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Int Med B

Internal Med

Ankylosing spondylitis Pathophysiology Epi - M>F, W>AA, ?50% native Am; assoc with: uveitis, IBD, enthesitis, ?reactive arthritis
Ankylosing spondylitis Sx/Sx Schober test (+) (spine curve inc <5cm on flexion); LBP worsens with rest improved with activity
Ankylosing spondylitis DDx OA, psoriatic arthritis (fx DIPs; arthritis mutilans); reactive arth; infxn; vert fx; bony mets; onchronotic arthropathy
Ankylosing spondylitis DDx: reactive arth soon after infxn, no org isolated from affected joint (CT, Yersinia, S/S/C); usu heel or LBP; dactylitis (sausage digits); conjunctivitis, urethritis
Ank spondylitis Dx studies xray (bamboo spine); HLA-B27
Ank spondylitis Tx NSAIDs max dose; MTX; sulfasalazine; TNF-alpha inhib (Enbrel, Humira, Remicade); injxn of SI joint
Osteoporosis Pathophysiology Decrease in bone density with increased resorption that can be contributed to use of SSRI, postmenopausal
Osteoporosis Dx studies Image: DXA => overestimate taller and underestimate shorter person; CT for taller/shorter person; T score < -1 => osteopenia, osteoporosis, fx
Osteoporosis Labs: serum Ca+, phosphate, PTH are normal; Low vitamin D (need serum 25-hydroxyvitamin D)
Osteoporosis Tx Vitamin D/Ca => higher dose in winter/prolong hospitalization; Bisphosphonate (alendronate, risedonate) => inhibit osteoclast resorption; HRT; Calcitonin
Felty syndrome triad: RA, leukopenia, SM
Gout Pathophysiology monosodium urate crystal deposition; local trauma => crystal shedding => inflammation (complement, prostaglandins, leukotriene B4); Tophaceous; arthropathy; uric acid urolithiasis
Gout RFs: trauma, surgery, starvation, fatty foods/meat/seafood, dehydration, drugs (allopurinol, uricosuric agents, thiazide or loop diuretics, low dose aspirin, niacin, cyclosporine), familial, ETOH (low renal excretion)
Gout Sx/Sx 3 stages: Acute gouty arthritis, Intercritical (or interval) gout, Chronic recurrent and tophaceous gout. Severe pain, dusky redness, swelling; early attacks resolve in days/weeks; 80% involve single joint, often LE, 1st MTP (podagra)
Gout DDx CPPD (pseudogout), septic arthritis, Reiter’s, monoarticular RA, Lyme, sarcoid, cellulitis
Gout Dx studies Polarizing microscopy: intracellular needle shaped neg birefringent (yellow when parallel & blue when perpendicular, with red compensator); CPPD: pos birefringent rhomboid; often chondrocalcinosis on xray; tx NSAIDs/glucocorticoids
Gout Tx: acute gout: Ppx for attacks = colchicine, NSAIDs (usually indomethacin); uricosuric = probenecid; uric acid synth inhibitor = allopurinol (for long term if >3 episode/month), febuxostat
Gout Tx: Chronic gout: colchicines, NSAIDs, glucocorticoids (given when NSAID are CI)
Polyarteritis nodosa Pathophysiology prob multifactorial & immune complex mediated; systemic necrotizing vasculitis that typically affects medium-sized muscular arteries (sometimes smaller mx arts)
Polyarteritis nodosa Sx/Sx typically systemic sxs: kidneys (most commonly involved organ), skin, joints, mxs, nerves, and GI tract; SPARES LUNGS
Polyarteritis nodosa: Skin: tender erythematous nodules, purpura, livedo reticularis, ulcers, and bullous or vesicular eruption, usu on LE, may be edema
Polyarteritis nodosa Neuro sx: mononeuropathy multiplex (or asymmetric polyneuropathy) affecting named nerves (eg, radial, ulnar, peroneal), typically with both motor and sensory deficits; myalgia, weakness; may see wrist or foot drop; abd pain, n/v/melena
Polyarteritis nodosa DDx infxs dz affecting vasc (IE, mycotic aneurysm, hep B or C, HIV); other vasc mimics (atherosclerosis , embolic dz (L atrial myxoma, chol crystals), thrombotic d/o (antiphospholipid syndrome), fibromx dysplasia, ergotism, radiation fibrosis
Polyarteritis nodosa Dx studies ANCA is NEGATIVE in PAN; acute phase reactants elevated; also get Cr, mx enzymes, LFTs, HBV / HCV, UA ; get CXR & blood cx to exclude other vasculitides; Tissue bx (medium art inflammation in renal bx is pathognomonic); arteriography and x-section imaging
Polyarteritis nodosa Tx glucocorticoids; may also require cyclophosphamide
Polymyositis Pathophysiology idiopathic; mx fiber necrosis, degeneration/regeneration, inflam cells invade mx fibers (scattered thru fascicle); increased CD8+ cells, enhanced MHC Ag expression
Bohan & Peter criteria: for: Polymyositis; prog proximal UE, LE, neck mx weakness; high mx enzymes; myopathic changes on EMG; mx bx abnml & absence of histopath sxs of other myopathies;
Polymyositis S/S Bohan-Peter; also: 25% dysphagia; CO2 retention 2/2 resp mx weakness; myalgias; mechanic’s hands
Polymyositis DDx giant cell arteritis; DM (Gottron’s papules, shawl sign, heliotrope rash, generalized erythroderma); inclusion body myositis, MG, ALS, HIV, MD, hypothyroid
Polymyositis Dx studies inc CK, LFTs, ANA; myositis-specific Abs (anti-Jo-1, anti-SRP, anti-Mi-2); mx bx (endomysial inflam), EMG (inc insertional activity / spont fibrillations; abnl myopathic low amp, short–duration polyphasic MPs, complex repetitive discharges); MRI
Polymyositis Tx corticosteroids (alt: azathioprine, MTX)
Carpal tunnel syndrome Pathophysiology Compression of median nerve; from repetitive movement or injury
Carpal tunnel Sx/Sx Burning, tingling pain worsened with activity; worse at night; may radiate to the forearm and also to neck and shoulder; (+) Tinel and Phalen (tingling in fingers after 30 seconds)
Carpal tunnel Tx Splinting for 2-6 weeks with NSAID; if worsens: corticosteroid injection or surgery
Low back pain Sx/Sx SLR (L4-L5), sensation (L5-S1 determines neurologic deficit), examine decreased ROM
LBP DDx lumbar strain (improves in 1-4 wks), OA, disk hernia (radn to leg 2/2 n. root impinge), Ao aneurysm, mets (night pain; prostate, Br, lung, lymphoma); ank spond; cauda equina (b/l leg weak, bowel/bladder); hip arth (can => LBP, buttock or groin pain)
LBP Dx studies Plain film good for locating infection, cancer, fracture
LBP Tx NSAID + education + yoga (best); Opioid: severe pain and for only 1-2 weeks; Diazepam, cyclobenzapine, carisoprodol=muscle relaxant (1-2 wk); Epidural corticosteroid: short term relief only, ineffective for chronic
Osteoarthritis (DJD) Pathophysiology Joint dz of aging w/ degeneration of cartilage / hypertrophy of bone at articular margins; Obesity is RF for hip and knee
Osteoarthritis Sx/Sx Insidious onset, worsened with activity/wt bearing and better with rest; crepitus; limited ROM; joint enlargement is bony hard and cool (spongy and warm in RA)
OA Dx studies Imaging shows narrow joint space with sharp articular margin, osteophyte formation, and dense subchondral bone
OA Tx Weight reduction and vitamin D; acetaminophen for mild dz; NSAIDs for those not responsive to acetaminophen; corticosteroid injection
Fibromyalgia Sx/Sx Present with MS pain w/multiple tender points, fatigue, HA, IBS, numbness; Pain / stiffness all over but worse in neck, shoulder, low back, hips
Fibromyalgia Tx amitriptyline, fluoxetine, pregabalin, and cyclobenzaprine: modest efficacy. Exercise has some benefits; NSAIDs, tramadol+APAP (Ultracet), opioid & csteroid ineffective
Myasthenia gravis Patho autoimmune; hyperplastic germinal centers in thymus which has clusters of myoid cells expressing AChR; Ab’s to AchR or MuSK
Myasthenia gravis Epi may be assoc w/thymic tumor or thyrotoxicosis; most common females w/HLA-DR3 (or men w/thymoma)
Myasthenia gravis Sx/Sx fluctuating weakness/fatigability of voluntary mx (diplopia, ptosis, difficulty swallowing); resp difficulty, limb weakness (worsened w/activity); bulbar sxs (dysarthria, dysphagia, fatigable chewing)
Myasthenia gravis DDx motor neuron dz, LEMS, botulism; thyroid ophthalmopathy; chronic progressive external ophthalmoplegia; myotonic dystrophy / oculopharyngeal dystrophy; brainstem and motor CN pathology
Myasthenia gravis Dx studies edrophonium test; NCS (decrementing response); EMG (jitter, variability); high serum Ach Ab or MuSK Ab
Myasthenia gravis Tx short-acting acetylcholinesterases (neostigmine, pyridostigmine), poss csteroids; avoid exacerbating meds (aminoglycosides); poss thymectomy
Parkinson dz Pathophysiology DA depletion from basal ganglia (extrapyramidal) 2/2 nigrostriatal system degen => disruptions in connections to thalamus / motor cortex => parkinsonian sxs (TRAP)
Parkinson RF nonsmokers, lack of exercise
Parkinson Sx/Sx TRAP: resting, pill rolling tremor, rigidity, akinesia/bradykinesia (shuffling/festination), postural instability; poss dementia, psychosis, mood d/o; masked facies, scalp seborrhea; Myerson sign (tapping on bridge of nose elicits sustained blinking)
Parkinson DDx multi systems atrophy, essential tremor, Lewy body, PSP, drug induced
Parkinson Dx studies response to DA tx; MRI?
Parkinson Tx sxs: levodopa or C-L (Sinemet); MAO B inhib (selegiline, rasagiline); DA (Mirapex, requip, rotigotine, apomorphine); COMT inhib (tolcapone, entacapone)
TIA Pathophysiology AHA/ASA defn: transient episode of neuro dysfn 2/2 focal brain, spcord, or retinal ischemia, w/o acute infarct; often 2/2 embolizn; mechm: Lg artery low-flow TIA; embolic (artery-to-artery, or 2/2 cardioaortic); lacunar
TIA Sx/Sx if carotid: contra weakness & heaviness (arm, leg, face); vertebrobasilar: vertigo, ataxia, diplopia, dysarthria, paresthesia on 1 or both sides;
TIA DDx seizure, migraine aura, syncope/hypoglycemia
TIA Dx studies ABCD2 score: age (>60), BP (>140/90), clinical (uni weakness, speech), duration, DM; CT, MRI, EKG; poss CTA, MRA, u/s
Hospitalize for 1st TIA if: within past 24-48 hrs; crescendo TIAs; sxs >1 hr; symptomatic ICA stenosis >50 percent; cardiac source of embolus (A fib); hypercoagulable state; high risk of early stroke after TIA
TIA tx: anticoag if TIA 2/2 cardiac embolus; prevention of future stroke; ASA if noncardiac
GAD Sx/Sx apprehension, worry, irritability, difficult concentrating, insomnia, somatic complaints; poss tachy, GI (n/v, epigastric), neuro (HA, syncope); somatic sxs (fatigue, mx tension, memory loss, insomnia)
GAD Dx studies to r/o other: cbc, chem, thy, ua, uds, ekg
GAD - usually comorbid: phobia, social phobia, panic d/o, depression
GAD RF FH, stressful events, h/o abuse; sub abuse, med AEs
GAD Tx Firstline: SSRI (parox, sert, cital); 2ndline: TCA (imipramine) or benzo [xanex, valium (used more, absorbed faster); flumazenil: for benzo OD (antagonist)] or buspar ( GI symptoms and dizziness); often with CBT
GAD Tx algorithm: SSRI => other SSRI => SNRI => TCA or other
Somatoform disorder RF F>M, low SES, ethnic minority; FH, childhood abuse
Somatoform disorder Types conversion; somatization d/o; hypochondriasis; factitious
Somatoform disorder Tx Schedule reg visits; collaborative, tx alliance; acknowledge sxs; eval/tx med dz; limit dx tests/referrals; reassure dz r/o; assess pt for psych/sub abuse; set tx goal= fnl improvemt; poss LD SSRI for hypochondriasis or BDD; avoid opioids
Mood disorder Pathophysiology internal factors (devt probs, neurotic), ext factors [genetic (neurotransmitter dysfn)], adversity/psychosocial stresses
MDD Neurotransmitters Monoamines (serotonin, norepinephrine, and dopamine), GABA, glutamate
MDD Sx/Sx Depressed mood, anhedonia, insomnia, wt change, withdrawal from activities, low energy, poor concentration, thoughts of worthlessness or guilt, recurrent thoughts about death or suicide
MDD DDx schizo, seizure, organic brain syndrome, panic d/o, anx d/o
MDD Depression assoc with: panc, lung, brain ca; cushing; hypothyroid, PD, stroke, Huntington dz
MDD Dx studies 5 item Geriatric Depression Scale; 2 item scale; PHQ-9; Beck Depression Inventory
MDD Tx Pt educ; tx w/ psychotherapy will take months; SSRI [Prozac, Effexor (long acting SNRI)]; TCA; MAOIs; antipsychotics; mood stabilizers; anxiolytics; poss hospitalization if suicide risk
MDD AE HA, n/v, insomnia, nervousness; HD or w/MAOI (selegiline)  serotonin syndrome (rigidity, hyperthermia, myoclonus, delirium, coma)
Somatoform: conversion d/o neuro sxs w/o neuro prob
somatization d/o preoccupation with physical sxs; numerous sxs in multiple organ systems, tend to be migratory; dramatic, demand med attention; CP, pseudoneurologic, GI, GU, sexual c/o
Alcohol dependence Pathophysiology EtOH is NMDA antagonist, GABA receptor facilitator, metabotropic glutamate receptors involved; assoc w/small amygdala, hippocampus, ventral striatum
Alcohol dependence Epi lifetime prev 12%, M>F, high M
Alcohol dependence Sx/Sx tremulousness, elevated BP, rhinophyma (bulbous ruddy nose), telangiectasias, tachycardia, HSM, peripheral neuropathy, evidence of physical trauma
Alcohol dependence Dx studies macrocytosis +/- anemia, high LFTs/GGT, carbohydrate deficient transferrin
Alcohol dependence Screen AUDIT, CAGE; at risk: >14/4 drinks (M), >7/3 (F)
Alcohol dependence Tx psychotherapy (CBT), hosp, pharma (naltrexone, oral or depot; acamprosate; disulfiram; possibly topiramate, baclofen, opiate agonist Nalmefene)
Tobacco use/dependence M 440k US deaths/yr (1 in 5); M>F, CV, COPD, lung ca, higher risk of oral, throat, esophagus, panc, kidney, bladder, cervical ca; stroke, PUD; hip/back fx
Tobacco use/dependence Tx screening, in-person counseling; pharma: patch, gum, lozenge, inhaler; bupropion (AE: reduces seizure threshold); varenicline (Chantix)
Psoriasis pathophysiology immune-mediated: T lymphs & dendritics; hyperprolifn & abnml diff of epidermis + inflam cell infiltrates & vasc changes => erythema and scaling: shortened cell cycle time for keratinocytes (36 hr vs 311 hr nl skin); dec epidermis turnover time
Psoriasis Epi / RF genetic/environ; RF: FH, smoking, high BMI, EtOH; Comorbids: coronary art calcification/MI, malig
Psoriasis: some meds may worsen: beta blockers, antimalarials, statins, lithium
Psoriasis: Sx/Sx erythematous papules / plaques w/silver scale; palmoplantar pustulosis; Koebner phenom (plaques at site of trauma)
Psoriasis: types Plaque (most common), Guttate (eruptive; abrupt appearance of multiple lesions), Pustular, inverse, Nail, and erythrodermic psoriasis.
Psoriasis DDx SLE, pityriasis rosea, seborrheic dermatitis, mycosis, onychomycosis, SCC, actinic keratosis, eczema, lichen planus
Psoriasis Tx: mild-moderate Pt Education; mild-mod: topical (emollients, steroids, vit D analogs, calcineurin inhibs/tacrolimus, UV light)
Melanoma Pathophysiology devt: neural crest => melanocytes => nevi => junctional nevus => compound nevus (radial growth phase, usu curable by excision); melanoma may migrate beyond basement mem, poss vertical growth phase (less often curable)
Invasive melanoma subtypes: superficial spreading (75%); lentigo maligna (sun-damaged areas in older pts, begins as a freckle-like tan-brown macule); Acral lentiginous (palmar, plantar, subungual, & mucosal surfaces); nodular. Mets to lung, brain
Melanoma Epi leading cancer COD (8100), 60,000 new cases/yr in US
Melanoma RFs FH, atypical nevi, high nevus count
Melanoma Sx/Sx ABCDE (asymmetry, border, color, diameter >6mm, evolution)
Melanoma DDx nevus, seb keratosis, BCC, actinic keratosis, dermatofibroma
Melanoma Dx studies dermoscopy, skin bx
Melanoma Tx excision w/wide margins; poss adjuvant tx (interferon-alpha); if mets: IL-2
Cellulitis Pathophysiology GABHS & SA; often lower legs
Cellulitis Sx/Sx pain, chills, fever; edematous, diffuse erythematous spreading infxn of dermis/subQ, warm plaque +/- vesicles/bullae
Cellulitis DDx DVT, necrotizing fasciitis, gas gangrene, toxic shock syndrome, bursitis, osteomyelitis, herpes zoster, erythema migrans
Cellulitis Dx studies high WBC, poss + blood cx
Cellulitis Tx IV abx, cover SA & GABHS; clinda, TMP-SMZ, doxy, or linezolid; if suspect CA-MRSA: vanc, clinda, or TMP-SMZ + beta-lactam
VZV Pathophysiology Develop immunization with chickenpox (varicella) and shingles (herpes zoster); Body builds antibodies and loses it => need vax; Remains dormant in cranial nerve and become herpes zoster
VZV Sx/Sx Fever, pruritic rash; form pustules then crusts after 7-14 days; Shingles affect dermatome with similar pustules as varicella
Hutchinson sign VZV; involve trigeminal nerve => eye and nose
Ramsay Hunt VZV; affect external ear, facial palsy, and geniculate
VZV Tx acyclovir for non complication; Tx w/TCA, opioid and capsaicin for complicated; Live attenuated VZV vaccine to 60+
Psoriasis Tx mod-severe: Pt Education; systemic (phototx, MTX (folate inhib)(watch liver tox), retinoids, calcineurin inhibs/cyclosporine, anti-TNF agents: adalimumab/Humira, etanercept)
Aplastic anemia Pathophysiology diminished/absent hematopoietic precursors in BM, usu 2/2 stem cell injury
Aplastic anemia Etio congenital (Fanconi); more commonly acquired [drugs (chloramphenicol, antiseizure, sulfonamides, nifedipine), chem, rad, virus]
Aplastic anemia Sx/Sx fatigue, cardiopulmonary compromise; recurrent infxn (invasive fungal infxn common COD), mucosal hemorrhage & menorrhagia; pallor, petechia; NO HM/SM/LA
Aplastic anemia DDx leukemia, MDS, megaloblastic anemia, PNH, HIV infxn, viral hemophagocytic syndrome
Aplastic anemia Dx studies CBC: pancytopenia, RBC usu normo / macro; BM bx: hypocellular (fat cells & stroma), no malig/infiltration/fibrosis
Aplastic anemia Dx criteria: Moderate (<30% normal cellularity), severe (<25%), very severe (Severe + WBC <2)
Aplastic anemia Tx better prognosis if younger & higher baseline cell counts; <20 yo: hematopoietic cell txp (HCT); 20-45 yo: HCT if donor, or immunosuppressive tx (IST): ATG +/-cyclosporine; >45yoL IST
Coag disorder Pathophysiology Factor XIII def (hemophilia A); Factor IX def (hemo B, Xmas); both x-linked recessive
Coag disorder Sx/Sx petechia, ecchymoses, menorrhagia; sites of bleeding: CNS, hemarthrosis (from synovial vessels, within joint cavity), skeletal mx, head & neck, GI, GU, posttraumatic bleed
Coag disorder DDx drug-induced, von W (Pos ristocetin cofactor test)
Coag disorder Dx studies Dz severity: Severe <1% factor activity, Mod 1-5%, mild >5%. Dx: FH,
Coag disorder Labs: hemo A, B, heparin, factor VIII def: nl plt & PT, long aPTT
Coag disorder Tx factor replacement tx; desmopressin, antifibrinolytic tx; for hemarthrosis: steroids to target joints
Leukemia Sx/Sx fatigue, wt loss, fever, pallor, ecchymoses, petechia, dyspnea, dizziness, palps, recurrent infxns
ALL Pathophysiology lymphoid neoplasm; precursor B-cell ALL arises from precursor B cells at varying stages of differentiation
ALL Epi 80% kids; 10-20% of adult leuk; T or B lymph
ALL RF h/o malig, prior chemo, exp to rad/toxins, smoking, genetics, FH
ALL Sx/Sx leukemia S/S, HM/SM/LA
ALL DDx precursor B Cell ALL vs precursor T Cell ALL (dx by immunophenotypic analysis)
ALL Dx studies BM aspirate +/- bx: >20% blasts; CBC: pancytopenia, hyperleukocytosis (>200k)
ALL Tx aggressive chemo (2 yrs: induction, consolidation, & maintenance phases): induction tx (anthracyclines, cyclophosphamide, asparaginase, prednisone, CNS ppx); BM transplant
CLL Pathophysiology lymphoid neoplasm; 60% cases, 40%, derived from naive B cells; CLL lymphs are clonal B-cells arrested in the B-cell differentiation pathway between the pre-B-cell and mature B-cell
CLL Epi most common leukemia (30%), usu >50 yo, M>F
CLL Sx/Sx usually indolent growth
CLL DDx 25% Asx; night sweats; freq infxns; wt loss; LA
CLL Dx studies RAI system for staging; high WBC/lymphs, smudge cells; HM/SM/LA
CLL Tx Chemo (FCR), BMT; XRT for bulky LA; surg for dx only
AML Pathophysiology may be assoc w/toxins (benzenes, rad, chemo)
AML Sx/Sx similar to ALL; HM/SM
AML Dx studies smear: Auer rods; high ESR
AML Tx Chemo:; induction + 3 consolidation; BMT; tumor lysis ppx (allopurinol)
CML Pathophysiology slow progressing, too many myeloid WBCs produced in BM; 3 phases: chronic, accelerated, acute/blast crisis (>30% of BM cells are blasts); poss 2/2 radiation exp
CML Epi 20% of leukemia; median age 42
CML Sx/Sx fever, bone pain, SM/LUQ pain, night sweats
CML Dx studies Phila chromosome (FISH for bcr/abl: quantitative; RT-PCR for bcr/abl: qualitative); WBC 170,000; low plt
CML Tx allo BMT; Gleevec
HL Pathophysiology arises from germinal center or post-germinal center B cells. Nodular sclerosing (80%, esp in younger), lympho-predominant, or mixed cellularity; assoc w/EBV; enlargement of lymphoid tissue, spleen, liver
HL Epi Incidence 7900; 20-40 yo and >50 yo; usu M 15-45 yo; FH
HL Sx/Sx Painless cervical , SC, mediastinal LA; constitutional B sxs: fever, night sweats, wt loss; SOB common with mediastinal mass
HL Dx studies CT of chest, abd, pelvis; PET; BM bx: Reed-Sternberg cells (bilobed nuclei)
HL Tx chemo (ABVD), then XRT
NHL Pathophysiology arise from cells in lymphoid tissue (90% B lymph); types: Follicular, Burkitt, Diffuse lg b-cell, Marginal zone, Cutaneous T-cell, anaplastic large cell
NHL Sx/Sx Painless LA (abd, retroperitoneal); B sxs: fever, night sweats, wt loss; abd pain, n/v, bleeding, edema; bulky LA → jaundice, hydronephrosis, SVC syndrome, SBO, wasting
NHL Dx studies CBC usu normal; LDH is tumor marker; CT of chest, abd, pelvis; PET; BM bx
NHL Tx depends on type/grade: watch&wait to chemo (Rituxan-CHOP, R-ICE) +/- XRT; tumor lysis ppx; poss BMT
Multiple myeloma Sx/Sx fatigue, anemia, bone pain (2/2 lytic lesions), recurrent infxn
Multiple myeloma Dx studies Triad: plasmacytosis, M spike on SPE, lytic lesions on xray; also CBC: anemia, rouleaux; Bence-Jones pro in urine; high Ca, renal fail
Multiple myeloma Tx Chemo (VAD, DVD); auto BMX
Lone star vector: Ehrlichia
Maltese cross on microscopy Babesia microti (Parasitic): significant in asplenia
Lyme dz Pathophysiology Borrelia (spirochete); deer have complement that clear infxn; deer amplify tick population; Ixodes (black leg tick); most transmission to humans, esp in spring/June-July; young males
Lyme Sx/Sx erythema migrans (target); neuroborreliosis; arthralgia/arthritis; AV block & myocarditis & pericarditis
Lyme Dx studies Step 1: ELISA or IFA; step 2: western blot
Post-Lyme syndromes MS pain, neurocog impairment, poly neuropathy, fatigue
RMSF Pathophysiology a few (10) orgs can be infxs; inc inoculation dose = dec incubation time
RMSF: vector Am dog tick (Dermacentor); brown dog tick
RMSF Sx/Sx rash; Multisystemic dz; usu mod-severe; 4-10 d (usu 7d); fever, HA, malaise, myalgia
RMSF rash rash on day 3-5: 5-15% pts; maculopapular, then petechial & defined; centripetal: starts on limbs, moves to trunk
RMSF DDx meningiococcemia, TSS, scarlet fever, leptospirosis, viral exanthem, other tick-borne
RMSF Dx studies Plt<150, dec Na, inc BUN, mild inc ALT/AST; IFA titer >1:64; CSF: mononuclear cell pleocytosis; elevated protein, normal glucose
RMSF Tx doxy 100mg PO BID x5-7 days (alt: chloramphenicol)
Ehrlichiosis Small obligate GNR; blood smear: morula (berry-like); pathognomonic (but low sensitivity)
Sarcoidosis Sx/Sx Bilateral hilar LA, Pulmo reticular opacities; Skin, joint, +/- eye lesions (uveitis); malaise, fever; unknown etio
Sarcoidosis Dx studies bx: noncaseating granuloma; high ACE level
Sarcoidosis Tx glucocorticoids
SLE s/s presenting sx often fatigue, wt loss, fever; myalgia, Raynaud, renal/GN, pericarditis, malar & discoid lesions; arth, swan neck deformity, osteonecrosis
Created by: Adam Barnard Adam Barnard