Internal Med
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| Bronchogenic carcinoma CXR | Solitary nodule (coin lesion): <3cm; malig: spiculated margins, periph halo, cavitary lesions w/walls >16mm; alig, ctrl calcification usu benign; CT any suspicious nodule
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| Bronchogenic carcinoma Tx | 1st: review prior CXR (estimate doubling time: <30 d is prob infxn, >465 d prob benign); routine screening no mort benefit); LDCT > CXR
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| Bronchogenic carcinoma mgmt | Low prob: watchful waiting; intermediate prob: bx (bronch lower yield for <2cm, fewer comps, TTNA higher yield, more comps), poss PET or VATS; high prob: staging & resection
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| Carcinoid tumors Sx/Sx | cough, hemoptysis, focal wheezing, recurrent pna; diarrhea, flushing
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| Carcinoid tumors DDx | asthma; other carcinoid syndrome: IBS, Crohn, menopause
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| Carcinoid tumors Dx studies | fiberoptic bronch: pink/purple tumor in central airway w/well vascularized stroma; CT to localize; urine 5-hydroxyindoleacetic acid, serum chromogranin A/B
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| Pulmonary embolism Pathophysiology | thrombi from DVT, usu iliofemoral vein; causes hypotension (SBP <90 mmHg or drop in SBP of ≥40 mmHg from baseline for >15 min; may be saddle PE (at bifurcation of L/R PA)
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| PE Sx/Sx | May be Asx; dyspnea, pleuritic pain, cough, orthopnea, calf or thigh pain/swelling, wheezing; tachypnea, tachycardia, rales; decreased breath sounds, loud P2, JVD
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| PE Dx studies | CXR; d-dimer (high NPV); V/Q scan; CT pulmo angiography; Wells criteria
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| Common sequela of PE | pulmonary HTN
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| Pulmonary hypertension pathophys | diffuse narrowing of pulmo arterioles; Mean PA pressure >25 mmHg at rest, and secondary RV fail
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| PPH plexogenic pulmonary arteriopathy: | medial hypertrophy, intimal proliferation and fibroelastosis, and necrotizing arteritis.
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| PAH Etio | (Group 1-5 ); Idiopathic PAH (sporadic & hereditary)(young women), drugs/toxins, CTD, HIV, portal HTN, congenital heart dz
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| PAH Sx/Sx | dyspnea, cyanosis; loud palpable P2, narrowly split or single S2; SEM or diastolic pulmonic regurg w/inspiration; RV 3rd ht sound, RV heave, JVD w/V wave; poss HM, ascites, pleural effusion
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| PAH DDx | PE, COPD, ILD, OSA, pickwickian, CTD/scleroderma, HAPE, P vera
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| PAH Dx studies | CXR (RVH, lg PAs), EKG (RAD, RVH, RBBB), echo, PFT, overnight oximetry, PSG, V/Q scan (confirmed by pulmo angiography)
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| PAH Tx | underlying cause; diuretic, O2, anticoag, digoxin, exercise tx; Group 3: O2 tx, NOTT trial; Grp 4: anticoag. Meds: CCBs, prostanoids (epoprostenol), endothelin receptor antagonists, transplant
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| Cor pulmonale Pathophysiology | Altered RV 2/2 pulmo HTN 2/2 dz; Pulmo vasoconstriction (2/2 alveolar hypoxia or blood acidosis); Anatomic reduction of pulmo vascular bed (emphysema, PE); Inc blood viscosity (polycythemia, SCD); inc pulmonary blood flow
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| Cor pulmonale Most frequent cause: | COPD 2/2 chronic bronchitis or emphysema.
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| Cor pulmonale Sx/Sx | Fatigue, lethargy, exertional syncope / angina; cough, wheeze, hemoptysis, hoarse (recurrent laryngeal n.); anorexia, RUQ pain (2/2 passive hepatic congestion 2/2 RV fail); loud P2, parasternal lift, tricuspid regurg, JVD, edema, HM, ascites
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| Cor pulmonale Dx studies | polycythemia, CXR (lg pulmo arts), EKG (RAD, RVH, big P wave in II), echo, PFT, R ht cath, radionuclide ventriculography, lung bx
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| Cor pulmonale Tx | O2, salt & fluid restriction, diuretics
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| Bronchiectasis Pathophysiology | local parenchymal collapse; irreversible dilation of part of bronchial tree 2/2 mx & elastic tissue destruction
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| Bronchiectasis requires | (1) an infectious insult and (2) impaired drainage, airway obstruction, or a defect in host defense -> transmural inflam, edema, cratering, airway neovasc -> permanent abnl bronchi dilatation / destn
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| Bronchiectasis Etio | obstruction (FBO), defective host defenses, CF, Young syndrome, rheumatic & systemic dz, dyskinetic cilia, pulmonary infxn, allergic bronchopulmonary aspergillosis (ABPA), smoking
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| Bronchiectasis Sx/Sx | cough, daily mucopurulent sputum; dyspnea, wheezing, recurrent pleuritic CP, rhinosinusitis, hemoptysis, crackles, urinary incontinence; digital clubbing uncommon
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| Bronchiectasis Dx studies | CBC, Ig quant, sputum C&S, serum alpha-1 antitrypsin (S or Z alleles and MM phenotype = alpha-1 antitrypsin def↓); PFTs
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| Bronchiectasis CXR: | obscured hemidiaphragm, thin-walled shadows, linear atelectasis, dilated/thickened airways (ie, tram or parallel lines, ring shadows on cross section), irregular ovoid peripheral opacities (= mucopurulent plugs)
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| Bronchiectasis Hi-res chest CT: | thick dilated airways +poss air-fluid levelsl tree-in-bud pattern.
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| Bronchiectasis tx | treat exacerbations: resp FQ +/- tobra; prevention: Ppx Abx (daily cipro or macrolide; 3 problematic orgs: PA, MAC, Aspergillus spp). Bronchial hygeine, hydration & mucus clearance; chest PT; surgery.
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| COPD RF | smoking, BMI<21, HIV, increased airway bacterial load, high CRP, decreased exercise capacity, male
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| COPD Sx/Sx | hyperinflation, decreased breath sounds, wheezes, crackles at lung bases, and/or distant heart sounds; diaphragm depressed /ltd motion; inc AP diameter of chest
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| End stage COPD s/s | Hoover sx (paradoxical retraction of lower interspaces during inspiration), tripod, accessory resp mx use, cyanosis, asterixis due to severe hypercapnia, enlarged, tender liver due to right HF
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| Chronic bronchitis | prod cough for 3 mos in 2 successive yrs
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| COPD Dx studies | GOLD criteria (I-IV: 30-50-80%); BODE index (BMI, FEV1/ obstruction, dyspnea, exercise capacity)
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| COPD Tx | SABA (& anticholinergics); LABA (salmeterol/Serevent, formoterol/Foradil); ICS (fluticasone/Flonase/Flovent, budesonide); Refractory: triple inhaler tx; systemic steroids; poss surgery for emphysema
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| Most common type of ILD | Idiopathic pulmonary fibrosis (epi >40 yo)
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| IPF RF | smoking, infection, environmental pollutants, chronic aspiration, and drugs
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| IPF DDx | other lung dz: drug-related, environmental, infxn, ARDS, amyloid, sarcoid, goodpasture, Wegener, pulmo edema (DDx for ILD: CHF, asthma, COPD)
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| IPF Dx studies | PFT = restrictive LD; CXR, hi-res CT (diffuse patchy fibrosis w/honeycombing), may req surg bx
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| Hyperthyroid Sx/Sx | sweating, heat intolerance, moist skin, fine thinning hair; stare/lid lag; poss cardiac (A-fib or atrial tachy); bone changes (high serum Ca, low PTH, clubbing); irritability; wt loss, loose stool, SOB; fine resting tremor, hyperreflexia
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| Graves S/S: | ophthalmopathy (exophthalmos, eye mx impairment, periorbital edema) & pretibial myxedema (nonpitting scaly thickening, orange-peel)
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| Hyperthyroid Dx studies | low lipids, high glucose, high alk phos, n/n anemia, poss prothrombotic
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| Hyperthyroid Tx | Graves: beta blocker for sxs; thionamides (methimazole, PTU); ablation (radioiodine or surgery)
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| Hypothyroid Dx studies | Primary (95%): high TSH (>5 mU/L), low FT4 (subclinical: high TSH, normal FT4); Central/Secondary: normal TSH, low FT4
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| Thyroiditis With thyroid pain/TTP | Subacute (granulomatous / de Quervain), infxs, radiation-induced, or trauma-induced thyroiditis; 2/2 viral infxn or postviral inflam process, often h/o URI (eg, coxsackie) & assoc w/HLA-B35.
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| Thyroiditis Without thyroid pain/TTP | [variant of hashimoto]: painless (silent) thyroiditis; postpartum, drugs (interferon, IL-2, lithium); fibrous (Riedel)
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| Thyroiditis Sx/Sx | painful: hyper (neck pain, tender diffuse goiter, high T4 and/or T3).then hypo, then recovery; infxs: abrupt neck pain/TTP, f/c, unilateral fluctuant neck mass
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| Thyroiditis Tx | Painful: anti-inflammatory (prednisone, ibuprofen); painless: poss beta for sxs; if TSH>10 during hypo phase, T4 replacement; Infxs: drain, Abx; Riedel: prednisone for sxs
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| Thyroid neoplasm classification | Papillary (75%): MAPK pathway gene mutations; Follicular (ca of thy epithelium; MIFC & WIFC growth patterns; RAS & PPAR-gamma mutations); Anaplastic (5%, undifferentiated, very aggressive) cancer
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| Thyroid neoplasm Sx/Sx | anaplastic: rapidly enlarging mass, bilateral asymmetric thy enlargement (poss dyspnea, dysphagia, hoarse, cough); anorexia, weight loss, fatigue, FUO
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| Thyroid neoplasm Dx studies | thy labs; U/S & FNA (FNA bx dx papillary but not follicular, which req path dx); For recurrence; U/S most sensitive
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| Thyroid neoplasm Tx | Surgery (primary tx for differentiated thy ca): usu uni lobectomy; RI tx; levothyroxine tx (T4 replacement & prevent TSH stim of thy); external beam RT for ca w/mets; For anaplastic: local resection if poss, aduvant tx (rad, CT: doxorubicin/cisplatin)
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| Cushing syndrome Pathophysiology | ACTH dependent (85%): pit adenoma or corticotroph hyperplasia/ ectopic ACTH secretion; ACTH independent(15%): iatrogenic/factitious (most common); adrenocortical adenomas / carcinomas
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| Cushing Etiology | PG 3rd tri, stress, gym rats, depression, EtOH/withdrawal, anorexia, panic dz
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| Cushing Sx/Sx | Centripetal obesity, facial plethora, glucose intolerance, HTN, weakness, proximal myopathy/mx wasting; moon face, buffalo hump, purple striae, hirsutism; osteoporosis; poor wound healing; psych changes
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| Cushing DDx | obesity, metabolic syndrome; EtOH, GHB, depression
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| Cushing Dx studies | firstline: late night salivary cortisol (>0.25 abnl), urinary cortisol, LD dex suppression test (abnormal is >1.9 mcg/dL); midnight serum cortisol >7.5 mcg/dL; also 24 hr urinary cortisol; high wbc, low lymphs, low K+
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| Cushing Tx | transsphenoidal resection of pit adenoma, then 1-3 yrs steroid replacement tx. Alt: gamma knife rad tx (23% cure rate)
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| Cataracts Pathophysiology | opacity of lens causes blindness; prob assoc w/photo-oxidative insult to stratified epi cells in matrix that have high cytoplasmic protein (crystallin) content
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| Cataracts RFs | >60 yo, smoking, EtOH, sunlight exposure, low education, malnutrition, physical inactivity, metabolic syndrome, DM, systemic corticosteroid use
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| Cataracts Sx/Sx | painless, progressive decline in vision; 3 components: nuclear sclerosis, cortical spoking, posterior subcapsular haze
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| Nuclear cataract characteristics | progresses very slowly, usu affects distant vision
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| Posterior subcapsular cataract causes: | disabling glare in bright light
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| Cataracts Dx studies | nondilated fundus exam: lens opacity, poss darkened red reflex, opacities within red reflex, or obscuration of ocular fundus detail. Slit lamp exam: opaque nucleus; “mature cataract” = when red reflex has been lost
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| Cataracts Tx | prevention (diet: lutein & zeaxanthin; vitamins: beta-carotene, C, E; stop smoking); outpatient microsurgery; Post-op: steroid eye drops, NSAID eye drops (ketorolac)
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| Macular degeneration Pathophysiology | degenerative dz of central portion of retina (macula) that results primarily in loss of central vision; dry (atrophic) or wet (neovascular or exudative)
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| Macular degeneration Poss etio | Dry: RPE ischemia or apoptosis; Wet: choroidal neovascularization
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| Macular degeneration Sx/Sx | early is Asx; Dry: gradual vision loss in one or both; Wet: acute visual distortion, usu unilateral
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| Macular degeneration Dx studies | Amsler grid: Wet = distortion of straight lines. Dilated eye exam: Dry = visible drusen; subretinal drusen; retinal pigment epithelium (RPE) atrophy, sub-RPE clumping.
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| Mac degeneration: Dilated eye exam: Wet = | subretinal fluid +/- hemo (growth of abnormal vessels into subretinal space)
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| Mac degeneration Tx | Dry: progresses slowly; no proven tx (try antioxidants & zinc). Wet: VEGF inhibs; thermal laser photocoagulation, photodynamic tx, surgery
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| Sialadenitis Pathophysiology | inspissated mucous plug -> ductal obstruction -> salivary stasis -> secondary infxn (SA) -> poss suppurative sialadenitis (life threatening); Acute bac usu parotid or submandibular
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| Sialadenitis Sx/Sx | swelling, pain w/meals, TTP & erythema of duct opening, purulence
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| Sialadenitis DDx | tumor, mumps, TB, sarcoidosis, dental abscess, Ludwig angina, angioedema
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| Sialadenitis Dx studies | u/s or CT
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| Sialadenitis Tx | IV nafcillin (1gm q6h), switch to PO for total 10 days (Alt: Unasyn, Aug, Keflex, Clinda); hydration, warm compress, sialogogues (lemon drops), gland massage
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| Esophagitis Pathophysiology | prolonged esophageal acid clearance
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| Esophagitis Etio | Transient LES relaxations; Hypotensive LES; hiatal hernia, obesity; PG; eosinophilic esophagitis (allergic)
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| Esophagitis Tx | eosinophilic: acid suppression, esoph dilation, elimination diets, steroids
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| Esophageal motility disorders etiology | diffuse esophageal spasm (DES), nutcracker, hypertensive LES (hypercontractile; resting, midrespiratory pressure >45 mmHg)
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| Nutcracker esophagus = | high amplitude peristaltic contractions in the distal 10 cm of the esophagus
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| Achalasia = | loss of peristalsis in the distal esophagus & failure of LES relaxation, due to degeneration of neurons in the esophageal wall
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| Achalasia Sx/Sx | heartburn, dysphagia, CP; achalasia: dysphagia, wt loss, regurg, CP
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| Achalasia Dx studies | Ba esophagram/xray: birds beak; manometry: high resting LES pressure, incomplete LES relaxation, aperistalsis; endoscopy: dilated esoph
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| DES Dx studies | excess numbers of simultaneous contractions in the distal esophagus; xray: rosary bead or corkscrew esoph
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| Achalasia: Tx | Non-achalasia: diltiazem, trazodone, or botox; dilation w/tapered dilator (bougienage); myotomy
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| Aortic insufficiency Sx/Sx | Asx for decades; wide pulse pressure; S3; water hammer pulse, Corrigan pulse (pulse collapse in carotid);
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| Aortic insufficiency Signs: | deMusset' (head bob), Duroziez (bruit when femoral art is partially compressed), Quincke (capillary pulsations in fingertips); murmur (mild: soft diastolic blowing), apical impulse laterally displaced
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| Aortic insufficiency Tx | serial monitoring; ACEI, CCB; surgery/valve replacement if EF <55%
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| PUD Pathophysiology | extend thru mx mucosa layer; epi: 500k/yr
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| PUD Etio | NSAID, HP, hypersecretion (Z-E syndrome)
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| PUD DDx | GERD, biliary, panc, gastric volvulus, Ao aneurysm
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| PUD Dx studies | upper endo w/gastric bx for HP; urea breath test; serum IgG; fecal Ag
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| PUD Tx | Triple tx: PPI + Amox + clarithro; Quadruple tx: PPI + bismuth + Flagyl + tetracycline
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| Acute Pancreatitis Etiology | EtOH 35%, genetic, obstructive (bil sludge/stones 45%, tumors), SLE, idiopathic 10-30%
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| Acute Pancreatitis Sx/Sx | abd pain, rad to back, worse supine, n/v/f, poss ileus, Cullen sx, Gray Turner sx
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| Acute Pancreatitis Dx studies | lipase more specific than amylase: 3xULN; EGD, ERCP, CT
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| Ranson’s criteria | for acute panc; GALAW (glu, age>55, LDH >2nl, ALT>6nl, WBC>16k
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| Chronic panc: Etiology | EtOH, genetic, obstructive (bil sludge/stones, tumors), SLE, 10-30% idiopathic
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| Chronic panc Sx/Sx | abd pain, rad to back, worse supine, n/v/f, poss steatorrhea, wt loss; late: DM2
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| Chronic panc Dx studies | gold std: secretin stim test; 72hr fecal fat (not sens/spec); serum trypsinogen; plain film KUB, ERCP, EUS, MRCP
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| Chronic panc Tx | panc enzyme preps (pancreatin); EtOH abstinence, pain meds
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| BPH Pathophysiology | dev in periurethral or transitional zone; BPH req older age and functioning Leydig cells. Poss: androgen, estrogen, stromal GF dysregulation, decreased cell death, inc stem cells, genetics
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| BPH Sx/Sx | AUA sx score (0-35, severe >20), IPSS; LUTS (irritative & obstructive sxs). DRE: firm smoothly enlarged, non-nodular
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| BPH DDx | overactive bladder, interstitial cystitis, prostatitis, prostate or bladder ca, UTI, neurogenic bladder, urethral stricture
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| BPH Tx | AUA score 0-7 (mild): watchful waiting; mod/severe: alpha blockers (terazosin, tamsulosin); 5alpha-reductase inhibs (finasteride, dutasteride); TURP; TUNA
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| Acute renal failure Pathophysiology | multiple: pre, infra (vascular, glom, interstitial, tubular [ischemic, nephrotoxic, sepsis), postrenal
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| ARF Etio | contrast, aminoglycoside, NSAIDs, COX-2, cisplatin
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| ARF Sx/Sx | poss edema, rash, purpura; ATN: wt loss; inc K+, dec Ca+
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| ARF DDx | CKD (anemia more likely); ATN: high U-Na, FeNa; lowU-Cr, UrOsmo; Prerenal Azo: low U-Na, FeNa; high U-Cr, UrOsmo
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| ARF Dx studies | FENa <1: prerenal azo; FENa >1: ATN; Inc Cr >0.3 or oliguria <0.5 mL/kg/hr
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| ATN on micro | brown gran cast/tubular epi
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| RBC Casts: | Glomerulonephritis
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| WBC casts | AIN, pyelo
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| Epithelial casts | ATN, AIN (also see eosino casts), GN
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| Granular casts | parenchymal
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| Waxy casts | advanced RF
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| Fatty casts | proteinuria
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| ARF dx studies | Renal US; IVP; CT; MRI
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| CKD etiology | DM (40%), HTN (33%)
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| Glomerulonephritis Etio | PSGS, Hep, Wegener, Goodpasture, Churg Strauss
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| Glomerulonephritis Dx studies | bx & stain (immunofluorescent)
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| Glomerulonephritis Tx | cyclophosphamide, prednisone
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| Nephritic syndrome | AKI, HTN, urinary sediment (RBC, RBC casts)
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| Nephritic syndrome DDx | PSG, SLE, SBE, IgA nephropathy, HSP, Wegener
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| Nephrotic syndrome Etiology | DM2, multi myeloma, amyloid, MCD; Hep C (membranoproliferative); HIV (FSGS)
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| Nephrotic syndrome Dx studies | proteinuria (>3.5 g pro/24hr), albumin <3g/dL, edema, hyperlipidemia; poss hypercoag
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| Respiratory acidosis Etio | impairment in rate of alveolar ventilation; acute medullary resp ctr depression (narcotic OD), resp mx paralysis, airway obstruction; chronic: emphysema, pickwickian
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| Resp acidosis Sx/Sx | somnolence, confusion, narcosis, asterixis; fundi: dilated, tortuous vessels, possible papilledema
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| Resp acidosis DDx | COPD, airway obstruction, CNS depression (opioids), neuromx (GBS, MG, botulism), myxedema
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| Resp acidosis Dx studies | ABG (inc bicarb, dec pH)
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| Resp alkalosis (hypocapnia) Patho/etio | hyperventilation reduces PCO2, inc pH; No. 1 is hyperventilation syndrome (including anxiety); also GNR septicemia/fever, cirrhosis, PE, CHF, ILD, pna, pulmo edema, HAPE, CVA, anemia, PG (2/2 progesterone stim of resp ctr), acute salicylism
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| Resp alkalosis Sx/Sx | lightheadedness, anxiety, perioral numbness, paresthesias
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| Resp alkalosis DDx | PE, pulmo edema, PTX, ARDS, pulmo art HTN, asthma, interstitial pulmo fibrosis
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| Resp alkalosis Dx studies | ABG (inc pH, low PCO2, low bicarb in chronic)
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| NAGMA = | extrarenal bicarb loss (diarrhea, renal bicarb excretion); renal tubular acidosis; CAIs, primary hyperPTHism, Addison dz
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| AGMA: MUDPILES | methanol, uremia, DKA, propylene glycol, isoniazid, lactic acidosis [shock, septicemia, hypoxemia], ethylene glycol, salicylates
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| AGMA: CUTE DIMPLES | C for Cyanide & T for Toluene plus MUDPILES
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| Metab acidosis Sx/Sx | CP, palpitations, HA, AMS (anxiety), decreased visual acuity, n/v/abd pain, wt loss, mx weakness, bone pain; Kussmaul (profound DKA), lethargy, stupor, coma, seizures; V-tach, hypotension
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| Metab acidosis Tx | IV bicarb if pH<7.1 and hemo unstable; tx underlying disorder
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| Metabolic alkalosis: chloride-responsive (low urine Cl): due to: | diuretic tx (contraction alkalosis) or loss of gastric secretions (2/2 vomiting or NG tube)
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| Metabolic alkalosis: chloride-resistant (high urine Cl): etio | Bartter or Gitelman syndrome; hyperaldosteronism; bicarb intake in CKD
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| Metabolic alkalosis: Dx studies | if hypertensive, w/u for hypercorticism (Cushing, or 2/2 renal art stenosis)
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| Metabolic alkalosis: Tx: Chloride-responsive: | correct ECF volume deficit with isotonic saline; d/c diuretics; add H2 blocker or PPI; IV acetazolamide if CV or pulmo dz
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| Metabolic alkalosis: Tx: Chloride-resistant: | surgical resection of mineralcorticoid-producing tumor; ACEI or spironolactone to block aldosterone effect
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| Which condition: low pH (<7.4), normal-high bicarb (26), high pCO2 (60-100) = | Acute respiratory acidosis
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| Which condition: high pH (>7.4), normal-low bicarb (16-20), low pCO2 (12-35) = | Acute respiratory alkalosis
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| Which condition: low pH (<7.4), low bicarb (4-10), low pCO2 (15-30) = | metabolic acidosis (with expected resp compensation if bicarb is 8-10)
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| Which condition: normal-high pH, low-normal bicarb (8-20), low pCO2 (12-30) = | Chronic respiratory alkalosis
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| Which condition: low pH, high bicarb (28-48), high pCO2 (50-110) = | Chronic respiratory acidosis
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| Which condition: high pH, high bicarb (28-52), high pCO2 (40-70) = | metabolic alkalosis (pCO2 lower = 40-50, if W/O expected resp compensation)
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| Cardiomyopathy types | HCM (auto dom), DCM, restrictive (2/2 amyloid)
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| Cardiomyopathy EKG/CXR | CXR cardiomeg, effusions; EKG: ST/TW changes
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| Giant cell arteritis DDx | PMR, Takayasu, RA, amyloid, SLE, polymyositis
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| Giant cell arteritis S/S / Dx test | low fever, temporal TTP, pale fundi, Ao regurg murmur; CRP, ESR, anemia
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| Giant cell arteritis tx | HD csteroids
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| Giant cell arteritis physiology | immune-mediated, large arts (subclavian, axillary, Ao); M>F; w/polymyalgia rheum
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| PVC: tx | beta, amiodarone, poss ablation
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| Tachyarrhythmia pathophys | narrow complex (QRS <.12) or wide (usu VT); either by abnormal impulse formation (enhanced automaticity) or abnormal impulse propagation (reentry)
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| Most common cause of Tachyarrhythmia | (reentry; >1 pathway; most common cause of tachy)
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| SVT RFs | hyperthyroid, HTN, MV dz; VT: prior MI, ischemia, long QT, antiarrhythmics, low Mg
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| AVRT/AVNRT tx | nodal blockers
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| Arterial occlusive dz RF | M>F; 20-30% of >70 yo; Smoking, dyslipidemia, HTN, homocysteinemia, DM, metabolic syndrome; <50 yo w/DM + 1 other RF; 50 - 69 yo with h/o smoking or DM; ≥70 yo
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| Arterial occlusive dz Pathophysiology | flow limiting stenoses occur segmentally
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| Arterial occlusive dz Sx/Sx | exertional intermittent claudication; dec periph pulses, bruits, hair loss, thin shiny skin, mx atrophy
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| Arterial occlusive dz 2 systems of classification | Fontaine and Rutherford: based on sx severity and presence of ulcer or gangrene
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| Leriche syndrome = | aortoiliac dz (arterial occlusive dz of buttock and hip)
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| Buerger test | foot pallor with elevation of leg and, in the dependent position, a dusky red flush spreading proximally from the toes
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| Arterial occlusive dz DDx | DVT, musculoskeletal d/o, peripheral neuropathy, lumbar degenerative spinal canal stenosis (not relieved w/rest) (pseudoclaudication)
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| Arterial occlusive dz: Dx studies | ABI <0.9 (nl = 0.9-1.3); duplex u/s & waveform studies (esp if false normal d/t DM or renal calcification); CTA or MRA; gold std: cath angio (only for pts getting revascularization)
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| Arterial occlusive dz Tx | RF mods: smoking, DM, HTN, HLD; surg (aorto-fem, fem-fem, fem-pop), angioplasty & stenting; cilostazol (PDE5 inhib)
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| Venous insufficiency RFs: | age, FH, ligamentous laxity (eg, hernia, flat feet), prolonged standing, inc BMI, SMK, sedentary, LE trauma, prior DVT, AV shunt, PG, high estrogen
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| Venous insufficiency Patho | reflux (incompetent venous valves), obstruction, venous pump dysfn
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| Venous insufficiency Dx studies | venous u/s; ABI; venography
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| Venous insufficiency Tx | Conservative: leg elevation, exercise, and compression therapy; derm agents; ulcer mgmt. If refractory >6 mos: ablation tx (chem, thermal, mechanical)
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| Venous insufficiency Mgmt guided by | CEAP (clinical, etiologic, anatomic, pathophysiologic) categories
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| AV block Pathophysiology: 1st degree: | AV node most common site; AV impulse is delayed PR >.20
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| AV block Pathophysiology: Wenckebach: | 2/2 normal pt w/heightened vagal tone, or drugs (digitalis, CCB, beta)
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| AV block Pathophysiology: 2nd degree Mobitz type II: | usu 2/2 His bundle block
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| AV block Pathophysiology: 3rd degree: | 2/2 lesion distal to His bundle; bilateral BBB
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| AV block Sx/Sx: 3rd degree: | wide QRS & V rate <50; wide pulse pressure, cannon venous neck pulses; syncope
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| AV block Tx | Mobitz II or 3d degree: need ventricular pacing
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| Venous thrombosis Epi | 1 in 1000?; M>F, AA>W
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| Venous thrombosis RF | inherited (Factor V Leiden, Pro S or C def), surgery, bedrest/immobility, PG, OCP; malig
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| Venous thrombosis Sx/Sx | DVT & PE; palpable cord (= thrombosed vein), calf or thigh pain, unilateral edema / difference in calf diameters, warmth, tenderness, erythema, superficial venous dilation; Homan sign
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| Venous thrombosis DDx | Mx strain/injury; lymphangitis / lymph obstruction; venous insuff; Baker cyst; Cellulitis
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| Venous thrombosis Dx studies | venous u/s (noncompressible veins); contrast venography; impedance plethysmography
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| Venous thrombosis Tx | – anticoag (not tx but secondary prevention); heparin (monitor aPTT) followed by warfarin x6 mos (PT 2-3); poss thrombolytics (streptokinase, urokinase, tPA)
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| Most common cause of LV OT obstruction | Aortic stenosis (pathogenesis assoc with genetics (NOTCH1) and atherosclerosis)
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| Aortic stenosis 2 types | Subvalvular (d/t: thin membrane (most common), thick fibromx ridge, diffuse tunnel-like obstruction, HOCM); Supravalvular (hourglass deformity (60-75%) or more diffuse narrowing along ascending Ao)
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| Aortic stenosis Etio | US: lipid accumulation, inflammation, CALCIFICATION ; Elsewhere: rheumatic valve dz (fusion of the commissures between the leaflets, with a small central orifice)
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| Aortic stenosis Sx/Sx: triad w/exertion: | HF, syncope, angina; Other: DOE (diastolic ventric dysfn); A-fib, V-arrhythmia, IE, Pulsus parvus et tardus;
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| Ao stenosis murmur | harsh midsystolic crescendo-decrescendo SEM best at RUSB 2nd R intercostal, radiates to b/l carotids. Louder w/squatting, quieter w/standing or Valsalva; sit patient forward, exhalation
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| Ao stenosis: echo | valve opening <3cm2; antegrade velocity across valve >2.6m/sec; progressive concentric hypertrophy
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| Ao stenosis Tx | prevention of dz progression (statin, ?ACEI, HTN tx, IE Ppx); valve replacement (esp concurrently w/CABG); Survival = 2-3 yrs w/o valve replacement
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| Mitral stenosis Pathophysiology | usu rheumatic; symmetric oval orifice & doming of the leaflets in diastole (2/2 fusion of leaflet tips); leaflet thickening / calc 2/2 chronic turbulent flow thru deformed valve -> leaflet fusion & thickening -> obstructed LA-to-LV blood flow
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| Mitral stenosis Sx/Sx | poss A-fib / pulmo HTN; dyspnea, hemoptysis, orthopnea, PND, CP, VTE, IE, R ht fail, hoarse
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| Mitral stenosis murmur: | low-pitched, decrescendo, holodiastolic rumble best at apex (auscult w/bell) in LLD, loud opening snap after S2, all louder with expiration (vs tricuspid stenosis)
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| Mitral stenosis EKG | P-mitrale: broad notched P wave
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| Mitral stenosis Tx | exercise; loop diuretic if pulmo art congestion; digoxin, beta; VTE ppx, IE ppx
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| Mitral insufficiency Pathophysiology | increases preload but reduces afterload; Stages of MR: compensated, transitional, decompensated (EF decreases); Etio – MVP (most common), IE, trauma; MVP can lead to flail MV regurg
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| Mitral insufficiency Sx/Sx | Asx for yrs; poss L ht fail; exercise intolerance, dyspnea
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| Mitral insufficiency murmur | quiet S1, split S2, S3 gallop; murmur holosystolic, best over apex, radiating to axilla / back, blowing and high pitched
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| Mitral insufficiency Tx | serial monitoring; tx A-fib or LA enlargement (poss vasodilators); surg if LV EF<60% or echo LV end sys diameter >4cm
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| Bacterial endocarditis Pathophys | SA, Viridans strep & Strep bovis; Enterococci; HACEK group; Rheumatic; bicuspid
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| Bacterial endocarditis general Sx/Sx | Fever; regurgitant murmurs/sx of HF; small and large emboli in fundi, conjunctivae, skin, digits: petechiae, splinter hemorrhages (nonblanching, linear reddish-brown lesions found under the nail bed)
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| Janeway lesions | macular, blanching, nonpainful, erythematous lesions on the palms and soles
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| Osler nodes | painful, violaceous nodules found in the pulp of fingers and toes, usu in subacute IE
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| Roth spots | exudative, edematous hemorrhagic lesions of the retina
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| Bacterial endocarditis Sx/Sx (SA) | SA: more rapidly progressive & destructive infxn (acute febrile illness, early embolization, valvular regurg, myocardial abscess).
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| Bacterial endocarditis Dx studies | 3 sets blood cx; CXR, EKG; TTE & TEE: evidence of vegetation; high ESR/CRP, normo/normo anemia
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| Bacterial endocarditis Tx | Vanc 1 gm q12h IV + ceftriaxone 2gm q24h (vs staph/strep/enterococci)
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|
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| Acute rheumatic fever Pathophysiology | post-GABHS infxn; strep strains with M protein (shares epitope w/myosin, thus may cause anti-myosin Ab rxn); perivascular granulomatous rxn w/vasculitis; peak 5-15 yo
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| rheumatic fever Sequelae include: | arthritis, carditis (pericarditis, cardiomeg, CHF), chorea, subcutaneous nodules, erythema marginatum
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| rheumatic fever DDx | RA, osteomyelitis, IE, chronic meningococcemia, SLE, Lyme, SCD
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| Jones criteria = | 1 major [carditis (pericarditis, cardiomegaly, CHF), erythema marginatum, sydenham chorea (usu face, tongue, UE), polyarthritis) & 2 minor (fever, polyarthralgia, long PR, high ESR / CRP)
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|
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| rheumatic fever: non-Jones | high ASO & anti-DNAse B to dx recent infxn
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|
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| rheumatic fever Tx | bedrest, salicylates, PCN, csteroids for joint sxs
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|
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| Aortic insufficiency Sx/Sx | Asx for decades; wide pulse pressure; S3; water hammer pulse, Corrigan pulse (pulse collapse in carotid);
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|
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| Aortic insufficiency Signs: | deMusset' (head bob), Duroziez (bruit when femoral art is partially compressed), Quincke (capillary pulsations in fingertips); murmur (mild: soft diastolic blowing), apical impulse laterally displaced
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|
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| Aortic insufficiency Tx | serial monitoring; ACEI, CCB; surgery/valve replacement if EF <55%
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|
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