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Shelf Exam Review Emma Holliday Ramahi
A patient comes in with chest pain…
• Best 1st test = EKG
• If 2mm ST elevation or new LBBB (wide, flat QRS) STEMI • ST elevation immediately, T wave inversion 6hrs- years, Q waves last forever
Lateral Inferior R ventricular
Circumflex RCA RCA
I, avL, V4-V6 II, III and aVF V4 on R-sided EKG is 100% specific
• Emergency reperfusion- go to cath lab or *thrombolytics if no contraindications • Right ventricular infarct- Sxs are hypotension, tachycardia, clear lungs, JVD, and NO pulsus paradoxus. DON’T give nitro. Tx w/ vigorous fluid resuscitation.
3 vessel dz (2 vessel dz + DM). nitrates. oxygen. nl by 7-10days • Tx w/ morphine. and b-blocker • Do CORONARY ANGIOGRAPHY w/in 48hrs to determine need for intervention. pain despite maximum medical tx. nl by 72hs Peaks 24-48hrs. Check enzymes q8hrs x 3. >70% occlusion. aspirin/clopidogrel. nl by 24 CKMB Troponin I Rise 4-8hrs Rise 3-5hrs Peaks 24 hrs.• Next best test = cardiac enzymes • If elevated NSTEMI. or post-infarction angina • Discharge meds = aspirin (+ clopidogrel for 9-12mo if stent placed) • B-blocker • ACE-inhibitor if CHF or LV-dysfxn • Statin • Short acting nitrates . • PCI w/ stenting is standard. • CABG if: L main dz. Myoglobin Rises 1st Peaks in 2hrs.
do chemical stress test w/ dobutamine or adenosine. Avoid caffeine or theophyline before – Positive if chest pain is reproduced. or hypotension on to coronary angiography . Do Exercise Echo instead. – If pt can’t exercise.• If no ST-elevation and normal cardiac enzymes x3… • Diagnosis is unstable angina. – MUGA is nuclear medicine test that shows perfusion of areas of the heart. ST depression. • Work up– Exercise EKG: avoid b-blockers and CCB before. – Can’t do EKG stress test if old LBBB or baseline ST elevation or on Digoxin.
Dressler’s syndrome. Tx w/ NSAIDs and aspirin. (probably) low grade temp? autoimmune pericarditis. Either V-fib or 3rd • “Cannon A-waves”? degree heart block • 5-10wks later pleuritic CP.Post-MI complications Arrhythmias. . V-fib • MC cause of death? • New systolic murmur 5-7 Papillary muscle rupture days s/p? • Acute severe hypotension? Ventricular free wall rupture • “step up” in O2 conc from Ventricular septal rupture RA RV? • Persistent ST elevation Ventricular wall aneurysm ~1mo later + systolic MR murmur? AV-dissociation.
healthy patient comes in with chest pain… • If worse w/ inspiration. worse at night. w/ transient ST elevation during episodes Prinzmetal’s angina – Dx w/ ergonovine stim test.A young. friction rub & diffuse ST elevation pericarditis • If worse w/ palpation costochondriasis • If vague w/ hx of viral infxn and murmur myocarditis • If occurs at rest. few CAD risk factors and migraine headaches. Tx w/ CCB or nitrates . better w/ leaning forwards.
edu/brokawt/MAT4..medscape.com/ispub/ijpn/volume_4_number_1_43/an_unusual_cause_of_seizures_in_a_10_year_old/seizures-fig1.ispub..lanecc.com/.jpg “varrying PR interval with 3 or more morphologically distinct P waves in the same lead”. “regular P-P interval and regular R-R interval” http://www.jpg Cannon-a waves on physical exam./889392-890621-3206.EKG Buzzwords “Progressive.jpg https://teach. Seen in an old person w/ chronic lung dz in pending respiratory failure . prolongation of the PR interval followed by a dropped beat” img.
Li or TCA OD .www. “Regular rhythm with a ventricular rate of 125-150 bpm and atrial rate of 250-300 bpm” “prolonged QT interval leading to undulating rotation of the QRS complex around the EKG baseline” In a pt w/ low Mg and low K.org/ecg/images/wpw_3a.jpg “Three or more consecutive beats w/ QRS <120ms @ a rate of >120bpm” www.jpg “Short PR interval followed by QRS >120ms with a slurred initial deflection representing early ventricular activation via the bundle of Kent”.emedu.emedu.org/ecg/images/wpw_3a.
www.jpg Renal failure patient/crush injury/burn victim w/ “peaked T-waves. JVD “Undulating baseline. hypotension. amplitude and duration of the QRS complex” in a patient w/ pulsus paradoxus. short QT and prolonged PR..co. no pwaves appreciated.ambulancetechnicianstudy.gif www.org/ecg/images/k_5.“Regular rhythm w/ a rate btwn 150-220bpm. “Alternate beat variation in direction.com/pi/emed/ckb/emergency_medici.emedu.uk/images/SVT.gif .co. distant heart sounds. irregular R-R interval” in a hyperthyroid pt.medscape.uk/images/SVT. widened QRS.” img.” Sudden onset of palpitations/dizziness.ambulancetechnicianstudy. old pt w/ SOB/dizziness/palpitations w/ CHF or valve dz www.
+ parvus et tardus • SEM louder w/ valsalva. • Late systolic murmur w/ click louder w/ valsalva and handgrip. louder w/ squatting. softer w/ squatting • Holosystolic murmur radiates to axilla w/ LAE Aortic Stenosis HOCM Mitral Valve Prolapse Mitral Regurgitation . softer w/ squatting or handgrip. softer w/ valsalva.Murmur Buzzwords • SEM cresc/decresc.
• Holosystolic murmur w/ late diastolic rumble in kiddos • Continuous machine like murmur• Wide fixed and split S2• Rumbling diastolic murmur with an opening snap, LAE and A-fib • Blowing diastolic murmur with widened pulse pressure and eponym parade.
VSD PDA ASD
A patient comes in with shortness of breath… cardiac or pulmonary?
• If you suspect PE (history of cancer, surgery or lots of butt sitting) heparin! • Check O2 sats give O2 if <90% • If signs/sxs of pneumonia get a CXR • If murmur present or history of CHF get echo to check ejection fraction • For acute pulmonary edema give nitrates, lasix and morphine • If young w/ sxs of CHF w/ prior hx of viral infx consider myocarditis (Coxsackie B). • If pt is young and no cardiomegaly on CXR consider primary pHTN
– Right heart cath can tell CHF from pulmonary HTN (how?)
Right Heart Cath
normal EF. dilated • Viral. crackles.CHF • Systolic.improves sxs (SOB.prevent remodeling by aldo. – B-blocker (metoprolol and carveldilol) improve survivalprevent remodeling by epi/norepi – Spironolactone. ETOH.improves survival in NYHA class III and IV – Furosemide. Chagas. • Diastolic. amyloidosis. Idiopathic • Alcoholic dilated cardiomyopathy is reversible if you stop the booze.decreases sxs and hospitalizations. edema) – Digoxin. NOT survival . cocaine.decreased EF (<55%) – Ischemic. • Tx– ACE-I improve survival. heart can’t fill – HTN. hemachromatosis • Hemachromatosis restrictive cardiomyopathy is reversible w/ phlebotomy.
edu/..luc.edu “Cavity containing an airfluid level” http://en..hilar adenopathy” ./Heart/Dscn0008a. consolidation.org/wiki/ “Upper lobe cavitation.uk hmc.wikipedia.edu www. air bronchograms” “hyperlucent lung fields with flattened diaphragms” “heart > 50% AP diameter.meddean.jpg “Opacification. cephalization.psu.luc. consolidation +/. Kerly B lines & interstitial edema” “Thickened peritracheal stripe and splayed carina bifurcation” www.meddean.co.CXR Buzzwords acutemed.
likely parapneumonic.2. cirrhotic • If low pleural glucose? Rheumatoid Arthritis • If high lymphocytes? Tuburculosis • If bloody? Malignant or Pulmonary Embolus – If exudative. cancer. etc. glc < 60): • Insert chest tube for drainage. likely CHF.5 ncbi.gov .Pleural Effusions • Pleural Effusions see fluid >1cm on lat decu thoracentesis! – If transudative.6 Protein eff/serum < 0. – If complicated (+ gram or cx. pH < 7.nlm. nephrotic. – Light’s Criteria transudative if: LDH < 200 LDH eff/serum < 0.nih.
long car ride. IVC filter if contraindications to chronic coagulation.Pulmonary Embolism • High risk after surgery. hyper coagulable state (cancer. tachycardia. – Tx w/ heparin warfarin overlap. Pulmonary angiography is gold standard. give heparin 1st! Then work up w/ V/Q scan. /gr1-midi. sinus tach. ABG w/ low CO2 and O2. tachypnea Decr pO2. nephrotic) – Sxs = pleuritic chest pain.. decr vascular markings on CXR. – If suspected. download. Use thrombolytics if severe but NOT if s/p surgery or hemorrhagic stroke. – Random signs = right heart strain on EKG. wedge infarct. hemoptysis. then spiral CT.consult.jpg .imaging..com/. Surgical thrombectomy if life threatening.
ispub.) Bilateral alveolar infiltrates on CXR 3. trauma.gif • Diagnosis: 1. pancreatitis.) PaO2/FiO2 < 200 (<300 means acute lung injury) 2. inflam mediator release... gastric aspiration.) PCWP is <18 (means pulmonary edema is non cardiogenic) • Treatment: mechanical ventilation w/ PEEP ./ards3_thumbnail. hypoxemia • Causes: – Sepsis. www. low perfusion.ARDS • Pathophys: inflammation impaired gas xchange.com/.
asbestosis. Reduced in Emphysema 2/2 alveolar destruction. Reduced in ILD due to fibrosis thickening distance . MG/ALS. phrenic nerve paralysis.PFTs Obstructive Examples Asthma COPD Emphysema Restrictive Interstitial lung dz (sarcoid.super obese. scoliosis ↓ <80% predicted ↓ <80% predicted Normal ↓ <80% predicted ↓ <80% predicted Nope FVC FEV1 FEV1/FVC TLC RV Improves >12% with bronchodilator DLCO reduced ↓ <80% predicted ↓ <80% predicted ↓ <80% predicted ↑ >120% predicted ↑ >120% predicted Asthma does COPD and Emphysema don’t. silicosis. Structural.
COPD • • • • • • • Criteria for diagnosis? Productive cough >3mo for >2 consecutive yrs Treatment? 1st line = ipratropium. PO or IV exacerbation? corticosteroids. 2nd Beta agonists. 3rd Theophylline Indications to start O2? PaO2 <55 or SpO2<88%. <59 Criteria for exacerbation? Change in sputum. albuterol/ipratropium nebs. Hypoxia is 94-95% instead of 100%? the only drive for respiration. Best prognostic indicator? FEV1 Shown to improve 1. If cor pulmonale.) Continuous O2 therapy >18hrs/day mortality? Why is our goal for SpO2 COPDers are chronic CO2 retainers. tiotropium.) Quitting smoking (can decr rate of FEV1 decline 2. increasing dyspnea Treatment for O2 to 90%. FQ or macrolide ABX. Important vaccinations? Pneumococcus w/ a 5yr booster and yearly influenza vaccine • • .
jpg New Clubbing in a COPDer = Hypertrophic Osteoarthropathy Next best step… get a CXR Most likely cause is underlying lung malignancy .org/lung/files/2009/02/nail-clubbing.Your COPD patient comes with a 6 week history of this… http://cancergrace.
night cough 2x a month and PFTs are normal? Albuterol + inhaled CS • If pt has sxs daily. Watch peak flow rates and blood gas. night cough 4x a week and FEV1 is <60%? Albuterol + inhaled CS + salmeterol + montelukast and oral steroids • Exacerbation tx w/ inhaled albuterol and PO/IV steroids. PCO2 should be low.Asthma • If pt has sxs twice a week and PFTs are normal? Albuterol only • If pt has sxs 4x a week. • Complications Allergic Brochopulmonary Aspergillus . night cough 2x a week and FEV1 is 60-80%? Albuterol + inhaled CS + long-acting beta-ag (salmeterol) • If pt has sxs daily. Normalizing PCO2 means impending respiratory failure INTUBATE.
erythema nodosum. ↑ACE Sarcoidosis. Get yearly TB test!. • Reticulonodular process in Asbestosis. Most common cancer is broncogenic carcinoma. Tx w/ steroids . • Hilar lymphadenopathy. but incr risk lower lobes w/ pleural for mesothelioma plaques.Random Restrictive Lung Dz • 1cm nodues in upper lobes w/ Silicosis. • Patchy lower lobe infiltrates. Give INH for 9mo if >10mm eggshell calcifications. Hypersensitivity Pneumonitis = “farmer’s lung” thermophilic actinomyces. 2/2 ↑ macrophages making vitD – Hypercalcemia? – Important referral? Ophthalmology uveitis conjunctivitis in 25% – Dx/Treatment? Dx by biopsy.
medscape. well circumscribed • Tx w/ CXR or CT scans q2mo to look for growth • Characteristics of malignant nodules: • Do open lung bx and remove the nodule – If pt has risk factors (smoker.com/ar ticle/358433-media . If >3cm.com/ article/356271-media http://emedicine. old).medscape.So you found a pulmonary nodule… • 1st step = look for an old CXR to compare! • Characteristics of benign nodules: – Popcorn calcification = hamartoma (most common) – Concentric calcification = old granuloma – Pt < 40. <3cm. if eccentric calcification http://emedicine.
Mets to liver. hemoptysis. Patient with ptosis better after 1 Lambert Eaton Syndrome from small minute of upward gaze? cell carcinoma. SIADH from small cell carcinoma. cough. Squamous cell carcinoma. bone. brain and adrenals Characteristics of effusion? Exudative with high hyaluronidase Patient with kidney stones. • • • • MC cancer in non-smokers? Adenocarcinoma. Superior Sulcus Syndrome from Small constricted pupil. Ab to pre-syn Ca chan Old smoker presenting w/ Na = 125. moist mucus membranes. repeated pnia or lung collapse. ptosis. High Ca Patient with shoulder pain. constipation and malaise low PTH +Paraneoplastic syndrome 2/2 secretion central lung mass? of PTH-rP. dyspnea.A patient presents with weight loss. Produces Euvolemic hyponatremia. and facial edema? cell carcinoma. Occurs in scars of old pnia Location and mets? Peripheral cancer. no JVD? CXR showing peripheral cavitation andFluid restrict +/. Also a central cancer. Low PO4.3% saline in <112 Large Cell Carcinoma CT showing distant mets? • • • • .
Inflammatory Bowel Disease
• Involves terminal ileum? Crohn’s. Mimics appendicitis. Fe deficiency. • Continuous involving rectum? UC. Rarely ileal backwash but never higher • Incr risk for Primary UC. PSC leads to higher risk of cholangioCA Sclerosing Cholangitis? • Fistulae likely? Crohn’s. Give metronidazole. • Granulomas on biopsy? Crohn’s. • Transmural inflammation? Crohn’s. • Cured by colectomy? UC. • Smokers have lower risk? UC. Smokers have higher risk for Crohn’s. • Highest risk of colon cancer? UC. Another reason for colectomy. • Associated w/ p-ANCA? UC.
Treatment = ASA, sulfasalzine to maintain remission. Corticosteroids to induce remission. For CD, give metranidazole for ANY ulcer or abscess. Azathioprine, 6MP and methotrexate for severe dz.
IBD Images & Complications
http://www.ajronline.org/cgi/con tent-nw/full/188/6/1604/FIG20 studenthealth.co.uk
low Fe Hemachromatosisbinding capacity hepatitis. normal Paget’s disease (incr hat size. Rotor • Elevated I-bili Hemolysis or Gilbert’s.LFT/Lab Buzzwords • AST>ALT (2x) + high GGT Alcoholic Hepatitis • ALT>AST & in the 1000s Viral Hepatitis • AST and ALT in the 1000s after Ischemic Hepatitis (“shock liver”) surgery or hemorrhage • Elevated D-bili Obstructive (stone/cancer) or Dubin’s Johnsons. golden skin • Low ceruloplasmin. low ferritin. DM. normal Ca HA.hepatitis. • Antimitochondrial Ab Primary Biliary Cirrhosis – tx w/ bile resins • ANA + antismooth muscle Ab Autoimmune Hepatitis – tx w/ ‘roids • High Fe. corneal deposits . hearing loss. psychiatric sxs urinary Cu (BG). Crigler Najjar • Elevated alk phos and GGT Bile duct obstruction. high Wilson’s. Tx w/ bisphosphonates. GGT. if IBD PSC • Elevated alk phos.
Infectious Disease .
meningitidis (tx w/ Ceftriaxone and Vanco) . H. N. >1000WBC is diagnostic. Influenza.Meningitis • • • • • • • Most Common bugs? In old and young? Add Lysteria. Roommate of the kid High protein and low glucose support bacterial in the dorms who has bacterial meningitis Rifampin!! and petechial rash? Strep Pneumo. then LP Diagnostic test? +Gram stain. (tx w/ Ampicillin) In ppl w/ brain surg? Add Staph (tx w/ Vanco) Randoms? TB (RIPE + ‘roids) and Lyme (IV ceftriazone) Best 1st step? Start empiric treatment (+ steroids if you think it is bacterial). Exam for elevated ICP/CT.
Tx w/ pip/tazo or imipenem+ Vanc hospital >5-7d • Old smokers w/ COPD? H. Klebsiella. Tx w/ M. Tx w/ M. Coxiella burnetti. Tx w/ doxy vomiting and diarrhea? • Just skinned a rabbit? Franciella tularensis. Tx w/ vanc • Just delivered a baby cow and have Q-fever. gentamycin . confusion. E. FQ or doxy people? • Hospitalized w/in 3mo or in the Pseudomonas. 3rd ceph • Most common bug. Dx w/ urine antigen. MRSA. doxy abd pain? • Just had the flu? MRSA. Coli.Pneumonia • Classic sxs… best 1st step? CXR! • Most common bug all comers? Strep Pneumo. diarrhea and Legionella. Tx w/ 3rd ceph • Old men w/ HA. FQ. Assoc w/ cold aggutinins. Tx w/ 2nd-3rd ceph • Alcoholics w/ current jelly sputum? Klebsiella. FQ. Tx w/ streptamycin. healthy young Mycoplasma. Tx w/ M. influenzae.
optic neuritis. chronically ill. ETOH. Hepatitis w/ mild bump in LFTs – Pyrazinamide.body fluids turn orange/red.Tuberculosis • If a patient is symptomatic best test is CXR • For screening – >15mm. nursing home. immune suppressed – If + PPD do CXR. – If CXR negative. >10mm if prison. • Drug Side Effects: – Rifampin.Benign hyperuricemia – Ethambutol. >5mm for AIDS. healthcare. – If +CXR do acid fast stain of sputum. . DM. induces CYP450 – INH.peripheral neuropathy and sideroblastic anemia (prevent by giving B6. other color vision abnormalities. or +CXR & 3 negative sputums – If positive tx w/ 4 drug RIPE Regimen for 6mo (12 for meningitis and 9 if pregnant) *Chemoprophylaxis (INH for 9mo) for kiddos <4 exposed to known TB.
septic emboli to lungs or brain • Treatment? Strep Viridens = 4-6 wks PCN. TTE then TEE. or uncorrected congenital lesion • *What if you find strep bovis bacteremia? Next step is colonoscopy!! . hx of EC. Staph = Naf + gent or vanco • Prophylaxis? if prosthetic valve.Endocarditis Acute endocarditis• most common bug? Staph aureus seeds native valves from bacteremia Subacute Native valve endocarditis• Most common valve? Mitral Valve (MVP is MC predisposition) • Most common bug? Viridens group strep IVDU • Most common valve? Tricuspid Valve (murmur worse w/ inspiration) • Most common bug? Staph Aureus • Diagnosis? Blood cx. Major and Minor Criteria • Complications? CHF #1 cause of death.
n/v/d +/. or Kaposi sarcoma .When to suspect HIV… • If a patient “travels a lot for work” that means they have sex with lots of strangers and are at risk for HIV • Acute retroviral syndrome = 2-3 wks s/p exposure but 3wks before seroconversion. • A young patient with unexplained thrombocytopenia and fatigue. lymphadenopathy. pharyngitis. Zoster. ELISA neg – Fever.aseptic meningitis • A young patient with new/bilateral Bell’s Palsy. headache. • A young patient with unexplained weight loss >10% • A young patient with thrush. ie. fatigue.
leukopenia. n/v. peripheral neuropathy Didanosine– HS rash.When to start Tx/Post exposure Prophylaxis • Start HAART when CD4 < 350 or viral load >55. SOB in 1st 6wks. D/C and never use again! Abacavir– Nephrolithiasis and hyperbilirubinemia Indinavir– Sleepy. lamivudine and nelfinavir for 4wks • Post-exposure prophylaxis- .000 (except preggos get tx >1.000 copies) – GI. muscle aches. psycho Efavirenz– If stuck w/ known HIV pt AZT. macrocytic anemia Zidovudine– Pancreatitis. confused. fever.
fever.. dry cough.Trim-sulfa 3rd.Atovaquone 2 .HIV+ patient with DOE. or pentamidine • When to add Steroids? When PaO2 < 70. CD4 prob <200. A-a gradient >35 d/c • Prophylaxis? Start when CD4 is <200.com/. • Best test? After CXR. do Bronchoscopy w/ BAL to visualize bug • 1st line Treatment? Trim-sulfa • 2nd line Treatment? Trim-dapsone or primaquine-clinda.Dapsone 4th./cow43. chest pain • Think PCP. Cannd is >200 for >6mo st www.jpg 1 . • CXR shows “bilat diffuse symmetric interstitial infiltrates” • Can see elevated LDH.learningradiology..Aerosolized pentamidine (causes pancreatitis!) .
rifampin – Prophylax w/ azithromycin weekly • Cryptosporidium. fevers.(<50) – Transmitted via dog poo. Oocysts are acid fast . swimming pools – Watery diarrhea w/ mucus.(<50) – Diarrhea.HIV+ patient with diarrhea • CMV. night sweats. – Tx w/ clarithromycin and ethambutol +/.(<50) – Dx w/ colonoscopy/biopsy. Diarrhea can be bloody – Tx w/ gancicylovir (neutropenia) or foscarnet (renal tox) • MAC. wasting.
HIV+ patient with neurologic signs Think Toxo. +India ink. consider biopsy for • If one ring enhancing CNS lymphoma. lesion? • If seizure w/ de ja vu Think HSV encephalitis. visual impairment. (predisposed for aura and 500 RBCs in temporal lobe). CSF? • If s/s of meningitis? Think Crypto. Assoc w/ EBV infxn of Bcells. Tx w/ HAART. Check serum. CSF and MRI to r/o treatable gait disturbanc? causes . Brain bx is gold standard dx Babinski? • If memory problems or Think AIDS-Dementia complex. Think PML. JC polyomavirus demyelinates at grey-white jxn. If no enhancing lesions? improvement in 1wk. Do empiric pyramethamine • If multiple ring sulfadiazine (+ folic acid) for 6wks. Tx w/ ampho IV for 2wks then fluconazole maintenance • If hemisensory loss. Give acyclovir as SOON as suspected.
Neutropenic Fever • Medical Emergency! • NEVER do a DRE on a neutropenic patient! • Defined by a single temp > 101. . then start 3rd or 4th gen cephalosporin (ceftazidime or cefipime) – Add vanc if line infxn suspected or if septic shock develops. – Add amphoB if no improvement and no source found in 5 days. • Mucositis 2/2 chemo causes bacteremia (usually from gut) • MC bugs are pseudomonas or MRSA (if port present).4 for 1hr.3 or sustained temp >100. • Work up 1st get blood cx. ANC < 500.
Random Infection Buzzwords • Target rash. no rash. fever. PCN for 6-12wks Gram + anaerobic branching . ↑ALT intracell inclusion. cavitary lung Nocardia! Tx w/ trim-sulfa dz (purulent sputum)+ weight loss. Heart or CNS dz needs IV ceftriaxone meningitis. AV block • Rash @ wrists & ankles (palms & Rickettsia! Tx w/ doxy. Ehrlichiosis! Can dx w/ morulae ↓plts and WBC. Gram + aerobic branching partially acid fast • Neck or face infection w/ draining Actinomyces! Tx w/ high dose yellow material (+sulfur granules). HA. • Tick bite. fever. soles). fever. myalgia. Tx w/ doxy • Immune suppressed. VII palsy. fever and HA. Lyme! Tx w/ doxy (amox for <8).
3% saline only if seizures or [Na] < 120. • Correct w/ NS if hypovolemic. • Hypervolemic hypoNa: CHF. . – Check osm. hypothyroidism. then check volume status. nephrotic.Electrolyte Abnormalities • ↓Na = gain of water. • ↑Na = loss of water. addisons. – Replace water w/ D5W or other hypotonic fluid • Don’t correct faster than 12-24mEq/day or else cerebral edema. cirrotic • Hypovolemic hypoNa: diuretics or vomiting + free water • Euvolemic hypoNa: SIADH (check CXR if smoker). Otherwise fluid restrict + diuretics. • Don’t correct faster than 12-24mEq/day or else Central Pontine Myelinolysis.
↓K – Tx w/ K (make sure pt can pee). sine waves. stones. Chvostek or Troussaeu. kayexalate. groans. ↑K Tx w/ Ca-gluconate then insulin + glc. max 40mEq/hr • peaked T waves.Other Electrolyte Abnormalities • numbness. ileus. Shortened QT interval. ST depression. Last resort = dialysis . ↑Ca • paralysis. albuterol and sodium bicarb. ↓Ca • bones. U waves. prolonged PR and QRS. psycho. prolonged QT interval.
4 = alkalotic – Check HCO3 and pCO2: • If HCO3 is high and pCO2 is high metabolic alkalosis • Check urine chloride» If [Cl] > 20 + hypertension think hyperaldo (Conns). If normotensive think Barter’s or Gittlemans.Acid Base Disorders • Check pH if <7. If >7. diuretics • If pCO2 is low and HCO3 is low respiratory alkalosis • Hyperventillation from anxiety. incr ICP. brainstem injury. diuretic.. fever. antacids . salicylates • If HCO3 is low and pCO2 is low metabolic acidosis – Check anion gap (Na – [Cl + HCO3]). RTAs (I. normal is 8-12 » Gap acidosis = MUDPILES » Non-gap acidosis = diarrhea. pain.4 = acidotic. vent prob . » If [Cl] < 20 think vomiting/NG suction. II and IV) • If pCO2 is high and HCO3 is high respiratory acidosis • Hypoventillation from opiate OD.
hepatitis Presentation/Dx Urine pH > 5. Hypoaldo any cause of aldo def. . uric acid and bicarb. Problem? Cannot reabsorb vitD def. amyloid.4 HypoK. Osteomalacia Myeloma. sickle cell. K. HCO3.Renal Tubular Acidoses Cause NAGMA Cause Type I Distal Type II Proximal Type IV Lithium/Ampho B analgesics SLE. Na. autoimmune dz Replete K Mild diuretic Bicarb won’t help >50% caused by diabetes! Hyperrenin Addisons. Kidney stones Problem? Cannot excrete H+ Treatment Replete K Oral bicarb *Fanconi’s syndrome HypoK. HyperK HyperCl High urine [Na] even w/ salt restriction Fludrocortisone *Fanconi’s anemia = hereditary or acquired prox tubule dysfxn where there is defective transport of glc. sickle cell. AA. Sjogrens. PO4.
tx w/ fluids (& tx CHF.5 rise in creatinine over baseline.Acute Renal Failure • >25% or 0. renal artery stenosis. • Work up– BUN/Cr ratio if >20/1 = prerenal – Check urine Na and Cr if FENA < 1% = prerenal – If pt on diuretic measure FENurea is <35% = prerenal • Treatment– Prerenal causes = anything keeping the kidney from being perfused. cirhosis. GN. etc) . – If prerenal.
Tx w/ bicarb w/ CPK of 50K. 1st test is • Army recruit or crush victim check [K+] or EKG. blood and Eos in the AIN. Prevent by s/p cardiac cath or CT scan? hydrating before or giving bicarb or NAC . +blood on dip to alkalinize urine to prevent but no RBCs? precipitation • Enveloped shaped crystals on Ethylene glycol intox. Stop offending agent. took Trim-sulfa 1-2wks ago? Rhabdomyolysis. Tx w/ fluids. Tx w/ UA? dialysis or NaHCO3 if pH<7. cisplatin or nephrotox and dialysis if indicated. (AGMA). prolonged ischemia? • Protein.2 • Bump in creatinine 48-72hrs Contrast nephropathy.Intrinsic Causes • Muddy brown casts in a pt w/ ATN. avoid ampho. Add urine + fever and rash who steroids if no improvement. AG.
5 Intoxication particularly antifreeze. Li • O• U- Overload of volume sxs of CHF or pulmonary edema Uremia pericarditis.Indications for Emergent Dialysis • A• E• IAcidosis Electrolyte imbalance particularly high K > 6. altered mental status • NOT for high creatinine or oliguria alone! .
Chronic Kidney Disease • #1 cause is DM. fluid retention CHF – Normochromic normocytic anemia loss of EPO – ↑K. • Complications = – HTN (2/2 ↑aldo). itchiness. next is HTN • #1 cause of death in CKD pt is cardiovascular dz so target LDL < 100. ↓Ca (leads to 2ndary hyperPTH) – ↑PO4 leads to precip of Ca into tissues renal osteodystrophy and calciphylaxis (skin necrosis) – Uremia confusion. ↑PO4. increased bleeding 2/2 platelet dysfxn . pericarditis.
best 1st test is ASO titer. MC cause. sore throat & cough? • 1-2 weeks after sore throat Post-strep GN. Abs to collagen IV • Hematuria + Deafness? Alport Syndrome.smoky/cola urine. Subepithelial IgG humps or skin infxn? • Hematuria + Hemoptysis? Goodpasture’s Syndrome. Berger’s Dz (IgA nephropathy). XLR mutation in collagen IV . edema and azotemia syndrome? • 1-2 days after runny nose. hematuria.So your patient is peeing blood… • Best 1st test? Urinanalysis • Painless hematuria? Bladder/Kidney cancer until proven otherwise • “terminal hematuria” + tiny Bladder cancer or hemorrhagic cystitis (cyclophosphamide!) clots? • Dysmorphic RBCs or RBC Glomerular source casts? • Definition of nephritic Proteinuria (but <2g/24hrs).
Tx w/ asthma and eosinophilia. cyclophosphamide. Tx w/ steroids or cyclophosphamide.• Kiddo s/p viral URI w/ Renal Henoch-Schonlein Purpura. sinus involvement. MAHA. • p-ANCA. arteries of every organ except the lung! Tx w/ cyclophosphamide . E. DON’T give platelets. Best test is lung bx. lung and Wegener’s Granuolmatosis. toxin) • Cardiac patient s/p TTP. NO lung Polyarteritis Nodosa. failure + abd pain. IgA. Tx w/ plasmapheresis. fever and Can tell from DIC b/c PT and PTT AMS.Coli O157H7 or shigella. kidney. arthralgia Supportive tx +/. renal failure. Hep B. • c-ANCA. • p-ANCA. ↓plts. Affects small/med involvment. diarrhea w/ renal failure. ticlopidine w/ renal failure.steroids and purpura. Churg Strauss. Most accurate test is bx. are normal in HUS/TTP. • Kiddo s/p hamburger and HUS. Don’t tx w/ ABX (releases more MAHA and petechiae.
– Chronic indwelling foley and Mg/Al/PO4 = struvite. klebsiella alkaline pee? – If leukemia being treated Uric Acid w/ chemo? Tx by alkalinizing the urine + hydration – If s/p bowel resection for volvulus? Pure oxylate stone.Kidney Stones • Flank pain radiating to groin + hematuria. • Best test? CT. pseudomonas. staph. Just hydrate – Stones >2cm Open or endoscopic surgical removal – Stones 5mm-2cm Extracorporal shock wave lithotropsy . Tx w/ HCTZ – Kid w/ family hx of stones? Cysteine. proteus. Ca not • Treatment reabsorbed by gut (pooped out) – Stones <5mm Will pass spontaneously. Can’t resorb certain AA. • Types– Most common type? Calcium Oxalate.
thick cap walls w/ subepi spikes • Assoc w/ heroin use and Focal-Segmental. Do CT or U/S stat! pain? Orthostatic. hypoalbuminemia. tx w/ ‘roids • MC in adults? Membranous.So your patient is peeing protein… • Best 1st test? Repeat test in 2 weeks.mesangial IgM deposits. bence jones in MM. UTI. then quantify w/ 24hr urine • Definition of nephrotic >3. edema. syndrome? hyperlipidemia (fatty/waxy casts) • MC in kiddos? Minimal change dz. protein C and S.tram-track BM w/ subendo deposits and low complement? • If nephrotic patient Suspect renal vein thrombosis! 2/2 peeing suddenly develops flank out ATIII. CHF . fever. HIV? • Assoc w/ chronic hepatitis Membranoprolif. Limited response to ‘roids.fusion of foot processes.5g protein/24hrs. • Other random causes? preggos.
com/wp-content/uploads/2009/02 1. ↓TIBC. ↓Fe. ↑ferritin. 2. ↓RDW . ↓Fe.A patient walks in with microcytic anemia… www. ↑TIBC.) MCV = 70. ↓retic. ↓ferritin. ↑Fe.ezhemeonc. 4. ↓retic. ↓TIBC 3. ↑RDW.) MCV = 70. nl ferritin.) MCV = 60.) MCV = 70.
↓retics. ↑homocysteine. ↓retics.edu 1. 3.) MVC = 100 2.A patient walks in with macrocytic anemia… healthsystem. ↑methylmelonic acid . ↑homocysteine.) MVC = 100.) MVC = 100. nl methylmelonic acid.virginia.
↑indirect bilirubin. Tx w/ sulfas. Budd-Chiari Paroxysmal Nocturnal Hemoglobinuria. syndrome. recent Mycoplasma infx. rifampin or Cancer. then spleen. nose + Cold Agglutinins. bilirubin Hereditary spherocytosis (AD loss of spectrin). gallstones. • Dark urine in AM. Lysis by complement. +FH. Destruction in • Sudden onset after PCN. ↓haptoglobin • Sickle cell kid w/ sudden drop in Aplastic Crisis. ceph. • Splenomegaly. splenectomy. Tx w/ splenectomy. Sickle Crisis from Hct? dehydration or acidosis • Cyanosis of fingers. Destruction occurs in the liver. Bite cells. Heinz bodies. ↑LDH. hypoxia. Warm Agglutinins. Incr risk for aplastic anemia • Sudden onset after primiquine.Normal MCV. ears. fava beans . Avoid oxidant stress. IgM mediated. G6PDH def. Defect in PIG-A. IgG. sulfas.steroids 1st. ↑MCHC.
Same 2wks of clinda has hemarthroses & for warfarin toxicity. tx w/ DDAVP. Then menses & petechiae.A patient walks in with thrombocytopenia • 30 y/o F recurrent epistaxis. heavy ITP. heavy VWD. petechiae. so PT increases 1st – 2 factors not depleted? VIII and vWF b/c they are made by endothelial cells. • 20 y/o M recurrent bruising. Tx w/ prednisone 1st. replace factors. ↓ II. that corrected w/ mixing studies. ↓plts only. hematuria. ↑ PTT otherwise. splenectomy. normal plts. ↑ Replace factor VIII (contains vWF) if bleeding continues. Hemophilia. & hemarthroses. IX and X. . Rituximab • 20 y/o F recurrent epistaxis. – 1st factor depleted? VII. menses. GI bleeding is MC cirrhosis. DDAVP for bleeding or pre-op. VII. • 50y/o M “meat-a-tarian” just finished VitK def. If mild. Tx w/ FFP acutely + vitK shot oozing at venipuncture sites. • 50y/o M “beer-a-tarian” w/ severe Liver Disease. bleeding time and PTT. IVIG if <10K.
ticlopidine. fibrinogen DIC! ↓./2005/20050804/images/s4. – Treatment? Plasmapheresis. snake bites. heatstroke.jpg • If PT and PTT are ↑.A patient walks in with thrombocytopenia and this smear… www. pancreatitis.nejm. quinine. cyclosporine. rhabdo. *Tx of M3 AML* – Causes? – Treatment? FFP. platelet transfusion. HIV.. correct underlying d/o • If PT and PTT are nl? HUS or TTP – Causes? O157H7. NO PLATELETS! .org/.. cancer. adenocarcinoma. D-dimer and fibrin split products ↑? Sepsis. OB stuff.
Her platelets are found to be 50% less than pre-op. start lepirudin CANCER Lupus Anticoagulant ↑PTT. false + VDRL Protein C/S deficiency Skin necrosis after warfarin is started Factor V Leiden MC inheritable pro-coag state.• 7 days post-op. reverse warfarin w/ vitK. • What to look for in someone w/ unprovoked thrombus? – – – – – – – HIT! – Mechanism? IgG to heparin bound to PF4 – Treatment? Stop heparin. a patient develops an arterial clot. OCPs/HRT No Go for women >35 who smoke Nephrotic syndrome Pee out ATIII protein C and S preferentially. V is resistant to C AT III Deficiency Heparin won’t work. Clots on heparin. multiple SABs. Puts at risk for Renal Vein Thrombosis .
A patient comes in w/ arthritis… OA. low grade fever. oral ulcers. malar rash. rash w/ silvery scale on elbows and knees.. thrombocytopenia. worse in the AM..learningradiology.org/. . • Symmetric. DIP involvement no swelling or warmth.yorkshirekneeclinic. Psoriatic Arthritis.hopkins-arthritis. worse @ the end of the day. proteinuria./radiology2.jpg DIP joint involvement.co.jpg RA.. Arthritis is not erosive or have lasting sequellae.jpg www. www. crepetence. bilateral arthritis./cow60.com/.uk/images/D3. www. PIP and wrists bilaterally.. Knee pain. SLE. pitting nails and swollen fingers.
• 70 yr old nun Staph aureus. Cx may be negative. negatively Gout. Look for work” also for tenosynovitis and arm pustules. SLE. Tx w/ nafcillin or vanco.A patient comes in w/ acute swollen painful joint… • 1st best test? Tap it! • WBCs >50K Septic arthritis • 30 yr old who “travels a lot Gonococcal. birefringent crystals. • Rhomboid shaped. Reiter’s • Needle shaped. • WBCs 5-50K Inflammatory. think RA. Tx w/ ceftriaxone. Monosodium Urate. positively Pseudogout. Calcium pyrophosphate. • Chronic TX? Probenecid if undersecreter. Allopurinol if overproduc. ank spon. hypertrophic osteoarthropathy. • WBCs 200-5K OA. trauma • WBCs <200 Normal. If no crystals. birefringent crystals. . • Acute TX? Indomethacin + colchicine (steroids if kidneys suck).
• Sjogren’s Syndrome? Anti-Ro (SSA) or Anti-La (SSB) • CREST Syndrome? Anti-centromere • Systemic Sclerosis? Anti-Scl-70. Anti-topoisomerase • Mixed connective tissue Anti-RNP disease? • 2 tests for RA? RF (against Fc of IgG) Anti-CCP (cyclic citrullinated peptide) .Antibodies to Know! • If negative. • Most sensitive for SLE? Anti-dsDNA or Anti-Smith • Drug induced lupus? Anti-histone (hydralazine). rules out SLE? ANA – peripheral/rim staining.
medscape.clevelandclinicmeded.com/medicalpubs/ http://www.com/pi/emed/ckb/dermatology/1048 http://www.clevelandclinicmeded.clevelandclinicmeded.com/medicalpubs/ http://www.Skin signs of systemic diseases: img.clevelandclinicmeded.com/medicalpubs/ Sign of Leser Trelat Dermatomyositis Seborrheic Dermatitis http://www.com/medicalpubs/ Dermatitis Herpetiformis Acanthosis Nigricans Erythema Multiforme .
clevelandclinicmeded.clevelandclinicmeded.com/best-practice/images/bp/3762_default.org/systemic/necrolytic-erythema.clevelandclinicmeded.Skin signs of systemic diseases part deaux: http://dermnetnz.com/medicalpubs/ Porphyria Cutanea Tarda Erythema Nodosum Necrolytic migratory erythema http://www.com/medicalpubs/ http://bestpractice.html http://www.com/medicalpubs/ http://www.bmj.jpg Bullous Pemphigoid Pemphigus Vulgaris Behcet’s Syndrome .
dermnetnz.com/.med..html Dermatitis of Pellagra secure.ab.html Acrodermatitis enteropathica (Zn deficiency) http://www.medscape.org/systemic/pellagra.org/systemic/acrodermatitis-enteropathica.ca Tinea Capitis library.utah..edu img.provlab.Other Skin Randoms http://dermnetnz.jpg Actinic Keratosis Kaposi Sarcoma Bacillary Angiomatosis ./276262-279734-252.
medscape. soles.ucsd.edu http://emedicine.medscape. mucous membranes in darker complected races). then wide local excision.com/article/1 101535-media . – Lentigo Maligna (head and neck. 2cm margin if 1-4mm thick. – Can use rads for tough locations. http://emedicine.com/article/ 276624-media • Melanoma– Superficial spreading (best prog.Skin Cancer • Basal Cell Carcinoma– Shave or punch bx then surgical removal (Mohs) • Squamous Cell Carcinoma– AK is precursor lesion (tx w/ 5FU or excision) or keratoacanthoma. good prog) – Need full thickness biopsy b/c depth is #1 prog – Tx w/ excision-1cm margin if <1mm thick. most common) – Nodular (poor prog) – Acrolintiginous (palms. 3cm margin if >4mm – High dose IFN or IL2 may help myhealth. – Excisional bx at edge of lesion.
I131 ablation or surgery (preggos & kiddos) – Tx of thyroid storm? PTU + Iodine (Lugol’s sol’n) + propranolol. high free T3/T4. dilute urine. DI. If ↓ = factitious or thyroiditis – Tx? 1st = propranolol + PTU/MTZ. Next best step? I123 RAIU scan. – Central. . Urine Osm ↑ w/ ddAVP – Nephrogenic. hyperNa. polydipsia.Urine Osm still ↓ s/p ddAVP. If ↑ = Graves. • See low TSH. Tx w/ HCTZ/amiloride.lack of ADH (or non-fxnal) Do water deprivation test to tell if crazy hyperOsm.urine Osm still ↓ s/p water depriv. Consider in amenorrhea/hypoT – Tx? Bromocriptine or cabergoline… even if macro (>10mm) • Order of hormones lost in #1 FSH and LH #2 GR #3 TSH #4 ACTH hypopituitarism? • Polyuria.Common Endo Diseases • MC pituitary adenoma? Prolactinoma.
psammoma bodies Follicular Spreads via blood. spreads via lymph. If malignant? Surgically excise and check pathology If indeterminate? Re-biopsy or check RAIU If cold? Surgically excise and check pathology – – – – – Papillary MC type. Excise or radioactive I131 If normal? FNA If benign? Leave it alone. must surgically excise whole thyroid! Medullary Assoc w/ MENII (look for pheo. Amyloid/calci Anaplastic 80% mortality in 1st year.Work up of a Thyroid Nodule • • • • • • • 1st step? Check TSH If low? Do RAIU to find the “hot nodule”. Thyroid Lymphoma Hashimoto’s predisposes to it. . hyperCa).
hypotension. Chest CT if smoker. central fat. Abdominal CT/DHEAS • Weakness. hyperpigmentation. DM. hirsutism Suspect Cushing’s. ↓pH Suspect Adrenal Insufficiency – Best screening test? Cosyntropin stimulation test (60min after 250mcg) • MC cause? Autoimmune (Addison’s dz) – Treatment? NaCl resuc.Adrenal Issues • Osteoporosis. weight loss. Long term replacement of dexamethasone and fludrocortisone. . ↑K. – Best screening tests? 1mg ON dexa suppression test or 24hr urine cortisol • If abnormal? Diagnoses Cushing’s Syndrome – Next best test? 8mg ON dexa suppression test • Suppression to <50% of control? Pituitary adenoma (Cushing’s dz) • No suppression? Either adrenal neoplasia or ectopic ACTH – Next best test? Plasma ACTH. ↓Na.
low K+.and plasma-free metanephrines Plasma aldosterone-torenin ratio Urine 17-ketosteroids Cushing symptoms or Overnight 1-mg normal examination results dexamethasone test • #2.• Best 1st step? Check functional status Diagnosis Features Work up of an Adrenal Nodule Biochemical Tests Pheochromocytoma Primary aldosteronism Adrenocortical carcinoma Cushing or "silent" Cushing syndrome High blood pressure.com/article/116587-treatment . low PRA* Virilization or feminization Urine. catechol symptoms High blood pressure.medscape.if <5cm and non-function • Observe w/ CT scans q6mo If >6cm or functional Surgical excision http://emedicine.
Parathyroid Disease Hypoparathryoidism – Perioral numbness.medullary thyroid cancer. pancreatic islet cell tumor. • MEN– MEN1. ↓*PTH+ – Kidney stones. parathyroid hyperplasia. pheochromocytoma – MEN2b. ↑*PTH] Hyperparathyroidism Dx w/ FNA of suspicious nodules. pheochromocytoma.pituitary adenoma. Can use Sestamibi scan. Chvortek. medullary thyroid cancer. ↑vitD. – MEN2a. remove all 4 glands and implant 1 in forearm.parathryoid hyperplasia. Trousseau s/p Thyroidectomy – ↓*Ca+. Marfanoid . ↓*PO4+. Tx w/ surgical removal of adenoma. constipation/abd pain or psychiatric sxs – ↑*Ca+. If hyperplasia. ↑*PO4+.
abdominal pain. vomiting. random glc > 200 + sxs (polyuria. Kidney? Check for microalbuminemia (30-300 in 24hrs). BP < 130/80. hyperkalemia – Tx? High volume NS + insulin bolus & drip. 3rd. Kussmaul respirations.Diabetes • Diagnosis of Diabetes? • Nausea. HHS confusion and coma w/ BGL = 1000? – Tx? High volume fluid & electrolytes. polydipsia. Start ACE-I Eye? Annual screening for prolif retinopathy Vitreous hemor/neovasc Nerves? Podiatric exam annually. profound dehydration. 4th. Add glc <200 • MC cause of death? Cardiovascular disease • Important screening? – – – – Heart? LDL < 100. Add K once peeing. coma w/ BGL = 400? DKA • Polyuria. 2hr OGTT > 200. polydipsia. FBGL > 126 x 2. May get ED. 6th CN palsy. Tx gastroparesis w/ metoclopramide or erythromycin. . blurred vision) – Dx? Ketones in blood (&urine). AGMA. May require insulin.
pain/temp on neck and arms & intact surgery to tx sensation. . His pain is worse w/ valsalva. MRI to dx. 2nd choice is CT myelogram • If same clinical picture in a patient w/ IV dexamethasone then MRI then radiation therapy.A 47 year old IVDU comes in requesting hydromorphone for back pain. and plantar response is upgoing. • Next best step? MRI of the spine. Anterior spinal artery • Pt w/ high cholesterol presents w/ acute onset flaccid paralysis below the occlusion. hx of prostate ca… next best step? • Pt s/p MVC w/ “whiplash” has loss of Syringomyelia. His LE have 4-/5 strength bilaterally. waist. loss of pain/temp w/ preserved Tx is supportive. his has flaccid rectal tone. vibration of position. and his L4 vertebra is TTP.
(>60% if <60y/o) • • • • .Stroke! • • • • Most common cause? 80% ischemic. surg w/in 2wks. 20% hemorrhagic Best 1st step? Non-contrast CT to r/o hemorrhage Most accurate test? Diffusion-weighted MRI best for ischemic.5) hours? TPA If later than that? Aspirin. basilar clot Contraindications to TPA? Stroke w/in 3mo. Don’t use ticlopidine! (why?) aspirin? If they had a subarachnoid Nimodipine to reduce ischemic stroke from vc (MC cause of M&M) hemorrhage? When to clip an aneurysm? W/in days or rupture or when <10mm When to do endarterectomy? When occlusion >70% and is symptomatic. Heparin only for those in a-fib. LP w/in 1wk If they had the stroke on Add dipyridamole or switch to clopidogrel. CT can be neg 1st 48hrs. Treatment? If w/in 3 (4.
• L hemiplegia/hemisensory loss in the leg>arm. • L hemisensory loss + Horners + R facial sensory loss. • Total paralysis except for vertical eye movements. • L hemiplegia + R ptosis & eye deviated to the right R Webber’s and down. L homonomous R MCA stroke hemianopsia w/ eyes deviated twoards the R + apraxia. .Where’s the lesion? • L hemiplegia/hemisensory loss. • Falling to the L + R ptosis & eye deviated to the right R Benedikt’s and down. R ACA stroke Confusion. vomiting. nystagmus and clumsiness with Major R cerebellar arteries the right arm. behavioral disturbance.R Wallenburg (PICA) • Vertigo. Paramedial branches of the basilar artery.
– Tx? 1st line = carbamazepine or phenytoin. burning rubber smell). Tx absence w/ ethosuximide – Tx? 1st line = valproic acid. atonic. carbamezepine. – They are simple if no LOC and complex if LOC (may have lip smacking). Then valproate or lamotrigine • Generalized seizures begin from both hemispheres @ once. infection. – Either grand mal or absence (5-10sec unresponsiveness in kiddos). de-ja-vu. (Arm twitch.Seizures • Medical causes include hypoglycemia. • Status Epilepticus. – Tx? Lorazepam + LD of phenytoin. hypocalcemia. myoclonic. ETOH or benzo w/drawal. then lamotrigine. stroke). • Partial seizures begin focally. Both can generalize. hyponatremia. structural (tumor. phenytoin . Then anesthesia. bleed. Then phenobarbitol.
EEG Buzzwords • 3 Hz spike-andwave. • Hypsarrhythmia Absence Seizure. Tx w/ ethosuxamide Creutzfeldt Jakob. Most are associated w/ mental retardation. Dementia + myoclonus Delirium. . Tx w/ ACTH. • Triphasic bursts • Diffuse background slowing. Contrast w/ psychosis that has no EEG changes Infantile spasms.
bending forward. Worse w/ coughing or prognostic factor is grade (degree of anaplasia).New Onset Severe Headache Things to consider: • “Worse headache of my life” Subarachnoid hemorrhage. • Deep pain that wakes them up Consider brain tumor. Abx then CT then LP. acetazolamide. claudication. Normal CT. elevated pressure on LP. • Unilateral pounding headache Temporal arteritis. Noncon CT 1st! • + Fever and Nuchal rigidity Meningitis. then nerve palsy/diplopia. Can lead to blindness. Check ESR. Most important at night. then w/ changes in vision and jaw give steroids. then shunt or optic nerve sheath fenestration. then do temporal artery biopsy. . Tx w/ weight loss. • Fat lady on minocycline or who Pseudotumor cerebri. Also assoc w/ takes isotreintoin w/ abducens OCPs.
Episode of double vision Neuro-deficits separated by time and space 6mo ago. EBV – Best tx? IVIG or plasmapheresis. Babinski on Multiple Sclerosis. Myasthenia Gravis. R. dysphagia. • Nasal voice.Neuro reasons to go to the hospital… • Diarrhea 3wks ago. – Best dx test? MRI of the brain. – Chronic tx? Pyridostigmine. accurate is EMG. Monitor VC for intubation req. GCs/azathioprine. (3 days IV then 4wks oral). Incr T2 @ periventricular white matter – Acute tx? Steroids. Most respiratory acidosis. HHV. beta1b. thymectomy (<60) – Meds to avoid? Aminoglycosides & beta-blockers • Urinary retention. Guillain-Barre. glatiramer reduce exacerbations . 1st test is Ach-ab. ptosis. – Acute tx? IVIG or plasmapheresis. Plasma xchng is 2nd line – Chronic tx? IFN-beta1a. CMV. now areflexia and ascending paralysis. Monitor VC for intubation req. decrease in muscle fiber contraction. CSF shows albumino-cytologic dissociation – Most likely bug? Campylobacter.
Gastroenterology Extra Slides .
CMV and HSV esophagitis .remember candida. • Manometry is the test of choice for achalasia.A patient comes in with dysphagia… • Best 1st test is a barium swallow • Next best test is endoscopy (can be dx and allow for bx of suspicious masses or tx in dilation of peptic strictures or injecting botox for achalasia). • 24 pH monitoring is the test of choice for GERD. • If HIV+ (CD <100) or otherwise immunocompromised.
wheeze. feels like MI w/ NO regurg botox. • True or false? False. Tx w/ CCB. incompetent LES.co. hoarse. Do endoscopy ifst“danger signs” present. Diffuse esphogeal spasm. or no want meds. or heller sxs. H2 block. Dysphagia worse w/ hot & cold liquids + chest pain that Achalasia. Barrett’s.• Bad breath & snacks in Zenker’s diverticulum. • Indications for surgery? bleeding. cough. PPI. nitrates. Most sensitive test is 24-hr pH eating or when laying down monitoring. max dose PPI w/ still sxs. then antacids. Tx w/ surgery the AM.org • Epigastric pain worse after GERD.uk myotomy Assoc w/ Chagas dz and esophageal cancer. jykang. Only contains mucosa • Dysphagia to liquids & solids. Tx w/ behav mod 1 . stricture. . Tx w/ CCB or nitrates ajronline.
NO edoscopy Tx? surgical repair if full thickness If gross hematemesis If progressive unprovoked in a cirrhotic dysphagia/wgt loss. tamponade only if you need to stablize for Best 1st test? transport barium swallow. Endoscopic sclerotherapy or banding *Don’t prophylactically band asymptomatic varices. Esophageal Carcinoma Gastric Varices Squamous cell in smoker/drinkers in the If in hypovolemic shock? middle 1/3. img. w/ subQ emphysema). NG lavage. w/ pHTN.medscape. Adeno in ppl with long medical tx w/ octreotide standing GERD in the or SS. then Tx of choice? staging CT. then endoscopy w/ bx.com /pi/emed/ckb/onco logy/276262 . Give BB. gastrograffin esophagram. do ABCs. Balloon distal 1/3. Can see pleural effusion w/ ↑amylase Boerhaave’s Esophageal Rupture Next best test? CXR.If hematemesis (blood occurs after vomiting.
check amylase and lipase and CT scan is best imaging for pancreas. • If biliary colic sxs predominate RUQ sono • If hx of stones or drinking. .A patient comes in with MEG pain… • #1 cause is non-ulcerative dyspepsia. • If GERD sxs predominate. recent unprovoked weight loss. Fe-def anemia or melena. hx of smoking and drinking. odynophagia. • Danger sxs warrant endoscopic work up– >50 y/o. Dx of exclusion. Tx w/ H2 blocker and antacid.tx empirically w/ PPI for 4 wks then re-evaluate.
multiple or atypically located ulcers. – Look for pituitary and parathyroid problems (MEN1) .MEG pain worse w/ eating. pylori. NSAIDs. – Tx H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer. H. ‘roids – Double-contrast barium swallow shows punched out lesion w/ regular margins. pylori.• Gastric Ulcers. • Duodenal Ulcers. long term PPI if metastatic. pylori – Healthy pts < 45y/o can do trial of H2 block or PPI – Can do blood. H2-block. Breath or stool test can be test of cure. benign. malign. stool or breath test for H. – Tx w/ sucralfate. Surgery if ulcer remains s/p 12wks treatment. • Zollinger-Ellison Syndrome– Suspect it if MEG pain/ulcers don’t improve w/ eradication of H. PPI. EGD w/ bx can tell H.MEG pain better w/ eating – 95% assoc w/ H. – Best test is secretin stim test (finding high gastrin) – Tx w/ resection if localized.pylori. large. pylori w/ PPI. clarithromycin & amoxicillin for 2wks.
fever (diff than sx-atic gall-stones) worse after fatty food. can place a percutaneous cholecystostomy. fever.rare.• Acute Cholecystitis– RUQ pain back.edu . • Cholangiocarcinoma. ERCP and stone removal. liver flukes and thorothrast exposure. Do cholecystectomy or ERCP to remove stone. high bili. jaundice (+hypotension and AMS) – Tx w/ fluids & broad spec abx. • Choledocothithiasis– Same sxs + obstructive jaundice. If too unstable for surg. +Murphy’s. • Ascending Cholangitis– RUQ pain. RF are primary sclerosing cholangitis (UC).virginia. – Best 1st test is U/S thickened wall. HIDA shows nonvisualization of GB. – Tx with cholecystectomy. alk phos – U/S will show stones. n/v. Tx w/ surgery. med-ed.
no extension into SMA or portal vein. LDH>350. itching and jaundice). Observe. decr calcium. WBC>16K. ARDs • Chronic Pancreatitis– Chronic MEG pain.pseudocyst (no cells!). hypox – Complications. nontender GB. hemorrhage. – Dx w/ EUS and FNA biopsy – Tx w/ Whipple if: no mets outside abdomen. If in head of pancreas Courvoisier’s sign (large. Glc>200. no liver mets. IV. malabsorption (steatorrhea) – Can cause splenic vein thrombosis • Adenocarcinoma– Usually don’t have sxs until advanced. NPO. Trousseau’s sign = migratory thrombophlebitis. DM. Turner’s and Cullens signs – Labs show incr amylase (>1000 means stone) & lipase. abscess.• Acute Pancreatitis– Gallstones & ETOH most common etiologies – MEG pain back + n/v. .worse if old. acidosis. no peritoineal mets. AST>250… drop in HCT. – Prognosis. Tx w/ NG. Best imaging is CT scan.
tachycardic. shigella. bulky. entamoeba histolytica • If hx of picnic B. staph food poisoning. CF if young person. 1-6hrs • If hx of abx use check stool for c. Norwalk on cruise ships • Check fecal leukocytes tells invasion. Whipple’s dz. vibrio parahaemolyticus. malnourished consider Sprue. – *Can cause niacin deficiency! (2/2 using all the tryptophan to make 5HT) Dementia. • If accompanied by flushing.A patient comes in with diarrhea… • If hypotensive. chronic pancreatitis. diff toxin antigen • If foul smelling. Dermatitis. Diarrhea. Give NS first! • Vial is #1 cause rota in daycare kids. salmonella. ceres. . Stool cx is best test • If bloody diarrhea consider EHEC. tachycardia/ hypotension consider carcinoid syndrome (metastatic).
Oncology Extra Slides .
BM transplant after 1st remission. Down’s. • Tx of AML? Danorub + araC. If *M3 give all trans retinoic acid . AML. *M3 has Auer Rods and causes DIC upon tx. petechiae. See enlarged • Tartate resistant acid spleen but no adenopathy. myeloprolif.A patient presents w/ fatigue. Most common cancer in kids. ↓monos & CD11 and Tx w/ cladribine 5-7day single course CD22+? Danorub. exposure. pred. RF = rads myeloperoxidase. vincris. More common in adults. infection bone pain and HSM… Defines Acute Leukemia on Biopsy • If >20% blasts? ALL. • CALLA or TdT? • Auer Rods. esterase? Hairy Cell Leukemia. Add intrathecal MTX for CNS • Tx of ALL? recurrence. Hairy Cells have numerous phosphatase. cytoplasmic projections on smear.
/197800-199425-29.jpg If Splenomegaly Tx w/ imantinib (Gleevec). splenomegaly and elevated WBCs w/ low LAP and basophilia? • Asymptomatic elevation in WBCs found on routine exam – 80% lymphs.gov/bookshelf/picrender. Stage 0 or 1 need no tx.. If Lymphadenopathy img. Cx = blast crisis. fever..12 yrs till death Stage 2 tx w/ fludrabine If Anemia If Thrombocytopenia Stage 3 or 4 tx w/ steroids .. www. 2nd line is bone marrow transplant..fcgi.nih.medscape.CML.ncbi.com/. night sweats.nlm.9:22 transloc tyrosine kinase CLL • A patient presents w/ fatigue. inhibits tyrosine kinase.
If still unsure. rubbery Think Lymphoma lymph nodes • Drenching night sweats. ↑ESR and LDH. large mediastinal LND • Best initial test? Excisional lymph node biopsy • Next best test? Staging Chest/Abdominal CT or MRI.• Enlarged. Bone marrow bx (esp for NHL • Orderly. • Staging? III = both sides of diaphragm. centripetal spread Hodgkin’s Lymphoma + Reed Sternberg cells? • Type w/ best prognosis? Lymphocyte predominant • More likely to involve Non-hodgkin’s Lymphoma extranodal sites? (spleen. staging laparotomy is done. >40. “B-symptoms” = poor prognosis along w/ fevers & 10% weight loss. II = 2 groups. BM) I = 1 node group. IV = BM or liver • Treatment? I/II get rads III/IV get ABVD chemo . painless. same side of diaphragm. extension into organ.
If old. immunoglobulin MGUS spike found on routine exam • Older pt w/ generalized Polycythemia Vera pruritis and flushing after hot bath.Scheduled phlebotomy.IgG monoclonal spike – Best 1st test– Confirmatory test. Hydration and • Dizziness. • No sxs. hearing/vision lasix then bisphosphonate for hyperCa problems and monoclonal Waldenstrom Macroglobulinemia IgM M-spike. – Best 1st test.Other hematologic randoms… • Bone pain. carboxy-Hb) – Tx.If young. melphalan + prednisone. BM transplant.Bone marrow bx showing >10% plasma cells. HA.Check epo. “punched out Multiple Myeloma lesions” on *x-ray*. Hydroxyurea can prevent thromboses . hyper Ca Serum protein elecrophoresis. – Tx. (PSG. Hct of 60%. make sure it isn’t secondary.
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