all Flashcards
(258 cards)
1
Q
Hallmark clinical manifestations of hyperkalemia:
A
Cardiac toxicity and peaked T waves, Ascending weakness
2
Q
What factors are used to calculate the TIMI score for ACS?
A
A - age (>65. >75) M - markers positive (troponin, CK-MB) E - ekg w/ st deviation R - risk factors for CAD (>=3) I - ischemia C - known CAD A - aspirin use in last 7 days
3
Q
After identifying that a patient has nephritic syndrome, what is the next test to order to narrow the ddx?
A
Serum complement
4
Q
What medical management might you use in a patient you believe to have a true total body excess of potassium (v. hyperkalemia)?
A
Kayexalate (ion exchange resin)
Diuretic
Dialysis
5
Q
When is thrombolysis indicated in the setting of a PE?
A
Hemodynamically unstable (i.e. shock, RHF)
6
Q
Hallmark clinical manifestations of hypokalemia:
A
Weakness or paralysis
Ileus
EKG changes: flattened T waves, prominent U waves
7
Q
Plasma osmolality is determined primarily by (3):
A
- Sodium
- Glucose
- BUN
8
Q
Medical DVT prophylaxis of choice in a patient with CKD.
A
Heparin (no renal clearance)
9
Q
3 features of Alport’s syndrome:
A
- isolated hematuria
- sensorineural deafness
- ocular problems (i.e.lens dislocation, cataracts…)
10
Q
EKG shows ST elevation in the inferior lead and V1-V3, what artery was most likely occluded?
A
R coronary artery.
11
Q
First line antibiotic regimen for CAP.
A
Macrolide (azithromycin, clarithromycin)
12
Q
Standard medical therapy for all ACS:
A
- Aspirin or clopidogrel (anti-platelet)
- Bblocker
- Nitroglycerin
- Morphine
- Oxygen
- LMWH or heparin (anti-coag)
- ACEI or ARB (remodeling)
- GP IIb/IIIa inhibitors - if PCI
- STATIN
13
Q
CURB-65 Guidelines for risk stratification in CAP.
A
Confusion Uremia (BUN >20) Respirations > 30 Blood Pressure Age >65
14
Q
Coverage for Pneumocystis
A
Bactrim
TMP-SMX
15
Q
Heparin-Induced Thrombocytopenia (HIT)
A
A thrombocytopenia with >50% decrease in platelets occurring 5-10 days after administration of heparin.
16
Q
Systems to consider in DDx of chest pain (5).
A
Cardio Pulm GI MSK Psych (anxiety)
17
Q
A patient with a history of asthma is being evaluated for nephritic syndrome. What is likely to be seen on renal biopsy?
A
Granulomatous inflammation, eosinophilia
18
Q
How might an MI cause hypokalemia?
A
Catecholamine excess! Drives potassium into intracellular space.
19
Q
EKG shows ST elevation in leads V5-V6, I, II, and aVL. What artery was most likely occluded?
A
L circumflex artery.
20
Q
What are the 3 broad categories of ATN etiologies?
A
- Ischemia (progression of pre-renal AKI)
- Contrast
- Toxins
21
Q
How does Goodpasture syndrome differ from Wegener’s granulomatosis in presentation?
A
Renal and pulmonary involvement in both.
Wegener’s with involvement of upper respiratory tract as well (epistaxis, perforation of septum…)
22
Q
Nephrotic syndrome is characterized by heavy proteinuria and what other hallmarks?
A
Hypoalbuminemia Edema Hypercoagulability Hypogammaglobulinemia Hyperlipidemia Lipiduria
23
Q
Membranous nephropathy associated diseases:
A
Hep B/C, tumors, SLE
24
Q
Physical examination findings in heart failure:
A
JVD, crackles, S3, hypotension, cool extremities
25
What tests might you order if a patient with pneumonia fails to respond within 72 hours?
Drug levels
Bronchoscopy (resistant organisms?)
Chest CT (fungal/viral v. complication)
26
What are the drugs known to cause ATN?
Aminoglycosides (i.e. gentamycin), vancomycin, amphotericin, cisplatin
27
Most important factors in predicting all-cause mortality after STEMI:
Age (>65, esp >75)
Systolic BP > 100
HR
28
Antibiotic regimen for HAP.
MRSA: vancomycin
Pseudomonas: pip/tazo, cefepime, or carbapenem
Others: FQ or [gentamicin + azithromycin]
29
What medications can be used for hyperkalemic patients in order to cause K+ shift back into cells?
Glucose + insulin
Bicarbonate (H+ out, K+ in)
Beta agonist i.e. albuterol (catecholamines)
30
What are some drugs that can cause pre-renal azotemia?
NSAIDs, Cyclosporine: vasoconstriction of afferent arteriole (block PGs)
ACEi, ARB: vasodilation of efferent arteriole (block angiotensin II)
CONTRAST
31
When is a chest tube indicated in a patient with pneumonia?
Loculated effusion
Pleural fluid with positive gram stain or culture.
pH 3x ULN
32
What urine sediment findings are indicative of ATN?
Muddy brown granular casts, tubular casts
| +/- RBC, protein
33
What urine sediment findings are indicative of GN?
RBC casts with dysmorphic RBCs
34
How is hyperkalemia treated urgently (i.e. serum K > 6, patient with EKG changes)?
Calcium gluconate
| also monitor EKG
35
Stimuli for ADH release:
```
High serum osmolality
Low blood volume
Angiotensin-II
Pain
Nausea (powerful)
```
36
How is post-renal azotemia diagnosed?
Catheterization with >100 mL remaining in bladder after voiding.
37
Modified Well's criteria for PE:
```
DVT sx.
PE is most likely
Tachycardia
Immobilization/Surgery
Hx of DVT or PE
Hemoptysis
Cancer in last 6 mo.
```
38
How to differentiate UA from NSTEMI.
Biomarkers. In NSTEMI there is release of troponins or CK-MB.
Also, NSTEMI does not respond to nitroglycerin.
39
Most common organisms causing catheter-associated UTI:
Yeast, E. coli
40
Virchow's triad
1. Endothelial injury
2. Venous stasis
3. Hypercoagulability
41
Most common causes of AKI in the ICU (4)
Sepsis
Major surgery
Low CO/hypovolemia
Drugs
42
A patient with nephritic syndrome is found to have low serum complement. What is your differential diagnosis?
Post-streptococcal GN
Lupus nephritis
Membranoproliferative GN
Infective endocarditis
43
Long term complications/sequelae after a PE:
Pulmonary hypertension
| Arrhythmias
44
What other electrolyte should always be checked in a hypokalemic patient and why?
Magnesium
| It blocks potassium excretion in the tubules, need to correct both to correct K.
45
Where in the kidneys is K+ actively excreted?
The distal tubule (by principle cells)
46
When should the FE of urea be used over the FE of sodium and why?
When a patient has taken a diuretic because FE of sodium will be high regardless of renal function.
47
Well's Criteria for DVT:
```
Cancer w/i 6 mo.
Immobilization
Bedridden/surgery
Tenderness along deep vein distribution
Swelling of entire leg
Swelling of calf
Unilateral pitting edema
Collateral superficial veins
Previous DVT
```
48
A patient with nephritic syndrome is found to have a normal serum complement. What is your differential diagnosis and what tests will you use to differentiate?
Goodpasture syndrome/anti-GBM disease: test for anti-GBM antibodies
Wegener's Granulomatosis: test for ANCA, will be C-ANCA positive
Microscopic polyangitis: P-ANCA positive
Churg-Strauss syndrome: P-ANCA positive
49
Light's Criteria:
Exudate If....
Pleural fluid protein/serum protein > 0.5
Pleural fluid LDH/serum LDH > 0.6
Pleural fluid LDH > 2/3 ULN
(Otherwise, transudate)
50
How is HIT treated?
Stop the heparin.
Give direct thrombin inhibitors (lepirudin, argatroban, danaparoid) as alternative anticoagulation and bridge to warfarin when platelet count is >150k.
51
What are endogenous toxins that may cause ATN?
Hemoglobin, myoglobin
52
What urine sediment findings are indicative of AIN?
WBC casts, WBC with negative urine culture
| +/- RBCs
53
Nephritic syndrome is characterized by hematuria and what other hallmarks?
Mild proteinuria
Azotemia/oliguria
Salt retention w/ periorbital edema and HTN
Dysmorphic RBCs in urine
54
Most common organisms isolated in surgical site infections.
S. aureus and other staphylococcus, Enterococcus, Pseudomonas
55
For external balance of potassium, what are 3 factors controlling K+ excretion?
1. Na+ delivery to the distal tubule (increased distal tubular flow = increased K+ excretion)
2. Acid/Base status (decreased H+ excretion = increased K+ excretion)
3. Aldosterone (induces transcription/placement of Na channels and Na-K pump in principle cells)
56
Most common organism causing bacteremia associated with lines.
S. epidermis
57
When is a CXR indicated for evaluation of a cough?
If accompanied by 1 or more:
Fever > 100
Tachycardia
2: rales, decreased breath sounds, no asthma history
Not improving or worsening
58
DDX Nephrotic syndrome (5):
```
Minimal change disease
Focal segmental glomerulosclerosis
Membranous nephropathy
Diabetic nephropathy
Systemic amyloidosis
```
59
A 23 year old male comes to the doctor because he recently noticed blood in his urine. He had a cold this week, but is otherwise healthy. What is the most likely diagnosis?
IgA Nephropathy
60
When is a TEE indicated in a patient with bacteremia?
If organism isolated is S. aureus.
61
Antibiotics associated with C. diff colitis
Clindamycin
Ampicillin
Cephalosporins
Fluoroquinolones
62
DDx for hyperosmolality:
Hypernatremia
Hyperglycemia
Renal failure (high BUN)
63
What is a normal range for plasma osmolality?
275-290 mOsm/kg
64
A patient identified to have a nephritic syndrome also has wrist drop and foot drop. What is the most likely diagnosis?
Microscopic polyangitis
65
Etiology of Alport's syndrome.
Defect of type IV collagen.
66
CAP antibiotics if admitted as an inpatient.
Macrolide + 3rd gen cephalosporin (cefotaxime, ceftriaxone)
OR
Fluoroquinolone
67
Medical DVT prophylaxis of choice in a cancer patient?
Lovenox (enoxaparin)
68
EKG shows ST elevation in leads V1-V5, most prominent in V2 and V3. There is also ST elevation in lead I and aVL with mild ST depression in aVR. What artery was likely occluded?
Left anterior descending.
69
When is a thoracentesis indicated?
New pleural effusion > 1cm on lateral decubitus.
| Parapneumonic effusion.
70
What antibiotics can be used to treat MRSA?
Vancomycin
Linezolid
Daptomycin
71
How does acidosis affect serum potassium?
Hyperkalemia
| shift of H+ into cell (in an attempt to reduce acidosis) causes shift of K+ out of cell (and into serum).
72
What drugs are known to cause an allergic interstitial nephritis?
B-lactams and other sulfa drugs, NSAIDs, PPIs
73
Antibiotics used to treat C. diff colitis.
Metronidazole
| Vancomycin
74
How does severe hyperglycemia affect serum potassium?
Hyperkalemia
| Hypertonic serum creates a solvent drag, this pulls water out of the cells and K+ follows.
75
Indications for dialysis: (AEIOU)
AEIOU refractory to therapy:
Acidemia
Electrolyte disturbances (hyperkalemia, hyperphosphatemia, tumor lysis)
Intoxication
Overload of fluid
Uremia w/ symptoms (esp. with pericarditis)
76
How to monitor heparin anticoagulation?
PTT, platelet count
77
What are the different hepatocellular injury processes in liver disease?
Hemochromatosis
Wilson's disease
Alcoholic hepatitis
Hepatitis A, B, C
78
What are the different cholestatic injury processes in liver disease?
NASH
Primary Biliary Sclerosis
Primary Biliary Cirrhosis
79
What are the laboratory findings in alcoholic hepatitis?
AST > ALT (>2:1) but not severe electation
Increased MCV of RBCs
Increased GGT
80
What will be shown in a liver biopsy of alcoholic hepatitis?
hepatocyte necrosis, Mallory bodies
81
How soon after exposure to hepatitis would you see...
IgM
HbsAg
HCV RNA
Igm HepA - early
HbsAg - early
82
SAAG =
Serum ascites-albumin gradient =
| serum albumin - ascitic fluid albumin
83
SAAG greater than 1.1 -->
Transudate --> portal hypertension
Causes: Cirrhosis, SBP, acute hepatitis, RHF, venous thrombosis, Schisto
84
SAAG less than 1.1 -->
Exudate
Causes: Peritoneal carcinomatosis, pancreatitis, peritoneal dialysis
85
How do you diagnose Spontaneous Bacterial Peritonitis?
Greater than 250 PMN – Blood cx at bedside increases yield of + cultures in SBP
Treatment:
86
How do you evaluate hepatic encephalopathy?
NH3 does not correlate well
87
How do you treat uncomplicated DVT?
Bridging heparin --> warfarin
Shorter warfarin course if provoked
88
How do you distinguish pre-renal from intra- or post-renal causes of AKI?
Fractional Excretion of Sodium or Urea
| -- Tubules will be intact in pre-renal cause, FENa
89
How do you treat a severe GI bleed?
2 large bore IVs
cross and type
aggressive in IVF resuscitation
90
Delirium is commonly caused by...
Drugs, Electrolytes, Lack of drugs, Infection, Reduced sensory input, Ictal, Urinary/Fecal retention, Metabolic, Stroke/Subdural
91
How do you treat uncomplicated DVT?
Bridging heparin --> warfarin
Shorter warfarin course if provoked
92
How do you treat STEMI?
Agressive Thrombolysis
i. PCI w/in 90 min or to PCI hosp w/in 2 hours
ii. thrombolysis w/in 30 min
93
What are the early complications of MI?
V-fib, new murmurs
94
What are the late complications of MI?
pericarditis, aneurysms, CHF
95
What is the treatment bundle for VAP?
limit prolonged ventiliation, increase stomach pH (no antacids), elevate head of bed 30-45, chlorhexadine rinse
96
If pH is normal,
CO2 is high,
bicarb is high
then you have...
Respiratory acidosis and metabolic alkalosis
97
What can lead to pseudohyperkalemia?
high cell counts, hemolyzed, traumatic blood draws
98
If AG is high and pH, CO2 and bicarb are normal then you have...
AG metabolic acidosis + metabolic alkalosis
99
If AG, pH, CO2 and bicarb are ALL normal then you have...
Non-AG metabolic acidosis + metabolic alkalosis OR Normal
100
If pH and bicarb are low ...
It's metabolic acidosis
101
What are the steps to evaluating Acid-Base disorders?
1) Classify primary disturbance (Acidosis/Alkalosis, Metabolic/Respiratory)
2) Determine compensation
3) Calculate Anion Gap (AG = Na-[Cl+HCO3])
4) Calculate potential bicarb (= HCO3 + ChangeAG)
102
If pH and bicarb are high...
Metabolic alkalosis
103
How does low albumin affect the anion gap?
Low albumin lowers the expected anion gap
104
How do you determine if there is respiratory compensation in metabolic acidosis?
WINTER's FORMULA
Expected pCO2 = [1.5(HCO3) + 8] +/-2
If pCO2 is HIGHER than expected --> resp acidosis
If pCO2 is LOWER than expected --> resp alkalosis
105
How does RTA change the urine anion gap?
Usually UAG = UNa + UK - UCl
A positive urine anion gap suggests a low urinary NH4+ (as in RTA).
NH4+ is the most important unmeasured ion in urine (accompanied by the anion chloride).
A negative urine anion gap can be used as evidence of increased NH4+ excretion. (diarrhea)
106
What factors must be reviewed on X-ray to evaluate it's accuracy?
Degree of rotation
Level of penetration
Amount of exposure
Level of inspiration
107
What is the finding to look for on a lateral chest x-ray film?
Spine sign
108
How do you determine if there is respiratory compensation in metabolic alkalosis?
Expected pCO2 = 0.8(changeHCO3) + 40
If pCO2 HIGHER than expected --> resp acidosis
If pCO2 LOWER than expected --> resp alkalosis
109
What is the best test to diagnose PE?
Spiral CT
| V/Q scan
110
What are the components of Virchow's Triad?
endothelial injury, venous stasis, hypercoagulable state
111
What are the main risk factors for DVT?
immobilization, cancer (tissue factor), surgery
smoking, prior DVT/PE, OCPs, pregnancy, nephrotic syndrome, heart failure, liver failure, antiphospholipid, HIT, tamoxifen, raloxifene, indwelling venous catheter, chemotherapy, growth factors, obesity
112
What are hereditary risk factors for DVT?
Factor V Leiden mutation, Protein C/S deficiency, prothrombin mutation, antithrombin deficiency, hyperhomocysteinemia
113
What are the high risk DVT locations? (risk of embolization)
deep femoral veins, pelvic veins
114
What drug can be used for DVT prophylaxis in CKD patients?
heparin (other drugs have renal clearance)
115
What are the contraindications to anticoagulation?
high bleeding risk, liver disease, severe HTN, prior surgery/trauma, pregnancy (warfarin)
116
What is the antidote to heparin and LMWH?
protamine
117
Symptoms:
| Dyspnea, pleuritic chest pain, cough, +/- hemoptysis -->
pulmonary embolus
118
What will be the ABG findings of patients with PE?
low PaO2, low PaCO2, high pH
| --> Respiratory alkalosis
119
What lab test should be ordered to assess for LOW risk of DVT or PE?
D-dimer
120
If you have a positive D-dimer, what test should follow for suspected DVT or PE?
DVT --> Ultrasound
| PE --> Spiral CT/CTA (or V/Q scan if contrast allergy/CKD)
121
How do you treat new DVT or hemodynamically stable PE?
Heparin/Lovenox anticoagulation --> Warfarin
If patient cannot tolerate anticoag --> IVC filter
Monitor heparin with PTT, platelets, warfarin with INR
Cancer: Lovenox + long term Lovenox
122
What complications can arise from DVT?
```
Post-thrombotic syndrome (venous insufficiency)
Compartment syndrome (blocked drainage)
```
123
What are the typical organisms found in wound infections?
Surgical site: Staph. aureus, other staph
| HA-bloodstream: Other staph, enterococcus, candida
124
What are the typical organisms found in healthcare associated pneumonia?
Staph aureus/MRSA
| GNRs: Pseudomonas, Klebsiella, E.coli, Enterobacter, Acinetobacter, Serratia
125
What are the typical organisms found in healthcare associated UTIs?
E.coli
| Catheter-associated: yeast, E.coli, CNR, enterococci, staph epi
126
How do you treat UTI?
Uncomplicated: nitrofurantoin, TMP-SMX, FQ
Complicated: TMP-SMX, FQ (Cipro/Levo)
127
What antibiotics might cause C.diff colitis?
Broad spectrum: clindamycin, ampicillin, cephalosporins, fluoroquinolones
128
What antibiotics might treat C.diff colitis?
Metronidazole (1st line, mild-mod)
Vancomycin (severe based on WBC, Cr, age)
Use both if complications like ileus, megacolon, shock, peritonitis
129
What can be used to treat MRSA?
vancomycin, daptomycin (not PNA), linezolid
130
What can be used to treat VRE?
Daptomycin, linezolid
131
What are the typical organisms found in Community Acquired Pneumonia?
Overall: Strep pneumo
COPD: H.influenzae, Moraxella
Young: Mycoplasma, Chlamydia, young
Elderly: Legionella
132
How do you treat community acquired pneumonia?
1st line: macrolide
Doxycycline
Recent abx: Fluoroquinolone (levo, moxi)
Inpatient: macrolide + 3rd gen ceph or fluoroquinolone
133
How do you diagnose C.diff colitis?
Stool EIA (toxins) or PCR or glutamate dehydrogenase
Only if the patient has symptoms, esp DIARRHEA
134
How can C.diff colitis be treated?
Antibiotics (metronidazole -> vancomycin)
Stool transplant
CT + surgery if toxic megacolon
Probiotics
135
How will hyperkalemia impact the EKG findings?
peaked T waves --> PR prolongation --> P-wave flattening --> QT prolongation --> sine waves
136
How will hypokalemia impact the EKG findings?
U waves
137
How will hypocalcemia impact the EKG findings?
QT prolongation (less Ca for action potential)
138
How will hypercalcemia impact the EKG findings?
QT shortening (more Ca for action potential --> quicker)
139
What are the criteria for AKI?
Creatinine increased by >/= 50% OR 0.3
| OR Urine output decreased to
140
What will the ABG show in renal failure?
Metabolic acidosis
141
When should FENa be measured?
It shouldn't, it will always be high
142
When should FEUrea be measured?
If the patient has taken a diuretic
143
What are possible causes of post-renal azotemia (high BUN)?
How to diagnose?
How to treat?
What are the sediment findings?
Outflow obstruction: BPH, prostate cancer, urethral stricture, bilateral compression (cancer, stones)
Diagnose with catheterization, renal ultrasound
Treat: catheterization, stents, underlying cause
Sediment findings: normal RBCs, no casts
144
How does the length of time of pre-renal obstruction affect FENa?
Early: tubules intact, FENa 2%
145
What can cause pre-renal azotemia?
What are the sediment findings?
Decreased blood flow: volume depletion, low CO, cirrhosis, sepsis, NSAIDs, cyclosporine, ACEIs, ARBs, orthostatic hypertension
Sediment findings: Bland, hyaline casts
146
What does Angiotensin-II vasoconstrict?
Efferent Arteriole
147
What drugs vasodilate the efferent arteriole?
ACEIs, ARBs (block Ang-II)
148
What vasodilates the afferent arteriole?
Prostaglandins (released by sympathetic NS)
149
What drugs vasoconstrict the afferent arteriole?
NSAIDs, cyclosporine (block PGs)
150
What is the most common cause of altered mental status/delirium?
Hypoglycemia
151
What are the risk factors for delirium?
elderly, polypharmacy, dementia, cognitive impairment, psychiatric condition, chronic medical
conditions, visual/hearing impairments, hospitalization, social isolation
152
The onset is rapid, fluctuating, may included visual hallucinations or abnormal vital signs, and has altered consciousness
Delirium
153
The onset is slow, progressive, and has degenerative changes
Dementia
154
Causes of delirium include:
```
Drugs
Electrolytes
Lack of Drugs
Infection
Reduced sensory
Ictal
Urinary/fecal retention
Metabolic
Stroke/subdural
```
155
When would a lumbar puncture be indicated to evaluate for altered mental status?
Suspect meningitis, subarachnoid hemorrhage, autoimmune inflammation
156
What three components make up the Glasgow Coma Scoring system?
```
Eye opening (4-spontaneous to 1-none)
Verbal response (5-oriented to 1-none)
Motor response (6-obeys commands to 1-none)
```
157
What medications can be used for delirium?
Thiamine --> glucose/dextrose
Haloperidol for agitation (monitor QTc)
AVOID benzos unless withdrawing
158
Alcohol withdrawal symptoms begin when and include what?
6-48 hours after last drink
anxiety, agitation, tremor, HA, confusion, N/V, sweats, hallucinations x3 (visual, auditory, tactile)
159
What are severe complications of withdrawal?
Seizures
160
How do you treat alcohol withdrawal?
Benzodiazepines, thiamine --> glucose, replete K, Mg, PO4
161
What might cause hepatic encephalopathy?
GI bleed, infection, constipation, hypoxia, electrolyte imbalance, sedatives/tranquilizers
162
How do you treat hepatic encephalopathy?
lactulose, antibiotics, sodium benzoate
163
What exam findings may be present in hepatic encephalopathy?
Sleep disturbance, mood change, disorientation, confusion
Asterixis, slurring, ataxia, hyperreflexia
Coma
164
What is an initial lab difference between hepatocellular injury and cholestatic injury?
Hepatocellular: initial ALT elevation
Cholestatic: initial ALP elevation
165
How can NASH disease be confirmed (non-invasively)?
Ultrasound showing fatty infiltrate
166
How do you treat acetaminophen toxicity?
N-acetylcysteine
167
What clinical features of hemochromatosis?
```
Cirrhosis
Secondary diabetes
Bronze skin
Cardiac arrhythmias
Gonadal dysfunction
```
Increased risk of hepatocelluar carcinoma
168
What causes Wilson's disease?
Autosomal recessive ATP7B gene mutation
Defective ATP-mediated copper transport (Ceruloplasmin low/absent copper)
Copper overload in hepatocytes --> serum --> tissues --> free radical damage
169
How are these transmitted?
Hepatitis A?
Hepatitis B?
Hepatitis C?
A: fecal oral
B: Blood, SEX, perinatal
C: Blood
170
What are transaminases? What do they do?
| Where are they found?
AST, ALT
Metabolize amino acids to synthesize proteins
AST = liver specific but not predictive of damage/disease
ALT = liver, skeletal muscle, RBCs, kidney, brain
171
What substances are made in the liver?
Prothrombin, Albumin
| Bilirubin (10% direct, conj in liver)
172
What patterns of transaminitis would be seen in acute and chronic hepatitis?
Acute: AST/ALT >1000
Chronic: ALT/AST
173
What might be suggested by AST & ALT >1000?
Toxins
Shock Liver
Viral Hepatitis
174
What disease is p-ANCA+, associated with IBD, has a 'string of pearls' imaging and 'onion skin' pathology, and has an increased risk of cholangiocarcinoma?
Primary Sclerosing Cholangitis
--> Increased ALP, GGT
(inflammation/fibrosis of intra/extrahepatic bile ducts)
175
What disease is associated with ANA & antimitochondrial Ab, women 30-65, fatigue and pruritus?
Primary Biliary Cholangitis
--> Increased ALP, GGT
(granulomatous destruction of intrahepatic bile ducts)
176
What disease is associated with ANA and anti-smooth muscle Ab?
Autoimmune hepatitis
--> More common in women, 80% present with cirrhosis, Patho = plasma cells + hypergammaglobulinemia
177
What hepatic disease will have AFP elevation?
hepatocellular carcinoma
178
What are risk factors for NASH?
obesity, diabetes, hypertriglyceridemia, metabolic syndrome, hypertension
179
What is the disease progression of NASH?
Steatosis (trig accumulation) --> steatohepatitis (inflammation + hepatocellular necrosis) --> cirrhosis
180
What lab values make up the MELD score?
What does the MELD score indicate?
serum bilirubin, INR, serum creatinine
3-month mortality, different for inpatient v outpatient
181
What are common pathogens in spontaneous bacterial peritonitis?
E.coli, Klebsiella, Streptococcus, other gut flora
182
What is the presentation of SBP?
fever, abdominal pain, encephalopathy, worsening clinical condition
183
What is a complication of SBP?
hepatorenal syndrome
184
When is paracentesis indicated?
new onset ascites, signs of SBP, clinical deterioration (with OR without current treatment for SBP), symptom relief
185
How do you treat SBP? When do you offer prophylaxis?
Cefotaxime (3rd gen)
Albumin infusion
Prophylaxis if hospitalized with GI bleed, ascites protein is 2.5, prior SBP
186
How do you treat ascites?
```
Sodium restriction
Water restriction
Diuretics (spironolactone + furosemide)
Paracentesis if symptomatic
Albumin infusion if >5L on para.
```
187
What is the most common cause of death in cirrhosis patients?
Variceal hemorrhage
188
How do you treat an acute GI bleed (variceal hemorrhage)?
Stabilize (large bore IV)
Octreotide (vasoconstrict)
Ceftriaxone (SBP prophy)
Band ligation +/- TIPS
Prophy with propranolol
189
How do you diagnose hepatorenal syndrome?
AKI, no response to volume challenge, diagnosis of exclusion if no other source of AKI
190
What is the cause of hepatorenal syndrome?
Splanchnic arteries vasodilation, renal circulation vasoconstriction
191
How do you treat hepatorenal syndrome?
Increase MAP by 10-15
ICU: norepi + albumin
Non-ICU: octreotide, midodrine, albumin
TIPS + dialysis
192
This is the most common acute viral hepatitis, diagnosed with IgM, for which there is a vaccine?
Hepatitis A
193
These viral hepatitis viruses are (+) RNA
Hepatitis A, C and E
194
These types of viral hepatitis are associated with cancer development
Hepatitis B (even without cirrhosis), Hepatitis C
195
How do you treat Wilson disease?
D-penicillamine (chelator)
196
Which viral hepatitis is the most common chronic form, but 20-40% of infections resolve?
Hepatitis C
197
What does each of these indicate?
```
HBsAg
HBeAg
Anti-HBe
Anti-HBc
Anti-HBs
```
```
HBsAg --> infection
HBeAg --> HIGH infectivity
Anti-HBe --> low infectivity
Anti-HBc --> chronic phase
Anti-HBs --> resolved/immune
```
198
How do you diagnose hemochromatosis?
Presents late adulthood-->
Increased ferritin, Increased transferrin saturation (>45%)
HFE genotyping
Liver biopsy +/-
Increased risk of hepatocellular carcinoma
199
What is shown on hemochromatosis biopsy?
Brown pigment in hepatocytes
Lipofuscin stains brown --> aging
Prussian blue stain distinguishes Fe (blue) from lipofuscin (brown)
200
Macrolide antibiotics
Include:
Cover:
Mechanism:
Erythromycin
Azithromycin
Clarithromycin
Cover: Gram + , some Gram -
Mechanism: protein synthesis inhibitors
201
Fluoroquinolone antibiotics
Include:
Cover:
Mechanism:
```
ciprofloxacin
gemifloxacin
levofloxacin
moxifloxacin
norfloxacin
ofloxacin
```
Cover BROAD spectrum gram + and gram -
Mechanism: topoisomerase inhibition
202
What would you call impaired renal tubule acidification caused by the inability to excrete acid leading to hyperchloremic metabolic acidosis?
Type I Distal RTA
203
What would you call impaired renal tubule acidification caused by reduced capacity to reclaim filtered bicarb leading to hyperchloremic metabolic acidosis?
Type II Proximal RTA
204
What are common causes of Type I RTA?
Autoimmune (Sjogrens, RA)
Hypercalciuria
Hereditary
Drugs (Ifosfamide, Ibuprofen)
205
What is the Anion Gap in RTA? Why?
Normal -
| low serum bicarbonate, high chloride
206
What will the urine pH be in RTA?
Type I - Distal - 5.5 or higher (normal) d/t progressive
| Type II - Proximal - usually less than 5.3
207
When might you see Type IV RTA?
In DM
208
Nephritic Syndromes are due to...
glomerular basement membrane dysfunction
NephrItic --> Inflammation --> hematuria, RBC casts
209
Podocyte disruption leading to impaired charge barrier and proteinuria are grouped as...
Nephrotic syndromes
210
These are severe nephritic syndromes that most commonly produce nephrotic range proteinuria >3.5g/day (2)
Diffuse proliferative glomerulonephritis
| Membranoproliferative glomerulonephritis
211
IgG, IgM, C3 deposition along the GBM
Most commonly seen in children 1-3 weeks p infection
Resolved spontaneously
"cola colored urine" with hematuria and RBC casts
"starry sky" appearance on Immunofluorescence
Acute poststreptococcal glomerulonephritis
(nephrItic --> Inflammation)
1-3 weeks following GAS infection of pharynx or skin
212
Renal insufficiency or URI or acute gastroenteritis
Episodic hematuria with RBC casts
Caused by immune complex deposits in mesangium
IgA nephropathy
2-4 days after mucosal infection (URI or gastroenteritis)
213
What is the pathology of acute tubular necrosis?
Ischemic OR nephrotoxic injury
- Ischemic: low blood flow, death of tubular cells
- -- PCT and thick ascending limb highly susceptible
- Nephrotoxic: substances, crush injury or hemoglobinuria
- -- PCT susceptible
214
What are the three stages of ATN?
Inciting event (injury)
Maintenance phase (oliguric 1-3w, high risk hyperK, met acidosis, uremia)
Recovery phase: polyuric, BUN/Cr fall, risk hypoK
215
This may present with nephritis (eosinophilic casts), fever, rash & costavertebral tenderness OR may be asymptomatic
Drug-induced interstitial nephritis
- -> May be weeks or even months after drugs
- -> diuretics, penicillin, PPIs, sulfas, rifampin, NSAIDs
216
Hematuria, normal serum complement and anti-GBM antibodies
Goodpasture syndrome/anti-GBM disease: test for
217
Hematuria, normal serum complement and C-ANCA positive
Wegener's Granulomatosis
218
Hematuria, normal serum complement and P-ANCA positive
May be Microscopic polyangitis or Churg-Strauss syndrome
219
What is the most common cause of death in cirrhosis patients?
Variceal hemorrhage
1/3 patients have variceal hemorrhage, each episode 30% mortality
220
What is hepatorenal syndrome?
Vasodilation of splanchnic arteries (portal HTN, SBP) and vasoconstriction of renal circulation
221
If high conjugated bilirubin, high alk phos, high ggt, low urine urobilirubin with dark urine and pale stool and pruritis?
Biliary tract obstruction
222
What are the clinical features of cirrhosis?
Portal hypertension: ascites, splenomegaly, hepatorenal syndrome
Increased ammonia: mental status change, asterixis, coma
Increased estrogen: gynecomastia, spider angiomata, palmar erythema
Jaundice
Hypoalbuminemia: nephrotic syndrome, edema
Coagulopathy: bleeding disorder, monitor with PT
223
What pattern of hepatic damage would be seen in:
Viral/autoimmune/hemochromatosis?
Alcoholic/NASH/vascular?
Viral/autoimmune/hemochromatosis --> periportal
Alcoholic/NASH/vascular --> central vein
224
How do you treat hepatorenal syndrome?
Increase MAP by 10-15
In ICU: norepinephrine and albumin
Not in ICU: octreotide and midodrine and albumin
If unresponsive to medical therapy, TIPS and dialysis
225
What are the indications for SBP prophylaxis?
Hospitalized cirrhosis with GI bleed
Ascites protein 2.5
Prior SBP
226
What are the complications of cirrhosis?
1) ascites and SBP
2) variceal hemorrhage
3) hepatic encephalopathy
4) hepatorenal syndrome
227
What is the first line therapy for peptic ulcer disease?
Triple therapy: PPI, Clarithromycin, Amoxicillin (or metro)
228
What is the TIMI score and what do the values indicate?
Risk stratification of patients with NSTEMI or unstable angina
- risk of death
- risk of ischemic events
- basis for therapeutic decision making
Score 0-2 --> meds, stress test --> angiography?
3 --> meds, early coronary angiography (before stress test)
229
What are the complications of MI?
0-24hr
1-4d
3-14d
2-10w
0-24hr: arrhythmia, cardiogenic shock, HF, acute valve dysfunction
1-4d: pericarditis
3-14d: rupture, pseudoaneurysm
2-10w: Dressler (immune mediated pericarditis), true aneurysm
230
What do Q-waves on an EKG indicate?
Necrotic tissue, may be 24-36hr after infarct
231
What are the long-term outcomes of RCA infarct vs LCA infarct?
RCA usually has improved function due to less oxygen demand than LCA, smaller muscle mass, lower afterload, better coronary perfusion (occurs during diastole and systole), better collateral flow from LCAs.
232
A patient presents with recurrent chest pain that occurs at rest, sometimes in the middle of the night and lasts for 10 minutes at a time. What is the likely diagnosis?
Prinzmetal angina
Dx with transient ST elevation during pain without high grade coronary stenosis
233
What are the risk factors for nosocomial infections?
External instruments, age extremes, malnutrition, smoking, immunosuppression, depressed consciousness, wounds, burns, trauma, ICU, length of stay, prior antibiotics
234
In what settings might you see Klebsiella pneumonia?
Alcoholics
Aspiration
HAP/HCAP
235
In what setting might you see Legionella pneumonia?
Elderly
Smokers
TNF inhibition
236
In what setting might you find Chlamydia pneumonia?
Young people
| Community-acquired
237
What patients might present with encapsulated bacterial pneumonia?
Post-splenectomy patients
238
What are possible causes of hypernatremia when urine osmolality is low (60 or lower)?
Diabetes insipidus
239
What are the risk factors for nosocomial infections?
External instruments, age extremes, malnutrition, smoking, immunosuppression, depressed consciousness, wounds, burns, trauma, ICU, length of stay, prior antibiotics
240
In what settings might you see Klebsiella pneumonia?
Alcoholics
Aspiration
HAP/HCAP
241
In what setting might you see Legionella pneumonia?
Elderly
Smokers
TNF inhibition
242
In what setting might you find Chlamydia pneumonia?
Young people
| Community-acquired
243
What patients might present with encapsulated bacterial pneumonia?
Post-splenectomy patients
244
What are possible causes of hypernatremia when urine osmolality is low (60 or lower)?
Diabetes insipidus
245
What are common causes of respiratory alkalosis?
```
Hyperventilation:
Hysteria
Hypoxemia (high altitude)
Salicylates (aspirin - early after ingestion)
Tumor
Pulmonary Embolism
```
246
What are common causes of respiratory acidosis?
Hypoventilation (airway obstruction, COPD, other acute/chronic lung disease, opioids, sedatives, weak resp muscles)
247
How is metabolic acidosis compensated for?
Metabolic acidosis = low pH, low bicarb, low PCO2
Compensate with hyperventilation
Next step: Check Anion Gap
248
What are common causes of metabolic alkalosis?
```
With compensation --> hypoventilation:
Loop diuretics
Vomiting
Antacid use
Hyperaldosteronism
```
249
What is the mnemonic for HIGH Anion Gap Metabolic Acidosis?
```
MUDPILES
Methanol
Uremia
DKA
Propylene glycol
Iron tablets or INH
Lactic acidosis
Ethylene glycol
Salicylates
```
250
What is the mnemonic for NORMAL Anion Gap Metabolic Acidosis?
```
HARD-ASS
Hyperalimentation
Addison disease
RTA
Diarrhea
Acetazolamide
Spironolactone
Saline Infusion
```
251
If a patient is tachypneic, he likely has this acid-base disorder
Respiratory alkalosis
Tachypnea --> Hyperventilation
252
If a patient has impaired gas exchange in the lung (from obstruction, oversedation, etc) he likely has this acid-base disorder
Respiratory acidosis
| Increased carbon dioxide concentration in blood
253
If a patient has nausea and vomiting, and possibly low chloride, he likely has this acid-base disorder
Metabolic alkalosis
| low plasma chloride + increased plasma bicarb
254
If a patient is using diuretics, he likely has this acid-base disorder
Chloride depletion metabolic alkalosis
255
If a patient has diarrhea, he likely has this acid-base disorder
Metabolic Acidosis (NORMAL anion gap)
Direct bicarbonate loss from the gut
256
If a patient has chronic renal insufficiency, he likely has this acid-base disorder
Metabolic acidosis
Mild-mod --> Normal AG
Severe --> High AG
257
If a patient has T1DM without insulin (DKA), he likely has this acid-base disorder
High AG Metabolic Acidosis
258
If a patient has circulatory shock (anaerobic metabolism), he likely has this present
lactic acidosis --> increased plasma anion gap
