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Step 2 CK - Renal, Cardio, Endo, Pulm

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Glomerular hematuria a/f URI. Dx?
1. IgA nephropathy (<5 days), nL serum complement
2. post-strep GN (10-21 days), decr. serum complement
Most common extrarenal manifestation of PKD is?
hepatic cyst
Development of renal abnormalities in DM?
1. glomerular hyperfiltration
2. thickening of GBM
3. mesangial thickening
4. nodular sclerosis
Side effect of prazosin?
priapism
Tx for Goodpastures?
emergency plasmapheresis
Increased DTRs, muscle cramps, (rarely) convulsions in post-op pt who rec'd multiple transfusions...?
hypo-Ca 2/2 citrate binding
Severe hypo-Mg can mimic hypo-Ca, but how?
decreases PTH secretion & peripheral responsiveness to PTH
Intra-abdominal pathology causing shoulder pain = ?
subdiaphragmatic peritonitis
In blunt trauma to the bladder, where will the rupture occur?
bladder dome, at developmental hiatus, where urachus originated. (can cause chemical peritonitis)
BPH begins in which prostate zone?
central
Tx for uric acid stones?
alkalinization of urine with KCl
Elderly pt wih
- bone pain
- renal failure
- hyper-Ca.
Diagnosis, doctor?
multiple myeloma until proven otherwise
Hyper-K in a patient receiving chemo. Dx?
tumor lysis syndrome
Young black male with painless hematuria. Cause? etiology?
sickle cell trait.
papillary ischemia. Papillary necrosis can occur, with massive hematuria. (Usually mild, resolves spontaneously.)
Drug-induced interstitial nephritis Sx.
arthralgias, rash, renal failure, eosinophiluria
Causes of drug-induced interstitial nephritis.
- penicillins, cephalosporins
- sulfonamides
- rifampin
- phenytoin
- allopurinol
- NSAIDs
If suspect BPH, w/u should include?
DRE, UA, serum Cr.
If any abnl, needs further w/u.
Most common type of kidney damage associated with HIV
FSGS
Most common type of drug-induced CRF is ?
analgesic nephropathy
Analgesic nephropathy. Path?
papillary necrosis & chronic tubulointerstitial nephritis
apple-green birefringence
amyloidosis (RA predisposes to this)
Acute Tx of symptomatic hyper-Ca
(if not caused by malignancy)
1 - IV fluids (incr. renal excretion of Ca by decr. Ca reabsorption in proximal tubule)
2 - loop (block Ca reabsorption in loop)
3 - identify cause and treat!
Acid-base d/o post-ictally.
lactic acidosis. resolves in 60-90 mins w/o Tx
In non-gap metabolic acidosis, how to narrow down DDx?
urine anion gap; to differentiate between intestinal and renal HCO3 losses.
Acid-base d/o in septic shock
lactic acidosis
Nephrotic patient with sudden onset:
- abdominal pain
- fever
- hematuria
renal vein thrombosis
Renal vein thrombosis is most commonly a complication of...?
membranous glomerulonephritis
Hypercoagulability in nephrotic syndrome is a result of...?
- urinary losses of antithrombin III
- altered levels of proteins C & S
- increased platelet aggregation
- hyperfibrinogenemia 2/2 increased hepatic synthesis
- impaired fibrinolysis
Screening test for cystinuria?
urinary cyanide nitroprusside. (also, hexagonal crystals)
Bowel ischemia can lead to what acid-base d/o?
lactic acidosis
Best treatment for hepatorenal syndrome?
liver transplant
How to treat recurrent hypercalcuric renal stones?
increase fluid intake
sodium restriction
thiazides
Characteristics of simple renal cysts (i.e. no further w/u)
- thin walls
- no solid components
- no contrast enhancement
Diabetic pt with non-gap metabolic acidosis, persistent hyper-K, and renal insufficiency. Diagnosis, doctor?
type IV RTA!
- caused by aldosterone deficiency or renal tubular insensitivity to aldosterone
- worsened by ACE-I's, ARB's
Acyclovir adverse effect.
crystalline nephropathy (prevent with adequate hydration)
- usually transient
- Tx with hydration as well as adjusting dose (slow rate of IV infusion)
What type of nephropathy is assoc with carcinomas?
membranous
What type of nephropathy is assoc with Hodgkin's lymphoma?
minimal change dx
Cause of abnormal hemostasis in CRF? Tx?
platelet dysfxn.
Tx: DDAVP (increases release of factor VIII:vWF multimers from endothelial storage sites)
--transfused platelets would quickly become inactive
Nephrotic-range proteinuria
+ hematuria
+ "dense deposits" in GBM
= ?
membranoproliferative GN, type 2.
Dense deposits stain for C3 (not IgGs!)
Cause of Membranoproliferative glomerulonephritis type 2?
IgG against C3 convertase, leading to persistent activation of the alternative complement pathway ==> kidney damage
Renal colic with negative KUB. Causes?
1. radiolucent stone
2. Ca stone 1-3 cm diameter
3. non-stone obstruction (i.e. bloot clot, tumor)
Winter's formula.
what pCO2 should be to compensate for metabolic acidosis.
paCO2 = 1.5 ( HCO3-) + 8
FSGS associations/risk factors?
HIV
obesity
heroin use
nL PCWP ?
6-12
nL QRS ?
< 120 msec
Claudication with normal ABIs?
[popliteal] arterial entrapment syndrome
- ABI's are falsely negative at rest; exercise ABI's abnl.
- on exam: nL pulses that decrease with plantar/dorsiflexion
for MI, how soon to balloon?
90 min.
___ increases rate of growth of AAA by 25%.
smoking
Drugs that improve mortality in CHF?
ACE-I's
beta-blockers
spironolactone
Etiology of isolated systolic HTN in elderly?
decreased vessel elasticity
___ is earliest manifestation of PKD
HTN
Leriche syndrome?
aortoiliac occlusive dx
- buttock claudication
- male impotence
- buttock atrophy
PACs...
are always benign
Sx of digitalis toxicity.
diarrhea, nausea, fatigue.
atrial tachycardia with AV block
Causes of digitalis toxicity?
Digitalis is renally cleared.
toxicity incited by viral illness vs. excess diuretics
Latex allergy common in what congenital disease?
spina bifida
___ causes reversible cardiomyopathy.
hemochromatosis
Etiology of non-pitting edema
- lymphatic obstruction
- increased interstitial pressure (myxedema)
Etiology of pitting edema
- increased intravascular hydrostatic pressure
- decreased plasma oncotic pressure
- increased capillary permeability
How does nitroglycerine treat angina?
decreases preload
Complications of anterior, posterior MI?
anterolateral ==> free wall rupture
posteroseptal ==> papillary muscle dysfunction
High output heart failure occurs when...
increased ventricular function can't meet body's metabolic demands.
Causes of high output heart failure?
- anemia
- hyper-T
- beriberi (thiamine def)
- Paget's
- A/V fistulas
What is neurocardiogenic syncope? how to Dx?
vasovagal syncope
tilt-table test
Kussmaul's sign?
increased JVD with inspiration
Causes of pulsus paradoxus
- tamponade
- tension pneumo
- severe asthma
SLE & chronic steroids are both risk factors for...?
accelerated coronary atherosclerosis
Electrolyte abnormalities in primary hyper-aldo
Conn's syndrome
- hyper-Na
- hypo-K
- metabolic alkalosis
Use defibrillation to treat which arrythmias?
vtach, vfib (never afib)
Tx of PEA
1. CPR
2. IV epinephrine or vasopressin
Myocardial contusion. EKG findings? Complications?
(can cause cardiogenic shock)
new LBBB or dysrythmia
- myocardial rupture
- septal rupture
- valvular insufficiency
Cause of statin-induced myopathy?
decreased Coenzyme Q10 (HMG-CoA reductase also makes CoQ10)
Prolonged QRS ==> ?
Prolonged QT ==> ?
bradyarrythmia
tachyarrythmia
Can PVC's cause syncope?
nope
When does fixed splitting of S2 happen?
- ASD (may also have RBBB)
- sometimes VSD
Abnormal breathing pattern seen in CHF.
Cheyne-Stokes
Evolution of EKG in STEMI
T ==> ST ==> Q ==> T ==> ST ==> T
(peaked T ==> ST elevation ==> Q waves ==> T inversion ==> ST normalizes ==> T normalizes)
___ maintains PDA patency.
___ closes PDA.
prostaglandin E1
indomethacin
Physical exam findings in constrictive pericarditis
- sharp "x" and "y" descents
- pericardial knock (early heart sound a/f S2)
Dipyridamole properties.
- inhibits platelet aggregation
- coronary vasodilator
Tx for first degree heart block.
no treatment indicated
Which CCBs affect the heart?
non-DHP.
- verapamil
- diltiazem
What happens if you give DHP-CCB's in STEMI?
they can worsen cardiac ischemia. cause peripheral vasodilation ==> reflex tachycardia.
- amlodipine
- nifedipine
What is DC cardioversion?
delivery of shock in synchrony with QRS complex--timed NOT to hit T wave (which could cause v.fib)
Cardioversion is used to treat which arrythmias?
- PSVT
- a-flutter
- a-fib
- v-tach with pulse
Tx for vtach WITHOUT hemodynamic compromise.
amiodarine or lidocaine
What is defibrillation?
delivery of shock NOT in synchrony with QRS
Defibrillation used to treat?
- v-fib
- pulseles v-tach
When treating "acute" afib, present for > 48 hrs (or an unknown time), what precautions should you take?
anticoagulate for 3 weeks before cardioversion and 4 weeks after. (or get echo to demonstrate no clot)
Tx for chronic afib
rate or rhythm control
EKG changes in hypo-Ca, hyper-Ca.
hypo-Ca ==> QT prolongation
hyper-Ca ==> short QT
Electrolyte changes in tumor lysis syndrome
hyper-K
hyper-PO4
hyper-uricemia
hypo-Ca
In HHNKS, why are there no ketones?
there is enough insulin to suppress lipolysis, but not enough to lower plasma glucose.
Why treat elderly pts with methimazole/PTU before radioactive hormone?
need to deplete thyroid hormone stores, otherwise hormone released from dying cells ==> thyrotoxicosis
In secondary hyper-PTH in CRF, Ca ___, PO4 ___, PTH ___.
Ca is nL to low
PO4 high
PTH high
Osteomalacia: Ca ___, PO4 ___, PTH ___.
Ca nL to low
PO4 low
PTH high
Tx for diabetic gastroparesis
1. Dopamine antagonists b/f meals (metoclopramide, domperidone)
2. Bethanechol (pro-cholinergic)
3. erythromycin
Causes of primary adrenal insufficiency
- TB
- fungal infection
- CMV infection
Fever + sore throat in a patient taking PTU/methimazole = ? Tx?
agranulocytosis. Stop drug and check WBC.
Substrates for gluconeogenesis
alanine
lactate
glycerol-3-phosphate
In DKA, best indicators of metabolic recovery?
- arterial pH
- anion gap
Pellagra = deficiency of ?
niacin
Pseudotumor cerebri 2/2 toxicity of ___
vitamin A
Hypokalemic periodic paralysis
- episodic paralysis 2/2 abrupt decrease in serum K
- cause: familiar or due to thyrotoxicosis
- attacks precipitated by meals, stress
- Pathophys: K influx into cell due to release of epinephrine & insulin
Initial screening test or primary adrenal insufficiency?
cosyntropin stim test
Increased extracellular pH alters electrolyte levels how?
increases affinity of albumin for Ca, effectively decreasing ionied (active) calcium
Somogyi effect?
when nocturnal hypoglycemia leads to morning hyperglycemia due to release of epi, NE, glucagon
Hyper-Ca can result from prolonged immobilization. Tx?
Bisphosphonates decrease hyper-Ca and prevent osteopenia
DHEA made in ___? DHEAS in ___?
DHEA: adrenals, gonads, brain
DHEAS: adrenals
Hormones produced by Leydig cell tumors?
estrogen. (Leydig cells have aromatase)
Hormones produced by choriocarcinomas?
beta-hCG
Hormones produced by seminomas?
serum tumor markers typically nL. But in those with syncytiotrophoblastic giant cells, beta-hCG may be increased.
Hormones produced by endodermal sinus tumor?
alpha-fetoprotein (yolk sac tumor)
APECED stands for?
autoimmune polyglandular endocrinopathy, candidiasis, & ectodermal dysplasia
- a cause of primary hypo-PTH
When does tertiary hyper-PTH happen?
when secondary hyper-PTH leads to autonomous PTH secretion ==> hyper-Ca. (e.g. pt with CRF & 2o hyper-PTH receives kidney transplant, but still has hyper-Ca after)
Correcting calcium in hypoalbuminemia
= 0.8 (4 - albumin) + serum Ca
Bartter Syndrome
defect in TAL
Gitelman syndrome
defect in DCT
Electrolyte changes in Bartter and Gitelman?
hypo-K
hypochloremic metabolic alkalosis
nL to low BP
elevated urinary chloride (similar to diuretic abuse)
(in chronic vomiting, urinary Cl is low)
Milk alkali syndrome?
Burnett's syndrome
- excessive ingestion of Ca leads to hyper-Ca, metastatic calcification, and renal failure
Vertical gaze paralysis
+ pupillary disturbances
+ eyelid retraction
pinealoma (Parinaud's syndrome)
- blocks hypothalamic inhibition pathway (leading to endocrine Sx)
- affects rostral midbrain at level of superior colliculus and CN III
In 21-hydroxylase deficiency (CAH), how is DHEA affected?
DHEA levels are normal
Central precocious puberty. Dx, Tx
increased LH, increased FSH
CT, MRI
Tx: GnRH analog
Sx of pure riboflavin (B2) deficiency
- sore throat
- hyperemic & edematous oropharynx
- cheilitis, stomatitis, glossitis
- normocytic, normochromic anemia
- seborrheic dermatitis
- photophobia
Causes of pellagra?
(niacin, B3 def)
- alcoholism
- long term isoniazid use
- carcinoid syndrome
- Hartnup's dx
Hartnup's dx
"pellagra-like-dermatosis"
- impaired absorption of neutral AA's, including TRP
==> can normally be converted to niacin
Sx of dry beriberi
symmetrical peripheral neuropathy with sensory & motor impairment of distal extremities
How to calculate tidal volume in assisted ventilation
~6 mL / kg ideal body wt
What happens to DLCO in emphysema?
decreased DLCO
What happens to DLCO in chronic bronchitis?
normal DLCO
on CXR, "triangular opacity in R hemithorax" = ?
R lower lobe atelectasis
postoperatively, hypoxemia + respiratory alkalosis = ?
postop atelectasis
most common precipitant of COPD exacerbation?
upper airway infection
Smoking cessation > ___ weeks preop decreases risk of postop pulmonary complications.
>8 weeks. Smoking cessation closer to surgery increases risk of postop pulm complications!
Most common cause of atypical PNA
mycoplasma
Skin manifestation in mycoplasma PNA
erythema multiforme
Can see mild LFT elevation in PNA 2/2 ___.
Legionella. Also GI, neuro Sx. Think cruise ships & hotels!
Legionella PNA. Dx? Tx?
Dx - urinary antigen
Tx - quinolone or macrolide
PE findings in pleural effusion
decreased tactile fremitus, decreased breath sounds
PE findings in consolidation
increased fremitus, bronchial breath sounds (i.e. full expiratory phase)
Kidney dx + upper + lower respiratory disease, suspect...?
Wegeners
Dx Wegeners?
c-ANCA and biopsy
c-ANCA is an antibody against what?
proteinase-3
Wegener's is defined clinically by what three criteria?
1. systemic vasculitis
2. upper & lower airway granulomatous inflammation
3. glomerulonephritis
Wegener's. Age of onset?
~ 40 y/o. M=F
Wegener's. Upper respiratory Sx / complications?
- epistaxis
- purulent rhinorrhea
- otitis
- sinusitis
- saddle nose deformity (destruction of nasal cartilage)
Wegener's. Cutaneous involvement?
- painful subQ nodules
- palpable purpura
- pyoderma gangrenosum
Adverse effects of amiodarone.
- pulmonary fibrosis
- corneal deposits
For a solitary, coin-shaped pulmonary nodule surrounded by nL parenchyma, what does calcification signify?
calcification favors benign.
"Popcorn" = hamartoma
"Bull's eye" = granuloma
Why should patients with DVT wear compression stockings?
to decrease risk of post-phlebitic syndrome, possible for up to 2 years.
In trauma, what is usually the primary reason for respiratory distress?
pulmonary contusion (which is often seen in trauma severe enough to cause flail chest)
___ is a common cause of empyema.
hemothorax. (blood is a great medium)
In pt with irregular bleeding (>8 weeks postpartum), enlarged uterus, and pelvic pain, think...?
gestational trophoblastic disease
Gestational trophoblastic disease can occur after...
- normal gestation (25%)
- molar pregnancy (50%)
- abortion (25%)
Name the two types of malignant gestational trophoblastic disease.
1. Gestational trophoblastic neoplasia (locally invasive)
2. Choriocarcinoma (highly metastatic--prefers the lungs)
Blastomycosis. epidemiology
- great lakes, Mississippi River & Ohio River basins
- highest infection rate in Wisconsin
Blasomycosis Sx.
Pulmonary Sx look like TB or histo
Systemnic Sx:
- "characteristic" ulcerated skin lesions
- lytic Bone lesios
Blastomycosis. Tx
itraconazole or amphotericin B
Coccidiomycosis epidemiology
Southwest US.
Coccidio Sx
fever, cough, night sweats.
(skin, meninges, skeleton can also be affected)
Histoplasma capsulatum epidemiology
- Mississippi / Ohio River basins, Central America.
- bird or bat guano (most people infected by adulthood, <25% develop symptoms)
Symptomatic lung infection with histoplasma
- self limitin, fevers/chills, cough
- CXR: patchy lobar or multinodular lobar infiltrate
Chronic cavitary pulmonary histoplasmosis
older COPD pts get this. progressive, fatal form
Disseminated histoplasmosis.
occurs in kids or immunocompromised
on CXR: Enlarged pulmonary arteries with "pruning" (rapid tapering of distal vessels) indicates...?
pulmonary hypertension
Pt with hypovolemic shock is intubated, mechanically ventilated, and crumps. What happened?
Positive pressure mechanical ventilation increases intrathoracic pressure, decreasing venous return to heart, decreasing preload. In patient with hypovolemic shock, this can rapidly cause circulatory collapse if volume not replaced b/f ventilation!
Pleural calcification = ?
asbestos
Type of reaction in aspirin sensitivity syndrome?
pseudoallergic reaction. i.e. an exaggerated release of vasoactive and inflammatory mediators.
Pathophys behind aspirin sensitivity syndrome?
- B/c aspirin inhibits cyclooxygenase 1,2, arachidonic acid is diverted through 5-lipoxygenase pathway.
- Therefore, leukotrienes accumulate, causing bronchoconstriction, nasal polyps
Tx for aspirin sensitivity syndrome
- avoid NSAIDs
- take leukotriene antagonist
Sx of theophylline toxicity
HA, insomnia, N/V, arrythmias
Causes of theophylline toxicity
cipro & erythro both increase plasma conc.
Possible cellular mechanisms for theophylline toxicity?
- PDE inhibition
- adenosine antagonism
- stimulation of epinephrine
Fat embolism Sx
respiratory distress, Mental status changes, petechiae
- Sx have latent period of 12-72 hrs after initial injury
Respiratory quotients (CO) for various foods?
- Carbs: 1.0
- Protein: 0.8
- Lipid: 0.7
Nonseminomatous germ cell tumors produce what hormones?
hCG & AFP. Occur in young men.
Can occur in anterior mediastinum as a primary site
locally invasive
___ is most specific test for GERD
24 hr pH testing
nL right atrial pressure
4-6 mmHg
nL pulmonary artery pressure
<21/15
nL wedge pressure
6-12 mmHg
Light's criteria
exudate if any true:
- pleural protein : serum protein > 0.5
- pleural LDH : serum LDH > 0.6
- pleural LDH > 2/3 serum normal [45-90]
PAO2 = ?
FiO2 ( Patm - 47) - (PaCO2 / 0.8)