Rapid acting - onset 5-15 min, lasts 3-4 hrs:

1. Lispro (humalog)

2. Aspart (Novolog, Nordisk)

3. Glulisine (Apidra)

Short acting - onset 30-60 min, lasts 6-8 hrs:

1. Regular insulin - good for IV for DKA

Intermediate acting - onset 2-4 hrs, lasts 10-20 hrs:

1. NPH - most pts need 2x daily

Long acting:

1. Glargine (lantus) - onset 1.5 hr, lasts 24 hr

2. Detemir (Levemir) - onset 1 hr, lasts 17 hr

Pre-mixed insulins:

1. 70/30 NPH/regular

2. 70/25 NPH/lispro

3. 50/50 NPH/lispro

4. 70/30 aspart protamine/aspart

1. Increased risk for DM, AD, fatty liver, cancer

2. Guidelines: Fasting glucose >100, BP >130/85, Trigs >150, HDL <40 (men) or <50 (women), waist circumference > 40 men or >35 women --> TEST QUESTION

1. cataracts - correlate with length and severity of DM

2. retinopathy

- T1DM: 25-50% w/in 10-15 years, 75-95% w/in 15 years, 100% in 30 years

- T2DM: Need to see ophthalmologist after being dx and every year thereafter.

- Proliferative: growth of new capillaries and fibrous tissue w/in retina and vitreous. Most common cause for blindness in US. Increased risk for retinal detachment

- Nonproliferative: earliest stae of retinal involvement by DM and is characterized by microaneurysms, dot hemorrhages, exudates, retinal edema

3. Glaucoma: 6% of DM

1. T1DM - 30-40%

2. T2DM - 15-20% - but you see more nephropathy in T2 because there are more T2DM than T1DM

3. Proteinuria. Microalbuminuria. Urea and creatinine accumulation in blood.

- nephrotic syndrome: hypoalbuminemia, edema, increase in LDL

- HTN, proteinuria, early CKD --> glycemic control is not helpful

tinea corporis/circinata

workup: KOH prep

tx: topical antifungals (miconazole, clotrimazole) - continue to treat 1-2 weeks after clearing

- Systemic: griseofulvin 4-6 weeks

tinea cruris (jock itch)

tx: drying powder (miconazole)

topical antifungals (terbinafine)

Systemic (griseofulvin)

1. home monitoring. type 1 - check BG at least 3x a day. type 2 - 1-2x a day for oral meds, more for insulin

2. check ketones when BG >300

3. A1C

4. 1% A1C = 35 BG

7 days of amoxicillin, nitrofurantoin, cephalosporin

- continuous low dose nitrofurantoin for prophylaxis for recurrent

screening: UA during first trimester for everyone

- culture every month until delivery

osteosarcoma

tx: chemo then surgery - no radiation

prognosis: based on response to chemo

chondrosarcoma

tx: surgical resection

1. 16 & 18

2. adenocarcinoma and squamous cell carcinoma (more common)

3. Sx: metorrhagia (breakthrough bleeding), postcoital spotting, cervical ulceration

4. studies: positive pap --> cervical bx and endocervical curettage or conization

5. tx:

- emergency tx of hemorrahge - ligate cervical, uterine, or hypogastric arteries

- CIS (stage 0): total hysterectomy if done having babies, cervical conization/cryo/or laser ablation if not. F/U pap every 3 mos x 1 year then 6 mos x 1 year

- Invasive carcinoma: hysterectomy + radiation + chemo --> referral

1. Monosodium urate, usually due to undersecretion by kidney

2. first attack usually 4-6th decades, usually monoarticular

3. Sx: red, swollen joint. Usually just one at a time. tophi, uric acid stones

4. Labs: 24 hr urine uric acid (low = undersecretion, high = overproduction), ESR and WBC, joint aspiration of tophus

5. tx:

- acute: NSAIDS (INDOCIN), colchicine, steroids, nutrition, NOT allopurinol

- chronic: allopurinol/uloric

1. most common sustained arrhythmia

2. Rhythm: irregularly irregular - loss of AV node synchrony, irregular ventericular response, rapid heart rate, impaired coronary flow, atrial rate >350

3. Causes: ectopic beats from pulmonary veins, alcohol, surgery, electrocution, MI, pericarditis, myocarditis, PE, hyperthyroid

4. most common cause: long standing HTN

5. Sx: most asymptomatic, palpitations, hypotension, pulmonary congestion, angina, syncope, dizziness

6. HALLMARK: exercise intolerance and easy fatiguability

7. workup: EKG w/ no discrete P wave and irregular QRS

- CXR, CBC, BMP/CMP, PT/INR/PTT, TSH, echo, stress test, holter monitor,

8. Acute Tx:

- anticoagulation to 2-3 INR - heparin acute

- Rate control: beta blocker or CCB

- r/o atrial thrombus if >24 hr duration

- hemodynamic instability: 200J synchronized cardioversion, amiodarone or procainamide

9. chornic tx:

- rate control: BB, CCB (verapamil, diltiazem), digoxin

- anticoagulation: coumadin, check INR q 4-6 weeks

Hx of TIA/Stroke/DVT

mitral stenosis

>75 y/o

HTn

CHF

LV dysfunction

L atrial enlargement

Spontaneous echo contrast

Outlines the major risk factors for stroke in pts w/ afib

C: CHF (1)

H: HTN (1)

A: Age >75 (1)

D: DM (1)

S: Stroke or TIQ (2)

Vit D promotoes absorption of calcium

Phosphorous inhibits calcium reabsorption - it is excreted when calcium levels are low

1. Ca > 10.1

2. GI effects usually first: thirst, n/v, constipation

- muscle weakness, hyporeflexia, ataxia, decreased tone

- arrhythmia, cardiac arrest, coma, paralytic ileus, stupor

3. Tx: hydrate w/ NS

- Loop diuretics (Lasix/furosemide) - NOT thiazides

- corticosteroids to block reabsorption

1. <3 wks

2. cough, sputum production

3. most common viral

- bacterial cuases: mycoplasma, chlamydia pneumonia, strep pneumonia, m. catarrhalis, h. flu

- bordetella pertussis in unvaccinated kids

4. tx: supportive, codeine/dextromethorphan sx relief, NSAID

1. smoking

2. at least 3 months a year for 2 consecutive years

3. sx: cough, overweight, cyanosis, mucopurulent d/c, DOE

4. CXR, spirometry

5. Tx: SABA, ipratroprium/theophylline, LABA, ICS

1. sx: cough 10-20 days, sputum production, usually no fever, malaise, CP, sore throat, rhinorrhea, headache

2. workup: cultures, cxr, spirometry

3. tx: supportive, codeine/dextromethorphan, Nsaids

1. >400-500 g (NL is 150g)

2. 750-1000 g

3. clear microorganisms from blod, synthesize IgG, remove abn RBCs, embryonic hematopoeisis

4. enlargement: increased RBC destruction (spherocytosis, thalassemia), congestion (splenic vein thrombosis, portal HTN, banti dz), myeloproliferative (sarcoid), neoplastic, other

5. sx: mild/vague abd pain, early satiety, signs of underlying infx

6. workup: CBC, platelet count, US, CT, splenic bx

malaria

portal vein obstruction

sickle cell

hereditary spherocytosis

TB

splenic abscess

Lupus

CHF

1. Septal

2. Anterior

3. Circumflex artery (lateral)

4. *** Inferior leads - 90% supplied by posterior descending branch of RCA

5. posterior

6. ST elevation

1. LAD MI - ST elevation in V1-V6, I, and aVL

2. RCA MI - ST elevation in II, III, and aVF

1. strep pneumo, H. flu, Strep pyogenes

2. s/s: otalgia, aural pressure, decreased hearing, fever, erythema, decreased mobility of TM, bulging, rupture, otorrhea if rupture

3. Tx: amoxicillin, augmentin, Omnicef, Keflex, cephaclor, ceftriaxone

Thiazides: HCTZ, chlorthalidone

- indications: HTN in blacks, older, obese, smokers

- SE: bone mineral loss; Decreases K, Mg, Na; Increases Ca, uric acid, LDL, TGs, Rash, Gout, ED

Loops: Lasix, furosemide

- Indications: HTN in kidney dysfunction (Cr >2.5)

- SE: *** HYPOKALEMIA, excessive diuresis, same electrolyte disturbance as thiazides

Aldosterone receptor Blockers (spironolactone, amiloride, eplernone)

- SE: *** HYPERKALEMIA, metabolic acidosis, gynecomastia

1. decrease HR, CO, and renin

2. Indications: HTN, cardioprotecive (angina, MI, stable CHF), migraines

3. SE: *** BRONCHOSPASM in predisposed pts (asthma, COPD), FATIGUE, LETHARGY, IMPOTENCEsinus node dysfxn (bradycardia, AV block), raynaud's, CNS (nightmares, excitement, depression), hyperglycemia

Indications: initial tx of choice in mild-mod HTN, more effective in young, white pts, agent of choice in DM bc it delays kidney disease, cardioprotective (CHF)

MOA: stimulate synthesis of vasodilating prostaglandins and reduce sympathetic nervous system activity

SE: *** COUGH, hypotension, hyperkalemia, rash, angioedema, CI In pregnancy

indications: HTN, to cardiovascular outcomes

SE: *** HYPERKALEMIA

MOA: peripheral dilation, less reflex tachycardia and fluid retention

Indications: single drug therapy in HTN, preferable to ACE or BB in blacks/elderly

SE: *** PERIPHERAL EDEMA, headache, bradycardia, constipation

Rate-limiting CCB: verapamil, diltiazem

MOA: relax smooth muscle and reduce BP

SE: *** Marked HYPOTENSION AND SYNCOPE AFTER FIRST DOSE

MOA: stimulate alpha-adrenergic receptors in CNS, reduce efferent peripheral sympathetic outflow

SE: dry mouth, sedation, sexual dysfxn, postural hypotension

Indications: HTN

SE: GI disturbances, tachy, ha, nasal congestion, rash, hirsutism, fluid retention

Blacks: Diuretics or CCB

DM: ACE, ARB

CKD: ACE, ARB, goal <130/80, may need loop

Total cholesterol >240

LDL >160

HDL <40

TGs >200

Dyslipidemia: pts who are not hypercholesterolemia but have low HDL and high TGs - increased risk of CHD

tests: screening lipid profile every 5 years starting at 20 y/o

should be measured at least twice under 12 hr fasting

cholesterol doesn't have to be fasting

Treatment:

- TGs >1000 - CHD and pancreatitis

- CHD or CHD-equivalent: lipid-lowering therapy

- lifestyle changes: 50% carbs, 30% fat, 20% protein

Niacin:

15-25% reduction of LDL

25-35% increase in HDL

SE: flushing

Bile-Acid sequestrants (chloestyramine, colesvela, colestipol)

- reduces coronary events in middle-aged men by 20%

- reduces LDL 15-25%

- increases TGs slightly

- no effect on HDL

- GI upset

HMG-CoA reductase inhibitors (statins):

- inhibits rate-limiting enzyme in formation of cholesterol

- Reduces MI and total mortality

- 35% reduction of LDL

- modest increase in HDL

- muscle aches, monitor LFTs

Fibrates:

- Potent TGs reduction and HDL increase

- 10-15% reduction in LDL

- 40% reduction in Tgs

- 15-20% increase in HDL

- Gemfibrozil, fenofibrate

Ezetimibe:

- Inhibits intestinal absopration of dietary and biliary cholesterol by blocking passage across intestinal wall by inhibiting cholesterol transporter

- 15-20% reduction in LDL

Increase TGs: thiazide, loops, non-selective BBs, isoretinoids, corticosteroids

Increase HDL: nicotinic acid, Fibrates, statins

Decrease HDL: BB, anabolic steroids, exogenous androgens

High risk:

LDL <100

Moderately high:

LDL <130

Moderate risk:

LDL <130 - drugs if >160

Low:

LDL <160 - drugs if >190

Cause: HPV

Tx:

- liquid nitrogen - 2 freeze-thaw cycles

- keratolytic agents (salicylic acid)

- podophyllum resin

- imiquimod 5% cream

- operation

- laser

Pt instruction: could progress to squamous cell carcinoma

1. Pathophys: mucosa infiltrated with eosinophils and T cells which activate mast cells, causing thickening of mucosal surfaces

2. Sx: wheezing, rhonchi, dyspnea, coughing, worse at night, prodrome sx before attack

3. *** ATOPY: predisposition to allergens due to overproduction of IgG

4. Tx:

- bronchodilators - SABA, LABA

- Anticholinergics (2nd line)

- Theophylline

- ICS - helps restore lung fxn and prevent sx

1. SABA

2. Add low dose ICS

3. Low dose ICS + LABA

- OR med dose ICS

4. Med dose ICS + LABA

5. high dose ICS + LABA

6. High dose ICS + LABA + Oral steroid

1. consistent inability to attain or maintain sufficient erection for sexual performance

2. causes: meds (HTN, antidepressants), androgen def, sympathetic denervation, retrograde ejaculation, psychological

3. TX
- hormonal replacement (monitor PSA)

- Vasoactive therapy

- injectable agents

- vaccuum erection device

- penile prosthesis

- vascular reconstruction

1. weight loss leading to body weight >15% below expected

- distorted body image

- fear of weight gain

- absence of 3 consecutive periods

2. sx: depression, anxiety, cold intolerance, constipaiton, bradycardia, hypotension, hypothermia, dry skin, increased lanugo, parotid enlargement, edema

3. labs: anemia, leukopenia, electrolyte abn, BUN/Cr elevation, Depressed LH/FSH

4. supportive care, behavioral therapy, psychotherapy

- TCAs, SSRI, lithium

Sx: binging and purging w/ feelings of guilt or depression, body weight w/in 20% of NL, gastric dilation, pancreatitis, poor denitition, pharyngitis, esophagitis, aspiration, electrolyte abn, constipation, hemorrhoids

tx: supportive care, psychotherapy, antidepressants (SSRIs),

1. primary: grave's, toxic nodular goiter, toxic adenoma, thyroid carcinoma, mutation of TSH receptor

secondary: TSH-secreting pituitary adenoma, thyroid hormone resistnace syndrome, chorionic gonadotropic-secreting tumor, gestational thyrotoxicosis

2. sx: sweating, heat intolerance, loosening of nail beds, hyperpigmentation, thinning hair, lid lag, stare, proptosis, tachy, palpitations, widened pulse pressure, afib, CHF, vomiting

3. TSH - low

T4/T3 - high

4. Tx: beta blockers for sx, radioiodide ablation, thyroidectomy, thionamides

Sx: weight gain, lethargy, fatigue, depression, weakness, dyspnea, arthralgias, myalgia, muscle cramps, menorrhagia, constipation, dry skin, HA, paresthesia

Tests: TSH, T3, T4, LDL, TG

Tx: levothyroxine 25-75 mcg PO daily

1. Hypothyroidism

2. Hyperthyroidism

3. Pituitary insufficiency

Sx: stead pain in RUQ usually precipitated by large/fatty meal, may subside over 12-18 hrs, n/v, fever

labs:

- Leukocytosis

- Bilirubin 1-4 mg/dl

- AST/ alk phos may be elevated

- HIDA

Tx: abx, cholecystectomy

1. def: clotting of blood in a deep vein - usually in calf, thigh, or pelvis

2. Most common cause of PE

3. superficial femoral, popliteal, posterior tib

4. risk factors: >60, cancer, smoking, estrogen receptor modulators (tamosifen, raloxifen), CHF, hypercoagulability disorders, immobilization, indwelling catheters, limb trauma, myeloproliferative disease, nephritic syndrome, obesity, oral contraceptives, pregnancy, prior DVT, sickle cell, surgery w/in past 3 mos

5. Sx: vague aching pain, tenderness along vein, edema, erythema, palpable dilted collateral veins, low grade fever, SOB, Homan's sign

6. Homan's sign: calf discomfort elicited by ankle dorsiflexion with knee extended

7. tests: US w/ doppler, D-dimer, venography, hypercoagulatibility testing

8. tx: Low molecular weight heparin or unfractionated heparin followed by warfarin

fondaparinux

IVC filter

9. Target INR: 2-3

1. UE: indwelling venous catheter

LE: varicose veins

2. Sx: pain, tenderness, indurated cord, warm red skin

3. tx: warm compresses, NSAIDs, local thrombectomy, heparin if extensive

BP Goal: <140/90 or <130/80 for DM or CKD

1. Lifestyle modifications

2. Drugs:

a. Stage 1 ( 140-150/90-99) without compelling indications: Thiazide diuretics or ACE/ARB

b. Stage 2 (>160 SBP or >100 DBP): two drug combo: thiazide + ACE/ARB, CCB, or BB

c. With compelling indications: diuretics, ACE, ARB, BB, or CCB

Heart failure: diuretic, BB, ACE, ARB, Aldo ant

MI: BB, ACE, Aldo ant

High coronary risk: diuretic, BB, ACE, CCB

DM: diuretic, BB, ACE, ARB, CCB

CKD: ACE, ARB

Stroke: Diuretic, ACE

1. infective endocarditis or aortic dissection

2. sx: acute HF or shock

chronic: insidious dyspnea, orthopnea, PND, palpitations, SBP increase, DBP decrease, widened pulse pressure

3. Murmur: blowing, high-pitched, diastolic, decrescendo

4. tx: acute: aortic valve replacement

chronic + sx: valve replacement

chronic w/o sx: vasodilators (CCB or ACE), diuretics, nitrates

1. Sx: exertional syncope, angina, dyspnea, reduced carotid pulse

2. *** Murmur: crescendo-decrescendo ejection murmur at RUSB w/ pt leaning forward

3. *** workup: echo, EKG (LVH), CXR (calcification of aortic cusp), cardiac cath

4. tx: aortic valve replacement, balloon valvotomy

sx: CP, dyspnea, palpitations, dizziness, syncope, migraines, anxiety

murmur: mid-systolic click at left apex in left lateral decubitus

tx: usually none. sometimes BB

Sx: acute - s/s of acute HF and shock

chronic - asymptomatic initially, then dypnea, fatigue, orthopnea, palpitations,

Murmur: holosystolic murmur at apex in left lateral decubitus that radiates to left axilla. decreases with valsalva

Tx: acute: emergency MV repair, nitroprusside, nitroglycerine

Chronic: ACE/ARB, furosemide, dig

1. rheumatic fever

2. sx: asymtpomatic until pregnancy or afib develops - dyspnea, orthopnea, PND, fatigue, hemoptysis, hoarseness, pulmonary HTN

3. Murmur: opening snap at LLSB then lowpitched decrescendo-crescendo diastolic at apex in left lateral decub

4. tx:

- mild sx: diuretics and BB or CCB

- severely sx: valvotomy, comissurotomy, valve replacement

- Abx prophylaxis for valve replacement

most common cause: pulmonary htn

sx: usually none. may have sx of right heart failure

murmur: high pitched, early diastolic decrescendo murmur

tx: manage underlying condition, pulmonic valve replacement

sx: asymptomatic then syncope, angina, dyspnea, JVD

murmur: harsh crescendo-decrescendo at left parasternal

tx: balloon valvuloplasty

sx: neck pulsations, JVD, right HF, dypsnea, pedal edema, ascites

complications: right HF, afib

murmur: holosystolic best at LLSB or epigastrium w/ inspiration (carvallo's sign)

tx: treat cause, annuloplasty, valve repair/replacement

1. rheumatic fever

2. complications: right HF

3. sx: flutter in neck, JVD, fatigue, cold skin, RUQ discomfort (due to enlarged liver), dilated scalp veins w/ recumbence, peripheral edema

4. murmur: opening snap and mid-diastolic rumble

5. tx: low salt diet, diuretics, aldosterone antag, ballon valvotomy, valve repair/replacement

atrial septal defect

tx: >3mm needs surgery

ventricular septal defect

tx: surgery for large defects

PDA

due to lack of prostaglandins

tx: fluid restriction and indomethacin, may need surgery

Coarctation of aorta

consider Turner's in females

tx: surgery in young, stent in older

1. cyanotic with R--L shunt

2. right ventricular outflow obstruction, large VSD, aortic override of ventricular septum, RVH

3. cyanosis, clubbing, PS murmur, tet spells (restlessness, agitation, crying)

PE: RV heave, SEM at LUSB

CXR: boot shpaed heart, RVH

EKG: RAD, RVH

4. Tx: squatting to decrease sx, morphine, surgery

Truncus arteriosus

tx: surgery to close VSD, take PA off common trunk

1. newborn murmur

2. peripheral pulmonary artery stenosis

3. Still's murmur

4. pulmonary ejection murmur

5. venous hum

6. innominate or carotid bruit

1. SEM: ASD, coarctation

2. pansystolic - VSD

3. continuous: PDA, arteriovenous malformation

angina

cardiomyopathy

endocarditis

heart failure

AMI

rheumatic carditis

physical activity

fever

anemia

hyperthyroid

HTN

pregnancy

1. immediate reperfusion with thrombolysis or PCI w/in 90 min

2. fibrinolytics if <3 hours of sx onset or if PCI is not an option

3. MONA-BAH

- Morphine

- Oxygen 2-4 L/min

- Nitro

- Aspirin (160-325 mg chewed)

- Beta Blockers

- ACE/ARB (in first 24 hours)

1. cath if impaired LV fxn, hemodynamic instability, or HF

2. if no cath, stress test 3-6 weeks later

3. drugs: statins, BB, ACE/ARB (if LVEF <40%), ASA, plavix x 1 year, warfarin x 3 mos, amiodarone if any arrhythmias

causes: AMI, CHF exacerbation, acute volume overload, mitral stenosis, a fib

Sx: severe dyspnea, pink/frother sputum, diaphoresis, cyanosis, rales, wheezing, rhonchi

CXR: increased interstitial markings, butterfly pattern, enlarged heart

tx: morphine, IV diuretic, nitrates, echo, cardiac cath

- on discharge from hospital: oral diuretic, ACE, +/- BB

renal parenchymal disease - glomerulonephritis, pyelonephritis, PCKD, obstructive uropathy

renovascular disease

pheochromocytoma

cushing's

primary aldosteronism

congenital adrenal hyperplasia

hyperthyroid

myxedema

coarctation of aorta

excessive alcohol

use of oral contraception

chlamydia

screen all pregnant women, all sexually active women <35 and men/women >25 w/ risk fators

tx: azithromycin IM 1g x 1, doxy 100 mg QD x 7 days, Levaquin 500 QD x 7 days

gonorrhea

tx: azithromycin, doxy, or ceftriazone

1: oral usually. recurrences rare after first year

2: genital usually. STD. recurrences common.

sx: same for males and females - 1st outbreak w/in 2 weeks - sores + flu-like sx

- subsequent attacks: burning, stinging, neuralgia, small grouped vescicles, tender lymphaenopathy

Labs: tzanck smear, western blot, ELISA

Tx: acyclovir/valacyclovir/famcyclovir at first sign of outbreak. topical corticosteroid redues size, duration, pain of lesions

sx: usually none

cancer of anus, oropharynx, penus, vagina, cervix

tx: no tx for virus, can treat warts and cancer

Primary: sx w/in several weeks of exposure. 1+ painless, indurated chancres lasting 3-6 weeks w/o tx

Labs: RPR, VDRL

Tx: Benzathine PCN G IM x 1

Secondary: 4-10 weeks after chancre, non-pruritic rough reddish brown rash on palms and soles, mucocutaneous lesions, adenopathy, fever, swollen lymph nodes, sore throat, patchy hair loss, HA, weight loss, muscle aches, fatigue

- Tx: Benzathin PCN G IM x 1

Tertiary: 1-20 years after infx, cardiovascular gummatous and neuro disease. Difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, dementia, death

Tx:

- early latent: Benzathin PCN G IM x 1

- latent >1 year: Benzathine PCN G IM X 3

trichomoniasis

tx: oral metronidazole 500 mg BID x 5-7 days

Sx: usually none. can by acute viral syndrome, lymphadenopathy, oral candidiasis, herpes zoster, diarrhea, fever, fatigue

Dx: HIV antibody testing - ELISA and western blot

nucleic acid amplification to determine viral load

Tx: combo 3 or 4 drugs from different classes - Nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, entry inhibitors, integrase inhibitors

Risks: increased risk of cervical, liver, and CNS cancer, +/- increased risk of breast cancer

Benefits: prevents pregnancy, decreased risk of ovarian, endometrial, and colon cancer

***younger age at menarche, later age at menopause, nulliparous, later age at 1st full term pregnancy

older age, white, presence of fibrocystic change or fibroadenomas, higher SES, high weight/BMI in post-menopausal, lower weight/BMI in pre-menopausal, smoking, increased alcohol consumption, family hx, BRCA 1/2, exposure to chest radiation

1. late stage of hepatic fibrosis resulting in widespread distortion of normal hepatic architecture

2. most common complication: pulmonary congestion

3. ascites, hepatic encephalopathy, esophageal varices

4. 80%

5. <5 years

6. <1 year

7. EGD q 2-3 years, check AFP, US for hepatocellular cancer

8. hep A, hep B, pneumococcal, flu

9. tx: liver transplant

MELD score: survival probability of a pt with end stage liver dz based on INR, bilirubin, creatinine, ferquency of dialysis in last week

Indications: ascites, bacterial peritonitis, variceal hemorrahge, malnutrition, portosystemic encephalopathy, metabolic bone dz, malignancy, pruritis

Contraindications: extrahepatic malignancy, active alcohol or substance abuse, severe comorbid disease, HIV

nitrogen and ammonia

Sx:

- subclinical: impaired psychomotor test

- stage 1: insomnia, confusion, forgetful, ammonia increased

- stage 2: lethargy, disorientation, asterixis

- stage 3: somnolence, disorientation, aggression

- stage 4: coma, decerebrate posture

Tx: abx (neomycin, rifaximin), lactulose is mainstay bc it doesn't allow ammonia to be absorbed by the gut, low nitrogen diet

giardia

tx: metronidazole

cryptosporidium

tx: supportive

Giardia: metronidazole

crypto: supportive

campylobacter: bloody, supportive - can consider quinolones or erythromycin

enterotoxigenic e. coli: supportive, can consider bactrim or quinolones

Shigella: bloody, quinolones or bactrim

lymphocytic colitis (increased lymphocytes in colon)

collagenous colitis (increased layer of collagen thickens colon)

tx: low fat/fiber diet, avoid NSAIDs, anti-diarrheals (loperamide, pepto), questran, prednisone, pentasa/sulfasalazine, methotrexate, azathioprine, colectomy

diversion colitis

tx: usually none. may need surgery if bad sx

chemical colitis

tx: supportive

ischemic colitis

tx: IV fluids, bowel rest, abx, surgery for full thickness necrosis

C. diff (pseudomembranous colitis)

tx: metronidazole or vanc

e. coli (hemorrhagic colitis)

tx: supportive - NOT ABX - can cause HUS

entamoeba histolytica

tx: metronidazole followed by iodoquinol, paromycin, or dilxanide furoate to eradicate cysts

Acute:

1. HCV RNA within days, elevated LFTs in 6-12 weeks

2. sx: usually none, can have malaise, nause, RUQ pain for 2-12 weeks

Chronic:

1. HCV RNA 80-100%, LFTs 60-80%

2. sx: usually non.e may have fatigue, n, anorexia, myalgia, weakness, weight loss

3. dx: screening assay to detect anti-HCV followed by PCR to detect HCV RNA

4. prognosis: 20-30% develop cirrhosis after 20-30 years

Tx:

1st line: pegylated interferon alpha-2a or 2b + ribivrin x 6-12 mos

2nd line: protease inhibitors

1. def: chronic transmural inflammatory disease that usually affects the distal ileum and colon but may occur in any part of the GI tract -- OFTEN INCLUDES SMALL BOWEL

2. pathophys:

- "Skip Lesions": segments of diseased bowel are sharply demarcated from adjacent normal bowel

- Predilection for right side of colon, spares rectum

3. sx: chronic diarrhea, abd pain, fever, anorexia, weight loss, tender abd, perianal fissures/fistulas, arthritis, anemia

4. Dx:

- labs to check for anemia, hypoalbuminemia, electrolyte abn, LFTs

- colonoscopy w/ bx

5. prognosis: intermittented exacerbations and remissions. can lead to colon cancer.

Symptomatic: loperamide, antispasmodics (dicyclomine), hydrophillic mucilloids, acoid dietary roughage to prevent strictures

Mild-Mod: 5-ASA (mesalamine), Pentase, Ascol, sulfasalazine

Mod-Severe: corticosteroids, azathioprine, 6-mercaptopurine, methotrexate, infliximab

Fulminant/abscess: hospitalize, IV fluids and abx, IV corticosteroids

Surgery

1. usually begins in the rectum

2. sx: bloody diarrhea interspersed with asymptomatic intervals, mild abd cramps, blood/mucus in stool, malaise, fever, anemia, anorexia, weight loss

3. tests: stool culture, sigmoidoscopy w/ bx

4. prognosis: increased colon cancer risk proportionate to duration of dz and amount of colon affected

General: avoid raw fruits/veggies & milk. Loperamide for diarrhea

Mild: 5-ASA (mesalamine) enemas 1-2x per day, corticosteroids and budenoside enemas

Moderate/extensive: oral & enemas of 5-ASA, high dose corticosteroids, azathioprine, infliximab

Severe: hospitalization, IV steroids, 5-ASA.

- If no response in 3-7 days: IV cyclosporine or infliximab

curative: proctolectomy

Most common causes: HTN and DM

sx: UREMIA - fatiuge, malaise, anorexia, pruritis, easy bruising, metallic taste, epistaxis, SOB, n/v, hiccup, nocturia, ED, restless legs, cramps, irritability, sallow appearance, urinous breath, HTN, cardiomegaly, neuropathy, elevated BUN/Cr, anemia, metabolic acidosis, hypokalemia, hyperphosphatemia

Tx: Dialysis, kidney transplant, low protein diet, limit fluids/salts/K/P

Skin: condyloma, HPV, verrucae, syphilis, HSV, scabies, Kaposi's, zoster, seborrheic, molluscum contagiosum

Oral: kaposi's, candida, multiple aphthous ulces, HSV, leukoplakia, HPV, gingivitis

Lungs: pneumonia, KS, lymphoma, pnuemocystis jirovecii, mycobacterium, histoplasmosis

CNS: toxoplasmosis, cryptococcosis, Neurosyphilis, lymphoma, dementai, CMV

CD4 count <200 + any of these:

bacillary angiomatosis, candida, cervical dysplasia, fever>38.5, diarrhea >1 mo, leukoplakia, zoster, ITP, listeria, PID, neuropathy, coccidiomycosis, cryptococcus, cryptosporidium, CMV, Encephalopathy, HSV, histo, isosporiasis, KS, lymphoma, Mycobacterium Avium Complex, TB, pneumocystic jirovecii

, pneumonia, leukoencephalopathy, salmonella, toxoplasmosis, wasting syndrome

Basal Cell Carcinoma

dx via bx

Tx: electrodessication and curettage (ED&C), surgical excision, MOHS, topical chemo

Bowen's Disease

tx: ED&C, surgery, cryo

sqamous cell carcinoma

tx: surgical excision, cryo, ED&C

Melanoma

tx: wide surgical excision, soemtimes adjuvent radiation and interferon alpha

Kaposi's sarcoma

tx: surgical excision, cryo, or coagulation

Anti-retroviral therapy for AIDS

Anticholinergics: Atrovent, combivent, DuoNeb, Spiriva

- MOA: antagonize acetylcholine receptors to produce bronchodilation

Beta-2 agonists:

- Short-acting: albuterol/levalbuterol

- long-acting: formoterol, salmeterol

- MOA: selectively stimulates b-2 adrenergic recepotrs to relax smooth muscle

Corticosteroids:mometasone, fluticasone, budesonide, beclomethasone

- MOA: anti-inflammatory, inhibits inflammatory cytokines

Leukotriene Modulators: zfirlukast, montelukast, zileuton

- MOA: block leukotrienes and therefore decease inflammation and bronchoconstriction

**Cromolyn: inhibits mast cell degranulation

Primary: sx explained by structural gynecologic disorders. lessens w/ age and after pregnancy. pain from uterine contractions and ischemia of myometrium

- Risk factors; Earlier age at menarche, long/heavy menstrual periods, smoking, fm hx

Secondary: sx due to pelvic abn such as endometriosis, uterine adenomas, fibroids, PID, IUDs, ovarian cysts - usually begins during adulthood

superficial: provoked vestibulodynia (pain in vesibular vagina), atrophic vaginitis, vulvar lichen sclerosis, vulvar dystorphies, congenital malformations, HSV, radiation, recurrent tearing

Deep: PID, endometriosis, pelvic muslce hypertonicity

2nd most common

peak at 60-75 y/o

95% adenocarcinoma

SX:

- right colon: bleeding, fatigue, weakness (due to anemia)

- left: alternating constipation and diarrhea, abd pain, bleeding

- rectum: bleeding w/ defecation, tenesmus, incomplete evacuation

Prognosis (10 year survival rates):

- limited to mucosa: 90%

- extension through bowel wall: 70-80%

- with + nodes: 30-50%

- mets: <20%

Tx: surgical resection + chemo/radiaiton

primary (idiopathic)

secondary: GABHS, mycoplasma, n/ miningitidis, salmonella, staph, strep, sepsis, malaria, toxoplasmosis, coxsacki, CMV, hepatitis, zoster, measles, mumps, varicella, candida, autoimmune

1. 5-15

2. GABHS

3. 6-21 days

4. sx: heaturia, proteinuria, nephritis, oliguira, edema, HTN, renal insufficiency

5. Tests: antistreptolysin O, CBC (shows casts), UA (shows proteinuria or hematuria)

6. Tx: high dose corticosteroids, cyclophosphamide, MTX, azathioprine

Goodpasture's syndrome

tx: stabilize respiratory

- daily plasmaphoresis for 2-3 weeks to removed anti-GBM, IV methylprednisone then oral prednisone

cyclophosphamide

Reiter's syndrome (reactive arthritis)

tx: NSAIDS, doxy 100 BID x 3 mos (if due to chlamydia)

sulfasalazine for arthritis

azathioprine or MTX if fulminant

bacterial: strep pneumo, H flu, chlmaydia, mycoplasma

viral: rsv, adenovirus, flu, paraflu

funga: histoplasmosis, coccidioides, blastomyces

** Tx: macrolides OR doxy

temperal arteritis/GCA

prednisone 60 mg/day x 4 weeks

 Type 1: 0.5 u/kg/day

Type 2: 0.7 u/kg/day

Basal (glargine, detemir): 1/2 TDD

NPH: 0.4 TDD in am, 0.2 Tdd in pm

Mealtime (aspart, lispro, glulisine): 1/2 TDD /3 - equal incements for each meal

Regular insulin (with NPH): 0.2 TDD in am an pm

Correction:

- Sensitivity factor; 2000/TDD

- correction: (BG-target BG)/sensitivity

Anterior: V1-V6, I, aVL - LAD

Inferior: II, III, aVF - RCA

meats, dairy, bakery

sx: n/v for up to 24 hrs, recovery in 24-48 hr

tinea versicolor

tx: topical selenium sulfid lotion, ketoconazole shampoo

systemic: ketoconazole, fluconazole

mild: 0.3-0.5 ml of 1:1000 epi SC or IM - repeat dose 5-20 min if needed

IV epi 2.5 ml diluted 1:10K at 5-10 min interval

Adults >50, kids <2
Kids <5 w/ asthma
pregnancy

long term health problems

seizure d/o

egg allergy

don't cause cardio and anticholinergic side effects & lower lethality of overdose

fluoxetine, fluvoxamine, nefazodone, paroxetine, sertraline, citalopram, escitalopram

lag in clinical response for several weeks, overdose risk, orthostatic hypotension

doxepin

Immune thrombocytopenic Purpura - treat with steroids +/- IVIG

HIT

Thrombotic microangiopathy - TTP, HUS

DIC

Post-transfusion purpura

neonatal alloimmune thrombocytopenia

mechanical

von willibrand

hemophagocytosis