Internal Medicine – Emma Holliday Ramahi

2mm ST elevation
– STE immediately
– T wave inversion 6hrs-yrs
– Q waves last forever
new LBBB (wide, flat QRS)

STEMI on ECG?

Anterior: LAD – V1-4
Lateral: Circumflex – I, aVL, V4-6
Inferior: RCA – II, III, aVF
RV: RCA – V4 on R side ECG!

Localized infarcts on ECG? [Anterior, Lateral, Inferior, RV]

<b>Cath lab</b>
…
<b>Thrombolytics</b> w/in 6hrs
Contra: bleeding, hx hemorrhagic stroke, recent closed head trauma

Emergency reperfusion options? Contraindications?

Sx: HoTN, tachycardia, clear lungs, JVD, and NO pulsus paradoxus.

Txt: vigorous fluid resuscitation, increase preload. DON’T give nitro, will worsen sx

RV infarct Sx? Txt?

ECG
Cardiac enzymes

CP workup?

NSTEMI
Check enzymes q8h x 3 to look for trend

Normal ECG, elevated cardiac enzymes. Dx? Workup?

<b>Myoglobin</b>
Rises 1st, peak 2h, nml by 24h (detect NEW infarct)
<b>CKMB</b>
Rise 4-8, peak 24h , nml by 72h
<b>Troponin I</b>
Rise 3-5h, peak 24-48h, nml by 7-10d

Cardiac enzymes? (3)

<b>M</b>orphine
<b>O</b>2
<b>N</b>itrates
<b>A</b>SA/clopidogrel
<b>B</b>eta-blocker

Coronary angiography w/in 48h

NSTEMI acute txt? Immediate workup?

PCI w/ stenting
CABG if:
– L main dx
– 3 vessel dx
– 2 vessel dx in DM
– &gt;70% occlusion
– pain despite txt
– post-MI angina

DC on:
<b>B</b>eta-blocker (Metoprolol, Labetalol)
<b>A</b>CEI if CHF or LV dysfxn
<b>S</b>tatin
<b>H</b>eparin (while in hospital)
+Nitrates

NSTEMI interventions and discharge Rx?

Exercise ECG
– dc Beta-blockers and CCB before
If + -&gt; Coronary angiography

Unstable angina workup?

Contra:
– old LBBB
– bilat STE
– on Digoxin

Exercise ECHO
Chemical stress test w/ Dobutamine or Adenosine
MUGA

Contraindications to exercise stress test and alternatives?

Multi Gated Acquisition Scan

nuclear medicine test
shows perfusion areas of heart
DC caffeine or Theophyline before

MUGA

Arrhythmias
(most Vfib)

Post-MI complications: Most common cause of death?

Papillary muscle rupture

Post-MI complications: New systolic murmur 5-7d s/p?

Ventricular free wall rupture

Post-MI complications: Acute severe hypotension?

Ventricular septal rupture

Post-MI complications: "step up" in [O2] from RA->RV?

Ventricular wall aneurysm

Post-MI complications: Persistent STE ~1mo later + systolic MR murmur?

AV-dissociation
Valve not opening properly -&gt; blood bounds back to neck
Either V-fib or 3rd degree heart block

Post-MI complications: "Cannon A-waves"?

Dressler’s syndrome

(probably) autoimmune pericarditis
Txt: NSAIDs, ASA

Post-MI complications: 5-10wks later pleuritic CP, low grade temp? Dx? Txt?

Pericarditis

diffuse STE on ECG
Txt: NSAIDs

Young, healthy pt w/ CP: worse w/ inspiration, better w/ leaning forward, friction rub. Dx? Txt?

costochondriasis

Young, healthy pt w/ CP: worse w/ palpation

myocarditis

Young, healthy pt w/ CP: vague w/ hx of viral infxn and murmur

Prinzmetal’s angina

Dx: Ergonovine stimulation test to ID blood vessel spasms
Txt: CCB or Nitrates

Young, healthy pt w/ CP: occurs at rest, worse at night, few CAD risk factors, hx migraine headaches (~female), w/ transient STE during episodes. Dx test? Txt?

Wenkebach/ Mobitz Type I 2nd deg heart block

Progressive, prolongation of the PR interval followed by a dropped beat

3rd deg heart block

regular P-P interval and regular R-R interval, Cannon-a waves on physical exam.

MAT (multifocal atrial tachycardia

varying PR interval with 3 or more morphologically distinct P waves in the same lead. Old person w/ chronic lung dx in pending respiratory failure

Ventricular tachycardia

Unstable pt: cardiovert
Stable pt: Lidocaine, Amiodarone

Three or more consecutive beats w/ QRS <120ms @ a rate of >120bpm Txt?

Wolf-Parkinson-White

Delta wave representing early ventricular activation via the bundle of Kent

Txt: Procainamide
Contra: Beta blokers, Digoxin, CCB (Verapamil, Diltiazem), anything that slows AV node conduction will worsen arrhythmia

Short PR interval followed by QRS >120ms with a slurred initial deflection. Txt? Contraindications?

Atrial flutter

"sawtooth waves"

Unstable pt: cardiovert
Stable pt: Beta blockers, Digoxin

Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm. Txt?

Torsades de pointe

Seen in a pt w/ low Mg and low K. Lithium or TCA OD

prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline

Supraventricular tachycardia

Txt: carotid sinus massage, ice to the face, Adenosine

Regular rhythm w/ a rate btwn 150-220bpm. Sudden onset of palpitations/ dizziness. Txt?

Hyperkalemia

peaked T-waves, wide QRS, short QT and long PR. Renal failure patient/ crush injury/ burn victim.

Cardiac tamponade

"electrical alternans"

Alternate beat variation in direction, amplitude and duration of the QRS in a pt w/ pulsus paradoxus, HoTN, distant heart sounds, JVD

Atrial fibrillation

Dilation of RA predisposes

Txt: rate control w/ Beta blockers or Digoxin

Undulating baseline, no p-waves, irregular R-R interval in a hyperthyroid pt (too much Synthroid), old pt w/ SOB/ dizziness/ palpitations w/ CHF or valve dx. Txt?

Aortic Stenosis

Cause: degeneration
Txt: replace valve

SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvus et tardus

HOCM
younger pt

SEM louder w/ valsalva, softer w/ squatting or handgrip.

Mitral Valve Prolapse

Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting

Mitral Regurgitation

Holosystolic murmur radiates to axilla w/ LAE

VSD

Holosystolic murmur w/ late diastolic rumble in kiddos

PDA

Continuous machine like murmur

ASD

Wide fixed and split S2

Mitral Stenosis

Rumbling diastolic murmur with an opening snap, LA enlargement and A-fib

Aortic Regurgitation

Blowing diastolic murmur with widened pulse pressure.

nitrates, lasix and morphine

Txt for acute pulmonary edema?

myocarditis (Coxsackie B)

young person w/ CHF?

primary pulomnary HTN

R heart cath –&gt; PCWP normal (elevated in CHF)

young pt w/ no cardiomegaly on CXR

EF&lt;55%
ischemic, dilated
Reversible: EtOH w/ abstinence

Systolic CHF

normal EF
Reversible cause: Hemachromatosis w/ phlebotomy

Diastolic CHF

<b>ACE-I</b> improve survival – prevent remodeling by aldo.
<b>B-blocker</b> (metoprolol and carveldilol) improve survival- prevent remodeling by epi/norepi
<b>Spironolactone</b> – improves survival in NYHA class III and IV
<b>Furosemide</b> – improves sxs (SOB, crackles, edema)
<b>Digoxin</b> – decreases sxs and hospitalizations. NOT survival

CHF Txt

Pneumonia

Opacification, consolidation, air bronchograms

COPD

hyperlucent lung fields with flattened diaphragms

CHF

heart > 50% AP diameter, cephalization, Kerly B lines & interstitial edema

Pulmonary abscess
(anaerobes, Staph)

Cavity containing an air- fluid level

Tuberculosis

Upper lobe cavitation, consolidation +/- hilar adenopathy

Mediastinal mass (LAD, CA)
LA enlargement from mitral stenosis

Thickened peritracheal stripe and splayed carina bifurcation

Systemic causes: CHF, nephrotic sx, cirrhosis

Transudative Pleural Effusion

Local causes: parapneumonic, CA

Exudative Pleural Effusion

+ gram or Cx
pH &lt; 7.2
glucose &lt; 60
Txt: drain w/ test tube

Complicated Pleural Effusion

RA
TB
malignant or pulmonary fibrosis

Transudative Pleural Effusion buzzwords: low pleural glucose? high WBC? bloody?

Transudative if:
LDH &lt; 200
LDH eff/serum &lt; 0.6
Protein eff/serum &lt; 0.5
(if any one violated –&gt; exudative)

Light’s Criteria?

Pleural Effusion
Txt: thoracentesis

>1cm fluid on lateral decubitus CXR. Txt?

after surgery
long car ride
hyper coagulable state (cancer, nephrotic)

Risks for PE?

Sxs: pleuritic CP, hemoptysis, SOB, Decr pO2, tachycardia.

Random signs: R heart strain on EKG, sinus tachy, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2.

Westermark Sign on CXR – focus of oligemia (leading to collapse of vessel) seen distal to a pulmonary embolism (PE)

Signs of PE

Give Heparin 1st!
V/Q scan
Spiral CT
pulmonary angiography (gold standard)

Suspect PE, workup?

Heparin/Warfarin overlap
Thrombolytics if severe (NOT if s/p surgery or hemorrhagic stroke)
Surgical thrombectomy if life threatening
IVC filter if contraindications to chronic coagulation

Txt for PE?

Acute Respiratory Distress Syndrome
impaired gas exchange, inflammatory mediator release, hypoxemia

bilateral fluffy infiltrates

Sepsis
gastric aspiration
trauma
low perfusion
pancreatitis

Causes of ARDS?

1) PaO2/FiO2 &lt; 200 (&lt;300 means acute lung injury)
2) Bilateral alveolar infiltrates on CXR
3) PCWP is &lt;18 (r/o cardio cause of pulmonary edema)

Dx criteria for ARDS?

mechanical ventilation w/ PEEP

Txt for ARDS?

low FVC, low FEV1 -&gt; <b>low FEV1/FVC</b>
high TLC
high RV
DLCO reduced in emphysema 2/2 alveolar destruction-&gt; more space

Ex: COPD, emphysema, asthma (FEV1 improves &gt;12% w/ bronchodilator),

Obstructive lung dx PFTs?

low FVC, low FEV1 -&gt; <b>normal FEV1/FVC</b>
low TLC
low RV
DLCO reduced in ILD 2/2 fibrous thickening distance

Ex: interstitial lung dx (sarcoid, silicosis, asbestosis), structural (obesity, MG/ALS, phrenic nerve paralysis, scoliosis)

Restrictive lung dx PFTs?

Productive cough &gt;3mo for &gt;2 consecutive yrs

COPD dx criteria?

1st line = ipratropium, tiotropium
2nd Beta agonists
3rd Theophylline

Goal SpO2: 94-95% bc pts are chronic CO2 retainers so hypoxia is the only drive for respiration

COPD txt? Goal SpO2?

PaO2 &lt;55 (If cor pulmonale, &lt;59)
SpO2&lt;88%

Indications to start O2 (in COPD)?

Change in sputum, increasing SOB

COPD exacerbation criteria?

O2 to 90%
albuterol/ipratropium nebs
PO or IV corticosteroids
Abx: FQ or macrolide

COPD exacerbation txt?

FEV1

Best prognostic factor for COPD?

1) Quitting smoking (can decr rate of FEV1 decline
2) Continuous O2 therapy &gt;18hrs/day

Interventions shown to improve COPD mortality? (2)

Pneumococcus w/ a 5yr booster
annual influenza vaccine

Vaccinations for COPD pt?

Hypertrophic Osteoarthropathy

Next best step… get a CXR
Most likely cause is underlying lung malignancy

New clubbing in a COPD pt?

Mild intermittent asthma
Step 1: SABA (Albuterol)

Asthma: sx 2x/wk, normal PFts. Txt?

Mild persistent asthma
Step 2: SABA + ICS

Asthma: sx 4x/wk, PM cough 2x/mo, normal PFTs. Txt?

Moderate persistent asthma
Step 3: low dose ICS + LABA (Salmeterol)

Asthma: daily sx, PM cough 2x/wk, FEV1 60-80%. Txt?

Severe persistent asthma
Step 4-6: med-high dose ICS + LABA (+ PO steroids)

Asthma: daily sx, PM cough 4x/wk, FEV1 <60%. Txt?

inhaled albuterol + PO/IV steroids
monitor Peak flow rates and blood gas (low PCO2)
Normalizing PCO2 –&gt; impending respiratory failure –&gt; INTUBATE

Asthma exacerbation Mgmt? Sign of impending respiratory failure?

<b>Silicosis</b>
Get yearly TB test! More predisposed. Give INH for 9mo if &gt;10mm

1cm nodues in upper lobes w/ eggshell calcifications. Mgmt?

<b>Asbestosis</b>
Most common cancer is broncogenic carcinoma, but incr risk for mesothelioma

Reticulonodular process in lower lobes w/ pleural plaques. Associations?

<b>Hypersensitivity Pneumonitis</b> = "farmer’s lung"

Patchy lower lobe infiltrates, thermophilic actinomyces.

<b>Sarcoidosis</b>
Also hypercalcemia 2/2 increased macrophages making vitamin D

Dx: biopsy – non-caseating granuloma
Txt: steroids

Hilar LAD, ↑ACE erythema nodosumm*. Dx? Txt?

Ophthalmology -&gt; uveitis conjunctivitis in 25%

Important referral for pt w/ sarcoidosis?

Pt &lt;4oyo
size &lt;3cm
well circumscribed
popcorn calcification = hamartoma (most common)
concentric calcification = old granuloma

Mgmt: CHR or CT q2mo to monitor for growth

Characteristics of benign pulmonary nodules? Mgmt?

smoker
older pt
size &gt;3cm
eccentric, spiculated calcification

Mgmt: open lung bx, remove nodule

Characteristics of malignant pulmonary nodules?

lung CA

A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated PNA or lung collapse

<b>Adenocarcinoma</b>

Occurs in scars of old PNA

Most common lung CA in nonsmokers?

AdenoCA (peripheral) –&gt; liver, bone, brain, adrenals

Lung CA mets?

<b>Squamous cell carcinoma</b>

paraneoplastic syndrome 2/2 PTHrP secretion -&gt; low PO4, high Ca

Pt w/ nephrolithiasis, constipation, malaise, low PTH, central lung mass?

exudative
high hyaluronidase

Characteristics of AdenoCA pleural effusion?

Superior Sulcus Syndrome from <b>small cell lung carcinoma</b> (central CA)

Pulmonary patient with shoulder pain, ptosis, constricted pupil (mitosis), and facial edema?

Lambert Eaton Syndrome from <b>small cell lung carcinoma</b>. Abs to pre-synaptic Ca channels

Patient with ptosis better after 1 minute of upward gaze?

SIADH from <b>small cell lung carcinoma</b>. Produces euvolemic hyponatremia.
Txt: Fluid restriction +/- 3% saline in &lt;112

Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD? Txt?

<b>Large Cell Carcinoma</b>

Peripheral CA
more likely to cause cavitation
highly metastatic

CXR showing peripheral cavitation and CT showing distant mets?

NSCLC easier to resect
SCLC more sensitive to chem/rads

Which lung cancer has a better prognosis, NSCLC or SCLC?

Crohn’s disease

mimics appendicitis
Fe deficiency

IBD involving the terminal ileum?

Ulcerative Colitis

Rarely ileal backwash but never higher

Continuous IBD involving the rectum?

Pyoderma gangrenosum

Assoc w/ Crohn’s dx
Txt: address Crohn’s, no I&amp;D or Abx

Ulcerative Colitis

PSC increases risk of cholangioCA

IBD w/ increased for Primary Sclerosing Cholangitis (PSC)?

fistulae – Crohn’s, give Metronidazole
granulomas on bx – Crohn’s
transmural inflam – Crohn’s
high risk CRC – UC
pANCA – UC

IBD with: fistulae? granulomas on bx? transmural inflam? high risk CRC? pANCA?

Crohn’s Disease

Smokers have a higher risk of which IBD?

Txt: ASA, sulfasalzine to maintain remission.
Corticosteroids to induce remission.
For CD, give metranidazole for ANY ulcer or abscess.
Azathioprine, 6MP and methotrexate for severe dx

IBD Txt?

Alcoholic Hepatitis

AST>ALT (2x) + high GGT?

Viral Hepatitis

ALT>AST & in the 1000s?

Ischemic Hepatitis ("shock liver")

AST and ALT in the 1000s after surgery or hemorrhage?

Obstructive (stone/cancer)
Dubin’s Johnsons, Rotor

Elevated direct bili?

Hemolysis
Gilbert’s, Crigler Najjar

Elevetated indirect bili?

Bile duct obstruction, if IBD -&gt; PSC

Elevated alk phos and GGT?

Paget’s disease

Sx: incr hat size, hearing loss, HA
Txt: Bisphosphonates

Elevated alk phos, normal GGT, normal Ca? Txt?

Primary Biliary Cirrhosis

Txt: bile resins
More common w/ UC

Antimitochondrial Ab? Txt?

<b>Autoimmune Hepatitis</b>

Txt: steroids

ANA + antismooth muscle Ab? Txt?

<b>Barium swallow</b> – best 1st test
<b>Endoscopy</b> – next best test, can be dx and allow for bx of suspicious masses or tx in dilation of peptic strictures or injecting botox for achalasia.

<b>Manometry</b> – achalasia.
<b>24 pH monitoring</b> – GERD

If HIV+ (CD &lt;100) or otherwise immunocompromised, remember Candida, CMV and HSV esophagitis

Dysphagia workup?

Achalasia

Txt: CCB, nitrates, botox, or heller myotomy
Assoc w/ Chagas dx and esophageal cancer.

Dysphagia to liquids & solids?

Diffuse esphogeal spasm

Txt: CCB or nitrates

Dysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regure?

GERD

Most sensitive test is 24-hr pH monitoring. Do endoscopy if "danger signs" present.
Txt: behav mod 1st, then antacids, H2 block, PPI.

Epigastric pain worse after eating or when laying down cough, wheeze, hoarse? Workup? Txt?

<b>Boerhaave’s Sx – Esophageal Rupture</b>

Next best test – CXR, gastrograffin esophagram. NO edoscopy
Txt: surgical repair if full thickness

If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase. Workup? Txt?

Gastric Varices

Txt: <b>Endoscopic sclerotherapy or banding</b>. Don’t prophylactically band asymptomatic varices. Give <b>Beta blockers</b>

If in hypovolemic shock?
do ABCs, NG lavage, medical tx w/ Octreotide or Somatostatin. Balloon tamponade only if you need to stablize for transport

If gross hematemesis unprovoked in a cirrhotic w/ pHTN? Txt? Acute Mgmt?

Esophageal Carcinoma

Squamous cell CA in smoker/drinkers in the middle 1/3.
AdenoCA in ppl with long standing GERD in the distal 1/3.

Workup: barium swallow -&gt; endoscopy w/ bx -&gt; staging CT

If progressive dysphagia and weight loss? Workup?

#1 cause is <b>non-ulcerative dyspepsia</b>. Dx of exclusion. Txt: H2 blocker and antacid.

• If GERD sx, tx empirically w/ PPI for 4 wks then re-evaluate.
• If biliary colic sxs predominate -&gt;RUQ sono
• If hx of stones or drinking, check amylase and
lipase, CT scan best imaging for pancreatitis.

Mid-epigastric pain

&gt;50 y/o
hx of smoking and drinking
recent unprovoked weight loss
odynophagia
Fe-def anemia
melena

Danger sxs warranting endoscopic work up in pt w/ mid-epigastric pain?

Gastric Ulcers

– <b>Double-contrast barium swallow</b> shows punched out lesion w/regular margins.
– <b>EGD w/ bx</b> – H. pylori, malign, benign.

– Txt: Sucralfate, H2-block, PPI. Surgery if ulcer remains s/p 12wks txt.

Mid-epigastric pain worse w/ eating and hx of NSAID and/or steroid use? Workup? Txt?

Duodenal Ulcers

– 95% assoc w/ H. pylori. Dx: blood, stool or breath test but EGD w/ bx (CLO test) can also r/o CA.
– Txt: Healthy pts &lt;45yo can try H2 block or PPI
– H. pylori txt: PPI, Clarithromycin + Amoxicillin for 2wks

Mid-epigastric pain better w/ eating? Workup? Txt?

Zollinger-Ellison Syndrome

– Best test is <b>secretin stim test</b> (finding high gastrin)
– Txt: resection if localized, long term PPI if metastatic.
– Look for pituitary and parathyroid problems (MEN1)

Suspect this if Mid-epigastric pain/ulcers don’t improve w/ eradication of H.pylori, large, multiple or atypically located ulcers? Workup? Txt?

Acute Cholecystitis

US -&gt; thickened wall
HIDA-&gt; shows non-visualization of GB.
Txt: cholecystectomy. If too unstable, can place a percutaneous cholecystostomy

RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy’s. Normal labs. Workup shows? Txt?

Choledocolithiasis

– Same sxs as acute cholecytitis
– US will show stones.
– Txt: cholecystectomy or ERCP to remove stone

RUQ pain radiating to back, n/v, fever, worse after fatty food, +Murphy’s. Labs: obstructive jaundice, high bili, alk phos Txt?

Ascending Cholangitis

Txt: fluids, broad spec Abx, ERCP and stone removal

RUQ pain, fever, jaundice (+hypotension and AMS)? Txt?

Rare
Primary sclerosing cholangitis (Ulcerative colitis)
Liver flukes
Thorothrast exposure
Txt: surgery

Risk factors for cholangiocarcinoma?

Acute Pancreatitis

– most 2/2 Gallstones &amp; ETOH
– Amylase &gt;1000 means stone
– Dx: CT scan imaging
– Txt: NG, NPO, IVF, Observe
– Prognosis: worse if old, WBC&gt;16K, Glc&gt;200, LDH&gt;350, AST&gt;250… drop in Hct, decr calcium, acidosis, hypox
– Complications: pseudocyst (no cells!), hemorrhage, abscess, ARDs

Mid-epigastric pain radiating to the back, N/V, Turner’s sign, Cullen’s sign. Labs: incr amylase & lipase Txt? Complications?

Chronic Pancreatitis

Can cause splenic vein thrombosis

Chronic mid epigastric pain, DM, malabsorption (steatorrhea)? Complication?

<b>Pancreatic adenoCA</b>
*Usually don’t have sxs until advanced, only if in head of pancreas
– Dx: EUS and FNA biopsy
– Tx: Whipple if: no mets outside abdomen, no extension into SMA or portal vein, no liver mets, no peritoineal mets.

Courvoisier’s sign = large, nontender GB, itching and jaundice Trousseau’s sign = migratory thrombophlebitis. Dx? Txt?

Hemachromatosis

Sx: hepatitis, DM, golden skin

High Fe, low ferritin, low Fe binding capacity?

Wilson’s Disease

Sx: hepatitis, psychiatric sxs (basal ganglia), corneal deposits

Low ceruloplasmin, high urinary Cu?

NS if HoTN, tachycardia
Fecal WBC – tests for invasion
stool Cx

Most commonly – viral, Rotavirus in daycare, Norwalk, cruise ships
Picnic – B. cereus, Staph, sx after 1-6hrs
Hx Abx use – stool for C. diff antigen

Diarrhea workup? Most commonly? Picnic? Hx Abx use?

EHEC
Shigella
Vibrio parahaemolyticus,
Salmonella
Entamoeba histolytica

Bloody diarrhea?

Sprue
Chronic pancreatitis
Whipple’s dx
CF if young person

Foul smelling, bulky diarrhea in malnourished pt?

consider carcinoid syndrome (metastatic)
*Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) -&gt; Dementia, Dermatitis, Diarrhea.

Diarrhea + flushing, tachycardia/ hypotension

Strep Pneumo
H. Influenza
N. meningitidis

Empiric txt: Ceftriaxone and Vancomycin

Most common meningitis bugs? Empiric txt?

Lysteria
Txt: Ampicillin

Common extra meningitis bug in old and young pts? Txt?

Staph aureus
Txt: Vancomycin

Common extra meningitis bug in pts w/ brain surgery?

RIPE + steroids

TB meningitis txt?

IV Ceftriaxone

Lyme meningitis txt?

Empiric Abx (+steroids if you think bacterial)
Exam for high ICP
LP, Gram stain

1st steps in meningitis management?

High protein
low glucose
&gt;1000 WBC (diagnostic)

LP bacterial meningitis?

Ppx w/ Rifampin

Advice for roommate of the kid in the dorms who has bacterial meningitis and petechial rash?

Strep pneumoniae

Txt: Macrolides, Fluoroquinolones, 3rd gen cephalosporine

Most common pneumonia bug? Empiric txt?

Atypicals: Mycoplasma
assoc w/ cold agglutinins
Txt: Macrolides, Fluoroquinolones, Doxycycline

Most common pneumonia bug in young healthy people? Txt?

HCAP:
Pseudomonas
Kelbsiella
E. coli
MRSA

Txt: Pip/Tazo, Impipenem + Vancomycin

Most common pneumonia bugs in pt’s hospitalized w/in 3mo or in the hospital for >5-7d? Txt?

H influenzae
Txt: 3rd gen Cephalosporin

Most likely pneumonia bug in old smokers w/ COPD? Txt?

Klebsiella
Txt: 3rd gen Cephalosporin

Most likely pneumonia bug in alcoholic w/ currant jelly sputum? Txt?

Legionella, aka "PNA+"
Dx: urine antigen
Txt: Macrolides, Fluoroquinolones, Doxycycline

Most likely pneumonia bug in old man w/ HA, confusion, diarrhea, and abdominal pain? Txt?

MRSA
Txt: Vancomycin

Most likely pneumonia bug in a pt who just had the flu? Txt?

Q fever (Coxiella burnetti – tick feces, cow placenta -&gt; aerosolized)
Txt: Doxycyline

Most likely pneumonia bug in farmer who just delivered a baby cow and now has vomiting and diarrhea? Txt?

Franciella tularensis
Txt: Streptomycin, Gentamicin

Most likely pneumonia bug in a pt who just skinned a rabbit? Txt?

PPD
&gt;15mm, &gt;10mm if prison, healthcare, nursing home, DM, ETOH, chronically ill, &gt;5mm for AIDS, immune suppressed

If + PPD –&gt; do CXR.

TB screening test? Next step if +?

+ CXR –&gt; acid fast stain of sputum (if negative x3 clear)
– CXR –&gt; need negative acid fast stain of sputum x3

Next step after +PPD and +CXR?

RIPE x6mo (12mo for meningitis, 9mo if pregnant)
<b>R</b>ifampin
<b>I</b>NH
<b>P</b>yrazinamide
<b>E</b>thambutol

Txt for tuberculosis?

children &lt;4yo

Ppx: INH x9mo (+vit B6)

Who should get chemoprophylaxis after a known TB exposure? What is the ppx?

<b>R</b>ifampin – orange/red fluids, +CPY450
<b>I</b>NH – periph neuropathy, sideroblastic anemia, hepatitis w/ mild LFT bump
<b>P</b>yrazinamide – benign hyperuricemia
<b>E</b>thambutol – optic neuritis, other color vision abnormal

RIPE side effects?

Staph aureus

Most common bug for acute endocarditis?

Viridens group strep
Mitral valve

Most common bug for subacute endocarditis of native valve? Which valve?

Staph aureus
Tricuspid valve
R side murmurs worse w/ inspiration

Most common bug for endocarditis in IVDU? Murmur features?

blood Cx
TTE then TEE
Major and Minor criteria

Dx of endocarditis?

CHF is #1 cause of death
septic emboli to lungs or brain

Complications of endocarditis?

Strep viridens txt: PCN x4-6wk
Staph txt: Nafcillin + Gentamicin or Vancomycin

Endocarditis abx?

Prosthetic valve
Hx of endocarditis
Uncorrected congenital lesion

Who gets ppx for endocarditis?

colonoscopy
assoc w/ CRC

Strep bovis bacteremia mgmt?

<b>Acute retroviral syndrome</b>
(looks like mono)

2-3 wks s/p HIV exposure but
3wks before seroconversion, ELISA neg

Fever, fatigue, LAD, HA, pharyngitis, n/v/d +/- aseptic meningitis

HIV

A young patient with new/bilateral Bell’s Palsy?

that means they have sex with lots of strangers and are at risk for HIV

Patient "travels a lot for work"?

HIV

A young patient with unexplained thrombocytopenia and fatigue?

HIV

A young patient with unexplained weight loss >10%?

HIV

A young patient with thrush, Zoster, or Kaposi sarcoma?

CD4 &lt; 350 or viral load &gt;55,000 (except preggos get tx &gt;1,000 copies)

When to start HAART?

Zidovudine

HIV Rx SE: GI, leukopenia, macrocytic anemia

Didanosine

HIV Rx SE: Pancreatitis, peripheral neuropathy

Indinavir

HIV Rx SE: Nephrolithiasis and hyperbilirubinemia

Efavirenz
(nNRI)

HIV Rx SE: Sleepy, confused, psycho

Abacavir
DC drug and never use again!

HIV Rx SE: hypersensitivity rash, F, N/V, muscle aches, SOB in 1st 6wks

AZT, lamivudine and nelfinavir for 4wks

Post-exposure ppx (HIV)?

PCP
Dx: Bronchoscopy w/ BAL to visualize bug

HIV+ patient with DOE, dry cough, fever, chest pain, elevated LDH? CXR: "bilat diffuse symmetric interstitial infiltrates" How to Dx?

1st line: Trim-Sulfa
2nd line: Trim-Dapsone or Primaquine-Clindamycin or Pentamidine

+ Steroids when PaO2&lt;70, A-a gradient &gt;35

Txt for PCP?

CD4&lt;200 (can dc if &gt;200 x6mo)

1st: Trim-Sulfa
2nd: Dapsone
3rd: Atovaquone
4th: aerosolized Pentamidine (~&gt; pancreatitis)

When to give ppx for PCP?

CMV
MAC
Cryptosporidium

HIV pt (CD4<50) w/ diarrhea? (3)

Sx: bloody diarrhea
Dx: colonoscopy w/ bx -&gt; intranuclear inclusions
Txt: Gancyclovir (~&gt; neutropenia), Foscarnet (~&gt; renal tox)

CMV in HIV pt? Dx? Txt?

MAC
Dx: bx negative, exclude alternative causes
Txt: Clarithromycin and Ethambutol +/- Rifampin

HIV pt (CD4<50) w/ diarrhea, wasting, fevers, night sweats? Dx? Txt?

CD4&lt;50
Ppx: Azithromycin weekly

MAC ppx in HIV pt?

transmitted via dog poo, swimming pool
Sx: watery diarrhea w/ mucus
Dx: oocysts in stool are acid fast

Cryptosporidium in HIV pt? Dx?

Toxoplasmosis

Txt: empiric <b>pyramethamine sulfadiazine</b> (+ folic acid) x6wks. If no improvement in 1wk, consider biopsy for CNS lymphoma.

HIV pt w/ multiple ring enhancing lesions on CT? Txt?

CNS lymphoma

Assoc w/ EBV infxn of B- cells
Txt: HAART.

HIV pt w/ one ring enhancing lesion on CT? Txt?

HSV encephalitis (predisposed for <b>temporal lobe</b>)

Txt: Acyclovir ASAP!

HIV pt w/ seizure + deja vu aura and 500 RBCs in CSF?

Strep pneumo

Also worry about Cryptococcus
Dx: +India ink
Txt: ampho IV x2wks then fluconazole maintenance

Most common meningitis in HIV pt? Workup?

sounds like MS
<b>PML</b> – JC polyomavirus demyelinates at grey-white jxn.
Dx: Brain bx

HIV pt w/ hemisensory loss, visual impairment, Babinski? Dx?

AIDS-Dementia complex

Check serum, CSF and MRI to r/o treatable causes

HIV pt w/ memory problems or gait disturbance? Workup?

Medical Emergency!
NEVER do a DRE – may induce bacteremia across gut wall

[single temp &gt; 101.3 or sustained temp &gt;100.4 x1hr. ANC &lt; 500]

Neutropenic fever cautions?

[single temp &gt; 101.3 or sustained temp &gt;100.4 x1hr. ANC &lt; 500]

Mucositis 2/2 chemo causes bacteremia (usually from gut)

Bugs: Pseudomonas or MRSA (if port present)

Etiology of neutropenic fever? Most common bugs?

Blood cx
Start <b>3rd or 4th gen cephalosporin</b> (ceftazidime or cefipime)

+ <b>vanc</b> if line infxn suspected or if septic shock
+ <b>amphoB</b> if no improvement and no source found in 5 days.

Neutropenic fever workup and mgmt?

Lyme
Txt: Doxycycline
(Amoxicillin for &lt;8yo)
Heart or CNS dx needs IV ceftriaxone

Target rash, fever, CNVII palsy, meningitis, AV heart block? Txt?

Rocky Mtn Spotted Fever – Rickettsia
"Rickettsia at wRists"
Txt: Doxycycline even if &lt;8yo

Rash @ wrists & ankles (palms & soles), fever and HA? Txt?

Ehrlichiosis

Dx: morulae intracellular inclusions
Txt: Doxycycline

Tick bite, no rash, myalgia, fever, HA, ↓plts and WBC, ↑ALT? Dx? Txt?

Nocardia (aerobic)
Txt: trim-sulfa

Immune suppressed, cavitary lung dx (purulent sputum) + weight loss, fever. Gram + aerobic branching partially acid fast? Txt?

Actinomyces (anaerobic)
Txt: high dose PCN x6-12wks

Neck or face infection w/ draining yellow material (+sulfur granules). Gram+ anaerobic branching? Txt?

Check osmolarity
Check volume status

Txt:
– Correct w/ NS if hypoV
– 3% saline only if seizures or [Na] &lt; 120
– fluid restrict + diuretics

Don’t correct faster than 12-24mEq/day or else <b>Central Pontine Myelinolysis</b>

Hyponatremia workup? TxT?

CHF
nephrotic
cirrhotic

Hypervolemic hypoNa causes?

diuretics or vomiting + free water

Hypovolemic hypoNa causes?

SIADH (check CXR if smoker)
Addison’s (adrenal insufficiency)
Hypothyroidism

Euvolemic hypoNa causes?

Replace water w/ D5W or other hypotonic fluid

Don’t correct faster than 12-24mEq/day or else <b>cerebral edema</b>

Hypernatremia txt?

HypoCa

tetany perioral tingling Chvostek (CNVII reflex) Troussaeu (BP cuff-> spasms) prolonged QT interval

HyperCa

■ kidney STONES ■ psychic MOANS ■ abdominal GROANS ■ achy BONES Shortened QT interval

hypoK
Txt: K+ (make sure pt can pee) max 40mEq/hr

paralysis, ileus, ST depression, U waves? Txt?

hyperK
Txt:
Ca-gluconate,
then insulin + glc,
Kayexalate,
Albuterol and Sodium bicarb,
Last resort = dialysis

peaked T waves, prolonged PR and QRS, sine wavesTxt?

Metabolic alkalosis

Check urine Cl
if [Cl]&gt;20 +HTN – hyperaldo (Conns), if normoTN think Barter’s or Gittlemans
if [Cl]&lt;20 – think vomiting, NG suction, antacids, diuretics

HCO3 high pCO2 high Next test? Ddx?

Respiratory alkalosis
hyperventilation from anxiety, high ICP, fever, pain, ASA

pCO2 low HCO3 low Ddx?

Metabolic acidosis

Check Anion gap (Na-Cl-HCO3)
Gap -&gt; MUDDLES
non-gap -&gt; diarrhea, diuretic, RTA (I, II, IV)

HCO3 low pCO2 low Next test? Ddx?

Respiratory acidosis

hypoventilation from opiates, brainstem injury, ventilation problems

pCO2 high HCO3 high Ddx?

Distal tubule, can’t excrete H+
Cause: Lithium/AmphoB, analgesics, SLE, Sjogrens, SCA, hepatitis
Dx: Urine pH&gt;5.4, <b>hypoK</b>, stones
Txt: replete K, PO bicarb

Type I RTA Causes? Dx/presentation? Txt?

Proximal tubule, can’t reabsorb HCO3
Cause: Fanconi sx, myeloma, amyloidosis, vitD deficiency, autoimmune dx
Dx: <b>hypoK</b>, osteomalacia
Txt: replete K, mild diuretic, NO bicarb

Type II RTA Causes? Dx/presentation? Txt?

hyperRenin, hypoAldo
Cause: DM (&gt;50%), Addison’s dx (adrenal insufficiency), SCA, aldo deficiency
Dx: <b>hyperK</b>, hyperCl, high urine [Na] even w/ salt restriction
Txt: <b>Fludrocortisone</b>

Type IV RTA Causes? Dx/presentation? Txt?

hereditary or acquired proximal tubule dysfxn
defective transport of glucose, AA, Na, K, PO4, uric acid, bicarb
-&gt; Type II RTA, replete K, mild diuretic

Fanconi’s anemia

&gt;25% or 0.5 rise Cr over baseline
Workup:
BUN/Cr -&gt; prerenal if &gt;20/1
Urine Na and Cr -&gt; prerenal if FENA&lt;1%
If pt on diuretic measure FENurea -&gt; prerenal if &lt;35%

ARF? Workup?

fluids and treat underlying issue (reason for low renal perfusion)

Prerenal ARF Txt?

<b>AEIOU</b>
<b>A</b> – acidosis
<b>E</b> – electrolyte imbalance (esp K&gt;6.5)
<b>I</b> – Intoxication (esp antifreeze, Li)
<b>O</b> – overloaded V -&gt; CHF sx or pulmonary edema
<b>U</b> – uremia -&gt; pericarditis, AMS
NOT for high Cr or oliguria alone!

Indications for emergent dialysis?

Intrinsic:
<b>ATN</b>

Txt: fluids, avoid nephrotox, dialysis if indicated

Muddy brown casts in a pt w/ ampho, aminoglycosides, statins, cisplatin or prolonged ischemia? Txt?

Intrinsic:
<b>AIN</b>

Txt: Stop offending agent. Add steroids if no improvement.

Protein, blood and Eos in the urine + fever and rash who took Trim-sulfa 1-2wks ago? Txt?

Intrinsic:
<b>Rhabdomyolysis</b>

1st test is check [K+] or EKG. Txt: bicarb to alkalinize urine to prevent precipitation

Army recruit or crush victim w/ CPK of 50K, +blood on dip but no RBCs? Txt?

Intrinsic:
<b>Ethylene glycol intox</b>

Txt: dialysis or NaHCO3 if pH&lt;7.2

Enveloped shaped crystals on UA? Txt?

Intrinsic:
<b>Contrast nephropathy</b>

Prevent by hydrating before or giving bicarb or NAC

Bump in creatinine 48-72hrs s/p cardiac cath or CT scan?

#1 cause of death <b>CVD</b> -&gt; goal LDL&lt;100
<b>HTN</b> (2/2 ↑aldo), fluid retention -&gt; <b>CHF</b>
<b>Normochromic normocytic anemia</b> -&gt; loss of EPO
<b>↑K, ↑PO4, ↓Ca</b>↓Ca* (leads to 2ndary hyperPTH)
↑PO4 leads to precip of Ca into tissues -&gt; <b>renal osteodystrophy and calciphylaxis</b>s* (skin necrosis)
<b>Uremia</b> -&gt; confusion, pericarditis, itchiness, increased bleeding 2/2 platelet dysfxn

Complications of CKD?

Uremia
bleeding 2/2 platelet dysfxn

confusion, pericarditis, itchiness, increased bleeding

Bladder/Kidney cancer until proven otherwise

painless hematuria?

bladder CA or hemorrhagic cystitis (cyclophosphamide)

"termina hematuria" + tiny clots?

Glomerular source

Dysmorphic RBCs or RBC casts?

Proteinuria (but &lt;2g/24hrs)
hematuria
edema
azotemia

Definition of nephritic syndrome?

Berger’s Dz (IgA nephropathy)

Hematuria 1-2 days after runny nose, sore throat & cough?

Post-strep GN

Sx: smoky/cola urine
Dx: best 1st test is ASO titer
EM: Subepithelial IgG humps

Hematuria 1-2 weeks after sore throat or skin infxn?

Goodpasture’s Syndrome

Abs to collagen IV

Hematuria + Hemoptysis?

Alport Syndrome

XLR mutation in collagen IV

Hematuria + Deafness?

Henoch-Schonlein Purpura

IgA. Supportive tx +/- steroids

Hematuria in Kiddo s/p viral URI w/ Renal failure + abd pain, arthralgia and purpura? Txt?

HUS

E.Coli O157H7 or Shigella. Don’t tx w/ ABX (releases more toxin)

Hematuria in Kiddo s/p hamburger and diarrhea w/ renal failure, MAHA and petechiae?

TTP

Txt: plasmapheresis. DON’T give platelets.

vs. DIC
PT and PTT are normal in HUS/TTP.

Hematuria in Cardiac patient s/p ticlopidine w/ renal failure, MAHA, ↓plts, fever and AMS? Txt?

Wegener’s Granuolmatosis

Dx: Most accurate test is bx
Txt: steroids or cyclophosphamide.

c-ANCA, kidney, lung and sinus involvement? Txt?

Churg Strauss

Dx: Best test is lung bx
Txt: Cyclophosphamide

p-ANCA, renal failure, asthma and eosinophilia? Txt?

Polyarteritis Nodosa

Affects small/med arteries of every organ except the lung!
Txt: cyclophosphamide

p-ANCA, NO lung involvment, Hep B? Txt?

CT for kidney stones

Best test for pt w/ flank pain radiating to groin + hematuria?

Calcium oxalate stones
Txt: HCTZ

Most common type of kidney stones? Txt?

Cysteine stones
Can’t resorb certain AA

Kid w/ family hx of stones?

Struvite stones = Mg/Al/PO4

Proteus
Staph
Pseudomonas
Klebsiella

Kidney stones in pt w/ chronic indwelling foley and alkaline pee?

Uric Acid stone

Txt: alkalinize urine + hydration

Kidney stones in pt w/ leukemia being treated w/ chemo? Txt?

Pure oxylate stone

Ca not reabsorbed by gut (pooped out)

Kidney stones in pt s/p bowel resection for volvulus?

&lt;5mm – will pass spontaneously, hydrate
&gt;2cm – open or endoscopic surgical removal
5mm-2cm – extracorporal shock wave lithotripsy

Txt for kidney stones of different sizes?

Repeat UA test in 2 weeks, then quantify w/ 24hr urine

Best 1st test for pt w/ proteinuria?

&gt;3.5g protein/24h
hypoalbuminemia
edema
hyperlipidemia (fatty/waxy casts)

Definition of nephrotic syndrome?

Minimal Change Disease

Fusion of foot processes
Txt: steroids

Most common nephrotic sx in kids? Txt?

Membranous Nephropathy

thick capillary walls w/ subepi spokes

Most common nephrotic sx in adults?

FSGS

Mesangial IgM deposits
Limited response to steroids

Nephrotic syndrome associated w/ heroin use and HIV?

Membranoproliferative GN

tram track BM w/ subbed deposits

Nephrotic sx assoc w/ chronic hepatitis and low complement?

suspect rental vein thrombosis

2/2 peeing out ATIII, protein C and S
Do CT or US ASAP

If nephrotic pt suddenly develops flank pain?

Orthostatic
Bence Jones in multiple myeloma
UTI
pregnancy
fever
CHF

Random causes of proteinuria?

Iron deficiency anemia

hypochromic microcytic anemia

Microcytic anemia MCV = 70, ↓Fe, ↑TIBC, ↓retic, ↑RDW, ↓ferritin

Anemia of chronic disease

Microcytic anemia MCV = 70, ↓Fe, ↓TIBCIBC*, ↓retic, nl ferritin.

Thalassemia
RDW – little variation, suggests genetic cause

Microcytic anemia MCV = 60, ↓RDW

Sideroblastic anemia

May be caused by INH

Microcytic anemia MCV = 70, ↑Fe, ↑ferritin, ↓TIBC

Folate deficiency

Macrocytic anemia MVC = 100, ↓retics, ↑homocysteine, nl methylmelonic acid.

B12 deficiency

Macrocytic anemia MVC = 100, ↓retics, ↑homocysteine, ↑methylmelonic acid

Acanthocytosis (spur cell)
-&gt; Liver dx

Macrocytic anemia MVC = 100

Aplastic Crisis

Sickle Crisis from hypoxia, dehydration or acidosis

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin in Sickle cell kid w/ sudden drop in Hct?

Cold Agglutinins

Destruction occurs in the liver. IgM mediated

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Cyanosis of fingers, ears, nose + recent Mycoplasma infx?

Warm Agglutinins

Destruction in spleen. IgG. Drug rxn or malignancy
Txt: steroids 1st, then splenectomy.

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ sudden onset after PCN, ceph, sulfas, rifampin or Cancer?

Hereditary spherocytosis
(AD loss of spectrin)
Txt: splenectomy.

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Splenomegaly, +FH, bilirubin gallstones, ↑MCHC?

Paroxysmal Nocturnal Hemoglobinuria

Defect in PIG-A. Lysis by complement. Incr risk for aplastic anemia

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ Dark urine in AM, Budd-Chiari syndrome?

G6PDH def

Heinz bodies, Bite cells. Avoid oxidant stress.

Normal MCV, ↑LDH, ↑indirect bilirubin, ↓haptoglobin w/ sudden onset after primiquine, sulfas, fava beans?

ITP

Txt: prednisone 1st. Then splenectomy. IVIG if &lt;10K. Rituximab

A patient walks in with thrombocytopenia: 30 y/o F recurrent epistaxis, heavy menses & petechiae. ↓plts only? Txt?

VWD

Txt: DDAVP for bleeding or pre-op. Replace factor VIII (contains vWF) if bleeding continues.

A patient walks in with thrombocytopenia: 20 y/o F recurrent epistaxis, heavy menses, petechiae, normal plts, ↑ bleeding time and PTTT*? Txt?

Hemophilia

Txt: DDAVP if mild, otherwise replace factors

A patient walks in with thrombocytopenia: 20yo M w/ recurrent bruising, hematuria, and hemarthrosis, ↑ PTT that corrects w/ mixing studies? Txt?

VitK def

↓ II, VII, IX and X. Same for warfarin toxicity.
Txt: <b>FFP</b> acutely + vitK shot

A patient walks in with thrombocytopenia: 50y/o M "meat-a-tarian" just finished 2wks of clinda has hemarthroses & oozing at venipuncture sites? Txt?

Liver Disease. GI bleeding is most common

1st depleted: VII, so PT increases 1st
not depleted: VIII and vWF b/c they are made by endothelial cells.

A patient walks in with thrombocytopenia: 50y/o M "beer-a-tarian" w/ severe cirrhosis? 1st factor depleted? 2 factors not depleted?

Schistocytes!
DIC

Causes: Sepsis, rhabdo, adenocarcinoma, heatstroke, pancreatitis, snake bites, OB stuff, Tx of M3 AML (Auer rods)
Txt: FFP, platelet transfusion, correct underlying d/o

A patient walks in w/ thrombocytopenia and this smear… If PT and PTT are ↑, fibrinogen ↓, D-dimer and fibrin split products ↑? Causes? Txt?

TTP/HUS
Causes: O157:H7, Ticlopidene
Txt: plasmapheresis, NOT platelets

A patient walks in w/ thrombocytopenia and this smear… If PT and PTT are normal? Causes? Txt?

HIT
IgG to heparin bound to PF4
Txt: stop heparin, reverse warfarin w/ vitK, start Lepirudin

7 days post-op, a patient develops an arterial clot. Her platelets are found to be 50% less than pre-op? Txt?

Cancer
Nephrotic sx – pee out ATIII protein C and S preferentially, at risk for RVT

What to look for in someone w/ unprovoked thrombus?

Lupus anticoagulant

What to look for in someone w/ unprovoked thrombus? ↑PTT, multiple SABs, false+ VDRL?

Protein C/S deficiency

What to look for in someone w/ unprovoked thrombus? Skin necrosis after warfarin is started?

Factor V Leiden
V is resistant to C

What to look for in someone w/ unprovoked thrombus? Most common inheritable pro-coag state?

ATIII Deficiency

What to look for in someone w/ unprovoked thrombus? Still clots on heparin?

OCPs/HRT

What to look for in someone w/ unprovoked thrombus? Female smoker >35yo?

OA

Knee pain, DIP involvement no swelling or warmth, worse @ the end of the day, crepetence.

RA

PIP and wrists bilaterally, worse in the AM, low grade fever.

Psoriatic Arthritis.

DIP joint involvement, rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers.

SLE

Symmetric, bilateral arthritis, malar rash, oral ulcers, proteinuria, thrombocytopenia. Arthritis is not erosive or have lasting sequellae.

Septic arthritis

A patient comes in w/ acute swollen painful joint… tap: WBCs >50K

Gonococcal

Cx may be negative. Look also for tenosynovitis and arm pustules.
Txt: <b>Ceftriaxone</b>

Septic arthritis in 30yo who "travels a lot for work"? Txt?

Staph aureus
Txt: <b>Nafcillin or Vancomycin</b>

Septic arthritis in 70yo nun? Txt?

Inflammatory
If no crystals, think RA, ank spon, SLE, Reiter’s

A patient comes in w/ acute swollen painful joint… tap: WBCs 5-50K

Gout – Monosodium Urate

Acute TX? <b>Indomethacin + colchicine</b> (steroids if kidneys suck).
Chronic TX? <b>Probenecid</b> if undersecreter. <b>Allopurinol</b> if overproduc.

Inflammatory arthritis w/ needle shaped, negatively birefringent crystals? Txt?

Pseudogout
Txt: Calcium pyrophosphate

Inflammatory arthritis w/ rhomboid shaped, positively birefringent crystals? Txt?

OA
hypertrophic osteoarthropathy
trauma

A patient comes in w/ acute swollen painful joint… tap: WBCs 200-5K

Normal

A patient comes in w/ acute swollen painful joint… tap: WBCs <200

ANA – peripheral/rim staining.

Ab If negative, rules out SLE?

Anti-dsDNA or Anti-Smith

Ab Most sensitive for SLE?

Anti-histone

Ab Drug induced lupus? (hydralazine).

Anti-Ro (SSA) or Anti-La (SSB)

Ab Sjogren’s Syndrome?

Anti-centromere

Ab CREST syndrome?

Anti-Scl-70, Anti-topoisomerase

Ab Systemic Sclerosis?

Anti-RNP

Ab Mixed connective tissue disease?

RF (against Fc of IgG)
Anti-CCP (cyclic citrullinated peptide)

2 Ab tests for RA?

Leser Trelat sign

Sign of systemic disease

Dermatomyositis

Sign of systemic disease

seborrheic dermatitis

Sign of systemic disease

erythema multiforme

Sign of systemic disease

acanthosis nigricans

Sign of systemic disease

Dermatitis herpetiformis

Sign of systemic disease

Porphyria Cutanea Tarda

Sign of systemic disease

Erythema nodosum

Sign of systemic disease

Necrolytic migratory erythema

Sign of systemic disease

Bullous pemphigoid

Sign of systemic disease

Pemphigus vulgaris

Sign of systemic disease

Behcet’s syndrome

Sign of systemic disease

Acrodermatitis enteropathica
(Zn deficiency)

Dermatitis of Pellagra

Tinea capitis

Actinic keratosis
precursor lesion for squamous cell CA
Txt: 5FU or excision

Kaposi sarcoma

Bacillary angiomatosis

Shave or punch bx then surgical removal (Mohs)

Txt basal cell carcinoma

treat precursor lesions (actinic keratosis or keratoacanthoma)
Txt: Excisional bx at edge of lesion, then wide local excision.
Can use rads for tough locations.

Txt squamous cell carcinoma

Superficial spreading (best prog, most common)
Nodular (poor prog)
Need full thickness biopsy b/c depth is #1 prog
Tx w/ excision
– 1cm margin if &lt;1mm thick,
– 2cm margin if 1-4mm thick
– 3cm margin if &gt;4mm
High dose IFN or IL2 may help

Mgmt for melanoma

Prolactinoma
Sx: amenorrhea/hypoT
Txt: Bromocriptine or Cabergoline even if large (&gt;10mm)

Most common pituitary adenoma? Sx? Txt?

#1 FSH and LH
#2 GR
#3 TSH
#4 ACTH

Order of hormones lost in hypopituitarism?

DI
lack of ADH (or nonfunctional)

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine?

Nephrogenic DI

Txt: HCTZ/amiloride

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p ddAVP? Txt?

Central DI

Polyuria, polydipsia, hyperNa, hyperOsm, dilute urine? Urine Osm still ↓ s/p water deprivation, ↑ w/ DDAVP?

I123 RAIU scan.
If ↑ = Graves
If ↓ = factitious or thyroiditis
1st Txt: propanolol + PTU/MTZ
I123 ablation
surgery (pregnant, children)

See low TSH, high free T3/T4. Next best step? Txt?

PTU + Iodine (Lugol’s sol’n) + propranolol

Thyroid storm txt?

1st: check TSH
if low -&gt; RAIU
if normal -&gt; FNA

Workup for thyroid nodule?

"hot nodule" -&gt; excision or radioactive I131
"cold nodule" -&gt; surgically excise and check pathology

RAIU workup (s/p low TSH)?

Papillary

Most common type of thyroid nodule, spreads via lymph, psammoma bodies?

Follicular
must surgically excise whole thyroid

thyroid nodule that spreads via blood?

Medullary
Assoc w/ MEN2 (look of pho, hyperCa)

Thyroid nodule associated w/ calcifications and amyloidosis?

Anaplastic

Thyroid nodule w/ 80% in 1st yr?

Thyroid lymphoma

Hashimoto’s predisposes you to this type of thyroid nodule?

Suspect Cushing’s
1mg ON dexa suppression test or 24hr urine cortisol
if abnormal, dx Cushing’s
8mg ON dexa suppression test

Osteoporosis, central fat, DM, hirsutism? Best screening test?

adrenal neoplasm vs ectopic ACTH
plasma ACTH
Chest CT if smoker
abdominal CT/DHEAS

Osteoporosis, central fat, DM, hirsutism? No adrenal suppression after 8mg ON dexa? Nest test?

Suspect Adrenal Insufficiency

Cosyntropin stimulation test (60min after 250mcg)

Weakness, hypotension, weight loss, hyperpigmentation, ↑K, ↓Na, ↓pH? Best screening test?

Autoimmune (Addison’s disease)
Txt: NaCl resuscitation, Long term replacement of dexamethasone and fludrocortisone

Most common cause of adrenal insufficiency? Txt?

hypoparathyroidism

Perioral numbness, Chvortek, Trousseau s/p Thyroidectomy, ↓[Ca], ↑[PO4], ↓[PTH]?

hyperparathyroidism

Dx w/ FNA of suspicious nodules. Can use Sestamibi scan.
Tx w/ surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in forearm.

Kidney stones, constipation/abd pain or psychiatric sxs, ↑[Ca], ↓[PO4], ↑vitD, ↑[PTH]? Dx? Txt?

<b>MEN1</b> – pituitary adenoma, parathyroid hyperplasia,
pancreatic islet cell tumor.
<b>MEN2a</b> – parathryoid hyperplasia, medullary thyroid cancer, pheochromocytoma
<b>MEN2b</b> – medullary thyroid cancer, pheochromocytoma, Marfanoid

MEN?

FBGL &gt; 126 x 2
2hr OGTT &gt; 200
random glc &gt; 200 + sxs (polyuria, polydipsia, blurred vision)

Dx of DM?

DKA
Dx: ketones in blood and urine, AGMA, hyperK
Txt: high volume NS + insulin bolus and drip, add K once peeing, add glucose&lt;200

Nausea, vomiting, abdominal pain, Kussmaul respirations, coma w/ BGL=400? Dx? Txt?

HHS
Txt: high volume fluid and electrolytes, may require insulin

Polyuria, polydipsia, profound dehydration, confusion and coma w/ BGL = 1000? Txt?

CVD

Most common cause of death in DM pts?

Heart: LDL&lt;100, BP&lt;130/80
Kidney: microalbuminemia (30-300 in 24hrs), start ACEI
Eye: annual screening for proliferative retinopathy -&gt; vitreous humor/neovasc
Nerves: podiatric exam qyr. Tx gastroparesis w/ metoclopramide or Eythromycin, may get ED, 3rd, 4th, 6th CN palsy

Important screening for DM pts?

80% ischemic
20% hemorrhagic

Most common cause of stroke?

noncontrast CT to r/o hemorrhage
diffusion-weighted MRI best for ischemic, CT can be negative for 1st 48hrs

Best 1st test for stroke? Most accurate test?

TPA w/in 3-4.5hrs
ASA &gt;4.5hrs
Heparin only for those in Afib, basilar clot

Stroke txt w/in 3-4.5hr? later?

stroke w/in 3mo
surgery w/in 2wks
LP w/in 1wk

Contraindications to tPA?

Add dipyridamole or switch to clopidogrel.
Don’t use ticlopidine! (why?)

If pt has stroke while on ASA?

Nimodipine to reduce ischemic stroke from vc (most common cause of M&amp;M)

If pt has SAH?

W/in days or rupture or when &lt;10mm

When to clip an aneurysm?

When occlusion &gt;70% and is symptomatic. (&gt;60% if &lt;60y/o)

When to do endarterectomy?

R MCA stroke

Where’s the lesion? L hemiplegia/hemisensory loss, L homonomous hemianopsia w/ eyes deviated twoards the R + apraxia.

R ACA stroke

Wheres the lesion? L hemiplegia/hemisensory loss in the leg>arm. Confusion, behavioral disturbance.

R Webber’s

Where’s the lesion? L hemiplegia + R ptosis & eye deviated to the right and down

R Benedikt’s

Where’s the lesion? Falling to the L + R ptosis & eye deviated to the right and down.

R Wallenburg (PICA)

Where’s the lesion? L hemisensory loss + Horners + R facial sensory loss.

Major R cerebellar arteries

Where’s the lesion? Vertigo, vomiting, nystagmus and clumsiness with the right arm.

Paramedial branches of the basilar artery

Wheres the lesion? Total paralysis except for vertical eye movements.

Lorazepam + LD of phenytoin.
Then phenobarbitol.
Then anesthesia

Status Epilepticus Txt?

simple if no LOC and complex if LOC (may have lip smacking)
Both can generalize.
Txt: 1st line = carbamazepine or phenytoin. Then valproate or lamotrigine

Partial seizures begin focally. (Arm twitch, de-ja-vu, burning rubber smell)? Txt?

1st line = valproic acid, then lamotrigine, carbamezepine, phenytoin

Generalized seizures txt?

ethosuximide

Absence sz txt?

Absence Seizure.
Tx w/ ethosuxamide

EEG buzzword: 3 Hz spike-and- wave Txt?

Creutzfeldt Jakob.
Dementia + myoclonus

EEG buzzword: Triphasic bursts

Delirium.
Contrast w/ psychosis that has no EEG changes

EEG buzzword: Diffuse background slowing

Infantile spasms.

Tx w/ ACTH. Most are associated w/ mental retardation.

EEG buzzword: Hypsarrhythmia Txt?

Subarachnoid hemorrhage.
Noncon CT 1st!

Acute HA: "Worse headache of my life"

Meningitis.
Abx then CT then LP

Acute HA: + Fever and Nuchal rigidity

consider space occupying lesion (brain tumor)
most important prognostic feature is grade (degree of anaplasia)

Acute HA: deep pain that wakes pt up at night, worse w/ coughing or bending forward

Temporal arteritis
Check ESR, then give steroids, then to temporal artery dx
Can lead to blindness

Acute HA: unilateral pounding, w/ changes in vision and jaw claudication

Pseudotumor cerebri
also assoc w/ OCPs
Normal CT, elevated P on LP
Txt: wt loss, Acetazolamide, then shunt or optic nerve sheet fenestration

Fat lady on minocycline or who takes isotreintoin w/ abducens nerve palsy/diplopia

Guillain-Barre
CSF shows albumino-cytologic dissociation
Campylobacter, HHV, CMV, EBV
Txt: IVIG or plasmapheresis, monitor VC for intubation req

Diarrhea 3wks ago, now areflexia and ascending paralysis? Most likely bug? Txt?

Myasthenia Gravest
1st test: ACh-Ab
Most accurate test: EMG, decrease in muscle fiber contraction
Acute txt: IVIG or plasmapheresis, monitor VC for intubation req
Chronic txt: Pyridostigmine, GCs/Azathioprine, thymectomy (&lt;60yo)
Rx to avoid: Aminoglycosides, beta blockers

Nasal voice, ptosis, dysphagia, respiratory acidosis? Dx? Txt?

Multiple sclerosis
neurodeficits separated by time and space
Dx: MRI, increased T2 at periventricular white matter
Acute txt: steroids (3d IV then 4wk PO), plasma exchange is 2nd line
Chronic txt: IFN-beta1a, beta1b, Glatiramer reduces exacerbations

urinary retention, Babinski on R, episode of double vision 6mo ago? Dx? Txt?

Acute Leukemia on Biopsy

A patient presents w/ fatigue, petechiae, infection bone pain and HSM… If >20% blasts?

ALL. Most common cancer in kids

A patient presents w/ fatigue, petechiae, infection bone pain and HSM… CALLA or TdT?

AML. More common in adults. RF = rads exposure, Down’s, myeloprolif.
M3 has Auer Rods and causes DIC upon tx.

A patient presents w/ fatigue, petechiae, infection bone pain and HSM… Auer rods, MPO, esterase?

Hairy Cell Leukemia. See enlarged spleen but no adenopathy.
Hairy Cells have numerous cytoplasmic projections on smear.
Tx w/ cladribine 5-7day single course

A patient presents w/ fatigue, petechiae, infection bone pain and HSM… Tartate resistant acid phosphatase, ↓monos & CD11 and CD22+?

Danorub, vincris, pred. Add intrathecal MTX for CNS recurrence. BM transplant after 1st remission.

Tx of ALL?

Danorub + araC
If *M3 -&gt; give all trans retinoic acid

Tx of AML?

CML- 9:22 transloc –&gt; tyrosine kinase

Tx w/ imantinib (Gleevec), inhibits tyrosine kinase. 2nd line is bone marrow transplant.
Cx = blast crisis.

A patient presents w/ fatigue, night sweats, fever, splenomegaly and elevated WBCs w/ low LAP and basophilia?

CLL

Asymptomatic elevation in WBCs found on routine exam – 80% lymphs.

If Lymphadenopathy – Stage 0 or 1 need no tx- 12 yrs till death
If Splenomegaly – Stage 2 tx w/ fludrabine
If Anemia, If Thrombocytopenia – Stage 3 or 4 tx w/ steroids

Staging CLL: If LAD? If splenomegaly> If anemia? If thrombocytopenia?

Think Lymphoma

Enlarged, painless, rubbery lymph nodes

"B-symptoms" = poor prognosis along w/ &gt;40, ↑ESR and LDH, large mediastinal LND

Drenching night sweats, fevers & 10% weight loss

Hodgkin’s Lymphoma

Orderly, centripetal spread + Reed Sternberg cells?

Lymphocyte predominant

Hodgkins lymphoma w/ best prognosis?

Non-hodgkin’s Lymphoma

Lymphoma most likely to involve extra nodal sites?

I = 1 node group
II = 2 groups, same side of diaphragm
III = both sides of diaphragm, extension into organ
IV = BM or liver

Lymphoma staging?

Stage I/II get rads
Stage III/IV get ABVD Chemo

Lymphoma txt?

Multiple myeloma
1st test: serum protein electrophoresis – IgG monoclonal spike
Confirmatory test: BM bx showing &gt;10% plasma cells

Txt: if young, BM transplant. If old, melphalan + prednisone. Hydration and Lasix, then Bisphosphonates for hyperCa

Bone pain, "punched out lesions" on x-ray, hyper Ca? Best 1st test? Txt?

Waldenstrom Macroglobulinemia

Dizziness, HA, hearing/vision problems and monoclonal IgM M-spike?

MGUS

No sxs, immunoglobulin spike found on routine exam?

Polycythemia Vera
1st test: EPO, make sure it isn’t secondary (PSG, carboxyHbg)
Txt: scheduled phlebotomy, Hydroxyurea can prevent thromboses

Older pt w/ generalized pruritis and flushing after hot bath. Hct of 60%? Best 1st test? Txt?