MedInterne Flashcards

Question

Traitement de l'angioedème

Answer 1

Épi si associé à anaphylaxie - Tx support, concentrés de facteur C1 inhibitor, icatibant (inhibiteur récepteur bradykinin-2), FFP, inhibiteur Kallikrein (Ecallantide)

Answer 2

Hémolyse intravasculaire 2nd réaction transfusionnelle Hémolyse 2nd CIVD Infection à malaria et clostridium Anémie hémolytique auto-immune (ex quinidine) Déficit en G6PD avec stress oxidatif Brûlures massives HPN Toxines (araignées, serpent) Hémolyse à hémaglutinine froides (mycoplasme pneumoniae, mono)

Answer 3

Thalassémie beta hétérozygote et homozygote Thalassémie alpha

Answer 4

Déficit dans la synthèse de l'hème, plus précisément dans la synthèse des porphyrines Corps d'inclusion de fer a/n GR Forme idiopathique chez les PA le + fréquent. Considéré forme préleucémique, avec transformation chez 5% Intox au plomb est une cause fréquente réversible d'anémie sidéroblastique Svt déficience concomittante en pyridoxine

Answer 5

Inadequate dietary intake Poor diet or overcooked or processed food diet Alcoholism Inadequate uptake Malabsorption with sprue and other chronic upper intestinal tract disorders, drugs such as phenytoin and barbiturates, or blind loop syndrome Inadequate use Metabolic block caused by drugs, such as methotrexate or trimethoprim Enzymatic deficiency, congenital or acquired Increased requirement Pregnancy Increased red blood cell (RBC) turnover: Ineffective erythropoiesis, hemolytic anemia, chronic blood loss Malignant disease: Lymphoproliferative disorders Increased excretion or destruction or dialysis

Answer 6

Inadequate dietary intake Total vegetarianism: No eggs, milk, or cheese Chronic alcoholism (rare) Inadequate absorption Absent, inadequate, or abnormal intrinsic factor, as seen in patients with pernicious gastrectomy and anemia; in anemia, autoimmune antibodies act against gastric parietal cells and intrinsic factor Abnormal ileum, as can occur in sprue and inflammatory bowel disease Inadequate use Enzyme deficiency Abnormal vitamin B12–binding protein Increased requirement by increased body metabolism Increased excretion or destruction

Answer 7

Intrinsic Enzyme defect Pyruvate kinase deficiency Glucose-6-phosphate dehydrogenase (G6PD) deficiency Membrane abnormality Spherocytosis Elliptostomatocytosis Paroxysmal nocturnal hemoglobinuria Spur cell anemia Hemoglobin abnormality Hemoglobinopathies Thalassemias (anemias) Unstable hemoglobin Hemoglobin M Extrinsic Immunologic Alloantibodies Autoantibodies Mechanical Microangiopathic hemolytic anemia Cardiovascular, such as prosthetic heart valve disease Environmental Drugs Toxins Infections Thermal Abnormal sequestrations, as in hypersplenism

Answer 8

Analgesics and antipyretics: acetanilid, aspirin, phenacetin Antimalarials: Primaquine, quinacrine, quinine Nitrofurans Sulfa drugs: Sulfamethoxazole, sulfacetamide, sulfones Miscellaneous: Naphthalene, fava beans, methylene blue, phenylhydrazine, nalidixic acid

Answer 9

Neoplasms Malignant: Chronic lymphocytic leukemia, lymphoma, myeloma, thymoma, chronic myeloid leukemia Benign: Ovarian teratoma, dermoid cyst Collagen Vascular Disease Systemic lupus erythematosus Periarteritis nodosa Rheumatoid arthritis Infections Mycoplasma Syphilis Malaria Bartonella Virus: Mononucleosis, hepatitis, influenza, coxsackievirus, cytomegalovirus Miscellaneous Thyroid disorders, ulcerative colitis Drug immune reactions

Answer 10

Hapten type with antibodies to the drug Complement-fixing antibody: Quinidine, quinine, phenacetin, ethacrynic acid, p-aminosalicylate, sulfa drugs, oral hypoglycemic agents Non–complement-fixing antibody: Penicillin dosages \>20 million units/day Autoimmune type with antibodies to the red blood cell (RBC) membrane: D-methyldopa, L-dopa, mefenamic acid, chlordiazepoxide Cephalosporins at dosages \>4 g/day may cause hemolysis by direct membrane injury

Answer 11

Peripheral blood smear Corrected reticulocyte index or reticulocyte production index Haptoglobin levels Plasma free and urinary hemoglobin Lactate dehydrogenase level Fractionated bilirubin level Direct and indirect Coombs test Red blood cell (RBC) membrane stability (osmotic fragility) Frottis: Hémolyse intravasculaire: shistocytes et helmet cells Hémolyse 2nd défaut GR acquis Ex toxines = sphérocytes Hyperslénisme: corps Howel-Jolly Infections ex malaria = corps d'inclusion

Answer 12

HbA (α2β2), HbA2 (α2δ2), and HbF (α2γ2) HbS = anémie falciforme et plusieurs combinaisons, avec sickle cell- b-thalassemie...

Answer 13

2 principales manifestations: hémolyse et crises vaso-occlusives Analgésie, hydratation Tx stroke: rtpa idem, échanges plasmatiques tx hydroxyurée Viser HbS \< 30%

Answer 14

Appropriately increased erythropoietin caused by tissue hypoxia Congenital heart disease with a right-to-left shunt Pulmonary disease (eg, bronchial-type chronic obstructive pulmonary disease) Carboxyhemoglobinemia High-altitude acclimatization Decreased tissue oxygen release from hemoglobinopathies with high oxygen affinity Inappropriate autonomous erythropoietin production Renal origin: Carcinoma, hydronephrosis, cyst Other lesions: Uterine fibroids, hepatoma of adrenal origin, cerebellar hemangioma Congenital overproduction Pure or essential erythrocytosis Acquired immunodeficiency syndrome (AIDS) and zidovudine treatment

Answer 15

Sx thromboses (IAM, EP, thrombose veineuse, AVC), saignement et ecchymoses Critères Category A Increased RBC mass In men: Hemoglobin \>18.5 g/dL In women: Hemoglobin \>16.5 g/dL Normal arterial oxygen saturation (\>92%) Splenomegaly Category B Thrombocytosis: Platelets \>400,000/mm3 Leukocytosis: WBC count \>12,000/mm3 (with no fever or infection) Leukocyte alkaline phosphatase score \>100 Vitamin B12 \>900 pg/mL, unbound vitamin B12–binding capacity Visons hématocrite inf 55% - phlébotomie et hydroxyurée, ASA

Answer 16

- LMC, polycythémie vraie - neutrophilie héréditaire - neutrophilie idiopathique chronique - maladie myéloproliférative chronique En cas d'hyperleucocytose sévère, leukaphérèse

Answer 17

Leucémie myéloide aigue - 60% Leucémie lymphoide chronique - 30% Leucémie myéloide chronique - 15% (sx constitutionnels, 20% asx, augmentation GB avec différentiel N, plt parfois augmentées, anémie associée)

Answer 18

Adhesion to subendothelial connective tissue: Collagen, basement membrane, and noncollagenous microfibrils; serum factor VIII (von Willebrand’s factor [vWF]) permits this function; adhesion creates the initial bleeding arrest plug Release of adenosine diphosphate, the primary mediator and amplifier of aggregation; release of thromboxane A, another aggregator and potent vasoconstrictor; release of calcium, serotonin, epinephrine, and trace thrombin Platelet aggregation over the area of endothelial injury Stabilization of the hemostatic plug by interaction with the coagulation system: Platelet factor 3, a phospholipid that helps accelerate certain steps in the coagulation system Platelet factor 4, a protein that neutralizes heparin Pathway initiation and acceleration by thrombin production Possible secretion of active forms of coagulation proteins Stimulation of limiting reactions of platelet activity

Answer 19

Thrombin-sensitive factors contributing to the metabolic response and local vasoconstriction: I, V, VIII, XIII Vitamin K-sensitive factors: II, VII, IX, X Sites of heparin activity: IIa, IXa, Xa (major site), XIa, platelet factor 3

Answer 20

Thrombin-sensitive factors contributing to the metabolic response and local vasoconstriction: I, V, VIII, XIII Vitamin K-sensitive factors: II, VII, IX, X Sites of heparin activity: IIa, IXa, Xa (major site), XIa, platelet factor 3

Answer 21

Quinine Ticlopidine Clopidogrel

Answer 22

Adhésion: déficit en VonWillebrand Défaut de libération: plts normales mais libération aN de sérotonine, calcium, ADP ...Ex ASA et inhibition cyclooxygenase et donc de la formation de thromboxane A2. Aussi urémie, dysprotéinémie Agrégation: maladie récessive de thrombasthénie

Answer 23

Facteur 8 anormal (facteur 8 formé au foie) Activité du facteur 8 = VIII:C activité 1-5% activité = sévère 5-10%= modéré \> 10% = léger Traitement: facteur VIII, si non dispo - cryoprécipités, DDAVP 0.3mcg/kg Cibles sgmt léger 25-40%, sgmt modéré 50%, sévère 80-100% 1 unités / kg augmente de 2% l'activité 1 unité = 1 mL de plasma d'un adulte normal En urgence, assumer le niveau de facteur VIII à 0. Because the half-life of factor VIII is 8 to 12 hours, the desired level is maintained by giving half the initial dose every 8 to 12 hours. Cryoprecipitate is assumed to have 80 to 100 U of factor VIII:C per bag; factor VIII:C concentrates list the units per bottle on the label. Possible développement AC inhibiteurs IgG , tx difficile, essai facteur VIIa,

Answer 24

1. Favorise l'Adhésion des plaquettes à l'endothélium vasculaire 2. Transporte le facteur VIII et permet de prolonger sa durée de vie type 1 (75%) déficit quantitatif partiel vWF type 2 déficit qualitatif vWF type 3 déficit total en vWF Tx: remplacement facteur VIII (idem à hémophilie A), DDAVP, dernier recours cryoprécipités, FFP

Answer 25

Déficit en facteur IX Tx: concentrés de facteur IX, PCC, plasma frais Concentrés de facteur IX 1 unité /kg = 1 % d'activité

Answer 26

Héparine non fractionnée = 1 mg / 100 unités HBPM: 1 mg / 1 mg HBPM

Answer 27

Néo: poumons, seins, prostate, rein, lymphome hodgkin, myélome multiple Tx: chirurgie, decadron 10 IV puis 16 mg / jour Radiothérapie

Answer 28

Envahissement du péricarde par néo (poumons, seins, néo hématologiques, mélanome) Épanchement 2nd obstruction lymphatique par ganglions lymphatiques obstrués Hypoalbuminémie Radiothérapie Chimiothérapie

Answer 29

Production PTH-rp (néoplasies épidermoides poumons, oesophage, tête/cou, endomètre/col/ovaires) Augmentation production calcitriol Ostéolyse 2nd invasion osseuse Production ectopique PTH

Answer 30

- hydratation IV - biphosphonates (acide zolédronique ou pamidronique) - calcitonine si réfractaire - dialyse - denosumab - cortico si lymphome associé

Answer 31

FR: taille tumorale élevée, sensibilité à chimio élevée, réplication importante avec grossissement (LLA, burkitt), IRC, hypovolémie, hyperuricémie sx:nausea, vomiting, lethargy, confusion, edema, seizure, myalgias, and tetany; dysrhythmias may result in cardiac arrest, changement ECG 2nd hypocalcémie et hyperkaliémie Tx: Hydratation IV Hypocalcémie: tolérer sauf si arythmies ou confusion/convulsions Tx standard hyperkaliémie Dialyse PRN Allopurinol ou rasburicase Allopurinol : analogue de l'hypoxanthine et inhibite la xanthine oxidase, empêchant la production d'acide urique. Accumulation de xanthine et hypoxanthine (peut aussi induire IRA) Rasburicase: analogue de l'enzyme urate oxidase et transforme l'acide urique en allantoine

Answer 32

hydratation IV Éviter pRBC Leukaphérèse Hydroxyurée Chimiothérapie

Answer 33

Acidose métabolique 1 PCO2 : 1,2 HCO3 Alcalose métabolique 1 PCO2 : 0,9 HCO3 Acidose respiratoire HCO3 : 0,1 PCO2 / 0,35 PCO2 Alcalose respiratoire HCO3 : 0,2 PCO2 / 0,5 PCO2

Answer 34

Hypoalbuminémie (anion gap corrigé = anion gap + 2.5 ( 4 - albumine sérique (g/dL) Hypertriglycéridémie Intoxication bromure Intoxication lithium Hypergammaglobulinémie Myélome multiple

Answer 35

Hyperventilation caused by hypoxia High altitude Severe anemia Ventilation-perfusion mismatch Central hyperventilation Voluntary or psychogenic Cerebrovascular accident Increased intracranial pressure (tumor, hemorrhage, trauma) Toxic or pharmacologic Salicylates Caffeine, nicotine Catecholamines Thyroxine Pulmonary Pulmonary embolism Pneumonia Pulmonary edema Asthma Mechanical hyperventilation (iatrogenic) Endocrine Pregnancy Hyperthyroidism Septicemia Hepatic encephalopathy Hyponatremia

Answer 36

CAT MUDPILES

Answer 37

Winter’s equation (PaCO2 = [1.5 × serum HCO3] + [8 ± 2])

Answer 38

Spurious elevation: Hemolysis due to drawing or storing of the laboratory sample or post–blood sampling leak from markedly elevated white blood cells, red blood cells, or platelets • Renal failure: Acute or chronic • Acidosis: Diabetic ketoacidosis (DKA), Addison’s disease, adrenal insufficiency, type 4 renal tubular acidosis • Cell death: Rhabdomyolysis, tumor lysis syndrome, massive hemolysis or transfusion, crush injury, burn • Drugs: Beta-blockers, acute digitalis overdose, succinylcholine, angiotensin-converting enzyme inhibitors, angiotension receptor blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), spironolactone, amiloride, potassium supplementation Patients with severe hyperkalemia may present with neuromuscular findings, including muscle cramps, generalized weakness, paresthesias, tetany, and focal or global paralysis

Answer 39

Renal losses: Diuretic use, drugs, steroid use, metabolic acidosis, hyperaldosteronism, renal tubular acidosis, diabetic ketoacidosis (DKA), alcohol consumption • Increased nonrenal losses: Sweating, diarrhea, vomiting, laxative use • Decreased intake: Ethanol, malnutrition • Intracellular shift: Hyperventilation, metabolic alkalosis, drugs • Endocrine: Cushing’s disease, Bartter’s syndrome, insulin therapy

Answer 40

Hypernatremia with Dehydration and Low Total Body Sodium Heatstroke Increased insensible losses: Burns, sweating Gastrointestinal loss: Diarrhea, protracted vomiting, continuous gastrointestinal suction Osmotic diuresis: Glucose, mannitol, enteral feeding Hypernatremia with Low Total Body Water and Normal Total Body Sodium Diabetes insipidus Neurogenic Elderly with “reset” osmostat Hypothalamic dysfunction Suprasellar or infrasellar tumors Renal disease Drugs (amphotericin, phenytoin, lithium, aminoglycosides, methoxyflurane) Sickle cell disease Hypernatremia with Increased Total Body Sodium Salt tablet ingestion Salt water ingestion Saline infusions Saline enemas IV sodium bicarbonate Poorly diluted interval feedings Primary hyperaldosteronism Hemodialysis Cushing’s syndrome Conn’s syndrome

Answer 41

Central Idiopathic Familial disease Cancer Hypoxic encephalopathy Infiltrative disorders Post supraventricular tachycardia Anorexia nervosa Nephrogenic Chronic renal insufficiency Polycystic kidney disease Lithium toxicitya Hypercalcemia Hypokalemia Tubulointerstitial disease Hereditary Sickle cell disease

Answer 42

Pseudohyponatremia Hyperlipidemia Hyperproteinemia (multiple myeloma, macroglobulinemia) Dilutional Hyperglycemia\* Hypovolemic Hyponatremia: Decreased Total Body Water and Sodium, with a Relatively Greater Decrease in Sodium Body fluid losses: Sweating, vomiting, diarrhea, gastrointestinal suction Third spacing: Bowel obstruction, burns, pancreatitis, rhabdomyolysis Renal causes: Diuretics, mineralocorticoid deficiency, osmotic diuresis, renal tubular acidosis, salt-wasting nephropathies Hypervolemic Hyponatremia: Increased Total Body Sodium with a Relatively Greater Increase in Total Body Water Heart failure Chronic renal failure Hepatic failure or cirrhosis Euvolemic Hyponatremia: Increased Total Body Water with Nearly Normal Total Body Sodium SIADH Drugs causing SIADH (diuretics, barbiturates, carbamazepine, chlorpropamide, clofibrate, opioids, tolbutamide, vincristine) Psychogenic polydipsia Beer potomania Hypothyroidism Adrenal insufficiency MDMA (ecstasy) Accidental or intentional water intoxication

Answer 43

Lung Masses Cancer (especially small cell) Pneumonia Tuberculosis Abscess Central Nervous System Disorders Infection (meningitis, brain abscess) Mass (subdural, postoperative, cerebrovascular accident) Psychosis (with psychogenic polydipsia) Drugs Thiazide diuretics Narcotics Oral hypoglycemic agents Barbiturates Antineoplastics

Answer 44

Malignant Disease Ectopic secretions of parathyroid hormone, multiple myeloma, cancer metastatic to bone Most common: Breast, lung, hematologic, kidney, prostate Endocrine Hyperparathyroidism, multiple endocrine neoplasias, hyperthyroidism, pheochromocytoma, adrenal insufficiency Granulomatous Disease Sarcoidosis, tuberculosis, histoplasmosis, berylliosis, coccidioidomycosis Pharmacologic Agents Vitamins A and D, thiazide diuretics, estrogens, milk-alkali syndrome Miscellaneous Dehydration, prolonged immobilization, iatrogenic, rhabdomyolysis, familial, laboratory error

Answer 45

Pour chaque diminution d'albumine de 10, augmenter la calcémie de 0.2

Answer 46

Hypoalbuminemia Hypoparathyroidism: inherited, postsurgical, autoimmune, infiltrative Vitamin D deficiency and vitamin D resistance: Malabsorption syndrome, liver disease, malnutrition, sepsis, anticonvulsants, lack of sunlight exposure Chronic renal failure Hyperphosphatemia Hypomagnesemia Respiratory alkalosis Severe pancreatitis Drugs: Bisphosphonates, phenytoin, phosphate, calcitonin Tumor lysis syndrome Rhabdomyolysis à l'urgence, le + fréquent: Hyperventilation: Anxiety, sympathomimetics Ethanol abuse, chronic malnutrition: Hypoalbuminemia Massive blood transfusion: More than 10 units Toxins: Hydrofluoric acid, ethylene glycol Severe pancreatitis

Answer 47

Iatrogenic: IV administration, dialysate • Oral administration: Laxatives, antacids, vitamins, cathartics, dialysate, parental • Impaired elimination—hypomotility: Bowel obstruction, chronic constipation • Impaired elimination—medications: Anticholinergics, narcotics, lithium therapy • Miscellaneous: Hypothyroidism, tumor lysis syndrome, adrenal insufficiency, milk-alkali syndrome

Answer 48

Decreased deep tendon reflexes 1.5 - 2 mmol/L Hypotension 2-3 mmol/L Respiratory insufficiency 4 mmol/L Heart block 4-6 mmol/L Cardiac arrest 6-10 mmol/L

Answer 49

Cesser apport exogène Hydratation IV Diurétiques Dialyse si instable - calcium IV - 5mL gluconate de calcium

Answer 50

Decreased Phosphate Excretion Acute and chronic renal failure Increased Renal Tubular Reabsorption Hypoparathyroidism Thyrotoxicosis Excess vitamin D administration Excessive Phosphate Intake Phosphate enemas or laxatives IV or oral phosphate administration Shift of Phosphate from Intracellular to Extracellular Space DKA Tumor lysis Rhabdomyolysis Spurious Hyperphosphatemia Paraproteinemia Hyperbilirubinemia Hemolysis Hyperlipidemia

Answer 51

**Decreased Intake or decreased Absorptive States** Chronic alcoholism Home parenteral nutrition AIDS Chemotherapy Vomiting Malabsorption syndromes Secretory diarrhea Vitamin D deficiency **Hyperventilatory States** Sepsis Alcohol withdrawal Salicylate poisoning Neuroleptic malignant syndrome Panic attacks DKA Hepatic coma **Hormonal and Endocrine Effects** Insulin loading Glucose loading Exogenous epinephrine Hyperparathyroidism **Medicationsa** Diuretics Chronic antacid ingestion Steroids Phosphate binders Xanthine derivatives Beta2-agonists **Disease States** Trauma Severe thermal burns Acute renal failure Gout

Answer 52

Central Nervous System Irritability Confusion Paresthesias Depression Dysarthria Seizure Coma Cardiovascular Cardiomyopathy Depressed myocardial contractility Arrhythmias Respiratory Acute respiratory failure Depressed myocardial contractility Gastrointestinal Ileus, dysphagia Hematologic Depressed levels of 2,3-diphosphoglycerate and adenosine triphosphate Leukocyte dysfunction Hemolysis Platelet dysfunction Renal Acute tubular necrosis Metabolic acidosis Hypercalcemia Endocrine Insulin resistance Hyperparathyroidism Rhabdomyolyse

Answer 53

HbA1C \> 6.5% Glycémie aléatoire \> 11.1 Glycémie à jeun \> 7 2hr post 75g glucose \> 11.1

Answer 54

Biguanides (ex metformine) Sulfonylurées (Ex glyburide, glyclazide) Thiazolidinediones ( Actos, Avandia, CI insuffisance cardiaque) Inhibiteurs de l'alpha-glucosidase : acarbose Meglinitides: sécrétagogues non sulfonylurées (ex repaglinide) Analogues GLP-1 (ex victoza) Inhibiteurs DPP-4 - qui dégrade GLP-1 (sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta) Inhibiteurs SGLT2 - protéine qui permet réabsorption tubulaire de glucose: canagliflozine (invokana)

Answer 55

Ajouter 3 de natrémie pour chaque augmentation de 10 de la glycémie

Answer 56

Pour chaque augmentation de pH de 0,1, la kaliémie augmente de 0,5

Answer 57

osmolarité \> 350 glycémie \> 33 svt atteinte fonction rénale sx neuro Acidose métabolique possible si acidose lactique par hypoperfusion ou atteinte rénale

Answer 58

increased cytoplasmic calcium concentration, leading to myocyte destruction, with the release of muscle components into the circulation. There are two primary mechanisms whereby calcium pathologically accumulates in the cell, direct cell membrane damage and ATP depletion Na+,K+-ATPase pump dysfunction leads to increased intracellular Na+, causing a temporary increase in Na+-Ca2+ exchanger function and resultant increase in intracellular Ca2+ 4 principes pathophysio de base 1. Impairment of the muscle’s production or use of ATP at the cellular level. ATP concentrations within the cell fall; energy-dependent mechanisms falter, including Na+,K+-ATPase pumps, leading to disruption of chemical gradients, sarcolemma and cell membrane compromise, and cell destruction. 2. Disruption in the delivery of oxygen, glucose, and other nutrients to skeletal muscle 3. Increases in metabolic demands beyond the ability of the organism to deliver oxygen and nutrients 4. Direct myocyte damage

Answer 59

Immobilisation prolongée Ischémie musculaire Activité musculaire intense Extrêmes de température (hypothermie, SNM, coup de chaleur, hyperthermie maligne) Électrisation aN électrolytiques: hyponatrémie, hypophosphatémie, hypokaliémie, hypernatrémie Drogues: LSD, opiacés, cannabinoides (par mécanismes divers) Médications: statine, antipsychotiques Infections: influenza A, legionnelle Myopathies héréditaires Maladie du tissu conjonctif / maladies autoimmune Toxines : serpent Hypothyroidie

Answer 60

Hyperkaliémie, hyperphosphatémie, hypocalcémie Hyperuricémie Acidose métabolique Hypercalcémie tardive ( par libération du calcium accumulé intracellulaire)

Answer 61

Wolff-Chaikoff : l'excès d'iode induit une inhibition de la libération d'hormones thyroidiennes (inhibition transitoire) Jod-Basedow: induction d'hyperthyroidie par excès d'iode chez pt avec goitre ou maladie de Graves

Answer 62

Maladie de Graves : AC anti récepteurs TSH - augmente la production/libération d'hormones Goître multinodulaires toxique: multiples nodules qui produisent les hormones , surtout femmes de plus de 50 ans Adénome toxique: nodule unique Thyroidite: + svt autoimmune, hashimoto Thyroidite post-partum: svt 3 phases; thyrotoxicose, hypothyroidie puis euthyroidie Thyroidite De Quervain ( ou subaigue): post viral, svt avec hypothyroidie au long cours, mais parfois thyrotoxicose initiale Thyroidite suppurative: infection aigue de la glande Thyroidite induite par Rx: amiodarone, lithium, trithérapie hyperthyroidie factice: prise d'hormones ou médicaments pour mai Hyperthyroidie subclinique: TSH diminuée, hormones N

Answer 63

Constitutional: Weight loss despite hyperphagia, fatigue, generalized weakness Hypermetabolic: Heat intolerance, cold preference, excessive perspiration Cardiorespiratory: Palpitations, dyspnea, dyspnea on exertion, chest pains, poor exercise tolerance Gastrointestinal: Nausea, vomiting, diarrhea, dysphagia Neuropsychiatric: Anxiety, restlessness, hyperkinesis, emotional lability, confusion, insomnia, poor attention Neuromuscular: Myopathy, myalgias, tremor, proximal muscle weakness (difficulty getting out of a chair or combing hair) Ophthalmologic: Tearing, irritation, wind sensitivity, diplopia, foreign body sensation Thyroid gland: Neck fullness, dysphagia, dysphonia Dermatologic: Flushed feeling, hair loss, pretibial swelling Reproductive: Oligomenorrhea, amenorrhea, menometrorhaggia, decreased libido, gynecomastia, erectile dysfunction, infertility Vital signs: Tachycardia, widened pulse pressure, bounding pulses, fever Cardiac: Hyperdynamic precordium, systolic flow murmur, prominent heart sounds, systolic rub (Means-Lerman scratch), tricuspid regurgitation, atrial fibrillation, evidence of heart failure Ophthalmologic: Widened palpebral fissures (stare), lid lag, globe lag, conjunctival injection, periorbital edema, proptosis, limitation of superior gaze Neurologic: Fine tremor, hyperreflexia, proximal muscle weakness Psychiatric: Fidgety, emotionally labile, poor concentration Dermatologic: Warm, moist, smooth skin; rosy cheeks, blushing face; fine brittle hair; alopecia, flushed facies; palmar erythema; hyperpigmented pretibial plaques, nodules, or induration that is nonpitting; onycholysis (Plummer’s nails, separation of the distal portion of the fingernail from the nail bed) Neck: Diffuse symmetric thyroid enlargement, sometimes with a bruit and palpable thrill; thyroid with multiple irregular nodules or a prominent single nodule; tracheal deviation, venous prominence with arm elevation (Pemberton’s sign

Answer 64

Hyperpyrexie Tachycardie importante Altération état conscience Insuffisance cardiaque Sx GI (avec atteinte fonction hépatique) facteur précipitant (svt avec atteinte thyroide préexistante): chirurgie, stress, trauma, accouchement, charge iodée, infection, SCA, EP, acidocétose...

Answer 65

Hyperthyroidie factice: thyroglobuline basse (p/r toutes les autres causes) et captation iode diminuée (comme thyroidite)

Answer 66

**β-Adrenergic Blockade** Propranolol 60–80 mg PO every 4 hours Metoprolol, 25–50 mg PO qid If IV route is required—propranolol, 0.5–1.0 mg IV slow push test dose, then repeat 1–2 mg every 15 min as tolerated to desired effect, then 1–2 mg every 3 hr ou Esmolol, 50–100 µg/kg/min infusion Strict contraindication to beta blocker—reserpine 2.5–5 mg IM every 4 hr **Inhibition of Thyroid Hormone Synthesis** Propylthiouracil, 500–1000 mg loading dose, then 250 mg every 4 hr or Methimazole, 60–80 mg/day in divided doses Preferred route, PO or nasogastric (NG); alternative route: PR (in rectum), enema prepared by pharmacy; same dose for all routes **Inhibition of Thyroid Hormone Release** Seulement après thionamides (peuvent augmenter production) Saturated solution of potassium iodide (SSKI, 50 mg iodide/drop), 1–2 drops PO or PR tid or Lugol’s solution (8 mg iodide/drop), 5–7 drops PO or PR tid or Sodium iodide, 500 mg IV bid in solution prepared by pharmacy or If allergic to iodine, lithium carbonate, 300 mg PO or NG qid **Administration of Corticosteroids** Inhibit T4 to T3 conversion; treat relative adrenal insufficiency. Hydrocortisone, 300 mg IV, followed by 100 mg tid or Dexamethasone, 2–4 mg IV qid **Diagnosis and Treatment of Underlying Precipitant** Consider empirical antibiotics if critical. **Supportive Measures** Volume resuscitation and replacement of glycogen stores D5/0.9 NS, 125– 000 mL/hr, depending on volume status and CHF Tylenol, with caution Cooling blanket, fans, ice packs, ice lavage **Miscellaneous** Lorazepam or diazepam as anxiolytic and to decrease central sympathetic outflow Cholestyramine (blocks enterohepatic recirculation of thyroid hormone), 1–4 g PO twice daily for severe or refractory thyrotoxicosis (surtout tx en externe) Considérer plasmaphérese ou dialyse **Conditions spéciales** **Thyroiditis (Subacute)** NSAIDs for inflammation and pain control Prednisone, 40 mg/day, if refractory to NSAIDs Beta blockade to control thyrotoxic symptoms No role for PTU, methimazole, or iodides **Factitious Thyrotoxicosis** Beta blockade for thyrotoxic symptoms Cholestyramine to block absorption of ingested thyroid hormone No role for PTU, methimazole, or iodides

Answer 67

Factors that may result in primary hypothyroidism include autoimmune disorders, infiltrative disorders, congenital thyroid dysfunction, pregnancy, radiotherapy, medications, infection, surgery, inadequate dietary iodine intake, thyroid medication noncompliance, and previous treatment of thyrotoxicosis. Hypothyroidism may also be associated with other autoimmune diseases, such as diabetes mellitus, pernicious anemia, Addison’s disease, and hyperparathyroidism. + fréquent: thyroidite d'hashimoto Lithium: inhibe libération T3 et T4 Amiodarone: inhibe conversion T4 en T3 En grossesse, augmentation TBG, donc diminution T4 libre. HCG ressemble à TSH, donc stimulation T3-T4 avec TSH abaissée. Augmentation métabolisme périphérique en grossesse

Answer 68

Vital Signs Systolic blood pressure, normal or low Diastolic blood pressure, normal or elevated Slow pulse to sinus bradycardia Respirations, normal or slow, shallow Temperature, normal, but prone to hypothermia with stress Hypometabolic Complaints Cold intolerance Fatigue Weight gain, but decreased appetite Cutaneous Coarse, brittle hair Alopecia Dry skin, decreased perspiration Pallor, cool hands and feet Coarse, rough skin Yellow tinge from carotenemia Thin, brittle nails Lateral thinning of the eyebrows Neurologic Slow mentation and speech Impaired concentrating ability and attention span Lethargy Decreased short-term memory Agitation, psychosis Seizures Ataxia, dysmetria Mononeuropathy Carpal tunnel syndrome Sensorineural hearing loss Peripheral neuropathy, paresthesias Muscular Proximal myopathy Pseudohypertrophy Delayed relaxation of reflexes (hung up or pseudomyotonic) Cardiac Decreased exercise capacity Dyspnea on exertion Sinus bradycardia Long QT with increased ventricular arrhythmia Chest pain, accelerated coronary disease Diastolic heart failure (delayed ventricular relaxation) Pericardial effusion (asymptomatic) Peripheral edema Respiratory Dyspnea on exertion Obstructive sleep apnea Primary pulmonary hypertension Gastrointestinal Constipation Ileus Gastric atrophy Reproductive Oligomenorrhea and amenorrhea Menorrhagia Decreased fertility Early abortions Decreased libido Erectile dysfunction Rheumatic Polyarthralgias Joint effusions Acute gout or pseudogout Head, Ear, Eyes, Nose, and Throat Hoarseness Deep husky voice Macroglossia Hearing loss Periorbital swelling Broad nose Swollen lips Goiter

Answer 69

Infection, sepsis (especially pneumonia) Exposure to cold Cerebrovascular accident Drug effect Altered sensorium—sedative-hypnotics, narcotics, anesthesia, neuroleptics Decreased T4 and T3 release—amiodarone, lithium, iodides Enhanced elimination of T4 and T3: phenytoin, rifampin Inadequate thyroid hormone replacement: noncompliance; interference with absorption (iron, calcium, cholestyramine) Myocardial infarction Gastrointestinal bleeding Trauma, burns Congestive heart failure Hypoxia Hypercapnia Hyponatremia Hypoglycemia Hypercalcemia Diabetic ketoacidosis **Présentation typique** Patient profile—older woman in the winter Known hypothyroidism; thyroidectomy scar Hypothermia—temperature usually \<95.9° F (36° C); \<90° F (32° C) is poor prognostic sign; as low as 75° F (24° C) reported; nearly normal in presence of infection Altered mental status—lethargy and confusion to stupor and coma, agitation, psychosis, and seizures (myxedema madness) Hypotension—refractory to volume resuscitation and pressors unless thyroid hormone administered Slow, shallow respirations with hypercapnia and hypoxia; high risk of respiratory failure Bradycardia (sinus), long QT and ventricular arrhythmias Myxedema facies—puffy eyelids and lips, large tongue, broad nose Evidence of severe chronic hypothyroidism—skin, hair, reflexes, bradykinesis, voice Acute precipitating illness (eg, pneumonia) Drug toxicity (eg, sedative, narcotic, neuroleptic) Hyponatremia

Answer 70

Protect airway, ventilatory support; monitor for alkalosis Fluid resuscitation 0.9 NS or D5/0.9 NS if hypoglycemia Watch for unmasking of CHF Thyroid hormone replacement T4 200–400 µg IV (give lower doses to patients who are smaller, have coronary artery disease or a history of arrythmia) loading dose Subsequent daily replacement of 1.6 µg/kg body weight PO, give 75% of this dose if given IV Hydrocortisone—100 mg IV every 8 hrs Hyponatremia Consider fluid restriction. Avoid hypotonic fluids; use only 0.9 NS or D5/0.9 NS. If \<120 mEq/L, consider 3% saline, 50- to 100-mL boluses. Passive rewarming Regular blankets; prevent heat loss If heating blankets are considered, pretreat with IV fluids and monitor blood pressure closely. Avoid mechanical stimulation. Treatment of any precipitating illness, with special attention to infectious causes

Answer 71

Zones du cortex : GFR

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