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what is SBP? what are the signs?: spontaneous bacterial paratinitis.
- fever, pain, decreased mental status
- often minimal symps- malaise, anorexia.

- caused by e. coli, klebsiella, strep pneumo.

- Rx is a 3rd generation cephalosporin
what is the difference between spontaneous and 2ry bacterial paratenitis?: spontaneous- from infected ascites
secondary- perfed bowel (surgical emergency)
how does one differentiate ascites?: paracentesis
albumin- 1.1. above is more likely hydrostatic- RHF, cirrhosis/pulm htn, budd-chiari, hepatic mets, myxedema
below 1.1- TB, cancer, pancreatitis, nephrotic syndrome
what are risk factors for liver disease?: alcohol- 80 grams of alcohol daily for 10-20 yrs (8 beers, 1/2 bottle of hard liqour)
viral- C and B, transfusions, needle sharing, cocaine, tattoos, acupuncture. homos, injection drug users, dialysis, HIV
biliary disease
cardiac disease
autoimmune hepatitis
Genes- hemochromatosis, Wilson's, alpha-antitrypsin deficiency)
Non-alcoholic steatohepatitis.
what is non-alcoholic steatohepatitis?: condition characterized by lobular inflammation and some degree of pericellular fibrosis.
what is hemochromatosis?: AR disorder- increased iron absorption, depostiion of iron in certain organs.
liver, heart, gonadal failure. pancreatic failure, skin pigmentation.

(2ry- from thalassemia)
What is wilson's disease?: AR disorder of copper excretion- increased accumulation of copper in the liver and brain. Pts may present w/ fulminant or chronic hepatitis, cirrhosis, psychiatric involvment or neuro disease
what is alpha anti-trypsin disease?: AR disorder characterized by abnormal alleles of antitrypsin- causes emphysema and asymptomatic cirrhosis
what causes ascites?: pulm htn
decreased albumin
increased na resorption from kidney

malignancy (pancreas, ovary)
Nephrotic syndrome
Cardiac failure
peritoneal tuberculosis
peritoneal mesothelioma
what are esophageal varices?: collateral veins in GE junction- causes hematemisis, melena.
(need to confirm w/ endoscopy since gastritis, PUD are also common w/ cirrhosis)
what is hepatic encephalopathy?: confusion, personality changes, asterixis. may be caused by nh4 levels. may be due to aminobutyric acid.
what is asterixis?: bilateral flapping tremor of the wrist, metacarpophalangeal, and hip joint. also seen in tongue, foot, skeletal muscle
what are common PEX findings in cirrhosis?: splenomegaly, internal hemorrhoids, and caput medusae

skin- jaundice, spinder telangiectases, clubbing, palmar erythema, dupuytren's contracture (permanent flexion of the 2rd or fourth metacarpal.
what labs are seen in cirrhosis?: hyponatremia (increased ADH)
decreased BUN (malunutrition, decreased protein production)
decreased albumin
increased bili
Heme- increased PT, macrocytic anemia, thrombocytopenia
what is the Rx for ascites?: na restriction
diuretics- k sparing.
large volume paracentesis
peritoneovenous shunt- peritoneum-venacaval shunt. (thrombosis, infection, DIC can all occur)
how do you treat esophageal varices: replace the blood
vasopressin- constrict portal blood flow and controls bleeding
- sclerotherapy- band ligation; immediate treatment reduces rebleeding rates.

- TIPS- transhepatic IVC-> portal shunt
B-blockers
what si the treatment of hepatic encephalopathy: correction of infection, GI bleed, excess dietary protein, hpokalemia, hypovolemia, alkalosis, and drugs.
lactulose- (decrease ammonia absorption
- neomycin- broad-spectrum antibiotic- decreases ammonia production from GI tract.
what is the common agent in CAP?: strep pneumo
how do you treat CAP?: ceftrioxone
azithromycin
what are the two nervous systems involved in controlling the heart?: renin-angiotensin
sympathetic nervous system
What is the role of cocaine and B-blockers?: beta-blockers can allow unapposed alpha. which can cause vaso-constriction-> hypertension.
what are the types of adenomas in colon cancer?: tubular- 80-85%
tubulovillous- 8-16%
villous- 3-15%

only 5% change into cancer
What are the factors associated w/ malignant transformation of a polyp?: increasing size- 2cm (10%)
Villous histology
what are the two key events to cause colon cancer?: activation of the ras oncogene
inactivation of the APC, dcc and p53 genes.
what causes DNA damage in colon cancer?: endogenous- oxidizing and alkylating products of cellular metabolism
exogenous- carcinogens, viruses, rads
what are risk factors for colon cancer?: hx of polyps
IBD- UC
FAP, HNPCC
Personal history of another malignancy
Family Hx of colon cancer

Diet- high animal fat
low fiber
obesity
ethanol
refined sugar
cigarettes.
what is the role of fecal occult blood testing in colon cancer screening?: sensitivity and specificity of 50%
- inexpensive, easy to do.
poor sensitivity and specificity; does not localize upper vs. lower
what is the roal of sigmoidoscopy in colon cancer screening?: 60 com flexible scope
- direct visualization, safer than colonoscopy, performed in the office, no anesthesia.

- doesn't look at the proximal colon.
what is the role of barium enema for screening of colon cancer?: sensitivity of 80-90% for lesions > 1cm.
50-75% for less than 1cm. Allows visualization of the proximal and distal colon. minimal discomfort. can't biopsy
what is the role of colonoscopy in colon cancer screening?: goald standard.
high cost, increased risk
uncomfortable.
what are the screening guidelines for colon ca?: start at age 50; flex sig fecal occult, dre every 3-5 yrs. or colonoscopy every 10

if w/ UC- colonoscopy after 8-10 yrs of disease, surveillance every 1-2 yrs

adenomatous polyps- 3-5 yrs after excission. every 1-3 if multiple large, villous, or malignant polyps

FAP- genetic couseling, screening; flex sig by age 10

HNPCC- colonoscopy by age 35-40- 10 yrs younger, surveillance every 3-5 yrs.
what is virchow's triad?: stasis, alt in blood vessels, hypercoagulability
what are some forms of stasis that contribue to PEs?: surgery
heart failure
chronic venous stasis
immobility
what are some alterations in blood vessels that contribute to PE?: fractures or surgery of lower extremity
major trauma
what can cause hypercoagulability?: postpartum period
malignancy
oral contraceptives
deficiencies of protein S, C, antithrombin III
lupus anticoagulant
activated protein C resistance (factor V leiden
Prothrombin gene mutations
hyperhomocysteinemisa.
what are the symps of PE?: sudden onset of unexplained dyspnea
Pleuriticchest pain
Cough
Hemptysis
other presentations syncopy, SVTs, and worsening of underlying heart failure or lung disease.
what is seen on PEX of a PE?: tachycardia
tachypnea
may have right sided heart strain- loud pulmonic component of second heart sound
S3
right ventricular heave
what is teh DDx for PE?: pneumothorax
MI
Pericarditis
Asthma
Pneumonia

hypotension- MI w/ shock
tamponade
tension pneumo
what can be seen on CXR in PE?: atelectasis
increased lung lucency in the area of the embolus
abrupt cutoff of vessel
wedge-shaped pleural-based infiltrate
Pleural effusion which if sampled by thoacentesis is often hemorrhagic.
What are well's criteira?: clinical DVT symps
Other Dx less likely than PE
HR >100
Immobilization
Previous DVT/PE
Hemoptysis
Malignancy
> 6 means
what are the indications for an IVC filter?: contraindication to anticoagulation
thrombosis despite antigcoag
large burden of thrombosis in LE that could be fatal if embolized.
What ar ethe causes of atrial fibrillation?: PIRATES
Pulmonary disease- infection
Ischemia, Hypertension
Rheumatic heart disease
Anemia
Thyrotoxicosis
Ethanol
Sepsis/Stimulants
What can cause Torsades de Pointes?: POINTES
Phenothiazines
Other meds (tricyclics)
Intracranial bleed
No known cause
Type I antidyrhythmics
Electrolyte abnlties
Syndrome of prolonged QT
What is the Rx for Torsades?: MgIV
Overdrive pacing
Beta blockers for prolonged QT syndrome
What are the common causes of pericarditis: Viral- happens after recent viral URI
Bacterial- TB, strep, staph
Mets- lung or breast
MI- Immediate post-mi- 24 hrs of a transmural infarct. Drssler's syndrome- pericarditis occurring one wk to months after an MI due to an autoimmune response to infarcted myocardium
Uremia- chronic renal failure
Rads
Drugs- hydralazine, procainamide, isoniazid
Collagen vascular tissue- SLE, scleroderma
Myxedema
Trauma- postpericardiotomy syndrome
Idiopathic
What is ITP?: Immune mediated thrombocytopenia
development of antibodies against platelet surface antiget.
what is the treatment of ITP?: corticosteroids, IvIg, platelet transfusion
splenectomy
what is the TTP pentad?: Fat RN
Fever
Anemia
Thrombocytopenia
Renal dysfunction
Neurologic dysfunction. (altered mental status)
what is the etiology of TTP?: malignancy
infection
antiplatelet agents, chemo, contraceptives
autoimmune disorders
preggers
what is the diagnosis of TTP?: Hemolysis: schistocytes on perpheral smear, decreaseed haptoglobin, elevated LDH, elevated total bili
Renal failure: elevated BUN, Cr
Fever, confusion
normal PT, PTT
what is the treatment of TTP?: plasmapharesis
may give FFP
What is DIC?: acquired coag defect that results in consumption of coag factors I, V, VIII, and XIII-> bleeding and thrombosis
what is the etiology of DIC?: obstetric problems- dead fetus, abruptio placentae, 2nd trimester abortion, amniotic fluid embolism

spesis- RMSF, HUS, malaria
Local tissue damage- snake bites, burns, frostbite

Chronic illness: Malignancy, liver disease
what are the signs and symps of DIC?: Petechiae
purpura
mucosal bleeding
chronic DIC may only have lab abnlties
what is the Dx of TTP?: thrombocytopenia
increased PT, aPTT, and TT
Decreased fibrinogen
Presence of fibrin split products
hemolysis on peripheral smear.

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