1. never palpate if suspected globe trauma

2. workup: visual acuity (snellen chart), pupillary reactions, IOP (schiotz tonometer)

3. Tx:

- penetrating: DO NOT REMOVE OBJECT, transport to ER for ophtho consult asap

- foreign body: fluorescien stain, evert lids, patch (<24 hr)

- metal: remove w/ rotating burr

- chemical: flush with water or NS for at least 30 min - transfer to ER

maxillary, palatine, zygomatic

Sx: swelling, misaligment, restricted movement (specifically inability to look up), double vision, subcu emphysema, exophthalmos

tx: refer to ophtho, avoid sneezing, nasal decongestants, ice packs, abx during transport

sx: pain, sensation of foreign body, photophobia, tearing, injection, blepharospasm (twitching eyelid)

workup: visual acuity; slit lamp or fluorescein stain

tx:

- topical anesthetic (cannot take home)

- abx ointment - polymyxin/bacitracin

- patching - no longer than 24 hrs

- follow up in 1-2 days

1. separation of retina from pigmented epithelial layer usually begins at superior temporal area

2. causes: spontaneous, trauma, extreme myopia

3. sx: "curtain of darkness" being drawn from top to bottom, flashes, floaters - monocular

- may be afferent pupillary defect

- fundoscopy may show rugous retina in vitreous

4. tx: emergency ophtho consult for surgery, stay supine

macular degeneration

laser therapy, intravitreal anti-VEGF, vitamins, antioxidants --> none are definitive

Central retinal artery occlusion

tx: emergent referral to ophtho for vessel dilation and paracentesis

workup for atherosclerosis to avoid recurrence

diabetic retinopathy

tx: glucose control, BP control, laser photocoagulation, vitrectomy

Causes: age, trauma, congenital cause, medications (steroids, lovastatin), sun exposure

sx: insidious onset of decreased visual acuity, double vision, fixed spots, reduced color perception, yellow discoloration of lens

tx: surgical excision with lens replacement

acute angle-closure glaucoma

tx: IV carbonic anhydrase inhibitor (acetazolamide), topical BB, osmotic diuresis

NEVER USE MYDRIATICS

- laser or surgical iridotomy is definitive

chronic open-angle glaucoma

tx: referal to ophtho

- topical and systemic meds to decrease IOP and aqueous humor production (timolol, acetazolamide) and increase outflow (prostaglandin analogs)

1. more common in kids

2. causes: sinusitis, dental infx, facial infx, globe/eyelid infx, lacrimal infx, trauma

3. bugs: strep pneumo, staph aureus, h. flu, MRSA, gram neg

4. sx: ptosis, eyelid edema, exophthalmos, purulent discharge, conjunctivitis, fever, decreased EOM, sluggish pupillary response

5. Workup: CBC, blood culture, culture of drainage, sinus xray and CT

6. Tx: hospitalization with IV ABX (broad spectrum until cause is found)

dacryostenosis

tx: warm compress, massage, surgical probe in unresolved

dacryocysitits

tx: warm compress, abx

blepharitis

tx: eyelid scrubs w/ diluted baby shampoo and cotton swabs

- topical abx if infx suspected

Hordeolum

(external is Stye)

tx: warm compresses, topical abx, I&D if refractory

chalazion

warm compresses, may need excision

entropion

ectropion

cause: adenovirus

- transmission via direct contact via fingers or in swimming pools

tx: eye lavage w/ NS BID x 7-14 days

- vasoconstrictor-antihistamine drops

- warm to cool compresses

1. common pathogens: strep pneumo, staph aureus, h. aegyptius, moraxella

- rare pathogens: chlamydia and gonorrhea

2. sx: purulent discharge, matting, mild discomfort

- Viral conjunctivitis is watery discharge

2. tx: topical abx (systemic for GC/chlamydia)

1. pinguecula

2. pterygium

3. xanthalasma

papilledema

HTN, hemorrhagic stroke, subdural hematoma, pseduotumor cerebri

1. blurred vision in one eye - anterior to optic chiasm
2. blurred vision in both eyes - at optic chiasm
3. corresponding defects in both visual fields - posterior to optic chiasm

Right Hemonymous hemianopia means right visual field of each eye is affected --> due to lesion on left side of brain

Binasal heteronymous hemianopia: loss of vision in the nasal field of both eye. Due to impingmenet of lateral retina fibers - usually due to calcification of internal carotid

Bitemporal heteronymous hemianopia: loss of vision in the temporal field of both eyes. Due to pressure on optic chiasm - usually due to pituitary tumor, craniopharyngioma, or meningioma

strabismus

tx: patch or surgery

1. amblyopia

2. icterus

3. osteogenesis imperfecta

1. Weber

2. Rinne

Sensorineural hearing loss

tx: hearing aids

conductive

Meniere's disease

tx: diuretics, salt restriction

may need surgery

acoustic neuroma (vestibular schwannoma)

tx: surgery

Aminoglycosides (streptomycin, kanamycin, neomycin)

ethacrynic acid (loop diuretic)

chloramphenicol

congenital: rubella, asphyxia, erythroblastosis

acquired: measles, mumps, pertussis, meningitis, flu, labyrinthitis

organisms: s. pneumo, h. flu, m. catarrhalis, strep pyogenes, staph aureus

recurrence: allergies, secondhand smoke

bullae suggest mycoplasma

spiking fever, postauricular pain - think mastoiditis - due to inadequate treatment

Treatment:

1. First Line: amoxicillin, erythromycin/sulfonamide, augmentin, bactrin, cefaclor

2. Erythromycin or clarithromycin for penicillin allergy

3. Myringotomy, tympanostomy, adenoidectomy if failure to resolve

4. IV abx for mastoiditis

1. most common organisms: pseudomonas, enterobacter, porteus

2. tx: abx drops

3. complications; malignant otitis externa - necrotizing infection requiring hospitalizaiton and parenteral abx - happens in diabetics or immunocompromised

1. true vertigo

2. peripheral vertigo

3. central vertigo

tx:

1. acute: diazepam - IM or PR

2. mild: meclizine, cyclizine, dimenhydrinate

3. severe: scopolamine

4. Chronic: encourage movement; surgery

labyrinthitis

tx: meclizine, promethazine, dimehydrinate

barotrauma

prevention: swallowing or yawning during pressure change to autoinflate tubes, topical decongestnats, myringotomy

organisms: viral most common, bacterial - s. pneumo, m. catarrhalis, h. flu (same as AOM)

risk factors: recent URI, chronic rhinitis, smoking, hx trauma/foreign body

sx: headache, face pain - worsens when leaning forward, puruelent drainage, fever, malaise

complications: osteomyelitis, cavernous sinus thrombosis, orbital cellulitis

dx: clinical, CT in chronic sinusitis resistant to treatment (waters view XR may be helpful but less than CT), MRI is more sensitivie than CT if malignancy is suspected

Tx: saline nasal spray, decongestants, hot packs /steam

abx if bacterial for 10-14 days

1. allergic rhinitis

2. vasomotor rhinitis

3. rhinitis medicamentosa

treatment:

1. allergic: avoid allergens, antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline, immunotherapy

2. vasomotor: avoid irritant

3. medicamentosa: discontinue irritant, topical corticosteroids

Complication: peritonsillar abscess/cellulitis (AKA quinsy) -

severe throat pain, pain with swallowing and opening mouth, deviation of soft palate/uvula, muffled voice

- tx: aspiration or I&D followed by abx. tonsillectomy in 10% (airway obstruction, persistent marked asymmetry, recurrent infx)

2. GABHS. tx: penicillin or erythromycin. treat if neg strep test but high clinical suspicion

3. viral pharyngitis. Tx: get strep screen. supportive if neg

4. GABHS complications: rheumatic fever, ludwig's angina (infx of floor of mouth), tonsillar abscess

fever >38C (100.4F), tender anterior cervical adenopathy, lack of cough, pharyngotonsillar exudates

3 or more criteria highly suggestive of GABHS

2 criteria indicates need for culture

1 criteria - GABHS unlikely

Laryngitis

tx: supportive, avoid using voice to avoid formation of nodules

1. apthous ulcers

2. candidiasis

3. leukoplakia

organisms: GABHS, staph, pneuomococci, H. flu (incidence has greatly decreased with H. flu vaccine)

diabetics at highest risk

- most common age group: 2-7 y/o, in adults 45-65 y/o

sx: abrupt high fever, difficulty swallowing, sore throat, drooling, sitting in tripod or sniffing position, muffled voice

workup:

1. lateral soft tissue neck xray - THUMB SIGN (thumb-like projection)

tx: Do not cause the pt distress

- intubation

- IV fluids and abx x 24-72 hrs followed by oral abx

- all unimmunized close contacts should get prophylactic rifampin

1. Kiesselbach's plexus

2. tx: apply firm pressure to nares with pt standing or sitting upright for 10-15 min.

- ID bleeding site

- anesthetize w/ cocaine or lidocaine, cauterize w/ silver nitrate if bleeding site is idenitified

- pack for 24 hrs

3. Woodruff's plexus (posterior bleed)

nasal polyps

tx: corticosteroids, removal if that fails although they're usually benign

Samter's triad: asthma, nasal polyps, aspirin sensitivity

Organisms: most commonly bacteria - Strep pneumo, h. flu, m. catarrhalis, staph aureus, kelbsiella pneumoniae, gram neg bacilli.

- viral causes: flu, RSV, adenovirus, paraflu

typical presentation: 1-10 days of increasing cough, purulent sputum, SOB, tachycardia, pleuritic CP, fever, hypothermia, sweats, rigors

breath sounds: crackles, bronchial over area of consildation

MOST COMMON ORGANISM: strep pneumo

Workup:

** PE alone is not enough to dx pneumonia **

- CXR: lobar or segmental infiltrates, air bronchograms, pleural effusion. No pathognomonic xray presentation.

- sputum culture to ID species

Tx:

1. oral abx if not immunocompromised or resp distress - doxy, erythromycin, macrolides (clarithro, azithro), fluoroquinolones

2. Inpt: ceftriaxone or cefotaxime PLUS azithro or fluoroquinolone (must cover strep pneumo and legionella)

Indications for inpt:

- neutropenia

- more than one lobe

- poor host resistance

- >50 y/o with comorbidities (relative)

- AMS

- hemodynamic instability

Efficacy: 51-86%

Pneumococcal conjugate vaccine (PCV) for 6w-15mo

Pneumococcal polysaccharide vaccine (PPV) 2-5 y/o and >65 y/o

1. low grade fever, cough, bullous myringitis, cold agglutinins (autoimmune hemolytic anemia) - mycoplasma pneumoniae (walking pneumonia)

2. slow onset, immunosuppressed pts. increased LDH, more hypoxemic than expected. interstitial infiltrates - PNEUMOCYSTIS JIROVECII (carinii)

3.  chronic cardiac or resp disease, hyponatremia, diarrhea - Legionella pneumoniae

4. longer prodrome, sore throat and hoarseness - Chlamydia pneumoniae

5. single rigor, rust-colored sputum - strep pneumo

6. currant jelly sputum, chronic illness, alcohol abuse - Klebsiella penumoniae

mycoplasma (erythromycin)

chlamydia (tetracycline)

legionella (erythromycin)

m. catarrhalis

sx: low grade fever, aches, fatigue, mild pulm sx

- common in otherwise healthy young adults

1. >48 hr

2. ICU and ventilator pts at highest risk

3. organisms: staph aureus, gram neg bacilli, pseudomonas (most common in ICU, worst prognosis), klebsiella, e. coli, enterobacter

4. dx: clinical, supported by sputum/blood culture and CXR

5. tx: empiric abx - cefepime, ticarcillin/clavulanic acid (timentim), piperacillin/tazobactam (zosyn), meropenem

1. pneumocystic jirovecii - tx: bactrim

2. others: strep, h. flu, pseudomonas, mycobaccterium - sx are more fulminant (sudden onset)

3. prophylactic Bactrim for all pts with CD4 <200 bc pneumocystis has nearly 100% mortality rate without treatment

1. organism: Mycobacterium tuberculosis - transmission via droplets
2. 10% infected with TB will develop dz - called primary TB
3. 5% of exposed people fail to contain primary TB and develop active TB within 2 years, which is called progressive primary TB
4. 95% of infected people have no sx, called latent TB. These patients are NOT infectious/contagious. Reactivation of TB in these pts is due to immunocompromise.
5. sx: fever, drenching night sweats, anorexia, weight loss, cough, pleuritic CP, dyspnea, hemoptysis, posttussive rales - typically last >3 weeks
6. Xrays:

- Primary: homogenous infiltrates, hilar/paratracheal adenopathy, segmental atelectasis

- progressive: cavitations

- reactivated: fibrocavitary apical dz, nodules, infiltrates, - healed primary infx: Ghon complexes (calcified primary focus), Ranke complexes (calcifed primary focus and calcified hilary lymph nodes)
7. screening: tuberculin skin test (purified protein derivative - PPD) - does not differentiate between active and latent infx
8. dx: ID mycobacterium TB from cultures or by DNA or RNA amplification

- acid-fast bacilli on sputum supports dx but does not confirm

- histological hallmark: bx with caseating/necrotizing granulomas

multi-drug regimens necessary for active TB:

1. Latent TB: INH x 9 mos or Rifampin for 4 mos or Rifampin and pyrazinamide for 2 mos (if in contact with resistant TB pts)

2. active TB: INH + rifampin + pyrazinamide + ethambutol x 2 mos THEN INH + rifampin x 4 mos (if INH sensitive TB)

3. Drug-resistant TB: seek expert advice for regimen

4. Converters (people who tested neg previously but now test pos): INH for 6-12 mos

5. kids and immunocompromised who have been exposed should be treated until skin test is neg 12 weeks after exposure

Pts with HIV require tx for at least 1 year

>/= 5 mm induration: confirm in HIV pos, recent contact of active TB, evidence of TB on CXR, immunosuppressed on steroids

>/= 10 mm induration: recent immigrants from countries with high rates of TB, HIV neg IV drug users, mycobacteriology lab personnel, residents/employees of high risk congregate settings (healthcare workers), DM, silicosis, chronic renal failure, <4 y/o, kids exposed to adults at high risk

>/=15 mm induration: persons with no risk factors

INH: hepatitis, peripheral neuropathy (co-administer B12 [pyridoxine])

Rifampin: hepatitis, flu, orange body fluids

Ethambutol: optic neuritis (red-green vision loss)

1. 90% caused by: viruses (RSV, rhinovirus, coronavirus)
2. organisms in pt with chronic lung disease: h. flu, strep pneumo, m. catarrhalis
3. workup: usually none unless to differentiate from pneumonia. CXR neg in bronchitis
4. tx: supportive

- abx for: elderly, underlying cardiopulmonary dz, cough >7-10 days, immunocompromised

1. definition: inflammation of broncioles (airways <2mm). primarily in infants and young kids
2. organisms: RSV (most common), paraflu, adenovirus, rhinovirus
3. sx: rhinorrhea, sneezing, wheezing, low-grade fever
4. CXR: usually normal, may have air trapping, peribronchial thickening
5. tx: usually supportive - nebulized albuterol, IV fluids, antipyretics, chest physiotherapy, humidified O2

croup

tx: none

may need corticosteroids, humidified O2, nebulized epinephrine

bronchogenic carcinoma

1. small cell

2. squamous cell carcinoma

3. adenocarcinoma

4. large cell carcinoma

sx: cough, hemoptysis, pain, anorexia, wt loss, asthenia (weakness), adenopathy, hepatomegaly, clubbing, paraneoplastic syndromes

workup: CXR/CT

- sputum cytology for cell type

- bronchoscopy w/ bx

- PET scan

tx:

- SC: chemo

- NSC: surgery

Prognosis:

- SC: mean 6-18 weeks. Rarely live >5 years

- NSC: 35-40% survival at 5 years if surgery

Endocrine: cushing's, SIADH, acanthosis nigricans

Neuromuscular: neuropathy, myesthenia, cerebellar degeneration

Heme: anemia, DIC, eosinophilia, thrombocytosis

Heme: anemia, DIC, eosinophilia, thrombocytosis

Metabolic: hypercalcemia, gynecomastia, acanthosis nigricans

Thrombophlebitis

S: SVC syndrome - plethora (Excess blood causing reddish complexion), HA, AMS

P: pancoast tumor (in lung apex) - Horner's syndrome, shoulder pain, brachial plexus injury

H: Horner's syndrome - anhidrosis, ptosis, myosis

E: endocrine - carcinoid syndrome (flushing, diarrhea, telangiectasias)

R: recurrent laryngeal nerve impingement (hoarseness)

E: Effusion (exudative)

Solitary pulmonary nodules (AKA coin lesions):
1. nodule if <3 cm, mass if greater
2. cause: usually infectious granuloma - TB, fungal infx, foreign body reaction. 40% malignant (rare before 30 y/o)
3. dx: usually found unexpectedly on CXR
4. findings suggestive of benign: well-circumscribed, >5 cm, calcification, central cavitation, doesn't enlarge in 2 years, no sx
5. tx: watch if low probability of malignancy - CT q 3 mos x 1 year then q6 mos x 2 years

- high chance of malignancy: resection asap

- intermediate chance: bx

carcinoid tumor/adenoma

tx: surgical excision

NEVER chemo or radiation - tumors are resistant

Asthma:
1. Characterized by 3 components: airflow obstruction, bronchial hyperreactivity, inflammation of airway
2. strongest predisposing factor: atopy
3. sx: intermittent cough, chest tightness, breathlessness, wheeze (wheeze less common in kids) with asymptomatic periods between attacks
4. Workup:

- PFT: FEV1/FVC <75% - indicates obstruction, increase in FEV1 >10% after bronchodilator therapy

- ABG: usually normal and not necessary but may reveal hypoxemia and hypercapnia in severe cases - PaO2 <60mmhg, PaCO2 >40 mmHg

- CXR: +/- hyperinflation

- special tests: Histamine or methacholine challege test (bronchial provocation test) when spirometry is nondiagnostic - decrease in FEV1 >20%

Intermittent asthma:

1. sx <2 days/week, no interference with daily activities

2. Nighttime sx: <2x/mon

3. Use of rescue: <2 days/week

4. PFT: FEV1 >80%, FEV1/FVC normal

Mild persistent:

1. sx >2 days/week, minor interference with daily activities

2. Nighttime sx: 3-4x/mon

3. Use of rescue: >2 days/week, not daily, not more than once a day

4. PFT: FEV1 >80%, FEV1/FVC normal

Moderate persistent:

1. sx daily, some interference with daily activities

2. Nighttime sx: >1x/week

3. Use of rescue: daily

4. PFT: FEV1 60-80%, FEV1/FVC reduced by 5%

Severe persistent:

1. sx continual, severe interference with daily activities

2. Nighttime sx: often daily

3. Use of rescue: several times a day

4. PFT: FEV1 <60%, FEV1/FVC reduced >5%

Step 1 (intermittent asthma): SABA

Step 2: low dose ICS + SABA

Step 3: (Low dose ICS + LABA + SABA) OR (med dose ICS + SABA)

Step 4: Med dose ICS + LABA + SABA

Step 5: High dose ICS + LABA + SABA + consider omalizumab for pts with allergies

Step 6: High dose ICS + LABA + SABA + Oral corticosteroid and consider omalizumab

Consider allergen immunotherapy for pts step 2-4 with allergies

Ideally, all pts should do daily peak flow monitoring

bronchiectasis

tx: bronchodilators, chest phsyio, abx if productive cough (amoxicilin, augmentin, bactrin, TCN), surgery if disabling sx (little long term benefit)

1. emphysema: condition in which air spaces are enlarged as a consequence of destruction of alveolar septae
2. chronic bronchitis: disease characterized by chronic productive cough (phlegm) occuring most days for 3 mos of the year for 2 consecutive years without an acute cause
3. most common cause: smoking
4. other causes: pollutants, recurrent URI, eosinophilia, bronchial hyperresponsiveness, a1-antitrypsin deficiency
5. sx: progressive SOB, excessive cough, sputum production

- emphysema-predominant: weight loss, chronic dry cough

- advanced dz: asthenia, dyspnea, pursed lips, grunting expirations
6. PE: increased AP diameter of chest, increased resonance, decreased breath sounds, crackles, wheezing, prolonged expiration, rhonchi, raspy breathing
7. CXR: hyperinflation, flat diaphragms,

- Emphysema: parenchymal bullae or subpleural blebs (pathognomonic)

- CB: peribronchial or perivascular markings
8. PFT: decresed FEV1/FVC, airflow obstruction on forced expiratory spirometry

Emphysema-predominant (Pink Puffers):

Sx: exertional dyspnea, quiet lungs, no peripheral edema, thin, barrel chest, hyperventilation

CXR: decreased lung markings at apices, flattened diaphragms, hyperinflation, small/thin heart, parenchymal bullae and blebs

Bronchitis-predominant (Blue Bloaters):

Sx: mild dyspnea, chronic productive cough, noisy lungs, peripheral edema, overweight, cyanotic, pursed-lip breathing

CXR: Increased interstitial markings at bases, diaphragms not flattened

1. single most important intervention: smoking cessation
2. Inhalors: anticholinergic (ipratroprium or tiotropium) better than B-adrenergic for long term

- SABA should be available for acute exac.
3. only intervention to improve course of COPD: supplemental O2
4. Encourage graded aerobic exercise
5. Yearly flu and pneumococcal vaccines

1. genetic inheritance: autosomal recessive
2. characterized by abnormal mucus production
3. increased risk for GI malignancy, osteopenia, arthropathies
4. median survival: 31 y/o
5. Suspect in any young pt with hx of chronic lung dz, pancreatitis, infertility
6. sx: cough, excess sputum, decreased exercise tolerance, sinus pain, purulent nasal discharge, steatorrhea, diarrhea, abd pain
7. workup:

- ABG: hypoxemia, compensated resp acidosis

- PFT: mixed obstructive/restrictive

- CXR: hyperinflation, peribronchial cuffing, mucus plugging, bronchiectasis, increased interstitial markings, small, round, peripheral opacities, focal atelectasis, pneumothorax

- special test: quantitative chloride sweat test >60 mEq/L on two different days
8. tx: comprehensive to clear airway secretions, reverse bronchoconstriction, tx resp infx, replace pancreatic enzymes, nutrition

1. result from inflammation of structures adjacent to pleural space or within chest cavity
2. 25% due to malignancy
3. type of effusion due to "leaky capillaries" - usually due to malignancy, trauma, infx: exudate
4. type with intact capillaries due to increased hydrostatic or decreased oncotic pressure - CHF, atelectasis, cirrhosis, renal dz: transudate
5. effusion of pus due to infection in pleural space: empyema
6. bleeding into pleural space due to trauma or malignancy; Hemothorax
7. sx: none if small. dyspnea, orthopnea,
8. PE: dullness, reduced breath sounds, possible mediastinal shift
9. workup:

- lateral decubitus CXR best for seeing small effusion

- thoracentesis is gold standard - send this fluid for workup
10. tx: thoracensis for removal of fluid

- transudates resolve with resolution of underlying dz

- malignant effusions may require pleurodesis

- empyema needs drainage then abx

1. pleural fluid protein to serum protein ratio >0.5

2. pleural fluid LDH to serum LDH ratio >0.6

3. pleural fluid LDH >2/3 upper limit of normal for serum LDH

1. tall thin males btwn 10-30 y/o are at most risk for primary (spontaneous) PTX
2. tension is secondary to sucking chest wound or pulmonary lac that allows air to enter pleural space but not leave
3. Chest percussion: hyperresonance, decreased fremitus, decrased breath sounds
4. Tx:

- small: none

- large, symptomatic: chest tube

- tension: needle decompression followed by chest tube

- serial CXR q24 hr until resolved

1. Causes: thrombi in venous circulation or right side of heart - tumors, DVT, air from central lines, amniotic fluid from labor, fat from long bone fx
2. Risk factors

- VIRCHOW'S TRIAD: hypercoagulable state, venous stasis, vascular inflammation or injury

- 50-60% of pts with DVT will have PE
3. Sx: pleuritic CP, dyspnea, apprehension, cough, hemoptysis, diaphoresis, tachycardia, tachypnea, crackles, accentuated S2, low grade fever

- Homan's sign lacks sensitivity and specificity
4. initial test of choice: spiral CT

- definitive test: pulmonary angiography - but reserved for cases in which dx is uncertain after CT
5. Wokrup:

- ABG: resp alkalosis

-EKG: tachy, NSTT changes, S1Q3T3 pattern is classic but seen in <20% (prominent S in I, Q and inverted T in III)

- CXR: non-specific

- ventilation-perfusion scan: perfusion defects with normal ventilation - NL SCAN RULES OUT SIGNIFICANT PE 

-pulmonary angiography

- Spiral CT
6. tx:

- Heparin acutely

- LMWH or coumadin after acute phase for min of 3 mos

- high risk pts: vena cava filter, early ambulation, intermittent penumatic compression stockings, low dose heparin, LMWH

Pulmonary HTN

tx: chronic oral anticoagulation, CCBs, prostacyclin (pulmonary vasodilator)

- heart-lung transplant often needed

- treat underlying disorder if secondary pulm htn

idiopathic fibrosing interstitial pneumonia (AKA idiopathic pulmonary fibrosis)

Tx: none

definition: chronic fibrotic lung diseases caused by the inhalation of coal dust or various inert, inorganic, or silicate dusts

sx: often none, dyspnea, inspiratory crackles, clubbing, cyanosis

pft: restrictive lung disease (decreased TLC, normal or increased FEV1/FVC)

tx: supportive - O2, vaccinations, rehab, smoking cessation, +/- steroids

1. ASBESTOSIS

occupation: insulation, demolition, construction
CXR: linear opacities at bases, pleural plaques
Complications: increased risk of lung cacner and mesothelioma, ESPECIALLY IF SMOKER - asbestosis and cigarette smoke are synergistic to cause lung cancer


2. COAL WORKER'S PNEUMOCONIOSIS

occupation: coal mining
CXR: nodular opacities in upper fields
complications: progressive massive fibrosis

3. SILICOSIS

occupation: mining, sand blasting, quarry, stone work
CXR: nodular opacities at upper fields
complications: incrased risk of TB, progressive massive fibrosis

4. BERRYLIOSIS

Occupation: high tech fields - aerospace, nuclear power, ceramics, foundries, tool and die manufacturing
CXR: diffuse infiltrates, hilar adenopathy
Complications: requires chronic steroids

Sarcoidosis

tx: corticosteroids at modest maintenance dose

1. 3 clinical settings account for 75% of cases: sepsis, multiple trauma, aspiration of gastric contents
2. underlying abnormality: increased permeability of alveolar capillary membrnes leads to protein-rich pulmonary edema
3. sx: rapid onset profound dyspnea, tachypnea, frothy pink/red sputum, diffuse crackles, cynosis, refractory hypoxemia

4. CXR: normal at first hen infiltrates at periphery (spares costophrenic angles), air bronchograms

5. tx: treat underlying condition

- supportive: O2 via intubation with low levels of positive end-expiratory pressure (PEEP)

- high mortality rate

1. Heimlich for acute

2. bronchoscopy otherwise

hyaline membrane disease

tx: ventilation

- administer exogenous surfactant

1. Definition: conditions involving hemoglobin or PRBC levels below normal
2. 4 general causes: increased rbc destruction, decrased rbc production, bleeding, systemic disease
3. sx: fatigue, HA, exertional dyspnea

- acute anemia: tachycardia, orthostatic hypotension, faintness, pale/cold extremities, pallor, cheilosis, jaundice, beefy red tongue, koilonychia (spooned nails)

- chronic: hyperkinetic ciruculation (large pulse volume, tachycardia)
4. retic count tells you increased destruction or decreased production:

- high retic count = increased destruction

- low retic count = decreased production

Males:

Hgb: 13.6-17.5 g/dL

Hct: 39-49%

RBC: 4.6-6.3 million/mL

Females:

Hgb: 12.0-15.5 g/dL

Hct: 35-45%

RBC: 4.2-5.4 million/mL

MCH: 26-34 pg

MCHC: 31-36 g/dL

MCV: 80-100 fL

RDW: 11.5-14.5%

Retic count (corrected): 0.5-2.5%

Low iron:

1. iron deficiency

2. Post-hemorrhagic

Normal iron:

1. anemia of chronic disease

2. thalassemia

3. sideroblastic

4. hemoglobinopathies

increased retic count:

1. hemorrhagic

2. hemolysis

normal retic count, megaloblastic:

1. B12 deficiency

2. Folate deficiency

normal retic count, non-megaloblastic:

1. hypoplastic marrow

increased retic count:

1. prior hemolysis

2. prior hemorrhage

normal retic count, normal bone marrow:

1. hypothyroid

2. liver disease

3. anemia of chronic disease

normal retic count, abnormal bone marrow:

1. myeloma

2. mets

3. myelofibrosis

4. Leukemia

5. Renal failure

1. Result from inadequate supply of iron for synthesis of hemoglobin.
2. In adults, GI bleed is almost universally the cause
3. other causes: NSAIDs, Asiprin, low dietary iron (kids and pregnancy), decreased iron absorption, increased iron requirements, hemoglobinuria, blood donation, iron sequestration, trauama, intravascular hemolysis

4. Never assume iron def anemia is due to menstruation in women

5. sx: pallor, easy fatigue, irritability, anorexia, tachy, tachypnea on exertion, poor weight gain in infants, brittle nails, cheilosis, smooth tongue, esophageal webs (plummer-vinson syndrome)

- PICA is hallmark

6. labs: low Hct and hgb

- smear: hypochromic microcytes, anisocytosis (cells of unequal size), poikilocytosis (abnormal shapes)

- plasma ferritin <30 ug/L

- Serum iron <30 ug/L

- transferritin saturation <15%

- TIBC increased

- elevated platelets in severe anemia

7. tx:

- Ferrous sulfate 325 mg TID - best on empty stomach, better with OJ x 6 mos and again during pregnancy/lactation

- parenteral iron for intolerant pts

- ID source of blood loss

1. definition: microcytic hereditary anemia in which synthesis of alpha-globin chains is reduced resulting in defecting hemoglobinization of RBCs
2. cause: gene deletion

3. population: SE asian/chinese
4. most prominent feature of all thalassemias: microcytosis out of proportion to degree of anemia

1. 4 copies of a-globin chain: normal
2. 3 copies of a-globin chain: silent carrier, no sx
3. 2 copies: trait/minor - mild microcytic anemia, no tx

- Hct 28-40% (slightly low)

- normal hgb on electrophoresis

- smear: acanthocytes, target cells

- retic count: normal
4. 1 copy: major (hemoglobin H disease) - chronic hemolytic anemia with periods of hemolytic exacerbations caused by illness and stress

- Tx:routine transfusion, folate, may need splenectomy or allogeneic bone marrow transplant, avoid iron supplements (risk of iron overload) and oxidative drugs

- Hct: 22-32% (very low)

- Hgb H on electrophoresis

- Hgb 3-6 g/dL

- smear: target cells, poikilocytes

- Increased retic count
5. 0 copies: still born (hydrops fetalis)

1. cause: point mutation

2. population: mediterranean

3. Pathophys: begins at 4-6 mos when the body switches from Hgb F to Hgb A

Minor:

- Only one B globin allele has mutation.

- Sx: microcytic anemia

- MCV: <80 fL

- Hct: 28-40% (slightly low)

- Electrophoresis: Hgb A2 and Hgb F

- Smear: target cells, basophilic stippling

- retic count: normal or increased

- alleles: B⁺/B or B⁰/B

Intermedia:

- may need transfusions in times of stress, illness, pregnancy

- alleles: B⁺/B⁺ or B⁰/B

Major (Cooley anemia):

- Pathophys: both alleles have mutations

- sx: severe microcytic anemia, splenomegaly, bony deformities, death by cardiac failure

- tx: blood transfusions, splenectomy, bone marrow transplant

- alleles: B⁺/B⁺ or B⁰/B⁺
or B⁰/B⁰

- Hct: 10%

- Electrophoresis: Hgb A2 and F

- Smear: target cells, poikilocytes, basophilic stippling, nucleated RBCs

- Retic count: increased

sideroblastic anemia

tx: treat underlying condition

- treatiron accumulation

- may need transfusion

- NOT erythropoietin

1. cause: organ failure or impaired marrow function resulting from systemic disaese
2. Upregulation of hepcidin in response to inflammatory mediators is important cause
3. T cell-mediated autoimmune suppression of hematopoiesis is most common cause
4. sx: those of chronic disease

5. labs:

- normal or increased iron stores and serum ferritin

- normal or low TIBC

- low serum iron and transferritin saturation

6. Tx:

- treat underlying disease

- erythropoieitin for renal failure, cancer, inflammatory d/o

1. normocytic, normochromic
2. cause: injury or abn expression of pluripotent hematopoietic stem cells
3. sx: weakness, fatigue, vulnerability to infx, pallor, purpura, petechiae
4. labs:

- PANCYTOPENIA

- Hypocellular bone marrow
5. tx:

- Mild: RBC and platelet transfusions

- Severe: bone marrow transplant, immunosuppression

1. cause: poor dietary intake (alcoholism, anorexia, low fruits and veggies), defective absoprtion through GI tract, pregnancy, hemolytic anemia, consumption of folic acid antagonists (phenytoin, bactrim, sulfasalazine)
2. daily requirement: 50-100 mg/dL - usually met by diet

- increased requirements in pregnancy, hemolytic anemia, exfoliative skin dz
3. sx: glossitis, vague GI sx, NO NEURO SX
4. labs:

- pathognomonic: macro-ovaloctyes and hypersegmented PMNs

- Howell-Jolly bodies

- RBC folate <150 ng/mL

- serum B12 usually normal
5. tx:

- oral folate 1mg/day

 - avoid alcohol and folic acid antagonists

1. most common cause: pernicious anemia
2. other causes: strict vegan diet, gastric surgery, blind loop syndrome, pancreatic insufficiency, Crohn's
3. where do you get B12: animal products
4. absorption occurs in the terminal ileum and storage in the liver
5. sx: golssitis, pale icterus, vague GI sx

- Neuro sx: stocking-glove paresthesias, loss of position/fine touch/vibratory sense, clumsiness, dementia, ataxia
6. labs:

- high MCV

- smear: anisocytosis, poikilocytosis, macro-ovalocytosis, hypersegmented PMNs

- low retic count

- high LDH and indirect bilirubin

- low B12
7. tx:

- pernicious anemia: lifelong B12 IM

- oral high dose cobalamin daily

- treat reversible causes

- Neuro sx reversible if treated within 6 mos

hemolytic anemias

1. intrinsic red cell defects

2. external/extracellular causes

general sx: jaundice, gallstones, pallor, sx related to decreased O2 to tissues

Labs:

Hallmark: elevated retic count in presence of falling or stable hematocrit

- smear: immature RBCs, nucleated RBCs, morphologic changes

- elevated indirect/unconjugated bilirubin

- elevated total bilirubin (4 mg/dL)

- elevated LDH

1. transmission: autosomal recessive
2. pathophys: hemolytic anemia caused by RBCs containing mainly Hgb S , which sickle under deoxygenated conditions
3. Population: blacks 1/400 have disease, 8% carry trait
4. Sx:

- begin in infancy when Hgb S takes over for Hgb F

- Crises: begin by adolescence - vascular occlusions produce pain, organ swelling/dysfunction/infarction lasting hours to days

- Crises induced by red cell dehydration, acidosis, hypoxemia

- Trait: difficulty concentrating urine
5. Labs

- Electrophoresis: Hgb S

- Smear: 5-50% sickled cells, target cells, nucleated RBCs, Howell-Jolly bodies

- Elevated retic count, WBC, platelets, indirect bilirubin
6. Tx:

- Crises: fluids, analgesia, O2, exchange transfusion

- Pneumococcal vaccine q10 years

- Folate supplements

7. Life expectancy: 40-50 years

Pts with sickle cell should avoid high altitudes - induce crises

1. transmission: X-linked recessive
2. Population: american black males (10-15%), Mediterranean
3. pathophys:

- This deficiency is protective against malaria

- Crises induced by oxidative stress: infection, drugs (aspirin, dapsone, primaquine, quinidine, sulfonamides, nitrofurantoin)
4. sx:

- episodic hemolysis, but otherwise healthy, no splenomegaly

- severe deficiency: chronic hemolysis

- Women carriers typically have no sx

- Favism: in some pts, episodes induced by eating beans (everyone with favism is G6PD deficient, not everyone with G6PD deficiency shows favism)
5. labs:

- During episodes: elevatted retic and indirect bilirubin

- Smear: bite cells, Heinz bodies (denatured hgb)

- Low G6PD levels
6. tx:

- supportive

- avoid oxidative drugs

1. Definition: a slowly progressive bone marrow disorder characterized by increased number of RBC and increased total blood volume. Unregulated expansion of RBC mass leads to hyperviscosity, which leads to decreased cerebral blood flow.
2. Dx: Presence of JAK2 mutation
3. secondary causes: smoking, renal tumors
4. morbidity and mortality: most commonly thrombosis, also bleeding, PUD, GI bleed
5. median age at presentation: 60 y/o (60% male) median life expectancy: 11-15 years after dx
6. complications: myelofibrosis, CML, AML
7. dx criteria: splenomegaly, normal arterial O2 sat, elevated RBC mass (RBCM)

8. sx: increased bloody viscosity and volume (HA, dizziness, fullness of head and face, weakness, fatigue, tinnitus, blurred vision), burning, pain, redness of extremities, stroke, pruritis after bathing, episatxis, PUD, plethora, systolic HTN, engorged retinal veins, splenomegaly
8. labs:

- Hct >54% (males) or 51% (females)

- Elevated platelets, WBC, Alk phos, B12, B12 binding capacity

- Smear: neutrophilic leukocytosis, increased basophils, increased eosinophils, large/bizarre platelets

- low erythropoeitin

- normal RBC morphology

- hypercellular bone marrow

- absent iron stores

- Hyperuricemia
9. tx:

- Phlebotomy

- myelosuppression wiht hydroxyurea or anagrelide

- low dose aspirin for thrombosis risk

ALL

Tx:

- induction chemo

- consolidation therapy

- allogeneic bone marrow transplant

Complication of tx:

- increased uric acid levels - need diuretics and allopurinol

Prognosis:

- >50% cured with chemo

- prognosis related to WBC count at dx

AML

Hallmark: AUER RODS

tx: induction chemo, consolidating therapy

prognosis: >70% who are <60 y/o acheive complete remission; further chemo leads to cure in 30-40%

CLL

tx:

Palliative

CML

Hallmark: PHILADELPHIA CHROMOSOME and BCR-ABL GENE

dx: Identification of BCR-ABL gene by PCR

tx: imatinib mesylate (STI571), dasatinib, nilotinib

- allogeneic bone marrow transplant - only therapy proven to be curative

1. Refers to a group of cancers characterized by enlargement of lymphoid tissue, spleen and liver and presence of REED-STERNBERG CELLS.
2. Epstein-Barr virus appears to be an important factor, found in 40-50% of cases
3. Population: bimodal peak: 20's and >50
4. sx:

- Presentation: painless cervical, supraclavicular, or mediastinal adenopathy, possibly pain in node after ingestion of alcohol

- Stage A: no constitutional sx

- Stage B: constitutional sx - fever, night sweats, wt loss, pruritis, fatigue
5. labs: CT of neck, chest, abd, pelvis

- bx of marrow

- recovery of reed-sternberg cells confirms dx
6. staging:

ANN ARBOR System

7. tx:

- ABVD (adriamycin, bleomycin, vinblastin, dacarbazine) chemo is curative in 50%

- Radiation for IA and IIA

I: single lymph node region OR simgle extralymphatic site

II: 2 or more lymph node regions on the same side of diaphragm OR one solitary extralymphatic site and one or more lymphnode regions on same side of diaphragm

III: lymph node regions on both sides of diaphragm with spleen involvement or solitary involvement of an extra lymphatic site OR both

IV: Diffuse involvement of extralymphatic sites with or without nodal involvement

A: no constitutional sx

B: constiutitional sx

1. peak incidence: 20-40 y/o
2. sx:

- painless adenopathy

- extralymphatic sites: GI tract, skin, bone, bone marrow

- constitutional sx
3. labs:

- bx enlarged nodes

- CT of chest, abd, pelvis

- marrow bx

- LDH
4. tx:

- Single node: radiation

- low grade: rituximab +/- chemo

- aggressive low grade: allogeneic transplant

- intermediate/high grade: chemo and autologous stem cell transplant

Multiple Myeloma:
1. malignancy of plasma cells. Possibly caused by herpes virus
2. med age at dx is 65
3. sx: anemia, bone pain (low back, ribs), infx, spinal cord compression, hyperviscosity, renal failure
4. labs:

- INCREASED PARAPROTEIN LEVELS

- hypercalcemia, proteinuria, elevated ESR

- anemia with rouleaux formation (RBCs stack like coins)

- XR: PUNCHED OUT LYTIC LESIONS on axial skeleton, esp skull

- positive BENCE JONES PROTEINS
5. tx:

- lenalidomide, dexamethasone, doxorubicine, bisphosphonates

1. Petechiae are seen almost exclusively in thrombocytopenia
2. If bleeding is caused by platelet problems, the skin and mucosa are usually involved
3. If bleeding is caused by coagulation problems, the skin and muscles are usually invoolved
4. Spontaneous hemarthroses are found only in hemophilia
5. Causes of acquired bleeding disorders: neoplasia, infection, malabsorption, shock, OB complications, drugs (NSAIDs, aspirin, abx, anticoagulants, thiazides, gold, heparin), SLE, CLL

6. initial assessment: plt count, smear, bleeding time (Pt, PTT), thrombin clotting time

1. Platelets

2. causes: acute ITP, chronic ITP

3. Sx:

- acute ITP: abrupt appearance of petechiae, purpura, hemorrhagic bullae on skin and mucus membranes

- chronic ITP: petechiae on skin and mucus membranes, epstaxis, oral bleeding, menorrhagia

- usually no splenomegaly

- HIT: same sx as ITP - also induced by sulfonamides, quinine, thiazides, cimetidine, gold

4. Labs:

- acute: decreased platelets 10-20K, eosiniophilia, mild lymphocytosis

- chronic: platelets 25-75K

- smear: megathrombocytes

- normal coag studies

5. Tx:

- Acute: resolves spontaneously. may need steroids or splenectomy

- Chronic: high dose prednisone. may need IVIG, immunosuppression, splenectomy, platlet transfusion, stem cell transplant

- avoid platelet antagonists

TTP - thrombocytopenic purpura

Tx: emergency large volume plasmapheresis

- prednisone

- anti-platelet agents

HUS

tx: conservative - fluids and electrolytes

- may need plasmapheresis in adults

DIC

tx: prompt and aggressive at underlying cause

- blood component transfusions

causes:

- congenital

- acquired: ASPIRIN AND NSAIDS MOST COMMON, drugs, uremia, alcohol, myeloproligerative disease, hypothermia, vit deficiency

sx: prolonged bleeding time, skin/mucus bleeding

labs: normal number of platelets, abn plt function study

tx: discontinue cause

- dialysis if uremia

- tranfusion may be necessary

1. transmission: autosomal dominant
2. characterized by reduced levels of Fact VIII antigen or ristocetin cofactor and deficient or defective Von Willebrand factor (vWF)
3. sx: bleeding in nasal, sinus, vaginal and Gi memebranes; exacerbated by aspirin; better with estrogens and pregnancy
4. labs:

- normal PT and PTT

- prolonged bleeding time

- low vWF
5. tx

- desmopressin acetate for Type I

- Factor VIII concentrates if factor replacement is necessary

1. other names: factor VIII deficiency or classic hemophilia
2. Hereditary disease characterized by prolonged coagulation time
3. transmission: X-linked recessive

- many older pts are HIV pos because of infected factor VIII tansfusions
4. sx: spontaneous hemorrhages with heparthroses, epistaxis, intracranial bleeding, hematemesis, melena, microscopic hematuria, gigival bleeding, bleeding after surgery or trauma
5. labs:

- prolonged PTT

- normal PT, bleeding time, fibrinogen, plt count

- low factor VIII, normal vWF
6. tx:

- infusion of factor VIII concentrates

- Desmopressin in mild disease

- avoid aspirin, celecoxib, opioids

Vit K-dependent factor deficiencies

tx: directed at underlying cuase

- oral/parenteral vit K to restore factor production

- FFP for hemorrhage

- increase leafy veggies

functioning pump

sufficient fluid volume

resistance

all cardiac pathology comes from abnormalities of one of these 3 factors

1. Definition: severe cardiac failure due to poor blood flow or inadequate distribution of flow --> both result in inadequate O2 delivery to tissues
2. Physical responses to shock are due to what 6 hormones? catecholamines (epi, NE, dopamine), renin, ADH, glucagon, cortisol, GH
4. sx:

- hypotension, orthostasis, tachycardia, peripheral hypoperfusion (cold extremities, "thready" pulse), AMS, oliguira, anuria, insulin resistance, metabolic acidosis
5. labs: CBC, T&C, coagulation studies, electrolytes, glucose, UA, serum Cr, pulse O2, ABG
6. tx:

- ABCs

- Trendelenburg to maximize blood to brain

- O2

- IV fluids

- sustain urine at 0.5 ml/kg/hr or more

- continuous EKG

- Pressors (dopamine)

1. causes: reduced CO, paroxysmal cardiac dysrhythmias, low blood volume, medications, endocrine/metabolic disorders
2. criteria: drop in systolice > 20 mmHg between supine and sitting and/or standing
3. likely cause based on PE findings:

- if accompanied by a rise in pulse >15 bpm, depleted blood volume is likely

- if no change in pulse - think meds, CNS disease (Parkinson's, Shy-Drager), or peripheral neuropathy

Primary (essential) HTN:
1. causes 95% of all HTN
2. cause: unknown, but has genetic influence (more common in blacks), increases with age, environmental influence (obesity, excessive salt intake)
3. exacerbating factors: alcohol excess, smoking, lack of exercise, polycythemia, NSAIDs, low potassium intake

4. sx: usually none, maybe non-descript headache

5. Workup:

- EKG: LVH with strain pattern in advanced disease

- CXR: LVH

- Labs: may have evidence of other diseases such as renal failure or DM

OSA

estorgens

pheochromocytoma

coarctation

pseudotumor cerebri

parenchymal disease

renal artery stenosis

chronic steroid therapy

Cushing's

thyroid and parathyroid disease

primary hyperaldosteronism

pregnancy

Urgency:>220/>125

- BP must be reduced within hours bc there are risk factos for end-organ damage

Emergency: diastolic >130

- must be reduced within one hour to prevent progression of end organ damage or death

Malignant HTN:

- elevated BP associated with papilledema and either encephalopathy or nephropathy - if untreated, progressive renal failure occurs

Normal: <120/<80

PreHTN: 120-139/80-99

Stage 1: 140-159/90-99

Stage 2: >160/>100

Dx criteria for stage 1 is >140/>90 on three separate occasions

1. Non-pharmacologic:

DASH diet: Dietary Approaches to Stop HTN - low sat fat, low cholesterol, low total fat, increased fruits and veggies, increased low fat and fat free milk products, increased fiber

- weight loss, increased exercise, smoking cessation, limited alcohol, limited sodium
2. Typical therapy:

- First line: Thiazide diuretics - consider need for K+ supplement

- Bblockers - more effective in younger pts

- ACE inhibitors - first drug of choice in pts with HTN and DM

- Others: ARBs, CCB, aliskiren (renin inhibitor)
3. Therapy for refractory cases: alpha-adrenergic antagonists, central sympatholytics, aldosterone receptor antagonists
4. therapy for emergencies:

- parenteral drugs - sodium nitroprusside, nitro, BB, nicardipine, enalaprilat, hydralazine, thrimethaphan, fenoldopam, loop diretics

- oral agents (for mild emergencies): clonidine, captopril, nifedipine

- do not lower BP too quickly

In HTN pt with renal dysfunction and only when close electrolyte monitoring is available

- Need K+ supplement

Indications: HTN, angina, arrhythmias, chronic headache, CHF, tremor, glaucoma, migraine, MVP, MI, pheochromocytoma, orthostatic tachycardia syndrome, tachycardia in anxiety and hyperthyroidism, theophylline overdose, aortic dissection, HOCM, Marfan syndrome, portal HTN, hyperhidrosis, anxiety

Actions: decrease HR and CO

HTN: better in young white pts

Indications: HTN, DM, CHF, renal failure, scleroderma, MI

vasodilation via prostaglandin production and inhibit bradykinin degredation

SE: cough due to bradykinin increase, hyperkalemia

CI:

Class I: no limitation of activity; normal activity does not cause undue fatigue, dyspnea, angia

Class II: slight limitation; ordinary activity results in sx

Class III: Marked limitation; comfortable at rest but less than normal activity causes sx

Class IV: unable to engage in any physical activity wihtout sx; uncomfortable at rest

1. Definition: clinical sydnrome characterized by dyspnea and abn retention of water and sodium
2. results from changes in at least one of 4 things: heart contractility, proload, afterload, HR
3. Adversely affects CO and Left atrial pressure
4. sx - left vs. right HF

- left: exertional dyspnea, nonproductive cough, fatigue, orthopnea, pnd, basilar rales, gallops, exercise intolerance

- right: JVD, hepatic congestion (sometimes tender), nausea, dependent pitting edema

- Both: parasternal lift, enlarged apical impulse, diminished first heart sound, S3 gallop, S4 gallop, pallor, cold skin, nocturia, hypotension, narrow pulse pressure
5. Labs: anemia, renal insufficiency, hyperkalemia, hyponatremia, elevated LFTs, hypokalemia from diuretics, elevated BNP or N-terminal pro-BNP
6. Xray findings: cardiomegaly, pulmonary effusion, perivascular/interstitial edema (Kerley B lines), venous dilation, alveolar fluid
7. EKG findings: non-specific, underlying arrhythmia, conduction defects, LVH, old MI
8. Echo findings: size of chambers, valve abn, pericardial effusion, shunting, wall abn
9. Tests to assess severity: stress test, radionuclide angiography, cardiac cath

11. causes: myocardial and pericardial disorders, valvular disorders, congenital anomalies

- high output filaure: non-cardiac causes (thyrotoxicosis, anemia)

First, treat reversible causes

1. non-pharm: progressive aerobic exercise, low-sodium diet, stress reduction
2. initial: thiazide or loop + ACE

- others: K-sparing diuretics, ARBs, BB, direct inotropes (Dig), arterial and venous vasodilators
3. to treat associated angina or HTN: CCB - amlodipine
4. other measures: anticoagulation, antiarrhythmics, implantable cardiac defibrillators, biventricular pacers, coronary revascularization, cardiac transplant

1. Definition: insufficient O2 supply to cardiac muscle
2. general causes: atherosclerotic narrowing, constriction of coronary arteries, congenital anomalies, emboli, arteritis, dissection
3. risk factors: male, age, low-estrogen, smoking, fm hx, HTN, DM, abdominal obesity, inactivity, dyslipidemias, alcohol, low intake of fruits and veggies, metabolic syndrome
4. sx: paroxysmal squeezing/burning CP, sensation of smothering, fear of death, midsternal - radiates to jaw, shoulders, arms, wrists, back of neck

- lasts <3 min, relieved by nitro and rest, exacerbated by physical activity
5. Levine's Sign: a clenched fist over the sternum and clenched teeth when describing CP
7. Wokrup:

- EKG changes: horizontal or down-sloping ST depression during attack, flattened or inverted T waves (EKG normal in 25%)

- most useful and cost-effective test: exercise stress test (pos if 1mm or 0.1 mV ST depression)

- other tests: echo, myocardial perfusion scintigraphy, radionuclide angiography, stresh echo, PET, SPECT, CT, MRI, EBCT, ambulatory EKG

- definitive dx procedure: coronary angiography
8. treatment:

- preventative/rehabilitative: exercise, weight loss, low fat and cholesterol diet, smoking cessation, DM/HTN/hyperlipidemia control

- Acute: nitro

- Long term: long acting nitrates, BB, Ranolazine, CCB (3rd line), platlet-inhibitors (aspirin, clopidegrel), revascularization

Includes 3 or more:

** abdominal obesity (40 in or more for men, 35 in for women)

trigs >150 mg/dL

HDL <40 (men) or <50 (women)

** fasting glucose >110 mg/dL (insulin resistance)

HTN

** - most important

Stable: lasts <3 min, relieved by nitro/rest

Unstable angina/MI: lasts >30 min, unrelieved by nitro/rest, occurs at rest or with little exertion, increasing pattern of pain from usual angina

Prinzmetal's/variant angina: caused by vasospasm at rest with preservation of exercise capacity

include 8-10 hr treatment-free interval to prevent tolerance

SE: HA, nausea, light-headedness, hypotension

1. a spectrum of problems ranging from unstable angina to MI, but classified as ST elevated or non-ST elevated events.
2. determination of MI is based on cardiac markers
3. Causes of MI: prolonged myocardial ischemia - usually thrombus formation from atherosclerotic plaque. Could be vasospasm, reduced blood flow, increased metabolic demand, embolic occlusion, vasculitis, aortitis, coronary artery dissection, cocaine
4. most common cause of death due to MI: Vfib
5. pt groups likely to present with atypical MI sx: elderly, women, DM
6. sx: increasingly severe CP >30 min, diaphroesis, weakness, anxiety, restlessness, light-headedness, syncope, cough, dyspnea, orthopnea, nausea, vomiting, abd bloating --> most commonly happen in early morning
7. PE findings: brady or tachycardic, hyper or hypotensive, low grade fever

- Lungs: clear, rales, or wheezing

- Cardio: normal, JVD, soft heart sounds, MR murmur, S4 gallop, pericardial rub after 24 hrs

8. MRI with gadolinium

Inferior: II, III, aVF

Anterior: V1, V2, V3 (Class: V1-V6, aVL)

Posterior/anteroseptal: V1, V2

Anterolateral: V4-V6

All pts: IV fluids, O2, nitro, pain mgmt, may need benzos for sedation, BB, risk stratification, CCB if can't tolerate nitro or BB

No ST elevation: antiplatelet (aspirin, clopidogrel) and anticoagulation (Lovenox, enoxaparin, fondoparinux, bivalirudin)

ST elevation: Aspirin and Clopidogrel, coronary angiography with PCI within 90 min

- thrombolytics w/in 3 hrs if cant do PCI (alteplase, reteplase, tenecteplase)

- statin in days following MI

Absolute: previous hemorrhagic stroke, any stroke w/in last year, knkown intracranial neoplasm, active internal bleeding, suspected aortic dissection

Relative: known bleeding diasthesis, trauma w/in past 2-4 weeks, major surgery in last 3 weeks, prolonged or traumatic resuscitation, recent  internal bleed, noncompressible vascular punction, active diabetic retinopathy, pregnancy, active PUD, current use of anticoagulants, BP >180/110

TIMI: thrombolysis in MI - one point for each:

>65 y/o, 3 or more risk factors for coronary disease, use of aspirin in last 7 days, known CAD with stenosis 50% or more, more than one episode of rest angina in last 24 hrs, ST deviation, elevated cardiac markers

- score of 3 or more is high risk

GRACE: global registry of acute coronary events:  more complex, usually not done

Tetralogy of fallot

Tet spells: extreme cyanosis, hyperpnea, agitation - medical emergency

4 defects: overriding aorta, large VSD, RVH, right ventricular outflow obstruction

PDA

tx: prostaglandin inhibitors - Indomethacin (NSAID)

Systolic: Aortic stenosis, Mitral regurg, Tricuspid regurg, pulmonic stenosis

Diastolic: aortic regurg, mitral stenosis

ARMS

1. most common presenting sx: dyspnea, fatigue, decreased exercise tolerance, cough, rales, PND, hemoptysis, hoarsenss, thready carotid pulses
2. typical pt with MVP: thin females with minor chest wall deformities
3. CXR findings for each

- aortic: LAE, LVH

- mitral: LAE
4. definitive method for dx: TEE, cardiac cath

- Doppler is good for pressure gradient assessment
5. tx:

- Long term: need surgery for repair, replacement or ballooning

- Short term, mild cases: diuretics, vasodilotors, dig, BB, abx for endocarditis prophylaxis

1. Usual presentation: in infancy or childhood - exercise intolerance, JVD, peripheral edema, hepatomegaly
2. Complications: due to right-sided pressure overload. RVH, systemic venous congestion, RHF
3. CXR: prominent right heart border, dilation of superior vena cava
4. EKG: RAD, P wave abnormalities associated with RAE, prominent R and deep S waves associated wtih RVH
5. definitive testing: echo and cardiac cath
6. tx: sodium restriction, diuretics, vasodilators, positive inotropes

- Definitive: surgery

Supraventricular Rhythms:
1. may be normal in athletes. Usually represents SA node pathology. increased risk for ectopic rhythms - Sinus Bradycardia <60 bpm
2. occurs with fever, exercise, pain, emotion, shock, thyrotoxicosis, anemia, HF, drugs - Sinus tachycardia >100 bpm
3. normal finding. do not alone constitute disease. - PACs
4. very common. occurs in people without structural problems. tx? - PSVT - tx: valsalva, coughing, breath holding, stretching, putting head btwn knees, applying cold water to face, unilateral carotid massage
5. most common chronic arrhythmia. risk increases with age, called "holiday heart" when caused by alcohol use or withdrawal. tx? - Afib - electric cardioversion, rate control (BB), anticoagulation
6. occurs in pts with COPD, CHF, ASD, or CAD. tx? - Aflutter - ibutilide or electric cardioversion, Amiodarone or dofetilide for chronic disase. Radiofrequency ablation for recurrent
7. occur in pts with normal hearts, myocarditis, CAD, or dig toxicity - Junctional rhythms

general sx? - palpitations, angina, fatigue, none
general Pharm tx - adenosine, verapamil, BB, CCB, dig

Non-pharm: surgery, ablation, cardioversion, pacing

V tach

- severe hypotension or LOC may require SYNCHRONIZED cardioversion

- pharm interventions: lidocaine, procainamide, amiodarone, Mg2+

- if recurrent, may need implantable defibrillator

Torsades de Pointes

may indicate hypokalemia or hypomagnesemia

tx: BB, Mg, temporary pacing

Long QT syndrome; QT interval 0.5-0.7 sec long (normal is 0.42s)

tx: implantable defibrillator

Brugada's syndrome

tx: implantable defibrillator

AV conduction block (first, second, third degree heart block)

tx: pacing

1st: Prolonged PR interval >0.2s

Mobitz I (Wenckebach): progressive prolongation of PR followed by a dropped beat- AV node disturbance

Mobitz II: atrial impulse is unexpectedly not conducted, resulting in a dropped QRS without previous prolongation of PR - Purkinje fiber/bundle of His disturbance

3rd: No communication between atria and ventricles - beat at completely different rates

1. Characteristic anatomical changes: massive hypertrophy of septum, small left ventricle, systolic anterior mitral motin, diastolic dysfunction
2. Cause: genetic
3. Outcome: sudden death in pts <30 y/o at rate of 2-3% yearly
4. Sx: dyspnea, angina, syncope, arrhythmia. Sudden death is often presenting sx
5. PE: sustained PMI, triple PMI, loud S4 gallop, SEM, bisferiens carotid pulse (double pulse per beat), jugular pulsations with prominent "a" wave
6. EKG: NSTT changes, exaggerated septal Q waves, LVH

7. Tx: BB, CCB, disopyramide (antiarrhythmic)

- ablation of hypertrophic septum

- pacing, implantable defibrillator, or mitral replacement may be necessary

Pericarditis. Key is relieved by sitting up leaning fwd. Tx: abx if bacterial cause, steroids, pericardiocentesis if effusion, colchicine, surgery

Complications: restrictive pericarditis, effusion

causes: pericarditis, uremia, truama

sx: due to restrictive pressure on heart - +/- pain, dyspnea, cough

tx: pericardiocentesis

EKG change: electrical alternans (changing QRS amplitudes that alternate beat to beat)

cardiac tamponade

tx: pericardiocentesis, pericardial window

abnormally large decrease in systolic bp >10 mmHg and pulse amplitude during inspiration - can hear a beat on auscultation but cannot feel that beat in the radial pulse

Kussmaul's sign: JVD on inspiration

 1. most common pathogens: staph aureus, group D strep, enterococci, HACEK
2. common causes: IV drugs (staph - tricuspid valve), prostetic valves  (staph, gram neg, fungi), chronic regurg, bacteremia (common after dental, upper respiratory, urologic, and lower GI procedures)
3. sx: fever, cough, dyspnea, arthralgia, back/flank pain, GI upset, stable murmur, pallor, splenomegaly

- CLASSIC: palatal, conjunctival, or subungual petechiae; splinter hemorrhages; Osler nodes; Janeway lesions; Roth spots
4. workup:

- 3 sets of blood cultures at least 1 hr apart, preferably before starting abx

- echo

- CXR to reveal pulmonary infiltrate
5. tx:

- empiric broad spectrum abx --> VANC + CEFTRIAXONE

- abx prophylaxis before dental work or surgery for pts with prosthetic valves, previous endocarditis, congenital heart disease, valve disease, HOCM, cardiac transplant, valvuloplasty --> amoxicillin

- valve replacement may be necessary

If abscess develops, fungus is the cause

Gram neg organisms that are part of normal flora but can result in endocarditis, esp in kids

• Haemophilus
• Actinobacillus
• Cardiobacterium hominis
• Eikenella corrodens
• Kingella

Major:

- 2 pos blood cultures of typically causative organisms

- evidence of endocardial involvement on echo

- development of new regurg murmur

Minor:

- predisposing factor

- Fever >100.48F

- Vascular phenomena (embolism, pulmonary infarct)

- Immunologic phenomena (glomerulonephritis, osler nodes, roth spots)

- pos blood culture not meeting major criteria

1. Def: systemic immune response occurring 2-3 weeks following infection with GABHS throat
2. Typical lesion: perivascular granuloma with vasculitis on a heart valve
3. Common valvular involvement: mitral > aortic > triscupid
4. sx: Jones criteria - see next flashcard
5. Tx:

- strict bed rest until stable

- salicylates and corticosteroids

- IM penicillin (erythromycin for penicillin allergy)

- Benzathene penicillin q4 weeks to prevent recurrence

Major: carditis, erythema marginatum (pink rings on trunk and inner surfaces of limbs, subcu nodules, Sydenham's chorea, polyarthritis

Minor: fever, polyarthralgia (pain w/o swelling), reversible PR prolongation, rapid ESR, CRP

Peripheral artery disease:
1. typically a result of atherosclerosis
2. sx: LE ischemia, pain relieved by rest (intermittent claudication), limitation of activity, weak peripheral pulses, numbness, tingling, ulcerations (lat surface of foot/ankle and distal toes), pallor, poikilothermia, paralysis, embolism, ED
3. 3 types:

a. Type 1 - limited to aorta and common iliac - in smokers and hyperlipidemia

b. Type 2 - involves aorta, common iliac, and external iliac

c. Type 3 - most common, arota, iliac, femoral, popliteal, tibial
4. workup:

- if <0.9 ABI - represents significant disease

- Doppler flow studies

- CTA/MRA
5. Tx:

- stop smoking

- progressive exercise

- statins

- cilostazol - main tx

- antiplatelets

- phosphodiesterase inhiitor for ED

superficial thrombophlebitis

tx: bed rest, local heat, elevation, NSAIDs

1. risk factors: major surgical procedures, prolonged bed rest, OCP, hormone replacement, clotting disorders, age, type A blood, obesity, multiparity, IBD, SLE
2. Virchow's triad: stasis, vascular injury, hypercoagulable state
3. sx: none, swelling, heat, redness
4. dx: Duplex ultrasonogrpahy is preferred

- Venography is most accurate but is associated with increased risk

- elevated d-Dimer - can rule out but not rule in
5. tx: Lovenox or Heparin followed by warfarin

1. characterized by loss of venous wall tension, which results in stasis of venous blood - often associated with hx of DVT, leg injury, varicose veins
2. sx: progressive edema, itching, dull pain w/ standing, ulceration just above ankle

- Skin: shiny, thin, atrophic, dark pigment, subcu induration
3. tx:

- elevate legs, avoid extended standing or sitting, compression hose

- ulcers: wet compression, compression stockings, hydrocotisone, zinc oxide - may need skin grafting

1. Systemic inflammatory condition of med-large vessels primary affecting >50 y/o, frequently associated wtih PMR
2. most frequently involves which artery - temporal artery and branches of carotid
3. complications: blindness, large vessels (aortic aneurysm)
4. sx: HA, scalp tenderness, jaw claudication, throat pain, vision problems, sx of PMR (shoulder/hip girlde), resp tract issues, mononeuritis multiplex, FUO, unexplained neck/head pain
5. workup:

- markedly elevated CRP and ESR

- CBC: anemia, thrombocytosis

- elevated alk phos

- TEMPORAL ARTERY BX for dx
6. tx: High dose prednisone for 1-2 mos with low-dose aspirin

1. causes: atherosclerosis, congenital defects (Ehlers-Danlos, Marfan's, giant cell arteritis, vasculitis, trauma, syphilis)
2. Classic patient with AAA: elderly MAN smoker with CAD, emphysema, and renal impairment
3. sx: asymptomatic, pulsating abd mass, abd/back pain, renal/LE occlusion

- Thoracic aneurysms: substernal/back/neck pain, dyspnea, stridor, cough, dysphagia, hoarseness, SVC syndrome

- Dissection: tearing severe back, abd, flank pain with hypotension and shock
4. imaging:

- abd US is choice for abd

- aortography, CT, MRI for thoracic
5. tx:

- surgical repair

1. sx: heartburn, regurg, dysphagia, hoarseness, halitosis, cough, hiccups, CP
2. dx: usually clinical
3. when to do EGD: severe disease, >45 with new onset sx, long-standing or frequent sx, failure to respond to therapy
4. r/o: myocardial ischemia with EKG
5. other tests: barium swallow, esophageal manometry, ambulatory 24 hr pH monitoring
6. tx:

- Lifestyle: smoking cessation, avoid eating at bedtime, avoid large meals, avoid foods that cause irritation and alcohol, raise head of bed

- Drugs: antacids, alginic acid for mild sx

- H2 blockers 1st line for mild GERD (famotidine, cimetidine, ranitidine, nizatidine)

- PPI is most powerful - first line for mod-severe disease, unresponsive to H2s, or have erosive gastritis (omeprazole, lansoprazole, etc)

- Nighttime sx: H2 at bedtime + PPI during day

- Avoid B-agonists, a-antagonists, nitrates, CCB, anticholinergics, theophylline, morphine, meperidine, diazepam, barbiturates --> decrease LES tone

1. rare except in immunocompromised
2. most common causes:

- Candida, CMV, HSV
3. sx: odynophagia, dysphagia in immunocompromised pt
4. workup: EGD reveals large deep ulcers if CMV, multiple shallow ulcers if HSV, white plaques if candida

- culture from EGD is definitive
5. tx:

- Candida: fluconazole or Ketoconazole

- HSV: acyclovir

- CMV: ganciclovir

Esophageal motility disorders:
1. most common presenting sx: dysphagia
2. workup: barium swallow, pharyngoscopy, esophagoscopy, esophageal manometry
3. general tx: dilation of strictures, resection of neoplasia

- medical managment: CCB, nitrates, botulinum

Types:
1. causes difficulty with solids and liquids due to injury to CN involved in swallowing --> Neurogenic dysphagia
2. outpouching of posterior hypopharynx causing regurg of undigested food and liquid into pharynx several hours after eating --> Zenker's Diverticulum
3. progressive dysphagia for solids.  slow progression indicates webs or rings, rapid progression indicates Neoplasm --> Esophageal stricture
4. global esophageal motor disorder in which peristalsis is decreased and LES tone is increased causing slowly progressive dysphagia with episodic regurg and CP. Barium swallow: "parrot-beak" appearance due to dilated esophagus tapering to a distal obstruction --> Achalasia
5. dysphagia or intermittent CP that may or may not be assocaite with eating --> Diffuse esophageal spasm
6. this disease eventually progresses into an esophageal motor issue but will first have many other systemic sx --> scleroderma

1. most common types: squamous cell and adenocarcinoma (Barrett's is precursor for adeno)
2. common mets: mediastinum
3. risk factors: smoking, chronic alcohol, exposure to caustic agents, hot roods, mucosal abn, poor oral hygiene, HPV
4. sx: progressive dysphagia for solid food + marked weight loss

- also heartburn, vomiting, hoarseness
5. workup:

- Biphasic barium esophagram best for visualizing

- endoscopy with brushings

- endoscopic US and CT for staging
6. tx

- surgery, +/- chemo and radiation

- 4-60% 5 year survival

1. definition: dilations of esophageal veins
2. causes: portal HTN from cirrhosis or chronic viral hepatitis OR Budd-Chiari syndrome causing thrombosis of portal vein

- NSAIDs exacerbate
3. dx: clinical in pt with cirrhosis and hematemesis
4. tx:

- hemodynamic support -  high volume fluid replacement, vasopressors

- EGD and pharmacologic vasoconstriction (octreotide)

1. Protective factors: mucus, bicarb, mucosal blood flow, prostaglandins, alkaline state, hydrophobic layer, epithelial renewal --> any imbalance in these can cause inflammation
2. Causes:

- autoimmune (pernicious anemia) cause Type A gastritis

- H. pylori - gram-neg spiral-shaped bacillus causes TYPE B gastritis

- NSAIDs (diminish prostaglandin production)

- stress

- alcohol
3. sx: dyspepsia and abd pain
4. workup: endoscopy w/ bx for extent and presence of HP

- urea breath test or fecal antigen test for HP
5. tx:

- treat cause, remove causes (NSAIDs, alcohol)

delayed gastric emptying

tx: prokinetic meds (cisapride, metoclopramide [reglan])

1. causes: HP is most common, NSAIDs, alcohol, stress
2. complications: malignancy, bleeding (most common cause of non-hemorrhagic GI bleed)
3. sx: burning/gnawing abd pain

- duodenal ulcer pain improves with food

- gastric ulcer pain worsns with food and often results in wt loss

- other: dyspepsia, bloating, distention, heartburn, nausea, belching
4. workup:

- endoscopy is best

- stool, blood, breath HP tests
5. tx:

- avoid irritating factors

- HP regimen

- PPI, misoprostol (synthetic prostaglandin)

1. PPI + clarithromycin + amoxicillin (sometimes add metronidazole)

2. bismuth subsalicylate + TCN + metronidazole + PPI

1. definition: gastrin-secreting tumor called gastrinoma causes hypergastrinemia with results in refractory PUD
2. r/o what syndrome? MEN-1 (multiple endocrine neoplasia)
3. sx: sx of PUD with secretory diarrhea, may be refractory to tx or may not
4. workup:

- fasting gastrin level >150 pg/mL indicates hypergastrinemia

- secretin test to confirm ZES - give 2 U/kg IV secretin, if + ZES gastrin will icnrease by 200 pg/mL

- Endoscopy, CT, MRI to locate tumor
5. tx: PPI, surgical resection of gastrinoma

1. epidemiology: one of the most common cancers worldwide but less in US, 2x more common in men, rare before 40, strong association with HP

2. sx: Dyspepsia + anemia + wt loss

- postprandial vomitng if lesion in pylorus
3. workup: endoscopy with cytology in any pt >40 with dyspepsia that is unresponsive to thearpy

- abd CT to determine extent
4. tx:

- curative or palliative resection

- chemo or radiation for palliation

- 80% cure rate if caught early, 50% cure rate if through muscularis propria, 10% if lymphatic spread

1. Virchow's node

2. Sister Mary Joseph Nodule

1. secretory diarrhea

2. inflammatory diarrhea

3. antibiotic-associated diarrhae

enterohemorrhagic e. coli

shigella

campylobacter

salmonella causes purulent diarrhea

giardia: metronidazole 250 mg BID x 10 days

cyclospora: Bactrim BID x 1 days

crypto is usually only seen with HIV

1. normal BM frequency:3/day - 3/week
2. pts over 50 with new-onset constipation should be evaluated for colon cancer
3. tx:

- lifestyle managment: fiber 10-20 g/day, fluids 1.5-2 L/day

- lasting >2 weeks or refractory to lifestyle mods - further investigation

1. most common causes: adhesions and hernias; then neoplasm, IBD, volvulus
2. sx: abd pain, distention, vomiting of partially digested food, obstipation
3. PE: high pitched bowel sounds and rushes --> becomes silent
4. lab and xr findings: dehydration, electrolyte imbalance

- XR: air-fluid levels
5. tx: NPO, NG suction, IV fluids, monitoring, may need surgery

1. causes: most common cause is neoplasm; strictures, hernia, volvulus, intussusception, fecal impaction
2. sx/pe: distention, pain; high pitched bowel sounds and rushes
3. labs/xr: dehydration, electrolyte imbalance; air-fluid levels
4. tx: NG tube, NPO, IV fluids, monitoring - surgery very likely

Complications of both: infarction, necrosis, peritonitis, death, shock (fever and tachy)

1. definition; twisting of any portion of bowel on itself,

2. most commonly in the sigmoid or cecal areas

3. sx: cramping abd pain, distention, nausea, vomiting, obstipation
4. PE: tympany, tachy, fever
5. dx via: abd xray - colonic distension
6. tx: urgent endoscopic decompression - surgery if this fails

7. complications: ischemia --> gangrene, peritonitis, sepsis

1. caused by problems in what 4 processes: digestion, absorption, imapired blood flow, impaired lymph flow
2. sx: diarrhea is usually primary complaint; bloating, abd discomfort, wt. loss, edema, steatorrha, specific sx to deficieincy
3. workup

a. 72 hr fecal fat test - if this is normal, do more specific tests

b. D-xylose test - to differentiate maldigestion from malabsorption - if D-xylose is detected in blood and urine after administration, then the body CAN properly absorb nutrients

c. specific test for specific deficiency

1. definition: inflammation of small bowel with the ingestion of gluten-containing foods - wheat, rye, barley - resulting in malabsorption
2. sx: highly variable - diarrhea, steatorrhea, flatulence, wt loss, weakness, abd distention, failure to thrive, iron def, coaguloapthy, hypocalcemia
3. dx: IgA antiendomysial and antitissue transglutaminase antibodies - comfirm with small bowel bx
4. tx: gluten-free diet, may also need lactose-free until inflammation resolves, supplements to correct nutritional deficiencies

- prednisone for refractory cases

1. AKA: regional enteritis
2. cause: unknown but genetic predisposition
3. characteristics: can involve all parts of GI tract from mouth to anus. Most common is terminal ileum and right colon. Often spares rectum. Skip lesions. Lesions are transmural.
4. complications: fistula, abscess, apthous ulcers, renal stones, colon cancer, toxic megacolon, perforation
5. sx: abd cramps, diarrhea, lowgrade fever, polyarthallgia, anemia, fatigue, blood in stool
6. dx: colonoscopy w/ bx - entire colon wall involved, granulomas often present
7. tx:

- acute: prednisone +/- aminosalicylates, may need flagyl or cipro

- elemental diet helpful

- Maintenance: Mesalamine

- Smoking cessation

- may need surgery (segmental resection)

1. characteristics: generally starts distally at rectum and moves proximally - no skip lesions
2. sx: tenesmus, bloody/pus-filled diarrhea; LLQ pain, wt loss, malaise, fever
3. complications: toxic megacolon, malignancy (these more common than in crohn's); episcleritis, scleritis, arthritides, sclerosing cholangitis, erythema nodosum (tender red bumps caused by inflammation of fat cells under skin), pyoderma gangrenosum (ulcers caused by necrosis, usually on legs)
4. smoking seems to be protective
5. dx via: colonoscopy or sigmoidoscopy
6. tx:

- Topical or oral aminosalicylates (sulfasalazine, mesalamine) and corticosteroids are mainstay

- immunomodulators for refractory disaese

- surgery can be curative (proctocolectomy)

In all IBD, avoid what tests during acute flares: colonoscopy, barium enema --> can cause perforation or toxic megacolon

1. cause: combo of altered motility, hypersensitivity to intestinal distension, psychological distress
2. epidemiology: more common in women, begins early-mid adulthood, usually lifelong
3. sx: abd pain worsened by food and relieved with defecation, gas, postpradial urgency, changes in stool freequency and character, alternating diarrhea and constipation, dyspepsia
4. dx: dx of exclusion - stool studies, colonoscopy, barium enema, US, CT to r/o other problems
5. tx: reassurance, avoidance of triggers,

- mainstays: high-fiber diet, bulking agents (psyllium hydrophilic mucilloid),

- antispasmodics, antidiarrheals, prokinetcs, antidepressants as needed

intussusception

tx: hospitalize all pts

- Kids: air or barium enema - may be dx and curative

- adults: CT, then surgery - do NOT do barium enema

1. incidence: 60% of pts >60 y/o will have diverticulosis, 20% of these pts will be symptomatic; 20% of diverticulitis is <40 y/o
2. prevention of diverticulitis in pts with diverticulosis: high fiber diet, avoidance of obstructing/constipating foods (nuts, seeds, popcorn)
3. sx: sudden onset abd pain usually LLQ or suprapubic; +/- fever, +/- peritonitis, n/v

- bleed: sudden onset large volume hematochezia that resolves spontaneously
4. workup:

- fecal occult blood

- CBC: mild-mod leukocytosis

- XR: to r/o free air

- CT: if no response to therapy

- Barium enema should be avoided during acute episode
5. tx:

- mild diverticulitis: low-residue diet and braod spectrum abx; may need hospitalization for IV abx, bowel rest, analgesia

- Surgery for peritonitis, abscess, fistula, obstruction

1. acute mesenteric ischemia

2. chronic mesenteric ischemia

tx: surgical revascularization and hydration

AMI has high mortality rate

1. definition: extreme dilation and immobility of colon - a medical emergency
2. cause in kids: Hirschsprung's disease
3. cause in adults: UC, crohn's, pseudomembranous colitis, infections
4. sx: fever, prostration, severe creamps, abd distension, rigid abdomen, rebound tenderness
5. xray findings: colonic dilation
6. tx: decompression, colostomy, resection

- fluids and electolyte balance

familial polyposis syndrome

screening: q1-2 years beginning at 10-12 y/o

1. 3rd leading cause of cancer death in US
2. 5 year survival: 90% at stage A (mucosa only), 70-80% at stage B (through wall, regional lymph nodes), 5 % at  C or D (+ lymph nodes, mets)
3. sx: slow-growing, disease is late by the time sx appear - abd pain, change in bowel habits, occult bleeding, obstruction, fatigue, weakness
4. lab findings:

- occult blood

- carcinoembryonic antigen for monitoring but not detection

- colonoscopy or barium enema for visualization

- CXR and CT for mets

5. Tx:

- surgery

- add chemo for Stage III (Duke C) or higher

- radiation for rectal tumors

anorectal abscess

tx: surgical drainage + WASH regimen (warm-water cleansing, analgesia, stool softeners, high-fiber diet)

anorectal fistula

tx: surgery

- Do NOT explore on exam bc it may open new tracts

Most commonly posterior midline

sx: tearing pain on defecation + hematochezia in stool or on TP

tx: bulking agents, increased fluids, sitz baths, topical nitro or styptic (silver nitrate, gentian violet)

I: confied to anal canal - may bleed with defecation

II: protrude from anal opening but reduce spontaneously. may have bleeding and mucoid discharge

III: require manual reduction after BM

IV: chronically protruding, risk strangulation

I-II: high fiber diet + increased fluids + bulk laxatives

III-IV: anesthetics/astringent suppositories

IV: surgery - banding, injection, sclerotherapy

pilonidal disease

tx: surgical drainage w/ abx

fecal impaction

complications: urinary obstruction, infection, colon perf, stercoral ulcer, appendicitis from fecalith

tx: digitally brekaing up impaction followed by saline or tepid-water enema

1. most common cause: fecalith

- less common cause is infection (CMV, adenovirus, histoplasma), collagen vascular disease, IBD
2. epidemiology: 10-30 y/o, most common abd surg emergency
3. complications: perforation and peritonitis (20%) - high fever, generalized abd pain, inceased leukocytosis
4. sx: intermittent periumbilical/epigastric pain that localizes to RLQ (McBurney's point) 12 hrs later and becomes constant - worse wtih movement

- nausea, anorexia, vomiting, low-grade fever
5. PE findings:

- Psoas sign: pain with raising leg against resistance while supine

- obturator sign: pain with flexing and internally rotating right him with knee bent while supine

6. workup: leukocytosis, microscopic hematuria/pyuria

- CT to confirm

7. Tx: appy + broad spectrum abx

1. common causes: cholelithiasis, alcohol abuse

- others: hyperlipidemia, trauma, drugs, hypercalcemia, PUD, meds
2. sx: epigrastric pain radiating to back that lessens when leaning fwd or in fetal position, n/v, fever, leukocytosis, peritonitis, hypovelemia, ARDS, tachy, shock
3. labs:

- amylase: elevated, sometimes for only 48-72 hrs

- Lipase: more specific if elevated 3x or more

- leukocytosis

- hemoconcentration

- LFTs elevated

- BG, bilirubin may be elevated

- Ca may be low

4. tx:

- BPO

- maintain fluids

- meperidine (demerol) for pain

- abx

- parenteral hyperalimentation

Complications: pancreatic pseudocyst, renal fialure, pleural effusion, hypocalcemia, pancreatic abscess

Leukocytes >16K

BG >200

LDH >350

AST >250

PO2 <60 mmHg

Base deficit >4

Falling Ca

Rising BUN

1. most common cause: alcohol (90%)
2. classic triad: pancreatic calcification, steatorrhea, DM (only actually in 20% of pts)

- others steatorrhea
3. labs:

- amylase elevated early but decreases with each episode

- Abd xr: calcification of pancreas in 20-30%
4. tx

- alcohol cessation

- low fat diet

- surgical removal of part of pancreas

1. definition: gallstone in common bile duct
2. sx: colic, jaundice, pancreatitis, cholangitis
3. best imaging: ERCP
4. labs:

- elevated DIRECT bilirubin, amylase, lipase

5. tx: ERCP, lap chole, common bile duct exploration

1. obstruction of bile duct, usually caused by a stone
2. sx: colicky epigastric or RUQ pain after high fat meal, may radiate to R shoulder/scapula, n/v, low-grade fever, costipation, mild paralytic ileus
3. workup:

- elevated bili, WBC

- HIDA (hepatoiminodiacetic acid) scan for confirmation

- may see stone on XR

- may need ERCP
4. tx - surgery

1. definition: potentially deadly combo of common bile duct obstruction + ascending infection (E. coli, enterococcus, klebsiella, enterobacter) that can lead to sepsis and death
2. causes: choledocholelithiasis (most common), neoplasm, stricture
3. sx: RUQ tenderness, jaundice, Fever (CHARCOT'S TRIAD)

- + AMS, hypotension (Reynold's Pentad)
4. workups:

- RUQ US - biliary dilation or stones

- CBC: leukocytosis w/ left shift, increased bili, increased trasnaminase

- ERCP is optimal for dx and tx - don't do until pt is stable or unless it's urgent
5. tx:

- abx (fluoroquinolone, ampicillin, gentamycin +/- flagyl), fluids, electrolyte replacement, analgeisa

- ERCP - drainage, sphincterotomy, stone removal, stent placement once stable

- cholecystectomy later

Primary sclerosing cholangitis

tx: Ursodiol + ERCP managment of stricture

- liver transplant is only tx with known survival benefit

viral

(alcohol is second)

1. A and E are transmitted by fecal-oral contamination
2. B, C, D are transmitted parenterally or by mucus membrane contact
3. sx of A and E: mild, no long term sequelae
4. sx of B and C: variable from asymptomatic to fulminant. may become chronic. often coinfection iwth HIV
5. D is only seen in conjunction with B and is associated with a more severe course
6. tx:

- acute: supportive

- chronic: avoid alcohol and hepatotoxins, treat HIV if present, vaccinate against other heps