Acute Coronary Syndromes

Myocardial ischemia typically due to atherosclerotic plaque rupture coronary thrombosis Spectrum of Acute Coronary Syndromes angina that is new-onset, crescendo, or at rest usually < 30 min Ddx (causes of myocardial ischemia infarction other than atherosclerotic plaque rupture) Nonatherosclerotic coronary artery disease Spasm Prinzmetal's variant, cocaine-induced (6 of CP cocaine use r i for Ml) Vasculitis Kawasaki's syndrome.Takayasu's arteritis. PAN. Churg-Strauss. SLE. RA Aortic dissection...

Chronic Kidney Disease CKD

Definition and Etiologies (A wah 2003.139 137) -- 3 months of reduced GFR (- 60 ml min 1.73 mJ) and or kidney damage (abnormal pathology, blood urine markers, or imaging) Prevalence 11 in U.S. Cr poor estimate of GFR use prediction equation, eg. MDRD equation www.kidney.org professionals KDOQI gfr_calculator.cfm nb. equation may underestimate GFR in Pts w normal renal function Etiologies include diabetes HTN, PKD (lancet 2007 3691287). glomerulonephritis. congenital disease, drug-induced,...

Babesiosis

Infection with parasite Babesia microti (U.S.). Babesia divergens (Europe) Transmitted by Ixodes Epidemiology Europe & U.S. (more commonly coastal areas & islands off of MA. NY. Rl. CT) Peak incidence spring and summer Clinical manifestations Range from asx to fevers, sweats, myalgias. & headache to severe hemolytic anemia. Risk factors for severe disease include asplenia, depressed cellular immunity. * age Blood smear with intraerythrocytic parasites PCR serology (late) Treatment...

Hemoptysis

Expectoration of blood or blood-streaked sputum Massive hemoptysis -600cc 24-48 h (though no absolute definition) gas exchange far more important than absolute blood loss Massive hemoptysis usually from tortuous or invaded bronchial arteries Bronchitis (most common cause of trivial hemoptysis) Bronchiectasis incl. CF (most common cause of major hemoptysis) Tuberculosis, aspergilloma, pneumonia lung abscess Usually primary lung cancer, sometimes metastasis PE. pulmonary artery rupture (2 to...

Acute Renal Failure ARF

Definition (jama 2003 289 747 Loocrt 200S 365 417) ARF T Cr 0.5 mg dl or T Cr --20 if baseline Cr -2.5 mg dl in - 2 wks Oliguria UOP 100-400 ml 24 h anuria UOP 100 ml 24 h History and physical recent procedures and medications, vital signs, volume status. signs and symptoms of obstruction, vascular disease or systemic disease Urine evaluation output, urinalysis, sediment, electrolytes and osmolality Fractional excretion of sodium (FEn> ) (Uni Pn ) (Uo Per) < 1 prerenal, contrast, or...

Disseminated intravascular coagulation DIC nejm 1W341 S86

Etiologies trauma, shock, infection, malignancy, obstetrical complications Pathogenesis massive activation of coagulation that overwhelms control mechanisms thrombosis in microvasculature ischemia microangiopathic hemolytic anemia acute consumption of coagulation factors and platelets bleeding chronic DIC able to replete factors and platelets - thrombosis Diagnosis t PT. PTT. i fibrinogen (may be nl b c acute phase). FDP D-dimer. i pits.0 schisto. t LDH.i hapto chronic DIC FDP D-dimer....

Glomerulonephritis

ANCA - Vasculitis (pauci-immune or minimal staining) Predominant ANCA type either p- or c-ANCA can be seen mi all three diseases (NEJM 1997 337 1512) Predominant ANCA type either p- or c-ANCA can be seen mi all three diseases (NEJM 1997 337 1512) Immune Complex (IC) Disease (granular staining) Renal-limited diseases Systemic diseases (fever. '5 BCx. valvular disease. 1 C3) (IgA nephropathy systemic vasculitis, normal C3) AGN RPGN lung hemorrhage is an emergency - requires early Dx and Rx ANCA...

Crystal Deposition Arthritides

Urate crystal deposition in joints and other tissues acute and chronic inflammation Epidemiology More common in men than in women peak incidence 5th decade Most common cause of inflammatory arthritis in men over 30 Rare in premenopausal women (estrogens promote renal urate excretion) Risk factors metabolic syndrome. HTN. chronic kidney disease t intake of meat. seafood, and EtOH (lancet 2004 363 1277 NijM 2004 3S0.1093) Etiologies (A mats 2005 143 499) Uric acid (UA) is end product of purine...

Fungal Infections

Microbiology C. albicans and nonalbicans species (consider imidazole resistance if prior Risk factors neutropenia, immunosuppression, broad-spectrum abx. intravascular catheters (especially ifTPN). IVDA. abdominal surgery, renal failure Mucocutaneous cutaneous (eg. red. macerated lesions in intertriginous zones) oral thrush (if unexplained, r o HIV) esophageal (odynophagia oral thrush) vulvovaginal Candiduria- typically colonization due to broad-spectrum abx and or indwelling catheter failure...

Heart Failure

Definitions (Brounwald's Heart Disease. 7th ed 2004) Failure of heart to pump blood forward at sufficient rate to meet metabolic demands of peripheral tissues or ability to do so only at abnormally high cardiac filling pressures Low-output (1 cardiac output) vs. high-output (t stroke volume t cardiac output) Left-sided (pulmonary edema) vs. right-sided (T JVP. hepatomegaly, peripheral edema) Backward (T filling pressures, congestion) vs. forward (impaired systemic perfusion) Systolic (inability...

Ascites

Portal hypertension related SAAG 2 1.1 Nonportal hypertension related SAAG < 1.1 cirrhosis (81 ), including SBP acute hepatitis extensive malignancy (HCC or mets) Postsinusoidal right-sided CHF incl constriction & TR Budd-Chiari syndrome. SOS Presinusoidal portal or splenic vein thrombosis schistosomiasis Peritonitis TB. ruptured viscus (T amy) Peritoneal carcinomatosis Hypoalbuminemic states nephrotic syndrome, protein-losing enteropathy Meigs' syndrome (ovarian tumor) Bowel obstruction...

Constipation Adynamic Ileus

Definition (Rome III criteria) must include 2 of the following (in at least ' 4 of BMs) straining during defecation, lumpy hard stools, incomplete evacuation, sensation of anorectal obstruction blockage stool frequency < 3 per wk Etiology fxnal (nl transit, slow transit, pelvic floor disorders. IBS) obstruction (cancer, stricture) metabolic (DM. hypothyroid. hypoK. preg panhypopiL. hyperCa) meds (opioids, anticholinergics ind.TCAs & antipsychotics, iron. CCB) neurogenic (Parkinson's....

Dyspnea

Asthma, COPD. bronchiectasis (permanent dilation of airways with obliteration by secretions, infections, fibrosis), tumor or foreign body cardiogenic LV systolic or diastolic dysfxn noncardiogenic ALI ARDS ILD Small vessel PHT. vasculitis. ILD. emphysema (T resistance to CW diaphragm expansion weakness of respiratory muscles) Chest wall diaphragm kyphoscoliosis, i abd girth Stimulation of receptors Oj carrying cap. (but nl P.Oj) Chemoreceptors hypoxemia, metabolic acidosis Mechanoreceptors ILD....

Abbreviations

Asymptomatic atrial tachycardia angiotensin II antithrombin III acute tubular necrosis all-trons-retinoic acid atrioventricular aortic valve area atrioventricular block AV nodal reentrant tachycardia aortic valve replacement AV reciprocating tachycardia azathioprine alkaline phosphatase bronchoalveolar lavage beta-blocker bundle branch block blood culture benzodiazepines bilirubin pressure bone marrow body mass index B-type natriuretic peptide bronchiolitis obliterans with organizing pneumonia...

Valvular Heart Disease

Calcific predominant cause in Pts '70 y risk factors include HTN and T chol. Congenital heart disease (ie. bicuspid AoV) cause in 50 of Pts - 70 y Rheumatic heart disease (AS usually accompanied by Al and usually w MV disease) AS mimickers hypertrophic obstructive CMP subAo membrane Clinical manifestations (usually indicates AVA < 1 cm2 or concomitant CAD) Angina T O2 demand (hypertrophy) + i Oi supply (i cor perfusion pressure) CAD Syncope (exertional) peripheral vasodil. wI fixed CO i MAP...

Bacterial Endocarditis

Infection of endothelium of heart including but not limited to the valves Acute ABE infection of normal valves with a virulent organism eg, S. aureus Subacute SBE indolent infection of abnormal valves with a less virulent organism eg, high-risk prior endocarditis, rheumatic valvular disease. AoV disease, complex cyanotic lesions, prosthesis 1.5-3 at 12 mos. 3-6 at 5 y medium-risk MV disease including MVP w MR or leaflet thickening . HCMP Abnormal risk of bacteremia IVDA. indwelling venous...

Acute Pancreatitis

Alcohol 30 of cases, typically in men usually chronic, with acute flares gallstones 35 of cases, typically in women usually small lt 5 mm stones are culprit Obstructive ampullary or pancreatic tumors. pancreas divisum Metabolic hypertriglyceridemia TG need to be 1000 and usually 4500 seen w type I and type V familial hypertriglyceridemia , hypercalcemia Drugs furosemide. thiazides, sulfa, didanosine. protease inhibitors, estrogen. 6-MP. azathioprine.ACE-l occur via hypersensitivity, toxic...

Complications of Hiv Aids

Seborrheic dermatitis, oral hairy leukoplakia. Kaposi's sarcoma, lymphoma Oral, esophageal, and recurrent vaginal candidiasis Pulmonary and extrapulmonary tuberculosis Pneumocystis jiroved pneumonia PCP . Toxoplasma. Bartonella Cryptococcus. Histoplasmo, Coccidioides Invasive aspergillosis, bacillary angiomatosis disseminated Bartonella CNS lymphoma. PML Etiologies CID 1999 28 341 infxn 88 MAC. CMV, eariy PCP, TB. histoplasmosis, sinusitis, endocarditis Workup guided by CD4 count, sis. epi amp...

Mechanical Ventilation

T alveolar ventilation and or reverse acute respiratory acidosis Relieve respiratory distress I work of breathing can account for up to 50 of total oxygen consumption I respiratory muscle fatigue Choosing settings NEfM 2001 344 1986 2 Choose volume-targeted or pressure-targeted 3 Set or remaining variables Vent delivers a minimum number of supported breaths Additional Pt-initiated breaths trigger fully-assisted vent breaths Vent-triggered breaths identical to Pt-triggered breaths Tachypnea...

Pericardial Disease

Two-layered parietal amp visceral tissue sac surrounding heart amp proximal great vessels Disease states Inflammation w or w o fluid accumulation pericarditis Fluid accumulation usually In setting of inflammation effusion or tamponade Change in compliance sequela of inflammation constriction Pericarditis and Pericardial Effusion Viral coxsackievirus, echovirus. adenovirus. EBV.VZV. HIV Bacterial from endocarditis, pneumonia, or s p cardiac surgery S. pneumococcus, N. meningitidis, S. aureus...

Metabolic Acidosis

anion gap AG Na - CI HCOs unmeasured anions - unmeasured cations if t glc. use measured not corrected Na expected AG is albumin - 2.5 ie. 10 if albumin is 4 g dl. 7.5 if albumin is 3 g dl T AG t unmeasured anions such as organic acids, phosphates, sulfates . AG - I alb or t unmeasured cations Ca. Mg, K. Li. immunoglobulin If T AG. delta-delta aa aAG aHCOj to assess if there is an additional metabolic acid-base disturbance aAG calculated AG - expected AG . aHCOj 24 - HCOj aa 1-2 pure AG...

Connective Tissue Diseases

Autoantibodies in Patients with Rheumatic Diseases D diffuse or homogeneous. S speckled. N - nucleolar. Primer on the fiheumcoc Orteoses. 12th ed 2001 D diffuse or homogeneous. S speckled. N - nucleolar. Primer on the fiheumcoc Orteoses. 12th ed 2001 Autoantibody testing is directed by clinical findings, as autoantibodies themselves do not define a particular connective tissue disease Overlap syndromes encompassing more than one connective tissue disorder may be reflected serologically by the...

Solitary Pulmonary Nodule

Definition single. 3 cm. surrounded by normal lung, no LAN or pleural effusion Often incidentalomas. but may represent early potentially curable localized malignancy Granuloma 80 TB. histo. cocci Hamartoma 10 Bronchogenic cyst.AVM. pulm infarct Echinococcosis, ascariasis. aspergilloma Wegener's. Rheumatoid nodule Lipoma, fibroma, amyloidoma. pneumonitis Bronchogenic carcinoma 75 adeno amp large cell peripheral squamous amp small cell central Metastatic 20 breast, head amp neck, colon,...

Electrocardiography

Approach a systematic approach is vital Intervals PR. QRS. QT and axis LAD or RAD Chamber enlargement gt LAE and or RAE. LVH and or RVH QRST changes Q waves, poor R wave progression. ST A. or T wave inversions Definition axis beyond -30 S gt R in lead II Etiologies LVH. LBBB. inferior Ml. elevated Left anterior hemiblock LAD often 45 and qR in I amp rS in II. lll.aVF and QRS 120 msec and no other cause of LAD Right axis deviation RAD Definition axis beyond 90 S R in lead I Etiologies RVH....