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1.10 First Aid for the Wards
Internal medicine Part 1
304
Medical
Professional
01/10/2013

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Term
What is the atrial rate in atrial fibrillation? ventricular rate?
Definition
atrial= 400-600; ventricular= 80-160
Term
What is the risk of developing AF as you age?
Definition
doubles with each decade over age55; at age 80, prevalence is about 10%
Term
What are some causes of atrial fibrillation?
Definition
COPD, pulmonary embolism, pheochromocytoma, pericarditis, Ischemic heart disease, hypertension, rheumatic heart disease, anemia, atrial myxoma, thyrotoxicosis, ehtanol and cocaine, sepsis
Term
What is the most common symptom of atrial fibrillation?
Definition
fatigue
Term
Describe the ECG of Afib?
Definition
narrowcomplex rhythm (QRS <120 msec), variable RR intervals and irrgular or absent P waves
Term
What workup is indicated for afib?
Definition
ECG, echo, TSH, INR/aPTT
Term
How can you emergently control ventricular rate of a fib?
Definition
IV calcium channel blockers (diltiazem( or beta blocker (metoprolol); hypotension is an adverse medication reaction that may require immediate DC cardioversion
Term
What are some ways to control ventricular rate of nonemergent a fib?
Definition
oral beta blockers (atenolol) and calcium channel blockers (verapamil or diltiazem) +/- digoxin
Term
About what do you want the ventricular rate to be if you are treating tachycardia secondary to afib?
Definition
less than or equal to 80 bpm at rest and up to 110 with activity
Term
What drug do you use to convert a fib to sinus rhythm?
Definition
amiodarone
Term
What are contraindications to pharmacologic conversion of afib?
Definition
onset >1 month and severe left atrial dilatation (chamber >46 mm by echo)
Term
What is more successful for cardioversion of a fib, drugs or cardiovert?
Definition
cardiovert
Term
What voltage do you start out with to convert afib?
Definition
100 J DC
Term
What should you do before electric cardioversion of afib?
Definition
if arrhythmia has been present for >48 hours, the patient must either be anticoagulated with warfarin for 3-4 weeks before cardioversion or recieve TEE to exclude an atiral thrombus
Term
After succesful electric cardioversion of afib it is important to always...
Definition
anticoagulate pt for at least four weeks after cardioversion
Term
What are the two surgical techniques to treat afib?
Definition
open maze procedure or catheter ablation
Term
By what percent are you decreasing stroke risk in pts with afib when you anticoagulate them?
Definition
with aspirin decreases by 22%; with warfarin decreases by 62%
Term
What is the risk of stroke in pts with afib each year?
Definition
4.5%
Term
What is the goal INR for anticoagulation of afib?
Definition
2-3
Term
What percent of elderly patients have CHF?
Definition
10% of those >70
Term
Most people hospitalized for CHF are what age?
Definition
>65
Term
What infections can cause CHF?
Definition
viral cardiomyopathy or HIV
Term
What is the most common cause of CHF?
Definition
chronic ischemic heart disease
Term
What are some common causes of CHF exacerbation in previously stable patients?
Definition
forgetting to take meds, arrhythmia, anemia, MI/ischemia, infection, increased salt intake, increased cardiac output (pregnancy, hyperthyroidism), renal failure, PE
Term
What is the most common cause of CHF in a previously stable patient?
Definition
excessive sodium intake
Term
Name some causes of dilated cardiomyopathy?
Definition
idiopathic, drugs (ethanol, cocaine, heroin, doxorubicin), postmyocarditis, postpartum,HIV, Chagas, anemia, thiamine deficiency, thyrotoxicosis
Term
Hypertension causes what type of heart failure?
Definition
"hypertensive burnout"= initially a diastolic dysfunction but after the myofibrils stretch, the EF falls and systolic dysfunction results
Term
Valvular heart disease causes what type of heart failure?
Definition
initally diastolic dysfunction but later systolic dysfunction
Term
Systolic dysfunction can be caused by what two types of problems?
Definition
decreased contractility or increased afterload
Term
What are some common causes of increased afterload leading to decreased contractility?
Definition
HTN, aortic stenosis, ventricular dilation due to aortic insufficiency
Term
Diastolic dysfunction can be due to what two kinds of abnormalities?
Definition
abnormal active relaxation (ischemia, hypertrophic cardiomyopathy), abnormal passive filling (restrictive cardiomyopathy or concentric hypertrophy from hypertension)
Term
What is the least common cardiomyopathy?
Definition
restrictive cardiomyopathy
Term
What are some infiltrative disorders that can cause a restrictive cardiomyopathy?
Definition
sarcoidosis, amyloidosis, scleroderma, hemochromatosis, glycogen storage disease
Term
Systolic dysfunction is defined as an EF of...
Definition
<40%
Term
What are some early signs of left heart failure?
Definition
DOE; decreased exercise tolerance
Term
What are some early signs of right sided heart failure?
Definition
anorexia, cyanosis and fatigue, increased JV, pulsatile hepatomegaly (with possible transaminitis), peripheral edema on exam
Term
Is tachycardia a sign of left heart failure or right heart failure?
Definition
left
Term
Is diaphroesis a sig of left or right heart failure?
Definition
left
Term
S4 can be caused by a number of conditions, most commonly...
Definition
hypertension, CAD, and diastolic dysfunction
Term
What is the most common cause of right heart failure?
Definition
left heart failure
Term
What are the NYHA classifications for CHF?
Definition
I= no symptoms with normal activities; II=slight limitation of activities; III= only comfortable at rest; IV= symptoms present at rest
Term
What are the AHA/ACC CHF stages?
Definition
A= at high risk for developing HF, B= structural heart disease is present but no symptoms, C= prior or current symptoms of heart failure, D= refractory heart failure
Term
What is the treatment for stage C heart failure?
Definition
full range of heart failure drugs (ACEI, ARB, beta blockers, and diuretics), and sodium restriction
Term
What is the treatment for stage D heart failure?
Definition
mechanical circulatory support, continuous inotropes, cardiac transplantation, or hospice care
Term
What is the cause of pulmonary congestion in diastolic dysfunction?
Definition
increased hydrostatic pressure (activation of the renin-angiotensin-aldosterone system is usually not prominent)
Term
What will CXR of CHF show?
Definition
cardiomegaly, pulmonary vascular congestion (dilated vessels, interstitial or alveolar edema, kerley-b lines)
Term
Is there ever an indication to do cardiac cath in a pt with CHF?
Definition
yes; if there is suspicion of concurrent MI
Term
Name two common beta blockers used to treat heart failure?
Definition
carvedilol or metoprolol succinate
Term
Results of the SOLVD trial=
Definition
ACEIs decrease mortality and hospitalization with pts with class II-IV CHF; however 1% of people stop the ACEI because of the cough
Term
results of the CHARM study=
Definition
ARBs have a similar effect on hospitalization and cardiovascular mortality as ACEis
Term
What are the results of the COPERNICUS trial?
Definition
carvedilol, a mixed alpha and beta blocker, decreases mortality and hospitalization in class I-IV CHF
Term
What are the results of the RALES trial?
Definition
spironolactone decreased mortality in patients with class III and IV CHF by 30% when given WITH ACEIs or diuretics +/- digoxin
Term
What were the results of the EPHESUS trial?
Definition
shows that eplerenone confers similar benefits of spironolactone in heart failure with a decreased incidence of side effects such as gynecomastia and impotence
Term
What were the results of the A-HeFT study?
Definition
hydralazine and isosorbide dinitrate is beneficial in pts with symptomatic CHF; a study ofafrican americans demonstrated a 43% decrease in oneyear mortality
Term
What were the results of the DIG trial?
Definition
digoxin yields sympomatic relief in CHF but has no significant effect on decreased mortality and may increase mortality in women
Term
Name some causes of high output heart failure?
Definition
thyrotoxicosis, severe anemia, Paget's disease, beriberi and AV fistulas
Term
How do you treat diastolic dysfunction heart failure?
Definition
diuretics (decrease afterload), CCBs (induce brady and fascilitate myocardial relaxation), beta blockers (induce mild brady and inhibits coronary remodeling), NTG (decrease preload and dilates large coronary arteries), antiarrhythmics (if indicated)
Term
What are some nonpharmacologic interventions useful for CHF?
Definition
weight loss, sodium restriction (<2g/day), and fluid restriction (<1.5 L/day)
Term
What is the incidence of HTN in the elderly?
Definition
>40% over 65
Term
What percent of HTN goes undiagnosed?
Definition
1/3
Term
What percent of HTN is "essential" or "primary"?
Definition
95%
Term
What are some risk factors for developing essential hypertension?
Definition
age, DM, obesity, family history, diet (salt, alcohol, fat), lifestyle (inactivity, stress), major depression, ethnicity
Term
Which ethnicities have the highest and lowests risk of developing essential hypertension?
Definition
african american > caucasian=hispanic > asian
Term
What are some secondary causes of hypertension?
Definition
renal disease, drug effects, endocrine disorders, pregnancy, aortic coarctation, obstructive sleep apnea
Term
What are some renal diseases that can result in HTN?
Definition
fibromuscular dysplasia in young women, atherosclerotic disease, renal parenchymal disease (polycystic kidney disease, and renal cell carcinoma)
Term
What are some drugs that can cause HTN?
Definition
OCPs, corticosteroids, COX-2 inhibitors, amphetamines, epoetin alfa (epogen), lead poisoning
Term
What are some endocrine disorders that can cause HTN?
Definition
cushing syndrome, hyperaldosteronism, pheochromocytoma, hyperthyroidism, hyperparathyroidism, PCOS, acromegaly
Term
How do you diagnose HTN?
Definition
diagnosis is based on the mean of two or more seated readings on each of three or more encounters; the diagnosis is valid if pts are >18 yoa, have no acute illness, and have no 2ndary causes (diabetes, renal failure)
Term
When should you be suspicious of secondary hypertension?
Definition
pt is < 20 or >50; sudden-onset or severe hypertension, has hypertension that is refractory to treatment or has a suggestive H and P
Term
Which patient population should you avoid calcium channel blockers to treat HTN and why?
Definition
women; increased risk of CV mortality
Term
What are the JNC 7 BP goals?
Definition
<140/90 unless they have diabetes or renal disease (<130/90)
Term
What is stage II HTN?
Definition
>159/>99
Term
Heart failure + HTN=
Definition
diuretics, beta blockers, ACEIs/ARBs, aldosterone antagonists
Term
Post-MI + HTN=
Definition
beta blockers, ACEIs, aldosterone antagonists
Term
HTN + high risk for CAD =
Definition
duretics, beta blockers, ACEIs, calcium channel blockers
Term
DM + HTN=
Definition
diuretics, beta blockers, ACEIs/ARBs, calcium channel blockers
Term
Chronic renal failure + HTN=
Definition
ACEI/ARB
Term
CVA/stroke + HTN=
Definition
diuretics, ACEIs
Term
Osteoporosis + HTN=
Definition
thiazides
Term
BPH + HTN=
Definition
alpha blockers
Term
What are the lifestyle recommendations for patients with HTN?
Definition
weight loss, sodium restriction <2.6 g/day, exercise, 1 drink/day for women or 2 drinks/day for men, and eating a diet high in fruits and vegetables and limited in saturated fat
Term
What trial proves that thiazides are the best first line therapy for HTN?
Definition
ALL-HAT
Term
Why are AA more susceptible to HTN?
Definition
they may have decreased nitric oxide levels and may be more sensitive to a high-salt diet than other groups
Term
Results of the ASCOT trial?
Definition
calcium channel blocker therapy (amlodipine) +/- AEIs decreases teh risk of stroke and heart attack in comparison to beta blockers +/- thiazides; statin therapy decreases CV events without regard to serum cholesterol level
Term
What are the features of hypertensive retinopathy?
Definition
arteriosclerotic narrowing, AV nicking, ischemic changes ("cotton-wool" spots), hemorrhages, exudates, papilledema, visual acuity loss (if the macula is involved)
Term
What is the mean age of onset for infective endocarditis?
Definition
60 yrs
Term
What is the mortality rate for infective endocarditis?
Definition
1/4
Term
What factors predispose to infective endocarditis?
Definition
local hemodynamic abnormalities, presence of endothelial damage, the presence of circulating bacteria and the status of the host's immune system
Term
What organism is the main cause of acute endocarditis? subacute?
Definition
infection of normal heart valves with s. aureus; infection of abnormal heart valves with S. viridans
Term
What are some findings on physical exam of infective endocarditis?
Definition
changing murmur; splenomegaly
Term
Name some risk factors for infective endocarditis?
Definition
rheumatic heart diseae, aortic valve disease, mitral valve prolapse, congenital valve abnormalities, the presence of foreign bodies (pacemakers, prosthetic valves), senile calcification, poor dentition and a history of IVDU
Term
What are some complications associated with infective endocarditis?
Definition
CHF, embolization, glomerulonephritis, anemia, and myocardial abscess formation
Term
What gender is more commonly affected by IE?
Definition
men
Term
What are the etiologies for culture negative endocarditis?
Definition
haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
Term
What are some cause of native valve endocarditis?
Definition
the most common causes are strep spp and enterococcus
Term
What are causes of presthetic valve endocarditis?
Definition
early= staph epidermidis; late= same as native valve
Term
What organisms cause post surgical endocarditis?
Definition
gram negative species or enterococcus
Term
Organisms responsible for endocarditis secondary to IVDU?
Definition
s aureus; consider this agent in the presence of a tricuspid valve lesion
Term
Name some fungi and atypical bacteria that can cause IE?
Definition
candida or aspergillus; rickettsia, chlamydia
Term
What labs should you get for IE?
Definition
CBC, ESR, UA, RF, at least two sets of blood cultures
Term
What does the CBC show in IE?
Definition
leukocytosis in acute; moderate anemia in subacute
Term
What duke criteria do you need to make a dx of IE?
Definition
two major, one major with three minor, or five minor
Term
What are the major criteria for IE?
Definition
persistently positive blood cultures; evidence of endocardial involvement or new valvular regurge
Term
What is the definition of persistently positive blood cultures?
Definition
two or more positive cultures sperated by at least 12 hours, three or more cultures at least one hour apart or 70% of cultures positive if four or more are drawn
Term
What are hte minor criteria for IE?
Definition
fever >38C, vascular phenomena, immunologic phenomena, predisposing heart abnormality or IVDU, + blood cultures, + echo
Term
What are some vascular phenomena associated with IE?
Definition
arterial emboli, janeway lesions, pulmonary emboli, mycotic aneurysms, intracranial hemorrhage
Term
What is a janeway lesion?
Definition
painless lesion on the palms and soles 2ndary to embolization
Term
What are some immunologic phenomena associated with IE?
Definition
osler's nodes, glomerulonephritis, +RF, roth spots
Term
What are roth spots?
Definition
retinal hemorrhages
Term
What are Osler's nodes?
Definition
immunologic phenomena causing painful nodes on the tips of the fingers or toes
Term
Heart valvular dysfunction requiring surgery is common with which class of organisms?
Definition
fungi
Term
What is the treatment for IE?
Definition
4-6 weeks of high dose IV antibiotics
Term
What is empiric treatment of IE?
Definition
vancomycin (traditionally beta lactam with two weeks of aminoglycoside for synergy, can still use aminoglycoside with vanc)
Term
When is surgery indicated for IE?
Definition
severe, refractory CHF; treatment resistant, infection of prosthetic valve, suspected fungal infection, recurrent embolic events, progressive intracardiac spread of infection
Term
What abx can prophylax pts with valvular abnormalities against IE when getting dental procedures?
Definition
amoxicillin or clarithromycin
Term
Syncope with head turning, tight collars or shaving=
Definition
carotid sinus hypersensitivity
Term
syncope with arm exercise=
Definition
subclavian steal syndrome
Term
"drop attacks" or neurogenic causes of syncope=
Definition
TIAs of the vertebrobasilar circulation (very large strokes of the antior circulation can lead to LOC but these patients will also have neurologic deficits if and when they arise)
Term
What is the definition of orthostatic hypotension?
Definition
systolic BP will decrease at least 20 mmHg within 2-5 minutes after the patient changes position from supine to standing
Term
What is the sensitivity of Holter monitoring?
Definition
20-50% sensitive
Term
How do you treat vasovagal syncope?
Definition
avoidance of triggers, beta blockers, anticholinergics, or pacemaker placement
Term
In sudden death in pts less than 35, what is the cause?
Definition
1/3 are idiopathic; 1/2 are cardiac
Term
What is the typical age of pts presenting with valvular heart disease?
Definition
7th decade; except for mitral stenosis which presents in the fourth and fifth decades
Term
What is the leading cause of valvular heart disease?
Definition
degenerative heart disease; MCly calcific stenosis related to atherosclerosis
Term
What are some risk factors for aortic stenosis?
Definition
rheumatic heart disease, congenital stenosis/bicuspid valve, age-related degeneration
Term
What is the clasic triad of symptoms for aortic outflow obstruction?
Definition
angina, syncope and heart failure
Term
What is the mortality rate for symptomatic aortic outflow obstruction?
Definition
depends on the symptoms; 50% mortality at 5,3, and 2 yrs respectively for angina, syncope, and heart failure
Term
What are findings on physical exam of aortic outflow obstruction?
Definition
pulsus parvus et tardus, sustained apical beat; S 4 and soft S2 heart sounds
Term
Describe the murmur of aortic stenosis?
Definition
midsystolic crescendo-decrescendo murmur at 2nd interspace radiation to carotids with a musical apical component, systolic ejection click
Term
What is the musical apical componenet of aortic stenosis murmur called?
Definition
gallavardin phenomenon
Term
T/F Intensity of murmur relates to severity of aortic stenosis.
Definition
false
Term
What is the HOCM murmur?
Definition
systolic diamond shaped harsh murmur at the apex and left sternal border, with poor transmission to the carotids; earlier and longer with decreased left ventricular size (valsalva or standing), decreased with increased left ventricle size (squatting)
Term
What is the treatment for aortic stenosis?
Definition
avoid afterload reduces (such as vasodilators and ACEIs) and Beta blockers; gentle diuretics for congestive symptoms, consider antibiotic prophylaxis
Term
When is ballon valvuloplasty used for AS?
Definition
as palliation for poor surgical candidates
Term
What are the critical values for evaluating aortic stenosis?
Definition
aortic orifice <0.5 cm2; or pressure gradient > 50mmHg
Term
What is the treatment for HOCM?
Definition
avoid strenuous exercise; beta blockers may be used to decrease outflow obstruction; surgical myomectomy or pacemaker placement
Term
What aortic valve diseases can cause aortic insufficiency?
Definition
rheumatic heart disease, endocarditis, congenital bicuspid valve
Term
What are some aortic root diseases that can cause aortic insufficiency?
Definition
HTN, ehlers-Danlos, Marfan's, collagen vascular disease, vasculitis (Takayasu's, giant cell), aortic dissection, syphilitic aortitis, idiopathic aortic root dilation, subaortic VSD, trauma
Term
What are symptoms of chronic aortic insufficiency?
Definition
gradual onset angina, dysnpea, orthopnea, PND
Term
What are some physical exam signs of aortic insufficiency?
Definition
signs of LVH and left heart failure, increase in stroke volume, widened pulse pressure, laterally displaced PMI,possible brachial pulsus bisferiens
Term
Twin pressure peaks assoc with aortic insufficiency=
Definition
brachial pulsus bisferiens
Term
What is the murmur of aortic insufficiency?
Definition
high pitched, blowing diastolic murmur over left sternal border that is loudest when leaning forward; austin flint murmur, midsystolic murmur at the base due to high volume flow
Term
What is an Austin Flint murmur?
Definition
similar to murmur of MS but without opening snap; assoc with aortic insufficiency
Term
How do you treat aortic insufficiency if aortic valve replacement is not possible?
Definition
afterload reducse (vasodilators such as nifedipine and hydralazine), diuretics, and/or digoxin; consider endocarditis prophylaxis
Term
How do you treat acute decompensation of aortic insufficiency?
Definition
afterload reduces (nitroprusside) and positive inotropes (dobutamine)
Term
Name the typical valvular abnormalities of rheumatic heart diseaes?
Definition
mixed AS/AI + MS
Term
What are some causes of mitral stenosis?
Definition
rheumatic heart disease, congenital stenosis, cardiac myxoma, connective tissue disease (SLE)
Term
What are the symptoms of mitral stenosis?
Definition
right or left heart failure symptoms
Term
What is the murmur associated with mitral stenosis?
Definition
mid diastolic rumble with opening snap at the apex
Term
How do you tell the difference between mitral stenosis and tricuspid stenosis?
Definition
mitral stenosis does not change with inspiration; vs tricuspid stenosis which will increase with inspiration
Term
How do you treat mitral stenosis/
Definition
avoid inotropic agents; consider endocarditis prophylaxis
Term
How do you treat grade I mitral stenosis?
Definition
sodium restriction, diuretics, anticoagulants, digitalis
Term
How do you treat grade II mitral stenosis?
Definition
same as grade I but consider balloon valvuloplasty if no improvement
Term
How do you treat grades III/IV mitral stenosis?
Definition
BV or for refractory disease; valve replacement
Term
What percent of the population has MVP and what predisposes people to have it?
Definition
7%; young women or marfan's syndrome
Term
What is the murmur associated with MVP?
Definition
late systolic murmur with midsystolic clikc (Barlow's syndrome) valsalva leads to an earlier and longer murmur
Term
What is the treatment for MVP?
Definition
don't treat unless symptomatic; routine prophylaxis not recommended and reserved only for high risk patients
Term
What three things can be affected to cause mitral regurg?
Definition
cusp diseae, cordae tendineae dysfunction, mitral annular expansion
Term
What causes cusp disease leading to mitral regurg?
Definition
rheumatic heart disease, endocarditis, congenital cleft valve, myxomatous degeneration
Term
What causes chordae tendinae dysfunction leading to mitral regurge?
Definition
MI, marfan's, MVP
Term
What causes mitral annular expansion leading to mitral regurge?
Definition
dilated cardiomyopathy
Term
What are the symptoms of mitral regurge?
Definition
left heart failure signs that can progress to right heart failure
Term
What is the murmur of mitral regurge?
Definition
high-pitched holosystolic murmur at the apex radiating to the axilla; systolic thrill; laterally displaced hyperdynamic PMI
Term
What is the treatment of acute sympomatic mitral regurge?
Definition
afterload reduction (nitroprusside), inotroipc support (dobutamine), and surgical repair
Term
How do you treat chronic mitral regurg?
Definition
ACEIs, vasodilators/nitrates, diuretics, digoxin, anticoagulants
Term
How do you diagnose chronic bronchitis?
Definition
excessive bronchial secretion with productive cough for at least three months per year over two consecutive years
Term
What is the emphysema pattern associated with smoking vs alpha 1 antitrypsin def?
Definition
smoking= centrilobular; def= panacinar
Term
What imaging findings are pathognomonic for emphysema?
Definition
parenchymal bullae, subpleural blebs
Term
Symptoms of COPD occur when ___% of lung function is lost.
Definition
50
Term
Decreased breath sounds is associated with what type of COPD?
Definition
emphysema
Term
Pursed lips is associated with what type of COPD?
Definition
emphysema
Term
DOE is associated with what type of COPD?
Definition
emphysema
Term
Cyanosis is associated with what type of COPD?
Definition
chronic bronchitis
Term
Crackles is associated with what kind of COPD?
Definition
chronic bronchitis
Term
CXR of emphysema shows=
Definition
hyperinflation, hyperlucency, loss of capillary-alveolar surface area, a flattened and depressed diaphragm, widened retrosternal air space and increased AP diameter
Term
CXR of chronic bronchitis=
Definition
ther are no specific findings for chronic bronchitis on CXR or PFTs except those assocaited with comorbid emphysema
Term
What are the findings of COPD on ABG?
Definition
acute respiratory acidosis; as well as increased alveolar arterial oxygen gradient
Term
What is first line therapy for COPD?
Definition
anticholinergics (ipratropium)
Term
What is the teratment for acute exacerbation of COPD?
Definition
supplemental O2, hydration, IV or oral steroids, anticholinergics and beta agonists; antibiotics (TMP-SMX, cefuroxime) in the presence of concurrent infection
Term
What is the only therapy that can slow the disease process of COPD?
Definition
smoking cessation
Term
What are indications for home oxygen for COPD?
Definition
PO2 <55mmHg or SaO2 88%; PO2 55-59 with symptoms of hypoxia (mental status changes, right sided heart failure from cor pulmonale, polycythemia)
Term
What are some complications that can result from COPD?
Definition
destruction of pulmonary vasculature>pulmonary hypertension>cor pulmonale; pneumonia; bronchogenic carcinoma
Term
What percent of CXRs have solitary pulmonary nodules and what percent of these are not malignancies?
Definition
0.1-0.2% of CXRs; 60-90% do not represent a malignancy
Term
OF all solitary pulmonary noduls what percent are primary lung and what percent are mets?
Definition
1/2 and 1/2
Term
What percent of smokers develop lung cancer?
Definition
15%
Term
What percent of lung cancers are caused by smoking?
Definition
85%
Term
Smoking + what other factors can increase the risk of lung cancer?
Definition
asthma and vitamin E supplementation
Term
Besides smoking, what else can increase your risk of lung cancer?
Definition
radon exposure, environmental exposure (arsenic, asbestos, uranium, chromium) and first generation familial history
Term
What percent of patients with lung cancer are asymptomatic at the time of diagnosis?
Definition
10-25%
Term
Why is it important to get a biopsy in the work up for lung cancer?
Definition
treatment and prognosis is predicated on whether the cancer is small cell or non small cell
Term
Name some complications from lung cancer?
Definition
superior vena cava syndrome, pancoast tumor, horner's syndrome, endocrine, recurrent laryngeal symptoms, effusions (pleural or pericardial)
Term
What is the treatment/prognosis of NSCLC?
Definition
surgical resection followed by radiation/chemo; early stage NSCLC is curable
Term
What is the treatment and prognosis of SCLC?
Definition
nonresectable but usually responsive to combination and radiation therapy; recurrence is common
Term
What is the definition of a chronic cough?
Definition
cough present for > 3 weeks
Term
% of 1/2 ppd smokers with chronic cough=
Definition
25%
Term
90% of chronic cough are caused by what causes?
Definition
GERD, asthma, smoking, postnasal drip, chronic bronchitis
Term
Name some less common causes of cough after the top 5 most commonl.
Definition
medication (ACEIs), airway hyperresponsiveness secondary to URI, malignancy, TB, aspiration, foreign bodies, occupational irritants, psychogenic factors, CHF, and irritation of cough receptors in the ear
Term
Which lung cancers have as strong association with smoking?
Definition
SCLC>squamous cell carcinoma
Term
Which lung cancer has a weak association with smoking?
Definition
adenocarcinoma
Term
Which lung cancer has a moderate association with smoking?
Definition
large cell carcinoma
Term
Name the different types of lung cancer and the % incidence?
Definition
SCLC (15-25); squamous (20), adeno (60), large cell (20), mesothelioma (3-5%), carcinoid (6)
Term
Where do carcinoids of the lung occur?
Definition
subsegmental bronchi
Term
Name some paraneoplastic syndromes with small cell lung cancer?
Definition
cushing's, SIADH, hypercalcemia, ectopic ACTH, peripheral neuropathy, lambert-eaton, SVC
Term
What is the 5 yr survival of SCLC?
Definition
5-10%
Term
What is pulmonary osteoarthropathy?
Definition
clubbing, periostitis, arthritis
Term
What are some paraneoplastic syndromes of squamous cell carcinoma?
Definition
hypercalcemia from PTH-related peptide, hypertrophic pulmonary osteoarthropathy, SVC syndrome
Term
What are some paraneoplastic syndromes of adenoca of the lung?
Definition
hypertrophic pulmonary osteoarthropathy, thrombophlebitis
Term
What mutation is associated with adenoca of the lung?
Definition
Ras gene mutations in 30%
Term
Name some paraneoplastic syndromes of large cell carcinoma?
Definition
gynecomastia, galactorrhea, hypertrophic pulmonary osteoarthropathy
Term
How long does it take asbestos to cause mesothelioma?
Definition
20-40 years
Term
What lung cancer is very uncommon in african americans?
Definition
carcinoid
Term
What are some symptoms of carcinoid of the lung?
Definition
tachycardia, flushing, bronchial constriction, diarreha, cushing's syndrome
Term
What lung cancer has the best prognosis regardless of stage?
Definition
carcinoid (60-95% 5 yr survival)
Term
What are the most common cancers to metastasize to the lung?
Definition
colon, breast, renal, osteosarcoma, melanomas
Term
T/F Pleural effusions are often asymptomatic.
Definition
true
Term
Name some causes of transudative pleural effusion.
Definition
CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis, SVC obstruction, myxedema, urinothorax, protein losing enteropathy, pulmonary embolism
Term
What are some causes of exudative effusion?
Definition
bacterial infection, neoplasm, pulmonary embolism with infarction, TB, viral infection, collagen vascular disease, pancreatitis, hemothorax, sarcoidosis, uremia, asbestosis, pericardial diseae, chylothorax, iatrogenic
Term
Name some causes of bloody pleural fluid.
Definition
neoplasm, TB, traumatic tap, pulmonary embolus, hemothorax
Term
What are some causes of pleural fluid with low glucose?
Definition
neoplasm, TB, empyema, RA
Term
What are some causes of lymphocytic pleural fluid?
Definition
viral infection, TB, malignancy
Term
What are some causes of milky pleural fluid?
Definition
chylothorax
Term
What are some physical exam findigns of pleural effusion?
Definition
decreased breath sounds, dullness to percussion and decreased tactile fremitus
Term
Pleural fluid with a very low glucose and negative gram stain==
Definition
RA
Term
What studies should you get on pleural fluid?
Definition
CBC with diff, glucose, gram stain, protein and LDH ratios, amylase, pH, cytology
Term
What are "light's criteria"?
Definition
pleural fluid protein/serum protein >0.5 and pleural fluid LDH/serum LDH >0.6 (or pleural fluid LDH > 2/3 the upper limit of normal serum LDH) are suggestive of an exudate as opposed to a transudate
Term
High amylase in pleural fluid indicates....
Definition
esophageal rupture, pancreatic pleural effusion or malignancy
Term
What is the normal pH of pleural fluid? What is considered acidic?
Definition
7.60; 7.30
Term
An acidic pleural fluid pH can be due to...
Definition
empyema, rheumatoid pleurisy, tuberculous pleurisy or malignancy
Term
What is a low pleural fluid glucose?
Definition
<60
Term
What symptoms characterize atypical pneumonia as oppossed to typical pneumonia?
Definition
atypical= dry cough, myalgias, headaches, sore throat, and pharyngitis
Term
What is empiric treatment for CAP?
Definition
flouroquinolones or ceftriaxone/azithromycin
Term
pneumonia with "rust colored sputum"=
Definition
pneumococcus
Term
pneumonia with "currant-jelly" sputum?
Definition
klebsiella
Term
pneumonia with cold agglutinins=
Definition
mycoplasma
Term
pneumonia with increased LDH=
Definition
PJP
Term
Breath sounds associated with pneumonia=
Definition
decreased vesicular but increased bronchial
Term
What are the breath sounds associated with pleural effusion?
Definition
decreased breath sounds with inspiratory crackles
Term
What antibiotics is commonly used in patients with pneumonia to cover for legionella?
Definition
azithromycin
Term
How do you determine whether to hospitalize a patient with pneumonia?
Definition
port score
Term
When can a patient with pneumonia on IV antibiotics switch to oral antibiotics?
Definition
if they have been afebrile for 24 hrs
Term
What can be done to loosen consolidation and improve aeration in patients with pneumonia?
Definition
incentive spirometry, ambulation, CPT, and hydration
Term
What are the suspected pathogens in outpatient CAP otherwise healthy?
Definition
S pneumo, mycoplasma neumo, H. flu, virus
Term
What should you use to treat outpatient CAP?
Definition
macrolide (clarithromycin or azithromycin), doxycycline, or beta lactam
Term
What kind of corganisms cause CAP in pts over 60 or with comorbidities?
Definition
S pneumo, H flu, aerobic gram negative rods (e coli, enterobacter, klebsiella), S aureus, legionella, viruses
Term
How do you treat CAP with age >60 or with comorbidities?
Definition
second generation cephalosporin (cefuroxime) or amoxicillin/clavulanate; add azithromycin if atypicals are suspected; alternatively flouroquinolone monotherpay
Term
What are some suspected pathogens in CAP requiring hospitilization?
Definition
S pneumoniae, H. flu, anaerobes, aerobic GNRs, legionella, chlamydia, mycoplasma, pseudomonas
Term
How do you treat CAP requiring hospitilization?
Definition
azithromycin with a second or third generation cephalosporin (cefotaxime or ceftriaxone) or a beta lactam with a betalactamase inhibitor; alternatively flouroquinolone monotherapy
Term
What are some causes of nosocomial pneumonia?
Definition
GNRs, including pseudomonas, S aureus, legionella and mixed flora
Term
Whom do you vaccinate against pneumococcus?
Definition
>65; children 2-23 months; chronic systemic illness, decresaed immune function, alaskan natives and selected native american populations
Term
What percent of patients with pneumococcal pneumonia get bacteremia?
Definition
30%
Term
T/F Pneumonia increases the risk of MI and stroke.
Definition
true
Term
What is the definition of acute renal failure?
Definition
abrupt decrease in renal function leading to retention of creatinine and BUn often accompnied by oliguria or anuria
Term
What is the definition of oliguria?
Definition
100-400 mL/day UOP
Term
What is the definition of anuria?
Definition
urine output <100mL/day
Term
How do you calculate the FeNa?
Definition
(urine Na X plasma Cr)/(plasma Na X Urine Cr) X 100
Term
When do you treat acutre renal failure with bicarb?
Definition
if HCO3- is equal to or less than 16 or serum pH is <7.2
Term
What dietary restriction should you impose on pts in acute renal failure?
Definition
K less than or equal to 40 mEq/day; PO4 <800 mg/day
Term
After relieve urinary obstruction, what complication should you look out for?
Definition
posobstructive diuresis can lead to inappropriate loss of fluid an delectrolytes
Term
Name some causes of prerenal ARF?
Definition
hypovolemia, systemic vasodilation, renal vasoconstriction (ACEI/ARBs), decreased cardiac output
Term
What are some types of intrinsic renal failure?
Definition
acute tubular necrosis, acute interstitial nephritis, renovascular, glomerular injury
Term
What are some causes of ATN?
Definition
ischemia, contrast dye, amnoglycosides, amphotericin
Term
What are some causes of acute interstitial nephritis?
Definition
beta lactams, sulfa drugs, NSAIDs
Term
What are some renovascular causes of intrinsic ARF?
Definition
HUS/TTP, DIC, vasculitis, cholesterol emboli
Term
Crystal precipitation in tubules causes what type of renal failure?
Definition
postrenal acute renal failure
Term
What are some distinguishing features of lab workup for prerenal ARF?
Definition
BUN/CR >20; FeNa <1%; urine osmolarity >500 mOsm/kg; bland UA with no hyaline casts
Term
How do you treat prerenal ARF?
Definition
fluid repletion in small defined boluses and frequent monitoring of electorlytes and acid base balance
Term
What are the distinguishing features of ARF due to intrinsic renal disease on lab workup?
Definition
BUN/Cr<20; FeNa >2%; urine osmolarity <350 mOsm/kg; UA shows muddy/granular casts +/- RBCs/protein in ATN; +eosinophils if AIN from antibiotics
Term
What are the distinguishing features of post renal ARF on laboratory workup?
Definition
bland UA +/- RBC casts if nephrolithiasis; renal U/S identifies upper an dlower tract obstruction and can also distinguish acute from chronic renal failure
Term
What are indications for dialysis?
Definition
acidosis unresponsive to medical therapy, electrolyte abnormalities (K >6.5 mEq/L), ingestions (methanol, ethylene glycol), overload of fluid, uremic symptoms (pericarditis or encephalopathy)
Term
What is the defnition of CKD?
Definition
three or more months of reduced GFR (<60 mL/min/1.73m2 and/or kidney damage (abnormal pathology, blood/urine tests, or imaging)
Term
What percent of americans ahve CKD?
Definition
16.8%
Term
When do symptoms develop from CKD?
Definition
usually around stage 3 or 4
Term
What are some general symptoms of CKD?
Definition
anorexia, N/V, fatigue, pruritus, metallic taste in the mouth
Term
What are some findings of physical exam suggestive of chronic kidney disease?
Definition
fetor uremicus (breath smelling of urine/ammonia), uremic frost,
Term
What are some cardiovascular complications/symptoms of CKD?
Definition
HTN, LVH, pericarditis, accelerated atherosclerosis, volume overload, CHF, hyperlipidemia
Term
What are some neurologic complications of CKD?
Definition
peripheral neuropathy, encephalopathy, seizures, stupor, coma
Term
What are soem hematologic issues seen with CKD?
Definition
anemia due to deceased production of EPO and also iron deficiency/anemia of chronic diseease
Term
Describe some metabolic poblems associated with CKD?
Definition
hyperkalemia, metabolic acidosis, hyperphosphatemia, hypocalcemia (due to vitamin D deficiency and binding with excess phosphate), secondary hyperparathyroidism leading to osteoporosis
Term
What is stage 1 CKD?
Definition
GFR >90
Term
What is stage II CKD?
Definition
GFR= 60-89
Term
What is stage III CKD?
Definition
GFR= 30-59
Term
What is stage IV CKD?
Definition
GFR= 15-29
Term
What is stage V CKD?
Definition
GFR <15; also caused ESRD
Term
When do you prepare pts with CKD for renal replacement therapy?
Definition
stage IV
Term
What should you do to care for the cardiovascular health of pts with CKD?
Definition
ACEIs/ARBs for HTN with a BP goal of <130/80 (has been shown to decrease the progression of CKD), sodium restriction and/or loop diuretics to prevent volume overload; statins to lower LDL cholesterol (goal <100mg/dL)
Term
When do you give EPO for pts with CKD?
Definition
weekly injections if hemoglobin is <12 in females or less than 13.5 in males; given iron supplementation to maintaine sufficient iron stores (%transferrin saturation >20% and ferritin >100ng/mL)
Term
What medical things in general should pts with CKD avoid?
Definition
nephrotoxic drugs (NSAIDs, aminoglycosides, contrast), avoid blood draws on one arm and subclavian lines to preserve vasculature for future access
Term
What should pts with CKD do to prevent metabolic abnormalities?
Definition
dietary restriction of Na, K PO4 and Mg; bicarb or citrate if HCO3 <22; oral PO4 binders like calcium carbonate taken with meals and calcitriol for renal osteodystrophy
Term
What is renal replacment therapy?
Definition
hemodialysis peritoneal dialysis or renal transplant
Term
What is the definition of nephrotic syndrome?
Definition
severe proteinuria (>3.5 g/day) generalized edema, hypoalbuminemia, and hyperlipidemia
Term
What causes the hypercoagulability of nephrotic syndrome?
Definition
imbalance of clottin factors in the coagulation cascade (due to an overal decrease in anticoagulation proteins especially antithrombin 3 lost in the urine; and to increased hepatic synthesis of procoagulant proteins such as fibrinogen
Term
What are some complications associated with nephrotic syndrome?
Definition
hypercoagulability and infection
Term
What is typically the albumin level in nephrotic syndrome?
Definition
<3
Term
What are some primary renal causes of nephrotic syndrome?
Definition
minimal change disease, focal segmental glomerulosclerosis (membraneous glomerulonephrtitis)
Term
What causes membraneous glomerulonephritis?
Definition
75% idiopathic, but secondary casues include SLE, penicillamine, gold, NSAIDs, HBV, HCV, syphilis, and malignancy
Term
What systemic disease can cause nephrotic syndrome?
Definition
diabetic nephropathy (renal amyloidosis, SLE WHO class V)
Term
Nephritic sydnrome causes can be divided based on what lab value?
Definition
serum complement levels
Term
Name some primary renal diseases that can cause nephritic syndrome with low complement.
Definition
postinfectious GN (membranoproliferative GN)
Term
Name some systemic diseases that can cause nephritic syndrome with low complement.
Definition
SLE WHO class III/IV, infectious endocarditis (HCV, cryoglobulinemia)
Term
What are some primary renal disease that cause nephritic syndrome with normal complement.
Definition
IgA nephropathy; rapidly progressive, ANCA-associated, pauci-immune glomerulonephritis (hereditary nephritis=alport's)
Term
What are some systemic disease that cause nephritic syndrome with normal serum complement levels?
Definition
SLE WHO class II (antibasement membrane disease=goodpastures, vasculitis= polyarteritis nodosa, microscopic polyarteritis, Wegener's granulomatosis, HSP; TTP, HUS)
Term
What is nephritic syndrome?
Definition
inflammatory disorder characterized by acute onset oliguria and ARF; hematuria, subnephrotic range proteinuria, hypertensiona nd edema are also present
Term
What are some signs and symptoms of nephritic syndrome?
Definition
proteinuria, hypertension, azotemia ( high BUN), RBC casts, oliguria, hypertension
Term
Besides UA and CMP, what else should you get to evaluate a patient with nephritic syndrome?
Definition
complement, ANA, ANCA, and anti-GBM antibodies should be measured; a positive ASO titer might be helpful
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