine stone management
*HY*
surgical removal and alkanilization of urine
**
Kidney stones:
<5 mm pass spontaneously

>5-7 mm: give Nifedipine and tamSulosin (Selectively blocks prostate alpha 1 adrenergic receptors), these will help let the stone pass

>5 mm to 2 cm: Lithotripsy

>2-3 cm: surgical removal (Lithotripsy would still fragment them into too big pieces)

struvite stones: remove them surgically (staghorn)

Stent placement is done when there is an obstruction in the ureters, especially at the UP junction (distal ureter)
...
Metabolic acidosis has what effect on bones
removes Ca2+
Tests used for :
1. stress incontinence
2. urge incontinence
1. have pt stand cough, observe for leakage

2. pressure measurement in half full bladder; manometry
urge incontinence treatment
bladder training exercises (dr wells office)
local anticholinergics
**remember, kegel exercises train musclur floor, but that is not really the problem here. it is the best long term treatment for stress incontinence
JNC 7 vs 8 diabetic HTN guideliens
JNC 7 : 130/80
JNC 8: 140/90 (8 is higher number)
Acromegaly can lead to HTN
(flip card)
Hypertension is an important complication of acromegaly, contributing to the increased morbidity and mortality of this condition. Prevalence of hypertension in acromegalic patients is about 35%, ranging from 18 to 60% in different clinical series, and the incidence is higher than in the general population
most effective way to lower BP
loose weight
Tobacco cessation stops HTN. True of false and why
False
tobacco cessation does not stop HTN but becomes especially important to prevent CV disease
Clonidine MOA
central acting alpha AGONIST
Pt with HTN and depression, what anti hypertensive to avoid
Beta blockers
Hyperthyroidism and HTN, first line drug
Beta blocker (remember, you give BB in thyroid storm)
Osteoporosis + HTN, good drug
thiazides (to reabsorb calcium )
Pt with history of CAD and now HTN, best drug choices
BB
ACE
ARB
best initial therapy for Hypertensive crisis
Labetalol OR Nitroprusside

**remember you need to monitor Nitroprusside with an arterial line, so that is why NP is usually not the first choice

equally acceptable forms:
Enalapril
CCBs: diltiazem, verapamil
esmolol

GIVE IV
BP goal in hypertensive crisis
160/110-100 mmHg
What happens to the cerebral autoregulation curve in chronic HTN?
it shifts to the RIGHT (an adaptive mechanism)

*in normotensive adults, cerebral blood flow remains relatively constant over a range of mean arterial pressure (MAP) between 60-120 mmHg because cerebral vasoconstricition limits excessive cerebral perfusion
*as the MAP increases beyond the normal range of cerebral autoregulation, there is cerebrovascular endothelial dysfunction and incrased permeability of the blood brain barrier, leading to vasogenic edema and the formation of micro hemorrhages--> pts manifest signs of HYPERTENSIVE ENCEPHALOPATHY
HYPERTENSIVE ENCEPHALOPATHY
n normotensive adults, cerebral blood flow remains relatively constant over a range of mean arterial pressure (MAP) between 60-120 mmHg because cerebral vasoconstricition limits excessive cerebral perfusion
*as the MAP increases beyond the normal range of cerebral autoregulation, there is cerebrovascular endothelial dysfunction and incrased permeability of the blood brain barrier, leading to vasogenic edema and the formation of micro hemorrhages--> pts manifest signs of HYPERTENSIVE ENCEPHALOPATHY
late preterm (age definition)
34-37 weeks

(remember: >38 weeks is Term baby)
normal HR range and HR range in newborn
RR: 40-60
HR: 120-160 beats per minute
APGAR score
what does the 1 minute score tell us
what does the 5 minute score tell us
at 1 minute: evaluates condition during labor and delivery
at 5 minute: response to resuscitative efforts

(remember, the APGAR score gives us a quantifiable measurement for the need and effectiveness of resuscitation)

*does NOT predict mortality*
*a low score is NOT associated with future cerebral palsy*
Apgar score
pulse 60-100 gets 1 point
but <60 = 0 points for pulse
conjunctivities in neonate after 3 weeks post birth
herpes infection
Why do we give 2 types of antibiotic drops into newborns eye.
What are we trying to prevent?
What are the 2 types of antibiotics?
opthalmia neonatorum

m/c bugs: N. Gonorrhea and Chlamydia trachomatis

**we give erythromycin or tetracycline
**silver nitrate solution
newborn that was delivered at home with no follow up, presents to ED with rectal bleeding. What is the underlying etiology?
clotting factor deficiency due to vitamin K deficiency
(2,7,9,10, protein C and S)
baby is born to hep B positive mom, next best step
Hep B vaccine (every child gets it regardless)
but this neonate will also get HBIG (hepatitis B Immunoglobulin)
G6PD inheritance pattern
x linked recessive
(remember picmonic: x suit )
neonate is born and labs show elevated RBC count. Baby also has splenomegaly, diagnosis?
this is NORMAL
*transient polycythemia of the Newborn*
hypoxia during delivery stimulates EPO and that (transiently) increases the RBC count. Once the baby takes first breath, the increase in O2 will normalize labs

**SPLENOMEGALY IN NEWBORN IS NORMAL
increased RR in a newborn after 4 hours of delivery, think of
SEPSIS
- you must do blood and urine cultures, LP if neonate displays neuro deficits/irratability/lethargy/feeding problems

**> 4 hours of tachypnea in a neonate after birth is considered SEPSIS
subconjunctival hemorrhage in newborn. Tx?
no treatment needed
(chest compression increases thoracic pressure when passing through birth canal)
name the 3 common skull fracture in the newborn
Linear (MOST COMMON *HY*)
Depressed
Basilar (MOST FATAL **HY)
what is the most common skull fracture in a newborn
*HY*
Linear skull fracture
what is the most fatal skull fracture in a newborn
*HY*
Basilar skull fracture
which scalp injury in newborn crosses suture lines?
Caput Succedaneum
Crosses Suture lines
C S
subperiosteal hemorrhage in a newborn, does it cross suture lines?
does NOT cross suture lines
(CS does, Crosses Sutures)
best treatment for Erb Duchenne palsy
immobilization
paralyzed hand with Horner syndrome in a newborn
Klumpke paralysis
Forcep use in delivery can predispose damage to ?
Facial nerve
Forceps-->Facial nerve
Causes of polyhydraminos
too much amniotic fluid
1. Neuro cause: Werdnig Hoffmann (infant unable to swallow)
2. GI cause: intestinal atresia
Oligohydraminos causes
too little amniotic fluid
-->because fetus can NOT urinate
Causes:
1. Renal agenesis: incompatible with life
(associated with Potter syndrome)
2. Prune belly: lack of abdominal muscles, so unable to bear down and urinate

(these babies can have lung hypoplasia and flat facies)
What are the 2 types of diaphragmatic hernias in a newborn?
*HY*
Morgani: defect is retrosternal or parasternal

Bochdalek: defect is posterolateral
(B-->Back defect=posterior)
Omphalocele is highly associated with what chromosomal abnormality?
Trisomy 18
**tip: NT defects and abdominal defects will increase AFP. So omphalocele will have elevated AFP

*HY*
...
m/c cause of elevated AFP
*HY*
incorrect dating
umbilical hernia in a newborn is highly associated with
congenital hypothyroidism
when is surgical intervention for umbilical hernia in a baby indicated?
>4 years of age

(90% of umbilical hernias close by age 3)
abdominal wall defect lateral to midline in a newborn
Diagnosis and management?
gastroschisis
(no sac)
**important: GRADUAL reintroduction of bowel contents. overly aggressive surgical reintroduction of the bowel will lead to third spacing and bowel infarction
m/c abdominal mass in a child
Wilm's tumor
hemihypertrophy of one kidney + Aniridia
Wilms tumor
best inital imaging study for Wilm's tumor?
what is the most accurate? CT contrast or no contrast?
US

CONTRAST enhanced CT is most accurate
Wilms tumor treatment/management
if unilateral: total nephrectomy + chemo + radiation
if bilateral: partial nephrectomy
WAGR syndrome
what is it and what chromosome?
due to deletion on chromosome 11
Neuroblastoma.
Look for these 2 highly tested findings:

**HY*HYHY**HY**
on PE: Hypsarrythmia (dancing eyes) + opsoclonus (dancing feet)

on labs: elevated VMA and metanephrines on urine collection
dancing eyes and dancing feet in a child, think
Neuroblastoma
m/c tumor in infancy
neuroblastoma
best initial test for varicocele

most accurate test?
physical exam showing "bag of worms'

most accurate test: US

"V"aricocele-->"w"orms
varicose vein the scrotal vein
Varicocele
**remember to do bilateral US, it is a bilateral disease
Hydrocele (pic)
must differentiate from inguinal hernia
Hypospadias vs Epispadias and their associations
Hypospadias-->ventral side
*high association with cryptorchidism and inguinal hernias*HY
**circumcision contraindicated

Epispadias-->"e"eye, dorsal side
**Bladder exstrophy
**high association with urinary incontinence
m/c cyanotic heart defect in children
Tetralogy of Fallot
m/c cyanotic heart defect in neonates
transposition of the great vessels
Tetralogy of Fallot is associated with what chromose?
chromosome 22 deletions
*HY*
There are only 3 holosystolic murmurs, what are they?
MR
TR
VSD

(know this)
m/c congenital heart defect in Down Syndrome

*HY*
endocardial cushion defect of antrioventricular canal
VSD is common in what chromosomal abnormalities
Trisomy 18 (Edwards), 13 (Patau) and 21
"egg on a string" on xray in newborn, next best step
Transposition of the great vessels
*give Prostaglandin E (to kEEEp ductus arteriosus open)
m/c cyanotic lesion in neonatal period

**HY
Transposition of the Great vessels
"globular shaped heart" (**HY) on CXR in a newborn with grayish/bluish cyanosis.
Hypoplastic Left Heart Syndrome
severe dyspnea in a newborn with signs of pulmonary HTN. Peripheral pulses are bounding and CXR shows cardiomegaly.
truncus arteriosus

**they need surgery within 4 months to PREVENT pulmonary HTN
"snowman sign" or "figure 8 sign" on CXR in newborn
Total Anomalous Pulmonary Venous Return
TAPVR

*there is no venous return of oxygenated blood to the left atrium but instead it is routed to the Superior Vena Cava
m/c common congenital heart lesion
VSD

(remember this is 1 of the 3 pansystolic/holocystolic murmurs). Child may eventually present with Eisenmenger. Classically, child comes to office . Was otherwise healthy and now has failure to thrive and pansystolic murmur

VSD: Echo is diagnostic, and catherization is definite
What would you see on ECG in a child with VSD?
RV hypertrophy
What drugs could be used (2) for VSD (in mild cases)?
Digoxin
Diuretics
m/c type of Atrial septal defect (there are 3 types)
Secundum defect

(a Primum defect is present when you also have Mitral valve abnormalities present)
wide fixed splitting of S2, think
*HY*
ASD
pt with calf swelling/pain after flight develops facial nerve palsy and left sided paralysis.
paradoxical emboli from deep leg veins that passed throught an Atrial Septal Defect
m/c complication later in life in a child with a PDA?

**
infective endocarditis

(these kids also have increased occurrence of respiratory infections)
ECG finding in PDA
LV hypertrophy
(secondary to high systemic resistance)
*HY*
PDA is a normal finding within the first 12 hours of life.
PDA is considered PATHOLOGICAL if after 12 hours of life.

*HY*
...
Cardiac CXR findings (Peds)

Pear shaped: pericardial effusion
Boot shaped: T of F
Jug handle appearance: primary pulmonary artery HTN
"3" like appearance or rib notching: Coarctation of Aorta
...
girl with Turner's. What might you see on chest xray?
(2 findings)
Rib notching
"3" like appearance

**coarctation of the Aorta classically gives you these 2 findings
hearing loss since birth, syncope, normal vitals and normal PE in a child that passed out
long QT syndrome
m/c vitamin deficiency
folate
what will you see on CXR of infant with pyloric stenosis?
"string sign"

also:
"mushroom sign": hypertrophic pylorus against the duodenum
"railroad track sign": excess mucosa in the pyloric lumen resulting in 2 columns of barium
"shoulder sign": filling defect in antrum due to prolapse of muscle inward
Doughnut sign on US, diagnosis?
Intussusception
**doughnut or target sign is generated by concentric alternating echogenic (mucosa) and hypoechogenic (submucosa) bands
Succussion splash, what is it?
Succussion splash is a sloshing sound heard through the stethoscope during sudden movement of the patient on abdominal auscultation. It reflects the presence of gas and fluid in an obstructed organ

**ex: Pyloric stenosis
CHARGE syndrome

*HY*
it is a set of congenital defects seen in conjunction
coloboma of the eye
infant turns blue with feeding and pink with crying, this finding is clinically diagnostic for ?

*HY*
Choanal atresia
choanal atresia
what is it?
diagnostic test ? (*HY*)
*HY* : what is it associated with ?
membrane between the nostrils and pharyngeal space that prevents breathing during feeding
*this condition is associated with CHARGE syndrome

diagnostic test: CT scan
Hirschsprung disease is diagnosed by? what will it show?
full thickness biopsy
*lack of ganglionic cells in the submucosa
imperforate anus has a hight association with ?
**HY
Down syndrome
VACTERL syndrome
Vertebral anomalies
Anal atresia
CV anomalies
Tracheoesophageal fistula
Esophageal atresia
Renal anomalies
Limb anomalies
Imperforate anus is part of what syndrome?
VACTERL syndrome
complete failure to pass meconium. Diagnosis?
imperforate anus

*remember: in Hirschsprung disease the infant may pass meconium... just very delayed, or with help (rectal finger exam)
Down syndrome child with billous vomiting. What is the underlying etiology ? (be specific)
lack or absence of apoptosis (programmed cell death) that leads to improper canalization of the lumen of the duodenum
most accurate test for pyloric stenosis
upper GI series

(US is best inital)
"sausage shaped mass" palpated in abdomen of child, think
Intussusception
*HY*
What are 2 associations with Intussuception ?

*HY*
Rotavirus vaccine
Henoch Schoenlein purpura

**HY
"currant jelly stool", think
Intussuception

**and remember: Currant jelly sputum is seen with Klebsiella in lungs
What is the most accurate test for Intussusception?
Barium enema
**because it is both: diagnostic and therapeutic

** it is contraindicated if the child has signs of peritonitis, shock, or perforation
painless blood per rectum in a male child under the age of 2, you must think of
Meckel's diverticulum

**get a Meckel scan
most accurate test for Meckel's diverticulum?
Meckelscan (technetium 99)
burn dermatomes and calculations
2nd most common cause of infant death worldwide
acute diarrhea
preterm with distended abdomen. supine xray shows air in the bowel wall.
Most likely diagnosis?
Most important initial step?
Necrotizing enterocolitis

**you MUST start empiric Abx (plus serial xrays to make sure no bowel perforation is occuring)

Yes, this comes before fluids
antibiotics of choice for necrotizing enterocolitis in a PRETERM newborn
vancomycin
gentamycin
metronidazole
pneumatosis intestinalis, pathognomic for ?

*HY*
necrotizing enterocolitis
preterm newborn with fever, vomiting, distended abdomen and bloody stool. What is the pathognomic xray finding?
And what do you see on CT scan?

*HY*
pneumatosis intestinalis (xray)

on CT scan: air in the portal vein
what GI abnormality can be seen in infants of diabetic mothers
Small left colon syndrome
* a congenitally smaller descending colon that leads to distention from constipation. It can be diagnosed by a barium study and treated with smaller and more frequent feeds.
flank mass and abdominal bruit in an infant of diabetic mother with hematuria +thrombocytopenia, think
Renal Vein thrombosis
what is the major cardiac change seen in infants of diabetic mothers other than transposition of the great vessels?
asymmetric septal hypertrophy due to obliteration of the left ventricular lumen, leading to decreased cardiac output
*it is diagnosed with ECG and treated with beta blockers and IV fluids
What are the 3 types of Rickets
1. vitamin D deficient rickets : not enough vitamin D in child's diet

2. vitamin D dependent rickets: can not activate vitamin D, thus child DEPENDS on Vitamin D

3. X-linked hypophosphatemic rickets: innate kidney defect results in the inability to retain phosphate
Workup in a child with febrile seizure
CBC with diff
blood and urine cultures
UA
CXR
LP (if lethargic, irritable)
You suspect Toxo infection in newborn,
best initial test? most accurate test?
best initial test: elevated IgM to Toxo

most accurate test: PCR for toxo
You suspect CMV infection of newborn.
Best initial test?
most accurate test?
best initial test: urine or saliva viral titers
(not blood)

most accurate test: urine or saliva PCR for viral DNA
(not blood)
scarlet fever treatment
penicillin
or
azithromycin
or
cephalosporin
child with croup in respiratory distress, next best step
racemic ephinephrine
(there is no medical evidence suggesting that intubation decreases mortality)

vs Epiglottitis: intubate
most appropriate next step in a resp. distress child with croup vs epiglottitis
croup: racemic Epi

Epiglottitis: truest pediatric ER * INTUBATE*
Once you intubated child with epiglottitis , next step?
adminster Ceftriaxone for 7-10 days
***Give rifampin to close contacts***
whooping cough diagnosis
made clinically

PCR of nasal secretion
or
Bordetella pertussis toxin ELISA
"butterfly pattern" on chest xray
whooping cough
Whooping cough treatment and in what stage
Macrolides
*only work in catarrhal stage (first stage)*
Abx do NOT help in "whooping stage" ( Paroxysmal stage)

**give Macrolides to close contacts****
In what other childhood disease do you give prophylactic Rifampin to close contacts?
Epiglottitis
Rapid DNAse antigen detection test = rapid strep test
...
gray pseudomemembranous membranes on the pharyngeal wall.

diagnosis?
tx?
etiology?
Diphtheria
Corynebacterium diphtheriae

Tx: ANTIBIOTICS DO NOT WORK !!!!!!! ****** HY*
give Anti toxin

DO NOT SCRAPE THE GRAY PSEUDOMEMBRANE
burning feet syndrome, what deficiency?
Vitamin B5 (panthothenic acid)
2 Findings of Vitamin A toxicity (what can it cause?)
pseudotumor cerebri
hyperparathyroidism
Folate is which vitamin
B 9
what is the most accurate diagnostic test for breast cancer
OPEN biopsy (not FNA or core needle biopsy)
-surgeon can send frozen section to path lab and then resect cancer right then and there
what type of biopsy for breast cancer if you want to determine receptor?
core needle biopsy (FNA can't)
*HY*
you CAN NOT test for Estrogen or Progesterone receptors with FNA**
...
Woman is scheduled for breast biopsy procedure, what test would benefit the pt?
mammography
*because you can assess the other breast too **
*you can also assess if there is just one or multiple lesions in the affected breast *
How do you tell the content of an abnormal, inaccessible lesion without biopsy?

(a CT scan can tell you the "abnormal" looking lymph node)
PET scan
cancer increases uptake on PET scan HY*
Hormonal manipulation in breast cancer
1. Tamoxifen --> but gives endometrial cancer
2. Raloxifene

Aromatase inhibitors: (prevent conversion to Estrogen)
Anastrazole
Letrozole
Exemestane
**these have a slight superiority in efficacy, so if SERMs and AI are given, choose AI as "most likely to benefit pt"
*Trastuzumab decreases the risk of recurrent disease *

vs

*Tamoxifen: it lowers the risk of breast cancer, this is useful in pts that have a history of breast cancer in family*
...
*HY*
Which one is more likely to give erectile dysfunction, surgery or radiation?
SURGERY

*HY*
What is "Gleason grading" used for?
it is a measure of the AGGRESSIVENESS or MALIGNANT POTENTIAL of prostate cancer
-high score-->take out prostate
*no chemotherapy is proven beneficial in prostate cancer *

*HY*

the higher the PSA, the greater the risk of cancer. PSA corresponds to the volume of the cancer
...
3 reasons when surgery is not the answer to lung cancer
1. disease is bilateral
2. malignant pleural effusion **
3. Heart, carina, aorta or vena cava is involved

(size is NOT a factor, a large lesion that is surounded by healthy tissue can be resected)
**Ovarian cancer is the only cancer in which removing large amounts of locally metastatic disease will benefit the pt. Remove all visible tumor and pelvic organs and give chemo

**after orhiectomy (men), radiation is used for local disease and chemotherapy is used for widespread disease. Testicular cancer is one of the ONLY malignancies in which chemotherapy can CURE widely metastatic disease, including spread to the brain

**hCG is elevated in ALL testicular cancers, AFP only by non-seminomatous cancers
...
HPV vaccine is recomended for what age group
11-26
ASCUS present.
**perform HPV next, if positive, do colposcopy
**if no HPV found, repeat pap smear in 6 months
...
SERMs vs Aromatase inhihibitiors in breast cancer:

both SERMs (Tamoxifen and Raloxifene) reduce breast cancer and thus lower mortality in pts that are asymptomatic but have first degree breast cancer relatives.
Aromatase inhibitors are very usefule in preventing metastases in those with proven breast cancer, but they are not proven to benefit those who are asymptomatic.
...
** when BRCA is positive "offer prophylactic bilateral mastectomy" is a wrong answer .

*remember, we don't really know what to do with a positive BRCA
...
pap smear is done from what ages?
21-65 every 3 years
Chlamydia screen women from what ages
15-25
*there is NO TEST proven to lower mortality from lung cancer*
...
How often do you screen adults for HTN?
every 2 years
Melanoma loves to metastasize to what organ?
brain
**besides sunlight, squamous cell cancer is greatly increased by organ transplant secondary to long term use of immunosuppressants.
All forms of SCC start out by looking like an ulcer that does not heal or continues to grow**
...
Mohs Micrographic Surgery, when is it used and what is it?
removal of skin cancer under a dissecting microscope with immediate frozen section is one of the most precise methods of treating skin cancer

**best for delicate areas--> there is no need to remove a wide margin around it, once one section is cancer free, you can stop
*only AIDS aquiered by sex is associated with Karposi Sarcoma *
...
below what CD 4 count do you see Kaposi's sarcoma?

*HY*
<100 CD 4+
Karposi sarcoma treatment
treat AIDS, so HAART

-also: intralesional IFN or vincristine are very successful
-if these fail, use chemo with doxorubicin
What is the premalignant skin lesion for Squamous cell carcinoma?
Actinic Keratoses
Imiquimod
what is it and what use?
local immunostimulant
can be used for:
Actinic Keratoses
BCC
SCC
condyloma accuminatum (warts)
Molluscum contagiosum (Dr Niebaum)
Leser Trelat sign, appearance of hundreds of _____ indicating underlying GI malignancy
seborrheic keratoses
Tacrolimus and Pimecrolimus are associated (rare though) with developing what type of malignancy?
Lymphoma
Medical treatment options in Atopic dermatitis (eczema)
1. Topical corticosteroids (orals only in severe disease)
2. TACROLIMUS and PIMECROLIMUS : T cell inhibiting agents that provide longer term control and HELP PT GET OFF STEROIDS
-use them topically (remember, they are used sytemically for organ transplant pts to prevent organ rejection)

3. Antihistamines (=anti pruritic)
mild disease: non sedating histamine blockers
severe disease: DOXEPIN (TCA), topical available

4. Antibiotics (cephalexin, mupirocin, retapamulin) when impetigo occurs
What is an alternative to topical steroid treatment (also for delicate areas like face and genital area) in pts with Exzema + Psoriasis?
Tacrolimus and Pimecrolimus (T cell inhibitors)
Treatment of severe psoriasis?
1. UV light
2. Antitumor Necrosis factor TNF inhibitors
3. MTX (last option, unless psoriatric arthrits, then earlier)
What is the underlying etiology of Dandruff?
hypersensitivity reaction to a dermal infection (*HY*) with a non-invasive dermatophyte organism
-this is why both topical steroids and anti fungal agents are useful
**What drugs can cause Pemphigus Vulgaris?

*HY**
*HY --> ACE inhibitors ****
-Penicillamine
-Phenobarbital
-Penicillin
(the 3 P's)
ACE inhibitors, besides causing Angioedem, can lead to what type of skin disease?
Pemphigus vulgaris
most accurate test for pemphigus vulgaris?
biopsy showing autoantibodies on immunoflorecence
*anti desmosomes* reticular/fishnet pattern
Pemphigus Vuglaris treatment

*HY*
1. Systemic steroids (remember this can be fatal, so we want sth strong), PREDNISONE

2. **HY** : Azathioprine or mycophenolate to wean the pt off steroids *HY : Azathioprine or mycophenolate to wean the pt off steroids eroids *HY*

3. Rituximab (anti DC 20) or IVIG in refractory cases
*HY*
mild bullous Pemphigoid responds to what treatment?
*HY*
DAPSONE and NICOTINAMIDE (not niacin)
also: erythromycin

(more severe cases, just like P. vulgaris)
What has hight association with Porphyria Cutanea Tarda?

*HY*
Hep C *HY*

others:
alcohol
iron overload
estrogen

(most tested association)
underlying etiology of blistering of skin when exposed to sun in pts with PCT?
Porphyria cutanea tarda is a hypersensitivity rxn of the skin to abnormal porphyrins when they are exposed to light
most accurate diagnostic test for Porphyria cutanea tarda?

*HY*
increased uroporphyrins in a 24 hour URINE collection (not blood)
Impetigo treatment, mild disease vs severe disease
this is a superficial skin infection , so we can use topicals

mild:
TOPICAL agents: Mupirocin ** (or Bacitracin,etc)

severe:
ORAL agents: Dicloxacillin or cephalexin

if Community acquired MRSA:
Clindaymycin **
TMP/SMX **

**=know this
skin infection vs pharyngitis with GAS, which sequelae
skin GAS infection --> GN (but not rheumatic fever)

pharyngitis-->both
Erysipelas treatment
deeper infection than Impetigo (so topicals will not work)

mild disease
ORAL meds:
Dicoloxacillin, cephalexin
(if penicillin allergy : Erythromycin, clarithromycin, clindamycin-all the mice)
MRSA: Clindamycin, TMP/SMX

Severe disease (=fever present)
INTRAVENOUS Abx **
Oxacillin, nafcillin, cefazolin
(penicillin allergy: clindamycin, vancomycin)
MRSA: vanco, linezolid, daptomycin, ceftraroline
*HY*
Which cephalosporin is the ONLY one covering MRSA?

*HY*
CeftAROLINE ("caroline")
Penicillin allergy,

if rash, use what?

if anaphylaxis, use what ? (differentiate between mild and severe disease, what can you use when?)
if rash, use Cephalosporins (**)

if anaphylaxis:

if mild disease:
macrolides **
clindamycin **
doxycycline **
TMP/SMX **

if severe disease:
vancomycin **
linezolid **
CeftAROLINE
daptomycin

**=know
Dermatophyte = superficial fungal skin infection=tinea
...
Fungal treatment basics:

**a KOH prep is NOT a fungal culture
KOH prep=best initial test (tells you whether there is a fungi)
fungal culture = most accurate test

**best initial therapy is a topical antifungal agent if NO HAIR or NAILS are involved

*if hair / nails ---> terbinafine (*), itraconazole is close in efficacy
...
*HY*
with a clear clinical presentation of oral or vaginal yeast infection, the next step is to treat the pt (not culture)
...
TEN treatment
IVIG

Steroids do NOT help
SJS treatment
IVIG

(steroids are not clearly beneficial)
Morbilliform rash (no Tx) < Erythema Mulitf. (prednisone) < SJS (IVIG) < TEN (IVIG, NO steroids)
...
**TEN and staphylococcal scalded skin syndrome present very similiar. both have (+) Nikolsky sign, skin involvement and mulitorgan involvement , so pay close attention to H/P
...
Staph scalded skin syndrome tx
oxacillin or nafcillin
Abx do NOT reverse the disease, they just kill staph that is producing the toxin
number one limiting factor prior to surgery is ?
history of CV disease
pt had a MI. When is it safe for him to have a surgery?
6 months (do a stress test at that time)
pt with history of heart disease, prior to surgery, what does he need to get checked?
ECG
stress testing to evaluate for ischemic coronary lesions
echo (for structural disease and EF)
when should a pt quit smoking before surgery?
6-8 weeks and use a patch
if pt is on dialysis tx, when should he be dialysed before surgery?
24 hours before
**
Pt with facial trauma and need for airway, what do you do
cricothyroidotomy ("CTO")
*HY*

SLE --> PAINLESS oral ulcers (very important)
...
Rheumatoid arthritis is associated with what allele?

*HY**
HLA DR 4
Which medications lower OCP effectiveness?

*HY*
Rifampin (Antibiotic)
Anti epileptics (phenytoin, carbamezapine, ...)
OCPs reduce the risk for what cancers

*HY*
OVARIAN cancer and endometrial cancer
woman had MVA. pallor. cool extremities, tachycardic. BP 80/40. what type of shock?
cardiogenic

(it can NOT be hypovolemic because you can NOT loose that much blood into pericardial sac to cause hypovolemia, same with head injury)
2 signs seen in splenic rupture
Kehr sign (pain in left shoulder)
** Balance sign: dull percussion on the left and shifting dullness on the right
Balance sign
*HY*
dull percussion on the left and shifting dullness on the right (splenic rupture)
"shifting dullness = "out of balance" mnemonic
pt presents with abdominal pain 10/10 but no peritoneal signs. made worse with eating.
What is the most appropriate next step?
Angiography
best initial test for bowel ischemia, and most accurate test?
best initial test: CT of abdomen
most accurate: Angio
Hamman sign
*HY*
crunching heard upon palpation of the thorax due to subcutaneous emphysema
m/c common cause of Esophageal perforation ?
Iatrogenic = of or relating to illness caused by medical examination or treatment.
(most common procedure to do so is upper Endo)

-m/c location of tear: left posterolateral aspect of the distal esophagus
most accurate test for esophageal perforation?
Esophogram using Gastrografin

(it will show leakage of contrast outside of the esophagus)
** do NOT use barium, caustic to tissue if it leaks out
gastric ulcer in posterior wall of stomach can lead to
pancreatitis
Name 3 signs of periotonitis
Guarding
Rebound tenderness
Abdominal rigidity
female with RLQ pain, get
pelvic sonogram and beta hCG
acute onset of severe abdominal pain in an elderly pt with history of constipation
acute diverticulitis
m/c complication after diverticulitis?
abscess formation
What will you see on US in pt with cholecystitis?
thickened GB wall and pericholecystic fluid
name 2 things that can cause abdominal pain radiating straight to the back?
acute pancreatitis
aortic dissection
complication of cholecystitis?
GB perforation
complication of appendicitis?
abscess formation and gangrenous perforation
n/v and abdominal pain with hyperactive bowel sounds, think
small bowel obstruction
What medication has been shown to alleviate obstruction from stool impaction in pts on chronic opiods

*HY*
Methylnaltrexone
third spacing
The accumulation and sequestration of trapped extra-cellular fluid in an actual or potential body space as a result of disease or injury.
best initial test for fecal incontinence?
most accurate test?
flexible sigmoidoscopy or anoscopy (best initial test)

most accurate test: anorectal manometry (esp if there is a history of anatomic injury, ex: tear during birth)
best test for stress fractures
NOT x-ray (will not show it)

get CT or MRI
athlete with persistent pain in the foot, think
stress fracture
get CT or MRI (xray shows nothing)
elderly person fractures rib from coughing, what type of fracture
pathologic fracture
Scaphoid Fracture management
xray won't show it for up to 3 weeks

**thumb spica cast
anterior vs posterior shoulder dislocation (how is forearm held0?
anterior SD: arm held to the side with externally rotated forearm with severe pain

posterior SD: arm is medially rotated and held to the side
you suspect trigger finger, next best step?
steroid injections
*have been shown to decrease pain AND recurrence of trigger finger
Dupuytren vs Trigger finger causes
Dupuytren: constricted palmar fascia (men >40 yrs)

Trigger finger: stenosis of tendon sheath
what may you see on UA in pt with fat embolism after femur fracture?
fat droplets
m/c knee ligament injury
ACL
slipped disc per PE.
Most appropriate next step in management?
most appropriate next diagnostic test?
next best step in management: Anti inflammatory agent

most appropriate next diagnostic test: get MRI
when is surgery indicated for AAA?
> 5 cm (of if asymptomatic)
AAA screening in smokers when ?
any smoker (current or former) > 65 years get a US
"WIND blew over the WATER as I was WALKING my WOUNDERFUL WONDERDOG(=drug) "
...
bilateral pulmonary infiltrates without JVD
ARDS
best initial test in PE ?

*HY*
ECG

*will show sinus tachy

then follow with CT angiogram
what hormone surge leads to morning sickness in pregnancy?
rise in beta hCG, progesterone and estrogen
LMP July 1, 2010. What is the estimated date of delivery?
LMP - 3 (mths) + 7 days
April 8, 2011
Naegele rule is used for?
estimated date of delivery
LMP - 3 (mths) + 7 days
Gestational age (GA) vs Developmental age (DA)
DA: number of days since fertilization

GA: number of days/weeks since the last menstrual period (usually 2 weeks longer than DA) "G comes after D, so GA is longer than DA)
term fetus
38-42 wks
preterm fetus
25-37 wks