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----------------------------------------------------------------  prolonged hypotension from any cause can lead to acute tubular necrosis o U/A: muddy brown granular casts consist of renal tubular epithelial cells o serum BUN:Cr ratio < 20:1 o urine osmolality 300 - 350 mOsm/L o urine Na+ > 20 mEq/L, FENa > 2% ----------------------------------------------------------------  broad casts: a/w chronic renal failure o arise in dilated tubules of enlarged nephrons that undergone compensatory hypertrophy in response to the reduced renal mass  waxy casts: chronic renal disease o shiny & translucent  RBC casts: glomerulonephritis or vasculitis; o Wegener’s, SLE, Henoch-Schonlein  WBC casts: interstitial nephritis & pyelonephritis o WBCs that originate in kidneys  fatty casts: nephrotic syndrome  hyaline casts: asymptomatics & prerenal azotemia o proteins that pass unchanged along urinary tract ----------------------------------------------------------------  meniscal & ligamentous tears can both be a/w a popping sensation following precipitating injury  meniscal injury: gradual joint swelling, 12 – 24 hr  ligamentous injury (ACL): rapid joint swelling & effusion due to hemarthrosis (ligaments have greater vascular supply than menisci, which rely on diffusion for nourishment)  definitive Dx: MRI ----------------------------------------------------------------  Ulcerative colitis: MC in females, Ashkenazi Jew, peak @ age 15 - 25  MC site: rectum, confined to mucosal layer  bloody diarrhea, tenesmus, pseudopolyps  severe disease: weight loss, fever, or anemia  +p-ANCA  confirm Dx: friable mucosa on colonoscopy & biopsy with mucosal inflammation  extraintestinal: erythema nodosum, uveitis, sclerosing cholangitis, spondyloarthropathy  complications: toxic megacolon & colorectal ca  surveillance: annual colonoscopies beginning at 8 - 10 yrs after Dx for colon cancer detection o colonic dysplasia is a/w progression to adenocarcinoma; Rx: total colectomy ----------------------------------------------------------------  young patient, aphthous ulcer, chronic diarrhea, abdominal pain, weight loss: Crohn’s  non-caseating granulomas, “cobblestone”, transmural inflammation, skip lesions, creeping fat, non-lymphoid aggregates  MC site: terminal ileum; rectum is spared ----------------------------------------------------------------  primary features of Chagas disease: recent immigrant from Latin America with chronic megacolon/megaesophagus & cardiac disease (CHF: pedal edema, JVD, S3, cardiomegaly)  systolic & diastolic heart failure, RBBB  Rx: benznidazole or nifurtimox ----------------------------------------------------------------  weight loss = most effective lifestyle intervention to reduce BP  DASH diet is the next most effective approach in prevent & treat HTN especially non-obese; then exercise, dietary sodium, alcohol intake  smoking causes a transient rise in BP ----------------------------------------------------------------  Rheumatoid arthritis o morning stiff >30 min, improves with activity o tenosynovitis of palms (“trigger finger”) o cervical joint involvement can lead to spinal subluxation  cervical cord compression o positive anti-cyclic citrullinated peptide (anti-CCP) o  CRP & ESR correlates with disease o XR: soft-tissue swelling, bony erosions, joint space narrowing  greatest risk for osteoporosis  Rx: physical activity, optimize Ca++ & Vit D intake, minimize corticosteroids, bisphosphonates ----------------------------------------------------------------  Paget’s disease of bone = osteitis deformans; due to osteoclast overactivity, leads to replacement of lamellar bone with abnormal woven bone ----------------------------------------------------------------  Osteitis fibrosa cystica (Von Recklinghausen disease of bone): due to hyperparathyroidism 2/2 parathyroid carcinoma  excessive osteoclastic resorption, leads to replacement with fibrous tissue & bony pain  XR: subperiosteal bone resorption, “salt-&-pepper” appearance of skull, bone cysts, & brown tumors of long bones ---------------------------------------------------------------- Caustic ingestion features chemical burn or liquefaction necrosis results in:  laryngeal damage: hoarseness, stridor, orofacial inflammation  esophageal damage: dysphagia, odynophagia  gastric damage: epigastric pain, GI bleeding management  ABCs  remove contaminated clothing, irrigate exposed skin  upper GI XR with water-soluble contrast for suspected perforation  CXR if respiratory symptoms  upper endoscopy within 24 hr  barium contrast (2 – 3 wks) complications  esophageal strictures  pyloric stenosis  ulcers, perforation  cancer  avoid interventions that provoke vomiting (activated charcoal, milk, vinegar, NG lavage)  in absence of perforation, upper endoscopy within 12 – 24 hr to assess damage & guide therapy ----------------------------------------------------------------  chronic GERD with new dysphagia & symmetric LES narrowing: esophageal stricture  body’s reparative response to chronic acid exposure  other causes: radiation, systemic sclerosis, caustic  Dx: endoscopic biopsy to r/o adenocarcinoma  DDx: adenocarcinoma (asymmetric narrowing), hiatal hernia, achalasia (aperistalsis) ----------------------------------------------------------------  early-onset HTN, progressive renal insufficiency, gross hematuria, flank pain, B/L abdominal masses ADPKD symptoms most are asymptomatic hematuria flank pain (due to renal calculi, cyst rupture, hemorrhage, or upper UTI) clinical signs early onset HTN B/L upper abdominal masses mild proteinuria, CKD extra-renal manifestation cerebral aneurysm hepatic/pancreatic cysts cardiac valves (MVP, AR) diverticulosis ventral/inguinal hernias diagnosis abdominal USS management monitor BP, renal Fx, & potassium control cardiovascular risk factors ACE-inhibitors for HTN ESRD: dialysis, renal transplant DDx  central obesity, facial plethora, proximal weakness, abdominal striae, ecchymosis: Cushing’s  headaches, palpitations, diaphoresis a/w paroxysmal BP elevations: pheochromocytoma o urinary vanillylmandelic acid, & metanephrines ----------------------------------------------------------------  alpha-1-antitrypsin: protease inhibitor that protects from neutrophil elastase, which breaks down elastin  AAT deficiency: uninhibited elastase cause bullous, panacinar emphysema of lower lobes (smoking-induced emphysema is centrilobular)  also causes liver disease: cirrhosis, or HCC  liver Bx: hepatocyte inclusion stain +PAS & resists digestion by diastase  Rx: purified human AAT ----------------------------------------------------------------  chemotherapy-induced peripheral neuropathy from vincristine (also cisplatin, paclitaxel) begins after several weeks  symmetric paresthesia in fingers/toes, spreads proximally in stocking-glove pattern  loss of ankle jerk reflexes, pain/temp sensation, occasional motor neuropathy (B/L foot drop) ----------------------------------------------------------------  early Lyme disease: erythema chronicum migrans  also a/w headache, malaise, fatigue, fever  unilateral Bell’s palsy  early Dx is based on trademark rash & recent travel  MCC: B. burgdorferi (spirochete)  Rx: oral doxycycline (age > 8)  Rx: oral amoxicillin (age < 8, pregos, or lactating) or cefuroxime ----------------------------------------------------------------  avascular necrosis is a/w heavy alcohol use, SLE, chronic systemic corticosteroids, sickle cell disease ----------------------------------------------------------------  sudden onset C/L lower extremity motor & sensory deficits with UMN signs, urinary incontinence: anterior cerebral artery (ACA) occlusion  MCC: ischemic stroke ---------------------------------------------------------------- Spinal cord compression causes spinal injury (MVA), disk herniation, malignancy (lung, breast, prostate, MM), infection (epidural abscess) features gradual, severe focal back pain; pain worse when recumbent & at night early: B/L LE weakness, absent DTRs, flaccid paraplegia late: B/L +Babinski, absent rectal tone, paraparesis with  DTRs, sensory loss, bowel/bladder dysfunction, urinary retention manage high-dose IV glucocorticoids, emergency spinal MRI, radiation-oncology, neurosurgery consult  pain worse on recumbent due to distension of epidural venous plexus ----------------------------------------------------------------  anterior spinal cord infarct: abrupt onset flaccid paralysis, loss of pain & temp sensation (anterior spinal artery), & autonomic dysfunction ----------------------------------------------------------------  recurrent pneumonia in the same anatomic region o bronchial obstruction or recurrent aspiration  bronchogenic carcinoma obstruction is most concerning with a smoking history  chest CT is indicated initially o central masses or negative CT: bronchoscopy o peripheral lesions: CT-guided biopsy  recurrent aspiration, same lung region o seizures o ethanol/drug use o GERD, dysphagia, achalasia  recurrent pneumonia in different regions o sinopulmonary disease (CF, immotile cilia) o immunodeficiency (HIV, leukemia) o vasculitis, bronchiolitis obliterans ----------------------------------------------------------------  painless vesiculopustular rash, tenosynovitis, & migratory polyarthralgia: disseminated gonococcal infection  2 - 10 skin lesions similar to furuncles or pimples  Hx of recent unprotected sex with a new partner  all patients should undergo HIV screening ----------------------------------------------------------------  hypotension, tachycardia, poor skin turgor, lethargy, confusion: hypovolemic hypernatremia o Rx: IV normal saline (0.9%) until euvolemic, then 5% dextrose  serum Na+ should be corrected by 0.5 mEq/dL/hr, as cerebral edema can result if too rapid ----------------------------------------------------------------  high serum & low urine osmolality due to inadequate ADH response is most likely due to lithium-induced nephrogenic DI  Lithium induces ADH resistance, resulting in acute-onset nocturia, polyuria, & polydipsia  hypovolemic hypernatremia  Rx: discontinue lithium; salt restriction & diuretics (amiloride: K+ sparing diuretic)  Rx: hemodialysis for lithium level ˃ 4 mEq/L or ˃ 2.5 mEq/L + signs of toxicity or renal disease ----------------------------------------------------------------  increased contractility & reflex tachycardia are secondary effects provoked by nitroglycerin due to changes in baroreceptor activity in response to decrease BP from venodilation ----------------------------------------------------------------  fever, headache, N/V, petechial rash, stiffness, & photophobia: meningococcemia  fever, arthralgia, sore throat, lymphadenopathy, mucocutaneous lesions, diarrhea, weight loss: acute HIV infection  migratory arthritis of large joints, carditis, erythema marginatum (raised ring-shaped lesions over trunk & extremities), subcutaneous nodules, Sydenham chorea: acute rheumatic fever o pharyngitis precedes onset by 2 - 4 wks ---------------------------------------------------------------- Common complications after acute MI  hours – 2 days  reinfarction  hours – 7 days  ventricular septal rupture  days – 2 wks  LV free wall rupture  hours – 1 month  post-infarct angina  1– 3 days  acute pericarditis  2 – 7 days  papillary muscle rupture  5 days – 3 months  LV aneurysm  weeks – months  Dressler’s pericarditis ----------------------------------------------------------------  acute pericarditis occur 1 - 3 days post-MI o pericardial friction rub with/without chest pain o self-limited, resolves with supportive care  posted-MI pericarditis occurring wks to months after an MI: Dressler syndrome o immune-mediated pericarditis o Rx: NSAIDs ----------------------------------------------------------------  MCC blunt abdominal trauma: uploads/Sante/ study-guide 11 .pdf