• β-blocker

UWorld 4126

• hyperlipidemia (↓ LDL receptors, hypercholesterolemia is seen most frequently).
• hyponatremia (inappropriate ADH secretion).
• ↑ serum muscle enzymes

UW 3483

• acute ascending cholangitis is characterized by Charcot's triad of fever, severe jaundice, and RUQ abdominal pain.
• Reynold's pentad - addition of confusion and hypotension (commonly seen with suppurative cholangitis).
• Initial tx of cholangitis: supportive and broad-spectrum abx. If pt is still unresponsive → ERCP (urgent biliary decompression).

UW 2978

• to determine if the pleural effusion is transudative or exudative.
• one of the following = exudate: 1) pleural fluid protein/serum protein ratio > 0.5, 2) pleural fluid lacate dehydrogendase/serum LDH ratio > 0.6, or 3) pleural fluid LDH > 2/3 of the upper limit of normal for serum LDH.
• LDH ↑ 2° lysis of neutrophils
• ↓ glucose in exudative pleural effusion is due to high metabolic activity of leukocytes and/or bacteria (< 30 mg/dl).

UW 4631, 4753

• abscess formation
• fistula
• perforation
• assess with CT; do not attempt colonoscopy/sigmoidoscopy, or barium enema in the presence of an acutely inflamed bowel.

UW 3467

• cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol.
• SSx: fever, rash, arthralgias, peripheral eosinophilia, hematuria, sterile pyuria, and eosinophiluria.

UW 2242

• smoking
• chronic pancreatitis, long-standing DM, obesity
• not risk factors: coffee, gall stones, etOH

UW 2966

• migratory thrombophlebitis (tender, erythematous, cord-like veins that migrate).
• highly suspicious for an occult tumor
• the most common tumor is an adenocarcinoma
• 24% have pancreatic carcinoma, 20% lung, 13% prostate, 12% stomach.

UW 2624

• SSx: QRS prolongation with peaked T waves, muscle weakness → flaccid paralysis.
• Tx: IV calcium gluconate to stabilize cardiac membrane, insulin & glucose/NaHCO₃/β₂ agonists (drive K⁺ into cells), Kayexalate.

UW 4760

• orthostatic proteinuria
• must obtain separate upright and supine urine collections; NOT 24 hour urine collection.
• common in children and young adults.

MKSAP p. 201

• urine + for leukocytes and leukocyte casts, negative culture (sterile pyuria); also fever, rash, and eosinophilia.
• Drugs, particularly β-lactam abx, are the most common etiology of acute interstitial nephritis. Also, NSAIDs
• ATN: usually occurs after a sustained period of ischemia or nephrotoxic agents; muddy brown casts; NO leukocytes or leukocyte casts.

MKSAP p. 201

• < 130/80 or < 125/75 if significant proteinuria is present.
• ACE inhibitors or ARBs are the preferred agents in chronic kidney disease; do not use together (no studies to support benefit).
• ↑ in creatinine of up to 30% is acceptable.

MKSAP p. 205 

• urine K⁺ loss of < 20 meq is suggestive of extrarenal loss.
• gastrointestinal loss is the most common cause of extrarenal K⁺ loss (e.g. laxative abuse).
• diarrhea → non-anion gap acidosis (loss of HCO₃^-)

• a circulating factor produced by neoplastic cells
• commonly associated with SCCa of the lung, esophagus, and head & neck.

MKSAP p. 212

• ratio of 1 is equivalent to 1 gram of protein/24 hrs
• ratio of 2.5 is equivalent to 2.5 g/24 hrs
• technically easier than a 24 hr urine collection
• urine dipstick 1+ (about 1 g/24 hrs assuming constant protein excretion throughout the day), 2+ = 2 g/24 hrs...

MTB p. 300

• throat or skin infection (impetigo)
• look for antistreptolysin O (ASO) titers and anti-DNAse Ab titers
• complement levels are ↓

MTB p. 320

Uremia is defined as the presence of:

1. metabolic acidosis
2. fluid overload
3. encephalopathy
4. hyperkalemia
5. percarditis

MTB p. 324

• recent streptococcal infection
• sarcoidosis (bilateral hilar lymphadenopathy or interstitial lung disease)
• TB
• histoplasmosis
• inflammatory bowel disease

UW 2317

• cardiogenic
• non-cardiogenic, e.g. ARDS
• differentiated by pulmonary capillary wedge pressure; PCWP > 18 2° to impaired left ventricular fxn, PCWP < 18 suggests a non-cardiac cause.
• ARDS: sepsis, severe bleeding, pneumonia, toxic ingestion, or burns → release of inflammatory mediators → ↑ alveolar capillary permeability.
• criteria for dx ARDS: acute dyspnea, an inciting condition, b/l infiltrates on CXR, PCWP < 18, P_aO₂/F_iO₂ ratio < 200.

UW 3432

• monospot test
• (+): EBV-associated infection, pharyngitis and cervical lymphadenopathy.
• (-): CMV, no pharyngitis, and cervical lymphadenopathy

UW 2270

• liver cysts
• ovarian cysts
• mitral valve prolapse
• diverticulosis
• cerebral aneurysm (most do not rupture)
• Renal failure is the most common cause of death (from recurrent pyelonephritis and nephrolithiasis → progressive scarring & loss of renal fxn).

MTB p. 328

• nephrogenic DI: lithium and demeclocycline

MTB p. 330

• characterized according to overall volume status of body.
• hypervolemia: CHF, nephrotic syndrome, cirrhosis; these pts are edematous w/ ↓ intravascular volume → ↑ ADH to maintain volume/perfusion → hyponatremia.
• hypovolemia: sweating, burns, fever, pneumonia → hypervenitilation, diarrhea, diuretics; these can all cause hypernatremia as well, but hyponatremia results with chronic replacement with free H₂O.
• euvolemia: pseudohyponatremia (hyperglycemia), psychogenic polydypsia, hypothyroidism, SIADH (small cell lung cancer produces ADH).

MTB p. 330

• K⁺ disorders interfere with muscle contraction and cardiac conduction.
• hyperkalemia: weakness, paralysis, ileus (paralyzed gut muscle), cardiac arrhythmias, NO seizures.
• Order an EKG immediately: peaked T waves, shortened QT interval, then as hyperkalemia worsens → wide QRS, PR interval prolongation.
• tx: calcium gluconate/chloride, insulin & glucose, NaHCO₃, Sodium polystyrene sulfonate (Kayexalate).
• β-blockers ↑ K⁺ via inhibting Na/K ATPase; albuterol can be used to ↓ K⁺.
• Hypokalemia: weakness, paralysis, loss of reflexes.
• EKG: U waves (a small wave that follows a T wave), also PVCs, flattened T waves, ST depression, prolonged QT interval.
• hypomagnesemia → urinary K⁺ loss. Mg closes up Mg-dependent K channels.
• both hypokalemia and hypomagnesemia → ventricular tachycardia.

MTB p. 333, UW2164

• diarrhea
• RTA
• the anion gap is normal b/c the Cl^- ion rises; therefore, aka hyperchloremic acidosis.
• RTA type I (distal RTA)- distal tubule unable to generate HCO₃ in response to aldosterone, thus acid cannot be secreted → pH > 5.5; dx: adminster acid to see if pH ↓, hypokalemia.
• RTA type II (proximal RTA) - damage to proximal tubule → inability to absorb HCO₃ → eventually, HCO₃ becomes depleted → ↓ urine pH ≤ 5.5. Damage occurs from amyloidosis, myeloma, Fanconi syndrome, acetazolamide, and heavy metals, test by giving HCO₃; hypokalemia.
• RTA type IV (hyporeninemia, hypoaldosteronism) - ↓ amount or effect of aldosterone; hyperkalemia.

MTB p. 336

• iron deficiency
• thalassemia (target cells are most common, but can occur w/ any of the microcytic anemias).
• sideroblastic anemia (alcohol's suppressive effect on bone marrow, lead poisoning, isoniazid, vitamin B₆ deficiency). sideroblasts are nucleated RBCs with granules of Fe accumulated in pernuclear mitochondria.
• anemia of chronic disease

MTB p. 206

• differentiate btw diarrhea and RTA in normal anion gap metabolic acidosis.
• UAG = Na⁺ - Cl^-
• acid is secreted by kidney as NH₄Cl; the more acid that is eliminated →↑ Cl.
• diarrhea → metabolic acidosis → ↑ Cl → (-) UAG value.
• RTA → kidney cannot excrete acid → (+) UAG value.

MTB p. 338

• when pt presents with clear nephrolithiasis → immediate analgesia (ketorolac) and hydration.
• CT scan is most accurate
• stone < 5mm: supportive, will pass on its own.
• stones 5-7 mm: nifedipine and tamsulosin to help pass.
• stones 0.5-2 cm: lithotripsy, any larger and the fragments will get caught in ureters; must manage surgically.

MTB p. 341

• dyspnea
• lightheaded
• confusion
• syncope
• hypotension/tachycardia
• angina

MTB p. 205

• terminal ileum
• ↑ homocysteine in both
• methyl malonic acid is ↑ in only B₁₂ deficiency
• hypokalemia is a risk when replacing folate or B₁₂

• inability to concentrate urine
• isosthenuria
• urine isoosmolar to blood

MTB p. 214

• IgM Abs against RBCs
• associated with EBV, Waldenstrom macroglobulinemia (indolent lymphoma, IgM type), and Mycoplasma pneumoniae.
• Coombs test is positive only for complement; Coomb's test detects IgG (warm agglutinin)
• steroids and splenectomy do not work in cold agglutinin disease.

MTB p. 216

• case-control studies. the patients have already developed the disease; exposure odds ratio.
• prevalence odds ratio is calculated in cross-sectional studies.
• relative risk/rate (incidence measure) are calculated in cohort studies, where people are followed over time for the occurrence of the disease.

UW 3931

• immunosuppressant that inhibits transcription of IL-2 (mainly T_H lymphocytes); calcineurin inhibitor.
• Side effects: gingival hypertrophy, hirsutism, nephrotoxicity, HTN, tremors, glucose intolerance, SCCa, N&V, diarrhea.
• tacrolimus has the same mechanism of action - calcineurin inhibitor. Similar side effects, but no gingival hyperplasia or hirsutism.

• immunosuppressant
• purine analog that is enzymatically converted to 6-mercaptopurine; inhibits purine synthesis
• dose-related diarrhea, leukopenia, hepatotoxicity.

UW 3980

• immunosuppressant
• inhibits de novo purine synthesis
• reversible ihibitor of inosine monophosphate dehydrogenase, the rate-limiting enzyme in de novo purine synthesis.
• Side effect: bone marro suppression

UW 3980

• paraprotein is an Ig or Ig light-chain produced in excess by the clonal proliferation of plasma cells.
• paraproteinemia (mainly Bence Jones proteins) → renal failure
• Bone pain, renal failure, hypercalcemia → multiple myeloma until proven otherwise (in an elderly pt).

UW 3943

1. levothyroxine overdose
2. subacute lymphocytic (painless) thyroiditis
3. subacute granulomatous thyroiditis
4. iodine-induced thyrotoxicosis
5. Note: most cases of thyroiditis occur during the postpartum period.

UW 2191

• tenosynovitis
• migratory polyarthralgias early in disease (No joint erythema or swelling), BUT
• can progress to suppurative infectious arthritis
• skin lesions - pustules (5-40) on extremities; purpuric or pustular lesions with a hemorrhagic component and occasionally central necrosis. 
• most likely to occur during menstrual period

UW 3320

• hx of tick bite
• systemic symptoms (fever, HA, malaise, and myalgias).
• leukopenia
• thrombocytopenia
• elelvated ALT/AST
• tx w/ doxycycline

UW 3247

• if CD4 > 200/mm³:
• MMR
• Varicella
• Zoster (age > 60 years)
• Yellow fever

UW 4478

• back pain, anemia, renal dyfxn, and ↑ ESR
• bone lysis caused by plasmocyte-released humoral factors and expanding plasma cell mass → hypercalcemia

UW 4013

• ASA: prevent MI: men (45-79), prevent stroke: women (55-79); both grade A.
• Abdominal Aortic Aneurysm: men 65-75, smoke hx, repair > 5 cm. 
• Blood Pressure: Screen all adults > 18; normotensive screen every 2 years, pre-hypertensive screen annually; grade A.
• Breast Cancer: women (50-74), every 2 years, grade B. Women > 75, no mammography.
• Cholesterol: men > 35, women >45, grade A; men 20-35, women 20-45 if at ↑ risk for CAD, grade B.
• Colorectal: screen all adults age 50-75; grade A.
• Coronary Heart Disease with EKG: grade D.
• HIV: screen age 15-65, grade A, interval unknown.
• Obesity: all adults; grade B.
• Osteoporosis: women ≥ 65, ≥ every 2 yrs, grade B.
• Prostate Cancer: grade D.
• Type 2 diabetes: sustained BP > 135/80; grade B.

• age 21 to 65, Pap with cytology every 3 years; grade A.
• or age 30-65, Pap w/ cytology & HPV testing every 5 years; grade A.
• Pap on women older than age 65 with adequate screening; grade D (against). 
• HPV testing in women < 30; grade D.
• Pap under age 21 is grade D; recommends against.

• flushing, wheezing, right sided cardiac abnormalities
• dx: urinary 5-hydroxyindolacetic acid (5-HIAA)
• tx: octreotide

MTB p. 259

• metoclopromide
• erythromycin
• tx gastroparesis

MTB p. 252

1. Erythema nodosum
2. Erythema migrans - lyme disease (round red lesion with pale center).
3. Erythema marginatum - serpiginous skin rash (rheumatic fever).
4. Erythema toxicum - neonate with splotchy areas of erythema w/ central clear pustule; pustules have eosinophils.
5. Erythema Multiforme - drug rxn, small "target" lesions, no mucous membrane involvement. may also be from herpes or mycoplasma. EM major = Stevens-Johnson Syndrome (immune complex mediated hypersensitivity). Most commonly caused by sulfonamides, NSAIDs, and phenytoin. EM minor usually occurs after a herpes simplex infxn/mycoplasma and mucosal involvement is rare and systemic symptoms are not as severe as SJ.

• Crohn's disease: transmural granulomas, masses and obstruction, antisacchoromyces cerevesiae Ab (ASCA).
• UC: entirely mucosal, ANCA.
• tx: acute exacerbation tx w/ steroids (prednisone or budesonide, which is specific for IBD), maintenance of remission - mesalamine (5-ASA derivative), azathioprine or 6-mercaptopurine to wean pt off steroids, fistulae and severe disease unresponsive → infliximab.

MTB p. 260

• PPI, clarithromycin, and amoxicillin
• unresponsive to above: metronidazole and tetracycline.
• retest with stool antigen or breath urea.

MTP p. 249

• metronidazole
• if patient gets better, but then relapses → metro again.
• unresponsive to metro → oral vancomycin or fidaxomicin.

MTB p. 255

• Serum Ascites Albumin Gradient
• > 1.1: portal HTN, CHF, hepatic vein thrombosis, constrictive pericarditis.
• < 1.1: infection (not SBP), cancer, nephrotic syndrome.
• with ascites spontaneous bacterial peritonitis is a concern; > 250 nØ is when thx is started; gram stain almost always (-); tx - cefotaxime or ceftriaxone.

MTP p. 266

• woman in 40s/50s, fatigue and pruritis, normal bilirubin, ↑ alk phos.
• antimitochondrial Ab
• tx: ursodeoxycholic acid

MTB p. 268

• genetic disorder → overabsorption of iron in duodenum.
• fatigue and joint pain (pseudogout)
• erectile dysfxn in men, amenorrhea in women (pituitary involvement)
• skin darkening
• DM
• cardiomyopathy
• best dx: abdominal MRI and HFE (C282y) gene testing; NOT liver bx (MRI spares pt from need fo bx).
• note: deferoximine is injeciton only; deferasirox and deferiprone are oral meds.

MTB p. 268

• Hep B: just one of the following - adefovir, lamivudine, telbivudine, entecavir, tenofovir, interferon.
• chronic Hep C: combination of interferon, ribavirin, and either telaprevir or boceprevir.
• AE: Interferon (arthralgias, thrombocytopenia, depression, leukopenia), ribavarin (anemia), adefovir (renal dysfxn).

MTB p. 270

• abnormally ↑ copper excretion into urine after penicillamine administration.
• ↓ ceruloplasmin is not the most accurate dx test.
• Wilson disease gives psychosis and delusions, not the encephalopathic features or delerium seen with any form of liver failure.

MTB p. 271

• add dipyridamole
• or switch to clopidogrel

MTB p. 275

• > 70% → operate
• < 50% → do not operate
• carotid angioplasty and stenting is of no proven value for stroke pts.

MTB p. 276

• gamma knife surgery/surgical decompression
• medical thx: oxcarbazepine or carbamazepine; also baclofen and lamotrigine have been effective.

MTB p. 278

• like lidocaine, it is a class 1b antiarrhythimc
• IV → hypotension and AV block
• fosphenytoin does not have these effects and can be given more rapidly.
• tx of status epilepticus: benzodiazepine first, if persists → phenytoin/fosphenytoin, still no resolution → phenobarbitol, seizure continues → sux/rocuronium → intubate → propofol

MTB p. 279

• RBC to WBC ratio is normal (1 WBC/500-1000 RBCs)
• ↑ ratio of WBC → meningitis
• SAH causes fever via meningeal irritation

MTB p. 281

• paralysis of entire face
• stroke will paralyze only the lower 2/3 of the face b/c of b/l UMN innervation.
• hyperacusis - CN VII controls stapedius muscle.
• taste disturbance - chorda tympani is a branch of the facial nerve.

MTB p. 295

• involvement of respiratory failure
• inspiration is the active part of breathing and the pt loses the strength to inhale.
• PFTs tell who might die from GBS.
• there is a ↓ in forced vital capacity and peak inspiratory pressure.

MTB p. 296

• even before edrophonium testing → Ach receptor Abs
• if (-) get anti-MUSK Abs (muscle-specific kinase)
• most accurate test: electromyography
• ALWAYS conduct CXR, CT, or MRI to look for thymoma or thymic hyperplasia.

MTB p. 297

• IGF-1; consistently ↑ throughout the course of the day, whereas GH levels can fluctuate.
• screen w/ IGF-1 → oral glucose suppression test → no suppression of GH → acromegaly.
• SSx: skin tags/colonic polyps, carpal tunnel syndrome, coarse facial features, arthralgias from joints growing out of alignment, body odor from sweat gland hypertrophy, HTN.

UW 4323, MTB p. 110

• hypercalcemia
• 2° to myeloma or metastatic bone cancers

UW 4013

• senile purpura is an ecchymotic lesion that occurs in areas susceptible to trauma in the elderly (e.g. dorsum of hands and forearms).
• atrophy of perivascular connective tissue
• not dangergous, requires no additional investigation.

UW 4355

• ALT > 2x the upper limit of normal w/ detectable HBsAg, HBeAg, and HBV DNA
• predicts a favorable response
• normal ALT → uneffective
• tx: interferon or lamivudine

UW 2961

• they are benign and never require any tx or follow-up.
• also PVCs, even when associated with an acute 

UW 3700

• II, III, aVF: inferior wall (5% mortality at 1 year)
• V2-V4: anterior wall (30-40% mortality at 1 year)
• V1, V2: posterior wall (the leads are read in the opposite direction of the rest of the leads → ST depression = MI)

MTB p. 64

• men age > 45, women age > 55; overall, more women will eventually die of heart disease than men.
• DM
• smoking
• HTN
• hyperlipidemia
• Fhx of premature CAD, 1st degree relatives only (men < 55, women < 65).
• smoking cessation, and not HTN control, results in the greatest immediate benefit for the pt.

MTB p. 50

• change with respiration (pleuritic)
• changes with position of the body
• changes with touch of the chest wall (tenderness)

MTB p. 53

• nuclear isotope uptake: thallium or sestamibi; normal myocardium picks up thallium (in the same way that K⁺ is picked up by Na/K ATPase).
• echocardiographic detection of wall motion abnormalities
• reasons for baseline EKG abnormalities: LBBB, L vent hypertrophy, pacemaker, digoxin use.

MTB p. 55

• ASA
• β blockers
• nitroglycerin (oral or patch)

MTB p. 57

A combination of Hydralazine & Nitroglycerin.

This is in the setting of congestive heart failure.

Also, if the patient develops hyperkalemia.

• < 100 mg/dl
• CAD equivalents: peripheral artery disease, carotid disease, aortic disease, DM.

MTB p. 59

• fibrates (gemfibrozil) → ↑ risk of myositis
• fibrates lower TG

MTB p. 60

• Use verapamil/diltiazem in CAD only: severe asthma (cannot use β blocker), prinzmetal angina, cocaine-induced chest pain, inability to control w/ maximum medical thx.
• AE: edema, constipation (verapamil most often), heart block.
• dihydropyridine CCBs (nifedipine, nitrendipine, nicardipine, nimodipine) may actually ↑ mortality in pts w/ CAD b/c → ↑ HR.

MTB p. 61

• ASA is most important (lowers mortality!!!)
• morphine
• O₂
• nitroglcerin
• ASA alternative if allx: clopidogrel

MTB p. 64

For how many days post-MI does troponin T stay ↑?

CK-MB?

• Troponin T, a more sensitive marker for cardiac injury, takes up to 10 days to return to normal.
• CK-MB returns to normal within 1-2 days.
• takes 4-6 hours for both markers to rise after an MI.

UW2737

• ↑ jugulovenous pressure on inhalation
• associated with constrictive pericarditis or restrictive cardiomyopathy.
• also found in constrictive percarditis is a "knock," which is an extra heart sound in diastole from ventricular filling; as heart fills to maximum, it hits the stiff, rigid pericardium with a "knock."
• best initial test is CXR that shows calcification and fibrosis.

MTB p. 63

• β-blocker
• nitroprusside
• β-blocker must be given before nitroprusside to prevent reflex tachycardia.

MTB p. 104

• #1 ASA
• #2 heparin

• based on ejection fraction < 40%

MTB p. 68

• STEMI: only in those undergoing angioplasty and stenting.
• unstable angina/non-STEMI:  use!!!; if all medications have been administered and pt is still not responding → angiography and possible angioplasty.

MTB p. 70

• sinus bradycardia (vascular insufficiency of SA node)
• thrid-degree AV block (will have cannon A waves, produced by atrial contraction against closed tricuspid valve)
• cannon A waves are the best way to distinguish sinus bradycardia from 3rd degree AV block.
• R ventricular infarct
• tamponade/free wall rupture: sudden loss of pulse
• valve or septal rupture: new onset murmur and pulmonary congestion; O₂ sat ↑ in R ventricle compared to R atrium (42% → 85%).

MTB p. 71

• a: atrial contraction
• c: ventricular contraction (tricuspid valve bowing in)
• x: atrial relaxation
• v: atrial filling
• y: opening of tricuspid valve

• high-fluid replacement
• avoid nitroglycerin (they worsen cardiac filling)

MTB p. 71

• prior to d/c: everyone gets a stress test
• ASA/clopidogrel/ticlodipine (if allx to both)
• β blocker (metoprolol)
• statins
• ACEi
• Do Not use prophylactic antiarrhythmics in pts post-MI, ↑ mortality; don't be tricked by "frequent PVCs and ectopy."

• implantable defibrillator: ischemic cardiomyopathy and EF < 35%.
• biventricular pacemaker: dilated cardiomyopathy, EF < 35% and QRS above .12 who have persistent symptoms.
• arrhythmia/sudden death is the most common cause of death in CHF.

MTB p. 80

• ursodeoxycholic acid; dissolves small radiolucent stones.
• avoid fatty foods
• pt should have normal, fxnl gall bladders.
• ursodeoxycholic acid ↓ cholesterol content of bile by ↓ hepatic secretion and intestinal reabsorption of cholesterol; may take several months of thx for stones to dissolve.

UW2939

• skin lesions (verrucous and crusted)
• lytic bone lesions
• fever
• night sweats
• productive cough
• weight loss
• broad based budding yeast
• tx: itraconazole or amphotericin B
• Great Lakes, Mississippi/Ohio River basins
• Coccidiomycosis can present similarly, but is found in the southwest.

UW3037

• Phenytoin toxicity
• Benzodiazepine toxicity
• Opioid toxicity
• Lithium toxicity

• phenytoin: horizontal nystagmus, cerebellar ataxia, confusion.
• benzodiazepine: slurred speech, unsteady gait, drowsiness (unlike opioid, no respiratory depression or miosis)
• opioid: sedation, respiratory depression, pupillary constriction.
• lithium: tremor, hyperreflexia, ataxia, seizures.

UW2664

• weakness/fatigue
• altered mental status
• N/V
• anorexia
• hypotension
• hyponatremia
• hyperkalemia
• eosinophilia is common in hypoadrenalism
• Note: test with cosyntropin (synthetic ACTH)

• β-blockers for both
• diuretics can be used for HCM (symptom management), but contraindicated in HOCM.
• HOCM specific thx: implantable defibrillators for pts experiencing syncope, ablation of septum (etOH injection into muscle via catheter, if fails → surgical myectomy.

MTB p. 95

• tardus - late
• parvus - weak/small
• seen in aortic valve stenosis

• pericardial tamponade
• different heights of QRS complexes b/w beats

MTB p. 100

• develops after delivery
• Ab against myocardium
• LV dysfxn is often reversible and short term.
• if no improvement → cardiac transplantation
• repeat pregnancy in women w/ peripartum cardiomyopathy will provoke enormous Ab production against myocardium.

MTB p. 105

• osteoporosis
• cataracts
• adrenal suppression
• fat redistribution
• hyperlipidemia
• hyperglycemia
• acne
• hirsutism
• thinning of skin
• striae
• easy bruising

MTB p. 132

• prolactin can be cosecreted with GH simply b/c of acromegaly.
• hypothyroidism → ↑ prolactin b/c ↑ TRH → prolactin secretion.
• intense exercise
• renal insufficiency (look for BUN/Cr ratio)
• ↑ chest wall stimulation
• cirrhosis (look at LFTs)
• pregnancy
• dopamine inhibition (DA inhibits prolactin secretion)
• SSx: W - galactorrhea, amenorrhea, infertility; M - ED, ↓ libido, gynecomastia (galactorrhea is rare).
• Do not do an MRI first in any endocrine disorder.
• tx: cabergoline (DA agonist), better tolerated than bromocriptine.

MTB p. 111

• asthma not controlled with albuterol → inhaled steroids.
• COPD not controlled with albuterol → anticholinergic (ipratropium/tiotropium) → inhaled steroids.

MTB p. 135

• TSH > 2x upper limit of normal w/ normal T4 → replace hormone.
• TSH < 2x upper limit of normal → test antithyroid peroxidase Ab/antithyroglobulin Ab → Ab (+) → replace hormone.

MTB p. 112

• sarcoidosis
• TB
• berylliosis
• coccidiomycosis
• histoplasmosis
• candidiasis
• Crohn disease
• langerhans-histiocytosis
• cat-scratch disease
• Wegener granulomatosis
• PCP
• macrophages/histiocytes convert 25-hydroxyvitamin D → 1,25-dihydroxyvitamin D

UpToDate (hypercalcemia in granulomatous diseases)

• malignancy
• PTH-related peptide (PTHrP)
• breast cancer, lung cancer (SCCa)
• also: ADH (small cell carcinoma, ACTH (small cell lung Ca or carcinoid).
• Lambert-Eaton (small cell lung cancer)

MTB p. 120

• Hypercalcemia: confusion, stupor, lethargy, constipation, short QT
• tx: NS hydration & bisphosphonates → then calcitonin
• Hypocalcemia: Chvostek sign (facal nerve hyperexcitability), Trousseau sign (tetany), carpopedal spasm, perioral numbness, mental irritability, seizures.
• HyperCa: lethargic and slow, HypoCa: twitchy and hyperexcitable.

MTB p. 118

• hypomagnesemia → urinary K⁺loss. Mg closes up Mg-dependent K channels.
• Mg is necessary for PTH to be released from the gland.

MTB p. 118

• ABPA occurs almost exclusively in pts with asthma and hx of atopic disorders.
• look for asthmatic pt with recurrent episodes of brown-flecked sputum and transient infiltrates on CXR.
• tx: oral steroids, itraconazole for recurrent episodes.

MTB p. 138

• C: confusion
• U: uremia (BUN > 30)
• R: respiratory distress (RR > 30, pO₂ < 60 mm Hg, pH < 7.35)
• B: BP low (systolic < 90)
• 65: age > 65
• 0-1 points: home, ≥ 2 points: admission

MTB p. 145

• pneumonia develops > 48 hrs after admission or after hospitalization in the last 90 days.
• much higher incidence of gram (-) bacilli such as E. coli or Pseudomonas.
• use: antipseudomonals - cephalosporins (cefepime or ceftazidime), antipseudomonal penicillin (piperacillin/tazobactam), or carbapenems (imipenem, meropenem, or doripenem).

MTB p. 147

• only in pts with a large-volume aspiration of oral/pharyngeal contsnts, usually w/ poor dentition, who is not adequately treated.
• lung abscesses are rare b/c of prompt tx of aspiration pneumonia.
• large-volume aspiration occurs from: stroke w/ loss of gag reflex, seizures, intoxication, endotracheal intubation.

MTB p. 149 

• CD4 < 200 and pt not on prophylaxis (TMP/SMX)
• LDH is always elevated
• if LDH is normal ≠ PCP
• dx CXR with b/l interstitial infiltrates
• sputum stain is specific if (+); no need for further testing.
• (-) sputum stain → bronchoscopy
• tx: TMP/SMX, add steroids to ↓ mortality if PCP is severe (pO₂ < 70, A-a gradient > 35).
• allx/toxicity to TMP/SMX → clindamycin & primaquine or pentamidine.

MTB p. 151

• rash
• bone marrow suppression

MTB p. 151

• When smear is (+): Rifamin, Isoniazid, Pyrazinamide, Ethambutol (RIPE).
• if TB is sensitive to all medications, there is no need for ethambutol.
• RIPE for first 2 months, stop pyrazinamide and ethambutol, continue rifampin/isoniazid for another 4 months (6 mos total).
• extend tx to 9 mos if: osteomyelitis, miliary TB, meningitis, pregnancy or any other time pyrazinamide is not used.
• toxicity: all TB meds cause hepatotoxicity; only d/c if transaminases > 3-5x upper limit of normal.
• pregnant pts should not receive pyrazinamide.
• latent TB: isoniazid for 9 mos; even if pt had previous BCG and PPD (+) → 9 mos isoniazid.

MTB p. 154

• CXR: atelectasis
• EKG: sinus tachycardia, nonspecific ST-T wave Δs
• ABG: hypoxia and respiratory alkalosis (↑ pH and ↓ pCO₂).
• CXR must be normal for V/Q scan to have any degree of accuracy; spiral CT if CXR is abnormal.
• spiral CT (-) → V/Q or LE doppler → (-) → withhold thx w/ heparin.

MTB p. 162

• contraindicaiton to use of anticoagulant (melena, CNS bleed)
• recurrent emboli while on heparin or fully therapeutic warfarin (INR 2-3)
• right ventricular dysfxn with an enlarged RV on echo. disease is so severe that even the smallest of emboli could be potentially fatal.

MTB p. 162

• systolic > 25, diastolic > 8

MTB p. 164

• pO₂/FIO₂ < 300
• FIO₂ is expressed in decimal format
• < 200 = moderately severe
• < 100 = severe
• wedge pressure is normal

MTB p. 165

• needle-shaped crystals with negative birefringence on polarized light microscopy; ↑ WBCs (2-50k) on joint aspirate.
• pseudogout: postively birefringent rhomboid-shaped crystals; ↑ WBCs (2-50k) on joint aspirate.
• nephrolithiasis can → ileus via vagal rxn to ureteral colic.

UW 2324

• NSAIDs, best initial thx
• corticosteroids by injection in single joint or orally for multiple joints if no response to NSAIDs or contraindicaiton to NSAIDs (renal insufficiency).
• colchicine (diarrhea/neutropenia) for those who cannot use NSAIDs or steroids.
• Chronic: colchicine, allopurinol/probenecid, pegloticase (dissolves uric acid).

MTB p. 170

• aka Pseudogout
• Risk factors: hemochromatosis, hyperPTH, DM, hypothyroidism, Wilson disease.

• #1 - NSAIDs (does not prevent progression of disease)
• #2 Steroids, when NSAIDs do not control symptoms immediately or as a bridge when waiting for DMARDs to take effect (does not prevent progression of disease).
• Best initial DMARD is methotrexate (liver toxicity, bone marrow suppression, pulmonary toxicity).
• no response to MTX → TNF inhibitor (infliximab, adalimumab, etanercept).
• for initial control MTX and TNFi are used together
• rituximab
• hydroxycholoroquine (can be used as monothx as a DMARD in cases of mild disease; retinal toxicity.

MTB p. 181

• high, spiking fever (> 104) in a young person with no clearly identified etiology, but associated with a rash (salmon colored on chest and abdomen).

MTB p. 182

• ↓ complement
• ↑ anti-dsDNA

MTB p. 185

• Russell viper venom test
• RVVT is prolonged with antiphospholipid Ab (lupus anticoagulant & anticardiolipin Abs) and does not correct with normal plasma.
• the best initial test is the mixing study; pts plasma mixed with equal amount of normal plasma → no correction of aPTT.
• recurrent thrombotic episodes are treated lifelong with warfarin (INR 2-3).

MTB p. 186

• aka Reiter Sydrome
• can't see, can't pee, can't climb a tree
• joint pain, uveitis/conjunctivitis, urethritis/balanitis
• associated with: IBD, STD, GI infxn (Yersinia, Salmonella, Campylobacter).

MTB p. 197

• C: calcinosis
• R: Raynaud
• E: esophageal dysmotility
• S: sclerodactyly
• T: telangiectasias
• anticentromere Ab
• antitopoisomerase Ab (SCL-70) is for scleroderma (systemic sclerosis).

MTB p. 186

• 25% of cases associated with cancer
• ovary
• lung
• GI
• lymphoma

MTB p. 188

• filter paper is placed against globe of eye and observed for amount of tears produced.
• best initial test for Sjögren
• worst complication of Sjögren is lymphoma

MTB p. 189

• hepatitis B and C
• lungs are inexplicably spared

MTB p. 190

• Henoch-Schönlein purpura

MTB p. 193

• pulmonary-renal syndrome
• also asthma and eosinophilia
• p-ANCA

MTB p. 193

• terminal complement deficiency

MTB p. 201

• a much more severe disease than impetigo; deeper layer of skin.
• more commonly streptococcus than staph.
• invades dermal lymphatics → bacteremia

• if multiple 1st degree relatives have breast cancer; ↓ risk of breast cancer.
• adjuvant chemothx (pt already has disease, but no clearly identified mets; thx to clean up presumed microscopic cancer cells too small in amount to be detected).
• use adjuvant chemothx when: lesions are > 1 cm or (+) axillary l.n. are found.

MTB p. 350

• erectile dysfxn
• urinary incontinence

MTB p. 350

• SCCa
• greatly increased by long-term use of immunosuppressants.

MTB p. 364

• involvement of mouth

• hepatitis C
• it is a blistering skin disease of sun-exposed areas in those w/ a hx of: liver disease, estrogen use, iron oveload.

MTB p. 370

• ketoconazole
• causes gynecomastia

MTB p. 375

• penicillins
• sulfa drugs (including thiazides, furosemide, and sulfonylureas)
• allopurinol
• phenytoin
• lamotrigine
• NSAIDs
• the drugs that cause hypersensitivity rxns are the same that cause hemolysis, interstitial nephritis, and often drug-induced thrombocytopenia.

MTB p. 375