• first degree heart block
• inferior wall infarction, rheumatic fever, digitalis poisoning

A combination of Hydralazine & Nitroglycerin.

This is in the setting of congestive heart failure.

Platypnea is dyspnea worse while sitting upright.

Orthodeoxia is a fall in partial pressure of O2 while in an upright position. This is indicative of V/Q mismatch. These findings are associated with hepatopulmonary syndrome. Liver disease (cirrhosis→portal HTN→ascites). Clubbing, cyanosis, and hypoxemia are characteristics of hepatopulmonary syndrome. The hypoxemia results from pulmonary vascular dilatation→intrapulmonary shunting→V/Q mismatch.

Angina, syncope, and heart failure

narrow pulse pressure, diminished carotid upstroke, sustained apical impulse, late-peaking systolic ejection murmur radiating to carotids, and S4 are characteristic findings of severe aortic stenosis.

Atrial fibrillation can be associated with rapid and severe clinical deterioration due to the more rapid rate and loss of atrial contribution to left ventricular filling.

p. 34

Pulmonary HTN and Interstitial Lung Disease.

These present differently!

PHTN - loud P2, fixed split S2, pulmonic flow murmur, tricuspid regurgitation.

ILD - restrictive lung disease with <80% lung volume, inspiratory crackles.

TB is the most common cause of lymphocyte predominant exudate, typically as high as 90-95% lymphos.

Pleural bx to dx.

p. 267

Patients with asthma exacerbation present initially with hypocapnea, but as fatigue sets in CO₂ starts to increase. Normal to slightly elevated CO₂ is indicative of impending respiratory failure (pulseOx < 95%, P_O2 < 75 mmHg, RR > 30, HR > 120)

p. 267

In addition to oral or IV corticosteroids, short-acting bronchodilators (albuterol or ipratroprium), and supplemental oxygen, abx are recommended. To cover the common organisms (H. influenzae, S. pneumoniae, M. catarrhalis) 3rd gen cephalosporin + macrolide or monothx with a fluoroquinolone.

In terms of O₂ thx, noninvasive positive pressure ventilation should also be considered (RR > 25, pH < 7.35, P_CO2 > 45). If, however, respiratory arrest is impending intubation should be considered.

p. 269

Inhaled 1) long-acting β-agonist paired with an acetylcholine inhibitor + 2) step-up thx to inhaled corticosteroids (fluticasone) + O₂.

If the patient is still symptomatic consider pulmonary rehabilitation, which consists of patient education, exercise training, psychosocial support, nutritional support, and evaluation for O₂ thx.

p. 270, Step-Up p. 73

Obstructive Sleep Apnea and Obesity-Hypoventilation Syndrome.

Both present with similar symptoms and one can accompany the other.

Dx of OSA requires polysomnography as clinical suspicion and physical exam findings are neither sensitive nor specific.

Patients w/ untreated OSA have a greater likelihood of developing systemic HTN.

p. 272

Drug-induced lung toxicity is a hypersensitivity reaction and is associated with the usage of amiodarone. Symptoms include fatigue, low-grade fever, cough, dyspnea, and peripheral eosinophilia. Onset is usually 1 month after initiating a drug and progresses slowly.

p.275

renal insufficiency

metformin is cleared renally

fasting blood glucose > 126

random plasma glucose > 200 and symptoms of hyperglycemia

2-hour oral glucose tolerance test > 200

A1C > 6.5% 

IFG - fasting glucose 100 - 125, or impaired glucose tolerance when plasma glucose is 140-199 after 2 hours.

1. blood glucose level
2. anion gap metabolic acidosis (arterial pH < 7.3, thus an abg is required)
3. serum CO₂ level < 15
4. + serum or urine ketones

IV fluids!!!

administration of insulin first can drive glucose back into the cell and theoretically pull water back with it, further depleting intravascular volume.

1. Smoking
2. HTN
3. Age ≥ 45 men, ≥ 55 women
4. ↓ HDL (< 40 mg/dl)
5. FHx of CAD

in patients with zero or one risk factor the target LDL-cholesterol level is < 160 mg/dl, lifestyle modification > 160, drug thx > 190; ≥ 2 risk factors, lifestyle ≥ 130, drug > 130 w/ 10 year risk 10-20% or ≥ 160 w/ 10 year risk < 10%).

1. ---

   DM
2. symptomatic CAD
3. peripheral artery disease
4. AAA

goal is cholesterol < 100, lifestyle modifications if ≥ 100, initiate drug thx if ≥ 130.

UW3823

1. pregnancy (↑ estrogen)
2. liver disease
3. oral contraceptive use
4. aspirin

Remember ↑ TBG = ↑ total T₄

What condition can cause an anion gap & an osmolar gap?

In what condition will you find an anion gap with a normal osmolar gap?

Ingestion of ethanol, ethylene glycol, or methanol.

 alcoholic ketoacidosis, DKA, or lactic acidosis

 Remember, only ethylene glycol is associated with acute kidney injury and calcium oxalate crystals (rectangular, envelope-shape) in the urine.

What are the symptoms of hypophosphatemia?

In which situations do you need to be wary of hypophosphatemia?

confusion, rhabdomyolysis, hemolytic anemia, and severe muscle weakness that can lead to respiratory failure. 

chronic alcoholics who have poor oral intake can present with normal phosphate levels; however, severe hypophosphatemia develops in 12-24 hours of admission because of administration of glucose which stimulates insulin release, forcing phosphate to shift into cells.

• Produced by neoplastic cells, and shares N-terminus sequence homology with PTH.
• primarily sereted by squamous cell carcinomas - lung, esophagus, head & neck, but also renal & bladder cancer, ovarian & endometrial cancer, and breast cancer.
• The diagnosis of humoral hypercalcemia of malignancy can be dx'ed w/o measuring PTHrP, but by detecting hypercalcemia with decreased PTH with a compatible malignancy.
• FYI - bone metastases → hypercalcemia via release of cytokines → ↑ osteoclast activity → bone resorption.

UW3101

Hyponatremia - N&V, HA (hyponatremic encephalopathy); worsening brain swelling causes ↓ mental status and seizures.

Hypercalcemia

Hypokalemia and metabolic acidosis

urine potassium is < 20 meq/L is suggestive of extrarenal K⁺ loss. GI disorder is the most commone extrarenal cause of K⁺ loss. Diarrhea → fecal K⁺ loss + normal anion gap acidosis due to ↑ HCO₃^- GI loss. 

Be on the lookout for underweight adolescents.

Cinacalcet binds to the parathyroid calcium-binding receptor, leading to decreased release of PTH.

This thx is only indicated for refractory secondary hyperparathyroidism of CKD (↓ serum calcium and ↑ PTH) or tertiary hyperparathyroidism (↑ serium calcium and ↑ serum PTH).

Tertiary hyperparathyroidism is a state of excessive secretion of PTH after a long period of secondary hyperparathyroidism and resulting hypercalcemia. It reflects development of autonomous (unregulated) parathyroid function following a period of persistent parathyroid stimulation.

It is a rating system used to determine the need for anticoagulation for patients with atrial fibrillation. 

Each letter, with the exception of S_troke, is assigned a value of 1 point. Stroke is valued at 2 points. Any score > 2 requires anticoagulative thx. 

CHF, HTN, Age > 75, DM, Stroke/TIA

Digoxin is given to patients with A. fib in an attempt to control the ventricular rate. However, it interupts the interpretation of the ECG during an acute coronary syndrome (non-specific ECG changes). Next step is to perform an echocardiogram looking for:

ventricular wall hypokinesis (indicating infarcted tissued).

Other conditions where an echo is preferred when diagnosing acute ischemia include:

1. LBBB
2. LVH
3. Pacemaker
4.  non-specific ECG changes
5. young females

LRs can be used to apporximate the probability of a disease AFTER a test is performed.

Must memorize LR  of 2, 5, 10 is equal to 15%, 30%, 45%. 

For example, if a pretest probability of X disease is 50% with a  positive LR of 13.3, add 45% to 50% to get a posttest probability of 95%. 

+LR = sensitivity/(false positive rate) 

False positive rate = 1-Specificity

One-time screening for aortic abdominal aneurysm for men between the ages of 65 and 75 who have ever smoked.

If the test is normal there is no need for further screenings; death from AAA rupture in this patient population is rare. 

• Women aged 65 and older should be screened routinely. 60 and  older if women are at increased risk for osteoporotic fractures.
• Risk Factors: ↑ age, thin body habitus, smoking, alcohol, corticosteroid, menopause, malnutrition, FHx, asian, and caucasian.

UW4122

Vaccination is indicated in all patients aged 60 years and older without contraindications (not immunocompromised), regardless of history of prior varicella infection. 

This is a live vaccine.

Immunization should be avoided if an immunocompromised person is living in the household.

Starting at the age of 50 the options are:

1. Colonoscopy every 10 years
2. Flexsigmoidoscopy every 5 years + high sensitivity fecal occult blood test every 3 years. Some groups recommend FOBT annually.
3. Double contrast barium enema every 5 years
4. Annual FOBT, at home sampling of 2-3 consecutive specimens, if patient is willing to follow up with a colonoscopy after an abnormal finding.

If patient has a 1st degree relative with CC screening is initiated at age 40 or 10 years earlier than age of dx. Then colonoscopy is repeated every 3-5 years. p.243

If the patient has a hx of IBD, annual (or every 2 years) colonoscopies are recommended 8 years after onset of disease. Random bx are performed in four-quadrant fashion throughout the entire colon. Colectomy is recommended if dysplasia is identified.

What is situational syncope?

What are the prodromal symptoms?

A neurocardiogenic (vasovagal) reflex mediated in response to a particular stimulus, typically coughing, micturition, or defecation. Also, pain, stress, sight of medical needles.

Sx: nausea, lightheadedness, pallor, and diaphoresis. Brief myoclonic jerking after syncope is not unusual.

Dx: Upright tilt table testing.

After death of a loved one, what is the normal period of bereavement?

When should pharmacologic intervention be initiated?

Most negative symptoms peak before 6 months.

Patients who have symptoms of major depression for at least 2 consecutive weeks 8 or more weeks after their loved one's death are candidates for pharmacologic thx.

Major depression in the setting of bereavement cannot be dx unless sx persist for > 2 months.

Your patient, known to use cocaine, is agitated and throwing himself against cars in a parking lot. On the way to the hospital the patient experiences generalized tonic-clonic seizures.

He is agitated, diaphoretic, and voicing paranoid thoughts,.

What medication should be administered?

Lorazepam (benzodiazepines is the tx of choice)

This patient is experiencing sympathetic syndrome. 

Drug induced seizures do not respond well to phenytoin; benzo's are the drug of choice. Haloperidol can actually lower the seizure threshold.

1. NSAIDs - first line medication tx
2. PT
3. if symptoms progress despite conservative thx after 3 months - 2 years, surgery is indicated.

failure = progressive neurological deficits and severe pain

What are some of the symptoms of vertebral osteomyelitis?

How is it dx?

1. Neck or back pain that gradually worsens over weeks to months.
2. fever is present in only 50%
3. leukocytosis is typically ABSENT
4. ESR is ↑ > 100mm/h
5. Tenderness to palpation over involved portion of spine.

Potential sources of infection are: skin (IV drug abuse), UTI, lung infxn, endocarditis.

Blood cultures should be obtained (+ in up to 75%)

MRI preferred imaging modality

1. back pain
2. muscle weakness
3. loss of bowel or bladder control

1. post-nasal drip syndrome (chronic sinusitis-rhinitis); aka upper airway cough syndrome (UACS); tx empirically  w/ antihistamine/decongestant
2. asthma (if presents with only a cough = cough variant asthma); tx w/ inhaled albuterol
3. GERD

BUT, first rule out smoking, ACE inhibitors, and normal CXR

1. varenicline (Chantex); most effective; nausea is common
2. buproprion (risk of seizure; 0.1%)
3. nortriptyline

combination of varenicline and nicotine replacement thx is not recommended (↑ risk of N&V, HA, dizziness)

BMI > 35 in patients with serious obesity-related comorbidities (HTN, DM, dyslipidemia, CAD, sleep apnea)

or 

BMI > 40 w/o comorbidities in whom attempts at weight loss, including drug thx, were unsuccessful.

menorrhagia = heavy menstrual bleeding

medroxyprogesterone acetate, a progestational agent, will stabilize the endometrium and stop uterine blood flow. alternatively, a monophasis oral contraceptive can be used.

if the patient is orthostatic or dizzy from blood loss, IV estrogen is effective in stopping the bleeding entirely (70% of cases); however, ↑ risk of PE and venous thrombosis. 

p 126

It is used to dx secondary amenorrhea (prolonged oral contraceptive use). 

Medroxyprogesterone acetate is administered and if enough estrogen is circulating bleeding should commence 2-7 days after finishing progestin indicating that the patient's amenorrhea is due to anovulation. No bleeding is indicative of a) low serum estradiol, b) hypothalamic-pituitary axis dysfunction or c) a problem with the uterine outflow tract.

p. 127

What is HYPOgonadotropic hypogonadism?

HYPERgonadotropic hypogonadism?

both result in amenorrhea 

HYPO - ↓ FSH & ↓ estrogen (usually due to prolactinoma)

HYPER - primary ovarian failure (Turner's, autoimmune, chemo/radiothx) 

In amenorrhea, the first thing to rule out is pregnancy!!!

p. 128

Cellulitis, a clinical dx, presents w/ a well-demarcated area of warmth, swelling, tenderness, and erythema, that may be accompanied by lymphatic streaking and/or fever & chills. 

Venous stasis dermatitis - bilateral involvement, absence of fever or leukocytosis, hyperpigmentation due to hemosiderin deposition, and minimal pain. It is due to venous HTN, edema, chronic inflammation, and microangiopathy.

p. 129

A mucocutaeous reaction characterized by targetoid lesions. The majority of recurrent cases of EM have been associated with infections, the most common being HSV-1/2. It may also be idiopathic or drug related. 

FYI - erythema migrans is associated with Lyme disease (no mucosal involvement).

DIAPERS 

Drugs, Infetion, Atrophic vaginitis, Psychological (depression, delirium, dementia), Endocrine (hyperglycemia, hypercalcemia), Restricted mobility, Stool impaction.

UTI is a very common cause of urinary incontinence  in the elderly.

Whispered-voice test (examiner stands 2 feet behind patient, occludes one ear canal while simultaneously rubbing external auditory meatus, and whispers 3 numbers or letters). Using a battery powered handheld audioscope is an acceptable alternative. 

Weber & Rinne test and Screening Hearing Handicap Inventory tests do not perform as well.

Oxybutynin - an anticholinergic agent.

During micturition the parasympathetic nerves → detrussor muscle contraction & internal sphincter relaxation.

Tolterodine is an alternative agent in the same drug class (anticholinergic).

1. abdominal pain (acute abdomen < 24 hours duration)
2. abdominal guarding (tensing of the abdominal muscles to guard against irritation of the inflamed peritoneum/organ)
3. rebound tenderness (pain when inflamed peritoneum snaps back into place)

1. Free air under the diaphragm (perforated viscus)
2. Air-fluid levels (bowel obstruction)

1. severe sudden abdominal and back pain
2. loss of consciousness
3. local containment can prevent immediate death
4. anemia
5. leukocytosis

p. 74

1. pain relieved with defecation
2. onset associated with change in stool frequency
3. onset associated with change in stool consistency

Contrast enhanced CT. 

Colonoscopy and Barium enema ↑ the risk of bowel perforation.

What is radiation proctitis?

What are the symptoms?

Radiation to the pelvic region (for colon cancer) results in direct mucosal injury of the rectum within 6 weeks of radiation thx. Usually resolves soon after discontinuation of thx. Chronic radiation proctitis on the other hand, occurs months to years after thx, and is associated with a worse prognosis.

sx - diarrhea and tenesmus (constant urge to defecate)

dx - flexible sigmoidoscopy

The infection is self-limited, so no tx is necessary. 

tx is only recommended for (1) immunocompetent patients < 2 y/o or > 50 y/o to avoid ↑ complications in these age groups, (2) immunocompetent pt w/ severe illness requiring hospitalization, (3) immunocompetent patients w/ known or suspected atherosclerotic plaques or endovascular or bone prostheses b/c of seeding of salmonellae to these areas during a bloodstream infxn, (4) immunocompromised pt.

↑ Direct (conjugated) bilirubin

↑Alkaline phosphatase

Charcot's Triad: fever, pain, jaundice

p. 79

G - gall stones (if pancreatitis is 2º stones, and patient was asymptomatic with stones up until -itis, cholecystectomy should be performed to prevent recurrence of pancreatitis; UW2933)

E - ethanol

T - trauma

S - steroids

M - mumps

A - autoimmune

S - scorpion sting

H - hypercalcemia/hyperlipidemia (TG > 1000 mg/dL)

E - ercp

D - drugs

Enteral nutrition with nasojejunal feeding (you don't want to stimulate the pancreas) 

for necrotic pancreas (non enhancing w/ contrast CT) use imipenem. If necrotic pancreas is infected → debride.

Triple thx - PPI, amoxicillin, clarithromycin

failure of triple thx - PPI, metronidazole, tetracycline

NSAIDs and H. pylori, which account for more than 90% of the cases.

NSAIDs are also associated with dyspepsia (indigestion/upset stomach)

p. 82

1. restore intravascular volume (fluids, packed RBCs, FFP if needed)
2. esophagogastroduodenoscopy
3. PPI
4. octreotide reduces portal blood flow via splanchnic vasoconstriction (portal HTN & hepatorenal syndrome, but effect on overall survival is unknown); tx active bleeding.
5. ateriography is EGD has failed; can embolize
6.  non-selective β-blockers are used to prevent variceal bleeding.

p. 84, UW2921

#1 abominal ultrasound

#2 follow up with alpha-fetoprotein (> 500 ng/ml) 

bx is not required if both 1 & 2 are present.

Liver CT is not used because ↑ radiation; screening is performed frequently in patients with Hep B or C, cirrhosis.

p. 85

Anti-smooth muscle Ab

Anti-mitochondrial Ab

Anti-endomysial Ab

Autoimmune Hepatitis 

Primary Biliary Cirrhosis  (associated with xanthomas & xanthelasma: soft yellow plaques that appear on medial aspects of eyelids; ↑ IgM; tx PBC w/ ursodeoxycholic acid)

Celiac Disease

Primarily occurs during the 4th and 5th decade of life, and affects men > women. It is characterized by progressive bile duct inflammation and destruction, and ultimately, fibrosis of the intrahepatic and extrahepatic bile ducts, leading to CIRRHOSIS.

associated with Ulcerative Colitis

p. 88

How is SAAG calculated?

SAAG > 1.1 g/dl?

SAAG < 1.1 g/dl?

Serum Albumin - Ascites Albumin = Gradient

> 1.1 = portal HTN (cirrhosis, constrictive pericarditis, right-sided heart failure, Budd-Chiari syndrome).

< 1.1 = infection, inflammation, low serum oncotic pressure (nephrotic syndrome, TB, malignancy).

p. 88

Erythema Nodosum - small exquisitely tender nodules on the anterior tibial surface; more easily palpated than visualized. Eruption is often preceded by a prodrome of fever, malaise, and arthralgia.

Pyoderma Gangrenosum - begin as tender papules, pustules, or vesicles that spontaneously ulcerate and progress to painful ulcers with a purulent base.

p. 89

Mesalamine or another 5-aminosalycylate agent. Mechanism of action is unknown, but it is postulated that prostaglandin/leukotriene synthesis is minimized in the colon.

Infliximab can be used in patients with severe disease or those that are unresponsive to corticosteroid thx; not an appropriate first-line thx. 

p. 90

Chronic watery diarrhea without bleeding.

2 types: collagenous (50's) and lymphocytic colitis (60's); women > men, cause unknown.

Colonoscopy is grossly normal, bx several locations to dx.

Collagenous - increased amounts of collagen beneath mucosa. Lymphocytic - increased number of lymphocytes. 

p. 90

Normal ferritin levels are 15-200 ng/ml

In patients with inflammatory states serum ferritin < 100-120 ng/ml may reflect iron deficiency.

Inflammatory cytokines can raise ferritin levels by as much as threefold.

p. 147

Heinz bodies (accumulation of oxidized hemoglobin)

Bite cells 

precipitated by drugs, infection, or DKA

p. 148

1. Thalassemia
2. Hemoglobin C
3. Asplenia
4. Liver Disease
5. Sickle Cell Disease

Vitamin B₁₂- ↑ methylmalonic acid & ↑ homocysteine

Folate - ↑ homocysteine only 

These elevations occur before vitamin B₁₂ levels become reduced.

Vitamin B₆ (pyridoxine) is also involved in metabolism of homocysteine. Vitamine B₆ deficiency → ↑ Homocysteine → hypercoaguability → DVT

p. 149, UW4384

1. Idiopathic
2. Drugs
3. Lymphoproliferative disorders
4. Collagen vascular diseases
5. Malignancies (eg CLL, MGUS, Waldenstrom, Myeloma)

In addition to a positive direct Coombs test, spherocytes can be identified on peripheral blood smears.

p. 150

1. increased bleeding time
2. borderline elevated activated partial thromboplastin time (aPTT); due to diminished levels of factor VIII.
3. low factor VIII level (vWF carries factor VIII)

von Willebrand disease is autosomal dominant

p. 151

What is the best way to screen for a bleeding disorder?

How does one differentiate between a platelet disorder and a coagulopathy?

Clinical history

Platelet disorder is associated with immediate bleeding after injury, and usually involves mucous membranes and skin, and presents with petechiae.

Coagulation-related bleeding may be delayed in onset, deep tissue bruises (ecchymoses). May produce hemarthroses in patients with congenital bleeding disorders.

p.152

It is due to repeated episodes of pulmonary infarctions (occurs in sickled cell disease).

Presentation is similar to pneumonia (chest pain, respiratory distress, pulmonary infiltrates, and hypoxia) 

These patients should be managed with EXCHANGE transfusion to minimize percentage of abnormal RBCs.

p. 153, p. 334 (Step Up)

Also, if sickle patient experiences an ischemic stroke manage with EXCHANGE transfusion, not thrombolytics! Symptoms are 2° to sludging of sickle cell as opposed to a true thrombus.

What is pseudothrombocytopenia?

Gestational thrombocytopenia?

Platelets agglutinate and are not recognized by automated cell counter. 

Occurs late in gestation and in 5% of pregnancy, platelet count ranges from 70,000 - 150,000, cause is unknown.

Lupus inhibitor & antiphospholipid syndrome (+VDRL), which leads to a hypercoagulable state. There is a strong correlation b/w these antibodies and pregnancy loss.

Tx with ASA and low molecular weight heparin; cannot use warfarin during pregnancy!

p. 157, UW2256

1. ↓ anion gap (↑ cationic light-chain)
2. anemia
3. proteinuria
4. hypercalcemia
5. renal failure (AKI is initial presentation in as many as one half of patients with MM)
6. osteopenia
7. leukopenia
8. infection with encapsulated bacteria

Classic Tetrad: CRAB (calcium, renal impairment, anemia, bone). Except in MM, hypercalcemia in presence of AKI is relatively unusual b/c hyperphosphatemia and ↓ renal 1-α hydroxylation of 25-hydroxycholecalciferol both act to predispose to hypocalcemia.

p.157, UW4466

1. ↓ serum monoclonal protein (< 3.0 g/dl)
2. < 10% plasma cells in bone marrow
3. absence of lytic bone lesions
4. absence of anemia
5. no hypercalcemia
6. no renal insufficiency

no specific tx is required, just close follow-up

p. 158

• Most frequently in AML
• age of onset: 60 yrs
• M3 type is responseive to all-trans retinoic acid (ATRA), a vitamin A derivative.
• DIC is a common presentation.

FA-Step1 p. 393

ultrasound of mass to determine if it is cystic or solid. If cystic aspirate the fluid and send for cytology if bloody or recurrent (f/u in 4-6 weeks to see if cyst recurs). A solid mass requires FNA, core needle bx, or excision. If BI-RADS 4 or 5, malignancy is much more likely and FNA or bx is most appropriate.

p.241

Lumpectomy (breast conserving), sentinel node bx, radiation

(no radiation→high risk for local recurrence)

Survival rate for women undergoing breast conserving thx is equivalent to mastectomy, but better cosmetic outcomes and ↓ morbidity.

p.242

Do Not Screen

• no method has been shown to reduce death from lung cancer
• ↑ false positive rate only leads to unnecessary anxiety and invasive testing
• Also no screening for pancreatic cancer, bladder cancer.

p.245

No further follow up if nodule is < 4 mm.

CT screening have shown that 25-50% of patients have one or more pulmonary nodules detected.

Tissue diagnosis is critical; biopsy the peripheral lymph node. This establishes both a diagnosis and a stage.

biopsy of the lung mass or hilar lymph nodes would establish the dx, but not the stage, and would not determine the resectability.

p. 245

PSA > 4.0 ng/ml, even if the patient is asymptomatic

also any rise > 0.75 ng/ml per year should be evaluated.

p. 246

The benefits of PSA/DRE screening are still under debate; therefore, a frank discussion regarding benefits/risks is in order prior to screening.

There is also no benefit in screening men > 75 years of age.

Androgen deprivation therapy; prostate cancer is a hormone responsive tumor

• Leuprolide, a GnRH analog that inhibits gonadotropin secretion through suppression of testicular and ovarian steroidogenesis.
• Castration

p. 247

Up until the age of 30 annual pap smears are recommended. Women at low-risk and > 30 can be screened every 3 years.

In women that are sexually active w/ multiple partners, have a hx of abnormal pap smears, or recently dx with a sexually transmitted disease, annual screens are still recommended.

p. 248

aka Tennis elbow

• pain w/ wrist extension or hand gripping
• point tenderness
• elbow ROM → no limitations → no pain/inflammation

p.288

RA - proximal interphalangeal joint, metacarpophalangeal joint

OA - proximal IP joint, distal IP joint

Trochanteric bursitis

tx - corticosteroid injection

Note: In patients with actual hip joint pathology, the pain will be localized to the groin and have painful, restricted range of motion.

p.289

Anserine bursitis; dx rests on finding focal tenderness on upper, inner tibia, about 5 cm distal to medial articular line of knee.

often mistaken for osteoarthritis, b/c many patients have concomitant OA.

tx - corticosteroid injection

CXR - searching for an underlying intrathoracic process (apical lung tumor, effusion, pneumothorax). 

This presentation is classic for referred shoulder pain.

p. 290

This is not a myositis! (does not cause muscle weakness)

• pain/stiffness in shoulders & hips (does not affect small joints)
• fever, malaise, weight loss
• occurs in patients > 50, associated with giant cell
• ↑ ESR, normal CK

tx - low-dose prednisone (sometimes methotrexate is added when multiple attempts at tapering are unsuccessful). Unlike giant cell where high-dose prednisone is used to prevent loss of vision.

FA p. 421, UW3317

Septic arthritis is a medical emergency. Hematogenous spread is the most common mechanism of joint infection.

Staphylococcus is the most common gram (+) affecting native and prosthetic joints, and infxn with MRSA is becoming increasingly common.

tx w/ Vancomycin (even if culture is negative for gram staining); ceftriaxone when gonococcal arthritis is suspected. 

Patients w/ previous joint damage (e.g. RA) and treatment with steroids or immunosuppresants are particularly susceptible to joint infxn.

p.291

presumed to have Septic Arthritis until synovial fluid analysis via arthrocentesis excludes this condition. 

This should be suspected especially in a patient with RA that presents with a sudden single joint flare.

p.291

• pain
• leukocytosis and fever are frequently absent
• synovial fluid WBC 50,000 - 150,000
• ↑ ESR
• gold standard for dx is arthrocentesis
• Staphylococcus aureus is most frequent cause

p. 292

• Rheumatoid Arthritis
• Prosthetic Joint Infection
• Osteomyelitis
• Polymyalgia Rheumatica
• Temporal Arteritis

• NSAIDs
• Corticosteroids and Colchicine are also options
• Colchicine is most effective in patients with monoarticular involvement and when used within the first 24 hours of symptoms.
• Allopurinol and febuxostat are xanthine oxidase inhibitors and are used in patients with recurrent attacks to minimize uric acid levels.

dx - needle shaped monosodium urate crystals engulfed by neutrophils.

p.292

Prophylactic colchicine, low-dose corticosteroids, or NSAIDs need to be administered at least 1 week prior to beginning of adjusting the dose of uric acid lowering thx to prevent disease flares associated with changes in uric acid levels.

Uric acid lowering thx should be considered in patients with recurrent attacks, uric acid tophi, or renal stones.

p.293

Calcium Pyrophosphate Dihydrate in Pseudogout

• pseudogout attacks resemble acute gouty arthropathy
• radiographic evidence: chondrocalcinosis is associated with this disease (calcification of articular cartilage); not tophi (associated with gout).

tx - NSAIDs, Colchicine, Corticosteroids

p.293, UW4582

• osteophytes
• joint space narrowing
• sclerosis
• cyst formation

characterized by pain on activity, relief with rest, minimal swelling, absence of warmth.

p.294

Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons. Pain is present on palpation of th distal aspect of the radial styloid.

Finkelstein test - flexing thumb into palm, closing fingers over thumb, bending wrist in ulnar direction → pain.

Cause - chronic overuse of wrist.

p.295

This is a (+) grind test. Chronic pain at the base of the thumb is suggestive of osteoarthritis. Occurs b/c of repetitive use of wrist or thumb.

• patients present with swelling/enlargement of carpometacarpal joint recognized as squaring or boxing at base of thumb.

p.294

X-ray - erosions of cartilage and bone are cardinal featues of RA.

Rheumatoid factor is not specific for RA and frequently occurs in other autoimmune disorders and chronic infections, most notably active chronic hepatitis C.

p. 296

Actinic = Aggressive; can transform into squamous cell carcinoma, although risk of malignant transformation is low. Due to prolonged and repeated sun exposure. aka Solar Keratosis

Seborreheic: harmless growths with no malignant potential; appear as if they were "stuck" on.

Step-Up p. 420, 425

For mild to moderate cancer-associated pain short-acting opioid is indicated when non-opioid drugs fail to control the pain. Once pain control is achieved long-acting opioid dosage can be calculated. Short-acting opioid can be used for break through pain. If short-acting is required more than 3 times daily, long-acting dosage must be adjusted. 

When adding a long-acting, to avoid over medicating, a starting dose of 30-50% of patient's average 24-hour dosage of narcotic is used. The dose of opioid for breakthrough pain is calculated as 10% of total daily opioid use.

p.251

Acute rheumatoid factor positive oligo- or polyarthritis. Viral arthritis usually resolves in 3 weeks; does not cause joint destruction.

other features include rash (not slapped cheek rash seen in children), IgM-Ab against parvovirus B19.

p. 296

Within 3 months of the onset of the condition; but basically as soon as the dx is established.

Methotrexate is often used as an initial DMARD; however, people CANNOT consume alcohol. Use hydroxychloroquine instead.

p.297

HIV patients with a CD4 count < 200, and not taking antiretroviral thx commonly have psoriasis or other skin conditions including photodermatitis, prurigo nodularis, molluscum contagiosum, and drug reactions.

20-40% of people with psoriasis go on to develop psoriatic arthritis.

p.297

Patients with inflammatory bowel disease can develop aseptic arthritis. Enteropathic arthritis can manifest as axial arthritis, such as spondyloarthropathy. The cause is not bacterial seeding of joints.

p. 298

• MRI of sacroiliac joints; especially with gadolinium enhancement; plain X-ray can be used to dx AS.
• Onset of AS usually occurs in teenage years or 20s and manifests as persistent pain and morning stiffness involving the lower back that are alleviated with activity. Tenderness of the pelvis can also be found.
• Anterior Uveitis is the most prominent extraarticular finding.
• Enthesitis (inflammation/pain at sites where tendons & ligaments attach to bone); prominent in AS, heel pain due to Achilles tendon tenderness.
• fusion of costovertebral joints → chest wall motion restriction (↓ FEV, normal FEV/FVR, but ↑ FRC b/c of fixation  of chest wall in inspiratory position).

p. 298, UW3165, 4575

It can be caused by TNF-α inhibitors such as infliximab. Many patients that use TNF-α inhibitors develop auto-antibodies, including ANA, anti-dsDNA, anti-Smith; rarely, these people develop drug-induced lupus. 

tx - stop TNF-α inhibitors and start prednisone.

p. 299

High-dose corticosteroids is required to prevent irreversible renal damage.

p. 300

• Access to hearing aids, glasses, and canes
• Removal of unnecessary restraints
• remove urinary catheters unless indicated (urinary retention, or monitoring fluid status in acutelly ill)
• NO benzodiazepines or diphenhydramine, unless indicated (alcohol withdrawal or allergic rxn)

p. 222

Based on psychomotor:

1. hypoactive
2. hyperactive
3. mixed delirium with hypo/hyperactivity
4. delirium w/o Δ in psychomotor activity

patients w/ delirium have acute, fluctuating mental status Δ, with difficulty focusing or maintaining attention and disorganized thinking; it is an acute state of confusion.

p.222

Antipsychotic agent (Haloperidol) 

Diphenhydramine is a major risk factor for delirium.

Lorazepam is deliriogenic.

p. 223

Due to Thiamine (Vit B₁) deficiency. To tx administer thiamine.

Triad of confusion, ophthalmoplegia, ataxia.

+ loss of memory (permanent), confabulation, personality Δ = Wernicke-Korsakoff syndrome (associated with periventricular hemorrhage/necrosis of mamillary bodies).

p. 223, FA p. 95 

Asterixis is a sign of toxic/metabolic encephalopathy and not dementia. In addition to asterixis, cognitive impairment + fluctuating lethargy, inattention, and hallucination. 

Look at medications as cause:

TCA (nortriptyline) - anitcholinergic

Lorazepam & Digoxin → cognitive impairment

p. 223

• dull, bilateral, or diffuse
• described as pressure or squeezing
• pain not worsened w/ movement and does not prohibit activity (lack of disabling pain)

p. 224

Patient must be evaluated for a catastrophic condition; maximal intensity of HA achieved within 60 seconds of onset (Thunderclap HA).

• non-contrast CT scan of head, if negative →
• Lumbar puncture (blood or xanthochromia, the yellowish coloration after heme degradation to bilirubin)
• other causes of TCHA not r/o by above can be excluded by CT angiography (unruptured cerebral aneurysm, carotid or vertebral dissection, cerebral venous sinus thrombosis, reversible cerebral vasoconstriction syndrome).
• Vasospasm → symptomatic ischemia/infarction is the major cause of M&M in patients with subarachnoid hemorrhage; apperaing in 7 days after SAH. Prevent vasospasm with calcium channel blockers (UW).

p. 225

• topiramate
• valproic acid
• amitriptyline
• β-blocker (propanolol, metoprolol, timolol)
• Petasites hybridus plant extract

p.225

Reaction to neuroleptic tranquilizers (D₂-receptor antagonists) and some antipsychotic drugs, of which haloperidol is most common.

• muscle rigidity
• hyperthermia
• cognitive Δ
• autonomic instability (diaphoresis, sialorrhea)
• seizures
• arrhythmias
• rhabdomyolysis

occurs within 2 weeks of initiating drug

p. 227

Essential tremor primarily occurs when a patient maintains a posture, such as when the hands are outstretched. Essential tremor also may be present during movement, particularly postural adjustments.

tx - propranolol (drug of choice), primidone, gabapentin, and topiramate

p. 228

It does not protect against serogroup B meningitis.

protects against serogroup A, C, Y, and W-135.

p. 229

Treat empirically with Vancomycin, amipicillin, and ceftriaxone. The most likely etiologic agents are S. pneumoniae, L. monocytogenes, N. Meinigitidis, and aerobic gram (-) bacilli.

Administration of adjunctive dexamethasone should be strongly considered in patients with acute bacterial meningitis.

p. 239

• Dyspnea
• Bibasilar crackles
• bibasilar infiltrates on CXR
• restrictive PFT patterns
• ↓ diffusion capacity

p.301

Dihydropyridine calcium channel blockers (amlodipine) are used as first line treatment.

Other agents used are peripherally acting α-1 blockers, phosphodiesterase inhibitors, and endothelin receptor antagonists.

p.301

Fibromyalgia is characterized by diffuse pain on both sides of the body, above & below the waist, as well as axial skeletal pain. It is a clinical dx.

American College of Rheumatology criteria requires pain in 11 of 18 specified potential tender points. However, some experts argue that these points are arbitrary and not essential in dx of fibromyalgia.

p. 302

• Symptoms - fever, musculoskeletal symptoms, vasculitis involving nervous system, GI, heart, and nonglomerular vessels.
• Sural nerve bx, and kidney angio to support dx.
• After exclusion of other vasculitides and no appropriate tissue to bx → angiography of renal arteries will reveal classic findings (microaneurysms, beaded pattern). 
• PAN commonly affects kidneys → HTN, kidney insufficiency, proteinuria, hematuria, renal vasculitis.
• p-ANCA

p. 303

Wegener Granulomatosis

also presence of antiproteinase-3 Ab

Patient presents with HA, temporal artery tenderness, acute visual loss, fever, and mild anemia. ↑ risk of aortic aneurysm (follow w/ serial CXR; UW4460) 

1. High dose corticosteroids (methylprednisolone)
2. Bx after steroid thx is begun (it will not affect results); must bx within 2 weeks.

p.303

If systolic < 220 or diastolic is < 120 antihypertensive medication should be withheld.

If aortic dissection, heart failure, or MI is not present, withhold medication.

p.231

confirm w/ elctromyography

Guillain-Barre will present with distal parasthesias (altered sensation - tingling, burning, pin pricks, numbness) of the lower extremities followed by limb weakness and gait instability. Deep tendon reflexes are absent or reduced. Stocking-glove sensory loss and areflexia.

CSF analysis shows characteristic albuminocytologic dissociation (cell count normal, ↑ protein).

tx - IV immunoglobulin and plasma exchange

p.232

Suspect RMSF in a patient with a nonspecific febrile illness within 3 weeks of POTENTIAL tick exposure and blanching erythematous macules located around the wrist and ankles.

tx with doxycycline

p.172

• most have onset of illness before 10, 95% before 20
• short periods of fever (1-3 days); associated with serositis (inflammation of the serous tissue; pleura, pericardium, peritoneum).
• fever is accompanied by elevated markers of inflammation such as leukocytosis, ESR.

p. 172

• Aggressive Fluid Resuscitation with resolution of lactic acidosis within 6 hours.
• Fluid resuscitation should target a central venous O₂ saturation of at least 70%. CVP of 8-12 mmHg, and urine output of at least 0.5 ml/kg/h; which often translates to 5-6 L over 6 hours.
• normal saline is the most common crystalloid; no survival benefit in administering colloid!!!

p. 174

• protein C is an anti-Coagulant
• improve survival in patients with severe sepsis and multiple organ failure (no survival benefit in patients with single failing organ system); APACHE score > 25
• when administered to patients with platelet count between 30,000 - 50,000 relative risk reduction in mortality of 30%.
• platelet count < 30,000 is a contraindication

p. 174

1. SIRS (Temp < 36 or > 38; WBC < 4,000 or > 12,000 or > 10% band forms; HR > 90; RR > 20 or P_aCO2 < 32) 
2. Sepsis = SIRS + infection
3. Severe Sepsis = Sepsis + organ dysfunction, hypoperfusion, or hypotension
4. Septic Shock = hypotension despite adequate fluid resuscitation
5. Multiple Organ Dysfunction Syndrome (MODS)

1. peritonsillar abscess ("quinsy"); emergency ENT consult
2. post-streptococcal glomerulonephritis (can occur after throat or skin infections; presents with periorbital swelling, hematuria, oliguria, proteinuria, RBC casts, ↓ serum C3).
3. rheumatic fever

p. 175

Similar to OM in children: Streptococcus pneumoniae (21-63%), Haemophilus influenzae (11-26%), Staphylococcus aureus (3-12%), Moraxella catarrhalis (3%)

Amoxicillin is the recommended abx of choice; if symptoms do not improve in 48-72 hrs switch to amoxicillin-clavulunate, cefuroxime, or ceftrixone. If allx to penicillin use macrolides (azithromycin, clarithromycin).

p. 176

1. fever
2. tonsillar exudate
3. tender anterior cervical lymphadenopathy
4. NO cough

if patient meets 2 of 4 criteria, use rapid streptococcal antigen testing to confirm.

Empiric abx tx is recommended in patients meeting all 4 criteria.

p. 176

Symptomatic management; no abx

Most cases are viral; only 0.5-2% are bacterial

Signs and symptoms are not reliable for dx purposes: unilateral facial pain, pain in teeth, pain on bending, purulent nasal discharge.

p. 177

ampicillin, amoxicillin, or nitrofurantoin

p. 177

in asymptomatic women, bacteruria is defined as 2 consecutive voided specimens with isolation of same bacterial strain in quantitative counts of at least 10⁵ cfu/ml.

 NO treatment in most non-pregnant women.

p. 178

nonpregnant, tx with fluoroquinolone

used to be trimethoprim-sulfamethoxazole, but ↑ resistance in E. coli and other gram (-) bacteria.

p.178

Cervicitis is the presence of mucopurulent discharge or endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os. Cervicitis is common induced by gonorrhea or chlamydia infection.

tx empirically with ceftriaxone + doxycycline or azithromycin.

p. 179

• arthritis, tenosynovitis, sparse peripheral necrotic pustules (prodrome of migratory arhralgia before settling in one or several joints).
• tx w/ parentreal ceftriaxone
• empiric tx for chlamydia with doxycyline
• test for syphilis & HIV

p. 180

• for an ambulatory patient → intramuscular ceftriaxone and oral doxycycline
• PID is a multimicrobial infxn of endometrium, fallopian tube, and ovaries.
• dx based on presence of abdominal discomfort, uterine or adnexal tenderness, cervical motion tenderness, cervical or vaginal mucopurulent discharge.

p. 181

• TMP-SMX + corticosteroids
• consider dx in pt with CD4 count < 200 who presents with fever, dry cough, dyspnea.
• corticosteroids is added in patients with evidence of hypoxia (P_aO2 < 70 mmHg or alveolar-arterial gradient > 35 mmHg).

p. 181

• TMP-SMX for Pneumocystic jirovecii
• TMP-SMX for Toxoplasma; if toxoplasmosis develops use Sulfadiazine and pyrimethamine to treat
• Azithromycin for MAC

p. 181

• fever, sore throat, anorexia, muscle aches
• small ulcers on tongue and buccal mucosa
• cervial and supraclavicular lymphadenopathy
• faint rash on trunk and abdomen

p. 166, 182

What is the best way to prevent ventilator associated pneumonia?

Prevent decubitus ulcers?

semi-erect position; prevents bacteria from stomach from reaching lungs.

Patient repositioning every 2 hours.

p. 184, UW3472

barrier protection & hand washing w/ soap and water

soap and water are not sporicidal, but helps to remove spores; alcohol-based products do not kill spores.

p. 184

• droplet precaution
• wear face mask when within 6-10 feet of patient
• human nasopharynx is the only known reservoir

p. 184

• TB
• Measles
• Varicella

patient must be placed in a private negative pressure room; masks worn by workers must have 95% filtering capacity.

p. 184

• immunocompetent > 15 mm → positive
• recent immigrant from high prevalence country, injection drug users,  residents or employees of high risk congregate settings (prison, nursing home, homelss shelter) > 10 mm → positive
• immunosuppressed (HIV, corticosteroids, patients considering TNF-α inhibitor thx) > 5 mm
• BCG vaccination should not influence interpretation of PPD reading ( > 15 mm → CXR & tx w/ isoniazid + pyridoxine B₆) 

p. 185, 186, 187

• Legionella pneumophila
• urinary antigen test (positive from day 1 and continues to be for weeks, 70-90% sensitivity, 99% specificity; therefore, negative test cannot exclude other species of legionella).

p. 188

Monotherapy with macrolides (azithromycin or clarithromycin)

Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae

The macrolides also cover Haemophilus influenzae. Use of fluoroquinolones is not recommended for fear of building resistance.

If patient with CAP needs to be hospitalized use Ceftriaxone plus azithromycin or fluoroquinolone alone.

In hospital acquire pneumonia tx is tailored towards gram (-) rods: ceph w/ pseudo coverage - ceftazidine or cefepime; imipenen; zosyn (piperacillin/tazobactam).

p. 189, Step-up 364-365

Ampicillin-sulbactam

Lung abscesses are polymicrobial infections caused by anaerobic bacteria that are normally present in the mouth; micro-aerophilic streptococci, viridans streptococci, and gram negative enteric pathogens.

p. 189

No prophylaxis

Prophylaxis is recommended in patients with:

• Prosthetic cardiac valves
• Hx of prior infective endocarditis
• Unrepaired cyanotic congenital heart disease
• Completely repaired congenital heart disease for 6 months following repair
• Repaired congenital heart disease with residual defects or abnormalities
• Cardiac transplantation recipients with cardiac valvulopathy

p. 189

When examining a diabetic patient with a draining foot ulcer and the probe used to evaluate the sinus tract contacts bone the bone must be biopsied!!!

Positive metal probe test has 90% positive predictive value for diagnosing osteomyelitis. If metal probe test is negative perform MRI.

Superficial cultures do not include the deep organisms responsible for the infection.

Failure to identify the causative deep-bone pathogen may lead to spread of the infection to adjacent bones or soft tissues and the need for extensive debridement or amputation.

p. 191

• Vertebral osteomyelitis
• Dx with MRI
• Dx cause with blood cultures
• If blood culture is negative, CT guided bx
• Hematogenous osteomyelitis most often involves the intervertebral disk space and 2 adjacent vertebrae
• In patients with hematogenous osteomyelitis leukocyte count is typically normal, but ↑ ESR
• If MRI is contraindicated (metal prosthesis) gallium nuclear study is very sensitive and specific

p. 192

• Stable angina (ASA, β-blocker both reduces mortality); nitrates for pain
• MI (ASA, β-blocker, ACE inhibitor)
• Ischemic Stroke (prevention & tx: given within 24 hours, but only if thrombolytics have not been administered!); warfarin only given to prevent future ischemic events due to cardiogenic emboli (e.g. a fib).

 Step-Up p. (4, 10, 208)

• Patients that present with ischemic chest pain but w/o diagnostic STE-segment elevation are catergorized as having unstable angina or NSTEMI. These 2 conditions are closely related and have similar pathophysiology and clinical presentations, but they differ in the severity of the myocardial ischemia.
• In NSTEMI ischemia is severe and results in detectable release of biomarkers; EKG w/ ST-depression in V₂-V₆.
• In unstable angina there is no detectable ↑ in biomarkers.
• Tx - β-blockers (metoprolol) are first-line thx in unstable angina and NSTEMI. Add CCB (verapamil) w/ ongoing ischemia despite thx w/ β.

p. 17, 25

• Infusion of fluid; these patients are preload dependent (↓ filling of left ventricle)
• Volume expansion improves hemodynamic abnormalities of r. ventricular MI b/c gradient of pressure from r. atrium to l. atrium maintains filling of left ventricle
• The classic triad: hypotension, clear lung fields, elevated CVP (JVD).
• EKG: ST-elevation in inferior leads (II, III, aVF, and right-sided precordial lead V₄R); occurs in more than 30% of cases of inferior wall MI.

p. 18, UW2156

Borrelia burgdorferi → Lyme carditis

p. 19

• Antianginal: β-blocker, calcium channel blocker, nitrates
• Vascular protective: aspirin, ACE inhibitors, statins
• β-blocker should be titrated to achieve a resting HR of 55-60 and approx 75% of the HR that causes anginal symptoms

p. 21

• Exercise stress test in patients with intermediate probability of CAD with a normal baseline ECG and no features of unstable angina. If ECG is abnormal perform nuclear medicine stress test.
• If dx of CAD is known, no benefit in performing an exercise stress test
• Note: Medical thx is more beneficial than coronary angiography & revascularization
• Angiography & revascularization if pt remains highly symptomatic despite optimal medical thx

p. 21, 24

• Best if performed within 12 hours (the earlier the better); this applies to thrombolytics as well.
• When deciding between PCI and thrombolytics, PCI is preferred provided that it can be done immediately or within 60 minutes if transferred to another hospital.

p. 18, 26

• No treatment necessary (PVCs at rest in the setting of structurally normal heart appear to be associated with little to no increased heart risk of cardiovascular events, particularly in patients < 30.

p. 29

• syncope and cardiac arrest due to torsades de pointes
• There are 2 forms congenital & acquired
• Acquired: female sex, hypokalemia, hypomagnesemia, structural heart disease, previous QT-interval prolongation, hx of drug-induced arrhythmia.
• Other causes of syncope and sudden cardiac death in young patients include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia.

p. 31

• Differentiates between dyspnea caused by CHF and COPD.
• BNP levels > 500 have a high likelyhood of having heart failure.

Step-Up p. 18; MK p. 32

• Thiazide diuretics (salt-sensitive HTN; common initial drug of choice)
• ACE inhibitors (first line thx for HTN in diabetics)
• CCBs
• Goal: BP < 140/90 or 135/85 in DM or renal insufficiency

Step-Up p. 432

• clinical diagnosis
• then confirmed & staged via spirometry; pretreat w/ bronchodilator to minimize variability
• FEV₁ < 80%, FEV₁/FVC < 0.7 established dx of COPD
• ↓ D_LCO is due to emphysema (loss of lung tissue), not really associated with chronic bronchitis (blue bloater).

p. 262

• proportionate ↓ FEV₁ & FVC
• normal FEV₁/FVC ratio
• ↓ TLC
• ↓D_LCO

p. 262

• In neuromuscular restrictive disorder FEV₁/FVC is normal + low maximum respiratory pressures (inspiratory & expiratory).
• monitor vital capacity to assess respiratory fxn; risk of ventilatory failure ↑ when VC < 15 ml/kg.
• e.g. amyotropic lateral sclerosis, myasthenia gravis

p. 263, UW4271

• VCD is associated with throat/neck discomfort, wheezing, stridor, and anxiety.
• Difficult to distinguish from asthma; however, patients do not respond to asthma thx!
• Dx with Laryngoscopy, which will show vocal cord adduction during inspiration.
• or Flow Volume Loop → flattened inspiratory limb
• thx: speech thx, relaxation techniques, tx anxiety

p. 265

• presence of loculated pleural fluid or
• pleural fluid pH < 7.2 or
• pleural fluid with glucose < 60 or
• LDH > 1000 or
• + gram stain/culture or
• presence of gross pus in pleural space

p. 266

Inhaled corticosteroids are safe and effective in pregnant patients with asthma.

p. 269

Tx with short course of oral corticosteroids.

If inaffective add long-acting β-agonist.

p. 268

This patient probably carries a rescue albuterol inhaler, and is using it regularly as her asthma symptoms worsen.

Long acting β-agonist should be added.

3rd line thx: theophylline or leukotriene modifying drug.

Note: long-acting anticholinergic drugs are beneficial in COPD patients, not asthma!

p. 269

• P_aO2 < 55 or O₂ Sat < 88% or Hct > 55% with or without hypercapnea
• use of long-term (continuous) O₂ thx  in patients with chronic respiratory failure improves survival (↓ mortality).
• smoking cessation also ↓ mortality.

p. 270, UW3716

• tempo of disease process: acute or subacute (symptom onset within 2 monts)
• presentation so suggestive of an acute/subacute lower respiratory tract infection that patients have almost ALWAYS been treated with one or more courses of abx that have invariably failed.
• respiratory symtoms with a dominant alveolar process & on CXR (opacification). COP opacities are bilat w/ varied distribution; tendency to "migrate" or involve different areas of lung on serial examinations.
•  Idiopathic pulmonary fibrosis, on the other hand, tends to have an interstitial dominant pattern on imaging. Progresses slowly over months to years.

p.273

• high resolution CT; reveals ground-glass and reticular line opacities, subpleural cysts, and honey-combing in patients with advanced disease.
• clinical findings + HRCT establishes dx
• If clinical context, temporal pattern of disease, and HRCT findings do not yield a dx → bx

p. 274

• Aortic insufficiency (regurgitation)
• Arteriovenous fistula (pulmonary or CNS)
• old age (↑ rigidity of arterial wall → ↓ compliance →↑ systolic BP, normal diastolic BP [isolated systolic HTN, ISH]); UW3994.
• patent ductus arteriosus

  ---

• trauma
• iatrogenic (eg, femoral catheterization)
• cancer

UW4459 

Ischemic hepatic injury occurs in the setting of hypotension (e.g. septic shock, heart failure) and manifests as acute, massive ↑ in AST & ALT with milder associated ↑ in total bilirubin (e.g. 1.2) and alkaline phosphatase (e.g. 162). In patients that survive liver enzymes typically return to normal within a few weeks.

UW4648

CDC recommends patients with liver disease (alcohol abuse, cirrhosis) be vaccinated against HAV, HBV, pneumococcal disease, and yearly influenza.

UW4476 

MS associated bilateral trigeminal neuralgia.

CSF pressure, protein, and cell count are grossly normal; however oligoclonal bands will be present. Again, normal protein levels, but Ig are ↑.

UW3462

Supplemental O₂ therapy

Indications for thx: PaO₂≤55, SaO₂≤88%, Hct>55%, or evidence of cor pulmonale.

UW3042

1. Macrocytic anemia
2. glossitis (shiny tongue)
3. neurologic Δ's that include peripheral neuropathy
4. Atrophic gastritis → ↑ risk for intestinal-type gastric cancer.

UW4356

Caused by Ab in the patient's plasma that react with donor's leukocytes.

Cell washing, which depletes leukocytes, reduces occurrences.

UW4160

What are the causes of an exudative pleural effusion?

How is exudative pleural effusion defined?

Infection, malignancy, pulmonary embolism, autoimmune

Light Criteria (exudate if ≥ 1 of the following)

• pleural fluid/serum protein > 0.5
• pleural fluid/serum LDH > 0.6
• pleural fluid LDH > 2/3 of upper limit of normal for serum LDH.

UW4613, 4073

NSAIDs → peptic ulcer → low grade chronic GI blood loss → Iron deficiency anemia

Fatigue, consider ANEMIA!!!

UW3936

S. aureus pneumonia

UW4867

• hx of recent upper respiratory infection
• dilated cardiomypothy 2° to viral or idiopathic myocarditis
• Coxsackievirus B (3.5-5% of infect patients)
• parvovirus B19, HHV6, adenovirus, and enterovirus
• cardiomyopathy via direct viral damage & inflammatory response (humoral or cell-mediated)

UW4061

Atrial tachycardia with AV block

very rare for ectopy (leads to tachycardia) and AV block to occur at the same time.

AV block due to digitalis induced ↑ vagal tone and ↓ conduction through AV node.

UW3096

What is the traditional target BP?

In diabetes?

• 140/190
• In diabetes or chronic renal failure the goal is 130/80

UW3903

Bed rest and simple analgesia (e.g. acetominophen)

Antiviral meds can reduce duration of flu by 2-3 days; however, is only effective if administered within 24-48 hours of onset of symptoms.

Amantadine/Rimantidine - only effective against influenza A

Zanamivir/Oseltamivir (neuraminidase inhibitor) - effective against both Influenza A/B.

UW4284

• FHF is defined as hepatic encephalopathy that develops within 8 weeks of the onset of acute liver failure.
• These patients must be placed on an emergent liver transplant list.
• Also be on the lookout for transaminase levels that ↓ from very ↑ levels with a concomittant ↑ in lab values that assess liver functionality (PT, PTT, albumin, cholesterol, bilirubin).

UW2986, 2900

Oral Isotretinoin

also give if patient has scars.

Topical retinoids - non-inflammatory comedones.

Mild inflammatory acne - topical benzyl peroxide or topical antibiotics, or a combination of the two.

Oral antibiotics - moderate-to-severe inflammatory acne.

UW4091

Cr > 1.5

1. Use non-ionic contrast agent
2. Adequate IV hydration
3. Acetylcysteine (Mucomyst)

UW4490

Proteus, which makes urease → alkaline urine

UW 3262

To distinguish between heart and liver-disease related causes of lower extremity edema.

UW4133

α-1 antitypsin deficiency

unsecreted A1AT accumulate in hepatocytes and retain stain.

UW2919

atherosclerosis of mesenteric arteries → abdominal angina

• chronic & severe abdominal pain, worsening post-prandial pain
• weight loss
• food aversion

UW2149

Characterized by the development of severe hemorrhagic erosive lesions after the exposure of gastric mucosa to various injurious agents or after a substantial ↓ in blood flow.

Aspirin ↓ protective prostaglandin production.

Aspirin & alcohol cause direct mucosal injury → ↓ mucin & HCO₃^- and ↓ integrity of epithelium → penetration of acid/protease to lamina propria → additional injury to vasculature → hemorrhage.

UW3704 

• ↓ dietary protein and oxalate
• ↓ Na⁺ intake
• ↑ fluid intake
• ↑ dietary Ca²⁺

protein → calcium stones

UW3895

triple endoscopy (esophagoscopy, bronchoscopy, laryngoscopy)

Squamous cell carcinoma of the mucosa of the head & neck. Common in people with a significant history of etOH & tobacco use.

The first manifestation may be a palpable cervical lymph node.

UW2614

1. non-selective β-blockers: interferes with β-2-mediated intracellular K⁺ uptake.
2. ACE, ARB, K⁺ sparing diuretic
3. Digitalis: inhibition of Na-K-ATPase pump.
4. Cyclosporine: blocks aldosterone activity.
5. Heparin: blocks aldosterone production.
6. NSAIDs: ↓ renal perfusion resulting in ↓ K⁺ delivery to collecting tubules.
7. Succinylcholine: causes extracellular leakage of K⁺ through acetylcholine receptors.
8. Trimethoprim-Sulfamethoxazole: TMP blocks epithelial Na⁺ channels in collecting tubule, especially with ↑ doses (think HIV prophylaxis)

UW8331

Mammograms should be performed every 2 years starting at the age of 50 in women at average risk for breast cancer. Routing mammography is not necessary beyond the age of 75.

UW3863

What are the symptoms of hypercalcemia?

What is the treatment in an acute setting?

Symptoms are vague and non-specific: constipation, N & V, abdominal pain are common.

Symptoms occur when > 12 mEq/L

Tx: if symptomatic & Ca²⁺ 12-14 or Ca²⁺> 14, IV fluid resuscitation in acute setting → renal excretion of Ca²⁺ by ↓ reabsorption in proximal tubule.

UW2169

Tobacco, Alcohol, Caffeine, and Stress

If asymptomatic avoid precipitants; symptomatic → treat with β-blocker.

UW2744

• worsening Hypertension (30% of patients)
• Headaches (15% of patients)
• flu-like symptoms (5% of patients)
• red cell aplasia (rare)

UW3978

• IgM spikes (multiple myeloma has IgG/A spikes)
• hyperviscosity (rarely seen in MM)
• hyperviscosity syndromes include retinal vein engorgement.

UW2597

Disorder resulting from distension of endolymphatic compartment of inner ear.

• episodes of vertigo that last 20 minutes - 24 hours.
• low-frequency sensorineural hearing loss & tinnitus
• vertigo with nausea & postural instability
• nystagmus
• triggers include: alcohol, caffeine, nicotine, ↑ salt foods.
• medical thx: diuretics, antihistamines, anticholinergics

UW4376

Cirrhosis → ascites → abdominal ascites fluid passes into pleural space via small defects in diaphragm; occurs most commonly on the right side.

tx option 1) therapeutic thoracentesis followed by salt restriction & diuretics, if effusion still develops 2) Transjugular intrahepatic portosystemic shunt (TIPS).

Primary tx is ofcourse liver transplant.

UW2969

Painless loss of vision from emboli (feels like a curtain coming over the eye); cholesterol particles (Hollenhorst bodies) may be seen in eye; a warning sign of impending stroke.

Most emboli occur from the carotid bifurcation;  duplex u/s to identify plaques.

UW3528

• Both have ↑ conjugated bilirubinemia
• In Dubin-Johnson syndrome a dark granular pigment is present in the hepatocytes.

UW2924

When is winter's formula used?

What formula is used for metabolic alkalosis?

P_aCO2= 1.5 x HCO₃ + 8 is used for primary metabolic acidosis, not alkalosis

P_aCO2 = 0.9 x HCO₃ + 16 ± 2

UW2806

Reentrant ventricular arrhytmia (V fib)

Acute ischemia creates heterogeneity of conduction in the myocardium. Areas of partial block of conduction are frequently formed that predispose patients to reentrant arrhythmia.

UW4093

Pericardial Effusion

enlarged globular-appearing cardiac shadow; water bottle/canteen shape. Electrical Alternans on ECG.

Causes include viral, pericarditis, cancer, lupus, Dressler's, hypothyroidism, kidney failure (↑ urea nitrogen).

Vitiligo is an autoimmune condition directed against melanocytes.

Sometimes associated with other autoimmune conditions, such as pernicious anemia, autoimmune thyroid disease, type 1 diabetes, primary adrenal insufficiency, hypopituitarism, and alopecia areata.

UW4296

Dihydropyridine (amlodipine, nifedipine, felodipine) - used to reduced systemic vascular resistance and arterial pressure. Vasodilation & hypotension can → reflex tachycardia. Although most ccb's are not used to tx angina b/c of tachy reflex, amlodipine, nicardipine, and nifedipine can be used to treat chronic stable angina as well as vasospactic angina. 

Non-dihydropyridine (verapamil) - relatively selective for myocardium and often used to treat angina.

Diltiazem, a benzothiazepine, lies between the 2 previous classes. By having both a cardiac depressant and vasodilatory fxn, it can ↓ arterial pressure without producing the same degree of cardiac reflex tachycardia.

1. Obstructive Sleep Apnea
2. Oral contraceptives (d/c if HTN is a problem)

UW3914

COPD

look for ↑ JVP, hepatomegaly, ascites, lower extremity edema, clear lungs.

pulmonary disease causes cor pulmonale; other causes include pneumoconiosis, pulmonary fibrosis, kyphoscoliosis, primary pulmonary HTN, repeated episodes of PE.

UW4297

• pulmonary fibrosis
• hepatotoxicity
• thyroid dysfunction (both hyper & hypo)
• Monitor PFTs, LFTs, and thyroid function tests

UW4453

enlarged atrium

e.g. mitrial stenosis from rheumatic fever

UW3874

• hypercalcemia secondary to bone resorption via osteoclastic activation; this can even occur in an teenager.
• Bisphosphonates thx is helpful in reducing hypercalcemia and preventing osteopenia.

UW4309

• saddle anesthesia
• bowel and bladder dysfunction
• low back pain
• sciatica
• lower extremity sensory and motor loss
• reflex abnormalities

cauda equina consists of spinal nerve roots; damaged by trauma, lumbar disk disease, malignancy, abscesses.

UW4392

• BUN/creatinine ration
• ↓ urine sodium not effective when using saluretics (HCTZ)

UW3958

For how many days post-MI does troponin T stay ↑?

CK-MB?

• Troponin T, a more sensitive marker for cardiac injury, takes up to 10 days to return to normal.
• CK-MB returns to normal within 1-2 days.

UW2737

• abnormal lipid metabolism; ↑ LDL, ↓ HDL → predisposing to accelerated atherosclerosis.
• hypercoagulable

UW2244

A diabetic patient with a non-anion gap metabolic acidosis, persistent hyperkalemia, renal insufficiency.

UW2810

Symmetrical distal polyneuropathy (stocking-glove pattern)

UW3795

Lung cancer → CXR

UW2602

Antibodies → autoimmune hemolysis, idiopathic thrombocytopenic purpura (aka immune-TP), neutropenia 2° to ab-mediated destruction of WBC.

This is a form of type II hypersensitivity.

UW4416

PE with wedge shaped infarction. Sometimes accompanied by pleural effusion; recall PE can cause exudative & transudative effusions.

UW4690

• Zinc deficiency
• Symptoms - alopecia, skin lesions, abnormal taste, impaired wound healing.

UW3790

• Chronic corticosteroid use, also chronic excessive alcohol, and hemoglobinopathies (eg, sickle cell).
• pt will complain of hip pain, but no local tenderness and normal ROM.
• dx: MRI

UW4564, 4565, 4047

Anticoagulation with heparin should be started immediately in any patient with a high likelihood of PE before diagnostic tests are done.

UW3717

Thymoma in 15% of patients; screen with chest CT.

extraocular muscle weakness → double vision, ptosis, jaw cramp with chewing, voice change (dysarthria) after talking, and dysphagia.

UW3891, 2667

• rhabdomyolysis
• mild elevation of liver enzymes.
• Check CPKs in patients on statins that present with myalgias.

UW3158

HTN

Smoking and DM are risk factors for stroke as well, but not nearly as significant as HTN.

UW3879

Subarachnoid Hemorrhage

rupture of saccular aneurysm is the most frequent cause of non-traumatic subarachnoid hemorrhage.

Other causes include rupture of AV malformation and extension of primary intracerebral hemorrhage.

UW3622

Porcelain Gallbladder

↑ risk of gallbladder carcinoma

UW3732

dark brown discoloration of colon with lymph follicles shining through as pale patches (melanosis coli).

frequent, watery, nocturnal diarrhea.

UW3593

• AV block
• bradycardia
• hypotension
• wheezing
• potential cardiogenic shock
• atropine & IV fluids are first line thx
• if above fails, GLUCAGON

Smudge cell in CLL; pathologist may report "leukocytes have undergone partial breakdown b/c of greater fragility."

Presence of thrombocytopenia is a poor prognostic factor.

Dx - flow cytometry helps to determind clonality of cells.

UW2888

Glomerular hyperfiltration; it is also the pathophysiologic mechanism of glomerular injury. Thickening of glomerular basement membrane is the first change that can be quantitated → mesangial expansion → nodular sclerosis.

UW3986

Rapid rewarming with warm water.

UW3876

• Rapidly progressive dementia
• Myoclonus (shocklike contractions of a muscle or muscle group).
• EEG (sharp bi/triphasic & synchronous discharges)
• Brain bx shows spongiform changes.
• CSF normal

UW3374

Toxic Megacolon

This subgroup of patients do not respond to treatment and progress with an unremitting course and signs of systemic toxicity (fever & weight loss). When symptoms of acute colitis are assiciated with radiologic evidence of colonic dilatation, the syndrome is called toxic megacolon. Can progress rapidly and result in colonic perforation.

Tx: IV fluids, abx, bowel rest; IV corticosteroids are the drug of choice. Emergent surgery may be required if the colitis does not resolve.

UW3834

Acute pseudoobstruction and dilation of the colon in the absence of any mechanical obstruction in severely ill patients.

Massive dilatation of cecum and right colon. Can occur after surgery (esp. after CABG & total joint replacement).

aka Acute megacolon to distinguish from toxic megacolon.

Wikipedia

Secondary (AA) Amyloidosis: chronic inflammatory disease (acute phase reactant, serum amyloid A) such as chronic infection, psoriasis, IBD, RA. AL amyloidosis = Multiple Myeloma.

AA is a systemic disease and the kidneys (proteinuria) and GI system are prominently affected. Liver → inhibit synthesis of coagulation factors resulting in ↑ bruisability. Heart → restrictive cardiomyopathy → bibasilar crackles.

If sarcoid is on differential (it can cause restrictive cardiomyopathy) it is more common in African-Americans and usually present in 20s-30s.

UW4585,2707

Hypocalcemia (parasthesias)

Prior to storage whole blood is generally mixed with solutions containing citrate anticoagulant, wich can chelate serum calcium. This is most likely after massive transfusion of more than one blood volume over 24 hours).

Whole Blood → Packed Blood

UW4402

• fever, fatigue, dry cough, weight loss, pleuritic chest pain.
• Cutaneous findings: erythema multiforme (targetoid, S-J/TEN/HSV) and erythema nodosum (Crohn).
• Arthralgias
• Histology - spherules filled with endospores; histoplasmosis → intracellular yeast within mØ.
• tx: oral fluconazole and IV amphotericin B.

UW2998

• GI complaints (pain, constipation)
• Poor concentration (fatigue)
• Anemia
• Peripheral neuropathy with high dose or chronic moderate dose.
• Basophilic stippling of RBCs.
• Renal disease
• Tx: EDTA or succimer

UW4862

JVD & RBBB on ECG.

Likely secondary to Massive PE.

While dyspnea and pleuritic chest pain are common symptoms of moderate and severe PE, syncope (think hypotension) tends only to occure in massive PE. Right heart strain progresses rapidly to right ventricular dysfunction, ↓ flow to left side, ↓ CO, left heart pump failure → resultant bradycardia.

UW2145

symmetrical, hyperpigemented, velvety plaques in the axilla, groin, and neck.

associated with DM (insulin resistance) in younger patients and GI malignancy in older individuals.

UW2753

Pica refers to an appetite for nonnutritive substances such as ice, clay, dirt, and paper products.

It is a behavioral symptom sometimes present in iron deficiency.

UW4348

crystalline nephropathy (nephrotoxicity) if adequate hydration is not also provided.

UW4414

Variant Angina (Prinzmetal's angina)

Tx - CCB or nitrates (diltiazem)

UW2722

Amphotericin B plus flucytosine

UW3254

Cardiovascular disease

UW4026

Found in patients with sickle cell disease, but also in sickle cell trait. Impairment of the kidney to concentrate urine. Urine has low specific gravity.

UW4436

• ataxia
• vomiting
• occipital headache
• gaze palsy
• facial weakness
• no hemiparesis

UW3726

• acute onset (minutes)
• severe eye pain
• blurred vision
• N & V
• red eye
• steamy/hazy cornea
• moderately dilated pupil that is non reactive to light (fixed pupil)

UW2851

• acute, severe retroorbital pain that wakes a patient from sleep.
• redness of ipsilateral eye, tearing, stuffed or runny nose.
• ipsilateral Horner's syndrome (ptosis, miosis, anhydrosis)

UW4253

1. Patient on diuretics - furosemide, thiazides
2. Patient with IBD - sulfasalazine, 5-ASA
3. Patient on immunosuppressives - azathioprine, L-asparaginase.
4. Patients with a hx of seizures or bipolar disorder - valproic acid.
5. AIDS - didanosine, pentamidine.
6. Abx - metronidazole, tetracycline.

UW3833

triad of fever, tinnutus, and tachypnea

↓ pH, ↓ P_aCO2, ↓ HCO₃

UW2803

internal malignancy, commonly ovarian cancer

regular age appropriate cancer screening is essential in these patients.

UW3208

• hyperglycemia
• ↑ LDL cholesterol
• ↑ plasma triglycierides
• also remember hyponatremia, hypokalemia, and hypercalcemia.

UW4171

Medical Emergency!!!

Absolute neutrophil count < 1500/μl; susceptibility to infection ↑ when ANC < 500/μl. Fever in neutropenic patient is defined as single T reading > 38.3 (100.9) or sustained > 38 (100.4) over one hour.

Tx is monotherapy with ceftazidine, imipenem, cefepime, or meropenem.

UW2992

• cardiac tamponade, pericadial effusion
• tension pneumothorax
• severe asthma (severely ↑ intrathoracic pressures)

UW4771

Simple Renal Cyst

Thin walls, no solid component, no enhancement

UW4181

Histoplasmosis (asymptomatic pulmonary nodule)

Less than 5% of infected people develop symptomatic disease; COPD → chronic cavitary pulmonary histoplasmosis; Immunocompromised → disseminated histoplasmosis.

UW4114

• high rate of progression to fulminant hepatitis in pregnant women.
• no effective vaccine
• transmitted via fecal-oral route

UW2915

• Bacterial (SECSY - Shig, EHEC, Campy, Salm, Yers)
• CMV colitis
• UC
• Entamoeba histolytica

During an episode of chest pain it means there is no ongoing coronary ischemia or infarction. A normal echo between episodes of chest pain does not rule out unstable angina b/c wall motion returns to normal between ischemic episodes.

p. 21

Inferior infarctions more common than anterior infarctions. Q-waves in II, III, aVF.

p. 25

It is an esophageal motility disorder. The LES is unable to relax.

vs. peptic stricture, which progresses from Barrett's esophagus (symmetric, circumferential narrowing of esophagus.

UW4694

Always suspect sickle cell train in a young black male who presents with painless hematuria.

UW3967

Niacin deficiency sydrome - the 3 D's (diarrhea, dermatitis, dementia; if untreated → 4th D, death).

Too much corn.

Rash presents in sun-exposed areas.

UW3087

Sensorineural hearing loss that occurs with aging (6th decade); high-frequency bilateral hearing loss. Patients often have a hard time hearing in noisy, crowded environments.

Otosclerosis is a chronic conductive hearing loss assoicated with bony overgrowth of stapes. Typically begins with low-frequency hearing loss and often found in middle-aged individuals.

UW2836

Warfarin induced skin necrosis presents with pain, bullae formation and skin necrosis. Breasts, buttocks, thigns, and abdomen are commonly involved.

UW2772

Wtih transient loss of vision lasting a few seconds with changes in head position and can be confirmed with ophthalmologic examination. Caused by ↑ intracranial pressure, which has its own associated symptoms such as morning headache or changes in headache intensity with position. When pressure is ↑, the pressure is transmitted to the optic nerve sheath. The papilledema ↑ the normal blind spot size.

UW4900

• Parkinsonism (bradykinesia, rigidity, tremor)
• akathisia
• dystonia
• tardive dyskinesia
• result of antiΨ → benztropine (anticholinergic) or diphenhydramine.
• EPS from metoclopromide → same tx as above
• antiΨ induced akathesia → propranolol

UW4886, 4366

• pulmonary toxicity
• thyroid dysfunction (hyper/hypothyroid)
• hepatotoxicity (↑ ALT/AST)
• corneal deposits (vision not effected)
• skin Δ (blue-gray discoloration, typically most prominent on face)

UW3769

1. flushing (episodic)
2. diarrhea
3. wheezing
4. also dyspnea, intermittent abdominal pain, heart palpitations, and hypotension.
5. first-line tx: surgical resection
6. if not possible tx with octreotide

UW2625

• ratio > 20: prerenal azotemia or postrenal obstruction.
• increased with GI bleeding (2° to Hb breakdown and reabsorption of urea).
• steroid administraton

UW4303

• #1-cirrhosis, #2-DM, #3-skin pigmentation (bronze diabetes).
• Pts may present initially with subtler clues: hypogonadism (testicular atrophy/↓ libido), arthropathy (eg, osteoarthritis), DM, and hepatomegaly.
• Fe deposition in cardiac myocardium → dilated or restrictive cardiomyopathy; conduction defects may arise (eg, sick sinus syndrome).

UW4639

• ALL
• leukemia dx via bone marrow bx
• peak age: 2-5 years
• SSx: bone pain, lymphadenopathy, hepatosplenomegaly, pallor (from anemia), petechiae (from thrombocytopenia).
• associated with down syndrome

UW3284

• diarrhea, nausea, and fatigue
• confusion
• also visual symptoms: scotoma, blurry vision w/ Δs in color, or blindness.
• pts chronically taking digoxin should have close, routine monitoring of digoxin levels.

UW4454

• my Lovely bell Had An STD
• Lyme, Herpes Simplex/Zoster, AIDS, Sarcoidosis, Tumors, DM

• Early localized (days-1 month): Erythema Migrans
• Fatigue, malaise, lethargy
• mild HA and neck stiffness
• myalgias and arthralgias

  ---

  
  
• Early Disseminated (wks-mos)
• Carditis (AV block, cardiomyopathy)
• Neurologic (Bell's, meningitis, encephalitis)
• Muscular (migratory arthralgias)
• Conjunctivitis
• Multiple Erythema Migrans
• regional or generalized lymphadenopathy

  ---

  Late of Chronic (mos-yrs)
• Arthritis
• Neurologic (encephalomyelitis, peripheral neuropathy)

UW3261

• Gilbert: mildly ↓ UDP-glucuronyl transferase, bilirubin ↑ with fasting.
• Crigler-Najjar type I: absent UDP-glucuronyl transferase, pts die w/in a few years; ↑ unconjugated bilirubin, jaundice, kernitcterus.
• Crigler-Najjar type II is less severe; tx with phenobarbital or clofibrate to ↓ serum bilirubin levels (jump starts liver enzyme synthesis); phenobarbital will have no effect on type I.

UW2923

• sepsis
• pneumonia
• pancreatitis
• aspiration
• toxic ingestion
• trauma
• burns
• look for PCWP < 18 mmHg (> 18 = cardiogenic pulmonary edema).
• criteria: acute onset respiratory distress in setting of predisposing condition, PaO2/FiO2 < 200, b/l infiltrates on CXR, and normal PCWP.

UW3020

• phenytoin
• microcytic anemia

UW4147