IM

 Consolidated Basic Science Review for IM



Hypercalcemia of malignancy treatment
- Use zoledronic acid unless GFR is too low, in which case use denosumab.
- This was seen in a patient with metastatic breast Ca
- search email for more information.

Unconsolidated Information:

DM1 - Fasting Glucose Cutoff - 126 mg/dl
NL - Fasting Glucose - 70-110 mg/dL
CSF glucose 40-70 mg/dl
CSF protein < 40 mg/dl
CSF pressure 70-180 mg/dl
Hematocrit 41-53% / 36-46%
LDH - 45-90 U/L
Bilirubin ttl .1-1.0 mg/dl, Direct 0-.3 mg/dl
Hemoglobin 13.5-17.5 / 12-15
Plates 150-400K
Erythrocytes 5M
Reticulocytes .5-1.5 % of RBCs
AST/ALT 8-20 U/L
Albumin 3.5-5.0 Hypoalbuminemia < 3.4
PT - 11-15, PTT 25-39 Bleed 2-7 min
ESR F <15, > 50yo <20 mm/hr, M <20, >50yo <30mm/hr
K+ - 3.5-5.0, Phosphorus 3.0-4.5, Phosphate 2.7-4.0, Ca2+ 8.4-10.2
HDL  > 40, LDL < 200, Trigs < 150
LDL = TTL  - HDL - TG/5
Lecithin / Spingomyelin < 1.5 in neonatal ARDS
cortisol 08:00 5-23ug/dl 16:00 3-5ug/dl
SGOT / SGPT > 1.5 in alcoholic hepatitis
ALK Phos = 20-70 U/L, Paget's ds = 200-700 U/L
Trasferin Saturation - 20-50%
BUN 7-18 mg/dl Creatinine .6-1.2 mg/dl
Alcoholic hepatitis AST/ALT Viral ALT>AST
STd & T-wave inversion - MI
TSH .5-5.0 uU/ml, PTH 230-260 pg/ml T4 - 5-12ug/dl = Thyroxine Free 7 ng/dl 
T3 - 115-190 ug/dl Triidothyronine
Preganancy increases T4, T3, normal free T4
Fribrinogen - 250 mg/dl is normal
Na 135-145 nEq/L 
Urine SG < 1.006 = DI, normal OSM 275-295
CPK Males 25-90, Females 10-70

MEN -> increased gastrin -> ulcers (also, isolated hyperthyroidism)
Hypofibringenemia - Fibrogen < 50 mg/dl
T3,T4,TSH - 150 ng/dl, 8.0ug/dl, 1uU/nl
RBC Hemolysis - increased LDH, decreased Haptoglobin- binds free hemoglobin
decreased Glucose leads to increased epinephrine, increased glucagon, increased cortisol, increased GH

Leukocyte Differential
Total 4500-11,000
Neutrophils 54-62%
Lymphos - 25-33%
Monos - 3-7%
Bands 3-5%
Eos 1-3%
Basos - 0-.75%



Most Accurate Tests:
Airway hyperresponsiveness (sensitivity to cold air) - Methacholine challenge test - NPV ~ 100%

Integrate the following notes into the web /FCE:

Well's Criteria for PE risk
SNTIPPP 
Sx: 3
No alternative dx: 3
Tachycardia: 1.5
Immobilization > 3 days or surgery in past 4 weeks: 1.5
Prior hx of DVT or PE: 1.5
Presence of hemoptysis: 1
Presence of malignancy: 1
0-1 Low
2-6 Moderate
6-12 High risk of PE
My acronym:
E - Evidence or symptoms
M - Most likely (no alternative)
B - Beats (tachycardia > 100 bpm)
O - Obtunded (immobilized > 3 days or surgery in past 4 weeks)
L - Latent
U - sangUigenous
S - Say "malignancy".

pretest prob / (1-pretest prob) * LR = post-test odds
posttest odds/(1+posttest odds) = post test probability
Remember: LR =2 increases 15%, 5 = 30%, 10 = 45%

Renal & pulmonary systems adjust this: CO2 / HCO3- ratio

Don't give ABX in HUS.
ADAMST-13 deficiency - TTP
- fever, thrombocytopenia, MAHA, CNS, renal insufficiency TX: plasmapheresis
- Ticlopidine, Clopidogrel can precipitate TTP

Cocroft Golf: 140-Age/1.6(50 BMI / 70 mm)

B.S. - hemisection of cervical cord
- all sx ipsi except contralateral pt loss below level of lesion

The big DDX: N/V Altered Mental Status
- Infectious
- Metabolic (Endocrine - DKA), Liver, K. Failure
- Neoplastic
- Drugs / Drug Interactions / Rec. Drugs
- Autoimmune

Empiric Tx for Meningitis:
ceftriaxone 2mg IV q 12hr
vanc
ampicillin 2g IV q 4hr
dex 10 mg IV q6hr (q4Day)
IVF NS 200ccc/ hr
if blood cultures grow S. aureus switch to Nafcillin
Why give Dex w/ ABX in meningits ? Decrease neuro sequalea. (need ref)

Prophylaxis for kid of pts w/ meningitis: 500 mg ciprofloxacin.

PO2 / FiO2 < 300 = shunt or V/Q mismatch

AG acidosis think KLUT - ketoacidosis, uremia, lactic acidosis, toxins

PCO2 = last 2 digits of pH in compensated metabolic acidosis.

NAGMA with resp compensation - acetazolamide
- type 2 RTA (carbonic anhydrase)

delta / delta = (AG-12 / 24-HCO3-) 1 = simul NL anion gap acidosis, 2 = simultaneous met alk or compenstated chronic resp acidosis
- expect resp alk in pts with ESLD

TB
pyrazinmide - should not be used in pregnancy
ethambutol - optic neuritis

Rheumatology Lecture

R/O ruptured Baker's cyst vs. DVT on US.
- If anticoagulate before imaging then risk of compartment syndrome, b/c
- Baker's cyst synovium opens into gastrocnemius. 
- 'Crescent sign' - eccymoses around medial maleolus in a "C" - shape.

DDX: Gout, cellulitis, septic arthritis
Tests: crystals, gram stain, bacteria

DDX CTS:
- amyloidosis
- autoimmune hepatitis
- Dupuytren's contracture
- Gleevec (remember peripheral eosinophilia)
- median nerve compression
- mycosis fungoides
- hypothyroidism
- MCTD
- paraneoplastic
- PMR
- polyneuropathy
- pregnancy
- RA
- radiculopathy
- scleroderma
- SLE
- ulnar neuropathy
 
CMRRR
constrictive pericarditis
massive PE
restrictive cardiomyopathy (hemochromatosis)
RV infarction
rarely cardiac tamponade

Atypical PNA
- chlamydia
- coxiella
- influenza
- legionella
- mycoplasma

Make an MS slide and include the following:

Marcus Gunn Pupil - afferent defect in optic neuritis - dilation of affected on swinging light from unaffected eye

 - specifically the afferent limb of the optic nerve in the affected eye is damaged, so light shined in affected eye does not cx constriction
 - light shined on undamaged side causes constriction in damaged eye
 
Dawson's fingers - MS plaques seen on MR scan
Fundal exam will appear normal on opthalmic examination.
Most eye lesions are retrobulbar.
Pregancy is considered to be an immunosuppressed state - frequent Crohn's and other diseases exacerbate post partum.
Gilenya - Novartis' new MS drug
Uhthoff's sign - transient sx exacerbation caused when nerve is heated (patient takes a shower)
---- end MS

This is my consolidated review, which will remain under revision until further notice.

Inguinal Ring
How would you distinguish INO (MLF) from medial adductor palsy ?

ANS: INO can easily be confused with a medial rectus palsy since 
the affected eye appears to have lost its ability to adduct. However, 
most patients with INO still have the ability to converge, as this ocular
movement pattern (bilateral ocular adduction in response to focusing 
on an object moving closer to the eyes) does not require an intact MLF. 
Additionally, INO is often the presenting sign of multiple sclerosis (MS). 
Most (92%) patients who develop INO because of demyelination will 
progress to full-blown MS.

Noto Bene: 50% of patients with MG present initially with extraocular 
muscle weakness. As such, patients in whom there is any question of 
the diagnosis should undergo testing for anti-acetylcholine receptor antibody.

DDX:
  1. Brain stem and fourth ventricular tumor
  2. Brain stem infarction
  3. Drug intoxication (eg, phenothiazines, tricyclic antidepressants, toluene, tacrolimus)
  4. Lyme disease
  5. Multiple sclerosis (the most common cause of bilateral INO in young adults)
  6. Subdural hematoma
  7. Syphilis
  8. Trauma
  9. Viral infection

Add:
infantile fibromatosis vs fibrodysplasia ossificans progressiva



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