Block 5 Case 2
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- Normal liver span and location:
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Total span 6-12cm.
No more than 2-3cm below costal margin. - Value and ddx of widened pulse pressure...
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>65 mm Hg
Aortic dissection, valvular regurg, AAA, Anemia, Restrictive cardiomyopathy, Hyperthyroid, Graves disease, Age (decreased aortic compliance) - Value and ddx of narrowed pulse pressure...
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<30 mm Hg
Cardiac Tamponade, aortic stenosis, hypothyroidism, extreme hemorrhage or volume loss - ALT: Primary purpose
- Sensitive and specific for hepatocellular disease.
- AST: Primary purpose
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Coronary artery occlusive diseases OR hepatocellular.
Found in high metabolic tissue (heart, liver, skeletal muscle... some kidneys) - Elevted AST indicates...
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CV diseases
Liver diseases
Skeletal muscle disease
Other: acute hemolytic anemia or pancreatitis. - Rapid strep test, methods and sensitivity/specificity
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Enzyme immunoassay, optical immunoassay, chemiluminescent DNA probe.
70-95% sensitivity
>95% specificity - Centor score criteria
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history of fever
tonsillar exudates
anterior cervical adenopathy
absence of cough - Centor score of 1 in presence of negative rapid strep?
- No testing, no treatment
- Centor score of 2,3,4 in presence of negative rapid strep?
- Throat culture for both children & adults.
- ASO: timeline
- Shows up 1week - 1 month after streptococcal infection
- ASO: Significance of rising titer vs single elevated value
- Rising is more significant.
- ASO: diagnostic use
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CANNOT be used to diagnose acute strep infection.
Elevated in 70-80% of acute rheumatic fever cases. - ASO: combined with what to get what sensitivity?
- Anti-DNase-B... an immunologic test that when combined with ASO is 95% sensitive.
- Rofecoxib: trade name, class, MOA, side effects
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Vioxx, NSAID
selective COX-2 inhibitor -> decreased prostaglandin synthesis
Withdrawn due to risk of MI and stroke. - Dopamine: uses, MOA (low, medium, high doses), side effects
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Treatment for shock due to renal failure, CHF etc.
1) Low dose: stimulates dopaminergic receptors->renal and mesenteric vasodilation
2) Medium: cardiac stimulation and renal vasodilation -> increased cardiac output, renal perfusion.
3)High: alpha-adrenergic receptors lead to vasoconstriction, increased BP - Milrinone: uses, MOA, adverse effects
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short term IV therapy for CHF and calcium anatgonist intoxication
phosphodiesterase inhibitor -> increased intracellular calcium and increased contractility.
long term use >48h leads to increased mortality - Furosemide: uses, MOA, adverse effects
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management of edema, HT
inhibits NA/CL/K transporter in ascending loop of Henle
can lead to electrolyte imbalance: hypo- kalemia, chloremia, calcemia, natremia etc. - Vancomycin: class, MOA, uses
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Glycopeptide antibiotic for gram+
MOA: binds to cell wall percursors (NOT same as penicillin) increasing permeability, also inhibits RNA synthesis... dual action = less resistance. CANNOT ENTER GRAM - CELLS.
Useful in MRSA, penicillin allergy. - Meropenem: class, MOA, uses, adverse effects
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Carbapenem antibiotic
Inhibits cell wall formation at PBP, very resistant to beta-lactamases
excellent vs aerobic and anaerobic!
lower risk of seizure compared to imipenem! - Doxycycline: class, MOA, pharmacokinetics, adverse effects
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tetracycline antibiotic
bacteriostatic vs both gram + and - by binding to 30S ribosomal subunit and inhibiting protein synthesis... humans cannot active transport it in, immune.
Oral absorption delayed by food, esp milk.
UNSAFE DURING PREGNANCY, CLASS D!! - Methylprednisolone: class, MOA, uses, adverse effects
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synthetic glucocorticoid
binds to cytosolic receptors, translocate to nucleus, modifies transcription.
Used in SLE, RA, vasculitis, poly and dermatomyositis...
Adverse: HPA axis suppression, osteoporosis, etc.... all dose dependant. - Viral myocarditis: causes
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Coxsackievirus (most common)
adenovirus
CMV
echovirus
EB virus
Hep C - Myocarditis: non-viral causes
- bacteria, fungi, parasites, drugs, toxins, immunologic disorders
- Viral myocarditis: pathophysiology
- inflammation of myocardium leads to necrosis of myocytes and inflammatory infiltrate... leads to heart failure.
- Viral myocarditis: symptoms
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Follows viral URI.
Chest pain, heart failure, arrhythmia, dyspnea and fatigue. - Viral myocarditis: physical exam
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Tachy, S3, murmur
JVD, edema
fatigue
fever - Viral myocarditis: Labs
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high WBC, lymphocytosis
LDH, CK-MB, troponin up
bacterial cultures negative if viral - Viral myocarditis: Imaging
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CXR: cardiomegaly, pul. edema
Echo: wall abnormalities
EKG: sinus tachy, low voltage QRS, T wave flattening or inversion. - Viral myocarditis: Dx gold standard
- endomyocardial biopsy showing lymphocytic inflammation.
- Viral myocarditis: treatment
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admit due to risk of deterioration.
Usually selflimiting: support with O2, BiPAP, diuretics, inotropic agents, possibly corticosteroids. - ARF: epidemiology
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US: 5-10:1000
High in developing world.
Males = females.
Follows .3% of GAS infection. - ARF: clinical manifestations
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High fever, tachycardia.
Cardiomegaly, CHF, pericarditis, murmurs.
SubQ nodules, erythema marginatum.
Arthralgia, migratory polyarthritis.
Sydenham's Chorea -- involuntary purposeless dancelike movements - ARF: onset related to?
- delayed sequelae to group A strep of PHARYNX. NOT after skin infection.
- ARF: Carditis
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Most serious manifestation
PANcarditis... inflammation of all 3 layers.
ASCHOFF bodies found in myocardium... swollen eosinophilic collagen surrounded by T cells. - ARF: erythema marginatum
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rash found on trunk and proximal parts of extremities... never on face!
expanding rash, older areas return to normal. - ARF: 3 theories of pathogenesis
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1) toxic effects of strepolysin O or A
2) serum sickness reaction
3) Antibodies against M proteins crossreact with glycoprotein antigens in heart, joints and other tissues. - ARF: post-disease risks
- increased vulnerability to future attacks with _pharyngeal infections_. Each attack is worse since damage is cumulative.
- ARF: Jones criteria requirements
- 2 Major OR 1 major/2 minor PLUS evidence of prior strep infection
- ARF: Jones criteria major
- Major: Carditis, Polyarthritis, Chorea, Erythema marginatum, subQ nodules
- ARF: Jones criteria minor
- Minor: Fever, arthralgia, previous RA, increased acute phase reactants or increased PR interval
- ARF: Jones criteria evidence of prior GAS infection
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Increased ASO or other strep antibodies.
Positive throat culture for GAS.
Positive rapid strep test.
Recent Scarlet fever. - ASO elevated values in adults and kids.
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Adult: >250U
Child: >333U - Next step after negative ASO in suspected ARF?
- Test anti-DNAase B, anti-DNAse and anti hyaluronidase.
- Normal PR interval, indication if long:
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.12 - .20s
Indicates AV block. - Normal QRS interval, indication if long:
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.04 - .12s
Indicates BBB. - EKG signs of hypertrophy:
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Diphasic P wave in V1 for Atrial enlargement.
R wave in V1 for RVH.
S wave V1+R wave V5 > 35mm for LVH. - EKG signs of infarction:
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Q waves >1mm wide or 1/3 QRS amplitude.
Inverted T waves... opposite QRS, indicates ischemia.
ST segment elevation (acute) or depression (old infarct) - S. aureus: ID
- Gram +, Catalase +, Beta hemolytic, Coagulase +
- S. aureus: virulence factors
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Protein A: binds to IgG, protecting from phagocytosis.
Penicillinase: inactivates PCN
Exfoliatin: skin sloughs
Enterotixins: N/V/D
TSST-1: toxic shock syndrome - S. aureus: antibiotics
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Penicillinase resistant PCNs.
Vancomycin.
Clindamycin. - S. Marcescens: ID
- Gram - bacillus, Motile, produces red/pink dye
- S. Marcescens: Antibiotics
- Cephalosporins, gentamicin.
- Candida albicans: ID
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Yeast-like fungi, hyphae and pseudohyphae.
Large, round, white colonies on agar. - Candida albicans: antibiotics
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Cutaneous: -azoles (fluconazole)
Invasive: agument -azoles with Amphotericin B. - Candida albicans: associated disease
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Oral thrush
Vaginitis (yeast infection)
Diaper rash
Candidemia (catheters, immunocompromised!)
Disseminiated candiasis - Aschoff bodies, morphology:
- Foci of swollen eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages.
- Aschoff bodies: location
- All 3 layers of heart, most commonly endocardium.
- Chronic rheumatic fever: changes
- thickening of mitral valve leading to stenosis, scarring where Aschoff bodies were, thickening of chordae tendinae.
- ARF: describe erythema marginatum
- Rash with paler center and rounded raised margins!
- Heart murmurs: 5 auscultary areas
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Aortic: 2nd right IC space
Pulmonic: 2nd left IC space
Pulmonic2: 3rd left IC space
Tricuspid: 4th left IC space
Mitral: apex at 5th IC space - Heart murmurs: grades
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I: barely audible
II: quiet but clearly audible
III: moderately loud
IV: Loud with thrill
V: very loud, easily felt thrill
VI: very loud, audible w/o stethoscope, thrill very easily felt. - Heart murmurs: signs of pathological murmur
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Symptoms (dyspnea, cyanosis etc)
Diastolic murmur (always bad)
Systolic click, opening snaps
S4 gallop - Benefits of mechanical vs bioprosthetic values
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Mechanical: last 20-30 years
Bioprosthetic: last 10-15 years, but require no thrombolytics.
Mechanical if young, can take warfarin.
Bio if old, or can't take warfarin. - Ejection fraction threshold for left ventricular dysfunction:
- < 50%.
- 3 post valve replacement syndromes:
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postpericardiotomy syndrome: fever, pleuritis, pericarditis.
Postperfusion syndrome: fever, splenomegaly, lymphocytosis. From CMV in blood transfusions
Cardiac tamponade. - INR recommendations in valve replacement:
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2-3: Normal mechanical valve
2.5-3.5: previous embolus, AFib, or mitral valve
3-4.5: tilted disc valve... highly thrombogenic - Poststrep Glomerulonephritis: strains
- GAS strains 12,4,1 most cause 90%.
- Poststrep Glomerulonephritis: time frame
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10 days after pharyngitis (or 1-2 weeks)
2 weeks after impetigo (or 3-6 weeks)
Depends on source - Poststrep Glomerulonephritis: pathophysiology
- Immune complex deposition of strept antigens and autoimmune reactivity.
- Poststrep Glomerulonephritis: Labs
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Creatinine elevated.
Complement (C3, CH50) low.
Circulating antibodies vs GAS: ASO, antiDNAse B etc. - Poststrep Glomerulonephritis: micro findings
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Large, hypercellular glomeruli.
Humps on epithelial side of golmeruli. - Poststrep Glomerulonephritis: treatment and prognosis
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Diuretics, !hypertensives, steroids to manage HTN, ECF volume, inflammation.
Good prognosis, rarely causes end stage renal disease. - Polyethylene glycol: trade name, class, MOA, Adverse effects
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Miralax
Laxative
osmotic agent causing water retention in stool
Can lead to electrolyte imbalance or dependance. - Warfarin: trade name, class, MOA, adverse effects
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Coumadin
Anticoagulant
Interferes with epoxide reductase, stopping vitamin K conversion from inactive to active. Effectively causes Vit K deficency.
Hemmorrhage. Treat with FFP and Vit K. PREGNANCY CLASS X! Use heparin. - Vitamin K dependant clotting factors:
- II, VII, IX, X, protein C and S.
- Spironolactone: class, use, moa, adverse effects
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potassium sparing diuretic
HTN, edema from CHF, cirrhosis etc.
Synthetic steroid and competitive antagonist of aldosterone.
Hyperkalemia, hyponatremia etc. - L-thyroxine: class, use, MOA, adverse effects
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thyroid agent
hypothyroidism, hyper TSH secretion
Same as endogenous. Suppresses TSH by feedback.
Overdose -> symptoms of hyperthroidism - Differin Gel: trade name, class, uses, MOA, adverse effects
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Adapalene
Retinoid Dermatologic
Acne
Acts at retinoic acid receptors to modulate cellular differentiation, keratinization, inflammatory process.
Avoid sunlight, tanning etc.