4 star topics Flashcards
(90 cards)
1
Q
Most common causes of acute pericarditis
A
Viral infections - HIV Bacterial - TB especially Neoplasms - mets or primary Trauma (CPR, cardiac surgery) Complications of MI (Dressler's Sn 2-4 weeks post MI) Rheumatologic disease (SLE, RA) Renal failure - uremic pericarditis Radiation Drugs
2
Q
Clinical findings suggestive of acute pericarditis
A
Pleuritic CP - worse with coughing or inspiration; worse when supine; better when sitting up and leaning forward
PE: pericardial friction rub
Testing:
ECG - diffuse ST elevation, PR depression
ECHO: pericardial effusion - usually transudative; exudative - neoplasm, TB; absent does not r/o
CXR: usually nl, may show enlarged cardiac silhouette - canteen heart
3
Q
Treatment of acute pericarditis
A
NSAIDs - ibuprofen, indomethacin
Colchicine
If no response in 1-2 weeks, look for other cause - neoplasm, bacterial, SLE, recent MI
4
Q
Causes of cardiac tamponade
A
pericarditis
hemorrhage - chest trauma, aortic dissection
5
Q
Physical exam findings suggest cardiac tamponade
A
Beck’s triad: hypotension, JVD, muffled heart sounds
Pulsus paradoxus - decreased capacity of LV
-SBP decreases >10 mmHg with inspiration
6
Q
Diagnostic tests in cardiac tamponade
A
ECHO - pericardial effusion/fluid, collapse of ventricles
ECG: low voltage, electrical alternans
7
Q
Main causes of acute pancreatitis
A
PANCREATITIS
hyperParathyroidism Alcohol Neoplasm Cholelithiasis Rx - NRTIs (didanosine, zalcitabine, stavudine), Ritonavir, Sulfanamides Ercp Abdominal surgery hyperTriglyceridemia Infection - mumps Trauma Idiopathic Scorpion sting - not in US
8
Q
Presentation and Diagnostic testing for acute pancreatitis
A
Rapid onset of severe epigastric abd pain
- may radiate to back
- Worse with eating -> sitophobia
N/V
Intravascular depletion -> tachycardia, hypotension/shock, multi organ failure
Cullen/Grey turner sign
Dx:
Elevated lipase (and amylase) - not indicative of severity
Ranson critieria for severity/prognosis
Best radiology study: CT scan - enlarged, inflamed, may show pseudocyst
Abd XR: dilated loop of bowel near pancreas “sentinel loop”; elevation of diaphragm, pleural effusion
9
Q
Ranson criteria
A
Severity of pancreatitis - one point for each
On admission: GA LAW Glucose >200 AST >250 LDH >350 Age >55 WBC > 16,000
During first 48 hours: CALvin and HOBBeS Serum calcium less than 8 Hematocrit decrease >10% paO2 less than 60 Base deficit >4 BUN increase >5 Sequestration of fluids >6L (bad sign)
0-2 points = 0-3% mortality
3-5 points = 11-15% mortality
6-11 points = >40% mortality
10
Q
Management of acute pancreatitis
A
IVF NPO NG suction - ppx for N Correct electrolyte abnormalities Opioids for pain control - use meperidine (morphine can cause sphincter of Oddi spasms)
If not tolerating referring -> Nasojejunal feeding (won’t stimulate pancreas) or TPN
Cholecystectomy if caused by choledocholithiasis
11
Q
Complications of pancreatitis
A
Respiratory failure Renal failure Shock Sepsis DIC Hemorrhage
Pancreatic necrosis, abscess, pseudocyst
Chronic pancreatitis
12
Q
Most common cause of chronic pancreatitis
A
alcoholism
13
Q
Symptoms suggestive of chronic pancreatitis
A
recurrent epigastric pain
N/V
Fat malabsorption/steatorrhea
14
Q
Best lab test for diagnosing chronic pancreatitis
A
fecal elastase is low
XR/CT - calcifications, enlarged ducts
MRCP
15
Q
Management of chronic pancreatitis
A
Stop etOH use Stop smoking Opioids for analgesia Pancreatic enzymes Vitamin supplements Small, low fat meals
Surgery to decompress dilated duct, resect part of pancreas
16
Q
Complications of chronic pancreatitis
A
Pseudocysts - resolve on one, or drain if complications, pain or not resolving
Obstruction of bile ducts/duodenum
Malnutrition
glucose intolerance/DM
pancreatic cancer
17
Q
Pancreatic pseudocyst vs true cyst
A
Pseudocyst: fluid contained by inflammatory tissue
Cyst - fluid contained by epithelial tissue
18
Q
Complications of pancreatic pseudocyst
A
rupture abscess pseudo aneurysm - erosion into adjacent blood vessel with hemorrhage into pseudocyst -painful as it expands rapidly -dangerous
19
Q
Test to distinguish pseudocyst from cystic pancreatic neoplasm
A
Aspirate fluid via CT guided percutaneous aspiration or endoscopic U/S needle aspiration
Pseudocyst fluid high in amylase
20
Q
Systemic lupus erythematosis (SLE)
A
MC in women, AA
Onset black women 15-45, all others 40-60
Features: 4 out of 11 over time
- Malar rash
- Discoid rash
- Photosensitivity
- Painless oral ulcers
- Arthritis - inflammatory, non erosive, affects at least 2 joints
- Serositis - pericarditis, pleuritis, pleural effusion
- Renal disorders - glomerulonephritis, proteinuria, renal failure - cause of death
- Neurologic disorders - seizures, psychosis, peripheral neuropathy
- Hematologic disorders - hemolytic anemia, leukopenia, lymphopenia, thrombocytopenia
- ANA high (1:160, 1:320)
- Immunologic disorder - anti-dsDNA, anti-Smith, antiphospholipid antibodies
Diagnostic testing:
ANA, anti-dsDNA, anti-Smith, antiphospholipid
Low C3 and C4
Anti-histone Ab - drug induced
Tx:
Avoid sun exposure
Hydroxychloroquine, NSAIDs, glucocorticoids
Complications:
- Hypercoagulability - lupus anticoagulant, anticardiolipin Ab, antiphospholipid Ab
- Immunocompromised
- CV disease
- Renal failure
21
Q
Drugs associated with drug induced lupus
A
SHIPP
Sulfonamides Hydralazine Isoniazid Phenytoin Procainamide
Anti-histone Ab
22
Q
Polymyalgia reumatica (PMR)
A
Strongly associated with Giant Cell Arteritis
MC: elderly women
Joint pain and stiffness in shoulders, neck, and/or hips
No muscular weakness
significantly elevated ESR and CRP
Anemia common
Negative serologic markers - ANA, RF
MRI or PET show synovial inflammation
Tx:
Low-dose glucocorticoids (15-20 mg/day) for 2-4 weeks, then gradual taper over 1-2 years
23
Q
Polymyositis and dermatomyositis
A
Progressive, symmetric weakness of proximal limb muscles - hip flexors, shoulders, deltoids; trouble climbing stairs, raising hands over head
Minimal muscle soreness/tenderness
Skin manifestations in dermatomyositis:
- malar rash
- heliotrope rash on eyelids
- Gottron’s papules on knuckles, elbows, or knees
- Mechanic hands (hyperkeratosis and cracking of hands or feet)
- “Shawl sign” on shoulders
- “V sign” on anterior chest
Dx testing:
Elevated CK, ALT, AST, andaldolase
ANA frequently positive
ANTI-JO1 - antisynthetase Ab
EMG distinguishes muscle pathology from nerve pathology
MUSCLE BX - muscle fiber degeneration and inflammatory cells
Tx:
High dose glucocorticoids for 4-6 weeks, then gradual taper
Methotrexate or azathioprine - may reduce duration of glucocorticoid tx
Complication: risk of malignancy - breast, prostate, colon, lung
24
Q
Fibromyalgia
A
Increased sensitivity to pain without specific cause
Risk: women 20-50
Assoc with inflammatory rheumatologist dz (RA, SLE), depression, IBS
Features:
Widespread muscle and joint swelling or inflammation
Multiple tender trigger points
Severe fatigue
Sleep disturbance
Depression or anxiety in at least 30% of patients
Cognitive disturbance - “fog”
Labs and XR normal
Tx: Non pharm: -Reassure -stretching exercises -sleep hygiene -Address psych issues - depression, anxiety, ptsd
Pharm: Acetaminophen and NSAIDS - avoid opiates Pregabalin SNRIs - fluoxetine, milnacipran, venlafaxine Sleep aids as needed
25
Systemic sclerosis (scleroderma)
Excess collagen deposition in skin and other tissues
Diffuse cutaneous systemic sclerosis
Limited cutaneous systemic sclerosis
Tx:
Supportive care - PPI, CCB, ACE-I
Tx severe skin sclerosis with methotrexate, mycophenolate, or cyclophosphamide
26
Diffuse cutaneous systemic sclerosis (dcSSc)
Widespread sclerosis involving skin and visceral organs
Progresses rapidly, early involvement of visceral organs
Skin may appear shiny and lack wrinkles - finger contractions and ulcerations
Assoc with anti-DNA topoisomerase 1 Ab - anti-Scl 70 and/or anti-RNA polymerase Ab
27
Limited cutaneous systemic sclerosis (lcSSc)
Skin involvement limited to hands +/- face and neck
Less visceral involvement; progresses less rapidly
```
CREST syndrome:
Calcinosis cutis: calcifications in deep layers of the skin, often in fingers
Raynaud phenomenon
Esophageal dysmotility - LES sclerosis
Sclerodactyly
Telangiectasis - lips, hands, or face
```
Assoc with anti-centromere Ab
28
Sjogren syndrome
Exocrine glands
Clinical features:
Xerophthalmia - dryness, conjunctivitis, sensation of sand in eyes
Xerostomia - dysphagia, enlarged parotid glands, dental caries
Arthritis
Nasal dryness
Vaginal dryness
Dx:
Anti-SSA aka Anti-Ro Ab
Anti-SSB aka Anti-La Ab
Tx:
Dry eyes: artificial tears, cyclosporin eye drops
Dry mouth: muscarinic agonists - pilocarpine, cevimeline
Arthritis: hydroxychloroquine or methotrexate
29
Osteoarthritis aka DJD
Joint degeneration with erosion of articular cartilage
Risk: aging, obesity, joint injury
Features:
Noninflammatory arthritis of hips, knees, ankles, hands/feet, spine
Pain worse with use, better with rest
No systemic sxs
Assymmetric arthritis with boney enlargement of DIP joints (Heberden's) and PIP (Bouchard's)
Dx:
XR: osteophytes and joint space narrowing
ESR normal, no Ab
```
Tx:
Prevent overuse, provide rest periods
Wt loss
Acetaminophen, NSAIDs, or celecoxib
Glucocorticoid joint injections
Hyaluronic acid joint injection
Joint replacement for severe disease
```
30
Rheumatoid arthritis (RA)
Type III hypersensitivity reaction -> immune complexes deposited in tissues -> joint inflammation and pannus formation (synovial hypertrophy, granulation tissue on articular cartilage)
Risk: Women, HLA-DR4
Features:
Chronic inflammatory arthritis - hands, wrists, large joints
Morning stiffness
Pain and stiffness worse with rest, improves with use - gel phenomenon
Systemic sxs: subcutaneous nodules, pleuritis, pericardiits, scleritis
Swelling of MCPs and PIPs - Boutonniere and swan neck deformities
Ulnar deviation of fingers (away from thumb)
Dx:
elevated ESR and CRP
Positive RF - anti IgG Ab
Positive anti-citrullinated protein antibodies (ACPA)
31
Treatment of RA
DMARDs, with adjuncts of steroids or NSAIDs
| Drugs in MSK treatment notecards
32
Psoriatic arthritis
Patterns of arthritis:
Assymetrical, inflammatory arthritis involving DIP joints
Symmetrical arthritis like RA
Severe, mutilating arthritis (arthritis mutilans)
Spondyloarthritis
```
Dactylitis - sausage fingers
Anterior uveitis (inflammation of iris and ciliary bodies) or conjunctivitis
```
Dx:
HLA-B27
Seronegative (negative RF, ANA)
XR: fingers "pencil-in-cup" deformities
Tx:
NSAIDs or celecoxib
Methotrexate, leflunomide, or TNF alpha inhibitors
33
Ankylosing spondylitis
White Men 20-30s
LBP worse with inactivity, improves with exercise
Reduced spine mobility - abnormal Schober test
Possible hip and shoulder pain
Anterior uveitis - eye pain, blurred vision, photophobia
CV Dz - aortic regurg, conduction disturbances
Dx:
HLA-B27
Negative RF, ANA
XR pelvis - sacroilitis and SI joint fusion
XR L-spine - vertebral fusion "bamboo spine"
Tx:
PT and exercise
NSAIDs or celecoxib continuously
TNF alpha inhibitors
34
Paget disease of bone
Focal areas of excessive bone remodeling (overcast overactivity -> osteoblast overactivity)
-axial skeleton, long bones of legs
```
Presentation: asx or
bone pain
arthritis
bone deformity - bowed tibias, kyphosis
Increased risk of fx
hearing loss
increased skull circumference - hat doesn't fit
```
Dx:
Elevated alk phos - marker of osteoblast activity
XR: osteolytic lesions and hyper dense sclerotic lesions
Radionuclide bone scan: "hot spots"
Tx: bisphosphonates or calcitonin injections
Risk: osteosarcoma
35
Anterior shoulder dislocation
MC
Arm position: external rotation and slight abduction
Bankart lesion - Tears anterior labrum and capsule of shoulder
Axillary artery and nerve at risk
Classic scenario: Blow to abducted, externally rotated, extended arm - block a basketball shot
Physical exam: Prominent acromion (if thin pt), loss of shoulder roundness
36
Posterior shoulder dislocation
Arm position: internal rotation and adduction
Unable to externally rotate
XR: "light bulb" on AP view
Neurovascular compromise unusual
Classic scenario: blow to anterior shoulder, seizure, electrocution
Exam: posterior prominence and anterior shoulder is flat
37
Treatment of shoulder dislocation
Pain control:
glenoid cavity lidocaine injection
Narcotics
Conscious sedation
Reduce:
traction-counter traction
-Hippocratic, prone, scapular manipulation
Sling immobilization
Re xray
F/up with ortho - likely to dislocate again
38
Immune thrombocytopenia (ITP)
Caused by anti-platelet IgG Ab
Could be primary ITP, Or secondary (HIV, hepatitis C, lupus, CLL)
Platelet count often below 50,000
Treatment -
Children: not necessary
Adults: glucocorticoids or IVIG; platelet transfusion for significant bleeding
39
Drugs known to cause thrombocytopenia
```
Heparin
Abciximab (GP IIb/IIIa inhibitor)
Carbamazepine, Phenytoin, valproate
Cimetidine
Acyclovir
Rifampin
Sulfonamides (sulfasalazine, TMP-SMX)
Procainamide, quinidine
Quinine
```
40
Heparin-induced thrombocytopenia (HIT)
Thrombosis plus thrombocytopenia - sudden decrease in platelet count by at least 50%
Heparin forms complexes with platelet factor 4
Antibodies against the complex cause platelet activation and aggregation -> risk thrombosis
Platelets are removed from circulation
Diagnostic testing:
ELISA detects platelets
Serotonin release assay- Gold standard but expensive
Heparin-induced platelet aggregation assay - specific not sensitive
Treatment:
Stop heparin
Anticoagulate with direct thrombin inhibitor, (argatroban) warfarin x3 mo
Lifelong avoidance of heparin and LMWHs
41
Thrombotic thrombocytopenia purpura - hemolytic uremic syndrome (TTP-HUS)
Enzyme deficiency -> unregulated platelet aggregation -> thrombosis
Consumption of platelets -> thrombocytopenia
Thrombosis-> Microangiopathic hemolysis
E coli O157:H7 - kids
HUS:
Hemolysis
Uremia (renal failure)
Thrombocytopenia
```
TTP:
Hemolysis
Uremia (Renal failure)
Thrombocytopenia
Neurological sequelae - AMS, seizures, coma
Fever - high
```
Treatment:
Plasma exchange plus glucocorticoids
42
HELLP syndrome
Sequelae of preeclampsia
```
Presentation:
Hemolysis
Elevated liver enzymes
low platelets
Hypertension
```
Treatment
Induce labor and deliver
43
Thrombocytopenia caused by impaired platelet production - causes
Infections: parvovirus b19, other viruses
Megaloblastic anemia - folate/b12 deficiency
Alcohol abuse - directly toxic to bone marrow
44
Thrombocytopenia caused by splenic sequestration of platelets - findings
Splenomegaly
Bone marrow biopsy is normal
Splenectomy curative
45
Multiple myeloma
Malignant monoclonal perforation plasma cells
Clinical features:
Normocytic anemia
Bone pain, back pain, pathological fractures
Hypercalcemia -> constipation, abdominal pain, encephalopathy, polyuria, dehydration
Kidney disease (light chain cast nephropathy "myeloma kidney")
Fatigue
Weight loss
Recurrent infections
Vertebral compression fractures -> radiculopathy or cord compression
Dx:
Serum protein electrophoresis (SPEP) - M spike (gamma) - usually IgG may be IgA
UPEP - Bence Jones proteins
Skeletal survey shows lytic lesions due to local osteolytic factors - punched out
Bone marrow biopsy shows increase plasma cells
Tx:
Cytogenetic testing -> prognosis, timing of tx
Chemo (lenalidomide) + bone marrow transplant (if aggressive)
46
Hodgkin's lymphoma
B cell lymphoma - Reed-Sternberg cell - large binucleated cells with prominent nucleoli and clearing around cell
-background of reactive lymphocytes and granulocytes
Bimodal age: 20 and 65
Clinical features:
Painless cervical lymphadenopathy - firm, rubbery
B symptoms: low-grade fever, night sweats, weight loss
Pruritus
Dx:
CXR or CT - mediastinal lymphadenopathy
4 subtypes: Nodular sclerosis (MC), Lymphocyte-rich, lymphocyte-depleted, mixed cellularity
Tx:
Chemo+rad
Hematopoetic cell transplants for relapse or progression despite chemo/rad
47
Nodular sclerosis subtype of Hodgkin's lymphoma
Most common subtype
Nodules of lymphocytes separated by sclerotic bands a collagen
Relatively few R-S cells
Good prognosis
48
Lymphocyte rich subtype of Hodgkin's lymphoma
Please common subtype
Few R-S cells
Best prognosis
49
Lymphocyte depleted subtype of Hodgkin's lymphoma
Abundant R-S cells
| Poor prognosis
50
Mixed cellularity subtype of Hodgkin's lymphoma
Second most common subtype
| Mix of lymphocytes and R-S cells without nodules or sclerotic bands
51
Non-Hodgkin's lymphoma
lack Reed-Sternberg cells
Presentation:
Pain is generalized lymphadenopathy
Constitutional "B" symptoms - fever, night sweats, weight loss
52
Diffuse large B cell lymphoma
Most common non-Hodgkin's lymphoma
| More common in elderly men
53
lymphoblastic lymphoma
Most common non-Hodgkin's lymphoma in children
54
Follicular lymphoma
Second most common non-Hodgkin's lymphoma overall
90% have t(14;18)
"Cleaved cells" - lymphocyte looks like a heart
55
Burkitt lymphoma
Associated with t(8;14)
Three forms: sporadic, endemic (EBV in Africa - mandible), immunodeficiency associated (HIV)
"starry sky" appearance on bx
56
Small lymphocytic lymphoma
Malignant cells are identical to chronic lymphocytic leukemia
57
Harry cell leukemia
Classified as a lymphoma
| Malignant cells have "Harry" cytoplasmic projections
58
Causes of polycythemia
Hypoxemia
- COPD
- Live at altitude
Inappropriate elevated epo (tumors)
- Pheo
- RCC
- HCC
- Hemangioblastoma
59
Classic presentation of polycythemia vera
Hyper viscosity causing vascular sludging
Visual disturbances: blurred vision, amaurosis fugax, scintillating scotoma, ophthalmic migraine
Thrombosis: stroke, MI or angina, DVT or PE, Budd-Chiari syndrome, superficial thrombophlebitis
Erythromelalgia - Burning pain in the hands and feet with erythema, pallor or cyanosis
Pruritis - especially after a warm bath
Facial plethora - reddening of the face
Hepatosplenomegaly
Elevated H&H and RBC mass, leukocytosis (40%), thrombocytosis (60%)
60
Treatment of polycythemia vera
Phlebotomy to keep hematocrit below 45% males, 42% females
->desirable iron deficiency anemia - do not supplement iron!
Add hydroxyurea if at high risk for thrombosis (over age 70, and prior thrombosis, platelets >1,500,000, or CV risk factors)
Aspirin every day to help prevent thrombosis (MI, CVA, PE, DVT)
61
Anterior cerebral artery (ACA) - region supplied, results of stroke
Medial cortex - frontal and parietal lobes
Motor/sensory defects of lower extremity and trunk
62
Middle cerebral artery (MCA) - region supplied, results of stroke
Lateral cortex - parietal and temporal lobes
Motor/sensory deficits of face and upper extremity, Aphasia
63
Posterior cerebellar artery(PCA) - region supplied, results of stroke
Occipital lobe
Impaired vision
64
Parkinson disease
Degeneration of dopaminergic neurons in the substantia nigra
- decreased dopamine + relative increase in ACh
- Lewy bodies: eosinophilic conclusions of alpha-synuclein and ubiquitin (halo around)
```
Risk factors:
Family history
Advancing age
Head trauma
MPTP (methyl-phenyl-tetra-hydropuridine) - byproduct of meperidine synthesis -> metabolized to MPP (methyl-phenyl-perideium) -> damage to substantia nigra
```
Features:
Decreased movement (bradykinesia, hypokinesia, akinesia)
Postural instability
Fenestrated gait
Resting tremor (pill rolling)
cogwheel rigidity
Mask like facies (hypokinesia of facial muscles)
Autonomic dysfunction, orthostatic hypotension
Cognitive dysfunction, dementia, depression, apathy
Clinical diagnosis
65
Amyotrophic lateral sclerosis (ALS)
Features:
Weakness with normal sensation
Initial presenting symptoms:
-asymmetrical in weakness - hands, fingers, shoulder girdle, lower extremity (foot drop), or pelvic girdle
-Bulbar dysfunction (dysarthria or dysphasia) - medulla involvement
UMN S/S:
movement stiffness, slowness and incoordination
Spasticity and hyperreflexia (spastic paralysis)
Slow rapid alternating movements - dysdiadochokinesia
Gait disorder
Bulbar UMN S/S:
Dysarthria, dysphasia
pseudobulbar affect - inappropriate laughing, crying, or yawning
```
LMN S/S:
Weakness, gait disorder
Reduced reflexes (flaccid paralysis)
Muscle atrophy
Fasciculations
```
Cognitive deficiets: frontotemporal executive dysfunction
Neuromuscular respiratory failure months to years after dz
avg survival - 3-5 yrs
Dx:
EMG: widespread acute and chronic muscular denervation and reinnervation
Tx:
Riluzole - slows progression of ALS and prolonged survival by decreasing glutamate-induced excitotoxicity
66
Normal pressure hydrocephalus (NPH)
Inflammation and fibrosis of the arachnoid granulations -> and impaired reabsorption of CSF -> excess CSF builds up in the ventricles
Presentation: (3 W's)
Wacky - cognitive impairment
Wet - urinary incontinence
Wobby - gait disturbance - magnetic, early sign
Dx:
MRI: dilation of the cerebral ventricles and enlargement
CSF pressure not elevated
Tx: ventricular shunting
67
```
Delirum -
Daily course:
Onset:
Memory:
Level of consiousness:
Visual hallucinations:
Prognosis:
```
```
Daily course: waxes and wanes in a day
Onset: acute - hours to days
Memory: impaired
Level of consiousness: decreased
Visual hallucinations: common
Prognosis: reversible
```
68
```
Dementia -
Daily course:
Onset:
Memory:
Level of consiousness:
Visual hallucinations:
Prognosis:
```
```
Daily course: consistent, Sundowning (more confused in evening)
Onset: gradual
Memory: impaired
Level of consiousness: normal
Visual hallucinations: uncommon
Prognosis: generally irreversible
```
69
Diabetes insipidus
Disorder of ADH directed water reabsorption -> dehydration and hypernatremia
Central vs nephrogenic vs lithium induced
Presentation: polyuria, polydipsia
```
Labs:
High serum sodium
High serum osmolality
Variable urine sodium - usually low
low urine osmolality
Water deprivation test - urine osmolality stays low despite water restriction
```
Tx:
treat underlying condition
Lithium induced - HCTZ + amiloride
70
Central diabetes insipidus
Posterior pituitary stops producing ADH
Causes: Brain trauma, destructive pituitary tumors, hypoxic encephalopathy, anorexia nervosa, idiopathic
Supplement ADH (desmopressin) -> increased urine osmolality
Tx: desmopressin
71
Nephrogenic diabetes insipidus
Kidneys are unresponsive to ADH
Causes: hereditary renal disease, lithium toxicity, hypercalcemia, hypokalemia
supplement desmopressin - urine osmolality stays low
Tx:
Restrict dietary salt
HCTZ
indomethacin
Lithium - HCTZ + amiloride
72
Hyperkalemia
```
Causes:
Metabolic acidosis
adrenal insufficiency
aldosterone deficiency
Tissue breakdown
Insulin deficiency
Renal failure
Potassium sparing diuretics
```
ECG:
Tall peaked T waves
Can predispose to ventricular tachycardia and asystole
73
Condition shifting potassium out of cells
leads to hyperkalemia
```
Low insulin
Beta blockers
Acidosis
digoxin
cell lysis
```
74
Condition shifting potassium into cells
Leads to hypokalemia
Insulin
Beta agonists - albuterol
Alkalosis - sodium bicarb
Cell creation/proliferation
75
Emergency treatment for hyperkalemia
Stabilize cardiac membranes - IV calcium gluconate or IV calcium chloride
Drive potassium into cells
- insulin + D50
- beta agonist - albuterol, nebulized
- sodium bicarb
Remove potassium from the body
Hemodialysis
Sodium polystyrene sulfonate (Kayexalate)
Loop diuretics - chronic
76
Hypokalemia
```
Causes:
Poor dietary intake
Alkalosis
Hypothermia
Vomiting
Diarrhea
Hyperaldosteronism
Insulin access
Diuretics
RTA 1 or II (renal tubular acidosis)
```
```
Presentation:
Fatigue and weakness
Hyporeflexia
Possible paralysis or parathesias if severe
Arrhythmias
```
ECG:
T wave flattening
ST depression
U waves
Tx:
Treat underlying disorder
Give oral or IV potassium - need central line to avoid sclerosing of veins
Avoid overly rapid replacement
77
Hypercalcemia
Corrected serum calcium or get ionized:
total serum calcium + (0.8 x (4-albumin))
Causes:
Hyperparathyroidism
Neoplasms - PTHrP (squamous cell lung ca), lytic bone dz
Thiazide diuretics
Milk-alkali syndrome - Ca carbonate antacids + mlik, Ca supplements
Sarcoidosis - macrophages generate vitamin D
Vitamin a toxicity
```
Presentation:
Bone pain
Fractures
Nephrolithiasis
Nausea/vomiting
PUD
Constipation
Weakness
Mental status changes
Polyuria
can cause acute pancreatitis
```
Labs: +/- increased PTH
ECG: shortened QT interval
Tx:
Hydration!!!
Calcitonin, bisphosphonates, Glucocorticoids
Surgery - hyperparathyroidism, resect neoplasms
78
Hypocalcemia
```
Causes:
Hypoparathyroidism
Hyperphosphatemia
Chronic renal failure
Vitamin D deficiency
Loop diuretics
Pancreatitis
Alcoholism
```
```
Presentation:
Tingling of the lips and fingers
paresthesias
Carpal and pedal spasms "cramping"
Tetany
Laryngeal spasm with difficulty breathing
Seizures
Chvostek's sign - cheek
Trousseau's sign
```
ECG: QT prolongation
Tx:
Treat underlying disorder
PO or IV calcium
Vit D supplements
79
Winters formula
pCO2 = 1.5 (HCO3) + 8 +/-2
predict pCO2 in metabolic acidosis with respiratory compensation
If measured pCO2 differs from predicted, indicates mix disorder rather than simple respiratory compensation
80
Causes of metabolic alkalosis
```
Vomiting - lose H+
Diuretics - contraction alkalosis (lose water relative to bicarb)
Cushing syndrome
Hyperaldosteronism
Adrenal hyperplasia
Volume contraction
```
81
Causes of respiratory alkalosis
```
Hyperventilation
Asthma
Pulmonary embolism
High-altitude
Aspirin toxicity - directly stimulates respiratory center in brain, early
```
82
Causes of metabolic acidosis - high anion gap
```
Methanol
Uremia
DKA
Propylene glycol
Isoniazid/iron
Lactic acidosis
Ethylene glycol
Salicylates - late aspirin toxicity finding
```
83
Cause of metabolic acidosis normal anion gap
```
Diarrhea - MC
Renal tubular acidosis
TPN
Hyperaldosteronism - type 4 RTA
Addison disease
```
84
Causes of respiratory acidosis
COPD - retain CO2
Respiratory depression - Brain injury
Neuromuscular diseases
Opioid overdose
85
Differential diagnosis of normal anion gap metabolic acidosis with hypokalemia
```
Renal tubular acidosis types I and II
Diarrhea
Fanconi syndrome (type II RTA)
```
86
Differential diagnosis of normal anion gap metabolic acidosis with hyperkalemia
Addison disease
Renal tubular acidosis type IV
Hyperalimentation (TPN)
87
Renal tubular acidosis (RTA) type 1
Distal
Impaired H+ secretion in collecting tubules (intercalated cells)
```
Causes:
autoimmune diseases
Drugs
Infection
Cirrhosis
SLE
obstructive nephropathy
```
Urine pH - high - over 5.3
Labs: low K
Calcium kidney stones
Tx:
Oral HCO3
K supplements
Thiazide diuretics
88
Renal tubular acidosis (RTA) type 2
Proximal
Impaired bicarb reabsorption in the PCT
```
Causes:
Multiple myeloma, amyloidosis - excess proteins and urine
Fanconi syndrome
Wilson disease
Vitamin D deficiency
Autoimmune diseases
```
Urine pH normal, below 5.3
Labs: low K, low HCO3
Tx:
Oral HCO3
K supplements
Thiazide diuretics
89
Renal tubular acidosis (RTA) type 4
hypoaldosteronism -> impaired potassium secretion
Principle cells of collecting tubules
Causes: Addison disease
Urine pH - less than 5.3 (normal)
Labs: hyperkalemia, normal HCO3
Tx: fludrocortisone, K restriction
90
Febrile seizures
6 mo - 6 y
Absence of CNS infection/lesion
Presentation:
tonic-clonic seizure less than 15 minutes, first day of illness
Postictal state less than 5-10 min
Tx- lower temp, reassure, no antiepiletics
-if seizure witnessed and lasting >5 min - IV diazepam or lorazepam, or buccal midazolam if no IV access
Testing not needed - LP if meningitis suspected
1-2% develop epilepsy, 40% will have another within 2 years
