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Medicine Shelf

Cardiovascular Derm Endo GI Heme Infectious Disease Oncology Pulm Renal / GU Rheum Miscellaneous

Cardiovascular
mksap 7, 17, 27 Pericarditis use an NSAID !efore steroids M ocarditis !viral" no s"ecific treatment# use $CEi / other diuretic% treat li&e usual CH'( )o "roven role for )*$IDs/steroids Di# to$icit often atrial tach cardia %ith varia&le &lock NS'(MI) + ,ave inversions% *+ de"ressions ,ith no * %aves C+ADS2 for ,arfarin in $ fi!- CH'% ++)% Age . /0% Dia!etes% Stro&e or +I$ h1 23 "ts# others 4 "t5( 6 or more 7 anticoagulate% 4 3 7 individuali8e% 9 7 don:t anticoagulate In heart failure !s stolic") 'itrate the &eta &locker to the heart rate of the "atient; Spironolactone if )<H$ III/I=% !ut also need >=E' ?60% Cr ? 3(0% @ ? 0 If pre#nant% avoid $CEi and use h drala,ine - nitrates In setting of cocaine use% don.t use an isolated &eta &locker/ leads to uno""osed al"ha rece"tor stimulation !y cocaine% increasing vascular tone% ,orsened cardiovascular effect( Can use la&etolol 2com!ined al"ha and !eta !loc&er5 Chronic NSAID use can cause failure of antih pertensive meds 2raise AP !y decreasing sodium e1cretion;5( $lso should discontinue if starting AC(i, etc( pretest) If S'0el, an#ina !ut no si#nificant coronar arter disease% sus"ect Prin,metal.s 2r1 ,ith Ca0channel &lockers5 'ach -&rad s ndrome if sym"tomatic% pacemaker 2"revent synco"e from !rady5 B/ drugs for tachycardia a0flutter %ith 2)1 &lock can use metop to slo, ventricular rate 1rd de#ree A02 &lock after an MI 0 tem"orary transcutaneous "acing# "ermanent if doesn:t resolve $t ris& for cardiac complications of non0cardiac sur#er ) note that AGE is not involved! +i#h0risk sur#er 2intra"eritoneal% intrathoracic% su"rainguinal vascular5 H1 of ischemic heart disease or C+3 H1 of sym"tomatic cere&rovascular disease H1 of insulin therap for dia&etes Serum Cr 4 256

+ pertension
Classification )ormal Prehy"ertension *tage I *tage II 'reatment Goals 176-86 or less in general 116-96 if dia!etic% renal insufficiency ? 439/C9 439 46D / C9 D9 2!oth5 4E9 40D / D9 DD 2either5 . 4F9 / 499 2either5 )o treatment >ifestyle modification >ifestyle B drug >ifestyle B 3 drugs

12:-7: if dia!etic% renal insufficiency% urine "rotein . 4g /3Eh ;P control is <1 for sto""ing dia!etic &idney d8 "rogress 2more ,ell esta!lished than tight glc control5

Pre#nant = +'N- la&etalol and alpha meth l0dopa are the !est evaluated for use( S'0elev "ersisting long after an MIG +hin& ventricular aneur sm/ Aortic dissectionH re"air if ty"e A 2ascending5 H may manage medically if ty"e ; 2transverse or descending5 use &eta &lockers to reduce shear stress Scleroderma renal crisis- a/, mar&edly increased renin levels% so use short0actin# AC(i 2captopril"

>ipids
>D>) 4F9 or higher increases CHD ris&( Statins, then niacin, then &ile0acid0&indin# resins 2!ut they increase +Gs;5 ? 166 !o"tional ?/95 for CHD or CHD ris& eIuivalent( ? 116 if 3 ris& factors# treat if . 4F9 ? 116 if . 3 ris& factors% !ut treat if . 469 ? 1@6 is O@ if 9 4 ris& factors( +D>) lo, if ? 60( Niacin is !est to raise 'As- normal 430% high if . 309( Niacin good to lo,er% !ut usually ,t loss% diet% e1ercise if ? 099 'i!rates used if all the other stuff fails alone(

Derm
Acne treatment Early things to try- topical retinoid B/ topical anti&iotic# com!ination BCPs too If that fails- add oral anti&iotic 2tetracycline class5# ta&es F C ,&s to ,or& Bral isoretinoin has C9J remission rate% !ut only for recalcitrant nodular acne# must have evidence of recent negative "regnancy test% informed consent from "t% counseling re-teratogenicity )o role for corticosteroids 2can cause acne5 unless acne fulminans% a rare side effect of oral isoretinoin Contact dermatitis treatment 2e(g( "oison ivy5 Bral prednisone% ta"er over 3 6 ,&s% if severe or on face/nec&/intertriginous areas +o"ical corticosteroids can reduce erythema !ut not recommended on a!ove areas# also not if !listering Psoriasis treatment- try topical corticosteroids 2med/high "otency% e(g( fluticasone5 first H to"ical vitamin D analogues 3nd line 2e1"ensive% don:t ,or& as ,ell5 H U= thera"y 2!ut incr( ris& of *CC5% then methotre1ate% cyclo"hos"hamide% etc( if really refractory( 'elo#en effluvium hair loss after !ig stress# ,ill come !ac& reassure/ Actinic keratosis) "redis"oses to SCC# don:t need to !1 Kust use topical :03C/ Darts- can use salic lic acid 2ta&es F 43 ,&s5or cr otherap if that fails Smallpo$ vs chickenpo$) H Smallpo$) "alms L soles% face# lesions in same stage of develo"ment# more Msic&N ,ith fever several days !efore rash H Chickenpo$) trun&% lesions in various stages of develo"ment 2su"erficial% a""ear in cro"s5# less Msic&%N fever ,ith rash

Bn chom cosis) get cultures of nail !ed if sus"ected can treat ,ith ter&inafine 2to"ical5 or ste" u" to oral #riseofulvin, itracona,ole

(ndo
mksap Aefore "rocedures ,ith I2 contrast 2"otentially ne"hroto1ic5% hold metformin Bsteoporosis- AMD ? 025: or any fragility fracture; Bsteopenia- AMD !et,een 01 and 025: Bsteomalacia- vitamin D deficiency- lo, serum Ca% Phos# high al& "hos Na decreases !y 15@ for every increase in 166 in plasma #lucose 2hy"o)a in D@$5 + poCa causes lon# *', h perCa causes short *'

pretest adrenal incidentaloma 4 1 cm- need to see if it:s functional measure "lasma metane"hrines% de1amethasone su""ression test for cortisol Pa#et disease of !one- cortical thickenin# L fi!rous change and elevated alk0phos# treatment is &isphosphonates M(N s ndromes) M(N 1 E pituitar , pancreatic, parath roid tumors M(N 2a E M'C, pheo, parath roid M(N 2& E M'C, pheo, Marfanoid% neuromas

Dia&etes Criteria
DM- 'AG . 12@% OG++ . 266 23hr5% random . 266 B s$ Predia&etes- 'AG 166012:% OG++ 1760188 23hr5 Aasic treatment goal- ? 7F +&A1c

'h roid cancerG Papillar is most common% a/, radiation thera"y% ,ith good "rognosis 2s"reads lym"hatically5 G 3ollicular is O3 common% !ut ,orse "rognosis 2s"reads hematogenously5 G Medullar is O6% a/, ME) in 66J% !ut ,orse still G Anaplastic is OE% a/, old "eo"le% ,orst "rognosis + perPH>) H Remem!er h poth roidism can cause h perPH>/ H Prolactinoma is most common% !ut don:t forget "regnancy H +1- DA0a#onist 2!romocri"tine% ca!ergoline5 Acrome#al - first line is transsphenoidal resection# can use octreotide adKunctively / to shrin& tumor

AI
mksap +hin& Ail&ert.s if as1% unconKugated hy"er!iliru!inemia Achalasia need an (AD 2loo& for tumors% other stuff that can mimic5#

+1- ca0channel &lockers vs "neumatic dilation, heller myotomy I;S ,ith lots of diarrhea- R1 loperamide Acute AI &leed- lose ,hole !lood 2Hct doesn:t dro" right a,ay5( $fter re"air% can still trend do,n 2fluid redistri!utes into vascular s"ace5 ,ithout ne, !leed Ascites I chan#e in mental status or signs of infectionJ 'AP for S;P/ pretest Pancreatitis) !ad "rognosis ,ith a#e 4 ::, D;C 4 1@k, #lc 4 266, >D+ 4 766, AS' 4 2:6 2ranson5 )ote that amylase / li"ase are not "rognostic; Aall&ladder d,) Cholelithiasis- !iliary colic after eating% at night# gallstone ileus( lap chole if recurrent Cholec stitis) RUP "ain B )/=% anore1ia% Mur"hy:s sign% lo, grade fever% leu&ocytosis( Choledocholithiasis) a!ove B Kaundice( Cholan#itis- RUP "ain% Kaundice% fever% !ad if se"tic shoc& B altered M* Aallstone pancreatitis- RUP U/* as 4st diagnostic test% then la" cholecystectomy after sta!le 2lots of rela"se5( (HCP if >'+s mar&edly a!normal or ductal dilitation

+eme
pretest H 'ransfusion0related acute lun# inKur - $! in donor "lasma !ind to recipient D;C, leads to noncardio#enic pulmonar edema 2e(g( day after a transfusion5 Inhi&itors- $! against certain factors( *us"ect if acIuired coa#ulopath 2e(g( ,ith malignancy incl( lym"homa% autoimmune disorders% "ost"artum5 D1 ,ith mi$in# stud 2deficiency ,ill correct% inhi!itor ,on:t5 >MD+ . ,arfarin for "revention of recurrent venous throm!oem!olism in metastatic cancer Anti0phospholipid A&s) H $/, lu"us% can !e idio"athic etc( Usually ,ith lu"us anticoagulant% anticardioli"in $!% or !oth( H Recurrent venous B arterial throm!i% throm!ocyto"enia% livedo reticularis H *ee lon# P''-P' ,hich is not corrected !y adding plasma5 R1 ,ith %arfarin to I)R 3(0 6(0

Anemias
Microc tic Iron deficienc Anemia of chronic disease 'halassemias 2'e normal/high% ferritin normal/high% +IAC normal% RDQ normal/high5 H ;eta0thal- mediterranean/middle east/Indian% less !eta chains( Hetero8ygote 7 mild disease# homo8ygote 7 thal maKor% elevated +&3% !ig time disease( H Alpha0thal- $frican $merican "atients% decrease in al"ha chains( *ilent if 4 gene missing% mild disease if 3% +&+ disease if 6 2really sym"tomatic5 Sidero&lastic anemia- disorder of RAC 'e meta!olism H hereditary or acIuired 2drugs- chloram"henicol% I)H% EtOH# lead# neo"lasia5( H *ee increased serum 'e% ferritin# normal +IAC% rin#ed sidero&lasts in !one marro,( H R1 !y removing offending agent# sometimes can use p rido$ine

Normoc tic

Anemia of chronic disease 2most times is normocytic5 Aplastic anemiaH idio"athic% radiation% meds 2chloram"henicol% car!ama8e"ine% sulfas5% viruses 2HP=% HC=% HA=% EA=% CM=% HR=% HI=5% chemicals( H Deficiency in multiple lines( Get &one marro% &$ ;12 deficiency 2"ernicious anemia% ileal disease% vegans% alcoholism5 H anemia% sore tongue% neuro"athy 2su!acute com!ined5% can lead to dementia H Elevated meth lmalonic acid, homoc stine B MC= . 499% h perse#mented PMNs H Do a Schillin# testL can r1 ,ith ;12 IM Mmonth 3olate deficienc ) smaller stores 26 mo5% green veggies H >i&e A43 ,ithout neuro s1

Macroc tic

+emol H H H H

H H

tic anemiasA@PD) see +ein, &odies004 &ite cells Spheroc tes, helmet cells- thin& e1travascular Schistoc tes) thin& intravascular 2MtraumaN5 Direct Coom&.s positive) thin& autoimmune hemol tic anemia S I#A is %arm 2,arm ,eather is Great5# e$travascular hemolysis 2s"lenomegaly5% a/, lym"homa% C>>% malignancy% collagen vascular diseases 2*>E5% al"ha methyldo"a( #lucocorticoids can !e useful S I#M is cold 2MMM cold ice cream;5 Intravascular hemolysis# idio"athic or secondary to infection 2myco"lasma% mononucleosis5 Bsmotic fra#ilit - thin& hereditar spheroc tosis Dark urine thin& hemoglo!inuria 2intravascular hemolysis5

Infectious Disease
mksap Osteomyelitis- MHI is imaging modality of choice if uncertain a!out "resence of osteo Aet a &one &$ to guide thera"y if you can "ro!e to !one / high sus"icion / d1 of osteo on MRI If murmur I conduction a&normalities% thin& endocarditis B paravalvular a&scess pretest) Providencia is a G)R that can cause U+Is in hos"itali8ed "ts ;lasto can cause chronic res"iratory s1 of infection% also skin lesions 2crusty% ulcerated% verrucous5 and/or osteol tic &one lesions SIHS, Sepsis, etc5 SIHS- 3B of ' . 6C(9 or ? 6F(9 +H . D9 HH . 39/min or PCB2 ? 63 mm Hg D;C . 43& or ? E&% or . 49J !ands Sepsis) SIHS B a confirmed infectious source Severe sepsis) Sepsis B or#an d sfunction, h poperfusion, h potension Septic shock) se"sis induced hy"o"erfusion / hy"otension despite adeMuate fluid resuscitation Aoal0directed therap for sepsis- ,ithin F hrs% &ee" central venous B2sat 4 76F% resolve lactic acidosis

Acute &acterial rhinosinusitis) duration . 4 ,&% ,orsening after initial im"rovement# ma1illary tenderness # "urulent discharge # "oor res"onse to decongestents( R1 ,ith amo$icillin 2*tre" "neumo% H( flu5 for 1016 da s( $lternatives- +MP *MT% do1ycycline( @ee" it narro, PPD cutoffs4 1: 4 16 lo% risk 2average "t5 immi#rant from high ris& country ,/in : rs, I2DC, prisoners, health care ,or&ers% "ts ,ith silicosis% DM% chronic renal failure, leukemia / l mphoma% cancer of head/nec&% recent si#nificant %t loss% gastrectomy / KeKunal !y"ass( $lso for healthy adolescents e1"osed to adults in high ris& category hi#hest risk for develo"ing active ';) +I2, immunosuppressed, "ts ,ith close contact to active ';, CNH c/, previous ';5 $lso% if 4 : mm and you:re going to start someone on immunosu""ression 2"rednisone . 40 mg/d% etc5% IN+ $ 8 months for "ossi!le latent +A

4:

Confusin# 0vir dru#s Ooster) 3amic clovir or valac clovir 2li&e acyclovir !ut !etter "harmaco&inetics% dosing schedule% efficacy5 CM2 in immunosu""ressed- #anciclovir, val#anciclovir

A&$ pp$ for endocarditis)


Dho needs itJ NB' lo, ris& "ts- previous CA;A% surgical re"air of ASD-2SD-PDA% M= "rola"se ,ithout regurg% innocent heart murmurs% "revious @a,asa&i:s or rheumatic fever ,/o valvular dysfunction% pacemakers - defi&rillators P(S for hi#h0risk) prosthetic valves, previous endocarditis% com"l1 cyanotic heart diseases 2trans"osition of great vessels% +et of 'allot5% surgically constructed systemic "ulmonary shunts / conduits P(S for moderate0risk- most other congenital cardiac malformations% acMuired valve d sf$n 2e(g( rheumatic fever with valvular d sf$n5% +CM, M2P with regurg and/or thic&ened leaflets% cardiac defects re"aired ,/in last @ mo ' pe of sur#er Dental , respirator , AI, AC, tonsillectomy / adenoidectomy% !ronchosco"y ,ith rigid !ronchosco"e% eso"hageal stricture dilation% ERCP if "t has !iliary o!struction% intestinal or res"iratory mucosa surgery thin& %hat could push &acteria into the &loodstreamJ If pp$ indicated ) Amo$icillin 2# orall 4 hr !efore "rocedure( $m"icillin 3g IM or I= 69 minutes !efore if can:t ta&e oral meds Clindamycin / a8ithromycin if allergic to PCn =ancomycin if moderate ris&% PC) allergy% high ris& GU/GI "rocedure 2a/, enteroccus5

Neuro
pretest H Cluster headache- use prednisone acutely% then taper over months( $lso tri"tans% O3 can hel" acutely H Hestless le#s- use "rami"re1ole% ro"inerole% or other direct dopamine a#onists Chronic inflammator dem elinatin# pol neuropath 2CIDP5- "rogressive% symmetric "ro1imal / distal ,ea&ness in all e1tremities% may have some num!ness L tingling too% develo" over several months# may "rogress or rela"se / remit( Use immunosu""resive thera"y( Demyelinating neuro"athy 2li&e chronic GA*5(

Bncolo#
mksap Hadiation for Hodg&in:s% to chest% "redis"oses to solid tumors &reast cancer in oun# %omen 209 F9J of ,omen treated ,hen 39 yrs old5 lun# cancer in smokers Alk latin# a#ent chemo- "redis"oses to AM> Pericardial mets- most freIuently &reast, lun# cancer (stro#en therap increases ris& of &reast cancer% Gris& for ovarian% uterine 2mi1ed data5 Use hormone re"lacement only short term for s1 control BCP decreases ovarian cancer SC>C- very chemo sensitive% treat ,ith chemo 2"latinum agent B eto"oside or irinotecan5( *urgical resection only if stage 4% and use induction or adKuvant chemo too chemo B !rain radiation if !rain mets can !e good for "alliation for 4 3 yrs NSC>C- if stage I=% rec hos"ice 2e(g( *CC5 very "oor "rognosis Solitar pulmonar nodule- !1 de"ending on ho, much you:re sus"icious for cancer( Malignancy- usually spiculated, little-no calcification, intermittent dou&lin# times 269 099 days5 Aenign may dou!le either ,ithin 69 days or remain sta!le over 3 yrs revie% past radio#raphs Consider follo,ing it ,ith serial chest C' if "t oun#er than 1: and no smokin# histor / Clcerative colitis ,ith lo% #rade d splasia on colo 7 proph lactic colectom CHC screenin#) "ositive 3;B' !uys you a colonoscop Prostate cancer) if P*$ . E% suggest 'CHP% es"ecially if PSA 4 16 Non0+od#kin.s > mphoma H A .. + for ty"e H Q;iops an >N 4 1 cm present for 7I %eeks that can:t !e attri!uted to infectionQ H Small l mphoc tic- indolent% old "eo"le% related to C>> H 3ollicular- most common% 00% "ainless >$D% indolent% can transform into diffuse large cell% radiation if locali8ed can cure 2!ut fe, are locali8ed5 H Diffuse lar#e cell- intermediate grade% mostly A cell# locally invasive 2large e1tranodal mass5% CHOP chemo cures C0J H > mpho&lastic- high grade% + cell lym"homa% more common in &ids% can "rogress to + $>>% aggressive !ut can res"ond to com!o chemo H ;urkitt.s- high grade% A cell% EA= related% C-4E translocation 2Aur&itt:s 7 C letters5% 09 F9J cure ,ith aggressive chemo H Mycosis fungoides- + cell lym"homa of s&in% cri!iform lym"hocytes% can cure ,ith rad / to"ical chemo if limited to s&in >eukemiasH AM>) immature myelogenous cells% adults% incr( ,ith rad e1"osure H A>>- immature lym"hocytic "recursors% &ids% very res"onsive to thera"y H C>>- mature lym"hocytes !ut not functional 2no $! "roducing PCs5% adults . F9% most common leu&emia in Qestern ,orld% not aggressive 2survive longer% die of other causes often5( Smud#e cells L really high QAC H CM>- mature myeloid cells% indolent !ut then transforms to acute leu&emia 2!last crisis5( +D-33 2"hiladel"hia5# R1 ,ith Imatini! or other +@ inhi!itors( Bther random stuff-

H H

Pol c themia vera- $ myelo"roliferative syndrome( hemato"oetic stem cells "roliferate . e1cessive erythrocyte "roduction( Hy"erviscosity% throm!osis% !leeding% he"atos"lenomegaly% H+)( *ee elevated H;C, +&, +ct !4:6" B/ throm!ocytosis% leu&ocytosis( Phle&otom to reduce Hct# consider hydro1yurea or I')al"ha M elod splastic s ndromes) clonal# ineffective hemato"oesis% apoptosis of m eloid precursors 7 panc topenia ,ith a NBHMA> or h percellular marro% 2vs a"lastic anemia5( Can see +o%ell0Roll &odies% !aso"hilic sti""ling% nucleated RACs% large% agranular "latelets( +1 is su""ortive( )eed AM+( (ssential throm&oc tosis- throm!osis/"arado1ical !leeding 2defective f1n5( Plt . F99&( R1- anti"latelets M elofi&rosis- fi!rosis of !one marro, 7 "ancyto"enia% e1tramedullary hemato"oesis( Massive s"lenomegaly( 'eardrop cells on PA*( Aone marro, as"irate 7 fi!rosis% Mdry ta"N if severe( Can pro#ress to AM> or die of !leeding / infection(

Pulm
mksap $ s mptomatic pneumothora$ !uys you a chest tu&e tension or not es"ecially if it:s &i# (ffusions 'horacentesis if free0flo%in#, . 16 mm in height 2get lat decu! CTR5 +hen chest tu&e if com"licated 2"us% Gram stain "ositive% "H ? /5 Other,ise manage ,ith I2 a&$ I o&servation pretest ;iPAP can !e used in acute COPD or CH' e1acer!ation if acute CO3 retention 2may hel" "revent intu!ation5 !ut can:t use if not "rotecting air,ay( Asthma e$acer&ation- !ad sign if silent chest 2air,ay constriction so !ad that can:t generate ,hee8ing5( Good if "ulsus "arado1icus ? 0 mm Hg P(- can have ,hee8ing 2asthma mimic5% !ut generally not &i&asilar rales 2suggest CH'% P)$5 + pophosphatemia can result from intracellular shift in respirator acidosis PCP 2in HI=5 often has an elevated >D+ Spirometr $!normal values if ? C9J "redicted 'E=4/'=C ? /9 7 o!structive lung disease D>CO decreased in em"hysema% I>D, normal in asthma% usually !ronchitis >i#ht.s criteria for effusions- to !e an e$udate, need 4B of pleural - serum fluid protein ratio of 4 65: pleural - serum >D+ ratio of 4 65@% or pleural fluid >D+ . 3/6 of normal upper limit for serum >D+ A0a Aradient H P$O3 7 2 'iO3 U 2/F9 E/55 2PaCO3 / 9(C5 7 409 2PaCO3 / 9(C5 if on room air( H $ a gradient 7 P$O3 PaO3( *hould !e ? 49# if elevated% thin& =P mismatch / shunt / etc(

Henal - AC
Nephrotic s ndrome- see urine sediment ,ith fatt casts# oval fat &odies can loo& li&e Maltese crosses

Minimal chan#e glomerulo"athy is O4 in younger "ts# can develo" Iuic&ly 2over ,&s5% can !e triggered !y infection / immune stimulus( H$ corticosteroids( )ormal microsco"y# foot "rocess effacement on EM( *electively lose al&umin 2lose negative GAM charge5( Mem&ranous glomerulo"athy O4 in older "ts% usually ta&es longer to develo"( Ms"i&e and domeN ,ith su!e"i de"osits% granular IM( caused !y drugs% infections% *>E% solid tumors 3SAS- also ta&es longer to develo"# +I2 associated Am loidosis 2congo Red Multi"le myeloma% +A% R$5 Dia&etic #lomerulonephropath - nonen8ymatic glycosylation of GAM# "ermea!ility / thic&ening of afferent arterioles( GAM thic&ening% mesangial e1"ansion% @ Q nodules( Mem&ranoproliferative) lo, C1% associated ,ith HA=/HC=( 2May !e ne"hritic# anything M"roliferativeN can !e ne"hritic% anything Mmem!ranousN can !e ne"hrotic5

Nephritic syndromes I#A nephropath !erger d8% e1acer!ation durin# CHI Post0strep AN 0 after infection# H+)% "erior!ital edema( Resolves s"ontaneously( M>um"y !um"yN glomeruli ,ith su!e"ithelial IC de"osition% granular I'( S>(0related) lo, C1 = C7 Hapidl pro#ressive - crescenteric- "oor "rognosis( Aoodpasture 2linear I'% males% hematuria% res" involvement5 vs De#ener.s 2c $)C$5 vs MPA 2" $)C$5

Acid0&ase = compensation
Meta&olic acidosis )ormal AA) 43 Vremem!er- )a 2Cl B HCO65W Is there a coe1isting $G and non $G meta!olic acidosisG chec& the delta delta 2does the decrease in !icar! from 3E eIual the increase in the $G from 43G If so% it:s a sim"le $G met acidosis5 Calculate Crine AA VUrine )a B @ ClW to determine if )HE !eing e1creted H'A t pe 1, 7- &idney not e$cretin# acid a""ro"riately% so CAA positive H'A t pe 2, diarrhea) &idney e1creting acid O@ 2R+$ ty"e 3 7 defect in !icar! rea!sor"tion5% so CAA ne#ative )ormal osmolar #ap ? 16 Vremem!er- 23 1 )a5 B 2glc / 4C5 B 2AU) / 3(C5W5 If high% thin& methanol% ethylene glycol% iso"ro"yl alcohol% etc( Meta&olic alkalosis H Crine Cl ? 16 7 Msaline res"onsiveN )G suction% vomiting% diuretics% "ost hy"erca"nia H Crine Cl 4 16 E Msaline resistantN S If AP elevated% thin& "rimary aldosteronism% Cushing:s% renal artery stenosis% S If AP normal% thin& hy"omagnesemia% severe hy"o@% Aartter:s% )aHCO6% licorice Compensation Meta&olic acidosis- Qinter:s formula 24(0 1 HCO6 B C B/ 35 Meta&olic alkalosis- generally for every increase of 1 in &icar&, 65:01 increase in PCB2 Others- see ta!le( Res"iratory acidosis is the only condition in ,hich "H can return to normal Hespirator acidosis - alkalosis- e1"ected com"ensation 2note PCO3% HCO6 go in the same direction5 PCO3 Acute res"iratory acidosis Chronic res"iratory acidosis Increased Increased 'or every 49 unit change in PCO3% HCO6 should change !y((( B4 B6 E

Acute res"iratory alkalosis Chronic res"iratory alkalosis

Decreased Decreased

3 0

Contrast0induced nephropath at ris& 7 volume depletion, C+3, DM, CSD% multi"le myeloma reduce ris& !y a##ressive volume resuscitation 2)* or isoosmotic sodium !icar! sol:n5 if "t can handle it

3eNaIn chronic kidne disease- 2a gross !ut useful oversim"lification5 H Decreased "hos clearance leads to elevated "hos% ,hich inh!iits 4%30 OH =itD "roduction H (levated phosphate and lo% calcium result% ,hich increases P'+ production H Increased P'+ then leads to renal osteod stroph

Henal 'u&ular Acidosis' pe 1 !Distal" Can:t secrete HB at distal tu!ule H H H H Can:t rea!sor! HCO6 at "ro1imal tu!ule Increased )a rea!sor"tion ,ith decreased H/@ secretion 2at distal tu!ule5 H H H H H H Can:t lo,er urine "H ? F + poS, h perCl, non0AA met acidosis $lso increased Ca-PB7 e$cretion ric&ets / osteomalacia% renal stones can result R1- Na+CB1 + poS, h perCl, non0AA met acidosis 'anconi:s% Qilson:s% other conditions No stones# no role for !icar! R1- restrict Na 2incr )aHCO6 rea!sor"tion at P+5 +PP(H0SA>(MIC 2only one5 Can acidify the urine "retty ,ell;

' pe 2

!Pro$imal"

' pe 7

!+ poaldo or resistance"

Hheum
mksap ;ursitis) a/, "ainful full el&o% fle$ion 2stretches !ursa tight5 Cr stalline - infectious s novitis- a/, "ain on any "assive Koint motion TPoppin#U B Koint line tenderness I "ain on #oin# up - do%n stairs, %alkin# 7 meniscal tear Aout treatment Don:t use allopurinol in acute flares NSAIDs are first line% then colchicine +ry to get serum uric acid do,n to ? @ m#-d> !y increasin# allopurinol if uric acid is still high Hel"s dissolve tophi L other urate de"osits since decreasing uric acid levels itself can induce a gouty attac&% keep colchicine on ,hile you increase allo"urinol( +ereditar hemochromatosis- classically M&ron,e dia&etesN !ut no, more often a/, arthropath , fati#ue, impotence, a&normal >3's

Pol m al#ia rheumatica- Pain% morning stiffness in a$ial Koints, pro$imal musclesL no muscle ,ea&ness / s,elling / "ain / ,armth / movement restriction( D9J have elevated (SH% usually 4 :6 rs old5 +reat ,ith prednisone(

pretest S>( high dose corticosteroids if hemolytic anemia% throm!ocyto"enia% or glomerular disease develo"s 3eet Ankle s"rain vs !rea&- Otta,a rules- only need T ray if 1" can.t &ear %ei#ht right after inKury or 2" point tenderness over medial or lateral malleolus( Plantar fasciitis 0 runners% heel "ain at first steps or after sittin#% then goes a,ay# O@ at night 'arsal tunnel syndrome posterior ti&ial nerve runs through# entra"ment leads to pain in ankle - heel, num&ness of sole of foot at night Metatarsal stress fracture) comes on suddenly% ,orse ,ith ,eight !earing% "oint tenderness% can have normal T ray Morton neuroma causes "ain% num!ness on !all of foot% made !etter !y ta&ing shoes off >o%er &ack pain, &uttock pain S mptomatic treatment for nons"ecific >AP ,ith no ,arning signs Acute sciatica- use NSAIDs if no cauda eIuina% s"inal cord com"ression s1( *urgery- s1 . F ,&s% "rogressive neuro deficits( Don:t MRI early lots of false "ositives Aut can get plain films in "ts . 09 2incr( ris& of malignancy% osteo"orotic fractors5 Spinal stenosis- "ain on standin#, %alkin#% relieved !y sittin# - &endin# for%ard NBHMA> A;I 2"seudoclaudication5 >e# ischemia - claudication- occurs ,ith %alkin# !ut not ,ith Kust standing A;I ? 658 often ,ith 426F decline %ith e$ercise

2asculitis
'emporal Arteritis .09% tem"oral aa / aorta / carotids% incr( ris& $o aneurysm% d1n( Constitutional s1% H/$% visual im"airment% Ka, claudication% tenderness% "olymyalgia rheumatica E*R elevated% serial !1 of tem"oral aa +reat- high dose steroids immediately% follo, E*R 'aka asu.s Arteritis <oung $sian ,omen% $o arch L !ranches% stenosis( Decreased "eri"heral "ulses% AP arm vs leg different% arterial !ruits( Constitutional s1% ischemia% lim! ischemia +1- steroids% treat H+)% surgery / angio"lasty% !y"ass grafting Chur#0Strauss Many organ s1( Constitutional findings% "rominent res"iratory tract findings 2asthma% dys"nea5% s&in lesions 2palpa&le purpura5( D1- A1 2lung/s&in5 ,ith eosinophils, P0ANCA( Poor pro#nosis 20 yr survival 30J% card / "ulm com"lications5( +1 ,ith steroids 209J survival5 De#ener.s @idneys% u""er / lo,er res"iratory tract( *inusitis% !loody nasal discharge% oral ulcers 2"ainful5% "ulm s1 2cough% hemo"t% dys"nea5% glomerulone"hritis% conKunctivitis / scleritis% arthralgias / myalgias( PAN has no lun# involvement( CTR- nodules / infiltrates( Elevated E*R% normochromic normocytic anemia% c0ANCA in D9J% B/ throm!ocyto"enia% can confirm ,ith o"en lung !1( Poor pro#nosis 2most die ,/in 4 yr5( +1 ,ith c clophosphamide, corticosteroids, can ha""en at any time( Pol arteritis Nodosa

Medium0si,ed vessels% incl( nervous system% GI tract( $/, +;2, +I2% drug reactions( PM) invasion of all layers% fi!rinoid necrosis% intimal "roliferation . reduced luminal area . ischemia% infarcts( 'ever% ,ea&ness% ,t loss% myalgias/arthralgias% a&dominal pain( $lso H+)% mononeuritis multiple$, livedo reticularis 2lace li&e% "ur"lish% lo,er e1tremities5 D1- !1% mesenteric angiogra"hy( (levated (SH, I-0 p0ANCA( +est for fecal occult !lood Prognosis "oor% im"roved ,ith treatment( corticosteroids L if severe% c clophosphamide ;echet.s S ndrome $utoimmune% multisystem# cause un&no,n( oral, #enital ulcerations 2"ainful5% arthritis 2&nees/an&les5% e es 2uveitis / o"tic neuritis% iritis% conKunctivitis5% CNS 2meningoence"halitis% intracranial H+)5% fever% ,t loss( D1- !io"sy# +1- steroids hel"ful ;uer#er.s Disease 2+hrom!oangiitis O!literans5 <oung men% smoke ci#arettes( *mall/medium si8ed arteries / veins% arms / legs% can lead to #an#rene( Ischemic claudication% cold / cyanotic% "ainful distal e1tremities% "aresthesias of distal e1tremities% ulceration of digits( Smokin# cessation reduces "rogression( + persensitivit vasculitis *mall vessel% hy"ersensitivity / drug r1n% infection% other stimulus( *&in- palpa&le purpura, macules, vesicles% can !e "ainful( Constitutional s1% D1 ,ith !1 of tissue% good "rognosis(

Autoanti&odies = %hatnot
Primar &iliar cirrhosis +ashimoto.s $nti mitochondrial $nti th roid pero$idase !'PB" $nti th ro#lo&ulin 2anti microsomal% !ut can also see in Grave:s5 +hyroid stimulating $! ANA 2sensitive% not s"ecific5 $nti dsDNA L anti SM 2s"ecific% not sensitive5 $nti ssD)$ 2not as good5 $nti histone Hheumatoid factor 2anti IgG5 not s"ecific% also not too sensitive Anti0CCP 2s"ecific5 c0ANCA p0ANCA anti HNP $nti SC> 76 2anti topoisomerase I" diffuse d8 2s&in lesions "ro1 to el!o,# e(g(% CRE*+ doesn:t give you s&in changes on chest5% rapid "rog( $nti centromere mostly limited / CH(S' syndrome $)$ B/ R' $nti Ho !SS0A", anti >a !SS0;" in E9 09J 2not too sensitive5 2+reatment o"tions include pilocarpine" $nti Ro01 2anti tR)$ synthetase5 !oth "oly L dermato H a/, disease activit fever% mechanic:s hands% I>D% arthritis% refractory to treatment

Arave.s S>(

Dru#0induced S>( Hheumatoid arthritis De#ener.s Pol arteritis nodosa Mi$ed connective tissue d, Scleroderma

SKo#ren.s

M ositides

$nti SHP) a/, cardiac manifestations L !ad "rognosis $nti Mi02- !etter "rognosis Autoimmune hepatitis $nti microsomal !did ou mean anti0smooth muscle or 0>SMJ also is ANAI"L liver &$ reMuired for d$

3elt .s s ndrome- R$ B neutropenia, splenome#al 2anemia% throm!ocyto"enia% lym"hadeno"athy5( H +hin& HA ,ith an increased risk for infections/

S novial 3luid Anal sisCondition Normal Noninflammator arthritis 2O$/trauma5 Inflammator arthritis 2R$% gout% "seudogout% Reiter:s5 Septic arthritis 2!acterial% +A5 Clear Clear% yello,# red if traumatic Cloudy yello, 3luid D;C-mm1 ? 399 ? 3%999 . 0%999 Usually . 09%999 PMNs ? 30J ? 30J 09 /9J RACs for trauma Pos !irefr for "seudogout )eg !irefr for gout Most are culture "ositive e1ce"t for gonococcal 230J only are "ositive5 Bther

+ur!id% "urulent

. /9J

Miscellaneous
Screenin# +'N + perlipidemia All adults 19I "er U*P*+' +ealth adults 26I get nonfasting total chol% HD> I 0 yrs( H If tot chol . 3E9 or 399 3E9 ,ith multi"le ris& factors% get full "anel H $dults ,ith C$D get full li"id "anel Men a#ed @:078 %ho have ever &een smokers 2U*P*+' ma&es no rec for those ,ho haven:t smo&ed# not for ,omen harm out,eighs !enefit5 Get a 3B;' ever ear along ,ith these recs

A&d C-S for a&d aortic aneur sm

Colonoscop

Blder than :6G Every 16 ears 2if "oly" found L resected% chec& again in 1 rs5 3irst de#ree relative ,ith CRC ? age F9% or 3 relatives ,ith CRC at any age A#e 76 or 16 ears prior to oun#est relative.s d$ 2,hichever earlier5 Re"eat M : rs Aenetic s ndromes)
3AP- genetic testing% or annual sigmoidosco"y starting at 49 43 y/o to see if they carry the gene% then yearly B/ resection +NPCC- colonosco"y M 102 rs starting at age 2602: or 16 ears prior to youngest relative:s d1 2,hichever comes earlier5

Chlam dia S'Ds

$ll pre#nant and se$uall active %omen a#e 27 or oun#er In general% test every!ody ,ho is at ris&( Gonorrhea% though% doesn:t have routine screening

li&e Chlamydia a!ove( Also opt0out +I2 testin# for "retty much ever &od Pap smear Start at age 21 or %ithin 1 ears of startin# intercourse H Qhile in 26s% M 2 rs# ,hile in 16s, M 1 rs 2if 6 in a ro, have !een normal5 H Can sto" if h sterectom for non cancer reasons L no lon#er have cervi$ H Can sto" if over @: and 1 normal Paps in a ro%# if ne, se1ual "artner after age F0% restart Pa"s I 6 yrs >ots of HP= "ositivity in adolescents 39 and younger so if >SI>% schedule a 12 month follo%0up and only refer for co"osco"y if hi#h #rade SI> or #reater on re"eat 2lots clear the infection on their o,n5( Old recs- Qomen E9B get mammo#rams M 102 rs% then earl after a#e :6 Ne% recs) Get mammogram M2 rs starting at a#e :6 $lso "hysician e1am I 6 yrs until E9% then yearly thereafter $ny!ody at ris& for develo"ing latent or active +A 2see PPD recs a!ove5 H Persons living in congregant settings 2prisons, #roup homes, homeless shelters, nursin# homes" H Persons routinely e1"osed to +A 2health care %orkers" H Persons ,ho are immunosu""ressed !+I2, transplant pts"

Mammo#ram

';

2accines Pneumova$ (lderl 24 @: -o" or hi#h0risk adults 2as"lenic% nursing home5( If initial vaccine given !efore age F0% give &ooster : rs later ;ooster ever 16 ears H If in the 180@7 a#e ran#e, give 'DaP as ne1t !ooster instead of +D( H =accinate health care %orkers ,ho haven:t had +DaP and had their last +D !ooster . 3 yrs ago $ll females a#es 802@ Adults 4 @6 -o $dults ,ith asplenia 2anatomical or functional5 or complement deficiencies Colle#e students in 4st year dorms, militar recruits +i#h risk 2health care ,or&ers% hemodialysis "ts% reci"ients of clotting factors% high ris& se1ual !ehavior% travelers to endemic areas% I=DU% household contacts of HA= carriers% "ersons in institutions for mental retardation5 'ravelers and "eo"le ,ith chronic liver d,, +C2 >ive vaccine "rimary series in &ids( Give to unvaccinated "eo"le( >ive vaccine "rimary series in &ids( Give to adults% adolescents ,ho have never had chic&en"o1% close contacts of immunocom"romised "ts% PEP in susce"ti!le Primary series in &ids( Don:t give to unvaccinated adults unless they:re going to travel to endemic areas(

'D-D'aP

+P2 +erpes Ooster Menin#ococcal +;2

+A2 MMH 2aricella Polio

Influen8a don:t !e afraid to tac& on some olsetamavir if "t ,ith ris& factors 2e(g(% COPD5 has e1"osure to virus 2e(g(% daugther has flu5 in addition to I= &illed vaccine

Pain control- if using PCA, ma&e sure to &olus morphine 4st 2PC$ for maintenence# doses are small L ,ould ta&e a long time to get to thera"eutic level5( A#e0related macular de#eneration- yello,ish drusens H advise to stop smokin#, consume antio$idants !AC(", see opththalmolo#ist Meta&olic s ndrome- 1-: of a&dominal o&esit 2,aist . 60in in '% E9in in M5% h per'As 2.4095% lo% +D> 2?09 in '% ?E9 in M5% ;P . 469/C0% insulin resistance 2fasting glucose . 44955 Note that LDLs not involved Domens. health initiativeH Estrogen B "rogesterone 2H+5 in healthy "ost meno"ausal ,omen . increase in &reast cancer over 0 yrs H H+ hel"s "revent osteoporotic fractures !ut no &enefit for coronar heart disease ,as found H If using H+% use it short0term in healthy "erimeno"ausal ,omen