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IM Block 16 Objectives
KYCOM Block 16
324
Medical
Graduate
05/11/2014

Additional Medical Flashcards

 


 

Cards

Term
in general what is the best type of information to have to make a diagnosis
Definition
clinical, LABS NEVER GIVE THE ANSWER, CANNOT RELY ON LABS
Term
what is the most common cause of arthritis in adults
Definition
osteoarthritis
Term
what is the most common cause of long term dissability in the US
Definition
osteoarthritis
Term
10 causes of osteoarthritis
Definition
age, female, race, genetics, obesity, injury, repetitive trauma, altered body mechenics, low vitamin d and C, joint dysplasia
Term
symptoms of osteoarthritis 17
Definition
history of joint pain, stiffness, deformity, loss of finction

insidious onset of pain, increases with use, decreases with rest, increases with age

gait disturbance, decreased ROS, joint instability

swelling, deformity, tenderness, joint effusion, morning stiffness

heperdines nodules
Term
what are heperdines nodules
Definition
PIP enlargement in osteoarthritis
Term
what is the most useful in diagnosing osteoarthritis
Definition
PLAIN X-RAY: HYPERTROPHIC REACTION ON X-RAY, CARTILAGE LOSS
Term
x-ray signs of osteoarthritis 7
Definition
hypertrophic reaction
cartilage loss
osteophytes/bone spur: lateral on spine
bony sclerosis
joint space loss
subchondral cysts
asymmetric narrowing
Term
complications of osteoarthritis 4
Definition
loose bodies
rotator cuff tear
spinal stenosis
spondylolesthesis
Term
4 goals of osteoarthritis treatment
Definition
control symptoms
maintain function
limit dissability
avoid toxicity
Term
osteoarthritis treatment of the hand: goals 2, RX 3, non RX 3
Definition
goals: prevent progression, tx symptoms

non: joint conservation, heat, cold

TX: NSAID, capsaicin, tramodol (NO opioids, do not even work)
Term
osteoarthritis treatment of the knee: non RX 7, RX 2
Definition
weight loss, strengthening quads, manual supervised therapy, patellar taping, wedge insoles

RX: acetaminophen or NSAID topical, oral, injection
Term
what pt cannot recieve normal knee osteoarthritis tx, why
Definition
chronic renal disease stage IV/V, no NSAIDS
Term
what should bever be used in knee osteoarthritis tx 6
Definition
chondroitin, topical capsaicin, glucosamine, opioids (don't work for chronic pain), duloxetine, hyalyronates
Term
treatment of hip osteoarthritis: non RX 4, RX 4
Definition
weight loss, CV exercise, hot/cold therapy

acetminophen, NSAID, tramadol, intraarticular injection
Term
what is not recommended for hip osteoarthritis tx 5
Definition
chondroitin, glucosamine, topical NSAID, duloxetine, opioids, hyaluronate
Term
what is DISH - not objective
Definition
diffuse idiopathic skeletal hyperostosis: bone hypertrophy at ligament and tendon insertions associated with DM2

seen on thoracic spine on the right, calcifications, asymptomatic, non-crippling
Term
what is chondromalacia patellae - not objective
Definition
localized OA of patella precursor of OA of knee seen in young women

x-ray normal, grap patella and have them tighten and theyll scream
Term
define rheumatoid arthritis
Definition
progressive, systemic, inflammatory disorder of unknown etiology
Term
3 characteristics of RA
Definition
symmetric synovitis
joint erosions
multisystem extra-articular manifestations
Term
pro-inflammatory fectors of RA 12
Definition
IL-1, 6, 8, 12, 15, 16, 17, 18
TGF-B, INF-y, GM-CSF, TNF
Term
anti-inflammatory factors 8
Definition
IL-4, 10, 11, 13, 18BP, IRa
SIL-IR, sTNFR
Term
old ACR criteria for RA
Definition
4+ FOR >6WK

MORNING STIFFNESS >1H
ARTHRITIS OF >3 JOINT AREAS
ARTHRITIS OF FINGER JOINTS
SYMMETRIC JOINT SWELLING
SERUM RF
RHEUMATOID NODULES
TYPICAL RADIOGRAPHIC CHANGES
Term
new criteria for RA categories
Definition
MUST HAVE 4 POINTS
joint involvement
serology
duration
phase reactant
Term
new RA criteria: joint involvement 5 categories
Definition
1 medium large joint = 0
2-10 medium large joint = 1
1-3 small joint = 2
4-10 small joint = 3
>10 small joint = 5
Term
new RA criteria: serology 3 categories
Definition
negative RF, anti-CCP = 0
one positive low titer (<3x) = 2
one positive high titer = 3
Term
new RA criteria: duration 2 categories
Definition
<6wk = 0
>6wo = 1
Term
new RA criteria: phase reactant 2 categories
Definition
normal ESR/CRP = 0
abnormal ESR/CRP = 1
Term
lab data supporting RA 6
Definition
RF, anti-CCP, ESR, CRP, CBC, phase reactants
Term
what role does x-ray have in RA
Definition
obtain baseline films
ask for evidence of specific patterns
not diagnostic by itself
Term
5 categories of RA treatment
Definition
NSAID
COX-2
steroids
DMARDs
biologicals
Term
NSAID: why used in RA 2, SE 4
Definition
controls symptoms (decreases swelling and stiffness) DOES NOT ALTER COURSE OF DISEASE

GI bleed- common RA COD
renal, hepatic, cardiac
Term
COX-2: why use for RA, 3 SE
Definition
improved tolerability over NSAID

risk of bleeding, perforation, cardiac risk
Term
3 methods of steroid use in RA
Definition
intra-articular
systemic
pulse
Term
what is the DOC for RA
Definition
methotrexate
Term
7 DMARDs used in RA
Definition
methotrexate - DOC RA
hydroxychloroquine - RA
sulfasalazine - RA
Rituximab - RA
anti-TNFa - RA
penicillamine - RA
cyclosporine - RA
Term
GI, renal, signs of RA 6 - not objective
Definition
mesenteric vasculitis
ulcer disease
pernicious anemia
interstitial nernal disease
proteinuria
mesangial GN
Term
neuro signs of RA 4 - not objective
Definition
C1-C2 sublexation
entrapment neuropathy
peripherial neuropathy
vasculitis
Term
bone signs of RA 6 - not objective
Definition
osteoperosis
avascular necrosis
osteomyelitis
swelling in MCP/PIP
swan neck: flex MCP, extend PIP, flex DIP
boutineer: extend MCP, flex PIP, extend DIP
Term
hematologic signs of RA 5 - not objective
Definition
anemia, leukopenia, thrombocytopenia, lymphadenopathy, lymphoma
Term
when does structural damage usually occur in RA - not objective
Definition
2-3y after disease, slow progression is linked to early tx
progressive benign disease
Term
what RA tx prevents long term dissability and premature mortality
Definition
DMARDs - methotrexate, hydroxychloroquine, sulfasalazine, penicillamine, cyclosporine, anti-TNFs, rituximab
Term
treatment of acute gout 8
Definition
colchine immediate than 1h later
indomethacin
NSAID
pain meds
steroids
ACTH: to make their own steroids
joint injection: clotrazine if normal renal function, endothecin in liver cirrhosis

NEVER STOP ALLOPURINOL IT CAUSES JOINT TO FLARE
Term
treatment of chronic gout 7
Definition
allopurinol
febuxostaat
probenecid: increase uric acid secretion in kidney, need to prove low uric acid in urine
sulfinpyrazone
NSAID
colchicine
pegloticase
Term
location of pseudogout
Definition
exclusivly around joints
polyarticular - may mimic RA
oligoarticular - usually in eldelry
Term
signs of early/acute pseudogout 3
Definition
mimics OA
similar to gout
may have fever, leukocytosis, elevated ESR
Term
signs of late/chronic pseudogout 5
Definition
charcot joint, similar to OA
symmetrical around mostly knees, some wrist and hips
isolated patellofemoral disease
Term
cause of pseudogout
Definition
calcium pyrophosphate crystals
pyrophosphate arthropathy
Term
cause of chondrocalcinosis
Definition
Ca chyrophosphate crystals formed due to elevated inorganic phosphate in synovial fluid and NTPPPHase (nucleoside triphosphate pyrophosphorlyase)
autosomal dominant
spiratic (rare <40yo)
Term
diseases associated with chondrocalcinosis 3
Definition
RA 5% (10% RF positive)
gout 25%
OA 50%
Term
epidemiology of chondrocalcinosis
Definition
sporatic rare <40
4% of adults
50% of >90yp
Term
what diseases can lead to chondrocalcinosis (non-hereditary) 8
Definition
hemochromatosis
hyperparathyroid
hypothyroid
amyloid
hypomagnesmia
hypophosphatemia
rickets
familial hypocalcuric hypocalcemia
Term
x-ray findings in chondrocalcinosis 6
Definition
incidental
chondrocalcnosis
crowned dens: neck pain due to crystal deposits surrounding dens
cord compression
weap around patella
erosive OA
Term
lab signs of chondrocalcinosis 2
Definition
crystals in joints test positive biphringent
10% RF positive
Term
how can you distinguish between gout and chondrocalcinosis in the lab
Definition
ca chyrophosphate is positive biphringent
monosodium urate is negative biphringent
Term
TX chondrocalcinosis 5
Definition
NSAID
colchicine
steroids: injected, oral for flare
PT
surgery
Term
how can you diagnose apatite like crystals
Definition
all have Ca and cannot be seen on light microscopy so need to stain with lizerin red and convasa back stain (Ca makes black flecks)
crystals not visible on microscopy
alizaren red stain red
von kossa stain black
Term
2 type sof apatite like crystals
Definition
carbonate substituted apatite
octacalcium phosphate
tricalcium phosphate
dicalcium phosphate dihydrate (brushite)
Term
6 apatite like diseases
Definition
bursitis
tendonitis
arthritis
renal failure
epiphyseal dysplasia
destructive OA
Term
things associated with urate increase 14 - not objective
Definition
estroegn
alcohol
age
BUN/CR
obesity
DM
TG
HTN
athlerosclerosis
hypothyroid
syndrome X
pregnancy
acute illness
dehydration
Term
negative associations with gout 3 - not objective
Definition
RA, SLE, ankylosing spondylitis
Term
causes of primary hyperuricemia 3 categories with many examples - not objective
Definition
inhibition of tubular urate excretion: DKA, lactic/keto acidosis, MSUD

Drug/toxin: hyperparathyroid, lead, cyclosporine, ASA, ethembutol, pyrzidamide, nicotinic acid, ethanol

over production: diet, muscle excretion, psoriasis, myeloproliferative, hemolytic, lymphoproliferative, glycogen storage diseases, G6PDH deficiency, Fructose-1-P aldolase deficiency, HGPRT, PRPP synthease superactivity
Term
progression of gout - not objective
Definition
1. asymptomatic hyperuricemia
2. acute gout: hot painful swollen red joint
3. incurrent period
4. chronic gout
Term
most common locations of gout - not objective
Definition
big toe #1
wrist, finger, elbow
hip - least common
Term
indications of treatment of gout 6 - not objective
Definition
acute gout
trophi (nodules on finger / outer ear with white)
uric acid stones
uric acid nephropathy
interstitial nephritis
repid: teeth marks on bony erosions on xray
Term
what is the goal uric acid level of someone with gout - not objective
Definition
<6 (saturation is 6.7)
Term
SE clochicine 3
Definition
dose related diarrhea (stop at diarrhea, severe SE soon)
aplastic anemia
death
Term
define fibromyalgia
Definition
chronic widespread musculoskeletal pain syndrome with tender points at discrete sites
Term
associated conditions with fibromyalgia 4
Definition
80% SLE
13% sleep apnea
15% OA
2% RA
Term
epidemiology fibromyalgia
Definition
2% population
3-6 million people
5% of general medical practice
female 40-60yo
Term
economic impact of fibromyalgia
Definition
10% work disabled
8 seperate physician evaluations cost of 5+ years prior to diagnosis
Term
myths of fibromyalgia 5
Definition
it isnt real disease
crazy women
it is just depression
its all in their head
waste basket diagnosis for all chronic pain and complainers
Term
facts of fibromyalgia
Definition
it has been described in medical lit for 200y
research proves existance in pt with no psych illness
classifications based on ACR in 1990 revised in 2012
Term
DDX of fibromyalgia 5
Definition
thyroid disease
sleep apnea
psychogenic rheumatism
chronic fatigue syndrome
myofascial pain syndrome
Term
lab signs of fibromyalgia
Definition
increased substance P
decreased epinepherine
decreased serotonin
Term
sleep signs of fibromyalgia 5
Definition
nonrestorative
alpha wave intrusion
decreased stage 3-4
moldofsky et al
fatigue
Term
physical symptoms of fibromyalgia 6
Definition
persistent generalized pain
headache
abdominal pain
numbness
swelling
temperature sensitivity
Term
psychological symptoms of fibromyalgia 4
Definition
mood disturbance
numbness
anxiety
depression - most common
Term
pathology of fibromyalgia
Definition
decreased cerebral blood flow to the caudate nucleus
Term
new criteria for fibromyalgia diagnosis
Definition
history of widespread pain for >3mo
no other condition causing symptoms

note number of areas of pain in teh past week:

chest
back
neck
jaw
abdomen
shoulder girdle
upper arm
lower arm
upper leg
lower leg
buttock or trochanter

diagnostic if severity >5 and widespread pain >7
OR severity >9
Term
what is the severity scale based on 3
Definition
cognitive symptoms
waking unrefreshed
somatic symptoms: pain, fatigue, IBS, nervousness
Term
old criteria for fibromyalgia diagnosis - requirements 7
Definition
history of widespread pain >3mo
no other condition causing symptoms
pain on left side of body
pain on right side of body
pain above waist
pain below waist
axial skeletal pain
Term
old criteria for fibromyalgia diagnosis - 9 trigger points
Definition
pain in 11/18 trigger points required

occiput
lower cervical (C5-7)
trapezius: midpoint upper border
supraspinatus: border of scapula
2nd costochondral junction
lateral epicondyle
gluteal
greater trochanter
knee: medial fat pat
Term
diagnostic tests for suspected fibromyalgia 6
Definition
labs: normal
x-ray: normal
muscle biopsy: normal
sleep study
CSF
always check TSH
Term
treatment of fibromyalgia - not objective
Definition
support groups
sleep training
consult: rheumatologist, PMNR, psychologist, psychitraist, counsler, PT

injections, biobeedback, acupuncture, massage, ultrasound

aerobic conditioning exercise 30 min daily no excuses

NSAID, analgesics, hyponotics, SSRI, steroids
Term
myofacial pain syndrome vs fibromyalgia: pain, fatigue, AM stiffness, tender points, prognosis, treatment
Definition
pain: F: diffuse M: local
fatigue: F: common M: not
AM: F: common M: not
tender point: F: diffuse M: local
prog: F: chronic M: resolve/relapse
tx: F: exercise, meds M: local
Term
chronic fatigue syndrome vs fybromyalgia: cause, myalgias, fatigue, sleep, depression, onset, fever, pharyngitis, adenopathy
Definition
cause: F: unk C: viral
myalgia: F: chronic C: chronic
fatigue: F: chronic C: chronic
sleep: F: poor C: poor
depression: F: common C: common
onset F: gradual C: acute
fever F: none C: low grade
pharyngitis F: no C: yes
adenopathy: F: no C: yes
Term
feinbergs 3 rules of rheumatology
Definition
use your brain, hx, physical. lab is secondary
always remember lupus is true systemic disease
always ask is it more likley lupus or something else causing the symptoms today
Term
epidemiology lupus
Definition
17-40yo
female > male
more common in black than white
Term
SLE old criteria
Definition
4/11

MALAR RASH
PHOTOSENSITIVE RASH
DISCOID RASH
ORAL ULCERS
SEROSITIS
ARTHRITIS
CNS
RENAL
ANA
HEMATOLOGIC
LAB: ANDI-dsDNA, ENE, OR VDRL
Term
new SLE criteria (general description)
Definition
posiive renal biopsy with ANA or anti-dsDNA
OR
4 criteria (1 clinical, 1 immunological (lab), 1 skin reaction, 1 any additional)
Term
what are the clinical criteria for new SLE criteria 9
Definition
oral or nasal ulcers
nonscarring aloplecia
serositis
arthritis
renal: 500mg protein in 24h urine, RBC casts
neurological lupus signs
hemolytic anemia
leukopenia
thrombocytopenia
Term
what are the signs of neurological lupus 6
Definition
seizure
psychosis
monpneuritis multiplex
myelitis
peripheral/cranial neuropathy
acute confusion
Term
what are the labs signs of lupus clinical criteria 6
Definition
ANA
anti-dsDNA
anti-SM
anti-phospholipid Ab
low complement (C3, C4, CH50)
direct coombs in absence of hemolytic anemia
Term
what are the 3 skin reaction types in lupus
Definition
acute cutaneous
subacute cutaneous
curonic cutaneous - scaring
Term
6 acute cutaneous lupus rashes
Definition
malar rash: spares nasolabial folds and under lips
billous lupus
photosensitive rash
oral apothous ulcers
maculopapular lupus
toxic epidermal necrolysis
Term
7 chronic cutenous lupus rashes
Definition
discoid lupus
lcalized - above neck
generalized - below beck
chillblains
hypertrophic (verucous)
lupus erythemaatosis tumidus
lupus panniculitis (profundus)
Term
what is a rheumatoid profile 4
Definition
ANA
RF
uric acid
ESR
Term
4 varients of RA
Definition
subacute/chronic cuteneous lupus
discoid: scarring rash with central atrophy
lupus perino: variant of sarcoidosis
systemic SLE
Term
signs of subacute/acute cutaneous lupus 3
Definition
non-fixed rash
non-scaring
SS-A antibody
Term
signs of lupus pernio 3
Definition
violacious plaques over face and ears
hepatic granulomas
hepatomeagly
Term
proven causes of drug induced lupus 7
Definition
procanamide
isoniazide
hydralazine
methyldopa
chlorpromazine
dilantin
quinidine
penicillamine
Term
possible causes of drug induced lupus 2
Definition
riseofulbin antibiotics
gold salts
Term
labs of drud induced lupus 2
Definition
ANA+ for 1y
ANTI-HISTONE ANTIBODY POSITIVE (watch out can be positive in SLE)
no change in complenent
CNS/Renal disease rare
Term
what lab must be positive to diagnose lupus
Definition
ANA, watch out often false negative
Term
lab signs of lupus 19
Definition
ENA-SSA Ro: shograns
ENA-SSB-La: shograns B
ENA-RMP: CT disease
ENA-SM: anti-smith
ENA-SCL-70: scleroderma
ENA-PM-1: polymyositis
ENA-histone
ENA-centromere
anti-dsDNA
VDRL: syphillis false positive
anti-ribosomal P protein: CNS lupus
B-ANA
anti-phospholipid Ab
CBC
ESR
BUN/CR
CRP
PT/PTT/INR
complement
Term
treatment lupus - not objective
Definition
control symptoms, none prevent progression
hydroxychloroquine
azothiaprim
methotrexate
steroids: life saving for brain involve
cyclophosphamide: DOC for CNS/renal
mycofenolate mofetil: DOC lupus nephritis in AA
marrow transplant
Term
systems that SLE affects
Definition
HEENT
CV
pulmonary
GI
GU
MSK
skin
psych
neurology
renal
Term
list a bunch of SLE signs - not objective
Definition
aloplecia
rashes
dysphagic
iritis, uvitis, conjunctivitys
sicca
nasal and oral ulcers
pericarditis, myocarditis
pericardial effusions
conduction abnormalities
tamponade
libman sacs endocarditis
vasculitis
raynauds
pleural effusions, pleuritis
pneumonitis
pulmonary emboli
shrinking lung (diaphram weak)
pancreatitis
mesenteric vasculitis
lupus peritonitis (small vessel vasculitis)
impaired fertility
pregnancy complications
vaginal dryness
neurogenic bladder
interstitial cystitis
dysmenorrhea
amenorrhea
oligomenorrhea
prostatitis
inflammatory arthritis: sublexation of MCP
avascular necrosis
malar, photosensitive, discoid, or bullous rash
livedo reticularis
lupus profundus/panniculitis
psychosis, depression
sleep disturbance
white matter plaquest
seizure, stroke, coma
subarachnoid hemorrhage
dementia ataxia
corea, tremor, rigidity
transverse myelitis
gullian barre
hemibalismus
mononeuritis multiplex
IgG deposits on nephron
mesangial lupus nephritis
focal proliferative lupus nephritis
diffuse proliferative glomerulonephritis
membranous glomerulonepheitis
sclerosing GN
Term
what is libman sacs endocarditis - not objective
Definition
warts/rugae on mitral in SLE
Term
antiphospholipid syndrome: criteria, labs, diagnosis, tx - not objective
Definition
vascular thrombosis and pregnancy related morbidity (miscarrage, blood clots, preeclampsia, eclampsia)

lupus anti-coagulant, aCL antibody, anti-B2 glycoprotein

1 clinical and 1 lab criteria

aspirin for life with lupus, cumidin for life it had clot
Term
what are the varients of scleroderma 6 - not objective
Definition
Localized: morphea
localized: linear
CREST
shulman's syndrome
progressive systemic sclerosis
toxic scleroderma
Term
localized scleroderma: signs, tx - not objective
Definition
thickening and hardened skin usually on extremities, no organs involved, that can retract skin
no tx
Term
what does CREST stand for - not objective
Definition
calcinoids: puss like
raynauds: vasospasm (cyanotic>red)
esophageal motility
scleroderma: localized linear
telangestica toxic
Term
shulman's syndrome: signs - not objective
Definition
when do do aerobic exercise with get patch of scleroderma
usually following trauma of single limb
Term
progressive systemic sclerosis signs 7
Definition
thickening and hardening of a tissue
pulmonary fibrosis
cardiac fibrosis: arrhythmias
renal A fibrosis: seen hypoten so systemically causes HTN
skin pulled tight, no wrinkles
raynauds
sicca complex
Term
major criteria for scleroderma diagnosis
Definition
proximal slceroderma
Term
minor criteria for scleroderma diagnosis 3
Definition
must have 2
sclerodactyly
digital pitting scars
bibasilar pulmonary fibrosis
Term
research criteria for scleroderma diagnosis 9
Definition
must have all

skin thickeniing proximal to MCP
skin thickening distal to MCP
puffy fingers: non-pitting edema
digital ulcers
digital pitting scars
telangestica
abnormal nailfold capillaries
raynauds
antibodies
Term
treatment for scleroderma - not objective
Definition
penicallamine, steroids, methotrexate, cyclophosphamide
immune supression
marrow transplant
Term
criteria for sjogers diagnosis 3 - not objective
Definition
positive lab: SS-A/SS-B OR RF/ANA
minor salivary biopsy
keroconjundtivitis sicca
Term
many signs of sjogerns - not objective
Definition
ocular dryness, pain, itch
dilated conjunctiva vessels
decreased salivary flow and dry mouth
oral candidiasis
dental carries
chronic bronchitis
interstitial pneumonitis
pseudolymphoma
pleural effusions
pulmonary HTN
atrophic gastritis
biliary cirrhosis
sclerosing cholangitis
vaginal dryness
raynauds
vasculitis
neutropenia
anemia
thrombocytopenia
lymphoma
angioblastic lymphadenma
glomerulonephritis
mixed cryoglobulinemia
amyloidosis
renal artery vasculitis
tubuloinerstitial nephritis
thyroiditis
myalgias
peripherial neuropathy
mononeuritis multiplex
Term
secondary causes of sjogerns 5 - not objective
Definition
RA, SLE, PSS, polyomyositis, primary biliary cirrhosis
Term
4 seronegative spondyloarthropathies
Definition
ankylosing spondylitis
psoriatic arthritis
reiter syndrome
enteropathic arthritis
Term
what seronegative spondyloarthropites is male predominated
Definition
ankylosing spondylitis
Term
diagnostic criteria for ankylosing spondylitis 7
Definition
low back pain for 3mo
cannot get head against wall spine fused
decreased ROM in spine
decreased chest expansion
symmetric fused SI (progresses up spine)
lumbar limitation in sagital and frontal
bilateral/unilateral sacroilitis - REQUIRED
Term
genetic sign of ankylosing spondylitis
Definition
HLA-B27 positive
higher in caucasian
Term
akylosing spondylitis: signs in back 6, chest 2, joints 3
Definition
back pain: dull, diffuse, improves with activity, insidious, 3mo min, worse in morning

chest: pain worse with cough/sneeze, fusion of costovertebral joints

joints: more in kid form, hip and shoulder most common, TMJ in 10%
Term
akylosing spondylitis: signs in eye 3, renal 1, systemic 4
Definition
eye: iritis, uveitis, sterile conjunctivits

renal: IgA nephropathy

systemic: fatigue, weight loss, temp, malaise
Term
akylosing spondylitis: CV signs 5
Definition
ascending aoritis
aortic insufficiency
conduction abnormalities: SVT, AFib
cardiomeagly
pericarditis
Term
akylosing spondylitis: pulmonary signs 3, neuro signs 3
Definition
pulmonry: decreased volume, ibrosis, aspergillus (likes fibrotic lung)

neuro: AA sublexation, nerve compression, cauda equine syndrme
*due to fracture, no shock absorption
Term
6 x-ray signs of akylosing spondylitis
Definition
sacroilitis
whiskering
osteoperosis: brittle bones without stress
bamboo spine: white between vertebrae
syndesmophytes: verticle growing spurs
calcification of anterior longitudinal ligament: fuses sacrum
Term
2 physical exam tests of akylosing spondylitis - not onjective
Definition
schober test: test spinal movility ASIS/5th vertebrae <15cm movement

chest expansion: <5cm movement
Term
tx akylosing spondylitis - not objective
Definition
posture, pain control, sleep habits,
methotrexate, sulfasalazine
no sports
anti-TNFa
Term
reactive arthritis: signs 3 categories - not objective
Definition
cannot see: conjunctivitis, iritis, uveitis

cannot pee: painless ulcer of penis, IgA nephritis, urethritis 1-2wk after GI infection

cannot climb a tree: aortic regurgitation, conduction abnormalities, fatigue, arthritis 1-2wk after exposure
Term
reactivie arthritis causes 6 - not objective
Definition
salmonella, shigella, yersenia, HLA-B27, yersinia, chalmydia
Term
reactive arthritis x-rays signs 4 - not objective
Definition
asymmetric
erosions of small joints hands/feet, SI
sacroilitis
asymmetric spondylitis: skip lesions, comma ossifications
Term
tx teactive arthritis - not objective
Definition
systemic: sulfasalazine, methotrexate, anti-TNFa (in spinal form stops progression)

eye: antibiotic drops, steroid drops

joint: NSAid, steroid injections

skin: topical steroid, PUVA
Term
epidemiology of psoriatic arthritis
Definition
7-42% of those with psoriasis have psoriatic arthritis
2-7% with psoriatic arthritis has psoriasis
Term
psoriatic arthritis causes 6
Definition
genetic: HLA-B27 (high in those with spinal disease), HLA-DR7 (high in those with psoriasis)

environmental

immunogenic: decreased CD4, increased IL-1B, increased leukotriene B4
Term
clinical signs of psoriatic arthritis 12
Definition
DIP
asymetric oligoarthritis
sausage digit
arthritis multilans
spondyloarthropathy
skin psoriasis
nails: pitting, ridges, onchoyolysis
eye: conjunctivitis, iritis
enthesopathy
Term
labs in psoriatic arthritis 3
Definition
NOT DIAGNOSTIC
ESR elevated
hypergamaglobulinemia IgA
elevated complement
Term
x-ray signs in psoriatic arthritis 5
Definition
asymmetric
DIP
sacroilitis
pencil in cup deformity
bone erosions
Term
treatment psoriatic arthritis 3
Definition
NSAID
steroids
DMARDS: methorexate DOC

DMARDS also: gold salts, penicillamine, asothiaprime, cyclosporine, antimalarias
Term
enteropathic arthritis - not objective
Definition
ulcerative colitis or chrons leads to peripherial arthritis or spinal arthritis

migratory oligoarthritis, apthous ulcers, liver disease, uveitis, clubbing, vasculitis, pyogerma gangrenosum

ESR elevated, RF negatie, ANA either positive or negative
Term
whipples disease - not objective
Definition
middle age white male with diarrhea, wasting, joint inflammation, PAS+ macrophages, rash, SQ nodules, clubbing, pleuritis, sudden cardiac death, aortic insufficiency, thyroiditis, nephritis, liver disease, uveitis, hyperpigmentation
Term
collagenous colitis - not objective
Definition
intermittent diarrhea and bleeding
10% have arthritis
linear deposit of hayline in colon subepithelium
Term
poncets disease - not objective
Definition
sterile arthritis in pt with extra-pulmonary TB
puyrexia, weakness, peripheral arthritis, lymphadenopathy
Term
gluten sensitive enteropathy - not objective
Definition
celiac disease
arthritis of large joints
sjogerns
Term
bypass arthritis - not objective
Definition
bacterial overgrowth within 1y post gastric bypass

raynauds, uricaria, e. nodosum, papules, painful, ESR elevated, cryoglobulins

antibiotics, NSAIDs
Term
osteomyelitis definition
Definition
inflammation of the bone caused by pathogenic organism
Term
how does osteomyelitis happen 4
Definition
hematogeosus spread from any location (pneumonia, surgery, abscess, trauma)

contigous spread: cutaneous ulcer, infected joint or prosthetic, abscess
Term
microbes in osteomyelitis 12
Definition
S. aureus
coag negative staph
strep
polymycrobial - esp foot
salmonella - esp sickle cell
gram negative
candidia - HIV
M. kanasii - HIV
nocardia asteroides - HIV
histoplasmosis - compormised
coccidiomycosis - compormised
blastomycosis - compormised
Term
signs of acute osteomyelitis in kids 4 and adults 4
Definition
adult: fever, point tenderness, muscle spasm, vague pain

kid: acute onset fever, chills, lethargy, irritability
Term
signs of chronic osteomyelitis 6
Definition
night sweats, low grade fever, weight loss, draining sinus, muscle spasm, point tenderness
Term
sighs of TB osteomyelitis 4
Definition
weight bearing joints affected
potts: TB of spine that destorys disc
vertebral collapse
spinal cord compression
Term
labs of acute osteomyelitis 6
Definition
increased ESR, WBC, phase reactants
positive urine culture
positive bone biopsy
positive blood culture
Term
labs of chronic osteomyelitis 3
Definition
increased ESR
normal WBC
negative cultures/biopsy
Term
signs of osteomyelitis of x-ray 2
Definition
not positive for 10d
lytic lesions not present for 6wk
Term
explain the control of thyroid hormone release
Definition
TRH released from hypothalamus stimulates anterior pituitary to release TSH and prolactin

TSH from thyrotrope cells stimulates synthesis of thyroglobulin, iodine uptake, iodiniation of TGB to T3/T4, storate of T3/T4, release of T3/T4

increased T3/T4 cause feedback to hypothalamus and pituitary
Term
which thyroid hormone is more active, which is more prevalent, why does this not matter
Definition
T3 IS MORE ACTIVE
T4 is more prevalent
T4>T3 by 5-deiodinase in the tissues
T3/T4 bound to albumin is unavailable
Term
what increase TBG 6
Definition
estrogen
OPC/pregnancy
tamoxifen
hepatitis
biliary cirrhosis
narcotics
Term
what decreases TBG 3
Definition
androgens
glucacorticoids
nephrortic syndrome
Term
what blocks conversion of T3/T4 (4)
Definition
propranolol
steroids
PTU
methimazole
Term
what blocks synthesis of T3/T4 (5)
Definition
lithium
iodine
amiodarone
PUT
methimazole
Term
what are the thyroid function tests 6, which is test of choice
Definition
serum TSH - TEST OF CHOICE
TRH stimulation
free T4
thyroid U/S
thyroid scan
radioactive iodine uptake
Term
Serum TSH: normal levels, what does it indicate
Definition
SCREENING TEST OF CHOICE FOR THYROID FUNCTION

NORMAL 0.5-5 UU/ML

knowning TSH and free T4 can dx most disorders
Term
thyroid ultrasound: what does it determine, how is it done
Definition
determines size and monitors change
can be used for guiding fine needle aspiration
solid nodule: possible malignancy
cystic nodule: usually benign
Term
thyroid scan: how is it done, what does it determine
Definition
radioiodine or scintillation scan uses isotopes to mesure thyroid activity

hot nodule: functional more likley benign

cold: non functional more likley malignant
Term
radioactive iodine uptake: how is it done and interperteted
Definition
give radioactive I, 24h later detect percent taken into thyroid
used to differentiate between thyroid disorders
Term
diseases causing increased radioactive iodine uptake 4
Definition
graves
TSH secreting tumor
hot nodules: toxic adenoma, toxic multinodular goiter
Term
diseases causing decreased radioactive iodine uptake 8
Definition
thyroditis: painless, autoimmune, post partum, subacute, amiodarine induced
thyroditis factitia: exogenous thyroid
iodine excess: contrast dye, diet, amiodarone
Term
what does amiodarone have to do with iodine 3
Definition
iodine rich so blocks peripheral conversion of T4>T4
can induce thyrotoxicosis: iodine induced hyperthyroid (type 1), destructive thyroiditis (type 2)
Term
explain how to evaluate a thyroid nodule
Definition
if TSH is low get thyroid scan and RAIU, if nodule is functioning it has no malignant potential

if TSH is high then nodule is not functioning get thyroid U/S
...if benign serial follow up
...if insufficient repeat FNA
...if follicular neoplasm get surgery
...if malignant get surgery
Term
when do you biopsy a thyroid nodule
Definition
NODULE > 1CM!
NODULE < 1CM IF...
...family hx, cervical lymphadenopathy, suspicious of cancer (hypoechogenicity, central vascularity, microcalcifications), incidental thyroid nodule
Term
symptoms of hypothyroidism 12
Definition
fatigue
dyspnea
cold intolerance
dry skin
constipation
weight gain
poor appetite
horse voice
difficult concentrating
menstural irregularities
diffuse aloplecia
myexedema: puffy hands, face, feet
bradycardia
serous cavitary effusion
delayed DTR / relaxation
carpel tunnel syndrome
Term
causes of primary hypothyroidism 10
Definition
autoimmine: hashimotos - most in US
iratogenic: iodine, thyroidectomy, radiation to neck
congenital
infiltrative disorders
iodine excess: amiodarone, IV dye
lithium
anti-thyroid drugs
iodine deficiency
post-partum thyroiditis
in course thyroiditis (burn out)
Term
diagnosis of subclinical hypothyroidism 2
Definition
high TSH
normal T4
Term
tx subclinical hypothyroidism
Definition
recheck and repeat labs in 6wk
tx those at risk for hypothyroid (TSH >10, pregnant, anti-TPO Ab, family hx, goiter)

30% convert to hypothyroid
Term
treatment of hypothyroid: normal, secondary, pregnancy, emergency
Definition
levothyroxine: start low, increase over 2wk, monitor TSH (lags by 6wk)

secondary hypothyroid: replace cortisol

pregnancy hypothyroid: always tx, monitor for thyroxine need

emergency hypothyroid: never postpone emergency surgery
Term
SE levothyroxine
Definition
caution in cardiac and elderly pt
Term
symptoms of hyperthyroid 20
Definition
hyperactivity
irritability
palpitations
tachycardia/AFib
heat intolerance
sweating
fatigue
weakness
weight loss
increased appetite
diarrhea
oligomenorrhea
loss of lobido
tremor
proximal myopathy
lid retraction/lag
goiter
gynecomastic
opthalmopathy and dermopathy in graves
Term
lab signs in hyperthyroid 4
Definition
decreased TSH, N-T4
increased T4, total T3
watch for T3 toxicosis
Term
causes of primary hyperthyroid 3
Definition
graves
toxic multinodular joiter
toxic adenoma
Term
causes of secondary hyperthyroid 2
Definition
TSH mediated increase in T4/TSH
pituitary adenoma
Term
stages of thyroid damage
Definition
1. release: thyrotoxic
2. recovery: hypothyroid
3. euthyroid: normal thyroid
Term
diseases caused by thyroid damage 4, which are painful, which are painless
Definition
subacute thyroiditis/de-quervan (painful)
postpartum thyroiditis (painless)
early hashimotos
destructive thyroiditis
Term
treatment of hyperthyroid symptomatic
Definition
BB - propranolol
Term
treatment of hyperthyroid therapeutic 4
Definition
antithyroid drugs: methimazole DOC, PTU DOC in pregnancy

radioactive iodine: good for goiter

surgery: causes hypothyroid, often needed in second trimester of pregnancy
Term
thyroid storm signs 4 and tx - not objective
Definition
fever, delirium, tachycardia, hypotension

emergency: BB, antithyroid (PTU), iodine, stress steroids, tylenol, fluids, cooling blanket
Term
cause, signs, TX of graves disease - not objective
Definition
IgG to TSH receptors increases free T4
thyrotoxicosis
goiter: diffuse, soft, symmetric
opthalmopathy: PROPOPTOSIS
dermopathy: periorbital myexedema
AFib/CHF in elderly

TX: thyroid ablation, PTU/methimazole, surgery
Term
SE of methamiazole and PTU 3
Definition
AGRANULOCYTOSIS, HEPATOTOXICITY
METHIMAZOLE CAN CAUSE APLASIA CUTIS IN FETUS
Term
what are the general characteristics of a benign thyroid nodule, what is the tx - not objective
Definition
solitary, cold 85% benign
95% solid nodules benign
100% hot cystic benign

tx complications: compression, neck pain, cosmetic, anxiety

sclerosing agents: ethanol, tetracycline, unilateral lobectomy
Term
what are the types of thyroid cancers and their prevalence 5
Definition
thyroid adenoma: benign
papillary carcinoma - most common
follicular carcinoma - less common
anaplastic carcinoma - rare
medullary carcinoma - sporatic
Term
thyroid adenoma: morphology, athogenesis, tx - not objective
Definition
hyperfunctioning non-TSH dependent thyroid tissue, benign, slow, follicular, solitary

if hot: large hyperfunctioning nodule in turned off thyroid

if cold: hemorrhagic necrosis causes pain and loss of function

TX: ablation, PTU/MMZ
Term
prognosis and tx of the 4 thyroid carcinomas - not objective
Definition
papillary: indolent, lymph spread, 95% 5y

follicular: NEEDS BIOPSY, MIMICS NORMAL TISSUE, hematogenous spread to lung and bone

anaplastic: very malignant, rapid, poor prognosis

medullary: distant metastasis, often with MEN2A/B, high serum calcitonin, cervical lymphadenopathy
Term
treatment for thyroid carcinoma - not objective
Definition
total thyroidectomy then total body scan
replace with synthroid
maintain TSH 0.5-2 to prevent hypertrophy of remnant

OR

radioactive ablation: TBG IS USED AS TUMOR MARKER NOT SCREEN
Term
DDX of a painful anterior neck mass 4
Definition
SUBACUTE THYROIDITIS
hemorrhage into thyroid cyst
acute suppurative thyroiditis
rapid growth of thyroid cancer or tumor
infected thyroglossal duct cyst or branchial cleft cyst
cellulitis of anterior neck
radiation thyroiditis
Term
what is the screening redigmein for the thyroid - not objective
Definition
WOMEN 35-50YO
(men >35?)
TSH assay repeat q5y if F-T4/TSH normal
Term
what are the 2 types of goiters and their tx - not objective
Definition
nontoxic: normal TSH/T4, tx if causing compression of trachea, veins, or going into thoracic via thyroidectomy or ablation

toxic: patchy hot nodules, high T3/T4, iodine ablation, anti-thyroid therapy life long
Term
hashimotos thyroiditis: signs 7
Definition
thyroid is NON-TENDER, firm, mild enlargement
chronic lymphocytic thyroiditis
GOITER, smooth symmetrical firm
metabolic normal
slow progression
LOW RAIU (GRAVES IS HIGH)
TPO-AB LEVELS HIGH
Term
post partum thyroiditis signs 3
Definition
PAINLESS SILENT
resolves in 8-12mo
hyperparathyroid in mo 1 then hypothyroid

ALWAYS TREAT
Term
when toes radiation thyroditis occur - not objective
Definition
7-10d post radiation
Term
subacute thyroiditis: signs 7
Definition
VERY TENDER THYROID
pain radiates to ears
POST VIRAL URI OR PHARYNGITIS
thyrotoxic then euthyroid
SELF LIMITED 1-2WK
LOW RAIU
HIGH ESR
Term
tx subacute thyroditis 2
Definition
ASA AND STEROIDS FOR INFLAMMATION
Term
functions and regulation of PTH
Definition
release: low Ca, high P, epinepherine
inhibits: high Ca, VITAMIN D

stimulates osteoclasts
stimulates VITAMIN D PRODUCTION
increases Ca reabsorption
decreases P reabsorption
Term
signs of hypercalcemia - not objective
Definition
bones: oseoperosis, bone pain
stones: kidney, nephrogenic DI, polydupsia, dehydration
groans: ulcers, dyspepsia, constipation, vomiting
psychic overtones: fatigue, forgetfulness, weakness, coma

EKG: PVC, short QT
Term
causes of hypercalcemia 12
Definition
primary hyperparathyroid
lymphoma
solid tumor: breast, SCC lung
VITAMIN D: INTOXICATION, SARCOIDOSIS
hyperthyroidism
immobilization
thiazides
vitamin A intoxication
milk alkali syndrome
addisons disease
Term
diagnosis of hypercalcemia
Definition
elevated PTH and CA: primary hyperparathyroid

normal PTH or low with high Ca: PTH related peptide, VITAMIN D CAUSED
Term
primary hyperparathyroid lab signs 4
Definition
high Ca, PTH, urine Ca >400 mg/24h
low P
Term
primary hyperparathyroid tx 7
Definition
surgery: radioguided minimal access

non surgery
..follow biannually with serum Ca
..follow annually with serum CR and DEXA scan
..modest Ca intake 1000-1200 mg and VITAMIN D 400-600mh
..bisphosphonates if osteopenic
..hydration, avoid thiazide diuretic
Term
indications for surgery primary hyperparathyroid 5
Definition
elevated serum Ca >1mg.dl
CR clearance < 60ml/min
age <50
bone density <-2.5
previous fragility fracture
medical surveillance not possible
Term
secondary hyperparathyroid: cause 2, labs 3, tx 5
Definition
cause: malabsorption, renal disease

labs: low Ca and VIT D, high PTH

tx: Ca, VIT D, decrease P
cinacalet if due to ESRD on dialysis
calcimimetic increases PTH receptor sensitivity
Term
tertiary hyperparathyroid: cause, tx
Definition
secondary progresses to autonomous production of PTH

parathyroidectomy
Term
tx of acute hyperparathyroid 5
Definition
volume replacement NS 200-300ml/h maintain urine >100ml/h (euvolemic)

bisphosphonates: inhibit bone resorb
calcitonin: if severe hypercalcemia
prednisone: if hematologic malignancies, sarcoidosis, VIT D TOXICITY
gallium nitrate: inhibit osteoclast and PTH secretion
Term
what do you do if there is volume overload during hyperparathyroid tx
Definition
add furosemide NO THIAZIDES
Term
bisphosphonates: 2 drugs, effect timeline
Definition
pamidronate: effects for 1-2wk
zoledronate: effects for 4wk, more potent

lag in onset, combine with IVF or calcitonin
Term
calcitonin: why use, when it takes effect
Definition
severe hypercalcemia
rapid response
decreases in 4-6h
gone in 48h
Term
SE gallium nitrate
Definition
nephrotoxicity
Term
which calcium disorder is most common
Definition
hypocalcemia, in 50% of ICU patients
Term
causes of hypocalcemia 20
Definition
hypoparathyroid: post-surfical, digeorge, infiltrative

DISORDERS OF VITAMIN D METABOLISM: NO SUNLIGHT, DERMATOLOGICAL DISORDERS, DIET DEFICIENCY, MALABSORPTION, RENAL DISEASE, LIVER DISEASE, RESISTANCE

PTH resistance: pseudoparathyroidism

hypomagnesia

anticonvulsants enhance VITAMIN D catabolism

cimetidine: decrease Ca absorption

extravascular resistance: pancreatitis, rhabdomyolysis, tumor lysis syndrome

sepsis

acute respiratory alkalosis

pseudohypoparathyroidism
Term
pseudohypoparathyroidism; cause, aka, 3 signs, 3 labs
Definition
post-receptor resistance to effect of PTH
aka albright disease

short stature, short digits, MR

low Ca, high PTH, high P
Term
signs of hypocalcemia 15 (3 severe, 2 chronic)
Definition
SEVERE: HYPOTENSION, SEIZURE, DEATH

chronic: cararacts, basal ganglia calcification

increased excitability of nerves and muscles: paresthesias, myalfias, chevosteck and trosseau sign

lethargy, laryngospasm, CHF, prolonged QT, biliary colic, steatorrhea
Term
causes of low PTH and hypocalcemia 2
Definition
hypoparathyroid, Mg <1 (impairs PTH secretion)
Term
causes of high PTH and hypocalcemia 2
Definition
vit D deficiency, pseudoypoparathyroid
Term
what level of Ca indicates hypocalcemia
Definition
<8.5 mg/dl
Term
causes of high P and hypocalcemia 2
Definition
primary hypoparathyroid
pseudohypoparathyroid
Term
causes of low P and hypocalcemia 2
Definition
secondary hypoparathyroid
VITAMIN D DEFICIENCY
Term
treatment of acute hypocalcemia 3
Definition
always correct Ca to albumin level (may falsley low in hypoalbuminemia)

emergency: symptomatic or prolonged QT: Ca glyconate DOC, Ca chlorid

if hypomagnesia is cause give Mg sulfate
Term
SE of Ca glyconate and Cal chlorid
Definition
tissue necrosis
Term
why do you not give bicarbonate or phosphorus in severe emergent hypocalcemia
Definition
can form insoluble Ca salts
Term
tx asymptomatic hypocalcemia 4
Definition
oral Ca carbonate: 1500 mg/d DOC goal Ca >8 (if gets hypercalcuria add thiazide)

VITAMIN D SUPPLEMENTS 50,000 UINT/WK
calcitrol in renal failure

phosphate binder if P >6: calcium calcitrate or calcium acetate

monitor Ca q3-6mo
Term
what is the dx is Ca is >13? what if they had Ca kidney stones? what if they have hypercalcemia for >6mo?
Definition
malignancy until proven otherwise

if has stones likely benign

if >6mo likely benign
Term
primary causes of adrenal insufficiency 7
Definition
autoimmune
TB
fungal
metastic cancer
adrenal hemorrhage
ectomidate
ketoconazole
Term
central causes of adrenal insufficiency 6
Definition
steroid
hypothalamus
pituitary adenoma
crainopharyngioma
sarcoidosis
cranial irritation
Term
signs of primary adrenal insufficiency 12
Definition
salt craving
postural dizziness
dehydration
hypotension
fatigue
nausea
anorexia
weight loss
abdominal pain
decreased lobido
decreased pubic and axillary hair
hyperpigmentation
Term
signs of central adrenal insufficiency 8
Definition
fatigue
nausea
anorexia
weight loss
abdominal pain
decreased lobido
decreased pubic and axillary hair
dehydration and slight decreased BP
Term
primary adrenal insufficiency lab signs 12
Definition
low cortisol, DHEA, ALD, Na, glucose, leukopenia

high ACTH, renin, K, eosinophilia

poor response to cosvnotropin

azotemia
Term
central adrenal insufficiency lab signs 9
Definition
low cortisol, DHEA, ACTH, Na, glucose, leukopenia

high eosinophilia

poor response to cosvnotropin

azotemia
Term
treatment of primary adrenal insufficiency 2
Definition
corticosteroid and mineralcorticoid replacement
Term
treatment of central adrenal insufficiency
Definition
corticosteroid replacement
Term
what is the mineralcorticoid and corticosteroid used in adrenal insufficiency
Definition
hydrocortisone
fludrocortisone (mineralcorticoid)
Term
4 thyroid disorders and their ALD and cortisol levels - not objective
Definition
primary hypercortisolism: inc cortisol, dec ACTH

secondary hypercortisolism (pituitary): inc cortisol, inc ACTH

primary hypocortisolism (addisons): dec cortisol, inc ACTH

secondary hypocortisolism (pituitary): dec cortisol, inc ACTH
Term
exogenous and endogenous causes of cushings - not objective
Definition
ACTH dependent: pituitary adenoma, SCLC, pancreatic CA, bronchial CA
ACTH independent: adrenal adenoma, adrenal carcinoma

exogenous: iratogenic due to steroid use (most common), drugs with steroid activity (megestrol acetate)
Term
signs of cushings - not objective
Definition
HTN
DM
glucose intolerance
central obesity
purple striae
muscle wasting esp proximal
osteoperosis
androgen excess: histurism, acne, oligomenorrhea
personality changes
facial plethora
peptic ulcer disease
Term
what is the main lab that helps diagnose cause of cushings, 6 tests for cushings, which is the best - not objective
Definition
ACTH
24h urinary free cortisol - BEST
dex supression test - overnight
...high: pituitary adenoma, etopic ACTH
salivary cortisol levels - night
MRI pituitary
octerotide (ectopic ACTH) scan
CT adrenal glands
Term
causes of primary and secondary hyperaldosteronism - not objective
Definition
primary: excess adrenal (adrenal adenoma, bilateral adrenal hyperplasia)

secondary: stimulating adrenal (decreased renal perfusion, CHF, renal artery stenosis, liver cirrhosis)
Term
signs of hyperaldosteronism - not objective
Definition
HTN
hypokalemia
metabolic alkalosis
polydypsia, polyuria
edema in secondary hyperALD (not primary)
Term
pheochromocytoma: cause, signs, tx - not objective
Definition
MEN2A/B
10% extra-adrenal
10% asymptomatic
10% malignant
headache
sweating
palpitations
anxiety
tremor
arrhythmia
abd pain
orthostatic HTN
weakness
nausea

SURGERY IS DOC BUT REQUIRES PREOP A BLOCKER SO B BLOCKER IN SURGERY DOES NOT CAUSE HTN CRISIS FROM UNOPPOSED A-ADRENERGIC STIMULATION
Term
adrenal incidentaloma: prognosis and tx - not objective
Definition
size determines malignancy >6cm 25% malignant

surgical resection if >6cm or increases by 1cm

observe if <4cm
Term
risk factors for DM1 - not objective
Definition
HLA type, family hx DM1/2, diet high in cow milk, no breast feeding, enterovirus, vit D deficiency, obesity, high socioeconomic statis, maternal age, preeclampsia, neonatal jaundice, low birth weight
Term
genes associated with DM1 4
Definition
MHC on CH6 HLA-DR3, DR4, B8, B15
Term
how do viruses cause DM1
Definition
destory Beta cells leading to indirect deficit of insulin and absolute deficiency
Term
what are environmental triggers of DM1 3
Definition
emotion, physical stress, diet
Term
signs of DM1 (13)
Definition
polyruia
polydypsia
polyphagia - uncommon
anorexia
weight loss
fatigue/lethargy
muscle cramps
abd discomfort
nausea
vision changes
headache
ketoacidosis
altered performance
Term
3 criteria for DM1 diagnosis
Definition
CLASSIC SYMPTOMS (P, P, WEIGHT LOSS) + RANDOM GLUCOSE >200

FG >126 on 2 OCCASIONS(FASTING 8h)

2h GLUCOSE >200 DURING OGTT USING 75h GLUCOSE LOAD
has HBA1C >6.5
Term
other than glucose, what are three diagnostic tests used for DM1
Definition
islet cell Ab
GAD-65 Ab

C PEPTIDE LEVEL: PROINSULIN SPLIT INTO C-PEPTIDE. DM1 CANNOT MAKE INSULIN SO C-PEPTIDE LOW
...DM2 HAVE HIGH OR NORMAL C-PEPTIDE
...FACTITIOUS DISORDER (HYPOGLYCEMIA) HAVE LOW C-PEPTIDE (INSULIN ABUSE)
Term
TX DM1 - not objective
Definition
diet and exercise: consistency in carb, fat protein ratio, eat at same time, carb count with insulin, no exercise restrictions

glargine or detemie long acting SQ 1-2x/d

lispro, aspart, glulisine SQ before eating 1 unit for 10g carbs

insulin pump: lispro or aspart

ORAL HYPOGLYCEMIA WILL NOT WORK FOR DM1 DUE TO DEFICIENCY OF INSULIN
Term
complications of DM1 (13)
Definition
microvascular disease: retinopathy, neuropathy, nephropathy, CAD, stroke, PAD

hyperlipidemia
chronic foot ulcer
charcot joint
hypoglycemia
diabetic ketoacidosis
weight gain
psych disorders
Term
ongiong monitoring of DM1 (7)
Definition
BP
height
weight
sexual maturation in children
blood glucose 4-6x/d
HBAIC q3mo
yerly screen after 5y with DM
Term
parts of the yearly DM1 screen 9
Definition
microalbuminuria for early sign of nephropathy
opthalmology exam after 3-5y
diabetic foot exam
cardiology exam
lipid profile
thyroid testing
CBC
chemistry pannel
annual influenza vaccine
Term
goals of DM1 therapy
Definition
BP <140/90
HBA1C <7%, <8% if older, <6% if younger
LDL <100 (<70 if CAD)
TG <150
HDL male >40, female >50
no microalbuminuria
Term
6 diagnostic requirements for DKA
Definition
glucose >250
pH <7.2
HCO3 <18
metabolic acidosis
ketones
acetone
Term
causes of DKA 8
Definition
noncompliance
insulin deficiency: bad vial or pump
infection
illnes
infarction
surgery
stress
meds
Term
pathogenesis of DKA
Definition
mostly DM1

insulin deficiency increases counter regulatory normones (glucagon, cortisol, GH, epinepherine) causing increase in hepatic gluconeogenesis, glycogenolysis, and lipolysis

hepatic metabolism of FA as alt energy sources causes ketones (esp B-HYDROXYBUTYRATE) which exceede buffer capacity and spill into urine, decrese pH and bicarb
Term
signs of DKA 13
Definition
EVOLVES OVER FEW DAYS
KUSSMAUL RESPIRATIONS: RAPID SHALLOW, THEN DEEP AND LABORED, GASPING
N/V: KETONES CAUSE
ABDOMINAL PAIN
MENTAL STATUS CHANGES
FRUITY ODOR TO BREATH
GLYCOSURIA: DEHYDRATION, THIRST, HYPOPERFUSION, LACTIC ACIDOSIS
HYPERKALEMIA
HYPOKALEMIA IF TOTAL DEPLETION
HYPONATREMIA
Term
why is the hyponatremia in DKA 2
Definition
DILUTIONAL EFFECT: WATER SHIFTS FROM IC TO EC SPACE

NA LOST IN URINE DUE TO OSMOTIC DIURESIS

FOR 100 MG/DL GLUCOSE OVER 100 NA IS DECREASED BY 1.6 MEQ/L
Term
DKA labs 10
Definition
glucose >250
ketones
acetone
amylase/lipase normal (RO pancreatitis)
anion gap >12
pH <7.35 causes acidosis
HCO3 <17 causes acidosis
both decreased so metabolic acidosis
serum osmolarity
possible ketones in urine
Term
causes of high anion gap 10
Definition
MUDPILES

METHANOL
UREMIA
DKA
PARALDEHYDE
ISONIAZID/INFECTION/ISCHEMIA
LACTIC ACIDOSIS
ETHYLENE GLYCOL
SALICYLATES
Term
TX DKA
Definition
FLUIDS THEN INSULIN

NS until glucose <250 then D5

0.1 unit insulin bolus
insulin gtt at 0.1 unit/kg/h
decrease glucose 100 mg/dl/h
check K q2h
if pH <7.1 IV bicarb
if P <1 give IV P 12mm/8h
if Mg low give IV Mg
Term
why does glucose have to drop slow
Definition
if over correction can shift water into IC space causing cerebral edema

will show improved metabolic state with worsening mental status

dont stop insulin gtt once acidosis resolved you have to give long acting insulin WAIT 2-3H
Term
why do we monitor K in DKA tx
Definition
K will drop fast due to shift into cells as acidosis resolves
Term
signs of resolved DKA 4
Definition
pt is eating
pt is on long acting insulin (2h before stop IV regular insulin)
HCO3 >18
anion gap/acidosis normal
Term
risk factors for DM2 (4) - not objective
Definition
family hx: 1st degree relative
gestational DM
obesity: causes insulin resistance
ethnicity: AA, latino, native american, asian, pacific islander
Term
pathogenesis of DM2
Definition
HIGH FAMILIAL SUSCEPTABILITY 100% IN IDENTICAL TWINS
pt retain some endogenous insulin secretion from pancreas
progressive resistance at receptor
Term
signs of DM2 (12)
Definition
polyuria
polydypsia
polyphagia
anorexia
weight loss
increased fatigue
lethargy
weakness
muscle cramps
vision changes
blurred vision
frequent infections
Term
3 diagnostic criteria DM2
Definition
glucose >200 and symptoms

FG >126 on 2 occasions

2h glucose >200 during OGTT with 75g glucose load
Term
treatment of DM2 (4)
Definition
exercise
ADA diet
oral hypoglycemics
insulin if not controlled
Term
oral hypoglycemics 15
Definition
glucophage and metformin
sulfonylureas: glipizide, glyburide, glimepiride
nateglinide
thiazolidinediones
A-GLUCOSIDASE INHIBITORS: ACARBOSE, MIGLITOL
dipeptodyl peptidase inhibitor: stigliptin, saxagliptiin, lingiliptin
EXENATIDE
pramlintide
lieaglutide
Term
SE metformin and glucophage (DOC for DM2) 4
Definition
weight loss, helps insulin resistance, lactic acidosis
cannot be used in renal disease
Term
SE glipizide, glyburide, glimepiride
Definition
hypoglycemia
Term
MOA mateglinide
Definition
stimulates B cell insulin release
Term
contraindications of thiazolidinediones 3
Definition
CHF, LE edema, liver disease
Term
MOA and SE acarbose and miglitol
Definition
a-glucosidase inhibitors
flatulence
Term
stifliptin, saxagliptin, linagliptin: use, nausea
Definition
can use alone or in combination with other classes
nausea most common
Term
MOA exenatide
Definition
INJECTION MIMICS EFFECTS OF INCRETINS (GLP-11) DPP-4 MECHANISM
Term
MOA pramlintide
Definition
decreases appearance of glucose in blood by slowing gastric emptying, supresses post prandial glucagon secretion, increases satiety
Term
liraglutide MOA
Definition
mimics effect of incretins (GLP-1)
Term
SE liraglutide
Definition
weight loss, more than others
pancreatitis
Term
insulin regidmen for DM2
Definition
basal: latnus, levemir SQ 1-2x/d
paradial: humalog, novolog SQ before meals
...1unit/10g carbs
insuln pump: humalog, novolog
Term
complications of DM2 (13)
Definition
retinopathy
nephropathy
neuropathy
CAD
PAD
stroke
hyperlipidemia
chronic foot ulcers
hypoglucemia
hyperosmolar nonkeratotoc state
excess weight gain
psychologicl problems
charcot foot deformity: foot broken down
Term
DM2 ongoing care 5
Definition
regular exercise and diet
BP <149/90
glucose 3-4x/d
HBA1C 3mo
yearly annual screening
Term
yearly annual screenings 10
Definition
microalbuminuria: early nephropathy sign
opthalmology exam
diabetic foot exam
cardiology evaluation
lipid profile
thyroid testing
CBC
chemistry pannel
annual influenza vaccine
Term
goals of therapy 7
Definition
BP <130/80
HBA1C <7
fasting flucose 70-105
bedtime 100-140
LDL <100 (<70 if CAD)
HDL male >40 female >50
no microalbuminuria
Term
hyperosmolar nonketotic state: signs 14
Definition
hyperglucemia >600
altered mental status
thirst, polyuria, polydypsia, weight loss, dehydration, hypotension, seizure, myoclonic jerks
elevated plasma osmolarity >320
drhydration
no ketoacidosis
pH 7.3
HCO2 >15
Term
hyperosmolar nonketotic state: pathogenesis
Definition
in DM2 insulin resistance (esp due to obesity) and decreased secetion
toxic effect of glucose on B cells in DM1 after 1st phase of insulin resistance lowering serum insulin
Term
hyperosmolar nonketotic state: causes 11
Definition
noncompliance
fever
sepsis
burns
MI
stroke
renal failure
BB
HCTZ
phenytoin
anesthesia
Term
hyperosmolar nonketotic state: goals of tx 4
Definition
rehydration with electrolyte hormones
correct hyperglycemia
tx underlying cause
monitor and assist CV, pulmonary, renal, CNS function
Term
hyperosmolar nonketotic state: tx
Definition
fluids first: NS and monitor urine, replace 1/2 volume deficit in first 12h and last 1/3 of the next 12h. switch for D5 with glucose until glucose 250

electrolyes and insulin: treat K like you do in DKA, checking BMP q2h. insulin gtt like DKA with switching over to long acting insulin and sliding scale once glucose under control
Term
somogyi effect pathogenesis
Definition
ELEVATED MORNING GLUCOSE OUT OF PROPORTION TO NORMAL DUE TO 2-3AM GLUCOSE LOW AND COUNTER REGULATORY HORMONES KICK IN CAUSING HYPERGLYCEMIA
Term
somogyi effect labs and tx
Definition
DECREASE OR MAINTAIN INSULIN DOSE

MAY HAVE LOW HBA1C
Term
dawn phenomenon pathogenesis
Definition
GLUCOSE INCREASES DUE TO RELEASE OF REGULATORY HORMONES (GH, CORTISOL, CATECHOLAMINES) MADE IN EARLY MORNING HOURS
Term
dawn pneomen signs and tx
Definition
2-3AM GLUCOSE NORMAL OR ELEVATED

INCREASE NIGHTLY INSULIN DOSE
Term
diabetic retinopathy: epidemiology, signs - not objective
Definition
leading cuse blindness 24-74 in US
DM 25x more likley

develops over time
atymptomatic until late
rapidly progressive once it begins
Term
signs of non-proliferative diabetic retinopathy 6
Definition
late 1st decade to early 2nd decade
MICRO ANEURYSM
OCCLUDED VESSELS
BLOT HEMORRHAGES
COTTON WOOL SPOTS
VISION LOSS USULLY VIA MACULAR EDEMA
Term
signs of proliferative diabetic retinopathy - not objective
Definition
neovascularization in response to retinal hyoxia leading to vitreous hemorrhage, fibrosis, retinal detachment
Term
prevention of diabetic retinopathy 5
Definition
BP CONTROL
LIPID CONTROL
TIGHT GLUCOSE CONTROL
KEEP HBA1C <7
YEARLY OPTHALMASCOPE EXAM
Term
dianetic nephropathy: signs 5, screening/labs, prevention - not objective
Definition
mesangial expansion, BM thickening, glomerular sclerosis, loss og GFR, proteinuria

BP each office visit with goal of <130.80
microalbuminuria 30-300 CR excretion and albumin excretion daily

yearly urine collection to assess protein, good glycemic control, control HTN <130/80, avoid nephrotoxic drugs, dietary protein restriction, strict lipid control, ACEI decrease HTN and proteinuria
Term
diabetic neuropathy polyneuropathy signs - not objective
Definition
distal symmetric from feet up proximal parasthesia and pain (tingling, sharp, burning), worse at rest and at night, sensory loss, loss of ankle reflex, abnormal position sense
Term
diabetic neuropathy mononeuropathy signs - not objective
Definition
cranial nerve palsy (III, IV, VII, bells), unlar and peroneal nerve palsy
Term
tx and prevention diabetic neuropathy - not objective
Definition
pregabain, gabapentin, TCA
improve glycemic control
Term
gastroparesis: epidemiology, pathogenesis, signs, dx - not objective
Definition
more in DM1

delayed gastric emptying due to neuropathy of vagus nerve when BG is high, muscles of stomach and intestines do not work normally, movememnt of food slowed or stopped

anorexia, N/V, early sariety, bloating, poor glycemic control

gastric emptying study with radiolabeled meal
Term
gastroparesis treatment 5
Definition
glycemic control: frequent small meals

metoclopramide: prokinetic and antiemetic

octerotide: induce digestive motor complex

ERYTHROMYCIN: MACROLIDE ANTIBIOTIC, PROMOTES GASTRIC EMPTYING

gastric electral stimulation
Term
genitourinary changes in DM - not objective
Definition
diabetic cystopathy: cant feel bladder or void, increased post-void residual, uti
tx: timed voiding, self cath, bethaencol

erectile dysfunction and retrograde ejaculation: early sign of DM neuropathy
tx: slidenafil
Term
CV diseases in DM and prevention, epidemiology - not objective
Definition
DM2 2x risk in men 4x risk in women
DM1 risk even higher
MI causes 70% death in DM

coronary artery disease
MI
peripheral vascular disease
stroke
silent ischemia: SOA, BP change

prevention: control HTN <130/80, ACEI IS DOC, control LDL, aspirin 81mg/d, smoking cessation
Term
diebetic foot ulcers: signs - not objective
Definition
delayed wound healing and skin ulcerations even with minor traums

untreated penetrate tissue, ischemia, gangrene, need amputations
Term
diabetic foot ulcer prevention 4
Definition
TEACH YOUR PATIENTS TO EXAMINE THEIR FEET
foot exam yearly
if affected specailist exam yearly
pressure relief: orthotics, shoes
Term
necrobiosis lipoidica diabeticorum: epidemiology
Definition
1% of diabetics
usually young female with DM2, neuropathy, retinopathy
no correlation with metabolic control
Term
necrobiosis lipoidica diabeticorum: signs 8
Definition
inflammation
yellow brown indurated plaque
central atrophy
central ulcer
talengictasia
ulcerations
pretibial red plaque that enlarges, darkens, irregular margins
asymptomatic or painful
Term
necrobiosis lipoidica diabeticorum: treatment
Definition
TOPICAL STEROIDS IF NO ULCERATIONS
Term
describe acanthosis nigricans, duptens contracture, xanthoma of DM - not objective
Definition
acanthosis: velvety hyperpigmented plaque on neck of axillae due to insulin resistance

contracture: thickening of palmar fascia leading to thickening and contraction

xanthoma: associated with elevated TG
Term
common infections of DM - not objective
Definition
foot infection
UTI
superificial fungal: oral candidiasis, onchymycosis
malignant external otiits (pseudomonas)
zygomycosis (mucormycosis)
pneumonia
empysematous cholecystitis
necrotizing fasciitis
rhinocerebral mucormycosis
Term
rhinocerebral mucormucosis signs - not objective
Definition
tissue destruction
poorly controlled diabetic
epistaxis
altered mental status
unilateral headache and eye irritation
black necrotic nasal turbinates
Term
malignant otitis media: cause, signs, tx, prognosis - not objective
Definition
pseudomonas aeruginosa

rapid evolving
ear and facial pain and swelling
osteomyelitis of skull base
purulent meningitis
multiple cranial palsies

urgent anti-pseudomonal pen or 3rd gen ceph with aminoglycoside or ciproflaxcin
surgical debridement of necrotic tissue

mortality rate high
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