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Internal Medicine General > Deck 1 > Flashcards

Deck 1 Flashcards

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1
Q

What is a mnemonic for the causes of clubbing?

A

CLUBBING ABCDEF

Cyanotic heart disease
Lung disease
UC + Crohn's 
Biliary Cirrhosis
Birth defects
Infective Endocarditis
Neoplasm
GI malabsorption syndrome (celiac)
Abscess
Bronchiectasis 
Cystic Fibrosis
DONT SAY COPD
Empyema
Fibrosis
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2
Q

DDx lower GI bleeding

A 
Colorectal cancer or polyps
Diverticulosis 
Angiodysplasia 
Anorectal disease
Enterocolitis
Brisk bleeding from upper GI
Rectal trauma

**pay particular attention to the hemodynamics lily unstable patient

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3
Q

DDx upper GI bleed

A
  1. Ulcerative or erosive processes–> PUD, esophagitis, gastritis
  2. Portal HTN
  3. Trauma (I.e Mallory Weiss tear)
  4. Tumours
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4
Q

DDx hemoptysis

A
  1. Airway disease–> inflammatory (bronchiectasis, bronchitis); neoplasms (bronchogenic carcinoma); other (foreign body, trauma)
  2. Pulmonary parenchymal disease–> infectious (TB, necrotizing pneumonia); inflammatory/immune (vasculitis); other (coagulopathy)
  3. Cardiac/vascular–> PE with infarction; elevated capillary pressure (mitral stenosis, LV failure); AV malformation
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5
Q

DDx abdominal distension

A
  1. Ascites–> low serum to ascites albumin ratio = exudative (peritoneal carcinomatosis); high serum to ascites albumin ratio = transudative (portal HTN)
  2. Bowel dilation–> mechanical obstruction (adhesions, volvulus); Paralytic (toxic megacolon, neuropathy)
  3. Other–> abdominal mass, IBS, organomegaly (hepatomegaly), pelvic mass (I.e ovarian cancer or others)
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6
Q

DDx hematuria

A
  1. Glomerular disease–> SLE, hemolytic uremic syndrome, vasculitis
  2. Post renal–> stones, bladder tumour, BPH, cystitis
  3. Haematological–> coagulopathy, sickle hemoglobinopathy
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7
Q

DDx cardiac arrest

A

CAD
Cardiac conduction abnormalities
Myocardial abnormalities
Non cardiac (I.e PE)

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8
Q

DDx chest pain

A
  1. Cardiac
    - -A. Ischemic –> ACS, stable angina pectoris
    - -B. Non-ischemic–> aortic aneurysm, pericarditis
  2. Pulmonary or mediastinal
    - -PE or pulmonary infarct
    - -Pleuritis
    - -Pneumothorax
    - -Malignancy
  3. GI
    - -esophageal spasm or esophagitis
    - -PUD
    - -Mallory Weiss syndrome
    - -biliary disease or pancreatitis
  4. Anxiety disorders
  5. Chest wall pain (I.e costochondritis)
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9
Q

DDx dyspnea

A
  1. Cardiac
    - myocardial dysfunction (I.e ischemic cardiomyopathy)
    - valvular heart disease
    - pericardial disease (I.e tamponade)
    - increased cardiac output (I.e anemia)
    - arrhythmia
  2. Pulmonary
    - upper airway (foreign body, anaphylaxis)
    - chest wall and pleura (pleural effusion)
    - lower airway (asthma, COPD)
    - alveolar (pneumonia)
  3. Central (metabolic acidosis, anxiety)
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10
Q

DDx lymphadenopathy

A
  1. Localized
    - Reactive (I.e tonsillitis)
    - Neoplasticism (metastatic cancer)
  2. Diffuse
    - infectious (I.e viral)
    - inflammatory (I.e sarcoidosis)
    - neoplastic (I.e lymphoma)
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11
Q

DDx pleural effusion

A
  1. Transudative–> I.e CHF, nephrotic syndrome, cirrhosis
  2. Exudative–>
    - A. Infectious (parapneumonic, empyema, TB)
    - B. Neoplastic (primary, mets, mesothelioma)
    - C. Cardiac/vascular (I.e PE, collagen vascular disease)
    - D. GI (I.e ruptured esophagus, pancreatitis, chylothorax)
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12
Q

DDx hyperkalemia

A
  1. Increased intake (usually associated with low excretion)
  2. Redistribution
    - A. Decreased entry into cells–> I.e insulin deficiency, beta 2 blockade
    - B. Increased exit from cells–> I.e metabolic acidosis, rhabdomyolysis
  3. Reduced urinary excretion
    - A. Decreased glomerular filtration rate–>I.e acute or chronic kidney disease
    - B. Decreased secretion–> I.e aldosterone deficiency, drugs (I.e spironolactone)
    * *dont forget to order and ECG to look for changes! (“T waves you wouldn’t want to sit on”)
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13
Q

DDx hypokalemia

A
  1. Decreased intake (I.e anorexia nervosa)
  2. Redistribution (I.e alkalemia, insulin, beta 2 adrenergic stimulating drugs)
  3. Increased losses, either renal or GI (I.e vomiting/diarrhea)
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14
Q

DDx weight loss

A
  1. Decreased nutritional intake–> psychiatric disease (anorexia, bulimia, depression), medical disease (chronic illness, esophageal cancer), illicit drugs or meds (alcohol, opiates, cocaine, amphetamines, anti cancer drugs)
  2. Increased energy expenditure–> hormonal (I.e hyperthyroid), chronic illness (COPD, HF), malignancy, infection, excessive physical activity (I.e runners)
  3. Caloric loss–> malabsorption (I.e diarrhea), diabetes
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15
Q

Define heart failure

A

Occurs when the hearts function as a pump is inadequate to maintain adequate perfusion, or the heart is only able to do so at HIGHER FILLING PRESSURES

SYNDROME not a diagnosis –>must determine underlying etiology

CLINICAL dx, do not need to wait for an echo to diagnose (though an echo can give further info on the underlying pathology behind the clinical presentation of heart failure)

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16
Q

What are the two key questions to ask yourself about HF?

A
  1. What type of HF is it

2. What is the etiology

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17
Q

what should you ask on history for an upper GI bleed?

A
  1. blood–> hematemesis, coffee ground emesis, melena, hematochezia (if brisk)
  2. abdominal pain
  3. hx of gerd
  4. medications
  5. EtOH consumption
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18
Q

what to look for specifically on physical exam for an upper GI bleed

A
  1. vitals–> tachy? hypotension or HTN?
  2. signs of anemia
  3. signs of liver disease
  4. FOB
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19
Q

investigations for upper GI bleed

A 
CBC and diff
chem-7
LFTs and lipase 
INR, PTT, group and screen 
urea breath test
serology
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20
Q

how would you manage an upper GI bleed?

A
  1. keep patient NPO–> send for EGD–> can be either diagnostic only or therapeutic i.e bleeding control with epinephrine/thermal hemostasis, endoclips, hemospray
  2. pantoloc 80 mg IV bolus then 8mg/hr thereafter
  3. variceal bleeds require octreotide
  4. consider iron supplements and fluids–> transfusion if hemoglobin drops and/or symptomatic and/or large bleed
  5. advise patient of lifestyle changes
  6. hold offending meds i.e NSAIDs, bisphosphonates, anticoagulants
  7. if H. Pylori is a factor–> triple therapy: PPI +amoxicillin + clarithromycin // quadruple therapy: PPI + bismuth + tetracycline +metronidazole
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21
Q

DDx for lower GI bleed

A 
Common:
diverticulosis--> CT to assess
ischemic bowel--> lactate and CT angio
infectious--> SECSY bacteria 
hemorrhoids, fissure

Less common:
brisk UGIB
IBD (UC>CD)
CRC or bleeding polyps

Other: coagulopathy/thrombocytopenia, post surgical bleed

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22
Q

what to ask on history for a LGIB

A

characterization of blood

abdominal pain

PMHX–cancer, IBD, diverticulosis

medications–anticoagulants, NSAIDs

anemia sx

B symptoms

infection sx

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23
Q

what to look for on physical for LGIB

A

are they hemodynamically stable?–vitals
signs of anemia
abdominal tenderness/masses
rectal exam

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24
Q

investigations for a LGIB

A

CBC and diff
chem 7
PTT, INR, group and screen, lactate
liver panel
stool C+S, FOB
colonoscopy, consider and EGD if suspect UGI etiology
consider angiography if suspect ischemic bowel or vasculitis

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25
treatment for LGIB
IV fluids--> transfuse if necessary hold anti hypertensives and diuretics consider vitamin K, FFP if needed
26
DDx of chronic/recurrent abdominal pain
1. inflammatory - PUD - biliary colic - IBD - chronic pancreatitis 2. neoplastic or vascular - recurrent bowel obstruction - mesenteric ischemia - sicke cell anemia 3. toxin - lead poisoning 4. other - mittleschmertz - endometriosis - porphyria - IBS - radiculopathy - abdominal wall pain syndrome
27
what should you make sure to rule out in acute upper abdo pain?
make sure you rule out thoracic sources like MI, pneumonia, dissecting aneurysm
28
DDx for acute inflammatory diarrhea
1. bacterial - shigella - salmonella - campylobacter - yersinia - E. coli (hemorrhagic) - C. diff 2. protozoal - entamoeba histolytica - strongyloides 3. others - NSAIDs - IBD - ischemic
29
define inflammatory diarrha
when there is damage to the mucosal lining or brush border which leads to passive loss of protein rich fluids and a decreased ability to absorb these lost fluids **blood only found in inflammatory diarrhea diarrhea may be perfuse or very small in volume often associated with abdominal pain and fevers/chills
30
define non inflammatory diarrhea
no damage to the mucosal lining... N/V may be present NOT present: fevers, chills, blood in stool, severe abdo pain or tenderness
31
DDx non inflammatory diarrhea
1. bacterial - S. aureus - C. perfringens - B. cereus - E coli (ETEC and EPEC) - salmonella enteritidis - vibrio cholera 2. protozoal - giardia 3. viral - rotavirus - norwalk - CMV 4. drugs - antibiotics - colchicine - laxatives - antacids (magnesium)
32
what should you rule out first when patients present with bloody diarrhea
IBD
33
DDx chronic diarrhea
1. inflammatory - IBD - infectious (TB, Cdiff, CMV, HSV) - ischemic bowel - radiation colitis - neoplasia 2. secretory - stimulant laxatives - post ileal resection/cholescystectomy - bacterial toxins - vasculitis - neoplasia - addison's disease - congenital syndromes 3. steatorrheic - giardia - celiac sprue - chronic pancreatitis - chronis cholestasis 4. osmotic - osmotic laxatives - lactose intolerance - chewing gum 5. functional - IBS - constipation (overflow diarrhea) - anal sphincter dysfunction
34
DDx nausea/vomiting with abdominal pain and relieved by vomiting
gastric outlet obstruction small bowel obstruction GERD (regurg)
35
DDx nausea/vomiting with abdominal pain and NOT relieved by vomiting
``` gallbladder disease pancreatitis MI hepatitis infectious gastroenteritis ```
36
DDx nausea/vomiting without abdominal pain and associated with headache/dizziness
cerebral tumor migraine vestibular disease increased ICP
37
DDx nausea/vomiting without abdominal pain and with no other symptoms
``` drugs uremia pregnancy metabolic (hypercalcemia) gastroparesis (i.e diabetes) ketoacidosis ```
38
DDx abdominal distension with FLUID
1. with portal HTN - cirrhosis - cardiac failure - hepatic vein thrombosis 2. with normal portal pressure - cancer (especially OVARIAN) - pancreatitis - TB
39
DDx abdominal distension with flatulence
``` functional bowel disease (IBS) fibre lactose intolerance chewing gum (sorbitol, mannitol) ```
40
DDx abdominal distension with reduced feces output
constipation colonic obstruction dysmotility
41
DDx abdominal distension--other
pregnancy obesity blood large tumors
42
what is a mnemonic to remember a DDx for abdo distension
``` the 6 Fs Fat Feces Fetus Flatus Fluid Fatal growth (large tumors) ```
43
DDx for jaundice with high UNconjugated bilirubin
1. overproduction - hemolysis - ineffective erythropoeisis (i.e in megaloblastic anemias) 2. decreased hepatic intake - gilbert's syndrome - drugs (i.e rifampin) 3. decreased conjugation - drug inhibition - Crigler-Nair syndromes type I and II - Gilbert's syndrome - neonatal jaundice
44
DDx for jaundice with CONjugated bilirubin
``` -common: drugs cirrhosis inflammation (hepatitis of any cause) infiltrative (i.e hemochromatosis) familial disorders (dubin-johnson etc) PBC PSC sepsis post op/TPN ``` -less common: 1. intraductal obstruction gallstones biliary stricture parasites malignancy (cholangioca) sclerosing cholangitis 2. extraductal obstruction malignancy (i.e pancreatic cancer or lymphoma) mets in peri portal notes 3. inflammation
45
foods/substances that aggravate GERD sx
``` EtOH caffeine tobacco fatty/fried foods chocolate peppermint spicy foods citrus fruits ```
46
typical symptoms of GERD
``` heartburn acid regurd sour regurg water brash sensation of lump in throat (globus sensation) frequent belching ``` non-esophageal sx are poor predictors of reflux i.e chronic cough, wheezing, sore throat, hoarseness, dental erosions
47
indications for gastroscopy in GERD
heartburn with red flags like bleeding and weight loss persistent reflux sx or prior severe erosive esophagitis after therapeutic trial of 4-8 weeks of PPI 2x daily history of esophageal stricture with persistent dysphagia
48
treatment for reflux
PPIs are most effective, relief in 80% of cases --usually need to be continued as maintenance can use antacids, H2 blockers for on demand relief diet helps the symptoms not the disease--avoid aggravating foods the only beneficial lifestyle change is weight loss if obese and elevating the head of the bed at night if having nocturnal symptoms
49
complications of GERd
esophageal stricture disease ulcer bleeding barretts esophagus/esophageal carcinoma
50
red flags of dyspepsia that raise suspicion of gastric malignancy
``` unintended weight loss persistent vomiting progressive dysphagia odynophagia unexplained anemia or iron deficiency hematemesis jaundice palpable abdominal massor lymphadenopathy family history of GI cancer previous gastric surgery ```
51
what is Carnetts sign
during exam for dyspepsia---indicates an abdominal wall muscle problem pain increases during muscle contraction (i.e sit up)
52
how is gastritis defined
histologically--inflammation of the stomach mucosa
53
define PUD
focal defects in the mucosa that penetrate the muscularis mucosa of the stomach or duodenum resulting in scarring
54
etiology of PUD
``` h pylori infection NSAIDs physiologic stress induced ZE syndrome idiopathic ```
55
6 classical features of duodenal ulcers
``` epigastric pain burning develops 1-3 hours after meal relieved by eating and antacids interrupts sleep periodicity *duodenal ulcers are rarely malignant ``` *gastric ulcers have more atypical symptoms and a biopsy is necessary to exclude malignancy
56
investigations for PUD
endoscopy upper GI series h pylori tests fasting serum gastrin measurement if ZE suspected
57
approach to PUD
stop NSAIDs acid neutralization h pylori eradication quit smoking
58
management of bleeding peptic ulcers
EGD to explore upper GI tract IV panto drip estbalish risk of rebleeding or continuous bleed since most stop bleeding spontaneously --increased age above 60, history of PUD, comorbid disease, hemodynamically unstable or endoscopic signs of recurrent bleeding if high risk for rebleed consider ICU admission
59
how do NSAIDs cause PUD
direct--> erosions/petechiae via local effect of drug on gastric mucosa indirect--> systemic NSAID effect--> inhibits mucosal COX leading to decrease synthesis of protective prostaglandins and thus leading to ulcers
60
risk factors for stress induced gastric ulceration
``` mechanical ventilation anticoagulation multiorgan failure speticemia severe surgery or trauma CNS injury ("cushings ulcers") burns involving more that 35% of body surface ```
61
What does stroke volume depend on?
Preload, after load and contractility
62
What determines cardiac output
Heart rate and stroke volume
63
Why is there reduced cardiac output in HF?
Either: 1. Impaired ventricular filling--> diastolic failure 2. Impaired ventricular ejection--> systolic failure
64
What is systolic heart failure?
HFrEF-->reduced ejection fraction Decreased myocardial contractility which results in low EF
65
What is diastolic heart failure
HFpEF--> preserved contractility and EF but with impaired cardiac compliance Higher filling pressures for a given LV volume--> increased filling pressures reflect back into the pulmonary and systemic circulations which results in overload sx The ventricle can't fill adequately and thus you get decreased preload and thus decreased CO--> fatigue, lethargy, ischemia If the echo is normal with clinical signs of HF you have HFpEF
66
How do you distinguish between "forward failure" and "backward failure" in heart failure?
1. Forward failure = COLD failure - -usually requires CCU admission as it is more severe - -heart is not pumping enough blood to meet organs needs--> under perfusion of brain, kidneys, periphery - -can't diurese these patients without pressor support 2. Backwards failure = WET failure - -fluid backs up because heart "can't keep up" - -volume overload--> pulm edema, SOB, peripheral edema
67
What are the two defining characteristics of systolic dysfunction? With these in mind, what can cause systolic dysfunction?
1. Impaired contractility--> myocardial ischemia/infarction, chronic volume overload, dilated cardiomyopathy 2. Increased after load--> aortic/pulm stenosis, HTN
68
What are the two defining characteristics of diastolic dysfunction? With this in mind, what can cause it?
1. Impaired relaxation--> LVH, HOCM, restrictive cardiomyopathy, MI 2. Obstruction to filling--> mitral/tricuspid stenosis, pericardial constriction, tamponade
69
What is the pathophysiology behind CHF?
Decreased CO leads to activation of the RAAS and sympathetic systems, which further exacerbates CHF CHF is a disorder of neurohormonal dysregulation Sympathetic stimulation--> vasoconstriction--> increased after load RAAS stimulation--> fluid retention--> volume overload
70
What are some causes of restrictive cardiomyopathy?
Sarcoidosis, amyloidosis, hemochromatosis
71
What are the different classes that make up the NYHA classification system for heart failure?
I--sx with extraordinary activity II--sx with ordinary activity III--sx at less than ordinary activity IV--sx at rest
72
What is a mnemonic for causes of acute CHF exacerbation?
FAILED ``` Failed to take meds Anemia, arrhythmia Ischemia, infection, infarction Lifestyle indiscretion--increased salt or fluid intake Endocrine (TSH), EtOH Drugs (NSAIDs, steroids) ```
73
What types of things should you ask on history for heart failure?
1. Characterize the symptoms - -dyspnea, Orthopnea, PND - -pedal edema, ascites, RUQ pain (liver congestion) - -fatigue 2. Investigate the cause - -Hx of HTN, CAD, valvular disease, arrhythmias - -cardiac risk factors - -Hx of anemia, thyroid disease, pregnancy - -recent flu--?myocarditis - -EtOH - -family history of dilated or hypertrophic cardiomyopathy or of hemochromatosis
74
What should you be looking for in particular on a physical exam for HF?
1. ABCs/general/vitals - -BP, tachy/Brady, hypoxia - -WOB, cyanosis 2. Respiratory - -crackles, wheezes 3. CVS - -volume assessment (JVP, peripheral edema) - -apex (may be dilated or displaced in a dilated cardiomyopathy, may be sustained in hypertrophic cardiomyopathy) - -S3, S4, murmurs 4. Abdo - -ascites, hepatomegaly
75
What labs would be appropriate to order in the setting of heart failure?
CBC--anemia causes high output HF Lytes, BUN, Cr--baseline before giving diuretics, ACEi LFTs--elevated with hepatic congestion If you suspect infiltrative disease: --calcium level (elevated in sarcoidosis, MM) --SPEP/UPEP (MM) --iron studies (hemochromatosis) TSH is suspect hyper or hypothyroid BNP--elevated in CHF (also elevated in PE, pulm HTN, LVH, Afib, ACS, renal failure)
76
What might you be looking for on ECG in the context of heart failure?
Active ischemia or arrhythmia Old ischemia or conduction disease LVH, atrial enlargement
77
What mighty you look for on CXR in the context of heart failure?
1. Cephalization of vasculature 2. Effusions 3. Cardiomegaly 4. Kerley B lines 5. Bat winging--perihilar fullness 6. Peri-bronchial cuffing
78
What imaging tests may be appropriate to order beyond a CXR in HF?
1. Echo--EXAM - -looks at EF, relaxation - -chamber sizes, valve anatomy - -pericardium 2. MIBI 3. Cardiac MRI 4. PET 5. Coronary angio for CAD
79
What are the best indices for CHF dx as per the JAMA article?
1. HX of CHF 2. Clinical gestalt 3. S3 4. Elevated JVP 5. Pulmonary edema on CXR 6. Afib 7. **BNP <100 RULES CHF OUT**
80
What is the acute management of CHF?
``` L(M)NOP Loop diuretic--lasix (Morphine--no longer recommended) Nitroglycerin--vasodilator O2 above 90% Position upright Positive pressure ventilation (BiPAP--decreases need for intubation and ICU) ```
81
What orders should you write for a patient presenting in CHF?
``` Diet--restrict salt to less than 2g/day and fluid <1.5L/day Frequent vitals Maintain O2 above 90% Daily weights Fluids in and out Furosemide IV BID--reassess daily ```
82
What are the goals of chronic CHF management
Decrease mortality, morbidity and hospitalizations | Improve quality of life
83
What lifestyle elements can help in the chronic management of CHF
Diet--restrict salt and fluid Quit smoking and drinking alcohol Exercise--cardiac rehab program
84
What drugs should be used in the chronic treatment of CHF
1. ACEi - -**improve survival** - -improve NYHA class, slow progression of disease - -attenuate LV remodelling - -SEs = cough, angio edema, hyperkalemia and elevated Cr--> check writhing 3-5 days of starting 2. ARBs - -as effective as ACEi for patients who cannot tolerate ACEi 3. Beta blockers - -NOT for acute HF because they suppress the tachy that is compensating for decreased heart function - -**improve survival** (metoprolol, bishop roll, carvedilol) - -improve NYHA and slow progression - -SEs = Brady, heart block, bronchoconstriction, initial worsening of CHF, hypotension, fatigue, sexual dysfunction - -metoprolol 100 mg PO BID - -carvedilol 25-50 mg PO BID - -bishop roll 10mg PO daily * *start at 1/4 dose and titration up 4. Aldosterone antagonists--> spironolactone - -**improves survival** - -indicated for NYHA III-IV, EF <40% - -improves NYHA - -SEs = gynecomastia, breast tenderness, AKI, hyperkalemia - -spironolactone 25-50 mg PO daily 5. Digoxin - -NO survival benefit - -decreases hospitalizations - -SEs = cardiac arrhythmias, GI disturbance, neutron changes (visual) 6. Loop diuretics - -NO survival benefit--used only for chronic treatment if chronically volume overloaded - -symptomatic benefit - -SEs = hypotension, volume depletion, hypokalemia, elevated Cr - -furosemide 20-40 PO BID 7. Vasodilators - -hydralazine + nitrate combo for after load reduction if ACEi or ARB intolerable (I.e renal impairment) - -mortality benefit ESPECIALLY IN AFRICAN AMERICANS
85
Which drugs used on the management of chronic CHF have survival benefit?
``` ACEi/ARB Beta blockers (not in acute) Spironolactone (aldosterone antagonists) ```
86
Which drugs used in the management of chronic CHF have no survival benefit?
Digoxin--decreases hospitalizations | Loop diuretics--symptoms management if volume overloaded
87
What are the three principles of diastolic heart failure management
Treat comorbidities Rate control Afib BP control HTN
88
What are some non-drug therapies to manage CHF?
1. Implantable defibrillators (AICD) - -survival benefit for Class III-IV on maximal medical therapy 2. Cardiac resynchronization therapy (CRT) - -survival benefit for class III-IV with WIDE QRS on maximal medical therapy 3. Heart transplant
89
What defines anemia in men and women
Men less than 130 | Women less than 120
90
What is a mnemonic to remember the Ddx for microcytic anemia?
``` TAILS Thalassemia Anemia of chronic disease Iron deficiency Lead poisoning Sideroblastic anemia ```
91
What is the Ddx for a normocytic anemia with a HIGH reticulocyte count?
1. Bleeding--GI, GU 2. Hemolysis - -inherited--> SCD, thalassemia, spherocytosis - -acquired--> MAHA (DIC, HUS, TTP), AIHA
92
What is a Ddx for a normocytic anemia with a LOW reticulocyte count?
1. Pancytopenia--> leukaemia, MDS, myelofibrosis, aplastic anemia, chemo, infiltrative disease (TB, amyloid, sarcoidosis) 2. Non-pancytopenia--> anemia of chronic disease 3. Mixed picture--> B12 + iron deficiency
93
What is the ABCD approach to macrocytic anemias?
``` Alcoholism B12/folate deficiency Chronic disease--> liver, TSH Compensatory reticulocytosis Dysplasia Drugs ```
94
What is a Ddx for megaloblastic macrocytic anemia?
B12/folate deficiency | Meds I.e chemo or methotrexate
95
What is a Ddx for non-megaloblastic macrocytic anemia?
Alcoholism Hypothyroidism Reticuocytosis Myelodysplasia
96
What things in particular should you elicit on the history of a patient presenting with anemia?
1. Possible causes - -family history of anemia - -bleeding (GI, GU, menorrhagia) - -diet (iron, B12, folate, Pica) - -PMHx of autoimmune disease - -Pancytopenia sx (bleeding, bruising, infection) - -meds (chemo, anti coagulation) - -PMHx hypothyroid or liver disease or symptoms of these 2. Possible consequences - -fatigue, headache, lightheadedness/syncope, malaise, weakness - -exercise intolerance, dyspnea, palpitations, chest pain - -dizziness, tinnitus - -dark urine
97
What things in particular should you look for on the physical exam of a patient with anemia?
1. HEENT--> pallor in mucous membranes, conjunctiva LAD ``` 2. Cardiac--> Tachy Orthostatic hypotension Systolic flow murmur Signs of CHF ``` 3. Derm--> Palmar crease pallor Jaundice Nail changes (koilonychia due to iron deficiency) Brittle hair Signs of ecchymoses, retro peritoneal bleeding, etc Gingival bleeding 4. Abdo DRE with FOB Pelvic exam--look for blood Splenomegaly
98
What investigations should you order when you are working up a patient for anemia?
CBC + diff, lutes, BUN, Cr, glucose Reticulocyte count Peripheral smear (look for schistocytes) Iron panel--in iron deficiency, expect low ferritin, low serum iron, high TIBC and low serum sat. In chronic disease, see elevated ferritin, low serum iron and low TIBC B12, TSH if macrocytic Bone marrow aspirate/biopsy, SPEP, UPEP Hemolysis panel--elevated reticulocytes, elevated unconjugated bilirubins, elevated LDH, low haptoglobin, schistocytes on peripheral smear Coombs test for AIHA Hgb electrophoresis if suspect hemoglobinopathy Liver panel if suspect liver disease INR, PTT, group and screen
99
How do you treat anemia from iron deficiency?
Oral supplementation-ferrous fulmar ate 300 mg TID x3-6 months IV supplementation is alternative If bleed is suspected, consider a scope
100
How do you treat anemia caused by renal failure?
EPO
101
How do you treat anemia caused by thalassemias?
1. Beta major--> transfusions + iron chelation to avoid iron overload, bone marrow transplant 2. Alpha--> similar
102
How do you treat anemia caused by sickle cell disease?
1. Hydroxyl rhea 2. Folate supplementation 3. Penicillin prophylaxis and vaccines 4. Bone marrow transplant 5. Treat crises with analgesia, oxygen, hydration
103
How do you treat anemia caused by B12 deficiency?
Monthly IM injections or PO supplementation
104
What is a Ddx for fever?
1. Infection--> bacterial, viral (HIV), TB - -can be in various sites I.e sepsis, meningitis, pneumonia, IE, pyelonephritis, septic joint 2. Neoplastic--> leukaemia, lymphoma, other malignancies 3. Autoimmune--> SLE, RA, vasculitis 4. Medications--> antihistamines, heparin, phenytoin 5. Other--> VTE
105
What types of things should you elicit on a history of fever?
1. Fever itself--> measured or unmeasured, time of day, response to antipyretic a 2. Systemic symptoms--weight loss, fatigue, rash, arthralgia, night sweats 3. Symptoms of possible source--> infection source or meds, PE/DVT sx, Hx of cancer, rheum disease 4. Infectious contacts--> travel history, TB contact, food borne or animal contacts, HIV risk factors, immunizations
106
Symptoms of UTI/pyelonephritis
Dysuria, frequency, flank Pai
107
Symptoms of pneumonia
Cough | Pleuritic chest pain
108
Symptoms of URTI
Cough Coryza Ear pain
109
Symptoms of meningitis
HA Confusion Nuchal rigidity Rash
110
Symptoms of osteomyelitis
Bone pain
111
Symptoms of skin infection
Purulence Redness Discharge Warmth
112
Symptoms of PID
Discharge Dyspareunia Lower abdo pain
113
Symptoms of gastroenteritis
Abdo pain Diarrhea BRBPR Vomitus
114
define SIRS
Tachycardia Tachypnea Elevated or low WBC Febrile or low temp
115
Define Sepsis
SIRS + likely source of infection
116
Define septic shock
Sepsis + hypotension and inability to resuscitate with fluids
117
What should you look for on physical exam in a patient with fever?
1. Vitals--SIRS/Sepsis/shock 2. General--mental status changes, diaphoresis, rigours 3. HEENT--oral ulcers, malar/discoid rash, LAD, Nuchal rigidity 4. Cardio/resp/abdo--murmurs, crackles, RUQ pain, hepatomegaly, murphys, splenomegaly, CVA tenderness 5. Derm--rashes, joint pain or swelling
118
What investigations should you consider in a patient with fever?
CBC + diff, lutes, BUN, Cr, glucose, liver panel, LDH, lactate ESR/CRP ANA, ENA, RF, ANCA UA Pan cultures (blood, urine, sputum, stool) + gram stain CT before LP Serologies for HIV, hepatitis, monospot (EBV), CMV Imaging--> CXR, echo (IE), consider PET, consider ECG TB skin test Biopsy of tissue identified
119
How do you manage fever
``` IVF Cold compresses Acetaminophen/ibuprofen as antipyretic Treat underlying cause If unstable, start broad spectrum abx and narrow upon sensitivities ```
120
What can cause a systolic murmur?
``` Aortic sclerosis/stenosis HOCM Flow murmur (anemia, sepsis, thyrotoxicosis) Pulmonary stenosis MR TR ``` "Can be caused by increased flow in a high output state like anemia or sepsis or thyrotoxicosis or by abnormal cardiac structures"
121
What types of things might you comment on for general appearance when assessing for a systolic murmur?
Cyanosis Distress Diaphoresis Increased work of breathing (accessory muscle use, tripoding, full sentences, tachypnea etc)
122
What types of things give you your "clinical gestalt" when assessing a systolic murmur?
``` Airway Breathing Circulation General appearance Vitals--look for signs of sepsis Volume exam (cap refill, skin turgor, JVP, dry axilla, tears, mucous membranes, postural vitals) ```
123
What types of things would you look for on extra cardiac exam when assessing for systolic murmur?
``` Pallor (anemia) Edema (volume) Peripheral pulses Brachioradial delay (Astenosis) Apical carotid delay (Astenosis) Carotid artery palpating--rate, rise, volume JVP ```
124
Describe the general cardiac exam
Inspection--chest wall deformities, scars, pacemaker? Palpation--heaves, thrills, PMI (displaced or sustained?) Auscultation--comment on S1, S2, EHS, then murmurs
125
How would you characterize a systolic murmur on exam?
1. Timing--> use carotid pulse to distinguish S1 and S2. Identify location in systole or diastole or continuous or both. 2. Pattern--> crescendo-decrescendo, pan systolic. 3. Radiation--> axilla, carotid arteries, clavicles. 4. Pitch--> high (louder with diaphragm) or low (louder with bell) 5. Intensity--> grade I to VI 6. Maneuvers (see another card)
126
What types of maneuvers can be done on exam to examine a systolic murmur more closely?
1. Quiet inspiration/sustained abdo pressure--> increases venous return and therefore increases R sided murmurs 2. Transient arterial occlusion--> inflate BP cuffs bilaterally to 20-40 > sBP which increases systemic vascular resistance and therefore increases L sided murmurs (except for HOCM, should decrease this murmur) 3. Stand to Squat/Passive leg elevation--> increases venous return and SVR, decreases murmurs of HOCM and MVP 4. Valsalva--> decreases venous return and increases SVR and thus decreases Astenosis intensity
127
Describe specific characteristics of an aortic stenosis murmur
1. Decreased carotid volume and slow rise of carotid pulse--> pulsus parvus et tardus 2. Loudest at RUSB 3. Decreased/absent S2 4. valve calcification on CXR 5. Radiates to carotids and/or clavicles 6. Sustained apical impulse 7. Bradioradial delay
128
Describe the specific characteristics of a mitral regurgitation murmur
1. Pan systolic 2. Loudest at apex 3. Radiates to axilla/left subscapular area 4. Displaces/enlarged apex beat 5. Left parasternal movement 6. S3
129
Describe the specific characteristics of a pulmonary stenosis murmur
1. Pre cordial lift due to RVH 2. Right sided S4 3. JVP prominent wave 4. Wide splitting S2
130
Describe the specific characteristics of a tricuspid regurgitation murmur
1. Increased with inspiration/abdominal pressure 2. Usually pan systolic 3. Low pitched 4. LLSB 5. Raised JVP 6. Pulsatile liver 7. Ascites 8. Peripheral edema
131
Describe the specific characteristics of HOCM murmur
1. Harsh, mid systolic murmur LSB 2. Louder with valsalva 3. Decreased with stand--> squat 4. Decreases with leg elevation 5. Softer with isometric hand grip 6. Sustained apex beat 7. S4
132
What types of findings would you expect to see in a patient with CHF?
Crackles on lung exam Pulsatile liver and/or ascites on abdo exam S3 (maybe S4 if stiffened ventricle depending on etiology)
133
What types of things are you looking for on the extra cardiac exam when you are examining a patient for CHF?
1. Signs of the cause of the CHF/underlying etiology - -Evidence of vascular disease-->PVD, atherosclerosis - -Atrial fibrillation 2. Consequences of CHF - -peripheral pulses, skin temperature - -EDEMA (pedal, sacral) - -dullness to percussion (pleural effusion) - -crackles or decreased breath sounds on ausculation - -enlarged, tender liver (may or may not be pulsatile) which may indicate hepatic congestion
134
How would you examine the JVP?
Position HOB 30-45 degrees Tangential lighting Stand at foot Look between two heads of the SCM Biphasic, changes with respiration, non palpable, non occludable Comment on the height (normal is less than 3 cm) AJR--> positive if sustained elevated JVP after two respiratory cycles or 10 seconds
135
What should you look for on pre cordial exam when you are assessing CHF?
Inspect for chest wall deformities, scars, pacemakers Palpate for thrills, heaves, PMI Auscultation for normal heart sounds, S3, S4, then any murmurs
136
What types of things should you comment on in your assessment of a patient with CHF
Right sided versus left sided? What investigations would you do? BNP, ECG, CXR, maybe echo History? Causes can include HTN, CAD, T2DM, smoking, MI, valvular disease Consequences? SOBOE, blocks, PND, Orthopnea, weight gain
137
Describe very briefly the flow of the physical exam for CHF
``` Formalities of introduction ABCs General appearance Vitals Examine for possible causes of CHF Examine for consequences of CHF JVP Pre cordial exam Decide whether R or L sided Comment on investigations, history, consequences ```
138
What might you see as soon as you walk in the exam room in a patient with pericarditis?
They may be sitting up and leaning forward, as this reduces pressure on the parietal pericardium
139
What findings might you expect when examining the heart of someone with pericarditis?
Pericardial friction rub (high pitched)
140
What must you rule out when you are assessing for possible pericarditis
``` Tamponade (beck's triad, pulsus paradoxus) MI Aortic dissection Pulmonary embolism Esophageal rupture ```
141
What might lymphadenopathy suggest in the setting of pericarditis?
Cancer
142
What should you look for in the extra cardiac exam when examining a patient for pericarditis?
1. Causes of the pericarditis - -signs of trauma to the chest - -lymphadenopathy (cancer) - -rheumatic disease - -systemic signs of sepsis 2. Consequences of the pericarditis - -TAMPONADE - -peripheral pulses, skin temp - -edema (pedal and sacral) - -Auscultation lungs - -abdo exam
143
What are the signs of cardiac tamponade?
Beck's triad: - -low arterial BP - -distended neck veins - -distant, muffled heart sounds Pulsus paradoxus--> abnormally large decrease in sBP > 10mmHg on inspiration Pericardial rub Hypotension
144
What exam finding is highly specific for pericarditis?
Pericardial friction rub Best heard with diaphragm Scratchy or squeaky Intensity increases with leaning forward
145
What investigations might you order in suspected pericarditis?
``` CBC and diff BNP ECG (widespread ST elevation or PR depression) CXR Echo ```
146
What can cause pericarditis?
``` Prior infection Radiation to heat Trauma Drugs/toxins Kidney failure Cancer Rheumatological history IBD ```
147
What is the major consequence of concern with pericarditis?
Tamponade
148
How do you diagnose pericarditis?
``` At least two of: Typical chest pain Pericardial friction rub ECG changes New or worsening pericardial effusion ```
149
What do you expect to see in the vitals of someone with Afib?
Tachy HTN Pulse irregularity
150
What should you examine for on the extra cardiac exam of someone with Afib?
1. Causes COPD CHF Focal neuro signs (stroke?) ``` 2. Consequences Evidence of heart failure Peripheral pulses Diaphoresis Volume exam ```
151
What can cause Afib? (Mnemonic)
``` PIRATES Pulmonary disease Ischemia Rheumatic disease Anemia (high output state) Trauma Electrolytes Sepsis and other high stress states ``` Holiday heart (EtOH)
152
What are symptoms of Afib?
``` Palpitations Fatigue Weakness Dizziness Lightheadedness Decreased exercise capacity Dyspnea Angina Syncope ```
153
What are some precipitants of Afib?
Exercise | Alcohol
154
What investigations might you order in the patient with Afib?
``` BNP CBC and diff ECG (look at LA size, is there a thrombus, valves, LV function, pericardium) CXR Echo K Mg ```
155
What must you rule out in a patient with Afib?
MI
156
Describe very briefly the organization of an exam of a patient with Afib
Formalities ABCs General appearance--diaphoresis, breathing Vitals--tachy, HTN, pulse irregular JVP Pre cordial exam--inspection, palpation, auscultation Comment on causes, symptoms, precipitants, investigations, rule out MI
157
What might you expect to see in the vitals of someone with pneumonia?
Low O2 sat | Look for signs of SIRS--> fever, high RR, high HR, elevated WBC
158
What are the important parts of the extra pulmonary exam when assessing for pneumonia?
Volume exam Mental status N/V/diarrhea Cardiac exam, abdo exam, skin inspection
159
Describe the general pulmonary exam briefly
Inspection--> increased WOB, cyanosis, stridor or wheeze, chest deformity, breathing movements, AP diameter Palpation--> chest excursion, trachea midline? Percussion--> resonant? Dull? Hyperresonant? Auscultation--> all lung fields
160
What aspects of the pulmonary exam should be of specific note in pneumonia?
1. Inspect for cough, sputum production, chills, rigours 2. Palpation for increased tactile fremitus 3. Percuss expecting decreased resonance over areas of consolidation 4. Auscultation for crackles
161
What organisms most likely cause community acquired pneumonia?
``` S. Pneumo Mycoplasma Chlamydia Viral H. Influenza M. Catarrhalis Legionella ```
162
What organisms most commonly cause HAP?
``` GNR--> Pseudomonas Klebsiella Ecoli MRSA ```
163
What are the symptoms of pneumonia
``` Cough Fever Sputum Chest pain N/V/D Dyspnea ```
164
What investigations might you order in someone with suspected pneumonia?
CBCD Blood CX Sputum CX and gram stain CXR
165
Describe very briefly an approach to the clinical exam for pneumonia
Formalities ABCs General appearance--> cyanosis, distress, diaphoresis, WOB, cough, tachypnea etc Vitals--> O2 sat, SIRS?--temp, RR, HR, WBC count Extra pulmonary exam--> volume status, mental status, N/V/D, cardiac, abdo, skin exam General resp exam--> note features expected in pneumonia Comment on causes/likely to etiology, symptoms, investigations
166
Name 4 special tests/signs used in the examination of COPD
Blow test Match test T-L height Barrel chest
167
What might you expect to find on the vitals of someone with COPD
Low O2 sat Tachypnea Tachycardia Pulsus paradoxus
168
What might you look for on the fingers of someone with COPD?
Nicotine staining
169
What would you look for on extra pulmonary exam in a patient with COPD?
``` NOT CLUBBING (COPD alone doesn't cause clubbing... You would have to have bronchiectasis or lung cancer or some other process as well) Volume exam Lymph nodes (especially cervical) ```
170
What should you look for on the pulmonary exam that is specific to COPD?
1. Inspection--> barrel chest with an AP diameter greater than or equal to chest width, PURSED LIP breathing 2. Palpation--> laryngeal height less than 4 cm, decreased expansion, RV heave due to pulm HTN 3. Percussion--> hyper resonant; resonant over cardiac area 4. Auscultation--> decreased breath sounds, wheeze
171
How long would you expect the forced expiratory time to be in a patient with COPD
More than 9s
172
How do you examine for pulsus paradoxus in a COPD patient
Inflate the cuff until no sounds are heard as you normally would Slowly decrease the cuff pressure until you hear sounds on expiration but not inspiration--note this reading Slowly continue decreasing the cuff pressure until you hear sounds throughout the respiratory cycle--note this reading If the pressure difference between the two readings is more than 10mmHg then this is pulsus paradoxus
173
What would help you rule in COPD?
Smoking history more than 40 pack years... Or just ever Sputum SOBOE Subjective wheeze
174
What are causes other than COPD for pulsus paradoxus?
Asthma Cardiac tamponade Constrictive pericarditis Big PE
175
Describe very briefly an approach to the exam of a COPD patient
1. Formalities 2. ABCs 3. General appearance-->pursed lip breathing? 4. Nicotine staining? 5. Vitals--> O2 sat, tachypnea, tachy, pulsus paradoxus 6. Extra pulm--> hands for clubbing (not caused by COPD), volume exam, lymph nodes 7. General pulm exam--> specific COPD findings 8. Special tests--> match test, blow test, pulsus paradoxus 9. Comment on what would help you rule in COPD
176
What two conditions in particular should you be examining for in a patient with e CXR suggesting effusion?
CHF and cirrhosis
177
What sign on General appearance can sometimes be seen in patients with CXR suggesting effusion?
Hiccups
178
What are you looking for in particular on vitals in a patient with a CXR suggesting effusion?
Tachypnea | Fever
179
What are you examining for on the extra pulmonary exam of a patient with a CXR suggesting effusion?
1. Hands--> clubbing? (Lung cancer) 2. Volume exam 3. Lymph nodes, especially cervical (lung, GI cancer) 4. Signs of CHF 5. Signs of liver cirrhosis 6. Signs of pericarditis
180
Describe a general pulm exam you would do in a patient presenting with CXR suggestive of effusion?
1. Inspection--increased WOB, cyanosis, stridor or wheeze, chest deformity, breathing movements, AP diameter 2. Palpation--chest excursion, tactile fremitus, trachea 3. Percussion--resonant? Dull? Hyper resonant? 4. Auscultation--all lung fields
181
What signs on pulmonary exam should you look for in particular in a patient with CXR suggestive of effusion?
1. Inspection--inspiration pain 2. Palpation--DECREASED tactile fremitus 3. Percussion--decreased resonance over effusion 4. Auscultation--decreased breath sounds
182
What may cause a transudative pleural effusion?
``` Systemic (I.e decreased oncotic pressure, increased hydrostatic pressure) CHF Constrictive pericarditis Cirrhosis Nephrotic syndrome ```
183
What are some causes of exudative pleural effusion?
``` Lung parenchymal infection Malignancy PE Collagen vascular disease GI disease Hemothorax Chylothorax ```
184
What is a chylothorax
Pleural effusion Results from lymph formed in the digestive system (chyle) accumulating the pleural cavity due to disruption or obstruction of the thoracic duct
185
How do you diagnose the cause of a pleural effusion?
Thoracocentesis for all pleural effusions more than 1 cm in the decubitus view
186
What exam should you always do in patients presenting with abdo pain?
DRE
187
What is your DDx for RLQ abdo pain
Appendicitis--4 tests Pyelonephritis--CVA tenderness Gyne--pelvic exam IBD--4 tests
188
What are you paying most attention to on General appearance in the patient with RLQ pain
``` Comfort, colour (jaundice, tan) Cachectic? Muscle wasting? Chills? N/V/D? ```
189
What are you paying most attention to in vitals for the patient with RLQ pain?
Fever
190
What are you looking for on extra abdominal exam in the patient with RLQ pain?
Lymph nodes--sister may Joseph's, virchows, Irish Special tests for appendicitis, IBD, Pyelonephritis, Tyne DRE!!!
191
What is sister Mary Joseph node?
Palpable nodule bulging into the umbilicus as a result of mets of malignant cancer in the pelvis or abdomen Suggesting of CANCER, GI most likely then gyne, rarely from appendix
192
What is the Irish lymph node?
Left anterior axillary enlarged lymph node, often involved in metastatic gastric cancer
193
What is virchows node?
Lymph node in the LEFT supraclavicular fossa Gets its lymph supply from vessels in the abdominal cavity Finding of enlarged, hard node is strongly indicative of the presence of abdo cancer especially gastric spread through lymph
194
Describe the general abdominal exam
1. Inspection--scars and lesions, skin wall abnormalities (striae), abdominal contours (scaphoid, bulging flanks, protuberant), visible peristalsis, pulsations or masses 2. Auscultation--bowel sounds, Bruits (aortic, iliac, femoral, renal) 3. Percussion--normal tympany? Gas? Fluid? Dullness? Pain? 4. Palpation--light palpation (look for guarding or tenderness) and deep palpation (look for rebound tenderness, enlarged organs, costovertebral tenderness)
195
What are the special tests for appendicitis?
McBurney's point tenderness--one third of the way from ASIS to umbilicus Rovsings sign--palpation of left lower quadrant increases pain in RLQ Psoas sign--indicates an inflamed appendix that is retrocecal; passively extend the thigh of a patient lying on his side with knees extended or ask patient to actively flex thigh at hip (if causes abdo pain sign is positive) Obturator sign--pain on internal rotation with hip and knee flex ion
196
Special tests for pyelonephritis
CVA tenderness | Fever
197
Special tests for Crohn's
Peri-anal disease Arthritis Eyes--uveitis, iritis, episcleritis Erythema nodosum, pyoderma gangrenosum
198
What special test would you do for possible gyne cause of abdo pain?
Pelvic exam
199
What test should you always do in patient with RLQ pain
DRE
200
What are some causes of RLQ pain?
``` Appendicitis Pyelonephritis Crohn's disease/IBD Cancer Gallstone ileus ```
201
What are some causes of diffuse abdo pain
``` AAA Ischemia bowel Bowel obstruction Gastroenteritis Metabolic disturbance IBS ```
202
What are some gyne causes of RLQ/abdo pain?
Ectopic pregnancy Ruptured ovarian cyst PID Endometriosis
203
What in particular would you look for when examining a patient for portal HTN
Stigmata of chronic liver disease Venous hum (due to increased collaterals circulation in cirrhosis) Systolic bruit (AAA) Friction rub over liver (tumour) DRE (haemorrhoids) Ascites
204
What would you look for on the hands in the extra pulmonary exam for portal HTN
``` Clubbing Palmar erythema Thenar, hypothenar, interosseous wasting Contractures Leukonychia Asterixis ```
205
What would you look for on the head in the extra abdominal exam for portal HTN
Parotid enlargement Jaundice Fetor hepaticus Temporal wasting
206
What would you look for on the body on the extra abdominal exam of a patient with portal HTN
``` Gynecomastia Testicular atrophy Spider angiomas Edema Needle tracks Tattoos ```
207
What would you be looking for in particular on the abdominal exam of a patient with portal HTN
1. Inspection--caput medusae 2. Auscultation--Bruits, rubs, venous hums around a ?palpable liver mass 3. Percussion--percuss liver span, percuss for spleen--> nixon's test, traube's space, castelle's sign 4. Palpation--liver edge, RUQ tendereness, splenomegaly, ascites
208
How do you assess Traube's space?
Bounded by the left anterior axillary line, the 6th rib and the costal margin Should be resonant on percussion Dullness indicates splenomegaly possibly
209
How do you assess Castelle's sign
Percuss in the lowest left intercostal space in the anterior axillary line Should remain resonant during full inspiration Dullness suggests possible splenic enlargement
210
What is nixons test
Place left hand under patients left posterior chest and pull upwards With right hand, begin palpation in RLQ Direct patients breathing by telling them when to take a deep breath and when to exhale While proceeding diagonally towards the LUQ, try to palpable the spleen edge during each inspiration phase
211
What test should you do in the exam of the patient with portal HTN?
DRE--haemorrhoids
212
How do you assess ascites?
Shifting dullness--percuss abdo midline (tympanic)...percussion moved progressively more lateral away from examiner until dull. Keep one finger on dull side and one on tympanic side--ask patient to lean towards examiner (right side)...wait for fluid to shift...dull position (on left) should now be resonant Fluid wave Bulging flanks
213
What are the causes of cirrhosis
``` Alcoholic liver disease Chronic hep B or C Acetaminophen Methotrexate Autoimmune PBC Hematochromatosis Wilsons RSHF A1AT deficiency NASH Hepatic veno occlusive disease ```
214
What are signs of portal HTN
``` Ascites Edema Splenomegaly Varicosity Haemorrhoids Caput medusa ```
215
What are the signs of chronic liver failure?
``` VARICES Varices Ascites Renal Icterus Coagulopathy Encephalopathy Splenomegaly ```
216
What would you look for especially on vitals in a patient with LGIB
Orthostatic vitals + if drop in HRmore than 30 or drop in sBP more than 20mmHg or drop in dBP more than 10mmHg
217
What are three really important exams for assessing a patient with LGIB
Vitals--orthostatic Volume exam DRE/FOB
218
What constitutes a volume exam
``` Cap refill Skin turgor Dry axilla JVP Tears Mucous membranes Postural vitals ```
219
What are you looking for on the extra abdo exam for a patient with LGIB
Hands--clubbing Lymphadenopathy--Anguilla, sister Mary Joseph, Irish, Virchow Constitutional--fever, weight loss, night sweats Syncope
220
What are possible causes of LGIB
``` Anatomical--diverticulosis (painless) Vascular--angio dysphasia (painless) Ischemic Radiation induced Inflammatory--IBD, infectious (painful) Neoplastic Haemorrhoids ```
221
Risk factors for diverticula the bleeding (arterial)
``` Aspirin/NSAID use Advanced age Obesity HTN Hyperlypidemia ```
222
Investigations to do in a patient with a LGIB
``` CBC Type and cross match Platelet count INR PTT Endoscopy ```

Internal Medicine General (4 decks)

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